3* &&: ^ NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service & DISSERTATION ON THE MIXED FEVER, D E L I V E R*E D June 30, 1789. AT . -A FULLIC EXAMINATION *on the DEGREE 0? BACHELOR in MEDICINE, BEFORE The Rev. JOSEPH WILL ARD-_ S.T.D, PRESIDENT, TheMEDICAL PROFESSORS, AND THE GOVERNORS of the UNI VERS ITT c -at CAMBRIDGE in AMERICA. By WILLIAM PEARSON.V Phoebe fave, novos ingreditot toa temjla facerdos. ^w~* ft. J.- %- T 0 *|f £>n. MARSHALL SPRING; In Teftimony of whofe Eminence id his Pfofeffion and extenfivc Practice, THIS DISSERTATION is refpecTfully infcribed, by his obliged and grateful PUPIL, William Pearfhm >** A DISSERTATION ON THE MIXED FEVER. UNDER a proper convi&ion of my inability to do juftice to the fubject affigned for the fol- lowing Diflertation, I (hall be careful to avoid obtruding any fentiments of my own upon this refpecV able auditory, except. fuch as have arifen from fa£ts which have fallen under my particular notice, or have been fuggefted by my own reflections upon the opinions of others— At the prefent early period of my medical purfuits, I prefume, it will be more becoming to confine myfelf to a number of inconteftible fa which produced a confiderfcble alteration in the doctrine of fevers. Dr. CuUen improved upon the labours of Hoffman, and has publifhed a fyftem which is pretty generally received in countries where theEnglifh language is fpoken. 1 fhall therefore adopt his arrangement and diftinclions in difcufling the fubjca afligned me. Dr. CuUen takes a paroxyfm of a regular intermittent as an example for all other fevers, as what is called continued fevers are only repeated paroxyfms of intermit- tents fo indiftindly marked as to be fcarcely viable. Dr. CuUen divides all the difeafes which afflift man- kind into four claffes. The firft clafs he calls Pyrexia, and gives it this chara&er,— a frequent pulfe coming on after horror, confiderable heat, many of the functions impaired, the ftrength of the limbs efpecially injured. Under this head are comprehended all inflammations, all eruptive difeafes, all haemorrhages, and profluvia which are naturally not bloody. i The firft order of this clafs is Fevers in general A fever, he defines to be pyrexia without any primary local affec- tion, following the languoijaffitude and other fymptoms of debility. He divides this order into fix genera, and diftinguifhes them into intermittent and continued fevers. The fourth genu^ of the order of fevers he calls { Synocha', Whofe character is, great heat; a frequent, ftrong and hard r 4 r i hard pulfe ; high coloured urine; functions of the fen- [ forium a little difturbed. Practitioners commonly call this ; tnfiammatory fever. The fif.h genus he calls Typhus, which (he defines to be a contagious difeafe, the heat not great- ly above the natural ; the pulfe fmall, weak, and for the , moft pari frequent; the urine but little changed ; the i functions of the fen forium very much difturbed, and the flrength greatiy diminifhed. This is commonly called • the " low nervousfever." The fixth genus Dr. Cullen calls " Synochus," which he defines to be a contagious difeafe, and is a fever com- fofed of the fynocba and typhus; in the beginning it is zjynocha, but towards the end a typhus, and this is the genus we mean particularly to treat of. It is called by fome authors * Synochus nen putris.----It is agreeable to the Cullenian fyftem to diftinguifli fevers into the Inflammatory and Nervous merely, or as they (how either 3n inflammatory irritation, or a weaker reaction, yet we nay fay with him, that the moft common form of con- tinued fevers in this climate feems to be a combination of he two genera, and called Synochus; Dr. Cullen fays he limits between the Synochus and Typhus is diftin- juifhed with difficulty, but he rather thinks the former s only a variety of the latter. This mixed fever fo com- non among us is defcribed under various names by dif- erent authors; fome call it the Bilious, fome the Remit, hg, and others the Autumnal. By Praaitioners in New- England It has been called the low Nervous fever. * Vid. Sydenham, Bagliri and Grant, *?. t 5 3 It feldom attacks fo brifkly or fuddenly as the inflam- matory fever, but begins with a wearinefs, a frequent inclination to yawn, an irregular fenfation of cold, ap- proaching to chillinefs, a confufed pain in the head, naufea, thirft, and very often vomiting.-----The pulfe is not fo ftrong and full as in the genuine inflammatory fever, the remiflions are more evident, and permanent, and there is more moifture on the fkin : On the other hand, the naufea, pain of the praecordia and anxiety are greater than in the inflammatoryfever, and there is moft commonly a bilious vomiting. The tongue has from the beginning a whitifh moift covering, which as the fever advances becomes dry and of a brown colour, which may alfo diftinguifh it from the true inflammatory. The fymptoms vary at different feafons and in different patients ; fometimes they are iiritated with in- flammatory fymptoms, fv metimes they are deprefled with the low nervous. Vogel fays the charafleriftic marks of this fever are a redness of the face, a moifture of the fkin, and a great and frequent