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V
HISTOEY AND TEEATMENT
OF THE
ENDEMIC BILIOUS FEVEH
OF THE
(Eastern 0l)ore of iHarglanib.
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in 2013
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CLINICAL APHORISMS: ^
CONTRIBUTION
TOWARDS -THE
HISTORY AND TREATMENT
OF THE
ENDEMIC BILIOUS FEVER
OF THE
(Eastern Qljore of iHarj^lcmir
DESIGNED FOR THE USE OF
THE YOUNG PRACTITIONER,
By peregrine WROTH, M.D.
HONORi.RY MEMBER OF THE PHILADELPHIA MEO. SOC.
Quid veram atque deceas^iicoet roga^ et omnis
Coiido el^iompono quce inox depromere possim.
um:
ilDCCCSLII.
iii3tt
JL ' -^
Entered, according to the Act of Congress, in the year eighteen hundred and
forty-two, by Peregrine Wroth, in the Clerk's office, of the District Court
of Maryland.
RCv5G
<^.\
•
PREFACE.
With unfeigned diffidence the author of this manual
ventures to lay before his professional brethren the
first-fruits of a long course of experience. Without
aspiring to the distinction of a systematic writer, he
has presumed to think that an epitome of clinical
practice in that fever which has so long been the
scourge of the peninsula, was a desideratum with the
profession : and, while he deeply laments that no
one better qualified has encountered the task, he ven-
tures to hope that his labor may not prove altogether
in vain.
It may indeed be found that every practitioner of
ten years' standing is already acquainted with every
practical precept in this small volume. For such it
is not intended. It is for the young, the uninitiated,
who cannot draw on the resources of experience, and
who will search in vain in medical libraries for a work
which details, with sufficient distinctness and minute-
ness, the daily routine of professional procedure.
VI PREFACE.
To this day his memory recurs, with painful sensibil-
ity, to his want of such a guide in his early years.
But while it is explicitly and candidly avowed that
this work is not designed for the adept, the author
hopes that it will be found not altogether unworthy of
his attention. He has sought to ground his clinical
instructions on that only foundation of sound practice ^
the pathological condition of the system. The theo-
retical visions of the older writers, to many of whom
the gratitude of future ages will be most justly ren-
dered, will find no place in a work which is founded
on observation.
So much has been written on bilious fever, that a
new work on that subject would seem to be unneces-
sary and uncalled for by the profession. The shelves
of our libraries are already loaded with systematic
works, and the medical periodicals of the day teem
with essays from every miasmatic district of the mid-
dle and southern states. The author has, notwith-
standing, ventured to decide that a small practical
compendium, a clinical vade mecum, a book of daily
reference, might be useful to the youthful practitioner.
It will serve as a travelling companion to a person
unacquainted with the road ; a guide which one may
PREFACE. VU
carry in his pocket, and, in his visits to his country
patients, may consult on any emergency. It may
stand in the place of an elder brother in the profes-
sion, with whom he may, on all occasions of difficulty
or doubt, hold a brief consultation.
The author does not claim originality in all his eti-
ological views, his pathological opinions, or his prac-
tical deductions. He has unscrupulously availed him-
self of the assistance of preceding writers, where
such could be found suitable to his purpose ; and he
has thus, without borrowing much, rendered them
tributary to his design. But, should striking coinci-
dences in theory or practice be discovered, let it not
be too hastily and uncharitably decided that a palpa-
ble plagiarism has been committed. Innumerable
truths have long become the common property of the
profession ; and a modern writer of experience might
be easily detected in inculcating doctrines which had
been taught and published long before, though he had
never heard the names of their authors.
The modesty of its pretensions, it is confidently
anticipated, will shield this little book from severe
criticism. The incessant labors of a country practi-
tioner have aiforded no time for polishing ; and an
Vlll PREFACE.
unpractised pen cannot be expected to possess the
power of arresting and fixing the attention by a dis-
play of fine writing. The hope may be indulged that
the importance of the interests involved in the sub-
ject will insure a fair examination. From such the
author will not shrink ; nay, he invites it, sincerely
desiring that all errors may be detected and cor-
rected.
The author begs that it may be distinctly under-
stood that he uses the name of " bilious fever" only
in compliance with common custom. In numerous
cases of our autumnal endemic, the hepatic system
will not be found to be the seat of the disease ; and,
from first to last, no bilious symptoms are seen to
exist. With much greater propriety the endemic of
the peninsula might be called gastric fever. During
the progress of the disease other organs generally
become involved, and symptoms are developed which
indicate that the brain, the intestines, and the gland-
ular system participate in the morbid affection.
It is not without fear and trembling that the author,
unknown beyond the limited circle of his daily labors,
thus sends forth his first-born into the world, unin-
vited, unpatronized. He does not profess to be sto-
PREFACE. IX
ically indifferent to censure or applause. However
unqualified for the task, his design is good ; and if
his little work shall be the instrument of saving one
human being from the grave, he will receive an am-
ple reward.
THE READER IS REQUESTED TO CORRECT THE FOLLOWING
ERRATA.
Page 28, in the Latin note, for "quo vero" read "qusB verse."
37, 2d line from the top, for Endionxeter read Ewdiometer.
37, in the note, 7th line, for Simoris read Simois.
37, in the Greek quotation, 1st line, for kov? read kai.
37, the reference J to page 29 should be to page 30.
44, bottom line, for Progressis read Pr<Egressis.
45, 3d line from the top, for functionis read functiones.
45, 8lh line from the top, for exacubatione read exacerbatione.
47, 13th line from the top, for lues read lues.
47, 18th line from the top, the same error.
48, place a comma (,) after nervous in the fool note.
50, in the quotation from Lucretius, for Cyenis read Cycnis.
55, in the note, for exciting cause read predisposing cause.
78, bottom line of the beading, for ideopathic read idiopathic ; and for
uteritis, read enteritis.
92, 4th line from the top, for nocivum read noarfum.
101, 16th line from top, for head read had and place a comma (,) after arms.
142, 1st line, for miasmata read miasmate.
151, 5th line from bottom, for clothes read cloths.
172, bottom line, for glazy read glairy.
183, in the T^. at bottom, for 9. i. f. read q. s. f.
184, in the 1^. at bottom, same error.
184, 1 9;. 3d line, for ft. read gt.
187, under chapter ix. erase "Congestive State of Bilious Fever."
201, 4th line from bottom, for glotis read glottis--.
^Sp
p u
INTRODUCTION.
Topography of the Eastern Shore of Maryland. — Rivers. — " The
Forest." — Timber. — Topographical features of Kent county. —
Soil and productions. — Shell-banks — their origin — application to
agricultural improvement. — Marl. — Green and black sand — con-
taining shells. — Nature of the soil and order of the strata — mould
or decomposed vegetable matter, clay and sand. — Mineral in-
gredients— phosphate of iron, lignite and pyrites. — Streams of
water, meadows and mill ponds, sources of miasmata.
As a step preliminary to tiie consideration
of the nature and treatment of the endemic
autumnal fever of the Peninsula, it is deemed
necessary, for the information of those not
resident in that region, that something be
said concerning its topography, and more
especially of Kent county, the theatre of the
author's practice.
The country comprised within the Dela-
ware bay on the east, the Atlantic ocean on
the south-east, the Chesapeake bay on the
south-west and west, and a line drawn from
Frenchtown to a point between Wilmington
XIV INTRODUCTION.
and New CastJe in the state of Delaware,
on the north, is known by the general name
of the Peninsula. This country embraces
all the counties on the eastern shore of Ma-
ryland, with the exception of a part of Cecil,
Kent, Sussex, and a part of New Castle
county in the state of Delaware, and the
counties of Accomac and Northampton in
Virginia.
Throughout its whole extent it is watered
by broad and deep rivers, the principal of
which are the Sassafras,* the Chester,* Wye,
Choptank, Nanticoke, Wicomico, and Poco-
moke, besides some others of inferior note.
In all of them the tides of the Chesapeake,
of which they are tributaries, flow almost to
their sources and render them navigable by
vessels of considerable tonnage, amply suffi-
cient for all purposes of commercial inter-
course.
The face of the country, with little varia-
tion, presents the aspect of extensive plains,
rising sometimes into hills no where exceed-
ing the height of a hundred feet. From the
* The aboriginal names of these rivers are Toc-woc and Ozenie.
INTRODUCTION. XV
head of the Sassafras river an almost un-
broken forest extends in a direction nearly
south down to the southern border of Mary-
land, and is filled with valuable timber, the
various species of oak, white, black, red,
Spanish, willow and swamp oaks, maple,
poplar or tulip tree, cypress, cfec.
Kent county in Maryland is bounded on
the north by the river Sassafras, on the south
by the Chester, on the west by the Chesa-
peake, and on the east by a line which sepa-
rates it from Kent county in Delaware.
The head waters of the Sassafras and Ches-
ter approach within two or three miles of
each other ; and the whole county, thus pen-
insulated, is intersected on three sides by
broad and beautiful creeks, which are navi-
gable by grain boats almost to their heads.
The principal of these creeks are —
Langford's bay,
Gray's Inn,
Swan,
Tavern, and ' '
\
flowing into Chester
Morgan's creeks, J
XVI INTRODUCTION.
Still-pond, ^
Churn, [ emptying into Chesa-
Worton, and ' peake bay;
Farley creeks,
Turner's and ^ which are tributaries
Lloyd's creeks, ) of the Sassafras river.
The face of Kent county offers to the eye
an agreeable undulation of surface, the high-
est hill not exceeding, it is believed, a height
of sixty to eighty feet above tide-water. The
whole county, now affording a pleasing va-
riety of woods, meadows, and arable land,
was originally covered with a dense growth
of red, w^hite, black, Spanish, and other spe-
cies of oak ; with chesnut, walnut, hickory,
ash, white and yellow poplar, pine, and other
trees of large size. It is believed that no
part of the Atlantic states bore a finer
growth of timber.
The soil, deep in the lower and thin in the
higher grounds, affords the usual variety of
fertility and sterility. An injudicious system
of husbandry perseveringly pursued for many
generations, successive crops of tobacco and
w^heat, oats and Indian corn, have exhausted a
INTRODUCTION. XVll
soil not originally of the first quality. And
when it is considered that few attempts have
been made, until recently, to regenerate the
soil by the grazing system, it is a subject of
astonishment that the agricultural produc-
tions are still not only sufficient to sustain
the population, but to afford a large surplus
for foreign markets. The lands on the wa-
ter courses are generally of good quality and
very productive. -
Little attention has been given, until with-
in a few years, to those numerous and exten-
sive shell- banks which are found on the
shores of the Chesapeake and its branches,
and which time accumulated around the
wigwams of the aboriginal race. Many of
these banks are so deep and wide as to lead
some to suppose that they must be of sub-
marine formation. But the absence of all
shells but those of the oyster, the fact that
they are all open, the occasional presence of
the bones of the deer, bear, opossum, and
other land animals, the intermixture of black
vegetable mould, and the fact that the ar-
row points and hatchets of the aborigines,
XVIU INTRODUCTION.
made of silex, are frequently found in them,
sufficiently prove that these extensive collec-
tions of shells were not formed under w^ater.
The magnitude of these banks w^ill cease to
surprise us when we reflect that the whole
aboriginal population from the Delaware
bay to the Alleghany mountains, during a
period of more than a thousand years, drew
their subsistence entirely from the woods
and waters by hunting and fishing.
The more enterprising of our farmers have
recently given their attention to these shells
with a view to the improvement of their lands,
and great quantities of them have been cal-
cined and applied with beneficial results.
To some, besides furnishing the necessary
supply for their own farms, they have be-
come a source of considerable revenue.
In other parts of the peninsula immense
and inexhaustible beds of marl have been
discovered and their value duly appreciated.
In many portions of Q,ueen Anne's, Caroline,
and Talbot counties, the worn out soil has
been completely renovated and fertilized by
these calcareous deposits; and as the spirit
INTRODUCTION. XIX
of improvement is now rapidly advancing,
in consequence, probably, of the institution
of agricultural societies, the time is confi-
dently anticipated when our peninsula will
be as remarkable for the exuberance of its
agricultural productions, as it has always
been for the intellectual and moral worth,
and the proverbial hospitality of its inhabit-
ants.
In Kent county there is but little marl of
a calcareous nature, and when found on
the shore of Chester river, a few miles below
Chestertown, it is so intermixed and em-
bedded in ferruginous sandstone as to be of
little value. But the State Geologist, Pro-
fessor DucATEL, has lately invited the atten-
tion of our farmers to their inexhaustible
fields of green sand, and micaceous black
sand, which have been found to contain pot-
ash. In the black sand, large beds of which
have been discovered and worked to profit
on the farms bordering on Lloyd's and Churn
creeks and near the head of Sassafras river,
numerous univalves have been found. When-
ever used, these silicious mixtures have been
XX INTRODUCTION.
proved to be useful in promoting the growth
of corn and the grasses.
In most parts of the peninsula or Eastern
Shore^ as it is frequently called, and more
evSpeciaily in the lower counties, the soil is
light and friable, showing a predominance
of silicious earth in its composition. There
are, however, districts even in those coun-
ties where the soil is stiff, compact, and ar-
gillaceous. In all places where the shores
of rivers, the w^ashing of ravines and the
sinking of wells have afforded opportunities
for geological examination, we discover suc-
cessive strata of vegetable mould at the sur-
face, clay of different colors and of sand, in
which are embedded silicious pebbles or
boulders of various sizes.
In the bold and precipitous shores of the
Chesapeake in Worton hundred, which rise
to an elevation of twenty to forty feet, we
see these strata distinctly marked. At the
surface is a soil of decomposed vegetables,
reposing on a bed of clay; and beneath it al-
ternate strata of sand and clay of various
colors. At the depth of a few feet from the
INTRODUCTION. XXI
surface there is seen a stratum of ferruginous
clay, from ten to fifteen feet thick, very pon-
derous and unctuous to the feel, and richly
impregnated with oxidated iron. In the
stratum of bluish clay, known by the com-
mon name of " fuller's earth," are found small
veins of phosphate of iron and larger quan-
tities of lignite and pyrites. The former is
seen frequently in masses resembling the
branches of trees, in the crevices of which
are deposited crystals of pyrites. The latter
is found in pieces of irregular form, and vary-
ing size, beautifully chrystalized in truncated
tetrahedral pyramids. It varies in color from
the brilliancy of silver to a copper hue; and
when long exposed to atmospheric influence,
effloresces and falls to powder. The late
Professor Woodhouse, of the University of
Pennsylvania, to whom I presented speci-
mens in 1806, found by analysis, that it was
composed of iron, sulphur, and argillaceous
earth.
Throughout the peninsula there are nu-
merous streams of water, bordered by low
grounds and meadows, throwing up a dense
XXU INTRODUCTION.
growth of alder, magnolia, hazel, spice wood,
<fec. &c., and running into the rivers and
creeks, on the margins of which are salt
marshes of considerable extent. These are
generally inundated by the diurnal tides,
though some have received such alluvial ad-
ditions from the higher grounds, that they
are overflowed only at the time of the vernal
and autumnal equinoxes, or after the preva-
lence of high south winds, which force the
waters of the Chesapeake and its branches
towards their sources. On the meadows and
swamps in the vicinity of the fresh water
streams, we see, even in dry seasons, a growth
more or less abundant,- of vegetation; by the
annual decay of which, together with the
putrefaction of myriads of insects and rep-
tiles, the air, in the summer and autumnal
months, becomes highly charged with offen-
sive and deleterious eflluvia.
On every stream of sufiicient magnitude,
dams have been erected with the view of
creating water-power for mills; and large
ponds have been formed, in which a dense
growth of underwood undergoes a slow but
INTRODUCTION. XXIU
sure decomposition. These reservoirs of
stagnant water serve as receptacles for the
decayed and decaying vegetable matter,
washed down from the high and low grounds
in the vicinity. Thus being exposed to the
influence of a powerful sun, decomposition
takes place on a large scale ; pestilential ef-
fluvia are evolved and whole neighborhoods
are prostrated by an unseen enemy.
Having given this brief and imperfect
sketch of the topographical features of the
peninsula, I proceed to offer a succinct ac-
count of the causes, nature and treatment of
our endemic bilious fever.
(E I) a p t e r I .
OF THE CAUSES OF FEVER.
Causes of bilious fever. — Rush's theory erroneous. — Interval be-
tween cause and effect. — Proximate cause not "morbus ipse."
Exciting and proximate causes synonymous and identical. — Re-
mote causes. — Malaria the sine qua non. — State of predisposi-
tion.— Exciting causes. — Excess in eating, &c. &c. — Opinions
of Cullen and Smith. — Origin of malaria or miasma. — Nature
unknown. — Vernal intermittents, cause of. — Opinion of Profes-
sor Potter. — Periodicity the character of malarious diseases —
not always. — How malaria acts, and on what organ.
I.
'^ Rerum cognoscere causas" has been in every
age of the world, the object of human pur-
suit. In no instance in the w^hole catalogue
of the arts and sciences is it of so much im-
portance to arrive at accurate results as in
the science of medicine. To fail in an at-
tempt where so many others have failed, is
not dishonorable. To succeed where the
great names of the present and all preceding
26 ENDEMIC AUTUMNAL FEVER.
ages have not been successful, will not be
expected of me. It is reserved, perhaps, for
some future Sydenham or Cullen to unfold
the chain of the sympathies, and to reveal
the action of that primordial law which has
established so intimate a connection between
the various parts of the body, and between
the body and the mind.
II.
It appears to me evident that medical au-
thors, while exercising their ingenuity and
displaying much learning in order to ren-
der clear the mode in which morbid action
is produced, have increased the difficulties
naturally embarrassing the subject. Our
illustrious countryman, the late Professor
Rush, of the University of Pennsylvania,
enumerated four classes of causes, by the
necessary co-operation of which, disease is
developed, viz : the remote, predisposing, ex-
citing, and the proximate causes. The last
in the chain he considered, with the cele-
brated Gaubius, as " morbus ipse" or the dis-
ease itself.
ENDEMIC AUTUMNAL FEVER. 27
in.
Presumptuous as it may be to question the
authority of a name so deservedly eminent,
it seems clear to me that in this arrangement
there are two errors : the first, that of unne-
cessarily multiplying links in the chain of
causation by considering the debility pro-
duced by the agency of the remote cause as
itself a caiise, when it is only a condition of
the system on which the exciting cause ex-
erts its power ; and the second, that of con-
founding cause and effect, by admitting or
asserting the identity of the proximate cause
with the disease produced by its action.
However inappreciable, there must be an
interval between the time lohen the cause is
applied, and the time when the effect is pro-
duced. The cause and effect, then, are not
simultaneous. To say that the proximate
cause is " morbus ipse," or identical with the
disease, involves an absurdity which no in-
genuity can render intelligible, and no au-
thority can make true.
28 ENDEMIC AUTUMNAL FEVER.
IV.
It is manifestly opposed to the rules of
sound philosophy to admit of more causes
than are necessary to produce an effect * I
shall, therefore, adhere to the rule laid down
by Newton, and refer to two only as gener-
ally necessary to produce disease, viz : the
remote or predisposing, and the exciting or
proximate. I say generally necessary, for it
will hereafter be seen that the long continued
or highly concentrated action of the remote
cause will, per se^ develope the symptoms
which characterize a fully formed fever.
The exciting and proximate causes should
be held to be synonymous — the exciting
cause or that which excites morbid action in
the system being unquestionably that cause
w^iich is nearest (the meaning of the word
proximate) to the disease.
* Causas rerum naturalium non plures admitti debere quain quo
et vero sint, et earuin phenominis expiicandis sufliciant. — Newton,
De Leg. Philos.
ENDEMIC AUTUMNAL FEVER. 29
V.
Doctor CuLLEN has left succeeding writers
very little to add with regard to the remote
causes of fever. Among these he mentions
tivo as more prominent than others, viz : ef-
fluvia from the human body, and marsh mi-
asmata. These, he observes, are remote
causes, arise from putrescent sources, are
sedative in their nature, and produce, the
first, fever of a continued or typhoid type,
the latter, or marsh effluvia, remittent and
intermittent fever.
It is doubted whether there be any other
agent directly engaged in the production of
endemic autumnal fever, than the effluvia
from marshes or low, moist and rich grounds.
Loss of rest, exposure to cold, &c., may co-
operate in reducing the body to that state of
debility in which it is peculiarly susceptible
of the action of exciting causes.
While then some physicians, inquiring af-
ter causes, have considered all diseases as a
Divine infliction, and others have descended
3*
30 ENDEMIC AUTUMNAL FEVER.
into the bowels of the earth and brought
forth morbiferous exhalations from its dark
and secret caverns, I do not hesitate to ad-
mit, as a fact susceptible of the strongest
proof, that marsh effluvia, miasmata, or ma-
laria are the efficient cause, the sine qua non,
in the production of those autumnal bilious
fevers w^hich desolate all tropical and many
parts of temperate latitudes. Laborers and
others who are most exposed both to the ac-
tion of the sun's rays and to night air, and
those who it may be supposed have the least
constitutional power of resistance to morbid
causes, as children, with those who are
slightly clothed and insufficiently fed, par-
ticularly such as sleep in old houses which
freely admit night air while they sleep, are
the first subjects of the fever in every year. It
is a fact also, which deserves to be mentioned,
that, twice in the course of my professional
life, my attention has been called to a great
mortality among the cats — immediately be-
fore the commencement of the endemic in
the month of August.
ENDEMIC AUTUMNAL FEVER. 31
VI.
The direct effect of the action of this pow-
erful agent (malaria) on the human body, is
that condition which, with great propriety,
has been called predisposing debility.
An individual may continue in this state
of predisposition for days, weeks, or even
months, and still be able to pursue his cus-
tomary vocation. All the time he is con-
scious of a degree of lassitude or indisposi-
tion to active employments ; his appetite is
not good, he has a disagreeable taste in his
mouth, his bowels are irregular. He is evi-
dently under the influence of the remote
cause. In this condition it is necessary, in
order to produce the full development of
fever, that the individual be subjected to the
action of an exciting cause.
VII.
The most common exciting causes are ex-
cesses in eating and drinking, more than
usual exertion of the motive powers, the
passions of the mind, and the long-continued
32 ENDEMIC AUTUMNAL FEVER.
action or highly concentrated application of
the remote cause. Instances of sudden death
have occurred in persons employed in marshy
grounds in consequence of the action of ma-
laria in a state of intense concentration.
Among the exciting causes, the action of
drastic purgatives must not be omitted. It
is not unusual for individuals who are ex-
posed to miasmatic influence to take active
medicine with a view to the prevention of
fever ; and it is still more unusual for such to
escape an attack. Every physician of ex-
perience must have seen numerous cases of
autumnal fever brought on by the very
measures injudiciously employed to prevent
them.
VIII.
Doctor SouTHWooD Smith, of the London
Fever Hospital, the author of a work on fever
which has raised to his name a monument
'' sere perennius," in his inquiry into the
cause of that disease, observes, '' Of all pre-
disposing causes, the most powerful is the
continued presence and slow operation of the
exciting cause," &c. Vide Smith on Fever.
ENDEMIC AUTUMNAL FEVER. 33
It must appear evident to all that the con-
dition spoken of as that which renders the
body susceptible of being acted on by the
exciting cause must be that produced by ma-
laria. This, it is well known, is the state of
hundreds who live in miasmatic districts,
w4io nevertheless escape the full develop-
ment of the fever. A careful avoidance of
all excitants will frequently secure them an
exemption when great numbers lie prostrate
around them, and when every breath they
draw is loaded w-ith the pestilential cause.
But one draught of stimulating drink, one
act of over-indulgence in eating, one parox-
ysm of anger or other exciting passion, will
rouse the slumbering predisposition and pro-
duce fever.
IX.
Moreover, it is evident that the condition
to which Dr. Smith refers, is produced by
some debilitating agent ; and hence it follows
that the cause which produces this condition
cannot be entitled to the name of excitins".
The result of the action of an exciting cause
must be excitement.
34 ENDEMIC AUTUMNAL FEVER.
X.
We here see two great names who differ
toto coeio with regard to the remote and ex-
citing causes, and to the position which they
occupy in the chain of diseased action, or
rather in the production of morbid affection.
CuLLEN considers miasm as the remote^ Smith
as tlie exciting cause. I sliall follow the
first — but " sub judice lis est." The opinion
however, may be hazarded, that when all
parts of the human organism perform their
functions with regularity ; when the precise
quantity of food to subserve the purposes of
nutrition, be taken ; when the exact quantity
of clothing necessary to preserve the just
equilibrium, be used ; when no extraneous
excitant and no internal stimulant be pre-
sent, it is very possible that the phenomena
of fever will not be developed, though every
avenue of the human body be filled with the
remote cause.
