Chapter IX: Part 9

10, As the Organs of Digestion have been considerably weakened through the Course of this Fever, there is a Necessity for the Patient's conducting himself very prudently and regularly long after it, with Regard both to the Quantity and Quality of his Food. He should also use due Exercise as soon as his Strength will permit, without which he may be liable to fall into some chronical and languishing Disorder, productive of considerable Languor and Weakness. *

[*] As our Jail, Hospital, and Camp Fevers may often be ranged in this
Class, as of the most putrid Kind, and not seldom occasioned by bad
Food, bad Air, unclean, unwholesome Lodging, _&c._ a judicious Use
may certainly be made of a small Quantity of genuine, and not
ungenerous, Wine in such of them, as are not blended with an
inflammatory Cause, or inflammable Constitution, or which do not
greatly result from a bilious Cause; though in these last, where
there is manifest Lowness and Dejection, perhaps a little Rhenish
might be properly interposed between the Lemonade and other Drinks
directed Sec. 241. Doubtless Dr. _Tissot_ was perfectly apprized of
this salutary Use of it in some low Fevers; but the Necessity of
its being regulated by the Presence of a Physician has probably
disposed him rather to omit mentioning it, than to leave the
Allowance of it to the Discretion of a simple Country Patient, or
his ignorant Assistants. _K._

__Chapter XVII.__

_Of malignant Fevers._

__Sect.__ 242.

Those Fevers are termed malignant, in which the Danger is more than the Symptoms would make us apprehensive of: they have frequently a fatal Event without appearing so very perilous; on which Account it has been well said of this Fever, that it is a Dog which bites without barking.

Sec. 243. The distinguishing _Criterion_ or Mark of malignant Fevers is a total Loss of the Patient's Strength, immediately on their first Attack. They arise from a Corruption of the Humours, which is noxious to the very Source and Principle of Strength, the Impairing or Destruction of which is the Cause of the Feebleness of the Symptoms; by Reason none of the Organs are strong enough to exert an Opposition sufficiently vigorous, to subdue the Cause of the Distemper.

If, for Instance or Illustration, we were to suppose, that when two Armies were on the Point of engaging, one of them should be nearly deprived of all their Weapons, the Contest would not appear very violent, nor attended with great Noise or Tumult, though with a horrible Massacre. The Spectator, who, from being ignorant of one of the Armies being disarmed, would not be able to calculate the Carnage of the Battle, but in Proportion to its Noise and Tumult, must be extremely deceived in his Conception of it. The Number of the Slain would be astonishing, which might have been much less (though the Noise and Clangor of it had been greater) if each Army had been equally provided for the Combat.

Sec. 244. The Causes of this Disease are a long Use of animal Food or Flesh alone, without Pulse, Fruits or Acids; the continued Use of other bad Provisions, such as Bread made of damaged Corn or Grain, or very stale Meat. Eight Persons, who dined together on corrupt Fish, were all seized with a malignant Fever, which killed five of them, notwithstanding the Endeavours of the most able Physicians. These Fevers are also frequently the Consequence of a great Dearth or Famine; of too hot and moist an Air, or an Air, which highly partakes of these two Qualities; so that they happen to spread most in hot Years, in Places abounding with Marshes and standing Waters. They are also the Effect of a very close and stagnant Air, especially if many Persons are crouded together in it, this being a Cause that particularly tends to corrupt the Air. Tedious Grief and Vexation also contribute to generate these Fevers.

Sec. 245. The Symptoms of malignant Fevers are, as I have already observed, a total and sudden Loss of Strength, without any evident preceding Cause, sufficient to produce such a Privation of Strength: at the same Time there is also an utter Dejection of the Mind, which becomes almost insensible and inattentive to every Thing, and even to the Disease itself; a sudden Alteration in the Countenance, especially in the Eyes: some small Shiverings, which are varied throughout the Space of twenty-four Hours, with little Paroxysms or Vicissitudes of Heat; sometimes there is a great Head-ach and a Pain in the Loins; at other Times there is no perceivable Pain in any Part; a kind of Sinkings or Faintings, immediately from the Invasion of the Disease, which is always very unpromising; not the least refreshing Sleep; frequently a kind of half Sleep, or Drowsiness; a light and silent or inward Raving, which discovers itself in the unusual and astonished Look of the Patient, who seems profoundly employed in meditating on something, but really thinks of nothing, or not at all: Some Patients have, however, violent Ravings; most have a Sensation of Weight or Oppression, and at other Times of a Binding or Tightness about, or around, the Pit of the Stomach.

The sick Person seems to labour under great Anguish: he has sometimes slight convulsive Motions and Twitchings in his Face and his Hands, as well as in his Arms and Legs. His Senses seem torpid, or as it were benumbed. I have seen many who had lost, to all Appearance, the whole five, and yet some of them recover. It is not uncommon to meet with some, who neither see, understand, nor speak. Their Voices change, become weak, and are sometimes quite lost. Some of them have a fixed Pain in some Part of the Belly: this arises from a Stuffing or Obstruction, and often ends in a Gangrene, whence this Symptom is highly dangerous and perplexing.

The Tongue is sometimes very little altered from its Appearance in Health; at other Times covered over with a yellowish brown Humour; but it is more rarely dry in this Fever than in the others; and yet it sometimes does resemble a Tongue that has been long smoaked.

The Belly is sometimes very soft, and at other Times tense and hard. The Pulse is weak, sometimes pretty regular, but always more quick than in a natural State, and at some Times even very quick; and such I have always found it, when the Belly has been distended.

