hours. Quotidians have the least cold stage, but the longest paroxism:
tertians are in the intermediate degree in both respects; quartans
have the most violent, or at least the longest cold stage, but the
shortest paroxism: their cold stage may be two hours, or longer. The
hot and sweating stages therefore constitute the greatest portion of
intermittent conflict. Quotidian paroxisms rarely exceed eighteen
hours: tertians are from six to twelve: quartans somewhat shorter.
Quotidians generally assault in the morning; tertians and quartans in
the noon and afternoon. Vernal are said not to be so refractory as
autumnal intermittents. But in young sound constitutions, agues, if
not inveterate, are frequently cured after a few paroxisms. When death
happens in them, it is generally during the cold stage. More frequently
their fatality is by transition into some other chronic diseases: such
as maladies of the stomach, digestive organs, liver, and intestinal
tube; bilious cachexy, jaundice, consumptions, dropsy. Some inveterate
corporeal infirmities have been relieved by intermittents. During their
revolution the type is frequently changed: quartan and tertian into
quotidian: the latter into remittent; and these into continued fever.
_Remittent Fevers:_ fevers with remissions and exacerbations, or which
have not a temporary and total cessation, are the most universal
febrile form in all parts of the globe. Throughout the equatorial
oven, or middle regions of the earth, from Cancer to Capricorn,
intermittents, but, above all, remittents and dysenteries are the most
universal type of fever. They are the locusts which devour whole crops
of mankind. During the periodical rainy seasons of the tropical zones;
particularly where they are choaked up with woods and morasses, and
in uncultivated new settlements, these fevers often ravage with the
desolation of an Egyptian pestilence; and are sometimes so precipitate
as to kill in one or two paroxisms, if not sooner repulsed; the doctor,
lawyer, and priest quickly succeeding each other in their visits.
They destroy not only multitudes immediately, especially of the new
European settlers; but when improperly treated, or when convalescents
from irregularity, fall back into relapses, they often terminate in
fatal chronic diseases, similar to those recently enumerated under the
intermittent train.
Not only within the tropicks, but likewise through the northern
hemisphere, to the verge nearly of the polar circles, we can descry
this remittent febrile host. In the sultry summer and autumnal seasons
of Europe, in low marshy countries, soils and situations such as
Italy and Hungary, where the summers are long and intense; and in
that northern morass, Holland, these are the epidemical tyrants.
Armies encamped are often at that season grievously infested with
them, and with dysenteric fluxes. In Britain and Ireland also, they
are frequent and fatal epidemicks; and are not confined to the summer
season only. Even in most dry countries and situations without the
tropicks, after an unusual close sultry summer, with long protracted
heats, we often see, or read of, such fevers and fluxes. The humours
then, says Pringle, are corrupted, the solids relaxed; and in such a
disposition of body, irregularities in diet, wet cloaths, and damp
air, may give activity to such latent indisposition. In that small
southern Mediterranean island, as described by Cleghorn, where the soil
is rocky, but the summer heats excessive, such fevers have raged with
atrocious severity.
Fevers intermittent and remittent, and those strictly simple
inflammatory, are greatly regulated, not only by the climate, latitude,
soil, local elevation or depression, but also in the same country by
the different seasons of the year. In summer and autumn, fevers tend
in various degrees to affect the stomach and intestines with sickness;
they are then, more or less remittent, and participate less of the
inflammatory. “In Holland,” continues Pringle, “towards June, a healthy
month, the inflammatory fevers begin to recede; and the remittent,
bilious, and putrid often succeed throughout the summer and autumn,
until the return of winter, when the inflammatory again recommence; the
seasons and diseases insensibly interchanging and running into each
other.” We may also add, that in all warm climates there is a copious
and superabundant secretion of bile; and that none of the animal fluids
so soon turn putrid. They are more obnoxious to remittent fevers who
are constantly exercised in labour and fatigue, and exposed to the
external air, than other ranks who are comfortably accommodated,
cloathed, and fed. Pringle remarks, that the peasants of Holland were
always greater sufferers by the summer, autumnal, and remittent fevers,
than those of the more opulent class; and also, that during summer and
winter, in the field and in garrison, the private soldiers were more
sickly than the officers, and liable to fevers.
