FIVE DISSERTATIONS O N FEVER. BY GEORGE FORDYCE, M.D., F.R.S., FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, SENIOR PHYSICIAN TO ST. THOMAS'S HOSPITAL, AND READER ON THE PRACTICE OF PHYSIC IN LONDON. SECOND AMERICAN EDITION, WITH AN INTRODUCTION. PHILADELPHIA: ED. BARRINGTON AND GEO. D. HASWELL. 1846. FTI3f Medicina igitur adhuc talitnrconiparataost, ut fuerit magis ostenta, quam claborata : etiam magis elaborala quam amplificata.— Bacon, Aug. Sc. Lib. ii. C/t. i. Solent autem homines naturam tanquam ex pra-alta turri ot o longe despicere, et circa gencralia nimium occupuri; quando si decendere placuerit et ad particularia accedere, ressque ipsus attentive et diligentius inspicere, magis vera el utilisfleret compreherisio.— Ibid, A Canto (35) from the Orlando Furiono, in the original, prefixed to the former edition is omitted in this. It was a harmless fancy in the author, but which there is no call for repeating here. CONTENTS. Fiust Symptoms. —Mind and body bothafl'ected—Uneasiness, restlessness, inability or difficulty in exercising locomotion and the mental faculties—Sensation of coldness— Difficulty of explaining this symptom by physiology—Difference between the actual coldness of the body and the sensation of coldness, in a febrile patient—Diminished evolution of heat in the body at this time—Inequality of the cold in different parts of the body, as measured by the physician in a thermometer—The patient does not feel such inequality—Diminished sensation and powers of perception—Probable causes or an explanation of this state —Reason of the physician's difficulty in learning the sensations of the patient—Pain in the back often the first symptom of fever—Diminished secretions—Tongue coated and loaded, of different colours —Horripilation felt at the very beginning of the disease—Skin changed in colour—Is closely applied to the muscles and also subjacent parts—Its sensibility greatly diminished —The eye, changed in its appearance and weakened in activity—Diminished secretion of urine and excretion of feces—Stomach weakened and unable to digest—Increased contractions of the heart and pulsations of the artery—Fever 'may precede this symptom and even prove fatal before it is seen—General synchronousness between the action of the heart and that of the arteries—Contractility of the arteries, in addition to mere elasticty— Other modifications, besides number in the pulsations of the arteries—Hardness of the arterial beat—This is accompanied by a particular change in the blood —Appearances of this fluid at this time, and their causes—Obstruction more common than hardness in simple fever—Irregular or intermittent action of the heart and arteries —Pain in head—Not arising from the brain—Similar pain felt all over the body—Delirium— Different species of—Weight, fulness, and uneasiness in the breast—Sometimes trumour and hardness in the stomach—Sometimes difficulty of breathing and cough—Affections peculiar to the stomach—Loss of appetite, nausea, vomiting, discharge of bile, which is merely accidental, and thirst—Depression of the powers of the mind— Change in the state and proportion of the constituents of the blood, not recognisable as peculiar in fever—Contraction or spasm of the extreme vessels, not an essential part, so much as an effect of fever—Violence of the symptoms, a measure of the violence of the disease. --------39 SYMPTOMS OF SIMPLE FEVER. Definition.—Restriction of the term fever by the author—It is different from phlegmonous inflammation, rheumatism, tetanus, and certain local diseases—Fever may exist with another disease.—Description—Thje history of fever must be made up entirely of the results of observation—Fever is a disease which affects the whole system.—Duration—Fevers have different periods of duiation —An ephemeral fever—Difference in the suddenness of an attack—May come on at any time in the twenty-four hours—In a large majority of cases the lirst attack is during the day— Difficulty in accounting for this fact. - - - - 33 DEFINITION, DESCRIPTION, AND DURATION OF FEVERS. Fever.—Its existence never conjectured from d priori reasoning—Only to be known by observation of the sick—Its history not well understood —Origin of the term, fever —Has no one pathognomonic symptom—Analysis of alleged pathognomonic symptom —Heat and cold, sensations of; frequency of pulse, restlessness, anxiety, state of the tongue or headache, give no exclusive indications of fever. - 37 GENERAL OBSERVATIONS. CONTENTS. IV CAUSES OF SIMPLE FEVER. Cavjses of fever, to be ascertained by experiment alone—Succession not to be confounded with causation—Illustrations —Infection, as a cause of fever—Explanation—Not ascertainable by the senses—Probably arises from a peculiar matter, transmissible by touch and the medium of the air—Infection not manifested in an ephemeral fever— It is in intermitting fevers—Impurity of air, by a number of persons crowded together, a cause of fever—This source of infection not confined to the human species—Example of it in sheep and hogs—One of these kind of animals does, not infect one of another kind, nor will man be infected by either—Infectious matter transmissible by a healthy person —Is not recognisable by the sense of smell —Putrescent matter an accidental accompaniment—Vapor from putrefying substances, animal or vegetable, a cause of fever —This vapor not chemical nor recognised by chemistry—Infectious matter not the product of putrefaction in the febrile patient—Some infectious matters cause disease after the fever ceases—Variolous matter —It has never been known to be originally produced—Came, probably, first from Indostan—Is confined to the human species—Period between the inoculation of variolous matter and coming on of fever— Longer period when matter is transmitted through the air—Measles ; seldom produced by inoculation—The plague—Where met with—Infectious matter is capable of combination with the constituents of the atmosphere, and of being thus neutralised— Limited range of infection from its source—Supposed increase when the air is moist — Constitutional disorder following a local affection, as erysipelatous sore throat, wounds, &c, is not fever, as understood by the author—Secondary fever in small-pox—Fever from inflammation, itself the produce of fever—Sudden exposure to cold, assigned, as a cause of fever—Partial attacks of fever, from infection—Rules of evidence —Cold, a relative term—Rapid transition from heat to cold—Partial as well as general exposure sufficient—Predisposition by fatigue, &c.—Moisture, a cause of fever—Three different modes of combination of water with the air—Texture of the clothing modifies the operation of moisture—Moisture more deleterious with warmth—Moisture with putrefaction, an alleged but not probable cause of fever—Moisture alone, without putrefaction, has caused fever—Example—Eating certain food seldom a cause of fever— May cause a relapse—Purgatives sometimes bring on a return of fever—Sudden mental excitement, with anxiety, a cause of fever—Fevers have occurred without being preceded by any of the above enumerated causes—Excessive repletion may be an accidental pre-existent fact, while infection was the real cause—States of the fluids, a reputed cause of fever—Putrefaction of the blood erroneously assumed as a cause— Alterations in the properties of the blood not proved—Redundancy of bile, as a cause of fever—Not proved to act in this way—Its importance overrated—Heat, as a cause of fever—Instances of its exciting, and indirectly exhausting, but not febrile agency— Conjoined causes of fever, not asccrtained--Fever continues its course after the removal or cessation of the cause—Renewal of cause docs not renew fever ; nor continuance of cause aggravate it, if ventilation be attended to. - - - - 63 MARCH AND STAGES OF SIMPLE FEVER. Com Fit, on First Stage or Fever—Is sometimes fatal—Erroneously called apoplexy or syncope—Subsequent paroxysms evince its febrile character—Short duration of the first stage, when it is fatal —Symptoms—Such cases more common in warm climates— Horror and rigor, or shaking—When these occur in a paroxysm, this is never fatal— Most generally they occur at the accession of continued fever, seldom after—They arc oftener seen in subsequent accessions of intermittent fever—Parts of the body to which horror and rigor arc to be ascribed 1—Most probably from affections of the stomach— Frequency of pulse only an accident in the first stage.—Second, or Hot Fit or Stage —Not always present in the hot fit; but in general arc one of its symptoms—Greater degree of heat not proportionate to frequency of pulse—Greatest degree of heat in fever—Sometimes the heat is below the common standard, in continued fever—Inequality of heat in different parts of the body, in fever—Second stage, a means of cure—Blood not changed in the several stages of fever—Two distinct parts in the attack of fever—contraction of the small vessels, and depression of the powers of the body—These not proportionate to each other—Sometimes an affection of the stomach superadded—These three possibly only indicate some other alteration, as yet un- CONTENTS. V known —Increased action of the heart, one of the means of cure of fever—Not to confound this action with increased hardness or resistance of the arteries—Excitement caused by spices and vinous stimuli, not the salutary action here described —Some action of the stomach another means of removing fever—Sickness may accompany the hot fit, but itself does not tend to abate the fever—Tartarised antimony and ipecacuanha tend to produce a crisis, but frequently without producing sickness —Their efficacy often greatest when they occasion no nausea—Some affection of the stomach concurs to remove the morbid condition of the small vessels, and the inaction of the body generally—Illustrations, showing influence of the stomach over the economy—Symptoms of the hot fit—Pulse full, strong, and frequent—Sometimes the disease terminates in topical inflammation, causing hardness of the pulse—General but unequal increase of the circulation, particularly at the beginning of the hot fit—Heat greater than common, even in the cold fit—Is general in the second or hot fit of simple fever; and to the patient seems intense—Is often less than in the cold stage, though still above the healthy standard—Augmented thirst in the hot stage—Restlessness greater then—Apparent causes of restlessness and anxiety in the system; accumulation of blood in the lungs, and in the great veins and the auricles; and, next, distension of thesmall vessels—Analogous symptoms from disorder of the stomach —Delirium, may occur in the first stage, more probably in the second stage of simple fever—Associated state of the pulse and pain of the head—Difference, in fevers, in the duration of the hot stage—Most commonly does not last beyond two hours, following a cold fit of the like duration. - - - - - - - - 91 TERMINATIONS OF SIMPLE FEVER. Cnisis, the first termination of a simple fever —Diminution of symptoms of first stage, by relaxation of vessels of the skin, and profuse sweats, sometimes only moisture— Restoration of healthy color of the skin—Increased secretion of urine, with turbidness, and deposit of flaky crystals of a red color—Absence of this deposit implies an imperfect crisis and a renewal of the fever—This deposited matter not the cause of the disease—The mouth and tongue become moist, and the tongue clean, by separation of a crust —Edges of the tongue first become moist—Relaxation and increased secretion from the salivary glands—Restoration of appetite—Removal of thirst—Renewed secretions of bile and pancreatic juice—Digestion completed—Intestines evacuated—Obstruction of the pulse removed, and its frequency and fulness abated—So, also is the affection of the stomach—Pain in the forehead and weakness removed, but the strength not immediately restored—Sleep often closes the crisis—If the crisis is not complete, the disease is not simple fever—The termination may be in other diseases —All fevers are successions or modifications of simple fever. - - 105 PROGRESS AND TERMINATION OF A REGULAR TERTIAN INTERMITTENT. Repetition of a paroxysm of fever at the end of forty-eight hours constitutes a regular tertian—Imperfect crisis of the first a probable cause of the coming on of the second— A tertian fever may return from habit—Paroxysm returns at forty-ninth hour from the beginning of the first cause of return of paroxysm 1—Fluctuation of return of paroxysm—Anticipating tertian and retarding tertian—Anticipating tertian rarely occurs at night—Paroxysm of a tertian resembles that of a simple fever, except in the completeness of the crisis—Symptoms that remain after it—Sometimes there is no crisis and the disease simulates continued fever—After a tertian period or two the crisis is more complete—The interval between the paroxysm sometimes one of average health, with enjoyment of all the functions—In some places no regular tertian is met with—Whole period of the fever, four months—Sanative effects of a regular tertian —Alleged planetary influence in causing diseases^—No change of the blood in tertian fevers.—Occasional recuperative effects of fever and of some other diseases—Regular tertians seldom fatal in temperate or cold climates—When they are, it is in the cold fit—Question presented, of how far a regular tertian should be left to itself 1 115 0* VI CONTENTS. TREATMENT OF A REGULAR TERTIAN INTERMITTENT. When Left to its Natural Course.—Attention to giving proper food and at proper times—Meals regulated by the times of the paroxysm and interval—In general the accustomed hour the best—One principal meal, only, in the forty-eight hours, and this on the intermediate day—In the beginning of a tertian, the food should be simple and in small quantity—Farinaceous matter the best—Starch combined with other principles is a good food—In potatoes and yams it is more apt to cause fermentation—Better for food in the seeds of the gramina—Of these rice most abounds in fecula—The seeds of the gramina generally are proper food in a regular tertian—First they should be coagulated by heat—Fermented bread — Panis bis cocta —In a temperate or cold country and a strong patient, whose remissions are slight, but little nourishment is necessary—The Greek physician subjected the fever-patient for some days to entire abstinence from food and drink—Watery drink necessary—The call of appetite to be obeyed here, viz., desire for drink and loathing of animal food—Especially where the intermission is not perfect—Water assuages thirst best when farinaceous matter, coagulated, is added—Barley water, acidulated with the juice of some fruit—This the only food for three or four days, in adolescents, and adults under fifty, and when the inteimission is imperfect—After this period or in more perfect intcrmittents, farinaceous matter, boiled, until it is dissolved, is proper—Sago—Punada—Mode of preparing barley water —Fruits—Afterwards milk and animal broths—Flesh of animals — Fish—Milk not previously coagulated—Birds—Boiling and broiling, the preferable modes of cooking meat—Importance of attention to the food—Hour of dinner varies with that of the paroxysm, so as not to be taken except in the interval—Breakfast and supper to be kept clear of the paroxysms, and to consist of vegetable food only—Example of the dietetic course in a regular tertian—An emetic to relieve the stomach of indigestible food—Its repetition—Useful by evacuating a tough slime from the stomach—Warm fluid to aid vomiting—Recapitulation of the proper food, and means to fit the stomach for digestion—Attention to the state of the intestinal canal—In regular tertian the peristaltic action is regular—When this last is deficient, laxatives are proper—Theory of a humor to be avacuated by purgatives—Erroneous and hurtful—The most gentle laxatives alone are required—Uilferent kinds of purgatives— Drastic purgatives improper—Advantage of mixing different kinds of purgatives— Laxatives and purgatives to be given in the interval—Opium not proper when the exacerbations are irregular—Causes disturbing sleep to be removed—When the intermission is regular and perfect, opium admissible to procure sleep—Its effects improved by ipecacuanha or antimony added—Rest in bed enjoined, just before and during the paroxysm —During the interval, the patient should be about as usual—Weakness caused by successive returns of the paroxysm of a regular tertian—Increased by imperfect intermissions. ... .... 122 TREATMENT OF A REGULAR TERTIAN INTERMITTENT. ( Continued.) Medicines to recruit the strength of the body—Confusion of ideas on this subject— First idea of strength as it appears in inanimated matter—Oohesiveness and inflexibility— Action of the various cavities of the body—Astringents increase the cohesive power of dead animal matter —Muscular strength not dependent on this power— Elasticity—Illustrations of—Vital muscular contraction—" Muscular Action" different from elasticity—Instance of the two powers counteracting each other in a bivalve shell-fish—" Tone of the Muscles," their permanent contraction to resist elasticity— Illustration in the case of the urinary bladder and the stomach—" Action of a Part," or shortening of the moving fibres beyond their tone —Two "Muscular Powers"— The tone of the moving fibres weakened by frequent attacks of a regular tertian— Medicines used to restore and keep up the tone—All of them contain a bitter juice, and various other matters with medicinal powers—Their mode of action on the living body not known—Some medicines act chemically—Not so with these —Their action VII CONTENTS. chiefly on the stomach—Their activity increased by combination—Modes of administratio —Given during the intermission—Exercise as a tonic—Effects of exercise— Difference between labour and exercise—The mind to be agreeably engaged—Degrees of exercise.—Treatment to Aiiuest the Natural Course of a Regular Tertia —No medicine uniformly efficacious—Propriety of removing the disease, when it is continued by habit—The question agitated at different times—The medicines indicated by the symptoms and crisis of the disease, and those found out by accident —Of the first class are emetics—Immediate and sensible effects of an emetic—Evacuation of the stomach and reaction ; followed by sweating and increased urination and discharge of feces —Resemblance of these elfects to a crisis of fever—An emetic during the paroxysm sometimes prevents its return—Its effects increased by warm watery drinks—Relative effects of ipecacuanha and tartarised antimony—Better to mix the two together—Large doses prove irritant—Quantity for a dose—To be given to the patient in bed —Times when an emetic may be administered—Antimony and ipecacuanha, even when they do not vomit, simulate in their effects the crisis of fevers— Moisture of the skin and mouth, and sweat following the use of antimony—but without nausea, and the person being ignorant of having taken the medicine—These medicines most efficacious as febrifuges where no nausea is induced by them—They act primarily on and through the stomach, and then promote all the secretions and tranquillise the nervous system—To be given in as large a dose as the stomach will bear, without nausea—Doses for this purpose—These medicines useful during the intermission, and to be given so as not to occasion sickness—The class of bitters—Cinchonia, or Peruvian Bark—Varieties and physical properties—Modes of administration —Best in substance—Mode of operation of the bark of cinchona, not determined—Other medicines, such as metallic preparations—Bitters without effect on a man in health—Combination of simple bitters sometimes useful; more generally fails—Preparations of iron, of zinc, of arsenic, and of copper— Effect of the cinchona when exhibited indifferent stages of the paroxysm—Its power is to prevent a return of the fever, but not to arrest it when present—Effects attributable to impression on the stomach—Large doses ; half an ounce, or an ounce, just before the expected paroxysm—Sometimes successful— Should be exhibited during the whole time of the intermission, —and on occasions, directly after a paroxysm—Difference of opinion respecting the utility of the cinchona, before there is a crisis and complete intermission—More perfect intermissions and a preparation for the use of the bark, by emetics and laxatives—Dose of the bark, a drachm every two hours, without interruption during the intermission—Prevention of a recurrence of the fever, best by continuance of the use of the cinchona, during the periods corresponding with former intermissions—Causes of failure to cure tertian fever —Opium to check a purgative effect of the bark—Rhubarb to be added to the medicine when there is costiveness—Profuse sweating, a means of preventing the return of the paroxysm—Various means of procuring this end—Their effects increased by the previous use of a stimulating purgative—Danger of hemoptysis after inflammatory symptoms about the thorax—Sweating may be only a collateral effect of the remedy—Antispasmodics, to prevent a return of a paroxysm—Strong emotions of the mind—Inflammation of the skin—Recapitulation—When blood-letting is useful — Distinction between the disease and the accidents sometimes accompanying it, 138 HISTORY OF A REGULAR CONTINUED FEVER. agttosis or Fever—An ephemera easily distinguished—Also an intermitting fever —Greater difficulty in diagnosis of a fever lasting for many days or two or three weeks—This is properly only a continuation of ephemera—Fever, a disease of the whole system—Cause of fever acts at once, and need not to be repeated—Rules for distinguishing various diseases, erroneously called fever, from true fever—Hectic fever, not true fever, as it wants the means of curing itself—Frequent pulse in tetanus —Inflammation causes febrile commotion—So, also, do rheumatism, gout and erysipelas —Phlegmonous inflammation of the intestines—Topical inflammation may carry off the fever—In the phlegmasia) it is enough to remove the local inflammation in order to carry off the febrile symptoms —In fever, the cause is not attended to—Rheumatism —Its treatment—Use of the bark of cinchona for its cure—In erysipelatous inflammation, and in enteritis, we do not attend to the general symptoms, but try to cure the local malady —Fever, and phlegmasia may be enjoined—Continued fevers sometimes begin at VIII CONTENTS. once, commonly it approaches gradually—Sleep in fever—Rest from exertion —Mind affected in fever—Powers of the mind investigated—Perception, memory, imagination, judgment—Period of rest for the mind required—The mind in sleep—Never a state of perfect rest —Rest of the muscular system—Diminished action of the heart, and lungs and digestive apparatus in sleep.—Some people, in madness, said never to sleep—The author says they are never awake—Effects of sleep—Waking from the system being full of power—Bad effects of want of sleep— Symptoms of Ffver,— State of the pulse—Author's terms, with regard to strength, hardness, softness, obstruction, or freedom of the pulse —Difference in the sense of touch, in determining the state of the pulse—A hard pulse, to be distinguished from a merely strong or obstructed pulse—Question whether fevers of many days duration consist of one paroxysm or of many successive paroxysms—Continued fever has been regarded by some as only a variety of intermittent—Duration of the first paroxysm of a continued fever. First paroxysm in the morning or in the day, the second in the evening—Why, this time for the second paroxysm—Evening paroxysm still more evident in most diseases— Causes reproducing fever are two, both of which are incomprehensible—Days of fever—Symptoms of second paroxysm—Depression of strength does not constitute an irregular fever—The disease not dependent on putrefaction — Symptoms—Third paroxysm—Inquiry into the hypothesis of putrefaction of the fluids —Man not subject to the laws of dead animal and vegetable matter—Is placed in the situation in which putrefaction most readily take place—False analogy, inferring a similarity of the operation of antiseptic substances in the living with that on the dcatl body—Exemption from disease of these exposed, putrid matter and exhalations—Depression of strength the cause not the elFect of putrefaction and scurvy—Symptoms of putrefaction—Alterations in the secretions—Discoloration of the skin ; dark purple spots—llasmorrhages, dangerous—Difference, in different epidemic seasons, rcspecing marks of putrefaction — Delirium—Distinction between delirium and mania—Two kinds of delirium—Does the mind exist in the brain—Structure of the brain—Its connection with the muscles— Description of the first species of delirium—Is worse in the evening—Second species of delirium—Brain affected in it—Increase of fever with progress of the delirium — Symptoms, appearances of the tongue, picking the bed-clothes, &c—Prognosis.— Deglutition and respiration easy, the augury is good, even though delirium or insensibility be present—Death may follow an abatement of all the other symptoms if the delirium persists.— Crisis —Explanation of the good and bad crisis—Crisis differently described in dilferent climates—Critical days—To determine which is the first day— Date of the fever from the second attack—Crisis rarely happen the first week, except in intermittent and remittent fevers—Days enumerated by Hippocrates—Cullen's mode of accounting for the critical days—Continued fevers observe, in some respect?, the type of interinittents—Continued fever of a quotidian type the first week—Tertian and quartian types—The fourteenth the most common critical day—Smaller number of the fevers terminate by crisis in London—Symptoms in the second week of continued fever—Prognosis—Abatement of disease by the fifteenth day—Weakness— Eruption, in the second week, about the neck and breast of brownish red specks, like flea bites—Another variety or warty kind of eruption, limited and less frequent than the other— ibatement and removal of the fever. . . . 17 L TREATMENT OF A REGULAR CONTINUED FEVER. When the Fever Runs its Course.—Two means of recovery—One by crisis j the other by gradual decline without crisis—Fatal complications—Question, as to the propriety of leaving the disease to run its course, or of means being used to carry it off?— Many practitioners reprobate the attempt to arrest the course of fever—Doctrine of morbid humor —not sustained by facts—Effort of nature to expol noxious matter — Vagueness of the word nature —A truer supposition, that the successive actions in disease, like those in health, are the result of fixed laws of organisation—.Relative success of cure—after the use of medicines, or when the fever has been left to itself— Difficulty of determining the question—Felt by the author, —-notwithstanding his large experience—Commonly some treatment has been attempted in the outset of fevers, before regular advice is procured—No sets of comparative cases recorded — Attentions to the patient, when the fever is left to its own course—A person with fever to be placed in an air of moderate temperature, —according to the climate in CONTENTS. IX which he lives—In London, a good range is from 55° F. in winter, to 65° F. in summer—The air should be colder than the surrounding bodies —These should not be less, in England, than 75° in winter or 80° in summer—Means of warming the air of the apartment —13y hot water, stove or furnace, and open fire—Equable warmth of the body kept up in bed—All exertion to be avoided—The kind of bedding and body clothes—Change of bed and body clothes—Too great heat to be avoided—Evaporation of water —fanning—light clothing—Rest in a horizontal position—Mind to be at rest also—Fresh air to be introduced into the apartment, and noxious vapours and particles to be removed—Draughts of air to be avoided —Duration of a regular continued fever, between two and three weeks—The kind of food and drink to be taken —Only small quantities of food allowable, and these not of an animal kind—Even after a crisis, relapse is often caused by the too early use of solid animal food —Strength restored by rest, sleep, and very moderate nourishment—Eggs and milk objectionable—Of vegetables, cabbages, lettuce, green peas, and the like, are to be rejected—Slight nourishment is required, in the beginning of a regular continued fever—The system supports itself, by the absorption of fat and other tissues—Adhesive food, such as animal jellies, to be withheld—Farinaceous matter, coagulated by heat and dissolved in water, such as barley water, &c, the best nourishment, —sago, rusk, &c.—Fruits, such as grapes, figs, and dates, —the first when recent, the two last when dried or exposed to the heat of boiling water; also, apples, pears, and peaches, when boiled, baked, or roasted, are good in this fever—Cucumbers, melons, &c, inadmissible —Animal food, of any kind, never necessary in regular continued fever—Prejudices strong in favor of animal food—The kind least hurtful—Albuminous substances arc bad—Milk may, on occasions, answer—The solutions of the flesh of young animals and of membranous and ligamentous parts not so digestible as those of the flesh of old animals—The oil or fatty matter to be removed by skimming, after the broth has been cooled—Animal food improper in the first week of continued fever—Thirst a distressing symptom in fever —The Greek physicians enjoined abstinence from drinks—Some modern practitioners have forced patients to drink water or watery fluids beyond their wants —Both practices objectionable—The temperature of the drink, —to be left, as well as the quantity, to the patient—The quality of the watery fluid —Mode of decomposition of certain salts, if largely diluted —Pure water is insipid or mawkish—Infusions of sage, balm, &c.—Weak vinous fluids—Small beer—Barley water, and the like, acidulated with lemon-juice. . . . . . . . . 215 TREATMENT OF A REGULAR CONTINUED FEVER. When the Fever Runs tts Course (Continued). —Symptoms caused by indigestible food in the stomach—Relieved, most readily, by an emetic—This remedy given, also, under other circumstances—Its modus operandi —Laxatives, to clear the bowels of residual and fecal matters—Caution respecting the use of neutral salts in cases of great depression—One dose sufficient —Followed, if need be, by simple laxatives—Difficulty of selecting any one laxative—Advantages of mixing several laxatives together—Some purgatives excite the pulse, such as jalap, scammony, &c, and hence they are inadmissible in fever—Difference in operation of the same purgative, at different times, on the same person—A second dose of a laxative apt to operate more than the first, a week intervening between the two —Another mode of administering laxative or purgative remedies, viz., per annm, or by glystcr—Purgatives by the mouth clear the whole intestinal canal better than glysters, and hence better in the beginning of a lever—After the first week, glysters are enough to evacuate any noxious matter from the intestines—Costiveness, or purging from irritating feculent matter, of several days duration, requires purgatives thrown into the stomach—Glysters less weakening— Vehicle for a glyster, warm gruel, decoction of mallows—Purgatives to be used, as glysters, in fevers, are manna, cassia, &c., ol ricini, senna, etc.—Better to mix them together—Glysters to be given in the evening, and repeated regularly, when there is no evacuation otherwise—Throe or four loose evacuations in the day will require a glyster of mucilaginous fluids—Weakness and exhaustion from want of sleep—Value of sleep'in fever—Means of a hygienic nature for inducing sleep—Opium, its effects in procuring sleep—Is apt to cause disturbed and unrefreshing sleep in continued fever — Difficulty of insuring its operation so as to give rise to sound sleep—Is mixed with many other substances—Small doses repeated at intervals, their effects—Of doubtful ad- CONTENTS. X vantage during the first week of fever—Opium is serviceable in the second week and relieves delirium—Antispasmodics to procure sleep—Hoffmann's liquor anodynus often brings on sleep in regular continued fever—Is, however, uncertain in its operation— No bad effects from employing it—Weakness, sometimes dangerous and fatal, apt to be caused by fever left to itself—Different causes of weakness —Means to prevent it— When present, to be obviated by certain medicines, that induce strong excitement of the system—The fever may go off and leave the patient with considerable power of the system, yet there be a want of exertion of that power—The stimulant must revive tho dormant powers, not induce extraordinary excitement, which weakens —Different measures with this view—Inducing inflammation of the skin, by means of certain stimulants—Effects of phlegmonous and erysipelatous inflammations —They weaken the system —Difl'ercnce of effect of applications to the body in health and in disease —Excit- inflammation of the skin, disturbs, causes wakefulness, and is not beneficial in the weakness towards the end of a regular continued fever—By their being absorbed, certain substances that inflame the skin may stimulate and revive the system, as cantharides —But this, also, is not to be recommended—Stimulants thrown into the stomach and acting on it, such as spices, &c. —These are not admissible —They quicken the pulse, but do not increase its fulness—Wine, the only remedy of use to excite the dormant strength of the system towards the end of continued fevers —It has also a narcotic property —Should be exhibited in moderate quantity, not to intoxicate —Otherwise it will exhaust in place of giving strength—Four ounces, of the strength of Port wine, enough—Three half pints in twenty-four hours, enough even for those habituated to it—Wine should be diluted and mixed with sugar—Distilled spirits,except in cases of extreme weakness, arc not admissible—Next inquiry is, whether the fever can be shortened by bleeding, purging, cutaneous irritation, Peruvian bark, stimulants, antispasmodics, preparations of antimony and ipecacuanha 1—Also, whether there are remedies to arrest putrefaction and hemorrhages 1 . . . 212 TREATMENT OF A REGULAR CONTINUED FEVER. PART SECOND. Treatment to Carry off the Fever.— Venesection —Frequency of pulse no symptom exclusively, of fever—Bleeding from a vein, never diminished, shortened nor carried off a fever—An accident, such as a general inflammation, which would kill of itself, may be checked by this means—Effects of blood-letting, weakness—Origin of the practice—Impatience and superstition—Examples—Does mischief ensue from blood-letting in this fever ?—Weakness, already considerable from the fever, is increased —Taking blood from the vessels of the head sometimes carries off fever and diminishes delirium accompanied with vascular fulness of the head —A morbid matter supposed to be removed by evacuation—Liut no particular matter can be separated from the blood by blood-letting—Secretions may throw off noxious matter —But fever may arise without such matter being applied, and- when is so applied the disease will, still run its course all the same—Neither fever in its essence, nor the operations of the body sufficiently known to determine the efficacy of any, medicine to carry oil'the disease —Experience alone the guide for the use of purgatives or other evacuations—Noxious matter supposed to require concoction before it is evacuated — Hence evacuations proper only at the beginning of a disease or towards its decline— Retained feculent matter aggravates the febrile disorder—Its evacuation is proper, but not with a view to carry olf the fever—Crisis supposed to follow concoction —Purga- employed with a view to hasten this result—Relapse caused by this practice— Purging beyond the simple evacuation of the prima vise not called for— Antimony no.t known to the Creeks—Description of the metal—Sulphuret of antimony furnishes the antimony employed in medicine—Number of chemical processes to give medicinal effects to this metal—Only three much in use, viz. kennes mineral, antimony with calx phosphor aid and tartarised antimony —Modes of preparing these—No remedy recommended by Galen or Celsus to put an end, at once, to the fever, except cold water—Alchemists, empirics—The first to administer antimony in fever and in intestinal inflammations —This practice reprobated by the regular physicians—Dr. James, the first to employ antimonial preparations freely in Great Britain —Dr. Cullen the first eminent teacher to recommend their use to carry off fever—His hypothesis to CONTENTS. XI explain their utility, was, that they produced sickness —The author of a different opinion—Other remedies that vomit not febrifuges, as the squill for example— Medicines will produce their destructive effects, if they vomit, by being given in large doses, as in the case of opium, Peruvian bark, and sugar of lead, wine, and spices—Tartarised antimony not efficacious, as a febrifuge, unless a quarter of a grain can be borne by the stomach —More than this tolerated by the stomach has produced critical symptoms in a complete crisis—The best preparation of antimony—Uncertainty of the operation of hermes mineral, and of James's Powder or pubis antimoniali —The uniformity of tartarised antimony—Vinous solution preferable—Effects of antimony, when it is given in a dose short of nauseating to a man in health— They resemble a crisis of fever—In this way given to a fever patient, antimony will carry off the disease—Best methods of employing preparations of antimony to produce a crisis in fever—An emetic often proper at the beginning of the disease—To select that which in its secondary effects may contribute to produce a crisis—The best is a mixture of tartar emetic and ipecacuanha—Moderate, better than violent vomiting —The proper dose—Reching injurious—To be obviated by drinking watery fluids — Indications for employing an emetic—Time for giving an emetic —Best in the evening, from its tendency to cause sleep—Sometimes the sickness continues through the night, with restlessness —More commonly, sleep and perspiration follow—An emetic proper in the first four or five days of fever—Divided doses of antimony at intervals of two, three or four hours to produce sweat, aided by c lothing and drinks—To be had recourse to early in the fever—Continued sickness and restlessness, after an emetic, removed by a grain of opium—The smaller doses of antimony to be given six hours after the action of the emetic is over—Dose of tartar emetic, two sevenths of a grain, or thirty drops of antimonial wine—Difference in the size of drops according to the vial— Some aromatic with the first dose of antimony—More prudent to repeat the antimonial preparation even after the subsidence of fever—The good effects of the medicino to be procured in four or five days—Still it may be continued longer—To desist when any evacuation is produced without relieving the fever—Profuse sweating sometimes serviceable—Circumstances requiring a repetition of the emetic—To be of ipecacuanha—The earlier the exhibition of antimony the better—Is blood-letting proper in some cases before using the antimonial preparation ] After one kind of evacuation, without relief of other functions'the antimony to be desisted from. . . 261 TREATMENT OF A REGULAR CONTINUED FEVER. Treatment to Carry off the Fever (Continued). — Is there any other medicine possessing the same febrifuge properties as antimony 1 Reference to the practice of the Greeks— Cold water exhibited by them—Also, entire abstinence from all drinks recommended by the Greek and Roman physicians—Small quantities of warm watery fluids by Boerhaave, to dilute the blood—The cold bath and sometimes the warm bath recommended in ancient practice—The root of ipecacuanha— First brought into practice as an emetic—Tendency in mankind to employ everything in medicine—Other remedial effects of ipecacuanha ascertained; as in rheumatism, diarrhoea, and dysentery—How far it is analogous to preparations of antimony in fever—Indications for its use as an emetic in the progress of the fever—The medicine seems to act in the same way, but with less power, as antimony, in fever—Dose, a grain, and sometimes two grains, without sickness being induced—The neutral salts, employed in fevers —Have little action in bringing about a crisis—This result procured, with any regularity, only by preparations of antimony and of ipecacuanha — Semicupium, or fomenting the lower extremities with warm water, similar, in its operation, to the warm bath—Should be applied in the evening—Directions for its use—Soothing effects of this remedy— Mucilaginous substances dissolved in water applied externally—No special advantage therefrom, nor from vinegar added to the water — External inflammation, in many cases, carries off diseases in other parts—Inflammation at the beginning of fever, not uncommonly carries off the disease—To guard against extending unduly the term fever —Removal of inflammation carries off at once the disease—Not so if cold or infection gives rise to fever—It persists whether they are removed or not —Inflamma- supervening on fever will sometimes carry it off; but its own symptoms continue and will require other appropriate treatment —Instance, pleurisy occurring in fever— These facts probably suggested recourse to means for causing external inflammation— XII CONTENTS. Theory on the subject—The noxious or febrile matter supposed to be driven off by the local inflammation, ending in suppuration—Fluid causing the fever thought to be carried off by blisters—Fever a disease of the solids —Morbid matter, if present, must be diffused through the circulation and cannot be eliminated at any one point—Sometimes the fever is carried off, but without a crisis, by external inflammation —Gene- this latter only abates the violence of the disease—The nearer to the pained part in fever, the more efficacious the action of the blister—Substances that excite inflammation of the skin—Effects of cantharides applied to the skin—Absorption of cantharides and their action on the neck of the bladder —Sometimes cause violent spasms in nervous subjects—Prevention of stranguary by mucilaginous drinks—Mustard and garlic to the feet, to produce derivation—In what cases of fever is the inflammation by cantharides to be produced—In simple fever, a blister between the shoulders—Its reapplication not good, if the first application have failed to relieve—Alleviation by the first will justify a second blister; but this failing, a third is not advisable—Bad effects of continued stimulus of a blister, in wearing out the strength—The mere slowness ot the fever no reason for blistering—Local affections in fever, benefited by blister— Headache, by a blister behind the ears : delirium by a blister on the shaved scalp, or on the neck, or between the scapulae, oppression about the precordia and cough, by one over the sternum —Relief is to be expected from the first but not subsequent application of the blister—Delirium, of two kinds—The second species, accompanied by fulness and turgescence of the vessels of the brain, and eyes blood-shot, —is relieved by opening the jugular vein, or better still, by a few leeches and afterwards warm moist cloths to the temples—Venesection at the arm of no use—Blood letting not necessary in the other kind of delirium—Both come on about the second week of the fever—Violent pain of the forehead removed, and sometimes the fever with it, by leeching the temples—No satisfactory explanation of this fact—The remedial effect uncertain from all these applications— Profuse sweating, the most marked appearance in the crisis of fever—Stimulating sudorifics, —s| ices,—to prevent the patient from sinking—General practice of giving this class of medicines —Sweating alone will not cure a fever, or bring on crisis—Weakness increased by over excitement —Irregular muscular contraction—Spasms—cramps—Fever sometimes called a spasmodic disease —Antispasmodics—Their enumeration—Camphor in the common dose, or camphor emulsion or mixture, productive of little or no effect—Recourse to it as an evidence ot doing something. . . . . . . . . 291 TREATMENT OF A REGULAR CONTINUED FEVER. Treatment to Caiiiiy off the Fever (Continued). —A regular continued similar to a regular intermittent fever—Power of bark of the cinchona to prevent a fresh paroxysm of intermittent fever—Difference between a regular continued fever and a regular intermittent one, in the paroxysm of the latter terminating by crisis, while that of the former is succeeded by another paroxysm—The bark, given, in large doses, in continued fever, with a view to bring about a crisis, and prevent the occurrence of the next paroxysm—Success, in some cases, of this practice—Failure and aggravation of the disease in more—In irregular continued fever its use may be advisable to prevent subsequent attacks — Cerussa acetata used by Gaubius—Depression of strength, an occasional cause of putrefaction of the fluids, which endangers life—Composition of animal solids and fluids—A solid substance, called by the author animal mucilage, combined with water—Change of properties of animal mucilage—When taken out of the living body and allowed to die it undergoes certain changes—AH the solid parts of an animal, capable of contracting, lose this power by death —Some change even in its chemical and mechanical properties—After death, animal mucilage becomes subject to various chemical changes— Putrefaction, one of these—Changes in the texture and other properties of the solids and fluids by putrefaction—Gradual change in a putrefied part, analogous to that of fermentation—Examples—Results of putrefaction —Means of preventing putrefaction and its effects in a dead body—Peruvian bark one of these—Five hundred grains to prevent one pound of dead animal matter from putrefying—Cannot be conveyed into the blood in quantity large enough to act, in this way, on the blood, and through it on the whole living body—A certain degree of putrefaction of the fluids in a living body, as in sea-scurvy —Means of its cure, not in antiputrescent —Alleged remedies to prevent and cure putrefaction—The matters added to the CONTENTS. XIII animal substance do not restore it: they combine with it, but not after a vital fashion —True means of preventing putrefaction, arc, to carry off the fever, and to avoid all depressing causes—Hemorrhage a dangerous sign—Bark, an ounce in the twentyfour hours, the remedy—Formula:.—Convalescence—A crisis before the sixth day is followed generally by fever of an intermittent type —Notion of concoction of febrile matter to be expelled from the system, erroneous—After signs of early crisis, peruvian bark to be administered every hour f ¦r forty-eight hours—A return of the fever, after an interval, shows the disease to be an intermittent, and it is to be treated as such— Crisis, brought about by preparations of antimony, ipecacuanha, or other medicines, to be followed by the exhibition of the bark —Removal of local pains and fever, by leeches, blisters, &c, does not require to be followed by the bark—Imperfect crisis, with remaining headache, foulness of tongue and depression of strength will justify the use of the bark, provided the symptoms are at first slight—In severer cases, where there are daily paroxysms, preparations of antimony, or the like, are most beneficial— A crisis, even though imperfect in the second week, would require the use of the cinchona subsequently—A crisis on the fourteenth day or afterwards, followed by a diminution of fever, indicates progressive diminution until it disappears entirely— Disposition of fever to return, great in the first week, less in the second, and very little, in the third week, gave rise to the idea of there being noxious matter undergoing a concoction—Purgatives used under this impression—They do no good in this way. Mercury causing salivation supposed to be carried off by purgatives—The author's experiments lead to a different inference—Fever and relapses brought on by purgative — These only required when there is costiveness, and then to produce but one evacuation—Food after a crisis, in the first or second week, to be the same as that in the fever,for several days—AH solid animal food to be avoided—Frequent relapses by the use of this food—Crisis, even in the third week, does not justify this kind of food. Very moderate nourishment and sleep, the means of restoring strength—Signs of subsidence of the fever, as enumerated, will not still justify the use of animal food— A perfect crisis in the first or second week, should authorise the patient to leave his bed and put on his ordinary clothing—So, also, after crisis in a more advanced period. . .... ... 309 HISTORY OF IRREGULAR INTERMITTENT FEVERS. Tertian, Quotidian, axii Quartan Fevers, Compared—Tertian thought by some to be the true fever type—Most common deviation from the tertian type is the recurrence of the paroxysm, after twenty-four hours, or the quotidian —Next, is the quartan, or recurring lever after seventy-two hours—Deviations in both quotidians and quartans from the precise hour, particularly in quartans —Anticipating quotidians and quartans—Retarding ones—Indisposition in anticipating and retarding quotidians and quartans, as in the regular tertian, to return in the night time—A quotidian left to itself runs a shorter course than a tertian—The first leaves the patient in about ten ¦weeks —A regular tertian in seldom less than fourteen weeks —A quartan will run on for six, seven, or eight months —A quotidian less apt to leave the patient free from any habitual disease than a tertian, and a quartan less than a quotidian—Sometimes, but rarely, there are quintans, sextants, and septants —'These soon return to the common types—Intermittents sometimes occur at the end of thirty-six hours—To all these going through their course regularly, and whose, paroxysms are not beyond eight, ten, or twelve hours, preceding remarks on regular tertian fever will apply—Irregularities and Accidents in Intermittent Fevers—First variation, a prolongation of the paroxysms—First cause of this prolongation, general inflammation —Sometimes this last called inflammatory fever or inflammatory diathesis—Differs from fever—It may arise, continue, and terminate, without fever—The most common symptom of general inflammation is hardness of the pulse—Difference in the sensitive powers of persons, in hearing and touch—Dr. William Hunter, and John Hunter—Their difference in the perceptions of sounds, and of the pulse—Appearance of the blood when drawn from the arm, if the pulse be hard—Conditions for the blood assuming a buffy coat—Gradation, in the degree of hardness of the pulse— Obstruction of the pulse, mistaken for hardness—So have fulness and strength —Hardness, a mark of strong action of the arteries—The blood kept fluid by its life, which it retains for some time after—Hardness of pulse, an evidence of increased activity of the living power—In a 1 XIV CONTENTS. regular tertian it prolongs the time of each paroxysm, and evinces general inflamma* tion—Other symptoms—Increased and stronger action of the heart; and increased frequency and fulness of pulse—Want of sleep, total loss of appetite, sense of distention, pains in the limbs, deep respiration, cough, headache, fulness of the eyes, and delirium—Death preceded by sinking, or the phrenitis may be fatal —General inflammation most common in intermitting fevers, in temperate and cold climates—Symptoms in the hot fit of a regular tertian, thus complicated— llemitritxa, or semi-tertian —Other anomalous varieties—Connection between intermittents and general inflammation —The latter may convert the intermittent into a continued fever— General inflammation, seldom fatal in cold and temperate climates —Seldom occurs, but when it does, is more dangerous, in warm climates. . . .331 TREATMENT OF IRREGULAR INTERMITTENT FEVERS. Means of Carrying off General Inflammation. —Blood-letting the most powerful means—Contraction of the blood-vessels so that they adapt themselves to their contained blood, a vital action—Diminished activity of body and mind after the loss of blood — Illustration—Diminution of the increased action of the heart and arteries in consequence —Means of diminishing the quantity of blood —Opening a blood-vessel, and stimulating the secretory or excretory ducts of the glands—This last draws more blood to the part and causes inequality and disturbance in the circulation —Opening a blood-vessel the best means, and venesection in the arm the mode—Sudden abstraction from a large orifice weakens much and is most beneficial—Illustration —A slow abstraction of blood less enfeebling—One large better than two smaller bleedings—The hot lit of the fever prolonged by general inflammation and made to assume the appearance ot continued fever with stupor and delirium—Blood-letting useful in such cases—Soma food allowable, when the intermission is tolerably perfect—In hot climates the intermissions and remissions are less perfect—Greater caution in abstracting blood, unless where the head is much affected—A sufficient quantity to be taken away at once— Other cases in which the paroxysm is prolonged to thirty-six hours in a tertian— Patient falls into a profuse sweat —Patient much weakened ; and is in danger of dying in the paroxysm—This variety called Hemitritcea or Semi-tertian —Remedies to hasten its conversion to the common type —An emetic in the evening, followed by a laxative next morning—The preparations of antimony or ipecacuanha, to produce effects similar to a crisis—Continued for several days till a longer intermission occurs — A perfect intermission, even for six or eight hours, to be treated with bark in powder—A drachm or two drachms every hour, or half hour—Its use to be renewed in the next intermission—If this do not come on, medicines, such as antimonials, to be had recourse to—In great prostration or weakness, the bark given in the best remission that can be procured—General inflammation a cause of the prolongation of the fit—Assuming the appearance of continued fever, except the evening exacerbations —A most formidable disease—Sometimes called the plague —In hot marshy regions, or where there are stagnant waters and thick forests, three diseases are especially fatal viz. dysentery, continued or remitting fever producing it, and an irregular semi-tertian — Irregular Semi-tertian, the product of putrefaction of animal and vegetable substance —Moisture generating cold, a cause of intermittents and their irregular varieties—Fevers occur in sandy plains, where there can only be under ground moisture — As in Flanders and in Peru — Infection stated to be a cause of semi-tertians —Neglect of sanitary measures at home followed by fevers of semi-tertian varieties, in certain towns —These attributed incorrectly to imported infection from abroad—A mere coincidence the arrival of vessels and the breaking out of the disease—General exemption of those who fly from the city into the country, explained—Instance given of a truly infectious fever in the combined French and Spanish fleet, during the American war. ......... 343 TREATMENT OF AN IRREGULAR INTERMITTENT FEVER. — {Continued ) Description of an Irregular Semi-tertian. — First attack sometimes so violent as to destroy life—May be called an ephemera —In the tropics and eastern coast of America is less intense at its onset —Patients seized, at times, with all the most violent CONTENTS. XV symptoms of the first stage of fever—These described—The disease makes its attack between six in the morning and eight at night, often without premonition—The first attack soon followed by more violent exacerbations—The author could not learn when these exacerbations occur—On the second, third, and fourth day the nausea increases, and a dark brown matter is brought up—This resembles the matter formed upon the tongue in some other fevers—Is most probably formed upon the surface of stomach and perhaps of the duodenum—Has neither the color nor the taste of bile— Bile sometimes excreted and brought up with it—At other times, there is no appearance of bile—Scarcely any medicine acts on the stomach at this time—Food is not digested and the patient is almost always cut off —At times spasmodic contractions of the extremities, like tetanus, take place—Sometimes the skin assumes a dark brown color, which has given the denomination of yellow fever to the disease —The color erroneously attributed to bile—Dysentery arising with this fever—The fevers seem to be a continued one—But it is a semi-tertian, as is shown in the often great relief and apparently beginning of recovery, when all at once, a fresh attack takes place, and the patient is carried off. Remedies Employed.—The most violent ones, had recourse to — Blood-letting—Active purginsr—Large quantities of mercury—Cold water dashed over the patient—All these and other violent measures seem to have increased the danger—Better to have been left to itself—The general inflammation not so great as to prolong the paroxysm and to require evacuation by bleeding—Furging, except to keep the bowels open, is injurious, by weakening the patient, causing a determination of blood to the interior and interfering with the effort of nature to bring on a crisis— Mercury employed in all cases of fever by some practitioners, but without any sensibly good effect—Its exhibition imprudent in these violent fevers—Is the fever to be left to go through its ordinary course 1 —If antimonial preparations are to be of use, they ought to be employed early—Dose from a quarter to a third part of a grain, with about half a grain of opium, to be repeated every four hours—The patient should be put to bed. under a light coverin duces the itch, would be able a priori to apply a remedy. He w r ould know, that it was apt to creep from the body it already occupies, to the body of another man which came into contact with it: that it would bite and stimulate a part where the mucus was soft, (as between the fingers for instance,) and occasion scratching; and excite a sufficient degree of inflammation to produce a pimple : that it would lay its eggs and propagate in this pimple ; from which the animal itself has frequently been taken out and shewn in a microscope. So far skilled in this distemper, he w T ould naturally apply a poison ; perhaps sulphur with grease, if he had no idea of cleanliness ; but if he had a greater regard to cleanliness, he might wash the parts affected with a solution of corrosive sublimate in water ; and he w T ould continue the application until the animal itself was killed, and all its eggs hatched, and all its young destroyed ; (which happens in about a month ;) and so cure the disease. — In these instances the mode of action of the medicine is known. — But when a medicine is to act upon the living powers of the body, it is impossible to account for its actions from mechanical or chemical principles ; (because the living powers are not governed by mechanical or chemical laws ; and all the knowledge respecting them mnst be learnt by experiment only). — So the chemical effects of a chemical operation are known ; but how these effects are produced is not known. (We know that sulphur and pure air form'vitriolic [sulphuric] acid; but why, no man can tell.) A bitter medicine does not act in restoring tone, by increasing the adhesive power of the moving parts ; for the tone does not depend upon the adhesive power. Neither does it act upon the elasticity, for by this the tone is counteracted. — Where its tone is diminished, so that a moving part is contracted too much or too little, in consesequence of a disease ; after the entire cessation of the disease, (as after a hemorrhage, arising from an accidental cut into a blood-vessel,) the tone will be much sooner restored if bitter remedies are exhibited, than it would be naturally. That is, if spasmodic contractions should 13 146 HISTORY AND METHOD OF TREATMENT OF take place, they will sooner go off; if the muscles become flabby, they will sooner become firm ; if water be deposited so as to form cedematous swellings, the tone will be restored to the exhalants and absorbents, (and water will be no longer deposited).— These instances are sufficient for demonstrating that these medicines have a power of restoring the tone. The action of many medicines producing effect upon the living powers is entirely upon the stomach. This proposition will be considered more fully afterwards. — These bitter medicines and preparations of iron (for instance) do not appear to be carried into the blood-vessels, and thence applied in different parts of the body ; but to act in the stomach alone. These medicines appear to be more efficacious when mixed together, than when exhibited singly ; and this opinion is supported by the prescriptions of almost every practitioner who has conducted the cases of many patients. — To state why this is the case, would lead the author at present into too great a digression. It is not necessary to give these bitter medicines in substance. An infusion or tincture of them may be employed with equal advantage ; and they are less disagreeable to the patient in this form. — Nor is it necessary to give them from the beginning of the disease : they would indeed be hurtful before perfect intermissions are produced. Perhaps, it is not necessary to exhibit them until appearances of want of tone begin to take place. They should be given during the .intermission ; in doses eqivalent to a drachm of the bark of cinchona, exhibited every six or eight hours. Whether these remedies give a stronger power of action, as well as restore the proper tone ; is uncertain. — In one light, a due tone must always produce a stronger action. If there be three fibres for instance in a moving part, and one of these be contracted too much, one properly, the third too little ; if the tone be restored, so that all three are by their tone properly contracted when brought into action; the whole force of the three will act together: (which would not be the case while the contraction from the tone was different). Another remedy, viz. exercise, both increases the tpne and power of action. Daily experience proves, that the power of action of a muscle is increased by bringing the muscle frequently into action. The bulk and elasticity of the muscles are also increased by it. — Where exercise is employed to increase the power of action, (in other words the strength of the human body,) it must be universal ; for only that muscle or set of muscles that is brought into action has its power increased. (A gold-beater exerts the powers of his arms only, while he leads a sedentary life: the strength of his arm is consequently increased, while that of the muscles of the lower extremities is even diminished ; and he is so far from being generally strong, that he is subject to debility and want of tone in the whole system, excepting his arms.) A REGULAR TERTIAN INTERMITTENT. 147 There is not a sufficient quantity of living power in any animal to keep any part in constant action: excepting parts the actions of which are absolutely necessary for existence ; (such as the action of the heart, the motion of the muscles of respiration, &c.) — It is necessary that all the other exertions of the body and mind should rest for a certain length of time ; that the organs of sensation perhaps should not give ideas of external objects to the mind ; that the operations of the mind should be suspended, as they are perhaps in sleep ; and that the muscles should be brought to rest. Exercise of any kind exhausts and renders sleep more necessary ; and if sleep does not take place, the exercise cannot be continued without weakening or destroying the body. Exercise diminishes the quantity of blood. This is directly proved when a man is forced to labor much without an adequate quantity of food. He not only becomes emaciated, but there is actually much less blood in his vessels; (as is easily seen from the smallness of the veins during life, and the small quantity of blood he can bear to lose without occasioning death). It is also seen upon dissection after death ; the museles being universally pale, and a very small quantity of blood being found in the veins. — The great appetite which takes place in a man in health after exercise is also an indirect proof; as are the large quantity he is capable of digesting, and the great evacuation made by insensible perspiration. Exercise, with proper food and sleep, in a pure air, gives strength to the system. — Exercise makes the blood return faster upon the lungs, where it is exposed to pure air. — It is not known by what means the blood is prevented from passing through the lungs, if a sufficient quantity of pure air is not applied to it. It is certain, however, that if the due proportion of air is not inspired, a quantity of blood is brought to the lungs, which does not readily pass through them ; but is accumulated in all the vessels about the right side of the heart. Anxiety and oppression about the proecordia take place : and derangement and loss of strength arise in the whole system. It is therefore necessary, that a proper quantity of pure air should be applied to the lungs, to allow the blood thrown upon them to pass through them ; otherwise the above appearances, followed by debility, will take place. It is proved, that exercise occasions a larger quantity of blood to be brought to the breast, by the veins being universally rendered much fuller: (a much larger quantity of blood flowing out in a given time, if one of them be opened.) If it flows in the veins when fuller, with increased velocity ; more must be carried to the lungs. In one respect, the air of the atmosphere is to be considered pure, in proportion as it contains the vapor necessary for the respiration of animals. This vapor (which has been called pure air) generally forms about one-fourth part of the atmosphere; but (as it has been but lately discovered what proportion it generally bears) it will require some time to investigate how far a greater or less proportion may be 148 HISTORY AND METHOD OF TREATMENT OF beneficial or prejudicial. It has been found that the constant and various currents in the atmosphere keep it nearly the same, as to the proportion of its contents. —If a man be shut up in a close place, where there is not this proportion of pure air; difficulty of respiration will take place ; and labor or much exercise in such circumstances will weaken, instead of strengthening him. The atmosphere may contain vapors : or, being very viscid, powders may float in it that may be hurtful to the lungs, or prevent blood from passing through them so readily : (gas or fixed air for example, which is always found in the atmosphere ; vapor of nitrous or muriatic acid, putrid vapor, and the air of large towns ; having powdered horse dung, soot, gravel, ashes, suspended in it.) Respiration will always be difficult, when these substances are inspired; and therefore prevent the good effect of exercise. The difference between labor and exercise lies in the attention of the mind. — That kind of exertion of the muscular power is exercise, which is employed wdth the accord and delight of the mind ; and then it tends to give strength to the system. On the contrary, that wdiich is employed against the consent of the mind, instead of giving vigor, diminishes the strength. But it is extremely difficult in many cases to discriminate what exertions of the body are with or without the accord of the mind ; for mankind would naturally be always at rest, if not stimulated into action by some passion of the mind, or some real want. (A North American Indian remains at rest, sitting, and looking straight forward, until forced into action to procure himself necessary subsistence, or until excited by passion or pain.) In some measure, all exertion whatever is against the will of the mind; but that in which the passions are excited and which is not produced by absolute necessity, is particularly the kind which gives strength. Whatever exercise therefore is employed merely for the purpose of restoring strength ; is less efficacious, than where an inclination for it is excited. If a man rides out for his health, the anxiety he feels, prevents the exercise from being useful ; but if he is going where he will be amused (as in following a pack of hounds,) he will be strengthened. Exercising a diseased part, tends always to derange,it still more ; excepting when the disease is want of tone only. Any attempt to exercise an inflamed muscle would increase the inflammation, without giving strength. A muscle affected with rheumatism would be weakened, instead of strengthened by exercise, while the rheumatism remained ; — and so generally. In the beginning of a regular tertian, when the intermissions are imperfect, exercise ought to be avoided. When considerable relaxations take place, (the pulse returning for many hours to its natural state, and the uneasiness and restlessness going off;) the patient should have his ordinary clothes put on during such relaxation.—Although he is only able to lie upon the bed, somewhat more of exercise will be used, than if confined to it. A REGULAR TERTIAN INTERMITTENT. 149 — Friction by rubbing with a flesh-brush or cloth, is a species of exercise which does not appear to be exertion to the patient. It was much more frequently employed by the Greeks and Romans, than it is at present: probably because their warmth of climate allowed of it without danger of the patient's catching cold. Where proper means are taken to obviate this difficulty, friction may be advantageously used in many instances. It does not exhaust the strength, and is extremely agreeable to the patient. When the intermissions at the beginning of a tertian are very imperfect, hardly any other exercise than friction should be used. When they are somewhat more perfect, but not so as to admit of great exercise : the patient for the first week or fortnight, (after more perfect intermissions have taken place,) should only go out of his bed-chamber into another room where the air is purer. If he lives in the country and the weather be fine, he may walk in a garden, or even among fields, for a little way ; but always so, that too great attention of the mind to the state of his health be not excited. After the disease has continued a fortnight, if the intermissions have become nearly, although not quite perfect; a greater degree of exercise may be useful; such as being carried in a chair or litter, (which although disused at present, would often be advantageous, if the patient were in a situation to employ it). The motion of a coach may succeed this, as an exercise somewhat more violent; or the patient may be carried in a boat. — Where the latter mode is used, it must only be upon a river or canal; w r here neither marshes nor ditches are upon its banks. If on a canal, it must be of considerable length, so that the water does not stagnate ; (the vapor arising from stagnating water often occasioning the paroxysms to be prolonged, and the intermissions to be disturbed). It must be remembered, that a moist atmosphere is the only cause that has an effect on the disease, after it has once been produced : therefore, a boat can only be used successfully in a serene and clear atmosphere. When the intermissions have become absolutely perfect, more violent exercise is useful ; such as riding on horseback. In these exercises all the muscles of the body are exerted. Many other kinds of exercise which have been frequently recommended, are injurious; as they militate against the rules to be observed.— Such are all great exertions of the muscles performed in the bed-chamber of the patient, or in any apartment where the air is confined ; (as striking heavy pieces of lead together, or forcing the body up and down on a chair supported by springs); for in these the air is contaminated by the respiration of the patient and any other animal in the room, and the patient's mind is occupied with anxiety on thinking of the necessity of thus exercising himself.—The utility of exercise in a carriage of any kind will be diminished, unless the patient's mind be at the same amused with the variety of prospects or objects presented to it, by the change from confinement, &c. ; therefore a chair or litter (although so easy in themselves) are often less 13* 150 HISTORY AND METHOD OF TREATMENT OF proper than a carriage, where there is conversation which may contribute to the amusement of the patient. Where riding for exercise is employed, the patient sometimes becomes weaker, instead of stronger ; unless he takes pleasure in the country he passes through, or has some object in view at the end of his journey. All kinds of exercise for the purpose of business, and considered by the patient as labor, are hurtful; — but with this exception, that greater anxiety may arise in his mind when he entertains suspicion that others are negligent of his concerns. Thus a ride of ten or fifteen miles (so that the patient does not over fatigue himself) will often contribute greatly to the restoration of strength ; if it be to see whether something in which the patient interests himself be properly performed ; especially if it turns out according to his wish. These exercises may be continued during the time the intermissions remain perfect. When a tertian which has been regular for a time with perfect intermissions, becomes again irregular, the paroxysms slighter although longer, and the intermissions less perfect; the same tonic medicines and the same exercise may be continued. Long experience has proved that when a disease is disposed to go off, it diminishes and goes off with as great obstinacy as it increases at the beginning. Many practitioners have conceived that when a tertian arises in a temperate or cold country, the fever itself is the natural cure of some other evil in the constitution : and therefore that a regular tertian (especially) should be left to go through its natural course. — Others more sanguine, (perhaps more w T ise,) think the sufferings of a,patient during the course of the most regular tertian, ought to make them employ every possible means to prevent the disease from going through its natural course ; and to relieve the patient immediately. There could not be a moment's hesitation in determining to restore the patient to perfect health at once ; were there any remedy or mode of treatment that would certainly prevent the returns of the paroxysms of a tertian intermittent ; and take off the symptoms remaining after the crisis, so that no other disease should follow. — But there most undoubtedly is no medicine uniformly efficacious ;' or that always leaves the patient in tolerable health, and secure of not being destroyed by the remains of the disease or by some other disorder arising in consequence of it. Were there any such, why should different practitioners attach themselves to particular varieties of bark ; (recommending the brown, the yellow, or the red, w r ith such decided preference?) Why should they prefer arsenic or zinc ; if any one of these varieties were uniformly successful ? It would not be an object for physicians of experience, who have practised in every case of the disease ; to recommend one or the other variety : nor any other remedy employed for the cure of regular tertians. — In many cases of perfectly regular A REGULAR TERTIAN INTERMITTENT. 151 tertians, the most skilful practitioners have been baffled in the use of Peruvian bark, and every other medicine recommended as useful in the disease.— Hence the necessity of laying down a mode of treatment to be pursued, supposing the disease to go through its natural course ; — as the author has done. There can be no doubt but that the paroxysms of regular tertians are repetitions of the paroxysm of simple fever.— The symptoms are in all respects exactly the same ; (excepting that in a simple fever all the appearances of the disease are carried off by the crisis : wdiile at the beginning of a tertian, the symptoms are never entirely carried off by the first crisis ; excepting when the patient had been before afflicted with the disease). — In the middle of the disease, when perfectly regular, there is no difference whatever between them ; (excepting there being only one paroxysm in a simple fever ; and in a tertian, a number of them). — Towards the end of a tertian, the paroxysms are less severe, with more imperfect intermissions. The only apparent reason for the return of the paroxysms in a tertian, seems to be that the first crisis is imperfect. — It appears probable, that remaining symptoms of the first stage (after a time) may increase suddenly, and produce a new paroxysm : — but why rather at the end of forty-eight hours, than at any other period, cannot be accounted for. Since also, when the patient has been before afflicted with a tertian, (even after the interval of a twelvemonth,) and a fresh attack of fever takes place which terminates in a regular crisis; the paroxysms nevertheless return : it would seem that the habit acquired by the former tertian occasioned simple fever to take this form. Hence it may be presumed, that when the intermissions become perfect, the disease is continued by habit. Upon these grounds, attempts may be made to carry off the disease : without suffering it to go through its regular course. — Although no alteration has been discovered in the solids or fluids during any part of the disease ; yet it may be possible that some contraction or motion of the body may have taken place ; for the removal of which, the exertions that arise in fever maybe necessary. — It becomes therefore matter of experiment to determine, whether a fever maybe stopped in its course without prejudice to the general system. — If regard w T ere had to the medicines only which were employed by the Greeks and Romans, and the earlier modern practitioners ; it must be determined that it was seldom proper to try to stop the natural progress. — But by the remedies of modern times, it is evident that tertians and other fevers may be put an end to with safety to the patient. We know however, that there is not any remedy which will certainly carry off the disease ; but that a regular tertian will sometimes go through its natural course in spite of every attempt to terminate it. It is also a question to be determined, whether by stopping a tertian in its course, some other disease may not be produced ; which 152 HISTORY AND METHOD OF TREATMENT OF will either be more distressing in itself, or which may terminate in the death of the patient ? — The author is of opinion that a tertian should not be checked in its progress ; if it be at the hazard of the life of the patient; — but where the risk is of some other disease not fatal, it may Be put a stop to in its course ; for few others are more painful. In considering the medicines to be employed, when the tertian is not permitted to go through its natural course ; the author thinks it most eligible to treat of those first, which appear to be pointed out by what happens in the disease itself; and afterwards of those, which have been found out by accident to cure it. Any medicine that would produce the same circumstances which happen when a perfect crisis takes place naturally, (by rendering the crisis complete ;) may occasion the fever to be entirely carried off, and not to recur. The first class of remedies tending to produce the same effects as occur in natural crisis, are emetics; which all occasion similar appearances in a greater or less degree. Ipecacuanha, or tartarised antimony, producing these effects in the greatest degree ; are therefore taken as examples. These when first thrown into the stomach produce no sensible effect, as they are not in the least nauseous to the taste ; but by degrees the patient becomes chilly, begins to look pale, and an uneasiness is felt about the stomach. The sense of uneasiness is changed into a feel of sickness ; the exterior parts of the body become colder and paler, (the latter evidently showing that the small vessels are contracted ;) and the skin being pale, shows the dirty brown color of the rete mucosum and sebaceous matter of the glands of the skin. The powers of the body and mind are depressed ; the sickness increases ; vomiting is produced ; — which has been imagined by some authors, not only to evacuate the contents of the stomach : but also, by producing great agitation of the body, to force obstructing matters through the small vessels. But whoever has experienced the agitation produced by an emetic, as also that which occurs on riding in a coach without springs on a rough pavement; must be sensible, that the latter is infinitely the most violent; yet without producing anv freedom from obstruction. ' If substances are contained in the stomach, these are thrown up without much uneasiness ; and the stomach becomes quiet. — After a time a glow of heat takes place in the extremities and exterior parts of the body ; the skin recovers its color, softness, and plumpness,, sweating comes on ; the sickness and uneasy sensation about the stomach cease ; and the muscular powers of the body recover their force to a certain degree. The patient remains quiet for some time. Soon after, however, the same symptoms recur, and vomiting is reproduced. If anything more be contained in the stomach, it is thrown up ; frequently bile along with it and other fluids, secreted by the glands whose excretory ducts open into the duodenum. 153 A REGULAR TERTIAN INTERMITTENT. After the second fit of vomiting is over, the same enlargement of the small vessels and other subsequent appearances take place. — The fits of vomiting, with all the concurring circumstances, may return three or four times. When they cease entirely, the patient often falls into a profuse sweat; the secretions from the kidneys and intestines are increased ; there is a greater flow of saliva in the mouth ; and all the appearances take place which arise in the crisis of fever. An emetic therefore, given during the paroxysm of a tertian, and acting along with the tertian itself; may produce a more perfect crisis ; sometimes such an one as to be quite complete, and the fever may not return.—This actually has happened in many cases. When the stomach is empty and drink is not administered during the action of an emetic ; the vain attempt at evacuation after the contents of the stomach are evacuated, always proves stimulating; and deranges the system very considerably ; (being often sufficient to prevent the beneficial effects of the general disposition to a perfect crisis.) —Therefore, fluids ought always to be drunk ; to give something that may be evacuated ; independent of washing clean the mouth and stomach. Vomiting produced by some emetics, is much more powerful than that produced by others ; in occasioning the appearances that take place in the crisis of fever. Drinking warm watery fluids gives a disposition to vomit, wmich is followed by very few critical symptoms ; and if the vomiting produced by other emetics be too long continued by means of warm water, the disposition to critical symptoms will be taken off; (and therefore, the chance of producing a perfect crisis.) When it is necessary to employ a vomit at the beginning of fever, to clear the stomach of its contents: those ought to be preferred, which have a tendency to produce symptoms of the crisis of fever. Ipecacuanha more certainly produces vomiting, than tartarised antimony ; tartarised antimony not uncommonly passing downwards and affecting the bowels ; but it is rather more efficacious in producing appearances of crisis after the vomiting is over. The better practice is therefore to mix them together. Neither of these remedies were known to the ancients ; nor indeed, any preparation of antimony, (for what they called stibium was undoubtedly an ore of lead.) Cold water, (an emetic of the same kind,) was employed by them ; which was to be drunk (as Celsus says) ultra satietatem ; so as to produce vomiting, and afterwards sweat. This remedy is not employed here, although it is still used in Italy and Spain. When a medicine is exhibited in too large a dose, it looses its peculiar effects and becomes a simple stimulant. If emetics be exhibited in too large a quantity in fever; they loose the effect of producing appearances of crisis, after the vomiting is over. It is true, that when the dose is large, great part will be thrown up in the first fit of vomiting; but not until it has made an impression on the 154 HISTORY AND METHOD OF TREATMENT OF stomach, which does not go off when the remedy is thrown out of it. Therefore large doses are less efficacious. A grain of tartarised antimony, with from five to ten grains of ipecacuanha, is quite a sufficient dose. In order to produce the full effects of an emetic in procuring the symptoms of crisis, it should be given to the patient in bed ; (that is, when the disposition to general increase of secretion and circulation in the exterior parts, may be aided by the equal warmth of the bed). Although symptoms of crisis are produced most strongly by tartarised antimony and ipecacuanha ; yet all emetics have this effect in some degree. — Even if the feathered end of a quill be put into the throat, so as to irritate it gently ; an attempt will be produced in the muscles of the abdomen, to contract and press upon the stomach, so as to throw up its contents ; and some degree of nausea will be brought on ; but there will not be any contraction of the exterior parts, nor alteration of the color of the skin, excepting in a very slight degree and very momentary; and although after the vomiting is over, there will be some glow of heat in the exterior parts and some disposition to sweat, yet they will continue for a very short time ; and secretions from the other secretory vessels will not take place. An emetic may be employed either in the beginning, middle, or towards the end, of the paroxysm of fever. — It may be exhibited immediately after the paroxysm is over, in the middle of the intermission, or a little before the paroxysm takes place. — Different effects will arise from the various periods of its exhibition, but these will be better explained in taking notice of the other remedies to be employed. Preparations of antimony, ipecacuanha, &c, administered so as not to produce vomiting; bring on appearances similar to those of the crisis of fever. — Many have imagined this to be the effect of sickness, although vomiting did not ensue. This can only be determined by experiment.—The author has frequently exhibited tartarised antimony to persons in perfect health ; in such a manner, that they were ignorant of taking any medicine, neither did they feel the smallest degree of sickness : yet in about an hour afterwards the skin became softer and moister, than it would have done under similar circumstances, if tartarised antimony had not been given. Sometimes the person has been thrown into a profuse sweat, the mouth became moister, there has been a greater secretion by the kidneys and from the intestinal canal, and greater ease has been felt over the w T hole body. It cannot be said that these appearances took place from sickness, w T hen the persons had not felt the least disagreeable sensation in their stomach, or any other part of the system. —Where these medicines have been administered to patients afflicted with fever ; and a crisis by their means has been produced which would not otherwise have happened ; the patients have frequently been entirely fre£ from any feel of sickness and every kind of uneasiness A REGULAR TERTIAN INTERMITTENT. 