CHAPTER IX.

_Of the Treatment of Fever._

We have seen that the first indication of disease in fever is traceable

to the nervous system; that the nature of this primary affection of the

nervous system is unknown; that it may possibly be the commencement of

inflammation, modified by the nature of the nervous substance, in which

the inflammatory action has its seat, and by the nature of the cause

that excites it, namely, a peculiar poison: or, on the other hand, it

may possibly be something distinct from inflammation, but having a

peculiar tendency to excite it. In either case, the inflammation that is

present in fever, is peculiar and specific, differing essentially from

ordinary or simple inflammation. Whether the affection of the nervous

system consist merely of inflammation of the nervous substance excited

by a peculiar poison; or whether it consist of some unknown condition of

the nervous system to which inflammation is superadded, and by which the

character of that inflammation is modified, the great practical result

is the same, namely, that febrile inflammation and ordinary inflammation

are not identical, and that the difference between the two affections is

such as to require a very considerable modification in the treatment

appropriate to each.

The only morbid condition of fever, of which we have any knowledge, and

over which the medical art has any control is that of inflammation.

Although, as has been so often stated, inflammation be not the primary

febrile affection, as far as regards the order of events, yet it is, at

least, the primary affection, as far as regards the treatment, if it be

not the sole affection that admits of treatment. The remedies proper for

febrile inflammation do not differ from those which are adapted to

ordinary inflammation; but they differ materially in the mode in which

they ought to be applied, and the extent to which they ought to be

carried. They can be understood neither in their mode nor measure, until

the following questions are determined; namely, What is the precise

object that should be aimed at in the treatment of fever? What is it

which it is most important to do, and which it is in the power of the

medical art to accomplish? An exact and true answer to these questions

will afford an invaluable guide in practice: it will point out with

clearness what is to be attempted; and it will put a stop to useless and

pernicious aims.

It is in vain to hope to terminate fever by a stroke of art. The pursuit

of a remedy, so long and so earnestly sought, endowed with the power of

cutting short the disease, is to the physician what the search after the

philosopher’s stone was to the alchymist, with this difference, that the

alchymist, engaged in a vain pursuit, lost only his time and labour; but

the physician, engaged in a pursuit equally hopeless, will often, in

addition, lose his patient. Fever cannot be cured instantaneously; and

to bring a fever patient under the influence of agents capable of

exciting a powerful influence upon the system, in the expectation of at

once removing fever, is pregnant with danger; and the expectation upon

which such practice is adopted, must appear fallacious to whoever has

studied the nature of the disease.

Fever cannot be cured instantaneously: it may be moderated; it may be

gradually subdued; from being violent and dangerous, it may be rendered

mild and safe: the physician may bring it to this condition; and this is

all that he can accomplish. If it come under his care early, and he know

with promptitude and decision at what to aim, he will rarely fail in his

efforts to secure this object.

Since the various forms or types of fever differ in nothing but the

degree of their intensity, in detailing the treatment, it will be

necessary only to state first of all, the remedies which are appropriate

to the disease; and, secondly, the modification of these remedies, which

may be required by the different degrees of intensity in which it is

commonly found to exist.

1. The common continued fever of this country, in its mildest form,

requires little or no treatment. There is no affection of any organ

intense enough to need the application of a powerful remedy. All the

organs which constitute the febrile circle are deranged in their

functions, but that derangement is so slight that a cure takes place

spontaneously in the course of a few days. Confinement to the bed; the

abstraction of stimuli; fever diet; a calomel purgative at night,

consisting of one or two grains of calomel with six or ten of rhubarb,

followed in the morning with half an ounce of castor oil; and these

remedies repeated every day, or every alternate day, constitute the

whole treatment which is required.

2. Whenever the fever passes beyond this, its mildest form, it becomes a

serious disease. It is never for a moment to be trifled with; never for

a moment to be neglected. Because it is moderate in the commencement, it

is not to be presumed that it will continue moderate through its

subsequent course: it may become most formidable; if the proper remedies

are not applied early and vigorously, it generally does become truly

alarming; the train only is apparent; the mine is concealed; the only

safety for the patient is to prevent the train from being kindled; if

that be once kindled, it may be no longer possible to save the patient

from destruction.

When the mildest case of fever passes to a severer form, what is the

event that happens? What is the change that takes place in the organs?

The preceding pathology will, indeed, have been written in vain, if

there can now be any doubt in the mind of the reader on that point. The

great value of the facts there disclosed is, that they teach us what

happens in organs which we cannot see, and declare to us by the external

signs or symptoms, the internal actions that are going on. Out of the

hundred cases which have now been recorded, and the history of which has

been made known from its commencement to its termination, take any one,

or fix upon any number, in which the symptoms from being slight became

moderate, and from moderate severe, or, in which the symptoms were

severe from the beginning, what is found after death? Inflammation, in

general, rising in degree, and increasing in extent, or both, in

proportion to the intensity of the febrile affection. If this, which may

be justly considered as the law of the disease, be not absolutely

constant and uniform, it may be safely affirmed, at least, that there

are as few apparent exceptions to it, as to any general law that can be

named.

The object to be aimed at in practice, then, is clear: it is to prevent,

or to remove inflammation. Accomplish this, the fever will not be cured

at once; it will still go on for some time; but it will come sooner to a

close, and it will proceed mildly and safely to its termination. Fail to

accomplish this, and the fever, however mild at first, will increase

more and more in severity until it become truly formidable, and death

take place at last, in consequence of the destruction of the organs by

the process of inflammation.

If excitement be set up in an organ which has as invariable a tendency

to terminate in inflammation as a stone to fall to the ground, what is

the proper remedy to prevent the transition of excitement into

inflammation? Bleeding. Before we can say that inflammation is

established we may foresee that it will come: if the preceding

excitement be not stopped, we know that it will as surely come as that

blood will flow from a wounded blood-vessel. Because we cannot tell the

precise moment when increased vascular action passes into actual

inflammation, are we quietly to look on and do nothing until we have

made that discovery? We know that inflammation is at hand; we know what

will prevent it, or, at any rate, what has a powerful tendency to

prevent it: shall we not bring into immediate and vigorous use our means

of prevention, or shall we wait until the inflammatory action shall have

given unequivocal and alarming indications of its presence and operation

before we interfere? To trifle in such a manner, to lose these precious

moments when we have such a fearful, such an active, and, if once it be

allowed to become active, such a masterless enemy to contend with as

fever, is as great a folly as it would be when a building is on fire to

stand idle by as long as the fire is smouldering, and to take no measure

to extinguish it until it has burst into flame, nay, not until the flame

has spread from the floor to the ceiling, and from the ceiling to the

roof. We may not be able to see a single spark, but if we see the smoke

and feel the heat, we know that there is fire somewhere, and that

however concealed at present it will soon make itself visible enough,

and that it will consume not only the structure in which it originates,

but others with which it may come in contact if it be not put out. With

equal certainty we know that fever, though apparently mild in the

commencement, will excite inflammation in vital organs, and that that

inflammation, if it be allowed to establish itself, will place the

fabric of the body in the most imminent danger. The physician, in the

first stage of fever, armed with his lancet, is to his patient what the

fireman with his engine, before the flames have had time to kindle, is

to a building that has taken fire. At this early stage, the former can

check inflammation with almost as much ease and certainty as the latter

can prevent the flames from bursting out. On the contrary, the physician

who is called to treat inflammation in the later stage of fever is in

the position of the man who arrives with the apparatus for saving the

house when its stories have been already consumed and its roof has

fallen in.

Bleeding in fever cannot be performed too early. The very first moment

of excitement, could that be discovered, is precisely the moment when

the employment of this powerful remedy would produce the greatest

effect. The earlier the bleeding, the greater will be the impression

made upon the disease, and the less upon the patient; or, the more

effectually will the inflammatory action be stopped by the loss of the

smallest quantity of blood.

When inflammation has actually come on, there is then not a moment to be

lost; that inflammation must be stopped; the accomplishment of this

object is the great end which the practitioner should aim at in every

thing he attempts; until he has done this he has done nothing; until he

has done this he ought to give neither sleep to his eyes nor slumber to

his eye-lids; until he has done this he ought to feel that there should

be no rest for himself, because there is no safety for his patient.

Until the inflammation is subdued blood must be taken; be the quantity

it may be necessary to abstract, in order to accomplish this object,

what it may; be the bleedings it may be requisite to repeat what they

may; the vein must be allowed to flow, and it must be opened again and

again until this object is secured. If this golden opportunity be

allowed to escape, and this object be not obtained, the risk is most

imminent. During this early period the physician is master over the

disease; if he allow it to pass away without obtaining the victory, the

disease becomes master over the physician. From that moment his control

over it is gone. Never can he regain his lost advantage. Fever is a

process that advances with a step as steady as time, and like time it

never retraces a step. At a subsequent period its progress may be

sometimes retarded, and now and then it may be weakened; but, after the

lapse of a few days, this is all which the most complete success is then

capable of accomplishing.

Mere relief of inflammation is nothing; to render a severe inflammation

a less severe inflammation is to do nothing; because the less severe

inflammation may be fatal just as certainly as the more severe: the

inflammation must be subdued, or the case, if not wholly lost, becomes

dangerous and doubtful.

The abstraction of blood must be carried to the extent of subduing the

inflammation: there is no other limit to the quantity to be taken but

that which is adequate to subdue the inflammation. To attempt to measure

the quantity by drachms or ounces is wholly vain; because, if the remedy

be properly employed, the quantity will vary in every individual case.

To take an ounce more than the subdual of the inflammation requires is

injurious; to take an ounce less is still more pernicious; to take the

quantity necessary to accomplish the object, and no more, is to use the

lancet—that powerful instrument, so dangerous in rash hands, and no less

dangerous in weak, with the discernment and decision of a master. He who

with a knowledge which gives and which justifies boldness and decision,

is able thus to employ this great remedy, is a skilful physician, who

has derived from study and experience the best fruit they can yield: he

who has not yet reached this perfection of his art, (and who among us

can pretend to the attainment?) must still go on to observe and to

learn.

The object to be accomplished then is clear; that means of obtaining it

are known; and when these means are promptly, boldly, and effectually

employed, what is the result of experience? That after all, the quantity

of blood it is necessary to abstract is not large. The tendency of the

preceding observations is not to countenance frequent and large

abstractions of blood in fever, but to save the blood of the patient, by

taking the due quantity at the proper time. Smaller bleedings will

subdue febrile than pure inflammation. Febrile inflammation, as has been

so often stated, is a modified inflammation, the modification consisting

in less activity in the vascular system and greater depression in the

nervous. Whence a moderate bleeding will make an impression upon febrile

inflammation which can be equalled in pure inflammation only by a large

bleeding. He who takes away sixteen ounces of blood in fever adopts a

bolder and more decisive practice, and brings more effectual relief to

his patient, than he who abstracts thirty ounces of blood in some other

forms of inflammation; and he who takes away six ounces of blood in one

febrile case, does more than he who takes away sixteen in another. But

the question never can be whether the bleeding should be small or large:

that is nothing. The thing to be considered is the condition of the

organs, the state of the system; not the ounces of blood to be taken,

nor the number of periods at which it is to be removed. Abstract blood

to the subdual of the inflammation—that is the rule; abstract blood at

the very commencement of the inflammatory action; if you are in time to

do it, at the very commencement of the febrile excitement. Then little

blood will be lost, and the patient will be safe. And when this is done,

nothing of importance remains to be done. The practitioner who has been

thus active in the commencement will be idle during the future progress

of the disease. Daily as he repeats his visit he will find that his

interference is not required, and will admire to see with what ease a

disease of frightful power is disarmed, and rendered innoxious, if it be

attacked in infancy, and not neglected or trifled with until it be

nurtured to maturity, and allowed, at last, to put forth unchecked the

strength of that maturity.

If, after the abstraction of sixteen ounces of blood at the commencement

of the attack, the vascular excitement be not completely subdued, in the

course of three or four hours the same quantity must be again taken; and

if, the next morning, that excitement continue, it will probably have

already passed into inflammation; and, therefore, the vein must be once

more opened, and the blood allowed to flow until the pain, wherever

seated, be entirely removed. To check the disease, instead of subduing

it, does not in the least diminish its future strength, and, by

weakening the powers of life, it even hastens the period of mortality.

Nothing is more common than the appearance of typhoid symptoms, on the

second or third day after bleeding has done nothing but lessen the

inflammatory action; whereas, had it been carried somewhat, and

generally only a little, farther, the patient would have been

convalescent at the very period when his danger becomes most imminent.