Remittent fevers seem to consist of a repetition of protracted diurnal
paroxisms, or periodical aggravated exacerbations, nearly similar
to the intermittent or primitive type; but without the latter’s
complete intermission. Authors have described them under a variety
of apellations; but they may be all comprehended as ramifications
of one great trunk, or integral genus: they appear in essence the
same disease, and are cured by similar remedies. In the medical
nomenclature, they are denominated remittent, semitertian, hemitritea,
tritophyea, double and triple tertian, putrid remittent, marsh,
camp, ardent, bilious fevers, gall sickness: tertian fever obscured
under a mist of one or more dangerous and prominent symptoms; hence
named tertiana lethargica, vertiginosa, soporosa, apoplectica,
paralytica, cataleptica, epileptica, convulsiva, phrenitica, hysterica,
syncopalis, asthmatica, arthritica, cardialgica, singultuosa,
rheumatica, pleuritica, dysenterica, atrabilaria, cholerica, emetica,
diaphoretica, pituitosa, miliaris, scorbutica.
Exclusive of the symptoms common to such fevers, and partly delineated
under the intermittent paroxism, remittent fevers are variously
diversified by a rotine and medley of nervous, putrid, and inflammatory
symptoms; but infinitely more of the two former. The climate, season of
the year, remissions, and the notorious epidemick or endemick of that
region or place, all contribute to their unerring detection. Sometimes
they attack very suddenly and violently with delirium and inflammatory
simulation; but soon afterwards, and at the interval of a few days,
remissions are evident. Sometimes their approach is in appearance mild,
but not less alarming. In general there are great lassitude, debility,
anxiety, restlessness, severe headach, frequently delirium, especially
at the exacerbations; disturbed sleep, and not refreshing; sickness
at the stomach, nausea, bilious vomiting, or efforts to evacuate
the ventricular contents; fecal excretion bilious with gripes;
inextinguishable thirst; tongue dry and parched; quick hot respiration;
skin sometimes dry. When bile is redundant, the intestinal excretion
is often putrid and offensive, with bilious diarrhœa or dysentery,
in repetition and quantity profuse, exciting tenesmus, and sometimes
excoriation of the anus; to these may be added pain in the stomach and
intestines, tension and elevation of the belly. According to Lind, the
tropical remittents are the most virulent, yet are not contagious,
unless accompanied with dysentery, or the sick crowded together; which,
if an irrefragable fact, distinguishes this fever from the nervous and
putrid: and besides, in those febrile epidemicks and endemicks, from
marshy effluvia, the remissions are more perceptible and synchronous
than in these from animal contagion. From the air, season, and medical
treatment, the remittent may be converted into the intermittent or
continued type; in the intermittent there is more security. In warm
climates putrescency and death may ensue in a few paroxisms; in others,
in all the intervals during three weeks: and usually the crisis is by
some of the larger excretories.
_Nervous and Putrid Fevers._ This febrile host are also widely
dispersed over the earth; and probably are not so much governed
or influenced as the preceding remittents by the climate, season,
and sensible qualities of the atmosphere; but may originate in all
countries, climates, seasons, and situations; and when extremely
virulent, may, like the plague or small pox, be communicated by
imperceptible emanation or contagion from one infected person to
another; by personal intercourse, by the medium of polluted goods,
furniture, apparel, cloaths, and houses; in all which the noxious
miasma may be concentrated and lodged. Sometimes they harrass a nation
or city in detachment only; and sometimes in formidable phalanx. Such
fevers are frequently engendered in jails, crowded with filth and
animal steams, and excluded from free ventilation: also in military
hospitals, crammed with sick, with dysenteries, putrid sores, and
mortifications: also in ships and large fleets, when hastened out in
the hurry and spur of approaching hostilities: also in wet and stormy
weather at sea, when the hatches are closed.