155 about the stomach : yet the symptoms of crisis have begun in less than an hour after their exhibition. — When the stomach in fever will bear but a very small dose of these medicines without producing sickness (as a fifth or sixth part of a grain of tartarised antimony, for instance); the author has rarely found that any critical symptom has been produced. On the contrary ; when the stomach was able to bear as large a dose as half a grain of tartarised antimony, without nausea following; the symptoms of crisis have been produced in a short time. — From these observations it appears then, that is not in consequence of the sickness that these critical appearances are brought on; but that the medicine has another power of inducing such appearances, totally independent of nausea. It is entirely unknown how they produce this effect. It would appear however to proceed from some impression they make on the stomach ; for their action is too quick to allow of their being carried into the blood-vessels; (commencing in many instances in half an hour or less, after the time of their exhibition). — When any medicine gets into the stomach, and afterwards into the blood-vessels, so as to be applied to any set of glands and to produce evacuation from them ; it is always after a much longer interval than five or six hours. Mercury, which gets into the blood-vessels and stimulates the glands of the mouth ; never produces an increased secretion of saliva in less than twelve hours. Even purgatives, which perhaps pass directly from the stomach into the intestines, hardly operate in less than two hours. Therefore medicines that commence their operations on the glands in the body in less than an hour, must be considered as making their impression on the stomach ; and so producing their effect. — Another circumstance pointing out that these medicines do not act by being absorbed, carried into the blood-vessels, and applied to the glands, is, that tartarised antimony dissolved in water and applied to the skin itself, is so far from producing softness in it and greater secretion from it, that it produces contraction and dryness of the skin ; and has all the other effects of an astringent topically applied. — Many other arguments might also be brought to show that these medicines have their effect upon the stomach. These medicines then, by the impression they make on the stomach, produce a greater secretion from all the glands of the body and all the secretory vessels ; a softness and pliability of all the parts ; an universal sensation of ease and tranquillity; in short, all the appearances that take place in the crisis of fever. — They often render the crisis perfectly complete, when exhibited in the paroxysm of a regular tertian-; and therefore not uncommonly terminate the disease in what would have been the first paroxysm of a tertian, if these medicines had not been exhibited : And so in any subsequent paroxysm. In order to produce these effects the medicine should be given in as large a dose, as the stomach will bear without producing sickness. — That is, two sevenths of a grain of tartarised antimony, or a 156 HISTORY AND METHOD OF TREATMENT OF grain and half of ipecacuanha, (and other such remedies in the same proportion); should be exhibited at the beginning of the paroxysm ; and repeated in about three hours afterwards; the patient being kept in bed. — If profuse sweating should take place, he should be kept in bed until it is entirely carried off. Where a perfect crisis is not produced, the continuing of these medicines during the intermission, produces beneficial effects; by taking off what remains of the paroxysm during the intermission. And also by diminishing the force of the next paroxysm, they tend to lessen the power of habit in producing subsequent ones. —They should be exhibited so as not to occasion sickness : and may be repeated every four, five, or six hours. — W T hen exhibited every six hours during the whole periods, they also often carry off the disease ; the paroxysms, after six or eight days, not returning. — This practice is also advantageous, as by procuring more perfect intermissions, food of greater nourishment may be allowed ; medicines increasing the tone of the parts may be employed more freely; and more exercise may be used; so that these remedies may act with greater advantage. Of the class of bitters, the powers of one are so pre-eminent, as perhaps to have brought the others into a conspicuous point of view. —The bark of a tree which grows in the kingdom of Peru, is a powerful remedy in preventing the returns of a fever generally. It has been called Cinchona, from the name of a lady who has been supposed to have been the first who exhibited it ; and this name has been adopted by the London College of Physicians. — The jealousy of the Spanish government with regard to their American possessions and trade, has prevented the specific characters of this plant from being perfectly known ; much less to allow seeds or plants of it to be brought to Europe. — The bark of this, as of other trees, consists of an internal part; having vessels which appear like fibres ; but which carry juices for the nourishment of the plant. The exterior part consists principally of cells; containing the peculiar medicated juice : and is therefore the part to be employed in medicine ; and is now indeed principally imported.—It has sometimes been thought that the bark from the small branches, was more efficacious than that from the large. Sir John Pringle obtained a quantity from the annual shoots ; part of which the author exhibited with very little effect. — It would seem that more of the interior fibrous bark was formerly imported with the exterior cellular part, it being then taken from the large, rather than from the small branches of the tree ; for now no difference is found between bark from larger or smaller branches, provided they have been of two years growth. Three kinds have been imported lately : one of a rich brown color ; one red ; and one somewhat more yellow than the ordinary brown: some practitioners have preferred one; some, another.— The author has exhibited them alternately with equal effect; excepting that a smaller dose has been necessary, when they have been 157 A REGULAR TERTIAN INTERMITTENT. very perfect of their kinds. — All these, (if perfect of their kinds) appear full of glittering particles, if broken and held in the sunshine ; which appearance is lost, if the bark be decayed ; and is destroyed, when a decoction is made from it, (which has sometimes been done without powdering it). The cinchona has been exhibited reduced to a fine powder ; or infused in water, or boiled in water, (the insoluble parts being separated and thrown away) ; or digested in alcohol, or in mixtures of alcohol and water, (the insoluble parts being rejected.) The water of the decoctions and infusions has been evaporated, so as to leave the dissolved part of the cinchona dry, which has been called an extract; and the alcohol and water of tinctures have been evaporated, leaving what has been called a resin ; or the remainder (after evaporating both tincture and decoction,) has been taken and called extract with the resin. It is certain that the powder is much more efficacious in preventing the returns of the paroxysms of tertians, than any other preparation of this bark : whether it be that there are some menstrua in the stomach, which dissolve it more perfectly than water, or alcohol; or that it acts on the stomach in a solid form. This bark should be reduced to as fine a powder as possible : both because the fine powder is more efficacious, and because it may be exhibited without producing nausea. In some other diseases (where the cinchona may be employed with advantage) the infusions, tinctures, and extracts, produce as much effect as the powder; but in all intermitting fevers the powder acts with very superior efficacy.— The powder has been objected to on account of its disagreeing with the stomach: and other forms have been recurred to as more agreeable to it, and to the taste. The taste of bark is less disagreeable than that of many other medicines: and provided it be reduced to a powder sufficiently fine, (so as not to be felt gritty between the tongue and the palate ;) less objection is generally made to it in this state, than in any other form. The greatest difficulty has arisen from practitioners themselves, who have suggested that it was unpleasant, and that they could find some more agreeable form ; but where the necessity is urged, even patients who are prejudiced against it, make no objection to taking the powder. But what operation, or in what manner the bark of cinchona prevents the return of intermitting fevers: is an interesting subject of inquiry. To determine this question, the author has exhibited it to a man in health, to the quantity of an ounce in twenty-four hours : (which is sufficient in many instances to prevent the return of a regular tertian ;) without any apparent difference taking place in the system. The blood on trial has consisted of the same parts and possessed the same properties, as it did before the cinchona was exhibited ; and the secretions that could be examined have remained the same, and in the same quantity: and the person has perceived no difference in any part of the system, but has had the same appetite, 14 158 HISTORY AND METHOD OF TREATMENT OF and the same sensations and powers of action. This medicine therefore produces no apparent effect on a man in health. A much larger quantity of cinchona has been frequently employed in topical diseases. (Such as gonorrhoea;) where the general system has not been affected. The quantity of even two ounces in twenty-four hours, for a fortnight together, has been exhibited ; without producing any difference in the chemical or mechanical properties of the matter of the body ; or without producing any apparent effect, excepting relief in the topical disease. — Therefore, nothing tending to elucidate the effect of cinchona, in preventing the returns of the paroxysm of fever, is to be found in administering it to persons in health or affected with topical diseases. Since the powers of cinchona have been discovered, other substances have been employed for the same purpose, such as the medicines already enumerated, which have the same kind of bitter taste and are employed for restoring the tone ; also preparations of iron, which have been supposed to have similar powers ; —likewise zinc, arsenic, &c. Bitter medicines produce no effect when administered to a man in perfect health, and where the tone is already sufficient; unless they have a mixture of some other medicated matter ; such as chamomile, which contains a stimulating essential oil; and orange peel, which contains an astringent matter. — Nor is any effect produced from the chamomile, if the essential oil be distilled away from it. The return of the paroxysms of fever have been sometimes prevented by these bitter medicines; although with much less certainty, (or in other words, much less frequently,) than by the cinchona. The author has actually prevented the return of the paroxysm of a tertian, by exhibiting chamomile, wormw r ood, and gentian, to the quantity of two ounces, during the intermission ; but they have much more frequently failed in their effect; (that is, perhaps forty-nine times out of fifty :) besides that their essential oils have considerably disordered the system. Preparations of iron, &c. appear to be somewhat more efficacious. — Preparations of zinc have in some degree the same power: and if exhibited in- a quantity sufficient to prevent the return of the paroxysm, they have no effect in health ; but their effects are not so well ascertained as those of bitters and of iron. — Preparations of arsenic and of copper have also the power of preventing the return of the paroxysm of fever: but given in the same dose to a man in health, produce great affection of the system ; (viz. violent pains in the extremities, and sometimes such affection of the stomach as to be fatal.) The principal reason for noticing these medicines is to show, that the cinchona is not the only substance which has the effect of preventing the return of the paroxysm ; and that it has an action common to many other substances. — What that action is, cannot be determined. It is only known, that it is more powerful in the cinchona, than in any of the other substances acting in the same way. — But A REGULAR, TERTIAN INTERMITTENT. 159 copper, zinc, and iron, are more efficacious than the bark, in preventing the return of the paroxysm of epilepsy. The next thing to be considered is, whether the cinchona has any power of taking off the paroxysm of an intermittent, which has already begun. When the cinchona was first employed, it was exhibited just before the coming on of the paroxysm ; and in some cases during the time of the first stage or cold fit.—A kind of tradition has been handed down, that exhibited in this way, it had proved fatal in certain eases : (and perhaps, if it be true, it was when exhibited during the time of the first stage). This has deterred the author from ever employing it during that time ; as he does not think a physician justifiable in trying any experiment that has been conceived to be fatal, unless when it has been contradicted by other observations. — But he has in many instances employed it from the beginning of the hot fit (or second stage of the paroxysm) of an intermittent. In this case, sometimes no effect whatever has been produced during that paroxysm; but it has gone on exactly as the paroxysm which immediately preceded. In other instances, the paroxysm has continued longer; and the crisis and intermission have been more imperfect: but he never met with a case in which the paroxysm stopped or became shorter, or where the crisis was more perfect, than was to have been expected if no medicine had been exhibited. — A conclusion to be drawn from this is, that the bark of the cinchona, (and probably all the medicines that act in a similar manner,) have no power of taking off a fever when present; but only a power of preventing a return : or if they have any action on a fever when present, they tend to prolong it and prevent a perfect crisis from taking place. There appears no doubt but that the effects of the cinchona are produced by the impression it makes on the stomach.—About twenty years ago many very irregular and obstinate intermittents were found in laborers, who had come from the fenny parts of Lincolnshire, and were admitted patients into St. Thomas's Hospital. These intermittents baffled the efforts of the physicians of the hospital; (of whom the author was one). The late Dr. Huck tried the various modes that had been recommended by authors for employing the cinchona. Among other modes of exhibiting it, half an ounce of the powder was sometimes given, (in some cases an ounce,) half an hour or an hour before the coming on of the paroxysm. In some instances the next paroxysm was prevented ; in others, it was not. The author following his example, exhibited it in the same manner, and with the same effect. The success was so small, as not to render it worth while to continue the practice ; but it succeeded so often however, as to ascertain that when applied in this way it had the power to prevent the return of the paroxysm, if exhibited an hour before the first stage of the paroxysm would have taken place. — It is three or four hours after the food is eaten, before chyle can be 160 HISTORY AND METHOD OF TREATMENT OF formed from it and betaken into the system. When the bark of the cinchona is exhibited in powder, it is therefore not very probable that it should be any way so dissolved as to pass into the system (or be absorbed by the lymphatics), in so short a time as an hour ; and produce any effect on the fluids or any part of the system. It is at least very improbable, that more than an eighth of the bark should be extracted, and carried into the other parts of the system. But the eighth part of an ounce, exhibited an hour before the coming on of the paroxysm of fever, (or two, three, four, or eight hours,) will hardly ever have the effect of preventing the return of the paroxysm of an intermitting fever.—It happens not uncommonly, that an hour after the exhibition of so Jarge a dose, vomiting takes place ; and a great part of the powder is thrown up ; (often as far as can be judged almost the whole): yet in some cases the intermittent is prevented from returning; from which it may be concluded, that its effects must have arisen from its operation on the stomach. (However there may be fallacy in this case ; as vomiting from an emetic exhibited just on the coming on of the paroxysm, may have prevented the paroxysm.) — Another reason for believing the effect of the cinchona to be ow T ing to the impression it makes on the stomach, is ; that no alteration can be discovered in the solids or fluids of the body, after it has been exhibited. Supposing it therefore to be proved that the powers of the cinchona arise from the impression it makes on the stomach ; the question is, how long does that impression remain ?—When a medicine makes an impression on a part on which it can act, (and which is called in consequence an irritable part,) the impression remains much longer than impressions on the organs of the senses. When, for example, any stimulating substances, (such as cantharides,) is applied to the skin, so as to produce heat and redness, but not a permanent inflammation, (which appearances continue, independent of the stimulus applied ;) the heat and redness do not go off in less than half an hour ; which is much longer than any impression remains on any of the organs of the senses, after the sensible object is removed. — The length of time the impression remains in preventing the return of the paroxysm of fever, when made on the stomach by the cinchona ; has been proved to be considerable, by the experiments made by many physicians. The author has tried it in several regular quartans, where the intermissions lasted sixty hours ; and where the intermissions were perfect. A drachm of the cinchona given every hour for sixteen hours, at the beginning of the intermission ; and discontinued for the last forty-four hours ; has prevented in several cases the return of the fever. — From this it. is evident that the impression made by the barkon the stomach lasts at least forty-two hours. A dose of bark therefore exhibited at the beginning of the intermission of a regular tertian, will have such an effect as to tend to prevent its return. This medicine consequently should be exhibited during the whole time of the intermissions ; as the impression made 161 A REGULAR TERTIAN INTERMITTENT. by every dose will have an effect in preventing the return of the paroxysm. It might be imagined that a small quantity of the bark of the cinchona may be exhibited at first, and in solution ; so as to have the least chance of producing sickness and uneasiness of the stomach : and that if found not sufficient to prevent the return, a larger quantity might be exhibited afterwards: or that if a solution could not produce the effect, it might afterwards be employed in powder. — But the author has been led to conclude from many observations, that, if the cinchona be exhibited in such a manner, as not to prevent the return of the paroxysms in the course of a few intermissions, its effect is generally lost ; and that it never can be exhibited afterwards in any dose, or in any manner, so as to produce its effect in the manner it would have done, if employed in a proper dose and mode from the first. — Frequently its power of preventing the return of the paroxysm is totally lost: and therefore it is of the utmost importance to use it at the beginning in such preparations and quantities as to be effectual. Where a first attack of fever goes through its three stages, terminating in crisis, although not absolutely perfect; the bark of the cinchona may be exhibited immediately after such a paroxysm ; and will often prevent the return of the fever. It is true, that in such cases it is by no means certain that the fever would have returned: but as it most frequently does in cases where slight symptoms of the first stage remain ; it is more advisable to give the patient the slight inconvenience of taking a small quantity of bark, than to hazard the risk of the return and continuance of the disease. If a first paroxysm is gone through, and very considerable intermission has taken place, and no means have been used to prevent a return ; should another paroxysm succeed, terminating incrisis, although not quite so perfect as to the first; still the cinchona may be employed without disadvantage, to prevent the return of the third paroxysm.— It often happens, however, that the subsequent intermissions become less perfect, and the fever acquires the force of habit. If the bark be exhibited during these imperfect intermissions, it will not with any certainty prevent the recurrence of the disease : — So that where the first intermission is passed over, an opportunity is frequently lost of employing the cinchona with advantage for some time. When an intermittent has begun with very little intermission or remission at the very first, and the intermissions have become gradually more perfect; and the cinchona has been exhibited before they have acquired a sufficient degree of regularity: its preventing a return of the paroxysm has been very uncertain ; or if it should have prevented the paroxysm from returning for once or twice, the disease has often returned in five or six days, although the cinchona has been continued. —This is, however, a matter of great controversy among practitioners; some insisting that cinchona should be exhibited as as soon there is a crisis, however imperfect. — In a temperate climate (such as that of 14* 162 HISTORY AND METHOD OF TREATMENT OF England) and in a person of tolerable strength ; either when the intermissions are very imperfect from the first, or when the first or second have been more perfect and the exhibition of the cinchona in them has been neglected ; it is better to wait till they become perfect, before the cinchona is exhibited ; even if it should be as long as eight or ten days. The cinchona (it is true,) will frequently prevent the next return of the paroxysm, exhibited in any part of the disease ; but on the other hand, its force is often entirely thrown away by this imprudent use of it; (so that it will not prevent the returns at the moment, nor afterwards cure the disease). When the irregularity of the intermissions render the use of the cinchona improper, the intermissions may be rendered much more perfect by keeping the prima? viae in proper order, by means of emetics, and laxatives : and by producing more perfect crisis by preparations of antimony, &c. — By these means intermissions are frequently rendered nearly perfect after two or three paroxysms, that would have remained as many weeks imperfect without them ; beside, that there is a chance in this case of removing the disease entirely by these remedies. When a tertian has continued regular during two or three months and the cinchona never has been exhibited ; and has become imperfect again ; although the intermissions have been very irregular, the author has found the cinchona efficacious in preventing their return. With regard to the exhibition of the cinchona, it has already been said that it should be given in powder. — Where there is perfect intermission at the beginning of the disease, the opportunity should be seized of employing it without any previous medicine being exhibited whatever ; so as to prevent the disease from being fixed by habit. If the intermissions should continue tolerably perfect after the second intermission, it is always better to clear the prima? viae by an emetic, and a laxative (such as rhubarb ;) before the cinchona is exhibited. The time of one paroxysm only is lost, and the remedy is rendered much more certainly efficacious. Where the intermissions have been very imperfect from the first or have become so afterwards, and then have grown naturally more perfect ; the emetic and laxative should precede the exhibition of the bark of the cinchona. If the intermissions have been rendered more perfect by these means : the cinchona may be immediately employed without any other previous remedy. If the intermissions should have become more imperfect again, late in the disease ; it is also proper to employ means for clearing the prima? via?, before the cinchona is made use of— When according to the above rules, it is proper to employ the cinchona; a drachm of the bark of it (reduced into very fine powder) should be exhibited and repeated every two hours at least. Most stomachs will bear this dose. If a larger can be borne, two drachms at the end of every four hours would be preferable. This exhibition of the cinchona should not be interrupted during the intermission; 163 A REGULAR TERTIAN INTERMITTENT. therefore, if the patient falls asleep, he should be awakened at the time proper for taking it. The cinchona should be continued till within "an hour of the time of the coming on of the next paroxysm ; (that is, an hour before the first sensible appearances of the disease take place.) Should no appearance of the disease arise, it is to be omitted during the time that the next paroxysm would have taken up. For if this remedy has had sufficient efficacy during the time of one intermission, to prevent the return of the next paroxysm ; it will certainly, during the term of the following intermission, have power to prevent the subsequent paroxysm. In a regular tertian this always is true. How far it holds in fevers of other types, will be treated of in the dissertation upon them. By this means the stomach has time to clear itself totally of the former dose before a fresh one is taken ; and the sense of weight and uneasines arising from large and frequent doses has time to go off. — If no traces of the paroxysm have appeared ; the stomach is left capable of digesting the food exhibited during this interval; or if the patient's sleep has been very much disturbed, time is given for repose. Although a paroxysm of an intermittent has been prevented by the cinchona: it frequently happens that if no medicines be employed, some slight appearances of a paroxysm will take place about the time the disease should have recurred.— When slight symptoms of the attack of fever (such as languor, pain in the small of the back, pain in the forehead) take place at the time the paroxysm should have recurred, subsequent to that which was prevented by the the cinchona : these symptoms increase for the three or four times that would have been the times of the paroxysms ; and at length a complete paroxysm recurs, and the disease proceeds as if it had never been prevented. — Several means have been employed to prevent this reproduction of the disease. The first and most efficacious, is to continue the use of the cinchona ; by employing it in the same dose as at first, at the time that would have been the time of the intermission after the paroxysm that was prevented by it ; (employing it as frequently as during the time of the first intermission.) It should be discontinued at the time when the subsequent paroxysm should have recurred. — And the same practice should be repeated during the time of the next intermission. That is, if the tertian had commenced at twelve at noon on Sunday, and completed its stages by midnight; a drachm of the cinchona should be exhibited at one on Monday morning, and continued every two hours till eleven on Tuesday morning. It is then to be omitted till one o'clock on Wednesday morning ; when it is to be given in like manner till eleven o'clock on Thursday morning. It is then to be omitted till one o'clock on Friday morning ; when it is to be exhibited till eleven on Saturday ; — And afterwards to be discontinued altogether for a time. Many practitioners deny the necessity of this long use of such a quantity of cinchona ; having frequently cured their patients in a 164 HISTORY AND METHOD OF TREATMENT OF shorter time, and with much less doses: — but they have also very frequently failed. This failure is usually attributed to the badness of the cinchona, to the particular constitution of the patient, to relapses produced by new causes, and to a thousand other things. But the author is convinced from his frequent trials of it in all ways, that in order to insure success it must be exhibited as above directed. — This even is not sufficient to insure success perfectly ; but an ounce should be exhibited during the day time, at the end of six days, for two days ; and again in the same manner, after an interval of six days more. — The author cannot help again repeating the necessity of exhibiting the cinchona in this manner ; having been so often disappointed when it was otherwise used ; and having so frequently found that this medicine, when once given so as to fail in its effects, generally loses the greatest part of its efficacy in afterwards preventing the return of the disease. If the bark should affect the intestines as a purgative ; it is a common and proper practice to exhibit opium to prevent this effect. — The opium ought to be employed so as to act on the intestines constantly and with efficacy. A third part of a grain (or its equivalent in any of its preparations) should be given ; and repeated at the end of every sixth hour. — It may be mixed with the dose of bark which falls in with that period.—When on the other hand the peristaltic motion of the intestines is prevented from going on, the natural evacuations ought to be produced by rhubarb, or some other gentle laxative ; for purgatives ought by no means to be exhibited so as to make large evacuations. Another means of preventing the returns of the paroxysms, is by producing a profuse sweat at the time that the paroxysms should take place. —A variety of modes of producing this effect have been attempted. The most efficacious means is to exhibit a spice of some kind, with opium, and tartarised antimony (or any other efficacious antimonial preparation); or w r ine or spirits, with opium, volatile alkali, and ipecacuanha : the formula? of which are in the author's Elements of the Practice of Physic. — These medicines should be given about an hour and a half before any sensible appearance of the paroxysm is expected ; the patient should be in bed, in cotton or flannel ; and in this climate the room should be heated (in winter to 55°, in summer to 73° or 74°); warm watery fluids, such as barley water, should be exhibited to the quantity of two or three ounces every five or ten minutes (and in such manner, as that the patient should not be obliged to raise himself from under the bed clothes ; from the spout of a tea pot for example). The head should be bound round with cotton or flannel; and more bed clothes should be used than the patient is commonly accustomed to. — If by these means a profuse sweat can be produced at the time when the paroxysm of the disease should have come on ; none of the symptoms of the attack will make their appearance; and in several instances the paroxysm is entirely prevented. — Exhibiting some very stimulating A REGULAR TERTIAN INTERMITTENT. 165 purgative, which affects the whole system, about ten hours before the use of these remedies ; renders them more efficacious : — Such as a mixture of scammony, coloquintida, aloes, and jalap ; given so as to produce five or six evacuations ; and so as that their purgative effects shall be entirely over by the time the sudorific remedy is to be employed.— The advantage of such purgatives is from the disposition to sweating which they leave (after their purgative effects are over), even when no sudorific remedy is made use of; and the consequent increase of the power of the sudorific. —Purgatives were originally exhibited with a view of a evacuating noxious matter ; which effect however there is no reason to think is produced by them. It is as little understood how the disease is prevented by these remedies ; as by the use of the cinchona, or any other remedy acting in the same manner. Whether this practice might be used advantageously, where the first and second intermissions are perfect, and the subsequent ones become imperfect; is not known. — Where the first and second intermissions have been tolerably perfect, and the subsequent ones for some time have become imperfect; it cannot be employed with advantage while they are very imperfect. Where the intermissions at the beginning are nearly perfect and continue so ; so where they are imperfect at first, and afterwards become perfect, or nearly so ; these sudorifics may be used advantageously. — There is one exception, however. When towards the beginning of the disease appearances of general inflammation arise, (such as hardness, fulness, and strength of the pulse during the intermission,) there is some doubt whether they have not a tendency to produce topical inflammation. This is however merely a theoretical idea ; as there is no proof of deleterious effects having arisen by the use of them under these circumstances. When inflammatory symptoms about the thorax continue during the intermission, (such as considerable difficulty of respiration, violent cough, pain in the side, with hardness of the pulse ; hamioptoe is apt to be produced by them. When the intermissions become again imperfect towards the end of an intermittent, after having been perfect or nearly so; a sudorific may in several instances be efficaciously employed. A sudorific remedy is rarely efficacious, when it does not produce sweating at the time the paroxysm sho.uld have recurred; sometimes however, even in this case, it prevents it. This shows that it is not merely sweating that prevents the paroxysm from returning : but that the sweating is perhaps only a collateral effect of the medicine ; and a sign of its acting thoroughly and efficaciously. — On the other hand, although sweating should be produced, it sometimes happens that the paroxysm takes place ; the sweating ceasing at the time of or soon after the attack, and during the hot fit; which however, is generally very much shortened. In many cases the crisis which follows, is rendered more perfect; and the whole disease goes on 166 HISTORY AND METHOD OF TREATMENT OF with a milder aspect. — It might be supposed that by repeating this remedy in the next intermission, where the paroxysm has not been prevented; the following paroxysm might be prevented. This happens sometimes. — The patient, however, is so much exhausted by these great exertions, (especially if a stimulating purgative had been made use of;) that it is not proper to employ them, at least in the subsequent intermission. If the purgative had not been given, it may be used in the following intermission : so as sometimes to produce an effect, and prevent the next paroxysm from returning. The exhibition of a sudorific remedy in this manner has not been much practised. It is one of the modes that have been used to prevent the return of fever; which sometimes succeeds ; although not so frequently as to put it into competition with cinchona, where it can be employed properly. Antispasmodics, (such as musk, opium, empyreumatic oil, ether, &c.) exhibited just before, or at the time of the coming on of the paroxysm ; sometimes prevent it, without proving at all sudorific ; but so seldom, as not to be worth serious attention. Another means of preventing the paroxysm from taking place, is to excite some passion of the mind very strongly ; of the success of which there are instances, although few. One, for example, was of a patient, a man in the twenty-ninth year of his age, in the third month of a quartan ; where the intermissions were regular ; and took place at two o'clock in the afternoon, and in the winter. His brother led him to walk by the edge of a mill-dam and pushed him suddenly in; which produced great terror, as he was unable to swim.— He was taken out; and the paroxysm was prevented from taking place : and no farther attack of the disease arose. By exciting inflammation of the skin in any part of the body, so that the inflammation may be considerable at the time the paroxysm should take place ; it is sometimes prevented, and the disease cured. — Hence bracelets of mustard seed and garlic have been applied to the wrists and ankles ; which sometimes have had an effect. Similar remedies are however so seldom efficacious, that regular physicians have rejected them. Empirics have sometimes employed thern : and when they chance to succeed in their hands, they are supposed by the vulgar to have a miraculous effect. Sudorific remedies exhibited just before the coming on of the paroxysm, have been ranked with these very uncertain remedies ; which they by no means deserve ; being, next after the cinchona and other medicines of the same kind, the most efficacious that can be employed. — Sudorifics are however, not to be put in competion with the cinchona ; where it is proper to exhibit the latter. But supposing the intermissions not quite so perfect as to render it prudent to employ it; or supposing that it has been employed improperly so as to have lost its effect; sudorifics are then of great value: because if they should not absolutely prevent the return of the paroxysm, they often render the next intermission more perfect; so as A REGULAR TERTIAN INTERMITTENT. 167 to bring the patient into a situation in which the cinchona may be exhibited with advantage. The following then are the remedies which have been employed to prevent the return of the paroxysm of a regular tertian. That is, first, the producing so perfect a crisis, as that no symptoms of the first stage shall remain after it has taken place: in which case it often happens that no subsequent paroxysm occurs. Secondly, employing the bark of the cinchona or other medicines which (if exhibited during the intermissions) prevent the return of the paroxysm ; without having any other sensible effect on the system. Thirdly, employing medicines, just before the paroxysm takes place, which throw the patient into a profuse sweat; which, if it should take place just at the time of the coming on of the paroxysm; prevents it from coming on at that time, ancT often carries off the disease. Fourthly, employing antispasmodics at the time of the attack, or during the paroxysm ; which prevent or diminish it. Fifthly, exciting inflammations ; which sometimes prevent the paroxysm frOm taking place. Those remedies remain to be examined which appear not to have a beneficial effect. The first of these is evacuation by bleeding; a powerful remedy in many diseases ; but in a regular tertian intermittent, it has not the least effect in preventing the paroxysm from taking place, or rendering it more regular, or inducing a more perfect crisis, or making the intermissions more perfect. There seems to be a great error in the view of remedies employed in fever ; practitioners frequently making no distinction between those used to cure the disease itself; and those employed to remove accidents that have arisen in it; —although such distinctions are extremely necessary to be made. If, for example, in the course of a tertian, a pleurisy should happen to arise ; taking away a quantity of blood would be a powerful remedy for the pleurisy; but although the pleurisy were removed, the intermittent tertian would go through its course just as if no blood had been taken away, (excepting that the patient would be rendered weaker). Those who are uninformed in medicine, except that diseases are to be cured by violent remedies and suddenly ; and the attention of bystanders is thus often drawn to practitioners who employ strong acrid medicines. — This has frequently induced those practitioners who are least acquainted with the real history of diseases, to use medicines the most violent in their apparent effects ; supposing that they would also be the most efficacious in curing the disease: while practitioners really well informed, find it often much more proper, to leave diseases to go through their natural course ; though they are careful not to let slip an opportunity of employing a remedy that is efficacious in carrying them off- This subject will be more amply treated of in the dissertation on the management of regular continued fever. Purgatives have often been employed in regular tertians, with a view 168 HISTORY AND METHOD OF TREATMENT OF to carry off certain humors supposed to occasion the disease. But it has been found, on the other hand, that purgatives have reproduced the disease after it has been carried off by other remedies ; and that, (excepting so far as they prevent costiveness, and excepting also the use of stimulating ones designed to assist the action of sudorific remedies,) purgatives tend to render the disease longer in its paroxysms, and the crisis less perfect. Evacuations, either by bleeding or purging, is hurtful; (in so far as it weakens the patient, and renders him less able to bear the repetitions of the paroxysms ; and on this account is improper) : although not so highly prejudicial as in continued fever ; for in the intermissions there is time for food to be digested, so as to replenish the bloodvessels. In this Dissertation the ground gone over is trodden and tolerably plain: the remaining parts of the subject are more difficult. The author nevertheless means to pursue them (according to his ability,) until the history of fever be completed by a third dissertation, viz., on a regular continued fever; — a fourth on irregular intermittents, and the accidents which happen in them ; — and the last will contain the history and the manner of treatment of the accidents which happen in continued fevers, and their irregularities. 15 A THIRD DISSERTATION ox FEVER; PART I. CONTAINING THE HISTORY AND METHOD OF TREATMENT OF A REGULAR CONTINUED FEVER, SUPPOSING IT IS LEFT TO PURSUE ITS ORDINARY COURSE, HISTORY OF A REGULAR CONTINUED FEVER. Di agnosis of Fever.—An ephemera easily distinguished—Also an intermitting fever —Greater difficulty in diagnosis of a fever lasting for many days or two or three weeks—This is properly only a continuation of ephemera—Fever, a disease of the whole system —Cause of fever acts at once, and need not to be repeated—Rules for distinguishing various diseases, erroneously called fever, from true fever—Hectic fever, not true fever, as it wants the means of curing itself—Frequent pulse in tetanus —Inflammation causes febrile commotion—So, also, do rheumatism, gout and erysipelas —Phlegmonous inflammation of the intestines—Topical inflammation may carry off the fever—In the phlegmasia? it is enough to remove the local inflammation in order to carry off the febrile symptoms—In fever, the cause is not attended to —Rheumatism —Its treatment—Use of the bark of cinchona for its cure—In erysipelatous inflammation, and in enteritis, we do not attend to the general symptoms, but try to cure the local malady —Fever, and phlegmasia may be enjoined—Continued fevers sometimes begin at once, commonly it approaches gradually—Sleep in fever—Rest from exertion—Mind affected in fever—Powers of the mind investigated—Perception, memory, imagination, judgment—Period of rest for the mind required—The mind in sleep—Never a state of perfect rest —Rest of the muscular system—Diminished action of the heart, and lungs and digestive apparatus in sleep.—Some people, in madness, said never to sleep—The author says they are never awake —Effects of sleep—Waking from the system being full of power—Had effects of want of sleep—Stmptoms of Ffver.— State of the pulse—Author's terms, with regard to strength, hardness, softness, obstruction, or freedom of the pulse —Difference in the sense of touch, in determining the state of the pulse—A hard pulse, to be distinguished from a merely strong or obstructed pulse—Question whether fevers of many days duration consist of one paroxysm or of many successive paroxysms—Continued fever has been regarded by some as only a variety of intermittent—Duration of the first paroxysm of a continued fever. First paroxysm in the morning or in the day, the second in the evening-—Why, this time for the second paroxysm—Evening paroxysm still more evident in most diseases— Causes reproducing fever are two, both of which are incomprehensible —Days of fever—Symptoms of second paroxysm—Depression of strength docs not constitute an irregular fever—The disease not dependent on putrefaction — Symptoms — Third paroxysm—Inquiry into the hypothesis of putrefaction of the fluids —Man not subject [to the laws of dead animal and vegetable matter —Is placed in the situation in which putrefaction most readily take place—False analogy, inferring a similarity of the operation of antiseptic substances in the living with that on the dead body—Exemption from disease of these exposed, putrid matter and exhalations—Depression of strength the cause not the effect of putrefaction and scurvy—Symptoms of putrefaction—Altera, tions in the secretions—Discoloration of the skin ; dark purple spots—Haemorrhages, dangerous—Difference, in different epidemic seasons, respecing marks of putrefaction— Delirium —Distinction between delirium and mania—Two kinds of delirium—Does the mind exist in the brain—Structure of the brain—Its connection with the muscles — Description of the first species of delirium—Is worse in the evening—Second species of delirium—Brain affected in it—Increase of fever with progress of the delirium— Symptoms, appearances of the tongue, picking the bed-clothes, &c —Prognosis.— Deglutition and respiration easy, the augury is good, even though delirium or insensibility be present—Death may follow an abatement of all the other symptoms if the delirium persists.— Crisis —Explanation of the good and bad crisis—Crisis differently described in different climates—Critical days—To determine which is the first day— Date of the fever from the second attack —Crisis rarely happen the first week, except in intermittent and remittent fevers—Days enumerated by Hippocrates—Cullen's mode of accounting for the critical days—Continued fevers observe, in some respects, the type of intermittents—Continued fever of a quotidian type the first week—Tertian and quartian types—The fourteenth the most common critical day—Smaller number 172 HISTORY AND METHOD OF TREATMENT OF of the fevers terminate by crisis in London—Symptoms in the second week of continued fever— Prognosis—Abatement of disease by the fifteenth day—Weakness— Eruption, in the second week, about the neck and breast of brownish red specks, like flea bites—Another variety or warty kind of eruption, limited and less frequent than the other— Abatement and removal of the fever. Diagnosis of Fever. — An ephemera, or fever consisting of one paroxysm only, (or, in other words, of a cold fit, hot fit, and crisis,) is easily distinguished from any other disease. Nor is it difficult to distinguish an intermitting fever, if regular; as it consists of several paroxysms, similar in all their parts to the one paroxysm of an ephemera. — But a fever going on for many days without any appearance of crisis ; or having only one marked crisis, after a continuance of two or three weeks'; or perhaps going off without any marked crisis : is with difficulty distinguished from many other diseases. — This seems to be the piincipal cause of the confusion found in the works even of practical authors, who have treated on this disease.— Should the author also fail in discriminating it, he will have this consolation ; that he has failed with many of the first practitioners who have written on this subject. A fever which continues for three, four, five weeks, or even longer, without any marked crisis ; and which afterwards goes off by degrees, one critical symptom happening after another ; is only (in the author's opinion) a repetition of ephemera ; — Where the subsequent paroxysm begins, before the crisis of the former has begun to take place. It has been shown, in a treatise on a regular tertian, that at the beginning of the disease, the succeeding paroxysm often commences before the beginning of the crisis of the preceding one : (were this to continue to the end of the disease, it would be a continued fever). — It has also been noticed, that if one very perfect crisis should take place, it sometimes terminates an intermittent ; — but that when the disease is not so carried off, it gradually diminishes after a certain time and ceases. — X regular continued fever begins in the same manner: increases for a certain time, remains nearly in the same degree for some time, diminishes from no apparent cause, and leaves the patient. Or otherwise, a crisis takes place during some part of its progress ; either carrying it off altogether', or converting it into an intermittent. A fever is a disease of the whole system: — so that if a disease of a part should go off, while the cause remains; and the system should not be generally affected in a greater or less degree ; it ought not to be considered as fever. One criterion of a regular continued fever is, that it increases for a certain time from its beginning ; remains for some time in the greatest degree, or (as the Greeks call it) acme then, without any apparent cause, gradually diminishes and terminates in health. — Or otherwise ; a crisis takes place during its progress, and carries off the disease ; or the crisis converts it into an intermittent; or otherwise in its progress it produces topical inflam- A REGULAR CONTINUED FEVER. 173 mation ; or else it kills the patient. — Any disease, not having these qualities, is not a regular continued fever. The author has before remarked, that when a cause is applied which produces fever, it produces it uno ictu, (at a blow); and the disease continues afterwards, although the cause be no no longer applied : neither is it increased, diminished, nor altered by the farther application of its cause.—The author, therefore, would not admit any affection of the general system to be a fever, which depends upon the constant application of the original cause. Should a disease arise with frequency of the pulse, and other affections of the whole system ; and these general affections not be such as are commonly found in fever; (that is, if there should not be contraction of the vessels, depression of strength, affection of the stomach, &c.) although the disease should arise from a cause, the continuance of which is not necessary for the continuance of the disease ; and although the disease should gradually increase, remain for some time with a certain degree of violence, then gradually diminish and go off; — nevertheless it must not be considered as fever. The following rules may be applied for distinguishing the several diseases which have been erroneously called fever, from that disease. When a disease has a tendency, after having increased to a certain degree, to diminish gradually, and go off without any apparent cause : This is a property of fevers ; but not of fevers only.—Acute rheumatism, when no medicine whatever is exhibited, increases for a certain length of time ; rises to a certain height; continues for a time in an equal degree; then gradually abates, and leaves the patient. Hemicrania increases for a time, then continues in the same state, (although a much longer time than acute rheumatism,) and, afterwards leaves the patient, without any apparent cause w r hatever; seeming only (if the expression may be used) to grow tired of a longer stay. — (Some cause, however, there must be for all such increase and diminution ; although it has not yet been discovered. This criterion of fever, therefore, is unfit for universal application ; — but it may be applied in many cases ; as for distinguishing the disease called hectic fever. — This disease sometimes agrees with regular continued fever, in arising without apparent cause ; but it commonly arises from, and is kept up by, the constant application of an apparent cause. There is coldness, paleness, and other symptoms of depression of strength and contraction of the small vessels : these are followed by heat, frequency of the pulse, foulness of the tongue, and other symptoms of the hot fit of fever. The attacks and subsequent apparent hot fits take place in the evening, terminating in the morning; often with several critical symptoms. Sometimes indeed the attack happens in the day time ; but not commonly. — This disease has been frequently called fever : but it wants this essential property ; that w r here it does not arise from an apparent cause, and often even when its cause is removed, it has no disposition to go off" 15* 174 HISTORY AND METHOD OF TREATMENT OF of itself; but remains, until it destroys the patient. — This want of means of curing itself, excludes it from the class of fevers. In tetanus, contraction often takes place in the muscles of various parts of the body; (continuing for a certain length of time, without any apparent intermediate relaxation ;) the general system is often affected ; and the pulse becomes frequent to a hundred and twenty strokes in a minute or more : there is, however, no other appearance of fever in the system : the patient is often in a profuse sweat, the tongue is clean, and the stomach not much affected. This affection of the system often arises without any apparent cause ; and frequently after some other disease has gone off, (as after the cure of a fever or the healing of an ulcer:) it then increases to a certain degree, continues for a certain length of time, diminishes, and goes off. The same affection of the system arises not uncommonly, with little, or without any spasmodic contraction of any of the muscles of the body. Although this case has not been remarked by any writer the author is acquainted with ; yet he has seen it several times.— First, where there has been spasmodic contraction in particular parts of the body ; and the affection of the system has been greater than in proportion to such spasmodic contraction : Secondly, when there has been no spasm in any part: the affection of the system subsisting without any continued cause applied. — This alfection cannot be called fever; because it totally disagrees with it in its appearances. Should a phlegmonous inflammation arise in any part of the body of a strong young person, distending the part considerably, and be accompanied with violent pain : as the inflammation increases, the pulse becomes hard, full, strong, frequent, and synchronous ; considerable degree of heat and of general tension takes place all over the body ; the tongue is covered with white fur ; the patient has headache (feeling as if his head would burst); pains occur in the extremities, and great sense of heat. These appearances gradually subside, when the phlegmonous inflammation has suppurated and the pus has made its exit externally : they are therefore kept up only by a constant apparent cause ; and are consequently excluded from fevers. Or should the inflammation be cured by any means, this affection of the system also goes off in the same mapner: — so that the affection of the system evidently depends here on the topical affection ; and therefore it is not fever. Should rheumatism arise in any part of the body, all the appearances in the system just enumerated, take place ; and often continue as long as the rheumatic alfection continues in any part or parts of the body. — Hut when the rheumatic affection has gone off, these appearances gradually subside also ; and leave the patient. — Sometimes, when the rheumatism is not in fact cured ; but has left the patient, in appearance free from disease ; after a short pause, a metastasis takes place to the head or breast, and soon proves fatal. —This remission of the symptoms is nothing like an intermission of fever ; for which reason it is here noticed. 175 A REGULAR CONTINUED FEVER. Similar appearances take place in the system, in ths gout and in other diseases which depend entirely upon their apparent cause ; — increasing as that cause increases, diminishing when it diminishes, and going off when it is removed. These appearances have often been called inflammatory fever, or general inflammation : but are excluded from the class of fevers by their dependence upon their cause. Should erysipelatous inflammation arise on the skin: it often happens (after the inflammation has taken place,) that the pulse becomes frequent to 120 strokes in a minute or upwards; the strength of the patient is universally depressed ; there is headache, foulness of the tongue, loss of appetite, and nausea ; the sense of heat is very much increased ; as is the degree of heat to 100°, or 103°, or 104° ; there is dryness of the skin ; and obstruction of the pulse. These symptoms are all very much increased in the evening; and there is some degree of relaxation of them in the morning. This disease is extremely similar to fever ; yet it is to be excluded from that disease by its total dependence upon its cause, (the erysipelatous inflammation of the skin ;) for if that be removed by application of alcohol diluted with water, to the inflamed part only ; all these affections of the system generally go off. Should an erysipelatous inflammation arise in the throat, producing whitish sloughs in it; similar symptoms appear in the system ; — but if the inflammation be carried off by the exhibition of large quantities of the bark of cinchona, and the whitish sloughs be made to fall off, (so that all diseases shall be removed from the mucous membrane of the throat:) the affection of the system generally ceases. This affection of the system, therefore, cannot be ranked among fevers, according to the rule, which excludes from fevers diseases depending on the constant application of their cause. Should phlegmonous inflammation take place in any part of the duodenum, jejunum, or illium ; and after the inflammation has taken place (as shown by the pain,) if the strength be greatly depressed ; if the pulse should become hard, and frequent to 120 strokes in a minute or upwa.uls, and much contracted ; if there should be a thick brown fur upon the tongue, great sense of heat, headache, paleness, and contraction of the skin, with nausea and vomiting: if there should even be delirium : — Yet let the inflammation of the intestines be cured by copious bleeding from the arm and skin of the abdomen, and by the application of sedative and relaxing fomentations to the abdomen ; — and these symptoms in the system generally will subside and go off. They cannot therefore, form a disease which ought to be included in the class of fevers In treating of the ephemera it has been observed, that in the middle of the hot fit, a topical inflammation sometimes arises ; and carries off the fever. —Thus, for example, in an hour or two after all the appearances of a paroxysm of fever have taken place ; a pain arises in the side, a little below the clavicle. The pulse either was before 176 HISTORY AND METHOD OF TREATMENT OF the pain in the side took place, or it becomes afterwards, very hard, full, and strong; (accompanied with difficulty of breathing, increased pain of the side on inspiration, and all the other appearances, which would have arisen had a phlegmonous inflammation taken place in the pleura:) without any preceding cold or hot fit. In the latter case (where the derangement in the circulation followed the pain;) if large evacuations be made by bleeding from the arm and skin of the breast; the inflammation of the pleura is carried off; when every morbid affection of the system ceases in consequence. —But it sometimes happens that the inflammation being carried off from the pleura, (that is the pain having left the side, and the difficulty of breathing having ceased ;).the frequency of pulse, heat, and all the other symptoms of fever, remain, notwithstanding ; and go through the course of a regular continued fever. This case the author finds a difficulty in discriminating ; — but he conceives that an ephemera had taken place in the first instance ; that the inflammation of the pleura had cured this ephemera; that the inflammation being carried off (by the evacuation or other remedies,) no fever remained in those cases, where the symptoms entirely ceased on the cessation of inflammation : but that when the febrile symptoms continued after the pleurisy was cured, a regular continued fever had been diminished by the inflammation of the pleura, but was not entirely carried off by it ; and that therefore, when the pleurisy was cured, the fever went on as it would have done, if no such inflammation had happened, It may be said, that it were more simple, to consider all these affections of the system, as fever. But it has been always thought, that in scientific subjects, nice distinctions should be made where they actually exist; in order to discriminate the natural properties of bodies. — In botany, for example, a superficial observer would rank together all beautiful and sweet scented plants under the name of flowers : all plants whose seed gives nourishment to mankind, under Ihe name of grain ; all plants whose leaves, stems, or roots, are eatable, under the name of pot-herbs ; and reckon all others as weeds, while the botanist would carefully distinguish between the figures and qualities of plants similar to each other in any one respect* — Some consider all noises the same ; a musician carefully distinguishes a semitone. Were diseases studied merely to investigate their properties, it would still be worth while to enter into accurate and minute distinctions ; but they become of much greater moment, when the object is to alleviate and remove the disease. One object in view in laying down the above distinctions, is to discriminate between those diseases where it is only necessary to remove their cause, to cure the patient; and those, where other circumstances of the disease are of moment. In what is called hectic fever, (which often continues after its cause is removed,) as it does not produce any means for its own cure ; some must be employed to carry off the disease, without attention to iss own ordinary progress. A REGULAR CONTINUED FEVER. 177 If a disease depends solely upon its cause, it is sufficient to remove that cause ; and in general, attention to the disease itself is unnecessary. — Should a phlegmonous inflammation produce the appearances similar to those of a paroxysm of fever ; medicines are to be employed that will carry off the topical inflammation, without attending to the general affection of the system ; (excepting that this general affection must sometimes be considered as an accident that may in itself be mischievous). Where phlegmonous inflammation cannot be cured, (if it should not prove fatal, from affecting some organ necessary for life,) the inflammation must be allowed to suppurate: and the suppuration must even be forwarded very frequently by means increasing the general affection of the system ; instead of employing medicines to diminish or remove it. — Whereas in fever, on the other hand, the whole attention is directed to the application of remedies that will either remove the disease ; or make it go through its natural course without danger to the patient; or with a less degree than it otherwise would possess: but totally neglecting the cause which first produced it. General inflammation excited by a disease affecting some part necessary for life, might however be fatal ; independent of the topical inflammation which occasioned it. In this case it would be necessary to employ means to take off the general inflammation : but they are commonly the same as those which take off the topical inflammation ; — and totally different from those that should be employed to take off fever. When rheumatism excites general inflammation, the general inflammation frequently appears to be the principal disease ; and until lately, practitioners have thought that it ought to be carried off by large evacuations, especially by bleeding. — Dr. Hugh Smith (an extraordinary practitioner) conceived that the evening attacks of violent pain, frequently happening in acute rheumatism ; were the returns of the paroxysms of an intermittent. He therefore exhibited the bark of the cinchona, in the quantity of an ounce and an half, during the interval of the pain ; although the pulse continued hard, full, strong and frequent: and thus succeeded in preventing the return of the pain. — This practice has since been adopted with success by many practitioners. — Some have even employed the bark of the cinchona, where there was no remission of pain ; but in the cases the author has seen, without effect.—While it was the practice to remove the general inflammation by bleeding ; metastasis frequently took place to the interior parts of the body, and destroyed the patient. This accident in the author's practice during the last fifteen years, has rarely happened. — In this period, he has entirely left off bleeding in acute rheumatism ; and has not lost above two or three patients ; although he has treated several hundreds in this disease. This may be considered as a digression ; but it is intended to shew, that general inflammation, in this case, has nothing in its treatment similar to fever. 178 HISTORY AND METHOD OF TREATMENT OF If in the gout, or in other diseases where general inflammation takes place, (unless it were so violent as immediately to threaten the destruction of the patient,) large evacuations by bleeding should not be made ; nor any means be employed to carry it off, which would increase the original disease : yet still in managing the gout or other such diseases in the best manner, remedies must sometimes be employed which evidently tend to increase the general inflammation. If in consequence of an erysipelatous inflammation of the skin, the pulse should become frequent to 120 strokes in a minute or upwards ; and there should be universal depression of strength, and other symptoms of general affection of the system : they ought not to be attended to ; — but solely the erysipelatous inflammation of the skin ; as on the ;ure of that, the affection of the system would cease. In erysipelatous inflammation of the throat, producing whitish .sloughs in it; the practitioner should endeavor to carry off' the erysipelatous inflammation and remove the sloughs without attending to the frequency of pulse, heat, or any part of the affection of the system generally. If from inflammation of the duodenum, jejunum, or iliurn, there should arise great depression of strength, frequency and smallness of the pulse, with other symptoms of general affection of the system, an experienced practitioner w T ould not employ cordials or Peruvian bark, to support or increase the strength; nor would he attend at all to the general affection of the system ; but would endeavor to cure the inflammation in the intestine, without paying the least attention to the general affection of the system. If an attack should take place similar to the attack of an ephemera, and violent pain should arise in the side, a little under the clavicle, increasing upon inspiration; the pulse becoming hard, full and strong, and other symptoms of general inflammation taking place ; — if by making large evacuations by bleeding from the arm and skin of the breast, by blisters and other remedies, the pain should be entirely removed from the side ; and yet the general affection of the system should not go off; that general affection is then undoubtedly to be attended to. — If during the existence of the pleurisy, a practitioner is enabled to determine that although the pleurisy shquld be carried off, the action of the system would still remain ; in this case, the general affection is to be attended to, both during the pleurisy and after it is carried off.— These distinctions, however important, have hardly ever been made matter of inquiry. A regular continued fever takes place exactly in the manner of an ephemera, or a regular tertian ; nor would it be possible from the appearances of the disease, to determine whether it would be an ephemera simplex, a regular tertian, or a regular continued fever.— The circumstance of a patient's living in a country, where intermittents were endemic, from moisture or putrefaction arising in marshy grounds, in warm climates ; or of intermittents being (from any cause) epidemic in dry countries : might make a practitioner 179 A REGULAR CONTINUED FEVER. suspect that the disease would be an intermittent or remitting fever. — But without such circumstances, no appearance in the patient himself would (within two or three hours of the attack), at all enable him to determine what kind of fever it would prove. Continued fevers sometimes then begin at once, exactly with the same symptoms as an ephemera. — At times, however, there arises immediately upon application of the cause of disease, (particularly if it should be exposure to cold, putrefaction, or infection,) some derangement of the system; but no complete paroxysm of fever. These derangements consist of languor; the patient's feeling himself not perfectly well ; and being unable to exert the powers of his body or his mind (whether for business or amusement,) so perfectly as when in absolute health. Sometimes his sleep is disturbed ; he does not go to sleep readily ; his sleep through the night is broken ; and he is not refreshed so much as usual. — It happens sometimes that these symptoms go off in a few days: sometimes they all at once increase very considerably ; and form a paroxysm, which is the beginning of the fever. The state of sleep has been variously represented by writers upon it, whether physicians or metaphysicians. The effects of sleep in fever, and particularly in continued fever, are so great; that it may be necessary for the author to state his ideas on the subject. Whence or how the powers of exertion and the various operations, either of the body or mind, are produced ; it is impossible to say : or at least everything that has hitherto been said on the subject, is visionary. It has already been observed, that the power exerted by the muscles is not derived from any mechanical or chemical construction or ration ; but that it is an original power arising from the life of the animal. This power may be infinite, so that all the muscles may be able to exert themselves constantly with an infinite force ; or it may be finite, so that the muscles of the body may act altogether with a certain force, and constantly continue that force of action ; or a certain number of muscles may occasionally exert all the force of the body, (the others being at the same time necessarily at rest). We find by experience that this force is not infinite ; and that only a certain quantity of it can be exerted in a given time. It may be exerted either in all the muscles at once, or in a certain number of them ; the remainder being at rest: (but no man can lift above a certain weight; therefore the force is not infinite). A man cannot run with velocity, and strike at the same time an equal number of blows of equal force with his arms, with a man keeping the muscles of his lower extremities at rest. A man might be able, either to exert his utmost muscular force constantly; or it might be necessary for him to come to a rest, after having continued to exert his utmost muscular force a certain time ; and to remain sometime at rest, (before he could again exert it.) The latter is known to be the case; (that is, when a man has ex- 180 HISTORY AND METHOD OF TREATMENT OF hausted himself by labor, it is necessary that he should be recruited by rest.) The rest from muscular exertion is not, however, absolute rest; for there are some of the muscular exertions of the body which must always be carried on, in order that a man should live. It is necessary, for example, that the muscles of the organs of respiration should continue to expel vapors from the lungs as they become unfit for the purposes of life ; and to draw in fresh vapors, (otherwise the life would be lost); that the heart and arteries also should be in constant action ; that such muscular powers as form the tone of all the moving parts of the body, should be constantly exerted, &c. —The body in short, may be compared to a machine, moved by a stream of water always sufficient to keep some parts of the machine in action ; but not the whole. If a dam be formed, leaving an outlet for part of the water sufficient to keep certain necessary parts of the machine in constant action ; the remainder may be retained for a time; and on opening a sluice, the water treasured up will set the whole machine in motion ; and continue its action until the dam is emptied. After a man has been at rest for a certain time, it is not necessary that he should exert the power he has reacquired: he may, if he pleases continue (in a certain degree) at rest. In fever, not only the body is affected ; but often the mind also.— It may, therefore, be necessary to make some investigation of the powers of the mind. — It is, however, by no means intended to treat of the pow r ers of the mind or its properties ; as they relate to diseases . of the mind ; but only in so far as they are connected with diseases of the body, particularly with fever. •«* The powers of the mind are, first, perception ; — that is, the power of receiving impressions from the organs of sensation. The organs of sensation are of a particular construction, by which some alteration is produced in them by external objects. — The eye, for example, (the organ whose operation is in this respect most evident,) has a membrane in it called the retina : upon which the image of an external object is painted, by the lenses of the eye : (so far the body contributes to the idea formed in the mind by an external object; and so far the perception is in the body). Anything in the body which prevents an object being painted on the retina, or painted with sufficient perception ; may be considered as a disease in the body preventing the perception of an external object. — Supposing the object is perfectly painted upon the retina ; yet frequently no impression is made upon the mind, and no idea whatever is excited. This may happen without any disease of the mind, merely from its attention being withdrawn to something else : since the tree in St. Paul's church-yard has been painted perfectly on the retina of millions of people, without exciting any idea in the mind ; (so much so as to be a common topic of jest-books. — This perception then must be considered as an operation of the mind, entirely separate from the painting of the object on the retina. A REGULAR CONTINUED FEVER. 181 The second operation of the mind is memory ; or the power of recalling ideas which have been formed by impressions made on some of the organs of sense: and it is certainly an operation of the mind alone. Imagination, or the power of arranging ideas in various ways ; has likewise been considered as an operation purely of the mind. Lastly comes judgment, or the power of determining whether ideas are properly arranged, and according to their original perception. The judgment, for example, would revolt, on having presented to it (by the imagination) a cow with a horse's head ; or St. Paul's church placed in Pekin. All these exertions of the mind are exertions of a certain pow T er ; but that power seems at first sight to be totally different from the muscular power of the body; — yet there is certainly this connection between them ; that if the body has been fatigued with exercise, the mind cannot exert its powers of judgment; nor carry on any process by which it may determine the congruity of ideas.—A student in mathematics, having once acquired the knowledge subservient to the demonstration of a problem ; would not be able, after having contended in an athletic game, to trace the steps by which that problem was demonstrated. — On the other hand, a mathematician, after having gone through a new and laborious demonstration, would be unable to exert the powers of his body in a fox-chase. Whether, therefore, it be the same power employed in the exertions of the muscles and the mind, or different powers ; yet these powers are so connected together, that the exertion of the one will prevent the possibility of exerting the other in so great a degree, as might have been, had there been no immediate previous exertion of either. The powers of the mind, (like the muscular power of the body,) are not infinite. —A man cannot perceive, remember, imagine, and judge of an infinite quantity of subjects, at the same instant: he must first perceive, then remember, then imagine, and then judge. — Neither can the imagination arrange an infinite number of different ideas, at the same instant; nor the judgment determine whether they are properly arranged ; nor the memory bring up at once all the ideas it has in store ; nor perception produce an infinite number of ideas at once. — Hence it is evident, that the powers of the mind are no more infinite than the powers of the body. The mind having exerted any one of its faculties for a certain length of time, can no more continue the exertion of that faculty; than a muscle, not necessary for the immediate purposes of life, can continue its motion. This renders it necessary, after the exertion of any of the faculties of the mind, that the faculty be allowed to rest some time before it is again exerted. If the powers of the mind be exhausted by the exertion of any one faculty, no other faculty of the mind can be exerted till after the rest has occurred. 16 182 HISTORY AND METHOD OF TREATMENT OF In all these respects the force of the muscles, and the powers of the exertion of the mind, are perfectly similar to one another. — There is one thing indeed which has been disputed by metaphysicians; namely, whether there be any exertion of the mind absolutely necessary for its existence, (as the respiration and the action of the heart are necessary for the existence of the body). — It is not our present purpose to inquire into this : all that is to be said is, that we do not know, either a priori or from experience, (that is, from reflection on the faculties of our own minds,) that it is necessary that the mind should perceive, remember, arrange, or judge of any set of ideas, in order to exist. Upon the whole, therefore, in order to exert the powers of the body and the mind in their full force, it is necessary that there should be intervals of rest. The author conceives that sleep is this rest; sometimes more, sometimes less perfect. In sleep we shall, in the first place, consider the exertions of the mind. The judgment (which is the most exhausting operation of the mind), is totally at rest. — Supposing even that the patient should dream, (that is to say, that the memory should present certain ideas and the imagination arrange them,) the judgment never exerts its powers at all. The mind never revolts at a cow with a horse's head, nor at the town of Pekin surrounding St. Paul's ; nor whether St. Paul's is placed upon its base, or turned topsy-turvy upon its cross and reeling. Imagination is left to go on freely in a dream, without correction from the judgment. This is therefore certainly a great degree of rest as to the greatest exertion of the mind. — Although it frequently happens in sleep, that the memory and imagination are employed (or in other words, that a man dreams) : yet it seems clear that they are at rest in a certain degree. If a man attends to what happens to him in a dream, he feels often that he has lost himself entirely ; that is, as if the memory produced no connected series of ideas, but flew from one object, and apparently from one period of time, to another: he is totally lost in short, and wonders that he has found himself again. — That constant connexion of ideas, therefore, which take place when a man is awake, does not exist in sleep. The memory, then, and the imagination do not exert themselves so much in'sleep, and so constantly, as when a man is awake. Without entering into the controversy, whether the memory and imagination are ever totally at rest; — the powers of perception in the mind are certainly, in many cases of sleep, totally at rest; without any defect in the organs or the exertions of the body. — It is very true (as has been already observed) that the exertions of the body are often such, as put parts of it into situations, in which the mind can take perceptions from it. The muscles of the eye for perception must exert themselves so, as to give the lenses the proper convexity to paint objects which are at different distances, correctly on the retina. Therefore, should a man sleep in daylight with his A REGULAR CONTINUED FEVER. 183 eyes open, (which has happened in a great number of cases,) the mind could not receive perceptions which are distinct, of objects which are at various distances. The lenses of the eye would certainly paint objects at a given distance very perfectly ; but the mind would receive no idea from such painting. — Therefore the mind, while a man is asleep, is at rest, so far as regards the power of perception. Here then two exertions of the mind, in tolerably sound sleep, are entirely at rest ; the power of receiving ideas from impressions from the body ; and the power of judging whether the imagination has properly arranged the ideas that may be represented to it. There is certainly likewise a diminution of the powers of the memory, in presenting ideas to the imagination: although perhaps not an equal diminution of the powers of the imagination in arranging such ideas; (which without the correction of the judgment, would arrange them as the wind blows, or as it listeth.) There are perhaps also (as has been contended by some metaphysicians) cases in which the memory presents no ideas to the imagination : which of course can make no arrangement of them : so that the mind is perfectly at rest. In a certain degree of sleep, the mind perhaps neither receives any impression from any external object, nor has any ideas brought up into it : of course no ideas can be arranged : therefore arrangement cannot be judged of; (or in common expression, a man does not dream at all, according to some metaphysicians.) This happens (we may say almost undoubtedly) in fainting fits, fits of epilepsy, hysteric fits, &c: where it was never known that any person, after coming out of them, ever remembered any dream at all. If in sleep, therefore, the mind is not at perfect rest: it is certainly at rest in a very great degree. It has been already said, that the body cannot exert itself always : but must occasionally come to a state of rest. — The next inquiry, therefore, is, how far the body is at rest during sleep, more than it is at any time while a man is awake. The first thing in which the different states are to be compared, is the power of giving perceptions to the mind. The eye is that organ, in which the power of the body in giving perceptions to the mind has been most completely discovered : although perhaps not quite completely. It admits rays of light: it collects them, and applies them to the retina, through transparent lenses : so as to paint there an image corresponding to the body, from which those rays of light were omitted. But in sleep the eye-lids are generally shut; so as to prevent the rays from falling upon the retina at all; or at least the eye-lids are so opaque, as not to allow the rays to fall upon the retina, so as to paint any image at all. Therefore the power of perception in the body is, in this case, suspended and at rest. — The author might say from analogy, that the same thing probably happens in all the other organs of the senses, and that they also are at rest; — but he does not think that any truth can be deduced from analogy. It must depend only on future 184 HISTORY AND METHOD OF TREATMENT OF experience to determine, whether the sensibility (or power of impressing an idea on the mind) by any of the other organs of sensation, is equally suspended in sleep ; as the power of the eye. In a tolerable sleep, therefore, the action of the body, which makes the impression on the mind, if not totally at rest: is much more at rest, than when the body is awake. When a man goes to sleep (supposing he is not prevented by any external accident,) he puts himself in a recumbent posture ; which is not a posture he commonly assumes when aw r ake. In this position, in the first place, he is supported by a great many more points than when standing, sitting, or walking, therefore more points being pressed upon, it requires less exertion to avoid the effects of such pressure. (It is true, however, that the exertion might be equal; although it does not seem to the feeling to be so.) In the ncxtplace, if a man is in an erect posture, it requires the exertion of a great number of muscles to keep up the equilibrium necessary for that posture ; while no such exertion is required in a recumbent posture ; every part of the body throwing itself in that situation, in which its gravity would place it. — So far, therefore, the body is more at rest when a man is asleep than when he is awake. Moreover it is well known, that what is habitual is performed with great ease : whereas going out of the habit requires a very considerable degree of exertion. Now the foetus in the womb is laid with its body bent, its knees brought towards the chin, and its arms folded. A man in health rather lies, therefore, in this posture, which he has acquired by habit; than exert himself against that habit. So far again he is at rest in sleep.—It is true that lying in this posture requires some muscular exertion ; and so we see that those who have been reduced to a great deal of weakness, lie, even when awake, upon their back ; where there is hardly any muscular exertion at all. This, being contrary to their habit, produces a certain degree of uneasiness ; wdiich occasions an attempt to shift their posture : which being made by the muscles of the back, they are constantly throwing themselves towards the bottom of the bed.—What has been just said shews, that in sleep there is a great degree of rest from muscular action. Again, the heat of the body is produced by the action of the living power.—It is very true that almost eveiy body, (excepting Dr. Cullen,) has attributed the heat of the body to some means of producing heat connected with a living body: (It would be a digression greatly too long to enter into at present, to state the arguments on this question here.) If the opinion be wrong, that it does depend upon the living power; it will affect the present argument but very little ; it being at present only intended to state a fact; to wit, that (although the heat of the body to the thermometer be the same in a man sleeping or awake ;) yet when a man is asleep, he cannot communicate so much to the surrounding medium, as when he is awake. (This is evident by the experience of every man, who falls asleep with the ordinary clothing which he wears when awake; for on waking A REGULAR CONTINUED FEVER. 185 again, he feels extremely cold; that is, he feels the substances that surround him, very cold.) Although the heart continues its action when a man is asleep, as well as when he is awake ; yet during sleep it happens very often that the pulse, (the measure of the action of the heart,) is neither so frequent, so full, nor so strong as when a man is awake. — Moreover, the breathing does not go on so quickly; nor the peristaltic motion of the intestines in the same degree ; nor any of the other actions necessary for life. — Thus, although there is not a total rest in those actions of the body, which must constantly take place in order to its existence ; yet the body does not exert itself in the same degree. In sleep, therefore, the judgment is often totally at rest; perhaps the memory and imagination are sometimes also totally at rest; the power of perception in the mind is certainly sometimes totally at rest; the state of the body, which gives the mind a means of perception, is also in some instances (perhaps in all) totally at rest: the muscular exertions, not necessary in life, are totally at rest, (excepting where habit has made it more easy for certain exertions to take place) ; and lastly, the muscular powers of the body, which are necessary for life, act with less vigor.— Sleep, therefore, may be considered as a state of rest, during which the powers of the system are recruited ; or, (to go on with the simile first begun with,) the dam is shut up ; so that the waters accumulate in it, and are ready to-be applied, to bring the whole of the machine into action. The only apparent objection to this view of sleep is, that people in madness, in many instances, never sleep : —But then the author would contend that they are never awake. Their judgment, (that which is the greatest exertion of the power of the system,) is never at all exerted in maniacs who never sleep. The imagination may arrange the ideas that the memory presents to it, without the judgment ever attempting to disturb it. The power of perception in their mind is undoubtedly perfectly confused : (a crown of straw, or even a single straw, painted on the retina, excites the idea of a crown of gold adorned with jewels ; a single straw the idea of a circle, and not of a line.) The power of impressions on the body is much less : it requires several times the dose of a purgative, or of any other medicine, to produce an equivalent effect. — The common stream of power flowing into the body, (if we may so speak,) may be sufficient to keep up such a degree of action as has just been described, constantly ; but not the actions which take place in a person whose faculties are sound. The next thing to be inqured into is the effects of sleep. Having shown that the actions of the mind are very considerably at rest in sleep, if not sometimes totally ; and that the exertions of the powers of the body are also in a great degree of inaction : if a quantity of living power be constantly generating in the system, it follows, that in sleep this power will be gradually accumulated ; as the water would be in a dam, if a constant small stream were flowing 16* 186 HISTORY AND METHOD OF TREATMENT OF into it, and only a part of that stream flowing out. The dam being filled, the water flowing over would set some of the parts of the machine at work ; which might raise the sluices of the dam, and put the whole of the machine in motion. — Thus in the system, when a quantity of power is accumulated, part of the exertions may take place ; as we see is the case in natural sleep. A man in health, and not much fatigued, first falls into a reverie; and then into sleep: which sleep at the beginning is accompanied with dreams; afterwards becomes more profound, until sometimes it becomes perfect, perhaps without any dream ; and the person is with difficulty awaked and excited into action. — After a time of such profound sleep, he begins again to dream ; all his powers are brought into action with great facility, if any stimulus be applied: otherwise they come into action and the person awakes, without any stimulus being applied ; as it* were from the system being full of power. If the subject be viewed in this light, it will appear, that sleep is simply that rest, which is necessary to recruit the powers of the body and the rnind, when they are exhausted ; — and that in the common and healthy state of the body, when there is the ordinary exertion, sleep is necessary after a certain interval, to restore the powers of the system ; so as to enable them to exert themselves. Want of sleep, therefore, will prevent the necessary accumulation of the powers of the body ; and consequently induce weakness, (or the want of sufficient power in the system to exert itself to any great degree). A continual want of sleep, (if the exertions take place, as when a man is awake,) will at last so exhaust the system, as to deprive a man of all power of action whatever ; so that he shall no longer exist. Sometimes want of sleep for a certain length of time produces mania ; (a state of the system which is not our business here to inquire into. It may be sufficient to observe, that we cannot pretend to determine a priori anything with regard to what would happen to animals : whence mania is a state of the system that no man could have imagined, if it had never actually taken place.) Supposing the system is weakened by the want of sleep, and that mania does not take place ; we are next to notice what happens, when the weakness is not so great as to destroy the patient. — If any machine be made on mechanical principles so as at once to perform many actions independent of one another ; and a force be applied to put that machine in motion, so that it shall perform all its functions ; if that force be diminished, some of its functions may cease entirely, and the others go on regularly. — Suppose that we have a time-piece, in which the motion of the parts keeping time should be produced or continued by a power, which is more than sufficient to produce the motions keeping time. The superfluous power may be employed to occasion another action ; such as the pumping of water, to which it is actually applied. The machine in such case might be so constructed, that the primary power should be sufficient to keep up the A REGULAR CONTINUED FEVER. 