In cases where general bleeding produces a decided impression on the

inflammation, but does not stop it, cupping, or even leeches, will often

complete what the lancet commenced.

A due impression having been made upon the inflammation by bleeding, the

subsequent treatment should consist of purgative medicines, given to the

extent of producing three, or at most four stools in the twenty-four

hours: beyond that number no advantage is obtained by purging; more

frequent evacuations, indeed, weaken the patient, but not the disease.

The best purgatives consist of one or two grains of calomel, with six or

eight of rhubarb, repeated every night, or every other night, and

followed the next morning by two drachms, or half an ounce of castor

oil, or by the common senna draught. Cold sponging, if the skin be hot;

acidulated drink, if there be thirst; perfect quiet, a dark room, a

silent nurse, affording prompt attendance, with a noiseless step, a

cheerful countenance, and no words—this, together with three tea-cups

full of thin arrowroot or gruel, in the twenty-four hours, given in

divided portions, at intervals of about two or three hours, comprises

all else that will be required, or that will be useful, until the period

of convalescence.

Such is the simple, but most efficient treatment appropriate to the

common fever of London and its neighbourhood (and I do not speak of the

treatment proper for any forms of the disease as it exists elsewhere,

and which I have not seen) in its ordinary degree of severity.[35]

Suppose, however, the proper treatment not to have been applied; suppose

the case to have been neglected or mismanaged; either not to have been

seen at all, or to have been too much contemned; suppose the pain in the

head to have been not severe; that no complaint was made of it; or that

giddiness only was felt; that the skin was not burning hot, but

moderately warm; that the pulse was neither strong, nor bounding, nor

hard; but of moderate strength, and soft; that the mind was tolerably

distinct, and the restlessness not great: why should blood be drawn?

what indication is there for the employment of so violent a remedy in so

mild a case? No symptom is prominent; no symptom is urgent; the case

will do well.

Such is the view that would be taken by the great majority of

practitioners of this kind of case, and their treatment, without doubt,

would be correspondingly inert. And this is the true origin, in many

cases, of typhus symptoms; of adynamic fever. The disease is allowed to

take its own course; and the product of every fever, at a certain stage

of its process, is adynamia: the physician does not perform his office;

the disease advances; the restlessness increases; there is no sleep;

delirium comes on; muscular tremor begins to be perceptible; the pulse

rises; the sensibility diminishes; and stupor, if it be not already

present, is close at hand. And now the disease, it is sufficiently

obvious, is severe; now, it is admitted, it calls for a powerful remedy;

and, now for the first time, the lancet is thought of. But the bleeding

relieves no symptom; it increases some; the progress of the inflammation

is not checked; the adynamic symptoms are more fully developed; the

patient is more prostrate, and the fever, in all respects of a worse

character: the inference is, that bleeding is a most inefficient and

dangerous remedy in fever; and this inference is deduced from

experience; those who draw the conclusion, judge from what they see;

they disclaim reason; they pretend only to understand and to respect the

lessons of experience.

I appeal to the attentive observer, whether this be not a faithful

history of the progress and termination of hundreds of fever cases;

whether such a history may not be recorded as of daily occurrence;

whether what has been stated be not commonly the view, the practice, the

result, and the lesson.

I will not appeal to the different history that belongs to cases that

are differently treated. But I do earnestly appeal to the pathology that

has been stated; that, at least, is experience, and it teaches a lesson,

which it is worse than foolish to despise or to forget. Every symptom

just enumerated, has been detailed over and over again in the cases that

have been laid before the reader: inspection after death must have made

the conditions of the organs, as indicated by those symptoms, familiar

to his mind. Of what avail can bleeding be, when the patient is brought

into the condition which first excites alarm, in the case here supposed?

The blood is no longer in its vessels; it is beneath the membranes, or

in the ventricles, or at the base of the brain; the inflamed capillaries

have done their work upon the cerebral substance and upon its membranes;

and have left proof enough of their activity, in the thickening of the

one, and the softening or the induration of the other. What can

blood-letting do in this state of the organs? What can shaving the head,

and applying cold do? What can blisters do? What can purgatives do? And

above all, what can wine do? Nothing can be done; at least, nothing

effectually or certainly.

If there be still pain, if the sensibility be little diminished, if the

pulse be not very quick and weak, it may yet be possible to check the

further progress of the inflammation; to prevent the disorganization of

the brain from advancing; but the means to accomplish this, must now be

tried with the most extreme caution: perhaps, in the whole compass of

medical practice, there is no case which requires a nicer discrimination

than this, when it has arrived at this point. The abstraction of a few

ounces of blood may stop the inflammatory action of the vessels before

they have produced such a change of structure as is incompatible with

life, and such as the powers of life cannot repair. But if the

abstraction, even of this minute quantity of blood, at this point of the

inflammatory process, do not put a stop to that process, the remedy will

co-operate with the disease, to depress the powers of life, and will

deprive the patient of what chance of recovery he might otherwise have

had. To decide in a case which requires such nice discernment, and in

which, even with the best discernment that can be exercised, the event

must always be so doubtful, is a task which few physicians, who

understand the nature of it, find either easy or agreeable.

But instead of bleeding, the proper remedy may possibly be the very

reverse: it may be requisite to afford a stimulus. The change of

structure produced by the inflammatory process may not have proceeded to

such an extent as to be absolutely incompatible with life; but the

powers of life maybe so exhausted by the inflammatory excitement that,

unless aid be brought to them, they will be overpowered, and sink:

afford them appropriate aid, and they will rally, and, although slowly,

ultimately repair the lesion which the organs have sustained.

This is precisely the condition, and perhaps it is the only condition,

under which stimuli are really beneficial in fever. Whenever such

remedies are indicated, the vascular action is weak, and there appears

to be a want of due supply of arterial blood to the brain. Of all

stimuli, wine or brandy is the best. If it be doubtful whether a

stimulus can be borne, or will prove beneficial, a few ounces of wine

may be administered. It will soon be manifest whether it be the

appropriate remedy. If the restlessness, the heat, the delirium increase

under its use, it will be obvious that it cannot be borne; if, after

some hours, no perceptible impression be made upon any symptom, it is

seldom of the least service, given to any extent, or persevered in for

any length of time. If it be capable of doing any good, some improvement

in the symptoms is commonly perceptible in a few hours after it is first

administered. Sometimes that improvement is sudden and most striking;

more commonly it is slight, slow, but still easy to be seen. If the

pulse become firmer, and especially slower, the tremor slighter, the

delirium milder, the sleep sounder, the skin cooler, and, above all, if

the sensibility increase, and the strength improve, it is then the

anchor of hope. It will save the patient if it be not pushed too far,

and if it be withdrawn as soon as excitement is reproduced, should that

happen, which it often does.

No certain indication for the administration of wine can be drawn from

one or two symptoms alone: neither from the state of the pulse, nor of

the skin, nor of the tongue; neither from the tremor, nor from the

delirium. There is an aspect about the patient, an expression not in his

countenance only, but in his attitude, in the manner in which he lies

and moves, being, in fact, the general result, as well as the outward

expression of the collective internal diseased states, that tell to the

experienced eye when it is probable that a stimulus will be useful.

Depression, loss of energy in the vascular system, as well as in the

nervous and the sensorial, indicated by a feeble, quick, and easily

compressed pulse, no less than by general prostration, afford the most

certain indications that the exhibition of wine will be advantageous:

and if the skin be at the same time cool and perspiring, the tongue

tremulous, moist, or not very dry, and the delirium consist of low

muttering incoherence, these symptoms will afford so many additional

reasons to hope that it will prove useful. On the contrary, if the skin

be hot, the eye fierce or wild, the delirium loud, noisy, requiring

restraint, and the general motions violent, it is as absurd to give

wine, as to pour oil upon a half-extinguished fire, with the view of

putting out the yet burning embers.

When wine is indicated, but does not produce a decided effect, brandy

may be substituted. I have seen no benefit arise from giving either in

large quantity. When the condition is really present in which alone it

can be useful, a moderate quantity will accomplish the only purpose it

can serve. In every other condition, wine may be administered to any

extent, (and I have given half a pint every hour) until the stomach

return it, by vomiting, without the slightest impression being made upon

the disease, or any, or scarcely any, upon the system. The malady is in

possession of the seat of sensibility; it has destroyed the organ; it

has abolished the function: what advantage can result from the

application of stimuli? The spirit that could feel their impression, and

answer to it, is gone: organs destroyed by overstimulation, cannot be

regenerated by the application of additional stimuli: the apparatus is

broken; the wheels are clogged; the obstruction lies in that part of the

mechanism in which the main power that works the machinery is generated;

that obstruction cannot be removed; the movements of the machine must

cease. Even when the case is not thus utterly hopeless, wretched is the

physician whose only dependence for the safety of his patient is in

wine.

These considerations ought not to make us desponding, or inert, even

under the worst circumstances, as long as the case is not absolutely

desperate; but they ought to impress deeply and indelibly upon the mind

of the practitioner who has the first charge of a fever patient, that

the disease must be conquered in the very first days, or it will

conquer, and that there are no means by which that conquest can be

rendered sure or probable, but that afforded by the lancet.

Very much the same observations apply to the exhibition of opiates.

There is a condition of the system in which an opiate puts a stop to a

state of exhausting agitation and restlessness; procures tranquil sleep;

lessens delirium, and operates most favourably on all the symptoms. This

may be when the skin is cool and perspiring; the tongue moist, or not

very dry; the delirium low, and the pulse and the patient weak. No kind

of opiate in any form in which it can be administered ever proves in the

least degree beneficial whenever the skin is very hot, the tongue very

dry, or the general motions and actions of the patient are violent.

Now and then the powers of life rally unexpectedly and wonderfully: they

throw off a load which appeared to have oppressed them totally and for

ever. It is therefore the duty of the medical attendant to be always at

hand until the termination even of the most desperate case, and

carefully to watch every change that takes place; for changes may

suddenly occur which may give him a clue to bring in invaluable

assistance. He may be suddenly called upon to give a stimulus; he may be

suddenly called upon to check re-excited and inordinate action. To

describe in words the countless variety of circumstances under which it

may be necessary that he should take very unexpected and decided

measures, and not a few of which may demand of him clear discernment and

nice discrimination, is quite impossible: he can acquire the power of

performing the most difficult and arduous duty he has undertaken only by

studying the disease, and by rendering himself perfectly familiar with

the principle of its treatment.

When the inflammatory action has proceeded unsubdued and has terminated

in some change of structure, probably accompanied with copious effusion,

as indicated by the symptoms detailed under the cases illustrating

cerebral affection, advantage is sometimes obtained by affecting the

system with mercury. In this condition of the brain it is not easy to

bring the system under the influence of mercury; when it can be

accomplished, the patient is commonly, though not invariably, snatched

from death. In several instances I have known this treatment successful

under apparently the most hopeless circumstances. When the success is

most complete, the convalescence is invariably tardy, and often appears

to be doubtful; the mind for a long time remains feeble, infirm, and

almost fatuous; and, as in the two cases recorded by Pringle, though

such patients recover of their fever, it is long before the nervous and

the sensorial systems are restored to a sound state. The best mode of

exhibiting mercury is in the form of a pill, consisting of two grains of

calomel with half a grain of opium, given every three, four, or six

hours.

3. To a fever which is severe from the commencement the preceding

observations apply with double force. Then, if the most powerful

remedies are not immediately employed, and if they are not brought to

bear at once upon the severe symptoms in the completest combination, the

case is wholly lost. The delay of an hour is pregnant with danger; the

delay of a few hours places the efficacy of any measures that can be

taken in great uncertainty; and the delay of a day or two renders their

most vigorous application utterly useless. Whereas, knowing, as we now

know, the condition of the organs upon which the severity of every case

depends, and knowing remedies appropriate to that condition of sovereign

efficacy, exceedingly few of such cases would be lost were these

remedies employed with due vigour at the commencement of the attack. The

typhoid symptoms with which it is commonly thought such cases commence

would never appear. The patient would be convalescent, or at least would

labour only under a mild form of fever at the period when, without these

remedies, his condition would be hopeless. The practitioner ought never

for a moment to forget that it is in the power of early and active

treatment to deprive these severe cases of all their severity and,

consequently, of all their danger; but that, after the lapse of a day or

two, all human skill will be exerted in vain.