pulfe : This we may fuppofe to happen in patients where a phlogiftic diathefis prevails; but when it happens in hypochondriacal pa- tients, who have weak ftomachr, the fymptoms are dif- ferent ; for in fuch, according to Baglivius, the humours are more corrupted, the tongue grows black, the pulfe fmal! and the extremities cold, together with great anxi- ety. As this fever, from its being contagious, attacks £vcry con-Hut ion, need we wender that it appears fo various [ 6 1 srarious in different people ? Sometimes there is an unu- . fual quantity of bile fecreted, producing a particular train of fymptoms which has induced fome to call it the bilious f fever, from an idea that the bile caufed the fever, when [ in fa& it is owing to the feafon or climate, which gives this variety to the difeafe ; but forms no funda- mental diftin&ion. This tendency in the bile to flow in unufual quantities is obfervable in all warm climates, • as well as in warm feafons; but it ought to be confideted among the effects and not among the caufes of this fever. That different feafons produce thefe varieties in fevers we know from Dr. Grant, who fays that every fumtner produces a difpofition to the fevers which we call ' putrid, and that nature carries them off by the fkin and the kidneys; that this difpofition or conftitution ends in the dy- w fenteric fever of Sydenham, which naturally goes off partly by the fkin and kidnej s, but chiefly by the bowels; that about the time of the autumnal equinox, nature feems difpofed to determine the morbid lentor chiefly towards the bowels, producing Cholera Morbus. Thefe determinations of nature, fays Dr. Grant, diftinguifh what is called the p bilious conftitution from the increafed fecretion of the bile, i and the colour of the evacuations, though this increafed fecretion is the effect and not the caufe of the difeafe. i , This conftitution terminates in an eryfipelatous fever^ j which differs in fevc.il particulars from the eryfipelas of ■ the fpring; this is fucceeded by the glutinofa fpontanea, which t 7 3 which appears in the form of peripneumonia notha of Sy- denham, and the atra bills or morbus hypochondriacs cum materia of the antients: This generally continues till the froft fets in, and is then fucceeded by the true inflamma- tory conftitution, which continues, more or lefs, through the whole winter and part of the fpring; but in the fpring it is complicated with epidemics peculiar to that feafon, the catarrhous fever, agues, fluxes, eryfipelas and febris humoralis, or fynochus non putris of the ancients. This diathefis continues in fome degree till near the fum- mer folftice, when it gives place to the fynochus putris. The mixed remittent fever or Synochus, appeared in the County of Middlesex, but efpecially in the neigh- bourhood of Watertown, during the fummer of the year 1788, nearly as Dr Moore defcribes it, excepting the tongue inftead of being covered with a whitifh mucus> for the moft part refembled raw beef; and the putrid fymptoms generally came on in three or four days aftei its appearance ; during this erythematic difcolouratior of the tongue and fauces, and previous to the appearano of putrid fymptoms, there exifted an extraordinary irri lability of the ftomach and fometimes of the inteftines which led us to conclude that the whole alimentar canal was limilarly affe&ed. In this ftate of the difeaft the* ufe of v. ine produced an intolerable burning fenfa tion.-—The fymptoms, in this fever, were greatly aug Rented towards evening, obferving the quotidian perio until [ 8 ] , until the decline of the difeafe, and then the exacerba- tions were moft confiderable in the morning, yet after a Jfhort remiffion there was a flight renewal of the fymp- jtoms in the evening.------- r, In a few inftances there were appearances of a Phlo- ft;ifiic Diathefis which induced fome Practitioners to bleed. Jn fuch, an inflammatory buff appeared, and yet if • venefedtion was repeated the coagulable lymph had a greenifh appearance from its tenuity, which with a bro- ken texture of the craflamentum deterred us from ad- vifing its repetition. In fome young perfons, with Srong fibres, and who were in plenitude of health pre- vious to the infection, there was a dry and diftreffing, ^:ough, with a pain in the thorax, which was moft com- , nonly accompanied with a bleeding from the nofe. As his haemorrhage commonly reliev'd the delirium which • bmetimes attacked the patient by the third day, it was uppofed that it was a falutary operation of nature, which ught to be imitated; but upon trial it was not found hat venefe&ion was advifeable. Neverthelefs all who led at the nofe in the firft ftage of this fever recovered, is didthofe that had thecatamenia, altho' they recovered sowly ; but all who bled at the nofe, or had any hae- iionhagic evacuation in the latter part of the difeafe, died, i Most commonly putrid fymptoms came on only about "ie fourteenth or fifteenth day. At this period there was great t 5> 1 great proftration of ftrength, with ifttrhims appearancee of the eyes and fkin ; and if no diarrhoea attended, the abdomen was tenfe, and to appearance more inflated than when otherwife and the patient nude