It is indeed acknow^ledged that it is ex-
ceedingly difficult to avoid all exciting
causes and to preserve the body in that ex-
ENDEMIC AUTUMNAL FEVER. 35
act state of equilibrium. It is however con-
tended that it is absolutely impossible to avoid
or escape the action of malaria in those lo-
calities where autumnal fever prevails. It
may then be considered as a legitimate con-
clusion that malaria should be received as
the remote cause : for if there be any mean-
ing in the term exciting^ and that meaning
be a certain circumstance which immediately
precedes disease, malaria cannot be the ex-
citing cause, as disease would inevitably be
produced in every individual exposed to its
influence.
XI.
Morever, the fact that a space of time
intervenes between exposure to miasmatic
influence and the development of fever,
proves that miasma should not be considered
as the exciting cause. Dr. Robert Jackson*
bears testimony that the body may continue
in health a long time during the constant ac-
tion of unwholesome exhalations ; and Dr.
Smith! admits that the '' febrile poison may
* Fevers of Jamaica, /)ogc 134. Edit. 179 i.
t Smith on Fever.
36 ENDEMIC AUTUMNAL FEVER.
be present without being sufficiently potent
to produce fever." If the correctness of
these views be admitted, it will appear evi-
dent that between the action of the remote
cause and the development of fever, some
intervening agent is required.
XII.
Whether, however, malaria be the remote
cause, according to Cullen, Cleghorn, Jack-
son, Rush, and many others, or the exciting
cause, according to the decision of Dr.
SouTHWooD Smith, it is on all hands con-
ceded that autumnal fever is the conse-
quence of the action, remote or immediate,
of that unknown and intangible agent, ma-
laria or miasma, on the human body. To
believe or to dispute this position may be
considered as a test of professional ortho-
doxy. What the chemical character of this
gaseous matter, the product of the action of
the sun's rays on putrefying masses of vege-
tation, is, remains to this day, notwithstand-
ing the acute and laborious researches of
Macculloch and others, a subject of mere
ENDEMIC AUTUMNAL FEVER. 37
conjecture. Though known to exist, it is a
singular fact that the nicest endiometer has >
never detected any appreciable difference
between the atmospheres of marshy and
mountainous regions. Let it suffice to say
that all believe it to be evolved from decom-
posing vegetable matter by the influence of
the sun's rays.*
* Homer (though it may seem strange to produce non-profes-
sional authority) was doubtless acquainted with this fact. When
he ascribes the pestilence which desolated the Grecian camp to
the anger of Apollo (the god of day), he means to allude to the
action of the sun's rays on vegetable accumulations. The situa-
tion too of the Grecian camp, on the margin of the sluggish and
marshy Scamanderf and its tributary stream the Simoris, was favor- ^
able to the production of Malaria. The bow, the arrows discharged ^
from the full quiver of the avenging god, and . the time when they
were darted forth, represent with perfect accuracy the mode of
attack by our unseen enemy and the time when the mischief is
done. The subjects also of the first invasion of the pestilence^ —
" Oipiiat; /uh TTpZrov i7r<liyjn:(i, kquc Kuvncdpym, "T
Baxx'." Iliad, lib. i. 50.—
accord so well with what we know, in modern times, to be true,
that there is left no room to doubt concerning the identity of the
plague in the Grecian army with the fever of malarious countries.
f Now called the Mender.
:J: Vide the fact mentioaed p. ^. ""^ C^ ^
X J Cr>
38 ENDEMIC AUTUMNAL FEVER.
XIII.
Let it be assumed, then, as a fact, unsus-
ceptible of successful contradiction, that ex-
halations from marshy grounds, or miasmata,
whatever be their chemical character, inde-
pendent of atmospheric vicissitudes, consti-
tute the sine qua non in the generation of
bilious autumnal fever. The fact of the
frequent occurrence of vernal intermittents
when the sources and causes of unwholesome
exhalations do not exist, does not militate
against this opinion. The impression made
on the body by malaria remains, in the opin-
ion of Professor Potter, of the Universitv
of Maryland, for years, in such as live within
the sphere of its influence for one year.
'' Hence," he observes, '' it modifies all their
diseases. The low temperature of winter
does not continue long enough to obliterate
the malarious predisposition, and hence we
see not only vernal intermittents but pneu-
monia biliosa from the combined operation
of malaria and vicissitudes of temperature."
ENDEMIC AUTUMNAL FEVER. 39
If autumnal fever be entitled to the name
of bilious, it cannot be denied to many cases
of vernal intermittent. We frequently see
instances in which there are evident indica-
tions of derangement in the biliary system.
My friend, Dr. Bordley, of Centreville, has
only seen vernal intermittents and remittents
in those persons who were the subjects of
the same diseases the preceding autumn.
XIV.
Caeteris paribus, the north borders of mill-
ponds and low marshy grounds are more i 4
generally unhealthy than the vSouthern side,
because the prevailing winds of summer and
autumn waft the malarious exhalations in a
northerly course. There have been, how-
ever, exceptions to this rule. In the fall of
1839, a family living on an elevated spot on
the south side of an extensive pond of stag-
nant fresh w^ater, near the shore of the Chesa-
peake in Kent county, was severely scourged,
while those on the north side almost entirely
escaped.
40 ENDEMIC AUTUMNAL FEVER.
XV.
Johnson and Macculloch contend that
malaria is not only the parent of autumnal
fever, but of many other diseases, as apo-
plexy, palsy, lethargy, epilepsy, hysteria, hy-
pochondriasis, tic doloreux, &c. &c. Accord-
ing to the former, periodicity or remissions
and exasperations afford ground for suspect-
ing a malarious origin.
It is doubted whether any of the morbid
affections above mentioned, w^hen primary ^
observe regular diurnal, bidual or tridual ex-
asperations. There are diseases, how^ever,
which do not possess the feature of periodicity
or remissions and exasperations which are
unquestionably produced by the slow opera-
tion of malaria, — as physconia of the liver,
spleen, &c.
XVI.
There is much diversity of opinion with re-
gard to the medium through which the mor-
bid impression is made on the body. Some
contend that it is through the lungs ; others
ENDEMIC AUTUMNAL FliVER. 41
that the miasma is mixed with the saliva,
and being deposited with that secretion in
the stomach, acts through the medium of
that organ; while a few affirm that it acts
through the cutaneous surface.
Though as a matter of curiosity it is desi-
rable to know the medium through which
this '' pestilence that walketh in darkness''
is introduced into the system, the full dis-
covery would arm us with no power to
prevent its effects. If it be through the
respiratory organ, we could not at any time
dispense with the use of that viscus when
exposed to unwholesome exhalations; and
the most watchful care could not defend the
stomach from a foe which has heretofore
eluded the most laborious research. Let us,
therefore, be satisfied when the same Al-
mighty Power, who, for wise purposes, has
designed this scourge as a part of the punish-
ment due to his violated law, has mercifully
provided the means of restraining its influ-
ence, and disarming its power.
42 ENDEMIC AUTUMNAL FEVER.
XVII.
But the question occurs, on what organ is
the morbid impression made? In answer to
this, it appears to me evident that the brain
and its nervous appendages, constituting the
organ of sensation, must be the part on
which all impressions, whether salutary or
morbid, are primarily made. Whether then,
the impression be made through the nose,
(by the nerves distributed on the Schneider-
ian membrane,) the lungs, the stomach or
the skin, a certain affection of the nervous
system must constitute the first link in the
chain of morbid action.
While on this subject, I will state that
twice in my life I have been attacked with
a violent congestive autumnal fever, in a few
hours after encountering a most offensive
smelly once in passing through a cabbage
garden, and again along a swamp, in the
month of September.
There are other fevers beside that which
is the especial subject of the present inquiry.
These fevers, as they differ in regard to their
ENDEMIC AUTUMNAL FEVER, 43
remote cause, so they differ in their access,
progress and termination. Among these, it
will only be necessary to refer to those ex-
anthemata which are produced by a specific
contagion.
Orijapter II.
OF THE CAUSES OF FEVER.
Nature of Fever. — Davidge's definition. — The endemic is either
remittent or intermittent. — Rush's opinion of the unity of dis-
ease.— Davidge's. — Fever is an unit. — The dysenteric, cardial-
gic, &c. are states of the same disease. — Bilious fever, whether
infectious or not. — Potter's Memoir on Contagion. — Dr. M.
Browne's opinion. — Alibert. — Emerson.
XVIII.
The term fever derives its origin from the
Latin noun febris, from febrio or ferveo,
which means " to be hot." The morbid af-
fection which has, from the dawn of medical
science, received this name, was so called
because increased heat constitutes a very
prominent feature. The late learned Pro-
fessor Davidge, one of the fathers of the
medical college of Baltimore, and among its
most distinguished ornaments, thus defines
the nosological character of the class of fe-
verous diseases, " Progressis languore, lassi-
^Jr-I^- a
^ ^
ENDEMIC AUTUMNAL FEVER. 45
tudine et aliis debilitatis signis, vel horrore ;
pulsus frequens, calor major, cutis arida ;
lingua sordida ; plures functionis laesae, viri- -f-
bus praesertim artuum, imminutis."
Genus I. Febris Remittens.
" Febris, miasmate paludum orta, acces-
sionibus pluribus, intermissione, saltern re-
missione evidente interposita, cum exacuba- %
tione notabili et plerumque cum horrore rede
untibus, cons tans : accessione quo vis die uni-
co tantum." In this genus are embraced
the common bilious remittent, the yellow fe-
vei\ and several species of intermittents, as
quotidians, tertians^ quartans, with numerous
varieties, a separate notice of v^^hich would
swell this manual to an inconvenient size
without increasing its value. Those who
wish to trace them will find them all sys-
tematically arranged and defined in Doctor
Davidge's Methodical Nosology, second edi-
tion, page 4, et sequent.
XIX.
The endemic fever of the Peninsula is
either intermittent or remittent. In truth^
J f ^M»!i'i'riiriiif|-iriiiii i immhhi «
46 ENDEMIC AUTUMNAL FEVER.
all remittents are continued fevers ; and w^e
frequently see intermittents, so called, ex-
hibiting such a morbid condition in that
stage which is called the intermission, that
we cdinnot justly call them by that name.
XX.
The illustrious Professor Rush, disgusted,
as he well might be, with the endless and
frequently useless distinctions of Nosology,
committed an error on the other extreme ;
and, boldly throwing off the trammels of the
schools, asserted that disease was '' an unit."
In a certain sense this is undoubtedly true.
" That every disease is ' morbid excitementj'
is a position so plain and so true that it nei-
ther admits of refutation nor illustration. It
is one of those self-evident propositions which
defies argument and is unsusceptible of
proof."^ But to contend for the identity of
morbid action in all its circumstances,
whether exhibiting the highest grade of in-
flammatory action or the lowest state of ex-
haustion ; whether requiring the most ener-
* Davidge. Introd. to Nosol.
ENDEMIC AUTUMNAL FEVER. 47
getic and powerful depletion, or demanding
the most prompt and decisive stimulation, is
to simplify our views without increasing our
knowledge- — to retard rather than to ad-
vance the progress of our science.
XXI.
" The original or primary change in or
departure from the healthy condition of the
body, must for ever be in kind according to
the nature of the operating cause, and equal-
ly with the causes, susceptible of division.
Thus that disease which we term small-pox,
or that which we term intermittent fever, or
that w^hich we term lues venerea, is refera- *%
ble for its peculiar phenomena to the nature
of the peculiar remote cause acting on the
animal system. The virus of the small-pox
will never, under any circumstances, pro-
duce the phenomena of lues venerea, nor y^
vice versa."^
xxii.
It was probably from Rush's theory of the
unity of disease that Dr. Southwood Smith
* Davidge ubi supra.
48 ENDEMIC AUTUMNAL FEVER.
borrowed, though without acknowledgment,
the hint which led him to the adoption of
his opinion of the identity of fever.
It is readily admitted that fevej\ in its es-
sential nature, is one, differing certainly in
form and grade, but identical in its principal
characteristics, and requiring only modifica-
tions in the treatment. But fever, in its
unmixed character, or unaccompanied with
local irritation or inflammation,* is of rare
occurrence.
XXIII.
Medical writers of deservedly high repu-
tation* have distinguished this disease by
names derived from the organs which seem
to be especially affected — as the dysenteric,
the cardialgic, the gastric, the hepatic, the
phrenitic, &c.
It is undoubtedly true that, in almost all
fevers, an investigation of the morbid condi-
tion of the larger and more important or-
gans will reveal functional or organic lesions
fC * Irritation is an affection of the nervous inflammation of the
vascular system. **
t Cleghorn, Alibert, and all the physiological school.
ENDEMIC AUTUMNAL FEVER. 49
or derangements. But these different states
present indications which call for variations
only in the details of the treatment, and are
useless in practice. And although the force
of the remote cause is sometimes concen-
trated on the various organs with a fatal
power, the local affections should be consid-
ered only as symptoms of the same identical
disease.
XXIV.
In the history of fever the old adage, ^' the
weakest goes to the wall," is no less true
than it is in civil and personal contests. It
is daily verified in febrile attacks. The
brain, the liver, the lungs, the spleen, the
stomach and intestines, all become the seats
of disease as these various organs happen,
by the operation of various causes, to be in a
state of predisposing debility. It is to this
circumstance that we must attribute the di-
versities observable in our autumnal fever —
the same in nature, differing only in its pa-
thological relations.
XXV.
It has become fashionable in modern times
5tllB' ENDEMIC AUTjUMNAL FEVER.
r curtail /f^o^Jj^wrcli the catalogue of infec-
tious* diseases, and it may be made a ques-
tion whether we have not gone too far in
banishing from the schools all notion of in-
fection in some of the loor^st states of our au-
tumnal bilious fever. For an able discus-
sion of this subject, the reader is referred to
a Memoir on Contagion, by Professor Potter
of the University of Maryland.
Without entering the field with that judi-
cious physician and distinguished writer, for
quid enim contendat hirundo
)t^ Cyenis ? (Lucret.)
it is stated as a fact which will probably not
be denied, that those who are much em-
ployed about the sick are, ceteris paribus,
more liable to attacks of the fever than
others, though it is admitted that many more
persons thus employed escape the fever than
* By some authors, the terms infectious and contagious, are em-
ployed synonymously. Strictly speaking, they are different — in-
fectious referring to those diseases which may be communicated
through the air without actual contact, as variola, scarlatina, rubeo-
la, and some others, confessedly infectious ; and contagious to those
which are only communicated by contact, as lues, psoriasis, and
probably the plague, &c.
^ 9a^ C</< vv^-^j i^^^ G^^e-H^ «»
ENDEMIC AUTUMNAL FEVER. 51
would escape if exposed to morbillous or
variolous infection. " Of the power of the
living body even when in health, much more
when in disease, and above all when that
disease is fever, to 2^Toduce a poison capable
of generating fever ^ no one disputes, and the
fact has never been called in question."*
My venerable preceptor,! now retired
from the labor of half a century, a physician
excelled by few for close observation and
sound judgment, always contended that, to
an individual long exposed in the chamber of
the sickj our bilious fever in its worst forms
proved infectious.
Dr. Alibert, after remarking that " exha-
lations from human bodies possess an energy
and virulence superior to that of marsh mi-
asmata," proceeds to say that he has '' seen
malignant intermittents rage in hospitals
w^hich had no marshes in their neighbor-
hood, and where no other infection could be
suspected than that which arose from too
* Smith on Fever, 377. f I^r. Morgan Browne, since dead.
52 ENDEMIC AUTUMNAL FEVER.
great a number' of persons crowded together
in one place. ^^^
"He who, with or without personal expe-
rience, has searched far into the annals of
medicine, fairly and impartially weighing
the different authorities, must be incredulous
indeed, if he does not admit that in febrile
diseases not originally infections^ where many
of the sick are crowded together ^ and proper
ventilation and cleanliness cannot bepreserved^
there is generated {an effluvium or) a specific
infectious matter^ capable of producing in a
healthy person sufficiently exposed to itj a simi-
lar disease J^t
XXVI.
In September, 1826, a gentleman in Ches-
tertown, well known to me, was attacked
with the autumnal bilious fever, then pre-
vailing in the town and neighborhood. It
proved a double tertian of a low grade of
action, and was aggravated with so much
visceral disease that his life was in imminent
* Alibert on Malig. Interm. prop. 17.
t Emerson, Epidem. Fever. Med. Journ. Vol. III. 194.
ENDEMIC AUTUMNAL FEVER. 53
danger. He did not recover until he vs^as
brought under mercurial influence. About
the time, when he became convalescent, his
w^ife, who had not been a subject of the fever
for many years, was taken with the same
disease, and died after an illness of seven
days. Of three ladies of the town, who kindly
assisted in nursing her, two, who were em-
ployed more immediately about her person,
became the subjects of the same fever, and
one died after a short illness. Three female
relatives from the country, one living four,
another nine, and the third twenty miles dis-
tant, visited the family, and were in almost
constant attendance in the chamber of the
sick. TJieij all were attacked with fever
and returned home, and one of them died of
the same malignant disease.
All these individuals, being in the house
where the first cases occurred, were of course
exposed to the same miasmatic influence,
which produced the fever in the first in-
stances. But so were others in the family
and in the immediate vicinity, who were not
employed in nursing the sick, and who,
54 ENDEMIC AUTUMNAL FEVER.
nevertheless, escaped an attack. It is not
unfair, then, to suspect that the effluvia from
the bodies of the sick, in rooms kept clean,
but not perfectly ventilated, possessed sorne^
if not a principal sJiare in producing the dis-
ease in those who were in constant attend-
ance on the sick.
XXVII.
It is admitted that an universal conviction
of the infectious nature of this disease would
limit the exertions of benevolence, and para-
lyze the hand of charity. Few would ven-
ture into an atmosphere charged with an
unseen enemy whose dart was sure to strike,
and whose wound might be fatal. But a
love of truth compels me to repeat that few
escape who watch by the bedside of the sick
and dying in confined apartments^ in the
worst forms of this fever. This opinion is
the result of an experience derived from a
practice of thirty years, and it is sanctioned
by authorities not to be despised.
With these remarks — and the acknow-
ledgment that, under ordinary circumstances^
ENDEMIC AUTUMNAL FEVER. 55
no danger is to be apprehended, the subject
is left to the decision of the judicious reader *
* It is, in the opinion of the undersigned, more conformable to
the general character of bilious or miasmatic fever, to refer the ex-
tension or multiplication of cases which frequently proceed from
isolated, and severe protracted cases of that fever, to the debihty con-
sequent upon fatigue, watching, anxiety and general derangement of
the regular and accustomed habits of those who are thus attacked.
Debility is known to be a powerfully exciting cause ; and the above 'X
causes are certain to produce it in some degree. t. c. k.
"r-
(Iljaptcr III.
OF INTERMITTENT FEVER.
Phenomena of intermittent. — Cold stage. — Accompanying symp-
toms.— In what manner the congestion is removed. — The chill a
state of congestion. — Severity and duration of the chill not in
proportion to the subsequent reaction. — Premonitory signs. — Hot
stage, how produced. — Sweating stage. — Restoration of the func-
tions, or apyrexia. — Three stages in each paroxysm. — Discharge
of bile no proof of increased secretion. — Suppression of the bil-
iary secretion in some cases. — Nausea, on what it depends. —
Morbid irritability of the stomach. — Spontaneous purging ; first
of serum, then of blood, very dangerous. — This bloody discharge
from the capillaries of the mucous membrane of the intestines. —
Its consequences.
XXVIII.
The phenomena of intermittent fever may
generally be traced to that condition of the
system which is denominated rigor, or the
chill. It is not always so distinct that the
patient can in every instance be positively
sure of its access or declension. In manv
cases there is no shivering, no sense of cold-
ENDEMIC AUTUMNAL FEVER. 57
ness. But even in such instances a practised
eye can discover a certain pallid and shrunk-
en appearance of the countenance and a
slight lividity of the finger nails.
In most cases, however, there is a decided
rigor, or shivering; a small, frequent, and
contracted pulse ; a hurried and oppressed
breathing ; insatiable thirst ; yawning and
stretching ; the knees are drawn up ; and the
head pressed down under the bed-clothes ;
the hands and arms crossed upon the breast,
indicating an instinctive propensity (for none
take time or feel an inclination to reason on
the subject) to keep them as near as possi-
ble to the source and fountain of heat, and
the frequent repetition of attempts to relieve
the laboring heart by making a full and deep
inspiration.
XXIX.
It is a circumstance worthy of note, that
while the patient is shivering with cold, or
the sensation of it, there is to another person
no appreciable diminution of temperature,
except in the extremities. The chill, then,
cannot consist in any actual loss of heat, but
58 ENDEMIC AUTUMNAL FEVER.
in its irregular or unequal distribution. This
loss of balance or unequal diffusion of heat
is owing to the altered action of the nervous
system, in consequence of the impression
made upon it by the morbid cause. During
the chill, the urine, if discharged, will be
found colorless as water.
XXX.
The symptoms enumerated in xxviii. are,
though in different degrees of intensity, at-
tendant on every chill. There are others
occasionally present — as wandering and con-
fusion of the powers of the mind, nausea,
vomiting, which generally soon ushers in the
hot stage by determining the circulation to
the surface, and a purging, sometimes copi-
ous, of thin, light stools, chiefly serous.
The occurrence of the last mentioned
symptom calls for the most prompt, ener-
getic, and persevering attention on the part
of the medical attendant. A delay of one
hour will frequently introduce a danger
which the skill of the most experienced and
judicious practitioner will fail to remove.
ENDEMIC AUTUMNAL FEVER. 59
XXXI.
It has been observed that vomiting some-
times puts an end to the chill by determin-
ing to the surface. This is probably effected
by the pressure of the abdominal muscles,
by which the blood accumulated in the por-
tal viscera is forced into the heart and thence
distributed through the arterial ramifications
to all parts of the body.
XXXII.
During the chill the blood is congested in
the large interior veins, particularly in the
portal circle, and produces a sensation of in-
creased heat about the praecordia. While
shivering w^ith a sensation of cold on the
surface, the patient is tormented with a most
urgent desire for cold drinks. In fact, a true
venous congestion exists, accompanied by its
characteristic signs — a pale countenance,
shrunken features, sighing, oppressed breath-
ing, &c. &c. The cutaneous vessels contain
less blood than in their healthy state. Now
as in many cases, there have occurred no
60 ENDEMIC AUTUMNAL FEVER.
evacuations by w^hich the quantity of the
circulating fluid could have been diminished,
it is evident that there must be an accumu-
lation in some other part. Accordingly we
find this congestion in the large interior
veins — a circumstance which sufliciently ex-
plains that anxiety and oppression which
coexist with the shrunken appearance of the
countenance before mentioned, and which
stamps the features with an expression hip-
pocratic and cadaverous.
xxxiii.
The duration of the chill varies from a
few minutes to several hours, and depends
probably on the varied degrees of physical
energy and the degree of concentration or
the period of application of the remote cause.
A modern author* of eminence distinctly
states that ''in proportion to the intensity of
the chill, will be the subsequent reaction."
In this latitude (N. 39° to 40°) the fact is
generally, if not universally, otherwise. A
* Johnson.
ENDEMIC AUTUMNAL FEVER. 61
cold stage of long duration sometimes passes
off so gradually that the succeeding stage of
reaction is both short and moderate. The
concurrent testimony of Dr. Cullen fully
sustains this statement."^ In some cases, the
efforts of nature to restore the equilibrium
between the central and superficial or capil-
lary circulation, are too weak ; the organs be-
come overwhelmed by an indomitable en-
gorgement ; there is no physician at hand to
administer relief, and the patient dies in the
chill.
XXXIV.
The chill, however, though that state to
which, as before observed, the disease is gen-
erally traced, and though it is almost always
the first symptom which awakens the atten-
tion of the patient, is not the first link in the
chain of morbid action in fever. Lassitude, an
indisposition to motion, an unpleasant feeling
in the head, not amounting to pain ; — these^ or
some of them always precede the access of the
chill, though at the time are seldom noticed.
* First Lines. Vol. I. .35.
62 ENDEMIC AUTUMNAL FEVER.
My friend, Dr. Bordley, informs me that "a
soreness in the balls, or over the orbits of the
eyes," is a premonitory sign seldom absent.
" If we attend minutely," says Dr. Jackson,*
"to all the circumstances of invasion, it will,
generally, not be difficult to perceive that a
disagreeable^ though indescribable affection of
the stomach, takes place previous to the small-
est perception of languor or debility, which
are commonly only immediate forerunners of
coldness or shivering."!
XXXV.
The arterial effort succeeds at length in
propelling the blood into the superficial ca-
pillaries and the hot stage commences. The
extreme vessels receive more blood and their
diameter is increased; the pulse gradually
increases in volume until it becomes full,
quick, and frequently tense ; the heat of the
* Fever of Jamaica, p. 138.
•f A tingling sensation of some superficial nerve, frequently of
the radial, is in some cases a sure prognostic of approaching chill.
