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     A TREATISE  sty^^F  Af/f
ON THE HIDDEN NATURE,
AND THE
TREATMENT  OF  INTERMITTING

      .  AND REMITTING FEVERS ;
ILLUSTRATED BY VARIOUS EXPERIMENTS AND OBSERVATIONS; '

             IN TWO BOOKS;

        BY JEAN ££NAC, M. D.

 TRANSLATED FROM THE LATIN, WITH NOTES,
BY CHARLES CALDWELL, M.D.,,
*&
-j. .*; uAk.. . . - j
A RECOMMENDATORY PREFACE,       '
BY BENJAMIN RUSH, M. D. &c.
             PHILADELPHIA .-
PRINTED AND SOLD BY KIMBER, CONRAD, & CO.
         NO. 93, MARKET STREET,
       AND NO. 170, SOUTH SECOND STREET.
                 1805. 
                         V
\
     District of Pennsylvania, to tvit:
          BE IT REMEMBERED, That on the twenty-fifth day of
October, in the  thirtieth year of the  independence of the United
States of America, A. D. 1805, Kimber, Conrad, & Co.  of the said
District, have deposited in this Office, the Title of a Book, the right
whereof they claim as Proprietors, in the Words following, to wit:
       A Treatise on the hidden nature, and the Treatment of Intermit-
   ting and Remitting Fevers, illustrated by various Experiments and
   Observations :  in T<wo Booh ; by yean Senac,  M. D.  Translated
   from the Latin, with Notes,  by  Charles Caldwell, M. D. and a re-
   commendatory Preface, by Benjamin Rush, M. D. iStc.
            In conformity to the Act of the Congress of the United
States, intitled, " An  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."  And
also to  the Act, entitled " An Act supplementary to an Act, entitled,
" An 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," and extending the bene-
fits thereof to the Arts of designing, engraving, and etching historical
and other Prints."
                     D.  CALDWELL,
                        Clerk of the District of Pennsylvania. 
CONTENTS.
BOOK  THE  FIRST.
                        OF THE NATURE
      OF  INTERMITTING AND REMITTING FEVERS.

    CHAP. I.  Of the various kinds of Intermittents.   -   page 1
    CHAP. II.  Of the various causes of Intermittents as laid
tdown by certain medical writers.......7
    CHAP. III.  Of other and more probable causes.   -     -   12
    CHAP. IV.  Of the remote causes.     -     -    -    -   18
    CHAP. V.  Of the febrile rigor, or cold stage of fever.   -    23
    CHAP. VI.  Of the effects of the cold stage of fever.    -    30
    CHAP. VII. Of the hot and sweating stages of fever.    -    38
    CHAP. VIII.  Of the state of apyrexy or freedom from fe-
ver, which succeeds each paroxysm......47
    CHAP. IX.  Of the cause of the disappearance and recur.
rence of the fever at stated periods......52
    CHAP. X.  Whether or not any thing can be deduced from
other morbid affections, or from the action of the various parts
of the body, to enable us to discover the cause of febrile periods.    60
    CHAP. XI.  Of the diversified action of the febrile cause     68
    CHAP. XII.  Of febrile affections, which, though differ-
ent from intermittents, assume their external appearance.     -    75
    CHAP. XIII.  Of affections, the mask or external character
of which,  is sometimes put on by intermittents that have degene-
rated from their own nature.    -      -----    81
    CHAP. XIV. Of the malignant form of intermittents.    -    89
    CHAP. XV.  Of the change of intermittents into remittents
and continued fevers.........gg
    CHAP. XVI.  Various  observations  adduced in confirma-
tion of the foregoing opinions and doctrines.     ...    108
    CHAP. XVII.  Further observations, setting fortli the va-
riety and danger of such fevers.......113 
                        CONTENTS.
   CHAP. XVIII.  Of the method of detecting or distinguish.
ing intermittents, when disguised under the mask or appearance
of other diseases.     -.......120
   CHAP.  XIX. Of the consequences to be apprehended from
the leading symptoms of the fevers under consideration.   -     -   126
   CHAP. XX. Of various affections attendant on intermittents. 135
   CHAP.  XXI. Of affections  which remain after the febrile
form of the disease has been removed.     ....     142
   CHAP. XXII. Of relapses in  intermittents.    ...    146
   CHAP.XXIII. Of the morbid appearances discovered in the
dissection of the bodies of those that have died of intermittents.   152
                BOOK THE  SECOND.



                     OF  THE TREATMENT

     OF INTERMITTING AND  REMITTING FEVERS.

    CHAP. I.   Of the difficulty of curing intermittents, and
wherein that difficulty consists.....„  page 159
    CHAP. II.   Whether or not all intermittents are to be treat-
ed with the same remedies ?  Whether or not when left to them-
selves, they terminate  or come to a crisis spontaneously ? and
whether or not,  an attempt should be  made to cure them at their
very commencement ?     -......264
    CHAP. III. Of blood-letting......iro
    CHAP. IV.  Of cleansing the primx viae.     -     -    .     175
    CHAP. V.  Of the use of purgatives.....184
    CHAP. VI.  Of the use of aperients.    -                    igg
    CHAP.  VII.  At what  time the remedies mentioned in
the foregoing chapters are to be administered.     -     -    -     195
    CHAP. VIII.  Of the various methods of  curing  fevers,
and first, of the cure by means  of sudorifics.     -     -    -     201
    CHAP. IX.   Of the mode of exhibiting sudorifics  in the
cure of fevers.   -                                            _. -
                                   .....206
    CHAP. X.   Of attempting the cure of fevers by specific
medicines: and, first,  an inquiry what these specifics are, and 
                         CONTENTS.
whether or not any emetics or cathartics are to be considered as
such...........211
    C H AP. X I.  Whether or not a true febrifuge power reside in
certain sudorifics, bitters, aperients, and other remedies.     -    215
    CHAP. XII.  Of the cure by means of the peruvian bark    223
    CHAP. XIII.   Of injurious effects produced by the peruvian
bark.     -     -     -........229
    CHAP. XIV.   Of the precautions necessary  to prevent mis-
chief in the administration of the peruvian bark.   ...    235
    CHAP. XV.  Of the method to  be  adopted in-the use of
the peruvian bark.    ........    244
    CHAP. XVI.   Whether or not a quartan fever require a
 mode of treatment peculiar to itself?.....252
    CHAP. XVII.   Of  impediments  arising from previous af-
 fections of certain parts of the system, or from different tempera-
 ments.    -.........258
    CHAP. XVIII.  Of impediments arising from the fever it-
 self, from the injuries which it usually does to various parts of the
 body,  and f-om an improper mode of treatment.   -              265
    CHAP. XIX.  Of the cure of fevers, which,  having ceased
 foratime, recur again, and also of certain symptoms that usually
 accompanythem.........273
     CHAP XX.   Of the cure of malignant intermittents.   -    283
    CHAP. XXI. Of the treatment of common remitting fevers,
 and also of those of a malignant nature.     ....    289 
RECOMMENDATORY PREFACE.
    THE following translation of  Senac's trea-
tise,  " De  recondita  febrium intermittentium,
" turn remittentium natura, et de earum cura-
u tione," was undertaken by Dr.  Caldwell, at
the request of the  Subscriber.   He has  long
known it to be a judicious and useful work, and
has derived much assistance from it in his prac-
tice.  He is happy in this opportunity of recom-
mending it to the students of medicine in the
United States, as peculiarly calculated to assist
them  in forming just opinions, of the  nature
and treatment of  the summer and autumnal dis-
eases  of our country.
                   BENJ. RUSH, M.  D.
          Professor of the Institutes and practice of Medicine^
              and of Clinical practice in  the University of
              Pennsylvania.
   June 29, 1805. 
TO  BENJAMIN RUSH, M. D.
 PROFESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINEj
     AND OF CLINICAL PRACTICE IN THE UNIVERSITY OF
                   PENNSYLVANIA.
      DEAR SIR,
          THE following translation of Senac's cele-
brated treatise, on the nature and treatment of intermit-
ting and remitting fevers,  is inscribed to you, without
your knowledge, because I am confident that had your
permission been asked, your modesty would have pre-
vented  you from granting the  request.  Were  any
apology necessary, on  my part, for the liberty I have
taken, it could be easily found in the relation in which
you stand to the work.  You first taught in your lectures
the important truths which have long lain concealed in
it, under the garb of the Latin language, and have also
been eminently instrumental in having them now stript
of this dark and dead covering, and clothed in the lan-
guage of the United States.   Of the  reality  and  use-
fulness  of these truths, it is  only  an echo of public
acclamation, to say, that you are one of the ablest judges
now living, as well as their most distinguished and  sue-
cessful teacher.   These circumstances would be alone
sufficient to designate  you, even in the public eye, as
the most proper and natural patron of the work.

    But  I am actuated,  also,  by other considerations,
which,  though more private and personal in their na-
ture, are not with me less powerful  in their operation.
These considerations, were they to be even  rejected by
the judgment, would appeal to the feelings, and though 
DEDICATION.
repulsed from the head, could never fail to gainadmis-
sion to the heart.

    During an intercourse of some continuance, particu-
larly during the term of my medical pupilage, and the
first years of my practice as a physician, I received from
you many acts of attention and courtesy,which as ayoung
man and a stranger in the place,  impressed me deeply
at the time, and have still continued  to be sources of
grateful recollection.   Out of these civilities, obliga-
tions naturally arose on my part, which our relative
situation has not yet allowed me  to cancel.  It is even
possible, that an opportunity of  cancelling  them  may
never occur.  I must,  therefore, beg  your acceptance
of this dedication as  some  acknowledgment of them,
accompanied by my sincere wishes for a long  continu-
ance of your health, happiness, and useful labours.  For
however grateful, in the evening of life,  the  otium  in
seccssu honestum may be to a philosophical and  con-
templative mind, I am unable to wish you such a re-
tirement.   It is enough that we should be deprived of
your labours and services when you shall have gone to
enjoy the  reward of them in a better world.

                              CH. CALDWELL.
   Philadelphia, Oct. 23, 1805. 
PREFACE,
BY THE TRANSLATOR.
    THE following treatise  on the nature  and treat-
ment of intermitting and remitting fever, after having
lain for many years entombed in the catacomb of a dead
language, is now for the first time introduced to the
light, through the medium of a living one.  Viewing
it in itself and in its several relations, it presents, as
the translator conceives, a well supported claim to the
attention and patronage of the physicians of the United
States.  He, therefore,  flatters himself that its recep-
tion among them will not be unfavourable, but that it
will be regarded as a valuable if not a necessary addir
tion to most of their libraries.  Besides containing much
matter calculated to  interest the scientific and to in*
struct the practical physician, it is the production of  a
character of great celebrity and worth.  Indeed in what-
ever light it be considered, whether in relation to its
origin, its execution, or its object, it will be found  alike
respectable, masterly, and useful.   To such readers as
are pleased  with  slight biographical notices, a few re-
marks on the subject of its  origin may not be unac-
ceptable.
                        A 
PREFACE.
   The name of Dr. Senac, the author of the work, is
deservedly enrolled among those of the most distin-
guished physicians of France.  Though educated with
a view to holy orders, yet an early inclination which
nothing could resist, led him at length to the profes-
sion of medicine.   He flourished in the reign of Louis
XV. and stood high in the estimation and favour of his
royal master.  Besides being for a considerable length
of time first physician to that monarch, whose favour-
ites were selected on account of their pre-eminence in
talents and worth, he had  conferred on him the hono-
rary titles of Counsellor of State, and Superintendant
General  of the  mineral waters  of the kingdom  of
France.   He was also elected to a seat in the Academy
of sciences at Paris, an institution choice and rigid be-
yond all others in its admission of members.  Of these
several places and appointments he proved himself to
be even more than worthy, for it was always considered
that he was rather an ornament to them than they an
honour to him.  He was one of those self-dependent
characters who shine not with borrowed light, but like
an electron per se,  contain their lustre within them-
selves.   He died in the year 1770, and was followed to
the grave by the regret of the literary characters of his
time, aad the tears of thousands whose sufferings had
been often times alleviated by his  skill.   Besides the
present treatise, he left behind him " A treatise on  the
causes of acids and the cure of the plague," " A trans-
lation of Hcister^s anatomy," " Anerv course of chemis-
 try, and  " A treatise on  the structure of the heart."
 This latter work  is the most extensive and weighty of
 all his writings.   It is said to have been the result of
 twenty years application and enquiry.  It is a work of 
PREFACE.
 gfeat learning, and is considered by the anatomists and
 physiologists of France, as a master piece  for depth
 and accuracy of research.

    To the skill of the physician, the science of the phi-
 losopher, and the learning of the scholar, Dr. Senac,
 added the accomplishments of the gentleman, and even
 the exquisite polish and elegance of the courtier.  He
 possessed, in an uncommon degree, the happy, but rare,
 art of appearing to equal advantage and acquitting him-
 self with equal  effect,  whether seated by the bed  of
 sickness, immured in his closet, or surrounded by the
 splendid circles of a court.   It is scarcely necessary  to
 add, that these various qualifications and excellencies,
 which are so seldom united in the same person, secur-
 ed to Dr. Senac for many years his choico of business
 in the metropolis of France.

    With regard to the real merit of the present work,
 there can be  little doubt but various and even opposite
 opinions will be formed.   For it is true that many phy-
 sicians are too apt to make their own customary modes
 of thinking and practising, the  standard  of  truth and
 excellence in others.  Peirhaps this is more particularly
 the case with those, whose reading and enquiries have
 been on too  limited a scale to enable them to be even
 tolerable judges.

    The translator has no wish to forestall public senti-
 ment on the present occasion.  Nor, if he even had, is
 he vain  enough to  fancy himself equal to such an un-
dertaking.   It is one of the felicities of a free country
that public opinion is too  independant to bow to  the 
PREFACE.
sceptre or submit to the controul of any individual.  If,
however, it be admissible for him to offer a remark or
two on the  subject, he will briefly observe, that he re-
coljects no work in any language, which comprizes such
an extent and rich variety of  general and practical in-
formation respecting the nature and treatment of inter-
mitting fever, as the  treatise  before us.   It is one of
those rare productions in medicine, thatmay be denom-
inated a work of principle  as  well as  fact.    For our
author has shewn himself to be able not only to observe
and to collect, but also to digest, arrange, and general-
ize.  Though the work contains here and there certain
fanciful  points  of doctrine and hypothesis, that are
known to be erroneous, and that have been long since
exploded, it bears no mark of having  arisen from the
pen of either a theorist or a copyist*  It exhibits every
where the strokes of a master if not of an  original in his
profession.  In composing it, Dr. Senac appears to have
had no pre-existing model in view.   He described dis-
eases as he had  seen them, and recommended that
practice which he had found most successful.  Like
Hippocrates of Greece, Sydenham of England, and a
physician now living in the United States, whose mo-
desty would be offended were I to mention his name,
he took nature for his text-book and observation for his
interpreter, disregarding alike the theories of his prede-
cessors and the dogmas of the schools.   Persevering
in this plan,  he necessarily  produced a work of fact
and  experience, interspersed with much original re-
mark and forcible reasoning.   He oftentimes,  indeed,
refers to preceding writers, and speaks of them in terms
respectful and modest.  But he quotes them rather for
their facts than their opinions; for what they have seen 
PREFACE.
rather than for what they have thought.  He does hom-
age  to  them no  further than they appear to  him to
have done homage to nature.  With the genius, judg-
ment, and experience of Cleghorn,  he has given  a
much more general and complete treatise on Intermit-
tents than that able  and excellent author attempted.
Cleghorn's celebrated treatise on the diseases of Mi-
norca has somewhat of alocaland circumscribed charac-
ter ; but the treatise of Senac is as general as the preva-
lence, and as varied as the nature, of Intermittents them-
selves.   It describes  them in all their forms, and un-
masks them in all their disguises.

    In clothing this treatise  in the English language,
the  translator has had other objects in view, than that
of merely putting the physicians of the United States
in possession of one single work of merit.  He wishes
to become instrumental in directing them to an impor-
tant source of information, to which he apprehends
they have hitherto paid  but little attention.  He al-
ludes to the medical writings on the continent of Eu-
rope.  It is greatly to be lamented, that, owing to their
being published in Latin, or some foreign language not
much read in the United States, these writings have
had but a very  limited circulation among us.  For
what we know respecting them we are chiefly indebted
to British translations and British reviews.  But this
is a  kind of dependence neither useful nor honourable
to us as a literary people.  It bespeaks a state of hum-
ble minority from which it ought to be our pride, as it
is certainly our interest, to endeavour to emerge.

   The British physicians translate such foreign pub-
lications in medicine  only, as arc accommodated to the 
PREr av.l.
diseases  of their own  climate  and country.  But the
diseases of Great Britain are very dissimilar to those of
the united  States.  Nor do they bear a much nearer
resemblance to the diseases that prevail in many parts
of the continent of Europe.   Medical  publications
higly useful both on the continent of Europe and in thi
United States,  may, in a practical point  of view, be
worth but very little to a physician in Great Britain.
It is scarcely to be expected, therefore, that we should
receive,  through the  medium of  the British  press,
those continental works  in  medicine,  best accommo-
dated to the diseases of our own country.  It is believ-
ed  that the present  translation of  a work written in
France, and but very little known to the physicians of
Great Britain, will serve as a confirmation of the truth
of these remarks.  Perhaps a spirit of national jealousy
and pride may have some influence  in making the phy-
sicians of Great Britain undervalue and  neglect the me-
dical writings of I ranee  and other nations.

    Recent and melancholy experience convinces us,
that the United States and the southern parts of Eu-
rope are nearly allied to each other on the score of epi-
demic diseases ;  for the same pestilential fever, arising
from the same  atmospherical causes,  has committed
the most deplorable ravages in both places. But, owing
to a different state and  temperature  of  atmosphere,
both Great Britain and the more northerly countries of
Europe are exempt from this calamity.

    Indeed if we compare the climate and summer tem-
perature of the United states with those of Spain, Por-
tugal, Italy,  and some parts of France, we will be at
once convinced that these several countries mustneces- 
PREFACE.
sarily be marked by a very considerable similarity of
endemic and epidemic diseases.   But a like compari-
son between the United States and Great Britain, will
as readily convince us, that the diseases of these two
portions of the globe must be greatly dissimilar.

   But our knowledge on the subject  does not termi-
nate here.   We are taught the same truths by a refer-
ence to medical  writings.  It is well known, that we
look in vain into British publications for accurate ac-
counts either as  to the histories or modes of treatment
of our indigenous diseases  of summer and autumn.
But this is not equally true with regard to certain con-
tinental  publications.  In them we find  such state-
ments, particularly with respect to the  histories of dis-
eases, as correspond precisely to our own observations.
This is,  perhaps,  more particularly the case with re-
spect to the medical writings of Italy and France.

   It is not the intention of the translator, by anything
here advanced,  to offer the least disrespect to the me-
dical character of Great Britain.   On the contrary, he
is convinced  that the physicians  of that  nation  are
more enlightened than those of any other country of the
old world.  But their actual experience  in their pro-
fession  is necessarily confined to such forms  of dis-
ease as fall under their immediate observation.   And
having  no opportunity of  witnessing those gigantic
and anomalous forms of intermittents and  remittents,
that oftentimes occur in the United States, and in the
south of  Europe,  it is not to be expected  that they
should be capable of either describing them accurately,
or teaching their  proper mode of treatment.   They 
PREFACE.
 are, no  doubt,  masterly physicians  in the climate of
 Great Britain, but very feeble and unsuccessful ones in
 that of the United States.  To treat our summer and
 autumnal diseases conformably to the rules of practice
 laid down in British publications, would, in many in-
 stances, amount to but little less than licenced murder.
 From these remarks, the reader will be sensible, that
 some of the British West and East India writers  are,
 in a great measure,  excepted.   Yet even these do not
 seem to have been conversant with forms of intermit-
ting and remitting fever precisely similar to those that
 occur in our own country.

    The translator will only add, that should the pre-
 sent treatise meet with a reception corresponding to its
 merit, it  is his  intention to submit to the  American
press, translations of other valuable continental works
in medicine.
 Philadelphia,
October 3d, 1805. 
BOOK FIRST.
                    OF

THE NATURE OF INTERMITTING

          AND REMITTING FEVERS.
                CHAPTER  I.

       Of the various kinds of Intermittents.

      AN intermitting fever  is a disease which
alternately commences and terminates at a given
time, and is  marked by regular  and distinct
periods.   On  stated days, for instance,  and at
stated hours of these days, a febrile rigor or chilly
fit occurs, and is succeeded by a hot stage, which
again gradually  abates  until it terminates  in a
state of true apyrexy or intermission.  But as
the duration of this intermission,  or the inter-
vals of time  between the recurrences of the
paroxysms of  the disease are various, it has ac-
cordingly been distinguished by various names.
Thus, when the disease commences and termi-
nates every day,  it is called a quotidian; when
on alternate days, a tertian ; and when on every
fourth day, a quartan.
                     B 
                      2
    Other forms of the disease are mentioned by *
both ancient and modern writers,  such as the
quintan, the sextan, the septan, and the nonan.
That quintans  do sometimes occur cannot be
denied ; but the existence of the others is a mat-
ter of very great uncertainty.  If the credit due
to the reports  of certain celebrated physicians
prevents us from denying their existence alto-
gether,  we must at least acknowledge that they
have been bilt rarely observed.   Even with re-
spect to those diseases wThich assume such  an
appearance, there is ample ground for the admis-
sion of  doubts.   It  may  indeed  accidentally
happen that some paroxysms fall on  the sixth or
seventh day; but it can scarcely be  admitted
that they pursue this course and  observe these
periods  with regularity for any length of time.

   But however reasonable  and specious these
observations  may  appear, I am unwilling that
too much  reliance  should be placed on them :
the course and operations of nature are very im-
perfectly understood :  those  things which we
consider as differing from her customs and laws,
are oftentimes found to be consonant to them :
paroxysms may occur on unusual days ;  as the
febrile power can  come into action every third
and fourth day,  it ought not to be considered as
very surprising  should it show itself every sixth
day.  A  patient  may  escape  one  or  two pa- 
3
 roxysms of a tertian,  in which case the disease
 will appear like a quintan or septan.   A similar
 occurrence in a quartan will produce other varie-
 ties in the type of the disease.

     But it is asked, do these occurrences actually
 take place ? Nor can the question be determined
 with any degree of certainty. We will therefore
 treat of those diseases only, that have a well de-
 fined  type,  and that  pursue a regular course.
 The quotidian we will not  rank among genuine
 intermittents, because its nature is totally differ-
 ent from  theirs,  as  will be elsewhere demon-
 strated.

    The diseases which deserve above all others
 to  be  denominated intermittents, are  tertians
 and quartans.   From  these arises almost every
 other form that is marked with distinct periods,
 such as the double tertian, and the double quar-
 tan : of these  the  course  and order  of the pa-
 roxysms are such, that their nature  and com-
 position are easily discovered.

    When, for example,  the disease comes on
 and terminates every  day, provided  the  pa-
 roxysm be alternately lighter one day and severer
 the next, it appears evident that there exist  two
 forms of fever, one consisting of lighter  pa-
roxysms and  the  other  of more  severe ones. 
                     4
Here the lighter paroxysms  correspond to the
lighter, and the more severe to the more severe,
every third day, that is, in the order of the ter-
tian  type.  The disease, therefore, which at first
view appeared  to  be  a  quotidian  is  evidently
composed of two tertians.

   The form and course of the double quartan
are still more easily detected.   This disease, for
instance, begins and terminates at a  given hour
for two days in succession, and does not appear
on the third ;  but,  on the fourth and fifth again,
it  recurs as at first.  Hence between the first
and third  paroxysms, and between the second
and fourth, there are intervals of two days each.
This is a composition or form of disease which
rarely occurs ;  yet in the frequency of quartans
it  does sometimes occur, as every physician of
extensive experience must be able to testify.

   Triple tertians and quartans more rarely ap-
pear. The disease is called a triple tertian, when
three paroxysms occur in the space of two days,
one, for example,  every  sixteen hours.   This
type was observed by Galen and Riverius, but
must be ranked among the unusual phenomena
of intermittents.   More  frequently two pa-
roxysms take place in one day,  while the next
proves a  day  of  complete intermission :  this
form of disease might be likewise denominated 
5
a double tertian, since it consists in reality of two
fevers, which recur every third day.

   As to the triple quartan, if the paroxysms
only be  regarded, it  cannot  be distinguished
from  the quotidian or double  tertian :  nor in-
deed have physicians observed any thing dif-
ferent in it, except the paroxysm that  falls on
that day which, in the double  quartan,  is a day
of apyrexy or intermission.  Such, for example,
was  the opinion  of Celsus, who treated of the
change  of that form of disease into a quotidian.
The sentiments of Celsus on this subject were
adopted by Hoffman,  who mentions the forma-
tion of a quotidian out of a quartan, in such a
manner,  however, he observes,  that  the  pa-
roxysms  do not commence every day at  the
same hour.

    Some physicians mention fourfold and six-
fold tertians and quartans; but these writers arc
led by mere hypothesis, rather than observation,
to speak of fevers of this description :  they have
seen paroxysms occuring in an irregular and dis-
orderly manner, and have endeavoured to arrange
them  under certain  types.   But, in the  first
place, fevers of this kind are not intermittents;
or if they are, they pursue no regular course :
departing in a  short  time from the course  in
which they began, they pursue a different one, 
                      6
and that altogether broken and disorderly. But,
to conclude  the matter at once,  physicians of
long and extensive experience have scarcely ever
witnessed diseases of the kind.

   Simple intermittents degenerate  into  other
compound forms of fever.   They may be con-
verted,  for example, as we shall  presently see,
into continued fevers, still, however,  preserving
so much of  their  original type as serves to dis-
tinguish them from all others.  They may like-
wise be  combined with other fevers, as with
those of a continued form. They have also been
known to be joined at times with certain  other
morbid affections.  But we will proceed first to
the consideration  of simple intermittents, that
we may thence be the  better  enabled to  com-
prehend the  nature of such as are compound. 
CHAP. II.
Of the various causes of Intermittents, as laid down by
              certain medical writers.
    THE pause of intermittents, which acts and
 lies dormant by turns,  is extremely difficult  to
 be understood.  Enquiries respecting it have ex-
 ercised the ingenuity of physicians in every age,
 and it has been supposed to reside in various parts
 of the body.   Many  have considered it as lurk-
 ing in the prima  via.  The principal argument
 in favour  of  this opinion  is  drawn from a
 symptom constantly  attendant on  intermittents,
 namely,  a vomiting  preceding  the paroxysms.
 As the febrile cause, therefore, acts first on the
 stomach, it would seem to have its seat in that
 organ.  But nausea and vomiting usually precede
 most kinds of acute diseases.  Small-pox, pleu-
 risy, and other similar diseases, do not  originate
 in the prima via, and yet they are for the most
 part ushered in by a vomiting.*

  * The translator, from his present view of the subject, is decidedly
of opinion, that the poison which produces bilious fever in all its
 forms,  and also the variolous poison in cases of casual small-pox, 
                        8
    Others derive an  argument no less  feeble
 from the effects of drinking cold water.  Thus a
 drink of cold water makes the disease more se-
 vere,  while a  draught  of warm water  renders
 the efforts to vomit  much lighter.  But in  the
 cold stage of the  fever every part of the system
 is contracted  or shrunk up ;  can it,  therefore,
 be inferred, that  the  first seeds of the disease
 lurk in the prima via, merely because a new or
 additional contracting power, such  for  instance
 as a draught of cold water, subverts  the action
 of the stomach ?

    The insufficiency of these arguments appears
 in a  particular manner,  from  the uncertainty
 that  accompanies the use of  emetic  remedies.
 If intermittents arose from the condition of the
 prima via, they  might be removed by  emetics
 or purgatives  alone. .  But  every one  must be
 acquainted with the fact, that they do not yield to
 remedies of this description,  and that they are
 not unfrequently even  rendered more  violent by
 them.  Besides, topical applications to the limbs,
 and  peruvian  bark used by way of  injection,

have their original seat in, and, therefore, make their first impres-
 sions on, some part of the prima vice. This leads him to an unquali-
 fied belief in the sympathetic doctrine of fever.  These opinions he
hopes to lay before the public, at some future period, accompanied
by such facts and arguments as may contribute to their further esta-
blishment and more general reception, 
9
have oftentimes been  known to cure intermit-
tents : but these remedies do not operate  by
evacuating the prima via.

    Physicians have accused another part of the
body, which is  no less innocent than the prima
via.  The pancreas, for example, has been con-
sidered as the seat of the febrile  cause, and this
opinion has been thought to derive support from
anatomical observations.  That organ has been
found sometimes schirrous,  and at other times
in a state of  suppuration.  But were not these
appearances the effect, rather than the cause of
the disease ?   How many persons have laboured
under obstructions of the pancreas, without ex-
periencing any  thing of intermitting fever ?  We
will pass over that opinion, therefore, as a mere
conjecture.  Nor are we inclined to set a higher
value on the sentiments of those, who consider
the fomes of the disease as lying hid in the reces-
ses of the mesentery,  because the hypothesis is
not supported  by either reason or experience.

    With as little reason and  justice has the dis-
ease been attributed to a deficiency of perspira-
tion.   There are indeed  some instances which
would seem  to favour the belief, that intermit-
tents may arise from such a  cause.  It has been
observed, for example, that boys who had eaten
largely of summer fruit, have been seized  with
                       c 
10
intermittents on plunging  themselves into a
stream of running water.   A  kind  of febrile
paroxysm appears also to be excited by the use
of the cold bath.   But it is no less certain that
perspiration  may be checked without producing
any febrile affection.   It appears also from  the
circumstances of the cold of winter, which is so
unfavourable to  perspiration, that persons when
warm are very often exposed to cold air without
experiencing any  febrile commotion  in conse-
quence of it.

   From these causes which they considered as
uncertain, some physicians  have retreated to
others less obvious to the senses.  Many seem
to be fully convinced, that the origin of intermit-
tents is to be sought for in the action of the
nerves; some, for instance,suppose it to be owing
to an inert or sluggish state of the nervous fluid,
while others attribute it to an irregular influx of
the same. They contend, in particular, that the
sudden invasion of the paroxysms can be  de-
duced  from  no other source than the nerves.
Examples are brought forward, where an inter-
mittent appears evidently to have been produced
by the passions  of the mind. For no  other rea-
son, according to some, can peruvian bark prove
serviceable,  but because it  gives relief in hys-
terical  or nervous affections. 
11
    It is indeed surprising that physicians should
have  fancied  causes  of this  kind, which are
so  remote from the  reach of  the senses.   I
confess that I  oppose  these hypotheses not with-
out difficulty.   Who, I would ask, can prove,
that the nerves are alone affected in intermittents?
Suppose a person to be attacked  by  fever, in
consequence of a violent agitation of the nerves,
what  then ? do not other  affections also  arise
from the  same  cause ?  Besides, what peculiar
affinity to such a cause  have cold,  heat, profuse
sweating, apyrexy,  and a return  of the  pa-
roxysms  at a stated  hour ?  Those who spend
their time in searching for these things in the
nerves,  are  idle  theorists rather than practical
physicians intent on the cure of diseases. 
CHAP.  III.
Of other and more probable causes*
   THOSE writers appear to have approached
nearer to the truth, at least to have more proba-
bility on their side, who have referred the cause
of intermittents to certain animal fluids.  Among
these the first to be mentioned are the more an-
cient anthors, who have laid the blame especially
on the bile,  namely on its redundancy or acri-
mony, qualities  which show themselves more
particularly  in the autumn,  or, from various
causes, at other seasons.

    If indeed any fluid can become too acrid, it
is the bile.   This appears evident from the cir-
cumstances of its origin and  formation, which,
however, do not seem to  be  very clearly under-
stood.   This yellow excretion cannot be said to
be  formed in the blood, and separated  from
thence by certain strainers,  because neither the
surface of the  body,  nor the internal parts  are
tinged by it, when the liver is entirely indurated.
In the internal recesses of that viscus, therefore, 
                      13
 the officina or laboratory  of the  bile is  neces-
 sarily situated.

    But it cannot be proved that the bile  can be
 formed either from fat,  from lymph, or from
 serum.   Fat is not saponaceous, since it is no-
 thing but mere oil; lymph is white, coagulates
 spontaneously in a short time, and does not form
 an extract with spirit  of  wine;  the serum into
 which all the humours are resolved, contains in
 it nothing bilious,  nor is any such quality attri-
 buted to  the urine.

    It is more probable, therefore, that the im-
 mediate matter of the bile resides in the red
 portion of the blood, for the blood like the bile, is
 saponaceous  when rubbed  on the hands ; it is
 also resinous, in as much as it  is inflammable
 when  dried,  and forms a  tincture with spirit of
 wine ;  finally, it is strongly disposed to putre-
 faction, and, when in a putrid and dissolved state,
 assumes a yellow colour: these latter circumstan-
 ces are illustrated in cases of echymosis, and in
 the putrefaction of blood under a gentle  heat.

    Now  the blood returning from the intestines,
 having left  its more fluid part behind it, has  a
 tendency  to a dissolved as well as to  an alkales-
 cent and  putrid state.  It  stagnates in the me-
senteric veins, is exposed to a gentle heat, and is 
14
tainted  by the putrid  halitus of the intestines.
It becomes therefore dissolved, and turns yellow
in the  liver  itself, in which it circulates  but
slowly,  and is at length separated or taken up by
the biliary tubes. Thus, as it is already inclining
to an acrid state, this acrimony can be the more
readily  increased by the mixture of febrile mi-
asmata.

   But if bile be the cause of intermitting fever,
it must necessarily have  first acquired some pe-
culiar and unusual power : for it is oftentimes
in very great super-abundance without giving
rise to this disease.  Nor indeed are those per-
sons who labour under jaundice more subject to
it, although the bile ought in such cases, if ever,
to prove troublesome and injurious ;  for it then
stagnates in the liver, taints the blood and other
humours,  disturbs  the functions of the body,
and fails to perform its usual offices in  the sto-
mach and intestines.

   Influenced, no doubt, by  these considera-
tions,  some have  supposed, that intermittents
are to be  attributed to  a certain putrid matter
contaminating  all  the humours of the body.
Hence arose their belief, that febrifuge medicines
possess properties strongly antiseptic ; such as
the peruvian  bark, for example, which is a pow-
erful preventative of putrefaction.  But it must 
15
be acknowledged, that they who lay the blame
on putridity alone, carry the matter to an extra-
vagant and  erroneous length.   Putrid aliment
does not  always produce intermitting fever :
besides, this disease oftentimes prevails in places
where not a vestige of putridity exists : there are
even certain remedies, such as testaceous sub-
stances, which promote putrefaction, and yet
possess febrifuge virtues.

   But whether it be acrid bile, or some putrid
matter, that is the cause of intermitting fever,
it remains to be enquired whether it is confined
to some particular part, or is diffused throughout
the whole body.   Some circumstances indeed
seem to prove, that the febrile cause is diffused
through the whole system ;  when about to dis-
appear, it shows itself on the lips and around
the mouth ; for it produces pustules on  these
parts, and leaves marks of its departure, when
it is gone.  This position is further  confirmed
by many other circumstances which sometimes
occur in certain cases of disease, and seem to
show  that a poison  is diffused throughout the
whole body.

   But there are arguments not without weight,
which  tend  to prove, that the febrile cause is
principally confined to some particular organ, or,
at least, that there is some part to which its ac- 
                      16
tion is more immediately directed and confined,
and which is, therefore  a greater sufferer in con-
sequence of that action.  This opinion is coun-
tenanced,  as  we  shall presently  observe,  by
various phenomena attendant on intermittents.

    From every view of the subject it would ap-
pear, that the part which more  immediately
sustains the action of  the febrile poison, is the
liver:  for, in intermittents, the urine  is tinged
with the same saffron and brick-dust colours, as
in hepatic affections.   So great is the super-
abundance of bile in these diseases, that, on the
exhibition of an emetic, it seems to overflow,
and is  often discharged of an  oily nature and
very viscid consistence.  So great is  its  accu-
mulation that it is necessary to have recourse to
vomits.  Such a tendency has the system to ge-
nerate  bile, that without procuring its evacua-
tion the disease cannot be removed.

    Hence, as  must necessarily  be expected, the
countenance is for the  most part suffused  with
some degree of  yellowness.  In those who are
unskilfully treated and imperfectly cured,  this
colour becomes so deep as to degenerate at length
into a true jaundice.   Unless  this affection be
removed,  it is not to be expected that the dis-
ease will disappear ; at least, if  it even should
terminate  for a while, it will  certainly have a 
17
strong disposition  to recur.  Lastly, in those
who  die of  intermittents,  the  liver is  always
more or less affected.   It cannot, therefore, be
doubted but that in this complaint, that organ is
particularly and chiefly diseased, and constitutes
the principal seat  of the fomes.

    But in an  investigation so extremely intri-
cate,  it is not allowable to proceed any further.
It appears evidently that a certain matter is either
generated in the body, or is introduced  into it
from  without, and that this  matter is diffused
throughout the whole of it, and proves noxious
to the liver in particular.  But how is it concen-
trated in that viscus,  and  how does it acquire
strength ?  How does it show itself, by making
as it were a sudden  attack, and afterwards gradu-
ally abate, till it at length ceases to act ? Finally,
how does the fomes remain in its lurking-place ?
How does it contaminate the humours  like a
ferment, and prove the cause of repeated pa-
roxysms ?  These things cannot be ascertained,
till we shall have  taken a survey of all the symp-
toms and effects of the fever.
D 
CHAP.  IV.
Of the remote causes*
   IT is much easier to enumerate the remote;
causes than to point out their mode of operation.
It is obvious to every one that intermittents are
the immediate offspring of changes in the wea-
ther ; yet it cannot be ascertained in what way
such changes  contribute to  the production
of these diseases  rather than of others.   We
only learn from observation, that by particular
states or conditions of the atmosphere, certain
motions or modes of actron are excited in living
bodies : nor are these motions produced alike in
all kinds of animals : dogs, horses, and cattle are
not so liable to intermitting fevers, at least they
are but very seldom attacked by them.

    The human system> on the other hand, is
very subject to these diseases.  There is scarcely
any  one who has not experienced  something of
intermitting fever.  This disease spares neither
childhood,  manhood, nor old age.  It  prevails
in the spring, though more extensively in the 
19
 autumn, and also makes its appearance occasion-
 ally during the severest cold of winter,  and the
 most intense heat of summer.  But during these
 latter seasons the occurrence of the disease is
 much more  rare.  In general, a continuance of
 intense cold or intense heat produces fewer dis-
 eases, and those of a different aspect?

    There are in the mean time certain years, in
 which intermittents are rare during the spring,
 and even during the autumn, the season in which
 they  more generally prevail. But at other times
 they  break forth sporadically, or epidemically,
 and that  in  particular tracts of  country rather
 than in others.   In such  cases they begin and
 terminate their ravages sooner or later, accord-
 ing to the changes of the weather, or the nature
 of the soil.   When they commence early in the
 season, we may look for an epidemic of consider-
 able  severity.   These epidemics  have  been
 known to continue with great violence and mor-
 tality, even  till  some  time in the winter.   On
 such occasions, however, those persons who hao^
 been attacked by the disease during the autumn,
 were the principal sufferers, while such  as had
 escaped till the commencement of cold weather
 were seldom affected afterwards.

    Intermittents prevail not only at certain sea-
sons  of the  year, but also in  particular situ- 
                     20
ations.  Persons living in the vicinity of marshes
are particularly subject  to them.   They rage,
for example, in the northern parts of France.
The French troops suffered once the greatest
mortality from them, when they were encamped
along the coasts of Holland.  On that occasion,
such was the nature and malignity of the fever,
that after having continued for a certain time it
scarcely admitted of a cure.  Even the most ro-
bust systems and vigorous constitutions, when
much reduced  by  the violence  of the disease,
carried the relicks of it with them through dif-
ferent climates.

    This fever  arose  from marine exhalations,
which  were,  therefore,  supposed to  contain
something noxious derived from the waters of
the ocean.   But other kinds of  exhalations are
not less hurtful.  Near to the  walls  of  a large
city stood a very extensive and deep pond of
water, which for forty  years had served as a re-
ceptacle of all  the  filth  from the houses and
streets.  As long as these putrid matters remain-
ed covered with water, they were productive of
no mischief. But when they had so far accumu-
lated as to rise  above the surface of the water, a
most malignant fever spread through the tract of
country adjoining the city.  Where, previously
to this,  only four hundred persons had died an- 
21
nually, not less than two thousand were now
swept away.

    Such was the peculiar power of these exhala*
tions, that persons living near the pond, could
not preserve meat for the space of three hours ;
it usually began to putrefy almost immediately,
and all kitchen furniture became in a short time
covered with a kind of crust.   Perhaps this fe-
ver was of a different kind : it was truly malig-
nant and produced various affections of the head,
a circumstance not so observable in the fevers
which prevail along the coasts of France.  These
latter diseases  more frequently  terminate  in
troublesome obstructions of the viscera.

