MODERN PRACTICE OF PHYSIC EXHIBITING THE CHARACTERS, CAUSES, SYMPTOMS, PROGNOSTIC, MORBID APPEARANCES, AND IMPROVED METHOD OF TREATING THE DISEASES OF ALL CLLMATES. BY ROBERT THOMAS, M. D. OF SALISBURY, ENGLAND. THE THIRD AMERICAN, FROM THE FOURTH LONDON EDITION, REVISED AND MUCH ENLARGED BY THE AUTHOR. <„ £N>. M\hlM APPENDIX, BY DAVID HOSACK, M. D. F. L. S. Professor of the Theory and Practice of Physic and Clinical Medicine, in the University of tile State of New-York. NEW-YORK: PRINTED AND SOLD BY COLLIN3 & CO. Printer and Importers of Medical Books to the New-York Medical Institution, and to the New-York Hospital 1815. DISTRICT OF NEW-YORK, ss. BE IT REMEMBERED, That on the twelfth day of July, in tiv fortieth year of the Indepen- dence of the United Slates of America, Colliks & Co. of the said district, have deposited in this office the title of a book, the right whereof they claim as proprietors, in the words and figures follow- ing, to wit: " The Modern Practice of Physic : exhibiting the Characters, Causes, Srnip.'oms, Prognostic. ^ Morbid Appearances, ;ind Improved Method of Treating the Diseases of all C im.ttcs. By Re'it-rt 1 Thomas, M. D. of Salisbury, England. The third American, from the fourth London edition, '■ revised and much enlarged by the autltor. With :m Ap;:'*ndix, by David Hosack, M. D. F. L. S. , Professor of the Tiieory and Practice of Physic and Clinical Medicine, in the University of the State of New-York." In conformity to the act of the Congress of the United States, entitled " An act for the encourage- ment of learning, by securing the copies of maps, charts and books, to the authors and proprietors of \; such copies, during the time therein mentioned," and also to an act, entitled " An act, supplement- ary to an act, entitled an act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned, and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints." THE RON RUDD, Clerk of the Southern District of New-York * v PREFACE TO THE ENGLISH EDITION. I HE very favourable Reception which the Three former Editions of this Work obtained, affords to the Author a well grounded Hope, that the present one will be equally acceptable, particularly as great Attention has been paid in revising it, and adding nearly one hundred pages of uc.v and highly important Matter. Moreover, the different Prescriptions have*j£>een altered in Conformity to the new Nomenclature of the last London Pharmacopoeia; a relative View of the former with the present one, has been annexed to prevent Mistakes, and a Table of the Synonyms of the three Colleges of the United Kingdom, has been added for the Purpose of rendering the work more generally useful. The Diseases have again been divided into the follow- ing Classes, viz Pyrexiae, or Febrile Diseases; Neuroses, or Nervous Diseases; Cachexia?, or Diseases connected with a general bad Habit of Body; Locales, or Diseases only affecting Parts; those not referrible to any particular Class; the Diseases of the Pregnant and Parturient States, and those of Infancy; and although this Arrangement is by no Means perfect or unobjectionable, still, it may be sufficient to answer all useful Purposes. f The latest Writers of Celebrity have been consulted, and their Opinions been noticed ; the Result of the Author's Experience and Observation during a Practice of nearly Forty Years, has occasionally been introduced ; the most effectual Means for arresting the Progress of all contagious Diseases and for annihilating Contagion of every Kind, as well as for preserving the Health of Europeans in warm Climates, and of Sailors at Sea, have been pointed out; and as both warm and cold Bathing, as also many of the Mine- ral Waters of this and other Kingdoms, may be regarded as powerful Auxiliaries in the Cure of some Disorders, their different Virtues and Qualities have been specified. IV PREFACE. As the Diseases of all Climates .arc duly investigated in the Work, and it has been made as accurate and compre- hensive as possible, it may be considered as an useful Com- pendium of the present State of Medical Practice, from which the inexperienced will be likely to derive much In- struction, while it may at the same Time prove a service- able Reference to those of longer standing in the Profes- sion.—Occasionally, it may also serve as a safe Guide to the Clergy, and other country Gentlemen, who, in any case of Emergency or sudden Attack of Illness, either in their own Families or those of the neighbouring Poor, might find it necessary to administer some appropriate Remedy in the Interval of their being able to obtain proper Advice and Assistance. To answer this Purpose more effectually, a Table of the Weights and Measures used in the compound- ing of Medicines is placed at the Commencement. The Author wishes it to be understood, that the Doses advised in the various Prescriptions, are intended for Adults, except where they are particularly specified for Children or Infants. His great distance from the Press, he requests may be accepted as an Apology for the typographical Errors which exist in the Work. Salisbury, June 4th, 1813. A SYSTEMATIC ARR,\NGEMENT THE DISEASES INTO CLASSES AND ORDERS; TOGETHER WITH AN EXPLANATION AND DERIVATION OF THEIR NAMES. CLASH I. N,PAGE YREXLE, (Febrile Diseases) from a ^a, f)re, and efi«, habit ..•, 1 ORDER I. Febres or Fevers Febris Intermittens, (Intermittent Fever) Febris Remittens, (Remittent Fever) Synochus, (Simple Coiffinued Fever) from a-we^u, to continue Synocha, (Inflammatory Fever) from ditto Typhus Mitior, (Low or .Yerrous Fever) from Tt>p«$, stupor ------ Gravior, (Malignant or Putrid Fever) from ditto y ib. 3 18 24 3G 40 50 Icterodes, (Yellow Fever)from rvQas, stupor, and otnf««,icterus 62 ORDER II. Phlegmasia, (Inflammations) from tpxiyu, to burn . .82 Phlegmon, (Phlegmonous Inflammation) . . .84 Erysipelas, (Erysipelatous ditto) from eevu, to draw, and za-fAos;, adjoin- ing; named from the neighbouring parts being affected by the eruption . . . . . . .92 Phrenitis, (Inflammation of the Brain and Us Membranes) from M5, the cramp 312 Hysteria, (HystericDisease) from J«-^«, the womb . \ ;w Epilepsia, (Epilepsy) from i7ri?MM.&ava)i to seize upon, so named from rhe suddenness of its attack ... 317 .SYSTEMATIC ARRANGEMENT OF DISEASES. Vll PAGE Chorea Sancti Viti, (St. Vitus's Dance) from y/>e,eiot, a dance . 323 Itisus Sardonicus, [Sardonic or Convulsive Laughter) . . 326 Tetanus, (Cramp) from mveo, to stretch . . . ib. Singultus, (Hiccup, or Convulsive .Motion of the Diaphragm and Slo>- much) ....... 333 Pertussis, (Hooping Cough) from per, much, and lussis, cough 334 Pyrosis, (WaterBrash) {rom.m^uns, a burning . . 339 Angina Pectoris, vei Syncope Angiuosa . . . 340 > Palpilatio, (Pal'pitulion of the Heart) . . . .345 A'Mmvd, (Js(hma) from cto£ea,ta fear 35!> Coiica, (Colic) from -/.oXat, the colon, one. of the large, intestines 367 Colica Pictonum, (Dry Bellyache, or Devonshire Colic) . 370 Cholera Morbus, (Vomiting and Purging) from ^oAjj, bile, and pea, to flow ....... 376 Diarrhoea, (Pur^inx) {rom hc/Zp'ptw, to flow through . . 379 Diabetes, (Excessive. Discharge of Urine) from ci», through, and [iam,, topa-s . . . . . . .335 ORDER IV. Vesanee, (Mental Diseases) from vesama, madness . . 395 Mania, (Madness) from fMtmpuu, to rage . . .391 Incubus, (Ni.rhi-mare) . . . . .411 CLASS III. CACHEXLE, (Cachectic Diseases) from xxkos, ill, and jf/?, a habit 412 order 1. Marcores, (Universal Emaciation) . . . .412 Atrophia, (Atrophy) from «, priv. and tpoepn, nutrition . ib. Phthisis, (Pulmonary Consumption) from , to consume . 415 Cachexia Africana, (Negro Cachexy) .... 440 Aphtha Chronica, (Chronic Thrush) from wra, to inflame . 442 order u. Intumescentee, (General Swellings) . . . 445 Polysarchia, (Corpulency) from voXv,, much, and A«r«v/£ the spine of the back . .481 V*U SVSTEUATIC ARRANGEMENT OF DISEASES. ORDER III. ?AGE Impetigines, (Cutaneous Diseases) from in, and petigo, a scab 487 Scrofula, (Scrofula, or King's Evil) from scrofula, a swine, because this animal is said to be subject to a similar disorder . ib. Mesenterii Glandulae Morbosae, (Diseased Mesenteric Glands) . 499 Syphilis, (Venereal Disease) from b-s^, an eye ib. Amaurosis, or Gutta Serena, from cc,u.xvgacrt<;, obscurity . 577 Paracusis, (Deafness) from ■*■:<,>*, wrong, and axva, to hear . 580 ORDER If. Increased Appeiile. DvsoRExr e, (Depraved Appclite-s) from <5V«, bad, and e£ef. ORDER V. Epischeses (Obstructions) from tTri^ea-n, a suppression, or retention 593 Obstipatio, (Constipation or Cosiiveness) from obstipo, to stop up ib Ischuria, (Suppression of Urine) from ivyj,, to restrain, and«f«», the urine 595 SYSTEMATIC ARRANGEMENT OF DISEASES. IX. PAGE Dysuria, (Difficulty of voiding Urine) from ^«, difficuir,, and v^ov, the urine . . • • .595 Amenorrhea, (Partial or total'.Obstruction of the Menkes from other Causes than Pregnancy) from x, priv. wnaioc,, monthly, and leu, to flow ....... '00 Chlorosis, (Retention of the Menses, or Green Sickness) from -^Xupitcu, to look green ...... 601 Amenorrhea Suppressions, (Suppressed Menses) - . 606 -----.------Difficilis, (Difficult and Painful Menstruation) . 608 ORDER vr. Tumores, (Tumours) ..... 609 Carcinoma, (Cancer) ...... :b. Fungus Haematodes, (Medullary Sarcoma) from fungus, and xi^xra^m from xipcx, blood ..... 623 B:onchocele, (Derbyshire Neck) from Bpov%oc,, the windpipe, and xijAjj, a tumour ....... 625 Dnicuncuius, (Guinea Worm) .... 6^9 ORDER VII. Dolorosi, (Painful Affections, unaccompanied by Pyrexia) . 631 Cephalalgia, (Headache) from x.e>, the head, and xXyor,, pain ib. Odontalgia, (Toothache) from o<$V«, a tooth, and «Ayo?, pain . 633 Faciei Morbus Nervorum Crucians, (Tic Douloureux, or Painful Af- fection of the Nerves of the Face) . . . .635 Gastrodynia, (Pain in the Stomach) from yusty, the stomach, and oo^a, pain ...... 637 Luxalio, (Sprain) . . . . .638 Cah.;i.'!(5s, (Stone in the Bladder and Gravel) . . 639 ORDER VIII. Dialyses, (Sol'dioiiSjOrDiscontinuily of Parts) from haWa, to dissolve 647 . ib. . 651 . 6c5 . 6a7 . 658 . 660 . 661 . 662 . 663 Ulcus, (Ulcer) Vuinus ex Ustione factum, (Scalds and Burns) Herpes, (Tetters) from tp-jru, to creep Tinea Capitis, (Scald Head) from leneo, to hold Psora, (Itch) from ij/upx, the itch Impetigo, (Ring-worm) GuitaRosea, (Pimpled Face) Chigre, (a>i Insect resembling a Flea) Pernio, (Chilblain) DISEASES NOT REFKRRIBEE TO ANY PARTICULAR CEASS, 6'' 4 Vermes, (Worms) . . . . . . ib. Venena, (Poisons) ...... 667 Animatio Suspcnsa, (Suspended Animation) .. . .682 Gelati;., (Frost-bitten) ..... 688 DISEASES OF THE PREGNANT STATE, 688 Convulsiones, (Convulsions) . . . . 694 Abortio, (Abortions and Floodings) . . . 697 (b) * X SYSTEMATIC ARH'.NGEMENT OF DISKASI'S. PAt-T DISEASES OF THE PUERPERAE STATE, . 706 Lochia, (Discharge after Labour) from Xo%eva, to bring forth ib. Febris Lactea, (Milk Fever) . . . . .707 Inflammatio Mammae, (Tumour and Inflammation of the Breast) 708 Papillae Excoriata;, (Excoriated Nipples) . . . 709 Eruptiones Miliarias, (Miliary Eruptions) . . .710 Phlegmatia Dolens, (Painful Intumescence of the Loner Extremity) ib. Hysteritis, (Inflammation of the Womb) from urepx, the womb 716 Peritonitis, (Inflammation of the Peritonaeum) from -xepireisu, to stretch round ...... 720 Febris Puerperarum, (Puerperal, or Child-bed Fever) . 723 Prolapsus Uteri, ...... 738 DISEASES OK INFANTS, . . 735 Asphyxia, (Apparent Cessation of Life,) from «, priv. and o-. Liquor. Ammon. Acctat. giij. &q. Cinnam. 3!]. — Purae gv. if\n. Anumon. Rl. x. Syrup. Cort. Aurant. gj. M. ft. Haustus. Vd IJ. Pulv. Antimonial. gr. ij. -----—Contrayerv, gr. x. M. ft.PuIv ^tis hori9 sumendus. Vd Ko. Pulv. IpecRc. C. gr.x. Capiat secunda quaque ftora. C 10 PYREXIAE OR FEBRILE DISEASES. CLASS I. In Dr. Lind we find an advocate for the exhibition of opium likewise in the hot fit. He tells us he has observed, that, if taken during the intermissions, it had not the least effect either in pre- venting or mitigating the succeeding paroxysm ; when given in the cold fit, it once or twice seemed to remove it : but that when administered half an hour after the commencement of the hot fit, it generally afforded immediate relief. When given in the hot fit, he observed the following effects to ensue: 1st, It shortened and abated the fit; and this with more certainty than an ounce of the bark was found to affect the disease. 2d, It generally gave a sen- sible relief to the head, took off the burning heat of the fever, and occasioned a profuse sweat. This sweat was attended with an agreeable softness of the skin, instead of the burning sensation which affects patients sweating in the hot fit, and was always more copious than in those who had not taken opium. 3d, It often produced a soft and refreshing sleep to a patient tortured in the agonies of the fever, from which he awaked bathed in sweat, and in a great measure free from all complaints. The Doctor has always observed, that the effects of opium are more uniform and constant in intermitting fevers, than in any other disease, and are there more quick and sensible than those of any other medicine. An opiate thus given soon after the com- mencement of the hot fit, by abating the violence, and lessening the duration of the fever, preserves the constitution so entirely unin- jured, that, since he used opium in agues, a dropsy or jaundice has seldom attacked any of his patients in those diseases. When opium did not immediately abate the symptoms of the fever, it never increased their violence: on the contrary, most patients reaped some benefit from an opiate given in the hot fit, and many of them bore a larger dose at that time than they could at any other. Dr. Lind offers it as his opinion, that opium in this dis- ease, is the best preparative for the bark ; as it not only produces a complete intermission, in which case alone that remedy can be safely administered, but occasions such a salutary and copious eva- cuation by sweat, as generally to render a much less quantity of bark requisite. When we obtain an intermission, the cinchona bark is to be given during the intervals, in large doses. One or two drachms of the powder may be taken every hour, if the stomach will bear so much, as the benefits to be expected from this medicine greatly de- pend on a large quantity being administered in a short space of time; for five or six ounces of bark taken in a few days, will be attended with a much better effect than perhaps as many pounds taken in the course of some weeks. If it will not sit easy on the stomach in substance, we must be content to substitute a decoction or infusion of it, or we may give the extract* joining a few dropi of sulphuric acid. * R. Extract. Cinchon. gr. xv. Decoct. Ejusdem J, jss. Tint. Cort. Aurant. gj. M. ft. Haustus 2da hora sumendus. MRDER I. INTERMITTENT FEVERS. 11 Where the intermissions between the paroxysms are long, as in the tertian and quartan types, we should delay giving the bark until within eight hours or so, of the accession of the cold fit. If all the forms which have been mentioned are nauseated and rejected by the stomach, we may advise the bark to be given in clysters, in which form it likewise proves very efficacious. For this purpose about a drachm of its extract, dissolved in a sufficient quantity of water, with the addition of a few drops of tinctura opii, in order to its being longer retained, will be most proper. With children who cannot be prevailed on to take the bark, we may ad- minister it with much efficacy in this way, repeating the clyster every four hours. For the cure of intermittents in children, the bark has likewise proved effectual when applied externally, by put- ting the powder of it into a quilted waistcoat. In most intermittents it would perhaps be the best practice to unite opium with the cinchona bark, as it would enable the sto- mach to bear much larger doses of the latter, and likewise add very considerably to its good effects. Various substances of either an astringent, stimulant, or aromatic nature, such as alum, the various preparations of iron, he. nut- meg, and snake-root, have been joined to the cinchona bark, with a view of increasing its powers; but as these lessen its dose by their bulk, it will be best to give it by itself, unless it occasions a purging, and then about eight or ten drops of tinct. opii, or about a drachm of the tinct. e kino, may be added to each dose. On the contrary, should it produce costiveness, some gentle laxative may be taken occasionally, such as a few grains of rhubarb. In intermittents of long continuance, where the person is ad- vanced in years, and weak, the habit phlegmatic, the season rainy, and the situation damp, it will be proper to make an addition of snake-root and some warm aromatic * to the cinchona bark, and when the symptoms have more of an inflammatory tendency, it may be given with a small portion of the potassae subcarbonas.f In cold climates, it will in general be advisable to wait for a per- fect and regular intermission before we give the bark: but in warm ones, where intermittents are apt to degenerate into continued fevers or remittents, and in which the habit is more irritable and weak, it will be right to administer it, even on the most imperfect intermission, or slightest remission. In all cases of intermittents, it will not be sufficient that the re- currence of paroxysms be stopped for once or twice by a use of the bark; a relapse is commonly to be expected, and it should there- ' R. Pulv. Cort. Cinchon. §j. Coq. in Aq. Font. Ibj. ad ibss. Colat. adde Tinct. Serpent. Rad. ———Card. C. a a gvj. M. Capiat Cochl ij. magna pro dos. f R. Decoct. Cort. Cinchons ^jss. Potassae Subcarbon. gr. x. ad xv. Syrup. Althsese fij. M. ft. Haust'us. 12 PYREXIA OR FEBRILE DISEASES. CLASS I- fore be prevented by a continued exhibition of the medicine at pro- per intervals ; even for some w< "ks after the disease appears to be removed, it may be advisable to take a little of it occasionally, par- ticularly in damp weather, or during the prevalence of an east- erly wind. Various species of the bark are now to be met with among the venders of this medicine, and we have been favoured with the re- port of several gentlemen * of eminence in their profession, giving a decided preference to the yellow (Cinchonas cordifoliae cortex,) as possessing virtues far superior to the red, or any other species yet introduced into use. From various trials made with it, these physicians report, that it is bitterer to the taste, and more astringent, than the other sorts; that a decoction and infusion of it are less liable to undergo fer- mentation ; and that in every instance in which it was used by them, it invariably proved successful. Half a drachm of the yel- low bark in powder, given every two hours, has in general been found sufficient for the cure of an intermittent; hence they have presumed that it possesses nearly a double febrifuge power to that of common bark. Of its good effects I can myself bear testimony, having used it with the most decisive success. During my residence in the West Indies, I met with many cases that resisted the powers of cinchona, and that gave way to a use of quassia. Indeed, so sovereign a remedy was this found in inter- mittents, and so easy was it to be obtained, that it was pretty gene- rally substituted by all practitioners for the cinchona in common cases on the plantations. The best way of administering it is in the form of infusion or decoction, as below.f The Angustura bark (cortex cusparis) is another remedy which I have often used with success. Other substitutes for cinchona have been mentioned and ad- vised. In the sixth volume of Medical facts and observations, published in the year 1795, we are favoured by Dr. Roxburgh with an account of a new species of the swietenia (mahogany,) which from repeated trials, and experience from its effects, he pro- poses as a substitute for the cinchona. He calls it the swietenia febrifuga, and says, its astringent and bitter qualities are more in- tense than those of the Peruvian bark, and that its active parts are much more soluble than those of the other, particularly in watery menstruums. He adds, that it contains a much larger share of active (bitter and astringent) powers than cinchona oblongi folia * Dr. Relph, Dr. Saunders, and Dr. Babington, physicians to Guy's Hospital • Dr. Lind, of Haslar Hospital; and the late Dr. Woodville. ' } 5>. Quassiae gij. Coq. ex Aq. Fontan. Ibj. ad ftss. Colat. adde Tinct. Card. C. 3J- M suraat Cochl. iij. 3tia quaquc hora. Vd Quassiae gij. Aq. Bullient. §viij. Post horam unam Col. ct adde Tinct. Cascaril. gj. M. ORDER I. INTERMITTENT FEVERS. 13 or red bark ; that watery preparations of it remain good much longer than similar ones of the latter; that spirituous and watery preparations of it bear being mixed in any proportion without de- composition ; and that its antiseptic powers are stronger. A great variety of other barks, such as the cinchona Jamaicensis discovered by Dr. Wright; the cinchona Charibbaea or St. Lucia bark, the Tellicheri bark, Sic. have been substituted for the Peru- vian with a very good effect when this could not be obtained. As a tonic and febrifuge, the willow bark has of late years been much employed with considerable success both in England and on the continent. The varieties of the willow which have been noticed by botanical writers are very numerous; but the salix latifolia or caprea (broad-leafed willow bark) seems to possess virtues greatly superior to the others. A late writer * has endeavoured indeed to convince us, that it has a superior efficacy above the cinchona in various diseases, more particularly that branch of the healing art termed medical surgery. The decoction is the form to which this practitioner gives the preference ; one ounce and a half of the dried and pounded bark boiled for a quarter of an hour in two pints of soft water. Of this, the ordinary dose is two or three large spoonfuls, given three or four times a day. A cheap substitute for the bark of cinchona and which has proved very successful, consists of equal parts of bistort and calamus aro- maticus, with the addition of a little ginger. This remedy may be given in the same doses as the former. The radix rhataniae is another substitute, which has lately been proposed for the cinchona ; but from a few trials I have made of it in intermittents, I am convinced that it is by no means deserving of the encomiums which have been lavished on it by Dr. Rees. Twenty grains of the powder may be considered as a moderate dose ; and it may also be employed either in the form of extract, decoction, or tincture. All these barks, probably, owe their efficacy to one common prin- ciple ; but what this is, it may be difficult to ascertain. Their febri- fuge power has been attributed by some principally to the tannin, which they all contain in a greater or less quantity; but this opinion must be erroneous, as it appears from Mr. Davy's experiments that very little tannin is contained in the cinchona, or in the other barks supposed to be possessed of febrifuge properties. In intermittents, where, from flatulency, distention of the abdo- men, or a retention of faeces, it becomes necessary to have recourse to laxatives, we may employ something of a warm aromatic nature,f * See Wilkinson's Experiments on the broad-leafed Willow Bark. f R. Pulv. Rhabatb. g. xv. vd ----Cinnam. Compos, gr. v. R. Infus. Senna; ?j«. Potassae Sulph. gr. xij. M. Tinct. Rhei 3JL ft. Pal vis. -----iiav. c. 3J. M. •ft. Haustus. li PYREXIA OR FEBRILE DISEASES. CLAbS I. which should be taken during the intermissions, so that its opera- tion shall have ceased before the accession of the next paroxysm. It often happens, when intermittents have continued a long time, that scirrhosities of the liver or spleen take place, which are vul- garly denominated ague-cakes. These complaints have been attri- buted to an improper use of the cinchona bark ; but they evidently arise from the great quantity of blood, which is thrown on these parts during the cold fit, which distends them, and so produces a scirrhosity in them, and which we often find it difficult to remove, although a stop is put to the fever. In such cases it may be pro- per to join deobstruents with cinchona, as below* If these do not answer, we must have recourse to mercury .f A small dose should be given every night, so as just to affect the mouth, but the toniG medicines are to be continued. If the patient cannot take this re- medy internally, he must substitute its external use in the form of unction, rubbing into the groins about a scruple, if an adult, of the unguentum hydrargyri fortius every night at bed-time. In warm climates particularly, these swellings are often to be met with as the consequence of long-continued intermittents; but of these, more particular mention is made under the head of Chronic Inflammation of the Liver. These tumours, by pressing on the ramifications of the vena por- tarum, which passes into the liver, and branches in the manner of artery, prevent the blood from returning from the abdominal an viscera with the same facility that it commonly does. The passage of the blood being thus retarded, occasions a greater extravasation of lymph in the cavity of the abdomen, so that the ordinary exer- tion of the absorbents is not sufficient to take up the whole lymph. Thus an ascites takes place ; and in this case we must have recourse to the means advised under that head. Dropsy likewise arises sometimes from mere weakness, without any tumour of the abdominal viscera, and occasioned by the long continuance of the disease. In these instances, it may be removed by exhibiting the bark of the cinchona together with stomachic bit- ters, diuretics, and chalybeates. As the strength returns, and the patient recovers his health, the dropsical appearances will diminish by degrees. When tumours are formed in any of the abdominal viscera, it not uncommonly happens, that they press on the ductus communis choledochus, the duct of the gall-bladder, the hepatic duct, or the pori biliarii, by which means the bile is prevented in part or wholly R.Pulv. Cinchon. 