This will be succeeded by a burning in the face, and soreness in
the balls or over the orbits of the eyes. Thos. C. Kennard.
ENDEMIC AUTUMNAL FEVER. 63
skin augments until it becomes intense in pro-
portion to the frequency and force of tlie pulse,
and in this early stage of the progress of the
disease, it frequently happens that the organ
which, by the operation or impression of the
remote cause, had been brought into a state
of predisposing debility, now takes on morbid
action.
The increase of heat which advances, pari
passu, with the increasing celerity of the circu-
lation, probably depends upon the augmented
quantity of oxygen gas inhaled during the
rapid respiration attendant on the cold stage.
The oxygen becomes fixed in the lungs, while
the caloric which held it in solution, is diffused
through the system. This chemical theory
is as much entitled to support as any with
which I am acquainted ; and we are indebted
for it, as far as I know, to the late Dr. En-
NALts Martin, an eminent practioner of
Easton, in Talbot county, Md."*^
* Vide Dr. Martin's valuable practical work on the Epidemic
Typhus of 1812.
My friend, Dr. Bordley, before mentioned, suggests the fol-
lowing theory : " The excessive excitement of the cutaneous ves-
64 ENDEMIC AUTUMNAL FEVER.
XXXVI.
The thirst is urgent, the skin is dry and
rough ; the tongue, more or less loaded with
a white secretion, is at first moist, but after
a few paroxysms becomes more inclined to
dryness; the face is flushed ; the eyes and ears
acutely sensible to light and sound; the tem-
poral arteries throb and every motion of the
head is attended with pain, more or less se-
vere ; the urine is high colored and scanty,
and pains in the back and inferior extremi-
ties are frequently very distressing.
XXXVII.
At an uncertain period after the access of
the hot stage, the skin becomes moist ; the
thirst less urgent or entirely ceased ; the pain
in the head, back and extremities abates, and
a diaphoresis, sometimes profuse, indicates
the approach of a state in which the natural
sels produced by the force of the circulation, checks perspiration,
and the usual frigorific effect of that excretion being suspended,
the superficial heat is exalted. Is not this," he asks, " more simple
chemistry?"
ENDEMIC AUTUMNAL FEVER. 65
functions are restored. It is at this time
that we sometimes see a discharge from the
bowels, but more frequently from the blad-
der, which, with that from the skin, intro-
duces the apyrexia or intermission.
This favorable crisis does not, however,
always occur. The sweat sometimes be-
comes more abundant, and cold, and clam-
my; the patient, more and more oppressed,
is extremely restless, frequently gasping for
breath: he sighs and throws himself from
side to side, with the vain hope of finding re-
lief in a change of posture; vomiting and
purging cease, if they had before been present,
because the excitability is exhausted, and the
patient dies.
In intermittent fever, the chill, the fever
(by which term our patients designate the
stage of excitement, and which, in obedience
to common usage, I have sometimes used in
the same sense) and the sweating stage, con-
stitute the paroxysm. Happy both patient
and physician, if these stages always suc-
ceeded each other in their natural and regu-
lar order. Every physician has, however,
66 ENDEMIC AUTUMNAL FEVER.
seen cases characterised by great apparent
mildness in the commencement, in which,
symptoms of great violence and malignity,
have been developed in the second or third
paroxysm.
XXXVIII.
Soon after the commencement of the cold
stage, nausea and vomiting frequently su-
pervene.
The discharge of bile by emesis has long
been considered by the sick and their attend-
ants, as an evidence of increased secretion
of that fluid, and full proof of its presence in
the stomach. This is not always true as to
the first supposition, and never as to the lat-
ter. The action of the abdominal muscles
forces the bile from the liver into the duode-
num, and thence into the stomach, whence
it is discharged by the emetic nisus. The
presence of bile would doubtless produce
nausea; but independently of that, nausea is
produced by a certain morbid condition of
the gastric nerves, either primary or in sym-
pathy with deranged cutaneous or hepatic
ENDEMIC AUTUMNAL FEVER. 67
action. This consent or connection between
the interior and exterior surfaces, is one link
in that continuous chain of sympathies, by
which the human body is bound up in one
beautiful, though complex whole. This sym-
pathy aflfords a wonderful exhibition of Di-
vine Wisdom; and may be compared to that
powerful attraction which draws the visible
universe towards one common centre, and
moulds it into one vast and harmonious
system.
XXXIX.
The worst cases of our autumnal fever are
sometimes characterized by a total absence
of the biliary secretion. Vomiting will con-
tinue to recur with the regular return of the
paroxysm for days, but no bile will be dis-
covered in the matter ejected from the sto-
mach or bowels. A favorable prognosis
may always be confidently drawn when,
after the entire suspension of the secretion,
bile is seen in the evacuations, sursum vel
deorsum.
XL.
But it is not in the cold stage alone that
68 ENDEMIC AUTUMNAL FEVER.
nausea occurs. It sometimes begins during
the stage of excitement : and when it com-
mences during the cold stage, it frequently
continues through the hot, and until the
sweating stage is established.
The most distressing nausea is temporari-
ly relieved by the effort to vomit, even when
nothing is thrown up. This fact affords sanc-
tion to the opinion before given (xxxviii.),
viz. that nausea depends not always on the
presence in the stomach of any offensive or
irritating contents, but on a morbid condition
of the gastric nerves. In this, as in all other
states and stages of the disease, it is import-
ant to ascertain the pathological condition of
that organ. This knowledge alone can lead
to a correct practice. It is evident that it
does not consist primarily in inflammation ;
for this w^ould not entirely disappear, as it
generally does, on the accession of the hot
or the sweating stage. It is not atony — for
then the stomach receives any quantity of
stimulating or other fluids without rejecting
them and without nausea. In the last stage
of our low bilious fever, in fatal cases, I
ENDEMIC AUTUMNAL FEVER. 69
have seen large quantities of diffusible stim-
ulants poured into the stomach with no more
effect than would have been produced by
pouring them into a basin.
In this morbidly irritable condition (the
true pathological state) of the stomach, there
is but one step to inflammation. This is fre-
quently kindled up by the too free and inju-
dicious employment of stimulants, and by
long continued and violent efforts to vomit.
This exalted sensibility or irritability spon-
taneously ceases when the cutaneous surface
becomes moistened by perspiration towards
the close of the paroxysm, if not before by
the equal diffusion of heat and the more uni-
form distribution of excitement at the access
of the hot stage. ^
XLI.
Soon after the access of the cold stage,
cases are sometimes seen in which a sponta-
neous purging, preceded by nausea and vom-
iting, comes on. It is not always copious at
first, but liquid and fetid, white or green, in-
dicating either a suspension or vitiation of
70 ENDEMIC AUTUMNAL FEVER.
the hepatic secretion. This terminates the
paroxysm, sometimes allowing an inconsid-
erable febrile movement, without a sweat.
The system becomes tranquillized ; the func-
tions are partially restored, and the patient
can wath difficulty be persuaded to submit
to measures calculated to guard against or to
moderate a recurrence of the fit.
XLII.
At the end, however, of a certain period,
depending upon the unexplained and inex-
plicable tendency to a quotidian, tertian, or
double tertian type, most frequently the last
in bad cases, the symptoms return with a
violence which threatens the extinction of
the vital powers. The chill is long and vio-
lent; the nausea most distressing; the op-
pression intolerable and attended with inces-
sant jactitation; and when the alvine dis-
charges commence (which they sometimes
do to the total prevention of the stage of re-
action), copious evacuations of incoaggula-
ble blood at once destroy life, or reduce the
sufferer to the borders of the grave. The
ENDEMIC AUTUMNAL FEVER. 71
third paroxysm surely ends the sufferings
with the life of the patient, unless arrested
by the most prompt and decisive treatment.
XLIII.
Here a question arises, whence proceeds
this sanguineous evacuation ? It cannot be
from the liver or spleen, as some suppose, as
a fatal disorganization must precede such
discharge : and that such disorganization
does not take place is evident from the fact
that these cases are not only not always fa-
tal, but yield readily to remedies if timely
and judiciously used.
While in this situation, the cutaneous sur-
face is relaxed, moist, and clammy, and the
laws of sympathy require that there should
be a corresponding relaxation of the internal
surfaces which are more immediately in-
volved in the diseased action.
It is, then, from the patulous orifices of the
capillaries which open into the cavity of the
intestinal canal, that this discharge proceeds.
These minute vessels, in a state of health,
give passage only to a thin halitus, but now
72 ENDEMIC AUTUMNAL FEVER.
are so much relaxed as to afford an exit to
red blood.
XLIV.
The immediate consequence of this pro-
fuse evacuation of the vital fluid is great 1
prostration. Muscular power is gone — and
the brain, losing its usual tension in conse-
quence of the sudden and great diminution
of the circulating fluid, ceases to exhibit its
usual phenomena. The mind wanders ; the
eyes are nearly closed ; the ears almost in-
sensible to sound ; the skin loses its sensibil-
ity, and the lamp of life is only preserved
from extinction by the most powerful stimu-
lants.
I
copter IV.
OF INTERMITTENT FEVER.
What is the cause of the periodical paroxysm. — Cullen's diurnal
revolution. — Balfour's lunar influence rendered probable by
facts.
XLV.
The researches of medical men have not
revealed to us the cause of the periodical
return of the paroxysm of intermittent fever.
We must be satisfied with knowing the fact.
It is probably one of those inscrutable ar-
cana which neither time nor science will
ever disclose. The difficulties by which the
subject seems to be invested have not, how-
ever, prevented some inquiring minds from
attempting a solution. '^ In every fever,"
says Dr. Cullen, '' in which we can dis-
tinctly observe any number of separate par-
oxysms, we constantly find that each parox-
ysm is finished in less than twenty-four
74 ENDEMIC AUTUMNAL FEVER.
hours : but as I cannot perceive any thing
in the cause of fever determining to this, I
must presume it to depend upon some gene-
ral law of the animal economy. Such a
law seems to be that which subjects the
economy, in many respects, to a diurnal rev-
olution. Whether this depends upon the
original conformation of the body, or upon
certain powers constantly applied to it and
inducing a habit, I cannot possibly deter-
mine ; but the returns of sleep and watching,
of appetites and excretions, and the changes
which regularly occur in the state of the
pulse, show sufficiently that in the human
body a diurnal revolution takes place.
"It is this diurnal revolution w^hich I sup-
pose determines the duration of the parox-
ysms of fevers : and the constant and uni-
versal limitation of these paroxysms, while
no other cause of it can be assigned, renders
it sufficiently probable that their duration
depends upon and is determined by the revo-
lution mentioned. And that these parox-
ysms are connected with that diurnal revolu-
tion, appears further from this — that though
ENDEMIC AUTUMNAL FEVER. 75
the intervals of paroxysms are different in dif-
ferent cases, yet the times of the accessions
of paroxysms are generally fixed to one time
of the day ; so that quotidians come on in
the morning, tertians at noon, and quartans
in the afternoon."*
XLVI.
This "diurnal revolution, depending on
some general law of the animal economy,"
probably gave to Dr. Balfour the hint which
led him to a fuller investigation of the sub-
ject. He had observed, while pursuing the
practice of his profession in India, a remark-
able coincidence between the accessions and
relapses of fever and the (as he calls them)
" novilunar and plenilunar periods." In a
treatise prepared for that express object, he
has accumulated a mass of testimony on this
subject, which can only be rebutted by at
least an equal weight of evidence on the
other side.
Without any knowledge of Balfour's
opinion, and without any suspicion of lunar
* Cullen's First Lines, vol. i. 55, .56.
76 ENDEMIC AUTUMNAL FEVER.
agency, I had for many years observed and
frequently mentioned the circumstance to
my professional brethren, Doctors Browne
and Fisher, of Kent county, that both in our
w^inter and autumnal diseases there would
occur a number of new cases within the
space of a few days, and afterwards very
few for about two weeks. After reading
Balfour's work I kept, in 1839, a register
of all the cases which occurred in my prac-
tice ; and an examination of that register
affords abundant proof that five-sixths of
them com^menced icithin three days before or
after the new and full moons.
Without acknowledging my full convic-
tion of the truth of Dr. Balfour's theory, I
confess that there is sufficient reason to sus-
pect that the coincidences which he and up-
wards of fifty other practitioners concur in
stating, could not be altogether fortuitous.
I shall only add on this point that the
same respectable authority ascribes the pe-
riodical recurrence of the paroxysms to sol-
lunar influence, and delares that they return
with nearly the same uniformity as the tides.
ENDEMIC AUTUMNAL FEVER. 77
The curious inquirer may consult, for more
ample information on the subject, the works
of LiND, Mead, Mosely, Jackson, Balfour,
and the authorities there cited.
If the foregoing statements be true, then
lunar agency must be introduced into the
number of exciting causes of Fever.
XLvn.
The symptoms enumerated in xxviii. xxx.
xxxii. et sequent, comprise the ordinary mor-
bid developments of a paroxysm of intermit-
tent fever. As in all other diseases, so in
fever, there are mild and severe cases, dif-
fering not in nature, but in intensity. Every
physician has seen cases in which there ex-
ists no evident determination to any particu-
lar organ. There is no pain in the head, no
suffusion of the vessels of the face, no tender-
ness in the epigastrium or the hypochondria,
no tumidity of the abdomen, no spinal or ar-
thritic disturbance. Such cases have but
little claim to professional attention.
Cljapter V.
REMITTENT FEVER.
Intermittents and remittents from the same remote cause. — Muta-
tion of type. — Cold stag;e. — Hot stage. — Remission. — Renewal
of the paroxysm. — Morbid developments. — Important rule. —
Milder forms not to be neglected. — Distinction by names, un-
founded and useless. — Signs of Cephalitis — of Gastritis, hepati-
^ tis, enteritis, &cc. — Different from ideopathic gastritis, uteritis,&c.
XLVIII.
Why the same remote cause should, in one
individual, predispose to intermittent, and,
in another, to remittent fever, wlW most pro-
bably remain to the end of time an unre-
vealed arcanum. That such is the fact
there is no room to doubt.
This opinion receives sanction from the
circumstance of the simultaneous prevalence
of these forms of endemic fever. The muta-
tion of type also, so often noticed by authors
and so frequently observed in every-day prac-
tice, is confirmatory of it. This change of
* #
ENDEMIC AUTUMNAL FEVER. 79
form is sometimes effected by remedial agents,
sometimes where none have been employed.
A remittent has been changed into an inter-
mittent by decisive depletion ; and intermit-
tents have still more frequently become re-
mittent by the premature and injudicious use
of stimulants and tonics.
Receiving it then, as an established truth,
that malaria does certainly produce our en-
demic fever of whatever form or grade, I
proceed to offer a brief history of remittent
fever.
XLIX.
As in intermittent, so in remittent fever,
the attention of the patient is first awakened
by a chill of greater or less violence and du-
ration. It is, however, seldom so severe as
in intermittents.
After an uncertain lapse of time the stage
of excitement commences, and its progress
is always marked by a morbidly exalted sen-
sibility. A loud noise is always painful, and
has frequently produced convulsions in chil-
dren. A disproportionate heat is perceived
in the head and abdomen. Pain in the head
(-.■
80 ENDEMIC AUTUMNAL FEVER.
and in the back, about the region of the lum-
bar vertebrae, is among the most distressing
of the symptoms.
This determination to the head, remarka-
bly urgent in those subjects who, previous to
the attack, had been engaged in business re-
quiring inordinate exertion of the mental
powders, presents to the physician all the
varied grades of mental disturbance from a
slight aberration of reason, to furious deli-
rium or profound coma. In some cases, the
subject of the fever, instead of exhibiting a
" diminution of the povrer to reason and to
judge,"* as is most commonly seen, displays
unusual intellectual vigor. New powers
seem to be created. I have sometimes been
astonished at the eloquence and the correct-
ness of the reasoning faculty in individuals
who w^ere never before suspected of possess-
ing either.
L.
The pulse is quick, frequent and full,
sometimes tense or corded; the skin dry and
* Smith on Fever.
ENDEMIC AUTUMNAL FEVER. 81
husky ; the tongue but little changed at first,
but soon becomes white, and exhibits through
this white coat, small red papillae ; the urine
scanty and high colored, like brandy or ley,
and w^hen dropped on the linen, stains it of a
yellow tint ; the thirst is insatiable ; a tough,
salivary secretion forms in the mouth and
sometimes a degree of nausea is felt, though
not so frequently as in intermittents.
In a few hours the skin softens a little,
not often w^ith a free perspiration ; the heat
becomes less ; the pulse softer and less fre-
quent ; the pain in the head, back and ex-
tremities, less violent, and a short interval of
sleep, not always refreshing, succeeds.
LI.
In about twelve hours from the time of the
commencement of the assault, the skin be-
comes more dry and heated, without an evi-
dent previous chill ; the circulation becomes
more accelerated ; the pulse more full and
tense ; the pain in the head, never entirely
relieved, returns with increased strength ; the
lumbar pain more distressing ; delirium super-
82 ENDEMIC AUTUMNAL FEVER.
venes ; the epigastrium exhibits tenderness on
pressure in a majority of cases ; in children,
convulsions sometimes come on; in adults,
seldom ; the bowels are constipated, and the
tongue more loaded with a white or yel-
lowish coat, yet moist at the edges, but
generally showing a dryish streak in the
middle.
In a few hours there will occur another
remission, after which the exacerbation re-
turns with increasing violence ; all the symp-
toms above enumerated being aggravated ;
the tongue, unless decisive measures have
been resorted to, now becomes more dry and
brownish ; the teeth look glossy, and, as the
disease advances, have more or less of a
brown sordes collected on them ; the deli-
rium is more constant; the remissions less
distinct; the sclerotic coat of the eyes be-
comes vascular; abdominal tenderness and
tumidity increase; inflammation, more or less
acute, has taken place in the brain or its
membranes, the liver and alimentary canal;
the pulse declines somewhat in force and
increases in frequency ; the heat is less ; the
ENDEMIC AUTUMNAL FEVER. 83
extremities become cooler and cooler ; coma,
with subsultus tendinum, appears, and the
sufferings of the unconscious patient will
soon be at an end — the period is uncertain —
from eight or nine to twenty days or more.
LII.
Such is the usual course of a severe case
of remittent fever, if not subjected to timely
and appropriate treatment : and it maybe
laid down as an unvarying rule, that when
the arterial excitement declines without a
corresponding declension or melioration of
the other symptoms, and without, at least, a
partial restoration of the functions, a fatal
issue is at hand.
In a majority of cases, under ordinary cir-
cumstances, the result would be different.
The exacerbations, after the seventh or ninth
day, decline in severity ; the pulse becomes
softer and slower ; the secretions are gradu-
ally restored ; the tongue throws off its white
or brown crust ; the skin becomes moist, and
a sweat, more or less profuse, brings on a
solution or crisis of the fever.
84 ENDEMIC AUTUMNAL FEVER.
LIII.
Some cases have been seen to terminate
favorably, without remedies, by a sponta-
neous diarrhoea. The arterial action never
rises high, the tongue continues moist and
but little changed in appearance, and regu-
lar remissions occur throughout; there is
little or no pain in the head or lumbar re-
gion, and no abdominal tenderness. Let no
physician, however, be induced by the ap-
parent mildness of the symptoms, to stand
by as an idle spectator. A fever may prove
ephemeral, or be mild throughout, but it also
may^ after a very mild commencement, as-
sume, in the second or third exacerbation,
symptoms of immedicable severity.
LIV.
Authors have attempted to distinguish va-
rious species of remittent fever, by the pro-
minent indications of their tendency to an
^' inflammatory or nervous diathesis," or " to
malignity." It appears to me that they have
signally failed in laying down the diagnostic
ENDEMIC AUTUMNAL FEVER. 85
signs by which they may, with absolute cer-
tainty, be known. Heat of surface, more
or less intense ; increased action in the pulse,
niore or less strong ; delirium, mild or furious ;
pain in the head, in a greater or less degree
of severity, are noted as symptoms in all the
species, and after all, it is acknowledged that
there is a certain something, a "je ne scais
quoi,'' seen in the countenance of the patient,
but unsusceptible of description^ by which the
various species may be distinguished.
It is well for the patient that the name of
the disease, in this day, gives • no particular
information with regard to the treatment to
be pursued ; and that to distinguish remit-
tent fever by different names, to each of
which is attached a long catalogue of unim-
portant symptoms, is unfounded in nature
and useless in practice.
LV.
It has been stated, in li., that in severe
cases not subjected to timely treatment, evi-
dent manifestations of visceral inflammation
soon appear.
86 ENDEMIC AUTUMNAL PEVEK.
A deep-seated pain in the orbits of the
eyes affords probably the first sign of com-
mencing cephalitis. The veins of the scle-
rotic coat of the eyes are not yet injected,
but soon will be : there is no delirium yet,
but it is approaching with rapid strides.
Pain in the head can now only be felt when
that part is agitated or the globe of the eye
rolled about or compressed ; but it soon will
be manifested w4th a violence which, in the
opinion of the patient, threatens the parietes
of the cranium. There is nothing more com-
mon than the complaint, " My head will
burst."
LVI.
When the stomach, the intestines, the
liver, or the spleen is inflamed, it may gene-
rally be sufficiently ascertained by pressure
on those parts. If the stomach be the prin-
cipal seat of the inflammation, the epigas-
trium will be found very tender, and much
pain w ill be produced by the slightest pres-
sure. In like manner, pain produced by
pressure on the right hypochondrium, about
the umbilicus, or the left hypochondrium.
ENDEMIC AUTUMNAL FEVER. 87
will point to the liver, the intestines, or to
the spleen as the affected organs.
It should be observed here that the visce-
ral inflammations accompanying, and, it is
believed, constituting in a great measure the
pathological character of our endemic fever,
are different from the primary, idiopathic in-
flammations of those organs. In the former,
the mucous or villous coat, in the latter, the
serous membranes, are the seat of the dis-
ease. There is also much difference in the
violence, the duration, and the comparative
danger of the two diseases, more especially
in the abdominal region.
LVII.
The young practitioner will sometimes
meet with cases of doubtful and anomalous
character, and his mind will be agitated with
doubts and fears with regard to the course
to be pursued. Under such circumstances I
have, in my earlier years, experienced inde-
scribable suffering. He alone whose *' con-
stitutional hardiness of nerve cannot feel.
88 ENDEMIC AUTUMNAL FEVER.
and therefore cannot fear," will be indiffer-
ent.
The best mode of obtaining relief from
these distressing anxieties is to examine
carefully and deliberately the pathology of
the case, draw on the resources of the sober
judgment, take your measures, and, in de-
pendence on Divine assistance, pursue them
with firmness, watching the effect of reme-
dies, and leave the event in the hands of Him
who alone can heal.
I have said and shall say nothing of criti-
cal days^ so carefully noted by some modern
and many ancient writers, believing with
Professor Potter, that "it is high time this
remnant of superstition should be exploded.
.... The termination of all fevers depends
upon the intensity of the causes, the inhe-
rent power to resist them, and the treatment
pursued. The energetic practice of modern
times sets at nought all the calculations of
judicial astrology, by taking the cure out of
nature's hands."
dljaptcr VI.
TREATMENT OF INTERMITTENT FEVER.
Fever can be cured. — Bloodletting vicarious to the critical sweat,
and in pneumonia to expectoration. — Vis medicatrix naturae. —
Treatment of the cold stage. — Erroneous view. — Usual course.
— Treatment of the cold stage. — Cold sweat or purging in the
chill very dangerous. — Measures to be adopted. — Perseverance
in them. — Bleeding in the chill. — A case. — Mackintosh's prac-
tice.— Treatment of the hot stage. — Cause of pain. — Important
precept. — Abdomen should always be explored. — Blood vessels
of the brain more liable to injury than others. — Davidge's opin-
ion, not tenable. — Stokes. — Effusion not always fatal, but always
dangerous. — Use of the ventricles of the brain. — Mode of feel-
ing the pulse. — Abdomen, tongue, &c., to be examined Blood-
letting, when necessary and when not. — When doubtful, how to
proceed. — After treatment. — Extent of bloodletting. — May be
carried too far. — Emetics when indicated, and when contra-indi-
cated.— Their action in relieving congestions. — Choice of ca-
thartics.— Vulgar and groundless prejudice against mercury. —
Calomel, safe, convenient, and efficacious. — Indispensable in
certain cases. — To be followed by other medicines. — Drastic
purges seldom proper. — Demulcent drinks. — Treatment of suc-
ceeding paroxysms. — Important caution. — Time to give cathar-
tics.— Local bleeding. — Preparations of bark. — Sulphate of qui-
nine.— How to give it. — The bark more effectual in preventing
relapses. — Epispastics, when to be applied, and where. — Diet. —
Indulgence in eating dangerous.
L. vm.
There ls high authority for the opinion that
90 ENDEMIC AUTUMNAL FEVER.
fever cannot he cured, One"^ eminent physi-
cian has pronounced this sentence without
hesitation or qualification ; and another,! of
deserved celebrity for his learning and pro-
fessional skill, saw " only one case in which
the fever seemed to be suspended or removed
without an evident crisis."
