NATIONAL LIBRARY OF MEDICINE
             Washington
Founded 1836
U. S. Department of Health, Education, and Welfare
             Public Health Serrice 
 
 
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     A

TREATISE
FEBRILE  DISEASES,
INCLUDING
THE VARIOUS  SPECIES OF FEVER,
AND
ALL DISEASES ATTENDED WITH FEVER
3
   BY A. P. WILSON EplLlP, M. D. F. R. S. Ed.
IELLOW OF THE ROTAL CO'-LEGE OF PHYSICIANS OF EDINBURGH, PHYSICIAN TO
            THE WORCESTER INFIRMARY, &C.

        WITH NOTES AND ADDITIONS,
           BY NATHAN SMITH, M. D.
  PROFESSOR OF PHYSIC, SURGERY,  AND OBSTETRICS, IN YALE-C0LLE8E
            IN TWO VOLUMES.

               VOL. I.

THE SECOND AMERICAN, FROM THE THIRD LONDON EDITION.
               HARTFORD, £ 3 ^ ^

       PUBLISHED AND SOLD BY COOKE & HALE :
SOLD ALSO BY CUMMINGS & HILLIARD, BOSTON ; HEZEKIAH HOWE.
     NEW-HAVEN ; COLLINS & CO., NEW-YORK ; AND
         BENJAMIN WARNER, PHILADELPHIA.
PRINTED BY BENJAMIN L. HAMEEV
18IR. 

                               DISTRICT OF CONNECTICUT, ss.  •

*********   BE it remembered, That on the eighth day of August, in the
* SEXL- • forty-first year of the Independence of the United States of Amer-
********* ica> Oliver D. Cooke, of the said district, hath deposited in this
office the title of a book, the right whereof he claims as proprietor, in the
words following, to wit:
  " A treatise on Febrile Diseases, including the various species of fever, and
all diseases attended with fever.  By A. P; Wilson Philip, M. D. F. R. S. Ed.
Fellow of the Royal College of physicians of Edinburgh, physician to the
Worcester infirmary, &c.  With notes and additions, by Nathan Smith, M
D. professor of  physic, surgery,  and obstet ricks, in Yale  College.  In two
volumes.  Vol. I.   The second American from the third London edition."
  In conformity to the act of the Congress of the United States, entitled," Aa
act for the encouragement of learning, by securing the copies of maps, charts,
and books, to the authors  and proprietors of such copies, during the  times
therein mentioned."
                                       HENRY W. EDWARDS,
                                  Clerk- of the District of Connecticut.
                      A true copy of record, examined and sealed by me,
                                       H. W. EDWARDS,
                                 Clerk of the District of Connecticut 
                          TO

     DR. BAILLIE, M.  D.  F. R.  S. L. & E.
        PHYSICIAN EXTRAORDINARY TO THE KING,
FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS IN LONDON,
     AND HONORARY FELLOW OF THE ROYAL COLLEGE
          OF PHYSICIANS IN EDINBURGH, &c. &c. &c.
    Dear Sir,

  The approbation, you were so kind as to express of the fol-
lowing treatise, has been a principal motive for the trouble it
has cost me to bring it into its present, I hope, improved state.
But this is only one of many reasons  for addressing it to you.
The testimonies of friendship I have received from you, the as-
sistance I have often derived from your excellent works, your
rank in the profession, and above all, your character as a man,
make this public declaration of esteem peculiarly gratifying to
me.
                    I am,
                     Dear Sir,
              With unfeigned respect,
                     Your obliged  Friend
                          And faithful Servant,
A. P. WILSON PHILIP. 
 
PREFACE.
   In revising the following treatise my only object has been to render
it more useful to the practitioner.  I have endeavoured to reduce it in-
to as small a compass as the nature of the work admits of; for it was
offered to the public not as an out-line, but as nearly the sum of our
knowledge on the subject.
   In one branch I have been particularly careful to avoid any omission
of importance.    It is  evident  that much must depend on a  minute
knowledge of the symptoms of diseases, by which  we acquire the pow-
er of accurately distinguishing them, and of ascertaining by the varia-
tion of their symptoms, the changes which are taking place internally.
   Although, for the sake of compression,  I shall  less frequently enter
on the opinions of others or give quotations from their works, and ma-
ny years' additional experience  has  enabled  me  to speak more fre*
quently from my own observation, than in the former editions, I shall
 not suppress any of the authorities there adduced.
   Of the observations which have been made  on this treatise, there are
 two which I feel myself called upon  to notice.    I have been accused of
 disrespect towards Dr. Cullen, and said  to espouse the practical tenets
 ©f Dr. Brown.
    It is true that, after  a very short discussion,  I rejected Dr. Cullen's
 doctrine of fever, but it was admitted by its author to be hypothetical,
 and confessedly brought forward only for the purpose ot connecting the
 different parts of the subject.   It is not Dr. Cullen's praise that he  in-
 vented an ingenious hypothesis, but that  he  new-modelled, if I may
' use the expression, the" whole practice of medicine ; that in his Synop-
 sis Nosologic Methodicee, he  defined and arranged diseases with an ac-
 curacy far beyond his  predecessors ;  and in  his  First Lines, reduced
 their  treatment to a decree of simplicity formerly  unknown.  In every.
 part of the treatise these merits of Dr. Cullen, the highest a medical
 writer can boast, are acknowledged not only with  frankness but with 
PREFACE.
 pleasure; for I had no less reason to love and esteem him as an indi-
 vidual, than to honour and admire him as the first physician of his age.
    Dr. Brown in forming his, certainly very simple and ingenious hy-
 pothesis, proceeded on a different principle.   It was not his object
 merely to connect together the different phenomena of fever, till we ar-
 rive at a more accurate knowledge  of the  nature of the disease.   He
 maintained the truth of his opinions, and founded  them on  principles
 whose truth all must admit, and w,hose truth indeed was universally ad-
 mitted long before  he wrote.  But I was so  far from adopting these
 opinions, that many pages were devoted to pointing out that his chief
 inferences are false ;  and with respect to  the  application of his doc-
 trine to the cure  of diseases, the following is the opinion given in both
 the former editions of this treatise.  " We come now to that part of
 " the Brunonian  system where truth for the first time wholly forsakes
 " us.  In other parts if errours have appeared, they are the erroursof
 " rash induction  ; that we are about to consider is, as far as I am ca-
 " pabi'e of judging,  altogether unfounded.   I mean the application of
 " the Brunonian  doctrine  of excitability to explain  the  phenomena
 " and treatment  of general diseases."*
  My opinion of the  nature  of  fever I stated some years ago in a
 separate essay.  It was once  my intention  to enter on a discussion of
 it in the following treatise, but from my wish to compress the treatise,
 and make it wholly  a practical work, I shall merely lay this opinion
 before the reader, and leave it for his consideration.  He will have an
 opportunity of judging in  the  perusal of the following work, how far it
 is consistent with the various phenomena of fever.
  It appears  from some experiments with  the microscope, related in
 the introduction  to the second part of this treatise,  that inflammation
 arises from debility of the capillary vessels, and their consequent dis-
 tension by the vis a  tergo;  and that we can at will produce inflamma-
 tion by debilitating  the  capillaries, and relieve it by increasing their
 action.   Wherever therefore, the symptoms of inflammation, increas-
 ed temperatue, redness and swelling appear, the capillary vessels are
debilitated and preternaturally distended.   Now  in the hot stage of
fever, the whole  surface is affected  with increased temperature,  red-
ness and swejling.  That  the capillary vessels  of the surface are here
in a state of debility  farther appears from the preceding symptoms,
those of the cold stage, in which,  the debilitated vessels not yet being
distended by  the vis a tergo the surface is  pale and  shrunk.   We can
have no doubt that the same state  of the vessels, which  we observe in
* Vol. 1, first edition, p. 492, second edition, 522. 
PREFACE.
vii
the external surface, obtains in the various internal surfaces, which is
indicated by the same dimunition or  loss of the  secreting power  in
them, and  as far as we can see, the same shrinking in the cold, and
fullness and redness in the hot stage ;  and as the debility of the capil-
laries of a part, as appears from direct observation,* always produces
increased action of the large arteries of the part,  this general debility
of the capillaries produces increased action  of the whole arterial sys-
tem.  In inflammation, the debilitated vessels being comparatively few,
the vis a tergo quickly and to a great degree distends them.   In  fever,
the debilitated vessels being very numerous  it produces its effect more
slowly and to a less degree, in proportion as  the resistance  is  greater.
Fever and inflammation, therefore, seem only to differ in the one being
a general, the other a local affection ; to which all the differences in
the phenomena of these diseases may, I believe, be easily traced-t
   As the small-pox has now become a less interesting disease than it
has long been, and  it is to be hoped will  be every day becoming less
so, I have greatly abridged my account of it.   I  shall still, however,
give a detailed account of its symptoms, and insist on those parts of the
treatment in which it bears a strong analogy to the diseases with which
it is classed ; for none of these have attracted so  much attention,  and
consequently been observed with so much care ; and did the small-pox
no longer exist, in observing the phenomena and improving  the  treat-
ment of the other Exanthemata, we should long have occasion to refer
to the observations which have been made on it. J

   * See the Introduction to the second part of this Treatise.

   + See what is said of hemorrhagy  and profluvium in the introduction to
 die second part.
   $ I take this opportunity of requesting M. Topelmann of Leipsick, who has
done the following treatise the honour of translating it into the German lan-
guage, in case the present edition falls into his  hands, to give from it, in an
appendix, such alteration* and additions as seem worthy of notice. 
 
CONTENTS.
                                                     Pag i
Introduction         -                                 1
Smith's Nosological arrangement                          29

                       PART  I.
           Of Idiopathic Fevers       -                  43

                       BOOK I.
           Of intermitting and Remitting Fevers           ib.

                       CHAP. I.
Of the Species and Varieties of Intermitting and Remitting
  Fevers                                              ib.
                        SECT. 1.
           Of the Varieties of the Tertian         -       45
                       SECT. II.
           Of the varieties of the Quartan and Quotidian     47

                      CHAP.  II.
Of the Symptoms of Intermitting and Remitting Fevers       48
                        SECT. I.
           Of the more Essential Symptoms of Intermitting
             and Remitting Fevers       -       -       ib.
           1. Of the symptoms of the Cold Stage of Inter-
             mittents         -        -               ib-
           2. Of the Symptoms of the Hot and Sweating
             Stages       -       -       -      -SI 
CONTENTS.
Page.
56
                      SECT. II.
          Of the Anomalous Symptoms of Intermittents     53
                      SECT. III.
          Of the Symptoms peculiar to the different
             Types         -
                      SECT. IV.
          Of the Manner in which the* Different Types
             Assume more or less of the Continued Form     60
                       SECT. V.
          Of the Diseases with which Intermittents are
             most frequently complicated       -       -  61
                      SECT. VI.
          Of the Prognosis in Intermittents       -        63

                    CHAP. III.
Of the  Morbid Appearances discovered by  Dissection in
  those who Die of Intermittents       -       -      -    73

                    CHAP. IV.
Of the Causes of Intermittents      ...       74
                        SECT. I.
           Of the Predisposing Causes of Intermittents     75
                        SECT. II.
           Of the Exciting Causes of intermittents    -    ib.

                      CHAP.  V.
Of the Treatment of Intermittents      -       -           83
                        SECT. I.
           Of the Treatment during the Paroxysm     -     ib.
           1. Of the Means to be  employed during the
             Cold Fit       -        -         -        ib.
           2. Of the Means to be employed during the
              Hot  Fit         ...      85
                        SECT. II.
           Of the Treatment during the Intermission       92 
                      CONTENTS.                      si

                                                    Pack.
           1. Of the Diet and Exercise during the  Inter-
             mission     -            .--     92
           2. Of the medicines employed during the Inter-
             mission        ..-        97

                     CHAP. VI.
Of the Modus Operandi of the Remedies employed in Inter-
  mittents      ....       -        114

                      BOOK  II.
           Of Continued Fever     -      -     -     122

                      CHAP. I.
Of the Symptoms of Continued Fever    -     -    -    123
                        SECT. I.
           Of the Symptoms of Synocha     -     -     124
                        SECT. II.
           Of the Symptoms of Typhus     -     -      126
           Of the State of the Animal Functions in the  pro-
             gress of Typhus     -    -    -     -    127
           Of the State of the  Vital Functions in the pro-
             gress of Typhus      -         -     -    129
           Of the State of the Natural Functious in the
             progress of Typhus     -     -     -      131
                       SECT. III.
           Of the Crises of Fevers       -       -       139
                      SECT. IV.
           Of the Prognosis in Continued Fever     -    147

                      CHAP. II.
Of the Remote Causes of Continued Fever     -     -     149
                        SECT. I.
           Of Cold as a Cause of Fever     -      -     ib.
                        SECT. II.
           Of Contagion     -     -     -     -      152
           Of the Source of Typhus     -    -     -    154 
CONTENTS.
                                                    Page.
           Of the ways in which Typhus Spreads     -    156
           Of the Means of Preventing the Generation and
             Checking the Progress of Typhus     -     161

                     CHAP. III.

Of the Treatment of Continued Fever     -     -    -    172

                     CHAP. IV.

Of the Varieties of Continued Fever     -     -    -    214

                       SECT. I.
           Of the Petechial Fever       •       -       216

                       SECT. II.
           Of the Miliary Fever     -      -      -      219
           1. Of the Symptoms of the Miliary Fever      220
           Of the Miliary Eruption     -     -     -     ib.
           Of the symptoms which precede or attend the
             Miliary Eruption     -     -     -    -    221
           Of the Febrile states in which the Miliary Erup-
             tion most frequently appears     -    -    223
           2. Of the causes of the Miliary Fever    -    224
           3. Of the treatment of the Miliary Fever      227

                       SECT. III.
           Of the Aphthous Fever     ...    232
           1. Of the symptoms of the Aphthous Fever    233
           Of the Aphthous Eruption     -          -    ib.
           Of the symptoms preceding and accompanying
             Aphthae      -                           239
           Of the febrile states in which Aphthae most fre-
             quently appear     -                     240
           2. Of the causes of the Aphthous Fever    -   242
           3. Of the treatment of Apthous Fever    -    244

                       SECT. IV.
           Of the Vesicular Fever     ...    253
           1. Of the symptoms of the Vesicular Fever    255
           Of the Vesicular Eruption       -       -     ib. 
CONTENTS.
xiii
                                                   Page.
           Of the Symptoms Preceding and Attending
             the Vesicular Eruption      -        -    257
          Of the  Febrile States in which the Vesicu-
             lar Eruption most frequently appears        258
           2. Of the Causes of the Vesicular Fever        ib.
           3. Of the Treatment of the Vesicular Fever    260
                       SECT.  V.
           Of the Erysipelatous Fever       -      -    261
           1. Of  the Symptoms of the Erysipelatous
             Fever                                  262
           Of the Erysipelatous Eruption       -        ib.
           Of the Symptoms which Precede or Attend
             the  Erysipelatous Eruption       -        266
           Of the Febrile States in which the  Erysipela-
             tous Eruption is most apt to appear    -    268
           2. Of the Causes of the Erysipelatous Fever    270
           3. Of the Treatment of the Erysipelatous
             Fever         -                         272

                     BOOK  III.

Of the Exanthemata           -        -        -      274

                       CHAP. I.

Of the small-pox           -           -         -     275

                        SECT. I.
           Of the Symptoms of the Small-pox      -     278
           1. Of the Symptoms of Distinct Small-pox      ib.
           2. Of the Symptoms of Confluent Small-pox    283
           3. Of the Symptoms of Anomalous Small-pox   286
                        SECT.  II.
           Of the Morbid Appearances on Dissection     290
                       SECT.  III.
           Of the Causes of the Small-pox         -      293

                       SECT.  IV.
Of the Treatment of the Small-pox
297 
iv                     CONTENTS.
                                                   Page.
                     CHAP. II.
 Of the Chicken-pox......313
                        SECT I.
           Of the symptoms of the Chicken-pox     -     ib.
                       SECT. II.
           Of the causes of Chicken-pox        -      316
                      SECT. III.
           Of the treatment of Chicken-pox      -       ib.

                     CHAP. III.
 Of the Measles      -      -      -      -     -      317
                       SECT. I.
           Of the symptoms of xMeasles     -     -     318
           1. Of the Symptoms of Regular Measles        ib.
           2. Of the Symptoms of Irregular Measles       324
                      SECT. II.
           Of the Appearances on Dissection    .    -  329
                      SECT. III.
           Of the Causes of Measles       -      -       330
                      SECT. IV.
           Of the Treatment of Measles         -        233

                     CHAP. IV.
 Of the Scarlet Fever        -         -        -       338
                       SECT. I.
           Of the Symptoms of Scarlet Fever      -     339
                      SECT. II.
 Of the Causes of Scarlet Fever      -       -       -     347
                      SECT. III.
           Of the Treatment of Scarlet Fever       -     349
                     CHAP. V.
 Of Hie Plague       -       -         -         .        35] 
CONTENTS.
xv
                                                 Page.
                      SECT. I.
          Of Pestilential Eruptions         -      -    353
          1. Of Pestilential Buboes        -     -     ib.
          2. Of Carbuncles         -         -    -  356
          3. Of the other Pestilential Eruptions    -    360
                      SECT. II.
          Of the other Symptoms of the Plague     -     362
                      SECT. III.
          Of the Causes of the Plague       -       -   375
                      SECT. IV.
          Of the Treatment of the Plague    -       -  380
                    CHAP.  VI.
Of the Urticaria       -                       -       384
                       SECT. I.
          Of the Symptoms of the Urticaria      -      385
                      SECT. II.
          Of the Causes of the Urticaria      -        386
                      SECT.  III.
           Of the Treatment of Urticaria         -      387
           Appendix        -                          •
             Of the Cow-pox. 
 
                   A

         TREATISE

                  ON

FEBRILE DISEASES,  #c.
INTRODUCTION.
   THE diseases we are about to consider may be  divided into two
"great natural classes.   In the one the fever is idiopathic,  in the other,
the consequence of a local disease.  Some nosological observations on
these classes,  and on the various species arranged under them, form a
necessary introduction to the following Treatise.
   The symptoms of a disease may be divided into those which form
the diagnosis, that is, distinguish it from others ; those which form the
prognosis, namely, those from which we prognosticate the event, and
those which in  the present state of our knowledge serve neither pur-
pose.
   It may be said  that we  should confine our attention to the. two first
sets of symptoms, and that a knowledge of the other symptoms can be
of  no use to the physician.  To this it may be answered, that these
symptoms may throw light on some of the functions, they may assist
in ascertaining the nature of the disease, and consequently the proper
remedies.  But should they serve none of these purposes, it is neces-
sary to  be acquainted with them, that their  appearance may not dis
concert us, and because it is possible that as our knowledge extends,
an acquaintance with them may prove more useful.
   Those whose  observations have served most to  advance the know
ledge of diseases, have accurately observed and recorded every fact
which presented itself.  And many facts which appeared useless have,
in a more advanced state of science, served to point out distinctions
and analogies, which coqld  not have suggested themselves to the first
observer. 
2                      INTRODUCTION.
  Of the  foregoing sets of symptoms, that which forms the  diagnosis
is the  most important.   The diagnostic symptoms of diseases have
been collected into  short sentences, which have been  termed  their
characters or definitions, by means  of which the learner is assisted in
acquiring the  power of distinguishing  them ;  and for the purpose of
farther aiding the memory,  these characters have been variously ar-
ranged, or digested into systems.
  The general  principle on which such  systems are constructed is
very simple.   From the symptoms common to the characters of those
diseases  which resemble each  other, a  general  character is formed,
under  which  the particular characters  are  arranged,  and which is
termed the character of  the order.   And in like manner from the
characters of several orders, having certain symptoms in common, the
character of a class including these  orders is  formed.   Thus diseases
are arranged under  classes, orders, and genera.  The  genera being
occasionally divided into species and these into varieties.
  There are two things then aimed at  by the nosologist; the first, to
give an  accurate character of each disease, by which is meant, (as
appears from what has just  been  said) not an account of all the symp-
toms, not a description of the disease as it really appears,  but  merely
an enumeration of a certain  set of  its symptoms, which either at the
same time or in succession constantly attend it, and distinguish it from
others.—The second thing aimed at by  the nosologist is to arrange the
characters of diseases methodically, that is,  in such a way as best
assists  the memory.  In each we shall find  difficulties which appear
to be unsurmountable, so that a perfect system of nosology is not to
be  expected ; but we have reason to believe that there is  still much
room for  improving our present systems.
  Dr.  Cullen's  system,  both in its arrangement  and definitions, so
much excels those which preceded it,  that it will be unnecessary to
take particular notice of any other.*   He divides all  diseases into
four classes, Pyrexiae, Neuroses, Cachexia?,  and  Locales.  The dis-
eases arranged under the first class are those  I am  to treat of.  Il
comprehends all  febrile  diseases.  These he divides into five orders,
Febres,  Phlegmasiae,  Exanthemata,  Haemorrhagiae, and  Profluvia,
The class he defines,
  " Post  horrorem pulsus   frequens, calor  major, plures functiones
" laesae, viribus  praesertim artuum  imminutis."!

  * The reader will find a short view of die nosological systems of Sauvages,
Linnams, Vogelius, Sagare, and M'Bride, in the first volume of Dr.  Cullen'a
Synopsis JVosologite Methodic*.
  t Characters of diseases are  generally expressed in Latin,  because  it 1^ 
                       INTRODUCTION.

  The first order arranged under it (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? functione; sanguis missus, et  jam  concretus, superficiem
" coriaceam albam ostendens.".
  The third order (the Exanthemata) Dr. Cullen defines,
  "  Morbi  contagiosi,  semel  tantum in  decursu titae  aliquem affi-
" cientes; cum febre incipientes ; definito tempore apparent phlogoses,
" saepe plures, exiguae per cutem sparsae."
  His definition of the fourth order (the Haemorrhagiae) is,
  "  Pyrexia  cum  profusione sanguinis  absque vi externa ; sanguis
:( missus ut in phlegmasiis  apparet."
  The last order (the Profluvia)  is defined,
  "  Pyrexia cum excretione aucta, natural iter non sanguinea."
   Such is Dr.  Cullen's mode of arranging febrile diseases.  I shall
here point out in what  I mean to deviate from it, and my reasons for
doing so ; which will make the reader acquainted with the plan to be
pursued in the following work.
   The orders arranged under Dr. Cullen's class of Pyrexiae materially
differ from each other in the following circumstances  :
  The fever  in two of these orders (the Febres and Exanthemata)
i$ strictly idiopathic.   It is  true  indeed that  local  affections accom-
pany the  Exanthemata ; but these appearing a considerable time af-
ter the commencement of  the fever, cannot be regarded as its cause.
Besides, its degree is not at all proportioned to that of the local affec-
tion ;  in some  instances  so much  the contrary, that the more con-
siderable the local affection, the milder is  the  fever.   This is the case
in the plague and the simple scarlet fever ; nay, where certain causes
conspire to prevent the fever, the  local affection, of the Exanthemata
often exists, 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 generally 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  others.  So far indeed is the
local affection from occasioning  the fever,  that the  latter generally

difficult to remember accurately what is expressed in the language ejnployed
for the common purposes of life ; we are apt to change the mode of expres-
sion, and consequently often  the meaning. 
4
INTRODUCTION.
suffers an abatement, and  is sometimes wholly removed, on the ap-
pearance of the eruption.
   In the Exanthemata then, the fever is as  truly an idiopathic affec-
tion as in fevers properly so called ; and in  laying down the practice
in those diseases 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 Phlegmasia,
Haemorrhagiae,  and  Profluvia)  the fever always accompanies some
local affection ; being not only proportioned  to it, but varying in kind
as the local affection  varies; and the  principles on which the practice
in these orders of diseases is  conducted, are so modified by this cir-
cumstance^ 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 disease ; in the
other, merely the consequence of some local affection.  In the former,
our whole attention is  directed  towards removing the  febrile symp-
toms ;  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 fever which attends it.
   These  circumstances considered,  does  it  not appear a  necessary
alteration of Dr. Cullen's mode of arranging febrile diseases, to divide
his Pyrexiae into two classes, the idiopathic,  and symptomatic fevers ?
   To arrange the Phlegmasiae after the Febres, and before the Exan-
themata, (diseases so much allied to the  Febres) and after considering
the Exanthemata, to  return to the Haemorrhagiae and Profluvia (diseases
in their nature so nearly resembling the Phlegmasiae) tends  to perplex
our ideas of the different orders of the Pyrexia.
   Dr. Cullen and other  systematic writers seem to have  adopted this
mode of arrangement, either because they regarded the Exanthemata
as diseases  compounded of the  Febres  and Phlegmasia, and conse-
quently considered it proper to treat of both the latter sets of diseases
before the former ; or they thought that their  account  of the inflam-
matory affection which  appears in  the Exanthemata, would be more
readily understood after treating of the Phlegmasia? ; and thus repeti-
tion 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 Phlegmasiae we mean any thing more than a local affec-
tion, (as will presently  more plainly appear) and.may lead to errors
in practice. 
                       INTRODUCTION.                      6

  The  latter seems a  better argument ;  for almost every thing we
say, when  we  describe the Phlegmon in the small-pox, for instance,
must be repeated in describing Dr. Cullen's first genus  of  the Phleg-
masia, the PWogosis.   This objection, however, is less  in a system of
practice, than in a nosological system.  In the former, for the sake of
perspicuity, nearly the same description  of the eruption in the  Exan-
themata is necessary, whether the Phlegmasia have been  previously
considered or not.
  Here then on each side we find an obstacle opposed to our advance-
ment in nosological accuracy: a probable  inference from which is,
that we are not proceeding on a proper plan.  The  errour seems to be,
that we are considering the  more complicated, before we have treated
of the  more simple diseases.
  Not  only the Parexia?, but the Neuroses and Cachexia?, ought to be
placed after the affections which are merely local, by far the greater part
of which are  constantly occurring in the general and more complicated
diseases.
  In the class of local diseases,  there should be an order for simple
inflammations, for such  inflammations as are not attended by fever, as
pimples", and that  habitual and superficial  redness of the face  and
hands which never produces fever.   Such an order indeed, would in-
clude some diseases of importance, certain species  of Ophthalmia,  for
instance,  and the Aphtha?  Infantum.   No  symptom of these is men-
tioned  in Dr. Cullen's definition of Pyrexia.  They might 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  the same rea-
sons, therefore,  for treating of simple inflammation before  the Phleg-
masia, which have induced nosologists to  arrange the latter before the
Exanthemata.   But the Exanthemata  also are compounded of simple
inflammation  and fever, not of Phlegmasia? and fever.   When  a
Phlegmasia supervenes on an Exanthema, the combination is of quite
a different nature from that of the primary fever of  the Exanthe-
ma  and the simple inflammation  which succeeds it.
  There is no better reason then (resulting merely from a view of the
diseases themselves) for arranging the Phlegmasia before the Exanthe-
mata,  than for  arranging  the Exanthemata before  the Phlegmasia.
But since in  both two more simple affections are combined,  these
should   be  considered  before either.  And since  in the Exanthemata
the  fever is idiopathic,  they should be arranged with other idiopathic
fevers, and consequently before  the Phlegmasia.
  Dr. Cullen is led into several  difficulties by treating of the Phleg- 
 (i                     INTRODUCTION.

 masiae  without  having previously  considered  simple inflammations*
 In the definition of the Phlegmasia?, Phlogosis is mentioned ; but
 Phlogosis is a genus of this order, so that this disease is arranged under
 an order, of whose definition it  forms  a part; as if we were to define
 the  Exanthemata,  fever attended  with  eruption,  and then arrange
 eruptions as a genus of the order.   Besides, Phlogosis is the name of a
 disease, and is here used before the disease has been defined.
   Dr. Cullen perceived the difficulty ; it  is one indeed which  it was
 impossible for him not to perceive, and,  in order to make it less ap-
 parent has recourse to  a degree of obscurity.   In the  definition of the
 Phlegmasia he says, " Febris  synoeha, phlogosis,"  &c. evidently im-
 plying by Phlogosis, nothing more  than a simple external inflamma-
 tion, 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 ; rf 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 disease not
 to be found in his nosology.
  The same circumstance forces him into an errour of no less  conse-
quence, in his definition of the Exanthemata.   There  again the  want
of a term expressive of simple inflammation recurs,  and he is again
obliged  to employ Phlogosis,  which  he  has defined to be a  febrile
disease.   Phlogosis is an  external  inflammation  occasioning,  fever ;
the eruption in the Exanthemata, instead  of occasioning, usually even
 relieves  it.
  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  although the sixth or seventh part  of the
whole nosology,  stands in his system as in  a parenthesis.
  He would not have been obliged to confound in one class, diseases
so different as idiopathic and symptomatic fevers, which he certainly
would have avoided, had not his mode of arrangement rendered it ne-
cessary to place the Phlegmasia before the Exanthemata, which could
only be done by making one class of all kinds of fevers.
  He would not have been obliged either  to exclude from his system
the simple inflammations, or to arrange the genera of this order among
febrile diseases.*   He would not have found  it necessary to employ

  *  Dr. Cullen might have formed an order in the Locales for simple inflam- 
INTRODUCTION.                     7
the name of a disease before he had denned it, nor run into the inaccu-
racy of arranging as a genus under an order,  a disease 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 noso-
logy, would have admitted of a more systematic arrangement.
   Such are the circumstances, which have induced me to divide  Dr.
Cullen's Pyrexia?  into two classes, the idiophathic and  symptomatic
fevers.   I am now to make a few nosological  observations on  each of
these classes.
   The former, I have already had occasion to observe, comprehends
only two of the orders of Dr. CuUen's Pyrexiae, the first and third,
the Febres and Exanthemata.  In every febrile disease, which  can-
not be referred to one of these orders, the fever,  we shall  find,  must
be regarded as symptomatic.
   However different the symptoms which distinguish the different ge-
 nera 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 ifc
 endeavour to determine what these symptoms are.
   We are informed by Van Swieten, that Boerhaave, with much la-
 bour, collected from a great variety of authors, all the symptoms 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 of fever, so short.  It was reduced
 to the three following, shivering, or as it has been termed rigours, a
 frequent pulse, and heat.
   But it may be observed that no one  even  of these symptoms con-
 stantly attends fever.  The shivering is almost always confined to the
 commencement of the fever, or to that of its exacerbations, and some-
 times is not observed at all—Both Boerhaave and his commentator al-
 low, that  although the shivering is present at  the commencement of fe-
 ver, when arising from an  internal cause, such as contagion, 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.
    Many of the ancients,  although  they did  not  wholly overlook the
 state of the  pulse, as appears from  several passages in  the works  ot
 Hyppocrates, seem to have regarded the last of the  three symptoms

 mations; but introducing them into any part of his system after the Phkg-
 masis, would have only rendered the difficulty of forming an accurat  defeu-
 tionofthe Phlegmasia the move apparent.  The only means of avouhng *e
 difficulties which have been mentioned, seem, to be making the Locales the
 first class of diseases. 
 8                     INTRODUCTION.

just mentioned (the increase of temperature) as that which constitutes
fever.
   It is well known, however, that in certain kinds of fever the tempe-
rature of the body often falls below the natural standard.   In the com-
mencement 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  nerv-
ous fever.   The shivering, or sense of cold, then, and  increase  of
temperature, are symptoms, not only  not present at every period  of
these diseases, but even not 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, for although a  frequent pulse is the most constant of all the
symptom's of fever, it is not universally present in this disease ; in ma-
lignant fevers the frequency of the pulse  is often observed to be no
greater, and sometimes considerably  less, than natural.   It has been
found to beat only 40, sometimes only 30, times in a minute.   Besides,
by considering fever as present wherever the frequency of the pulse is
increased,  we class together the most dissimilar affections.  With fe-
ver, for instance, we must class palpitation of the  heart.
   The inference from these observations is plain, that no one symp-
tom can be regarded as characteristic of fever.  We ascertain its pre-
sence, not by attending to any one, but several, of its  symptoms.   In
selecting the train of symptoms which characterise it,  there  is  much
difficulty.  'The following  is the selection made by Dr. Cullen  ; lan-
guor, lassitude,  and other signs of debility, followed by Pyrexia (that
is, by rigours, frequent pulse, increased heat, and derangement  of the
functions, particularly a want of vigour in the limbs,) without any pri-
mary 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 difficul-.
ty of the subject.  The most exceptionable part  is  the  definition ol
Pyrexia contained in it.
   Fever, it has just been observed, is not always attended by rigours ;
even increased heat is not uniformly present during its progress.  In-
Creased heat, however, it is necessary to retain as a part of the  defini-
tion of fever, since it is very generally present, and the frequent  pulse,
without increased heat, often attends  diseases of a very different na-
ture.  The derangement of the functions, particularly the debility of
the limbs, does not very properly  enter into the definition; since the
derangement of some of the functions is observable in almost all dis-
eases,  and the derangement particularly specified (the debility  of the
limbs) is frequently absent in fever, in which indeed the vigour  of the 
INTRODUCTION.
S
wbole system is often preternaturally increased.  For  it is to be ob-
served,  that by Pyrexia in this definition, Dr. Cullen does not mean to
express  the symptoms of the commencement of fever only.
 ' Having arranged under the term Pyrexia so many diseases, Dr. Cul-
len found  it necessary so to define this word as to express the  charac-
teristic features of a great variety of diseases.   If we lay aside the
term Pyrexia, (not attempting to class together so many) we  shall con-
siderably  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 of  fevers that of Pyrexia,.
By arranging separately the idiopathic and symptomatic fevers,  we
get rid of this embarrassment.  Idiopathic fevers, as far as I can judge,
may be defined as follows :—Pragressis languore, lassitudine, et aliis
debilitatis signis ;  pulsus frequens, calor auctus, fine morbo locali pri-
mario.  This is the definition of Dr. Cullen's first order  of the Pyrexiae,
with this  change, that pulsus freqnens, calor auctus is inserted, instead
of Pyrexia.  He uses the  definition as the character of an order, only
comprehending fevers properly so called.  I shall use it,  with this al-
teration, as the character of a class, comprehending both fevers properly
so called, and the Exanthemata.
 •   Under this class may be  arranged three orders; Intermitting and
Remitting Fevers  ; Continued Fevers ;  and the Exanthemata.
   Dr. Cullen gives the following definition of intermitting and remit-
ting fevers ::—*' Febres miasmate paludum orta?, paroxysmis pluribus,
" apyrexia, saltern remissioneevidente, interposita.cum exacerbatione
 " notabili, plerumque cum horrore, fedeuntibus, constantcs ; paroxys-
 " mo quovis die unico tantum."
   In this definition Dr. Cullen,  very properly, I think, includes both
 intermitting and remitting fevers; because (as he observes)  they arise
 from the  same cause,  are cured by the same means,  and in the same
 person  the fever often changes from  the one form to the other.
   " Paroxysmo quovis die unico tantum" seems exceptionable as both
 hi  intermitting and remitting fevers, there are, often two paroxysms in
 the same  day.  Dr. Cullen appears to have introduced this  part of the
 definition to assist in forming a diagnosis between this set of fevers, and
 those termed-continued.   It gives very little assistance,  however, we
 f-hall find, towards this diagnosis, nor is  such a diagnosis so  necessary,
 as at first sight it may appear.
   With this exception, Dr. Cullen's  definition of intermitting and re-
mitting fevers appears to be  extremely  good,  and sufficient,  we shall
find, without the objectionable part to dNinguhh'thc  fevers arranged
under it.   It ic ^mpl;1 nod short, ruv.1 at onct  din ."*-   the attention to 
10                     INTRODUCTION.
  the leading features of the disease.   The species and varieties  of this
  order I shall presently have occasion to consider at some length.
    The second order of idiopathic fevers, that is, the second section of
  Dr. Cullen's first order of the Pyrexia, (continued fever) he defines,
  " Febres sine intermissione, nee miasmate paludum ortae, sed cum re-
  " missionibus et exacerbatoribus, parum licet notabilibus, perstantes,
  " paroxysmis quovis die  binis."
    The latter part of this  definition,  "paroxysmis quovis die binis,"
  must be regarded as  exceptionable, this circumstance being seldom
  distinctly observed in continued fevers.
    Dr. Cullen observes, that since continued fevers consist of repeated
 paroxysms, it may sometimes be difficult to distinguish them from re-
 mitting fevers ;  and this difficulty  may seem increased by the change 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 of the degree and length
 of their remissions.  There is no symptom of the one, which does not
 occasionally attend the other.  In this, however, and similar difficul-
 ties, we shall find, that when the symptoms of two diseases impercepti-
 bly run into each other, the same is true of the modes of practice suit-
 ed to them ; so that a  perfect diagnosis between them is  unnecessary,
 for nosology derives all its importance  from its being subservient to
 practice.
   The ancients (Dr. Cullen  remarks) mention fevers,  in  which there
 was no appearance of remissions throughout their whole course.   Such,
 however, are seldom if ever observed.   It is  therefore to fevers with
 slight remissions, that we apply the term continued.
   Continued fevers have long been divided into acute and chronic ; and
 many disputes have arisen concerning this division.   In  acute fevers
 the symptoms are  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 thi?
 period to sixty days ; and Galen divides the acute fevers into  acute,
 which extend to any day between  the seventh and the twentieth  day ;
 and peracute, which terminate before or on  the  seventh.   The  pera:
 cute, he subdivides into exactly peracute, which are not protracted be-
 yond the fourth day; and  not exactly peracute ; which extend to the
 seventh.   The acute he in like manner subdivides into, exactly acute,
 which  terminate on the  fourteenth  day;  and  not  exactly acute,
 which  are  protracted to  the twentieth.  All  these days,  we  shall
find, were regarded by the ancients  as chief critical days.*  The?r
divisions are altogether arbitrary, and of no use in practice.
  * Days on which the great changes offerers most frequently lmnpen. 
INTRODUCTION.                    n
  The division of continued fever into Inflammatory and Nervous, or,
as they have been termed, Synocha and Typhus, .is one of more con-
sequence, and  at present  more generally adopted by physicians.   It
points out the only species of continued fever, which can be well de-
fined ;  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 pluri-
" mum auctus, pulsus frequens, validus, et durus, urina rubra, sensorii
" functiones parum turbata."   Many objections might  be made to
this definition, but it would be difficult to give a better.   In forming it>
Dr. Cullen chiefly kept in view the circumstances  which distinguish
this species of fever from the Typhus;  and he rather gives the symp-
toms of the more strongly marked cases ©f  Synocha, than of Synocha
in general.
  The same observation applies to the definition of Typhus. " Morbus
** contagiosus,  calor pamm auctus, pulsus parvus, debilis, plerumque
" frequens, urina parum mutata, sensorii functiones plurimum turbata,
" vires multum imminutae."—Nor does  it seem possible to avoid this
inaccuracy, since as Synocha  and Typhus insensibly run into each'  -
dther, it is only in the more strongly marked cases, that they can Well
be distinguished.
  A simple Synocha or Typhus is a fever which we rarely,  if ever,
meet with.   For however high the inflammatory symptoms at an early
period, those of Typhus always, at least in this country, sooner or la-
ter supervene; and however well marked  the symptoms  of  Typhus
may be in the progress of fever, in almost  every case the first  symp-
toms are more or less inflammatory.
  On this account Dr. Cullen makes a third species of continued fever,
which he terms Synochus; and defines,  "  Morbus contagiosus febris
" ex Synocha et Typho composita ;  initio Synocha, progressu, et ver-
" sus  finem, Typhus."
  The fevers mentioned  by  authors, under the names Synocha, and
Typhus, are in fact no  other than varieties of the  Synochus.  When
the  symptoms of debility predominate, the fever has been  termed Ty-
phus ;  when the  inflammatory symptoms  are most remarkable,  and
present through the greater part of the disease, it has been called Sy-
nods'—These varieties of continued fever  so run into each other, the
difference seeming often to depend on adventitious circumstances, that
they may properly be considered as one disease ; wonderfully varied
indeed, but between the varieties of which no well marked line can be
drawn.
  There are other varieties of continued fever, however, which in eon^C 
12
INTRODUCTION,
 respects are better marked.  Eruptions of different kinds often appear
 in this disease ;  and as they seem to modify its symptoms, or nt least,
 as each particular eruption is most apt to shew itself when a certain
 train of symptoms is present, they may serve to distinguish some varie-
 ties  of it.                                          • •       ■     -
   When physicians became acquainted with the  Exanthemata; when
 they had observed that a certain  train of febrile symptoms is always
 followed by an eruption of a particular kind, and that every one in-
 fected by a person labouring under such a fever is seized with the same
 train of febrile symptoms, followed  by the same  eruption, they seem
 to have inferred, that wherever an eruption occurs in continued fe-
 ver, preceded by, or attended with, a particular train of febrile or oth-
 er symptoms, the disease is an  Exanthema ; that it is.of a nature dif-
 ferent from that of a common continued fever;  and that when commu-
 nicated from one person to another,  it would always be attended  with
 its peculiar symptoms  and eruption, as happens  in the small-pox and
 measles.  Thus they regarded the Petechial fever, thus they still re-
 gard the Petechial fever, thus they  still  regard the Miliary, the Aph-
 thous, and several other varieties of fever as Exanthemata.
   A more  particular attention to  these diseases has long ago (at least
 in this country)  convinced  physicians of  their errour, with respect to
 the Petechial fever; and they begin to suspect it with respect to sever-
 al others, which noso'ogists 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  belongs  to
this order ;  or I may  rather say, he adduces sufficient arguments to
prove that it does not.
  " Inter medicos, specialim Viennenses, de indole morbi miliaris
 nuper acriter disputatum est; et imprimis an unquam idiopathicus, an
vero semper symptomaticus sit, certatim  quaeritur.   Quod nunquam
idiopathicus sit,  prater  opinionem medicorum, a medio seculideciny
-cptimi  in  hunc  fere diem, omnium, et contra sententiam medicorum
hujus avi quondam spectabih'um,  affirmare  non ausiin ; sed  cum ex-
perientiam in hac re ssspe  fallacerri, at medicos plerosque  iraitatonim
aervum  pecus fuisse noverim, dubitare cogor ; et, utcunque sit, mor-
bum  miliarem  plerumque  symptoniaticum fimse, ex  o^servatione
propria, per multos annos  frequonti,  certo  novi.   Nunquam  con-
tagiosum,  nee manifesto epidemicum,  quibusdam  licet  temporjbus
solito frequentiorem, vidi.   Morbis  febrilibus  quibuscunque, turn in-.
 Iimmntorits turn putrid i> aliquando adjuhgi'.ur ; in nullis tamen, nisi 
INTRODUCTION.
ia
i^gtmine   calido et  sudoribus,  praeuntibus,  ortum,  et  in  pluribus,
Kegimine temperato, et sudoribus vitatis, morbum, alias expeetandum,
prorsus vitatum observavi.  Inquibusdam corporis partibus quasi  arte
excitatum aliquoties novi.  Denique, cum contagionum  specificarum
plcrarumque indolem materia, si qua datur, miliaris nequaquam imi-
tetur, turn quod certo morbi die eruptionem non efficiat, turn quod non
semel  tantum, sed saepius in  vita?  decursu,  hominem afficiat.*   De
hujus igitur  materia? natiira specifica, vcl ad morbum quemvis idio-
pathicum gignendum apta, valde  dubito.  In hac re raccum sentientem
eXperientissimum  et  peritissimum  Carolum  White habere  milu
gratulor.   Vide White on the Management of Lying-in Women. '"J
   Dr. Cullen, to overcome the difficulty as far as possible, cousistently
with the place it holds, in his nosology, divides the miliary fever into
two varieties, the idiopathic and  symptomatic.   The former, he con-
fesses he mentions, not from his own observations? but those of foreign
writers.   All the cases of miliary fever which he himself saw, he re-
fers to the latter variety.|
   But I have found no facts in the writings'of any foreign autlior who
treats of the miliary fever, capable  of warranting 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 fever is even most apt to attack those who have formerly
laboured under it.  See Vogel de Cog. ct Cur. Morb.—I 'mow a woman who
is subject to this eruption in almost every  indisposition  under which  she
labours.
  f See Cullen's Synop. Nos. Meth. genus 32.
  i It is  when the miliary eruption is of that kind which has bfeen called
the white  miliary  eruption, that  the disease is supposed to  have the best
claim to be considered an Exanthema ; but its claim seems no better founded
than that in which the red miliary  eruption appears ; both kinds frequently
appear on the same patient at the same time.
  § The principal foreign authors I  allude  to are Hoffman in  his Opera
Physico-Medica, "Van Swieten in his Comment, in Aph. Boerhavii, Lieutaud
in his Synopsis Praxeos Medicine, De Aaen, in his Ratio Medendi, Burse-
jius in his  Institutiones Medicine  Practice, Vogel  in his work  de Cog. et
Cur. Morb. Qtiarin in his excellent  work de Febribus, Allionius in his trea-
tise de Miliarium  Origine, and Planchon in his work de la Fievre Miliaire.
The following works also, Welsch  de  Novo Puerper. Morbo, Fantonus de
Febre Miliare, Fischer de  Febre Miliare, Gastallier snr la Fievre Miliaire
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 anxious to procure these trea-
tises, as I found, after perusing what is said of the  miliary fever by a few
of the authors just  mentioned, there was little  to be  met with in  the
works ofmW-rs but  a  it-petition of the same ^serva'ions.. It must always 
14                     INTRODUCTION.
   The miliary eruption has doubtless now and then attended the pre-
 vailing 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 ren-
 der the inhabitants  of any particular neighbourhood  subject to the
 miliary eruption, while labouring under fever.  Can we suppose any
 thing peculiar in the fever produced by a fractured limb ?  Yet cases
 of this kind are often  attended by the miliary eruption.   In what fe-
 ver does it appear so frequently as in the Puerperal, between which
 and the Exanthemata there is surely very little analogy ?  This erup-
 tion in short, appears in all febrile diseases, when its peculiar causes
 happen to  have been applied.    It appears  in the  Exanthemata, the
 Phlegmasia?, the Haemorrhagiae, 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 ac-
 cidental symptom,  which is most apt to occur in fever,  but may ap-
 pear in any disease whatever.    And,  like Petechia?, it also sometimes
 appears unaccompanied by any  other disease.*
   There are nearly the same reasons for rejecting the Aphthous, as the
 miliary fever, from the number of the Exanthemata.  " I doubt, (says
 *'* Dr. Cullen) whether or not the Aphtha? ought to be arranged under
 " the Exanthemata.  Most cases of Aphtha? which I have seen (he ob-
 " serves) appeared without fever ; and if at any time a fever did at-
 " tend the Aphtha? infantum, the former generally supervened upon the
 " latter.   A fever indeed (he continues) does accompany the Aphtha
 " of adults, but this fever is of  no particular kind,  and  the Aphtha
 " generally appear towards its termination; nor as far as I know is
 " there any fever well defined, or even mentioned by medical writers,
 " which constantly attends Aphtha?."
   The Aphthae infantum is  an  idiopathic affection,  and this form of
 the disease has sometimes appeared in adults.t  But a disease unat-
 tended by fever does not certainly belong to the order of Exanthemata.

 happen that after six or  eight authors,  who have been conversant with a
 disease, have given a copious account of it, few important  facts  relating to it
 will remain to be mentioned by others.
  * SeeHuxham  on Fevers, White on  the Diseases of Lying-in Women,
 Burserius Institutiones Medicine Practice, &c.
  f Cases of this kind are mentioned by Boerhaave, by Ketelaer in his Trea-
tise de Aphthis nostratibus, Arneman in his Commentatio de Aphthis,  and
others.  Such cases however, are extremely rare.  Van Swieten lived  for ma-
ny years in a country where Aphthe were very common, yet  he never saw a
case of Aphthe in an adult not labouring under fever ; and Dr. Cullen makes
 the same observation with respect to his own experience. 
INTRODUCTION.
15
We have to consider how far those cases in which Aphtha appear in
fever deserve a place in this order.
  I have just quoted Dr. Cullen's observation, that Aphtha do not ap-
pear in a fever distinguished by any particular symptoms, as the erup-
tions in the Exanthemata are observed to do.*   They appear in all
kinds of fevers, in  the symptomatic, as well as the idiopathic.  In
many of the former indeed they are more common than in the latter.
Sydenham declares, that there is no disease  in which he found Aphtha
so common as in dysentery, and  in those fevers on  which dysentery
had supervened.  We know that this affection is one of  the most com-
mon forerunners of death in Phthisis, &c.   With what  propriety then
are Aphtha ranked among the Exanthemata ?   We shall even  find,
when we  come to  consider them more particularly, that, when atend-
ed by common continued fever, they can generally be traced to causes
different from those which produce the fever in which they occur;  very
frequently to affections of the prima? viae, or suppressed sweats.
   Dr. Cullen has also expressed his doubts  respecting the propriety of
ranking the Erysipelas among the Exanthemata ; and regards the spe-
cies which have been termed Erysipelas pestilens and Erysipelas con-
tagiosum, as  nothing more  than Typhus attended by an Erytheraatic
inflammation.
   AH the  arguments urged for the exclusion of the miliary fever  from
the Exanthemata, seem equally strong when applied to the Erysipelas^
it is not a contagious disease ; the eruption often appears, indeed, like
those just mentioned,  in contagious fevers, but it is not necessarily
communicated with such fevers.   Like the miliary eruption, it ap-
pears in various kinds of fever, in the symptomatic as well as idiopa-
thic.   External warmth and irritation are capable  of producing the
Erysipelas in the predisposed, as well as the miliary eruption.  There
is no particular period of the fever at  which the Erysipelas shews it-
self; 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 disease, in which the
same kind of inflammation appears  as in the Erysipelas, termed by
Sauvao-es and  Cullen  (for other authors  we shall find  have used the
word in a very indefinite  sense) Erythema.  The difference between
the Erysipelas and Erythema is, that in the former,  the inflammation

   *  Certain symptoms indeed  generally precede all eruptions; but in the
cases we-are at present considering, the attending  symptoms appear  occa-
sionally in all kinds of fevers, and at all periods of them. Whereas in the true
E vanthemata, the fever from its commencement i* of a peculiar ki'vJ, at leart
attended with peculiar symptoms 
16
INTRODUCTION.
supervenes on a fever ;  in the latter, the inflammation is the primaty
affection, and the fever merely  its consequence.   The  Erysipelas
seems to be nothing more than  an Erythema, supervening on any
kind of  continued fever; and as such I shall consider it along with
the other eruptions which appear in these fevers.*
   The disease I am now speaking of is Dr. Cullen's first  species  of
Erysipelas, (the Erysipelas vesiculosum) ; the disease which  he  ar-
ranges as a second species of this disease, differs from it considerably.
This he  terms the Erysipelas Phlyctaenodes.   It is the same which is
termed by Pliny,  Zoster ; by Hoffman, Zona  ignea ;  in  English the
Shingles :|  it is certainly not very properly  regarded  as a species of
Erysipelas ;  nor does its place  in a system of nosology seem well as-
certained.

  * I have arranged the Erysipelatous fever among the varieties of Synochus^
because, like those  just mentioned, it has been  arranged among the Exan-
themata ; but if the view I have here taken of it be just, and that it is so will
I 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 combination of a Phlegm-
asia and continued fever;  and it is of the combinations of Symptoms, not of
diseases, that nosology treats.  It may be  said indeed, that as  all the erup-
tions we  have been considering, occasionally appear unaccompanied by any
other disease, the same objection holds against admitting the other varieties
of Synochus into a nosological system.   And  this cannot be denied. But
most of these eruptions appear so rarely as a distinct disease, that their ap-
pearance  in continued fever, or rather the causes which produce them,  so
modify many of its symptoms without altering the nature of the fever, as w e
shall find the  appearance of the Erythematic inflammation generally does,
that it is  useful in practice to regard those combinations as single diseases.
The most methodical arrangement in a system of nosology is not always the
most useful: for another proof of which I may refer to what was said of the
definitions of Synocha and  Typhus, in which we introduce symptoms not  es-
sential to these diseases, in order to  draw a line of distinction which nature
has not made, because  the division is useful in the practice in fevers, and
still more so in teaching the principles of that practice.  It was to such cir-
cumstances I alluded, when it was  observed that a perfect system of nosology
is not to be expected.  Although,  for the reasons just given, I have arranged
the Erysipelatous fever as  a variety of the Synochus, yet we  shall find on con-
sidering it more particularly, that  it will be necessary to defer entering fully
into its treatment till I come to speak  of  the Phlegmasie ; because it  par-
takes so much of the nature of a Phlegmasia, that the principles,  on which
Lhe practice in idiopathic  fevers is conducted, will not apply to it.
  i See an account  of this disease in the  2d vol. of Burserius's  Inst. Med.
Prar. i 1 Schroeder de Feb. Hrysip. in his Opusc. Med. in Vogel's  Prelect.
\cad. de  Cog. ct Cur. Morb. and Smith's Essay on the different Species of
Inflammation, in the 2d vol. of  the Med. Communications ; eee also Russel
'lcTubc bland, p. 124. 
INTRODUCTION.                     17
  Sydenham also ranks as a species of Erysipelas, the disease  termed
Urticaria, (Dr. Cullen's 53d genus.)  This however we shall find dif-
fers essentially from Erysipelas, and seems to have a better claim to be
regarded as an Exanthema.
  Another disease to be regarded  in nearly  the same light with the
foregoing, is the Pemphigus, or vesicular fever.   There is no particu-
lar kind of fever in which the eruption appears ;  there is  no particular
period of the fever at which it shews itself.   Dr. Cullen says it appears
on the first, second, or third day ;  Sauvages observes that it sometimes
appears on the fourlh ;  and Dr. Dickson,* who seems  to be better ac-
quainted with the disease than either of these  authors,  declares it may
appear on any day.
  The cases related by Salabert, in  his Observations  des Fievres In-
flammatories, are evidently cases of common continued fever, in which
the vesicular eruption proved critical.
   The  celebrated Morton, the contemporary and rival of Sydenham,
takes notice of  this disease, but without particularly describing it.
The name by wfiich be calls it, however, seems to imply that he  re-
garded it merely  as a  symptomatic  affection, " Febris Synocha cum
" vesiculis per pectus et eollum sparsis."<
   Dr. Cullen was  but little acquainted with the Pemphigus, as ap-
pears both from what he says in a note, and from the  definition which
he gives of it, the most exceptionable perhaps in his nosology ;  yet the
knowledge he had of it led him to doubt of its being  an idiopathic af-
fection.  And  all that Burserius says in favour of its  being so is, that
we must at least allow those cases to be idiopathic, in which the erup-
tion is  unattended by  fever.  This he observes, frequently happens.
I have seen three or four cases of this kirid.t
   Like the foregoing, it is not  confined to continued fever.  We have
a remarkable instance in which it accompanied a Phlegmasia (the Cy-
nanche Maligna) in the Pemphigus Helveticus, of which there is  an
account in the  Acta Helvetica by Dr. Langhans.   Much  difference of
opinion  has arisen "among -physicians  respecting the nature of  the
disease described  by Dr. Langhans,  from  their not admitting  the
vesicular eruption to be merely symptomatic ;  for,  this granted,  the
difficulty is removed ;  we  know  that symptomatic eruptions appear
in all kinds of fever, whether idiopathic or not.

   * See Observations on Pemphigus, by Dr. Dickson, Prof, of Medicine ir.
the University of Dublin, in the Transactions of the Royal Irish Academy
for 1787-
   f See  one related by D-  Whtr-'bottom, in thi "J vol  of Medical F3ct=
and Observations, p. 10. 
w
INTRODUCTION.
   I may also add, that the vesicular eruption, like some of the other
 symptomatic eruptions, (Aphtha?, for instance) is not confined to  the
 skin, but often attacks the oesophagus, stomach, and intestines ; a cir-
 cumstance which has not  been observed of any of the eruptions of the
 true exanthemata.*  There is every reason to believe, indeed, that all
 the symptomatic eruptions, as well as the Aphthous and Vesicular, oc-
 casionally attack  the stomach and intestines.  That the Erysipelatus
 eruption does,  appears  from what Dr. Cullen  says of Gastritis and
 Enteritis.   I have myself seen this eruption spread from  the mouth and
 fauces to the stomach,  and prove fatal.  Of the miliary fever, Vogel
 observes, that the peculiar prickling felt in the skin  when the miliary
 eruption is coming out, is also frequently  at the same time felt in the
 intestines.  And with respect to the petechial eruption, from what we
 know of its nature, there is every reason to believe that it may appear
 wherever there is a lining of cuticle.
   The diseases we have been considering then, the  Petechial, Milia-
 ry, Aphthous, Erysipelatous, and Vesicular fevers,  are to be regar-
 ded  merely as  varieties of continued fever.   After treating  of con-
 tinued fever in general, I  shall consider each of them separately ; that
 is, I shall point out the forms of continued  fever in which these differ-
 ent eruptions most frequently appear, the peculiar  symptoms which
 generally attend them, the causes which produce them, and the change
 which their  appearance  renders necessary  in  the  treatment of the
 fevers in which they occur.
   Petechia?, it may be said, are improperly classed among these erup-
 tions ; being merely a symptom of debility, the consequence of mor-
 bid tenuity of the blood, and relaxation of the vessels.  This, however.
 docs not seem  to be precisely the case ; other circumstances than the
 presence of debility are requisite  for their appearance.   It often hap-
 pens in Typhus, even where the debility is extreme, that no Petechia
 appear ;  this was the case, for instance, in the jail fever of Winchester,
 described by  Dr.  C. Smith ; it  is very frequently the case  in thr
 plague.  Besides,  Petechia? are  often observed  where  there  are  no
 signs of debility whatever.   Grant, in his Treatise on the Fevers most
 common  in London, Eller,  in his Obs de Cog. et  Cur. Morbis, and oth-
 ers, relate cases in  which Petechia? attended well-marked Synocha.
   The second order of Idiopathic fevers then comprehends Synocha
 and Typhus, or  the Synochus  (for Synocha and Typhus are rather to
 be regarded as different stages of the  Synochus, than different diseas-

  * It was once supposed that the small-pox was apt to attack  the intestines ;
but since the publication of Cotunnius's Treatise de Sedc Variolarum tln<
 i'o generally admitted to have been a mistake. 
INTRODUCTION.
19
 es) and its varieties, viz. the Synochus Petechialis, the Synochus Mi-
 liaris, the  Synochus Aphthosus, the Synochus Erysipelatosus, and the
 Synochus Yesicularis ; the definitions of which will be considered when
 I come to speak of these  varieties separately.
   The third order of Idiopathic fevers comprehends the Exanthemata
 properly so called.   The Exanthemata form  the third  order of Dr.
 Cullen's Pyrexia, and are defined by him, " Morbi contagiosi semel
 "  tantum in decursu  vita? aliquem afiicientes; cum febre incipientes,
 "  definito  tempore  apparent  phlogoses,  sa?pe plures,  exiguae, per
 "  cutem sparsae."
   " Semel tantum in decursu  vitae aliquem afficientes", though  not
 strictly true  of any of the Exanthemata, and certainly very far from
 being true  of some  of them ;* yet as so  much more characteristic  of
 the true Exanthemata  than of other eruptive fevers, seems  properly
 admitted as part of the definition.
   I have already offered my  reasons for rejecting from this definition
 the term Phlogoses; in the place of which I shall use Pustulae, which
 we must suppose to have been arranged, and consequently defined,
 among the Locales,  which I have endeavoured to shew should form the
 first class of diseases.
   The following then  may be adopted  as the definition of the third
 order of idiopathic fevers ; Morbi  contagiosi semel  tantum in decursu
 vitae aliquem afficientes,  cum  febre  idiopalhica incipientes, definito
 tempore apparent pustulae, saspe  plures, exigua?,  per cutem sparsae.
 Under this order are arranged the Variola, the Varicella,  the Rubeola,
 the Scarlatina, the  Pestis, and the Urticaria.
   The  class of symptomatic  fevers comprehends the three remain-
 ing orders of Dr. Cullen's Pyrexia?, namely the second, fourth, and fifth,
 the Phlegmasia?, lIa?morrhagiae and Profluvia, and may be defined,
   Morbi locales primarii oalore aucto, puhu frequente.
   On the arrangement of this  class of diseases, a  few words will be
 efficient;  but  it will  be nece-sary to premise some  observations  on
 that of the local affections which characterise them, and which some-
 limes appearing unaccompanied by any other disease, should have  a
 place ina system of nosology.

  * Tlie plague is gewerally admitted to attack the same person repeatedly;
 and there are many well-authenticated instances on record  of all the  other
Exanthemata attacking the same person a second or third  time, or oftener.
See Burserius's Inst.  M'-d. I'rac.  Uos«;n in Mailer's Di put. ad Mor. Ilipt. et
Cur. Per. S^c. 
m                    INTRODUCTION.
             Of the local Affection of the Phlegmasia.

  Simple  inflammation is of two kinds, the one  vulgarly  termed a
pimple, the other a stain, blotch or efflorescence.—Neither is includ-
ed in Dr. Cullen's nosology.   The  former is different  from his Phleg-
mon, the latter from his Erythema,  both of which are febrile diseases.
In the nosology of Sauvages pimples are mentioned in the definition of
the Efllorescentiae, the second order of his first class, Vitio.  The defi-
nition of the order is, " Tumores humorales exigui gregales, vel cutis
" elevatio per pustulas, papulas, phlyctaenas varos, similesve  asperi-
" tates."  After  giving this definition, Sauvages begins to explain the
terms employed  in it, demonstrating the imperfection of his arrange-
ment, since pustules are not always symptomatic ;  Sagare makes them
a genus.—They  are defined by Sauvages, " Phyma parvulum apice
ruptum."   I shall adopt the term  pustule from Sauvages,  but not its
definition  for reasons which will  readily suggest themselves, as we
proceed.
   With respect to the other species of simple inflammation, it is more
difficult to find a  technical name for it, which shall be unobjectionable.
Such confusion of terms has crept into this part of medicine, that there
are no less than three different affections known by the same names, and
for each of which at least two names have been used.   Before we can
speak of these diseases,  it is necessary to know  the  meaning of the
terms we employ.  A chronic inflammation of the skin,  never  occa-
sioning fever, is  called by some  writers  Erythema,  by  others
Erysipelas, and by some  the  terms  are used  indiscriminately.---
The same terms  have  been applied often with as little discrimination
to another inflammation of the skin, which is  a febrile disease.  This
disease, (that is the inflammation  and the fever  it occasions,)  some-
times supervenes on simple  fever,  and to this combination, which I
have already had Occasion  to nention, and which we shall afterwards
consider at length under the name of Synochus  Erysipelatosus, the
same terms Erysipelas, and Erythema have been applied.
   Dr. Cullen, following Sauvages, confines the term Erythema to the
diffuse  cuticular inflammation occasioning fever.   By the term Erysi-
 pelas, we have seen, he expresses  the combination of Erythema with
 simple fever ; and with respect to simple Inflammation, as there is  no
 place for it in his nosology,  he gives it no name.  He has found much
 difficulty in his systems, both of nosology and practice, in distinguish-
 ing the Erysipelas and Erythema,  and in the  latter he is forced into a
 mode of arrangement which makes this difficulty conspicuous ; for find-
 ing that in Erysipelas, the symptoms which precede the inflammation 
INTRODUCTION.
21
of the trunk and extremeties are often hardly or not at all to be per-
ceived, so that the disease has little or no appearance of an Exanthema,
but that the preceding symptoms are generally considerable if the in-
flammation is about to appear on the face and head, the cause of which
will be evident when we come to speak of Erysipelas ; in treating of
the disease  he considers this case  alone, " I suppose," he observes,
" the  Erysipelas to depend on a  matter generated within the body,
and which analogous to the other cases of Exanthemata, is in conse-
quence of fever thrown out on the surface of the  body.  I 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 therefore consider here."   He
thus refers other cases of the disease, if they are considered  at all, to
the order of Phlegmasia?, so that if the inflammation in Erysipelas ap-
pears on  the head, the disease is an Exanthema, if on the trunk and ex-
tremeties, a Phlegmasia.*   Can this view of the subject be correct ? Be-
sides how shall we arrange the cases, in which the inflammation appears
on the head without being preceded by any febrile symptom, for such we
shall find occur.  The question then still remains, how are we to distin-
guish the diseases termed by  Dr. Cullen, Erysipelas and  Erythema,
for it is absolutely necessary to distinguish a disease evidently  refera-
ble to the Phlegmasia^, and in which the mode of treatment, we shall
find, is the same as in the other Phlegmasia?,  the fever being symptom-
atic ; from the Erysipelas of Dr. Cullen, in which the fever is idiopa-
thic,  and must, as experience has  taught, be treated as such, except as
far as it  has been modified by the appearance of the local affection.
   The only way, as far as I can judge, to remove all difficulty,  is to
give a name to the simple inflammation, which is unattended by fever,
and to the phlegmasia, the Erythema of Dr. Cullen, regarding his Ery-
sipelas as a combination of this disease and fever, which never assumes
the appearance of an Exanthema,  and to which there is no good reason
for assigning any name, we might as well give a  name to the combina-
tion of Erythema, and worms.   According to this view of the subject,
I shall term the simple inflammation Erythema, and the phlegmasia,
Erysipelas ;  the latter term will then be confined to the cases in which
the local affection is preceded either by no symptoms of general de-
rangement, or by such as frequently precede the local affection in the
other phlegmasia?.
   In  looking over the nosological system of Sauvages, Linnaus, Voge-
lius, Sagare, Mc. Bride, and Cullen, we find the  second species  of sim-
ple inflammation mentioned as a genus  only by Sagare.  The Bacchia

       * See Dr. Cullen's observations on Erythema,  in his First Lines. 
22
INTRODUCTION.
 of Linnaeus, Encausis of Vogelius, and Psydracia of Sauvages, seem to
 include it but not very accurately.
   Sagare terms it Bacchia,  it is his ninth genus and the fourth of the
 order, Effiorescentice.   The  following is the definition of  the genus,
 which is as readily  understood without as  with that of  the order.
 " Macula? rubra? vet efflorescentia nasi et partium adjacentium erdem,
 guttata?, plus minus prominentes, aspera? furfurascentes, diuturna ; hoc
 genus ambigit inter maculas et efBorescentias."
   This definition does not very accurately apply to the inflammation
 we are speaking of, in which the surface is  uniformly smooth.   Such
 an inflammation, as Sagare here describes, frequently occurs, but were
 we to rank as a distinct genus, every cutaneous  inflammation which in
 any  respect differs from every other, instead  of two we might have fif-
 ty diseases of this kind.  Our intention in a general system of Nosolo-
 gy,  is tully answered by dividing simple inflammations into two spe-
 cies  which comprehend all the others, if indeed there are any others
 well defined.
   The  Pustule  and the Erythema,  are distinguished in the following
 manner.
   In the former there is an evident swelling rising in the shape  of a
 cone, the apex of which is sooner or later formed  into a small cavity,
 filled with yellow matter  called pus.—In the Erythema  there  is no
 swelling of this kind, although some general swelling of the part it occu-
 pies  ib always more or less observable ; the surface  is uniformly smooth,
 there is no sudden elevation of the  cuticle and pus is never formed.
 Of both, redness is a characteristic  symptom, but in the former it ex-
 tends only to the little cone, and a short way around its base ; in the
 other it is more diffuse, frequently spreading  over the face and hands,
 the parts most frequently occupied by it, in a perfectly uniform manner.
 In both, the temperature is. increased.  They also agree in  being fre-
 quently attended with some degree of pain, although this is  by far the
least constant symptom.  In the Pustule it is more obtuse and pulsatory,
 in the Erythema often stinging.
  All inflammations then, for as I have just  had occasion to observe,
 they are all included  in thpse, agree in being attended with redness,
 increased temperature,  pain and swelling.—These symptoms  may
 therefore be assumed as the character of simple  inflammation, forming
 an order of the Class Locales.   " Nota? vero inflammationis,"  Celsus
observes, " sunt quatuor,  Rubor et Tumor  cum Colore et Dolore."
The  genera arranged under this order then are tlie Pustule and the Ery-
thema, the former may be defined,
  Inflammatio tumore  circumscripta, in  fasti^ium  tlcvato, sa?pe in
apostema abeunte.—The latter* 
INTRODUCTION.
23
  Iaflammatio rubore uniformi seTpente, tumore partis  saepe vix  evi-
dente.
  As species of these should be arranged, (as has been observed above,)
some diseases  which Dr. Cullen, from the waut of such an order, air-
ranges  among the Pyrexia?.
  The local affection in the Phlegmasia?, we shall find, does not differ
in its nature, but only in degree, and the parts of the body it occupies,
from simple inflammation.

    Of the  Local Affections of the Hemorrhagic; and Profluvia.

  The local affections of these, as of the Phlegmasia, occasionally ap-
pear unaccompanied by fever.  The local affection of the one consists
of a flow of blood, of the other of ah increase of some colourless  secre-
tion ; and it is common, whether fever attetid or not, to call the disease
Uamorrhagy, catarrh, &c.
  In a strict nosological point of view, however, the same observations
apply  to these affections  as to Inflammationsv-^They frequently  exist
without fever, and should therefore have appellations, and a place in
nosological systems to distinguish them from febrile diseases ; and when
the reader  is  informed, that the plan of treatment when they are, and
are not febrile diseases, is very different, he will be surprised that this
distinction  has not been generally made.
  To avoid the introduction of new terms,  I shall use Hemorrhagy and
Profluvium to express the local affections, and to express the more com-
plicated diseases, Febrile Hemorrhagy and Febrile Profluvium.  These
local affections, belong to the fourth order of Dr. Cullen's last class,  Lo-
cales,  which  I have given my reasons for thinking ought to be the first
in a system  of  nosology.  The order termed Apocenoses is defined,
" Fluxus sive sanguis aut humores alii, solito uberius profluens, sine py-
" rcxia, impetuve fluidorum aucto."
   Hemorrhagy is his first genus which he terms profusio, and defines
" Fluxus sanguinis."-   For the local affection which I term profluvium,
he has no  given term,  his mode of arrangement not requiring such n
term.   He arranges its different species as  genera.  It may be defined,
Rxcretio aucta naturahter non rubra.
  Such arc  the observations which it seemed necessary to premise
respecting  the local affections of symptomatic fevers, previous to con-
sidering the definitions and nosological arrangement of those diseases.
  Dr.  Cullen's definition  of the first  order of symptomatic fevers, the
Phlegmasia?, (the second order of his Pyrexia,) haF.btcii given.
  According  to the arrangement I have adopted. Ibis deflnition must \>c
made to include  that of the cla- of wHirh it '   m order : '-irnl f think 
24
INTRODUCTION.
there  are  several reasons for  rejecting the  latter  part of it, namely,
" Sanguis missus et jam concretus superficiem coriaceam albam osten-
dens."  The appearance of the buffy coat  on the blood does not, we
shall find, uniformly indicate the presence of inflammation.   Besides,
although it were a certain diagnostic, it should not enter into a  nosolo-
gical character, because its existence can only be ascertained after we
have prescribed the remedy.   I have already given my reasons for
rejecting the term Phlogosis.
  But as the other parts of the character are not always, though gene-
rally, sufficient for distinguishing  the diseases  arranged under  it, I
would propose, instead of  sanguis missus,  &c. to insert pulsus durus,
which at least as constantly attends the.Phlegmasiae, as the buffy coat
of the blood.   Febris Synocha is also perhaps  exceptionable, as we
shall find that in certain species of Phlegmasia?, the fever is Typhus ;
for example, in the Pneumonia Putrida of foreign authors, and the Cy-
nanche Maligna.   In the Gastritis and Enteritis too, notwithstanding a
degree of hardness in the pulse, the fever certainly partakes more of the
nature of Typhus than of Synocha.   There is  an  evident inaccuracy
in admitting Synocha,  into the definition of an order, when we find it
necessary in several  of its genera to call the fever Pyrexia typhodes.
As far as I can judge, pulsus durus answers every purpose which Syno-
cha can serve, in this definition, and it seems proper for other  reasons
that pulsus durus should form a part of it.  .
   I would propose the  following definition of the Phlegmasia :  Febres
symptomatica?, pulsu duro ; quibus est promorbo locali, vel inflamma-
tio externa, vel dolor topicus simul laesa partis interna? functione.   Still
supposing  simple inflammation to have been defined in the class Lo-
cales.*
   The Haemorrhagia? (the fourth  order of Dr. Cullen's Pyrexia) form
the second order of symptomatic fevers.
   " Sanguis missus ut in Phlegmasiis apparet," cannot here be ob-
jected to, for the same reason that " Sanguis missus et jam,"  &c. was
omitted in the last definition.  But as the buffy coat is not always ob-
served in Hemorrhagies, and indeed may be regarded as belonging on-
ly to a particular species of them, as its degree is regulated by a varie-
ty of accidental circumstances, and as the definition, without this addi-
tion,  is sufficient to distinguish the diseases arranged under it,  it seems
better to omit it.  It is also necessary to alter the definition, in order to
suit it to the general mode of arrangement I have adopted.   It may be

  * Before entering on  the consideration of the Phlegmasise, it will be nc
cessary to make some observations on the simple inflammations. 
INTRODUCTION.
26
expressed in the following manner, Febres symptomatica, quibus est
pro morbo locali, sanguinis fluxus absque vi externa.
  The definition of the Profluvia^ the third and last order of symptom-
atic fevers, (the last order of Dr. Cullen's Pyrexia) requires no farther
alteration than the mode of arrangement  I follow renders necessary ;
Febres symptomatica?, quibus est pro morbo locali, excretio aucta na-
turaliter non rubra.!
   Such is the mode of arrangement which I mean to adopt.  It may
be proper to present it to the reader at one view.

  | I have changed sanguinea for rubra, because the menstrual discharge,
though red, does not appear to be blood, but like all other healthy discharg-
es, a secretion.  When it is much increased, however, it seems always to be
mixed with a large proportion of blood, and the disease, therefore, belongs
rather to the Hemorrhagies than Profluvia.
                    ARRANGEMENT

                           OP

            FEBRILE  DISEASES,

                       AND OF THE

                 LOCAL AFFECTIONS,

      WHICH CHARACTERISE CERTAIN SPECIES OF THEM,  J



                     CLASS1S  I.
                       LOCALES.
                        ORDO I.
                   1NFLAMMAT1Q.

          Partis rubor et tumor cum calore et dolore.
                   GENUS I.—Pustula.
Inflammatio tumore circumscripta in fastigium elevato, sa?pe in
ostema abeunte. 
26
INTRODUCTION.
                    GENUS 2.—Erythema.
  Inflammatio rubore  uniformi serpente, tumore partis saepe vix evi-
dente.
                         ORDO II.
                       APOCENOSES.

  Fluxus sive sanguis, aut humores alii, solito uberius profluens, sine
pyrexia impetuve fluidorum aucto.
                  GENUS  l.—Hcemorrhagia.
  Fluxus Sanguinis.
                    GENUS 2.—Profluvium.
  Excretio aucta naturaliter non rubra.*

                        CLASSIS II.

                FEBRES IDlOPATHLCM.\

  Pragressis languore, lassitudine, et aliis debilitatis signis ;  pulsus
frequens, calor auctus, sine morbo locali primario.

                          ORDO I.

  FEBRES INTERMITTENTES ET REMLTTENTES.

  Febres idiopathica, miasmate  paludum orta, paroxysmis pluribus,
apyrexia, saltern remissione evidente,  interposita, cum exacerbatione
notabili, et plerumque cym  horrore redeuntibus, constantes.

                          ORDO II.

                   FEBRES CONTINUJE.

   Febres idiopathica sine intermissione, nee miasmate paludum orta
sed cum remissionibus et exacerbationibus, parum  licet notabilibus,
perstantes.
                     GENUS l.—Synoclut.
   Calor plurimum auctus, pulsus frequens, validus et durus, urina ru-
 bra, sensorii functiones parum turbata.

  * I here of course,  enter no farther on  the Class Locales, than it  is con-
nected with febrile diseases.
  f A single word would be preferable to the circumlocutions Febris Idiopa-
thica and Febris Symptomatica, but I wished to  avoid  the introduction of
 rie\v terms. ' '. 
INTRODUCTION.                   2t
                     GENUS 2.—Typhus.
  Morbus contagiosus, calor parum auctus, pulsus parvus, debilis, ple-
rumque frequens, urina parum mutata, sensorii functiones plurimum
turbata?, vires multum imminutae.
                    GENUS 3.—Synochus.
  Morbus contagiosus, febris ex  synocha et typho composita; initio
synocha, progressu et versus finem, typhus.
           Species 1.—Synochus Simplex.
           Species 2.—Synochus Petechialis.
           Species 3.—Synochus Miliaris.
           Species 4.—Synochus Aphthosus.
           Species 5.—Sijnochus Erysipelaiosus.
           Species 3.—Synochus Vesicular is.*

                          ORDO  III.

                     EXANTHEMATA.

   Morbi contagiosi, semel tantum in decursu vita aliquem afficientes,
 cum febre idiopathica incipientes ; definito tempore apparent pustula?
 saepe plures, exigua, per cutem sparsa.
                     GENUS \.—Variola.
                     GENUS 2.—Varicella.
                     GENUS 3.—Rubeola.
                     GENUS 4.—Scarlatina.
                     GENUS 5.—Pestis.
                     GENUS 6.—Urticaria.

                        CLASSIS III.
                 FEBRES^SYMPTOMATICJE,

  . Morbi locales primarii, calore aucto, pulsu  frequente.

                           ORDO I.

                       PHLEGMASIJE.

   Febres symptomatica, pulsu  duro; quibus  est pro morbo locali, vel
 inflammatio externa, vel dolor topicus simul la?sa partis interna? func
 tione.
                     GENUS   1.—Phlegmon.
                     GENUS  2.—Erysipelas.
   * The definitions of those species and of the following genera, dull bt
 considered when I come to treat of them .eparately. 
2d
INTRODUCTION.
                   GENUS  3__Ophthalmia.
                   GENUS  4.—Phrenitis.
                   GENUS  5.—Otitis.
                   GENUS  6.—CynancJie.
                   GENUS  7.—Pneumonia.
                   GENUS  8.—Carditis.
                   GENUS  9.-^Peritonitis.
                   GENUS 10.—Gastritis
                   GENUS U.—Enteritis.
                   GENUS 12.—Hepatitis.
                   GENUS 13.—Splenitis.
                   GENUS 14.—Nephritis.
                   GENUS 15.—Cystitis.
                   GENUS 16.—Hysteritis.
                   GENUS 17.—Rheumatismus.
                   GENUS 18.—Podagra.

                         ORDO II.

                    HEMORRHAGIC.

  Febres symptomatica, quibus est pro morbo locali, sanguinis fluxus
absque vi externa.
                   GENUS l.—Epistaxis.
                   GENUS 2.—Hcemoptysis.
                   GENUS 3.—Hcemorrhoh.
                   GENUS 4^—Menorrhagia.
                   GENUS 5.—Hamatemesis.
                   GENUS 6—Hematuria*

                         ORDO III.

                       PROFLUVIA.

  Febres Symptomatica; quibus  est pro morbo locali, excretio aucta
naturaliter non rubra.
                   GENUS 1— Catarrhus.
                   GENUS 2.—DysenteriaA

  * The Haematemesis and Hematuria, regarded by Dr. Cullen as always
symptomatic, are sometimes,  though rarely, idiopathic. I have seen the
Hematuria idiopathic.  The Cystirrhagia (his last species of Hemorrhagy)
is never perhaps idiopathic.
 "t At the end of the work we shall be enabled to take a more detailed view
of that part of a nosological  system which  comprehends febrile diseases,
when we shall have considered their definitions and  varieties. 
INTRODUCTION.
29
                              A

     NOSOLOGICAL  ARRANGEMENT

                              OF

                     DISEASES.:

                 BY NATHAN SMITH,  M. D.

  Nosological writers, have generally adopted the plan of natural his-
torians.   This method, though  it may have some advantages in  ar-
rangement, is defective in many respects.   Natural history, treats of
things which have permanent characters, remaining the same under
all varieties of circumstances, and is chiefly employed about obvious
qualities.  Nosology, treats of  the changes  which take place in or-
ganized bodies; always  varying and never remaining  the same for
any  length of  time.  The difference in the  objects, in  these two de-
partments of science,  is so great, that we  should hardly expect the
same scheme of arrangement would be equally applicable to both.
 - Though Nosological writers have adopted  the plan of natural histo-
rians, yet in making out their arrangements and dividing diseases into
classes, orders, genera, and species, they have been governed by prin-
ciples somewhat  different; some having arranged them according to
their symptoms, or more obvious appearances ; while others have had
more regard to the causes which excited  the disease, and others have
chiefly  regarded  the. part of the body in  which the  diseases were
seated.   The greater^)art have, in different instances, been influenced
by all these circumstances.
  If we look Sinto Dr. Cullen's Nosology, we shall  find, that some of
the orders have no affinity with others belonging  to the same class,
either in their exciting causes, the part of the body on which they are
seated, or in the remedies which are employed in curing them,  and
that  the similitude, which brought them together in the same class, de-
pends on some circumstances trifling in its nature, affording no data,
from which we can deduce the  nature of the disease, or the  proper
mode of treating it.   In his  fifth order of class Pyrexia, he has but two
genera,  that is Catarrh and Dysentery, these he has likened to each
other, from this single circumstance, that in both there is  a discharge of
mucous.
   In other instances, Dr. Cullen has given  a common generic name,
to several diseases,  merely on account of their  being seated on or 
 30                    INTRODUCTION.

 about the same part of the  body, though they are considerably dif-
 ferent in all other respects, and though seated near the same part of the
 body, they affect different organs.   I refer to his  tenth genu* in his
 order phlegmasia, where he has put down cynanche as a genus, and di-
 vided it  into five species—that is,  Cynanche Tonsillaris, Cynanehe
 Maligna, Pharynga, and Cynanche  Parotidea.                  ^
   These diseases are dissimilar in many things, the first, Cynanche
 Tonsillaris, is a simple local inflammation of the phtegmontic kind, fre-
 quently terminating in suppuration.
   The second, Cynanche maligna is a contagious, and very dangerous
 disease,  affecting the same persons but once.
   The third, Cynanche Trachealis,  is often epidemic, is not confined
 to the trachea, but often extends throughout the whole of the mucous
 membrane of the bronchial vessels.
   The fourth  Cynanche Pauryngae, is a very rare disease,  and if it
does occur, is either caused  by swallowing acrid  matters, or is sym-
tomatic of affections of the stomach.
   The fifth,  Cynanche Parotidea, is  a  contagious disease,  affecting
chiefly, the purotid  glands, with  the testicles in males,  and breast in
females.
   Respecting Dr. Cullen's class of diseases, called by him,  neuroses,
it  is evident, that he intended to refer to this class, all morbid affec-
tions peculiar to the nervous  system.   This  is perfectly agreeable to
the plan  1 have adopted, but on a careful attention  to the subject, it
appears, that he has placed under this head,  some diseases  which do
not belong to H.   He has divided his class neuroses into four orders, e.
g.   1 Comata,  2 Adyna?mia,   3 Spasmi,  and 4 Vesania.   Under the
second class Adynaemia, we find Syncope, Vertigo, Dyspepsia, Hypo
chandriasis, and Chlorosis.  We do not perceive, any affinity between
Vertigo and chlorosis, nor between the latter and Hypochandriasis.
   Under order third, called Spasmi,' we  find several diseases,  which
do not exhibit, one symptom in common,  some of which I should think,
cannot belong to the  diseases of the nervous system, as I can see no
good reason for considering affections of the stomach, the  lungs or*
kidnies, as belonging to the nervous  system, any more than the affec-
tions, of any of those organs  which belong to what has been called or-
ganic life.  We do not perceive in  several  of these affections,  any
evidence of spasm.   What affinity has Diabetes with Tetanus, or what
similarity is there between Pyrosis and Epilepsy ?
   In justice to Dr. Cullen, it should be  observed, that he has left us
some important hints, respecting the  similarity of diseases ;  in his pre-
face to his nosology, he has  these words, « I wish two things might 
INTRODUCTION.                     3l
be particularly attended to, which may greatly assist in indicating the
similitude of diseases.   The one is, that similitude of cause, argues a
similarity in disease.  The other thing, which shews the similarity of
diseases, is  the similarity of medicines by which they are cured."—
Respecting  the similarity of diseases,  which are excited by the same
cause, applied to different persons, there can  be no doubt, but that the
same cause, will produce similar diseases,  on different persons.   In
proof of this we refer to the causes of epidemics and the effects of con-
tagious and morbid poisons-  But as to the similitude of diseases be-
ing indicated by the similarity of remedies by which they are cured,
this must be very vague and uncertain, as it is  an  indisputable  fact
that some medicines will cure several diseases which are very dissimi-
lar.  Mercury is a remedy in several diseases, which have never been
considered  as having any relations to each other,  such as affections  of
the liver, lues veneria and dropsy.   Dr. Cullen has  hinted at the
scheme of indicating the similitude of diseases from their being seated
 in the same part  of the body, but he does it in a manner totally differ-
 ent from the plan I propose.
   In the following arrangement of diseases,  I have attempted to class
 them, physiologically—that is, I have  divested the body, into parts,
 which are destined to perform certain functions, and have classed those
 diseases together, which derange or interrupt the same function.
     |n pursuing  this method,  it will be  seen that, strictly  speaking,
 there are no general diseases, for it is not probable that  any disease
 attacks or deranges all the functions, at the same time ; but being
 seated in one part which exercises a certain function, that function is
 first affected, and next, those functions which more  immediately de-
 pend on that, till at length, all the functions  are deranged  or over-
 thrown, and  the animal dies.
    In another point of view, however, certain diseases may with some
 propriety be considered as general, for instance, the nervous, sangui-
 ferous, and absorbent systems, are co-extensive with the body: there-
 fore, when any disease affects either of those systems, throughout its
 whole extent, such disease may be considered as  being  in a  sense gen-
 eral ; remembering at the same time  that such disease was primarily,
 confined to one of those systems, and that  the other systems, or the
 otljer parts of the body, are affected secondarily; so that we can,  with
 a good degree of certainty, pronounce the disease to have  originated in
 one or the  other of those parts of the body.
    Palsy belongs to the diseases of the nervous system, and fever and
 inflammations are diseases of the vascular system.   Yet  a palsy may
 destroy the functions of the sanguiferous system, and fever and inflam-
 mations may destroy the  functions of the brain and nervf^ 
32
INTRODUCTION.
        There is another circumstance to be attended to in classing diseases
      in this manner, and that is, that in diseases affecting particular organs
      which have certain functions allotted to them, the disease may, or may
      not primarily affect the functions of such organs.  All the organs of the
      body possess vascularity and sensibility, and are liable to inflamma-
      tions, and ulcerations, diseases which belong to the vascular system,
      which do not necessarily  destroy the functions of those organs.
        From this view  of  the  subject, the first and most  general division
      of diseases, is into  general and  local; considering all those as general,
      which primarily affect the whole of the nervous, sanguiferous, or lym-
      phatic systems, and also, all such  as affect the organs destined to per-
      form  important functions, so  as  materially  to derange their offices ;
      __and all such as  local, which affect only a part of those systems  or
      organs, w ithout injury to their  functions.
        I do not propose to enumerate the local diseases in this place.
        That this mode  of classing diseases is founded on the nature  of the
      animal ceconomy,  and in the nature  of disease itself, I am induced  to
      believe, from the following considerations :
        The exciting causes of several morbid  affections, exert their prin-
      cipal force,  on particular parts of the body, in preference  to others,
      in whatever manner  they are applied, or with whatever part of the
      body they first come in contact.
        This is the case with all kinds of contagious, and with most of the
      morbid poisons ; and we observe something  like  it  in the  effect  of
      remedies, which are applied for the cure of diseases ; for notwithstand-
      ing the  attempts  which have been made within the last fifty years,
      to reduce all diseases in theory,  to one or two simple  modes of de-
      parture from the healthy standard ; and remedies,  to one simple prin-
      ciple or  mode  of  action on the  animal body,  differing only in de-
      gree of force ;  yet I  apprehend,  that experience  will warrant us  in
      asserting, that particular remedies exert their power more  on one  part
      of the system, than on every other part.   Some substances  when ap-
      plied to the system, in health or disease, appear to exert their  power
   v   chiefly on the nervous  system, while others,  affect the chylopoietic
tfV*-* aipwrn, and some  seem to  affect particular organs of that system,
      rather than others.  Formerly, the writers on materia medica, were
      so fully possessed of  this opinion, that they arranged those substances
      according to their effects on certain functions of  the body.   Though,
      perhaps, they have  not always done this judiciously,  and though the
      same remedy may affect several functions, yet it is sufficient for our
      purpose, if such a principle is found in the effect of medicines.
        There is-still another circumstance which confirms me in the opinion 
INTRODUCTION.
33
that the plan adopted, is founded  in sound principles—I am induced
to believe from this,  that is, the first step  towards a rational practice,
is to investigate the disease.  We  do this by carefully attending to
all the functions of the body, to ascertain whether they are well or ill
performed, and  are governed  in making our prescriptions,  by the
part of the body affected.
  In pursuing this plan, we divide the body in the following manner,
e g. into the
     Nervous System,
  Including the brain, medulla  spinalis,  the  nerves emanating from
them, and the extremities of those nerves which are the immediate or-
gans of sense.
  The sanguiferous system, including the heart, arteries, and veins.
  The lymphatic system, including the lacteals and lymphatic vessels
with their common trunk.
  The chylopoietic viscera,  including  all the organs,  concerned in
chylification, and contained within the abdomen.
  The Bronchial system.
  The Urinary organs.
  The genetile organs in women.
  The genetile organs in men.
  The cellular substance.
  The skin.
  The bones.
  To this plan of arrangement, and classification of diseases, several
difficulties stand opposed.
  The functions of the body are so connected, and dependant on each
other,  that it is often difficult to determine to which class the disease
primarily belonged ; and as several of the organs perform a vicarious
part for each other, an affection of one may shew its most sensible ef-
fect iu another.    I do not pretend that I am able to settle these diffi-
culties, or that the arrangement I have made is free from errours ; but
these difficulties are those  which we have to encounter, in our daily
practice,  and our success will depend,  very much on the correctness
of our decisions.
  We shall begin with the diseases of the Nervous System, called by
Dr. Cullen  Neuroses,  but more properly, diseases  affecting animal
life.
  In pursuing the subject, we shall not divide  the diseases of this class
into order.-, genera and species;  but shall consider, first, those disease?,
which may be considered as general diseases of this system : that is,
those diseases which by their "j aeral pffe^  appear to *>- leafed in the
                               .5 
34
INTRODUCTION.
brain,  and medulla spinalis, whereby they  affect the whole, or the
whole of one half, the muscles of voluntary motion ; into those which
affect the intellectual faculties, and into diseases which affect the or-
gans of sense generally.  All which, on the  principles I have adop-
ted, maybe considered as general diseases.
   Those diseases which affect only a particular organ of sense, or par-
ticular voluntary muscles, may be considered as local  diseases  of the
nervous system.

   General diseases of the Nervous System, affecting animal life, are,
   Apoplexia; an abolition of animal life, while organic life is continued.
   Paralysis ; a loss of the power of volition  over  the voluntary mus-
cles, sometimes attended with a loss of the sense of touch, and at other
times without.  This, when it affects one half the voluntary muscles,
may be considered as a general disease, as it evidently has its seat in
the brain and spinal marrow.
   Tremor, when general, or when it affects the whole or one half the
voluntary muscles, may be considered as a general disease,  and rela-
ted to palsy.
   Syncope; a diminution, or cessation of the action of the heart for a
time.
   Spasmi; an irregular motion of the muscles, or a contraction of the
muscles contrary to the will.
   Tetanus  ; a spasmodic contraction of  many muscles,  more or less
general.
   Convulsio ; a violent irregular contraction of the muscles  without
sleep ; in which the muscles are alternately contracted and relaxed.
   Chorea ; a disease  affecting children between  eight  and  fourteen
years of age, consists in an irregular motion of the muscles ; in which,
when the will determines  to  move  one set of  muscles, another is
moved ; and when  extreme, the muscles are moved and agitated with-
out the will, and against its influence.
   Epilepsy  ; a convulsion  of the voluntary  muscles,  attended with a
loss of sense, and terminating in sleep for a time.
   Palpitatio ; not often depending on the affections of the nervous sy*
tem, but more generally, on organic affections.
   Affections of the intellectual faculties.
   Amentia or idiotism ; that state of mind in which the individual doe?
not perceive the relation of things, easily  perceived by others.
   Insanity; that  state of the  mind in which the individual  forms
a wrong  judgment of things.  This is either partial,  or total, about
certain things only, or of every thing pertaining to human affairs. 
INTRODUCTION.
35
  Local affections of the Nervous system, are,
  A loss of power in some particular muscles.
  A loss of power in the organs of sense, or an irregularity in their
functions ;  as loss of sight, hearing, smell, taste, and touch ;  or an  ir-
regularity in  those senses, producing false visions,  false hearing, false
taste, smell, and touch.
  All the diseases  of the  Nervous System may be divided  into two
classes : that  is, they consist in a loss or diminution of nervous power,
or in an irregular action  of the  same.  Idiotism and Insanity have
the  same relation to each other as palsy and convulsions.

                Diseases of the Sanguiferous System.
  Under this head we include all  those morbid affections of the body,
which originate in the action of the circulating system ;  divided  into
those which  affect the heart and great arteries, and those which affect
the  capillaries.
  The diseases of the first order, or those which  affect the heart and
great arteries primarily, are generally local affections and will not  be
mentioned here.
  Diseases of the capillaries, comprise nearly all Dr. Cullen's class of
Pyrexia.  As all febrile diseases seem to depend on a morbid excite-
ment of the capillaries, and all cases of spontaneous haemorrhagia.
  Pyrexia ;  a term denoting febrile diseases generally—consisting  in
a morbid excitement in  the whole, or a part of the capillary  arteries,
commencing  with a  diminution of action and sense of cold, and ter-
minating in an increase of action and sense of heat.
  Fever ; an affection of the capilliary arteries, of the whole system;
commencing  with torpor, and sense of cold, which is changed into  an
increased action accompanied with a sense of heat, disordering several
of the functions of the body.
  Fevers are either continued or intermittant, arising from  known,  or
unknown causes.
  Fevers which  arise  from known  causes, are intermittant fevers,  and
all fevers which arise  from contagion.
  Fevers which arise from unknown causes, are common typhus fe-
ver, and some epidemic diseases, attended with fever.
  Typhus Fever ; a disease common to all countries, to people of eve-
ry age, and  condition in life ;  liable to attack at all seasons  of the
year ;  arising from an unknown cause ; to a certain degree infectious ;
not  often attacking the same person twice.
  Intermitting  Fever ; a disease  arising from Marsh Miasmata, pro-
 lucing its sensible effects on the system, at uncertain  periods of time 
36
INTRODUCTION.
 from its reception into the body, from four weeks to one year, and at-
 tacking with a cold fit, followed by preternatural heat, and terminat-
 ing by sweat;  the fits returning every day, every other day,  or eve-
 ry third day.
                        Contagious Diseases.
   Diseases  which arise from a  specific contagion, produced by, and
 emanating from, a body sick of a contagious disease, producing a dis-
 ease in the person to whom it is applied, similar in all its essential fea-
 tures to the disease which produced the contagion ; attacking the same
 person but once.
   The usual time,  from the  reception  of  the contagion, to that in
 which it produces its first sensible effects on the system,  is  about two
 weeks, or half a lunation.
                            Small Pox.
   A contagious disease, communicated by  effluvia, arising from the
 body of a person sick of the disease, from fomites,  and also by inocu-
 lation with the  variolous matter, affecting the same person but once.
   When the contagion is received by  effluvia, or fomites,  the  erup-
 tive fever commences  in about fourteen days, from the application of
 the  contagion ;  when received by inoculation, the fever begins on the
 eighth day, and the eruption commences on the third day of the fever,
 whether the contagion  be received by effluvia or by inoculation.   The
 eruption begins on the head and face, and by the fifth day extends to the
 feet, by the eighth day the pustles begin to supperate,  which  finally
 scab and fall off,  leaving pits on the skin.  When the disease is violent.
 it affects the mucous membranes of the fauces, producing salivation.
                    Varicella, or Chicken Pot.
   \ contagious disease, commencing with slight fever,  and in a day
 or two  followed by  an eruption of small pustles, which fill with a
 transparent fluid, not often suppurating.

                       Rubeola or Measles.
   A contagious disease, attended with  an inflammatory fever  and a
 flux  of  humours from  the nose  and eyes ; also affecting the mucous
 membrane of the bronchial vessels, producing cough and hoarseness •
 on the fourth day  small pimples begin on the face  and extend to  the
 lower extremities; on the sixth day the pimples subside, coming off
 in small brany scales, leaving no pits or durable marks on  the skin.

                   Scarlatina or Scarlet Fever.
  A  contagious disease which commences in  about fourteen day* from
the application of the contagion,  attended with but little fever, 1.redu-
cing  an  eruption on the «kin of a  bright scarlet colour. smnewrU re- 
INTRODUCTION.
3T
ijembling the measles;  but subsiding,  without  producing any disqua-
mation of the cuticles.   A disease distinct from the Cynanche Malig-
na, and not dangerous—never affecting the fauces.

            Cynanche Maligna, or Ulcerous Sore Throat.
   A contagious disease, attended with a malignant fever of the Typhus
tipe, attacks with soreness of the throat and hot fever; at an uncertain
time from the attack, there is an efllorescence on the skin ; sometimes
the redness of the skin is confined to the throat, hands and feet, atoth-
<?r times it spreads over the whole body.   After the fever subsides, the
cuticle falls off from those parts where the redness was most intense,
and the hands and feet swell, sometimes the whole body becomes o?de-'
rnators.   ■
   This disease is often fatal.—More liable to attack children than
adults, and of adults, women are more liable to it than men.
   The precise time taken up, from the exposure to the contagion, to
the commencement of the fever, is not known.

                           Chin Cough.
   A contagious disease, attacking persons of all ages, dangerous to in-
fants and  to adults, who have previous affections of the  lungs, such as
asthma and incipient Phthisis.—Affecting the mucous membrane of the
lungs, causing a discharge from that membrane of white frothy muscus
and attended with  a  peculiar irritation, causing  paroxisms of violent
 ougbing, with a  hooping sound  in inspiration, continuing several
months.   This disease commences in  about fourteen days from the ex-
posure to the contagion.

                  Cynanche Parotidcea, or Mwnps.
   A contagious disease, attacking  persons of all  ages; attacks with
swelling of the paroted glands, and slight fever of the inflammatory kind,
in adults, two or three  days after the paroted glands swell, it affects
the breasts in females, and testicles in males, with swelling  and  sore-
ness.
                        Epidemic Catarrh.
   A disease from an unknown cai.se,  affecting  great numbers of per-
sons about the same time, spreading from one  part of the country to
•mother, sometimes from south to north,  and at other times from north
ro.south ;  either communicated from person to person, or originating in
-omething in the atmosphere, independent of temperature or moisture.
Differing from other contagious diseases in this, that the same person is
 iHen  affected by it many times,  always producing some local affec-
'i.<>n .">'"   ii.'  n: •""'v.tiomc part"  cronr-rally confined  to the mucous 
38
INTRODUCTION.
membrane, but sometimes affecting the serous membranes of the tho-
rax and abdomen.
                          Inflammations.
   A local disease belonging to the sanguiferous system.   As I did not
propose to make out a catalogue of local diseases, I have omitted the
particular cases of inflammation.

                 Diseases of the Absorbent Systerm,
   The general diseases of this  system  are, of  two kinds, one de-
pending on torpor producing dropsy ; the other consists in too much
action,  inducing emaciation  with a voratious  appetite.   Scrofula
seems also to belong to this system,  producing  swelling in the  lym-
phatic glands, and often affecting other parts of the body.

                   Diseases of the cellular System.
   Obesity, appears to  depend  on certain  conditions of the cellular
system, whioh disposes it to attract to itself, and retain  the oily part
of the nutriment taken in.
   Besides obesity,  the cellular system is  subject to unaccountable
variations in bulk, so much so, that it will swell up, and subside in a
sensible manner, under the eye of the observer.

                       Diseases of the Bones.
   The general diseases  of the  bones,  are of two kinds,  the one con-
sists in a deficiency of solidity, and hardness, in which the weight of
the body, or the action of the muscles, change their natural shape, and
is  called Rachites : the other  consists in a  too fragile  state of the
bones, in which  they are easily broken, by  the weight of the body,
or by common exercise.  The first of these diseases is confined to
children, and the other to adults.

                Diseases of the  chylopoietic viscera.
   Dyspepsia.
   An affection of the stomach itself, independent of other diseases, in
which the power of the stomach on the aliment taken in, is weakened,
so that the food taken in, lays  too long in the stomach, and passes in-
to a state, unlike healthy chyme.
   Costiveness.
   An affection of the Intestines in which  aliment taken in is  too  Ion*
in passing and the   stools  unfrequent,  attended with  pains,  in the
bowels or at least with uneasiness and  tension of the abdomen.
   Dysentery.
   A disease of warm climates, and of the warm season, in temperate
climates. 
INTRODUCTION.
39
  Symptoms.   Frequent, small, mucous, bloody stools, attended with
pains in the abdomen, accompanied with fever, often of the  inflamma-
tory kind, but sometimes of a typhus tipe.
    The Peristaltic motion of the  small intestines, is suspended in the
dysentery, and the foeces seldom  appear in the stools, unless solicited
by  art
  The stomach is often affected with nausea, and vomiting. This dis-
ease, though  it commences without contagion, is sometimes communi-
cated from one person to another.  The dysentery has no certain pe-
riod for its duration.   Children are oftener afflicted with it than adults.
and women,  than men.

                             Diarrhea.

   A disease, in which the Peristaltic motion downwards, is preternat-
 urally increased, producing  stools  more frequently than in  health,
 while the stools, are more  liquid, and greater in quantity,  than usual
 with the same person.
    Colic.
    A disease, in which the Peristaltic motion of the intestines  is sus?
 pended, attended with pains in the abdomen, and often with puking.
    Cholera.
 1   A disease of warm climates, and of warm seasons in the temperate
 climates ; consists in an inverted motion of the stomach and puking of
 serous fluid  mixed with bile, at the same time the peristaltic motion of
 the intestines is increased accompanied with large dejections  of serous
 fluid.
    When the disease is severe the voluntary muscles are affected with
 spasms.
                        Diseases of the Liver.
    Jaundice.
    An obstruction of the bile  which prevents its passing from the liver
 and gall bladder into the duodenum.
    Respecting the diseases of the Spleen, Pancreas, and Mesentery, I
 am unable to give any account of them. I have seen some dissections of
 dead bodies, where  those organs were found in a diseased state, but
 do not recollect any  peculiar symptoms  which preceded the death of
 the patients.

           Diseases affecting the functions of the kidnies are,
    Diabetes Millitus.
    A disease in which the urine  is abundant, containing  a large por-
 tion of sugar and sweet to the taste. 
40
INTRODUCTION.
    Diabetes Serosus.
    In which the  urine  is in too great a quantity,  but retains ail the
 sensible qualities of urine.
    Suppression of urine, through want of secretions.
    This is sometimes Idiopathic, at least, it happens without any as-
 signable cause.
    The suppression of urine, in cases of dropsy, is not to  be attributed
 to a defect in the action of the kidnies, but  to  the escape of the serous
 part of the blood,  into the cellular substance, and cavities of the body,
 thereby depriving the kidnies of their proper pabulum.
    Beside the diseases above stated, which pertain to the kidnies, they
 secrete urine of an unhealthy quality, which disposes it to form calcu-
 lous concretions in the bladder,  which may be considered, as the effi-
 cient cause of urinary calculi.   There is not perhaps, in the whole
 body, a single organ, which is so much influenced by the  condition  of
 the other  functions, as the kidnies.   This has been noticed by many
 medical writers.   There is not one of the diseases,  here placed to the
 account of the kidnies, but has been attributed.to the condition of oth-
 er organs.

    Diseases of the Genidle organs in 7nen, affecting Uieir functions.
    Nocturnal emissions attended with lascivious dreams, and erection.
   Nocturnal emissions unattended with erection, and without dreams.
   Impotency arising from the want of erection, priapim without emis-
 : ion.

 Diseases of the Genitile organs of women,  affecting their functions ure,
   Amenorrhaea; want of menstruations in women, over  fifteen and un-
 der forty-five, without pregnancy, and attended with a disturbance  of
 several of the functions of the  body,  especially, the functions of the
 stomach.
   Menorrhagia.
   When the menses  flow in too  great a quantity, or too often, either
 with, or without pain.
   Leucorrhaea.
   A discharge of serous fluid from the vagina.

                  Diseases of the Bronchial System.
   Diseases of the lungs are of two kinds, that is, those which affect the
lungs as a viscus, possessing vascularity and sensibility,  without affect
ing their functions necessarily, and those which affect the functions es-
sentially, thereby endangering or destroying life.
   Of the first kind are  inflammation and ulceration, for though either or 
INTRODUCTION.
41
both of those affections may, when extensive, impede the functions of
the lungs, yet they may exist, to considerable extent, without materi-
ally  affecting the function  of respiration.
   The diseases which affect  the functions of the lungs, are of two
kinds, that is, those which prevent the air from entering the lungs, and
those which affect  the lungs,  so  as to prevent their action as an organ,
#hile the air is inhaled.
   Diseases  which prevent the  air  from entering  and  inflating the
lungs are affections of the  muscles of respiration, which by preventing
or destroying  their contractile power, renders them incapable of en-
larging the cavity of the thorax.
   Wounds, penetrating the cavity of the thorax,  so as to admit the air,
have the same effect, as do also  obstructions in the trachea.
   In those cases of disease the cause is external to the lungs.
   Diseases which  affect  the  lungs themselves, and destroy or impair
their functions,  are  seated in the mucous membrane of the lungs, ex-
tending to the vesicles and thereby preventing the influence of the air
on the blood.   Of this kind are  all asthmatic affections and those epi-
demics which produce croup.

                        Diseases of the Skin.
   The earliest physicians considered the skin as an organ of perspira-
tion, and imputed  many diseases to causes which checked or  impaired
this  function ; but independent  of those  affections of the skin which
cause a sudden suppression of perspiration, depending  on change of
temperature, the skin probably has its own peculiar diseases as an or-
gan.  Those  affections would seem to be such as  morbidly increased
or diminished perspiration, or rendered the fluid discharged, through the
skin of an unhealthy quality.
   On  this head, so far as I know, there  has been but  little said by
medical  authors,  and  I am not  able  to point out those  morbid affec-
tions in  the system, which may depend on the impared functions of
the  skin.
                         Morbid Poisons.
   Diseases, produced by specific poisons, are those  morbid  affections
which arise from the contact of something applied to the human body,
which excites a diseased action  of a peculiar kind.
   Some  morbid poisons are produced by  animal secretions in disease.
Such are the poisons of rabid animals, lues, lepra, veueria, and  sever-
al other  poisons which are produced by diseased actions.
   Besides these there are a class of poisons which are  produced by
animal secretions  in health, such are the  poisons of serpents  and other
                                6 
42                     INTRODUCTION.

poisonous reptiles, the poisons of the bee, and several insects of that
kind.  Each of these  poisons, when applied to the living animal sys-
tem, produces a disease peculiar to itself and unlike every other mor-
bid affection.
  Morbid poisons differ from contagion in this, that they are not com-
municated from person to person,  except  by contact, and are  capable
of producing their specific effects  on the same person as often  as they
are reapplied. 
PART I.
                  OF IDIOPATHIC FEVERS,

  Idiopathic fevers, it has been observed in the Introduction, are dis-
tinguished  by the following symptoms :  Languor, lassitude, 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 Fevers, Continued  Fevers, and the
Exanthemata.


                           BOOK I.

       OF INTERMITTING AND REMITTING FEVERS.

   According  to the definition given in the Introduction, intermitting
 and remitting fevers consist of repeated paroxysms, returning with an
 evident exacerbation, and generally with shivering, complete apyrexia,
 or at least an evident remission being interposed.  I am now to con-
 sider the phenomena of these diseases more fully.


                            CHAP. I.