It remains to say a word or two relative to the modification of the more

powerful remedies, as the prominent affection may have its seat in the

brain, the lungs, or the intestines.

I. OF THE MODIFICATION OF THE TREATMENT IN CEREBRAL AFFECTION.

The treatment in a cerebral case of moderate severity has been already

sufficiently explained. Blood must be drawn to the subdual of the

inflammation, and if blood be abstracted early, two, or at most three,

moderate bleedings will be all that will be required.

But when the attack commences with severe cerebral affection, the

bleeding must be proportionally large, and early as it is copious. A

bleeding adequate to subdue a moderate, will be utterly inert in a

severe degree of cerebral disease. I give, as a specimen of what may be

sometimes required, the case of Dr. DILL. I saw my friend at the very

commencement of his attack, and was, therefore, able to carry into

effect what I conceive to be the proper treatment with due promptitude

and vigour. I saw him before there was any pain in the head, or even in

the back, while he was yet only feeble and chilly. The aspect of his

countenance, the state of his pulse, and the answers he returned to two

or three questions, satisfied me of the inordinate, I may say the

ferocious, attack that was at hand. Having taken an emetic without

delay, as soon as its operation was over, blood was taken from the arm

to the extent of twenty ounces. During the night, severe pain in the

limbs, especially in the loins, and intense pain in the head came on.

The blood that was taken on the preceding evening was not inflamed.

Early in the morning he was again bled to the extent of about sixteen

ounces, with great diminution, but not entire removal of the pain: the

pain not lessening, towards the afternoon he was again bled to the same

extent: the pain was now quite gone; the blood from both these bleedings

was intensely inflamed. During the night the pain returned, and, in the

morning, the eyes were dull and beginning to be suffused, while the

pulse continued slow and intermittent, and the respiration suspirious;

but the face was blanched, and the pulse, in addition to its other

characters, was weak. Instead of opening the vein afresh, twelve leeches

were applied to the temples; these very much relieved, but still did not

entirely remove the pain; for this reason, he was cupped to the extent

of sixteen ounces: this operation afforded very great relief, and he

continued easy until the following evening, when the pain returned, and

he was again cupped on the temples to the same extent. Immediate relief

followed this second operation; but, unfortunately, the pain returned

with great violence towards evening, and it was now impossible to carry

the bleeding any farther. Within twenty-four hours, it was plain that

typhoid symptoms in abundance would be present, for the fur on the

tongue was becoming brown, and there was already slight tremor in the

hands. No more blood could be taken with any prospect of advantage, nor

even with safety; yet, without the aid of some powerful remedy the case

was lost.

The whole scalp was now enveloped in ice, but so intense was the heat of

the head that it was melted in a few minutes, and the clothes, steeped

in the evaporating lotion, dried with extraordinary rapidity. Neither of

these expedients produced the least perceptible effect.

What was to be done? Recourse was had to a measure the efficacy of which

is but little known and less appreciated; a remedy the power of which is

second only, if, under some circumstances, it be not even superior, to

that of the lancet; a remedy which can never supercede the lancet nor

dispense with it, but which, when added to it, forms by the combination

a treatment so powerful and efficacious that it might render death, from

the acutest cerebral inflammation, as rare as recovery is at present.

This remedy is known by the name of the cold dash. It consists of

pouring a column of cold water upon the head in a continued stream from

a height of from six to ten feet. The mode of applying it is as follows.

The patient is seated in a large tub; a table is placed at the side of

the tub upon which a man stands, and at as great an elevation as his

arms can reach, pours upon the naked head of the patient a steady but

continued stream of cold or iced water, from a watering-pot without the

rose. The stream is made to fall as nearly as possible upon one and the

same spot. At first the elevation must be slight, for the shock is too

violent if the stream be poured at once from the highest point. There is

a record, that in the East, where ingenuity so long laboured for tyranny

to invent the most exquisite modes of torment, the victim was placed

with his bare head under a small stream of cold water which was so

directed as to fall unceasingly upon one spot. In this instance cruelty

was cheated of its object by its ignorance of the mode in which its

expedient operated. The device was well adapted to kill but not to

produce pain, for insensibility must soon have put an end to suffering.

Employed as a remedy, there is no degree of burning heat which the

animal economy is capable of producing, no intensity of vascular action,

and no violence of pain that can resist its continued application.

Sooner or later, usually in from ten to twenty minutes, the heat, though

most intense, disappears, the skin becomes cold, the face pallid, the

features shrunk, while the pulse is reduced to a mere thread, and the

pain of the head, however violent and intolerable, entirely ceases.

After the patient has been wiped dry, which he should be as rapidly as

possible, and placed in bed, the symptoms may soon return in all their

violence; the same process will again remove them, and as often as the

former recur the latter must be repeated. Three or four repetitions will

commonly suffice to subdue the most intense cerebral affection. In the

case of Dr. Dill, the relief it brought was instantaneous and most

complete. From a state of intense suffering it rendered him perfectly

easy, and from a state of imminent danger, safe. I had no anxiety about

him from the moment he came out of his tub, although it was necessary to

pass him through the same ordeal three times; but he himself having

tried this remedy on his sister, having in her case witnessed its

efficacy, and now felt it in his own, was extremely desirous that it

should be repeated as soon as he was conscious of any return of pain. In

consequence of its application, together with the copious depletion that

preceded it, at the period when under ordinary treatment, the most

exquisite typhoid symptoms would have been present, he was

convalescent.[36] If we consider how powerful the abstraction of caloric

must be by every fresh current of water that falls upon the head, to

what a mere thread the minute external blood-vessels must be

constringed, and consequently to what an extent the internal must be

affected, we shall not wonder at its efficacy. Powerful as the cold

affusion is when exhibited in its ordinary mode, yet the impression it

makes upon the brain, compared with the effect produced by this remedy,

may be said to be what the application of six leeches to the temples is

to the abstraction of thirty ounces of blood.

Cold applications to the head, and evaporating or iced lotions, are

useful in mild cases; they may keep up the effect produced by this in

the more severe, but to hope to control the latter by their aid alone,

is to expect to coerce a giant, by twisting around his arms a spider’s

thread.

II. OF THE MODIFICATION OF TREATMENT IN THORACIC AFFECTION.

Fortunately, there is a remedy nearly as powerful and efficacious in

intense thoracic affection, as blood-letting and the cold dash are in

the cerebral. In the severe bronchial affection of fever, blood-letting

is of little avail. It seems to have scarcely any control over the

peculiar affection of the lining membrane of the bronchial tubes, or

even over the inflammation of the substance of the lung, which so often

accompanies the intense form of thoracic disease. It weakens the

patient, without making a decided impression upon the disease. Laennec

states that the pathology of pneumonia could scarcely be learnt under

his practice; for that he treated the disease, not by blood-letting, but

by tartar emetic; and that all his patients recovered. I thought this

one of the exaggerated statements in which medical writers sometimes

delight to indulge; but it immediately occurred to me that this remedy

might prove exceedingly efficacious in the bronchitis of fever. Its

efficacy has surpassed my expectation. It seldom fails if exhibited with

promptitude and decision. The mode in which it is most efficiently

administered, is in doses of two grains, dissolved in an ounce of water,

and repeated every second, third, fourth, or sixth hour, according to

the severity of the case.

In the slight bronchial affection, which is so constantly present in

fever, nothing is required but the mucilage of gum-arabic, or a little

of the almond emulsion now and then, with the tincture of hyosciamus, or

two or three grains of the compound powder of ipecacuanha, to allay the

irritation of the cough. The inflammation of the mucous membrane, when

slight, spontaneously subsides.

III. OF THE MODIFICATION OF THE TREATMENT IN ABDOMINAL AFFECTION.

No remedy at all comparable in efficacy to the preceding has yet been

discovered for the inflammation of the mucous membrane of the

intestines, which forms so constant and formidable a part of the organic

affection of fever. General bleeding has but little influence over the

disease. If employed early and with due activity, it will prevent the

affection from occurring, but, when once it has supervened, large

bleedings are out of the question, and even small and repeated bleedings

are not as effectual as leeches. In severe cases, the abdomen should be

covered with leeches, and they should be re-applied daily, until the

pain and tenderness are gone, or, at least, have become slight, for it

is often impossible entirely to remove the tenderness. The abdomen

should be covered with a poultice as soon as the leeches fall off.

Afterwards, the application of a linen rag, moistened constantly with

the oleum terebinthinæ, keeps up the effect produced by the leeches,

and, when the affection is slight, may supersede their use altogether.

When the purging is considerable, five grains of the hydrargyrum cum

cretâ, with five of the pulvis ipecacuanhæ compositus, given every night

or every night and morning, often checks it; if this remedy fail, a

stronger opiate may be exhibited, and sometimes an anodyne enema may be

administered with great advantage. If there be constipation, one or two

drachms of castor oil is the proper laxative. Active or irritating

purgatives are highly injurious.

When blood is mixed with the stools or there is considerable hæmorrhage

from the intestines, every thing that can irritate the mucous membrane

must be carefully avoided. The mineral acids sometimes appear to check

the discharge. The infusion of roses rendered stronger by the addition

of a few drops of the sulphuric acid, is a convenient mode of

administering such medicines, and the efficacy of the draught is

sometimes improved by the addition of a drachm of the tincture of

hyosciamus. It is not uncommon for copious discharges of blood to

alternate with constipation. In this case the mildest laxative must be

administered with caution. The powers of life are sometimes so

prostrate, that three or four stools, excited by purgative medicines,

are sufficient to exhaust them. A tea-spoonful of castor oil, repeated

at intervals of six hours, is all that should be attempted. Now and then

a stimulant has a greater effect in checking the hæmorrhage than an

astringent, and then the oleum terebinthinæ is the best remedy.

IV. We have spoken of a fever still more intense

even than this, severe as it is, under the name of the intensest form of

fever. And of this, the same may be said as was stated of the mildest,

that there is little or nothing to be done. As far as regards the

treatment, the two extremes of fever, the mildest and the most intense,

meet, for in the first no remedies are required, and in the second, none

are of any avail. In these latter cases, there is no remedy and no

combination of remedies yet known, capable of affording effectual aid.

The abstraction of the smallest quantity of blood is fatal: the

application of the cold bath is out of the question; the warm bath is

inert; the vapour-bath affords rather more prospect of benefit; but the

proper remedies, if any exist, remain to be discovered.

When a person has swallowed a certain quantity of laudanum, there are

remedies which are capable of counteracting the poison and of saving the

patient. When he has swallowed a larger dose, provided it amount to a

certain quantity, no remedies will avail, excepting the application of

the stomach-pump. Unless the poison be promptly expelled from the

system, adopt with the utmost vigour the best-concerted expedients which

the medical art can supply, the patient will die. A person afflicted

with the intensest form of fever, is in the condition of a person who

has swallowed this large dose of poison. When a pump is invented,

capable of extracting _his_ poison from the brain, he may be saved.

V. OF THE TREATMENT OF SCARLET FEVER.

Little modification is required in the treatment of scarlet fever. The

most important difference between continued fever without and with an

eruption, is the greater predominance of nervous affection in the former

and of inflammatory affection in the latter. Accordingly, in scarlatina

there is not only a greater tendency to inflammation than in ordinary

fever, but the inflammation which is set up in the febrile circle of

organs approximates more to the character of pure inflammation. There is

greater vascular action, with less nervous and sensorial depression. The

consequence is, that blood-letting may be carried to a greater extent,

and will be attended with still more decided and more certain efficacy

than in ordinary fever. After a decided impression has been made upon

the vascular excitement by general bleeding, the application of ten or

twelve leeches to the throat is of sovereign efficacy. If scarlatina be

treated in this manner on the second day, or sometimes even on the

third, though it commence with exceedingly severe symptoms, yet the

patient will be convalescent in the course of three or four days.

It is not probable that much advantage would be derived from the detail

of numerous cases to illustrate the modification of treatment, and the

circumstances under which particular remedies should be chosen. A few

are subjoined as specimens of the ordinary extent to which bleeding may

be carried, and of the usual conditions under which wine may be

exhibited, and of the results, when favourable, produced by each remedy.

CASE CXI.

MARY ANN HUNT, æt. 24, servant. Admitted on the 14th day of fever:

attack commenced with shivering, succeeded by heat, nausea, and

head-ache; until last night, has had no stool for five days. At present,

no pain of head or chest; much pain of limbs; sleeps well; severe pain

over the epigastrium, increased considerably by coughing and by

pressure; tongue thickly coated with a whitish-yellow fur, through which

the papillæ appear large and prominent; much thirst; no appetite; no

stool to-day; skin warm; catamenia regular; pulse 135, of good strength.