33. ——Rhei. gjss. Sodx Subcarbon. gij. Syrup. Zingib. q. s. M. ft. Elect. Cujus sumat Cochl. min. ter quaterve in die. f R. Hydragyr. Submuriat.gr. j. Confect. Opii. gr. iij. M. fiat Pilula omni nocte sumenda. Vd R. Pilul. ex Hydrargyro gr. iij. ----ex Opio gr. ij. M. ft. PiUla. & J ORDER I. INTERMITTENT FEVERS. 15 from getting into the duodenum; it is therefore absorbed, and pro- duces jaundice of itself, without any concomitant dropsical symptom, or along with it, ascites. When this happens, the disease is general- ly fatal. The blood, by being determined from the blood-vessels upon the abdominal viscera, when the patient becomes weak after an inter- mittent has continued for some months, sometimes occasions an in- creased secretion from the glands of the intestines, and thus gives rise to a diarrhoea. This affection usually proves more severe during the remissions and intermissions; and 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 consider- ably, and not unfrequently occasions dropsical appearances. At first, oedematous swellings appear in the lower extremities; these increase, rising up to the thighs, and then to the integuments of the abdomen. Ascites also takes place. If astringent remedies be em- ployed, so as to put a stop to the diarrhoea, the dropsical appear- ances usually increase, and the intermittent continues to recur, al- though often very obscurely and very irregularly. If the diarrhoea be permitted to go on, or if it has been stopped, and is allowed to return by leaving off the astringents, the weakness increases in such a degree as to destroy the patient. If the bark of cinchona be ex- hibited, it often increases the diarrhoea without having the effect of preventing irregular returns of the attacks or exacerbations. In this case Dr. Fordyce* says it will be best to clear the prima? viae, by employing about twenty-five grains of rhubarb; after its opera- tion is over, 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 tinctura opii, together with a moderate quantity of any of the warmer spices every four hours. In some cases of intermittents, which have continued a great length of time, owing to their having been entirely neglected in their beginning, or where the cinchona has failed to procure the desired effect, preparations of iron and copper have been administer- ed with success. The oxydum zinci given in the dose of two grains thrice a day, has removed obstinate intermittents, when the usual remedies have failed. The sulphas zinci has likewise been administered with much success. The sulphate of copper given in doses of a quarter or hah a grain every four or six hours, is also said to have proved very ef- ficacious in some cases of obstinate intermittents. As a tonic, the cuprum ammoniatumf has been given with advantage. All * See his Fourth Dissertation on Fever. f R- Cupr. Ammoniat. ^j. Mic. Panis gij. >•_ Syrup. Cort. Aurant. q. s. M. fiant pilul. No. xxiv. Capiat j. vd Ij.—^ilj- (sensim augend* dosem) hora decubitus quotidie. 16 PTREXI^ OR FEBRILE DISEASES. CLASS 1. these may be employed along with a decoction of the cinchona, or any of the other tonic bitters which have been mentioned. Arsenic has been strongly recommended as a remedy in intermit- tents, and it is undoubtedly a very powerful medicine, for I have found it to remove obstinate intermittents which had long resisted all other means. The inhabitants of a considerable portion of the country which surrounds Salisbury (the place of my residence) arc very subject to these fevers, but I have never yet been disappointed . in removing even those of an obstinate nature, by a proper use of arsenical solution; it is however my constant practice to conjoin four or five drops of tinctura opii with each dose of it. The late Dr. Fowler seems to have been the first physician to ad- vise this medicine in agues, and on his recommendation many prac- titioners have used it, agreeably to his directions, with the most pointed success. The preparation he advised is now introduced into the London Pharmacopoeia, under the name of Liquor Arseni- calis. The dose is from two to twelve drops, once, twice, or oftener in the day, according to the age, strength, &c. of the patient. Eight days administration of the medicine, in the manner just mentioned, will generally be found sufficient for the radical cure of an inter- mittent. Vomitings, gripings, swelling'-, and the loathing of food, arc the troublesome symptoms now and then produced by an improper use of the arsenical solution. They however disappear generally on a discontinuation of the drops, or only require the exhibition of gentle opiates, or some warm cathartic, such as the tincture of rhubarb. From the observations which have been made on the use of arse- nic in agues, there seem just grounds for believing it to be the most powerful of all the medicines which have been recommended in these complaints. In Lincolnshire, which is a fenny country, where agues are very prevalent, it is universally used, and with the most . uniform success. Military and naval surgeons will find the arse- nical solution a valuable substitute for the bark of cinchona, when their store of this is small or exhausj«d. Arsenic has long beea administered by empirics with the greatest success in intermittents, under the appellation of the ague-drop. The manner in which arsenic acts in curing intermittent fevers, Dr. Darwin thinks, cannot be by its general stimulus, because no intoxication or heat follows the use of it; nor by its peculiar stimu- lus on any part of the secreting system, since it is not in small doses succeeded by any increased evacuation or heat, and must therefore exert its power on the absorbent system. He suspects its success in the cure of intermittents to depend on its stimulating the stomach into stronger action, and thus by the association of this viscus with the heart and arteries prevents the torpor of any part of the sangui- ferous system. A combination of the arsenical solution with cinchona* in sub- • R. I.iquorii Arsenical, m. iij.—xij. j ------Opii 111. v. M. Decoct. Cir.chon. "Zx. { ft. Haustus ter in die sumendus. Tinct. Core. Aurant. gij. Vd ORDER I. INTERMITTENT FEVER. 17 stance, decoction, or infusion, is likely, I think, to prove a valuable remedy in cases of obstinate intermittents, and where either of these medicines administered singly might fail. During the fits of an intermittent the patient's strength is to be supported by food of a light nutritive nature, such as preparations of barley, sago, panado, and the like; but when the fit is off, he may be allowed animal food, and a moderate use of wine. A change of air and situation has sometimes a happy effect in removing an intermittent, particularly if from a low marshy country to an ele- vated one. In autumnal intermittents it has been found that the air of a city or large town is more favourable than that of the country, owing most likely to the great number of fires that are always burning. When none of the viscera are affected, cold bath- ing may be used with advantage. As intermittents are very apt to return, the patient should care- fully avoid all such causes as might produce a fresh attack. Should he be incommoded by a giddiness of the head, which is not uncom- monly the case even after a slight attack of this fever, it may gene- rally be relieved by volatiles* and the bark in wine. The chief malady which prevailed among the British troops on the island of Walcheren, and which swept off so many of them in a short space of time, was evidently the endemic fever of marshy countries. It made its appearance towards the close of summer, and became very prevalent during autumn, particularly in the months of August and September, shewing itself at first under the quotidian, tertian, double tertian, quartan and even remitting type, (but of all these the double tertian was the most common) after- wards degenerating in many instances into a continued fever of the typhoid nature, accompanied with considerable malignancy. The disease apparently, was not contagious in itself, but assumed this new form and character of fever wherever ventilation was defective, the patients much crowded together, or where other local causes of impurity prevailed. This was particularly noticed at Flushing, where the accommodations for the sick were very con- fined and crowded, and where the ditches were foul and obstructed from the consequences of the siege, and the streets filthy from an imperfect police. Among those whose constitutions had not been habituated to the climate, who had been much exposed to wet and damp, who had undergone great military fatigues, and who were accommodated in close confined quarters, the disease assumed a cha- racter of much maligt-.ity, corresponding with the degrees of com- binations of all the predisposing causes. On the approach of winter, the disease subsided, but was only R. Infus. Rad. Columb.g xij. Liquor. Arsenical. Ml. v. Tinct. Opii IU. viij. _ —— Cinchonas C. gj. M. ft. Haustus 4ta vel6ta quaque hora capiendus. Rj. Aq. Menth. % iijss. Spirit. Ammon. Aromat. TO., xxx.—L. Syrup. Cort. Aurant. J;ss. M. Capiat Cochl. larg. j. ter quaterve in die. D 18 PYREXIA OR FEBRILE DISEASES. CLASS I. put a stop to by removing the convalescents as speedily as possible to England previous to the entire evacuation of Walcheren. The treatment was varied as the fever assumed an intermittent, remittent, or continued type, and the appropriate remedies noticed under each of these heads, were resorted to accordingly. Most of the cases which did not terminate fatally, were tedious and subdued with difficulty, and when overcome, left behind them great debility as well as a strong disposition to relapse : perfect recoveries were rare, convalescence never secure, and where the recurrences of fever did not destroy life, they laid quickly the foundations for vis- ceral obstructions, thereby rendering a large portion of the sufferers unfit for after military purposes. Chronic diarrhoea, dysentery, and dropsy, were frequent consequences. The deaths were nume- rous and often sudden. Had several large hospital ships been moored in convenient si- tuations at a little distance from the land, and the convalescents been quickly removed to them on their recovering from the first attack of the fever, several of the fatal relapses which took place among those who continued to be exposed to the local exhalations might have been prevented, and many valuable lives have been saved. REMITTENT FEVER. 13y a remittent is to be understood where the fever abates, but does not go off entirely before a fresh attack ensues; or, in other words, where one paroxysm succeeds the other so quickly, that the patient is never without some degree of fever. It is to be observed, moreover, that the remissions happen at very irregular periods, and are of uncertain duration, being sometimes longer and sometimes shorter. This fever is principally induced, as well as the intermittent, by marsh miasma, and is most apt to arise when calm, close, and sul- try weather quickly succeeds heavy rains or great inundations. In warm climates, where great heat and moisture rapidly succeed each other, the remittent is a very prevalent type of fever. It is like- wise often met with in low marshy situations abounding with wood and water, and is most apt to attack those of a relaxed habit, those wHo undergo great fatigue, and those who breathe an impure air, and make use of a poor and unwholesome diet. Although this fever is produced originally by marsh miasma, still it probably may afterwards be spread by contagion, and not un- clim" ~ °meS a Prevailin§ epidemic, particularly in tropical Preceding an attack of a remittent fever, the patient is usually heavy and languid, and is troubled with anxiety, listlesness, sigh- ing, yawning, and alternate fits of heat and cold. On its accession he experiences severe pains in the head and back, intense heat over the whole body, with thirst, difficulty of breathing, and great de- S1 lSPm.tS; the t05Sue is whJte; the eyes Imd skin appear yellow; there is pain and a sense of swelling about the region of ORDER I. REMITTENT FEVER. 19 the stomach ; nausea, and a vomiting of bilious matter, ensue ; and the pulse is frequent and small. After a continuance of these symptoms for a time, the fever abates considerably, or goes off imperfectly by a gentle moisture diffused partially over the body; but, in a few hours, it returns with the same appearances as before. In this manner, with exacer- bations and remissions, it proceeds at last to a crisis, or is changed into a fever of a different type. In warm climates, the remission often occurs so early as the second day ; but in cold ones, it fre- quently does not take place until from the fourth to the sixth or eighth day. The accession of fever, which has just been described, is how- ever the mildest form under which it ever makes its appearance ; for sometimes a severe delirium arises, and carries off the patient during the first paroxysm ; or the remission, perhaps, is scarcely per- ceptible, and is immediately followed by another paroxysm, where- in there is a considerable aggravation of all the symptoms. The heat of the body is greatly increased, the face is highly flushed, the thirst is excessive, the tongue is covered with a dark brown fur, respiration is laborious, the pulse is quick, throbbing, and tremu- lous, and a delirium arises. At the distance of some time, perhaps another short or imperfect remission again takes place ; but the symptoms return once more with redoubled violence, and at length destroy the patient. The symptoms which attend a remittent fever are apt to vary according to the situation and constitution of the patient, and like- wise the season of the year, and therefore it is impossible to give a certain detail of them; for sometimes those pointing out a re- dundancy of the bile predominate ; sometimes the nervous are most prevalent; and at other times the putrid. A remittent fever is always attended with some hazard, particu- larly in warm climates, in which it usually goes through its course in the space of five or six days; but in cold ones, its crisis is not usually effected until the twelfth or fourteenth. The shorter and more obscure the remissions are, the greater will be the danger, and each succeeding paroxysm is attended with more risk than the former. On the contrary, the milder the attack, and the nearer the fever approaches to an intermittent, the fairer will be the prospect for a recovery. The usual appearances on dissection are, congestions of blood in the liver, inflammations in the alimentary tube, and a morbid state of the brain. From the determinations to particular organs, which take place in a remittent fever, and the marks of inflammation which are to be observed on dissection in the stomach and biliary organs, it would seem that bleeding is a necessary operation. In cold climates, and in a very early stage of the disease, it may be proper to have re- course to it, where the patient is young and of a full plethoric habit, the pulse full and hard, the heat intense, the breatliing difficult, or 20 PYREXIJE OR FEBRILE DISEASES. CLASS I. the head much affected with stupor or delirium ; but m warm cli- mates, when few or none of these symptoms are present, it would certainly prove injurious, especially if the person has been an in- habitant therein for any length of time, and not lately arrived from Europe. . In every instance almost in which bleeding has been adopted, it has proved highly pernicious by inducing a state of extreme debih^, under which the powers of life soon become exhausted. To allay the violence of the fever, it will be more prudent care- fully to remove and avoid every thing that might in the least con- tribute to increase it, such as too strong a light falling on the eyes, all noise and motion, and likewise any excess of heat. The patient is therefore to be kept perfectly quiet; the covering of his bed is to be light, and his chamber of a moderate temperature, by allowing a free admission of cool air into it. To assist these means, ht should be presented from time to time with some cooling acidulated liquor, such as lemonade, tamarind beverage, or a solution of the crystals of tartar, or even cold water. Throughout the whole course of the disease, it will be advisable to change his body-linen, as well as that of the bed, frequently: to sprinkle his chamber often with vinegar; and to remove immediately whatever he voids by stool. As nausea usually prevails at the commencement of the disease, it will, in all cases, be right to cleanse the stomach by giving a gentle emetic of ipecacuanha, or a solution of tartarised antimony, which perhaps may be preferable : the operation of this being over, the bowels may then be emptied by some gentle laxative, which will seldom fail in bringing off a considerable quantity of dark bilious matter. Drastic purges, by determining inwardly and increasing the irritability of the stomach, would be prejudicial; and therefore, if it is necessary to obviate costiveness in the course of the disease, it will be most advisable to do it by the laxative medicines here prescribed,* assisted now and then with aperient clysters. The necessity of carefully inspecting the alvine discharges in remittent fever cannot be too strongly inculcated, as it affords the best or principal index as to the regulation of our employing pur- gative medicines. In this fever, as well as typhus icterodes, the submuriate of mer- cury combined with rhubarb or jalap may be regarded as a valuable remedy, where we wish to carry off putrid feculent matter from the bowels, and there is at the same time any degree of nausea or * R. Potassx Tartrat. 3ij. Rj.Pulv. Rhei. gr. x.—xv. Infus. Sernae §jss. Hydrargyr. Submuriat. gr. v. Tinct Jalapas TO- **• M. Syrup, q. s. M. ft. Haustus. Fiant Pilul. v. pro dos. Vd Vd R. Hydrargyr. Submur. gr. v. Pulv. Jalap, gr. xv. M. ft. Pulvis. ORDER 1. REMITTENT FEVER. 21 vomiting present; as, from the smallness of its bulk, it may pos- sibly be retained on the stomach, when every other purgative might be rejected. After these evacuations, and where there is no delirium present, an opiate will be found of great service in quieting the commotions induced either by the spontaneous or artificial discharges, and in enabling the patient to retain on his stomach both nourishment and medicines. In the remittent fevers of warm climates, as well as of temperate countries in the hotter seasons of the year, the best effects are to be derived from cold affusion, or throwing cold water over the pa- tient ; but it is to be understood that the height of the paroxysm is the proper time for the application of the remedy. The sensations of heat are then strong; the head-ache is violent, and delirium fre- quently runs high. By employing the remedy at an early period, we may be able either to arrest the disease precipitately, or bring about an early solution of the paroxysm, but at the least we may for the most part so ameliorate its aspect as that from an obscure remittent it will soon become an intermittent of a distinct and re- gular type. Where signs of congestion, or irregular action, pre- sent themselves in the abdominal or biliary system, and the disease is recent, it will be advisable, previous to having recourse to affusion, to premise proper evacuations. In the progress of the disease, where much debility has arisen, aspersion, or sponging the body over with cold water and vinegar, together with an internal use of wine, may be substituted for affu- sion or immersion. The general effects to be observed from affusion, where it can be practised with propriety, are a diminution of heat and anxiety, greater cheerfulness of countenance, improved recollection, ten- dency to sleep, the pulse becoming fuller and more uniform, and the skin moist, with now and then a distinct remission. To alter the type of the fever, and bring the remission into per- fect intermissions, if possible, by promoting a gentle diaphoresis, it will be proper to give antimonials in small and frequently repeated doses. They may be prescribed as mentioned under the head of Simple continued fever, or as below ;* -.nd to assist their effect, the patient should take frequent small drafts of some tepid dilut- ing liquor. Where frequent vomitings prevail, antimonials will not be pro- per. In their stead we may direct the saline medicine to be administered so as that the effervescence shall take place in the sto- mach, with the addition of about ten drops of tinct. opii to each dose. Moreover, we may direct flannel cloths wrung out in a warm * R. Pulv. Jacob. Ver. gr. iv. Camphor, gr. iij, Confecr.. Rosae q. s. M. ft. Bolus, 3tia vel 4ta hora sumendus. o> PYREXLE OR FEBRILE DISEASES. CLASS I. decoction of chamomile-flowers and bruised poppy-heads, with an addition of rectified spirits, to be kept constantly applied over the region of this organ. Should these means fail in procuring the desired effect, a large blister may be put immediately over the part, which will be found, in general, a very effectual remedy. The early application of a blister, even in cases where no great irritability of the stomach prevails, might in most instances be proper, as it will tend to pre- vent the determination to that organ. Blisters likewise prove highly serviceable in the latter stages of a remittent fever, when the spirits flag and the pulse is low and fluttering, with insensibility or a disposition to coma. In such cases they may be applied between the shoulders, or to the legs. Sinapisms of mustard may also be put to the soles of the feet. Wlien a severe vomiting has arisen, the patient ought to swallow as little drink as possible, and should only now and then just moist- en his mouth and throat; for whatever reaches the stomach is sure to be rejected shortly with considerable violence ; and each time it is thrown into these convulsive motions, the disease is strengthened and the person exhausted. Under such circumstances, it will be better to support the strength by administering clysters composed of broths and other nutritious liquids, than to attempt it by giving any thing by the mouth. When the stomach is not in an irritable state, and every thing is retained readily, the patient is to be supported by food of a light ge- nerous nature. During the remissions a little wine maybe mixed with it. As soon as the fever shews a disposition to yield, and a perfect remission takes place, we ought to give the bark of cinchona in substance, and in such doses as the stomach will easily bear: and if about twenty drops of the acidum sulphuricum dilutum are added to each dose, the effect will be increased. Should the cinchona in powder prove either disagreeable to the patient, or excite nausea, then a decoction or infusion of it must be substituted. If any of its preparations should occasion a purging, about ten drops of the tinc- tura opii, or a drachm of the tinct. catechu, may be added to each dose. r . In cold climates we m%JQ wait for a perfect and complete remission before we give the cinchona ; but in warm climates we ought to administer it oven on the most imperfect and short remission; and although it may not prove sufficiently efficacious to pre vent a fresh attack at first, yet it will seldom fail to mitigate the subsequent re- turns of the fever, and will at last bring about a regular and perfect intermission. By neglecting to give the cinchona in the West Indies and other warm climates upon the first remission, the fever is apt to assume a continued form. Where danger is to be apprehended with every re- turn of the paroxysm, and where the interval is likely to be short we should give at least half an ounce of this bark at once immediately ORDER I. REMITTENT FEVER. 