If this be true, how humiliating to profes-
sional pride ! If, however, to shorten a par-
oxysm of fever by active depletion, to place
the patient in a condition which will allow
the employment of tonics, and thereby pre-
vent the recurrence of a paroxysm, which,
without such measures, w^ould have inevita-
bly returned, be not to cure the fever, I con-
fess myself unable to understand the mean-
ing of the term.
LIX.
It will not be denied that certain actions
which may be properly called vicarious^ do
take place. Without referring to numerous
examples so well known to the profession,
it is asserted that the loss of blood from the
* Smith. t Jackson.
ENDEMIC AUTUMNAL FEVER. 91
arm, or a copious evacuation from the bow-
els, may be employed as vicarious to the
usual solution of the paroxysm of fever by a
sweat. This is not only possible and ra-
tional, but is sustained by facts which re-
cently came under my observation.^ Thus,
in pneumonia, every practitioner who visits
his patients in the first hours of the attack,
and who treats his cases with proper energy
and on correct principles, Will have the sat-
isfaction to meet with instances of perfect
recovery without a sweat and without ex-
pectoration.
In all deference, then, to such high au-
thority, it appears to me that there is suffi-
cient ground, furnished both by reason and
experience, for the opinion that fever can be
cured. If this were not true, physicians
should, in common honesty and candor, throw
away the lancet, and abandon a profession
which is only an imposition on the credulity
of mankind.
LX.
Time immemorial, authors have asserted
* See cases C. C. and M. E. W.
92 ENDEMIC AUTUMNAL FEVER.
the powers of nature to resist morbid causes,
and to throw off peccant humors — and thus
to heal disease by producing a crisis, or the
^ discharge or excretion of a nocivum aliquid
from the body.
That there is in the human body a cer-
tain power of resistance, is rendered at least
probable by the fact that so many individu-
als escape disease when all are exposed to
the influence of the remote cause. That
fever, or, more correctly speaking, arterial
excitement, is an effort of the vis medica-
trix, is much more questionable. If, indeed,
the stage of excitement be such effort, and
that effort be salutary, how inconsistent in
the advocates of that theory to employ meas-
ures calculated to reduce it ! The use of
the lancet, or even of cooling drinks, would
of course only tend to render the healing
effort less effectual.
LXI.
The fact that these miscalled efforts fre-
quently prove destructive instead of saluta-
ry, cannot have escaped observation. In
ENDEMIC AUTUMNAL FEVER. 93
the stage of excitement a fatal effusion in
the brain is more frequently seen than a
salutary epistaxis. And the physician who
would stand idle by his patient when his
brain was oppressed by intr av3iS'dtionj and
not unsheathe the lancet, but wait for the
operation of the vis medicatrix, would be as
justly chargeable with the death of that pa-
tient as the man who, discovering a house on
fire in time to extinguish the flames, and
failing to use a supply of water at hand,
would be guilty of being accessory to the
burning of that house. The notion that
" heat is friendly and ought to be encour-
aged," is now obsolete, except with the de-
luded followers (now almost extinct) of a
bold and ignorant empiric of modern days,
whose name is not worthy of being men-
tioned.
TREATMENT OF THE COLD STAGE.
LXII.
During the cold stage of intermittents,
little attention has been paid, heretofore, to
94 ENDEMIC AUTUMNAL FEVER.
treatment. It has not been considered by
some, as in itself a morbid condition of the
system, but merely as a precursor of febrile
excitement to which alone it was necessary
to call the attention of the physician.
Those who have been accustomed to take
this erroneous view of the chill, will see the
necessity of professional interference when
they consider well the morbid manifesta-
tions. The cold stage exhibits a true con-
gestive state. The circulating fluid is driven
from the surface (by, if you please, " a spasm
of the extreme vessels,^^) and impacted in the
large interior veins, especially the venae por-
tarum, and produces that livid or pallid and
shrunk appearance of the features, and that
anhelation and frequent repetition of deep
inspirations, by which the patient hopes to
relieve the laboring heart.
LXIII.
The usual routine of treatment consists in
laying on additional bed clothes, in admin-
istering hot drinks, as infusions of balm, mint
or peppermint, and in obstinate cases in
ENDEMIC AUTUMNAL FEVER. 95
giving laudanum, brandy and water, and
applying hot bricks or bottles of hot water
to the back and extremities, sinapisms to
the epigastrium, ankles, wrists, &c. &c.
One of the most troublesome and distress-
ing symptoms which occur during the chill,
is vomiting. This extends through the cold,
and into tiie hot stage sometimes, and will
require different treatment according to the
accompanying indications. An opium pill,
or a dose of laudanum, while the stomach
is very irritable, and the head unaffected, to
be repeated every half hour or hour, pro re
nata, will in most cases relieve the nausea
and vomiting in a short time. When these
fail, a sinapism or other calefacient applica-
tion on the epigastrium will generally suc-
ceed. But after the hot stage commences,
opium is seldom admissible. In such cases,
small quantities of cold water, frequently
swallowed, a lump of ice, broken up and
taken a little at a time, — a soda powder, or
an effervescing draught, made by mixing 9i
of potass, carbonat. dissolved in a spoonful
or two of water, with § ss of the fresh juice
96 ENDEMIC AUTUMNAL FEVER.
of lemons — to be taken while in a state of
effervescence. These, or such of them as
seem to give most relief, may be repeated
frequently, until the vomiting shall cease.
LXIV.
The powders of nature are generally, though
unassisted, quite equal to the task of reliev-
ing the congestion of the portal viscera, and
thus diffusing warmth over the surface, by
forcing the blood into the superficial vessels.
There is reason to doubt whether hot drinks
be calculated to hasten that event. The
patient complains of great internal heat
and is tormented with an urgent desire for
cold drinks. In such instances it will gen-
erally be safe to gratify him : and the phy-
sician will frequently witness, after their
use, a glow on the surface and a degree of
moisture on the skin, which puts an end to
the cold, and moderates the succeeding stage
of excitement.
Dr. Rush, the distinguished professor of
the Practice of Medicine in the University
of Pennsylvania, when speaking, in his lee-
ENDEMIC AUTUMNAL FEVER. 97
tures, of the vis medicatrix naturae, com-
pared it to " a finger-board on a public road,
pointing out to the traveller the icay^ and
indicating the distance, but not going one
step farther."
The intense thirst in the cold stage of
fever, may be considered as the linger of
nature pointing to a remedy. Indulge the
desire of the patient for cold water, and the
period of the chill will generally be short-
ened. Cold water taken into the stomach
will remove the congestion of the large veins
near it; it increases the heat on the surface,
by lowering the internal temperature, and
thus equalizing it, and often proves an ef-
fectual, as it is a convenient, means of pro-
ducing sweat.*
LXV.
Every practitioner will meet with cases
in every year when the most imminent dan-
ger will arise from profuse cold sweats, or
from excessive purging. These symptoms
* Cullen's First Lines, Vol. L p. 43. Ed. 1784.
9
98 ENDEMIC AUTUMNAL FEVER.
are especially dangerous if they occur dur-
ing the chill. The danger is so immediate
that life will soon be destroyed, unless the
sweating and purging can be arrested, and
warmth restored. To effect so desirable an
object, diffusible stimulants, as brandy, Ja-
maica spirit, &c., should be freely used ;
mint slings as it is called, made by bruising
mint leaves in a tumbler and adding brandy,
sugar and water; the application of mus-
tard plasters to the epigastrium, abdomen
and extremities; dry frictions to the back
and extremities; wrapping the legs in a flan-
nel roller wetted with hot spirit; terebinth,
liquid or solid carbonate of ammonia, with
small additions of opium or laudanum, should
be perseveringly employed. I say small
doses of ophim, as nothing so soon or so ir-
retrievably exhausts excitability as large
doses of opium.
In this critical and most dangerous situ-
ation of the patient, the physician should not
leave the bed-side for a moment. If the ex-
citability be not exhausted, perseverance
will restore warmth and reaction. Then
ENDEMIC AUTUMNAL FEVER. 99
the medical attendant should carefully watch
the progress of it, and be cautious not to
proceed too far with the stimulating plan.
If it be continued too long, a new and pow-
erful enemy, inflammation of the stomacli
and duodenum, may present difficulties which,
in the then low condition of the patient, will
not be easily overcome. The total exhaus-
tion of excitability may be known by the
cessation of the purging, if it had previously
existed; the absence of nausea and of the ra-
dial pulse; by a profuse, clammy sweat, and
by the stomach's receiving any quantity of
diffusible stimulants without ejecting them.
It may be considered as a favorable sign, if
the stomach reject drinks while the patient
is in this state of prostration.
LXVI.
The use of the lancet in the chill has been
long known, but has been more particularly
brought up to the attention of the profession
by Dr. Mackintosh* of Edinburg. Numer-
• Vide Dr. Mackintosh's Practice, Vol. I. Art. Intermit. Fever.
is
100 ENDEMICT At'TUMNAL FEVER.
LIBRARY
^, ous cases given b/ this gentleman attest the
i5^success of the practice in his hands.
in one case only have I opened a vein in
the chill, though many cases do occur in
w^hich it may be done w^ith perfect safety
and advantage. In this case I was induced
to draw blood by the opinion which I held
of its congestive nature, and by remember-
ing the fact that I had many times bled,
with great relief, in catarrhal affections^
where, though there evidently existed arte-
rial excitement, the patients constantly com-
plained of chilliness.
In the month of September, 1839, I was
called to Mrs. F., about 38 years old, who
had been for some years the subject of an-
nual attacks of bilious intermittent. I found
her shivering with cold, while to me she felt
warm, excepting the nose and hands. She
complained of much pain in the head. When
the arm was bared for the purpose of tying
on the ligature, it immediately assumed the
appearance of the cutis anserina, or goose-
skin. A vein was opened, and ten ounces of
blood were drawn. The chill soon disap-
ENDEMIC AUTUMNAL FEVER. 101
peared, the pain in the head ceased, her
breathing, before oppressed, became natural,
and the succeeding hot stage was moderate,
and of short duration. A cathartic was
given in the intermission. The paroxysm
was renewed at the tertian period. The
chill was characterised by great pra^cordial
oppression, by nausea and vomiting, and soon
by a purging of thin, serous stools. In this
critical state I saw her and gave opiates,
brandy and water, and applied mustard to
the stomach and extremities. By these
measures, reaction was soon established and
went on with no unfavorable symptoms. In
the next intermission she took sulphate of
quinine, was blistered on the arms and head^
an hour before the expected return of the
fit, a bolus of camphor and opium. No re-
turn occurred, and she recovered soon on the
use of tonics.
This case was evidently shortened by the
mode of treatment. In bad cases we seldom
see less than four to five or six paroxysms.
The result was encouraging — but, as a gen-
eral rule, it is the safer plan to defer deple-
/
102 ENDEMIC AUTUxMNAL FEVER.
tion until the accession of the stage of ex-
citement.
LXVII.
It is difficult to mark by any certain signs
those cases which will allow the loss of
blood in the chill, and those which will not.
Where the symptoms of congestion are
clearly marked, and especially where a livid
face and pain in the head show the brain to
be the principal seat, or that part where
most danger is to be apprehended, then blood
taken from the arm cautiously, observing the
effect and closing the orifice, when relief is
obtained, will produce a speedy solution of
the paroxysm. This relief will consist in
the speedy disappearance of the rigors, the
breathing will become freer, and less hurried,
the pulse fuller, and warmth will be diffused
over the system.
LXVIII.
Dr. Mackintosh has before been quoted
as an advocate for this practice. Let him
speak for himself ''Bleeding," says he, "in
ENDEMIC AUTUMNAL FEVER. 103
the cold stage will, in a great majority of
instances, cut it short : in fact it will rarely
fail in stopping the existing paroxysm, and
in many cases, it has prevented" a return of
the disease, to which the patients had been
long subject, and by which they were nearly
worn out. It is difficult to determine what
quantity of blood it will be necessary to
draw in any given case. Sometimes it will
require twenty-four ounces. I have known
three ounces suffice — and in one case, one
ounce and a half produced the full effect.
The larger the orifice in the vein is made,
the greater is the chance of arresting the
disease, at a small expense of blood. But in
many cases the operation is attended with
considerable difficulty, from the convulsive
tremors which affect the whole body. I
was once successful in arresting the disease,
by bleeding in a cold stage, which had con-
tinued twenty-six hours; but I regard this
as an extreme case. The blood sometimes
only trickles down the arm, and as the
system is relieved, the stream becomes
larger and stronger, till at last it springs
104 ENDEMIC AUTUMNAL FEVER.
from the orifice, and frequently before six
ounces are taken, the patient will express
relief from the violent pain in the head and
loins, and it will soon be observed that he
breathes more freely If the patient
be properly managed with respect to bed-
clothes, neither hot nor sweating stage will
in general follow. Most of those who have
been treated by myself, or by my pupils
under my immediate inspection, have fallen
asleep immediately after the operation, but
some have even got up and dressed them-
selves."
TREATMENT OF THE HOT STAGE.
LXIX.
Early in the hot stage of intermittent^
the circulating mass is urged on, by the vis
a terofo, into the weakened vessels of the
predisposed organ ; their parietes are dis-
tended; pressure is thus made on the nerves
of the part, and pain, indicating the organ
on which the fever exerts its force, is thus
produced. This local affection is generally
ENDEMIC AUTUMNAL FEVER. 105
to be ascertained with sufficient accuracy,
where no pain is complained of, by request-
ing the patient to shake his head, or to roll
his eyes, or by applying the pressure of the
hand on the abdomen.
It is in this stage, frequently not until the
second or third paroxysm, that the country
practitioner first visits his patient. A care-
ful examination will reveal the pathological
aspect of the case. And here let me incul-
cate a most important practical precept : —
The abdomen should always he explored^ not
even excepting those cases where the head,
breastj or extremities^ are clearly pointed out
as the principal seats of the morbid affection.
If pressure with the open hand afford no
clear information, pointed j^^^f^ssure ivith the
fingers will seldom fail to detect some vis-
ceral lesion.
LXX.
In cases where cerebral determination is
the prominent symptom, danger is always
to be apprehended. The pain, as before
noticed, is produced by the enlargement
and consequent pressure of the blood-ves-
106 ENDEMIC AUTUMNAL FEVER.
sels on the brain. Admitting, as a fact,
what is at least doubtful, that the coats of
the blood-vessels distributed through the
brain are of equal thickness and strength
with those in other parts, it is certainly true
that the soft medullary structure in which
they are embedded, does not afford an equal
degree of support to their parietes. Thence
may justly be deduced the inference that,
caeteris paribus, the blood-vessels of the brain
are more susceptible of injury from arterial
excitement than others.
LXXI.
I am aware of the opinion of the late Pro-
fessor Davidge, who ranked as second to no
physiologist of his day, that the boney case
which envelops the brain, admits of no dila-
tation, and that one drop of blood cannot be
introduced into that organ without driving
another out; and I readily admit that when
full^ it can only contain a certain quantity of
blood. But who will assert that the vessels
always contain that exact quantity? Who
will contend that the individual who ab-
ENDEMIC AUTUMNAL FEVER. 107
stains altogether from food for some hours or
a whole day, or for many days, as the sick
generally do, has the same quantity of blood
in the sanguiferous vessels that he had be-
fore his abstinence commenced ? And is it
not, therefore, fair to conclude that, when
the vessels of the brain are relaxed, a full
meal, or increased arterial action may pro-
duce a more than natural plethora in that
viscus? It is demanding too much to re-
quire us to believe that the vessels are al-
ways so full as not to be capable of receiv-
ing another drop; and it remains to be proved
that the loss of equilibrium in the contents
of the arteries and veins of the brain is, ac-
cording to Abercrombie, the cause of all the
phenomena of cerebral disease.
LXXII.
For the most part the cerebral affection
consists merely in increased vascularity-
There is either an unusual quantity of blood
in its vessels* or more than ordinary action
* Dr. Stokes, of the Meath Hospital, one of tlie ablest physi-
cians now living, contends, in his lecture on paralysis, that the brain
108 ENDEMIC AUTUMNAL FEVER.
in the arteries of the part. But in some
cases a true phrenitis exists, terminating,
when fatal, by an effusion of lymph, between,
or on its membranes, or of serum or blood
into the v^entricles.
This effusion, if not in such quantity as to
derange the action of the brain by pressure,
is not always necessarily fatal. Blood, we
have the undoubted testimony of Dr. Stokes,
has been effused and absorbed or converted
into organised matter; and I have seen cases
is a compressible organ. " Here is a specimen," says he, " of apo-
plectic effusion. See how extensively the substance of the brain
has been torn. The cavity formed in this way, is, you will per-
ceive, filled up with a large clot. Now there is one consideration
which strikes us at once in looking at an effusion of this kind into
the substance of the brain, whatever may be its situation or extent,
and this is, that the brain must be a very compressible organ. Here
we see the brain torn, a cavity of large size formed, and this com-
pletely filled with blood. Now it is obvious that the rest of the
brain must give way in order to give room for the formation of this
cavity. If then, it be true, that the brain is compressible so far as
to admit of the formation of a large cavity, it necessarily follows,
that, contrary to the opinion of Drs. Abercrombie and Clutter-
buck, the quantity of blood in the brain may vary and be greater at
one time than another. These authors think that the quantity of
blood circulating in the brain never varies ; but here you will per-
ceive we have a remarkable cavity and it is plain that the rest of
the brain must have yielded before it could be formed — and it fol-
lows as a natural inference that the brain must be compressible,
ENDEMIC AUTUMNAL FEVER. 109
in which dilatation of the pupil, strabismus
and incontractility of the iris afforded ground
for believing the existence of effused fluid,
and which, nevertheless, had a favorable
issue.
LXXIII.
This fact furnishes additional ground for
the conclusion that the ventricles of the brain,
like all other known cavities of the body,
are supplied with lymphatics. The effusion
may be in small quantity — the exhalents
and that, consequently, the quantity of blood contained, may vary
at different times.
" It may be argued against this that the illustrative proof in this
case is derived from a pathological condition, and that under such
circumstances, the brain has room for the formation of a cavity by
the emptying of some of its vessels. Here, it is urged, is a cavity,
but the emptying of the vessels of the brain compensates for it.
Thus, room is found, and there is no increase in the quantity of
blood circulating in the brain. This, however, I look upon as a
mere petitio principii ; nor have we any reason to think that in a
case of apoplectic effusion, there is any corresponding emptying of
the vessels ; for dissection almost always shows a surcharged state
of all the vessels. The result, then, in my opinion is, that the brain
is compressible and may admit a larger quantity of blood at one
time than it does at another. On this subject I advise you to con-
sult Dr. Mackintosh's work on the practice of physic, and also
the review of Dr. Clutterbuck's essay on Apoplexy in the Lon-
don Cyclopoedia of Practical Medicine as given in the Dublin Medi-
cal Journal, Vol. II."
10
110 ENDEMIC AUTUMNAL FEVER.
may^ in consequence of the reduction of gen-
eral vascular action, cease to pour out their
fluid, and the absorbents may take it up.
All this may happen. An effusion, however,
into the ventricles of the brain, affords little
hope of relief; and when its characteristic
signs are present, the physician will seldom
be deceived in anticipating a fatal issue.
The ventricles of the brain serve an im-
portant purpose in the animal economy, viz.,
to obviate the effects of pressure on that or-
gan. Were there no cavities, fatal pressure
would follow every instance of turgescence
in its vascular apparatus.
LXXIV.
When the physician enters the bed-cham-
ber of his patient, a few minutes should
always be allowed to pass before he applies
his fingers to the radial artery. I say fin-
gers^ because there is decided advantage in
feeling the pulse with all of them. A much
more accurate judgment can be formed of its
degree of fullness or tension than when one
only is used. If equal pressure be made,
ENDEMIC AUTUMNAL FEVER. Ill
and the pulse be soft, it will be felt only by
the linger nearest to the superior portion of
the artery ; or if felt by those nearer the
hand of the patient, it will be very indis-
tinct. If the pulse be tense or corded, the
throb will be plainly felt by all the fingers,
and it will be found that much pressure is
necessary to destroy the pulsation.
The propriety of waiting a few minutes
before examining the pulse is obvious. The
presence or sudden entrance of any person
not of the family, accelerates the circula-
tion, communicates to it an unwonted sharp-
ness, and thus may mislead the most careful.
The pulse should be thoroughly examined
at the radial artery, and, when there is cer-
ebral determination, the carotids also; and
the patient or nurses should be questioned
with regard to the state of the secretions
and excretions. The abdomen should be
then explored — the tongue examined, and
the state of the stomach ascertained — whe-
ther there be an acid or bilious taste in the
mouth — if vomiting, the nature of the mat-
ter thrown up : if the vomiting occur from
112 ENDEMIC AUTUMNAL FEVER.
taking drinks, ascertain what time inter-
vened between swallowing the fluid and its
ejection — bearing it in mind that the instan-
taneous ejection of drinks indicates either
inflammation or morbidly increased sensibil-
ity of the mucous membrane of the stomach.
LXXV.
If there be found a high grade of arterial
action, the first step is to reduce it by taking
blood from the arm. If the skin be hot, the
pulse quick and full or hard, with pain in
the head or loins, more especially if there be
abdominal tenderness, there is no room to
doubt with regard to the absolute necessity
of the measure. And here let it be ob-
served, that we may not expect so high a de-
gree of arterial excitement in cases of pri-
mary fever as in the phlegmasiee.*
But when the pulse is soft and easily com-
pressed, and not much increased in quick-
ness,t heat of surface not great, no pain, or
* Smith on Fever.
t There is a real distinction between quickness and frequency.
Quickness means the celerity with which each pulsation is made ;
frequency, the number of pulsations in a given time.
ENDEMIC AUTUMNAL FEVER. 113
very slight, in head or back, no epigastric or
abdominal tenderness, the treatment during
that paroxysm may be safely trusted to saline
neutrals, effervescing draughts, as soda pow-
ders, &c., cold water, light bed-clothes, &c.
(fee. The patient, burning with thirst and
ardently desiring cold drinks, should not be
restricted in the use of cold water, or even
iced water in moderate quantities, when
agreeable to the stomach, — with this cau-
tion, that its use is inadmissible during the
exhibition of antimonials. Large draughts
of cold water are seldom to be used without
some care. The sudden and great reduc-
tion of heat from the stomach might do irre-
parable mischief
LXXVI.
The symptoms are sometimes rather of a
dubious character, and the physician will
hesitate about the course to be pursued.
The pulse may not be decidedly strong — the
pain indistinct or obtuse — increase of tem-
perature not great. Under such circum-
stances, doubts have arisen with regard to
10*
114 ENDEMIC AUTUMNAL FEVER.
the expediency of drawing blood, while the
practitioner may fear the consequences of
omitting it.
A practised eye will observe the ^' tout
ensemble" of the condition of the patient.
A certain plumpness and tension of the skin,
a lively glance of the eye, the vigor and ce-
lerity of muscular motion, will afford an in-
dication almost as clear as arterial excite-
ment. Where there is room to doubt, less
injury will probably be sustained from the
cautious use of the lancet than from its omis-
sion. A vein may be opened, and if the
pulse immediately give way, or syncope come
on, the orifice may be closed before any in-
jury be sustained.
LXXVII.
After the decisive use of the lancet, little
will be required during the remaining part
of that paroxysm but the treatment men-
tioned in the latter clause of Ixxv., unless,
after the bleeding, there should occur de-
cided reaction. In such event the orifice
ENDEMIC AUTUMNAL FEVER. 115
should be reopened and blood allowed again
to flow.
The extent to which depletory measures
should be carried is not to be determined by
ounces or pounds. It would be well if the
physician would never look at the vessel into
which the blood flows. With his fingers on
the pulse and his eye on the countenance of
the patient, he will clearly see when the
orifice should be closed. This should never
be done while the strength of the pulse is
undiminished, the face flushed, and the pain
acute. In severe cases there is no safety for
the patient until the pain in the head be re-
lieved, or so far mitigated as to encourage
the hope that it soon will be. The first no-
tice that an impression has been made ou
the system by the bleeding, will be given by
the increased frequency and diminished force
of the pulse.
LXXVIII.
By this mode of procedure, the patient
will generally be placed in a state of safety,
so far as the reduction of arterial excitement
116 ENDEMIC AUTUMNAL FEVER.
can make him safe. The succeeding hot
stage will probably be milder; but should
the same symptoms recur, the same rule
nmst be observed in the treatment of the
second paroxysm, the third, &c. &c. &c.
In the treatment of fever, however, let it
ever be borne in mind that, where there is
evident internal inflammation, the patient
inay be so reduced and prostrated by bleed-
ing, that a trifling degree of unsubdued topi-
cal affection may prove fatal. Remedies do
not bring on healthy actions; but, by re-
ducing morbid excitement, allow nature
time to effect the necessary change. The
recuperative powers, then, should not be too
much impaired. Nature should be assisted^
not prostrated.