In cities, contagious fevers may be traced to prisons, perhaps
sometimes to hospitals; certainly often to narrow courts and alleys,
and small crowded apartments; to the houses of the indigent; to filth,
rags, and squalid poverty, co-operating with foul unventilated air:
and in the open perflated streets, are much less frequent. Cities,
therefore, should be more infested with them than the country; and
the poor more than the affluent. Children with adults are subject
to them, but more of the latter. In London, perhaps, nine-tenths of
the fevers, are of the remittent, nervous, and putrid type, and not
of the simple inflammatory. But I exclude from this calculation the
exanthematous order, and the topical inflammations. Some, not without
argument, alledge, that slow nervous fevers are in general derived
from the same origin; and that they differ from the putrid in degree
only. Petechial spots are by no means constant symptoms of the putrid
type; but when they occur, they point out the disease more unerringly,
and its greater malignity. In many instances, their differences may
be rationally imputed to climate, season, constitution, miasma, and
medical treatment.
I meet with inextricable embarrassment, in endeavouring to draw
the exact limits, not only between nervous and putrid fevers, but
also between them and what some authors have termed the universal
remittent of this island; and which is not limited to any season of
the year. I take this opportunity, therefore, to avow, that in what
proportion these very general fevers with remissions originate from
marshy effluvia, from climate, and constitutional indisposition, from
animal contagion, or from other occult causes, I am unable to decide:
Their precise relation as to lineage and consanguinity, is beyond my
penetration. Nervous and putrid fevers have been described under the
following different names: slow nervous fevers, febricula, maligna
lenta insidiose mitis, nervous and putrid fevers, putrid remittents,
typhus castrensis, jail, hospital, infectious, putrid, malignant,
continued, putrid, spotted, purple, petechial fevers; yellow fever of
the West Indies, or typhus Icterodes.
Slow nervous fever frequently steals on with treacherous mildness; the
sick are rendered unfit for business, but yet not confined to bed, and
except to sagacious judges, the fever is not apparently alarming; and
too often the sick and their friends are lulled into fatal security.
The symptoms slight alternate chills and fugacious heats, especially
in the evenings; heaviness, giddiness, and headach, particularly
in the posterior and superior part, and the pain often descending
down the spine; great debility and prostration of strength; and in
both nervous and putrid, the functions of the brain, and of muscular
motion, considerably weakened, and interrupted; also depression of
spirits, sighing, restlessness, very little sleep and not refreshing;
accelerated, weak, and small pulse; nausea, total inappetency;
inconsiderable heat of the skin or thirst; dry tongue, a little yellow
at the sides; pale urine, and without sediment; irregular sweats;
sometimes pains resembling rheumatick. After a few days, the fever,
stupor, delirium, and headach increase, with low muttering delirium,
chiefly during the nocturnal exacerbation, and with noise in the
ears, and universal debility of the corporeal and mental organs.
The remissions are generally more distinct in the beginning, and, by
degrees, more obscure.
Putrid fever sometimes creeps on with deceitful approach under the
nervous cloak; and sometimes, with furious onset, counterfeits
the inflammatory. The symptoms when radicated and inveterate are,
unremitting headach, pain in the back and loins, and course of the
spine; vertigo, throbbing of the temporal and carotid arteries, noise
in the ears; delirium, extreme diminution of strength and despondency
of mind, trembling of the hands and tongue when thrust out; anxiety,
restlessness, or no refreshing sleep; intense burning heat of the skin,
especially in the evenings; nausea, bitter taste in the mouth, vomiting
of green or black bile: sometimes insatiable thirst; at other times the
sick are insensible to thirst and heat, and only complain of universal
languor and weariness; the tongue, teeth, and lips covered with a brown
or black tenacious crust, with thrush and ulcers; the fecal excretion
black, and fetid; the breath and perspiration offensive to the smell;
the pulse progressively small, irregular, and quick, often 130 to
140 pulsations, even in adults, every minute; the eyes glazy, the
vessels of the tunica albugina turgid with blood, and what is called
blood-shot: in stages of still more virulency, petechial eruption
sprinkled on the skin, with hemorrhages from the gums and nose, and
hemorrhagick subcutaneous extravasations. In the yellow fever of the
West Indies, there is a jaundice-colour of the eyes.
In the duration, crisis, and termination of nervous and putrid fevers,
there is considerable diversity. Some may be suddenly stifled before
they burst into a flame: some of inveterate malignity may prove fatal
in a few days; others may terminate in all the intervals within three
weeks, or even later. Some terminate auspiciously without any sensible
crisis or evacuation: in others, there is more or less sensible
defecation by some of the excretories, by perspiration and sweat;
diarrhœa and fetid stools; turbid urine; exspuition and salivation;
vomiting; tumor of the parotid glands; eruption about the mouth.