23 on the commencement of the intermission. During the rest of the intermission or remission we may administer it in doses of about two drachms repeated at such distances as that the patient shall take an ounce, or an ounce and a half, if possible, previous to the next accession. When the interval is pretty long, the remedy may be divided into smaller doses. To guard against a relapse, the cinchona should be continued for some days after a cessation of the attacks, and not be too hastily left off, as is sometimes the case. The late Dr. Fowler found the most beneficial effects from the use of arsenic in the form of solution in this fever, as well as in in- termittents. From his report, published in the ninth volume of the Medical Commentaries, it appears, that he experienced its virtues from repeated trials made of it on himself, having been so unfortu- nate as to have been visited by several attacks of a remittent, be- tween the years 1786 and 1791. He took the solution as directed to be prepared under the title of liquor arsenicalis, in doses of from eight to ten drops twice a day, and always experienced the cu- rative effects of the medicine, during each period of its administra- tion, to be very pointed and successful. We are also informed by Dr. Ferriar,* that he has employed it in some very dangerous and tedious remittents, and always found it a safe and certain remedy. He observed that it generally lessened, if it did not suspend, the second paroxysm after its being exhibited, and it effected the purpose without producing the slightest distur- bance in the habit. To an adult, he usually gave five drops of the saturated solution every four hours, and seldom found it necessary to exceed this dose. The only sensible effects produced by it, Dr. Ferriar tells us, are the removal of the crust on the tongue ; the appearance of a sediment in the urine; and increased firmness of the pulse. Probably it might be best to administer this solution combined with the cinchona, either in substance, decoction, or infusion. See Intermittents. Every thing that may have a tendency to bring on a fresh attack of fever is carefully to be avoided during the state of convalescence. A change of air and situation (particularly if it has been low and damp) may have a good effect in expediting the patient's recovery ; and if the appetite does not return readily, he may take stomachic bitters with advantage. See Dyspepsia for these. Gestation in the open air in wheel-carriages is a remedy which has been strongly recommended by Dr. Jaclcson,f towards the close of the bilious remittent fever of warm crates, as well as of all others which have arisen from infection; and he cites many instan- ces which fell under his treatment and immediate observation, whilst he officiated as physician to the army, both on foreign sta- * See the new Edition of his Medical Histories and Reflections. + See his Exposition on applying cold Water in Fever, p. 398. 21 PYREXLE OR FEBRILE DISEASES. CLASS I. tions and at home, in which it was employed not only with safety, but with the highest efficacy, particularly so in those where the dis- eased action had ceased, but where the healthy movement was slow. He observes, that although the good effects of gestation be in them- selves conspicuous, they are at the same time much increased by ablutions; by an entire change of clothes ; and by frictions, both before the journey is undertaken, and after it is finished. In seasons and places where this fever is prevalent, it will be advisable, by way of preventative, to take a proper dose of the tine. cinchona; composita about twice a day, but more particularly on an empty stomach in the morning. CONTINUED FEVERS. 1} evers of this nature continue for several days with nearly the same violence, having evident exacerbations and remissions daily. SYNOCHUS or SIMPLE CONTINUED. Dynocha and Typhus, blended together in a slight degree, seem to constitute this species of fever, as has before been observed; the former being apt to preponderate at its commencement, and the lat- ter towards its termination. It is contagious, and is of more frequent occurrence in this country than any other kind of fever. Every thing which has a tendency to enervate the body, may be looked upon as a remote cause of fever; and accordingly, we find it often arising from great bodily fatigue, too great an indulgence in sensual pleasures, violent exertions, intemperance in drinking, and errors in diet; and now and then likewise, from the suppression of some long-accustomed discharge. Certain passions of the mind (such as grief, fear, anxiety, and joy) have been enumerated among j the causes of fever, and in a few instances it is probable they may have given rise to it; but the concurrence of some other power seems generally necessary to produce this effect. The most usual and universal cause of this fever is the application of cold to the body, giving a check to perspiration; and its morbid effects seem to depend partly upon certain circumstances of the cold itself, and partly upon certain circumstances of the person to whom it is applied. The circumstances which seem to give the application of cold a due effect, are its degree of intensity; the length of time which it is applied ; its being applied generally, or only in a current of air ; its having a degree of moisture accompanying it, and its being a consi- derable or sudden change from heat to cold. The circumstances of persons rendering them more liable~"to be affected by cold, seem to be debility, induced either by great fatigue or violent exertions ; by long fasting ; by the want of natural rest; by severe evacuations ; by preeeding disease ; by errors in diet; by intemperance in drinking; by great sensuality ; by too close an ap- ORDER f. SIMPLE CONTINUED FEVER. 2.5 plication to study, or giving way to grief, fear, or great anxiety; by depriving the body of a part of its accustomed clothing; by exposing any one particular part of it while the rest is kept of its usual warmth ; or by exposing it generally or suddenly to cold when heated much beyond its usual temperature : these we may therefore look upon as so many causes giving an effect to cold, which it otherwise might not have produced. Another frequent cause of fever seems to be, the breathing of air contaminated by the vapour arising either directly or originally from the body of a person labouring under the disease. A peculiar mat- ter is supposed to be generated in the body of a person affected with fever, and this floating in the atmosphere, and being applied to one in health, will no doubt often cause fever to take place in him, which has induced many to suppose, that this infectious matter is produced in all fevers whatever, and that they are all more or less contagious. The effluvia arising from the human body, if long confined to one place without being diffused in the atmosphere, will, it is well known, acquire a singular virulence, and will, if applied to the bodies of men, become a cause of fever. Exhalations arising from animal or vegetable substances in a state of putrefaction, have been looked upon as another general cause of fever; marshy or moist grounds, acted upon by heat for any length of time, usually send forth exhalations which prove a never-failing source of fever. Marsh miasma, as these exhalations are usually termed, have undoubtedly the peculiar effect of inducing fever on human bodies, exposed under certain conditions to their influence. From their de- nomination it is too commonly understood, that marshes are the only sources whence these exhalations arise ; but they also proceed from moist earth, slime, mire or mud, in a great variety of situations and climates, of inhabited, as well as unfrequented and uncultivat- ed tracts of country, in almost every quarter of the globe. They are more powerful, concentrated, and virulent in hot climates and in warm seasons, than in temperate ones. It further appears that the types, or periodical evolutions of the fever which they excite, are chiefly governed by the degrees of concentration which these exhalations possess; the type being more continued and less inter- mittent or remittent, in proportion to the power of the exhalation. Numerous are the writers, who, for upwards of a century, have successively exerted their talents in pointing out what each conceiv- ed to be the proximate cause, or essential nature of fever; some supposing it to consist in a noxious matter, introduced into, or ge- nerated in the body, the increased action of the heart and arteries being an effort of nature to expel this morbific matter; others offer- ing it as their opinion, that it consisted in an increased secrelion of bile ; and others again, that it is to be attributed to a spasmodic con- striction of the extreme vessels on the surface of the body, which, indeed, was the doctrine taught by the late Dr. Cullen. A modem 2G PYREXIAE OR FEBRILE DISEASL?.. CLASS I. writer,* however, tells us that the local and primary seat of idiopa- thic fever is in the brain, and that it is nothing more or less than a species of phrenitis, or topical inflammation of the brain. Dr. Currie supposes debility of a peculiar kind to be the first ope- ration of the remote cause producing fever; the necessary conse- quence or concomitant effect, is, he thinks, a spasm or contraction of the arteries, but more especially of the extreme vessels and capilla- ries of the surface ; hence follows an accumulation of blood on the heart and lungs, the reaction of these organs, the separation of mor- bid heat, and morbid association. The ground of this theory is in- deed nearly the same with that of Dr. Cullen, resting, however, more fully on morbid heat, and admitting into the chain of opera- tion an appendage of morbid association. To investigate these different hypotheses, would lead me into a train of theoretical and vague reasoning, inconsistent with the plan of this publication; I shall therefore proceed to point out the man- ner in which fevers usually come on, barely observing that the prox- imate cause of fever is by no means, as yet, satisfactorily ascertained, and that it is a disease, the whole of the appearances of which have not been accounted for.f An attack of synochus is generally marked by the patient's being seized with a considerable degree of languor or sense of debility, together with sluggishness in motion, and frequent yawning and stretching; the face and extremities at the same time become pale, and the skin over the whole surface of the body appears constricted : he then perceives a sensation of cold in his back, passing from thence over his whole frame; and this sense of cold continuing to increase, tremors in the limbs and rigors of the body succeed. With these, | there is a loss of appetite, want of taste in the mouth, slight pains in /•' the head, back, and loins, and a small and frequent respiration. The sense of cold and its effects, after a little time, become less j violent, and are alternated with flushings, and at last, going off al- * together, they are succeeded by great heat diffused generally over the whole body; the face looks flushed; the skin is dry, as likewise the tongue ; universal restlessness prevails, with a violent pain in the head, oppression at the chest, sickness at the stomach, and an in- clination to vomit. There is likewise great thirst and costiveness, and the pulse is full and frequent, beating perhaps 90, 100, or 120 strokes in a minute. When the symptoms run very high, and there is a considerable determination of blood to the head, delirium will arise. In this fever, as well as most others, there is generally an increase of the symptoms towards evening. If the disease is likely to prove fatal, either by its continuing a long time, or by the severity of its symptoms, then a starting of the tendons, picking at the bed-clothes, involuntary discharges by urine and stool, coldness of the extremities, and hiccups, will be observed : • See Enquiry into the Seat and Nature of Fever, by H. Cluttcrbuck, M. $ See Dissertation on Fever by Dr. G.orgc Fordycc ORDER I. -.fMPLE CONTINUED FEVER. 27 where no such appearances take place, the disease will go through its course and at length cease. As a fever once produced will go on, although its cause be entirely removed, and as the continued or fresh application of a cause of fe- ver neither will increase that which is already produced, nor occa- sion a new one,* there can be no certainty as to the duration of fever; and it is only by attending to certain appearances or changes, which usually take place on the approach of a crisis, that we can form any opinion or decision on this head. The symptoms pointing out the approach of a crisis, are, the pulse becoming soft, moderate, and near its natural speed ; the tongue losing its fur and becoming clean, with an abatement of thirst; the skin being covered with a gentle moisture, and feeling soft to the touch; the secretory organs performing their several offices,, and the urine depositing flaky crystals of a dirty red colour, and becoming turbid on being allowed to stand any time. Many physicians have been of opinion, that there is something in the nature of all acute diseases, except those of a putrid kind, which usually determines them to be of a certain duration ; and therefore that these terminations, when salutary, happen at cer- tain periods of the disease rather than at others, unless disturbed in their progress by an improper mode of treatment, or the arising of some accidental circumstances. These periods are known by the appellation of critical days, and from the time of Hippocrates down to the present, have been pretty generally admitted. The truth of them, I think, can hardly be disputed, however they may be interrupted by various causes. A great number of phenomena shew us, that, both in the sound state and the diseased, nature has a tendency to observe cer- tain periods : for instance, the vicissitudes of sleeping and watch- ing, occurring with such regularity to every one ; the accurate pe- riods that the menstrual flux observes, and the exact time of preg- nancy in all viviparous animals, and many other such instances that might be adduced, all prove this law. With respect to diseases, every one must have observed the defi- nite periods which take place in regular intermittents, as well those universal as topical, in the course of true inflammation, which at the fourth, or at the farthest the seventh day, is resolved, or after this period changes into either abscess, gangrene, or scirrhus: in ex- anthematous eruptions, which, if they are favourable and regular, shew themselves on a certain and definite day; for example, the small-pox about the fourth day. All these appear to be founded on immutable laws, according to which the motions of the body in health and in disease are governed. The days on which it is supposed the termination of continued fevers principally happens, are the third, fifth, seventh, ninth, eleventh, fourteenth, seventeenth, and twentieth. * Ideas supported by Dr.-George Fordyce.—See his Treatise on Simple Fever. ^ INTERMITTENT FEVERS. CLASS J. A simple continued fever terminates always by a regular crisis in the manner before mentiord; or from the febrile matter falling on some particular parts, it excites inflammation, abscess, eruption, or destroys the patient. Great anxiety, loss of strength, intense heat, stupor, delirium, irregularity in the pulse, twitchings in the fingers and hands, picking at the bed-clothes, startings of the tendons, hiccups, invo- luntary evacuations by urine and stool, and such-like symptoms, point out the certain approach of death. On the contrary, when the senses remain clear and distinct, the febrile heat abates, the skin is soft and moist, the pulse becomes moderate and is regular, and the urine deposits flaky crystals, we may then expect a speedy and happy termination of the disease. It sometimes happens that the fever does not affect every part of the system equally ; the symptoms being less severe in one part of it, than in another. This, which the young and inexperienced practitioner, and the by-standers in a much greater degree, are apt to think it fortunate for the patient, is, in fact, the very re- verse, as has been very judiciously observed by Dr. Fordyce ;* there being nothing more dangerous in fever, than its not affecting every part of the system in an equal degree. The usual appearances which are to be observed on dissection of those who die of this fever, are an effusion within the cranium, and topical affections, perhaps of some of the viscera. In fever, all motion of the body should be avoided, especially that which requires the exercise of the muscles; the patient ought therefore to be confined to his bed. The exercise of the mind proving a stimulus to the body, all impressions which lead to thought, especially those which may excite emotion or passion, are to be earefully shunned. A person labouring under a fever, ought there- fore to be kept as composed and quiet as possible, and his chamber should not be close and warm, as is too usually the case • but on the contrary, perfectly cool and sufficiently ventilated, taking c'are, however, that the air does not come in a direct stream or current upon him. He is likewise to be lightly covered with bed-clothes. The strict pursuance of an antiphlogistic regimen will be highly necessary to be observed in this fever, as well as in some others of the continued kind. That sort of aliment which "ives the least stimulus, will be the most proper: the food should &be light, nou- rishing, and easy of digestion, consisting of preparations of barley oatmeal, sago, vermicelli, tapioca, and the meal of Indian arrow- root, varying them now and then for panado, roasted apples &c. Animal broths produce an increase of heat in the body, and are there- fore improper, unless the patient is in a state of convalescence For drink, he may take barley-water, linseed-tea, toast and water milk-whey, thin gruel, and lemonade, which may be varied now and then for an infusion of balm, and such other herbs, carefully shunning the use of any kind of spirituous or fermented liquor. * See his fifth Dissertation on Fever. ORDER I. SIMPLE CONTINUED FEVER. 29 In fever, it is no uncommon occurrence for peculiar longings to arise, and when they do, should always be gratified in moderation, although they may seem not altogether proper. The stomach and rest of the alimentary canal are manifestly af- fected in many cases of fever in a higher degree than other parts of the body, and therefore emetics and purgatives are usually the first means which present themselves to the notice of the physician. In fever it will therefore be necessary to pay an early attention to the state of the stomach, and if there are any crudities or corrupted humours, producing nausea or vomiting, to dislodge them by ad- ministering a gentle emetic* To assist its operation, the patient should drink freely of lukewarm water, or an infusion of chamomile- flowers. To remove the feculent contents of the bowels, some gentle laxa- tive f may be taken ; and throughout the remainder of the disease, the body should be kept open, if necessary, by a repetition of some such medicine, administered as the occasion may require, or by means of aperient clysters.J Where the disorder seems to have arisen from, or to be kept up by a redundant secretion of bile, mild purgatives will still be more highly necessary, and perhaps the submuriate of mercury joined with a few grains of jalap or ca- thartic extract may best answer our purpose. Purgative medicines are sometimes combined with antimonials.^ In the simple continued fever it will seldom be necessary to have recourse to the lancet, particularly in warm climates; but should the disease have arisen in a young person of a plethoric habit, and the attack of fever have been severe, with considerable flushing of the face, redness of the eyes, delirium, and a full, hard, and ob- structed pulse, we may then advise the taking away eight or ten ounces of blood. This quantity should be drawn off at once from a large orifice, and not by repeated bleedings ; as by the former mode there will be greater temporary, but less permanent weakness in- duced by the evacuation. Under no other circumstances will it be advisable to resort to this operation, as we might thereby occasion a slower recovery by inducing a state of extreme debility. By bleeding unnecessarily at the commencement of this fever, such a degree of weakness may be induced as, added to the depres- sion of strength, which arises in its progress, might produce symp- toms of putrefaction in the second or third week of the disease, so * §>. Pulv. Ipecac, gr. xv. Antimon. Tartarizat. gr.j. Aq. Menth. Virid. ^ jss. M. ft. Haustus. fR. Potassae Tartrat. 33s. Mannae Optim. %). Aqua; Fervent. ^ iij. ——Cinnam. |ss. ft. Sblutio cujus sumat dimidium, et repetatur dos. post horas duas nisi alvus prius res- pondeac. t R- Sodce Sulph. 3" ss. Decoct. Malvx Composit. 5* xij. Olei Olivaj ^ss. M. ft. Enema. § R- Hydrargyri Submuriat. gr. v. Pulv. AritimoniaJ. ?.r. j.—ij. M.. h. Putvie. 30 PYREXIiE OR FEBRILE DISEASES. CLASS I. as to prove fatal. By neglecting to bleed, however, when the pulse is full, hard, and quick, the respiration hurried, breath hot, skin dry, and the head highly painful, we shall commit a dangerous error, and endanger the life of the patient. Bleeding in fevers is strongly recommended by a late writer* and he seems to value it far more highly than any of his cotempo- raries. In malignant fevers, it has generally been considered as inadmissible; but even in these, as well as the fevers of tropical climates, he deems it on many occasions to be an essential part of the preparation for his curative means. It is necessary, however, to observe, that he by no means considers bleeding as a debilita- ting process. Its effects, he says, are stimulative, relatively ac- cording to the circumstances of the subject, and they are extensive, for they are felt in all parts of the circulating system, and conse- quently through the whole extent of the animated machine. The abstraction of blood, by its express effect, diminishes the quantity of a body to be moved, and therefore increases the power of the mover: it thus facilitates motion ; but this, we are told, is not all. The di- minution of the quantity of blood, and change of movement in con- sequence of such diminution, is in some manner productive of a change of condition at the sources of life : motion is affected, chang- ed, even suspended ; diseased motions are arrested ; an opportunity is thereby furnished for the more effective action of those powers, which are provided and expressly calculated for the stimulation of the due action of health. Bleeding, as it is the most manageable power, so it possesses the most absolute influence over animal move- ment, either as directly effective of a final purpose, or as preparatory to the action of other means necessary to insure the final purpose. Such is Dr. Jackson's mode of reasoning, and although plausible, still I conceive there will be found few among our modern physicians who will be ready to adopt his practice, but particularly those whose patients compose the higher classes in life, and whose enervated frames are ill calculated to bear copious depletion by venesection. The stout, robust, and hardy British soldier may undergo such a discipline with less injurious effects, and in cases of severe attacks may undoubtedly require a free use of the lancet; but surely the remedy in question cannot be so universally necessary as Dr. Jack- son supposes. He moreover tells us f that a certain condition of susceptibility is necessary to insure the action of whatever means we may employ in fever, and that where this does not exist natural- ly, it must be excited artificially, which is to be accomplished in some degree by applying fomentations to the legs and feet; or by immersing the lower parts, and even the whole of the body, in a warm bath, but principally by subtracting blood from a vein, the quantity of which is to be measured according to the circumstances of the case, and the effect which arises in the course of the progress, * See Dr. Jackson's Appendix to his remarks on the Constitution of the Medical De- partment of the British Army. * See his Exposition on the Practice of applying Cold in Feveri. ORDER I. SIMPLE CONTINUED FEVER. 31 and not by any preconceived opinion of what may be sufficient; for few, he observes, can be supposed to possess such a knowledge of the nature of things as to be capable of measuring it with exactness in the prescription-book. The effect to be looked for, and which is to decide the measure of the quantity, he notices, implies a remission of pains of all denominations, relaxation of the skin, freedom in all the secretory functions, and change in the condition of the pulse, which, instead of being hard, tense, and tumultuously agitated, be- comes free, open, and regular. Dr. Jackson is at the same time ready to admit, however, that many instances occur where the action of the fever is not principally manifested in the circulating system, either by increase or defect of action ; consequently, Avhere bleed- ing is not the remedy of chief dependence. If great heat, with much thirst, prevails, refrigerant* medicines may be taken with advantage, and the most useful of this class is the nitrate of potass, which may either be joined with others,* or be added to whatever the patient uses for common drink.f Acids of all kinds, when sufficiently diluted, are refrigerant reme- dies well adapted to continued fevers. Those most in use are the sulphuric, muriatic,' and vegetable, but more particularly the latter, such as the acid of tamarinds, oranges, lemons, mulberries, &c. As a refrigerant, cold water may likewise be drunk. For the purpose of arresting the febrile course, and moderating or abstracting the morbid excess of heat, and restoring a healthy action, cold bathing has of late years been much employed in fevers. The practice of bathing in fevers appears indeed to be of great antiquity, for its use and management were well known to Galen, and are well defined by him. It farther appears, by the relation of travel- lers, to have been long used by several of the Eastern nations. We have likewise indisputable proof that cold affusion had long ago been employed by Dr. Wright, of Jamaica, and some other physici- ans in the West-Indies, particularly by Dr. Jackson. The notice which this remedy has attracted, in England, lias certainly, however, been owing to the popular manner in which the subject has been treated by the late Dr. Currie, of Liverpool. For the safest time, and most advantageous mode of employing cold affusion in fevers, I beg leave to refer the reader to the admonitions given under the heads of Typhus Mitior and Typhus Gravior. Under the present, I will only observe, that affusion with cold water, either by means of a large watering-pot, so as to allow the streams to pour on the head and shoulders with some force, or by dashing it out of a pail, may be boldly and fearlessly resorted to at the commencement of the greater number of fevers of every climote, whore no catarrhal symp- * R Potassx Subcarbon. p)j.vel. q. s. f &. Decoct. Hordei.fljij. Succi Liiuon. jss. Potassae Nitrat. gr. x. Potassae Nknu.