It has been before observed, that the first
effect of bleeding appreciable by the opera-
tor, is an increase of the frequency and a
diminution of the strength of the pulse.
While therefore the practitioner keeps stead-
ily in view his grand object — to subdue the
existing inflammation or inflammatory ac-
tion, let him beware of carrying depletory
ENDEMIC AUTUMNAL FEVER. 117
measures too far. When this frequency or
irritability of pulse continues, active evacu-
ations by bleeding or otherwise must be
abandoned, and nutricious aliment, blisters,
and even anodynes, be cautiously employed.
LXXIX.
As soon as the intermission shall super-
vene, or sooner, if the fever be moderate,
and seem not to tend to intermit, a cathar-
tic or an emetic should be administered.
If the pain in the head be entirely re-
lieved, if there be no epigastric tenderness,
and no inflammatory action in the arterial
system, emetics may always be given with
safety and advantage, and more especially in
those cases in which the stomach is loaded
with vitiated secretion. In an excellent
paper on the " Use and Abuse of Emetics,"
in the fifth volume of the Western Journal,*
Professor Drake, of Cincinnati, says: "As
they are unpleasant medicines, it would be
desirable to dispense with emetics altogether.
* Page 543.
118 ENDEMIC AUTUMNAL FEVER.
But this, I apprehend, cannot be done with-
out injury to the resources of the profession.
I am even inclined to believe that many
physicians have already gone too far in their
neglect of these ancient and powerful reme-
dies : and I propose to recall the attention
of the readers of this Journal to their value."
Under the head of " Precautions necessary in
the use of Emetics," the Doctor observes:
" A plethoric state of the blood-vessels, with
powerful action of the heart, contra-indicates
their use : and when this condition of the
general system is connected with inflamma-
tion of any of the important organs or tissues,
they may be extremely injurious. Thus, in
high grades of autumnal fever, and in acute
gastritis and arachnitis, they are decidedly
improper. The predisposing remedy in these
and other specimens of intense phlogistic
action, is copious blood-letting ; immediately
after which, if vomiting should be indicated,
it may be brought on with facility, safety
and good effect, especially if tartarized anti-
mony be selected and so administered, as to
excite protracted nausea."
ENDEMIC AUTUMNAL FEVER. 119
LXXX.
The stomach is intimately connected with
all parts of the body by the sympathies; and
it will be readily seen that a powerful ac-
tion of that organ will exert an extensive in-
fluence.
When a large quantity of bile is contained
in the liver, the pressure of the abdominal
muscles (during vomiting) expels it into the
duodenum, and thence into the stomach.
When the hepatic secretion is imperfectly
performed or vitiated, the same pressure, al-
ternating with relaxation, has a salutary in-
fluence in restoring it, — and the arterial ex-
citement is reduced by the determination to
the skin, which is one of the most salutary
consequences of the emetic effort.
It is in this way, viz., by determining to the
skin, that the emetic effort, even when full
vomiting is not produced, tends to restore
the lost balance of the circulation in those
cases where congestions exist in the viscera.
Whatever enlarges the diameter of the
extreme vessels, (or, if the reader please,
120 ENDEMIC AUTUMNAL FEVER.
*^ relieves the spasm of the capillaries," as
CuLLEN would say,) or promotes sweat,
breaks up congestions by unloading the large
interior veins.
Emetics are also contra-indicated by great
irritability of the stomach. If given in such
a state or during the chill, or so as to act
during the cold stage, the effect produced
on the intestinal canal might be rapidly fatal.
LXXXI.
With regard to the choice of cathartics,
it is not, as some erroneously suppose, a
matter of indifference, and to be left to the
caprice of the patient, but of infinite import-
ance.
It is believed, on good grounds, that mer-
cury exerts an influence on the liver which
reduces inordinate and increases defective
secretion.^ No other article in the materia
medica has so powerful an effect on the
secreting system. Saline aperients have
little effect beyond that of expelling the
* Dr. Ayre.
ENDEMIC AUTUMNAL FEVER. 121
contents, and that imperfectly, of the intes-
tinal tube; and it is in this way only that they
are useful in diseases in which the biliary
apparatus is involved. The contents of the
intestines may be evacuated — dozens of li-
quid stools may be produced, and we shall
have done no good until the pori biliarii are
emulged.
LXXXII.
The present age has witnessed a rare
spectacle — that of physicians who are wil-
ling to sacrifice correct principles to amhitAon
for popularity! This offering, made on the
altar of a vulgar and groundless prejudice,
would place the preparations of mercury
under the ban of professional interdict. It
makes the admission that the ignorant mul-
titude are better qualified to judge of the ef-
fects of medicines, than those who have spent
all their days in unceasing efforts to acquire
a knowledge of their nature and action on
the human body.
Should a physician presume to instruct an
attorney in the principles of law, a carpenter
in the use of the jack-plane, or a blacksmith
11
122 ENDEMIC AUTUMNAL FEVER.
how to employ the various implements of his
trarde, he would be justly chargeable with
officious interference in matters of which
he was ignorant. The old adage, " ne sutor
ultra crepidam," would be triumphantly
urged, and he w^ould be laughed at for his
presumption. Let him then, when the pre-
parations of mercury are assailed by the ig-
norant, throw back the proverb and advise
the ''shoemaker to stick to his last," the
blacksmith to his anvil, and the carpenter to
his jack-plane.
LXXXIII.
It is admitted that the injudicious or too
unguarded use of calomel has sometimes
produced a premature, unnecessary and pain-
ful salivation, and that constitutional injury
has thus been sustained. Quacks and nos-
trum venders, ^^et id genus omne^^^ with whom
the w^orld swarms, and will swarm while ig-
norance and credulity reign among men, have
availed themselves of this, and have secured
a transient popularity for their pills and pa-
naceas by averring (what, by the by, is very
ENDEMIC AUTUMNAL FEVER. 123
often untrue) that they contain no mercury y
but are purely vegetable.
As a cathartic, calomel is convenient, safe
and efficacious. Children may be induced
to take it when nothing else could be forced
upon them, or if forced, would be instantly
ejected by the stomach: and in adults, when
the stomach is nauseated, it would be borne,
when the sight of a larger dose would pro-
duce instant vomiting.
The use of calomel is safe. Attention to
the effect will admonish the medical attend-
ant to give a Seidlitz powder, some sulphate
of magnesia, castor oil or infusion of senna
to assist its operation and secure the sick
from salivation. Uncombined and unas-
sisted, calomel is seldom sufficient. The
evacuations are not numerous, but generally
large and fcecal, and the stomach is thus pre-
pared for those larger doses wiiich it is, for
the most part, necessary to add.
Calomel is efficacious. It is fully ascer-
tained by experience, that no other medicine,
as before observed, has so thorough an effect
on the secreting organs. If the hepatic se-
124 ENDEMIC AUTUMNAL FEVER.
cretion be redundant, calomel brings it down
to the healthy standard ; if vitiated, calomel
corrects it; if entirely obstructed, calomel
emulges the pori biliarii and re-establishes
the natural secretion. In certain combina-
tions, it is an excellent emmenagogue, a good
diuretic, and as a deobstruent and absorbent
unrivalled. In short, mercury, more than
any other article in the animal, vegetable
or mineral kingdom, deserves the name of
Panacea.
The vulgar notion that mercury enters
into the bones and is the cause of those pains
in the limbs, those ulcers, mail maris, (which
we sometimes observe to succeed lues,) and
of a thousand other evils, the consequences
of dissipated habits, and the evidences of a
broken down constitution, is not worthy of
serious consideration.
LXXXIV.
In selecting the cathartic to be employed,
the judicious practitioner will always ex-
amine carefully into the state of the secre-
tions, particularly that of the liver. A mer-
ENDEMIC AUTUMNAL FEVER. 125
curial purge is indispensable in all cases
where either an increase, vitiation or obstruc-
tion of hepatic action exist.
An increase of the biliary secretion may
be correctly inferred from its redundant dis-
charge sursum vel deorsum. A vitiation,
from the evacuation per anum, of green or
black stools, and an obstruction from a yel-
low tinge of the skin, from white or clay-
colored alvine discharges, or from the ab-
sence of bile in the matter thrown up, after
continued vomiting.
In whatever mode it be effected, it is a
fact long known to the profession that the
biliary secretion is in direct proportion to
the atmospheric temperature. The liver is
thrown into increased action by sympathy
with the cutaneous surface or the brain.
More especially is there a remarkable sym-
pathy between the latter organ and the
liver. ''^
LXXXV.
On the declension, then, of arterial excite-
* Johnson.
11*
126 ENDEMIC AUTUMNAL FEVER.
ment, the patient should take a dose of calo-
mel— and for an adult, ten to fifteen grains are
probably sufficient. When a prompt action
on the bowels is not desired, it is a good
mode to give, every two hours, a dose of three
or four grains, until an operation, or until
twelve to sixteen grains shall have been
given. In whatever mode it be used, it
should be followed up in a few^ hours, say
six or eight, unless a sufficient effect be pro-
duced, by an infusion of senna and manna,
a dose of castor oil, or sulphate of magnesia.
When the stomach is weak or irritable, a
dose of calcined magnesia, followed imme-
diately by a glass of lemonade, will be found
useful in aiding the operation of calomel.
A citrate of magnesia will be formed in the
stomach which will be found nearly as active
as the sulphate.
The use of acids after calomel has been
objected to, as they are supposed to produce
griping, and frequently severe and painful
operation. It is, probable, however, that in
the few^ hours intervening between the exhi-
bition of the calomel and the acid, the former
ENDEMIC AUTUMNAL FEVER. 127
will have passed the pylorus, and thus a
chemical union will be prevented *
LXXXVI.
The more drastic articles, as jalap, gam-
boge, colocynth, &c. &c., are seldom neces-
sary or proper — never, indeed, except in
those cases of intestinal torpor where the
milder articles will not succeed. Much
troublesome and dangerous intestinal irrita-
tion has been produced by Brandreth's pills
and other drastic purgatives. One thing
should be remembered by the physician —
that many large liquid stools may be procured
without benefit to his patient. Stools must
hefceculent to do much good.
During the operation, if griping be trou-
blesome, gruel, chicken water, barley or gum
w^ater, may be freely allowed, and wull be
found useful in allaying or preventing irrita-
* "When you are administering mercurials, 1 think you should
be cautious in the use of acids. Although medical men are of late
rather less cautious in giving acids during the use of mercurials,
r think the practice not entirely devoid of danger." Graves'
Clinical Lectures, p. 261.
128 ENDEMIC AUTUMNAL FEVER.
tion. These diluent drinks do not, as many
erroneously suppose, increase the purgative
effect of the medicine. They rather weaken
the medicine by dilution — and if taken freely
before the operation commences, might pre-
vent it altogether.
LXXXVII.
On the accession of the next paroxysm, if
the pulse still resist pressure, and the cere-
bral determination or abdominal tenderness
continue in a considerable degree, the lancet
should be again resorted to according to the
rule laid down for the treatment of the pre-
ceding hot stage. The exhibition of cooling
neutrals and drinks should be repeated ; and
when the intermission again succeeds, ca-
thartics or aperients should again be given,
and perse veringly used ichile the alvine dis-
charges continue dark and offensive^ if the
strength of the patient allow such treat-
ment.
In administering cathartics, from first to
last, great care should be taken that they
be so given that the operation be over before
ENDEMIC AUTUMNAL FEVER. 129
the accession of the next expected chill.
During a practice of thirty years, I have
had this always in vievs^, in consequence of
seeing the case of an elderly woman to
whom her husband gave a dose of jalap and
calomel just at the commencement of the
chill. "^ I was called, and arrived in time to
see her die in horrible agony. Two hours
did not intervene between the taking of the
purge and the death of the patient : and I
am fully persuaded that such will be the
result of similar practice, unless the mildest
aperients be used, and the constitution of the
patient be uncommonly vigorous.
It may, then, be laid down as a rule, from
which the prudent physician will never de-
part, that the operation of cathartics should
never interfere (in intermittents) with the
sweating stage of the preceding ^ or the cold
stage of the succeeding paroxysm. In other
words, never give a purging dose while the
patient is still in a sw^eat — and be careful to
* Many similar cases have come to my knowledge during my
practice, and always from taking purging doses without consulting
a physician.
130 ENDEMIC AUTUMNAL FEVER.
give it so that its operation may be com-
pleted before another chill comes on. The
sweat will reduce the patient fast enough
without the aid of a purge ; and, ivith it,
will probably soon place him beyond the
reach of all your skill.
Lxxxvm.
It will generally happen that bloodletting
will not be demanded by the urgency of the
case after the second paroxysm, though so
favorable a result is not always seen. In
many cases, the inflammatory action cannot
be so speedily subdued. The physician will
be guided by the state of the pulse and the
degree of abdominal or cerebral affection.
It will, however, generally happen that, in
the first two or three paroxysms, active de-
pletion will defend the patient from serious
organic lesion, though the fever be not alto-
gether subdued.
When it becomes doubtful whether bleed-
ing from the arm can be carried farther
without seriously prostrating the strength,
and when evident inflammation is believed
ENDEMIC AUTUMNAL FEVER. 131
to exist, in any of the viscera, recourse should
then be had to local bleeding by cups or
leeches,* the latter generally to be preferred.
A tender abdomen will seldom bear, with-
out a great increase of pain, the application
of cups.
LXXXIX.
Dr. Stokes, of the Meath Hospital, says
that it is an important fact that inflamma-
tions of the mucous membranes are not to
be subdued at once by the lancet, as inflam-
mations in the parenchyma or the serous
membranes of the organs. The effect of
drawing blood is not so soon seen, he says,
in inflammations of those parts where the
circulation is less active. The mucous mem-
branes are not so accessible as muscular
* Though cups and leeches are doubtless useful in many cases,
I do not coincide in the opinion which many distinguished mem-
bers of the profession entertain with regard to their superior effi-
cacy. In visceral inflammations, especially the abdominal, the
application of cups or leeches to the abdomen, does not draw blood
directly from the diseased organ. The vessels of the skin have a
much more remote connection with the vessels of the stomach, the
liver or intestines, than the veins of the arm. In fact there are few
cases where local bleeding, strictly speaking, can be practised.
Wardrop 071 Bloodlettings p. 18.
132 ENDEMIC AUTUMNAL FEVER.
parts. When, then, general bleeding can no
longer be employed, and disease still threa-
tens the mucous membranes, the applica-
tion of Jeeches should not be omitted.
For instructions with regard to the ap-
plication of cold water or ice to the head
during the paroxysm, see Treatment of Re-
mittent Fever.
xc.
When a free sweat shall have brought
about a perfect intermission, after the stom-
ach and bowels have been thoroughly evacu-
ated, then, and not before, according to my
experience, may decided benefit be derived
from the preparations of the Peruvian bark.
It cannot be surprising to physicians of
the present day that medical writers ac-
knowledge that Peruvian bark is possessed
of little efficacy in shortening the duration of
remittent fever ^ though it is matter of aston-
ishment that they should think it useful in
such cases hy supporting the tone and vigor
of the powers of life!'
*
* Dr. R. Jackson.
rj f ? LtJin^ 4J^ . .. , ^AU ^H^
ENDEMIC AUTUMNAL FEVER. 133
I Dr. Perrine has published a paper on the
use of quinine in autumnal fever, in the Phi-
ladelphia Medical and Physical Journal,^ in
which he speaks of that preparation as a
good diaphoretic, equal to James' powder,
and declares that it may and ought to be
used in all stages of the fever without any
regard to the state of the pulse or the skin,
in doses of ten grains.
I confess I have never tested the efficacv
mJ
of this practice, and cannot pronounce it
pernicious, nay, wrong, from experience. I
can say, however, that I have seldom used
it in imperfect intermissions without injury.
If quinine or the bark, even where there
was a perfect intermission, be continued
after the time for the recurrence of the chill
has passed, and during the time the stage
of excitement would have existed^ the conse-
quence will surely be an increase of heat
and of the force of the circulation. This
fact has been noticed by Fordyce and
others, but I have never seen the action
* Vol. XI. p. 250.
13
134 ENDEMIC AUTUMNAL FEVER.
thus induced rise so high as to endanger
the patient.
xci.
Dr. Mackintosh admonishes his reader to
''beware of any preparation of bark while
the patient has fever, or complains of op-
pression about the praecordia." This rule
may be considered as generally safe and
good; but there are some exceptions. In
cases of obstinate intermittents in w^hich
there is no satisfactory apyrexia — where the
arterial action is insufficient to justify the
use of the lancet, I have sometimes con-
cluded that the preparations of bark would
do less harm than the continued recurrence
of the paroxysms. By the exhibition of sul-
phate of quinine I have succeeded in arrest-
ing the chill, at the expense of some increase
of febrile action, w^hich was afterwards re-
duced by antimonials, aperients, and mercu-
rials.
xcii.
Soon after the sweat shall have reduced
the pulse to the natural standard, the exhi-
bition of the sulphate of quinine should be
ENDEMIC AUTUMNAL FEVER. 135
commenced. In common cases it will only
be necessary to give one or two grains every
two hours during the intermission, until about
six hours before the expected return of the
chill, when it should be given every hour,
and in double doses. I have never exceeded
five grains at a dose, though ten or more
have been given without injury. I have
found the following recipe :
R. Ctuinin. sulphat. g. xviij.
Gum. acac. 5 iss.
Ol. cinnam. gt. ij.
Sacch. alb. 3iij.
Aq. font. § vi.
ft. mixt.
or the quinine in form of pill, so effectual,
generally, as to take off my attention from
other preparations of the bark. One thing,
however, is deemed worthy of notice. After
the chill has been arrested, there is fre-
quently danger of relapse ; and since I have
adopted the practice of giving the bark or
its extract, in substance or infusion, after
convalescence begins, continuing its use for
136 ENDEMIC AUTUMNAL FEVER.
a few days or a week, three or four times a
day, with mild aperients occasionally, re-
lapses have been of rare occurrence.
The sulphate of quinine, as Dr. Perrine
observes, acts in a remarkable manner on
the skin. It is probably for this reason that
it is inferior in tonic power to the bark from
which it is extracted.*
XCIII.
I shall reserve the chief part of what I
have to say about blistering in our autumnal
fever, for the chapter on the treatment of
remittent fev^er. In this place it will only
be necessary to state that there are many
* Since the above was written, a paper of Dr. Monett, of Mis-
sissippi, has fallen into my hands. The climate in which Dr. M.
practised will probably account for the diiference of opinion. In
this latitude (39° — 40° N.) I have sometimes given quinine where
there existed some febrile excitement, but only in those cases
where danger was apprehended from the recurrence of the chill. —
I do not hesitate to say that in my hands, and in the hands of other
physicians in this vicinity, quinine has been very successful when
given in cases where there was a perfect intermission, and not when
given in the stage of excitement, as advised by Dr. Monett.
Whether the article be a tonic or a febrifuge — or, as Dr. Per-
rine thinks, a diaphoretic — or, according to Professor Drake, a
narcotic sedative, I will not decide.
ENDEMIC AUTUMNAL FEVER. 137
cases of intermittent fever in the treatment
of which the application of epispastics can-
not be omitted without danger.
In those cases in which there is much
vomiting, or in which the chill is long and
violent, the bli.stering plaster should be ap-
plied to the epigastrium six or eight hours
preceding the time for the chill. They
should not, however, be employed while in-
flammatory action continues — while it is
necessary to draw blood and administer ca-
thartics.
If the stomach be not particularly affect-
ed, the epispastics may be applied to the
extremities, observing the same rule about
the time of their application. As soon as
the plaster shall have been removed, which
should not be until the chill has passed, let an
emollient poultice of bread and milk, or
scalded cabbage leaves, be applied to the
blistered surface, renewing the application
two or three times in the twenty-four hours.
Under this treatment the blistered part
will generally heal in a few days. If not,
some mild ointment, as that made by tritu-
12*
138 ENDEMIC AUTUMNAL FEVER.
rating prepared chalk, with simple cerate or
lard, should be used.
Sometimes blisters ulcerate or become
gangrenous. In such cases, sometimes very
troublesome, various lotions and poultices, as
diluted tincture of myrrh and the bark poul-
tice, or sprinkling the surface w^ith pulver-
ized myrrh and charcoal, w^ili become neces-
sary.
xciv.
Another important aid to the quinine will
be found in the following pill :
R. Gum. Camphor, g. iv.
Gum. op. g. iss.
Elix. paregor. q. s. f. pil. ij.
one to be taken two and the other one hour
before the chill ; and in cases of prostration
allowing the use of Port or Madeira wine,
or brandy and water, according to the ur-
gency of the cases.
Cases will occur in which there will be
found no good intermission, and in which
the preparations of the bark cannot be given
without increasing the febrile action, and
ENDEMIC AUTUMNAL FEVER. 139
adding greatly to the danger. Such cases
will be found, complicated with gastric or
enteric irritation, or inflammation, or visce-
ral lesion. In such, mercurials and antimo-
nials in alternate doses, will be indispensa-
ble, together with diaphoretics, cooling or
cordial, according to the symptoms.
xcv.
Nothing has been said of the proper diet
to be used by the patient. In the early part
of the attack, when it is necessary to reduce
the sick by various means, the articles used
should not be such as contain much nourish-
ment, or such as will make much blood.
Toast-water, milk and water, one-third milk,
tea with a little grated cracker, and these in
small quantities, will be sufficient.
When the tonic plan shall be commenced,
tapioca, seasoned with loaf-vsugar, nutmeg,
and a little wine, chicken broth, &c., should
be given to support the strength and afford
important aid to the tonic medicines.
The medical attendant frequently encoun-
ters much vexation and trouble, arising from
140 ENDEMIC AUTUMNAL FEVER.
the ignorance of the sick and the prejudices
of nurses. In the first days of fever there
is always a more or less complete loss of
appetite. After a few days, however, the
patient sometimes, and the nurses always,
begin to think that nourishing food is neces-
sary to prevent the powers of life from fail-
ing. Neighbors are always kindly concerned
and set themselves to work " to cook up"
something nice to tempt the flagging appe-
tite. Preserves, rich puddings, custards,
jellies, partridges, squabs, &c. flow in from
all quarters, and the physician, who had
witnessed with triumph the gradual retreat
of the fever, is frequently perplexed by
seeing a complete renewal of the febrile
action with a greatly diminished power of
resistance on the part of the patient. Death
or indomitable obstructions not seldom suc-
ceed imprudence in diet. Dr. Beaumont has
ascertained that during febrile excitement,
when acidity of the fauces with thirst exists,
" no gastric juice is secreted^ even ichen ali-
mentary stimMlus is applied — that drinks do
not remain in the stomach ten minutes,
ENDEMIC AUTUMNAL FEVER. 141
being absorbed or otherwise disposed of;
and that food remains for forty-eight hours
undigested, unassimilated, and, of course,
aggravating the morbid action."
Or^pter VII.
TREATMENT OF KEMITTENT FEVEK.
Definition of Dr. Davidge, incomplete and incorrect. — Essential
fever rare. — Always some local affection. — Treatment of long-
continued vomiting in remittents. — The lancet, to vv^hat extent
to be used. — Cold applications to the head. — Caution. — Graves
*' on cold applications, and on tepid sponging and steeping." —
Case. — Emetics and cathartics. — Cooling neutrals. — ^Diaphoret-
ics.— Compound diaphoretics, as Dover's powder. — Yellow fever
and remittents identical, according to Sir John Pringle and Pro-
fessor Potter. — Fever of Galliopolis, Ohio. — Last resort. — Blis-
tering, when proper and when not. — Modus operandi. — Their
effects. — On what part to be applied. — Rubefacients, when use-
ful.— Mustard and turpentine. — Tonics. — Diet. — The fever of
one year not exactly like that of another year. — Synochus and
typhus essentially resemble each other. — Local lesion more to
be dreaded than debility.
XCVI.
vji^ " Febris, miasmata paludum orta, accession-
ibus pluribus, intermissione, saltem remis-
sione evidente interposita, cum exacerba-
tione notabili et plerumque cum horrore re-
deuntibus, constans: accessione quovis die
ENDEMIC AUTUMNAL FEVER. 143
unico tantum."^ In his Synopsis of Method-
ical Nosology, Dr. Cullen does not give a
separate and distinct character to remittent
fever, but makes mention of it only as a spe-
cies or variety of intermittent, and as assum-
ing the varied forms of tertian, quartan, quo-
tidian, &c. The synonymes introduced on
the authority of Sauvages, Vogel, Boer-
HAAVE, RiVERIUS, ClEGHORN, JuNCKER, ToRTI,
and a hundred other authors, answer no good
purpose, but on the contrary tend to pro-
duce confusion and dismay in the mind of
the young practitioner.