Miliary fever, febris purpurata, rubra and alba, is never epidemick,
and is denied to be a primary disease; but is spurious, symptomatick,
accessary, or fortuitous; it is very rare, and may be complicated
with the nervous and putrid, and with small pox and measles. The
miliaris alba is more frequent amongst the female sex, especially
during the puerperal state, and in other females debilitated by fluor
albus, and hemorrhages, of weak constitutions, delicate, prolifick.
It sometimes exhibits previous symptoms of angina, pleurisy, catarrh,
rheumatism, erysipelas. Its peculiar diagnosticks are extreme languor,
anxiety, despondency, terror, sighing, prostration of strength,
headach, delirium, restlessness, quick weak pulse, oppression of
the breast and stomach, dry cough without expectoration; sometimes
profuse sweats towards the third day or later, and the sooner the
worse; inextinguishable thirst; urine and stools various. In different
stages of the fever, after a few days, a cutaneous efflorescence is
perceivable, from which the disease takes its name, preceded by and
accompanied with itching and pricking heat of the skin, and eruption
of diminutive pustules, the size of millet seed, and, by the fingers,
may be felt prominent: they are rarely seen on the face; commonly on
the neck, back, breast, and extremities; some of them change into small
serous vesications, distinct or clustered, and emitting a peculiar
sour odour: of these there is often a retrocession and new eruption,
variously protracting the fever to a few days, or even weeks. It is
distinguishable from measles by the pruriency and sour smell, and the
absence of morbillous sternutation.
_Inflammatory Fevers_, synochus continua non putris of Boerhaave. To
this we may add the febris diaria. A different genus of fever, both in
its nature and cure, from the remittent, nervous, and putrid, is the
simple inflammatory. The frequency and the fatality of this fever, is
infinitely inferior to the preceding groups; and in comparison, is as
a wasp to a tyger; or a babe to Hercules. The false lights hung out
successively by multitudes of authors, and transmitted, in some degree,
through the Boerhaavean school, to steer with the antiphlogistick
compass and lancet in each hand, in the generality of fevers, have
been the cause of numerous shipwrecks. Inflammatory fever is frequently
complicated with some local inflammation, and then is distinguished
under a different name, and hereafter described. Pringle observes, that
in military camps, pleurisies, and peripneumonies are the most frequent
form of fever with inflammation; and next to these acute rheumatisms.
The predominancy and reign of inflammatory fever in northern latitudes,
is in winter and spring, in cold climates and rigorous seasons,
and where cold and moisture are combined. It commonly attacks the
robust, strong, athletick, and those in the vigour of life: it is not
contagious; and neither its remission nor exacerbation are conspicuous.
Its assault is sudden and violent, with severe headach, quick laborious
respiration, interrupted sleep and restlessness, or sometimes
somnolency; sometimes delirium; but in general the mental functions
are not greatly disordered, nor the muscular debility so great as in
the nervous and putrid fevers: pulse accelerated, strong, full, and
tense; commotion and throbbing of the temporal and carotid arteries;
intense heat of the skin, dryness of the mouth, fauces, tongue, and
nose; ingurgitation of drink with avidity; the urine somewhat crimson
in tincture, and in small quantity; the belly generally costive; the
blood drawn, forming a buffy incrustation on the contracted coagulum,
complete its portrait. The natural crisis is various by nasal
hemorrhage, by sweats, turbid urine, diarrhœa; and the duration of
the fever from four to eleven days. The Febris Diaria of a few days
continuance, is a sort of minor or infant species, an appendix of the
inflammatory: it begins suddenly with nausea, vomiting, shivering,
cold, headach, lassitude, heat of the skin, flushed face, restlessness,
or disturbed sleep, strong quick pulse: and is rarely dangerous.
With respect to all the preceding confederate genera of fevers, we
shall make the following general observation. In the preceding century,
during the last thirty years, febrile mortality, by the London bills,
is rated at 87,645: and the mortality of the present century is seen
in the Chart. Formerly, in this metropolis and island, and probably
throughout Europe, fevers seem to have been much more prevalent and
fatal than at present: their essential nature and cure is now much
better understood by physicians; and we are provided with far more
powerful auxiliary remedies, and are more expert in their application.