^ij.- Aq. Foncaii. 5 jss. it. Pot us. Syrup. Viola: Jj. M. ft. Haustus 3tia quaq. hora suttiendus. ' :# PYREXLE OR FEBRILE DISEASES. CLASS I. toms or inflammatory affection of the lungs are present; but in the advanced* stages, or latter periods of most, and where there is much debility, this remedy should be adopted with due caution, and a care* ful consideration of the attendant circumstances. With a view to determine the circulation to the surface of the body, it will be right to resort to an early use of such medicines as possess this peculiar power. To excite a perspiration, it will in many cases be sufficient only to make the patient lie abed, and drink plentifully of diluting liquors; but should these simple means not prove efficacious, it then will be necessary to resort to more powerful agents. Neutral salts, * when taken into the stomach, soon produce a sense of heat on the surface of the body; and if it be covered close, and kept moderately warm, a gentle sweat is often readily brought on. These, therefore, being possessed of the power of deter- mining to the surface, are highly useful in fever, and may be prescribed as in the undermentioned forms. . Emetic medicines, and particularly antimonials, given in small nauseating doses, have likewise a similar power of determining the circulation to the surface of the body, and of producing symptoms -imilar to those which take place in the crisis of fever : these arc , therefore advisable. They may either be combined with those of ■' the before mentioned class,, or be given by themselves.f From the uncertainty with which Dr. James's powder and the pulvis antimonialis act, the tartarised antimony may be considered as preferable in many cases. To increase the diaphoretic effect of these medicines, the patient ■should take frequent small draughts of some tepid liquor. Warm bathing, or fomenting the lower extremities, are reme- dies sometimes employed in*fever to produce moderate sweating. R. Ammon. Carbonat. gr. x. Succi Limon. f, ss. Aq. Menth. Virid. ^"j. Tinct. Lav. Comp. IP., x. Syr. Althacae gij. M. i. Huustus. Vd R. Succi Limon. r jss. Potassa: Subcarbon. z:\. vd. q. s. Aq. Mtnth. ijj. ------Fontan. 3113. Antim. Tartarizat. gr. jss. ud ij. .Syrup. Caryoph. 5jij. M. :'.:. Mistura cujus capiat Cochl. ij. mag- na secunda quatjue hora. Vd <\. Liquor Ammen. Acetatis. Aqu» Cinnam. aa 5SS. -----Fontan. ^j. Yini Antimon. tr[. xv. Spirit iEtheris Nitrici. gss. M. ft. Haustus 3tia quacj. hora sumendus. f R. Pulv. Antim. gr, j. ad iij. Confect. Rosae gr. x. M. ft. Bolus 4tis horis sumendufe. Vd R. Pulv. Jacob. Ver. gr. v. pro dos. Vd R. Pulv. Ipecacuanhx gr. iij. Confect. Cort. Aurant. gr. x. M. ft. Bolus. Vd 'BP. Antim. Tartarizat. gr. jss. Aq. Fontan. ^vj. Syrup. Caryoph. 51J. M. ft. Mistura cujus sumat Cochl. ii, magna s>da vet 3tia hora. 8RDER I. SIMPLE CONTINUED FEVER. 03 Where these relieve delirium, induce sleep, and are easily borne by the patient, we may be assured of their propriety. Sweating, however, when excited in fevers, by stimulant, heating, and inflam- matory medicines, is almost sure to prove hurtful. It likewise proves injurious, when excited by much external heat: as also where, instead of relieving, it rather increases the frequency and hardness of the pulse, the anxiety and difficulty of breathing, the head-ach and delirium. When sweating is partial, and confined to the superior parts of the body, it will be more likely to prove hurtful than salutary If a cough accompanies the fever, and a rawness and soreness in the fauces, together with a tightness at the chest, are present, then, besides pursuing the antiphlogistic plan before advised, we may give demulcents * in frequent repeated doses. Should a vomiting arise in the course of this fever, and the irri- tation prove considerable, a saline draught may be taken in the act of effervescence, or it may be administered, so as that this shall take place in the stomach. The manner of doing it is by giving the patient about half an ounce of lemon-juice mixt up with a little mint-water and syrup, and immediately afterwards, about a scruple of the potassse subcarbonas dissolved in an ounce of common water. If the irritation at the stomach is not abated by this means, we may add a few drops of tinctura opii with a little aqua cinnamomi. In this fever, partial evacuations, such as purging and sweating, which have no tendency to prove critical, often arise. When these happen, we should, by all means, put a stop to them. The former- may be checked by astringents as below,f or as advised under the head of Diarrhoea $ and the latter, by keeping the patient cool, by washing his body frequently with a sponge dipped in cold water, and giving him refrigerants. We may distinguish critical evacuations from those which are not so, by attending to the appearances which take place in other parts of the system. For instance, if a purging should arise, and the tongue continue foul, and the skin dry, without any abatement of heat and thirst, then we may regard it as by no means critical; but if on its taking place, the tongue becomes clean and moist, the * $>. Cctacei £ij. I f R. Confect. Aromat. gij. Vitel. Ovi q. s. ad solut. Aqux Pulegii Jiv. Aq. Cinnam. 3J. Mel. Acetat. Scil. jiij. Syrup. Tolutan. gij. M- ----Fontan. 3 iij. ft. Mistura. Vd Tinct. Catechu gij. M. R. Mucil. G. Acacia;. Aq. Fontan. aa jiij. ft. Mistura cujus sumat Cochl. ij. Potassae Nitrat, gj. Vin. Antimon. Ill. LX. magna post singulas s'Aes li- Syrup. Limon. §ss. M. ft. Mistura. Cochl. ij. pro dbs,- tuV-'c quidas. urgenti sumu"Ta. 3& PYREXLE OR FEBRILE DISEASES. CLASS I pulse moderates, the febrile symptoms abate, and the skin has a gentle breathing sweat universally diffused over it, then a crisis may he expected. In the progress of this fever, it sometimes happens that parti- cular parts of the body are much affected, and that there prevails either great oppression of breathing, or that violent pains in the head, stuporv or delirium ensue. In all such cases, the application of a blister near the part affected will be proper, and relief will often be quickly procured by it. Where there is any unusual coldness of the extremities, with a sinking pulse, blisters to the inside of the legs will likewise prove highly serviceable. Their efficacy in such cases may be increased by the application of stimulating catap- lasms * to the soles of the feet and palms of the hands. Camphor, ammonia, musk, and aether, are remedies which may be used at the same time, either separately or combined together; and the patient should be allowed a liberal use of wine, both in a diluted and undi- luted state. When we administer camphor in this or any other disease in a liquid form, in order to render it properly diffusive in water, and obtain its full effect, we should (instead of trusting to the mistura camphorse of the London dispensatory, which contains but a small proportion of the resin) dissolve it in a little rectified spirit, or ex- pressed oil, and then triturate it wTell with mucilage of gum acacias, previous to adding the water. Severe pains in the head accompanied with a throbbing of the ar- teries, or any degree of delirium, may possibly be relieved by the application of a few leeches to each temple ; after which, linen rags moistened in cold water, or even aether, may be laid on. In synochus, there is often a great interruption to sleep ; and the more violent the fever, the greater in general is the interruption. It is.unfortunate, however, that it cannot be procured with safety to the patient, "as opium proves generally prejudicial in all fevers, ex- cept those of the typhus kind. To procure rest, therefore, in that which I am treating of, we must be contented in directing him to be kept as still and quiet as possible. If necessity obliges us to a use of sedatives, the spiritus aetheris- nitrici, and Hoffman's liquor, will be the least exceptionable. Where this fever is kept up merely by weakness and irritability, opium given in small doses may be proper. If it is found to procure refreshing sleep, the dose may be repeated the ensuing night; but if the rest has been much disturbed, its use ought to be discontinued. By introducing opium into the system by means of friction, as ad- vised under the head of Cholera Morbus, it possibly mi°-ht not be attended with any injurious effect. In this fever, as well as in all others where we wish to procure sleep, and cannot have recourse to ~ '_*•- ———.—.......— * R. Seminum Sinapeos Crass. Medulla; Panis aa ifoss. Aceti quantum satis sit. M. et fiat Cataplasm. ORDER I. SIMPLE CONTINUED FEVER. S3 opium, on account of delirium being present, we may recommend a pillow filled with hops to be laid under the patient's head in the same manner as in mania, in which disease this remedy is known to have been used with singular advantage ; or we may employ some of its preparations, such as its extract or tincture. Hyoscyamus is said to have been given under similar circumstances with much benefit. This fever is, in some instances, continued and kept up solely by debility, as has been just mentioned. In such cases, if the symp- toms are mild, we may venture to prescribe a use of the cinchona bark ; and as it will be more likely to sit easy on the stomach, in the form of decoction * or infusion,f these preparations of it will here be preferable to giving it in substance. If, on a trial, the patient sleeps well, breathes easily, and does not find any increased heat, we may then venture to go on with it; hut if, on the contrary, it produces restlessness, difficulty of breathing, &c. its use should be omitted. In the continued fevers of warm climates, we should by no means wait for a complete crisis, in order to administer the bark of cincho- na. In these, it will be prudent to embrace even the least remission, let it be ever so imperfect, or of short duration, as likewise to give it in as large doses as the stomach will bear, and to repeat these fre- quently. The same attention must, however, be paid to the effects it produces, as have been mentioned, or may hereafter be noticed. In cold climates, it is usual to wait for a regular intermission be- fore the cinchona is given. As a tonic, this medicine has acquired the greatest celebrity in all febrile cases, and is therefore usually- preferred to all others; its effects are evidently more obvious when given in substance, than in any other form. About a drachm of the powder is a common dose, and this may be repeated every two or three hours, according to the exigency of the case. Ten or twelve drops of the acidum sulphuricum dilutum may be added to each dose. The bark of cinchona is apt, at first taking it, to effect the bowels, and pass off by stool, with many people. When this happens, five or six drops of the tinctura opii, or about half a drachm of the tinc- tura catechu, may be added to each dose. With some persons, the cinchona bark will not sit easy on the stomach, almost in any shape. In such cases, we may substitute the use of quassia,J or any of the other astringent bitters noticed under the head of Intermittents. On a recovery from fever, the patient should cautiously avoid any • R. Pulv. Cinchonas. 31. 1 (• R. Cort. Cinchonae. in pulv. trir. |ss. Aq. Fontan. Ife jss. Coque ad. ibj. et Col. dein adde Tinct. Calumbas §j. M. ii. Decoctum. I R. Quassias 3 ij. Aq. Bullient. gvj. Colat adde Tinct. Calumb. -Card. Com. la ^ss. M Aq. Bullient. §vj. Colat. adde. Tinct. Cort. Aurant. 3ij. M. ft. Infusio. ft. Mistura cujus capiat CochL ij. tertiis horis, cum. m. xv. Acidi. Sulphur. Diluti. 36 PYREXIAE OR FEBRILE DISEASES. (LASS I.* fatigue, exposure to cold, or improper food. As restoratives, a ge- nerous diet with a moderate use of wine will be serviceable ; and if the season of the year will admit of cold bathing, it will likewise be advisable. A change of air, with moderate daily exercise, either in a carriage or on horseback, will prove powerful auxiliaries in ena- bling the convalescent to regain his strength. Where the appetite is defective, we may prescribe stomachic bitters. See Dyspepsia. SYNOCHA or INFLAMMATORY FEVER. Oynocha is a fever with much increased heat; a frequent, strong, and hard pulse ; the urine red; the animal functions but little dis- turbed, although at an advanced stage the sensorium is apt to be- come much affected. We may readily distinguish synocha from ei- ther typhus mitior or typhus gravior, by its being attended with Symptoms of an inflammatory nature. It makes its attack at all seasons of the year, but is most prevalent in the spring; and it seizes persons of all ages and habits, but more particularly those in the vigour of life, with strong elastic fibres, and of a plethoric con- stitution. It is a species of fever almost peculiar to cold and temper- ate climates, being rarely met with in very warm ones, except among Europeans lately arrived ; and even then, the inflammatory stage is of short duration, as it soon assumes the typhoid type. The exciting causes are, sudden transitions from heat to cold, the application of cold to the body when warm, swallowing cold liquors when much heated by exercise, too free a use of vinous and spirit- ous liquors, great intemperance, violent passions of the mind, expo- Sure to the rays of the sun, topical inflammation, the suppression of habitual evacuations, the drying up of old ulcers, and the sudden repulsion of eruptions. It may be doubted if this fever ever origi- nates from personal infection ; but it is possible for it to appear pret- ty generally among such as are of a robust habit, from a peculiar State of the atmosphere. It comes on with a sense of lassitude and inactivity, succeeded by vertigo, rigors, and pains over the whole body, but more particu- larly in the head and back ; which symptoms are shortly followed by redness of the face, throbbing of the temples, great restlessness, in- tense heat, and unquenchable thirst, oppression of breathing, and nausea. The skin is dry and parched; the eyes appear inflamed, and are incapable of bearing the light; the tongue is of a scarlet Colour at the sides, and furred, and white in the centre ; the urine is red and scanty, the body is costive, and there is a quickness, with a fulness and hardness in the pulse, not much affected by any pres- sure made on the artery. Its pulsations are from 90 to 130 in a minute, and when blood is drawn, it exhibits a yellowish or buffy erust on its surface. If the febrile symptoms run very high and proper means are not used at an early period, stupor and delirium come on at a more advanced stage; the imagination becomes mucli disturbed and hurried, and the patient raves violently. ORDER I. INFLAMMATORY PEVER. Ti The disease usually goes through its course in about fourteen days, and terminates critically, either by a diaphoresis, diarrhoea, hemorrhage from the nose, or the deposit of a copious sediment in the urine ; which crisis is usually preceded by some variation in the pulse. In some instances, it, however, terminates fatally. Our judgment as to the termination of the disease must be formed from the violence of the attack, and the nature of the symptoms. If the fever runs high, or continues many days, with great action of the heart and arteries, flushed turgid face, red eyes, intolerance of light, with vertigo or early stupor and delirium, the event may be doubtful; but if to these are added, picking at the bed-clothes, start- ings of the tendons, involuntary discharges by stool and urine, and hiccups, it will then certainly be fatal. On, the contrary, if the fe- brile heat abates, and the other symptoms moderate, and there is a tendency to a crisis, which is marked by an universal and natural per- spiration on the body; by the urine depositing a lateritious sedi- ment, and by the pulse becoming more slow or soft; or by a hemorr- hage from the nose, diarrhoea supervening; or the formation of abs- cesses ; we may then expect a recovery. In a few cases, this fever has been succeeded by mania. On opening those who die of an inflammatory fever, an effusion is often perceived within the cranium ; and now and then, topical af- fections of some of the viscera are to be observed. From the symptoms which attend this disease, it is evident our endeavours should be early exerted to avoid the mischief that may- ensue from general inflammation ; and as evacuation by bleeding is the chief mean we can confide in, it should be resorted to on the first of its attack; and one large bleeding at this period will have a much better effect than repeated small ones afterwards. If the symptoms run high, therefore, and the person is young and pletho- ric, twelve or fourteen ounces may be drawn off at once from the arm through a large orifice. In repeating the operation, we are to be governed by the effect it produces on the pulse, and by the ap- pearance the blood puts on after standing some time. If the former continues full, strong, and tense, and the latter exhibits a buffy sizy coat on its surface, the bleeding should be repeated by all means, but in smaller quantity than before. Bloodletting relaxes the vas- cular system, diminishes its action and takes off plethora. The pulse in this fever, is apt, however, to become fuller and stronger after bleeding, which may easily be explained; for the plethora may be so great as to distend the vessels beyond their proper tone : in such cases the vessels cannot act fully, and the pulse is contracted; but when the plethora is taken off by copious bleeding, and the vessels are allowed to contract properly, the pulse becomes fuller, which shews that the remedy has been proper, and should induce us to re- peat the operation if the case requires*!. It may be difficult to determine whether drawing blood from the temporal artery, ought not to be preferred in severe attacks, to vene- section at the arm. Both, indeed, will relievp the head-ache, gid- 38 PYREXIAE OR FEBRILE DISEASES CLASS Ii diness, and stupor; but I conceive that a more permanent benefit will be derived from the former. When the fever has been of several days standing, and the head is much affected either with severe pain or delirium, topical bleeding, by the application of three or four leeches to each temple, may be preferable to any other mode of drawing blood. Applying linen cloths wetted in cold water or sether to the fore- head and temples, may be attended with some advantage in such cases. With a view of diminishing inflammation and general excitement, digitalis has been proposed as a remedy in this disease, after having employed proper venesection, and probably may prove serviceable. If any nausea prevails at the commencement of the disease, the stomach may be relieved by making the patient drink one or two cupfulls of an infusion of the flores anthemidis ; but should these simple means not be attended with the desired effect, he may then take a' table-spoonful of an emetic solution,* every quarter of an hour, until sufficiently eased. To obviate costiveness, one or two motions should be procured daily, by means either of some aperient medicine,f or by laxative clysters. J In synocha, cathartics, particularly the saline ones, will prove singularly useful. If the stomach is in an irritable state, we can substitute a few grains of the hydrargyri submurias, made up in- to pills, with a small quantity of cathartic extract, instead of the other laxative medicines. To abate thirst, the patient should be directed to drink frequent- ly of diluting liquors, acidulated with lemon-juice or potassa? super- tartras. He may likewise take small and frequently repeated doses of the nitrate of potass ;^ or as a refrigerant, he may be allowed to drink freely of cold water. For the purpose of moderating or ex- tracting the morbid excess of heat, various parts of the body should be sponged frequently with cold water. Cool air may be freely ad- mitted also, as it has been found that a person in fever may be kept * R. Antimon. Tartarizat. gr. ij. Aq. Fontanae 3" iij. Syr.Caryophil. 31J. M. R. Fol. Sennae giij. 7 R- Pulp. Tamarind. 3" sj. Potassas Supertartrat. gij. Aq. Bullientis 3V. Celat adde Aq. Cinnam.^j. Antimon. Tartarizat. gr. j. M. Sumat Cochl. iv. et repetatur dos. post horas duas nisi alvus prius respondeat, Vd Rj. Infus. Sennas 3" jss. Magnes. Sulphat. gvj. Mannae Optim. gij. M. ft. Haustus aperiens. § R- Potassae Nftrat. 3IJ. -Supertart. ^iij Aq. Fontanae 3* xvj. Coque Ieniter ad § xij.et Colat adde Magnes. Sulphat. gj. Ol. Olivas gj. M. ft. Enema. Antimon. Tartarizat. gr. jss. M. ft. Pulvis dividend, in Chart No. vjk Stitnat j. terkia hora. ORDER r. INFLAMMATORY FEVER. 39 much cooler than one in health without uneasiness or harm. The acid fruits, such as oranges, &c. will be very proper. Sudorifics do not appear to be advisable in this fever, as they might bring on profuse sweating; and it is not possible to keep the body warm without producing a considerable increase of heat. The neutral salts may be given in any of the forms advised under the head of Simple Fever, every two or three hours, joined with small nauseating doses of tartarised antimony, or the like. A pediluvium at night may assist their effect. Should the breathing be oppressed, or should stupor or delirium arise, it will then be right to apply a blister in the neighbourhood of the part so affected. If the pulse sinks, and the extremities be- come cold, the application of sinapisms to the soles of the feet will be proper. Camphor, aether, ammonia, and cordials, will be pro- per remedies on such occasions. In this fever, as in most others, sleep is much interrupted, and from a want of this, delirium often arises; opium here would be an uncertain medicine, for, should it fail to procure rest, the delirium would be greatly increased by it. It should therefore be given only in cases of imminent danger, and even then, only in small doses fre- quently repeated, paying a strict attention to the effect it produces. In other instances, we should be contented with giving directions for the patient to be kept as quiet as possible. Probably, wre might employ some of the preparations of the hu- mulus lupulus (hop,) or hyoscyamus, in this fever with benefit in lieu of opium. In cases of severe delirium threatening phrenitis, might not a use of the circular swing, noticed under the head of Mania,. produce a good effect ? Throughout the whole course of the disease, the patient is to ab- stain from solid food and animal broths, supporting nature with gruel, and preparations of barley, sago, tapioca, &c. His chamber is by no means to be kept warm, either by fires or by being closely shut up, as is too generally the case : on the contrary, it should be of a proper temperature, by allowing the admission of cool air into it from time to time. His bed ought to be lightly co- vered with clothes. On his recovery, a strict attention should be paid to regimen, scru- pulously avoiding to overload the stomach, and partaking only of such things as are light, nutritive, and easy of digestion: all other causes likely to induce a relapse, are also to be carefully shunned. Fresh air, gentle exercise on horseback or in a carriage, agreeable company, and a moderate use of wine, will greatly contribute to the recovery of convalescents. Should the appetite not readily return, or the digestion prove weak, stomachic bitters,* conjoined with the hark, may be advised. See Dyspepsia. * R. Infus. Gentian. C. §v. Tinct. Cort. Cinchonas; C. 3"ss. Calumbae giij. M. Capiat Cochl. iij, ter in die. Adde pro re nata. Acid. Sulph. Dihu. Ml. xv. ad xx. 40 pyrexia: or febrile diseases. CLASS t. TYPHUS MITIOR or NERVOUS FEVER. J. his fever is so named from the effects it produces on the nervous system, typhus being derived from r^o5, stupor. It does not affect the habit so universally as the one last described ; neither do the ex- acerbations produce a hot fit, in order to bring about a crisis. It may be distinguished from typhus gravior at its commencement, by the attack being more gradual, and the symptoms much milder: in the progress of the disease, by the absence of those symptoms of putrescence enumerated in typhus gravior; and by its being accom- panied with less heat and thirst, less frequency of the pulse, and no bilious vomitings. It principally attacks those of weak lax fibres; those who lead a sedentary life, and neglect proper exercise ; those who study much ; and those who indulge freely in enervating liquors. It likewise is apt to attack those who are weakened from not using a quantity of nutritive food, proportionable to the exercise and fatigue they daily undergo; hence it is very prevalent among the poor. Owing to the relaxed habits of those who reside in warm climates, this type of fever frequently occurs, and all other continued fevers are apt to de- generate into this, or typhus gravior. It is often generated in jails, hospitals, transport and prison ships, ill-constructed and crowded barracks, work-houses, and the ill-ven- tilated apartments of the poor. It is also to be met with very fre- quently in the damp and dirty cellars of the poorer class of manu- facturers in large towns. Typhus mitior may be induced by whatever impoverishes the blood, debilitates the general system, or depresses the mind; but the most general cause is contagion. From Dr. Haygarth's experiments * it appears that not one in twenty-three, or even one in thirty-three, escapes infection, when exposed for a sufficient length of time, and that as many persons are liable to receive typhus as the variolous contagion. A short exposure to pestilential atmosphere may, in some instances, pro- duce a fever; but still there is reason to presume that the poison- ous miasms do not generate a fever, till they have been respired without interruption for some days; and hence it is probable, that in most cases an accumulated quantity of the poison may be re- quired to give rise to it. It appears, from the example of medical practitioners, that air strongly impregnated with infectious miasms may be breathed for a short time, and air weakly impregnated for a long time, without injury. A certain dose of infection, as also a certain time of exposure, seem to be necessary, in order to the effect being produced. Persons confined in the midst of contagion are enabled however, to bear up against a much larger dose of it than others. Thus it is a well-known fact, that felons have worn clothes without" * Sec hi:- Letter to Dr. Percival on the Prevention of infectious Fevers. ORDER I. NERVOUS FEVER. 