The Skin is often neither hot, dry, nor moist: it is frequently overspread with petechial or eruptive Spots (which are little Spots of a reddish livid Colour) especially on the Neck, about the Shoulders, and upon the Back. At other Times the Spots are larger and brown, like the Colour of Wheals from the Strokes of a Stick.

The Urine of the Sick is almost constantly crude, that is of a lighter Colour than ordinary. I have seen some, which could not be distinguished, merely by the Eye, from Milk. A black and stinking Purging sometimes attends this Fever, which is mortal, except the Sick be evidently relieved by the Discharge.

Some of the Patients are infested with livid Ulcers on the Inside of the Mouth, and on the Palate. At other Times Abscesses are formed in the Glands of the Groin, of the Arm-pit, in those between the Ears and the Jaw; or a Gangrene may appear in some Part, as on the Feet, the Hands, or the Back. The Strength proves entirely spent, the Brain is wholly confused: the miserable Patient stretched out on his Back, frequently expires under Convulsions, an enormous Sweat, and an oppressed Breast and Respiration. Haemorrhages also happen sometimes and are mortal, being almost unexceptionably such in this Fever. There is also in this, as in all other Fevers, an Aggravation of the Fever in the Evening.

Sec. 246. The Duration and _Crisis_ of these malignant, as well as those of putrid Fevers, are very irregular. Sometimes the Sick die on the seventh or eighth Day, more commonly between the twelfth and the fifteenth, and not infrequently at the End of five or six Weeks. These different Durations result from the different Degree and Strength of the Disease. Some of these Fevers at their first Invasion are very slow; and during a few of the first Days, the Patient, though very weak, and with a very different Look and Manner, scarcely thinks himself sick.

The Term or Period of the Cure or the Recovery, is as uncertain as that of Death in this Distemper. Some are out of Danger at the End of fifteen Days, and even sooner; others not before the Expiration of several Weeks.

The Signs which portend a Recovery are, a little more Strength in the Pulse; a more concocted Urine; less Dejection and Discouragement; a less confused Brain; an equal kindly Heat; a pretty warm or hot Sweat in a moderate Quantity, without Inquietude or Anguish; the Revival of the different Senses that were extinguished, or greatly suspended in the Progress of the Disease; though the Deafness is not a very threatening Symptom, if the others amend while it endures.

This Malady commonly leaves the Patient in a very weak Condition; and a long Interval will ensue between the End of it, and their recovering their full Strength.

Sec. 247. It is, in the first place, of greater Importance in this Distemper than in any other, both for the Benefit of the Patients, and those who attend them, that the Air should be renewed and purified. Vinegar should often be evaporated from a hot Tile or Iron in the Chamber, and one Window kept almost constantly open.

2, The Diet should be light; and the Juice of Sorrel may be mixed with their Water; the Juice of Lemons may be added to Soups prepared from different Grains and Pulse; the Patient may eat sharp acid Fruits, such as tart juicy [65] Cherries, Gooseberries, small black Cherries; and those who can afford them, may be allowed Lemons, Oranges and Pomgranates.

[65] The French Word is _Griettes_, which _Beyer_ englishes, _the
Agriot, the red or sour Cherry_; and _Chambaud, the sweeter large
black Cherry or Mazzard_--But as Dr. _Tissot_ was recommending the
Use of Acids, it is more probably the first of these: so that our
Morellas, which make a pleasant Preserve, may be a good Substitute
to them, supposing them not to be the same. Our Berbery Jam, and
Jelly of Red Currants, may be also employed to answer the same
Indication. _K._

3, The Patient's Linen should be changed every two Days.

4, Bleeding is very rarely necessary, or even proper, in this Fever; the Exceptions to which are very few, and cannot be thoroughly ascertained, as fit and proper Exceptions to the Omission of Bleeding, without a Physician, or some other very skilful Person's seeing the Patient.

5, There is often very little Occasion for Glysters, which are sometimes dangerous in this Fever.

6, The Patient's common Drink should be Barley Water made acid with the Spirit No. 10, at the Rate of one Quarter of an Ounce to at least full three Pints of the Water, or acidulated agreeably to his Taste. He may also drink Lemonade.

7, It is necessary to open and evacuate the Bowels, where a great Quantity of corrupt Humours is generally lodged. The Powder No. 35 may be given for this Purpose, after the Operation of which the Patient generally finds himself better, at least for some Hours. It is of Importance not to omit this at the Beginning of the Disease; though if it has been omitted at first, it were best to give it even later, provided no particular Inflammation has supervened, and the Patient has still some Strength. I have given it, and with remarkable Success, on the twentieth Day.

8, Having by this Medicine expelled a considerable Portion of the bad Humours, which contribute to feed and keep up the Fever, the Patient should take every other Day, during the Continuance of the Disease, and sometimes even every Day, one Dose of the Cream of Tartar and Rhubarb No. 38. This Remedy evacuates the corrupt Humours, prevents the Corruption of the others; expells the Worms that are very common in these Fevers, which the Patient sometimes discharges upwards and downwards; and which frequently conduce to many of the odd and extraordinary Symptoms, that are observed in malignant Fevers. In short it strengthens the Bowels, and, without checking the necessary Evacuations, it moderates the Looseness, when it is hurtful.

9, If the Skin be dry, with a Looseness, and that by checking it, we design to increase Perspiration, instead of the Rhubarb, the Cream of Tartar may be blended with the Ipecacuana, No. 39, which, being given in small and frequent Doses, restrains the Purging, and promotes Perspiration. This Medicine, as the former, is to be taken in the Morning; two Hours after, the Sick must begin with the Potion No. 40, and repeat it regularly every three Hours; until it be interrupted by giving one of the Medicines No. 38 or 39: After which the Potion is to be repeated again, as already directed, till the Patient grows considerably better.