    Hence it appears, that in epidemic constitu-
tions of the  atmosphere, there is something that
rises from the earth, and floats in the air, which
tends to  the production of intermittents rather
than of other diseases:   Of the nature and com-
position of this, it is extremely difficult to judge.
We learn, however, from observation,  that a
similar  cause  may be  generated in our own
systems, and that it sometimes originates from
the aliments we use ; yet  these aliments cannot
be regarded as a certain cause of intermittents.
For, when any one, after an error in  diet, is at-
tacked by a  disease of this kind, he might have
been before pre-disposed to it;  he might have 
                      22
 received  a certain portion of miasma from the
 reigning constitution of the season.   Thus, in
 camps, for instance, it is certain that if the pro-
 visions be heavy and glutinous, like beans, or
 austere and harsh, like unripe fruit, attacks of
 intermitting fever are apt to be common through-
 out the autumn.

    Thus,  then, it stands,  with respect to these
 and other occasional causes, such as sleeping in
 humid situations,  cold air, fatigue,  passions of
 the mind,  such as anger and sorrow, long con-
 tinued watching, and the use of heating medi-
 cines.   To these things, not  as  their proper,
 but as their exciting causes, fevers are known
 to succeed very  frequently.   The body being
 already pre-disposed, has a disposition to take
 on these diseases.  Under  such circumstances
 the solids and fluids are, so to speak, thrown into
 the flame of fever by a slight cause.   It would,
 indeed, be a secret, well .worth possessing, to
know how to reduce the fever certainly to an in-,
 termitting type. 
CHAP.  V.
Of the febrile rigor, or cold stage of fever.
    WHEN the febrile  cause begins to act,  a
sensation of coldness is immediately  experi-
enced, a circumstance which occurs in other
acute diseases as well as  in intermittents.  But
in continued fevers the  progress and violence
of the cold stage are widely different from what
they are in those of an intermitting type.  There
are indeed some continued fevers of a malignant
character, which are ushered in by a severe and
dangerous chill.  But in general it neither lasts
so long, nor is so troublesome to the sick. This
serves to apprize the practitioner of  the nature
of the impending fever, and enables him to dis^
tinguish it from other diseases, even before the
hot stage is  formed.  For it may be laid down
as a general principle, that  fevers which com-
mence with the greatest  rigor, are to be classed
with  those whose course is  marked by stated
paroxysms. 
                     24
    The rigor or cold stage of fever can be attri-
 buted to no other immediate source than an im-
 pression or irritation made on the nerves by
 some  hidden cause exciting them to action.
 That this  is the case appears from various ex-
 amples  that occur in practice.   Thus, for in-
 stance, the irritation of a biliary calculus on the
 ductus  choledocus, sometimes excites the most
 severe rigor throughout the whole body.   The
 same effect is oftentimes produced by a catheter
 touching the bladder, and even by  an  enema
 thrown into the rectum, when greatly pained by
 a hemorrhoidal affection.  A similar rigor arises
 from certain  visceral complaints,  such as a
 strangulation of the intestines,  and also from
 the formation of pus in  any of the cavities  of
 the body.   I once saw a soldier who, in conse-
 quence of a large abscess of the liver, died of a
 chilly fit which lasted two days.   There is no
 doubt, therefore, but the  cold stage of intermit-
 tents may be produced by a stimulus acting on
 some part of the body.

    The access of the chilly fit is usually pre-
ceded  by  various  phenomena.  These are,  a
 general lassitude and heaviness, a sense of anxi-
ety,  a yawning and stretching, a paleness, and
 sometimes a disposition to sleep ; then succeeds
the chilly fit, which puts  on  a variety of forms ;
 sometimes,  for instance,  beginning at the feet, 
25
at other times about the scapulas, and again in
the back, it runs through the whole body, in a
manner resembling small  streams  of  water,
poured irregularly  in  every direction:  hence
horripilations, shiverings, and repeated rigors,
as if cold water were dashed over the limbs.

    The shiverings  and rigors are oftentimes so
great as to produce a continued tremor ;  the
hands, arms, and other members begin to shake;
the lower jaw in particular is seized with a very
quick and  alternate tremulous motion,  which
rises at times to such a pitch  of violence and
force, that the teeth clash against each other with
a considerable noise,  and are even  said to be
sometimes  broken.  The motions being con-
vulsive and involuntary cannot be checked, not-
withstanding the greatest  efforts of the patients
for that purpose. Agitated by such concussions,
the sick are unable either to sit or stand : they,
therefore, are forced to lie down, and  to draw
themselves together in such a  way that their
liwibs may press on and support each other.

    It  frequently happens that ail parts of the
body are not alike affected by the cold fit.  I have
oftentimes seen the lower parts extremely cold,
and the  upper ones parched with heat.  Men-
tion is made of a patient who had one side cold
and the other hot.  I myself had a person under
                      E 
                      26
my care in fever, who felt a coldness only in one
arm.   There are other  circumstances not less
rare, which variously affect the duration, strength,
and appearance of the cold stage.   But as these
do  not very frequently occur, it is inadmissible
to dwell  on them  at  present.   Those  things
which deviate from  the common course of na-
ture,  do  not fall within the province of art.*
Besides, these anomalies are usually connected
with  spurious  fevers,  not  with true intermit-
tents.

    Varieties also occur in the cold fit which pre-
cedes intermittents.  Thus  it varies in degree,
being sometimes light, sometimes moderate, and
at  other times very severe.  It attacks  princi-
pally  the extreme parts of the body, and  but
rarely reaches, or is felt in, the internal parts. It
varies also according  to the age and tempera-
ment of the subject.  It is much more severe in
old and relaxed  subjects, than in  such as  are
youthful and vigorous.   Its duration is also dif-
ferent in different cases, as it sometimes lasts
two and sometimes three hours : I have  known

  * That is, stated rules cannot be laid down for anomalous occur-
 rences. Under the pressure of such occurences, the practitioner
 has nothing to depend on but his own sagacity and discernment.
 Could rules be laid down, or predictions be formed respecting them,
 the events wou d cease to be anomalous and become regular.......
 Trans. 
                       27
it to be  protracted even to the fourth and fifth
hour.

    When the cold fit is longer than usual, this
circumstance is  not to be considered as always
portending a  more  obstinate  and  severe pa-
roxysm.  In general,  indeed, the violence of the
hot  stage of fever corresponds to that of the
cold:* but I have oftentimes observed,  that a
tremor of but short duration was  succeeded by
a most intensely severe paroxysm of many hours
continuance.  On the other hand, I have been
surprized to find a long cold fit  sometimes fol-
lowed by a short and light attack of fever.

    The cold fit  is  not alike troublesome in all
the paroxysms of the  same disease. Sometimes
it is scarcely  felt by the patients, when the dis-
ease has run  on  to a considerable length : nor is
it indeed,  at  times, less inconsiderable  even in
diseases of recent  origin.   There are  some of
these which begin with a chill only at  first,  or
at most in two  or  three of  the subsequent pa-

   * Our author alludes here to the intensity, but not to the duration
of the hot stage.  It is certainly true that a very severe cold fit, ac-
companied by a chattering of the teeth, and what is called, in common
language, a general shake, for  the most part ushers in a high state of
febrile action.  But this state is seldom of long continuance.  A co-
piousperspiration soon comes  on, and terminates in a short time the
increased heat and arterial commotion.....Trans. 
28
roxysms.  After this the access of the paroxysms
is announced by a very slight chill, if by any at
all.  But in true intermittents, unless they have
degenerated in consequence of the lapse of time,
the case is otherwise;  these do not in general
deviate from the usual rule.

   When the paroxysms are so  protracted as
almost to run into each other, the cold fit is ge-
nerally less evident.  Nevertheless,  most per-
sons are admonished of the approach of the
fever by a slight degree of  chilliness.   Some-
times the coldness occurs only in the feet, and
at other times it is not attended to by the sick
at all;  while  in other instances again, an oppo-
site state of things occurs.  Thus, in fevers, as
in other movements or processes of nature, there
is no  absolute stability.   Some fevers  do not
steadily pursue  the course or type with which
they commenced, and  others  deviate from the
common laws of similar diseases.

   It is not  to be wondered at, therefore, if in
irregular intermittents, some unusual symptoms
should manifest themselves in place of thecoldfit.
I have accordingly seen some patients who com-
plained of a fixed pain in  some part of the body,
resembling true rheumatism.  There are others
again,  who, on the approach of a paroxysm, are
seized with a  sleepiness.   Indeed so great is this 
29
sleepiness,  that  it  sometimes  resembles  real
coma.   A certain female patient could scarcely
be roused up ; and  when she was roused, im-
mediately fell asleep again, and lay as if deprived
of sense : from hence it appears how easily the
mind may be affected.  I once knew a woman
who, just before the paroxysm, became very lo-
quacious, nor was the approach of the disease
announced  to the  by-standers by  any other
sign. 
CHAP.  VI.
Of the effects of the cold stage ef fever.
    THE cold stage of fever produces many ef-
fects on the system at large.   To speak first of
those that occur exteriorly, the arteries are con-
tracted.  Nor can this be attributed to any other
cause than the  action  of the  nerves  on them.
Hence the pulse becomes small and frequent. It
begins, for instance, some little time before the
cold fit, to be depressed and to beat more slowly.
Afterwards it becomes  more  frequent and irre-
gular, particularly in persons advanced in years.
In such subjects it is often  rendered  tremulous
and uneven.  In those  that are more youthful,
it is not usually either so much depressed or so
irregular ;  but  of these  things we  will treat
hereafter.

    From this contraction of the arteries arises a
paleness, which shows itself in the nails, the lips,
the countenance, and the other parts of the body
generally.  To this even a livid colour is often-
times superadded.   I once saw a woman whose 
31
nose, during the  cold  stage of fever, was suf-
fused with something of an azure cast. At times
the skin is checkered with spots of a brownish
and  bluish colour.  The blood having passed
fromthe arteries,  is collected and detained  in the
fine net-work formed by the incipient branches
of the veins.   This appears  from injections of
the blood-vessels, by which small specks  or pe-
techias are sometimes  formed.  But these phe-
nomena occur more  rarely in the cold  stage of
fever,  though  they  often  show themselves in
parts rendered livid  by the action  of  external
cold.  In this latter case, the blood  stagnating
in the incipient  venous branches,  assumes  a
blue or violet colour.

    But a contracted state of the parietes  of the
arteries is not of itself sufficient to produce a
stagnation of the blood.  These vessels, even
when thus contracted, may possess great energy.
The blood must, necessarily, therefore, be thrown
into them with difficulty, during the cold stage
of fever.  At this period that fluid  is collected
in the larger veins, and the vena cava in particu-
lar is overcharged and oppressed by it.   The
right auricle and ventricle of the heart  are both
turgid at the same time, and may, therefore, be
considered as in a kind of press formed by their
own contents.   Hence the contraction and dila-
tion of the ventricles are necessarily much con- 
                      32
fined.   From this source arises that convulsive
motion and palpitation of the heart, which some-
times occurs in the cold  stage of fever.  Finally,
to the same cause must we attribute that great
anxiety, and  occasional  syncope, experienced
by  some persons at the. commencement of a
paroxysm.

   But wherefore is the blood collected in the
cavities of the heart ? Observation  proves that
such a collection actually takes place.   As to
the cause, it appears that the blood, being forced
by the violence of the cold fit from the external,
is driven to the internal  parts of the body, and
is then by the various succussions or agitations
of the different parts directed towards the larger
veins.   But not being able to pass immediately
through the lungs, it must necessarily be collect-
ed in  considerable quantity in the pulmonary
artery,  as  well as in the right ventricle and au-
ricle of the heart.

   Several causes co-operate in producing a stag-
nation of blood in the lungs.  First, the texture
of the  viscus itself presents a constant barrier to
the blood,  as it issues from the  heart:  hence
that  fluid is necessarily accumulated in the pul-
monary vessels.  Secondly, the state of respira-
tion, during  the cold stage of fever,  contributes
to the same end.  The  acts of inspiration  are 
                      S3
  artial  and contracted:  but when the vesicles
 of the lungs are not properly expanded, the fluids
 cannot  find their way through them without dif-
 ficulty, and must, therefore, be unavoidably ac-
 cumulated  in their vessels.   It is not to be
 wondered at, then, if patients sometimes expire
 in the cold stage  of fever, and if,  after death,
 their lungs are found distended with dark and
 grumous blood.

    Nor ought it to appear more strange,  that,
 seeing the viscera  are thus turgid  with blood,
 the patients should suffer a burning heat within,
 while the external parts of their bodies are freez-
 ing with cold.  When the hands and feet are
 almost frozen in winter,  the armpits and groins
 generally retain the degree of heat that is natural
 to them.   But the same thing occurs in the cold
 stage of fever.   Indeed the surface of the body
 being chilled at the commencement of the pa-
 roxysm, the action of the viscera is  thereby
 rendered more intense, whence the heat in them
 is necessarily augmented.

   The degree of this internal heat may be dis-
 covered in  some measure from the intensity of
the thirst:  for thirst is most troublesome when
the viscera are raging with heat.  As in  such a
state the fauces are drier than usual, we may pre-
sume the same thing to be the case with respect
                      F 
                     34
to the surface of the aesophogus and stomach it-
self.  But  it is no less certain that thirst  is
sometimes  troublesome without any preternat-
ural increase  of heat.   It  is excited in such
cases  by acrid  aliment, and  by  that saburra
which accumulates at  times  in the.  prima via ;
thus bile accumulates in these passages, the na-
ture of which  is apt  to be greatly  vitiated in
febrile affections. I once saw a woman labouring
under a hepatic affection, who suffered great
thirst as often as the bile flowed in  large quanti-
ties into her stomach.

    That bile contributes to the production  of
thirst, is further confirmed by the nausea and
vomiting  to which patients are  subject, dur-
ing the cold  stage   of fever.  In  the  begin-
ning of paroxysms, in particular,  large quanti-
ties of bile, sometimes tough and at other times
more liquid, are discharged by vomiting : that
fluid is even observed at times to be foetid. But
although this cause  may  be a powerful one,
others  of no less moment may  be  combined
with it.  The  liver is affected,  as we have  al-
ready intimated: in  the region of the stomach
spasms arise, which are to  be  attributed to the
stagnation  of  blood  and the irritation  thence
arising. Nor  is it necessary for inverting the
motions of the prima via that the cause of in-
termitting  fever be present.   Pleurisy, nephri- 
35
tis, and affections of the uterus are accompanied
by vomiting.  The agitation of certain  nerves
is sufficient for inverting the action of the sto-
mach.

   This vomiting, or effort to vomit,  is mark-
ed with some variety.  It generally occurs at the
onset of fevers, and is violent and troublesome in
proportion to their  severity.   In vernal inter-
mittents it is less violent than in aut»mnal ones.
Even in the latter season it becomes milder after
a certain continuance of the disease.   It finally
disappears altogether, and leaves nothing behind
it  but the cold fit.   From this subverted mo-
tion  or  evacuation  of the  stomach,  no relief
whatever is  to be expected.   It  is evidently a
morbid affection ;  and notwithstanding the vast
quantities of offensive  saburra thus spontane-
ously discharged,  there always remains  a resi-
duum behind that ought to be thrown off by an
emetic.

    When by the force of the cold fit the action
of the  nerves is thrown on the  stomach, and
even the intestines themselves are constricted, it
is not surprizing that the fibres  of all parts of
the system should be velicated and suffer some
degree of violence.  Therefore it is, that on the
access or during the prevalence of the cold stage
of fever, various pains are so often felt through- 
                     36
out  the  whole body.   Sometimes the  joints
ache, and the limbs  are so painful,  that they
seem to be affected by rheumatism.   At  other
times again, the pain is situated in some inter-
nal part.  I have seen cases in which the intes-
tines themselves  were tortured with  pain.   In
general,  however, wandering pains and a kind
of painful pricking sensations are more frequent-
ly experienced throughout the whole or in cer-
tain  parts o§ the skin.

   But notwithstanding the  pains  excited at
times by the cold stage of fever,  yet  when that
affection is very severe, it  renders sensation
much less acute.  Under such  circumstances,
if a slight wround be inflicted,  no pain whatever
is experienced.   There have even been patients
who were not sensible of  the heat, when their
feet  were moved close to the fire.   For the same
reason purgatives do not act on the intestines if
exhibited during or just before the cold fit.  The
stamina or constituent fibres and  smaller vessels
of the parts are constricted by the action of the
cold ;  the  blood and vital principle cannot cir-
culate through  their usual channels; there is,
therefore, a deficiency of motion,  which is the
principle of sensation, or, at least,  that condi-
tion  without which all  things  languish  and
decay. 
37
    Hence  we see what disorders  may arise  in
the functions of all parts of the body.  The or-
gans of respiration are affected : the brain itself
is sometimes a sufferer :  the secretions are dis-
turbed : perspiration  is  obstructed:  the  urine
becomes coloured, is thin, watery, and in small
quantity :   as the renal tubes are constricted by
the action of the nerves,  none but the  more
fluid parts of the urine can pass off, for when the
motions in these  small  vessels are  necessarily
diminished, the grosser particles can neither be
separated from the others, nor pass off through
such narrow channels : whence they must either
remain in  their proper  strainers, or  be carried
elsewhere. 
CHAP.  VII.
Of the hot and sweating stages of fever.
    AFTER the cold fit has continued  for  a
time, it begins to abate, and is succeeded by a
degree of heat which spreads gradually through-
out the extreme  parts, and is  marked by con-
siderable variety.  It is more  intense,  for in-
stance, if the cold fit has been very severe.  The
thirst still continues, with dryness of the mouth
and skin, pains in the joints, and not unfrequent-
ly great disquietude, tossing, and anxiety.  The
whole body is  now  flushed,  particularly the
countenance,  the urine is of a  red or flame co-
lour, &x.

    To arrive at  some knowledge of the  cause
of this heat, let us attend to the circumstances
and mode of its  occurrence in certain  cases.
When a person  is immersed in a cold bath, he
generally experiences  soon afterwards a degree
of feverish heat.   When the hands, already stiff
with cold, are rubbed with snow, a heat and red-
ness  are excited in  them,  and a  vapour or 
39
smoke  arises, from them.   When any one ex-
poses himself for  a considerable time to a very
cold wind,  or a  freezing atmosphere,  his  face
begins  at length  to glow and be flushed.   The
same thing takes place,  accompanied  also with
pain, in every part of the body which has experi-
enced an intense degree of cold.


    Cold ought therefore to be considered as an
irritating cause:*  in  those parts long  exposed
to  its  action  a pungent  stimulus  remains,  and
the small  vessels  being  contracted in  their dia-
meters,  the fluids  are accumulated in them  and
made to stagnate.   In this state of things the  im-
pression of the cold either alone,  or assisted in
its action by  the  irritation of the serves, rouses

    * Be the essence of cold what it may ; whether it consist sim-
ply in the absence  of heat, or in the presence of an setherial fluid of
equal subtility with the matter of heat, it is unquestionably, as our
author pronounces it, an irritating cause.  In more fashionable me-
dical  language, it is certainly a stimulus.  This is a point as suscep-
tible of clear and satisfactory proof, as any one in the science of
physiology.  We must necessarily bestow the name of stimulus on
whatever  is capable of exciting in us motion or sensation.  But a
moment's reflection will convince us that cold is capable of producing
both.  A current of cold air produces a blush and a glow of heat on
the face, by exciting action in the cutaneous arteries of the part. If
a person be in a deep sleep, a lump of ice or a ball of snow applied
to his skin, will awake him as instantaneously as the application of
hot water, or even of a burning coal.  Innumerable other instances
of the stimulant power of cold might be adduced ; but it would be
equally improper and impracticable to dwell on the subject in the
limits of a note.  Besides, the above instances are deemed suffici-
ent for my present purpose.......Trans. 
                     40
the vital energy of the part: the blood being in-
cessantly urged forward with more violence than
usual, acts  forcibly on the vessels that oppose
its passage : but from this constant motion and
distraction of the fibres, an  increase  of heat
must necessarily  result.

    There is no doubt  but a similar cause oper-
ates in the case of intermitting fever. The blood
being  accumulated by the violence of the cold
fit,  stagnates in the cavities of the heart,  in the
lungs, and in the  mesenteric vessels.  The con-
stant  stimulus of this  volume of blood excites
the vital energy,  or the  action  of the nerves :
hence necessarily  follows an increase in the mo-
tion of the arteries, and  a corresponding in-
crease of heat.   In the mean time, the greater
the  contraction of the parts and the consequent
stagnation of the  fluids,  the greater  in general
will be the degree of heat.  Yet, at times, so
great  has been the extent of  this contraction,
that the vital power being oppressed and suffo-
cated, as it were,  has  been incapable of being
roused, and death has consequently ensued.

    But we  do not attribute so much to this
cause as to alledge that the hot stage is produced
by  it  alone.  There can  be no doubt whatever
but fever arises from other causes besides a cold
fit.   This is evident from those intermittents 
                      41
 which come on  without a previous chill, at
 least without a chill of any severity, and which
 are notwithstanding at times extremely violent.
 Besides,  in continued fevers, in pleurisy,  and
 other similar affections,  a cold  fit  generally in-
 troduces the  disease ; but afterwards there re-
 mains  an  irritating cause or inflammation, on
 which  the succeeding hot stage and the whole
 course of the  fever depends.   Lastly,  I have
 myself seen a periodical cold fit, which was not
 succeeded by any appearance of febrile heat.

    What seems to render it probable, that the
 hot stage ought to be attributed to the preced-
 ing cold one, is the effect of certain remedies.
 It is observed, for example, that by these reme-
 dies both the hot  and cold  stages of fever are
 prevented.   But if they have succeeded when
 taken before the commencement of the cold fit,
 who will venture to assert, that they did not ex-
 ert their influence alike on the proper cause both
of the cold fit, and of  the hot one ?   That  this
 is indeed the case, innumerable circumstances
 concur to prove, as we shall demonstrate when
 treating of the cure of fevers.

    The heat  of the body in intermitting fever
rises higher than might perhaps on the first view
of the subject be imagined.  It  even surpasses
the heat that usually occurs in some very acute
                      a 
                     40
fevers.  It sometimes rises as high as the 39°
of Reaumur.   Hence we see how great the heat
must be in those ardent fevers which oftentimes
partake of the nature of intermittents.  It will be
the more intense, for instance, in proportion as
there is a greater quantity of blood accumulated
in the vena porta, the region of the heart, and
the lungs.   It is in these  parts,  therefore, that
patients experience such a burning heat, for the
same reason that, in other diseases, other parts
suffer a similar heat, as the head,  for example,
in phrenitis, and  the fauces in argina inflam-
matoria.

    Sweat is a phenomenon of febrile heat.  As
it flows, for the most part, copiously, when the
body is agitated by violent exercise,  so it also
issues  in abundance, when the action  of the ar-
teries is somewhat increased.   If,  however, the
fever and heat be very violent, the pores of the
skin are not opened, but, on the other hand, the
texture of all parts of the body is constricted, or
thrown into a state of spasm.  Under these cir-
cumstances a burning heat and dryness prevail
over the whole body, and must be expected to
continue till the fever abate : then the  cutaneous
fibres and  excretories being relaxed, the per-
spiration breaks forth on every side, and is pro-
moted by the degree of fever that remains, the 
43
relaxation of the surface of the body, and the
fulness of the cutaneous vessels.

    The reality of these causes of the flowing of
the sweat is obvious and well established.  That
there is a relaxation induced, towards the close
of the fever, cannot be doubted. By the febrile
impulse the fibres are overstretched and weaken-
ed, for we know that flesh is rendered more ten-
der and soft by heat and motion.   The fluids,
therefore,  can  pass more  easily through the
pores,  and that the more especially, as the cuta-
neous vessels  are kept distended by the force of
the circulation being greater than natural.  The
flowing of the  matter of perspiration through the
pores of the  skin, is  much facilitated  by the
change  that occurs in the  crasis of  the blood.
It is evident that that fluid  is in some measure
dissolved in those persons  who have suffered an
attack  of fever :  for such subjects become pale,
and, as it were,  bloodless, and are yet subject
at times to hemorrhages:  they even fall occasion-
ally into  a scorbutic diathesis in consequence of
the vitiation of the blood.

    Hence it appears that great variety may oc-
cur with respect to the sweating stage of fever.
In some patients, for instance,  the sweat begins
to flow  at the  very commencement of the hot
stage :  in others it is more tardy, not appearing 
                     44
till a little after the body has become hot; while
in others again it breaks out'at a still later period:
it continues also to flow for a longer  or shorter
time, and is sometimes profuse and  at other
times in smaller quantity.  These circumstances
are necessarily varied  according to the cause of
the disease, the affections of the viscera, the va-
rieties that occur in the hot and cold stages, and
the temperament  of  the  patient.  Hence  the
perspiration  is at  times unusually copious.   I
once saw a person labouring under intermitting
fever, who experienced such a deluge of sweat
six times a day, that  he was forced to change
his linen twice or three times every hour.

   As the action of the hot stage on the organs
of perspiration is various,  the same thing is true
with regard to the other organs of secretion ;
hence the urine assumes a red colour.  This
fluid is  thin during the prevalence of the cold
stage;  for, during that period, all the secreting
tubes being constricted or affected by  a spasm,
and the motion of the  fluids being languid, none
but the  finer particles can pass through the se-
cretory vessels of the kidneys, while the grosser
ones remain  mixed with the  other humours.
But as the febrile action increases, the urine ac-
quires a flame  colour; this colour  arises  from
bilious and oily particles being mixed and incor-
porated as it were with each other, and is mark- 
                     45
ed with some variety of appearance ;  that is, it
is sometimes deeper and sometimes  lighter.
The  colour of the urine is rendered deeper by
profuse sweating, because, in such a case, the
more subtile and  limpid  fluids pass off by the
pores of the skin, whence the urine is necessarily
robbed of them, and its redness  becomes con-
sequently more concentrated and more deep.
Thus, when any one has used severe exercise
and perspired plentifully,  the  urine  which he
discharges is hot and in small quantity, but is at
the same time frothy and has its surface covered
with a thin pellicle :  in this case, when the force
of the paroxysm has abated, a two-fold sediment
is deposited, namely,  a lateritious one, and a
smooth white one.  The first of these, of which
we  will  treat elsewhere,  is  a symptom of dis-
ease, but the other a sign  of  solution  or return-
ing health.  Respecting  these sediments the
ancients  have written much, but I  would not
vouch for the authenticity of their observations
and opinions.  By modern writers the subject
appears to have been too much neglected.

   At the very commencement of intermittents,
Galen was in the habit of predicting their termi-
nation from the appearances of the urine.   Ac-
cording to him, the solution is to be looked for
after the fourth paroxysm, if  the urine be red or
yellowish, and emit a smell;  after the seventh, 
                     46
if the urine be only red, and after the third, if on
the first  day of  the  disease a smooth and even
sediment be deposited.   This subsidence is in-
deed  of  great moment,  particularly in quartan
fevers, but,  as we will elsewhere demonstrate, is
subject to great  variety. 
CHAP.  VIII.
Of the state of Apyrexy, or freedom from fever,
       •which succeeds each paroxysm.
    AFTER the sweating stage an apyrexy or
freedom from fever succeeds, and all things seem
to be restored to their natural state.   But the
course or progress of this period during which
fever lies dormant is various,  and many things
occur in it  worthy of notice.   As far as our
senses are  capable of investigating the subject,
the intervals might indeed be considered as per-
fectly exempt from disease (for they are scarce-
ly marked by the shadow  of a complaint:) but
it is hardly possible that so very rapid a transi-
tion could  be made from health to disease, and
from disease to health.  Hence Galen expresses
some doubts respecting a state of perfect apy-
rexy.   He could not be induced to believe, that
the intermediate days  were perfectly free from
fever.

    With many persons the nights preceding the
paroxysms are restless and uneasy, and, if the 
                      48
 matter be carefully examined, it is evident that
 some slight symptoms of disease remain during
 the days of intermission :  at least it may be laid
 down as an  established  point, that it is during
 the middle portion only of the intervals between
 the paroxysms, that the system can be free from
 all preternatural action.   Even  during that pe-
 riod the tranquillity and health of the system can-
 not be complete, because the fomes of  the dis-
 ease still remains, and must, from one  paroxysm
 till another, act the part of a preternatural stimu-
 lus.   Besides, health cannot be considered as
 sound, while  disease still remains pictured in
 the countenance, while the urine and faeces put
 on  unnatural appearances, and while the appe-
 tite is for the most part defective, and  the di-
 gestion imperfect.

   As the stated hour  of  the  paroxysms ap-
proaches, a  commotion  or disordered action
 more or less perceptible is necessarily  excited in
the  system.   The access  of these paroxysms
 generally falls on the same hour of the  day.  Not
 unfrequently, however, their order is  interrupt-
ed.   They sometimes anticipate, for example,
the  usual time of  their invasion, so as to occur
 before it, sometimes by very short and  at other
 times by longer  spaces.   This is an evidence
 that the disease is acquiring strength, and hasten-
 ing on to a continued form. But if, on the other 
                      49
 hand, the fever makes its attack at a later hour,
 this is a proof that it is losing strength.   Each
 postponing  paroxysm  is  milder and  shorter,
 whence  a  hope may be derived that the disease
 is inclining to a speedy and  favourable termi-
 nation.

    But  there  are other circumstances besides
 the time of their invasion or commencement, in
 which the paroxysms differ from each other in
 different fevers.  The intervals  between them,
 for instance,  are  sometimes  longer and some-
 times shorter.   Hence tertians are divided into
 two kinds, the legitimate or true, and the bastard
 or spurious.   The paroxysms of the legitimate
 kind  are said to last  twelve hours, but those of
 the spurious somewhere about eighteen.  As to
 the first, namely, the legitimate or common ter-
 tian,  its paroxysms are scarcely  ever observed
 to continue  so long as  twelve  hours, at least
 such  a thing has not occurred to me during a
practice of forty years  continuance.  We learn
from  daily experience, that the  paroxysms  are
limited to five, six, seven, or eight hours.  From
this rule, however, we must sometimes except
the first few fits of the disease, which, in certain
constitutions, are protracted occasionally to a
greater length.
H 
                     50
    It is supposed that the course of the pa-
roxysms has many things in common with con-
tinued fevers.  Some are of opinion, for instance,
that,  as  certain continued fevers terminate in
seven days, so a tertian fever is to be limited to
seven rounds or paroxysms. But it ought to be
remarked, that a continued fever rages both day
and night for the space of seven days, whereas,
an intermittent continues only from five to eight
hours out of twenty-four.  Besides, there  are
some continued fevers, which terminate on the
eleventh, fourteenth, or twenty-first day ; on what
principle, then, can these be referred to any de-
scription of intermitting fever? can they be refer-
red, for instance, to the quartan which is of longer
duration than the tertian ? Let us suppose that the
termination  of this disease falls on the sixtieth
day, a position which is altogether doubtful :
there will occur during this  period fifteen ac-
cessions or fits, each one of six or eight hours
duration : but, on the other hand, the continued
fevers run on throughout the whole of the four-
teen or twenty days without any intermission.

    If there be any point of similitude between
intermittents and  continued fevers, it lies  ex-
clusively in the circumstance of their remission
or  abatement.   They  both,  for instance,  are
marked by exacerbations and remissions occur- 
51
ring at stated times.  But the fever is perma-
nent, and even its remission extremely short,
and at times scarcely perceptible;  while, on the
other hand, the intermittent ceases or appears to
cease entirely  for  one or two days.  But there
can be no real affinity between fevers that con-
tinue without intermission for a  long space  of
time, and those  which alternately appear and
disappear at stated times. 
CHAP.  IX.
Of the cause of the disappearance and recurrence of
             the fever at stated periods.*
     WHENCE  is  this  alternate disappearance
and regular return of the fever at stated periods ?
If indeed it  be practicable to fathom this subject

     * The physician who undertakes to account for the periodical
 recurrence and termination of the paroxysms of an intermittent, may
 be  truly said to " attempt the bow of Ulyssis"  As there are few
 subjects more curious and interesting, so there are none more dif-
 ficult, in the science of medicine.   Although our author fails entire-
 ly in his attempt to explain it, I am unable to direct the reader to
 any writer who has been more successful.  The matter is as much
 an  arcanum natures now, as it was in the days of the father of physic.
 Nor does it seem at all probable that the thick veil which has hitherto
 concealed  it will be shortly removed.  This veil is of too strong a
 texture, and is too  firmly secured in its place, to yield to the lili-
 putian efforts of hypothesis.  It resists with equal ease  the torpor,
 and the accumulated excitability of Darwin, and the debility, spasm
 and consequent re-action of Cullen.  Although the rapidly progres-
 sive state ot physical science convinces me that it will yet be removed,
 I am equally confident that its removal must be reserved for a much
 more enlightened period  than the present.  Without the least ex-
 pectation of shedding any additional light on the subject, I will sub-
 mit to the reader the following remarks.

     Intermitting fever arises from a local affection, produced by an
 aeriform poison which gains admission by the mouth.  This affec- 
53
at  all,  the  solution  of  the  question must  be
sought for in  the  phenomena  and  analogies of
the febrile cause, and in the alternate movements
or  states of action of various parts of the body,
and of various affections.  We must first, there-
fore, enquire into the varied march or progress
of the  febrile cause....Why it breaks out or ma-
nifests itself at one time and lies dormant at ano-
ther,  a  subject  in   itself both  intricate  and
obscure.


     Of the nature of  this  cause we are  entirely
ignorant:  this only  we know,  that it possesses


tion has  its seat in some part of the  prima via, most probably the
stomach. After it has existed for a certain length of time, it brings
the whole system into sympathy, thereby producing a paroxysm of
fever.  But to explain why this paroxysm terminates within a given
time, and returns again at a  stated period, " hie labor, hoc opus est."
When we have arrived at this point,  we may be truly said to have
reached the " ultima thule" of the present state of pathology.

     In the mean time, I have little doubt but the regular returns of
the paroxysms of an intermittent at the same hour of the day, are in-
timately connected with solar influence. The disposition  of the sub-
jects, when cured, to relapse at weekly periods, bespeaks also the
subjection of this disease to lunar influence. It appears highly pro-
bable, then, that the two great heavenly luminaries, the regents of
the day and of the night, which exercise such an extensive and well
known agency over the ocean, the atmosphere, and the vegetable
kingdom, will be yet found to act a very important if not  a principal
part, in producing the periodical recurrences and other phenomena
of intermitting fever.  It must be recollected that the human system
when debilitated by disease,  is very  readily and greatly affected by
causes, which make no sensible impression on it when in a state
of health.....Trans. 
                     54
 a power of stimulating and inflaming, or, at least,
 exciting heat; that it  attacks and greatly op-
 presses the vital principle, until being itself at
 length  subdued by the increased motion  and
 heat which it excites, it seems to act as a remedy
 against itself.   Here  the circumstances  and
 mode of action are somewhat similar to those
 that occur in a case of surfeit,  where the sto-
 mach  is oppressed by a super-abundance  of
 food, and where a fever which isforthwithexcited
 by this oppression, subdues, concocts and throws
 off from the system all hurtful matters that had
 been mixed with the blood.  But the fever ex-
 cited  by a surfeit differs  from an intermitting
 fever in this, that the former  perfectly  cures it-
 self, and does not recur again, unless re-produced
 by a fresh error in diet.

    The seeds of intermitting fever still remain
 in the  system after the  paroxysms, and, there-
 fore, when at stated times they break out and
 show themselves in fresh paroxysms, this must
 arise either from their power increasing and dif-
 fusing  Jtself like a ferment in every direction,
 or from a collection and concentration  in some
 one part, of that  which  was before  dispersed
 throughout  the  body.   But  if these  seeds  of
fever exert their powers in consequence of their
energies being  increased or concentrated, how
 is it that they remain or appear to remain wholly 
55
 inactive during the time  they are acquiring
 strength by such increase or concentration ?  In
 this respect,  the power of the febrile cause to
 excite  inflammation  or heat resembles the in-
 flammable property of gun-powder, which, when
 left to itself is altogether inert,  but explodes as
 soon as it is brought into contact with fire.

    When,  therefore, the seeds of intermitting
 fever lie dead as it were during the days of inter-
 mission, they want a cause to excite them to ac-
 tion.   But to determine what this cause is, is a
 point  of no small difficulty.  Many things in-
 deed seem suited to excite the fever;  but these
 cannot be subjected or made subservient to any
 particular type.  It follows,  therefore, that, at
 stated periods, the febrile cause must break out
 of itself; and these periods  are separated from
 each other by longer or shorter intervals, accord-
 ing as the cause derives strength from extrane-
 ous and surrounding  circumstances.

   But what seems truly surprising is, that the
 febrile cause, while still lurking in the system,
 may  be prevented from  exciting  real fever,
 though not from producing other morbid affec-
tions.   By the exhibition of certain remedies,
for instance,  the paroxysms  may be completely
suppressed, and yet the whole system continues
to be disordered.  Thus, there are sick persons 
in whom the suspension of fever is succeeded
by a sense of  general heaviness and debility, a
swelling of the abdomen, and a loss of appetite,
symptoms not to  have  been expected, had the
paroxysms continued.  Sometimes the patient
is relieved from all these complaints by a renewal
of the paroxysms, so that his cure seems to arise
from a return of the febrile affection.

   At other times, what is still more surprising,
after all the symptoms have disappeared, the fe-
brile fomes still remains behind perfectly harm-
less.  It acquires strength  in secret, or rather
lies hid like embers concealed by ashes.  In this
state of things, if any error in diet be committed,
if the body be exposed to cold  or humidity, or
if the functions  be deranged in any other way,
then the fever, which had lain dormant for  a
month or longer, returns and rages with as much
violence as at first.

   Nor can the disease be said to originate from
these causes :  for there is nothing in them cal-
culated to produce intermitting fever rather than
any other affection.  The original disease is re-
newed, therefore, only because no  other form of
fever can  then occur.  If the original complaint
was  a tertian or quartan, that which breaks out
afresh, as here stated, assumes the very  same
type.  The same cause, therefore, still remains, 
                      57
without having sustained the slightest change in
its nature.

   This same constancy or immutability is ob-
served to exist even in cases of re-duplication.
When these happen in a tertian, the disease be-
comes a double tertian ; and when in a quartan,
a double  quartan  is the result: the paroxysms
still pursue the same  order, and correspond to
each other every third or fourth day.  Even in
cases of  anticipation, intermittents not unfre-
quently preserve a certain order ; thus, at times,
the paroxysms precede  the stated hour of acces-
sion every7 day by an  equal period.*  Lastly,
in their decline and disappearance, these fevers
do not depart from this  order.  In a double ter-
tian, for instance, one of the diseases sometimes
terminates, while the  other still remains with all
its usual  characters.   The same thing is observ-
ed in double and  even triple quartans.

    It must not, however, be supposed that the
nature and form  of fevers  are so uniform and
immutable as not to admit of a  tertian  being
changed  into  a  quartan,  or  (a  circumstance
which more rarely occurs) a quartan into  a ter-

  * This is a point of which the practitioner should never lose sight,
 as it is calculated to serve him  very materially in his attempts to
 break the course of an irregular disease....1 Vans.
I 
                    58
tian or a quotidian.  Hence it appears, that each
of these forms of fever arises from nearly  the
same  cause, or,  at  least, that they are closely
allied  to each other.   But the tertian is apt to
be the most irregular; it oftentimes undergoes
such changes, that it retains  nothing of its pri-
mary  type, and can therefore scarcely be distin-
guished.   Perhaps the most remarkable of these
changes is, when it assumes the form of a hectic
fever, and clothes itself in symptoms totally dif-
ferent from those that are common to it.

   Intermittents when somewhat on the decline
are extinguished at times by a single blow as it
were, nor can we discover how the causes that
thus destroy them possess such an influence over
them.  They  are removed by great and sudden
emotions of the mind or body, as terror, for in-
stance, has been known  to cure a quartan ague.
The same thing has  been effected by anger, in-
tense heat,  violent  exercise, and great com-
motion  of the internal  parts of the  system.
But, what is less to be wondered at, these same
causes are  capable of rousing into action  the
hidden and dormant fomes  of intermittents.
Thus the  mere appearance of  an unusual object,
the sight of a dormouse, for instance, has been
sometimes known to renew the disease with the
utmost violence. 
59
    What is perhaps more singular still, inter-
mittents  are  removed by various remedies,
which are even sometimes opposite to each other.
Whatever  these remedies may be, the diseases
are cured by them on nearly the same principle
on which poisons are counteracted by their anti-
dotes. At other times the febrile poison leaves
the system spontaneously, as it were, without
any previous commotion whatever.   But, what
is more  to our present purpose, after the fever
itself has ceased, certain vestiges of it frequently
remain behind. Thus there are morbid affections
which show  themselves  about the same time
of day at which the paroxysms usually occured.
These affections consist in a heaviness or pain in
the head or body, or in a certain disagreeable
sensation which affects the whole system.  If
certain authors are to be credited, an intermitting
fever, when it recurs even after a long suspen-
sion, or interval of health, usually attacks the
patient at the same time or about the same hour
of the day, at which its paroxysms had formerly
occurred. 
CHAP.  X.
Whether or not any thing occurs in other morbid ejec-
  tions, or in the action of the various parts of the
  body, to enable us  to discover the cause of febrile
  periods.
    LET us how return to the question formerly
proposed,  namely, whether or not  any thing
arises out of the foregoing considerations,  that
can enable us to explain why the cause of inter-
mittents acts and lies dormant in the system al-
ternately? Here it  must be  acknwledged,  that
the preceding history of the phenomena of inter-
mittents, instead of illustrating the matter, tends
to render the laws and principles by which this
cause is governed, more uncertain and intricate.
Let us see,  therefore,  whether or not any thing
can be deduced  from other affections calculated
to shed light on  this obscure subject.  In these,
many things occur which may be well applied to
intermitting fever:  even  in those  affections
which are dissimilar to each other, certain phe-
nomena  take place, from which  we may dis-
cover, or at least form some idea respecting, 
                       61
 the causes of alternate motions or states of ac-
 tion in the system.