V.S. ad ℥xxvj. Haust. Sennæ Sal. quam primum. Acid. Mist. pro potu.

Mist. Acet. Amm. C. 6tâ q. h.

15th. Pain of limbs quite gone; that of epigastrium also entirely

removed; no tenderness on the fullest pressure; tongue more clean; less

thirst; several stools; slept well; skin cool; pulse 84, soft. Blood in

both basons very buffy. Cont. med.

16th. Continues quite free from pain; tongue nearly clean; two stools;

skin cool, moist; pulse 88. Pt. med.

18th. No return of pain; tongue clean; pulse 87; four stools; skin

natural. Pt. med.

22d. Sat up yesterday and the day before, since which the skin has

become more warm, the pulse more quick, and the tongue more loaded, but

there is no local pain, and the bowels are open.

23d. Pains of limbs returned; slept ill; tongue loaded at root; pulse

110.

24th. Pains diminished; pulse 100; tongue still furred; skin warm.

26th. Pains gone; skin cool and moist; tongue the same; two stools;

pulse 100.

28th. Tongue more clean; skin warm; pulse 76.

35th. Convalescent. Inf. Case. c. Senna bis.

41st. Dismissed cured.

CASE CXII.

ELEANOR WELBY, æt. 21, servant. Attacked four days ago with chilliness,

shivering and pain of head. At present, pain of head gone; mind

distinct; little or no sleep; eyes suffused and injected; no uneasiness

of chest nor cough; throat sore, with difficult deglutition; tenderness

of abdomen on pressure; tongue loaded on body with white fur, extremely

red at edges and tip; lips and teeth sordid; some thirst; bowels

regular; pulse 129, of good strength, yet easily compressed;

efflorescence of skin of dark red colour, approaching to a dusky hue.

V.S. ad xvj. Hirud. viij. gutturi. Ol. Ricini, ʒiij. quam primum. Mist.

Acid. pro potu.

6th. No uneasiness of head; slept ill; eyes suffused and injected; face

swollen; still complains of soreness of throat, which is undiminished;

tongue moist; teeth sordid; lips sordid and cracked; less thirst; three

stools; pulse 120, firm; blood very sizy and cupped. Rep. V.S. ad ℥xiij.

et Hirudines viij. gutturi. Pt. Med.

7th. Expression of countenance more natural; face less swollen; more

sleep; throat greatly relieved; deglutition quite easy; no tenderness of

abdomen on full pressure; tongue more clean and moist; lips and teeth

less sordid; pulse 111; eruption less distinct. Haustus Sennæ Sal. c. m.

8th. No uneasiness of head, throat, or abdomen; sleep natural; tongue

beginning to clean, much less red; pulse 114; skin exfoliating.

9th. Convalescent.

14th. Has been gradually gaining strength and is now quite well.

Dismissed cured.

CASE CXIII.

MARY JONES, æt. 33, married. Three days ago attacked with shivering,

succeeded by glows of heat, severe pain in the back and lower

extremities, with much head-ache. At present, pain of head severe,

especially over the forehead; mind distinct; scarcely any sleep; no

uneasiness of chest; some cough; abdomen tender on pressure; tongue not

much loaded; some thirst; no appetite; one stool; pulse 108, of some

power.—V.S. ad ℥xvj. Ol. Ricini, ʒiij. q. p. Mist. Acid. pro potu.

Hora 3tia, p. m. Pain of head diminished since the bleeding, but by no

means removed; much pain of back; some of abdomen; pulse 112, strong,

full, sharp, and not easily compressed. Blood with firm and thick buff.

Rep. V.S. ad ℥xvj. statim. Pulv. Aper. Mit. h. s.

4th. After the second bleeding last night, the pain was entirely

removed: she slept well, and the pain continued absent until this

morning, when it returned with great severity, or rather violence. She

was bled to the extent of fourteen ounces with immediate and great

relief: blood in both cups with firm buff and proportion of crassamentum

large: at present, the head is quite free from pain; there is scarcely

any pain in the back; no tenderness of the abdomen; tongue loaded in

middle with white fur, moist at edges, of natural colour; four stools;

pulse 120, weak.—Pt. med.

5th. No return of pain in the head; that of back continues; slept ill;

tongue much more clean and quite moist; four stools; pulse 120, weak;

skin warm and damp. Omit. pulv. Pt. alia med.

6th. Pain of head returned with great severity last night, for which she

was bled to the extent of four ounces with only temporary relief; no

sleep on account of the severity of the pain; skin hot; entire scalp

extremely hot; face pallid; nothing unnatural in the appearance of the

eye, and no intolerance of light; pulse 120, sharp, but easily

compressed; tongue loaded with white fur; thirst; four stools; buff on

blood pretty firm.

C. C. ad ℥x. nuchæ. Camphoræ, gr. v. c. Extract. Hyosci. gr. iij. 6ta.

q. h. Pulv. Aper. Mit. h. s. Lotio frigida capiti raso.

7th. Pain of the head entirely removed since the cupping, and has not

since returned; slept well; face continues very pallid; tongue loaded

with white fur in middle; very pallid; pulse 120, of good strength;

feels quite easy, but very weak. Cont. Pilulæ. Capt. Haust. Quininæ

Sulph. 6ta. q. h.

8th. No return of pain in the head; some in loins; scarcely any sleep;

tongue the same; four stools; pulse small and extremely weak. Pt. Med.

omnia. Capt. Vini Albi, ℥iv. in dies.

9th. Free from pain in the head, back, and every organ; scarcely any

sleep; much restlessness; delirium; countenance pallid and sunk; feels

very weak; tongue the same; four stools; pulse 120, not so weak as

yesterday. Pt. Med. Vini Albi ad ℥viij.

10th. Slept ill; much restlessness and delirium; frequent and deep

sighing; severe pain in the lower extremities recurring in paroxysms;

she says the pain is as if some one were rending her limbs from her;

tongue white, moist; four stools; pulse 110, weak; takes and relishes

her wine. Statim capiat Haustus Anodynus, c. Liq. Opii Sedativi, gtts.

xl. Augt. Vini Albi, ad ℥x. Cont. alia med.

11th. Long and tranquil sleep after the draught; less delirium; no

sighing; no return of pains in the limbs; mind perfectly distinct;

“feels greatly better;” countenance much more animated; tongue the same;

pulse 108, more strong and firm, but still easily compressed. Cont. Med.

Rept. Haustus Anodynus hora decubitus.

12th. Slept well all night; “feels very much better to-day;” no return

of pain; complains only of sense of lowness; pulse 96, weak. Pt. Med.

omnia.

13th. Continues to improve in all respects.

14th. Feels stronger; pulse 108, of good strength; occasional muscular

tremor. Pt.

18th. Continues steadily to improve. Pt. Jus. Bov. lbj. in dies. Vini

Albi, ℥vj.

23d. Convalescent. Omit. Med. Inf. Cascaril. c. Senna, bis.

33d. Free from complaint. Dismissed cured.

In this case bleeding was carried to the utmost extent to which it could

be carried with safety, and rather beyond it; but it was one of those

cases in which less was to be apprehended from the bleeding than from

the disease.

CASE CXIV.

FRANCES JACOB, æt. 17, destitute. Four days ago seized with nausea,

vomiting, headache, and other febrile symptoms. At present, much pain of

epigastrium, which is extremely tender on pressure; throat sore;

deglutition very painful; much vertigo; scarcely any headache; no sleep;

mind confused through the night; some pain of chest on full inspiration;

cough, with viscid copious sputa; very considerable dyspnœa; aspect of

countenance leaden-coloured and oppressed; skin warm, of a dusky,

unhealthy red colour; tongue very red, not much loaded; bowels

constipated; pulse 135, tremulous and indistinct. Abradat. Capillitium.

Hirud. viij. faucibus externis. Postea Empl. Emoll. Empl. Lyttæ nuchæ.

Inhal. Vap. Aq. Calid. Garg. c. Borat Sodæ. Ol. Ricini ʒiij. q. p. Pulv.

Aper. Mit. h. s.

5th. No pain of head; no sleep; mind confused; much low talkative

delirium; still uneasiness of chest on full inspiration; throat less

painful; deglutition more easy; dyspnœa and cough the same; abdomen

tender; tongue unchanged; four stools; pulse 120, feeble and indistinct;

skin covered universally with very unhealthy red, dusky efflorescence.

Pulv. Aper. Mit. h. s. Mist. Camphor, ℥iss. c. Tt. Hyosciami, ʒj. et

Ammon. Carbon, gr. x. 4ta. q. h. Vini Albi, ℥vi. in dies.

6th. Much delirium; some sleep; skin of same colour; rather more

sensible to-day; says she has no pain of head, but sense of severe

soreness all over her; much cough; four stools; pulse 120, weak. Pt.

Med. et Vin.

7th. Slept well; less delirium; “feels much better;” countenance greatly

improved; skin more warm; colour much more natural; throat still

painful; deglutition difficult; some tenderness of the epigastrium on

full pressure; scarcely any over the abdomen; tongue red at edges, brown

and dry in middle; much thirst; three stools; pulse 108, soft, not very

weak; lips and mouth surrounded with an herpetic eruption; skin not

abraded, but covered with soft scab. Pt. Med. omnia.

8th. Slept well; asleep at present; no delirium pulse 108, soft.

9th. Still more improved; pulse 96, soft.

13th. Pulse 87; other symptoms the same. Pt.

14th. Complains more of pain of epigastrium, which is considerably

tender on pressure; other symptoms the same. Catap. Sinap. epigast. Pt.

alia.

15th. Epigastrium much relieved; other symptoms the same. Pt.

18th. Convalescent.

24th. Dismissed cured.

CASE CXV.

MARGARET SKEY, æt. 37, married. Five days ago attacked with sense of

cold, shivering, and heat, together with pains in the bones. At present

complains of pain in small of back; no headache; no pain of chest; some

cough; no tenderness of abdomen; tongue white and dry; much thirst;

bowels constipated; sleeps tolerably; pulse 112. Haust. Sennæ Sal. q. p.

et c. m. Rep. Mist. Acid. pro potu.

6th. Abdomen very tender; tongue red; four stools; much thirst; skin

warm; face flushed; pulse 100, easily compressed. Hirud. x. abdom.

Postea Catap. Emoll. Rep. alia.

8th. Much delirium through the night; considerable muscular tremor; pain

of abdomen gone; tongue tremulous, but not much coated; much thirst;

four stools; pulse 100, weak; frequent shivering. R. Quininæ Sulph. gr.

ij. Aq. Rosae, ℥j. M. Sit Haustus, 6tis. q. h. sumendus. Jus. Bov. lbj.

in dies. Rep. alia.

10th. No sleep; mind confused; two stools passed in bed; urine in bed;

respiration laborious; pulse 90, weak. Alcohol (brandy) ℥iv. ex Aqua per

diem. Pt. Med.

13th. Slept better; less delirium; two stools not passed in bed; pulse

96.

15th. More power; stools not passed in bed; other symptoms the same. Pt.

17th. Strength again rather diminished; tongue rather brown; much

thirst; pulse 100; no pain. Pt.

21st. Little change, excepting that the tongue is more brown, dry, and

tremulous; pulse 108, extremely feeble; mind distinct; no delirium; two

stools. Aug. Alcohol ad ℥vj.

22d. Tongue less brown and more moist; pulse 108, stronger; slept well.

Pt.

24th. Countenance much more animated; tongue more clean, quite moist,

still brown towards root; pulse 110. Pt.

25th. Countenance still more improved; tongue more clean; no longer

brown; pulse 102, weak.

26th. Much improved; tongue nearly clean; two stools; pulse 108, weak.

27th. Gains strength. Alcohol ad ℥iij.

34th. Convalescent, but still very weak. Cerevis. lbj. Pt. alia.

45th. Has been gradually, though very slowly gaining strength; tongue

now clean; appetite good; bowels regular (Low Diet); 2 ozs. meat daily.

52d. Dismissed cured.