10, If the Strength of the Sick be very considerably depressed, and he is in great Dejection and Anguish, he should take, with every Draught of the Potion, the Bolus, or Morsel No. 41. If the _Diarrhoea_, the Purging is violent, there should be added, once or twice a Day to the Bolus, the Weight of twenty Grains, or the Size of a very small Bean, of _Diascordium_; or if that is not readily to be got, as much Venice Treacle.

11, Whenever, notwithstanding all this Assistance, the Patient continues in a State of Weakness and Insensibility, two large Blisters should be applied to the fleshy Insides of the Legs, or a large one to the Nape of the Neck: and sometimes, if there be a great Drowsiness, with a manifest Embarrassment of the Brain, they may be applied with great Success over the whole Head. Their Suppuration and Discharge is to be promoted abundantly; and, if they dry up within a few Days, others are to be applied, and their Evacuation is to be kept up for a considerable Time.

12, As soon as the Distemper is sufficiently abated, for the Patient to remain some Hours with very little or no Fever, we must avail ourselves of this Interval, to give him six, or at least five Doses of the Medicine No. 14, and repeat the same the next Day, which may prevent the Return of the Fever: [66] after which it may be sufficient to give daily only two Doses for a few Days.

[66] Observation and Experience have demonstrated the Advantage of the
Bark, to obviate a Gangrene, and prevent the Putrefaction of animal
Substances. We therefore conclude it may be usefully employed in
malignant Fevers, as soon as the previous and necessary Evacuations
shall have taken Place. _E. L._--Provided there be very clear and
regular Remissions at least. _K._

13, When the Sick continue entirely clear of a Fever, or any Return, they are to be put into the _Regimen_ of Persons in a State of Recovery. But if his Strength returns very slowly, or not at all; in Order to the speedier Establishment and Confirmation of it, he may take three Doses a Day of the _Theriaca Pauperum_, or poor Man's Treacle No. 42, the first of them fasting, and the other twelve Hours after. It were to be wished indeed, this Medicine was introduced into all the Apothecaries Shops, as an excellent Stomachic, in which Respect it is much preferable to Venice Treacle, which is an absurd Composition, dear and often dangerous. It is true it does not dispose the Patients to Sleep; but when we would procure them Sleep, there are better Medicines than the Treacle to answer that Purpose. Such as may not think the Expence of the Medicine No. 14, too much, may take three Doses of it daily for some Weeks, instead of the Medicine No. 42, already directed.

Sec. 248. It is necessary to eradicate a Prejudice that prevails among Country People, with Regard to the Treatment of these Fevers; not only because it is false and ridiculous, but even dangerous too. They imagine that the Application of Animals can draw out the Poison of the Disease; in Consequence of which they apply Poultry, or Pigeons, Cats or sucking Pigs to the Feet, or upon the Head of the Patient, having first split the living Animals open. Some Hours after they remove their strange Applications, corrupted, and stinking very offensively; and then ascribe such Corruption and horrid Stink to the Poison they suppose their Application to be charged with; and which they suppose to be the Cause of this Fever. But in this supposed Extraction of Poison, they are grosly mistaken, since the Flesh does not stink in Consequence of any such Extraction, but from its being corrupted through Moisture and Heat: and they contract no other Smell but what they would have got, if they had been put in any other Place, as well as on the Patient's Body, that was equally hot and moist. Very far from drawing out the Poison, they augment the Corruption of the Disease; and it would be sufficient to communicate it to a sound Person, if he was to suffer many of these animal Bodies, thus absurdly and uselessly butchered, to be applied to various Parts of his Body in Bed; and to lie still a long Time with their putrified Carcases fastened about him, and corrupting whatever Air he breathed there.

With the same Intention they fasten a living Sheep to the Bed's-foot for several Hours; which, though not equally dangerous, is in some Measure hurtful, since the more Animals there are in a Chamber, the Air of it is proportionably corrupted, or altered at least from its natural Simplicity, by their Respiration and Exhalations: but admitting this to be less pernicious, it is equally absurd. It is certain indeed, the Animals who are kept very near the sick Person breathe in the poisonous, or noxious Vapours which exhale from his Body, and may be incommoded with them, as well as his Attendants: But it is ridiculous to suppose their being kept near the Sick causes such Poison to come out of their Bodies. On the very contrary, in contributing still further to the Corruption of the Air, they increase the Disease. They draw a false Consequence, and no Wonder, from a false Principle; saying, if the Sheep dies, the Sick will recover. Now, most frequently the Sheep does not die; notwithstanding which the Sick sometimes recover; and sometimes they both die.

Sec. 249. The Cause of Malignant Fevers is, not infrequently, combined with other Diseases, whose Danger it extremely increases. It is blended for Instance, with the Poison of the Small-Pocks, or of the Measles. This may be known by the Union of those Symptoms, which carry the Marks of Malignity, with the Symptoms of the other Diseases. Such combined Cases are extremely dangerous; they demand the utmost Attention of the Physician; nor is it possible to prescribe their exact Treatment here; since it consists in general of a Mixture of the Treatment of each Disease; though the Malignity commonly demands the greatest Attention.

__Chapter XVIII.__

_Of intermitting Fevers._

__Sect.__ 250.

Intermitting Fevers, commonly called here, Fevers and Agues, are those, which after an Invasion and Continuance for some Hours, abate very perceivably, as well as all the Symptoms attending them, and then entirely cease; nevertheless, not without some periodical or stated Return of them.

They were very frequent with us some Years since; and indeed might even be called epidemical: but for the five or six last Years, they have been much less frequent throughout the greater Part of _Swisserland_: notwithstanding they still continue in no small Number in all Places, where the Inhabitants breathe the Air that prevails in all the marshy Borders of the _Rhone_, and in some other Situations that are exposed to much the same humid Air and Exhalations.