In this particular instance, modern medicine, especially of the century
in which we live, is signalized, and may, without arrogance, claim
triumphal honours. The supposed innumerable varieties of fevers,
and from which perplexity Sydenham could not altogether extricate
himself, is now disproved by repeated experience, and by the infallible
efficacy of general remedies. It is, however, as yet impossible to
fix any definite medium or average of mortality in the above genera
of fevers, whether remittent, nervous, putrid, or inflammatory. We
have modern authentick records, wherein, under judicious and skilful
treatment, of 200 sick in remittent fevers only one died; and even
in the nervous and putrid, the blanks were trifling compared to the
prizes; whereas, under different and erroneous management, one half,
and often the greatest part of the sick perished. The corroboration of
these assertions may be seen in those learned authors, Lind, Millar,
Robinson, Clarke, Lettsom, Sims, and others.
Throughout the intire morbid host of human foes, there is probably
no such flagrant variation in the therapeutick barometer, or scale
of mortality, as in that of the fevers hitherto described. Different
curatory processes and remedies soon change the natural genus,
symptoms, crisis, prognosticks, and event. No dangerous diseases almost
whatsoever, are more successfully oppugnable under discreet medical
regimen; and when entrusted to nature, from the days of Hippocrates
to the present time, they have ever been extremely fatal. Sorry I
am to add, that, perhaps in many instances, the errors and fatality
of nature, have been less destructive than those of artificial and
therapeutick mismanagement. Since the discovery of antimonials and
Peruvian bark, few now, under skilful medical pilots, die, compared to
the multitudes of sick: but still in the aggregate list of funerals,
except perhaps pulmonary Consumptions, it may be doubted whether any
other of the belligerent morbid foes commit such ravages amongst
mankind.
_Small Pox_, natural and inoculated. We have no vestiges, neither in
history nor tradition, of this loathsome disease, nor of the measles,
before the irruption of Mahomet and his followers from the Arabian
deserts, about 1,300 years ago; and from whom this extraneous contagion
was first transplanted into Europe. It is little more than 200 years
since the exportation of this exotic poison to the American continent,
where it had never before been seen nor heard of. The havock by this
scourge of the human race, amounts, in London, to nearly a decimation
of the inhabitants; or to about one tenth, or one twelfth. It is
equally or oftener much more fatal throughout the torrid and frigid
zones; and in the adult age is more violent than in childhood. It
attacks the same person but once in life: had this not been the case,
the human race must long since have been extinct. On a promiscuous
average, one of every seven infected die of the natural disease;
but under inoculation only 1 of 500. Besides, to the former deadly
catalogue may be superadded a frightful train of mangled constitutions
and countenances, of consumptions, abscesses, ulcers, opthalmias,
blindness.
In every large metropolis, small pox is an annual epidemick. In
country towns and open districts, its invasions are more distant;
at uncertain intervals of some years, when numbers contiguous are
attacked at the same time. In our climate, it is alledged to be most
prevalent in spring and autumn. Very few of the human species escape
the small pox, especially in populous cities and towns, wherein there
is always lasting variolous fuel, or, lurking embers: a wooden horse
with ferocious foes in ambuscade, tolerated within their walls, rioting
in human slaughter, and infantile immolation. It might easily be
demonstrated, that in London, and probably in all other large cities,
variolous ravages are principally amongst children under five years of
age. Without entering into any elaborate argumentation, or proofs of
this assertion, the reader may, in some degree, be convinced, by only
turning his eye to the first Chart, and to a small table of London
mortality during ten years; wherein he will observe the trifling
annual mortality in the interval between 5 and 20 years; before which
last period, a mere handful of the native progeny of the metropolis
can be supposed to have escaped an infection with which they are
constantly enveloped. It is obvious that the total annual mortality
by all diseases, inclusively, in London during this adolescent period
of life of 15 years, is not equal to variolous carnage singly. As
to inoculation, or artificial engrafting of the contagion, it is
throughout the greatest part of Europe a modern practice of the present
century, and is yet in its cradle. Even in the London small pox
hospital, since its first institution, forty years ago, there have not
been inoculated altogether 25,000.