187 motion of the time-piece and something more. But the power also might be diminished so as not to be more than sufficient. In that case it would cease to act upon the pump ; so that the motion of the time-keeper might continue, without the motion of the pump. — Or otherwise, a mechanical machine might be so contrived, as that the power originally generating motion should act equally in producing all its motions ; in that case, if the original power was diminished, all its motions would be diminished equally. — Neither of these is the case in the human body, when the power which actuates it is dimished for want of sleep or by any other means. Some of its actions do not cease while others go on, nor are they all equally diminished ; but the whole of its actions become irregular. While some of them diminish, others increase; and this indiscriminately ; that is, it is uncertain which will increase and which diminish. Want of sleep, therefore, produces irregularity in the whole actions of the body, and great irregularity in fever. So does also any other cause diminishing the powers of the body ; — but not nearly so much as want of sleep. — For example, if a man in health should be prevented from sleeping during a whole night; little more would happen, than that all the powers of the body and mind would be somewhat diminished. He would not be able 1o make such great exertions in walking and riding; nor would he exert the muscular actions of the interior parts of the body in so great a degree. The powers of his perception, as far as depended on the body, would not be so complete. (For example, he would not be able to adapt his eye so exactly to the distance of an object, as that it should be painted perfectly on the retina ; the mind would take less readily or perfectly the impression from the object painted on the retina ; the memory would be less ready in bringing up ideas to the imagination ; the imagination would be less ready to arrange them ; and the judgment would be much less exerted in determining the justness of that arrangement.) — So far the system would be affected pretty nearly in the same manner as a mechanical machine which had lost part of its power. — Let the same man be prevented from sleeping a second night, then irregularity would begin to take place through the system. A strong contraction would begin to take place in some of the muscular fibres of the intestines ; the appetite would begin to be lost; the muscles in the exterior parts of the body would some of them act more strongly, others more weakly ; the heart would sometimes contract more frequently, sometimes (although seldom) more slowly ; the powers of perception, as far as depended on the body, w r ould some of them be stronger for a short time, and soon after in the same organ weaker. The same thing would happen in the power of perception, as far as it depended on the mind : memory would sometimes bring up ideas very fast, and sometimes very slowly ; the imagination would sometimes arrange ideas very readily, but not very often in the order which the judgment would approve of; and the judgment in many cases would not be exerted at all, but leave the 188 HISTORY AND METHOD OF TREATMENT OF fancy to arrange them just as it pleased. —- And if a man in health continued to be prevented from sleeping ; these derangements would go on ; and mania would often be produced. On the other hand, if such derangements as have been described should take place from any other cause in a man in health, sleep would be prevented. In fever (as well as in many other diseases,) these disorders in the system prevent sleep in a much greater degree; — and want of sleep produces them again in a much greater degree; only instead of mania, delirium takes place. While the disorders, in the system which take place in fevers, prevent sleep ; the want of sleep in fevers, weakens the whole system, produces the disorders which have been enumerated, and occasions delirium. To return from this digression. If a continued fever is produced sometimes when the cause of the disease is applied, there is not the least appearance of fever, or any apparent alteration from health, for many days ; until all at once a complete paroxysm of fever comes on. — Sometimes, when the cause of fever is first applied; some slight febrile appearances take place, which continue till a perfect attack of fever arises : which comes on at once, and its first paroxysm is easily ascertained ; although now and then they gradually diminish and go off, without any permanent fever arising. — When such slighter febrile symptoms take place, they do not increase gradually so as to constitute a fever ; but the patient goes on with his ordinary occupations ; not well indeed, but not so as to be confined; until at once a paroxysm (such as has been described in the dissertation on the ephemera simplex) takes place : so that the patient can almost always mark the very hour in which the attack comes on. — Sometimes a complete paroxysm of fever is produced immediately on application of the cause. Symptoms of Fever. — If none of the symptoms of fever happen between the time of the application of the cause and that of the first paroxysm, a strong attack takes place at once : and begins often with a sense of coldness, horror, and rigor ; the cold is followed by a sensation of heat, which is succeeded again by a sense of coldness; and so alternately, for the first twenty-four hours. — Sometimes there is nb sense of coldness,.but the patient feels from the beginning very hot. — Whether there be a sense of coldness or a sense of heat, the thermometer under the tongue rises to about one hundred, or from that to one hundred and five degrees of Fahrenheit's scale; excepting at the very first beginning of the attack. Whether there be a sense of cold or of heat, there is always great depression of strength, both in the powers of the body and the mind ; which is generally according to the degree of fever ; and is sometimes so great as to render the patient unable to support himself in an erect posture ; but sometimes not so considerable as to prevent him from doing his ordinary business, if he makes extraordinary exertions. It has often happened, that physicians have been too apt to go on without attending their patients for a day or two after a paroxysm has actually taken place •, A REGULAR CONTINUED FEVER. 189 who unfortunately have been by that means so exhausted, as not to be able to go through the remainining part of the disease: but have been cut off. The depression of strength is, in all degrees, between these extremes. The pulse during the first twenty-four hours, beats seldom less than ninety times in a minute, and very seldom more than one hundred and five in a minute ; (whereas in an ephemera, or in the first paroxysm of an intermittent, it very often rises to one hundred and twenty or thirty pulsations.) It is sometimes full and strong ; always obstructed ; sometimes small and particularly soft; sometimes of the natural fulness, but with a particular degree of softness ; (when this is the case, it indicates a fever which will be very violent especially in respect to the depression of strength.) The author wishes in this place to explain his terms with regard to Strength, hardness, softness, obstruction, or freedom of the pulse. Great numbers of practitioners have called obstruction, hardness; freedom, softness of the pulse. The feelings of the organs of the senses are often different in different men. The ear, for example, of one person, can distinguish accurately the different notes on the musical scale ; the ear of another can distinguish nothing but that the sound is louder or less loud. In like manner, the fingers of some are only capable of distinguishing whether the pulse is more or less frequent; and that by comparing it with some other measure of time. — It is necessary, therefore, that we should have some other criterion of the differences of pulsation, than the feel of the practitioner; in order*to be able to teach young practitioners how to discover if they have any power of feeling different sensations, and distinguising them. When the pulse is hard, (whether it be strong or not,) the blood is long in coagulating : the consequence of which is, that if the blood flow from a vein in a large stream through the air, into a vessel nearly the section of a sphere ; the red particles will fall down towards the bottom of the blood, and leave the upper surface of the coagulum colorless after the blood has coagulated. Whereas if the pulse be strong, without any hardness; the blood will coagulate much sooner under the same circumstances; so as not to give time for the red particles to fall down from the upper surface of the coagulum, which will therefore remain red.—In like manner, if the pulse be obstructed, and not hard; the coagulum will be red on the upper surface. —• This then is a criterion by which strength and obstruction may be distinguished from hardness ; (viz. when the pulse is hard, the upper surface of the coagulum is not red). It is necessary that the practitioner should make himself master of the feel of the pulsation under these different circumstances. This may be done by feeling the pulse of a patient affected with an intermittent; in which there is often strength, fulness, and obstruction ; but no hardness : and in this case a quantity of blood may be taken away without any detriment to the patient. And the same again happens in a pleurisy; where there is strength and hardness, 190 HISTORY AND METHOD OF TREATMENT OF and where blood is taken away with great propriety. — By these means any man with the faculty of feeling, (sufficient to distinguish the different sensations arising from pulsations,) may make himself master of the difference between hardness and strength, or obstruction ; which (as will be shown afterwards) is very essential in the management of fever; obstruction being an essential symptom of fever. Hardness is an irregularity; and consequently is to be referred to that treatise, in which irregular fevers are to be considered.— In the same manner, when upon the application of the cause of fever, some slight symptoms of fever take place and continue some time ; (whatever were the previous symptoms, on the attack of the fever,) cold'ness may suddenly take place, followed by heat: or otherwise, a much greater degree of sense of heat may arise suddenly, with a much greater depression of strength, and a similar pulsation of the arteries, &c. —Along with these symptoms there is generally pain in the forehead ; and all the other appearances which arise in ephemera or in the first paroxysm of an intermittent, (and which have been enumerated in the dissertations on those subjects). They proceed in the same manner ; —excepting that they are much more irregular in the first paroxysm of a continued fever, than they are in an ephemera, or an intermittent (where the first paroxysm of an intermittent is terminated by a crisis). The sense of coldness and heat return alternately ; without any regular duration of either: (this especially happens when the fever is severe.) The depression of strength is likewise greater or less, at different times.—Thus there is an irregularity during the whole of the first paroxysm. It has been a question much agitated by authors, whether fevers lasting for many days, consist of one paroxysm ; or of many paroxysms following each other, (as happens in intermittents). It has been observed, in the dissertation on a regular tertian, that for the first days there was no crisis in many cases ; but the disease, as it went on, showed more and more critical symptoms ; until a very evident, or at last a complete crisis took place ; and the disease terminated in an intermittent.— In continued fevers, the appearances are such as take place at the beginning of intermittents, where there is at first no intermission ; the paroxysms does not terminate in a crisis ; but there is some relaxation, after which a fresh paroxysm takes place. — This may be considered as an argument, that a continued fever is only a variety of an intermittent. The Author of the world has laid the distinctions between different things so as to run into one another by shades. (How much soever, for example, a man may differ from wheat; yet nevertheless it is difficult to determine whether a spunge be an animal or vegetable substance; things, therefore, being shaded into each other, by no means prove them to be the same.) It requires, therefore, that we should be extremely circumspect in determining, that a continued fever is esssentially the same disease with an intermittent and an ephemera. —There is simi- 191 A REGULAR CONTINUED FEVER. larity of all the appearances in the three diseases; (excepting that one crisis often happens in a continued fever, and entirely carries off the disease ; which takes place likewise in the ephemera; but although sometimes no crisis takes place in a continued fever, this happens neither in an intermittent nor in an ephemera.) — This similarity has determined practitioners of the greatest eminence through the whole history of medicine to consider them as the same disease. —Many nevertheless have thought they varied, in this circumstance ; namely, that in a continued fever the subsequent paroxysm takes place in the hot fit of the prior paroxysm : in an ephemera, no subsequent paroxysm takes place : and that in an intermittent, the subsequent paroxysms happen in or after the crisis, of the former. A question arises, how long the first paroxysm of a continued fever lasts, before the second paroxysm begins. The author has seen it happen, in a few cases of an ephemera, that the disease has continued thirty-six hours, and in one case above forty hours from the attack to the termination of the crisis ; but this is very rare. - The first attack of a fever begins more frequently by much, (as has been observed in a former dissertation,) between six o'clock in the morning and eight in the evening. In a continued fever, if the attack should be between six o'clock in the morning and eight in the evening of one day; a fresh exacerbation or sudden increase of the disease takes place, between five and six in the evening of the succeeding day. It has been said above, that sometimes a paroxysm of fever takes place as soon as the cause is applied ; and likewise that fever takes place at least ten times between six in the morning and eight in the evening, for once, that this happens in the remaining part of the twenty-four hours. — This might be accounted for, from a man being exposed to the causes of fever much oftener in the day time, than during the night; when the attack follows the cause immediately. — When some slight symptoms only of the disease take place at the time of the application of the causes, and when no appearances occur for many days after the application of the first cause ; if in either of these cases the first paroxysm begins between six in the morning and eight in the evening, the author has nothing to offer to account for this phenomenon. That it is a fact he is Avell assured, from the observation he has made for many years in the cases of a great many patients. If it be true that a continued fever is only a set of paroxysms of fever running into one another; it becomes a question how long these paroxysms last; and what is the cause of their return. — In the first place, so far as the author's observation has gone, the first paroxysm of continued fever lasts, if it begins at six in the morning or at any other hour before eight in the evening, until five and six in the evening of the following civil day : (that is, if it should happen at anytime between six o'clock in the morning and eight o'clock in the 192 HISTORY AND METHOD OF TREATMENT OF evening, the second exacerbation will begin at six o'clock nearly of the subsequent civil day). But if the first paroxysm should take place between eight o'clock in the evening and five o'clock in the morning ; then the second exacerbation will take place in the evening of the subsquent day, if it should be before midnight; and on the same day, if it should be after midnight. (In other words, supposing that the first paroxysm of fever should take place at six o'clock on Sunday morning, or at any time between that and six o'clock on Monday morning ; the second paroxysm will take place between five and six on Monday evening.) The next thing to be attended to, is the reason why this second exacerbation (or new paroxysm of fever,) should take place between five and six o'clock in the evening. — It has been before remarked, that all men, even in the most perfect health, have a feverish attack in the evening, which goes off in the morning. In a man in perfect health this attack, although not much marked, is yet sufficiently sensible. — In the first place, there is a depression of strength, both in the body and the mind, sufficiently evident. There is not the same alacrity of mind, in the evening ; nor power of memory, imagination, and judgment, as there is in the morning. — This proposition has been controverted by poets and philosophers, who have often praised midnight study. Two things might be objected to them ; first, they are not willing to give up their connections with the world for the sake of study; and therefore defer it until every body else is at rest. Secondly, there is that indolence in mankind, (especially in those who consider speculation as their supreme happiness,) which makes them wish to defer everything to the last moment. — It is easy, however, to refer the "fact to the feeling, or in other words, to the experience of all mankind. The alacrity of the mind in the morning, and its dulness in the evening ; have the one been celebrated by poets and philosophers, and the other reprobated. The muscular power of the body is likewise greater in the morning : laborers, whatever may be their habits, universally get up in the morning to their work, and go soon to bed : hunters rise early in pursuit of their game in every situation ; even where the scent of the game lies better on the ground, (as where a wood is enclosed, in which it is equal at any time of the twenty-four hours). — Some of the appearances which constitute part of fever, (such as"the contraction of the small vessels,) are evidently much greater in the evening. The complexion of a woman is pale in the evening, that was rosy in the morning. If in perfect health this natural evening paroxysm of fever is visible ; it is infinitely more so in diseases of most kinds, there being none in which it has not been observed by practitioners ; (so much so, that it is not necessary for any further illustration of it to be laid down here). The cause of this natural evening paroxysm of fever has not as yet been investigated. It cannot depend upon the sun, for it happens at a time of day when he is at no particular meridian : much less can it A REGULAR CONTINUED FEVER. 193 depend upon the moon, it being fixed to a particular time in the evening, whereas her appearance is perfectly mutable. — It might be supposed to depend upon the fatigue of the day : but it happens equally to the laborer who goes to the plough at four o'clock in the morning, and to bed at eight in the evening ; and to a woman who goes to bed at four in the morning, and rises at two in the afternoon. — It may be said, that it depends on habit; as infants, until they come to a certain age, are put to bed early.in the evening; and rise early in the morning. This reason is refuted by the following circumstance : the sun rises at different times at different parts of the earth ; so that it is morning at one part of the earth, when in another it is evening. If a man, brought up in one part of the earth where it is morning, when it is evening in another part; should pass from his native country to the country in which his former morning is evening ; if it were habit, the natural evening paroxysm of fever ought to take place in him in the morning: but the fact is, that it takes place in the evening, in the same manner as in the natives of that country. — No method has, therefore, hitherto been found out, to account for this appearance. Whatever be the cause of the return of a paroxysm of fever in the evening, even in health, it is evident that this propensity is the cause of the return of the second paroxysm in a continued fever. It has been said, that if a fever takes place any time between five and six o'clock in the morning of one civil day, and five and six in the morning of the second day ; the second paroxysm takes place between five and six o'clock in the evening of the second day. —It sometimes happens, however, that no second paroxysm takes place between five and six in the evening of the second day : in this case, the fever wears off, and is an ephemera. Such cases, however, rarely happen : but the author has had occasion to observe them four or five times in his practice. — As far as can be judged, therefore, it is the disposition to natural evening paroxysm of fever, that reproduces the paroxysms of continued fevers. The causes then which reproduce fever are apparently two ; — one that reproduces a remittent and intermittent fever at the expiration of a certain period of time ; the other the natural evening paroxysm,' which reproduces a continued fever ; — both of which, as far as the science of medicine has hitherto been investigated, are perfectly incomprehensible. It is to be remarked in the first place, that these different causes serve to distinguish between an intermittent and remittent on one hand ; and a continued fever on the other hand.— For if we find, in the first days of a fever, when there is no perfect intermission ; that the exacerbation takes place between five arid six o'clock in the evening, or a little later; we may conclude, that the disease is a continued fever ; — but if the exacerbations take place at any other time in the twenty-four hours, that it will terminate in an intermittent or remittent fever. 17 194 HISTORY AND METHOD OF TREATMENT OF The next circumstance, that depends upon this doctrine, is the time of the beginning of a continued fever. There has been much said about the days of a fever.—It is clearly impossible to determine the day, unless we can [\e\\ on what day the fever began.—If, in continued fever, the second exacerbation always takes place between five and six o'clock in the evening; then the third paroxysm, and the fourth, fifth, &c, also begin between five and six o'clock in the evening. The first must be conceived to begin between five and six o'clock in the evening, whatever time it really took place ; according to the rule already laid down, (by which it has been shewn at what time the second paroxysm actually takes place ; the first being cpnsidered as beginning twenty-four hours sooner.) It has been already said, that the first paroxysm of a continued fever is irregular, with a greater or less degree of violence : seldom however, so violent as the subsequent paroxysm.) The second paroxysm is generally regular. It .rarely begins a sense of coldness ; the headache is considerably increased ; the pulse is from ninety strokes in a minute to an hundred and ten ; (seldom more frequent, excepting when the disease is to be an irregular continued fever, which is to be the subject of a future dissertation ;) it is always obstructed, not often hard ; when it is hard, this likewise indicates irregular fever, (which will also be the subject of a future dissertation ;) lastly, it is of different degrees of fulness and strength. — Depression of strength is undoubtedly an universal and constant symptom of fever : and therefore, cannot be considered as an irregularity; the degree, however, of depression of strength, is very various ; and when it is very great, the pulse has a very peculiar feel of softness. The heat taken by the thermometer under the tongue, is from ninety-nine to one hundred and five of Fahrenheit's thermometer ; (to the feel of the patient, it is generally greater, and sometimes excessive ; and to another person, always more or less pungent.) — The appetite is likewise lost to a greater or less degree, according to the violence of the disease ; often totally. There is always some degree of nausea ; often sickness: and sometimes vomiting. Thirst i*s sometimes very great; but sometimes inconsiderable, or hardly felt. The evacuations are generally suppressed: the patient is costive ; the skin is dry ; the urine is in small quantity; and after standing some time, continues transparent; the mouth is dry. The mind is always more or less confused ; sometimes, even so early as in the second paroxysm, the patient is delirious during the whole night: sometimes again the sleep is only confused with dreams. The tongue, (which in the first paroxysm was only covered all over with a very thin whitish crust,) is now generally become browner; if the fever is more severe, this crust is thicker ; and when the depression of strength is great, it is clammy. There is a sense of weight about the precordia ; — likewise a sense of depression and anxiety. The author has hesitated much whether he should describe a fever, 195 A REGULAR CONTINUED FEVER. in which the strength is very much depressed, as an irregular fever. After mature deliberation, however, he can hardly allow himself to distinguish it as such. It is true, Sir John Pringle and many other practitioners, (being attracted by the appearance of putrefaction ¦which takes place in fevers where the strength is greatly depressed :) have supposed that the disease depends on putrefaction of the fluids; and not the putrefaction of the fluids upon the disease. If the putrefaction of the fluids is subsequent to the depression of strength, and if a certain degree of depression of strength takes place in all fevers: in that case certainly the putrefaction of the fluids cannot be considered either as the effect of putrefaction ; or as an accident happening in fevers. This argument will be more fully entered into afterwards. It is therefore, only to be remarked now, that according to the degree of depression of strength, a greater or less weight is felt about the precordia; sometimes depression of the mind: as if some great misfortune had happened to the patient, w T hich he cannot describe :) and sighs arise involuntary from his breast. The degree of depression of strength generally determines the wish to be in bed : where, (as has alreadybeen observed,) the muscles have the least exertion. When it is not very great however, and when the patient naturally is spirited : he wishes to get up in the day-time : but is generally forced to lie down several times in the course of the day. The skin appears of a dusky, dingy color; (the ground of which has been already explained in a former dissertation.) There is pain in the forehead, immediately over the eyes : which feels to the patient in the skin, or immediately beneath. This pain is sometimes slight, sometimes very severe ; sometimes reaches all round the head ; but is always external, to the feel of the patient. — Sometimes there is depression of strength only in the extremities, and a feel of weariness — At other times there is a feel of soreness, as if the patient had been beat all over; or such as arises after a very strong contraction of any muscle- (This last symptom takes place only when the fever is very severe.) All these appearances come on, or are increased, between five and six o'clock in the evening ; then increase gradually ; and are at their greatest height about two or three o'clock in the morning. Afterwards, in slighter cases, the patient has some tolerable sleep. It is a very severe fever indeed in which he has none ; though even then he is less restless : but he is relieved in a greater or less degree from all the symptoms about five or six o'clock in the morning. — Although all the appearances that have been enumerated remain ; yet they remain with less severity than they possessed about two o'clock in the morning. The third paroxysm is more severe than the second ; and so, every evening, the disease continues to increase for the first week. The author has already ventured to hint an opinion, that the putrefaction of the fluids, which sometimes take place in fever, is the 196 HISTORY AND METHOD OF TREATMENT OF consequence of the depression of strength, and not the cause of it. — The contrary opinion has been held by Sir. John Pringle, and many other of the first authorities in medicine ; and therefore requires very particular attention. It has pleased the Almighty, that animals and vegetables should be continued by succession. (The present race of both die; some in a shorter, some in a longer period of time ; but all die at last, and are succeeded by their progeny: each species producing successors perfectly, or nearly, similar in properties to itself.) — When one race dies, it is evident that some means should be adapted to destroy the matter of which it consisted. A new race of vegetables would have no room on the earth, if the old vegetables remained exactly in the same situation in which they died : a tree would soon be buried in its own leaves. Even animals would soon cover the whole face of the earth ; so as not to give room to new animals, without constantly treading over the bodies of their ancestors. The sea would become one mass of dead fish. — The all-wise Creator of all beings has, therefore, found means, with perfect facility, to get rid of this, as well as every other difficulty, that the small degree of discernment of mankind has been able to perceive in the creation. There are two modes in which this is performed, as far as the subject has been investigated. — One is by creating many insects and reptiles, which live upon dead matter. These are much more numerous in the warmer regions of the earth ; where both vegetation and the growth of animals go on with greater rapidity. (How soon do the termites ants destroy, in a warm climate, all dead vegetable matter?) — The other mode is by making animal and vegetable substances subject to processes, which are called fermentations; (the ground of which the author has endeavored to set forth in his Treatise on Digestion ;) which fermentations terminate in putrefaction. It would be improper here to say anything further of this process ; than that it converts all animal and vegetable matter into certain salts, and into vapors in a small proportion ; but principally into earth and water. It has been observed, in recounting the causes of fever, that one cause w r as, the vapor arising from putrefying substances. — If to dead animal matter, a putrefying substance or vapor arising from a putrefying substance be applied ; a putrefaction will take place in it much more readily, than in a dead animal or vegetable substance to which no such putrefying substance or vapor has been applied. A question therefore arises, whether a putrefying substance, or the vapor arising from a putrefying substance, applied to living animal matter; will produce putrefaction sooner, than if no such substance or vapor were applied. It has been already shown, that it is necessary that dead animal and vegetable substances should be destroyed ; and it has also been said, that it has pleased the Almighty, that all living animals and vegetables should die. A REGULAR CONTINUED FEVER. 197 The manner in which all living animal and vegetable substances are to die, and so to be lost; is very different however from the mode in which animal and vegetable matter, when dead, is to be destroyed. A living animal, or vegetable, is produced by its parent, weak at first, and imperfect. It acquires perfection by degrees ; until it becomes capable of all the purposes for which it is destined. — Among these purposes, one is, to be capable of propagating its species; and for this, after some time, it has less and less power. At last its faculties begin to decay, and do gradually decay, until the whole of them are lost: and the animal or vegetable dies. (In man this progress is more marked than in any other part of the creation.) In this manner, man is to live through his life, and to die. — But during his life he is not subject to the laws of dead animal and vegetable matter ; and among these, therefore, not subject to putrefaction. If a man, when alive, were subject to the laws of putrefaction; why should he be placed in every situation in which putrefaction most readily takes place ? — Putrefaction takes place most readily in a heat of 100° of Fahrenheit's thermometer; it goes on much more slowly in a heat of 110°; hardly at all in animal substances in the heat of 150°. It goes on more slowly in less degrees of heat than 100° ; and scarcely at all in 40° of Fahrenheit's thermometer. — The heat of the human body, in health and vigor, is generally 97° and an half of Fahrenheit's thermometer. It varies in disease ; sometimes from 92° to 107°. It is always therefore, both in health and disease, near the most proper heat for putrefaction ; —yet no appearances of putrefaction take place in the blood, nor in any part which is alive ; excepting in fever and sea scurvy. Another circumstance which forwards putrefaction is exposure to pure air. — If an animal substance, the moment it dies, is perfectly excluded from pure air; it will not putrefy. On the other hand, if a great blast of pure air be constantly applied to it; it will putrefy much more slowly, than if a moderate quantity be applied. The application of a moderate quantity, therefore, is the best means of producing putrefaction; and a moderate quantity of pure air is actually applied to the matter of the body of a living man. — The vapors constituting the atmosphere contain a fourth part of pure air; and are applied only to the surfaces of the body, (that is, to the skin and to the surface of the nostrils, mouth, and lungs,) which form a very small part of the solids ; and the pure air of the atmosphere has a moderate effect on the blood passing through the lungs; (for that it does affect it in a certain degree, appears from its giving a yellow color to the red blood ; so as to render it scarlet.) — As far, therefore, as application of air tends to produce putrefaction : the human body is in that situation, in which putrefaction would most readily take place. Another circumstance under which the putrefactive fermentation takes place more readily, is motion. In the human body the fluids 17* 198 HISTORY AND METHOD OF TREATMENT OF are in constant and very rapid motion. The heart contracts seventythree times in a minute : and it has been supposed, (as near as can be measured,) that it sends out at each contraction two ounces of blood in a minute. Supposing then that the blood is in the largest quantity that has ever been stated, to wit sixty pounds ; (the amount of) the whole of it will be circulated through all the canals in the body, and return to the heart in six minutes. To give a more distinct idea of the velocity with which the blood moves in the veins, (where it moves with the least velocity,) let a man compress a vein on the back of his hand at some distance from the valve immediately above : and squeeze out the blood up 1o the next valve : so that the vein shall disappear ; then let him immediately remove the pressure, he will find the vein fill again faster than his eye can trace. The blood, therefore, has always constant and rapid motion. It is evident, therefore, that the matter of the living human body is always in circumstances, in which dead animal matter would putrefy most readily. It has been alleged, that certain salts or other matters, contained in the blood and other parts of a living man, prevent the other matter in his body from putrefying : or that the putrescent matters are carried off", and fresh matter introduced : so as to prevent putrefaction from taking place. Those who have advanced the former part of this doctrine have forgotten, that if the body of a dead man is left in the heat of ninety-seven and a half degrees of Fahrenheit's thermometer, without motion and application of the air to the blood or the lungs ; (although the same salts, or other substances remain exactly :) putrefaction takes place in twenty-four hours in a very violent degree. Against the opinion of some authors, that matter is constantly carried off and new matter introduced, and by that means the putrefaction prevented ; the following arguments is sufficient. It is well known that a man may live under all the necessary and most powerful circumstances of putrefaction, without anything being taken in for twenty-four hours, or evacuated (excepting the water that flies off by insensible perspiration ;) yet there is not the smallest appearance of putrefaction in the body. — If, however, a man had been destroyed instantly, when in perfect health, by some accident (such as a wound in the spinal marrow, between the first and second vertebra? of the neck ;) putrefaction would take place in twenty-four hours if the temperature of the dead body was confined to ninety-seven degrees and an half of Fahrenheit's thermometer ; although it was not assisted by exposure to the air in respiration, or by motion. — Since, therefore, it is known, that although the body of a living man be in every situation most proper for putrefaction, and nothing is applied which would prevent the same body (if it was dead) from putrefying; nevertheless the body of a living man has no appearance of putrefaction : it necessarily follows that there is in the life, independent of all other circumstances,) a pow r er of preventing putrefaction. (In 199 A REGULAR CONTINUED FEVER. other words, it is the property of living matter to remain untainted by putrefaction: and the property of dead animal and vegetable matter to putrefy.) Mankind, ever inquisitive, (from the disposition which the Almighty has chosen to place in their minds,) are constantly endeavoring to find reasons for every effect according to something they are already acquainted with. — In this particular case, they have supposed that the operations which take place in living animal matter, should agree chemically with operations that they can perform in dead animal matter. They have, therefore, concluded ; that since animal matter, when alive, is prevented from putrefying in certain circumstances, in which it would have putrified very readily when dead ; this must be occasioned by means which would have prevented dead animal matter from putrefying, if it had been in the same circumstances. —No such means, however, have been shewn to be applied to living animal matter. — But was it not as easy for the Almighty to make a law, that living animal matter should not putrefy ; and that dead animal matter should putrefy: as to make a law that if one mass of matter be placed at a distance from another mass, the two should immediately (if not prevented by some cause) begin to approach each other ? — The author by no means wishes it to be understood, that it is unnecessary to inquire, whether it be or be not so ; for that must be investigated by experiments and observations.—He has merely she wn that every circumstance which would make putrefaction take place in the dead body of a man, is constantly applied in the living body ; and that no chemical circumstance has been discovered in the body of a living man, to prevent such putrefaction from taking place. He therefore concludes, that it is an original law given by the Creator, that living matter should not putrefy ; and that animal or vegetable matter, when dead, should putrefy and be destroyed. The heat of living animal and vegetable substances will admit of a parity of reasoning; but this is foreign to the present subject. Thus far the author has inquired, whether the human body, when alive; has a power of resisting putrefaction when exposed to all the circumstances which promote putrefaction in a dead human body. The point that the author set out with was, whether putrescent matter, applied to the body, produced fever ; and in that fever, the depression of strength, which occasioned putrefaction: Or if the putrid matter applied to the body occasioned putrefaction of the fluids, (as a ferment or otherwise,) after which putrefaction brought on a depression of strength. Many people are constantly exposed to putrid matter, both in a solid and fluid state ; as also to the vapors arising from putrid substances ; and yet no putrefaction, or any appearance of putrefaction, is found in their blood. (Those, for example, who are employed in cleaning out putrid ditches, or the common sewers of great towns ; have in their blood, and in no other part of their body, any dis- 200 HISTORY AND METHOD OF TREATMENT OF coverable appearance of putrefaction.) — When therefore no fever is produced, and depression of strength as part of that fever; it is evident that putrid matter does not occasion any appearance of putrefaction. — Even when a fever is produced by putrid vapor or any other cause, if the fever be in a great, degree, and there is great depression of strength at the first; yet for several days there is no appearance whatever of any putrefaction in the fluids. Blood taken from the arm coagulates firmly ; the tongue is covered with a whitish crust; there is no putrid smell in the air coming from the lungs, or in any of the evacuations ; there are no marks upon the skin ; there is no appearance of putrefaction in short in any part of the body : but besides the great feel of depression of bodily strength, there is great depression of spirits, and sense of weight about the precordia ; with a peculiar imbecility in the pulse. As therefore the depression of strength takes place first, and the putrefaction afterwards, according to the usual precedence of cause and effect, (to w T it, that the effect follows the cause,) it seems to be sufficiently proved, that depression of strength is the cause of the putrefaction ; and not the putrefaction the cause of the depression of strength. In sea scurvy, as it is called, the putrefaction of the fluids arises undoubtedly from animal food being used, without a sufficient quantity of vegetables of a loose texture ; (to prevent it from entering in part into the putrefactive fermentation, during the digestion). This happens especially when the animal food is preserved by salt. — In such cases a chyle is thrown into the blood-vessels loaded with putrescent matter. — In this disease the first symptoms which take place are always languor and depression of strength ; and inability of exerting the muscular powers. Afterwards symptoms of putrefaction come on.— This shows that even in this case it is the depression of strength that occasions the putrefaction. Since, therefore, the solids and fluids of a living man are placed in situations the most proper for putrefaction ; —since there is nothing applied to the living body to prevent putrefaction, which is not also applied to the dead body when it putrefies very fast; — since no fresh matter is added to the living body during the time in which the dead body (placed in the same circumstances) would putrefy ; — since the depression of strength takes place always in a fever before there be any appearances of putrefaction ; — and lastly, since when the blood is rendered putrid by putrescent matter being thrown into it, depression of strength always takes place before there be any appearances of putrefaction: — It may be concluded, that the depression of strength is the cause of the putrefaction of the fluids in fever; and not the putrefaction of the fluids the cause of the depression of strength. Symptoms of putrefaction rarely appear in the second paroxysm of a continued fever ; and seldom in the third paroxysm (or third day of the disease); counting as has been already laid down. A REGULAR CONTINUED FEVER. 201 The symptoms of putrefaction, when they first take place, are alterations in the appearance of the secretions. The urine first has a more viscid appearance than common : is frothy, browner, and not absolutely transparent; (although there is no cloud or sediment). If the putrefaction is still greater; it becomes of a dark brown, and loses its transparency ; and sometimes a dark brown sediment falls to the bottom of the vessel, after it has stood an hour or two. The feces begin to be fetid ; and at last have a very putrid fetor ; (which, however, is to be distinguished from the fetor of the inflammable air, which is often discharged and is very fetid, although there be no putrefaction). The feces are also not uncommonly black and liquid. The sweat, if there should be any, tinges the linen with a dilute ichorous appearance. The crust which forms upon the tongue, appears browner and more clammy ; and as the fever goes on, it grows browner and browner, until at last it is quite black. The teeth, rubbing it off from the tongue, become as it were burried in a black slime : (this hardly takes place before the end of the first week of the disease). The breath also becomes fetid. There sometimes appear upon the skin, (but not excepting the putrefaction has arisen to a considerable degree,) a kind of discoloration ; similar to the appearances which we find in polished marble not purely white (which are called bluish veins.) When the degree of putrefaction is more considerable ; dark purple spots, of various sizes, are formed in the skin. If the putrefaction be still more considerable ; the skin becomes all over of a dark purple color. — At the beginning, when the putrefaction has not gone to any great length; if blood should happen to have been taken from the arm, the coagulum is loose and easily broken ; the serum being hardly of a browner color than common. Sometimes when the depression of strength is not very great, the blood retains this appearance during the whole course of the disease. Should the patient become so weak, as to be carried off by the weakness ; this appearance is not altered ; (for it is depression of strength, not weakness, which produces putrefaction). — If there is greater depression of strength, (and by consequence putrefaction is in a greater degree,) the serum becomes of a brownish color. — In a still further degree, it is red. In this case, on examining the red particles with a microscope, many of them are found diminished in size, and not regular spheres or oblate spheroids : some have even the appearance of being broken in two, and look like half moons: but most of them retain their healthy appearance.—If putrefaction goes on still further, there is hardly any distinction between serum and coagulum.—If still further, the coagulable lymph forms a kind of bag ; leaving the serum on the outside, distinct. In the substance of the bag itself there is no intermixture of red particles; so that it looks like the buff, which is on the surface of the coagulum in cases of general inflammation : but within this bag a red fluid is contained ; which (upon being examined with a microscope,) shows the red particles 202 HISTORY AND METHOD OF TREATMENT OF under a variety of forms.—All these appearances the author has seen. — There are some cases upon record in which it is stated, that the blood was absolutely fetid ; and a practitioner of perfect credit, (who practised a considerable time in hot climates,) told me he had seen several cases, where the blood taken from the arm was thus actually fetid. As depression of strength produces putrefaction of the fluids ; so, on the other hand, putrefaction of the fluids occasions greater depression of strength: sometimes in a degree that proves fatal. In this case, the pulse often towards the end beats faster than can be counted. It happens more frequently that hemorrhage arises (almost indiscriminately) from any of the cavities which open externally. These hemorrhages are very dangerous, and often fatal. Depression of strength happens in a greater or less degree in all fevers. In many, it does not happen in such a degree as to produce any sensible appearance of putrefaction of the blood : yet as the cases in which it does produce putrefaction of the blood, and those in which it does not produce any appearance of it, only differ in degree ; it can never form an irregularity of fever. It can only give rise to a variety, which does not at all affect the practice ; (as will be afterwrards shewn). At particular times, it is very rare that any great mark of putrefaction takes place : at other times, it is more frequent. It was common enough in London from 1750, to 1765 ; from that time the severer symptoms of putrefaction have been seldomer seen ; and from 1775 to this period (1797,) they have been very rarely seen indeed in fevers. Among the symptoms of the disease, which gradually increase from the second exacerbation to the end of the first week, or sometimes a little longer ; is delirium ; which will likewise require a more minute investigation. In the first place, it is necessary to distinguish between two derangements of the mind; delirium and mania.—The common distinction has been, that delirium is derangement of the mind, with fever ; and mania, without fever. Those who have given this distinction, have by no means that idea of fever which the author has endeavoured to illustrate. If they mean by fever, frequency of the pulse ; mania undoubtedly exists very often with frequency of the pulse. It is rare for a person affected with mania to be seized with fever : It is also very rare for a person in a fever (such as the author is endeavoring to describe,) to be seized with mania. Mania is that derangement of the mind in which, although the material parts of the organ of sensation are in perfect order ; yet the mind often takes wrong ideas from them. Although a wind-mill be painted on the retina ; the figure represented to the mind is that of a giant. — In delirium, the impression made on the organ of the senses is always imperfect, as far as the material part is concerned : (the eye, 203 A REGULAR CONTINUED FEVER. for example, is incapable of adjusting itself so as to form a distinct image on the retina, which can be perceived by the mind ; but as far as it can be perceived, it is always true). A man in a delirium never takes one object for another: he has only an obscure sensation, from which he endeavours to take some idea. Having no accurate idea impressed by the organs of the senses, nor brought up by memory ; he has nothing in his mind but complete confusion. — But a man in mania ; (supposing the ideas taken from his senses and brought back by his memory, were true :) still has his imagination such, as often to arrange his ideas perfectly ; and his judgment is sometimes clear in determining whether the arrangement is just. — In mania, agreeable objects frequently occupy the mind ; — in delirium, hardly ever. The patient is wandering among tombs, falling over precipices, deserted by his friends, or perpetually in some other misfortune. — Delirium takes place in many diseases, in which there is no fever. In fever, delirium may arise from the fever itself; or from certain accidents which take place in irregular fevers. — Delirium which takes place from fever itself, is at present to be inquired into. When delirium has taken place from fever itself; it has been generally believed that it arose from an inflammation of the brain. — There are indeed some cases recorded ; in which it has been said, that upon opening the heads of patients who have died of delirium from fever, a suppuration of the brain has been found. Hence it has been concluded, that delirium in fever has always been owing to inflammation of the brain. — The author has caused the heads of many patients, who have died with very great delirium in fever, to be opened ; and never found any marks of suppuration. Most commonly, the brain appeared exactly as it is commonly found. Sometimes the blood-vessels were distended with blood ; but never was any suppuration found : generally no uncommon appearance at all. — Among the numerous dissections which are made in the anatomical schools, many are made of those who have died of fevers ; yet it is very rare for anything like suppuration in the brain to be seen. It has just been said, that delirium may arise from accidents, which take place in fevers : Such deliriums will be treated of in that dissertation, in which the irregularities which arise in continued fevers will be described. Delirium arising from the fever itself, will only here be treated of. Delirium arising from the fever itself, appears to be of two species. — One, in the first place, in which, neither in the body while it is alive, nor by dissection in the dead body ; can any mark of alteration in the material part of the brain be found. — In the other species of delirium, we might have some suspicion, even during the life time, that the material part of the brain was altered ; and some alteration of the material part is actually found upon dissection after the death of the patient. — In that species of delirium, in which there is no mark of affection of the material part of the brain during the 204 HISTORY AND METHOD OF TREATMENT OF life of the patient, or on dissection after his death ; is it to be supposed, that the material part of the brain is actually affected ? Is it to be taken for granted, that the mind exists in the brain ; and governs the body, seated as on a throne ; sending its messengers to the other parts of its dominions ? — It may be necessary to consider the question. The structure of the brain is very grossly and imperfectly known ; but its ordinary appearances have been so well described by anatomists, that it is by no means necessary to enter into particulars here. — Suffice it to say, that in the human brain there are two laminse ; one of a whiter color, one of a browner grey, laid upon one another ; and puckered up (as well as could be) in the cavity of the skull. The whole is covered on the outside with membranes ; which touch and adhere to the skull on the outside ; and touch each other on the inside, but do not adhere; (so that fluids now and then get between them.) From the white part arises a number of fibres, (which run to every part of the body,) which we call nerves. When these nerves are cut through ; the mind loses its power of producing muscular contraction. From anatomy this is the only reason to suppose, that the mind is situated in the brain ; and that it can be deranged by the derangement of the material part of the brain. — Again, certain alterations of the material part of the brain undoubtedly derange the mind. A man whose skull is fractured, is generally (in consequence of the mischief done to the brain) rendered delirious. An inflammation of the brain in many cases produces delirium ; (not in all.) This might lead to a belief, that the mind resides in the brain. — On the other hand, the nerves going to a part, may be totally cut through in the human body; yet motion in that part may remain : It may live long afterwards, may regain its sensibility, and in consequence affect the mind ; even although the nerves were not again reunited. (This was the case in Mr. Hewson, who in dissecting, cut the nerve going to one of his fingers; and after some time recovered perfect sensation and use of it, although the nerve never reunited.) — Injuries done to other parts of the body, as well as the brain, produce delirium; when there is not the smallest appearance upon dissection, of any injury (Jone to the brain. (Inflammation of the diaphragm produces delirium and death ; when on dissection, there is no apparent alteration of the brain.) — The brain may also be very much altered, almost entirely converted into pus ; without deiirium. (Of this instances have appeared in Dr. Hunter's dissecting room. In one of these, it was well known, that there was no derangement of the mind during the inflammation or suppuration ; but the patient was carried off by by a disease, in which the brain could hardly be conceived to have its material part at all disordered.) — So far there may be very considerable doubt, whether delirium always arises from disorder of the material part of the brain. — Again, if we refer to our feelings ; we undoubtedly feel as if the A REGULAR CONTINUED FEVER. 205 memory, imagination, and judgment were in the head. The sensations, however, are generally referred to the part of the body to which the application is made : (thus we feel pain in the finger, when it is pricked with a needle:) and the passions are always referred to the breast; as common language shows. — Lastly, the author has in several cases seen it happen, that a delirious patient in fever, (without any abatement of any of the other symptoms of the disease,) has become perfectly sensible. In all such cases death has followed shortly ; (that is, in less than twenty-four hours ;) as if the mind had escaped from the disease of the body, before it had left the body entirely. — All these considerations induce a doubt in the author, whether delirium may not arise in fever, as an affection of the mind only ; (independent of any affection of the material part of the body.) Another kind of delirium takes place from the fever itself; and the patient dies in consequence of the delirium : (or at least when the delirium is very severe.) —In this kind, on dissection; the author has found the vessels of the brain, (including the whole of it, that is, the brain, cerebellum, membranes, &c.) all turgid with blood ; although it never happened (in any of the cases which he has caused to be dissected,) that there was any peculiar affection of one part more than of another; or anything like suppuration. From the foregoing statement the author is led to think ; that from fever itself and without any accident or irregularity,) two species of delirium arise : one without any material affection of the brain ; the other with fulness of the vessels of the brain. Independently of (what is thus discoverable by the aid of dissections;) the author conceives that external appearances of the two kinds of delirium take place, in consequence of a regular continued fever itself; — which he now means to attempt to describe. The first species seldom happens in the first paroxysm of a regular continued fever, excepting it be very severe. There is very often some appearance of it in the second evening of the disease. The patient sleeps confusedly: immediately upon waking, he does not recollect his bed or bed chamber or the people that are about him ; but recollection returns in a few minutes; the eyes are sufficiently clear, neither confused nor stupid : nor are the blood-vessels fuller than in the ordinary state. There is a degree of perfect stupidity and listlessness in the appearance of the eye, which takes place not uncommonly in the first exacerbation of a continued fever: which is a very fatal symptom ; but which the author thinks is an irregularity in the disease ; (and which in consequence will be taken notice of in a future dissertation.) The want of perfect recollection, if the disease is not very violent, goes off generally in the morning, about seven or eight o'clock of the civil day ; and the patient remains recollected till the beginning of the fourth paroxysm ; but yet not perfectly clear in his ideas, and in full possession of the powers of his mind.—Every evening the delirium grows more and more severe ; but still there is very considerable relaxation in the day time ; and 18 206 HISTORY AND METHOD OF TREATMENT OF this continues to increase, until the seventh or eighth day of the disease. When this kind of delirium arises to a great height, about five or six o'clock in the evening, the patient begins to be very confused ; hardly knows the people about him ; talks much and confusedly about his affairs ; and is violent. This violence increases till about midnight; when if the disease is very great, he endeavors to jump out of bed or tries to climb up to the top of it; and becomes perfectly unmanageable. This goes on till two or three o'clock in the morning. Then by degrees it subsides; and he becomes something more sensible about tour o'clock in the morning. Afterwards perhaps he gets a little sleep ; awakes not so confused ; and during the day time remains more or less sensible to external objects. These appearances go on much the same for five or six days, if no crisis should take place. About the fourteenth day of the disease this delirium begins to subside ; the patient becomes much more sensible in the day time ; the evening attacks become much more conspicuous, although not so violent; until the disease finally goes off; — the delirium being almost the first symptom of it that disappears. The second species of delirium, arising in a regular continued fever from the fever itself, seems to go through the following progress. Like the other, it begins to appear in the second paroxysm of the disease. There is in the evening the same confusion in the perception ; the eyes have their vessels somewhat enlarged ; the cheeks are a little flushed. These appearances go on increasing during the first week of the disease ; the confusion grows greater in the evening, and sometimes all that violent agitation (which has been described in the former species of delirium) takes place : but in that case the patient does not recover in the morning, but lies stupid and almost insensible. Afterwards if the disease be very violent, a stronger and more violent degree of delirium begins to take place between five and six o'clock in the evening ; which increases until two or three o'clock in the morning ; and then by degrees the patient again falls into the same stupor. If this should continue till about the fourteenth,day, the evening attacks become by degrees less ; but the stupor continues with deafness and inattention to external objects :— and these appearances uemain as the verylast symptoms of the disease. — The author is rather induced to believe, (from the fulness of the vessels of the eye, the flushing of the. face, and the continuance of the stupor after the fever is gone off; that in this species of delirium, the material part of the brain is affected ; especially as when patients have died of this species of delirium, the author (upon dissection) has found the vessels of the brain distended with blood. It is to be observed, however, that between these two appearances of delirium there are gradations ; as w T e find in almost everything relating to the human body. Whether the author be right or no, in supposing that there are these two species of delirium depending upon fever itself: delirium 207 A REGULAR CONTINUED FEVER. (whether it be of one species or the other,) affects not only the mind ; but the functions of the body also. From the second day of the disease, the delirium (if it takes place,) gradually increases ; and along with it, all the appearances of fever. The tongue grows fouler from the beginning to the middle of the second week, excepting where there are appearances of putrefaction, as have already been enumerated : there is indeed no sliminess, but a greater crust. Towards the end of the second week this crust, more or less, disappears ; and the surface of the tongue looks raw when moist: w-hen dry, it has a polished glaze, especially about the middle ; (some of the crust remaining upon the sides, towards the edges). The skin has a more dusky color, and feels uneasy. The patient picks hairs from the bed clothes: the eyes appear more confused : black spots seem to the patient to be moving in the air. The appetite is more or less diminished ; and often totally lost. Spasmodic contractions of the intestines take place in a greater degree. The pain in the forehead (or rather the sensation of it,) is not so much complained of. The secretions continue suppressed ; the skin dry,&c. There are greater flatulencies : — And the fever every way increases along with the delirium. Prognosis. — Whether it be that the fever is gradually increasing, and delirium along with it; or that delirium is the occasion of the increase of it; the fever goes on in proportion with the delirium. — Although the patient should be insensible to all external objects ; although he should sleep very little, or scarcely at all ; yet, if the deglutition and respiration should remain unimpeded, the patient is not to be despaired of: it happens even most commonly that he recovers. — But if he respires with great difficulty, or hardly at all ; or if the deglutition be almost totally prevented ; or if the attempt to swallow throws him into convulsive contractions ; he rarely recovers. On the other hand, even if the other febrile appearances do not keep pace with the delirium : (that is, though the pulse should become more slow, and less obstructed ; though the tongue should become cleaner and moister ; though the color of the skin should become more natural ; the secretory vessels more relaxed, without stupor or deafness, and other marks which have been pointed out as accompanying delirium :) provided there be only fulness of the vessels of the brain ; yet in such case, (notwithstanding the practitioner and bystander are flattered,) the patient is frequently cut off. — When these last described appearances take place, (that is, if delirium continues of the first kind without diminution,) the author has conceived that some mischief has happened to the brain, or some other part of the body. But although he has caused several to be opened who have died under these circumstances ; he has never been able to find any appearance different from what is commonly found in persons dying of diseases, which make no alteration in the structure of the body. Thus the fever continues to increase, from the beginning of the 208 HISTORY AND METHOD OF TREATMENT OF first, and sometimes to the middle of the second week ; and continues in the same degree ; unless it should be carried off by a crisis. A crisis in a continued fever, as described by Hippocrates, has been a matter of great debate ; not only since, but probably long before his time. A crisis which takes place in a regular continued fever may be considered in the following manner. — The author has endeavoured to state, that a continued fever differs from an intermittent or remittent, in this ; that in an intermittent or remittent, the paroxysms (or exacerbations) recur principally between six o'clock in the morning and five o'clock in the evening of the civil day; but that in continued fevers, the exacerbations take place between five and six o'clock in the evening. — When a very severe exacerbation occurs in a regular tertian intermittent, the author has already said (in a dissertation on that subject) that a complete crisis sometimes takes place; and carries off the disease. In like manner, in continued fever, if a strong exacerbation should happen in the evening ; the seventy of the attack may prove fatal : but on the other hand, instead of producing only a relaxation between five and six o'clock in the morning, it may occasion a complete crisis ; and so in a few hours terminate the disease. In speaking of a crisis in a regular continued fever, it is always to be understood, and is so considered by Hippocrates,) that there may be a bad crisis, and even a fatal one, from the violence of the attack of that paroxysm ; or a good crisis, carrying off the disease altogether, or giving great relief. The first thing to be taken into consideration is, whether any such crisis ever takes place or not. How this should have become a question can hardly be conceived ; since instances of such crisis must have occurred to every practitioner who has had occasion to see a number of cases of the disease. — Others indeed insist, that crisis happen in all continued fevers: but this opinion can never be held by any practitioner who has had much practice in England. In different climates, the taking place of crisis has been variously described.— In very hot climates, fevers are represented (by practitioners versed in the diseases of those climates) as if they were all intermittent or remittent; in which case, more or less perfect crisis always take place : (to wit, in climates in which the temperature of the atmosphere in the shade is from about eighty degrees to one hundred, or an hundred and ten) —(The same thing is also true where the variation of the temperature is very great: as in Carolina ; (where in one day, from the variation of the wind, the heat may rise from under ten to upwards of sixty degrees of Fahrenheit's thermometer). — In countries not quite so hot, and not so variable, (as in the Mediterranean ;) authors have described continued fevers as almost always terminating by crisis.—In England, as far as the author's observations has gone ; hardly one third of its fevers have been carried off by crisis, such as the author has just described.— In colder countries, where the inhabitants expose themselves to the A REGULAR CONTINUED FEVER. 209 temperature of the cold atmosphere, (as in Siberia ;) continued fevers are very rare ; and crisis scarcely every take place. Hippocrates has not only laid down that continued fevers are terminated by crisis ; but also that these crisis take place on certain particular days of the disease ; which he has called critical days. — This doctrine has afforded a ground of great dispute. When it is affirmed, that a fever terminates on a certain day of the disease by crisis ; the first question undoubtedly is, what is to be accounted the first day of the disease. —The author has endeavoured to show, that the beginning of the fever is not to be counted from the hour of the first attack; but from the second attack, (or first exacerbation of the disease,) which begins between five and six o'clock in the evening. He has said, that most commonly, if the disease begins before six o'clock in the morning ; the second attack takes place between five and six o'clock in the evening of the same civil day ; and by consequence, that the fever is to be considered as beginning between five and six o'clock in the evening of the preceding civil day : but that generally, if the first attack be after six o'clock in the morning of the civil day (as is commonly the case), the fever cannot be considered as beginning till five or six o'clock in the evening of the same civil day ; the second attack (or first exacerbation of the disease) not happening till five or six o'clock in the evening of the subsequent civil day. (In others words ; supposing the disease should take place between six o'clock in the morning of Sunday, and six o'clock in the morning of Monday ; the beginning of the first day of the fever must generally be taken between five and six o'clock in the evening of Sunday.) There are some cases in which there are exceptions ; (but these will be considered among the irregularities which take place in the disease). Having thus pointed out from what time we are to reckon the beginning of the disease ; and that crisis take place in the first twelve hours of the exacerbation ; it will be easy to settle the days of the disease on which crisis occur. Excepting in intermittent and remittent fevers, crisis very rarely happen in the first week of the disease ; unless on the seventh day. — Hippocrates enumerates however (in the different works ascribed to him,) the fifth, sixth, seventh, ninth, eleventh, thirteenth and fourteenth, seventeeth, twentieth and twenty-first days, as critical days. —He also says, that although these be the true critical days ; yet that there are spurious critical days, (viz. the eighth, tenth, and twelfth, &c.); and that it is known whether the fever had perfect or spurious critical days, by one day being an indication of another. — Hence, if you find a strong exacerbation take place on the seventh, and also considerable relaxation between five and six o'clock in the morning; that is, if a coldness takes place about six o'clock in the evening, or at least considerable dryness of the skin, very great heat, greater foulness of the tongue, and more violent delirium on the beginning of the seventh day, (viz. between five and six o'clock IS* 210 HISTORY AND METHOD OF TREATMENT OF in the evening;) and if these appearances increase very much till three or four o'clock in the morning, and then subside and the patient is more sensible than he was in the morning before ; if his skin and tongue become moister, his tongue cleaner, and the secretory vessels relaxed : although no complete crisis take place, you are to consider in that fever the seventh, ninth days, &c. as the true critical days : (and that the patient had a better chance of recovering on these days). — On the other hand, if a stronger attack and greater relaxation take place first, at the beginning of the eighth day of the disease ; then the disease will observe spurious critical days ; and the tenth, twelfth, &c. will be the critical days ; and the patient will have more chance of recovering on these days : — But in this last case he will have a less chance of the crisis being so perfect, or carrying off the disease. The only plausible mode of accounting for these critical days, is that which was pointed out by Dr. Cullen, (in a clinical lecture he gave about the year 1797) ; to wit, that continued fevers observe in some degree the types of intermittents. — He said, that during the first week of a continued fever, it observed the quotidian type ; that in the second, it observed the tertian type ; and in the third, the quartan type : that is to say, that in the first week every day's paroxysm increased ; (by which is to be understood, that the third paroxysm was greater than the second ; the symptoms of the fourth were more severe than those of the third, &c.) ; that in the second week there was a stronger exacerbation one day, and less strong the next day ; and that in the third week there was a strong exacerbation on one day, and on the two subsequent days a weaker exacerbation ; and that on the beginning of the fourth day, (counting exclusively,) a stronger exacerbation again took place.—Again, he said that it often happened in intermitting fevers, that a paroxysm occurs every day ; but that the paroxysms were unequal ; (the paroxysms every other day being slighter, every other day more severe :) or that they might begin at other times of the day. In other words, supposing a severe paroxysm (after the intermittent was formed) had taken place on Sunday at noon ; a paroxysm might take place on Monday, (which might be either at noon, at ten or eleven o'clock, in the morning, or one or two in the afternoon, but less severe : and again, that if on Tuesday a stronger paroxysm took place at noon, (similar to that which took place on Sunday,) a slighter paroxysm might take place on Wednesday similar to that which took place on Monday. — Such cases he called double tertians : (they were also called double tertians by many of the ancient Greek and Roman physicians, and likewise by practitioners after the revival of the science of medicine in Europe). In such cases, Dr. Cullen observed, that the severe paroxysms were shorter, and productive of more perfect crisis. If therefore the continued fever should be governed by a tertian type in the second week of the disease ; that then the paroxysms, or exacerbations, 211 A REGULAR CONTINUED FEVER. might recur every day ; but be more strong every other day, and terminate with a more perfect crisis. They might indeed be so short, and terminate with such a perfect crisis; as entirely to carry off the disease. — In like manner, if a continued fever observed a quartan type, and there were two slight exacerbations after a severer one ; followed by two slight exacerbations, and then again a severer exacerbation, (and so on); there was a greater likelihood of the severe exacerbation being the shortest and being followed by a more perfect crisis ; and often by so perfect a crisis, as to terminate the disease. Connecting this idea with what has been said above, a continued fever observes the quotidian type in the first w r eek. — If a crisis takes place after the first two or three exacerbations, the disease recurs ; and becomes an intermittent fever. — But if it goes on as far as the fifth day, and a crisis should take place on the fifth day of the disease, that crisis would terminate the fever entirely: the same thing may be said of the sixth day ; (but these two days seem to be uncertainly marked as critical days, complete crisis happening on them rarely). If the first paroxysm of the tertian type should take place on the seventh day, then there would be a chance of a crisis on that day ; and in consequence, on the ninth, eleventh, and thirteenth days). As far as is known, there is no reason for believing that the fever changes its type more frequently on the seventh, than upon the eighth day ; and therefore if the fever changes its type on the eighth day ; the eighth, tenth, and twelfth would become critical days in the second week, (and according to Hippocrates would be spurious critical days). Hippocrates accordingly says, that if you find a severer attack take place at the beginning of the seventh day, and go off w r ith some critical symptoms, (such as moisture on the skin, greater cleanness of the tongue, &c.) then you are to conclude that the seventh, ninth, eleventh, and thirteenth days are the critical days of the second week.—If a stronger exacerbation should take place on the sixth or eight days, followed by critical appearances, (as have been above observed); then you are to reckon the eighth, tenth, and twelfth the critical days of the second week; and so far (according to Hippocrates) the critical days are the days of the stronger exacerbations of the tertian type in the second week. If again the fourteenth day should be the first day of the quartan type, then there would be greater disposition to crisis on that day. Indeed the fourteenth day is by much the most common day on which a crisis takes place. If the fever was now observing a quartan type : the fifteenth and sixteenth days being days of weaker exacerbations, there would be little chance of crisis upon them ; and on the seventeenth day there w r ould be a stronger exacerbation according to the quartan type, and in consequence a greater disposition to crisis; on the eighteenth and nineteenth days, there being weaker exacer- 212 HISTORY AND METHOD OF TREATMENT OF bations according to the quartan type, there would again be less chance of crisis upon these days: but on the twentieth day, there being a stronger exacerbation again, according to the quartan type, there would be a greater chance of crisis on that day. This doctrine will by no means agree for the twenty-first day ; which it is more probable that Hippocrates (and the physicians of his time) reckoned the critical day, instead of the twentieth, because it was an odd day; which they considered more fortunate than an even day. This whim was probably the ground of their considering the seventh, ninth days, &c, as being the true critical days, and the eighth, tenth, &c, as spurious critical days. In compliance with .this idea, some of those authors who have admitted the fourteenth as the most common critical day, (as it has actually been found in practice,) have called it an odd day ; because it was the second seventh ; and so have perhaps likewise admitted the twenty-first among the critical days, as the third seventh. The truth of this doctrine may also be supported by what happens in hot and in cold climates. It has already been said, that crisis much seldomer takes place in cold climates than in hot climates; and also that fevers are much oftener intermittents and remittents in hot than in cold climates : — it is much more probable therefore, as intermittents are governed by types, that types have a greater power over continued fevers in hot climates, than in cold ones. This perfectly accords with Dr. Cullen's doctrine. It has already been said also, that not above one-third part of the fevers which happen in London are terminated by a crisis ; that is to say, in not above a third part of the fevers which happen in London does a much stronger attack take place in the evening, than took place in the evening of the civil day before ; and either kill the patient; or otherwise terminate with so complete a freedom from the disease before eight o'clock in the morning, as to render him, should there be no relapse, perfectly safe. In cases in which no actual crisis takes place, still it sometimes happens in regular fevers in England, but not always, that there are stronger exacerbations every other day in the second week, and every fourth day in the third. — By the end of the seventh day, the fever has often increased to nearly its greatest height; when it is regular ; and the second week is sometimes gone through without very distressing symptoms. But sometimes cases with symptoms of the greatest distress and danger occur. — And there are all gradations between these extremes. It is necessary that the author should here observe, that hehas been describing the disease and its progress, when it has not been increased or rendered irregular by imprudent practice. The appearances then in the second week are sometimes frequency of the pulse, to perhaps an hundred or an hundred and five in the 213 A REGULAR CONTINUED FEVER. evening ; and in the morning, from ninety-five to an hundred. (In many cases of fever the pulse is much more frequent, but this will be described as an irregularity in a future dissertation.) The tongue is covered with a brownish fur; which is not slimy excepting when putrefaction takes place, as has already been described. When the disease is severe, it is not uncommon for the middle of the tongue especially to lose this fur ; and appear when moist, cleaner and rawer than it is in its natural state ; and, when dry, with a degree of polish as if it were glazed over. The eyes have always, provided the fever be regular, a degree of confusion ; but it is greater or less, as there is more or less delirium as has been already described. The skin is of a dirty dusky color; and this symptom is in a greater or less degree, according to the violence of the disease. If the headache is often less complained of by the patient ; his occasional silence on this subject appears rather to depend upon the confusion of his mind, than upon his head's being actually relieved. The appetite is often totally lost. The patient frequently speaks less of thirst during the second, than during the first week ; but this want of thirst probably arises from the disturbance of the mind ; for sometimes, especially when the fever is very violent, he will drink a great quantity at once, and at other times in the same circumstances will hardly drink an ounce. The skin continues very dry and parched : that is, feels very hot and dry to the by-stander. The urine continues perfectly transparent, as has been described. There are flatulencies in the intestines ; generally with costiveness ; but now and then there are one or two thin and very fetid evacuations in twentyfour hours ; even when there is no other appearance of putrefaction. The sleep, when the patient obtains any, is more or less quiet; partly according to the delirium, and partly according to the general restlessness. If the fever should be slight, and perfectly regular ; if the practitioner has patience, and does not press the patient wilh improper remedies, nor the by-slanders apply improper nourishment ; this stage of the disease passes over with tolerable tranquillity. — On the other hand, if the delirium and other symptoms of fever be very violent, it proceeds, with the utmost anxiety to the practitioner and danger to the patient. — The issue in these cases happens in all gradations, from the most severe and fatal, to the slightest. Provided there has not been such a depression of strength as to occasion putrefaction of the fluids (and by that means to destroy the patient): provided that neither of the kinds of delirium which have been described should prove fatal : that the patient also should not be destroyed, by strong symptoms of fever taking place at the beginning of a critical paroxysm : that the delirium when of the first species described, keeps pace with the other symptoms of the first stage; or if of the second species, begins to be converted into deafness and stupor : and lastly that the fever was of itself perfectly regular ; and 214 HISTORY AND METHOD OF TREATMENT OF has not been rendered irregular by improper treatment: it then rarely happens that it is dangerous after the second week. On the fifteenth day, and often sooner, the symptoms of the disease begins to abate. — The first appearance of this abatement is not uncommonly a cleanness and healthy look about the edges of the tongue ; or sometimes the skin becomes of a more natural color ; sometimes (although not very generally) a sweating takes place all over the body, and the skin afterwards continues moist. The delirium, if it be of the first kind, abates in the day time, and returns at night: or if of the second kind, the patient is deaf and stupid, with little difference in the twenty-four hours; and this deafness and stupor remain until thcwhole of the disease has disappeared. The depression of strength generally goes off, but leaves real weakness behind. — This is at no time more conspicuous, than when the depression has been so great as to occasion putrefaction of the fluids. In this case, all the appearances of putrefaction which have been already described, begin to disappear; (that is to say, the tongue is no longer covered with slime, nor the teeth buried in it; but the tongue generally looks raw, if moist, and with a polished gloss on the surface when dry ; the marbling goes off from the skin ; or, if there w T ere any purple spots, these become yellowish and disappear ; the breath and secretions no longer are fetid, nor bear other marks of putrefaction.) This diminution of the appearances of putrefaction does not happen at once ; excepting a crisis should take place ; (and then they go off almost entirely in one night.) It is to be remarked, that in the second week of the disease it often happens, that an eruption takes place on the skin ; quite different from that marbling or those purple spots, which arise from the putrefaction of the fluids.) — This eruption sometimes happens even in the first week of the fever; but much more commonly in the second week. — It occurs principally about the neck and breast, and resembles very much the appearance of flea bites ; (that is, there are a number of small brownish red specks, often not the twentieth part of an inch in diameter ; with a brownness of the surrounding skin.) — How or why this eruption takes place the author could never satisfy himself: —And perhaps it is of no great importance, since the course of the fever is not at all altered by it: the fever neither being increased nor diminished by its appearance, nor any ways apparently altered ; neither is there any increase, alteration, or diminution of the fever, upon its going off; (which it does commonly in a few days.) There is also another kind of eruption, which does not commonly take place before the third week of the disease ; and more frequently occurs when there have been symptoms of putrefaction in the first and second week. — This eruption consists of excrescences, something like warts ; but of less diameter, and greater height from the skin ; of a blackish color ; and of pretty fine texture. — The author 215 A REGULAR CONTINUED FEVER. has not been able to discern any cause of their taking place, more than in the preceding instance ; or any consequence arising from them to the patient, (either in the appearances of the fever itself, or otherwise.) — This appearance is much less frequent than the one just described. The eruptions are not nearly so numerous, nor are they dispersed all over the body. — These seldom appear before the end of the second week : and they go off (or rather the excrescences drop off) about the middle of the third week ; without any increase or diminution of the disease. To return to the abatement of the disease in the third week: — The urine sometimes deposits a copious lateritous sediment for a day or two, and afterwards returns to its natural appearance. Sometimes there is a copious lateritious sediment in the urine made in the night; and a mucous sediment in what is made in the day. — The costiveness goes off; and the feces return to their ordinary appearance.