Sec. 251. There are several Kinds of intermitting Fevers, which take their different Names from the Interval or different Space of Time, in which the Fits return.

If the Paroxysm or Fit returns every Day, it is either a true Quotidian, or a double Tertian Fever: The first of these may be distinguished from the last by this Circumstance, that in the Quotidian, or one Day Fever, the Fits are long; and correspond pretty regularly to each other in Degree and Duration. This however is less frequent in _Swisserland_. In the double Tertian, the Fits are shorter, and one is alternately light, and the other more severe.

In the simple Tertian, or third Day's Fever, the Fits return every other Day; so that three Days include one Paroxysm, and the Return of another.

In a Quartan, the Fit returns every fourth Day, including the Day of the first and that of the second Attack: so that the Patient enjoys two clear Days between the two sick ones.

The other kinds of Intermittents are much rarer. I have seen however one true Quintan, or fifth Day Ague, the Patient having three clear Days between two Fits; and one regularly weekly Ague, as it may be called, the Visitation of every Return happening every Sunday.

Sec. 252. The first Attack of an intermittent Fever often happens, when the Patient thought himself in perfect Health. Sometimes however it is preceded by a Sensation of Cold and a kind of Numbness, which continue some Days before the manifest Invasion of the Fit. It begins with frequent Yawnings, a Lassitude, or Sensation of Weariness, with a general Weakness, with Coldness, Shivering and Shaking: There is also a Paleness of the extreme Parts of the Body, attended with Loathings, and sometimes an actual Vomiting. The Pulse is quick, weak, and small, and there is a considerable Degree of Thirst.

At the End of an Hour or two, and but seldom so long as three or four Hours, a Heat succeeds, which increases insensibly, and becomes violent at its Height. At this Period the whole Body grows red, the Anxiety of the Patient abates; the Pulse is very strong and large, and his Thirst proves excessive. He complains of a violent Head-ach, and of a Pain in all his Limbs, but of a different sort of Pain from that he was sensible of, while his Coldness continued. Finally, having endured this hot State, four, five or six Hours, he falls into a general Sweat for a few more: upon which all the Symptoms already mentioned abate, and sometimes Sleep supervenes.

At the Conclusion of this Nap the Patient often wakes without any sensible Fever; complaining only of Lassitude and Weakness. Sometimes his Pulse returns entirely to its natural State between the two Fits; though it often continues a little quicker than in perfect Health; and does not recover its first Distinctness and Slowness, till some Days after the last Fit.

One Symptom, which most particularly characterises these several Species of intermitting Fevers, is the Quality of the Urines which the Sick pass after the Fit. They are of a reddish Colour, and let fall a Sediment, or Settling, which exactly resembles Brick-dust. They are sometimes frothy too, and a Pellicle, or thin filmy Skin, appears on the Top, and adheres to the Sides of the Glass that contains them.

Sec. 253. The Duration of each Fit is of no fixed Time or Extent, being various according to the particular sort of Intermittents, and through many other Circumstances. Sometimes they return precisely at the very same Hour; at other Times they come one, two, or three Hours sooner, and in other Instances as much later than the former. It has been imagined that those Fevers, whose Paroxysms returned sooner than usual, were sooner finally terminated: but there seems to be no general Rule in this Case.

Sec. 254. Intermitting Fevers are distinguished into those of Spring and Autumn. The former generally prevail from February to June: the latter are those which reign from July to January. Their essential Nature and Characters are the very same, as they are not different Distempers; though the various Circumstances attending them deserve our Consideration. These Circumstances depend on the Season itself, and the Constitution of the Patients, during such Seasons. The Spring Intermittents are sometimes blended with an inflammatory Disposition, as that is the Disposition of Bodies in that Season; but as the Weather then advances daily into an improving State, the Spring Fevers are commonly of a shorter Duration. The autumnal Fevers are frequently combined and aggravated with a Principle of Putrefaction; and as the Air of that Season rather degenerates, they are more tedious and obstinate.

Sec. 255. The autumnal Fevers seldom begin quite so early as July, but much oftner in August: and the Duration to which they are often extended, has increased the Terror which the People entertain of Fevers that begin in that Month. But that Prejudice which ascribes their Danger to the Influence of August, is a very absurd Error; since it is better they should set in then than in the following Months; because they are obstinate in Proportion to the Tardiness, the Slowness of their Approach. They sometimes appear at first considerably in the Form of putrid Fevers, not assuming that of Intermittents till some Days after their Appearance: but very happily there is little or no Danger in mistaking them for putrid Fevers, or in treating them like such. The Brick-coloured Sediment, and particularly the Pellicle or Film on the Surface of the Urine, are very common in autumnal Intermittents, and are often wanting in the Urine of putrid Fevers. In these latter, it is generally less high coloured, and leaning rather to a yellow, a kind of Cloudiness is suspended in the Middle of it. These also deposite a white Sediment, which affords no bad Prognostic.

Sec. 256. Generally speaking, intermitting Fevers are not mortal; often terminating in Health of their own Accord (without the Use of any Medicine) after some Fits. In this last Respect Intermittents in the Spring differ considerably from those in the Fall, which continue a long Time, and sometimes even until Spring, if they are not removed by Art, or if they have been improperly treated.

Quartan Fevers are always more obstinate and inveterate than Tertians; the former sometimes persevering in certain Constitutions for whole Years. When these Sorts of Fevers occur in boggy marshy Countries, they are not only very chronical or tedious, but Persons infested with them are liable to frequent Relapses.