     Some writers,  in  their enquiries after the
 cause of febrile periods, have considered the dif-
 ferent parts of the bodies of animals so construct-
 ed  and  disposed,  as  to be capable  of  being
 brought  into  subjection  to certain  arbitrary
 laws;  thus,  for  instance,  any person  may, at
 pleasure, say they,  so regulate the alvine evacu-
 ations, as to  make  them occur at a stated time ;
 the appetite for food may  be so regulated as to
 be felt only at certain hours; sleep may also be
 circumscribed  within given limits,  for we  can
 accustom ourselves to awake  regularly at  the
 same hour in the  morning:  But what are we to
 conclude from hence ?  Surely it cannot be said
 that in intermitting fever the different parts  of the
 system become by habit accustomed to alternate
 rest and motion ;  because from the very begin-
 ning of the disease, they assume that  state  of
 action which they are to continue till  its close.

    There are certain motions or states of action
 both natural and preternatural,  which approach
 nearer to  the movements' of intermitting fever.
 The  catamenia,  for instance,  appear only at
stated times;  the  same thing happens not un-
frequently in  hemorrhoidal  affections.   In both
these cases  we can  attribute the phenomena to 
                      62
no other cause, than the volume of blood, which,
increasing for a time, makes its way at length
through the outlets of the uterus, or through the
patulous  mouths  of the  hemorrhoidal vessels.
To a similar cauce may we attribute the efflux
of bile, saliva, perspirable matter, and sweat,
which sometimes observes stated periods.  The
same thing may be said  respecting the urine,
which, at times,  is discharged more copiously
than usual, at stated periods.

   Somewhat similar  is the disposition of cer-
tain tumors, which are accustomed to pour forth
periodically, a quantity of blood.  These tumors,
when carefully examined, exhibit veins  changed
by a  great   dilatation into large canals:  the
blood being poured from  the arterial capillaries
into  these canals,  increases  to  a considerable
volume, and  at stated times bursts the  barriers
opposed to it, and escapes.  I have seen occasi-
onally another example in various tumors when
cut through the middle :  from these, a periodi-
cal hemorrhagy has taken place, on account of a
collection of blood in some cavity.

   There are other periodical affections which
cannot be deduced from the same cause: such
are different  forms of hemicrania, and pains
sometimes extremely  acute, which appear and
disappear alternately, and as it were in a certain 
63
routine or regular order.  There are many other
movements or states of action that occur in the
animal machine, which may be likened in some
measure to  the ebbing and flowing of the sea.
Even continued fevers themselves are marked by
remissions and exacerbations.  They are gene-
rally worse at night and better in the morning.

    But from what cause can these things be de-
duced with more probability, than from some
kind of matter, the quantity of which is increas-
ed or diminished,  or else  which becomes alter-
nately more acrid and more mild in its qualities ?
May not an argument  in  favour of this opinion
be drawn from continued fevers that terminate
by  an imperfect crisis ?   A  large quantity of
morbific matter is expelled, and  therefore tran-
quillity is restored to the system for some time :
but the morbific matter still remaining behind,'is
collected  afresh,  and  recovers  strength, and
hence a relapse is apt to occur.

    Something similar  appears in gout and epi-
lepsy.  In gout,  in particular, there can be no
doubt but there  is present a  certain  morbific
matter which gives  rise  to  the  disease: for a
long time this matter circulates through the sys-
tem without producing either commotion or in-
jury : it is collected or accumulated, at last, in
certain places fit for its reception :  but when i 
                     64
has become thus collected, and is by any means
set in motion, an attack of gout is the immedi-
ate consequence.

    As to epilepsy,  that disease also  appears at
times to  originate from a collection of morbid
matter.   When,  for instance,  it arises from a
particular spot that has been bruised or wound-
ed, does there  not appear  to be  in that spot a
certain collection of particles by which the nerves
are at length irritated and roused to morbid ac-
tion ? and is not  this much more evidently the
case when the cause  of the disease consists in a
retropulsion of miasmata ? for if the pores of the
skin remain open and these miasmata be expelled
through them, the disease is brought to a termi-
nation, and  a collection of the miasmata thus
prevented.

    These remarks are  applicable, at least in
part,  to intermitting fever, in as much as there
are many circumstances which are common to it
and the  diseases just mentioned.   Thus the
cause of gout, like that of intermitting fever, can
lie dormant for  a given space of time;  it  is
sometimes roused suddenly into action,  either
spontaneously  as it  were, by  passions of the
mind, or by errors in diet;  it produces at times
a fever not unlike intermitting  fever ; it may be
repelled into various parts of the body, and there 
                       65
  give rise to various diseased affections;  it is at
  length subdued or rendered inactive by pain and
  length  of time;  besides all  these  points  of
  likeness  between intermitting fever  and gout,
  when the  accumulated matter of the  latter dis-
  ease is dissipated and ceases to act,  the fomes
  still remains behind in the system, perhaps un-
  changed, and towards autumn, but oftenerin the
  spring, comes again into action and produces the
 complaint anew.

    Notwithstanding  the dissimilitude of epi-
 lepsy and intermitting fever,  these diseases ex-
 hibit certain  characteristics which are common
 to both.   Epilepsy  is sudden and unexpected
 in its  attack ; it  irritates the nerves and draws
 them into  consent or  sympathetic and synchro-
 nous action;  it is sometimes regularly  perio-
 dical ; it is excited by passions of the  mind and
 errors in diet, and its cause is subdued or ex-
 pelled,  by  internal  and  external motions  or
 states  of  action;  still, however, there remains
 behind a fomes by which similar attacks may be
 afterwards produced.

   An  attack of hysteria bears also some  de-
gree of resemblance  to an attack of intermitting
fever.   That  affection arises from a tumes-
cence of the uterus, and is sometimes sudden
K 
                     66
in its occurence, like  epilepsy, from which it
does  not greatly differ ;  it  disorders the  sto-
mach,  produces coldness,  and excites other
troublesome commotions in the system.   In
this  case the nerves are irritated and continue
under this  irritation till the  menstrual evacua-
tion  takes place, and the congestion  of blood is
removed.

   If, then, it be allowable to indulge a conjec-
ture  on the subject, it  would  appear from  the
the foregoing considerations,  first,  That there
exists in intermitting fever a certain noxious or
morbific matter generated within the body or in-
troduced from without, capable, as we have al-
ready said, of being diffused throughout   the
whole system.   Secondly,   That this  matter
is particularly hurtful to the liver,  that it is
accumulated in, and exerts  its action on  that
viscus.   Thirdly, That  after  this  matter   has
attained to  a  certain  state of accumulation,
and  acquired a certain degree of power, it ir-
ritates the texture and nerves of the liver,  like
a foreign stimulus, retards the progress of  the
blood, and renders that fluid  acrimonious  and
vitiated  in  its qualities.   Fourthly,  That  this
matter by  its powerful action on  the nerves
throws the whole body into commotion, and is
at length,  by the fever that  ensues, expelled 
67
and dissipated as it were both from the place
primarily affected, and from  every  other part
of  the  system.   Fifthly,  and  lastly,  That  a
fomes  still remains behind,  which,  gaining
strength by degrees, may produce a recurrence
of the same commotions. 
CHAP.  XL
Of the diversified action of the febrile cause.
   BUT whatever conclusions mayr be formed
relative  to  the preceding points of discussion,
it at least appears obvious  what a great variety
may occur in fevers, or what various appear-
ances these diseases  may assume. The febrile
poison may put on  forms altogether different
from each other.   So greatly at times do the fe-
vers which  it induces appear  to differ from one
another, that some writers have considered them
as belonging to different species :  yet the ac-
tual difference  between them is  not so great :
diseases arising from the same source may pur-
sue  dissimilar  courses, or be accompanied by
different symptoms.

    Some authors contend that they can prove by
many arguments,  that vernal and autumnal in-
termittents are  not of the  same kind.  Vernal 
                     69
 intermittents, say they, are of salutary effect; they
 require little or no medical aid ;  they usually ter-
 minate with the seventh paroxysm ; they are not
 accompanied  by  malignant symptoms;  they
 are not characterized by such a degree of nausea,
 vomiting, and burning heat; the urine in them
 is not so high coloured, nor does it deposit such
 a  lateritious  sediment;  the sweats attending
 them being less copious, the strength of the pa-
 tients  is not so much exhausted; vernal  inter-
 mittents do not  commence as quartans, nor do
 the tertians assume  that form ;  finally,  autum-
 nal intermittents are eradicated by  vernal ones,
 and vernal ones  by those of autumn.

    But arguments of this kind are altogether in-
 conclusive.   What  proves  at  once that  these
 diseases  are  in  reality of the same nature, is,
 that during the course  of  the same  epidemic
 prevalence,  they do not differ from each  other
 in  appearance.  If,  for instance,  an epidemic
 intermittent occur in the spring, it abates or en-
 tirely disappears in  the course of the summer,
 but, on  the approach of autumn, oftentimes
 breaks out again, is attended with the very same
 symptoms, and assumes the  same character.

    Nor,  indeed, are vernal and autumnal inter-
mittents  more dissimilar to each  other,  even
when they are not epidemic.  Both  their symp- 
                      70
 toms  and their  type are precisely  the same.
 Their only difference consists in this, that the
 vernal intermittents happen at a time best cal-
 culated to effect their solution or cure.  At
 that season our bodies are renovated as it were,
 perspiration  is free and active,  and hence it is
 that those autumnal intermittents which run on
 till spring usually terminate then.

    It appears then that there is only more or less
difference in the effects of the febrile poison, its
 nature being always the same.  The most strik-
 ing difference in  its effects is that which forms
the different  types  of disease, such as tertians,
quartans, &c.  These  affections, however dif-
ferent  from  each other in appearance, are the
same in  their nature, for they are sometimes
changed  into each  other.  Every experienced
practitioner  must have seen  tertians changed
 into quartans, and  quartans into  tertians : be-
sides, the same symptoms are common to both
forms of the disease :  in both, the cold, the hot,
and  the  sweating stages succeed each other in
the same order :  if any difference  whatever oc-
cur in  the causes  of these affections, it consits in
their being more or  less powerful:  but how it
happens that  the poison comes  into action and
excites disease every third or every fourth day,
is a question  that cannot be determined. 
                      71
    There are notwithstanding, in  the opinion
 of many persons,  certain points in which ter-
 tians and quartans differ from  each other.   If
 we may give credit to certain writers, it is even
 practicable to  foresee from its very  commence-
 ment what type the disease will assume.   Ter-
 tians,  for  instance, are marked by a shivering
 and a great coldness, but quartans most frequent-
 ly  by a chilliness or  shivering alone: if a real
 coldness does  occur in quartans, it  is not pun-
 gent  and pricking, but a more dull sensation,
 as if the  bones were  bruised; the cold stage is
 also, for the most part, of longer duration, par-
 ticularly in persons advanced in years, to whom,
 as we have already remarked, it proves some-
 what dangerous.

    If we can give credit to certain observations
 that have been  made, the pulse exhibits a differ-
 ence no less striking in these two forms of dis-
 ease.   Thus, at the accession of tertian's  it is
 said not to be much slower than natural, but is
 considerably more  so  at the commencement of
 quartans.   In  the latter form of disease, as in
 old age, it is slow and hard;  in  many cases tre-
mulous, obscure, and very unequal; after hav-
ing been quick, frequent and small,  the pulsa-
tions  oftentimes   become  stronger, and  are
marked by considerable intermissions. In con- 
72
firmation of what we have here advanced, Galen
has remarked, that the  pulse  seemed confined,
almost as  much as  in  the  case  of an ossified
artery.

    The hot stage in quartans is not so intense
and burning as in tertians.   The flowing of the
sweat is in some cases  less and in others more
profuse.   The urine also assumes different ap-
pearances in different cases: according to Galen,
it  is crude and pale in the beginning, but be-
comes higher coloured  as the disease advances:
it then deposits a kind of settling which is white,
not red or  lateritious.   Some physicians, how-
ever,  have  witnessed phenomena altogether dif-
ferent  from these.  They have  seen the urine
saturated or turbid at the commencement of the
paroxysm, and afterwards depositing a laudable
sediment.  On the days  of intermission they
have observed that fluid to be more thin and lim-
pid ; but, what is of greater moment, it became
turbid and black previously to the solution and
termination of the disease.

    There is no doubt,  indeed, but these pheno-
mena have been observed ;  but  they must not
be considered  as constant and uniform.  As  far
as my experience  and  observation have gone,
the difference  between tertians  and quartans 
                       73
 is in general not so great.  The appetite is in-
 deed,  for the most  part, stronger and better in
 quartans than in tertians ; the cold fit also  lasts
 longer;  but the shivering  and agitation of the
 limbs are not so great; the pulse is more de-
 pressed and unequal;  the febrile heat is  less in-
 tense; the  paroxysms are  shorter ; the sweats
 are more protracted, but less profuse, and occur
 not  unfrequently at night  even during  the pe-
 riods of  intermission  ; the urine  is of a lighter
 colour, and if  the  intermission  happen to be
 longer than usual,  becomes oftentimes  thinner
 and  more limpid during the continuance of it;
 not unfrequently however, it is observed  to con-
 tain  a lateritious sediment.

   A greater difference exists between tertians
 and  quartans with respect to their course, solu-
 tion, and cure.  Quartans  are of the  longest
 duration, running on for a year and sometimes
 longer.   When  they   continue  for  a  greater
 length of time,  they are cured with more diffi-
 culty.  They are said to have oftentimes  yielded
 to the hemorrhoidal flux.  But on these  several
 points  enough and even more than enough has
 been already  advanced.  We  will intentionally
 pass over other circumstances which ancient
writers  mention as peculiar  to  these  ttvers,
but  which,  though  they may  be  true, are  not 
74
perfectly conformable to  our own experience.
It is of most consequence to have a thorough
knowledge of those circumstances  that are most
frequently met with  in  practice ;  the more
rare occurrences are not so much the  objects
of art. 
CHAP. XII.
Of febrile affections which, though different from in-
   termittents, assume their external appearance.
    INTERMITTING fevers, the course and
nature of which we have endeavoured to define,
are, in general, very easily distinguished from
other diseases.  But we meet occasionally with
certain febrile affections, which,  though altoge-
ther different from intermittents, assume not-
withstanding their external appearance and cha-
racter,  and fallaciously seem to be of the same
species.   Febrile affections of this description
are numerous, and arise  from various causes.
It becomes an object of consequence,  therefore,
to  point out  the mode of distinguishing them
from genuine intermittents.

    In certain  catarrhal affections, the fever lies
dormant or intermits during the day, and comes
on at the approach of night, being preceded by
a chilly fit.  After  various pleuritic affections,
when the  patients  have   been  tolerably well 
                     76
throughout the day, paroxysms occur towards
evening,  which give us  cause  to suspect the
existence of an  abscess or some other  relic  of
the disease.   In those fevers to  which lying-in
women are subject, something like an intermis-
sion takes place. Even in continued fevers, the
system is oftentimes in some measure cool and
tranquil in the morning, but  night brings along
with it a  paroxysm sometimes of greater and at
other times of less severity,  and which for the
most part is not preceded by  a cold fit.  These
fevers disappear  in general by degrees, and that
without  the assistance of febrifuge  medicines.
Finally, hysterical affections are marked at times
by an appearance of febrile paroxysms : towards
night the pulse  oftentimes rises, and an inex-
perienced practitioner  would consider  the pa-
tient as affected by a true fever :   but in a short
time this commotion of  the  arteries ceases  or
abates, nor do these sudden glows of heat con-
tinue as  long as real febrile paroxysms.

    Again, there are other affections truly febrile,
which physicians call quotidians, because they
are plainly marked by daily  recurrences or pa-
roxysms :  they  come on particularly  in  the
afternoon or towards  evening:  they are fre-
quently ushered in by a little  chilliness or a very
slight  shivering:  sometimes,  however,  these
symptoms are entirely wanting, and then  the 
                     77
heat is neither intense nor dry and burning, but
moist, moderate, and unequally diffused.  The
pulse is small,  or  at least but little elevated,
varying, however,  in  this respect, in different
cases.   The paroxysms  are  sometimes longer
and sometimes shorter,  they  do not go off by a
plentiful sweat, nor do they in general terminate
in a complete  apyrexy :  some vestige cf  fehri-
cula still remains. The urine is not lateritious,
but thin and transparent in the beginning, and
oftentimes continues so  throughout the whole
course of the disease :  at other times, however,
as the  disease advances it becomes  thick and
turbid.

    These febrile affections,  which are so very
frequent,  are observed to occur in those persons
who labour under some obstruction, particular-
ly of parts  situated in the abdomen.   They at-
tack, for instance, such subjects as have diseases
of the  liver or  stomach, and  also such as are
worn down by long watching, passions,  or la-
borious  exercises whether of body  or mind.
Fevers of this description occur also in  persons
who indulge in frequent debauches of the table,
as well as in those who waste  their  spirits and
consume their strength in pursuit of criminal
pleasures.  Lastly, affections of  this  kind take
place also in females who labour under obstruc-
tions of the uterus or ovaria, and in such as suf- 
                      78
fer greatly from a want of the  menstrual  dis-
charge.  Even persons in very early life are not
exempt from these fevers.  Girls of about twelve
years of age, or who have arrived at that period
of life when the catamenia are about to appear,
are particularly  apt to suffer from them.

    But although these fevers resemble intermit-
tents in their type, they are in reality altogether
different from them  in their nature.  They can-
not be  considered as  either double tertians or
triple quartans.   In the former of these, the al-
ternate paroxysms, as we have already observed,
accurately  correspond  to   each  other.   But
in the quotidians  now under consideration, the
case  is  otherwise:  besides,   in  the course  of
these diseases, no positive apyrexy occurs; nor
does  the urine,  in general, assume a lateritious
appearance :  there  is also an  absence of certain
other symptoms which we  have mentioned  as
being attached  to every genuine intermittent.
Finally, when the cure of these affections is at-
tempted by specific febrifuges,* the remedies
cither produce no effect, or prove injurious.  By
such treatment a hectic fever  is  sometimes pro-

    * The term « febrifuge" occurs very frequently in the course
 of this work.  It is made to denote tonic remedies in general, but
 more particularly the peruvian bark. It  is seldom used, I believe,
 by our author, without some reference to  this latter article.......
 Trans. 
                      79
duced, which nature alone, or the use of gentler
remedies can subdue.

    But, as quotidian fevers  sometimes resem-
ble intermittents, so true intermittents assume
occasionally the appearance of quotidians.   In
those subjects who have been long harassed by
tertians, or who have had their diseases removed
by an  unskilful mode  of treatment, a certain
fomes still  remains,  by which, as evening ap-
proaches,  a kind of febrile  paroxysm is pro-
duced.   But here obstructions for the  most
part exist, occupying various parts of the  abdo-
men.  This fever, therefore, which arises from
the relics or remaining fomes of intermittents,
approaches very near to the  nature of quotidi-
ans.  It is generally rendered worse by the use
of febrifuge medicines, particularly if they  be
possessed of heating or stimulating qualities :
nor indeed are remedies  of this description ad-
missible at all, unless the functions of the affect-
ed parts be first restored.

   Having stated  the  foregoing observations,
which are  founded  on actual experience, it
would be quite superfluous to go into the con-
sideration of all those circumstances which the
ancients  have  attributed to  quotidian  fever.
Respecting this  form of fever nothing is  to  be
found in the genuine writings of  Hippocrates. 
                        80
   Celsus, on the other hand,  has given a tedious
   account of it, and has described it as sometimes
   regular and sometimes  irregular  in  its  type.
   Galen who  is  more accurate on  the subject,
   has mentioned some of its peculiarities which
   he had become acquainted with in a long course
   of experience.   That w riter was  induced  by
   various examples to attribute its origin to vis-
   ceral  obstructions.  Yet I apprehend  that  in
   some points he exceeded the bounds of experi-
   ence ;  for the  disease does  not  occur as fre-
   quently as the  writings of certain physicians
   would lead us to believe.

      Mercuridis never saw this disease during a
   most  extensive practice of forty yrears duration.
   Riverius very judiciously remarks,  that  out  of
   six hundred patients who sustained  daily acces-
   sions  of fever, scarcely one experienced a real
   quotidian :  in the mean time he mentions some
   of the characters and properties of that disease.
   Thus, according to him, it produces  a tension
  of the preecondia, and may  be protracted to the
•  fortieth day,  or even to the expiration of the
  second or third month:  it  is accompanied by-
  various symptoms, and  degenerates at last into
   some  other disease, such as cachexy, dropsy  or
  lethargy. 
CHAP.  XIII.
Of affections, the mask or external character of which
   is sometimes put on by intermittents that have dege-
   nerated from their own nature.
    BUT  if there are certain fevers which as-
 sume occasionally the mask of intermittents, so
 there  are  also other  affections, the  mask of
 which intermittents themselves at times put on.
 Sometimes the fomes or active cause of an inter-
 mitting fever may lie hidden or be accumulated
 in a certain part, so that that part may appear to
 be the only or principal sufferer :  at other times
 it may give rise to peculiar symptoms,  in which
 the whole force of the disease appears to be con-
 centred : and,  lastly,  it may  counterfeit other
diseases, which pursue a course peculiarly their
own, exhibiting no resemblance and possessing
no affinity whatever to intermitting fevers.

   We will first adduce a  few of the most sim-
ple and familiar examples on the subject. Some- 
                     82
times, without any perceptible  change in the
pulse,  the most acute pains take place, and re-
turn at stated periods.   Thus I have frequently
observed an excruciating affection of this kind
situated above the eye, unaccompanied by any
other symptom.  The  commencement of this
pain is sometimes attended by a sort of palpita-
tion around the affected part.  I have also  met
with a kind of periodical opthalmia, which uni-
formly made its attack at a stated hour.  Al-
though an  inflammation of this kind does not
usually disappear in a  short space of time, yet
in the affection under  consideration the eye was
soon restored to its natural state.

    We meet occasionally  with cases of excruci-
ating periodical hemicrania, which are the off-
spring of intermitting fever, or, rather, which
are intermitting fevers converted  into  hemi-
crania.  The whole head is also at times attack-
ed by  a  pain arising from the same source.   I
once saw a person so dreadfully tormented with
a pain of this kind, as to be rendered almost in-
sane.  At first view the nature of  the affection
was not clearly discovered  ; but, on a  closer ex-
amination,  it was  completely unveiled ; for  it
always made its attack towards noon,  raged for
a few hours with great violence,  and then re-
mitted. 
                      83
     But the febrile cause fixes itself not only in
 the orbit, and in the  eyes  themselves, but also
 on the external surface of the head.   Indeed it
 is capable of attacking every  part of the system
 separately.   So  true  is this, that in some  pa-
 tients certain parts  seem to suffer from fever,
 while all the others are exempt from it.   Some
 of these parts are periodically affected by a sense
 of coldness or heat;  others  by convulsive or
 tremulous motions,  so various are the  forms
 under which the disease appears.

     But, what is not less surprising, pains arising
 from a febrile cause, yet unaccompanied by any
 external signs of fever, oftentimes attack the in-
 ternal parts of the body.  I remember to have
 seen a case  in  which a  very  acute pain  in  the
 stomach, marked byr periodical recurrences, was
 at length cured entirely  byr febrifuge remedies.
 This pain was accompanied by no change in  the
 state of the  pulse, no preternatural heat,  and
 during its continuance  the functions of all  the
 other parts of the system wrere unimpaired.

    In general, however, things assume a differ-
ent aspect.   When the febrile poison pervades
various parts, it usually produces in them more
or less fever.   This poison is sometimes  con-
fined, as to its sphere of action,  to a few parts 
                     84
of the body, and at other times attacks a greater
number of them ;  it even occasionally passes in
succession from  one part to another.  I once
saw a patient who in the course of the same pa-
roxysm experienced  the most acute pains in the
following order : they  commenced  in the  legs
and thighs, then ascended towards the abdomen,
and finally to the he&d, producing a kind of apo-
plexy. There are still other and very dangerous
forms of disease, under which intermitting fever
sometimes masks  itself.   Most of  these differ
so widely from its natural form,  that  in  put-
ting them on, it would seem  to have changed
its nature, and cannot even be detected without
difficulty7.

    This change or transformation of intermit-
ting fever may arise from various latent causes.
Whatever these causes may be, the febrile poi-
son  is, under such  circumstances, more active
and  deleterious, and is diffused from its  own
fomes over various parts of  the body.  This
diffusion appears from the erratic or wandering
nature of the poison, in as much as  it may lie
hidden or be fixed  in  various places.   These
observations are confirmed by troublesome ob-
structions which originate from the febrile poi-
son,  and remain  after  the fever itself is  sub-
dued. 
85
    But when, by the influence of these causes,
the attacks of the fever take on unusual and dan-
gerous symptoms, these do not generally appear
at the veryr commencement  of the disease, but
show themselves,  at furthest, in the third  or
fifth paroxysm.   In this  stage of  the disease,
either the cold fit cannot be removed at all, and
the patients sink under il;  or  else a slight de-
gree of warmth takes place,  but soon afterwards
the extremities become cold again.  The  func-
tions of the viscera are now variously disorder-
ed, some more, others less, to which  succeeds
sometimes an inability to move,  or else a toss-
ing and perpetual anxiety. Either of these states
denotes the utmost danger.

    It is necessary to remark, that the pulse is
almost universally so small and frequent, that it
can scarcely be felt.  I say,  almost universally,
for there are  some  cases in which it possesses
more strength.  Thus when a determination to
the head takes place, and the patients are attack-
ed by lethargic or comatose affections, the arte-
ries act  with greater  force.   Their action is
equally strong when  the disease assumes a rheu-
matic form.  We must not be surprised at this
variety in the force of  the arteries, since the fe-
brile  poison exerts its   power  so  variously.
Sometimes, for instance, this poison attacks cer- 
                      86
 tain parts of the body like a caustic, corrodes
 them, and even draws from them discharges of
 mucus and blood.  In other parts again it excites
 spasmodic motions or convulsions.   This latter
 mode of attack is veryr frequently met with in
 practice.

    The fever thus masked under such a foreign
 or  counterfeit  form, may pursue  a variety of
 courses, and depart entirely from the common
 fashion or type of paroxysms. Sometimes those
 symptoms which  have  so unexpectedly  taken
 place, run on in form of a continued fever.  At
 other times,  and that more frequently,  they con-
 tinue only for a few days, abating sooner or later
 in different subjects.  Under these circumstan-
 ces the nature of the fever cannot be easily dis-
 covered, for its symptoms do not perfectly either
 remit or intermit.   The oppressed parts do not
 recover their proper tone, nor are their functions
 restored to health.

    But not unfrequently the febrile poison, even
 when thrown on particular parts, preserves its
 nature and acts conformably to its proper laws;
 for it still attacks and remits periodically in the
form  of paroxsms.   Hence it appears that this
poison may be in some measure subdued or dis-
sipated and exhausted, even without intense fe- 
87
brile action or any remarkable increase of heat:
I say, in some measure subdued,  for there still
remain behind certain vestiges of these local af-
fections, which, in a subsequent paroxysm, pro-
duce for the most part symptoms of a more ge-
neral  and  worse  nature.   But, what is more
unusual, after a  perfect  intermission of seve-
ral days,  the disease sometimes  breaks  out
afresh.

    We must not suppose that the force of the
febrile poison, when wandering about and thrown
on  certain  parts of the body, manifests itself at
all  times in the same way, or proves in every
case equally injurious.   When  the paroxysms
have been broken by the operation of febrifuge
remedies, it sometimes happens that the poison
or its relics are thrown  on the  external parts :
these parts are then attacked by pains more or
less severe, which are removed in no other way
than by a recurrence  of the fever.   But more
frequently the poison is thrown on the internal
parts;  in this case the abdomen sw-ells, or the
functions of some of the  viscera become  dis-
ordered.  But, in order that all things may be
restored to their  natural  and healthy state, it is
still necessary, in certain  subjects, that there
should be a return of  real fever :  at least, in these
subjects, nature not  unfrequently  cures such 
                     88
diseased  affections in that  way.    Hence it
aj pears how greatly motion  and heat contri-
bute to the subduing or elimination of febrile
poison. 
CHAP.  XIV.
Of the malignant form of Intermittents.
    AFTER what has been  premised, we are
 now prepared to enter on the history of malig-
 nant intermittents. Oftentimes almost the whole
 force of these diseases  falls on the brain: the
 patients become comatose;  the mind  is disor-
 dered ; a lethargy is induced, and, at times, even
 a true  palsy and apoplexy  follow.   In some
 cases, (though this is a rare phenomenon) a kind
 of catalepsy has been met with.  We must not
 be surprised, then, at the occurrence  of convul-
 sive motions, subsultus tendinum, tremors, de-
 fects  of vision, hearing,  and other senses, or,
 finally,  an  entire prostration of the vital prin-
 ciple.

   All these symptoms, so very unexpected, are
 marked by variety in their origin, progress, and
 decline.  They sometimes proceed from a slight
and at other times from a serious and dangerous
beginning.   In some cases their violence is such
                      N 
                     90
from their commencement, that they appear to
be idiopathic, that  is, altogether foreign from
the nature of an intermittent.  But their true
nature becomes at  length unmasked,  for after
a certain time they usually remit, and then pro-
ceed in  the  form of paroxyms.   In  different
subjects the remission is more or less complete.
Some  persons during  the  remission remain
heavy and almost senseless ;  others labour un-
der a total loss  of memory :  but,  what  is less
frequently  met with, some patients who in the
second paroxysm appear to be entirely free from
danger,  experience, on the  recurrence of the
third, all the alarming symptoms  of the first.
Even when a perfect intermission has lasted for
several days, all  apprehension for the future is
not to be abandoned; for, as we have already
observed, a relapse many times occurs, and the
whole phalanx of dangers breaks forth  anew.
But these threatening symptoms may be subdued
either by the  powers of nature or by proper re-
medies.   At times they  are carried  off by a
diarrhoea or a copious discharge of urine.   For
the most part, however,  they yield to  certain
remedies only.

   The febrile poison falls not only on the brain,
but also  on the organs of respiration.   It less
frequently, however, attacks these latter parts,
nor indeed is the reason of this sufficiently tin- 
                      91
 derstood.  When it does attack them its mode
 of action is not  always the  same.   It  mostly
 excites spasms in them, which are at the same
 time communicated to other parts of the system.
 But  from these spasms, or from  the irritating
 and almost corrosive action of the poison arise
 various  pains.  These  sometimes  attack  the
 diaphragm, and settle there, raging with  the ut-
 most severity.   At  other times they become
 fixed in  the sides, and occasion such torture to
 the patients, as to render them unable to chanq-e
 their position.

    No wronder, then, if from these causes  respir-
 ation becomes confined and difficult, attended
 with  cough, panting, and shortness of breath.
 Indeed, at times, the disease assumes something
 of the form of suffocative catarrh or asthma, from
 a  congestion and  oppression  of the  lungs  by-
 means of a thick mucus. But it, occasionally,
 appears  in another  shape no less  formidable,
 namely,  that of a severe pleurisy or peripneu-
 mony. The patient is then affected by a spitting
 of  blood, a fixed  and lancinating pain  in the
 thorax,  and a depressed  pulse.   This   latter
 symptom does not  well agree with the preced-
 ing one.

    The stomach is apt to be a very distinguished
sufferer from the action of the febrile poison. 
                    92
Sometimes this organ becomes the seat of the
most  intolerable anguish ; at other times of a
sharp and gnawing pain :  you might suppose
it to be affected by inflammation or even erosion.
Hence arise nausea, and forcible, though fruit-
less efforts to vomit.  In this state of the dis-
ease, the occurrence of deliquium animi, the face
and whole countenance being bathed in sweat,
a dimness  of vision,  a small and feeble pulse,
and a coldness of the skin, seem to threaten ap-
proaching death.   Nor indeed is it possible for
the patients to survive, if these symptoms con-
tinue long, increase in force, or recur in several
successive paroxysms.

    In the midst of these troublesome and dan-
gerous symptoms, a distressing vomiting often-
times  occurs.  The  matter evacuated in  this
way is bilious, yellow, porraceous, foetid, some-
times bloody and black, and is thrown up with
great force.  In some patients similar evacua-
tions occur  by  stool, although  the  epigastric
region alone suffers pain and anguish.  In the
mean time it is  not in the stomach and bowels
alone that the force of the disease .manifests it-
self.   The tongue is scurffy, and the urine is
secreted in small quantity,  owing to the spasms
that affect the kidneys.  These spasms are com-
municated to the external parts and produce in
them various motions and  effects.  The same 
93
 symptoms therefore occur in intermitting fever
which take place in cholera morbus.  There
 exists,  however, this difference,  that in fever
 these symptoms end when the paroxysm ends ;
 whereas in cholera there is no such respite.

    At times the febrile poison expends its force
 not on the stomach, but on that portion of the
 alimentary tube  which is situated  beneath  it.
 Hence arise excruciating pains, as if the intes-
 tines were acted on  by a caustic.   The evacua-
 tions by  stool are profuse and various, being
 either serous, bilious, or mixed.   But in some
 patients the  acrimony of the irritating cause is
 such, that the stools are mucous or bloody as in
 dysentery : at times they are marked with pure
 blood, and at other times they resemble the lo-
 tura carnis,  or  water in wrhich  raw flesh has
 been washed.  To these symptoms great pros-
 tration of strength succeeds.  The patients are
 affected with singultus, become  cold,  and  lie
almost lifeless.   A person inexperienced in the
 disease,  would  scarcely believe it possible for
them to rise again.   But, strange to tell, at the
termination of the  paroxysm,   these  terrible
symptoms abate, and oftentimes entirely disap-
pear.  In various diseases of the intestines, the
irritation  remains even after the cause is remov-
ed, but  when  the febrile poison is dissipated or 
                     94
 exhausted, it seems to carry all its effects along
 with it.

    The  force of the miasmata may fall on the
 external  as well as on the internal parts of the
 system.   Thus, papulae  or pimples of various
 kinds occur at times over the whole surface of
 the body, and yield to the use of febrifuge reme-
 dies. At another time the skin is suffused with
 a deep red,  which is lighter however in some
 parts than in others. But more frequently a kind
 of Sudor Anglicanus  breaks out.  In  many
 cases this flows abundantly from the forehead
 and  breast; it is every  where warm ;  and the
 more plentifully it flows, the more intense  is the
 fever.  After  a certain space of time, sometimes
longer, sometimes shorter, the sweat becomes
 cold; the pulse is depressed and in some cases
 creeping.  Under  these circumstances,  some
patients experience a  tightness and oppression
 about the praecordia, others a sense of heat and
 burning  in the stomach, while all  are affected
 with restlessness,  tossing,  and a suppression of
 urine.   The appearance of the body itself be-
 speaks impending danger,  for the flesh becomes
 of a livid or blueish colour.

    When the fever is  ushered in by a severe
 chill and shivering, the patient is usually attacked 
                      95
 by pains in various parts of his body.   Hence
 it appears, that in whatever form the febrile poi-
 son makes its attack, it may ultimately produce
 the same  kind of affection.   In those  profuse
 sweats of  which  we have just spoken, the sick
 sometimes experience in their legs and thighs
 such sharp and excruciating pains, that the parts
 would seem as if pierced with a sword.   In cer-
 tain cases  a kind of  rheumatic pain is diffused
 throughout the whole body, in others it settles in
 some particular part, and in others again wanders
 about from place to  place.   Though this pain
 seems to be the leading symptom, yet it is ac-
 companied by various others.   In some patients
 it produces deliquium animi, in others spasmo-
 dic affections, and is  not unfrequently attended
 with inflammatory local  affections, which shift
 from one part of the body to another.

    But if the febrile poison may prove injurious
 to certain parts, and even become fixed in them,
 it may also attack the  vital principle, itself,  and
 derange the whole economy of the system.  This
 is the  case in those persons who labour under
 an alarming syncope  during the paroxysms of
 the disease.   Under  these  circumstances  the
 countenance is cadaverous, the eyes are closed,
the respiration  is  laborious, and  every thing
seems to threaten  immediate dissolution. 
                     96
    But there are cases in which the principle of
life and  motion does not seem to be so imme-
diately attacked as the source of heat.   Some-
times when the paroxysm is ushered in by a cold
fit, no hot fit succeeds ; at other times,  after the
hot fit has commenced,  it is  gradually extin-
guished  again.   The  external  surface of the
body has then a marbled appearance, the counte-
nance a leaden  cast, the  extremities are livid,
and, to embrace  every  thing in a few words,
all those  symptoms occur which are met with in
the malignant causus.*  There are also  at times
accidental symptoms which  do  not  uniformly
prevail, such as  intense  thirst, a dullness and
feebleness  of intellect,  a diminished  flow  of
urine,  &c.

    In  the proteiform  course of intermittents
many things occur different from all we have laid
down on the subject.  But we  thought it best
to mention nothing except what has fallen Avith-
in the limits  of our own experience.  Our ob-
servations  are  confirmed  by those of the cele-
brated Morton, and also by those of the  very
learned and accurate Torti.  But there is ano-
ther more ancient and very respectable physician,
who has considered with no less discernment

    * A name given by the Greek physicians to ardent or inflamma-
matory bilious fevers. 
                      97
 the metamorphoses or irregularities of intermit-
 ting fevers.   I allude to Salius Diversus, who
 has paid the greatest attention to these diseases,
 and from whose writings it will not be uninter-
 esting to extract the following paragraph.

    " In the commencement of some intermit-
 tents, says he, while  the  patient experiences a
 slight chilliness or shivering, such a great retro-
 cession  of heat  occurs, that the skin becomes
 quite cold, the countenance like that of a person
 in a dying state,  and  the pulse so small and fee-
 ble as to be  scarcely perceptible.   As the hot
 stage comes on the pulse  increases a little, but
 is still small, unequal, frequent, and weak : the
 thirst  is  obstinate and distressing, with great
 anxiety, dejection, and restlessness:  the sense
 of  heat  to the  patient himself is  intense  and
 burning, while to the touch of another person it
 is either imperceptible or very  slight:  there is a
 great debility or alienation of mind, with cold
 sweats, palpitation cf the heart, and trembling.
 As the  febrile paroxysm  declines all  these al-
 arming  symptoms abate,  and  at the very com-
 mencement  of the decline  of the paroxysm, the
 pulse rises, and the heat returns. The paroxysms
 of these fevers continue at times for sixteen or
 eighteen hours, and I have observed that, on the
nights  preceding the  paroxysms,  the  patients
though not feverish are restless and uneasy."
                     o 
                     98
   Valesius  has  also had occasion  to witness
the deleterious power of similar fevers, and has
expressly denominated them malignant.  Louis
Mercatus has given their history  in a very able
and  definite  manner, laying down  with great
clearness and precision their diagnosis and prog-
nosis, and  delineating their  proteiform  nature
and various appearances with such accuracy,  as
to render it evident that there is no form  of dis-
ease  which they cannot assume.  Deriving his
knowledge on the subject from his own  exten-
sive experience, not from the writings of  others,
that  author omitted scarcely one of all those
symptoms  that are apt to deceive physicians  or
prove destructive to patients. 
CHAP.  XV.
Of the change of Intermittents into Remittents and
             continued fevers.
    OF the foregoing description are oftentimes
 those affections, the form of which intermitting
 fever assumes; but that disease can also put on,
 and lie concealed under, the mask of other fevers,
 which seem to be equally foreign from its nature.
 That physicians may be able to detect it under
 every possible mask or disguise, we make a few
 further remarks on  its various  appearances and
 various courses or tyrpes.

    Most physicians are of opinion that an inter-
 mittent may be joined or associated with other
 fevers :  almost every  one, fbr  instance, thinks
 that he has seen it joined with a true quotidian;
but a true quotidian very rarely occurs, and it is
extremely  difficult to distinguish  it from other
 forms  of disease.   How,  then, can  any one 
                     100
ascertain, in a satisfactory manner, that it is join*
ed to a single or double tertian ?  Must it not lie
concealed under the symptoms of its associate
diseases ? All the ancients, and many  modern
physicians who lived before the time of Harvey,
were too much devoted to theory.   They fan-
cifully believed in the existence of a commixture
or conflict between phlegm and bile, and asserted
that as the one or the other of these gained the
ascendency, fevers of various descriptions made
their appearance.