II. TREATMENT DURING THE CONVALESCENCE.

The management of the convalescence is one of the most difficult parts

of the treatment and one of the most unsuccessful, not because there is

any thing which requires to be done, nor because there is any disease

which prevents recovery, but because the patient is considered as well

when he is only convalescent. Of the great tendency there is to relapse

during the whole of this period few medical men are sufficiently aware,

and the unprofessional attendants on the sick are totally ignorant of

it. For a long time the brain, the bronchi, and the intestines remain so

irritable that the slightest excitement is capable of renewing the

diseased action which has recently subsided; but without excitement of

some kind, that renewal never takes place. It is the duty of the

physician and the nurse to guard the patient from such excitement, which

they may always do completely; so that whenever there is a relapse, the

physician, or the nurse, or both must be in fault: as long as they

perform their duty with judgment and firmness there is no such thing;

but this part of their duty which is extremely simple, they cannot be

induced to believe to be of importance: no one who has not seen death

happen over and over again from the neglect of it will believe it, and

even those upon whom melancholy experience has impressed the truth most

strongly, constantly allow themselves to be surprised at the slightness

of the excitement by which, and the advanced period of the convalescence

at which relapse may happen. It is not easy for a nurse to resist

incessant importunity and even reproach; and there are suspicions to

which a physician is subjected, which, when he sees that they are

entertained, it requires some moral courage to enable him to bear.

Without doubt he deserves the worst that can attach to him if he allow

the caprice, or the impatience, or the injustice of his patient, or any

earthly consideration to induce him to swerve from the faithful

discharge of the duty he has undertaken. The unreasonableness of the

convalescent, should be considered and treated as the delirium of the

preceding stage.

The mismanagement of the convalescence consists chiefly in allowing the

patient to rise too early from bed, and to take solid food too soon and

in too large a quantity; and these are by far the most frequent causes

of relapse. Were I to place on record all the instances I have seen of

fatal relapse from these two causes alone, the list would be frightful.

Many patients, the very day they become convalescent, think they ought

to be allowed to get up. They feel well, they think they are so; they

earnestly declare that they are so. They are impatient of bed; they

imagine it keeps them weak: “if you would but allow me to rise how

thankful I should be; how much more it would refresh and strengthen me

than any thing that can now be done.” Such is the language which is

constantly addressed to the physician in the early period of

convalescence, and if he be weak enough to yield to it and allow his

patient to rise, it is a chance if he ever rise again. The most cautious

and experienced physician sometimes finds himself deceived, falling into

the same error with his patient, and thinking him stronger than he is.

Whenever this happens, the physician has great reason for self-reproach,

_because he ought to allow no risk to be run_. Often, however, in

private practice, the physician is allowed to have no control whatever

over the management of the convalescence—he is dismissed as soon as the

patient is out of apparent and urgent danger; dismissed hastily, often

to be more hastily recalled to witness the death of him whom every one

thought to be well.

But if merely rising from bed at too early a period occasion the death

of great numbers, eating heartily of solid food is a still more frequent

and certain cause of it. The appetite is generally keen immediately

after fever has subsided: if animal food be allowed as soon as the

appetite craves for it relapse is sure to be produced. Often and often

have I seen fatal cerebral and abdominal inflammation excited in a few

hours after the commission of this error. I do not expect, by any

language at my command, to communicate to others my own conviction of

its danger. I know that such a conviction can be produced in no one who

has not an opportunity of observing the convalescence of large numbers;

and I know that no one who has such an opportunity can be without it.

There are three conditions under which this danger is peculiarly

imminent. First, when the disease has been unusually severe and

protracted. The more intense the fever and the longer it has lasted, the

more are all the organs enfeebled, and the longer do they retain the

irritability of weakness, In this state, anything beyond the gentlest

stimulus will induce vascular excitement, which will rapidly pass into

inflammation.

Secondly, when the disease was severe in the commencement, and has been

promptly subdued by active treatment. Whenever copious bleeding brings

on a precocious convalescence, that convalescence is invariably

uncertain and infirm. It is always steady as long as it is properly

protected, but it has not strength equal to its apparent health: it is

as tender and fragile as it is sensitive: the least noxious agent

impresses it; the least stimulus overpowers it. The patient is suddenly

relieved from a load that oppressed him; the organs react with

preternatural vigor; they have enough to do to sustain the reaction of

the system: stimulate them still further by animal food and wine, and

they will be sure to be over done; and this artificial excitement will

be as fatal as the excitement of disease. It can be of little

consequence to the patient whether he die of malaria or of chicken.

Thirdly, when the disease was slight in the commencement and through its

subsequent progress, but the convalescence proved tardy and imperfect.

In this case, animal food and wine are pernicious and highly dangerous,

and often prove more fatal than a severe form of fever. Nothing is

advantageous or safe for such a patient but perfect rest and quiet and

the blandest farinaceous diet.

I have now laid before the reader all that I have been able to learn of

this frequent and most formidable disease. I am conscious that some of

the views which have been exhibited are opposed to the prevalent

doctrines of the day, and that some parts of the treatment recommended

must appear to many unnecessary and hazardous. But since I have

suggested no doctrine which has not been deduced from a long and careful

study of the phenomena, and recommended no practice which has not been

derived from large experience, I trust that the former will not be

rejected without examination, nor the latter condemned until its failure

have been witnessed. I have opposed with earnestness, perhaps some may

think with vehemence, certain opinions and modes of practice which I

conceive to be pregnant with evil; but as I have never intended the

slightest reproach or blame to the advocates of the doctrines I condemn,

so I shall feel truly grateful to any one who will point out any mistake

into which I may have fallen. Those who have studied this disease with

the best success are the most sensible how much remains to be done to

render our knowledge of it perfect and our treatment of it effectual.

Many are the dark spots that still remain upon this part of the field of

knowledge; many are the labourers that must work long and skilfully

before they are removed; while, if the successful investigation of

medical science in general contribute largely to the well-being of man,

the successful study of this branch of it must be pre-eminently

beneficial. It is computed that upwards of one-half of the human race

perish by this fell disease in one or other of its forms: when this fact

is coupled with the truth disclosed by the annexed tables, which shew at

what age this malady is most prevalent and fatal, we become duly

impressed with the importance of labouring to render our knowledge of

this dreadful disease complete, that we may lessen, as far as possible,

the suffering of our common nature, and extend to its utmost limit the

term of human life, too brief when most protracted, but constantly cut

short by this great enemy of our race, just as adolescence is ripening

into manhood.

APPENDIX.

The annexed Tables furnish, in general, their own commentary. The facts

established by some of them are curious and important. I lay them before

the reader without observation, at present; but I shall have occasion to

return to them hereafter.