Sec. 257. A few Fits of an Intermittent are not very injurious, and it happens sometimes, that they are attended with a favourable Alteration of the Habit in Point of Health; by their exterminating the Cause or Principle of some languid and tedious Disorder; though it is erroneous to consider them as salutary. If they prove tedious and obstinate, and the Fits are long and violent, they weaken the whole Body, impairing all its Functions, and particularly the Digestions: They make the Humours sharp and unbalmy, and introduce several other Maladies, such as the Jaundice, Dropsy, Asthma and slow wasting Fevers. Nay sometimes old Persons, and those who are very weak, expire in the Fit; though such an Event never happens but in the cold Fit.

Sec. 258. Very happily Nature has afforded us a Medicine, that infallibly cures these Fevers: this is the _Kinkina_, or Jesuits Bark; and as we are possessed of this certain Remedy, the only remaining Difficulty is to discover, if there be not some other Disease combined with these Fevers, which Disease might be aggravated by the Bark. Should any such exist, it must be removed by Medicines adapted to it, before the Bark is given. [67]

[67] This admirable Medicine was unknown in Europe, till about one
hundred and twenty Years past; we are obliged to the Spaniards for
it, who found it in the Province of Quito in Peru; the Countess of
Chinchon being the first European who used it in America, whence it
was brought to Spain, under the Name of the Countesses Powder. The
Jesuits having soon dispensed and distributed it abroad, it became
still more publick by the Name of the Jesuits Powder: and since it
has been known by that of _Kinkina_ or the Peruvian Bark. It met
with great Opposition at first; some deeming it a Poison, while
others considered it as a divine Remedy: so that the Prejudices of
many being heightened by their Animosity, it was nearly a full
Century, before its true Virtue and its Use were agreed to: and
about twenty Years since the most unfavourable Prejudices against
it pretty generally subsided. The Insufficience of other Medicines
in several Cases; its great Efficaciousness; and the many and
surprizing Cures which it did, and daily does effect; the Number of
Distempers; the different kinds of Fevers, in which it proves the
sovereign Remedy; its Effects in the most difficult chirurgical
Cases; the Comfort, the Strength and Sprits it gives those who need
and take it, have at length opened every Persons Eyes; so that it
has almost unanimously obtained the first Reputation, among the
most efficacious Medicines. The World is no longer amused with
Apprehensions of its injuring the Stomach; of its fixing, or
_shutting up_ the Fever (as the Phrase has been) without curing it;
that it shuts up the Wolf in the Sheepfold; that it throws those
who take it into the Scurvy, the Asthma, the Dropsy, the Jaundice.
On the contrary they are persuaded it prevents there very Diseases;
and, that if it is ever hurtful, it is only when it is either
adulterated, as most great Remedies have been; or has been wrongly
prescribed, or improperly taken: or lastly when it meets with some
latent, some unknown Particularities in a Constitution, which
Physicians term an _Idiosyncrasy_, and which prevent or pervert its
very general Effects. _Tissot._

Sec. 259. In the vernal, or Spring-Fevers, if the Fits are not very severe; if the Patient is evidently well in their Intervals; if his Appetite, his Strength, and his Sleep continue as in Health, no Medicine should be given, nor any other Method be taken, but that of putting the Person, under such a gentle Intermittent, upon the Regimen directed for Persons in a State of Recovery. This is such a Regimen as pretty generally agrees with all the Subjects of these Fevers: for if they should be reduced to the Regimen proper in acute Diseases, they would be weakened to no Purpose, and perhaps be the worse for it. But at the same Time if we were not to retrench from the Quantity, nor somewhat to vary the Quality of their usual Food in a State of Health; as there is not the least Digestion made in the Stomach, during the whole Term of the Fit; and as the Stomach is always weakened a little by the Disease, crude and indigested Humours would be produced, which might afford a Fuel to the Disease. Not the least solid Food should be allowed, for at least two Hours before the usual Approach of the Fit.

Sec. 260. If the Fever extends beyond the sixth, or the seventh Fit; and the Patient seems to have no Occasion for a Purge; which may be learned by attending to the Chapter, which treats of Remedies to be taken by Way of Precaution; [68] he may take the Bark, that is the Powder No. 14. If it is a Quotidian, a daily Fever, or a double Tertian, six Doses, containing three Quarters of an Ounce, should be taken between the two Fits; and as these Intermissions commonly consist of but ten or twelve, or at the most of fourteen or fifteen Hours, there should be an Interval of only one Hour and a half between each Dose. During this Interval the Sick may take two of his usual Refreshments or Suppings.

[68] It happens very seldom that intermitting Fevers require [69] no
Purge towards their Cure, especially in Places, which are disposed
to generate Putridity. There is always some material Cause
essential to these Fevers, of which Nature disembarrasses herself
more easily by Stools, than by any other Discharge: And as there is
not the least Danger to be apprehended from a gentle Purge, such at
those of No. 11 or 23, we think it would be prudent always to
premise a Dose or two of either to the Bark. _E. L._

[69] Yet I have known many in whom no Purge was necessary, and have seen
some rendered more obstinate and chronical by erroneous Purging.
But a Vomit is very generally necessary before the Bark is given.
_K._

When the Fever is a Tertian, an Ounce should be given between the two Fits: which makes eight Doses, one of which is to be taken every three Hours.

In a Quartan I direct one Ounce and a half, to be taken in the same Manner. It is meer trifling to attempt preventing the Returns with smaller Doses. The frequent Failures of the Bark are owing to over small Doses. On such Occasions the Medicine is cried down, and censured as useless, when the Disappointment is solely the Fault of those who do not employ it properly. The last Dose is to be given two Hours before the usual Return of the Fit.