 Of the Species and Varieties of Intermitting and Remitting Fevers.
   Intermitting and remitting fevers have long been divided into Quoti-
 dians, Tertians, and Quartans, that is, fevers returning every day, eve-
 ry second day, and every third day.*
   Hippocrates mentions  intermittent which  returned on the fifth, se-
 venth, or  eigth day.   Boerhaave says  he saw a Septenary ;  and Van
 Swieten saw a Quartan change to a  Quintan.  Many similar observa-
 tions have been made.   Burserius enumerates  many  authors who saw

   * The interval or period, it must be remembered, is the space of time oc-
 cupied by what is called a complete revolution of the fever, that is, the time
 from the accession of one fit to that of the next.  And when  physicians talk
 of a Tertian, Quartan, &c. they count from the beginning of a revolution.
 Thus, in a Tertian, the day on which the fever appears is the first day ; the
 next,'the second ; and the next, on which the fever again xJs.es place, the
 third.  Some confusion of names has arisen from not attending to  this mode
 ofreckoniug.
   For the sake of brevity I shall use the term  intermitting fever to express
 both intermitting and remitting fever, except where the contrary is specified. 
4*                  INTERMITTING AND

Quintans, Septenaries, and Octans; several who met with fevers return-
ing on the ninth, the  tenth, and even the fourteenth  or fifteenth day.
We also read offevas which are said to have returned once a month,
once in two months, Lc.   These have been termed  Menstrua?, Bimen-
strua?, <yc. and some authors even speak of fevers which returned year-
ly, 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 accu-
racy.  Galen, whose practice was more extensive perhaps than that of
any other physician, never saw a  fever with a longer interval than a
Quintan,  and very rarely this.*   The particular state of the weather
:\l certain times of the year, by producing fever in the predisposed, of-
ten gives rise to  the appearance of an annual intermittent.  But in
such cases the fever is of the continued kind.
   In some intermittents the return of the paroxysm is irregular, that  is,
their revolutions are not performed in equal times.   These  are con-
sidered by Dr. Cullen, as varieties of the Tertian and Quartan.  They
have  been termed  Erratica  Quintana, Septana, Octana,  Nonana, Lu-
natica.t
   Each intermittent has also been divided into Benigwa, Maligna  or
Corruptiva Primaria, Secondaria or Symptomatica, Periodica ; Partia-
lis, that is,  affecting  the body partially ; Sporadica, Endemica  and
Epidemica.  Such divisions (as may be inferred from the  meaning of
terms) are quite useless.
   Certain symptoms, coma, for instance, syncope, convulsions, an efflo-
rescence on the skin, much sweating, great inquietude, nausea, vomit-
ing, delirium, &x.  have been assumed as a foundation for a division of
Intermittents ; hence the names Elodes, Assodes, Syncopalis, &c.  This
division is also quite useless.
   The same may be said of the division of  intermittents,  founded on
their being accompanied with other diseases; Scurvy, Syphilis, Worms,
Dysentery, Epilepsy, Gout, &c. and of that, on the nature of the remote
cause.  There is very little room we shall find for any division of this
kind.
   Of the various species of intermittents, it will be necessary to consid-
er particularly  only the  three first-mentioned, the quotidian, tertian

   * Even the Quintan has been suspected by later writers to  be a variety of
 :he Tertian.
   f There are n-.:my fevers of this kind mentioned in the works  of F.trsulle,-.
Van Swietcr, De Kaen, by different authors in Ilalleis's Disp.  ad Morb Hist 
REMITTING  FEVERS.                  45
and quartan.  The others  have not been accurately  observed, very
rarely occur, and are supposed by many, and not without reason, to be
only varieties of these.

                            SECT.  I.

                  Of tjie Varieties of Hie Tertian.

   I\ 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.   It is ot
 such frequent occurrence,  indeed, that Dr. Fordyce  and  some other
 writers  arc of opinion that  all fevers, whether continued or interrait-
 Linc;, are only varieties of this,*
   The Tertian is defined by Dr. Cullen, " Paroxysmi similes intervallo
 :' quadraginta octo circiter horarum,  accessionibus meridianis."
   The Tertian, whose paroxysm does not exceed twelve hours,  is cal-
 led the true simple Tertian ; that whose paroxysm exceeds twelve hours,
 is called the spurious simple  Tertian.   The former,  frequently comes
 on about the middle of the day, and goes off the same evening ;  the oth-
 er, comes on much  earlier, and often lasts for eighteen hours.  It is an
 observation as old as Hippocrates, that the paroxysms -of Tertians,  as
 well as other intermittents, are less frequently protracted when the pa-
 tient is young, his general health good, and particularly when he is not
 troubled with visceral obstructions.
    The Tertian varies in the frequency of the recurrence, as well  as
 the length of its paroxysms ;  instead of every second day, it sometimes,
 returns every day ; it is  then distinguished from the Quotidian by its
 alternate paroxysms being similar,  but more or less severe, in all, or
 some of their stages, making their attack at an earlier or later time of
 the day, &c. than the paroxysms of  the intervening  days.   When the
  paroxysms recur in this way, the fever is termed Tertiana duplex ; and
 there  might be a division of the Tertiana duplex  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 of the disease.
  And this division sometimes assists,  we shall find, in forming the prog-
  nosis, particularly  in double Tertian remittents.!  It has been observ-
  ed that the most severe fit is followed by the most complete apyrexia.
  Double Tertians, if the fit does not exceed twelve hours, are termed true
  double Tertians :  when it exceeds twelve hours, spurious double Ter-
  tians.
    * Dr. Fordvce's first Dissertation on Simple Fever.
    f Dr. Cleghorn on the Tertian, in his Treatise on the Diseases of Minorca. 
4t>                   INTERMITTING AND

  When the fits are so protracted that one begins almost as soon as the
preceding fit ends, the fever has been termed subintrant, or sub-contin-
ued.  Subintrant fevers are almost always remittents, complete apyrex-
ia rarely taking place in them.
  The Tertian sometimes returns twice  every second  day,  the inter-
mediate day having no paroxysm ; it is then termed Tertiana duplicata.
  It sometimes returns twice every second day, while one  paroxysm
takes place on the intermediate day ; the fever is then  termed Ter-
tiana triplex.  And Tulpius relates a case of the Tertiana quadruplex,
which has escaped the observation of most authors, in which two parox-
ysms take place  every day.*  It is  still to be remembered that the
Tertian type is discovered by the paroxysms being similar on alternate
days.  When we consider the manner in which intermittents suffer a
reduplication of their paroxysms,  we shall find, that as often as an ad-
ditional paroxysm takes  place, both the new  and the original parox-
ysms are more protracted than the latter were before the accession of
the  former.   Considering this circumstance, and the frequence of the
paroxysms in a quadruple Tertian,  the remissions must be extremely
slight, and the disease  consequently  must nearly assume the  appear-
ance of a  continued fever.
  When a single paroxysm takes  place  every  day, but the remission
between the first and second paroxysm is more considerable than that
between the second and third,  and  so on ;| the Tertian has  been call-
ed  Haemitritaeus or  Semitertiana.   Authors, however, do not emplo^
these terms in the same sense.|
  The interval of the Tertian,  it was observed, is  forty-eight  hours.
but sometimes it is rather less, the fit coming on earlier; and sometimes
it is more, the fit coming on later.  When the former  happens, the fe-
ver is called an anticipating Tertian  (Tertiana praevertens) ;  when the
latter happens,  a  postponing Tertian (Tertiana tardans).   And Dr.
Cleghorn has observed of the double  Tertian,  that the more  severe  fit

  * The case mentioned by Tulpius supervened on a double Tertian.  See
his  Observationes Medicx, I.  iv. c. 46.
  ■j-  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.
  *  Celsus, in his account of the Hxmitritaeus, wholly overlooks the remi-
sion which takes place, according to the above definition,  between the unc
qual and equal days.  The sense in which others use the term Haimitritxiis
differs still more  widely from the definition, and approaches very nearlv to
that given of the Tertiana triplex.  It  is used in this sense by Lommius in
his Observ. .Medic, libri tres, p. 22, and Eller in his Observ. de Cog. et Cur.
Morb. sect. 4, p. 83. 
REMITTING  FEVERS.
47
often comes on a little earlier in each period, while the slighter fit  re--
turns at the same hour, or perhaps later.
   It is remarkable that postponing agues, after the accession of the par-
oxysm is  postponed to eight o'clock in the evening, frequently have
their next accession early in the morning of the day following that on
which the fever should have  returned ; and in like manner, after an  an-
ticipating paroxysm  has occurred at eight o'clock in the morning,  the
next accession is often on  the evening of the  day preceding that on
which it should happen.  A postponing  intermittent is  a safer fever,
than an anticipating one.

                            SECT.  II.

           Of the Varieties of the Quartan and Quotidian.

   The varieties of the Tertian having been considered at some length,
a  few  words will be sufficient  respecting those of the Quotidian  and
Quartan.   The latter  is defined by Dr. Cullen, " Paroxysmi  similes
"  intervallo septuaginta duarum circiter horarum, accessionibus pomer-
"  idianis."
   Like the Tertian, it 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 Quartana dupli-
cata.   Sometimes three every  fourth  day ;  it is then called Quartana
triplicata.  Sometimes, of  the four days, the third only is  without a
paroxysm ; a single paroxysm taking place on the first, second,  and
fourth days, each paroxysm being similar to that which  occurs on the
fourth day defore  it  ; the fever is then called Quartana duplex.  The
paroxysm returns  sometimes every day ; it is  then called  Quartana
triplex.
   The following is Dr. Cullen's definition of the Quotidian, " Paroxys-
"  mi  similes intervallo viginti quartuor  circiter horarum, paroxysmis
"  matutinis."
   This  fever  varies chiefly in the length of its paroxysms,  and the
state  of the patient between them.  These are the only ways in which
Celsus regards the Quotidian as varying.   According to  Burserius,
however, it varies also in having one, two, or even three paroxysms in
the day ;  and these varieties he terms the  simple, double,  and triple
Quotidian.  But a Quotidian with the appearance of two or three pa-
roxysms in the day, (for they are never very distinctly marked) is not
to be distinguished  from a  continued fever.   The terms  anticipating,
postponing, subintrant, <$'c.  applied to the Quartan and Quotidian, are
employed in the same ?cnse ss when applied to the Tertian. 
48                  INTERMITTING AND

  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 remarka-
ble  of all fevers, that nine  perhaps in ten make their attack  between
eight o'clock in the morning, and eight in the evening.  This observa-
tion is curiously illustrated by what is said above of anticipating and
postponing agues.


                           CHAP.  II.

      Of the Symptoms of Intermitting and Remitting Fevers.

  These present so great a variety, that it will be  necessary,  for the
sake of perspicuity,  to consider them under different heads.   In  the
first Section, I shall give a detail of the symptoms which more proper-
ly belong to intermitting and remitting fevers.   In the second, I shall
take a view of what may  be termed the anomalous symptoms of these
diseases.  In the third, point out the symptoms which characterise the
different species, or types as they have been called.   In the fourth, the
manner in which they assume more or less of the continued form.   In
the fifth, the diseases with which they are most frequently complicated.
And in the last, I shall more particularly consider the prognosis, which
is collected from what will be said under all the preceding heads.

                            SECT. I.

        f)fihe Symptoms of Intermitting and remitting Fevers.
  A short account of these fevers has  already been given.   We are
told, in the definition, that they consist of repeated paroxysms, complete
apyrexia, or at least an evident remission being interposed.
   A regular fit or paroxysm  of an intermittent is divided into three sta-
ges.  The most striking symptoms of the first stage are, a  sense of cold
and shaking,  from  which it is termed the cold stage.   The second,
characterised by an increase of temperature,  is called the hot stage ;
and the chief symptom of the last, which is termed the sweating stage,
is a copious secretion by  the skin.

         1. Of the Symptoms of the  Cold Stage of Intermittents.*
   The commencement of the  fit is often denoted by the patient fre-
quently yawning and stretching himself ; and complaining of an unea-

  * That the following account of the symptoms of intermittents may be less
complicated, I shall omit many which will be mentioned under the head Prog- 
REMITTIING  FEVERS.
49
  sy weariness over the whole body.  Sometimes  the  weakness is such,
  that he is scarcely able to support himself.   He  is restless, soon tired of
  the same posture, yet feels  the exertion of changing it  painful.  His
  thoughts succeed each other more  rapidly than usual,  and he  feels it
  irksome to bend his attention for some time to one object.  The pulse
  is now weaker and sometimes slower than natural.   At the commence-
  ment of these symptoms the patient does not always complain of cold,
  but his skin, especially in the extremities,  often feels  cold to another
  person.   The  nails soon begin to grow pale, the same  gradually hap-
  pens to the fingers, toes, lips, Lc. and the skin becomes lough as when
  exposed to cold, and less sensible than usual.  Fie now complains of a
  sense of cold, generally referred to the back, and a trembling soon after
  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 per-
  haps glows with heat ; and while the cold  is severe on the surface, a
  burning heat is sometimes felt internally.
    After the  shaking has  lasted for some time,  the patient still com-
  plaining of cold, the warmth of his skin to the feeling of another person,
 or measured by the thermometer, gradually  increases.
   The pulse during the cold stage,  is small, frequent, sometimes ir-
 regular, and often  hardly to be felt; the respiration frequent and anx-
 ious, accompanied with a cough, or interrupted by  sighing ; and there
 is a sense of weight and  often of  tightness and oppression about the
 praecordia, with great dejection of spirits.
   The remembrance of things at other times desirable, now disgusts j
 and in the more  severe  cases the hurry of thought which attended
 from the beginning of the paroxysm  increasing, some degree of deli-

 nosis, and shall here give those which may be regarded as more properly con-
 stituting the disease.  El is necessary to have recourse to this, or some other
 such means when the symptoms of diseases are  very numerous, in order to
 avoid confusion ; which is not to be done, when the reader is at once present-
 ed with a great variety of symptoms.  We  have sufficient proof of this in
 the  manner in which the symptoms of diseases  are generally laid down by
 foreign systematic writers, Lieutaud, Hurserius,  Frank, &.c.
  * The teeth strike against each other, often with such force, that  instances
 are on record of the teeth of old people being knocked out by the cold fit of a
 Quartan.  The trembling over the whole body indeed is sometimes so severe,
 that after the cold fit the patient has hardly strength to move his limbs.  Even
 syncope is apt to occur during this stage when the strength has been much
reduced.  It seldom  occurs  repeatedly without  endangering life.  In very
severe and long continued cold fits, particularly in old people, the body has
been known to become stiff almost like drat of a  dead person.
                                 7 
m                   INTERMITTING  AND

rium or stupor comes on.   Delirium is a more frequent attendant on
the hot stage, and stupor or coma as it has been called, on the  cold ;
the latter often appearing almost  at the very commencement of the
paroxysm.                                             .   .
   Although neither delirium  nor coma attend the cold fit, it  is not un-
common for some of the senses to be considerably  impaired ; the pa-
tient often complains of numbness in the limbs  ; and in some  instances
both sight and hearing have been almost lost.   When this happens the
 stomach is generally loaded with bile.*
   Pains of the back, limbs and loins, or a sensation as if the body had
 been bruised, frequently attend this stage.
   The extremities shrink so that a ring,  at other times tight, drops off
 the finger.   Ulcers often dry up,   and tumours subside.f
    The natural  functions  are much deranged.   The  appetite  ceases,
 and nausea and  frequently a vomiting of bile succeed.  In the inter-
 mittents, and still  more in the remittents of sultry climates, and even
 of the warmer seasons of temperate climates, bile is often poured into
 the  stomach and  intestines  in  prodigious quantity.  Sometimes the
 matter.rejected  by vomiting, is a ropy, transparent fluid, nearly  insip-
  id ;  also frequently secreted in great quantity.
    When there  is much bile  in the stomach  and  intestines, it  is fre-
  quently (particularly towards the beginning of the hot fit)   passed by-
  stool as well as vomiting;  bile indeed often predominates  so much in
  these fevers, that the patient seems to labour under the jaundice, and
  the serum of the blood and the urine are tinged with yellow.
    The thirst is constant, the mouth and fauces dry and clammy.  The
  urine, if not tinged with bile, is almost colourless and without cloud or
  sediment; and, if there be no bile in the prima? via,  stools are  un-
  common at this period.
     Such are the symptoms of the cold stage.   In different  cases, how-
  ever, there is great variety.  The foregoing  symptoms are not always

    *  We know that the stomach is oppressed, when there is a bitter taste in
   the mouth, when the breath is fceted, the tongue yellowish and  covered with
   thick mucus, when the patient is troubled with eructations, anxiety, and a
   sense of oppression, pain or heat about the  stomach, nausea, vomiting, heavi-
   ness or pain of the head, vertigo, thirst, and spontaneous diarrhoea.  When
   these, or part of these, symptoms are present to a considerable degree, they
   form one of those useless divisions of intermitting fever above alluded to,
   termed Intermittens Gastrica.  See a copious account of this species of inter-
   mittent, in the first volume of Frank's excellent Work, entitled Epitome de
   Cur. Horn. Morb.
     f These effects are only temporary ; during the hot stage, or after the pa-
   roxysm, tumours and ulcers return to their former state. 
REMITTING  FEVERS.
SI
equally well marked, nor are all of them observed in any one case.—
Even the leading symptoms, the sense of cold, shaking, &c. have been
absent, so that we can hardly say there was any cold stage.
   Its duration  varies much ; sometimes it  lasts four or five hours or
more, particularly in the intermittents of long periods ;  at other times
not above half an hour, or even a shorter time, particularly  in remit-
tents, and especially in those approaching to the continued form.   Its
mean duration perhaps is between one and two hours.*
   The cold stage  generally becomes shorter as the  disease increases
in violence, and, particularly, we shall find as it suffers a prolongation
and reduplication of its paroxysms.   See the third section of this chap-
ter.
         2.  Of the Symptoms of the Hot and Sweating Stages.

   The hot  stage  seems sometimes  to be  induced  by  the  vomiting
which accompanies the cold stage ;  or the cold and shivering, after al-
ternating for some time with short fits of heat, gradually abate,  and
more permanent heat is at length diffused over the body.  The pale-
ness and shrinking of the  skin, are succeeded by  a general redness
and fullness, which,  however, give the appearance rather of turges-
cence than relaxation, the skin still remaining parched.
   The heat in this stage often raises Farenheit's  thermometer, six or
eight  degrees  above  the natural temperature.   Dr. Fordyce states
105° as the greatest degree of febrile heat which he  has observed.
Other writers mention higher degrees.
   The pulse now becomes regular, strong, and full.  And this state of
it generally  increases till the sweat  breaks out.   The breathing is
deeper and more 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 anxious than in health.
   The sensibility which is  impaired in the cold stage, is morbidly in-
creased in the hot.   The patient cannot endure noise ; and the light is
offensive.  The pains of the limbs continue : and the pain of  the head
comes on or increases, frequently accompanied with a throbbing of the
temporal arteries and tinnitus aurium.  The confusion of thought  is
upon the whole greater in  this than in the first stage,  and more fre-
quently arises to delirium.!

  * M'Bride's Introduction to  the Theory and Practice of Medicine.
  ■j- It is not uncommon at this period for the patient to complain of pain,
heat, and tension, accompanied also with a sense of pulsation in the stomach
and bowels ;  diis, however, is  a less frequent symptom, and seems  generally
to depend on the presence of some irritating matter,  and sometimes indi-
cates inflammation, in theprimae viae. 
INTERMITTING  AND
   The nausea and vomiting abate,  but the  thirst generally  increases.
The urine from being limpid, often becomes high-coloured, but is still
without sediment: in other respects the state of the natural functions is
nearly the same as in the  cold  fit.   Except when  a diarrhcea at-
tends stools seldom octu* Jill  the end of the  paroxysm, and  then there
is usually a loose stool.
   Hemorrhagies most frequently occur in the  hot stage.   The blood
flows from the uterus, from the rectum, if the patient happens to labour
under the hemorrhoids, 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,  Dr. Cleg-
horn 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, are generally the consequence of too rapid  a circu-
lation ;  and if not attended  with relief are seldom to be regarded as
unfavourable.  When we consider the symptoms of typhus, I shall
have occasion to notice another species of hemorrhagies, which seldom
attend the fevers I  am speaking of, till, in  consequence of a debilita-
ted state  of the system, they  have nearly assumed the continued form,
and which are almost always unfavourable.
   The appearance of hemorrhagies only assists us in judging of the
event, when  we attend to the symptoms 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.  I shall only remark,
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 conse-
quences.
   When  the fever has  lasted for a considerable time,  and  the remis-
sions have become less  complete, especially when the epidemic is of
a malignant nature ; a variety of symptoms denoting great debility,
and affording a bad prognosis,  shew  themselves.  But these belong
rather  to continued, than intermitting fevers.
   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 of-
ten observed, however, that the longer the cold stage is, the more vio-
lent is the succeeding  hot  fit, the type of  the fever being the same.
With respect to  the intermittents of different types,  this  is  by no
means  the ca*e, but rather we shall find the contrary. 
                    REMITTING  FEVERS.                  53

   The hot stage is at length terminated by a profuse sweat.  The
sweating generally begins about the head and breast, extending grad-
ually to the back and extremities.  The unusual strength and frequen-
cy of the pulse  now abate,  and the breathing becomes  free.  The
urine deposits a  sediment like brickdust, which has been termed late-
ritious, or a light copious reddish or white sedimemt;  and  the patient
generally falls into a sleep,  while  the symptoms  of the fever  abate,
leaving him weak and wearied.
   Although the patient, between the paroxysms of an intermittent, is
free from fever, he seldom enjoys perfect health, especially if they are
severe.   He  appears dejected and drowsy,  is easily  fatigued, com-
plains of want of appetite, if the skin is not parched, there  is a greater
tendency to sweat than in health, and vomiting and purging are not un-
usual at this period.  The more he is harrassed  by such symptoms  du-
ring the  apyrexia, the more reason there is to dread that the ensuing
paroxysm will be severe.
   All intermittents are apt to change  to a more or less continued form,
the tendency to become continued is unfavourable.   The contrary ten-
dency affords  a good prognosis.

                            SECT. II.

            Of the Anomalous Symptoms of Intermittents.

   The anomalous appearances of intermittents, may be divided  into
four classes.   The  first, comprehending those  cases in which the or-
der of the different stages constituting the paroxysm is deranged, or in
which some of the stages are found wanting.  The  second comprehend-
ing those cases in which the whole paroxysms or some of its stages are
confined  to particular  parts of the body.  The  third, those in which
certain symptoms prevail so much as to alter considerably the appear-
ance of the disease ; and the last,  those in which  other  diseases or
particular symptoms assume the form of an intermittent.
   It  is observed, by Cleghorn,* Senac,t and others, that the cold stat;e
particularly at an early period of the disease, is sometimes wanting.
Sometimes it  accompanies only some of the paroxysms:  Frankj re-
marks,  that even the hot stage itself is sometimes scarcely perceptible ;
at other times, as in cases mentioned by Senac,§ the hot and sweating
stages occur  together.  The hot fit  Frank  observes, sometimes pre-
cedes the cold, and sometimes there  is no sweating  stage, the skin re-
maining dry during the whole paroxysm.||  " The tumult and uneasi-
   * Dr. Cleghorn on the Diseases of Minorca.    f Senac de Febribus.
   j Frank's Epitome de Cur Morb.   § D^ F; cbribns.   !! Senac de Febribus. 
54
INTERMITTING  AND
" ness (says Dr. Jackson,*) of intermittent fever which terminate in
" most cases by sweat, went off in some by urine or stool, or perhaps
" declined in others without the appearance of any preternatural evac-
" uation."  Dr. Cleghorn makes similar observations.   And there are
cases mentioned in the works of Burserius t and SchenkiusJ  in which
the order of the stages was so far inverted, that, in one instance, the
cold stage was the last, and in another the sweating stage, the first.
  The second class of the anomalous  cases of intermittents  compre-
hends those  in which the paroxysm, or some of its stages, is confined
to particular parts of the body.    Vogel§ observes that the cold some-
times seizes on one member only, for instance the arm, and  is  some-
times confined to one half of the head; nay the whole fit is sometimes
confined to a particular part of the body, which undergoes the symptoms
of the cold,  hot, and sweating stages,  while the rest of the body  re-
mains unaffected.|j
  The third class comprehends those in which certain symptoms pre-
vail so much, as to alter considerably the appearance of the disease.
  " Sometimes one or two symptoms of the fit (Dr. Cleghorn observes)
" predominate with such violence that the rest are obscured or altogeth-
" er eclipsed.   Hence we so frequently meet with hemicranias, chole-
" ras, dysenteries, and chin-cough, returning  regularly at stated peri-
" ods ; and several fevers of this  class, upon account of some predom-
" inant symptom, have had particular names bestowed on them."   I
formerly had occasion to notice them. Dr. Cleghorn observes in another
place that intermittents are sometimes so complicated with pains of the
head,  breast, belly, back or limbs, as to appear like a pleurisy, phren-
zy, hepatitis, orlumbago, particularly when the remissions are obscure.
  I have known patients says Stork,** who along with  fever were eve-
ry day, at a certain  time, seized with palpitation of the heart, or great
anxiety about the precordia, with fruitless and violent  coughing ; oth-
ers were attacked  with a  violent pain of the  whole  or  part of  the
head.  Sir John Pringlett observes, that among the intermittents « hich
prevailed in the army,  there were some which attacked the head so
suddenly, and  with  such violence, that the men  without any previous
symptom of indisposition  ran about in  a wild manner, and were be-
lieved to be  mad till the solution of the disease, and  its periodic  return
shewed its real nature.
  * Jackson on the fevers of Jamacia.     | Burserius Institut. Med. Pract.
  * Scher.kius Observat. Med. Rariores.
  § Yogel's Prxlect. Acad, de Cog. et Cur. Morb.
  |i There is a striking instance of this kind related in the Nosologia Method-
jca of Sauvages.                ** Stork's Anni. Medici.
  ft; Sir John Pring-le's Observation? on the Diseases of the  Army; 
REMITTING FEVERS.                  55
   Dr. Rush,* and many others, mention cases of intermittents coming
on with delirium, particularly Mr. Clark in the fourth volume of the
Medical Observations and Inquiries.   Great swelling of the tongue, a
strangury, dreadful horrour, with a desire to die,  and boils on the skin,
mentioned as frequent symptoms in the billious remittent fever of Bus-
sarah, may also  be regarded as anomalous.t  In the sixth volume of
the Edingburgh Medical Essays there is a case related by Mr. Bain, in
which epilepsy attended the paroxysms of an intermittent;  and, in the
fifteenth 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  belonging  to
this class, are very various.  It is impossible to enumerate all that have
been  observed ;  those mentioned are sufficient to put the practitioner
on his guard, and prevent  embarrassment.   It appears from the obser-
vations 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 it.
   And still farther to perplex intermittents, and increase their irregular-
 ity, in one paroxysm certain symptoms shall  predominate, and in an-
other, symptoms of quite  a different nature.
   When such symptoms predominate, they often derange the fever, so
that it is impossible to say of what type it is.  But if they  have su-
pervened on the fever, when they abate, it generally assumes the same
 type which it had before  their appearance.
   The last class of anomalous cases, comprehends those in  which oth-
er diseases, or particular  symptoms, assume  the form of an intermit-
 tent.
   Certain symptoms, such as pain in some part of the head, coma, de-
 lirium, 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 va-
riety of other authors.   But it does not always happen that the symp-
 toms which thus  recur periodically have accompanied an intermittent.
 They sometimes appear from the first without fever,  and continue to
 recur at the quotidian, tertian, or quartan interval.
   Stork J relates a case of amaurosis which recurred in this way. Rheu-

   * Rush's Medical Ob. and Inq.
   | There is a good account of this dreadful fever  in a work entitled,  The
transactions of a Society for the Improvement of Medical and Surgical lv.imv!-
 wlge, for 1791.
   t See his Vnni Med id. 
OtJ
INTERMITTING  AND
 matic pains have often been observed to do so.  Dr. Rush* relates seve-
 ral cases of this kind.   There is a very curious account of pulmonary
 complaints assuming the form of an intermittent, by Dr. Chapman, in
 the first volume of the Medical Commentaries.  Dr. Strackt enumerates
 many of the 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 convulsions,
 as apt to assume the same form.
   It deserves particular attention, that such cases almost always yield
 to the same means which remove intermittents, however dissimilar to
 these fevers in all respects, except  their periodical recurrence.  This
 curious fact has been established by very extensive observation.
   I shall only add, before I leave the anomalous symptoms of intermit-
 tents, that these fevers have sometimes left behind them irregular shak-
 ings, which often prove very obstinate.  There are cases of this kind
 related by Dr. Monro in the second  volume of the Edin. Med. Ess.  and
 Obs. and in the fc.irth volume of the same work by Mr. Andrew Wil-
 lison.  The case related by the latter yielded to the cold bath.

                            SECT. III.

           Of the Symptoms peculiar to the Different Types.
  .. »»-
  We have now considered the symptoms essential to, or attendant  up-
 on intermitting  fevers in  general.   It is proper, however, before we
 leave this part of the subject, to say something of the symptoms pecu-
 liar to each of the species, the varieties of which have been consider-
 ed.
  The quotidian  is comparatively a rare fever ; some have even  de-
 nied its  existence , for which they are deservedly censured by  Eller.
 We often meet with intermittents whose paroxysms return every day ;
but most of these are double  tertians, in  which the fits do not return ev-
ery 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 proportion
  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  fre-
quently  wanting than in the tertian or quartan. But the whole paroxysm
is generally longer than in either of these fevers ; and the quotidian is
See his Med. Obs. and Inq.
f Strack de Feb. Intermit. 
REMITTING  FEVERS.                  57
most apt to assume the continued form.   Any of the others, about to
become continued, in  the first place so  far assumes the appearance of
the quotidian, as to have a paroxysm every day.
  Galen says, every physician  ought to know, from the appearance of
the first fit, of what type an intermittent will be.   He gives the follow-
ing diagnosis for distinguishing the paroxysm of a quotidian. The heat
is more moist than in other intermittents, and joined with a kind of acri-
mony, which is not immediately perceived on applying the hand ; the
thirst is less, and there is a discharge of  phlegmatic humours, by vomit-
ing and stool;  the body abounds with crude humours ;  the patients 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 cannnot, however, trust to this diagno-
sis in predicting the type of the fever, although it is not to be altogether
overlooked.   Whatever the extensive practice  of Galen enabled him
to do, it is now generally admitted that we can seldom determine the
type of an intermittent from the symtoms of one paroxysm.
  Upon the whole, however, a mild paroxysm coming  on in the morn-
ing,  particularly in the spring, often  proves a fit of the quotidian.
  In the simple tertian the cold stage is generally longer and more se-
vere than that of the quotidian, but the  whole fit is shorter, in most ca-
ses 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 prickling ; the thirst (he
remarks) is always urgent, the heat very great, and universally diffu-
sed over the body, strongly affecting the hand of the Physician on first
touching the patient, but soon after seeming to be less than that of his
own hand.  Such observations 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.*  It
is not difficult to suppose that the diseased secretion from the skin may
modify the sensation produced by the increased temperature.
  Eller maintains that the cold is more  considerable in the tertian, and
confirms Galen's observation  that  the heat is greater (calor  magis
urens) than in other intermittents ;  Hoffman, Huxham, and others have

  * See the observations of Sir John Pringle, Huxham in his wo.ik on Fevers
Moore in his Medical Sketches, and others on this  subjer
                               8 
58                  INTERMITTING AND
        also endeavoured to characterise a paroxysm of the tertian, but there
        is no diagnosis which enables us with any certainty to distinguish it
        from that of other agues.  Nor are we enabled to do so by the time of
        the day  at which it appears.   It frequently, indeed, makes its  attack
        about mid-day,  but this is by no means constant.   In double tertians
        the fits are sometimes alternately before and after mid-day.   It has
        been observed, that the paroxysms which occur towards evening, are
        generally most severe.
          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.  It is  upon the whole, less obstinate than other
        intermittents.   But Frank* justly remarks 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,  wbich rarely happens.
          The vernal intermittents are almost always either quotidians  or
        tertians.   Sydenharat considered them as not  only safe, but salutary,
        and if  protracted till the  autumn, he observes, which season  is unfa-
        vourable to these species of intermittents, they generally cease spon-
        taneously.   It may be observed on the other  hand, that if autumnal
        tertians are protracted to  the following spring,  it also generally puts a
<ptZfc "-pajpi to them.
          The vernal  intermittents, the type being the same, are less severe,
        less liable to become continued, to be accompanied by  billious symp-
        toms, and  followed  by dangerous consequences, than  the autumnal :
        they are  also less disposed to return.
          In the  vernal intermittents, increased excitement generally prevails ;
        in the autumnal, debility.  We shall afterwards find the following ob-
        servation fully illustrated ; that we always  have it in  our power  to
        diminish excitement as much as we please, but often find it impossible,
        sufficiently to increase it.   Hence it chiefly  arises that autumnal agues
        are more dangerous than vernal  ; and it  will appear, as we proceed in
        considering febrile diseases, that this observation,  more than any other.
        influences our practice  in all idiopathic  fevers.
          Dr. Brocklesbyf informs us, that  !ie  never saw an  instance of a
        quartan which came on in the spring, and his experience was  very ex-
        tensive^

          * Epitome de Cur. Horn. Morb.
          t Syndenhami Opera Sect, de Feb. Ietermit.
          * Dr. Brocklesby's Observations  on the Diseases of the Army.
          § We shall find, in speaking of the causes of intermittents, that in climates 
REMITTING  FEVERS.                  59
  It often makes its attack 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 some-
times longer.   Dr. Grant * says, he has seen the cold fit of the quartan,
last fifteen hours.   Eller and others, observe, that the sensation of cold
is not in general so great, as in the cold fit of the tertian.
  The  whole fit of the quartan is generally shorter than that of either
the quotidian or tertian.
  At the invasion of quartans, Galen observes,  the pulse is as it wrere,
bound up and drawn inwards, nor is there that sense of painful prick-
ing  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 is perhaps
the best diagnosis of a fit of the quartan ;  the cold is not so violent as
in the tertian, but of longer duration ; the heat is more gentle and dry,
and the sweating scanty.t
   The  quartan  is more  apt  to be followed by  obstructions  of the
viscera than other  intermittents, owing probably to its being more ob-
stinate.  It has, like the  gout, been termed the Opprobrium Medico-
rum.  Some authors assert that  they have  known a  quartan  last for
twenty or thirty years.   It is a remark of Sydenham, however,  that
if a person be attacked by it for the second time,  it generally goes off
after a few fits.   When it has been obstinate, and attended with deliri-
um, the patient has sometimes remained in a state of fatuity for a long -   v -,"* ,
time after it, as happens more frequently  after certain species  of con-
tinued fever.
   The quartan  is particularly  severe on  old  people ;  young people
generally get the  better of it, on or before the succeeding  spring.
Sydenham says,  he has been surprised to see infants labour under a
quartan for six months, and bear it well.
   Although an autumnal ague, it is  less apt  than any other to become
continued, or be attended with symptoms of danger.
   Upon the whole, the principal difference between the paroxysms of
the different types consists in their duration, and the proportional dura-
tion 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 of the 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

where the changes of the seasons are remarkable, spring and autumn are
those in which they most frequently appear.
  * Dr. Grant's observations on Fevers, most frequent in London.
  j Eller deCr.g et Cur. Morb 
b'O                  INTERMITTING AND
quartan in  general has the longest cold fit, but the shortest paroxysm.
The duration of the cold fit then in the different types is proportioned
to that of  the intermission.   The contrary is true of the duration of
the whole  paroxysm.
  We are now to consider the manner in which the different types as-
sume more or less of the continued form.   Some of the facts relating
to this  part of the  subject indeed have already been mentioned ; it
may be useful to present them at one view.

                           SECT. IV.

Of 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 place  in them
can often hardly be perceived.    But how fruitless their labours have
been, appears at the first view of their several opinions.  Even Syd-
enham's speculations on this subject are but ill warranted by observa-
tion.  It would be mispending time  to enter on the merits of these  hy-
potheses ;  let us take a short view of the facts which gave rise to them.
  When the fits of  the quotidian are lengthened, there is no time for
any apyrexia; and thus the intermittent is  changed into a remittent.
As the paroxysms are protracted, the  remissions appear less remarkable,
and the  fever at length becomes continued.
   The tertian, we have seen, is liable  to a reduplication of its parox-
ysms, and then it also may readily assume the continued  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 parox-
ysm upon the whole is protracted, the duration of the cold fit is dimin-
ished as that of the  hot is increased, so that when the fever has assum-
ed the  continued form, the cold  fit for the most part  is scarcely to be
perceived.   It is also to be observed, that when an  intermittent as-
sumes the continued form, the symptoms of  the hot  stage,  in propor-
tion as it  is protracted, generally become more severe ;  and those of
the cold stage, in  proportion as it is shortened, milder.
   The quartan seldom assumes the continued form.   The  quartana
triplex is a rare disease.   If it suffers a reduplication of its  paroxysms
it may readily become continued.
   The new paroxysms, added to a tertian or quartan,  when they be- 
REMITTING  FEVERS.
61
come double, for instance, always resemble the paroxysms of the first
fever, in being of the same type.
  Van  Swieten observes that, as far as he knows, quintans and other
intermittents of more  protracted types never  assume the continued
form.
   It will afterwards appear, that the chief if not the only circumstan-
ces tvhich  determine  intermittents  to  assume more of the continued
form, are the inflammatory diathesis, and  debility.   It is the former
we most frequently have to  combat in  these fevers; the means of re-
moving it with safety,  therefore,  (that is, without running the risk of
inducing the opposite and more dangerous state of debility,) forms an
essential part of their treatment.
   Instead  of becoming more continued, intermittents sometimes be-
come less so, which is always favourable.   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 them.
   Intermittents sometimes assume a more  intermitting form by chang-
ing  their type.   It is not uncommon for an autumnal quotidian or ter-
tian to be  changed into a quartan,  after the  violence of the fever is
broken.
   Continued fevers also change to a more or less  intermitting form.
When this happens, they have formerly, for  the most part, been inter-
mittents, or appeared with inflammatory symptoms while intermittents
were epidemic; but all kinds of  continued fever may assume the in-
termitting form.

                             SECT. V.

Of the Diseases with which Intermittents are most frequently complicated.
   With re^frd to a variety of symptoms which often  appear in inter-
mittents, arising from  their being complicated with  other diseases, lit-
tle  can be said  here, as I am not to treat of the  different diseases to
which they belong.   The  diseases with which intermittents are most
frequently complicated are, diarrhoea, cholera, dystentery, obstructions
of the  viscera, dropsy, jaundice, and different species of inflammation.
   Inflammation of some of the viscera and remittent fever is one uf the
most common of  these combinations.   De Haen* and  other? relate
many  cases of remittents, in which the stomach and bowels were found
on dissection inflamed and sphacelated.   This combination has been
* S«?e his Ratio Medendi. 
62
INTERMITTING AND
 observed to be remarkably frequent in certain epidemics.  Bartboline*
 in particular gives an account of an irregular remittent  that raged  at
 Copenhagen,  which was always accompanied with inflammation of the
 stomach and duodenum ; and we have an account of a similar fever  at
 Leyden, by Professor Silvius de la Boe.t   The brain is also sometimes
 the seat of inflammation in remittents, as appears from the account  of
 dissections by Sir John PringleJ  and others.   Rheumatism frequently
 accompanies the intermittents of cold climates.§
   The vernal intermittents are most frequently complicated with in-
 flammatory diseases.   Those of autumn with diseases of debility, par-
 ticularly dysentery.
   The concurrence of some of the foregoing diseases and intermitting
 fever  is to be ascribed to the nature of the epidemic, the climate,  or
 the constitution  of the patient;  but some of them are the effects of the
 fever itself; schirrous indurations of the viscera, for instance, and their
 consequences, atrophy, jaundice  and dropsy.   The liver  and spleen
 are the viscera most frequently  affected.||
   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, &c.**
   It has long been the opinion of physicians, that intermitting fevers,
 if not unusually severe, pre-dhspose to good health and  long life.  Un-

  * Barthol. Hist. Anatom. Rar. hist. 56.
  f Prax. Med. Append, tract x.
  t See his Observations on the Diseases of the Armv.
  § Seethe epidemics described by Sir John Pringle, in his Observ. on the
 Dis. of the Army.
  || When we reflect on the nature of the circulation in the liver, and whence
 the greater part of its blood is supplied, we are at no loss to account for die
 ascites that sometimes attends its induration.  Nor is it difficult to conceive
 in what manner an induration and enlargement either of this viscus or the
 spleen frequently produces an anasarca of the lower extremities, gradually
 extending over the whole body, as the cava ascendens is exposed to the pi es-
 sure of  the enlarged viscera.  That jaundice must frequently be the conse-
 quence of an induration of the liver  or pancreas, is evident from consider-
 ing the situation of the biliary ducas, which may be pressed upon by enlarged
 portions of either of these organs.
  Long protracted agues produce  cachexy and atrophy, by occasioning ob-
 struction of the mesenteric and other glands of the abdomen.
  ** See observations on these effects of intermittents, in Strack de Febribus
 Intermittentibus,  Brock lesby on the Diseases of  the  Army, Jackson on the
Tevrr* of Jamaica, he 
REMITTING  FEVERS.
63
less these fevers, says Boerhaave,* are malignant, they dispose the bo-
dy to longevity, and purge it from inveterate disorders.   Nor do I be-
lieve, his commentator observes, that any physician who has considered
this disorder will deny that after quartan fevers, disturbed by no pow-
erful 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.t   This opinion, however, seems far from being generally
well founded, and has often done harm by preventing  the endeavours of
the practitioner to stop the fever at an early period.
   It is not to be denied that an ague supervening on other diseases, has
sometimes relieved them ; and when these are more to be feared than
the ague, it must  be removed with caution.  Habitual  rheumatisms,
inflammations,  cutaneous eruptions, indigestions, epilepsy, histeria,
&c. Dr. Fordyce|  observes, are relieved by a regular tertian.  The
quartan, says Vogel,|| has often prevented gout, asthma, convulsions,
and hypochondriacal affections; and even Hippocrates says that  the
quartan is a safe fever and prevents others.   Those  affected with con-
vulsions, he adds,  are relieved from them by a quartan.   Intermittents
are also said to relieve or remove palsies, &c.   Some are inclined to
doubt of many effects of this kind which have been ascribed to them.§

                            SECT. VI.

                  Of the Prognosis in Intermittents.

   As the prognosis in intermitting fever  is collected from the symp-
toms of the paroxysm, and the state of the patient between the parox-
ysms, 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  of  the  voluntary motions become
more remarkable,  as the danger increases.  Involuntary twitchings of
the  muscles, (subsultus  tendinum) and  startings, often terminate  in
general convulsions, in  which the patient expires.  Coma frequently
comes on,  and as  death approaches it  is  often impossible to rouse  the
patient.   Delirium is  still  more unfavourable.   The  danger is very
great when it  is among the first  symptoms, as  happened in  severaj
epidemics above  alluded to, and that of Bengal,  described by  Dr.
Lind, in which the patient generally died in the third paroxysm.

   *  Aph. Eoerhaarii.        -j Comment, in \ph. TVicvhuav.
   t  First Diasert. on Simple Fever.
   || Pradtct. Acad,  de Cog. et Cur. Morb.
   §  See some observations on this  part of the subject, in a Treatise on Ma-
lignant Intermit'enKln .Yuriviliirs, in BsldiirgerV. Sj.llogeOpirsculornm. 
64                   INTERMITTING AND

  To this head belongs the depravation of particular senses, especially
false vision, which in all fevers is among the worst symptoms.   Deaf-
ness is generally favourable.
  With regard to the vital functions, palpitation of the heart and much
anxiety are unfavourable symptoms.   The pulse before death general-
ly becomes very frequent, weak, and irregular, except when  a consid-
erable degree of coma is present;  it is then often slow  and  regular r
but, while the coma continues, this state of the pulse  by no means as-
sures us of the patient's safety; it frequently precedes  a fatal apoplexy.
In this, as in most other diseases, death often approaches with a pale-
ness, shrinking, and coldness of the extremities ; the pulse is then hard-
ly or not at all perceptible.
  There is also danger in the  opposite state  of the circulation,  in
which the pulse is remarkably strong and full; this however we have
it more in our power to  correct.
  The respiration is much affected as the fatal termination approaches ;
it becomes anxious and  quick, though often at the  same time less fre-
quent than natural, interrupted with sighs and groans ;  and, a little be-
fore death, sometimes suffers considerable intermissions.  .
  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 cases where the brain  is
more particularly the seat of the disease.  Dr. Whytt takes  notice of
its being a common symptom in  the hydrocephalus internus.*
  Under the head of respiration, it may be observed,  that  hiccup is a
dangerous symptom, if it occurs  while the  others are  alarmiug; espe-
cially if accompanied with vomiting.
  Every change in the  voice from its natural  tone indicates danger,
and the loss of speech is often the forerunner of death.
  With respect to the natural functions, much nausea,  the  abdomen
swelled, hard and painful to the  touch, with obstinate costiveness,  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 sometime before death the  patient is unable to swal-
low, the tongue, mouth, and  fauces becoming very foul.   " The dan-
  * 1 met with a case in  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 ill, and was much reduced.  Before his death a considerable
degi'ee of coma came on, and his breathing for about the last half hour was so
much interrupted that there were not less than six or  eight minutes between
each inspiration, so that his friends, thinking him dead, repeatedly closed his
eyes, and were astonished a short time  after to hear him make a very sono-
rous inspiration 
                     REMITTING FEVERS.                   65

 '* ger is very great when the tongue is immoderately dry or black, dr
 " covered with a white slimy gelatinous substance.  To the above we
 " may add, a sodden or parboiled appearance of the tongue, which indi-
 " cates much danger."*
   A spontaneous, or what has been termed colliquative, diarrhoea fre-
 quently precedes death, and the stools are often black and fetid from
 the vitiated state of the bile.   A black matter like coffee grounds, dis-
 charged either  upwards or  downwards, denotes  much danger; this
 symptom is generally  the consequence of hemorrhagy from the stom-
 ach or bowels.  In the remittents of warm climates the bile sometimes
 assumes this  appearance, more frequently that of tar or molasses.
 Whatever be the matter evacuated,  vomitting is  dangerous if it does
 not abate towards the  end of the paroxysm, especially if the anxiety
 is great,  and the discharge does not bring relief.
   The urine or sweat being offensive, the former of a  dark colour, and
 depositing a brown or blackish sediment,  the latter tinging the pa-
 tient's linen  with a brown colour, both of which  appearances proceed
 from an admixture of blood, and the eyes  being suffused with  blood,
 are among the most alarming symptoms.t   The sphincters are frequent-
 ly relaxed for some time before death, so that the urine and faeces are
 passed  involuntarily.
   It may be observed upon the whole, that much danger is  indicated
 by the  various symptoms denoting great debility in the natural func-
 tions.   These will 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  universally
 diffused, and not occasioning much loss of strength, affords a favourable^
 the opposite of these, an unfavourable prognosis.!
   With respect  to the prognosis during the remission,  or apyrexia, in
 proportion as these are shorter, and less complete, the  danger is  great-
 er.  A simple quartan is a safer (ever than a tertian ; a simple tertian

  * Dr. Jackson's Treatise on the Fevers of Jamaica.
  f These are the most fatal of the hemorrhagies above alluded to, which al-
 most always afford a bad prognosis.
  | Dr. Rollo observes in his account of the diseases of St. Lucia,  that ** a
" comatose disposition, remarkable dejection, coldness of the skin, partial
" cold sweats, hiccup, involuntary stools, subsultus tendinum, loss of speech,
 " Sic. 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 lips
" and eyes  without his being sensible of their attachment, it is a certain mark
 " of danger.  Indeed these insects never made their appearance, in any num-
" bcr, until danger, by other signs was too apparent:'1
                                9 
66
INTERMITTING AND
than a quotidian ; and this  becomes the more dangerous, the more its
paroxysms run into  each other.  These observations, however, By no
means apply universally.*
   If the patient, during the apyrexia, even although this be complete,
feels himself weak and oppressed, especially if there  be a tendency to
cederaa in his feet and legs, he  is not free from danger.  We should en-
quire, Burserius observes, if on the days of intermission the tongue be
dry and  rough ; if  the patient be unquiet, 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 the in ensuing paroxysm cardialgia, cholic, lethargy, or some
such  alarming symptom.
   All combination of other diseases with intermittents are dangerous.
   The favourable  prognosis may be readily collected from   what  has
been said of the symptoms affording an  unfavourable one.   The  pa-
roxysm being moderate, the patient bearing it without much  loss of
strength,  and enjoying good health during a long apyrexia, are the best
. signs.
   There is a set of symptoms which occur now and then in allkinds-of
 fever, and have generally been observed to attend, and generally sup-
 posed to occasion, a favourable change  in the state of the disease.   On
 this account they are termed.critical.  Sweating, by which the parox-
 ysm terminates, is  a symptom of this kind.  We shall  have occasion
 to consider this subject more  at length in treating of continued fever.
•" An eruption about the mouth and ears (says Dr. Rollot) with a swel-
 " ling of the upper lip, either in this fever or in the  intermittent, hap-
 " pening when the paroxysm  was going off, was a certain sign of re-
 " covery, except when the  other symptoms were  dangerous ; these
 " then assisted the unfavourable  prognosis."  Intermittents,  YogelJ
 observes, are often removed by cutaneous eruptions, particularly the
 miliary eruption, and small pox, by the ha?morrhois, by a salivation, or
 by an ulcer of the  lips.
    The most obstinate intermittents are not always the most dangerous.
 Tertians, upon the whole, are removed with most ease, and quartans
 with most difficulty.  Hippocrates has pronounced a quartan to be the
 longest and safest of fevers.   This observation applies only  to the  sim-

   • Burserius and Frank give a good account of the symptoms which afford an
 unfavourable prognosis during the apyrexia.  See the Epit. de Cur. Hominum
 Morb. by Frank, vol. 1, p. 59 and the Institut. Med. Pract. of Burserius.
   f Sec his Obs. on the Dis. of St. Lucia.
    $ Prx.  Acad, de Cog.  et. Cur. Morb. 
REMITTING FEVERS.                   67
pie quartan ;  when it has suffered a reduplication of its paroxysms, the
prognosis is no better in it than in other intermittents.  Celsus ob-
serves that the quartan is a  safe fever, unless it become  a quotidian.
   Upon the whole, intermitting fever, though often a very obstinate, is
not generally a very dangerous, disease.   The symptoms enumerated
as affording an unfavourable prognosis, seldom make their appearance,
unless it has suffered a reduplication and protraction of its  paroxysms,
or is complicated with other diseases.   In the latter case, the danger
cannot be ascertained without being acquainted  with the prognosis  in
these diseases.  Epidemics indeed occur, which form an exception  to
this observation, particularly in sultry climates.
   Death may happen at any period of intermittents.  It most frequent-
ly happens in the  hot stage, except in the quartan, in  which, Syden-
ham observes, death generally happens in the  cold  stage.  The pa-
tient rarely dies in the sweating stage ; if he is much reduced, howev-
er, and the sweating is profuse,  death may happen at this  period also.
It also sometimes happens during the remission,  in consequence of the
violence of the preceding paroxysm.
   If the first paroxysms of an intermittent are  mild, the  prognosis is
good ;  if from being severe they become  mild,  it  is better.    But we
must not form a decided opinion from the  mildness of one  or two par-
oxysms, and the health of the patient during their intermissions.
   It may upon the wkole be remarked, that the safety of the patient is
rather to be estimated from the mildness of the  paroxysms, than from
the length and completeness of the apyrexia.*  It has been  observed  of
complicated intermittents,  that those are  most  to  be dreaded  whose
paroxysms are most severe on the  even days.
   Some attempt to foretell the period  at which the fever will terminate
favourably,  by attending to that at which it comes to its height;  that
is, the time at which the paroxysms from becoming more  violent, be-
gin to become less so ; for  it is common in these fevers for every par-
oxysm, during  the  first intervals, to be more violent than  that which
preceded it.   " The tertian intermittents, 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, ter-
" minate about the sixth or seventh."   Cleghorn speaks of the tertians
of Minorca.   No general rule  of this kind can be  laid  down.   Every
one must make such observations for himself  in  the climate, and even
epidemic, in which he practises.   It is sufficient  to be warned, that by

  * There are some good observations on this  part of the subject, in the first
chapter of the third hook of Torti's Therapeutice Specials. 
08                   INTERMITTING AND

making such observations he will  be enabled, with more accuracy, to
foresee the event of the disease.
  A paroxysm which, without any evident cause, is considerably more
severe than those which  preceded it, is often the last, the patient re-
maining well after it.*
  To the head of prognosis, belongs the doctrine of critical days.
  This doctrine the reader will find noticed in the writings of physician?
ever since the days of Hippocrates, who plid particular attention to it.
  Some regard it as wholly unfounded.   This opinion, however,  ap-
pears to be the result of a confined view of the subject.  The disease-
of different climates vary, and the observations on which it is founded,
have been too frequently repeated to permit us to doubt that  there is a
tendency  to  periodic changes in the fevers of certain latitudes.  But
were it wholly unfounded, it is necessary to be acquainted with a doc-
trine so generally blended with medical writings.
  Physicians were soon led to observe what has been  termed the crisis
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 happen.   Having  observed  a crisis
take place  in more than one patient on the same day of the fever, they
were  led to pay attention to this  day in other cases, and when they
found a day, as the 4th, 7th, &e. of the disease on which a crisis hap-
pened  more frequently than on most  other  days,  this they  termed a
critical or judicial day.   Thus the days, during which  a fever lasts,
came to be divided into those which are, and those which are not, crit-
ical.   Those numbers which are made up by adding alternately four
and three (with  an exception I  shall presently point out) denote  the
chief critical days, the 4th, 7th, 11th, 14th, &,c.t
  The other days on which crises frequently  happen are termed, by
Galen, coincidental; and are esteemed an inferiour class of critical
days,  because on them,  crises do not happen  so often,  as on  the true
critical days.  When crises happen on  the coincidental critical days,
Galen  taught  that the natural course of the  disease  is disturbed by
some irritation of the-system, or by a new attack;  thus he calls the

  • Fordyce's second Dissertation on Simple Fever.
  f Dr. Cullen considers all the uneven days, the 3d, 5th,  &.c. to the 11th, as
critical days.  After the 11th he regards every third day as critical, the 14th,
17th, and 20th.  lie marks no critical day beyond the 20th.  «' Because (lie
" observes)  though fevers arc sometimes protracted beyond this period,  it is
"however more rarely, so that there arc not a sufficient number of observa*
tl tions  to ascertain the cour<e of them ; and further, because it is probable
" that in fevers long protracted, the movements become less exact and regu-
" lar, and therefore less easily observed."  6re Dr. Cullen's First Lines, vol. i. 
REMITTING  FEVERS.                   69
7th a good critical day, but the 5th a bad one ; for he supposed that a
favourable crisis happening on a  coincidental, was less  to be depend-
ed upon, than that happening on a true, critical day.*
   In the first week, or, as it is called, septenary, there are many co-
incidental and critical days, because, according to the ancients, the vi-
olence of fevers which run their course in so short a time, often dis-
turbs the crisis which ought only  to happen on the 4th or 7th day.  In
the second septenary, the ninth is esteemed almost the only coinciden-
tal critical day ; thus it is, that after the  14th day,  the  coincidental
critical days are of little  consequence, the crisis generally happening
on or about the true,  critical days.
   Hippocrates observed, that the crisis happened very often on the
fourth day of the  first and second week, that is, on  the 4th and 11th
days of the disease.  These  days he therefore esteemed of much im-
portance in fevers.   But  as he observed the crisis to happen very fre-
quently 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 dnv, not the 21st, is the last
day of the third week, and this  also he lliought a chief critical day:
ot all  these days, crises are said to happen most frequently on the 17th.
   The critical days which follow the 20ih are the 21th, 27th,  34th,
40th, not the 41st, which is the 7th day from the 34th, for a? the third
week begins on the same day on which the 2d ends, so the Gth  begin.*
on the same  day on which the 5th ends;  thus we count but six day-
for each of these weeks.   The same  happens in the 9th, 1 Jth, and
every succeeding  3d week, therefore the GOth, POth,  &c. days, are
eritical days.
   Notwithstanding what is hero said, Hippocrates  remarks, that fever*.
unless they leave  the  patient on  niuven  days,  usually  rrti.rn ; the
most favourable termination therefore generally takes place on uneven
days.   In some places he calls the 21st a critical  day ; tbeso passages
are by many believed to be spurious.   This, says Van Swieten, is ve-
ry probable, since there is no mention of the 21st day  in the histories
of the cases given in  his book of epidemics.   In the doctrine of crili-

  * The opinion-that the course of the fever is disturbed  when the termina-
tion happens on any other but a critical day, seemed farther confirmed by
the observations of Hippocrates ; from which it appears, that although the
fatal, like the favourable terminations, generally happen on critical days, yet
a much larger proportion of the  former, than of the latter, happen on the non-
critical days.  Thus, Dr. Cullen  remarks, all the terminations of fevers, men-
tioned  in the writings of Hippocrates, wliich happened on the 6'Ji day, were
either fatal, or not finally salutary. 
70
INTERMITTING AND
  cal days, as delivered by Hippocrates, however, there are certainly
  contradictions;  this Dr. Jackson attributes to his having related  some
  cases from memory, and others only in part given him by different per-
  sons ;  he observes also, that when the fever began in the evening, or
  during the night, Hippocrates  generally reckoned the following  the
  first day of the disease.  Dr. Jackson adds, that the  21st  is too fre-
  quently mentioned in the writings of Hippocrates as a critical day, to
  be considered, as Van Swieten and Dr. Cullen suppose it to be, an er-
  rour in the original manuscript.   Dr. Cullen  ascribesmany  of the con-
  tradictions in the doctrine of critical days to the opinion of Hippocra-
  tes respecting the  supposed  power of numbers. -
    Certain terminations, according  to the Ancients,  most  frequently
  take place on certain critical days; 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 generally terminate by sweat.
  It was supposed indeed  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  pa-
  tients  are good, if they begin on the 3d,  5th, 7th, 9th,  11th,  14th,
  17th,  21st * 27th, 31st, or 34th days, for the sweats which  happen not
  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;  in this way the doc-
  trine assists the prognosis, and critical days have received the name of
  judicial or indicating.
    If on a critical day the patient  finds himself better, although on the
  next day he  relapses into his former state, the physician may expect a
  more considerable remission on the following critical day.   On the con-
  trary, if the 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 are milder.   Thus every
  critical day is an  indicating day to that which succeeds it.
    Admitting this, it follows that by carefully attending to tlie severity
  of the symptoms  on these days, or the degree of relief obtained, wc

    * It has already been observed that Dr. Cullen supposes the  21st day by
  mistake put for the 20th. He alledges that in continued fevers the tertian
  type prevails to the 11th day  and from this day to the 20th the quartan type.
  But, admitting what he says of the 21st day to  be just, he cannot reconcile
  his view of the doctrine of critical days with what is said of the 4th day  in
  the writings of Hippocrates; unless we admit what he alledges, which  is
  probable, that the writings attributed to Hippocrates are  in fact the works
  of different people, and that the most genuine of them have suffered corrup-
  tions 
REMITTING  FEVERS.                  71
may not only form a conjecture respecting the termination of the fever,
but also respecting its distance.   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 exa-
cerbation which takes place ; on the other hand, if a remission of the
symptoms happens on the critical  days, we expect  a favourable ter-
mination, and judge of its distance  from  the degree of the remission.
   In proportion as the disease is slower in  its progress, the  critical
days are more  distant from  each other: thus  in  fevers which do  not
exceed  three weeks, the 4th, 7th, 11th, &c. are  critical days ; 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 contin-
ues above forty days, Hippocrates esteems only  every 20th  day cri-
tical, to wit, the 60tb,  80th, and  100th, &c.   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,  and
 we do  not find in modern authors  any addition of consequence, if we
 except what is said of the  application  of this doctrine to intermittents
 of complicated types by Dr. Jackson, in his account of the diseases of
 Jamaica.
    The reduplication of paroxysms, which often  takes place in inter-
 mittents, 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 of the odd day ter-
 " minated the disease, the crisis  was necessarily on an odd  day ; but
 " if that fever, (namely that consisting of the paroxysms which super-
 " vened 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,  the crisis  was then  on an even
  " day, reckoning from the beginning of the illness,  though  still on an
 " odd day, dating from the commencement  of  the second  fever.  It
  " was the observation of  this fact which first gave me the idea of cal-
  " culating the critical days by the periods of the disease."
    Dr. Jackson always reckoned  the period of the tertian 48 hours, al-
  lowing that time for every revolution, although it was sometimes com-
  pleted in less.  As for quotidians, he observes, their crises were gene-
  rally  on an odd day.   It is not to be overlooked that  in double ter-
  tians, on whatever day the crisis happens, Dr. Jackson's mode of n c\-
  oning mal.rs  it an odd day. 
72
INTERMITTING  AND
   By simplifying intermittents in this way,  he observes, their  crisis
will be found to happen as regularly on the critical days  as those of
continued fever.  Of sixty cases, which under his care terminated fa-
vourably, ten terminated on the 3d day, ten on the 5th, twenty on the
7th, ten on the 9th, five on the 11th, three on the 13th, and two on
the 17th.   This nearly coincides with what Hippocrates  says of the
days on  which fevers terminate by sweats, which has  just heen quo-
ted.
   " Of nine cases  which terminated  fatally, (Dr. Jackson continues)
■** one terminated on  the 6th, one on the 7th,  six on the 8th, and  one
" on the 10th.   The even days, he observes, were fatal in the propor-
tion of three to one, which he accounts for in the following manner.
The paroxysm which  destroyed life, like most other changes, took
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 sustained, so that death generally happen-
ed on the next, that is,  the even day ; although it was  the conse-
quence of a violent paroxysm which had taken place on the odd day.
It also sometimes happened that the patient was tolerably well after this
severe paroxysm, but a new one recurring after a short interval, speed-
ily provedfatal 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 then  he died in the height of a severe paroxysm, ol-
" ten carried off by convulsions, apoplexy, or some other accident."
   Dr. Cleghorn has  observed  of complicated intermittents, 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 easily reconciled with  Dr.
Jackson's as Dr. Cleghorn reckons in the usual way without simplify-
ing the complicated types.
   It is remarkable, that we still find something in the  severity of the
paroxysm which disposes to health.  It was formerly observed that in
double tertians, the most severe paroxysm is generally followed by th»-
niost complete apyrexia,  and that in  intermittents in  general au un-
usually severe paroxysm  often proves the last,  the patient  remaining
well after it.
   Many of the first  physicians of antiquity  endeavour to assign the
cause of these periodic movements in fevers.  Their opinions, howev-
er, are now justly regarded as groundless, and many of them indeed arc
quite whimsical.   The most ancient opinion was founded on the  Py-
thagorean doctrine of the  power of numbers.  Hippocrates  seems to 
REMITTING FEVERS.
73
have been of this opinion ; Galen disclaims so absurd a doctrine, 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 writ-
ers, and we shall  find that an  opinion similar to it,  and claiming thn
authority of extensive observation has lately been maintained.
                           CHAP. HI.

 Of the Morbid Appearances discovered by  Dissection, in those  who
                   die of Intermitting Fevers.

   Many diseases prove fatal, without leaving any trace to be discover-
 ed by dissection.  This,  strictly speaking,  is true of intermitting as'
 well as of continued fever.   Various morbid appearances indeed are
 observed in those who die of agues ; none of them however can be re-
 garded as essentially connected with the fever ; none of them seem at
 all connected with its cause, nor are there any which can be regarded
 as its immediate consequence.   Intermittents are often the cause of oth-
 er diseases, indurations of the different viscera, &c. and in this view may
 be regarded as the cause of the morbid appearances belonging to them.
 But we must be careful not to confound these fevers with their conse-
 quences, which has given rise to the opinion of intermittents depend-
 ing on certain states of the bile, and  other ill-founded hypotheses.  I
 have had occasion to enumerate the diseases most frequently complica-
 ted with agues ; their effects in the different cavities of the body, we
 find mentioned by writers as the consequences of intermittents.
   The stomach, intestines, omentum, and mesentery, are  frequently
 found inflamed, or of a dark colour, and sometimes sphacelated.   The
 omentum and mesentery  sometimes  appear wasted; in other cases
 have tumours formed on them.   The stomach and intestines are often
 enlarged, the consequence of having been distended with air; and in
 various parts of the latter, preternatural constrictions are frequently ob-
 served.  The gall bladder is often turgid, and an unusual quantity of
 bile is found in the stomach and intestiues.   The liver is frequently in-
 durated and enlarged,  sometimes diminished and of a  whitish colour,
 and it has now and then been found, only six or eight hours after death
soft, and it is said, putrid.  In some cases it  seems gorged with blood,
 the venae 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 liable to be af-
fected in intermittents.   It is often enlarged, frequently weighing many
                              10 
74
INTERMITTING AND
 pounds.  Its structure has sometimes been so completely destroyed,
 that it presented the appearance of congealed blood wrapt in a mem-
 brane.  More frequently it is indurated ; in this state it has  got the
 name of ague cake,  being felt by the patient himself through the integ-
 uments of the abdomen.  This  affection of the spleen  is particularly
 apt to occur in the  bilious  remittents of tropical  climates.   Strack
 thinks that children  are more liable to it than adults.  The mesenteric
 and other smaller glands of the abdomen are also frequently  found in-
 durated.
   Traces of inflammation in the lungs and pleura frequently appear, and
 the former are sometimes found soft and gangrenous.  The heart too is
 often flaccid and enlarged,  and the  vessels of the  lungs turgid,  with
 dark coloured blood.  This state of the heart and blood vessels is the
 consequence of the circulation in the lungs having  been impeded for
 some time before death, so that it is most  remarkable in those cases
 where the dyspnoea has been greatest.   When the.skin is tinged with
 yellow, the serum in the thorax and other cavities is of course of the
 same colour.
  Morbid appearances of the head in intermittents are less frequently ob-
 served.  Polypi are sometimes  found in the sinuses.   But these are
 frequently met  with of whatever disease the patient dies.  Traces of
 inflammation, and even abscesses, are now and  then met with in the
 brain.
   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 appear-
 ance, if we except a general state of flaccidity when the strength has
 been greatly exhausted, that can be regarded as essentially connected
with the fever, and it has probably been magnified for  the purpose of
serving certain hypotheses.
                           CHAP. IV.          ,

              Of the Causes of Intermitting Fevers.

   In speaking of the remote causes I shall not always treat seperately
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 ;  in many diseases the
same circumstances acting  sometimes as predisposing, at  other time?
as exciting causes. 
REMITTING FEVERS.
75
    In intermitting fevers this division of the remote causes is less ob-
 jectionable than in most other diseases ; for various observations seem
 to prove that these fevers arise chiefly, if not solely, from one exciting
 cause, effluvia from  marshy grounds, called by  medical writers the
 marsh miasma.*

                              SECT. I.

           Of the predisposing causes of Intermitting Fevers.

    Of the various circumstances favourable to the action of the exciting
 tiause of intermittents, there are some which operate by rendering the
 body more susceptible  of its action; others which seem  to act by in-
 creasing the  power of  the cause itself;  and some  which act in both
 ways.  It will be the most distinct plan, and save repetition, to con-
 sider the whole, under the head of marsh miasma, as circumstances fa-
 vourable to its action in producing intermitting fev«r.

                               SEC. II.

              Of the exciting causes of Intermitting  Fevers.

    We have  many  instances of the striking effects of an atmosphere
 loaded with noxious vapours.  White females born and constantly re-
 siding in the lower districts of the province of Georgia, it is said,  have

   * Respecting the remote cause of intermitting fever,  it is always one, and
 the same, and arises from marshes, or from the waters which issue from those
 places j but it is difficult to determine precisely, what  the circumstances are
 that produce this specific poison, as stagnant waters, do not always produce
 it  In twenty-eight years  practice on the banks of Connecticut river, and on
 all its tributary streams, in New-Hampshire and Vermont, I have never seen
 a patient sick of the intermitting fever, who contracted it in that region, not-
 withstanding, there are many ponds in that country, both natural and artifi-
 cial.  While on the banks  of the North river, whose tributary  streams issue
 from places producing the cause of intermitting fever,  and in situations re-
 mote, from marshes, and  stagnant waters, the inhabitants are often affected
 with this disease. From the known fact,  that large districts of country, are
 entirely exempt from intermitting fever, it appears, that no combination of
 circumstances, can produce the disease, without the specific cause, any more
 than they can produce the small-pox, without the contagion.
  There is one circumstance, respecting the effects of marsh miasmata on the
human body, worthy of notice. In some instances, it produces the intermitting
fever in a few weeks, after it is received, and in others, many months elapse,
before the patient feels the effects of it.  I have known it produce its first
sensible effects on the system, more than a year after its reception into the
 bodv.                                                         N. S. 
76                   INTERMITTING AND
seldom lived  beyond the age of 40 ; males sometimes approach to fif-
ty.   Similar  observations have been made  respecting some parts of
Egypt near the banks of the Nile.*  There are swampy situations in
the  Carolinas and Virginia which are destructive of life in a still great-
er degree; "  I am credibly informed (says Dr. Jacksont) that there is
" not on record an instance of a person, born in Peterborough in Vir-
" ginia and constantly residing in the same place, who has lived to the
" age of twenty-one."
  The influence of marsh miasma in producing agues was first observ-
ed by Lancisi, about the middle of the seventeenth century, and is now
so generally admitted, that it is unnecessary to adduce many facts in
support of it.
  It is almost an universal observation,  indeed, that intermittents pre-.
vail in low marshy countries.  Our climate, on the whole, cannot be
regarded as favourable to the production of these  fevers.   In Lincoln-
shire, however, and the  other fenny counties, there are few diseases
more  frequent.   Near stagnant pools, especially when  the weather is
hot, they are often epidemic.
  In other countries we have more remarkable proofs of the effects of
marsh miasma.   In Egypt,  after  the  Nile  retires, leaving the wet
ground covered with a variety of putrifying animal and vegetable sub-
stances, these fevers  begin  to prevail.   We are  informed that  the
Arabs, when they wish to be revenged on the Turks of Bussarah, break
down part of the banks of the Euphrates, which by the deserts in the
neighbourhod of that city are laid under water.  The stagnating water
and dead fish soon become putrid, and dreadful fevers, generally of the
remitting form, are the consequence.   The  fevers induced by a single
inundation of these deserts have been known to destroy between twelve
and fourteen thousand of the inhabitants of Bussarah.J
  When so powerful a cause is applied, we seldom meet  with inter-
mittents.  Intermittents and  remittents arise  from  different degrees of
the  same cause.  " In Jamaica (Dr. John Hunter observes) the  fevers
" in the most healthy seasons are generally intermittents ;  in the rainy
c* and other unhealthy seasons, remittents.§
  It is generally observed that  during the more temperate seasons the
regular intermittents prevail, and for the most part yield readily to the

  * Bruce's Travels to Abyssinia, &c.
  f Dr. Jackson's Account of the Diseases  of Jamaica.
  * See the Observations on the Fever of Bussarah, above alluded to, in the
Transactions of a Society for the Improvement, &c. for 1793.
  § See the observation of Sir J. Pringle on the diseases of Flanders, and Oth-
er works on this subject. 
REMITTING FEVERS.
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.
The dreadful remittent of Bussarah is always most feared in the hot-
test seasons.   And  in  the higher latitudes, even when the  autumnal
fevers are of the most continued kind, if they arise from marsh miasma,
they begin to  intermit when  the cold weather sets in,  and  before the
winter is far advanced,  often terminate  in simple tertians or quartans.
   The true intermitting fever, therefore, is a  disease neither of very
warm nor very cold climates.   Bontius,* Lysons,t Clark,J  and others
remark, that it is seldom met with near  the equator.   The  remittent
may be regarded as the endemic  of sultry climates.   Upon  the whole,
however, of the climates which may be called temperate, the warmest
are the most  favourable to the production of intermittents.   In  such
climates as our own they generally prevail most when the weather has
been for some time unusually warm, particularly when the  rains sud-
denly set in after a warm summer.
   Sudden changes of weather, whether from hot to cold,  or the contra-
ry, are favourable to the production of intermittents.   It is  constantly
found,  says Raymond§  of the  intermittents, of Mettleburgh, that  if
the cold and wet weather of autumn suddenly  succeed an unusual  dry
and warm summer, these fevers rage more  generally, and show a great-
er tendency to become malignant.
   It is particularly observed also by army physicians, that  agues  arc
frequent if the warm day is succeeded  by a cold damp night.  This
often happens in marshy countries : for the  exhalations which   rise
during the  day being condensed when the  influence of the sun is \\with-
drawn,  the ground is covered for some hours with a thick mist.
   Damp, applied to the body, is  particularly favourable to  the opera-
tion of the marsh miasma.   It is observed  that those who live on small
eminences, though equally exposed to the  marsh miasma, are less lia-
ble to agues ;  and that people inhabiting ground floors are more liable
to them than those in higher parts of the same houses.   Sir John Prin-
gle even observes, that of two battallions,  quartered near each other,
and on ground of the same height, the one in a town,  the other in the
peasants' houses in the country, the latter  was more  subject to agues,
from the greater dampness of the cottages.  In the works of Dr. Donald

  * De Medicina Indorum.        f Essays on Fevers, &.c.    «
  i On the diseases in long Voyages to hot Climates.
  § Raymond on the intermittents of  Mettleburgh, in Baldinger's Sylloge
Opusculorum. 
78                  INTERMITTING AND
Monro, Dr. Brocklesby, and other army physicians,  we find  similar
observations.
  It has been urged, that we cannot  suppose moisture  favourable to
the  production of agues, as they are more  frequent when there is but
little water remaining on the surface, that when the whole country is
covered with it.   The inhabitants  of Egypt, for example, are but lit-
tle troubled with intermittents while their conntry  lies  under water ;
it is after  the Nile retires within its banks that they chiefly prevail.
And in the West-Indies, it is observed,  that while the pools are deep
the  fevers are either few, or of a milder nature.  It is generally after
their bottoms appear, that the worst fevers begin to rage.
  But when the country is under water, there is, of course, less marsh
miasma than when the moist ground is exposed to the action of the sun.
Besides, the rapidity of  evaporation we know  is proportioned  to the
temperature and extent of surface.   When the ground is wholly over-
flowed it presents a smooth and consequently the least possible surface,
while, from the water being nearly pellucid, the  rays of the sun have
but little effect in raising its temperature.*  When the water is drained
off, the surface is increased by its being rendered unequal, and  the sun
acting now, not on the pellucid  water, but the moist ground,  greatly
increases its temperature, which is farther increased by the putrefaction
that in such circumstances proceeds rapidly.   We frequently observe
a thick mist over damp ground, but seldom on the surface of water.
  Moisture seems to have so great a share in  the  production of agues,
that at first view we are inclined to attribute  the whole tendency  of
marsh  miasma to  the damp that accompanies it.   Dr. Moseley t  re
marks, that agues are frequent during the rainy season  in  warm cli-
mates where there are  no marshes.  And Dr.  Lind \ observes, that  a
person may be seized with  an ague in the most wholesome  spot  of
ground in  England.   It is not a fair objection to this opinion,  that  an
atmosphere loaded with moisture is not found  to produce agues at sea,
since on ship-board every thing is much freer  from damp than in damp
situations  on land.
  There are many observations, however, which seem to prove, that
whatever effect damp may have  in producing  agues, it is not the only,
3nd probably not the chief, circumstance to which  marsh  miasma owes
its effects.   Dr. Lind remarks, that ships lying at a  considerable dis-

  * It appear*, from die experiments of Mr. Melvil, in the Edinburgh Liter-
ary Essays,  that light only increases temperature in proportion as it is ob-
structed, reflected, or refracted.
  ■j  See Dr. Moseley on Tropical Dise.i^e.s.
  %  Seethe Appendix to his Essavs 
                    REMITTING FEVERS.                  79

 tance from a swampy shore,  escape intermittents ;  while others lying
 nearer, about the distance of a mile, perhaps,  are subject to them.
 We cannot in this case  attribute  them  to  the moisture of the land
 breeze,  since the  thickest fogs on ship-board do  not produce them.
 Many have doubled whether damp ever produces agues independently
 of marsh miasma.   That it renews them there can  be no doubt.
   It seems to be, by the damp they occassion, that extensive woods fa-
 vour the action of marsh miasma.   They shed a constant moisture on
 the ground, and prevent both the rays of the sun from falling  upon it,
 and the wind from passing over it.   Besides, they confine the moist air,
 so that those who inhabit woody places  are  constantly exposed to an
 atmosphere loaded with moisture.
   Soldiers encamped in woods seldom escape agues.  There is ample
 proof of this observation in the works of Sir John Pringle, Dr. Cleghorn,
 and others.   It  appears from other observations, however, particularly
 those of Dr. Jackson and Dr. Rush, that scattered woods are of service,
 and in particular  tend to prevent agues  among those who live in the
 open country.   One very  evident way in which  they may have this
 effect, is by preventing the diffusion of  marsh miasma.   Army physi-
cians, therefore, recommend having a wood, if possible, between mar-
 shy grounds and an encampment.
   If Dr. Rush's observations be just, this is not the only way in which
 they tend to prevent these fevers.   It would lead  into too tedious a dis-
 cussion to consider this subject at length ;  the  reader may consult his
 Observations on  the Causes of ilie Increase of Intermitting Fevers in
 Pennsylvania.*
   The banks of rivers, if not  swampy, have been recommended for the
 encampment  of troops, with a view to prevent agues ; the motion of
 the water occasioning a constant circulation of air,  and thus tending to
 carry off the noxious vapours.
   There are few causes which in a greater degree promote the action
 of marsh miasma than exposure to the night air.  It appears from the
 observations of  Mr. Badinock,t that this is a principal  cause of the
 bilious  remitting fever of sultry latitudes  ; ana to the same cause Bon-
 tius wholly attributes the worst fevers of Baiavia.J   It is well known,

  * See the 2d vol. of Rush's Med. Inq. and Obs.
  + See the 4th vol. of the Medical Observations and Inquiries.
  * Of the baneful effects of the night air at Batavia, Dr. Lind relates a strik-
 ing proof.  " During the sickly season, a boat, belonging to the Midway man
 •* of war, which attended on shore every night to bring fresh prox isions, was
 M three times successively manned, not one of her crew having survived fliat
 *' service." 
80                   INTERMITTING  AND

indeed, both in the East and West-Indies,  that people are often attack-
ed  with  agues from passing a single night abroad, especially  in  the
woods.
  Dr. Hales, in the 1st vol. of the Medical Museum, proposes wetting
the body with salt water, as a means of preventing the bad effects of
exposure to the night dews of warm countries, and adduces some facts
in support of  the benefit derived from this  practice.
  Respecting the predisposing causes of  intermittents in general, it
may be observed, that whatever tends to weaken the body, predisposes
to them, whether it be excessive heat, or a cold  and damp atmosphere,
a poor and scanty diet, or gluttony and an abuse of  fermented liquors,
too much exercise or habitual indolence, bad cloathing, strong passions,
long watching, the  habitual use  of  irritating medicines, particularly
strong cathartics, and  whatever else tends to disorder the primae viae,
an improper use of  the warm or cold bath, suppressed sweats or erup-
tions, or the ceasing or increase of any  habitual discharge.  In short,
those who live well and  at ease, who are not given to excess in  eating
or drinking,  nor disturbed by strong passions, and who use moderate
and regular exercise, are least subject to intermittents.
  Some have thought  that particular kinds of food predispose to these
fevers.  Aurivillius maintains that those who live on pork and fish,  are
more subject  to them than others ; those at least are so,  who live on
food of a bad quality and difficult digestion.
  Almost all  the circumstances which have been mentioned as favour-
able to the action of marsh miasma, are  capable of renewing intermit-
tents, independently of the cause which first produced them.
  A curious  circumstance seems  to deserve a place among their pre-
disposing causes,  which, like the  doctrine of critical  days,  has  not
gained general credit; although,  like that also, it seems to rest  on  ex-
tensive observation.   Dr. Lind,  Dr. Jackson, and others,  have made
some observations relating to the  influence  which the changes of the
moon are supposed to have in determining the accession or renewal of
fevers, particularly those of warm climates.
  After stating briefly what has been done  by others on this subject,
the latter observes,  "  In  order to  ascertain the truth of this conjecture,
" which I considered a matter of some  importance, I provided myself
" with the  almanack of the year 1776, and  marked in the blank  leaf
" of it, the precise date of attack of all those  fevers which came  un-
" der my care."  On looking over those memoranda at the end of  the
year, he found he had set down thirty cases of  proper remitting fever,
twenty-eight of which made their attack on one or  other of the seven
days immediately preceding new or full moon. 
                     REMITTING FEVERS.                   81

   He continued the same plan through the following year, the result of
which was similar.  Besides the  cases of proper remitting  fevers,
there were also marked in the almanack, many  slight feverish  disor-
ders, the accession of which, in like manner, was for the most part in
the second and last quarters of  the moon.   The greatest  number of
these accessions  were within three  or four days  of the  new or full
moon, for the nearer these periods, the more frequent were the attacks.
   Dr. Jackson supports  these observations by  others, and from the
manner in which they were made, there was  little room  for fallacy.
Dr. Lind accounts for the frequency of fevers at the new and full moon,
by the greater height  of the tides at  these periods.  This, however,
the former thinks  cannot be  admitted, since the influence of the  moon
in fevers is as observable in inland situations, as on the coast.*  Con-
cerning  this  subject, future  and  very  extensive  experience must
decide.
   We know from the laws of gravitation, that at  new  and  full moon,
every body in those parts of the earth where the sun at twelve o'clock
of the day, is a certain number  of degrees above  the horizon,  has its
weight twice in the course  of the twenty-four hours more  diminished
and more increased than when  the moon is in its  quarters, and  the
nearer the sun is  to the zenith at twelve o'clock, the greater it is evi-
dent this difference must  be.  What effect this may have on the  hu-
man body, we neither can, nor  probably ever shall be able to deter-
mine.   It  is in vain to say that  the difference is too inconsiderable to
produce any effect, when we speak  of a structure  so complicated, in
many of its parts so sensible, and of which  it must be confessed we
know so little.   It is worthy of remark, that it is in those parts of the
world, where the difference of weight just alluded to, is most consider-
able, namely, within the tropics, that the  changes of the  moon have
been observed to influence the accession of fevers.   It is a curious fact,
mentioned by Dr. Lind, that several sailors and others were attacked
with fevers during an eclipse of  the moon ; that is, at the very time of
full moon.
   It is a common opinion, that salt water mixed with the fresh water
of marshes, produces a more noxious  exhalation than fresh water alone.
Sir John  Pringle considers this fact as  undoubted.   The opinion  has
gained ground by its having been found that a  small quantity of  salt
promotes  fermentation.    The  author just mentioned, who made exr

  * For further information on this subject, the reader may consult the work
from which the above quotation is  extracted, Dr. Jackson's Treatise on  the
Fevers of Jamaica ; ha may also consult Dr. Lind's Thesis and Dr. Balfour «n
Putrid Fevers.
                                11 
82                  INTERMITTING AND

periments in order to determine this point, observes,  " Nothing could
" be more unexpected than to find sea-salt a hastener of putrefaction ;
" but the  fact is thus—One dram of salt preserves two drams of fresh
" beef in two ounces of water about thirty hours uncorrupted, in a heat
" equal  to that of the human body ; or what amounts to the same, this
" quantity of salt keeps flesh sweet twenty hours longer than pure wa-
" ter ; but half a dram of salt does not preserve it above two hours lon-
" ger than pure water.   Now I have since found (he adds) that twen-
" ty-five grains have little or no antiseptic virtue,  and that ten grains
" both hasten and heighten the putrefaction."*
  By others, however it is asserted, that whatever be the septic power
of a small quantity of salt, the admixture of salt water with the water of
marshes is not found to increase their tendency to produce intermitting
fevers.  And Dr. Jackson remarks, that as far as he has observed, the
usual epidemic was less frequent and less formidable on the banks of riv-
ers  after their waters become mixed with those of the sea, than before
this happened, unless the circumstances were in other respects more fa-
vourable to the production of the disease.
  He also affirms, that although sea and river water are mixed together
in  various proportions in Savanna la Mar, in Jamaica, and in the nu-
merous islands on the coasts of die Carolinas, yet these places are sel-
dom more unhealthy than where the lakes and rivers are unmixed.
 . Concerning the manner in which  marsh  miasma acts in produc-
ing agues we can say nothing with certainty.  Nor has it even been
ascertained, indeed, what the marsh miasma is.  We know that it is the
effluvia, together with the moisture, perhaps of marshy grounds ; and
this is all that we know  of iL   Is it the gas disengaged in the  process
of putrefaction ?
  Intermitting fever seems in general  to arise from repeated exposure
to marsh miasma.   In most cases we cannot observe that the patient at
the time the fever makes its attack, is  particularly exposed to its action.
Sometimes its effects are  more sudden.  " In the month  of August,
1765," Dr. Lind observes, " the thermometer often rose to  82° in the
" middle of the day, and the  marines, who were exercised  early in the
" morning on  the south sea-beach, from the effects of the stagnant wa-
" ters of  an adjoining morass, suffered mych ; half a  dozen at a time
" were often taken ill in their ranks  when under arms."
  I have  already had occasion  to observe,  that  the  marsh miasma is
generally regarded as the only exciting cause of intermitting and remit-
ting fevers.   Contagion, however, seems to have a claim  to be ranked
as such.   With regard to intermittents it may be doubted  if they ever

  * Appendix to Sir John Pringle's Observations, &.c. 
REMITTIING FEVERS.
83
arise from this cause.   Trnka, in his elaborate treatise, entitled, Histo-
ria Febrium Intermittentium, quotes a variety of authors, with a view
to prove that even they are sometimes contagious.  As to remittents,
they are  frequently so, and  in general the more so the more they as-
sume the continued form.

                                    t
                            CHAP. V.

             Of the Treatment of Intermitting Fever.

   The treatment of intermitting and remitting fever, may be divided
into two  parts, that  of the  paroxysm, and  that of the  remission or
apyrexia.   The former is to be regarded as palliative only; it is on
the treatment during the apyrexia or remission that we depend for the
Cure.

                            SECT. I.

               Of the Treatment during the Paroxysm.

   Our view in the treatment of the paroxysm is constantly to  put a
fimak to the stage which is present, by inducing that which naturally
succeeds  it, till a general sweat comes on.
   There are two indications, therefore,  in the paroxysm of an inter-
mittent ;  to endeavour during the cold stage, to  induce the hot; and
while the patient labours under the hot stage, to promote a free secre-
tion by the skin.   The following observations,  however, must be kept
in sight ; that although it is our view during the cold fit, to induce the
hot, we are not indiscriminately to employ every means which tend to
this effect.   Many are otherwise so hurtful, that their bad effects more
than compensate for any advantage  to be procured by shortening the
cold fit.   A similar remark applies to the hot stage ;  all the means we
employ at  this period tend to promote a sweat, but every thing which
has this tendency is not proper.

        1. Of the Means to be employed during the Cold Fit.

   The patient's feelings generally point" out the greater part of  the
treatment necessary in the cold fit.   He should be put to bed and kept
warm,  and  some  have recommended the warm bath.  In  warm cli-
mates it is both beneficial and grateful to the  patient to stretch himself
out in the sunshine.
   The moderate  use of warm diluting, but not  stimulating, fluids is 
84
INTERMITTING AND
 proper.   The latter increase the symptoms  of the hot fit.   All kinds
 of aromatics, therefore,  distilled liquors,  and  wines, should be used
 with caution, and altogether forbidden when there is any tendency to
 the inflammatory diathesis.  Many  do not allow drink of any kind, in
 the  cold fit, except to promote vomiting, as much fluid in the stomach
 and bowels, generally increases the oppression.*
   It  is common in all kinds of fever, to acidulate the patient's drink.
 For this purpose cream of tartar, or the vegetable, vitriolic or muriatic
 acids are employed, and they are particularly useful when the stomach
 and bowels  are loaded  with bile.   These,  however,  and the other
 medicines, which have been termed refrigerant, are  improper in  the
 cold stage.
   The most effectual means of bringing on the hot fit, is the operation
 of an emetic.   This, if the disease be severe, should be exhibited  as
 soon as the  cold stage is formed, if  it  has not been given before ;  for
 we shall find that thu  cold  fit is sometimes prevented by this means.t
 The  antimonium tartarisatum is here the best  emetic, and should be
 given in pretty  large doses.  Nauseating doses are more properly  in-
 dicated in the hot stage.   When spontaneous vomiting from bile  or
 other irritating matter comes on, diluents only are necessary.
   Purging in the cold stage is improper, and blood-letting altogether in-
 admissible.  Blisters are proper if coma or delirium attend.   They may
 be applied to the back of the neck, or if these symptoms be consider-
 able, the head may be shaved, and a large blister applied over it.J

   * See the observations of Dr. Cleghorn and others.
   7 For the use of emetics in the cold fit, the reader may consult many of the
 authors who have been mentioned.   See also a paper in the 4th volume of the
 Bdinburgh Medical Essays and Observations, by Dr. Thompson.
   t There is a curious paper, by Mr. Kellie, in the 19Ui vol. of Dr. Duncan's
 Medical Commentaries, concerning the  application of tourniquetes  to  the
 limbs, with a view to prevent or remove the cold fit of agues.  From  the ob.
 servations which he made, he drew the following conclusions :__1.  That at
 any time during the cold  fit of an intermittent, if tourniquetes be so applied
 as to  obstruct the circulation in two of the extremities, in three minutes
thereafter the hot stage will be induced.—2. That if the tourniquetes be ap-
 plied  previous to die accession of the paroxysm,  die cold stage will  be  en.
tirely prevented.—3. that where the cold stage of an ague is either thus
 shortened or prevented, the following hot stage is rendered both  milder  and
 shorter.   Mr. Kellie's observations deserve attention ; they are too confined
 however fully to ascertain either the success or safety of his proposal. I am
 informed that his experiments have been repeated at the infirmary of Edin.
burgh without success.  Mr. Kellie has since published a work on the use of
 tourniquetes in various diseases-. 
REMITTING  FEVERS.                  8a
  Such are the few- directions  to be attended to in treating the cold
tit of an  intermittent.  The practice  in the hot stage is rather  more
complicated.

         2.  Of the Means to be employed during the Hot Fit.

  The indication of cure in the hot stage of intermittents, I have already
had occasion to observe, is to promote a flow of sweat.   This is done,
  I. By removing every cause of irritation.
  2.  By dilution.
  3.  By the use of sudorifics.
  4.  By moderating excitement when the symptoms of synocha attend.
  6.  By supporting  the strength when debility prevails.
  1.  Every cause of irritation tends  to protract the hot fit, Cathar-
tics, it has just been  observed, are  improper in the cold   fit ;  they are
necessary in the hot, unless the bowels are  moved spontaneously ;  but
much purging, as counteracting the tendency to sweat, is improper.
  Of cathartics, calomel has lately been much recommended in fevers
of all kinds, especially by the practitioners of warm climates ;  when
the primae viae are oppres.sed with bile it should always at least form a
part of the cathartic*   It will presently appear that small doses of an-
timonium tartarisatum are, for another purpose, exhibited in the hot
stage of intermittents.  These often sufficiently excite the bowels.
  The exhibition of emetics in this disease sometimes renders that of
other medicines troublesome.   But as emetics are not so well suited to
the second as  the first stage of intermittents, the only difficulty  arises
from the operation of the emetic given in  the cold fit still continuing.
When this happens, if the bowels are languid we mu^thave recourse to
clysters.  They are not however to be depended on,  as their action is
chiefly confined to the larger intestines, and a cathartic  should be ex-
hibited as soon as it can be made to lie on the stomach.
   Various causes of irritation will  be   pointed out when  we  speak of
continued fever, as it is more  particularly  in it,  that their effects  are
felt.   As far as these operate in the paroxysm of an ague, the observa-
tions which will then be made are applicable to it.
  2. During the hot fit the patient should  not be  refused the use of
diluting  fluids.  Many indeed do not permit him to drink till the swea-
ting stage commences.  But  thirst is hurtful, and unless the quantity
be very  large, such fluids in the hot fit will not be found to increase the
Oppression,  and they tend to promote sweat.
   In the cold stage, and while the hot is forming, whatever drink the

  ■* Dr Lvsons's Treatise on the u<je of Camphor and Calomel in Fevers. 
86                   INTERMITTING AND
 patient uses should be tepid ; when the hot stage is perfectly formed,
 cold drink  is both  more  grateful,  and  more generally  beneficial.
 When a moisture appears on the skin, the drink should again be tepid.
   In the treatment of all fevers we should have in view that the evacu-
 ent and diluent plan is  debilitating,  and must therefore  be used with
 caution, unless the excitement is considerable.  It is also to be  remem-
 bered, in attempting to discharge the bile from the stomach and intes-
 tines, that purging, and still more, vomiting, tend to emulge the biliary
 ducts, and seem  often to excite the liver to a more  copious secretion.
 We might therefore endanger the patient's life, were  we to persevere
 in p-tempting entirely to free his stomach and intestines of a matter
 which, in consequence of the means we employ, is poured into them in
 greater quantity.
   In the hot as in the cold fit, when a vomiting  and purging  of  bile
 occur spontaneously,  diluents only are necessary ;  and if these  mo-
 tions prove obstinate, they must  be allayed (when there is  reason  to
 suppose that the greater part of  the  bile is discharged)  by opiates ;
 which we shall presently see are otherwise useful at this period.
   3.  I have already had occasion to observe  that  vomiting is not so
 well suited to the second as the first stage.   Nauseating doses, partic-
 ularly of antimonial emetics, are more serviceable in the  hot fit, espe-
 cially when combined with opium, and when their operation is deter-
 mined to' the skin by gentle warmth.
    As our view  here is to promote  perspiration, James's  powder,
 which is supposed by many to be better calculated to excite the skin
 than the other preparations of antimony, is generally  preferred to the
 antimonium  tartarisatum.*    The  Pulv. Ipecacuanhas compositus is
 used  with the same view, but seems inferiour.  Opium  alone,  when
 nothing counterindicates its use, has been  found  a  powerful means of

  * The preparation of James's powder was long a secret,  and procured its
 inventor much reputation and gain.  It is now known to be a preparation of
 antimony,  and perhaps  in few respects superiour  to the antimonium tartari-
 satum.  Till lately James's Powder  was supposed to be the calx antimonii
 nitrata.  Dr. Pearson's experiments, which have generally been supposed to
 place the nature of those powders  beyond a doubt,  make  it the pulv is an -
 timonialis  of the  London Pharmacopeia.—See Dr. Pearson's paper in the
 Philos. Trans, for 1791.—Dr.  Higgins used  to observe  in his lectures, that
 James's Powder is prepared from a mixture of crude antimony pulverised
 and chared bones, calcined in a reverberatory furnace.
  It is said Dr. James generally gave his  powder conjoined with calomel, to
 which many attribute the  success of this medicine in the hands of its inven-
tor. 
REMITTING FEVERS.                   87
shortening the hot fit.*   It seems to act chiefly by promoting perspira-
tion.
   The cold affusion has been employed in  intermitting  fever;  and
from what  is said in the 31st and following pages of Dr. Currie's Trea-
tise,! it is probable that it will be found a very useful remedy  in the
hot fit.  It is chiefly to be employed when the excitement is consider-
able without damp on the skin.  On the effects of the cold affusion in
intermittents, however, observations are still wanting.  Dr. Currie al-
so used it with success as a means of preventing the accession of the
paroxysm,  when the strength was sufficient to bear it in the absence of
fever.
   4. Wherever the  inflammatory diathesis is considerable, not only
the duration of the paroxysm, but that of the fever, will be protracted ;
and as this is the most frequent cause of obstinacy in intermittents, the
means of  relieving it may be regarded as the most  important part of
the treatment during the paroxysm ;  and, indeed, wdien these are not
indicated,  and the symptoms are moderate, little  in general is neces-
sary at this period, except what the feelings of the patient  point out;
for although the foregoing means always tend to shorten the hot fit, it
is chiefly when they counteract the inflammatory  diathesis, that they
are to be regarded as essential to the cure of the disease.J
   The means of relieving this diathesis are different, according to its
degree.   Various  saline  preparations are  recommended  with this
view, and are often  sufficient,  when the inflammatory symptoms are
not urgent.   Whatever  other means we employ, indeed, these always
make a useful addition  to them.  Saline draughts, nitre, and the Aq.
Ammonia acetata are the best.
   To the same class of medicines belong the vegetable  acids.  The
mineral acids possess little refrigerant power.
   But when the excitement is considerable  we must have recourse to
more powerful remedies.   I have already  had occasion to speak of
diaphoretics.   Antimonial diaphoretics are always proper  when the
excitement is decidedly above  the healthy degree.  I have also had
occasion to make some  observasions on cathartics, the moderate use of
which is then doubly indicated.
   No other remedy so effectually diminishes  excitement  as blood-let-

   * See the observations of several of die authors who have been mentioned,
particularly Dr. Lind, for  the use of opium in intermitting fever.
   j- Dr. Currie's Medical Reports on the effects of water, cold and warm, as
a remedy in fever, and other diseases.
   if This observation will be sufficiently illustrated in considering the use
of the bark  in intermittent*. 
88
INTERMITTING AND
 ting.  It is  not to be ranked among the curative means in the treat-
 ment of intermitting fever, but regarded as the remedy  on which we
 chiefly depend for counteracting a certain diathesis that tends to pro-
 tract the disease.   This observation must be kept in view, since  it has
 been asserted by some that the cure of intermittents may be attempted
 by blood-letting alone ;  which  has often led to improper modes of
 practice.  Mild  vernal  intermittents, indeed,  which are  generally
 more or less  of an  inflammatory nature, now and  then yield to this re-
 medy ; but the only inference from this is, that such fevers, being very
 mild, require no remedy after the inflammatory tendency is removed**
 So far indeed is blood-letting from being the remedy on which we de-
 pend for the  cure  of agues, the truth seems  to be, that except in  those
 cases where  actual inflammation, or that state which disposes to  it, is
 present, it is universally hurtful  in  these fevers.   Even  Sydenham,
 who recommends venesection with so much freedom, observes, that in
 young people a quartan, which would have terminated in six months, is
 by blood-letting protracted  to twice that  period : and in  old  people
 the disease is not only  protracted, but life endangered, by the rash  use
 of the lancet.
   It is impossible to lay down any rule respecting blood-letting,  in
 the different  species of intermittents,  which will  be  found generally
 applicable.   The  attempt to do this has involved  the subject in much
 perplexity.   We must consider what the symptoms are which  render
 blood-letting  necessary ; at  what period of the disease it is proper  to
 employ it; what the consequences to be dreaded from it are ; and in
 what circumstances,  these consequences  are most apt to take place.t
 I  shall make a few observations on each of these heads.
   Wherever  the countenance is flushed, the head-ache  cousiderable,
 the delirium  obstinate, or dyspnaea comes  on with a  full  and  hard
 pulse, blood-letting is necessary.   When  along with this state of  the
 pulse, although unaccompanied by the foregoing symptoms, the  fever
 assumes more of the continued form, we must have recourse to it. j

  * I use the  terms inflammatory diathesis and increased excitement as near-
 ly synonimous, for although a tendency to inflammation often exists without
 increased excitement, yet it is only when attended by the latter that we can
 with certainty  determine its presence.  There is reason, however, to suspect
 its presence in all cases in which an intermittent proves obstinate, if the epi-
 demic be of an inflammatory nature, and the season of the year and state of
 the weather be such as dispose to inflammatory affections.  In such cases al-
 though there be little increase of excitement a moderate blood-letting* is
generally attended with good effects.
  | When the delirium  or difficulty of breathing  is urgent, as sometime*.
happens, with  a low pulse, and in cases where the strengtli of the patient hn* 
REMITTING  FEVERS.                   89
   It is difficult to point out the degree of excitement which, indepen-
dently of local affections or the fever assuming a more continued form,
warrants the employment of blood-letting.   It must  be  kept in view,
that, for two reasons, a less degree of excitement warrants blood-letting
in intermitting than in continued fever.   The  removal of increased ex-
citement, is of more  importance in the cure of the former; and in.it
also we have less  reason to dread the debilitating effects of blood-let-
ting.
   Where there is no increase of excitement, and still more where the
pulse is small, frequent, and intermitting, it is never to be employed.
   With regard to the period of the disease at  which we should employ
blood-letting,  as the continuance of every disease tends to debilitate,
the symptoms which indicate this remedy are seldom present  after it
has lasted for  a considerable time.   Except, therefore,  a new  disease
requiring blood-letting supervene, it is seldom proper in protracted ca-
ses.  At the first attack, on the contrary, it is often necessary, particu-
larly in the spring, or at other times  when the epidemic has an  inflam-
matory tendency.1T
   Blood-letting in the hot fit of agues was regarded by the Ancients as
a dangerous practice ;  succeeding experience, however, has contradict-
ed this maxim.  It should be avoided during  the  cold  and  sweating
stages, and at the time the paroxysm is expected.
   If we  reflect on the intention  of blood-letting in intermitting fever,
indeed, so far from following the Ancients, we shall find reason for
confining this  remedy to the hot fit.   It has already been observed, that
blood-letting is not to be regarded as one  of the means of a radical cure.
It has been a  favourite opinion in medicine,  and still is with  many,
that fevers depend  upon a noxious matter existing in the fluids, which
may be evacuated by blood-letting.   We have every reason to believe,
however, 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  excite-
ment, which, although not so violent as to threaten immediate danger, if
much increased, always induces a degree of corresponding debility, and
even when but little above the healthy standard, tends  to protract in-
termittent;.

been much  reduced, eiUier by the  continuance of the disease, or previous
evacuations, local is preferable to general blood-letting.
   U See Dr. Curtin's letter to Dr. Duncan,  in the 9th  vol. of the Medical
Commentaries,  and the observations indeed of most authors who treat of th*'
fevers of warm  countries.
                                12 
00                   INTERMITTING AND
   During the remission or apyrexia, the excitement is never consider-
 able, and blood-letting at this period will not prevent increased excite~
 ment during the ensuing paroxysm with the same certainty, that it will
 relieve it when present.  Besides, in proportion as the excitement is
 increased, the patient bears  the loss of blood better.*
   In intermitting fever, therefore, the most proper time for letting blood
 is during the hot fit of the first paroxysms.
   The certain consequence of repeated blood-letting, especially when
 not employed with judgment, is  debility,  which is now  and then so
 sudden, that patients have sometimes expired almost immediately after
 venesection.  This is a rare  occurrence,  but the  powers of life are
 frequently so impaired as to render the fever more  obstinate and dan-
 gerous ; or  even to undermine the  constitution, and induce dropsy or
 other diseases of debility.
   A consequence of blood-letting, not to be overlooked in diseases of
 long continuance, is plethora.   It is well known  that the quantity of
 blood  formed by the system is generally proportioned to the demand
 for it, and,  consequently,  that habitual blood-letting seldom  fails to
 produce habitual plethora.
   There are kw remedies whose good  and bad effects more  frequent-
 ly seem to balance each other; so that cases occur in which the most
 experienced and accute physicians  can hardly determine  whether  it
 ought to be  employed or not.  The general rule is, that wherever de-
 bility is present, or with certainty expected, blood-letting is danger-
 ous and yet  in both these cases we must sometimes employ it.  In idi-
 opathic fevers, unaccompanied by any local affection, however, it is on-
 ly the latter of the difficulties with which we have  to struggle.   For
 wherever debility is actually present in such  fevers, blood-letting we
 shall find is decidedly improper.
   In sultry  climates fevers run their course rapidly, so that a strong full
 pulse, and the other symptoms of synocha, shall, in two  or three days,
 be succeeded by those of extreme  debility.   This debility we know to
 be in a great degree the consequence  of the previous excitement; yet
 the only means we have of effectually relieving the  latter are of all re-
 medies the most debilitating.!

  * Dr. Lind regretted that he had  bled a patient during the apyrexia ; the
 event was unfortunate, and he owns that an experienced physician thought it
 probably would have been otherwise had the blood been taken during the
paroxysm.
  f Mr. Clark, after relating the fatal terminations of three ca< es in which
 blood-letting  was employed to moderate the violence  of excitement at the 
REMITTING  FEVERS.
91
  In all countries, if the  epidemic tends to debility, we must  be cau-
tious in the employment of blood-letting, whatever be the degree of ex-
citement at the beginning; particularly if the patient is, or has lately
been, subjected to the action of other debilitating causes :  It must be
sparingly used in hospitals, where patients are often exposed to a nox-
ious atmosphere, and their strength has frequently been reduced by  a
scanty diet.  For similar reasons, it is more  to be feared in large and
populous cities, than in the country; and in summer and autumn than
in winter and spring ; fevers in the former seasons tending more to de-
bility.  " ./Estate et autumno," Burserius observes," sanguinis missio
" in intermittentibus minus convenit."                          .
  In all cases it is to be remembered, that blood-letting is more or less
pernicious  according to  the  constitution and habits  of  the  patient.
Those accustomed to it,  bear it better than others and require  it more.
The same may be said of people of a robust habit, and in the vigour of
youth.
  A moderate blood-letting for an adult is ten or twelve ounces, but its
extent of course must vary according to circumstances.
  It appears, then, from what has been said,
  i. That  the symptoms indicating bJood-letting in agues are those of
increased excitement, and such as denote a disposition to local inflam-
mation ;  especially if they appear when the fever shews a tendency to
assume more of the continued form.
  ii.  That the period most proper for this remedy, is the hot fit, espe-
cially during the first paroxysms of the disease.
  iii.  That the consequences most to be dreaded from it are  debility
and its attendants ;  and
  iv.  That,  on this account, it is most to be feared where  the body is
at the  same time exposed to other debilitating causes.
  5.  Wherever there is much debility,  especially where those symp-
toms appear  which  denote a  great degree of debility in  the natural
functions, the paroxysm is protracted and the patient in danger of fall-
ing into typhus.  I have already observed that these symptoms are sel-
dom present  to a considerable degree till the disease assumes,  more or
less, the nature of  this fever.   The treatment is then the  same  as in
typhus, which we shall soon have occasion to consider at length.
  All  that  we have to attend to in the sweating stage is to avoid what-
ever might tend to check the sweat; and to support the strength,  if it
is much reduced, by gentle cordials.

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, except in inflammations. 
92                   INTERMITTING  AND

                            SECT. II.

      Of the Treatment of an Intermittent  during the Apyrexid.

  The treatment during the Apyrexia I have already had occasion to
observe, is the most important, and that which, strictly speaking, can
alone be regarded as curative.
  The indications are, to restore the patient's strength, and to prevent
the return of the paroxysm.

    1. Of the Diet and Exercise  during the remission or Apyrexia.
  When the inflammatory diathesis prevails, the diet must be such as
lends to counteract it.   It should consist  of milk  and the farinaceous
vegetables ;  and,  unless the strength is much reduced,  fermented li-
quors should be avoided.
   When debility prevails, the diet should be  as full as the stomach
will easily bear.  It often happens in debilitated states, that the strong-
er kinds of animal food occasion temporary fever.   Beef, mutton, &c.
ought therefore to be avoided ; veal,  lamb, and chicken,  when  the
powers of  digestion  are not much weakened,  will  be  found  equally
nourishing, and irritate less.  The object  is to chuse that kind of food
which affords most nourishment,  with least irritation.    The same rule
applies to liquids : When the strength  is  much reduced, the patient's
drink should never be pure water, and in no case any mixture contain-
ing distilled spirits,  except where fermented liquors, which have not
been distilled, cannot be procured.    Wine,  particularly port wine,
properly diluted, is the best; the quantity is easily  regulated by at-
tending to the constitution and habits of the patient,  and the effects
which the wine produces.   Of the fermented liquors of this country,
cider  and  porter are generally  found  the best.   He  should eat fre-
quently and slowly, and  take care not to oppress  the stomach by eat-
 ing too much at one time.
   While the digestive  powers  remain but little impaired, these  are
 the only regulations necessary respecting  the diet during the apyrexia.
 But it is not uncommon for a considerable degree of dyspepsia to at-
 tend, and then a more particular attention to it is requisite.
    Acescent and oily articles of  food, with a large proportion of liquid,
 compose the diet most  difficult  of digestion.    The opposite  to this,
 therefore, is that which agrees best with  dyspeptics.   I have just had
 occasion to observe, that  the flesh of old  animals 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 found
 to be the  case.   The flesh of  old animals in general  is most easy of 
REMITTING  FEVERS.                  93
digestion.*  Nearly the same may be  said of the food derived from
the animal  kingdom,  compared  with that composed of vegetables.
The former is constantly found more irritating, more apt to induce fe-
ver ;  the latter more difficult to digest.
   We must observe, therefore, the  tendency to fever or dyspepsia,
and regulate the diet accordingly.
   Where it is our view to obviate the symptoms of dyspepsia, a diet
composed pretty much of animal food and stale bread is the best.  All
k.inds of soups, gravies, and fresh vegetables, should  be  avoided, and
every thing into the composition  of which butter, or  any other oily
substance, enters.  The same maybe said of all hard animal substances,
salted and smoked meat, cheese, &c.   The harder animal food is, it is
the more difficult of digestion.  This is not true of vegetable substances.
 Few things are more easy of digestion than a hard sea-biscuit, provi-
 ded it be properly masticated.  The tough, thready, and membranous
 parts of vegetables are of most difficult digestion; next  to  these, the
 cold  vegetables eaten raw, melons, cucumbers,  &c.   Every  thing,
 which by mastication forms a tenacious pulp, is of difficult digestion.
   Wine  properly diluted, particularly port wine,  if its constipating
 tendency is obviated, is still the best drink.  Many  have recommend-
 ed distilled spirits and water, as less acessant, but these in every form,
 seem to apply a hurtful  stimulous to the digestive organs.  The same
 may be said of taking the drink very warm ; the temporary assistance
 it gives to  the digestion, is more than compensated  by its debilitating
 tendency.  Cold drink, acts as a tonic to the digestive  organs ; but I
 know many  dyspeptics  who cannot take it without injury  below a
 certain temperature, and have seen a fit of dyspepsia induced by tak-
 ing ice.
   The rule of eating little and often, is the more necessary, the more
 the stomach is weakened.   However well chosen the food may be, the
 dyspeptic must be restricted with respect  to quantity.  This caution
 is the more necessary, because the appetite in dyspepsia is often mor-
 bidly increased.
   The exercise both of mind and body,  at this period, also demands
 particular attention.
   The different kinds of bodily exercise may be arranged under three
 heads.  That in which the body is moved by its own exertions, as in
 walking ; that in which it is moved by other powers,  as in the various
 modes of gestation ; and  that in wrhich the  circulation is promoted

   * There is  an exception with respect to beef, which is more difficult of
 digestion Uian veal. 
94
INTERMITTING AND
 without moving  the body,  by  friction, for example,  or merely by
 pressure.
   Intermitting fever may induce such a degree of weakness, that fric-
 tion may be  the only kind  of exercise which the patient can  endure
 without fatigue.  This,  however,  is seldom the case when the inter-
 missions are considerable ; but wherever the strength is much reduced,
 although a little of some rougher exercise may be borne, friction is al-
 ways useful.   It 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  pa-
 tient 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 is often serviceable
 in  all  cases of debility, and particularly in debility of the stomach
 and bowels.*
   Next  to  sailing, the gentlest exercise in common use is the motion of
 a carriage.  But for the  most part in such climates as our own, the pa-
 tient must  either be confined in a close  carriage, or run the  risk of
 taking cold.   As a substitute for a carriage, but inferiour to it, swings
 and spring chairs  are  used.  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.t
   It is to be remembered, however, that any rough exercise, and par-
 ticularly riding on horseback, soon after meals, disturbs digestion.
   When walking can be borne for an hour or two  without fatigue,  it  is
 the best exercise.  It is that which nature intended.   It is accompa-
 nied with a uniform and  general exertion of the muscles, and from the
 valvular structure of the veins, is better fitted than any other, to pro-
 mote circulation.  It  is generally of service to combine the different
 modes of exercise.
   When the body is debilitated, the mind is  often languid and listless.