_Meteorological Table, with reference to Admissions and Deaths, for

1825._

┌──────┬──────┬───────┬─────────┬─────────┬────────────────────┬──────────────┐

│Weeks.│Admis-│Deaths.│ Heat. │Moisture.│ Wind. │ Weather. │

│ │sions.│ │ │ │ │ │

├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤

│ 〃 │ 〃 │ 〃 │Max. Min.│Max. Min.│ 〃 │ 〃 │

├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤

│ 1│ 6│ 0│ 54 32½│ 964 685│West. North. │Fine. │

│ 2│ 9│ 2│ 46 34│ 966 755│North. East. │Hazy. │

│ 3│ 16│ 1│ 46 34│1000 763│West. North. │Cloudy. │

│ 4│ 13│ 4│ 50½ 32│ 984 711│North. North-West. │Cloudy. Hazy. │

│ 5│ 7│ 1│ 51 30│ 839 614│West. West by North.│Fine. │

│ 6│ 10│ 2│ 48 33│ 971 783│South-West, WbN. │Fine. Hazy. │

│ 7│ 9│ 1│ 51 38│ 870 820│East. West. │Cloudy. Rain. │

│ 8│ 8│ 3│ 47 36│ 962 659│East. North. │Cloudy. │

│ 9│ 4│ 0│ 46 36│ 932 538│West, North-West. │Fine. Cloudy. │

│ 10│ 8│ 2│ 52 34│ 966 658│West. North. │Dark. C. Hazy.│

│ 11│ 2│ 0│ 48 31│ 862 452│North. East. │Cloudy. Fine. │

│ 12│ 5│ 3│ 52 39│1000 598│East. South-East. │C. H. Dark. │

│ 13│ 12│ 1│ 61 42│ 807 347│East. North. │Fine. Hazy. │

│ 14│ 10│ 2│ 62 41½│ 904 522│East. North-West. │Fine. Cloudy. │

│ 15│ 19│ 3│ 63 46│ 844 470│North. West. │Fine. Cloudy. │

│ 16│ 7│ 2│ 63 53│ 901 553│West. East. │Cloudy. D. F. │

│ 17│ 12│ 1│ 71 54│ 801 538│South. East. │Rain. Cloudy. │

│ 18│ 4│ 1│ 67 52│ 907 516│South-West. North. │Cloudy. Rain. │

│ 19│ 10│ 1│ 63 53│ 712 516│North. East. │Cloudy. Fine. │

│ 20│ 11│ 2│ 74 53│ 765 442│East. West. North. │Cloudy. Fine. │

│ 21│ 6│ 3│ 66 54│ 905 466│West. West. │Cloudy. Rain. │

│ 22│ 6│ 3│ 81 63│ 748 449│South. North. West. │Fine. Cloudy. │

│ 23│ 5│ 1│ 80 59│ 774 404│North. East. │Fine. Cloudy. │

│ 24│ 18│ 2│ 71 57│ 721 421│North-West. South. │Cloudy. Fine. │

│ 25│ 11│ 2│ 72 58│ 800 472│North-West. East. │Cloudy. Hazy. │

│ 26│ 8│ 0│ 84 57│ 937 439│West. South-West. │Fine. │

│ 27│ 10│ 2│ 87 75│ 727 437│East. South-East. │Fine. │

│ 28│ 13│ 1│ 78 63│ 850 429│East. North. │Fine. Cloudy. │

│ 29│ 9│ 2│ 86 65│ 660 357│West. South-West. │Cloudy. Rain. │

│ 30│ 15│ 2│ 70 65│ 793 488│West. North-West. │Cloudy. │

│ 31│ 20│ 0│ 69 62│ 855 660│West. North. │Cloudy. │

│ 32│ 22│ 2│ 70 60│ 793 488│West. North-West. │Cloudy. │

│ 33│ 13│ 1│ 69 62│ 855 575│West. North. │Cloudy. │

│ 34│ 10│ 1│ 76 60│ 971 635│East. North-East. │Cloudy. Rain. │

│ 35│ 16│ 5│ 73 61│ 949 598│North. West. │Cloudy. Fine. │

│ 36│ 12│ 5│ 68 60│ 770 554│West. North. │Fine. Cloudy. │

│ 37│ 11│ 3│ 69 63│ 971 749│South. West. │Cloudy. Rain. │

│ 38│ 19│ 3│ 70 54│ 968 700│South. West. │Cloudy. │

│ 39│ 19│ 2│ 67 52│ 937 717│West. North-East. │Fine. Rain. │

│ 40│ 10│ 2│ 65 58│ 935 749│West. South-East. │Rain. Cloudy. │

│ 41│ 13│ 3│ 63 55│ 935 652│West. North. S-East.│Cloudy. │

│ 42│ 15│ 2│ 63 40│ 937 618│West. West. │Rain. │

│ 43│ 13│ 3│ 54 37│ 924 627│West. North-West. │Cloudy. │

│ 44│ 15│ 1│ 57 48│ 879 713│West. West. │Cloudy. │

│ 45│ 10│ 3│ 56 38│ 961 705│West. West. │Cloudy. │

│ 46│ 14│ 3│ 44 31│1000 557│North. North. │Foggy. Rain. │

│ 47│ 16│ 4│ 53 36│ 943 781│West. West. │Cloudy. Rain. │

│ 48│ 12│ 4│ 62 40│ 968 767│West. West. │Cloudy. Rain. │

│ 49│ 14│ 2│ 50 36│1000 790│West. North-East. │Foggy. Cloudy.│

│ 50│ 11│ 0│ 52 38│1000 762│West. East. │Foggy. │

│ 51│ 11│ 4│ 51 41│ 967 763│West. South. │Foggy. Cloudy.│

│ 52│ 9│ 1│ 47 28│ 971 585│West. West. │Cloudy. │

├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤

│ Total│ 588│ 104│ │ │ │ │

└──────┴──────┴───────┴─────────┴─────────┴────────────────────┴──────────────┘

_Meteorological Table, with reference to Admissions and Deaths, for

1826._

┌──────┬──────┬───────┬─────────┬─────────┬────────────────────┬──────────────┐

│Weeks.│Admis-│Deaths.│ Heat. │Moisture.│ Wind. │ Weather. │

│ │sions.│ │ │ │ │ │

├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤

│ 〃 │ 〃 │ 〃 │Max. Min.│Max. Min.│ 〃 │ 〃 │

├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤

│ 1│ 4│ 0│ 40 33│ 968 794│East. East. │Cloudy. Fine. │

│ 2│ 10│ 3│ 33 21│ 910 612│North. North. │Hazy. │

│ 3│ 10│ 1│ 42 17│ 963 745│East. North. │Fine. Cloudy. │

│ 4│ 9│ 1│ 40 31│1000 783│West. East. │Cloudy. Foggy.│

│ 5│ 9│ 4│ 50 39│ 966 709│South. East. │Foggy. Cloudy.│

│ 6│ 15│ 1│ 52 33│1000 702│South. West. │Rain. Fine. │

│ 7│ 10│ 5│ 52 39│ 968 110│South. South-East. │Fine. Cloudy. │

│ 8│ 8│ 1│ 52 35│1000 680│West. West. │Fine. │

│ 9│ 7│ 3│ 53 40│ 940 624│West. West. │Cloudy. │

│ 10│ 7│ 1│ 62 39│ 970 698│West. East. │Fine. │

│ 11│ 13│ 2│ 52 37│ 963 500│East. North. │Fine. Hazy. │

│ 12│ 12│ 3│ 57 44│ 87 74│West. North. │Fine. │

│ 13│ 12│ 2│ 62 56│ 60 76│West. West. │Cloudy. │

│ 14│ 13│ 1│ 62 58│ 63 81│East. East. │Fine. │

│ 15│ 9│ 0│ 54 49│ 72 80│West. West. │Cloudy. Fine. │

│ 16│ 15│ 3│ 56 50│ 61 74│East. North-East. │Fine. Cloudy. │

│ 17│ 5│ 5│ 58 52│ 59 68│East. East. │Fine. │

│ 18│ 14│ 0│ 66 56│ 63 69│East. West. │Fine. │

│ 19│ 10│ 5│ 66 59│ 60 76│East. East. │Rainy. │

│ 20│ 9│ 1│ 65 59│ 63 68│East. West. │Cloudy. │

│ 21│ 12│ 1│ 73 66│ 60 68│N-East. N-East. │Fine. │

│ 22│ 18│ 2│ 74 68│ 63 90│West. East. │Fine. │

│ 23│ 20│ 1│ 74 65│ 80 95│East. North. │Fine. │

│ 24│ 15│ 1│ 78 74│ 65 86│East. South. │Cloudy. Fine. │

│ 25│ 14│ 2│ 78 74│ 66 76│West. West. │Cloudy. │

│ 26│ 14│ 0│ 74 74│ 53 79│West. West. │Fine. │

│ 27│ 17│ 2│ 74 62│ 66 76│West. West. │Fine. │

│ 28│ 14│ 1│ 78 67│ 61 72│North. East. │Fine. │

│ 29│ 18│ 4│ 78 68│ 59 75│East. North. │Fine. Cloudy. │

│ 30│ 10│ 3│ 73 49│ 61 92│North. North-East. │Rain. Fine. │

│ 31│ 19│ 2│ 84 55│ 60 84│East. North-East. │Variable. │

│ 32│ 16│ 1│ 78 55│ 65 84│North-East. West. │Variable. │

│ 33│ 20│ 1│ 73 65│ 59 79│West. South-West. │Variable. │

│ 34│ 15│ 4│ 85 60│ 50 72│West. South-West. │Cloudy. Fair. │

│ 35│ 15│ 2│ 79 57│ 65 75│West. South-West. │Cloudy. Fair. │

│ 36│ 14│ 3│ 73 40│ 69 91│West. South-West. │Cloudy. Fair. │

│ 37│ 19│ 2│ 69 47│ 71 88│West. West. │Fine. │

│ 38│ 19│ 2│ 71 51│ 73 93│East. North-East. │Fine. │

│ 39│ 15│ 1│ 69 44│ 74 91│East. South-West. │Cloudy. Rain. │

│ 40│ 12│ 3│ 70 41│ 75 88│S-West. S-West. │Foggy. │

│ 41│ 14│ 1│ 67 42│ 75 89│S-West. S-West. │Foggy. Rain. │

│ 42│ 14│ 2│ 66 45│ 76 96│South. South-West. │Foggy. Cloudy.│

│ 43│ 12│ 5│ 69 40│ 80 96│West. North-West. │Foggy. Rain. │

│ 44│ 17│ 1│ 56 40│ 78 98│West. West. │Foggy. Rain. │

│ 45│ 10│ 2│ 50 31│ 78 98│West. North-West. │Foggy. │

│ 46│ 10│ 4│ 53 33│ 82 97│West. North-West. │Cloudy. │

│ 47│ 13│ 1│ 47 38│ 75 93│East. North-East. │Rain. │

│ 48│ 8│ 1│ 50 30│ 74 93│West. South-West. │Fine. Foggy. │

│ 49│ 18│ 3│ 54 33│ 82 98│West. North-West. │Cloudy. Rain. │

│ 50│ 16│ 4│ 54 45│ 87 99│S-West. S-West. │Fair. Foggy. │

│ 51│ 14│ 3│ 49 33│ 85 98│East. North-East. │Foggy. Fair. │

│ 52│ 11│ 3│ 52 34│ 85 98│N-East. N-East. │Foggy. │

├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤

│ Total│ 676│ 110│ │ │ │ │

└──────┴──────┴───────┴─────────┴─────────┴────────────────────┴──────────────┘

_Meteorological Table, with reference to Admissions and Deaths, for

1827._

┌──────┬──────┬───────┬─────────┬─────────┬────────────────────┬──────────────┐

│Weeks.│Admis-│Deaths.│ Heat. │Moisture.│ Wind. │ Weather. │

│ │sions.│ │ │ │ │ │

├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤

│ 〃 │ 〃 │ 〃 │Max. Min.│Max. Min.│ 〃 │ 〃 │

├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤

│ 1│ 10│ 1│ 49 18│ 98 74│West. North. │Fair. │

│ 2│ 7│ 2│ 53 31│ 98 85│West. South-West. │Rain. Fair. │

│ 3│ 14│ 0│ 53 25│ 96 76│West. North-East. │Cloudy. Fair. │

│ 4│ 8│ 1│ 42 18│ 95 81│West. North-East. │Cloudy. Foggy.│

│ 5│ 12│ 3│ 46 27│ 98 75│East. North-East. │Fair. │

│ 6│ 6│ 1│ 41 28│ 93 75│East. North-East. │Fair. │

│ 7│ 9│ 3│ 40 19│ 87 80│East. North-East. │Fine. │

│ 8│ 13│ 1│ 40 29│ 89 72│East. North-East. │Fair. Cloudy. │

│ 9│ 10│ 0│ 50 30│ 98 82│West. South-West. │Cloudy. │

│ 10│ 10│ 1│ 56 32│ 93 78│West. South-West. │Fair. Rain. │

│ 11│ 12│ 0│ 56 32│ 88 77│West. North-West. │Fair. │

│ 12│ 4│ 0│ 48 35│ 97 75│West. West. │Fair. │

│ 13│ 10│ 1│ 58 35│ 89 76│West. West. │Cloudy. Fair. │

│ 14│ 2│ 0│ 67 46│ 98 75│West. North-East. │Fine. │

│ 15│ 8│ 0│ 58 41│ 92 72│West. West. │Fine. │

│ 16│ 19│ 4│ 52 39│ 92 78│East. North-East. │Cloudy.Rain. │

│ 17│ 6│ 2│ 71 34│ 88 68│Variable. Variable. │Fair. │

│ 18│ 11│ 1│ 72 44│ 95 79│West. South-West. │Cloudy. │

│ 19│ 14│ 1│ 59 34│ 94 72│East. North-East. │Fair. │

│ 20│ 16│ 0│ 70 46│ 88 75│East. South-West. │Fair. │

│ 21│ 12│ 2│ 72 45│ 90 73│West. West. │Cloudy. │

│ 22│ 21│ 0│ 70 45│ 92 78│West. West. │Cloudy. │

│ 23│ 9│ 0│ 70 48│ 92 74│West. West. │Fair. │

│ 24│ 23│ 2│ 75 52│ 92 71│East. West. │Fair. │

│ 25│ 13│ 1│ 74 50│ 87 73│West. West. │Fair. │

│ 26│ 23│ 5│ 72 58│ 98 77│West. West. │Rain. Fair. │

│ 27│ 13│ 1│ 79 55│ 92 74│Variable. Variable. │Fair. │

│ 28│ 15│ 0│ 80 53│ 82 70│East. North-East. │Fair. │

│ 29│ 15│ 2│ 76 56│ 82 68│East. East. │Cloudy. │

│ 30│ 17│ 1│ 84 57│ 92 78│West. West. │Cloudy. Fair. │

│ 31│ 17│ 3│ 80 53│ 84 72│West. West. │Cloudy. Fair. │

│ 32│ 17│ 2│ 72 50│ 86 74│West. West. │Cloudy. │

│ 33│ 16│ 2│ 72 54│ 93 74│East. North-East. │Fair. │

│ 34│ 18│ 5│ 78 52│ 90 75│East. North-East. │Fair. │

│ 35│ 20│ 2│ 78 53│ 93 78│East. North-East. │Cloudy. Fair. │

│ 36│ 14│ 6│ 68 51│ 96 80│East. Fair. │Cloudy. │

│ │ │ │ │ │ North-East. │ │

│ 37│ 17│ 6│ 71 51│ 91 78│East. Fair. │Cloudy. │

│ │ │ │ │ │ North-East. │ │

│ 38│ 16│ 1│ 64 49│ 91 81│West. Fair. │Cloudy. │

│ │ │ │ │ │ South-West. │ │

│ 39│ 14│ 0│ 64 52│ 100 87│West. South-East. │Cloudy. │

│ 40│ 16│ 2│ 61 47│ 100 95│West. West. │Cloudy. │