The Doses, just mentioned, frequently prevent the Return of the Fit; but whether it returns or not, after the Time of its usual Duration is past, repeat the same Quantity, in the same Number of Doses, and Intervals, which certainly keeps off another. For six Days following, half the same Quantity must be continued, in the Intervals that would have occurred between the Fits, if they had returned: and during all this Time the Patient should inure himself to as much Exercise, as he can well bear.

Sec. 261. Should the Fits be very strong, the Pain of the Head violent, the Visage red, the Pulse full and hard; if there is any Cough; if, even after the Fit is over, the Pulse still is perceivably hard; if the Urine is inflamed, hot and high-coloured, and the Tongue very dry, the Patient must be bled, and drink plentifully of Barley Water No. 3. These two Remedies generally bring the Patient into the State described Sec. 259: in which State he may take on a Day, when the Fever is entirely off, three or four Doses of the Powder No. 24, and then leave the Fever to pursue its own Course for the Space of a few Fits. But should it not then terminate of itself, the Bark must be recurred to.

If the Patient, even in the Interval of the Returns, has a foetid, furred Mouth, a Loathing, Pains in the Loins, or in the Knees, much Anxiety, and bad Nights, he should be purged with the Powder No. 21 or the Potion No. 23, before he takes the Bark.

Sec. 262. If Fevers in Autumn appear to be of the continual kind, and very like putrid Fevers, the Patients should drink abundantly of Barley Water; and if at the Expiration of two or three Days, there still appears to be a Load or Oppression at the Stomach, the Powder No. 34 or that of 35 is to be given (but see Sec. 241): and if, after the Operation of this, the Signs of Putridity continue, the Body is to be opened with repeated Doses of the Powder No. 24; or, where the Patients are very robust, with No. 21; and when the Fever becomes quite regular, with distinct _Remissions_ at least, the Bark is to be given as directed Sec. 260.

But as autumnal Fevers are more obstinate; after having discontinued the Bark for eight Days; and notwithstanding there has been no Return of the Fever, it is proper to resume the Bark, and to give three Doses of it daily for the succeeding eight Days, more especially if it was a Quartan; in which Species I have ordered it to be repeated, every other eight Days, for six Times.

Many People may find it difficult to comply with this Method of Cure, which is unavoidably expensive, through the Price of the Bark. I thought however this ought not to prevent me from averring it to be the only certain one; since nothing can be an equivalent _Succedaneum_ or Substitute to this Remedy, which is the only sure and safe one in all these Cases. The World had long been prepossessed with Prejudices to the contrary: it was supposed to be hurtful to the Stomach; to prevent which it has been usual to make the Sick eat something an Hour after it. Nevertheless, very far from injuring the Stomach, it is the best Medicine in the Universe to strengthen it; and it is a pernicious Custom, when a Patient is obliged to take it often, to eat an Hour after it. It had also been imagined to cause Obstructions, and that it subjected Patients to a Dropsy: but at present we are convinced, it is the obstinate and inveterate Duration of the Intermittent, that causes Obstructions, and paves the Way to a Dropsy. The Bark, in Consequence of its speedily curing the Fever, does not only prevent the former Disease; but when it continues, through an injudicious Omission of the Bark, a proper Use of it is serviceable in the Dropsy. In a Word, if there is any other Malady combined with the Fever, sometimes that indeed prevents the Success of the Bark, yet without rendering it hurtful. But whenever the intermitting Fever is simple and uncombined, it ever has, and ever will render the Patient all possible Service. In another Place I shall mention such Means and Methods as may in some Degree, though but imperfectly, be substituted instead of it.

After the Patient has begun with the Bark, he must take no purging Medicine, as that Evacuation would, with the greatest Probability, occasion a Return of the Fever.

Sec. 263. Bleeding is never, or extremely seldom indeed necessary in a Quartan Ague, which occurs in the Fall oftner than in the Spring; and with the Symptoms of Putridity rather than of Inflammation.

Sec. 264. The Patient ought, two Hours before the Invasion of the Fit, to drink a small Glass of warm Elder Flower Tea, sweetened with Honey, every Quarter of an Hour, and to walk about moderately; this disposes him to a very gentle Sweat, and thence renders the ensuing Coldness and the whole Fit milder. He is to continue the same Drink throughout the Duration of the cold Fit; and when the hot one approaches, he may either continue the same, or substitute that of No. 2, which is more cooling. It is not necessary however, in this State, to drink it warm, it is sufficient that it be not over cold. When the Sweat, at the Termination of the hot Fit, is concluded, the Patient should be well wiped and dried, and may get up. If the Fit was very long, he may be allowed a little Gruel, or some other such Nourishment during the Sweat.

Sec. 265. Sometimes the first, and a few successive Doses of the Bark purge the Patient. This is no otherwise an ill Consequence, than by its retarding the Cure; since, when it purges, it does not commonly prevent the Return of the Fever; so that these Doses may be considered as to no Purpose, and others should be repeated, which, ceasing to purge, do prevent it. Should the Looseness notwithstanding continue, the Bark must be discontinued for one entire Day, in order to give the Patient half a Quarter of an Ounce of Rhubarb: after which the Bark is to be resumed again, and if the Looseness still perseveres, fifteen Grains of Venice Treacle should be added to each Dose, but not otherwise. All other Medicines which are superadded, very generally serve only to increase the Bulk of the Dose, while they lessen its Virtue.