— The eyes (unless when the delirium has ended in stupor) begin to have a more healthy appearance ; are more composed ; and express a greater attention to the objects around them. — All the secretions become gradually increased : not equally ; but sometimes one increases, and sometimes another. — The sleep returns, but not in an uniform manner : (the patient sometimes passing a tolerable, at others a restless night.) — There is sometimes a greater degree of thirst than was shown in the second week. — The appetite returns, but seldom regularly : being sometimes voracious, though the patient is notwithstanding satisfied with a very small quantity of food : in other cases it returns very slowly. — The depression of strength sometimes goes off almost at once ; and (what is singular) leaves the patient with a greater feel of weakness. — Thus the disease disappears, and the patient recovers his strength very quickly. The cases, in which Relapses take place, will be described in that dissertation which will treat of irregular continued fever. TREATMENT OF A REGULAR CONTINUED FEVER. When the Fever Runs its Course. —Two means of recovery—One by crisis; the other by gradual decline without crisis—Fatal complications—Question, as to the propriety of leaving the disease to run its course, or of means being used to carry it off'?— Many practitioners reprobate the attempt to arrest the course of fever—Doctrine of morbid hnmoi —not sustained by facts—Effort of nature to expel noxious matter — Vagueness of the word nature —A truer supposition, that the successive actions in disease, like those in health, are the result of fixed laws of organisation—Relative success of cure—after the use of medicines, or when the fever has been left to itself— Difficulty of determining the question—Felt by the author, —notwithstanding his large experience—Commonly some treatment has been attempted in the outset of fevers, before regular advice is procured—No sets of comparative cases recorded— Attentions to the patient, when the fever is left to its own course—A person with fever to be placed in an air of moderate temperature, —according to the climate in which he lives—In London, a good range is from 55° F. in winter, to 65° F. in sum- 216 HISTORY AND METHOD OF TREATMENT OF mer—The air should be colder than the surrounding bodies—These should not be less, in England, than 75° in winter or 80° in summer—Means of warming the air of the apartment —By hot water, stove or furnace, and open fire—Equable warmth of the body kept up in bed—All exertion to be avoided—The kind of bedding and body clothes —Change of bed and body clothes—Too great heat to be avoided—Evaporation of water —fanning—light clothing—Rest in a horizontal position—Mind to be at rest also—Fresh air to be introduced into the apartment, and noxious vapours and particles to be removed—Draughts of air to be avoided—Duration of a regular continued fever, between two and three weeks—The kind of food and drink to be taken—Only small quantities of food allowable, and these not of an animal kind—Even after a crisis, relapse is often caused by the too early use of solid animal food—Strength restored by rest, sleep, and very moderate nourishment—Eggs and milk objectionable—Of vegetables, cabbages, lettuce, green peas, and the like, are to be rejected—Slight nourishment is required, in the beginning of a regular continued fever—The system supports itself, by the absorption of fat and other tissues—Adhesive food, such as animal jellies, to be withheld—Farinaceous matter, coagulated by heat and dissolved in water, such as barley water, &c, the best nourishment, —sago, rusk, &c.—Fruits, such as grapes, figs, and dates, —the first when recent, the two last when dried or exposed to the heat of boiling water; also, apples, pears, and peaches, when boiled, baked, or roasted, are good in this fever—Cucumbers, melons, &c, inadmissible—Animal food, of any kind, never necessary in regular continued fever—Prejudices strong in favor of animal food—The kind least hurtful—Albuminous substances are bad —Milk may, on occasions, answer—The solutions of the flesh of young animals and of membranous and ligamentous parts not so digestible as those of the flesh of old animals —The oil or fatty matter to be removed by skimming, after the broth has been cooled —Animal foo'd improper in the first week of continued fever —Thirst a distressing symptom in fever —The Greek physicians enjoined abstinence from drinks —Some modern practitioners have forced patients to drink water or watery fluids beyond their wants —Both practices objectionable—The temperature of the drink, —to be left, as well as the quantity, to the patient—The quality of the watery fluid—Mode of decomposition of certain salts, if largely diluted —Pure water is insipid or mawkish —Infusions of sage, balm, &c—Weak vinous fluids—Small beer—Barley water, and the like, acidulated with lemon-juice. The author comes now to lay before the public the Treatment of a regular continued fever. It has been stated, that in the ordinary course of a regular continued fever, there are two means by which the patient may recover, without the aid of medicines.— One of these is Crisis ; which terminates the disease most commonly in the second or third week, in less than twenty-four hours. The other is, the disease beginning to diminish after the fourteenth day ; and going off of itself, without any marked crisis. — If either of these means of terminating, the disease by the efforts which arise in its ordinary progress, always took place; the practitioner would in that case have nothing further to do, than to take care that the patient should be supplied with proper nourishment to support him through the disease, and prevent any accident which would destroy him. It has. also been observed, that sometimes depression of strength, sometimes the attack in the critical paroxysm, sometimes the delirium, (even when it merely keeps pace with other appearances of the disease,) is fatal. There arises, therefore, a question, whether fever is to be left to itself, to go through its ordinary course ; or whether means are to be taken to carry it off; — and what these means are ? A REGULAR CONTINUED FEVER. 217 In considering this subject, it is evident, that if there was any medicine that would certainly carry off the fever immediately, or soon after its exhibition ; and would act equally and certainly in all fevers; it would be infinitely better to employ such medicine, and immediately relieve the patient from the pain and uncertainty of the disease ; than to allow it to pursue its course. It is true that any attempt to carry off fever has been reprobated by many practitioners of great experience.—Many practitioners have believed that some /;u??io>-,(that is to say, some noxious fluid,) or to give the doctrine its full scope, some noxious solid or vapor; by some means gets into, or is produced in the body ; and that fever is only an exertion of the body to destroy or evacuate this matter, or convert it to an innoxious or useful substance. The author however has never read or heard of any experiments, by w T hich any such noxious matter was proved to exist. (It appears, indeed, that sometimes a degree of putrefaction arises in the body ; but this has been already sufficiently considered.) In the next place, the author has already observed, that all fevers produce some substance, which (if applied to the body of a man in perfect health) has a tendency to produce, and actually has produced fever in many cases : but he has also endeavoured to show, that this infectious matter has no influence on the fever, when it has once been excited. — In practice moreover it is found, that if a person ill of a fever, has that fever terminated in consequence of medicines employed ; the fever does not return ; nor does any other disease take place. — It is however exceedingly difficult to argue on the negative side of a question. Hence if a man in any science makes an assertion, it behooves him to bring some proof of such assertion : but this has unfortunately been very rarely the case in medicine; where a man has very often taken his own whim as the truth, without bringing any proof. — If there be actually any noxious substance in the body, why have not those practitioners who have said there was ; pointed out its properties ? Is it solid ; is it fluid ; or is it in vapour in the heat of the human body ? is it red ; is it yellow ; or is it blue ; or any mixture of these colors ? is it hard or soft ? has it any taste or smell ? what is its specific gravity ? have its effects been investigated in mixing or combining it with various other substances ? If those who suppose such matter to exist, have not shown that it can be investigated by any of these or by other qualities ; it is a phantom of their own brain. — It has however been a common assertion, that although you are not able to demonstrate it by any such quality ; yet it cannot be demonstrated that it is not. But can a practitioner gain any more by this assertion, than by saying, that the moon cannot be demonstrated not to consist of cream cheese ? — So far, therefore, in treating a patient in fever, this idea of humor is to be totally neglected. Since however many practitioners of eminence have assumed the idea, that there is some humor or matter in the body; it may be worth while to inquire into the origin of such belief. 19 218 HISTORY AND METHOD OF TREATMENT OF In fever itself, there is only one appearance which can give any shadow of probability to such a doctrine. This is, if a crisis should happen in a fever which appears to be a continued one, on the first, third, or fourth days of the disease ; the disease commonly returns, and continues as an intermittent. If a crisis should take place soon in the beginning of the second week, and not be quite perfect in itself; relapses frequently take place. If a crisis should take place towards the end of the second week, it is seldom that the fever returns ; although the crisis should not be quite complete. In the third week of the disease, if anything like a crisis should make its appearance, the disease almost always goes off. — It has been said, that this depends upon an effort of Nature to throw noxious matter out of the system. It has been supposed for example, that at the beginning of the disease, this matter not being concocted, the effort of nature is premature ; and that therefore the matter by remaining, occasions the fever to return, and to become an intermittent: That when - the crisis does not take place till towards the end of the first or beginning of the second week, the matter becomes more concocted ; and nature by her efforts throws off a larger quantity, and there is not enough left to occasion an intermittent; but yet enough sometimes to occasion a relapse : And lastly, that if nature does not make an effort to produce a crisis till towards the end of the second or third week, the matter has been so far concocted, that from that time it ceases to be capable of reproducing the disease. — The author however can only consider all this as a repetition of the same facts in other terms. What is nature ? is it a discerning being ? for if it is, it is very much mistaken w r hen it tries to throw matter out of the body before it is concocted. Nature indeed is a word so vague, and is applied in such ambiguous and various ways ; that it is impossible it should be understood : but it is a term under which men are always inclined to hide their ignorance. The author is not disposed to point out the various ways in which it has been used ; (for on this subject he refers his readers to Lord Bacon :) he only means here to endeavor to point out the meaning (as far as he can judge) in which it has been taken by those, who have said that nature endeavors to produce a crisis in fever before matter is concocted. — A man is born with few or no ideas: (whether with any or no, is a proposition the author does not mean to argue.) When he comes into the world, his eyes open ; and objects form pictures on the retina, and by degrees impress ideas on the mind. It has been said, that nature produced these ideas. In that case however, it would undoubtedly be perfectly superfluous that pictures should be painted on the retina. — The samp, thing may be said of all the other impressions made on the other organs of the senses. A man, when he is born, has his teeth formed in his jawbone : if after the proper time of his receiving nourishment by sucking the breast of his mother, the teeth rise up and cut through the gum ; it has been said that nature makes his teeth rise up, when it is necessary to cut through solid food. It is undoubtedly the Almighty 219 A REGULAR CONTINUED FEVER. (who cannot err) that made this contrivance; and not nature, a secondary, fallible, and imaginary being. —In like manner, in inflammation ; a quantity of fluid is extravasated into the cavity or cavities of the inflamed part: this matter so extravasated, is converted into pus, destroys the part originally inflamed, makes its way externally, and is evacuated out of the system ; leaving a cavity, which is afterwards filled up by granulating flesh : a fresh skin is formed over this; and the granulating flesh is converted into parts similar to those which were destroyed. This surely was a contrivance of that Being, who in his infinite wisdom created all things : why should we transfer it to a secondary imaginary being ? — So in fever, the author has endeavored to show, that when the attack of fever takes place, it is followed by a hot fit; and that the operations of the body which take place in the hot fit, have a tendency to carry off the derangement which has taken place in the cold fit. — So also it has pleased the Almighty to give powers to the human body capable of producing a crisis, which carries off the disease.—Why should there here be introduced such an imaginary being, as nature, to make blunders ; (not knowing when some other imaginary substance has suffered an imaginary change ?) — Is it not much easier comprehended, that the body is so constructed, that in all paroxysms of fever an effort is produced to carry off the disease ; although that effort does not always succeed ? — Nor do other efforts always succeed that the Almighty has pleased to give to organised beings. (All seeds of plants attempt to grow ; though not one in a million succeeds: and a single cod-fish lays three millions of eggs in a year; though not three of these produce cod-fish which arrive at maturity.) — It is not therefore singular, if the Almighty has chosen so to form the human body ; that every attack of fever should produce a hot fit, in which operations of the body arise tending to carry off the disease, but which in fact do not always succeed. Is it then necessary to have any reference to a secondary and imaginary being, w T ho may make a blunder ; and try to carry off matter, before it is prepared for it ? — The fact is, that a fever begins gradually, increases to a certain point, and continues in that degree for a certain time ; afterwards (if the patient is not killed in the manner already mentioned or cured by a complete crisis) it gradually diminishes ; and goes off without any cause which has as yet been discovered. But let us return to the consideration, whether a fever should be left to itself ; without the practitioner's employing any means to carry off the disease, but only attending to the patient during the progress of it: or-whether he ought to employ some remedy to attempt to carry it off, either by producing a perfect crisis, or by carrying off the disease without any attention to the natural crisis by which it is frequently cured. The first thing which influences the practice is the inquiry what remedies have been found out; by which a perfect crisis maybe 220 HISTORY AND METHOD OF TREATMENT OF produced ; or which may cause the disease to be carried off, without any attention to the natural progress or cure of it. The first thing that is of moment in attending to this proposition is the efficacy of such medicines as have been employed for the purpose of shortening the duration of fever, (without having any attention to what happens in its ordinary course.) And whether actually more fevers have been cured, so that the patient has perfectly recovered, when such medicines have been employed : or when the fever has gone through its ordinary course. This question is exceedingly difficult to determine, from the very great inaccuracy of the evidence as to medicine ; an inaccuracy so great, that the author himself has no means of determining the question. It is true in the first place, that besides his private practice for upwards of twenty-five years ; he has been physician to an hospital which receives nearly four thousand patients in a year ; and in which patients laboring under fever, are always admitted in preference to others. There is almost always also febrile infection, which frequently produces fevers in this hospital; notwithstanding the utmost precaution to keep it clean and well aired. He therefore might be supposed to possess sufficient evidence, for determining whether a regular continued fever more frequently terminates in patients being restored to health, when they are left entirely to themselves, excepting for the attendance given them, their receiving proper nourishment, and other safe-guards during the progress of the disease ; or whether a greater number recover, when means are employed to shorten the disease. It must be observed, however, that those people brought into the hospital already afflicted w r ith fever, may have had the course of that fever disturbed, by remedies employed before the patients are received into the hospital : though this cannot generally be found out. These fevers are beside rendered irregular by the motion and fatigue of bringing the patients into the hospital. Those who catch the fever in the hospital are often ill of other diseases : the symptoms of which are so intermingled with the fever, as to render it perfectly irregular. From these causes the author has not been able to discriminate, with any degree of certainty, what number of patients would recover, supposing they were taken ill of a regular continued fever ; the fever being supposed left to pursue its ordinary course, without the assistance of medicine.— In the second place, the practice of medicine is so unfortunately constituted in England, that when a person is taken ill of any disease ; he generally does whatever the first violent man he meets with tells him is proper to be done ; or he applies to mercenary practitioners, whose business it is to mix medicines according to the prescription of physicians who are supposed to study the art: without its being decided whether the cases are the same. Supposing, therefore, that physicians were even very perfect in the knowledge of fever, the disease is commonly totally deranged before it comes under their inspection. If they 221 A REGULAR CONTINUED FEVER. were to endeavor to lay down the evidences by which it might be determined whsther a regular continued fever, in pursuing its ordinary course, would more frequently terminate in health, supposing it was left to itself, the practitioner attending only to giving the patient proper food, and taking care that those other things, which are called non-naturals, to wit, sleep, secretions, &c, be properly regulated ; or whether the patient would more frequently recover when medicines were administered ; still it would be hardly possible, without such a formula, as the author has already pointed out in the Medical and Chirurgical Transactions, to determine the question with any degree of accuracy. It is further to be lamented in the third place, that where this difficulty does not take place, (as it certainly does not in several parts of Europe, where the practice falls entirely into the hands of physicians, yet no sets of comparative cases have been recorded. These physicians have not pointed out whether the diseases, in pursuing its own ordinary course, (what have commonly been called non-naturals having been only attended to,) has oftener terminated in health ; than where medicines have been employed to carry off the disease. Physicians have been too often more anxious to recommend some favorite practice or medicine ; than after divesting themselves of all prejudice, to endeavor to render medicine as certain a science as it will admit of being made. Such being the situation of the subject, how can the author determine, whether (supposing fever was perfectly regular) it would be better to let the disease go through its whole course ; or endeavor to carry it off by medicine.—-It is therefore left to him to show first, how to conduct the patient through the disease, (supposing the fever perfectly regular in itself; and that nothing has as yet been discovered, which will carry off the disease at once :) — and in the second place, to consider what are the powers of the medicines, which have been supposed to produce a crisis similar to that which takes place in the ordinary course of a continued fever, (as has already been described) ; or to carry off the disease in a manner altogether dissimilar to those, which put an end to it in its ordinary course. The first argument therefore to be pursued is, what attentions are to be paid, supposing we are to do nothing that shall prevent the fever from going through its ordinary course. The first attention to be paid is to the situation of the patient. — Man evidently was originally an inhabitant of a warm climate only: where he wants no more covering to defend him from the inclemency of the atmosphere, than what he was born with or afterwards grows upon him. He was probably driven into colder climes by war ; and in colder climes he began to have more vigor : still, however, it was necessary for him, even in perfect health, to defend himself by external clothing; and, when without exercise, to give heat to the atmosphere by various means which he had invented, particularly by the burning of fuel. — A man affected with fever has the powers of his system depressed ; and therefore cannot defend himself against the 19* 222 HISTORY AND METHOD OF TREATMENT OF cold of the atmosphere. Besides, a degree of cold greater than a man has been accustomed to, contracts all the external vessels ; and therefore prevents that relaxation which ought to take place in the crisis; and of consequence tends to prevent a crisis from taking place. It also tends to render the diminution of the disease in the morning less considerable. — On these accounts, a man in a fever should not be suffered to remain in an atmosphere (or any other medium) of too small a degree of heat. The heat of the surrounding bodies has a different effect on the human body, according to the degree of heat it is accustomed to bear. If a man is accustomed to live in a heat of 90° of Fahrenheit's thermometer, he will feel surrounding bodies, heated to 70° extremely cold ; (he will feel them as cold as a man, accustomed to live in 70° of heat, will feel a medium of 60°). Therefore, in defining the heat in which a man should be kept in a fever, reference must be had to the country he is in. -— In London, in the summer, an atmosphere heated to 65°, will not do mischief from being too cold ; nor in winter, will an atmosphere heated to 55°, be noxious from its cold.— In other climates, different rules will take place : and what these rules are, the author cannot accurately lay down. He conjectures however from what information he can procure, that in the warmest climates, 80° would not be noxious from its cold [heat ?] in the atmosphere ; and that in the coldest climate, less than 50° would be hurtful. There is a great difference, how r ever, in the degree of heat which the atmosphere should have ; and in the degree of heat which the substances immediately surrounding the body ought to possess. —The atmosphere is often only applied to the face, and drawn into the lungs ; especially when a man is in bed. — The face has been accustomed to various changes in the atmosphere ; and whatever part has been accustomed to such changes, is much less affected by them. — With respect to the lungs ; the atmosphere is tempered in its passage through the nostrils, mouth, throat, larynx, and the beginning of the trachea ; so that it cannot go so cold into the. lungs, as to affect them much from its temperature. Moreover, there is in the atmosphere about a fourth part of a vapor, which w r e call pure air ; which is necessary to be applied to the blood in the lungs, in order to give the necessary vigor to the system. As in a fever there is also depression of strength ; it certainly ought not to be still more depressed, from a sufficient quantity of pure air not being thrown into the lungs. But since the warmer the air of the atmosphere is, it will be more rarefied ; a less quantity of pure air will be contained in the same volume of it when the atmosphere is warm ; while a small increase of coldness of the atmosphere thrown into the lungs, will be counterbalanced by a greater quantity of pure air giving vigor to the system. On these accounts, the atmosphere in which the patient is, may be colder than the bodies which immediately surround him. — With regard to the bodies which immediately sur- A REGULAR CONTINUED FEVER. 223 round his person, their heat should be much superior to the heat of the atmosphere ; in order that they may not do mischief, by producing contraction ; (thereby increasing the fever, and preventing relaxation and crisis from taking place). In England, the heat of bodies immediately surrounding the patient should never be less than 75° in winter, or 80° in summer. The next thing to be attended to is, how this temperature of the atmosphere, and likewise the temperature of the bodies immediately surrounding the patient; are to be kept up. — In the first place ; if the atmosphere be of too cold a temperature, its heat ought to be increased by some means which will not diminish the proportion of pure air in it; nor introduce into it any noxious vapor, or any noxious fluid or solid floating in it in small particles. — According to the means which men have of procuring conveniences, (either in sickness or in health,) different measures ought to be pursued ; and where the means are not sufficient, the measures pursued must be according to what can be afforded. — If a man has sufficient means ; the best mode of warming the atmosphere is, to allow the air to enter into vessels surrounded by boiling water ; afterwards to let it.pass into vessels cooled (by any means) to at least 60° of Fahrenheit's thermometer; there being in these latter vessels, a means of allowing condensed water to pass off, without any communication between the contained vapor and the vapor of the external atmosphere. The air should then pass from these vessels into another set of vessels, surrounded by boiling water; and from these the air so heated, should enter into the bed chamber of the patient; (so as too keep its heat up to the degree which has been pointed out). — The advantage of this apparatus is, that all the water which was suspended in the air of the external atmosphere will be dissolved in it, when it is drawn into the vessels surrounded by the boiling water ; (as hot air dissolves a much greater quantity of water, than cold air). When the air is carried from the vessels surrounded by boiling water, into the vessels cooled to 60° or under ; the sides of these vessels will cool the air next to them ; and precipitate the water dissolved in it as the air passes along, (for all of it successively comes in contact with the sides of the cold vessels). All the water which cannot be kept dissolved in the air in the heat of 60°, (or whatever less degree of heat is applied,) will be precipitated ; and carry along with it all noxious particles, whether solid or fluid ; (which will pass off along with the water in the apparatus applied for that purpose :) and thus the air will be left pure. — The air warmed by the second set of vessels surrounded by the boiling water, may be led into the bed chamber of the patient, in such quantity as to give the proper degree of heat. — Such would be the most perfect means of warming the chamber of a patient afflicted with fever. It is in the next place necessary for the author to state, when such means are not in readiness; in what manner heat'may be produced in a proper degree. 224 HISTORY AND METHOD OF TREATMENT OF The first thing to be attended to is, that the mode of producing heat shall not diminish the proportion of pure air in the atmosphere ; nor introduce any noxious vapor or any noxious fluid or solid particles floating in the atmosphere. — Therefore no fuel, (for the burning of fuel is the common mode of producing heat,) should be burnt in the room, unless all the vapors arising from it can be entirely carried off. For besides that the burning of fuel destroys a quantity of pure air, and renders it totally unfit for respiration ; and therefore would oblige the patient, whose strength is already too much depressed, to make deeper or more frequent respirations, so that his strength would be further exhausted ; there are also very often noxious substances (as vapors or small particles of solids or fluids) produced by the burning of fuel. (If there be, for example, pyrites or arsenical ores in the fuel; then volatile vitriolic acid, calx of arsenic, and other noxious matters, will be mixed with the atmosphere which the patient breathes.) From this consideration, the rooms in w r hich the patient afflicted with fever is, should never be heated by fuel burnt in a chaffing-dish or brazier; or by any contrivance by which the whole of the vapor arising from the burning fuel is not entirely carried off. — Moreover, if the fuel be burned in a stove or furnace in the middle of the room, or where the vapor arising from such metallic substances is not entirely carried off; two mischiefs will arise. In the first place, a calcination of the metal will destroy the pure air ; and leave the atmosphere (which the patient is to breathe) with a less proportion of it; and by consequence render it necessary for the patient to make more frequent and fuller respirations, in order to take the same quantity of pure air into his lungs. In the second place, it often happens that noxious vapors arise from metallic stoves (in which fuel is burnt), which are pernicious. — If, however, a stove or furnace, containing the burning fuel; is constructed of porcelain, or any other substance not altered by heat; neither of these causes of mischief will arise. If the outside of any such stove was to be heated to a much greater degree than that of boiling water ; then indeed particles of animal and vegetable matter, which often float about the room, falling, upon the surface of a stove, would be rendered empyreumatic ; and so contaminate the air as to render it noxious when respired. The author does not see any objection to heating the air of the bed chamber when necessary, by such a stove or furnace, (not apt to be at all decomposed or altered by heat;) if the heat of the external surface of such stove or furnace is alw T ays kept under the heat of boiling water. — If the chamber be kept heated by fuel burning in a grate or open fire-place, where all the air serving for the burning of the fuel, together with all the vapor arising from the burning fuel itself, is carried off by a chimney ; there certainly can no objection arise from the diminution of pure air in the atmosphere, or from noxious matters thrown into it. The only question with regard to the heat produced in this way is, whether it be perfectly and equally diffused over the whole chamber 225 A REGULAR CONTINUED FEVER. of the patient, or at least over that part of it in which the patient is. If it be so diffused, no mischief can arise. But if cold air should be drawn into the room, in such manner as to pass over the patient; then indeed this mode of heating the room would have all the bad effects that have been above enumerated, as arising from the patient being exposed to too cold an atmosphere. Attention should therefore be paid, in this case, that no stream of cold air be allowed to pass over the patient. — These are the means which have been practised to heat the atmosphere surrounding the patient by burning fuel. — The author is not acquainted with any means of generating heat in the patient's bed chamber preferable to burning fuel. The next means of keeping the patient in a proper degree of heat, are the modes of heating the substances immediately surrounding the body, as well as the air of the atmosphere. For this purpose, it is much better that a .patient should be kept in bed ; where the heat is more equally diffused all over his body, than when he is in the ordinary clothing which he wears when out of bed. There are other more cogent reasons for keeping him in bed in fever, which will be afterwards enumerated. — Supposing, then, that a patient should be seized with fever, and that he is immediately to be put to bed ; if the bed itself is not perfectly dry, it should be dried and heated before a large fire ; and clean sheets are to be laid upon it, which are also to be properly warmed, (as are the other coverings.) The bed should by no means be heated by any hot substance, such as a warming pan ; which, if there be any moisture about the bed or bed-clothes, raises that moisture ; thus doing essential mischief to the patient, as will afterwards be explained.—After the patient is in bed, the heat of the bed-clothes or substances immediately surrounding him, can only be kept up by the heat generated by the patient himself. All that can be further done, if it be necessary from the state of the external atmosphere to warm them, is, that they should be kept warmer, by forming them of substances which communicate heat with difficulty, and which therefore confine the heat generated by the patient. It is likewise necessary that the strength of the patient should not be exhausted by exertion. In the first place the bed which is under the patient, should be of soft feathers ; which w r ere better loosely quilted that they may be firm enough to give support without giving way ; and at the same time sufficiently loose to be very bad conductors of heat. (The author must here remark, that he is giving the best directions, as far as his judgment goes, knowing at the same time that they cannot be always perfectly complied with ; yet it is necessary that the best should be known, that they may be approached as nearly as possible.) Some have thought that the bed had better be a mattress ; formed of wool or hair, firmly quilted. This the author conceives to be part of that superstition, which inclines men in health to believe, that it is a meritorious act to give themselves pain. In fever, the body should certainly be supported by substances, which 226 HISTORY AND METHOD OF TREATMENT OF make its own weight less disagreeable to the patient. (This observation however, belongs to another object of attention during fever ; w r hat is now treated of, being only the heat of surrounding substances.) — Under the circumstances at present under consideration, the heat is not to be lost by the patient's being laid upon good conductors of it. Upon these general principles the following directions are given. The covering over the patient ought to add, to the quality of not conducting heat readily, that of being of very little weight. The immediate covering of the patient should be cotton cloth ; (that is, his shirt and sheets ;) as being less apt to conduct heat than linen. The author mentions in the first instance, that which is the best without regard to expense. Therefore, an eider-down covering, quilted in some thin material, is the best; for although certainly pressure of bed clothes ought to be avoided, since supporting that pressure is an exertion of the powers of the body ; there is something in the habit of bearing pressure more than equal to such slight covering. — At any rate the covering which goes over the sheets should be, where it can be had, of the newest and lightest woollen cloths, such as are called blankets : (for the wool of animals is so constructed, as upon being pressed together frequently, to weave itself into a thick and heavy substance, called felt ; which would by no means be a proper covering for a patient affected with fever.) All kinds of clothes, when moistened with any watery fluid, become much better conductors of heat than when they are perfectly dry. — For this reason, if (from the exudations from the patient himself, or in any other way) they should become moist, they ought to be removed; and fresh and dry coverings be substituted in their room. — Another reason for removing any of the coverings of the patient when moist is, that the evaporation of the moisture produces cold ; which cold is apt to be transmitted to the patient, and to produce the mischief which has already been said to arise from his body's being exposed to too great a degree of cold. The cold thus produced is also apt to act more forcibly upon particular parts of the body, which have not usually been accustomed to exposure to cold ; and therefore is much more hurtful. * Hitherto means have been proposed to prevent the patient's being too much exposed to cold ; either of the air of the atmosphere, or of the solid substances surrounding him.—The next thing to be taken notice of is, how to avoid too great a degree of heat; either in the atmosphere or in the solid substances surrounding the patient. This indeed is a matter of much greater difficulty to give directions about: and especially for the author, who has always practised in temperate and cold countries (particularly as few or no attempts have been made in warmer climates to give coolness to the atmosphere and the substances surrounding the patient.) He can therefore only conjecture by what means this object may be obtained.—Even in the climate of England, the atmosphere is sometimes heated to a greater degree 227 A REGULAR CONTINUED FEVER. than is convenient in fevers, (as has already been shown.) The only way of cooling it, that can at all be put in practice, is by the evaporation of watery fluids ; which may be produced by sprinkling water upon the floor and other parts of the bed-chamber of the patient. — But then there is danger of the evaporation producing at times too great a degree of cold, or partial cold. The effectsof this are somewhat obviated by using (instead of pure water) water impregnated with the essential oil of aromatic plants. (The author, however, has not much dependence on this, although it feels very refreshing to the patient.) Whenever the patient is in a climate, whose heat is less than ninetyseven degrees of Fahrenheit's thermometer, (which is nearly the heat of the body of the patient,) removing the air in immediate contact, by putting the atmosphere in motion by any kind of fan ; renders the air which is in immediate contact with the body much colder than it otherwise would be. — Such means, in case of too warm an atmosphere, seem to be very proper to be employed. It is a question, whether-exposure to a stream of air colder than the heat of the human body, would be safe ? — Certainly if that stream of air contains moisture, it would do mischief; in consequence of the particles of water (which were before suspended in the air) being dissolved in it by the superior heat of the body itself; and thus producing cold in too great a degree. — If the air however passing over the patient under these circumstances, had no water suspended in it; the author does not apprehend any mischief; (excepting there was moisture immediately covering the skin ; which being dissolved in such dry air, might produce too great a degree of cold.) The solid substances covering the patient, in case of his being in too warm an atmosphere, ought to be thin ; but still, however, they should be bad conductors of heat, (such as cotton wove thin): for if these should happen to get moist, if they were good conductors of heat, the cold generated by the solution of such moisture in the air, being immediately applied to the patient, might do a great deal of mischief (as has already been explained). In fever, a patient should avoid all extraordinary exertions. — He should be placed therefore horizontally in his bed, or as nearly so as he is accustomed to be when in health. In this position he is supported everywhere by the bed ; and is not obliged to exert any of his muscles, (as he is when in an upright posture,) to keep the parts in equilibrium. At the same time, great care should be taken, that his mind be kept free from all exertions whatever ; and especially all such as produce any anxiety. — In regular continued fever, when severe, the patient is not able to judge of anything truly. The mind cannot arrange the arguments on each side of a question, so as to draw from them any perfect conclusion ; much less can it form a rule for any action : nor, when it has formed one, can it imagine the mode in which the effect is to be produced. — No advantage can, therefore, be 228 HISTORY AND METHOD OF TREATMENT OF gained, by exciting the patient's attention to his affairs: and the force of the system is only exhausted by fruitless attempts.—If a regular continued fever should even be less violent in its beginning, so that a man might then attend to his affairs with some effect; yet any advantage gained by such attention would be much overbalanced by imprudently exerting the force of the system. — As soon, therefore, as a patient is seized with a febrile attack, he should immediately be put to bed ; and left under the care of one attendant only ; and everything that can call the operations of the mind into action is to be avoided. — It might be conceived, that the practitioner, who was called in to attend the patient, need not be warned to avoid exciting anxiety in the mind of the patient about his disease : the hint however is necessary; as there are many practitioners, who (from inattention) make the disease the subject of their conversation, in the hearing of the patient. It has even been affirmed (by those who wish to vilify medicine,) that there are practitioners who, out of a point of vanity, talk learnedly to the patient about his disease ; and that there are some who have even wished, by alarming the patient, to fix the disease, and prevent it from being carried off. That this is true, the author can hardly believe : he only intends to warn all practitioners not to disturb the mind of a patient at any time in disease, but more particularly in fever. The patient being laid in bed, in a posture nearly horizontal, with a proper degree of heat and covering ; the next thing to be attended to is, the quality of the atmosphere which he breathes and also of that which surrounds him. — ft is necessary, as has already been observed, that a man should take into his lungs a certain quantity of a vapor, called pure air ; which has a certain effect on the system, necessary for life. This vapor does not affect the matter of the body, in a way which is manifest to the senses; excepting that it adds yellow to the red particles of the blood ; which is always so altered in the circulation through the body, that it must pass back into the lungs, in order that a man should exist. — This vapor makes about a fourth part of the atmosphere. —i The whole atmosphere is so mixed together by the currents which are constantly taking place in it, that pure air is found nearly in equal proportions 1 in almost all situations ; at least where the atmosphere does not stagnate; being the same in this respect in a room in a private house ; in the ward of an hospital in the centre of such a city as London; in a cultivated or uncultivated country ; or over the sea ; or indeed in any situation where currents of the atmosphere are constantly taking place. — In order, therefore, to keep up the due proportion of pure air in the bed-chamber of a patient, it is merely necessary that the air should not stagnate. The next thing to be considered is, whether a different proportion of pure air would be better adapted to the respiration of a patient in a fever, than that proportion which is found commonly in the atmosphere. — It is but lately that the proportion of pure air to the A REGULAR CONTINUED FEVER. 229 other vapors contained in the atmosphere has been found out; (it having been long known, however, that there were various other vapors mixed with it in the atmosphere). — Whenever any new and seemingly important fact has been discovered, (and especially if it cannot immediately be applied to any advantageous purpose in mechanical or chemical arts,) mankind in general, and very often even practitioners in medicine, conceive it must be applicable to some medicinal purpose. (Just as an infant, when allured by any thing which glitters in its eye, applies it to its mouth, supposing it must be likewise exquisite food ; so infants in medicine are dazzled with any surprising discovery, and immediately employ it for the cure of diseases.) They do not consider how extremely difficult an art medicine is; how fallacious experiments made in it often are (as has been observed long ago by Hippocrates) ; and by what slow degrees valuable medicines have had their powers investigated ; (as for example, how long it was before the effects of the bark of the cinchona, and of mercury and antimony, were brought to light ; so far as they are already known). —The author therefore conceives, that in fever it certainly, is not at all known, whether the fever will go through its ordinary course better or worse for the patient's breathing an atmosphere having a larger or less proportion of pure air.—The other vapors which constitute the remaining threefourths of the atmosphere, may some of them be noxious ; and others of them may be breathed along with the proper proportion of pure air, without any detriment. As the vapors which constitute the atmosphere are extremely viscid, they suspend innumerable fine particles of various solids ; and also innumerable drops of fluids, which are principally water, (the effects of which last have already been attended to.) — Many such substances maybe very noxious and very improper for the patients to breathe in health, and be still more noxious in disease. —That they are very noxious in many diseases, is easily seen from what happens in hospitals ; as for example, in almost all kinds of wounds and uicers, inflammations and suppurations, and in all affections of any of the parts employed in respiration. In all these diseases the patients in hospitals recover much more seldom, than in the air even of London ;) a town at least seven miles long and three in breadth:) and in such a toWn these diseases go on much worse than they do in the country, at the distance of ten miles from it. What are the noxious particles, or vapors, mixed with the atmosphere, which render it so hurtful in these diseases ; has not been investigated. — The breath arising from the lungs of animals, the vapors which arise from their bodies, the vapor arising from the immense quantity of water which is constantly putrefying, the vapor which has served for the inflammation of fuel, &c. are all improper for respiration. The particles of soot, ashes, horse-dung, gravel, and a vast variety of other bodies, floating in the air of a large town, render it undoubtedly improper for respiration : — but which of all 20 230 HISTORY AND METHOD OF TREATMENT OF these small particles, vapors, fluids, or solids, are hurtful in the diseases which have been enumerated ; has by no means been investigated by experiment; (the only means of investigation which can in the least be depended upon.) However noxious these vapors may be, which ordinarily contaminate the atmosphere of an hospital or large town, in the diseases which have been enumerated ; — they do not seem to have very bad effects in a regular continued fever. A patient in a regular continued fever, goes through its course under exactly the same treatment, as safely in St. Thomas's hospital; as he does in the country, or in an air in which no noxious particles are known to exist. — It is undoubtedly true, that vapor arising from putrid substances depresses the strength ; and in so far must be noxious in fever ; but when care is taken to avoid such putrefaction, and (by a proper circulation) to keep a due proportion,of pure air; infectious vapor and most other noxious substances, do not seem (from experience) to have much effect in regular continued fever. Two things must be observed, therefore, in regulating the air of the room in which the patient is confined in such a fever. First, that there shall be a circulation of the air; or, in other words, that such a quantity of air shall enter the room and pass out of it, as is sufficient to keep up the proper proportion of pure air. This must be done in such a manner, as that the fresh air passing in shall not flow in a stream over the bed of the patient; lest it do mischief by its temperature.— Secondly, it is necessary that the air shall not be contaminated by putrescent matters. It is much better then that the food, (and whatever else is necessary for the patient,) should be prepared in a chamber adjacent to that in which he lies; and that only the attendant upon the patient should be suffered to remain in his room. A regular continued fever, if it be left to pursue its own course, continues (as has already been said) for between two and three weeks; if the patient is not lost, or if no crisis takes place. A man cannot live for so long a time without some nourishment; it is therefore necessary, in the next place, to inquire what food and drink should be employed during the progress of the disease. . In the first place it is to be observed that in a regular continued fever, there is no time in which the patient is free from the disease, (as there is in a regular tertian) : and therefore those rules, which have been laid down as proper to be followed in a regular tertian, are by no means applicable in a regular continued fever. In a regular continued fever, no principal meal can ever be employed ; as the organs of digestion are always too much deranged, to be capable of converting a large quantity of food of any kind into chyle and blood. On the other hand, there is this great difficulty in the ordinary state of the body in health; namely, that in man, any interruption to the process of digestion, arising from fresh matter being thrown into the stomach, always interrupts the process, so as 231 A REGULAR CONTINUED FEVER. to render it much more imperfect; and often induces disorder of the whole system. (This however is not the case in all animals ; for a horse is constantly throwing in fresh matter, and the processes notwithstanding are going on very perfectly.) A man is often so far deranged in fever, as to render it in many things necessary to deviate from his ordinary modes of life in health. — In a regular continued fever, for instance ; the food cannot be thrown into the stomach in great quantity at once ; without greatly disordering the whole system, increasing the disease, and rendering it irregular. Small quantities only must therefore be thrown in at a time ; and this must be often repeated. In a regular continued fever, be it ever so slight, no solid animal food ought ever to be employed ; (whether quadrupeds, birds, reptiles, or insects). — Solid animal food, during its digestion, in a regular continued fever, greatly increases the heat to the feel of the patient ; still more to the feel of the by-stander ; and frequently (though not always to the thermometer. It produces great restlessness and sense of uneasiness, and an increase of depression of strength in the patient, during the time it remains in the stomach and intestines. — It totally deranges the fever; and often produces the appearance of afresh paroxysm. If it be made use of about noon, or before the next evening exacerbation ; this is almost always rendered more violent. It is true, indeed, that if an error be committed by employing solid animal food ; yet after it. has once passed through the intestinal canals, the system generally recovers itself; the patient being only weakened by the extraordinary exertion, and rendered less able to support himself during the remainder of the disease. —But if this kind of food be persisted in, it increases the evening exacerbations extremely ; brings on delirium much faster, and in a much greater degree than it would otherwise arise ; and prevents the fever from being worn out by its own progress, (as it otherwise would be). —All solid animal food is therefore, in every case, to be rejected throughout the wdiole progress of the disease. Even after the disease has been terminated by a crisis, animal food in a solid state should be rejected ; there being no cause which has produced relapses, (as far as the author's observation has gone,) so frequently as using solid animal food too soon. Supposing even a complete crisis should have taken place, and entirely terminated the disease ; it ought to be at least five or six days, before any solid animal food is ventured upon. — The author wishes to press this more strongly ; because, if a perfect crisis should take place, the appetite often returns and the patient is left in a very weak state. It has, in this case, been often conceived by the patient, and much more frequently by the by-standers ; that solid animal food would restore his strength soon. It must, however, be remembered, that when a complete crisis takes place, and carries off the fever entirely ; the depression of strength (which was a symptom of the fever) ceases ; and the weakness which was produced by the exertions and derangement 232 HISTORY AND METHOD OF TREATMENT OF of all the faculties in the system, is no longer increasing ; and that the patient, with very moderate nourishment, and with the sleep and rest so apt to ensue after the fever has been completely carried off, will have his strength restored in a very short time ; — without using anything that shall run any risk of re-producing the disease. The same objections arise against the use of such animal fluids as are coagulated by the coagulating juice of the stomach ; (such as serum, eggs, and other fluids of the same kind). — These become solid as soon as they are thrown into the stomach ; and have the same effects in disturbing the whole system, during their digestion, as have been just enumerated to be produced by solid animal food. — Milk is a fluid of this kind ; (being coagulated by the ooagulating juice of the stomach as soon as thrown into it) : and we find, that it. has been reprobated by Hippocrates, and many other practitioners. This subject, however, wiil be considered more fully hereafter. All such vegetable substances, as cabbage, lettuce, green peas, and the like, are to be rejected ; on account of their disposition to run into the vinous and acetous fermentations; which the stomach (having its pow T ers depressed by the fever) is now not strong enough to counteract. — Neither is it able to induce those fermentations which convert the food into chyle. — Chyle is therefore not formed from such food ; but a considerable quantity of vapor is extricated during the times these substances remain in the stomach and intestines ; distending and producing in them spasmodic contractions. In the beginning of a regular continued fever, no very great nourishment is required ; the system being, able to support itself for a time, without anything being thrown in to be formed into chyle and blood. In the case of a man in health, whatever quantity of food is thrown in, a certain part only is converted into blood : the remainder being either converted principally into water, and thrown out of the body; or into expressed oil, and deposited in the cellular membrane, (or what is by some called the adipose membrane). Hence we see, that where food can always be had in plenty, and the appetite is such as provokes a person to employ a great deal more food than is capable of maintaining the proper quantity of blood; if the superfluous quantity of chyle be converted into water, and evacuated, the person remains thin : — But if on the other hand, a great part of the superfluous quantity of food is converted into expressed oil ; a great quantity of fat is accumulated in almost every part of the body. When more food is used than is necessary for keeping up the proper quantity of blood ; there is always some quantity of expressed oil (and perhaps some other substances) formed in the body. These are laid up, as it were, in a reserve ; are absorbed and brought into the circulation again ; and are converted into blood, and supply in a degree the want of proper nourishment. — By what process they are converted into blood is not at all knowm ; but that they are so, is evident; inasmuch as a person strong and well-nourished, does not lose his fluids and become so A REGULAR CONTINUED FEVER. 233 emaciated in fever, and in many other diseases ; as if he had had less blood in his blood-vessels, and less fat, &c, when the disease first took place. — But when a great quantity of expressed oil is deposited in the cellular membrane ; it does not supply the place of food better, than if a moderate quantity had been so deposited ; the powers of the body not being able to make above a certain quantity of expressed oil into blood. Or in other w r ords it may be said, that although a man with a moderate quantity of expressed oil (that is, a man moderately fat,) can undoubtedly support himself in a fever, better than a man who was emaciated when the disease took place ; yet a man with a very large quantity of expressed oil is hurt by the absorption being increased in consequence of the fever. —The power of the system is thence oppressed by the quantity of expressed oil absorbed ; which not being converted into blood, must be converted into water, to be thrown out of the body. When therefore a man is in a proper state of nourishment when a fever begins, since in his body there is matter which may in part supply the loss of the blood during its progress ; it is not proper to disturb the system by exhibiting any kind of food liable to produce this effect, in the first days of this disease. If it could be foreseen, when a fever begins, (as it may be in many cases,) that it would be converted into a regular intermittent in a few r days ; it would not be necessary to derange the system, by exhibiting any kind of food that might produce any disorder in it; (such derangement preventing perfect intermissions from taking place).— But if it be known, (from the rules that have already been laid down,) that the disease is more likely to be a continued fever; although no nourishment is wanted immediately, there will afterwards come a time when a much greater quantity of nourishment will be required. The derangement of the organs of digestion also is not so great in the first days of the disease, as it comes to be afterwards; so that upon the whole, considering what may happen afterwards, (that is to say, how much nourishment will be wanted,) it is better not to let the patient sink ; but to give him as much food and such food, from the beginning, as will not produce disturbance. Every kind of food which is adhesive to the stomach when it gets into it, produces considerable disturbances in the system during the time it remains in the stomach ; (such as a strong solution of gum arabic, and jellies formed from the meat of young animals, or from the membraneous parts of animals dissolved in water :) such substances, therefore, should be avoided. — Farinaceous matter, coagulated by heat and afterwards dissolved in water, forms a food which gives indeed moderate nourishment; but then it is not adhesive to the stomach ; does not produce any disturbance in the system, in consequence of solidity ; nor is it apt to fall into the vinous or acetous fermentation, (and is not therefore acescent or flatulent.) — Farinaceous vegetable food, if dissolved in water, without being first coagulated by heat or otherwise, affords a very viscid solution ; which adheres to the sto-21* 234 HISTORY AND METHOD OF TREATMENT OF mach ; and produces great disturbances in the system. — We have seen that the ancient Greek physicians were extremely careful to coagulate farinaceous matter before they exhibited it to their patients, either in a solid form or dissolved in water; as their panis biscodus, or bread twice baked ; (the coagulation not penetrating sufficiently through the whole of it on its first exposure to heat.) On the same ground they broke down the farinaceous seeds of wheat and other grains, into small particles, (although not quite into flour ;) and exposed them to heat in an oven until they were browmed. — So likewise barley water is prepared, by boiling in the first place the barley in w T ater, till it be coagulated ; throwing away that water ; and then employing fresh water, by which part of the barley shall be dissolved. Such a solution of farinaceous matter in water, forms the simplest nourishment in fevers and other acute diseases. — Solutions of farinaceous seeds, thus prepared, (first by taking off the husks from the seed, then boiling the cotyledons or farinaceous parts in water, afterwards throwing away that water, and lastly adding more water, until a part or the whole of the farinaceous residue is dissolved ;) form that kind of nourishment which gives the least disturbance during its digestion. — It has been contended by many practitioners, that no other food should ever be employed in a regular continued fever ; as they have thought that it is of much more consequence to avoid all disturbance, and consequent irregularity of the fever ; than to give nourishment in a greater degree. Others, again, have thought it of consequence to give more nourishment. The next preparation of farinaceous matter is made by forming it into a cake, baking it, and afterwards boiling it in water until it is not quite dissolved ; and so exhibiting it to the patient. (Sago seems to be the farinaceous pith of some palm tree, prepared in this manner.) The author, in his Treatise on Digestion, has shown (by an accurate experiment,) that the same quantity of the same food in a solid form, gives much greater nourishment, than when it is dissolved in water: at the same time it is not improbable, that even when it is nearly dissolved, it is of somewhat more difficult digestion than wdien the dissolution is complete. , Next to food prepared in the manner which has been already described ; the cotyledons of farinaceous seeds (asof barley,for example,) boiled in water, until they have become very soft ; give somewhat greater nourishment; and have been thought by many to constitute a food of quite as difficult digestion, as ought ever to be employed in continued fevers. —Bread twice baked (which in our language is called rusks,) is nearly of the same degree of facility of digestion ; and of the same nourishment. — Farinaceous seeds, broken down into small particles and afterwards exposed to heat until they are brown; and given either in that state or boiled in water; appear to have been much employed by the ancient Greek physicians : although they are not now in use. 235 A REGULAR CONTINUED FEVER. Fruits are of various qualities with regard to digestion and nourishment. — Some of them contain a very considerable quantity of an acid ; which is evidently capable of digestion, as it corrects the putrescency of animal food ; (which no other acid does:) showing that it enters into the fermentations of the stomach along with animal food. — This is a subject, however, which it would be improper to argue here ; since fruits, whose juices .principally consist in this acid (such as lemons,) do not afford nourishment enough to be depended upon in fevers. Some fruits contain a mucilaginous substance, which is itself exceedingly apt to fall into fermentation ; and also to produce in the sugar which, in some quantity ? is found in all fruits, the vinous and acetous fermentations ; and thus to induce these fermentations in the stomach. These fruits are therefore flatulent and ascescent ; and of consequence cannot be employed with any propriety in this disease. Cherries, for example, are of this kind. Other fruits which contain a great deal of sugar and hence afford great nourishment, and but little of that mucilage which is so apt to fall into fermentations ; are easy of digestion ; and may therefore be employed in fever. The principal of these which are cultivated, are grapes, figs and dates; which are all of them agreeable to the stomach ; and may be employed along w T ith the preparations of farinaceous matter, which have been above enumerated.—While in their recent form however, the fruits last mentioned contain rather too large a quantity of essential oil, to be agreeable to the stomach during the time of a regular continued fever ; although the flavor of this essential oil is often very agreeable to a man in health. They also contain more or less of a mucilaginous adhesive matter.—By drying or by exposing them to the heat of boiling water, the adhesive matter is coagulated, and loses its adhesiveness; the essential oil is in a great measure evaporated ; and the objections arising from these sources are of consequence got rid of. The mischief however arising from their flavor and from their adhesive mucilage, is not so great as to prevent them from being employed, when recent; should they be good of their kind, and especially grapes; provided they be fully ripe. Another class of fruits contains, besides native vegetable acid, fermentable mucilage, sugar, and generally a small proportion of an adhesive mucilage like gum, with a quantity of farinaceous matter; and such are apples, pears, apricots, peaches, and nectarines. In the tribe of apples there is a large proportion of farinaceous matter and adhesive mucilage; and therefore apples and pears may be employed in regular continued fevers: but not unless they have had their mucilaginous substances coagulated by heat; which also destroy, in a great measure, the fermentable mucilage w T ith which they likewise abound. Boiled, baked, or roasted, they may therefore be employed as food, in a regular continued fever. Peaches and other fruits of the same kind, when they have been 236 HISTORY AND METHOD OF TREATMENT OF improved by cultivation, contain little else but farinaceous matter and sugar ; and may therefore be employed without any previous preparation. The fruits of the cucurbitaceae, whether ripe or unripe, are very unfit to be given in regular continued fever ; or indeed in any disease, when it is necessary to employ food of easy digestion. They contain a mucilage, which falls into fermentations with more difficulty, than any substance that we know. They resist so strongly the fermentations which take place in ; the stomach, although themselves of a loose and flabby texture ; as to have remained in the stomach above three days ; and to have been thrown up again undissolved and almost unaltered. Of this kind are cucumbers, melons, &c. These are the vegetable substances employed for food, with the properties which render them fit or unfit to be made use of, in regular continued fever (according to the degree of the disease). — That is, in a very violent regular continued fever, at the beginning, if the patient be in perfect health and strength and well nourished ; nothing but solutions of farinaceous matter, coagulated by heat, should be given. — If the fever is not so violent, although there appear to be no necessity for much nourishment at the moment; yet, as there will come a time afterwards when the fever will be more violent and alfect the organs of digestion more, it is proper to employ farinaceous matter coagulated, and nearly dissolved again in water, (such as sago); or only somewhat softened again by the water, (as barley boiled soft, &c.) ; together with such fruits as have been above pointed out. It has been a question, whether any animal food should ever be employed in regular continued fevers ; many practitioners having contended strongly, that no animal food should ever be given. —¦ Animal food, of any kind, is certainly much more apt to disagree with the stomach, to produce a great sense of heat throughout the system, and to render the pulse more frequent; than those vegetable substances which have been enumerated as proper to be employed in regular continued fever. Moreover men may live and be nourished, and their strength be perfectly kept up, by vegetable food alone ; even when they undergo great labor, or use violent exercise.— If thus in health, food of easy digestion is sufficient to maintain the powers of the body ; it is certainly capable of maintaining them in disease ; (where from the facility of its digestion, a greater proportion of it will be converted into chyle, than of animal food of much more difficult digestion). Whether it be ever proper for mankind to use animal food, is a question foreign from the present dissertation. The present question being whether animal food should be employed by a patient afflicted with fever. — The author is inclined to think, that it is never necessary or proper for the patient to use animal food of any kind in a regular continued fever. But the habit in England of using animal food in A REGULAR CONTINUED FEVER. 237 (a large proportion to the whole) has induced an idea, that a patient could not be sustained through a regular continued fever without using animal food. This prejudice is so strong, that it is impossible to prevent the attendants on the sick from giving them animal food. — It must therefore be considered, what kind of animal food will produce the least disturbance in the system. In the first place, no solid animal food should ever be exhibited to a patient' affected with a regular continued fever. Solid animal food (even such as is of the easiest digestion, such as fowls ; and white fish of a moderate degree of firmness, as whitings;) has been the cause of the greatest number of relapses, when used after a crisis or by a convalescent; that have come within the knowledge of the author. Of consequence, it must do much mischief during the time of are gular continued fever, by rendering the relaxations more imperfect, and the exacerbations more violent ; and ought therefore, by no means to be used, until the patient becomes perfectly free from all appearances of the disease. If animal food then is to be employed at all, it should be in solution in water but all solutions of animal food in water are not of the same kind. In the first place, there are certain solutions of animal food in water, which contain mucilaginous matter, which coagulates (that is to say, becomes insoluble in water :) and consequently is made solid, as soon as it gets into the stomach. Such substances when they are thrown into the stomach are as difficult of digestion as solid animal food ; and ought therefore to be rejecled, such as whites of eggs, serum of blood, &c. Such substances may in general be easily known, by heating them to the heat of boiling water; in which degree they coagulate. Milk, however, is a fluid which always coagulates in the stomach ; but does not coagulate in the heat of boiling water. It has been generally thought, that this fluid ought not to be made use of in continued fevers. In one part of the works of Hippocrates, it is said simply that it is bad : in another, that it ought not to be given ; unless the fever is very long. Sometimes the author has seen it coagulate in the stomach so firmly, as to render the patient sick ; the sickness bringing on vomiting, during which, coagulum was thrown up, resembling a tendon. In such cases milk is undoubtedly a very improper food. Milk, consists of a solution of mucilaginous substance in water, expressed oil, and sugar; and there is perhaps likewise a little of the neutral salts of the blood. The sugar contained in it corrects any putrescency that might take place in the chyle, rather disposing it to be acescent; and the expressed oil being every where mixed with it, prevents it, when it coagulates, from forming a very firm mass ; so that although it be always coagulated in the stomachs of children, it digests easier than almost any kind of food, at the same time that it gives them greater nourishment. This would tempt us to employ it in fever, at least as an animal food of easy digestion; and the author is not certain, notwithstanding it has 238 HISTORY AND METHOD OF TREATMENT OF been condemned by Hippocrates, and notwithstanding a few cases where he has seen it disagree with the stomach, that it is not fit to be employed, where animal food is given. Of the solutions of animal mucilages in water, w r hich are not coaguble by the juices of the stomach ; there are none found commonly in animal bodies, which give nourishment. They are made by dissolving the solid or coagulated fluids of animals in water by heat.— These differ from each other, in forming with water a solution, either more or less viscid or adhesive. It has already been observed, that everything adhesive is of extremely difficult digestion ; and at the same time produces great disorder in the system during the digestion. All such solutions of animal mucilage in water, as form with the water an adhesive compound ; are therefore improper to be employed in fevers. Such are solutions of all parts of young animals, as veal, lamb, &c; and also the solutions of the membraneous, tendinous, and ligamentous parts of all animals. If therefore we employ any animal food in regular continued fevers, it should be solutions of the muscular parts of animals which have attained their full growth, as of oxen, sheep, fowls, &c. In making the solutions of parts of animals in water, (which we call broths and soups,) we extract a quantity of expressed oil. This is fluid in the heat of boiling water; but generally solid in the heat of the atmosphere; and contains the flavor of the animal; which depends probably on an essential oil diffused through the expressed oil.— When the whole solution is set to cool, this expressed oil rises to the top ; and as it cools becomes solid; and therefore maybe easily strained off, carrying the flavor along w T ith it; and this should always be done before it be exhibited to the patient. At the beginning of a regular continued fever, when it has attacked a patient who is in full vigor and well nourished ; it is certainly improper to employ animal food, in the first week of the disease ; and when such food is given, it ought to be in small quantities at a time. These are the attentions to be paid to nourishment during the continuance of a regular continued fever. Thirst is often a very distressing symptom of fever: and the opinions of practitioners have differed very much'with regard to the quantity, as well as quality, of the fluid to be made use of for drink. The ancient Greek physicians thought it improper that the patient should drink anything at all, during at least part of the disease ; as they conceived that any kind of drink increased the fever, and occasioned greater thirst; even water alone. Modern practitioners, (with a view of rendering the blood thinner,) have forced the patient to drink a much larger quantity of water or watery fluids, than he w T ould drink of his own accord. That the blood is thick, and in consequence obstructs the small vessels in fever; was a doctrine formed by authors, who were not acquainted with the substances of which the blood consists. — They did not know that its most essential parts are red particles, coagu- A REGULAR CONTINUED FEVER. 239 lable lymph, and serum ; that there is besides these a solution of mucilaginous substance, (similar to that which is formed where putrefaction has taken place ;) that there was a solution of natron muriatum, ammonia muriata, and ammonia phosphorata; besides other neutral and earthy salts; and that besides all these substances there is also water, (not in a state of chemical combination with any substance, but diffused through them.) — There is therefore a larger quantity of water already in the blood-vessels, than is necessary to dissolve or combine with any of their contents. — That it is true that there is water not chemically combined, is shown by this; that when the blood is exposed to some of -the fine filters in the body, (such as the pores of the skin or the kidneys,) w r ater is filtered off, sometimes perfectly pure. But filtration being a process which never separates two substances chemically combined ; water so filtered off, is not in combination with any of the substances from w r hence it is filtered. — If more superfluous matter were thrown into the blood than is already in it, it would not render any part of the blood thinner, or more capable of passing through vessels it could not pass through before. The only effect of it would be, that when blood came to a vessel so small, as not to let any other part of the blood pass through ; the water would pass through, and leave the other parts of the blood behind. Throwing, therefore, a larger quantity of water into the blood-vessels would not thin any part of the blood, that was too viscid ; so as to make it pass through vessels that it could not pass through before (on account of its viscidity). — It is not necessary therefore, to force the patient to drink more water than he chooses, for the purpose of thinning the blood ; as no such effect arises from throwing in a larger quantity. — There are many other arguments, by which it might be shown, that drinking more water than the patient is naturally inclined to do from his thirst, in no way alters the chemical properties of the blood ; (that is, those properties which distinguish the several parts of it from one another, or from any other substance.) — But what we have already urged appears perfectly sufficient. As it is not necessary or useful to give a quantity of water greater than the patient chooses to drink : so on the other hand, the not giving a sufficient quantity according to the thirst, seems to have arisen (as far as can be judged) from that superstition, which has induced mankind to refrain from things agreeable, in order to produce some salutary effect; (just as men think they will go to heaven by not eating animal food for two days in the week.) — The author then conceives, that the patient should be allowed to drink as much as he desires. Another question has been much agitated ; namely, whether the drink should be exhibited hot or cold. — The ancient Greek physicians exhibited water in fever, not only cooled to the heat of the atmosphere, but cooled to the freezing point; and they gave such cold water, to the quantity of a quart or two, to be drunk at once. 240 HISTORY AND METHOD OF TREATMENT OF The purpose for which such quantities of very cold water were exhibited, will be taken notice of afterwards. —At present only the ordinary food and drink of the patient are treated of. Some modern practitioners conceive, that cold thuds thrown into the stomach, would render the blood thicker; and would make it produce obstruction. Cold undoubtedly increases the viscidity of all fluids ; (as is shewn by a cold fluid passing through a filter much slower than the same fluid when it is hot). But the body is always kept nearly in the same degree of heat ; — and probably one of the uses of this equal heat is, that there shall be no alteration of the viscidity of the fluids, so as to affect the filtrations which are constantly taking place ; (by which some of the most important animal functions are performed).— When cold water is thrown into the stomach, the power in the stomach itself of keeping its own temperature, (in common with the other parts of the body,) will prevent the heat of the blood in it from being brought below the ordinary heat of the animal. — The rapidity with which, the blood passes through the vessels of the stomach, would hardly allow time for it to be much affected by the heat of water in the stomach. After a man has put his hand in w T ater even as cold as the freezing point, the author has found blood taken from a vein of the arm not cooled below 90°. — If the blood was rendered so thick as to be capable of obstructing the vessels, the vessels of the stomach itself would not escape obstruction : but no mischief arises to the stomach when frozen watery fluids are thrown into it. (Thousands of the inhabitants of London are everyday in the practice of eating ice ; and we find no mischief arise from throwing it into the stomach, in health,nor yet in fever.) —When a vein also is opened, and blood Hows from it into a basin ; the coagulable lymph separates from the water by which it was dissolved, and becomes solid: But the coagulable lymph becomes solid equally, whether the blood be kept in the heat of the human body : or be heated only to the heat of thawing water, which is less ; or to the heat of 130° of Fahrenheit's thermometer, which is more than it can ever be exposed to in the human body. — There is therefore no reason to believe, that cold water thrown into the stomach, especially in such quantity as the patient chooses to drink, can make any alteration in the thickness of the blood,' by its operation in the stomach. — The author therefore concludes, that as it is of no use to restrain the patient from drinking as much as he pleases, or to compel him to drink more than he chooses ; so it is of no use to prevent him from drinking it of the degree of heat that he likes best. The next thing to be inquired into is, the quality of the watery fluid that is used for drink in continued fevers. Water is obtained without any artificial process, as it flow's out of the bowels of the earth by springs. But in this case it almost always contains some saline substances; most commonly natron muriatUm, or magnesia vitriolata, or both ; and likewise very often a vapor, which was called gas by Van Helmont, who first discovered it; and since his time, fixed air, and by many other names. When the A REGULAR CONTINUED FEVER. 241 water passes in a stream from the spring, exposed to the atmosphere, the gas evaporates, and the salts are decomposed ; so that in a river, (although it may be mixed with earthy matter which destroys its transparency,) nothing is found chemically combined with its waters. There is a mode of decomposition of certain salts, consisting ot an acid and an alkali, called neutral salts ; of an acid and a metal, called metallic salts ; and of an acid and an earth, called earthy salts: which has been taken too little notice of by practitioners in medicine ; although it is very often of great importance in the exhibition of medicines. — If a neutral, metallic, or earthy salt, be dissolved in barely as much water as will dissolve it, and be merely exposed to the air, no change will take place : but if this saturated solution be now diluted with a considerable quantity of spring, river, or rain water, and stand exposed to the air, the salts will be decomposed. — The neutral salts will first have their alkali converted into magnesia ; afterwards the acid will be lost ; and the magnesia will then fall to the bottom. In metallic salts, also, the metal falls to the bottom in a calx which is combined with pure air ; and that calx is sometimes combined with gas. In earthy salts the acid again will be lost ; and the earth will fall to the bottom. — An easy experiment shows this. Make a saturated solution of cuprum vitriolatum in water, and let it stand in a wine-glass exposed to the air of the atmosphere ; and it will remain perfectly clear and transparent: but if we put a drop of this solution into a wine-glass, holding two ounces, full of spring, river, or rain water ; the liquor will be at first perfectly transparent: but in less than a minute it will begin to grow opaque ; and in less than an hour, a blue calx will fall to the bottom. — This explains what happens in mineral waters ; when the neutral, metallic, and earthy salts contained in them, when the\ are but in small proportion to the water, are decomposed on being exposed to the air of the atmosphere. — In like manner, if we dissolve a grain of tartarised antimony in an ounce of spring, river, or rain water, with a view of giving a quarter of an ounce, and of consequence a quarter of a grain of tartarised antimony, at the end of every six hours : The first quarter of an ounce may contain a quarter of a grain of tartarised antimony ; but the second quarter of an ounce will contain less ; the third quarter of an ounce, still less ; and the last quarter of an ounce, almost none at all. To return from this digression ; a person accustomed to any stimulus applied to the organs of the senses, feels an uneasiness if that stimulus be removed, (such as a man feels when the light he has been accustomed to is removed) : So pure water, applied to the palate, is insipid ; and gives that disagreeable sensation which has been called mawdcishness. Thus the inhabitants of London are fonder of water issuing out of the earth by springs, (containing magnesia vitriolata, and natron muriaticum, and gas;) than distilled water: and from being accustomed to the former, distilled or pure water is disagreeable to their taste. — It seldom happens that a solution of any saline 21 242 HISTORY AND METHOD OF TREATMENT OF substance, which is not disagreeable to the taste from the salt contained ; can do any mischief to a patient affected with regular continued fever: and therefore, whether he drinks pure water alone, or water combined with such salts and such a quantity of gas as is commonly found in springs ; is of no consequence. It has often happened that water has been impregnated with the essential oils of some of that class of plants, which in Linnceus's system are called dydynamia gymnospermia, such as sage, balm, &.c.; and been exhibited for drink in fevers.— This practice has arisen from an idea, that increasing the hot fit of fever, by stimulants; would tend to produce a crisis. Although this hypothesis was considered by Sydenham, in this couritry, as not true ; and is given up by practitioners of knowledge in medicine ; the practice of giving these infusions has notwithstanding continued from mere habit. This practice seldom does mischief; but it is of no manner of use. — Weak vinous fluids are in a state of fermentation ; and as substances in a state of fermentation are apt to excite any other fermentation that the same substances are capable of; such are perhaps useful to excite in the stomach the fermentations by which the food is converted into chyle: they are therefore so far perhaps better than pure water. Sydenham accordingly recommends small beer, (a weak vinous fluid, formed from an infusion of malt,) provided it be perfectly in the vinous state; as a drink proper to be employed in continued fever. — Solutions of farinaceous substances, after they are coagulated, such as barley water, have not only the advantage of making the superfluous water of the blood remain longer in the blood-vessels ; so as to carry off more effectually the superfluous saline substances, and putrescent mucilage of the blood : But they likewise afford nourishment of very easy digestion: and are therefore very useful as drink in all fevers in which such nourishment is required. They may be rendered more palatable by mixing a little acid from any vegetable, such as lemons or oranges : and if it should be more agreeable to the patient, a little sugar likewise, which also tends to give nourishment. TREATMENT OF A REGULAR CONTINUED FEVER. Whew the Fever Runs its Course {Continued).