│ 41│ 13│ 2│ 64 43│ 98 86│West. West. │Fair. Cloudy. │

│ 42│ 15│ 2│ 63 57│ 98 85│West. South-East. │Foggy. │

│ 43│ 16│ 2│ 60 37│ 100 89│S-East. S-West. │Fair. Cloudy. │

│ 44│ 23│ 2│ 57 39│ 99 78│West. North-West. │Foggy. │

│ 45│ 13│ 3│ 60 39│ 98 92│West. North-West. │Fair. Cloudy. │

│ 46│ 5│ 0│ 52 40│ 100 86│East. South-East. │Foggy. │

│ 47│ 12│ 1│ 45 25│ 100 83│N-West. N-West. │Fair. │

│ 48│ 15│ 3│ 53 41│ 100 96│West. West. │Cloudy. Rain. │

│ 49│ 9│ 0│ 56 36│ 97 80│West. West. │Fair. │

│ 50│ 9│ 2│ 55 38│ 98 86│West. West. │Rain. Fair. │

│ 51│ 9│ 3│ 55 39│ 98 97│West. West. │Rain. │

│ 52│ 17│ 1│ 52 31│ 98 87│West. South-West. │Foggy. │

├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤

│ Total│ 676│ 87│ │ │ │ │

└──────┴──────┴───────┴─────────┴─────────┴────────────────────┴──────────────┘

_Meteorological Table, with reference to Admissions and Deaths, for

1828._

┌──────┬──────┬───────┬─────────┬─────────┬────────────────────┬──────────────┐

│Weeks.│Admis-│Deaths.│ Heat. │Moisture.│ Wind. │ Weather. │

│ │sions.│ │ │ │ │ │

├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤

│ 〃 │ 〃 │ 〃 │Max. Min.│Max. Min.│ 〃 │ 〃 │

├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤

│ 1│ 8│ 3│ 50 33│ 98 96│East. West. │Cloudy. │

│ 2│ 9│ 0│ 47 28│ 99 85│East. South-East. │Cloudy. Snow. │

│ 3│ 11│ 1│ 56 38│ 99 86│East. North-East. │Rain. Cloudy. │

│ 4│ 14│ 3│ 53 40│ 98 90│West. West. │Cloudy. │

│ 5│ 11│ 1│ 54 39│ 96 90│West. West. │Rain. Fair. │

│ 6│ 8│ 2│ 54 28│ 98 90│West. East. │Cloudy. Snow. │

│ 7│ 11│ 0│ 41 28│ 98 90│West. West. │Fine. │

│ 8│ 13│ 2│ 52 36│ 98 90│East. West. │Cloudy. Rain. │

│ 9│ 7│ 1│ 57 38│ 98 94│West. West. │Fair. │

│ 10│ 11│ 1│ 55 31│ 98 76│East. North-West. │Fair. │

│ 11│ 18│ 2│ 62 44│ 94 86│West. West. │Fine. │

│ 12│ 5│ 0│ 64 36│ 98 92│West. West. │Fair. Hail. │

│ 13│ 13│ 2│ 52 33│ 98 92│East. North-East. │Foggy. Rain. │

│ 14│ 8│ 3│ 53 35│ 98 82│East. North. │Cloudy. │

│ 15│ 15│ 1│ 61 38│ 98 95│East. South-West. │Rain. Fine. │

│ 16│ 14│ 4│ 61 43│ 98 94│West. West. │Rain. │

│ 17│ 14│ 2│ 65 39│ 97 80│West. West. │Fair. │

│ 18│ 16│ 3│ 68 45│ 98 75│West. East. │Fair. │

│ 19│ 10│ 0│ 66 43│ 98 80│East. West. │Fair. │

│ 20│ 16│ 2│ 68 47│ 92 85│East. South-East. │Fair. │

│ 21│ 8│ 2│ 68 47│ 98 90│East. South-East. │Rain. Fair. │

│ 22│ 8│ 1│ 71 52│ 98 78│West. West. │Fair. │

│ 23│ 3│ 0│ 70 51│ 94 77│West. West. │Fair. Rain. │

│ 24│ 13│ 1│ 73 54│ 78 75│N-West. N-West. │Fair. │

│ 25│ 13│ 1│ 73 56│ 96 75│S-East. S-East. │Rain. Fair. │

│ 26│ 12│ 1│ 80 55│ 96 79│N-West. N-West. │Fine. │

│ 27│ 8│ 1│ 79 56│ 100 91│West. West. │Cloudy. │

│ 28│ 18│ 0│ 77 65│ 74 43│S-West. S-West. │Cloudy. Rain. │

│ 29│ 11│ 1│ 73 55│ 66 48│N-West. N-West. │Cloudy. │

│ 30│ 24│ 2│ 73 51│ 50 49│N-West. N-West. │Fine. │

│ 31│ 13│ 0│ 72 66│ 51 49│East. East. │Rain. Fine. │

│ 32│ 14│ 2│ 74 53│ 50 49│S-East. S-East. │Fine. │

│ 33│ 18│ 3│ 74 44│ 52 40│West. South-West. │Cloudy. Rain. │

│ 34│ 12│ 2│ 68 42│ 50 47│S-East. S-East. │Fine. │

│ 35│ 22│ 1│ 73 56│ 54 50│S-West. S-West. │Foggy. Fine. │

│ 36│ 11│ 4│ 66 45│ 55 51│West by North. West.│Foggy. Rain. │

│ 37│ 16│ 1│ 63 48│ 56 51│West. West. │Foggy. Fine. │

│ 38│ 10│ 3│ 63 39│ 55 50│N-West. N-West. │Foggy. Fine. │

│ 39│ 17│ 4│ 63 38│ 68 52│East. South-West. │Foggy. Fine. │

│ 40│ 14│ 4│ 53 39│ 68 55│East. South-East. │Fine. │

│ 41│ 8│ 0│ 53 26│ 67 55│S-East. S-East. │Fine.Foggy. │

│ 42│ 13│ 2│ 56 26│ 75 55│S-East. S-East. │Fine. │

│ 43│ 8│ 1│ 63 42│ 64 55│East. North-West. │Fine. Foggy. │

│ 44│ 5│ 5│ 54 39│ 68 58│East. North. N-East.│Fine. Cloudy. │

│ 45│ 4│ 0│ 44 35│ 67 53│S-East. South. │Fine. Foggy. │

│ │ │ │ │ │ S-East. │ │

│ 46│ 12│ 3│ 54 28│ 74 63│East. South-East. │Rain. Cloudy. │

│ 47│ 7│ 1│ 56 41│ 68 56│S-West. S-West. │Fine. │

│ 48│ 13│ 0│ 59 35│ 68 56│West. North-West. │Fine. Cloudy. │

│ 49│ 13│ 1│ 53 38│ 65 64│West. S. South-West.│Foggy. Rain. │

│ 50│ 10│ 1│ 56 40│ 68 65│West. West. │Fine. Cloudy. │

│ 51│ 9│ 0│ 57 41│ 65 65│N-West. W. N-West. │Fine. │

│ 52│ 9│ 0│ 45 36│ 69 65│S-West. S-East. │Foggy. Rain. │

├──────┼──────┼───────┼─────────┼─────────┼────────────────────┼──────────────┤

│ Total│ 597│ 81│ │ │ │ │

└──────┴──────┴───────┴─────────┴─────────┴────────────────────┴──────────────┘

Occupation of Patients, with reference to Susceptibility, for one year.

Servants 150

Labourers 126

Shoemakers 18

Tailors 17

Fruiterers 13

Carpenters 10

Weavers 10

Bricklayers 8

Bakers 6

Dress Makers 6

Painters 5

Plasterers 5

Sailors 5

Printers 3

Sawyers 3

Butchers 3

Porters 3

Sweeps 3

Chair Women 3

Pot-boys 3

Shop-boys 3

Silversmiths 2

Grocers 2

Furriers 2

Curriers 2

Woodmen 2

Grooms 2

Skinners 2

Fishmongers 2

Gardeners 2

Corkcutters 2

Farmers 2

Braidmakers 2

Watchmakers 2

Cagemakers 1

Guncapmakers 1

Blacksmiths 1

Combmakers 1

Coppersmiths 1

Firemen 1

Distillers 1

Masons 1

Cabinetmakers 1

Milkmen 1

Saddlers 1

Ferulemakers 1

Coachbuilders 1

Mercers 1

Bargebuilders 1

Cheesemongers 1

Sawmakers 1

Clockmakers 1

Upholstresses 1

Poulterers 1

Destitute 230

———

Total 679

Sex of Patient, with reference to Susceptibility.

┌────────────┬────────────┬────────────┬────────────┐

│ 1825. │ 1826. │ 1827. │ 1828. │

├────────────┼────────────┼────────────┼────────────┤

│Males 289│Males 325│Males 337│Males 278│

│Females, 299│Females, 351│Females, 339│Females, 319│

│ ———│ ———│ ———│ ———│

│ Total, 588│ Total, 676│ Total, 676│ Total, 597│

└────────────┴────────────┴────────────┴────────────┘

Sex of Patient, with reference to Mortality.

┌────────────┬────────────┬────────────┬────────────┐

│ 1825. │ 1826. │ 1827. │ 1828. │

├────────────┼────────────┼────────────┼────────────┤

│Males 53│Males 56│Males 48│Males 33│

│Females, 51│Females, 54│Females, 38│Females, 48│

│ ———│ ———│ ———│ ———│

│ Total, 104│ Total, 110│ Total, 86│ Total, 81│

└────────────┴────────────┴────────────┴────────────┘

Locality of Patient, with reference to Susceptibility.

Country Unhealthy. Town Unhealthy. Town Healthy.

Servants 12 31 96

Labourers 0 88 48

Destitute 0 43 50

Table of Ages, with reference to Susceptibility.

┌────────────┬────────────┬────────────┬────────────┐

│ Age, for │ Age, for │ Age, for │ Age, for │

│ 1825. │ 1826. │ 1827. │ 1828. │

├────────┬───┼────────┬───┼────────┬───┼────────┬───┤

│Under 10│ 42│Under 10│ 27│Under 10│ 25│Under 10│ 31│

│ 15│ 67│ 15│ 87│ 15│ 70│ 15│ 80│

│ 20│172│ 20│170│ 20│163│ 20│136│

│ 25│133│ 25│143│ 25│164│ 25│107│

│ 30│ 81│ 30│102│ 30│107│ 30│ 84│

│ 35│ 29│ 35│ 46│ 35│ 35│ 35│ 47│

│ 40│ 28│ 40│ 37│ 40│ 50│ 40│ 45│

│ 45│ 10│ 45│ 28│ 45│ 20│ 45│ 21│

│ 50│ 10│ 50│ 13│ 50│ 13│ 50│ 17│

│ 55│ 10│ 55│ 7│ 55│ 8│ 55│ 6│

│ 60│ 1│ 60│ 5│ 60│ 13│ 60│ 14│

│ 65│ 1│ 65│ 3│ 65│ 2│ 65│ 6│

│ 70│ 2│ 70│ 3│ 70│ 4│ 70│ 1│

│ 75│ 1│ 75│ 4│ 75│ 2│ 75│ 2│

│ 80│ 1│ 80│ 1│ 80│ 0│ 80│ 0│

│ 85│ 0│ 85│ 0│ 85│ 0│ 85│ 0│

│ │———│ │———│ │———│ │———│

│ Total │588│ Total │676│ Total │676│ Total │597│

╘════════╧═══╧════════╧═══╧════════╧═══╧════════╧═══╛

Table of Ages, with reference to Mortality.

┌────────────┬────────────┬────────────┬────────────┐

│ Age, for │ Age, for │ Age, for │ Age, for │

│ 1825. │ 1826. │ 1827. │ 1828. │

├────────┬───┼────────┬───┼────────┬───┼────────┬───┤

│Under 10│ 3│Under 10│ 1│Under 10│ 5│Under 10│ 4│

│ 15│ 5│ 15│ 10│ 15│ 5│ 15│ 5│

│ 20│ 29│ 20│ 35│ 20│ 16│ 20│ 12│

│ 25│ 25│ 25│ 14│ 25│ 17│ 25│ 11│

│ 30│ 17│ 30│ 20│ 30│ 18│ 30│ 12│

│ 35│ 2│ 35│ 3│ 35│ 1│ 35│ 4│

│ 40│ 7│ 40│ 7│ 40│ 10│ 40│ 7│

│ 45│ 6│ 45│ 4│ 45│ 5│ 45│ 5│

│ 50│ 4│ 50│ 5│ 50│ 4│ 50│ 7│

│ 55│ 3│ 55│ 1│ 55│ 2│ 55│ 1│

│ 60│ 0│ 60│ 3│ 60│ 1│ 60│ 4│

│ 65│ 0│ 65│ 2│ 65│ 0│ 65│ 3│

│ 70│ 2│ 70│ 1│ 70│ 0│ 70│ 0│

│ 75│ 1│ 75│ 2│ 75│ 2│ 75│ 1│

│ 80│ 0│ 80│ 2│ 80│ 0│ 80│ 0│

│ 85│ 0│ 85│ 0│ 85│ 0│ 85│ 0│

│ │———│ │———│ │———│ │———│

│ Total │104│ Total │110│ Total │ 86│ Total │ 76│

╘════════╧═══╧════════╧═══╧════════╧═══╧════════╧═══╛

_Relation between Date of Attack, Admission and Cure, in 600 Cases._

┌────────────────────┬────────────────────┬────────────────────┐

│ Admitted on. │ Dismissed on │Duration of Disease.│

├────────────────┬───┼────────────────┬───┼────────────────┬───┤

│1st Day of Fever│ 2│11th Day │ 11│11 Days │ 11│

│ │ │12 │ 2│12 │ 2│

│2 │ 6│13 │ 6│13 │ 6│

│ │ │14 │ 8│14 │ 8│

│3 │ 29│15 │ 4│15 │ 4│

│ │ │16 │ 9│16 │ 9│

│4 │ 47│17 │ 7│17 │ 7│

│ │ │18 │ 15│18 │ 15│

│5 │ 54│19 │ 14│19 │ 14│

│ │ │20 │ 15│20 │ 15│

│6 │ 43│21 │ 18│21 │ 18│

│ │ │22 │ 11│22 │ 11│

│7 │138│23 │ 19│23 │ 19│

│ │ │24 │ 27│24 │ 27│

│8 │ 35│25 │ 15│25 │ 15│

│ │ │26 │ 17│26 │ 17│

│9 │ 25│27 │ 24│27 │ 24│

│ │ │28 │ 22│28 │ 22│

│10 │ 20│29 │ 25│29 │ 25│

│ │ │30 │ 13│30 │ 13│

│11 │ 4│31 │ 13│31 │ 13│

│ │ │32 │ 15│32 │ 15│

│12 │ 7│33 │ 12│33 │ 19│

│ │ │34 │ 12│34 │ 12│

│13 │ 4│35 │ 16│35 │ 16│

│ │ │36 │ 13│36 │ 13│

│14 │ 71│37 │ 24│37 │ 24│

│ │ │38 │ 14│38 │ 14│

│15 │ 11│39 │ 12│39 │ 12│

│ │ │40 │ 10│40 │ 10│

│17 │ 3│41 │ 8│41 │ 8│

│ │ │42 │ 7│42 │ 7│

│18 │ 2│43 │ 7│43 │ 7│

│ │ │44 │ 15│44 │ 15│

│19 │ 1│45 │ 7│45 │ 7│

│ │ │46 │ 6│46 │ 6│

│21 │ 43│47 │ 7│47 │ 7│

│ │ │48 │ 3│48 │ 3│

│28 │ 8│49 │ 8│49 │ 8│

│ │ │50 │ 6│50 │ 6│

│30 │ 2│51 │ 7│51 │ 7│

│ │ │52 │ 4│52 │ 4│

│42 │ 2│53 │ 2│53 │ 2│

│ │ │54 │ 5│54 │ 5│

│56 │ 1│55 │ 1│55 │ 1│

│ │ │56 │ 1│56 │ 1│

│60 │ 1│57 │ 4│57 │ 4│

│ │ │58 │ 3│58 │ 3│

│Unknown │ 21│59 │ 2│59 │ 2│

│ │ │60 │ 5│60 │ 5│

│ │ │62 │ 1│62 │ 1│

│ │ │Beyond 62 │ 24│Beyond 62 │ 24│

│ │ │Unknown │ 16│Unknown │ 16│

└────────────────┴───┴────────────────┴───┴────────────────┴───┘

Relation between date of Attack, Admission, and Death, for one year,

comprehending 84 Cases.