Sec. 266. Before our thorough Experience of the Bark, other bitter Medicines were used for the same Purpose: these indeed were not destitute of Virtue in such Cases, though they were considerably less available than the Bark. Under No. 43, some valuable Prescriptions of that kind may be seen, whose Efficacy I have often experienced: though at other Times I have been obliged to leave them off, and recur to the Bark more successfully. Filings of Iron, which enter into the third Prescription, are an excellent Febrifuge in particular Cases and Circumstances. In the Middle of the Winter 1753, I cured a Patient of a Quartan Ague with it, who would not be prevailed on to take the Bark. It must be confessed he was perfectly regular in observing the _Regimen_ directed for him; and that, during the most rigid Severity of the Winter, he got every Day on Horseback, and took such a Degree of other Exercise in the open Air, as disposed him to perspire abundantly.

Sec. 267. Another very practicable easy Method, of which I have often availed my Patients, under tertian Fevers (but which succeeded with me only twice in Quartans) was to procure the Sufferer a very plentiful Sweat, at the very Time when the Fit was to return, in its usual Course. To effect this he is to drink, three or four Hours before it is expected, an Infusion of Elder Flowers sweetened with Honey, which I have already recommended Sec. 264; and one Hour before the usual Invasion of the Shivering, he is to go into Bed, and take, as hot as he can drink it, the Prescription No. 44.

I have also cured some Tertians and even Quartans, in 1751 and 1752, by giving them, every four Hours between the Fits, the Powder No. 45. But I must acknowledge that, besides its having often failed me, and its never succeeding so speedily as the Bark, I have found it weaken some Patients; it disorders, or disagrees with, their Stomachs: and in two Cases, where it had removed the Fever, I was obliged to call in the Bark for a thorough Establishment of the Patient's Health. Nevertheless, as these Medicines are very cheap and attainable, and often do succeed, I thought I could not properly omit them.

Sec. 268. A Multitude of other Remedies are cried up for the Cure of Fevers: though none of them are equally efficacious with those I have directed: and as many of them are even dangerous, it is prudent to abstain from them. Some Years since certain Powders were sold here, under the Name of the _Berlin_ Powders; these are nothing but the Bark masqued or disguised (which has sometimes been publickly discovered) and have always been sold very dear: though the Bark well chosen, and freshly powdered when wanted, is greatly preferable.

Sec. 269. I have often known Peasants, who had laboured for several Months under intermitting Fevers; having made Use of many bad Medicines and Mixtures for them, and observed no Manner of Regimen. Such I have happily treated by giving them the Remedies No. 34, or 35; and afterwards, for some Days, that of No. 38; at the End of which Time, I have ordered them the Bark (See Sec. 260) or other Febrifuges, as at Sec. 266, 267; and then finally ordered them for some Days, to take Morsels of the poor Man's Treacle (See Sec. 247, _Art._ 13) to strengthen and confirm their Digestions, which I have found very weak and irregular.

Sec. 270. Some Intermittents are distinguished as pernicious or malignant, from every Fit's being attended with the most violent Symptoms. The Pulse is small and irregular, the Patient exceedingly dejected, and frequently swooning; afflicted with inexpressible Anguish, Convulsions, a deep Drowsiness, and continual Efforts to go to Stool, or make Urine, but ineffectually. This Disease is highly pressing and dangerous; the Patient may die in the third Fit, and rarely survives the sixth, if he is not very judiciously treated. Not a Moment should be lost, and there is no other Step to be taken, but that of giving the Bark continually, as directed Sec. 260, to prevent the succeeding Fits. These worst Kinds of Intermittents are often combined with a great Load of putrid Humours in the first Passages: and as often as such an aggravating Combination is very evident, we should immediately after the End of one Fit, give a Dose of Ipecacuana No. 35, and, when its Operation is finished, give the Bark. But I chuse to enter into very few Details on this Species of Intermittents, both as they occur but seldom, and as the Treatment of them is too difficult and important, to be submitted to the Conduct of any one but a Physician. My Intention has only been to represent them sufficiently, that they may be so distinguished when they do occur, as to apprize the People of their great Danger.

Sec. 271. The same Cause which produces these intermitting Fevers, frequently also occasions Disorders, which return periodically at the same Hour, without Shivering, without Heat, and often without any Quickness of the Pulse. Such Disorders generally preserve the Intermissons of quotidian or tertian Fevers, but much seldomer those of Quartans. I have seen violent Vomittings, and Reachings to vomit, with inexpressible Anxiety; the severest Oppressions, the most racking Cholics; dreadful Palpitations and excessive Tooth-achs: Pains in the Head, and very often an unaccountable Pain over one Eye, the Eyelid, Eyebrow and Temple, on the same Side of the Face; with a Redness of that Eye, and a continual, involuntary trickling of Tears. I have also seen such a prodigious Swelling of the affected Part, that the Eye projected, or stood out, above an Inch from the Head, covered by the Eyelid, which was also extremely inflated or puffed up. All these Maladies begin precisely at a certain Hour; last about the usual Time of a Fit; and terminating without any sensible Evacuation, return exactly at the same Hour, the next Day, or the next but one.

There is but one known Medicine that can effectually oppose this Sort, which is the Bark, given as directed Sec. 260. Nothing affords Relief in the Fit, and no other Medicine ever suspends or puts it off. But I have cured some of these Disorders with the Bark, and especially those affecting the Eyes, which happen oftner than the other Symptoms, after their Duration for many Weeks, and after the ineffectual Use of Bleeding, Purging, Baths, Waters, Blisters, and a great Number of other Medicines. If a sufficient Dose of it be given, the next Fit is very mild; the second is prevented; and I never saw a Relapse in these Cases, which sometimes happens after the Fits of common Intermittents seemed cured.