— Symptoms caused by indigestible food in the stomach —Relieved, most readily, by an emetic—This remedy given, also, under other circumstances —Its modus operandi —Laxatives, to clear the bowels of residual and fecal matters —Caution respecting the use of neutral salts in cases of great depression—One dose sufficient—Followed, if need be, by simple laxatives—Difficulty of selecting any one laxative —Advantages of mixing several laxatives together—Some purgatives excite the pulse, such as jalap, scammony, &c, and hence they are inadmissible in fever —Difference in operation of the same purgative, at different times, on the same person —A second dose of a laxative apt to operate more than the 243 A REGULAR CONTINUED FEVER. first, a week intervening between the two —Another mode of administering laxative or purgative remedies, viz., per anion, or by glyster—Purgatives by the mouth clear the whole intestinal canal better than glysters, and hence better in the beginning of a fever—After the first week, glysters are enough to evacuate any noxious matter from the intestines—Costivencss, or purging from irritating feculent matter, of several days duration, requires purgatives thrown into the stomach—Glysters less weakening— Vehicle for a glyster, warm gruel, decoction of mallows—Purgatives to be used, as glysters, in fevers, are manna, cassia, &c, ol ricini, senna, &c. —Better to mix them together—Glysters to be given in the evening, anil repeated regularly, when there is no evacuation otherwise—Three or four loose evacuations in the day will require a glyster of mucilaginous fluids—Weakness and exhaustion from want of sleep—Value of sleep'in fever—Means of a hygienic nature for inducing sleep—Opium, its effects in procuring sleep—Is apt to cause disturbed and unrefreshing sleep in continued fever— Difficulty of insuring its operation so as to give rise to sound sleep—Is mixed with many other substances—Small doses repeated at intervals, theireffects —Of doubtful advantage during the first week of fever—Opium is serviceable in the second week and relieves delirium—Antispasmodics to procure sleep—Hoffmann's liquor anodynus often brings on sleep in regular continued fever—Is, however, uncertain in its operation— No bad effects from employing it—Weakness, sometimes dangerous and fatal, apt to be caused by fever left to itself—Different causes of weakness—Means to prevent it— When present, to be obviated by certain medicines, that induce strong excitement of the system—The fever may go off and leave the patient with considerable power of the system, yet there be a want of exertion of that power—The stimulant must revive the dormant powers, not induce extraordinary excitement, which weakens—Different measures with this view—Inducing inflammation of the skin, by means of certain stimulants—Effects of phlegmonous and erysipelatous inflammations—They weaken the system —Difference of effect of applications to the body in health and in disease—Exciting inflammation of the skin, disturbs, causes wakefulness, and is not beneficial in the weakness towards the end ofa regular continued fever—By their being absorbed, certain substances that inflame the skin may stimulate and revive the system, as cantharides —But this, also, is not to be recommended—Stimulants thrown into the stomach and acting on it, such as spices, &c. —These are not admissible—They quicken the pulse, but do not increase its fulness—Wine, the only remedy of use to excite the dormant strength of t)jc system towards the end of continued fevers—It has also a narcotic property —Should be exhibited in moderate quantity, not to intoxicate—Otherwise it will exhaust in place of giving strength—Four ounces, of the strength of Port wine, enough—Three half pints in twenty-four hours, enough even for those habituated to it—Wine should be diluted and mixed with sugar—Distilled spirits, except in cases of extreme weakness, are not admissible—Next inquiry is, whether the fever can be shortened by bleeding, purging, cutaneous irritation, Peruvian bark, stimulants, antispasmodics, preparations of antimony and ipecacuanha?—Also, whether there are remedies to arrest putrefaction and hemorrhages 1 When the Fever Runs its Course ( Continued). —When a man is seized with fever, it often happens that before the moment of the fever taking plaee he felt himself in perfect health. It may happen, therefore, that just before the fever came on, he may have eaten a considerable quantity of food ; which of course could not be digested, converted into chyle, and pass into the blood-vessels; nor would it any how else be emptied out of the prima? vise : and the powers of digestion being lessened, as well as the other powers of the body, the food would remain in the stomach undigested. When food remains in the stomach or intestines undigested, it either goes through the vinous and acetous fermentations ; or else it putrefies; and in both cases occasions great disturbance in the system. It produces sometimes uneasiness about the stomach itself; and at first a sense of coldness all over the body ; afterwards a sense of heat, or of heat 244 HISTORY AND METHOD OF TREATMENT OF without any preceding coldness; a feel of fulness in the abdomen, with flatulency ; frequency of pulse ; pain in the forehead ; sometimes sickness ; and sometimes cutaneous eruptions ; or even inflammation about the head. All these derangements ought to be avoided in fever. — The readiest mode of getting clear of these mischiefs is, to employ an emetic to evacuate such substances out of the stomach. If such undigested food should have got into the duodenum or jejunum, an emetic will evacuate these likewise ; as is evident from its bringing up a quantity of bile, (which never gets into the stomach in the healthy state of the body). — Supposing that no food has been thrown into the stomach for many hours before the fever begins ; so that all that has already been thrown in has digested, and the stomach and intestines have been cleared of it entirely : even in this case, most practitioners have considered it as necessary to exhibit an emetic. It may be, that something like the same crust that is formed on the tongue, may also be formed upon the surface of the stomach, and be evacuated by the emetic ; or perhaps the patient is relieved so much by some other effect of the emetic, as to have induced all practitioners to recommend it at the beginning of fever'; or even five or six days after the fever has begun, (supposing an emetic has not before been given). — It maybe doubted whether the emetic produces relief in all cases, by evacuating something noxious out of the body ; or whether the action of the emetic may not give relief to the patient in some other way. This is a question which will be agitated hereafter; when at the same time the quality of the emetic and the mode of exhibiting it will be treated of. Among the powers of the body which are depressed by fever, the peristaltic motion of the intestines is one. The intestines in this case do not carry down the undigested part of fhe food : nor yet the bile, pancreatic juice, nor other substances secreted in them. But any of these substances remaining in the bowels produces a sense of fulness, weight, and uneasiness and restlessness in every part of the body : and augments the fever very considerably. It becomes necessary on this account to employ some laxative to keep up the peristaltic motion of the intestines; and produce an evacuation every twenty-four hours. - At the beginning of a fever there may be undigested food in the intestines, at a time when the patient is better qualified to bear a larger evacuation than afterwards. In this case it is not of much consequence what laxative is employed. But after the fever has gone on for some time, especially if the strength of the patient be reduced, the practitioner should never employ laxatives, which are uncertain in their operation ; lest by too large an evacuation taking place, the patient should be very materially hurt. Purgatives are very far from having one quality in all of them ; some act, for example, in much less time than others. Such purgatives as neutral salts, or such salts as contain magnesia, combined with an acid, increase the secretions from the intestines and operate in an hour or A REGULAR CONTINUED FEVER. 245 two after their exhibition ; and their effects are soon over. Others, as aloes and rhubarb, increase only the peristaltic motion of the intestines; and neither produce so copious an evacuation ; nor are they so quick in producing their effects ; very often not operating in less than ten or twelve hours. Of these two species of purgatives, it may be proper to employ such as increase the secretions, and operate quickly for the first time ; because the intestines will thus be quickly evacuated ; and the substances contained in them, not be suffered to remain long enough to increase the fever or make it irregular; provided the patient should have a sufficient degree of strength. If he should be very weak, when attacked by the fever; the risk must not be run even at the beginning, when his strength is not at all exhausted by the fever itself; of exhibiting even one dose of such a purgative as neutral salts, &c; lest large evacuations should be produced by it, and the patient so reduced, as never to have his strength recruited so as to be able to be supported through the disease. If one dose of such a purgative as increases the secretions from the intestines, and produce quick evacuations, be exhibited at the beginning of the disease ; it is improper to repeat it: because the want of appetite and even the loathing of food in the patient, prevent him from throwing down such substances as w T e want to evacuate very quickly or to wash off afterwards. It is much better to employ such purgatives as increase the peristaltic motion only ; and for this purpose, cassia, manna, and other such laxatives, together with senna, rhubarb, and sulphur, are to be employed. Although they are longer in their operation, and perhaps even give a little more pain to the patient: their effects are much more limited; so that they run little risk of weakening by too copious an evacuation: and they also clear the intestines more certainly of what is wanted to be got rid of. It may be said, that we might fix on some laxative which is preferable, and which ought always to be employed ; this way being much more simple and determinate. — It is to be observed, however, in the first place, that the constitutions of different patients are often different from each other, and that substances applied to different men have different effects; so that if one laxative happens not to produce sufficient effect in its ordinary course, it may be supplied by another which can. Moreover, in one situation one laxative maybe procured, when another of the same kind cannot. But the principal ground on which it is necessary to enumerate various laxatives is, the advantage that arises from mixing several of them together. — When one laxative is employed alone, and in a sufficient dose ; it is apt to produce sickness and pain in the bowels; and is uncertain in the degree of its operation; when several laxatives are mixed together, they are much less apt to produce sickness or pain and are much more certain in their operation. This observation is applicable to a variety of. different classes of medicine; but it would be much too great a deviation to enter into any discussion of this subject here. 21* 246 HISTORY AND METHOD OF TREATMENT OF Certain purgatives not only affect the stomach and intestines singly, but also produce considerable effects on the whole system : rendering the pulse frequent, for instance. Such are jalap, scammony, and many others ; and it would be certainly improper to employ any of these to act as laxatives in fever. — When the patient has gone through the first week of the fever, his strength begins to fail; and any great evacuation might bring him so low, that he could not afterwards be easily supported through the remainder of the disease.— It is therefore a question, whether it is proper, after the first week, to give him a laxative by the mouth. It happens unfortunately, that medicines do not operate precisely in the same manner and in the same degree, every time they are exhibited ; although given in the same dose, and under circumstances perfectly similar, (as far as can be judged). The same purgative, or mixture of purgatives, exhibited to the same person in health at the distance of a week, (when such person appears to be exactly in the same state in all circumstances ;) will operate often very differently ; hardly ever exactly in the same manner. At the first exhibition it shall purge four or five times, with or without much pain ; at the second, perhaps twice, and with the reverse proportion of pain ; or it shall purge the first time only twice, and the second time three or four times. The action, therefore, of such purgatives is very far from being constantly the same. — It is to be remembered, that it is stated that these doses are given at least with the interval of a week : but if two equal doses of the same purgative be exhibited to the same person with a day's interval, the first dose generally purges much more than the second.—A laxative medicine thrown into the stomach after the first week of the disease, (although given in the same dose which before produced one evacuation in twenty-four hours,) may now therefore produce five or six ; and may by this means diminish the powers of the system too much : and hence it is to be exhibited with great caution. — If however there were no other mode of evacuating feculent matter which has been accumulated, yet the mischief arising from the accumulation is such, that a laxative given by the mouth must still be employed ; although certainly w T ith caution. ' There is, however, another mode of applying purgative or laxative remedies ; so as to affect the intestines, increase their peristaltic motion, and occasion their contents to be evacuated, and even add to their secretions. — If purgative medicines are injected into the rectum only, or with such force as to throw them up also into the colon ; they will operate so as to occasion any feculent matter in them to be evacuated. This mode of applying purgatives or laxatives, differs only from the former in the degree of their operation ; and is said to be by glyster. — The question here to be agitated is, whether it may be better or safer to employ purgatives or laxatives, in the latter part of fever, to keep the intestinal canal clear of feculent matter, in this way ; or by the mouth. 247 A REGULAR CONTINUED FEVER. As purgatives thrown from above into the stomach, and passing from thence into the intestinal canal, are immediately applied to the excretory ducts of all the glands of the intestines: they of course stimulate all these glands : and if they act by stimulating the glands ; and by thus producing a flow of fluids in every part, and wash the whole canal clean from beginning to end ; they are so far preferable. Since such purgatives likewise as tend to increase the peristaltic motion of the intestines, when thrown into the stomach, are applied to the whole internal coat as they pass along; they increase the peristaltic motion through the whole ; and so empty the intestines completely. — Purgatives therefore thrown into the stomach, clear the wdiole intestinal canal, better than glysters.—In the beginning of fevers, the food that was not digested remains in the upper part of the intestines ; and therefore at the beginning of regular continued fevers, it is better on this ground, to gives purgatives by the mouth. When purgatives are thrown into the rectum and colon, (as they perhaps never rise above the colon ;) it is a question whether their influence, (as acting on the rectum or colon,) extends to the ileon or higher: and whether therefore they can clear the inner parts of the intestines. — For the present purpose this need not be argued ; for after a fever has continued a week and is regular, if purgative medicines by the mouth have been given to clear the upper part in that week, little food and that only of the easiest digestion, being employed afterwards ; all that is required is to keep the lower parts clear of the recrementitious parts of that food, and of the fluids secreted in the intestines. Glysters therefore, after the first w*eek of the disease, seem sufficient to evacuate any noxious matter that may be in the intestines.—It is true that it may often happen (and actually does often happen), that during the first week of a continued fever, the practitioner who has attended to the patient, has not thought of the state of the prima? vise; but left the patient without one evacuation from the intestines for several days ; and that this costiveness continues, or a purging arises (from the feculent matter having putrefied or otherwise become stimulating). In this case purgatives or laxatives must be thrown into the stomach : But such cases will be treated of more fully in the dissertations on irregular fever. Glysters have this difference in their action from purgatives, that they are not near so apt to produce a number of very loose evacuations ; and so weaken the patient. As therefore they are sufficient to keep the prima? via? clear after the first week, they are preferable for the reasons above given. Nearly the same substances used for laxatives given by the mouth may be used for glysters. The vehicle should be some mucilaginous watery fluid ; as a solution of farinaceous matter in w r ater. A solution of the flour of oats, (which w r e call water gruel,) may be used: and decoctions of mallows, &c, are proper. Such mucilaginous substances are preferable 248 HISTORY AND METHOD OF TREATMENT OF to pure water; as they prevent the stimulus of the purgative from acting so immediately on the intestine ; and causing the glyster to be evacuated* directly, without bringing the feculent matter along with it. —It would be too great a digression here to enter into the explanation of this subject; it is sufficient to say, that the effect is actually found to be so. — For the same reason oil has also commonly been added to the glysters. Oil has also the effect of smoothing the inside of the intestines ; and of allowing hard feculent matters to pass easily over them. The purgatives to be used in glysters, in regular continued fevers, are manna, cassia, &c, ol. ricini, senna, &c. ; which do not stimulate the system. It is also much better to mix them together, as in the elect, sen. comp., and other compositions; as purgatives given by the mouth are better mixed. — In continued fevers, where glysters are merely used to keep the prima? via? clear, neutral salts are not so applicable for glysters: because they are apt to induce a watery secretion from the intestines ; which is not wanted, but is hurtful. If after the first week of a continued fever, the patient should have had no evacuation from the intestines for twenty-four hours ; a glyster should be used about six or seven in the evening: that the feculent matters may be evacuated before the time of sleep. — This should be repeated every evening, when there has been no evacuation in the former part of the day. If there should be two or three looser evacuations in the course of the day, it is also useful to employ glysters of mucilaginous fluids ; (but this will also be more properly considered among the irregularities which take place in the disease.) When sleep in fevers is prevented from being either so long or so sound as in health ; the patient is of consequence very much weakened. It has been shown also, that sleep occasions the cessation of all irregularities in the system ; and therefore that it has a tendency to carry off fever; fever being a very considerable irregularity. As the ordinary hours of sleep among mankind are generally the time of the greatest force of the hot fit in continued fevers ; if sleep could be procured, especially before the time of the crisis or relaxation, which is about four in the morning, it would 'by its tendency to remove all disturbances in the system, assist the hot fit in carrying off the disease. It would therefore be of great consequence if sleep could be procured in fever ; as the force of the living power would be recruited, crisis would be more apt to be produced, and all disturbances in the system would be got rid of. After exercise, whether it be that of labor or for amusement, man is disposed to sleep. But in a fever, as the patient can neither labor, nor employ exercise for his amusement; he ought undoubtedly to be kept as much at rest as possible both in his body and mind ; (the method of procuring sleep by exercise, being here quite out of the question.) There are some things that induce mankind to sleep, when the 249 A REGULAR CONTINUED FEVER. powers of the system are not at all exhausted : as perfect quietness of mind ; freedom from pain and uneasiness in the body ; no passion rousing to exertion ; nor bodily pain strongly drawing the attention; with everything that gives constant and pleasant sensation. As an instance of the last case we may reckon among some nations gently pinching the skin. Gentle motion in the air from the waving of fans; and the gentle and uniform noise of the flowing of water, or of the wind rustling through trees ; also lull a man to sleep. Such attention however to uniform and agreeable objects can hardly be employed with efficacy, to release the mind from that anxiety which rentiers the patient restless in fever. Something of this kind nevertheless the author once saw successful ; that is, the dropping of water, running slowly through a filter, into a basin of fluid placed below. Opium is a medicine which has been known to produce sleep, and give rest to those who are fatigued : probably as long as the efl'ect of any medicine has been known. There is some medicine said to have been given by Helen to Telemachus to produce this effect; which indeed is the only medicine mentioned by Homer as having any effect when exhibited internally: and opium was certainly well known in the earliest ages in Greece. — In many cases, as when a man is exhausted by labor or weakened by evacuations, it procures a quiet, easy, and refreshing sleep, if exhibited in the quantity of from half a grain to a grain. — In regular continued fever, if exhibited in this quantity it often produces sleep : — but this sleep is disturbed : the patient is often distracted with various incoherent and frequently disagreeable dreams ; and often wakes in the morning with a persuasion that he has not slept at all. Instead of a relaxation of the fever taking place in the morning, his headache is greater, he has more thirst, and his appetite is less. Sleep therefore so procured, is so far different from that rest, which gives time for the powers of the body to be recruited ; that these powers are more exhausted during such sleep, than they would have been if the patient had not slept at all. It is true, there are some cases in continued fevers in which such a restlessness from the opium is not produced ; but a quiet, easy, refreshing sleep follows its exhibition. These cases occur when there are irregularities in the disease ; and will be described in a future dissertation. A great many substances have been mixed with opium to render the sleep procured by it more quiet and refreshing; such as spices, acid of benzoin, preparations of antimony, antispasmodics, and many others ; but no mixture has as yet been found out, which renders such doses as have been described, capable of producing easy and refreshing sleep in regular continued fevers. About five and twenty years ago, there arose a practice in St. Thomas's Hospital of exhibiting opium in a small quantity ; (to wit, in the quantity of a quarter of a grain for a dose ;) and repeating it at the end of every six or eight hours. When given in such doses, it produces no immediate effect; but by degrees the patient falls into a 250 HISTORY AND METHOD OF TREATMENT OF stupor which gradually increases ; and although this stupor does not end in a complete sleep ; yet it grows in a day or two into that kind of stupor that we find, w r hen there is a commencing diminution of that species of delirium from fever, which is attended with apparent fulness of the vessels of the brain. It is true, indeed, that this dose of opium is obtained by adding a few drops of laudanum to that mixture, which is called mithridate ; but the author has often employed the opium in his private practice, with ten grains of castor, with equal or rather better effect. — Lately, many practitioners have exhibited opium three or four times in the twenty-four hours in fevers ; having borrowed their practice probably from that which has been pursued in St. Thomas's Hospital ; the practice of this Hospital being open to the inspection of many pupils. These practitioners have not learned, however, that it is the smallness of the dose that produces beneficial effects ; for if the dose be increased so far as to half a grain, the same restlessness, the same disturbed sleep, dreams, &c, as above noticed, are brought on. — Mithridate, Theriaca, Andromachi, &c, contain an immense mixture of mucilaginous medicines, spices, and astringents, with a small quantity of opium. This vast farrago renders their effects totally unintelligible ; and they have therefore been thrown aside. But many practitioners have given them up with great reluctance, especially old practitioners. It may be said, indeed, that a man who has been in the habit of exhibiting any medicine in a disease, does not like to be disturbed in that habit: but it is not improbable that they have been led to continue the use of these, from the good effects arising from the exhibition of the small doses they contain. Whether such small doses of opium can with propriety be employed during the first week of the fever, has not been determined. The author has not ventured upon employing such ; nor does he know that any other person has employed them during the first week of the disease. It is a question, whether it might be proper to employ opium in the second week, notwithstanding there is delirium of either kind in a considerable degree. This question, however, seems to be determined by practice ; for in either case of delirium it w r ould appear that it is proper ; since it considerably abates the delirium ; and especially takes off that violent increase of dfelirium of the first species, which arises in the evening. Opium is not the only medicine which has been employed with a view of procuring sleep. There are certain medicines which have been called antispasmodic ; which have also been employed for the same purpose by many practitioners. An antispasmodic medicine is a medicine which takes off any contraction arising without an apparent cause, or continuing after the cause of the contraction has been removed ; but this definition has been by no means adhered to. — The medicines which have been more particularly employed to procure sleep in a regular continued fever, and which are ranked among antispasmodic medicines ; are ether and oleum vini ; and sometimes musk, castor, and camphor. The author has very seldom seen the A REGULAR CONTINUED FEVER. 251 three last procure sleep in this disease ; — but a mixture of alcohol, ether, and oleum vini (such as Hoffman strongly recommends under the name of liquor anodynus; and which is probably the same as the spiritis etheris vitriolici compositus of the London Dispensatory,) the author has seen procure sleep in many instances in regular continued fever. The great drawback from depending on its powers is the uncertainty of its operation : for sometimes, given to the quantity of a drachm in the evening, it procures a perfectly sound and quiet sleep ; or if the like dose be repeated every six hours, sleep takes place at the ordinary hours of rest; (quiet, sound, and refreshing.) On the other hand it is to be observed, that its effects in producing sleep are perfectly uncertain, and that the patient is often just as restless after it has been exhibited, as if he had taken no medicine at all ; it happens even much more frequently that it does not produce any effect. Moreover, it cannot be distinguished, by any sensible appearance in the patient, in what cases it will produce an effect, or where it will not produce any effect at all. No bad effects, however, arise from employing it, as far as the author has been able to discern ; there is therefore, no reason for not employing it when the patient is restless and without sleep, how r ever capricious it may be in having this effect during the disease. Where a regular continued fever is left to pursue its ordinary course ; the efforts that take place in the fever, and the want of sufficient nourishment and sleep ; frequently weaken the patient towards the end of the disease to such a degree, as to be dangerous and even in some cases fatal. — It often happens likewise, that this weakness is greatly increased by evacuations, which have been unnecessarily made by injudicious practitioners. Weakness is also induced by evacuations which arise from irregularity in the fever; and which consequently will become the subject of future dissertation. Weakness also often takes place for want of food ; first, from the necessity of withholding food from the patient in sufficient quantity ; and next, if the patient should take in a larger quantity of food, yet from its not being digested and converted into blood, it must either be evacuated without change, or converted into water and carried off by an effort which would still further diminish the force of the system. Weakness may be also produced by not exhibiting that quantity of food that in truth might have been digested; either from want of skill in the practitioner, or the carelessness of the attendant. What the quantity and the quality of food are which ought to be given, has already been described. Weakness may also be induced by practitioners employing medicines that occasion considerable efforts in the system, without diminishing the disease ; although no improper evacuations have been made. If no unnecessary evacuations have been made ; if care has been taken to give food in such quantity and quality as the patient can digest during the progress of the disease ; if the patient has not been exhausted by the application of improper medicines ; it rarely happens 252 HISTORY AND METHOD OF TREATMENT OF that such a degree of weakness arises in a regular continued fever, as to endanger the life of the patient. If such a degree of weakness should take place at the end of a regular continued fever, as to endanger the life of the patient; the force of the body may in some degree be kept up, by employing medicines which will induce the powers of the system to act with all their force : until the fever shall so far diminish, as to allow of the stomach digesting food of better nourishment, or of the powers of the body being recruited by sound and refreshing sleep. The practice of exciting the body to act with all its powers, until the fever is so far gone off, depends upon the following principle. — Let the patient ill of a'regular continued fever be ever so weak at the time of the crisis, or at the time when the disease has gradually worn itself out; yet as soon as the fever is entirely terminated, (provided the patient is allowed to be perfectly at rest; and provided proper nourishment be exhibited, to wit, such as he can digest ;) the powers of the body begin instantly to be on the increase : and the patient will be gradually restored to his health. — Although however there may be considerable power in the system ; yet there may be a want of exertion of that power: so that the patient may sink and die from weakness, though there be still in the body powers, which if they had been exerted might have kept the patient alive. By employing medicines to make the body exert these pow r ers until the fever is gone off; the patient will be preserved, and afterwards gradually recover his strength. — If this was not the case, all stimulants employed in fever would evidently be extremely hurtful: for every extraordinary exertion tends to weaken the system, and to exhaust the powers that it brings into action ; and therefore if all the powers in the body were already in action, the increasing that action would weaken the system much more, and render the weakness more fatal; (instead of preventing the patient from being destroyed by it.) — The stimulant employed then must rouse the dormant powers, in order to have good effects. The medicines which have been employed for making those powers exert themselves that otherwise would not, are now to be treated of. (The ordinary means of recruiting the strength in'health, by nourishment and sleep, have already been attended to ; as far as they have an effect in regular continued fevers. With what variation food and sleep are to be managed in a regular tertian, has already also been sufficiently argued: And what attention is to be paid to them in irregular, continued, remitting, and intermitting fevers; will make part of future dissertations.) The author means then here to take notice of the several different modes that practitioners have employed to excite the action of the living power, in regular continued fever; and to give his own opinion with regard to them, whatever has been the opinion of other practitioners of whatever estimation. First then, many practitioners have endeavored to excite the dor- 253 A REGULAR CONTINUED FEVER. tnant powers of the body (which as the author has just observed, can alone be excited to advantage) ; by producing inflammation of the skin through the application of various stimulants. If an inflammation is produced in the exterior parts of the body, so as to occasion an alteration in the system generally; —in case it be phlegmonous inflammation ; the pulse becomes hard, full, strong, and frequent; and there arises an universal sense of heat: but the powers of digestion are impaired ; the patient loses his appetite, (so that he cannot swallow so large a quantity of food ;) the ordinary quantity of food which he makes use of in health and of the ordinary quality, produces sickness and vomiting, or at least great uneasiness and disturbance throughout the whole body ; the faculties of the mind cannot be equally exerted, (and especially the imagination and judgment;) the muscular powers are also diminished, (since a man cannot go through the same labor ;) and the sleep is likewise prevented. Phlegmonous inllammation therefore prevents the body from being recruited by food and sleep ; and the muscular powers of the body and the powers of the mind are by means of it considerably depressed. — If an inflammation of the skin (that is, an erysipelatous inflammation), be produced in a man in health, so as to occasion affection of the general system ; the pulse becomes much more frequent, (often to one hundred and twenty strokes in a minute, or more ; it also becomes smaller and w r eaker; the strength is generally depressed ; and all the powers of the body and mind are in consequence less powerfully exerted.— In a person otherwise in health therefore, neither the inflammation of the substance of the exterior parts of the body, nor an inflammation of the skin, can increase the powers of the system : on the contrary, they diminish the powers of the whole. If it w T ere wished that a man should lift a greater weight; in order to enable him to make such greater exertion, no one would apply a blister to his back, or make a deep and painful wound in any part of his body. (It is true, that we spur a horse to make him run swifter, but the greater exertion in this case is from his endeavor to escape from pain.) —Although then exciting any kind of inflammation by no means increases the force of the body, if it be in a state of health; yet in health the actions of applications to any part of the body may have a very different effect from what the same applications would have, if they were made to the body when diseased. — Whether exciting inflammation has or has not the same effect in a regular continued fever, w T hich it has in health ; can only be known by making these applications to the body of a person affected wnth regular continued fever. — As far as the author's experience goes, if any stimulas has been employed so as to produce inflammation, when a patient has become weak towards the end of a regular continued fever; the only difference that has occurred has been, that phlegmonous inflammation has not produced hardness, fulness, and strength of the pulse : but both phlegmonous inflammation and inflammation of the skin have occasioned greater frequency of the pulse, and have ren-22 254 HISTORY AND METHOD I F TREATMENT OF dered it weaker and smaller, and (as in health) have prevented sleep, and the patient's taking the same quantity of nourishment; and have depressed and deranged the whole system. — The author therefore has concluded, that stimulants applied to the skin so far as to excite inflammation ; by producing such inflammation, do not keep up the strength or make any dormant power act; but that on the contrary they weaken the patient: and that therefore exciting inflammation of the skin is not to be employed with a view to keep up the strength, when weakness takes place towards the end of a regular continued fever. When substances nevertheless are applied to the skin so as to excite inflammation ; such substances may be absorbed, carried into the general course of the circulation, and be applied to all the irritable parts of the body ; and may so act upon some or all of these, as to bring the dormant powers of the body into action : and so may keep up the strength towards the end of a regular continued fever. — It may be worth while therefore to inquire into the effects, which the substances commonly employed to excite inflammation of the exterior parts produce ; when they are absorbed, get into the general course of circulation, and are applied to the various irritable parts. The stimulating matter of cantharides, has been very commonly employed to excite inflammation of the skin; and to keep up the strength towards the end of continued fevers. — That this matter is often absorbed there can be no question : for it very frequently (in consequence of being absorbed) produces inflammation of the neck of the bladder, which we call strangury ; and when it produces this effect, the pain and constant sense of uneasiness irritate and exhaust the patient at all times. Every practitioner who has employed cantharides to excite inflammation and attended to their effects, must have observed them often, when absorbed, bringing on subsultus tendinum, convulsions, and hysteric fits; all of which are certainly very far from keeping up the patient's strength in continued fevers. — In like manner, if we examine-any other stimulant which has been employed to excite inflammation externally, in order to keep up the strength towards the end of a continued feverwe shall find lhat when they are absorbed, they produce effects upon the irritable parts of the body, which are not at all conducive to support the strength towards the end of continued fevers. — The author, therefore, is obliged to reject the excitement of inflammation of the exterior parts of the body, as a means of supporting the strength towards the end of continued fever. — He does not say, however, that it may not be proper to excite external inflammation for other purposes in regular continued fevers;) but this will be a matter of future consideration.) The next means of exciting the action of the dormant powers of the body, so as to make them support the strength at the end of a continued fever, when the patient is weak ; is the application of A REGULAR CONTINUED FEVER. 255 substances which act upon the stomach itself; thence exciting the other parts of the system to exert themselves poweifully.—The first kind of these to be enumerated is that class of plants, called by Linnaeus Tctradynamia; together with the several species of Allium ; and likewise Ammonia. These stimulants, when thrown into the stomach, act upon it immediately, long before there is time for them to get into the blood-vessels ; their effects go off also in an hour or two ; and while they produce any effect, it is principally that of making the pulse more frequent, without increasing its strength or fulness. Such stimulants have therefore been rejected from the remedies fit to be employed, in order to make the dormant strength of the system be exerted towards the end of continued fevers. — The gums (as they were formerly called) are resinous substances which exude from vegetables ; forming either a pure resin, or a mixture of mucilaginous and resinous matter. — Neither these, nor preparations of mercury, seem to ae.t upon the system generally, when they are immediately thrown into the stomach; but require some days before they produce any effect; being probably absorbed, and applied to the several irritable parts in the system. Of these, mercury is much too apt to produce evacuations to be trusted ; lest such evacuations should weaken the patient much more, and even to that degree as to destroy him ; and the resinous substances pointed out have not been so much made use of, as that we can determine the propriety of their exhibition. The author indeed has seen them employed ; but if he remembers right, without any great effect. — The spices, (such as cinnamon, nutmegs, cloves, pepper, and cardamoms,) have been very often and very much employed to keep up the strength in continued fever. They are not nearly so much in use at present, as they were about fifty years ago. When they have any sensible effect, they render the pulse much more frequent, smaller, and weaker ; and hence are certainly improper. It is true, indeed, that by adding a quantity of acid to them, the frequency of the pulse is reduced, and is in some way in a certain degree prevented. They are, however, in general very improper remedies for this purpose ; except when there is a great deal of flatulency in the prima? via?, which depresses the strength of the patient; for flatulency is an effect which these spices are powerful in relieving. Wine seems to be the only remedy that is of use to excite the dormant strength of the system, when weakness takes place towards the end of continued fevers. It tends to increase the force of the system, without increasing the frequency of the action of the heart; and on this ground it may be more safely employed than any other stimulant. It has also a narcotic power. — Wine however should be employed in moderate quantity. When exhibited in large quantity it produces intoxication ; the effects of which every man who has drunk it in such quantity, very easily perceives. The stomach, after the intoxication is gone off, is disordered ; spasmodic contractions take place in it; and it is not capable of digesting food : which 256 HISTORY AND MKTHOD OF TREATMENT OF last effect would render the patient w r eaker from want of receiving sufficient nourishment. Wine should be used, therefore, sparingly ; and not in the least to intoxicate. — It ought only to be employed, when the weakness has just become considerable, and in moderate quantity : for if we exhibit it in greater quantity than is sufficient to produce a proper exertion of the dormant strength of the system ; it will exhaust that dormant strength ; and not leave a sufficient quantity to support the patient during the remaining part of the disease. — When wine is first employed by persons not accustomed to use it, where it becomes necessary to employ it from weakness ; four ounces is a sufficient quantity of wine of the strength of Port-wine. — The strength of wines can hardly be transmitted to posterity by any permanent mark ; for the strength does not depend merely on the alcohol they contain ; but likewise on the quantity of a vapor, which was called by Van Helmont gas silvestre, probably different from that vapor which he called gas simply.) and which has since been called fixed air and carbonic acid ; although the author thinks these improper names ; a point, however, foreign to the purpose of this dissertation. — The author has also to observe, that in patients who have been accustomed to drink wine even in large quantities ; three half pints are quite sufficient to be exhibited in twenty-four hours. — If wine is made use of, it should be well fermented. As it is very rare that weak wines are well fermented, it is better that strong wines should be used. Sweet wines are perhaps preferable from the nourishment contained in them ; but they are seldom well fermented, except they be very old ; and if not well fermented, they are acescent and flatulent. It has been a question whether it is better to employ the w T ine by itself; or diluted, with the farinaceous or mucilaginous vegetable substances we employ for nourishment to the patient ? It appears to the author, that they should be diluted with farinaceous or mucilaginous substances, mixed with sugar; as these take off the immediate stimulus with which wine, when strong and pure, is apt to act upon the stomach. — On the same ground the author would perhaps condemn all distilled spirits ; excepting in some sudden cases of extreme weakness ; such as happen from too copious an evacuation from any excretory organ in the body. The author has now shown the means of treating a regular continued fever, supposing it is left to pursue its ordinary course. The next thing to be inquired into is, whether means have been found out to shorten the fever, by producing a crisis or otherwise ; so that the patient shall be restored to health ? This inquiry will lead the author to consider whether bleeding (either from any vessel in the body indiscriminately, or from some particular vessel, in a particular part of the body;) has the power of carrying off the fever: — Whether purging, or making any other evacuation to any degree, has a power of carrying off a regular continued fever : — Whether exciting inflammation in the skin, or in any A REGULAR CONTINUED FEVER. 257 other part, has any power of carrying off a regular continued fever: — Whether Peruvian bark (or any other remedy acting on the same principle) has any power of carrying off a regular continued fever: — Whether stimulants, such as spices, have any power of carrying off a regular continued fever : — Whether antispasmodic remedies have any power of carrying off a regular continued fever— Whether there be any medicine which carries off a regular continued fever, that has no apparent action on the body, when in health or when affected with other diseases: — Whether preparations of antimony or ipecacuanha, or of those of other medicines which have been enumerated in the dissertation on a regular tertian, (as bringing on a crisis similar to that which takes place in fever itself, or which render it more perfect) ; have any power of carrying off regular continued fevers : — Whether, if symptoms of putrefaction of the fluids should arise, any remedy, and what remedies, may be employed to restore them to their healthy state : —Whether, if haemorrhage should arise in consequence of putrefaction ; any remedy, and what remedies may be employed to stop such haemorrhage : — And lastly, if any of these remedies have a power of carrying off or diminishing a regular continued fever ; in what manner they are to be employed for this purpose ; and what circumstances may make it improper to exhibit them? These inquiries will form the second part of this dissertation; which is in great forwardness. END OF THE FIRST PART OF THE THIRD DISSERTATION 22* A THIRD DISSERTATION on F E V E K; PART II. CONTAINING AN INQUIRY INTO THE EFFECTS OF THE REMEDIES WHICH HAVE BEEN EMPLOYED WITH 4. VIEW TO CARRY OFF A REGULAR CONTINUED FEVER, WITHOUT LEAVING IT TO PURSUE ITS ORDINARY COURSE, TREATMENT OF A REGULAR CONTINUED FEVER. PART SECOND. Treatment to Carry off the Fkv«R.— Venesection —Frequency of pulse no symptom exclusively, of fever—Bleeding from a vein, never diminished, shortened nor carried off a fever—An accident, such as a general inflammation, which would kill of itself, may be checked by this means—Effects of blood-letting, weakness —Origin of the practice—Impatience and superstition—Examples—Does mischief ensue from blood-letting in this fever 1 —Weakness, already considerable from the fever, is increased —Taking blood from the vessels of the head sometimes carries off fever and diminishes delirium accompanied with vascular fulness of the head—A morbid matter supposed to be removed by evacuation—But no particular matter can be separated from the blood by blood-letting—Secretions may throw off noxious matter —But fever may arise without such matter being applied, and when is so applied the disease will, still run its course all the same—Neither fever in its essence, nor the operations of the body sufficiently known to determine the efficacy of any medicine to carry off the disease—Experience alone the guide for the use of purgatives or other evacuations —Noxious matter supposed to require concoction before it is evacuated— Hence evacuations proper only at the beginning of a disease or towards its decline— Retained feculent matter aggravates the febrile disorder—Its evacuation is proper, but not with a view to carry off the fever—Crisis supposed to follow concoction —Purga- employed with a view to hasten this result—Relapse caused by this practice— Purging beyond the simple evacuation of the primx vim not called for — Antimony not known to the Greeks—Description of the metal —Sulphuret of antimony furnishes the antimony employed in medicine—Number of chemical processes to give medicinal effects to this metal —Only three much in use, viz. kermes mineral, antimony with calx phosphorata and tartarised antimony—Modes of preparing these —No remedy recommended by Galen or Celsus to put an end, at once, to the fever, except cold water—Alchetnists, empirics—The first to administer antimony in fever and in intestinal inflammations—This practice reprobated by the regular physicians—Dr. James, the first to employ antimonial preparations freely in Great Britain—Dr. Cullen the first eminent teacher to recommend their use to carry off fever—His hypothesis to explain their utility, was, that they produced sickness —The author of a different opinion—Other remedies that vomit not febrifuges, as the squill for example— Medicines will produce their destructive effects, if they vomit, by being given in large doses, as in the case of opium, Peruvian bark, and sugar of lead, wine, and spices—Tartarised antimony not efficacious, as a febrifuge, unless a quarter of a grain can be borne by the stomach —More than this tolerated by the stomach has produced critical symptoms in a complete crisis—The best preparation of antimony—Uncertainty of the operation of hcrmes mineral, and of James's Powder or pubis antimonialis—The uniformity of tartarised antimony—Vinous solution preferable —Effects of antimony, when it is given in a dose short of nauseating to a man in health— They resemble a crisis of fever —In this way given to a fever patient, antimony will carry off the disease—Best methods of employing preparations of antimony to produce a crisis in fever —An emetic often proper at the beginning of the disease —To select that which in its secondary effects may contribute to produce a crisis—The best is a mixture of tartar emetic and ipecacuanha—Moderate, better than violent vomiting —The proper dose—Reching injurious—To be obviated by drinking watery fluids— Indications for employing an emetic—Time for giving an emetic—Best in the evening, from its tendency to cause sleep—Sometimes the sickness continues through the night, with restlessness —More commonly, sleep and perspiration follow—An emetic proper in the first four or five days of fever —Divided doses of antimony at intervals of two, three or four hours to produce sweat, aided by clothing and drinks —To be had recourse to early in the fever—Continued sickness and restlessness, after an emetic, re- 262 REMEDIES EMPLOYED TO CARRY OFF moved by a grain of opium—The smaller doses of antimony to be given six hours after the action of the emetic is over—Dose of tartar emetic, two sevenths of a grain, or thirty drops of antimonial wine—Difference in the size of drops according to the vial— Some aromatic with the first dose of antimony—More prudent to repeat the antimonial preparation even after the subsidence of fever—The good efiects of the medicine to be procured in four or five days—Still it may be continued longer—To desist when any evacuation is produced without relieving the fever—Profuse sweating sometimes serviceable—Circumstances requiring a repetition of the emetic—To be of ipecacuanha—The earlier the exhibition of antimony the better—Is blood-letting proper in some cases before using the antimonial preparation 1 After one kind of evacuation, without relief of other functions, the antimony to be desisted from. Treatment to Carry qff the Fever.—Having in the first part of this dissertation, pointed out the history of a regular continued fever ; the accidents that take place in it; and the manner of avoiding these accidents, if it should be left to pursue its ordinary course ; (excepting one accident, to wit, putrefaction, which arises but seldom:)— The author in the next place is to take into consideration the remedies by which the fever may be carried off; so as to leave the patient in health in a shorter time ; or to conduct him through with less danger, than if the fever had been left to pursue its ordinary course. Since (as has been already observed) the essence of fever, or the state in which the system in fever differs from the healthy state, is altogether unknown ; the effects of medicines also in removing that state, can only be known by observation or experiment; there being no remedy that has any property, either chemical or mechanical, or any operation, when given to a man in health, that can point out any ground for employing it to carry off this disease. —The author now therefore comes to show ivhat remedies have been employed by practitioners, to carry qff regular continued fevers; whether they have been employed in consequence of some hypothesis, or have been found out by mere accident. The first remedy to be considered is opening a vein in the arm, or indiscriminately in any other part of the body ; and letting a quantity of blood flow out. Authors and practitioners have confounded fever, such as the author has defined it, with many other diseases ; particularly with all diseases in which the pulse is to a certain degree frequent. —Many diseases, in which the pulse is frequent to a certain degree, differ from one another in almost every other respect. The pulse is frequent to upwards of an hundred strokes in a minute in a pleurisy ; it is often frequent to above an hundred strokes in a minute in gangrene and mortification: but pleurisy, and gangrene and mortification, are very different diseases ; and require treatments totally different from each other. In pleurisy, taking away large quantities of blood is one of the most powerful remedies for carrying off the disease; whereas in gangrene and mortification, taking away large quantities of blood would be the most effectual means of destroying the patient. In gangrene and mortification also, the best mode of 263 A REGULAR CONTINUED FEVER. putting a stop to the disease, is to exhibit the bark of the cinchona in large quantities, with wine and spices; whereas in pleurisy, exhibiting large quantities of the bark of cinchona, with wine and spices, would be the surest way of increasing and rendering the pleurisy fatal. — Certainly therefore diseases in which the pulse is frequent, may differ from each other in all things, excepting mere frequency of the pulse ; which yet Dr. Boerhaave makes a specific mark of fever. (It is to be observed, that at the time Boerhaave gave this definition, he had never seen a fever ; having studied theology, and not medicine.) It has already been shown that the pulse in fever is by no means always frequent ; and that therefore frequency of the pulse can by no means be considered as a pathognomonic symptom of fever. — If all diseases, in which the pulse is frequent, be confounded together and called fever ; it certainly cannot be said that taking away blood never cures the disease. But if the disease, which the author has endeavored to define, as fever, be alone me'ant; the taking blood from a large vein, in any part of the body indiscriminately, never diminished, shortened, nor carried off a fever in any case he has seen ; nor has he found any upon record in which it had this effect. — It is true that an accident, such as general inflammation, may happen in an irregular fever, capable of destroying the patient; which accident may be counteracted and prevented from doing mischief by taking blood from the arm, or any other part indiscriminately; (as will be described when such irregularity is treated of.) The accident being removed, the fever may afterwards continue its course, may terminate by a crisis, or wear itself out; as if no such accident had taken place. The author having affirmed that taking away blood from the arm, or from any large vein, neither increases nor diminishes a fever, nor alters its course, as far as he has seen ; he next comes to consider what might be expected from taking away a quantity of blood indiscriminately from any blood-vessel, during a fever. A quantity of blood flowing out of the body, whether it be taken on purpose, or by any accident, occasions weakness. If the blood continues to flow the weakness will increase ; so as to render the body incapable of performing any function or action whatever; and in consequence will kill. If it does not continue to flow, it yet weakens a man; and the weakness continues until the blood is reproduced by the digestion of food of proper nourishment ; or perhaps by the conversion of expressed oil or other substances deposited in the body, into new blood. This weakness, with the accidents that arise from it, are the only effects of the loss of blood, which are perceivable. As fever takes place equally in a strong and a weak man ; it is also equally violent, as far as regards the fever itself, in a weak man as in a strong man ; and it is apter, or at least as apt, to run out to a great length in a weak man, as in a strong man. It is not, therefore, a priori, at 264 REMEDIES EMPLOYED TO CARRY OFF all probable, that weakening a man should diminish or shorten a fever. It comes then to be inquired into, why taking away blood indiscriminately from any large vein has been so often practised in fevers even by practitioners of the first rank in medicine ? — The author can only refer this practice to the impatience with which mankind bear any evil ; and to that superstition which predominates in them. If any violent disease takes place, men immediately recur to some violent remedy ; but their recurring through impatience to some very violent remedy, is no proof that such remedy is useful. If a man who has gone upon a journey, should return and without previous notice find his house burnt down, his family and property destroyed, and his friends ruined ; he would be apt to stamp upon the. ground, beat his breast, and tear his hair ; but stamping upon the ground would not rebuild his house, nor would beating his breast,' restore his family and property, nor tearing his hair retrieve his friends. As it is mere impatience which makes him have recourse to these violences ; so mere impatience makes mankind have recourse to violent remedies in diseases ; although no experience has shewn that they are of any use in the disease for which they have been employed. To this argument the author will have occasion to recur, when he comes to treat of irregular intermittents in a future dissertation.— So in like manner it is often from superstition that such violent remedies, and especially blood-letting, have been employed. Mankind are exceedingly apt to believe, that refraining from some gratification is agreeable to the Almighty, or to the gods which their imaginations have created ; even if they enjoy that gratification without any injury to their own health or constitution, or without injury to their fellow-creatures or any animal whatever, or without hurt to their moral character. Some pretended teachers of religion have gone so far as to refuse to their disciples, when dying of so distressing a disease as pulmonary consumption, the gratification of enjoying the cheerful warmth of the sunshine. Under this or some very similar idea, men have thought that their gods would be content with one part of their body, to save the whole ; whence among many rude nations, a finger or toe is cut off or a tooth or two' knocked out; in order that the rest of the body may be left safe. Blood likewise has attracted the attention of mankind by its intense red color, and because the loss of it, as has already been said, in a certain quantity is fatal: whence the losing a quantity of blood, has become the object of their superstition. Losing blood has been looked upon as the greatest oblation that could be made in the most solemn ceremonies : and men as the mark of the greatest bond of secrecy and steadiness, have signed contracts with their blood. Taking away therefore a quantity of blood has been thought a sacrifice the most powerful for carrying off a disease ; (and for carrying off fever as one of the most violent and fatal of diseases.) —The author does not mean A REGULAR CONTINUED FEVER. 265 to say that every practitioner, who bleeds constantly at the beginning of a regular continued fever, has these ideas in his mind. The greatest number of practitioners follow the practice of those who went before them; without examining from whence that practice has arisen, or upon what ground it is founded. From this view of the subject it may perhaps appear, why blood-letting has come into practice in the beginning of ail regular continued fevers. Practitioners also have not compared cases of fevers in which it has been practised, and cases of fevers (treated in other respects in the same manner) in which it has not been practised. The author having said, that taking away a quantity of blood from any large vein indiscriminately, in any part of the body, neither increases, diminishes, nor shortens a regular continued fever: — the next inquiry is, whether any mischief may arise in a regular continued fever from taking away a quantity of blood? The author has already shown, that a patient afflicted with regular continued fever cannot digest his ordinary quantity of food ; that therefore the fluids, which are constantly wasting, cannot be recruited ; and that the system must be weakened : that in a regular continued fever there are constant exertions which likewise debilitate ; that the repose which takes place in sleep is necessary to restore the living power; but that sleep being prevented in fever, the living power is not recruited : and that in consequence of all these causes of weakness the patient] is actually so debilitated, as to be destroyed in many instances. — The farther debility therefore arising from emptying the vessels by taking away a quantity of blood, is often such, as to destroy the patient in the remaining part of the disease. — Patients in consequence have very often been cut off, when blood has been taken indiscriminately from any large vein at the beginning of the disease ; as the author has seen in a great many cases. (In the first part of the author's practice, the Boerhaavian doctrine prevailed ; which induced practitioners to take blood from the patient in all cases of fever ; so that the author has had occasion frequently to see the effects of this practice.) The author having said, that the essence of the disease is not at all known ; it follows hence, that it cannot be said a priori, whether any particular remedy will be of use in shortening or entirely carrying off fever. — Taking away blood from the vessels of the head has, indeed in some cases, immediately carried off fever; and it has also tended to diminish that species of delirium accompanied with fulness of the vessels of the head, even when it does not shorten the disease : — But the first of these effects will be considered in a dissertation on the irregularities of fever; and the second in a future part of this dissertation. Many practitioners have supposed that fever arises from some peculiar kind of matter that has got into the body ; and that fever is an effort produced in the body to induce some operation, by which such matter might be destroyed. — Sydenham judiciously supposes that a 23 266 REMEDIES EMPLOYED TO CARRY OFF fermentation takes place, which alters the qualities of the matter ; or converts it into another species of matter, which has not the property of producing or keeping up this disease. — If it were indeed true that any particular species of matter produced and kept up a fever; it would follow, that until such matter was destroyed by a fermentation or some other process that might take place in the body, or else was evacuated ; the fever would continue. — In that case, it would become a question whether some other means than such as exist in the body of itself, might be employed to take this matter out of the body or to destroy it; so that it might no longer keep up the disease. Some practitioners have supposed that this might be done by evacuation. If a blood-vessel is opened, the wdiole circulating fluids are equally evacuated; (that is, every fluid, good or bad, noxious or innoxious, those that are commonly in the body and those that are there only by accident). No particular matter would be taken out more than another. And therefore it is not to be supposed that the matter occasioning a fever would be removed, by making this evacuation. — If the substances evacuated out of the body by the various excretions be examined slightly, they appear to be more different than when examined more minutely ; but still even upon minute examination they differ very much. It might happen therefore th'at some secretory organ is disposed to throw some particular noxious matter out of the system ; and that increasing such secretion, since an increase of any secretion to a certain degree, occasions the secreted matter to be thrown out of the body, might cause the matter producing and keeping up fever, to be evacuated ; so that the fever should cease. — But it may also happen on the other hand, (as has already been noticed,) that a fever may arise without noxious matter being applied to any part of the body, or being generated in the body ; and that in this case, there being no noxious matter to evacuate, neither the operation of purgatives nor any other evacuant would carry off such matter ; and so remove the disease. — It has also been shown, that noxious matter does sometimes produce fever when applied to the body ; and that after the fever is produced, it is really contained in the body ; (as in the case of fever arising from the application of variolous matter); but then it has been shown, that in such cases the noxious matter produces the disease at once ; and that what is contained in the system after the fever has taken place, has no effect upon the disease : It neither increases it, nor does its absence diminish it; and the fever often goes off, when there is the largest quantity of such noxious matter in the body. In such cases it would not surely be conceived, if we could evacuate such matter, that the disease would be carried off: and in such cases therefore, purgatives would be of no use. Hitherto the argument has been pursued a priori. But neither the essence of fever,nor the operations of the human body, are sufficiently known, as the author has before observed, to determine the efficacy A REGULAR CONTINUED FEVER. 267 of any medicine to carry off fever. Experience must therefore be called in, to determine whether purgatives or any other medicine producing evacuation from a gland, may be employed to carry off the present disease. If the question be referred to the experience of the most judicious authors ; all those who have conceived fever to depend upon matter of a peculiar kind contained in the system, have agreed that it must be concocted, before it can be evacuated ; (that is, that it must undergo some process before it is prepared for evacuation :) otherwise that evacuation neither by purging nor by increased secretion from any of the glands, can have effect in carrying off the disease. They are agreed at least, that evacuation before concoction must only be made at the beginning of the disease, to be efficacious : for after the disease has continued a day or two, they have no longer any expectation that evacuating the matter will carry off the disease. The author, therefore, would be warranted by authority to say, that evacuation by purging or any other increased secretion from glands, would have no power to carry off fever ; excepting the evacuant should be employed in the first twenty-four hours ; or else at the end of the disease, after the matter is concocted, or has undergone such an alteration as to render it fit for evacuation. — It is farther to be observed, that when any matter is applied to the body, so as to produce fever, not immediately, but at the interval of several days, (such as the matter of the small pox, or the measles, or putrid or infectious vapor) ; if purgatives are employed during the interval between the application of such matter and the taking place of the first paroxysm of fever, the fever has never been prevented from taking place ; at least in any case which the author has seen or which has been recorded. This is equally to be observed in those cases, in which the application of the cause has produced some immediate appearance of the first stage of fever, without producing a perfect paroxysm ; these appearances continuing until a complete paroxysm has taken place. — In those cases where the application to the body of the matter which occasioned the fever, has produced no appearance of the disease ; but the patient has felt himself in perfect health, until the complete attack of the fever came on : even in this case, neither purgatives nor any other medicine increasing secretion, have prevented the disease. — If the evacuation therefore by purging or by increased secretion from any of the glands, does not carry off the matter from the body, before it has produced the disease ; there seems to be little reason to hope that such evacuation will carry off the matter occasioning the fever, and the fever itself, after the fever has actually taken place. The author has already observed, that feculent matters remaining! in the intestines, which they are apt to do when a fever takes place,* tend to increase the disease. Though their removal prevents the mischief they tend to produce ; yet, as far as the author has been enabled to judge from the attention he has paid to such cases, their 268 REMEDIES EMPLOYED TO CARRY OFF evacuation has in no case done more, than merely obviate the mischief connected with their retention. (Such evacuation has never, in any degree removed the fever; or prevented it from pursuing its ordinary course.) Those practitioners who have believed that fever depends upon some noxious matter contained in the body : and that such noxious matter is concocted ; (that is, goes through some operation by which it is prepared for evacuation): have also supposed, that when a crisis took place, the matter was evacuated after having been concocted ; and that so the fever was carried off. They have thought, that if it was not completely evacuated, it was necessary to employ purgatives, to evacuate wdiat might remain of the matter in the body, lest it should reproduce the disease. They have also thought that when no marked crisis took place in the disease, but that it gradually subsided, that it has subsided more slowly on account of the noxious matter not being all at once evacuated : — And therefore they have employed purgatives to make it be evacuated more speedily ; so that the disease should sooner subside. — But the author, from his own practice, is obliged to be of a contrary opinion ; since he has seen relapses much more frequently take place when purgatives have been employed after a marked crisis, or after the disease has gradually subsided ; than when purgatives have not been employed. Upon the whole then the author believes that though it is perfectly necessary at all times, during the progress of a regular continued fever, to keep the intestinal canal free of feculent matter; yet that making farther evacuation by purging, or by increasing the secretion from any of the glands so as to occasion evacuation, is of no use in carrying off the fever; but rather tends to prevent the fever from being carried off; or if it is carried off, to produce relapses. — Moreover the author has already shown, that it required the whole force of the system to support the patient through the ordinary course of a regular continued fever : He has also shown that the force of the system is reduced by evacuation. He must therefore conclude, that simple evacuation by purging, excepting in as far as it is necessary to keep the prima vice clear of feculent matter, is detrimental instead of being useful ; and that simple evacuation also from any of the glands, as tending to weaken, is equally detrimental. It does not appear with any degree of certainty that Antimony, a medicine which has been employed to carry off fever within this century or two, w T as at all known to the Greek philosophers, physicians, or artists.— There was a substance which they named stibium, which was employed to give a blackness to the eyes ; but the effects which were produced from it, cither among the Greeks and Romans, or among the modern inhabitants of Asia, show that this substance was more probably a kind of lead ore, than an ore of antimony. Antimony, or as it is more commonly called crude antimony, is the ore of a metal which exists in many parts of the earth : being a coin- 269 A REGULAR CONTINUED FEVER. pound of sulphur* and a metal; in which the sulphur bears a much greater proportion to the metal, than can be combined with it chemically. More properly, it is a compound of sulphur and the metal, diffused through a superfluous quantity of sulphur. But though part of the sulphur retains some of its own properties ; yet the sulphur so covers the metal or is so combined with it, as to prevent it from producing its medicinal effects. —This ore is solid in the heat of the atmosphere. It requires a little less than that degree of heat which renders substances luminous, to melt it; somewhere probably between five and six hundred degrees of Fahrenheit's thermometer: but its melting point has not been exactly ascertained, in as far as the author knows. It is of a dark blue color. It is generally found in a kind of crystallisation ; and sometimes in complete crystals, (which are prisms terminated by pyramids at one end, and at the other generally attached to each other :f) otherwise it is in a mass without form. More commonly these crystals are united together, so as to form a striated mass ; especially when they are unmixed with any other substance. — The metal has lately been found also combined with some substance, so as to form the same kind of crystals or striated mass; only of a dark red color; shining however with metallic lustre. — It has been conjectured, rather than confirmed by experiment, that these crystals or this striated ore, contain arsenic, besides sulphur and the metal of antimony. This conjecture is probable ; because this red ore of antimony has been almost always found with regulus of arsenic ; (that is, the metal of arsenic pure :) and therefore experiments made to verify the existence of arsenic in this red ore, should be made in such parts of it, as are perfectly clear from the particles of the metal of the arsenic in which it is found. — The metal has also been found, but very rarely, certainly however sometimes, uncombined with any other substance ; but so rarely as not to be employed medicinally. Upon the whole, all the antimony which has been employed in medicine, has been procured from that ore of antimony, consisting of antimony and sulphur. — This ore, when dug from the mine, is laid upon an inclined plane ; formed from a mixture of clay and sand burnt in the fire. The inclined plane is heated red hot; when the ore of the antimony, being laid upon it, melts and runs off from the other substances with which it is mixed ; and is received into a large and deep earthern vessel, in which, when it has stood to cool, it concretes into a solid mass. — If this solid mass concretes so, as when broken, to exhibit long striated shining spiculae ; it is a pure compound of antimony and sulphur : and fit to be employed medicinally. A vast number of chemical processes have been employed to give * Antimony readily combines with sulphur or phosphorus; but not with carbon, hydrogen, or azote. f Hauy says that the primitive form of the crystal is octahedron, and of the integrant particles tetrahedron. 23* 270 REMEDIES EMPLOYED TO CARRY OFF to antimony medicinal effects ;* more than two or three thousand. Of all of these, there are only three preparations at present much in use. First. One is made by boiling the antimonial ore, or crude antimony, in a solution of pure or prepared kali in water. The decoction, after it has been strained, is diluted with a considerable quantity of water; at least ten times its weight. The diluted solution is placed in a shallow vessel, and the surface exposed to the air ; until a powder falls to the bottom of the vessel; which, being taken out and dried, is called kermes mineral.] Second. The second process is performed by mixing the ore of antimony, or crude antimony, finely powdered, with an equal weight of the shavings of the horn of any animal. This mixture is to be put into an iron pot, which is to be heated red hot; and the mixture is to be stirred : the pot being kept red hot until it ceases to smoke. The mixture is afterwards to be allowed to stand until it cools. It is then to be put into a crucible ; which is to be covered with another crucible, whose mouth is to be turned down into that crucible which contains the materials. The crucibles, with the materials, are exposed to a white heat for two hours: when part of the matter remains of a white color in the under crucible, which is to be used \\ (and part sublimes into the upper crucible, which is to be throwm away.) Third. The third preparation is made by combining the metal of antimony with ta?iar(nn acid§ produced in the fermentation of various wines ; which is found adhering to the sides of the vessels in which the wine has stood for a year or more, after the active fermentation has ceased). — When two substances, which unite with one another only in one proportion, are combined together chemically, and the compound is purified ; the substance is undoubtedly the same in all its properties. — It happens, nevertheless, with respect to the chemical combination of two substances w r hich unite with each other in one proportion only ; that when they are combined together by different processes, there are often different imperfections in the combination, or some want of purity in the compound. This, though not made sensible by any chemical test, often occasions a yery considerable difference in their actions as medicines. — In the present instance of the compound formed of tartar and the metal of antimony, (or, perhaps, if strict adherence was to be had to chemical accuracy, we should say the compound formed of tartar and the calx of antimony ;) this difference is conspicuous. Of the several methods of forming this compound, the following is * Pee Bergman's Dissertation on Antimonintcd Tartar, (in his Physical and Chemical Essays, translated by Dr. Edmund Cullen ;) for some of these processes, i. 39o. | This was also known among the French by the name of JLe poudre den Chartreu.r. t This the author calls afterwards "calx of antimony with calx phosphorata. § Tartar, as a salt> may be considered as a vegetable alkali supersaturated with a vegetable acid. 271 A REGULAR CONTINUED FEVER. the best for medicinal purposes. — Take an equal weight of the ore of antimony separated from extraneous substances by fusion, as has been above described, and of kali nitratum. Powder them together, and throw the mixture into a crucible, heated so as to be just luminous, by very small portions, about twenty grains at a time, until a deflagration takes place ; wait till the deflagration is over; then throw in a little more of the mixture ; wait again till the deflagration is over: and proceed in this manner, until the whole is deflagrated. Cover the crucible, and expose it to an heat just sufficient to melt the whole mass. Pour the melted mass into an iron vessel of a conical form, the point of the cone being downwards ; and the whole will be found, when it is cold and solid, divided into two substances : — one of a reddish-brown colour and heavier, which has fallen to the bottom ; and the other, of a grey color, which is found at the top and is specifically lighter. —The heavier part is a compound of sulphur and the metallic part of the antimony. A portion of the sulphur wdiich was united with the antimony in its ore, more than was necessary to combine with the metal of the antimony ; is converted into vitriolic acid, by uniting with the air of the nitrous acid. This vitriolic acid is found in the upper greyish mass ; combined with the kali of the kali nitratum; and forms kali vitriolatum.— The antimonium sulphuratum, found at the bottom, is to be powdered, and to be mixed with one-third more than its weight of purified tartar; and boiled in six times its weight of water for a quarter of an hour: the solutionis to be filtrated, and the water evaporated: and the compound, of the tartar and the metal of the antimony, is to be crystallised. — This salt for chemical purposes may be purified, by dissolving it again in water and re-crystallising it; (but it is a question whether it would not lose some portion of its medical powers by this purification). Again : The metal of the antimony maybe separated from the sulphur with which it is found combined in its ore, by mixing the ore with five times its weight of kali preparatum ; that is, with kali combined with gas; which gas been called also fixed air and carbonic acid. The mixture of the kali preparatum and ore of the antimony is to be melted together, by a heat just sufficient to render them perfectly fluid.—The crucible being taken from the fire, is to be left till it is quite cold ; and on breaking it, the metal of the antimony will be found at the bottom; and the compound of kali and sulphur at the top. — This is not the most economical mode of obtaining the metal of antimony ; — but provided we take the ore separated from the other substances with which it is found mixed in the mine, as has above been described, the metal by this process is obtained in the purest state for medicinal purposes. —If the metal thus obtained is powdered finely, and boiled with pure tartar in water ; a compound of the tartar and antimony will be obtained ; which, if purified by recrystallisation, will be exactly the same with that obtained by the process above described, in all its chemical properties. Another (or third) mode of obtaining this compound is—Take the 272 REMEDIES EMPLOYED TO CARRY OFF ore of antimony purified (as has been already described ;) powder it, and put the powder into a flat vessel ; heat it till it begins to smoke ; keep up the heat, (but take care not to render it so great as to melt the mass,) until it no longer smokes in any heat not sufficient to melt it. . The remaining mass, which is the metal of antimo?)]/ calcined (probably combined with pure air) ; if exposed to a greater degree of heat, will melt into a glass. — If this glass be powdered, and boiled with pure tartar in water, a compound of antimony and tartar will also be procured : which, when purified by repeated solutions in water and repeated crystallisations, will (in all its chemical properties) be the same-as when the salts is procured by the two processes already described ; — but if not cristallised a second time, it will not agree exactly in its medicinal effects. Lastly and fourthly: The metal of antimony may be combined with muriatic acid, by several processes, for the purpose of making the compound here in question. — One of these for instance, is : Mix the ore of antimony with that compound of muriatic acid and mercury, which has been called corrosive sublimate. Perform a distillation or rather a sublimation ; and expose the matter thus sublimated to the air of the atmosphere, until it has attracted water enough to render it fluid ; pour this solution of antimonium muriatum in water (or any other solution made by this or any other process in which the w r ater is saturated with the antimonium muriatum,) into eight or ten times its weight of distilled water. — A calx of antimony will fall down in a white powder ; which has been called powder of algaroth ; — and this being boiled with pure tartar in water will combine with it, and form antimonium tartarisatum ; — which (if purified by recrystallisation) will be the same to all chemical and medical purposes as the antimonium tartarisatum produced by the three foregoing processes ; but not exactly in its medical effects unless purified by recrystallisation. Although the antimonium tartarisatum when obtained by any of these four processes, and purified by re-dissolution in water, and recrystallisation ; may perhaps be the same for medicinal as well as chemical purposes, which however has not been proved by experiment — yet when it has only simply been formed by these four different processes, without re-dissolution in water and re-crystallisation ; there is a difference in its operations as a medicine. When the London College of Physicians reviewed their pharmacopeia for its reformation and republication in the year 1786, it became a question which of the four processes they should adopt. — Whenever any question of a chemical or pharmaceutical kind occurred, it was referred to a committee consisting of some members of the College and of the Company of Apothecaries ; and the processes were actually performed in the laboratory of the Company of Apothecaries ; that so the best mode of performing the operation might be verified by experiment. — A question then having arisen with regard to the tartarised antimony, it was prepared by all these processes. — The tartarised antimony produced by these processes was A REGULAR CONTINUED FEVER. 273 put into the hands of the Physicians of St. Bartholomew's and St. Thomas's Hospitals. In St. Thomas's Hospital they were given to more than a hundred patients ; so that one and the same patient took of each kind in small doses. — The tartarised antimony prepared with the crocus met alio rum* and tartar, was found to be capable of being exhibited in a larger dose than any of the others without producing sickness ; and to act more powerfully as a sudorific, and therefore was preferred ; (whether properly or not, will be argued afterwards). At the time when the science of medicine was revived with the other sciences (first in Italy,) there does not seem to have been any medicine to put an end to fever immediately, found to have been recommended either by Galen or Celsus, or any of the Greek or Roman writers upon the subject; excepting cold water drunk in large quantities at once. It was not supposed that a fever might be cured by any other method immediately, so as to prevent any future appearance of the disease ; either by preventing the returns of the paroxysms, or carrying oiT the disease instantaneously, or by producing an immediate crisis. The doctrine then was to attend to the disease while it pursued its ordinary course ; only taking care of the accidents which might happen during that course ; that is, taking fever according to that idea of it which the author has been endeavouring to lay down. There arose in Europe some time afterwards, a number of alchemists ; who made many processes with a view to convert metals into gold. Having formed many substances by processes which did not make gold, but which produced many things which they were not able to turn to any profit ; they tried to apply them to the cure of diseases. All such chemists must be considered as empirics ; and the greater part of the substances which they produced were in fact of no use. Antimony, however, gained a reputation for carrying off some diseases without their going through their course, if otherwise left to themselves : and it is probable it was employed for this purpose in fever, as soon as the time of Van Helmont. — These chemists did not study medicine, nor did they distinguish diseases ; but only aimed at making some profit of the result of their processes. They called every disease Fever, in which there was great sense of heat in the patient, and greater frequency of the pulse than in health : So that they not only employed preparations of antimony in fever ; but in internal inflammations and various other diseases. Practitioners, who were educated in the regular practice of medicine, studied principally the writings of the ancient Greek and Roman physicians, who for the most part used vegetable substances for remedies in diseases. The [first] modern practitioners, therefore, reprobated all the substances which were the result of chemical operations; and considered * That is, by the first of the four processes above named ; the crocus metullorum being formed " by detonating in a crucible equal weights of sulphuret of antimony, and nitre; and washing the residuum in water, till the liquid comes off tasteless." 