The definition of Professor Davidge is
evidently incomplete, and, indeed, incorrect.
It gives no place to a gentle perspiration on
the decline of the paroxysm or exacerba-
tion ; admits an intermission w^hich never
occurs, a chill with the returning exacerba-
tion seldom felt, and allows one accession
only in each day.
XCVII.
The remittent fever, as it prevails in this
• Davidge *s Nosology.
144 ENDEMIC AUTUMNAL FEVER.
peninsula, is, in fact, a continued fever ; but
in every day there are, generally in the
morning and evening, tivo remissions, the
morning remission more distinct ; and for
the first days more or less moisture on the
skin on the declension of the pyrexial exa-
cerbation.
Fever, uncomplicated with local affection,
or pure, essential fever, is of exceedingly
rare occurrence. Dr. Stokes declares that,
after many years' attendance in the fever-
vv^ards of Meath hospital, he has seen very
few cases of fever in its simple character.
It is this disposition to local disease, this
proclivity to topical lesion of function or
structure, which imparts to fever its danger-
ous character ; and although these affections
are secondary, it is to them that the atten-
tion of the physician should be especially
directed. " There is not a single acute local
disease," says Dr. Stokes, " which may not
occur during the progress of fever."
XCVIII.
With these remarks, I proceed to give
ENDEMIC AUTUMNAL FEVER. 145
some account of the treatment of remittent
fever.
In this form of the autumnal fever the pa-
tient is seldom seen by his physician in the
chill. When he is, the same mode of treat-
ment recommended in the cold stage of in-
termittentSj should be pursued. If the vomit-
ing continue long after the hot stage has
commenced, and the epigastrium show acute
tenderness on pressure, and drinks be in-
stantly ejected, there v^ill be ground for
apprehending that gastric irritation has been
exalted into inflammation. If so, much heat
of skin and a corded pulse will accompany
the symptoms. In such case, frequently
giving a small lump of ice will be highly
useful, but the lancet will be indispensable.
I have seen this act like a charm. Medical
authors have observed, and my experience
sanctions the observation, that long con-
tinued vomiting is very apt to jyrochice inflam-
mation where it did not previously exist.
xcix.
Pain in the head, one of the most common
13
146 ENDEMIC AUTUMNAL FEVER.
and most dangerous symptoms, during the
exacerbation, when attended with a high
degree of vascular action, calls loudly for
those measures which have a direct effect on
the circulation. There is only one class of
remedies to be relied on. The operation of
cathartics is too slow — sweating too uncer-
tain, and in many cases, insufficient. The
lancet must be resorted to — and to the ex-
tent of relieving, or at least mitigating, pain.
The reader is referred to the rules for the
treatment of intermittent fever in the hot
stage, (Ixviii. et sequent.) If any diversity
of practice be proper or necessary, it is that
the treatment of remittent fever should be
more decidedly active. The pathology of
this form of fever is better understood than
that of intermittents. There is evidently
more cerebral, gastric, hepatic and enteric
irritation or inflammation; and, as in cere-
bral affection, so in others, bleeding should
be expected to relieve or mitigate the symp-
toms which indicate its existence.
ENDEMIC AUTUMNAL FEVER. 147
C.
If the cerebral determination be great and
be not soon diverted by the use of the lancet,
the use of the cold dash^ or the application
of ice to the head should not long be delayed.
A bladder, or varnished silk bag, filled with
pounded ice and laid on the head, previously
shaved or having the hair cut closely with
scissors, or iced water poured on the head
from a height of some feet,*" is a measure of
great power and efficacy. It will reduce
the pulse in a short time to a mere thread
when the lancet has failed to produce the
necessarv reduction. Its use should then be
intermitted — renewed, if reaction take place
to any considerable degree, and thus con-
tinued until relief be permanently estab-
lished.
While on the subject of cold applications
to the head, it is proper to admonish the
young practitioner that the utmost caution
should be observed, lest injury, instead of
* Vide Smith on Fever.
148 ENDEMIC AUTUMNAL FEVER.
benefit, result from the measure. " I have
seldom met with any person," says Dr.
Graves, "who seemed to bear in mind the
true principle upon which cold is applied as
a means of repressing local heat. In cases
of determination of blood to the head oc-
curring in fever, the common practice is to
have the head shaved and cold lotions ap-
plied. Enter the room of a patient who is
using cold applications, and you will observe
the process conducted with great aj)parent
nicety. The head is accurately shaved and
carefully covered with folds of linen, wet
with a lotion to which spirit of rosemary or
some odoriferous tincture has communicated
an agreeable and refreshing smell : but,
when you come to examine the patient, you
will find the head smoking and the heat of
the scalp increased. The nurse applies the
lotion once every half hour, or perhaps not
so often : indeed she seldom repeats the ap-
plication until her notice is attracted by the
steam rising from the patient's head, or un-
til she herself, awaking from a comfortable
nap, and going to examine the head, finds the
ENDEMIC AUTUMNAL FEVER, 149
folds of linen as hot and dry as if they had
been hung before the fire Whether
applied to reduce local inflammation in any
part of the body, or to cool the scalp in de-
termination to the head, cold lotions, as or-
dinarilij employed^ do infinitely more harm
than good. The cold is applied at distant
intervals — its effect soon ceases, and reac-
tion constantly takes place, leaving the part
as hot or hotter than it was before If
you put your hand into snow for a few mo-
ments, and then take it out, it quickly re-
sumes its natural heat : and if you repeat
this at considerable intervals, so as to give
time for reaction to occur, the vessels assume
a more energetic action, and it becomes hot
and burning. If you keep it in snow for a
long time, its heat becomes completely ex-
hausted, reaction does not take place until
after a considerable period, and very slowly,
and the hand remains at a low temperature
for a good while. Bear this in mind, for it
will direct you in the application of cold to
reduce local heat There is a vast
difference between a thing being done and
13
150 ENDEMIC AUTUMNAL FEVER.
its being loell done. So it is with regard to
cold lotions. So difficult is it to insure their
proper application, that I have entirely given
them up in hospital practice, and rarely or-
der them in private." Dr. Graves then goes
on to observe that the head is the only one
of these cavities in which long practice has
sanctioned the application of cold. Latter-
ly, however, some medical men have de-
clared that they have used ice poultices
to the chest and abdomen with safety and
success ; but he confesses that he is not pre-
pared to adopt the practice, although a re-
view of the subject might incline him to
give up his prejudices. He then says, —
" Sponging the bare scalp with tepid or
warm water and vinegar, or even frequently
steeping the head and temples^ will often suc-
ceed much better in abating the headach and
restlessness of fever ^ than any cold applica-
tions whatsoever In 1832," he says,
" in an influenza in Dublin, this pain in the
head was relieved by nothing so effectually
as by steeping the temples, forehead, occiput.
ENDEMIC AUTUMNAL FEVER. 151
and nape of the neck loith water as hot as it
could be hoiiie.''^
The sound instructions contained in the
above extract from a lecture of one of the
best practitioners of the age, will justify its
length. It brings to my mind a case which
occurred in my practice in 1839, before I
had seen Dr. Graves' opinion on the sub-
ject.
In 1839 I visited a patient ill of remittent
autumnal fever. The pain in the head was
so violent, the eyes so red, face so flushed,
and, for a delicate female, the pulse so
bounding, that I was seriously apprehensive
of the rapid approach of phrenitis. A vein
was immediately opened, and blood allowed
to flow from a large orifice until some relief
was acknowledged. There was no ice at
hand, and a bucket of water from a pump in
the yard was ordered to be placed in a
chair by the bed. In this linen clotlies were
soaked, and kept on the face, head, and
neck, and renewed every few moments.
Notwithstanding these continual cold appli-
cations, the pulse reacted in half an hour,
152 ENDEMIC AUTUMNAL FEVER.
the orifice was again opened and more blood
drawn. Relief, but not lasting, was ob-
tained by these measures, and, soon after,
the cold lotions became disagreeable. Hot
water was then substituted, and very soon
gave much and more permanent relief.
This case, which soon terminated favora-
bly, taught me to believe that, iclien the ap-
"plication of cold becomes painful or disagree-
able, hot water may be advantageously substi-
tuted.
CI.
With regard to the exhibition of emetics
or purgatives in remittents, observe the rules
laid down under the treatment of intermit-
tents (Ixxix. to Ixxxvi.), with this differ-
ence— that, generally^ it will be necessary to
continue tlie use of cathartics for a longer
time. After a preliminary or preparatory
bleeding, it is well to commence the cathar-
tic treatment by the exhibition of a dose of
the sulphate of magnesia or of soda, still
further to reduce vascular action before re-
sorting to calomel or the more drastic arti-
cles.
ENDEMIC AUTUMNAL FEVER. 153
CII.
The depleting plan should be continued
and persevered in as long as demanded by
the urgency of the symptoms ; and, to fill
up the intervals between the employment of
more active measures, the exhibition of the
cooling neutrals, cold drinks, and cool air,
will be found useful.
cm.
When the catharsis has been carried suf-
ficiently far /or the time (and it will always
be necessary to give the bowels some rest),
important aid may be derived from the use
of diaphoretics. A free action on the cuta-
neous surface will carry off an exacerbation,
or so far diminish arterial excitement as to
lessen the danger of organic injury, to guard
against which the efforts of the physician
should be unceasingly directed.
The choice of the diaphoretic should be
determined by the existing grade of action,
carefully adapting the article to be used to
the excitement. If, after the use of the Ian-
154 ENDEMIC AUTUMNAL FEVER.
cet and cathartics, the action of the pulse be
still considerable, but not so exalted as to
justify their further employment at that time,
the saline neutrals, as tartrite or supertar-
trite of potash, citrate of potash or soda,
with antimonial wine or a solution of tar-
tarized antimony, in mmute doses, will be
found useful in promoting diaphoresis. But
in those cases where the febrile heat is mod-
erate, and no evidence of cerebral, gastric,
or visceral determination be present, the ad-
dition of sweet spirit of nitre and camphor-
ated tincture of opium to the saline mixture,
may be made with advantage.
CIV.
This plan, aided by diluent drinks, as
acidulated balm tea (I mean in mild cases
of fever) and toast-water, given ad libitum,
will generally produce a sweat more or less
profuse, and a remission more or less com-
plete.
The compound diaphoretics are adapted
to those cases only where the force of the
circulation has been reduced by previous
ENDEMIC AUTUMNAL FEVER. 155
treatment. The sudorific drops, composed
of sp. nitr. dulc. vin. antimon., and tinct. op.
camphorat.j and the pulv. ipecac, compos.,
which has become so celebrated under the
name of Dover's powder, afford an instance
of the efficacy of combined action on the
mucous coat of the stomach. The specific
action of each of the ingredients seems to be
lost or merged in one combined power.
While the opium increases the energy, in
some degree, of the sanguiferous system, and
allays irritability by its anodyne power, the
other ingredients relax the extremities of
the cutaneous exhalents, and sweat is thus
produced.
cv.
Much caution should be observ^ed in the
exhibition of the preparations of opium.
Uncombincd, opium is inadmissible when the
skin is hot and dry^ and the tongue red or
brown. Accompanying such symptoms as
these states of the tongue, there is reason to
apprehend more or less of gastric or enteric
irritation, if not inflammation, if any credit
be given to the opinions of two accurate ob-
156 ENDEMIC AUTUMNAL FEVER.
servers, Abernethy and Broussais. It must
not, how^ever, be concealed that Dr. Stokes,
whose opinion is always worthy of atten-
tion, that the condition of the tongue affords
information, not of the morbid condition of
the intestinal canal in particular^ hut of the
system generally. The varying opinions of
these distinguished men will not, however,
lead to any difference in practice.
cvi.
Steadily pursuing these measures, the
practitioner will generally find that the fe-
brile symptoms will be so far subdued within
the first week as to give no farther anxiety
for the issue. I say generally ^ for, as in ma-
lignant fevers, so in our peninsular endemic,
cases will sometimes occur which baffle the
art of the most experienced and judicious.
In all diseases, the pathological character of
which is visceral inflammation, there is a
grade of indomitable severity, in which pro-
fessional skill will meet with certain defeat.
We sometimes see cases which closely re-
semble yellow fever, a disease which, in the
ENDEMIC AUTUMNAL FEVER. 157
opinion of Sir John Pringle, is identical with
bilious fever, differing only in intensity.
Professor Potter, of the University of
Maryland, in his excellent Memoir on Con-
tagion, inculcates the same doctrine, though
the object of his Memoir is to establish the
non-contagious nature of yellow fever. In
that work he gives an account of a fever
which appeared in a detachment of the
United States army, then stationed at Galli-
opolis on the Ohio river. The fever doubt-
less originated from a pond near the canton-
ment. While the neighboring village w^as
suffering from the fever, the garrison was
healthy. In a few days, however, the wind,
which until that time had blown in a direc-
tion from the pond to the village, now
changed and brought the exhalations from
the pond towards the camp. '' In five days
half the garrison were on the sick list, and,
in ten, half of them were dead." Durins:
the prevalence of this mortalitj, the symp-
toms so accurately described by Maj. Prior,
were those of yellow fever. After the pond
was filled up, and fresh earth w^as spread
14
158 ENDEMIC AUTUMNAL FEVER.
over the surface, the fever did not appear in
this form. It became a common remittent,
and gradually assumed the intermittent form,
thus rendering it extremely probable that
the cause of yellow fever and the common
endemic of these latitudes is identical^ differ-
ing only in the degree of concentration ; and
the fevers the same, differing only in grade.
CVII.
Too often, notwithstanding the most judi-
cious treatment, it will be found, in those
cases which had undisturbed possession of
the system for some days before a physician
was called, that the fever will decline in se-
verity without lessening the danger. The
tongue will become dry and brown or red ;
the skin harsh and arid, while the alvine
discharges will be dark and offensive ; the
abdomen tumid and tender, and delirium
constant. Under such alarming circum-
stances not a moment is to be lost. Cups or
leeches should be applied to the abdomen ;
calomel and pulv. antimonial, be given in
doses of two to four grains each, every two
ENDEMIC AUTUMNAL FEVER. 159
or three hours, according to thek effect ; mu-
cilaginous drinks freely allowed, and an ep-
ispastic applied over the abdomen and on
the lower extremities. The additional use
of mercurial frictions should not be omitted :
and when, by the combined internal and
external use of mercury, which in such cases
is our only hope^ the gums become swelled,
and ptyalism appears, there will be ground
to expect the recovery of the patient, even
in the most hopeless cases.
USE OF EPISPASTICS.
CVIII.
Blistering, by the application of plasters
made of cantharides, has been recommended
by all writers on bilious fever, and much
mischief has been done by their too un-
guarded and early use. They are revulsive
agents, drawing off action from one part by
increasing it in another. While the inflam-
matory symptoms run high, and while it is
still necessary to use the lancet, the stimu-
lus of the cantharides renders their employ-
158 ENDEMIC AUTUMNAL FEVER.
over the surface, the fever did not appear in
this form. It became a common remittent,
and gradually assumed the intermittent form,
thus rendering it extremely probable that
the cause of yellow fever and the common
endemic of these latitudes is identical^ differ-
ing only in the degree of concentration ; and
the fevers the same, differing only in grade.
evil.
Too often, notwithstanding the most judi-
cious treatment, it will be found, in those
cases which had undisturbed possession of
the system for some days before a physician
was called, that the fever will decline in se-
verity without lessening the danger. The
tongue will become dry and brown or red ;
the skin harsh and arid, while the alvine
discharges will be dark and offensive ; the
abdomen tumid and tender, and delirium
constant. Under such alarming circum-
stances not a moment is to be lost. Cups or
leeches should be applied to the abdomen ;
calomel and pulv. antimonial, be given in
doses of two to four grains each, every two
ENDEMIC AUTUMNAL FEVER. 159
or three hours, according to their effect : mu-
cilaginous drinks freely allowed, and an ep-
ispastic applied over the abdomen and on
the lower extremities. The additional use
of mercurial frictions should not be omitted :
and when, by the combined internal and
external use of mercury, which in such cases
is our only hope^ the gums become swelled,
and ptyalism appears, there will be ground
to expect the recovery of the patient, even
in the most hopeless cases.
USE OF EPISPASTICS.
CVIII.
Blistering, by the application of plasters
made of cantharides, has been recommended
by all writers on bilious fever, and much
mischief has been done by their too un-
guarded and early use. They are revulsive
agents, drawing off action from one part by
increasing it in another. While the inflam-
miatory symptoms run high, and while it is
still necessary to use the lancet, the stimu-
lus of the cantharides renders their employ-
160 ENDEMIC AUTUMNAL FEVER.
meat not only useless, but positively injuri-
ous. There is a blistering point which is too
carelessly attended to. When there is de-
termination to the head, or inflammation in
the brain or its membranes, blistering plas-
ters should never be applied until cold appli-
cations to the scalp, and bleeding, general
and local, are no longer admissible. Then,
and not till then, some benefit may be ex-
pected from their employment.
cix.
The vesicles formed by the action of the
cantharides, are generally filled with serum ;
but w^e sometimes see them consist of
lymph. This last is only effused in those
cases which are decidedly inflammatory, and
when seen, affords a sure indication of the
premature use of the epispastic.
ex.
The discharge of serum from the blistered
surface, and, after a few days, of pus from
the inflamed skin, is too inconsiderable to
exert much influence on the general system ;
ENDEMIC AUTUMNAL FEVER. 161
and hence it is probable that the modus ope-
randi is by their stimulus. This has not,
however, been settled by the common con-
sent of medical men. — We see patients who,
previous to the application of blistering plas-
ters, were languid and listless, assume a
cheerful and animated countenance ; the be-
fore creeping pulse becomes fuller ; the pale
and cold extremities, where the circulation
had nearly ceased, becomes warm, and the
glazed and sunken eye grows bright and
lively. In short, the effect resembles that
produced by a glass of wine, though in a
less degree, and accounts readily for the
benefit derived from blistering in arresting
the fit of intermittent fever.
CXI.
But there is another effect which follows^
if it is not &\ve(ii\j produced by the applica-
tion of epispastics, viz., a gentle and general
sweat. This may probably be accounted
for by the fact that, while the epispastic is
drawing, the patient remains motionless, as
every motion is attended with pain. Thus
14*
162 ENDEMIC AUTUMNAL FEVER.
the covering of the bed is undisturbed, and
no variations occur in the temperature of the
surface of the body. To whatever circum-
stance, however, it is to be attributed, the
fact is indubitable that, in many cases, a free
and general perspiration is the consequence
of their application ; and in remittent fever
much benefit is derived from this source.
CXII.
When the physician judges that blistering
is necessary, the extremities are the parts
on which, in general^ they should be applied.
But when there is much gastric disturbance,
or a tendency to spontaneous purging, either
of serous or bloody stools, the abdomen, from
the epigastrium downwards, is the place,
from the blistering on which, the greatest
amount of benefit is to be expected.
CXIII.
Rubefacients, though useful, make no per-
manent impression, and of course are not so
much to be relied on in common cases.
Where, however, the extremities are cool and
ENDEMIC AUTUMNAL FEVER. 163
the general action vei-y feeble^ they are highly
useful ; and as little or no danger is to be
apprehended of a consequent gangrene, as
we sometimes see from blistering in such
cases, the various rubefacients are to be pre-
ferred.
Of these articles, those in most common
use, and probably the best we have, are
mustard and spirit of turpentine. To make
the mustard plaster, it should be mixed into
a paste with sharp vinegar, and spread thick
on a piece of muslin or linen. The best
mode of using the turpentine is to wrap the
extremities with a flannel roller saturated
with it. The turpentine and mustard should
both be applied warm, and continued until
decided action be produced on the skin.
Some hope may be entertained even when
the feet are cold and apparently bloodless,
the pulse barely perceptible, and the lamp
of life nearly extinguished. If there be one
spark of excitability, these measures, with
the use of diffusible internal stimulants, will
rouse it, and the practitioner and patient
need not utterly despair. The reader will
164 ENDEMIC AUTUMNAL FEVER.
remember that the loio state here spoken of,
more frequently occurs in in^ennittents.
cxiv.
Before dismissing the subject of epispas-
tics and rubefacients, it is deemed proper to
introduce the opinion of an eminent modern
writer. " They generally," says he, '• allow
them to remain on too long, and the conse-
quence of this is often violent excitement of
the organ over which they are applied, great
constitutional irritation, strangury, and bad
sores. The best mode of using them is to
cover the blister with silver paper, and,
having put it on with the paper next to the
skin, to let it remain until a decided sense of
smarting is produced you will have
no strangury, no stimulation of the whole
economy, no excessive local irritation, "^ and
the inflammation will heal kindly. The
mode of applying a blister sprinkled over
with an additional quantity of powdered
cantharides, and leaving it on twelve, twen-
ty-four, or thirty-six hours, particularly in
* And no good will be done to the patient.
ENDEMIC AUTUMNAL FEVER. 165
the case of females, is nothing better than
horse-doctoring. During a seven years' ex-
perience at the hospital of Tours, Bretton-
NEAU, by attending to this principle, never
had a case followed by these troublesome
symptoms, and yet never failed in producing
the necessary counter-irritation."*
In my opinion, certainly not to be put in
competition w^ith that of Dr. Stokes, the full
effect of blistering is, in many cases, so im-
portant, and is so seldom obtained short of
vesication, and the evils resulting from stran-
gury, &c., so inconsiderable, we should not
hesitate to incur the risk of a trifling mis-
chief in order to secure a greater good. I
have constantly forbidden even gauze to be
placed between the epispastic and the skin,
and direct it to be kept on from six to eight
hours, unless it be certainly ascertained that
the desired vesication is produced sooner.
Exceptions should of course be made in the
case of children and delicate females, on
whom it will seldom be necessary to keep
them longer than four or fiwe hours. Deep
* Stokes' Pathol, and Treatment of Gastritis, Lect. V.
166 ENDEMIC AUTUMNAL FEVER.
and troublesome inflammations, suppurations
and mortifications, may always be prevented
by the timely application of emollient poul-
tices, and slightly touching the inflamed sur-
face with ol. ricini.
cxv.
When the returns of the exacerbations of
remittents shall cease, and the patient may
be considered convalescent, it will sometimes
be necessary to give some mild tonic to re-
cruit the wasted strength. In all cases they
should always be given with caution and in
connection with aperients, as blue mass and
rhubarb, calcined magnesia, &c.
ex VI.
Much mischief has been done by indulg-
ence in eating during early convalescence, as
well as before the crisis of the fever. It is
known that increased vascularity is the con-
dition of the stomach during the process of
digestion. For this reason, as little work as
possible should be given to the stomach to
do, as the transition from vascularity to in-
ENDEMIC AUTUMNAL FEVER. 167
flammation is short and easy. More cases
of relapse in remittent fever have been pro-
duced by indulgence in eating than by all
other causes put together. A strict adher-
ence, therefore, to a mucilaginous or farina-
ceous diet should be enjoined. When con-
valescence is established, tapioca, the ani-
mal jellies and broths, may be added cau-
tiously ; and when the patient shall be able
to w^alk or ride in the open air, a more libe-
ral allowance may be safely granted. The
convalescence should be watched, as invin-
cible obstructions have been produced by
yielding too much to the longings of the
patient. The reader is referred back to
xcv., page 139.
ex VII.
It is worthy of remark that no fever of
one season ever exactly resembles the fever
of a preceding or succeeding year ; and that,
in different stages of the same autumn, the
prevailing fever will sometimes demand va-
riations in the treatment. It will also be
observed that the individual cases in the
same year present variations in type, grade,
168 ENDEMIC AUTUMNAL FEVER.
and intensity, depending on the constitu-
tional varieties of the individual subjects.
When the autumnal fever succeeds a sum-
mer of unusual drought, the cases, though
the number be less, will generally assume
a more decidedly inflammatory character.
The practitioner will closely attend to the
first cases, watching, with anxious eye, their
full development, and thus learning every
succeeding year the peculiarities of each.
*' JVatura nihil Jit per saltum.^^ We never
see an autumnal fever of low grade suddenly
succeeding catarrh, cynanche, or pneumony,
of a high grade of action, and vice versa.
CXVIII.
Let not the impatient reader, now anxious
to come to the conclusion of a subject, per-
haps too tediously discussed already, accuse
me of endless repetitions if I further remark
that, in the fever now under consideration,
unless the febrile action be subdued or miti-
gated in the first days, inflammation, acute
or sub-acute, will surely be revealed. Tiie
physician, if his measures have been weak,
ENDEMIC AUTUMNAL FEVER. 169
temporizing, and vacillating, will suddenly
see an enemy of ferocious aspect starting up
before him, and bidding defiance to his pro-
fessional tactics. This will be the conse-
quence in those cases distinguished by that
type which has been called typiwid^ equally
with those of a higher grade, or those char-
acterized by a phlogistic diathesis. In all
cases terminating fatally^ there is local affec-
tion consisting in functional or structural
lesion.