  * See Dr. Gilchrist's Treatise on the Use of Sea Voyages in Medicine.
  f Of all kinds of exercise, Dr. Whytt (See his Treatise on Nervous Com-
 plaints) observes, riding on horseback, has been  justly esteemed the best.
 Sydenham is extravagant in his praise of this mode of exercise, and particu-
larly recommends it in hypochondrical and hysterical disorders.  Riding, he
observes, is preferable to walking, as it shakes the bod}- more, and fatigues tf
less. 
REMITTING  FEVERS.
95
This state of mind is more or less counteracted by  a due degree  of
bodily  exercise, but the occupation of the  mind itself, is  the best
means of cure.
   The maxims by which the exercise of the body is regulated are also
applicable to that of the mind.  The great rule is to exercise without
fatiguing it.  Any study which fatigues, is injurious, and a mind whol-
ly unoccupied  is no less so.  When  the debility is  considerable, the
mind should be occupied by amusement alone ; and even those amuse-
ments which greatly interest the feelings, or occasion any considerable
exertion of mind, may be hurtful.  When, on the other hand, the pa-
tient has recovered a considerable degree of strength, a moderate at-
tention, even to business is serviceable.  However varied our occupa-
tions are,  if they tend only to present gratification, they soon become
insipid.   The mind must have something in view,  some plan  of im-
proving its condition, in order to arrest the attention  for any length of
time.   There is nothing of  greater advantage than the conversation of
friends, who constantly  present to the patient the fairest side  of  his
future prospects.
   The time of  day, at" which either  the mind or body is exercised,
is also a matter of some  importance.   Towards the evening every kind
of exertion becomes irksome, and consequently hurtful. In the debilita-
ted, a degree of fever  (probably the consequence of the unavoidable
irritations of the day) comes on at this time ;  which is only to  be re-
lieved by  repose ;  going early  to bed,  therefore, is of  much  conse-
quence to them.
   Exposure to the night air often appears  to be more pernicious than
we can easily account for.
   But although  it is of consequence  for the  debilitated to go early  to
bed, there are few things more hurtful than remaining in it too long.
After the  degree of strength, of which the present state of the system
is capable, is restored by sleep, any longer continuance in bed tends
only to  relax.   Getting  up an hour or two earlier in the morning often
gives a degree of vigour which nothing else can procure.  I know peo-
ple whose  feet constantly  become cold  and damp  if they remain  in
bed a few hours longer than usual in the morning.  For those  who are
not much debilitated and sleep pretty  well, 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 require more  sleep than those
in health ;  but rising  early will  gradually prolong  the sleep on the
succeeding night, till the quantity which the patient  enjoys  i"s equal
to his demand for it. 
9b'
INTERMITTING AND
  Lying late is not only hurtful by the relaxation it occasions, but al-
so by occupying that time of the day, at which exercise is most bene-
ficial.
  In every circumstance respecting diet and exercise, much  attention
must constantly be paid to the patient's age, habits,  and inclinations.
  In old age repose is more necessary, and exertions of every kind are
less beneficial, and more  apt to be hurtful.
  Old people are less subject to  that diathesis which  disposes to in-
flammation, than the  young ;  in them debility  is most  to be feared,
and is removed with most difficulty.   We seldom find occasion, there-
fore, to recommend a low diet to them.
  No general  rule,  however,  can be  laid down ; in old people  we
sometimes meet with the inflammatory diathesis,  which must be treat-
ed in the manner just pointed out,  but with  the more  caution the older
the  patient is.
  In both old  and young the inflammatory diathesis is most  frequent
in an early stage of the  disease ; the repetition of the  paroxysm  tends
to overcome it and to produce debility ;  a poor  diet, therefore, is sel-
dom proper in protracted cases.
  When the remissions are but imperfect, the patient has little or no
desire for food  or exercise, and nothing can be more hurtful than to
force him to take either.  An inclination to sleep, during the  intermis-
sion, especially  if it is short, should be encouraged.   On  the other
hand, when he has an inclination to  eat or  walk  about, we are not to
insist on his keeping his bed, or abstaining from food.   The necessity
for  sleep or food is best  determined by  his own feelings.   Longings
for  particular  articles of food,  if not improper,  should be  indulged ;
the  irritation they occasion when not gratified,  does harm.
  In  regulating  the diet, during the  intermission,  some  attention
should be paid to the season of the year.   In spring,  I  have already
had  occasion to  observe, the  inflammatory  tendency prevails more
frequently than  in autumn.   In  the  latter season,  especially  at its
commencement, we dread debility; fevers are then  most apt to be-
come malignant.  The  warmer and moister  the season is, this is the
more to be feared.   The inflammatory tendency prevails most 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, we  must  be
cautious in the use  of animal food and  fermented liquors ;  when ac-
companied with symptoms of debility, every thing that weakens is to
be avoided,  and  as full a diet advised as the  state of the patient ad-
mits of. 
REMITTING  FEVERS.
97
   2.  Of the Medicines employed during the  Remission or Apyrexia.
   These may be divided into two classes :  those exhibited during the
whole, or a great part of the Apyrexia ; and those which are only em-
ployed about the time the paroxysm is expected.
   Of all the medicines,  recommended in intermittents, none has been
so generally employed  as  the  Peruvian Bark.*   On  it indeed,  most
Physicians wholly depend  in these fevers.
   A remarkable cure performed by it on  the  countess del  Cinchon,
the Spanish viceroy's lady, in the year 1640, first drew the attention
of Europeans to it.   It is said,  that the Indians  were not ignorant of
its virtues as early as the year 1500.   In  1649, a Jesuit brought a con-
siderable quantity of it into Italy, which was distributed by the fathers
of that order at a high price over a great part of  Europe, from wliich
circumstance it  got the  name of Jesuit's bark ; and,  about  the same
time, the Cardinal de Lugo imported a quantity of it for the use of the
poor  at Rome.  " When  first  introduced  (Dr. Cullen t observes) it
" was found to cure intermittents very readily ;  but  whether it was
" that a medicine  of more seeming  efficacy  was at the same  time
" brought into Europe, or whether timid practice lessened the dose,  it
" went out of credit,  and was not till thirty years afterwards restored
" by Talbot."
   The  bark is  an astringent bitter, with some degree of aromatic flar
vour ; to none of these  qualities, however, can its powers be  attribut-
ed,  since no combination  of astringents,  bitters, and aromatics,  is
found equally effectual.
   A variety of prejudices respecting it prevailed for a long time after
its introduction into Europe, and  prevented its general employment.
The  more ancient of these do not even deserve to be  mentioned, that
those who use this medicine die within a year, or according  to others
within seven years, that it  is paticularly pernicious to fat people, &c.
The  more rational prejudices against it arose chiefly from the nature of
the fevers in which it is recommended.^

  * This medicine is mentioned by authors under  a variety of appellations,
chincona, chinachina, chinchina, kina kina, kinkina, quina  quina, quinquina,
pulvis coinmitissae, gentiana indicn,  antiquartium Peruvianum,  jesuiticus
pidvis, Cardinal de Lugo's powder, &c.
   f Dr. Cullen's Materia  Medica.
   * Dr. Millar (Account of the Diseases most prevalent in Britain) declares
it his opinion, contrary to what he once thought, that the fever, and nof  the
bark, is the cause of die obstructions and dropsies which frequently supervene
on agues, and that the bark is the best means of preventing these  affections.
Dr. Jackson (Account of the Diseases of Jamaica) remarks, that  he always
found dvsenterv, dropsv, and  vtscoral obstructions, most common where the 
98                   INTERMITTING  AND
    Although most practitioners at present employ the baric  in agoes,
 at least when they are protracted beyond a few  paroxysms, there is
 some difference of opinion  concerning  the period of the disease  at
 which it ought to be exhibited, the preparation of the patient, &c.
    We determine when and how the bark is to be given by  attending
 to the following circumstances :
    1.  The period of the disease.
    2.  The nature of the symptoms, particularly the presence of the in-
 flammatory diathesis, or debility.
   3.  The climate and season of the year.
   4.  The age and habit of the patient ; and
   5.  The nature of the epidemic.
    1.  There has been  some dispute respecting the  best  time of the
 apyrexiaj for the exhibition of the bark.   Many give it immediately
 after the paroxysm, and at intervals till the fever returns ; others only
 during a few hours before the paroxysm.   The question  may be de-

 bark was most sparingly employed.  When the ague, Dr. Lind observes, was
 stopped by the bark immediately after the first or second fit, 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
 remissions 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 of the preceding fits,
 or to the continuance of the fever.
   The bark, indeed, is by many ranked among the best means of removing
 such  affections, when they are the consequences of agues.  Dr. Brocklesby
 (On the Diseases of the Army) recommends it in cases of visceral obstruction
 after the use of mild and repeuted emetics and cathartics; and Dr. Strack (De
 Febribus Intermittentibus) remarks, that he has found the bark more power-
 ful than any other medicine in removing indurations of the spleen, and has ob-
 served it successful in the dropsical affections which supervene on intermit.
 tents.
  It was a prevalent opinion in many places, that agues cured by the bark
 more frequently return than those which leave the patient after running their
 full course.  This also is now regarded as a groundless  prejudice (Torti's
 Therapeutics  specialis). In short, amidst  all the prejudices entertained
 against it, wherever it has been fairly tried in agues it has  proved  both safe
 and successful.
  f While the intermitting form remains distinctly marked, it is universally
admitted that the exhibition of the bark  during the  cold  or  hot fits is
improper.  Dr. Fordyce made a trial of the bark during the hot fit, and found
that it both increased the length of the paroxysm, and rendered the crisis less
perfect. Dr. Cleghorn also remarks, that when the bark was  given during
the paroxysm, the patient died; but he recovered often after his case seem-
ed desperate,  if the remissions were seized for the exhibition  of this medi-
cine. 
REMITTING FEVERS.
99
icrmined 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 dose.*
   When the apyrexia is short, and the quantity of bark required con-
siderable, it must be given immediately after  the  paroxysm and con-
tinued till the return of the next at longer or shorter intervals, accord-
ing as  the case is more or less urgent, and the stomach able to bear it.
On the other hand, when the apyrexia is  long, and especially when a
great quantity of the bark  is not necessary, its exhibition should be de-
layed till within six or eight hours of the time at which the paroxysm
is expected.  For a considerable quantity given at this period is more
likely  to succeed, than the same quantity given in  smaller doses,.
throughout  a long apyrexia.
   It appears probable from many observations that in the cure of in-
termittents  this medicine acts chiefly by  its effects on the stomach and
 intestines, and consequently that our endeavours should be directed to
have a considerable quantity of it in the prims viae, at the  time the
 paroxysm is expected-
   Many have attempted to determine the quantity of bark which will
with certainty remove an intermittent ;t this, however, depends on va-
 rious circumstances which will be pointed out  as we proceed.  It may
 be remarked upon the whole that tertians require more bark than quo-
tidians ; and quartans, than tertians.
   When the pulse is strong and full, and still more  when it is  hard,
 when  the face  is flushed,  and the heat considerable, especially when
 these symptoms are accompanied with rheumatic or pleuritic pains, or
 difficulty of breathing, even although the apyrexia  be complete and
 long, the bark must not be exhibited, till the recurrence of such symp-

   * While the prejudices against the bark were prevalent,  it was generally
 exhibited in the former of these ways, in all cases.  The doses were  small,
 and the intervals at which they were given long.  Sydenham disapproved of
 giving the bark in large doses, and generally endeavoured  to seize long in-
 tervals for its exhibition.  He recommends mixing an ounce of bark with sy-
 rup of roses, and giving the patient the size of a nutmeg morning and eve-
 ning, on the days of intermission, until the whole  quantity is finished.  The
 same quantity was repeated in 14 days, which was given a third time in the
 same manner.  While suck was the mode of prescribing the bark, we cannot
 be surprised that it was not  found very successful.
   + Dr. Millar observes, that he cannot recollect a case of remitting fever, in
 several years extensive practice, in which the patient died after taking two
 ounces of bark.  And Mr. Reid, in his Account of the Diseases of the West
 Indies, makes the same observation. 
100
INTERMITTING AND
 toms is prevented by the means  already pointed out in the treatment
 of the paroxysm.*
   It is chiefly at the commencement of the disease that the inflamma-
 tory diathesis prevails, and when this is  corrected, mild, especially
 vernal intermittents, often yield spontaneously.!  The continuance of

  * What is here said is well illustrated by Sir John Fringle's Account  of
 the Intermittents  prevalent among the British troops on the Contincut, wliich
 were of an inflammatory nature.   He generally found it  necessary to begin
 with opening a vein, and to repeat the blood-letting according to the urgen-
 cy of the symptoms.  Most of the remittents which came  under his care, ei-
 ther in spring or towards the end of autumn, were accompanied with pleuri-
'tic  or rheumatic pains ; and the use of the bark often changed them into con-
 tinued inflammatory fevers. It may be observed, in confirmation of what was
 «aid of the proper period for blood-letting in these fevers, that he particular-
 ly recommends the hot fit for this  purpose.   He generally gave a  cathartic
 immediately after the blood-letting.   There are few author.s  who treat of
 intermittents,  who have not had occasion to make observations similar  to
 those of  Sir John Pringle.—Dr. Donald Munro,  in particular,  gives  nearly
 the same account of the remittents which prevailed  among the soldiers on
 the continent.—When the bark had failed on several trials, Dr. Rush observes,
 one or two moderate blood-lettings  generally secured its success ; in these
 cases, he adds, the pulse is full and  a little hard, and the blood sizy.  The
 bark is always unsuccessful, he justly remarks, when blood-letting is neces-
 sary, and be says he has known many instances in which pounds of this medi-
 cine had been given without effect, which yielded readily after ten or twelve
 ounces of blood 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.  How different a mode of treatment is to be pursued, when  our prac-
 tice in agues is not incumbered by the presence of the inflammatory diathesis,
 will appear from  comparing what  is said  by these authors, with  what Dr.
 Jackson says of the fevers which prevailed among the troops in America.  In
 the autumnal months, when signs of malignity and danger were present,  he
 generally seized the first intermission for exhibiting the bark, without pre-
 mising either vomiting or purging, even where the bowels were loaded.  He
 gave two drams for a dose, and repeated it every two hours, while the fever
 was absent.  Two ounces, he observes, taken  in the space of eight or ten
 hours, were often more effectual than double the quantity in bmall doses and
 at long intervals.
  j 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 the patient preserved his strength, and if a laterious  sediment ap-
 peared in the urine, he  oficn  ventured to trust the cure to nature.  As he
 judged from this paroxysm of the  future treatment of the disease, he was
 careful to premise such medicines as tended to moderate  it, and prepare the
 body for immediately receiving the bark, in case the pymptn-r-? of the third 
REMITTING FEVERS.
101
disease tends  to overcome  this  diathesis ;  thus  we constantly find
as was observed on a former occasion, that however well marked it is
at the commencement of intermitting fever, it always disappears in its
progress.   On this account practitioners have found, that many inter-
mittents yield to the bark with more ease, 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 rule, that the bark  is not to be given at  the commencement of
agues ;  and this rule they found the more useful,  as it was  often  ne-
cessary to clear the primae  viae before its exhibition.   Such  appear to
be the sources of the prejudice against giving  the  bark at  the com-
mencement of intermittents;  for  a  prejudice  it  certainly  is, when
made a general rule.   If confined to  those cases in  which the inflam-
matory diathesis prevails, it is the result of universal experience.
   It would appear, however, that we are  not,  in such cases,  as  Dr.
Brocklesby and others recommend,  to defer the bark till the continu-

paroxysm  proved it  to be necessary.  During the  first three or four days,
therefore,  he ordered evacuations.  It was his custom  to take away  a little
blood at the commencement of the disease, if the state of the patient admitted
of it ; and he never failed to clear the prims viae  of any iiTitating matter
which they happened to contain, at this period ; and to these means alone the
complaint  sometimes yielded.  But  if the third paroxysm was the longest
and most  severe that had happened, if it was attended with any dangerous
symptoms, if the sick became giddy, feeble, or languid, without delay he  had
recourse to the bark.  As soon as the sweat ceased to flow, he ordered two
scruples or a dram of it to be given every two or three hours, or every hour
and half, so that five or six drams might be taken before next day  at noon
It is necessary, he remarks, that a considerable quantity 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 medicine.  It is  to be remembered,
however,  that Dr. Cleghorn practiced in the mild climate of Minorca.  In
general we shall find that the exhibition of the bark should not be  delayed so
long as he  recommends, particularly in autumnal agues.
  * When the patient was athletic, Dr. Brocklesby observes,  he allowed
the fever to run on for a little, before he gave the bark.   Giving- the bark too
early, he remarks, in athletic habits, produced much pain of the  head, yel-
lowness of the eyes, and sometimes continued fever.—Hillary also observes,
that he has frequently seen the early use of the bark render the fever contin-
ued, and of a bad kind.  See Brocklesby on the Diseases of the Army, and
Hillary's Account of the Diseases of Barbadoes.
   In those cases, where the tendency to inflammatory symptoms prevents us
giving much of the bark, Dr. Brocklesby recommends giving small doses of
it with myrrh, snake-root, or  some other such medicine, till the inflammatory
diathesis is sufficiently removed to admit of giving it in larger doses. 
102
INTERMITTING AND
ance of the disease has overcome this diathesis; but till it is corrected
by the proper use of the means above pointed out.   There is nothing
in the nature of  intermittents, except  their being frequently attended
by the inflammatory diathesis, which prevents  the use of  the bark, af-
ter the first paroxysm.
   When the pulse is feeble and quick, and the strength greatly redu-
ced, the early exhibition of the bark is  indispensable.*
   While the mflammatory diathesis is present, the bark proves the
more hurtful, the more the fever shows a tendency to become continu-
ed.  The use of the bark in these circumstances indeed often renders
it so.
   The contrary of this observation is true of the cases in which debil-
ity  prevails; in these, provided  the  remissions are still distinctly
marked, the greater tendency  the fever  shows to become continued,
the greater quantity of bark is required ; and when the debility is ve-
ry great and  the  remission short, it may be given through the whole
paroxysm.!   The more the patient is capable of receiving, the greater
tendency the fever shews to resume the intermitting form.

  * Dr. Brocklesby observes, that when the patient was weak  and irritable,
he g»ve the bark  immediately, and then did not even wait for the previous
exhibition of emetics and cathartics, whatever the state of the bowels might
be.  This part of Dr. Brocklesby's observations is well illustrated by those of
Mr. Ckvrk on the Diseases in long Voyages to hot Climates, which in a strik-
ing maimer point out the propriety of having immediate recourse to the bark
wherever there is much debility; and particularly if the symptoms peculiar
to tvphus make their appearance.  •' If the remissions are distinct, (he ob-
** serves) die bark will have a more speedy effect; but even although thedis-
** ease," (which was always attended with symptoms of debility) " is continu-
** ed, by its use, it is effectually prevented from growing dangerous and ma-
" lignant"  When the patient was too weak to receive the bark in powder
he had recourse to the decoction, and when even this could not be retained
alone, he gave along with it a large dose of solid opium;  for the patient's
life seemed to depend on its exhibition.  In such cases he found much bene-
fit from giving wine along with the bark.  This is not only serviceable by
supporting the strength, but also by rendering the bark more effectual;  for
in very debilitated states of the system much larger quantities of the bark
are required, to prevent the return of the fever.
  | The bark  (says Raymond) should be given during the paroxysm, with
much acid, particularly the vitriolic  acid, when the patient has the facies
byprocratica, when he is  subject to syncope or coma, when his pulse inter-
raits, and his breathing is stertorous, and then, he adds, it is the best of all
remedies, and often rescues the. patient from the very jaws of death.  See
Raymond** paper on the Intermittaits of Mittlinburgh, in Baldinger^ SyUog>-
©pusculorum. 
REMITTING FEVERS.
103
  These observations, have been  frequently overlooked, and  much
confusion has arisen from writers attempting to lay down, as generally
applicable  to the treatment of agues, the  maxims of practice, which
they found suited to the particular cases which fell under their own ob-
servation.
  In the exhibition of the bark, more attention  has been paid than
seems necessary, to the state of the stomach and bowels.  It is a very
prevalent opinion, that while the stomach and bowels are loaded, what-
ever 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 primse viae have been cleared, and most writers on the subject
make similar observations.
  When the symptoms are not urgent, and especially when the inflam-
matory diathesis prevails, 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 operation of an emetic and cathartic.
  But in urgent cases, and where there is no inflammatory diathesis
we have reason  to believe that the exhibition of the bark ought not to
be delayed whatever be the state of the stomach and bowels ;  for it
even appears from many observations that actual vomiting and purging
should not induce us to delay the exhibition of the bark, when the state
of the  fever greatly demands it.  " I may remark," says Dr. Jackson,
" that  the bark was often  rejected by the  stomach, and in some cases
" past off almost instantly by stool, yet the course of the fever seemed to
" be no less effectually  checked by it than when  such effects did not
" occur."—" In violent cases," Dr. Donald Munrot observes, ** where
M it was necessary to give the bark before emetics and cathartics could
" be exhibited, I often gave it along with a cathartic,  and found that
" keeping up a catharsis, did not prevent the bark curing the ague."
From these and  similar observations it appears, that the remark of Dr.
Millar^ and others, that the exhibition of the bark  can be of no service
while  a diarrhaea continues, is unfounded ; or at least not to be admit-
ted in its full extent.
  From the  same observations also, we must infer  that the common
practice of giving large doses of opium, and other medicines, 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 its salutary effects, if it can be made to lie on the stomach
only for a 6hort time, and the dose be constantly repeated; and  by

  * Monita et Prsecepta Medica.
  ■f Dr. Munro's Account of the diseases of the Army.
  t- Dr. ftfiHar's work on the (fiseases most prevalent in Grea>Brifcu"jfc 
104
INTERMITTING AND
checking them we  lay up a fruitful source of irritation, which never
fails to increase the fever.
   In less urgent cases, where the immediate  exhibition of the bark is
not necessary, if spontaneous vomiting and purging occur, the proper
treatment is to promote these evacuations  by diluents, till the primae
viae  are sufficiently cleared; and  then to allay the commotion excited
by opiates, before we order the bark.
   3. The climate  and season of the year influence our practice in the
use of bark.   As in sultry climates the changes in fevers are frequent-
ly very  sudden ;  evacuations,  though apparently necessary at their
commencement, often prove 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 inflammatory diathesis,  appear,
instead of preparing the patient for the bark by blood-letting,* it is often
safer to defer the  febrifuge till a few paroxysms  of the fever have re-
moved this diathesis, and at most to promote this effect by  cooling lax-
atives, and diluent clysters.t
   In this, as in many other instances, much depends on  the discern-
ment of the practitioner, even after he is made acquainted with every
circumstance which ought  to influence his judgement.   When the in-
flammatory 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 excilcment, even wdiere life is not in immediate danger, is itself
a highly debilitating cause, and will  often  debilitate more than a well
timed blood-letting, which relieves it.|
   In cold  climates, fevers of all kinds, and particularly agues, are

   * Dr. Lind, in his account of the Remitting  Fever of Bengal, relates a re-
markable instance of the bad effects of blood-letting in tropical climates, ev-
en when employed with caution.  A patient of his, convinced  that it would
Relieve him, insisted on being bled.  Dr. Lind in vain dissuaded him from
it.   Although only five  or six ounces were taken from him, he immediately
lost  his strength, and in less than an hour was carried off by die next fit.
Mr.  Badinock and the surgeon of the Fonsborne, he observes, bled each of
them two patients ; each lost one.
  | It is on account of the tendency to debility  in the fevers of sultry climates
that w e find authors insisting particularly on the necessity of having recourse
to the bark in these fevers at an early period.  I have already quoted the ob-
servations of Dr. Jackson. The early use of  the bark,  Dr. Brocklesby ob-
serve.;, is particularly necessary in the fevers  of the  West-Indies, especially
•in those which appear in the rainy season.  It  was observed above, that it is
during the rainy season of sultry climates that the most dangerous fevers pre.
v,ail-               * Dr. Lind's Treatise just referred to. 
REMITTING FEVERS.
105
 more generally accompanied with  inflammatory symptoms; evacua-
 tions previous  to the use of the bark, tiierefore,  are more necessary,
 and fortunately are not attended  with the same danger.
   Even the season of the year in the same climate  influences the ex-
 hibition of the bark.  In  spring, from the  greater prevalence of in-
 flammatory symptoms, evacuations  are both more necessary and safer
 than in  autumn, in which debilitating causes are apt to change agues to
 the continued form.
   4. In the young and plethoric, the pulse  is often full; and evacua-
 tions, previous to giving the bark, necessary.  In the old and those re-
 duced by low diet, previous disease, or any other cause, it is seldom
 proper unless there be a tendency to  local inflammation, to prepare the
 patient  for the bark in any  other way,  than by a gentle emetic and
 catliartic when the stomach and bowels are loaded.   In these  cases
 the bark should be given in considerable quantity  during  the first or
 second  remission, because in debilitated habits  the continuance of the
 fever is not only most to be dreaded, but a greater quantity  of bark is
 required  to stop it.  It is to the last circumstance, together with the
 power of habit, that  we are to  attribute the obstinacy of protracted
 cases.
   5. The nature of the prevailing  epidemic is constantly to be kept
 in view.  When it is frequently attended with local  inflammation, or
 when the inflammatory symptoms of the fever itself run high, the bark
 must be  used  with caution ;  and never till  after  proper evacuations.
 When, instead of these symptoms, there is a tendency to debility and
 consequently to typhus, it must be given early, and in large quantity,
 and evacuations cautiously advised.
   The  bark may be used in extract, tincture, infusion,  or decoction j
 but it is now generally admitted that when the stomach can bear it, the
 simple powder is the best preparation.  It never succeeds  so well as
 when given in substance.
   When we cannot persuade the  patient to take the bark by the mouth
 or it will not  remain on the stomach, it  may be injected per anum.
 This, however, is a much less efficacious way of giving it.
   The  external use of the bark  has  also been recommended, and is
sometimes serviceable.   It is not, however, to be depended on.   It is
only in children, who require a smaller dose, that we can expect much
ad\antage from it.   The best mode of applying it is to sew the pow-
der into  that part of the clothes, wliich is wrapt about the body.   It is
                               14 
IQg                 INTERMITTING AND

sometimes made into poultices, and applied to the stomach and wrists,
or the decoction is used as a bath for children.*
  In some cases it is proper  to give other medicines  along with  the
bark.  When 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 between the doses of the bark.   When the stomach  is very
irritable, a dose of solid opium, or opium and camphire, given with it,
often enables the stomach  to retain it.  Nothing 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 ;  when the thirst is
urgent, chrystals of tartar and vegetable  acids may be given with it.j
  In soldiers, sailors, and others, who have been accustomed to the use
of distilled spirits, brandy and water is often  the most convenient ve-
hicle.  Porter was recommended by Morton,  and by Dr. Lind in  the
fever of Bengal.   Lime water is particularly  recommended by  Mr.
Skeete, and muriate  of ammonia by Dr. Brocklesby, as increasing the
virtues of the bark.  The  former thinks that rubbing the  powder with
calcined magnesia  previous to preparing the infusion has the same effect.
   When the stomach is habitually weak, aromatics, bitters,  or astrin-
gents joined with the bark are often beneficial; they  are recommend-
ed  by Drs. Mead, Brocklesby, Lysons, and others.
   When it occasions purging,  we must have recourse to opiates and as-
tringents ; of the latter, the gum kino and extract of logwood are among
the  best.   If there is reason to suspect that the purging proceeds from
acidity, which is sometimes occasioned by the bark deranging the di-
gestive powers,  an  acid must he combined  with it.   If on  the other
 hand  it occasions  costiveness,  it is necessary to give gentle apperients
 with it;  for this purpose  rhubarb is particularly recommended by Dr.
 Mead ; it has the  double  advantage of moving the body and tending to
 restore tone to the stomach and bowels.
   Milk and liquorice are the best means of covering the  taste of the
 bark.J
   There are  three kinds of  bark in use  in this country,  the'red, the
 pale, and the yellow.   The genuine red bark is more bitter and astrin-
 gent to the taste than the  pale, and shows a greater degree of astringen-
 cy  with chalybeate solutions.  It likewise contains  more resin.   But
 the proportion of the resin differs in  different parcels.  Rubbing  the

   * For the external use of the bark see the 2d vol. of the London Medical
  Observations.
t Dr. Lind on the Remittent of Bengal. * The Materia Medica of Dr. L 
REMITTING FEVERS.
107
pale bark with calcined magnesia before it is infused, is said to increase
the deepness of the colour, the astringency, bitterness, and antiseptic
power of the infusion.  Calcined magnesia, produces none of these ef-
fects on  the red bark.*   There can be  little doubt  that the genuine
red bark is more powerful in the cure of agues than the pale, as appears
from  the observations of Saunders! and Rigby+ 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, but thought it
more apt to affect the bowels.
   Whatever be the efficacy of the genuine red bark, it is very doubt-
ful whether  that now sold be at all superiour to the pale.   It  is said to
owe 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.
   Physicians seem to agree that the yellow bark is the most  powerful
we now possess.   It  was hardly  known in England before  the year
 1793.   Dr. Ralph, physician to Guy's Hospital, has published some
observations on it.
   I have treated of the  bark at considerable length, because in most
places the cure of agues  is  now almost entirely trusted to this  medi-
cine ;  and where it has met with a fair trial, it has been attended with
a degree of success which sufficiently justifies  the general partiality in
its favour.   Sometimes however,  it is ineffectual;  in some  places it
cannot be easily procured ; in others its  high  price often prevents the
poorer ranks from using it in sufficient quantity ;  it is therefore neces-
sary to  he  acquainted with the other  medicines which  may be used
with the greatest probability of success.
   I shall in the first place make some observations on the other barks
 which have been employed in agues.
   The Angustura  bark  was first imported  from the West-Indies in
 1788.   It has been found successful, though inferiour to the  Peruvian
bark in the  cure of agues.  We are not acquainted with the tree which
produces it, its place  of growth,  &c.   Respecting  these  points Mr.
Brand, in a treatise on  it, the second edition  of which appeared in
 1793, makes some conjectures.  The Angustura bark is given in small-
 er doses than the Peruvian bark.  It is less apt to disorder the bowels,

   * Skeete's Treatise on the Bark.   j Saunders on the Red Peruvian Bark.
   t Itigby on the Red Peruvian Bark.
   § See hjs Account of the Diseases of the West-Indies- 
  108*                 INTERMITTING A^D

  and has sometimes succeeded in agues where both the red  and pale
  bark had failed.   It is to  be observed  that an intermittent's yielding
  now 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 in-
  stances  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 papers referred to in it.
   The  cinchona  Jamaicensis,  discovered by Dr.  William Wright,
 lias also been used with success in  intermittents ; it seems inferiour,
 however, to the  bark last mentioned.   The  reader  will find Dr.
 Wright's account of it, in the Philosophical Transactions for the year
  1772.  There are also some observations on it in Dr. Skeete's Treatise
 an the quilled and red Peruvian  bark.
   The St. Lucia bark or cinchona Caribbaea has also been found suc-
 cessful in these fevers.  Dr. Kentish has published an account of some
 experiments made with it, and Mr. Wilson, of St. Lucia, wrote a paper
 on it, which appeared in the Philosophical Transactions.  Dr. Skeete
 thinks it probable,  that a similar bark is produced in all  the West-In-
 dia Islands.   This is perhaps superiour  to the  cinchona Jamaicensis.
   The bark of the mahogany tree, Dr. Wright informed me, has often
 been used with  success in   intermittents*  But from the trials he has
 made he considers it as much inferiour to the Peruvian bark.   It is so
 like  the latter that  it has been fraudently mixed with it, or even sold
 for it unmixed.
   The Tellicherry bark, or as it is called in the East-Indies, the corte
 de Pala, has also been found successful.
   The bark termed Swietenia febrifuga, an account of which the read-
 er will find in a thesis, published at Edinburgh in 1794, by Dr. An-
 drew Duncan, jun. has been emploj'ed in agues.   This bark was dis-
covered and sent from the East-Indies by Dr. Roxburgh.  Dr. Duncan
 terms it Swietenia soymida.  Soymida from  the  Indian name of the
tree from which  it is procured.   It often succeeds ; but from the  trials
made with  it, both  at  Edinburgh and in other places, its virtues seem
to be considerably inferiour to those of the Peruvian bark.
  Til.; broad-leaved willow bark is also occasionally successful, though
inferiour to most of the preceding.
  Sur'i are the principal  barks which have been recommended in  in-
termittents.   A aeat variety of  other articles  have occasionally been
employed. 
REMITTING  FEVERS.
109
   The lignum quassiae is much praised by  Linnaeus  and Aurivillias.
It has not, however, come into general use ; we now know it, contrary
to the opinion of these authors, to be much inferiour to the bark.
   The faba sancti Ignatii has been  used by Dr. Lind and others with
success.   Bitters in general indeed have been found a more or less suc-
cessful substitute for the bark in intermittents.   Those just mentioned,
wormwood, carduus benedictus, cammomile flowers, gentian,  Virginian
snake-root, the lesser centaury, and the bitter orange peel, are among
the chief of this class of medicines.
   A variety of astringents have  also been employed; oak  bark and
^alls, alum, the various preparations of iron, &c.   Astringents in gener-
al are inferiour to bitters  in these fevers.   The combinations of astrin-
gents and bitters seem to be more powerful than either singly.
   Aromatics also have been  recommended ; camphire, musk, myrrh,
<$-c.  The reader may consult a paper by Mr.  Collins, in the 2d vol-
ume of the  Medical Communications,  for the use  of the capsicum in
agues.
   Various metallic preparations have  been employed.   There are
some observations on the use of the calx and sulphate of zink, particu-
larly of the former,  in the cure of agues by Dr. Blane, in  his work  on
the diseases incident to seamen.  Mercury in various  forms has also
sometimes been  successful.   The reader will find instances of agues
cured by mercury in the 6th volume of the Edinburgh  Medical Essays
and Observations.   In one instance, related by Dr. Donald  Monro in
the 2d volume of the Medical Transactions,  this fever yielded to no
remedy that could be thought of, till after a course  of mercury, which
had no apparent effect but that  of reducing the  patient's strength.  It
then yielded readily to the bark.  Hoffman  and Willis* have also re-
commended mercury in intermitting fevers.  Its powers,  however, in
these fevers are but inconsiderable.   Van Sweiten t says, he has seen
a quartan  last through the whole of a very complete mercurial  saliva-
tion ! and De Meza %  even alledges, that mercury sometimes increases
the malignity of intermittents.

  * See Willis, Opera Omnia, published at Geneva, in 1782.
  f See his Comment, in Aph. Boerhaavii.
  * See the first vol. of the Acta Societat. Med. Havniensls.
  See also  a paper by Schulze and Grxvius on the use of Mercury in Quitr-
'.ans, in the 5th vol. of Holler's Disput. ad Morb. Hist, et Cur. Pertin, 
no
INTERMITTING AND
  A metallic oxyd, of greater activity than any of the medicines which
have been mentioned,  has lately been much employed.  The medi-
cine called Ague Drops, it is said, owes its efficacy to arsenic.
  The use of this mineral in agues, however, has not been confined to-
the  practice of empirics.  Many practitioners of  the first respectabili-
ty employ it; and it is certain, that agues, which have resisted the
most assiduous use of the bark and other medicines,  have yielded  to
arsenic, as I have myself repeatedly witnessed.   I have already had
occasion to observe, that an intermittent's yielding to a, second remedy
after the first had failed, is no proof that the second is upon the whole
preferable.  From many observations, however, we have reason to be-
lieve arsenic the most effectual of  all the medicines which have been
used in  these fevers.   In the medical reports of the use of arsenic  in
the  cure of remitting fevers and periodic headachs, by Dr.  Fowler  of
Stafford, we have ample proof of its success, and, as far as his  experi-
ence goes, of  its safety.*
  In the 19th volume of  Dr. Duncan's Medical  Commentaries  there
are  a (ew additional observations on this subject, by the same author ;
and in some letters subjoined to Dr. Fowler's Treatise it has the sanc-
tion of many respectable  practitioners.  We cannot, however, I think,
regard its  safety as ascertained.  It would  require a very  extensive
experience to determine  the propriety of having recourse to  it, before
safer means have failed.  Its use, at least the throwing any considera-
ble  quantity into the system, even in small  doses, must for a  long time
be a doubtful  practice.   It is well known that lead and mercury often
remain  in  the  body for some time,   without producing their  effects,
which, when  they do  appear,  are proportioned, not to the quantity
taken in any one dose, but  to  that which  has  been taken  upon the
whole.
  The bad effects which small doses are apt to produce, even  when
given with caution, are, disorders of the stomach and bowels, swellings
of the face, or other parts of the body, an increased or diminished flow
of urine, slight eruptions, head ache, sweating, and tremours.   These

  *The  following is his mode of giving it:—64 grains of white arsenic re-
duced to a very fine powder, and mixed with as much vegetable alkali, is ad-
ded to a  half a pound of distilled water, and gently boiled in a Florence flask,
in a sand heat, till the arsenic is completely dissolved;  half a pound of com*
pound spirit of lavender is then added to it, and as much more distilled water
as makes the whole solution amount to a pound. The dose of this is from
two to twelve drops once, twice, or oftener in the day, according to the age,
strength, &c. of the patient. 
                    REMITTING FEVERS.                  Ill

effects may generally be removed by gentle laxatives and emetics, or
merely by discontinuing the use of the  arsenic.  Combining with  it
small doses of opium has been found in some measure to obviate them.
   Other medicines have been employed,  chiefly by the vulgar, and
have occasionally succeeded ; such as bay leaves dried and powdered,
in the quantity of a dram, three times in a day ; half a dram of the
inner bark of the ash, or half an ounce of sulpher in a glass of strong
beer, taken occasionally, &c.  Some of these seem to operate chiefly,
if not  wholly, by their effect on the  mind, such as  camphire and
saffron hung  in a bag at the  pit of the  stomach, cobwebs mixed with
crumbs of bread taken in pills, &c.  It is a practice among the vulgar
in some places for the cure of agues to take half a pint of their own
urine three mornings successively, which is said to be a very effectual
remedy.  Any thing capable of  making  a strong impression on the
mind, whether by exciting horrour, superstitious dread, or confidence,
occasionally  succeeds.
   The means recommended when the paroxysm is  expected, form the
last division of those employed during the apyrexia.
   When the  paroxysm is expected, the patient should  avoid exposure
to cold.   Some have recommended the use of  the  warm bath.  He
should avoid taking much food or drink ; and if there is no tendency
to the inflammatory diathesis, what he takes  should be  moderately
stimulating.   Diaphoretics are  frequently serviceable, given  a little
before the fit is expected ; for  if we succeed in keeping up a sweat,
the accession of the paroxysm  is  often prevented.  " Intermittentes
 " tertianas autumnales," Sydenham observes,  " hoc pacto aggredior
 " JEgro in lectulo composite  et stragulis undique cooperto sudores pro-
 44 voco, sero  lactis cerevisiato, cui salvise folia  incocta fuere, quatuor
 1: circiter horis ante paroxysmi adventum."
   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 ca-
 thartic.  Few medicines more powerfully promote  perspiration than
 emetics, and to this their effects in preventing the  paroxysm of  agues
 must in part be  ascribed.   They seem  also to operate by making a
 strong impression on the nervous system.
   The employment of cathartics at  this period is a more doubtful
 practice, and seems to have been rather the result of hypothsis than ob-
 servation.   Should the acrid contents of the bowels produce spontane-
 ous diarrhosa, it may be proper to encourage it by warm diluting fluids.
 Checking the purging would lay up a source of irritation which would
 not fail to aggravate the symptoms of the ensuing paroxysm :  but  it 
112
INTERMITTING AND
purging do not spontaneously occur, it ought not to be induced at thi*
period.
   The  means which prove successful in preventing the  paroxysm of
agues in the way I am speaking of, produce either a sudden and strong
impression on the nervous system, a quickened circulation, or sweat.
   Purging produces none of these,  but rather their  opposites.  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.
   Sydenham 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 nervous system, but  also gives a  temporary
vigour  to the powers supporting  circulation ;  and is  one  of the  most
powerful diaphoretics we possess.
   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 fluids.
   When we have endeavoured  in vain during the  first paroxysms to
prevent their accession, by inducing vomitting or sweat, 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 in endeavouring to prevent  the paroxysm  by
keeping out  a sweat, has often  changed the  fever  to the continued
form.
   Many medicines however have been employed with the same view,
which instead of debilitating tend to invigorate.  It has been found
that a large quantity of the bark  received into the stomach immediate-
ly  before the paroxysm is expected, frequently prevents 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 removes the disease.  This,  howev-
er, is far from being the best mode of giving  it.   Few stomachs can
bear so large a dose, and it seems to answer better when given at inter-
vals as above recommended.   In this way not  only a greater quantity-
may be accumulated in the stomach and intestines  at the time of acces-
sion ; but by giving it at intervals its effects appear to be  accumulated
in the system, for those  of each dcse continue  for a considerable time
after it is  taken; some suppose,   and not without reason, while any
part of the medicine remains in the dimcntary canal. 
REMITTING FEVERS.
IIS
  A vast variety of articles have been employed at this period, chiefly
by the vulgar, and have occasionally  succeeded in preventing the re-
turn of the fit.   These are, either such as make a strong impression on
the  stomach, as spirit of turpentine, wine, warm strong  beer,  brandy,
&c. with a variety of peppers and other acrid substances ; or such as
strongly impress the  mind, swallowing a living spider, a powder pre-
pared from human bones,  and many other things of this kind.
  By regular practitioners the powder of cammomile flowers, worm-
wood, or other strong bitters, have been used in the same way.   The
foetid gums have also occasionally been serviceable ;  and some recom-
mend a variety of external irritating  applications, salt mixed with the
white of eggs, applied to the wrists, 4-c.
  Such are the means of cure to be employed at the various periods of
intermitting fever, between the accession of one paroxysm and that of
the  next;  between which and the third paroxysm 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 considera-
ble  time, and the patient  has been much  reduced.   It is  therefore pro-
per in general to continue the use of it for some time, gradually dimin-
ishing the dose, and giving it chiefly at the periods 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  its operation.   Exposure  to cold,
(we have seen) irregularities in diet, or  any other cause which debili-
tates, is capable of renewing agues.
  The rules respecting diet pnd  exercise in the apyrexia must also be
attended to for sometime after the removal of the disease, both in or-
der to prevent its return, and  to restore the patient's strength.
  When exposure to the causes of agues is unavoidable, as in the rainy
seasons of sultry climates, the bark ought to be used as a preventive.*

  *  See the 47th and following pages of Dr. Lind's Essay on the means of pre-
serving the health of seamen.
  The most effectual  method of interrupting the fits in intermitting fever,
and of finally curing the disease, that I have seen tried is die following, that is,
two hours before the fit is expected, give the patient a full dose of laudanum,
put him toiicd, apply warmth to his feet, by means of a bottle of hot water,
or a heated brick, give him warm herb  tea to drink, keep him in this situa-
tion six hours after ihc lime ihat the 1U should have temrinaUxi  't'hesweats
                                 IS 
114
INTERMITTING AND
                            CHAP. VI.

 Of the Modus Operandi  of the Remedies employed in Intermitting
                              Fever.

   It is a-law of the animal economy, that an irritating cause applied
 to any part of the system, tends to induce such motions as are calcula-
 ted to remove it.   When these motions are excited in the more minute
 parts of the  animal body, they are  traced with difficulty.  Thus  an
 extraneous body introduced  beneath the skin, excites inflammation and
 suppuration,  by means of which it is  expelled ;  but we cannot trace
 all the steps  of this process.  Where the  larger parts, however, are
 thrown into action, we trace with more ease the different motions ex-
 cited, and  can often perceive distinctly in what manner they operate
 in removing the offending cause.  Thus, an irritation of the nares pro-
 duces a sudden and violent contraction in  all those  muscles which are
 brought into action when  we  expire forcibly.  The consequence  of
 which 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 occasioned  by an extraneous body
 lodged in and irritating the trachea.  We see an instance of the same
 thing in the involuntary 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
 contents.
  Concerning the action  of the muscles  employed,  some difference of
 opinion has arisen.   It has generally been supposed that the abdomin-
 al muscles and diaphragm act together,  by which  the  stomarJh being

let him cool very slowly.  As soon as the period of the fit is passed, give him
a dose of Peruvian bark in substance, and repeat it once in six hours, during
the apyrexia;  two hours before the next fit should happen repeat the dose of
 laudanum, and treat the patient as before, then follow with the bark.  If the
fit should be interrupted, on the first application of the remedy, it should be
continued and repeated as directed above during three or four periods of apy-
rexia and paroxysms ; then, if the fits are suspended, give the opium at the
accustomed time, and sutler the patient to keep about; also  continue the
bark.  In this way continue the remedies several weeks to prevent the return
rtf the tits.                                                  |(j> g 
REMITTING FEVERS.
115
forcibly  compressed between these muscles, its  contents are thrown
out by the oesophagus.   An eminent professor observes, that as the pa-
tient must inspire if the diaphragm contracts in the act of vomiting,
part of the contents of the stomach, in their passage over the wind-pipe,
would be drawn in with the breath.  He, therefore, supposes that the
diaphragm immediately before the act of vomiting, is fixed by a strong
permanent 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 rigid diaphragm.
   Concerning this theory of vomiting, 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 he-
sitate in admitting it.  The following observation, as far as I am able
to judge, altogether sets it aside.  Both in  this and the common ac-
count of vomiting, one effect of the violent contraction  of the abdomin-
al muscles is overlooked, that of drawing 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 while under the operation
of an emetic.   We know that  if the ribs descend, the  diaphragm must
at the same  moment either contract or yield to the pressure of the ab-
dominal muscles, which we cannot suppose  it to do in the act of vomit-
m<r.  It would, therefore,  seem that the  diaphragm  and  abdominal
muscles must contract  at the same instant; the latter drawing  down
(he ribs, lessen the capacity of the thorax  in one way, in  proportion
as the descent of the diaphragm enlarges it in another.  To assist in
depressing the diaphragm,  expiration, any one may readily perceive
in himself, is forcibly prevented by his involuntarily pressing down
. the epiglottis.
   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 intermittents',
we cannot speak with the same certainty; there is reason to believe
that it does  so, both in consequence of the sympathy which is known
to subsist between the stomach and the surface, and because the agita-
tion which vomiting occasions proves a stimulus to the system in gene-
ral.
   With  regard to cathartics.   Catharsis is induced by a double ope-
 ration of these medicines,  which still act,  as  in the case of vomiting,
 by exciting such motions as tend to expel them from the body.   This
 they do  partly by increasing  the  peristaltic motion of the intestines,
 di:d partly by increasing the secretion from their surface. 
116
INTERMITTING AND
   It is almost unnecessary to observe, that different medicines are :.'•
 ted to excite different 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, are almost insipid.
   But the remedies employed during the paroxysm of an intermittent,
 whose modus operandi has most demanded the attention of Physicians,
 are opium and blood-letting.
   In a treatise, entitled An  Experimental Essay on  the  manner in
 which opium acts on  the living animal body, I  have endeavoured by
 comparing the numerous experiments  which have been made  on  this
 subject,  whether by myself or others, to give a view  of  the modus
 operandi of this medicine.  It would be improper here to enter on any
 account'of the experiments by which  we arrive  at this knowledge ; I
 shall  only quote from the treatise the result of what is there said.*
   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 essentially from that of other
 local  irritations.   It is doubtful  whether the first impression  made on

  * As other  authors had  given a  different account of the re. .;lt of several
 experiments related in my treatise, I took an opportunity, in the summer of
 1796, when I  read a course of lectures on  febrile diseases at Ldinburgh, of
 publicly repeating' these experiments.   The pupils stood as near the table,
 on which the experiments  were made, as their number would permit, and ex-
 pressed their satisfaction with respect to the result.  Many of them were men
 well acquainted with the subject,  and  indeed wih medicine in general.  In
 the treatise alluded to I have mentioned several circumstances in the experi-
 ments in question, which may have occasioned to others, results different from
 those  which occurred to me.  A gentleman, however, present at the above
 meeting, Dr. Woolcomb, suggested a circumstance to which I am now inclin-
 ed, almost wholly, to attribute this difference,  namely, that  the authors allu-
 ded to had not distinguished the spasms induced  by an over-dose  of opium,
 from the voluntary struggles of the animal.  This admitted, explains the dif-
 ference of result, in almost every case.  And that  the authors  alluded to
 permitted themselves t» be deceived in this way is  probable, because they
take no notice of the spasms occasioned by opium being of a peculiar kind • a
circumstance which must have struck them had tiiey properly distinguished
these  spasms,  which, both  in the warm and cold blooded animals, always as-
sime  the form of that species of tetanus  which is termed the opisthotonos.
Dr. Woolcomb indeed made the observation in consequence of having some
time before been present  when  one  of these audiors repeated the  experi-
ments without making this distinction. 
                     REMITTING  FEVERS.                 117

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 ca-
pable, perhaps, of instantly killing annimals less tenacious of life  than
frogs and rabbits are, which were the subjects of the experiments above
alluded to.  A variety of strong impressions, that, for instance,  pro-
duced by drinking alar^e quantity of spirits of wine, or of very cold
water when the body is overheated, are well known to have occasion-
ed 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 according to the division I
proposed, are those on the heart and blood vessels ; namely, that of in-
creasing their action when it  is applied in small quantity ;*  and that of
altogether destroying it when applied more  freely.   In neither of these
effects, however,  does the action of opium differ essentially from that of
other agents.  Most active substances applied in small quantities, ex-
cite contractions in the muscular fibre, and  destroy its power when ap-
plied more freely.  It does not appear, that the quantity of opium ab-
sorbed 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 injected into
it, or  into the blood vessels.   Opium received  into the stomach, there-
fore, never induces death in this way.
   It is ascertained, by the experiments related  in the above  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 produ-
ces no other effect; the excitability of all the other muscles of the bo-
dy remaining unimpaired.  It is almost unnecessary to observe, that I
here speak of the effects of opium 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.
   These, when the dose  is moderate, are 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 mo-
derate 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 tli<* heart; from which, in the course  of

  * Compare a note in the 99th  page, of my Essay  on Opium  with Dr.
Crumpe's experiments on the pulse.  SCe TJr.  Crumpe's*Treatiie, entitled
" An Inquiry into the X.-i'TO and Properties of Opium. 
llfr
INTERMITTING AND
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, be-
cause opium directly applied and confined to the brain, produces the
same effects on  the nervous system, as when it  is permitted to circu-
late 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 similar to
those produced  by other violent irritations of this organ—convulsions
and death.  And this is the way in which opium received into the sto-
mach, 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  produces sleep,  convulsions,  or death ; for
opium,  even in the human body,  does not  always prove fatal  when it
induces convulsions.*  It  appears from the foregoing  observations that
in all its effects on the living animal, opium has much in common with
other agents; at the  same time we can perceive  in  each, as  pointed
out in the above treatise, something peculiar to itself.
  The effects of  opium, on which the benefit derived from it in agues
appears to depend, are the impression it makes on the nervous system,
and its increasing the action of the heart and blood  vessels,  which be-
ing combined with the effects of those medicines that relax the  skin,
tends to induce perspiration.
  There is no remedy whose modus operandi demands  more attention
than blood-letting.
  Wc know that the heart, deprived of the stimulus or the blood,  ceas-
es to contract almost instantly in the human body, and in a  short time
in all animals.   The presence of the blood, therefore, is as necessary
for  the continued action of the heat, as the peculiar structure by which
it is fitted for contraction.   But every thing capable of exciting con-
tractions in the muscular fibre,  produces within certain  limits more or
less powerful contractions, in proportion to the quantity  applied.
  In the change from a state of health to synocjia, one  of three things
must take place ;  either the blood is conveyed to  the heart  in greater
quantity than usual, or it becomes more capable of stimulating the

  * In some of the experiments alluded to in the Treatise I have been speak.
ing of, convulsions were induced on rabbits by large  doses of opium, wliich
were not sufficient, however, to prove fatal;  and there are  several cases 0:1
record in which this happened in the human body.  See cases related by M:\
Dobson and an anonymous author in th,e Medical Museum, 
REMITTING  FEVERS.                 119
heart, or the heart itself becomes more capable of being acted upon,
and thus contractions more powerful than those consistent with health
are excited.
   Whichever of these be the cause of  the stronger action of the heart
in synocha, it still holds  good, that the effect of the stimulus is within
certain limits proportioned to the quantity  applied, and  consequently
that lessening the quantity of blood must diminish the force of its con-
tractions.
   The following experiment directly  ascertains the  point,  which  is
otherwise so well established indeed as not  to require this  additional
proof: Dr. Hales opened the  blood vessels of living animals, adapted
glass tubes to their orifices, and observed to what height the blood rose
in the tubes at each systole of the heart; he then drew from the animals
different quantities of blood,  and observed the force of  heart  dimin-
ish in proportion 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 of the
heart and vessels, for the same  observations apply to them.  When it
is gradually abstracted, their capacity  is readily adapted to the quan-
tity which remains.  When more suddenly,  the change of capacity is
effected with greater difficulty.   The diminislied action of the  powers
supporting circulation, when the abstraction of blood is made suddenly
is in  a great measure to be attributed  to the vessels not  immediately
adapting themselves to their contents, and consequently the quantity of
blood returned  to the heart, being more diminished 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 strong people who conld lose six times the quantity without  in-
convenience were it abstracted more  slowly.   Syncope  from loss of
blood in general indeed, 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 we find it.  It was common with the ancitnts, in  a variety
of diseases, to  bleed the patient till he fainted, and this is still recom-
mended in some cases.
   If diminishing the action of the heart and blood vessels, be the only
effect of blood-letting in indiopathic fevers, it follows, that this remedy
can only he of service in these diseass when the symptoms of synocha
prevail.   Till lately indeed it has been the practice to have recourse to
blood-letting in typhus as well as synocha.   This practice was chiefly
founded on hypothesis;  in part, however, it  was cbunteuanced  by
<>bcv\ vation-   Thcro Can he  little doubt that a spontaneous  hemorr 
120
INTERMITTING  AND
hagy sometimes proves  a favourable crisis in typhus, but it is very
doubtful whether the hemorrhagy is the cause or  consequence  of the
favourable change;  I am inclined to the latter opinion because  I have
not, either in the course of practice or reading, met with any unequivo-
cal case in which artificial loss of blood was of decided advantage  in
this fever.   If the state of body in some rare cases of typhus be such
that the advantages derived from venesection will more than  compen-
sate for the harm done by its debilitating effects ; nobody  has yet suc-
ceeded in pointing out the means of distinguishing such cases.
   We shall afterwards find reason to believe that the  other symptoms,
which are termed critical, a flow of sweat, a sediment  in the urine, Lc.
are also rather the consequences  than the  causes of the favourable
change which attends them.
   One part of the modus operandi of blood letting has as far as I know
been over-looked by writers.   It chiefly respects those cases in whicb
the disease is wholly or in part local.  We  know that in inflammation
of the lungs, for example, or of the abdominal viscera, great relief is
often obtained  by taking such a quantity of blood from the skin, in the
immediate neighbourhood of the inflamed part, as would produce little
or no effect if taken from a distant part.   Why this should be the case
it seems difficult to say,  because there is often no direct  communica-
tion of vessels between the diseased part and that from which the blood
is  taken; between the  skin of the chest and lungs, for example, that
of the abdomen and bowels,  &c.   This question seems to be  of the
same nature  with the following ;  why is inflammation apt to spread to
contiguous parts, although there is no direct communication of vessels,
from the  bowels  to the parietes of the  abdomen, from the  lungs  to
those of the chest, and vice versa ?   Inflammation of  the bowels is  al-
most as apt to spread to contiguous bowels, as in the course of the vessels
of the inflamed part, I mean  before any adhesion of parts  takes place.
The adhesion does not seem to take place till after both surfaces have
been inflamed.
   For an explanation of such phenomena we must look to the sympathy
which exists between different parts of the body through  the medium
of  the nervous system.   This explanation seems  to be  supported
by a curious fact, which we shall see fully illustrated  in considering
the Phlegmabise, that in those  cases where the inflammation exists \n
one  part,  and the pain  is referred by nervous sympathy  to another
which is -oiind ; the  latter if the disease continues,  will  also become
inflamed, although the cause of the  inflammation is wholly confined to
'.he part i)<:<\ affected.   This we shall find has been clearly ascertains! 
REMITTING FEVERS.                 121
 by dissection.   We have a  similar instance of it in some cases of he-
 patitis.  The pain is often  referred to  the top  of the shoulder;  it is
 evident, however,  that at the commencement, there  is no disease  in
 the latter part, we may press and rub it without giving it any  uneasi-
 ness ;  but after the pain has for a considerable length of time been re-
 ferred  to it, it often, as I have repeatedly observed, becomes so tender
 that the patient can hardly bear it to be touched.  And if the hepatitis
 is relieved, although by means as much as possible confined to the region
 of the  liver,  the affection of the shoulder yields with it.  It may then
 be pressed or rubbed as before.
   Thus we see that local blood-letting not only relieves the vessels of
 the the part from which the blood is taken, but also of the parts which
 sympathise with it, that  is, sometimes of distant parts, but always of
 neighbouring parts, for all neighbouring parts sympathise.   These ob-
 servations thus far apply to general blood-letting, that as the heart and
 largest vessels contribute most to support the circulation, there  is some
 advantage in  taking the blood from those parts  which most sympathise
 with them;  hence  appears to be one advantage of bleeding from the
 upper rather  than the lower extremities.
   On the modus operandi of the means employed during the apyrexia
 I have only to remind the reader of a few observations which have  al-
 ready been made.
   I have had occasion to point out the way in  which the  medicines
 given at the time the fit is expected, seem to act.   The effects of many
 of these can only be ascribed to the impression made on the nervous sys-
 tem, since they are too sudden to be  attributed to any change induced
 on other parts.   It is only hi this way that  we can account for  the ef-
 fects of the bark, when the paroxysm is prevented by this medicine giv-
 en only half an hour before the time at which it should have appeared.
 And when we 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 reason 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 circumstance of agues being frequently removed by affections of
the mind prove, that  they may bo  cured by means acting  wholly
through the medium of the nervous system*
16 
122
CONTINUED FEVERS.
                           BOOK II.

                   OF CONTINUED FEVERS.

  Continued Fever is defined in the Introduction, an Idiopathic Fe-
ver with slight remissions and exacerbations.
  For the sake of perspicuity, this fever was divided into two Genera.
the Synocha  and Typhus.
  The Synocha was defined, a continued Fever,  in which the tempe-
rature of the body is greatly raised, the pulse frequent,  strong and
hard, the urine high coloured, and the sensorial functions but little dis-
turbed.
   Typhus, it was observed, is characterised by being a contagious
disease,  by the temperature being little raised, the pulse small, weak,
and frequent, the  urine little changed,  the sensorial functions  much
disturbed, and the strength greatly reduced.
   It was remarked, however,  that although  this division  is useful in
practice, and still more in acquiring a knowledge of continued fever, it
 cannot be regarded as accurate, since we scarcely ever meet with sim-
ple synocha  or Typhus;  almost every continued 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 prevails, there is  infinite variety ;  and  it is convenient to
 apply the terms  Synocha, or  Typhus, according as the symptoms  ot
 the one o. the other predominate.*

   * In 28 years practice, I have never seen a continued fever in this country,
 that answered to the synocha described by European authors ; having never
 seen a continued  fever excepting the Typhus,  that was not evidently con-
 nected with local inflammations. Nor did I ever see a Typhus fever begin in sv-
 nocha;  for though in the commencement of Typhus, there is considerable
 excitement in the action of the heart and great arteries, yet there is a mark-
 ed difference between this excitement and Uiat in true-inflammatory diseases.
    I consider  the Typhus fever as a disease sui generis, possessing n character
 marked and defined, shewing as little variety  in different cases, as most of
 of die contagious diseases,  to which it is nearly allied ; for although it is
( produced without contagion, when once excited it is capable of being com-
 municated, and the same person does not often have the typhus fever twice. 
CONTINUED FEVERS.
123
                            CHAP. I.


              Of the Symptoms of Continued Feveb.

  The  symptoms of continued fever are less regular and more pro-
tracted than those of agues.   The cold stage is more frequently absent
and generally consists of irregular chills,  or of short fits of cold and
heat, which frequently  alternate with each other 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 uni-
formly raised.
  The  cold and shaking are  never so severe as in agues, but the at-
tending symptoms, languor, weariness, soreness of the flesh and bones,
bead-ache, &c. are often equally so.  The  pulse during the chills in
typhus, as in the cold stage of agues,  is small and frequent; but in sy-
nocha, even during the chills, it is often strong, regular, and full.
  It is generally less frequent at the commencement of continued, than
at that of intermitting fever.*
  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 more gradual than in intermitting fever.
   As the hot  stage advances, the various functions are affected in  the
S4me way as  in agues ; but the heat, except in well marked synocha, i,
generally less in continued, than in intermitting fever.  It is not, as in

   The prevalent notion  that fevers change their type  in  the course of
them, I believe to be ill founded ; as they begin, so they  they continue; if a
fever is typhus in the end, it was so in the beginning ;  and if it was synocha
in the beginning, it is so to the end. The small pox, in my opinion, is as lia-
ble to change into measles, as the typhus fever is to change its type.
  The high degree of excitement, which often  takes place  in the beginning
of Typhus, does not indicate any difference in the kind of fever.  Blood-let-
ting holds a sovereign controul over the high arterial excitement, in cases ot
inflammation ; but has no good effect in typhus, even where the excitement
is high.  Cold water, externally applied, will subdue the  inordinate heat and
excitement in typhus, like a charm.  In cases of active  inflammation, it is
not always safe.                         .                     *""■ ^
   • See Dr. Fordyct's third Dissertation on Fever. Part I. 
i'-i
CONTINUED FEVERS.
 the latter, relieved in a few hours by sweat, but continues along with
 the other symptoms of the hot stage, suffering more or less evident re-
 missions, once or twice in the day, often for weeks, or even months ;
 and at length frequently leaves the  patient gradually,  without a  re-
 markable increase of any of the excretions.*   In other cases, the symp-
 toms of continued fever are more suddenly relieved in various ways„
 afterwards to be pointed out.
   During the first days of  the disease, the symptoms generally return
 with increased violence after the slight remissions which  take place ;  if
 they  do so  for many  days, the danger is great.   When they begin to
 return with less violence after each remission, the prognosis  is favour-
 able.
   It frequently happens, however,  that the symptoms continue to re-
 turn with nearly the  same degree  of violence, for many days ;  and
 then, if they are  not  alarming, and  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  principal
 circumstances in  which it differs  from agues.   It is necessary to con-
 sider its symptoms at  greater length ; and it will be the  most distinct
 plan, to  give separately those of the two species,  into which it has
 been divided.


                            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 fevvrs is generally le^ considerable; and the  cold stage is more
 frequently absent in synocha, than in typhus.

   * During the exacerbations the heat generally rises one  or two  degrees
 above the mean heat of the fever  in trie trunk, and more in  the extremities.
 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 the heat  under the
tongue as low as 92° of  Farenheit, and he mentions 105° as  the highest  de-
gree 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 degree; nor is the heat diffused
w,ith any regularity, but is sometimes greater in one place, sometimes in an-
other, and this irregularity continue.? till by degrees the heat becomes general
and steadv. 
CONTINUED FEVERS.
I2j
   The pulse, even in the cold stage, is seldom small or very frequent;
after the heat commences, it becomes full, rapid, equal, or, asithas been
termed, vibrating ; still, however, its frequency is less than it often is
in those fevers in which debility prevails.
   The  respiration is  frequent, hurried, generally oppressed,  and  at-
tended 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.*   The
face is full and florid ;  the eyes inflamed and incapable of bearing the
light.
   The secreting powers are more completely suspended than in most
cases of typhus.   The skin, mouth, and throat  are dry, and the mucus
covering the tongue, becomes foul  and viscid.   The urine is  scanty
and high-coloured, and the bowels costive.
   Thehead-ach  is generally considerable with  watchfulness, throbbing
of the temples, or tinnitus  aurium.   The depravation of 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, it rises to a
degree which,  from the debilitated state of the  system, we hardly ever
meet with in typhus. The patient becomes frantic, and seems to acquire
preternatural strength.
   When the delirium  is obstinate,  or  the patient  is oppressed with
coma, w:e have reason to suspect an inflammatory affection of the brain.
In enumerating  the  symptoms of phrenitis, I shall have occasion to
point out the circumstances which form the diagnosis between this dis-
ease and synocha.
   It is said that  when synocha proves fatal in a few days (which, if it
ever happen, is a rare occurrence) the pulse, 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 re-
missions 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 foregoing paroxysm ;
which is soon renewed, however, with its former violence.
   Hemorrhagies, which frequently  occur in this fever,  are generally
from the no>e, ears, lungs, rectum (if the patient happen  to labour un-
der the hemorrhoids) or from  the uterus ; and are almost always fa-
vourable ;  the  blood discharged, has the healthy appearance, except

  * See the observations on the heat in typhus, in Sect. ii. of this chapter. 
 126                 CONTINUED FEVERS.

 that the coagulum is frequently covered w ith the buffy coat.*  Hemor-
 rhagies from the higher parts of the intestines, kidneys, urethra, skin,
 eyes, &c. are rarely, the two last perhaps never, observed in synocha.
   Such are the symptoms of well marked synocha.   They vary in dif-
 ferent cases from those just enumerated, to the mild  febrile symptoms
 attending a common catarrh.
   After they have continued for some time, they always, at least  in
 this country, begin  to  be changed to those of typhus.   The propor-
 tional duration, as well as violence, of the synocha and  typhus, is dif-
 ferent, in  different cases; and  proves  an endless  source of variety.
 The  manner  in  which  the  symptoms  of synocha  are changed into
 those of debility,  also  varies much.  The duration of continued  as
 well as intermitting fevers is shorter, their symptoms more violent, and
 their changes more rapid, in the warm, than in the cold, and temperate
 climates.
   The symptoms which follow the state of increased excitement, are
 the most dangerous, a* well as most varied part of  the fever.

                             SEC. II.

                    Of the Symptoms of Typhus.

   Ax uneasy and peculiar sensation in the stomach, sometimes attend-
 ed  with  nausea and  giddiness,  frequently  denotes  the approach  of
 those fevers, in which the symptoms of debility prevail.!  In many-
 cases, however, this sensation is scarcely, or not at all, perceived, and
 the fever comes on with lassitude, anxiety about the praecordia, altern-
 ate heats and  chills, or a sense of creeping in different parts of the
body, which has been termed horripilatio.
   The patient complains  of uneasiness of the bead, and fixes his at
tention 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.
  Either sleep forsakes him, or he is more inclined to sleep than u.-ual,
and then  his sleep is such as does not refresh, disturbed by groans and
starts.

  * We shall afterwards have occasion to consider this appearance.

  f Dr. Jackson's Account of the Fevers of Jamaica, Dr. Smith on the ja:^
Fever of Winchester, &c. 
                    CONTINUED  FEVERS.                 127

  At this period the pulse for the most part is frequent, small and easily
compressed;  in other cases it is nearly natural, and the patient often
labours for some days under more or fewer of these symptoms, not well
enough to engage in business, nor sufficiently indisposed to be confined
to bed.
   The first symptoms of typhus are often more severe.   It makes its
attack with a troublesome head-ach, acute pains in the back, loins, and
extremities, which often resemble  a general rheumatic affection, a dis-
tressing sense of weariness, much thirst, and nausea, sometimes attend-
ed with a burning pain of the stomach, more frequently by  vomiting,
vertigo, dimness of sight, or numbness of the extremities.
   In some instances, the rigours from the first are strong, the pulse soft,
small, frequent,  and sometimes  irregular.   The  general uneasiness,
confusion of head, and dejection of spirits  excessive.   There  is often
great debility from the very commencement.  The tongue trembles,
impeding the speech, the limbs shake, and the patient with difficulty
supports himself.   There are, even instances of people, on the first at-
tack of typhus, falling suddenly to the ground, as if shot.*  There are
few diseases  in  which the symptoms are  more varied,  either in the
commencement or progress.

   Of the State of the Animal Functions in the Progress of Typhus.

   As the disease  advances, the debility of the  muscles  of voluntary
motion  increases.    In the advanced stage, the patient, incapable of
 any  exertion, lies on the back, and if turned on either side, soon re-
 sumes 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 effected with a tremulous motion.  Sometimes
 tormented with extreme anxiety, he is constantly changing his posture,
 in other cases the limbs are affected with numbness or palsy, more fre-
 quently they  are moved  by a constant  twitching of  the muscles,
 which now and then  proves the  forerunner  of general convulsions, in
 which the patient expires ;  sometimes in the  first attack, more  gene-
 rally after several returns.   In  some  cases  the muscles of the limbs
 are  affected  with more permanent spasm,  and cases are on  record, in
 which complete tetanus has. supervened towards the fatal termination
 of malignant fevers. |

   '*■' This sometimes happened in the late dreadful fever of Grenada, descri-
 bed by Dr. Chrisholm.

   | Spo Vopel. De Co?", et Cur. Morb. m>J others- 
128                  CONTINUED FEVERS.
    The head-ach is often a source of great uneasiness.  It most  fre-
 quently has its chief seat  in the forehead, sometimes in the occiput,
 and in some cases in the under par of the orbits,  sometimes  the orbit
 of one eye.  It is generally attended with strong throbbing of the tem-
 ples ; the carotid and temporal arteries often beat strongly,  while the
 pulse at the wrist is small  and weak.*
   The confusion of head increases with the debility, and often on 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 eve-
 ning for several days.  As the symptoms increase, a wandering of the
 mind remains throughout the day,  and sometimes  arises at night to a
 degree of  phrenzy,  resembling the delirium of synocha.   More fre-
 quently, however, the patient is rather stupid than violent.   At a more
 advanced period he  continues uniformly  sullen and sad, muttering to
 himself as if brooding over some misfortune.   The countenance  is de-
 jected, and the eyes heavy and inflamed.  When the evening exacer-
 bations 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.   In other cases
 insensibility, or as  it is termed in fever, coma comes  on.   If this in-
 creases, the jaw at  length falls, and the patient lies in a  state of  apo-
 plexy.
   The different organs of sense are variously  affected in the  progress
 of typhus.   Deafness is generally, not always, a favourable symptom-t
 A depravation of the sight is always unfavourable.   As the  fatal ter-
 mination approaches, the  patient frequently  starts  up; catching  at
 things  which  he sees passing  before him, or picks  the bedclothes,
 which appear to him striped or covered with black spots ; some times ev-

  * When this state of the circulation 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 inflammatory affection of the brain or its
 membranes.  In these cases,  abscesses are now and then  found in the en-
 cephakm after death.   Cases of this kind are related by Sir John Pringle and
others.  Dr.  Fordyce has  justly observed, however,  that abscesses of the
 brain very rarely occur in the fevers of this country.  The same throbbing,
 also frequently indicating an inflammatory affection is sometimes observed in
other parts of the body, particularly in the fevers of warm climates. "In the yel-
 " low fever," Dr. Linn nig observes, " there is  a remarkable throbbing in the
" temporal arteries and hypochondria j in the latter sometimes so great, as to
 " cause a constant tremulous  motion of the abdomen."
  f Dr. Hush and others mention fevers in which deafness was a very unfa-
vourable symptom. 
CONTINUED FEVERS.
129
wy thing appears indistinct as if seen through a mist.   The eyes in-
deed  are variously affected throughout the disease ; and some  assert,
that from their appearance alone the state of the fever may be ascer-
tained.  In  the commencement of typhus they are dull and languid ;
the tunica albuginea having a bluer, and sometimes whiter appearance
than ordinary.  In the furious delirium  they  are red, quick, and pier-
cing ;  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 flow from them.
For some time before death they  appear  hollow, involuntary tears
sometimes fall from them, and they become fixed and glossy.   The
sensibility  of the skin  seems often  much  impaired ;   and the taste
and smell are  frequently depraved or  lost.  The patient often com-
plains of a nauseous bitter 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  and frequent :*  and these

  * In tedious fevers, in which the symptoms are moderate,  the pulse is oft-
en as slow as natural for some hours during the day ; and in  the more malig-
nant forms of typhus, it has sometimes been observed a great deal slower.  I
mean even in those of Uiis country.  In the fevers of some tropical climates,
this is much more frequently the case.   This  state of the pulse in malignant
fevers  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 hi9
Dissertations on Fever, observes, that the pulse is sometimes as low as 50 or
even 45.  In the late dreadful Fever of Philadelphia, Dr.  Rush  found  the
pulse at 44, and in  one instance as low as 30.
  The pulse at a certain period  of the yellow fever becomes as slow, or slower
than natural, and continues so till within a short time of the patient's death
for recovery is rare after this change of the pulse  takes place.   When  the
pulse becomes slow, the heat at the same time sinks to the  natural standard
and sometimes  below it.  This and the other peculiarities of the fevers of
sultry latitudes  depend on some local affection.  The slow pulse indicates an
affection of the brain, which is farther indicated in many cases of the yellow
fftver by a dilatation of the pupil and squinting.  Dr. Chisholm particularly
takes notice of the slow pulse and dilatation of the pupil in the fever of Gre-
nada, and found water in die ventricles of the brain in those whom he examin-
ed after death.
  The yellow fever is so  called from the skin  being tinged with yellow ;
when the yellowness is late in appearing, it sometimes comes on so suddenly
that the patient almost instantly becomes of a yellow, deep orange, or copper
colour.  This circumstance, together with the urine and discharge from blis-
tered  parts  not always  appearing yellow  when tire skin i- cr\ demonstrate,
17 
130
CONTINUED FEVERS.
states of it increasing as the disease advances, it often becomes inter-
mitting, or otherwise  irregular.  As death approaches,  its weakness
and  irregularity become more remarkable, till at length the extremi-
ties grow  cold and it  cannot be felt.  This sometimes happens ten or
twelve hours before death.   There  is a tendency to syncope on the
slightest  exertion, particularly in  the  erect  posture ; and for some
time before the fatal  termination,  the debilitated state of the circula-
tion  occasions a shrinking of the features, and conspires with the re-
laxation of the muscles of voluntary motion to occasion what has been
termed the Fades Hippocratica, a  presage that cannot be misinterpre-
ted by the most  inexperienced.   The  face  assumes a  livid, cadeve-
rous appearance,  the nose is sharpened, and the cheeks become  hollow.
In the progress of typhus, the face during the exacerbations is generally
flushed, and pale  in the remissions.   In  both it often has  a bloated ap-
pearance.  There is an expression of countenance peculiar  to this fe-
ver which cannot be described, but is easily recognised  by those who
have seen it.
   The state of the breathing corresponds to that of the circulation ;  it
is weak,  generally frequent and  interrupted with  sighing or a dry
oough; 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 wheezing.   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 seldom
much increased,  and even in the progress of the disease is sometimes
little more than natural.*  But in general, after the first days, especial-
ly when the worst symptoms shew themselves, a person touching the

contrary to what was once supposed, that the yellow colour is not owing  to
the presence of hile 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 less
frequently than the heart.
   * This is often the case in what has been termed the nervous fever, the Ty-
phus Mitior.  " Calor non raro naturalem  vix superans," Frank observes, in
describing this fever.  It is not uncommon in malignant fevers, particularly
those of warm climates, for the extremities to be considerably below the nat-
ural temperature, while there is a burning  heat in the breast and other parts
of die trunk. 
CONTINUED FEVERS.
131
patient perceives a heat of a penetrating kind, which  remains in the
hand for sometime after it is removed from the patient.*

  Of the State of the Natural Functions in the Progress of Typhus.]

  The tongue at the beginning is covered with a thin white mucus ;
as the  disease advances, this mucus becomes thicker and of a brown-
ish  colour, and the clamminess of the  mouth and brown  colour of the
tongue generally increase with the fever.   In the advanced stage deep
chops  often form in the tongue, the mucus covering it becomes fetid,
dry, and firm, and a corresponding change taking place in that which
besmears the teeth  and other parts of the mouth,  and probably also in
the mucus  of the trachea  and bronchia?,  the breath  becomes offen-
sive, and the deficiency of moisture renders  the speech  inarticulate.
Sometimes, however, the tongue continues moist to the end of the dis-
ease, and 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 and teeth.  The last appearance of the tongue
Sometimes  supervenes in the progress of fever, although at an earlier
period it has been covered with mucus.

  * 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 mod-
" erate, and even in the advanced state, on first touching the patient, seems in-
" considerable ; but upon feeling the pulse  for some time, I have been sensible
" of an uncommon ardour, leaving an unpleasant sensation iu my fingers for a
" few minutes after.  The first time  I observed this," he continues," I refer-
" red it to the force of imagination ;  but I  was assured of the reality by re-
peated experiments, and by the testimony of otiiers, who, without knowing
" my observations, had made the same remark."
  Dr. Moore, in his Medical Sketches, Dr.  Huxham, in his work on the ulcer-
ous Sore-Throat, and others have also taken notice of this peculiarity of the
heat in Typhus.   Frank observes of it, " saepe manifeste  acer  digitosque
" urens."  Dr. Wright calls it a biting heat.  (Annals of Med. vol. 2.)  It
Was remarked, in speaking of intermittents, that Galen makes a similar obser-
vation respecting the heat in some of diem.

  +1 have here adopted the usual division of the functions into animal, vital
and natural; the reader, however, will readily perceive that there is no well
denned line of distinction between the twokst. 
132                 CONTINUED FEVERS.
   There is often a difficulty of swallowing from the dryness, sometimes
from a paralytic affection, now and then from convulsive* contractions
of the throat.t   The fauces are sometimes covered, particularly  to-
wards the end of the disease, with apthae,  that is, specks  of a white,
brown, or blackish colour,  often becoming  ulcerous ; and  when  they
occur in the worst kinds of fever, very commonly the  forerunner  of
mortification.   We shall have occasion to consider this  eruption  more
particularly, when I come  to speak  of it as characterising  a variety oi
fever.
   The patient complains of thirst, which is seldom, however, so urgent
as in  the synocha,J  the appetite is impaired or wholly  tost; and nau-
sea and vomiting  are frequent  symptoms  at an early  period.   The
matter rejected is frequently  a viscid, colourless, transparent   fluid,
without much taste or smell;  an astonishing quantity of which is oft-
en secreted  in fevers.  It is frequently mixed  with, and sometimes the
matter discharged almost wholly consists of, bile ; often in a very  vi-
tiated state, especially in the fevers of warm climates.§
   The bowels, as in other fevers, are generally costive, except  there
be irritating matter in them, and are often affected with flatulence and
spasmodic contractions.   A little before death, an ichorous diarrhoea
frequently occurs,  without any  evident cause ; this is  always one of
the worst symptoms.  At  an  earlier period, diarrhoea  is for the most
part salutary.

   * Even the hydrophobia  has been known to supervene towards the fatal
termination of malignant fevers.
   f If the respiration and deglutition be free, Dr. Fordyce observes, the prog-
nosis  is seldom bad, although the other symptoms appear alarming.
   + Not to complain of thirst, when the mouth and fauces are very dry, is an
unfavourable symptom, as it generally denotes a considerable degi'ee of in-
sensibility.  In the low nervous fever,  however, even when the sensibility is
not impaired, there is often no thirst.
   §. The black vomiting, a symptom so much dreaded  in the fevers of sultry
climates, in which the matter discharged resembles coffee grounds, appears
to be the consequence of a very  vitiated state of the bile which assumes this
appearance.  When the progress of the fever is rapid, Dr. Jackson observes,
this matter is often as black as soot.   When it is more gradual, it is  not so
dark, and often of a greenish colour.  The bile in these fevers is often passed
also by stool in so acrid a state as to inflame and excoriate the anus and parts
in its neighbourhood.  Towards the fatal termination, the stools in the yellow
fever of the West Indies often assume the appearance of tar or molasses. 
CONTINUED FEVERS.
133
  The appearances of the urine are various.  Sometimes it is pale or
limpid, which is never a favourable appearance ;  sometimes high col-
oured, and turbid, often giving a good deal of uneasiness in being dis-
charged, which  is sometimes favourable, and is never to be regarded
as unfavourable.   The  same cannot be said of the urine  appearing
brown, and depositing a matter like coffee grounds.   This is owing to
an admixture of blood, and is uniformly a bad symptom.   Sometimes
the urine is of a dark olive colour, the effect of  bile in the circulating
system.   It sometimes deposits a lateritious, or branny sediment; these
have been termed the critical sediments, and their appearance is gen-
erally, though  not universally, a favourable  symptom.  In some epi-
demics it has been found a very fatal one.*   These sediments have
obtained much of the attention of  physicians, and 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.t
  The urine is sometimes suppressed, or passed in small quantity, al-
though the bladder is distended.  This is an unfortunate accident, from
the irritation it occasions.  Sometimes it is suppressed without pain or
distension of the  bladder, which denotes a suspension of the secreting
powers of the kidneys, and affords  a more unfavourable prognosis.
  The skin for the most part is dry ; sometimes a moisture  is  observ-
ed on it, particularly  in the  mornings, and while this continues,  there
is generally some abatement of the pymptoms.J   In some cases a freer
discharge by  the skin  takes place, but this symptom with the  man-

  * See Dr. Linning's Observations on die Yellow Fever of America, in the
2d vol. of Essays and Observations, Physical and Literary.
  f In particular epidemics the urine has assumed a variety of uncommon ap-
pearances, probably depending on some affection of the urinary organs, but
none of these have been very distinctly marked.   Thus, Dr. Cliisholm ob-
serves, the urine was sometimes green, sometimes inclining to black, and of
in oily consistence.  Those which have been mentioned are the more com-
mon changes  which happen in the progress of fever.  Dr. Fordyce has at-
tempted to describe a state of the urine which he regards as peculiar to malig-
nant fevers, and his  account is probably accurate; but the circumstances
which characterise this  state of the urine do not admit of being sufficiently de-
fined to enable common observers to distinguish it.  " The urine has a more
"viscid appearance than  common; is frothy, browner, and not  absolutely
transparent,  although Uiere is no cloud or sediment."   Dr. Fordyce's 3d
Diss, on Fever.  Part 1.
  t In malignant fevers the sweat often tinges the linen with an ichorous ap-
pearance.  Fordyce's 3d Diss, on Fever. 
134
CONTINUED FEVERt.
ner in which we form the prognosis from it, will also be considered at
some length, in speaking of the crises of fevers.  It may, according to
the circumstances which attend it, afford a very good, or very bad prog-
nosis.
   I have already had occasion to observe, that hemorrhagies are to be
regarded as unfavourable in typhus.   Hemorrhagies from the eyes and
kidneys have already been mentioned.*  It would not, we should sup-
pose, a priori afford a much better prognosis when blood flows from
the stomach and intestines, occasioning a vomiting of blood, and tinging
the stools  with a dark red, or blackish colour.   These, however, are
much less fatal appearances, and I have often seen them attend a gener-
al abatement of the symptoms.   There is  perhaps  no hemorrhagy
which may be regarded as  affording a more unfavourable prognosis in
typhus, than that from the pores of the skin ; which is not an  uncom-
mon occurrence in the  worst forms of the disease.  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 ear-rings, or places where the patient on former
occasions had been let blood, &c.   In the worst cases  of malignant fe-
ver, indeed, blood, or rather a thin serum,  in which more or fewer of
the red globules are broken down  and suspended, sometimes runs from
almost every surface of the body, whether external or internal.
   The epistaxis is the most favourable hemorrhagy in typhus.   This
also indeed is often a bad symptom, 'especially  when the blood falls
only in drops ; when it flows more freely,  it has sometimes  been at-
tended with a sudden and favourable change.
   Other hemorrhagies, enumerated among the symptoms of synocha,
also occur,  though less frequently,  in typhus.   These are not so often
favourable as the epistaxis, but more so than those which more pecuv
liarly belong to typhus.j   I shall have occasion to recur to this subject
in speaking of the crises of fever.

  * Dr. Linning observes of the bloody urine in  typhus, that he always found
the admixture of blood become less, when the pulse acquired any degi'ee of
fulness, and again increase as the pulse sunk; denoting how much such he«
morrhagies depend on a debilitated state of the system.
  f Dr. Fordyce, in his 3d Dissertation on Fever, gives the following account
of the state of the blood in malignant fevers. It is the best I have met 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
" loo?^ and easily broken, the serum  being hardly of a browner colour than 
CONTINUED FEVERS.
!#i
  It sometimes happens in typhus, that the blood which flows from the
Vessels of the skin is detained beneath the cuticle, giving the appear-
ance of small round spots, which have been termed petechiae.  So fre-
quent are petechiae in the typhus gravior, that this fever has got the
appellation of typhus petechialis.   But typhus (it was observed in the
Introduction) often appears in its very worst forms, unaccompanied by
this symptom.
  Petechiae occasion no elevation of the cuticle, so that they are seen,
but not felt.   They  are red, brown, or blackish ;  the darker the co-
lour, the more they indicate danger.   Their shape is also various ; in
general they are circular, at other times running into each other  they
assume various forms.  They vary from a size scarcely perceptible to
that of a shilling, and are sometimes even larger.   Petechiae generally
make their first appearance on the neck, breast, and back ;  they more
rarely appear on the face and extremities, except on the inside of the
arm, where  the skin  is tender,  and  about  the wrist.    They are
sometimes so crowded together, that at a little distance the skin ap-
pears  uniformly reddish.  In other cases they are thinly scattered.
For the most part they appear before the end of the second week, and
are generally,  but not universally,  an unfavourable symptom.  There
are  instances of the febrile symptoms abating on their appearance-
   Instead of petechiae the skin  is sometimes covered with blotches of a
larger size, and  generally of a  purplish colour, termed  vibices ; at
other times  it is marked with  streaks  or stains of different colours,
which sometime cover almost the whole  body,  particularly the breast,
and give it the appearance of stained marble.

** common.   Sometimes, when the depression of strength is not very great,
" the blood retains this appearance during the whole course of the disease.
                          *       *      *
  " If there  i9 greater depression of strength, and by consequence putrefac-
" tion 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 the red  parti-
" cles 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 their
•' healthy appearance.  If the putrefaction goes on still further, there is hardly
rt any distinction between serum and coagulum -, if still further, the coagula-
* ble lymph forms a kind of bag, leaving the serum on the outside distinct.
" In the substance of the bag itself there is no intermixture of red particles,
" so that it looks like the buff which is on the surface of the coagulum  in ca-
'* ses of general inflammation; but within this bag a red fluid ie contained,
n which upon being examined with a microscope, shews the red particles of a
" variety of forms-." 
136
CONTINUED FEVERS.
   These are symptoms which indicate  much  danger.   The danger,
however, is not always proportioned to the number of petechias or vi-
bices.   It is usually the greater, the earlier they appear.  Ramazzini
observes,  that those in whom they appeared on the first day, almost
all died.   Petechiae do not always continue through the whole course
of the disease, but sometimes disappear in a few days ; in other cases
they disappear for a short time, and return.   They have been observ-
ed to continue, however, not only during the whole course of the di-
sease, but for a considerable time after every  other symptom had dis-
appeared.*
   Petechias sometimes, though much more rarely, appear in  synocha.
The reader will find cases of this kind in Eller de Cognos. et Curand.
Morbis, and Dr. Grant's Treatise  on the fevers  most frequent in Lon-
don.!
   Petechiae and the worst kinds of hemorrhagies or other symptom s de-
noting extreme debility in the vital and natural  functions are general-
ly accompanied with a tendency  to gangrene, the sweat and other se-
cretions having a putrid smell.  Gangrene sometimes occurs spontane-
ously.   It is then most apt to appear on the nose, lips, cheeks, fingers,
and toes. Sometimes it attacks a whole limb, the hands or feet becom-
ing black ;J  and it has  been known to extend  as high as  the elbow or
knee.   The extremities thus affected become cold, and often remain

  * Strack de P'eb.
  f Petechia sometimes  appear unaccompanied by fever of any kind.  For ca-
ses of this kind the reader may consult the inaugural Dissertations of Dr. Ed-
ward Graaf and Dr. Adair, Dr. Grant's Treatise just alluded to, Dr. Duncan's
Medical Facts and Observations, and the last vol. of his Commentaries in
which there are four cases of this disease.   It is mentioned by various other
writers,  and is  not very uncommon especially among the lower ranks, al-
though it is only of late that it has demanded much of the attention of physi-
cians in this country.   I have seen many cases of it in this neighbourhood. It
has received a variety of appellations:  Petechiae sine febre, Petechianosos, &c.
It belongs to  the third order of Dr. Cullen's third class of diseases, the Impeti-
gines.  It is often accompanied with a tendency to hemorrhagy in diflerent
parts of the body ; the disease itself indeed is to be regarded as  very nearly
allied to hemorrhagy. It has sometimes disappeared with a flow of sweat,
lasting for several days,  more frequently without any remarkable crisis. In
some cases it has proved  fatal.
  i Huxr.m on Fevers, Frank's Epitome de Curand. Horn. Morb. Vogel de
Cog. et Cur. .Morb. &c.   Vogel particularly notices spontaneous mortification
in  Typhus, and points out the parts of the body most liable to i*. 
CONTINUED FEVERS.                 137
 in this state  for many days before death.   In general, however, mor-
 tification 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 extremities.
   I need hardly observe, that this tendency to mortification, or in oth-
 er words to the extinction of the powers of life, affords a very unfavour-
 able prognosis.   Notwithstanding Dr. Miller, in his account of the dis-
 eases most prevalent in Great-Britain, and some others, have main-
 tained that a degree of  mortification appearing on the ends of the fin-
 gers, is to be regarded as a favourable symptom in  bad kinds of ty-
 phus.*
   The  patient often groans and seems uneasy, but is unable to ex-
 plain or point out the seat  of  his uneasiness.   This  is an unfavoura-
 ble symptom, not only indicating  a considerable  degree of stupor, but
 the presence of an irritation, which cannot fail to increase the disease.
 It is the business of the attendants to discover the source of this irrita-
 tion, and if possible to remove it.  It often proceeds from the urine be-
 ing too long retained,  very frequently from excoriations, inconsequence
 of the patient having lain too long in the same posture.  This, incases
 where the  tendency to mortification  is considerable, is often attended
 with very melancholy effects.   Instances have occurred in which, af-
 ter the danger from the  fever is past, a mortified sore  on some part of
 the body, on which the patient had lain,  is discovered, which baffles
 all the  succeeding care of his  attendants.  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 on-
 ly on the back, the parts on which he chiefly rests should be defended
 by proper  plaisters.  But such in many cases is the proneness to mor-
 tification, that no care can prevent it.
   Typhus sometimes terminates in ten or twelve  days, or within that
 period ;  if it be protracted for a longer time, the symptoms usually suf-
 fer  but little change during a considerable part of the  disease.   When
 it is protracted beyond the  14th day, without the more alarming symp-
 toms of debility shewing themselves, the prognosis is generally good.
  Dreadful as this fever often is, it  may appear in  a very mild form.
 Those who have  been exposed to the contagion or other causes of ty-
 phus, are sometimes affected with alternate heats and chills, listlessness

  * It must be admitted, that hi some rare cases the appearance of gangrene
has been attended with a favourable change, the fever abating soon after it
                                18 
138
CONTINUED FEVERS.
 and debility; yet never become so ill as to be confined to bed ; and
 these symptoms after teasing the patient for days, sometimes weeks,
 often wholly disappear.   Between the worst and mildest forms  there
 are innumerable degrees, which insensibly run into each other.
   If the case  is about to terminate fatally,  the symptoms which have
 been enumerated denoting extreme debility, gradually shew them-
 selves.   Cold viscid sweats at length 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, or is carried off by
 convulsions.
   When the event is about to prove favourable, the state of the patient
 is sometimes evidently changed  for the better in the space of a few
 hours.  After each succeeding remission, the symptoms return with di-
 minished violence, till the fever is wholly removed, leaving the vari-
 ous functions in a state of debility, from which in general they soon re-
 cover, and often acquire a greater degree of vigour than they possess-
 ed before the fever.
   In many cases, however, the debility which  remains after long pro-
 tracted fevers is the source of fatal diseases, of the various kinds  of
 dropsy, of phthisis, or any other disease to which the patient happens
 from other causes to be predisposed.*   For the circumstances which
 usually act as predisposing, often  become exciting causes in debilitated
 states of body, however induced.
   It is not uncommon for fevers,  in which  much debility prevails, to
 be followed by a  permanent derangement of some  of the  functions.
 The patient has been known to remain deaf or blind.   More frequent-
 ly these senses are only impaired.  The voice  also is sometimes  so
 much altered,  that it  never recovers its  usual tone, and in some cases
 is wholly lost.'  It is not uncommon for the judgment to  remain im-
 paired, particularly after fevers in which the delirium has been obsti-
 nate. From this melancholy consequence the patient  generally recov-
 ers, if he has no hereditary predisposition to it.
   When the change to health is sudden, it is generally^ attended with
some of the symptoms that have been termed critical.   Before leaving
the symptoms  of fever,  it will be proper to make a few additional ob-
servations on these. 
CONTINUED FEVERS,                 139-
                            SECT. III.

                      Of the Crises of Fevers.

  -Of the symptoms which attend the more sudden 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 the symptoms abate, it is
passed in greater quantity, and generally deposits a more or less copi-
ous sediment.  This sediment consists either of red chrystals, which
usually do.not  appear till several hours  after the urine is passed, and
fall to the bottom, leaving it limpid;  or of a white and sometimes
pinky  matter,  wliich generally appears  sooner, and only falls in part
to the bottom,  the urine remaining turbid.  The latter of these sedi-
ments has been termed furfuraceous or branny; the former from its re-
semblance to brick-dust,  lateritious;  but the last term has not been
used in a very  definite sense.   Sometimes both take place from the
same portion of urine.  But when there is much of the one, there is
generally little of the other.
   These sediments were long regarded as a morbific matter, the cause
of the fever, and to the discharge of which its abatement was ascribed.
But the truth is, that both sediments are almost constancy met with in
greater or less quantity in the urine of people in lealth.
   I had occasion some years ago to make observations on the urine,
with a view to determine the modes of life which  dispose this fluid to
deposit, what its discoverer Scheele calls lithic, now called uric, acid,
of wliich the  brick coloured sediment  of febrile  patients consists.*
From these observations it appears, that this sediment is most copious
when, from an  acescent diet or a debilitated state of the digestive pow-
ers, there is much acidity in the primae viae, or when the perspiration
is checked, in consequence  of which, the acid, which ought to have
passed by the skin, is  thrown upon the kidneys t

  * An account  of these observations was published in 1792, entitled An In-
quirt, into  the Remote Cause of Urinary Gravel.
  ■j- It is ascertained by  experiment, in the Treatise alluded to, that an acid
passes off even by insensible perspiration, and that all acids as far as they'
were tried, even the carbonic acid gas^ occasions the precipitation of uric 
MO                 CONTINUED FEVERS.

   It is farther shewn, that if while the perspiration is checked, the ac-
tion of the kidneys is also debilitated, the acid causing this deposition
from the urine accumulates in the system, 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 is merely a symptom of re-
turning health, but generally indicating  a less  free  perspiration  than
natural.
   The other, the cream-coloured or furfuraceous sediment, which also
now and 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 alkalescent diet, or in whom
the perspiration was unusually free, so that any  acid received into, or
generated in, the body passed chiefly by the skin.   Both depositions
were most copious when the urine was  highest  coloured  and had the
strongest smell,  demonstrating that it was much  charged with the pe-
culiar  substances  excreted by the kidneys.   The same portion. of
urine, however, as in fevers, never deposited a great deal of both.
   The latter sediment, therefore,  like the former, is merely a symp-
tom of returning health, and particularly indicates the  renewal  of a
free secretion  by the skin, which in fevers is  generally a favourable
symptom.
   But whether a favourable symptom or not, it is still  attended  with
the same deposition  from the urine.   In  some fevers terminating fatal-
ly there is an  unusual tendency  to sweat,  which  only exhausts the
strength.  In these,  this deposition constantly attends, but without re-
moving the fever.   This is the case in hectic fever.  I have observed
this deposition in all cases  where there were night  sweats  although
without fever.   Nay I have found on repeated  trials, that I could at
pleasure occasion it in the urine  of healthy people,  by promoting the
perspiration by small doses of  antimon.  tartaris.  or pulv. ipecac.
comp.   These appearances in the  urine, therefore, at the favourable
termination of fevers, are certainly not the  cause, but the consequence,
of recovery.*

acid from the urine.   The circumstance of acids occasioning this precipitar
tion was first noticed in an anonymous publication on the origin of gout and
gravel, afterwards claimed and republished by Mr. Murray Forbes.
  * The following are the only appearances of the urine, if we except those
it assumes in consequence of morbid affections of the urinary organs, which
can be distinctly marked.  The pale urine without  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 light cloud formed in it 
CONTINUED FEVERS.                 141
  Next to the critical deposition  of the  urine, there is no symptom
which so generally attends the change from fever to health as sweating.
This we found is almost uniformly the crisis of intermittents, and con-
tinued fever seldom terminates favourably without  some degree of
moisture appearing on the skin.*
  It is surprising that the best effects, even in those fevers in which
debility prevails most,  sometimes attend profuse  and long continued
sweats,  provided they are general, and the patient bears them without
much loss of strength.   Dr. Donald Munro  remarks, that in  the pete-
chial  fever the sweat often continued for three or  four  days with the
best effects.   Another  remarkable peculiarity of this fever (the pete-
chial} says Hoffman, is the profuse cold sweats, of an acid smell, con-
tinuing for several days and nights, and proving a salutary crisis.
  He justly adds, however, that these sweats, although proving critic-
al, always indicate much  debility,  and that if the patient's strength be
not supported while under them, he frequently sinks when on the brink
of recovery.
  From  these facts, however, we are not to draw an inference, which
long mislead physicians,  and proved a source of much mischief;  that
the solution of the fever is to be wholly attributed to the flow of sweat,
and that could this symptom by any means be  induced, it  would al-
ways prove equally beneficial.   To this hypothesis,  besides other er-
roneous practices, we may trace the employment of the hot regimen in
fevers ;   an errour so fatal, that it may be seriously questioned, wheth-
er the medical art, during its  prevalence,  did more good or harm in
these diseases.   It has just been shewn, that the  critical sediments in
the urine are to  be regarded, not as the cause, but the consequence, of
recovery.   Nearly the same may  be  said of critical sweats.   It  fa-
vours this opinion that in  certain symptomatic fevers  when the disease

without sediment; the high-coloured urine remaining clear, or having a light
cloud formed in it and depositing usually  a considerable time (from 4 to 12
fiours) after it has been passed a red crystallized sediment;  the high-colour-
ed urine becoming turbid after it has been passed for a short time  (from half
an hour to two hours) and depositing a light-coloured sometimes pinky sedi-
ment, now and then (after the urine has stood for a longer time) mixed with
moreor less, if the light-coloured sediment  is copious, never with much of
die red rrvstallized sediment; and in almost every disease as well as in health,
the urine occasionally assumes all these appearances.
  *  The crisis in Synocha,  says Hoffman, is in most cases a profuse sweat.
Dr. Grant remarks of the synochus, " Nor do I find the crisis ever perfect.
" till the night kindly sweats begin to flow ;" and Dr. Iluxham declares that
he never saw " a malignant typhus cured till more or less of sweat had is-
sued." 
142
CONTINUED FEVERS.
is removed wholly by local means,  sweating, notwithstanding,  often
attends the change to health.
   Nothing would be more hurtful than  checking a sweat which is at-
tended with relief, and it is even proper, as will be pointed out more
particularly in considering  the treatment of fevers,  to use innocent
means to promote sweat; but to endeavour to  force it out by warmth
and heating medicines, is universally prejudicial.  The wished for
crisis is never obtained  in this way, and the attempt has often proved
fatal.
   Even spontaneous sweats are not  always to be encouraged.   When
they continue without relieving the  symptoms,  they indicate danger,
and ought to be checked.  Nor are those sweats  to be  encouraged
which are viscid and partial.   Unless the sweat be thin and universal,
it is seldom attended  with a remission of the fever.
   Sweating not  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 a frequent forerunner of
death in the yellow fever.*  It is of the same fever that  Dr. Linning
observes,  that the urine often shows the critical sediment on the very
first day, which he uniformly found  a bad symptom, and the more co-
pious  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 Britannica ; the chief symptom of which was a profuse flow
of sweat, from which  it received the appellation of Sudor Anglicus.J
   If we except the critical deposition from the  urine and  sweating,
there is no symptom which oftener attends  tlie  more sudden changes
from fever to health than diarrhoea.   If diarrhoea supervene 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 either 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 dysenteric.  It
is in autumn, the season in which dysenteric affections are  apt  to ap-
pear, that fevers most frequently terminate by a discharge from the in-
testines. ||

  * See Dr. Jackson's observations on this  fever.
   (- See Dr. Linning's letter to  Dr. Whytt, on' the  yellow fever of South
America, in the 2d. vol. of the Essays and Observations, Physical and Literarv
  * See Caius de Ephemera Britannica.
  § See his Historia Febris Petechialis.
  !! Quarian Def<-hri^"< 
CONTINUED FEVERS.                 U3
   The crisis is often for some time  preceded by flatulence, gripes,
■and pains of the loins.
   Spontaneous diarrhoea, however,  is far from  being universally fa-
vourable.  If it does not soon bring relief, and particularly if it is at-
tended with much loss of strength, it should be  checked.  The diar-
rhoea, which by medical writers is emphatically termed colliquative, I
have already had occasion to notice.
   Vomiting may also be enumerated  among  the crises  of fevers; it
never proves critical, however, except at, or very soon after, the com-
mencement of the disease ; then,  whether spontaneous or induced by
art, it sometimes stops the fever.
   A spontaneous flow of blood from different parts of the body, we
have seen, is frequently attended  with an abatement, or total removal
of the  symptoms of Synocha; and, what we  should not a priori have
expected, sometimes of those of typhus.
   As physicians inferred  from the 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 fe-
ver could be removed; and  as they inferred from the relief obtained
during critical  sweats, that this matter may be thrown off by  the skin
so they inferred, from the abatement of the symptoms which frequently
attends hemorrhagies, that it may be expelled from the system by ve-
nesection.  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 whole mass, prevent them from recommending ve-
nesection in all kinds of fever.
   If there be  any practice which has been more baneful than the hoi
regimen, it is the indiscriminate use of blood-letting, in these diseases.
This subject it  will soon be necessary to  consider at length, it is suffi-
cient here  to observe that the effects  of  venesection and spontaneous
hemorrhagy in fevers, are often so different, that the favourable change,
which frequently attends the latter, must be  attributed  to something
else than the loss of blood.  And as we certainly know that the critic-
al depositions of  the urine, and have  often reason to believe that cri-
tical sweats are the consequence, and not the cause, of the favourable
change which  attends them ; so we have reason to believe of sponta-
neous hemorrhagy, that it is, at least, in part owing to the general re-
laxation of the  extreme vessels which  takes place in the change irum
t'vvcv to health.   The loss of blood in  critical  hemorrhagies, indeed „£
often too  trifling to be «npposed capable of any crpdderabte effect. 
144                 CONTINUED FEVERS.
   Of hemorrhagies, that from the nose is most frequently critical.   It
is generally preceded by some of the following symptoms. An unusual
redness of the eyes, sometimes  an increased secretion of tears, a sense
of weight in the temples, dimness of sight, pain of  the head, general-
ly, Qjuarin observes, of the occiput, itching of the nose, and the pulsus
dicrotus,  regarded by physicians as one of the chief symptoms por-
tending a critical  hemorrhagy in fevers.  In this state of the pulse,
which is also called rebounding, the artery seems at  each diastole to
give a double stroke to the finger.
   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 malignant fevers,
however,  are not preceded by any other symptoms than those of gen-
eral  debility, and never prove critical.
   The symptoms which precede critical hemorrhagies  seem to oppose
the idea of their being the effect of the general relaxation of the ves-
sels ;  but wre know that in all states of the  system the above symptoms
are generally the  consequence of the congestion  which precedes  the
rupture of vessels.
   Critical hemorrhagies,  it has been observed, are most frequent  in
those fevers which arise from cold gluttony, the abuse of intoxicating li-
quors, or suppressed discharges.
   Eruptions of various kinds now and then prove critical in fevers ;
this is sometimes,  but not often, the  case with the eruptions enumerat-
ed in the Introduction  as characterising particular species of synochus.
Of these eruptions aphthae most frequently bring relief.*
   Aphthae, however, are far  from always  being favourable.   When
light-coloured, and  accompanied with a considerable flow of  saliva,
they are 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 fa-
tal symptom.
   An increased secretion of mucus from the fauces, or  of  saliva, unat-
tended  with aphthae,  is  often  favourable.!   The latter  sometimes

  * "Ad Aphthas," Sydenham observes, " cum jam discessum meditarctur,
" erat propensior."  (See Sydenham De Febribus Continuis}.   The favoura-
ble termination of that species of synochus, which is attended with the milia-
ry eruption, is often preceded by the appearance of aphthae.  ' (See  Mead's
Monita et Precepta Medica.
  ■\ The former of these is mentioned as having generally been attended with
an abatement of the symptoms in the late dreadful fever of Philadelphia. 
CONTINUED FEVERS.                 146
amounts to a salivation, and has been known to prove critical.   Both
Sydenham *  and Huxham t relate cases of this kind,
   A scabby eruption appearing about the mouth or behind the ears,
more frequently than any of the preceding eruptions attends the favour-
able termination of fever, j
   One of the most remarkable crises of fevers, is  a swelling and sup-
puration of glandular and other parts of the body.   This crisis rarely
happens in the synocha.  The parotid glands are the parts most com-
monly affected.  They swell and become inflamed,  and  the  event of
the fever seems often to depend on the discharge of the matter generat-
ed in them.
   It has generally been found the most successful practice to lay  them
open as soon as, or even before 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 the  softness of the tumour, which may never happen.  The
''  pus  being  here so  very viscid, that  after  it is ripe the part will
"  feel as hard, as if the suppuration had not begun."§
   I have heard Sir Walter  Farquhar observe, that when  he attended a
regiment on the continent,  there appeared among the troops a violent
fever accompanied with a swelling of the  parotid  glands, which never
came to suppuration. Almost every patient attacked with this fever di-
ed, till  it occurred to him that an incision of the enlarged gland might
prove serviceable ; from  which he found the best effects.
   "■ Swellings of the parotid glands,"  Dr. Donald Munro ||  observes,
"  appeared 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."IT

  * See Sydenham de  Febribus Continuis.
  ■j- See Huxham on Fevers.   Vogel observes, that intermittents are  some-
times cured by a salivation.
  t Rush on the Yellow Fever of Philadelphia, Chisholm on that of Grena-
da, &c.
   § Sir John Pringle's Observations on the Diseases of the Army.
   || See Dr. Munro's Treatise on the Diseases of the Army.
   f Whose case demonstrates in a striking manner the connection between
the suppuration of the parotids and the solution  of the fever.  A swelling
appeared on the right  side, which came to suppuration  and proved  critical
The fever in a short time returned ; another swelling appeared on the other
                                19 
146
CONTINUED FEVERS.
    Dr. Munro applied poultices and gummous plasters to the inflamed
  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  would seem to point out Sir John Pringle's mode of treat-
  ment to be preferable.   Some epidemics,  however, afford a different
  inference, as appears from the observations of Acrel,<,in the Memoirs of
  the Royal Academy of Sciences at Stockholm.   He often met with ab-
  scesses 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 of the  matter is distinctly per-
  ceived, a purulent discharge from the intestines, fauces, or nose super-
  vening, the tumours subside, and the fever ceases. Physicians have en-
 deavoured to promote the termination which nature pointed out,  giving
 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 matter, the tumours subsided, and the fever disappeared.
    The tumours sometimes appear in the arm-pits, or in the groin, and
 sometimes in the testicle.  Dr. Rush observes, that the glandular swel-
 lings frequently  accompany the yellow fever.  He never saw them
 come  to  suppuration,  but generally  found them   favourable.  Dr.
 Chisholm, however,  remarks, that they were  among the  unfavourable
 symptoms of the  late dreadful fever of the West-Indies, which differed
 in many respects from the common yellow fever, particularly in being
 accompanied, at least in Grenada, with pestilential eruptions.
   A peculiar affection of the testicles and scrotum sometimes appeared
 in this fever, and proved critical.*
   The last symptom I shall mention, as deserving a place among the
 crises of fever, is shivering. When this occurs  in the progress of con-
 tinued fever, it is sometimes followed by the hot stage, and other symp*
 toms of the  paroxysm of an ague, and the fever assumes  the  intermit-
 ting form.
   Various other symptoms are said by authors to be critical  in fevers,
 but most of them  have been observed so rarely that  their occurrence
 may rather be regarded as accidental, than as particularly connected
 with the solution of the fever.   Suppurations in different  parts of the

side, which came also to suppuration, and the fever  again ceased.  The pa-
tient afterwards died hectic, in consequence of the profuse secretion from the
sores. '.
  * See the 122d and following pages of Dr. Chisholm's Treatise. 
CONTINUED FEVERS.
147
body happening a considerable time after its termination, rheumatism,
catarrhus vesicae, or common catarrh, occurring about the time the fe-
ver goes off,  indolent swellings, schirrus of the different viscera, vari-
ous  affections of the teeth, jaws, joints, and bones,* spasmodic and ner-
vous affections, &c.