Admitted on

3d day of fever 5

4 4

5 2

6 4

7 11

8 6

9 3

10 3

11 2

13 1

14 13

17 1

21 16

28 5

30 1

42 3

Unknown 4

──────────────────────────

Died on

7th day of fever 1

8 2

9 2

10 4

11 7

12 2

13 1

14 6

15 2

16 2

17 2

18 1

19 1

20 5

21 3

22 1

23 2

24 4

25 2

26 1

27 3

28 3

29 1

30 3

31 4

32 1

33 1

35 4

36 2

37 2

40 1

41 1

42 1

60 2

Unknown 4

──────────────────────────

Died on

1st day after admission 4

2 5

3 11

4 8

5 5

6 8

7 5

8 2

9 1

10 5

11 4

12 4

13 1

14 7

15 1

16 3

18 1

19 2

20 1

28 1

30 1

34 2

44 1

Proportions of Type out of 300 Cases.

Synochus 235

Typhus Mitior 21

Typhus Gravior 1

Scarlatina 40

Intermittent 1

Remittent 2

Proportions of Internal Characteristic Affection out of 300 Cases.

Cerebral 66

Thoracic 79

Abdominal 60

Mixed 95

Proportions of External Accidental Affection out of 300 Cases.

Erysipelatous 11

Glandular 6

Cynancheal 5

Herpetic 3

Laryngeal 1

Phlegmatial 1

Rheumatic 1

───────────────────────────────────────

Miscarriage 7

Preternatural Cutaneous Sensibility 4

* * * * *

PRINTED BY G. HAYDEN, LITTLE COLLEGE STREET, WESTMINSTER.

-----

Footnote 1:

Observations on the Treatment of Epidemic Fever, &c. By Henry

Clutterbuck, M.D., p. 3–9.

Footnote 2:

Sydenham’s Works, p. 1, 2, &c.

Footnote 3:

Cullen, First Lines, S. 46.

Footnote 4:

Pathological Observations, Part II. on Continued Fever, &c. By W.

Stoker, M.D. p. 32.

Footnote 5:

Ibid. p. 34.

Footnote 6:

Pathological Observations, &c. pp. 73, 74.

Footnote 7:

A Practical Treatise on the Typhus or Adynamic Fever, by John Burne,

M.D.

Footnote 8:

Pathological Observations on Continued Fever, &c. p. 110.

Footnote 9:

Practical Treatise, &c. p. 161.

Footnote 10:

A Lecture upon Typhus Fever, by W. R. Clanny, M.D. p. 12.

Footnote 11:

Ibid., p. 16.

Footnote 12:

Observations on the Prevention and Treatment of the Epidemic Fever, by

Henry Clutterbuck, M.D. p. 5, 6.

Footnote 13:

See a paper in the Medico-Chirurgical Review, for 1828, entitled An

Eclectic Review on Fever.

Footnote 14:

Broussais’ exposition of his own doctrine in his own words is as

follows. On doit regarder comme nécessairement affectés, dans une

maladie, les tissus dont l’irritation est constante durant la vie, et

qui en offrent toujours des traces après la mort. Or, les phénomènes

de la sur-excitation des muqueuses, et surtout de la gastrique, ne

manquent jamais, dans le typhus fébrile, puisque leurs symptômes sont

identiques avec ceux des gastro-entérites sporadiques; tandis que ceux

des autres phlegmasies ne s’y montrent qu’accidentellement. Ensuite,

lorsque les personnes affectées de typhus out le malheur de succomber,

on trouve toujours ces membranes rouges, brunes ou noires, pendant que

les autres tissus n’offrent d’alteration que dans certaines

circonstances accidentelles: done l’irritation des membranes muqueuses

est inséparable du typhus fébrile.

Les typhus fébriles sont donc des gastro-entérites, ordinairement

compliquèes de catarrhes pulmonaires; ces deux phlegmasies sont le

résultat d’un véritable empoisonnement, plus ou moins analogue à celui

des champignons et des poissons gâtées, et qui en a tous les

caractères.

Le foie, principal annexe du canal digestif, est irrité

secondairement, et sa sécrétion est plus ou moins augmentée. Plus le

miasme est actif, plus cette lésion est marquée le typhus carcéraires

plus la chaleur est intense, plus l’irritation du foie est

inflammatoire (la fièvre jaune.)

Le cerveau n’est inflammé primitivement que par l’effet de certaines

circonstances qui ont fait prédominer l’action dans son tissu; telles

sont les affections morales, la nostalgie, les chaleurs, etc.; mais il

souffre toujours beaucoup par sympathie et quelquefois au point que

son irritation passe au degré de la phlegmasie, et devient aussi grave

que si elle était primitive.—_Examen. de la Doctrine Medicale, par F.

J. V. Broussais, p. 112–114._

Il n’y a de difference entre les gastrites qui sont ici dépeintes et

ces fièvres, que celle qui dépend du degré; car les gastrites aigües

qu’on ne peut pas arrêter arrivent toujours ou à l’ataxic ou a

l’adynamic, dont les symptômes ne different pas de ceux du typhus.

D’ailleurs, la gastrite dont il est ici question est déjà pour les

ontologists, une fièvre ataxique.—_Histoire des Phlegmasies, par F. J.

V. Broussais, Vol. III. p. 39._

Footnote 15:

Observations on the Prevention and Treatment of Epidemic Fever, &c.

pp. 11–12.

Footnote 16:

Thus Dr. Stoker states that the remedies “may be arranged according to

their relative importance in the treatment of fever, in the following

order; viz. In mixed fever, 1. Cleanliness. 2. Ventilation. 3. Cool

regimen. 4. Plentiful dilution. 5. Purgatives. 6. Topical bleeding. 7.

Antimonial or James’s Powder. In Typhoid Fever. 1. Yeast or barm. 2.

Wine. 3. Aperients. 4. Emetics. 5. Blisters. 6. Tepid or cold

affusion. 7. Peruvian bark.”—_Pathological Observations &c., p. 111._

In neither of these catalogues is general bleeding mentioned at all:

in the first, topical bleeding is mentioned, but it is placed the last

but one in the list, while in the second, allusion even to topical

bleeding is wholly omitted. And Dr. Clanny states that the first

proposition relative to the cure is how to restore sanguification, or

how to afford fresh chyle to the blood; that although in full habits,

at the commencement of typhus fever, general blood-letting is often

attended with good effects, yet we should remember that if we take one

ounce too much, we may thereby prevent sanguification altogether; that

therefore it is better to have a sufficient quantity of lymphatic

blood in the system them to run the risk of having too little of the

pabulum vitæ, for the purpose of carrying on the functions of life,

and that in fact venesection is not called for in nine cases out of

ten of typhus fever. Let me caution young practitioners, he adds,

against the repeated use of the lancet, when the buffy coat shews

itself, for in many cases, which have come under my notice, I have

observed the buffy coat to be present after repeated bleedings, AND

WHICH COULD NOT BE ATTRIBUTED TO ANY OTHER CAUSE THAN

DEBILITY.—_Lecture on Fever, pp. 21–2–3._

Footnote 17:

It is remarkable that the word which expresses fever, both in the

Greek and the Latin languages, signifies to burn or to boil, and it is

probable that this state of the system is denoted in most modern

languages by some term bearing a similar meaning.

Footnote 18:

A Treatise on Fevers, &c. By A. P. Wilson Philip, M.D. p. 10.

Footnote 19:

Treatise on Fever, &c. By A. P. Wilson Philip, M.D. p. 12.

Footnote 20:

Sydenham’s Works, Chap. 3, p. 11.

Footnote 21:

Sir John Pringle on the Diseases of the Army, p. 66, &c.

Footnote 22:

In scarlatina the affection of the skin modifies the febrile symptoms,

as has just been said, considerably: in small-pox exceedingly. If, on

this account, any one enamoured of nosological distinctions should

wish to separate these varieties of disease, it might be done by

dividing continued fever into—

1. Continued fever without an eruption;

Synochus mitior, Typhus mitior,

—— gravior, —— gravior:

2. Continued fever with an eruption;

Scarlatina, Variola,

Synochodes, Synochodes,

Typhodes, Typhodes:

and so on of all the Exanthemata.

Although the eruption may, and without doubt does give rise to some

peculiar symptoms and so modifies the fever, yet the true character of

the disease, or _the disease as a subject of medical treatment_,

depends entirely on the nature, that is in truth on the intensity of

the fever. If, therefore, the Exanthemata can find no place under the

genus fever consistently with the principles of nosological

arrangement, it appears to me that these artificial distinctions ought

to be abandoned: because it is better to reject nosology, than to

overlook or to mistake pathology.

Footnote 23:

Observations on the Prevention and Treatment of Epidemic Fever, by

Henry Clutterbuck, M.D. p. 15.

Footnote 24:

See pathology—chest cases. John Potter.

Footnote 25:

See page 107.

Footnote 26:

See page 163, 1.

Footnote 27:

See page 163, 2.

Footnote 28:

Those morbid appearances which, not being constant in fever, must be

considered as accidental, are placed in brackets throughout this

chapter.

Footnote 29:

See Case L.

Footnote 30:

See page 51. et seq.

Footnote 31:

Observations on the Diseases of the Army, by Sir John Pringle, Bart.,

p. 11. et seq.

Footnote 32:

Observations on the Diseases of the Army, by Sir John Pringle, Bart.,

p. 36.

Footnote 33:

See a Memoir on Contagion, more especially as it respects the Yellow

Fever, &c., by N. Potter, M.D., Baltimore.

Footnote 34:

In pursuing these researches, I hope to have the advantage of the

co-operation of my friend Dr. Dill.

Footnote 35:

It would be trifling, while treating of so momentous a subject as the

proper management of fever, which requires the prompt, vigorous, and

yet cautious exhibition of the most powerful remedies, to spend any

time in discussing the merits of saline, refrigerant, diaphoretic,

antimonial medicines, and the rest of the apparatus, which

unfortunately continues to hold the place of direct, honourable, and

well-earned (if any thing can be well-earned) remuneration to the

practitioner.

Footnote 36:

Watchful of the convalescence as experience had taught us it is

necessary to be after so severe an attack, still he was allowed to put

himself too forward. When to all appearance recovered, though still

weak, he undertook a journey of fifty miles, that he might the more

completely re-establish his health in the country. He had not arrived

at his journey’s end an hour before he relapsed. He was again bled,

and the cold dash was applied a second time with success. From the

commencement to the termination of the disease, 120 pounds of blood

were abstracted in this case.

------------------------------------------------------------------------

TRANSCRIBER’S NOTES

1. Silently corrected typographical errors and variations in spelling.

2. Retained anachronistic, non-standard, and uncertain spellings as

printed.

3. Enclosed italics font in _underscores_.

End of Project Gutenberg's A Treatise on Fever, by Thomas Southwood-Smith