In this view of the subject, viz., ihsit fever
has an invariable tendency to local injury^ the
young practitioner will find no real difficulty
in deciding on the measures to be pursued.
Let him bear in mind an old and valuable
maxim, ^^venienti occurrite morbo;" and,
casting aside all fear of that raw-head a7id
bloody-bones invented by Browne, of Edin-
burg, to frighten the timid, that bug-bear,
DEBILITY, to which morc victims have been
immolated than to the grim idol of Jugger-
naut, attack the disease in its commencement.
By a free use of the lancet in all cases of
high arterial excitement, and a more mode-
is
170 ENDEMIC AUTUMNAL FEVER.
rate use of it in connection with cupping,
leeching, vomiting, purging, and other modes
of depletion, in those of a lower grade, he-
fore the fever 'produces local injury , that long
train of unmanageable typhoid symptoms,
that debility so much dreaded will be pre-
vented ; while a timid and over-cautious pro-
cedure will insure that state of things which
it was expected to prevent.
In the early part of November, or about
the time the ground begins to freeze, our
autumnal fever disappears, or only lingers in
a few obstinate cases. Diseases of a differ-
ent kind then present themselves to our at-
tention. But the transition is not very sud-
den. There is generally a breathing inter-
val, in w^iich convalescents recover their
strength, and the worn-out physician reposes
from his toils.
dljaptcr VIII.
CONGESTIVE STATE OF BILIOUS FEVER.
Symptoms. — Loss of balance in the circulation. — Diagnosis. —
Change from the congestive to the inflammatory state favorable.
— Treatment. — Debility apparent, not real. — The cause. — Use
of the lancet. — When necessary and when not. — Emetics. — Ca-
thartics . — Calomel.
CXIX.
In the congestive, as in other forms of our
autumnal fever, the premonitory lassitude is
soon succeeded by a chilliness more or less
distinct. The precordial oppression is more
remarkably severe — the countenance more
disturbed and anxious — the paleness of the
face assumes a dingy hue — the breathing is
irregular, anxious, and sighing; there is
great dejection of spirits ; the extremities
are cold — there is a dull, obscure, deep-seated
pain in the head — dulness of the eyes, and,
for the most part, some injection of the scle-
rotic coat, and confusion of intellectual man-
172 ENDEMIC AUTUMNAL FEVER.
ifestations, accompanied by great apparent
debility or prostration of strength.
After a time, longer or shorter in propor-
tion to the violence of the case, some reac-
tion takes place, and the surface becomes
somewhat heated, the eyes more suffused
and dull, and the pain in the head more se-
vere. Sometimes w^e see incoherence of the
mental operations, delirium, and, at last,
coma. The congestion of the organs con-
tinuing, the pulse never becomes full and
bounding, but is small, contracted, and op-
pressed.
" The v^^hole appearance of the sick im-
presses the attentive practitioner w^ith the
idea that the system in general is oppressed
by some extraordinary load.'"^ Almost
every breath is voluntary, and is not drawn
without an effort ; the epigastrium is tumid
and tender ; the secretions are either much
diminished or altogether suspended, espe-
cially the secretion of bile ; the most violent
efforts in vomiting eject only the drinks,
sometimes mixed with a glazy mucus. The
* Armstrong. '^
ENDEMIC AUTUMNAL FEVER. 173
disease is characterized by unusual depres-
sion of the circulation, from its source in the
heart to the minutest ramifications of the
vessels, and sometimes by the total absence,
or partial and imperfect development of the
stage of excitement.
cxx.
There is a loss of balance between the
arteries and veins. In the normal state both
these parts of the circulating system are
equally filled with the fluid which supplies
all the secretions, and sustains and nourishes
every part of the body. In congestive fever
the large interior veins are unusually full,
and of consequence the arteries contain less
blood than usual. This pathological condi-
tion, it may be supposed, is produced by a
diminution of that nervous influence which
is necessary to sustain the venous circula-
tion, by the powerful impression of the re-
mote cause. In instances where the remote
cause is in a state of high concentration, the
energies of the brain and nervous append-
ages may be so prostrated, that the venous
15*
174 ENDEMIC AUTUMNAL FEVER.
circulation will be more and more embar-
rassed, the supply of venous blood to the
heart will be more and more diminished, the
heart will cease to beat, from the want of its
accustomed stimulus, and the patient will
soon cease to live.
cxxi.
The blood-vessels and nerves mutually
act on each other. It is nervous influence
which communicates to the sanguiferous
vessels the power by which the circulation
is sustained ; and a certain degree of ful-
ness and tension in the blood-vessels is ne-
cessary to insure the permanency of nervous
power. In this state of fever the arterial
tone is in direct proportion to the quantity of
blood in the arterial system.
CXXII.
It will doubtless be observed, by the at-
tentive reader, that all the symptoms above
enumerated have already been mentioned as
the morbid indications of intermittent and
remittent fever. Every case of the last
ENDEMIC AUTUMNAL FEVER. 175
named forms is more or less congestive in the
cold stage ; and probably the most remark-
able difference between a common inflam-
matory intermittent and a congestive fever,
may be found in the fact that, in the former,
the congestion is completely removed by the
access of the hot stage, while, in the latter,
the hot stage is more imperfectly developed,
and the portal and other congestions remain,
or, in other words, in the simple and inflam-
matory forms of fever, there is a much more
full development of superficial heat than in
the congestive. In the latter, the tempera-
ture, though sometimes increased, is frequent-
ly not above, and often much below, the
standard of health. The one may be called
centrifugal, the other centripetal. (Rush.)
CXXIII.
The pain in the head in congestive fever
arises, doubtless, from the same cause which
produces that symptom in the simple and
inflammatory forms, viz., the pressure of the
sanguiferous vessels on the origin of the
nerves. In the inflammatory state the press-
176 ENDEMIC AUTUMNAL FEVER.
ure is arterial, in the congestive, venous.
To a superficial observer, the same morbid
condition seems to exist, and is frequently
considered apoplectic. In point of fact,
however, the pathological condition of the
encephalon is very different. In death from
the comatose state of congestive fever, dis-
section reveals no arterial rupture and no
red blood in the ventricles. In true apo-
plexy, these, or at least a greatly distended
state of the arteries, are always seen. In
the one case there is diminished, in the other,
increased arterial action. The one state is
sometimes relieved and removed by stimu-
lants, the other never.*
cxxiv.
In treating of congestive fever I have not
made the usual division into cold, hot, and
sweating stages, for the sufficient reason that
we do not see these stages succeeding each
other with uniformity. In many of the worst
cases there is only one stage. And when in
others reaction sometimes takes place, and
* Potter's Armstrong, note 24, p. 81.
ENDEMIC AUTUMNAL FEVER. 177
decided feverish excitement becomes devel-
oped, the disease so far lays aside its conges-
tive character, and assumes the type of the
simple or inflammatory fever. This muta-
tion of form we sometimes witness, and it
may generally be considered favorable, as
we then have plain sailing, with a fair wind.
No adverse gales make it necessary to
change our course, and no clouds and fogs
conceal a lee shore from our view.
cxxv.
Those who have been educated in the
creed that the lancet should never be un-
sheathed but in those cases where there are
flushings in the face, acute pain, tense pulse,
and increased heat, will be very apt to
shrink from its employment when the coun-
tenance is pale and bloodless, the pulse
scarcely to be felt at the wrist, the skin cold,
and when praecordial oppression is indicated
by continual sighing.
In the commencement of the attack the
debility is apparent, not real. Though the
patient complain only of iceakness, let not
178 ENDEMIC AUTUMNAL FEVER.
the physician partake of his alarm, but
calmly institute an inquiry into the circum-
stances which have produced this sudden
debility. An hour before, the patient en-
joyed his usual health, and could have borne
the loss of much blood without injury. In
the meantime nothing has occurred to im-
pair his strength. No alvine evacuations,
no colliquative sweats, have drained off the
vital fluid or the materials from which it is
formed. The feeling of debility, then, so
suddenly brought on, must be a delusion. It
is the inequality in the distribution of the
mass of blood, the congested or engorged
state of the venous system, which imparts
the sensation of a praecordial load, and forces
from the patient the complaint of exhaus-
tion.
cxxvi.
In a majority of instances more danger
will be incurred from the omission than from
the employment of blood-letting. Let a
vein, then, be opened ; and if no blood can
be obtained from the veins, and if the head
be the principal seat of the congestion, the
ENDEMIC AUTUMNAL FEVER. 179
temporal artery, and let blood be taken, at
first slowly and cautiously. The loss of a
few ounces will not produce dangerous ex-
haustion in the early stage of any disease.
The most inexperienced physician will
soon be taught by the mode in which the
blood shall escape from the orifice, and by
the effect on the pulse, whether the opera-
tion be salutary or otherwise. If the blood
continue long to trickle down the arm, and
at the same time the pulse, before w'eak, be-
come more feeble and indistinct, the orifice
may be closed in time to prevent serious
mischief. In such circumstances, a stimu-
lant, such as wine or brandy, should be
always at hand that it may be used if the
pulse fail. But if the blood, at first coming
from the puncture by drops, at length springs
from the arm and falls into the basin with
some force, the pulse simultaneously rising
in strength, no doubt can be entertained for
a moment of the propriety, nay, of the ne-
cessity of the measure. The nearer the
approach made by the stream of blood, as it
issues from the arm, to a straight line, the
180 ENDEMIC AUTUMNAL FEVER.
stronger the jet which it makes from the
orifice, the more urgent the necessity for
abstracting it.
When the pulse evidently increases in
strength as the blood flows, the orifice should
be allowed to remain open until a percepti-
ble diminution of the force of the pulse be
felt. The result of this practice will fre-
quently be the conversion of a congestive
into a simple fever, the treatment of which
has been laid down in preceding pages.
There is no peculiar mode of treating this
form of fever, when feverish excitement has
supervened, that is not equally applicable to
all others. The reader will, therefore, re-
vert to the instructions before given, and
repeat the bleedings, if the force of the cir-
culation require it.
CXXVII.
The use of the lancet, however, is not
always necessary or proper. If the patient
be not visited in the commencement of the
attack, the congested state of the viscera
will not be easily removed, and the abstrac-
ENDEMIC AUTUMNAL FEVER. 181
tion of blood will indeed induce exhaustion,
the power of reaction no longer existing.
In the less severe cases of congestive fever,
some small degree of reaction will soon be-
come manifest, and the use of the lancet in
such cases might do irretrievable injury. In
such cases an opium pill, gr. i. to iss., to be re-
peated in half an hour or an hour, pro re
nata, and even again, if necessary, will tran-
quillize the system, and frequently relieve
the congestive symptoms, by equalizing the
circulation.
CXXVIII.
The use of the lancet should be speedily
followed, unless there be clear evidence of
cerebral engorgement, by an emetic of ipe-
cacuanha or emetic tartar. The influence
of this in removing internal congestions
w^ill be understood from what has been said
before, under the head of treatment of in-
termittent fever. If decided relief be not
obtained by this measure, calomel should be
resorted to in a dose of fifteen to twenty
grains, and repeated every two or three
16
182 ENDEMIC AUTUMNAL FEVER.
hours in doses of five to ten grains, until the
liver and intestines shall be unloaded of their
vitiated secretions. The stools will gene-
rally be almost as black as tar at first, or
w^hite and very fetid. When they become
natural in color, showing a more healthy
biliary secretion, if at the same time the op-
pression be relieved, and the skin become
w^arm and moist, the most favorable prog-
nostic may be drawn. If, on the contrary,
the skin remain cold, and the pulses become
weaker, real debility may now be appre-
hended, and diffusible stimulants should be
largely employed, combined with opium and
calomel in smaller doses.
cxxix.
By the use of large doses of calomel in
the commencement, we may expect not only
an operation on the bowels, but its specific
efTect on the salivary glands. When this is
established, the venous congestions generally
give way at once, and we have nothing to
contend with but a salivation.
After some free alvine evacuations have
o
ENDEMIC AUTUMNAL FEVER. 18
been obtained, opium may, and in cases of
weak arterial action, always should be com-
bined with the calomel, in such portions as
may check but not entirely arrest its action
on the bowels. And when the calomel alone
should not soon produce stools, senna or
jalap may be given alternately with it. It
is of great importance to evacuate the bow-
els.
cxxx.
As soon as a few stools have been pro-
cured, a large epispastic should be applied
on the abdomen, previously rendered more
amenable to its action by the application of
a mustard poultice. There are two modes
of removing congestions, viz., by bleeding
and by stimulants, general and local. The
former method, when admissible, is the safer.
When we are under the necessity of having
recourse to the latter, wine, brandy, and
pills of camphor,"^ calomel, and opium ; or,
Gum Camphor, gr. xx.
op. gr. i.
Calomel, gr. vi.
Elix. paregor. 9, i. f.
PU. vi. — — -*
(7 ..'<(. -tu..
^
r
^*'^"'''^^' ****^''«- CUi^ -1^ < " tj%..4
184 ENDEMIC AUTUMNAL FEVER.
in cases of great prostration, pills of carbon-
ate of ammonia^ and opium are among the
articles most to be relied upon. A medium
between these extremes frequently confirms
the truth of the old maxim, '' in medio tutis-
simus ibis." The evacuating plan, by the
free exhibition of cathartics and emetics,
sustaining the strength of the patient under
debilitating discharges by wine with tapioca
or arrow root, will in many cases be at-
tended with ultimate success.
cxxxi.
In some instances the stools will be large,
frequent and exhausting. The cretaceousj
julep, with a few drops of laudanum, as-
sisted by starch injections, will in such cases
be found useful. If cool extremities and a
* Ammon, carbonat. gr. xviij.
Gum op. gr. i. or iss.
Conserv. ros. 9. i. f^pil. vi. >C
t p Calc. carbonat. (Cret. pptt.) ^ij.
Pulv. gum. acac. ^ij.
01, cinn. vel. caryoph. ft. ij. B
Sacch. alb. ^iij.
Aq. font. gvi.
Ft. julep.
>
^ h~A^y\yt, ^K^^^yj O * (^ • Z_ .
8
""^^Z^
ENDEMIC AUTUMNAL FEVER. 185
declining pulse show a rapid diminution of
strength, spiced brandy, or sound old Port or
Madeira wine, may be given freely as drink,
diluted with water, and tapioca, properly
seasoned with brandy, taken as food. Mus-
tard plasters should be placed on the wrists,
ankles, and soles of the feet, and should be
succeeded, when they become warm, by
blistering plasters. In those cases of great
oppression, attended with continual sighing
and jactitation, when the lancet has been
used without relief, or when the use of it
has been judged inadmissible, a full anodyne
will generally remove all restlessness, in-
crease the fulness and lessen the frequency
of the pulse, and re-establish the lost balance
in the circulating system. After this, the
judicious exhibition of calomel, with some
mild aperient, will frequently be followed by
a favorable convalescence.
CXXXII.
I have said nothing of the use of tonics, \
as quinine, extract of bark, Colombo, &c. &c.
&c., in congestive fever, because I never saw
« •
16*
186 ENDEMIC AUTUMNAL FEVER.
them do any good. In almost every case
w^here congestions remain, the bark, in all its
forms and preparations^ is most decidedly in-
jurious. After the disease appears so far
subdued that danger is no longer appre-
hended, small doses of calomel and opium,
assisted by aperient measures when neces-
sary, with mild and bland articles of diet of
a mucilaginous or farinaceous nature, will
bring the case to a much safer termination.
Olljapt^r IX.
A FACT highly worthy of being known and
remembered, but which excites too little at-
tention, may here be mentioned. It is that
of those mimerous cases of visceral derange-
ment, as physconiae of the liver, spleen, me-
sentery, and, probably more frequently than
is suspected, of the pancreas,^ which begin to
awaken attention about February or March,
nine-tenths occur in those individuals in
whom the endemic was not fully developed
during the preceding autumnal months. The
sufferer will then recollect that during the
prevalence of the fever he was frequently
* In the month of October, 1841, in the post mortem examina-
tion of a boy who died, as was thought, of an injury done to the
brain by a blow on the head, I discovered a ruptured pancreatic
abscess, and about a pint of pus and much disorganized glandular
substance in the abdominal cavity. Before death, the tumor was
thought to be in the spleen.
188 ENDEMIC AUTUMNAL FEVER.
unwell ; had a bad taste in his mouth ; felt
slightly feverish ; his head sometimes ached
a little ; his appetite was not very good, and
when he took food in the usual quantity, he
soon became puffed up and flatulent. He
sometimes resorted to brandy or wine to
sharpen his appetite and improve his diges-
tion. There existed a disinclination to pur-
sue with spirit his common vocation, but he
was not so decidedly sick as to call in a
physician. Doubtless he had imbibed the
morbid cause, not in quantity sufficient to
produce the usual result, but enough, by its
slow and sure action, to generate those ob-
structions which are so much more to be
dreaded. The process may be compared to
the slow combustion of a train leading to a
magazine. The morbid cause thus advances
by imperceptible degrees, to entrench itself
in the very citadel of vitality ; and, before
serious danger be apprehended, produces an
explosion fatal to the vital organs.
cxxxiv.
It is about the time mentioned (in cxxxiii.)
ENDEMIC AUTUMNAL FEVER. 189
that the physician is called on to prescribe
for those hepatic and other visceral derange-
ments, which too often terminate in fatal
serous effusions. Bearing these things in
mind, we might frequently become acquaint-
ed with those, at first, apparently trifling
disorders in time to prevent a fatal result.
cxxxv.
It will not be expected that, in a treatise
expressly devoted to the consideration of our
endemic bilious fever, our attention will be
extended to the causes and treatment of
dropsical effusions, and to those numerous
cases of gastric disturbance which, under
the name of dyspepsia, so often disappoint
the hopes of the patient, and baffle the skill
of the most experienced physician. A
dropsy succeeds those cases only of fully de-
veloped fever which have been imperfectly
cured. The same may be said of the above
named gastric affections, with the additional
remark that these last are sometimes the
consequences of long continued antimonials
and drastic cathartics. The attempt to cure
190 ENDEMIC AUTUMNAL FEVER.
such cases by stimulants and tonics, as is
too often the practice of some, is about as
rational as to expect to extinguish a fire by
putting on additional fuel.
cxxxvi.
Physconia, however, of the liver and
spleen, having, as is believed, a malarious
origin, and being, as Dr. Rush would call
them, " suffocated bilious fevers," may be
properly introduced here to the notice of the
reader.
In their incipient stage there are few
chronic derangements which more readily
submit to medical treatment. If allowed to
continue until a general cachexic condition
is manifested, or until ascitic or anasarcous
effusions commence, little hope can be given
of ultimate recovery.
cxxxvii.
The subjects of these visceral derange-
ments, as before remarked (cxxxiii.), are
chiefly those in whom the autumnal fever
never was fully formed, and, in a few in-
ENDEMIC AUTUMNAL FEVER. 191
stances, those who had it in the preceding au-
tumn, but were imperfectly cured, (cxxxvi.)
The symptoms are — a gradually increasing
tumidity of the abdomen, indisposition to
exercise, lowness of spirits, ^allowness of the
complexion, flatulence and acidity, sluggish-
ness, the urine tinges the linen of a yellow-
ish color, and is secreted in small quantity,
timidity, continual apprehension of some evil,
sometimes lying on the left side is painful,
febricula^ or, as the sick generally call it,
" inward fever." The bowels are slow, and
the stools clay-colored, white, or nearly
black. These morbid appearances are some-
times so slight, that the subject of them
either does not discover his situation, or
thinks it of no consequence, until his ana-
sarcous extremities awaken his fears.
CXXXVIII.
It will be observed, by the intelligent
reader, that some of the more prominent
symptoms, as above detailed, are identical
with those noted by authors as symptoms of
hypochondriasis ; and he will be surprised to
192 ENDEMIC AUTUMNAL FEVER.
hear that volumes have been wTitten on that
disease without the least reference or allu-
sion to visceral disorder as its cause. Those
ancient authors who gave the name of hypo-
chondriasis to that congeries of symptoms,
were better acquainted with its pathological
relations than many succeeding writers, who
have treated it as altogether a mental affec-
tion— a " disease of the spirits." The word
hypochondriasis is compounded of two Greek
words, vTTo, under, and xov(5po?, cartilage, and
refers to the parts under the false ribs. The
true pathology of the disease is a chronic
obstruction of the liver, known by the name
of hepatalgia. The remedies advised by
these writers, in perfect accordance with
their pathological views, were directed to
the mind. Among them may be named em-
ployment, with the view of diverting the
attention from imaginary evils ; cheerful
company ; the sports of the field, as hunt-
ing, &c. ; play, as chess, backgammon, and
cards; music, rural scenery, travelling, &c.
ENDEMIC AUTUMNAL FEVER. 193
CXXXIX.
When the attention of the patient is once
awakened to symptoms, too often neglected
until no longer removable, an instinctive ap-
prehension of bodily danger drives him to
his medical adviser. If the disease were
purely mental, his spiritual dir^ector w^ould
be more capable of giving counsel in his
case. But the poor hypochondriac/66/5 that
he is diseased, and, anxious for remedies,
goes to his physician for advice. The latter,
to indulge his fancies^ prescribes some bread
pills, or water colored by cochineal, promis-
ing the most beneficial results from their use.
This " pious fraud" has been sanctioned by
some medical men of reputation ; and thus
many individuals have been deluded and be-
guiled with false hopes, until a fatal atrophy,
tabes mesenterica, or dropsy, has laid them
in the grave.
CXL.
While on this subject, it will not be ex-
pected that I should enter into a full exami-
17
194 ENDEMIC AUTUMNAL FEVER.
nation of that mysterious connection which
exists between the body and the mind. Let
it suffice to say that they reciprocally act on
each other, and when one is suffering, the
other is inevitably brought into sympathy.
Whatever imparts vigor to one, gives a cor-
responding tone and strength to the other,
and vice versa. While, therefore, the physi-
cian wields the instruments which a benefi-
cent Creator has provided for our bodily ills,
he will not forget that there is also a medi-
cina mentis^ a balm for a wounded spirit,
which it is equally his duty and his privilege
to employ. Every one who has observed at
all, has noticed the fatal influence of fear
and apprehension of death in many cases of
disease. Every one has seen the salutary
influence of confidence excited in the mind
of the patient in certain cases. The watch-
ful physician will avail himself of this know-
ledge, and use hope as a lever of sufficient
power to remove mountains of difficulty. In
concluding these cursory remarks on mental
affection, I will only add that, though such
ENDEMIC AUTUMNAL FEVER. 195
may exist, I have never seen an instance of
essential mental derangement unconnected
with and independent of bodily disease.
CXLI.
A few words now in relation to the treat-
ment of those visceral obstructions mentioned
before, (cxxxvii.) In cases of hepatalgia, or
enlarged and obstructed liver, the bowels
are generally slow. The treatment should
be commenced by an active purge, a dose of
calomel at night, followed in eight or ten
hours by an infusion of senna and manna, or
a dose of jalap and supertartrite of potass.
After this, ten to fifteen or twenty grains of
carbonate of soda may be given three or
four times a day. In a day or two it will be
necessary to repeat the cathartic, when cas-
tor oil or senna may be used, followed, as
before, by doses of carbonate of soda or so-
luble tartar, or carbonate of potass. If the
alvine discharges continue to afford evidence
of obstructed or vitiated secretion, the purges
should be continued, filling up the intervals
196 ENDEMIC AUTUMNAL FEVER.
by giving carbonate of potassae or soda, with
infusion of chamomile flowers.
This plan may be continued until relief be
obtained, or until the patient's strength evi-
dently declines without the removal of the
obstruction. In this case, blue mass and
rhubarb, in doses gently aperient and alter-
ative, or calomel in similar doses, should be
resorted to with a view of producing ptyal-
ism. If these measures should fail, nitric
acid internally, together with the nitro-mu-
riatic foot bath, frictions over the abdomen
with a flesh-brush or woollen or coarse linen
cloth, and along the whole course of the
spine ; or a large blister on the right hypo-
chondrium should be tried. If all these
remedies do not succeed in removing the
obstruction, and rousing the biliary organs
to healthy action, recourse should be had to
iodine and hydriodate of potash, internally.
CXLII.
In physconia of the spleen or mesentery,
it is seldom necessary to have recourse to
salivation. The use of cathartics, small
ENDEMIC AUTUMNAL FEVER. 197
alterative doses of blue mass or calomel,
abdominal and spinal frictions, gentle exer-
cise, a diet thin and aperient, will generally
succeed in removing the symptoms. In
cases of long-standing physconia of the
spleen, I have seen iodine act like a charm.
Regard should be had to the state of the
stomach, and it will generally be useful to
give at the same time some alkaline prepa-
ration, with chamomile, cascarrilla, or an
infusion of the bark of the cerasus sylvestris,
or wild cherry.
17*
APPENDIX.