41 injury, which, nevertheless, communicated infection to fresh per- sons, in a court of justice. With respect to the' period at which typhus fever becomes infec- tious after its commencement, Dr. Haygarth has not been able to determine. The latest period of infection appeared to him to vary from a few days to two months, without any regularity as to this point. It is not easy to detect the causes of the facility- with which con- tagion diffuses itself at particular times, whilst at others, its ma- lignancy is circumscribed within narrow limits. The state of the atmosphere has been accused, but no sensible condition has been pointed out, with which such varying conditions of disease could be connected, and later observations have demonstrated that the atmosphere at large is never impregnated with contagion, nor is it the medium of its communication, except near the persons of the sick. It is probable that a predisposition in the human con- stitution to be excited into febrile action by contagion, may be occa- sioned in various ways, and particularly by such causes as produce great debility. Thus, perhaps, we may explain the fact of the ready spreading of an epidemic fever among an army which has for some time suffered great fatigue and exhaustion, as happened with that under the command of Sir John More on his retreat to Corunna, or among a people who are ill supplied with nutritive food ; whence war, famine, and pestilence have been observed to succeed each other, or to occur together from the earliest periods of history. A season of continued heat, and particularly when combined with moisture, appears also to predispose the human constitution to re- ceive the impression of contagion ; for contagious diseases more generally become epidemic in the autumnal period of the year. Want of proper clothing, and a sufficient quantity of nutritive food, loss of sleep, great fatigue and anxiety of mind, intense study, grief, fear, filth, long exposure to cold and a confined and unwholesome air, &c. may all conspire in various instances to induce a state of predisposition easily to be influenced by the operation of contagion ; while whatever supports the vigour of the constitution, may tend to render it more capable of resisting its influence. Typhus mitior generally comes on with a remarkable mildness in all its symptoms ; and although the patient experiences some trifl- ing indisposition for several days, still he has no reason to suspect the approach of any severe disease. At first, no rigors are per- ceived, there being only a slight chilliness, which is not succeeded by any increase of heat, or redness of the face ; on the contrary, it is'unusually pale and sunk. He perceives, however, some degree of lassitude and debility, with anxiety, dejection of spirits, sighing, and a loathing of food ; and towards evening these affections are somewhat increased. In the course of a few days, and as the disease advances, there arise a difficulty of breathing, oppression at the chest, pains in the head, accompanied with a confusion of ideas; there is great depre*;- G <12 PYREXIAE OR FEBRILE DISEASES. CLASS I. sion of strength, even to fainting, whenever the patient attempts to sit up; the tongue becomes dry, and is covered with a dark brown fur; the teeth are thickly incrusted with the same; the pulse is small, low, and frequent, and now and then intermits; cold clammy sweats break out on the forehead and backs of the hands, while the palms glow with heat; the urine is pale and watery, like whey; the whole nervous system is much affected with tremors and twitch- ings; involuntary motions of the muscles and tendons arise ; the patient picks at the bed-clothes almost incessantly, and either mut- ters to himself or talks incoherently. There is seldom, however, any high degree of delirium, nor is this fever ever attended with violent ravings, or with any fulness of the vessels of the head; but there is usually a dilatation in the pupils of the eyes. In the progress of the disease, the system is unequally affected ; for sometimes head-ach, restlessness, and uneasiness, prevail in a high degree, while at the same time the tongue is clean and moist: and at other times, while there is no head-ach or restlessness, the tongue will be dry and foul, and profuse sweats will break out. This fever, moreover, is not only thus irregular in affecting various parts of the body differently, but it is also irregular in its exacerba- tions ; and these, instead of taking place in the evening, will arise often in the morning. Again, sometimes the fever is very violent for the first three or four days; it then diminishes for a time, and then perhaps increases again. Evacuations, such as sweating and purging, are very apt to ensue in the course of the disease, which never fail to exhaust the patient. In typhus fever, a great discharge of saliva sometimes occurs, but as it now and then continues for a considerable time without affording any relief to the patient, it may be concluded to arise from some accidental circumstance, perhaps not unlike to the pty- alism that sometimes takes place in hysteria. In many instances, the spitting is so viscid and ropy as to inconvenience the patient very much, and by clogging up the fauces, greatly to impede both deglutition and respiration. In such cases, moreover, the tongue and whole of the mouth are frequently beset with aphthous ulcera- tions. Typhus mitior frequently runs on for some weeks, and produces such a state of debility as to destroy the person from that cause alone, or it degenerates into a typhus gravior; but when it termi- nates favourably, it usually goes off about the fourteenth or twen- tieth day, perhaps, either by diarrhoea, or by a gentle moisture dif- fused equally over the whole body; but often it exceeds a month in duration, and terminates at last without any evident crisis. Profuse evacuations by sweating or purging, much watchfulness, sinking of the pulse, great incoherency of ideas, mutterings, picking at the bed-clothes, considerable dilatation of the pupils of the eyes, involuntary discharges by urine and stool, starting of the tendons^ and hiccups, point out the near approach of death ; whereas, on the contrary, the pulse becoming fuller and more slow, the tongue moist ORDER I. NERVOUS FEVER. 43 respiration free, a gentle moisture coming on about the fourteenth day, deafness ensuing, tumours appearing behind the ears, or mi- liary eruptions, unattended by profuse sweats, being perceived on the body, promise a favourable termination. The usual appearances on dissection are, a softness and flacciditv in the solids; a dissolved state of the fluids, particularly of the blood ; collections of sanious matter in the different cavities ; tur- gescence and inflammation of the thoracic and abdominal viscera ; and in the ulterior parts of the brain, collections of a serous fluid. From the very gradual manner in which this fever comes on, the great mildness of the symptoms at its commencement, and the time that usually elapses previous to absolute confinement, it is seldom that practitioners have it in their power to cut short its progress by a timely exhibition of proper remedies. If there is any nausea or vomiting at the time of applying for ad- vice, it will be right to recommend a gentle emetic of about four- teen or sixteen grains of ipecacuanha, to be immediately taken ; or should any costiveness prevail, we may prescribe some laxative medicine, to carry off the feculent matter; and to ensure and keep up a regular alvine evacuation in the further course of the disease, it will be proper to repeat this from time to time, or to have re- course to emollient laxative clysters. In many instances, however, the stimulus of the latter being limited merely to the rectum, may not be adequate to procure so complete an evacuation as may be necessary ; and therefore, in these cases, we ought to employ ape- rient medicines that will dislodge, and bring off whatever feculent matter may be contained in the bowels, which by retention might be likely to prove highly offensive, as well as irritating. In ad- ministering purgatives, we ought, at the same time7to guard against employing them in such doses, as to excite unusual secretion into the intestines, or watery stools, as we should thereby induce great debility. Small doses of hydrargyri submurias, and jalap, or a so- lution of some mild neutral salt, will be the most proper medicines of this class. With these we may evacuate the contents of the bowels with safety and advantage in typhus, from the commence- ment to the termination of the fever. Bleeding is a remedy not to be resorted to in this fever. In temperate and cold latitudes, and in the winter season of the year, it is by no means an uncommon occurrence to meet with ty- phus complicated with more or less of topical inflammation of the thoracic viscera. In such cases, I have known venesection to have been employed ; but even in these, it has appeared to me to be de- trimental, and in two instances which lately fell under my obser- vation, seemed indeed to have destroyed the patients. Instead, therefore, of having recourse to the lancet, where topical inflamma- tion of the viscera of the thorax attends on typhus, I would recom- mend drawing blood from the chest, either by means of a few leeches, •r by the application of a scarificator and cupping-glass. 44 PYREXLE OR FEBRILE DISEASES. CLASS I. Affusing the body with cold water, is one of the most powerful and efficacious means which we can make use of in typhus fever; but its effects will be more salutary hi proportion as it is adopted early, or during the first stage of the disease. Such being an indis- putable fact, established upon the firmest basis, we ought always to employ it very soon after we have evacuated the contents of the alimentary tube in the manner just mentioned. We are informed by Dr. Currie* that the safest and most advan- tageous time for using cold water, either in aspersion or affusion (but he gives a preference to the latter,) is when the exacerbation is at its height, which is marked by increased flushing, thirst, and restlessness; or immediately after its declination has begun, which induced him to direct its being employed from six to nine o'clock in the evening ; but he thinks that it may be used at any time of the day, when there is no sense of chilliness present; when the heat is steadily above what is natural, and when there is no general or pro- fuse perspiration. During the cold stage of the paroxysm of fever, while there is any considerable sense of chilliness present, or where the body is under profuse sensible perspiration, this remedy ought never to be employed, as we might extinguish life by it. When coid affusion is used in the advanced stage of typhus, where the heat is reduced, and the debility great, some cordial, such as wine warmed with an addition of spice, or even brandy, should be given immediately after it. In the early stage of the disease, cold affusion appears to cut short the progress of the disease. At more advanced periods, when the strength of the patient, and other cir- cumstances, will admit of its application, it will seldom fail to mo- derate the symptoms, and materially contribute to a favourable termination. Whilst cold water dashed forcibly from a pail, or falling from a height in considerable quantity from a garden watering-pot, is de- cisively impressive, and ordinarily safe, when employed in an early stage of this, and other typhoid fevers; so aspersion, or ablution of the body by means of a sponge, will be more eligible and safe in the advanced periods. The effects produced by both modes are grateful and refreshing to the patient, and they usually bring about an abatement of fever, followed by more or less, of a diaphoresis, and this again by a refreshing sleep. We have lately been gratified with an ingenious publication from the pen of Dr. Jackson, on the subject of cold affusion ;f and although he agrees with Dr. Currie as to its utility and propriety in the milder forms of fever (whether infectious, and such as is. usually called typhus, or endemic, such as arise from the action of common causes in a diffused form,) in the early stages of fever, still he dif- fers from this gentleman on other important points. Dr, Currie had employed the affusion of cold water in the mild * See his Medical Reports on the Effects of Water in Fevers &c f gee his Exposition on the Practice of applying Cold in Fevers, ' ORDER I. NERVOUS FEVER. 45 and open forms of fever, without any previous preparation, and likewise in those which are violent, concentrated, and complicated, provided the temperature of the body, on being measured by a thermometer, was higher than the natural standard; but when lower than this, he advises us to abstain from its application. Dr. Jackson, in resorting to it, is guided by what he terms the evidences of a susceptible condition of the system, connected with the simple condition of the disease being obvious, of the presence of which he judges by the sensation communicated to his hand in touching the patient's body. Where he'finds this deficient in any degree, or where it is unusually distributed on the surface, and unaccompanied by any primary mark of local inflammation, or congestion of any one of the internal organs being discernible, he endeavours to restore the susceptibility of impression, by conducting the patient into an apartment, where the air is of a high temperature; by applying warm fomentations to the extremities; by purifying the skin by warm water, soap and brushes, and then by immersing the whole body in a warm bath, or by affusing warm water generally over its surface. Where there is either a violent or rapid action, or a slug- gish circulation, he does not consider these as proper conditions for the cold affusion, but to make them so, he recommends a prepara- tory process of general bleeding, and other evacuations ; whereas Dr. Currie considered venesection unnecessary to a previous use ofeold affusidn, except in cases of idiopathic inflammation. The afiusion of cold water on the surface of the body, is con- sidered by Dr. Jackson as a power which makes a strong and gene- ral impression on the system, and which arrests the disease, or changes its condition in virtue of that impression; but not by sub- tracting increased heat, as supposed by Dr. Currie. Indeed, the good effects of the remedy in question cannot, I think, be wholly owing to the mere subtraction of heat; for it has been used with great advantage in many cases of fever, where there has been no perceptible increase of temperature, and where, by affusion, ablu- tion, or aspersion with cold water, the disease has been cut short abruptly, as well as in those where it had risen to a high point. I think we may safely infer that cold affusion, or the suddenly pour- ing cold water over the whole surface of the body, operates as a powerful stimulant, although its effects probably are of short dura- tion unless frequently repeated, they are produced by the sudden- ness of the application affecting the nervous energy, and by the shock rousing the dormant susceptibility, so as to induce a new ac- tion, as it were, of the nervous system, removing spasmodic con- traction of the extreme vessels on the surface, carrying off a large portion of morbid heat by general evaporation, and the remainder by insensible perspiration; thence restoring the healthy action of the exhalents and capillaries. Although medicines, which might excite profuse sweating, would be highly improper in this fever, still we may venture to give those 46 PYREXLE OR FEBRILE DISEASES. CLASS 1. possessed of a mild diaphoretic power.* Antimonials do not seem very advisable in the true typhus. In the progress of the disease, it has been usual, when particular affections arise, such as either a difficulty of breathing, violent pains in the head, delirium, or stupor, to excite an inflammation in the neighbourhood of the part affected by the application of a blister, and not unfrequently the poor patient has been tortured with half a dozen at a time in the advanced stage of the disorder. This prac- tice is certainly very reprehensible. The application of even a single blister to the back and head in this fever, with the view of relieving stupor and coma, is much disapproved of by many physi- cians, and Dr. Darwin mentions f that he has seldom seen any be- neficial effect derived from it, but on the contrary a prejudicial one. The observation is perfectly just, and therefore I cannot advise the remedy. Where stupor, coma, or delirium prevail, the pediluvium, to- gether with frequent washings of the temples, and whole of the head (having it properly shaved,) with cold water and vinegar, or applying linen cloths dipped in aether to these parts, may be sub- stituted. If a purging arises, it is to be stopped by having recourse to as- tringents^ as advised below; but in the progress of the disease, if a gentle diarrhoea takes place, and seems likely to prove critical, it should by no means be checked. Profuse sweats are to be obviated by the person being lightly covered with bed-clothes; by keeping his hands and arms un- covered; by admitting fresh air freely into his chamber, and by giving him whatever he drinks, cool, and properly acidulated with lemon or orange juice. Much rambling and low delirium are apt to arise in typhus from a want of sleep, and to make it necessary to have recourse to opium in order to procure it. The most advisable way of using it in such f See his Zoonomia. t R Succi Limon. 3*ss. Potassae Subcarbonat. Qj. Aq. Cinnam. ^j. Confect. Aromat. gr. xv. Syrup Zingib. ^ij. ft. Haustus 4tis horis sumendus. Vd R. Misturae Camphorae. 3"x. Liquor Ammon. Acetat. ^iij. • Spirit. iEther. Nitrici. gss. ft. Haustus 3tia hora capiendus. Vel Rj. Camphorae gr. iv. Pulv. Contrayerv. C. gr. x. ■Ipecac, gr. ij. Confect. Rosas q. s. M. ft. Bolus 6tis horis sumendus. \ Rj. Misturae Cretae. giv. Extract. Lign. Camp. ^j. Tinct. Catechu gij. Aq. Cinnam. Spirit. Pimentae aa 5j. Tinct. Opii m. xl. M. ft. Mistura cujus sumat Cochl. ij. magna 3tia quaq. hora. Vel R. Pulv. e Cret. cum Opio gr. xij. Gum. Kino gr. v. Confect Aromat. gr. x. Syrup. Zingib. q. s. M. ft. Bolus ter quaterve die sumendus. 6r»er i. NERVOUS FEVER. 47 cases, is to combine it with some gentle diaphoretic* By giving it in this manner early in the evening, we shall in general experience the most beneficial effects from it. Opiates are indeed more admissible in this species of fever than in any other: and it seems now to be nearly the universal practice to give one every night during its whole continuance. The best effects have been obtained from this mode of proceeding, as I have witnessed in innumerable instances, aad therefore I usually recom- mend it. To support the patient's strength, it will be necessary, to allow a liberal use of wine, which is preferable to all other cordials. • Sago, gruel, panado, arrow-root, and the like, mixed with a due pro- portion of it, must be given to him as food; and wine-whey, or small negus, sharpened with the juice of orange, will be most proper for ordinary drink. Wonderful, indeed, are the effects pro- duced by wine in typhus fever, as we often see persons recover b} a free use of it, under the most unpromising circumstances. A late physician f of great celebrity, recommends wine and opium, in small quantities, repeated every three hours alternately, and this with a view of rousing the system from a state of torpor and debility. In advising a free use of wine with opium, I must at the same time caution the practitioner not to run into excess, and over-sti- mulate the patient, as this might destroy him. Wine, although a very grateful and convenient stimulus, is very liable to be abused by being given in too great a quantity. In ordinary cases a very good effect may be obtained by half a bottle in a day, and this may be regarded as a moderate quantity for an adult; but in some cases, a whole bottle may be necessary, and in some a little more ; but it should always be given with an equal part of water. The best rule is to proportion the quantity to the degree of debility present, the age of the patient, and the effect produced on him by it. When we are certain of the nature of the disease, wine may be given even before any symptoms of debility, coma, or delirium come on, perhaps from the second, or third day. Spirits have sometimes been recommended as a substitute for wine in cases where the latter cannot be afforded, or procured ; but they do not answer so well. When given, they should be administered much diluted, as in the form of punch. Cyder has been considered by some physicians, particularly Dr. Gregory of Edinburgh, as the best substitute for wine. Where wine dis- f Dr. Darwin. * R. Liquor. Ammon. Acetat. 5HJ. Aqua; Cinnam. 5|j. Tinct. Opii lit. xl. Syrup. Zingib. -Jij. M. ft. Haustus. Vd R. Mistur. Camphorx. §j. Vin. Antim. m.. xx. Syrup. Papav. Somnifi. 3 iij. M. ft. Haustus. 48 PYREXIA OR FEBRILE DISEASED CLASS f agrees with the patient, these may be employed, together with aromatics. Throughout the whole course of the disease he should be kept perfectlv quiet, and none but those whose business it is to attend on him "ought to go near him, except in those cases where the symptoms are very mild, and where there is little or no affecticn of the head. In such cases the presence of a friend may soothe the mind and help to dispel gloomy ideas. The chamber should be kept freelv ventilated and cool, and his bed be lightly covered with clothes; he should be solaced and comforted with the hope of a speedy recovery, and his thoughts be diverted from that anxiety and dread of danger which invariably attend the com- plaint. Many practitioners are in the habit of giving the cinchona bark in this fever, without waiting for even the most imperfect crisis; some having in view its supposed febrifuge qualities, and others, its tonic powers. In mild cases, where there prevails hardly any stupor, or other affection of the head, and where the remissions are regular, it may perhaps be of service ; but in a state of convales- cence it will prove highly beneficial, and may therefore be given either in substance, decoction, or infusion, as may be found to sit best on the stomach. Where the skin and the tongue are dry, where the remissions are irregular, and where the fever abates for a day or two, and then returns with violence, I have always found ti prove prejudicial. Miliary eruptions sometimes appear as the crisis to this fever; they ought therefore by no means to be checked by any kind of evacuation, nor should the patient, on the contrary, be kept too warm in order to force them out. Where there prevails any unusual coldness in the lower extremi- ties, the application of a couple of small blisters to the inside of the legs, or of stimulating cataplasms to the soles of the feet, will be proper. In the last stage of typhus, when neither cinchona, wine, or brandy, cold bathing, or even occasional doses of Cayenne pepper. had the effect of rousing the powers of life, or of lessening the thick crust which covered the tongue, it appears by Dr. Ferriar's report, that the most singular advantages were obtained by giving the arsenical solution. He found that it did not operate as a gene- ral stimulant, but merely as an active tonic, and therefore thai neither the concomitancy of cough or dyspnoea, prohibits its use in typhus. As soon as the febrile paroxysms are stopped, he thinks it will be best to suspend the use of the arsenical solution, and to support the patient with bark and different cordials. A very severe case of typhus lately fell under my care, the patient having suffered two relapses of the fever, and her life despaired of, when I was induced to make trial of the mineral solution. Its effects ex- ceeded my expectations, for the woman's life was apparently pre- served by it. It was administered in an infusion of cascarilla, with an equal quantity of camphorated mixture. ORDER I. NERVOUS FEVER. 