   The association of an intermittent with cer-
tain other fevers is a matter of less uncertainty.
It is occasionally joined with pleurisy, and pre-
serves its regular remissions and exacerbations.
I have also seen it,  at  times, go on in the same
regular periodical course, when associated even
with small pox; but its junction with real con*
tinued fevers, which is so often  spoken of,  is a
circumstance not so easily discovered.   Galen
very properly acknowledges the difficulty of ar-
riving at  certainty on this point.   For my own
part, I am inclined to believe, for reasons which
appear to me satisfactory, that such an associa-
tion is not only  oftentimes suspected  to exist
when in  reality it does not, but that its exist-
ence is even  contrary to the principles of na-
ture. 
                     101
    Opinions on these subjects should be drawn
from observation and reasoning.  That an inter-
mittent may indeed become a continued fever
cannot  be denied.   When it assumes a type
that is not natural to it, the time of its continu-
ance in that form is various and uncertain.   It
runs on for  eight, eleven, fourteen,  or  even
twenty days.  It is the form, however, and not
the nature of the disease  that is changed.  It is
still marked by paroxysms more or less evident,
and which return at stated hours.  Besides, it
terminates for the most part in a true intermit-
tent,  namely,  in  a  single or double  tertian.
Whence it appears, that  there is no new disease
induced, but that the former one, which was a
continued fever, has lost one part of itself, or is
divided into two distinct parts by means of  an
intermission.

   Nor does this change consist less  with rea-
son than with experience. For, when  the power
of the febrile poison is  great, the paroxysms
must  neeessarily be  of  longer duration : they
may even be so protracted as to touch or run
into one another.   In such a case they assume
the appearance of a  continued fever.   But, in as
much as the violence of the disease increases at
stated  hours,  and there  is a regular  periodical
recurrence of certain symptoms, the intermittent
form and habit are still retained and manifested. 
                     102
Besides, the paroxysms become daily shorter or
longer, sometimes so very long as to run  into
each other.  Still the disease is distinguished by
the violence with which the paroxysms com-
mence, and by a previous remission or sense of
coldness.

    But that we may not be thought to  digress
in pursuit of uncertainties, we will decline  any
further disquisition on this subject. It is enough
for us to know that intermittents do assume the
appearance of continued fevers, that they resem-
ble them more or less closely,  that a greater or
a less number of paroxysms succeed each other
without an intermission, and that the remissions
may be more or less evident and striking.  There
is also a great  diversity in the circumstances or
symptoms that usher in, as well as in those  that
terminate,  the paroxysms.  In some  cases a
chilliness occurs, while in others the patients are
entirely free from it; the same thing is true  with
regard to sweating, for sometimes the discharge
by the skin flows plentifully,  sometimes  very
moderately, and at other times not at all.

    Hence we  may understand what is meant by
remittents, subintrants, and double tertians con-
tinued. A remittent is a disease in which, after
a paroxysm has continued for a time it abates,
until at or  near to a  stated hour another pa- 
103
roxysm takes place.   A subintrant is a disease
in which the first paroxysm has not terminated
when the second commences,  so that each pre-
ceding paroxysm seems to  run into  each suc-
ceeding one.

    Hence  it appears  that subintrants and re-
mittents are diseases of the same kind, differing
only in degree ;  or rather, that they differ only
in name, being  in reality the  very same.  As
to double tertians continued,  they are diseases
which run on  in  a continued  form,  but are
marked besides by daily exacerbations occurring
at stated hours.  Hence it is easy to see that
they are of the same nature  with remittents and
subintrants.

    Nearly   allied to  these  is  the  semitertian,
which was  so much dreaded by the ancient phy-
sicians.  This disease,  according to Hippocrates,
commences with a shivering, and is continued
and acute,  but is lighter and more severe every
other day alternately.   According to Celsus it
occupies thirty-six hours out of forty-eight, and
does  not disappear  entirely during the  remis-
sion.  In  the mean time it has such frequent
accessions,  that it might be taken for a disease
of a different kind.   But Galen has more accu-
rately  said  of it, that  it is a continued disease,
but is marked by an exacerbation and a chill 
                     104
 every third day;  he says that it consists of two
 fevers, a tertian, and a continued quotidian, and
 occupies forty-eight hours  in  its period.*  In
 some things, indeed, that  writer seems to con-
 tradict himself, and this is particularly observa-
 ble in what he has here and there written on the
 subject of the semi-tertian.

    From these ciscumstances, or rather from
 the hidden nature of this form of fever,  many
disputes   have  arisen  respecting  it  among
more  modern   writers.  Some have endea-
voured  to ascertain clearly the  sentiments of
 the  ancient  physicians on  the subject;   to
 these many have   added  something  of  their
 own, derived either from  opinion,  or observa-
tion.   Some, for  instance,  have  conceived
that two paroxysms occur  on the  same  day ;
this was  the case  with Riverius, who  even
makes mention  of a quadruple-tertian  being
joined with a continued  quotidian. Others have
suspected the continued fever to arise from an
inflammation of  some viscus, and have derived
from thence the  shiverings that sometimes suc-
ceed each other.  All these writers,  however,
agree that  the disease is a compound of a ter-
tian and a continued fever,  and have attributed

    * The word " period" as used in this place, includes b:)th the
 paroxysm and the succeeding interval of remission. These two terms
ef time added together make up the space of forty-eight hour*. 
105
to  the  joint  influence of these  two,  certain
inequalities  and  irregularities  by which it  is
marked.

    Feeling but little interest in these controver-
sies, we will not enquire into the minutiae of the
sentiments of former writers respecting this dis-
ease,  but only  how  their  general  sentiments
agree with  what we  derive  from observation.
The febris hemitritaa or  semitertian fever,
then, we consider as a continued double tertian.
Such however is the peculiarity of its type, that
one of its paroxysms is ushered in by a  cold fit,
while the next is not, and so on alternately.  It
is also accompanied by wandering and uncertain
rigors and shiverings, which occur more or less
regularly at stated hours.  Hence it appears that
the hemitritaea or semitertian fever is a disease of
a malignant aspect,  and approaches somewhat to
a malignant causus.

    In the same point of view  was this disease
considered both  by the ancients and their im-
mediate successors.  Hippocrates pronounces
it fatal, and says that it is accompanied by vo-
miting,  tremors, and a sense of burning at the
stomach. Galen represents it as extremely dan-
gerous : the pulse in it, he observes,  is slow and
crawling, the heat  forsakes the extremities and
retreats to the central parts of the body,  particu-
                     p 
                    106
larly to the abdomen and thorax, and it is at-
tended with a comatose disposition, or with de-
lirium and watchfulness.  By Rondeletius it is de-
nominated/^™'.? syncopalis. By Schenkius it is
described as of a pestilential nature.   Spigelius
declares it to be a real pestilence.  Forestus was-
accustomed to  meet with it during the preva-
lence of malignant  fevers.  Valaeus considered
the rigors and tremors, with which he generally
observed it to be accompanied, as  strong evi-
dences of its malignity.

    No wonder, then, if the several descriptions
of the semitertian, as given by medical writers,
should differ widely from  each other.  All the
symptoms which we have enumerated do not
occur in the same case of fever.   In some cases
more of  these symptoms are manifested, in
others fewer, and in others again symptoms al-
together different appear.  At times the disease
is introduced by a severe chill, at other times by
a slight chill or shivering.  In  some instances
cold and hot fits succeed each other alternately,
and the exacerbations or paroxysms are nume-
rous and  frequent.   Whatever symptoms are
unfavourable in intermittents, (and we have al-
ready said that the symptoms of this description
are various,) are dangerous when  they occur in
the semitertian.  Hence the signs and evidences
/ 
107
of malignity in these two diseases are alike plain
and intelligible.

    Of nearly the same kind are the febres tri-
taiophia, a sort of tertians so called by Galen,
but which nevertheless  approach nearer to re-
mittents,  and  are therefore  more  mild.   Yet
even these are oftentimes dangerous, particular-
ly when they have irregular and inordinate exa-
cerbations.   But  there  are other fevers closely
allied to  these, which  are no  less dangerous,
namely the febres  ardentes, or causi, of the
ancients.  These, as Galen  observes, carry with
them conclusive evidence that they are tertians
in disguise: in this alone do  they differ from
common  tertians,  namely, that  they are not
ushered in  by a cold fit, nor do they perfectly
intermit.   It is certain, however, that they ter-
minate  in tertians  or true intermittents,  from
which,  if we regard the name, theyr appear not-
withstanding to differ very  widely. 
CHAP.  XVI.
Various observations adduced in confirmation of the
       foregoing opinions and doctrines.
   HENCE it appears, that intermittents may
be masked by and of themselves,  as is the case
when they put on the form of continued fevers
or remmittents.   But, that their disguise, how-
ever various, may be more readily detected, and
their nature more accurately understood,  I will
endeavour to give a faithful history of those that
have fallen under my notice in  certain epidemic
seasons.

    The summer of a certain year having been
warm and dry,  fevers prevailed extensively  in
the autumn.   These fevers  took on,  at first, a
continued form, but retained it for only five or
six days: they resolved themselves  then into
true intermittents.  In  the  autumn of the  fol-
lowing year, the fevers generally commenced
with the type of double or  single tertians, but 
                     109
soon degenerated into continued fevers of fifteen
or twenty days continuance.   During  this pe-
riod various paroxysms occurred, in some cases
at stated  hours,  either at night,  early in the
morning, or, not unfrequently, in the afternoon.
Occasionally the  paroxysms were lighter, and
more violent on alternate days.  It was not un-
common for the  sick to suffer three exacerba-
tions on the same day, or on alternate days.

    Seldom  in  these  fevers were  the exacerba-
tions preceded by a regular cold fit.  Yet some
patients experienced at their commencement, a
slight  sense   of chilliness:   in   such  cases,
the fever  did  not rage  with so  much  vio-
lence, as in others,  where the paroxysms were
not introduced by a chill.  Ultimately, however,
these fevers were  for the most part changed into
regular  or irregular intermittents.   Some per-
sons remained tolerably well  during  the  day,
but were  attacked  by fever on the approach of
night.  Many others experienced various symp-
toms, which it  would be altogether superfluous
to enumerate at present.

    Two years afterwards another epidemic pre-
vailed, in  *4iich  the diseases assumed  the form
of triple tertians.  In these,  the  exacerbations
were preceded by a cold fit, which  furnished sa- 
                     110
tisfactory evidence of their being of the nature
of intermittents.

   In this epidemic, however, the fevers did not
always assume the same type :  their symptoms
were also different; I saw many cases where the
disease, without  any previous cold fit, ran on
like  a  continued fever till the eleventh, four-
teenth, or twentieth day.  In these cases nothing,
in general,  occurred  till  towards their close,
from which it could be inferred that the disease
was of the nature of a remittent; then it seemed
to abate at  stated times, and to be marked by
lucid intervals.  Still, however, the violence of
the paroxysms was such as to threaten the sick
with the utmost danger.

   In the spring of the following year, fevers
assumed a different aspect.  Most of them were
slight in the beginning : for the first six or ten
dayrs they  pursued a continued  course, without
manifesting any thing of an intermitting or re-
mitting type : the paroxysms were severe, and
not preceded by  any cold fit, unless perhaps  in
certain cases,  where the patients experienced a
slight chilliness accompanied by something of a
cough : this disclosed to us the nature of the dis-
ease.  At times the fever took on the form of
an irregular intermittent  from its very  com- 
Ill
mencement.   The same type was assumed by
those attacks of disease which began as continu-
ed fevers and  changed to intermittents; they
became at last a kind of double tertians.

    In these continued fevers I have observed
an appearance different from any yet mentioned.
In many persons several remissions and exacer-
bations occured on  the same day : in others a
sense of heat and cold continued to succeed each
other alternately, for several days.  At length,
however,  these fevers were changed into true
remittents or intermittents, as well as  the others
of which we have treated. But there were cases
in which, without this alternate vicissitude of
heat and cold,  the fever continued to  rage with
great violence  for three or  four days  or more :
a remission then took place, which  lasted one
day  or perhaps longer : after this the fever re-
turned again, and raged without intermission for
three or four  days  longer.   Most frequently,
however,  these remissions  and  exacerbations
succeeded each other in such a  way  as not  to
constitute any regular type of fever.

    Hence it appears  that all these  epidemics
may  be  reduced to the following kinds or de-
scriptions of  disease.   1.  Genuine  intermit-
ting  fevers.   2. Fevers  which are  changed
into remittents.  3.  Fevers which assume  at 
                     112
first a continued form, although they originate
from the real cause that produces intermittents.
4. Others  which,  from having been intermit-
tents,  become  continued  fevers.   5.  Fevers
which run on in a continued form for five or six
days or  even more.   6.  Those of the same
nature that run on as continued fevers for fifteen
or twenty  days.  7.  Fevers marked by  re-
missions longer or shorter, more or less con-
spicuous, and sometimes  not even obvious to
the senses.   8.  Fevers  with  exacerbations
sometimes  preceded by a cold fit, and sometimes
not.  9. Fevers altogether irregular both as to
exacerbations and remissions. 
CHAP.  XVII,
Further observations setting forth the variety and
           danger of such fevers.
    AMONG the most remarkable epidemics
 within my recollection, I will mention one which
 originated from  a very  extensive pond  filled
 with putrid substances.   Previously to the dis-
 ease to which I allude, the neighbourhood where
 it prevailed had been infested by fevers such as
 we have just described : but there occurred at
 length a remittent inclining to a continued form,
 in the paroxysms of which  the head was greatly
 affected.  This disease was, for the most part,
 marked with great oppression at the breast and
 about the precordia, delirium, and convulsions :
 it oftentimes  assumed the  appearance of true
apoplexy, but more frequently that of lethargy :
at times the sick  lay motionless, deprived of the
exercise and powrer of their senses ; not unfre-
quently the paroxysms commenced with severe
 head-ache, and the most excruciating pains in the
                      o.. 
                     114
joints.  On the remission of the fever all the9e
symptoms abated,  and sometimes the sick ap-
peared to be quite out of danger.

    At other times the disease assumed an as-
pect someAvhat different; the febrile symptoms
ran high, with an acute pain in the side :  the
breast, as in peripneumony, was oppressed with
a heaviness  and a difficulty of breathing:  in
some cases there was a continual and very dis-
tressing vomiting : in others, suffocating sensa-
tions, pains in the bowels, and such like symp-
toms, raged with great violence during the whole
course of the paroxysms : besides spasms and
convulsive motions, many of the sick were  sub-
ject to syncope ; most of them to such extreme
debility,  that  they seemed  ready  to  expire;
some of them indeed lay as if already dead;
during this great prostration of strength, the
surface of the body was cold and of a marbled
appearance.

    In all these cases the force of the pulse was
various.   At times the violence of the symp-
toms was so great,  as to break in on the regular
course of the  paroxysms and render them ob-
scure ; the pulse was then contracted and weak,
as if there had been a deficiency of vital energy;
but at other times, and that most commonly, the
febrile symptoms were high ; under  these cir- 
115
 cumstances the pulse was strong and very fre-
 quent ; in some instances, however, it was less
 elevated, and struck the fingers with less force :
 still it was sufficiently forcible to show of itself
 that the fever was very high.

    In the following  year  a  fever of the same
 kind became prevalent. It was a double tertian
 and continued subintrant.  In this disease apo-
 plectic and lethargic symptoms came on at the
 very commencement of the cold fit, and, such
 was their force, that they continued throughout
 the  whole course of the paroxysm;  but as the
 paroxysm passed off,  the sick revived as it were
 from this deplorable condition, and returned  to
 the exercise of their senses and their intellect:
 you would have sworn that they had  suffered no
 injury.   So great was the remission of the fever
 and the intermission of the  bad symptoms, that,
 provided the subjects were young, they did not
 at  first view appear to be sick :  but when ad-
 vanced in years, their situation was much more
dangerous, and unless art  came  opportunely  to
 their relief, they soon fell victims  to the dis-
 ease.

    Three years afterwards I met with another
epidemic of the same kind with, or at least not
very dissimilar to,  the foregoing ones.  This
disease prevailed throughout  the summer and 
116
autumn, and proved extremely fatal in its course
But that its symptoms may be the more clearly
comprehended,  I will describe a few  curious
cases of it:  from these it will be easy to judge
of the great variety that may occur in the effects
of febrile poison.   It will appear, in particular,
how dangerous  this poison may be, even in
cases where the sick entertain the most sanguine
hopes of a recovery, and where no  danger can
be apprehended from the violence  of the  dis-
ease.

   A young woman was attacked by a remit-
ting fever.  In the third paroxysm she became
insensible; her lungs were oppressed, her breath-
ing became stertorous, and  in  eight hours she
died.  The fate of my  next patient  was no less
unfortunate and melancholy.   He had been at-
tacked  by a  double tertian fever.   During the
third paroxysm he fell into a delirium which
continued for three days.   During the day his
fever was moderate, but it encreased on the ap-
proach of night, and put a  period to his exist,
ence.

   Another person was attacked by  a remitting
fever, somewhat inclined to  become a continued
one.  On the fifth day, he fell into a lethargy or
coma, and an oppression of the breast coming
on, he  expired.   In a certain female subject,  a 
117
disease of the same kind assumed a different ap-
pearance, and pursued a different course.  The
patient was attacked, for instance, by a genuine
intermittent;  but on  the  fourth or  fifth  pa-
roxysm her mind became deranged....she con-
tinued in that  state,  without much  fever, for
six days, and  then recovered her senses ;  but
the fever again encreasing, she was carried off
by the next paroxysm.

    A certain gentlemen ill of a remitting fever,
put himself under my care. He had daily  a rigor
and shivering : at length on the fifth day, he fell
into a lethargy  which continued for twenty-four
hours.   By degrees,  however, he recovered his
senses, and was of a  sound and firm mind for
one day, but a  shivering and paroxysm  occur-
ring again, he died of a kind of asthmatic suffo-
cation.  No less unexpected  was the  fate of
several other patients,  who,  after moderate pa-
roxysms,  became cold on the  surface  of the
body  and were  seized with faintings;  their
strength then failed entirely, and, after suffering
great oppression, they expired.

   It appears from the foregoing circumstances,
that  these fevers  attack more  particularly the
brain,  the seat of the  intellect,  but  that they
also do great violence and injury to the lungs.
Nor are  the praecordia  less affected,  and even 
                     118
the heart  itself is a great sufferer.   In a word,
even  the  vital  principle  is attacked and over-
whelmed,  as it were, by the febrile poison, and
from  hence are to be deduced the dangerous
symptoms which  the  sick experience : these
symptoms are so violent, particularly in persons
advanced in years, that,  unless the  greatest at-
tention  be paid to them in the commencement
of the disease, they  run on  to a  fatal issue.
Youthful  persons more readily recover;  yet
many  even  of them are  carried  off  either
through a neglect of remedies, or by the force
of the disease proving superior to the resources
of art.

    It may be thought singular in these diseases,
that sometimes from so slight  a beginning, the
danger should become so urgent and threaten-
ing in the course of a few days.   But  it is  a
problem no less difficult to solve, howT a cause
which so  disorders the brain,  and so oppresses
the lungs, can  of  its own accord give  the sys-
tem a temporary respite, or cease for a time to
act.   Thus,  after the  third or  fourth  day the
action of this cause is suspended, and for a day
pr more  the patients seem  free from disease.
Other maladies do not pursue such a  course;
in them the affected parts recover  only by de-
grees ;  and after they have recovered, or appear
to have recovered in the space of a day or  two, 
                     119
the  life of the patient  is seldom brought into
danger again by a sudden return of the disease ;
at least this is not generally the case, as it is in
malignant intermittents.

    Hence may be deduced a rule or conclusion
of no small moment in acute diseases.  It ap-
pears,  for  instance,  that there  may be  great
disorder in the functions of the body without
either real  inflammation or  any fixed disease in
the solid parts.   Many  patients are delirious,
raving, and appear to labour under a peripneu-
mony, others suffer the most excruciating pains,
while  others  again  have  their stomach and
bowels greatly disordered; they appear, indeed,
to  be  in as much  danger  as if they were la-
bouring under the greatest inflammation, un-
der a wound, or some strong irritation about to
extinguish the vital principle; yet those parts
which had experienced such deep and distress-
ing affections, may in a short time be entirely
relieved.   Hence it appears that these terrible
symptoms may arise from some wandering sti-
mulus, which flies off and returns, or acts and
lies  dormant, alternately;  and that they  are
sometimes  more alarming in appearance, than
dangerous in reality. 
CHAP.  XVIII.
Of the method of detecting or distinguishing Intermit-
  tents when disguised under the mask or appearance
   of other diseases.
   HAVING  thus  delineated  the   different
phases  or appearances of  intermittents,  and
given an accurate history of the  symptoms
under which they are usually masked, it remains
that  I should mention the signs  by which the
nature of these masked diseases may be detect-
ed.  They possess, for the most part, such vio-
lence, that unless their nature and tendency be
well  understood,  they may prove highly dange-
rous to the persons whom they attack.

   The origin and nature of  these fevers  may
be known from their modes of attack: if  they
have  intermitted or only remitted,  and after-
wards returned and run on with unusual symp-
toms, there is ground  to  suspect that they; are
masked diseases.   This suspicion will be  con- 
121
verted into certainty, if the exacerbations should
be ushered in by a cold fit.   But .should  there
be nothing but a slight chilliness, recourse must
then be had to other signs, for the disease exhi-
bits  only  the  appearance of a continued fever
marked by periodical exacerbations.   But there
are many fevers of this description, that have no
affinity to remittents.

   But if fevers, which are even not ushered in
by a cold fit, be marked by paroxysms sudden-
ly occurring,  if the patients, when apparently
well, be attacked instantaneously as if they had
received a blow ; if stretchings and pains  of the
head, instead of a cold fit, precede the paroxysms,
under these circumstances, there is good reason
to believe that the disease is an intermittent un-
der a masked  form.

    The same conclusion is* to be drawn relative
to  the  nature of the  disease, when it has pa-
roxysms that are succeeded by a striking remis-
sion. So great, at times, is the violence of these
paroxysms, that they are accompanied with real
danger, whereas during their remission,  which
is quite a lucid interval, the patients seem to be
in no danger  whatever.  Under such circum-
stances, there can be no doubt but the diseaae
is a remitting fever wearing the mask of a con-
tinued one.
                     R 
                    122
   The nature of the fever is equally manifest,
if  the  exacerbations  terminate in  a copious
sweat;  if the paroxysms return about the same
hour ; if they exactly correspond with each other
every day or  on  alternate  days;  if there occur
very violent and alarming symptoms which ap-
pear and  terminate periodically, such as deliri-
um, fierce ravings, lethargy, most acute pains in
the head,  a failure of  strength, tormina of the
intestines, he.

    Lastly, masked intermittents, may be no less
certainly detected, as was formerly observed, by
the colour of the urine.   In  that  disease the
urine is very  often lateritious, which is a sign,
almost  infallible, that the disease belongs to the
family of intermittents.  But the  urine is lateri-
tious  only during  the remission;  whence  it
ought to  be attended to and examined with the
utmost care

    The following instances will show with what
 confidence these signs may be  depended on, and
 how readily the disease may be detected amidst
 the various and unusual symptoms that attend
 it and render it obscure.   I once attended a fe-
 male patient, who  was  thunder-struck,  so  to
 speak, by hysterical affections, tormented  with
 pains shooting through her whole body, and ap-
 peared indeed on the point of dissolution.  Du- 
123
ring this prostration of strength, some paroxysms
suddenly occurred, which convinced me that
the disease was an intermitting fever in disguise.
I, therefore, had recourse to febrifuge medicines,
which soon restored my patient to health.

    I once attended another female patient who
laboured under  an hsemopthisis : she had  an
acute pain in her side; and was reduced to a
state of extreme danger by means of various and
repeated exacerbations.   But when  I was in-
formed that the disease had commenced  Avith a
chill, and that some of the earlier paroxysms had
terminated in a sweat, I immediately determined
on the exhibition of febrifuge remedies, which
in a short time removed the fever, and all the
symptoms that had appeared so formidable.

    A gentleman whom I once attended in a very
severe pleurisy,  experienced unusual and peri-
odical exacerbations. These exacerbations came
on not by degrees,  but  very suddenly.  Besides,
during the paroxysms  there was a copious dis-
charge of blood from  the mouth, a  symptom
which is  extremely rare.   In this state of things
I conceived an opinion, that all the unfavourable
appearances of the  case were owing to the latent
cause or fomes of  intermitting fever, and that a
cure was to be accomplished  only  by febrifuge
medicines.  This practice was accordingly adopt- 
                    124
ed, and the patient who had been in the utmost
danger, was in a short time restored to health.

   A gentleman accustomed to hunting was at-
tacked by  a fever of extreme violence.  In a
short time he fell into a fierce delirium, and ex-
perienced aborning heat, and a restlessness that
nothing could restrain.  But as these symptoms
alternately increased and  abated in violence  at
stated periods, I began immediately to suspect
that the disease was a masked intermittent. Re-
 course was had without delay to febrifuge reme-
 dies, to which the disease soon yielded, although
 it appeared to have been aggravated by  other
 modes of treatment.

     A young female was attacked by a continued
 fever  somewhat inclined to remit: but the re-
 mission was so short and  slight as  to be scarcely
 perceptible.   In the mean time the danger was
 extreme.   Such  was  the violence of the pa-
 roxysms that  the patient seemed ready to ex-
 pire.  Alarmed at this dangerous state of things,
 the first lucid interval  that occurred although it
 was very short, I  exhibited febrifuge medicine
  in  large quantity', and that not without advan-
  tage, for all the symptonas were rendered much
  milder.

     Other examples of the same kind might be
  adduced, but the foregoing are sufficient for  our 
125
purpose. I must not, however, omit to mention,
that during the prevalence of an epidemic inter-
mittent, I am pretty generally led to suspect thatall
cases  of fever partake more or less of the nature
of intermittents. When there is no general pre-
valence of intermittents, the periodical return of
exacerbations, the disease being one day milder
and the next more  severe, an  evident remission
however short  it may be,  and a sudden recur-
rence of violent symptoms....these circumstan-
ces, I say, furnish me in general with satisfactory
evidence that the fevers are intermittents in dis-
guise.  On such occasions the urine retains in
many cases nearly its natural colour. 
CHAP. XIX.
Of the consequences to be apprehendedfram the leading
     symptoms of the fevers under consideration.
   FROM masked forms of fever let us return
to true intermittents,  and enquire into their ef-
fects  and dangerous  relics  or  consequences.
Those relics or  consequences which we  shall
enumerate are  not  uniform  occurrences, for
such  are  the nature and  powers of the animal
economy, that the fever itself generally returns,
and does awayr  all danger.  But the  dangers
which we are about to mention in this place are
not to be considered as necessarily  attached to
every case of intermitting fever ;  they are only
such  as do or may occasionally take  place in the
course of this disease.

    We have already enquired into the immediate
effects of the cold fit, and cannot, therefore, be
ignorant of the dangerous consequences to which 
                     127
 it is likely to give rise.   There is no doubt, in-
 deed, but from the constriction which it induces,
 and the consequent stagnation of blood  in the
 lungs and  liver,  these parts are pre-disposed to
 various obstructions, and irregular states of ac-
 action.   Hence the liver is so often diseased.
 From  the  constriction of that organ, the bile
 does not pass freely through the ducts : the pa-
 tients become livid ; the digestive powers of the
 stomach are weakened ; and some of the other
 viscera are injured in a similar way, and render-
 ed unfit for the performance of their functions.

    But the greatest violence may be done to the
 heart.  Its ventricles together with the vena cava
 may be much  enlarged.   Hence the palpitations
 and polypous  concretions,  to which those per-
 sons are subject, who have laboured under severe
 and  long continued intermittents.   The mass
 of blood stagnating in the lungs  may  prove
 equally injurious.   It produces  occasionally  a
 spitting of blood, or a kind of asthma.  These
 symptoms do not, indeed, very frequently occur.
 It is sufficient, however, that they may occur.

    There  is still, as we have already intimated,
another point  of view in which the power of the
cold fit  proves highly dangerous.   It depresses
the vital principle in such  a manner as to ren-
der it at times incapable of re-acting: hence this 
                     128
principle is,  sometimes,  so completely  over-
whelmed, that the patients die under the influ-
ence of the cold fit.  Nor is this, indeed, to be
wondered at,  when the pulse either ceases to
beat, or becomes small and frequent, when res-
piration is disturbed, and, lastly, when the fluids
stagnate in the brain and in various other parts
of the system.  Hence the sick are in real danger,
in cases where the cold fit is of long duration.  I
have  seen  many persons reduced to such an
alarming state, that without medical assistance,
they would necessarily have  expired.   To  pa-
tients who are in the prime of life the cold fit of
an intermittent is  not so often dangerous ;  but
to persons advanced in years it  is very frequent-
ly so.

    The danger arising from the hot stage of fe-
ver is  not  so great.  As soon as a sick person
has escaped from, or passed over the  cold stage,
he  is  usually  considered as safe.   But is there
not a secret taint introduced into, or generated
in the system, which increases by degrees,  and
at length breaks out when not expected ? In an
intermitting fever, a tertian for instance, the heat
of the  body rises as high as the 39° of Reaumur,
and higher still in compound fevers.   But if in
a person in health the temperature  should rise
equally as high,  every day,  or every other day,
and continue at  that degree  for six or eight 
                      129
 hours, would he be free from danger, even  al-
 though he should enjoy the usual temperature of
 the human  body during the remainder of the
 day and night ?

    On this  point we may form some opinion,
 from the effects usually produced by a high de-
 gree of heat.   What a rarefaction takes place in
 the texture of the softer parts of the body ?
 What a  distraction or laceration of the more
 tender fibres ?  What a  change in the fluids,
 which are the source of heat ? In  as much as
 men and  other animals are oftentimes destroyed
 by passing through high degrees of heat, it is
 wonderful that sick persons are not more injured
 by the great burning that occurs in intermitting
 fever.

    But  however patients may seem to escape
 danger, when parched by a strong febrile heat,
 the organs of the body and their functions ard
 necessarily  injured  by  it.  Some patients  are
 subject to great agitation and tossing during the
 hot stage  of  the fever :  others again suffer the
 most distressing anxiety about the region of the
heart.  The burning heat that exists in the lungs
 proves equally troublesome and oppressive. The
 head itself feels as if on fire, and there is no doubt
but the very  tender medulla of the brain suffers
from this intense heat.
                     s 
130
   How great  then  is the injury that may be
done  to  these and other parts  of the system,
which are burnt up,  as it were,  by this febrile
fire ?  Were wre to trust to theory alone, the dan-
ger would indeed seem to be great and immedi-
ate.   But experience and observation teach us,
that the powers of nature are such as ought to
prevent us from despairing of the fate of the sick
in these scorching fevers. Unquestionably, how-
ever,  the system must suffer much from the in-
tense  heat of the paroxysms, and their frequent
returns must pave the way to many diseases.

   In summing up the causes that tend to  the
injury of the system, we must add the action of
the vessels,  which corresponds  to  the degree of
heat,  and which, during  the course of the pa-
roxysms, is so great, that the frequency  of the
pulse is  doubled, and the  degreo of heat greatly-
increased.   Hence we  may  infer, in general,
what  the vessels  themselves suffer,  both  the
larger ones, and the capillaries  which terminate
in a tender pulp.  The texture and function of
the glands and other parts are necessarily injured.
From the increased rapidity and force in the mo-
tion of the blood arises a most  acute pain of the
head,  with a more frequent and difficult respira-
tion.   But a circumstance still  more dangerous
is, thatthere is a kind of congestion formed in the
vena porta? and liver ;  for it is not practicable for 
                     131
the blood to circulate through the intricate wind-
 ings of that organ, as rapidly as it flows from the
 arteries into the veins.

    Sweats, even when profuse, do not portend
 the same degree of danger.   But although they
 contribute greatly to the relief of the  system
 when the paroxysm is declining, they do not en-
 tirely remove the cause of the fever.   Even the
relief which they afford tends to exhaust the sick.
 Suppose, for instance, a person in consequence
 of some error in diet, or after a debauch in eat-
 ing should swreat very profusely for three or four
 hours every other day ;  could such an event ul-
 timately contribute  to  health? or would it not
 rather be attended with danger, since it is  known
by  experience that  five or  six pounds  of the
fluids of the body are  discharged through  the
pores of the skin  during that space of time ?
There can be no doubt as to the effect  on the
 system  in the case of febrile sweats, when pro-
fuse,  long continued, and frequently repeated.

    Nor are  the  fluids  discharged by the  skin
simply  aqueous,  although  if they  were, even
then their loss would be injurious:  the thicker
juices themselves, which are destined to the nou-
rishment and reparation of the system make
their escape; whence the vital organs are neces-
sarily debilitated.  Sick persons are sometimes 
                     132
so greatly disposed  to such discharges from the
skin, ihat they flow copiously without any known
cause, particularly during the night.  Even after
the fever is removed,  this disposition to sweat
frequently continues, and can scarcely be check-
ed.  But,  what is of more consequence,  there
still remains, under such circumstances, either
some fomes of the disease, or  else a local affec-
tion of some particular part of the system.

    The thinner parts of the fluids,  in particular,
having escaped by the cutaneous pores, it is evi-
dent that those which remain in the vessels are
more gross ; a  circumstance  which  seems  to
threaten no small degree of mischief to the sys-
tem.   On this theory, however, too much  reli-
ance must not be placed.   The grosser parts of
the blood are at the same time dissolved  or
made thinner, a circumstance  which,  taken in
conjunction with the influence of the febrile heat,
tends to keep it in  motion.   This dissolution
is greatly promoted by acrid and alkalescent bile,
which, being regurgitated into the blood, is dif-
fused throughout the vascular system.  The
other humours of the body are also rendered
acrid, as appears from pustular eruptions which
occur  about the  mouth.   Hence patients who
have laboured long under fever, appear blood-
less and pale. 
133
    The change in the humours  appears  also
 from the urine itself. During the febrile action,
 that fluid is flame-coloured, as already mention-
 ed,  but, as the paroxysm declines, becoming
 thick, frothy and very red, it puts on at length
 a  brick-dust  colour.   This  colour  appears in
 particular  in  the  sediment which is generally
 copious.   The sediment is nothing but a red-
 coloured earth, as I have oftentimes ascertained
 by experiment.  This earthy sediment is apt to
 lodge and create a temporary  obstruction in the
 vessels of the kidneys.

    This kind of urine belongs so peculiarly to
 intermitting fever, that, provided the disease be
 genuine, it  is seldom wanting.  Indeed there is
 no solid  reason to believe that the system is free
 from the fomes of the fever, while the urine re-
 tains its  lateritious  colour, or is in  any measure
 tinctured with red.   This phenomenon does or
 can prove fallacious only in cases where the  sick
 labour under some  hepatic affection.  If at any
time the urine  should  exhibit  a white matter
settling copiously to the bottom of the  vessel,
this  is to be considered as a favourable symp-
tom, and even  a sign of a crisis in  the disease.
I must confess, however, that this phenomenon
has but seldom fallen under my notice. 
134
    In  some intermitting fevers the urine does
not assume a lateritious colour.   I allude parti-
cularly to  certain  vernal  intermittents,  or to
those  that  change into continued or  remitting
fevers. Even in these, however, the urine does
exhibit something of a lateritious  appearance
during their remissions.  At those times, when
the secretory^  vessels of the kidneys are  suffered
to relax,  in consequence  of an abatement  of the
febrile spasm, the grosser and red coloured par-
ticles  are  allowed to  escape.   Whence it ap-
pears, that  at the commencement  of the disease,
if it be very severe, the urine  does not depart
from  its  natural  colour,  but  assumes a red
and lateritious cast when the  symptoms abate.*

    * Physicians, like other characters, are apt to fly  from one ex-
treme to the other.  In former times the appearances of the urine
of sick persons were, perhaps, on all occasions, too closely and too
credulously  consulted; at present they appear to be too much ne-
glected.  Such a copious and important excretion must very gene-
rally exhibit certain characters, that might serve as something of an
index to the state of the system.  By paying a proper attention to
the appearances of the urine, I am persuaded that physicians might
oftentimes discover and predict the crises of diseases, much to theip
own credit, and to the benefit of their patients......Trans. 
CHAP.  XX.
Of various affections attendant on Intermittents.
    WE have  now seen  what is  to be appre-
hended from  each leading symptom  properly
and necessarily attached  to intermittents.  It
remains to ascertain what those affections  are,
which,  not being attributable to any of the
symptoms  in  particular,  must be  referred to
them all collectively, or rather  to  the disease it-
self, taken as a whole.  These affections are not
indeed perpetual,  or uniform, because they may
either occur or be wanting: but it remains to
be enquired what injury they may do, when pre-
sent, to certain organs of the body.

    It is very-common in  intermitting fever,  for
p atients to experience pains  in the head,  some-
times slight and at other times extremely acute.
It would seem, at first sight, that the violence of
these pains is to be attributed to the impetus of
the blood against the brain. But that is not the 
136
 cause to which the mischief is to be always refer-
 red.  The blood circulates, at times, with ex-
 treme violence without producing any such affec-
 tions of the head.   We have already mentioned
 that the febrile poison oftentimes  attacks the
 seat of  the intellect, producing convulsions, le-
 thargyr, and even madness.  For the same  rea-
 son it  stimulates the membranes of the brain.
 Hence arises  the most excruciating pain, which
 usually rages during the  actual continuance  of
 the fever, and ceases during its intermission.

    Other patients are heard to complain of af-
 fections of the stomach.   That organ is affected
 with nausea, vomiting, and loathing of food, or
 with a sense  of heaviness, burning,  and tight-
 ness.   Some  patients  experience in  it at  the
 same time pains  of different kinds.   But  a
 symptom which occurs no less frequently,  and
 is of no  less importance is, a  distension or
 swelling of the stomach. This symptom is some-
 times met with even in intermittents that have
 not been of long duration, and continues in many
cases after the febrile symptoms have terminated:
 but it occurs  most frequently in those which
 have been of  long continuance, or which have
 been treated in an injudicious manner.

    But we more frequently  meet with a swell-
 ing of the abdomen or lower belly, which as- 
                      13T
sumes a variety of appearances. It is sometimes
soft, and at other times the integuments appear
like dry parchment;  but most frequently  the
abdomen is  very much distended.   On  some
occasions its hardness and resistance to the touch
are so great as to resemble marble.   Notwith-
standing this,  it is as true as it is surprising,
that on  these occasions,  there can be nothing
found in the  abdomen but air distending the in-
testines by its elastic force.

    All these symptoms proceed, for the most
part,  from some derangement in the functions
of the liver.  The secretion of bile, for instance,
is either checked or diminished, or that fluid be-
comes acrid and unfit for the business of healthy-
digestion.  If the fever be of a higher grade, the
sick sometimes  complain of a sense of heaviness
and anxiety  thence arising, or of severe  pains
in  the right hypochondrium.   Some persons
suffer a  slight attack of hepatitis.   Hence we
plainly perceive  why the countenance becomes
yellow or livid,  and how readily an intermitting
fever  may be succeeded by a jaundice, a circum-
stance which frequently occurs in  certain epi-
demics.*

    * Attacks of jaundice were uncommonly frequent among tIk-
citizens of Philadelphia daring the winter of 1793-4.  The pre-di*-
position to that complaint had been produced by the malignant epi
                      T 
                        138
    There are  many  other  troublesome symp-
toms which originate from the same source.  It
is not to be wondered at if such a serious affec-
tion of an organ so necessary to life should prove
highly injurious to the surrounding parts ;  if it
should  render the intestines  tumid, and cause
even the external  parts of the body to swell.  In
some epidemics I have seen this swelling occur
as early as the eighth or ninth day of the disease.
In  general,  however,  it makes  its appearance
later,  and arises, like dropsy, from some morbid
affection of the viscera.

    But the liver proves the  cause of still further
evils in  the  course of intermitting fever.  With-
in the texture of this viscus the blood accumu-
lates and there  stagnates.  That blood which is

demic of  the preceding autumn.  In  its  future occurrences the
malignant fever was not productive of jaundice to the same extent.
The explanation of this fact does not appear very difficult.  During
the epidemic of 1793, but few of our physicians treated the disease
by copious blood-letting  and purging.   Hence hepatic congestion
was not in general sufficiently removed.  Of this remaining conges-
tion jaundice was a natural consequence.  On all subsequent occur-
rences of the malignant  fever, copious blood-letting and purging
were more generally adopted in practice.  Hence the liver was un-
loaded and consequently  obstruction and jaundice prevented.  I be;,
lieve it may be laid down as a principle to which there is no exception,
that proper and timely evacuations will always prevent bilious affec-
tions of every description from terminating in either jaundice or
dropsy......Trans. 
                      139
 thrown into the vena porta? cannot go forward :
 the other parts of the abdomen therefore  must
 necessarily  become turgid,  because the blood
 which flows  constantly into them,  is subject to
 a  similar stagnation  or  delay.  The spleen in
 particular becomes  turgid,  and is oftentimes
 greatly increased in bulk :  the parietes of the
 stomach and intestines become thickened,  and
 the« mesentery also is subject to  tumefaction.
 From this state of things arise obstructions, pu-
 trid diarrhoeas, dysenteries, and dangerous dis-
 charges of blood.  All these symptoms frequently
 occur in certain epidemics and in fevers of long
 duration.