When this work was commenced, it was my inten-
tion to append a number of cases in illustration of my
views of the nature and treatment of our endemic
fever. Having been disappointed, by the paucity of
deaths and the unwillingness of surviving friends, in
obtaining opportunities of examinations after death,
I have determined that a large number of cases
would serve only to swell the size of this manual
without adding much to its value. A very few cases,
then, only will be given ; two of which will proba-
bly have some influence in determining the question
whether fever can he cured.
CASE I.
Mrs. , a lady of delicate appearance, aetat?
35, the mother of six or seven children, with general
good health, though not robust. August 2, Mon-
day.— Had been unwell some days, pain in the lum-
bar region. To-day became chilly at 1 P. M. Re-
action commenced after a short chill. Rose high —
pulse about 100, some tension and fulness — violent
200 APPENDIX.
nephritic pain, frequent micturition in small quanti-
ties, pain in the head, great tenderness in the course
of the ureters and the sphincter vesicae. V. S. :
warm fomentations to the inguinal region — warm
bath. There was found great relief from these
measures. At night small doses ( 5 ij.) of sulphate of
magnesia, mallows infusion, and gum-water,
Tuesday, 3d. — Medicine operated slowly through
the next day, small stools, greenish and mucous. At
night a dose of calcined magnesia — no fever — no
pain — seemed pretty well, perfectly free discharge of
urine.
Wednesday, 4th. — Not very well this morning.
Directed mucilaginous drinks — had no apprehension
of an intermittent. About 1 P. M. chill, long and
severe — very moderate reaction, distressing nausea
and oppression, violent headach, disproportioned to
the fever — several thin offensive stools from the
magnesia during the chill ; pulse not much excited.
Gave essence of peppermint and laudanum, and left
her two hours. Purging came on again, three large,
light, offensive stools — pulse sunk. Pill of opium,
and afterwards small doses of laudanum with brandy
and water, freely — sinapism to epigastrium and lower
extremities. Medicines and external applications
acted well — stools checked, pulse rose and became
stronger — continued moderated use of stimulants.
Left her at 10 P. M. with moderate action of pulse?
APPENDIX. 201
and considered her safe from the present paroxysm,
evidently of intermittent form. Ordered tapioca,
seasoned with brandy, frequently through the night.
Visited her again at 1 o'clock. Frequent inclination
to stool — directed her to indulge it. Prodigious fla-
tus, but no alvine discharge. Toddy and red drops,*
every hour. Thursday, 5th, morning. — Two loose
stools. Starch injection with laudanum — cretaceous
julep with ol. ess. cinnam. and laudanum. Brandy
and water and red drops continued. Empl. episp. to
the ankles. Noon. — Complete apyrexia. Ordered
quinine, gr. iss., every tw^o hours through afternoon
and night. No excitement but that produced by
stimulants. Red drops with quinine. Friday, 6th. —
Continued quinine with red drops, brandy, tapioca,
&c., through forenoon. Gave a pill of camphor and
opium, and applied a blistering plaster to the epigas-
trium, the latter five hours, and the former two hours
before the expected return of the paroxysm. Es-
caped the chill, but had feeble pulse about the chill
time, with oppression. Directed her to thrust her
finger down to the glotisj with the view of giving j^s
relief by the emetic effort. Great relief, after some
retching — great eructation — symptoms produced by
flatus. Directed warm chamomile tea with carbon-
* The medicine here familiarly called red drops is composed of
equal parts of paregoric, Hoffman's anodyne liquor, and spirit of
lavender compound. Dose, from twenty to thirty drops.
202 APPENDIX.
ate of potash. Evening. — Doing well. Directed
tapioca seasoned with brandy through the night.
Saturday, 7th. — No stool since Thursday. Mag-
nesia julep every two hours. Evening. — No effect.
Emollient enema. Small stool. No fever. Having
seen persons escape the sick fit one day, and have a
return of it at the next succeeding tertian period,
ordered quinine again, to be taken as before until the
hour should pass. Sunday, 8th. — Continued quinine.
Evening. — No stool — aperient of rhubarb and mag-
nesia. Monday. — Operated gently. A little fever-
ish. Slight headach. Continued quinine too long
Some tumidity of abdomen, without tenderness.
Small doses of calomel, 1 gr. every three hours.
Opened the bowels. Corrected the secretions. Con-
valescent.
CASE II.
Miss , aetat. 18. August 4th. — General good
health, with the exception of slight dyspeptic symp-
toms. Taken this day with a shivering which did
not last long. Pain in the bowels — gastric tender-
ness— griping — tenesmus — small dysenteric stools.
Moderate arterial action at first. 2 o'clock, P. M. —
Directed sulphat. sod. 5 ij., tertia quaque hora. 8,
P. M. — Visited her again. Fever much increased,
violent arterial action, with great pain in the head,
and considerable relief of the abdominal affection.
APPENDIX. 203
V. S. to § xviij. sulphate of magnesia, ice to the head,
and iced water for drink. Medicine soon operated.
When she rose to the chair, became faint, near to
complete syncope. Head much relieved. Getting
cool. Her fever almost gone.
August 5. — Had a good night. Medicine operated
copiously. Arterial action natural. No medicine
ordered. Light food in small quantities. August
6th. — Very slightly feverish. Attention to diet.
August 7th. — About the same. Ordered a small
dose of sulphat. magnes. Operated gently. 8th —
Convalescent.
CASE III.
I was called to see Miss , a little girl, about
10 or 11 years of age. Very inflammatory habit.
Taken with a chill. I had at the time a number of
cases of remittent fever. When I arrived, the chill
had so far abated that part of the bed-clothes which
had been heaped on her were removed. The hot
stage was commencing. Skin dry and very hot —
tongue but little altered, pulse rising every moment,
and violent pain in the head. I immediately took
blood until pain in the head nearly ceased, and she
became very pale. The arterial excitement abated
very soon — a gentle moisture appeared on the skin
— ihe fever departed, and returned no more.
204 APPENDIX.
CASE IV.
Miss , aetat. 70. August 1 5. — Was taken with
a chill — the succeeding hot stage was stated to be
moderate, and soon went off. The next day she was
pretty well; on the 17th the chill returned, and a
violent fever followed. 18th. — She took a dose of
castor oil, and in the evening sent for me. I saw her
then for the first time, and found but little fever.
The cathartic dose had not acted, and I advised a re-
petition of it. 19. — Chill again, and fever. I could
not see her, as she lived several miles from town,
until after night, when the fever had gone down
with a sweat. She had suffered much with pain in
the head, and had been quite delirious. Gave calo-
mel, and directed ol. ricin. in the morning. Ope-
rated well. 21st. — Visited the patient on the decline
of the fever. Some moisture on the skin — pulse
quick and still very hard and full — intense pain in
the head — veins of the eyes injected. V. S. about
20 oz. with much relief. She would take nothing
but soda powders — a free sweat succeeded. 22d. —
Apparently perfect intermission. Ordered quinine.
Took but three doses before fever rose. This day
she was visited by my nephew, who gave more ol.
ricin. Six stools in the night. 23d. — I visited her
in the paroxysm. No sensible chill — but high arte-
rial excitement. Tongue, before white, now brown
APPENDIX. 205
and dry — she was calm, but delirious, and made no
complaint of pain. Pulse very hard and quick, about
100 in the minute. Slie was bled to 20oz. The
tongue became moist and of a better color in less
than an hour ; soda powders given freely ; gentle
perspiration, delirium ceased, and danger seemed
over for this paroxysm. 24th.^ — Almost an intermis-
sion. Pulv. antimon. and spirit, nitr. dulc. every two
hours. At night, episp. to back of the neck and
ankles. 25th. — No return of chill or fever. Sp.
nitr. gt. XV. with 5 gt. paregor. ; tapioca with a little
wine. 26th. — Infus. cort. cum elix. vitriol. Conva-
lescent. 30th. — Was called to visit her. Had taken
nothing and had no stool since I last saw her, not-
withstanding she was charged to keep her bowels
open. She ate oysters and peaches. Soon had vio-
lent pain in bowels — chill, fever, with delirium. An
aperient enema was given immediately, and a mild
cathartic dose afterwards. No return of chill or
fever. Recovered favorably.
CASE v.
Mrs. , aetat about 60 or 70. Large, and gen-
erally healthy. Bilious habit. Wednesday. — Had
been unwell since Sunday — indistinct chills and some
fever — not enough to compel her to go to bed. She
took calomel, and several Seidlitz powders, and mag-
nesia, yesterday, after having a chill at 10 A. M.
18
206 APPENDIX.
To-day it came on at 11. The medicine operated
very freely. I was called this evening, and found
her laboring under a distressing nausea, and complain-
ing much of her head. She was cool, and had a
rapid and feeble pulse. Had taken laudanum. Gave
an opium pill, and applied a mustard plaster on the
epigastrium. Much relief. Directed red drops and
tapioca through the night, every two hours. Some
perspiration. Thursday. — Apyrexia. Still some
nausea — pulse feeble. Red drops. Chill expected
at 10. Gum. camph. gr. iij., gum. op. gr. iss., ft., bol.
ij., one to be taken at 8 and the other at OJ. Es-
caped chill. 9 o'clock, P. M. — Quinin. sulph. gr. i.
every three hours through night, and every hour
through forenoon of Friday, and the same camph. et
op. doses at the same time. Escaped chill. Next
day an aperient with infusion of bark, to be contin-
ued several davs. Recovered.
CASE VI.
Mr. , age about 30; small person, delicate
and feeble appearance ; was born in New York.
This his second year on the peninsula. Was taken
on Monday, August 17th. Chill and fever. Did not
call a physician, but took, on the 18th, calomel, and
followed it up by a dose of sulphate of magnesia.
19th. — Chill and very high fever. Complained much
of pain in the head. Visited him in the evening after
APPENDIX. 207
the declension of the excitement with a free sweat.
Bowels open. Directed the saline mixture (sol. tart.),
with antimonial wine. 20th. — Medicine continued,
being slightly feverish. 21st. — Chill again, followed
by fever with delirium. Visited him in the time of
fever. Pulse rapid and feeble. Would probably
have borne bleeding in the fever of the 19th, but
not now. His pulse was rapid and very feeble —
heat not great — mind confused. Directed epispas-
tic to his arms. At night a sweat came on, and was
profuse — prostrated, cold, and almost pulseless. Had
during night many thin stools of natural color. Was
called in the night, and found this state of prostra-
tion. Directed Portwine freely, tapioca seasoned
with French brandy, and gr. i. of sulphate of quinine
every hour. Strangury from the blisters. Sinapism
to the inguinal region — a camphorated julep and
Holland gin toddy; strangury relieved. 22d. —
Pulse looks up. In twenty-four hours he took a bot-
tle of Port, besides the brandy and gin. Continued
quinine, and, two hours before the time for the chill,
a bolus of two grains of camphor and one of opium.
Escaped chill. Had some nausea, and considerable
deafness and tinnitus aurium — common effects of qui-
nine, never injurious so far as I have seen. Changed
quinine for infusion of bark, with cort. cin. One
good stool on 23d. 24th. — Found some fpver from
too free use of wine and bark by nurses. Directed
208 APPENDIX.
an aperient julep of magnesia, and soda powders for
drink. At night still some fever. A stool or two.
Soluble tartar. 25th. — Fever very slight. At night
none. Infusion of bark. Tapioca with w^ine sea-
soning. 26th. — No stool. Feverish. Does not bear
bark well. Continued aperients, and after some days
his bowels became regulated, and he slowly recov-
ered by nourishing but not stimulating food, cooling
drinks, and gentle aperients.
METEOROLOGICAL TABLES.
The following account of the State of the Thermometer, for the
months of July, August and September, during the three success-
ive years of 1839, 1S40, and 1841, is copied from a Register kept
for many years by my I'riend George S. Hollyday, Esq. of
Chestertown, a gentleman of well known accuracy and intelli-
gence. The blanks sometimes seen, mark the days or parts of days
when he was necessarily absent.
The thermometer (Fahrenheit's) is placed on the north-west
side of a large two-story brick house, in a porch with a roof.
JULY, 1839.
DAY
OF
MONTH.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
THERMOMETER.
A
r
MORN.
NOON.
NIGHT
74°
84
73
80
73
78
76
78
68
74
68
72
70
76
72
76
74
80
77
80
81
86
77
79
74
79
75
76
72
77
• »••••
74
79
76
76
75
82
79
86
80
86
80
84
81
89
81
86
77
86
77
85
81
86
81
87
76
84
76
82
78
84
80
87
STATE OF WEATHER.
S. clear and warm.
N. E. cloudy, rain.
N. cloudy, rain.
S. clear.
N. clear.
N. clear, gust, rain.
N. clear.
— rain, clear.
— clear, calm.
Do. do.
S. cloudy, overcast, rain.
S. W. clear.
13th, calm, overcast, rain.
S. cloudy, rain.
S. clear.
calm, clear.
Do. do. rain.
S. clear.
S. clear.
S. cloudy, clear.
S. E. cloudy.
S. clear, gust, rain.
N. W. clear.
N. clear, cloudy, rain.
N. E. cloudy, gust.
N. clear.
N. Do.
S. E. cloudy.
S. cloudy, mist.
S. clear.
S. E. rain, clear, gust.
18*
210
METEOROLOGICAL TABLES.
AUGUST, 1839.
D A y
THERMOMETER. |
^ 1
OF
f
\
MONTH.
MORN.
NOON.
NIGHT
1
78=^
84
2
75
76
3
73
78
4
74
80
5
72
82
6
74
82
7
77
83
8
76
* *
f)
79
10
73
79
11
74
80
12
76
85
13
74
78
14
73
79
15
72
, ,
1(>
71
69
17
66
72
18
71
73
• •••••
19
70
78
20
72
80
21
75
82
22
76
. ,
23
74
79
24
74
, ,
2.5
78
81
26
78
, ,
82*"
27
82
85
82
28
78
79
76
29
68
, ,
68
30
31
66i
64"
64
69
65
68
STATE OF WEATHER.
Calm, clear.
N. E. cloudy, rain.
N. cloudy.
N. clear.
calm, clear.
S. clear.
S. W. clear.
rain, S. cloudy,
rain, S. clear, N. W.
calm, clear, N. W.
calm, clear.
S. clear, gust, rain.
N. clear.
N. do.
N. do.
N. cloudy, much rain.
S. cloudy.
rain, cloudy.
N. cloudy.
N. do.
calm, gust, rain.
cloudy, gust, rain.
E. cloudy, rainy.
cloudy, S. E.
calm, rain,
do. clear.
S. W. clear, rain.
calm, cloudy, S. W.
N. cloudy, N. E. high wind.
N. E. heavy rain, calm.
N. W. clear.
METEOROLOGICAL TABLES.
211
SEPTEMBER, 1839.
DAY
THERMOMETER.
OF
■>
MONTH.
MORN.
NOON.
NIGHT
1
66°
2
66
71
72
3
67
74
71
4
70
74
74
5
71
, ,
74
6
75
80
78
7
75
82
79
8
78
79
79
9
79
85
82
10
75
76
75
11
72
, ,
71
12
68
69
^ ,
13
64
65
64
14
58
, ,
65
15
64
70
69
16
68
74
, ,
17
66
79
73
18
73
77
71
19
68
73
71
20
70
80
75
21
72
80
76
22
75
79
, ,
23
76
. ,
73
24
70
74
72
25
68
74
74
26
68
64
65
27
62
64
68
28
62
62
60
29
58
62
61
30
60
58
54
STATE OF WEATHER.
N. clear,
calm.
N. E. cloudy.
Rain, cloudy, N. E.
S. cloudy.
S. W. clear, cloudy.
S, clear.
S. E. cloudy, rain.
S. cloudy, clear.
N. W. cloudy, clear.
N. W. clear,
N. W. clear.
Do.
Calm, clear.
S. clear.
Calm, clear.
E. cloudy, rain.
S. E. cloudy, gust, S. rain.
N. W. clear.
Calm, clear.
Calm, clear, S.
S. clear.
N clear.
Calm, clear.
S. clear, wind,
N. W. clear, windy.
S. E. cloudy, rainy.
N. clear.
N. clear.
N. cloudy, rain.
212
METEOROLOGICAL TABLES.
JULY, 1840.
DAY
THERMOMETER.
A
OF
^
MONTH.
MORN.
NOON.
NIGHT
STATE OF WEATHER.
1
67°
72
66
N. clear.
2
65
64
60
N. cloudy, rain.
3
62
66
62
N. E. cloudy, rain.
4
65
, ,
65
N. clear.
5
66
80
67
Calm, clear, N. E.
6
65
66
61
N. E. cloudy, rain.
7
64
. .
68
N. cloudy, clear.
8
70
80
75
N. E. rainy, S.
9
74
, .
74
S. cloudy, rain.
10
73
83
75
S. clear.
11
76
84
77
Calm, clear, N.
12
79
92
78
S. clear.
13
78
, ,
79
S. cloudy, rain.
14
79
86
^ ^
N. clear, W.
15
, ,
, ,
Clear.
16
«
92
81
Clear, S.
17
79
94
82
S. E. cloudy, clear.
18
84
94
76
S. clear, gusty, rain.
19
78
89
78
S. cloudy, rain.
20
70
77
68
N. clear.
21
69
71
, ,
Calm, clear.
22
73
87
75
S. clear.
23
74
78
75
S. cloudy, rain.
24
75
. ,
72
N. W. cloudy.
25
70
81
71
N. cloudy, clear.
26
72
85
77
Calm, clear, S.
27
75
85
76
S. clear, S. E.
28
76
, ,
81
S. clear, cloudy.
29
79
86
76
S. cloudy, rain.
30
74
• •
78
S. cloudy,
31
75
80
75
Calm, S. E. rain.
METEOROLOGICAL TABLES.
213
AUGUST, 1840.
DAY
THERMOMETER.
A
OF
f
■\
MONTH.
MORN.
NOON.
NIGHT
1
73°
84
76
2
72
84
77
3
78
84
76
4
78
^ ,
78
5
78
84
76
6
74
85
79
7
72
78
65
8
68
71
. ,
9
70
78
68
10
67
73
, ^
11
76
, ,
79
12
77
, ,
79
13
75
^ ^
72
14
71
, ,
^ ^
15
72
84
76
16
72
81
73
17
72
• •
73
18
71
81
73
19
73
, ,
74
20
75
86
76
21
78
^ ^
80
22
79
90
82
23
80
91
76
24
73
82
74
25
70
80
69
26
65
^ ^
66
27
66
. ,
70
28
68
^ ,
74
29
70
^ ,
74
30
75
85
76
31
76
85
74
STATE OF WEATHER,
N. cloudy, S. clear.
rain, S. cloudy.
S. cloudy, rain, gust, clear.
S. clear, cloudy.
S. clear.
Calm, cloudy, S.
Calm, N.
N. clear.
N. W. clear.
N. clear.
S.
S. cloudy.
S. E. cloudy, rain.
N. W. clear, rain.
N. clear.
N. cloudy.
N. cloudy.
N. E. cloudy.
S. clear.
S. clear.
S. clear.
Do.
S. clear, gust, rain.
N. W. clear, cloudy.
N. clear.
N. clear.
N. clear.
N. clear, cloudy.
calm, clear.
S. E. cloudy, S.
S. cloudy.
214
METEOROLOGICAL TABLES.
SEPTEMBER, 1840.
DAY
THERMOMETER.
OF
r
^
MONTH.
MORN,
NOON.
NIGHT
STATE OF WEATHER.
1
70
80
68
S. clear.
2
70
80
75
S. clear, rain.
3
67
72
%Q
N. cloudy, calm, clear.
4
59
. .
62
N. E. cloady, rainy.
5
60
62
61
S. E. cloudy, rain.
6
63
72
64
N. clear, calm.
7
60
79
66
Calm, clear, S.
8
65
78
70
S. cloudy, clear.
9
69
78
72
S. cloudy.
10
73
80
62
S. cloudy, rain, clear.
11
59
, .
58
N. E. cloudy, clear.
12
53
63
56
N. W. clear.
13
55
68
58
N. W. clear.
14
56
70
62
N. clear, calm.
15
61
70
65
Calm, clear.
16
60
80
66
Calm, foggy.
17
65
, ,
68
S. clear, rain.
18
63
59
57
N. rain.
19
58
, ,
58
N. W. clear.
20
62
72
64
S. clear, rainy.
21
58
62
52
N. W. clear.
22
48
55
50
N. W. clear.
23
50
, ,
58
Calm, clear.
24
58
71
60
N. clear.
25
54
70
60
N. foggy, calm, clear.
26
56
61
N. clear.
27
65
70
56
S. cloudy, rain, clear.
28
55
• •
54
N. W. clear.
29
51
58
58
Calm, foggy, S. clear.
30
' 60
60
S. cloudy.
METEOROLOGICAL TABLES.
215
JULY, 184L
DAY
OF j
THERMOMETER. 1
f
>
MONTH. MORN.
NOON.
NIGHT
1
82
87
79
2
78
81
73
3
66
67
4
64
68
5
74
79
6
76
80
7
84
68
8
66
6S
9
68
^ ^
76
10
73
• •
70
11
67
73
66
12
68
76
72
13
74
83 •
79
14
79
87
80
15
80
86
80
16
76
86
71
17
70
79
71
18
71
82
74
19
72
74
78
20
86
76
21
, ,
85
76
22
76
82
80
23
80
87
81
24
82
89
83
25
83
90
77
26
75
79
27 f ..
^ ^
28 ..
^ ^
• •
29 ..
• •
, ^
30 I 74
^ ^
69
31
! 68
76
64
STATE OF WEATHER.
S. W. clear.
N. cloudy.
N. clear, calm.
N. Clear.
S. clear, rain.
N. clear, cloudy.
N. E. rain.
N. W. clear.
N. W. clear.
S. cloudy.
N. clear.
N. clear.
S. cloudy, clear.
S. cloudy, clear.
S. cloudy, clear.
N. clear.
N. clear.
Calm, clear.
S. cloudy.
S. cloudy, clear.
S. cloudy.
S. cloudy, clear.
S. clear.
S. clear.
S. cloudy, rain.
N. clear.
S. rain.
N. cloudy, rain.
216
METEOROLOGICAL TABLES.
AUGUST, 1841.
DAY
THERMOMETER. 1
OF
'
■\
MONTH.
MORN.
NOON.
NIGHT
STATE OF WEATHER.
1
2
65
68
79
65
69
N. cloudy.
Calm, clear.
3
4
69
75
••
71
76
N. cloudy.
S. clear, rain, thunder.
5
74
77
72
Rain.
6
71
, ,
73
N. clear, calm.
7
72
, ,
72
Calm, clear.
8
76
80
75
S. clear.
9
• •
80
78
Rain, S.
10
11
12
13
80
75
70
71
79
76
74
70
73
S. cloudy, rainy, hard.
S. cloudy, rainy.
N. cloudy.
Calm, cfoudy.
14
15
16
71
70
67
81
78
73
70
68
Calm, cloudy.
N. cloudy, clear.
N. clear.
17
68
77
68
Calm, clear.
18
65
. ,
68
Calm, cloudy.
19
20
65
81
74
78
ff'oggy, calm, S. clear.
pCalm, clear.
21
22
75
77
88
74
71
S. cloudy, rain, thunder.
N. clear.
23
24
25
26
27
69
67
66
66
70
77
77
77
67
70
66
69
73
N. cloudy, clear.
Calm, cloudy, N.
N. cloudy.
N. E. cloudy, rain.
Rain, calm, S.
28
29
30
73
76
73
84
75
78
75
N. E. cloudy, clear.
Calm, cloudy, S. clear.
Rain, N. clear.
31
70
80
72
S.
METEOROLOGICAL TABLES.
217
SEPTEMBER, 1841.
D A Y I TH ERMOMETER.
MONTH. MORN. NOON. NIGHT
1
70°
2
77
3
80
4
80
5
74
6
74
7
73
8
70
9
68
10
68
11
68
12
75
13
71
14
68
15
63
16
65
17
60
18
61
19
62
20
, ^
21
64
22
65
23
66
24
62
25
72
26
63
27
61
28
69
29
, ,
30
, ,
79
86
84
80
80
76
78
71
75
72
72
78
80
77
71
72
70
70
71
68
72
73
68
64
65
57
66
65
65
64
72
72
64
66
64
STATE OP WEATHER.
Calm, clear, N.
S. clear.
S. clear.
S. cloudy.
X. W. clear.
N. clear, S. clear.
N. E. cloudy.
N". clear.
IV. clear.
N. E. cloudy.
Calm, clear.
N. cloudy.
X. cloudy, clear.
X. clear.
N. clear, cloudy.
X. E. cloudy.
N. E. rain.
N. W. clear.
lV. clear.
Calm, cloudy, clear.
N. cloudy,
S. cloudy, rain.
Calm, cloudy.
S. E. cloudy, N. W. clear
S. clear.
S. clear.
S. cloudy.
f
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