49 In bad cases, where startings of the tendons and hiccups arise, besides making use of the means advised, it may be necessary to have recourse to antispasmodics, * such as musk, ammonia, aether, eamphor, and opium. If this fever threatens in its progress to degenerate into typhus gravior, we should administer the mineral acids, but more particu- larly the muriatic, in such doses as the patient is capable of bearing. To prevent its affecting the stomach and bowels, a few drops of tinctura opii may be added to each dose. An infusion of cinchona or columbo may be employed as the vehicle, or we may give the acid in a little wine and water. See Typhus Gravior. In an advanced stage of this disease, it sometimes happens that little white ulcers or aphthae appear in the inside of the mouth and fauces. In such cases, a gargle pomposed of borax, honey, and an infusion of roses, should be used three or four times a day. When the fever goes off, and the patient has somewhat regained his strength, he may take daily exercise on horseback or in a carriage; and in order to remove the irritability and weakness which are left behind, he should enter on a course of the cinchona bark and other tonics. After a little time, the cold bath will be a proper remedy, if the season of the year is such at to admit of it. If the appetite does not readily return on the cessation of the fever, stomachic bitters f will be proper. See Dyspepsia. A degree of mania, or temporary alienation of the mind, some- times arises at the close of typhus. All that can be done in such a case' is, to support the patient with a generous nutritive diet; to keep him as quiet and tranquil as possible ; and to put him under a course of tonics, carefully avoiding all evacuations. As this fever is of an infectious nature, every endeavour should be exerted for suppressing its further propagation, and for wholly destroying its contagion by a strict attention to cleanliness, free ventilation and fumigations, as recommended under the following head. As circumstances may occur for rendering it necessary to remove " R. Mosch. gr. x. Aq. Cinnam. 3* jss. Spt. JEther. Sulphuric. Ill. xx. Tinct. Opii 171. xv. M. ft. Haustus ter in die sumendus. Vd R. Castor, gr. v. Camphor, gr. iv. Opii gr. ss. Confect. Aromat. q. s. M. ft. Bolus 6ta quaq. hora sumendus. Vd IJ,. Misturae Moschi ————Camphoraj. aa 3*iij. Spirit. JEther. Sulphuric. 3ij. M. ft. Mistura de qua capiat Cochl. ij. magna tertia quaque hora. H f fy. intus. uentian. i_omp. 31V. Tinct. Card. C. Calumb. aa 3*ss. M. " Capiat Cochl. ij. mane, hora meridiafia et vespere. Adde pro re nata Acid. Sulphur. Dilut. fTl. xxv. Vd Rj. Infus. Cort. Cascaril. 5X. Tinct. Gentian. C. Cinnam. C- aa 3F Acid. Sulph. Dilut. HI. xv. M. oO PYREXIA tfpr-FEBRlLE DISEASES. ' CLASS I. patients labouring under typhus fever to some distance, it is im- portant to know that this mav be effected without subjecting them to any risk. Indeed considerable benefit has been derived on such occasions by conveying the sick in open carriages, or spring waggons,* for several miles, freely exposed to the air. TYPHUS GRAVIOR or PUTRID AND MALIGNANT FEVER. 1 his fever lakes its name from the malignancy of its nature, and the evident symptoms of putrefaction which are to be observed, after a continuance of some days. It is to be readily distinguished from the inflammatory, by the smallness of the pulse, the sudden and great debility which ensues on its first attack, the br< .vn5 or black tongue, the dark and fetid sordes about tiie teeth, ■ h iivid flush of the countenance, and the acrid and more intense heal of the skin: and, in its more advanced stage, by the petechias, or purple spots, which come out on various parts of the body, and the fetid stools which are discharged; and it may be distinguished from typhus mitior, by the great violence of all the symptoms on its first coming on. The most general cause which gives rise to this disease is conta- gion, applied either immediately from the body of a person labour- ing under it, or conveyed in clothes or merchandize, &c.; but it may be occasioned by the effluvia arising either from animal or ve- getable substances in a decayed or putrid state; and hence it is, that in low or marshy countries it is apt to be prevalent when in- tense and sultry heat quickly succeeds any inundation. A want of proper cleanliness, accumulated human exhalations, and confined air, are likewise causes of this fever; hence it prevails in the houses of the poor, in hospitals, gaols, camps, and on board of ships, especially when such places are much crowded, and the strictest attention is not paid to a free ventilation and due cleanliness. A close state of the atmosphere, with damp weather, is likewise apt to give rise to typhus gravior. Those of lax fibres, and who have been weakened by any pre- vious debilitating cause, such as poor diet, long fasting, hard la- bour, continued want of sleep, &c. are most liable to attacks of it. We are, therefore, to look on these as so many predisposing causes. It has been denied by some physicians of the present time that either the plague, yellow fever, or typhus, are contagious diseases; and it is true, indeed, that we cannot, in every case, ascertain that the complaint originated from a communication with diseased persons ; nor will the actual communication always produce fever : many predisposing causes are requisite, and moreover, the human constitution is evidently less susceptible of disease at one time * See-outlines of the History and Cure of Fever, by J. Jackson, M. D__Re- marks on the Constitution of the medical Department of the Army by the same." ORDER I. PUTRID FEVER. 51 than at another. Whoever has paid proper attention to the symp- toms of typhus, may, however, be induced readily to conclude that the surrounding atmosphere, to an extent more or less great, particularly in small, close rooms, may become sufficiently impreg- nated with the particles continually exhaling from the diseased body, to infect other persons with a similar disease. Some writers have supposed infants to be as liable to fevers as adults, and from the same causes, but 1 cannot agree with them ; for I have observed that infants do not readily take fevers, although exposed for a long time to that contagion which has appeared to affect adults round them ; and every physician who attends lying-in hospitals, must not only have known many infants suckled without injury, through the whole stage of bad fevers from which their mo- thers have recovered ; but also, in other instances, sucking greedily within an hour or two of their mother's death. On the first coming on of typhus gravior, the person is seized with languor; dejection of spirits ; amazing depression and loss of muscular strength ; universal weariness and soreness ; pains in the head, back, and extremities, and rigors; the eyes appear full, heavy, yellowish, and often a little inflamed ; the temporal arteries throb violently ; the tongue is dry and parched; respiration is commonly laborious, and interrupted with deep sighing ; the breath is hot and offensive ; the urine is crude and pale ; the body is costive, and the pulse is usually quick, small, and hard, and now and then fluttering and unequal. Sometimes a great heat, load, and pain, are felt at the pit of the stomach, and a vomiting of bilious matter ensues. As the disease advances, the pulse increases in frequency (beating often from 100 to 130 in a minute :) there is vast debility ; great heat and dryness in the skin; oppression at the breast, with anxiety, sighing, and moaning; the thirst is greatly increased ; the tongue, mouth, lips, and teeth are covered over with a brown or black tenacious fur ; the speech is inarticulate, and scarcely in- telligible ; the patient mutters much, and delirium arises. The fever continuing to increase still more in violence, symptoms of pu- trefaction shew themselves; the breath becomes highly offensive ; the urine deposits a black and fetid sediment ; the stools are dark, disagreeable, and pass off insensibly; hemorrhages issue from the gums, nostrils, mouth, and other parts of the body; livid spots or petechias appear on its surface ; the pulse intermits and sinks ; the extremities grow cold ; hiccups ensue; and death at last closes the tragic scene. When this fever does not terminate fatally, it generally begins, in cold climates, to diminish about the commencement of the third week, and goes off gradually towards the end of the fourth, without any very evident crisis; but in warm climates it seldom continues above a week or ten days, if so long. Our opinion as to the event, is to be formed by the degree of violence in the symptoms, particu- larly after the appearance of petechia?, although, in some instances. 52, PYREXIAE OR FEBRILE DISEASED. CLASS I.. recoveries have been effected under the most unpromising appear- ances. An abatement of febrile heat and thirst; the tongue be- coming moist and clean ; a gentle moisture diffused equally over the whole surface of the body; loose stools; turbid urine ; the pulse being stronger, but less frequent, a free secretion of saliva j tumor and suppuration of the parotid, axillary, or inguinal glands ; a scabby eruption about the mouth, and the delirium and stupor, abating or going off, may be regarded in a favourable light. On the contrary, great muscular debility, very laborious respiration, difficulty of deglutition, stupidity and listlessness of the eyes, per- petual writhing of the body, petechia? of a livid colour, with dark, offensive, and involuntary discharges by urine and stool, fetid and cadaverous sweats, hemorrhages, subsultus tendinum, and hiccups, denote the almost certain dissolution of the patient. The appearances usually perceived on dissection are, inflamma- tions of the brain and viscera, but more particularly of the stomach and intestines, which are now and then found in a gangrenous state. In the muscular fibres there seems likewise a strong ten- dency to gangrene. On the very first taking place of any of the symptoms of this fever, we should immediately attend to them, and endeavour to prevent any bad consequences from ensuing, as they will never go off of themselves, but will continue to increase, until a disease of a most dangerous nature takes place. This being the case, we should re- sort to proper remedies at the first onset, and not wait until the body is enervated. The most proper remedy at first, will be an emetic of about fifteen grains of ipecacuanha with one grain of tartarised antimony, which may be worked off with an infusion of the flores anthemidis. An emetic at the commencement of the dis- ease, is a very important article, and the clearing of the stomach is not the only good effect to be expected from this remedy. After its operation is over, the bowels may be opened with some gentle laxative.* Possibly, a few grains of hydrargyri submurias com- bined with jalap may be preferable to any other. Should the de- sired effect not be produced by the medicines, an aperient clyster may be administered-! Throughout the course of the disease, the patient in no case should be more than two days without a stool, for a great deal of fceces are produced in fever although little food is taken, and costiveness is apt to induce an increase of heat, and affections of the head, as delirium, &c. R. Mann. Optim. ^ss. Potassae Supertartrat. £ij. Aq. Fervent. §iij. M. ft. Solntio pro dos. Vd R. Potassae Tartrat. 311J. Mann. Optim. ^ij. Aq. Fervent. 3" iij. Cinnam. ^ss. M. Capiat dimidium pro dos. Vd R. Hydrargyr. Submur. gr. v. Extract. Colocynth. C. gr. iv. Fiant pilulae No. iij. pro dos. t B- Decoct. Malvae compos. 5*xij. Magnes. Sulphat. 3;ss. 01. Olivae §j. M. ft. Enema. ORDER I. PUTRID FEVER. 53 These steps being pursued, and the nature of the disease clearly ascertained, I would advise the ablution of the patient with cold water, or rather a general allusion, provided the heat of the body is steadily above the temperature of health. The good effects of this mode of practice I have often experienced. The late Dr. Currie, of Liverpool, reports, that this fever having made its appearance in a regiment quartered in that town, he had the men drawn up and examined, seventeen of whom were found with symptoms of it upon them: these he subjected to the cold affusion once, or sometimes twice a day. In fifteen of this number, the contagion was extinguished, and in the remaining two, the fever went through its course. The healthy part of the regiment bathed in the sea daily, and by these means he effectually destroyed the contagion. He further relates, that of thirty-two who went through the disease, by its being too confirmed to be re- moved at the time of his first seeing them, only two died; and with these, the cold affusion was not had recourse to. This gentleman's report, with the authorities of other practiti- oners of eminence, clearly prove the application of cold water by affusion on the first attack of the complaint to be, under certain restrictions, an efficacious remedy for stopping its progress, as like- wise that of other low contagious fevers. Doctor Currie found, that the most advantageous time for using the cold affusion is, when the exacerbation is at its height, or im- mediately after it is begun, which is generally from six to nine in the evening; but he observes it may be used with safety at any time of the day, when there is no great sense of chilliness present; when the heat of the surface is steadily above what is natural; and when there is no general or profuse perspiration. The same remedy has likewise been successfully employed by him, myself, and many ethers in the more advanced stage of the fever, so as seldom to fail of procuring a safe termination. He relates the case of a soldier who was in the ninth day of the disease when he first saw him : his pulse was 100 and feeble, his heat was 104, his thirst very great, his tongue foul and black, his mind much con- fused, and at times he was delirious, and petechia? were dispersed over his whole body.—The mode of treatment was as follows : his strength was directed to be supported by administering a bottle of wine a day, with an equal quantity of gruel; every night he took an opiate draught, and his body was kept open by laxative clysters, and wdien these failed, by a few grains of calomel. A bucket-full of salt water was directed to be thrown over him im- mediately, which was to be repeated according to circumstances. The effect was, that, in a few minutes after the affusion, the heat lessened to 98, the pulse moderated to 96, and his mind became more calm and collected. Two hours afterwards he had relapsed nearly into his former state, but the night was passed with greater tranquillity. The whole of this practice was continued with nearly the same result, until the twelfth day of the disease, the affusion 54 PYREXLE OR FEBRILE DISEASES. CLASS I. having been performed in the evening, and occasionally at noon. The fever continued its usual period; but on the twelfth day, the beat having sunk to its natural standard, the cold affusion was thenceforth omitted, and instead of it, the body was sponged all over once or twice a day with vinegar. In those cases where the fever had been of eleven, twelve, or thirteen days standing, and the heat of the body was inconsiderable, he thought it prudent to make the degree of cold very moderate, and in some instances he substituted tepid ablution, or sponged the body over with vinegar by itself or diluted with water. Some communications to Dr. Currie from Mr. Marshall, surgeon of the Cheshire regiment, bear further testimony of the good effects of this remedy in typhus fever. In sixty cases out of sixty-four, in which it was employed at an early period, the disease was arrested by having recourse to it three or four times, and in the other four which were advanced in their progress, although the disease was not stopped from going through its natural course, still all the pa- tients recovered. Mr. Marshall mentions, that from the time he began the cold affusion he used little or no wine, no opium, nor indeed scarcely any other remedy in any one case in which the cold affusion was employed; which report is of itself sufficient to estab- lish its decided superiority over every other mode of treatment. It is, however, in the early stages of low contagious fevers, that we can employ it with most advantage. It has indeed been used by many practitioners in some instances so late as the twelfth or even the fourteenth day with safety and success; but it can only be employed at this advanced period, in the instances in which the heat keeps up steadily above the natural standard, and the respi- ration continues free. In such cases it has been observed to ap- pease agitation and restlessness, dissipate delirium, and, as it were, snatch the patient from impending dissolution. When the remedy is to be had recourse to, every arrangement should be made for the affusion before the patient is moved at all, and fatigue as well as disquiet should be avoided as much as possible. In those cases where the delicacy of the system, or the apprehensions of the patient or of the by-standers, may prevent cold affusion from being employed, we may substitute tepid affusion for the more powerful remedy, or we may recommend either ablution or aspersion. A memorable instance of the good effects of cold affusion came under my immediate knowledge some years ago, whilst I practised in the West Indies. A professional gentleman of my acquaintance, residing in the island of Nevis, was attacked with this fever, and it proceeded with such violence, that in a few days petechia? appeared on different parts of his body, and a hemorrhage of blood issued from his nostrils, mouth, and other places. Under these unfavour- able circumstances he was freely exposed to the open air, and one or two buckets of cold water were thrown over him ; he was then wiped perfectly dry, and replaced in his bed; which plan of pro- ceeding was repeated twice and sometimes thriee a day. Bv means ORDER I. PUTRID FEVER. 55 of this application, the administration of an opiate at night, and a liberal allowance of wine, his life was preserved to the great, but pleasing astonishment of all his friends. Of late years I have been much in the habit of recommending cold affusion or ablution in most cases of typhus fever, and with very beneficial effects. The same practice has been adopted in the London house of recovery, and apparently with the most decided success. Obvious, however, as are the advantages to be derived from the remedy in question, still there are many practitioners, who look on it as an innovation, and are therefore averse to it. This prejudice, I hope, will soon subside. In the early stage of typhus, the superior efficacy of affusion over ablution is unquestionable; its operation extends beyond the mere abstraction of heat from the surface ; it acts powerfully on the nervous system. Besides its effectually removing the uneasy sensa- tion of heat in the beginning of febrile diseases, and thus indirectly recruiting the animal powers, it induces sleep. We well know that when any disagreeable sensation is removed, sleep soon follows; and it happens so in this instance. After the fourth or fifth day of fever, the influence of both affusion and ablution is greatly diminished, and not sufficient to interrupt the morbid actions; at a still more advanced stage the heat is removed nearly in the same degree by washing the surface of the body with a wetted sponge, or cloths dipped in water, as by pouring cold water on the naked body; and the patient is relieved nearly the same by one mode of treatment, as by the other. Thus much for the comparative merits of affusion and ablution. In the advanced stages of typhus gravior as well as of typhus mitior, where either the affusion of water of a low temperature, the immersion of the patient, or even the sprinkling his body with cold water, might in the least endanger our arresting the move- ments of life, we should always take the precaution of giving a glass of warm wine, or some other powerful cordial, immediately after employing the remedy. It is no uncommon occurrence for the symptoms to run very high at the commencement of this fever, so as to give it rather an in- flammatory appearance, which has induced practitioners, at times, to draw off blood, by opening a vein ; but sad experience has fully- evinced the impropriety of so doing. Contagion certainly weakens the force of the solids; for which reason, whenever we suspect a fever to have arisen from this cause, we should proceed with the greatest caution in drawing blood, even although the symptoms may run pretty high at the beginning, and may seem actually to demand the taking away a considerable quantity. Instead, therefore, of bleeding, or using any other evacuation than keeping the body open with mild laxative medicines, in such cases as are purely typhus, and proceed from contagion or de- pressing passions, we should support the patient by allowing a li- beral use of wine. It may be given in panado, gruel, or whatever 5ti PYREXLE OR FEBRILE DISEASES, CLASS |. he takes for food, and likewise in his drink, observing to dilute it properly, and to add sdrne grateful acid, such as the juice of oranges. The drink should be all cold. The mineral acids likewise are, beyond all doubt, better reme- dies in this and other malignant diseases, than we have been ac- customed to regard them; and from having employed them, but more particularly the muriatic, for several years with very great success in typhus gravior, I can vouch for their efficacy. My usual plan of proceeding is as follows: Having relieved the stomach by a gentle emetic where nausea prevails, cleared the bowels of their feculent contents by a proper dose of hydrargyri submurias joined with a few grains of the extract, colocynth. c, and subjected the patient to cold affusion when the circumstances already noticed have admitted of it, I prescribe for adults, ten or twelve drops of the muriatic acid guarded with five drops of tinctura opii, and as a vehicle I employ about an ounce and a half of an infusion of casca- rilla or columbo. This draught I direct to be repeated every four hours, gradually increasing the quantity of the acid in each, to eighteen or twenty drops or more. When the fever begins to de- cline, or to shew remissions, I substitute a decoction of cinchona instead of the infusion of columbo or cascarilla. The effects of the muriatic acid in all febrile diseases of a malig- nant nature are truly great; and from using it in all such cases, my practice has been attended with the most decided success. As a confirmation of its utility, it is proper to mention that a consi- derable pension has been granted by the King of Prussia to Dr. Reich, professor of medicine at the university of Erling in Fran- conia, for making.known a remedy by the use of which, all dan- ger was removed in acute diseases of a malignant nature, and that, on a disclosure of the secret, it proved to be the acids containing oxygen, but particularly the muriatic. In cases of extreme danger, we are told by him * that one or two drachms of the acid may be given at once. The discovery, however, cannot be claimed by the Prussian professor, as it is well known that the late Sir William Fordyce highly recommended the muriatic acid to be given inter- nally in diseases of a putrid or malignant nature, and likewise to be applied in the form of gargle to the sloughs of the throat which often accompany such fevers. In typhus gravior, as well as in scarlatina, the internal use of the oxygenated muriatic acid is a powerful and highly efficacious me- dicine. A material circumstance to be attended to, not only at the com- mencement of this fever, but through its whole coi.rse, is to covu the patient lightly with bed-clothes, and to keep his apartment cool and properly ventilated, by allowing a regular and free admission of fresh air into it; and in order to render it pleasant both to him- self and his attendants, it ought to be sprinkled several times a dav with warm vinegar and camphorated spirits. Fumigations in the manner herein after noticed will also be advisable. Cleanliness in * See a translation of his German work, by Dr. Parry, of Bath. ORDER I. PUTRID FEVER. 