   Hence it appears that the  force of flatus not
 only  distends the abdomen,  but also increases
 the size of the viscera.   The blood and other
 fluids  being accumulated and made to  stagnate
 in certain internal parts, are converted into solids
 and thus augment the  bulk of these parts.  The
 truth of this  will be demonstrated by the dissec-
tions  of which we shall  speak hereafter.  We
must not be  surprised, therefore, at finding the
abdomen to appear uneven, filled as it were with
tumors, and  much harder than in a natural or
healthy state.  From the irritation of the fever
some  degree of rigidity cannot fail to occur in
this part. 
140
    It is much more surprising that, during the
existence of this abdominal tumefaction, the fe-
ver in many cases not only remits, but  even
ceases altogether or changes its nature.   When
the febrile poison exerts its force on the viscera
of the abdomen,  it appears to desert the other
parts  of the body, or rather to act on them in a
different way.   The  same thing takes  place in
swellings of the lower parts, of  which we will
treat  presently.   When  such swellings occur,
the fever  disappears or  gives ground  to hope
that it soon will disappear.   But this exemption
from  fever is not  universal.   In  some  subjects
the fever  continues, even  when  the abdomen,
the lower extremities, and other parts of the
body  are greatly tumefied. Under such circum-
stances a  new disease  is superadded to the ori-
ginal  one.

    Although the foregoing effects of intermit-
ting fever are very  distressing,  we must not
consider  them  as necessarily fatal.   Youthful
persons who are most subject to them, and who
are sometimes  so reduced by them that death
appears inevitable, do, notwithstanding, often-
times recover from them, and that sometimes by
the powers  of nature  alone.   In adults  also,
when the functions of the abdominal viscera are
so much diseased, that it  seems scarcely practic-
able for the relics of life to  be  continued any 
141
longer, remarkable recoveries sometimes occur.
Many persons  by the proper administration of
remedies, and many others by a change of cli-
mate, and even  by the approach of summer are
restored  to such  perfect  health,  that no one
would suspect them to have been indisposed.

   From these  circumstances it would seem that
the obstructions arising from intermitting fever
are of a  peculiar kind,  and not so  dangerous
as those arising  from  other  causes.   Hence
remedies  may  be administered  and  hopes  in-
dulged even in  cases of the most unpromising
aspect. 
CHAP.  XXI.
Of affections which remain after the febrile form of the
            disease has been removed.
    SO much for those affections which occur
during the course of intermittents.   But there
are many others, and those of no inconsiderable
moment,  which remain after the febrile form of
the disease has been cured.   Thus,  some pa-
tients are subject to a most acute and distressing
pain in the head.   To such a height does  this
pain sometimes arise,  that the whole  original
disease would seem to be changed into it.  The
patients sometimes declare that the head feels as
if it  were cleft asunder in the  middle.   Under
such circumstances it cannot be supposed  that
the whole of the febrile poison is eliminated from
the system.  In some instances, however, after
having given rise to such  excruciating pains, 
143
it is dissipated either by the spontaneous powers
of nature, or by the aid of diluents alone.

   At other times, after the febrile  symptoms
are gone, the whole body  seems as if it would
melt away.  At night, in particular,  the sweats
are so profuse and oppressive, that they exhaust
in a short time the strength of the system.  Dur-
ing this  deluge,  it is a great error to suppose
that the fever is cured : the febrile cause seems
to be only thrown on the skin.  At  times,  in-
deed, sweats may occur from mere  debility  of
the system ; but  they never fiow  in such abun-
dance, unless some morbid  cause  be acting on
the  viscera.   By  such  a fomes the discharge by
the  skin  is rendered  so profuse  that  it can
scarcely  be restrained;  and if it be restrained
by  an unskilful  mode of treatment, the  step
proves always injurious to the patient, as I have
learnt from  repeated observation.

    Of all the complaints that remain or can rer
main after the fever is  removed, by far the most
troublesome are the morbid affections of the vis-
cera.  Indeed when we consider the great pow-
er which  the febrile  poison sometimes  pos-
sesses, we cannot be surprised at certain vestiges
of it remaining in the  system for a considerable
time.   These show themselves more particular-
ly in the liver, and from that organ arise many 
144
affections,  from which the sick are with great
difficulty relieved.   There are also other parts
of the system  in  which very troublesome and
grievous relics of the disease remain :  the pan-
creas becomes indurated ; the spleen is enlarged;
the intestines with difficulty recover their healthy
functions;  the appetite  is  weak;  the strength
is exhausted ; and the countenance is overcast
with a livid or yellowish hue.

   Hence  it appears how  readily  this disease
may  be  succeeded by a  watery swelling in va-
rious parts  of the body.   As soon as the vio-
lence of the fever abates, the feet  and legs  in
many cases become  cedematous.  This effusion
into  the cellular membrane  takes place, partly
from the obstructions that remain, and partly  in
consequence of  the  force of the febrile poison
being  determined to  the  lower  extremities.
Hence the occurrence  of a watery swelling  of
this  kind may be considered as a sign that the
fever is declining.  Youthful persons are not  so
subject to swellings of this nature.  Indeed such
affections occur most frequently among persons
in indigent circumstances, either because these
subjects  are deprived of the advantage of able
medical  aid, or  because their bodies,  being
worn out by fatigue,  are thereby rendered more
liable to obstructions. 
                      145
     This swelling of the feet and legs oftentimes
 degenerates into true and  general  dropsy; and
 oftentimes into an anasarca only.  But it occurs
 in certain  epidemics more frequently  than  in
 others.   Last year,  for instance,  was remark-
 able  for  swellings of the feet, legs,  arms and
 hands : the lungs themselves were oppressed by
 the effusion ;  sometimes the difficulty of breath-
 ing was  very great: the sick were  harrassed
 by a troublesome cough, particularly in  cases of
 general  anasarca.   These affections  occurred
 more frequently as the consequences of irregu-
 lar intermittents.

    Occasionally,  however, they  are  produced
 by simple  intermittents.  A man aged thirty,
 was lately ill  of a  tertian  fever.   The  disease
 having been neglected for several months, as-
 sumed an irregular type.   It was at length suc-
 ceeded by a general anasacra, which no remedies
 could remove.  What seemed most surprising
 in this case was, that on dissection scarcely any
 disease was discovered in the viscera,  which
 could be considered as the cause of the  anasar-
 cous swelling.   Hence it appears,  that an uni-
 versal diffusion of the febrile poison can produce
an universal and fatal effusion  into the cellular
 membrane.
                    -tr 
CHAP.  XXIf.
Of relapses in Intermittents.
   FROM these affections of the viscera in in-
termittents,  it is evident that the febrile poison
may, for a long time, remain in the system, and
produce frequent and unexpected returns of the
fever.  So subject are patients to relapses in this
disease,  that,  in the opinion of some persons,
great  precautions ought still to be used on the
day and at the hour of its usual occurrence.   It
has been observed by certain  writers that after
the entire solution of the fever, and even after
a long intermission of its paroxysms, those pa-
roxysms are apt to recur about the same hour
of their original commencement, in case any im-
prudence be committed about that time.   I will
not vouch for the perfect accuracy of this ob-
servation. 
147
     Be these  circumstances as they may, it ap-
 pears from actual experience, that if the fever be
 not radically cured,  it does not give a respite of
 more than  fourteen  or  fifteen days.*   This,
 however,  is not always the case,  but it is to be
 considered  only as a general rule.  Sometimes
 the disease grants a much longer respite;  thus,
 for example, the patient is not unfrequently ex-
 empt from it throughout the winter, and attack-
 ed by  it again  in the  spring :  it  disappears a
 second  time  during the summer  months,  but
 returns again in the autumn, unless prevented by
 proper remedies.  In the intervals  between those
 periods  the disease  is  oftentimes excited  into
 action by various causes.


    But  as these causes are  various, so are also
 the febrile relapses which they produce.   Often-
 times  when the prospect  of a recovery is very
 flattering,  all  the symptoms return as at first:
 the paroxysms for instance recur with various

    * Intermitting fever has certainly a strong disposition to return
 at weekly periods, for a considerable time after the suspension of its
 paroxysms. The knowledge of this fact is of much importance both
 to physicians and their patients.   By using proper precautions at
 these periods, the return of the disease may be easily prevented.
 As a week is about the fourth part of a lunation, some physicians
 have attributed this hebdomidal recurrence of intermittents to lunar
 influence.  Conformably to this opinion, they contend that the dis-
 ease manifests the strongest disposition to return about the full and
change of the moon. Be this matter as it may, there appears to be
 but little reason to doubt the reality of at least some degree of- lu-
nar influence on the human system.... Trans. 
                    148
degrees of force and duration ;  in a certain time
thef* cease v$gam and are again renewed,  but
sornetffnes with  more irregularity than  before.
The disease now and then assumes the form of
a remittent or a continued fever, and afterwards
returns to that  of an  intermittent.  Thus  it
oftentimes runs  on for a great length of time,
harassing the sick  by  various and irregular
symptoms.

    These circumstances may occur at any time,
but they  happen  most frequently  during the
prevalence of epidemics. I have met with these
alternate appearances,  and  with this alternate
cessation and return of the complaint, more es-
pecially in those fevers that rage in marshy situ-
ations.   When  these diseases have continued
for a certain time they scarcely admit of a  per-
manent  cure.   Relapses  happen on the most
trivial occasions. Oftentimes when the patients
seem to be nearly restored to health,  that is, re-
lieved from the paroxysms,  they are suddenly
carried off by the disease.  Others drag on with
difficulty a wretched existence from autumn till
summer.   Nor are they all freed from the  dis-
ease even then : many of them are only somewhat
relieved. In the mean time relapses are very apt to
occur, in consequence of the relics of the fever
that  remain in the system, and the  various
symptoms by which the sick are affected. 
149
    In these relapses the appearances are various.
The  paroxysms recur indeed  at stated hours
and on stated days, but without a perfect inter-
mission intervening.  On the days of intermis-
sion some degree of fever still seems to prey on
the internal  parts of the system.   In some  of
these cases, the sick are scarcely able to sustain
themselves, having at the same time a pale and
yellowish appearance.  The fever is a  kind of
continued one, although marked with paroxysms
that pursue the usual order. Hence there seems
to be a two-fold cause of the disease or febrile
action ;  one of these consists in a diseased affec-
tion of the viscera ;  the other in the presence of
the miasma, which  constitutes the fomes of in-
termitting fever.

    In some instances, these diseases seem to in-
cline  more to the  form  of hectic fever.   The
regular  periodical  paroxysms   cease,  but  the
pulse rises in the night, without either a cold or
a hot fit of any consequence. The intermediate
dayrs are  never free from some degree of fever,
particularly in  those patients,   who have been
treated unskilfully.   Relics of the same kind are
met with in those who suffer frequent relapses
in consequence of an affection of the viscera, or
of the force of the febrile poison.

    We will proceed no further in considering
the various kinds of  relapses.  But although in 
                     150
 certain cases they are so frequent and diversified,
 it is still the opinion of some writers, that persons
 who have once laboured under intermitting fe-
 ver, and been perfectly cured by a true crisis
 and proper remedies,  are in general less liable to
 it during the remainder of their lives than they
 were before.  There  are at least very few per-
 sons who have been subject to frequent attacks
 of quartan fever.   I do not mean by this, that
 those  who  have been once subject to intermit-
 ting fever have nothing to  apprehend from epi-
 demics, or from those places in which epidemics
 of the kind usually  prevail:  for  when their
 bodies are surrounded by  febrile miasma, that
 poison cannot fail  to make some impression on
 them,  notwithstanding their being less pre-dis-
 posed  to  receive its  action.  The meaning of
 physicians on this  subject appears to have been,
 that those persons who have once experienced
the  effects of the poison of intermitting fever,
 are  not,  in  general,  so  susceptible  of them
 again.

    Be this  matter as it  may, it appears from
 what has been said, that there are two  points of
primary consideration with respect to the relics
 of intermitting fever.   Either the febrile fomes
remains in the system  and re-produces a regular
 intermittent; or some principal and important
parts of the system suffer serious local affections. 
151
In these cases relapses are to be dreaded, and
when they take place do not easily admit of a
cure :  or if the intermitting form of the fever be
removed, still  the patients are apt to continue
infirm and sickly during the remainder of their
lives :  in particular,  obstructions of the viscera
remain,  which greatly  impede the performance
of their functions. 
CHAP. XXIII.
Of the morbid appearances discovered in the dissection
  of the bodies of those that have died of Intermittents.
    IN the dissection  of dead bodies the fore-
going obstructions and  local affections are dis-
covered.  It is not my intention to treat of those
that are found in bodies that have died of a com-
pound remitting fever. In that disease the vital
principle  is  overwhelmed  or  extinguished by
the force of the febrile poison ; the head is se-
verely attacked ; other parts suffer great injury ;
the whole system is thrown into commotion by
spasms  and  irritation, and hence death is pro-
duced  in  the  same  manner  as  in continued
fevers.

    But simple intermittents, or those that dege-
nerate into hectic or such like fevers,  leave va-
rious vestiges of themselves in the body. Certain 
153
 parts, however, they attack with more violence
 than they do others.   The  head,  for instance,
 seldom exhibits  any  morbid  appearances, al-
 though it sometimes experiences the most ex-
 cruciating pains.

    But the organs of circulation and respiration
 suffer  greatly,  as we  have  already mentioned.
 The auricles of the  heart, and  the  pulmonary
 vessels are turgid with black blood.  A great
 congestion takes place in the minute lobules of
 the lungs, and there is water effused into the
 cavity of the thorax.   In some cases the peri-
 cardium is  distended with  water.   This latter
 circumstance is particularly observable in those
 who die  of intermitting fever  in  maritime situ-
 ations.

    As the stomach is so often affected with vo-
 miting,  it is no wonder, as already mentioned,
 that it should  be found greatly distended with
 flatus.   The distension and the irritation from
 whence this distension arises,  sometimes pro-
 ceed so far as unquestionably to prove the cause
of death, by occasioning in many cases a spasm
of the parietes of the stomach.  I have seen per-
sons  who, when apparently  free from  fever,
have been destroyed by overloading their sto-
mach at supper.  In these cases the stomach
was wonderfully distended either with flatus or
                      x 
                     154
with water, or was overpowered by the quantity
of food taken in.

   But the  deepest ravages are  found in the
liver.  That organ is for the  most  part  pale,
bloodless, and somewhat wasted away. At times,
however,  it is  enlarged in its size,  indurated,
and variegated  on its  surface with small yellow
glands; at other times  again it is turgid  with
blood, and that very black.  In some patients I
have found an abscess of the  liver after tertian
fever; while in others, again,  I  have seen the
vena  porta? converted  into a  very  large tube.
Many other affections of the liver are  mentioned
by  medical writers ;   it  has been found  very
remarkably   enlarged;   the  ducts  distributed
throughout its substance are entirely obstructed.
The gall-bladder is also found obstructed, and
distended with bile.

    The pancreas is also subject to the ravages
of  intermitting  fever.   In  some dead bodies
only certain parts of  that  viscus  are found ob-
structed ; in others  its whole mass is  either
schirrous or greatly enlarged;  some physicians
have seen it in a state  of suppuration ; for this
reason, as I have elsewhere observed, they have
considered it as the great repository of the fomes
of intermitting fever.   It  is not,  indeed,  to be
wondered at, that obstructions should occur in 
                      155
  this viscus,  since  the  blood stagnates,  or at
  least moves very slowlyr in the hepatic veins.

     For the same reason the spleen has been sub-
 ject to the same charge.   Its bulk, for instance,
 is sometimes greatly enlarged.  I  have even
 known  it to acquire  this increase of bulk in a
 short  space of time.   But,  what seems more
 surprising, that viscus has returned to its natu-
 ral state again, by the exhibition of febrifuge re-
 medies alone.  But the spleen not unfrequently
 suffers another kind of morbid  affection : it is
 filled with black blood resembling tar or pitch :
 it then runs  into something of a gangrenous
 state.   A woman laboured under a neglected
 quartan ; being  destitute of the common  com-
 forts of life, she died suddenly.   In  the  dissec-
 tion of her body, the spleen was  found in some-
 what of a dissolved  state;  and a large quantity
 of blood was  effused into the abdomen.

    Hence it appears, as  mentioned on a former
 occasion, how liable to disease  the peritoneum
 and  messentery are; in these parts schirri and
 abscesses have been  found.  Having oftentimes
 examined these parts,  I  have plainly observed
 the glands of  the mesentery in a diseased state.
 In very yToung people, in particular, I have seen
these glands obstructed and greatly increased in
size.   In the duplicative of the peritoneum va- 
                     156
rious tumors occur, which either produce a con-
gestion,  or are the effects of  one.   The fluids
in consequence  of stagnating become consoli-
dated, and firm, and thus form a kind of steato-
matous substance.

    In the intestines  certain  appearances  arc
observed, which may be attributed to the fever;
these parts,  as we have already observed,  are
greatly distended ; but as they are distended in
some places,  they are constricted in others.   In
the colon, in  particular, I have found various
contractions of its diameter, especially where it
passes over  the left kidney,  and  dips  down
again, previously to its terminating in the  intes-
tenum rectum.   From  these contractions  or
narrownesses many consequences arise, which I
shall not mention at present, as they may  be
readily foreseen  by every medical reader.

    There are still other morbid affections which
take place after intermitting fever. These,  taken
in conjunction with  such as have been already
mentioned, enable us to judge whether or not
intermittents ought to be ranked among the sa-
lutary processes  or states of action  of nature.
That this is the case, many writers haveattempted
to prove, both by argument, and by the autho-
rity of the ancients.   But can a disease  be  of
itself salutary, or can it be considered as such in 
                     157
its nature and real tendency, when,  during its
course,  so much local injury is done to various
parts of the system ?

   Theory is too oftentimes nothing more than
the visionary offspring of the imagination : it is
experience alone on which we can finally depend.
Many physicians seem to be convinced by ex-
perience that quartans contribute much to lon^
gevity.  This only, in my opinion, can be main-
tained on the subject, namely, that intermittents
may  sometimes  cure  certain  other diseases.
There  are, for example, relaxed or debilitated
bodies in which the motions and actions of the
internal parts of the system are too weak :  there
are also certain nervous and convulsive affections
which may  be removed by adding strength to
the motions of the  internal parts:  by this in-
creased motion, stagnations are removed;  new
power is bestowed on the vital organs ;  noxious
humours are thrown off by perspiration; a new
crasis  or constitution is given to the  blood;
and the  whole habit of the body is changed.

   A certain description of febrile paroxysms,
therefore may restore or confirm health.  But if
these paroxysms be very severeandlongcontinu-
ed, they not only will not prove salutary, but will
do mischief, and that the more dangerous in its
nature,  in proportion as the  system  is  more 
158
weak and delicate, or more affected by other dis-
eases.   Persons subject  to jaundice, cough or
any  other  pulmonary affection, have no  advan-
tage to expect from an attack of intermitting fe-
ver.   This at least is generally true, nor can it
indeed be otherwise,  unless there be  in the sys-
tem,  certain noxious humours, which produce
these affections, and w hich may, by the action of
the fever, be changed or  corrected. 
         BOOK  SECOND.

                 OF THE

TREATMENT OF  INTERMITTING

          AND REMITTING FEVERS.
                CHAPTER I.

 Of the difficulty of curing Intermittents, and wherein
             that difficulty consists.

     IT now remains to consider the treatment
and  cure  of intermitting fevers.  To many it
will  seem scarcely necessary  to touch on this
subject;  for there  is no one who does not con-
sider himself competent to the cure of these
diseases.   A firm  belief has hence arisen, that
few  or no  persons ever die of intermittents.
These fevers sometimes terminate spontaneous-
ly, or are  in many  instances easily cured ;  nos-
trums for that purpose are in the hands of every
one, and are even publicly sold under the sanc-
tion  of medical characters.  Whatever precepts
and modes  of practice, therefore,  may be laid
down on the subject, will be considered by many
as an ostentation of learning. 
160
    But  intermitting fever  is  sometimes  ex-
tremely dangreous, and in many cases difficult
to be removed.  The mode of cure itself may
prove injurious ;  and numerous controversies
have arisen  respecting  the proper mode.  As
there is no opinion, however ridiculous that has
not originated with or been supported by some
philosophers ; so there is no remedy, however
absurd and injurious, that has not been the se-
cret nostrum of some physician.

    Nature herself appears to us to act caprici-
ously in the cure of diseases.   Thus, fevers are
sometimes cured alike by heat and  by cold ;  in
some cases acrid substances, in others demul-
cents, effect  a cure ;  in some, wine and ardent
spirits, in others,  copious  draughts of water;
even poisons themselves have become celebrated
for various cures;  finally, there is  scarcely any
thing whether noxious or innocent, that has not
cured  intermitting fevers.   Even  when these
diseases have been attacked to  no purpose in a
rational mode of practice, it has not unfrequent-
ly happened, that they have been  completely
subdued  by a very preposterous and perverted
mode.

    The road, therefore, which leads to the cure
of intermittents, instead of being plain and easy,
is, on the other hand, extremely difficult and la- 
161
 borious.  The greater the number of remedies
 appears to be, the easier it is to err in the choice
 of them.   That an opinion may be the  more
 readily formed respecting them, we will premise
 a few considerations.

    Those things that are not consistent  with
 themselves,  or which do not generally succeed
 in effecting a cure, cannot be considered as reme-
 dies ; but of this description are many things
 that  are  carried about and  sold as  antidotes.
 Much more ought we to reject whatever may be
 attended with any degree of danger, such as
 acrid and heating substances, which are almost
 always  hurtful, even when  they effect a cure.
 The same thing must be  said respecting reme-
 dies of opposite powers.  Of two remedies  pos-
 sessing contrary qualities, one must he hurtful,
 particularly if their action  on the system be
 powerful.

    From so many cures, which are attributed to
 these remedies,  it will  appear that nothing can
 be deduced, if we enquire into their true cause.
 Such are the nature and principles of the febrile
cause, that at times nothing seems necessary to
the cure of intermitting  fever, but some striking
and sudden change; hence fear or terror sudden-
ly  induced  sometimes  eradicates  the  disease.
The same effect is produced  by great heat,  ex- 
162
ercise,  the  use  of acrid  substances,  &c. but
these are not certain and well established reme-
dies ; for, though they may succeed in one case,
they fail in many.  Besides,  if they do not hit
their  mark,  and  destroy the fever as it were by
a single blow,  they are sure to render it more
obstinate and dangerous.

    Nor can even the remedies proper in  inter-
mittents be  safely exhibited unless with the ut-
most circumspection and care.  There are some
remedies which may remove the disease, and
prove at the same time hurtful to the patient.
Hence the dissentions between physicians of dif-
ferent countries ; they trust and distrust certain
remedies, and that, at  times, for reasons alike
unsatisfactory.  Those physicians who even use
the same remedies, are scarcely able to agree re-
specting the proper method.  Thus the lives of
their  patients are sometimes exposed to danger
by their controversies.

    Amid so great a variety of opinions,  it is a
matter of no small moment to select the best me-
thod of cure. This method consists in the pro-
per use of two kinds of remedies, namely,  those
which are called general,  or  common to other
diseases, and those that are specific, or peculiar-
ly suited  to intermitting fever.   The general
remedies, such as evacuants, diluents, and ape- 
                     163
rients, are the most powerful; by  their use the
body is reduced nearer to its natural state.  The
circulation  of the  blood is  easier,  the  several
parts of the system perform their functions bet-
ter, and the depraved juices are altered or eject-
ed.   Specific remedies, therefore,  may be ad-
ministered most certainly and safely, after general
remedies have been premised.  By these latter
remedies the way is paved for a cure,  while by
the former the cure is accomplished. 
CHAP. II.
Whether or not all Intermittents are to be treated with
   the same remedies ?   Whether or not, when left to
   themselves, they terminate or come to a crisis spon-
   taneously ? and whether or not an attempt should be
   made to cure them at their very commencement ?
    WE must now enquire whether or not every
intermitting  fever ought to be treated  in  the
same manner.   There is a wide difference  be-
tween vernal  and autumnal intermittents : their
nature is indeed the same, but the febrile poison
seems to be milder in the former than it is in the
latter:  this,  however,  is not always the case,
for we sometimes observe vernal intermittents to
be possessed of a malignant character.

    But, in general,  these diseases of the  spring
are easily removed.   After having run on for a
short time,  they  very frequently terminate of
their own  accord.  An  attention to regimen 
165
alone is adequate to the cure of them.   If they
require any remedies, neutral salts and other
aperients are for the most  part sufficient.  It
would seem that if there be any fevers of a salu-
tary tendency it must  be these ; they open the
vessels and pores that have been  obstructed du-
ring the winter ;  they  communicate motion to
the stagnating fluids, and, by means of febrile
action,  either change  them  or discharge them
through the different emunctories.

    Fevers  happen also at other  seasons of the
year which are by no means obstinate or difficult
to be cured.  This arises either from these dis-
eases attacking persons of favourable habits of
body, and not abounding in depraved humours;
or, what is very common, from the febrile poi-
son being extremely weak.  In attempting the
cure of such diseases, but little can be done; at
least a few remedies are sufficient,  such as dilu-
ents,  aperients,  and mild purgatives.  If specifics
be necessary, it is not requisite that they should
be exhibited with such great precaution. Thus
the method of cure ought to be suited to the cha-
racter of the disease.

    Here a  question of great moment  arises,
namely, whether or not, if intermittents be left
to themselves, they admit of a spontaneous cure ? 
                     166
 Some  writers believe that they terminate after
the seventh paroxysm, and that they have a fixed
 period of duration as well as continued fevers. I
 am, indeed, of opinion, that if in intermitting fe-
 ver the patients be confined to a strict regimen,
such as is usually prescribed in acute diseases,
 the intermittent will soon come to a close.  Se-
veral examples have occurred  to convince me
of the truth of this.   But to do away every  re-
maining doubt on the subject,  it would be ne-
cessary to confine  a  certain  number of sick
persons to this regimen alone without any other
remedy.

    But,  (a circumstance which is less doubtful)
if, during the observance of such  a  regimen,
gentle remedies be administered, these diseases
are in general very easily cured, provided they
be not  marked with  great violence ;  and provi-
ded there be no serious epidemic prevailing. But
there is a necessity  for using the remedies just
mentioned, because  there is frequently too much
blood  in the system ; because  the  primae vise
abound with depraved humours;  and there is
sometimes a great  accumulation of bile.  All
these impediments must be forthwith removed,
in order that nature  may be able to do her work
spontaneously, and  by her own inherent pow-
ers. 
                     167
   If nature  be thus dealt with and regulated,
she usually brings about a kind of crisis in the
disease.   The third paroxysm  is more severe
than the  two preceding ones, but the sixth is
the most severe of any.   The seventh, which is
generally the last, grows milder, but is succeeded
either by  a gentle sweat, or a diarrhoea,  or the
morbid cause is  carried off by both these modes
of evacuation occurring at the same time.  Some-
times these efforts  of nature occur several days
after the seventh paroxysm.  It must be acknow-
ledged, however, that in many cases no  critical
evacuation can  be  observed.    This happens
more particularly when the system is disturbed
by  a  multiplicity of remedies,  or  the  febrile
symptoms subdued at once  by  their  specific
power.

    There arises another question of no less con-
 sequence relative to the use of both general and
 specific remedies in these diseases.  It is enquir-
 ed, for instance, whether or not it  be  best to
 attempt   the cure of intermittents immmedi-
 ately on  their commencement, or to  suffer them
 to  run  on  unmolested  for a certain length of
 time ?

    We do not here allude to those patients  on
 whom intermittents may have a salutary effect. 
                     168
If these complaints are likely to eradicate some
other disease, they may then,  indeed, be left
to nature for some time.   But if they attack
persons in health,  will they,  under these cir-
cumstances,  prove serviceable  to  them ? and
whether will it be better for those attacked to be
relieved from them, or  to  suffer the poison of
them to rage through their systems ? We are
persuaded from every view of the  subject, that
the poison ought to be eliminated from the body
as soon as possible,

   I am in the habit of paying particular atten-
tion to the force and character of the fever, and,
as soon as I discover that it cannot he subdued
without difficulty  by the powers of nature, hav-
ing first prepared the system in the proper man-
ner,  I  have  immediate recourse to specific
remedies.   Nor have I ever, in the course of
many years, known any7 mischief to arise from
this mode of practice.  Even  fevers  of a bad
aspect  have  been removed w ithout leaving any
vestiges of themselves behind.  On this circum-
stance  alone  the  issue  of  the matter entirely
depends,  namely,  that the  medicines be  skill-
fully  administered,  and the system properly
prepared for  them by a diluting, cooling, and
opening regimen.    I acknowledge, indeed, that
if physicians  have  recourse immediately to fc- 
                     169
brifuge medicines, and those of  heating quali-
ties, they will, in many instances, do mischief;
but it does not follow from thence, that inter-
mittents ought for a certain time to be left to
themselves.  When thus neglected they gene-
rally take deeper root and become more obsti-
nate and difficult to be cured.
z 
  CHAP.  III.


Of Blood-letting.
   THE first remedy  that  presents  itself is
blood-letting.  Vet it must be confessed that this
alone is  not a cure for intermitting fevers.   It
is, therefore, that it is so often spoken  of unfa-
vourably, and accounted altogether useless : if
some writers are to be credited, it is even to be
considered as injurious.  Perhaps this opinion
has been derived from the effects of very copious
hemorrhages,  which, at times, have appeared to
add strength to these fevers.   It does not, how-
ever,  follow  from thence, that blood-letting is
to be entirely rejected, as if  incapable of doing
good in such diseases.

   On this subject nature  and experience fur-
nish us many things worthy of notice.   I have
oftentimes seen double  tertians  converted  into
simple tertians by a single blood-letting.   Half 
171
of the disease, therefore, may be removed by the
loss of blood.   But, what is of no less moment,
I have learnt from certain and repeated observa-
tion,  that the paroxysms  are rendered much
milder by it, and made  to recur at a later hour.
Besides, after blood-letting, the  febrile heat is
less distressing, the sweats are less profuse, the
pain in the head is milder, and all the functions
of the body go on with more regularity.

    It may be laid down, therefore, as an esta-
blished principle, that if venesection does  not
absolutely cure intermittents, it  paves the way
for other remedies,  and is on that account high-
ly necessary.  It remains, therefore, only to be
determined, whether or not it be necessary in all
cases,  whether  it may not be, or rather ought
not to be omitted in some, and, finally, what are
ihe limits that ought to be set to it ?

    It would, indeed, be absurd to have recourse
to blood-letting in every febrile affection. There
are cases in which it is allowable and even neces-
sary to  abstain from it; these are such as are
mild in themselves, or such as attack persons al-
ready  very  much exhausted and  debilitated.
Fevers of this description stand the less in need
of such a remedy,  in as much as many of them,
and those of a serious aspect, have been occasi-
onally curetf without blood-letting.  But these 
                     172
few examples ought not to divert our attention
from the precepts of reason and the result of ex-
perience.   It is safer to have recourse to blood-
letting even when not absolutely  necessary, than
to neglect it when it is necessary7.

   It  would be particularly  injurious to omit
blood-letting in  cases  where  the biood-vessels
are turgid, the fever intense, and the patients dis-
tressed with a burning heat,  or,  an extremely
acute pain of the head: by such an omission
the fever would be rendered worse, and the va-
rious functions of the system probably injured.
To the neglect of blood-letting is the obstinacy
of fevers  to  be  generally attributed; from this
source must  we  oftentimes derive the failure and
even hurtful effects of febrifuge remedies. It ap-
pears from the best founded experience, that  a
fulness of blood, an impetuous circulation, and
the febrile heat thence arising are unfavourable
to the success of such  medicines.

   How far  blood-letting ought to  be carried,
it is impossible to state.  This depends  on the
constitutions of patients,  and  the violence of
their symptoms.   In as much as these circum-
stances may be various,  so may the amount of
blood necessary to be drawn ;  at times, indeed,
it must be large. The nearer the fevers approach
to a continued form,  the more frequently must 
173
recourse be had to the remedy of blood-letting.
This precept,  which is founded  on experience
and reason, shall here be illustrated by a few
examples.

    In an epidemic constitution which once pre-
vailed in this place,  the fevers were double ter-
tians, and many assumed even the appearance of
continued fevers. In these the sick experienced
no relief till  after three or four blood-lettings.
In many cases the  pulse  was  so hard,  and the
pain of the head so acute, that the practitioners
were obliged to repeat the blood-lettings five or
six times.   If this remedy  was  neglected, the
heat was intense and burning; the pains of the
head w7ere intolerable ; and the disease generally
put on a  true continued form.  But after the
tone of the  system had been reduced byr blood-
letting, all the symptoms soon remitted, and left
an opening for the exhibition of other remedies.

    In tertian fevers of a spurious  and  violent
kind, I have oftentimes met with a similar occur-
rence.  When blood-letting was used too spar-
ingly,  the  symptoms  were  usually rendered
worse ; it was in vain that relief was looked for
from other remedies.  But when practitioners,
urged  to it  by the  obstinacy of the disease, had
recourse again to blood-letting, after having used
it  too sparingly at first, the state of the sick was 
                     174
 immediately changed for the  better, the heat
 abated, and the paroxysms became more mild.
 Other remedies which had before been exhibit-
 ed to no purpose, now succeeded in  producing
 a cure.

    In the mean time, in simple intermittents,
 and even in double  tertians, provided they do
 not assume a continued form, one or two blood-
 lettings will be generally sufficient. Nor ought
 the practitioner to go beyond this, in case the
 apyrexia between the paroxysms be perfect, and
 the fever during the paroxysms so moderate that
 it can to appearance be borne, without any ma-
 terial injury being done to the functions of the
 body.

    But, under what regulation shall  blood-let-
 ting be  used, in those intermittents which dis-
 appear for a certain time, and then recur again ?
 must it  be  had recourse to as often as  they thus
 make their appearance ?  It would seem  useless
 and improper to continue to lose blood in cases
 where it has been frequently lost  already;  in
 cases where the disease has oftentimes disappear-
 ed for  a few days, and  then returned again;
 where its  long duration has brought on a cha-
chectic  habit  of body ; and  where,  from the
summer or autumn it has been protracted to the
midst of winter. Finally, to include every thing 
175
in a few Words, the strength of the system ought
to be such as to be able to bear blood-letting, nor
should we ever have recourse to it unless com-
pelled by the violence of the symptoms.

   We have already observed that blood-letting
does not eradicate the cause of the disease, but
merely curbs its violence. But what benefit can
be derived from such a check, in cases where the
vital energy is already too languid ?  The objec-
tions which we here raise can serve only to re-
strain imprudence. No one but a madman will,
in treating a febrile complaint, persist long in at-
tempting to overcome it by very  profuse blood-
letting.  To this practice, when carried to ex-
cess, the king of  Spain is said to have fallen a
victim, and from  the same cause several others
have, to my certain  knowdedge, shared the same
fate.   I do  not mean, by what is here said, that
blood-letting is to be  rejected in every case of
fever of long standing.   If the pulse demands or
admits of it,  if the febrile  symptoms  run  too
high, it becomes unsafe to neglect this  remedy. 
      CHAP. IV.


Of cleansing the prima; via:.
   BOTH before and after blood-letting, a very
light diet must be strictly enjoined, and that even
on the days of intermission.  This is necessary,
at least in the beginning of the disease, and must
be considered as laying the foundation for a per-
fect cure.  At  the  same time diluents must be
used,  in order that the system may  be properly
cleansed; for evacuating medicines do  not  act
with success, unless aided by a plentiful use of
aqueous drinks.   The use  of such drinks is
particularly necessary to  persons inured to ex-
ercise, and such as  are plethoric, bilious, and of
a dry temperament.  In  addition to these dilu-
ents,  recourse should be  had  to injections,  for
the purpose of evacuating the lower intestines.

    These things being  done, measures  must
now be taken to cleanse the primae vise,  and  the 
177
whole intestinal tube.   The fomes of the fever
does  not indeed reside in this part of the sys-
tem :  but the disease may be rendered much
worse by depraved, putrid, or bilious humours:
by such humours the blood is vitiated, an acri-
mony is  created in it, and heat and irritation are
produced ; at least from them arises some impe-
diment to the efficacy and success of febrifuge
remedies.  Experience bears  testimony to the
truth of this, because, while the stomach and
intestines are  overloaded  with  crude humours,
the cure of intermittents continues to be diffi-
cult.   Affections which may be easily removed
after proper evacuations, take deep root and be-
come obstinate if such evacuations  be omitted
or neglected.

   But with  which ought we to begin, emetics,
or cathartics?  It will perhaps to some  seem
best  to refrain from  emetics,  because,  at the
commencement of the paroxysms, the sick are
subject to painful and repeated  vomiting.  Add
to this, that whatever offensive matters remain in
the recesses of the stomach, must be necessarily
expelled  by the efforts and kind offices of nature.
But experience has taught us that such efforts
are useles ;  for  the fever continues, notwith-
standing, extremely violent, and recurs at stated
periods.   This febrile vomiting,  therefore, not
only is not useful, but even does mischief, be-
                     a a 
                     178
cause in the commencement of  the fever there
is a general constriction  of  all parts of the
system;  hence the stomach cannot be properly
evacuated ;  it is  only affected by a morbid ir<
ritation,  which distressess it,  and subverts its
action.

    The  cure of the disease, therefore, calls for
a vomiting to be excited  by art.  It has been
already demonstrated that  the liver is very par-
ticularly  affected : it becomes the seat of a col-
lection^ of vitiated bile: the  blood stagnates in
the branches of the vena p'jrtae ;  and unless this
stagnation be removed, it will operate in con-
junction   with  the vitiated  bile  like a  second
fomes of disease, wdiich readily7 produces fever.
But we cannot with more certainty remove this
stagnation and bilious congestion, in any  other
way, than by emetic medicines  :  for when these
excite  vomiting,  the liver is,  as k were,  in a
press, where it  is agitated by alternate and re-
peated concussions. By such pressure and con-
cussions the blood is forced out of its small ves-
sels, while the bile is pressed into the intestines,
and from thence with the other juices of the sto-
mach discharged by the mouth.

    This  medicine appears particularly neces-
sary in  certain  fevers, or in certain  epidemic
constitutions ; for the sick throw up vast quan- 
                      179
 titles of green, tough bile, similar in consistence
 to very thick oil.  But what is truly surprising,
 or at least of great moment, so rapid is the for-
 mation of this bile, that to vomit once is seldom
 sufficient; for after a short time, such a fresh ac-
 cumulation of bile takes plase,  that another pa-
 roxysm of vomiting occurs as  plenteous as be-
 fore.  But as often as this redundancy of bile
 returns, so often does fever also recur ; whence
 it can be made to appear  by many arguments,
 that the disease is actually kept up by7 the bile,
 a  fluid in other respects  so necessary to  the
 system.

    Nor is there any doubt but  stagnations also
 occur in other parts of the body.  That  this  is
 true, appears from the power and influence of the
 cold fit,  and also from the irregularity and in-
 creased force of the circulation.  The same thing
 may be inferred from  the  obstructions that  so
 often follow intermitting fevers,  But the  circu^
 lation  of the fluids is  greatly promoted by the
 influence and operation of  emetic medicines.
 These medicines rouse the nervous energies, and
 throw  into action the capillary vessels through-
 out the whole system.   Hence the  fluids which
had begun to stagnate and grow solid, as it were,
in the extreme vessels, are again urged onward
in  the course of circulation. 
180
   All these things are confirmed by innumer-
able experiments. Emetic medicines are, indeed,
so efficacious in intermittents, that they often-
times bring them to a close as it were by a single
blow.   Should they even survive, their force is
much diminished.   But, what  is of the utmost
moment, the system is thus prepared for the use
of other remedies, which would have been ad-
ministered in vain, and even to the injury of the
patient, had they not been preceded by the oper-
ation of emetics.   A very material object, then,
in the exhibition of emetics is,  to pave the  way
for the safe and certain  use of febrifuge reme-
dies.

   It is a circumstance no less certain, that when
emetics are neglected, the disease  is apt to be-
come stubborn ond tedious.   In such a case it
can be  successfully  combatted only by emetic
medicines. This is an argument greatly in their
favour.   I have learnt from innumerable experi-
ments, that there is no hope of a recovery with-
out copious  vomiting.   So efficacious has this
remedy appeared to me to be, that I have con-
sidered it practicable to prevent impending fevers
by its proper use.  Nor, indeed, have I betfn de-
ceived in this opinion.  I have kept many  per-
sons free  from  intermittents, though strongly
inclined to them,  by the repeated use of eme-
tics. 
                     181
    Young persons and adults are alike benefited
by the operation of emetics.  Nor is the use of
tartarized antimony to be considered as hazard-
ous to the  former.   Experience has taught me
that the action of that medicine is milder in chil-
dren than in persons further advanced in years.
Many times, however, to avoid alarming my pa-
tients or their friends, I have administered Ker-
mes mineral instead of it,  and that with a happy
effect.   In the case of a female child three years
old,  who  laboured  under a tertian  fever which
also at times assumed the quartan form, I remem-
ber to have used this latter remedy.  As often as
vomiting was excited by it, so often  did I obtain
for my patient a respite of eight or twelve days.
In this  manner did the  disease continue to the
great distress and eminent danger of the child,
from autumn throughout the winter,  and even
to the following summer, when the powers of na-
ture and  the  change of the season effected a
cure.