                            SECT. IV.

                Of the Prognosis in Continued Fever.

   The prognosis in continued fever has been delivered in what has
been said of the symptoms and crises of this disease, and of the progno-
sis of intermittents.
   The danger  in fevers arises from two causes, increased excitement,
and debility.   The symptoms of  increased excitement  are less to be
dreaded than those  of debility, because we possess more certain means
of removing them.
   There is a third  head, to which authors refer many of the symptoms
of typhus, namely putrescency.   " From  all  this it  appears," Dr.
Cullen observes of the prognosis in fevers, " that the symptoms shew-
" ing a tendency to death may be discovered by their being either the
spmptoms
   "  Of violent reaction ;
   "  Of great debility  ;
   "  Or of a  strong tendency to putrefaction in the fluids."!
   In the  105th paragraph he observes, " the symptoms denoting  a
 " putrescent state of the fluids  are,
   " 1. With respect  to  the stomach ; the loathing of animal  food,
 nausea and vomiting, great thirst, and a desire of acids.
   « 2. With respect  to the fluids ; 1. The  blood drawn out of the
 " veins not coagulating as usual.  2. Hemorrhagy from different  parts,
 " without marks of increased impetus. 3. Effusions under the skin  or
 " cuticle, forming petechiae, maculae and vibices.  4. Effusions of a yel-
 " low serum, under the cuticle.
   " 3. With respect to the state of the excretions ;  fetid breath, fre-
 " quent, loose, and fetid stools, high-coloured turbid urine, fetid sweats,
 " and the fetor and livid colour of blistered places.
   " 4. The cadaverous smell of the whole body."
   *  Some of die latter  perhaps have abetter claim to be regarded as con-
 nected with the solution of the fever. See Vogel deCog. etCur. Morb.
   f  Sec Dr. Cullen's First Lines, vol. i. p. 160 
146                CONTINUED FEVERS.
  The first set of  symptoms, the loathing of animal food, nausea and
vomiting, thirst, and a desire of acids are common to  all kinds of fe-
ver, and as strongly marked in synocha, in which no  putrescency of
the fluids can be suspected, as in typhus.
  Of the second set of symptoms it may be observed, that the hemor-
rhagies and effusions so common in malignant  fevers are readily ac-
counted for, and  might have been foreseen from the relaxed state of the
solids independently of any change induced on the fluids.  We know,
however,  that in such fevers the blood  is  thiner  and  consequently
more apt to be extravasated than in health, but in a machine so com-
plicated as the animal body, may not this change  be  owing to  many
other causes than putrescency ?  Is not the debilitated state of the vari-
ous functions in typhus, particularly that of the secreting organs, suffi-
cient to account for it ? That the blood is in no degree actually putrid,
even in the Worst forms of typhus, we are well assured.   It  does not
indeed coagulate so readily  as usual, but  never has any fetor.
  It is only at first  view that the remaining symptoms seem to afford a
better argument for the opinion of a putrescency of the fluids.
  When the various functions are much impaired, the  contents of the
stomach and alimentary canal  stagnate.   These form no part of the
living body.  They are as  apt to run to fermentation as the same mat-
ter out of the body exposed to the same degree of heat and  moisture,
unless the antiseptic fluids of these cavities are  supplied to check this
tendency.   Thus it happens, where the powers  of life are  much ex-
hausted, that the contents of the intestines become putrid.  The same
happens on the surface of the body.  The failure of  the due secretion
and absorption there causes a stagnation and putrefaction of the natural
moisture.   Hence  the putrid smell of the sweat.  This also happens in
parts which have been blistered, in ulcers, &c. so that it is easy to ac-
count for the cadaverous smell of the body,  without supposing any de-
gree of putrefaction in the circulating fluids. And those labouring under
typhus, being m -e subject to gangrene  than people  in  health,  only
proves, that in them the vital powers are more languid and apt to fail.
   It would seem, therefore, that the various symptoms arranged  by au-
thors under the head of putrescency,  come under  that of debility.
And in considering the treatment of fever, we shall find that  the means
employed with a view to obviate what are Called the symptoms of pu-
trescency arc only effectual in proportion as they restore the impaired
vigour. 
CONTINUED FEVERS                  149
                           CHAP, II.

          Of the  remote Causes of Conthvued Fever.

  I have already had occasion to observe that I would not always at-
tempt a division of the remote causes into predisposing and exciting :
because the same causes  often act in both ways.    This is  true of
the remote causes of continued fever.   There are two, however, which
generally act as exciting causes ;  cold, occasioning the fevers charac-
terised by an increase of excitement ; and contagion, those in which
debility prevails.  As the remote causes of intermittents were arrang-
ed under the head of marsh miasma, I shall arrange those of continued
fevers under the two heads of cold and contagion ; because in consider-
ing these, we shall have occasion to take a view of the various circum-
stances  which produce, or tend to produce this order of fevers.

                           SECT. I.

                   Of Cold as a Cause of Fever.

  This part of the subject Dr. Cullen has considered fully in his First
Lines ;  and to what he has said, there is little to be added.   I  shall
therefore quote his observations, omitting such as appear to be hypo-
thetical.
   " The operation of cold on a living body is so different in different
" circumstances as to be of difficult explanation ; it is here,  therefore,
" attempted with some diffidence.
   " The power of cold may be considered as absolute or relative.
   " The absolute power is, that by which it can diminish the tempera-
" lure of the body to which  it is applied.  And thus, if the  natural
" temperature of the  human body is, as we suppose  it to be,  that of
" 98 degrees ofFarenheit's thermometer, every degree of temperature
" less than that,  may  be considered as cold with respect  to the human
" body ; and in  proportion to its degree will have a tendency to dimin-
" ish the temperature of the body.   But as the living human body has
" in itself a power of generating heat, so it can  sustain its own proper
" heat to the degree above-mentioned,  though surrounded by air, or
"other bodies of lower temperature than itself; and  it appears from
" observation, that in this climate, air, or other bodies, applied to the 
150
CONTINUED FEVERS.
" living 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 retained in
" its proper temperature of 98 degrees ; for in this climate every tem-
" perature  of the 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 appears, that the absolute pow-
" er of cold with respect to the human body is very different from what
" it  is with respect to  inanimate bodies.
  "  The relative  power of cold, with respect to the  living body, is,
" that power by which it produces a sensation of cold in  it ; and with
" respect to this it is  agreable to  the general  principle 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 applied immediately before.   Ac-
" cordingly, with  respect to temperature the sensation produced by
" any degree of this,  depends upon the temperature to which the bo-

  * There is an evident inaccuracy in this statement, because the velocity
with which the temperature  of an animal is reduced by the surrounding me-
dium, is not regulated by its temperature only.  The temperature of the hu-
man  body is not diminished by air at the temperature of 62° ; but it is dimin-
ished by water or quicksilver at the same temperature.
  + There is also an inaccuracy  in this statement.  For the increase of tem-
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,
and Mr. Hunter, that the living  body resists an increase as well as a diminu-
tion  of its  temperature, and that there is  no  temperature to which we can
venture to expose it, which will raise internal parts more than a very few de-
grees above the natural temperature.  See  an account of Dr. Crawford's ex-
periments 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 OZconomy.  Mr. Hun-
ter's experiments, if accurate, are the most conclusive in favour of the living
body possessing a peculiar power of resisting an increase of temperature, as
in them the result cannot  be attributed  to the effects of  evaporation.  Dr.
Crawford's experiments prove,  that an animal disengages a  less quantity of
caloric in a high  than in a low temperature ; but if Mr. Hunter's experiments
are accurate, our bodies must possess a power of combining, as well as dis-
engaging, caloric.  A temperature above 62°,  therefore, may rather be said
to exhaust the powers, than  increase the temperature of our bodies. 
                    CONTINUED FEVERS.                 151

" dy had been immediately before exposed; so that whatever is high-
 ' er than this feels warm, and whatever is lower than it feels cold ;
" and it will therefore happen that the opposite sensations of heat and
" cold, may, on different  occasions, arise from the same temperature
" as marked by the thermometer."
  " With respect to this, however, it  is to be observed, that although
" every change of temperature gives a sensation of cold or heat as it is
" lower or higher than the temperature applied immediately  before,
" the  sensation is in different cases of different duration.  If the tem-
" perature at any time applied  is under 62 degrees,* every increase
" of temperature applied will give a sensation of heat; but if the in-
" crease 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 bo-
"dy, lower  than that  of the body itself, gives  a  sensation of  cold;
" but if the temperature applied does  not  go below 62 degrees,  the
" sensation of cold will not  continue  long, but  be soon changed to a
'* sensation of heat."  The paragraphs  which follow in Dr. Cullen's
First Lines, respecting the manner in which cold acts on the living an-
mal body, are omitted,  as not only hypothetical but in some parts in-
consistent.  In  the 92d paragraph Dr. Cullen enumerates the morbid
effects of cold :
   " 1. A general inflammatory  disposition of the system, which is
" commonly accompanied with rheumatism or other phlegmasiae.
   " 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 produces
 " 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
 ,c of these morbid effects, and it is difficult to determine in what cir-
 l< cumstances it especially operates in producing them.  It  appears to
 " me, that the morbid effects of cold depend partly upon certain cir-
 ,; cumstances of the person to whom it is applied.
   L' The circumstances of the cold applied which seem to give it effect
 ; are,  1. The intensity or degree of the cold.  2. The length of time
 lk durin? which it is  applied ; 3. The degree of moisture at the same
*  See note in page 20o. 
 152                CONTINUED FEVERS.

" time accompanying it. 4. Its being applied 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  of the system, and
" particularly the lessened vigour of the circulation,  occasioned by
" fasting, by evacuations, by fatigue, by a last night's debauch, by ex-
" cess in venery, by long watching, by much study, by rest immedi-
" ately after  great exercise, by sleep, and by  preceding disease.
" 2. The body, or its parts, being deprived of their accustomed cover-
" ings. 3. One part of the body being exposed to cold, while the rest
"' is kept in the usual or a greater warmth.
   " The power of these circumstances is demonstrated by the circum-
" stances enabling persons to resist cold.   These are, a certain vigour
" of constitution, exercise of the  body,  the presence of active passions,
" and  the use of cordials.
   " Beside  these, there are other circumstances which, by a different
" operation  enable  persons to resist cold, acting as a sensation j such
" as passions, engaging a close attention to one  object, the use of nar-
" cotics, and that state  of the body  in which sensibility is greatly di-
" minished,  as in maniacs.   To,*Ujvhich is to be added, the power of
" habit with respect to those  parts of the body  to which cold is more
 ' constantly applied, which both diminishes sensibility, and increases
" the power ot the activity generating heat."
  When cold acts as the exciting cause, the fever is  generally of that
species which has been termed synocha.  It is chiefly, when cold con-
curs with the marsh miasma or contagion in producing intermitting fe-
ver or typhus, that it acts as a predisposing cause.


                            SECT. II.

                         Of Contagion.

  Without  detaining the reader, by remarks on the indefinite manner
in  which the terms contagion and infection have been employed ; it
will be sufficient to define the sense in which I shall use them.
  If it can be proved that the plague, for instance,  is communicated to
a healthy person, not only by the sick themselves, (in- which case it is
possible to ascribe the spreading  of the disease to sympathy) but also
by any thing which has been in contact with the  sick, although  the
person infected  is ignorant of its  having been so;  if this, I  say, is an 
                     CONTINUED FEVERS.                 153

established fact, it is then ascertained, that matter of some kind passes
from the sick, to the person receiving the disease.   This matter I shall
call contagion ;  and its action on the  person in whom it  produces  the
disease I shall call infection.
   The following observations may be  divided into three parts.
   In the first we shall consider the source from which contagious fever
springs.
   In the second, the different ways in which it spreads ; and
   In the last, (what depends on a knowledge of these) the means of
preventing its appearance and checking its progress.
   There are few parts of medicine involved in greater obscurity, than
the nature of contagion.   Universal experience only could convince us,
that the application of a matter, which for the most part cannot be de-
tected, and  which is  often applied in very  small quantity, should so
constantly produce nearly the same train of symptoms, whatever be  the
state of the body at the time it is received into it.
   Many have attempted to ascertain the origin of contagious diseases;
but such enquiries have for the most  part proved fruitless, and often
led to very absurd opinions.
   In the history of medicine we observe  contagious  diseases  which
had long prevailed suddenly disappearing, and others arising in their
stead.  But the  facts  preserved, concerning  the production and disap-
pearance of these  diseases, throw no  light on the sources from which
they arose.   The  leprosy of the Jews,  and other species  of leprosy
which raged in  Europe in the 12th and 13th  centuries,  are  scarcely
now to be met with.  We find Celsus speaking of the hydrophobia as
a new disease;  and we have a remarkable instance both of the pro-
duction and disappearance of  a contagious  disease  in the Ephemera
Britannica, or,  as it was  termed, the Sudor Anglicus,  described  by
Caius* and others.   The  gangrenous  sore throat, Allioniusj observes,
was scarcely known before 1610, since which time it has made dread-
ful  havoc in almost every country of Europe.  The Plica Polonica
seems to have made its appearance only in the last century.  The ad-
dress of the Polish physicians to the University of Paris is still extant,
in which the disease is described as new.,  extremely contagious, and
incurable by any  means  they could think of.   The " yaws," Dr.
FerriarJ observes,  " the sibbens, and other  national infectious disor-

  * Caius de Ephemera Britannica.
  | Allionius de Miliarium Origine.
  * Dr. Ferriar's Medical Observations and Reflections.
                                SO 
154                 CONTINUED FEVERS.
 * ders 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  ap-
 pears that Dr. Cullen is wrong in attempting to  limit contagions to  a
 very few species.
  Concerning the source of the above and other contagious diseases,
 there is but one conjecture which appears at all probable.   That each,
 though afterwards propagated by contagion, is at first produced inde-
 pendently of contagion,  by a  concurrence of causes which rarely
 takes place.   And when, at any period, it happens, that no person la-
 bours under the disease,  it must of course cease to exist; and  cannot
 be  reproduced unless a sufficient quantity of the contagion is preserv-
 ed in fomites,* till the same causes,  which first gave rise to it,  again
 conspire.  Thus contagious diseases may  for a long time disappear,
 while a different combination of causes may give rise to others, which
 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 difficulty of tracing the source of other contagious
 diseases, it is no difficult  matter to detect that of typhus.   The combi-
nation of a very few circumstances,  and those of frequent occurrence,
 is sufficient to produce this disease.
  It may arise in any ill-ventilated and crowded place.  Mr.  Howe]
 and others, who escaped  from  the black hole of Calcutta,  were seized
 with 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, &c. when  due at-
tention has not been paid to ventilation.   It is evident, therefore, that
the  effluvia of the living body, become putrid by stagnation, are capa-
ble  of producing it.
  Putrid effluvia, from any other source, may have the same effect.
Thus uncleanliness of all  kinds  is favourable  to the production  of this
disease ; and on this  account  such  fevers generally take  their rise
among the poor, and among them are most fatal.t

  *  Substances impregnated with contagion.
  f  See the observations of Sir J. Pringle, Dr. Ferriar, 8cc.   It is observed,
by Dr. Fordyce and others,  that many brute animals are subject to typhus',
when crowded togedier in ill-ventilated places.  This fever has been observ-
ed to break out among hogs, and more frequently among sheep 
CONTINUED FEVERS.                 \bii
   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  as to be capable
of producing it.   Senac gives an account of a malignant fever occa-
sioned by the offal of a city being accumulated  without the  walls.*
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 fever of the  same kind, which raged at Egmont, in North
Holland, occasioned by a whale left on the shore.
  The putrid effluvia of animal and vegetable substances produce con-
tinued fever when the  situation  and  air are dry, and intermittents
when they are damp.t
  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 fe-
ver arises, and whatever appearance it at first assumes, it may by va-
rious accidents be protracted, and become a contagious typhus.
   It is said, that typhus has been found more  apt to arise among peo-
ple  who live much on animal food, particularly if salted, than among
those who use a large proportion of fresh vegetables.  It is least apt to
arise when the diet is such as best preserves the vigour of the system ;
and this diet is different  in different circumstances.    Peculiarity of
constitution and habit influence it much.  I shall presently have oc-
casion 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, inde-
pendently  of the  circumstances which have  been pointed out as the
sources of typhus, often  produce this, as well as other contagious fe-
vers.  This induced Sydenham to mark attentively  the  state of the
weather, in different years, during which epidemics of different kinds
prevailed.  But after very careful observation he was obliged  to con-
fess  that  he could perceive no difference in seasons in which the con-
tagious diseases were very different.
   Van Swieten made a similar set of observations, which led him to
the same conclusion.   He noted for ten successive years, three times
a day, the height of the barometer and thermometer, and the direction
and strength of the wind.  He also marked the quantity of rain that
fell,  the various changes of the air, diseases, number of the sick, and of

  * The air was so loaded with putrid effluvia, that those  who lived near
the heap of putrilying matter could not keep meat sweet for three hours.
  f Compare what is here said with what was said of the remote causes of
intermitting fever, B. i, c. iii 
156                 CONTINUED  FEVERS.
 those who died.  These observations, like those made by every per-
 son in the course of his own experience,  prove, that certain diseases,
 pleurisies, quinsies, Lc. are most frequent in certain kinds of weather;
 but they throw no light on the source of contagious diseases.

               Of the  Ways in wliich Typhus spreads.

   In whatever manner  typhus is produced, it is generally* propagated
 by contagion.
   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 probable,
 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 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 instances
 perhaps is applied to the body ; It is common  for people to be infected
 in consequence of approaching 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 conta-
gious 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 diseas-
es ; 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 considerable dis-
tance.   In proof of this,  many facts might be  adduced; one of the
most striking on record happened on the  11th of May, 1750, at the
Old Bailey.  The prisoners  were kept for nearly a whole  day  in
small, ill-ventilated, and crowded apartments  ; some of them labour-
ed under the jail fever.   When they were brought into court, the win-
dows at the end of  the hall,  opposite to the place  where the judges

  * It is remarkubie indeed, that we sometimes meet with malignant fevers,
which do not appear to be at all contagious.   " Sometimes," Dr.  Lind ob-
serves,  " one man may be seized widi the petechial, or with the yellow fever,
"while the rest continue unaffected."  Dr. Lind  gives several instances  in
support of this observation. 
CONTINUED FEVERS.
157
 sat, were thrown open ; the people on the left of the court, on whom
 the wind blew, were infected with the  fever, while those on the op-
 posite 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 distem-
 per.  Many  of the 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 contagion
 in the air ; that it may be perceived by the  sight or smell.   There
 seems to be no proof of this opinion, and  much of what has been said
 of it  must 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, and of a cloud hanging over a
 city where such disorders rage.   Caius observes of the Sudor Anglicus,
 that a disagreeable smell preceded the distemper, and a black cloud
 was seen to move from  place to place as if driven by the  wind, "the
 distemper following the course of the cloud.   Concerning the accura-
 cy of observations, which so many have had the same opportunity of
 making, and so few  have made, there must  be  much doubt.
   The smell  of patients labouring under  fever, ^eems from a variety of
 facts,  to depend on something distinct from the  contagion.  Fomites
 may be highly impregnated with contagion without having any par-
 ticular smell  ; where the smell of  the patient is strongest  the conta-
 gion is often weakest, and vice versa.  Upon the whole we have rea-
 son to conclude, with Dr. Fordyce, that  the presence of  contagion in
 the air is not to be detected  by any of the senses.
   It is remarked above, 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.  Calm  weather,  we
have just seen, often appears favourable  to it.  The plague  has been
found  to spread more rapidly in damp foggy, than in clear dry weath-
er.  Dr. Lind observes of typhus, that a damp air seems to increase
the strength of its contagion ; Dr. Smith  makes a  similar observation.

  * We may thus explain why contagious diseases have sometimes appeared
to be most malignant in calm weather,  the wind being a principal means of
preventing the accumulation of  the  contagion.  It is  said that during  a
plague at Vienna, the wind did not blow for  three months ; at the end of diis
time a breeze  arose, by which the distemper was alleviated.  See Van Svvie,
ten's Comment, in Aph. Boerhaavji. 
158
CONTINUED FEVERS.
 This has been ascribed to the contagion being diffused through the air
 with great difficulty when loaded with watery vapour.  It is more pro-
 bably owing to the sickly state of body which a damp air induces ; it
 checks the perspiration, disorders the stomach, and often renews febrile
 and other diseases.*
   It is generally supposed, that hot weather is favourable, and cold
 weather unfavourable, to the  spreading of contagious diseases  ; and
 this, with some exceptions, is true.   It is common  for contagious dis-
 eases to suffer a check, or cease altogether, when the winter sets in.
 But the worst fevers have often raged at the coldest seasons.  The
 plague did so in London, and  there have been instances of the plague
 suffering a check as the weather grew warmer.
   There seem to be particular  states of the air,  not to be distinguish-
 ed by the senses, which are favourable to the spreading of contagious
 diseases.   It appears, from the observations of Dr. Linning  on the
 yellow 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 account, that the same  fever brought to this  coun-
 try in several American ships,  attacked those only who  had been on
 board the ships, others remaining uninfected, notwithstanding the free-
 est intercourse with the sick on shore.
   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 ; and then the effluvia from his body.
   The last of the ways in which contagious disease may spread, is by
fomites, substances impregnated with the contagion.   Fomites often re-
 tain contagion for a great  length of time, and may  convey it to any
 distance.  It is a general opinion, that fomites more readily communi-
 cate the  disease, and communicate it in a worse  form than the sick
 themselves.t

   *  See the observations on the  states of body which dispose to infection,
 towards the end of this section.
   \  " It appears to me probable," Dr. Cullen observes, " that contagions as
 " they arise from fomites are  more powerful, than as they arise immediately
 " from the human body."  In the observations of Sir John Pringle and others,
 we find striking instances of the virulence of infection from fomites.  Dr.
 Lind remarks " I am convinced, from very extensive experience,  that the
 " body of the sick is not so apt to communicate the infection, as the dirty
 " linen, &c. which has been about him."  The  sick, Dr. Smith observes, and
 even the dissection of those who died, were not  so apt to communicate the> 
CONTINUED FEVERS.
159
  Contagion adheres to the furniture and utensils employed about the
9ick, as well as to all kinds of clothes, woollen, cotton, linen, &c. and
even  lurks in the walls of the apartments where the sick have  lain.
Woollen materials  and wood, are thought most apt to retain it.
  It is a curious and wholly unaccountable fact, that contagious diseases
generally run a certain  course, notwithstanding all the means which
can be employed to check their progress, and after this cease sponta-
neously, while the  walls of the houses, furniture, <$*c. must still be sup-
posed to be highly impregnated with the contagion.   This observation
is made by Russel and others of the plague, and has been made, in-
deed, of all contagious diseases.
  Those who have been near the sick, may infect others without being
infected themselves.  Nay, those who have only been exposed to putrid
effluvia may excite typhus in  others, while they themselves escape.
*' The  most pernicious infection next to the plague," Lord Bacon ob-
serves, " is the smell of  the jail, where the prisoners have been long,
" and close, and nastily kept, whereof we had in our time experience,
" twice or thrice,  when  both the judges  who sat  upon  the  jail,  and
" numbers of those who attended the business,  sickened upon it  and
" died, therefore it were  good wisdom, that in such cases the jail were
" aired before they be brought forth." " It is probable," Sir John Prin-
gle observes, after quoting this passage, " that one of the times hinted
" at, by this noble author, was at  the fatal assizes held in  the year
" 1577, of which we have a more particular account  in Stow's Chroni-
" cle, in these words.   On the 4th, 5th, and 6th  days of July, were
" the assizes held at Oxon, where was arraigned and condemned Row-
«• land  Jenkins, for a  seditious tongue, at which  time there arose
" amidst  the people,  such a damp (an expression in the language of
•' those days, signifying bad air) that almost all were 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."
  The greater the debility, and the more strongly marked those symp-
toms which have been called putrescent, petechiae, fetor of  the breath,
 and perspiration, 4*c. the  more contagious in general is the fever.
This, however, is far  from being an universal rule;  the milder form'-
of typhus are sometimes as contagious as the more malignant.

disease, as substances which  had been  in contact with  them.  It is eyen
said, that contagion may be conveyed in the smoke arising from fomites while
burning.  Dr. Mead makes this observation, with respect to the contagion,
both of small-pox and typhus.   See Mead's Muoita et  Prsecepta M.dica.
The siime observation is also made by Van ?\\ 1 '-'en and others 
160
CONTINUED FEVERS.
   The time during which the contagion lies in the body, before it ex*
cites the disease, is differenMn different cases.   Sometimes its effects
are almost immediate ; in general, however, the infected feel no symp-
tom of the disease  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 patients la-
bouring 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 of the small-pox, been sud-
denly attacked with  sickness, head-ach,  pain in various parts of the
body, and other febrile symptoms, which have gone  off without shew-
ing any of the  symptoms peculiar to small-pox.*   Dr. Chisholm ob-
serves,  that those exposed to the contagion of the  fever of Grenada,
were often immediately seized witb nausea and slight rigours, which
always proved transitory, the fever not appearing till the 2d or 3d day,
or perhaps not appearing  at all.
   Similar to these observations are  those of Sydenham and Rush, res-
pecting the measles.   What Sydenham calls the  morbillous fever, and
Rush the internal measles, are diseases in certain respects resembling,
in others differing from, measles ; but which frequently attacked those,
who were exposed to the  contagion of rneasle=.   Rush also observes,
that he frequently met with a slight feverish disease, which those who
formerly had had  the measles were subject to, on approaching  patients
labouring under the disease.
   It is not only true,  that  many exposed to the action of contagion es-
cape  infection, but  it appears from  a variety  of  observations, that
toany escape infection who  have actually received the  contagion  of
typhus into the system, or have it lurking about them tor a considera-
ble time, in such a manner that it may readily be called into action by
slight causes.  This  is sufficiently confirmed by the observations of Dr.
Lind in his Treatise  on  Fevers and Infections.  He found that those
who 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 be-
ing free from the contagion,  had the  fever renewed by  such causes.
He remarks that sailors, after they have been for some  time on shore,
are frequently seized with fever, which at first seems merely the efi
feet of a  debauch, or some  such cause,  but  which soon assumes the
precise form  of that  which  raged  in the ship they had left.   In such
* Cases of this kind are mentioned by Dr. Lind and others. 
CONTINUED FEVERS.                161
cases we find contagion acting merely as the predisposing cause.
These observations  are illustrated by what is said by  other writers,
particularly by what Dr. Rush says of his own situation while the yel-
low fever raged at Philadelphia.
   In speaking of the means of preventing the progress of contagious
diseases, I shall have occasion to mention circumstances favourable  to,
or tending to prevent, their spreading, which to save  needless repeti-
tion I omit at present ; particularly those states of body which are fa-
vourable to,  or tend to prevent, infection.  It is remarkable, that al-
though typhus, as has been  observed, sometimes arises among brute
animals, in the same  way as among  men, and is communicated from
one to another in the same manner, yet brutes canrfoT-cornmunicate it
to men, nor men to brutes ;* nor can one species of brute communi-
cate it to another.   Hogs, for instance, cannot communicate typhus to
sheep,  nor  vice  versa.   It is remarkable, that white  people cannot
communicate certain contagious fevers to blacks.  And I have been in-
formed by West-Indians, that there are among the negroes many con-
tagious febrile diseases, to which white people are not subject.

The means of preventing the  Generation, and checking the  Progress of
                             Typhus.

   With regard to the means of preventing the generation of typhus,
all that is  necessary to be  known was delivered in  speaking  of  the
sources of its contagion.   If these are avoided, its  generation will be
prevented.   It will be  necessary  to speak at greater length of  the
means to be employed for checking its progress.
   On what has been said of the different ways in which contagious dis-
eases spread, are  founded  many of the precautions  employed  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

   * Illud pratterea notabile est (Waldschmidt observes) venenum pestilen-
tiale, hominibus infestum, non nocerebrutis ; et e contrario brutorum pestem
non nocere hominibus.  See Haller's Disput. ad  Morb.  Hist, et Cur. perti-
nents, vol. v.   There are instances however, of human contagion proving fa-
tal to brute animals.  Bocacce says, he  saw two hogs  eat some pieces of
bread thrown from a poor man's house, who had  died o<  the plague, in conse-
quence of which they were seized with convulsions  and exoiredin an hour
                                21 
162
CONTINUED FEVERS.
approach the sick.  But as contagion is carried from place to place by
the wind, and as every place where the sick have been, even for a short
time, may be supposed to be  more or less  impregnated with  it,  it
must frequently happen, in close, and  crowded parts of cities,  when
the number of sick is great,  that the whole atmosphere  will become
more or less loaded with contagion.  And it is difficult for those who
inhabit such places to escape infection.  It  is prudent, therefore, on
the breaking out of pestilential distempers, to remove to the less po-
pulous parts of  the city.   Europeans residing at Aleppo, and  other
places frequently visited by the plague, choose the suburbs for their re-
sidence.   By this  means, and  by shutting themselves up in their hou-
ses, and avoiding all intercourse  with their neighbours, while the dis-
ease rages, they rarely suffer from  it.   Even the inhabitants  of colleg-
es and monasteries in these countries, who live in a great measure se-
cluded from  intercourse with their neighbours, frequently escape infec-
tion.
   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 fur-
ther precautions.
   Contagion sufficiently diffused  becomes inert; were not this the case,
the very purifying of goods impregnated  with it,  (which is  generally
done by exposing them  to the air) would be sufficient to spread the dis-
ease on all sides.   Whether  it is owing to this circumstance, or the
specific gravity of contagion, it has been observed, that those who re-
side in the upper parts of  houses often escape,  while those  living on
the ground floor are attacked with, pestilential fevers.
   The greater purity of the air  at some distance above the surface,
in places where these fevers rage, has been so thoroughly ascertained,
in eastern countries, that those who  shut  up (as  it is termed) during
the plague,  converse with their neighbours 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 fe-
ver which rages below.  Dr.  Russel,*  was accustomed  to  prescribe
for a croud 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 dis-
ease himself,  nor communicated it to those he lived with.
   It should  lie the endeavour therefore, of those who live w here the
deaths arc numerous,  to be supplied  with  air from  the  tops of their
houses.   Li those countries where most rooms have chimnies, a  very
* See Russel on the plague. 
CONTINUED FEVERS.
163
simple expedient  is  sufficient for this purpose, 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 healed chimnies, the doors and windows being kept  close, the  ex-
ternal air can enter only by the chimnies which have  not been heated.
By similar means miners often  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 hospitals, 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 experiments, that the air  towards the ceil-
ing, on a level with the open windows, was pure  enough  to preserve
the'life of birds ; while in the lower parts of the same ward, on  a lev-
el with the patients'  beds, they sickened and died.   This fact tends
to confirm the observation just made respecting the specific gravity of
contagion ;  and shews the necessity of ventilating the wards of hospi-
tals, where  contagious fevers rage, by  openings near the floor as well
as the ceiling ;  and it is probable, that the former of  these  modes  of
ventilation will be found the most effectual.
  The knowledge of the air being  a  medium  through  which conta-
gious diseases spread, has suggested another set  of means, whose  ob-
ject is to destroy, or correct the noxious properties  of the contagion,
while suspended in the air.
   It is necessary, however, to premise that it is impossible  in every
instance, to  discover whether these  means  operate by  destroying, or
correcting the properties of the  contagion; or merely by fortifying
the body against its action.  Many of them may be supposed to act in
both ways.   I shall arrange under the present head, those  which may
be  supposed to act in  the  former way ; and under  another division,
point out the  means which  act evidently  by  fortifying the body
against 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 whether any particular means possess the power
of destroying or correcting the properties of contagion, by observing
whether they  are capable of purifying fomites.   What means have,
in this way, been proved to possess  that  power, will be pointed out in
speaking of the purification of fomites.
   Heat is one of the most  ancient means employed  for destroying or
correcting the properties of contagion suspended in  the air.   It  has 
Id4                 CONTINUED FEVERS.
   been an opinion 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 of it.  And it will appear, when we consider  the
   means employed for  purifying  fomites, that this opinion  is probably
   true.  But how shall we apply the temperature sufficient for this pur-
   pose,  which we shall find is very considerable, to the infected air ?
   Fires have frequently been made in the streets throughout a whole city,
   where the plague or  other pestilential fevers raged.  From this, how-
   ever, we should not, a priori, expect much benefit ; and the fact is, it
   has not been attended with any  good  effect.*
     It even appears, upon the whole, that fires employed in  this way,
   by overheating the atmosphere  are often hurtful.   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 been destroyed during  the preceding three
   or four weeks.
     It appears, I think, upon the  whole, that there are only two  ways
   in which heat proves useful in checking the progress of  contagion, by-
   supporting a free circulation of  air, in some such  way as that above
   pointed  out, and by destroying, or correcting the  properties of conta-
   gion lurking in fomites.   The manner in which it is employed for this
   purpose we shall presently have occasion to consider.  Some4have sup-
   posed, that it is of service in contagious diseases, by drying the  air in
   damp situations.
     Various substances are supposed, while burning, to possess a peculiar
   power of destroying or correcting the properties of contagion, inde-
   pendently of  the heat which attends  their use.   Most of these howev-
   er,  being employed for  the  purpose  of purifying fomites, as well as
   the contagious atmosphere, will be  considered  with more propriety,

     * In the year 1721, the plague raged at Toulon with such violence, that in
   the space of 10 months, it  destroyed  about two  thirds of  its inhabitants.
   Many having insisted on fires being made in different parts of the city, the
r   public records were consulted, and it was there found that on a  similar occa-
   sion the  same means had been tried without success.  This, however, did not
   prevent the inhabitants from repeating the  experiment.  Wood was  there-
   f >: e laid before every house, and at the sound of a bell all the fires were light-
   ed, by which the city was involved in a thick smoke for nearly  a whole  dav
   T ie plague, however, suffered no abatement.  The same measure was  had
   recourse to both at Marseilles and  London, when the plague raged in these
   cities, widi no better success. 
CONTINUED FEVERS.
165
 under the next division.  The firing of gunpowder is chiefly employ-
 ed with a view to purify the latter, and is frequently used in hospitals,
 on shipboard, &c.  How it acts, has not been certainly ascertained ;
 the agitation of the air, occasioned by the  sudden explosion, must dif-
 fuse the contagion through a larger tract of air, and may thus render it
 milder, and its properties, as  some have suspected, 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 derive some
 support from its having been observed, that in southern climates, pesti-
 lential fevers generally suffer a check  during the vintage, which  has
 been ascribed  to the gas evolved from the fermenting vats.  However
 this may be, there are  other circumstances during the vintage, which
 tend to this  effect.   The fresh fruits, the approach of the cold season,
 and the general cheerfulness which harvest inspires.
   A variety of strong smelling  substances are  supposed to correct the
 properties of contagion, without the assistance of heat.   This quality
 is commonly ascribed to the  odour of pitch  and  tar.   When  the
 plague raged in London, few of those employed about the shipping, it
 is said, were seized with it.   We are also  informed,  that  those who
 work in storehouses of spices, are less liable to contagious disorders,
 than others.  One of the most celebrated of this class of substances is
juniper.*   There are none of them, however, on which much depend-
 ance 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.
   The steam of  water has been recommended  for purifying the air in
jails and  hospitals,  and  is probably  more  effectual.!. Many have
 thought, that large tubs filled with cold water,  with fresh  willow and
 other boughs thrown into it, and placed  in the apartment of the sick,
 especially in summer, are serviceable.
   But of all the means belonging to  this head, the  fumes of mineral
 acids seem, from  various trials, to be by far the most effectual.  The
muriatic and nitrous acids appear to possess equal power.   The latter
is preferable, as it is breathed with least inconvenience.   In Dr. Car-
michael Smith's Treatise on  the effect of the Nitrous Vapour in pre-
venting and destroying Contagion, ascertained by  a variety of trials.

  • Dr. Monro's Treatise on Inoculation.

  f See Considerations on Contagion in Maidstone Jail, by Mr. Day; and Dr
Alderson's Essay on Contagion. 
166                 CONTINUED FEVERS.
 made chiefly by Surgeons of his Majesty's Navy, &c. and in the Re-
 port of the Council of Health, on  purifying  the Air in the Military
 Hospitals of the French Republic, the reader will  find  ample proofs
 of the efficacy of the acids, and an account of the best mode of using
 them.*
   The means of preventing infection through the medium of substan-
 ces,  which have been in contact  with, or  near, the  sick, (for fomites
 may receive the contagion from the air) equally demand attention.
   It was once a custom to destroy the apparel, and  other substances,
 which  had been in contact with the sick ; and, if the disease  was of a
 highly contagious nature, even to pull down their houses.
   The total destruction of clothes, furniture, &c. however, being ex-
 pensive, various means have been  proposed, and practised with success
 to purify infected goods.  It is unnecessary to give a detail of all the
 means  which have been employed with this view7.   I shall point out
 those which have been found most successful.
   The most simple means of purifying houses  and goods, is washing
 and exposing them to the air, and these are  generally sufficient.  It is
 common to wash, or what  is better,  whitewash the walls of houses,
 where the sick have lain ; and to  procure a free circulation of air by
 opening the windows, and making fires in the house.  The clothes, and
 other articles  which have been in contact with the sick, are washed
 and exposed to  the air for a  considerable time.  And in the different
 lazzarettos 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 ex-
 posure to air ; and those employed in washing fomites run the risk of
 infection.   Dr. Lind particularly cautions against washing clothes, im-
 pregnated with  contagion, in warm water, as the  steam is dangerous,
 unless they have been steeped for some time   in water, or 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.

  * Some  dispute exists respecting the person to whom we are indebted for
the first proposal of using the acids in this  way. Those who wish to enter
on die merits of  the dispute may consult the Publications of Dr. C. Smith,
and Dr. J. Johnstone, of Birmingham, on this  subject.  The latter supports
the claim of his father, the late Dr. Johnstone, of Worcester,  author of sev-
eral ingenious Essays. 
CONTINUED FEVERS.
167-
   Fomities, highly impregnated, should be fumigated before they are
exposed to the air, both on account of this  circumstance, and because
the purification of substances highly impregnated with contagion, espe-
cially such as  have been in  contact with  the sick, ought not to be
trusted to exposure to air alone.
  Fumigation has been performed in various ways, and with a great va-
riety of materials.  The most simple way, is smoking  with coals or
wood ; the latter is preferred  by Dr. Lind, and  some think charcoal
preferable to  either.   The articles to be purified being inclosed in a
convenient place, fires are kindled, and the smoke and heat confined,
which 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 clo-
sed, and fires kindled within.
   Much of the good effects of smoking  in this way, seems to depend
on the temperature, wliich, it is said, should be but little  inferiour to
that for baking bread.  And this degree seems capable  of destroying
contagion in every thing which can be exposed to its action for  a suffi-
cient length of time.   Dr. Lind says he never  knew an  instance  in
which a ship, after being smoked, did not become quite healthy.
   But in order to make  the purification as complete as possible,  differ-
ent articles have been added to the fire.   The chief of these are yel-
low and white arsenic and  sulphur.  The  last has been known as an
antidote against infection since the infancy of medicine.   In the same
manner, tar, pitch, rosin, frankincense, caraphire, cascarilla, various
spices and aromatics,  juniper, pine-tops and shavings, turpentine, &c.
have occasionally been used.
   But we are often obliged to  purify a house or ship, when, from vari-
ous circumstances, the patients are prevented from leaving  it.  It is
then of course necessary to avoid the use of sulphur, arsenic, and oth-
er pernicious articles,  to employ a less degree of heat, not  too much to
diminish the oxygenous part of the air;  and in particular to  avoid the
use of charcoal.  The purification, on these  accounts, was much less
perfect  than when the  inhabitants could be removed    Sometimes,
cascarilla and other aromatics were merely burned at the patient's bed-
side.  All these means are now superseded by the employment of the
vapour of the nitrous  or muriatic acids,  unless the infected goods are
of such a nature as to be injured by it.
   It is to be observed, under this head, that there should be as little
furniture as possible in the bed-rooms of the  sick.  It is an  observation
of Dr. Rush, which  has  not been sufficiently  attended  to, that  every
diing around a  patient  being  charged  with  the contagion,  not only 
168
CONTINUED FEVERS.
renders those about  him  more liable to infection,  but increases the
virulence of his disease.   To  this circumstance we must in part at-
tribute the  benefit derived from  removing those  labouring under con-
tagious diseases to fresh apartments.
  Wood  and  woolen materials, as observed above, seem particular-
ly apt to retain contagion, and should therefore be used by the sick  as
little as possible.   The bedsteads in hospitals should be of iron ; and
Howard advises the floors to be laid with bricks.
  Certain states of body have been observed to be more favourable to
infection  than others.   When the body is vigorous, and the mind un-
disturbed, we are  least liable to  infection.  Whatever debilitates and
relaxes is favourable to it.   These observations point 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 infection, is a generous, but
temperate diet, and regular exercise.   Wine has been long celebrated
as a preventive ;  and it is,  upon the whole, the best.  This can on-
ly be said, however, of the moderate use of  it.   The body is at no
time more liable  to infection than  after intoxication, of which there
is sufficient proof  in the observations of many of the authors whom  I
have  had occasion to mention.  If, however, when the debility sub-
sequent to a debauch in wine commences, it be  driven off by again
having  recourse  to wine,  the  tendency  to  infection  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 less
powerful in preserving against infection.
   Opium and  tobacco seem to  act in the same way, but are  inferi-
our to wine.   Tobacco,*  whether used  as snuff, smoked, or chewed,
has long been a celebrated   preventive.   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 attention to this circumstance ; yet as it is not impro-
bable, from several facts which I shall presently have occasion to men-
tion, that the first attack of contagion is sometimes on the stomach,  a
precaution so easy should not be neglected.   For similar reasons we
 are advised to stand with the back towards the patient.

         •  See Van Swieten's Comment, in Aph. Boerhaavii. 
CONTINUED FEVERS.
169
  To this head belong those remedies which have been termed tonics.
The Peruvian bark, when it neither oppresses the stomach  nor other-
wise deranges the system, may be ranked next to wine, 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, a great
variety of articles of less note,  most of which do not deserve to be
mentioned.   Vinegar is used in  various  ways ; frequently  washing
the mouth and  hands with it, or dossils of lint dipt in it, or in a mix-
ture of vinegar and spirits of rosemary, and  put into the  nostrils, are
precautions little to be relied on.   Some place  confidence in chewing
lemon peel and other aromatics, in wearing camphire about  them, &c.
The opinion  that mercury tends to prevent infection, has in some pla-
ces gained ground.   Whatever be the truth of  this opinion,  quicksil-
ver worn in a quill, which has sometimes been done even by medical
men, can be regarded as nothing better than an amulet; a great varie-
ty of amulets are in use  among the vulgar in every  country.   What
truth there is in the observation, that those who have issues in any part
of the body  are  less subject to infection than others, it  is difficult to
say.*
  We have reason  to believe, from the observations of  Dr. Currie in
a treatise which I shall have occasion to mention more particularly in
considering the treatment of fever, that the cold bath will be found a
better preventive, than most of the other means employed as such.
  One powerful mean of fortifying the body against infection, on many
accounts deserves attention, namely,  the frequent exposure to conta-
gion.   It is well ascertained, that  those who are frequently  exposed
to contagion become at length, in some measure,  hardened against its
effects, as those who are accustomed to drink much wine are less readi-
ly intoxicated by it.  Thus nurses and physicians often escape infec-
tion.
  Few things are  better  preventives than fortitude  and equanimity.
Nothing, we are informed by those who voluntarily exposed themselves
to the contagion of the most pestilential fevers, was found so effectual
as a steady adherence to  their  duty,  banishing  from their minds, as
much as possible, all thoughts of danger, and avoiding  every kind of
passion, particularly the depressing passions.  Every body knows,
how much fear disposes to infection ; on  this  account it  is of conse-
quence to strengthen the  faith of the  ignorant in the efficacy of  any
thing they believe capable of preserving against it.

  * See Dr. Smith's Treatise on the Jail Fever of Winchester.
                               <?2 
I TO                 CONTINUED FEVERS.
  Not only fear,  and the other  depressing passions, but every thing
else that debilitates, disposes to it. " The yellow fever," Dr. Lining
remarks, " was most fatal to those  deprived of fresh air, those from
" cold climates, those who had most dread of it, those who over-heated
" 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 fever of Gre-
nada  ; visiting the sick with an empty stomach, he adds, or when per-
spiring, was dangerous.
   In short, we may regard every cause of derangement as predisposing
to infection ;  immoderate evacuations ; the depressing passions, or the
debilitating effects of the exciting ; a poor and scanty diet, or excess
in eating and drinking; much heat, or a cold and damp air ;  long con-
tinued vigilance,  &c.  Even sleep, in  which  the vital  functions are
more languid than while   we are awake, has been very generally  ob-
served to be favourable to the action of contagion.   It is remarkable,
that so slight a debilitating cause as a disagreeable odour may have the
same effect.*
   In checking the progress of contagious diseases, it is of great impor-
tance, as much as possible, to separate the sick from the healthy.   No
more attendants should  be employed than are absolutely necessary ;
and on the breaking out of a contagious fever a proper house should be
prepared for  the  reception of the poor, who  are  attacked  with the
disease.
   The proper choice of nurses, and other attendants is also a matter of
consequence.   As those  employed about the sick are unavoidably ex-
posed to infection, it is of importance to choose such as are  least  lia-
ble to  it.   The  attendants on  the sick in particular should be made
acquainted with the circumstances which dispose to, or tend to prevent.
infection ; and when, as  frequently happens, there is any set of people
in the place, who from having formerly  had the disease, from having
been frequently exposed to contagion, or any other cause, are less hV
ble to infection than others, they should be induced to undertake UV
office of attendants.

   * Every kind of soap, Van Swieten observes, has a nauseous smell but par
ticularly the coarser kind,, which are made of impure alkaline matters and
quick lime mixed with train oil.   Diermerbroeck observes, that in his hosni
tal three women who had  been washing linen were next morning  seized
with the plague, and were all of them persuaded, they had taken it from the
fetid smell of the soap. 
CONTINUED FEVERS-.
171
   All the exanthemata, and even the yellow fever of  sultry climates,
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 Africa, 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 yellow fever.   It was probably owing to
this circumstance, that Dr.  Rush having assured the black inhabitants
of Philadelphia that they were in no danger from the fever which lately
raged 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 Grenada, however, that al-
though people of all colours were subject to it, mulattoes and mustees
were  less subject to it than whites, 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.  An attention to these,
it is evident, is proper in  choosing attendants  for the sick.   People
labouring under certain disorders are less liable to infection than  oth-
ers.   But from the diseased we cannot choose attendants.
   While such as are least subject to infection  are chosen for attend-
ants,  care should be  taken to prevent those  from approaching the sick,
who from any peculiarity in their situation  are particulaly liable to it.
   It is observed, in cities where pestilential distempers rage, that those
lately from the country are particularly liable to infection, 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, in consequence 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 and
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 con-
tagion acts, and the parts of the system on which it makes its first at-
tack, nothing  satisfactory has been determined.    It is a  common
opinion,  that it makes its first  attack upon the stomach.   This is far
from  being ascertained ;  although  some  plausible arguments may be
adduced in support of it.  A  disagreeable sensation  in the stomach,
and other disorders  of this organ,  are often the first symptoms of con- 
t72
CONTINUED FEVERS.
tagious fevers.  Dr. Lind even observes,  that  an uneasy sensation in
the stomach is sometimes perceived the instant  the patient is infected.
It is also in favour of this opinion, that dyspeptic affections often oc-
casion 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 diar-
rhoea.   But when we reflect on the sympathy which subsists between
the stomach and other parts of the system, 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 for-
mer disease or other causes.  From  which it does not appear impro-
bable, that the superiour sensibility  of the stomach is the only  cause
of its being particularly affected at the commencement of those diseas-
es.
  It is remarkable that contagious diseases seem  (to use the language
of medical  authors) to change  others into their own  nature ;  so that
while a contagious fever rages  very generally,  few other  diseases
make their appearance, and those which do, commonly partake  of the
symptoms of the prevailing  disease.   This observation has often been
made  of typhus, and still more frequently of the  plague.  This curi-
ous subject is considered at some  length in Dr. Rush's work on the Fe-
ver of Philadelphia.
CHAP. HI.
             Of the Treatment of Continued Fever.

  I have in the preface given a short outline of my opinion of the na-
ture of fever.   I endeavoured in the Essay there alluded to,  to  shew
that what in inflammation takes place in the capillaries of a part,  takes
place in those of the whole system in fever ; and that  as inflammation
is removed by restoring the due action of the capillaries of the inflam-
ed part, fever is removed by restoring that of the capillaries of the
whole system.  To this conclusion, it was observed, we are led, both 
CONTINUED FEVERS.
173
by the experiments related in the Introduction to the second part of this
Treatise, and by the various phenomena of fever.*   I here  offer it to

   * The difference between this opinion and that of Dr. Cullen consists chief-
ly in the cause of fever according to the one, existing in the nervous, accord-
ing to the other, in the vascular system.  Dr. Cullen supposes that the re-
mote causes of fever act by debilitating the nervous system, and that  the fe-
ver can only be removed by restoring the energy  of the brain, which is sup-
posed to  give energy to every other part.  I have viewed the brain  as affected
only secondarily, in the same way as the skin, kidneys, and other organs, by
the state of the vascular system ; and the renewal of its energy I bave regard-
ed as nodiing more than an indication that the functions of this system are re-
stored.
   Dr. Cullen appears to have been led to his opinion by a position which was
taken for granted by the earlier Physiologists, that the heart derives its pow-
er from the nervous system.  If it can be shewn that the brain is the only ac-
tive part of this system, the nerves being merely channels by which its influ-
ence,  and the impressions which excite it, are conveyed; and that the heart
is often in  perfect vigour where no brain has ever existed, is it not  proved
that the power of the heart is independent of this system ?   (See my essay on
the Nature of Fever, page 94 and 95, and the first note marked 32.)       ,
   It is worthy of remark, that all the muscles of involuntary motion  are ex-
cited by stimuli immediately applied to the muscles themselves, while those
of voluntary motion are excited by the influence of the brain communicated
through the nerves.  (See the 31st and 32d notes in the Appendix to the Es-
say just referred to.)  This circumstance alone seems to demonstia e that
the two sets of muscles are not equally dependent on the nervous system, and
to afford an easy explanation, without having recourse to the supposed office
of the ganglia, or any other  hypothesis, of the one set being subjected to the
will, and the other independent of it.  A muscle of voluntary motion becomes
one of involuntary motion if a strong stimulus is immediately applied to its
fibres; but its action appears then to be independent of any influence deriv-
ed from the brain, for  it takes place with the same readiness, while the struc-
ture of the muscle remains entire, whether its communication with die brain
remains, or is wholly cut off.
   As the circulation  and the functions immediately  depending on it have
been called the vital functions, and the more evident functions of the brain,
and those immediately depending on them, the animal functions ;  I shall, to
save circumlocution, call the organs of the former set of functions the vital
system, those of the latter,  the animal system.  All die functions may be di-
vided into those two  classes.   By die one  the animal is preserved, by the
other it is connected with the world.   If we  attempt  any farther division of
the functions, we  find no well marked line of distinction ; those which have
been termed natural,  being  included in the  vital functions.  The action  of
the stomach and bowels, and of the various secreting  organs, is as necessary
to the life of the animal, though less immediately so, as that of the heart. 
174                 CONTINUED FEVERS.
the reader's attention, only as enabling us to simplify the arrangement
of the means of cure.   How much it enables us to do, will appear by
comparing the arrangement of  Dr. Cullen, with that adopted  in  the
following pages.
   All causes which debilitate the vital system produce fever,* and in
the treatment we shall find, that all the means which prove serviceable
tend directly or indirectly to restore its vigour ; and as some of those
causes act on the central, and others on the extreme parts of the vital
system, namely,  the  various secreting  and absorbing surfaces,  the
means of cure, we shall find, admit of the  same division.
   It appears from  the symptoms of fever, that although the extreme
parts of the vital system are slways in a state of debility in this disease,
the fever ceasing as soon as  the  tone  of the secreting and absorbing
surfaces is restored; the central parts are often in a state of increased
excitement,  namely, while sufficient excitability  remains in the heart
and larger vessels  to enable them to obey the increased stimulus  ari-
sing from  the lessened action of the capillaries.!   We shall therefore
find, that  while at  all periods of fever, the means of exciting the ex-
treme  parts of the  vital system are indicated ;  those of exciting  the
central parts are  only  proper in the advanced stages.
   It farther appears, as we shall find  in the case  of inflammation, that
although the increased action of the heart and larger vessels evidently
tends to excite the capillaries : yet it frequently, when there is great
difficulty in exciting them, becomes so violent as to occasion debility
of the central parts of the vital system, before the due action of its ex-
treme parts is  restored.   When the action of the heart and larger ves-
sels, therefore, is so much increased  as to threaten this consequence,
our practice must be directed to restrain it; a long continued and gen-
tle stimulus often  effecting what a  more  powerful and transitory  one
fails to do.
   We find that the debility of the extreme parts of the vital system
may be induced, not only by debilitating powers  immediately applied
to this system  ; but also by too great and long continued excitement of
the animal organs,  as might a priori have been inferred, the functions
of the brain and nerves immediately depending on the action of the ca-
pillaries.  It is hence apparent, that debility of the latter having taken
place, excitement of the animal organs must increase it.
   The reader  will perceive that, from this view of the subject, the va-
rious indications in fever resolve themselves into two.

  * Sec the Essay above referred to, page 123, and seq.
  7 See the Introduction to the second part of this Treatise. 
CONTINUED FEVERS.                 175
  I. To remove the causes which tend to increase the debility of the
capillaries, which is done ;
        1. By removing the causes of the fever.
       2. By removing ar far as we can, all causes which excite the
     animal functions ;
       3. By lessening the sensibility to those which remain.
   II. To restore the due action of the capillaries, which is done :
        1. By the use of stimuli, which act immediately on the capil-
     laries.
        2. By so regulating the action of the heart and larger vessels as
     may tend most effectually to restore vigour to the capillaries.
   For the means of fulfilling the first part of the  first indication,  it is
 only necessary to refer to what has been said  of the causes of fever.
   The causes which excite the animal functions are :
 1.  Exercise either of mind or body.
 2.  All impressions on the external senses.
 3.  The irritation occasioned by the presence of aliment, or  seculent
 matter in the alimentary canal.
   1. When the symptoms of fever are considerable, every kind of ex-
 ertion is to be avoided, and that posture preferred  which requires the
 least exertion, the horizontal.   The bed should  not be too hard, that
 the patient may be as little as possible oppressed with his own weight,
 and the covering should be light.   Speaking, it has justly been ob-
 served, as it accelerates  the respiration, is particularly to be refrained
 from.
   In the Typhus mitior, which is often protracted for a great  length of
 time, and in which the febrile symptoms are mild, some degree of ex-
 ertion, sitting up a few hours, or if the weather is favourable, being
 carried into the open air is  often serviceable.   In  the use of such
 means, however, much caution is requisite.
   With respect to the mind; whatever excites the attention, whether
 business, or amusement, is hurtful; and whatever excites the  passions,
 still more so.   Some have thought mere is advantage in calling the pa-
 tient's attention to familiar objects,  when he is threatened with deliri-
 um.  This cannot be carried far without injury.
    2.  The sensation of thirst must be removed, by permitting the pa-
 tient to drink as freely  as he pleases : and the irritation of a noxious
 atmosphere is to be  avoided by proper ventilation, by permitting only
 one attendant to remain in the patient's room, and by the speedy re-
 moval of all  rNcrementitious matter.   And as it is  necessary that the
 patient should not only respire a pure air, b^t tha* hi^ body ."'-"-mid no' 
 176                 CONTINUED FEVERS.

 be long immersed in its own effluvia, he should  have frequent changes
 of linen, than which there is nothing more refreshing to febrile patients.
 In all kinds of fever, except when the patient is perspiring, or his tem-
 perature is  below the healthy degree,  the linen should be cold.   It
 should always be dry.
   Even while the symptoms of synocha remain distinctly  marked ;  if
 the disease has arisen from contagion, the body is found to generate it.
 In these cases, therefore, to the foregoing  means,  should be added,
 those for destroying or correcting the properties of contagion, pointed
 out in the last chapter.
   No part of the treatment deserves more attention than the tempera-
 ture of the patient's room.   In considering cold as a cause of  fever,  it
 Was observed, that the temperature of the human body is not diminish-
 ed by so rare a medium as the air, unless it be  under 62° ; nor in air
 of this temperature is its heat  permitted to accumulate above the heal-
 thy degree ; the rapidity with which it is abstracted being duly pro-
 portioned to the quantity evolved.
   But if the body disengage more heat than  in health, a lower temper-
 ature will be required for its  due abstraction.   This always  happens
 in synocha, and for the  most part in typhus.*   How much below 62°
 the temperature of the air should be, must be determined, by the tem-

   * We have reason to believe from various experiments (see the  different
works on animal temperature) that wherever the temperature of the body  is
increased, independently of an increased temperature of the surrounding me-
dium, the blood passes throvgh  the lungs more  frequently  than in health,
and consequently that the rapidity of the circulation is increased.  That this
should happen in synocha cannot appear surprising;  but in typhus, where the
powers supporting the circulation are weakened, we should expect to find
the circulation less rapid tfian in health, and consequently a less quantity of
heat disengaged, and-this is the  case in exquisitely formed typhus, in which
the temperature of the body falls belows  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
circulation is increased, and a greater quantity of heat disengaged.  In de-
termining the temperature in typhus we should always use the thermometer ;
 if we judge by the feeling the acrid secretion by the skin which attends this
fever, will generally make the temperature seem higher than it really is.  Dr.
Currie, in the Treatise above referred to, describes the thermometer and the
manner of using it, which h e foi md most convenient.  It would be more accu -
rate in the preceding and similar passages to use the term caloric instead  of
heat, there being a very evident  objection to using the same term for the
sensation and the cause which produces it.  But caloric is not vet familia-
in medical writings. 
CONTINUED FEVERS.
177
perature of the patient.  In synocha, when there is no tendency to lo-
cal inflammation the application of cold may be freer than in typhus.
In the former, the temperature of the patient's room,  when the state of
the weather permits it, should never,  perhaps exceed 35°  or 40°, and
may often,  with advantage,  be  still  further 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 should be preserved by  covering it, that the  patient may enjoy
the refreshing effects of breathing a cool atmosphere.
   When the temperature of the air is too low, there  are many evident
ways of raising it.  The only circumstances which  require attention,
are, that it shall be  as  uniformly  raised as  possible, that  the patient
shall not be exposed to a current of air, and that the due proportion of
oxygen gas in the air shall not be diminislied ; for the last purpose we
must take care  that no part of the vapour arising from burning  fuel,
shall remain in the  room, and that the external air shall have free ac-
cess.
   It is much to be  regretted  that we are  not  possessed of means for
lowering,  equally efficacious with those for raising, the temperature of
the air.  When it is to high, which it always is in well marked syno-
cha, if it exceed 45°,  we have no means of reducing it many degrees.
This  seems a principal cause of  the great fatality of the fevers  of
warm  climates.   The hotter  the weather the more fatal they are ob-
served to be ; and it is even said of the yellow fever of the West-Indies.
that the weather becoming very warm or cool during this fever,  is of-
ten sufficient to save or destroy the patient.  The only means we have
of lessening the temperature of the patient's room, in sultry weather,
is, as much as possible, to exclude the light, while the air is freely ad-
mitted ; and frequently sprinkle the  floor and other  parts of the  room
with cold water.
   As the  means we possess of reducing the temperature of the air are
so limited, various  methods have  been proposed  for reducing that of
the patient's body.  " Whenever the patient is  in a  climate whose
" heat is less than 97° of  Farenheit's  thermometer, which  is nearly
" the heat of the body of the  patient, removing the aif which  is in im-
" mediate contact  by means of putting the atmosphere in motion by
" any kind of  fan, renders that  which is in  immediate  contact with
u the body much colder  than it would otherwise be.  Such  means in
" case of too warm an atmosphere  seem to be very proper to be era-
" ployed."*  They also tend to reduce the temperature of the patient's

   * S<»e T)r. Fordyce's Third Dissertation on Fever.
                                ?3 
17»
CONTINUED FEVERS.
body by promoting evaporation.   " When the object is to diminish
" heat, that may be obtained with great certainty by the repeated use
" of the tepid affusion suffering the surface of the body to be exposed
" in the interval to the external air, and if the beams of the sun are
" excluded, and a stream of wind blows over it, the heat may thus be
" reduced where cold water cannot be procured, even in the warmest
"regions of the earth, on the plains of Bengal, or the sands of  Ara-
" bia."*  Dr. Wrightj practised  a similar method.   " Some lucky
" expedients, however, he observes have been practised, which success
" alone can justify ; thus, when the most urgent symptoms have  been
" subdued, the patients were wrapt up in a wet blanket, a profuse sweat
" was brought on,  and an immediate recovery was the consequence."
  Noise of any kind,  and any degree of light which attracts the atten-
tion are injurious.
  3. Irritation of the primae  viae is to be prevented by abstinence, by
emetics at  an early period,  and at  all periods, by supporting a free
and regular action  of the  bowels.   Of all these means, which are also
employed  in fevers for other purposes,  I  shall have occasion to speak
at length.
  Besides removing as far as possible all causes of irritation, most  phy-
sicians think it proper to diminish by  opium the sensibility to those
still applied in all fevers, where  the excitement  is riot considerable.
Some have opposed this practice, it would seem, however, not on  suffi-
cient grounds ; but attention to the state of the symptoms is necessary
in recommending it.   When the skin is soft, and the increase of tem-
perature and other symptoms during the exacerbation inconsiderable,
a moderate dose of opium may be  given at bed time.  But when the
skin is parched, and'the temperature rises considerably during the ex-
acerbation, we must either defer the opiate till the symptoms begin to
remit, and particularly till the hot-parched skin is in some degree relax-
ed,  or give a few grains of James's powder, or some other antimonial
along with it; I have often seen (as others have remarked) small and
repeated doses of opium succeed where larger doses fail.   Dr.  Currie
proposes to combine the exhibition of opium with the affusion of cold
or tepid water, of which I shall presently have occasion to speak.  If
we  cannot succeed in  inducing a degree of relaxation in the skin, and

  * See Dr. Currie's Treatise on the Use of Warm and Cold Water in Fevers.
W& shall soon have occasion to consider more paticularly  the use of water
in fever, as a means of exciting the action of the skin as well as of diminish-
ing the temperature.
f See Annals of Medicine, vol. 2 
CONTINUE!) FEVERS.                 179
prevent the opium increasing the heat, it must be deferred till towards
the decline of the exacerbation, or perhaps to a more advanced period
of the fever.*
   Such are the means of answering the first indication in fever.  The
more powerful parts of the treatment belong to  the second indication,
namely, to restore  due  action  to the  capillaries.   This indication, it
has been observed,  is answered, 1. by the use of stimuli, which act im-
mediately on the capillaries; and 2. by so regulating the action of the
heart and larger vessels  as may tend most effectually to  restore vigour
to the capillaries.
   It has from  the infancy of medicine been observed, that increasing
the action of the skin often removes fever, but it is only lately that we
have been taught how this ought to be done.  When the patient was
confined to a hot room and loaded with bed clothes, if a sweat were indu-
ced it was the  consequence of the exhausting effect of the temperature,
not of a return of the healthy action of the skin ; and so far from being
accompanied with the good effects of spontaneous sweating, it almost al-
ways did harm,  by  leaving the skin in a more debilitated state than be-
fore its  appearance, not to mention  the injury done by the painful im-
pressions occasioned by this mode of treatment.
   We now excite the action of the surface, by forcibly propelling the
blood towards it  by emetics; by diaphoretic medicines; and by the
application of cold.   The means which excite the  usual action of the
skin are more  powerful  in relieving fever, than those  which tend di-
rectly to produce sweat, during which this organ seems to be rather in
a state of relaxation than of vigour;  we  succeed better with tartarised
antimony than with the  compound powder of ipecacuanha; and for the
same reason, we succeed better by the application of cold than by the
hot regimen.
   It is only in the commencement of fever that we succeed in exciting
the healthy action of the extreme vessels by emetics.  On the first or
second day, they sometimes put a period to the disease ;| but after it
has lasted for some time, a remedy, whose  operation can be longer con-
tinued,  becomes necessary.

  * In a letter to J. Bedley by Dr. Martin Wall, the reader will find an ac-
count of some cases of typhus treated with opium.  For the use of opium in
fevers he may also consult Dr. Fordyce's Dissertations on Fever; Dr. Lind's
Treatise on Fevers and Infections ; Dr. Blane's Treatise on the Diseases of
Seamen, and Dr. Campbell on the Fever of Lancashire.
  ■J- See several  of the authors I have had occasion to mention, particularly,
Dr. kind, on Fevers and Infections. 
180
CONTINUED FEVERS.
   Physicians  have very generally abandoned the practice of giving
 wine and other heating medicines, with a view to promote sweat in fe-
 vers, and opium is rarely employed with this view, except in  inter-
 mittents, or in srnall doses to aid other medicines.
   Nauseating doses of emetics are more successful.  The following are
 the circumstances to be attended to in their exhibition.
   As nauseating doses of emetics are debilitating, either by promot-1
 ing sweat or catharsis ;  they are best adapted to an early period.
   They may often be employed with advantage at later periods,  if
 given about the commencement of the exacerbations, when these are
 distinctly marked.
   When much debility is expected, and they  do not soon relieve the
 symptoms,  we should not persevere in  giving them.
   Ipecacuanha and the preparations  of antimony are the medicines
 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 powder and
 tartarised antimony are the preparations of antimony at present gen-
 erally used in fevers.  Most practitioners  prefer  James's powder.
Plow far this preference  is well founded, it is  difficult to say.   When
 emetics  are employed, tartarised antimony is preferable  and all other
 medicines in these diseases.
   The power of neutral salts in promoting*diaphoresis is less than that
 of antimony,  although almost all of them seem  to possess this property
 in a greater or less degree.   The salts composed of an acid and ammo-
 nia,  particularly the acetate of ammonia given in a state of efferves-
cence, and the aqua ammomoniae acetatae, possess most of it.
   Various other medicines are recommended as diaphoretics in fever,
 chiefly by the older writers, which appear to  have little effect of any
kind.
   The external and internal use of water both cold and warm are  to
 be ranked among the most powerful of this class of remedies.
   I.  Of the employment of cold water in fever.
   I have already had occasion to  make some  observations on the ad-
 ?antage  of a cool atmosphere.
   In warm weather the  skin is more  relaxed, in cold weather  it is
 more vigorous.  Even when the relaxation occasioned by warm weath-
er goes so far as to produce sweat, the secreting power of the skin  is
 not so great as  under a due degree of exercise in a cold atmosphere.
 This appears both from the state  ot  the urine, from which, as  I have
 ■kVpwherc pointed out. the  degree of activity  of the skin may  be as-- 
CONTINUED FEVERS.
181
.certained,* and from the greater appetite in the latter  case.  Now a
 state of fever comes in place of exercise, it supports the proper warmth
 of the body under the application of cold to its surface, and secures its
 good effects ; for the application of cold to the surface is  never proper
 in fever when the temperature falls below the healthy degree, and  is,
 most beneficial when it is considerably above it, provided the skin is
 dry.   In short, it is most successful in fevers in the  same circumstan-
 ces in which it is found  in health most to excite the action of the skin ;
 only in the one case, the increased temperature is supported by exer-
 cise, in the other, by a preternatural stimulus applied to the heart and
 blood vessels.
   It seems to be from not having attended to such circumstances, that
 there has been so much  difference of opinion respecting the propriety*
 of sweating in  fevers.   From comparing the various observations  on
 the subject, we have reason to believe that it is only when the  sweat
 indicates a return of vigour to the skin, that it  is beneficial.  In  this
 way the reader will find, that apparently  contradictory observations
 may be reconciled.  Clammy and partial sweats, and even general
 and  profused sweats, unattended by  other signs of returning vigour,
 are unfavourable.
   Both the external and internal use of cold water in fevers was known
 to the ancients ; but among the  moderns, it is only lately that the
 former has demanded much  attention.   Washing the body with cold
 water is said to have been first practised in fevers, in modern times, at
 Breslaw, in Silesia ;t  and it appears that the practice was followed in
 some of  the neighbouring countries.    Whatever were the effects  of
 these trials, however, it  has never been prevalent in Europe, probably,
 as Dr. Currie supposes,  from the manner in which it should be regula-
 ted,  not having been unde rstood.
   Several late practitioners in sultry climates, particularly  in  the
 West-Indies, have  employed it  freely;  and  in 1786, Dr. William
 Wright, who had practised for many years in the Island of Jamaica,
 gave an account of some cases of fever successfully treated by the  af-
 fusion of cold  water, in the London Medical Journal.   He has since
 published some additional observations on the same subject, in a letter
 to Dr. Garthshore, in the 7th volume of the Medical Facts and Obser-

   * In a Treatise published many years ago, entitled, an Experimental Inqui-
 ry into the Remote Cause  of Urinary Gravel.

    f See a Dissertation entitled, Epidemia Verna qux Wratislaviam anno
 1737 afflixit, in Act. Nat.  Curios, vol. X. 
 182                 CONTINUED FEVERS.

 vations, in which he gives an account of Dr. Gregory's manner of em-
 ploying  this remedy,  and the success which attended its use in the
 Royal Infirmary of Edinburgh ; and in the 2d vol. of Annals of Medi-
 cine, be  again gives a favourable testimony of its effects in the fevers
 of the West-Indies.  Dr.  Jackson* (who was among the  first who at-
 tempted  to bring it into general use,) and others in that climate, em-
 ployed it.   Even the  alternation of the warm bath and affusion of cold
 water has been there  practised in fevers, and it is said with 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
 the late Dr. Currie, of Liverpool.!
  The most effectual way of using cold  water externally in fever, is
 by affusion.  The patient is stripped naked, and a bucket of cold wa-
 ter is thrown over him.  The temperature of the water should be  from
 40°  to 60° ; the quantity from three to five gallons.
  Dr. Wright used sea water ; Dr.  Currie at first used fresh water, af-
 terwards fresh water and vinegar, lastly a  solution of  common  salt.
 ;' I was led," the latter author observes,  " to prefer salt water 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  pre-
 " vented.  Salt water, either for the purpose of immersion or affusion,
 " is more grateful to the patient than fresh water ; and it is well 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 satu-
 " rated 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
 " when removed from it."
  Dr. Currie used brine in preference to vinegar and  water, on ac-
 count of the greater expence of the  latter; but thinks that vinegar and
 water of a proper strength will probably be found preferable.   He ob-
 serves, however, that no bad consequences ensued from performing the
 affusion without the addition of either salt or vinegar.
  Washing the body with cold water, or cold water and vinegar, is a
milder, but  less effectual way, of using this  remedy.  It may be em-
ployed when the patient  refuses to submit to the affusion,  or when
from debility or  the advanced state of the disease,  the latter is judged
 :mproper.

  • See Dr. Jackson's Treatise on the Fevers of Jamaica.
  f See D-. Currie's Treatise just referred to. 
CONTINUED FEVERS.
183
   The proper period of the disease for the external use of cold water
 is the commencement of the hot stage.   It cannot be employed  too
 early, provided the chills are over, and  the  temperature is steadily
 above the healthy degree.   On the  first or second day,  if the hot fit
 is completely formed at so early a period, it often  puts  a stop to the
 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, dur-
 ing the first eight or ten days, it is 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, he
 observes, the  water should not be more than  fifteen or twenty degrees
 below 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, wash-
 ing  the  body with  tepid vinegar and water answers 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 ;
 au application of cold, safe  in the violence  of fever,  often proving
 hurtful after it has subsided.
   Dr. Currie  frequently employed the cold affusion twice in the day,
 at noon and  in the evening. When it was only employed once in the day,
 the evening was found the best  time.   " The safest and most  advan-
 " tageous time,"  he  observes, " for using the aspersion or  affusion of
 " cold water,  is when the exacerbation is at its height, or  immediately
 " after its declination is begun ;  and this has  led us almost always to
 " direct it to be employed from six to nine o'clock in the evening."
   The immediate effects of the  external use of cold water in fever are
 a diminution of the temperature and  of the frequency of the pulse,
 which are generally followed by diaphoresis and sleep.
   In the following quotation Dr  Currie enumerates the cautions to be
 kept in view,  in the employment of this remedy.
   "  1. If the  aspersion of cold water," he observes, "on the surface
 " of the body be used during the cold stage of the paroxysm of fever,
 " the respiration is nearly  suspended  ; the pulse becomes  fluttering,
 " feeble, and  of an  incalculable frequency; the surface and extremi-
 " ties become doubly cold  and  shrivelled, and  the  patient seems to
 " struggle with the pangs of instant dissolution.  I have no doubt from
 •' what I have observed, that in such circumstances the  repeated affu-
" siou of a few buckets of cold water would extinguish life.   This re-
" medv, therefore, should never be used when any considerable sense
" of.chillness is present, even although the thermometer  applied to the
1; trunk of the hodv should indicate i ik-ree of heat greater  than usu- 
184                 CONTINUED FEVERS,

<> al."   In the 37th and 38th pages of his Treatise, Dr. Currie relater-
a striking instance of the bad effects of cold affusion employed during
the chills.
  « Neither ought it to be  used when  the heat measured by the ther-
" mometer is less than, or even only equal to, the natural heat, though
" the patient should feel no degree of chilness.   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 im-
" portant  in proportion to the  continuance of this perspiration.  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 be hazarded with little risk,
" and  sometimes may be resorted to with great benefit."  The accu-
racy of this observation may in the  present state of our experience be
questioned.  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 proved favourable, yet it suddenly produced a de-
gree of cold in the extremities that was alarming, and had not the tem-
 perature  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  remained 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 always  a cool-
 " ing  process in itself, hut in bed it is often prolonged  by artificial
 " means, and the body is prevented from cooling under  it to  the na-
 " tural 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 errour.  In this situation, how-
 " ever, 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 applica-
 " tion of cold water either by affusion or immersion is accompanied by
 " a loss of heat and a deficiency of reaction, wliich  are  altogether in-
 ** consistent with safety."



   * The immersion is more troublesome and less beneficial than the  affusion.
  The former was the manner in which the ancients used this remedy in fevers. 
CONTINUED FEVERS.
185
   * When employed in the advanced stages of fever, where the heat
*'  is reduced and the debility great, some cordial should be given im-
"  mediately after it, and the best is warm wine."
   Most of the trials which have been made with the cold affusion have
been in contagious fevers, that is, in those fevers in which more or less
of the synocha is succeeded by a greater degree of the typhus, which
forms the chief part of the disease.  It is while the symptoms of syno-
cha last, however, as appears from the foregoing observations, that the
cold affusion is most beneficial.
   Dr. Currie relates many striking proofs of the good effects of the
cold affusion in  these fevers ; of seventeen soldiers attacked with a
fever of this kind, all of whom 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.  In the last edition of Dr. Currie's
work, the reader will find similar instances of success attested by oth-
ers.
   What Dr. Currie calls the cool affusion, is a milder form of the cold ;
the temperature  of the water employed in the cool affusion is from 75°
to 87°.  This, like washing, is recommended where from debility, or
the continuance  of the disease, the cold  affusion is  judged to  be ha-
zardous.
   The same cautions are  still to be attended to,  whether we  recom-
mend affusion, immersion, or washing.   When there is a sense of bur-
ning 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, it is not to be used
as a drink in the cold stage.  It increases the chills and other symp-
toms of this period.  After the hot stage is completely formed, and es-
pecially when the 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 af-
fusion,  but  in a less degree, diminishing the heat  and  frequency of
rhe pulse, and disposing to perspiration and sleep.
   After the  sweat has become general, cold water is  inadmissible.
" At  this time," Dr. Currie observes, " I  have perceived in more
A than one instance, an inconsiderate draught of cold water produce a
" sudden chillness both on the surface and at the stomach, with great
" sense of debility and much oppression and irregularity of respiration.
" At such times  on applying the thermometer to the surface, the bps'.

                  * See Dr. Currie's Treatise., p. 71
                                21 
186
CONTINUED FEVERS.
" has been found suddenly and greatly reduced.  The proper remedy
" is to apply a bladder filled with water heated from 110° to 120° to
" the scrobiculus cordis,  and  administer  small and frequent doses of
'* tincture of opium, as recommended by Dr. Rush.   By these  means
" the heat is speedily 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  flows more freely, and thus bring the fever to a
speedy issue.
   It appears, in short, that the action of cold drink in fevers, being in
every respect similar to,  though less powerful than that of the cold af-
fusion, the same cautions  are necessary in the exhibition of both.
   II. Of the 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 temperature is from
87° to 97°.   When the water is  applied by immersion 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,  however, 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 of  the 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 tempera-
*' ture 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 affusion 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
are much less permanent.  He never saw the tepid  affusion  stop  the
progress of fever.
   The effects of immersion in tepid water, however, do not correspond
With those of the tepid affusion.   The tepid bath  is  always improper
where the temperature is considerable and  often serviceable when it
has fallen  too low. 
                     CONTINUED FEVERS.                 r87

   The same may be said of the internal  use of warm water in fever.
 During the cold fit, or in a more advanced stage, when the temperature
 has fallen below the healthy degree, it is proper ; and where the tem-
 perature is not much above this degree, it assists the operation of other
 sudorifics.   The drink should also be tepid after the sweating has com-
 menced, by  whatever means induced,  except in those  debilitating
 sweats whicb occur in typhus, and reduce the strength without bring-
 ing felief.  With these exceptions,  cold drink is  more beneficial in
 fevers.
   It will be necessary afterwards to  make some additional observa-
 tions on the internal use of water as a means of diminishing excitement.
   It is said that the application of distilled spirits to the skin, has been
 of great use in fevers.*   Rubbing it with warm oil is also said  to have
 been of  service in certain species of fever.   This appears a doubt-
 ful practice from the heat and irritation which must attend it.
   Among the means of exciting the action of the skin may be ranked
 the use of mercury, which is very  generally  recommended  by the
 practitioners of sultry climates, and whose good effects seem in part to
 depend on its diaphoretic property.  '* By calomel," Dr. Wright ob-
 serves, " the pores of the skin were opened, a revolution of the fever
 " was brought about, and the patient happily recovered.';   In  another
.place  he observes,  " And we recollect of no instance, where mercury
 " had been freely given, and persevered  in till it shewed  itself in the
 " mouth, which was  not attended with the happiest consequence."
   Dr. Chisholm gave mercury to very great extent,  endeavouring as
 soon as possible to excite a salivation.  He sometimes gave  ten grains
 every three hours till this effect was produced, by which means he ob-
 serves he has succeeded in cases which seemed  desperate.
    It is probable, however, that these observations will not be found to
 apply to  the fevers of this country.   I have already had  occasion to
 remark,  that the fevers of  the sultry climates are generally accom-
 panied with local affections.   For many of which mercury is a power-
 ful remedy.
   Dr. Chisholm is one of the few practitioners who have given us any
 account  of the  appearances on dissection after death in  the fevers of
 such climates.  From his dissections it appears that, besides other lo-
 cal affections, the liver, as indeed might be inferred from the symptoms
 of most of the fevers  of the West-Indies, was almost always diseased.
 It is owing to the local affections which attend the fevers of sultry Iat-
* Medical Observer, vol, 2. 
188                 CONTINUED FEVERS.

itudes, that their treatment is so difficult, and that that which suoceed3
in one epidemic is often hurtful in another.
   Such are the means of promoting the action of the skin in fever, and
the circumstances which influence their  employment.  Blisters  and
rubifacients have been much recommended in this  disease, and might
at first view be supposed an effectual means of exciting the action of
the skin.  From their operation being partial, however, and from the
nature of inflammation,  this- inference  appears  doubtful, and their ef-
fect;? by  no means  sanction it.   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 gener-
ally attended with a disposition to gangrene,  they often  induce it.*
The species of continned fever therefore in which blisters are chiefly
employod, is the typhus mitior, or what is commonly called the nerv-
ous fever.  And respecting the propriety of employing them even in
this fever, unattended by any locafaffection,  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 fe-
" ver,  where the source of infection is not very violent, if twenty pa-
" tients be blistered, sixteen  will next morning be entirely free from
v head-ach, beat, pain,  and fever."  Dr. Cullen was also  a strong ad-
vocate for the use of blisters in fever;  but thought that they are employ-
ed with most  advantage at an advanced period of the disease.  " It ap-
" pears to me that blistering may be employed at any period of con-
" tinued fever ; but that it will be of most advantage in the advanced
" state of such fevers, when the  reaction being weaker, all ambiguity
" from the stimulant power of blistering is removed."
   When we  compare these observations with  those of other authors,
however, we cannot help suspecting that both Dr. Cullen and  Dr.
Lind had too favourable an opinion of this remedy.   " Whether exci-
ting inflammation,"  says  Dr.  Fordyce, " has or has not the same ef-
"  feet in a regular continued fever, which it has in health, can  only
"  be known by making these  applications to the body of  a person af-
■''  fee ted with  regular  continued fever.   As far as the  author's ex-
"  perience goes,  when any stimulus has been employed  so as to pro-

   *  See the observations  of Sir John Fringle, Mr. Clark, and others.  A thick
tough matter like leather,  covering blistered  parts,  shews  a tendency to
gangrene.  "  If under this," Dr. Lind observes, " white or ruddy specks ap-
" pear, it is a  favourable symptom ;  if pale or dark, a very bad  one. 
CONTINUED FEVERS.
189
" duce inflammation, when a patient  has become weak towards  the
" end of a regular continued fever, the only difference which has oc-
" curred has  been,  that phlegmonous  inflammation has not produced
" hardness, fulness and strength  of the pulse ;  but both phlegmonous
" inflammation,  and inflammation of the skin have occasioned greater
" frequency of the pulse, have rendered it weaker and smaller, and as
" in health have  prevented sleep,  and 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 inflammatory af-
fection of the brain.  " Blisters before  useless became then of service."!
He also remarks of the inflammatory fever, that at first  he used to em-
ploy blisters at an advanced period of the disease, when die thought
the patient could not bear any  further loss  of  blood, but afterwards
confined their use to those cases where the head-ach was considerable,
which they seldom fail to relieve.
  " Notwithstanding my having watched the effects of blisters,"  Dr.
MooreJ observes, " with all the attention I am capable of, and former-
" ly with a strong prepossession in their favourj I cannot assert that I
" ever knew vesications of any use in  this disease,"  the typhus mitior,
" but I have frequently seen the patient teazed  by their irritating qua-
" lity 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 to prove that  little is to be expected from blis-
ters in fevers  unaccompanied by local affections.  For the removal of
 many of these, they are among the most powerful remedies we pos-
sess.  When  used with a view to remove head-ach, coma or delirium,
they should be applied to the nape  of the neck, or if these symptoms be
considerable the head should be shaved, and the blister applied over it.
For like other local remedies, blisters  are the more powerful, the near-
er they are applied  to the part affected.   Blisters sometimes occasion
a degree of strangury from the absorption of the cantharides;  this ef-
fect may generally be prevented  or  removed by small doses of cam-
phire or merely by dilution.
  With respect to rubefacients, they  are still more improper than blis-
 ters in the synocha, because they  occasion an equal or greater degree

       * Dr. Fordyce's third Dissertation on Fever.
       f Observations on the Diseases of the Army.
       t  Medical Sketches. 
190
CONTINUED FEVERS.
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 gangrene,  where there is
much tendency to it,  and it does not appear, that in any kind of ty-
phus, unattended by local affections, they have been  found of much
use.  Mustard poultices applied to the feet are often employed,  with
advantage when coma supervenes on the typhus mitior.
   Analogous  to the office of the skin, the external surface of the animal
system  is the office of its internal surface, if I may use the expression,
the alimentary canal; and such is the sympathy between  these surfa-
ces, that if one is languid, the other is generally affected  in the same
way; and if we excite either, we at  the same time,  in  a  greater or
less degree,  increase the action of the other.   If  the bowels are  con-
stipated we find  the skin dry and shrunk : as soon as  the bowels are
restored to action, the skin becomes soft and moist, and vice versa, ex-
cept when, the secretion by the skin being suddenly stopped, the fluid
which should have passed  by it, is thrown on the  bowels, applying to
their vessels a stimulus which prevents  their inactivity.
  We might, therefore, from the effect  of diaphoretics, a  priori, have
expected considerable advantage from exciting the bowels, not to men-
tion that their vessels  form so large a portion of the  circumference of
the vital system.  Every physician must have observed the excellent
effects of supporting the due action of the bowels in fever ;  but no other
writer has placed this subject in so clear a point of view as Dr. James
Hamilton, of Edinburgh.*  I have found the most decided  advantage
in the earlier  stages of fever from exciting catharsis to the extent which
he recommends.   So free  a use of cathartics has not appeared to me
equally  beneficial in  the more advanced stages.   Dr.  Hamilton  gives
the following account  of his practice, and of the circumstances which
led to it.  Speaking of the calx antimonii nitrata he observes :  " This
" antimonial  remedy was not ineffectual; but I remarked, that it wa-
" beneficial only when it moved the belly, the stools were  black and
" fetid,  and  in general, copious.  On the discharge  of these, the low
" delirium, tremors, floccitatio, and subsultustendinum, which had pre-
" vailed, abated in some cases ; the tongue,  which had been dry and
" furred, became moister  and cleaner; and a feeble creeping  pulse
'■' acquired a  firmer beat.
  fi Reflecting afterwards  on these circumstances, it occurred to me,

  * Observations on the Utility and Administration of Purgative Medicines
in several Diseases, by James Hamilton, M. D. &c. 
CONTINUED FEVERS.
191
■-"•?as the purgative effect appeared to have been the useful one,  that
" any purgative medicine might be substituted for the calx antimonii
" nitrata; and that by this substitution,  the unnecessary debilitation
' •' of an exhausted patient, by vomiting and sweating, might be avoided.
  " More extended experience confirmed these conjectures ; and I was
" gradually encouraged to employ purgative medicines early in typhus,
" and to repeat them in  the course of the disease.  And after having
" long and strictly'directed my attention to this point of practice, I am
" now thoroughly persuaded that the full  and regular evacuation of the
" bowels  relieves the oppression  of the  stomach,  and mitigates the
" other symptoms of fever."
   In one part of the preceding quotation, my experience does  not cor-
respond with that of Dr. Hamilton.  I think I have seen very  decided
advantage from combining antimonials with the purgative plan in the
commencement of fever ; and in a  great number of  instances I have
seen the former produce the  best effects, even  where  they  did not
prove cathartic*
   The debility  produced by cathartics  is  less permanent than we
should be led to suppose, either  from the extent of the discharge, or
its effects in subduing excitement.   This arises from its being  only
the thinner  and less important part of the  Hood which  is abstracted
by them.
   Some attention is requisite in the  choice of cathartics.  In the com-
 mencement of fevers, particularly when  the excitement runs high, the
 mercurial, antimonial, and saline cathartics are the best.   At more ad-
 vanced periods, those which tend less to reduce the  excitement are
 preferable, rhubarb, aloes, &c. and  Dr.  Fordyce has justly observed,
 that when several cathartics are combined, they occasion less  sickness
 and pain, and are more certain in their operation than when taken sing-
 ly.  Clysters have been much used in fevers for the purpose  of exci-
 ting the bowels.  By their effect, however, the upper and more impor-
 tant part of the alimentary canal is little if at  all excited.   They
 shohld never be trusted to for the purpose of  moving the bowels in
 fever.j  We shall presently see, that they are sometimes used  with ad-
 vantage for another purpose.

    * There are few medical writers to whom the public are so much indebt-
 <id as to Dr.  Hamilton.  It is not the practice in fevers only which has been
 improved by the above work, but that of many other diseases.  In the chorea
 S. Viti in particular, hitherto so little under the po^cr of medicine^ I have
 found his plan almost uniformly successful.
    f See Dr. Hamilton's observations on this subject. 
 192                 CONTINUED FEVERS.

   The only other secreting surface of sufficient extent to demand par-
 ticular attention in the treatment of fever is that of the kidneys.  Medi-
 cines have seldom been used in this disease expressly with  a view to
 excite the kidneys, but many of those  employed  for other  purposes
 seem to owe much of their beneficial effects to their action on these or-
 gans, particularly the acetate, nitrate,  and super-tartrate of potash.
   Such are the means of  fulfilling the first part of the second indica-
 tion in fever, those which act by more directly stimulating the capilla-
 ries.   We are now to consider those,  by which the action  of the heart
 and larger vessels may be so regulated, as may tend most effectually to
 restore vigour to the capillaries.
   The general principle to be kept in view, in this part of the treat-
 ment, is,  that the action of the capillaries is best restored, as appears
 from  a variety of observations, by a moderate, and long  continued ex-
 citement of the heart and larger vessels ; if their excitement is allowed
 to run high, which it is apt to do, when the  debility of the capillaries
 is great,  and there  is considerable vigour remaining in the system,
 these organs are debilitated before due action is restored to the capilla-
 ries ;  and if on the other hand it is allowed  to fall  too low, the  stimu-
 lus applied to the capillaries, even though long continued,  may  be  too
 feeble to excite them.
   As the  means which more directly excite the capillaries tend to  re-
 move the  cause of preternatural action in the heart and larger vessels,
 and as by the evacuation which they occasion they tend to reduce the
 volume of the blood, the remedies we have just been considering, it is
 evident, with their other good effects, must reduce the excitement which
 is almost always  too  great at the commencement of fever,  and  are
 sometimes sufficient for this purpose.
   In the early stages  of most fevers, however, which last above a few
hours, it is proper, with the preceding means, to have recourse to such
 as more effectually reduce the increased action of the heart and larser
                                                              o
 vessels.
   It appears from the observations made in speaking of blood-letting
 in intermittents, and the  modus operandi of this remedy, that dimin-
ishing the quantity of blood is the most powerful means of diminishing
the action of the heart and blood-vessels.  But as the quantity of blood
cannot be much diminished without debilitating every function of the
system, it is of consequence where the symptoms run high, to lessen as-
much as we can its stimulating power, that the excitement  may  be di%
minished with as little evacuation as possible. 
CONTINUED FEVERS.                 193
   The means of diminishing the stimulating power of the blood are,
   1.  Dilution, and
   2.  The medicines which have been termed refrigerant.
   1.  There  is  a  large  proportion of water in the blood, to which it
owes  its fluidity ;  and the  power of this fluid to excite the vessels, its
quantity being the same, is inversely as the degree in which its saline
and other stimulating parts are diluted.   Dilution, therefore, is the
most successful means of diminishing this power, and that which 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 gene-
rally insatiable.    Every person in this fever, Van Swieten remarks,
unless his  intellects be deranged,  is led by instinct to demand water
and watery liquids.  And this instinct best  points out the quantity
which is necessary.   We are neither, as was once a practice, to pre-
vent the patient from satisfying his thirst, nor to run into the extreme
of the Dieta Aqueaof the Spanish and Italian physicians, and force the
patient to take every day eight or nine pints of water.*
   When the excitement is considerable, diluting liquids should also be
injected per anum.  Sydenham made much use of clysters  composed
of a mild vegetable 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, lest the excitement be brought too low.
   Dilution is  also the  chief means of diminishing the stimulus of the
food.   The food of a patient in synocha, should consist of mild decoc-
tions, barley water, or water gruel, or water thickened with sago, &c.
Fresh acidulous fruits, should make  a principal part of the diet.  These
belong to the head  of refrigerants, although from their refreshing ef-
fects, and nutricious quality, they are useful in all kinds of fevers.
   2.  The  use of neutral salts, which possess more of the  refrigerant
quality is confined to those cases in which the excitement is above the
healthy dgree.
   " Some metallic Salts,"  Dr. Cullen observes, " have been employ-
" ed as refrigerants in  fevers, and particularly the sugar of lead.  But
" the refrigerant powers of this are not well ascertained, and its de-
"  leterious qualities are  too  well known  to admit  of its being freely
" used."
   When the foregoing means fail sufficiently  to diminish  the excite-
ment, we must have recourse to venesection.

   * See an account of the Dieta Aquea, in the 36th vehirne of the  Philoso
phical Transactions.
                               25 
 194                 CONTINUED FEVERS.

   As the increased excitement of the heart and blood vessels supports
 that of every other part of the system, it is not surprising  that blood-
 letting has been found the most effectual remedy in synocha.
   Our view in the commencement of fever, however, is not to reduce
 the action of the  heart and larger  vessels to the natural standard.
 This would be obviating the means  which  the nature of the  circula-
 tion affords for removing the cause of the disease.   It is only our ob-
ject to lessen excitement when it goes beyond the degree most favour-
 able to this end.
   If the means employed be so injudicious,  as  to reduce the excite-
 ment of the heart and larger vessels more than  is necessary to insure
 its  requisite continuance, the patient will sustain a double  injury.
 The stimulus necessary to the excitement of the capillaries will be re-
 moved, and the debility of the heart and larger vessels  hurried on, so
 that the fever will soon begin to assume its worst form.  As blood-let-
 ting is the most powerful means of diminishing excitement, it is con-
 sequently the most apt to induce debility ;  and  caution is particularly
 necessary  in the synocha, which, if not terminated at an early period,
 is constantly succeeded by a disease of debility.  It will be requisite,
 therefore,  at some length, to consider the various circumstances which
 demand attention in the  employment of this remedy.
  It is not always sufficient in the treatment of fever,  to study  the
 symptoms of the case for which we prescribe.   If the fever be epidem-
 ic,  we must acquire  a knowledge of its general course, that we may
know what symptoms to expect;  for  our plans  in the treatment  of fe-
 ver are often influenced as much by what the state  of our patient will
 be, as by what it is.   If much  debility is expected,  we must be
 cautious in recommending evacuations.   An attention to  the prevail-
 ing epidemic,  therefore, is mentioned by Dr. Cullen, as  the first cir-
 cumstance to be attended to in considering the  propriety of blood-let-
ting in fevers.
  We must attend to the nature of the cause, which produced the fe-
ver.  It appears from what was said of the causes of fever, that an at-
mosphere loaded with putrid effluvia  is one  of the  most common, and
that a fever thus produced is afterwards communicated by  its peculiar
contagion.  All fevers, it was observed, arising from putrid effluvia or
contagion, Whatever be the state of the patient at the time he is attack-
ed, or the  nature of the symptoms at an early period, will soon assume
the form of typhus.   In  such cases, therefore, blood-letting  is seldom
admissible, even although the  excitement at the  commencement be
 considerable. 
CONTINUED FEVERS.                 196
  When, on  the contrary,  the fever has arisen from cold, from strong
passions, violent exercise, &c. although we know, that if it be protract-
ed for many days, the symptoms of synocha will be succeeded by those
of typhus ; yet we have reason to believe, that the synocha will form
the  principal part of the disease, and that if the excitement be prevent-
ed from running high at the commencement, the debility  towards the
termination will probably be inconsiderable.   In these fevers, there-
fore, blood-letting is more frequently proper.
  The season, climate, and even situation, are  not to be overlooked in
employing this remedy.
  On this part of the subject, some observations were made in speak-
ing of intermittents.  It is most to be dreaded  in those circumstances
in which the fever is apt suddenly to assume the form of typhus ; both
because the symptoms of debility are  then generally  more alarming
than where the change is more gradual ;  and because, when the typhus
supervenes soon after blood-letting, it often proves fatal.
  I have already had occasion to observe that 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, we have seen, it is often difficult to determine what is best to
be done.  At the commencement, the symptoms are sometimes so vio-
lent as to endanger life, and yet we 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 such climates,
we find them much divided in their opinion.  Some advising the libe-
ral  use  of the lancet;  and others, having frequently experienced its
dangerous  consequences, almost binding themselves by a solemn en-
gagement 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 excitement is such as threatens to
prove fatal, either  by carrying off the patient in the height of the sy-
nocha, or by the debility which always follows violent  excitement ;
and then only to that extent, which the  symptoms  absolutely  require.
 What the symptoms are which mark this degree of excitement, I shall
presently endeavour to point out.
   Although the changes of fevers are more sudden, and  consequently
blood-letting more dangerous, in large cities than in the country, even 
196
CONTINUED FEVERS.
in temperate climates ; yet this  case never proves as  perplexing as
the foregoing, for here the excitement, at  the  commencement of
idiopathic fevers, is seldom very great.   The  same observation  ap-
plies to the autumnal fevers of temperate climates ; the excitement is
rarely such as renders blood-letting propter.
   In determining the degree of excitement which  warrants blood-let-
ting in  idiopathic fevers, we are  influenced by the observations just
made ; for the same degree of excitement which  would induce us to
recommend  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 warrants it in fevers from cold, rage,  or violent  exercise, does
not warrant it in fevers from putrid effluvia or contagion.  In the lat-
ter case, although the excitement at an  early period be considerable,
we know that  the nature  of the fever will soon overcome  it.   In
the former,  if the excitement is not diminished  at the commence-
ment, there is reason to believe that it will increase, while at the same
time we know that the debilitating effects of blood-letting in this case
are less to be dreaded.
   Let the nature of the fever be what it may, however, we must keep
in view, that violent excitement is itself a highly  debilitating  cause,
and often debilitates  more than a well-timed blood-letting which re-
                                                u
lieves  it.
   The degree of  excitement which warrants blood-letting in the cold
and temperate climates and in the country, does not warrant it  in sul-
try climates and large cities, because in the  latter case9 we generally
dread more the deficiency than the excess of excitement.
   The age and habit of the patient is also to be 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.
   If the  patient has  been subject to inflammatory diseases these are
apt to be renewed on slight occasions ;  and consequently symptoms
indicating their approach  must often be removed by more  vigorous
means, than are necessary for the  removal  of the same symptoms in
those who have not been subject to such diseases.   If the patient has
been in the  habit of losing blood, it is often proper  to employ this
remedy where it would not otherwise have been necessary.  Habitual
blood-letting produces habitual plethora, which constantly demands a
repetition of the same  remedy. 
                      CONTINUED  FEVERS.                197

    It thus appears that no general  rule can be laid down respecting the
 degree of excitement in fevers which demands blood-letting ;  the& de-
 termination of this question, unless the excitement be extreme, depend-
 ing as much on the consideration of the circumstances just mentioned,
 as the symptoms present.
    When the excitement is such as to be accompanied with delirium,
 which when it arises from violent  excitement is of the furious kind,  or
 when coma, which more rarely happens, appears in well marked sy-
 nocha, we must always have recourse to blood-letting.
    Delirium from excess of excitement is mentioned as a symptom de-
 noting the necessity of blood-letting in all cases : but in general it  is
 indicated by a much less  degree of excitement.   If the face be flush-
 ed, the pulse full and strong, and the  heat considerable, it  is usually
 to a greater or less extent employed with advantage, unless the nature
 of the fever or the situation of the patient  particularly  counterindi-
 cates it.
    What was said respecting the period of the disease proper for blood-
 letting, in speaking of intermitting, is nearly applicable to  continued
 fevers.  As soon as the  symptoms of synocha  begin to decline, the
 proper period for blood-letting is past.   Even Huxham, prejudiced  as
 he and most of his cotemporaries were in favour of this remedy, admits
 in his treatise on fevers, that " bleeding, unless in  the beginning, sel-
 " dom did service."
   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 of the blood  which particularly de-
 mand attention in fevers.
   I.  Where there is much of the inflammatory diathesis  the blood  is
 either more fluid  or  coagulates more slowly than natural, so that the
 red globules in part subside before  the coagulum is formed.  Hence
 there are no red globules  on the upper part of the coagulum,  which,
 on this account appears of a buff  colour,  and  has  been  termed  the
 buffy coat.  In different cases it is thicker or thiner, according as the
 blood has remained fluid for a longer or shorter time.  The thicker
 the buffy coat is, and the more it contracts  giving a cup-like form to
 the coagulum, it generally indicates the greater degree of  inflammato-
 ry diathesis.   The  buffy coat, however, does not universally indicate
the presence of this diathesis, nor does it universally appear when  the
diathesis is present.  It is sometimes absent, even  in cs^fsof actual
inflammation, and now  and then appears when  blood-letting has been
 very improperly employed. 
198
CONTINUED FEVERS.
   It may also  appear thicker or thinner, or its appearance  may be
wholly prevented, by the circumstances of the blood-letting.   If the
blood flows slowly, and is permitted to trickle down the arm, the co-
agulation 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 thinner.   These circumstances, therefore,
are to be attended to, in forming our judgment from it.
   When  the  buffy 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.
   II. The  blood is sometimes of a thin  consistence.  There are too
few red globules in it, 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.
   III.  The last kind of blood is found in the vessels of those labouring
under typhus gravior and scurvy.   It has a dissolved appearance, does
not coagulate so readily as healthy blood, the serum is of a redder  col-
our than natural, and the  crassamentum of a looser consistence.*
   If the blood drawn in fever, be  of the first kind, it gives encourage-
ment to  repeat the blood-letting,  should the symptoms seem to  re-
quire it.
   If, on the contrary, it be of the second, and still more if of the last
kind, we shall generally have  committed an errour in  recommending
venesection,  which, especially if repeated, may destroy the patient.
   In  determining  the propriety  of repeating  the  blood-letting,  we
must attend to the  effects it has produced.  If the symptoms  are  al-
leviated,  if the  pulse from  being  strong and full, becomes nearly  nat-
ural, and the heat  is diminished, there is no occasion for repeating it.
If the strength  is much reduced,  if the disease begins  to assume the
form-of typhus, which sometimes  very suddenly happens after an ill-
timed or  excessive blood-letting, the repetition of it would 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 continue, but with a consider-
able abatement, it will be proper  to repeat the blood-letting as soon as
they begin to suffer an exacerbation, which  very often happens, till the
operation has been performed several times.