57 the strictest sense of the word is to be most carefully attended to : and therefore not only the bed and body linen should be changed frequently, but whenever a motion takes place, it ought immedi- ately to be removed. The viscid phlegm which collects about the tongue and teeth should be coagulated by some austere acid, and then it may be scraped off by a knife ; or be wiped away with a bit of flannel dipped in vinegar or salt and water. Although there is not usually any regular crisis to this fever, Still nature sometimes endeavours to throw it off by a gentle moisture diffused equally over the whole surface of the body; to promote this, we may advise some gentle diaphoretic ;* but we are carefully to guard against exciting profuse sweats, which would certainly prove highly prejudicial. A physician ^ of some eminence, speaks highly of the effects of the spiritus astheris sulphurici in this fever, when given with antimonials, as having an advantage over most cor lials in not increasing the heat of the body or quickening the pulse ; but, on the contrary, rendering the action of the heart more regular and slow, and, moreover, proving serviceable in promot- ing a diaphoresis, and lessening anxiety and tremors. In the first stage of the disease, where there arises any violent affection of the head, or any great difficulty of breathing, it has been usual to apply a blister to the neighbourhood of the part affected ; but blistering seems a doubtful remedy in typhus gravior. as well as in the mild species of the disorder. Where stupor pre- vails, with little or no delirium, we need not employ it; but where the delirium is violent and accompanied with great wildness of the eyes, so as to threaten a phrenitis, we may recommend it. After symptoms of putrescency have become obvious, the application of a blister would be highly improper. When hemorrhages ensue and petechia? have appeared on tiie body, we should have recourse to the most powerful antiseptics, such as vegetable and mineral acids, carbonic acid in every form, liquors in a state of fermentation, oxygen gas, oxygenated muriate of potass,f aerated waters, wine, cold affusion, and cinchona.J § Dr. Carmichael Smyth. * R Camphorae. gr. iv. Pulv. Ipecac, gr. iij. Confect. Aromat. § j- M. ft. Bolus 6ta hora sumendus. f R. Muriat. Potassae Oxygenat. 9 '• 3 ss' Tinct. Cinnam. Comp 2|ij. Aq. Cinnam. ^ jss. * Syrup. Cort. Aurant. 3 j. M. ft. Haustus zda vel 3tia hora capien- dus. i FJc Cort. Cinchonae. Crass. 3" ss. Rad. Serp. Contus. 3 iij. Ci.que in Aq. Fontan. Ibj. ad ibss. Colat. adde Tinct. Cinnam. 5 j. M. ft. Decoctum, cujus sumat uncias duas secunda quaque hora cum Acid. Nitrici III x.—xv. Vd rt. Pulv. Cinchon. 3 s«—3 j. Tinct. Ejusdem 7, ij. Aq. Cinnam. 3* jss. Tinct. Opii. Ill viij. Acid. Muriat. Ill viij.—xv. M. Pro haustu secunda vel tertia quaque hora sumenda. Vd Rj. Decoct. Cinchon. 3* jss. Tinct. Ejusdem 3 iij. Acid. Muriat. Oxygenat. ni xv.. xx. M. ft. Haustus }ti* horis capiendus. I 58 PYREXIJE OR FEBRILE DISEASES. CLASS I. We may also administer clysters of diluted vinegar,* or crystal- lized acid of lemons in moderate quantities, that they may remain in the rectum, and thereby be likely to be absorbed. The exhibition of fixed air has been recommended in this fever. The Rev. Edward Cartwright, having read of the power of fixed air in preserving meat from putrefying, was induced to make trial of it on a boy of fourteen years of age who had been ill several days of a putrid fever, for which bark and wine had been exhibited without any apparent advantage, and where there was but little hope of a recovery. He directed two table-spoonfuls of yeast to be taken every three hours, which having been complied with, the boy found almost immediate relief, and recovered very quickly. Mr. Cartwright reports, that he gave the same remedy to above fifty patients in this fever, without losing one. With respect to the use of yeast internally in this fever, some practitioners have looked upon it rather as a doubtful remedy, al- though they readily subscribe to its good effects as an external ap- plication in fetid putrid ulcers. I have made trial of it, and, as I conceive, with some advantage; nor did it in a single instance ex- cite any commotion or disorder, either in the stomach or bowels of my patients, as some have reported to have happened with them on making use of it. As the good effects of yeast seem to depend on the fixed air which it contains, it is probable that we might substi- tute water impregnated with the gas to great advantage, as we should thereby avoid the disagreeable consequences attributed to it. The mode in which I administered yeast was by adding one or two table spoonfuls of it to a quart of an infusion of malt or mild porter, of which the patient took a wine-glassful very frequently. Whatever may be the mode of action of yeast in typhus, the fact appears to be indisputable that fixed air takes off that extreme debi- lity of the stomach so conspicuously marked in disorders of this na- ture ; and in proportion as that subsides, the pulse rises, becomes slower and fuller, the burning heat on the skin disappears, and a truce is gained for the reception of nourishing supplies. For the healing of ulcers in the mouth we may employ a solution of alum in water (an ounce of the former to a pint of the latter,) as a gargle, which will quickly take away the stench that arises from them. In typhus gravior it is of the utmost consequence to procure rest, and therefore, where there is no great delirium, we may give an opiate towards bed-time. Combining it with some diaphoretic f will t &• Liquor Ammon. Acet. % iij. Aquae Cinnam. 5 j. Tinct. Opii m. xl. Syrup. Zingib. 3 ij. M. ft. Haustus. * R. Infus. Anthemidis Flor. 3 v. Aceti Communis 5 ij. M. Pro Enematc. Vd R. Decoct. Malvx compos. 3 vj, Aceti Communis 3 ijss, M. it. Enema. ORDER I. PUTRID FEVER. 59 prevent any deleterious effects from it, and therefore it will be best to give it in this way. A slight purging, attended with a gentle moisture on the skin, not unfrequently arises towards the close of this fever, and now and then assists in carrying it off; but where it does not seem to produce a critical effect, it ought to be stopped as quickly as pos- sible by astringents.* When we succeed in removing the symptoms entirely, by the means which have been pointed out, or in procuring a cessation of the fever, we are to endeavour to prevent its return by a free use of cinchona bark, the cortex angustura?, infusions of gentian and orange-peel, and other stomachic tonics ; and in order to recruit the strength, the patient should be directed to use a nourishing diet, with wine in moderation; and he should take such gentle exercise as his state of convalescence will admit. Having pointed out the mode of treatment to be adopted when the disease actually takes place, it seems proper likewise to mention the precaution it may be necessary to pursue, in order to prevent its contagion from being communicated to others. When the disease arises, the sick ought to be removed to a clean and well-aired room in the most remote part of the house, and as much separated from the rest of the family as possible ; his bed- linen should be changed frequently; his body be kept clean; what- ever comes from him, be immediately removed and emptied ; and his chamber be well ventilated by allowing a free admission of fresh air into it; it may likewise be sprinkled frequently with warm vinegar, in which some of the aromatic herbs have been infused. No fire should be kept in the room. In summer the patient should be covered only with a sheet, and in winter with a single blanket above the sheet. The good effects which arise from removing pa- tients in this fever from contaminated air are particularly remark- able among the poor; for a great many of them will recover when brought to an hospital or ward of recovery, although they take little or nothing; whilst those who remain at their own houses and have the best medicines and attendance will sink rapidly. None but the necessary attendants should have any communication with the sick, and these, to guard against contagion, should avoid sitting down on the patient's bed; and they must likewise carefully avoid inhaling the vapour arising immediately from his body. When near him, they may keep a sponge or handkerchief, moist- ened in camphorated spirits or vinegar, to the nose and mouth. " R. Confect. Aromat. 3 ss. Aq. Cinnam. ——Pimentae aa 3" jss. Fontan. 3" ij. Tinct. Kino 3 ij. ——Opii m L. M. ft. Mistura cujus sumat Cochl. jj. magna 4tis horis. 60 PYREXLE OR FEBRILE DISEASES. CLASS "f, In hospitals, camps, and on board of ships, where a number are unavoidably crowded together, so as to render it impossible to cut off the communication between the healthy and the diseased, these simple means will not prove sufficiently powerful for destroying the contagion, and therefore others must be adopted. In all such instances, besides well fumigating the apartments, clothes, beds, bedding, and hammocks of the sick, as hereafter advised, changing them frequently for fresh ones, paying the strictest attention to cleanliness in every respect, well ventilating every place where they are lodged, by a constant and free admission of fresh air, we should oblige those in health, as well as those tainted by the conta- gion, to undergo daily ablution with cold water. Nitric acid has been used by Dr. Carmichael Smyth, as a fumi- gation, with the greatest success in this fever. In the year 17S0, the disease broke out among the Spanish prisoners confined in Winchester castle; he embraced the opportunity of giving the re- medy a fair trial, and obtaining the most decisive evidence of its happy power in preventing the spreading or farther communication of the infection. He found he could use it without risk or inconve- nience to respiration, and therefore thought it the most proper an- tidote to be applied, where persons are unavoidably obliged to be present. At the suggestion of Dr. Smyth, important experiments were made by desire of the Lords of the Admiralty, with the nitric acid vapour, on board the Union hospital-ship in November 1795, to correct the contagion of a very malignant fever which had made great ravages among the crews of the Russian ships at Sheerness; the success of which was so complete, as not to leave the least reason to doubt of the high efficacy of this fumigation. Many sub- sequent trials have confirmed this opinion, and have induced the House of Commons to vote a reward to Dr. Smyth for his valuable and easy method of destroying the contagion of infectious fevers. The Doctor's mode of obtaining nitric acid is by decomposing nitre by means of heated sulphuric acid, which may be done as follows: Put half an ounce of this acid into a crucible, glass, china cup or saucer, and warm this over a lamp, or in heated sand, adding to it, from time to time, some nitre : these vessels he di- rects to be placed at 20 or 30 feet distance from each other, ac- cording to the height of the ceiling, and the virulence of the con- tagion. In hospitals and prisons, he advises the lamps or vessels containing heated sand to be placed on the floor; but on board of ships, he recommends to hang them to the beams by waxed silk cords. From the well-known efficacy of the sulphuric acid in destroying contagion, he advises it to be employed as a fumigatioif for clothes ' and furniture &c.; but for purifying empty prisons, hospital wards, and ships, he gives the preference to the nitric, its va- pour being more volatile and penetrating, and not leaving the dts- ORDER I. PUTRID FEVER. 61 agreeable smell which the sulphuric does, and thinking it at the same time equally efficacious. Monsieur Guyton Morveau, in his Treatise on the Means of pu- rifying infected Air, claims the merit of being the discoverer of the power of the mineral acids to destroy contagion, and endeavours to establish the superiority of the muriatic acid over all others. Upon a full investigation of the matter it appears, however, that the power of the mineral acids to destroy contagion was known to Sir John Pringle as early as the year 1750, and their utility for that purpose was mentioned by Dr. Johnstone in his pamphlet published in 1758, in which we are told that the vapour of muriatic acid was success- fully employed by him in correcting the contagion of a very malig- nant fever, which had raged at Kidderminster two years before that period. Dr. Smyth has also claimed the having been the first who used the mineral acid gases in the apartments of the sick, and has alleged that they never had been employed by Dr. Johnstone, but in places where no one was present, or whence the sick were removed. This opinion has been refuted by Dr. Johnstone's son, and the invention of his father most incontestibly established* What Dr. Smyth seems therefore entitled to, is the merit of having brought the dis- covery into public notice, and of having applied and extended it to general use. It seems of little consequence whether we employ the nitric acid or the muriatic in the form of gas for the purpose of destroying con- tagion and purifying infected air, as the powers of both are exten- sive and certain. The muriatic is however thought to be more dif- fusible than the other. When we give it the preference, it may be used in the following manner : Put one pound of common salt into an earthen vessel, and pour over it from time to time a small quan- tity of sulphuric acid, till the whole salt is moistened. If the air is foul and peculiarly offensive, apply a gentle heat under the vessel, to extricate a larger quantity of vapour; but in general, the sim- ple addition of the acid to the salt will be found sufficient, unless the apartment is very large. The most effectual, however, of all fumigations, is perhaps the following, but it requires some nicety. Take of manganese in pow- der two parts, the same of common salt, of sulphuric acid three parts, and of water one part. Put an ounce of the mixed manga- nese and salt into a bason, add of water a large tea-spoonful, then, drop in half a tea-spoonful of sulphuric acid, and repeat this till you have used a tea-spoonful and a ,half of the acid. In this manner keep up a sensible extrication of the fumes. On the appearance of typhus or any infectious disorder in a gaol, hospital, workhouse, garrison, transport-ship, or any other place where many persons are crowded together, we should not fail to advise one of these gaseous fumigations in every room, in addition 'o a free ventilation and the greatest cleanliness. The same steps * See Dr. John Johnstone's reply to Dr. Smyth. 62 PYREXIJE OR FEBRILE DISEASES. CLASS I. should be adopted in academies, boarding-schools, and even our dwelling -houses. Of the YELLOW FEVER, or TYPHUS ICTERODES. 1 his disease takes its name (improperly however) from one par- ticular symptom, but which although pretty general, is by no means universal, nor even essential to its existence. By Sauvages, it has been denominated typhus icterodes; by Cullen, typhus cum flavi- dine cutis ; by the French la maladie de Siam, and fievre des Matel- lotes, and by the Spaniards, vomito prieto. With respect to the origin of the yellow fever in America, there has prevailed a great difference of opinion; some supposing it to have been introduced from the West Indies; and others, that it took its rise from the exposure of putrid animal and vegetable sub- stances on the public wharfs of the city of Philadelphia ; which opi- nion is firmly supported by Dr. Rush, as he found that the streets adjoining to these wharfs were the first in which the disease made its appearance, and that in several instances it could clearly be traced from thence to other parts of the city. Let this be as it may, it is evident, from the report of Dr. Chisholme, and others, who have written on the disease, that the fever which prevailed in Philadel- phia, was exactly the same with that which raged in the West India colonies. Dr. Clarke informs us, that there appears to have been such an extensive and very peculiar deranged state of the atmosphere in the towns of the West Indies and in North America, that it is more probable the disease was produced by this general cause breaking out nearly at the same time in these different places, than that it was carried from the one to the other, either by persons or in any kind of goods or merchandise. We are informed by Dr. Miller, of New-York, that the yellow fever in America always begins in the lowest part of a populous mercantile town near the water, and continues there without much aKecting the higher parts. It rages most where large quantities of new7 ground have been made by banking out the rivers, for the pur- pose of constructing wharfs. The appearance and prevalence of the yellow fever in low situations, have led to the belief, he tells us, that the disease was imported by ships from the West Indies. But a person seized with this fever in an affected part of the town, and conveyed to one that is healthy, or carried into the country, does not communicate it, he asserts, to the neighbourhood, nor to those immediately around him. He therefore is of opinion that the yel- low fever is generated by the impure air or vapour which issues from the new-made earth or ground raised on the muddy and filthy bottom of rivers, and which deteriorate the air above it, in like manner as air becomes offensive and injurious when it approaches or passes over a body of vegetable or animal matter in a state ©f putrefaction. toRDER I. YELLOW FEVER. 63 It appears that the shores of the rivers of New-York and Phila- delphia have undergone great and rapid alterations from their na- tural state within a few years, on account of the vast increase of commerce, and for the sake of making wharfs ; and Dr. Miller men-. tions, it is only in such parts where these alterations have taken {dace, that the yellow fever has been produced. The parts where ittle or no alteration has taken place on the East and North river, and which continue nearly in their natural state, do not produce the yellow fever. He adds, eighty new wharfs have been made since the war, the consequence of which has been, that great quan- tities of filth and corruptible matter, deposited in the muddy bottom of the river, contiguous to the shore, and which produced no ill ef- fect while exposed to the air and washed twice every four-and- twenty hours, have been covered over several feet deep with new earth, and closely pent up so as to exclude the tide. It is in these places, and these only, that the yellow fever is produced, we are told. Dr. Bancroft* is of opinion that the only existing cause of yellow fever is the application of marsh miasmata to the human body, and that the disease is really a marsh remittent fever. He thinks him- self justified from repeated observations, in concluding that the joint influence of marsh miasmata, and of an atmosphere un- usually and sufficiently heated, upon persons habituated to a cold or temperate climate, is, of itself, fully capable of causing an epi- demic yellow fever, resembling that which has committed such ra- vages in the West Indies, the United States of America, and the South of Europe. We are told by him that the common bilious remittent of hot climates, which is universally admitted to be the effect of miasmata, differs from the yellow fever only by being less violent; that at the utmost their symptoms only vary in degree, and consequently the danger being greater in the latter than the former, for the yellow colour appears in both. Some have imagined, that the fever, which has for some years occasioned such havoc and devastation, is totally of a different nature from the yellow fever formerly met with in the West Indies and other tropical climates; but in my opinion, it seems to be the same, and that its only difference consists in its having prevailed as an epidemic, from the subsisting vitiated state of the atmosphere, and from its having, from other concurring circumstances, acquired a degree of malignancy and virulence unknown before. During a residence of nine years in the West Indies, from 1776 to 1785,1 had frequent opportunities of meeting with the yellow fever among seamen and such new-comers as were imprudent on their first arrival; and although the disease never prevailed during that period as an epidemic, still I always looked on it as contagious, and never failed to recommend the adoption of proper precautions to prevent its spreading. * See his Essay on the Disease called Yellow Fever. 64 PYREXLiE OR FEBRILE DISEASES. t'LAS^ I. It is probable that marsh exhalations, and the effluvia arising from putrid vegetable and animal substances, under a concurring vitiated state of the atmosphere, were the causes which gave rise .to this fever, and that it was afterwards kept up by contagion, heightened, by various accidental circumstances, to a pestilential de- gree of violence. Very hot and sultry weather, with a long drought, will greatly predispose to the prevalence of this fever as an epidemic, in all tropical climates ; and it may have a similar ef- fect in America, where the summer months are intensely warm. Dr. Rush and a few others are of opinion that the yellow fever is not contagious in its simple state, and that it spreads exclusively by means of exhalations from putrid matters, which are diffused in the air; and Dr. Bancroft tells us that, of the many thousands, who in the West Indies, as well as at Charleston, Norfolk, Bal- timore, Philadelphia, New-York, &c. were removed beyond the reach of marsh miasmata, whilst labouring under the disease or after having imbibed the poison, though in many of these, the disorder appeared under its worst forms and proved fatal, still it has never been communicated to others. This point, however, has by no means been satisfactorily established, and some facts which have been brought forward by Mr. M'Cregor,* shew that this fever may be communicated by contagion. The persons most liable to be attacked by it in the West India islands, were the Europeans who had lately arrived; and hence it was, that the troops sent out to recruit our armies, and the seamen to strengthen our fleet, fell its earliest victims. Women were ob- served to be less liable to its attacks than men, and children still less so than these ; and the people of colour were by no means so apt to be seized with it as the whites. When the disease did ap- pear among them, it was always much milder, owing most likely to their necessary temperance. Those of a full plethoric habit, and that were intemperate in their mode of living, were much greater sufferers by it than those of a lax fibre, and who were guilty of no irregularity. There is evidently something peculiar in the constitution of peo- ple from a cold country, which renders them more obnoxious to fever in a warm climate than either the natives or those who have been assimilated to it by a long residence. Accordingly we find, that the same exposure to the causes, predisponent and occasional, will produce fever in a stranger, while the native or old inhabitant remains in good health ; and the symptoms will be tenfold moir urgent in the one than the other, supposing both are attacked. Hence it happens that long residents, and natives in general, arc not liable to the yellow fever; but when they are attacked with the remittent of the country, the symptoms partake more or less of the malignancy of the prevailing epidemic. The heat of the body of new-comers in the West Indies has been * See his Medical Sketches. ORDER I. YELLOW FEVER. 