   But it is necessary that vomiting be  excited
either by this or some other medicines.   For if,
as sometimes happens, their action be directed
to the  bowels  so as to produce a purging, their
effect is not equally salutary.   I have remarked
this in many cases of disease, but particularly in
a certain epidemic constitution, in which medi-
cines usually passed off by the bowels.  From an 
182
 intestinal evacuation, however copious, the same
 benefit was not derived, as commonly result-
 ed from  vomiting.   In this case it appeared to
 me that ipecacuanna was preferable to tartarized
 antimony, because  it produced with more cer-
 tainty an evacuation of the stomach.

    If it were requisite to confirm these things
 by the authority of others, arguments might be
 drawn from sundry medical writings.  Vomiting
 is necessary, says Celsus, in all cases where the
 paroxysms are introduced by a coldness and a
 shivering.   Galen makes mention of many per-
 sons  being perfectly cured by vomiting alone.
 Paulus and Aetius speak also  in praise of eme-
 tics.  Some more modern wTriters attribute also
 great efficacy7 to these medicines.  Among these
 Riverius  extols them greatly:  in  his opinion
 they are  more certain and useful in  their opera-
 tion  than any other  remedy.: he considers them
 particularly beneficial when  administered  for
 three mornings in succession.   Such  a practice
 must not,  however, be ventured on  but with
 great caution.

   There are some physicians who  fly to wild
 spikenard, as  the only sheet-anchor of safety in
 protracted intermittents.  Others, according to
 Jacotius,  cure them with salt of vitriol.  Some
have recourse, and that successfully, to the aqua 
                     183
benedicta  of  Rulandus ;  while others  do not
shrink from the adoption of more powerful me-
dicines, such  as red precipitate, and other pre-
parations of mercury.  But the human mind is
so fluctuating  and unsteady, that it cannot with-
out great difficulty  be brought to  rest at any
fixed point.   Tossed on the uncertain tide  of
opinion, it is constantly borne about in pursuit
of new discoveries.   Hence it is that physicians
wrill neither tread in the footsteps of the ancients,
nor be led  by  the observations of others, to re-
peat the experiments on which those observa-
tions were  founded* 
CHAP.  V.
Of the use of Purgatives.
    I  WOULD not, however,  be understood
to mean, that no intermittent can be cured with-
out the use of emetics.  Many diseases of the
kind are removed or terminate of themselves
without any previous vomiting.  Some of them
are too slight to stand in need of such a powerful
remedy.   Besides, impediments sometimes oc-
cur which forbid the use of emetics.   In  many
cases,  for  instance,  the stomach  cannot  bear
their  irritating power.   They  are particularly
hurtful in affections of the lungs. They are also
hurtful to cachectic patients, who  labour under
local affections of other parts. Finally, it would
be unreasonable and absurd to harass the sick
with emetics, on each return of long continued
intermittents. 
185
    But when this remedy cannot be called to
our aid, purgatives must by no means be omit-
ted.  If the stomach only  be  evacuated by the
emetic, or the bow7els, as often happens,  be but
slightly moved, they must be solicited to fur-
ther discharges.  Some practitioners, therefore,
are in the habit of employing emetics and cathar-
tics combined together.   To me,  however, it
would seem better to exhibit, first, some gentle
purgative, and afterwards when it has begun to
operate,  to administer an emetic.  In this way
both  the  desired effects  are obtained.  The
cleansing of the bowels  by means of purgative
medicines is so necessary, that, unless it be pre-
viously attended to,  other remedies are very fre-
quently employed to  no purpose.   This posi-
tion can  be  established  by  numerous  argu-
ments.

    It may be laid down as a general principle
that a plethora, of whatever kind it may be, is
hurtful in fevers.   It is necessary, therefore, to
expel,  as soon as practicable, all depraved and
putrid  juices from  the  intestinal tube.  This
cleansing of the alimentary canal is of the more
consequence,  in as much as it relaxes  the sur-
rounding parts, makes the blood circulate more
freely,  and opens the secretory  and excretory
ducts.   In consequence of this relaxed  state of
things, the bile, which acts an important part in 
                     186
intermittents, will pass off with more ease. The
urine also, the free secretion of which is of such
moment, will pass more copiously through the
kidneys.

   Certain remedies, besides their purgative pow-
ers, are also possessed of other properties no less
useful. Many of these not only act on the intes-
tines,  but  are   truly aperient;  they  stimulate
the liver  for instance, and produce a flow  of bile
from it.  Thus, when that viscus is obstructed,
laxatives are prescribed, such as burdock-root,
vitriolated  tartar,  and  arcanum  duplicatum :
senna  itself is  also  given  at  times  in certain
doses, of the effects of which we  have satisfacto-
ry evidence.

    But to speak more particularly of  intermit-
ting fevers,  it is well known that they have been
cured by certain purgatives, and those  not mild
and lubricating, but  stimulating and  acrid.
Scammony,  hedge-hyssop, the  powder of cor-
nachinus, the pills of sagapenum by Querceta-
nus, and the antimonial preparations of Bontius,
have  been of service in many quartans.   The
preparation of  Riverius composed of calomel
and jalap has produced the same happy7 effects.
1 am acquainted with a  popular or vulgar reme-
dy,  which has cured vast numbers of people  in
the country ; it is a powder composed  of scam- 
                     187
 mony, turpith mineral, jalap,  senna, cream of
 tartar, rhubarb, cinnamon,  and ginger.   Simi-
 lar effects have been produced by another reme-
 dy of the same kind, devised by Helvetius,  and
 since his time  vended about  as a secret. The
 strength of this nostrum  resides  in the gum
 which it contains.

    But whatever be the strength of these reme-
 dies, it is best that they be not too acrid,  else
 they will prove injurious to those whose stomach
 and bowels are tender and irritable.   Besides,
 milder remedies are sufficient for the cure of in-
 termittents. In the mean time it is not sufficient
 that they be administered once; in various  dis-
 eases of the kind frequent recourse must be had
 to them3 in order to pave the way for a  certain
 cure.  This is particularly necessary when there
 is an accumulation of bile,  when the intestines
 are loaded  with a  collection of  offensive and ill
 digested humours^ and, lastly, when the febrile
 action is high.

    An open habit of body is peculiarly necessary
 in the course of the cure.   It is certain that if
 the discharge from the bowels goes on gently and
as it were spontaneously7,  and  the bile be thus
drawn off, the fomes of the fever will be the more
readily eradicated.  The truth of this is confirm-
 ed by  several of the phenomena of the disease. 
                     188
There are many persons, for instance, to whom
febrifuge remedies had been exhibited for a long
time without any advantage : but while these re-
medics, when given alone,  were useless  or per-
haps hurtful, they oftentimes removed the fevers,
when laxatives were joined with them.   After
the fevers are thus overcome,  they are for the
most part ready  to  return again, in case a cos-
tive habit occurs. Nor can  the evil be prevented
in any other way than by the exhibition of some
mild purgative joined to febrifuge remedies.

   I know that the sentiments here advanced are
contrary to  the opinions entertained  by many
physicians.   These consider it wrong to open
the bowels in the cure of intermittents.   They
assert that,  after the  disease has terminated,  it
will even return again,  in case  a purgative me-
dicine be administered.  Experience is adduced
in confirmation of the truth of this by many wri-
ters, and even Sydenham himself sanctions it by
his authority.   But the  circumstances wdiich led
him and others to the adoption of this opinion,
are wholly unfounded.

   It is certain that if at any time purgative
medicines,   when used in the cure of intermit-
tents, have  seemed to do mischief, the circum-
stance has been owing to  some error.   Either
some necessary preliminaries have been neglect- 
                     189
 ed, or the evacuation of bile itself has not been
 attended to.   When that fluid has begun to ac-
 cumulate, evacuants too  heating and irritating,
 or such as evacuate but imperfectly, have been
 administered.  It may also have happened that
 they were not joined with febrifuge remedies,
 or that they were given in improper doses.  No
 wonder, then, that the fever appeared to increase.
 But the fault lay in the physicians, not in the
 purgatives.

    As to those  fevers which have terminated,
 and which seem to be cured, their poison may,
 as formerly mentioned, lie dormant for a long
 time.  It  may  even be  silently  accumulated,
 and  thus  gather  strength.  If, when things are
 in this state, the body be much disturbed by an
 ill-timed purge, it is not  to be wondered at, if
 the fever  which had lain in ambush, as it were,
 ready to  break  forth,  should suddenly and un-
 expectedly make its appearance.   The  febrile
 poison would not have acted thus, had it been
 subdued;  and had the purgative been admini-
 stered  with the necessary precaution,  it would
have eradicated the last relics of the poison. The
 proper use of purgative medicines does not, then,
 pave the way for relapses. 
CHAP.  VI.
Of the use of Aperients.
    BUT although the necessity for purgatives
is great, it does not follow that no intermittent
can be cured without them.  But we must direct
our attention to those occurrences and principles
which are most common,  and not suffer  our-
selves to be diverted from them by such as are
much less common.  In general,  therefore, as
we have already observed, it is absolutely neces-
sary to have recourse to purgatives in the cure
of intermittents.

   There are, in the mean time, cases in which
the evacuation of the intestines can be less rea-
dily dispensed with than in others.  If,  for in-
stance, the disease be of very  long standing; if
the abdomen be tumid or hard;  if the  skin be
tinged with bile; if the urine  be thick  or  high
coloured;  finally,  if the habit be cachectic in 
191
consequence of obstructions ;  if, I say, any or
all of these circumstances exist, the medicines
called specific febrifuges are.of no  avail; the
cure must not be  attempted  with them,  until
the impediments be first removed by a discharge
of the vitiated humours.

    But, for the complete discharge of these hu-
mours the evacuation of the bowels is not alone
sufficient.  Impediments  exist in many other
parts of the system, which must also be remov-
ed ;  thus, the various secretory and excretory
passages or ducts must be opened;  motion must
be restored to the stagnant fluids;  their fluidity
which is partially lost must be restored again,
and the bile must be recalled to  its own proper
ducts, and to the cavity of the intestines.   Re-
course must, therefore, be had to diluents, aperi-
ents, refrigerants, and saponaceous medicines,
and to these must be added some purgative me-
dicine, for the purpose of keeping the bowels
open.

    The effects of the juices of herbs properly
prepared in removing obstructions of the abdo-
minal viscera are truly surprising.  This may
be inferred from the influence of green herbs on
the bodies of horses, cattle, &c.  These animals
are purged, and become lean in the spring;  their
fliiids are made  to circulate  more freely,  and 
192
their  secretions are rendered more free and ac-
tive.  The  same thing may be done by a phy-
sician, if to  aperients and deobstruents he adds
a mild  purgative  just sufficient to move  the
bowels.

    What I  have  found best for unlocking the
passages of the liver is a purgative decoction or
beverage, made for the most part of wild  bur-
dock, succory, hart's-tongue, and other herbs
of the kind.  To this I have mostly added some
purgative salt,  such as sal glauberii, or arcanum
duplicatum.   This beverage will  generally re-
move the obstructions unless they be  uncom-
monly obstinate.   It will never, however, prove
entirely efficacious, unless it move the bowels
two or three times a day.

    These laxatives and aperients are necessary
not only in  fevers of long standing, and in such
as are kept up by obstructions ; there are others
of recent origin  in which the same remedies
ought to  be used.  Some fevers,  for  instance,
attack and run on with great violence ;  in these
the viscera are parched with  extreme heat;  the
liver is particularly affected; the bile is of a deep
yellow or green colour, the feces are highly of-
fensive ;  the urine is red or of a brick-dust co-
lour ;  cases  of disease where these symptoms
prevail resist common febrifuge  remedies, arid 
193
unless recourse be had to such as open the pas-
sages of the body, the febrile poison  cannot be
readily vanquished.

   In cases of this kind, I have derived advan-
tage  from putting my patients for a week or
longer on  the use of aperients and laxatives.
To some of these I have prescribed the juice of
succory, borage, and bugloss, with sal glauberii,
or some other saline purgative ; to others a de-
coction or  beverage prepared from the same or
some other  herbs, with tartarum vitriolatum in
it; and, lastly, cases have occurred to  me in
which my patients derived the  greatest benefit
from the use of whey.   Whey is a liquid which
contains the juices of herbs, prepared and con- .
cocted, as  it were, in an animal laboratory.   It
is also impregnated with a quantity of vegetable
salts, which sometimes operate actively7 as pur-
gatives.

    This mode of treatment very seldom disaj*
points our expectations.    Such is the extent of
my confidence in it,  that as often as I have met
with an obstinate case of intermitting fever,  I
have had recourse to the foregoing, or such like
remedies.   Of such remarkable efficacy have  I
eonsidered these remedies, that in many cases I
have not hesitated, after the exhibition of gene-
ral remedies, to continue some time  in the use
                     c c 
194
of aperients.   In this way the system  was the
better prepared for the action of febrifuge medi-
cines.

    There  is yet another remedy in which  I
place great confidence,  when  the patients are
willing to submit to it.   After their bowels are
sufficiently evacuated, I put them on a watery re-
gimen for three  or four days.  During that time,
I  prohibit them from using  any other kind of
drink or food.   By thus drinking six or eight
pounds of water a day, the fever is almost entire-
ly removed.  I consider warm  water as the most
effictcious, yet  cold water will answer in the
summer season.  This  method seldom fails of
success.  It has succeeded with me in remov-
ing obstinate fevers, which had resisted every
 other mode of treatment. If some relics of these
 fevers  still remained behind, they were easily
 subdued,  and that by gentle means.   Is it not
 surprising that we should ransack Asia and Ame-
 jjca for remedies, when more efficacious ones
 are every where to be found 
CHAP.  VII.
At what time the remedies mentioned in the foregoing
         chapters are to be administered.
    IT remains to  consider, at what time the
foregoing remedies are to be employed.  Blood-
letting may  be practised both  during the pa-
roxysm  and during the  intermission.   When
employed during the paroxysm, it is intended
to break the violence of the fever, and of its con-
comitant symptoms;  when during the inter-
mission,  it is used as a prophylactic, to render
the succeeding fits lighter, and thus to pave the
way for other remedies.

    These circumstances are so plain as scarcely
to require any directions.  But such has been
the rashness of some men,  that  they have ven-
tured to  open a vein during the  cold fit.   This
practice is unreasonable and hazardous.   When 
196
the pulse is so depressed as to be almost imper-
ceptible ;  when the  blood scarcely  circulates;
when the vital  principle seems  to  be already
overpowered,  what  benefit is to be expected
from blood-letting ?   Can it be had recourse to
without danger in old persons, as such are some-
times known to expire under the violence of the
cold fit ?

    During  the cold fit is a time equally im-
proper for the use of other evacuants.   Those
in particular which  act with  force are hurtful.
Emetics,  therefore,  cannot be ventured on, al-
though the patients be affected with  nausea and
vomiting. It is not in this as it is in that vomit-
ing which arises from a superabundance or an
acrimony  of the humours.  In the cold stage of
fever, the  action of the stomach is inverted by
nervous irritation, and an affection of the liver.
That organ like all other parts of the system is
contracted.   It does not, therefore, obey the
action of remedies as in a state of intermission
or health.   These remedies can only produce
anxiety and very distressing pains, without being
able to excite any discharge from the constrict-
ed vessels of the viscera.

    It must be confessed, however, that even un-
der such circumstances, emetics do sometimes
succeed.  Vomiting, says Riverius, excited at 
                     197
the commencement  of a paroxysm  renders it
milder and shorter.  There was lately an Eng-
lish physician, who,  during a practice of twenty
years continuance, was in the habit of giving an
emetic at the commencement of the cold fit.  In
case excessive tremors forbade this, he usually
administered it at the commencement of the hot
fit.  Somewhat similar to this was the practice
of Asclepiades.   Celsus more judiciously exhi-
bited only tepid water slightly impregnated with
salt, for the purpose  of exciting vomiting. Not-
withstanding these circumstances,  any inverted
action of the stomach, unless produced by warm
water alone, is to be  dreaded.

   Sydenham with  more propriety  timed his
emetic so, that its operation might be terminated
previously  to the access of the paroxysm.  So
far was he  from  believing that a tumult excited
in the viscera at the beginning of the fever could
be beneficial,  that he  recommended to his pa-
tients  a  gentle anodyne after  the operation of
the emetic, and immediately before the attack of
the paroxysm.   Both, however, had better be
omitted.

    Some practitioners have, with equal indiscre-
tion, administered purgatives during the cold
stage, or, what is still hurtful,  at the  very com-
mencement of the hot stage.  They did not, or 
                     198
would not see, that when the system is constrict-
ed in every part with cold, or agitated by heat
and motion, the bowels cannot well be opened,
and that the application of irritants must excite
the greatest  commotions.    Those  physicians
have acted with  more prudence and discretion,
who have exhibited such medicines previously
to the  commencement of  the paroxysm.  In-
stead of four hours  before this commencement,
as some writers direct,  the purgative medicine
should be given six or eight hours before it.
This is the way to  render  it useful, as appears
from  various examples.  Some physicians have
known the disease to be removed by administer-
ing cornachinus  in powder, a certain time pre-
viously to the paroxysm.

    So averse  have the more skilful  physicians
been from the use of purgatives, in the cold stage
of fever, that they have, on the other hand, used
remedies of a heating nature.   Some of these
have given three, six, and even twelve grains of
pepper: others have had recourse to theriaca,
and assert that by these means the fever was re-
moved.   Others again have prescribed heating
substances  and febrifuges combined, and that
with the same degree of success.  Nor, indeed,
does this practice appear, at first sight, so con-
trary to reason as does the use of purgatives and
emetics during the cold stage.  When the whole 
                     199
system is affected with cold and shivering, heat-
ing substances would seem rather useful; but
they are, notwithstanding, to be rejected. They
generally augment the violence of the fever. If,
however,  the vital principle seem to flag, and
the violence of the cold stage be extreme, it is
admissible to  have  recourse to  some gentle
cordials.

  i Thebody, therefore, is not only not to be purg-
ed, nor stimulated by heating medicines, during
the cold stage of fever; but, on the other hand, it
ought not to  be disturbed at all; tepid water
alone, or mixed with some gentle cardiac should
be taken in.   Nor ought  the system to be in any
measure agitated, during the succeeding hot fit.
All  heating substances and purgatives will be
hurtful.  Acid,   or  acescent  drinks are better
calculated for moderating the febrile heat. Even
water alone will suffice,  particularly when the
sweat begins to flow.   Thus,  the fluid which
passes off by the skin, is restored by the mouth,
and the grosser humours are sufficiently diluted.
That the  aqueous drinks, however, may be the
better mixed with the blood, let some syrup be
added, such as syrup of violets, syrup of cit-
ron-peel,  or  let some Rhenish wine*  be given

    * The propriety of adding wine, or any other highly stimulating
liquid to the drinks of patients in the sweating stage of intermitting
fever, is, at best, problematical. I ought rather to have said, that 
200
to prevent  the sick from being too much ex-
hausted.  In this way  will the sweats  be pro-
perly regulated;  for if they  be too profuse,
they will prove hurtful;  the fever will become
worse, and may even assume a continued form.

   As to aperients,  it is scarcely necessary  to
give any7 directions respecting their  use.  Pro-
vided they be lenient, they may be given at any
time.  Vegetable ptisans holding nitre in solu-
tion, and lemonade,  are highly useful during the
continuance of the fever; so, likewise, are weak
infusions  of borage,  bugloss,  and other bever-
ages of the kind.  But those  articles  which are
possessed of much  activity, and  which are in-
tended  for the removal of obstructions, ought
not to be used before the termination of the pa-
roxysm ;  indeed their  exhibition must  even be
deferred  till the  primae viae be cleansed  by
emetics or purgatives.  This precept ought to
be attended to, at least in the commencement of
fevers.   But when they are of long standing, or
when the sick  have  relapsed into  them,  as their
character is changed,  a change must also take
place in the method of exhibiting the remedies.
But this  subject will be considered in a subse-
quent chapter.

 the practice is hazaidius and should not be adopted. On such oc-
 casions, mild, diluting drinks arc all that are, in general, either ne-
 oessary or admissible.....Trans. 
CHAP. VIII.
Of the various methods of curing fevers, and first, of
         the cure by means of sudorifics.
    ALTHOUGH the remedies  already men-
tioned, possess great power, they only pave the
way for a cure.  We pass on, therefore, to the
consideration of others, which have a more  par-
ticular or specific relation to intermitting fever.
There are two methods in which the cure of this
disease may be attempted.   The first consists in
endeavouring to prevent  the  occurrence of the
cold fit  by  mild sudorifics.  To enable  the
reader to judge the more correctly of these re-
medies,  or  their effects,  we will premise a few
remarks, founded on  observation and  experi-
ence.

    Previously to the sick being seized by the
cold fit, half an hour  for instance before  the im-
                       D(l 
L202
mediate attack, all the functions of the system go
on, at times, without any disorder.  The patient
does not seem to be at  all  infected by a febrile
poison ;  nor does he experience any sensation
to warn him of the approaching paroxysm.  To
produce the paroxysm, then, the poison must
burst into a blaze, as if fire wrere applied to it.
But cannot this flame be prevented, or, which
amounts to the same thing, while the poison is
yet inactive, can it  not be smothered so as to
prevent it  from breaking out in  the form of  a
cold fit or fever ?

    Such a project certainly does not appear  un-
reasonable.   On the other hand it seems highly
probable, that if a sweat be excited before the at-
tack of the cold fit, it will be entirely prevented.
But, in case of its prevention, there will be no
congestion or stagnation in the liver, the auricles
of the heart,  or the lungs.   Besides, it would
seem that part, at least, of the febrile poison may
be dissipated. Thus, if the skin be constricted,
the more gross fluids are accumulated in its ves-
sels and excretory tubes; if in this  state of things,
a very7 copious sweat breaks out, the obstruc-
tion will be removed  through the cutaneous
pores.   But the same  thing will occur with re-
spect to  the state of the viscera,  when a febrile
paroxysm is impending.  Therefore the febrile 
203
 cause if not entirely  removed, will be at least
 greatly weakened.

    But in medicine, all reasoning is uncertain,
 unless confirmed by experience.  Even experi-
 ence itself, teaches us many things that do not
 precisely accord with what is here laid down.  It
 is certain,  indeed, as already mentioned, that
 those sweats which follow the paroxysms do not
 always  check the febrile action.   Yet those fe-
 vers where no sweats occur,  generally continue
 longer, and  rage  with more violence.   Those
 physicians,  however,  who, with a view to pre-
 vent a paroxysm, endeavour to force a sweat by
 great external heat, or who administer for the
 same purpose  a heating decoction of  guaia-
 cum  or sassafras,  generally7  render the disease
 worse.

    From these considerations, however, no well
 founded arguments can  be  drawn  against all
 kinds of sweats.   Those sweats, for instance,
 which succeed the  paroxysms are morbid, or
 constitute in reality,  a part of the disease; for
they frequently occur while the bowels are still
parched with the febrile heat.  It is, therefore,
in intermitting fever, as it is in eruptive fevers;
 sweats oftentimes flow copiously without afford-
 ing any  material  relief to the sick.   In both
cases, the more fluid parts are thrown  on the 
204
surface of the body by the febrile action, while
the fomes of the disease still remains within.

   With respect to sweats excited by too much
external heat, or by the force of heating reme-
dies, they  are  wholly unfavourable to the cure
of fevers.  Thus, the stimulus of guaiacum is
too acrid,  and excites by far too great a degree
of heat in the bowels.   So hurtful, at times, are
the effects  of that medicine, that I have seen
cases of jaundice produced by it.  But whatever
thus disorders the functions of the viscera, even
although it produce  the most copious sweats,
cannot be a remedy for fever.   Let  it be laid
down then, as a principle, in the cure of fevers,
that  the  body  must  not be overheated.   The
force of the  disease is necessarily increased, if
the heat in the viscera be increased.

    Those  sweats, therefore, are most beneficial
which are not forced from unwilling nature, but
which flow7 at the proper time and in  a gentle
manner.    To procure such sweats,  the follow-
ing  circumstances must be attended to.  First,
too much heat must not be  excited :  Secondly,
aperients should be always mixed with sudori-
fics : Thirdly, in certain affections of the liver,
or of the other viscera, they must not be exhibit-
ed any more than they must in the highest state
of cachexy:  Fourthly, and lastly, where there 
                    205
is a turgid state of the  blood-vessels, or when
the stomach is loaded with vitiated humours, a
cure  by means of sweating must not be aU
tempted.

    These things being attended to, and the ne-
cessary general remedies being premised, that
method will be most salutary and  safe,  which
attempts the cure of intermittents by sudorifics.
Yet these remedies will  be more useful in the
beginning than in  an advanced stage of those
diseases. 
CHAP.  IX.
Of the mode of exhibiting sudorifics in the cure of
                 fevers.
    AFTER having premised the foregoing ge-
 neral rules, it would seem scarcely  requisite to
 give  any particular  directions on  the subject.
 But to close up every avenue through which error
 might find an entrance, we will specify the  time
 most suitable for these remedies ;  we will  then
 point  out the remedies  to be selected as most
 useful;  and, lastly,  describe  the  method  to
 be observed  in  their exhibition.   After  hav-
 ing gone through these several heads, wre will
 endeavour to make it appear how far this method
 of cure is to be relied on.

    As to the  time, the patient must be allowed
 a sufficient degree of rest to refresh his system,
agitate J by the fever and debilitated  by the pro-
 fuse sweat.    But as soon as practicable,  it  will 
                     207
 be proper to have recourse to the sweating plan*
 Yet experience has oftentimes taught me that it
 will be sufficient to prevent the cold fit, if the
 medicine be exhibited three  or four hours be-
 fore its access :  but if given  at a later period, it
 will be either useless or very nearly so :  the hu-
 mours of the  body cannot then become suffici-
 ently impregnated with it, and they consequent-
 ly7, will not be prepared to pass off by the pores
 of the skin.

    Those remedies which appear to me to ac-
 complish the object in view  most safely  and
 certainly, are  certain medical substances, endu-
 ed  with penetrating yet  mild qualities.   The
 principal of these are sarsaparilla, burdock, bit-
 ter-swreet, and male speedwell, all of them  ape-
 rient remedies.   I  am well persuaded that other
 remedies  would effect the same purpose, but I
 am here laying before the reader the result of myr
 own experience only.   I do not consider it ne-
 cessary that all these articles should be prescribed
 at the  same time;  I have sometimes exhibited
 one or another of them singly, with great advan-
 tage, and that in the cases of many  sick persons.
 I will adduce one very  memorable example in
 confirmation of this.

    An old man, aged eighty, had experienced
two  paroxysms of a quartan fever.   So violent 
208
had the cold fit been, that he was threatened with
certain death in case of another attack similar to
the two former ones.  Deeply affected at this
melancholy prospect, I prefered a sudorific me-
dicine to all others.  I therefore exhibited a de-
coction of sarsaparilla and burdock with  sal
ammoniac.   By this remedy  the cold fit and
paroxysm were prevented, nor did any vestige
of the fever remain behind.  Perhaps this cure
might, by some, be attributed to the sal ammo-
niac.   But the decoction has at other times suc-
ceeded equally well with me, without the addition
of that salt.

   In the mean time the mode of administering
this remedy,  may  contribute much to its force
and  efficacy.  The  decoction  must be drank
not sparingly, but in large quantities.  Five or
six pounds of it, for  instance, ought to be used
on every day of intermission, with this precau-
tion, that previously to the time of the occurrence
of the fever, the patient compose himself in bed.
These previous steps being taken, the sweat
will be brought on the more readily, if the plen-
tiful use of the diaphoretic decoction be still con-
tinued.   Nor must  this remedy be  laid aside,
even when the body  begins to be covered with
moisture, but should be persevered for several
hours. 
                      209
    However safe this administration of sudori-
 fics may appear, I have been sometimes appre-
 hensive of exciting too much heat  by it.   To
 prevent this, it appears advisable  to prescribe,
 immediately after the  remission of  the fever, a
 warm infusion of borage or bugloss, which will
 be rendered the more cooling by the addition of
 a moderate dose of nitre.

    What has established in my mind the utility
 of this mode of exciting a sweat,  is a  common
 and therefore a valuable remedy, of which I have
 had some experience.   When I have been desi-
 rous of employing more lenient  sudorifics,  I
 have tried  the efficacy  of warm water.   I have
 directed, for instance,  a large quantity of this to
 be drunk a few hours before the paroxysm. Con-
 trary, in some measure, to  what I was prepared
 to expect,  the cold fit was  prevented as if by a
 charm.  This result I have witnessed not only
 once, but frequently, nor indeed have repeated
 experiments which I have made, left in my mind
 any doubt  as to its reality^

    But  whatever may be thought  respecting
these particular medicines,  it is certain that the
method of removing intermittents by sudorifics,
is in various cases absolutely necessary.  This
method must be had recourse to, if the cold fit be
violent, and dangerous; indeed there is no other
                      e e 
210
way in which the cold fit can be counteracted. I
would not, however,  assert that this method
eradicates the  fever so perfectly,  as to render it
unnecessary to have recourse to any other reme-
dies to complete and confirm the  cure.  Perhaps
the effects of the febrile poison are only kept
down by sudorifics, while the poison itself still
lurks in the system, and silently pervades all its
parts.   Those who have been relieved from  in-
intermitting fevers, cannot, therefore, be per-
fectly safe, unless the poison has been thoroughly
eradicated by specifics :  this,  at  least, is in ge-
neral  the case. 
CHAP. X.
Of attempting the cure of fevers by specific medicines :
   and first, an inquiry what these specifics are,  and
   whether or  not, any emetics or cathartics are to be
   considered as such.
    THERE is, therefore, a more safe and cer-
tain method for the removal of fevers, namely,
that which consists in curing them by peculiar,
appropriate,  or specific remedies.   Medicines
of this kind,  have been earnestly sought for  in
every age, and many practitioners have suffered
themselves to be persuaded, that such were actu-
ally found, when in fact they were still wanting.
Physicians, however, left nothing untried in this
inquiry.   We have already treated of emetics
and purgatives :  in these remedies certain phy-
sicians, and those not of inferior reputation, have
reposed unlimited confidence.  Some select me-
dicines of this class have even  been vended about
as secret nostrums. 
212
   We have already said, that emetics and pur-
gatives do much towards the cure  of intermit-
tents, but that they do this only  by paving the
way for other remedies.   Since,  indeed, such is
the nature of intermitting fevers, that they may
sometimes be removed by a shock, or a sudden
change in the natural movements of the system,
it may so happen, that they may  be cured by the
action of emetics or purgatives.   Besides, such
may be the state of the body, that,  after the eva-
cuation of the stomach and intestines, the func-
tions of the  several  parts may  be  restored to
health.   Finally, the  febrile poison may be eli-
minated by a kind of crisis, and, as it were, by
a single exertion.  But this success is only ac-
cidental.  These are not the proper remedies for
intermittents, nor are they calculated to over-
come the febrile cause of themselves.

    But  although these remarks are true in gene-
 ral,   I would not have them considered  as ap-
 plicable to all medicines of the kind. There may
 be in some medical articles which excite vomit-
 ing  and purging a power peculiarly febrifuge.
 No  doubt but this may be the case with respect
 to Riverius's remedy for quartans. The precise
 nature of that  preparation is  not known, but
 it appears to contain both mercury and antimo-
 ny in its composition. 
                     213
    I  am also acquainted with a vegetable sub-
stance of a purgative nature, long celebrated in
this country  as  a febrifuge, and which is  even
purchased  up at a considerable price.   It is the
cuticle or  external covering of the sea-lettuce.
This,  when  dried before a gentle fire, and re-
duced to  a powder, is exhibited in doses of a
scruple, and  continued in this manner for  seve-
ral  successive days.   Some practitioners  have
prefered giving it  infused in milk.

    There is another  milder purgative,  which
was formely  a secret nostrum, namely, cream
of  tartar,  exhibited frequently in doses  of an
ounce.   This article is at  once cooling, purga-
tive, and antiseptic ;  whence in the commence-
ment of fevers, it appears to me to be a remedy
not to be slighted.  The same thing may be said
of  the nostrum of  Mynsichtus,*  which has
oftentimes cured intermittents when other reme-
dies had failed.  I  have myself prescribed that
remedy sometimes with the happiest effects.  It
is cooling, purgative,  and  aperient,  and is pe-
culiarly  calculated for correcting bile,  and re-
moving hepatic obstructions.  Hence it  is en-
titled  to  a  respectable rank  among febrifuge
remedies.
   * The formula of this nostrum is not mentioned by our author.
Tram. 
                     214
   Equally to be esteemed  is  the febrifuge of
Riverius, which is composed of vegetable alkali
and sulphuric acid.   From the union of these
two articles arises a salt* not dissimilar  to that
which constitutes the foregoing nostrum of Myn-
sichtus, as appears from a chemical examination
of it.   But I have ascribed very different virtues
to magnesia alba,  which some  practitioners use
as a febrifuge.  This, however, is  not  always
alike  efficacious.   It is sometimes,  however,
when  mixed  with cream of tartar,  prescribed
with happy7 effects.   I  once knew  a physician
who used an infusion of it in wine as a  purga-
tive.

    But although  remedies  of  this  kind do at
times much good, we must not in most inter-
mittents trust to  them  alone.  They very  fre-
quently disappoint us,  or produce only  a  tem-
porary7 suspension of the disease.  It is of great
importance,  however,  to   be  acquainted  with
them, in order that they may be joined with ac-
tive febrifuges,  or substituted occasionally in
place of them. There are certain temperaments,
and certain irregular  fevers, to which remedies
of this kind  are best suited.  The  physician,
therefore,  must be supplied with such a stock
of remedies, as will enable  him to accommodate
his practice to different cases,
               * Sulphate of pot-ash. 
CHAP.   XI.
Whether or not a true febrifuge power reside in certain
  sudorifics, bitters, aperients, and other remedies.
    WE have already treated of sudorifics and
the mode of administering them.  These cannot
be  considered as  true  febrifuge remedies,  if
they  only excite swTeat.  To deserve to be ac-
counted antidotes to intermitting fever, it is ne-
cessary that they should possess a certain peculiar
or  specific power.   In  theriaca no such power
resides,  although  it was attributed to it by the
ancients.  How far such a remedy is to be trust-
ed, appears from Galen himself.  That writer
remarks,  that by the  exhibition  of it, a simple
quartan was converted into a double and even a
triple one.  He mentions the same thing as hav-
ing happened to Eudemus the philosopher.  It
is to be lamented that encomiums are frequently
bestowed on medicines of this description, which
are not only useless, but even hurtful. 
216
   Physicians have had recourse to other reme-
dies,  better calculated for the cure  of fevers
Even the  ancients  themselves,  suspected the
existence of a febrifuge power in bitters.  They
therefore, made trial of gentian, germander, the
lesser centaury, and a species of trefoil, and that
oftentimes with happy effects. They have spoken
highly of the lesser centaury in particular; but I
have observed it to excite very great heat, and
not unfrequently to increase the violence of the
fever.   Yet it cannot be denied, but that, when
added to the peruvian bark, it has been some-
times of great service ; for it has subdued fevers
which had resisted other remedies.  It is said,
that  if the system being  first properly prepared
for it, a decoction of it be given combined with
laudanum,  it will  be productive  of still better
effects.   The same thing is said  respecting an
infusion of the flowers of broom.

   Respecting other bitters, I can say7 nothing.
Their effects are uncertain, sometimes even hurt-
ful.   Thus gentian is not undeservedly blamed
on this score,  in as  much as  its bitterness  is
acrid, and apt to excite heat.  What appears no
less foreign from the cure of fever, many of them
have  astringent as  well  as febrifuge properties.
Some practitioners have  exhibited alum,  others
plantain and  cinquefoil.   Alum  certainly pos-
sesses some degree of anti-febrile power; for 
                     217
 patients have taken  it dissolved in water with
 advantage.   Many have declared plantain to be
 possessed of the same power, and have exhibit-
 ed it either  immediately before, or  about two
 hours before, the accession of the paroxysm.  I
 have indeed known obstinate fevers removed by
 a beverage  in which the leaves of this herb had
 been boiled.  Cinquefoil has in the mean time
 succeeded  still better,  as also the bark  of the
 root of  the wild plum-tree.  Still, however,
 these remedies ought not in my opinion to be
 often used;  for when they  constrict parts that
 contain the febrile poison, it is apt to remain in
 them at a greater  depth, and with more per-
 manence.

    With more  justice are praises bestowed
 on  certain  articles possessed of a  penetrating
 power, such as aperients, and saponaceous sub-
 stances.   Among these, burdock holds  a con-
 spicuous place,  wdiile  it is at the same  time a
 sudorific.   By this remedy  Henry III. king of
 France, is said to have been cured of a quartan
 fever.   Many other similar instances are men-
 tioned.   The herb,  speedwell, possesses  the
 same power in  an equal degree, according to
 Cesalpinus, who was  a most able and accurate
judge of these things.   Finally, of the same effi-
 cacy and value is  the juice  of the rape-root,
 which is so  highly extolled by Crato. Notwith- 
                     218
standing what has been said,  daily experience
teaches us that we must not rely on these reme-
dies,  as true febrifuges.   Although they have
cured some, they have failed in the cure of many
more.

    It appears to  me that  more confidence is to
be placed in the aperient salts, of which we have
already treated, or in the febrifuge salt of Sylvius,
to which physicians,  and even the author him-
self, have given  a  higher  character than it de-
serves. Purging  salts, have, indeed, at the same
time  a febrifuge  power, but this power does not
always act with certainty ; to these, therefore, sal
ammoniac is to be greatly preferred. This reme-
dy, indeed, possesses great efficacy in the remov-
al of fevers  which are even highly  obstinate.
Hence, at times, when other remedies prove in-
effectual, we are forced to have recourse to that
 salt.

    Finally, the effects of the salts of Tachenius
 must be referred to  an aperient and penetrat-
 ing power. The  virtues of the plants from which
 they are extracted cannot still remain in them ;
 for their principles are changed by the action of
 the fire.  They  are partly alkalescent, and con-
 tain  also a portion of thick oil;  whence, being
 of a  saponaceous nature, they are  extremely
 well calculated for the removal of obstructions. 
                     219
    But it is not alkaline  salts  alone,  certain
earths also possess qualities calculated for the re-
moval of intermitting fever.   Thus, burnt egg-
shells  are  exhibited with happy effects in that
disease.  The truth of this  is established by
many experiments detailed in medical writings.
To  these  earths vegetable  alkali is sometimes
added,  and I once knew a physician who used
a mixture  of these two  articles with very flatter-
ing  success.   These earths  first calcined and
then mixed with salt of tartar, have  been used
by Riverius  in various cases of disease.   The
mixture was usually dissolved in simple water,
and given to the sick in solution.   I have, my-
self, sometimes used this remedy with  success
in obstinate quartans.   I would not, however,
recommend it to general use, as it seems to be
possessed of too much acrimony,.

    There  are other remedies, and  those some-
times of opposite qualities, which physicians use
in practice, such as aromatic antiseptics, which
stimulate the system, and narcotics, which act as
sedatives.  Of the class of stimulants, I shall treat
of only two, the efficacy of which is worthy of no-
tice. Theancients themselves spoke in the highest
terms of worm-wood, which has been also used
with success by a late  Italian physician.   Cha-
momile is  spoken of as no less efficacious by a.
physician of Portugal, and Morton  considers its 
                    220
flowers as highly useful.  But if these vegetables
do possess  febrifuge  virtues,  a  circumstance
which cannot be denied, it must, notwithstand-
ing, be confessed that they more frequently dis-
appoint  our  expectations,  and even  excite  a
pungent heat, which is very unfavourable to the
cure of fevers.

   As to narcotics, w7e must acknowledge with
Riverius, that they possess some efficacy in pre-
venting the paroxysms of fevers.  Trallian used
opium, which,  combined with castor and some
other articles, he exhibited two hours before the
fit as a certain remedy.   Heurnius recommends
the same, combined with some other medicines,
in terms equally  strong.  I  knew  a physician
who was  in the habit of exhibiting  it in combina-
tion with camphor, with the happiest effects.  I
have no doubt but opium combined with saffron
would be efficacious in removing the cause of fe-
ver.   Both of these articles possess some febri-
fuge virtues, besides, that saffron  is  gently ape-
rient.   They ought, however, to  be taken with
caution.

   Finally,  that nothing might be left untried,
some physicians have  had recourse even to poi-
sons themselves.   They have exhibited arsenic,
and have succeeded with it "in the removal of
many  intermittents.   Some of  the  patients, 
                     221
however, thus cured, have  afterwards died of
phthisis.   There is a certain vegetable poison,
namely,  the bean of St.  Ignatius, which is less
deleterious.  I was acquainted with a man who
was in the habit of exhibiting it to people in the
country with the greatest success.  There is al-
so a remedy used by great numbers in this city,
and that not w ithout  success.   Its efficacy  de-
pends on its being composed in part of the bean
of St.  Ignatius, an article which most  people
dread, and which physicians condemn as a poi-
son.