  * See a  quotation given in p. 134, from Dr. Fordyce's third Dissertation on
Fever. 
CONTINUED FEVERS.
199
   Such are the circumstances  which should influence our judgment in
the use of venesection in continued fever.
   It sometimes, though rarely, happens in fevers, that the excitement,
instead of being diminished, increases after blood-letting ; a circum-
stance which might disconcert a practitioner not aware  of 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 the symptoms of  violent excitement.
Although (says Van Swieten) the most necessary and only remedy in vio-
lent fever is blood-letting, yet it sometimes happens in plethoric peo-
ple, that after venesection the  fever from being low, becomes very vi-
olent.  He relates two cases of this kind, one from Sydenham's works,
and another which Boerhaave used to relate in his lectures on 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
of synocha, till the excitement  is sufficiently diminished.
   It appears from what was said of the modus operandi of blood-let-
ting, that it  is the more effectual, the more suddenly  the blood  is  ab-
stracted.  On this account it was  once the practice to let  blood from
both  arms at the same time.   It is enough, however, to make the or-
ifice pretty large, a circumstance not always sufficiently attended to.
   For the same reason that  we abstract the blood suddenly,  namely,
that the action of  the powers supporting circulation may be diminish-
ed 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 degree of  syncope by a small  loss
of blood.   The effects of this mode of blood-letting, however, are tran-
sitory, and the horizontal posture is usually  preferred, that we  may
not be prevented  taking away  the proper quantity of blood.  In  this
posture,  many can bear the  loss of 16 or  18  ounces with ease,  who
could not in the erect posture lose half the  quantity without fainting.
   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 consequence from
what  part the blood is  taken, provided  it  be from the  upper part
of the body for a reason given,  in  considering  the  modus operandi
of blood-letting.  The most convenient place, therefore, the arm, is
generally chosen.   But when there is present  any local  affection which
may be relieved by blood-letting,  by  abstracting the  blood from the
part affected  or its neighbourhood, the same operation may answer the
purpose, both of general and local blood-letting.  Thu«  when delirium 
2(00
CONTINUED FEVERS.
 or coma supervenes in synocha, it is better to take the blood  from the
 temple artery, or the jugular vein, if this can be readily made to swell,
 than from the  arm.   In bleeding from the jugular vein in  affections of
 the head, we  must compress that vein alone from which  the blood is
 about to be taken.
   When the state of the symptoms requires both blood-letting and the
 exhibition of  an emetic, the blood-letting should precede the emetic.
 Sydenham says he could mention several cases where this precaution
 was not attended to, in which the efforts of vomiting produced such a
 flow of blood to the head, that a rupture of some of the vessels of the
 encephalon and a fatal apoplexy were the consequences.
   Blisters also should be delayed till after the blood-letting,  because
 their irritation will be less hurtful when the excitement is diminished.
   Till within the last fifty years, it was an opinion almost universally
received among physicians,  that the cure of typhus as well as synocha
 was to be attempted  by venesection ;  and this opinion is still so  pre*
 valent in many places, and has lately been maintained by such respec-
 table authority, that it will be  proper at some  length to consider the
 foundation on  which it rests.
   Blood-letting has been employed in typhus from a  very early peri-
 od of medicine.   Galen particularly  recommends it.   Celsus looked
 upon it as one of  the most  valuable  remedies  in pestilential fever.-.
 And Prosper Alpinus informs us, that the Egyptians let blood in all pu-
 trid disorders.  We  know with what freedom Sydenham used the lan-
cet.   " Ac proinde," he observes of the continued fevers of 1669, 71,
and 72, which were for the most part of the nature of typhus, " eadem
" ipsa methodo turn  quoad  venaesectionem, turn repetitas purgationes,
" febrem hanc aggressus sum ; quam  in dysenteric  curatione  supra
" fusius diximus."*
  In the petechial fever, Hoffman observes,  blood-letting  is generally
necessary if the patient is plethoric, and has been accustomed to this
evacuation.
  " And here first let me note," says Huxham,t that though malignant
 " and  pestilential  fevers at  the  very onset  greatly  sink the  spirits,
" and cause surprising  and sudden  weakness, especially when  from
" contagion, yet, bleeding, to some degree, is commonly requisite, nay
" necessary in the strong and plethoric, not only to lessen  the  moles;

  * See also his practice in the epidemics of the year 1665 and 66, during
which time the  plague infested London.
f Huxham on Fevers. 
CONTINUED FEVERS.                 201
" movenda, and give a freer play to the oscillating vessels ;  but  also
" to prevent any inflammatory obstructions, which may  form in  the
" very beginning,  and  likewise to  moderate  the  friction and heat,
" which are often very considerable  in the first days of  the  disease ;
" and which more and more exalt the salts and sulphurs of the blood
" increasing the  acrimony and putrescent state of the humours, and
" greatly  favour the action of the morbific matter."   In the former
part of this quotation, we see the practice of Huxham ;  and in the lat-
ter part, the foundation on which it rested.
  Every body, says Hassenohrl, lets blood in petechial fever, repeat-
ing the operation as often as the necessity of the case seems to require,
or as the particular tenets of the  physician  incline him to  do.   In
these fevers, he  continues, the blood often shows the buffy coat, but in
some, from the very beginning,  it is fluid and dissolved.   " Ex his
" quoque conficitur," he adds, " inanem esse  metum illorum, qui in
" febribus, sic dictis malignis, manum semper  a venaesectione tempe-
" randam esse contendunt;  ne scilicet debilitatem, in principio morbi
" jam presentem, augeant; cum enim haze debilitas, incipientibus morbis,
" frequentissime  ortum suum debeat sanguini spisso immeabili  phlogis-
" tico;  dare  elucescit  phlebotomise  administrationem  in  febribus
" continuis, nullis circumscribi limitibus nisi conditione segri, numero
" et vehementia symptomatum."*
  The same opinion has been adopted to a greater or less extent by
Dr.  Mead,| Eller, Sir John Pringle, Dr. Grant,  Dr.  Donald Monro, &c.
  Yet there are hardly any of these writers who did not occasionally
witness the bad  effects of blood-letting in typhus.  Thus Sydenham
remarks, "  Quoties mihi cum aegris res est, quorum sanguis vel per se
" imbecilior existit, (uti fere in pueris) vel justa spirituum copia des-
" tituitur,  ut  in decliviore aetate,  atque etiam  in juvenibus,  diuturno
<l aliquo morbo confectis, a venaesectione manum tempero."  Hoffman
confesses, that in many cases  of fever it is very difficult to determine
whether or not we ought to have recourse to blood-letting.  The can-
dour of Huxham supplies us with ample  proof of the impropriety of
his  own practice.   " The first blood," he observes, " in malignant fe-

  * Hasenohrl's Historia Febris Petechialis.
  f Although the state of the puls«  seems to counter-indicate it, Dr. Mead
observes, we must in general begin by letting blood in all continued fevers.
" Sanguinis missione plerumque incipiendum est,  etiamsi  ex pulsus tenore
" vix indicari videatur."                                         N^ 
202
CONTINUED FEVERS.
" vers, frequently appears florid, what is drawn twenty-four hours after
" is  commoly livid, black, and too thin,  a third  quantity livid, dis-
" solved, 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
" superiour part being a livid gore, or a kind of a dark green and ex-
" ceedingly soft jelly.  Besides the pulse in these cases sinks often-
" times surprisingly after a second bleeding, nay, sometimes after the
" first, and this I have more than once noted to my great concern and
" astonishment, and that even where I thought I had sufficient indica-
" tions from the pulse to draw blood a second time."
   In his Essay on the Ulcerous Sore-throat, the same  author observes,
" 1 have very often met with this buffy or sizy appearance of the blood
" in the beginning of  malignant fevers,* and yet the 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, who died by dozens,
" of a pestilential fever.  In this fever the French surgeons bled every
" day, or every second day, a7id I  several times  saw  the blood of some
" of the officers a mere sanious  gore en  the third or fourth blood-
" letting'".
   Huxham was led  at length to see the impropriety of blood-letting in
most cases of typhus,  and he confesses that in those fevers which arise
from contagion, it is generally followed by bad consequences.  He of-
fers the reason of this, in the following manner.   " The contagion  be-
" ing diffused through the  whole mass of  blood, you will  little lessen it
" by drawing off a  small quantity  of this fluid."   On this passage Dr.
Moore t observes, " The reason here assigned  for bleeding not being
" indicated, is unquestionably very ingenious ; but the  reason  which
" makes the strongest impression  on my mind for not bleeding in this
" fever, is simply because  it seems generally to do harm."
   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.  Dr. Monro, who says he was often obliged  to give cordials  to
support the strength after blood-letting, is  among the latest of the fore-

  * From these and similar observations it appears, that the buffy coat some-
times covers the blood in cases where it neither indicates a repetition of the
blood-letting, nor the propriety of having had recourse to it.
-j-Medical Sketches. 
CONTINUED FEVERS.
203
going writers.  He endeavours to support his practice, less by his own
experience, than the authority of Hassenohrl, who again supports his
by opinions, such as those just quoted from  his works,  respecting the
supposed viscidity of the blood and the means of correcting it.
  On reading such observations as those  just quoted, we are inclined
to ask, what were the advantages expected  from blood-letting in  these
fevers that such consequences should have been risked ?   To this ques-
tion we have no answer but that which the  favourite hypothesis of the
time afforded ; which taught, in opposition  to every day's experience,
that the cause of fever may be, as it were drained off by blood-letting.
  It is true, indeed, that a few instances may  be collected, in which
blood-letting seemed to be serviceable in typhus.   The most  remark-
able instance I  have  met with, is  an  epidemic, a  short account of
which, Dr. Donald Monro gives from Riverius ; but nobody acquaint-
ed with the nature of fever will regard solitary instances of this  kind,
as capable of  influencing the conclusion,  which general observation
warrants.  Singularities are constantly observed in particular epidem-
ics, from which no inference can be drawn  respecting fever in general.
  There are are many reasons for believing that the epidemic descri-
bed  by  Riverius  was attended with  some  abdominal inflammation.
Visceral inflammations  often exist, as dissection  has shewn,  without
being  indicated by the usual symptoms.  This is particularly apt to
happen in fevers.   It happened, frequently for instance, in the fever of
Grenada, described by  Dr. Chisholm ; and in that of Philadelphia, de-
scribed  by Dr. Rush,  and may account for the  practice which was
found most successful in them.  Quarin,  De  Haen, Bartholine,* Van
Swieten, Sir J. Pringle, Silvius de la Boej  and other" writers mention
similar instances.
   It has been maintained in  a late learned work on Fever,J that this
disease always consists in an inflammatory state of the  brain.   Could
this opinion be defended, the practice of blood-letting in typhus  might
be  defended on rational principles.  I have, in the Edingburgh Med-
ical and  Surgical  Journal,§ pointed out the reasons which appear to
me conclusive against this opinion.

  » Barthol. Hist. Anat. Rar. Hist. 56.

  \  Prax. Med. Append. Tract. X.
   I An inquiry into the Seat and N:t"ire of Fever, by Dr. Clutterbuck.
§ Vol. IV page 20. 
204
CONTINUED FEVERS.
   To the state of increased excitement, whatever be the mode ot ticat-
ment, if the fever lasts above a few days, alway-  succeeds that of de-
bility.  The action of the heart and larger  vessels now falls below,  as
in the first stage of fever it rises above the healthy degree.   If we cam
not permanently increase it, the debility of the capillaries increasing
with that of the central parts of the vital system, the powers of life are
at length lost in the former, and death gradually extends to the centre.
   We endeavour to increase the power of the sanguiferous  system.
   1. By an attention  to diet, as far as the state of the digestive organs
will admit of it ;
   2. By the application of cold as far as the  temperature  of the skin
warrants it;  and,
   3,. By the use of strengthening medicines.
   1. In the more severe cases of typhus, the powers of. digestion are
wholly suspended, and the only effect of food, if the patient could be
made to take it, would be to oppress the stomach.   In the typhus mi-
tior these powers continue,  though much impaired, and some attention
to the diet is  proper.
  The food should be mild,  nourishing, easy of digestion, and given fre-
quently and in small quantity.   It should consist chiefly of fresh fruit,
the farinaceous vegeatables, and bread.  No kind of animal  food is
proper while a  tendency to  exacerbations continues,   " Even after
the disease"  Dr. Fordyce observes " has been terminated by a crisis,
" animal food in a solid state should be rejected, there  being no cause
•' which has produced relapses, as  far as the  author's experience  has
" gone,  so frequently  as using  solid animal food too soon."
   The diet here should not, as in synocha, consist chiefly  of liquids,
which, without the admixture of some solid matter, are very imperfect-
ly digested.   I have found from repeated trials, that even the strongest
beef tea given alone, and when the stomach is perfectly healthy,  will
neither afford requisite nourishment, nor allay the  calls of hunger,  in
whatever  quantity it  may  be taken.   But  if  mixed  with any solid
matter, although much less nutritious, it becomes sufficiently so.
   It is of great consequence in all kinds of typhus not  to permit the
stomach to remain long empty.   If its state does not admit of any kind
of food, some  liquid more or less stimulating should  be frequently  giv-
en ; but I shall not enter on the use of wine as an article of diet, as it
will presently be necessary  to treat of it at length as a medicine.
   2. The application of cold  at.the various periods of fever has  al-
•<»ady bc-n considered. 
CONTINUED FEVERS.                 205
  -3. We come now to that part of the treatment  of fever, the knowl-
edge of which appears the most defective, the best  writers differing so
much respecting some of the means employed in it, as to lay down dia-
metrically opposite rules of practice.  While all seem agreed with res-
pect to the propriety  of using the medicines strictly termed tonic in ty-
phus, they differ widely respecting those to which the name of stimulant
has been more exclusively applied.  The chief of these are opium and
wine.
  I have already had occasion to  make some observations on the use
of opium in fever, as  a means of allaying irritation and procuring sleep.
It has also been employed in typhus for the purpose of increasing the
action of the heart and blood vessels.   Some have recommended it for
this purpose in very  large doses, and there is reason to believe that it
would have been more generally used with this view, were it not that
we have in wine, means of producing the same effect, in many respects
less objectionable ; and physicians seem now to be every  day more
and more confining the use of opium in fevers to the purposes of which
f have already treated.  But many equally object  to increasing the
action of the heart and blood  vessels in  the second  stage of fever by
wine.
   It is but lately that wine has been given with freedom  in any kind
of fever.  Sydenham, and his cotemporaries made but little use of it.
Since his time the practice of giving it in  typhus has been  gradually
*ainin<r ground, but the reader will find  by consulting  the  works of
Hoffman, Boerhaave, Van Swieten, Huxham, Mead, De Haen, Hasen-
ohrl Eller, Pringle, Monro, &c. that the best writers till within the last
30 or 40 years, speak of its employment with great caution.
   Dr. Cullen is among the first who recommended it in large quantity.
Dr. Brown and his followers advised  a still freer  use of it, and of late
it has not been uncommon for two bottles of the stronger, and three or
even four of  the  lighter wines to  be  drank in twenty-four  hours, by
those labouring under certain species of fever.
   The prejudices of the  earlier writers appear to have contributed to
this surely excessive  use of wine  ; for later physicians finding, that it
might in many cases be given to much greater extent than they advise,
not only with safety, but advantage, imagine that the caution of their
predecessors  was wholly unfounded ;  and  seem  to regard wine  as a
specific in all fevers, in which the excitement falls below the healthy
decree.  The ill success which often  attends the injudicious use of
wine in fever, has, on the other hand, led some physicians of eminence, 
206                  CONTINUED FEVERS.

altogether to  doubt  its beneficial tendency in this  disease, and they
have nearly banished it from their practice.
  Such is the present state of medical opinion on a point of the  first
importance.  After reading all that has been  written on the subject,
the physician finds himself left to his own observation  to determine,
whether he is to place his chief reliance on wine in the treatment of ty-
phus, or to shun it as always  injurious in this disease.
  The following remarks are  the result of pretty extensive experience,
and if not of accurate,  at least of anxiously attentive observation.   For
the   last thirteen years, I have practised in a county peculiarly subject
to fever, where I have  not only seen many patients, who were  from
the commencement of the disease under my own care, and consequent-
ly afforded me opportunities of observing the effects of the plan which
appeared  to me the best ; but  from the practitioners of the smaller
towns, whose attention is necessarily  divided among all the branches
of the profession, occasionally requesting the assistance of the physi-
cian  in the more serious medical cases, 1 have had an  opportunity of
comparing the effects of different modes of practice.
  As far as I can judge from what I  have  seen of the use  of wine in
fever, the difference of opinion which prevails on this subject, has in a
great degree arisen  from physicians having attempted  to apply their
rules, either for or against it,  to all cases indiscriminately.   Whereas,
it would appear that the use of wine in typhus must be  almost as much
regulated  by circumstances, as that of blood-letting in synocha.   Two
genera] observations,  however,  appear to  me to be warranted,  that
more or less wine is beneficial in all cases of  typhus, and  that there
are few, in wliich very  large quantities are  not  injurious.
  When we see a patient labouring under symptoms of extreme debil-
ity, and find them almost uniformly relieved  by a large  quantity of
of wine, it is difficult at first view to persuade  ourselves that it can be
pernicious.  But an attentive  observer will look beyond its immediate
effects, and will often see sufficient reason to doubt the safety of carry-
ing this practice very far.  He will find that the temporary  excitement
he thus procures, is frequently succeeded by a greater decree of debil-
ity, than that which the stimulus bad removed ; and if he j erstveres in
*he practice under such circumstances,  the pulse upon the  whole will
gradually  become  more frequent and feeble till  it ceases  altogether.
These effects I have often witnessed.
  Physicians have  also been  led  to an excessive use of wine in ty-
phus by the comparatively small effects it  produces.   That a pint of 
                     CONTINUED FEVERS.                207

wine in typhus does not produce a greater effect than a glass in health
is adduced as an argument, fcr the pint in the one case being as inno-
cent as the glass in the other ;  but it is to be  recollected that wine
in typhus  only produces  less excitement than in health, in propor-
tion  as the remaining excitability is less ; and  consequently, that
a degree  of excitement which would occasion little or no inconven-
ience in health, may produce a fatal exhaustion in typhus.  Here there
is no excitability to spare, and one of the first principles of the treat-
ment seems to be, as much as possible  to prevent its exhaustion.   A
moderate and uniform exhibition ofstimuli seems often necessary, that
the action of the central parts of the sanguiferous system may not fall
too low to support that of the extreme parts.  All excitement beyond
this appears to have no other effect, but that of exhausting the vigour
which yet  remains.
  The proper quantity of wine is to be determined by an attention  to
the following circumstances.
   The degree of the debility, and the nature of the symptoms.
   The stage of the fever, and the time it has lasted.
   The nature of the cause which produced it.
   The age and constitution of the patient.
   His habits of living, and former diseases.
   The climate,  season, and particular situation in which the disease
appears.
   The effects of the wine.
   When the debility is inconsiderable, I believe the quantity of wine
used in fevers should be very small, and  it should  be given diluted.
In proportion  as the debility is greater,  we may cautiously  increase
the quantity, recollecting, however, that  it is not our object suddenly
to correct the symptoms of deuilty, much less to occasion any consid-
erable degree of excitement, but to afford such  support to the vital or-
gans as shall tend to prevent an increase of debility ;  and in more se-
vere cases, to relieve the  symptoms of immediate danger.  Those ca-
ses of typhus which are  accompanied with  petechia;, and a tendency
fo gangrene,  seem  to call most  for the  use of wine ; and those  in
which  the  skin is soft and inclined to be damp bear it best.
   If very large quantities of wine are ever proper in fever, it appears
to be when extreme debility comes on very rapidly.   In the same de-
gree of debility coming on more  slowly and consequently  at a later
period  of  the disease, there is  less prospect of advantage from them.
If the setund stage of fever has lasted for sjme time v. •:>-> lit<!f Increase
of debilitv  wine sho;ild be used. •' 'i'!i </rr:it raui'P.-. 
208                 CONTINUED FEVERS.

  There is every reason to believe that fevers from contagion bear
wine better than those from  other causes, especially if the patient is
still exposed to a  highly contagious atmosphere.
  The dose of wine must in some degree be regulated by the patient's
age and constitution.  In old age and weak habits, the  symptoms re-
quiring the use of wine are of course most apt to appear, and the same
degree of debility indicates a freer use of it, because in them debility
is most apt to increase rapidly, and produce symptoms of danger.
  The more the patient has been accustomed to a free use  of ferment-
ed liquors, the less will be the effect of the same quantity of wine in fe-
ver.   Those who have   been long accustomed  to a very  simple diet,
making little  use either  of fermented liquors or animal food, are very
sensible to the stimulus  of wine in this disease.   Such as  have been
subject to former attacks of typhus, or other  diseases of debility, are
more liable to the symptoms requiring it, than those whose  previous
diseases have been of an inflammatory nature.
 The climate, season, and even the particular situation in which the dis-
ease appears, should influence the use of wine in typhus.   As in sultry
climates the changes in fevers are rapid, they often demand more pow-
ful stimulants than are usually proper in the fevers of temperate climates.
In the latter, the tendency to debility is greater in autumn than in spring
and the moderate use of wine, therefore, more generally necessary;
and cases of that extreme debility which seem to call for a freer use of
it, more frequently occur in autumn. In certain situations of the same
country, diseases tend  more to debility than  in others.  In  towns
which lie low, and  in which  the inhabitants are  crowded, fevers are
found to require the use  of wine more than in higher situations, and in
the country.   This  difference is strikingly exemplified, even in differ-
ent parts of Worcestershire.   In Worcester and Kidderminster for ex-
ample, it is necessary to make a freer use of wine in fevers, than on or
near the Malvern and Broadway Hills.
   The effects of the wine must be carefully watched.   If it quickly,
and to any considerable  degree raises  the pulse, we may be assured
that we are giving too much.   If we find that its effects are transitory
if soon  after the cordial effects of each dose, sinking and debility re-
turn, we shall seldom gain much ground by its use,  and by increasing
the dose we shall generally accelerate the fatal  termination.   When
on the other hand, the wine without appearing to produce any very re-
markable degree  of  excitement at the time  it  is taken,  seems more
permanently to relieve  the symptoms of debility, we may with confi- 
                    CONTINUED FEVERS.                 209

dencc expect advantage from it.  But we must be cautious  how we
venture to increase the quantity which has this effect.  When our pa-
tient is  upon the whole improving, this should satisfy us.  If we  at-
tempt to accelerate his recovery by increasing the  wine we shall often
do harm.
  Various other fermented  liquors have been used  as substitutes for
wine, the best of these appear to be cider and perry.  These are neither
so oppressive to the stomach as malt liquor, nor do they afford so hurtful
a stimulus  as  distilled spirits which, diluted or defended in whatever
way, as I have observed from many  trials, never produce the invigora-
ting effects of the fermented liquors which have not been distilled.
  The vitriolic and nitrous ethers have been much recommended in ty-
phus.  To the free use of ether nearly the same observations  apply as
to that of distilled spirits.   It is often used with advantage in small do-
ses as an antispasmodic.
  It is not many years since it was a common practice to employ blis-
ters as a stimulus in typhus, and many of the older practitioners still
employ them with this view. Of their use in fevers, I have already had
occasion to speak. Their general stimulant effect appears to be trifling,
and perhaps  hardly ever compensates for the irritation and trouble
they occasion.   Dr. Cullen justly observes, that the general stimulat-
ing effects of blisters must be inconsiderable, since they are found of so
much service in cases of local inflammation.
   To the head of tonics belong the various astringents, bitters and aro-
matics, and the mineral and vegetable acids.*
   Of these medicines, the most celebrated is the bark.   It differs from
fermented liquors in its stimulus being less powerful  but more perma-
nent ;  and  in its being not at all nutricious.  It is even probable from
some observations related in speaking of intermitting fever,  that it is
either not received into the mass of blood, or although in  part received
its  effects are  chiefly to be attributed to  its action on the stomach and
intestines.   On the muscular fibre the  bark seems to exert  but little
power ;  its immediate  action  appears to be  on the nerves, through
which  its invigorating effects are diffused to other parts of the  system.
   Mo.-1 of the authors I have had occasion to mention used the bark in
fevers with  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 decoc-

  * Iron has seldom been employed in  fevers except towards their decline
 when symptoms of dyspepsia come ^n. 
210                CONTINUED FEVERS.

tion with aromatics and a small quantity of distilled spirits ;  and Has-
enohrl is one of its strongest advocates.  " Supervacaneumquidem est,"
he observes, " aliquid addere quod egregiam cortics Peruviani  virtu-
" tem in febribus admodum malignis demonstret."*
  We  found in treating of intermittents, that wherever the inflammato-
ry diathesis is considerable, blood  letting is necessary  previous to the
exhibition of the bark.  Some practitioners, losing sight of the circum-
stances which gave rise to this practice, seem to have regarded vene-
section previous to the exhibition of the bark as  necessary in all cases
of fever.  In consequence of which it has sometimes been very improp-
erly employed.   Dr. Cullen justly remarks, in  his Materia  Medica,
that wherever blood letting is proper in continued fever, the bark is al-
ways prejudicial.
  But  the  prejudice that chiefly  opposed the use of the bark in  this
fever, and which  also originated from  the practice found most  success-
ful  in  agues, was that it would not succeed unless there were evident
remissions.*  This observation is just if it be confined to those fevers in
which  the symptoms of synocha prevail;  but in typhus the  continued
form of the disease does not forbid  its  use.   I had occasion to observe,
in speaking of the treatment in agues, that, although where the excite-
ment is considerable, the bark is only to be exhibited in the  absence
of fever, and  that where the  inflammatory diathesis exists, its exhibi-
tion is  to be delayed altogether; till this diathesis is removed ; yet in
other cases, particularly where the debility is considerable, the incom-
pleteness of the remissions only indicates the necessity of using the bark
more freely :  and it  may now be  observed, that under the  latter  cir-
cumstances, although the fever be of the continued form, the bark is to
be given, though generally, in smaller doses.   It is true indeed,  that
where  there are no remissions we do not expect it to stop the fever ;  but
it tends to obviate the symptoms of debility and shorten the disease.
  While any  degree of the synocha prevails  the bark is hurtful,  and
even about the time of the change from the synocha to the typhus, I
have found the lighter bitters, the columba, the serpentaria,  the casca-
rilla or gentian better  than the bark ;  which if given at this period, is
apt to  recall the symptoms of synocha.  But after the typhus  is fairly
formed, that is, after the pulse remains weak dyring the exacerbations,

              * Hasenohrl's Historia Febris Petechialis.

  * Dr. (.rant's Treatise on Fevers and other works which I have had occasion
to mention. 
CONTINUED FEVERS.
211
  more or less bark  is always perhaps useful; and  when symptoms of
  malignity, and particularly that tendency to gangrene so frequent in
  the worst forms of typhus, appear, the largest quantity the stomach will
  receive is necessary.
    In these cases it is adviseable to give it in substance if the stomach
  Will bear it.   In  milder  cases the infusion is sufficient, and, being:
  less apt to oppress the stomach, should be preferred.
    It is always proper to combine with the bark,  in whatever form it
  is given, some  of the mineral acids.  I have already had occasion to
  speak of acessent  fruit and other vegetable acids as beneficial in all
  kinds of fever.   In many eastern countries the natives trust the cure
  of malignant fevers chiefly to what we should call an excessive use of
  lemon juice.   Peppermint, cloves, cardamoms, and other  aromatics
  are occasionally added to the bark and other bitters, to increase their
  stimulating quality, and render them more grateful to the stomach.
    The mineral acids may be given much  earlier in'fever than either
  the bark or wine.   As soon as the symptoms of synocha begin to abate,
  they should be mixed with the drink; and  as the typhus comes on.
  given  very  freely.   Till  lately the  sulphuric  acid has been  chiefly
  employed ;  most physicians now prefer the muriatic.  The nitric acid
  has not been much used in fevers.  Analogy is in its favour, especial-
  ly when bilious symptoms predominate.
     A new stimulus has been introduced into the treatment of typhus
  by West-India  practitioners, and from the trials which have been made
  with  it, there is reason to believe that it  will prove a valuable  medi-
  cine,  though probably better  adapted to warm  than temperate cli-
  mates.  Dr. Wright in his report respecting the yellow fever of the
~"*West-Indies, in the 2d vol. of Annals of Medicine, observes,  " We did
  " not, however, despair ; we gave capsicum pills with the most mark-
  " ed success, and  even where  melaena or the black vomit had taken
  '• place, the capsicum has snatched the  patient from the most immi-
  " .nent danger."  Others have made  similar observations.  The bene-
  fit derived from the capsicum in the  cynanche maligna suggested its
  exhibition in typhus, and affords as strong  an argument in favour of the
 ^practice as  analogy can supply.
    There is a class of medicines, whose  stimulus  seem particularly
  Calculated to  remove that  state of debility,  which is attended with
  spontaneous contractions of the muscles of voluntary motion, occasion-
  ing subsultus tendinum, and other involuntary motions of the trunk and
  limbs; the chief of these are ether, opium, musk,  camphire,  castor, 
212
CONTINUED FEVERS.
 and ammonia.  All of which have been  regarded as powerful  medi-
 cines in typhus.
   Of ether and opium, I have already had occasion to speak ;  and if
 we  estimate the value of the others by the general opinion of practi-
 tioners,  we shall find them  fall  much  short of the encomiums which
 some have bestowed on them.   Of these,  camphire, on  wliich Hux-
 ham placed much reliance, is the most  useful in fevers ;  in small  doses
 it often has a considerable effect in allaying restlessness and anxiety,
 and does not interfere with the exhibition of more powerful medicines.
 The mistura camphorae is often a good vehicle for  the bark in typhus.
   Camphire* combined with opium forms perhaps  the most poweful
 medicine we possess in obstinate vomiting, which both on account of
 its debilitating effects,  and because it prevents the  exhibition of medi-
 cines, is always an  alarming symptom.|
   The ammonia and musk have been chiefly recommended when the
 low delirium, characteristic of typhus, has supervened ; and in such ca-
 ses they often afforded  relief, but their effects are transitory.
   In extreme typhus the circulation, being  comparatively slow, the in-
 creased frequency,  not compensating for the greater  feebleness of the
 systole of the heart and arteries, the blood passes less frequently through
 the lungs, and consequently  is less subjected to the action of the oxyge-
 nous part of the atmosphere than in health.   Hence probably its  dark-
 er colour.  The effects of the le9s frequent passage of the blood through
 the lungs would probably, as far as respects the change occasioned by
 the oxygenous part of the atmosphere, be counteracted by supplying the
 patient with air containing a larger quantity of oxygen, in proportion
 as the circulation is  less rapid.   What effect correcting the venous state
 of the blood in typhus might have, it is difficult to say.
   If we contemplate the change  which has been taking place in  the
 treatment of fevers during the last fifty years, we shall find, that physi-
 cians have been gradually diminishing the number  of their medicines,

  * Dr. Lysons gave large doses of camphire with nitre at the commence-
ment of fevers, and when, with the assistance of a little white wine whey, it
succeeded in exciting the action of the skin, it seemed frequently to  be of
great service.

  f Saline draughts given in the state of effervescence or a mixture of the
sulphuric acid,  conserve of roses, and peppermint water strained, also fre-
quently allay this symptom 
CONTINUED FEVERS.                  213
and incf easing the doses of those they retained.   In proportion as it has
been rendered less complicated, it has become more efficacious.*

  * The author's description of the typhus fever, corresponds so exactly with
the appearances  of the disease,  known by that name in this country, as to
leave no doubt on the mind of its being essentially the same; and he has de-
scribed the symptoms so minutely, that nothing need be added under this
head.  I shall therefore confine myself to some general observations on the
nature of the disease, and general mode of treatment.
  Typhus Fever I have defined to be a disease arising from an unknown cause,
incident to persons of every age and sex,  appearing in all countries, and un-
der all circumstances of climates and seasons.
  When once produced, capable of being communicated from one person to
another, and not often affecting the same  person twice ; possessing a charac-
ter  marked and defined, shewing  as little variety  of appearance in diflerent
Cases, as many of the contagious diseases, to which it is nearly allied.
  Respecting the production of typhus fever without infection, I know of no
cause that can be assigned, as it sometimes  leaves large districts of country
free from it for many years.  It cannot be produced by accidental causes af-
feeling persons, such as exposure to cold,  errours in diet, fatigue, &c. for in a
thousand people, those causes must be nearly the same in even year.
  During the first ten years of my practice, I saw but three patients sick of
the typhus fever, and these were in the last and last but one of the ten years
Thus I practiced eight years  before I saw a case of typhus fever, and I was
also informed by the inhabitants of that part of the country where I practiced,
that the nervous fever as it was then called, had prevailed there about twenty
years before ; hence this part of the country had been free  from that disease
between twenty and thirty years.
  In the summer of 1798,  the typhus fever appeared at Hanover  in New.
Hampshire ; and about the same time, it  commenced in several other  towns
in that state, and in Vermont.  Since that period, the typhus has been the
general epidemic of that part of the country ; and as far as my knowledge ex-
tends, it is so at present throughout die United States.
  Respecting the nature of typhus fever, it has its seat in the capillary sys-
tem of vessels, in common with all other febrile diseases ; but how this  mor-
bid excitement differs from the diseased  actions in cases   of acute inflam-
mation, it is  difficiilt  to determine.   Some writer on this subject, whose
name I do not now  recollect, has accounted for  the difference between ty-
phus and other fevers, on the supposition that in typhus, the morbid excite-
ment was confined more especially to the  capillary arteries  bestowed on the
brain and nerves j and if I am not mistaken, he has cited some  cases of clis-
section of those who had died of typhus,  where the appearances supported this
opinion.
  The peculiar affection of the animal function  in typhus,  also corroborates
diis doctrine ;  but it does not explain all the peculiar phenomena of this dis-
ease.   In typhus the evolation of heat on the surface of the body, is quite as 
214
PETECHIAL FEVER.
                            CHAP.  IV.


               OfUie Varieties of Continued Fevek.


   Continued fever, or, as it has been termed,  Synochus, is according
to the arrangement I  adopt, divided into five varieties ;  the Synochus
Simplex, unaccompanied by any  eruption, the Synochus Petechialis,
the .Synochus Miliaris,the Synochus Aphthosus, the Synochus Erysipe-
latosus, and the Synochus Vesicularis.

great as in cases  of active inflammation, even  while the skin  remains pale,
which renders it more probable that the difference between the morbid ex-
citement in typhus and inflammatory diseases, depends on the mode, or kind
of action in the capillaries, rather than its being seated in any particular part
of that system ; and that this difference depends on the nature of the cause,
which excites the disease.  This is analogous to many other affections.  The
same part of the body, or system of vessels, is capable of being thrown into
different kinds of diseased action, by different causes of morbid excitement—
Witness the effects of morbid^poisons.
  Respecting the treatment of the typhus fever, if we consider it as a peculiat
disease, excited by a specific cause, and destined to run a certain course, our
object should be rather to conduct the patient through it with safety,  than
to attempt a cure immediately by strong measures ;  for notwithstanding what
has been said of interrupting the disease jn the commencement, I am not sa-
tisfied, that I have ever been able to do this in a single instance, when the dis-
ease has been formed so as  clearly to shew its peculiar character;   it has al-
ways continued a considerable number of days.  In a disease, differing so
widely in diflerent cases as to its violence, and duration,  when it happens to
terminate at an early  period,  the physician may, if he please, attribute the
termination at that particular time, to what he has administered, and it would
be difficult to prove the contrary ;  but when we see the  same remedies ad-
ministered in many cases of the same disease, and under circumstances appa-
rently similar, which continue two or three times as long, we may at best be
allowed to doubt, whether the short duration of the disease  in the first in-
stance did not depend more on the nature of the disease  itself, than on what
was done to cure it.
  In treating of the particular remedies which have been employed  in typhus
fever, blood-letting should be considered first, for if it be necessary, it is so at
the onset of die disease.  On this point it appears that the physicians in Et»-
rope, as well  as the United States, are divided—while some recommend it,
others consider it always injurious.  Arguments  drawn from theory should 
PETECHIAL FEVER.                   215
   The synochus simplex has been considered.   I am now to point out
the circumstances  in which  the other varieties differ from it.

have but little weight in such cases; but it is difficult to reconcile such con-
tradictory opinions  among men of talents and experience on a subject of a
practical nature, which so often comes before them,  and I can only say, that
my experience so far as it goes happens to be against the use of the lancet in
typhus.
   Venesection does not hold that control  over the morbid excitement in ty-
phus, that it does in other diseases of a different character.  It does not sen-
sibly  diminish  the heat of the body,  and I have never known  it  cut
short the disease.  In a few cases where the pain in the head  was very severe,
a single bleeding has mitigated the pain in the head without producing any
other sensible change in the disease, and those cases in which I have bled the
most, I have been the most unfortunate.
   After the consideration of bleeding, emetics are first prescribed.  Physi-
cians are better agreed about this remedy than they are about blood-letting;
almost all  physicians give an emetic in its commencement.  To this  there
can be no objection, provided the emetic is of the right kind, and adminis-
tered in a proper dose.  But we are not  to  expect that a single emetic will
make any very essential change in the disease;  and it is  often necessary to
repeat the emetic several times in its course.  Ippecacuanha and a decoction
of Eupatorium  Perfoliatum or thoroughwort, are the best emetics.  Tartar
emetic is perhaps the most objectionable.   It is apt like blood-letting to pros-
trate  the strength of the patient without  changing the morbid action, and if
given at first cannot be repeated with safety.
   Cathartics should be used with no other view than to evacuate the contents
of the bowels.   The total neglect of cathartics, and the use of the stronger
purgative  medicines,  are alike  injurious, and equally dispose to diarrhoea.
When the patients  are costive, and  the bowels remain long without motion,
the accumulation of acrid matter at length stimulates them into unhealthy ac-
tion,  a diarrhoea follows.  I have after observed a troublesome diarrhoea to su-
pervene, immediately after the operation of a strong cathartic.  Calomel
alone, or combined with rhubarb, given in small doses, is one of the best ca-
thartics.  Neutral salts, though they are  mild cathartics,  are not good, they
tend  to weaken the tone and energy of the stomach and intestines, and dispose
to diarrhoea.
   That class of inedicine called refrigerents, is generally worse than useless.
Nitre, especially if it be given in such quantities as to have any effect, always
has a bad one ; it injures the  power of the stomach, which should  be pre-
served with great care ;  the same is true of almost all the neutral salts.
   The carbonic acid, given  in  a effervescing mixture, and in  beer in a state of
fermentation, is almost always  agreeable,  and may be indulged  in freely.
   The vegetable acids may  be allowed to patients who like them.  Some of
the mineral  acids have been advbed and especially the muriatic.   Where
acids are agreettble, they aregoud, but tor svmspati^.ts they •nedisar.eeiVe 
216
PETECHIAL FEVER.
                              SECT. I.


                       Of the Petechial Fever.


   The Synochus Petechialis may be defined,
   Synochus, incerto morbi die, plerumque post varia debilitatis signa,
apparent maculae parvffi, rubra?, circulares, minime  cminentes per cu-
tem, praecipue  colli  et pectoris, sparsae.

and cause a sense of heat in the stomach ; in  such cases  they should be dis-
pensed with.
  Cold water is  perhaps the best refrigerent in fevers, and it should certainly
be  administered  to patients  who  crave  it,  but  where  the thirst  is
great, it is better to subdue it by the external  application of cold water than
by drinking it.  Large quantities of liquids taken into the stomach are not
good ; it serves to weaken the stomach without allaying the thirst.  A pint of
water applied to the face so as to keep it constantly wet as long as it lasts,
will do more towards removing a troublesome drought than a quart taken in-
to the stomach.   It alleviates the dryness of the mouth very much to let the
patient draw his breath through a thin muslin, laid over the mouth, and kept
constantly wet with cold water. This may be done in all cases, where the
mouth is dry, and the tongue parched, without any regard to the stage of the
fever, or heat of die body.   It is now eighteen years since I have been in the
practice  of applying cold water in fevers, especially- in the typhus.   I have
sometimes taken them out of bed, and poured the water over the body, but I
have thought that a better method was to sprinkle the patient as he lies in
the bed, and to repeat it often so as to keep down the heat.
  When patients are very sick, the exertion they are obliged to make in get-
ting out of bed,  is too much ; besides it often happens  that  the head  and
breast are very  hot, while the feet are cold ;  in such  cases by applying the
water when they lie in bed, we can apply it to the head and breast, and at
the same time keep the feet warm, which should be always done in such cases'
The cold water  may be applied in this way whenever the heat is above  na-
tural, and if die heat of the body is above natural in one  part and below  Uiat
standard in another, warm applications should be applied to the cold parts,
and cold water to the parts preternaturally hot.   In diis way the heat may be
kept down and much of the  vital principle saved, for an  excess of heat  is a
very exhausting power.
  Opium is a doubtful remedy in typhus ;  some it composes and gives quiet-
ness and sleep;  others it makes wakeful, and  increases  the confusion of
head.   Where it agrees with the patient a dose may be given  once in twen-
ty-four hours. 
PETECHIAL FEVER.
217
  There is little to be added to what has already been said of this va-
riety of synochus.  Petechiae* seldom appear in the first, very frequent-
ly in  the  second  stage of synochus.   They  are most  apt to appear
where there is a tendency  to the  hemorrhagies characteristic of this
stage.

              * See the Section on the Symptoms of Typhus.

  Wine is,  perhaps, a safer medicine in typhus that opium, but it is general-
ly the most useful in the latter stage of the disease.
  The Peruvian bark is not often useful  in typhus of this country.  I have
tried it in many cases, where I was obliged to desist from the use of it, as it
increased the heat and restlessness of the patient.   In a few cases it has been
useful.
  Ardent spirits are hardly admissible in this fever.   In one case after a ve-
ry great loss of blood from the bowels, and total extinction of the febrile symp-
toms, the patient being exhausted, brandy and water was taken with good
effect; but while the febrile action Continues in force,  the spirits  are not ben-
eficial.  It  does  not follow because bleeding and other depleting remedies
are improper, that the strong stimulants are useful.
  In the typhus fever, besides the use of remedies here pointed out,  much
depends on what properly belongs  to the  department of  nursing,  which
should be particularly directed by the physician.   The room should be dark-
ened, and kept perfectly clean, all unnecessary furniture should be removed,
and the patient's bed should be placed in the middle of the room, if the weath-
er is hot one or more windows should be kept open  night  and day ; and in
the day time, the floor and walls should be often sprinkled with water. The
bed and body linen should be often changed, and every part of die patient's
body should be kept clean, by washing him with water, or soap and water.
If the patient be a man, he should be shaved every, or every other day at fur-
thest.  Clean linen in cases of typhus should be  rigorously observed, both
for the comfort and recovery of the patient, and for the safety of those who
attend him, as the danger of contracting it is much increased where  that is
neglected.
  "As patients, sick of the typhus fever, are generally torpid, and do not often
call for what is necessary, the nurse should be vigilant, and not suffer the pa-
tient to lay long without sprinkling his  head and face with  water, or giving
him some  liquid, either as food or drink.  Respecting  particular symptoms
in typhus, that demand attention, a liquid diarrhoea is the most  frequent at-
tendant in  a majority of the cases that I have managed, this has taken place
to a greater or less  degree.   When it is moderate,  it requires no particular
treatment; but when it is copious and frequent, it is a troublesome and dan-
gerous symptom, and should be checked if possible.
   Opium and ipecacuanha may be tried with mucilagenous substances taken
internally,  such as arrow root,  and injections of starch and opium should be
                                   28 
218
PETECHIAL  FEVER.
   This eruption sometimes accompanies other diseases, particularly
scurvy, and is sometimes idiopathic.  We still, however, find it ac-
companied with a tendency to the worst forms of hemorrhagy.
   All that is known of its causes is, that whatever debilitates, disposes
to it.  It nevertheless sometimes appears when the excitement is con-
siderable ;* and on the other hand, we often meet with extreme debili-
ty in fevers, as well as other diseases, unattended by petechiae.
   As petechiae generally denote debility, their appearance in typhus
indicates a strict attention to the invigorating plan; and antiphlogistic
measures should be employed with caution when they shew themselves
in synocha.
   When petechiae appear as an idiopathic  affection, tonic and astrin-
gent medicines are indicated, the bark, port wine, sulphuric acid, and
alum are the best.   It will be necessary to consider the other varieties
of synochus at greater length.t

  * See Eller de Cognosc. et Cur. Morb. ' Dr. Grant's Treatise on the Fevers
most common in London, &c

  ■j- It is evident, that, what the author has said of petechial fever, does not ap-
ply to the disease, called spotted fever in this country, for that disease is on-
ly a variety of typhus.
  Respecting the disease called spotted fever in New-England, although the
name may be improper, as spots do not constantly appear, yet, by it we un-
derstand a disease of a peculiar character, differing in several respects from
every other.
  Notwithstanding the spotted fever has existed more than ten years in New-
England, the faculty are still divided about its cause, nature, and proper mode
of treatment.  I shall not pretend to decide on those questions, but shall con-
tent  myself widi stating such facts as have come under my own observations,
and leave die reader to form his own opinion.

administered.  When they fail, astringents, such as the gum catechu and al-
am,  may be given. In one case, when all those remedies had failed, the di-
arrhoea was cured, by giving the patient equal parts of lime water and milk
for a beverage, of which he took freely.
  Another symptom in typhus which occasionally occurs, is a discharge of
blood from the bowels.  This kind of hemorrhage is apt to take place about
the time the fever begins to decline.  The discharge is often.very copious, is
always alarming, and sometimes  fatal; but if the patient survives this symp-
tom, it generally terminates the fever.
  Astringent injections, composed of alum water, and  Peruvian bark in sub-
stance, and the same given internally, together with stupes of hot brandy ap-
plied to the abdomen, have succeeded in several cases.
                                                             N. S. 
MILIARY  FEVER.                   219
SECT. n.
                        Of the Miliary Fever.


   The MiHary Fever is defined by Dr. Cullen,
   " Synochus cum anxietate, frequenti suspirio, sudore olido, et punc:
'; tionibus cutis.  Incerto morbi die, erumpunt papulae rubrae, exiguae,

   I have mentioned, in a note on epidemic catarrh, some facts,  which go to
shew, that the spotted fever may be a variety of that disease.  The following
circumstances would lead us to believe, that it depended on a peculiar, mor-
bid, excitement of the capillary vessels in the brain, which soon extended it-
self to this system of vessels throughout the body.   The disease attacks sud-
denly.   The arteries of the neck and temples beat strongly, the head is hot,
while the pulse at the wrist is small, and the  extremities cool.  The  func-
tions of animal life are soon impaired or lost
   Several persons, affected with this disease, who have recovered their health,
have lost die sense of hearing; and others have been afflicted with blindness
for several weeks.  In one case it affected the muscles of voluntary motions,
with tremour, which has ever since  deprived the patient of the power of
walking.  As  to the treatment of spotted fever, when it  prevailed  in Ver-
mont in the year 1812, and in its worst form, the following method obtained
the  most credit—The patient, as soon as attacked was put into bed, and the
vapour of hot  water was conducted into the bed, so as to keep the body im-
mersed in the vapour from the feet up to the neck; at the same time cloths
wet with cold water, were applied to the head, or bladders filled with snow
and ice.   While in this situation the patient drank freely of hot herb tea, and
when the sweat flowed freely, laudanum, and ardent spirits were sometimes
added.
   This process of sweating was continued till the pain in  the head and other
symptoms of the disease abated,  and then the patient was suffered to cool
very slowly.
   When the stomach was affected with nausea, emetics of ipecacuanha were
given to advantage; and when to the universal torpor, which  commenced
with the disease, a high degree of excitement succeeded, blood-letting Was
practiced with good effect.
   In many instances, the spotted fever attacks with such violence, that it
puts the patient beyond the reach of remedies at once.  Some skilful and ju-
dicious physicians have related cases of this disease, where enormous  quan-
tities of opium and ardent spirits, have apparently snatched patients from the 
220                   MILIARY  FEVER.
" discretae, per totam cutem, praeter  faciem, crebrae,  quarum apices,
" post unum vel alterum diem, postulas minimas, albas, brevi manen-
" tes, ostendunt.'"
  It appears from  what was said of this fever in the Introduction, that
it is to be regarded only as a variety of synochus, characterized by a
particular eruption, and a certain train of symptoms which attends that
eruption,  whether it  appears in fever or other diseases.   In laying
down the symptoms then of what has been termed  Miliary Fever, it
will be the most distinct plan, in the  first place, to describe  the erup-
tion ; secondly, to enumerate the symptoms  which generally precede
or attend  it; and lastly, to point out the febrile states in whicb it is
most apt to appear.


             1. Of the Symptoms of the Miliary Fever.

                     Of the Miliary Eruption.

  This eruption is sometimes preceded by a roughness of the skin, re-
sembling that produced by cold,   It consists of a number of small red
pustules, about the size of millet seeds, from which they are termed mil-
iary. They often lose their redness, and appear of the ordinary colour
of the skin.  Their prominence is so inconsiderable that it can scarce-
ly be seen ; to the touch it  is always  sufficiently evident.   For  the
most part they are distinct, now and then in clusters.   After they have
remained for ten or twelve hours, or longer, a small vesicle appears on
the top of each, which  is at first of a whey colour, but soon after be-
comes white.*

  •  The matter of the pustules at first appearing of a whey colour and after-
wards white has given rise to a very improper division of the white miliary
eruption into pellucid and white.  See the 388th paragraph of Burserius's In-
stitut.  Med. Pract. where the reader  may also see some oUier divisions of
the miliary eruption which are equally useless.

grave; but it must be confessed that this like other modes of treatment has
often failed, and even where this treatment is resorted to, the sweating regi-
men combined with it, would certainly render the practice safer.
  We should always suspect, when an over dose of medicine is given without
producing its appropriate effect, that the medicine is not adapted to the case,
and that sometliing else should be done to favour its operation, rather than
to repeat the same remedy.                                    N. s, 
MILIARY FEVER.
221
  Such is the  appearance of the white miliary eruption, and the red
only differs  from it in the pustules  retaining their red colour, and the
matter formed in them being yellow.
  In two or three days the  vesicles break, if they have not been rub-
bed off, and in either case are succeeded by small crusts, which fall off
in scales.
  The miliary  eruption generally first appears  about the neck  and
breast, gradually spreading to the trunk and  extremities, but rarely
appearing on the face.  The white and red eruptions for the most part
appear separately ; sometimes they  are  intermixed.   In both, the
matter formed in the vesicles, has an offensive smell, and, it is said, a
very acrid taste.
  The miliary, like other symptomatic eruptions, often  appears repeat-
edly in the course of the disease, and it is not uncommon for one crop
immediately to succeed another for many days;  new pustules appear-
ing while the former advance to maturation and decline.
  We are assisted  in forming the prognosis in Synochus Miliaris, by
the appearances of the eruption.  The red generally indicates a mild-
er disease than the white; and it is frequently observed,  that the greater
the inflammation that attends the eruption, the better is the prognosis.*
Quarin,t however, remarks,  that both kinds of miliary eruption ap-
pearing at the same time, indicates a worse disease than either singly.
The same may  be  said of a very numerous eruption compared with a
scanty one.   The  eruption  being  steady is more favourable than  its
frequently disappearing and coming out again ;{  and  it is better that
when the places covered with the eruption should appear swelled and
stretched, than sunk and flaccid.
   The prominence of this eruption sufficiently distinguishes it from pe-
 techiae.   The circumstances which distinguish it from other eruptions
 will be pointed  out as we proceed in describing them.§

    Of the Symptoms which precede or attend the Miliary Eruption.

   It is not  uncommon  for the fever, a short time before  the  miliary
 eruption shews  itself, to suffer an*evident exacerbation, which appears

  * Mead's Monita et Prsecepta Medica.
   f De Febribus.            * Burserius.
   § The white miliary eruption has been termed purpura alba ; the red, pur-
 pura rubra. 
222
MILIARY  FEVER.
chiefly in an increase of temperature and restlessness.   The eruption
is generally preceded by depression of spirits, and a sense of tightness
about the praecordia, the breathing becoming laborious, and  being in-
terrupted with sighing or cough.*
  With  the increase of temperature, there is frequently a sense of
pricking or itching  in  the skin, which is also sometimes felt in the
bowels,! and is now and then accompanied with a degree of numbness
in the extremities, particularly in the fingers ;J  For sometime before
the eruption comes out,  the patient is generally bathed  in  a profuse
sweat of a sour, rank odour, during which the pulse is often contracted.
  It is  sometimes preceded by pains  of the head or internal ear, or
tinnitus aurium, and now and then by delirium ; sometimes by pains
in the back, limbs, and loins,§ or a peculiar sense of pungent heat re-
ferred to the back.   Sometimes the belly becomes swelled and tense.;
at other times  there  is a swelling and redness  of  the face,||  the eyes
appearing inflamed   or  watery.1T    The  internal fauces also are  fre-
quently inflamed, and there is  now  and then a considerable  flow ot
saliva.   In many cases it is preceded by aphthae,  (there is often, we
shall find, an evident connection between  these eruptions) and some-
times, though very rarely, by an epileptic fit.**
  Upon the whole, dejection of spirits and  anxiety, with  unusually fe-
tid sweats, are the most common forerunners of the miliary  eruption.
  Most of the foregoing symptoms  are relieved on its appearance.
The sweating, however,  if means are not used to check it, for the most
part continues, and then  fresh crops of the eruption will probably con-
tinue to come out for many days.
  The more severe  the preceding  symptoms, and particularly the
greater the debility  and  depression of spirits, the more unfavourable is
the  prognosis.   If the sweat is  moderate, and the respiration free, die
prognosis is generally good.  Itching, instead of the sense of pricking,
on the coming out of the  eruption, has been regarded as unfavourable.!!
  The miliary eruption  sometimes appears unattended by fever. Even
in this case it is often preceded  by restlessness, sickness, anxiety, and
a sense  of sinking ;   and accompanied by sweating, or a watery dis-
charge from  the bowels or kidneys, and sometimes by salivation-!}
  The red miliary eruption,  the rash as it is vulgarly termed, more
frequently appears unaccompanied by fever  than  the  white.   " The

  *  Quarin.          ~  Vogel.        $ Aliionius. Vogel.
  §  Quarin. Vogel.          fl Burserius.           T Quarm.
         ** Rur.eriu-        ft; Burseriufe.        l$Hoffmati. 
MILIARY FEVER.
223
*'miliary glands of the skin," Huxham remarks, " appear very turgid,
u and mimic a rash upon profuse sweating, even in the most healthy."


Of the Febrile States in which the Miliary Eruption most frequently ap
                              pears.

   This eruption is most apt  to  shew itself when  debility prevails.
That species of synochus, therefore,, of which typhus forms the princi-
pal part, is most frequently accompanied with it; and in the works of
those who treat of the miliary fever as a distinct disease, and conse-
quently endeavour to point out its characteristic symptoms, those are
enumerated which have been  mentioned as attending this species of
synochus.
   The  cold stage, it has been observed, is generally very evident, of-
ten attended with considerable langour and  depression of spirits, some-
times with syncope.   The pulse during the chills is for the most part
very small and weak ; after the heat is generally diffused, it becomes
stronger and fuller ; but never, it is observed, acquires a great degree
©f strength, and generally in  a few days  becomes small, soft,  and de-
pressed.  The various symptoms denoting much debility, such as tre-
mors,  cramps,  subsultus  tendinum, delirium, &e. enumerated among
the symptoms of typhus, have been regarded as characteristic of this
fever.  When we consider the nature of the fever, the irritation of the
eruption, and the profuse sweats which attend it, it will not appear sur-
prising that these symptoms very frequently accompany the Synochus
Miliaris.
   Such is the disease which has been termed the Miliary Fever.   In
what does  it differ from other cases of typhus, except in the eruption
and  certain symptoms connected writh it, which,  as will  be evident in
considering its causes, are accidental appearances,  that may often be
prevented by a proper mode of treatment ?
   Some allege that  the  miliary eruption generally  shews itself on a
certain day of the fever, demonstrating  an  essential connection be-
tween the  fever and eruption.  Allionius says that  it appears on the
third or fourth day; Huxham says it appears on the seventh, ninth, or
eleventh ;  and  other  days are  mentioned  by other  writers ; from
which it is sufficiently evident, and practitioners indeed now admit,
that it may appear on any day ; it is not common,  however, for it to
appear before the third or  fourth day, probably because the debility
is seldom considerable before this period. 
224                    MILIARY FEVER.
    The foregoing observations apply chiefly to the white miliary erup-
 tion,  the form  in which it generally appears  in typhus.   The  red, I
 have bad occasion to observe, is a slighter affection, and often appears
 in synocha.   Even here, however, it is generally  attended with  op-
 pression and sinking of the spirits.
    The symptoms connected with the miliary eruption for the most
 part suffer a remission on its appearance, and in some instances there
 is also an abatement  of the febrile symptoms ;*  in general, however,
 the eruption, and the sweats and other symptoms that  attend it, only
 increase the debility, and we shall find that they are always, if possi-
 ble, to be prevented.  An increase of the symptoms of debility, on the
 coming out of the eruption, affords an  unfavourable prognosis ; but  the
 prognosis is still worse, if such symptoms shew themselves  or suffer a
 considerable exacerbation on its sudden disappearance.  When in this
 case, excessive anxiety and dejection, obstinate vomiting, delirium or
 convulsions supervene,  the danger is very great.
   Dropsical swellings of the legs and sometimes of the belly are apt to
 supervene on miliary fevers, and are regarded by some as part of the
 disease; they seem, however,  merely the  consequence of debility.
 For the most part as the patient gains strength,  the  swellings disap-
 pear without the assistance  of medicine, especially if they are merely
 anasarcous.  In some cases they are suddenly removed by a spontane-
 ous flow of sweat.   We shall soon have occasion  to consider a species
 of  eruptive fever, the scarlatina, almost uniformly succeeded by ana-
 sarcous swellings.
   From the great debility which prevails in the synochus miliaris, it is
 liable to be followed by the various consequences of protracted fevers.
 See the observations of Vogel and Burserius on the consequences of the
 miliary fever.

              2. Of the Causes of the Miliary Fever.

   A fever, says  Allionius,! which may be considered  a new disease
 from the miliary eruption which attends it, in which, if the eruption

  * Quarin observes, that it is chiefly in catarrhal  and rheumatic fevers that
the miliary eruption brings relief.  Sweats, however induced, more frequent-
ly bring relief in these, than in most other febrile diseases.  But as Plane-
hon (in his  Dissertation sur la Fievre Miliaire) justly remarks, when this
eruption does relieve the fevtr, the favourable change is not to  be depended
on, the symptoms often retui' ing widi equal and sometimes greater violence
  t See his Tractatio de Miliarium Origine, &c. 
MILIARY FEVERS.
225
 subsides, the patient fills into convulsions and soon expires,  appeared
 at Leipsic  about  the middle of the last century.   And the generality
 of writers agree with Allionius, that the miliary fever which appeared
 at this place in the years 1652, 1653, and  1654, is the  first fever of
 this kind of which we  have any account.
   The eruption first shewed  itself in the fever which frequently  at-
 tacks women after  delivery, termed puerperal ;  but soon spread, and
 appeared in various fevers, attacking persons of  every age and  sex.
 " Ita ut,"  says Allionius, " pueros cum  juvenibus, adultos cum seni-
 " bus, viros cum fceminis, aggrediretur."
   Many, however,  doubt of the miliary  fever having  appeared at this
 period for the first time.   " It  seems to me  very  improbable,"  Dr.
 Cullen observes,  "  that this should have been really  a  new  disease
 '* when it  was first considered as such ;  there appeared  to me very
 rt clear traces of  it  in  authors who wrote long before  that period, and
 " if there  were  not, we  know that the descriptions of the ancients
 " were inaccurate and imperfect, particularly with respect to cutane-
 " ous affections ;  whilst we know also very  well  that those  affections
 " which  usually are symptomatic, were commonly neglected or con-
 " founded together under a general appellation." Burserius thinks,  that
 the miliary eruption has been confounded with petechiae by some of
 the older writers ;  and Mr. White, in his Treatise on Pregnant and
 Lying-in Women, observes, that it is highly probable, that the milia-
 ry fever  has occurred to practitioners ever since  the days of Hippo-
 crates.   The reader will find,  in Planchon's Treatise sur la Fievre
 Miliaire, quotations from Hippocrates and iEtius,  to prove that the mi-
 liary fever was known to these  authors.   This dispute is  of  little mo-
 ment.
  In speaking of the causes of  synochus miliaris, we  must  take  the
 same view of the disease as in enumerating its  symptoms, endeavour-
 ing to trace the causes, not of the fever, but  of the eruption which at-
 tends it.
  There is no  symptom which more constantly  attends the miliary
eruption  than sweating, and the causes of both are often the  same ;
 thus it frequently happens in the same epidemic,  that in those treated
 with the  cool regimen  there is  neither sweat nor eruption ;  while in
 others, treated with the hot regimen, sweats are  forced out, and  the
eruption  soon makes its appearance.   Sweating, indeed, is so frequent-
 ly accompanied with this eruption  in  febrile diseases, that Dr. Cullen
 regards it merely as a disease of the skin, produced by heat and forc-
                               20 
526                    MILIARY FEVER.
ed sweats*  and little connected with the general affection of the sys-
tem ;  this opinion he thinks is further confirmed by the eruption never
appearing on the face, by  its appearing chiefly on those parts  which
are most covered, and by its being possible to bring it out on particu-
lar parts by external applications.
   It is certain, however, that in some fevers, as in the puerperal, it is
more  frequent than in others.
   Dr. Cullen remarks, " that of persons sweating under febrile diseas-
•* es, those are especially liable  to the miliary eruption who have been
" previously weakened by large evacuations, particularly of blood."
Quarin and others  make the same observation ; thus it  probably is
that lying-in women are more frequently attacked by it than others.
Those also who have laboured under frequent and copious menstrua-
tion, or a long continued fluor albus, are frequently subjects of  it.  It
has often been remarked, that it is apt to appear in fevers arising from
wounds, where the loss  of blood has been considerable.
   Every debilitating cause, as well as loss of blood, predisposes  to it.
In  lying-in wromen, it  often makes its appearance  before delivery.
The interruption as well as excess of any habitual discharge, such as
that of the menses, even habitual costiveness, is ranked among its caus-
es.  A bad diet, from a deficiency either in quantity  or quality, or
intemperance,  predisposes to it; to this cause,  and also to excessive
venery,  it is attributed both by Hoffman and Planchon ; even the de-
bility produced  by a damp atmosphere seems sufficient to give the pre-
disposition.  Quarin says, it is often epidemic in marshy countries.
   Persons of a lax habit of body, and sanguine temperament are most
subject to it; children more than adults ;  old people  than such as are
in  the vigour of life; women  more than men ;  and those who have
formerly laboured under the disease, are more subject to it than others.
   Though the causes of the miliary fever, Hoffman observes, have al-
ways  existed, the  disease  itself has made its appearance  only  of late
years, since the introduction of tea and coffee, and it is chiefly among
the drinkers of these that miliary fevers are frequent.
   A variety of  observations  point out a  striking connection between
the appearance of the miliary eruption and the state of the primae vitsp.
Van Swieten, Quarin, Planchon, Zimmerman, and others have  observ-

   * Even in the  writings of foreign authors, who generally contend for the
miliaria being an exanthema, and particularly in those of Vogel and Quarin,
there is sufficient proof of the miliary eruption being generally the conse-
quence of forcing out sweats by warmth and stimulating medicines. 
MILIARY FEVER.
227
ed, that it is  occasioned  by an accumulation of irritating matter in
the stomach.  On the offending matter being discharged, the eruption
has beeu known immediately to disappear.   We shall find other erup-
 tions, particularly the erysipelatous, equally connected with the state
of the primae vitae.
   All these, and other debilitating powers,  should  be regarded  per-
haps, chiefly as predisposing causes, while the  hot  regimen  is to be
looked upon as the principal exciting cause of this eruption.   At least,
we shall not err much by forming this opinion,  since it is found, that
 whatever the  state of the  patient may be, the miliary eruptions is ve-
 ry generally prevented by cool drink, and exposure to cool  air.   To
 this,  however, there are some exceptions.  In 1758, Quarin observes,
 this eruption  was epidemic.  Almost  all that  were  confined  to bed
 were seized with it,  although the primae vitae  were cleared, the pa-
 tients kept cool, and all heating medicines avoided.   Van Swieten and
 others observe that the miliary eruption is sometimes epidemic, inde-
 pendently of  any particular mode of treatment, and both Stork* and
 Planchon! mention instances where it occurred after every precaution
 had been used.
   Moist variable  weather is most favourable  to its  appearance.  It
 is most frequent in spring, and more frequent in autumn than in  win-
 ter or summer ; winter is least favourable to its appearance.
   The reader will find a variety of causes of miliary fever enumera-
 ted by authors, particularly by Burserius in the 2d vol. of his Institut.
 Med. Pract.   But these  are rather the causes  of the fevers  in which
 this  eruption most frequently  appears, than  of the eruption itself;
 such authors  regarding  the miliary fever as an idiopathic disease.
   Some dispute exists  concerning the contagious nature of the miliary
 fever, some asserting that it is, others  that it is  not, contagious.  The
 dispute could only have arisen from its being regarded as an idiopathic
 disease.  When it is known that the miliary eruption is an accidental
 appearance in all kinds of fever, the cause of this difference inopinionj
 and the means of reconciling it, are sufficiently apparent.

              3.  Of the Treatment of the Miliary Fever.

   As what has been termed the miliary  fever fs nothing more than the
 miliary eruption with the peculiar symptoms  that always  attend  it,
 supervening on continued fever, and as the treatment of continued fe-

               • Anni Medici.         f Sur ia Ficv  Mi*- 
228
MILIARY FEVER.
 ver has already been considered, we have only at present to point out
 how far this treatment is influenced by the appearance of the  miliary
 eruption.
   When a sweat comes on in any continued fever,  especially where
 the debility is considerable, without relieving the symptoms, we have
 reaspn to fear that its continuance, among other bad effects, will induce
 this eruption, with the anxiety,  oppression,  &c. that generally attend
 it.
   Concerning the propriety of checking such sweats there can be no
 doubt.  A dread of this practice, especially where there is particular
 reason to expect the miliary eruption, is expressed in the writings of a
 variety of authors.  It seems, however, to have arisen, less from observ-
 ing its bad effects, than from certain opinions respecting the eruption
 which, according to these writers, is the means employed by nature to
 throw out the morbifio  matter, from which  they suppose  the fever tt,
 arise.  The effects of the practice indeed fully warrant tie assertion
 just made.
   The most effectual means of checking sweat is the application of
 cold, and in many cases it is the  best.   "But the employment of it re*
 quires some caution.
   If the fever be typhus, in uhich however, the increase of the tem-
 perature is considerable aud steady, the application of  cold may be
 free.   The  same  may be said  of synocha, if we  have no reason to
 dread a tendency to local inflammation.  But in  the synocha, sweats
 rarely occur without relieving  the symptoms.  The application of
 cold requires much caution in the exquisite')- formed typhus,  where
 the temperature is little, if at all, above the healthy degree.  Here we
 must trust chiefly to the other means of invigorating the system, which
 have been  pointed  out,  Astringents are particularly indicated ; the
 bark, sulphuric acid and alum.
  When the propriety of applying cold  to check the sweating is de-
 termined on, it should be done  gradually.   The air of the bed-room
 should be cooled, part of the bed-clothes   removed, the patient de-
 sired to lie with his arms bare, and allowed cold drink.
   We ought at the same time to employ gentle cathartics.  An equal
 prejudice has prevailed  against this practice, and for similaf  reasons
it  is equally groundless.  It appears from the foregoing observations
respecting the connection between the state of the primae viee and the
miliary eruption, that  wherever  we have reason to suspect the pre'
«nce of irritating matter in  these cavities,  much  is to  be expected 
MILIARY FEVER.                    229
from removing it.   We should inquire,  therefore, whether the patient
feels a sense of weight about the stomach, whether the breath be offen-
sive, whether  he is troubled with the head-ach, eructations, or nausea,
swelling of the belly, or griping pains.
   When the stomach is  oppressed, Quarin  recommends diluents, and
if these  fail,  an  emetic.  Much dilution, however, is evidently im-
proper where we wish to avoid sweats ;* and emetics  as doubly hurt-
ful by promoting perspiration and increasing debility, should be avoid-
ed, except where the eruption is evidently caused by  the contents of
die stomach.
   When it happens, that notwithstanding our endeavours, the sweat
.continues, and the miliary eruption appears, or when the  eruption has
been induced by improper treatment,  what mode of practice is to be
adopted ?
   " It has been an unhappy opinion with most physicians," says Dr.
" Cullen, " that eruptive diseases were  ready to be hurt by cold, and
" that it was, therefore, necessary to cover up the body very closely,
'; so as thereby to increase the external heat.  We now know that it its
'• a mistaken opinion, that increasing the external  heat of the body is
'• generally mischievous, and that several eruptions not only admit but
>; require the  admission of cool air.  We are now persuaded,  that the
'' practice which formerly prevailed in the case of miliary eruptions
'• of covering the body close, and both by external means and internal
 ' remedies encouraging the sweating which accompanies this eruption,
■' was  highly pernicious, and  commouly fatal.  I am, therefore,  of
" opinion, even when a miliary eruption has appeared, that in all cases
" where the sweating is  not manifestly critical, we should employ all
'*■ the  several means  of stopping it that are mentioned above,  and I
•' have sometimes bad occasion to observe,  that even the  administra-
>' tion of cool air was safe and useful."
   From the observations of other  writers we might be  inclined to in-
fer,  that however uniformly  safe  the application of cold previous to the
appearance of the eruption, it is a more doubtful  practice while the
eruption is present.  Cases are recorded in which it did harm.!

  * Hoffman cautions against the  use of warm diluting liquors, unless the
eruption has been repelled.

  j The reader will find cases  in which this eruption  was repelled, and an
alarming train of symptoms induced by exposure to cold, mentioned by Hoff-
man and others. 
£30
MILIARY FEVER.
  But in these, the application of cold was unguarded, and the state of
the patient such that sudden exposure to cold might  have induced the
same  train of symptoms, had  there been no eruption.  Unless  the
temperature is steadily above the healthy degree, any sudden or con-
siderable exposure to cold is always improper.  Even those who have
seen the eruption repelled by  cold, warn us against the  more danger-
ous extreme of heat ;  for while an unguarded application of cold now
and then proves hurtful, keeping the patient warm never fails to be so.
  While the old practitioners  oppressed the patient with bed-clothes,
they were not aware that the eruption  may be repelled by whatever
debilitates, and that much heat may have this effect,  as well as im-
prudent exposure to cold.   There is reason to believe indeed, that the
latter cause often produced the effect  in consequence of the previous
application of the former.  The retrocession  of  the  eruption rarely
happens when the cold regimen has been employed from the beginning
of the disease.   Delirium, subsultus tendinum, dyspnoea, anxiety, con-
vulsions and often death, says Burserius, is  the consequence of  repel-
ling the miliary eruption, and this may be done, he adds,  by too much
heat, or too free  an exposure to cold, by keeping the patient too long in
the erect posture, by violent affections of the mind, particularly by an-
ger, terror, or grief.   There is no  eruption,  according to Burserius,
which is so readily repelled as the miliary.   The same remark is
made by Quarin and others.  The latter thinks that the retrocession
is the  more  dangerous the more copious the eruption.   The various
symptoms of debility  which attend  it, and which have been errone-
ously  regarded as wholly arising from  it, in many  cases precede it*
It is in the  typhus gravior where the debility is great, that the retroces-
sion is most  common, and  attended with the worst symptoms.   See
what is said of the doctrine of repelled  eruption in speaking of ..the
treatment of the synochus aphthosus.
  Hoffman and Allionius forbid the use of acids in  the miliary fever,
for which the former has been justly censured by Planchon and others.
It is the worst of prejudices, says Quarin, which has  instilled itself into
the minds of some practitioners, that because  the sweat in  miliary fe-
vers is acid, absorbents should be employed, and acids of every kind
avoided.
   It seems to be the  same hypothesis  that led to  the exhibition of al-

  • See the observations of Planchon and others.  Subsultus tendinum, syn-
cope, convulsions, delirium, 8tc. Planchon observes, often shew them-elves a
short time before the eruption recedes. 
MILIARY FEVER.                    231
kalis in the  miliary fever.*  The  ammonia is that  which has been
most employed, and is often serviceable when it does  not increase the
perspiration ;  but its good effects are to be attributed to its cordial, not
its alkaline property.
  With regard to saffron, castor, elder-flowers, milfoil, and  many oth-
er such medicines, much extolled in miliary fever, they seem to be of
little or no use, and as they tend to excite disgust and oppress the sto-
mach, ought to be avoided.
  When the miliary eruption brings no relief to the febrile symptoms,
it may be regarded as a new disease,  which combines its  influence
with that  the patient previously laboured under to reduce his strength.
Its  appearance in typhus ,  therefore, is an additional argument for a
strict adherence to the tonic plan ;  the  irritation  of the miliary erup-
tion, indeed, and the debilitating sweats which attend it,  will even at
an early period of fever induce symptoms  of typhus.  Opium, from
its tendency to promote perspiration, should, as  far  as the symptoms
admit of  it, be avoided.  Tralles,  in his  work on opium,  alleges that
the miliary eruption may often be induced by the use  of this.medicine.
   As  the appearance of miliary eruption in continued fever  renders
the tonic  plan more necessary, it follows as a consequence, that it ren-
ders  the  opposite plan more precarious.  The bad effects of blood-
letting, in the miliary fever have often been observed ;  and it is rank-
ed by most writers among the principal causes of  retrocession.
   We are not, however, to adopt  the  prejudices  of those who forbid
blood-letting  in  all cases where the miliary eruption appears.   It  is
determined by experience, says  Burserius, that if while the miliary
eruption is  present, an inflammation of the viscera be feared, or if the
fever be very vehement, a large blood-letting may be employed with-
out repelling the eruption.   Quarin and others make similar observa-
tions.  Blood-letting,  says Quarin, is particularly necessary in the
miliary fever, when it has  arisen from the abuse 'of spirituous liquors,
or the suppression of the lochia.
   In considering the treatment of the synochus miliaris, I  have taken
no notice of blisters,  which have been warmly  recommended in this
fever, as there is nothing to be added on this part of the subject to  what
was said in  speaking of the treatment in the synochus  simplex.  It ap-
pears from what was then said, that their cordial property, for which
they seem chiefly to have been recommended in the  miliary fever,  is
very inconsiderable.

   * See this part of the subject considered rtt length by Biu'spri'Ts. 
%3%
APHTHOUS FEVER'.
  The remedies which have been employed, when  a retrocesssron of
the eruption, attended by various symptoms of debility,  happens, are
the same as those recommended in similar circumstances in other erup-
tive fevers, and which we shall soon have occasion to consider more at
length.   In the disease before us,  musk and camphire are particularly
recommended where convultions supervene ; opium, blisters, frictions
of the skin, and tonic medicines in all cases.  But our principal  view
should be to bring out and support a sweat, and if  the retrocession be
followed by  any considerable evacuation, we must be careful not to
check it too suddenly.   If a sudden and copious evacuation follows the
retrocession of the eruption, Burserius observes, such  as much sweating
or copious diarrhtea, the bad effects are  prevented.   Different  means,
it is evident, will be proper in different cases, according to the cause of
the retrocession.   See what is said above of the  causes of the retroces-
sion.

                            SECT. Ill-

                    Of the Aphthous  Feveri


   The Aphthous  Fever is defined by Dr. Cullen,
   •« Synochus.  Lingua tumidiuscula, linguae et faucium color purpu-
* rascens ; escbara in faucibus, et ad linguae  margines, primum com-
" parentes, os internum totum  demum  occupantes,  albidaj, aliquando
'• discretae, saepe  coalescentes, abrasae citorenascentes, et incerto tem-
M pore manentes."
   This  definition we  shall  find,  does not include all the affections
which have been known by the name of  aphthae ; but it describes with
sufficient accuracy that  to which, by  the general consent of physi-
cians, the term is now confined.
   It  appears  from  what was  said  in the  Introduction, that the aph-
 thous fever is to be  regarded  in the same light as the miliary, being
 nothing more than the common synochus accompanied with an erup-
 tion  of aphthae, and  the peculiar symptoms that attend it.
   In detailing the symptoms of the synochus  aphthosus, I shall pursue
 the same method as  in the  synochus miliaris;  in the first place giving
 an account of the  eruption, then  enumerating the symptoms which
 precede or attend it, and lastly pointing out the febrile states in which
 it most frequently appears1." 
APHTHOUS FEVER.                    23S
            J. Of the Symptoms of the Aphthous Fever,


                    Oftlie Aphthous Eruption.


  The aptha infantum* is  the same eruption which occasionally ap-
pears in synochus ; and whether it attacks the  infant or the adult, and
whether it appears with or  without fever, it is attended with the same
train of symptoms.  Asa symptom of synochus it has not demanded
so much attention as when it appears as an idiopathic affection, which
it seldom does in  adults.   In the writings of those  who treat of the
aphthae infantum, therefore, we find the  best  account of this erup-
tion.  I shall describe the idiopathic affection  as it appears in  chil-
dren, and then point out  the symptoms which attend this eruption
when it shews itself in synochus.
  The local affection  of  the  fauces is often the first symptom of the
aphthae  infantum ; certain symptoms,  however, sometimes precede it
even in the youngest children.  From appearing in health they  very
suddenly shew signs of uneasiness ; they either refuse  the breast, or
if they receive the nipple, do not suck ;  they appear restless and  anx-
ious, cry, sleep less than usual, and the sleep they have  is disturbed.
They become pale  and emaciated, and are often troubled  with hic-
cup, and diarrhoea, in which the  stools are acrid and fetid.   Cur-
dled milk is  sometimes  past by stool, and bile is  vomited.!  If the
child is not very young, the pulse is sometimes considerably affected,
becoming more frequent than in health, the temperature is increased,
and a sleepiness sometimes  approaching to coma supervenes.  In gen-
eral, however, in children, the affection of the mouth and fauces is the
first symptom, they become redder  than natural, the tongue swells and
becomes rough, and the nurse perceives an increase of temperature in
the child's mouth.   Sometimes the mouth becomes pale instead of
red, which generally presages a worse form of the disease.
  Soon  after these appearances, the aphthae begin  to shew themselves
in the internal fauces, and about the edges of the  tongue.  " Pustulas

    • The thrush.
    f Arnemann's Commentatio de Aphthis
                               30 
234
APHTHOUS  FEVER.
" sunt albicantes," says Ketelaer,* who saw as many cases of this dis-
ease as perhaps any other physician, " summis ac  internis oris, et
" interdum vicinis, respirationis partibus  insidentes."   The true aph-
thae are described  in nearly the same manner by most of the authors
who practised in those countries where the disease is common.   Arm-
strong compares their first  appearance to  that of broken curds.   Even
on their first coming out, aphthae sometimes so run together that they
look like a white compact  crust, covering a great part of the internal
fauces, and as it were, arising from the oesophagus.!
   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 and degree of conflu-
ence are particularly to be attended to,  as the prognosis rests much
upon them.         x
   In determining  the number of aphthae we  may sometimes  be  de-
ceived, since  they are often numerous on  the  deeper seated parts,
while they are  but thinly  scattered on the tongue and other parts of
the mouth.];  A person  acquainted  with the nature  of the disease,
however, can hardly be mistaken, for wherever the aphthae are numer-
ous in internal parts, sickness, hiccup, oppression, and generally pain
referred to the  stomach, with much debility, point  out the danger,
which  when these  symptoms occur, is always urgent, whatever be the
state of the fauces.  The presence of this variety of the disease,  it is
evident, is not  so easily  ascertained in  children as  in adults.   But
whatever  be the attending symptoms, when  the crust, mentioned by
Boerhaave, appears to ascend from the oesophagus, it  is probable  that
the more  internal parts are considerably affected, and the prognosis,
therefore, is unfavourable.  Nor is the case more favourable when the
whole mouth appears covered with a crust, and becomes dry and even
rigid, the process which ought to throw off this crust  being absent or
extremely languid.  If  this state continues long, the power of swal-
lowing is  lost, and the danger becomes very urgent.   When the crust
spreads to the fauces, it sometimes occasions suffocation.

  * Ketelaer's Treatise de Aphthis Nostratibus.

  \ Aph. Boerhaav. 984.  It is in this case that the symptoms abovemention-
ed most frequently precede the  appearance of aphthx, they often arise from
the disease first attacking the oesophagus.

  $ See Van Swieten's Commentaria in Aph. Boerhaavii. 
APHTHOUS  FEVER.
2oo
  The colour of the aphthae has occasioned some dispute, which seems
to have arisen from the same aphthae changing their colour, and becom-
ing darker the longer they adhere ;  for  there seem to be  no well au-
thenticated cases  in which the  aphthae on their first appearance  were
of a dark brown or black colour, as some writers have alledged.  Boer-
haave indeed observes, that the colour of aphthae is various, being eith-
er of a pellucid or shining white, like pearls, or of an opaque white or
yellow colour, livid, or even black.*  But  he speaks not of the differ-
ence of aphthae on their coming out, but  of the appearance of the  same
aphthae at different periods ;  for his commentator Van Swieten, Arne-
mann, Ketelaer, Armstrong, and others,  who  had extensive opportuni-
ties of seeing this disease, declare  that  they  never saw aphthae dark
red, brown,  or black on their  first  appearance.!   We, therefore, see
the propriety of Dr. Cullen's making whiteness one of the distinguish-
ing marks of this eruption.  Aphthae, on their first appearance, howev-
er, sometimes assume a light brown or  ash colour.   Arneraann terms
them " fiavaj vel fuscae cineritiae."
   The white pellucid aphthae,  like  pearls, are always the safest,^ and
when  they are few  in number the disease is scarcely attended with
any danger.   When aphthae appear from  the first of a brownish col-
our, the prognosis is bad.   Van Swieten says, that he has uniformly
found  such cases fatal.  The  prognosis is  between these extremes,
when the aphthae 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 urgent ; they are  then to be regarded  as
small gangrenous sloughs, which often reduce the whole internal fauces
to  a state of mortification.
    It has just been observed that it is only after the aphthae have remain-
 ed  for a considerable time   that they become  brown  or black ;
hence the time they adhere becomes a point of consequence in forming
the prognosis ; but when*they begin to fall, we shall often  be deceiv-
 ed if we  look for the immediate termination  of the disease since  it fre-

   * Aph. 985.
   f « Non enim verisimile est,"  Ketelaer observes, " ut  in rebus sibi adeo
" vicinis, et cognatis, fors tantum polleat,  cum albae plus millies nobis ob-
«latae  sint ut rubrarum, nigrarurave, ne  umbra: quidem unquam apparu-
 " erint."
   * When they appear of an opaque  white, like lard, they are less favour-
 able. 
236"                  APHTHOUS FEVER.

quently happens,  that a fresh crop succeeds  that which has  fallen or
been  rubbed of.
   If this crop appears  more numerous and crowded together than the
first, the prognosis is worse than when the aphthae appear fewer and
more  distinct.   But upon the whole one crop falling off and another ap-
pearing affords a more favourable prognosis, than the same  crop contin-
uing.
   Aphthae sometimes fall off in the space of ten or  twelve  hours, at
other times  they remain attached  for many days ; nor do they- fall
from the whole fauces at the same time,  nor always  first from anyone
part, but in  this respect they a^e as variable as in their duration.
   Although  when the disease  continues  for a- considerable  time, re-
peated crops of aphthae afford  a more favourable  prognosis  than the
same  crop remaining throughout the disease ;  yet the prognosis is still
better, when the aphthae fall early, as in  the former case,  and are not
succeeded by a fresh crop or only by a very scanty one ;  it is, there-
fore, a matter of much consequence in forming the prognosis to be  able
to foresee whether or not a fresh  crop of  aphthae is about to come  out;
and this in some measure may be learnt from the appearance of the pla-
ces which the former occupied.
   If they be clean, red, and moist, the aphthae either do not re-appear
or only re-appear in a small  number;  but if they  appear  foul and
parched, we may certainly expect a renewal of the eruption,  and in
such cases,  the separation and reproduction of the aphthae often  take
place a great number of times before the final  solution of the disease;
Both Ketelaer and Van Swieten observed this process repeated to the
sixth, seventh or eighth time.  Upon the whole, however frequently
the aphthae return, those which fall off the soonest are the safest.
   There are two seemingly opposite states, which are perhaps equally
dangerous.  The one, when the new crop supervenes before the old crop
is  thrown off;  this not only gives rise to a great number of  aphthae
adhering at the same time, but  also shews that they  have little tenden-
cy to separate.  The other, and no less dangerous case, when the first
crop falls off, and from  the appearance of the fauces we are led to ex-
pect another, which, however, does not  come out, or at least, is delay-
ed for  some days.  If, under these circumstances much anxiety, op-
pression, and other marks of debility, or  a degree of coma supervene,
the danger is very great.  The re-appcarance of the aphthae is gener-
ally attended with relief. 
APHTHOUS  FEVER.
237
    "In the most favourable cases then, the  aphthae appear of a white
  pearly colour, fall off early, leaving the places  they occupied clean,
  red, and moist;  and upon the separation taking place, all the  symp.
, toms begin  to abate, and in a short time wholly disappear.  On the
  other hand, the more the aphthae assume a brownish 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  anoth-
  er, or the greater the symptoms of debility, or the  coma when a se-
  cond crop does not make its appearance, the danger is  the more ur-
  gent.
    When they adhere very long the parts beneath are sometimes af-
  fected with gangrene,  which has  been known  to spread to the palate
  bones and other neighbouring parts.*
    We have hitherto considered the course  of  aphthae in the fauces,
  where it may be seen, but this disease sometimes extends to the more
  internal parts, and seems to run the same course in them.!
    The symptoms  which in infants, teach us that the disease is extend-
  ing along the alimentary canal, are, an appearance of much anxiety,
  oppression and debility, vomiting, hiccup,^ what Armstrong calls wa-
  tery gripes,§ and convulsions.   What places  the  matter beyond  a
  doubt is finding aphthae about the  time they are observed to separate
  in the fauces, thrown up from the  stomach, or passed by stool.-
    The quantity thrown out in both ways is often astonishing.   " Aph-
  " thas quando jam maturuerunt et excernuntur," says Ketelaer, "tan-
  " ta copia aliquos dies per os et per alvuin nonnunquam rejici,  ut ali-
  " quot pelves vel matulae congestas eas vix capiant."   Vogel makes a
  similar observation.  This is almost incredible, and denotes the worst
  form  of  the disease.  Were there nothing to destroy  the patient but
  'lie debility which so profuse an evacuation must occasion, he could

    * Aph. Boerhaavii, Aph. 939.
    -j- "Latins quandoque propagantur  aphthae," Lieutaud (Synopsis Med
  Pract.) observes, " quae oesophagum,  ventriculum et intestina  haud sine pre-
  " senti vitae discrimine nonnunquam invadunt."  The same observations have
  r» m made by all who have been conversant with this disease.
    \. Hiccup attends aphthae in the oesophagus or stomach.  See Van Swiet-
  cn's Commentary on the 659 Aph. of Boerhaave.
    § This is one of the most fatal symptoms, as we shall see more particular-
  ly in considering the treatment in this disease, which must if possible be so
  regulated > to prevent its appearance, 
238
APHTHOUS FEVER.
not long  support it.   The more aphthae spread downwards the worse
is the prognosis.
   They  have also been found in the trachea and bronchise.*  They
are known to have spread to them by the dyspnoea, and by their being
thrown up by coughing.   This is always attended with great danger,
the aphthae often accumulating in these passages, so as to occasion suf-
focation.
   When the  aphthae of the mouth fall off, a salivation sometimes en-
sues, in part at least caused by the extreme sensibility which frequent-
ly remains after the aphthae fall, the whole  internal  fauces appearing
as if the cuticle had been abraded.
   About the.same time also, a diarrhoea frequently supervenes, which
may either be produced by the affection of the stomach and the intes-
tines, if the disease has extended to them, or by the acrid matter  se-
creted in the mouth being swallowed.  These symptoms coming on to-
wards the termination  of the disease, when the patient is much debili-
tated, sometimes prove fatal after the attendants, and even the physi-
cians believe, the danger to be nearly passed.
   When such discharges are moderate, they  have been looked upon as
salutary.   This  opinion appears to have been  as much an inference
from hypothesis as from observation; it being a  favourite maxim with
the older physicians, that the dregs of the  fever,  as they were termed,
should be carried off by catharsis or venesection.  The patient indeed
often recovers about the time the salivation and diarrhoea appear.   But
at this period the aphthae fall, and the disease generally remits wheth-
er they  occur  or not.   A  moderate diarrticea at the time the aphthae
fall, however, is often useful, especially when the disease has spread to
the stomach and bowels ; the irritation of the  fallen  aphthae  in  the
bowels frequently occasioning a relapse.
   The taste  in general is nearly lost, and deglutition is often prevent-
ed while the aphthous  incrustation remains.!  After  it is separated, on
the contrary, the taste is so acute,  and the  whole  internal fauces  so
sensible, that the mildest food gives pain, and the patient is now, al-
though from a different cause, often as incapable of swallowing as  be-
fore.

   * Lieutaud's Synopsis Med. Pract. and other works on  this disease.

   | Aphthae, Vogel observes, often occasion suffocation merely by the swell-
ing of die fauces which attends them. 
APHTHOUS FEVER.                  239
  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 we recollect that the seat of aphthae is in the stomach and intes-
tines, as  well as in the fauces, we shall not be surprised at  the variety
of symptoms which attend, or follow them, denoting inflammation, ex-
coriation, or gangrene in the alimentary canal.
  The aphthae infantum are sometimes complicated with other diseas-
es most frequently with worms.
  Idiopathic aphthae rarely occur in adults.  Ketelaer indeed declares
that such cases are very  common; but it was observed in the Intro-
duction that Boerhaave had seen but two cases of this kind ;  that nei-
ther Van Swieten nor Cullen had seen one,  and  Arnemann very  few.
When aphthae appear as  an idiopathic  affection in  adults,  both  the
symptoms and treatment are the same as in the aphthae infantum.


       Of the Symptoms preceding and accompanying Aphthae.

   Although the diseases in  which the miliary eruption occurs, are no
less various  than those occasionally attended by aphthae, yet it appears
from what was said of the former eruption, that in whatever  disease it
appears, a certain train of symptoms generally attends it.   The same
is true of aphthae, although the accompanying symptoms in this instance
 fess uniformly attend.
   When aphthae begin in internal parts (which  is sometimes the case
 in  the symptomatic as well  as idiopathic aphthae) their appearance in
 the fauces is consequently preceded by  the various symptoms denoting
their presence in other parts of the alimentary canal.   In  this case the
 aphti.ae  appear to ascend  from the oesophagus in the same manner, as
 in  the worst cases of aphthae infantum.
    Anxiety, oppression, and debility, however,  often precede  the ap-
 pearance of aphthae, when they are about to make their first attack on
 the fauces,  and like most other eruptions, they are now and  then  pre-
 ceded by a degree of coma, less frequently  by delirium.
   But such symptoms frequently occur  in fevers where no aphthae are
 about to appear, and aphthae sometimes  appear without being preceded
 by these, or indeed any other symptoms, which can be supposed  par-
 ticularly connected with them ; so that although there are certain symp-
 toms which frequently precede this eruption, especially when it begin* 
240
APHTHOUS  FEVEH-.
 in internal parts, yet there are none from which we can  with much
 certainty predict its appearance.
   If, however, 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 aphthae.

     Of the Febrile States in which Aphtha most frequently appear.

   In some fevers there is a remarkable tendency to dysenteric affec-
 tions.  The symptoms of dystentery are afterwards to be considered ;
 it is sufficient at present to  observe, that in fevers  attended by much
 griping and  mucous  and bloody stools, the appearance of  aphthae is
 more frequent than  in most others.
   The first mention of aphthae which occurs in the works of Sydenham,
 is in his account  of the dysenteric fever of the years 1C69,  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 diarrhoeas checked by the unsea-
 sonable use of astringents.  Arnemann  makes the same observations.
   Sydenham further observes of this fever, that it was seldom or never
 attended with sweats, while in  fevers  which appeared at the same
 time, unaccompanied by aphthae, the sweats were often profuse.  This
 remark has been confirmed  by many succeeding observations.   Kete-
 laer even goes so far as to maintain, that it is the deficiency of perspi-
 ration that renders aphthae more frequent in cold than in warm climates;
 and in support of this opinion observes, that he has found aphthae ren-
 dered milder by a copious flow of sweat or urine, and that every thing
 tending to check these  discharges, increases the disease.
  Aphthae, notwithstanding,  are apt to appear in  the miliary  fever,
 where there is generally much sweating.*  Such is the similarity be-
 tween some  of the symptoms  attending aphthae, and the miliary erup-
 tion, that many believe these eruptions to arise from  the same  cause,!

  * Sydenham seldom met with aphthae  in fevers, except in the one just
 mentioned, remarkable for its dysenteric tendency ; and in that which  was
mentioned when speaking of  the synochus miliaris, in which he frequently
observed both eruptions.   See also AI'Bride's Introduction to the Theory and
Practice of Medicine.
  | " Materiem apbthosam et miliarem eamdem  esse judicabanV    Stall's
 Ratio Medendi. 
APHTHOUS FEVER.
241
and that when the one is prevented, the other, the general state of the
symptom remaining the same, is a necessary consequence.*
  We are well assured,  however,  that  the miliary eruption may be
prevented without inducing aphthae.  It will  appear more clearly
from  what will be  said of the causes of aphthae, that irritation of the
prims viae and skin tends, from a well known  sympathy which sub-
sists between the  different parts of the alimentary canal, and between
every  part of it and the skin, to give rise to this affection of the fau-
ces ;  and it is in this way that we may  account for aphthae being so
common in dysenteric fevers, and in those where the skin is unusually
parched, or covered with so irritating an eruption as the miliary.
  Aphthae are also apt to shew themselves where the debility is con-
siderable ;  and particularly where those symptoms, which have been
termed putrescent, make  their appearance-!
  Upon the whole  the characteristic  marks of  the  fevers  in which
aphthae most frequently appear  are morbid affections of the  skin and
bowels, and much debility.
  There are many other diseases  occasionally  attended  with this
eruption.   Among the principal of these are worms  and dysentery,
further denoting the tendency of  aphthae to accompany affections of
the alimentary canal ;J  and scurvy,  phthisis pulmonalis, and the last
stage  of all kinds of dropsy, further denoting their tendency to appear
in debilitated states of the system.
  Such are the aphthae properly so called, the symptoms which attend
them, and the fevers in which  they are  most apt  to  appear.   The
term aphthae, however, has been used  to express diseases very differ-
ent from that we  have been considering.   Most  of  these are local af-
fections of little consequence.
  The indefinite  use of the term aphthae is chiefly met with  in  the
works of the ancients, " Nam quae a priscis medicinae conditoribus aph-
" thae describuntur, adeo a nostris diversae sunt, ut toto coelo distent."§
Many doubt whether the true aphthae  wrere at   all known to the  an-
cients, and think that we  have borrowed a  term  from them for the

  * Van Swieten comment.

  ■j- Arnemann.

  i  Boerhaave remarks, that aphthae are apt to accompany  all visceral in-
flammations.

  § Ketelaer de Aphthis Nostratibus.
                                31 
242
APHTHOUS  FEVER.
 name of a disease, which was unknown in the times and  countries in
 which they practised.*  In the works of Hippocrates, Aretaeus, and
 Galen, we not only find, mentioned under this term, affections of the
 mouth different from aphthae, (small sores for instance on the inside of
 the cheeks  and about the lips)! but  also  similar eruptions 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 I have
 known several instances.
   The reader will  find an  account  of other eruptions termed aphthae
 by the ancients in the works of Fernelius,! and in those of Sennertus in
 his chapter  entitled, De Oris Inflammationibus et Ulceribus.

   2. Of the Causes of the Aphthous Fever.

   In the southern  parts of Europe aphthae are hardly known ; an ad-
 ditional reason for supposing that the ancients  were unacquainted with
 them;  while in  Holland and other northern countries there  are few
 diseases  more frequent.   Van Swieten observes, that while he prac-
 tised in bis native country  (Holland)  there were  few symptoms
 which  more frequently occurred  to him in acute diseases, whereas at
 Vienna he had not  met with  a single instance of aphthae in the space
 of five years.
   Aphthae  are most frequent in low marshy situations, and  in spring
 and autumn, particularly  in  the latter when it  is  unusually moist,
 and follows  a warm  and moist summer.   In short, cold and moisture
 are among the principal causes of this disease.   In Zealand, which
 lies lower than the surface of the sea, which  is prevented  from over-
 flowing it by raised banks, aphthae are so frequent, that Ketelaer calls
 them the endemic distemper of the island.

  * Sennertus asserts, on the authority of Aretaeus, that aphthae were common
 in Syria and Egypt;  but the disease mentioned by Aretaeus is not the same
with that now termed aphthae.

  ■j- Van Swieten describes a thrush of a peculiar kind, which he thinks the
 same with one of the species of aphdiae mentioned by Aretaeus.   It was epi-
demic in  Holland in the 18th year of the present century, appearing in small
ulcers about  the lips, cheeks, and gums, and when neglected on account of
the little uneasiness  it gave at first, quickly  eroding the parts it  occupied,
and forming putrid sores. This like the true aphthae, was most apt to attack
 children,  and when it appeared in adults was generally milder.
t Fernelii Universa Medicina. 
APHTHOUS FEVER.
243
  Although aphthae appear in people of all ages,  infants  and old peo-
ple  are most subject to them.   In many parts of  Holland, it is unusual
for a child to escape aphthae during the first month ;  but they are gen-
erally of so favourable a  kind, that medical assistance is not necessa-
ry.   In old people, in whom they appear during fevers, they are for
the most part of a bad kind, and often prove fatal.
  Although cold and moisture have a principal share in  producing the
disease, the operation of other causes  seems necessary, since the ma-
jority of children in most countries, however cold and damp, escape it.
  One of the chief  is derangement of the  primae vise.   Aphthae, we
have seen, are frequently preceded by symptoms indicating such de-
rangement, and in the treatment  we shall find that the state of the pri-
mae viae, more  than any other  cause, influences the course  of thi?
disease.
  It does not appear that derangement of these passages by its  lo-
cal irritation, first produces aphthae in the stomach and  bowels,  which
afterwards spread to the fauces ;  but from the  sympathy of parts, it
occasions their eruption in the fauces.
  The  various causes of derangement in the alimentary canal then are
to be regarded as occasional causes of aphthae, and it appears to be in
this way  that worms and aphthae are  so frequently combined.  Bad
milk  is a frequent  cause of this  disease ;  Lieutaud observes that a
drunken nurse often occasions aphthae in the infant, and the same may
be  said of whatever else disturbs the nurse's health, anxiety,  violent
passion, &.c.
   Some  suppose that  bad milk  may operate  in producing aphthae,
merely by irritating the fauces, and it would be difficult to ascertain
that aphthae proceed from the action of the milk on the stomach and in-
testines alone, although there are many reasons for  believing that this
 is  the  case.   There can be little doubt, however, that more pow-
erful irritations  of the  fauces are sometimes the  exciting cause of
 aphthae.*  By the irritation of  the primae viae,  also, we  may account
for an increased secretion  of bile occasioning this  disease.  Fernelius
 considers this as one of its most  frequent causes.  It has  not however,
 been generally so regarded ; an immoderate secretion of bile being
 rare in those countries where aphthae prevail.
   Such are the chief circumstances which have  been determined res-
 pecting the causes of the aphthae infantum ; yet in many cases they do

  * See the work of Sennertus, Dr. Home's Principia Medicins, &c 
244                  APHTHOUS  FEVER.
 not seem to proceed from any of those which have been  mentioned ;
 and in a still greater number of instances, those  causes are applied,
 without producing the disease.
   Still less is known respecting  the causes which give rise to aphthae
 in adults.  The presence  of the different diseases in which they oc-
 cur may doubtless be looked upon as the predisposing causes, and  in
 considering in what  kinds of fevers they most frequently appear, we
 found  certain circumstances, besides  affections  of the primae viae.
 namely, unusual deficiency of perspiration, the presence of the miliary
 eruption, and debility, favourable to their appearance.

            3. Of the Treatment of the Aphthous Fever.

   The treatment of the aphthae may be divided into two parts.  In the
 first, we shall consider the treatment of idiopathic aphthae ; and in the
 second, that of aphthae  sipervening on fever.  As for those cases  in
 which aphthae supervene on dropsy and other diseases,  unaccompanied
 by fever, their treatment is in no respect different from that of idiopa-
 thic aphthae, except as far  as the  treatment of the primary disease ren-
 ders it so.
  We are in the  first place then, to consider the treatment of indiopa-
 thic aphthae.
  The  first thing to be done is  to remove the remote  causes, if they
 still continue 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  examined, and if it be  found
 that no  attention  to diet renders it mild and sweet, it is necessary  to
 change  the nurse.
  Wherever  we suspect  the  disease to  have arisen from the ingesta,
 we must begin the treatment by clearing the primae viae.  Both emetics
 and cathartics are recommended  by those  who have  been  most con-
versant  with the disease.
  The  exhibition of the  latter requires caution.   They have  some-
times induced a fatal  hypercatharsis.   Children,  indeed, even where
no cathartic has been  given, are very  frequently  carried off by diar-
rhoea.
  This must not, however, deter us from employing gentle laxatives
at the commencement.  It is  in fact one of the best means of prevent-
ing  profuse purging, for the irritating matter,  when permitted to'accu-
mulate  in the alimentary canal, is often the means of inducing  it. 
APHTHOUS FEVER.
245
Those were the worst and  most dangerous cases, Ketelaer, from very
extensive experience observes, in which cathartics were not employed
in the beginning.
   Thus far then the practice seems well ascertained ; a gentle cathar-
thic is proper in all cases at the commencement, particularly where
there is reason to suspect irritating matter  in the alimentary canal.
Nor should the disease appearing in its mildest form, induce us to neg-
lect this caution.
   If  there be symptoms of acidity in the primae viae,  absorbents are
proper.  Magnesia forming with the acid generated in the bowels a
cathartic salt, answers a double purpose.   Dr. Aery, in the second vol-
ume of the Medical  Museum, says, that he has  almost  entirely laid
aside other remedies in this disease, confining himself to magnesia in
small doses; and with this practice for many years  he had lost only
one in thirty.   Dr.  Underwood also trusts chiefly  to  absorbents in
mild cases.*
   Should the purging  induced, shew  a tendency to become excessive,
which is always attended with danger, a gentle anodyne is proper  af-
ter the offending matter is evacuated.
   It sometimes, though rarely happens, that symptoms denoting  a ten-
dency to visceral inflammations shew themselves.   It is  then better to
permit the purging to continue  till the symptoms are relieved,  and at
all events not to check it  by opiates.   Children are much less subject
than adults to  such inflammations.   The chief danger.in the aphthae
infantum arises from debility.
   When there  is no inflammatory tendency, opiates may be  used to
procure sleep, proper  means being employed to prevent constipation.
   But  the practice  which is proper at the commencement of the dis-
ease is by no means  suited to the advanced stage of it.   If the disease
has been properly treated from the beginning, there cannot at this pe-
riod be any occasion for catbarthics.  But even in those instances, in
wliich proper evacuations have been omitted till the disease is far ad-
vanced and the stomach and bowels are loaded with irritating matter,
 we are not warranted to recommend them.   They have often induced
 a fatal hypercatharsis.   The faeces may be evacuated by clysters, but
 it seems dangerous to go further.
    Arnemann proposes to give cathartics in small doses till the desired
 effect is produced, in order to guard against hypercatharsis ; but most
* Dr. Underwood on the Diseases of Children. 
246
APHTHOUS FEVER.
writers are of opinion 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 observa-
tions on the use of cathartics.  " Eaebem rationes etiam contra purga-
" tionem earn militant, quae cacochymiae propria et accommadata, ab
c< universo corpore et ulterioribus viis, noxios quosque humores trahit.
" Ea hie funestissima est, et intra  paucas horas hypercatharsi finern
" vitse plerumque facit."  But there is another kind of  purging,  he
adds, if so it can be called, which may be employed with propriety,
as it only evacuates the faeces,  that induced by clysters.   These, he
continues, are excellently suited to  this disease, in  which costiveness
is frequent; they not only employ the intestines, thus removing a nox-
ious irritation ;  but they often relieve oppression, and what is of equal
consequence, restore the other excretions, particularly those of the skin
and kidneys, and tend to loosen the aphthae.
  The indiscriminate use even  of clysters in this disease, however, as
indeed Ketelaer in other passages admits, seems often dangerous ; they
have the same tendency with  cathartics, though in a less degree,  and
should never perhaps be employed at this  period,  when the  body is
moderately open ; unless the  disease be mild  and the  inflammatory
tendency evident.  Hypercatharsis is chiefly to be dreaded when the
disease has spread to the stomach and bowels.
   Reflecting on what has been said, we readily perceive the effects to
be  wished for, and those to be dreaded from clysters.  By an attention
to these, we determine what their composition ought to be.  The first
thing we have in view is to evacuate the faeces with as little irritation
as possible, they must therefore be mild, they should consist chiefly of
water gruel or some other mucilaginous decoction.   Some have recom-
mended the addition  of a  cathartic, but this should only be had re-
course to, When milder clysters are found  ineffectual.  We have also
 in  view to relax the excretories.  On this account, the quantity in-
jected should be inconsiderable.  When the aphthae spread to the great
 intestines, clysters serve a further use, in lubricating and softening the
 parts to which they are immediately applied, and thus  disposing the
 aphthae to fall.   In short, they produce effects similar to those of gar-
 gles in the fauces,  and should, therefore, in these cases be gently deter-
 gent as well as mucilaginous.   When such clysters are  found to pro-
 duce but little evacuation,  which is  often the  f?.?e, they may be fre-
 quently repeated. 
                      APHTHOUS FEVER.                  247

  That I may give at one view, what is to be said of the employment
of catliartics in the aphthae infantum, which forms a principal part  of
the treatment, it may be observed, that there is  a period which suc-
ceeds that I am speaking  of, in which their exhibition again becomes
proper.
  We must, says Arnemann, be careful not to exhibit purgatives while
the aphthous  crust still adheres to the  intestines and their surface is
raw and excoriated ; but  they are necessary in the beginning of the
disease, and in its  decline, when the aphthae begin to fall, and are pas-
sed by stool.   They are  then serviceable  by  expelling the  fallen
aphthae which,  when  allowed to remain, soon begin to  corrupt and
produce a new train of morbid symptoms.
  But even after the  aphthae begin to fall, the danger of hypercathar-
sis, is by no  means passed,  and sometimes scarcely at all lessened.
We must not, as soon as a few aphthae are thrown out by stool or vom-
iting, order  a  cathartic ;  but wait at least twenty-four hours after this
appearance, in order  to learn whether the separation of the aphthae
be  really the solution  of the disease, or merely partial and succeeded
by a fresh crop, which  is known by the symptoms suffering no abate-
ment.   In this case, nothing more than an emollient clyster is to  be
recommended.
  When on the  other hand,  the symptoms abate, and  particularly
when the aphthae of the fauces fall,  leaving the parts  they occupied
elean and moist, a cathartic  is  not only safe, but necessary.  If ir-
ritating matter in the primse viae  is capable  of producing the disease,
where it has not previously existed, it may certainly be the means of
renewing it.
  However flattering the state of  the patient, hypercatharsis, even at
this period may be induced by a rough medicine, the intestines being
often left in  a very irritable state. Rhubarb has been much celebrat-
ed  as a cathartic in this disease.
  Such are the circumstcinces to be attended*to in the employment of
cathartics in idiopathic aphthae,  without an attention to which,  the
oractitioner must often  be guilty of fatal errours.
  At the commencement emetics  are given for the same reason as ca-
thartics, to assist in evacuating the morbid contents of the alimentary
canal; but on  many accounts are often more beneficial; their opera-
tion tends less to weaken, and  is particularly easy in young children.
Besides the cause of tl le disease seems  often lodged in the  stomach
rather than the intostii  »os.  A pain in the stomach and vomiting more 
24t>
APHTHOUS FEVER.
frequently precede  the  appearance  of aphthae,  than a  griping or
diarrhqea.  The stomach is an  organ of greater  sensibility than the
intestines, and its affections produce greater and more sudden effects on
distant parts.  If aphthae be ever produced by acrid matter applied to
the fauces, it is chiefly from  the stomach that it comes.  In  short  the
stomach  is that part ot the primae viae which seems most connected
With the  state of the disease.  " Emetica infantibus praescripta, says
" Arnemann, omnibus medicamentis reliquis palmam praeripere viden-
" tur, quando morbi fomes in ventriculo adhuc latet, et anxietas, singul-
" tus, ructus male olentes vel vomituritiones  ipsae 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  be-
cause they are found to  weaken much less.   They seem serviceable
too, he might have added, by promoting perspiration, and it is proba-
bly 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 probable
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 harm  where  the  aphthous incrustations
have spread to the oesophagus and stomach, by producing hemorrhagy,
excoriation,  or inflammation.
   Dr.  Armstrong  and Ketelaer recommend antimonial preparations
both as emetics and cathartics in this disease.  The propriety of  an-   '
timonial  cathartics may be questioned.
   Disputes have arisen respecting the  propriety of blood-letting in the
aphthae infantum.  Some asserting that all periods are equally proper
for the  employment of this remedy, should inflammatory symptoms ap-
pear ; others deeming it  so  dangerous to let blood after  the  appear-
ance of aphthae, that  there is scarcely any symptom which will induce
them to have recourse to  it.
   From the nature of the disease the question seems a priori easily de-
cided, and the judgment we are thus led to form is  sanctioned by expe-
rience.   Whatever other  effect venesection  produces,  it always  im-
pairs the  strength.   The  question then is, are there any symptoms of
the aphthae infantum  which  we would endeavour to remove at this
risk? In  perhaps ninety-nine of a hundred cases there are not.  The
excitement is never such as to threaten danger, and visceral inflamma-
tion seldom occurs in this form of the disease.   When it  does, blood-
letting  may be employed at  any period ; but the more cautiously, the 
APHTHOUS FEVER.
24*0
later the period.   Such is the practice warranted by experience, and
with respect to assertions which pre-conceived opinions have exiorted,
even from the  best writers, they deserve little attention.*
  The diet in  aphthae requires some attention.   When fever is present,
it must be regulated  by an attention to the febrile symptoms.   If the
excitement be considerable, it must be light and  diluent; if too low,
as happens in  the majority of cases, the diet must be more nourishing ;
but in all it should be mild and mucilaginous.   In most cases it is pro-
per in the advanced  stages, to give cordials ! composed of a little wine
and aromatics, sweetened.
  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
prevented, mild nutricious clysters are often serviceable.
  It only now remains to make some observations on the local reme-
dies employed in  the aphthae infantum ; and these,  in the mildest ca-
ses  where the aphthae spread no farther  than the  fauces, with  the ex-
ception of gentle aperients, are all that are necessary.
  In infants, 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 a hair pencil, or a bit of rag at the  end of a
stick.   The former are not only useful by their  effects in  the  fauces,
but serve a similar purpose in the stomach and intestines when the aph-
thous 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 wa-
ter, and sweetened with honey, 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
veal broth, boiled  with rice and bruised  turnips, which has the  advan-
tage of being  nutricious.
  When the rectum is affected, the clysters should consist of such de-
coctions.
  * « Omnem igitur, pracsentibus aphthis,"  says Ketelaer, " incisionem ve-
" nae hue usque damnamus, atque pi-oscribimus."  But in another place the
same author  admits, diat plentiful blood-letting is necessary when an inter-
nal inflammation supervenes at any period of the disease, and gives a case in
which it saved  the patient's life.
  + For the use of the bark in this disease, see what is said of it in speaking
of local remedies.  It will then be necessary  to mention it, and it will sav«
repetition to throw together the few observations to be made on it.
                                32 
250                   APHTHOUS FEVER.