65 noticed by Dr. M'Kittrick to be between three and four degrees above that of the temperature of the natives, and to this he ascribes in part the predisposition of new-comers to the yellow fever. Dr. Pinckard, late a physician to the army in the West Indies, from having observed this fever exhibited such instability, and va- ried so incessantly in its character, that he could not discover any one symptom to be decidedly diagnostic, has been induced to offer it as his opinion (see Vol. V. of Dr. Rush's Medical Observations of the University of Pennsylvania) that the yellow fever so called is not a distinct or specific disease, but merely an aggravated degree of the common remittent or bilious fever of hot climates, rendered irregular in form, and augmented in malignity, from appearing in subjects unaccustomed to the climate. The yellow fever usually attacks with lassitude and weariness, chilly fits, listlessness of every thing around, faintness, giddiness, flushing of the face, redness of the eyes, pains in the eyeballs and lower part of the forehead, as likewise in the back, debility and sigh- ing, thirst, and a tendency to coma: the urine is high-coloured, small ":i quantity, and turbid; the perspiration is irregular, inter- rupted, and greatly diminished; the saliva is viscid; the tongue is covered over with a dark fur; the bile is secreted in unusual quan- tities, and thrown into the stomach, from which it is again speedily ejected ; and the skin is hot, dry, and hard. The disease continuing to advance, the eyes become of a deep yellow, the face and breast are tinged with the same hue; an inces- sant retching and vomiting of frothy bile ensues; great costiveness prevails, and a peculiar delirium arises, which is attended with a permanent dilatation of the pupils of the eyes. There is hardly ever an evident remission until the fever has en- tirely gone through its first stage, which is generally in thirty-six or forty-eight hours; when there is often such an abatement of symptoms as to induce the patient to think himself tolerably wrell; but an early recurrence of the symptoms in an aggravated form, accompanied with extreme debility, soon convinces him of the con- trary. In the last stage of the disease, the greatest debility prevails, and symptoms of universal putrefaction arise; large patches of livid spots are to be observed on different parts, the tongue becomes dry, and black, the teeth are incrusted with a dark fur, the breath is highly offensive, the whole body exhibits a livid yellow in many cases, but not in all, hemorrhages break forth from the mouth, ears, and nostrils, dark and fetid stools are discharged, hiccups en- sue, the pulse sinks, and death follows very quickly. These are the usual appearances to be met with; but great ir- regularities have been observed by different practitioners. Dr. Chisholme mentions, that he often found patients, without any pre- vious complaint, suddenly become giddy, lose their sight, fall down almost insensible, and remain in that state for half an hour or up- wards ; the body then became overspread with a cold sweat, and K i Gt3 PYREXliE OR FEBRILE DISEASES. CLASS I. this was succeeded by intense heat, a quick, small, hard pulse, vio- lent pain of the head, particularly in the forehead, great anxiety about the praecordia; the eyes were much inflamed, watery, pro- truded, and wildly rolling; the face was much flushed; there was great heat at the pit of the stomach, with nausea, frequent retching and vomiting, as also severe pains in the small of the back and calves of the legs. During 12, 18, 24, or 36 hours, he found all these symptoms con- tinue to increase, except the quickness and hardness of the pulse, which were not materially changed, and that they were then suc- ceeded by general coldness, clammy sweats, and a greater or less degree of coma or delirium. Life, in this case, was lengthened out to sixty or ninety hours from the attack. A short interval of rea- son perhaps took place, the patient considered himself better, and flattered himself for the moment with the hope of recovery; but a fit, as sudden and as unexpected as the first, came on, during which he rolled his eyes dreadfully, foamed at the mouth, and threw out and pulled back his extremities in violent and quick alternate suc- cession. Dr. Chisholme observes, that, in general, the patient ex- pired in this fit; but in a few instances he recovered from it, and continued rational for a short time, when another has ensued and carried him off. He noticed, that, in a few instances, the patient complained of violent pains in the testicles, and on examination, he perceived them much lessened in size and retracted, wTith an excoriation of the scro- tum : now and then he found a remarkable change in the voice, and that it became weak and shrill; in a few instances, he could dis- cover little or no yellowness of the skin. Dr. Rush says, the disease appeared with different symptoms in different people : he observed the premonitory signs of it were, costiveness, a dull pain in the right side, defect of appetite, flatu- lency, perverted taste, heat in the stomach, giddiness or pain in the head, a dull, watery, brilliant yellow or red eye, dim and im- perfect vision, a hoarseness or slight sore throat, low spirits, a dis- position to sweat at nights or after moderate exercise, or a sudden suppression of night sweats. More or less of these symptoms fre- quently continued for two or three days before the patients were confined, and in some they continued during the whole time of the prevalence of the fever in the city of Philadelphia, without pro- ducing the disease. Many went to bed in good health, and awoke in the night with a chilly fit; many rose in the morning after na- tural and regular sleep, and were seized at their work, or after a walk, with a sudden and unexpected attack. He observes, that it frequently came on with a weak pulse, and often without any preternatural frequency or quickness; and that, in some instances, it was so low as not to be perceived without pressing hard on the artery; in some cases, the pulse intermitted, and these intermissions occurred in several persons who were in- fected, but who were not confined by fever; in others there was a ORDER I. YELLOW FEVER. 6 I more than ordinary slowness of the pulse, which was now and then accompanied with a dilated pupil of the eye. Hemorrhages hap- pened at the commencement of the disorder, chiefly of the nose and uterus; and as it advanced, the discharge of blood became more universal, and then issued from the gums, ears, stomach, bowels, and urinary passage. Many complained of a dull pain in the region of the liver, but few felt any soreness to the touch or pain at the pit of the stomach : in some, a determination of blood took place to the lungs, but the brain was chiefly affected with morbid congestion, which was indi- cated by the suffusion of blood in the face, redness of the eyes, di- latation of the pupils, pain in the head, hemorrhages from the nose and ears, by sickness or vomiting, and by an almost universal cos- tive state of the bowels. With respect to the secretions and excretions, there appeared to be a preternatural secretion of bile, which was discharged from the stomach and bowels in large quantities, and of very different qua- lities and colours, being in some cases yellow and in others black. The urine was sometimes plentiful and of a high colour; sometimes it was pale, and at others it was small in quantity and turbid ; more- over, sweats of a yellow colour, and highly offensive to the smell, often broke out. On the first and second day, the tongue was in- variably moist and white; but as the disease advanced, it became red, and put on a smooth shining appearance; towards the close, a dry black streak appeared in its middle, which gradually extended to every part of it. The effects produced on the nervous system were different, accord- ing as the fever affected the brain, the muscles, the nerves, or the mind. In a few instances, apoplexy was induced, which usually proved fatal; tremors of the limbs and twitching of the tendons were common ; delirium was a frequent symptom, but many passed through the disease without the least derangement of ideas: in some cases, the pain in the head was acute and distressing, and the stomach, towards the elose, was affected with burning or spasmodic pain of the most severe nature. The senses and appetites exhibited several marks of the ravages of this fever upon the body. Deafness and dimness of sight sometimes took place. Thirst, and want of appetite, were present, as in most other fevers. The convalescence was marked by a sudden renew- al of the propensity to venery.* Swellings in the inguinal and parotid glands took place in a few instances, which did not proceed to suppuration. In some cases, the skin was preternaturally warm ; in others, it was cooler than in health. The yellow colour was by no means universal; wdien it took place, it was seldom to be ob- served before the third day, but more frequently about the fifth or seventh from the first attack. The eyes seldom escaped a yellow tinge. There were eruptions of various kinds on the skin, and, ii: * The same is frequently noticed on recovering from the plague. 68 PYREXLE OR FEBRILE DISEASES. CLASS I. the latter stage, petechia? were common ; carbuncles also took place in some. The disease ended in death in various ways. In some, it was sudden; in others, it came on gradually. The last hours of some were marked with great pain and strong convulsions; but, in many, death seemed to insinuate itself into the system with all the gentle- ness of natural sleep. In every case that came under Dr. Rush's care, there were evi- dent remissions or intermissions of the fever, or of such symptoms as were substituted for it. The disease continued for 15, 20, or 30 days in some people. He observed that all were affected by it; but persons in the prime of life were most liable to it. Men were more subject to its attacks than women. He likewise observed, that the refugees from the West Indies universally escaped it; whereas the natives of France, who were settled in the city of Philadelphia, were much annoyed by it; and he found, that the people of colour took the disease in common with the white people, but in them it was usually much milder. Critical days were hardly ever distinguishable in this fever, nor was the crisis often very evident. Sometimes a copious perspira- tion put an end to it; and at others, the return of sleep, an he- morrhage from the nose, or sudden diarrhoea, carried it off. Dr. Fordyce is of opinion* that typhus icterodes ought to be regarded rather as an irregular semi-tertian than as a continued fever; for it often happens, that a patient becomes greatly relieved, and appears to be recovering, when all at once a fresh attack takes place and carries him off. He thinks that the dark brown colour of the skin in this fever arises rather from a greater secretion of the matter secreted by the sebaceous glands of the skin, than owing to a quantity of bile getting into the bh>od-vessels. In support of this opinion, he observes, that the colour is very different from that which takes place in jaundice. The evacuations from the intestines have not that clay-like appearance which is common in jaundice. The secretion from the kidneys has not that dark yellowish brown, nor that thick sediment, which have almost always been noticed in those persons in whom bile has got into the blood-vessels. The dark brown matter which the patient throws up by vomiting, he thinks, has the appearance of the matter observed upon the tongue in very violent fevers, and that probably it is formed on the surface of the stomach, and perhaps of the duodenum, or even on the beginning of the jejunum. The force of the exertions in vomit- ing, often occasions a greater quantity of bile to be secreted, and so to be thrown back into the stomach, and be brought up with the dark brown matter. When this happens, it gives to the matter thrown up, he observes, the taste and appearance of bile. At other times, however, there is no appearance of bile at all, but only of this dark brown matter. * See his Fourth Dissertation on Fever. ORDER I. YELLOW FEVER. 69 Dr. Bancroft is of opinion,* that the black matter thrown up in this fever is merely blood which has been effused from some of the small arteries, ruptured in consequence of the separation of certain portions of the villous coat, and has coagulated within the cavity of the stomach, or on the surface over which it was effused, and hav- ing been afterwards detached and triturated by the violent and fre- quent contractions of that organ in the efforts to vomit, has had its appearance as a coagulum of blood altered, and its colour darkened by the gastric juice, or by some chemical decomposition, either spontaneous or produced by the action of the air, or other matters contained in the stomach. Concerning the nature of the black vomit, various opinions have indeed been entertained. Some have considered it as consisting of putrid bile, some as composed of a mixture of blood and bile, some of the villous coat of the stomach dissolved in the progress of in- flammation, terminating in sphacelus, and others, of bile mixed with the septic acid contained in the alimentary canal. Dr. Cathrall of Philadelphia,j- considers all these opinions as erroneous, and of- fers it as his, that the black vomit is an altered secretion from the liver. We are informed by him, that the black vomit, or matter so called, appears to be of two kinds : one consisting of a number of flaky particles, resembling the grounds of coffee ; the other, of a dark-coloured inspissated mucus. From various and repeated ex- periments, he concludes, that the black vomit, besides a consider- able proportion of water tinctured with resinous and mucilaginous substances, contains a predominant acid, which is neither the carbo- nic, phosphoric, nor sulphuric, but hints it may be the muriatic. It appears from Dr. Cathrall's experiments, that the black vomit, when applied to the most sensible parts of the body, produced little or no effect. It likewise appears that large quantities of this fluid, may pass through the stomach and bowels of quadrupeds and other animals, without apparently disturbing digestion or affecting the health. This fact incontestibly proves the inactivity of this fluid, and renders it probable that the speedy death which ensues after this discharge in yellow fever, is not from any destructive effect of this matter on the stomach and bowels, but most likely from the de- gree of direct and indirect debility, which had been previously in- duced. Another fact which has been proved by this gentleman's experiments is, that an atmosphere highly impregnated with the odour of the black vomit recently obtained, would not produce fever, apparently under the most favourable circumstances. The yellow fever differs from typhus in the following circum- stances, viz. it usually prevails only during, or immediately after very hot seasons, in which typhus is soon extinguished, and it is in its turn completely annihilated upon the accession of cold weather, in which typhus is commonly most prevalent, particularly if accom- * See his Dissertation on the Yellow Fever. f See the New-York Repository of 1800, for his Memoir on the Analysis of the black Vomit, ejected in the last stage of this fever. 70 pyrexia: or febrile diseases. class i. panied with humidity of the atmosphere. It attacks most readily and violently the young and robust, over whom typhus is allowed to have the least power ; it begins with much greater exertions of the living power than typhus, is attended with many symptoms of a different nature, and it frequently changes into a regular remittent, and sometimes even to an intermittent fever, which true typhus is n ever observed to do. It differs from the plague, in that it prevails only in those coun- tries, and in those seasons in which the heat is, or has recently been so great as to destroy or stop the progress of the plague ; in the in- ter-tropical climates therefore, so favourable to the existence of the yellow fever, the plague is unknown. The glandular and cutaneous affections called buboes and carbuncles so constantly accompanying the plague, are not met with in the yellow fever. A violent febrile paroxysm is essential to the character of yellow fever, whilst accord- ing to the best authorities persons have been attacked by the plague without having the least febrile affection. In forming an opinion as to the event of the yellow fever, we must have in view the nature of the symptoms, the mode of attack, and the age and habit of the patient. Youth and a plethoric state, are invariably circumstances of danger. A sudden oppression of all the functions at once ; great debility; weak irregular pulse ; sigh- ing ; severe vomiting of dark matter ; tremors of the body when moved, with a tendency to faint on the slightest exertion ; pensive sadness in the countenance ; and a dilatation of the pupils of the eyes, with coma ; are signs of great danger. Black and fetid dis- charges by urine and stool, the breath being highly offensive, and the appearance of petechias, portend almost certain death. The symptoms that we may regard as favourable are, a settled state of the stomach, lessened head-ach, eyes lively, appearance of an eruption on the skin, known in tropical climates by the name of prickly heat, free perspiration, copious and high-coloured urine, bilious flux, and sound sleep. No disease, however, exhibits a great- er variety of symptoms, and often less to be depended upon, than this; for sometimes it goes on with favourable appearances, then suddenly changes to the worst, and sometimes patients apparently almost in a state of convalescence, expire in a few hours. Dissections of the bodies of those who have died of the yellow fever have shewn the coats of the oesophagus corroded ; the sto- mach and intestines loaded with a black fetid matter, or both to be often much inflated, inflamed, and sphacelated ; the liver, in many cases, to be shrunk to less than half its natural size, very flaccid, and of a colour approaching to buff; and the gall-bladder to be flaccid and greyish, having but little bile contained in it. In some instances, the lungs have been found inflamed ; and the bladder has been observed to be much thickened, and to contain a considerable quantity of urine. In those cases where there has been a dis- charge by vomiting of a black coagulated matter resembling the grounds of coffee, the gall-bladder and biliary ducts have been ORDER I. YELLOW FEVER. 71 found distended with the like substance. Where an affection of the head has formed a prominent feature of the disorder, the integu- ments of the brain have been observed more or less inflamed, the vessels of the dura and pia mater to be very turgid with blood, and occasionally extravasation. Sometimes the volume of the brain has been found increased, and the substance of it more firm than usual. The same difference of opinion which arose among the profes- sional gentlemen of Philadelphia, with regard to the origin of the disease, seems likewise to have subsisted between them, as to the mode of treatment to be pursued ; some recommending and adopt- ing the antiphlogistic plan, by bleeding, purging, and a low diet; some, the stimulant plan, with a liberal use of the bark, wine, opi- um, and the cold affusion; and others, again, either purged mode- rately with calomel, or bled on the first or second day of the fever, and then resorted to a free use of bark, wine, laudanum, and aro- matic tonics ; and this practice they adopted on the supposition that the disease was inflammatory in its first stage, and putrid in its last. According to the report of Dr. Rush, this last mode of treatment was scarcely more successful than the tonic and stimulant one ; and that which he found to succeed best was the antiphlogistic, pursued even to a degree of extreme rigour ; for we are given to understand, that although in some instances he allows of one or two moderate bleedings being sufficient, still, in most cases, he was in the habit of repeating the operation much oftener, and of drawing off a consi- derable quantity each time, even from the poor who resorted to his house for advice. Whether or not bleeding may be practised with advantage to the patient in America, or to what length it may be carried, I am not capable of determining, never having been on that continent; but being well acquainted with the climate of the West Indies, from a long residence there, and having often met with the disease (al- though not under its present malignant form,) I must concur with the objectors who contend, that bleeding cannot there be resorted to with advantage. If ever it is advisable, it can only be where the fever has made its attack on a newly arrived European of a full plethoric habit and vigorous constitution, and on the very first ap- pearance of indisposition. Even here it is probable that it may be more likely to do harm than good. By the communications of Dr. M'Larty, of Jamaica, inserted in the Medical and Physical Journal * we are to under- stand that the principal practitioners of Kingston consider bleeding as a remedy, which in no case of the fever of new-comers is produc- tive of advantage ; but in most instances of much evil. The case of a seaman who was bled the same morning that he was taken ill, is reported by this gentleman. The patient was a remarkably stout young man, nineteen years of age, and laboured under a violent head-ach, flushings in the face, redness of the eyes, and general un- * See vol. ix. page 3 -. 72 PYREXIAE or febrile diseases. CLASS I. easiness. A vein was opened in the arm while sitting; but no sooner had he lost three or four ounces of blood, than surprising syncope compelled him to lie down. In this posture, when about eight ounces more were taken away, he became so extremely lan- guid as to make it advisable to tie up the arm. He never again got up; from that moment he continued feeble, and debility advanced prog;re-sively in spite of every thing given to obviate it, till the third day, when he died. It seemed, indeed, as if the powers of life had been so exhausted by the loss of blood, as to be incapable of being again aroused into action. Dr. Clarke, in his treatise on this disease, mentions, that no na- tive recovered when the lancet had been used; and Dr. Chisnolme observes, that although the blood drawn, in the cases where this re- ined) was employed,"appeared remarkably florid, and always threw up an inflammatory crust of greater or less thickness, and although the pains seemed to undergo a temporary mitigation, yet the conse- quence, at the expiration of a few hours, was always fatal, notwith- standing the patients were remarkably robust, florid, and generally in the vigour of life. These observations fully justify the remarks which I thought it necessary to make under the head of Typhus Gravior, and which I beg leave again to repeat, viz. that the contagion certainly weakens the force of the solids; for which reason, whenever we suspect a fever to have arisen from this cause, we should proceed with the greatest caution in drawing off blood, even although the symptoms may run high at the beginning, and may seem actually to demand the taking away a considerable quantity. Dr. Hector M'Lean, who has likewise published on this fever, is one of the few West India practitioners who approves of bleeding.— He observes, that the determinations to particular organs, which take place in the disease, and which constitute its greatest danger; the marks of inflammation, which dissections have shewn in the sto- mach and biliary organs, evidently point out the propriety of this evacuation. He adds, that experience confirmed its utility; for his practice was much more successful, after he had adopted blood-let- ting, than before. By way of caution he mentions, however, that it is only in the very early stages he thinks it advisable to have re- course to the operation, and that if it is not performed as early a? the second, or at farthest the third day, he apprehends it will not be successful. Dr. Jackson, in his Exposition of affusing cold Water in the Cure of Fever, tells us, that he holds a subtraction of blood in large quantity to be a most decisive process in the more intense and con- centrated forms of the endemic fever of the West Indies, and that the remedy produces a condition, susceptible of being more readi- ly acted upon afterwards by cold affusion, and the other means we may employ. He adds, that whatever may be the precise quantity necessary to produce the effect, it must always be supposed to stand high, and seldom lower than thirty ounces ; in strong athletic Eu- ORDER I. YELLOW FEVER. 73 ropean soldiers, recently transported to a tropical climate, some- times far above it. Dr. Bancroft (who is the latest writer on the yellow fever) is of opinion that bleeding may be resorted to in certain cases not only with safety but advantage, and he quotes himself as an example; but he says that the propriety of the operation, and the quantity of blood to be taken away, must be determined by the circumstances of the patient. To obviate the inflammatory diathesis which prevails during the first stage of the disease, and to take off the determination from the head, as well as to cleanse the prima? via; of acrid and offending hu- mours, we may employ gentle purging, so as to procure one or two evacuations daily during the continuance of the fever; but as the stomach is seldom in such a state as to be capable of retaining those purgatives which are in common u:-.e, besides a triple dose being generally necessary, it has been found best to administer the hydrargy- ri submurias, either by itself or combined with jalap, as below.* In no stage of typhus icterodes can emetics be administered with safety, owing to the disposition to vomit which usually prevails, and which it is often difficult to allay. Instead of prescribing emetics, we are to endeavour by every possible means to calm and allay the irritation of the stomach. The means by which a perspiration is to be excited, not being altogether innocent, sudorific medicines do not seem proper. Mercury being known to be a kind of specific in local inflamma- tions of the liver, and there being evidently a great determination of blood to this viscus in the yellow fever, practitioners have been induced to employ it likewise with the view of exciting a degree of salivation; and where an incessant vomiting has prevented their using the submuriate of mercury in sufficient doses to effect this, they have substituted mercurial frictions. In some of the cases where the hydrargyri submurias was administered with this view, its quantity was obliged to be increased to an almost incredible ex- tent. Dr. Chisholme mentions a case, where 400 grains were giv- en before the salivary glands were affected; and in the Medical Commentaries for the year 1795, Dr. Duncan, of Edinburgh, takes notice that a correspondent in Jamaica had reported an instance where, within the space of a few days, the patient had taken 270 grains of it, and had rubbed in twenty drachms of the strongest mer- curial ointment, from which the happiest effects were at last produced, On such authorities, and from the well-known efficacy of mercury in inflammations of the liver, it may, probably, be a proper and, valuable remedy in typhus icterodes. To ensure its success, it should, however, be employed at the very commencement of the disease, and be so conducted as to affect the mouth before the dangerous ';* R,. Hydrargyri Submur- gr. iv. Pulv. Jalap, gr. viij.—xvj. Syrup. Zingib. q. s. M. ft.