    Inunctions and  external applications to  the
wrists are more in use among the common peo-
ple than among physicians.  Inunctions  and
frictions along the spine  were first instituted to
remove the sensation of coldness, which is usu-
ally experienced in  that part.   There is  no
doubt, indeed, but the friction and motion,  as
well as the power of the medicine with which the
sick are anointed, may sometimes be of service.
These remedies, however,  are not to be confi-
ded in,  nor ought their  application, indeed,  to
be opposed, in case any person believing in their
efficacy, wishes to use them.

    As to applications  to the wrists,  if any  re-
lief be derived from them,  it is not to be con-
sidered as depending on any power specifically 
222
febrifuge.  Certain cures,  which are truly sur-
prising,  are rather to be attributed to motion
excited in the whole or a part  of the body by
the application of a stimulus.   There are  cer-
tain unguents, for instance, which, if rubbed on
a particular part of the body, will produce erup-
tions in various other parts, and even excite mo-
tions in the viscera themselves.   The same, or
something similar happens in the use of epicar-
pia, or applications to the wrists. If the ranun-
culus  of the meadows  be applied to the hands
and wrists, heat, pain,  and  excoriation are the
consequences.  By the force of this stimulus,
and the effluvia making their way to the internal
parts,  the fever may be eradicated so as not to
revive again.

    We must not, however, imagine that fevers
can be removed by external applications, which
possess no stimulant power.  Although the ef-
fects of such remedies are extolled by writers of
high respectability, they are,  notwithstanding,
very doubtful.  If there be any truth  in the
praises bestowed on them,  their efficacy  arises
from the power of certain subtle effluvia, which
make  their way into the internal parts of the sys-
tem.  But let those persons believe in the effi-
cacy of such remedies, who have had satisfactory-
proofs of it. 
            CHAP.  XII.


Of the cure by means of the peruvian bark.
    THE foregoing remedies, not very certain,
and sometimes, not very safe in their operation,
were  succeeded by  the peruvian  bark.   This
divine discovery was unknown to our ancestors.
Nor did our own age come willingly into the use
of it.   A few physicians were its advocates, but
many suspected it of some deleterious qualities.
But uniform and successful  experience  over-
came at length their obstinacy and their fears.

    I  do not mean, however, to insinuate, that
all controversies and complaints on this subject
are terminated.   There are countries in which
this celebrated remedy is  still  in  bad repute.
Among  the Dutch and the  Germans, the com-
mon people reject it entirely7. But all the charges
which they bring against it, are to be attributed 
                     224
to an  improper method of using it.  Among
the Spanish,  the French, and the English, it is
no longer held in suspicion. Its use is sanction-
ed by general approbation.

    So efficacious and innocent is it, that among
all the sick persons  to whom I  have ever pre-
scribed it, I have heard no well-founded com-
plaints respecting  it.  It not only suspends the
fever for a time, but, if the system be  properly
prepared, eradicates it entirely7. It is in the high-
est degree friendly  to  the stomach, promotes
perspiration, acts  favourably  on the blood and
nervous  system, and is a powerful antiseptic in
the prima? viae.   But as the mode  of using it
ought to  be accommodated to various tempera-
ments, and various descriptions of fever, there
are several preparations of it,  with which it is
necessary to be acquainted.

    Some physicians employ this medicine in the
form of an extract, others of a decoction, others
of an aqueous infusion, and others again of a spi-
rituous tincture.

    But that the febrifuge virtues may be the bet-
ter extracted, physicians have recourse to ano-
ther menstruum more suitable for the  purpose.
The bark, for instance, is infused in  some gene-
rous wine for the space of twenty-four  hours, or 
                      225
it is exhibited in powder in a glass of that liquid.
In this latter case the extract is made in the sto-
mach itself.  When the extract is thus prepared,
whether within or without the body, it is a reme-
dy of a very active and  penetrating nature.  It
differs greatly in  its powers both from wine and
spirits, in consequence of the gummy and resi-
nous principles of the bitter febrifuge which it
contains.

    As to the efficacy of the remedy thus  pre-
pared, it cannot be denied that it has been beni-
ficial to many.  I can, myself, from experience,
bear witness to its activity;  but its strength and
utility are increased, by adding to it some spirits
of wine ; whence it would appear that the febri-
fuge virtue of the bark resides principally in its
resinous part; for it is best extracted by a spiri-
tuous menstruum.  A remedy so heating as this
preparation is, ought, however, to be given with
caution, else it may at times prove hurtful.

   When the bark alone in whatever way it may
be administered, appears to be insufficient to
remove certain intermittents,  physicians  have
added many7 things to it as auxiliaries.  Some, to
increase its  efficacy, have mixed aromatics with
it, such as Virginian snake-root: others, for the
same purpose, have added certain  febrifuge  me-
dicines  to  it,  particularly bitters : many  have
                     GS 
226
joined aperients with it, that it might thus gain
access the  more readily to the internal recesses
of the system:  finally, a very considerable num-
ber have,  for the accomplishment  of the  same
end, called to its aid certain salts which are pos-
sessed of a searching or penetrating power, such
as salt of wormwood, and sal ammoniac, the
latter of which  is itself, as we have already  men-
tioned, highly useful in obstinate intermittents.

    Of all these and many other remedies  it  is
not my intention to treat  at large.   I shall, ne-
vertheless speak of two or three of them, which
are certainly capable of being highly useful.  If,
in some obstinate  cases  of intermittents, the
lesser centaury be added  to the peruvian  bark,
it may prove a very efficacious remedy.   It ap-
pears that the flesh of the viper dried, reduced to
powder,  and exhibited with the bark, has  been
equally effectual. By these mixed remedies  many
persons have been  relieved from intermittents,
after having tried all other medicines in  vain.
But the  following remedy which is  purchased
at a very considerable price, seems to contain
the virtues of both the foregoing : viz. Take,
        Of peruvian bark, two drachms.
        Of millipedes, powdered, one drachm.
        Of lesser centaury, do one drachm.

    Let this mixture be infused in  eight ounces
of generous wine,  and given  to the patient  in 
                      227
 bed.  At other times the powders are given in
 honey in the form of an electuary.

    But very  often  the primae vias  are  loaded
 with vitiated humours, which may serve to keep
 up the fever.  Purgatives are, therefore, in par-
 ticular, added  to the  bark.   The bark itself, in-
 deed, purges many persons, but, a circumstance
 which is peculiar to it, it considerably increases
 the action of other purgatives; hence small doses
 of them only need be added to this febrifuge.  By
 some physicians a species of the lily, and also
 the agaric have  been used  as remedies.   The
 latter article enters into  the composition of one
 of our nostrums,  which proves oftentimes effi-
 cacious. I have, myself, known it to be exhibit-
 ed with advantage, to many  people in the coun-
 try.  This remedy, however, should be admini-
 stered with great caution, on account of the heat
 or feverish action, which is apt to be excited by
 the irritating quality of the agaric.  Persons of
 tender and irritable viscera ought to reject it al-
 together.

    Some physicians are in the habit of exhibit-
 ing peruvian bark, mixed with stronger purga-
 tives, such as pulvis  cornachini, or jalap ;  nor
 can it, indeed,  be denied,  that  this composi-
tion has been  sometimes found  useful.   It is,
 in general, however,  better to give the bark in 
228
combination with such doses of arcanum dupli-
catum, or vitriolated tartar, as may serve to keep
thebow^els moderately open.  I have been in the
habit of administering the pulvis Stahlii in com-
bination with the bark with singular advantage.

    But my favourite remedy is, a febrifuge and
purgative decoction prepared in the following
manner.  Take of peruvian bark, coarsely pow-
dered, an ounce, or an ounce and an half;  boil
it in two pounds and an half of water to  two
pounds ; towards the end of the process, add of
the  leaves of senna, half  a drachm, and of the
leaves of the borage and bugloss, of each, half a
handful. Instead of the senna, I  oftentimes use
some purgative and aperient salt, such as epsom
salt, or sal polychrest,  to  the amount of  four
drachms.   This preparation, consisting as  it
does, of purgative, cooling, aperient, and febri-
fuge articles, is calculated to answer every indi-
cation that can occur in the treatment of com-
mon intermittents. 
CHAP.   XIII.
Of injurious effects produced by the peruvian bark.
    BY the mixture of all these articles with the
peruvian bark, its efficacy has appeared to some
physicians to be diminishedrather than increased.
By the bark alone, say these characters,  vast
numbers have  been and still are cured.   There
are places in which intermittents are endemic ;
yet most persons who are attacked by them, use
scarcely any thing  for  their  removal, but the
bark alone.  Nor, if we may  give credit to re-
port on the subject,  was any other remedy ne-
cessary in  those times when the  bark was first
introduced into practice.   At that period, in-
deed, this  article was of better quality than  at
present, and not liable to be fraudulently  mixed
with other substances.  Some physicians assert,
that if it be carefully selected even now,  it will
certainly cure intermittents, when given even in 
                     230
a moderate dose, and that without any medicines
either preceding it, or being joined with it.

    But these  instances must not be considered
as universal.  The bark if exhibited alone, may
be oftentimes  hurtful.   It is bitter, astringent,
tonic, and aromatic. If given, therefore, in cer-
tain cases or temperaments, it excites heat, pro-
duces dryness over the whole skin, injures the
stomach,  sometimes occasions pains in it, af-
fects the lungs, and extends its unfavourable in-
fluence even to the blood itself.

    But this remedy may produce no less injury
in other  parts of the system.   In some cases,
after it has removed the fever, pains still remain
in the hypochondriac regions.   It frequently at-
tacks even the spleen itself. That viscus, as we
have already mentioned, becomes enlarged,  and
even inclines to suppuration. But I  have learnt
from experience, that this  affection is to be at-
tributed to peruvian bark as frequently as to the
fever itself.

    Another objection against this remedy7 is,
that it is not always certain  in its effects. Many
fevers,  and those really intermittents, cannot be
cured by it.  Even when it appears to succeed,
it not unfrequently happens, that it only sus-
pends the disease for a certain time.  Many pa- 
231
 tients worn out, as it were, by this remedy, and
 by an irregular fever, have dragged on a misera-
 ble existence during the autumn and  winter.
 Peruvian  bark alone, therefore, has been con-
 sidered as nothing but a palliative  remedy, and
 is accounted only such by some physicians even
 at the present day.

    But a more weighty objection is, that this re-
 medy oftentimes suffers the febrile poison to re-
 main in the system  in a latent state.   We see
 many persons who, after  the removal of the fe-
 ver, languish under a pale, tumid, yellow coun-
 tenance, an enlarged abdomen,  and anasarca of
 the legs and other parts of the system ; they ap-
 pear  to have  only exchanged their original dis-
 ease for a secondary one that is much more dan-
 gerous :  for there are many who recover  from it
 with difficulty, or at least not till after a tedious
 lapse of time.

    We meet with others who experience cer-
 tain anxieties  or uneasinesses at those times at
 which the paroxysms had  usually occurred.
 Others again fall into  a deep sleep, or stupor,
 about the same hour.  Some, having the cause
 of the disease directed to  other  parts  of the
 system, are attacked by a diarrhoea or dysentery.
Finally, sometimes  when the fever is checked,
wandering spasms occur in place of the regular 
232
paroxysms, and excruciating pains at  the same
time  attack  the  limbs,  bowels,  breast  and
head.

   From  the very cure of the fevers, then,  an
argument of some weight arises against the effi-
cacy of the  bark alone.  When the preceding
symptoms assume the place of the regular pa-
roxysms,  a  renewal of the fever, as we have  al-
ready observed, becomes sometimes necessary
for their removal;  for it has been remarked that
they disappear on its return, and  vice versa.
Some  physicians, on discovering this, have
sought not for a febrifuge remedy, but for one
calculated to recall fever ; and they declare that
they have found  spirits of sal ammoniac to be
possessed of that property.

   From these circumstances it appears, that
the peruvian bark is  calculated  to restrain  the
effects of the febrile poison,  rather than to  de-
stroy the poison itself.  For the poison may in
fact  remain  sound and untouched,  as it were,
even after  the paroxysms have disappeared.

   No wonder then that some  physicians de-
cline considering this remedy as a true antidote
to intermitting fever.   For, besides the restrain-
ing of the paroxysms, which may be accom-
plished by other remedies, such as astringents 
                     233
and bitters, it is further  necessary that the fe-
brile poison be altered in its nature or expelled;
but this expulsion is effected either by the natu-
ral action  of the system, the force  of the pa-
roxysms, or by other auxiliary remedies which
do not possess any true febrifuge power.

    But if by the peruvian bark the occurrence
of paroxysms may be prevented, by an improper
and unskilful use of that remedy, simple inter-
mittents  may be changed into continued fevers,
double tertians or quartans.   And if such a
change even be not actually effected, still the fe-
brile heat may be increased,  all  the  symptoms
may be rendered worse, and their cause may be
made to take deep root.  Hence the disease will,
with more difficulty, yield to  remedies ; and (a
circumstance which no one would have believed,
who had not learnt it from experience) the  ut-
most danger will result to the patient.

    Sydenham  relates the cases of an officer in
the army, and  of an  apothecary, who died in a
very short time, in consequence of the use of
peruvian bark.   The remedy had been adminis-
tered previously to a paroxysm, whence either
the fever was rendered more  violent, or, which
is more probable, being quite smothered, the
febrile poison was thrown on the vital  organs,
and thus destroyed their functions by its delete-
                      Hh 
                    234
rious power.  Hence arose sudden death, which,
perhaps, paroxysms much more severe would
not have produced.   From what has been said,
it will not appear surprising, that, in cases where
intermitting fever has been removed by the bark
alone, some obstructions should remain behind.
The febrile poison which it too frequently suf-
fers still to lurk in the body, may be determined
to, and act injuriously on, any or all of the organs
or parts of the system. Hence there is no doubt,
but the  mania which  Sydenham speaks of  as
having succeeded a quartan fever, arose from the
relics of the fever, or of the febrile poison, being
thrown on the brain. 
CHAP. XIV.
Of the precautions necessary to prevent mischief in the
       administration of the peruvian bark.
    FROM what has been said, it follows, that
the peruvian bark is not a remedy of such a na-
ture, as ought to be immediately exhibited in
every case of intermitting fever.   Yet what we
have said  respecting its virtues,  is  incontro-
vertible and certain.  Those fatal events which
are charged to its account,  very  rarely occur.
All the unfavourable accidents which are urged
by the common people, and  by certain physici-
ans, as arguments against this remedy, are to be
attributed to the imprudence of those who have
made use of it;  for if it be not taken by the sick
till their  systems are properly prepared for it, by
previous remedies, these accidents are not to be
dreaded.   We have, therefore, treated of them,
only with  a view to prevent  the use  of this ex-
cellent specific from being turned into abuse. 
236
Acting on the same principle, we will now lay
before the reader, those cautions necessary to be
attended  to in its administration.

   It will be prudent and wise in us, to take na-
ture for our guide, in the cure of intermitting fe-
vers.   These diseases occur  about the com-
mencement of autumn ; a:> that season advances,
they become, as it were, more fixed ; they are in
their highest  state of confirmation, or obstinacy,
during the winter;  but on  the return of warm
weather they  terminate of their own accord. By
the warmth of the season the system is relaxed,
and the pores of the skin opened.   To effect the
cure of intermittents, remedies ought to operate
in the  same  way ;  or,  which amounts to the
same thing, the body must be subjected to a kind
of summer  temperature ;  medicines of gentle
warmth must be taken internally, in order  that
the perspiration may be promoted.   Such is the
effect of this cutaneous evacuation, that, provided
it be kept up to a sufficient degree, during the
exhibition of the bark, a cure will certainly be ef-
fected.   But, on  the  other hand,  there is no
ground to hope for this, if  the skin be dry.

   But it may be laid down as an established
principle on the subject, and  as one which em-
braces every  thing necessary in  the use of the
peruvian bark, that intermittents cannot be cured 
                     237
 by it, unless the functions of the internal parts of
 the system be in an active and healthy state.  If
 the viscera be in any measure diseased,  this re-
 medy will be exhibited in vain.  Should the dis-
 ease even be suspended by it for a time, it soon
 recurs  again with as much  severity as before.
 On the other hand, if the internal organs be in a
 sound and healthy state, the fever will be so easi-
 ly removed, that it will be scarcely necessary to
 join any thing else with the bark.  It will in ge-
 neral, under such circumstances, prove suffici-
 ent of itself for the cure of the disease.

    It must be the earnest endeavour of the prac-
 titioner, therefore, to prevent any stagnation of
 blood in the viscera.  Hence  arises the necessity
 of blood-letting, of which we have already spoken
 in  such favourable  terms.   Equally attentive
 must the practitioner be to promote the secre-
 tion of bile;  for while  that secretion goes on
 actively, remedies will the more easily reach the
 cause of the disease ; all the  symptoms  will be
 more mild, both the cold and the hot fits will be
 less violent, the patients will not be exhausted by
 such profuse sweats, nor will the humours  ac-
 quire such a degree  of  acrimony.  The several
 symptoms will be still more alleviated,  and  the
 state of the system be rendered more promising,
 provided the  pores  be  kept  open and the skin
moist. 
238
   The functions of the stomach must be very
particularly attended to.   If that organ be dis-
ordere I,  or only loathe food, there will  be no
ground to hope for a cure of the  fever by the
use of the peruvian bark.   On the other hand,
the disease even acquires fresh strength from the
exhibition of  that remedy ; a sense of pain and
heat is excited in the stomach by it, which  is
usually extended even to the lungs.   But if the
appetite be good under the use of the bark, that
is an infallible sign that the patient will soon be
restored to health.   At least very few instances
occur, where  persons  with keen  appetites are
not soon relieved from the  disease.

    The intestinal tube  is  the third part, to the
functions of which attention should be paid.  If
it be  not in a healthy  condition,  the cure  of
the fever will, as  w7as  formerly mentioned,  be
very difficult.   Indeed  it  is in vain to attempt
the cure of  intermittents,  if the bowels be not
kept open.  To  the peruvian bark,  therefore,
the practitioner should always add  some lenient
purgative;  lenient, I say,  and such as may but
gently excite the peristaltic motion  of the intes-
tines : for if an acrid and  highly stimulant pur-
gative be  given,  such commotions may be ex-
cited,  as  will greatly augment the  febrile heat;
or such a  profuse evacuation may be occasioned,
as will carry  off entirely'the febrifuge qualities 
                     239
 of the bark, and thus prevent the success of the
 remedy.

    There occurs at times, either in consequence
 of affections of the foregoing parts, or from some
 other cause, a state of the system which is no less
 unfavourable to the cure of intermittents.  Some-
 times, for instance, in these fevers, the sick are
 parchedas it were, by a very acrid orpungent heat.
 If, in such a state of things,  the peruvian bark be
 exhibited, it never proves successful.   If its use
 be persevered in, it will even become highly in-
jurious ;  the febrile heat will be rendered more
 intense,  the humours  will  become extremely
 acrid,  and  the force of the  paroxysms  will  be
 augmented.  The fever may  even assume a con-
 tinued form, or if it be by chance removed, there
 will be reason to  apprehend the occurence  of
 those other numerous  and  troublesome symp-
 toms, of which  we have already spoken.   Nor
 can  we,  indeed,  while there exists a burning
 heat in the internal parts of the  body, expect
any thing else from an astringent and bitter re-
medy.   Its use is  adding stimulus to stimulus,
and fire,  as it were, to fire.

    So frequently does this fire or burning heat
prevent the cure of intermittents, that as often
as I have observed these diseases refusing:  to
yield to the peruvian bark,  particularly at their 
240
commencement, I have almost always suspected
the existence of such a heat in the viscera.  In-
fluenced by this suspicion and by long experi-
ence, I have uniformly been of opinion, that, un-
der such  circumstances,  the  use of the  bark
ought to be laid aside.  In cases of this descrip-
tion, I have  been in the  habit of prescribing
cooling and opening injections, by which, in a
short time, all th^ symptoms are rendered mild-
er, and the fever so changed as to be easily re-
moved by the febrifuge powers of the bark. Even
in the most obstinate intermittents, this remedy,
when properly managed, has seldom failed with
me to produce a cure.

    Hence, we see, with what little judgment
those physicians act, who, in their attempts to
cure intermittents, begin immediately and indis-
criminately with  the  peruvian  bark,  or who
throw  in vast quantities of that remedy in a short
time.   Sometimes, indeed, it may prove inno-
cent and  even produce a cure.   It has remov-
ed intermittents when exhibited to the amount
of an ounce in six or eight hours. But an at-
tempt  to cure these diseases in this way, is not
always safe.   A sensation of weight and tight-
ness is immediately produced in the stomach;
the thirst is rendered more intense;  pains arise
in the  hypochondriac regions ; a burning heat is
excited.  All these symptoms terminate, finally, 
                     241
in some other disease, such as jaundice, an en-
largement  of the spleen,  or a continued fever,
which is sometimes less dangerous than the other
symptoms.

    From what has been said, it plainly appears,
how rash and hazardous it is, to administer bark
at the commencement of the cold fit.  Some-
times, indeed,  this remedy removes intermit-
tents when mixed in  wine or  spirits  of wine:
it accomplishes the same object, as we have al-
ready observed, when given in conjunction with
jalap or agaric.  But  lest any one should be led
into an  error by this treacherous experience, let
it be held in remembrance, that intermittents are
frequently7 cured by very dangerous medicines.
But as it would be the height of madness to trust
to such  deceptious experiments,  so it would be
no less irrational to be led by similar arguments,
to the exhibition of peruvian  bark in the cold
stage  of fever.

    What  can be  expected from a  remedy of
this kind, whilst, as was formerly mentioned, the
system  is, in all its parts, labouring under a con-
striction ;  whilst the  stomach can scarcely bear
even warm water ; whilst the blood is stagnating
in the vena portae, in  the auricles of  the heart,
and in the lungs themselves ? Surely by the use
of such a remedy,  under such  circumstances,
                     i i 
242
great anxiety or uneasiness would be produced;
the force of the cold fit w ould be increased ; and
the violence of the paroxysms augmented.  But
those physicians have been  still more unfortu-
nate, who have ventured to administer essential
oils and other more heating substances during
the cold fit;  for by such practice death has been
sometimes suddenly produced.

    By this rash mode of treatment, the salutary
efforts of nature are necessarily suppressed. We
formerly intimated that, the febrile  poison is ex-
pelled by a kind of crisis.  Galen  observed this
crisis, and asserted that evidences of it manifest-
ed themselves in  a Aery7 early stage  of the dis-
ease.  These  evidences appear in the urine ; not
indeed, in a lateritious and gross sediment, which
is  always the sign of a violent fever; but in a
white and  very thick sediment.   The cause of
the fever is  also carried off by the bowels and
the pores of the skin.

    Many physicians are firmly of opinion, that
intermittents are removed  by  peruvian  bark,
without any  crisis;  for that remedy appears
sometimes to destroy them as if by a single blow,
and that w ithout any evacuations either from the
bowels, the urinary organs, or the pores of the
skin; at least  many practitioners assert, that
they have not observed any such evacuations. 
                      243
But it is very doubtful whether or not they have,
in  these cases,  been  accurate  observers of na-
ture.  When  intermittents are cured by the
peruvian bark, the crisis is not always very per-
ceptible.   But it is  certain, that unless the na-
tural evacuations, which had  been checked  or
disturbed,  be restored, a perfect cure will not  be
obtained.  But this restoration is a kind of crisis.
That such a crisis  does, therefore, occur, is a
truth which  no one will either deny or doubt,
who has examined the subject with the neces-
sary degree of attention. 
CHAP.  XV.
Of the method to be adopted in the use of the peru-
                vian bark.
   WITHOUT any  further preliminary re-
marks on the subject, we  will now proceed to
mention that method for the use and exhibition
of the peruvian bark, which is founded on long
experience,  and is fairly  deducible from what
has been already laid down.

   Having premised the necessary preparative re-
medies, such as blood-letting, evacuation of the
stomach and bowels, and the use of aperients, the
bark may be exhibited alone in doses of, from a
drachm to a drachm and an half, at such intervals
that four  or  five doses, or  more or less, accord-
ing to  circumstances, may be taken during the
period of intermission.   In  this way, the sick
being at the same time under a proper regimen, 
                      245
 many intermittents have been, and still are cured.
 When the bark was first introduced into practice,
 the mode of using it was very different,  At that
 time, as soon as the bark was taken, the patient
 was directed to take also some solid food, a prac-
 tice which is alike inconsistent with both reason
 and experience.   The sick should  be supported
 principally by broths, until the close of the fever,
 when a more generous diet may be allowed.

    In the mean  time,  strict  attention  must be
 paid, to ascertain whether or not  the medicine
 agree with the stomach;  whether  or not it ex-
 cite an appetite for solid food ;  whether or not
 the  surface of the body in general be moist;
 whether or not the bowels be in an open state;
 and, lastly, whether or not the natural colour be
 restored to the  urine.   If there be any thing
 amiss  on either of these scores,  gentle purga-
 tives, aperients, and refrigerants must be called
 in to the aid of the bark.  In such cases, vitriol-
 ated tartar or some other cooling neutral  salt
 combined with the bark will answer an excellent
 purpose.   To avoid the necessity, however, of
 recurring to these remedies  during the course
 of the cure, they  ought not to be omitted in the
 beginning of it.

    But as the bark in powder is oftentimes dis-
agreeable to the  stomach, as we  have already 
246
mentioned, and as the prima? viae may for a cer-
tain time, be troubled by bilious and very acrid
humours, there  is another method in which I
have thought proper to prescribe this remedy7,
and that with much advantage.  After cleansing
the stomach by an emetic on  the day of inter-
mission, I order a strong decoction of the bark
to be administered in the  form of injection, in
the quantity  of  four  or five ounces every  two
hours.  This preparation both  acts as a febri-
fuge, and tends to keep the bowels in a free and
open state.  The dose may be increased or di-
minished according to circumstances.

   In some constitutions the peruvian bark pro-
duces severe and copious purging.  When this
is the case, its purgative effect must be prevented
by laudanum, else its febrifuge qualities will pass
off by the  bowels, and not enter the system at all.
Besides, it may even irritate the bowels to such
a degree, as to add to the violence of the fever.
Its purgative effect, however, must not be check-
ed if it move the  bowels only five or six times
a-day,  and that only7  during  the first or second
day of its exhibition.  I have never known such a
moderately7 purgative effect to have any influence
in preventing a cure.   On the other  hand, it
even contributes greatly  towards it,  by carrying
off whatever may be left behind of the depraved
humours. But should the bark continue to purge 
                     247
for several days, this effect must be moderated,
else it will debilitate the system of the  patient.
Still, however, this  remedy will remove inter-
mittents the sooner,  provided it  continue  to
keep the bowels open to a moderate degree.

    Intermittents do  not, in general, terminate
immediately by the use of these remedies. Some-
times thesubsequent paroxysm maybe even more
severe, and that, perhaps, in consequence of the
tumult  excited  in the system by the purgative
effect of the medicine.   In general, however, the
paroxysm is mitigated in force, and sometimes
does not occur at all.  At  least the third pa-
roxysm will  almost  ahvays be prevented. By
pursuing  this method, therefore, intermittents
may be cured both speedily  and safely.  Hence
those physicians have  erred greatly, who have
not hesitated to assert, that the  action of pur-
gative medicines is unfavourable to the effects of
the peruvian bark.

    We must not desist from  the use of febri-
fuge remedies,  as  soon as the fever terminates.
The cure must be  confirmed, and the febrile fo-
mes entirely eradicated.  This is the more ne-
cessary to be attended to, in as much as during
the first stages of the  cure, the patients frequent-
ly experience slight affections of the  head, yawn-
ings, something of chilliness, sleepiness, or some 
248
other diseased sensation of body. These, indeed,
are, as it were, only so many remembrancers of
an  evil that is past, but they may break out into
a real fever similar to the original one.   It is
necessary, therefore, to continue the use of the
bark, till the cause of the  disease be entirely
vanquished.   The precise length of time during
which the administration of this remedy ought
to be continued it is impossible to determine ;
that  depends  on many circumstances  which
are very different in different patients.

    In the mean time, certain general principles
may be laid down, to which all directions  on the
subject are reduceable.   Thus,  the bark ought
to be exhibited in  certain doses, for six or eight
days after  the disappearance of the  fever, and
then gradually diminished daily, or thereabouts.
It may, at length,  be laid aside entirely, and that
sooner or later, accordingly as the different parts
of the system  are more or less perfectly restored
to their healthy functions.   Finally, the patient
cannot be  considered secure from a return of
the disease,  while  there is any deficiency in the
secretion  of bile,  or the openness of the bow-
els, or any thing wrong in the colour or quantity
of the urine.

    Such is the method, which,  to many physi-
cians  as well as to myself, appears preferable to 
                     249
all others.   There are, however,  other  modes
of exhibiting the bark, from the merits of which,
I would not wish to detract.   Different methods
may have  their peculiar excellencies, as being
better accommodated to particular constitutions;
some, for instance, to tender and delicate habits
of body,  and others to such as are more robust:
some remove disease more speedily, while others
accomplish the same  end by  a slower process.
There are, however,  innumerable cases in which
we are forced to depart from the usual practice.
Hence, we must accede to the apparently contra-
dictory opinions published by different physici-
ans;  they have all employed the proper specific,
but  the  method must be different according to
the  constitutions of  the sick and the nature of
the disease ; and it is right that every one should
be governed by his own experience.

    There is no other method, however, prefer?-
able in the cure of a double tertian to that which
we have  prescribed.   The only  difference  be-
tween simple and double intermittents is, that
the  latter are  superior  in violence,  and  are
characterized by shorter intervals between their
paroxysms.  From   these two circumstances,
then,  must be deduced  the differences  that
necessarily  exist  between  the proper  modes
of treating double and single  intermittents.
                       K k 
                      250
    The more violent  the fever, then, and the
greater the danger that accompanies it, the great-
er circumspection it calls for in the exhibition
of the first or preparatory remedies.  The more
strict, for instance,  must be the patient's  diet;
the more  diluents must he use ; the more must
the febrile heat  be  moderated;  and the more
strictly must the use of aperients  be  enjoined;
but, in particular, the  more copious must be the
evacuations from the stomach and bowels, in or-
der, that whatever might tend to increase the ac-
tion of the febrile  poison  may be discharged.
At length recourse must be  had  to the bark.
This remedy, however, must be deferred till a
later period than in a less violent disease,  unless
the most urgent circumstances  should call for a
different procedure.

    If there be any form of intermittent, in which
the bark is not  to be immediately exhibited in
substance, it is more  especially the double ter-
tian.   In  this disease it is better and safer to em-
ploy a decoction of the bark, with some cooling
and purgative neutral  salt dissolved in it.  The
production of acrid and putrid humours is then
more copious ; whence  results the necessity of
a remedy  calculated both to evacuate,  and  to
counteract fever.  In as much as the paroxysms
in this disease press closely on each other, it is
necessary to give a glass of this decoction every 
                      251
second hour.  We do not, however,  lay this
down as an invariable rule.  But it is most cer-
tain, that the practitioner  must here perform in
a shorter interval, what he usually performs in a
longer one, in cases of simple  intermittents.

    To this mode of treatment a double tertian
seldom fails to yield.   By the exhibition of the
preparatory remedies alone all  the symptoms are
mitigated,  and sometimes the disease  declines
into a simple tertian.  But  even in case things
should not go on so successfully as this, still by
persevering in the same mode of exhibiting the
bark, the disease will begin to be removed.  In
a double tertian the fevers that constitute it are,
for the most part, cured in succession, or one at
a time.   Thus, as  we formerly mentioned, one
of the two tertians disappears immediately, while
the other still remains.  When both shall have
disappeared, then a  simple decoction, or  the bark
in substance, may  be exhibited, and that either
with or without some purgative salt, as  circum-
stances may require. 
CHAP. XVI.
Whether or not a quartan fever requires a mode of
          treatment peculiar to itself.
   THE foregoing  considerations relate to in-
termittents of every kind.   We must now en-
quire, whether or not the quartan fever calls for
a mode of cure peculiar  to itself.  Previously to
the discovery of the peruvian bark, this disease
was considered as the opprobrium of physicians
and the torment of patients.   Even at  the pre-
sent day, it is  believed by  many, not to yield
to that remedy.   Although,  say they, it often-
times seems  to be cured by the bark, yet it fre-
quently  disappears only for  a certain time.  It
oftentimes continues throughout the winter, and
on the  occurrence of the spring or summer, is
cured by the favourable influence of the weather,
rather than  by  the febrifuge virtues  of the
bark. 
                     253
    It must, indeed, be acknowledged, that the
quartan  fever possesses  something peculiar to
itself.  It differs from other forms of intermit-
ting fever particularly in this, that it appears to
take deeper root in the system than they do, un-
less it be checked at an early stage.   But if it
be of recent origin, there is no doubt but it will
yield to the mode of treatment already mention-
ed, and that as readily as  any other form of in-
termittent.   As  it may, however, degenerate
into a more obstinate disease, there are certain
precautions  which should be used to  prevent
such frequent relapses in it, to the reproach of
both the peruvian bark and the  medical pro-
fession.

    Unless the symptoms of the disease be very
slight, a  strict diet must be firmly enjoined, al-
though the intermission of two days which oc-
curs between the paroxysms may not seem to
require it.  Even this will not succeed  without
blood-letting.  So important a remedy is blood-
letting in quartan fevers, that it almost immedi-
ately reduces their violence,  and many of them
cannot be cured  without it.   Emetics are no
less essential in the cure of the disease ;  if they
be neglected, the febrile fomes will for the most
part remain in the system.  Purgative remedies
are not altogether so necessary, because the ac-
cumulation of vitiated humours is not  in general 
254
so abundant in diseases of this description. It is,
notwithstanding,  adviseable to keep the bowels
in a laxative state.

    These precautions being attended to, there
is no doubt but the fever will be subdued, pro-
vided it be treated in the manner which we have
laid down. As it is, for the most part, however,
extremely obstinate, a larger portion of the bark
must be administered.  For the same reason, it
is better to mix with that  febrifuge some other
remedies of a penetrating nature.   Certain aro-
matic  substances mixed with vegetable alkali,
are sometimes exhibited with the  best effects.
Cascarilla,  in particular,  is a very  powerful re-
medy in the treatment of quartan fevers.  This
mode of practice is sanctioned by daily experi-
ence, as well as by the authority of the ancients,
who were in the  habit of prescribing the more
heating kind  of  remedies, not  constantly, in-
deed, but in certain cases.

    It is particularly in quartan fevers that the
peruvian bark, mixed with the lesser centaury
or agaric in powder, may be exhibited  with great
advantage.   Even in persons  of delicate,  but
more especially in those of robust constitutions,
and in such as were subject to no diseases of the
viscera, I have oftentimes used the following re-
medy,  namely, Pulv.  Cornachini gr.  xxiv : 
                      255
 Agarici. gr.  xv.  Sal Ammon.  one  drachm:
 Cort.  Peruv. four drachms, M. f.  Electuar:
 The mode of administering this  preparation is,
 to give the fourth  part of it to the patient every
 third hour.

     I have known  a great many quartans cured
 by this remedy alone, although  they had already
 run on for two or three months. It is necessary,
 however, to persist several days in the use of it,
 taking care  only to diminish,  if requisite, the
 quantity of the purgative medicines.   In the
 mean time, let the patients use  ptisans of aperi-
 ent and gently cordial qualities.  It will also be
 adviseable to administer to them moderate doses
 of nitre, both for the purpose of increasing  the
 urinary discharge,  and also of moderating the in-
 ternal heat, which may possibly be produced by
 the foregoing remedies.

    After the quartan fever has yielded to the ac-
 tion of these remedies, the use of  the bark must
 not  be  immediately  relinquished.  In conse-
 quence of the just apprehension of a relapse, this
 febrifuge must be continued for  a very  consider-
 able time.  If neutral salts and chalybeates be
 combined with it, they render it a prophylactic of
 still higher value.  This compound preparation
restores  tone to the system,  removes  obstruc-
tions, and promotes the secretion of the bile. 
256
   But although all these acrid and heating ar-
ticles, of which we have treated,  be almost infal-
lible remedies against quartan fevers, they can-
not be administered to everyone labouring under
it. Those persons whose constitutions are weak
and irritable cannot bear their action.  In  such
patients, therefore, the preparatory  remedies
are to be exhibited with greater caution than in
others,  and the peruvian bark  must be used in
the same  manner as in simple tertians, that  is,
combined with gentle purgatives and aperients.
Sometimes the heating quality  of the bark is to
be moderated.  This may be done by making it
into a decoction along with borage and bugloss,
and adding to the liquid thus prepared, a quan-
tity of nitre or  arcanum duplicatum.

    In  persons advanced  in years, still further
precautions are essentially necessary.  In  such
subjects quartan fevers are more dangerous, be-
cause the vitalprinciple is sometimes overwhelm-
ed by the cold fit.  If, therefore, the violence of
the cold fit be very great, a return of it must, if
possible, be prevented.   This end will be most
likely to be attained by emetics, followed imme-
diately  by  a copious use  of the peruvian bark.
But, as in old age, the different parts of the body
are less permeable, and  their  excitability less
keen, the activity of the bark must beencreased
by  some stimulating aromatic  and penetrating 
                     257
 salt.  These additions are still more necessary in
 the winter season.

    To what is  here said, respecting the use of
 bark in quartan fever, I must add, that I am ac-
 quainted with what I consider as a certain reme-
 dy against the obstinacy of that disease.  I allude
 to warm  mineral waters  possessing purgative
 properties, which have produced a perfect cure,
 when all other remedies had been tried in vain.
 Many have been cured under these circumstan-
 ces by the waters of Bourbon.   The waters of
 other places have also produced the same effect.
 Several persons, who,  after the last war in Flan-
ders,  retained the relics  of  obstinate quartans
and  even  tertians, were restored  to health by
these, when  all  other remedies had completely
failed.

                      Ll 
CHAP.  XVII.
Of impediments  arising from  previous  affections of
   certain parts  of the system, or from different tern-
  .peramenls.
    THE foregoing directions cannot be strict-
ly followed  in all cases.   Such,  frequently, is
the nature or  temperament of patients, the con-
stitution of some particular parts of the system,
the nature of  the fever itself, and the variety of
symptoms,  that  difficulties occur on all hands.
To remove these difficulties, therefore, the prac-
titioner must pursue a different  course, or  ra-
ther,  he must vary the course already pointed
out, so as ultimately  to attain the cure  of  the
disease.   The use of the bark must be accom-
modated to  the  various impediments which  are
thrown in the way7, whether these impediments
exist  in  some  particular  part,  or  be  spread
throughout the whole body. 
259
    The stomach itself oftentimes  rejects the
bark.   It cannot, for instance, bear the taste of
this remedy, though by no means very7 disagree-
able.  To remove this difficulty, Fuller prepared
a draught composed of bark,  syrup  of cloves,
and some cordial distilled water.   In this pre-
paration there is nothing to offend the stomach,
and the only thing to be dreaded is, lest it may
prove too highly stimulant.   To prevent  that,
let  some cooling, and aperient ptisan, with nitre
dissolved in it, be given at the same time.

    The same objection exists against an infu-
sion of bark in generous wine.  To render the
preparation  less  disagreeable, some  physicians
use Spanish wine, but direct the infusion after it
is made, to be boiled a little.   They are of opi-
nion that, by this process the  wine loses part of
its native strength, and may be prescribed with
safety.   If any wine, however, be admissible, it
is particularly Rhenish wine, as being more ape-
rient  and less stimulant.  But, as I have very
frequently mentioned, remedies of this kind are
always too heating.  They  may answer a better
purpose in fevers  that have nearly  worn them-
selves out, than in such as are more violent and
of recent origin.  In  this latter description of
fevers, a watery infusion of the bark,  holding
some neutral salt in solution, forms a more suit-
able remedy. 
                    260
   But an impediment to the use of the bark fre-
quently arises, not only from the repugnancy of
the stomach, but from its injured functions. An
obstinate vomiting sometimes forbids the use of
this remedy.  To remove this difficulty Syden-
ham was  in the habit, after the manner of Ri-
verius, of exhibiting lime juice  and  vegeta-
ble alkali,  and afterwards  liquid laudanum for
the purpose  of allaying  irritation.   Others,
pursuing a bolder practice, have attempted the
cure of fever by exhibiting the bark combined
with opium or laudanum.  But if the  violence
of the  fever be  not too  great to be borne w ith
safety  by the patients, my first step is to remove
the affection of the stomach, which being done,
the general disease can be the more readily sub-
dued.

    But the intestinal tube no less than the sto-
mach  oftentimes presents difficulties to the cure
 of intermittents.  In either case the sick may be
 relieved in  the same way, namely, by exhibiting
the bark in the form of injections.  When given
in this way, however, it has been observed to be
more serviceable to young persons than to adults.
But it will do little or no good, unless it be re-
tained for a considerable time  in  the colon and
 rectum. It will be very readily discharged, par-
 ticularly  if a diarrhoea exist.   In such a case,
 recourse must be had to  narcotics, which may 
                     261
be  given  in the decoction of the bark.  The
proper  doses  of these  remedies are the only
points that now remain to be determined.  Great
care, however, must be taken not to give too
large a dose of narcotics, else the issue will be a
deep stupor.