274 REMEDIES EMPLOYED TO CARRY OFF them only as the boast of ignorant empirics. This opinion went so far, that even so late as the time of Boerhaave, mercury was rejected by regular practitioners in the venereal disease. — Some practitioners, (for there always will be men who balance between two different doctrines,) employed indeed preparations of antimony, but such as had little or no effect; (such as antimony, calcined by deflagrating it with three times its weight of nitre ; and various other preparations equally inefficacious). They of course did not find any advantage arising from preparations of antimony ; and therefore reprobated the use of all antimonial medicines in fever. Hence it happened, that these preparations were not much employed with efficacy in Great Britain, before the time of the late Dr. James. Dr. James was a physician of regular education (having studied at the University of Cambridge) ; but was considered in some degree as an empiric, in consequence of employing a preparation of antimony, which he kept as a secret. The preparation he made use of consisted principally of antimony, calcined by mixing it with shavings of harts-Ztom, and exposing the whole to a great degree of heat. Upon analysing it, (which was done long before his death,) it was found to consist of a calx of antimony, mixed with bone ashes. It is extremely probable, that he mixed along with it a proportion of tartarised antimony : (for the author knows that he purchased considerable quantities of tartarised antimony, two pounds at a time, from an eminent druggist). This might easily escape the scrutiny of a chemical analysis ; since the quantity contained in one dose did not certainly exceed a quarter of a grain. From the very easy decomposition of tartarised antimony, when dissolved in a large proportion of water ; so small a quantity might not be observed. Dr. Cullen was the first eminent teacher of medicine who recommended the use of preparations of antimony to carry off fevers directly. —As most of the principal practitioners of the present day, in Great Britain, have been pupils of Dr. Cullen ; its use has lately very much prevailed. If this had not been the case, it would have been a question whether it would not have sunk into oblivion ; like any other empiric remedy whose preparation w ( as kept secret. Dr. Cullen conceived, that the effect of preparations of antimony arose from their producing sickness. Tartarised antimony is much more certain of producing sickness, than any other preparation that was known to him ; and of course that preparation of antimony which produced sicknesss in the smallest dose he considered as best. The author is of a different opinion ; to wit, that it is not the sickness produced by the preparations of antimony, that has the effect of carrying off fever immediately; but some other operation of the medicine. First; because there are many other remedies which produce sickness to as great a degree as any preparation of antimony: yet these have no power whatever of making fever terminate sooner 275 A REGULAR CONTINUED FEVER. than it would if it was left to pursue its own course. The root of the squill, for instance, often produces sickness to a much more severe degree than any preparation of antimony; yet it has never been alleged, that it has the power of carrying off fever sooner than it would otherwise go off; supposing it allowed to pursue its ordinary progress. Moreover, the author himself has frequently exhibited the root of the squill as an emetic; and likewise in such doses as to produce nausea without vomiting: also in such doses as just not to produce nausea ; without ever producing anything similar to the appearances which take place in a crisis of fever; or without ever once occasioning a fever to terminate sooner than it would have done if left to pursue its own course. So far, therefore, the author must conclude, that the sickness occasioned by the exhibition of a preparation of antimony, is not the cause of its carrying off fever. Secondly ; the stomachs of different men, though otherwise in the same situation, are affected differently by the same quantity of any particular medicine ; the stomach of different persons, or of the same person at a different time, being able to bear a comparatively large dose without its producing sickness or vomiting. Indeed, almost every medicine given in a certain dose will produce sickness and vomiting; so that even opium, if given in a certain dose, (that is, to the quantity of two or three grains,) will sometimes produce sickness and vomiting, and sometimes purging. When a medicine is given in such a dose as to produce vomiting, it often loses its peculiar effect. The bark of the cinchona, when given in such a dose as to produce vomiting, either from the disposition of the stomach of the patient not to bear so large a quantity as the stomachs of men will generally bear, or from its being exhibited in a larger dose than common ; will often fail in putting a stop to the progress of an intermittent fever. It may be said indeed, first, that, the Peruvian bark, by producing sickness and vomiting, will be thrown out of the stomach before it has time to be absorbed and carried into the bloodvessels. But the author has shown in his dissertation on a regular tertian, that it does not put a stop to the progress of an intermittent fever by being carried into the intestines and absorbed ; but by the impression it makes on the stomach and intestines. In the second place, it may be said, that the bark of the cinchona, by producing vomiting; is prevented from remaining a sufficient time in the stomach to make its impression there. But the author has also shown in the same dissertation, that the bark of the cinchona exhibited half an hour before the beginning of a paroxysm of a tertian intermittent, often makes sufficient impression to prevent the paroxysm from taking place. It is often indeed, more than half an hour after the exhibition of a dose of the bark of the cinchona before it occasions vomi- ting ; but when it does occasion vomiting, it often does not prevent the return of the disease. In the third place, cerussa acetata given in a small dose does not produce either vomiting or purging ; but cn the contrary, a diminution of the peristaltic motion of the intes- 276 REMEDIES EMPLOYED TO CARRY OFF tines : and not uncommonly a paralytic affection of them, and likewise of the extremities. Yet when it has been by accident taken in a considerable dose, to the quantity of a drachm or two, as the author has seen happen in several cases ; it has produced both vomiting and purging; but no paralytic alfection of the intestines or of any other part of the body has ensued. The author, therefore, conceives that when any remedy produces vomiting, it very often by this effect loses its other operations on the system ; and that preparations of antimony in like manner, if they produce vomiting or even sickness, though no vomiting should ensue; lose their effect in carrying off' fever. The author farther conceives, that every medicine given in too great a dose, acts as a simple stimulant on the part to wdiich it is applied ; and loses its peculiar effects both on that part, and on the system generally. Thus a moderate quantity of wine makes the stomach digest the food more readily than it otherwise would have done: but a large quantity of wine prevents digestion from taking place at all. A moderate quantity of spice gives a feel of w T armth over the whole system ; but a large quantity of the same spice produces pain in the stomach, and coldness over the whole system, and frequently sickness and vomiting. It would be too great a digression to enter fully on the maximum of the doses of medicine ; but if the author should live to finish these dissertations, it is a subject that he means to pursue. In the next and last place, the author has observed, when tartarised antimony has been exhibited in fevers; that when the patient's stomach could not bear a quarter of a grain of it, prepared as has been said, Without producing sickness; it has happened rarely that it has produced anything like a crisis, or in any way diminished or carried off'the disease. On the contrary, when the stomach would bear more than that quantity, prepared in the same way, and by the same individual process, without producing any nausea, it has very often produced critical symptoms, or a complete crisis ; so as to carry off the disease. The author then differs in opinion from Dr. Cullen ; and believes that it is not the sickness that has the power of producing a crisis, or any appearance of crisis, in a regular continued fever : — For it appears first, that several medicines, producing as great a degree of sickness as preparations of antimony ; have no power whatever of carrying off fever, by producing crisis or appearances similar to crisis or in any other way.—Secondly it is proved, that producing sic kness prevents medicines generally from operating in their own appropriate manner. — Thirdly, it is shown that preparations of antimony when they produce sickness in small doses, are not so efficacious in carrying off fever, as when it requires a larger dose of them to produce nausea ; and also that they are more efficacious when no nausea is produced. It appears therefore, upon the whole, that it is not the nausea produced by preparations of antimony, that renders them efficacious in producing symptoms similar to those that take place in the crisis of a A REGULAR CONTINUED FEVER. 277 fever and so carry off the disease. On the contrary; that any preparation which can be made to act with certainty in a larger dose, without producing nausea ; is preferable for carrying off fever. Farther, it appears that tartarised antimony, as prepared by boiling crocus metallorum with tartar in water, and not purified by a repeated solution and crystallisation ; is the best manner of preparing the compound of tartar and antimony for this purpose. The next question then is, whether tartarised antimony, prepared as has been described ; or regulus of antimony, mechanically mixed with sulphur, as in that preparation which has been called kermes mineral; or the calx of antimony, mixed with calx phosphorata (which formed at least a principal part of Dr. James's powder ; and is the pulvis antimonialis of the last edition of the London Pharmacopeia :) — are the preferable preparations of antimony for immediately producing symptoms similar to those that take place in the crisis of fevers. The regulus of antimony in the kermes mineral, and the calx of antimony in the pulvis antimonialis, are neither of them soluble in water. — It has been held by many practitioners, that substances not soluble in water, must be combined with some menstruum in the stomach with which they form compounds soluble in water to be efficacious. If this be the case, these preparations of antimony, (to wit, kermes mineral and pulvis antimonialis,) will be subject to an uncertainty in their operation ; by their meeting or not meeting with a menstruum with which they may combine, so as to form a compound soluble in water. — The first thing then to be inquired into is, whether it be true, that if any solid substance, insoluble in water, be thrown into the stomach ; it will act upon the stomach and intestines, or upon the system generally ; without finding a menstruum with which it will combine, so as to form a compound soluble in water. It is well known, that sulphur thrown into the stomach in fine powder, (as it is when precipitated from an alkali by means of an acid,) or in fine crystals, (as when it has been recently sublimed ;) will act as a purgative. — In either of these cases, if the sulphur be perfectly pure and unmixed w T ith any extraneous matter whatever; it is not soluble in water in the smallest degree. — It is true, that if sulphur be thrown into water, and left in the water with the surface of the water exposed to the atmosphere for some length of time ; the sulphur will combine either with the air of the atmosphere or of the water; and form vitriolic acid, which is soluble in water. —But sulphur recently precipitated from an alkali by means of an acid, or recently sublimed ; has not acquired any air; and yet it acts equally as a purgative. Moreover, vitriolic acid rarely acts as a purgative in any dose, if given uncombined with any other substance ; whereas sulphur rarely fails of acting as a purgative. It is therefore to be considered, whether sulphur meets with any substance in the stomach with which it will combine ; so as to form 24 278 REMEDIES EMPLOYED TO CARRY OFF a compound soluble in water. — In the first place, it meets with water in the stomach ; with which, it has been already said, it will not combine : nor will it be altered by it; excepting by long digestion, in the heat of the human body. : — If it should alter by combining with the pure air of the water, the acid thus formed rarely acts as a purgative ; nor does inflammable air, the other element of the water, act as a purgative. It is therefore extremely improbable that it should act as a purgative, by decomposing the watery fluid that it meets with in the stomach. — Again : the water found in the stomach is impregnated with animal mucilages, (such as the solid matter of the mucus) ; but w r ater, impregnated with animal mucilages, is not decomposed more readily by sulphur being applied to it; nor does it more readily combine with sulphur in consequence of its being already combined with such animal mucilage. The gastric juice (as it is called, in counter-distinction to other fluids found in the stomach) has been thought by some to be a powerful menstruum ; and to unite with the food, so as to form chyle, or some compound preparatory to the formation of chyle. Concerning this solvent power of the gastric juice the author has argued in his Treatise on Digestion ; the result of which argument appears to be, that it has no such solvent power; on the contrary it appears that its sole power is to coagulate certain animal and vegetable substances, so that they may be retained in the stomach until they go through that part of the process of digestion which is necessary in the stomach. No experiments also have been made to show whether or not this gastric juice will combine with sulphur so as to form with it a compound soluble in water. It is extremely improbable that it does ; since waler, combined with other mucilaginous matters, does not dissolve sulphur more readily than pure water. Gastric juice likewise renders certain substances insoluble in water, that are otherwise capable of being combined with water. It is therefore improbable, that gastric juice should so combine with sulphur as to form a compound with it soluble in water. — Farther : in the juices of the stomach, there is sea salt, (that is, natron muriatum,) ammonia muriata, and ammonia phosphorata, and sometimes perhaps calx muriata, as there are in all the other juices of the body : but none of these salts combine with sulphur so as to form a compound soluble in water. — Other substances indeed are occasionally found in the stomach, but not always ; but sulphur almost ahvays proves purgative ; and therefore sulphur does not act on the stomach and intestines, in consequence of meeting with a substance in the stomach which is accidentally found there. — Sulphur consequently does not act as a purgative in consequence of anything it meets in the stomach, with which it forms a compound soluble in water. Sulphur, when it gets into the duodenum meets with bile ; which might combine with it, and form a compound soluble in water. The like might happen with pancreatic juice ; with which it often meets in the duodenum. — But from the author's experiments, which it would be too great a digression to relate here, sulphur is neither capable of 279 A REGULAR CONTINUED FEVER. combining with bile nor pancreatic juice: And therefore sulphur does not act by combining with bile or pancreatic juice, so as to form a compound soluble in water. — As the same observations may be made with regard to the other fluids it meets with in the intestinal canal; it is at least extremely probable, that it does not combine with any of them, so as to form a fluid capable of being combined with water. Sulphur indeed is capable of being combined with that vapor which \ an Helinont first noticed and called gas ; but which has since been called fixed air, and by many other names: This vapor is found sometimes in the intestinal canal. — Sulphur is also capable of being combined with inflammable air. — But neither of these vapors is found generally in the intestines ; wdiereas sulphur almost always acts as a purgative. We must therefore conclude that sulphur acts upon the stomach and intestines in a solid form. — And as it is capable of acting on them independently of any mechanical effect; a solid is capable of acting on the stomach and intestines medicinally. Regulus of antimony, and the calx of antimony made by mixing antimony with shavings of hart's-horn, burning them together, and exposing them to a great degree of heat ;) may therefore so act upon the stomach without being combined with any substance, as that the compound shall become soluble in water ; and therefore they may act independently of any menstruum they may meet with in the stomach. — It has been often affirmed in medicine, that whatever was shown to be possible, was also true. This however is a proposition totally repugnant to all the laws of evidence. It does not follow, therefore, that although one solid in powder may act upon the stomach and intestines, every solid does. The next question then that comes to be discussed is, whether the fine powder of the regulus of antimony in kermes mineral, and the calx in the pulvis antimonialis, do act in a solid form; without being combined with some substance with which they form a compound soluble in water. In the healthy state of the body, the fine powder of the regulus of antimony in kermes mineral, and the calx of antimony in the pulvis antimonialis, being thrown into the stomach; will frequently act as an emetic. — In the healthy state of the body, there is no acid in the stomach not combined with an alkali: therefore neither of those preparations of antimony can act in consequence of being dissolved by an acid in the stomach; — unless they should decompose the neutral salts. Whether they can decompose the neutral salts, to wit, sea salt, common sal ammoniac, or phosphoric ammoniac, as they are found in the stomach ; or whether they are soluble in the neutral salts themselves, is not known ; and therefore the argument must be taken on another ground. If tartarised antimony (prepared as has been described) be exhibited to a man in health ; it hardly ever happens that a third part 280 REMEDIES EMPLOYED TO CARRY OFF of a grain can be taken without producing sickness and vomiting, or purging. It very rarely produces any nausea, if taken in the quantity of a fifth part of a grain, by an adult. On the other hand ; the quantity of three grains of pulvis antimonialis, or of kermes mineral, will sometimes be required to produce sickness and vomiting; and very often in other cases, even the quantity of eight or ten grains may be taken without any sensible effect. (The author indeed has seen them often employed to the quantity of twelve or fifteen grains, without having any apparent effect at all.) — Moreover, kermes mineral, and the pulvis antimonialis, the author has seen (in several instances) exhibited at the interval of six hours, for four-and-twenty hours or forty-eight hours, without producing any sensible effect; and at last, (all at once) they have brought on a severe vomiting and purging; so as to weaken the patient very much. — It must, therefore, be concluded, that either they are not active in a solid form, unless combined with some menstruum that will form with them a compound soluble in water; — or otherwise, that acting in a solid form, they are very uncertain in their operation. — In either case, tartarised antimony is a preferable preparation to kermes mineral, or the pulvis antimonialis (which last is considered as the equivalent of Dr. James's powder, and agrees with it as to its uncertainty.) The author does not by any means say that tartarised antimony, prepared as has been described ; is the best possible preparation of antimony. On the contrary ; he thinks that if a preparation was to be found out, of which the stomach would bear a much larger dose without sickness, and act with the same certainty ; it would be preferable to tartarised antimony (prepared as has been described). Another circumstance must be remarked. If tartarised antimony be dissolved in a large proportion of water, it will be decomposed, like all other metallic compounds with acids which are soluble in water, in case the solution stands with a surface exposed to the vapors which constitute the atmosphere. It will be less apt to be decomposed, if it be dissolved in recently distilled water ; than in river, spring, or rain water. — It will be still less apt to be decomposed, if combined with wine, and especially a sweet and 'strong wine ; and it is therefore much better to keep it dissolved in wine. The solution is convenient, w r hen the wine contains a quarter of a grain of tartarised antimony, in half a drachm (by measure) of the wine ; (as in the vinum antimonii tartarisati of the London Dispensatory). Of this solution, half a drachm by measure may be exhibited, or any greater or less quantity ; mixed with an ounce of any watery vehicle, and taken before it has time to decompose. The other known preparations of antimony, excepting those which have been enumerated, are so uncertain in their operations ; as to make them totally unfit to be employed in fever. It it an undoubted fact, however, that other preparations of antimony than the three enumerated above, have been exhibited to a patient ill of a fever; and have occasioned appearances similar to A REGULAR CONTINUED FEVER. 281 those which take place in a crisis which happen during the progress of regular continued fevers, left to pursue their ordinary course.—Such crisis has terminated in fever in the manner in which it is terminated by an ordinary crisis ; so that the patient has been freed from the fever in a few hours; and it has not afterwards recurred. — But these medicines act so uncertainly, that it is not worth employing them. Preparations of antimony, when exhibited to a man in perfect health in such a dose as just not to produce sickness ; occasion, after two or three hours, a breathing sweat, and softness of the skin ; not unfrequently a lateritious sediment in the urine ; also an open body ; and afterwards an universal tranquillity over the whole system. They occasion therefore appearances similar, as much as can be, to those which take place in the crisis of fever. — It is attested by many authors that on the exhibition of Dr. James's powder, the pulvis antimonialis, kermes mineral, or tartarised antimony ; in two or three hours afterwards (or from that to five or six hours), the symptoms which ordinarily arise in the crisis of fever, have taken place ; and that the fever has been carried off in less than twenty-four hours ; so that the patient has perfectly recovered. —The author has seen each of these preparations of antimony exhibited in a fever, during the ordinary progress of the disease: in the first week of a fever, as well as in the second week. He has seen, in less than five hours after the exhibition of the medicine, the symptoms which take place in the ordinary crisis of a continued fever, arise; and the fever has ceased in less than twelve hours. — This effect of these medicines the author has seen, in many cases, where there was no appearance that a crisis would have taken place in the fever; supposing that it had been left to pursue its ordinary course. —Again a crisis generally takes place, in a regular continued fever, in the nighttime ; that is, from four to six or eight o'clock, in the morning : but the author has seen it produced (by the means in question) at other times of the day. — Where these preparations of antimony have been exhibited, the author has seen fevers much more frequently carried off by crisis, than in proportion to the number of crisis which happen in fevers left to pursue their ordinary course. — He has seen these things happen in many hundred cases of fever. — It may therefore be concluded, that these preparations of antimony, being exhibited in a fever, often produce symptoms similar to those which arise in the ordinary crisis of fever; or, in other words, that they produce a crisis similar to the ordinary crisis in fever; and carry off the disease. The next question which occurs is ; whether there is any other medicine which produces the same effects either more or less certainly, or equally certainly, compared with the preparations of antimony which have been enumerated ? — It is matter of consideration whether this question should be first discussed ; or whether it would be better to enter into the argument in what manner the preparations 21* 282 REMEDIES EMPLOYED TO CARRY OFF of antimony (hitherto described) should be employed, so as to have the best chance of carrying off'the disease ? Reasons might be urged for taking the one or the other argument into discussion first; but it is not worth debating this. It is therefore the author's determination, upon the whole view of the subject, to attend first to the best method of employing preparations of antimony to produce crisis in fever; though he is not sure that he is right; as he may be obliged, in many instances, to take notice of the effects of other medicines which have a similar action in fevers, and produce a crisis in them. The author has already said, that when a patient is attacked with fever, it often happens that 1here is undigested food in the stomach ; which will therefore require to be evacuated. From the fever itself, likewise, other noxious matter is probably produced in the stomach ; in some degree similar to that which we find covering the tongue. — It is necessary to evacuate such undigested food ; because by remaining, it may contaminate the food that may be afterwards thrown into the stomach, by exciting in it the acetous, putrefactive, or other noxious fermentations, and prevent it from being converted into a substance which is afterwards to be formed into chyle. Vomiting in itself has a tendency, after the sickness wdiich produces it is over, to occasion a glow or warmth over the whole body ; followed by moisture on the skin, softness of it, an universal softness and relaxation of the whole muscles, a flow of fluids through the whole secretory vessels, a general tranquillity over the.whole system, and a disposition to sleep. — Although vomiting, induced by any means, has this effect in some degree when the sickness occasioning it is gone off; yet it has not the same effect, in an equally powerful manner, when produced by any means whatever. — If vomiting be produced by tickling the throat, or by introducing any solid substance into it, as a feather or the finger ; or if by a cough the larynx be forced up into the throat; some sensible effect similar to what has been just described takes place. — But if preparations of antimony or ipecacuanha be exhibited, so as to produce vomiting ; the appearances of crisis which have been above described, arise in a much greater degree, when the sickness is gone off. — Although therefore all emetics, when the sickness is gone off which occasions the vomiting, have a tendency to produce appearances similar to the appearances which take place in the crisis of fever ; and therefore actually tend to produce crisis in fever : yet they do not all tend to produce crisis of fever equally. It is therefore best to choose such substances for emetics, as have the greatest tendency to produce critical symptoms after the vomiting is gone off; in order that the emetic may have a better chance to produce a crisis in the disease. — It is consequently better to employ preparations of antimony or ipecacuanha, as emetics, in the beginning of a fever; than warm water, infusion of chamomile, white vitriol, squills, &c. ; which have no tendency to produce symptoms similar to those which take place in a crisis of fever, independent of the action of vomiting. 283 A REGULAR CONTINUED FEVER. It is not always that any of the known preparations of antimony produce vomiting, when exhibited to a man either in health or in a fever. Sometimes tartarised antimony in the dose even of several grains, does not produce vomiting, but purging ; (given either in health or to a patient affected with fever.) It is wished, however, that we should be certain of producing vomiting, to occasion the evacuation of any noxious matter, such as has been described, from the stomach. Ipecacuanha, the root of a plant of which the jealous government of Spain has prevented the perfect investigation, is very certain in its operation as an emetic ; much more so than any other substance which is at present known. It has besides the same kind of pow T er which antimony has, though perhaps not in so great a degree of pro-, ducing those appearances which take place in the ordinary crisis of a fever. It is therefore better to mix ipecacuanha with tartarised antimony ; and to exhibit them so mixed, as an emetic, at the begining of fevers. The next point to be argued is, the dose of the medicine we are to employ as an emetic at the beginning of fevers. When a medicine is to be exhibited as an emetic, it does not appear under one view to be of much consequence how large the dose is : for let the dose be ever so great, the first evacuation would seem to bring up everything which is superfluous ; so that the superfluous part of the dose should no longer act: and this consideration explains why the very various doses of emetics which have been exhibited in various cases, produce very often nearly the same effect. — But though this be the case in many instances, it is not in all; for it happens in many instances, that a large dose of an emetic produces most violent vomiting, which is repeated many times with great distress to the patient. Hence it would seem that an emetic may lie so long upon the stomach, before it is brought up ; as to make an impression which lasts after the emetic itself is entirely evacuated. In fevers, the violence of the exertions, when an emetic thus continues to operate, (perhaps six or eight times,) in the first place exhausts the force of the system ; (which is not to be thrown away in this disease :) and therefore on this account too large a dose of the emetic should be avoided. Moreover, it has already been observed, that when any medicine is made to act in too great a degree, it loses its proper effect; and becomes a simple stimulant. Hence the action of vomiting itself, by being too frequently repeated (from exhibiting too large a dose of the medicine,) does not produce appearances those which arise in the crisis of fever; so as to carry off the disease. For this reason ipecacuanha and antimony do not produce these appearances, if given in too great a dose. Thus by giving too large a dose of these medicines as emetics, the effect of carrying off the fever, either by the action of vomiting itself, or by the effects of the antimony, and ipecacuanha, is frustrated. 284 REMEDIES EMPLOYED TO CARRY OFF 'Ihe proper dose may be about eight grains of ipecacuanha, and one grain of tartarised antimony. It an emetic of almost any kind, which takes up a very small volume, be exhibited, and there should be nothing in the stomach to be evacuated, there arises an effort to evacuate, (or in other words, a retching ;) which is attended with a great deal more uneasiness and pain, than if there was a quantity of some substance in the stomach to be evacuated. This has induced practitioners to give, after an emetic has been exhibited, watery fluids to drink; that there might be something to be evacuated, in order to take off the uneasiness and pain of the retching. At the beginning of a fever, emetics, as we have just observed, are employed for two purposes. First, to from the stomach any undigested food which was either contained in it when the fever look place or was thrown into it afterwards ; or some noxious matter formed in the stomach in consequence of the fever. In the second place, by the action of the vomiting, and of the medicines employed as emetics, joined together, to induce a crisis to the fever ; so as to put an end to the disease. For evacuating noxious matter from the stomach, (if it be undigested food ;) two or three evacuations by vomiting are certainly sufficient; and especially, if after the first evacuation, a quantity of warm watery fluid be thrown into the stomach. If noxious matter also be formed in the stomach itself in consequence of the fever, and if that should be affixed to the stomach, as the crust is to the tongue ; no force will ever separate it; and if it should not be so affixed, two or three evacuations will be sufficient to carry it off. If two or three fits of vomiting therefore, should take place, it is sufficient for all these purposes. On the other hand, these moderate efforts will not prevent either the act of vomiting itself, or the effect of the medicines, w T hich have been enumerated as proper to produce it, from bringing on appearances similar to those that arise in the ordinary crisis of fever. It does not seem indifferent at what time of the day an emetic is employed ; if we wish it to produce any other effect than simply to evacuate the noxious matter contained in the stomach in fever. —In the first place, the operation of vomiting, after it is over, tends to produce sleep. Mankind being generally disposed to sleep about nine, ten, or eleven in the evening ; if the disposition to produce sleep, brought on by the emetic, coincides with the ordinary time of the twenty-four hours in which there is a disposition to sleep ; the two together will be more powerful in producing their effect, than either of them alone. The rest thus procured by this double disposition, will be sounder and more refreshing, than it would have been from either of them simply ; and will tend to restore or support the strength of the patient. Moreover, it has been observed, that sleep produces a disposition for all derangements of the system to go off, and consequently fever: it therefore increases the chance of the 285 A REGULAR CONTINUED FEVER. action of the vomiting, and the power of the remedies employed to produce it, in occasioning the appearances which arise in the ordinary crisis of fever ; and consequently in carrying it off. — Secondly, it has been observed, that the exacerbation of a regular continued fever takes place generally between five and six o'clock in the evening ; and that the effort towards a crisis made in the hot fit is strongest about three or four o'clock in the morning. — If the emetic.be then exhibited between seven and eight o'clock in the evening ; the disposition to crisis produced by the vomiting, by the action of the substances employed as emetics, by the sleep, and by the ordinary effort of the fever itself; will all operate together so as to have a better chance of producing a crisis in the disease. It would therefore seem, when we employ an emetic in a fever to evacuate any noxious matter from the stomach, which has got into or is formed in it by the means described, that it is better to exhibit in a moderate dose, such emetics as have a tendency to produce symptoms similar to those which take place in the ordinary crisis of fever. — It seems also necessary, in order to prevent the violence of the retching, to introduce some watery fluid into the stomach ; but it is better not to employ this fluid in too great a quantity ; nor to repeat it too frequently. — It is likewise better to exhibit the emetic about seven or eight o'clock in the evening. Thus the action of the vomiting itself, of the medicines employed to produce it, the sleep, and the ordinary effort of the evening paroxysm of fever, itself, will all operate together in tending to bring on a crisis and terminate the disease. — If any one should think the author is too minute in these attentions ; he must consider that if, by omitting any of them, a crisis should not be produced, where it otherwise might have been; the patient maybe subjected for a fortnight (or longer in some instances) to a distressing and dangerous disease. It happens sometimes, when an emetic is employed, that with every precaution the sickness will continue : and the patient shall pass a restless and distressing night, (more so than would probably happen if no emetic had been exhibited); but this must be left to be considered among the irregularities which happen in the disease. — On the other hand, it happens not uncommonly w r hen a patient has taken an emetic, especially if regulated as is described above, that he falls in less than an hour after its operation, into a quiet sleep ; when a gentle easy perspiration takes place at first, and increases into a sweat more or less profuse ; all the secretory vessels are relaxed, and the skin and the muscles also ; a perfect crisis is produced ; and the patient is freed from the disease. — It happens likewise not uncommonly, that though perfect crisis does not take place, the fever is considerably alleviated, and goes through its remaining course with less danger to the patient. — The author therefore thinks, that if a practitioner be consulted in the beginning (that is, in the first four or five days), an emetic should always be exhibited in a regular continued fever. 286 REMEDIES EMPLOYED TO CARRY OFF Independent of vomiting ; the preparations of antimony (such as have been described) have other means of producing appearances similar to those that arise in the ordinary crisis of a regular continued fever. — These preparations of antimony have been employed in several ways to produce this crisis. First, if some one of the preparations above described be exhibited in a dose just not sufficient to produce sickness (when they have been exhibited empirically this has not been much attended to) in the evening about six o'clock ; and if the same dose be repeated about half an hour past eight, and again at eleven : — then if the patient be laid in flannel or cotton or some other bad conductor of heat, his head being bound round with a cloth of the same kind, and small quantities of warm watery fluid (such as barley water) given frequently, so as to throw him into a profuse sweat if possible ; and if this sweat be kept up by repeating the preparations of the antimony every four, five or six hours, as the patient can bear it, without occasioning any sickness ; and if this practice be continued for four-and-twenty hours: it has happened in many cases, that when the preparations of antimony above described have been thus exhibited, a crisis has been produced ; and the fever been entirely carried oft'. This happens particularly if the remedy be exhibited in the first three or four days of the disease. The crisis is thus very evidently the effect of the medicine ; and there is a degree of brilliancy in this practice which has made it be adopted by many practitioners who have a degree of empiricism. — It is to be observed, that such practitioners and all empirics have often exhibited antimony in this manner (or sometimes in one dose without repetition) at any time in fever; sometimes with success; but this will be considered afterwards. The mode however in which antimony appears to the author to have the best effect, with the least detrimental consequences, is, in the first place, to employ it as soon as possible in the disease ; for it is more efficacious in the first attack of the fever, than in the second day of the disease, counting the days as has been before pointed out ; and it is more effiacious in the seco'nd day of the disease than in the third ; and so in the third than in the fourth, &c. It should be employed in the first place as an emetic, mixed with ipecacuanha; as has been already described', and if the weather should be cold, it is better to lay the patient in cotton ; and treat him as has been described in the management of a regular continued fever left to pursue its natural course. After having exhibited the emetic, as has already been described; if the patient being in bed, should continue sick and restless, as has been above described, which is sometimes the case, about a grain of opium (or an equivalent dose of its tincture) may be given without detriment; along with a little tincture of cinnamon or any other aromatic. (This medicine should only be exhibited under the cir- 287 A REGULAR CONTINUED FEVER. cumstances of the patient's continuing sick and restless : in which case it takes olTthe sickness; and suffers the antimony to act.) Six hours after the action of the emetic is over, if the patient should be awake, a dose of one of the preparations of antimony above described, should be exhibited ; and in such quantity as the stomach can bear without sickness. If he should be asleep at this interval (from the last action of the emetic,) as soon as he awakes it should be given. The author prefers tartarised antimony ; (prepared as is described above, in the last edition of the Pharmacopoeia of the London College). — And the dose of tartarised antimony the author would exhibit, in the first instance, is two-sevenths of a grain. Or if the tartarised antimony be dissolved in wine, as is above described, in the vinum antimonii tartarisati of the Dispensatory, thirty drops of this solution should be dropped out of such a phial as is commonly made to contain two ounces in England. — The author is sensible of the uncertainty of measuring anything by drops ; the quantity contained in a drop depending upon the viscidity of the lluid dropt. (Four drops and an half of alcohol, for example, dropt from the same vessel, weigh only one drop of w T ater; the alcohol being much less viscid or adhesive than the water.) Again ; the size of a drop depends upon the thickness of the lip of the phial from which it is dropt ; or rather on that part of the lip from whence it is dropt.—These difficulties maybe easily obviated; by trying how many drops of any fluid dropt from one part of the lip of any one phial, measures or w T eighs. If the phial be not above four fifths full, the same number of drops, if they exceed twenty, will be found always nearly of the same measure and weight. —The author prefers this mode of determining the dose as the easiest, and most readily measured. — It has this advantage, that if thirty drops of the vinum antimonii tartarisati should produce, on its first exhibition, any nausea ; it may be diminished by four or five drops on the second exhibition. If upon this second exhibition it should produce no nausea ; or if upon its first exhibition, in the quantity of thirty drops, no nausea should ensue ; an additional quantity of two drops may be added to each dose ; until the greatest quantity is found out that the stomach can bear without nausea. (The author has already observed, that nausea prevents the medicine from having a disposition to produce symptoms similar to those that arise during the crisis of fever ; and so to carry off the disease). The practitioner can therefore thus ascertain the exact dose which can be given without producing nausea. If the author should be mistaken in thinking that tartarised antimony, prepared as has been described, is the best preparation of antimony for producing crisis in fever already known ; or if some better preparation should be found out ; yet, as the stomachs of different men, or the stomach of the same man at different times, are differently impressed by the same doses of almost all medicines ; he 288 REMEDIES EMPLOYED TO CARRY OFF conceives that some mode should be taken similar to that which has been described above, to ascertain what quantity of the preparation of antimony to be employed the stomach can bear without nausea; and that it should be exhibited in that dose. Along with the first dose of antimony, to be exhibited in six hours after the last operation of the emetic, it may be proper to give a moderate quantity of some aromatic ; so as to render it more agreeable to the stomach of the patient; such as the infusion or distilled water of mint or cinnamon ; or any other medicine of the same kind. If the emetic exhibited should have produced a quiet gentle sleep, and'the symptoms of a'crisis appear ; if the pulse has returned to the ordinary number of pulsations in a given time, and the patient should appear to be entirely freed from the fever: yet it will not be superfluous to repeat the preparation of antimony in the manner described; as no mischief whatever can arise from it, and it may secure the patient from the return of the disease. After a dose of antimony is thus exhibited, it is to be repeated at four or five or six hours interval. —The interval is to be determined from the effects which this dose has produced. — If the patient has had a crisis produced by the emetic, and a general freedom from the disease has taken place (only with some languor); it will be sufficient to repeat it every six hours ; and continue it for twenty-four hours. — If hardly any relaxation should have taken place in consequence of the emetic, but all the symptoms of fever, such as great depression of strength, weight about the precordia, pain in the forehead, dryness of the skin, &c, should remain in a great degree ; it will then be proper to repeat it every four hours ; and continue such repetition for four or five days. If a preparation of antimony is given in this way at the beginning of fever, and continued for four or five days, without producing a crisis by which the fever is cured or converted into an intermittent ; it rarely produces a crisis afterwards : nevertheless it often makes the relaxation greater, prevents -or diminishes delirium, and makes the whole fever go on with less violent symptoms. — It is better therefore to continue to exhibit such a dose of the 1 preparation of antimony, as the stomach will bear without nausea, every six hours. — If symptoms of weakness begin to appear; or if the antimony should produce sweating, purging, or any other topical evacuation, without relieving the fever; it is immediately to be omitted. It happens however, in many instances, that in the course of this time, the patient has a moisture produced in the skin, while a lateritious sediment takes place in the urine, the skin by degrees becomes soft, the tongue begins to grow moist on the edges and is cleared of the crust that forms upon it, and all the other critical symptoms take place gradually ; the patient becoming freed from the disease. If either the symptoms of the attack of the disease should be so violent, as to give little hopes that the patient will recover, in case the disease should pursue its ordinary course ; or if such an epidemic A REGULAR CONTINUED FEVER. 289 should be prevalent, as destroys the greatest number of patients afflicted with the disease: under such circumstances perhaps, it might not be improper to force a profuse sweat, (in the manner that has been described.) Unless, however, there should be little hopes of the patient's recovery if the disease should go on in its ordinary progress, such means of occasioning sweating ought not to be employed. —First, because sweating, though it be one of the appearances that take place in the ordinary crisis of fever, yet is very far from being the only one ; for not only the secreting vessels of the skin are relaxed and secrete a larger quantity than usual; but all the other secretory vessels are equally relaxed, and also the muscles, and whatever other part is relaxed in the ordinary crisis of fever. We see also that profuse sweating takes place sometimes in a regular continued fever, without any relief to the disease. In the second place, every unnecessary evacuation tends to weaken the patient; and to give him a less chance of being supported through the course of the disease, if a crisis should not be produced. — Therefore it is not proper to attempt to produce profuse sweating, in case there be any tolerable chance of the patient's recovery, should the disease be left to pursue its ordinary course. Hitherto the author has been supposing the patient to apply to a practitioner in the first day or two of the fever. In that case, provided the disease be a regular continued fever, by employing preparations of antimony in the manner described, symptoms similar to those which take place in the ordinary crisis of fever will be produced (as far as the author can judge from his experience) in one half, perhaps he thinks he can say certainly in one third, of the cases of regular continued fever. If no medicine has been given during the first days of the disease, or if no emetic has been exhibited; it will be proper to employ an emetic (in the manner which has been mentioned) at any time in the first week of the disease, or even on the eighth or ninth day ; especially if there should be a greater foulness of the tongue, or more nausea, than in proportion to the other symptoms of the disease. If an emetic should have been employed at the beginning of the disease, and the patient at any time afterwards during the course of it should have a greater foulness of the tongue, weight upon the stomach, and nausea, than in proportion to the other appearances of the disease ; it is proper to repeat the emetic. In this case, only about five grains of ipecacuanha should be given, which rarely fails of proving emetic. It should be exhibited in the evening : but the other regulations that have been laid down for the exhibition of an emetic at the beginning of the disease, are not necessary to be attended to. If no preparation of antimony has been exhibited on the first two or three days of the fever ; the exhibition of it afterwards will have less chance of carrying off the disease: for after the fever has conti-25 290 REMEDIES EMPLOYED TO CARRY OFF nued longer than three days, the system has acquired an habit which renders the disease more fixed. Although the sooner the preparation of antimony is employed, the production of a crisis, or the gradual going off of the disease by critical symptoms taking place after each other, is made more probable ; the fever in many instances will be carried off" even by exhibiting it before the end of the second week of the disease. The sooner, however, it is exhibited, it will have the greater chance of removing the fever. Although preparations of antimony should not produce a crisis so as entirely to carry off the fever; they produce a crisis in manycases, which though not quite perfect, yet converts the disease into an intermittent fever ; which is a disease much more easily managed than a continued fever. Supposing preparations of antimony not to produce such a crisis as to conveit a continued fever into an intermittent, or to carry off the disease ; yet it happens also in many cases that they give great relief to the patient; so that the headache is diminished or entirely carried off, a less degree of delirium takes place than otherwise probably would have occurred, the primce vice are not so much disordered, and the fever pursues its course with less distress and danger. It happens sometimes in the first two or three days of the fever, that there is great hardness, fulness, and strength of the pulse ; as well as obstruction ; that with these, there is flushing of the face and redness of the eyes ; and that other symptoms of general inflammation take place in such a degree, as to render it necessary to take away a quantity of blood. In this case it becomes a question whether preparations of antimony should be employed immediately at the beginning of such fever : before blood is taken away ? — This is a case, however, which happens much seldomer than would be suspected from what authors have written on this disease ; and the argument will be entered into in that dissertation, in wdiich the irregularities that take place in continued fevers will be noticed. If upon exhibiting preparations of antimony, some one evacuation should take place, without a relaxation of the other secretory vessels; the antimony should not be persisted in. Thus if profuse sweating should be produced ; and at the same time the tongue should remain dry and covered with a fur, and the patient continue costive, and the other parts be contracted : if also a lateritous sediment should appear in the urine, or a flaky white sediment, the skin remaining dry and contracted, and the tongue dry and covered with a fur ; or if the patient should be purged, the skin remaining dry at the same time : In any of these cases, there is little hope of antimony being of any kind of use, if the system should continue in this state for forty-eight hours. — The medicine will then rather tend to weaken and destroy the patient; and iherefore ought not to he continued. A REGULAR CONTINUED FEVER. 291 TREATMENT OF A REGULAR CONTINUED FEVER. Treatment to Cahiit off the Fevkh (Continued). — Is there any other medicine possessing the same febrifuge properties as antimony 1 Reference to the practice of the Greeks— Cold -water exhibited by them—Also, entire abstinence from all drinks recommended by the Greek and Roman physicians—Small quantities of warm watery fluids by Boerhaave, to dilute the blood—The cold bath and sometimes the warm bath recommended in ancient practice—The root of ipecacuanha—First brought into practice as an emetic—Tendency in mankind to employ everything in medicine—Other remedial effects of ipecacuanha ascertained ; as in rheumatism, diarrhoea, and dysentery—How far it is analogous to preparations of antimony in fever—Indications for its use as an emeiic in the progress of the fever—The medicine seems to act in the same way, but with less power, as antimony, in fever—Dose, a grain, and sometimes two grains, without sickness being induced—The neutral salts, employed in fevers—Have little action in bringing about a crisis—This result procured, with any regularity, only by preparations o f antimony and of ipecacuanha — Semicupium, or fomenting the lower extremities with warm water, similar, in its operation, to the warm bath —Should be applied in the evening—Directions for its use—Soothing effects of this remedy— JWucilaginoits substances dissolved in -water applied externally—No special advantage therefrom, nor from vinegar added to the water— External inflammation, in many cases, carries off'diseases in other parts — Inflammation at the beginning of fever, not uncommonly carries off the disease—To guard against extending unduly the term fever—Removal of inflammation carries oft at once the disease—Not so if cold or infection gives rise to fever—It persists whether they are removed or not—Inflammation supervening on fever will sometimes carry it off"; but its own symptoms continue and will require other appropriate treatment —Instance, pleurisy occurring in fever— These facts probably suggested recourse to means for causing external inflammation— Theory on the subject—The noxious or febrile matter supposed to be driven off by the local inflammation, ending in suppuration—Fluid causing the fever thought to be carried off'by blisters—Fever a disease of the solids —Morbid matter, if present, must be diffused through the circulation and cannot be eliminated at any one point—Sometimes the fever is carried off", but without a crisis, by external inflammation—Generally this latter only abates the violence of the disease—The nearer to the pained part in fever, the more efficacious the action of the blister—Substances that excite inflammation of the skin—Effects of cantharides applied to the skin—Absorption of cantharides and their action on the neck of the bladder—Sometimes cause violent spasms in nervous subjects—Prevention of stranguary by mucilaginous drinks—Mustard and garlic to the feet, to produce derivation—In what cases of fever is the inflammation by cantharides to be produced—In simple fever, a blister between the shoulders—Its reapplicatiou not good, if the first application have failed to relieve—Alleviation by the first will justify a second blister; but this failing, a third is not advisable—Bad effects of continued stimulus of a blister, in wearing out the strength—The mere slowness of the fever no reason for blistering—Local affections in fever, benefited by blister— Headache, by a blister behind the ears: delirium by a blister on the shaved scalp, or on the neck, or between the scapula;, oppression about the precordia and cough, by one over the sternum—Relief is to be expected from the first but not subsequent application of the blister—Delirium, of two kinds—The second species, accompanied by fulness and turgeseence of the vessels of the brain, and eyes blood-shot, —is relieved by opening the jugular vein, or better still, by a few leeches and afterwards warm moist cloths to the temples—Venesection at the arm of no use—Blood letting not necessary in the other kind of delirium—Both come on about the second week of the fever—Violent pain of the forehead removed, and sometimes the fever with it, by leeching the temples—No satisfactory explanation of this fact —The remedial effect uncertain from all these applications— Profuse sweating-, the most marked appearance in the crisis of fever—Stimulating sudorifics, —spices,—to prevent the patient from sinking—General practice of giving this class of medicines—Sweating alone will not cure a fever, or bring on crisis—Weakness increased by over excitement —Irregular 292 REMEDIES EMPLOYED TO CARRY OFF muscular contraction—Spasms—cramps—Fever sometimes called a spasmodic disease —Antispasmodics—Their enumeration—Camphor in the common dose, or camphor emulsion or mixture, productive of little or no effect—Recourse to it as an evidence of doing something. It is next to be considered whether there is any other medicine, which has the same effect with preparations of antimony ; — that is, whether there be any other medicine that will induce the appearances wdiieh take place in the ordinary crisis of fever, so as to carry off the disease. In the history of medicine that we are able to collect from the Greek and Roman authors, whose writings have come down to us ; there is one instance only of a medicine having had this effect, to wit; when the physician of Alexander the Great exhibited to him a medicine, which is said to have occasioned the appearances which ordinarily take place in the crisis of fever ; so as to carry off the disease in less than twenty-four hours. We have no trace of what this medicine might be ; (and it is singular that the same medicine should not have been exhibited to him again in that remittent which he caught, by surveying the marshes of the Euphrates, near Babylon ; in order to have them drained). Cold water was exhibited by Greek physicians, in fever; often evidently with a view of immediately putting an end to the fever. From the best information the author has been able to make out from perusing their writings, they exhibited it reduced nearly to the freezing temperature ; in the quantity of from one to two quarts at once : so as to produce great evacuation by vomiting, purging, and sweating. It was by no means the practice of the ancient Greek physicians, (w r ho were the principal and almost only practitioners in the Roman dominions,) to give watery fluids, or indeed anything to drink, at the beginning, or during the paroxysms of fever. In Petronius's satire, one of Trimalchio's guests says, that a man, at whose funeral he had been, was a very obedient patient to his physicians ; for he did not suffer a drop of fluid to pass his lips for seven days: and he died notwithstanding. — It also was not the practice of the Greek or Roman physicians to give even cold water constantly for drink in small quantities ; — but in a large quantity at once, perhaps with a view r of drowning out the heat, which they considered as the essence of the disease : It was to be drunk, as Celsus says, ultra satietatem. It is described, however, as bringing on those appearances which take place in the ordinary crisis of fever ; and in certain cases, as carrying off the disease. — This not having been practiced during the last period of forty years, the author has had no experience of giving large quantities of cold water at once for drink ; and cannot therefore say what its effect may be. During this period of time however it has been common, in consequence of Dr. Boerhaave's idea of rendering the fluids thinner in fever, to exhibit small quantities of warm watery fluids very frequently A REGULAR CONTINUED FEVER. 293 for the same purpose. — That warm watery fluids, forced upon the patient often in fevers, are of no manner of use, the author is obliged to believe from repeated experience. It would be easy to show that every reason on which this practice was introduced, was perfectly without foundation ; but as no knowledge whatever is to be gained by the discussion, the author does not draw the reader's attention to the subject. It was also a practice among some of the ancient physicians to employ the cold bath, in certain cases of fever, to produce a crisis ; and sometimes the warm bath : but the history of both these practices is so little detailed in their writings, that the author has not been able to make out their effects ; or whether they actually occasioned symptoms similar to those that take place in the crisis of fever ; or whether they actually carried off the disease or no. The author has had good information, that both in Italy and Spain, drinking large quantities of cold water at once, as well as using the cold or warm bath ; are still in practice in diseases called by them febrile : but he never could from their books, or from the conversation of the physicians of those countries whom he has seen here ; make out the idea they affix to febrile diseases, nor the action of these remedies. The author must therefore dismiss this subject, viz., the application of cold water; as nothing is known of it at present from anything which can be considered as evidence. — It requires half a century at least to destroy the bloom of novelty w r hich deludes, when a new T medicine is recommended ; or indeed to fix any evidence in medicine. (Tt was much longer before the bark of the cinchona was brought into general practice in intermittent fever: and it was longer still before mercury w T as allowed by regular practitioners to be employed in medicine.) The next substance which has a tendency to produce those appearances which take place in the ordinary crisis of fever, is the root of ipecacuanha; (an American plant; and which could not therefore be known to the ancient Greek and Roman physicians.) The root of this plant was first brought into practice as an emetic. — There is a tendency in mankind to employ almost every thing in medicine ; (a tendency perhaps given them by the Almighty to supply the want of the knowledge of the ground on which medicines act; medicine being a science of so very great difficulty.) — Of the substances already known in those countries with which Europeans were acquainted, before the discovery of America ; almost everything had been tried, and even celebrated in medicine: as dead men's bones, cobwebs, and the rags that enveloped the bodies of the ancient Egyptians ; as well as opium, colocynthida, and squills. Whenever therefore new countries were discovered, and in consequence new plants ; we constantly find practitioners in medicine using them in disease. — Hence then the root of the ipecacuanha, being found out to have an emetic quality, was employed first as 25* 294 REMEDIES EMPLOYED TO CARRY OFF an emetic. — Afterwards, when it came into Europe, its other effects began to be investigated ; as its action in rheumatism, diarrhoea, and dysentery : in all which cases it seems to be analogous in its operation with preparations of antimony. The present inquiry is to determine, how far ipecacuanha is analagous to preparations of antimony in fever. It has been already mentioned, that if it is wished to produce vomiting at the beginning of fever, it is better at least to mix ipecacuanha with preparations of antimony ; it being thus surer of acting as an emetic. — If at any time, during the progress of the disease, there should be a consklerable degree of sickness, (especially if it should he attended with a thick brown fur upon the tongue ;) though an emetic has already been exhibited, it is useful to employ from five to ten grains of ipecacuanha, to act as an emetic (as has been already observed). It not only throws off any noxious matter that may be in the stomach ; but also produces moisture upon the skin ; the sickness is relieved ; and sometimes a complete crisis takes place, and the fever is carried off. — If a symptomatic purging should take place in fever, without any relief as to the disease ; if such purging should take place along with the fever, or soon after its beginning; then (as far as the author's experience goes,) ipecacuanha is better used alone as an emetic. In this case it is also better to give such small doses of it, as just not to produce sickness, every four or six hours. Such doses have a chance of carrying off the purging ; — and likewise of producing symptoms similar to those which arise in the ordinary crisis of fever, (and so entirely to carry off the disease :) herein exceeding the preparations of antimony. In all cases of fever, ipecacuanha seems to act much in the same manner as preparations of antimony, in producing symptoms similar to those produced by preparations of antimony ; — and in many instances they carry off the disease, though not with the same certainty. — If we give ipecacuanha, instead of preparations of antimony ; the stomachs of most patients will bear a grain, without occcasioning sickness ; and few stomachs will bear two grains without sickness. — In other respects, the same attentions are to be paid when we employ ipecacuanha ; as when we employ preparations of antimony. Several of the neutral salts, (such as kali vitriolatum, ammonia muriata, ammonia acetata, and some others,) have been employed in fevers ; with a view of producing the symptoms which take place in the ordinary crisis of fever ; in order to carry off the disease.— The author has seen moisture of the skin arise after exhibiting them ; but he cannot say that in any one instance he could determine that they brought on a complete crisis, in a regular continued fever. During the exhibition of these neutral salts, an ordinary crisis sometimes takes place ; but not oftener than if they had not been exhibited : and therefore such crisis cannot be said to arise from their exhibition. The author then upon the whole does not known of any remedy A REGULAR CONTINUED FEVER. 295 which has a tendency to produce a crisis in fever oftener than it would have taken place, if no remedy whatever had been exhibited, (whether such remedy has a tendency to produce vomiting or not; excepting preparations of antimony and of ipecacuanha. — Possibly it may be admitted, that the ancient Greek physicians for this purpose employed cold water internally, or the cold or warm bath, or some other remedy (with which we are now totally unacquainted), with good effect. Semicupium (or fomenting the lower extremities with warm water) is similar in some respects to the warm bath. — This practice has been used, especially when the patient is affected with delirium in the second week of the disease.—It is different from the warm bath ; inasmuch as it can be employed wdthout greatly disturbing the patient, and in consequence without wearing him out by exertion.— When this fomentation of the lower extremities is employed ; it should be applied in the evening. The bottom of the bed-clothes, under the patient's lower extremities, should be so covered as to prevent them from being moistened ; and the covering may be taken away after the fomentation is no longer applied. — The fomentation should be performed by means of flannel (or anything wdiich is a bad conductor of heat) made moist wdth water, and heated to about 100° of Fahrenheit's thermometer. The flannel or other substances so employed should be wrung out, so as to leave very little moisture in it: afterwards it is to be applied to the legs and feet, until it begins to cool. — As soon as the flannel begins to feel cool, it is to be removed ; and fresh flannel is to be applied, moistened as before, with warm water. — The time of cooling will be different according to the heat of the atmosphere : but at a medium, it will be about five minutes. — Fresh flannels are thus continually to be applied for about half an hour. The covering of the under part of the bedclothes is then to be removed ; and the upper part to be brought over the lower extremities of the patient; who is afterwards to be left quiet. — It sometimes happens that a moderate sweat breaks forth ; and the patient falling asleep, becomes considerably relieved. The author has seen in a few cases, (but very few, in proportion to those in which this practice has been employed,) in which a complete crisis has taken place ; when the patient has been freed from the disease. In several cases the patient has slept; and the delirium has been considerably relieved. — In the greater number of cases, however, no advantage whatever has arisen from the application ; yet as it hardly tends to exhaust the patient, it is worth while to employ it. Some, instead of moistening the flannel or other clothes, with pure water ; have employed mucilaginous substances dissolved in (such as decoction of marshmallow root, &c.); and some have employed decoction of poppy heads. The author's practice has not ascertained that any advantage has been gained by the addition of either. — In cases where there have been appearances of putrefac- 296 REMEDIES EMPLOYED TO CARRY OFF tion, some have joined a small proportion of vinegar : which (as far as the author can judge from the cases in which he has seen it employed) seems rather to have prevented the good effects of the application : but on this this the author is not quite sure. An inflammation of an exterior part of the body, in many cases, carries olf diseases which have arisen in other parts of the body. Perhaps an inflammation of an interior part may also carry off diseases which have taken place in other parts of the body : — for fever is one of the diseases which is carried off by an inflammation of either an exterior or an interior part of the body. It has been before observed, that an inflammation arising at the beginning of fever (particularly in the first paroxysms of the disease) not uncommonly carries off the fever altogether ; as also that inflammation often produces very considerable alfection of the whole system, which many practitioners (both ancient and modern) have called and considered as fever. — One principal scope of these dissertations however is to point out ; that every affection of the system, in which there is frequency of the pulse and an increased degree of heat, is by no means fever: many of these affections depending upon a continuance of their cause. — Thus an inflammation of the pleura generally produces at the time hardness, fulness, strength, and regularity of the pulse ; which is much more frequent, than in health : with this alteration of the pulse from its common state, there is an increased heat (both as to the sensation of the patient and the physician, and as to the thermometer): there is a crust also formed upon the tongue, sometimes white, but more frequently of a yellowish hue ; there is pain in the internal part of the head, flushing in the face, and often delirium ; there is less appetite ; and there are other disorders in the system. If the inflammation of the pleura however be cured, as it sometimes is, by one copious bleeding (that is by taking away from four-and-twenty to thirty ounces of blood from the arm,) all these appearances subside in less than twenty-four hours ; and the patient recovers his health ; excepting that he is somewhat weakened. Whereas, let a fever arise in consequence of exposure to cold or to infectious vapors, or almost,any other cause of fever, the appearances continue and go through their ordinaiy course equally ; whether the cold or infection continue to be applied or not. The author has already observed, on the other hand, that it happens often in fever, that inflammation takes place at the very beginning of the disease, in the first or second paroxysm ; and that such inflammation immediately carries off the disease, without anything like the appearances which take place in the crisis of a fever; but that the fever simply ceases. If it be such an inflammation as produces no affection of the system, as external inflammations often do not; then the symptoms of the inflammation in the part affected, alone continue. But if the inflammation be such as produces frequency of pulse, heat, and other general affections of the system ; these symptoms will continue, although the fever be cured ; but will subside, when the 297 A REGULAR CONTINUED FEVER. inflammation itself is carried off by means which would not affect the fever. — Thus suppose in the second day of fever, a pleurisy should arise and cure the fever; then notwithstanding the fever be carried off, there will remain frequency of the pulse, foulness and dryness of the tongue, loss of appetite, great heat, urine remaining transparent when it has stood for several hours, &c. These appearances do not in the least constitute fever, but entirely depend on the pleurisy ; and if the pleurisy be cured, by bleeding for example, all these appearances will subside ; (although the bleeding would neither have had effect on the fever, nor carried off any of its symptoms ; if the pleurisy had not first arisen, cured the fever, and produced these symptoms. The knowledge that fever might be cured by exciting inflammation in some part of the body, may possibly have been derived from physicians observing that a fever was actually cured in many instances when an inflammation arose in some part of the body ; even when no application, (as far as the physicians could judge) was applied to excite that inflammation. The physician hence might think, that by applying something that would produce an inflammation in some part of the body, die disease might be carried off ; and that an artificial inflammation might have the same effect with that which had arisen in the fever itself, without any apparent cause excepting the fever. He might therefore produce an inflammation in some part of the body, by stimulating it ; with a view of carrying off the fever. — Or perhaps that strong disposition in mankind not to w r ait the tracing of knowledge by experiment, might make physicians suppose, that the fever depended upon some noxious matter being diffused through the whole system ; and that the application made might draw (like a magnet) the noxious matter into one part of the body; and produce an inflammation in that part, instead of a fever in the whole. It is still the opinion of many practitioners, that when an inflammation carries off a fever, if it be such an inflammation as tends to terminate in suppuration ; the matter that occasions the fever in the whole system, is accumulated in the inflamed part. When the abscess is formed and breaks, and the pus is evacuated ; they still believe that the matter which first produced the fever is evacuated. Other inflammations, such as arise in the skin for example, do not terminate in suppuration, but in a blister rising ; (that is the scarf skin separates from the true skin ; and a fluid appears between them which consists principally of the superfluous water and the neutral salts of the blood, sometimes along with a little serum ; and sometimes also with coagulable lymph, which coagulates and gives some degree of solidity to the matter contained in the blister.) The scarf skin afterwards breaks, and leaves the skin excoriated, till a new scarf skin is formed ; but until that happens, a quantity of the superfluous water of the blood, together with the neutral salts, flow out. In such case it has been supposed that the fluids (or whatever other 298 REMEDIES EMPLOYED TO CARRY OFF matter it might be that occasioned the fever) continue to be evacuated ; and that so the fever is carried off. —But the objections to this opinion are very strong. First, the author in his first dissertation upon this subject, has endeavored to show that a fever is a disease of the living solids only; and that all the matter of the body, during the progress of many fevers, had exactly the same properties, as if the patient were in perfect health. In the second place, supposing that any matter existed in the body which occasioned the fever; that matter must either be confined to some particular part'of the body; or be circulated in the bloodvessels ; or be thrown out by the exhalants and taken up by the absorbents, and circulated through the absorbents. — If it was lodged in any particular part of the body; an inflammation in another part might excite the action of the absorbents of the part where the noxious matter was lodged ; so as to occasion it to be taken up and carried into the general circulation. If they did not take it up, it would remain in the part where it was at first deposited, and where it produced the fever; (as is evident to every person tolerably acquainted with the anatomy of the human body, as it is now known :) for to bring the matter from a particular part where it produced the fever, into a part whose inflammation cured the fever ; it is necessary that it should be absorbed ; and carried into the general circulation. — But supposing the matter to be absorbed and carried into the general circulation ; or supposing it to be originally blended with the whole fluids in circulation, so as to occasion the fever ; the same argument will apply ; — and it is as follows. If any matter be in general circulation, it is mixed minutely with the whole blood : for whether it passes through the blood-vessels only, or passes also through the exhalants into the cavities and absorbents ; in both cases it is mixed with the wdiole blood returning from every part of the body, in the right auricle of the heart. The motion which takes place from the right auricle to the right ventricle, mixes it still more thoroughly with the whole blood ; and it is still more perfectly intermingled with the whole of the fluids, in passing through the lungs ; and again in the left auricle and left ventricle: so that it must be blended most perfectly, and most minutely in the aorta ; so as to be equally distributed through all the vessels. It passes through them indeed with such velocity, that no difference of specific gravity can prevent its being equally distributed to every part of the body. If then there be no particular structure in any part of the body by which such matter may be caught; it will circulate equally through the whole body. — If there was any structure in any part of the body in its ordinary state, by which the matter of a fever could be caught, and produce inflammation ; then it would be the inflammation of that part only which would carry off fever. But the inflammation of any part part of the body indiscriminately, in many instances, carries off fever; and therefore there must be a change A REGULAR CONTINUED FEVER. 299 in the structure of the part in which the inflammation arises, in order to account for the matter's being caught in that part: but no such change has been shown by any experiment, nor any cause of such change: so that we have an unknown thing, endeavored to be accounted for by a thing equally unknown. We must therefore simply conclude, that an inflammation arising in any part of the body without any apparent cause, (excepting the fever itself,) in many cases terminates the fever. How or why this happens, not being as yet investigated; we are only led from this fact to inquire, whether artificial inflammations may not carry off a fever, as well as inflammations which arise without any apparent cause. — The author has seen in several instances inflammation, produced by applying stimulants to a part of the body, when a patient is affected with fever ; carry off the fever entirely, in the space of twenty-four hours. When an inflammation is excited in the exterior parts of the body, so as to carry off a fever; it does not produce appearances similar to those which take place in the ordinary crisis of fever; but the fever simply ceases, the headache goes off, the tongue becomes clean, depression of strength leaves the patient, all the evacuations come into their ordinary state as in health, the patient sleeps, and his appetite is restored. — But though an inflammation produced in any exterior part of the body now and then carries off fever entirely ; yet it has but seldom this effect. It only commonly alleviates the disease, or takes off some of the symptoms : it sometimes carries off headache or diminishes it; it diminishes, rarely carries off delirium entirely, if it has arisen ; and so of the other appearances which take place in fever. Since exciting an inflammation sometimes alleviates and carries off the symptoms of fever from particular parts of the body ; if it should happen that one part of the body should be more affected in the fever, than the other parts ; an inflammation excited near that part is more apt to carry off the particular affection of that part, than one excited at a distance. (If, for instance, there should be great pain in the forehead ; an inflammation excited behind the ears is more apt to carry off that pain, than if it had been excited in the back ; and if there should be great affection of the breast, an inflammation excited in the skin of the breast will be more apt to relieve the breast, than if it had been excited in the extremities.) There are several substances which, wdien applied to the skin, will excite inflammation ; (viz. mustard seed bruised, horse-radish, and many other of the class tetradynamia of Linnaeus ; many of the species of allium ; euphorbium, and other resinous substances; as well as cantharides, ammonia, and many others.) Of these, modern practitioners have generally chosen to employ cantharides to excite inflammation in fever ; and sometimes mustard seed. If cantharides be powdered, and mixed with an oily or watery substance, and applied to the skin, they excite an inflammation in 300 REMEDIES EMPLOYED TO CARRY OFF the skin : which is followed by a blister, in which the scarf skin is raised from the true skin, so as to contain in it a watery fluid. When the scarf skin is broke, this fluid flows out; and the same kind of fluid continues to ooze out from the skin for some time afterwards. Upon examining this fluid, the author has found it to contain water : in which is dissolved natron muriatum, ammonia muriata, and ammonia phosphorata ; with a little mucilaginous matter ; and sometimes serum. The fluid oozed out therefore contains the superfluous water together with the neutral salts, commonly contained in the blood-vessels: and also the putrescent mucilage. Nothing therefore, which is not commonly contained in the blood-vessels of a man in health, is found in this fluid. — But the superfluous water, neutral salts, or putrescent mucilage of the blood, were never known to occasion fever in a man in health. There is therefore, no reason to suppose, that it is this particular fluid which occasioned the fever; or that this as an evacuation, is of any consequence, or in sufficient quantity to weaken the patient. — The whole effect therefore, of the application of cantharides, so far as they produce mere evacuation, must be considered as of no consequence ; it being the inflammation only which carries off the fever or its symptoms. The juice of cantharides is often absorbed by the vessels of the skin, and carried into the general circulation of the blood ; (as is evident from its stimulating and occasioning inflammation of the neck of the bladder, when cantharides are applied to the skin so as to inflame it.) — And some have been of opinion that the juice of the cantharides so absorbed, produced some effect upon the matter which occasioned and kept up the fever. — Such opinion, how T ever, is not founded on any experiment. That there is any peculiar matter in the body which keeps up a fever, has not been shown by any experiment; much less has it been shown that the juice of the cantharides has any effect upon such matter. This opinion, therefore, resting upon nothing more than an idle dream, cannot be made a foundation for medical practice. Many animal poisons when absorbed and carried into the system, by their action on the irritable parts, occasion spasrns or involuntary contractions of the moving parts of the body.—The same effect is also now and then produced by the juice of cantharides, when it is absorbed and carried into the system. The author has, in several instances, seen subsultus tendinum, (in women especially,) and also more violent spasmodic affections, arise from the application of blisters in fever, as well as in other diseases. The absorption therefore, of the juice of cantharides, when it has this effect: so far from being useful, is evidently hurtful. But this does not happen often enough to prevent cantharides being used. Cantharides are therefore better employed to excite inflammation with a view to carry off or alleviate the fever, than other stimuli; as they most readily produce inflammation, the inflammation produced by them is carried off more easily, and it is also more readily kept 301 A REGULAR CONTINUED FEVER. up (if that should be wished.) Sometimes, indeed, the absorption of their juice produces spasmodic affections; but these occur but rarely; and soon go off, if the cantharides are no longer applied, (generally in less than twenty-four hours.) But cantharides are apt to produce strangury ; which yet may be obviated or alleviated by employing mucilaginous medicines, (such as gum arabic dissolved in barley water.) How these mucilaginous substances produce their effect in the last case, the author cannot satisfy himself: but that they do many times produce the effect, is certain. The author has several times applied cantharides, so as to excite inflammation, to more than forty patients running. To the one half of them he has given mucilaginous substances, dissolved in water, and to the other half has given none ; when a much smaller number of those patients who took the mucilaginous substances, were affected with strangury, than of those to whom the mucilaginous medicines were not exhibited. Some have preferred the application of mustard seed or some other of the class teti-adynamia and genus allium, to the feet and legs in cases of delirium in fever. This practice seems to have arisen from the doctrine of derivation, viz. to derive the matter as far from the head as possible ;) which is mere hypothesis. In practice it is found that if any particular part of the body be afflicted with a disease, an inflammation produced in another part carries off the disease more certainly, if the inflammation is excited near the diseased part; than if excited at a distance. (The proof of this, however, would be a digression too long to be entered into here, more especially as the author believes it is generally acknowledged.) Suppose then that cantharides are preferred to excite inflammation in fever ; the next question will be in what cases such inflammation should be produced. Supposing that a patient is seized with a regular continued fever ; and that the practitioner had no other means of putting a stop to the disease, excepting by exciting an inflammation ; or supposing that he has employed preparations of antimony, (or other medicines already enumerated,) without being able to induce a crisis in the fever; or even supposing that there were other means of inducing a crisis to the fever or carrying it off immediately, without any critical symptoms; and supposing the fever w r as perfectly regular, and affected the whole system equally: in any of these cases it is often worth while to attempt to carry off or to alleviate the fever, by exciting an inflammation, by means of cantharides, in the skin, between and over the scapulae, about six inches square. If the fever should be carried off by this means ; the inflammation may be suffered to go off, and the blister to heal. — The circumstances being the same, and the cantharides having been applied and an inflammation produced ; if the fever should not be carried off, or in the least alleviated; the application of cantharides, or any other stimulant to produce inflammation a second time, rarely relieves the disease : and therefore it is not worth while to keep up 26 302 REMEDIES EMPLOYED TO CARRY OFF or renew the inflammation of that part or any other part of the body. It will only wear out the system, and give the patient a less chance of sustaining the ordinary course of the disease. — Supposing the circumstances are the same, and the disease is alleviated, but not carried off; it may be advisable to excite a new inflammation after the first is carried off. If this new inflammation however should not carry off, or very much alleviate the whole disease ; a third inflammation is not to be attempted. The constant stimulus kept up by the remedies employed to excite a third inflammation, and the inflammation itself will wear out the patient so much, that no probable advantage arising from it can compensate for the mischief. — When a patient is going through the long progress of a fever, which takes up perhaps one-and-twenty days, or even longer, and when no medicine has been tried, or none has been found capable of preventing its continuing its ordinary course ; the practitioner, and much more the friends and attendants lose their patience ; the latter wishing that the practitioner would do something efficacious. In this case he is often compelled to apply cantharides to excite inflammation; notwithstanding the inflammation will probably be of no manner of use ; but tend to wear out the patient. The relations, nurse, and by-standers, are satisfied with what they call a fine blister, and with the practitioner's doing something : which certainly ought to be no inducement to a practitioner to torment the patient with an additional disease ; or to wear him out by producing additional action ; and so give him a less chance of going through the ordinary course of the disease. It happens often that some part of the body is more affected in fever, than in proportion to the affection of the system generally. — This forms an irregularity in fever; but (not to have to recur to the excitement of inflammation again) the author means to notice it here. Sometimes there is a much greater headache, (that is, pain in the exterior part of the forehead, or all round the head,) than in proportion to the febrile affection of the other parts of the system. In this case, at the very beginning of the disease, cantharides applied behind the ears, (so as to excite inflammation,) often relieve the headache ; and sometimes carry off the whole fever. The sooner the inflammation is excited, the greater is its power; and therefore under such circumstances it is better to apply them so as to excite inflammation and occasion a blister, in the first two or three days of the fever. — Sometimes, also, delirium arises earlier than we should expect from the other appearances of the disease. In this case an inflammation produced by cantharides, so as to occasion a blister to arise on the head after removing the hair, or on the skin of the neck, or between the scapulae; has sometimes considerable effect in diminishing, and sometimes in carrying off the delirium : and sometimes it even carries off the whole disease. — Sometimes likewise the breast is more affected than in proportion to the appearances of fever in other parts of the body : there being, for instance, sometimes a greater weight and oppression about the precordia, than corresponds to the appear- 303 A REGULAR CONTINUED FEVER. ances of fever in the other parts of the body ; sometimes greater difficulty of respiration, attended with cough ; and sometimes greater frequency of the pulse. In all these cases, (when they arise from greater affection of the breast,) an inflammation excited in the skin over the sternum, has often given considerable relief; and sometimes has carried off the whole fever. — But it is to be remarked in all these cases of topical affection, that if the first inflammation excited or blister produced, neither alleviates the appearances in the particular part of the body, nor diminishes the whole fever ; a second or third inflammation (excited by cantharides or otherwise) has seldom any beneficial effect; (but tends to irritate the whole system and wear out the patient; so as to render him unable to be supported through the remaining progress of the disease). —If however the inflammation so excited should have given considerable relief; in that case, keeping up the inflammation, or (which is preferable) renewing it after it is gone off, is often useful. In all cases where inflammation is excited either to carry off the fever totally: or to alleviate the symptoms, when they have taken place in a greater proportion in one part, than in the whole system ; the sooner it is excited, the more it is likely to prove efficacious; (excepting there should be great hardness, fulness, and strength of the pulse, and other appearances, which would render evacuation by bleeding necessary ; but this is rarely the case.) The practice, however, has rather been to leave the excitement of inflammation till later in the disease; (with a view perhaps to the practioner's reserving to himself something to do to satisfy the patient and by-standers, rather than appear to allow the disease to go through its ordinary course.) It often happens that in the course of a regular continued fever, delirium takes place. This delirium has been described in the former part of this dissertation, as of two different kinds: (the first, in which there is no appearance of affection of the brain, either when the patient is alive, or upon dissection ; and the second in which, when the patient is alive, there is fulness of the vessels of the eye and flushing in the face ; and on dissection, the vessels of the brain are much fuller of blood than they are found to be in men killed by accidents not affecting the brain. Both these species of delirium generally begin towards the end of the first w r eek of the disease ; but prevail principally in the second week. In the second species, taking away blood (by opening the external jugular vein and letting five or six ounces of blood flow out) has diminished the delirium considerably ; sometimes has carried it off entirely ; and with it the whole fever. The same effects have been produced by applying two, or three, or four leeches, and allowing them to fall off of themselves ; and afterwards applying cloths moistened with warm water, and allowing the wounds to bleed for four or five hours; (which last method is most efficacious.) In such cases of delirium, therefore, it is proper to take away a small quantity of blood. The quantity of blood to be taken away should be according to the strength of the 304 REMEDIES EMPLOYED TO CARRY OFF patient. If his strength be much diminished by the fever or otherwise, the application of one leech to each temple is still of considerable use. — Taking away blood from the arm or any other part of the body distant from the head, is of no manner of use; as the author has seen in a great number of cases. (It was much the practice about the year 1760, to take away blood from the arm in cases of delirium of both kinds ; the practitioners believing that delirium arose from inflammation of the brain ; but the author never saw any advantage arising from this practice.)