  The ingredients left, after the preparation of some of these decoc-
tions,  are often applied to the external fauces by way of cataplasm,
and tend to relieve the internal parts.
  More stimulating remedies seem in many cases to produce better ef-
fects.  Dr. Armstrong found a solution of sulphate of zinc, in the pro-
portion of about half  a  scruple,  or rather more, to eight ounces, very
successful;  and about a dram of this solution,  he observes, now and
then swallowed,  is of  service by cleansing the stomach and bowels.
He generally applied it,  however, by means of a bit of rag three or
four times  in the  twenty-four hours.
   I shall have occasion to consider more particularly when treating of
the cynanche maligna, the different applications to the internal fauces,
employed when a tendency to gangrene shews itself.
   There has been much  difference of opinion concerning  the use  of
 refrigerant  and astringent gargles in aphthous affections.   Practition-
 ers having observed,  that in certain cases an alarming train of symp-
 toms sometimes attends the sudden retrocession of aphthae, have disap-
 proved of such gargles.  Ketelaer reprobates  them  in the  strongest
 terms.
   This appears  to be  reasoning not only a priori, but reasoning also
 on very bad grounds.  As this mode of reasoning, however, has been
 very generally adopted in this and similar cases, it may not be impro-
 per to take this  opportunity of  making some observations on it.
    In  almost all eruptive fevers it now and  then happens, that the erup-
 tion suddenly disappears, a train of symptoms supervening, which, if
 effectual means  for restoring the eruption  are  not speedily employed,
 often terminates fatally.   It has been inferred, that  the train of symp-
 toms which attends  the retrocession is its consequence ;  and that the
 same effect will follow if we repel, or even retard the eruption, what-
 ever  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.   In this case
  it was remarked above,* that  the  inference was  invalidated  by re-
  flecting, that  the critical symptoms and the  solution of the disease,
  may be the effect of a common cause.  So in that before us ; although
  dangerous symptoms are sometimes observed to supervene on the erup-
  tion's spontaneously  disappearing, it is  by no means  an inference
  from this, that  the  train  of unfavourable  symptoms is occasioned by
  the retrocession of the eruption ; both may be the effects of a common
  cause, the disappearance of the eruption  being  only one of the unfa-
* See page 139 et seq 
APHTHOUS  FEVER.
251
vourable symptoms, and  having no  share in producing the others.
And that this is generally the  case appears highly probable, when we
know that the  accompanying symptoms often appear before the retro-
cession, that it is in debilitated states of the system,  and after debili-
tating causes have  been applied, that the retrocession generally hap-
pens ;  and that debility often produces the same train of symptoms in
cases where there is no eruption.
   That such symptoms will not follow the retrocession  or retardation
of the eruption, except the body be  somehow  or other peculiarly pre-
disposed to them,  appears from numberless facts, which seem  at first
accidentally  to have  obtruded themselves on the attention of physi-
cians.   Thus  we know that  retrocession in the  small  pox or miliary
fever has been  accompanied by the same symptoms which attend
the retrocession of aphthae.   In a thousand cases, however, the  most
vigorous means  for repelling the  eruption in these  diseases are every
day employed, and they are actually impeded and kept back, and yet
no bad consequences, but on the contrary, the best effects ensue.
   It is true indeed, that when the eruption is recalled,  the unfavoura-
ble  symptoms generally disappear ; but what are the  means of recal-
ling the eruption ?  those which obviate the debility that occasioned its
retrocession';  and  we have reason to believe, that  the  relief obtained
is not the consequence, but the cause of its re-appearance.
   In considering the propriety then of astringent gargles in aphtae, let
us appeal from the doctrine of retrocession to simple fact.
   Have astringent  gargles been  employed in  this disease, and  what
have been their effects ? They were  employed  in cases of aphthae as
early as the days of Sydenham ;  for this author used the bark in fevers,
 while aphthae were present, and  found that the fever yielded and  the
 separation of  the aphthae was promoted by it.   Such was the dread of
 astringent applications while aphthae were present, that, even in typhus
 long after the benefit derived from the bark in this fever was ascertain-
 ed, the appearance of aphthae was deemed a sufficient reason for avoid-
 ing it,  till Sydenham and some other practitioners ventured to employ
 it.  I was encouraged to give the bark in debilitated aphthous patients,
 says Van Swieten, in  whom the incrustation often became very thick.
 It was  given  in decoction, because  the powder is not easily swallowed
 when the fauces are covered with aphthae.   I did not give the bark in
 those cases without some fears that by its astringency it  might do harm ;
 of two evils,  however, the best that could be done was to choose  the
 least.  I therefore continued to give the  bark, interposing between the 
252
APHTHOUS FEVER.
doses emollient  decoctions, to correct  any hurtful tendency it might
have.   I had not, he adds, continued this practice long, before I wa6
astonished to find that the aphthae terminated  favourably in those pa-
tients who took the bark, sooner than  in those who did not, although
the latter were not only stronger but had also less fever.
   So well convinced physicians now are of the safety of bark in  aph-
thae, that they not only use it occasionally as a gargle, but give it in-
ternally in large doses, even where there is no fever, if the symptoms
of debility are alarming.*
   The same objections have been urged against the use of acids, tend-
ing, it was supposed from their refrigerant powrer to repel the eruption,
and particularly against the sulphuric acid  on account of its  astringen-
cy.  Some practitioners, however, have been  bold enough to employ
them, and have established the propriety of doing so.!   The muriatic
acid properly diluted, has been found particularly useful.
   Such  is the treatment of the  aphthae infantum, and from what has
been said may be readily collected  that of every other 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  difficult to
perceive how hurtful many of the prejudices just mentioned must prove,
if permitted  to influence  our practice in every disease in wliich this
eruption occurs.
   When indeed aphthae prove critical in fevers, which rarely happens,
it would be  improper to employ any means which might tend  to im-
pede the eruption.  The use of astringent  gargles,  even  in this case,
has not, as far as I know, been found injurious.   From analogy, how-
ever, we should be inclined to avoid them.   It is improper,  we know,
to check other critical discharges, those for instance by sweat or stool.
   It only remains to make a  few  observations on certain symptoms,
the treatment of which does not fall under the  general plan of cure.
   Those which chiefly demand attention, are profuse diarrhoea or hy-
percatharsis, and the  symptoms which attend  retrocession.   It often

  * See the observations of Boerhaave, Van Swieten, Ketelaer, Vogel in his
Jk-aclectiones de Cog. et Curand. Morbis, &c.

  f For a variety of applications to the internal fauces, see Vogel  and oth-
ers on Aphthous Fever. For relieving 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 decoction of agrimony with
hnr.p" ; when it is obstinate and profuse, gentle astringents. 
VESICULAR FEVER.                 253
happens indeed that in neither of these we can be of any service.  In
the latter we must trust  chiefly to tonic medicines.   The eruption
seems to recede in consequence of debility, and when this is obviated,
it  often  re-appears.   Bark and astringent wines are  the  remedies
chiefly to be depended on.  Thus the means which have been suppos-
ed capable of occasioning retrocession, are not only the best means of
preventing it, but also of obviating the danger  which attends it.  Gen-
tly stimulating applications to the  internal  fauces are 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  extract 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 even hypercatharsis, and the diar-
rhoea which  occurs in the decline of the disease  and throws  out the
fallen aphthae, we have seen, if not profuse, is  salutary.
SECT. IV.
                      Of the Vesicular Feven


  Concerning the characteristic symptoms of this fever there lias been
some dispute.  It is defined by Dr. Cullen,
  " Typhus contagiosa, primo, secundo, tertio,  morbi die, in variis
" partibus vesiculae avcllanae magnitudine, per plures dies manentes,
" tandem ichorem tenuem effumdentes."
  Dr. Cullen never saw the disease but once, and some of those who
have seen it more frequently have proposed considerable alterations in
his  definition.   Dr. Dickson* observes, that he doubts much whether
this disease should be considered as contagious.  He saw six cases, in

  • See his paper on  Pemphigus (the name by which this fever is generally
known,) in the Transactions of the Royal Irish Academy, in 1787. 
254
VESICULAR FEVER
 none of which it was  received by contagion, nor communicated to
 those who 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 appeared on other days.*   Per plures dies  manentes, he also
 thinks exceptionable, as  he never found the vesicles remain for many
 days.
   The fluid of the vesicles, instead of being a thin ichor, as mentioned
 by Dr. Cullen, was a blind, inodorous, and insipid fluid ; and lastly he
 observes, instead of being poured out, it was generally 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, internal! as  well  as external, of vesicles
 " 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. Cullen,
 not because the disease never appears in the form described by him,
 but because it is necessary to have a definition including every form of
 it.
   Dr. Cullen's definition applies perhaps to the generality of  cases.
 On the continent, where the disease is more frequent  than  in  these
 kingdoms, it seems generally to  assume the appearance  described by
 him.   The  blisters in particular, are generally filled with an  acrid se-
 rum, which is discharged, not absorbed-!
  Mr. Blagden, in a letter to Dr. Simmons, relates cases of pemphigus
which fell under his care, and very accurately correspond to  Dr. Cul-
len's definition.
  There is another letter on the same subject, addressed to  Dr. Sim-
mons, by Mr. Christie, whose observations agree better with those of
Dr. Dickson.   He thinks the disease ought to be divided into two spe-
cies, pemphigus simplex, and pemphigus complicates.


  * Sauvages remarks, that the vesicular eruption sometimes appears on the
fourth day.

  f We shall find this eruption is not confined to the skin.

  t See the observations of Burserius and other foreign writers on this dis.
ease. 
t
VESICULAR FEVER
255
   I. 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, some-
times as large as walnuts, more frequently about the  size of almonds,
and often much less, surrounded by more or less inflammation.  They
appear on the  face,* neck, trunk, arms,  and now and then over the
whole body,! and sometimes run into  each other.
   It has just been observed that external parts are not the only seat-of
this eruption.   The mouth and fauces, where it now and then makes
its first appearance, are particularly  apt to be attacked by it.   This
happened in a case related by Dr. Dickson, in which, on the third day
of the fever, the patient complained of a smarting itching, and, as she
termed   it, tingling of her tongue and  inside of her  mouth.  Her
tongue was of a florid red colour, dry and clean.   On the day follow-
ing there appeared upon it a large pellucid vesicle filled with a yellow-
ish serum, a smaller one of the same kind appearing on the inside of
the cheek.
   In some instances the disease spreads  along the whole  alimentary
canal.   " No  person," Dr. Dickson remarks, " has  noticed an extra-
■" ordinary peculiarity in this disease, that the vesicles have taken pos-
" session of the internal parts of the  body,  and proceeded in succes-
" sion from the mouth downward through the whole  tract of the ali-
 " mentary canal, some rising while others decayed."j
   The  following  symptoms  indicate that  this  eruption is spreading

   * Burserius observes, that they are particularly apt to appear on the face
 and nose.
   ■j-  See a'paper by Dr. Stewart, in  the Med. Commentaries.   When they
 have appeared on the scalp, the hair generally falls from the places they
occupied.
   t  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 interrupted
 for a year and a half, during which  period the patient had been twice before
 subjected to the same disease, and each time it followed a vomiting of blood.
 The other case in which Dr. Dickson met with this eruption spreading along
 the alimentary canal, he relates very minutely.  He-? the first appearance n+
  be eruption was in the  mouth 
zu&                  VESICULAR FEVER.
 along the alimentary canal.  Great difficulty of swallowing, the vesi-
 cles in the mouth, when there are any there, at the same time begin-
 ning to shrivel and  crack,  the  eruption  being apt,  in  spreading to
 neighboring parts, to leave those it first attacked.  From these symp-
 toms, especially if accompauyed with hiccup,  we infer  that  vesicles
 are coming out  in the oesophagus.
   When  they have  spread  to  the stomach, the patient complains of
 pain  referred to that organ, and nausea ; whatever is taken is vomited,
 and often mixed with blood.
   Similar symptoms  attend their presence in the intestines, a general
 sense of soreness is felt in the abdomen, and tbe 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 begin to shrink, and
 in a short time  disappear.  And this perhaps is the most favourable
 termination, when they  break  they sometimes  leave troublesome ul-
 cers.!  The vesicles  which first appear soonest subside.
   From perusing the cases of pemphigus,  which  have been accurately
 described, we should be inclined to think that the eruption is most apt
 to attack internal parts when the matter of the vesicles on  the surface is
 absorbed ; from one or two instances, however, no general conclusion
 can be drawn.   It is said,  that in a  pemphigus  which raged in Swit-
 zerland, in which  the eruption  often attacked the fauces, these parts
 were  always most affected when the skin was least so ; but there is rea-
 son to believe that the vesicular fever has  sometimes been confounded
 with the scarlatina.
  Pemphigus  resembles the small-pox, in frequently leaving pits iu
 the skin;  and in the parts which the vesicles occupied, remaining for
 a considerable time afterwards of a dark colour. J
  The time during which new vesicles continue to come  out is as un-
 certain as their  duration.  According  to  Dr. Cullen's definition,  no

  * It sometimes happens in the same case, that the fluid in some of the ves-
 icles is ichorous, in others bland. See the observations of Dr. Stewart above
 alluded to.

  |Mr. Blagden observes of one of his patients,  in whom the vesicles broke,
that the sores were not completely healed in less than two months.  For the
most part they heal readily.

  *.Dr. Winterbottom's Paper, in the third volume of Uie medical Facts and.
Observations, and Mr. Blagden's letter. 
VESICULAR FEVER,
257
fresh vesicles appear after the third day, but this we have seen by no
means applies universally.*
  Swellings and abscesses of the parotid, inguinal and axillary glands,
have frequently accompained this eruption; and as in  other cases  of
continued fever, accompanied by these swellings, the safety of the pa-
tient seems  often to depend on the matter formed  in them being dis-
charged.
  The vesicular eruption seldom brings relief.  But the prognosis in
this variety of fever is in some respects influenced  by its seat and ap-
pearance.   When the vesicles are not numerous and only appear on
external parts, they demand little attention ; when they are numerous,
when  they attack the alimentary canal and are attended with a small
hard pulse, the danger is considerable.
  When the ulcers left by the vesicles, although external, appear livid
shewing a tendency to gangrene, which seldom happens except in well
marked typhus, the danger is very great.   Even in idiopathic cases of
this eruption, where there is no fever, gangrene has been known to su-
pervene.   There  is then considerable danger.!  In  general where
there is no fever it is unattended by danger.

  Of the Symptoms preceding and attending the  Vesicular Eruption.

  In some cases, like the foregoing eruptions, it is  preceded by anxi-
ety and depression, but  more generally by no peculiar symptoms.f
  A degree of coma, it was observed, frequently precedes the appear-
ance of the miliary and  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, particularly frequent in
the vesicular fever.
   Nor is this eruption generally accompanied with  any peculiar symp-
toms,  besides those already enumerated, which the eruption itself oc-
casions.

  * In chronic cases, as I have myself witnessed, they often continue to com«
out for a great length of time.  See a case related by Mr. Christie.

  | Burserius relates a case of this kind which terminated fatally

    t It appears, from what was said of one of Dr. Dickson's patients, that
 when the eruption is about to appear in the mouth,  it is sometimes preceded
by a peculiar sensation and change of colour in the parts which it is aboyt t« 
258
VESICULAR FEVER.
Of the febrile States in  which the Vesicular  Eruption most frequently
                            appears.

   Like other symptomatic  eruptions,  it is most apt to shew itself in
those fevers in which the typhus prevails.   The symptoms of the cold
stage are generally well marked, attended with head-ache,  sickness,
and oppression, the pulse is frequent,  seldom strong or full, and deli-
rium is a common symptom.
   It appears from what was said of the definition of the synochus vesi-
cularis, that there is no particular period of the fever at which uWerup-
tion shews itself.  It  now and then appears  in other diseases.  (See
an account of the  Cynanche Maligna  in the Acta Helvetica,  by Dr.
Langhans.)   There is reason to believe, that in several epidemics
which raged in different parts of  the Continent, the vesicular eruption
attended  cynanche maligna, but the accounts of them are far from be-
ing distinct.   This eruption has  sometimes  accompanied  irregular
forms of small pox.  See Sydenham's account of the small-pox of 1670,
1671, and 1672.
   I have frequently seen the vesicular eruption unaccompanied by fe-
ver of any kind.  (See papers by Dr. Winterbottom, and Mr. Gaitst-
kell, in the 4th vol. of the Mem. of the  Med. Soc. of London.)  Burse-
rius speaks of this eruption without fever as  a  frequent occurrence
where he practised.

              2. Of the Causes of the Vesicular Fever.

   The vesicular fever was unknown to the Greek, Roman,  and Ara-
bian writers.
   Some indeed assert that mention of  it is to be found in the writings
of Hippocrates and Galen;  but this seems to be  a mistake.  Sauva-
ges considers it as described by  Bontinus, in his Medicina  Indorum ;
but Dr. Dickson asserts, that, except one case  related  by Carolus Pi-
so, 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 describing it particularly.
   Sauvages met with it himself in the hospitals  of Montpelier, near the
beginning of the present century,  aiid gives the following account of

  * Burserius even doubts whether  the disease mentioned by Morton be the
pemphigus; of this, however, there can be little doubt.  See what is said in
the Introduction. 
VESICULAR FEVER.
259
it, " Pemphigus, febris, est acuta exanthematica bullis seu ampullis
fl pellucidis avellanae magnitudine, per corpus^enascentibus, insignita."
Since his time it has been described by various authors ; most of what
they say of it, however, consists in the  narration of particular cases, if
we except  some, for the most part indistinct, accounts of it, as it ap-
peared in the form of an epidemic on different parts of the Continent.
   As little  has been  determined  concerning the causes of the vesi-
cular eruption, as those of perhaps any other disease.  There is one
instance in which it occurred three times in the same patient, during a
long interruption of the menses, and another in which it occurred twice,
each time  attacking the patient on a visit to a cold climate.*   It ap-
pears from such cases,  as well as one related by Dr. Hall,  in Dr. Dun-
can's Annals of Medicine, that the disease  is  apt to attack the same
person more than once, and that  it probably, like some other symp-
tomatic eruptions, particularly the erysipelatous and miliary,  leaves
behind  it a predisposition to future attacks.
   As with respect to the other eruptive synochi, some dispute? have
arisen concerning  the contagious nature of vesicular fever.   Most
foreign  writers regard  it as contagious, and some of the cases mention-
ed by British practitioners seem to support this opinion.
   On the contrary, many under this disease, have been admitted into
public hospitals without  communicating  it  to their  fellow patients ;
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, Dr. Stewart, Dr. Winterbottom, and
Mr. Christie, did it appear contagious, nor was it so in the case which
Dr. Cullen saw.   Dr. Hall  inoculated  with  the matter of the vesicles
without producing the disease.!
   It has been proposed to  divide pemphigus into two kinds,  the one
contagious, the other not.   The reader will find an attempt of this kind
in the lOGth paragraph of Burserius's  Institutiones Med. Pract.  The
contagious pemphigus, he  observes, is always accompanied with much
fever, and  symptoms of malignity  ; whereas in that which is not con-
tagious, the fever is either moderate or absent.   For  several reasons,
however, which will readily suggest themselves from what has been

   * See the observations of Dr. Winterbottom and Mr. Christie.

   f See Observations on the Pemphigus Major of Sauvages, by Dr. R  Hall, in
Dr. Duncan's Annals of Medicine for the year 1799 
260
VESICULAR FEVER.
said, this division seems to be inadmissible.  It is more than probable,
that it has in part arisen from confounding the cynanche maligna with
the synochus vesicularis.
   The truth seems  to be, that the vesicular, like other symptomatic
eruptions, appears both  in fevers  which are and are not contagious;
and it is probable, that like these also it will sometimes be  propagat-
ed with the fever and sometimes not ;  but it does not appear, as in
the case of the miliary eruption, what the circumstances are which fa-
vour its appearance.

   3. Of the Treatment of the Vesicular fever.

   The same prejudices  which have for many centuries, influenced the
treatment of other fevers, have  extended to that of pemphigus.   " In
"  Switzerland," says M'Bride,* " the physicians began the cure with
"  one or two large bleedings, then blistered the head,  laid cataplasms
"  on the neck, and endeavoured  to raise sweats by sudorific medicines."
   As the pemphigus was considered a  disease  essentially  different
from common fever, particular modes of practice have been  tried, and
specifics looked for.   "In Bohemia," Dr.  M'Bride continues, "the
" only medicine which did service was the acetum bezoardicum, and
"  this is said to have cured all who took it, while those who trusted to
"  other things died."   It seems more  surprizing,  that Dr.  M'Bride
should credit this assertion, than  that Thierry  the  practitioner who
makes it, should either himself  have  been deceived, or  wished to de-
ceive others.
   The result of all that has been written  on the treatment of  pemphi-
gus, as far as I am capable of judging, seems to be, that it is the same
as in simple synochus, with the  addition  of local remedies for the erup-
tion, which in general seems very little to modify the fever.
   With regard to the  local remedies, the larger vesicles are generally
opened,! and kept clean ;  when any  have  appeared in  the mouth and
formed ulcers there, demulcent  and  detergent gargles are employed.
When the ulcers are obstinate,  they  come under the care of the  sur-
geon, and therefore are not to be treated of here.
   If there is reason to think, that the  eruption has spread to the ali-
mentary canal, copious  draughts  of  some mucilaginous decoction are

  * See his Introduction to the Theory and Practice of Medicine.

  f The propriety of opening them  is doubtful. 
                   ERYSIPELATOUS FEVER.                26]

proper, and when the irritation is considerable  and prevents sleep, if
the symptoms of the fever admit  of it, opiates should be given.


                            SECT. V.
                      Of the  Erysipelatous Fever.


    The Erysipelas* is defined by Dr. Cullen,
    " Synocha duorum vel trium dierum, plerumque cum somnolentia,
 " saepe cum delirio.    In aliqua cutis parte, saepius in facie, phlogosis
 " erythema."!
   It was observed  in the Introduction, that although I have arranged
 the erysipelas as a variety of synochus, because like the foregoing dis-
 eases,  it has been arranged  among the exanthemata, yet  if the view
 there taken of it be just, and that it is so will I think appear more ful-
 ly in considering its symptoms, causes, and  mode of treatment, it
 should  be regarded as a combination of two diseases of synochus, and
 Dr. Cullen's second species  of phlogosis,  the  erythema,  and conse-
 quently should have no place in a system of nosology.   We shall here
 find  the eruption forming a much more important part of  the disease
 than in the preceding varieties of synochus, and modifying the general
 plan of treatment as well as the symptoms of the fever.

  *  Erysipelas is the name given to  this  disease, by the Greeks; by the Ro-
 mans it was termed ignis sacer, or merely,  ignis, by which appellation it is
 known in many parts of the Continent;  but none of these terms have been
used in a very definite sense.  Sennertus calls it rosa; authors, however, have
 not adopted this name.  By the  vulgar of this country it is called the rose or
 St Anthony's fire; foreign writers generally confine the latter appellation to
 Dr. Cullen's second species of it, which is also termed zona or zoster ; and the
 erysipelas of the face has been called sideratio.

  f Phlogosis Dr. Cullen defines, " Pyrexia, partis extemae rubor, calor,  el
" tensio  dolens."
  The erythema is his 2d species of phlogosis, which is defined,  " Phlogosis
" colore  rubicundo, pressione evanescentej ambitu insequali  serpente; tu
" more vix  evidente,  in cuticulae  squamulas, in phlyctaenas  vel vesicula6,
" abeunte ; dolore urente." 
 262               ERYSIPELATOUS FEVER.

        1. Symptoms of the Erysipelatous Fever.

                   Of the Erysipelatous Eruption.

   This eruption appears  in the form of a red blotch or stain,  which
 spreads with more or less rapidity.   The  redness  sometimes disap-
 pears on pressure ;  sometimes it does not, shewing that the inflamma-
 tion has 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 which surrounds it.  The parts beneath,
 however, as well as those in the neighbourhood, are  generally affected
 with some degree of swelling,  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 occu-
 pied, when it spreads to others.  But in this respect there  is much va-
 riety.
   After the  redness has continued for an uncertain time,  blisters of
 various  sizes  sometimes rise on the skin, generally  containing a thin,
 sometimes limpid, sometims yellowish fluid.   In some cases the fluid
 is viscid,* and instead of running out as generally happens, when the
 blister is broken,  adheres to and dries upon the skin.
   In unfavourable cases these blisters sometimes degenerate into obsti-
 nate ulcers,  which  now and then become gangrenous.  This, howev-
 er, is rare, for although it is not uncommon for the surface of the skin,
 in the blistered places to appear livid or even blackish ; yet the tend-
 ency to gangrene seldom spreads deep,  and generally disappears with
 the other symptoms.
   The red colour changes  to yellow as the eruption goes off,  and  the
parts which were  not occipied by the blisters  often suffer a desquama-
tion.  If the colour  of the eruption  change from a red to a purple or
blackish hue, the  prognosis is bad.
   When it has spread deeper than usual, suppuration sometimes takes
place, and it sometimes renews ulcers which had been long healed.!
   The duration of the eruption is very uncertain.   In mild  cases it
often gradually disappears,  or  is carried off by spontaneous sweating,
in a  day or two.   In others it continues without beginning to decline
for twelve or fourteen days, or longer.

  * Tissot's Avis au Peuple.
  f See the 6th number of Dessault'i Chirurgical Journal 
ERYSIPELATOUS FEVER.
.263
  It has obtained different appellations according to the appearance of
the eruption, erysipelas benignum,  malignum, gangrenosum, tubercu-
losura, scabrum, vesiculosum, pustulare, #c*
  The eruption differs considerably according to the different parts it
attacks.   In the mildest cases it appears 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 degree of itchi-
ness or burning, or slight pain resembling the stinging of nettles, there
is little tension, and it will probable be of short duration.
   In other cases, it soon extends along the leg, the skin over the tibia
becoming highly inflamed, stretched, and glossy, attended with sharp
pains, increased by the slightest touch, often shooting along the course
of  the  muscles, with  much swelling of  the limb, which sometimes
leaves  behind it an obstinate oedema.  When it attacks the trunk, it
is a more severe disease.   In the breasts of women, it is often attend-
ed  with much pain,  the breasts 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 erysiplatous eruption much less  frequently at-
tacks 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 attacks
 children soon after birth, begins about the umbilicus, and often spreads
 over the whole abdomen.}   It is not very  uncommon  indeed  for chil-
 dren to be born with the face or belly, particularly the parts about the
 umbilicus, uniformly red and swelled.   It is more common,  however,
 for the erysipelas  to appear a few days after birth,  and it somtimes

    * Burserius' Institut. Med. Pract.

    + Erysipelas in glandular parts, Schroeder observes, especially if cold as-
 trident and spirituous applications have been made to it, sometimes leaves
  behind it schirrus of the part.   See Schroeder de Febre Erysipelatosa, m
 his Opuscula Medica.

    * See an account of this species of erysipelas  in two papers, one by Dr.
  Bromfield, and another by Dr. Garthshore, in the 2d vol. of the Medical Com-
  muntatious, and also in Hoffman's Practice of Medicine, and in  Dr Under-
  wood's. Treatise on the Diseases of Chddven. 
264
ERYSIPELATOUS FEVER,
 makes its first attacks upon the genitals.  The inflamed skin is  hard,
 and very painful to the touch.
    This species of erysipelas is most  apt to  terminate  in gangrene.
 The belly often becomes uniformly tense, and sphacelated spots  make
 their appearance.  Dr. Bromfield relates a case of this species of ery-
 sipelas in the extremities,  in which the gangrene  spread so deep that
 several joints of the fingers were lost.   Any appearance of gangrene in
 it affords a bad prognosis.
    Suppuration also, though more rarely,  occurs in the erysipelas  in-
 fantum.
   It appears from dissections mentioned by Dr. Underwood, that  the
 inflammation sometimes spreads to the abdominal viscera.    •
   The other variety of erysipelas of the trunk, which deserves particu-
 lar notice, is Dr. Cullen's second species, the erysipelas phlyctaenodes.*
 This disease, it was observed in the Introduction,  is not very properly
 ranked as a variety of erysipelas, the appearance of the eruption dif-
 fering considerably from that above described.  Instead of appearing
 an uniformly inflamed surface, it consists of a number of little pustules,!
 which  in a short time  have vesicles  formed  on them.  It generally
 surrounds the trunk, and appears like  a red belt thrown round the bo-
 dy a little above the umbilicus, from  wliich it has gotten the name of
 zona.   It is not always, however, confined to  this  part,  sometimes it
 spreads round the neck and shoulders.
   This is generally regarded as more dangerous  than other forms of
 erysipelas affecting the trunk and extremities.  And Schroeder indeed,
 though surely without reason, regards it as the  most fatal  of all the va-
 rieties of this disease.   It is certainly by no means so in this country.!
   When the erysipelatous eruption attacks  the face  and head,  it is
 most dangerous.  It has the same appearance as on other parts of the
 body.

  * It is this species of erysipelas which  has been  termed zona or zoster.  In
 English it is called the shingles.  See the 2d vol. of Burserius's Instit.  Med.
 Pract.  Schroeder de Feb. Erysip. in his Opusc. Med.  and Vogel Prselect
 Acad, de Cog. et Cur. Morb.

  f When narrowly inspected, however, die erysipelas on other parts of the
body sometimes has more or less of the same appearance.

  $ Dr. J. C. SmiuYsobservations on Inflammation in the Lond.  Med.  Com-
munications, vol. 2. 
ERYSIPELATOUS FEVER.
•265
  A red spot appears on some part of  the face, generally of no  great
extent, which spreads till it sometimes covers, not only the whole" face*
but the scalp also, now and then descending a considerable way down
the neck, and occasioning what Tissot  calls, " Esquinancie  tres fa-
" cheuse."
  As in other cases, it often leaves the part  it first attacked, when it
spreads to neighbouring parts.
  The face and frequently the whole head swell,* and the tumid eye-
lids sometimes suppurate.
  The duration of the  eruption on  the  face, as on other parts of  the
body, is various.   It generally lasts eight or ten days,  sometimes lon-
ger.  Dessault, in his  Surgical Journal,  mentions a case in which it
lasted 23 days.   The  uncertainty  of the duration of symptomatic
eruptions is one of the circumstances in wliich they differ from the  ex-
anthematic.
  The greater danger of erysipelas of  the face, arises chiefly from  the
inflammation being apt to spread to the brain.   There is reason indeed
to believe, from symptoms that will presently be mentioned, that  the
inflammation sometimes attacks the brain at the same time, or even be-
fore it appears on the face.
  This form of erysipelas sometimes spreads to the fauces  and  along
the alimentary canal, which is also a very alarming accident.   Some-
times, Schroeder! observes, it spreads to the nares, trachea, and thence
to the lungs, producing all the symptoms peculiar to inflammation  of
these parts.
  The inflammation sometimes  removes suddenly  to  distant parts,
what phyisicians have  termed Metastasis takes  place.  Leaving  the
skin, it seizes on some of the viscera.   The viscus most commonly af-
fected is the brain ; but for the most part, as  Dr. Cullen remarks,  the
brain is not affected by metastasis, but merely by a spreading of the
inflammation.
  In metastasis of this disease, the inflammation also now and then at-
tacks the intestines, liver, uterus, and bladder.   I shall hereafter have
occasion  to make some observations on attempts which have been made
to distinguish erysipelatous inflammation of internal parts, from what is
called phlegmonous.   In the latter,  the  inflammation extends  deeper,

  • See Sydenham de Feb. Erysipel

  f Opuscula Med.
                                3* 
 266               ERYSIPELATOUS FEVER.

 and differs otherwise from  the erysipelatous, particularly  in being
 more apt to terminate by suppuration.
   Sometimes erysipelas is not confined to any particular part of the
 skin, but spreads equally over the face, trunk, and extremities.* This,
 which is very rare, most frequently happens in the erysipelas infan-
 tum.
   In certain  countries this disease seems most disposed to attack  par-
 ticular parts  of the body, thus Sauvages observes, that  in Germany,
 the erysipelas generally seizes on the grom, thighs, and arm  pits ;  in
 England and in France, it more frequently attacks the face.
   It appears from what has been said, that the prognosis  is particular-
 ly influenced by the seat ofthe inflammation ; in the extremities it is saf-
 er than in  the trunk, in the trunk than in the  face, and cet. par. the
 more extensive the inflammation, the greater the danger.
   Suppuration in general is  to be regarded as unfavourable.  It fre-
 quently, especially in the face, leaves troublesome ulcers, and is sel-
 dom of a favourable kind-!   Quarin, however, on  the  authority  of
 Strack, mentions  an epidemic erysipelas, in which those only recover-
 ed in whom suppuration took place.   We have reason to fear suppur-
 ation,  when  the  inflammation  spreads deeper than usual;  which is
 known by the redness not disappearing on pressure, the  pains being
 deep seated,  and  the swelling considerable and hard.
   It was observed above, that a degree of gangrene often appears on
 the blistered  parts ; and that  if the habit of body be good, and particu-
 larly if the  eruption  still  retains the  florid appearance   in other
 parts, it is generally superficial; but if the patient is debilitated, espe-
 cially if he is advanced  in life,J and the eruption in general assumes a
purple or livid hue, the mortification often spreads deep,  and  the dan-
 ger is very great.§


 Ofthe Symptoms which precede or attend the Erysipelatous Eruption.

  The erysipelatous eruption is often preceded by  the  same symp-
toms which precede the other eruptions we have been considering ;  and

  * Vogel, Schroeder.
  | See an account of the Epidemic Erysipelas, by Tissot and  others.
  t See the  observation of Platerus, on what he terms Macula Lata.
  § Vogel de  Cog. et Cur. Morb. 
ERYSIPELATOUS FEVER.
267
like these also, it sometimes appears without being preceded by any
peculiar symptoms.
  The oppression  and anxiety are often considerable, and frequently
attended  with other  symptoms  denoting  derangement of the  primae
viae;  a bitter  taste in the mouth, foul tongue, pain  of the  stomach,
eructations,  dyspnoea, head-ach, confusion of thought, vertigo, nausea,
and even vomiting and purging, frequently of bile.  Most of the fore-
going eruptions we have found connected with the state of the primae
viae ;  this connection  is  not more remarkable in any than the erysipe-
latous.*
  It is very frequently preceded by a degree of coma, especially when
it is about to appear on the face, and sometimes,  though but seldom,
with delirium.  It is  from the  state of  the brain in erysipelas of  the
face,  that we chiefly collect the prognosis.   When  neither delirium
nor coma precede the eruption, nor supervene after its appearance,
there is little danger.   But when it is preceded by a considerable de-
gree of either, and still more when they  rather increase than abate af-
ter its appearance, there is reason to believe that the  inflammation has
spread to the brain, and the danger is great.
  When they are  considerable from the beginning of the disease, it in-
dicates that the inflammation first seized on the internal parts, and then,
in a nosological point of view, the disease  must be regarded in the
same light as  when the  external inflammation is  the first  symptom ;
that is,  it must be regarded simply as a case of phlegmasia ; and we
shall  find that  the  treatment which experience has established, is the
same as in other phlegmasiae.
  . The affection of the  brain, in general,  is not relieved  by the ap-
pearance of the inflammation externally, the coma often increasing as
the inflammation extends ; so that as this inflammation, when it makes
its  first attack on  the face,  sometimes  spreads  to the brain without
leaving the  face ;  when it makes its first attack on the brain, it is apt
in like manner to  spread to the face without leaving the part it first oc-
cupied, which always affords an unfavourable prognosis.
   From what was said  of the tendency of erysipelas to attack other
 internal parts, it will readily be perceived, tnat  the symptoms which
 occasionally.attend this eruption must be very various.    We shall
 have occasion,  in the next volume, to consider at length the  various
 symptoms which accompany inflammation of the different viscera.

  * See the observations of Schroeder, Tissot, Burserius, Dr. Smith and oth-
 ers on this disease. 
26S
ERYSIPELATOUS FEVER.
  Oftht Febrile States in which the Erysipelatous Eruption ts most apt to
                              appear.

    The erysipelatous eruption differs from the eruptions we have been-
  considering,  and agrees with inflammations,  in  appearing more fre-
  quently in synocha than in typhus.   On this account it generally ap-
  pears  earlier in fevers ;  so that, although we  find  authors differing
  about  the time of its appearance, it seems to  he generally admitted,
  that it does not often appear later than the fourth or fifth day;  but
 within this period, the time of its appearance is  as uncertain, as that
 of any other eruption which has been mentioned.
    Like the appearance of other inflammations it generally increases
 the febrile symptoms,* the pulse becomes harder, the nostrils, fauces,
 and skin more parched, and the breathing more laborious  ; and when
 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  fulness of  the pulse  increasing.
 Other inflammations supervening on the typhus mitior, often have the
 same effect.   All the preceding eruptions., on the contrary, tend to in-
 crease  the symptoms of debility.
   The more the febrile symptoms, and particularly the coma or diliri-
 um increase on the appearance of the eruption, the more unfavourable
 is the prognosis.
   When the eruption is about to disappear favourably, it generally as-
 sumes a yellowish hue, and all the  symptoms connected with it, gra-
 dually subside.
   Such is the general course of erysipelas, and the circumstances wliich
 influence the prognosis.  But  Van  Swieten justly observes,  that we
 must always be prepared for sudden changes in this disease ; and  that
 cases apparently unaccompanied by danger, have often, all at once,
 undergone such a change,  that death was hourly expected,  the inflam-
 mation having attacked the membranes of the brain.  It  sometimes
 happens, says Tissot, that without any apparent fault of the patient or
 practitioner, the inflammation suddenly changes its seat, attacking the
 brain or lungs, and then the  patient is carried off in a very short time,
 although, previous to the metastasis, there  seemed little or  no dangerv
 These observations I have seen strikingly confirmed.

  * In some rare cases, however, the erysipelatous eruption has proved criti-
 cal.  The reader Will find cases mentioned by Van Swieten and others, in
 which the fever ceased on the appearance of  this eruption.  In these cases,
of course, the inflammation is too slight to occasion fever. 
ERYSIPELATOUS FEVER.
2G9
  It has been observed  above, that the erysipelatous  eruption  often
makes the fever resume the character of synocha after the typhus had
commenced ; this, however, is only where the symptoms of typhus are
not strongly marked.  When this eruption appears in the typhus gra-
vior, instead of changing the  nature of the fever, the  eruption, as I
have  frequently witnessed, partakes of its  nature,  shewing a strong
tendency to gangrene, and increasing the debility., The  disease  is
then, what has  been termed by foreign authors, febris erysipelatosa
maligna or pestilens; in its exquisite form it is seldom met with in this
country.  In different parts of" the Continent  it  has sometimes  been
epidemic, as at Thoulouse, in  the year 1716, where it appeared in so
dreadful a form, that it was compared to  the plague, and proved little
less fatal.  This epidemic is analogous to those mentioned by DeHaen,*
Bartholine,  ! Professor  Silvius de la Boe, I and others, in which  an
inflammation ofthe stomach and duodenum accompanied the fever.
   The erysipelatous eruption  is  apt  to appear  in  other  diseases.
Among the  chief of  these, Schroeder enumerates dropsy,; jaundice,
wounds, particularly those of the cranium, § injuring the  membranes
of the brain, fractures, or considerable abscesses  in any part of the bo-
dy.  Erysipelas from wounds, Quarin observes, affords a bad progno-
sis.  Erysipelas  also frequently attends schirrus, and cancerous, or oth-
er  considerable ulcers.   It  also frequently accompanies diseases,  oc-
casioning derangement ot the  primae viae,  particularly worms,  and is
often one of the effects of poisons.
   Various divisions of this disease have been adopted by Celsus, Fer-
nelius, Hoffman and others, to which I have already had  occasion to
allude, founded on  the appearances of the eruption ; according  as the
inflammation is more or less superficial, as vesicles do or do  not form,
or  leave ulcers behind them ;  and the ulcers being superficial or deep
well conditioned or otherwise, have also afforded other useless divi-
sions. ||

   * Ratio Medendi.
   ■J- Hist. Anatom. Rar. hist. 56,
   t Prax. Med. Append, tract, x.
    § Gunshot wounds are particularly apt to produce  erysipelas,  and  aft
 wounds, Dr. Smith observes, which are attended with much laceration.
    || See the 2d chap, of the 3d book of the Pathology of Fernelius, and
 Schroeder's  Opusc. Med.   See also a division of erysipelas equally objection-.
 able, in Burseritis's Institut. Med. Pract. 
27U
ERYSIPELATOUS FEVER.
             2. Causes ofthe Erysipelatous Fever.

    In the causes, as in the symptoms of erysipelas, we still find it  par-
 taking of the nature ofthe phlegmasiae ;  with these it agrees, and dif-
 fers from symptomatic eruptions, in having been known from the earli-
 est times.  The young, and those in the vigour of life, are most dis-
 posed to this disease, especially those of a sanguine and choleric tem-
 perament, and of a phlethoric habit ;  and it is most apt to attack those
 who have formerly laboured under it.
    One of the most frequent ofthe exciting causes, 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, too full a diet, particularly the abuse  of fermented li-
 quors, the suppression of any habitual discharge, as  the drying up of
 an issue,  suddenly  checking hemorrhois, abstaining  from habitual
 blood letting, or any other  cause of plethora.*   It  is  frequently re-
 produced by local  irritation, whether chymical or mechanical.
   In some of its other causes the erysipelas seems to bear a stronger
 analogy to symptomatic eruptions.   It has been observed of all of these,
 that they seem frequently to arise from derangement ofthe  primae viae.
 We shall find, however, that the  phlagmasiae even when affecting  dis-
 tant parts, more frequently arise from this cause, than  has usually been
 supposed.!   Purging, says Tissot, is in general necessary  in erysipe-
 las, to evacuate the corrupting bile from the primae viae, which is  the
 most frequent cause of this disease.   Such is the connexion of this dis-
 ease with the primae vise, Schroeder observes, that  we often wholly re-

  * Schroeder mentions several instances of erysipelas  recurring at the time
 the menstrual discharge should have appeared.   This is not very unusual.

  ■j- It will appear from a variety of observations, that  inflammations of the
 viscera of the thorax  in particular, are apt to arise from various affections of
 the abdominal viscera.  See an Account of the Pleuritis Verminosa, in  the
 43d, 44th, and 45th Sections of the 21st Epistle of Morgagni.   See also an
 Account of Dissections by Wendt in his Treatise de Pleuritide in Sandifort's
 Thesaurus, an Account of die Pleuritis Biliosa  in Bianchus's Ilistoria Hepa.
 tica, and  in the 5th volume  of the  Edinburgh Medical Essays, and several
 papers, in the second volume of llaller's Disputationes ad Morb.  Hist, et Cur.
pertinent, on the Pneumonia  Putrida which seems often influenced, if not
caused, by affections  of the prims vis. 
ERYSIPELATOUS FEVER.
271
move it by removing the irritating matter, which is generally bilious,
from the stomach and intestines.*
   The redundancy of bile in the stomach and intestines so frequently
accompanying erysipelas, gave rise to the hypothesis of its being occa-
sioned by a bilious state of the fluids, a doctrine! long maintained, and
adopted by so late an author as Quarin.   But irritation of the primae
viae from  other causes  also produces erysipelas, and  other eruptions,
we have seen, not suspected  to depend on a bilious state of the fluids,
arise from this cause.
   It is perhaps by affecting the state of the primae viae, the passions of
the mind, particularly rage, terrour, and vexation, frequently excite ery-
sipelas, and that pregnancy disposes to it.
   Erysipelas seems  also now and  then to arise from affections of the
ether abdominal viscera, particularly those of  the liver.   The erysi-
pelas infantum in  particular has been  observed to  arise from  this
oause.
    It is not contagious, but like symptomatic eruptions, as  well as cer-
tain phlegmasiae, often attends the prevailing epidemic.  Is has already
been observed, that such epidemics seldom occur  in Britain.   Dr.
Bromfield, in his Surgical Cases and Observation, mentions an erysi-
pelas ofthe head, which was epidemic for two years,  in which it was
necessary to  employ cordials and Peruvian bark, evacuations general-
ly proving fatal.   Instances of epidemic  erysipelas are to  be found in
the works of Sydenham, Burserius, Tissot, and others.
   It is remarkable that the erysipelas  sometimes returns periodically,
making its attack once or twice in the year, or oftener ; when this hap-
pens to old people, and those of a  bad habit, it gradually exhausts the
strength.  Hoffman relates several cases of this kind. In one of these, the
return of erysipelas was prevented by an issue and low diet, two ofthe
most powerful means, we shall find, of preventing the recurrence of the

   • Schroeder has been at the pains to collect a number of authorities with a
view to prove that this disease frequently arises from the presence of irrita
ting matter in the alimentary  canal;  the fact indeed is generally  admitted.
 We are referred to the  works of Hippocrates, Galen, Ballonius,  Hoffman,
 Lieutaud,  Tissot, Baglivius, Bianchus, Friend, Richa, Mead,  Brocklesby,
 Zimmerman, Molinarius, and  others of less note, to which Quarin, Vogel.
 Burserius, Dessault, and other late writers may be added.  Dessault in his
 Surgical Journal relates  several strking cases of erysipelas arising from, o-
 supported by, derangement ofthe primse vix.
   f See this doctrine considered at length  in  Bureau's Treatise on Erysipelas 
272               ERYSIPELATOUS FEVER.-

phlegmasiae.  Vogel  and Schroeder mention cases of the same kind,
It has been remarked as of the gout, that those who are subject to ery-
sipelas are often exempt from other diseases.

  S. Ofthe treatment of the Erysipelatous Fever.

  From what has been  said of the symptoms and causes  of erysipelas
it appears,  that in those cases where the affection of the skin has been
present from  the  beginning, or where the disease has been attended
from the first  with coma or delirium, it is to be regarded as a phlegma-
sia ;  and universal experience has ascertained, that the  treatment  in
these cases is the  same  as in the other phlegmasiae ; it  will,  therefore,
be considered when we come to speak of these diseases.
  We are at present to  inquire how far the appearance  of the erysipe-
latous eruption in  the progress of synochus, influences the treatment of
this fever.
  The appearance of the erysipelatous eruption in the  first  stage of
synochus, that is, while the inflammatory symptoms prevail, occasions
but little change in the  mode of treatment, except that as the inflam-
matory affection of the skin increases the  symptoms, the means of re-
ducing 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 often recalled  by  it. They
are not only recalled, but maintained, for the typhus which supervenes
towards the end of an erysipelatous fever is less considerable, in pro-
portion to the preceding symptoms,  than in other varieties of syno-
chus  ;  the  erysipelatous fever in this respect also approaching to the
nature  of the phlegmasiae.   Sydenham  did  not scruple to  employ
blood-letting in erysipelas, almost as freely as in any of these diseases.
  How the evacuations are to be regulated by the state of the local af-
fection will appear more fully in treating of the phlegmasiae.   All that
need be said at present  is, that the more severe the local affection, that
is, the  greater the swelling, heat, pain, and the further the  inflamma-
tion extends, especially if its seat be the head or trunk, and the great-
er coma or delirium, the more powerful must the antiphlogistic meas-
ures  be, provided the pulse continues full and strong, still more if it be
hard, which is generally the case when the local affection is considera-
ble.
  We must not, however, employ evacuations as freely  in the case  be-
fore us, .as when erysipelas appears as a simple phlegmasia, particular- 
ERYSIPELATOUS FEVER.               273
ly if the fever has arisen from contagion, or  shewn a tendency to ty-
phus.   Besides the erysipelatous,  like  other eruptions which appear
in  continued fever, has been known suddenly to  recede, an alarming
train of symptoms, of which debility is the characteristic feature, su-
pervening.  This is a rare  occurrence; as in similar cases, however,
it is most apt to happen where  debilitating causes have been applied.
It is also to be remembered, that  when retrocession takes  place, the
patient is seldom out of danger till  the eruption is recalled,  which is
done with the greater difficulty  the more he  is debilitated.
  The advantages of blood letting  over other evacuations for modera-
ting excitement have been pointed out;  but erysipelas being often in-
creased, if not caused by derangement of the primae  viae, evacuations
by  the bowels sometimes have a greater effect in allaying this inflam-
mation, than blood-letting.   We shall  find, in considering  the phleg-
masia;, that in all inflammatory affections ofthe head, purging  is partic-
ularly  useful;  in erysipelas ofthe head, therefore, it  is doubly indica-
ted ; and in all forms of the disease, when the symptoms are mode-
rate, it generally renders the employment of blood-letting unnecessary.
  Schroeder justly observes, that  catharsis  should always precede
blood-letting in the erysipelas.   It is, however, to be  kept in view,
that if the local affection  proceeds from the  state of the primae viae,
tlie  beneficial effects of purging will very quickly be  observed, so that
if it does not soon produce a favourable change, we should not perse-
vere in employing it to a greater extent, than would have been proper
ha"d no erysipelas  supervened.   Frequent purging, says Quarin, espe-
cially  where the habit is debilitated and the pulse frequent and small,
renders the erysipelas more  alarming ;  but even where  the pulse is
strong and  hard, if the first exhibition of cathartics is not attended with
beneficial effects,  it is better, for the reasons  given in speaking ofthe
modus  operandi of blood-letting, to reduce  the excitement by this re-
medy, than by repeated  purging.   And with  regard to the opinion,
that venesection is apt to occasion a retrocession of the eruption, or a
metastasis  to  internal parts, the observations made  above on similar
objections  to it in  other eruptive synocha, are applicable here.*
  If the erysipelatous eruption appears at an  early period ofthe fever,
vomiting should precede catharsis, except in erysipelas of the head, in
all cases of wliich  an emetic is at least a doubtful remedy.

  *  When the  eruption recedes, blisters and  cordials, with diaphoretics,
have been found the best means of restoring it.  See the  observations of a
variety  of authors, particularly those of Hoffman, M'Bride and Schroeder.
                                35 
274                   EXANTHEMATA.
  While we endeavour to evacuate the morbid contents of the alimen-
tary canal, we should at the same time endeavour to  correct what
may still remain, by the use of acids or antacids, according as bile or
acid prevails.
  The semicupium and sinapisms applied to the feet, have  been par-
ticularly recommended in erysipelas of the  head attended with coma ;
but these,  and other parts of the treatment, will be considered in speak-
ing of phlogosis and phrenitis.
  It has been  observed,  that the  erysipelatous eruption sometimes
shews itself after the typhus is formed, or even far advanced.   The
combination is then, we have seen, of a very different nature.
  As the appearance of the erysipelatous eruption in synocha, renders
the antiphlogistic mode of treatment more necessary ; so, on the other
hand, its  appearance  in the typhus gravior, renders the  invigorating
plan more  so. Bark, wine, and the mineral  acids are still the remedies
on which we chiefly depend.*
  We  must be cautious, however, not  to give either  bark or wine
while any degree of the synocha still prevails, by which  Dr. Smith
observes,  he has often seen gangrene induced, instead of prevented.
The typhus must be completely formed,  and the florid  appearance of
the inflammation beginning  to change, before the bark can be freely
exhibited.
BOOK  III.
OF THE EXANTHEMATA.
  The class of idiopathic fevers was divided into three orders,! inter-
mitting and remitting fevers, continued fevers, and the exanthemata.
The last of these we are now to consider.

  *  See an Account of the Malignant Erysipelas in the works of foreign
writers, Burserius, Quarin, &c.
f See the Introduction. 
SMALL POX.                       275
  It appears from what was said in the Introduction, that the fever in
this order of diseases, is  as truly idiopathic as in either of the fore-
going ;  and in laying down the practice, we shall  find  it treated as
such.
  Among the orders of idiopathic fevers, we readily perceive a  strik-
ing analogy.  Between remitting  and continued fevers,  it is impossi-
ble to draw the line of distinction, and the exanthemata, we shall find,
bear a strong resemblance to the eruptive fevers we have been consid-
ering.   The whole forms evidently a natural class of diseases, the ar-
rangement, which has been adopted, pointing out the manner in which
its different orders run into each other.
   The exanthemata were defined in the Introduction,  contagious dis-
eases beginning with an idiopathic fever, at a certain period of which,
pustules, often in considerable number, appear  on the skin.
   This order comprehends six species :  Small-pox, Chicken-pox, Mea-
sles, Scarlet Fever, Plague, and Nettle-rash.
                            CHAP. I.


                       Ofthe Small-Pox.*


     The Small-Pox is defined by Dr. Cullen,
  " Synocha contagiosa, cum vomitu et ex epigastrio presso, dolore.
" Tertio die incipit, et quinto finitur, eruptio papularum, phlegmono-
" dearum ; quae spatio octo dierum, in suppurationem, et in crustas de-
■; mum abeunt,  saepe cicatrices depressas sive  foveolas in cute relin-
" quentes."
  Such are the distinguishing marks of the disease as it most common-
ly appears, but  we constantly meet with cases  to which this definition
will not apply.  We shall find that the eruption does not uniformly ap-
pear on the third day, nor does it always cease on the  fifth, and  in

  * The small-pox is termed by medical writers, Variola or Febris Variolides.
  I have in the Preface given my reasons for detailing the symptoms of small-
pox at considerable length, notwithstanding there is reason to hope that this
disease will be every year becoming less frequent, and at no very great dis-
tance of time perhaps, will cease to  exist. 
276                       SMALL-POX.
 mahy cases the matter of the pustules remains so crude, that they can
 hardly be said to have undergone suppuration.  Even the pain of the
 stomach increased on  pressure  and vomiting do  not  constantly at-
 tend the eruptive fever.  Nay,  in certain cases,  there  has been no
 eruptive fever r.t all, the pustules appearing without any previous dis-
 ease.   But the definition just quoted, marking the common course of
 the disease, is perhaps the best that can be given.
    The small-pox has been long divided into distinct and confluent.
 The former is defined by Dr. Cullen,
    " Variola, pustulis paucis, discretis, circumscriptione circularibus,
 " turgidis, febre, eruptione facta, protinus cessante."
    The distinct  small-pox occasionally varies from that described in
 the foregoing definitions, in the following circumstances.
    Sometimes the matter of the pustules, instead of being purulent, is a
 colourless fluid.  This variety is termed Variola Discreta Crystallina.
    It sometimes happens, that small vesicles appear in the interstices of
 the pustules.  This  variety has been termed Variola Discreta Vesicu-
 laris.
   Sometimes these vesicles are empty, or the matter of the pustules
 themselves disappears laaving them empty, the disease  is then termed
 Variola Discreta Siliq-iosa.
   The pustules sometimes remain solid throughout; the solid pustules
 either  appearing alone, or being interspersed with others of  a more
 common appearance.  This is a  rare form ofthe disease.   It has been
 termed the Warty Small-pox, or Variola Verrucosa.*
   When the pustules are ofthe common appearance, but very numer-
 ous, yet upon the whole distinct and unattended  by any of the  symp-
 toms just mentioned, the disease has been called  Variola Adjuncta ;
 and this may be regarded as the connecting  link between the distinct
 and confluent small-pox.
   All these varieties are  attended with more  danger than the simple
 distinct kind, where the pustules are few in number, and suppurate fa-
 vourably.  The empty vesicles indeed sometimes appear in very mild
 cases.
   Many more varieties of distinct small-pox are enumerated by  au-
thors*   Sauvages,! for instance, enumerates twelve species, but most

  * CJeghorn's Diseases of Minorca, Burserius' Institut. Med. Pract. Mead
De Variolis, Friend's Epistola de quibusdam Variolarum Geticiibus, &c-
^ The Nosologia Mc'.hodi--:' of Sauvages. 
SMALL-POX.                      277
of them are marked by symptoms which cannot  be regarded as char-
acterizing different species ofthe disease.
  Dr. Cullen defines the  confluent small-pox,
  " Variola, pustulis numerosis, confluentibus, circumscriptione irreg-
" ularibus, flaccidis, parum elevatis, febre post eruptionem perstante."
  Although,  as expressed in this definition, the number of pustules  in
the  confluent, is generally much greater than in the distinct, small-pox,
yet it sometimes  happens that, though numerous, the pustules remain
distinct; and, on the other, hand, but more rarely, that, though few,
they appear in clusters and ruu together.
  The nature ofthe disease is best known,  and consequently its name
should be determined, from observing the state of the face, the danger
being better estimated by the number and appearance  of the pus-
tules  there, than on any other part of the body.   If they be distinct
and few  in number on  the face, even, although, in some degree conflu-
ent  elsewhere, the  disease is termed the distinct small-pox, and the
danger is inconsiderable.   If, on the  other hand, there be a load of
pustules on the face, if they run into each other so that it appears uni-
formly of a whitish colour, as  if,  to use Sydenham's  expression,  it
were covered with parchment, whatever appearance the eruption may
have on other parts of the  body, the disease is termed confluent, aud
the  danger is considerable.
  Dr. Sims, in his Account of Epidemical Diseases, even observes, that
the  danger was not to be estimated so much from the number of small-
pox on the whole lace, as from that on the upper part ofthe forehead,
about the junction ofthe hairy scalp with  the smooth skin.   If any
were distinct there, and filled properly, little was to be apprehended.
  It is evident, from what has been said, that we can draw  no  line of
distinction between the distinct and confluent small-pox.   In the worst
kinds  ofthe confluent,  there are generally some distinct pustules.   In
cases  which deserve the  name  of  distinct, we often  observe  two  or
more  pustules  running together.
  The more numerous and confluent the pustules  are,  the  more the
appearance of the pustule itself departs from that of  the most benign
small-pox.
  The confluent small-pox varies in the same manner as the distinct;
hence the names variola  confluens  crystallina, vesicularis,  siliquosa,
verrucosa, &c. all which varieties  are  attended with  great  danger.
Most of the symptoms expressed by these terms are more apt t-j attend
the  confluent, than the distinct  form of the disease, 
278
SMALL-POX.
   In the confluent, the pustules sometimes appear almost black from u
 degree of mortification taking place, and blood being mixed with the
 matter they contain ; hence one variety is  termed Variola Confluens.
 Nigra.
   When blood is effused into the cavities of the pustules without giv-
 ing them a black appearance, the  disease has  been termed Variola
 Sanguinea.
   When the pustules are here and there collected together in clusters,
 with few in the intermediate spaces, it has been termed  variola  Coa-
 fl'iens  Corymbosa.
   When petechiae appear between the pustules, it i3  called Variola
 Confluens Petechialis, or Maligna.
   After laying before the reader the symptoms  of  the  regular small-
 pox, it will be necessary to take notice of some of its principal varie-
 ties, which may properly enough be termed  anomalous.


                            SECT. I.


                Ofthe Symptoms ofthe Small-Pox.

   The symptoms of this disease are so various, that to avoid confusion,
 it will be proper to consider those of the distinct and confluent small-
 pox separately.
   The former has been divided into the simple  distinct,  and contigu-
 ous distinct; the latter into the simple confluent,  and putrid confluent;
 a division of no use.   The  contiguous are only  the worst form of the
 distinct; and the putrid the worst form of the confluent.

          I. Ofthe Symptoms of  the Distinct Small-pox.

   Small-pox attacks in a manner similar to  the fevers  we have  been
considering.
   The patient sometimes, though rarely, complains of sickness for se-
 veral days before the fever  is distinctly formed.   The latter generally
comes  on about mid-day, with the  symptoms of a cold stage, frequent-
ly attended with a considerable degree of drowsiness.
   If the  patient is old enough to  give an account of his feelings, he
complains of languor and listlessncss, with the other uneasy sensations 
SMALL-POX.
279
that attend the commencement of simple fever, which are soon follow-
ed by considerable heat, thirst, and the other symptoms that character-
ize those fevers in which the synocha prevails.
   The  skin and fauces are parched, the bowels costive,  the  urine at
first pale, afterwards more scanty and high-coloured, and hemorrhagies
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 is termed the eruptive fever,  is always a synocha,  and the
more  moderate the symptoms of excitement, the  more favourable  is
the prognosis.
  Such are the symptoms which  this fever has in common with many
others,  but certain symptoms generally attend, by which it may  be
known  before the  eruption makes its appearance.
   Severe pains of the back, limbs,  aad loins, coma,* in adults an un-
usual  tendency to  sweat,! and a coldness of the extremities in children,
have  been ranked among its diagnostic symptoms.!:  But the most un-
equivocal are those mentioned by Dr. Cullen in the foregoing defini-
tion,  the  vomiting and  pain  of  the  stomach increased on  pressure.
Even these,  however, do not always attend.§   The vomiting is fre-
quently bilious.||
  A little before the  appearance of  the eruption, some change in the
state  of the symptoms generally takes place.
  An epileptic fit at this period,  if the child has teethed, may always
be regarded as the forerunner of the pustules.   If it only occurs once or
twice it is hardly to be regarded  as unfavourable.H  Instead of the fit,

  * Bang observes, that coma is most apt to supervene in  this disease, in
the vigour of life.  Acta Societ. Med. Hafu.
  -J- Sydenham says, he never observed diis symptom in children either be-
fore or after the appearance of the pustules.
  t 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. Thomson has asserted that
the vomiting is most frequently bilious in women and children.   See Dr.
Thomson's Treatise on the Small-pox.
  1 Epileptic  fits  have  sometimes, though rarely occurred at a late pe-
riod of the distinct small-pox.  The son of Lord Saunderland, inoculated by
Mr. Maitland soon after the introduction of inoculation into England, died of
an epilectic fit after the greater part of the pustules were dried off.   See
Woodville's Historv of Inoculation. 
280
SMALL-POX.
 children sometimes have a grinding of the teeth, and convulsive twitch-
 ings about the mouth and other parts ofthe face.  The fever at this pe-
 riod frequently suffers an exacerbation, the lips are edged with  in-
 flammation, the eyes glare and cannot endure the light, the face glows,
 there is a considerable increase of temperature, the skin and fauces be-
 come parched, and coma,  when it has not shewed itself at an earlier
'period, frequently  supervenes.  Cramps in the legs, and a severe pain
 in the  back also sometimes precede the eruption.  Few of these symp-
 toms, however, are observable in mild cases ;  the coma and cramps of
 the legs gene rally forebode a copious eruption.
    In the distinct  small-pox the eruption  generally  appears towards
 the end of the  third day, or the  begining of the fourth, counting from
 the commencement of the febrile symptoms.   If we  class  together all
 kinds of small-pox, we shall perhaps find the third day the mean time
 of its appearance.*   The  later the eruption the more favourable is the
 prognosis.
    The pustules on their coming out are small  red points,  appearing
 first on the  face and hairy scalp, then on the neck, and at  length over
 the whole body.   The patient is  often affected with sneezing as soon
 as the  pustules make their appearance, which continues to  recur while
 they are coming out.   The ceasing of this symptom has been regarded
 as a sign ofthe eruption being completed.
    About the fifth or sixth day, counting firm the commencement of the
 fever, that is, the second or third of the eruption, a little vesicle, which
 appears depressed  in the middle,  is seen on the top of each  pustule,
 containing  a matter nearly colourless.  For two or three days the ve-
 sicles increase in breadth, the matter gradually assuming the  purulent
 appearance.  About the eighth  day ofthe disease they become  spher-
 ical, and the pustules are completely formed ;  being  then very  itchy,
 hard and prominent, and almost terminated by 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.

   * Nothing can be more vague than the manner of ascertaining the period of
 the eruption.  The eruption is said to happen on  the second, third, fourth,
 &.c. day, whether it  occurs in the morning or  evening of these days, and
 whether the accession of Uie fever has been in the  morning or evening.
 Great accuracy in this respect, however, would not be of much consequence.
 It has been proposed to make every day consist of 24 hours in computing  the
 appearance of the eruption.  See Dr. Thompson's Treatise on Small-pox. 
SMALL-POX.
231
    In the most benign small-pox, from their  first appeannce they are
 surrounded with a perfectly circular inflamed margin.  When the pus-
 tules are more numerous, though still of a favourable kind, the margin
 is less exactly circular.  These margins coalescing in places where the
 pustules are crowded, give a red colour to the skin lying between them,
 which is always a favourable appearance.
   In the mildest cases, no pustules appear after the end ofthe first day
 ofthe eruption, or the second at furtherest.   Id cases where they are
 about to be numerous, they often continue  to make their appearance
 for a day or two longer.
   About the eighth  day, when the pustules  are pretty numerous, the
 face swells and  is often affected with lancinating  pains.  The swelling
 sometimes extends to the whole head, the eye-lids seem as if distended
 with a fluid,  and are often so much enlarged as entirely 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 form-
 ing on the cornea.   Pustules are more apt to appear on the sclerotica,
 where they are  less  to be dreaded.
   When the tumefaction of the face begins to subside, which happens
 about the tenth or eleventh day, the hands and feet swell, which in the
 space of some days subside in like manner.
   The  swelling is inconsiderable in  mild cases ; at the same time  it is
 not to be overlooked, that when the  other symptoms are severe, if it is
 not in excess, it is to be  regarded as favourable.
   As the disease advances, the matter of the pustules becomes by de-
 grees more opaque, thick, white, and at length yellow.
   When the pustules are very numerous, it  is thinner and not so yel-
 low.
   About the eleventh or twelfth day, still counting from the commence-
 ment of the fever, the pustules have gained their full size, which dif-
 fers a little  in different epidemics, but is generally about that of a pea.
 A dark spot appears  on each.  From being soft and smooth,  they  be-
 come rough and  throw out a yellow matter. They now begin to shrink,
 and the   matter drying forms  a small crust.  Sometimes only part is
 thrown  out,  which,  together with what remains, hardens; and, in a
 few days, falls off, leaving the skin in the places which it covered of a
 dark-brown  colour, that often continues for a long time after the pa-
tient is well. While  this takes place, the swelling ofthe face and oth-
er parts gradually subsides.
                               3G 
nt
SMALL-POX.
  But the tbregoihg process does not go on at the same time on every
part of the body.  The pustules in those places on which they first ap-
peal first arrive at maturation.   They generallj'- remain longest on the
hands.  The sooner the pustules become dry and fall off, the better in
general is the prognosis.
  It often happens in cases where the pustules have been more  numer-
ous on the face, continued for a longer time, and been filled with a mat-
ter less thick and benign than  usual, that after they fall off, the parts
which they cover suffer desquamation, so that small pits are formed, for
the pustles do not on falling off leave pits ; they are formed by a suc-
ceeding operation.
  It sometimes happens that the matter of the pustles, particularly on
the arms and hands, is either absorbed, or,  as Dr.  Walker alledges,
transudes through the cuticle, so  that they appear empty vesicles, giv-
ing rLe to the variety termed siliquosa.  Dr. Lobb* observes,  that he
has seen  these  empty vesicles fill with a well-conditioned  matter,
which is  a favourable symptom.  It is not uncommon indeed, when
the strength is  considerably reduced, for the  pustles on every part of
the body to appear rather flat;  the tumour of their base subsides, and
the matter seems in part either to have transuded or been absorbed ;!
and on the exhibition of any remedy which renews the strength, walk-
ing for instance in a cool  air, or in certain  circumstances  using the
cold bath, the pustles again swell and become turgid with matter.
  On the coming out of the  pustles,  the fever suffers a  remission,
and in the mildest  cases disappears entirely about the  fifth day, at
which time the eruption  is completed.J   About the sixth or  seventh
day,  when  the pustles are numerous,  some  uneasiness of  the throat
comes on, with an increased secretion of saliva, the voice at the same
time often becoming hoarse.  A considerable degree of any of  these
symptoms tends to afford an unfavourable prognosis.
   As the  disease proceeds, the secretion  from  the mouth and throat
often becomes thick, and is not easily spit out, sometimes occasioning
such difficulty of swallowing, that liquids taken into the mouth  are spit
out again, or rejected by the nose.   The -swelling or parched state of

  * See his practice of Physic.

  | Dr. Walker's Treatise on the Small-Pox.

  i When the tendency to sweating has occurred, it has been observed, not-
withstanding the abatement of the fever, to continue nearly to  the time of
maturation. 
SMALL-POX.
283
the fauces also  sometimes considerably affects the breathing, and the
pustulary affection ofthe meatus auditorius externus, now and then oc-
casions deafness.  These symptoms, however,  in the distinct  small-
pox, are  generally  of little  consequence ; and  disappear with  those
which are more essential.
   When the pustules are numerous, a return of  fever usually happens
about the  eleventh day, a period we shall find much dreaded in some
forms of the disease ;  but in the distinct small-pox, it is for the most
part slight, and disappears in a few days.
   In the more severe cases even of this form of the disease, a train  of
symptoms indicating more danger now and then supervenes  at an ear-
lier period, about the seventh or eighth day, and has leen called  the se-
condary fever.
   After the pulse has returned to its natural frequency, and the  danger
seems past, symptoms of fever, more or less gradually, in some cases
very suddenly, return ;  and in the space of a few hours  the pulse be-
comes more frequent, and the other febrile symptoms more severe than
at any former period.
   The secondary fever is attended with less danger in the  distinct
small-pox, than  in the confluent.  In die former  it seldom appears
when the pustules are of a benign kind,  and almost never when  the pa-
tient uas 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 disease is term-
 ed the Confluent Small-pox.   The symptoms peculiar to this form of
 it we are now to consider.

    2. Ofthe  Symptoms ofthe Confluent Small-pox.

    Although there is much similarity in the eruptive fever of the dis-
tinct and confluent small-pox, ytt, even from  the commencement, in
 some respects they  differ essentially.  The  symptoms  common to
 both, the sensation of cold, the anxiety, sickness, vomiting, &c. more
 uniformly attend, and are experienced to a greater degree, in the con-
 fluent than in the distinct form of the disease.
    The pains of the back and limbs in particular, which are only some-
 times troublesome  in the distinct  small-pox,  very  generally precede
 rlie confluent^eruption.
   The most striking difference, however, between the eruptive fever of 
284                      SMALL-POX.
the distinct and confluent forms of the disease, is that in the distinct rt
is synocha, never shewing a tendency  to typhus, while  in the conflu-
ent,  although at the beginning synocha, it generally soon shews this
tendency.  In the most alarming cases  indeed the  fever is  a typhus
almost from the first; petechiae, and sometimes hemorrhagies  of a bad
kinc^ appearing at a very early period.
   Epileptic fits often occur during the first days, and have even prov-
ed fatal before the eruption appeared ;  at other  times they continued
to recur after the eruption is out, and sometimes  through  the whole
course of the disease.
   The tendency to sweat is uncommon  in this form 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 hap-
pen  in  the distinct  small-pox.  If the stools are  unusually  fetid, the
prognosis  is bad.
   This diarrhoea is generally  confined to  children;  in adults an af-
fection of the fauces, often amounting to a salivation,  attends  in tts
stead.*  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 expira-
tion of the first twenty-four hours; and  fresh pustles continue to come
out for the space of three or four  days.   The time  of its appearance,
however, is more uncertain than in the distinct small-pox.   It is some-
times delayed  by inflammatory symptoms supervening, to the fourth
or even to the fifth  day.  An  acute pain of the loins resembling a fit
ofthe gravel, in the side like that ofthe pleurisy, in the limbs resemb-
ling  rheumatism,  or in  the stomach accompanied  with sickness and
vomiting, are enumerated by Sydenham as symptoms which retard its
appearance.
   On the second day of the fever an eryfhematic 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 forerunner ofthe pus-
tles, which begin to emerge from  it in the form of small red points, ma-
ny of which soon coalesce.   They sometimes  appear in clusters, the

   *  The salivation sometimes, though rarely, appears  in children.  Tissot
 Kays, he has seen several scarcely four years of age, seized with  salivation,
 while the bowels remained costive.   See Trssot's Treatise on the Small-pox,
 A poplexy, and Dropsy. 
SMALL-POX.                       286
intermediate spaces being free from them ; at other times many parts,
and particularly the face, seem almost covered with them.  On their
first appearance they sometimes so much resemble the measles, that
they can only be distinguished by the accompanying symptoms.
   Matter is formed sooner in the cenfluent than in the distinct small-
pox.   The pustles are  not much raised above the surrounding r)arts,
nor do they retain  the circular form, but  even in places  where  they
are not confluent become of an irregular shape ;  nor are they surround-
ed with an inflamed margin,  the spaces between the pustles being pale
and flaccid, and the pustles 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 vesicle,
the surface being perfectly smooth.
   The matter becomes whitish, brown or even black, but never  thick
and yellow, like that of the distinct small-pox.  The lighter coloured
the matter, the better is the  prognosis.   When it is black, the danger
is very great.   The same may be said of those cases where extravasa-
ted blood is mixed with the matter, giving it the appearance of a bloody
sanies.
   It has sometimes been so virulent as not only to destroy  many of the
soft, but also the  bony, parts ofthe face.  The palate, fauces velum
pendulum palati and uvula, even the nose and cheek-bones have been
wholly destroyed by it, and the jaws so much affected, that the teeth
 have fallen from their sockets.!
   The  swelling of the face, which only sometimes occurs in the dis-
 tinct 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 of  the eruption, that is, the eleventh ofthe
 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 numerous and confluent
 the  pustules are, and the  darker their colour, the longer they are in
 disappearing ;  and the desquamation is sometimes protracted beyond
 the twentieth day.
   • This flat appearance ofthe pustles has been termed Sessile.  By some
 writers the confluent small-pox is termed Variola Sessilis.
   t See Burserius's Institut. Med. Pract. and other works on this disease 
286                        bMALL-POX.
   It often happens that although the pustules are crowded on the face,
they  are  few, and even distinct, on every other part.   But while the
face is loaded with those of the confluent kind, they never on other
parts have a benign appearance ;  they are never circular, raised, nor
filled with a well-conditioned matter, but in this respect resemble those
on the face.   In the confluent small-pox, however, the pustules on the
trunk and  extremities are generally rather larger, and more prominent,
than those on the face.
  Although  the fever often abates on the  appearance ofthe eruption,
it never wholly ceases.  This remission generally continues till about
the sixth or seventh day, that is, till near the time of maturation, when
it suffers a remarkable exacerbation, the commencement of the second-
ary  fever,  which often appears  with more alarming symptoms  than
any  that  preceded it.   If coma does  not supervene,  the patient is
distressed  with head-ache and  obstinate watchfulness, often the fore-
runners of delirium.   The inflammatory affection of  the fauces, with
hoarseness and  dyspnoea,  increases;  in many  gases  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
which  it made its attack.   This  day the  reader will find frequently
mentioned by Sydenham, and other writers, as the most fatal in small-
pox.
  Such are the appearances ofthe regular distinct and confluent small-
pox.  It will be necessary to notice some ofthe anomalous  forms of
this disease.

  3. Ofthe symptoms of Anomalous Small-Pox.

  It will be  sufficient to point out  the circumstances  in  which some uf
the most remarkable forms of anomalous differ from the regular distinct
and confluent, small-pox.
  One of  the most common is  that termed  chrystalline from the ap-
pearance of the pustules.
  Dr. Rogers* divides the chrystalline small-pox in the same way in
which the  regular has been divided, into distinct, contiguous, and  con*
fluent.   But  here there is not the same room for such a division ; for
although in  some instances the pustules are fewer and more  distinct
than in others, yet the state of the matter, as well as the appearance

      * Dr. Rogers' Er.say on Epidemic Diseases. 
SMALL-POX.
<!87
o"f the pustules themselves, does not vary much in different cases ; and
in all, the danger is considerable.
   The chrystalline small-pox makes its  attack, like other forms ofthe
disease, with the common symptoms of fever.
   The vomiting, pain at the pit of the stomach increased on pressure,
and  coldness of the feet and hands, are still the diagnostic  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,  prostration  of
strength,  petechiae hemorrhagies, &c.  the  typhus more  frequently
shewing itself at an early period.
   The eruption on its first appearance frequently looks well, and even
continues  to do so for a day or two.   The pustules are of  a good co-
lour  and distinct,  producing  a considerable remission  of the  febrile
symptoms.  About the third day  of the eruption, however,  there gen-
erally appears a numerous crop of pustules ; which, although often dis-
tinct, are  of an irregular shape.
   After the eruption is finished, a considerable remission ofthe fever
takes place, but never complete apyrexia ; and the urine generally re-
mains limpid throughout the disease.  The distinguishing symptom is
the appearance ofthe matter, which is a colourless fluid that rarely ac-
quires any degree of the purulent  appearance.
   As in the regular small-pox, there are now  and then  interspersed
among the pustules some wliich are empty, or clear and dense  having
no cavity.
   Whatever be the appearance of  the pustules  on their first coming
out, they soon became pale.  They are never indeed surrounded with
the well-defined florid margin, and the interstices have the flaccid ap-
pearance observed in the confluent small-pox.
  The period at which the face and head swell is more uncertain than
in the regular  small-pox, and the swelling in a day or two after its ap-
pearance is often suddenly translated to the hands or feet; and  then it
has been observed  that no salivation takes place.
   If the eruptive  fever  runs high, it  is frequently followed  by  a con-
fluent eruption, and the  danger which is at all times considerable is
now  very  great, the fever in general  soon becoming a malignant ty-
phus.
  In the worst cases, the face and head either do not swell at all, or
only  in a slight degree, but instead ofthe swelling  inflammation often 
288                       SMALL-POX-
 appears about the eye-lids, lips, throat,*  or  some neighbouring part.
 sometimes the inflammation seizes on the encephalon, occasioning vio-
 lent head-ache and delirium;  and traces of inflammation of the brain
 and its membranes are apparent after death.   Even abscesses form in
 different parts ofthe head, and matter is sometimes discharged by the
 ears.!  The strong pulse at the temples, while that at the wrist is fee-
 ble, mentioned among the symptoms of synochus as  denoting a  tend-
 ency to phrenitis, is  a frequent symptom in the chrystalline small-pox,
 and there affords the  same inference.
   This form of small-pox sometimes proves suddenly fatal before  the
 eruption appears; more frequently, however, death  is delayed to the
 seventh day ; sometimes to the fourteenth, seventeenth, or even longer.J
   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 in speaking of contagion,
 that while a contagious disease  rages other diseases partake of its na-
 ture.
   We have an instance of this form of small-pox in the  epidemic  de-
 scribed by Sydenham, which raged in  London in 1670,  1671, and
 1672.   It continued  after the measles had ceased, gradually becoming
 milder and more regular till the year 1674, when the measles again be-
 came epidemic, and  the small-pox as irregular and fatal as before.§
   The  prevalence of measles, however, does not always  either  in-
 crease its  fatality, or render it irregular.||
   It is  also very remarkable, that  if, while  a patient labours  under
 the small-pox, he  is seized with the  measles, the course of the former
 is  interrupted till  the eruption of measles  is finished.1T  In  the  third

  * Dr. Cleghorn's  account of the Diseases of Minorca, and other works on
the Anomalous Forms of Small-pox.
   f In the irregular forms of small-pox it is not uncommon for abscesses to
form in other parts  ofthe body, and recovery seems often to depend on the
pus being properly  discharged.  See die observations of Rossen, in Haller's
Disp. ad Hist, et Cur. Morb. Pert.

   t Dr. Walker's Treatise on the Small-pox.

   § Sydenhami Opera, sect. iii. chap. 6.  De Variol. Anomal.

   || See the 134th  and following pages of Dr. Sim's Treatise on Epidemic
Disorders.
  1 See the first volume of Dr. Duncan's Medical Commentaries, &c. 
SMALL-POX.
289
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 ofthe former being interrupted.*  Analogous
to the foregoing fact, is one mentioned by Dr. Heberden, in Dr. Kirkpa-
trick's Analysis of Inoculation, that when the small-pox appeared during
an epidemic intermittent, if  any labouring under the fever were seized
with it, the former ceased till  the small-pox had run its usual course,
and then went on as before  ; and another by Dr. Jenner, in the Con-
tinuation of his Observations relating to the Cow-pox, that the scarlati-
na was interrupted by the appearance of this disease.
   There is still another form of the small-pox which may certainly be
regarded as anomalous, and  deserves to be mentioned.   It is met with,
only in children, and seems  to be merely the regular confluent small-
pox, considerably  modified by peculiarity of constitution, those only
of a debilitated habit being subject to it.
   The patient is attacked with  languor  and oppression, that continue
for some days without considerably affecting the pulse, which is seldom
much more frequent, than in health, and the temperature is not above
the healthy degree, sometimes below  it.  As the symptoms advance,
the patient  loses his appetite, is troubled with nausea  and insatiable
thirst, becomes drowsy and  often comatose.  On  the third day  a few
pustules generally come out, but they soon disappear, and the coma in-
creasing, the patient expires in a few days.
   There is a set of symptoms, or rather certain modifications of some
of the symptoms which have been enumerated, which deserve the name
of anomalous, yet do not constitute a  distinct form of the  disease.
They are apt to occur when its course is disturbed by improper treat-
ment, or other causes.  Obstinate and profuse sweating, diarrhoea,  and
salivation, suppression of urine, &c.   As it will be necessary to con-
sider the means to be  adopted when such symptoms appear, to save
repetition, I shall defer any  further observations on them till we come
to this part of the subject.
   After the exsiccation of  the pustules,  a new crop sometimes comes
out;  and, on  the other hand, the fever, with all its peculiar symptoms,
sometimes appears  without any eruption  at all.!    It   is asserted by

   * Cases of this kind I have  known.  Several are related  in the  Medical
and Physical Journal.  Vogel mentions from Pechlinus a case in which  it is
said small-pox appeared on one side of the body, and measles at  the same
time on the other.
   + See Sydenham's chapter entitled Variola: Regulares,p. 140.
                                37 
290   -                   SMALL-POX.
 Frank, Burserius-, and others, that in the latter case the patient is as
 secure against a second attack, as if the eruption  had made its appear-
 ance. There are some observations, however, in opposition to this opin-
 ion.  In the fourth volume of the Memoirs of the Medical Society of
 London, Mr. Kite relates two cases in which inoculation produced the
 usual suppuration  in the part  inoculated, and at the usual time  the
 patient sickened,  but no  variolus eruption  followed.  Both patients
 were again  inoculated fourteen days after the first inoculation.   One
 of them had the disease in the usual way and in a mild form ; the oth-
 er remained unaffected.
   The  small-pox, especially when confluent  or  irregular, is  apt to
 leave behind it a variety of troublesome consequences.  Most of those
 who survived the irregular small-pox of Minorca, Dr. Cleghorn informs
 us, remained blind, consumptive, or lame with caries ofthe bones, ul-
 cers, &e.  Sometimes a gangrenous erysipelas ofthe limbs, or apoplexy
 has supervened and proved fatal  The blindness from a pustulary af-
 fection ofthe 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 inflam-
 matory  diseases, particularly to rheumatism, ophthalmia, and visceral
 inflammations.   On this part of the subject the  reader may consult the
 582nd and following pages of the fifth volume  of Haller's Disput. ad
Hist, et Cur. Morb. Pertinentes, and the third vol. of Frank's Epitome
 de Curand;  Horn. Morb.
SECT. IL
             Of the Morbid Appearances on DUsecticft.


   In those who have died under a load of pustules, the nares and in-
side of the cheeks are often found covered v\ illi them, and the teeth are
besmeared with a thick visced saliva.  Pustules are frequently observed

  • See Vogel Dc Cog et Curand. Morb. and others. 
SMALL-POX.                       291
on the upper, very rarely on the under part ofthe tongue, which is bet-
ter moistened with saliva ;  the palate is often covered with them ; they
also frequently occupy the  more  external, very rarely  the  internal,
parts ofthe meatus auditorius.
   The maxillary, frontal, and 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  where the swelling is most
consideraMe, is often distended with a serous fluid as in anasarca.
   On removing the cranium the dura mater appears perfectly  sound,
but the vessels  of the  brain are more turgid and filled with a darker col-
oured blood than usual, and a greater quantity of serous fluid is found,
particularly towards  the base of the  brain, " Circa infundibulum, in*
*  tegra ilia  arachnoideae vagina quae nervos tertii paris, adsitasque par-
"  tes concludit, saccum aqua plenum referebat."*  In other respects
the brain is generally sound.
   On examining the parts situated in  the neck, the oesophagus is found
free from pustules, even where flie pharynx  is loaded with them ;  or
if any be observed in it, they are towards the upper part.  The state
ofthe larynx  and trachea is often very  different.    These with the
bronchiae as far as their third division  are sometimes  more or less af-
fected with pustules,  from which, and the state of the nares, we readily
account for the dyspnoea and cough that frequently  attend this disease.
It sometimes  happens, however, even  in the worst forms of it, that
the wind-pipe  is wholly  free • from pustules*  Tissot  says he has
dissected some so covered with them externally that there was scarce-
ly room for one more, without finding any in  the larynx or trachea.
The trachea is sometimes covered with a whitish crust which is easily
separated, and the secretion from the bronchiae is now and then tinged
with blood.
   The fluid of  the pericardium is also  sometimes tinged with blood,
and small particles like coagulated blood broken down  now and then
appear floating in it.   The surface of the heart has been found rough-
er than usual, i and  polipi  are sometimes found  in its cavities.  It is
doubtful  if any of these appearances  be essentially  connected with
the disease.   With respect to the last, it is a common appearance after
death.!   The  lungs are often of a darker colour, and their moisture is

         * See Cottunnius de Sede Variolarum, p. 22.

   f See Dr. Baillies' observations on this subject, in his Treatise on Morbid
Anatomy. 
292                       SMALL-POX.
more copious than usual.   When no inflammatory affection has super-
vened, they are in other respects sound.  The form of the thorax has
been observtd considerably altered by enlargement of some ofthe ab-
dominal viscera ;  this seems to be merely accidental.
  The various parts, as the mouth, pharynx, larynx trachea, &c. 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 mucus frequently assumes this
appearance  when it has lain  for some time in these cavities.   In ex-
amining  bodies, we often of course meet with morbid appearances,
which cannot be regarded as connected with the disease of which the
patient died, as they are not observed in perhaps one of fifty cases.
Thus in the present instance, the liver is sometimes enlarged, some-
times soft,  at other times hard and gritty, now 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 in-
testines.
   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 observations of Cottun-
nius that they had mistaken small lymphatic glands for pustules.  He
dissected forty bodies in  the presence of several people, without ob-
serving any pustules on the stomach or intestines.   Did they spread
along the alimentary canal indeed, there would necessarily be a train
of symptoms, never observed in this disease.
   It appears then that variolous pustules only attack those cavities of
the body, to which the air has free access ; as the  nose, mouth, tra-
chea, the larger branches of the bronchiae, and the outermost part of
the meatus auditorius.  It has also been observed in cases of prolapsus
ani, that pustules frequently attack that part of the gut  which is ex-
posed to the air.
   Cottunnius  alleges  as the cause of this, that moisture prevents their
appearance ; and in confirmation of his opinion, observes, that  if the
eye-lids  be kept moist by wet bread from the first attack ofthe  dis-
ease, pustules never appear upon them ; and  by  the same means, he
thinks pustules may be prevented in other parts.   This  opinion, how-
ever, is invalidated by the faetus in utero being subject to the variohis
eruption. 
                          SMALL-POX.                      293

  The seat of the pustules is neither the true skin nor the cuticle, but
the mucus which lies between them.  The author just mentioned made
frequent dissections in order to determine this point.  " Quoties  pus-
tulam incipientem dissecui, vidi cuticulam  elevatam ad pustulae  for-
" mam, cutis corpore intacto, et tumoris immuni."*   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 treat-
ment of the disease.
                           SECT. III.


                  Of the Causes of the Small-Pox.


  This disease  has only made its appearance  in  Europe in modern
times.  There is no mention of'it in the writings of the Greek or Ro-
man physicians ; and we are unable to determine how long it has been
known in other parts ofthe world, or where it first made its appearance.
  The Arabian writers are the earliest we are acquainted  with, who
mention it.   Both Rhazes and Avicenna treat of it.  Of these, Rhazes
is the oldest.  The oldest writer on the small-pox whom he  mentions
[Ahron] resided at Alexandria, when it was besieged by the Saracens
in 640 of the Christian aera.  There is no distinct mention of the small-
pox earlier than this.
  The most prevalent opinion is,  that it first appeared in  the eastern
parts  of Asia, having been known  in  many of  these,  particularly  in
China, from very  early times.   Many circumstances, hoviever, tend
to contradict this opinion.   There is reason to  believe that it  raged
among the Abyssinians, when they besieged Mecca in the year 569 ;!
from whence it was probably introduced into Egypt by the Saracens,
spread with them along the northern parts of Africa, and accompanied
them  when they came to Europe-!

  * Cottunnius de Sede Var. p. 202.

  f See Dr. Woodville's History of Inoculation.

  t See Friend's History of Medicine from the days of Oaten to the begin-
ning ofthe 16th century. 
294
SMALL-POX,
  The opinion that the small-pox was first brought into  Europe by the
crusaders is unfounded, as Dr. Woodville has met with it, under the
name Variolae, in manuscripts ofthe Harlean and Cottonian Collections
in the British Museum, which bear  evidence of thaving been written
before the  year 900.   There can be  little doubt, however, that by
means of the crusaders the small-pox was more generally  disseminat-
ed *   It is mentioned by British writers as  early as the 13th century,
but at what time it was introduced into this island is  not ascertained.
In America it  was unknown  till carried thither by Europeans.
  This imperfect history of the small-pox, although there were no
other facts  on the subject, is sufficient  to prove, that it arises from a
peculiar contagion.
  The fatality of the small-pox soon led to  the employment of various
means to obviate its effects.   It is computed that one of six, who re-
ceive  the small-pox in the  natural way,  dies ; 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 this disease.!
Of these means by  far the most successful, if we except the introduc-
tion  ofthe  cow-pox, of which I shall presently have occasion to speak,
is inoculation.   In  the former editions  of this work I treated of it at
considerable length.  But as there is now reason  to hope, that inocu-
lation  for cow-pox will  soon  wholly supercede that for small-pox, I
shall not enter on the latter here.J

  * In some of the northern parts  of Europe, which have little intercourse
with the rest, the small-pox was not known, it is  said, before the beginning
©f the last centuary.
  \ " The celebrated Mr.  D.  La Condamine computes, that in France one
" in ten of all who are born dies ofthe small-pox.  Dr. Rosenstein, who wrote
a an excellent Treatise on the Diseases of Children, shews, that every tenth
" boy and every ninth girl dies  of it in Sweden, according to the accurate re-
" ports of the commissioners appointed to make the inquiry. In London, the
" births were to  the  deaths by the small-pox, as six  and a fourth to one ;
" in Manchester, as six and a half to one ; in Liverpool, as five and a half to
" one ; in Chester, as six and two-thirds to one."  See the Introduction to
Dr. Haygarth's  Sketch of a Plan  to exterminate the casual Small-pox, &c.
At certain times the small-pox proves much more fatal.  Of thirty-seven ill
ofthe worst kind of small-pox, attended by Baron Dimsdale  in Russia, thirty-
five died.

  % Those  who wish for a  knowledge of it, may consult  some ofthe follow-
ing works :—Dr. Alex. Monro, sen. on the  Inoculation of the Small-pox,  in
Scotland, Dr. Thomas Dimsdale on inoculation, 8vo. Lond/1781, Dr. J. Kirk- 
SMALL-POX.                       295
  The circumstance which has chiefly prevented the salutary effects of
inoculation  is, that the inoculated, like the casual small-pox, being con-
tagious, both are generally introduced at the same time. This circum-
stance banishes all hopes of preventing the casual small-pox by inocu-
lating for this disease.  But the labours of Dr. Jenner, which will for
ever place him in the first rank of the benefactors  of mankind,  have
supplied us with the means not only of preventing the casual small-pox,
but of wholly extirpating the disease.  It is painful to think how much^
they have been counteracted in this country.
   The Cow-pox has been long known in some parts of England, and
even known as a preventive against the small-pox, but Dr. Jenner first
called the attention  of the public to it, in a treatise entitled, " An In-
" quiry  into the Causes and Effects of the Variolae Vaccinae, &c." and
by a series of accurate and laborious experiments, proved its efficacy.
   Cows are subject to an affection of the teats, which appears in irreg-
ular pustules, surrounded  by an erysipelatous inflammation.  These, if
neglected, often degenerate ito troublesome eating sores, the animals-
seem indisposed, and the  secretion of milk is lessened.
   Inflamed spots often appear on  the hands  and wrists of those em-
ployed in milking such cows, at first assuming the appearance of small
vesications,  similar  to those produced by scalds.  They quickly, how-
ever, run to suppuration, the edges of the suppurating parts,  which
are generally circular, being raised.   Tumors  appear in the axillae,
and in many cases all the usual  symptoms of fever with more or less
severity supervene, occasionally attended with  pains in the limbs, and
loins, vomiting, head-ache, and even, though very  rarely, with deliri-
um.
  These symptoms continue from one to three or four days, and trou-
blesome sores are sometimes left on the  hands.   The lips, nostrils, eye-
lids, &c. are also now and then affected with ulceration, but this seems
to proceed from the patient  touching those  parts with  the hands, for

Patrick's Analysis of inoculation  of  the  Small-pox, 8vo. Lond. 1761, Mr.
Chandler's Treatise on Inoculation, Camper Sur les Avantages de  l'inocula-
tion et la meilleure methode  de l'administrer, Sir George Baker's Treatise
on the Inoculation of the Small-pox, 8vo. Lond. 1766, Mr. Burgess's Account
of die Preparation and Management necessary to Inoculation, Dr. Gale's  Dis-
sertation on the Inoculation of Small-pox, in America, Dr. Andrews's Prac-
tice of Inoculation, Impartially Considered, Mr. J. Mudgeon the Inoculation
ofthe Small-pox, 12mo. Lond. 1777.   In most of the works on small-pox
which I have had occasion to mention, the reader will find an  account of ,-.-
^dilation 
296-                      SMALL-POX-.
when eruptions appear in the cow-pox, at a distance from the inocu-
lated part, they are not apt to degenerate into sores.
   As the  cow-pox certainly does not belong to the exanthemata, nor
indeed I may say to febrile diseases, for fever is not essential to it, nor
even to its preventive effect with respect to the small pox,* I shall not
enter upon any account of it here ;  but refer the reader to the works
of Dr. Jenner, Dr. Willan, and others, and only make a few observa-
tions on its safety and efficacy as a preventive against small-pox.
   The cow-pox appears to be almost if not quite as good a preventive
against the small-pox as this disease itself is;  for  it  is  to be remem-
bered that there  is no  absolute preventive against the small-pox ; there
are  many instances of its having occurred two or more times in the
same person.!
   Ofthe proofs ofthe efficacy of cow-pox as a preventive against small
pox, I hope it is now unnecessary to say much, and if it were necessa-
ry,  the  following quotation  from the report of the College of Physi-
cians of  London would  be sufficient.    " The security derived from
" vaccination, if  not absolutely perfect, is as nearly so as can perhaps
" be expected from any human discovery ;  for, amongst several  hun-
" dred  thousand  cases, with the results of which the college have been
" made acquainted, the number of alleged failures have been surpris-
" ingly small; so much so as to form, certainly, no  reasonable objec-
" tion to the general adoption of vaccination ; for it appears, that there
" are not nearly  so many failures in a given number of vaccinated per-
tl sons, as there  are deatlis in an equal number of persons  inoculated
"for the small-pox.''''
   It has been alleged that the preventive power of the cow-pox, con-

   * " Vaccination," Dr. Jenner observes " gives complete security  to the
" constitution when no  indisposition has  been perceptable throughout th«
" whole progress of the pustules on the arm."   See a letter to Dr. Willan,
" in his Treatise on the Cow-pox.
   f Many instances of this, were it not that the fact is now generally admit-
 ted, might be adduced.  I have myself  seen the small-pox attack the same,
 person  a second  time.   In the second attack it appeared in the confluent
 form.  I  knew an instance of a person so deeply seamed with the small-pox
 that he received a nick-name from  it, who, notwithstanding had a second at-
 tack of  the  disease.   For similar.instances  the reader may consult the
 Inst. Med. Pract.  of Burserius, the Collect. Soc. Hafn. vol.  2. Hauler's Disp.
 ad Hist, et cur. Morb. pert. vol. 5.  Papers by Mr. Kite, and Mr. Withers,
 in the Memoirs of die Med. Soc. of London, vol. 4. &c.  In Dr. Jenner's con-
 tinuation of facts relative to the Var. Vac. Dr. Mills,  who had the small-pox
  a second time from inoculation, relates his own case. 
SMALL-POX.
29*7
tinues only for  a limited time.    But a sufficient number of instances
have now been adduced by Dr. Jenner,  and others,  to prove the fal-
lacy of this opinion.  Cases have been authenticated in which the
contagion of small-pox was  resisted by  those who had been casually
affected with cow-pox, forty, fifty, and even sixty* years before.
  But the prejudice which has most retarded the progress of vaccination
in this country is the opinion that it injures the constitution, and gives
rise to other diseases-!   We cannot have a more satisfactory refutation
of this prejudice than by again recurring to the report of the College
of Physicians.  " The testimonies before the College of Physicians are
" very decided in declaring, that vaccination does less mischief to the
" constitution, and less frequently gives rise to other diseases than the
" small-pox, either natural  or inoculated.   The  College  feel them-
" selves  called upon to state this strongly, because  it  has been object-
" ed to vaccination, that it produces new, unheard of, and monstrous
" diseases.   Of such assertions no proofs have been produced ; and af-
" ter diligent enquiry, the College believe them to have been the in-
" ventions of designing, or the mistakes of ignorant men."
   No man of common feeling can contemplate without emotion, the ef-
fects already produced by vaccination ; whole nations protected from
a pestilence which has  for ages been their greatest scourge.   In  what
tarms shall we speak of those, if there be any, who would knowingly
deprive mankind of such a blessing, and in what terms express our ac-
knowledgments to that individual, to whose exertions we owe it  ? ex-
ertions which will save more  of his species^ than all the calamities of
bii age,  great as they are, can destroy.
                           SECT. IV.


                  Oj the Treatment of Small-Pox.


  ,1 shall not, for reasons I have already mentioned, consider the treat-
ment of small-pox at the same length as in the former editions of this

  * See the report of the Medical Faculty of Kiel, upon the Cow-pox, in the
Duchies of Schleswig and Hoistein,
  | Fatal cases have occurred so very rarely, that we are inclined to doubt
 whether  in these, death was wholly to be  ascribed to this disease.  See Dr.
Woodville's Reports of a series of'Inoculation for the Vitriols Vaccinae.
                               . 38 
298                      SMALL-POX.
treatise.   For the sake of perspicuity I shall divide it into that of the
Distinct, and that of the Confluent forms of the Disease ; or rather, I
shall in the first place consider the mode of treatment in the former, and
afterwards point out the circumstances in which the treatment of the
Confluent differs from that ofthe Distinct.  And farther, to avoid confu-
sion, I shall refer the reader to the end of this section,  for the means
to be employed when those symptoms which have been termed ano-
malous appear, which will prevent interruption in laying down  the
general plan of cure.

   1. Ofthe treatment ofthe Distinct Small-Pox.

   It was soon observed  that the  appearance of the eruption in small-
pox generally brings relief, and  from this circumstance very unwar-
rantable  inferences were drawn, which for a long time influenced the
practice  in this disease, and, it cannot be denied, greatly increased its
fatality.
   Because the eruption was generally attended with a remission ofthe
symptoms, it was inferred, that the more copious it was, the more re-
lief it would bring.  All means tending to promote it were  therefore
employed, and whatever tended to check it carefully avoided.  By ex-
ternal warmth and stimulating medicines, physicians endeavoured to
support the fever ;  while evacuations and every thing else tending to
moderate excitement, were  forbidden.  A very extensive experience
has now  contradicted these maxims.   The mode of reasoning which
led to them,  the reader will perceive, is the same as that which has
been employed respecting the critical symptoms of fever, and the re-
trocession of eruptions, which I have had occasion to consider at length.
So far from the most copious eruption bringing most relief, the symp-
toms are always mildest when the eruption is most scanty ;  so that in-
stead 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  it may be as scanty
as possible.
   All that was said of this indication in speaking ofthe treatment of
synocha, is nearly  applicable to the case before us.   The chief differ-
ence is, that in the latter, the means for diminishing excitement should
be more  powerful in proportion to the excitement.   In  common syno-
cha, which  is succeeded by typhus, a liberal use  of antiphlogistic
■measures is seldom warrantable.   In  the eruptive  fever of .the distinct 
SMALL-POX.
299
small-pox,  on the contrary, the synocha is not succeeded by typhus
but terminated by the appearance ofthe eruption.
   Here indeed, such means are not only more safe but greater advan-
tage is to be expected from them,  the severity ofthe  ensuing disease
being more generally proportioned to the degree of excitement which
prevails in the beginning.
   The very effects which we dread from evacuations in  the common
synocha, may be the consequence of abstaining from them in the erup-
tive fever of small-pox ; for wherever it runs high, the secondary fever
is apt'to supervene ; and this, in spite of all we can do, often degener-
ates into a  bad typhus.
   It is not  to be inferred, however, that the use of antiphlogistic meas-
ures, and particularly evacuations,  cannot be too free.   Excitement
must never be unnecessarily diminished.
   Such are the principles which regulate the  treatment of the eruptive
fever ofthe distinct small pox.  Their application will be rendered
 easy by referring to what was said of the treatment of simple synocha.
I shall make a few observations on the most powerful remedies employ-
ed in this  disease.
   It is remarkable that Sydenham made little use of cathartics in the
 small-pox, at present regarded as  indispensable ; and very generally
 recommended venesection, the propriety of which in ninety-nine cases
 of one hundred is now called in question.
   It is an observation to which there are few exceptions, that blood-
 letting is only to  be employed when the effects expected from  it  can-
 not be procured by other means.  Of all remedies it may  be consider-
 ed the most dangerous.  There is no disease which tends  more  direct-
 ly to impair the powers of life ; and in many cases it is often doubtful
 whether the disease, or the loss of blood which relieves it, is most to be
 dreaded.
    It is true indeed, that in cases of unimpaired vigour, a moderate loss
 of blood is not attended with danger.  But in the strongest its frequent
 repetition is  always to be feared, and a prudent physician, as he can-
 not with absolute certainty foresee the course of any disease, and still
 less what new diseases may supervene, will reserve so powerful a rem-
 edy, lest  symptoms should appear  that may render  it indispensable.
  It is one of the first maxims in the treatment of febrile diseases,  to
  save  the patient's strength as much as possible, that our practice may
  have sufficient latitude, if I may use the expression ;   when it is cramp
  ed by debility, the danger i.- always great. 
300
SMALL-POX.
    We are to inquire then what advantage is to be expected irom blood-
 letting here,  which cannot be procured by less debilitating means.
 The question seems easily answered ;  if it be admitted, that diminu-
 tion of excitement is the  only effect to  be expected from blood-letting
 in idiopathic fevers,* there can be no occasion for this remedy while
 cool air and mild cathartics,  by which only the thinner and  less im-
 portant parts ofthe blood are evacuated, sufficiently diminish the ex-
 citement.   When  the  increased excitement resists gentler means,  a.e
 it is of the greatest consequence that it  should be reduced at an early-
 period, we must have recourse to it; and here the following remark of
 Sydenham is fully warranted by experience, " Vulgare illud atque tra-
 " latitium argumentum, quo adversus phlebotomiam aliasque evacuati-
 " ones utuntur, nempe quod non Jiceat a circumferentia ad centrum ino-
 '* vere humores, cum natura in hoc morbo contrarium adfectare videa-
 '* tur, nullarum plane virium est."
   When blood-letting is improper before the eruption, it must be still
 more so after it, when the  fever either  becomes milder or wholly disap-
 pears.  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 will not be reliev-
 ed by the appearance of an eruption, but will suddenly assume  the
 form of typhus, if the antiphlogistic plan be carried too  far.
   Some authors, and those of  the highest authority, have recommend-
 ed blood-letting, at the very termination of the disease, or rather after
 every symptom  of it has  disappeared.!  This practice is now very
 generally abandoned, unless symptoms demanding blood-letting super-
 vene.  It was not  however, the mere offspring of hypothesis.  The
 small-pox, like  some of the other exanthemata,  we have seen, often
 leaves behind it a predisposition to inflammatory diseases; but it is sufli-
 cient to have recourse to blood-letting when  the presence of these rend-
 ers it necessary.   The reader may consult what was said above, con-
 cerning blood-letting during the apyrexia of intermittents, which is ap-
 plicable to the case before us ; in which  indeed there is an additional
 argument  for  not  letting  blood till the  symptoms requiring  it shew

  • See the observations on this subject in the Chapter on the Treatment of
Continued Fever.

  f See Sydenham de Variolis.   Mead's  Monita et Pracepta Medica cum
Notis Wintringhami, &c. 
                          SMALL-POX.                      30!

themselves, namely, that there is much less chance of their appearance
than ofthe recurrence ofthe paroxysm of an intermittent.
   Local blood-letting, by scarification ofthe temples, or leeches appli-
ed to them, is a valuable remedy, where the coma or inflammation of
the eyes is considerable.
   Although I was only considering the treatment of the eruptive fever,
when I had occasion to mention b'ood-letting, it appeared a more dis-
tinct plan to collect in one place the remarks to be made on this reme-
dy,  than repeatedly to mention it in speaking ofthe different stages of
the disease.
   Of all the means employed for moderating excitement in the erup-
tive fever, none has proved so generally beneficial as the  application
of cold.   Sydenham* was the first who in this country introduced the
cool regimen in small-pox ; one of his greatest improvements.   The in-
jury done by a high  temperature, and the advantage of a free admis-
sion of cool air, in continued fever, have been pointed out.   Both are
still more remarkable in small-pox.
   The advantage of the  cool regimen in this disease has long  been
known in the East; it is only lately, however,  that it has  been intro-
duced into Europe, for even the authority of Sydenham could  not ren-
der  it prevalent.   It is now practised to a greater extent than he ventu-
red to recommend.
   The patient should at no period be confined to the house, whatever
be the season, unless the fever  be such as confines him to bed.   He
should lie with few bed-clothes, and on a mattress ; his room should be
cool;!  and a free use of cold drink and frequent changes of cold  linen
are equally grateful and salutary.
   There can be no doubt, however,  that the cool  regimen, like every
other practice, may be  carried too faT.  Dr. Makittrick Adair,!  in  a
letter to Dr. Duncan, makes some observations on the Suttonian plan of
treatment; that is, the very low diet and free  exposure to cold ; and
alleges that it often does harm, especially when carried so far as en-
tirely to prevent the eruption.   This, however, rarely happens, and

   * See his chapters De Variol. Regular. An. 1667, 1668, 1669 ; and De Va-
riol.  Anomal. An. 1670,  1671, 1672.

   f See what was said of  diminishing the temperature ofthe patient's bed-
room, in the treatment of continued fever.

   t See the 8th volume of the Medical Commentaries. 
302,
SMALL-POX,
although Dr.  Adair's  observations certainly  demand attention, ut
comparing them with those of other writers, as well as with what we
every day see, it will appear, I think, that he endeavours too much to
restrict the employment of the cool regimen.
  Many have  advised us to continue the exhibition  of cathartics and
the cool regimen in their full extent after the eruption  is finished, and
even when the fever has almost or wholly disappeared.  But if our
view in the employment of these means, is to moderate excitement, of
what service can  they  be when the excitement has returned  to the
healthy degree ? and the truth is that  when employed to any consi-
derable extent they are then found to do harm.   The opposite ex-
tremes of constipation and a heated atmosphere, however, even at this
reriod, are still more prejudicial.*
  If, on the other  hand, the remission  is inconsiderable on the com-
pletion of the eruption,  the use of cathartics and the cool regimen is as
necessary as at earlier periods ; and as  they  are the best  means of
moderating the eruptive fever, they are also the most effectual for pre-
venting the appearance ofthe secondary ; which is always to be feared
under these circumstances.
  The use of the cold affusion has been extended to the small-pox, and
it is said with  great success.   Its employment  in this disease is regu-
lated by the same rules as in continued fever.   In the worst forms of
the disease in  which the typhus shews itself at an early period, it is a
doubtful remedy, as may be  inferred from the observations of Dr. Cur-
rie, above quoted.   In  the second  volume of the last  edition of. his
work, he relates two cases of confluent  small-pox, in one of which the
cold, and in the other, the tepid, affusion were  employed  without suc-
cess.
  The Indian.1-. Dr. Rush informs us, plunge themselves into cold wa-
ter as soon as  they perceive the eruption 01 small-pox; which is found
to moderate the disease.  Cold bathing in the  small-pox has also been
practised by Europeans in sultry climates.   A  person who had spent
many years in the East-Indies, informed me, that  when  the pustules
have a flaccid unfavourable appearance,  on the use of the  cold bath

  *. A very striking instance of the injury done by  an unguarded relaxation
ofthe cold regimen is related by Mr  Perkins, in the "d vol. of the Medical
Observations and Inquiries. 
SMALL-POX.
303
     they become in the space of a few minutes both  prominent and well
     filled.
        Although the eruptive fever in the distinct small-pox is always a sy-
     nocha ; if the fever has continued after the enption, and especially if
     the secondary fever has supervened, a greater or less degree of typhus
     always shews itself; and then the treatment is the same as in typhus
     from other  causes.