    Difficulties arise from the state of the lungs,
no less than from that of the stomach.   When
the lungs  are tender and irritable, and the sick
subject  to a spitting of blood or a troublesome
cough, they appear incapable of bearing the pe-
ruvian bark.   But it is to be remembered, that
the disease itself is more injurious to this pec-
toral  affection  than  the  action of the remedy.
The bark must, therefore, be  employed, but
care should be taken at the same time to admini-
ster lenient and demulcent medicines along with
it.  For this purpose, I am in the habit of adding
to the decoction of it, the root of the althea,  or
the flowers of the poppy.   In  the case  of a fe-
male, who ha4 been  attacked by a very severe
and incessant  cough, I employed these demul-
cents  w ith the  greatest advantage;  for the
cough  and fever  wrere  removed  at the  same
time.

    In cachectic  and hypochondriac patients,
the bark must be used with precautions suited
to the particular nature and character of the ex- 
262
isting affections.   In persons of  the  latter de-
scription, some of the viscera are diseased, in
consequence of which,  the  nerves are affected
with  irregular and preternatural  motions.   If,
therefore, heating substances be administered, if
the peruvian bark be given alone, without any
previous preparation, an intense degree of heat
is excited, and a constriction is produced in the
diseased vLcera. Hence, emollients, gentle laxa-
tives, aperients, and refrigerants,  ought both to
precede the use of the bark, and also, to accom-
pany it.   If a  different  mode of treatment be
attempted, the fever will be rendered more obsti-
nate and severe.

    Difficulties equally great arise in the cases of
chlorotic females, or such as labour under men-
strual  irregularities.   Subjects  of this descrip-
tion are with difficulty relieved from  intermit-
tents, because they are affected by two diseases.
The practitioner must begin by administering
emetics to them, as such remedies  are no less
efficacious in the removal  of the original affec-
tion than of the fever itself.  As the stomach is
always disordered by  a  suppression of the ca-
tamenia, a  remedy which  will  excite that or-
gan to severe action,  cannot fail to be of ser-
vice.   Aperients are also of advantage in such
affections. 
                      263
    In children the cure of intermittents  is  at-
 tended with no less  difficulty.   These  young
 subjects reject all medicines.  It is peculiar to
 them, however, that  they  are in less danger
 than  adults.   We  frequently  see  children of
 every age, labouring for a longtime under inter-
 mitting fever,  and recovering at length without
 any disagreeable consequences, and that with-
 out medical  assistance.   But they would have
 recovered more readily, had mild emetics been
 administered to them in the beginning  of the
 disease.   I  have prescribed tartar  emetic to
 children  of  two years old.  I am  convinced
 from experience, that this  medicine  operates
 more mildly  on them, than it does on adults.

    The emetics will be productive of more sa-
 lutary effects,  provided  they  be followed  up
 byr  febrifuge  remedies.  The syrup of the pe-
 ruvian bark  will answer  very well, particularly
 if it be combined with the rob of elder berries.
 This  medical preparation, by  acting as a mild
 purgative, prevents in many children the neces-
 sity of any other cathartic.   But if it cannot
 be employed, recourse must be had to  absorb-
 ents with rhubarb and cream of tartar. In young
 children these remedies are real  febrifuges :  in-
deed, in many cases, it is scarcely necessary to
use any other  medicines; hence, let  them be 
264
administered as plentifully as practicable.  For,
although so many children recover of their own
accord, yet in  many others the abdomen swells,
the viscera are  obstructed, and the liver becomes
greatly enlarged.  These symptoms are render-
ed worse, if the bark be injudiciously adminis-
tered ;  indeed, it  may even produce them,  if
they have not  yet occured. 
CHAP. XVIII.
Of impediments arising from  the fever itself, from the
   injuries which it usually does to various parts of the
   body, and from an improper mode of treatment.
    OTHER  difficulties   present  themselves,
which arise either from the fever itself, or from
an improper mode of treating it.  These may be
considered  collectively or separately.   Taken
collectively, or in  a general point of view, they
may be reduced to an obstinacy of fever, and af-
fections of the  abdominal viscera.   In some
cases the fever absolutely refuses to yield  to the
peruvian bark; sometimes it is not in the least
affected by it, even when all the usual prepara-
tory medicines have regularly preceded it. The
efficacy of the peruvian bark appears to be dif-
ferent, according as the seasons are different.  In
certain  yTears it is attended with  the happiest ef-
fects, while in others again it does more harm
than  good.  There  are  also  certain   place^
in  which  it  is a  very  unsuccessful remedy,
                       M m 
266
 such,  for  instance,  as  marshy  regions  and
 those bordering on the sea.  There  is a great
 variety in the strength of the febrile poison.
 When  more acrid,  it takes deeper root in the
 solids and fluids  of the body,  and adheres to
 them more closely, and with greater obstinacy.

    When intermittents are obstinate or per-
 verse as it were, it would be madness to perse-
 vere in the exhibition of an useless remedy, when
 it might even become hurtful.   In vain do some
 practitioners have recourse to larger doses, with
 a view  to  overcome the febrile  fomes by force.
 In such a case, either the cause of the  disease re-
 mains in the viscera,  after the paroxysms have
 been suspended, or, as we formerly mentioned,
 fuel is added to the fire, and the  fever  is render-
 ed more obstinate.   It becomes necessary then
 to desist from the use of bark, and to return to
 that of diluents and aperients.   But,  above all,
 an  emetic  must be administered.   Many prac-
 titioners in marshy countries err  in this, that
 they place too little  dependence  on  emetics.
 Such  is the efficacy of these remedies against
 fevers,  that I have known  many' persons who
used them as prophylactics, to escape an  at-
 tack.

   When  intermittents are  obstinate, many
considerations concur  to  convince us how im- 
                     267
 portant  it is,  not to abuse the  peruvian bark.
 From improper modes  of treatment, various lo-
 cal affections arise, which  remain with the pa-
 tients during  the  remainder of their  lives.   I
 have- known many of the most robust  men,
 who, after attacks of  intermittents,  have  ex-
 perienced various disorders of  the princi-
 pal  functions  of  the  system, and have  fallen
 at length into  very grievous affections.  Some
 of   these  became  melancholy and cachectic,
 others were  liable to  obstructions, and  not  a
 few,  being never  perfectly  restored to health,
 have at length fallen victims to their sufferings.
 In some persons it has brought on a premature
 old age.

    In obstinate cases of  intermittents  many
 things occur, and those of a peculiar nature, which
 forbid the use of the peruvian bark.  When this
 remedy is employed, many persons as  wre form-
 erly  mentioned, experience a sense of heaviness,
 a burning, and a constriction or tightness.  But
 these are so many certain impediments to a cure.
 In such cases,  one of two things exist, namely,
 either there is some latent affection of the  coats
 of the stomach, which must  be treated in a
manner suitable to its nature ;  or (as usually
happens) that viscus is over-loaded with vitiated
humours, of  acrid and highly stimulating quali-
ties.   But these humours must necessarily  be 
                     268
expelled and changed ; hence again  appears the
necessity of having recourse to emetics and al-
teratives.   Nor  must the  bark  be any  more
employed, unless these remedies have preceded
it, or be administered along with it.

    Similar impediments  arise out of the state
of the duodenum, or the other portions of the
intestinal tube.   Oftentimes the bowels are ren-
dered more costive by the use of the peruvian
bark.   The stools burn as it were, are  bilious,
of a yellowish-red, or of a black colour, so that
they sometimes even seem to corrode the patient's
linen; if under these circumstances bark be exhi-
bited, the sick are sure to be injured by it.  All bad
consequences  may be guarded against by gentle
emetics, repeated if necessary ; after this, gen-
tle purgatives, refrigerants, and aperients, if con-
tinued a sufficient length of time,  will effectually
cleanse the alimentary canal, and carry off the
whole  mass of depraved humours.   These  are
the only remedies on which we can confidently
rely, in cases where the use  of the peruvian bark
has produced  an accumulation of such humours,
nor must that remedy be employed again, until
the state of the system be materially changed.

    But we must look deeper into the very foun-
tain or source of all  these impediments.   They
almost always depend on the  state  of the liver. 
                     269
If that viscus be oppressed from the beginning,
by the excessive violence of the fever, it would
be an error  fraught with destruction to admini-
ster the peruvian bark ; and if its use be found
unfavourable to the secretion  and excretion of
bile,  it is to be no less carefully avoided on that
account :  for if it be persevered in, an accumu-
lation of very thick and acrid bile will be form-
ed ; the liver will become parched  as  it were;
the  faeces will acquire  a darker  colour;  the
urine will become  very  red, and will deposit a
copious brick-dust sediment.  But there is  no
need of all these symptoms, to convince us that
there is some disorder in the functions of the li-
ver,  which  impedes the cure.   If the counte-
nance be either livid or pale, or put on a yellow-
ish cast, even in cases where  the fever appears
to have left  the patient, it must be considered as
still  lurking in the system ready to break forth
again.

    To remove all these symptoms,  the use  of
the peruvian  bark must  be immediately relin-
quished, and  medicines given for some time,
with  a view to unlock the liver.   For this pur-
pose, I have frequently used with advantage, the
depurated juice of certain saponaceous plants, to-
gether with that of borage and bugloss, holding
in solution a quantity of neutral salts, such as ar-
canum  duplicatum, &c.   Such is the efficacy of 
270
purgatives in affections of the liver, that I have
frequently removed them by the use of such re-
medies alone.  Having accomplished this, which
was done sometimes sooner, and sometimes later,
I then had recourse with success to the  peruvi-
an bark.

   The impediment is still worse, if the abdo-
men become tense and hard, whether this effect
be produced by the action of the fever, or by re-
medies  unskilfully administered.   The cause
of this hardness  is situated in the viscera just
mentioned.   In consequence of the congestion
and obstruction  which occur in these viscera,
the blood does not circulate freely through them,
and the other humours stagnate in them. Hence
arises a rigidity of the fibres, an astriction of the
intestines, and a plethora of the vessels of the
mesentery.   But when these  occurrences  take
place, it is impossible to cure the fever without
their removal.

    While these  symptoms exist, the peruvian
bark cannot be exhibited without hazard.   The
natural  softness can be restored  to the viscera
only  by free  and  repeated evacuations.   Nor
will the bark answer for this purpose, although
it may prove purgative, and even open the bow-
els five or six times a-day.  For the  stimulant
power of this remedy certainly irritates and ex- 
                     271
 cites heat, even while it solicits the intestines to
 a discharge of their contents.  Therefore, nei-
 ther their fibres, nor the texture of the other
 viscera are relaxed by its action.

    Lenient purgatives contribute most to the
 removal of this hardness of the abdomen.  As
 often as that symptom has occurred in my prac-
 tice, I have cured the rigidity of the intestines by
 cassia and other similar remedies.  I have also
 prescribed, at the same time, the juice of succory
 and other herbs  of that kind  slightly impreg-
 nated with salts.   By  the assiduous exhibition
 of  these remedies for a certain time,  I have al-
 ways succeeded in removing this hardness of the
 abdomen, particularly in those cases of disease,
 to the treatment of which I was called soon after
 their commencement.

    But  in fevers of longer  standing, this mild
 treatment does not succeed so well.  In them the
 cachectic habit of body, and  the hardness of the
 abdomen must be attacked by remedies of great-
 er strength.   I have,  therefore,  oftentimes ex-
hibited a purgative mixture composed of senna
 and some milder laxative, such as cassia, tama-
 rinds,  or manna ; I have then directed some
laxative  and emollient  beverage, with soluble
tartar dissolved in  it.   By this mode of treat-
 ment I have generally accomplished my object, 
272
and have very often succeeded in removing even
the fevers themselves.  But a cure  effected  in
this way is not to be fully confided in.  After the
complete subsidence and softening of the abdo-
men, therefore, it ought to be confirmed by pe-
ruvian bark.

    This mode  of cure is far  more necessary
still,  in  case the abdomen  be greatly7 enlarged.
Such an enlargement is not an unfrequent oc-
currence, even without any collection of water.
It takes place in various fevers, particularly in cer-
tain  epidemics,  and that sometimes in an early
stage of the disease. More frequently, how ever, it
does not appear till after the disease has run  on
to a  certain period.  Not only the abdomen,
but the face, the arms, and the  lower extremi-
ties  swell.   In this state of things the peruvian
bark must be cautiously  avoided.   Purgatives
and  aperients, which we  have so often recom-
mended, constitute here the principal remedies.*
Some reliance may be also placed on diuretics.
I have oftentimes cured both the fevers and the
swelling by  the use of wine in which juniper-
berries had been infused, and to which the mar-
tial salt of Riverius and sal prunelle were added.

    * Obstructions snch as our author is here treating- of, appear
 to be most certainly and effectually  removed, by the exhibition of
 mercury, till a gentle ptyalism be produced.....Trans. 
CHAP.  XIX.
Of the cure of fevers which, having  ceased for a time,
   recur again, and also of certain symptoms that usu-
   ally accompany them.
    IF the impediments just mentioned be re-
 moved, the fevers will be easily removed, nor
 will any of the febrile poison remain behind. But
 all patients  have not  the  good  fortune to be
 thoroughly freed from this poison.   In many
 persons the paroxysms are only suspended for a
 certain time ;  either  a very slight cause brings
 them back again, or they return of their own ac-
 cord.   Thus,  alternately  disappearing and re-
 appearing, these fevers are frequently protracted
 for a great length of time.

    To counteract this state of things physicians
have fallen on various expedients. One whilethey
have exhibited the bark in increased doses, and
another while mixed various articles with it, for
                       n n 
                     274
the purpose of adding to its efficacy.   It must,
indeed, be acknowledged that in a great many
cases this remedy thus variously exhibited does
succeed.  When combined with the lesser cen-
taury it  has been  found  capable  of  removing
many obstinate fevers.  Mixed with purgatives
it has been no less efficacious. I have seen many
patients, who  had taken  large quantities of  the
bark alone without effect,  in whom a perfect cure
was afterwards  effected in a short  time, by this
same remedy when taken in  combination with
neutral salts.  Not only purgatives, but diluents
and aperients also, should accompany the use of
the bark.

   But,  these remedies failing, I have, when  the
sick  were willing to submit to it, adopted a
much more certain  mode of cure.   I  have, im-
mediately ordered my patients to bed,  as if they
were under an attack of a more serious disease.
I have then  confined them to an extremely low
diet, and sometimes to water alone for several
days.  I have  next  had recourse to the use  of
aperients and gentle purgatives, and directed it
to  be continued for  a certain  time.   To  this
treatment the fever  has generally yielded;  or if
it did not entirely give way, its violence and  ob-
stinacy have at  least been greatly diminished.  It
then readily yielded to the peruvian bark, if pro- 
275
 perly administered, and the patient had no ground
 to dread a relapse.

    This method is highly necessary  in certain
 fevers, which not unfrequently occur.  In some
 cases where the paroxysms have disappeared, the
 pulse remains frequent;  it rises in force particu-
 larly after the patient has taken exercise or food,
 although he has not been intemperat  in either.
 In the mean time he does not appear to be in-
disposed,  because he is, or has been, in the use
 of febrifuge remedies.  But if he be guilty of any
 irregularity in diet;  if he return to his usual oc-
 cupations;  and if, in  addition to these things,
certain changes in the atmosphere occur ; under
 these circumstances, the fever which  seemed to
be removed, immediately recurs again. In vain,
 then, will recourse be had to the  bark, however
plentifully  it may be exhibited.   That remedy
will produce only fallacious and short lived sus-
pensions of the disease;  hence there will be an
absolute necessity of employing those auxiliary
means which we have just mentioned.

   I would notj from what I have here advanced,
be understood to mean, that  the fever must be
attacked by these same remedies, every time it
may recur. Sometimes very obstinate fevers may
be left to themselves ; if, for instance, they recur
in the winter, and the febrile poison cannot be 
                     276
checked, it will be necessary to wait the arrival
of the spring.   Even at other seasons,  and in
certain  temperaments,  it becomes  requisite to
relinquish  entirely the unavailing use of reme-
dies.   I have indeed seen, though rarely, inter-
mittents even in the summer season,  so obsti-
nate as to resist all remedies.  I have committed
such complaints to nature, taking  care only to
regulate the diet of  the sick,  and to prescribe
such gentle remedies as might aid the viscera in
their respective functions.  In some instances I
have derived more advantage from this mode of
practice than from any7 other.

    So much for the mode to be pursued in those
intermittents, which remain obstinate,  after  hav-
ing run on for a considerable length of time.
In recent cases, where the disease has been re-
moved and threatens a relapse, a different mode
of treatment  must be  adopted.  When  the
strength of the patient is not  much  impaired,
and the fever has  not taken very deep root, it
will be most safe to  return to the preparatory
remedies.  Whence, if it can be done, both  eva-
cuants and diluents must be administered. After
all  remaining  obstructions have been thus re-
moved, febrifuge  remedies may be given  with
advantage.  Yet these must be varied in use ac-
cording as the fevers  or the nature  of the symp-
toms are various. 
                     277
    Some  patients, for instance,  though free
 from fever and paroxysms, are subject to obsti-
 nate  watchfulness, or most  acute  pains of the
 head.   In such cases, the remedies must not be
 relinquished, but  rather urged with a zeal pro-
 portioned to the urgency of the symptoms; for
 we are not to consider the fever as actually sub-
 dued, but only the force of the febrile poison as
 thrown on  the  head ; after  it has changed this
 seat, the paroxysms return again as before.

    In this situation of things, the febrile stimu-
 lus must be drawn from the head.   But in the
 cases of most  sick persons, I have observed that
 this could not be done in any way better than by
 blood-letting.   By this  remedy alone, however,
 a cure cannot  be accomplished.  Hence I  have
 considered it  safe and certain to have recourse
again to emetics;  next  I  have directed laxative
 and aperient drinks, which,  with the occasional
addition of soluble tartar,  I have generally found
sufficient for every necessary purpose.

    Profuse sweats to which the patients are oc-
 casionally subject,  after the removal of the fever
 or the suspension of the  paroxysms, prove at
times no  less troublesome.  If this excessive
evacuation arises, as it usually does, from an im-
 perfect cure, the disease  must be treated with the
proper remedies.   To this  end, if  it be not of 
278
very long standing, if the strength of the patient
be but little reduced, or if those remedies which
ought to have been premised have been neglect-
ed, I generally have recourse  to blood-letting,
and that with advantage.  In such cases, there is
no doubt,  but the viscera are subject to some
preternatural stimulus ; blood-letting, then,  by
diminishing irritation, renders all things better.

   But in addition to this, other remedies must
be administered,  which  seem  betfer calculated
to put an immediate stop to the sweats.   Eva-
cuants, indeed, draw off the fluids,  which were
more slowly making their escape,  through the
natural outlets of the body.   But this  avails
very  little,  unless attention be paid to the ob-
structions of the viscera, and  the secretion and
excretion of the  bile  and urine be promoted.
Nor must  we neglect such remedies as are cal-
culated to allay the internal heat.  For, during
the flowing of these sweats,  there generally ex-
ists a burning internal heat, and an acrimony
which stimulates the surrounding parts.

   But these sweats which succeed the termi-
nation of a fever, may flow from a different cause;
such  as the state of the blood, or debility  of the
system.  The affection must,  then, be treated
in a different way.  The bowels, indeed, as well
as the urinary  passages should be  kept open ; 
279
but tonics, that is, remedies calculated to restore
the lost tone of the fibres, constitute the princi-
pal means of cure.   Hence the peruvian bark, or
a vinous tincture of it, are for the most part suf-
ficient.   Sometimes bitter infusions taken along
with chalybeates answer every purpose.  These
remedies will be the more effectual,  if exercise
be called to their aid, which  alone, with an at-
tention to regimen,  is sufficient to restore the
strength of the circulation and the tone of the
vessels.

   But there are other affections which are  still
more difficult to cure.  Thus, after  the fever
has been checked, there sometimes remain con-
stant anxieties, a loathing of food, a heaviness,
and a loss of strength ; indeed the symptoms of
an ill-cured fever manifest themselves in all parts,
but particularly  in the countenance, which be-
comes livid or of a yellowish colour ; all these
symptoms have occurred to me in practice, par-
ticularly during a certain epidemic, which com-
mitted great ravages in this place.   On that oc-
casion, fevers which seemed  to be perfectly
cured,  generally recured  again.  It  was then
with difficulty that the  sick survived.   Many
fell at length into a putrid diarrhoea,  or a dysen-
tery.   In some cases a copious effusion of blood
broke forth, and proved fatal to the patient. 
280
    In the treatment of this fever it  was abso-
 lutely necessary to reject the bark entirely.  That
 remedy seldom failed to render all things worse
 instead of better.  The heaviness, the prostra-
 tion of strength, and the affections of the sto-
 mach and liver, were relieved only by aperients
 and deobstruents. The putrid diarrhoea could be
 safely checked only by mild evacuants.  The dy-
 senteric symptoms required, also, a peculiar and
 specific mode of treatment.  Even after all the
 troublesome symptoms had become  milder, or
 disappeared  entirely,  there were some practi-
 tioners who still would not venture again on the
 use of the peruvian bark.  They waited till na-
 ture or a  change of the season  should complete
 the cure of the disease.   But  these  physicians
 had too great a dread of the effects of this reme-
 dy.   It could be safely used provided it was  pre-
 ceded by  the proper remedies.    Having previ-
 ously7 prepared the systems of my patients for
 its action, I then had  recourse to it with  the
 greatest success.  We have already  treated of
 the watery and  flatulent swellings which occur
 during the actual continuance of the fever.   But,
 as we have elsewhere mentioned, a swelling ve-
 ry often  attacks the  lower extremities after the
febrile affection has terminated.   Provided, how-
ever,  the fever has been treated and  cured  in a
proper manner, nothing serious is to be appre-
hended from  this swelling ; for the water  col- 
                     281
lected in the cellular membrane passes away of
its own accord, as the strength of the patient re-
turns.   If, however, the water be  in large quan-
tity, or if,  in  consequence  of a laxity  of the
fibres,   it remain  longer  than  usual  in  the
cellular receptacles, the exhibition of diureties
and tonics becomes necessary.

   On such occasions, a decoction of some bitter
aperient vegetables,  holding in  solution a quan-
tity of soluble tartar, is an excellent remedy.  I
have also in many cases derived advantage from
the use of wine, in which juniper-berries  had
been infused, and which contained at the same
time, in solution, a portion of the martial salt of
Riverius.  But these are not the only remedies
that  may  be administered.   There are  others
which have  been given with  success, such as a
lixivium of broom ashes.   There is but little
difference, however, between  this  remedy and
the febrifuge  water  of  Riverius,  which  con-
sists of salt of tartar dissolved in  common
water.

    Such are the remedies which I have found by
experience to be efficacious in removing  the re-
lics of intermittents, or certain affections which
are attendant on these diseases.  If in prescrib-
ing these remedies,  I have sometimes been silent
                      o o 
282
respecting the peruvian bark, it is not, from such
silence to be inferred, that I meant  to induce
practitioners to neglect the use of it.  If the fe-
ver has not been  cured in  a  proper manner, if
there be any apprehension that its fomes still re-
mains in the viscera, the use of the bark cannot
safely be dispensed with.   When  by the use of
other remedies the symptoms have disappeared
or  become milder, the cure must be perfected
and confirmed by the bark. 
CHAP. XX.
Of the cure of Malignant Intermittents.
   MUCH less must practitioners neglect the use
of the bark  in the treatment of intermittents, if
they be of a malignant nature.   But there is a
double plan of treatment which must be pursu-
ed in such diseases ; one of these must be adopt-
ed during the violence of the paroxysms, and the
other in their decline, or rather during their in-
termission.   For as some of the symptoms are
foreign from the nature of the fever, these symp-
toms  and the febrile cause call each for remedies
peculiar to themselves.

    This circumstance,  as formerly mentioned,
was observed by Louis Mercatus.  That physi-
cian was  the first who treated extensively of
these  foreign symptoms, but Morton and Torti
have  approached nearer to  a proper method of 
                     284
 cure.   We will briefly lay before the reader our
 experience on this subject.

    We will not treat separately of all the symp-
 toms that occur, but only mention the principal
 remedies  by which  they  may be combatted.
 When the head  is severely attacked, when a de-
 lirium occurs, or a  kind of apoplexy, lethargy,
 or coma oppresses the patient, a peculiar mode
 of treatment becomes necessary.  Blood-letting
 has  oftentimes  been observed to remove these
 symptoms like  a charm.  Nor is  this remedy
 less  serviceable  in those acute pains resembling
 rheumatism which attack  the  limbs,  back, he.
 in severe gripings or spasms of the stomach or
 intestines, and in oppressions at the breast.  In-
 deed it may be  used with advantage in all such
 affections,  provided  the strength of the patient
 be not too much exhausted.

    In the apoplectic, lethargic, and comatose
 state of fever,  blistering must by no means be
 neglected.   Nor is  this  remedy less  useful in
 those paroxysms, in which the patients lie with-
 out  motion or  sensation.   But, although  the
 practice may to  some appear less likely to prove
 useful,  I  have   even ventured to try  the  same
 remedy in certain very acute pains ; for as these
 pains are, for the most part,  spasmodic,  it is
practicable to effect a revulsion or derivation of 
                     285
the morbid action from one part of the system
to another.  I am convinced by experience that
blistering is also  a  very  important remedy  in
oppressions at the breast.

    The use of opiates is no less recommended,
by  the nature of the remedies themselves,  by
experience, and also by the painfulness of some
of the symptoms.  Indeed the rheumatic pains
in the limbs, are  sometimes so severe as to call
for the immediate exhibition of these remedies ;
and in pains of the  viscera, particularly of the
stomach  and intestines, it  would oftentimes be
almost criminal to  neglect them.   By opiates
vomiting and diarrhoea may be checked,  which
sometimes bring the patients  into the utmost
danger.  It is in  the mean  time to be observed,
that opium should  not be  exhibited alone.   It
ought to be mixed  with aromatics, as  in theri-
aca, and  the liquid laudanum of Sydenham.   It
may7 also be exhibited along with aether,  which
is of  itself an excellent remedy for oppression
and vomiting.

    I  will not here  treat of diluents or demul-
cents, which contribute to allay irritation, and
the advantages of  which are known to every one.
Nor is it requisite to dwell on the use of  reme-
dies calculated to awaken motion and excite heat.
It must be ovious to every  one,  how necessary 
286
these are in cases of prostration of the vital
principle, in great depression  of the pulse, and
in a very obstinate  cold  fit  where the surface
of the body assumes a marbled appearance. But,
that remedies may be exhibited with the more
advantage, no less regard must be paid to the
symptoms than to their cause.  This cause is the
poison which vitiates the fluids,  and disturbs
the functions of the system.   It is necessary to
enquire,  therefore, what may be capable of re-
sisting this  deleterious cause, until its violence
abate, and an intermission ensue.

    When the paroxysm has passed over and the
symptoms have become more mild, then is the
proper time  to administer that febrile antidote,
the peruvian bark.   This remedy may indeed
be exhibited in decoction, but there is reason to
apprehend that in this way it cannot be taken in
sufficient quantity.  In a disease,  therefore, so
rapid in  its  progress, recourse must  be had to
the bark in  substance, or rather, indeed, to the
extract ;  nor need we be apprehensive of giving
it in too  large doses.  If the doses be small, they
will be insufficient for the end in view, which is,
to  overpower, as it were, the  febrile  poison.
Hence, let the patient take a drachm  of the  ex-
tract of bark at a dose, and repeat this two or
three times  during the intermission. 
                      287
    A question occurs here to be solved, name-
 ly, whether or not purgatives ought to be mixed
 With the peruvian bark ?   These remedies, in-
 deed, will not be amiss in affections of the head
 they may also be administered when the force of
 the disease falls on the breast, as well as in rheu-
 matic pains of the joints and limbs.   The bow-
 els ought, however, only to be kept gently  open
 rather than  to be severely  purged, lest the  effi-
 cacy of the bark should pass off  in  that way.
 The force of the medicines must be particularly
 directed against the febrile poison, whose impe-
 tus is to be counteracted.

    But there are various other affections in which
 the bowels must not thus be moved.   When the
 stomach  and intestines,  for instance, receive
 the whole force of the  disease,  the  practitioner
 must decline the use of purgatives.  If a diarrhoea
 exist,  it  must even  be restrained.   It would
 be no less improper to  administer purgatives in
 cases where  there is  a  prostration of the  vital
principle, or where, during the cold fit, the heat
has retreated from the surface and extremities to
the internal parts of the body. In cases of this de-
 scription, we must rather have recourse to aro-
matics, such as Virginian snake-root,  in combi-
nation with the bark, that it may the more effec-
tually penetrate the recesses of the system, and
thus rouse it into action.  For  the  same pur- 
                     288
pose I have oftentimes administered the bark in
wine.

    Another question occurs, and that of no less
moment, in as much as it relates more immedi-
ately to the danger of the disease.  It is enquired
whether or not the physician must always wait
for a remission of the paroxysm in order to ex-
hibit the bark ? If, indeed,  the febrile action be
not very intense, but, on the other hand, if there
be  a prostration  of  strength and a debility of
pulse, if there be not great  irritation in the sto-
mach or  intestines,  finally,  if the force of the
symptoms will by any means admit of it, I know
no good reason  why, in so doubtful a state of
things,  the  bark may not be exhibited either
alone or combined with some other remedies*
Although the symptoms usually intermit, yet
the degree and duration of the intermission are
both uncertain.   In the mean time the danger is
great, and there  is consequently  a pressing call
for the exhibition of the antidote. 
CHAP.  XXI.
Of the treatment of common remitting fevers, and
       also of those of a malignant nature.
   SO much for the treatment of intermittents ;
we will now pass on to the consideration of that
of remittents.   These,  as we have already re-
marked, are of various kinds ;   or rather, they
vary with respect to their violence and their type.
They  are  often attended with unexpected  and
dangerous  symptoms.   Hence,  although they
originate from the  same fomes,  and the same
cause, it is requisite to enquire whether  or not
they call for the same,  or for different modes of
treatment.  It is frequently difficult to institute
a mode of treatment, and this difficulty  arises
from numerous causes.

    The first thing to be attended to, is, the na-
ture and use of the remedies necessary to  be ex-
hibited.   The  fevers are continued,  because
they  are marked by no  perfect intermission.
                        pp 
                     290
No other mode of treating them, then, immedi-
ately occurs, but that which is employed in con-
tinued fevers.  But  their nature and  character
are opposed to all specific febrifuges, particularly
to tonics, bitters, astringents, and such remedies
as  excite heat.   The  peruvian bark  appears,
therefore, to be improper in the treatment of re-
mitting fever.   For  if that remedy proves, for
the most part, injurious in genuine intermittents,
when their  paroxysms are protracted,  and their
violence is great, can it do good in a fever of a
continued  course, although its  violence  may
sometimes  abate ?

    Yet as remittents belong to the same  class
with intermittents, is it possible  that  they can
call for remedies altogether different ?  Can that
medicine be improper in the treatment of remit-
tents, which is best calculated to subdue and eli-
minate  their cause ?   In order to reconcile all
these  circumstances, which appear so inconsist-
ent with each other, we must look a little deeper
into the subject.  We must enquire, for instance,
whether or not the symptoms of intermitting and
remitting fevers are so different from each other,
that they require to be cured  by different modes
of treatment ?

    The symptoms of these diseases do not, ex-
cept at first sight, appear to differ so greatly from 
291
 each other.  In most respects the mode of treat-
 ing intermittents and remittents  is nearly the
 same.   For,  as the bark does mischief if admi-
 nistered in intermittents,  during the actual ex-
 istence of the paroxysms ;  so also, in remittents,
 if it  be exhibited during the  prevalence of the
 paroxysms, it renders every thing worse.   The
 practitioner must,  therefore,  wait for the re-
 mission, in order to administer this remedy  with
 advantage to the sick.   Previously to  its  use,
 the prima? viae must be well cleansed, for if they
 become turgid with faecal matter, or if the bowels
 be in a costive state, the fever will be encreased
 in violence.

    In the treatment of these diseases, there ex-
 ists only this difference, namely, First, that in
 remittents the  fever  only  abates, and  allows,
 therefore,  less time for the use  of remedies to
 counteract it,  and, Secondly, that the febrile  heat
 is more intense, and the  secretory functions less
 free and active.  The fomes of the disease will
 consequently be eradicated with more difficulty,
 because it will be removed only by slow degrees.
 The action of the bark, however, both on it and
 its effects is certain, though somewhat feeble; it
at least weakens its force, if it does not complete-
ly eradicate it.   Let the impediments to the  use
of the bark be done away, and  that remedy  w ill
be at length successful. 
                     292
    The efficacy of the bark is particularly mani-
fested in its preventing the paroxysms, or reduc-
ing their force.   Hence, it appears, that if  the
paroxysms be very severe, this remedy may be
advantageously employed against them.  It may,
indeed, increase the heat of the body, and will
not immediately,  as in intermittents, destroy the
febrile fomes.   But the  greater evil  must be  ob-
viated ; and the impetus of the fever  will do more
mischief to the system, than  the action of  the
bark when used as a remedy for it.   The state
of things is here precisely as it is in a case of
disease, consisting of a  pleurisy joined to an in-
termitting fever.   No doubt but, in such a case,
the peruvian bark may somewhat injure the in-
flamed lungs ;  yet, as this remedy  weakens  the
force of the intermittent, and may  do away  the
danger arising from paroxysms, it  ought to be
employed.

   But there are certain principles by which the
exhibition of the bark ought to be regulated.  It
should not be employed, unless the fever to be
removed be certainly of the intermitting  kind.
It appears from the daily controversies of physi-
cians, how difficult a thing it is to  discover  the
real  nature and  character  of fevers.  Skilful
practitioners do not expect to derive any advan-
tage from  the  use of peruvian  bark in febrile
complaints  unless they be  of the nature of 
                     293
intermittents.    But  there  are  physicians  of
less  knowledge and abilities, who,  as  often as
they meet with a case of fever, marked by perio-
dical exacerbations, attempt its removal by the
peruvian bark.  But as this remedy would  be
hurtful in inflammatory fevers, although charac-
terized  at times, by periodical and regular exa-
cerbations, will it be likely to prove less injurious
in various other fevers, which differ equally from
the nature of intermittents ?

    In every fever,  however, which derives its
origin from the fomes of intermittents, the pe-
ruvian bark is  not  calculated to check the pa-
roxysms.  If in the spring,  for instance,  an  in-
termitting fever be changed into a continued one,
or if it assume that form from the beginning, it
must be treated like a  simple continued fever.
In this  way, it is induced at length either to  re-
mit or intermit; or is sometimes, by such treat-
ment, even cured entirely.   It is worthy of re-
mark, that I have oftentimes seen the fomes and
cause of an intermittent completely7 eradicated
by a continued fever.

    In a similar manner must we treat the double
tertian  remittent,  which is marked by regular
exacerbations, and never  departs from its pro-
per type.  Sometimes  this  disease runs on to
the eleventh, fourteenth, or twentieth  day, and 
294
 is considerably violent  even during the  time of
 its greatest remission.   But while it prevails to
 such a degree, the peruvian bark must not be ad-
 ministered ;  for it induces great heat, and adds
 to the intensity of the fever.   It is necessary to
 wait, therefore, till its remissions become more
 considerable.

    There are  some practitioners who have di-
 rected a trial to be made of that remedy,  on this
 condition, that its use be immediately relinquish-
 ed in case  it does not succeed.   Others again
 conceive that it ought not to be exhibited earlier
 than the twelfth day of the disease ;  but  both of
 these classes are in an error.   Uncertain reme-
 dies ought not  to  be tried, nor should we fix a
 certain  period  for the  exhibition  of remedies
 which nature herself has  not fixed;  our best
 plan  is to follow  her as our guide,  and  to give
 her such aid when labouring for her own relief,
 as she seems to require.

    Many remitting fevers  occur, in which the
 paroxysms or exacerbations come on with great
 violence, and bring the sick into the  utmost dan-
 ger.  In  such  cases the practitioner must pro-
 ceed in a very different manner.  The bark must
 be exhibited with boldness.  Nor must its use
 be dreaded,  because the remission is,  perhaps,
rather slight. It will be sufficient if there be any 
295
remission at all.   It is only incumbent on the
practitioner to enquire, whether  or not, any
thing ought to be mixed along with the  bark,
and what assistance may be derived from other
remedies.

   A  mode of practice which I have generally
found successful, is, to exhibit an emetic on the
decline of the  paroxysm, and  after this to give
a febrifuge potion,  consisting of bark, together
with some  laxative and aperient remedies,  so
prepared as to be capable of producing a speedy
effect.   By such treatment as this,  all the symp-
toms are  generally7 rendered milder ;  I say,
milder, for, in fevers of this description, we are
not to expect  that the paroxysms will be entirely
removed, as they are in intermittents ;  they de-
cline, for the most part, only in a very gradual
manner.  Frequently,  however,  remittents  of
this  kind are changed  into intermittents, not,
indeed, into tertians or quartans,  but more ge-
nerally into the form of double tertians.

   It more frequently, however, occurs, that in
fevers of this description, the paroxysms are  so
protracted,  that the preceding almost runs into
the succeeding one, leaving the intermission ex-
tremely short.   Decoctions of bark, therefore,
should not then  be used,  because they require
too long  a  space of time for their operation. 
296
Recourse must consequently be had to the bark
in substance, or rather to the extract of bark.  A
drachm of the extract is equal in strength to an
ounce  of the bark in powder ;  hence the neces-
sary doses  may  be more easily repeated, and
thus the patients placed in a state of safety.    In
such cases, if in any, the extract may be mixed
with some cooling purgative salt. For the burn-
ing heat should be  allayed,  and if practicable,
the bowels kept open, for which  purpose,  the
remedies ought  to be  given  in  very  large
doses.

    The same remedy must be pushed to a still
greater extent,  in those fevers where malignant
symptoms arise.  When, for instance, the head
is very grievously attacked ;  when an apoplec-
tic or lethargic state supervenes ;  when the lungs
are greatly oppressed,  or  the abdominal viscera
affected with a very acute and excruciating pain
___under these circumstances,  I  say, there is
the utmost  danger in delay,  nor can the lives
of the patients be sufficiently guarded in  any
other way, than by a plentiful use of the peruvi-
an bark. When the febrile poison has disspread
itself throughout the whole system, this remedy
meets and extinguishes it, as it were, and, at
times,  restores the patients  from  such a low
state, that they  might almost be said to be raised
from the dead. 
                     297
    The mode of administering the bark depends
on the nature of the fever,  the force of the symp-
toms,  the longer or shorter duration of the pe-
riod of remission, and the laxity or costiveness
of the bowels.   But amid such a variety of cir-
cumstances, it is impossible here  to  point out
what may be necessary for each particular case.
We can only say in general, that there is no great
difference between the proper treatment of dou-
ble  tertians and  malignant  remittents, except
that in the latter,  the remedies must, in the same
space of time, be given in larger quantities ;  for
when the danger is so pressing,  the febrile poi-
son should be subdued and eradicated as speedily
as possible.

    It is indeed best to wait till the exacerbations
remit;  but there are cases in which the remis-
sions are  scarcely perceptible.   Then, indeed,
having  first used  the proper preparatory reme-
dies, the bark must be boldly exhibited.   This
remedy is the less to be dreaded, in as much as
the pulse is for the most part depressed ; but if
it even  were not depressed, still the bark must
by all means be used.   In such a doubtful dis-
ease, it  is, as we have already said, the  sheet an-
chor of safety by which alone the vital  principle
can be  supported.
c^q 
                    298
   In the mean  time a very special regard is to
be had to those symptoms, in which the whole
force of the disease seems to centre.   It is, in-
deed, in counteracting these symptoms that the
bark is  so  efficacious.   But  other remedies
should be  also frequently exhibited in such cases.
From what we have said on the subject of ma-
lignant intermittents, the reader may readily col-
lect our sentiments as  to the several means that
mightcontributeto a cure in the present instance.
What was there advanced may be  applied to all
cases that  usually occur in malignant remittents.
Indeed  there is no other difference between the
two diseases, except that between the  paroxysms
of malignant intermittents there is a longer in-
terval, and that during this interval the  patients
are more free from fever.

    For the better illustration of the  method  of
cure, I had prepared for publication a  number
of cases.   But  it appeared  best  on reflection
that these should be omitted.   There  are not
two cases of disease precisely  alike; whence,
there are not two  in which the same remedies
will produce precisely  the same effects.   It
seems most adviseable,  therefore, to reduce to
certain general laws, all the  facts which experi-
ence has  brought to light, and from these, to de-
duce a mode of cure accommodated to the state 
299
and condition of each patient.  It is oftentimes
the fault of observers, that while they carefully
treasure up all facts that fall under their notice,
they seem quite  regardless  of the  principles
which these  facts are calculated to suggest and
support.   But  the establishment of just princi-
ples, besides being  the  proper and natural end
of observations  and  facts, is certainly  what con-
fers on them their highest value.
THE END. 
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