—In delirium of the first kind, where there does not appear any symptom of fulness of the vessels of the brain ; the author has not seen any advantage gained by taking away blood in any way from the head, or from any other part of the body. At the beginning of fever, it happens sometimes that very violent pain takes place in the forehead ; which feels to the patient as if it affected the integuments of the cranium, and was merely external. In this case, the author has seen three or four leeches applied to the temples give considerable relief to the patient by removing the pain ; and sometimes they have carried off the w T ho!e fever. The author cannot conceive in what way such evacuation from the vessels of the head should be of use, when taking away blood from a distant part of the body is of none. Every man versed in anatomy must know, that from whatever part of the body blood is taken, it is the same blood ; excepting for the difference there is between arterial and venous blood ; (which are to be converted the one into the other in a few seconds.) The vessels of the exterior part of the head have very little connexion with the vessels of the interior parts ; so that taking away blood from the temples by means of leeches can have very little influence on the circulation of the interior parts.—The reason why such topical evacuations by bleeding carry off or diminish the delirium or pain in the forehead, or even sometimes the whole fever ; is consequently wholly unknown to the author. The only thing that he knows with regard to it is, that it is often effectual; which was long ago taught to him ; and which he has found confirmed by repeated experience. « In this case (as well as in the application of all the remedies employed to carry off or relieve fever) the effect is uncertain. — Sometimes this topical evacuation is of very great advantage, or evidently carries off the fever without occasioning any of the appearances which take place in the ordinary crisis of the disease ; and not unfrequently it has no effect at all. — But as so small an evacuation can hardly be of any disadvantage to the patient, it is worth while to employ it in the cases enumerated. The most conspicuous appearance, which takes place in the crisis of fever, is profuse, sweating. — Whatever substances therefore tend to produce profuse sweating, suggest themselves as remedies proper for carrying off the disease. — Spices are among the substances which tend to occasion profuse sweating ; and have therefore been conceived to be proper remedies for carrying off the disease. — Indeed the A REGULAR CONTINUED FEVER. 305 great depression of strength, and great sense of coldness, which take place at the attack of fever; and when the coldness is gone off, the great depression of strength which continues ; suggest the propriety of employing such powerful stimulants as pepper, cinnamon, nutmegs, capsicum, &c. ; to prevent the patient from sinking under the disease. The impression made by the appearance of weakness in the patient, and by seeing the fever carried off by a crisis in which profuse sweating takes place ; has determined all nations in the beginning of medicine to employ such powerful stimulants as the spices enumerated, (or the most powerful they could procure) to produce a crisis : and. practitioners have also employed them to support the strength of the patient. — It is not till medicine has subsisted for a long time in any country which has had no communication with others, or until the practice of other nations who have had much longer experience in medicine has been communicated to them ; that such stimulants have been thrown aside ; or the cool regimen (as it has been called,) has come into practice. — It is moreover to be observed, that many practitioners in medicine have been nearly or totally without that education, which could teach them the knowledge of the experience of those practitioners who went before them ; and in consequence, on what ground the practice of medicine is founded. (Unfortunately, in all the schools of medicine, the professors have been more anxious to infuse into the minds of their pupils some hypothesis ; rather than a true history of the diseases they have treated of, or the efficacy of the remedies which have been employed.)— It is not therefore at all to be wondered at, that the application of spices and other powerful stimulants, should often be re-introduced. The same depression of strength, which originally brought spices and other such stimulants into practice ; and the profuse sweating which takes place in the crisis of the disease ; have made untaught and inexperienced practitioners fall into the same train of thought and the same practice, that prevailed in the rude state of medicine ; (that is, to keep up the force of the patient, or to bring on a sweating ; supposing by that means to occasion a crisis in the fever.) — This is called the warm regimen, and has been thus brought forward repeatedly. — For the same purpose, the patient has been kept in an air of a very warm temperature, and covered with bed-clothes that are bad conductors of heat; and with the same effect. It has been already shown, that stimulating the body when there is depression of strength, but not actual weakness ; is a means of exhausting the powers of the system instead of increasing them.— It remains to be inquired, whether sweating produced by simple stimulants, or keeping the patient in a warm atmosphere or loaded with clothes ; will produce a crisis, or carry off the disease ? — Sweating alone does certainly not carry off a regular continued fever. (Every practitioner, who has seen a moderate number of patients afflicted with regular continued fevers, must have observed sweating fre- 26* 306 REMEDIES EMPLOYED TO CARRY OFF quently take place without carrying off, or even producing the smallest alleviation of, the disease.) — In the crisis of fever, there is not sweating alone observed ; but an universal increase of the secretions. The tongue becomes moist, and the crust which covers it is exfoliated ; a laxity takes place in the intestines, and sometimes a considerable purging ; the skin regains its healthy appearance, and is no longer contracted upon the muscles ; and a relaxation everywhere occurs. — None of these other appearances happen when sweating is produced merely by stimulants, or keeping the patient in a warm atmosphere, or covered with clothes which do not conduct heat: On the contrary, the mouth becomes more parched and drier, and the thirst is increased ; the intestinal canal is more constipated ; and the patient is far from being relieved from any part of the disease. — If therefore the attempt to carry off the disease by stimulating, by means of the remedies enumerated or by keeping the patient hot ; is viewed in any such light, it is to be totally rejected. It happens not uncommonly in the human body, that a muscle contracts without any volition in the man, or even against and contrary to his will ; and this, when there is no apparent stimulus applied either to the part itself, or to any other part of the system. Although this contraction exists often in a very great degree; yet the tw T o ends of the muscle cannot be brought nearer each other, because there is a counteraction : and in this case the body of the muscle generally swells, and occasions pain to a violent degree. — This contraction has been called spasm. — This kind of contraction takes place not only where there are evident muscular fibres of a red color, but in all the other parts of the body which have a power of contraction similar to muscular contraction ; an act not at all depending on their elasticity. For example, the gastrocnemii muscles of the leg contract without any volition or against the volition, and without any stimulus being applied ; so that the belly of each muscle swells, and is extremely painful : and in like manner the skin contracts upon the interior parts, and produces an uneasy or painful sensation, without the patient's volition and when no apparent stimulus is applied. That there is some cause for such contractions taking place there can be no doubt ; but it is a cause that to us is imperceptible. — Such contractions are called spasms, properly and strictly speaking. — Contractions which arise from stimuli, applied either to the part itself or to some other part of the body, or from affections of the mind ; have been called likewise in a vague sense spasms. — The contractions which, strictly speaking, are called spasms, sometimes last for a very short time, (not above a minute or two,) and then go off; sometimes they continue for a more considerable length of time, and produce affections of the system which have been fatal. — The spasm of the muscles of the leg for instance, which is called the cramp, does not last above a minute or two : it then goes off, leaving behind a degree of soreness. — A spasm of the annular muscular fibres of the intestines continues for two or three days : it produces extreme A REGULAR CONTINUED FEVER. 307 pain in the part; and a more frequent contraction of the heart, and in consequence more frequent pulsation of the arteries ; so that they, often beat more than one hundred and twenty times in a minute. A great depression of strength in the whole system comes on ; a loss of appetite, difficulty of respiration, and derangement of all the other functions of the system, take place : and sometimes the effects prove fatal in a few days or even hours. It has already been shown, that in Fever, there is contraction of the parts which have muscular power, generally ; and that Fever often arises from causes perfectly unknown. Here is, therefore, a contraction in certain points similar to what is called spasm. Some practitioners have therefore considered fever as a spasmodic disease ; and the whole of it as consisting entirely of a spasmodic contraction of all parts of the body which have a power of muscular contraction, totally independent of their elasticity. —¦ It is to be remarked, however, that contractions of the various moving parts is but a part of the disease : for there is (besides this contraction) a depression of the powers of the body.—This arises even before there is any appearance of contraction ; and in many cases it is by no means in proportion either to the degree or to the universality of the contraction: and this depression continues in many instances when the contraction in many parts of the body is gone off. — There is likewise a regularity in the attacks, the hot fits, and the crisis of the disease, not at all similar to what happens in those contractions which are called spasmodic : these being almost always vague and irregular. There are certain remedies which, being applied to the stomach or skin, or some other parts of the body of the patient affected with spasmodic contractions ; in many instances will immediately carry off the spasm. In a spasmodic contraction of the muscles of the calf of the leg; ether poured upon the skin of the leg will (in some cases) immediately carry off the contraction — It is to be remarked, with regard to these medicines, that they have something peculiar in taste and smell, which we have not sufficient words to express: for in truth we have but few words to express the sensations which we receive from the taste and smell. These sensations are at first, what we call fetid to the smell; and their particular odor has given a dis - tinction to these remedies. — Those which we hence commonly call antispasmodics, are some plants of the natural class of ringent flowers, by (Linnaeus called didynamia gymnospermia,) such as mentha pulegium, &c. : Some of the natural class of umbelliferous plants, which come under the pentandria digynea of Linnseus, as ferula assafeetida, &c. ; Some plants which have compound flowers, (most of which are contained in the syngenesia of Linneeus,) as matricaria, &c.: Some medicines, the product of chemical processes, such as ether, &c. : And some found in animals, as musk, &c. Most of these have been used to take off spasmodic affections; and several of them have been used in fever with a view of taking off fever immediately, or of gradually diminishing the disease. 308 REMEDIES EMPLOYED TO CARRY OFF It has been already said, that ether and oleum vini, dissolved in .alcohol sometimes produce sleep ; in which sleep a crisis of the fever now and then takes place, and the disease is entirely carried off; (but this has been sufficiently treated of in the first part of this dissertation). Resinous substances (such as galbanum, sagapenum, oppoponax, &c.) have sometimes been made use of; but rather as laxatives, than with a view of carrying off the disease. Assafoetida and gum ammoniac, produced from the same class of umbelliferous plants, though they have been much employed as antispasmodics in other diseases; yet as far as has come to the knowledge of the author) have not been made use of with a view of carrying off or diminishing fever. Musk has been employed, in many cases, towards the end of a regular fever, where the strength has been much diminished; with a view however, rather of stimulating and keeping up the strength of the patient, than as a medicine applicable to the carrying off or alleviating the fever itself. It certainly, as far as the author can judge from frequent experience, has been of little use in either supporting the strength or alleviating the disease. Castor has been employed in many instances ; but especially along with small doses of opium, (as has been described in the former part of this dissertation). The author thinks he can say, from his experience, that this has been done with very considerable advantage in assisting the opium in producing a degree of stupor and sleep ; so as considerably to alleviate the disease. Camphor, (a very peculiar substance produced by the crystallisation of the essential oil of the laurus camphorifera, and found often in cavities formed by the cracking of the tree itself;) has been very much used ; particularly in the second and third weeks of a regular continued fever. — This substance has been so much and so universally employed by the very first practitioners in medicine, (by those of the greatest skill, as well as reputation ;) that the author's practice can be put in no competition with their opinion. — There are many things, however, that make him dubious of its effioacy, either in alleviating or carrying off the disease. — In the first place, he has frequently employed and omitted it throughout the second and third weeks of a regular continued fever, in similar cases; without observing that the fever was more alleviated in the patients w T ho made use of the champhor, than it w r as in those patients who did not make use of it. — In the second place, the dose which has been commonly employed in what is called the champhor mixture, cannot possibly amount to two grains; whereas the author has frequently exhibited to patients in regular continued fevers upwards of ten grains, and to patients in other diseases twenty, forty, and even sixty grains of camphor ; without producing in most cases any sensible effect. Sometimes indeed, when given in the quantity of thirty grains and upwards; it has occasioned a little giddiness and stupor, (which how- 309 A REGULAR CONTINUED FEVER. ever have soon gone off.) He does not think, therefore, that in so small a dose it can be very efficacious. — Again : in fever which is running on for two or three weeks, and in which no efficacious medicines have been employed with success ; (but the disease has gone on in its ordinary course;) the flavor of camphor gives the appearance of the practitioner's doing something efficacious, or at least attempting to do something; while in truth he is regarding the progress of a fever pursuing its ordinary course. It is wearisome to the patient, as well as to the by-standers and to the practitioner, to conceive that no remedy of any efficacy can be exhibited : and this, the author suspects, has been the cause that camphor has been exhibited. — Its flavor however often disagrees with the patient's stomach, and produces sickness or nausea sufficient to prevent him from using food of sufficient nourishment. TREATMENT OF A REGULAR CONTINUED FEVER. Tbbatment to Oaiuiy off thk Ff.vku (Continued). —A regular continued similar to a regular intermittent fever—Power of hark of the cinchona to prevent a fresh paroxysm of intermittent fever—Difference between a regular continued fever and a regular intermittent one, in the paroxysm of the latter terminating by crisis, while that of the former is succeeded by another paroxysm—The bark, given, in large doses, in continued fever, with a view to bring about a crisis, and prevent the occurrence of the next paroxysm—Success, in some cases, of this practice—Failure and aggravation of the disease in more—In irregular continued fever its use may be advisable to prevent subsequent attacks— Cerussa acetata used by Gaubius —Depression of strength, an occasional cause of putrefaction of the fluids, which endangers life—Composition of animal solids and fluids—A solid substance, called by the author animal mucilage, combined with water —Chatige of properties of animal mucilage—When taken out of the living body and allowed to die it undergoes certain changes—All the solid parts of an animal, capable of contract ins 1 , lose this power by death—Some change even in its chemical and mechanical properties—After death, animal mucilage becomes subject to various chemical changes— Putrefaction, one of these—Changes in the texture and other properties of the solids and fluids by putrefaction—Gradual change in a putrefied part, analogous to that of fermentation — Examples—Results of putrefaction —Means of preventing putrefaction and its effects in a dead body—Peruvian bark one of these—Five hundred grains to prevent one pound of dead animal matter from putrefying—Cannot be conveyed into the blood in quantity large enough to act, in this way, on the blood, and through it on the whole living body—A certain degree of putrefaction of the fluids in a living body, as in sea-scurvy —Means of its cure, not in antiputrescent —Alleged remedies to prevent and cure putrefaction—The matters added to the animal substance do not restore it: they combine with it, but not after a vital fashion —True means of preventing putrefaction, are, to carry off the fever, and to avoid all depressing causes—Hemorrhage a dangerous sisrn—Mark, an ounce in the twentyfour hours, the remedy—Formula,—Convalescence—A crisis before the sixth day is followed generally by fever of an intermittent type —Notion of concoction of febrile matter to be expelled from the system, erroneous — After signs of early crisis, peruvian bark to be administered every hour fur forty-eight hours—A return of the fever, after an interval, shows the disease to be an intermittent, and it is to be treated as such— Crisis, brought about by preparations of antimony, ipecacuanha, or other medicines, to be followed by the exhibition of the bark—Removal of local pains and fever, by leeches, blisters, ,a or Semi-tertian. — It differs entirely from those intermittents, which have their paroxysms prolonged by general inflammation. When this case of semi-tertian arises in temperate or cold countries, generally — if the disease be left to itself—the paroxysms shorten the crisis, and intermissions become more perfect; and the disease is changed into a regular quotidian, tertian, or quartan. — The remedies to be employed, to hasten its conversion into a regular tertian, are in the first place clearing the intestines from noxious matter contained in them, by an emetic ; which it is best to employ in the evening, in the same manner as has been directed in a regular fever. On the next day, in the morning, a moderate dose of rhubarb — or some other purgative which tends to increase the peristaltic motion of the intestines—should be exhibited, — After the intestines have been cleared of their contents, preparations of antimony or ipecacuanha ; or such other medicines as tend to produce appearances similar to those which take place in the crisis of fever; should be exhibited at the interval of four, five, or six hours ; so as to act constantly on the system. These should be continued for several days; until a 30 350 HISTORY OF AND REMEDIES EMPLOYED perfect and longer intermission has taken place. When a perfect intermission has been procured, (if it should continue but for six or eight hours,) the bark of the cinchona should be given in powder, to the quantity of a drachm or two drachms every hour, or even every half hour; or as much in quantity and as frequently as the stomach will bear. The bark is to be omitted w T hen the next paroxysm, if it should return, has come on ; and be repeated again in the next intermission ; provided it is as perfect as the former one. If it be not, the medicines producing appearances similar to those which take place in the crisis of fevers, are to be employed ; until another intermission has been produced ; in which case the cinchona is to be again exhibited. — If the exhibition of the cinchona should have prevented the return of the paroxysm altogether, the practice should be followed that has been pointed out in a regular tertian. — Supposing that the exhibition of such medicines as produce appearances similar to those, that arise in the ordinary crisis of fevers, should not produce a perfect crisis, nor shorten the paroxysms; and that the patient is so much weakened, that his life is endangered from the weakness taking place in the disease : the cinchona is to be employed in the best remission that can be procured ; and its exhibition regulated as has been already described in the management of a regular tertian. Tertians, quotidians, or quartans, which have their paroxysms prolonged in temperate or cold climates, are still not very formidable ; either falling of themselves or by means of medicines, into fevers, the paroxysms of which are shorter, or the crisis of them more perfect; (as has been above described.) When general inflammation takes place at the beginning of an intermittent, although it has not been accounted for why the general inflammation should prolong the hot fit; yet it is evident, that it is often the cause of its prolongation.—When there is no great hardness of the pulse ; and often when there is no great fulness and strength of it, but only frequency and obstruction ; the hot fit is frequently prolonged ; even so as to leave no other mark of an intermittent to distinguish it from a continued fever, excepting the exa6erbations not taking place in the evening. — When this happens in hot climates, the disease is the most formidable which is incident to mankind. It has frequently been called the plague ; and by several other names, indicating the most fatal disease. In countries wbere the heat of the atmosphere rises above ninety degrees of Fahrenheit's thermometer : wdiere the ground is marshy, or where there are stagnating waters, or where thick forests prevent the heat of the sun from drying the earth ; three diseases the most fatal to the human race, (to wit, dysentry alone, continued or remitting fever producing it, and irregular semi-tertians) frequently arise. Of these diseases the author at present means to treat only of irregular semi-tertians. 351 IN IRREGULAR INTERMITTING FEVERS. Irregular semi-tertians (as well as these other diseases) arise, as has been said, from water stagnating in marshes; or from the air's being kept moist in countries covered with wood, and where great quantities of rain fall. — In all these cases in hot countries, if there should be any animal or vegetable matter at hand liable to putrefaction, (one hundred degrees of Fahrenheit's thermometer being the most proper heat for putrefaction) the animal and vegetable substances fall readily into the putrefactive fermentation. The vapor arising from putrefying animal and vegetable substances, has already been shown in a former Dissertation, to be one of the most powerful causes of fever; and several practitioners have thought this vapor always to be the cause of the semi-tertians, which are treated of at present. — The author has shown in a former Dissertation, that moisture when dissolved in the atmosphere or when evaporating, generates cold. That cold so generated is also one powerful cause of fever: and that it is often the cause of intermittents, as well as of the other diseases which have been above enumerated, without any putrefaction taking place ; is certain from several proofs. — These diseases have been produced in countries where the water was found at a foot or two under the surface of the earth: moisture arising thence, and contaminating the air, so as to occasion these diseases ; though the soil has been perfectly dry, and there has not been the least appearance of putrefaction, the country being clear from woods. In this case it could be nothing but the moisture that produced the disease. One instance of this occurred in the encampment of the English army, in a war about the year 1745, in a sandy plain in Flanders. Another in a region of Peru ; where water is everywhere to be found at about seventeen inches below the surface of the earth ; though the country itself is barren for want of water, but is uninhabitable from the number of dysenteries and semi-tertians which take place in it. The author could mention many instances of the like kind : but these are sufficient to show, that moisture without putrefaction often produces this disease. The next thing that draws our attention is, whether infection be not also one cause of these semi-tertians. The author has already said that fevers are infectious ; regular tertians being the least infectious, and a regular continued fever, when its symptoms are in an intense degree, the most infectious. — The opinion about the infectiousness of the semi-tertians of hot climates, where they are so very fatal, has been various; and has been given by young and unlearned practitioners with such positive and contradictory firmness ; that it is very difficult hereto form any true conclusion. It has happened that a town or even several towns have grown up near harbors suddenly, in countries before uncultivated ; and the inhabitants paying attention to trade only, have neglected the means of carrying off putrescent matter. When the heat has in this case arisen to any very considerable degree, putrefaction has taken place ; and has occasioned such semi-tertians, as at Philadelphia. A semi-tertian arising in a town 352 HISTORY OF AND REMEDIES EMPLOYED under these circumstances, the inhabitants have been alarmed, and anxious to investigate the cause : and one origin has then suggested itself to them : viz., that infection has been imported by ships arriving from countries in which infectious fevers have subsisted: but this suspicion has almost always occurred without any minute attention to the rise of the disease. — When this happens in a town where the heat, under certain circumstances, is very intense ; as where winds blow r in the beginning of the summer over a sea or over a continent, lying near the equator, and which at other times is subject to extreme cold, from winds blowing over a continent farther from the equator : In such towns, when the summer is a little advanced and the heat becomes constant, great putrefaction takes place. In consequence, fevers have arisen very suddenly, and universally. — At this time, many ships, from local circumstances, have arrived from countries where infectious fevers are very common : and the sudden breaking out of this very fatal fever has been ascribed to the arrival of such ships : —though ships of this description have arrived at other times of the year (when no such heat or putrefaction w r as prevalent,) without any infection having taken place. This renders it extremely doubtful, whether the fevers arise from imported infection. The inhabitants of such towns as have been described, upon the breaking out of such a fever, have (from terror of the infection) fled into the country. — In this case two things might happen to prevent the disease arising among those who had gone into the country : the one, their not being exposed to the infection, supposing the infection existing ; the other, the removal from masses of putrescent matter. — It is to be inquired therefore, to which of these two causes the exemption from such fevers, in those who thus removed into the country, was owing. — The author himself never having been in a situation to observe the circumstances, which could determine his opinion, must depend upon facts related to him by those who have been present under these circumstances, and whom at the same time he has had an opportunity of cross examining; for no good evidence can be procured from the writers, who have lately treated on this subject in such situations ; from the great attachment to'hypothesis which is so manifest among them. —From the evidence the author has been able to collect, it would seem that these semi-tertians are not very infectious ; since in hospitals, where patients w T ere received in such fevers, the physicians, surgeons, and other attendants, were not oftener seized with the fever, than the other inhabitants of these towns. Moreover, though many ships have arrived from these towns in the several ports of Europe, (and in many certainly without performing any quarantine,) yet the disease has never been produced in Europe. On the other hand, in the war between Great Britain, France and Spain, (where the American independence was the ground of the pursuit,) when [a truly] infectious fever broke out in the combined fleets of France, and Spain, which obliged them to put into the harbor of Brest: in this case, in the hospitals of Brest, every one of 353 IN IRREGULAR INTERMITTING FEVERS. the nurses, and above one hundred and fifty of the practitioners in medicine, caught the disease ; and were cut off by it. The author therefore thinks he may believe, that though, (as he has before asserted) all fevers are infectious ; yet these semi-tertians are — like the other varieties of intermitting fevers — not very infectious. It may be concluded, therefore, that these fevers arise sometimes from putrefaction ; sometimes from cold, generated by small drops of water evaporating or dissolving in some or all of the vapors which constitute the atmosphere ; and sometimes from infection. TREATMENT OF AN IRREGULAR INTERMITTENT FEVER. ( Continued) Description op an Irregular Semi-tertian. — First attack sometimes so violent as to destroy life—May be called an ephemera —In the tropics and eastern coast of America is less intense at its onset —Patients seized, at times, with all the most violent symptoms of the first stage of fever—These described—The disease makes its attack between six in the morning and eight at night, often without premonition—The first attack soon followed by more violent exacerbations—The author could not learn when these exacerbations occur—On the second, third, and fourth day the nausea increases, and a dark brown matter is brought up—This resembles the matter formed upon the tongue in some other fevers—Is most probably formed upon the surface of stomach and perhaps of the duodenum—Has neither the color nor the taste of bile— Bile sometimes excreted and brought up with it—At other times, there is no appearance of bile—Scarcely any medicine acts on the stomach at this time—Food is not digested and the patient is almost always cut off—At times spasmodic contractions of the extremities, like tetanus, take place—Sometimes the skin assumes a dark brown color, which has given the denomination of yellow fever to the disease—The color erroneously attributed to bile—Dysentery arising with this fever—-The fevers seem to be a continued one—But it is a semi-tertian, as is shown in the often great relief and apparently beginning of recovery, when all at once, a fresh attack takes place, and the patient is carried off. Remedies Employed.—The most violent ones, had recourse to — Blood-letting—Active purging—Large quantities of mercury—Gold water dashed over the patient—All these and other violent measures seem to have increased the danger—Better to have been left to itself—The general inflammation not so great as to prolong the paroxysm and to require evacuation by bleeding—Purging, except to keep the bowels open, is injurious, by weakening the patient, causing a determination of blood to the interior and interfering with the effort of nature to hring on a crisis— Mercury employed in all cases of fever by some practitioners, but without any sensibly good effect—Its exhibition imprudent in these violent fevers—Is the fever to be left to go through its ordinary course 1 —If antimonial preparations are to be of use, they ought to be employed early—Dose from a quarter to a third part of a grain, with about half a grain of opium, to be repeated every four hours—The patient should be put to bed, under a light covering, and drink warm watery, farinaceous and mucilaginous drinks—Phis practice should be begun within six hours from the attack—If it cause moisture, it may be continued for two or three days—If the disease is abated, and an approach to crisis manifest, Peruvian bark in substance should be given, in the dose of a drachm every hour—Little to be expected from other or topical remedies. Symptoms of Semi-tertians Resemhling Regular Intermittents or Remittents. First account in history was that issued by the physicians of Alexander of Macedon. 30* 354 HISTORY OF AND REMEDIES EMPLOYED These semi-tertians begin at once with an attack of the first or cold stage of fever— Symptoms—Scarcely any remission of the first paroxysm, which is of a tertian type— Second exacerbation in the day time, is followed by something like a crisis—This more conspicuous after the third and fourth—Otherwise the paroxysms run into each other, delirium comes on and death ensues—Sometimes the fever runs its course, and ends in health, in two or three weeks—Diarrhoea in the state of relaxation after the paroxysm—Ceases when this comes on again—No time to be lost in a semi-tertian. J'he Remedies. —Blood-letting rarely necessary—The prima vie to be cleared, immediately by an emetic and a laxative—Antimonials and the like to be exhibited during one or two attacks and remissions—Afterwards, without waiting for remissions the bark is to be given every hour, and in quantity as large as the stomach will bear —Opium with aromatic powder may be added—The author not able to speak of the good effects of leeches to the temples or blistering. Irregularities in Ihtebmittents in Temperate Climates.—Cough and difficult respiration without expectoration resembling catarrh or even peripneumony—General inflammation sometimes takes place—Hardness of pulse anil other symptoms—The pulse also contracted and small—Weakness and emaciation—Evening paroxysm ends in sweating—The disease assumes the appearance of phthisis—Besides the remedies already recommended to produce perfect intermissions, leeches and cups to be applied to the chest—Blisters to the same part —Experiments—Mucilaginous and oily medicines—Then to prevent the return of a paroxysm, by a purgative—Just before the return of a paroxysm, ipecacuanha or antimony, along with stimulants and opium—The patient to be in bed, and to use warm watery drinks—The inflammatory symptoms removed, then the bark is to be given. Enlargement of the Spleen and Liver. —Swelling of the spleen—Its appearances—Swelling of the liver, hard and unequal—Tumours of the abdomen, ague cukes —More common in quartans than in tertians, and more so in tertians than in quotidians—Changes in the tumours —Give rise to ascites—Also to jaundice —The disease then generally fatal—Increased determination of blood to the abdominal viscera has caused diarrhoea, followed sometimes by dropsy—Astringent remedies increase the dropsical symptoms—Treatment—a laxative of rhubarb, followed by the bark, in a drachm dose, and a grain of ipecacuanha, and fifteen drops of tincture of opium, every three hours—Dropsical swellings after abdominal tumours — Less in the paroxysm—The dropsy rarely fatal—In other eases the dropsy externally assumes the appearance of phlegmasia —The paroxysm to be stopped by the bark, even though the dropsy seems at first to be worse—This will ultimately be benefited by the cure of the fever—In certain cases of intermittents, running into a remittent form with frequent pulse and foul tongue, the metals have been employed— Jlsenic the most efficacious —Great care in its preparation and administration —Preparations of zinc most powerful after arsenic—Preparations of copper—Sulphate of copper cupium viiriolatum, the most certain of these—Preparations of iron often very seiviceable in keeping up the tone of the system—All these metallic preparations to be exhibited in as large doses as the stomach will bear. The author now means to attempt a description of this disease. — It must however again be remarked, that he has never had an opportunity of observing this disease himself; never having been in a hot climate. — His knowledge of it in the first place is taken from descriptions of it in authors, which nevertheless are in many particulars very defective: In the second place, from descriptions of it which have been given him by many practitioners, who have treated the disease in warm climates ; and five of whom had been affected with it themselves: In the third place, from the descriptions of it by several patients who had been afflicted with the disease ; and from whom (although they had not any knowledge of medicine) he has had an opportunity of inquiring what appearances they recollected during the time of the disease. The author wishes first to describe the disease in its most violent form ; and when it approaches nearest to a continual fever. IN IRREGULAR INTERMITTING FEVERS. 355 In the first place, the attack of the disease has been so violent, as to carry off the patient in the very first paroxysm : in which case the disease, properly speaking, must be called an ephemera. (This was seen more particularly at Bencoolen, when Fort Marlborough was situated in a marsh, near the sea-shore ; though it has ceased to be so fatal, since the fort has been removed to a more elevated ground.) It happens in a less violent degree in other cases : Thus, when European troops have been sent to the islands between the Tropics, lying on the eastern coast of America ; the first onset of the fever, [though severe,] has rarely been fatal. — The patient has been seized at once with all the most violent symptoms of the first stage of fever. Sometimes a sense of coldness ; shivering ; rigor and horror ; great depression of strength, and want of disposition to exert the powers of the mind ; and a total apathy to all external objects ; have occurred. There has been great thirst; the tongue sometimes has been covered with a thick fur; and nausea, a total aversion to food, a want of sleep, and all the other most violent symptoms of the attack of a regular fever ; have taken place. — Moreover the disease in all those who had been affected with it whom afterward the author had occasion to see, (and who remembered the circumstance ;) began between six in the morning, and eight at night: the attack having been well marked ; and no symptoms of the first stage having preceded for several days before. — After the first attack, the exacerbations became much more violent; so that the disease increased very fast. The author however could never gain any information, whether these exacerbations took place in the evening, or at any other part of the day. A knowledge of this fact would have furnished the great criterion between intermittent or remittent fever, (whose exacerbations take place between six in the morning and six o'clock in the evening;) and continued fevers, (in which the exacerbations always take place between five and six in the evening.) On the second, third, fourth, or fifth day, the nausea increases: and the patient begins to bring up a dark brown matter; which has the appearance in some degree of the matter formed upon the tongue in very violent fevers. It is most probably formed upon the surface of the stomach, and perhaps of the duodenum, or even on the beginning of the jejunum ; but it has neither the color nor taste of bile. — The force of the exertion in vomiting however often occasions a greater quantity of bile to be secreted and thrown back into the stomach ; and brought up along with the dark brown matter ; and when this happens, it gives to the matter thrown up the taste and appearance of bile. (At other times it is repeated, there is no appearance of bile at all ; but only of this dark brown matter.) — When such vomiting has taken place to any great degree, the action of any medicine thrown into the stomach is apparently prevented ; the food is not digested ; and the patient is almost always cut off. —This has given the name of black vomit to the disease. 356 HISTORY OF AND REMEDIES EMPLOYED At other times, spasmodic contractions of the extremities take place, (similar to the varieties of tetanus ;) with violent delirium : and these symptoms are often fatal, though not so constantly as the vomiting which has been just described. At other times the skin assumes a dark brow r n color ; which has given it the denomination of yellow fever. —Many have supposed, that this was owing to a quantity of bile getting into the blood-vessels ; and have conceived that bile was the cause of the appearance. The color, however, is very different from that which takes place in jaundice. The evacuations from the intestines have not that claylike appearance, which is common in jaundice : and the secretion from the kidneys has not that deep yellowish brown nor that thick sediment, which have almost always been seen in those persons, in whom bile has got into the blood-vessels. — The dark brown color of the skin therefore seems to the author rather to arise from a greater secretion of the sebaceous matter, secreted by the sebaceous glands of the skin: than from any other cause. This fever often likewise has dysentery arising in it; but (as the author does not at present mean to treat of that disease) he has only to observe, that this dysentery, along with the fever, very soon weakens and wears out the patient; and also renders the disease extremely fatal. The fever, as the author has described it, seems as if it were a continued fever. — There is one circumstance, however, which has convinced him that it is a semi-tertian. — This is, an agreement of all those who have had, or have seen, or have treated the disease ; in the following observations. — It happens often, that a patient to appearance becomes greatly relieved, and in a state as if he were recovering ; when all at once a fresh attack takes place, and carries him off. Remedies employed. — This disease (when it takes place is so violent a degree) is so very frequently fatal, that it seems rather to have confounded practitioners, and made them employ all kinds of the most violent remedies they could think of; as if a very violent and fatal disease could only be got rid of by very, violent means. — Some practitioners have taken away large quantities of blood ; some have purged largely ; some have given large quantities of mercury ; some have thrown cold water upon the patient.—All these and other violent measures seemed to have enhanced the danger : and rendered the disease much more fatal, than it would have been, if it had been left to go through its ordinary course. It would indeed seem not at all proper to exhibit medicines w r hich are not found to avail in ordinary and less dangerous cases of the disease. There does not seem to be so considerable a degree by general inflammation, as to render it necessary to make evacuation by bleeding; (to obviate the danger that arises in consequence of such general inflammation). The general inflammation is not so great as to prolong the paroxysm and thus to require this evacuation ; and the author has before affirmed, that bleeding from any large vessel indis- 357 IN IRREGULAR INTERMITTING FEVERS. criminately, in any part of the body, has no power of diminishing or carrying off fever. As far therefore as he can judge, he should expect no advantage, but great mischief, from taking away a quantity of blood, or repeating the evacuation. He thinks it would hardly ever be prudent, to take away blood at all. Purging (as has been said in former Dissertations) excepting so far as to keep the bowels free from putrescent matter; is extremely hurtful in fever. The quantity evacuated weakens the patient, and diminishes the powers of the body ; so as to render a patient unable to support himself during the course of the disease. At the same time, the alteration in the circulation arising from the purgative, (causing a larger (low of blood to take place in the interior parts of the body) makes the effort in the hot fit to produce a perfect crisis or greater relaxation of the paroxysm, less efficacious : (for its efficacy depends on the uniformity of its action in every part of the system, as the author has formerly pointed out). The author must therefore be of opinion, that large evacuation by purging is very detrimental, instead of being useful in this disease. Mercury cures the veneral disease ; which no other medicine will cure, (or at least not with any degree of certainty): and physicians have seemed to have concluded, that whatever medicine will cure one disease, which no other medicine can cure ; will cure all diseases, which no other medicine will cure. This supposition has occasioned mercury's being employed in a variety of diseases, where it evidently does a great deal of mischief. It has also occasioned it to be employed for a great many purposes, for which other medicines are much more properly adapted. Mercury has been employed in all cases of fever, of an ordinary degree of intenseness, (whether continued or intermitting,) by various practitioners ; without any sensible good effect, either in producing crisis, occasioning more perfect relaxations, or shortening the ordinary course of the disease. It is evident therefore, that it is imprudent to exhibit it in these most violent fevers. The next thing that requires consideration is, whether we should leave the fever to go through its ordinary course ; as although it is a very dangerous disease, it is by no means always fatal, but in many cases has gone off when left entirely to itself: or whether some effort is to be made to carry it off: or whether some medicine may not be employed to make it go through its course with less danger to the patient ? Preparations of antimony, ipecacuanha, and other medicines, have been shown to produce symptoms similar to those which take place in the ordinary crisis of fever : and these, (especially Dr. James's powder) have frequently been employed in this very violent disease. The patient's stomach very soon becomes so extremely irritable, that any dose of such medicines as might be expected to be at all efficacious, has produced vomiting ; which, when it takes place in any great degree, has hardly ever been got over; but has destroyed the 358 HISTORY OF AND REMEDIES EMPLOYED patient. The author conceives that preparations of antimony, (of which he has in aformer dissertation said that tartarised antimony is the best hitherto known,) if they have any chance of carrying off the disease, by producing symptoms similar to those which take place in the ordinaiy crisis of fever; ought to be exhibited immediately on the attack of the disease. This immediate exhibition of them, he apprehends, has been prevented ; either in the first place by the great depression of strength and perfect apathy of the patient, which arise immediately on the attack of the disease; secondly, by the general want of energy of the inhabitants of very hot climates ; thirdly, by the hurry Which takes place in all military operations (this disease being particularly apt to arise in armies in very hot climates): and lastly, from the great hurry of practitioners, when a town, district, or country, is seized with an epidemic disease. The author can say nothing from his own experience ; but should be disposed, at the moment of the attack of such a disease, to employ as great a dose of tartarised antimony as the patient could bear without producing nausea ; (that is, from a quarter to a third part of a grain;) together with about half a grain of opium. The medicine should be repeated every four hours. The patient should be laid in bed, and covered with a light covering of cotton ; and warm, watery, farinaceous and mucilaginous fluids should be drunk frequently. If this practice be not begun within six hours from the attack, the author should not expect much success from it: and at any rate he proposes it with great diffidence. —If by this practice, the moisture should be restored to the skin with which it is generally covered in hot climates, this course may be continued for two or three days. — And if the symptoms of the disease should be so far diminished, as that anything like a crisis should be brought on, and the stomach remain quiet; the author then would recommend the exhibition of Peruvian bark in substance, to the quantity of a drachm every hour, (or as much as the stomach will bear without producing sickness.) — As to the action of any other remedy, which the author has pointed out, as carrying off or alleviating regular continued fever, or regular tertians, such as inflaming the skin in any part of the body, applying leeches to the temples, fomenting the lower extremities, &c, he has little hope that any of them will be of use. — The method which has been recommended of nourishing and supporting the strength : with a treatment in other respects as in a regular continued fever, while it is going through its ordinary course ; should also be employed in this disease. Symptoms of Semi-tertians, Resembling Intermittents, and Remittents. — When Semi-tertians happening under similar circumstances and from the same causes, are not so near in their appearances to continued fevers ; but are nearer to regular remittent and intermittent fevers ; the following appearances take place ; as far as the author can collect from histories of the disease which have been given by authors, or which have been related to him by those conversant in the disease. 359 IN IRREGULAR INTERMITTING FEVERS. The first accounts of the occurrence of such serai-tertians as the author now means to describe, are to be found in the notes daily issued by the physicians of Alexander of Macedon. (The author cannot help taking this opportunity of giving his opinion of this man ; who he thinks had the grealest energy of mind, and was the greatest lover of the happiness of the human species, of any whose history has reached our times.) Those notes or bulletins were intended to inform the Grecian and Persian nobility of the progress of the disease, which (as the author has already said) he caught by surveying the marshes on the banks of the Euphrates ; in order to form a plan for draining them. These notes are preserved by Arrian. —Neither the Greek physicians, (in the time when the Lacedemonians and Athenians contested the dominion of the coasts of the Meditterranean and other parts ; or during the [Macedonian or] Roman empire); nor the very few Roman physicians whose works have come to us ; were conversant in diseases of countries, the heat of which w T as generally, for any considerable part of the year, above 90° of Fahrenheit's thermometer in the shade, or in the night time. — The author, therefore, has not been able from their works, (which are the great foundation of all medical knowledge,) to investigate the history or manner of treatment of those semi-tertians which are between those which resemble continued fevers, and those which Greek physicians have described. The author must therefore rely for farther information upon the very few modern accounts, which can be depended upon. These have been published by practitioners who have practised for a considerable time in very hot climates; and who had before received a regular medical education. Beside these, he has received information from those who had lived in such climates, and have attended patients afflicted with the disease ; as well as from patients who have themselves gone through the disease. The semi-tertians now to be treated of, begin at once with an attack of the first stage of fever. There is generally chilliness ; and not uncommonly rigor and horror ; and considerable depression of strength: but not that total carelessness about everything which takes place in the fever just described. There is dryness of the skin ; and nausea. The chilliness is followed by heat ; great thirst takes place, and the pulse becomes frequent (to a hundred and twenty, or a hundred and thirty strokes, in a minute). Most commonly the tongue is also dry and covered with a whitish fur. There is often violent pain in the forehead ; evidently in the external parts (that is, those without the cranium). In the first paroxysm, which observes the tertian type, there is hardly any appearance of remission ; except it be that the pulse becomes less frequent about thirty-six hours after the attack. The second exacerbation does not take place in the evening ; but between six o'clock in the morning and five in the afternoon ; and after the second exacerbation, something more like a crisis takes place : which result is more conspicuous after the third and fourth. —If the disease 360 HISTORY OF AND REMEDIES EMPLOYED should continue longer, and have less appearance of crisis ; the paroxysm run more into each other. Delirium, if it did not take place before, often arises; and the disease is frequently fatal. — Nevertheless it sometimes terminates its course, if left entirely to itself, in two or three w T eeks; and the patient recovers much more frequently than in the case just before described. It happens also very commonly in this case of semi-tertian, that during the beginning, in the violence of the attack and hot lit; no evacuation takes place from the intestines. During the relaxation from the paroxysm, diarrhoea however takes place ; but it ceases upon the recurrence of a fresh paroxysm of the disease : and when this happens, it weakens the patient; and adds considerably to the danger. In a semi-tertian, such as has here been described, no time is to be lost; the disease being very often full as acute, as a continued fever in temperate climates: (that is to say, it often terminates in the second, or at most in the third week of the disease.) Remedies. — It hardly ever happens, that there is such a degree of general inflammation as to require evacuation by bleeding : and if bleeding be not necessary, it is always hurtful, by weakening the patient. The primce vice ought to be cleared immediately upon the attack, by an emetic and laxative, (such as have been described in treating of irregular tertians;) and in doing this there must be no delay. Medicines (such as preparations of antimony, of ipecacuanha, &c.) wdiich have a tendency to produce such appearances as arise in the ordinary course of a regular fever, are to be exhibited during the time of one or two attacks and remissions : afterwards without waiting for a perfect intermission, the bark of the cinchona is to be exhibited in the best remission that can be procured, every hour; and in as large a quantity as the patient's stomach can bear. If the stomach should reject a small quantity of it (such as forty grains), or if it should occasion purging: a moderate quantity of opium, (such as five or six drops of tinctura opii, equal to a fifth part of a grain of opium,) with five grains of the pulvis aromaticus of the London Dispensary ; may be given along with each dose of it. — The powder of the cinchona is to be given during the last eighteen hours of the paroxysm and remission, if the fever observes the tertian type, (which it generally does.) Afterward the bark should be omitted, (whether the paroxysm return or not,) for twenty-four hours ; and then be repeated again : and this practice is thus to be continued, till the disease is carried off, (if it can be effected by this medicine.) The effects of inflaming the skin in any part of the body, bleeding with leeches applied to the temples, or any other remedies which have been said in former Dissertations to be useful in the disease ; the author can in no wise judge of; as he has not had any opportunity of observing them himself. Neither has he been able to collect their effects, either from the authors who have treated of such dis- IN IRREGULAR INTERMITTING FEVERS. 361 eases ; or from those persons who have seen or been affected by them, with whom he has had an opportunity of conversing. Irregularities in Intermittents in Temperate Climates. — The author now returns to irregularities which take place in intermittents, such as happen in temperate climates. It happens not uncommonly, that in an intermittent of any type, the quantity of blood thrown upon the lungs in the attack of the disease occasions cough ; attended with expectoration ; (especially when the fever has continued for some time).—At the beginning, the cough and difficulty of respiration are often without any expectoration. Sometimes also during the time of the paroxysm, the cough is without expectoration; but expectoration takes place during the time of the remission or intermission. — This affection of the lungs is sometimes somewhat similar to peripneumony, but more frequently to catarrh ; or rather to a mixture of catarrh and peripneumony. — In either case, general inflammation (such as has been described) sometimes takes place. The pulse becomes hard and frequent ; without being full and strong ; or without being attended with affection of the brain, or tension in the whole system (such as have been enumerated). The frequency and hardness of the pulse continue during the intermission ; and give an appearance of remission only, and not of intermission of the disease. — When this cough goes on for any length of time, the pulse becomes contracted and small; continuing at the same time hard and frequent. The natural evening paroxysm of fever is considerably increased. The proper attacks of the intermittent, whether it be tertian or quartan, are rendered more obscure. The patient is weakened and emaciated. The natural evening paroxysm also goes off with sweating between four and five o'clock in the morning ; — so that the disease puts on the appearance of, and has often been mistaken for, phthisis. If such inflammatory affection of the breast should arise soon in an intermittent; it becomes necessary, beside employing the methods already recommended to produce perfect intermissions, to bleed upon the skin of the breast ; by means of leeches or scarification, or of the application of cupping glasses. The skin of the breast should be inflamed by blisters. Expectorants (such as gum ammoniac and squills) ought to be employed. Mucilaginous and oily medicines are to be exhibited ; (to defend the mucous membrane from the stimulus of the neutral salts of the thin mucus which is secreted). — If by these means the inflammatory appearances, whether they were peripneumonic, or catarrhal, be entirely got the better of, or very much relieved ; we are next to endeavor to prevent the return of the paroxysm. — This is to be attempted, in the first place, by employing a purgative immediately on the going off of the paroxysm. An hour before the attack of a fresh paroxysm is expected, we are to exhibit ipecacuanha or antimony; along with stimulants and opium. We are then to lay the patient in bed ; and to give him frequently warm watery fluids to drink, along with mucilaginous 31 362 HISTORY OF AND REMEDIES EMPLOYED substances, in small quantities ; so as to endeavor to ing. By these means, the paroxysm is often prevented from taking place : the manner of accomplishing this having already been fully described. — It is better to attempt to carry off the disease in the first place, by these means, than to employ the bark of the cinchona ; (for this bark is apt to increase the inflammatory affection of the thorax.) — These remedies however do not counteract the accession and prevent it from taking place : and therefore if the inflammatory symptoms of the thorax have been in a great measure subdued by the remedies which have been just mentioned; then the cinchona is to be employed during the intermissions (as has been stated in the second Dissertation,) so as to put a stop to the disease. — The cinchona, however, is by no means to be made use of, if the inflammatory affection of the thorax be not subdued in a very great degree.— When the patient has been considerably weakened, and the ordinary evening paroxysm of fever has much increased, so that hectic symptoms have come on ; the author hesitated very much in the beginning of his practice, whether it were proper to employ the cinchona with a view of putting a stop to the disease : but from trying various treatments in many cases, he is satisfied, that it is by much the best to employ the cinchona in large quantities, (as has been before described). With any practice, however, the disease in this case is not uncommonly fatal. Enlargement of the Spleen and Liver. — The next danger which is apt to take place, arises also from the blood's being propelled from the exterior parts, in the time of the attack, to the large internal vessels : but especially to the vessels of the abdomen ; and particularly to those of the spleen and liver. — The spleen becomes enlarged and hard, and sinks lower in the abdomen ; so as to appear as a hard tumor there. Upon dissection after the death of the patient, it has been t found much enlarged, hard, and particularly unequal in its internal appearance. The whole abdomen in this case is swelled ; or there is rather the feel of a haYd circumscribed tumor in it. The patient perceives a sense of weight and distension; the digestion does not go on well; and costiveness is apt to' take place. This case however is not very fatal.— A like swelling and hardness are apt to arise in the liver. The tumor in this case is more in the region of the liver ; and does not descend so low. Upon dissection the liver has the same appearance of hardness and inequality. — There are tumors in the abdomen, so situated and so arising that the author cannot believe they can be affections either of the spleen or of the liver; but he has not been able to find any case of a patient's having been opened, where the tumor subsisted in any other part. — These tumors have been called ague cakes. — They arise more frequently in quartans than in tertians, and more frequently in tertians than in quotidians. These tumors do not seem much to alter the progress of the disease ; nor do they seem to prevent the disease from being carried off, IN IRREGULAR INTERMITTING FEVERS. 363 either by the ordinary progress of the fever itself, or by the exhibition of the cinchona or of any other remedy, which has been employed to carry off the disease. — If the disease should be terminated either in its ordinary course, or be cured by any medicine ; these tumors are left and continue for many months, or even years : without any great detriment to the patient; as they at last gradually subside. — Sometimes when they have arisen after a quartan has continued for a month or two ; they have again subsided, after it has continued for two or three months longer ; and before the quartan has finally ceased. — When a fever has ceased of itself, or has been carried off by any medicine, and these tumors have been left; they are always distressing, and often hurtful to a considerable degree. The patient is uneasy, his appetite is more or less diminished, he feels a sense of weight and indisposition to action, the peristaltic motion of the intestines does not go on regularly, the color of his skin does not recover its clearness, and though not so ill as to be prevented from going through his ordinary business, he is nevertheless languid. —If from any cause the intermittent should recur, and continue for some time ; it is still not uncommon for these tumors to subside again ; and when the disease is carried off by medicine or goes off by its ordinary course, the patient recovers his health perfectly. In many cases, a tumor arising in the liver, from the same or any other cause, produces hardness, like scirrhosity, in various parts of the viscus. — These tumors, by pressing upon the branches of the vena portarum, which passes into the liver and there divides its course in the manner of an artery ; prevent the blood from returning from the abdominal viscera with its usual facility. — The passage of the blood being thus retarded, occasions a greater extravasation of lymph into the cavity of the abdomen ; so that the ordinary exertion of the absorbents is not sufficient to take up all the lymph ; and thus an ascites takes place. — The tumor which arises in consequence of the accumulation of water in the abdomen, pressing upon the liver, increases the scirrhosity there ; and this case generally becomes fatal. — These apparently scirrhous tumors not uncommonly press on the ductus communis coledochus, the duct of the gall bladder, the hepatic duct, or the ducts which have been commonly called pori bilarii, but which the author would rather call hepatic ducts. Such pressure upon any of these ducts may prevent the whole or part of the bile from getting into the duodenum : and by occasioning it to be absorbed, may of itself produce jaundice, without any concomitant dropsical symptom : or along with it ascites. When this happens, the disease is generally fatal. — When ascites is occasioned by such scirrhous like tumors, produced in the liver in intermitting fevers; the skin often assumes a dirty yellowish brown color. This color the author rather attributes to the coloring part of the rete mucosum, or to the sebaceous matter secreted by the glands of the skin ; than to bile absorbed, or to its not flowing into the duodenum. 364 HISTORY OF AND REMEDIES EMPLOYED — There is no appearance which shows that bile does not get into the intestines, such as want of color in the faeces, &c; or that it has got into the blood-vessels, such as the urine becoming of a yellow dye, &c. — The author has already shown, that no bile is ever contained in the blood-vessels, unless it has been previously formed in the liver and absorbed. The same determination of blood from the blood-vessels upon the abdominal viscera, when the patient becomes weak after an intermittent has continued for two or three months or longer; and sometimes occasions an increased secretion from the glands of the intestines. Thus diarrhoea is produced. —This diarrhoea, like that which has already been described, as taking place in the intermittents of hot climates ; is more severe during the remissions and intermissions ; and is less severe, or ceases altogether at the time of the accession, and during the time of the paroxysm.— Such diarrhoea tends to increase the weakness considerably. — Frequently this weakness occasions dropsical appearances. At first oedematous swellings appear in the lower extremities; which increase : rising up to the thighs, and then to the integuments of the abdomen. — Ascites also takes place. This is an accident very dangerous and difficult to get the better of. If astringent remedies be employed, so as to put a stop to the diarrhoea; the dropsical appearances increase ; and the intermittent continues to recur, although often very obscurely, and very irregularly. If the diarrhoea be allowed to go on ; or if it have been stopped, and be allowed to return by leaving off the astringents ; the weakness increases in such a degree as to destroy the patient. — If the bark of the cinchona be exhibited, it often increases the diarrhoea ; without having the effect of preventing the irregular returns of the attacks or exacerbations. It appears therefore to the author to be the best in this case, first to clear the prima? vise, by employing about twenty-five grains of rhubarb ; and after its operation to exhibit cinchona in pretty considerable quantity, such as a drachm every three hours ; and to give at the same time a grain of ipecacuanha with fifteen drops of tincture of opium, equal to half a grain of opium, together wiih a moderate quantity of any of the warmer spices, every four hours. The author however, is very far from saying, that this practice is always efficacious in curing the disease, which when it has been allowed to run on in this state is not uncommonly fatal. Suppose that no tumor has arisen in any of the abdominal viscera, (so as to compress either the lymphatics or the veins,) and that no diarrhoea has taken place ; yet it happens not uncommonly, when an intermittent has run out to a great length, that such weakness arises as to produce a dropsy. — This happens more frequently in quartans, than in tertians; and more frequently in tertians, than in quotidians. — First of all, oedematous swellings begin to take place in the lower extremities. These, as usual, increase while the patient is in an erect, and diminish when he remains for some time in nearly a hori- IN IRREGULAR INTERMITTING FEVERS. 365 zontal posture : and as he is generally in an erect posture during the day time, they are greater in the evening ; but as he is in a horizontal posture during the night, they are less in the morning. Beside this increase and diminution of the tumor, (in consequence of the patient's being in an upright or in a horizontal posture ;) an increase of the tumor takes place during the intermission ; the tumor being, as far as the cause just mentioned allows it, greatest at the end of the intermission. When the paroxysm comes on it diminishes ; and during the time of the paroxysm it totally subsides, (if the weakness have not become very considerable.) — The increased exertion of the lymphatics during the hot fit appears to occasion a total absorption of the lymph ; but the want of this exertion during the day in which no paroxysm takes place, allows the lymph to be accumulated in the cavities. Supposing the disease to be left entirely to itself, and to terminate by a more severe exacerbation's producing a perfect crisis, or by the disease wearing itself out and gradually subsiding; this dropsy is very rarely fatal. After the disease is gone off, if the strength be restored, the lymph is absorbed ; and the patient regains his former health. If the fever should go on, the tumor rises higher; occupies first the integuments of the abdomen, and the cellular membrane among the muscles of the loins; afterward ascites is joined with it ; the functions of the intestines are hurt, and the patient sinks: the external appearance of the dropsy becoming gradually nearer phlegmasia, than anasarca. When the bark of the cinchona, (or other remedies having similar effects,) prevent a return of the exacerbation; then the exertions of the lymphatics during the hot fit, and the absorption of the lymph, do not take place ; the lymph is not absorbed ; and the dropsical symptoms appear to be very much increased. —The dropsical symptoms appearing thus to increase, when the intermittent has been stopped by the cinchona (or other medicines having a similar effect), has occasioned an opinion, that the cinchona gave occasion to the dropsy, and the practice of exhibiting it has hence been reprobated by many practitioners. — It is to be observed however, that such dropsical symptoms have arisen solely from the weakness occasioned by the continuance of the disease. It is farther to be observed, that the increase of the dropsical symptoms, after the paroxysms of the fever have been prevented from returning; is owing to the want of that alleviation of the dropsy which took place during the paroxysm, by the greater exertion of the absorbents during the hot fit. At the same time, this, as well as the other exertions during the paroxysm, tend to weaken the patient; so as to become the very cause of the final increase of the dropsy. — The putting a stop to the paroxysm, therefore, although it prevents the temporary alleviation of the dropsical symptoms; yet at the same time removes their original cause. It would appear therefore from this view, that it is proper if possible, 31* 366 HISTORY OF AND REMEDIES EMPLOYED to put a stop to the farther progress of the disease ; and so prevent the patient from being more and more weakened. — The author, accordingly, for many years has not hesitated, when dropsy has arisen in an intermittent which has continued long, and there has been no cause to suspect induration in any of the viscera occasioning pressure on the lymphatics or veins ; to exhibit the bark of the cinchona, and to endeavor by this means to prevent the return of the paroxysm. He has found in such cases, that the dropsical appearances, although they at first increased ; yet as the strength returned, generally began by degrees to diminish ; and at last disappearing entirely, the patient recovered his health. It happens not uncommonly, if intermittent fevers haVe been entirely neglected in the beginning, or when the bark of the cinchona has been employed improperly ; (that is, not according to the mode prescribed in the Dissertation on regular tertians ;) that the disease runs out to a great length, whatever its type may be. It also becomes irregular; varies its type, and is often only a remittent. — In these cases the patient is weakened ; and is apt to sink under such weakness, without any dropsical symptom or affection of the thorax. — When this happens the pulse always keeps up a degree of frequency. The paroxysms and remissions are sometimes sufficiently distinguishable ; but at other times they are hardly to be discovered. The tongue is sometimes constantly covered with a mucus (which is of a whitish or brown color); the appetite is lost; and the patient gradually sinks. — He may however remain in a doubtful situation for many weeks ; and at length recover. — In such cases (and more particularly in those in which cinchona has been employed improperly, or so as not to cure the disease) ; preparations of the Metals (such as have been enumerated in the Dissertation on regular tertians) have been employed, and sometimes with good effect. Of these, the preparations of arsenic seem to have been most frequently efficacious. If it be ever proper to employ any preparation of arsenic internally, the best seems to be the compound of kali with calx of arsenic ; (which many modern chemists called acid of arsenic ; and which has been knowm by the name of white arsenic). The author has often attempted to give arsenic under various forms, in cancerous cases ; but although he has taken care to exhibit it in such small quantities, as not to affect the stomach and intestines; yet upon continuing it, such excruciating pain has taken place in the extremities, and such a degree of stupor ; as always to force him to desist from it. — Add to this, that it is a medicine so dangerous, that if it happen to be given in too large a dose, it is offen fatal. — It is not to be intrusted therefore in the hands of such young men, as are too frequently employed to compound medicines in the shops of the apothecaries of this country. Since an error of half a grain in a dose may be fatal; it is not to be trusted to the scales commonly employed in apothecaries' shops, which are often not sensible to half a grain. IN IRREGULAR INTERMITTING FEVERS. 367 Next to arsenic, preparations of ;mc seem the most powerful.— The calx which is found in the chimneys of furnaces, in which brass is produced by combining copper with zinc ; (and which, when it is of a light grey color, has been called cadmia ; and if of a dark dirty blue color, tutty;) was formerly, very much in use in complaints which return by paroxysms ; and among others in intermitting fevers.—Lately the calx called flowers of zinc (formed by exposing to the air of the atmosphere the surface of zinc melted and heated to a white heat,) has been more in use : I3ut the author does not know of any comparative experiment on which this has been grounded. — Sometimes likewise zincum vitriolatum has been exhibited for the same purposes. Preparations of copper have been used more seldom ; though perhaps, they are as efficacious.—Formerly cuprum acetatum was much employed, both externally and internally ; though it has now fallen very much into disuse.—It has been conceived, that copper combined with ammonia muriata, (in consequence of moistening sheets of copper with a solution of ammonia muriata in water, and exposing them to the air;) is less stimulant in proportion to its other powers ; and consequently is less apt to affect the stomach and intestines; and therefore more proper to be employed. The tendency of preparations of copper to affect the stomach and intestines, has made them in general to be considered as a very active poison ; which however, independent of this effect, is not true. If cuprum ammoniacale however, actually did produce less effect on the stomach and intestines in proportion to its other powers, it would be undoubtedly a more useful medicine ;—but the author has not found upon trial that this is the case ; he conceives, that cuprum vitriolatum is the most certain of the preparations of this metal. The preparations of iron, which have been employed in medicine, have been very various ; but whether it be exhibited in its metallic form, or calcined, or combined with acids or w T ith alkalis or with neutral salts; its virtues do not seem to be very different. — Its powers of preventing the returns of the paroxysms of an intermittent seem to be less than those of the others of these four metals: — At the same time it has no noxious or deleterious effect. — As a strengthening medicine to keep up the force of the system, during the progress of an intermittent; its powers are very considerable ; and it has often been used. But whichever of these metals, or whatsoever of their preparations, are employed with a view to prevent the return of the paroxysms of an intermittent; they should be exhibited in as large doses as the stomach will bear. — They ought also only to be exhibited in the times of the intermissions. — This rule however is not to be so strictly adhered to, as in the exhibition of the bark of the cinchona; (especially if the intermissions h ive become imperfect, or been converted into remissions.) — In other respects the same rules are to be followed, as have been before laid down in regard to the exhibition of the cinchona. A FIFTH DISSERTATION ox FEVER; COXTAIXIXG THE HISTORY OF AND REMEDIES TO BE EMPLOYED IN IRREGULAR CONTINUED FEVERS. TOGETHER WITH A GENERAL CONCLUSION TO THE FIVE DISSERTATIONS. ADVERTISEMENT, BY THE EDITOR IN ENGLAND. The original of Dr. George Fordyce's Fifth Dissertation on Fever, was delivered to me, several months ago, by Miss Fordyce; with a request, which her father (shortly before his death) had desired her to make, that I would superintend its publication. It is in the hand writing of Miss Fordyce ; to whom it was the custom of her father to dictate what he meant to publish ; and in almost every page there are alterations in his own writings ; so that no doubt can be entertained of its authenticity. — The author, how T ever, was accustomed to reserve the principal corrections of any work he was about to publish, till what are called the proof sheets were sent him by the printer. The present work, therefore, must be considered as in some degree imperfect. — The alterations, which it seemed very obviously to require in point of language, I have ventured to make ; and in doing this I have not taken a greater liberty than what he permitted me to use with respect to three of his preceding publications on fever. WILLIAM CHARLES WELLS. London, Dec. 12, 1802. [N.B. The author of the above advertisement'was at this time one of the Physicians of St. Thomas's Hospital in London, and one of the Fellows of the Royal Society in that city ; and has been known to the literary world by various publications.] Dr. Well's " Essay on Dew," — republished in one of the earlier volumes of the " Select Medical Library," — is a work of deserved celebrity. HISTORY AND TREATMENT OF IRREGULAR CONTINUED FEVERS. General Inflammation Intermixed with Continued Fever —la apt to take place at the beginning of the fever in persona of strong habits —Rarely in those who live in crowded cities and who are exposed to vapours of putrefying and other substance —Men formed to live in warm climates—Driven by necessity to colder climates —Their mind strengthened by exertions to guard against the inclemencies of cold — Living in a colder atmosphere increases the powers of their bodies—Blood-vessels adapt themselves to the quantity of blood contained in them—This adaptation depends on a vital contraction—A smaller quantity than common in the blood-vessels gives rise to greater exertion in these, —like labour, causing muscular contraction—Exhaustion follows the long continued contraction in both cases—Muscular action may and must cease—The contraction of the blood-vessels must be. continued, and to sustain it, —if their quantity of blood should be constantly diminished, the living power will be withdrawn from every other function—Arrangement of the blood-vessels— Anastomosing arteries and veins— Capillary vessels the intermediate ones—Exertion to contract the larger arteries anil veins greater than that of the capillaries—Less blood required to kill an animal taken from a large artery or vein than from smaller and capillary ones—Rationale of the effect of living in warm air to cause weakness —Of that of cold to give strength—General inflammation most common in countries in high latitudes, and in elevated situations, and in the winter and spring seasons—No difficulty in having recourse to blood-letting, when general inflammation occurs at the beginning of intermitting fever—The intermissions, made more perfect thereby—In continued fevers, the question is one of more difficulty—Three dangers, —Fatal delirium from the quantity of blood thrown in the brain by increased action of the heart and arteries—Injury to the brain by this action—A sudden removal of the tension produced by the blood being thrown into the small vessels and the patient sinking—Dangerof weakness from ill-timed blood-letting—Also, of putrefaction in the second week—Mischievous effect of Boerhaave's aphorism—Rules for blood-letting, when it is proper—Small and repeated bleedings recommended, but not on sufficient grounds—General inflammation is to be checked by the decided impression from a full bleeding—If the inflammation be slight, the loss of blood is unnecessary—A state of plethora in the young and robust, indicated by a full and resisting, or an oppressed pulse, will justify blood-letting in the beginning of fever—Other Irregularities in Continued Fevers — Unequal affections of different parts of the body —Absence of headache —Misleading prognosis from absence of certain symptoms —The danger is really greater, when there is mildness in one region, and severity of symptoms in another—Examples—The fever is more tedious and less controllable by remedies— Irregularity in the progress of the fever, as where there are fluctuations in the increment and decline of the disease—The usual remedies failing to produce a crisis at the tenth day, these are to be desisted from—The physician to watch the farther progress of the disease, and to give light nourishment and a little wine—Powerful remedies to be avoided—Alteration of exacerbation and crisis with relaxation, until the former increases and the latter is less, and the patient dies in a paroxysm, or his strength is gradually worn out —Large doses of bark to be given on the coming on of each relaxation or remission—The practice frequently succeeds ; but it sometimes fails entirely —Still it is worth a trial—This fluctuating kind of fever sometimes epidemic—Instance in London—Advantages of the bark practice on this occasion— Hysteric symptom —Pulse very frequent, without much oppression in breathing or foulness of the tongue—The skin is moist and the other functions not much affected —There is great depression of spirits, and great anxiety of mind, without apparent cause—Sometimes there is subsultus tendinum —These cases to be treated by the administration of animal broths without fat and by farinaceous substances in a fluid state, mixed with some, but not much wine—Opium is, also, to be given in small quantities,—with some antispasmodic—Blisters to be avoided—The patient's mind to be kept tranquil— Many 372 HISTORY OF AND REMEDIES EMPLOYED Critical Symptoms taking place at once —These come on early in the morning—Still there is great danger if there be delirium and a frequent pulse,—with restlessness and precordial oppression and unquiet sleep—After death under these circumstances, dissection did not show any apparent injury of the or ians—The delirium may suddenly subside, leaving the pulse very frequent and great depression of strength with much functional derangement. Death generally closes the scene in such a case. In the fourth Dissertation on fever, the author has endeavored to point out the irregularities and accidents, which are apt to take place in Intermitting Fevers. — He comes now, in the last place, to point out the diseases which may be complicated with, and the irregularities and accidents which may occur in, " Continued Fevers." General Inflammation Intermixed with Continued Fevers. — The disease first to be noticed, (as being likewise intermixed with continued fever) is General Inflammation. — This has been described in the fourth Dissertation, as it arises sometimes in intermitting and remitting fevers ; (prolonging often their paroxysms so that they run into each other; and making them appear, especially at the beginning, to be continued fevers ; — the only difference being, that the exacerbations take place in the day time, instead of the evening.) — General inflammation is apt to take place also at the beginning of continued fevers : and when it does, it alters very much their progress ; and occasions a difference, not only in the appearances, but likewise in the Treatment of the disease. General inflammation is apt to take place in continued fevers, at the beginning of the disease, in men of strong habits. — Therefore, it seldom occurs in those who live in parts where the atmosphere is contaminated, by being mixed with noxious vapors, or by noxious powders or particles of noxious fluids suspended in it; since all of these generally prevent men from acquiring great strength. — These noxious substances, diffused through, or suspended in the air, are found more particularly in great towns, or where there is a great concourse of mankind. The vapors exhaled from putrefying substances which are found in such circumstances; together with powders ground down by the treading of animals and the rubbing of carriages ; the vapors arising from the burning of fuel; and the soil and ashes which are carried into the atmosphere : all tend to diminish the powers of the body. It is but very rarely that general inflammation arises at the beginning of continued. fevers under these circumstances.