bitter complaints whenever it was prefled upon. The tongue had now an aphthous covering, or was black and rough, as if fcorched, unlefs where hemorrhage attended. The difcharges at this period were frothy and mixed with blood, having the appearance of water in which raw flefh had been wafhed, and emitted a cadaverous fmell. In fome the putrid fymptoms ran to fuch a length as to produce a difeafe which for malignity was not far fhort of the plague. A. B. of Bedford, aged 30, of a ftrong athletic habit and fanguineous temperament, had never,been fick until the fummer of 1788. He was mowing in a very hot day in July, and when in a profufe fweat was thorough- ly wet, by a copious fhower of rain ; having got to his houfe, he laid down and flept fome hours in his wet clothes, and when he awoke complained of ftiffnefs of the joints and great languor, which was pretty foon fol- lowed by rigor. The next day he complained of fevere headach and naufea, with univerfal forenefs. In this ftate he took a cathartic and the following day was bled. On the 25th (the fourth from the feizure) his pain and other r. « i other fymptoms were, increafed, and the venefeclioii Was repeated. On the 27th other advice was applied for, and he Was found with a foul tongue, naufea and frequent difcharges by ftool, of dark coloured matter, with an univerfal tremor. He had taken fifteen grains of Ipecacuanha, without producing any vomiting; he now took thirty grains, but it excited only a cathartic affec- tion, after which, fome Emetic Tartar was thrown in, which in like manner operated only downward. At ,' this period of the difeafe (viz. 10th) the patient was fo funk by thefe evacuations, that Vibices appeared on his legs and arms, together with a ftupor, fmall weak pulfe, tumefied abdomen, dark coloured very foetid ftools2 aphthae on the tongue and fauces, and at length a niccough. \» this ftage of the diforder he took freely of bark " and wine, with the faline draughts, Spt. Minder. clyfters of chamomile, and alfo fixed air. The next day he appeared fomewhat better, he had lefs ftupor, the Vibices were brighter and the ftools lefs frequent, his abdomen ftill much tumefied. The injections of fixed air were continued, together with the bark and the wine. About the 14th day of the difeafe he feemed ftill better, his urine depofited a copious fediment, his pulfe was however very weak, and the Vibices turned to dark gangrenous floughs, they were drefled with tincture of myrrh, being very foetid, fomented with antifeptic herts, and the parts were held over Sat. Abfinthii and lemon juice* r. " i juice while effervefcing-----the ftools were then ids Se- quent and looked much better, but yet great deafnt".. and confiderable ftupor remained. From this period \ feemedto be on the recovery, and foon acquired ftrength fufficient to wa'k up ftairs, th; floughy vibices now changed to the ftate of fimple purulent ulcers, and had begun to cicatrife, when he expofed himfelf afrefh to wet and cold, for there was no confining him to a proper room, which was more owing to the delirium never en- tirely leaving him, than to an obftinate difpofition. He was now feized with rigor, his former putrid complaints immediately returned, together with bloody difcharges by ftool. At this time he was inadvertently purged, in confequenceof which he funk very much : The phyficiara being again called, ordered him an Enema of white pak bark, the Peruvian bark in tincture and fubftance, with decoclum urticarum, claret wine, alum whey, with the infufion of malt for common drink—This courfe check- ed the bloody difcharges, but his violent fymptoms were not abated, his pulfe was now very low and his body covered with Petechias, while nothing patted his bowels unlefs procured by an Enema : At length he coughed up a purulent matter and his whole body was almoft covered with black petechiae—He laid conftantly on his back, and a fanious matter oozed thro' every part of his fkin, while he expectorated pus mixed with blood until he died, which was on the 49th day from the firft attack. What What puzzles the youn^ practitioner, and not un frequently perplexes the -oil in this fever, is to knotv when the A^tiph'ogiftic Regimen is necefTary, end hcrv far it may be carried r It is equally important to know at what period of the fever a diff.rent mode of treat- ment is necefTary, si i to what degree the tonic or cordial courfe of remedies may be carried. An Antiphlogiftic regimen is found necefTary in fome degree, in all fevers at their beginning, particularly in the fpring of the year ; but then what we feem to gain in the beginning by evacuations, we lefe it; the end, even if the patient firvives, for in all fuch their recovery is very flow. The general mcJe of treatment is, tft, To diminifh the Diathefis Phiogiftica, if it ey • and concurring circumftances render it allowable. 2d. To prevent the irritation arifing from the morbid * accumulation and ftagnation of bile, and its confequent abforption, by feafonabie evacuations. 3d. To avoid all unnecefTary evacuations and obviats the effecls of debility and the fepric tendency by fuitable tonics, applied as well to the cuticular as the alimentary' furface.