        2. Ofthe Treatment of Confluent Small-pox.

        The more alarming the eruptive fever, the more assiduous,  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 has some-
     times 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 apprehended ; and there, it ap-
      pears  from the observations of authors, chiefly at  the time of matura-
      tion.   It will be found, however, on reviewing the history of such ca-
      ses, that previous to the  exposure to cold, the patient had  generally
      been debilitated by the hot regimen, or other improper modes of prac-
      tice.   When the disease has  been properly treated  from the com-
      mencement, retrocession is very rare ;  and  even where  the  hot regi-
      men has been employed, unless the application of cold be  very incau-
      tious,  it is generally attenJed  with  the  best effects!.   The employ-
      ment of the cool  regimen, like that ofthe cold affusion, must, of course,
      be regulated  by the temperature of the patient, otherwise great mis-
      chief may be done.
        There is but one form of small-pox in which the good effects of the
      cool regimen have been called in question.   Dr. Rogers, of Cork, who
      had extensive opportunities of  treating the crystalline small-pox, de-
      clares that he has not there found it produce its usual good effects.
        No part ofthe treatment of confluent small-pox  demands more atten-
*     tion than the employment of cathartics.   Practitioners were first led to
      recommend  catharsis in confluent small-pox from  observing that when

        * See the observations of Dr. Dimsdale, and  others.
        f See the observations of Sydenham, and Sir George Baker, in hi"  Trea.
      tise on this disease. 
304                       SMALL-POX*
a spontaneous diarrhoea occurred, especially  if  it appeared" early w,
the disease, the pustules were less numerous, the fever more  moderate
and the swelling of the bead less considerable*.
  The  reader will find cases to prove  the benefit of  purging in the
confluent small-pox in Dr. Walker's Treatise, and in that of Dr. Friend,
entitled " De Purgantibus in Secunda Variolarum confluentium Febre
" adhibendis."  " Vides ut aliis," Dr.  Friend remarking on these ca-
ses, observes, " inopinatam  praesentissimamque opem attulerit pur-
" gatio ; ut aliis paulisper subvenerit cunctatius per vices repetita."!
  Cathartics produce their good effects most slowly, and their frequent
repetition consequently is most  necessary where the excitement  is
greatest.
  Upon the whole it appears,  that  they are  useful at all periods  of
small-pox, and particularly during the eruptive fever, and  at the time
the secondary fever  is expected, unless a  diarrhoea has  supervened ;
and that the more  severe the disease, even although  the  symptoms of
typhus have come  on,J as I have myself witnessed, they are the more
indispensable.
  The  use of cathartics  in this disease has perhaps been carried too
far by some 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 cathartics,  or
employ only those of the gentlest kind.
  It has long been a practice  in eastern countries, and  it is recom-
mended by some late European writers, Tissot, Burserius, and others,
to dischasge  the matter of the pustules by piercing them with fine nee-
dles, which occasions a copious secretion by the skin ;  for the pustules
soon fill again, and are again opened, which  is  always done by mak-

  * Dr. Cleghorn's Account of the Diseases of Minorca.

  f Dr. Friend even relates one case, in which the gangrenous blisters  men-
tioned by Sydenham, and which he always found a fatal symptom, appeared ;
which treated with mild cathartics terminated favourably.  There are some
good observations on purging in small-pox  by Dr. Simpson, Professor of Me-
dicineat St. Andrews's. For this practice the  reader may also consult the
works of Hoffman, Huxham, Mead, and Wintringham.

  % "If an apprehension," say's Dr. Walker, " of weakening the vital powers
" in this species of small-pox," viz. the putrid, " when neither diarrhoea nor
" any other apparent evacuation occurs, excepting what is discharged by the
" salivary glands, induce us to suspend purging altogether, or  even  delay it
'' long, tire prognosis in every case of this sort, must be desperate.'* 
SMALL-POX.
305
ihg 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 between the prevention of the
secondary fever in this way and by the use of cathartics ; but how an
increased secretion either by the skin or bowels acts in preventing it, it
is impossible to'say.
   More harm may be done by incautious blood-letting in the confluent,
than in the distinct small-pox, and it is more  difficult to  determine
when it should be employed.  In the former the eruptive fever is very
often characterised by  great excitement, accompanied with  violent
pains ofthe back, breast  and head ;  so that an inexperienced prac-
titioner would judge copious blood-letting necessary.  Those acquaint-
ed with the disease, however,  will recollect, that these symptoms are
the forerunners of a confluent eruption, and that symptoms of  typhus
will suddenly supervene if the excitement  is too much reduced.   The
pustules will assume a more  unfavourable character, and the patient
often sink under that train of symptoms which has been termed putres-
cent.!
   With respect to the treatment  after typhus has supervened, almost
all that was said ofthe treatment of this fever is applicable here.
   The typhus may either, as  in the worst cases,  shew  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 followed by any considerable
degree of this fever.   In anomalous cases,  it often precedes, and more
frequently follows a distinct eruption.
   The earlier the typhus shews itself the tonick  plan is the more indis-
pensable.
  Morton was among the first practitioners who employed the bark in
confluent small-pox. Those who succeeded him adopted the practice,
but the late  Dr. Alexander Monro was the first  who gave it freely in
this disease.  It  is now employed with  the same freedom as in com-
mon typhus.   By the use of the bark,  Dr. Monro observes,  empty
vesicles were filled with matter;  watery  sanies changed into  white,
thick pus ; while petechiae became paler,  and  at last  disappeared.

  * It has been considered as dangerous to admit air into their cavities.

  f The reader will find these observations illustrated in a striking manner,
in Dr. Cleghorn** Account of a Malignant Small-pox which raged in Minorcs
                               39 
306
SMALL-POX.
Whatever  restores vigour, changes  at the same time  the state of the
matter, from which in most  cases the prognosis may with great cer-
tainty be collected.
   In many cases other astringents are employed with advantage.   Al-
um mixed with Peruvian bark, Vogel* observes, is the best of all me-
dicines when the pustules are bloody.   Dr. Wall! also insists oh the
advantage of alum in such cases.   The sulphuric acidj has been just-
ly celebrated in all the worst forms of this disease.   Acids§ of all kinds
have been much employed.   Dr.  William Wright|| particularly recom-
mends a mixture of vegetable acids and common salt in this and all ca-
ses called  putrid.
   I shall consider  the treatment of the anomalous symptoms the more
at length,  as the same  observations apply to  the other exanthemata
when similar symptoms appear in them.
   Inflammation of the brain is a  more frequent  accident in  the cry-
stalline than in other forms of small-pox.  When the patient is attacked
with an acute pain of the head, or delirium ;  when the  eyes  are infla-
med,  and  incapable of bearing the light, the carotid and temporal ar-
teries beating strongly while  the pulse at the wrist is small and feeble,
we have reason to   fear inflammation of the  brain, the treatment of
which  will  be considered  at length in the next volume.  The chief
difference  in the treatment of idiopathic phrenitis,  and  that we are
speaking of, is, that we can seldom  employ venesection  so  freely in
the latter,  and must trust more to local means.
   Inflammation is  also  apt to seize on other viscera, particularly the
lungs,  occasioning much difficulty of breathing and cough ; a similar
observation applies to the treatment  in this case-
   Dyspnoea often supervenes  in small-pox from other causes, a pustula-
ry affection of the larynx, trachea, and larger branches of the bronchiae,
or an unusual degree of swelling  in  the fauces,  which also  impedes
deglutition.   In these cases, large blisters applied as near the part af-

  * Praelect. Acad. &c.

  f Philosophical Transactions, No. 484, §. 4.

  i Dr. Brocklesby mentions an instance in which recovery seemed owing to
the exhibition ot large doses of this  acid.  The patient took no less than aa
ounce of the acid. vit. ten. daily.

  § I am induced by long and repeated experience, says Tissot, to regard
mineral acids as the most valuable remedy we have in the small-pox.

  U See Dr. Wright's Letter to Dr. Morgan. 
sM ALL-POX.
J01
fected as possible, are  the  most successful remedies.  The same may
be said  of difficulty of deglutition in consequence  of the viscidity of
the saliva, in which gargles, such as those recommended in the aphthfe
infantum, should at the same time be employed.  Bang recommends a
gargle, of oxymel of squills and water, and the application of sinap-
isms to the bands  and  feet, with gentle laxatives ; and if the difficulty
of breathing be great, the antimonium tartarisatum.  Dr. Brocklesby
observes, that small doses of ipecacuanha tend to restore the salivation
when it is either suppressed, or too viscid, and to alleviate the dyspnoea
which often attends this  accident.   When the state  of the fever admits
of vomiting, it is often the means of relieving the swelling of the fauces
 and promoting the secretion of  saliva.*  The dyspncca which conies
 on upon the sudden interruption of the salivation, seems often to arise
 from a degree of pneumonia.
   The salivation, on  the other hand, is  sometimes so copious  as to
 threaten  suffocation from the fluid falling constantly into the trachea,
 especially where there  is  any degree of  coma.   In this case Vogel
 thinks cathartics  the most successful  remedy.
   Profuse diarrhoea is a troublesome  symptom in confluent small-pox,
 particularly in children.  Unless it should  produce a dangerous debil-
 ity, we must be cautious how we check it; and  even when it does
 occasion much debility, the  safest plan is  to endeavour to lessen the
 discharge by tonic medicines.   There is  perhaps no instance, except
 towards the termination of the disease, in which the diarrhoea should be
 stopped by opiates and astringents, unless  it is so  profuse  as to threat-
 en danger, and then it  is to be stopped very gradually ; and when the
 medicines produce too sudden an effect, they must be counteracted by
 aeutle laxatives.  The  diarrhoea  is sometimes, though 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
 strength and preventing the exhibition of medicines.  If  from the na-
  ture of what  is evacuated the vomiting appears to proceed from irn-
  litin- matter collected in  the stomach, we must in the first place by
  draughts of some mild  fluid assist the stomach to  empty  itself,  and it

    * Dr Cameron dissuades from vomiting in this case, and alleges that it has'
       imes occasioned suffocation.   He strongly recommends  breathing the
       of a decoction of marshmallovvs, myrrh and honey in vinegar and water.
sometimes occasion
steam
Seethe 22d vol. ofthe Gentleman's Magazine. 
 308                      SMALL-POX. „

 the matter discharged be bilious or acid,  we must endeavour  to cor*
 rect 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 inoffensiveness of the
 matter  rejected,  we must have recourse to such medicines as tend to
 allay its irritability.   These  were  pointed  out in speaking  of  the
 same symptom in continued fever.   The extract of cascarilla given  in
 some agreeable distilled water often allays vomiting.*   In many cases a
 blister applied to the pit ofthe stomach succeeds.   If it arises from any
 degree of inflammation or a  deranged  state of  the  bile, the  means
 which correct these must be employed.
   The sweating is sometimes so profuse  as considerably to reduce the
 strength.  In the worst forms of the disease, however and in infants in
 any form of it, this symptom  rarely appears, so that its excess  is less
 to be dreaded*   When it shews a tendency to become profuse, the pa-
 tient should avoid being in bed in the day time, which with the cool
 regimen, laxative plan, and sulphuric acid, almost always sufficiently
 counteracts it.
   A suppression of urine sometimes comes on, particularly in the con-
 fluent and  anamolous  forms of  the disease, and proves  obstinate.
 People in the vigour of life, and particularly  those  accustomed  to a
 free use of spiritous liquors, are most liable to this symptom.  It seems
generally to arise from neglecting evacuations at the commencement of
the disease,' or keeping Ihe patient too warm.
   If, as frequently happens, it be attended with costiveness, we 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  current of cool air.  The
 same practice is recommended by Bang! and others. Dr. Cameron of
Worcester observes, in the 22d vol. of the Gentleman's Magazine, " To
" facilitate the discharge of urine which is often difficult in the small-
 " pox, Sydenham directs us to get the patients up and lead them about
 '• the room,  but I would beg all  young  physicians to read Hoffman's
 " Dissertation, De Situ erecto, in Morbis periculosis valde noxio, be-
 " fore they either advise or allow of this practice.  I have known sud-
 " den and 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

  * See Vogel's Obs. on the Treatment of Measels in his Prslcct. Acad.
! Praxis Med, Systematic* fcxposita. 
SMALL-POX.
309*
 " to be had, for that  will seldom fail to answer this  intention.  The
 former psrt of this observation, however, is chiefly applicable to cases
 where the debility is considerable.  Where there is much excitement
 the case in which suppression of urine most frequently  happens,  al-
 though it may be proper in the first place to try the salt of amber, there
 is little hazard in adopting Sydenham's plan ; and where the increase
 of temperature is  steady and there is no moisture on the skin, if this
 pbn fails it may be proper to dash cold water on the  legs, as is-some-
 times practised to solicit the  alvine discharge.  If there is no absolute
 suppression of urine, but frequent  and painful micturition, small  doses
 of camphire and extract of white poppies given at intervals, will often
 relieve it.
   One or two epileptic fits,  it was observed above, even in  the  mild-
 est forms ofthe disease,  frequently precede the  eruption without being
 attended by danger.   In the confluent and anomalous forms of the dis-
 ease, however, the fits,  we have seen,  are more frequent, and in pro-
 portion to their frequency more to be dreaded.  This  symptom is rare
 in adults, but in them it is most dangerous.
   Blood-letting was at one time very generally employed to remove or
 prevent them, but practitioners now agree that it is seldom successful;
 and the operation of blisters, Dr. Cullen observes, comes too late.
   As the violence and frequent repetition of the fits generally depend
 on the violence of the primary disease, the various means of moderat-
 ing this, are the best for moderating and preventing the fits.  But of all
 the means which have been employed, none has been found so success-
 ful as opium, and  the warm bath.   On opium Dr. Cullen chiefly dc
 pends  and advises its exhibition per anum while the fit lasts.
   These are not only useful  as antispasmodics but also by  promoting
 perspiration, one ofthe best means, it has been found, to prevent the
 return of the fit.   Dr. Walker recommends for this purpose a prepara*
 tion similar to the compound powder of ipecacuanha.  Vogel with the
same view  recommends  a mixture of cinnabar,  the sulphur antimonii
praecipitatum and musk.  The last is also recommended by Dr. Brock-
 lesby' and Bang, who likewise employed some other of the medicines
 termed  antispasmodic.   There are none of these, however, much to
 be relied on.  Cataplasms applied to  the extremities are sometimes
serviceable.  Whatever other means are employed, laxatives are not
to be neglected, as the irritation of retained faxes may renew the fits,
especially in children. 
310                      SMALL-POX.
   The pustulary affection ofthe eyes is often very troublesome, and i»
sometimes, we  have seen, followed  by loss of sight.   When the pus-
tules  are numerous on the face, the  use of mild and gently  astringent
eye-washes should never be neglected.   M. De Lassone* recommends
frequently wetting the eyes and eye-lids with rose-water, in order to
prevent the appearance of pustules ; or if they have appeared,  to di-
minish inflammation.   Burserius recommends water, in which ignited
iron has been quenched.
   It is of great  consequence to prevent the eye-lids from growing to-
gether, which is often the source of all the mischief, increasing the pus-
tulary affection  and preventing the use of colly ria.   This accident may
generally be prevented, by bathing  the eyes, from time  to  time with
warm milk, and annointing the tarsi with any mild ointment.
   When the load  of pustules on the face is very great, it has been re-
commended to immerse the extremities in warm water, and apply sin-
apisms to them, or even to scarify them.!  Vogel  condemns  the com-
mon practice of moistening the face, with a view to prevent or moder-
ate the eruption there.  When pustules have actually appeared on the
eyes,  we must have recourse to emollient poultices and mild mucilagi-
nous decoctions  ;|  and fomentations are useful when there is much swel-
ling of the eye-lids.
   It has been observed above, that  in small pox, as in other eruptive
fevers, a retrocession of the eruption sometimes happens, attended with
an alarming train of symptoms.   I have already had occasion to point
out the  means to  be employed on the retrocession of other eruptions,
and the observations then-made are applicable to the case before us.
   The treatment  is in  some measure  influenced by the  causes  which
produce the retrocession.   The chief of these are, the sudden applica-
tion of cold when  the hot regimen has been  employed particularly if
the cold be applied about the time of maturation and when the patient
is  much debilitated ; the excessive  employment of the hot regimen ;
fatigue from remaining too long out of bed  or  in the erect  posture ;
syncope; strong affections ofthe mind particularly terrour  or  grief;
and above  all, profuse evacuations.

  * Memoire sur quelques Moyens de remedier aux accidents graves dans
les Petites Veroles, in the 3d vol. of the Histoire de lu Socieie Royale de Med-
ecine.
  ! Vogel De Cog. et Cur. Morb.
* See the Observations of Burserius and Tissot. 
SxMALL-POX.
311
  The  remedies of  most general application are  wine and opium.
These,  Rosen* observes, are particularly indicated when the retroces-
sion is the consequence of profuse evacuations.   When it is the conse-
quence  of the sudden  application of cold, increasing the temperature
and even the warm  bath are generally of service, and the  application
of sinapisms and blisters in  this case is particularly recommended.
When it is the effect  ofthe hot regimen, cool air must he cautiously
applied.  Musk and camphire, as in other cases of repelled  eruption,
are very  generally  employed, but little to be  depended  on.  Vogel
thinks ammonia, the  semicupium, and blisters applied to the  feet,
the most  successful  remedies.  If a diarrhoea supervenes on the retro-
cession ofthe eruption, as in other similar cases, it is generally of ser-
vice and should  not be checked.   Some have  recommended  blood-
letting.  But if, as Burserius justly  observes, whatever  debilitates
tends to occasion this accident, blood-letting is surely the last means
we should think of employing.!
   When the swelling of the face subsides, (especially if it subside sud-
denly) and is not followed by that of the hands, Dr. Brocklesby re-
commends the application of blisters to the wrists and fore arms, which
often excites the swelling of the hands, or  if not, tends to obviate any
consequences to be feared  from  its absence.  He  recommends the
same practice when  the salivation suddenly ceases without swelling of
the hands.   When  towards the period of maturation there is reason
from the debilitated state of the system to apprehend that the swelling
ofthe face may suddenly subside, Dr. Cameron, in a paper just alluded
to, recommends the following plan, to which the author's extensive expe-
rience naturally calls our attention. " On the day before the face  is ex-
" pected  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  known adults in the  confluent small-pox in
" less than an hour 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 and fill  even to bursting  with  laudable pus,
" and this dangerous  period pass  without  one alarming symptom."

   * Halter's Disp. ad.  Hist, et Cur. Morb. pert.

  f The reader who lias sufficient knowledge of Medicine to separate fccr*
from  theory,  will find some excellent observations  on blood-letting in t!>
case, in Or Cameron's Paper in the 22d vol. of the Gentleman's Magazine. 
312                      SMALL-POX.
 About the same period the whole body has been anointed with mercu-
 rial ointment apparently with good effects.
    When the  swelling of the face and neck is excessive, bathing the
 lower extremities  and applying sinapisms to them, often  relieve 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, and the tepid bath seem
 frequently to promote its appearance.  The first of  these means must
 of course be employed with caution.
   When the pustules are longer of drying than usual, they  should be
 opened; and if the dried pustules adhere  too long, fomentations are
 Uie best means to make them separate.
   When the patient is plethoric we may let blood with a view to stop
 hemorrhagies; in other cases we must  trust  chiefly to astringents.*
 The serum lactis aluminosum has been particularly recommended, es-
 pecially if the hemorrhagy be from the skin, tinging  the matter of the
 pustules.!
   When pustules appear in the nares and fauces, Tissot recommends
 washing them frequently by means of injections.  This is preferable
 to gargling, as the rriotion of the throat in gargling sometimes increases
 the pustulary affection.
   We have been advised to open the tumours, which  now and then ap-
 pear  after the  small-pox, if they have  suppurated ; if not, to apply
 poultices to promote the suppuration.   The propriety ofthe latter prac-
 tice, particularly in scrophulous habits, is doubtful.  When the sore does
 not heal  readily,  the  bark is serviceable, if there be no tendency to
 visceral inflammation.
   Various  means have been proposed to prevent  pitting, but none of
them seem to have answered the. expectations of those  who  proposed
them.
   It is a prevalent opinion  that  exposure  to the air is the cause of
pitting, from its not  happening  to parts which are  covered.   It has
therefore been proposed to cover the face with something that shall ex-
clude the air.  The reader will find an account of this method, and ar-
guments for having recourse  to it, in Dr. Walker's  Treatise on Small-

  * Burserius's Inst. Med. PraCt.  The various means both local and gene-
ral to be employed in hemorrhagy will be considered in another part of  this
Treatise.

  | Sec the foregoing observations on Uie use of alum  and Uie bark: 
CHICKEN-POX.                    313
pox.  It would require an extensive experience to determine its  sue*
cess, as pits are not always the consequence of even a numerous erup-
tion.  Our faith in it  is lessened by  reflecting that the hands  are of-
ten as much exposed to the air as the face, and that there is something
in the  disease which  determines it to affect the face in preference to
other parts.  The pustules and swelling always appear first on the su-
periour parts of the body, and the former are there most numerous, and
in the more severe forms ofthe disease, of a less benign appearance.
Besides, children, I have  already had  occasion to observe, have  been
born marked with the small-pox.
   Other means have  been proposed  for preserving the face,* but it is
needless to give an account of them, as none have been found such a,s
would encourage us to recommend them.
CHAP. II.
Of the Chicken-pox.
SECT. I.
                 Of the Symptoms of Chicken-pox.


  The Chicken-pox, Varicella, as it is termed by medial writers, is
defined by Dr. Cullen,
  " Synocha, papulae post brevem febriculam erumpentes, in pustulas
il variolae similes,  sed vix in  suppurationem euntes, post paucos
'* dies in squamulas, nulla cicatrice relicta, desinentes."

  * See a paper by Detharding in Uie 5th vol. of Haller's Disp. ad Hist, et
Cur. Morb. pertinent. 
314
CHICKEN-POX.
   The chicken-pox is so mild a disease, that it seldom requires the as-
sistance of the physician.  It resembles  the mildest  cases  of small-
pox.
   In all cases of small-pox, the disease begins with more or less fever,
on the third or fourth day of which the pustules appear.  In the chick-
en-pox, the eruption in many cases, appears without any previous sign
of indisposition.   In others, the pocks are preceded by a degree of
chilliness, lassitude, cough, broken sleep, wandering pains, loss of ap-
petite, and feverishness for two or three days.*
   On the first day of the eruption the pustules are similar to those of
the small-pox ; on the second day there is formed on each a small blad-
der which contains sometimes a colourless, sometimes a yellowish, flu-
id ; at this time, or at farthest, on  the third, day, the  pocks arrive at
maturity, and those  which are fullest very much  resemble  what the'
small-pox are on the fifth  or sixth day.   It frequently happens,  how-
ever,  either by the rubbing of the clothes,  or the patient's scratching
to allay  the  itchiness,  that the vesicles are broken on the first or se-
cond day of their appearance.   When  this  happens,  the pustules,
previously more or less raised, subside, and the matter forms  a crust
without having assumed  the yellow colour.  ' Even in those pustules
which escape being broken, it has very little of the purulent appear-
ance.  On the  fifth day  of the eruption  the pustules  are dry  and co-
vered with crusts, which in the small-pox does not happen till  the eighth
or ninth day, that is, the  eleventh or twelfth of the disease.   The pus-
tules in chicken-pox are less inflamed, and their size is sometimes less
than those of small-pox, but in the latter respect there is often little dif-
ference.
   The chicken-pox  is rarely  confluent! or very  numerous.    The
greatest number which Dr. Heberden says  he ever saw,  was  about
twelve on the face and two hundred  on  the  rest of the body.   The
eruption  sometimes makes its first  appearance on the  back.   When
this happens, it affords  another mark of distinction, the eruption of
pmall-pox always first appearing about the face, neck, and breast.
   The last circumstance mentioned in Dr. Cullen's definition " nulla
" cicatrice relicta," assists but little in forming the diagnosis, the mild-

   * Dr. Heberden's Obs. Med. Trans, vol. i.

  \ The chicken-pox is'sometimes confluent.   See Dr. Willan's Treatise on
Vaccine Inoculation.  Mr. Ring has given a coloured engraving of confluent
chicken-pox in the Med. and Phys. Journal, 1805. 
CHICKEN-POX.
315
er kinds of small-pox being rarely followed by pitting,  and pitting
having sometimes, though rarely,  been the consequence of chicken-
pox.
   Upon the whole, then, the small-pox and chicken-pox differ, in the
eruption of the former being preceded by a fever of a certain duration,
while that of the latter is either preceded by none,  or one of uncer-
tain duration ;  in the vesicles and succeeding scabs  appearing much
earlier in the chicken-pox than in the small-pox ; in the matter of the
former never acquiring the purulent appearance, which it always does
in the distinct small-pox, the only form of the disease which  can be
confounded with  chicken-pox.  As the chicken-pox runs its course ra-
pidly, and not at the same time on different parts of the body, those
pustules which first appear,  first coming to maturation and decaying,
we may see,  about the fifth or sixth day, pustules in all their various
stages.   " This circumstance," Dr.  Willan observes, in  a work just
referred to, " majr be added to the diagnostics of Varicella, as it can-
" not take place  in the slow and regulated progress ofthe small-pox."
The  diagnosis between these diseases is important,  as it is of conse-
quence  to know whether or not a person has had the small-pox.
   With respect to the prognosis  of  chicken-pox,  it  is so uniformly
good, that practitioners are less  acquainted with this disease, than
with  most other eruptive fevers ;   and we have reason to believe that
it has not only been mistaken  for small-pox, but that its matter has
been used for that of small  pox in inoculation.
   Dr. Heberden describes  a disease which he  believes to be only a
more severe species  of chicken-pox, in which the  symptoms of the
eruptive fever are considerable and continue for three or four days be-
fore the eruption appears.   Nor does the fever remit on the appear-
ance of the eruption even  where there are but  few pustules.  The
pustules are redder than in the common chicken-pox, spread wider,
but hardly rise so high, and instead of one little vesicle, they have
from four to ten or twelve.   In other respects they resemble the com-
mon  chicken-pox.   He  thinks  the  swine-pox and chicken-pox  the
same disease.  See also the 1263rd  and 1264th paragraphs of Lobb's
Practice of Physic.  The reader will  find an excellent account of
chicken-pox in Dr. Willan's Treatise on Vaccine Inoculation.  He al-
so considers the swine-pox, and .likewise what in the northern parts of
England and in Scotland is called the hives, but in the southern parts
of England is included under the term of swine-pox, as varieties of 
316
CHICKEN-POX.
chicken-pox.   So that he divides this disease into three varieties, and
with great accuracy points out the diagnostic symptoms of eacb*
SECT. II.
                  Ofthe Causes of Chicken-pox.


  The Cbicken-pox, like other exanthemata arises from a specific con-
tagion, which seems to produce the disease about the same period afc
ter infection with that of the small-pox.    Dr. Heberden thinks that
people are not liable to a second attack of chicken-pox.   " I wetted
** a  thread"  he observes, " in the  most  concocted  pus  like  liquor  of
" the chicken-pox which I  could find, and after making a slight inci-
" sion, it  was confined on the arm of one who formerly had the dis-
" ease, the little wound healed up immediately, and shewed no signs
" of any infection"
SECT. Ill,
                 Of Hie Treatment of Chicken-pox,.


  The  treatment of  chicken-pox  is very  simple,  and  differs-  in
nothing from that of a gentle synocha.  The mildness ofthe symptoms
renders blood-letting and other powerful means unnecessary.  Cooling
saline cathartics in sufficient quantity to keep the bowels open, with a
mild and diluent diet, form the principal part of the treatment.   With
respect to temperature and exercise^ they should be regulated by the
patient's feelings. 
MEASLES,
347
CHAP. III.
                         Ofthe Measles.

   The Measles, or, as it is termed by medical writers, Rubeola, Mor-
 billi, or Febris Morbillosa, is defined by Dr. Cullen,
   " Synocha contagiosa  cum sternutatione epiphora, et tussi sicca rau-
 " ca.   Quarto die, vel paulo serius erumpunt papulae, exiguae, confer-
 " tae, vix eminentes, et pest tres dies in squamulas furfuraceas minim-
 M as abeuntes."
   Dr. Cullen divides this disease into two species, the Rubeola Vulga-
 ris, and Rubeola Variolides.   The former he defines.
   *' Rubeola, papulis minimis confluentibus corymbosis, vix eminenti-
 " bus."
   Under this species he  ranks three  varieties.
   1.  " Rubeola Vulgaris, Symptomatibus gravioribus et decursu minus
 " regulari."
   2.  " Rubeola Vulgaris, Comitante cynanche."
  3.  " Rubeola Vulgaris, Comitante diathesi putrida."
  His second  species, the Rubeola Variolides, he defines,
  " Rubeola papulis discretis eminentibus."
   Of this species, he observes, " Sauvagesium secutus, hunc morbum
 " hie indicavi, etsi multum dubito, an  recte ad rubeolam  rcferendus
 " est,  non  solum enim forma pustularum plurimum differt,  sed, quod
 " majoris momenti esse videtur, est plerumque absque symptomatibus
'" catarrhalibus, rubeolae adeo propriis."*    Matthiew is of the same
 opinion, and observes, that this disease is seldom  met with  unless the
 small-pox be prevalent at the same time with the measles.!
  The  following is the division of measles generally adopted by au-
 thors.   It comprehends only the first species of Dr. Cullen.
  I. Rubeola Vulgaris or  Morbilli Regularis,  the measles, such  as
 they generally appear  when their course is undisturbed by any unusu-
 al symptom:

  • Dr. Cullen's Syn. Nosologic Meth. p. 136.
  | Matthiew's Observations  on this species of Measles in the 47th and fol-
lowing pages of the 4U) vol. of Baldinger's Sylloge Opusculorum Select. 
318                       MEASLES.
   2. Rubeola Anomala, Morbilli Anomali,  Morbilli Epidemici,* or,
the putrid measles, comprehending those forms of the disease in which
the usual course is disturbed : and
   3. Rubeola Anginosa, in which the  affection of the fauces makes a
principal part of the disease.
   The similarity of the measles  and small-pox has induced, Eller, and
some other writers, to regard them as little more  than varieties of the
same disease.
   In by far  the majority of cases, however, there is  a well marked
difference  in the symptoms of the eruptive fever; and in all, in the
appearance of the eruption.
SECT. I.
                   Of the Symptoms of Measles.

  It will be sufficient to divide the measles into the regular and irreg-
ular forms of the disease ;  the characteristic symptoms of rubeola an-
ginosa not being of sufficient importance to constitute a separate divi-
sion.
  The division of measles into regular and irregular, has not unaptly
been  compared to that of  small-pox  into  distinct  and confluent.
The irregular measles,  however, is not so well defined a form of dis-
ease as the confluent small-pox, and the division  may be more justly
compared to that of small-pox into regular and  anomalous.

  1. Of the symptoms of Regular Measles.

  I shall here pursue nearly the same order which was followed in de-
tailing the symptoms of small-pox ;  in the first place, pointing out the
symptoms which precede the eruption ; then describing the eruption ;
in the third place, enumerating the symptoms which attend it,- and last-
ly those which  follow it.
* Morton, Huxham, &c. 
MEASLES.
319
  It is a more distinct plan and better assists the memory to describe
the  different appearances of the eruption, and having done so, recur to
the  period of its commencement,  than constantly to interrupt  the ac-
count of it, to notice the symptoms which accompany it.
  We cannot distinguish the first attack of measles from that of other
fevers.  The patient, for the first day generally complains of alternate
heats and chills.  On the second day, though sometimes not  till the
third, the fever is completely formed,  and certain symptoms make
their appearance by which it may generally be  distinguished.  The
symptoms of the eruptive fever, therefore, may be divided into those
which it has in common with other fevers, and those which character-
ise  it.
  Along with other symptoms  common to febrile diseases the patient
generally complains of much thirst, often of nausea, sometimes attend-
ed with vomiting.  The tongue is generally white and moist.   In the
more alarming  cases  subsultus tendinum, spasms of the  limbs, some-
times delirium, more frequently coma supervene.
  The last symptom indeed so frequently attends the eruptive  fever of
measles, that by some it is  regarded as one of its diagnostic symptoms.
In all eruptive  fevers  it is more common than  in fevers  properly so
called.
  Pains of the  head, back and loins are frequent symptoms ; the face
is flushed, the pulse  frequent and hard, and the respiration hurried.
There is generally some remission in the morning,  the symptoms re-
turning  in the evening with increased severity.
  On the third day,  the nausea and vomiting increasing or appearing
now for the first time, the skin becomes hotter  and more parched.  In
severe cases, if the patient has hitherto escaped delirium, it frequently
shews itself on the evening of this day, or increases if it had superve-
ned at an earlier period.  When there is  no coma the inquietude is
considerable, and the sleep, if there be any, disturbed.   The inquiet-
ude and distress of mind, Rhazes observes,  is greater in  the measles
than in the small-pox.
   The  matter rejected by vomiting is generally bilious, and when  a
diarrhoea  supervenes, which  is not unusual, the stools are frequently
of tbe^ame kind ; and  in children for the most part of a green colour;
« Quo fluxu,"  Burserius observes, " ubi supervenit, vomitus et vomi-
» turitio fere sedantur."  The diarrhoea, he adds, does not impede the
appearance of the eruption.   In other cases, however, the  bowels  are 
320                        MEASLES.
costive, and sometimes as in small-pox, there is a tendency  to sweat*
ing.*
  As far as the prognosis depends on the foregoing symptoms, it is col-
lected  in the same way as  in  fevers properly so  called.   The  more
parched the  skin,  the  harder and  more  rapid  the pulse, the  more
hurried and difficult the breathing, the more the countenance  is flushed j
and the greater the coma or delirium, the less favourable is the  prog-
nosis.   A considerable  affection of the breathing  with an  unusually
hard pulse, is particularly to be dreaded, on  account  of the tendency
to pneumonic inflammation  in this disease.
  The diagnostic symptoms are the symptoms of common catarrh ;
but in  catarrh they are not   accompanied with those just enumerated,
the fever for the most part is moderate, and always, we shall find, pro-
portioned to the affection ofthe head, fauces, or chest.
  On the second day of measles, if not earlier, the patient is attacked
with a dry cough  and hoarseness, with a sense of heaviness, in the
bead and eyes.  The cough is often severe  and obstinate,  Morton t
calls it, " Tussis admodum  molesta, frequens, pertinax  et ferina, quae
" opii  ipsius  vires soporiferas plane superat."   A cough often precedes
the eruption in small-pox and  scarlatina, but  it is seldom so  violent as
that of the measles, which is sometimes the first symptom of the dis-
ease-!
  About the time that the cough generally supervenes,  the throat be-
comes  inflamed, impeding deglutition, and increasing  the  secretion of
saliva.  In some cases, a  profuse ptyalism  comes on,§ and there is
generally a sense of oppression and uneasy tightness about the breast;
occasioning some degree of dyspnoea.

  * Adults, Frank (Epitome de Cur. Horn. Morb.) says, have been observed
to sweat, but not so frequently or profusely as in small-pox.  These sweats,
he remarks are often beneficial.

  f See Morton de Morbillis  in his Work De. Febribus Inflammatoriis.

  $  Sometimes, Hoffman observes, it troubles the patient for a  fortnight be-
fore the fever comes on.  Other writers make Uie same observation.  Of  an
epidemic in London in 1753 Dr. Heberden remarks, the cough often preced-
ed the measles for seven or eight days.  In such  cases Uie  cough is  some-
limes accompanied with pains  ofthe throat, head and back.
% Frank Epit. de Cur. Horn. Morb. 
MEASLES.
321.
  The appearance of the eyes, however, may be regarded as the best
diagnostic.  They are red, swelled, itchy, very sensible  to light, and
watery, tears sometimes falling over the cheeks.
  The membrane of the nose is also inflamed, a copious thin secretion
often running from it, and occasioning frequent sneezing.   Hemorrha-
gy from the nose is not uncommon, by which the head, eyes, and fau-
ces are relieved.  It has sometimes been so profuse as to threaten dan-
ger.   The various hemorrhagies which occur in synocha  occasionally
appear in the eruptive fever of measles.
  The eruption is less frequently preceded by epileptic fits, than in
small-pox.  As in the latter, severe  pains  of the back,  preceding  the
eruption are unfavourable.
  Such is the eruptive fever of measles, by the severity of which we
may often judge of that of the succeeding disease.
  With respect to the prognosis at this period, it is derived less from
the state of the catarrhal, than of the febrile symptoms, unless the for-
mer threaten suffocation, which sometimes happens in children, or we
have reason to dread an inflammatory affection ofthe lungs.
  It appears  from what has  been said, that the circumstances  which
distinguish the eruptive fever of measles from catarrh are, 1. The one
disease  arising from contagion, the other from cold.   2.  The greater
violence of the febrile symptoms compared  with the catarrhal  in the
measles.  3. The state of the eyes ; for, however, mild  the other ca-
tarrhal symptoms are, the affection  of the  eyes  which in catarrh are
less generally affected than the nose and throat, is always considerable.
Lastly, certain symptoms which frequently accompany  the eruptive
fever of measles, and are seldom observed in catarrh, particularly coma.
  When the eruption makes its appearance, it places the  nature of the
disease beyond a doubt.   It generally  shews itself towards the  end of
the third, or beginning of the fourth day ; sometimes not till the fifth.
It comes out on the forehead, in small points, which are generally dis*
tinct at first, but here and  there increasing in number  and size, are
soon formed  into small clusters, so that the face seems marked with
red stains of various size and figure.  In these clusters the individual
pustules are seen with difficulty, but are always readily felt, rendering
the parts they occupy rough  to the  touch.   While the eruption is com-
ing out, some degree of moisture is frequently  observed  on  the skin ;
which is a favourable appearance.
  From the  face the eruption  gradually spreads to  the  neck,  breast
trunk,  and extremities.  It generally appears on the extremities, the
                                41 
32£                       MEASLES.
day  after it shews itself on  the face, seldom  either later or earlier.
Sometimes, though rarely, it does not appear on the extremities at all.*
Frank observes, that themorbillous like the variolous eruption, some-
times appears in the mouth affecting the tongne.
   On the trunk and extremities the small pustules are often more nu-
merous, but they are generally less prominent, than on  the face, so
that  on the former the red stains are broader, though seldom so rough*
as on the latter; in all places where there is redness the inequality of
the cuticle may be perceived.  These stains vary in different cases,
being broader and redder in some than in others.
   Those on the face continue red or rather increase in redness for two
days.  On the third they  assume a brownish colour.  In the course of
the fifth  or at most the sixth, that  is, about the eighth or ninth day of
the disease, the redness on the face nearly disappears, although traces
of it often  remain for four or five days longer.   The cuticle is  now
broken and raised in the places which the eruption occupied, so that the
face appears covered with  a light whitish powder.
   It is observed by Frank andothers, that  when the eruption is not ve-
ry favourable, it sometimes leaves pits in the skin  like those which fol-
low the small-pox.
   When the redness has almost left the face it is  at its heighth in the
extremities, where  about a day or two later it runs the  same course.
 The eruption continuing  red longer than usual,  is an  unfavourable
symptom.   The more early and free the desquamation, which occasions
 the  whitish appearance just  mentioned, the more favourable  is the prog-
 nosis.   The eruption sometimes becomes  livid, and has even assumed
 almost a black colour.   These  appearances  indicate  much danger.
 Sydenham and others observe, that they are not uncommon when the
 hot regimen  and stimulating medicines have been employed, and are
 only to  be removed by discontinuing this  mode of treatment.
   During the eruption, the face is turged, but not swelled as in small-
 pox, and subsides as the  eruption goes  off.   The eye-lids are  some-
 times so much swelled as to close the eyes.
   It sometimes happens, as in mild cases of small-pox, that on the ap-
 pearance of the eruption the fever entirely ceases ; more  frequently,
 however, it brings only partial relief.   Sydenham and  Burserius ob-
 serve, that they never saw the vomiting  recur after the eruption was
 out.  But the cough and difficulty of breathing are often increased at
* Dr. Heberdsn. 
MEASLES.
32*
this period, even when the other symptoms suffer a considerable remis-
sion.   The affection of the eyes and coma often remain undiminished.
More rarely even the  febrile symptoms  suffer  no remission, and in
some cases they become more severe, and continue so till the period of
desquamation ;  when the remission is often preceded by a flow of
sweat or of urine,  a diarrhoea or other spontaneous evacuation.   Dr.
Heberden mentions an instance in which the cough was relieved by a
copious salivation.
  In some cases the fever continues, and now and then increases even
after this period.   The coma in particular, the author just mentioned
remarks, sometimes returns,  and has even proved fatal after the erup-
tion was gone.
  There is generally a considerable tendency to inflammation through-
out the whole course of the  measles, and those parts  are most subject
to it, which are most apt to  be inflamed  in common catarrh, the eyes,
nose, fauces, and lungs.   The inflammation of the eyes, nose, and fau-
ces, is usually of little consequence ; it seldom becomes very trouble-
some, and declines with the other symptoms.   The  inflammation of
the lungs may supervene at  any period, but is  most frequent after the
eruption is gone.  If the fever continues the cough seldom fails to. do
so likewise, and this cough and fever often become a real pneumonia,
or m scrophulous habits degenerate into phthisis pulmonalis.  Such in-
deed is the tendency to  inflammation in measles, that blood taken at
any period generally shews the buffy coat.*
  When neither the habit nor mode of treatment are bad, however,
such consequences are  far from being frequent, the febrile symptoms
are generally moderate and the danger  inconsiderable.   Sydenham,
from very extensive experience,  has pronounced the measles a safe
disease.  It can only be regarded as such, when the fever abates on
the appearance ofthe eruption, and ceases altogether at the .period of
desquamation,  leaving the patient free from cough and dyspnoea.
   The diarrhoea, which  is generally salutary towards the termination
of the disease, sometimes becomes profuse, or even  dangerous ;  and
Frank observes that a profuse hemorrhagy from the nose has sometimes
proved fatal after the eruption had disappeared.

  *  Those, says Sydenham, who had been treated with the hot regimen and
 timulating medicines were most subject to inflammation ofthe lungs, 
324
MEASLEs.
  Such is the course of the regulaT measles.   It sometimes varies in
circumstances so trifling, that the disease still deserves the name of re-
gular.   Thus the eruption sometimes makes  its first  appearance on
the neck or shoulders, instead of the face ;  sometimes  sooner, and
sometimes later, than the usual  time, and there is sometimes no des-
quamation on its disappearance.
•  Although these varieties do not warrant the name of irregular, yet
they seem to indicate a  disease more dangerous, and  in  particular
more liable to be attended with inflammation of the  lungs, than the
most regular form.   Thus Sydenham observes that more died  of the
measles of  1674, in which  there   was  no desquamation, than  of
that formerly epidemic.   The  fever and dyspnoea,  in the decline of
the disease, were more severe, and bore a greater resemblance to true
pneumonia.   Quarin* indeed remarks, that the eruption ofthe measles
sometimes goes off without desquamation, the state of the patient not-
withstanding being quite favourable.   These variations from the com-
mon course, may be regarded as the  connecting link between the reg-
ular and irregular forms of the disease.

  2. Oithe  Symptoms of Irregular Measles.

  This is a very dangerous, but  fortunately not a very common disease.
Sydenham says  nothing of it, for that of 1674 does not deserve the
name of irregular, yet it certainly raged in London during his prac-
tice.   He describes the  measles of 1670 and  1674, and passes over in
silence the irregular measles which raged in  1672, as we are informed
by Morton, who says that this epidemic destroyed nearly 300 ! weekly.
  It appeared in the autumnal season, whereas the regular measles,
like other inflammatory diseases, generally makes its appearance about
January, continues to increase to the  vernal equinox, and then gradual-
ly declines,  till it altogether disappears,  about the summer solstice.
The irregular, like the regular,  measles, however, most frequently ap-
pears in the vernal months.

  * De Febribus.

  f D;-. Dickson accuses Morton of having greatly exaggerated the fatality of
this epidemic.   See Dr. Dickaon's paper in the  4th vol. of the Medical Ob-
servations and Inquiries, 
MEASLES.                        326
   Since the time of Morton, the irregular measles has been described
by a variety of authors, Huxham,* Matthiew,! Burserius,! Vogel,§&,c.fj
   In the eruptive fever  of the irregular measles, there  are not many
circumstances to distinguish it from  that of  the regular.   The symp-
toms in general  are more violent, and the fever is sooner formed,  the
affection of the eyes and the cough,  being often considerable  from the
commencement.  On the first night the patient is very restless, and on
the  next  day the fever  generally rises  high, the cough and inflamma-
tion of the eyes  increasing.
   The eye-lids are sometimes so much swelled  that they cannot be
seperated, and the eye-ball itself is  often swelled and  prominent; in
some cases there is  much pain and inflammation ofthe meatus audito-
rius.
   The pulse is  now often more frequent, but less  hard  than in the re-
gular measles'.   For the most part there is  some degree of dyspnoea,
and little or no  expectoration  attends the cough.   When an expectora-
tion of mucus occurs, it  often  relieves both the febrile and local symp-
toms.
   The restlessness increases, with a parched skin,  much  thirst, and a
sense of tightness and 'oppression- about the praecordia.   If coma does
not supervene,  there is generally an acute pain, often  accompanied
with a sense of heaviness in the head, or delirium.

   * Huxham de Aere et Morbis Epidemicis, where he gives a short account
of the epidemic  measles which  raged in Uie autum of 1742.

   | See a paper by Matthiew in Balinger's Sylloge Opus. Select, in which he
gives a copious account of  the irregular measles which raged in Alsace, in
 1766, and 1767.   In this paper  the reader will find references to  other wri-
ters who treat of this form of the disease.

   $ Institut. Med. Pract.   The irregular measles described by Burserius dif-
 fers considerably from that described by other writer*, and resembles more
 tie measles of 1674  described by Sydenham, which Burserius  regards as
 irregular.

   § De Cog. et Cur.  Morb.
   | In the 4th vol. of the Medical Observations, the reader will  find an ac-
 count of this form of the  disease by Dr. Watson, as it appeared in the Found-
 ling Hospital, in the springs of 1763, and  1768.  Most of  the later writers
 on measles indeed notice  it. 
326                        MEASLES.
    The fauces are of a deep red colour, and sometimes assume the same
 appearance as in the cynanche maligna,* the tongue being very foul,
 and the stools unusually fetid.!
    The  eruption frequently makes its appearance on the second or
 third day ; it is sometimes delayed to the fourth, fifth, sixth, or even
 a later period.^
    When the eruption is delayed to the fourth or fifth day, or  longer,
 the excitement is generally less than in regular measles, the fever oft-
 en assuming the form of typhus at an early period.   This always in-
 dicates much danger, and if the patient survives his recovery is gener-
 ally very slow.
    The eruption does not always appear first on the face, as in the more
 benign forms of the disease, but sometimes on the shoulders, 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, for the the most part it
 disappears 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
 twelfth,  fourteenth,  seventeenth, or even  twentieth  day, at different
 times assuming various colours, red, pale or livid, or even black.
   Whether the disease is rapid or not, the febrile symptoms generally
 suffer  a considerable remission, and are sometimes though not often
 wholly removed, after the disappearance of  the eruption.   In  neither
 case however,  is there any remission, but generally an increase of
 these symptoms on its coming out.  If nausea and vomiting have not
 appeared earlier, they very frequently supervene after the appearance
 ofthe  eruption, and are more distressing than in the  regular measles.
 The affection of the  throat increases; the same may be said ofthe de-
 lirium  and coma, when these symptoms have  appeared at  an early pe-
 riod ; where they have not, either the one or the other often makes its
 appearance now.   The pulse becomes  more frequent  and less full, and
 when the disease has been protracted, small, feeble, and often  irregu-

  * See Vogel de Cog. et Cur. Morb. Dr. Cameron in  Uie 21st vol. of the
Gentleman's Magazine, mentions several cases in  which it had this appear-
ance, so Uiat he regarded the disease  as  a combination ofthe measles and
cynanche maligna.

  \ Matthiew.
t Burserius and others. 
MEASLES.                       327
lar; the cough and the hoarseness increase, the breathing correspond-
ing to the state ofthe pulse, becomes frequent and anxious, or the pa-
tient is oppressed with dyspnoea.  Symptoms denoting the last stage of
debility  succeed, dropsical swellings, petechiae, the worst kinds of he-
morrhagy, tremors, subsultus  tendiwm, and convulsions often the fore-
runners of death.
  In general, however, the fatal termination  is delayed to a later peri-
od.  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 febrile symptoms, as we have just seen, for
the most part, abate, the cough,  dyspnoea, and oppression frequently
increase, with a frequent, feeble, and sometimes irregular, pulse.  Di-
arrhoea often comes on, but generally serves only to increase the debil-
ity.  When  the delirium returns the danger is very great.
  When on the contrary the skin becomes moist, the restlessness is di-
minished, the cough and dyspnoea abate, and the strength begins tore-
turn, the pulse becoming fuller and less frequent, the prognosis is good.
   Inflammation of the lungs is more frequent at all  periods  of the ir-
regular than the regular measles.  Suppurations  of the brain, internal
ear, and other parts sometimes occur, and now  and then prove fatal.
In  some  cases swellings appear about the neck, on or abovit the fifth
day.   If the patient survives, they often form abscesses and give much
trouble.*  The affection of the eyes sometimes degenerates into obsti-
nate sores.
   From what has been said it appears, that the  regular and irregular
measles differ chiefly in the following circumstances.
    1. All the symptoms, whether febrile or catarrhal, are  generally
more violent in the irregular, than in the regular measles.
    2. The fever in the former always shews  a tendency to  typhus.
   3. In the  regular measles, the affection ofthe fauces always  resem-
bles 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 ofthe different stages of the irregular measles is
 more uncertain.
    The  irregular measles might be divided  into two varieties, that in
 which the symptoms run high and are soon  terminated,  and  that in
 which they are  less violent and  longer protracted ;  and there  is the
 more room for such a division, as the one of the^c varieties  has been
* Matthiew. 
328
MEASLES.
epidemic without the other making its appearance-   The same epi-
demic, however, often assumes both forms.
   Besides the  regular and irregular forms of the  disease, there are
certain varieties, as in small-pox, which now and then make their ap-
pearance.  The fever with all its  usual symptoms, Quarin observes,
has sometimes appeared without the eruption.  Others make the same
observation, the accuracy of which  is called in question by Frank, but
not, (it appears from a variety of observations) on sufficient grounds.*
   It even appears from some observations,  that the  contagion of meas-
les may produce some of the symptoms peculiar to the measles, with-
out either fever or eruption.   Dr. Home, in his account of the  manner
©f communicating  the measles by  inoculation, which  I shall presently
have occasion to describe, observes " March 27, inoculated a  child of
*' eight years old, with the same blood which had been kept ten days
•* loosely in my pocket-book ; I was afraid when I used it that it was
•* too weak.  The sixth  day this child sneezed much, but never was
M 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  symptom of
the disease is gone, the fever again  returns, and is again attended with
the eruption.!  The second appearance ofthe measles is most frequent
in the irregular form of the disease.   Matthiew observes of that of Al-
sace, that soon  after the eruption had disappeared, a new fever came
on, followed by a second eruption.
   No disease is more  apt than the measles to  call into action, if I may
use the expression, any scrophulous tendency.   Hence its most fre-
quent consequences are,  the various forms of scrophma ; glandular tu-
mours, marasmus from obstruction in the mesenteric glands, obstinate
sores! often affecting the bones, and phthysis pulmonalis.   Other  in-
flammatory affections of the lungs are also frequent after this disease.
  * " During this measly ser jon," (it is remarked in the fifth vol. of Uie Medi-
cal Essays) " several people who never had had the measles, had all Uiepre-
" ceding symptoms of measles,  which went  off in a few days without any
" eruption, which they underwent months or years afterwards."  TheYeader
will also find a case of the same kind related in Morton's work, " De Febri-
" bus Inflammatoriis Universalibus.''  The case is entitled, *' Febris morbil-
" losa, absque ulla efflorescentia vel comitante vel subsequente, sanata."

  ! See Med. Museum, vol. 2.                                     •

  $ See the observations of Dr. Watson in the 4th vol. of the Medical Obser-
vations, and Dr. Huxham's Account ofthe Malignant Measles which raged at
Plymouth, in '745. 
MEASLES.
329
   The bowels are often left in a very weak state, a chronic diarrhoea
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 affected through-
out the  whole disease.  The ophthalmia often remains after the  other
symptoms, and becomes obstinate; and 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 termin-
ates in dropsy, and other  diseases of debility.
   All these consequences  are  most frequent in the irregular forms of
the disease.
SECT. II.
                    Appearances on Dissection*


  On this part of the subject, there is little to be observed.  If the pa-
tient dies under the  eruption, the trachea and larger branches of the
bronchiae, as in the small-pox, are often found covered with it; which
may account for the  increase of the cough after its appearance.
  When the  patient dies with a swelled belly and hectic fever, the
glands ofthe mesentary are found indurated ; when of phthisis, indu-
rated tumors of various size, some of them containing pus, and ulcers,
are found in the lungs.f  Such appearances, however, it  is evident,
are not essentially connected with measles.
  It was observed above, that inflammation  ofthe viscera is more fre-
quent in  the irregular than in the regular measles; in  the former also
it is more  liable to run  to gangrene.  Hence,  in the  accounts of the
dissection of those  who 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 died, some sunk under laborious respi-

  • Vogel.

  f See the account of the appearances on Dissection in Phthisis Puknonalis
in Uie last volume.
                                42 
330
MEASLES.
" ration, more from dysenteric purging, the disease having attacked
" the bowels, and of these,  one died of a mortification in the rectum.
" Besides this, six others died sphacelated in some one, or more parts
" ofthe body.   The girls who died, most commonly became mortifi-
'" ed in the pudendum."  He also mentions ulcers, which were some-
times gangrenous on the cheeks, gums, and jaws.
  " Several were opened," Dr. Watson continues, "  under different
" circumstances  attending this disease.  In some who  died of labori-
" ous respiration, after the feverish heat and eruption were passed, the
" bronchial system was  found very little loaded with  mucus, but the
" substance of the lungs was tender, and the blood vessels were very
" much obstructed and distended.   In some  who died of laborious res-
" piration and extreme debility, many strong adhesions were found be-
" tween the lungs and pleura.  The lungs were distended with blood,
" and part of them had begun to sphacelate.  Part ofthe jejunum was
" sometimes inflamed  and contained several  worms."   In some who
died suddenly, it was found that the sphacelus of the lungs had occa-
sioned a fatal hemorrhagy.  " Collections of purulent matter," he adds,
" were observed  in none ; on the contrary, in this putrid disease, eve-
" ry morbid appearance indicated a sphacelus."
SECT. III.
                    Ofthe Causes of Measles.

  The measles, like the small-pox, seems to have been unknown to
the  ancients, although on this indeed there is. some dispute.*   The
Arabians certainly first accurately described the disease.   It is  from
them we have the name morbilli.  Rhazes, in particular, gives us both
its symptoms and the mode of treatment practised in Arabia, which as
well as the treatment of small-pox was more judicious than in modern
times, till early  in the last century.
  From what we know of the history of measles, and what we every
day see, we cannot doubt that it arises from a specific contagion.

  *  See the observations of Matthiew and others. 
MEASLES.                        331
  So much was  said of contagion in general,  that there is little to be
added here.  The measles appear earlier after infection than the small-
pox, and the time of its appearance is rather more uniform, being gen-
erally about the  sixth and seldom later than the eighth day.  Dr. He-
berden observes, however, that he has known its appearance delayed
even to the  14th or 15th day.
  The  circumstances  which determine  the severity pf the measles,
are far from being well ascertained; almost all we know on this sub-
ject is, that  it is  particularly unfavourable in plethoric, and often still
more so in scrophulous, habits.   It appears to  be  less dangerous  in
pregnant women than the small-pox ;  as in the latter,  however,  the
foetus in utero is sometimes  infected with it from the mother.
   The measles seldom attacks the same person a second time, of which,
however, there are a few well authenticated instances.*
   The great success which  attended inoculation for the small-pox, in-
duced many to believe that similar advantage might be expected from
it in measles.   The very prevalent opinion of the latter being receiv-
ed  in the  natural way by  the lungs, and the lungs being 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  no matter being formed in the
measles, and his not being able to collect a  sufficient quantity  of brok-
en cuticle at the time of desquamation, to produce the disease.  " I
" then applied," he observes  " directly to the  magazine of all epi-
" demic diseases, the blood."   He chose the blood when the  eruption
began to  decline in patients who had a considerable degree of fever.
He also ordered it to be taken  from the most superficial cutaneous veins
 where the eruption was thickest.
    While the blood came slowly from a slight incision it was  received
 upon cotton, and an incision being made on each arm of the person to
 be inoculated,  the cotton, as soon as possib'e after it had received the
 blood, was applied over  these incisions, and kept upon them, with a

   * "Nunquam  enim,"  Morton  observes, " in tota mea praxi novi quern-
 " quam, prater unum puerum, secunda vice hoc morbo correptum."  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.  " Quod
 " secundo et tertio eumdem  hominem in eos incidisse,  ex fidis observatis
 " constet;" and  in the fifth volume of the Edinburgh Medical Essays, it is
 observed ofthe  measles of 1735 and 1736, Uiat many who had formerly had
 Uie disease  were seized with all its symptoms, not excepting the eruption. 
332
MEASLES.
 considerable degree  of pressure.   He also used the precaution of al-
 lowing the incisions  of those to be inoculated,  to  bleed for some time
 before the cotton  was applied, that the fresh  blood  might not wash
 away or too much dilute the morbillous matter.   The cotton was per-
 mitted to remain on  the part for three days.   How far all these pre-
 cautions  are necessary to success  has not been determined.
   Dr. Home inoculated ten or twelve patients in this way, in  whom
 the success ofthe operation was equal to his hopes.  The eruptive fe-
 ver generally commenced six days after inoculation, and the symptoms
 ofthe disease were milder than they usually are in the casual measles.
 The fever was less severe, the cough either milder or wholly absent,
 and the inflammation of the eyes  trifling ;  they watered, however,  as
 much, and the sneezing was as frequent, as in the casual measles ; nor
 did bad consequences follow any  case of inoculated measles.   No af-
 fection of the chest remaining after it.
   The chief difference between  the casual  and inoculated  measles
 seemed to be, the absence of pulmonic  affection at all periods  of the
 latter.
   Dr. Home now regarded it as ascertained,  that the natural measles
 are received by the lungs,  and that on this circumstance  depends  the
 danger ofthe disease.  He wished, however, to observe the symptoms
ofthe disease when evidently received in this way, and 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 cotton.  This very unjustifiable experiment,  although repeat-
 ed, did not succeed in inducing the disease.   Nor, it is evident, if suc-
 cessful, would it have decided the question, whether or not the casual
measles is received by  the lungs.   Dr. Home's experiments have not
met with the attention they deserve.  In schrophulous habits particu-
larly, it would certainly be worth while to try his mode of inoculation.
If more extensive experience prove it capable of producing the effects
which he ascribes to  it, it will certainly be an improvement of consid-
erable importance.
   It was observed  above, that  when  the small-pox prevails  at the
same time with measles, the former is  often of an unfavourable kind.
This has been particularly remarked of the irregular measles. 
MEASLES.                        333
SECT. IV.
                  Ofthe Treatment of Measles.


  We may divide the treatment of this disease into that of regular, and
of irregular measles.
  As inoculation  is not practised in  the measles, we seldom have the
advantage of certainly knowing under what disease the patient labours
as soon as he is attacked.   If, however, he never has had the measles,
and has about  six days before the appearance of the fever been expos-
ed to its contagion, and  the  fever is accompanied  with the diagnostic
symptoms above pointed out, there can be little doubt of the  nature of
the disease.    The information required, however, cannot always be
procured, and  the diagnostic  symptoms are often not alone sufficiently
decisive at an  early period, so that in many cases we cannot positively
ascertain its nature, till  the eruption appears.   But this is not a matter
of much consequence, as the train of symptoms present require  very
nearly the same mode of  treatment, whether the disease be measles,
common synocha, or catarrh ; the chief difference being that the same
remedies are employed more assiduously  in measles.
   The diet  should be the same as in the more severe forms of the dis-
tinct small-pox.  We seldom see the measles so mild a disease as the
most favourable inoculated small-pox, for even in the least  dangerous
forms, inflammatory affections are to be dreaded.   On this account, we
find practitioners insisting much on a diluent and  antiphlogistic diet.
" A carnibus  quibuscunque  arcebam," Sydenham  observes  " juscula
" avenacea, hordeacea et  similia,  nonnumquam et pomum coctum
" concedebam."  " Dietam  vero  diluentem," Huxham *  remarks,
*' mollem, omni carni vacuam  instituere  oportet."  Morton, Mead,
Burserius, and many  others, might be quoted to the same purpose  ; the
last of these even dissuades  from the use of milk.   M. De Lassone,
however, having  experienced the good effects of milk in the small-pox,
made trial of it in measles, and thinks it of great use, particularly when
the bilious diarrhoea becomes profuse.   Dr. Mead recommends  asses'
milk-   The debilitating effects of  antiphlogistic  measures,  however.
* De Acre et Morbis Epidemicis. 
351
MEASLES.
are never to be overlooked.   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, to remain in bed, he should not be  prevented ; at
the same time there is no occasion to confine him to it against his in-
clination.   In all cases, towards the  period of the eruption,  he feels
fatigued and averse to motion.
  Whether he be in bed or not, extremes of heat and cold are equally
to be avoided.  By the former we always increase the  febrile, by the
latter we may increase the catarrhal symptoms.
  After the benefit  derived from the  application of cold in  the small-
pox was perceived, many recommended it with equal  freedom in the
measles, and  this practice is  still defended by  some, particularly the
followers of Dr. Brown.   Sydenham, who contributed more  than any
other  practitioner of this country, to introduce the  cool regimen, when
he cautions against keeping the patient too warm in measles, says noth-
ing ofthe application of cold.   " Neque autem, vel stragulis vel igni,
" quibus sani adsueverant quidquam adjici patiebar."   In other places
he makes similar observations.  Morton, the contemporary and almost
the rival of Sydenham, adopted the same practice, and their example
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 ;* we may,
therefore, say ofthe degree of temperature, as of  the exercise,  that it
should in a great measure be  regulated by the patient's feelings.   It
is particularly to be observed, that the partial or sudden application of
cold, or exposing the patient  to a current of air, is dangerous.
  In most cases it is necessary to have recourse to other means for di-
minishing excitement.   It is  needles to repeat what has  been said of
nitrate of potash, saline draughts,  &c. these are  useful in all cases of
increased excitement.  Acids are to  be avoided,  if they increase the
cough.
  Gentle cathartics are  indispensable  in all cases.   They are not only
useful by removing  irritating matter and diminishing  excitement, but
alsp by obviating the tendency to inflammatory affections of the head.
  Emetics have not been much employed in this disease, except for the
removal of certain symptoms, the treatment of which does not  come
under the general plan of cure.
  * See the 650th paragraph of Dr. Cullen's First Lines. 
MEASLES.
335
   The remedy which principally  demands attention  in measles,  is
blood-letting.   Though its utility when the symptoms run high is gen-
erally admitted, there has been some difference of opinion respecting
the period at which it should be employed.  For the most part Syden-
ham did not recommend it till  towards the decline of the disease ; for
which he has been censured by many, particularly Dr. Mead.*  Had
Sydenham, however, taken the trouble to defend his practice, he might
have found  many  solid arguments to support it.  Unless the inflamma-
tory symptoms run unusually high, the danger at the commencement 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 unnecessarily reduce the
patient's strength in the  two former stages,  when in the  last, more
strength than  can remain after such a disease is often required to bear
without injury the only  effectual means of relief.  " As this fever,"
 Dr. Cullen remarks, " is sometimes  violent before the eruption  though
 " a sufficiently mild disease be to follow,  so bleeding   is seldom very
 " necessary during  the eruptive  fever,  and   may often be reserved
 " tor the periods of greater danger which are perhaps to ensue."!
   In some cases, however, even unattended by visceral inflammation,
 the excitement is sufficient to warrant blood-letting at an early period.
 When the  excitement is  such as threatens immediate  danger or much
 subsequent debility, we must have recourse to it.f
   With regard to the employment of blood-letting at  a late period of
 measles, it cannot be fully understood till the reader is made acquaint-
 ed with its employment in inflammatory affections ofthe chest.
    It is remarkable that blood-letting sometimes removes certain symp-
 toms remaining after measles, for the removal of which under other cir-

   * « Sanguis itaque, incipiente morbo, pro sctatis ac virium ratione detra-
 hendus est."  See Dr. Mead's Monita et Pracepta Med.  In Uiis observation
 we perceive the remains of the hypothesis which led to an indiscriminate use
 of blood-letting in fevers.

    + 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 observa-
  tions on it.
    t The presence of the menstrual discharge, Dr. Heberden justly remarks,
  is no objection, as some have supposed, to the employment of blood-lettmg m
  Uie measles. 
336                     MEASLES.

cumstances very little is to be expected from it.  Thus it has removed
cough, although unaccompanied by fever, or the other symptoms deno-
ting inflammation.   It has even been found a successful remedy in the
diarrhoea which remains after measles.   " Quin et diarrhoea,"  Syden-
ham observes, " quam morbillos excipere diximus, venaesectione pariter
" sanatur.
  Concerning the use of blisters so generally recommended in this dis-
ease,  it is only necessary  to repeat an observation already made.  If
our view in using them be to  remove fever, we shall very constantly be
disappointed ;  if to  relieve local affections, we shall find them a pow-
erful remedy.   I shall presently have occasion to make some observa-
tions on the symptoms for which they are employed.
  Ofthe treatment of irregular measles it will not be  necessary to say
much.
  When the fever is synocha, the treatment differs only in degree from
that of the regular  measles.  Cooling laxatives, and in many cases
blood-letting are necessary, and must be employed to sufficient  extent
to reduce the symptoms of excitement,  whatever be  the period ofthe
disease.   In measles, as in small-pox, a prejudice has  prevailed against
letting blood before  the appearance of the  eruption.   It is equally un-
founded.
  The  chief difference in the treatment of irregular measles  accom-
panied with synocha,  and  the regular form of the disease,  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 excitement often indicat-
ing the most vigorous  antiphlogistic means, while debility frequently
supervenes so suddenly as to  render their use, even in the earliest stage
precarious.
  The safest plan appears to be to avoid blood-letting, if the excite-
ment  can be diminished by less debilitating means ; if not, to employ it
only to that extent which the state ofthe  symptoms absolutely requires.
If the excitement is prevented from rising too high during the first days,
the nature of the disease will soon overcome it, and then every ounce of
blood which has been lost unnecessarily, adds to the danger.
  When the fever has changed to typhus, the guarded use of wine and
opiates, with bark, are the best medicines.  There is nothing to be ob-
served in addition to what has already been said of them.*  Some have

  * See the Observations on  the use of these medicine in continued fever' 
                           MEASLES.                       337

been afraid of the bark in every form of measles ; this fear, however,
appears to be groundless.   Among other writers on putrid measles, the
reader may consult for the use of the bark in this disease, the observa-
tions of Dr. Cameron, in the first volume ofthe  Medical Museum, and
the 21st ofthe Gentleman's Magazine.
   It only remains to point out the means to be employed when certain
symptoms supervene, the treatment of which does not come under the
general plan of cure.   On this  part of the subject there is little to be ad-
ded to what was observed respecting the treatment of the correspond-
ing symptoms in  small-pox.
   The symptom  which demands most attention is the cough, tha treat-
ment of which we shall have  occasion to consider at length under the
heads of Phthisis  and Catarrh.
   A hoarseness wliich now and then remains after the measles, when
accompanied neither by fever nor  dyspnoea, is sometimes removed by
the bark.*
   Dyspnoea may often be relieved by inhaling the vapour of warm war
ter, or by the medicines termed Antispasmodic, particularly the Am-
monia, when not  counter-indicated by the other Symptoms.  A gentle
cathartic frequently relieves it.  These failing we must have recourse
to venesection if  the  pulse admits of it; if not, blisters aTe the best
remedy.   When  it remains after  the measles, a perpetual blister on
the sternum, or a seaton in the side are the best means ; when it is ur-
gent and attended with fever, blood-letting is necessary.   The treat-
ment of this symptom will be better understood when we have consid-
ered that of Pneumonia.
   It is proper to  use some precautions to prevent the inflammation of-
the eyes  from  becoming troublesome; exposure to light  should be
avoided,  and they may  be washed occasionally with a little rose  or
plaintain  water.   If  inflammation  has supervened, more powerful
means are necessary,  which  I shall have  occasion  to enumerate  in
treating of Ophthalmia.
   A spontaneous  diarrhoea should be moderated, but not stopped, par-
ticularly by the use of astringents and opiates.   When it remains after
the disease Hoffman, recommends  the carscarilla.  If it docs not dis-

   * See a paper by Dr.  Whytt, in the third volume  of Essays and Observa-
tions Physical and Literary.  Testaceous powders are said to be often ser-
viceable in this hoarseness.  See a paper in the second volume of the. Medi-
cal Museum.
                                43 
338                   SCARLET FEVER.

appear soon after the febrile symptoms, it is to be treated like a simple
diarrhoea, but still with caution, on account ofthe tendency  to inflam-
matory affections after the measles.   For the same reason it is necessa-
ry for some time, cautiously to avoid exposure  to cold, and the other
causes of such diseases.
CHAP. IV.
                     Ofthe Scarlet Fever.


  The Scarlet Fever termed by medical writers Scarlatina, is defined
by Dr. Cullen,
  " Synocha contagiosa.  Quarto morbi die facies aliquantum lumens ;
"simul in cute passim rubor floridus, maculis amplis tandem coalescenti-
" bus, post tres dies in squamulas furfuraceas abiens, superveniente dein
" saepe anasarca.
  He divides this disease into two varieties,  the Scarlatina Simplex,
and the Scarlatina Cynanchica.
  The former is defined, " Scarlatina nulla comitante cynanche."
  Dr. Cullen observes, that although  in the space of forty years be had
seen the scarlet fever epidemic six  or seven times, it had always as-
sumed the  appearance of the scarlatina cynanchica, and was, for the
most part, attended with ulceration ofthe fauces.   It appears, however
from the observation of Sydenham and others, that the simple scarlati-
na has sometimes been epidemic, without the other form of the disease
shewing itself.  It frequently happens, that in the same epidemic some
have the scarlet fever with,  and others  w ithout,  the  affection of the
throat ;  while others have the affection  of the  throat without any
eruption.
  It has long been  disputed  whether the scarlet  fever and malignant
sore throat  ought to be esteemed different diseases, or only varieties of
the same disease.  This dispute is only of consequence from its having
made some noise.  I shall defer any observations  on it till the symp-
toms of both diseases have been laid before the reader.

  *■' Dr. Clarks treatise on fevers and other works on this disease. 
SCARLET  FEVER.                   339
  The second variety of scarlatina, Dr. Cullen defines, " Scarlatina
cum cynanche ulcerosa."
  In considering the symptoms of scarlet fever, I shall follow the same
mode of arrangement as in the foregoing exanthemata.
  It may seem proper in laying  down the symptoms of scarlatina, to
keep in  view the division of this  disease into the two varieties just
mentioned ; and this division might be compared to that of the small-
pox into distinct and confluent, or that of the measles into regular and
anomalous.
  For several reasons, however, it is unnecessary to insist much on the
symptoms of scarlet fever, unaccompanied by cynanche ; it is not often
met with ;  it may be readily known from what will be said ofthe scar-
latina cynanchica, and it is a very mild disease, and does not require
any particular mode of treatment.   The following  is Sydenham's de-
scription of it.   The patient, as in other fevers, is seized with chills and
rigours, but does not complain  of much  sickness; soon  after this the
whole skin is covered with small red stains, more numerous,  broader,
redder, but not  so uniform as  those in measles;  these stains remain
for  two or three days  and disappear with a desquamation ofthe  cuti-
cle, in small scales that fall off and appear again two or three times in
succession.*

                             SECT. I.

                  Of the Symptoms of Scarlet Fever.       **

   At the commencement, this  fever differs little from others.   It comes
on  with lassitude, languor, dejection, chills, and shivering, often alter-

  * See the 2d chapter of Uie 6th section of Sydenham's work, Circa Morbo-
rum Acutorum Historiam et Curationem.
  * In the winter  of 1813, a disease appeared in Vermont and New-Hamp-
shire, under the following circumstances ; that is, it was contagious, and Uie
length of time which passed from Uie exposure to the contagion to its attack,
was about 14 days.
  It was constantly attended with a bright scarlet eruption, beginning on Uie
face, and proceeding to the extremities. The eruption resembled the mea-
sles, excepting that the pimples were broader and of a brighter red.  They
did not elevate the cuticle so much, and went off without any desquamation.
This disease was in no instance attended with an affection ofthe throat; and
Uie febrile  symptoms attending  it were very slight.  1 saw but few cases
which required medical aid, and none that proved fatal or dangerous.   N. S. 
340                    SCARLET FEVER.
nating with fits of heat.   The  thirst is generally considerable, and as
the disease advances, the patient complains of a sense of anxiety, and
sometimes of pain in the stomach, and is frequently troubled with vo-
miting ;  but the  anxiety  and  vomiting  are rather symptoms of cy-
nanche maligna, than of scarlatina.
   The patient soon feels some degree of pain about the throat, increas-
ed on swallowing.   This  is to  be regarded as a favourable symptom ;
in cynanche maligna there is little pain in  swallowing, and it is as it
approaches to this disease  that the scarlatina is dangerous.
   The uneasiness ofthe throat is sometimes among the first symptoms,
and in some cases, it precedes the others.*   The sore throat is not of-
ten attended with cough or other catarrhal symptoms, but  frequently
with a sense of stiffness in the muscles of the neck, which  distinguish-
es the eruptive  fever of scarlatina from that of measles.
   In some cases, however, the eyes, as in measles, are inflamed, wa-
tery, and incapable of bearing the light,  with swelling ofthe eye-lids
and sneezing.  Rather more frequently  the  patient is troubled with a
cough.!
   On examining the internal fauces, they are found red, and more or
less swelled.  A florid appearance, and a considerable degree of swell-
ing are favourable symptoms.
   On the tonsils, velum pendulum palati, and uvula, the parts chiefly
affected with inflammation, there generally appears a number of small,
whitish,  or'greyish specks, or sloughs.  The darker  their colour  the
less favourable is  the prognosis.
   The skin is now very hot, the pulse  frequent, sometimes full  and
strong, which is a favourable symptom,  at other times,  particularly
where the throat is of a purplish hue, and the specks of a dark colour,
small and weak, though at the same time often hard, a state which al-
ways indicates danger.   The breathing is hurried, difficult, and some-
times rattling.  The fever suffers an  exacerbation towards night,  and
when  it is considerable, delirium or coma often comes on.   Either in-
dicates danger.

  * Aaskow, Acta Societ. Hafniensis, and others.

  f Frank's Epitome De Cur. Horn. Morb.   The works of Morton, one of
the earliest writers on the disease, and Dr. Cotton's letter to Dr. Mead on a
particular form of scarlatina prevalent at St. Alban's, in 1748.  Dr. Sims ob-
serves of  an epidemic scarlatina, that a short cough was  a very frequent
j/v\ptmn, which was most severe when the Uiroat was least affected. 
SCARLET  FEVER.
SI!
    What first seemed greyish specks, now frequently appear small ul-
 cers.   The internal fauces and mouth are  loaded with  viscid mucus,
 and the swelling of the fauces increasing, the  swallowing becomes
 more  difficult and painful.
    In milder cases, the sloughs  continue till the  fever is passed, and
 then falling off, an ulcer appears on one or both tonsis,  which for the
 most part is well conditioned, and heals readily.
    Hemorrhagy from the nose at an early period, often relieves the fau-
 ces.   A thin discharge from the nose, especially if fetid, and  if it ex-
 coriate the lips and nostrils, is a bad symptom.  The same may be said
 of a diarrhoea,  which seems often to proceed from  the morbid secre-
 tion of the fauces being swallowed.
    But the purple colour and ulceration of the fauces,  the  coryza at
 least when the matter discharged is acrid, and the diarrhoea, are rath-
 er to be  regarded as symptoms of the cynanche maligna than of the
 scarlatina.
    If the swelling of  the throat at any period of the disease suddenly
 subside, a swelling sometimes appears in a  neighbouring part.   In an
 epidemic mentioned by Dr. Rush, a swelling behind the ear often fol-
 lowed that of the throat.   Such a translation of the swelling generally
 denotes  an unfavourable form of the disease.   That mentioned  by Dr.
 Rush approached to the nature ofthe cynanche maligna.
    In unfavourable cases,  a little before the  eruption appears, the face
 is sometimes flushed and swelled.   It sometimes happens, though very
 rarely, that in children the eruption is preceded by an epileptic fit.*
   The period of the eruption is more uncertain than in the exanthe-
 mata.   When the symptoms are moderate,  it is generally delayed to
 the third or fourth day ; in more severe cases, it  often appears on the
 second or even  on the first.  Bang often saw it on the first  day,  Dr.
Clark met with  it within twelve hours from  the commencement of the
disease,  and Dr.  Cotton mentions cases in which the eruption appear-
 ed  as soon as the fever.
  The eruption  first appears on  the  face, most frequently, about the
}iose and mouth, like  a red stain or blotch which  disappears on press-
ure-!   R soon spreads over the neck,  breast, trunk, and at length over

  * See Sydenham's work on Acute Diseases, sect. 6th, chap. 2d, and a paper
by Bang,  in the ~d volume ofthe Acta Soc. Med. Hafniensis.

  f  It sometimes makes its first appearance on the neck.  See the observa-
tions of Eickcl in the Act. Soc. Med. Haf. and others. 
,342
SCARLET FEVER.
every part of the body which often appears uniformly red.  The prog-
nosis is then better than when the redness appears here and there  in
blotches, which is sometimes the case on the trunk, while at  the same
time the redness is uniform on the extremities.  The degree of redness
also varies much ;  it is sometimes such, as not to be very remarkable ;
in other instances, the whole body is so red, that it has been compared
to a boiled lobster.
  When the eruption is nearly inspected, it appears to consist of innu-
merable little pimples running together.   Upon the extremities and in
the interstices of the blotches on the trunk, small points  are  often ob-
served more prominent than those forming the stains, which is general-
ly an unfavourable appearance.
  The eruption seems much connected with the state of the throat, so
that the former  is seldom completely and uniformly diffused if the lat-
ter be alarming ;  and on the contrary if the affection of the throat be
slight, the redness is more general.
  The duration of the eruption is as uncertain as the  time of  its ap-
pearance.  It frequently remains for three or  four days, sometimes
disappears within twenty-four hours.  In general,  however, the red
colour begins to change into a brown in the space of two or three days;
soon after this the skin becomes rough, and the  cuticle begins to peel
off, sometimes in  small scales, at  other times in large pieces, which
process now and then continues as late as the twenty-eighth  or thirti-
eth day.  In most instances it is finished  much sooner.
  The nails have, though very rarely, been cast off with  the cuticle ;
sometimes the cuticle ofthe tongue peels off at the same time*.   The
tongue, Eickel observes,  becoming clean  while the desquamation goes
on,  is a  favourable appearance.
  When the desquamation begins, a gentle sweat very generally ap-
pears, and all the symptoms  abate and are soon wholly removed.
  Such is the general course ofthe  eruption in scarlatina ; considera-
ble variations have occasionally been observed.   " Die  autem morbi
'• quarto,  quinto, vel sexto,  singuli scarlatinam efflorescentiam per cu-
'•• ticulam ubique sparsam perpetiebantur, eamque per septeni, octo,
" vel decern dies protensam."!    The most remarkable variety in the
eruption of scarlatina is analogous to the variety of measles,  termed
Rubeola Variolides.  " In some,"  Dr. Rush observes, " an eruption

  * See the observations of Bang and others.
f Morton De Fob. Soaj-lat. 
SCARLET  FEVER.
343
" like the chicken-pox attended the sore throat."  This variety is call-
ed by Sauvages Scarlatina Variolosa.
  The symptoms  which accompany  the  eruption  differ  little  from
those which precede it.  The febrile symptoms  are seldom relieved
by its appearance.   The inflammation and  swelling of the internal
fauces in some cases abate ;  in others, they are increased ;  and the
viscid mucus,  which is  now often secreted in  considerable quantity,
renders  the deglutition more difficult.  The swelling, however, is sel-
dom so great as it frequently is in other kinds of sore throat.  When
the maxillary and parotid glands partake of the swelling, it is some-
times so considerable as to affect the breathing.
   The  mucus  frequently assumes  the  appearance of a crust co-
vering the tonsils  and neighbouring parts.   When by the use of
gargles  it  is  washed off, which may readily be done, the surface
sometimes appears inflamed but sound, at other  times covered with
small ulcers.  In the worst cases, small masses resembling coagulated
blood are frequently spit up, and  the acrid secretion from the  nares is
increased or supervenes  if it did not appear before the eruption,  exco-
riating the  lips and nostrils.   The eyes assume a dull and  heavy ap-
pearance, and the face seems bloated, and is affected with oedematous
Swelling ; the hands and fingers are often affected  with the same kind
of swelling, and painful on pressure ; or severe pains ofthe extremities
without swelling, much  restlessness, delirium or coma supervene. But
such cases belong rather to cynanche maligna than scarlatina.
   In the most favourable cases the symptoms upon the whole become
milder after the appearance of the eruptio  . The febrile symptoms in-
deed are seldom much relieved,but the inflammation and swelling  of the
fauces begin to abate, and by the time the eruption is over, if there be
a free desquamation with moisture on the skin,  have  wholly disappear-
ed, at most leaving only superficial ulcers ofthe tonsils, which soon heal.
   The fever now abates, and for the most part in  a  short time wholly
disappears, more or less of an oedematous swelling  appearing on the
le"S  and sometimes over the whole body, which in two or  three day-
goes off without the assistance  of medicine ; and the debility which re-
mains, as the appetite is generally keen, is soon removed by a  nour-
ishing diet.   In less favourable  cases, the febrile  as well as  other
symptoms continue to harrass the patient after  the eruption has disap
peared.
   It sometimes happens that although the patient is free from complaint
for some days after the  eruption  is na.«^d, yet in a short  time, par 
344
SCARLET FEVER.
 ticularly if the skin has remained dry during the desquamation, symp-
 toms of fever again shew themselves, and as sometimes happens in the
 other exanthemata, nave been followed by a second eruption.*
   A running from the ear now and then comes on towards the decline
 of the disease, and is sometimes very  copious  and fetid, by which the
 hearing has been impaired or wholly lost.   It sometimes  happens that
 a  swelling of the parotid glands comes on at the same period,  which is
 now and then relieved by a  spontaneous salivation.   The swelling of
 the parotid glands is unfavourable,  the running from the ear more  so,
 and the  prognosis is still worse if both symptoms attend, especially,
 Eickel observes, if the  parotids shew a tendency to suppuration, from
 which, he  says, he never observed any benefit.!
   The swelling ofthe parotids is generally relieved when the running
 from the ears is considerable, and again increases when this is lessen-
 ed.   While the running from the ear and the swelling ofthe parotids
 remain, it  is very difficult to produce a general moisture on the skin.
   Sometimes the  symptoms wliich  succeed the eruption take a differ-
 ent turn, the patient falls into obstinate anasarcous  swellings, or is at-
 tacked with  dropsy of some ofthe cavities.   When the swelling of the
 glands about  the neck suppurate, obstinate sores, at the same time, often
 form in the nose and ears, and even affect the bones.   The mouth, lips,
 and  palate,  and the parts in the neigbourhood of  the anus,  also  oc-
 casionally  suffer from ulceration.
   The inflammation sometimes spreads to  the trachea and lungs,  oc-
 casioning  hoarseness,   violent coughing,  and  wheezing, or  rattling

   * If the skin remains dry, Eickel observes, after  the beginning ofthe des-
 quamation, the disease will either be dangerous or  protracted ; Uie afiection
 of Uie fauces and fever become worse, and in some cases a new eruption ap-
 pears on Uie face and neck ; which unfavourable symptoms, he adds, general-
 ly  disappear as soon as the skin becomes moist.  The same author remarks,
 that a similar  train of symptoms are also most apt to appear in the measles
 and erysipelas, when the skin remains dry at the time of desquamation.

  | The swelling of the parotid glands, Dr. Sims observes, occurs at various
 periods of Uie disease, and seems when it is late of appearing to protract all
 Uie symptoms, or even to  renew thein after the) had ceased, the eruption it-
 self not excepted.   See a  paper by Dr. Sims  in the 1st vol. of the Mcmoirs
 of Uie  London Medical Society.  Plenciz in his  Tractatus de Scarlatina.
Quarin in his work De Febribus, and others, make similar observations. 
                        SCARLET FEVER.                   345

breathing ;*  or, as in cases mentioned by Drs. Rush, Home, and oth-
ers, a squeaking  voice similar to that which attends the croup.!
   Symptoms of debility often accompanied  with scanty, sometimes
with bloody, urine, have  now and then appeared after the patient has
remained well for some days or even weeks.  This train of symptoms
is mentioned by Plenciz,  Quarin, and  De Haen  in  the continuation of
the 1st vol. of his Rat. Med.  Dr. Sims and Dr. Withering mention a
similar train of symptoms.!
   Although  the swelling of the parotids has not previously appeared,
it sometimes attends the anasarca,  and even goes  on to suppuration,
The  reader  will  find cases of this kind mentioned by Bang, who ob-
serves that epileptic fits sometimes both precede and follow the drop-
sical swellings.   De Meza also says that during these swellings he has
seen both children and  adults  seized with epilepsy,  which did not,
however, prove dangerous, and seemed generally owing to exposure to
cold, or some errour in diet.
   Death  seldom happens at  a very  early  period of the scarlatina.
When the symptoms run high and the eruption appears on the  first or
second day,  the patient is sometimes carried off on the  fourth or fifth,
in other  cases seldom sooner than the eighth or ninth day, and often
later.§
   It may be observed upon the whole, that the true scarlet fever is a
very mild disease.  It is  only in proportion as  it partakes of the  na-
ture of the cynanche maligna that it becomes dangerous.   In collecting
the prognosis, therefore, the symptoms shewing a tendency to the cy-
nanche maligna particularly, demand attention.  These I  shall reca-
pitulate,  contrasting  them with the corresponding symptoms  of  the
mild scarlatina.   They are not only of  consequence in determining

  * See the observations of Dr. Clark.

  ■j- In the case of Dr. Morton's daughter, related by him, the Scarlatina ter-
minated in an  intermitting fever, which was removed by the bark.

  * These symptoms indicate a tendency to  dropsy, as farther appears from
the treatment  found most successful in them. Diuretics and cathartics, De
Haen observes, were somelimes serviceable, diaphoretics very rarely. The
medicine  chiefly  recommended by Plenciz and De Haen, has for its  princi-
pal ingredients calomel and squills.  The cases mentioned by Dr. Withering
often terminated in confirmed  dropsy.  See Dr.  Wiihering's Treatise on
Scarlatina.
§ Dr. Clark on Fevers.
44 
346
SCARLET FEVER.
the prognosis, but of the first importance in regulating  the  treatment
of the disease.
   If the  scarlatina makes its attack with only  a degree of lassitude,
languor, dejection of spirits, and shivering, the  disease promises to be
less dangerous, and to approach less to the nature of cynanche malig-
na, than when, along with these symptoms, the patient is troubled
with anxiety, nausea, and vomiting.
   If the internal fauces are of  a florid colour, and considerably swel-
led, with difficulty and painful deglutition, the prognosis is better, than
when they appear of a dark red or purple  colour, without swelling,
the deglutition being easy and attended with little or no pain.
   If the specks, which appear about the tonsils, velum pendulum, and
uvula, be of a whitish colour and are not soon changed into ulcers, the
disease is more favourable,  than when  they are of an  ash  or  brown
colour, and become ulcerous at an early period.
   When there is no running from the  nose, or such as produces no ex-
coriation, the prognosis  is better, than when a thin acrid  and  fetid
secretion runs from it.
   It is also a sign ofthe mildness of the disease to be unattended with
purging, and of great danger when the purging excoriates the anus.
   When the  pulse is strong and full the disease is less dangerous, than
when it shows a tendency to become weak and irregular.
   When the  patient  bears the disease well, and without much loss of
strength, his situation is more favourable than when  he  is restless and
debilitated.
   When the  mental functions remain unaffected, the prognosis is bet-
ter than when delirium or coma supervene.
   If the eruption is delayed till the third or fourth day, the disease is
safer than when it appears earlier.
   When it is universal,  every part of  the body becoming  uniformly
red, the prognosis is better than when it comes  out here and there in
stains or blotches, or in small points.
   A tendency to swelling in the neck, hands, and feet,  and the  erup-
tion being less on the trunk than the extremities, add to the unfavoura-
ble prognosis.
   The same  may be said of the eruption appearing unsteady, glandu-
lar, swellings  coming on,  and the fever not  remitting at the period of
desquamation. 
SCARLET FEVER.
347
  When the dyspnoea is considerable, without much swelling about
the throat, there is reason  to  apprehend that the  inflammation  has
spread to the trachea, which is always an alarming  accident.*
  Hemorrhagies in  general are unfavourable, except at an early peri-
od and  when the excitement is considerable.  Bloody saliva!  in par-
ticular denotes an unfavourable state of the fauces.
  All anomalous consequences of the scarlatina are  to be dreaded.
SECT. II.
                Of ike Causes of the Scarlet Fever.


  There  is no mention of the scarlet fever in  the  works of Hippo-
crates ;  nor do we find it mentioned as a distinct disease by any other
of the Greek or Roman writers.  Some of them have taken notice of a
scarlet rash as an accidental occurrence in fever.
  Prosper Martianus, an Italian physician, is among the earliest writ-
ers on this disease.  He  gave an account of the scarlatina as it appear-
ed at Rome about the middle of the seventeenth century.  It soon af-
ter made its appearance in London, and was described both by Syden-
ham and Morton, who term it Febris Scarlatina.  Sydenham describes
it in its  mildest state.  Morton in  its more severe forms, and varying
in some respects from the ordinary course of the disease ;  but he did
not always distinguish very accurately between measles and scarlatina.
The disease described by Prosper  Martianus resembles that described
by Sydenham-!

  * The inflammation also sometimes extends along the oesophagus to the
9tomach.  See what was said  in speaking of Uiis accident in the aphthous
fever.
  f  Plenciz's Tractatus de Scarlatina.

  $ The scarlet fever which Morton describes, prevailed in the same year in
which Sydenham died, which is the reason we do  not find it mentioned by
Uie latter. 
318
SCARLET FEVER.
  The cynanche maligna, so intimately connected with the scarlatina,
is said to have made its first appearance about the year 1610, in Spain,
where  it is called Garrotillo.  From Spain it  soon spread to  other
countries of Europe.  It appeared in Naples, in 161C, where it  raged
for twenty years  destroying great numbers.  If we compare the ac-
counts of these epidemics with what Sydenham  and Prosper Martianus
say of the scarlatina, we shall be inclined  to  believe that this  fever
and the  cynanche maligna, on their first appearance, were more dis-
tinct diseases than we now find them to be.
   It appears from the history ofthe scarlatina,  that its exciting  cause
is a specific contagion.   Concerning its predisposing causes little has
been determined.   It has only been ascertained that children are more
subject to  it than adults, and those of a lax habit  of body, than Uie
more robust.  Females have generally been supposed to be more lia-
ble to it than males.*
   The scarlet fever may appear at any season of the year, but it most
frequently shews  itself about the end of  summer.   It is sometimes
checked by  a severe winter.   Dr. Sims remarks that he  has seen it
 wholly at a stand during some days of sharp frost, after which it seem-
 ed to recover new vigour.   It generally disappears in the spring, but
 has been known  to  continue  for several years, and consequently has
 withstood the different  seasons.
   Physicians have endeavoured to ascertain the  circumstances  which
 determine the severity of this disease.  " The remote  and external
 " causes," Dr.  Clark observes, " which bad  the most obvious influ-
 " ence  in rendering the epidemic malignant, may be reduced to the
 " three following, namely, the heat and moisture ofthe air, and effiu-
 " via arising from many persons being crowded together in the same
 " house, or  often in the same room."
    I have  seen it  at the same time assume  all  its various appearances
 in different  individuals of the same  family.   We have reason to be-

   * It  seemed  particularly fatal to girls,  Dr. Sims  observes, from two to
  eight years of age.  He  saw but one child at the breast who had it and Uiat
  but slightly.  Dr. Fothergill observes, that women are more subject to it than
  men.   This,  however, is contradicted by the  observations of Dr. Clark: see
  Dr. Clark's Table of Patients labouring under Scarlatina, received  into the
  Newcastle Dispensary;  and Bang asserts that all under thirty are  equally
  subject to it. But whatever may have happened in the particular epidemics
  which he saw, it has been well ascertained, that those under puberty are most
  liable to this disease 
SCARLET FEVER.
34L<
lieve that it is most severe in the debilitated and the plethoric.   In the
latter 1 have known it assume its worst form, while in others similarly
circumstanced it proved very mild.
  Respecting the means of prevention, there  is nothing to be added to
what was said when speaking of contagion in general.*
  It has  been asserted by  some,  that the scarlatina never attacks the
same person a second time.  Bang and  others  declare  they never
knew^this happen.   More  extensive observation has contradicted this
opinion.   It appears, however, that the scarlatina properly so called,
namely,  that in which the eruption is complete, very rarely attacks the
same person a second time ; that  in which the  eruption is imperfect
and the affection of the throat considerable, is more apt to do so.   The
recurrence of the true cynanche maligna  in the same person has not
been  questioned, although this disease, also, is  less apt to attack those
who  have  formerly laboured under  it.   It is observed in  the Edin-
burgh Medical  Essays, that such as formerly  had had scarlet  fever
without sore throat, were now attacked with the sore throat  without
the eruption ; those who had formerly  had the sore throat,  now had
the fever and eruption without any affection of the throat.  There are
even instances in the  same epidemic of the same person having the
disease first in the one form, and  then in  the other.
SECT. III.
             Of the Treatment of the Scarlet Fever.


  As the treatment of small-pox was divided into that of the distinct,
and that of the confluent form, and the treatment of measles into that of
regular and that  of  irregular measles, so the treatment of scarlatina
may be divided into that of simple scarlatina, and  that of the scarlatina
cynanchica.

  * Dr. Sims says, he found rhubarb given in small doses,  so as to support
a moderate catharsis, a good preventive.  He also thought  it was of use in
moderating the ensuing disease, when given between  the period of infection
and Uie commencement of the disease. 
350                    SCARLET FEVER.
   It is unnecessary to enter particularly  into the treatment of the for-
 mer ; it differs little from that of a mild synocha, and consequently lit-
 tle from that of the distinct small-pox, or regular measles.  The par-
 ticular nature of these diseases, however, points out some difference in
 the treatment of even the mildest cases, which is not to be overlooked.
   In the small-pox, the application of cold can hardly be too free.   In
 the scarlatina, from the greater tendency to inflammatory affections, it
 requires more caution.  Any sudden or partial  application of cold in
 measles is still more to be feared, the catarrhal  symptoms always de-
 manding particular attention, which is not  the  case either in the dis-
 tinct small-pox, or simple scarlatina.   As the fever in distinct small-
 pox ceases  when the eruption is completed, and as the application of
 cold is very free, other antiphlogistic measures are less necessary than
 in the  measles and scarlatina, where even in mild cases the fever usu-
 ally does not cease while  the eruption is out, and an equally free appli-
 cation  of cold is inadmissible.   Besides  the greater  tendency to in-
 flammation in the measles and  scarlatina, enforces  the necessity of an
 attention to the antiphlogistic plan ; and as the measles are most apt
 to be accompanied with or followed by visceral inflammation, in it a
 strict attention to this plan is least dispensable
   Many  recommend the  cold affusion in  the scarlet fever ; and  regu-
 late its employment in the same way as  in simple  fever, without re-
 gard to the presence ot the eruption.   In the second volume  (second
 edition) of Dr. Currie's work on the use of cold and  warm water  in
 fevers, the reader will find his observations and those of Dr. Gregory of
 Edinburgh, on this subject, with a minute detail of cases, in which the
 cold affusion was employed.  The cold affusion has been unintention-
 ally employed in measles.  " I should have been still  less inclined,"
 Dr. Currie o'jserves, " to have  prescribed it intentionally in the mea-
 " sles, on account ofthe disposition to pulmonary  affection which at-
" tends that  disease.  It has happened to me, however, to have direct-
 " ed it four  different times by mistake, in the eruptive stage  of  mea-
" sles, and in like manner, the disease that followed was singularly mild
" in every instance."
  With regard to the treatment of the  scarlatina  cynanchica, as this
 form of the disease may be regarded as  a combination of  the simple
scarlatina and cynanche maligna,  its treatment cannot be understood
 without a knowledge of the latter.   For the treatment  of the scarlatina 
PLAGUE.                          351
cynanchica, therefore, I must refer to what will be said under the head
of cyn«nche maligna, in the next volume.*
CHAP. V.
                           Of the Plague.


   The plague is defined by Dr. Cullen,
   " Typhus maxime contagiosa.  Incerto morbi die eruptio bubonum
" vel anthracum."
   Although  few  British physicians  have  occasion to practise in the
plague, the propriety of being acquainted with a  disease, which has

  * The reader will find an excellent account both of the scarlatina and mea-
sles in Dr. Willan's Treatise on cutaneous diseases, and exceedingly good en-
gravings, illustrating his descriptions.  Ofthe scarlatina, especially, he gives
a very full account, with copious quotations from the principal auUiors on it.
I shall have occasion to refer more particularly to his observations on it, in
treating of the cynanche maligna, which he considers  as the same  disease
with scarlatina.
  He thinks Uiat when the eruption of measles appears with little or no fever,
or catarrhal affection, as sometimes happens when this disease is prevalent, it
does not secure against a second attack.  The measles and  scarlatina  have
frequently been mistaken for each other ; to this he ascribes many supposed
cases of the former having occurred a second time in the same person.  This
does not seem surprising when it  is considered that diseases so different as
small-pox and measles,  have not always been  distinguished.  The Arabian
physicians, although they give very good accounts of both, treated of them as
the same disease, and it appears from what is said above (p. 318) Uiat the mo-
derns are not wholly free from this charge.  He notices a mode of inoculating
for measles, from the matter of miliary pustules which sometimes  appear in
the eruption of this disease when at its height.  From  the few trials which
have been made of it, independently of our seldom having an  opportunity of
putting it in practice, it seems more uncertain and less capable of producing
a mikTdisease, Uian the method practised by Dr. Home, with which Dr. Wil-
lan does not seem to have been acquainted. He remarks of the  measles as
has been frequently remarked of the small pox, that children sometimes have
it before birth.   Some have been born with Uie eruption, and others  with
traces of having had it 
352                         PLAGUE.
demanded so much attention, and  bears so strong  an analogy to dis-
eases which every day fall  under their care, is apparent.   Besides,
we cannot foresee in what circumstances we may be placed ; and  for
a physician to betray ignorance ofthe plague would be unpardonable.
   There are few diseases so remarkably  varied, and there  are  few,
perhaps none, of which it is more  difficult to give an account, which
shall be at the same time sufficiently full and distinct.
   As much as possible to prevent confusion, authors have  divided the
plague into different classes ;  nor is it possible without this  to give a
just view of it, since no  two diseases are more opposite than its differ-
ent forms.   In one we shall find it  the most dreadful of all fevers, des-
troying without exception all whom it attacks ; in another we shall find
it  consisting chiefly of an eruption  unattended by  danger.   Why, it
may be asked, are diseases so different, regarded only as varieties of
the same ?  However different these extremes, they are not only produ-
ced by the same specific contagion, but almost insensibly run into each
other ; from which some idea may  be formed oi the variety which the
plague presents.
   I shall not spend time by laying before the reader the modes  of ar-
rangement adopted by different  writers, or by pointing out the obicc-
tions which might be made to them.   The objections consist chiefly,
in many ofthe divisions not being marked with sufficient precision, so
that it is often impossible to say what are  the  corresponding divisions
in the different accounts ofthe disease ; as the reader will  perceive if,
for example, he compare together the different accounts ofthe 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 be  distinguish-
ed by some symptom or train of symptoms which constantly attends it,
not accidental or unconnected with  the state of the symptoms in gener-
al, which would  render the division useless, but marking a variety, in
which the symptoms on the whole, and, what renders the division of
more importance, the prognosis, differ from those of other forms of the
disease.
   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 generally been done, by  which we are forceo
to use terms before  they have been defined ;  and it is equally objccj
tionable, where the variety of symptoms is so great, and where the,r£
is  so much to be  said ofthe different eruptions, to interrupt  the account 
                            PLAGUE.                        353

ofthe general course of the disease, in  order to describe them.   It ap-
pear* necessary,  therefore, to depart from the order which has been
pursued in laying down the symptoms of the other exanthemata, and to
regard bubo, carbuncle, &c. as terms which must be defined, before we
proceed to consider the symptoms of the plague.
SECT. I.
                    Of Pestilential Eruptions*


                    I. Of Pestilential  Buboes.


  A pestilential bubo at its commencement is a small, hard, round tu-
mor, 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 alter-
ed 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 an oval,
shape, becoming at the same  time less moveable.  The integuments
now begin to thicken and the  swelling to appear externally.
  The appearance of the bubo is often preceded by a sense of tight-
ness and pain sometimes lancinating, or itchiness, in the part where it
is about to appear, now and then accompanied by shivering.  In ma-
ny cases, however, the small swelling just described conies on without
being preceded by any peculiar symptoms.
  Some buboes are indolent  and insensible,  others very sensible and
rapid in their progress.  The tumour advancing quickly to suppuration,
is usually regarded as favourable.*
  It is difficult to foresee in what way a bubo will terminate.  The
fluctuation is often scarcely perceptible where suppuration  has taken
place,  and buboes are  sometimes resolved after fluctuation  has  been
very evident.  Their progress indeed is almost always more or less ir-
regular, especially after the first week.   At one time they seem advan^

  *  De Mertens' Account of the Plague of Russia.
                               45 
354                        PLAGUE.
cing to suppuration, at another show a tendency to resolution.  " But
" these variations," Dr. Russell* remarks, " chiefly respected the in-
" teguments; for the gland itself when carefully explored was seldom
*' found to alter, and where the  tumor actually dispersed, it was not
" suddenly but by slow degrees.   At the same time I  am  far from
" thinking that  this fluctuation was never real."   And Chenot!  ob-
serves, "  Vidimus  quoque abruptam suppurationem in his resuscitari
" ac demum per effusionem puris  absolvi."
  The bubo as  it increases in size becomes somewhat flat; and gene-
rally in the second  week, the skin over it  grows tense and painful, and
begins to be inflamed.   In some cases the inflammation is moderate,
in others consider ;ble ; but it seldom terniinates in gangrene, although
the skin now and then assumes a  bluish colour.
  It sometimes  happens, however, that the bubo runs  to suppuration
without any degree of inflammation appearing on the skin, and then,
as it is generally harder than a suppurated venereal bubo,  it is often
difficult to determine  whether suppuration has taken  place or not.
When buboes break spontaneously, it generally happens in  the third
Week, sometimes later.
  Buboes most frequently appear  in the groins or  a  little lower,
among the lowest clusters of the inguinal glands ; they  also frequently
appear among the axillary glands ;  sometimes, though more rarely, in
the parotid, the disease is then by many reckoned  most dangerous.
They still more rarely appear in  the maxillary or cervical glands.
  " The maxillary and cervical glands,"   Dr. Russell remarks' " were
" seldom observed  to swell without either the  parotid swelling at the
" same time or  soon after, or a carbuncle  protruding near them ; they
" never were the sole pestilential eruptions, and I recollect few instan-
" ces of their coming to maturation."   It has been remarked by others,
that the parotid bubo seldom appears unaccompanied by one or  more
in the axilla or groin.
  It may  upon  the whole be observed, that the axillary buboes suppu-
rate more frequent  y than those situated about the  fauces, and the in-
guinal more frequently than the axillary.
  Buboes often  make their appearance on the first day ;  sometimes in-
deed they are among the first symptoms.   It has been observed, that
when they appear  later than the  third or  fourth day, they are general-

  *  See his Work on the Plague.
f Chenot De Peste 
PLAGUE.                        355
ty preceded by an exacerbation ofthe febrile symptom.  Those which
come out at so late a period, however,  are not, for the most part, the
first which appear; for a succession of them  sometimes takes place,
till three or four have made their appearance.   In  this case several
hours usually  intervene between the appearance of any two.
   When the  inflamed gland  advances to suppuration  more rapidly
than the integuments, troublesome fistulous ulcers are sometimes form-
ed, if an artificial opening has not been made  in Uie skin.  This acci-
dent, however, is rare ; in general the buboes, left to themselves, give
little trouble.
   When they do not suppurate,  and the  patient  recovers, they gene-
rally disperse in the space of a few weeks.   In some cases, whether
they have suppurated or not, they are succeeded by an induration of
the glands which remains  for many months.   This  induration never
 terminates in cancer.
   Such are the circumstances to be learned from attending to the ex-
ternal appearances of buboes ; some further circumstances, of less mo-
 ment however, have been ascertained by dissection.
   It has been the practise of many, particularly the French surgeons,
 to extirpate the buboes ;  which gave them an opportunity of observing
 the internal change which takes place in them.  From the appearances
 on dissection they have been divided into several different species.   It
 is unnecessary to detain the reader with an account of this hitherto use-
 less division  ; he will find  it at length in the Traite de la Peste from
 the 428th to the 434th page.  One observation deserves attention ; it
 has just been remarked, that the skin covering the buboes never runs
 to gangrene ; dissection shews that it is otherwise with respect to  the
 gland  itself-   " Je coupai par le milieu celle (h. e.  the bubo) qui etoit
 « sur les  vaisseaux, que je  trouvai  toute  noire."   " Le lendemain
 « j'ouvris le  bubon, j'y trouvai le corps  glanduleux comme un rein de
 41 mouton, tout noir."*
    Another pestilential eruption has received the name of bubo, and to
  distinguish it has been called spurious.  It  is so rare, that some who
  mention it, have been accused of misrepresentation.
    The principal circumstance in  which the spurious, differs from  the
  true bubo,  is in the former appearing indiscriminately on almost every
* See Traite de la Peste, p. 447,448. 
35b"
PLAGUE.
part of the body,* while the true bubo is  confined to the parts just
mentioned.
  Spurious buboes, if they are not lanced at a proper time, sometimes
grow to a great size, particularly those on the scapulae or back ; in oth-
er parts they seldom much exceed the size of a hen's egg.   They gen-
erally make their appearance about the second or third day, and for the
most part,  after the protrusion of true buboes or carbuncles.   They
suppurate less rapidly than true buboes.!

  2. Of Carbuncles.

  Next to buboes,  carbuncles are the most remarkable of the pestilen-
tial eruptions.
  The reader will find them divided by different writers  into several
varieties.  One makes three, another four,  a third five.
  Dr.  Russell divides them into five  varieties.
  The first  appeared  in the form of a small pustule about the size of
half a pea, on its upper surface of a dusky or yellow colour, and a little
wrinkled.  The skin  which immediately surrounded this pustule was
hard and inflamed.  The pustule itself soon became very painful and
continued to  increase, till it was ofthe size of a nutmeg, and some-
times that of a walnut ; and a yellowish matter was secreted  under
the cuticle, which was sometimes moist, at other times dry and crusty j
the base assumed a dark reddish colour, the circle which -surrounded
it appearing at different times of  various hues.
  On the third, fourth, or fifth  day ofthe carbuncle, a gangrenous crust
appeared on the middle of it, which soon occupied the whole surface
of the tumor, exactly resembling the black  eschar formed by caustic.
  This crust, when the termination was favourable, was thrown off by
suppuration,  leaving an ulcer of various depth, which for  sometime
continued to  secrete  matter.  When the case  terminated fatally, the
crust remained dry and often spread to the  inflamed  circle, so as to
form a gangrene of considerable extent.
  The second kind of carbuncle  appeared in the form of a small angry
pustule, not rising  so high as the former, more disposed to spread, and
becoming gangrenous on the second day.   In  this state it was not easi-
ly distinguished from the other,  but was generally surrounded with  a

      * Dr. Russell's Treatise on Uie Plague, p. 119.