— When men live in the country, (where the air is not contaminated by such mixture,) general inflammation in many instances takes place in a very great degree. Men are undoubtedly formed to live in warm climates : since they have no natural defence, such as hair (or that species of it we call wool) or feathers, to protect them from the cold even of temperatures which fall but little below sixty degrees of Fahrenheit's thermometer. When men live in a climate where the heat of the atmosphere rarely falls below seventy-five degrees, (provided the situations which they inhabit are not moist from stagnating waters or violent rains;) they IN IRREGULAR CONTINUED FEVER. 373 commonly enjoy perfect health: at least they are not particularly subject to fevers. — Men are driven from such situations principally by war. An instinct (perhaps the strongest in the human mind) leads them into quarrels between families, tribes, or nations. In such wars, the powerful oblige the weak to quit the most fruitful countries and those most congenial to mankind ; and to take up their abode in others less fruitful, and of a temperature which makes it necessary for them to exert their faculties in contriving, in the first place, some means of defence against the coldness and inclemency of the atmosphere. — The exertions necessary for procuring such defence, strengthen the powers of their minds. There results at the same time, from living in a colder atmosphere, an increase of the powers of their bodies. — It might be thought sufficient to have taken notice of this fact simply : but the author means to try to explain on what it depends. — It is necessary that the bloodvessels should always adapt themselves to the quantity of blood, which is contained in them : ( That is, they must always be full of blood-, and always cylindrical, if they are not rendered of some other shape by external pressure : at least they are always so contracted, when alive.) This property cannot depend upon the elasticity of [he blood-vessels ; but on a contraction ; similar to that which is exerted by the muscles. If there should be a smaller quantity of blood in the blood-vessels than that, to which they are at the time disposed to contract, there must be a greater exertion of the blood-vessels to suit the quantity of blood which they contain. In consequence, the living power must be drawn from some other part, and be exhausted ; as it is by the contraction of the muscles in exercise or labor. It is not necessary that a greater exertion of common muscular power, such as takes place in exercise or labor, should be continued always ; indeed this is impossible. A man exerting common muscular power must necessarily come to rest ; until the powers of his body are recruited by that perfect rest which takes place in sleep ; for if such rest, is not allowed, the powers of the system will be expended ; and it will be impossible for him to continue the same exertions. When there is a smaller quantity of blood in the bloodvessels than that which they are disposed to contain ; these vessels are obliged nevertheless to contract, and to adapt themselves to this smaller quantity. This has a similar effect in weakening the system with muscular motion too long continued. There is this difference, however: That muscular motion may and must cease ; whereas, since blood cannot instantly be formed, the contraction of the bloodvessels, in order to correspond to the blood which is in them, must constantly exist. Rest cannot take place in this exertion, nor can sleep relieve it. This exertion is the most material of any in the system ; for if the blood-vessels have not a sufficient quantity of blood to fill them according to their disposition to contract at the moment; a quantity of power muse be drawn from the other parts of the body, to contract theln to the quantity of blood which they contain ; so 32 374 HISTORY OF AND REMEDIES EMPLOYED that, if the quantity continues constantly to diminish the living power will be drawn from every other function, until the animal dies. The blood-vessels consist of large arteries gradually branching off into smaller ones ; which terminate in vessels opening into each other, called anastomosing arteries and veins. These anastomosing arteries and veins, have blood flowing through them in every direction ; (that is to say, blood enters sometimes into either end of them, and flows out with rapidity at the other end ; sometimes entering at the end at which it formerly llowed out, and with the same rapidity flowing out at the end into which it formerly entered.) Those small vessels which are continuations of arteries through the blood into a set of smaller vessels of the same description : and these, again into a set of still smaller vessels likewise of the same kind ; until at last the blood is thrown into a set of vessels which no longer diminish. These throw the blood into another set of similar vessels which are larger, these again into a set of vessels which are still larger, and these terminate in vessels called veins; which carry the blood towards the heart. It has been common to call the anastomosing vessels, while they are diminishing, anastomosing arteries ; and when they begin to increase again, anastomosing veins : but as the smallest set of these vessels neither increase nor diminish, it is impossible to call these either arteries or veins. The author would therefore give them some other name ; and from their extreme minuteness, he joins with those who have called them capillary vessels. —All these vessels, the large arteries and veins, and the anastomosing and capillary vessels must contract, so as to be always cylindrical, and always full of blood. It may easily be conceived that the exertion used in contracting one set of blood-vessels, may exhaust the living power more than the exertion used in contracting another set of them. That is, the exertion of the arteries before they begin to anastomose, and of the veins, after they have received the blood from the capillary vessels, when contracting so as to adapt themselves to a less quantity of blood ; may exhaust the living power, more than the contraction of the capillary vessels themselves. That this is really the case', appears from the following observation; namely, that to kill an animal, it requires a much less quantity of blood to be taken from a large artery or a large vein, than from a small artery or a small vein; (sometimes not half the quantity.) When a large blood-vessel is opened, and the blood Hows very fast from it, the large vessels are more evacuated ; and the animal is destroyed ; the small vessels not having time to contract and replenish the large vessels with blood.—Consequently, the contraction of the large vessels exhausts the power of the body more than the contraction of the small vessels. The large vessels (both arteries and veins) lie principally in the interior parts of the body; while a greater number of small vessels are found in the external parts, than in the interior. — When a man is in a warm atmosphere (or surrounded by any other "warm medium) IN IRREGULAR CONTINUED FEVERS. 375 the heat occasions a much larger quantity of blood to circulate in the exterior parts, where the small vessels abound ; in consequence of which the large vessels are emptied of blood, and, obliged to contract to a greater degree. — Hence, those living in warm climates, have their strength thus exhausted :—But in cold climates, the cold contracts the vessels in the interior ; and the powers of the body not being exhausted by their contraction, the vigor of the whole system is suffered to increase. Countries are cold, in the first place, as they are more distant from the equator (especially in winter) ; general inflammation may be expected, therefore, in continued fevers, most frequently in countries in high latitudes. — In the second place, coldness is found in countries in proportion as they are elevated above the level of the sea ; and hence general inflammation is often found in such fevers in mountainous countries and in the middle of continents. — Again, since in the winter the atmosphere is cold, while in the summer it is warm ; general inflammation is to be expected more frequently in the spring than in the autumn. When general inflammation happens at the beginning of an intermitting fevent, and prevents perfect intermissions from taking place ; there is no difficulty in the question whether it should be taken off by large evacuation by bleeding ; because, when the intermissions become more perfect, there is time for sufficient food to be digested so as to replenish the blood-vessels : — But in continued fevers this question meets with greater difficulty. In continued fevers, where we are not to expect any such remission as will allow food of great nourishment to be digested, so as to replenish the blood-vessels, and to take off the exhaustion of the living power (occasioned by the necessary contraction of the vessels, in order to adapt themselves to a smaller quantity of blood) ; it becomes absolutely necessary that the practitioner should strictly weigh the following argument. — There are three dangers : one, lest an increased action of the heart and arteries should throw forward such a quantity of blood upon the brain, as to induce a fatal delirium : a second, lest the same action should so hurt the brain as to make it unable to bear that mischief which induces such delirium, as has been already described in the Treatise on Regular Continued Fever ; and lastly, lest the tension produced by the blood being thrown (by the strong action of the heart and arteries) into the small vessels throughout the system, should be suddenly taken off: and the patient should sink. These reasons, on the one hand, induce a necessity of removing the general inflammation as quickly as possible ; by making a large evacuation by opening a blood-vessel. — On the other hand, supposing that, after having made such evacuations, the practitioner should not be able to carry off the disease by the means laid down in the Treatise on Regular Fever ; it would then of necessity go through its course: and the following difficulties would occur. In the first place, a degree of weakness is then induced, which (added to the depression of 376 HISTORY OF AND REMEDIES EMPLOYED strength arising from fever) often produces symptoms of putrefaction in the second week of the disease, so as to prove fatal ; (of which many instances have come under the author's observation). In the next place, supposing such symptoms of putrefaction not to have made their appearance, yet a fatal degree of weakness has arisen towards the end of the fever ; (from the living power being obliged to exert itself in contracting the vessels to the smaller and smaller quantity of blood that is left in them). This happens, first from the evacuation made by bleeding ; and secondly, from the want of the powers of digestion to form a sufficient quantity of blood, if even food could be exhibited : whence the patient has sunk and been destroyed. — The author cannot help lamenting, on this occasion, the terrible proposition laid down in one of the aphorisms of Dr. Boprhaave, namely, that it is difficult to diminish the strength at the beginning of fevers ; but easy to support it towards the end : the contrary of which the author has found by long experience to be true. This proposition of Boerhaave, from the year 1730 to 1760, destroyed more men than fell in battle in the whole of that period, during two dreadful wars in Europe. It will well behove therefore a practitioner to weigh both sides of the argument, before he proceeds to employ the lancet at the beginning of continued fevers. If the danger from the general inflammation is great and if it very much overbalances the mischief that would arise afterwards: he will then undoubtedly take away a quantity of blood by opening a bloodvessel. — If this should be the case, the following rules are to be observed— In the first place, the practitioner should weigh well in his mind the danger arising from the general intlammation, with the general strength of the patient ; and from thence determine what quantity of blood it is necessary to take away at once, to remove the danger from the general inflammation ; without so weakening the system, as that the patient shall sink towards the end of the fever. That is to say, if the general intlammation is great, and the symptoms from it very dangerous ; and if at the "same time the strength of the patient when he was attacked by the fever was also great; it will be necessary to take away as large a quantity of blood at once, as sixteen or twenty ounces ; which may be done with safety and advantage. On the other hand, if the danger from the general inflammation be but trifling, and the patient was weak when attacked with the fever ; it will be better not to take away any blood at all: but rather to run the risk of the mischief which may arise from the general inflammation ; than of that which may take place from putrefaction if the fever be very violent, or of the weakness which may occur towards the end of the disease. — If there should be a less considerable degree of general intlammation, but still danger from it, even though the fever should not be very violent; and if the patient was not very weak when he was attacked by the fever : it may be necessary in this case also, to take away a quantity of blood,: but the quantity should be less. However, it rarely happens that there is danger from any 377 IN IRREGULAR CONTINUED FEVERS. degree of general inflammation, if it can be obviated by taking away less than ten ounces of blood. Tt has been the practice in many nations and among many practitioners, to take away a small quantity of blood at once, such as perhaps four ounces ; and if this does not succeed in removing the danger from general inflammation, to take away four ounces more in a few hours; and so to proceed until the danger from the general inflammation is removed : And this practice at first sight seems very rational. —The reasoning however which we have before laid down must be applied to this point. It has been said that emptying the large vessels produces a greater temporary weakness, than emptying the small vessels ; and that if a large quantity of blood is taken away at once, the large vessels will be more emptied, (as the small vessels have not time to contract so as to replenish the large vessels with blood ; and therefore that an animal will die sooner if a large quantity of blood be taken away at once, than if the same quantity be taken away at intervals;) and that, of consequence, a greater degree of temporary weakness will be produced by taking away a large quantity at once ; and a less degree of permanent weakness.— Now we wish in fever to produce a great degree of temporary weakness, so as to get rid of the danger arising from the general inflammation ; and at the same time to leave as little permanent weakness as possible ; (so that there shall be strength enough left in the system to support the patient during the remaining part of the disease). It is certain, therefore, from all these circumstances, that a practitioner should weigh well the danger from the general inflammation, and the danger from the weakness ; and if necessary, take at once boldly the quantity of blood necessary to remove the danger from the general inflammation, (if it be ten, twelve, fifteen, twenty, or even four-and-twenty ounces). — On the other hand, if there should be general inflammation, and yet not in so great a degree as to threaten any material mischief; he must be as obstinately resolved not to take away any blood at all. There is still one more situation in which it may be necessary to take away blood at the beginning of fever. It has been observed in a former treatise, that there is a general contraction of the vessels, especially of the small vessels in fever, [f the blood-vessels should be very full of blood, (which sometimes happens to persons between the age of fifteen or sixteen, and thirty or five-and-thirty); and if such persons should be attacked with fever, the quantity of blood is so great in proportion to the tone of the vessels, as to fill the heart and arteries to such a degree, that they have no longer (if the author may use a vulgar expression) room to play : (That is to say, there is such an influx of blood into the ventricles of the heart, as not to suffer them to contract, so as to empty themselves entirely, before a fresh quantity of blood is thrown in from the auricles ; and in like manner blood is so quickly thrown from the heart into the arteries, that they also have not time to con-32* 378 HISTORY OF AND REMEDIES EMPLOYED tract themselves completely, so as to empty themselves of blood into the capillary vessels, before a fresh quantity is thrown into them by the heart.) This state of the vessels is called plethora.— It is pointed out by a particular feel of the pulsations of the arteries ; they feeling always full, and hardly receding from the finger. When this happens, the hngcr discovers a very small difference between the contraction and relaxation of the artery ; the artery appearing always of considerable size ; with a kind of feel of softness. — This feel in the pulsation of the arteries has been called oppression of the pulse. — If the pulse should be very,much oppressed, (which it hardly ever is in persons of a different age from what has already been mentioned ;) it will be necessary, in order that the hot fit of the fever may operate so as to produce relaxation or crisis ; that some blood should be taken away. Taking away eight or ten ounces is always sufficient for this purpose. The author wishes it to be understood, that these reasons for taking away blood at the beginning of fever must be clear to a practitioner, before he ventures to open a blood-vessel with a lancet. (There have been more patients destroyed by a contrary practice in fevers, such as he has defined them, than by any other whatever.) Other Irhegulaiutif.s in Continued Fever.—The author having shown, in the Third Dissertation, the circumstances in which taking away blood from particular parts of the body is of use in fevers; and likewise the accidents which arise from disposition to putrefaction, and the means of obviating them : comes now to treat of the other irregularities which take place in continued fevers. The first irregularity which is to be taken notice of is the fever not affecting every part of the system equally ; the symptoms being less severe in one part than in another ; (as for instance, there being little or no pain in the forehead). The young and inexperienced practitioner thinks, (and the by-stander in a much greater degree,) that the mildness, or total want of some symptom of the fever; is very fortunate for the patient. In fact it is the very reverse, there being nothing more dangerous in fever than its not affecting every part of the system in an equal degree. — It is true indeed, when all the symptoms are equally mild, and every part of the body equally little affected ; that the fever, if left to itself, (although there be a less chance of a crisis,) will go through its course with less danger to the patient. It will, also, more readii)* yield to the application of medicines which produce appearances similar to those which take place in a crisis ; and the disease will be more readily carried off by. them. — But this is far from being the case, when the symptoms are mild in one part of the body, and severe in another.— It will therefore be necessary to enumerate the cases, in which the symptoms are mild in one part of the body, while they are severe in other parts. Sometimes a fever does not attack the patient all at once ; and he cannot exactly ascertain the time at which the first attack took place. IN IRREGULAR CONTINUED FEVERS. 379 In this case most commonly the system is not equally affected. — In the next place, it sometimes happens,that although the fever came on in such a manner, that the patient can perfectly ascertain the time of the attack ; yet at the moment he felt no sense of coldness, (or, as he generally expresses himself, of chilliness). If this should happen, the fever is often irregular; but not so frequently as in the former case.—In the third place, when the attack comes on, the depression of strength sometimes appear much greater than corresponds with the contraction of the small vessels; and sometimes the reverse. If the depression of strength be more than in proportion to the contraction of the small vessels ; there is a greater danger of delirium (such as has already been described) at the beginning of the second week of fever. If the contraction of the small vessels be greater in proportion than the depression of strength, there is less chance of a crisis ; and a greater probability of the disease running out to a great length. —In the fourth place, the absent symptoms are the patient's being either totally free from headache, or very slightly affected with it; the tongue's not being covered with a crust, not only at the beginning, but likewise through the first week of the disease ; and there being no costiveness, but rather too great evacuations from the intestines. This last symptom sometimes increases to a diarrhoea ; which (besides the irregularity it shows, as not corresponding with the rest of the disease) tends also very much to weaken the patient. — The appetite not being totally lost is a very deceitful symptom ; because it would give an inexperienced practitioner the idea, that food might be easily digested ; and so the strength be preserved during the progress of the disease. — The skin's being soft and moist, and the sleep not being at the beginning of the fever very much disturbed ; are also to be regarded as irregularities. If one, or two, or three of these mild appearances should take place, and all the other symptoms should not be equally mild ; the fever is likely to run out for a great length of time ; and has a much less chance of being terminated by a crisis. — This is not only the case ; but every attempt to carry off the fever by any remedy is frustrated. Every medicine, (such as preparations of antimony, ipecacuanha, &c.) tending to produce symptoms similar to those which take place in the crisis of fever ; has its whole force exhausted upon those parts, in which the appearances of fever are slight; without at all affecting those parts which are most afflicted by the disease. (For example ; if there should be considerable pain in the forehead, and the skin should be soft and moist; then upon preparations of antimony being exhibited, the patient will fall into a profuse sweat, without the least relief of the pain of the forehead.) —It is farther to be observed, that not only if there should be a want of febrile symptoms in any one particular part of the body; but if even those appearances should arise, which takes place in a crisis, in some particular part of the body, and not in the whole at the same time ; 380 HISTORY OF AND REMEDIES EMPLOYED the mischief is much greater, and the patient in such case rarely recovers. (If, for example, there be a lateritious sediment in the urine from the beginning of the disease ; or if it take place before the middle of the second week, and neither the headache nor delirium be in any way diminished; if the skin should remain hot, contracted and dry, the tongue covered with a mucous crust, and the pulse continue of equal frequency : it hardly ever happens that the patient recovers from the disease. In like manner, the skin having been dry and contracted at the beginning, if a profuse sweat afterwards take place, and continue for some time without any diminution of the other symptoms of the disease ; that is, if there should be no lateritious sediment in the urine ; if the costiveness and the headache should continue ; instead of these being favorable appearances, we are to expect that the disease will prove fatal.) — Indepently of the mischief arising from inequality in the disease, any evacuation will weaken the patient, and render him incapable of supporting the further progress of it; (when there is not at the same time an alleviation of the other appearances of the disease). If any symptom of the disease should be wanting, and the others be present in as great a degree as when the body is equally affected; there is no remedy at present known, which will increase the particular appearances of fever in those parts in which they are wanting: nor (as far as the author knows) has it ever been attempted to increase the appearances of fever in those parts where they have been wanting; so as to give success to the efforts towards a crisis arising in the ordinary course of the disease, or after the application of such medicines as tend to produce appearances similar to those which take place in the crisis of fever. — For example : when there is no pain in the forehead, (while all the other symptoms of the disease are very violent,) no attempt has been made to produce pain in the forehead; in order to render the efforts similar to those made in the ordinary progress of the disease, (where medicines act equally upon the whole system, so as to carry off the disease.) When the want of a sufficient degree of fever in any part of the body has been attended with considerable evacuation from that part; then indeed means have been employed to put a stop to such evacuation ; and so to prevent the mischief arising from the weakness it would produce.—If profuse sweating should arise without any relief of the fever, astringents have been employed to contract the vessels of the skin; (such as the mild vegetable astringents, as infusion of red roses, agrimony, hypericum, and others of the same kind ; along with the vitriolic and muriatic acids :) and these are frequently efficacious. The patient at the same time should not be covered with too great a quantity of bed-clothes : though this is to be regulated by the heat of the atmosphere. If there should be purging without any relief of the disease; after exhibiting a moderate quantity of rhubarb (from twenty to thirty grains for example) to clear the prima? vise of their contents ; it is proper to give small doses of opium, such as from ten to fifteen drops of the IN IRREGULAR CONTINUED FEVERS. 381 tinctura opii every six hours, and along with it some moderate astringent ; (for example, about ten grains of tormentil root every six hours.) — If the patient should have very considerable strength, as is often the case in the first week of the disease, and purging should arise; it is not proper that any astringent should be employed so powerful as those just mentioned. The practitioner must trust to clearing the primse vise with a small quantity of rhubarb ; and exhibiting a grain of ipecacuanha every six hours; or any other medicine which will determine the circulation to the exterior parts of the body. Chalk or bone ashes are the most powerful astringents which ought to be employed in this case. If, notwithstanding the use of these milder astringents, the evacuation should still continue, and the patient's strength be considerably diminished ; recourse must be had to more powerful astringents, (such ashave already been proposed.) The next irregularity which happens in continued fever is in the progress of the disease. If a fever should begin either with mild or violent symptoms, but which, as has been before observed, are equal throughout the system ; if it should then gradually increase during the first week, or perhaps to the eight or ninth day; if the symptoms should afterwards continue nearly with the same violence at the end of the fourteenth or fifteenth day ; and if it should then begin to diminish gradually and wear itself out, so as to leave the patient on or before the twenty-first or twenty-second day of the disease ; — and if in proceeding thus, it should not observe any critical days ; the treatment has already been pointed out in the Dissertation on Regular Fever. If on the other hand, a fever in temperate and cold climates should observe critical days, and be entirely left to itself; these critical days ought to become apparent in the first week of the disease : (that is, the aggravations of the fever ought to be very apparent on the evening of each day ; and the relaxation in the morning ought likewise to be very considerable ; only that the aggravation of every subsequent day should be more severe than that of the preceding day, and the relaxation in the morning 1 proportionably less.) — If the fever should then change its type on the sixth or seventh day, and the exacerbation on either of those days be more severe ; and if there should be some appearance of critical symptoms in the morning after such severe exacerbation, but on the seventh or eighth evening the symptoms of exacerbation should not be so considerable, and the symptoms of relaxation or crisis on the following morning should not be so great: and again, if the symptoms of aggravation should be more violent on the eighth or ninth day than they were on the seventh or eighth, and so on during the farther progress of the disease, until it changes its type from the tertian to the quartan, (which commonly happens on the fourteenth day;) then, if critical appearances do not arise on the fourteenth day, so as to carry off the disease ; the disease ought at least to have less aggravations at the beginning of the 382 HISTORY OF AND REMEDIES EMPLOYED fifteenth and sixteenth days, and the relaxations in the morning should be more considerable on the sixteenth day ; a somewhat stronger exacerbation also should take place on the following evening than did on the beginning of the fiftenth or sixteenth day ; and during the night more perfect critical symptoms should take place, and the patient be much relieved in the morning. — There should be still slighter exacerbations on the eighteenth and nineteenth, and there should be a stronger exacerbation and a perfect crisis on the twentieth day ; or the few remaining symptoms of the disease should gradually w r ear off. — The treatment under these appearances has been pointed out in the Third Dissertation. If in the first case which we have put, (that is, where the disease observes no critical days ;) the disease instead of gradually increasing to a certain height, then remaining at that height for the time that has been stated, and afterwards gradually diminishing and going off: the patient should sometimes be better for two or three days, and then grow worse, and the symptoms should again abate for a day or two and then return with greater force ; and so continue for the first three weeks of the disease ; the fever (instead of gradually leaving the patient) will now often continue and fluctuate for four, five, or six w T eeks, or longer : and the patient will be cut off at last, in many cases by weakness.—When a practitioner therefore, finds a fever thus to deviate from the ordinary course, in the first fortnight; he ought to be very anxious (where the symptoms of weakness have not already come on) to endeavor to take off the disease by medicines producing symptoms similar to those which take place in the crisis of fever, (such as preparations of antimony, ipecacuanha, &c.) If these do not succeed and no crisis is produced, he must in this case desist from them about the tenth day of the disease ; otherwise they will run a risk of occasioning partial evacuations : (which weaken the patient unnecessarily, and add considerably to his danger.) The author does not know a more unpleasant situation than that of the practitioner in this case ; since all that he can do is to endeavor to keep up the strength of the patient, by such food as his stomach can digest, and by a very moderate quantity of wine. The patient, his relations, and the by-standers, in the mean time, are constantly urging him to use some powerful remedy; while he knows that if he complies with their importunity, it will only add to the danger, without affording the least chance of shortening the disease, (excepting by the destruction of the patient.) It is his duty, therefore, to resist every consideration of this kind ; and wait patiently until the disease is worn out. In the second case which has been pointed out, that is, where the fever actually observes critical days : —if there should be considerable appearance of crisis on one of these critical days, and the patient be much relieved, and continue better for two or three days, but afterwards grow gradually worse again for two or three days longer; or 383 IN IRREGULAR CONTINUED FEVERS if there be a strong exacerbation followed by few or no critical symptoms, and the patient be left during the next relaxation with much severer symptoms of the disease ; and if afterwards for a day or two the patient continue extremely ill, and then on a subsequent critical day there be strong appearance of a crisis, and the patient be relieved again for a day or two, and then gradually get worse ; or if a much stronger exacerbation follow again, with hardly any symptoms of crisis, and the disease go on ; then either the recurrence of one such strong exacerbation destroys the patient; or the disease runs on until the patient is so much exhausted, that he sinks. — This mischief is increased considerably, if the appearance of critical symptoms should take place on a day that is not critical in the disease; (that is to say if the fever assume the tertian type on the fifth day of the disease, and consequently the seventh, ninth, and eleventh be the critical days.) In a case of this description, if a great relaxation after a strong exacerbation should take place on the sixth, eighth, or tenth, &c, day of the disease : and the disease should then gradually get worse again, as has just been pointed out; or if the tertian type should begin on the sixth day of the disease, so that the critical days, which Hippocrates calls bastard critical days, should be on the eighth, tenth, &c; and if after a severe exacerbation a greater relaxation should take place, on the seventh, ninth, &c. days: the danger increases both of the patient's being carried off by a severe exacerbation ; and also of the disease running to a very great length, (so that the patient shall sink under the weakness.) —Where great relaxation takes place in any of these fluctuating cases, the appearances are a great degree of cleanness of the tongue, (especially about the edges ;) the costiveness going off; the skin becoming moist; and a mucous cloud appearing in the urine, interspersed with various particles of flaky t whitish, or lateritious matter ; and the patient's sleeping better. — These, and other critical symptoms, continue for a day or two ; and then again the tongue becomes foul, the skin dry, the sleep ceases, the delirium is increased (either gradually, or all at once ;) and with these, the other symptoms are also augmented to such a degree, that death is often the consequence. In such cases, it is worth while immediately after such considerable relaxation of the disease, to employ large quantities of the bark of the cinchona in substance ; that is, to the quantity of a drachm every two or four hours, to prevent the return of the disease. This practice frequently succeeds. But when it does not, it often increases the difficuly of respiration, or the affection of the head; so that the patient dies. It is nevertheless worth running the risk; since disease, if left to itself, is much more frequently fatal. — This kind of irregularity in continued fever is fortunately not very frequent; and many practitioners may not have noticed it. Sometimes, however, fevers of this fluctuating kind are epidemic in a very high degree. In the course of two or three months, (about sixteen or twenty years ago) the author saw at least forty such cases 384 HISTORY OF AND REMEDIES EMPLOYED in St.JThomas's Hospital. He had remarked this irregularity before that time ; and had seen it in most cases fatal, by wearing out the patient. No perfect crisis took place ; nor did the disease spontaneously cease in about three weeks, as continued fevers generally do. In this epidemic, the irregularity was such as to weaken and carry off the patient, in most cases, in less than three weeks. This induced the author to try the exhibition of large quantities of Peruvian bark, to endeavour to put a stop to the disease ; and from that time, the author did not lose more than one patient out of seven.—It is necessary to observe, however, that of those patients who died, several were lost from great affection of the head or breast; evidently in consequence of the effects of the cinchona. This happened not only in the Hospital, but also in many cases which elsewhere fell under his care. — It must be observed, on the other hand, that this kind of irregularity in the disease, when the cinchona was not employed, was fatal to more than half the patients in whom it occurred. It must lastly be mentioned, that this kind of irregularity is in all degrees; and therefore, that when it is in a very slight one, there is room left to consider whether this practice ought to be pursued. The next irregularity which is to be taken notice of is, when hysteric symptoms occur during the progress of the disease. — It happens sometimes, that hysteric symptoms take place in men, as well as in women, when they are otherwise in ordinary health ; though this is very rare : but in fevers, both sexes are nearly equally apt to be affected with them. These hysteric symptoms are, great irregularity in the appearances of the disease. The pulse sometimes rises to a hundred and fifty or sixty strokes in a minute, (or even more than can be counted) : this happens without any great oppression upon the breast, or any great affection of the head, or in short, without any aggravation of the other symptoms of the disease. The tongue is at the same time tolerably clean, (even cleaner sometimes than it is in its ordinary state); the skin is moist; and the other functions of the body not much affected. Sometimes there is great depression of the spirits and great anxiety of mind without any apparent cause. Sometimes the patient falls into violent floods of tears; for which he is unable to assign a reason. Sometimes there is a great flow of almost-colorless urine; or it is sometimes of a faint white color, like whey. Now and then subsultus tendinum arises in the wrists ; but without much affection of the head. — The hysteric symptoms however are more alarming to the patient, his relations, and even to practitioners of no great experience in the disease ; than they are dangerous. But it must be remarked, that they often prevent the disease from subsiding by its ordinary course ; (which sometimes runs on beyond three weeks;) and, in consequence, weakens the patient so as to be fatal. In case such hysteric affections should make their appearance, the patient ought to be supported by animal broths, from which all fat has been carefully separated, (by allowing them to cool, and strain- 385 IN IRREGULAR CONTINUED FEVERS. ing them before they are used); and by farinaceous vegetable solutions, (such as water-gruel, panada, sago, &c.,) mixed with a moderate quantity of wine, not exceeding a pint in twenty-four hours. — At the same time the patient should take a moderate quantity of opium (about eight or ten drops of the tinctura opii,) with some antispasmodic (such as about ten grains of Russian castor), every four hours. — He ought also by no means to be irritated by blisters, especially those containing cantharides ; (which the author has known in many cases to have been absorbed; and to have irritated the system, so as to produce these symptoms. — Very great care must also be taken not to irritate the patient's mind, by allowing anything to be revealed to him, with regard to his affairs ; (which is a precaution necessary in all cases of fever, but especially in this). The last irregularity to be mentioned, as apt to happen in fever, is, when many critical symptoms take place all at once, either on a true, or (as Hippocrates calls it) on a bastard critical day. These happen generally about four or five o'clock in the morning. They are, a copious sweat; one or two loose evacuations from the intestines ; the tongue becoming clean all over, or at least about the edges ; a lateritous sediment falling to the bottom of the urine on standing, &c. If the delirium, nevertheless, do not at all subside, (especially when that delirium has not been attended with symptoms of. fulness of the vessels of the brain); or if, though the delirium has subsided considerably, the pulse remain equally frequent, or become more frequent than it was before ; or if the patient be at the same time very restless; or if the oppression about the precordia continue as considerable as it was before, together with difficulty of breathing; or if, notwithstanding the appearance of several critical symptoms, the sleep continue unquiet and unrefreshing; or if the appetite have not at all recurred; — in all these cases, (when they have come under the author's observation,) the disease has always been fatal. The author has suspected in these cases, that some mischief has happened, during the disease, to some particular part of the body (such as the brain, the heart, the lungs, or some of the other viscera necessary to life); and he has in consequence had the body opened by Mr. Hunter, and others of the first anatomists of the age : but yet without finding any apparent injury in any of the vital parts. It happens sometimes, that in this irregularity, and appearance of several critical symptoms, the delirium (which had been very great almost from the beginning of the disease) has all at once subsided, and gone off entirely ; the pulse remaining at the same time frequent to perhaps a hundred and ten or twenty strokes in a minute ; the depression of strength continuing without any variation ; the appetite being lost to a still greater degree ; and the whole functions of the body being more deranged. The patient remains in this state to appearance perfectly in his senses ; and then all at once sinks and is carried off; (as if the mind, though conscious of its connection with the material part of the system, had disentangled itself from all attention to it). 33 GENERAL CONCLUSION TO THE AUTHOR'S FIVE DISSERTATIONS FEVER. The very vague manner, in which most authors have defined and described the disease they have called "Fever leaves it difficult to ascertain what they mean by this term. Such of them, however, as have written after long practice, mean certainly one individual disease. — This induced the author of the preceding Dissertations to try to investigate exactly the disease these authors intended to explain. He was the more induced to this undertaking,* by finding systematic writers, who had generally seen little or no practice, confound themselves, and, what is worse, their readers, in a labyrinth, from which they had no clue to extricate themselves. — Another motive for this undertaking arose from the confusion to be found in almost every school of medicine ; where teachers have almost always endeavored to introduce some plausible hypothesis. If they could infuse into the enthusiastic minds of young men a fondness for their doctrines, it has been sufficient always to render the school famous, and to attract to it numerous students. After the teacher's death, the school has gradually diminished ; and a new hypothesis, in some other part of Europe, has then attracted to it a new attention, with the same success. (Witness the Italian schools; those of Montpelier, Paris, and Leyden ; not to mention others nearer our own time.) — It is also to be observed, that the success of Linnaeus, in establishing, if the author may so call it, a dictionary of plants ; (in which he has made use of the different figures of the parts of fructification, as the first letter of his alphabet;) induced him to make similar attempts, not only in all other parts of natural history ; but also in diseases. In this last attempt he has been imitated by many others; who have labored to make the same kind of dictionary of diseases. Such attempts must cease of themselves, perhaps for ever ; at least until our knowledge of diseases is advanced far beyond the point at which it is arrived at present. — The fallacy of this mode, and wdiat has been already observed, were the motives which led the author to so arduous a task as that which he has undertaken. First then, he has endeavored to discriminate exactly that disease, 387 GENERAL CONCLUSION. which has been understood by practitioners of much experience, by the name of Fever: such as was understood by that name by the ancient Greek physicians ; and is described in that compilation of their medical knowledge, which goes by the name of the works of Hippocrates; such as was afterwards described by Celsus, Galen, Aretaeus, and other physicians, who practiced in the Roman Empire about the time of Augustus Caesar, or in a century or two after it; and such as was likewise understood by Hoffmann, and some others, after the revival of literature. Synopsis of the First Dissertation on Fever. — The author has endeavored to show, in the First Dissertation -— first, that though fever is a disease of the whole system, it does not necessarily occupy the whole of it at the same time. It is sometimes not present in particular parts of the body ; and there is no symptom that may not be wanting, even during the whole time of the disease. There is none therefore that can be considered as the first letter of an alphabet, (such as the number and position of the stamina in plants ;) on which account it is impossible to make any such arrangement in this disease, as has been attempted by Linnaeus, Sauvages, and many others. (The disease consequently must be looked at in all its parts, to be comprehended.) —In the second place, he has endeavored to show that fever is a disease in itself, not depending on any other disorder in the system ; (or, in other words, not a symptomatic, but an idiopathic disease.) He has endeavored also to enumerate some of the causes producing this disease ; and likewise to show, that it often arises from causes which are not at all known : that from whatever cause it arises, when it once takes place, it is totally independent of the cause which produced it, (and goes through its farther progress most commonly in the same manner, whether its original cause continues to be applied or not:) that in itself it is a short disease, hardly ever continuing above twenty-four hours, and never so long as seventy-two hours : and that it consists of an attack, a natural cure, and the appearances which take place during the time of its going off. Of the Second Dissertation. — In the Second and Third Dissertations the author has shown, that fever may be continued for a longer time by repetition ; (that is, by a new paroxysm taking place after the first has gone off, or during the time that the first is going through its progress). In the first place, he has shown in the Second Dissertation, that one paroxysm may entirely go off, and another, after a certain interval take place ; also that when one paroxysm has taken place and gone through its stages, so as to leave the patient free from every symptom of the disease, or, in other words, when the crisis is perfectly complete,) it rarely or perhaps never recurs ; that is, the patient is not more subject to fever, than a man is who was never before affected with that disease: — But that sometimes, although rarely, some symptom of the disease, (not perceived by the patient or bystanders or even by a practitioner in medicine,) may still remain ; in which case the disease often returns. 388 GENERAL CONCLUSION. When a crisis more or less complete, but not absolutely complete, has taken place in the first or some subsequent paroxysm, in the first week of a fever; the disease recurs ; and is called an intermitting or remitting fever. — When a new paroxysm of fever occurs in this manner, it rarely arises from the same causes which originally produced the disease ; but most commonly from some unknown cause ; which is most apt to act at the end of about forty-eight hours ; and which sometimes also acts (but not so frequently) at the end of about twenty-four or seventy-two hours; (though there are cases in which it acts at the end of almost any other number of hours. — Not only each paroxysm has a natural cure, which carries it off more or less perfectly: but the paroxysms at the beginning of the disease grow more and more violent for a certain period of time ; then remain nearly in the same degree for another period ; and afterwards diminish and entirely subside, (leaving the patient in health, but much weakened by the disease). — On the other hand, it sometimes happens, that a perfect crisis terminates one of the paroxysms ; and then the disease does not recur ; but leaves the patient in health ; only weaker than before the attack of the disease. The disease may attack the patient in any one of the paroxysms, with such violent symptoms of the first stage, as to prove fatal.— In the ordinary progress also of the disease, such a degree of weakness may take place, as that the patient shall sink ; or some of the viscera may be so much hurt, as to produce fatal effects. The treatment of the disease may be considered in three lights; first, the disease may be allowed to go through its course, (taking care only that no mischief shall happen to the patient during its progress:) secondly, such medicines may be used, as shall induce a perfect crisis in one of the paroxysms (so as to prevent the disease recurring), or at least render the intermissions so perfect, as to allow of proper nourishment and exercise (and to prevent the patient from being weakened and exhausted), until the disease wears itself out: and lastly, medicines may be employed which shall counteract the unknown cause of the recurring of the paroxysms, and prevent the return of the disease. Of the Third Dissertation. — In the Third Dissertation, the author has pointed out those cases, in which a fresh paroxysm occurs during the continuance of the symptoms of the former ; (or, in other words, during the hot fit of the preceding paroxysm of the disease ; which shows that some exertion is made towards carrying off the disease). — This attack of the fresh paroxysm takes place in consequence of some cause, which induces in all men some appearance of fever in the evening, in whatever climate they happen to be : (a fact, which although it is evident in all mankind, has had no adequate cause assigned for it). — In this case, a fresh attack of the disease takes place in the evening of the same civil day, if the first attack was before six in the morning of that day: — But if the first attack was after six in the morning of a civil day and before midnight of GENERAL CONCLUSION. 389 the same day, (which is almost always the case,) and if the hot fit continue, without producing a crisis, till six o'clock in the subsequent civil day ; then the first exacerbation arises between five and six o'clock in the evening of the subsequent day : and the second exacerbation of the disease and the following ones all take place between five and six o'clock of each succeeding day.—This is called a continued fever. There are three methods by which a continued fever may terminate without the aid of medicine. First; the exacerbations may gradually become more and more violent every day, for a certain length of time, (commonly during the first week of the disease) : and in consequence, the fever will gradually increase. Afterwards the exacerbations may become more severe every other day; or the disease may continue nearly equal for a certain length of time, (generally to the end of the second week or fourteenth day of the disease). — The appearances of the disease itself are therefore nearly equal during this period. After this, the disease gradually diminishes of itself, and entirely leaves the patient; (commonly by the twenty-first day after the attack). — The duration of these periods is however uncertain ; so that the period of the increase of the disease may be extended (but rarely) much beyond the first week. The period of its remaining stationary may be.increased considerably beyond the second week ; and the period of its diminution may be still farther enlarged : so that the disease may be extended to six weeks, or even longer ; and be entangled with symptoms of irregularity, &c.) as described in the fifth Dissertation). — This is the first way in which a continued fever may terminate, without any assistance from medicine. Secondly, an inflammation may take place in some part of the body, (sometimes in one part, and sometimes in another,) without any apparent cause ; and may terminate the fever itself; so that sometimes the patient shall recover his health immediately ; (excepting for the symptoms of the inflammation, or the affection of the system arising in consequence of it). —The same thing may happen from an active hemorrhage taking place. — In this second mode also, the patient may be entirely freed from the fever, without any assistance from medicine. A third method in which a fever is often terminated without the aid of medicine, is, by a crisis putting an end to one paroxysm completely ; so as entirely to liberate the patient from the disease. — In this third way, the crisis takes place, in the first week, on the days of the quotidian type ; in the second week, on the days of the tertian type ; and in the third week, on the days of the quartan type. Farther; when such a crisis takes place in the first week, the disease is apt to recur: but if such a crisis should take place in the second week, the disease is less apt to recur ; and if it takes place in the third week, the fever rarely recurs. — Generally, the more perfect is the crisis, the less probable is the return. 33* 390 GENERAL CONCLUSION. Thus, then, there are three ways in which a fever may be terminated, and the patient restored to health, without any assistance from medicine : (nay, even though a practitioner had used every means that was likely to destroy the patient, or prevent the fever from going off by the powers inherent in the body). — A practitioner, therefore, is not to believe that the remedies he has employed cure the patient, if he gets well; unless he understands how the disease would have proceeded, if no medicine had been employed. It has been also stated in the third Dissertation, that a continued fever may be terminated by the exhibition of medicines, which produce appearances in the body similar to those which take place in the crisis of fever. (The principal medicines which produce this effect, are preparations of antimony, ipecacuanha, and cold water, drunk in large quantity.) These medicines tend to produce relaxation in all parts of the body ; and have their principal and most powerful effects when employed at the beginning of the disease. They certainly produce crisis in fever much more frequently, than it would have arisen if they had not been exhibited : but still, it is necessary, if they do not produce such crisis, that a practitioner should attend to the ordinary progress of the disease. — In the next place, the disease sometimes may be carried off by producing a hemorrhage, or an inflammation, in some part of the body. The only cases in which occasioning a hemorrhage has been known to succeed, are those in which it has been produced by opening some vessel of the head ; when the head has been particularly affected at the beginning of the disease. Inflammation also has been excited in the external parts of the body ; in consequence of which the disease has sometimes been carried off, or at least diminished. All these methods, although they may not carry off the fever entirely ; yet in many cases diminish the symptoms considerably : so that the disease goes through its ordinary progress ; and the patient recovers, when otherwise he would have been destroyed. When such medicines however are exhibited as produce the ordinary symptoms of crisis ; they sometimes act partially ; and increase some one evacuation, so as to render the patient weak and unable to sustain the ordinary progress of the disease. If this should happen, they are to be abandoned. — The producing of hemorrhage from the head, (if that be the part chiefly affected,) also occasions weakness ; and is therefore improper, if the evacuation be considerable. — Exciting an inflammation by cantharides or otherwise, in any exterior part of the body, is apt to irritate the patient; and render the disease more hazardous : and should not, therefore, be practised, except some part of the body be considerably affected. (In this opinion, however, the author differs from many practitioners ; some of them being among the most judicious ; while others of them are tempted to employ this remedy by the desire of impressing on the minds of the relations of the sick and the by-standers, that they are not inattentive to the means of curing the disease). GENERAL CONCLUSION. 391 The author has also said in the third Dissertation, that many have employed the Bark of the cinchona to prevent the recurring of the exacerbations in continued fevers: but he has also mentioned, that it seldom has this effect; and that where it fails, it increases the affection of the head and breast, so as to endanger the life of the patient. The author has likewise taken notice of an opinion, which has been adopted by many practitioners; to wit, that no effort should be made to check the ordinary course of the disease, but that it ought to be suffered to go through its progress ; (which they call, leaving it entirely to nature). — Supposing that no medicine has been found out that would carry off a fever ; it would still not be indifferent what attention is paid to the patient. — It is also clear, that when those medicines, which have been found to carry off fever in a number of cases, have failed ; it is even then not indifferent in what manner a patient has been treated. The author, therefore, has shown in the third Dissertation, that in all fevers it is necessary to clear the primae viae of any noxious matter that may be contained in them ; that the patient should have such nourishment as shall not disorder either the primae viae or any part of the system ; that the mind should be kept perfectly at rest; that the patient should remain in bed, in a moderate degree of heat, and in an air free from noxious matter; and that evacuations which are not critical ought to be checked, when in too great a quantity. It was next to be inquired in what manner a fever may be fatal to the patient. In the first place, the disease may be fatal from its own violence ; secondly, from some particular part of the body being much more affected than the other parts of the system ; in the third place, from the patient's being weakened and worn out by the disease ; and lastly, by some accident, which may destroy the patient, (and which either might have been fatal, had it happened in a person not afflicted with fever ; or yet proves fatal in consequence of the state of the system during such disease.) The notice of the method of obviating these dangers properly belonged to the fourth and fifth Dissertations : but as the means of diminishing the fever, are the same as those which often entirely carry it off; this subject was in fact discussed in the second and third Dissertations. One. of the accidents which are apt to arise in the disease, and sometimes to destroy the patient; is a degree of putrefaction which takes place in the fluids. It has been shown in the third Dissertation, that this disposition to putrefaction depends entirely on the depression of strength ; and that, therefore, no anti-putrescent is of any use in preventing or carrying it off; but that taking care not to make unnecessary evacuations at the beginning of the disease, employing such food as can be perfectly digested without difficulty, and endeavoring by other means to avoid wasting the powers of the system ; are the only measures which can be employed ; (excepting where hemorrhage takes place ; and that in this case, the bark of the cin- 392 GENERAL CONCLUSION chona is to be exhibited, together with acids, of which the vitriolic and muriatic seem to be the most powerful.) The other dangers,to which patients in fever are exposed,have been treated of in the fourth and fifth Dissertations. It has been shown in these, that general inflammation is sometimes fatal by such a quantity of blood being thrown upon the brain, as to produce delirium and destroy the patient; or by such a degree of tension taking place in every part of the system, that if by any accident the strong action of the heart and arteries ceases (even for a very short period of time), the tension likewise ceases, and the patient is carried off; or by an inflammation occurring in some particular part of the body, without entirely carrying off' the (so that the patient shall labor under two diseases ; namely, the inflammation with its effects on the system, and the fever.) Of the Fourth Dissertation. — It has been shown in the r ourth Dissertation, that this general inflammation often renders the intermissions of an intermitting fever imperfect; so as to cause the paroxysms to run into each other, and even to resemble a continued fever, in the first week of the disease : that in this case, a quantity of blood may be taken away to remove the general inflammation ; (since, if the intermissions become more perfect, time will be afforded to employ nourishment to replenish the vessels:) that this general inflammation very rarely happens in w r arm climates : and that weakness in those climates being much more dangerous, evacuation by bleeding should hardly ever be made in the fevers which occur in them. In the Fifth Dissertation it has been shown, if the fever cannot be carried off, but goes necessarily through its ordinary course; that then, although no mischief appears immediately from taking away a large quantity of blood ; yet, as no time is afforded for food to be digested, the vessels cannot be replenished: and such a degree of weakness is produced in the third week in consequence of the bleeding, as to carry off the patient. —Another mischief also happens, which is, that the weakness produced by the bleeding, together with the depression of strength ; often produces putrefaction of the fluids in the second week of the disease, to a degree that is fatal. — It is, therefore, very necessary to avoid taking away blood at the beginning of continued fevers ; except there be such a degree of inflammation present, as threatens the life of the patient. In the Fourth Dissertation it has been shown, that in intermitting and remitting fevers in hot climates, (in which they occur by far the most commonly) the paroxysms are peculiarly violent: so that when a few of them have taken place, the disease is often fatal. In this case, practitioners have been frightened; (a£ spectators are, when violent torrents are carrying everything along with them ;) and losing their presence of mind, some have employed copious evacuations by bleeding ; some, active purgatives ; some, emetics ; others, mercury in large doses so as to produce salivation ; and some of them have thrown large quantities of cold water upon their patients. But all GENERAL CONCLUSION. 393 these measures have proved equally unsuccessful; as appears, when fevers have arisen in armies, by the returns made of those who have died. — The practice therefore recommended in the second Dissertatation, should alone be attended to in remittents in such climates. Of the Fifth Dissertation.—In the Fifth Dissertation, the author has shown, that sometimes the brain, the lungs, or the heart, or at least some part about the head or breast, have been so hurt, that although a crisis has taken place so as to carry off the fever itself; the patient has nevertheless died. In the same Dissertation the author has also shown the mischiefs which arise from the several parts of the system not being equally affected with the disease ; and the modes that may be employed to remedy this. He has likewise taken notice of the hysteric symptoms which often occur in irregular fevers ; (and has said that they may be relieved by small doses of opium and antispasmodics.) Replies to Criticisms. — The author, having thus briefly recapitulated the principal subjects of his several Dissertations, and taking example from Columella, who published his works upon agriculture at different times, wishes now to notice the criticisms, which as he has heard, have been made upon him. — — , . — * — . . First: It has been said by some, that he has been too minute in describing the disease itself, and the remedies to be employed in it; or, as these observers have expressed it, he has been too verbose in these Dissertations. But he begs leave to remark, that most authors, and teachers of medicine at this time are scandalously negligent in giving accounts of diseases, and the remedies that are to be employed in them ; so much so, that there are teachers in London, who pretend to teach the whole knowledge of all the diseases incident to the human body, as well as the effects of the remedies applicableto them, in thirty-six lectures of somewhat less than an hour each. —If a man were but to reflect on the great importance of this science to mankind, and on the immense detriment it is to a family, to lose either a father or a mother at premature age ; not to mention the distress arising from parents losing their children ; he would take great care, before he began to practice this art, to inquire into it in the most minute manner. The author has found, in correcting the copy of the second edition of the first Dissertation, that, without adding any one new idea, he has been obliged to extend it considerably in words. Secondly: With regard to plagiarism, he will take for instance, (what he has been said to borrow from Dr. Cullen,) his remarks on the use and mode of action of antimony. He certainly cannot justly be said to take the use of antimony in fevers from Dr. Cullen; because it is well known, that Dr. James, (a regular bred physician) had brought it into general use, before Dr. Cullen began to teach medicine. Neither can he be said to have taken the mode of its 394 GENERAL CONCLUSION. action from Dr. Cullen ; because Dr. Cullen called it a nauseating medicine; and ascribed its effects in carrying off fever, to its producing sickness; and this he taught to the author; who embraces this opportunity of acknowledging the acquirement of much knowledge from so great a master in medicine; and also his great friendship in admitting him at all times like a son into his house. The author, on the other hand, when he came to see a great number of patients, after, being chosen physician to St. Thomas's Hospital; found, as he has observed in these Dissertations, that so far from the sickness produced by antimony being the cause which carries off fever, even small doses made the effect much less certain, where they produced sickness; and also that other medicines, which occasion as great sickness as is induced by antimony, such as squills, have not the least power of producing symptoms similar to those which take place in the crisis of fever. Lastly: The author has to remark; that he has not made the species of fever such, as have commonly been made by almost all authors from the beginning of medicine. — In the first place, the author has excluded from fever, all diseases in which the pulse becomes more frequent, the tongue foul, and the system is otherwise deranged, when this derangement evidently arises from some manifest cause ; (such as inflammation, suppuration, extraneous substances lodged in some particular parts of the body; and various other similar circumstances ; which during their action keep up the above mentioned appearances in the system ; and which when they cease, permit the body to return gradually to its healthy state). — He has said, also, that the action of causes of fever produces the disease at once ; and that the fever continues, wdiether the cause be present or be removed: (and he has by this means cut off a great many diseases, which by many practitioners have been called fevers). He has in short, admitted only two distinct species of fever; to wit, continued fevers, and intermitting or remitting fevers. — These he has distinguished, in the first place, by the causes of the returns of the paroxysms. This cause in continued fevers is the evening paroxysm of fever, (which occurs to all men, whether in health or in disease ;) between five and six o'clock in the evening. The cause of the re-: turns of the paroxysms of intermittent fevers is certain periods of time, (which are nearly about the end of forty-eight, twenty-four, or seventy-two hours; excepting that there is an indisposition to the returns from ten o'clock in the evening to six in the morning): and these periods of time have been called types. — There is also another essential difference between these two species of fever. The attacks in intermittents are much more severe and the intermissions or remissions much more perfect than in continued fevers. -— And farther: continued fevers, (if no accident occurs,) go through their course, so as to terminate before the end of the third week; while intermittents generally run on for a longer time ; but remittents, (especially in warm climates,) are often fatal even in the first week of the disease. GENERAL CONCLUSION. 395 Many distinctions have been made in continued fevers, by various authors in all ages of medicine, taken from some symptom arising in their course. Fevers were reduced by Sydenham (who wrote only from his experience) into three species, which he called epidemics. — This distinction has since his time been very generally followed : — but the names given them are different. They have been called by some inflammatory; pestilential or malignant; and nervous: by others they have been called inflammatory ; putrid [or] jail; and nervous fevers: by others synocha, typhus, and synochus, (using Greek terms, in which the present age abounds; as if changing the language or name was by some magic to produce a new real difference). — The author, (led by the authority of Sydenham, and by many other modern practitioners of great experience,) when he first began to teach medicine in the year 1766, himself divided continued fevers into three species ; — but he has since found, by long experience, that these apparent species merely proceed from the accidents of general inflammation, disposition to putrefaction, destruction of some of the vital parts of the body, irregularity, hysteric symptoms, or weakness, occurring in the disease ; (but which by no means constitute any specific difference). — Men will have some specific name for the fever with which a patient is afflicted ; (as when there is bile thrown up, they call it bilious fever; when there is delirium, brain fever:) But these names surely constitute no useful distinction either for understanding or curing the disease. INDEX Action of a part, 143 Ague-cakes, 362 Air, its purity, not to be affected by heating rooms, 224 stagnant, to be avoided, in a sick room, 228 Alchemists, the first to use antimony in medicine, 273 Antimony, its different preparations, 269 tartarised, its efficacy in fever, without vomiting or sickness, 98, 276 combined with aromatics, 288 effects of, in health, 281 how it acts in fever, 274 how given to produce a crisis, 286 is decomposed in large solution in water, 280 mixed with ipecacuanha, as an emetic, 153 rules for its continuance, 290 to be continued during the intermissions of a tertian, 156 vinous solution of, 287 Antispasmodics in tertian fever, 166 in regular continued fever, 307 Appetite, loss of, in fever, 57 Arsenic, preparations of, to prevent return of paroxysms of intermittents, 158, 366 Ascites, from enlarged liver, 363 34 Ascites, colour of the skin in, 363 Atmosphere, modes of warming, 223 Bath, cold, in fevers, 293 Bile, not redundant, in fever, 58, 84 Bitters, to restore tone in tertian fever, 144 most efficacious when combined together, 146 their action entirely ia the stomach, 146 uncertain effect in intermittent fever, 158 Blister, in fever, 300 fluid of, 300 relieves headache, 302 delirium, 302 affections of the breast, 303 when proper in fever, 301 Blood, its composition, 53, 82 changes in the, 53, 60 connected with a particular state of the arteries, 53, its coagulating and other appearances, when drawn, vary from several causes, 337 in continued fever, 201 quantity of, how diminished, 346 Blood-letting, accidental accompaniments of tertian fever, 167 does not shorten regular continued fever, 263 for the general inflammation in continued fever, 376 from the head, serviceable, 265, 304 one large, the best fashion, 347, 377 Brain, organ of the mind, 204 398 INDEX. Brain, how altered in structure in delirium, 204 Breast, sensations in the, in fever, 56 Camphor, of little use in fever, 308 Cantharides, to inflame the skin in fever, 253, 300 Capillary vessels, 374 Cerussa acetata in fever, 311 Cinchona, see Peruvian bark. Clothes, attention to the bed and body, of the patient, 223 Cooling, means of, in fever, 227 Cold, sensation of in fever, 40 a cause of fever, 72 difficulty of measuring, 42 increase of the powers of the body from moderate, 373 Conclusion, general to the Five Dissertations, 386 Copper, preparations of, in intermittent fever, 158, 367 Contraction or spasm, not a cause of fever, 60 of blood-vessels, a cause of exhaustion, 315, 373 Convalescence, in fever, 322 rest and exercise in, 327 the bark in, 323 purgatives injurious in, 326 proper food in, 326 Crisis, the first termination of simple fever, 105 a supposed effort of nature to expel noxious matter, 218 in regular continued fever, 208 less frequent in cold climates, 212 occurrence of, a guide to the use of remedies in convalescence, 324 variously described in different countries, 208 Critical days, 209 explanation of, 210 in irregular continued fever, 382 Criticisms, replies to, 393 Delirium, in fever, 55, 103, 202 a obstruction of blood for second species, 303 difference between and mania, 203 how far depends on affection of the brain, 204 increases with the fever, 207 of two species, 205, 303 relieved by a blister, 302 Delirium, sndden subsidence of, a bad sign, 385 Diarrhoea from enlarged liver, 364 Diseases, when left to go through their natural course, 167 Distilled spirits, not useful in regular continued fever, 256 Dormant powers of the body, means of raising the, 252 Drink, the kind, proper in fever,239 abstinence from, in fever, 292 Dropsy, in fever, after diarrhoea, 364 is rarely fatal, if the fever wears itself out, 365 ultimately cured by the Peruvian bark, 365 Elasticity, a property of the moving fibres, 141 opposed to tone of the muscles, 143 Emetic, in regular tertian fever, 131 154 aids in bringing on a crisis, 285 drinks after an, 132 in regular continued fever,[244 when to be administered, 285 when to be repeated, 289 Ephemera, 37, 104 carried off by topical inflammation, 175 the worst variety of semitertian, 355 Eruption, in continued fever, 201, 214 Evacuations, hurtful in regular tertian fever, 168 Evening, febrile excitement at this time, 102 Exercise, morbid and healthy effects of, 147 difference between, and labour, 148 Exertion, to be avoided in fever, 225 Eye, changed appearance in fever, 48 Fever, general observations on, 27 origin of the name, 28 no pathognomonic symptoms of, 29 heat and pulse, considered, 29 definition of, 33 description of, 35 a disease of the whole system, 36 duration of, 36 ephemera, 37 simple, symptoms of, 38 its essence not under stood, 62 399 INDEX Fever, simple, causes of, 63, 80 slow operation of, 83 co-operation of the, 87 not increased by renewal of cause, 89 march and stages of, 91 first or cold stage, 91 sometimes suddenly fatal, 92 second, or hot stage, 93 two distinct parts in the attack of, 96 terminations of, 105 crisis in, 105 regular continued, 172 diagnosis of, 172 first symptoms of, 179 does not follow directly, application of the cause, 188 symptoms of, 188 time of beginning, 194 depression of strength does not constitute an irregular fever, 195 successive paroxysms of, 194, 195 putrefaction in, 201 appearances of skin in, 201 putrefaction in, 201 prognosis of, 207 crisis in, 208 abatement of, 214 treatment of, 216 attempts to carry it off reprobated by some, 217 supposed humours giving rise to, 217 comparison of results between leaving the fever to itself and use of medicines, made with difficulty, 221 preliminary treatment in, 221 food and drink in, 230 animal food injurious in, 231 emetic in, 244 laxatives in, 244 stimulants in, 252 treatment to carry it off, 262 venesection in, 262 purgatives in, 267 Fever, regular continued, tartarised antimony, 276, 281 abstinence from drinks in, 292 cold water in, given by the Greek physicians, 292 external inflammation for the cure of, 253, 296 not caused by matter in the system, or the circulation, 298 as a spasmodic disease, 307 similar to a regular intermittent, 310 Peruvian bark, used in, 311 cerussa acetata, 311 see Intermittent, regular tertian, irregular continued, 372 irregularities of, intermittent, in temperate climates, 361 treatment of, 376 blood-letting in, 376 unequal affection of different parts in, 378 prognosis in, 379 hysteric symptoms in, 384 in its progress, 381 yellow, 356 quartan, see Quartan Fever. quotidian, see Quotidian Fever. semi-tertian, see Semi- Tertian. Fevers, differ in duration of the hot fit, 104 continued, whether of one or of many paroxysms, 190 irregular intermittent, 355 only two distinct species of, 394 simple, length of paroxysm in, 111 Farinaceous matters for food in fever, 233 Fluids, change in the, alleged cause of fever, 83 not altered by the hot fit, 96 putrefaction of the, 106, 200 cause of, 197 warm watery, in fevers, 292 see Putrefaction. Food, eating, a cause of fever, 79 animal, 236 modes of preparing, 125,129 400 INDEX. Food, proper, in convalescence, 326 the kind proper in fever, 231 Friction, useful, in tertian fever, 149 Fruits, their varieties, 235 used in fever, 235 Glyster, different kinds of, 247 when used in fever, 248 Headache, in fever, relieved by a blister, 302 by leeches to the temples, 304 Heart, increased contractions of, 50 may carry off a fever, 96 Heat, a cause of fever, 85 increase of in fever, 94, 101 modes of procuring, 223, 225 relative, 222 Hectic fever, unlike true fever, 173 Hemitritaea, see Semi-Tertian. Hemorrhage, in advanced fever, a bad sign, 322 means of stopping, 322 Hemoptse, when produced in tertian fever, 165 Horripilation, 46 Horror and rigor, in cold stage of fever, 92 Infection, a cause of fever, 65 doubtful if imported, 352 may exist in all fevers, 66 not recognisable by the senses, 65 of the small-pox, 69 of the plague, 70 producing local diseases, not properly fever, 71 seldom a cause of semi-tertian, 351 Inflammation, erysipelatous, 176, 178 external, as a means of cure in fever, 253,296 general, danger from, 177,375 i phlegmonous, 174, 175 of the intestines, 175,178 sometimes carries off the fever, 296 symptoms of, 335,340 means of cure, 344 with continued fever, 372 Inflammation, general, blood-letting in, 377 Intermittent, a regular tertian, 115 blood-letting in, 348 accidents during, demand a particular treatment, 167 anticipating tertian, 117 are rarely fatal, in temperate climates, 121 cause of return of paroxysm in, unknown, 116 clears the system of other diseases, 120 continued by habit, 151 definition of, 115 duration of. 333 emetic in, 131 emetics useful in, as imitating in their effects a crisis, 152 , food proper in, 123 general inflammation in, 340 laxatives in, 133 medicines to recruit the strength in, 139 metallic preparations in, 158 perfect intermissions in, 119 Peruvian bark in, 156,162 simulatingcontinued fever, 119 treatment of, 122 when fatal, it is in the cold fit, 121 whether to be stopped without injury, 151 Intermittent fevers, types of, 331 irregular, 335 tendency to come on in the day, 334 general inflammation in, 335 blood-letting in, 348 semi-tertian variety of, 349 see Semi-Tertian, with, causes the worst forms of fever, 350 irregularities of, in temperate climates, 361 treatment of, 361 metallic preparations in,366 Intermissions, in regular tertian, 118 exercise in, 149 food during, 129 laxatives in, 135 Ipecacuanha, its use in fever, 98, 153, 253, 293 401 INDEX. ipecacuanha, how far analogous in its operation to antimony, 294 with tartarised antimony, 284, 294 ron, preparations of, in intermittent fever, 158, 307 Jaundice, from enlarged liver, 363 Laxatives, in regular tertian, 133 different kinds of, 245 in regular continued fever, 244 their times of administration, 135 Liver, enlargement of the, in intermittent fever, 362 a cause of jaundice and ascites, 363 diarrhoea from, 364 schirrosity of, 363 Man, originally an inhabitant of a warm climate, 221, 372 Milk, detrimental in fever, 237 Mind, connection of brain with, 204 faculties of, 181 sudden excitement of, a cause of fever, 80 to be kept free from care in fever, 237 weakened in fever, 39 Moisture, a cause of fever, 76 Mucilage, animal, the -basis of the solids, 312 Mucilaginous substances dissolved in water, externally applied, in fever, 295 Muscular action, a contractile power, 142 powers, of two kinds, 144 their mode of action, 179 Mustard and garlic, to inflame the skin in fever, 301 Nature, inquired into, 218 Nausea, in fever, 58 Opium, to procure sleep in fever, 136, 249 substances combined with, 249 when proper, 250 Pain, of the back, in fever, 44 of the head, 55 over the body, 55 Paroxysm, of a regular tertian, 116 emetic in a, 131, 153 patient to be in bed during the, 136 Paroxysm, purgatives injurious in, 135 regular return of, 117 remedies to prevent a, 167 repetition of the paroxysm of simple fever, 151 return of prevented by the bark, 158 return prevented by profuse sweating, 164 tendency of, to come on, in the day, 334 times of appearing in the different types of intermittens, 332 weakness left by, 137 of continued fever, duration of, 191 when coming on, 191 cause of unknown, 193 Passions, exciting the, a case of tertian fever, 166 Peruvian bark, its efficacy, in intermittent fever, 156, 162 dose of the powder, 162, duration of period of its use 163 during convalescence in fever, 323 effects depend on impression made on the stomach, 159 in semi-tertian, 350,358, 360 its different prepaiations, 157 its little effect, in health, 157 its modus operandi not known, 157 powder most efficacious, 157 prevents a return, but does not cure fever when present, 324 its use in regular continued fever, 311 times for using it, 159,161 when to be combined with opium, 164 when with a laxative, 164 Pulsations of the arteries, dependent on contractions of the left ventricle, 51 hardness of, 54, 189, 338 varieties of, 52 Pulse, in violent fever, 55 differences in the, 189 difference in readiness to appreciate these, 336 fulness and strength, 339 greater frequency of, in the hot fit, 95, 100 hard, 54, 189 obstruction of the, 338 402 INDEX. Purgatives, active, injurious in regular tertian, 133, 168 increase mercurial action, 326 in regular continued fever, 267 injurious in, 268, 326 varieties of and their effects, 134, 246 Putrefaction of the fluids, in scurvy, 200, 319 an effect, not a cause of fever, 196, 200 caused by depression of strength, 195, 200, 312 causes favouring, 197 hemorrhage with, a dangerous sign, 322 means of prevention are to carry off the fever, 321 most evident at certain times, 202 not cured by antiputrescents, 319 symptoms of, 201 of the solids, phenomena of, 314 means of prevention, 317 opposed by living organisa• tion, 199 similar to fermentations 315 vapors caused by, 316 Patient, in regular continued fever, preliminary attentions to, 221 Quartan fever, type of, 332 anticipating, 332 attended with more complications than tertian fever, 335 duration of, 333 retarding, 332 Quotidian fever, its type, 332 anticipating, 332 period of duration, 333 retarding, 332 Regimen, the warm, injurious in fever, 305 Restlessness and anxiety in fever, 102 Rheumatism, 174 Salts, neutral, in fever, 294 Scurvy, sea, putrefaction of the blood on, 200,319 Semicupium, use and effects of in fever, 295 Semi-tertian fever, 342, 349 treatment of, 349 irregular, 350 called yellow fever, 356 treatment of, 349 resembling intermittents and remittents, 358 symptoms of, 359 treatment of 359 causes of, 250 description of, 354 infection seldom a cause of, 352 in its worst form, an ephemera, 355 matter vomited in, 355 yellow colour of the skin in, 356 Sensation, diminution of, in fever, 42 Spices injurious in fever, 255 Skin, colour of the, changed in fever, 47 appearances of in continued fever, 201, 214 inflammation of the, to cure fever, 263 means to excite inflammation of, 299 sensibility of, diminished, 47 Secretions changed in fever, 49 restored in the crisis, 106,306 Sickness, not a cause of the removal of fever, 98 . Sleep, to be procured, in fever, 136 effects of want of, 186 how procured in fever, 249 the rest procured in, 179 state of the mind in, 182 rest of the body in, 183 wanting at times in madness, 185 Spasm not a cause of fever, 159,160 some of its bad effects, 306 Spleen, enlargement of the, in fever, 362 Stages of fever, 91 Stimulants, in regular continued fever, 255 Stomach, affection of, in fever, 57, 97, 98 in carrying off fever, 99 impressions, on of bitters of 145 Strength, confusion of ideas respecting, 139 depression of, in fever, 195 does not constitute an irregular fever, 195, 202 INDEX 403 Strength, depression of, a cause of putrefaction of the fluids, 195,200,312 increased by putrefaction of the fluids, 202 by stimulants, 305 Succession not to be confounded with causation, 64 Sweating, profuse, a means to prevent the return of a paroxysm of tertian fever, 164 accompanies crisis in regular continued fever, 304 alone, does not carry off fever, 305 Thirst, in fever, 58, 102 means of moderating in fever, 238 Tone of the muscles, 143 Tongue, coated, in fever, 45 Tongue, other appearances of, 46, 201 Variolous matter, causing fever, 68 Vapours, noxious, a cause of diseases, 229 not detrimental in fevers, if there be ventilation, 230 Venesection, its value in regular continued fever, 262 see Blood-letting Vomiting, best caused by tartarised antimony or ipecacuanha, 252 Water, a drink in fever, 240 cold, 292, 293 Weakness, in fever, 39, 251 means of relieving, 252 Wine, good effects of in regular continued fever, 255 Zinc, preparations of, in intermittent fever, 158, 367 THE END.