Sec. 272. In Situations where the Constitution of the Air renders these Fevers very common, the Inhabitants should frequently burn in their Rooms, at least in their lodging Rooms, some aromatic Wood or Herbs. They should daily chew some Juniper Berries, and drink a fermented Infusion of them. These two Remedies are very effectual to fortify the weakest Stomachs, to prevent Obstructions, and to promote Perspiration. And as these are the Causes which prolong these Fevers the most obstinately; nothing is a more certain Preservation from them than these cheap and obvious Assistances. [70]

[70] I have seen several Cases in very marshy maritime Countries, with
little good drinking Water, and far South of _Swisserland_, where
intermitting Fevers, with Agues at different Intervals, are
annually endemic, very popular, and often so obstinate as to return
repeatedly, whenever the weekly precautionary Doses of the Bark
have been omitted (through the Patient's nauseating the frequent
Swallowing of it) so that the Disease has sometimes been extended
beyond the Term of a full Year, and even far into a second,
including the temporary Removals of it by the Bark. Nevertheless,
in some such obstinate Intermittents, and particularly Quartans
there, wherein the Bark alone has had but a short and imperfect
Effect, I have known the following Composition, after a good Vomit,
attended with speedy and final Success, _viz._ Take of fresh
Sassafras Bark, of Virginia Snake-root, of Roch-Allom, of Nutmeg,
of diaphoretic Antimony, and of Salt of Wormwood of each one
Drachm. To these well rubbed together into fine Powder, add the
Weight of the whole, of the best and freshest Bark; then drop in
three Drops of the chemical Oil of Mint, and with Syrup of Cloves
make it into the Consistence of an Electuary or Bolus, for 12 Doses
for a grown Person, to be taken at the Distance of three or four
Hours from each other, while the Patient is awake, according to the
longer or shorter Intermission of the Fever.

I have also known, particularly in obstinate autumnal Agues there,
an Infusion of two Ounces of the best Bark in fine Powder, or two
Ounces and a half in gross Powder, in a Quart of the best Brandy,
for three or four Days (a small Wine Glass to be taken by grown
Persons at the Distance of from four to six Hours) effectually and
speedily terminate such intermittent Agues, as had given but little
Way to the Bark in Substance. This was certainly more suitable for
those who were not of a light delicate Habit and Temperament, and
who had not been remarkable for their Abstinence from strong
Liquors: the inebriating Force of the Brandy being remarkably
lessened, by the Addition and long Infusion of the Bark. These
Facts which I saw, are the less to be wondered at, as in such
inveterate, but perfectly clear and distinct Intermittents, both
the State of the Fluids and Solids seem very opposite to their
State in an acutely inflammatory Disease. _K._

__Chapter XIX.__

_Of the Erisipelas, and the Bites of Animals._

__Sect.__ 273.

The Erisipelas, commonly called in English, St. Anthony's Fire, and in Swisserland _the Violet_, is sometimes but a very slight Indisposition which appears on the Skin, without the Person's being sensible of any other Disorder; and it most commonly breaks out either in the Face, or on the Legs. The Skin becomes tense, or stiff, rough and red; but this Redness disappears on pressing the Spot with a Finger, and returns on removing it. The Patient feels in the Part affected a burning Heat, which makes him uneasy, and sometimes hinders him from sleeping. The Disorder increases for the Space of two or three Days; continues at its Height one or two, and then abates. Soon after this, that Part of the Skin that was affected, falls off in pretty large Scales, and the Disorder entirely terminates.

Sec. 274. But sometimes this Malady is considerably more severe, beginning with a violent Shivering, which is succeeded by a burning Heat, a vehement Head-ach, a Sickness at Heart, as it is commonly termed, or Reachings to vomit, which continue till the _Erisipelas_ appears, which sometimes does not happen before the second, or even the third Day. The Fever then abates, and the Sickness goes off, though frequently a less Degree of Fever, and of Sickness or Loathing remain, during the whole Time, in which the Disease is in its increasing State. When the Eruption and Inflammation happen in the Face, the Head-ach continues, until the Decline, or going off, of the Disease. The Eyelid swells, the Eye is closed, and the Patient has not the least Ease or Tranquillity. It often passes from one Cheek to the other, and extends successively over the Forehead, the Neck, and the Nape of the Neck; under which Circumstance the Disease is of a more than ordinary Duration. Sometimes also when it exists in a very high Degree, the Fever continues, the Brain is obstructed and oppressed; the Patient raves; his Case becomes extremely dangerous; whence sometimes, if he is not very judiciously assisted, he dies, especially if of an advanced Age. A violent _Erisipelas_ on the Neck brings on a Quinsey, which may prove very grievous, or even fatal.

When it attacks the Leg, the whole Leg swells up; and the Heat and Irritation from it is extended up to the Thigh.

Whenever this Tumour is considerable, the Part it seizes is covered with small Pustules filled with a clear watery Humour, resembling those which appear after a Burn, and drying afterwards and scaling off. I have sometimes observed, especially when this Distemper affected the Face, that the Humour, which issued from these little Pustules, was extremely thick or glewy, and formed a thick Scurf, or Scabs nearly resembling those of sucking Children: they have continued fast on the Face many Days before they fell off.

When the Disease may be termed violent, it sometimes continues eight, ten, twelve Days at the same Height; and is at last terminated by a very plentiful Sweat, that may sometimes be predicted by a Restlessness attended with Shiverings, and a little Anxiety of some Hours Duration. Throughout the Progress of the Disease, the whole Skin is very dry, and even the Inside of the Mouth.

Sec. 275. An _Erisipelas_ rarely comes to Suppuration, and when it does, the Suppuration is always unkindly, and much disposed to degenerate into an Ulcer. Sometimes a malignant kind of _Erisipelas_ is epidemical, seizing a great Number of Persons, and frequently terminating in Gangrenes.