      ■fr Traite de la Peste, part  1st, p. 435. 
PLAGUE.
357
more highly inflamed ring.  It chiefly attacked tendinous parts, par-
ticularly the joints ofthe fingers  and toes.
  In the third variety, the cuticle was at once raised into a  blister of
the size of a horse bean, filled with a dusky yellow or blackish fluid,
and the skin which surrounded this variety, was less tense and of a pa-
ler red, than that surrounding either ofthe  foregoing.   When the blis-
ter broke, the cuticle fell upon  the flat surface, which was of a dark
colour and soon became black.  At this period, that is about the third
or fourth day of the carbuncle, it resembled the preceding varieties, ex-
cept that it was flatter.   The circle surrounding the eschar  gradually
assumed a very dark red, but never became gangrenous.  The eschai
was about the size of a six-pence.   This carbuncle was  very painful,
and five or six sometimes appeared on the same patient.
   The fourth variety was  a small red spot raised only  to the  touch,
which gradually rose higher and spread, till in 24 hours it was a flat-
tish dusky pustule, surrounded by a light rose-coloured margin.  It was
very painful, and when it appeared on  the face occasioned swelling
without inflammation of the skin.   It often became black beyond the
 rose-coloured margin on the second day,  and  the mortification spread
 to neighbouring parts.   This  species of  carbuncle  always accompani-
 ed other eruptions,  and  was usually pretty numerous.
   The fifth and last variety was  on the second day  a pustule  resem-
 bling that ofthe  small-pox ; it rose in the  form of a cone to twice the
 size of a large distinct pock with a blunt yellowish point, which, in-
 stead of advancing to suppuration, became black to the size  of a large
 field pea.  The gangrene, however, did not spread farther.   The mar-
 gin became of a dusky red, but appeared brighter as the suppuration
 which threw  off the eschar advanced.  After the second day, it differ-
 ed from the third and fourth varieties only in the gangrenous part being
 of less extent and the pustule more raised.
    In other writers  we find an account of carbuncles in some respects
 differing  from the  foregoing.   Samoilowitz,  in  his account of Uie
 Plague of 1771  in Russia, observes, that  the petechia  or macula are
 very large and confluent, and often turn to carbuncles a short time be-
 fore death,  which  happens in the following manner :  two,  three,  or
 four large petechia run together and form a large  pustule ; sometimes
 a similar pustule arises on each petechia ; in either cases, on opening
 the pustules  a true carbuncle  appears beneath.   In  the Traite  de la
 Peste  it is observed of a plague  which raged in the eastern parts  of 
358
PLAGUE.
Europe,  that purple 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,  however, thinks
that he describes its appearance at one period only.
   Dr.  Gotwald  describes a  carbuncle, appearing at first as 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 ten-
dinous parts, about the knee, behind the ears,  upon the toes, &c.  A
streak of different colours has sometimes been observed proceeding
from carbuncles on the fingers.
   Dr. Hodges mentions an eruption of  vesicles, which in one  case he
found covering the whole body.  When the inflammation was consider-
able, they sometimes became gangrenous, and were changed into car-
buncles ; they then resembled Dr. Russell's third variety.
   Eruptions now and then appear in the plague in some respects dif-
fering considerably from any ofthe carbuncles just described ; in oth-
ers resembling them.  Gotwald, (says Goodwin in his  Historical  Ac-
count) observed  the papulae ardentes or fire bladders in two patients
only, bothof 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.
   It would be tedious to enumerate all the eruptions of this kind which
have been observed in different epidemics.  The true pestilential car-
buncle may  be defined,
   A pustular or vesicular eruption, sooner or later running to gangrene.
   The eruption  called anthrax,  is nothing more than a carbuncle after
it has sphacelated.
   Carbuncles, to whatever variety they belong, for  the most  part do
not exceed the size of a walnut; they have  sometimes been observed
considerably larger.  The time of their appearance is uncertain ; they
sometimes show themselves on the first day, but more commonly not till
a later period ;  and when several  appear on  the  same person, they
generally succeed each other rapidly.   They have  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  seldom
"  more than one or two were observed in the same subject,  in general 
                             PLAGUE.                        358

  « one only.   The other varieties occurred in greater number, and in-
  ^ eluding those of the fifth, I  have sometimes counted between twenty
    and thirty, but this happens very rarely."
    This eruption is always attended with considerable pain, which in
  some cases is very violent.   No external part of the body is exempted
  from carbuncles, «  I have observed them every where,"  the author
 just quoted remarks, " the penis and scrotum not excepted, but  never
  «• observed them on the tongue, the tonsils, and internal  parts of the
  " mouth," (there have been instances, however, of their appearing on
  the tongue)  " though in  carbuncles on the cheek, near the corner of
  " the mouth the gangrene spreads inwards, and in one instance of a
 " carbuncle on the eye-brow, the gangrene spreading upon  the  globe
  " of the eye had destroyed part of it."
    Carbuncles were  regarded by the Russian physicians,  Dr. Guthrie
 informs  us, as a sign of greater malignity than buboes.  They thought
 the carbuncle  indicated less danger when  red than when livid;  when
 it suppurated than when  it did  not.   When the hands and feet  were
 the seat of carbuncles, Dr. Guthrie observes, the patient seldom or nev-
 er recovered.  Carbuncles on the spine were also regarded as  partic-
 ularly unfavourable.
   It is remarked, in the Traite de la  Peste, that in those cases in which
 little or  no eruption  appeared, and  in which the  patients died on the
 fourth or fifth day, some of the viscera were generally found much dis-
 eased, the intestines, chiefly  the small intestines, the mesentery, the
 liver, the internal parts of the stomach or the lungs, being eroded, or
 having large pustules or gangrenous spots formed on them.
   Carbuncles and buboes often appear separately ; they are also fre-
 quently combined, and  in the latter case,  it has been remarked, that
 the carbuncles most  frequently appear on the same side of the  body
 with the buboes.  This,  however,  is far from  being universally the
 case.  The carbuncle sometimes comes out very near the bubo, and
 sometimes though rarely, upon it.*
   Carbuncles now and then give  rise  to buboes, for it frequently  hap-
 pens that when the former  appear on the arm, the glands of the axilla
 swell ; these  have been observed to be less painful  than primary bu-
 boes, and they disperse  when the carbuncles come to a favourable sup-
puration ; which  is not the case with primary  buboes.  These  lym-
phatic buboes, as  they have been termed, are also observed, but much

  * Dr  Guthrie'-; observations on the Phgue of Russia,
\ 
360
PLAGUE.
 more rarely, in the groin, when the carbuncles, appear on the thighs,
 legs, or feet.
   The  foregoing  are  the  eruptions  which  distinguish  the plague.
 There are some others,  however, which occasionally  attend this dis-
 ease.

   3. Of other Pestilential Eruptions^

   Common boils or furuncles, as they have been called, appear more
 rarely than buboes or carbuncles.  They are  protruded suddenly, and
 are very much  like the pustule which precedes some kinds of carbun-
 cles, but considerably larger.  They soon rise to a point, suppurate,
 and discharge good matter.
   From what has been said of petechia, it will not seem surprising that
 they should attend a fever, of which debility, we shall find, is  one of
 the most striking   features.   Thejr  are  not, however,  a  constant at-
 tendant.   In some epidemics they have  been rarely observed.  It is
 chiefly this eruption which has been called tokens ; by some, God's
 token ; but these names have not been used in a very definite sense-
   The appearance of petechia in  the  plague adds to the unfavour-
able prognosis.  By the Russian  physicians they were regarded as a
 very fatal symptom.
   I need not say much  of the different classes into which, from their
 different appearances they have been divided.  In some cases they
 appear  red, afterwards becoming  brown, or  even black; in others
 they are brown from the first, and  become  black sooner.  In some
 cases they are few in  number,  and confined to the superiour parts
 of the body,  in others they are  more numerous and appear on  eve-
 ry part.  They are  sometimes small circular  spots,  at  other  times
 larger  and  of  a  more irregular  shape.   As in  other  fevers,  the
 darker their colour the  more  danger they indicate.  Eruptions very
 different from petechia are mentioned under this name by writers, on
 the plague.*
   As in other malignant fevers,  petechia often run together, forming
 blotches of various size and figure.   Sometimes blotches appear with-
 out petechia, properly so called, the skin being variegated with stains
 of different colours, which have been compared with clouds and stains
 in marble.   In  different places it its blue,  yellow,  red brown, black,
of various shades and brightness.  "  The skin," Dr. Russell observes,
• Goodwin's Historical Account 
PLAGUE.                        361
'* in various  places was sometimes deformed by narrow streaks of a
" reddish, purple or livid colour.  When  such took possession of the
" face they gave a frightful appearance to the countenance, and  fre-
" quently produced such an alteration of the features, and so complete-
" ly disguised the patient,»as to render him hardly  known by his ac-
" quaintance.  A streak nearly of the same kind was sometimes ob-
" served darting  from the edges of the  buboes and carbuncles."
  Very often, the stains or blotches do  not appear till after death, and
then, particularly on the fleshy parts, the body seems as if it had been
bruised.   " Sometimes," Dr. Russell  continues, " the whole skin of
" the thighs, back, and shoulders, turned livid, while the corpse  was
" yet warm."  These appearances, he remarks, are not often observed
at the commencement of the epidemic ; which is to  be  regretted, as it
is then that a characteristic mark ofthe plague is most wanted.
  Such are the oestilential eruptions.   In Dr. Russell's Treatise, the
reader will find tables, giving the proportional frequency of the  differ-
ent kinds of buboes and carbuncles.  The following are the result.
  Of* 2700, 1841  had  inguinal buboes, 569 axillary, 231 parotid, 74
spurious buboes, 490 carbuncles.  From these  tables  it appears  that
buboes in the right groin were more frequent than in the left, 729  had
the former, 589 the latter.   In another instance, 161 the  former,  130
the latter.  Buboes were also  rather more frequent in the  right  axilla,
than in the left, though  not in so great a portion;  184 had  buboes in
the  right,  165 in the  left axilla.   In  another table, the  numbers,  of
those who had them in the right and left  axilla differed only by one,
and that was in favour  of the left.   Not above one  in ten or twelve
had buboes in both groins, or axilla.
   The  fourth table shews  the number of cases in which buboes in the
parotids, carbuncles, or spurious buboes, were the sole eruptions, com-
pared with that in which they were combined with inguinal or axillary
buboes.
   Buboes in the parotids in 130 were unattended, in 110 Were attend-
ed, by inguinal or axillary buboes.
  Carbuncles were the  only eruption in 85 cases ; they were combin-
ed with axillary or inguinal buboes, in 405.
  Spurious buboes appeared alone  in  37 cases ; they were  combined
with axillary or inguinal buboes, in the same number.
   In 143, inguinal and  axillary buboes were variously  combined.   In
$02, there was a complication of various eruption*. 
362
PLAGUE.
  It is to be remembered, however, that these proportions are drawn
only from one or two epidemics, and will not,  perhaps, apply  with
much accuracy to others; they may serve upon  the  whole to give
some idea of the comparative frequency of the different eruptions.
SECT. II.
               Of the other Symptoms of the Plague.

  That I may abridge the following  account of the symptoms of the
plague, and consequently render it more distinct, it may be observed,
that all the symptoms, both of synocha and typhus occasionally attend
this fever.  It is unnecessary  again to detail all of these, for which I
refer the reader to the second book ;  and shall here consider at length,
those  which characterise the plague, or appear in this  disease under
peculiar modifications.   It has already been remarked, that in the se-
veral divisions of the plague adopted by writers, many of the varieties
are ill defined.   They seem  to be marked by  accidental symptoms,
and some of them by no particular symptom, but the general mildness
or severity of the disease.  In the former case the division can  be of
no use ; in the latter it can admit  of no precision.  Besides, most wri-
ters on the plague, speaking from their own observation alone, describe
the disease as it appeared in one or two epidemics; and in almost all
epidemics there are peculiarities.   It is only by comparing many that
we can form an account of the disease generally applicable.
  On  comparing different epidemics, we shall find, that whatever be
true of other eruptions, buboes are  salutary.    They almost always
mark a form of the disease less generally fatal, than that unattended by
this eruption.   " Those perished," Dr. Russell  remarks, " sometimes
" within the twenty-four hours, sometimes on the second or third day ;
" they had neither buboes nor carbuncles, and it was  very  rare to find
" suspicious marks of infection on  the dead bodies."   In another place
he observes,  " The total absence  of buboes in those who died sudden-
" ly I have no doubt of."  He also remarks, " That the  plague, un-
,( der a form  of all others the  most destructive, exists without its  char 
PLAGUE.
365
" acteristic eruptions,  or other external  marks reckoned pestilential,
" can admit of no  doubt."  The Russian physicians, Dr. Guthrie in-
forms us, found the cases attended with buboes less fatal  than those at-
tended with carbuncles.   Carbuncles and petechia, De Mertens,  in
his Account of the Plague of Moscow, observes, are not critical erup-
tions, they only denote a putrid condition of the humours,  whence  it
follows, that in  proportion as buboes are more common, and petechia
and carbuncles  more rare,  the milder is the  plague.  Orrceus, in hia
Treatise on the same Plague, observes indeed,  that buboes, often at-
tended  the most acute form of the disease ; yet in another place he in-
forms us, that there were no buboes in the worst form, their germs on-
ly being sometimes observed after death ; and Samoilowitz,* in his ac-
count of this plague, in describing  the worst form of the disease, noti-
ces petechias and  carbuncles as frequent symptoms, but makes no men-s
tion of buboes.
    Upon the whole then, the  plague  unattended by buboes, runs  its
 course  more rapidly, and is more generally fatal, than when accompa-
 nied by this eruption.   The plague may .therefore be divided into that
 which  is, and that which is not, attended with buboes-!   The first of
 these includes  many varieties, from that in which the prognosis is  al-
 most uniformly good, to a form of the disease little less fatal than that
 unattended by buboes.
    The appearance of the buboes also affords the means of subdivision,
 for it will be found, on comparing  the accounts  of different epidemics,
 that upon the whole the earlier the  buboes appear, the milder is the
 disease : thus,  for example, in the first class of Dr. Russell's division,
 which was the  most fatal, buboes were very rare ;  in the second, which
 was also very fatal, though less uniformly so, buboes appeared on the
 third day or later; in the third class, which was less fatal, they  ap-

    * Memoire sur  la Peste qui en 1771 ravage* l'Empire de Russie surtout
 Moscow, par M. Samoilowitz.
     + Some writers have divided the  plague into three species; that attend-
  ed with buboes, that attended with carbuncles, and that attended with> pete-
  chil  It wiU appear, I think, from a very cursory view of the disease, that
  there is no room for such a division.                 ...        o  ,
    Bv some ofthe older writers we find plagues mentioned, m no  case of
    wlh  i^s s-id any eruption appeared.   This is said of a plague winch ra-
  wh.ch, it is s-id, anj    p     l                 ^^  ^^ tQ ^
  ?dm^Z"^^™*^™^  ThatofUielSthcen-
  lu^P^h^ been of Uie-same nature with the.Sudor Anglicu, 
364                        PLAGUE.

peared earlier;  in the fourth, which was still milder, buboes generally
appeared on the first day ;  in the fifth, which never proved fatal, they
were among the first symptoms.
   To the two foregoing forms of the disease, a third  may be added ;
for the pestilential eruptions  towards the decline ofthe epidemic some-
times appear without fever.  This form is a mere local affection unat-
tended by danger.
   The most fatal form ofthe plague makes its attack in various ways,
sometimes merely with depression of strength, a sense of weight in the
head, confusion of thought, giddiness, dejection, and oppression about
the praecordia,  often  accompanied with a bitter taste.*   The patient
is inclined to be silent, shews much  anxiety in his countenance,  but
makes few complaints ; the febrile symptoms are very moderate. The
attendants suppose the patient a little indisposed, but suspect nothing
alarming;  yet  such  patients often die within  the first  twenty four
hours, sometimes on the second day.!
   In general,  however, thjs  form of the Plague makes its attack less
deceitfully.  In an epidemic described  by Chenot,| and that of Mar-
seilles,§ it appeared with violent and  irregular  shaking.   Delirium is
sometimes the first symptom.   At other times, a remarkable state of
the pulse, which very suddenly becomes so weak that it can hardly be
felt, frequent and intermitting, with much debility  and languor, an-
nounces the disease.  The prostration of strength is sometimes so sud-
den and great, that Mr. Smith, Dr. Guthrie||  informs  us, saw men  in
apparent good health, on being infected by the  plague, suddenly drop
down as if shot.  Sometimes the first symptoms are extreme horrour
and despair.   In other cases, the disease attacks with very  slight chills,
in a short time followed by a burning heat; as soon as the. heat com-
mences, the patient complains of insufferable head-ache and excessive
thirst.   Sometimes, as in the plague of Russia, described  by Orroeus,

  * The bitter taste the reader will find mentioned by different writers as
characteristic of the plague.   It is observed by some that a favourable change
seldom happened while this symptom continued.

  f See RusseU's Treatise on the Plague, and Oitceus on the Plague of Mos-
cow.

  $ Chenot de Peste

  § Tr: . e de la Peste.

  I Observations on the Plague of Russia. 
PLAGUE.                         :>C5
he is suddenly seized with violent shivering succeeded by a hot fit, the
shivering alternating several times.   The first  symptom is sometimes
a violent beating of the temporal arteries, while the pulse at the wrist
is small and feeble.   In this case the heat is generally moderate, but
the head-ache 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 were the first symptoms.   It  sometimes
comes on with violent palpitation,  and  strong convulsive  tremblings.
The plague which raged in London, in  1665,  often made its attack in
this way.
   As the disease advances, it assumes more of the appearance of the
fevers we have been considering.   The inflammatory symptoms gene-
rally run high for the first day or two ; 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 habi{, and in  whom a full meal
appeared to be  the immediate exciting cause.  In general, however,
 it is of that species which characterises typhus, the patient  appearing
 rather stupid than outrageous, and complaining of  a pain at  the heart,
 a frequent symptom in the plague.   When coma comes on early, it has
 been looked upon as affording a worse prognosis than delirium, partic-
 larly if it suffers no remission in the day time.   The remission in the
 day time is generally more evident when the  patient is delirious than
 when he is comatose.
    Whether he become comatose or not, there  is always a very remar-
 kable muddy appearance of the eyes, which  is sometimes observable
 at the' very commencement, and is  one ofthe most characteristic symp-
 toms ofthe disease.  This appearance of the eyes resembles that in
 the last stage of malignant levers.   It is not, however, described as al-
 together such, for with the muddiness thereis blended a degree of lustre.
 It is an appearance very remarkable to those who have seen it, but not
 easily conveyed in words.   Chicoyneau says  of it, " Les yeux etoient
 •'  ternis, le regard fixe et egarc  annoncoit la  terreur et le desespoir."*
 Chenot calls  it, "  Oculorum languor et maestitia ;"  in another place,
 "  occuli tristes scintillantes," wliich last might almost be  supposed a
 translation of Dr. Russell's account of it.   The eyes, Orroaus observes,
 are unusually prominent and preternaturally red,  watery, and of a
 sparkling fierceness, but in the advanced stage of the disease, they sink,

                          * Traite de la Peste. 
366
PLAGUE.
 the redness goes off and a little before death, they appear dull  and as
 if covered with a Aim.  This change may be observed to a greater or
 less degree, during each remission, for it is in the exacerbations that the
 peculiar appearance of the eyes is most remarkable.
   Almost all writers on the plague take notice of an expression of coun-
 tenance, which to those who are conversant with the disease,  is one of
 its best diagnostics.   It was 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 repeat-
 edly observing it,  he could with some certainty  pronounce whether the
 disease was the plague or not.
   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 delirium ; and  it sometimes happens,  that  the
 coma and delirium, with  the peculiar casts of countenance which ac-
 company them, alternate with each other.   In the delirious, however,
 there is still an appearance of muddiness, and the eyes retain some lus-
 tre in the comatose.   These appearances ofthe  eyes are less remarka-
 ble in  children than in adults.  The danger  is very  generally propor-
 tioned to them.  When the eyes resume  the natural appearance,  par-
 ticularly after sweats, the prognosis is favourable.   In the  form of the
 plague we are considering, this rarely happens.
   The changes which take place in the  eyes are not always  confined
 to their appearance ;  the retina is sometimes much affected.   The pa-
 tient complains of  seeing sparks, flashes of fire, and various colours
 passing before the eyes ;  this is only a greater degree of the symptom
 termed musca vo'itantes.  Deceptions of sight,  however, are  not  fre-
 quent symptoms in the plague.   Deceptions of hearing  are still more
 rare.   Deafness as in other fevers, is a favourable symptom, but it sel-
 dom attends this disease.   With respect to the other senses,  nothing
 particular is to be observed.  The depravation of taste, which is in
 some measure characteristic of the plagues, I have already had  occasion
 to notice.
   The anxiety in many cases is extreme, the patient constantly chan-
 ging his posture, and soon finding the present as uneasy  as the last, so
 that be is sometimes perpetually in  motion.  When this symptom is
considerable, it affords a very unfavourable prognosis.   The  appear-
ance it assumes when at its height, which generally  indicates the ap-
proach of death, is described by authors,  who have termed it  a mortal
inquietude, in very strong terms.  The  patient incessantly twists his 
PLAGUE.                        367
body as if in agony, but is incapable of giving any account of his feel-
ings, so that it is difficult  to determine whether  it is  occasioned by a
great degree of anxiety or severe pain.
  The temperature is sometimes, but not often, very high.  While the
chills continue to recur, its increase is not considerable, and in the ca-
ses where it is most so, it  seldom equals that which we often meet with
in common  synocha.
  The state of the pulse varies.  In most cases  after the first days, in
many after  the first hours, and  in some from  the commencement,  it is
feeble and frequent.  Sometimes it is remarkably hard and small  but
regular, at other times it  is irregular or intermitting, and at length flut-
tering.
  During the exacerbations at  an early  period, it often becomes  full,
open and strong, as  Dr.  Russell expresses  it;  after which it  again
sinks ; in the more advanced  stage,  the opposite change is observed,
the  pulse  during the exacerbations, becoming so feeble that it can
with difficulty be felt.  It has  been  observed that though to a slight
touch the pulse is strong and full, it  is  often easily compressed.*  It is
very remarkable that it has often been observed nearly natural while
the other symptoms indicated much danger.
  The increase of debility is generally indicated by a considerable af-
fection of the speech ; in some cases  there is only a degree of confusion
and faltering, or a change of tone ;  in others the voice  is greatly  im-
paired or lost.  When the  debility is excessive  from  the beginning,
when, as Chenot observes, " ^Igri erecti stare  aut  sedere imputes,
" proprio pondere Iabebantur," a considerable affection of the  speech
is generally observed on the  first night, or the second at farthest.
   The tongue often  retains  the natural  appearance  throughout the
greater part ofthe  disease.  Sometimes it is moist, and covered  with
thick mucus, at other times dry. " Sometimes," Dr. Russell observes,
" it became parched with a yellow streak on each side,  and reddish
" in the middle, but  it never was 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, " rarely
« corresponded with the  febrile symptoms,  for the tongue was often
" moist where the external heat was  intense and  the pulse indicated

  * In the Traite de la Peste the reader will find this state ofthe pulse men-
tioned both bv Chicoyneau and Conzier.  «II etoit ouvert et anh e"   The
former observes,  «It disparoisoit  cependant si on pressoit  Tartce  avec le
« doigt." 
368                        PLAGUE.
" high fever;  and on the contrary,  parched where the fever in ap-
" pearance 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 situated about the orifice
of the stomach.  As it often accompanies vomiting, he was at first led
to believe that it arose from bile or other irritating matter in the stom-
ach.  He found,  however,  that it was not relieved by the discharge.
It seems more  than probable, 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 some-
times of a dark colour and mixed with blood ;  and it is not  uncommon
for worms to be thrown out by vomiting.   They must of course have
existed before the attack of the disease by which they were expelled.
Whatever be  the appearance of the matter rejected,  when vomiting*
occurs at an early period  and returns at intervals, the prognosis is bad.
  Nausea without vomiting is a frequent  symptom.  It does  not
seem to proceed  from  irritating matter in  the  stomach, as repeated
emetics are not found to relieve  it.   There are kw means more effect-
ual in allaying nausea and vomiting than those which promote perspira-
tion.   It has been observed of the plague, that if the repeated reach-
ing occasions a moisture on the skin, the nausea abates.
  A diarrhoea frequently  supervenes, sometimes during the  first days,
more  frequently at a  later period.  This is  invariably a   dangerous
symptom.  The  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 often  met with dys-
enteric purging in the plauge.
  As there are  few fevers in which purging is so unfavourable, so there
are  none in wliich constipation appears to  be less injurious.   " A num-
" ber of the sick," Dr. Russell observes,  " were disposed to be costive
:' throughout the disease, and 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 sluggishness of the bowels were by
" no means what might have been expected, for on comparing a num-
" ber of cases  in which the body had been all along regular, with oth-
" ers 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 costivoness in others" 
PLAGUE.
369
   The urine  is often observed in no respect different from that of a
person in health ; at other times it is pale, high-coloured, frothy,  tur-
bid, or deposits a great  deal of sediment, and is sometimes more or
less tinged with blood ;  in short, it  assumes in different patients, or
sometimes in  the same at different times, all the various appearances
observed in other fevers.
   There is no excretion of such consequence in the plague  as that by
the skin.   When it remains  parched,  or when only slight, clammy,
partial sweats appear, the prognosis is bad; when  on the other hand
a thin, general and copious sweat takes place, it  often proves more or
less critical.
   Dr. Russell remarks, that the breath  and perspiration were seldom
or never  fetid.  Other writers, however, have observed that they are
often so to a great degree.
   Slight convulsive motions of the  limbs  and subsultus tendium are
frequent;  hiccup rarely, and sneezing almost never, attends the plague.
   Hemorrhagies are a  common symptom, and unless very moderate,
generally  indicate danger.   They  are  not  uncommon,  as appears
from what has been said, from  the  stomach,  intestines, and kidneys.
They are  most frequent, however, from  the nose, and in women  from
the uterus.  These particularly the hemorrhagy from the nose, when
they  occur early in the disease, and the patient is young and plethoric,
sometimes bring relief.   At a later period,  hemorrhagies  are always
unfavourable, and when they become profuse the  patient rarely sur-
vives.  It has been remarked, as might have been inferred  a priori,
that the  blood which flows in these hemorrhagies is thinner in propor-
tion as the disease  is further advanced.
   Such are the symptoms ofthe worst form ofthe plague. The strength
gradually  sinks, till the  pulse impresses the finger with only a weak,
 undulating, or  tremulous motion, with  frequent intermissions.  The
surface,  particularly on the extremities, becomes cold and covered with
 clammy moisture,  the pulse cannot  be felt, and the patient calmly ex-
 pires, or, as sometimes happens in  all idiopathic fevers, is carried off
by convulsions.
  The second and more common form of the  plague, that accompanied
with buboes,  includes endless varieties.*   What I am about to say of

   * Some objection might be stated to regarding the plague as  an exanthe-
'ma.  Were it not that it arises from a peculiar contagion, it ought rather to
be ranked as a species of synochus.
                                 47 
370
PLAGUE.
 this form, maybe divided into two parts; the circumstances in which
 it differs from the preceding form, and those in which its principal va-
 rieties differ from each other.
   In the first place, of the circumstances in which this form differs
 from the preceding.   If we except the appearance of buboes,  we shall
 find no symptom constantly attending the one, and never present in
 the other.  There are certain symptoms, however, more frequent in
 the one than  the other.
   Both vomiting and diarrhoea are most frequent in cases where bu-
 boes are about  to appear.  They sometimes attend from the  com-
 mencement ;  at  other times  supervene at a  later period.  When the
 vomiting and purging commence early,  they often continue to harass
 the patient through a greater part ofthe  disease.
   Although the  delirium  and  coma are sometimes as uniform in this,
 as in the preceding form, it is not generally so.  In most instances, in-
 deed, some degfee of these affections comes on in the evening and con-
 tinues  through the night, but in the majority of cases, unless the disease
 is far advanced, the patient during the day is nearly and sometimes al-
 together free  from them.   An epileptic fit now and then, very rarely,
 precedes the eruption, a symptom hardly ever observed, in the form of
 the disease we have been considering.  The sudden depression  of
 strength is upon the whole less  remarkable,  and the pulse for the  most
 part continues longer full, and is less apt to become irregular.   The
 duration of the disease upon the whole is longer, petechiae and  vibi-
 ces are more  common, and  the  body more  frequently becomes  livid
 and black after death.
   The great difference between the general course of the symptoms in
 the first and second  forms ofthe plague,  is that in the  latter, they are
upon the whole less alarming  and more protracted,  the patient often
labouring  under various  symptoms for  some days before  the fever is
formed.*  In the danger  and rapidity of the  second form, however,
there  is  great  variety;  it varies from  a  degree of  severity nearly
equal to that  of the  first, to a degree of benignity approaching to that
ofthe last, in which the eruptions are unaccompanied by fever.
   Although the varieties  of the second  form  are  in reality  endless,
there are only three which can be distinctly marked,  for (notwithstand-

  * See what  Orroeus  calls the period of infection,  in his  Account of Uie
Plague  in Russia. 
PLAGUE.                        371
ing the  numerous di\ isions of authors)  I  can discover  no symptom
which characterizes any varieties included under these ; and varieties
ill-characterized, instead  of conducing to  perspicuity, tend to perplex
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,  is  not sufficient to
characterise  different  varieties ofthe plague, unless it can be shewn
that the  general course of the disease is materially influenced by the
absence or delayed  appearance of such symptoms,  which on perus-
ing the account of different epidemics we do not find to be the case.
   The first variety ofthe second form, according to the division I have
adopted, is characterized  by the buboes not appearing till the second
or third day, or later.  In this case the symptoms are generally  more
violent, and the  prognosis worse than  v.hen they  appear on the first
day,  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 of the disease, that the difference consists almost solely
in the appearance of buboes in the former; thus the first and second
forms of the plague imperceptibly run  into each other.
   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.  If they are accompanied
with irregular flushing, a sense of internal heat, pain  about the praecor-
dia, and  incessant inquietude, the danger is extreme; as in the first
form, these symptoms often precede that diminution of temperature and
cold  dampness of the surface, that announces the patient's death to be
inevitable, which is often, however, at  the distance of a day or two,  or
more.  After this,  although the  heat of the body returns, the symp-
toms upon the whole gradually become worse. When the strength has
not been greatly reduced by the vomiting and purging, a remission is oft-
en observed  on the  third day, but if the  foregoing train of symptoms
has previously occurred  it is always fallacious, and the disease returns
with increased  violence.  The patient often survives to the fifth  or
sixth day or  later, the remissions constantly becoming slighter, and the
exacerbations more severe. 
372                        PLAGUE.

   On the second or third day, sometimes later, buboes make their ap-
pearance, in general without bringing relief; carbuncles also frequent-
ly 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.  In some epidemics,
Waldshmidt* remarks, when the symptoms were most alarming, the
appearance of buboes  often saved the patient, but in others they were
not attended with any advantage.
   In this variety the body is frequently covered with  petechia or vi-
bices, 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 vomit-
ing and purging do not occur, or  at least not in such a degree as great-
ly to reduce the strength, the foregoing train of symptoms  does not ap-
pear, and the patient  escapes.   In these cases,  the delirium  or coma
seldom comes on before the second night, and the remissions which take
place  in the morning  are more considerable.  Such flattering  appear-
ances, however, often  prove deceitful, and even a salutary sweat on
the morning of the  third day is sometimes succeeded by  a fatal train
of symptoms.
   The fatal termination frequently happens  on the fifth  day, some-
times 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, according
to the division I have  adopted, buboes appear on the first  day.  Here
the symptoms are wonderfully varied.   Many caees 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, which corresponds to this va-
riety, " The fourth class was  the most  numerous of all, comprehend-
" ing those forms ofthe disease,  which,  from  the various  and sudden
"  changes in their  course, so often, though not constantly, met with,
'*  cannot easily be represented in concise and connected  description ;
"  I therefore enter on the attempt with diffidence, and  as a supplement

  * See Halter's Disput. ad Hist, ct  Cur.  Morb. pert. vol. 5.

  ■J- See the observations of M. Chicoyneau, in the Traite de la  Peste. 
PLAGUE.                       373
,4 for defects, must refer to the cases themselves noted  below.   The
" distinctive marks of this class are,  the continuance ofthe inflamma-
" tory and febrile symptoms with less interruption  than in the former;
'* a pulse more constantly sustained or soon recovering itself when sunk
" and hurried in the exacerbations ; the length and rigour ofthe exacer-
" bations decreasing in the advance of the disease  ; and above all, the
" prevalent tendency to a favourable crisis by the  skin, with the crit-
" ical sweats on the third, fifth, or subsequent days."
   Vomiting is not so frequent a symptom in  this, as in the former va-
riety.   The symptoms upon the whole, however, are  sometimes as
severe as in that variety ; but for the most part they are milder.  The
fever is  more moderate ; and delirium or coma still more rarely ap-
pears on the first night, during which the patient is less restless and anx-
ious.
   The remission on the second morning is generally considerable, and
during the  second day the symptoms undergo many changes ;  at one
time running  high, often with more or less coma, soon afterwards suf-
fering an evident remission, which in many cases  is only a prelude to
a new exacerbation.
   The exacerbations are sometimes followed by a sweat, more or less
general on  the morning of the  third day, 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 other 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  brings such relief
that the  patient remains free from danger.
   This remission however is  frequently inconsiderable,  and the exa-
cerbation 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 be-
 come 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 ofthe fourth day again brings re-
 lief, and if the exacerbation on this day be less, the sweating is more
 profuse and brings more relief 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 
374                        PLAGUE.
 patients are more profuse and bring more relief on the mornings ofthe
 odd, than on those ofthe even days.*
   All  who escape, however, do not recover in  this way, but often
 very slowly, and with little or no sweat.
   In the last variety ofthe second form  of the plague, namely, where
 the eruption of buboes is among  the first symptoms,  many cases  are
 attended with a considerable degree of fever, sometimes 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, wliich nearly corresponds with this variety, "  Subinde vix ulla
 " bubonis ortum praecedit stipatve agritudo.   Ipse carbunculus nonnun-
 •* quam prodit, pravia tantum miti commotione  febrili,  manifestior,
 " tamen plerumque est quam in bubone."
   The  patient  is sometimes not even confined to the  house, and very
 often not to  bed.   In short, the mildest cases of this variety almost re-
 semble  the last form ofthe plauge, in which the eruptions are  the only
 symptoms.
   Such are  the symptoms of the plague,  and  the gradations by which
 the first form runs  imperceptibly  into the last, than which it is impos-
 sible to  conceive two diseases more dissimilar.
   Before leaving this part of the subject  it is necessary to observe, that
 although most  cases of the  plague will be found referable to  some of
 (he foregoing heads, there are many anomalous cases which cannot be
 arranged under any one description, as they differ  from each other, as
 well as  from all other cases.  Dr.  Russell forms a separate class  for
 such anomalous cases,  without, however, attempting  any general ac-
 count 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 fore^o-
 " ing classes, admits of course of no general description.   The partic-
 " ular cases, to which have sometimes  been subjoined occasional  re-
" marks, may be consulted agreeably to  the references made below 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  re-
semble those of another.  All that can be done, is  to warn the practi-

  *See what is said in the first b^ok ofthe Doctrine of critical davs. 
PLAGUE.                        375
tioner that anomalous appearances are to be looked  for, which do not
seem, however, materially to influence the mode of treatment.
SECT. III.
                    Ofthe Causes ofthe Plague.


  The history of the plague is involved in much obscurity.  It is im-
possible to say from what source, or where it originated.   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 as-
sured,  that it  arises from a peculiar contagion.   Professor Stoll of Vi-
enna, indeed, and  some others, have combated this opinion, but  it
would  be mispending time to  trouble the  reader  either with the argu-
ments  of these writers, or any refutation of them, as they have  scarce-
ly now a single advocate-!
  The subject of contagion has already been considered at length.   It
is needless to repeat what has  been said of the means of preventing the
generation and checking the  progress of  contagious diseases ;f  and it
would  be tedious here to describe lazarettos and the various precau-
tions employed to prevent the introduction of the plague ;  for these I
shall refer the reader to the works of Mr.  Howard and Dr. Russell.
  The contagion of the  plague, like that  of other diseases, is active on-
ly for  a short distance around the patient.

  * See Waldshmidt's Treatise  on the Plague, in the fifth volume of Halter's
Disput. ad Morb. Hist, et Curat, pert.
  +  See the Traite de la Peste,  and Dr. Russell's work on the Plague.
  *  De Mertens recommends, as a good preventive, wearing a cloak of oiled
cloth over the clothes,  while in the rooms ofthe sick.  It has also been re-
commended to annoint the body with oil.  De Mertens thinks issues  not to
be depended on.  The reader will find, in his Treatise on the Plague ot Mos-
cow formula for what have been termed antipestilential powders ;  they are
similar to the fumigating powders mentioned above,  in speaking ofthe puri-
fication of fomites : the  manner  of using tl.cn aNo, is there pointed out. 
3*76
PLAGUE.
   Some  facts would lead us to suppose that peculiar states of the air
are favourable to the production of the plague.  It has sometimes ap-
peared in many  parts of a country at the same time.*   More generally,
however, it appears at  first in one place only, and gradually spreads
to others.
   As in other contagious fevers, warm weather is generally favourable,
and cold  weather unfavourable, to  its progress.   The plague was great-
ly weakened, De Mertens informs us, while the thermometer stood be-
tween 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.  All the plagues with  which Aleppo  has been visited during
this century, the Rev.  Mr. Dawes, observes, are said  to have regular-
ly ceased in  August or September.
   The young and  robust, it has been observed, are more liable to in-
fection than the old and infirm.   It has  often  been  remarked  of the
plague,  as of most other contagious fevers, that infants are less liable
to it than adults.  Waldshmidt saw several infants who sucked  nurses
ill of the plague, and yet escaped infection.  He even observes, that
one infant sucked two nurses  ill of the plague, both of whom died, yet
the child did not receive the disease.   A woman who suckled her
child five months old,  was seized with the plague and died after  a
week's illness, but the  child who  sucked her  and  lay  in the same bed
with her, escaped  the distemper.   De Mertens and others make simi-
lar observations.  It is remarkable, however, that the foetus in utero
sometimes  receives the  disease, and that even  where  the mother
escapes.!
   It has been observed of some of the exanthemata! that certain con-
stitutions are not liable  to them.   This seems to be true of the plague.
Waldshmidt knew a  woman  who was servant in a family where seven
people died of the  plague, and afterwards in another all of whom died

   * See a Letter by Uie Rev. Mr. Dawes from Aleppo, in the third volume of
Uie Medical Museum.

   ■j- " Last year as well as Uiis, says Dr. Dawes, there has been more Uian one
" instance of a woman's being delivered of an infected  child with Uie plague
" sores on its bodv, though the mother herself has b«en entirely free from
" the distemper." In pregnant women Uie plague generally produces abortion.

   i This has often been remarked of the small-pox and measles.  Respecting
Uie latt»r Dr. Willan doubts the accuracy ofthe observation. 
                            PLAGUE.                        377

of it, and yet remained uninfected.   A Greek lad, Mr. Dawes observes,
made it his business for many months to wait on the sick, and to wash,
dress, and bury the dead, yet escaped the disease.
  Those who have once had the plague are less subject to it than oth-
ers.   This circumstance,  together with the success which had attend-
ed inoculation for the  small-pox, induced  some to  recommend  inocula-
ting 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, un-
der the cuticle ofthe  arm, a little ofthe matter from a pestilential ab-
scess.   On the fourth day after inoculation the  fever appeared ;  he
treated himself in all respects in the same way as  if he had  been inoc-
ulated for the small-pox, paying particular attention  to the  cool regi-
men.   His only medicines were cold water  and vinegar, with a little
wine.   The disease proved so mild that he was never confined to bed,
but was generally in  the open  air.   It was not more severe  than the
common inoculated small-pox.
  He afterwards regularly attended an hospital allotted for  the recep-
tion of patients under the plague,  without suffering from the disease ;
while most of the other surgeons fell a sacrifice to it.  From one case,
however, no conclusion  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 pro-
duces 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, however, its effects are more
sudden.   Waldshmidt mentions the case of a person, who while  he
was drying some clothes which had been worn by a patient under the
plague, was immediately seized with nausea and head-ach, and died
on the sixth day, a bubo and  other pestilential symptoms having made
their appearance.
  Brutes are incapable of receiving this  disease,  although  like other
things  which have been in contact with or near the sick, they are of-
ten The means of conveying the contagion.  It appears, however, from
an instance related by Boccacio, and some similar ones mentioned by
Waldshmidt, that the  contagion of the plague, if received into the sto-
mach often produces violent effects on brutes ;  a circumstance wliich rrf-
                                18 
378                        PLAGUE.
  fords a strong argument against contagion, in casual infection, making
  its first attack on the stomach.
    The contagion of the plague, like that of typhus, appears sometimes
  to act merely as a predisposing cause.  In speaking of the  latter, it
  was  remarked, that the observations of Dr. Lind have proved, that the
  contagion of typhus may sometimes lurk in the body and remain inac-
  tive  for a considerable  length of time, if the  patient is not exposed to
  other causes of disease, which seem to prepare  the  system for its ac-
  tion.  De Mertens  makes a similar observation with respect  to the
 plague; many, he observes, were suddenly seized after a hearty meal,
  a fit  of anger, or violent exercise.
    It  is of great importance to determine how long  the  contagion of
  plague will lurk in  the human body, or in fomites while  freely expos-
 ed to the air, and retain its activity, as this circumstance determines
 fhe duration of quarantine.   Dr. Cullen thinks forty days  longer than
 necessary for the quarantine of people ; and that if goods are properly
 unpacked and  aired, the term of their quarantine may also be short-
 ened.
   " 1 suggested," Dr. Guthrie observes  in his letter to  Dr. Duncan,
 " to Baron Ash, physician general to the Russian army, a doubt ofthe
 " possibility that the very active contagion of the plague  could remain
 " so long latent in the body, as the quarantine of persons  seems to iim
 " ply, and that it appeared to me to be founded on an imperfect knowl-
 " edge of the disease, drawn  from a period of ignorance or of  general
 " consternation  and terrour.   His  answer was, that he  did not think
 " that the contagious nature of this violent disease could  remain long-
 " er in the body than fourteen days without declaring itself on, or be-
 " fore, that period, but  that from his own observation and  experience
 '* he could not take  it upon him to say that it could not be concealed so
 " long.  Such were likewise  the answers I received from the other
 " medical gentlemen whom I consulted on the subject.   Some gave a
 " little more latitude and some less, as it can only be  a matter ofopin-
 " ion, but none exceeded fourteen days."
   From different facts, just stated, it would seem that the plague gen-
 erally appears as early  as the  fourth or fifth day  after infection ; but
 we do not  know  how long a person who has laboured under the  disease
is capable of infecting others, nor how long the contagion  may lurk  in
 an unfavourable  habit without producing the disease, and be commu-
nicated and excite the disease  in habits more  susceptible  of infection. 
PLAGUE.
37S
Upon the whole we have reason to believe, that a quarantine of  forty
days is considerably longer than  necessary.   Experience,  however,
has not yet ascertained how much this term maybe shortened.
   The most unaccountable circumstance respecting the contagion of
the plague, which has also indeed been observed to a greater or less
extent of that of other fevers, is that it often suddenly and without any
apparent cause ceases to produce the disease.   The  plague,  says  De
Mertens, ceased at one time over the whole Russian empire, after having
prevailed  at Moscow and other places for a year and a half.   " But a
" greater difficulty," Dr. Russell observes, " than that  of all persons
"  not being susceptible of infection, arises from the cessation of  the
"  plague at a period when the s'ipposed contagious effluvia preserved in
"  apparel, furniture, and other fomites,  at the end of a pestilential sea-
"  son, must be allowed not only to exist  in  a much  greater quantity
"  than can be supposed to be at once accidentally imported by  com-
" merce, but in a state also of universal dispersion over the city.  The
" fact, however unaccountable, is  unquestionably 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
" liable to retain  the latent seeds of infection.   But at Aleppo, where
•*  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 revives in certain seasons, and  at
"  length, without the interference of human  aid, ceases entirely."
"  Ubi pestis nondum penitus extincta fuit," says Waldshmidt, " hac
" sua sponte praeter omnium expectationem ita cessavit, ut ne  vestigium
"  quidem ejus postea apparuerit."   Nor was any one infected by an-
other, he adds, although the latter still had the pestilential buboes about
him,  while articles which had  been in contact with  the sick entirely
lost the power of communicating the disease.
   At the beginning ofthe epidemic, the plague generally assumes the
first form according to the arrangement I have followed, so that it ap-
pears  without its peculiar eruptions.   It is  also then less contagious
than at the height of the epidemic  ; two circumstances wliich  often
lead to fatal errours.   During  its progress it inclines more  and  more
to the last form, in which it generally terminates.
   It is remarkable that convalescents from the plague have the vene-
rea! appetite unusually strong, a circumstance  wliich often counteract 
380
PLAGUE.
the endeavours of the magistrate, and  tends to spread  the distemper.
The same thing has been observed respecting other  malignant fevers.
It is particularly remarked  by Dr. Rush of the late fever of North-
America.
SECT. IV.
                  Of the Treatment of the Plague


   " In the cure ofthe  plague,"  Dr. Cullen  justly remarks, " the in-
dications are the same as those of fever iB general." I therefore refer
the reader to what was said of the treatment of  continued fever, and
shall now only make a dew additional remarks particularly  applicable
to this disease.
   The Asiatics  employ  blood-letting in all cases  of the  plague,  and
even recommend it as late as the fourth, fifth, sixth, or seventh day, and
some European physicians have  used it with great freedom.*
   The reader will find many declaring that they could not  perceive
that a small blood-letting, particularly at the commencement did harm.
They appear to have assumed it as an axiom, that if blood-letting is
not evidently hurtful, it  must be beneficial in this disease ; and  all
that they seem anxious  about is to adduce cases and arguments in sup-
port of its innocence.
   Nothing can be more  fallacious, however, than the arguments  em-
ployed for this purpose, as the reader will  readily perceive, when he
reflects that the consequences to be dreaded  from blood-letting  in the
plague, the various symptoms indicating a general loss of  tone, occur
in all the  more alarming  cases of this disea.-e, and supervene at differ-
ent periods.  How  then shall wc ascertain that  blood-letting has not
accelerated, or even occasioned, their appearance ?

  * It Is a remark of Sydenham that blood should  be lot if the physician set
the patient before any appearance of  u bubo.  The reader may consult on
this subject  Dr. Alexander 1;>>-V1;. Lf;count of the plague in his Xatrr.-1
/.tibtcry of A;-- ;i*o. 
PLAGUE.
381
  ** Upon finding the pulse sink so suddenly after bleeding," an author
I have frequently had occasion to mention observes, " I was at first in-
" clined to attribute it to  that evacuation, and  to suspect in less  ple-
" thoric habits bleeding must prove still more prejudicial ;  but I after-
" wards found the low state inseparable from certain forms of the dis-
" ease, and often could observe  no material difference in its progress
" in cases where blood-letting had or had not been omitted."  The au-
thor in this quotation confesses that the symptoms of debility were
those which he dreaded, and also those to be feared from the means he
employed, without informing us of any advantage to be expected  from
it, to counterbalance the risk.
   Others run to the  opposite but safer  extreme, and maintain  that
blood-letting is universally hurtful in the  plague.
   The more we study the observations of the original writers, we shall,
 I think, find the more reason to-believe,  that the employment of blood-
letting in  this disease is to be regulated by the same maxims as in oth-
er idiophatic fevers.
   Many of the Turks employ local  instead  of general blood-letting,
 and in  the latter they usually draw much less blood than we are accus-
 tomed to  do ; circumstances which have probably contributed much to
 establish  the safety of blood-letting in the plague.
   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
 it had  this  effect.   Direct experience is not sufficiently extensive and
 accurate  to determine the question, whether blood-letting, if otherwise
 indicated, should be delayed when an eruption is expected ;  if we ad-
 mit of reasoning from analogy, it may witfiout hesitation  be answered
 in the  negative.
   We are  led by analogy to believe that emetics may be useful ot the
 commencement of the plague, and they have sometimes beer, employ-
 ed with  advantage.  " Vomiting,"  Dr. Alexander Russell* ob*« ive*,
 ■: was also of the utmost consequence 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 ofthe first symptoms, and working it off n ith acid
 •; drinks.  If the nausea and bitter taste in the mouth were not rehtv-
 li ed by the first, they gave a second and sometimes a third and lourth ;
 :i nav  if the symptoms were very urgent, Ihey gave two or three in  the

                     ^ccbis Natural His^w of Aleppo. 
382
PLAGUE.
 " 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 objections 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  prejudice 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, and by their debilitating effects they
 may do harm.  When retching occurs without vomiting, an emetic is
 frequently serviceable.  When it fails to allay this symptom, opiates
 often succeed.
   There appears to be little doubt of the propriety of opiates, used for
 the  purpose of allaying restlessness and procuring sleep, in all cases
 where the excitement is not considerable.   Dr. Patrick Russell says
 he never saw them produce coma.
   Almost all physicians who have practised in the plague  agree,  that
 much purging is hurtful.  A spontaneous diarrhoea is always a danger-
 ous symptom ;  on this account,  in those places  where  the disease  is
 frequent, there is the utmost dread of cathartics ; 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 bowels often remain inactive for
 a long time, and it  is said without the patient appearing to suffer from
 it.
   We may say of this, as of blood-letting, that in a  disease whose
 symptoms are so varied, it requires much experience to ascertain the
 effect of any mode of treatment; and we have a double reason for draw-
 ing our conclusions cautiously, when the measures which appear safe,
 have in similar cases been found pernicious.   Besides, although the
 common  inconveniences of costiveness be less felt in this disease, than
 in many others, it seems often, by occasioning  an accumulation of ir-
 ritating matter  in the intestines, to induce the very effect which we
 dread from cathartics.
    When diarrhoea occurs, whether spontaneously or from medicine, it
 is  for the most part readily checked by opiates at the commencement
 of the disease ; but in the advanced stages, opiates,  astringents, and
  all  other means often fail, and then  the prognosis is fatal.
    It was observed that  spontaneous sweating is  often attended with
 the best  effects.  But, as I nave already had occasion to remark, there
 is  generally a  great  difference between  the  effects  of  spontiiieou 
PLAGUE.                        383
sweating and that produced by art.   The effects of antimonials in the
plague have not been ascertained.   Dr. Russell thinks that combined
with opium, they promise to be of service.   Little is to be expected
from valerian, contrayerva, bezoar, and other similar articles, regard-
ed as diaphoretics, and much celebrated in this disease.  I have not
seen any account of the cold affusion having been employed in it.   We
have reason to believe that it may often be of use in the early stages.
   A very different mode of exciting the action of the skin, to which I
alluded in speaking of the treatment of fever, has  lately, it is said,
been attended with great success in the plague.   It was proposed by
Mr. Baldwin, the British agent and consul-general at Alexandria, and
has been made known to the public by a  smal) Treatise in the  Italian
language by Count Bertchfold ; the following  extract from which has
been translated into different  languages, and circulated 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
 14  room, and over a brazier of hot coals, with a clean sponge dipped  in
 44  warm olive oil, his  body must be very  briskly rubbed all over,  for
 44  the purpose of producing a profuse sweat.  During  the friction, su-
 "  gar and juniper berries must be burnt in the fire, which raise a dense
 44  and hot smoke that contributes to the effect.
    44 The friction ought not to  be continued more  than four minutes,
 44  and a pint of oil is enough to be used at each time.
    44 In general, the first rubbing is followed by  a very copious perspi-
  14 ration ;  but shoild  it fail of this effect, the operation may be  repeat-
  44 ed, first wiping the body with a warm, dry cloth ;  and in order still
  14 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 ;  and other tender parts ofthe  body  may  be rub-
  " bed more gently.
    44  Every possible precaution must be made use of to prevent  the pa-
  « tient taking cold, such as keeping covered those parts ofthe 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 symp-
  « toms of recovery, begin to appear.  If there  are already tumours on
  -the body, they should be  gently and  more frequently rubbed   till
  « they appear to be in a state of suppuration, when they may be dres-
  « ed with the u«ual  plainer*. 
384                       I RTICAHIA.
   44 The operation ought to be begun on  the first appearance of  the
;4  symptoms of the disease ;  if neglected till the nerves and tne mass of
::  blood are affected, or a diarrhoea has commenced, iitt;e hopes can be
;'  entertained of cure ; but still the patient should not be despanv i of,
44 as, by an assiduous  application of the  means proposed, some  few
"  have recovered even after diarrhoea bad commenced.
   " During the first four or  five days the  patient must observe a very
14  abstemious diet; the author allows only a small quantity of vermicel-
44  li, simply boiled in  water.  Nor must  any  thing be taken for the
"  space of thirty or  forty days,  except very light food ; as he says,
44  an indigestion in any stage of the disorder might be extremely dan-
" gerous.   He  does not allow the use of wine till the expiration of for-
i4 tydays.
   44 There is no instance of the person  rubbing a patient having taken
<4 the infection.   He should previously'  anoint himself all over with oil,
" and must avoid receiving the breath of the infected  person into his
44 mouth and nostrils.   The prevention  to be used, in all circumstances,
14 is that of carefully anointing the body, and living upon light and ea-
" sily digestible food."
   Mr. Badlwin observes, that among upwards of a million of people
who died ofthe plague in Upper  and Lower Egypt, during  the space
of four years, he could  not discover a single oil-man or dealer in oil.
   The buboes  and carbuncles often require some  attention, but  their
treatment belongs to the province of surgery.
CHAP. VI.
                        Of the UitTicARi.i


   The Urticaria or Nettle-rash is defined by Dr.  Cullen,
   ri Febris amphimerina.*   Die secundo rubores  maculosi urticarum

  * The term amphimerina is generally used to express a fever, which re-
turns daily, and is always finished within the day,  so  that it is a quotidian
intermittent.   The term, however, has not always been employed in precisely
the same sense. 
URTICARIA.
385
J< puncturas referentes, interdiu  fere evanescentes, vespere cum febre
* redeuntes, et post paucos dies in squamulas minutissimas abeuntes."
SECT. I.
                Of the symptoms of the Urticaria.

  Dr. Cullen remarks, that he gives the character of the nettle-rash
rather from the accounts of others than from his own observation, as he
had seldom seen the disease, and never a single case of it, in which  it
run 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 pustules over the whole
body, resembling the appearance produced by the stinging of nettles.
The reader will also find  it described by Vogel,* Eller,! Burserius,|
Dr. Heberben,§  and others.   The best account of it which I have  seen
is by Dr. Willan.
  44 The  symptoms preceding the eruption," he observes,44 are pain and
ft sickness at the stomach, head-ache, great languor or faintness,  with
" a disposition to sleep, a sense of anxiety, an increased  quickness  of
44 the pulse, and a white fur on the tongue.  In two days and sometimes
44 later, after these symptoms, the wheals," (Dr.  Willan's name for the
eruption ofthe urticaria),  4i appear with an efflorescence in patches of
44 a vivid red, or sometimes nearly of a crimson colour.   They are pre-
44 ceded  by fits of coldness and shivering, and are attended with a  most
44 troublesome itching or  tingling, which is greatly aggravated during
44 the  night,  and  which prevents  rest for many  hours.   In order
44 to avoid this inconvenience, I have known many persons sleep on a
44 sofa without putting off their clothes, as their distress begins immedi-

       *  Pradect Acad, de Cog. &c

       |  De Cog. et Cur. Morb.

       $  Institut. Med. Pract.
       '-  First Volume ofthe Medical Transact iuix.
                                 49 
386                       URTICARIA.
" ately on uncovering the body.   The patches  often coalesce  so as to
" produce a  continued redness :  they  appear on  most parts of  the
44 surface, but they are diffused particularly on  the shoulders, loins,
" nates,  thighs, and  about  the knees.   They extend likewise to  the
44 face ; and there is  sometimes a red circle round the palm of the hand,
'4 accompanied with  a sensation of  violent heat.   They appear and
" disappear irregularly, first on one part, then on another, and they
44 may be excited on any part of the skin by strong friction or scratch-
" ing.   During the day, the efflorescence fades, and the wheals  in
44 general subside, but  both o/ them  return with slight  febrile parox-
44 ysm in the evening.  The red patches of efflorescence are often ele-
44 vated  above the level of the adjoining cuticle, and form dense tu-
" mours, with a  hard distinct  border: the  interstices are of a dull
44 white colour.   When the patches are numerous,  the  face, or the
44 limb chiefly covered with them,  appears tense, and considerably en-
'4 larged.   At the latter end of the disorder, the eyelids are  red and
44 tumefied, and there is often a swelling and inflammation on the sides
44 ofthe feet.   On the appearance ofthe  eruption, the pain and sickness
44 at  stomach are  in  general relieved,  but when it disappears, these
44 symptoms return.   The  whole duration of the febrile nettle-rash is
44 seven  or  eight  days.  As the  eruption declines the tongue becomes
44 clear, the pulse returns to its usual state, and  all internal  disorder
" ceases : the efflorescence exhibits a light purple or pink colour, and
44 then gradually  disappears, being succeeded by slight  exfoliations of
44 the cuticle."
  This disease in general is unattended with danger, although instan-
ces have occurred  of its  proving fatal in  very unfavourable habits.
One is related by the author just quoted.
  The eruption of urticaria unattended  by fever is a very common dis-
ease.  In  Worcestershire  there  are  few affections of the skin more
frequent.   Dr. Willan enumerates  several species of it.
                            SECT. II.

                    Ofthe Causes of Urticaria.

  Urticaria is most apt to appear in summer ;  and in those of a san-
guine and pletbocic habit.  It is more frequent  in children than in ad-
ults.  Like many other eruptive fevers, it is connected with the state 
URTICARIA.
387
of prima  viae.   Sydenham observes,  that it  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 irri-
tating matter in  the prima viae, or from the perspiration being check-
ed ; and Dr. Willan gives cases in which it evidently arose from affec-
tions ofthe stomach.   In children it seems often occasioned by teeth-
ing.  It seems doubtful from these circumstances, whether it be prop-
erly arranged among the exanthemata, from which it also differs in not
being contagious.  It  may attack the same person several times, and
there are  instances of its constantly recurring on every  slight cause of
derangement.    It seldom,  however, appears as  a symptomatic affec-
tion, and  one species of it at least, is always preceded b}r fever.
SECT. III.
                 Ofthe Treatment ofthe Urticaria.

  The treatment of urticaria differs little from that of common synocha.
An emetic, as may be inferred from what has been  said, should always
be exhibited at the commencement, and the bowels cleared.  Dr. Wil-
tan thinks antimonials objectionable, on account of the debility which
frequently attends this disease, and for the same reason recommends in
its decline, peruvian bark with the sulphuric acid. 
 
APPENDIX.
  As I consider it the duty of every medical man to contribute as far
as he is able to extend the  knowledge of the cow-pox ; and as the na-
ture of this treatise only allowed me to point out its safety and efficacy
as a preventive of small-pox,* I am happy in  having it  in my power
to lay before the reader the following instructive extracts from a letter
with which I was favoured by Dr. Jenner.
   44 The vaccine pustule exhibits many varieties of tint during its pro-
gress.   The three following are the most predominant; (observe I am
now speaking of the correct vaccine pustule) pink, pearl and amber,
from the 6th  or 7th, to the 9th or 10th.  About this time, and some-
times onward to the  lith or 12th day, it assumes a  bluish cast;  but
this is not common, nor is it of any consequence whether it appears or
not.  In my early treatises, when speaking on  this subject, I  particu-
larly noticed this colour, but I was then alluding  chiefly to its colour
as  it appears on the teats of the cow.
   44 I will just mention, as I  wish it to be as universally  understood as
possible, that the chief point  to be attended to by every one who vacci-
nates, is the state ofthe patient's skin, as it is so apt when under the
influence of herpetic  eruptions  to  induce varieties of  the vaccine pus-
tule ; and these varieties,  according  to their gradations or deviations
from the perfect pustule, produce gradations with  regard to security—
that is to say, if the deviation is trifling, security may be depended on ;
 if the pock in its progress puts  on a midway appearance, partaking as
 much of the herpetic as the vaccine character, the case is doubtful ;
 and when the  herpetic  character follows  the  puncture, and prevails
throughout its course, then it is to be considered of no avail whatever.
 However, with due attention, this tendency to anomaly can commonly
 be controuled  with great facility.  If I find the pustules running wild
• Vol. I, p. 295, and seq. 
U                         APPENDIX.

in consequence of these blotches, I deaden them at once, by the use of
ung. hydrargyri nitrati.   In early infancy, when they are detected
behind the ears or  on any tender part ofthe skin, my  application
is a solution ofthe sulphat of zinc or the acetate of lead.  It is curious
to observe how quickly then will the pustule assume its  perfect"charac-
ter and maintain it; thus affording the security sought for.  It would
have been extraordinary indeed if the whole phaenomena of vaccina-
tion had burst upon  my mind at once.   It was not  till the year  1803
that I discovered this was the ordinary cause of interruption to the per-
fect progress of the vaccine pock ; and in 1804 I  published my first
paper on the subject in the Med. and  Phys. Journal for August.   My
next was incorporated with Dr. Willan's work on vaccination.
   54 The same coincidence (irritative eruptions) I  am convinced from
the most ample testimony, is the source of failure in variolous inocula-
tion and ofthe small-pox more than once in the same individual  when
communicated in the  natural  way.   Here I could launch out pretty
widely had I  time or limits.   What a field does this open to the view
of the physiologist!   A single vesicle, such as appears  on  the lip,
for example,  in catarrh, is capable of altering the action  of the skin,
consequently the stomach, and next the whole fabric.   What light does
it throw on the action  of blisters !"
   The following extract I give at  Dr. Jenner's request  from his let-
ter to Dr. Willan* just alluded to, farther illustrating the subject ofthe
latter part ofthe above extracts.
   44 Thos. Church, son ofThos. Church, carpenter, at Berkeley, was
inoculated" 44 for small-pox," 44 by Mr. Williams, (late a surgeon of
eminence at  Dursley, in  this county, a very experienced inoculator,
but who has now retired from business,) with a party  of near twenty
other young persons.   Nothing  very particular was observed during
the progress  of infection, except that  his arm inflamed  early and with
more than ordinary violence, maturated, and was several  weeks in
healing.   He sickened about the usual time, and had eruptions,  which
were considered as  variolous, but whether they maturated or not, I can-
not ascertain.   After the  lapse of four years, on being exposed to  the
small-pox, he caught  the  disease and had it severely.  This  youth
was, from his infancy, affected with  tinea capitis, and a pretty con-
stant succession of blotches  about his face and different  parts  of his
body.  His head was now well, and his  skin nearly  free  from any

   * See Dr. Willan's Treatise on Vaccine Inoculation,  Appendix, p.  6,  and
seq. 
                           APPENDIX.                        rii

eruption.   That  the disease he caught, four years after the inocula-
tion, was really the small-pox, there could be no doubt, as several chil-
dren were inoculated from the pustules who had  it correctly.
  44 I have often been astonished at seeing how small, and apparently
how trifling, a local affection of any part of the skin is capable of occa-
sioning deragements in its  action  in parts at a distance, although  its
disordered state  be of such a nature, as not to be discernible by the eye.
For example; a small excoriation behind the ear—two or  three vesi-
cles, even though of catarrhal origin,* on the lips or about the nostrils
—a few scurfy spots on any part of the body—and even those vesicles,
and the subsequent state of the skin, that are produced by  external in-
jury, (as I lately witnessed on vaccinating a boy whose face was injur-
ed  by  the explosion of gun-powder,) appear as  capable of producing ir-
regularity in the progress of the vaccine vesicle, as more extensive cu-
ticular affections.  Vaccination, when thpse maladies are present, seems
to shew, that the whole surface  of the skin is   influenced at the same
time, but in separate portions ; for on one arm I often produce a per-
fect vaccine pock, and on the other from the insertion of a  portion of
the same virus, one that is imperfect and which would afford  no securi-
ty. Indeed, on the  same  arm within  the space of an inch from  each
 other, there  will often be this difference in the appearance of the pocks
 —one  putting on the  perfect character, and the other deviating so wide-
ly, as  to resemble more nearly that of an herpetic vesicle, accompanied
with inflammation, and commonly ending in a  soft, amber-coloured or
blackish scab—and sometimes, especially if it be  much disturbed by
 scratching, in ulceration.   The  probability then is, that the skin, at
 the point of insertion, is sound and in its natural state in the one instance
 and diseased in the other ; but not so, as I have observed, as to be per-
 ceptible to the eye.
    44 1 have not seen a person vaccinated while affected with syphilitic
 eruptions, but I think it proper to  mention, that the suppurative itch,
 deranges the progress of the vaccine pustule, like the other cutaneous
 diseases, to which it bears a resemblance."
    I subjoin the instructions for vaccine inoculation, published by order
 of the medical Council of the Royal Jennerian Society.
    44 An accurate knowledge of the'signs of infection, and of the  charac-
 ter and progress of the vaccine vesicle, is essential to the success of th.«
 inoculation.
    * Hern<- Tibialis .  see Pep on Diseases in London, nnge 6 
IV
APPENDIX.
   44 The Signs of Infection, and Description ofthe Vaccine Vesicle.


   44 When vaccine inoculation proves successful, a  small  red spot,
with  a degree of elevation which may be felt, commonly commences
on the third day.  When examined with a magnifying glass, it seems
to consist of a small tumour, surrounded by a slight efflorescence.
   44 Between the third and sixth day, a  vesicle  appears ; the  shape
and magnitude of which depend much on the mode in which the inocu-
lation has been performed ; when it is performed by a slight puncture,
the vesicle will be small and circular.
   44 The edge of the vaccine vesicle is elevated and well defined ; the
centre is depressed, and a speck is there visible, of a darker colour than
the rest of the surface.   This vesicle is distinguished from other vesi-
cles by the peculiarity of its structure, which is cellular, and somewhat
hard and firm.  At first it is of a light pink colour, sometimes blended
with a bluish tint, gradually changing  in  its progress into a pearl
colour.   Its contents are  limpid, and almost colourless.   It commonly
increases in size till about the tenth day.
   44  In  its early stages it has usually a small  inflamed  ring  round its
base, which about the  ninth day begins to spread rapidly; and about
the tenth forms an  areola, more or less  circular, an  inch and half or
more in diameter.   This areola is of a pink,  scarlet, or crimson hue ;
and  is  attended with  some degree of hardness and tumefaction.   It
continues nearly stationary a day or two, and then begins to fade ;
sometimes forming on its  decline, two or three concentric circles.
   44  When the areola is  perfectly formed, the vesicle  begins  to  de-
cline ; first it turns brown in the centre ;  then it is gradually convert-
ed into a hard, smooth, shining scab, of  a  dark mahogany brown co-
lour,  approaching to black;  and, in  its general appearance, has not
unaptly been compared to the section of a  tamarind  stone.  This
scab commonly falls off about the end of the  third week ; and leaves
a circumscribed cicatrix, clearly denoting that the true skin has been
affected.
   44  In the computation of time, the day of inoculation  is to be con-
sidered as the first day. 
APPENDIX.
v
" Occasional Deviations of the  Vaccine Vesicle from its ordinary Ap-
                     pearances and Character.
  44 Deviations are occasionally  met with, even in the  genuine vac-
cine vesicle ;  chiefly with regard to its rise, duration, and contents.
  44 It seldom or never appears earlier, but often later than  the period
already mentioned ;  rometimes not till  after the expiration of a fort-
night or three weeks ; but if it then makes a regular progress, it ren-
ders the patient equally secure as if it  had appeared at the usual time.
  44 Sometimes the vesicle is ruptured by  external violence.  In that
case, the scab will in general be less firm, and of a lighter colour.  Oc-
casionally also, instead ofthe regular progress to desiccation, as above
described, it passes into a state of ulceration, with a much more extend-
ed inflammation.
  44 The contained fluid instead of being limpid as usual,  is now and
then found opaque.
  44 Spurious Pustules, which afford no Security against the Small-pox.


   44 The success ofthe operation is doubtful, when there is any consi-
derable deviation from the usual course of the disease ;  whether pre-
mature  inflammation, irritation, itching,  or vesication occurs ;  or the
progress ofthe vesicle is too rapid, its contents yellow or opaque, its tex-
ture soft, its centre elevated, or its form not well defined ; or whether
a premature  efflorescence takes place, and a distinct, vivid, circum-
scribed areola is wanting.
   "• This anomalous vesicle, or spurious pustule, as it is called, is more
liable to be broken than the  regular genuine vesicle, from  its  centre
being more elevated, and  its texture  less firm.  When broken, it is
frequently  succeeded by ulceration ; or by a  light brown, or amber■
coloured creeping scab.
                                ,50 
VI
APPENDIX.
             44 Probable Causes of Spurious Pustules.


   44 Spurious pustules may be occasioned not only by  matter taken
from a spurious pustule, but also by matter taken from a  genuine vesi-
cle at too late a period ; or by that which has been  injured by keep-
ing, exposure to heat, or any other cause.   They may  also be occa-
sioned by using rusty lancets in  inoculating ;—by rude and unskilful
methods of performing the inoculation ;  or by the genuine vesicle hav-
ing been destroyed at an early stage ; and  the regular progress of the
disease thus interrupted.
w The Methods of taking Vaccine Matter for inoculation, and of pre-
                     serving and conveying it.
   44 Matter may be taken from a genuine vesicle at  any time from its
commencement till the areola begins to spread ; commonly till  the
eighth or ninth day, sometimes later, but never after the areola is fully
formed.
   44 It is to be taken by small superficial punctures, made in several
parts ofthe vesicle with the point of a lancet introduced  horizontally.
Time should be allowed for the fluid to exude, which will appear on
the vesicle in the form of small pellucid drops.  If necessary, very
slight pressure may be applied with the flat surface  of  the  lancet, to
quicken the discharge.
   44 Great caution must be observed in this process ;  or violent inflam-
mation, and extensive ulceration may sometimes ensue.
   44 The matter may be received on the points of  common  lancets,
when it is designed for use immediately, or within a very few days;
otherwise these instruments cannot with propriety be employed either
for the preservation or conveyance of vaccine matter, as when charg-
ed with that fluid they soon rust.  An ivory lancet is not liable to this
objection.   It may be fixed in a handle, and screwed  into a case, in or-
der to exclude air. 
APPENDIX.
vn
  44 A common method is, to take two small  square pieces of glass, on
the centre of one of which the matter may be received, by applying
the glass to the vesicle, punctured in several  places in the manner be-
fore described, and covered with the fluid ; it may then be suffered to
dry, and applied to the vesicle repeatedly.   When fully charged, and
dry, it is  to be  covered with  the corresponding piece of glass, and
wrapped up in writing paper, or goldbeater's skin.
  '4 Matter may be also taken on thread, which, being imbued with it,
must be suffered to dry, and then charged again :  this process may be
repeated till  it is well saturated : it may be  kept in a phial, or in a
quill, or  a piece of a tobacco-pipe, stopped  with  white wax :—the
heat necessary to melt sealing-wax might injure the matter.
  44 Another  way of preserving matter is, to take it on the end of a
quill, which, when dry, may be  inserted  into the  barrel of another
quill ;  or if slender portions of a  quill be  pointed like tooth picks,  a
number of them, when charged, may be inclosed in the barrel of one
quill.   These, as well as the thread, afford convenient  modes of con-
veying the matter in a letter to any distant place.
  44 A small  instrument made of ivory,  shaped like  the tooth of a
comb, and pointed like a lancet, which may  be called a Vaccinator, is
in every respect as well adapted  to the same purpo&e ; and not being
liable to bend, it is  introduced into the  puncture with more ease and
certainty than the tooth-pick.   These  instruments require much  less
matter to charge them than thread or glass  ; but when they are not in-
tended to be used soon, they ought to  be repeatedly charged.—When
they are to be used in a short time, it is  sufficient  to  wrap them in
paper.
  44 Matter must always be allowed to dry without heat in the shade,
and be kept in a dry and cool place.
  44 Every practitioner who has not a constant succession of patients,
ought to take matter when he has an opportunity, and to preserve  it for
any future occasion.
                   44 The Modes of Inoculation.


  44 The constitutional, as well as the local symptoms of the vaccine
affection, depend in a great degree on the mode in which the virus is 
VHl
APPENDIX.
inserted.  The smaller the wound of the skin is, the lighter in general
is the disease.
  44  Fluid matter is better than dry, when it can be procured, because
it is  more likely to produce infection ;  and the operation is more light-
ly and quickly performed. Hence it is evident, that in every instance
where  it is practicable, the patient from whom the matter is to be
taken should be present, and the matter should be transferred immedi-
ately from arm to arm.
  44  Inoculation is generally performed in the upper arm, near the in-
sertion of the  deltoid muscle ;  but in  some adults, who are likely to
use the arm much, it is more adviseable to inoculate  on the inside of
the leg, a little below the knee.
  44  The point of a lancet being charged, the skin should be stretched,
that the cuticle may be  penetrated with more ease.  A small superfi-
cial puncture is then to be made with  the point of the lancet,  which
will  be more likely  to leave the matter in contact with the skin,  and
to produce the desired effect, if it be held nearly in a horizontal direc-
tion.   It is  also worthy of remark, that when held in this direction,
the lancet meets with greater obstruction when it has penetrated to a
sufficient depth.  On the  contrary, when it  is inserted in a more ob-
lique or a perpendicular  direction,  it often penetrates suddenly to  such
a depth as to cause an effusion of blood, which washes away the matter,
and prevents the operation from succeeding.   In order to render infec-
tion  more certain, the point  ofthe  lancet may be  charged with  matter
a second time, and wiped on the puncture.
  44  When several  successive  inoculations are to be  performed, the
lancet should be dipped  in cold water, and wiped after every puncture.
  44  Dry matter has been sometimes known to succeed after the ex-
piration of several months, but that which is recent is  always prefera-
ble.
  44  Dry matter on glass may be moistened  with a little cold or tepid
water  on the point of a  lancet, allowing it some  time  to dissolve, and
blending it by a little friction  with the lancet.   It must not be much
diluted,  but  of a thick  consistence.   It is to be inserted in  the same
manner as the  recent fluid.
   44  Dry matter on the  barrel of a quill may be applied without dilu-
tion, to a very small abrasion or incision  of the skin :  and, being  held
in contact for some time, and   then repeatedly drawn  over the part,
it will dissolve and be lodged in the wound. 
APPENDIX.
IX
  44  When ivory lancets, tooth-picks, and vaccinators, charged with
dry matter, are used, the matter should not be first diluted, but a punc-
ture  having been first made with a common lancet, the point of the in-
strument is to  be  inserted, and  held in the puncture half a mmuteor
more ; when the matter will gradually dissolve, and remain in the part.
If the  part  of the instrument which is charged, be afterwards wiped
repeatedly upon the edges of the puncture, it will tend to ensure SUC-
CcoS.
  44  Thread, charged with dry matter, may be used either dry  or just
moistened with cold or tepid water.   A slight incision or abrasion is
then to be made, not more than  the  eighth part, of an inch in length,
on wliich a small portion of the thread is  to be placed.   This is to be
covered with a small bit of paper, and to be retained two or three days
by a mild adhesive plaister :—what  is called court plaister is liable to
produce irritation.
  44 Inoculated patients must be cautioned not to wear  tight sleeves,
and  not to injure the arm by pressure, friction, or any other  violence,
lest  extensive inflammation or ulceration should ensue.
   44 One vaccine vesicle secures the patient from all danger  of the
small-pox ; but in many  instances  it is  better to inoculate in  both
arms, especially when the small-pox is epidemic, or the matter  is dry,
or the place of the patient's  residence distant.
  11  Lancets used for inoculation should be  kept clean and bright.
•' Constitutional Symptoms.
  ii The constitutional symptoms sometimes occur at a very early pe-
riod ; but more commonly from the seventh to the eleventh day.
  " In some cases the patient is drowsy ;  in others restless.   Some-
times there is a chilliness, succeeded  by heat, thirst, head-ache, and
other  marks of febrile affection.   Now and then a sickness or vomiting
takes place, especially in infants.
  44 The constitutional symptoms, of whatever kind, are  in  general
slight and transient,  and such as require no remedy.
  '■ In a great proportion of cases there is no perceptible indisposition ;
nrvortheless, the person vaccinated is not the less secure from  the  fu- 
tl                          APPENDIX.
ture infection of the small-pox, provided the progress of the vesicle
has been regular and complete.
  44 Care must be taken not to confound the symptoms of infantile or
other diseased with those of vaccine inoculation.
44 Medical Treatment.
   44 In general no medicine is required in this mild affection ; but  if
 the  symptoms happen to run a little more high than  usual, the same
 remedies are to be applied, as if they proceeded from any other cause.
   44 No preparation is necessary; and no cathartics need be given ei-
 their before or after vaccination.
   44 Should inflammation of the arm exceed the usual bounds, which
 rarely happens but from  tight sleeves, pressure, or friction ;  it may
 soon be checked  by the very frequent application  of compresses of
 linen dipped in water, aqua lithargyri acetati composita, or a solution
 of one drachm of cerussa acetata in a pint of water.   These are to be
 applied cold.
   44 If the scab be rubbed off prematurely,  and ulceration take place,
 cooling and astringent  applications  may be used, such  as  a drop of
 aqua lithargyri acetati, which should be allowed to dry on the part;
 and  then be covered with compresses, dipped in water, or any of the
 saturnine applications above mentioned, and frequently renewed.
   44 When  the ulceration is deep or  extensive,  a poultice, either of
 bread  and milk or  of bread with any of the saturnine preparations,
 may be applied, as the case seems to require.  They must never be
 applied till they are nearly or quite cold.
   44  In such foul and obstinate sores as resist the foregoing applications,
 the unguentum hydrargyri nitrati, the argentum nitratum, or other sim-
 ilar  applications, are sometimes resorted to with advantage.   A single
 dressing  with  these substances is usually sufficient;  after  which  the
 sore  heals under the mildest applications.
   44  Spurious pustules are frequently followed by ulceration at an ear-
 ly period.   This  ulceration is to be treated  in the same manner as  if
 it proceeded from the genuine species.
  44  An assurance of perfect security from vaccine inoculation can only
he obtained by carefully observing the whole progress  of the disease.
If any doubt remain, the operation ought to be repeated. 
APPENDIX.
XI
  44 When the patient has been previously exposed to the infection of
the small-pox, that disease will be  superseded more or less, according
to the time which is suffered to elapse before the inoculation of  the
cow-pock.
   44 The advantages of vaccine inoculation being now fully ascertain-
ed, it is the duty of every member of society, and particularly of eve-
ry member of the medical profession, to discourage the inoculation of
the small-pox."

   The foregoing observations may be regarded as containing nearly
the sum of our practical knowledge of cow-pox. 
 
APPENDIX  No.  2.
       DR. SMITH'S  TREATISE  ON DROPSY.


   For the benefit of those, who may not have had an opportunity of
 perusing Maclean's book on Hydrothorax, I have given the following
 short treatise on dropsy, which,  though not  copied  from Maclean's
 book, contains nearly the same principles,  as to the theory and prac-
 tice in that disease, with the  addition of some remedies,  which from
 my own experience, I have found efficacious in dropsy.


                      Definition of Dropsy.

   Dropsy is an accumulation of serous fluid in some part of the body.
 It is either local or general.
   When the serous fluid  is  confined to any of the cavities of the body,
 it is called a local dropsy ;  but when this fluid is diffused in the cellu-
 lar substance, it is denominated anasarca, or general dropsy.  These
 two  conditions of the disease  often run into  each other.   A general
 dropsy often terminates in a collection of water in the thorax and abdo-
 men ;  and a collection in the  thorax or abdomen, if it continue, and
 become considerable, will  cause a deposition of water in  the cellular
 membrane.


                        Theory of Dropsy.

   In collections of water in the system, the  immediate source of it, is
 the exhalent vessels; whether the water be  collected  in the cavities,
or diffused in the cellular  substances.  But the common received opin-
ion hvs been, that the  accumulation depends on the loss of action, m
                               *1 
 xiv                   APPENDIX No. 2.

 power in the absorbents to take up, and convey into the circulation, the
 fluids discharged by the exhorbents.   The great power of the absor-
 bents in taking up the  extraneous fluids, thrown  into the cavities, and
 into the cellular substance certainly leads to the conclusion, that so long
 as the absorbents act with their  usual  energy, any increased quantity
 of serous fluid, which might for a time, be poured out by the exhalents
 would be removed by their agency.  But whether we consider dropsy
 as the effect of an increased and morbid action ofthe exhalents, or de-
 pending wholly or partly on the want of power in the absorbents, it is
 pretty evident, that the scarcity of urine in  cases of dropsy, has no
 share in producing the  disease, and should be considered as the effect.
   The rapid escape of  the serous part of the circulating mass of fluids,
 by some other outlets, whence it is not returned by the  absorbents, de-
 prives the kidneys of their proper pabulum to act upon,  torpor, and;in-
 action of those organs follow.
   The thirst in cases of general dropsy is produced in the same man-
 ner.
   The causes which dispose to dropsy, are either of a local or general
 nature.  The local causes are such as affect the  absorbent vessels of a
 particular part.  A diseased state of some ofthe viscera contained in a
 cavity, often causes a collection of water in it.   An organic affection
 of the heart, the great vessels arising from it, or of the lungs often pro-
 duces a collection of water in  the  thorax.   In like manner a diseased
 liver or uterus, is often the cause of  ascites.
   The causes of  dropsy  which affect the system generally,  are great
 and  repeated losses of red blood, the abuse of ardent spirits,  and other
 intoxicating liquors, and also wasting diseases.


                       HYDROTHORAX.

  Symptoms.—One of the first symptoms of hydrothorax, is a difficult
 ahd hurried respiration  on any considerable exercise, especially in run-
 ning or walking up hill.  The pulse in hydrothorax, is I  believe, ah
 ways irregular, at least, it is so, when the disease is  considerably ad-
 vanced ;  and is rendered more irregular by any considerable muscular
 action.   In this disease the  pulse,  besides being irregular,  is always
 feeble.   As the disease advances, the patient  finds some difficulty  in
 laying  in a horizontal posture, with his head and shoulders low ; and
is ofteu waked from his sleep with  a sense of distress and fear.
  The face in cases of hydrothorax has a peculiar appearance, which
 when once seen, is afterwards easily recognized.   The colour is liv 
APPENDIX  No. 8.
xv
id ; that is, those parts which are naturally flushed, such as the lips and
cheeks, have a peculiar dark colour, approaching to blue.
  The thirst in this disease, especially in the commencement, is not
great and there is not that scarcity of urine, which usually attends gen-
eral dropsy.
  In the advanced stage of hydrothorax, symptoms of general dropsy
usually appear, such as  an eodematus state of the  feet and legs, and
even of the whole cellular substance ;  the  urine then becomes scarce
as it does in anasarca.
   Hydrothorax attacks persons of both sexes and every age ; but peo-
ple in advanced  life are most liable to it;  and  of such, those who
have indulged in too free use of  intoxicating liquors, are most liable.
The corpulent are more  than the lean and spare, especially when cor-
pulency has been induced  by the bottle.  I have seen several patients
affected with this disease,  who have been attacked with hemiplegia in
the advanced stage.  Whether this arose from a collection  of water
in the cavity ofthe cranium, or whether it was induced by the obstruc-
tion to the  returning blood from the head, and  thereby  producing  a
veinous plethora in  the brain, I am not able to decide, having never had
 an opportunity of disecting the body of a patient affected in this manner.
   The causes of Hydrothorax.—Some organic affection ofthe heart, or
 great blood vessels in the thorax, is frequently the cause of diseases of
 the lungs, such as  obstruct the passage of the blood through them, are
 also not an unfrequent cause of collections of water in that cavity, and
 other  parts of the body.
    In some cases it seems to be produced  by abesity.
    The abuse of intoxicating liquors, perhaps is the cause of nearly one
 half of the cases of hydrothorax.
    In a few  instances the hydrothorax  succeeds the pneumonic inflam-
 mation ;  and I have known it follow  parturition,  where the patient
  had sustained a great loss of blood.
    In one case, where the patient was often bled on account of an  af-
  fection of the brain, which seemed imperiously to demand that evacu
  ation, the hydrothorax supervened, and terminated life.
    Hydrothorax is  sometimes connected with pthisis pulmonalis.
    Treatment.—I cannot from own experience say much in favour of
  evacuating the  water in hydrothorax by  the operation of paracentesis
  of the thorax.   I have performed that operation four times in the course
  of my practice; once for a collection of purulent matter, and  three
  times for collections of water.
    The first patient that I performed the operation on was a physician ;
  he had  been affected with  a cough,  and symptoms of an incipient 
xv»                   APPENDIX No. 2.
phthisis for several months, when by riding on horseback he discover-
ed a fluctuation of water in the right side of the chest.   On examina-
tion the fluctuation was distinctly felt on the right  side.  He insisted
on having the water evacuated by an operation,  which I consented to
perform.  I drew off about two quarts of clear limpid water.  Previous
to the operation, his  pulse was over an hundred ; immediately after
the operation, tbe pulse fell below foity in a minute, and remained so
about twenty-four hours, then suddenly became very frequent, so much
so, that the pulsation could hardly be counted,  and continued so till
dissolution, which took place  in one week from the operation.
   The second time that I performed this operation, was for a collection
of purulent matter.   The  patient was a young man.  He was attack-
ed in the month of April with a pneumonic inflammation ;  after some
time, the inflammation abated, but left a sense of weight in the leftside
of the thorax,  attended with some cough,  and shortness  of  breath.
These  symptoms gradually increased  till the September following,
when I  was called to his assistance.   The left side of the chest  was
greatly distended, and the diaphragm on that side w?as forced down a
considerable distance below the lower edge ofthe ribs, so that it was
distinctly felt in the  abdomen, and the  ribs were greatly elevated, and
considerably separated from each other.
   On examination we could produce a distinct fluctuation in the part.
   The operation of  paracentesis was performed,  and something more
than two gallons of purulent matter was discharged.  After the opera-
tion a tube was introduced, and from time to time  purulent matter was
drawn off.  A  cough and hectic fever supervened, which continued
to waste him for several months, but at length  it abated so much that he
was able to dq some  business.  He commenced, and went  through the
study of  physic with a brother-in-law, but was unable to  do business
abroad  in the  winter.  The  discharge of purulent matter continued,
and his countenance  was always livid, resembled in some degree the
countenance in cases of hydrothorax.  Seven years after I performed
the operation, he came to me and informed me that he could draw in
air through the trachea, and discharge it through the tube by which he
used to evacuate the matter.   I doubted his  assertion, and supposed
that he might be under a mistake ;  but on making the experiment,
he convinced me that he was correct.
   This patient lived  between nine  and ten  years  after the operation,
and at last died of the hydrothorax.  I did not see him in his last sick-
ness, but was informed that the body  was inspected  after death, and
that the left lobe of  the lungs was entirely wanting, and that  in  the
right side of the che6t was considerable water. 
APPENDIX No. 8.
XV u-
  The third patient, on whom I performed this operation, was a young
woman.  She had many symptoms of phthisis, namely, a  cough, at-
tended with shortness of breath, even more difficulty of breathing than
is usual in phthisis.  At length a distinct fluctuation was felt in the left'
side;  the operation of paracentesis was performed, and about three
pints of limpid fluid was discharged.   The water was drawn off from
time to time with a catheter;  and it gradually changed from limpid
water, to a perfect purulent matter;  the cough continued and the pa-
tient died hectical after three or four  months.
   The fourth case happened on a young man.   He  had for several
months been afflicted with a cough, and symptoms of phthisis, when a
fluctuation of  water was  perceived in the left side  of  the thorax.
About two quarts of limpid water was drawn off, and direction given
to introduce a catheter occasionally  to evacuate any  fluid  that might
collect; but the attending physician  was not able to effect  it, and the
wound was suffered to heal. About three months afterwards the ope-
ration was again performed, and nearly two quarts of fluid  was drawn
off,  which  was of an intermediate appearance between water, and
purulent matter.   After the second operation, the catheter was  intro-
duced once in  two or three  days, and the fluid gradually changed in
its appearance,  till it  became perfect pus.  This  patient  lived  about
three years, and was carried off by the typhus fever.
   Respecting the  benefit  derived from those four  operations; in the
second case which was a  collection of purulent matter, the  operation
was  indispensable; and undoubtedly  prolonged life for a long time.
But in the  first case,  life was probably  shortened by the operation.
   In the  third case the operation did no good.  In the last  case it is
difficult to determine whether  it protracted life or not.
   In all the cases where the operation was performed  for the evacua-
tion  of water, it should not have been done  till other remedies had
been  more fully tried ;  and  had  I  known the  power  of internal
medicines  in removing the water in  cases of dropsy, as  I  now do, I
should not  have  consented to perform either of those operations; at
least not till I had made a thorough trial of internal remedies.
   Upon the whole, it  is doubtful whether the operation of paracente:
 sis ever should be  performed on  the  thorax for the evacuation of wa-
 ter.
   Respecting  internal remedies for the hydrothorax.
   Digitalis stands at the head of that class of medicines called diuret-
 ics, and  perhaps  deservedly  so,  when used in the manner, and with
 the' regimen and auxiliaries directed by Maclean.   Digitalis has lost 
XV111
APPENDIX No. T.
 its reputation  as a  remedy in dropsy with many physician*  in this
 country, as I believe, from the improper use of it.
   It is frequently  given  in  tincture alone unaccompanied with any
 other medicine, and without  any  particular regimen being enjoined
 on the patient  ; and when given in  this careless manner, it frequently
 fails.  The first account I had of the effect of digitalis in dropsy, came
 from Dr. Withering, who  first brought it  into notice as a remedy in
 that disease.   Dr. Withering directed the  leaf to be given  in powder,
 or in infusion,  in considerable doses  ; and also,  that the patient while
 taking it should drink freely of some diuretic.   Dr. Maclean's direc-
 tions for using digitalis,  are very  similar to Dr. Withering's.  His
 favourite mode of administering the digitalis  in dropsy, is the follow-
 ing.
      Hr  Digitalis     -     -     -     3iss
         Canella Alba, Ginger    -   aa Bi
         Boiling water      -     -     38
   Infuse one hour, and give a table  spoonful once in six hours.
   While taking this, the patient is required to drink freely of some di-
 uretic beverage.  I  have given an  infusion of Juniper berries with  as
 cuich Cream of Tartar dissolved in it, as would bold in solution.
   When the bowels  arc torpid, they should be roused with small doses
-of calomel.
   Administered in this way, the digitalis has seldom  disappointed my
expectation, in  removing water  extravasated in the system.
   Dr. Maclean, is of opinion that the digitalis has no direct effect on
the kidneys but that its operation is principally on the absorbents which
causes them to  tnke  up the cxtravsaated fluid,  and bring it  again into
the circulation.  The diuretics,  which are taken  with the digitalis,
stimulate the kidneys, and  enable them more readily to discharge the
watery fluid from the body.
   I have considered two circumstances requisite, to give digitalis its
proper effect in  dropsies ; one is, that the bowels should be excited, so
as to produce a moderate catharsis ;  and the other, that it  should be
accompanied with some medicine, that would stimulate  the kidneys.
To fulfil those indications, I have given small doses Of calomel sufficient
to move the bowels ;  and for diuretic medicines, I have given juniper
 tea with cream of tartar in solution.   I„ some cases, I  have witnessed
the best effects  from  the use of the following pill—viz.
     *  S(IuiIls        "      -        -        3ss
        Digitalis               .       .       9J
        Cantharides               .       .    ^ 
APPENDCt No. 2.
xix
        Castile Soap       -       -          3ss
        Simple Syrup       -       -         q. s.
  Mix and make 20 pills.  Dose for an adult one pill night and morn-
ing, which may be increased or diminished according to circumstan-
ces.
  In the use of digitalis, it is necessary to watch its effects, as it may,
when  given in too large doses, prostrate all the powers  of life, and
cause death.
   I have seen one case, where it appeared, that the patient was killed
by a  very great dose.   It was  given in decoction by a person, who
was unacquainted with its virtue, and did not  know that it possessed
any .deleterious quality.
   In  an another case,  where this remedy was administered by the ad-
vice of a physician in  very large doses, it produced such a prostration
of vital power, that it  was doubtful for  several  days whether  the pa-
tient  would survive it; which however he did.
   Dr. J. Cheyne, in his treatise on hydrocephalus, says that he has
known the  digitalis to continue to affect the system, three days after
the use of it was discontinued.  I am confident, that I have seen cases,
in which, its effects have continued more than twice that time.
   This circumstance should make us cautious in its administration ;
 for some  times, when  we repeat the doses frequently without perceiv-
 ing its effects under two or three daysy then the system will be suddenly
 affected; seemingly with the accumulated effects of all we had admin-
 i stored.
   When the  digitalis has had a  diuretic effect in cases of dropsy, i
 have observed that it  has been accompanied with a singular  sense of
 depression  at the precordia,  and to remove this I have given cordials
 to advantage.  Good  wine given hot is. as good as any which I have
 used.                                            ,      ,.     . .
    In reading Dr. Maclean's book on hydrothorax,  I was d.sappo.nt-
 ed to find that he had not mentioned the use of cantharides in that dis~
 ease   It is now twenty six years since I first employed canthandes in
 hydrothorax.  The first patient who consulted  me in a case of hydro-
 thorax, was a woman  about 35 years of age.   The disease succeeded
 pneumonic inflammation, and when I first saw  her, it had advanced so
 fer that she was confined to the bed, and obliged to lay with her head
 and  shoulders considerably elevated ; no fluctuation could be perceiv-
 ed in the thorax, but the chest was considerably enlarged,  and. the
 ZZ  was voided in very small  quantities, and  very hi,h  coloured 
XX
'   APPENDIX No. %.
At that time I had not been acquainted with the use of digitalis m drop-
sy   I gave her several of the common diuretic medicines, without per-
ceiving any  effect, and the disease still increasing under their use.  1
then save her the cantharides in the form of a pill combined with cam-
phor and soap.   The pills contained half a grain of cantharides each,
and I gave one pill morning, noon and night.   This soon increased the
quantity  of urine, and rendered it of a more healthy quality.  Lnder
die u«e of those pills  and without any other medicine, she soon recover-
ed  so as to  be able to  walk, and ride in a carriage, she then made a
journey to the Ballstovvn springs, and returned perfectly cured.
  This woman lived  more than twenty years afterwards, during which,
she enjoyed perfect health.  I am not acquainted with the  cause, and
circumstances of her death.
  Since  1 employed  the cantharides in the above stated case.  I have
used that remedy in a  great many  cases, both  in local, and  general
dropsies; and I  believe, that it has  succeeded as often in my hands as
any one  medicine.
   The use of cantharides I consider perfectly safe, if administerd with
common prudence.   The only ill effects that is ever experienced from
the use  of  this  remedy in ordinary doses, is a troublesome Ischuria,
which is easily obviated. and never followed by  any bad  effects.  In
most casts it produces no other symptoms, than  an  inclination to void
urine, more frequently than  usual ; and the urine, which in dropsical
cases, is generally high coloured, and thick, is made in greater quanti-
ties,  and of a more limpid, and healthy appearance.   Besides the for-
mula, which I have given for combining  cantharides  with digitalis,
I have administered  it in several others.
   I have generally combined cantharides with squills  and castile soap.
   The dose of cantharides should be from  half a grain to a grain, given
 ni°ht and morning.   I have administered it in the following manner
 with the best effects.
          He Cantharides        ...       9
             Squills       -       -       -             3i
             Castile Soap     ...         9Jj
             Simple Syrup       -        -        -      q. s.
    Mix and  make 40 pills.  Dose one or two pills night and morning.
    I huve also given the  tincture of cantharides  in dropsy with advan-
 tage.
    The  following recipes I obtained from whom, I do not know, but as
 1 have  often witnessed  their good effects, I have given them a  place
 here. 
APPENDIX No. 2.
XXI
         Hr Horse Raddish Root, fresh      -     -     gj
            Juniper Berries     -        .        .      3SS
            Mustard Seed half a gill.
  Bruise, and steep in a pint of Holland gin, and half a gill of good
vinegar, saturated with potash.  Dose half a gill three  or four times a
day.
  While taking the above medicines, the following pills may be given.
           Hr Opium                                 9j
             Squills     -       -       -            3ss
             Calomel        ...        9sg
             Castile Soap      -       -       -    9ij
             Simple Syrup   -       -       -     -  q. s.
  Mix and make twenty pills, dose one pill night and morning.
  Besides  the diuretic  medicines,  which we have mentioned, there
are several of our indigenous vegetables, which have been  employed
to great advantage in dropsy.   I have given a decoction of the root of
the Asclepias Syriaca, with great success in many cases.   Dose half a
pint of a pretty strong decoction may be taken, three or four times in
twenty-four hours.  When given in  this manner, it generally increases
the quantity of urine, and excites a free perspiration, an evacuation
too little attended to in dropsical cases.
   The following case of hydrothorax was relieved  by a set of reme-
dies somewhat different  from those which  have been mentioned.  A
woman over forty years of age, and not long after child-bed sickness,
was affected with a sense  of weight and oppression  about  the precor-
dia.  Notwithstanding the use of remedies, this complaint increased,
and at length the symptoms of hydrothorax were unequivocal, and ad-
vanced till symptoms of general dropsy came on.   The feet and  legs,
as well as the  whole  cellular substance  became  loaded with water,
and her respiration was very  difficult.
   I took a quantity of the  common blue mercurial ointment  of the
shops, and  diluted it with  an equal quantity of hogs lard, and rubbed
this over the whole body for some time.  I then applied flannel band-
ages from the toes to the hips,  and also a broad flannel bandage around
the abdomen up to the lower  part of the thorax,  as straight as  she
could bear, without impeding  her respiration too  much :  I then gave
her a powder composed of one grain of opium, four grains of calomel,
and ten of  gum guaiacum.  I used  the remedies  in the evening,  and
during the night following, she voided a very large quantity of urine,
which had  been before very scarce ; continuing these remedies, with
                              .52 
 Mii                    APPENDIX No.«.

 the addition of charybeates, a cure was effected. She remained free from
 dropsy about eight years, then relapsed, and died of  the same disease.
   The common tartrite of potash has been successfully employed  in
 dropsy.   It is often  prescribed  in  a watery solution ; and combined
 with  diuretic medicines  of  the vegetable kind, often proves a good
 auxiliary.  But when we depend on that alone, it should be given in
 larger doses than can well  be taken in solution.  From one  to two
 ounces of the cream of tartar, mixed with a fourth of its weight of gin-
 ger, has been given in divided doses, during the course of twenty-four-
 hours, with good success in several cases.
   The terebinthinate medicines,  such as the balsam  copaivse, oil of
 turpentin, and oil of juniper, have been recommended in dropsy.  The
 balsam copaivae has  succeeded the best with me ; but I have not been
 very fortunate in the use of this class of remedies.
   As the extravasated water, in  cases of dropsy, is rather to be con-
 sidered as an effect of disease, than the  cause, so the mere  evacuation
 of the  water, does not effect a cure of the disease ;  and unless some-
 thing is done to change the  morbid state  of  the system, which is the
 efficient cause of dropsy,  though  the water should  be entirely evacu-
 ated,  it will soon  be collected  again.   To  remove this disposition  in
 the system to effuse  water into the  cavities, and cellular  substance,
 tonic remedies have been recommended, of these, iron is the best, that
 i have seen used.
   It was once  supposed, that the water should be wholly  evacuated,
 before we attempted to give tonics, but experience shows that it is not
 necessary,  and that tonic remedies may be given,  with  advantage,
 through the whole course  of the cure.
   I have generally attempted to excite a copious discharge of water,
 by the kidneys ; and as soon as this  evacuation has  commenced, I have
 ecomrnended the use  of chalybeates, and have continued  them   till
 health was restored.
   Respecting the preparation of iron.   Griffith's myrrh mixture, and
his pills are perhaps as good as any.
   I have sometimes employed the following to advantage.
         ft Crystals of Tartar                       3j
             Iron Scales in fine powder       -       3jj
   Pulverize and mix.   Dose a tea spoonful three or four times a day.
    et.  ft Sulphas Ferri           -       .       3;
            Saccharum Alburn        -       .      gj
  One nutmeg, pulverize, and mix.   Dose a tea spoonful in half  a gill
»f pennyroyal tea, night and morning. 
APPENDIX No. 2,
xxin
   Respecting the use of drastic cathartics in dropsy, given with a view
to evacuate the water by the bowels, I have never  seen  this practice
resorted to with any permanent benefit to the patient.

                            ASCITES.

   When water  is collected  in the  abdomen, it  is either  diffused
throughout that cavity, or it is contained in a cyst.   In females it is of-
ten contained in  the ovaria; sometimes it is collected  in hydatids, which
are connected to some of the abdominal viscera.
   When the water is diffused in the cavity of the abdomen, the abdo-
men is equally distended, and a fluctuation is easily felt by applying one
hand on one side ofthe  abdomen, and stroking on the other side with
the other hand.  When the  water is  encysted a fluctuation is  not so
easily perceived, and in the  commencement of encysted dropsy, the
abdomen is not equally distended, but projects more in one  part than an-
other, the tumour has a  firmer  feel,  and is not so compressible as in
diffused dropsy.
   In the advanced state of encysted dropsy, when the water is collect-
ed  in the ovarium, the cyst becomes so large as to  occupy the whole
cavity ofthe abdomen ;  in that state, it cannot be distinguished from a
case of diffused dropsy, till after the water is drawn  off, when a tumour
will be perceived in some part ofthe  abdomen.
   I have  never  seen the  water  in hydrothorax gellatinous or  thick ;
but I have  seen several  cases of abdominal dropsy,  in which the  wa-
ter was so  tenacious, that it would not  run through the canula of the
trocar, nor even  through a pretty  large opening made through  the pa-
rietes of the abdomen with a knife.
   The causes of ascites are very similar to those of hydrothorax.  It
is often connected with a disease of the abdominal viscera,  especially
of the liver.  Those causes which tend to produce a general hydrop-
tic diathesis,  are also productive of ascites.  I have known it follow
child-bed sickness  in several instances.
   In ascites the pulse is not often irregular ; and till the disease is far
advanced,  it  is not  much  affected.   When  the  abdomen  is very
tense, I have thought that  the pulse at the wrist is rendered  preter-
naturally hard and  full,  by  the  pressure of water on the descending
aorta, and  its branches in the abdomen.
   In the commencement of ascites, there is no great thirst, nor scar-
city of urine  ; but in the advanced : tages, the urine is almost entirely 
XX1V                  APPENDIX No. 2.

suppressed ; and if  the water  is not removed, the lower extremities,
and sometimes the whole body, becomes oedematous.
  Remedies.—In dropsy ofthe abdomen, tapping, or drawing off the
water by an operation, is  more excusable than in cases of hydrotho-
rax ; and yet there cannot be much said in its favour.   I  have per-
formed  this operation many times, but am still in doubt  whether this
practice has, on the  whole, protracted life.  In a few cases, it has un-
doubtedly been the  means of prolonging  life, for a short  time ;  but in
others, it has in all probability, shortened it.
  But one patient among all  whom I  have tapped for ascites, has ob-
tained  a complete  cure ;  and  that was  a girl about 17  years of age.
I drew  about two gallons  of water from the abdomen, and then put
her under the use of chalybeates.  She soon recovered so as to be able
to ride ; and then she took a journey to the Ballstown springs, and wa*>
restored to  perfect  health.  She has since been married,  and  has a
family of children.
  But this case, perhaps, should not be imputed entirely to the opera-
tion.   It  is  more  than  probable by a judicious use of remedies  she
might have been cured without it.
   Notwithstanding  the unfavourable account I have given  of the ope-
 ration of tapping,  in cases of ascites,  there  may be cases  in which it
should be tried.   When all the  most powerful remedies proper for that
disease have been fully and faithfully used without effect,  and the ab-
domen is so distended that  life is burdensome, the water may then with
propriety be drawn  off, and the internal remedies tried again.  En-
 cysted  dropsy of the abdomen, u not so often  affected, or removed  by
general  remedies as  the  diffusod kind; and tapping  perhaps never
makes a cure.
   When ascites proceeds from a disease of some of the abdominal vis-
 cera, though the water be discharged by an operation, or  removed by
 internal remedies,  it will certainly return,  unless the  disease of the
 viscera be of such  a nature as to admit a cure by medicine which I
 believe very rarely happens.
   The internal remedies in ascites are the same which have been re-
 commended in cases  of hydrothorax.  There is one internal remedy
 Admissible in ascites, which cannot be applied in cases of hydrothorax,
 so long as the  water is confined to the chest, viz.  the  pressure made
 by a bandage,  wliich I am  confident has been  of great service in
 ascites; more  especially  where ascites  has been connected with ana-
 sarca, which is not an unfrcqnent occurrence. 
APPENDIX No. 2.
XXV
  Drop9y in the  abdomen is  always an alarming disease, as  it may
arise from causes which are beyond the controul  of medicine ; but in
the course of my practice I have seen so many  cases of that disease
completely cured by medicine, that I have much more  confidence in
the use of remedies than I once had.*
                          ANASARCA.

  This disease when unconnected with the dropsy of either ofthe cav-
ities, is the most curable case of dropsy.
  In anasarca the water is effused into the  cellular substance.   It is
probable, that the effusion is the same throughout the whole of that
part of the body : but from its gravity, and the facility with which flu-
ids  pass from one part of the cellular substance to another, 'the  water
appears first  about the feet and legs, if the  patient sets  up or  walks
about.
  In cases of anasarca, the thirst and scarcity of urine, commence ear-
lier in  this disease, than they do in cases of local dropsy.
  All  the internal remedies, which have been  prescribed for local
dropsy, are proper in anasarca, and have a more direct effect.
  In anasarca we have the advantage of one important external  reme-
dy, which cannot so well be applied  in cases of local dropsy, namely,
by bandages. This remedy has been avoided  or neglected by some from
an apprehension, that by expelling the water from the cellularsubstance
on  the extremities it would merely shift its  place, and accumulate in
some part where it would be more injurious  to the patient.
  This apprehension, I believe has deterred  many from the use of ban-
dages,  especially in cases of anasarca, connected with hydrothorax, or
ascites.   This opinion, however, I think is ill founded.  I have already
stated  a  case, in which anasarca was connected with  hydrothorax,
where  the bandage was applied with great  advantage, and could re-
late many more where this remedy has been applied with the best ef-
fects.  Several years since I was consulted in a case  of hydrothorax,

  * In  one case of dropsy ofthe abdomen, in  which the distension was very
great, and where other  remedies had failed, the patient was cured by small
doses  of sulphate of copper, given in form of pills.  Dose one pill weighing
(Vr.ti :i  fourth to half a grain, given three or four  times  each day, 
XXVI
APPENDIX No. 2.
 which came on soon  after child-bearing.  The patient was a woman
 under the middle age.  She had water in the abdomen, and the lower
 extremities were anasarcous.
   Several remedies were  prescribed, which for a time seemed  to have
 some effect; bu,t at length they ceased to render her any service, and
 her attending physician discontinued his visits, supposing her case des-
 perate.   Being called into the neighbourhood in which she lived, and
 learning her situation, I volunteered my services for her relief, and I
 found  the abdomen prodigiously enlarged, and the cellular  substance
 loaded with serous fluid.   I applied flannel bandages  from her toes to
 the  thorax, around the extremities, with a  good  degree of  tightness,
 and over  the abdomen as tight as she couid bear, wiihout impeding re-
 spiration.
   The patient at this time was  taking nothing  but  Balsam  Copaivae,
 which produced little  or no effect.  This medicine was continued, and
 nothing more given.  On the application ofthe bandages the urine was
 greatly increased, and her health was finally  restored without any oth-
 er remedy.  This was a pretty fair trial  ofthe efficacy of pressure in
 dropsy.   In cases where the cellular substance is  enormously distend-
 ed with water, the good effects of bandages are rendered more  certain
 by puncturing the skin about the ancles, and calves of the legs, before
 the bandages are applied.   In one case of hydrothorax connected with
 anasarca,  where the cellular substance was considerably loaded in the
 legs and arras, as well as over the whole  body,  I applied bandages to
 the lower extremities,  without any good  effect.   The patient thought
 her respiration was rendered more difficult by them.   I then punctured
 the skin on the legs and arms, and after the water had escaped, so as
 to diminish the swelling in some degree, I applied  the bandages again
 and the good effects were almost immediately perceived.   The  diuret-
 ic medicines, which she had taken before without any benefit, now had
 their appropriate effect, and she discharged  a great quantity of urine
 during the first twenty-four hours, after the bandages were  applied.
 In this case I applied a weak mercurial ointment  over the whole sur-
 face ofthe body, before using the bandages.   I have never known any
 injury  to arise from  puncturing the extremities, in  anasarca, when that
 operation has been properly performed.
  The puncture, should be made on the tops of the feet, about the an-
cles, and calves of the  legs, and this should be done with the point of a
 yood lancet, which should barely  penetrate the true skin.  Five or six
 punctures on each limb, will be sufficient.   In cases where the cellular 
APPENDIX No. 2.
XXVll
substance is greatly distended, it often happens that neither internal,
nor external  remedies,  will have any effect,  till  the distension is in
some degree reduced by the evacuation of the water.   I am inclined
to think that mercurial ointment, applied to the skin, in such cases after
the water is evacuated, assists the operation of  the bandages in stimu-
lating the absorbents, to take up the effused fluid. Blisters, when applied
to the pit of the stomach in dropsy, sometimes assist the diuretic me-
dicines.   But I have seen so much mischief done  by applying them to
the lower extremities that I never apply  them there.   I have  lately
seen  a case, where a dreadful gangrene was produced by a blister ap-
plied to  a dropsical leg.  In  cases where the stomach  is  in a torpid
and inactive state and where the strength of  the patient  is not  too
much reduced, emetics, often have  a very  happy effect,  and render
the  system more sensible to the impressions of other medicines.   The
best medicines for such cases are Sulphate of Copper,  with Ipecacu-
anha or Tartrite of Antimony. 
 
 
 
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