Of the Treatment of Fever.

We have seen that the first indication of disease in fever is traceable to the nervous system; that the nature of this primary affection of the nervous system is unknown; that it may possibly be the commencement of inflammation, modified by the nature of the nervous substance, in which the inflammatory action has its seat, and by the nature of the cause that excites it, namely, a peculiar poison: or, on the other hand, it may possibly be something distinct from inflammation, but having a peculiar tendency to excite it. In either case, the inflammation that is present in fever, is peculiar and specific, differing essentially from ordinary or simple inflammation. Whether the affection of the nervous system consist merely of inflammation of the nervous substance excited by a peculiar poison; or whether it consist of some unknown condition of the nervous system to which inflammation is superadded, and by which the character of that inflammation is modified, the great practical result is the same, namely, that febrile inflammation and ordinary inflammation are not identical, and that the difference between the two affections is such as to require a very considerable modification in the treatment appropriate to each.

The only morbid condition of fever, of which we have any knowledge, and over which the medical art has any control is that of inflammation. Although, as has been so often stated, inflammation be not the primary febrile affection, as far as regards the order of events, yet it is, at least, the primary affection, as far as regards the treatment, if it be not the sole affection that admits of treatment. The remedies proper for febrile inflammation do not differ from those which are adapted to ordinary inflammation; but they differ materially in the mode in which they ought to be applied, and the extent to which they ought to be carried. They can be understood neither in their mode nor measure, until the following questions are determined; namely, What is the precise object that should be aimed at in the treatment of fever? What is it which it is most important to do, and which it is in the power of the medical art to accomplish? An exact and true answer to these questions will afford an invaluable guide in practice: it will point out with clearness what is to be attempted; and it will put a stop to useless and pernicious aims.

It is in vain to hope to terminate fever by a stroke of art. The pursuit of a remedy, so long and so earnestly sought, endowed with the power of cutting short the disease, is to the physician what the search after the philosopher’s stone was to the alchymist, with this difference, that the alchymist, engaged in a vain pursuit, lost only his time and labour; but the physician, engaged in a pursuit equally hopeless, will often, in addition, lose his patient. Fever cannot be cured instantaneously; and to bring a fever patient under the influence of agents capable of exciting a powerful influence upon the system, in the expectation of at once removing fever, is pregnant with danger; and the expectation upon which such practice is adopted, must appear fallacious to whoever has studied the nature of the disease.

Fever cannot be cured instantaneously: it may be moderated; it may be gradually subdued; from being violent and dangerous, it may be rendered mild and safe: the physician may bring it to this condition; and this is all that he can accomplish. If it come under his care early, and he know with promptitude and decision at what to aim, he will rarely fail in his efforts to secure this object.

Since the various forms or types of fever differ in nothing but the degree of their intensity, in detailing the treatment, it will be necessary only to state first of all, the remedies which are appropriate to the disease; and, secondly, the modification of these remedies, which may be required by the different degrees of intensity in which it is commonly found to exist.

1. The common continued fever of this country, in its mildest form, requires little or no treatment. There is no affection of any organ intense enough to need the application of a powerful remedy. All the organs which constitute the febrile circle are deranged in their functions, but that derangement is so slight that a cure takes place spontaneously in the course of a few days. Confinement to the bed; the abstraction of stimuli; fever diet; a calomel purgative at night, consisting of one or two grains of calomel with six or ten of rhubarb, followed in the morning with half an ounce of castor oil; and these remedies repeated every day, or every alternate day, constitute the whole treatment which is required.

2. Whenever the fever passes beyond this, its mildest form, it becomes a serious disease. It is never for a moment to be trifled with; never for a moment to be neglected. Because it is moderate in the commencement, it is not to be presumed that it will continue moderate through its subsequent course: it may become most formidable; if the proper remedies are not applied early and vigorously, it generally does become truly alarming; the train only is apparent; the mine is concealed; the only safety for the patient is to prevent the train from being kindled; if that be once kindled, it may be no longer possible to save the patient from destruction.

When the mildest case of fever passes to a severer form, what is the event that happens? What is the change that takes place in the organs? The preceding pathology will, indeed, have been written in vain, if there can now be any doubt in the mind of the reader on that point. The great value of the facts there disclosed is, that they teach us what happens in organs which we cannot see, and declare to us by the external signs or symptoms, the internal actions that are going on. Out of the hundred cases which have now been recorded, and the history of which has been made known from its commencement to its termination, take any one, or fix upon any number, in which the symptoms from being slight became moderate, and from moderate severe, or, in which the symptoms were severe from the beginning, what is found after death? Inflammation, in general, rising in degree, and increasing in extent, or both, in proportion to the intensity of the febrile affection. If this, which may be justly considered as the law of the disease, be not absolutely constant and uniform, it may be safely affirmed, at least, that there are as few apparent exceptions to it, as to any general law that can be named.

The object to be aimed at in practice, then, is clear: it is to prevent, or to remove inflammation. Accomplish this, the fever will not be cured at once; it will still go on for some time; but it will come sooner to a close, and it will proceed mildly and safely to its termination. Fail to accomplish this, and the fever, however mild at first, will increase more and more in severity until it become truly formidable, and death take place at last, in consequence of the destruction of the organs by the process of inflammation.

If excitement be set up in an organ which has as invariable a tendency to terminate in inflammation as a stone to fall to the ground, what is the proper remedy to prevent the transition of excitement into inflammation? Bleeding. Before we can say that inflammation is established we may foresee that it will come: if the preceding excitement be not stopped, we know that it will as surely come as that blood will flow from a wounded blood-vessel. Because we cannot tell the precise moment when increased vascular action passes into actual inflammation, are we quietly to look on and do nothing until we have made that discovery? We know that inflammation is at hand; we know what will prevent it, or, at any rate, what has a powerful tendency to prevent it: shall we not bring into immediate and vigorous use our means of prevention, or shall we wait until the inflammatory action shall have given unequivocal and alarming indications of its presence and operation before we interfere? To trifle in such a manner, to lose these precious moments when we have such a fearful, such an active, and, if once it be allowed to become active, such a masterless enemy to contend with as fever, is as great a folly as it would be when a building is on fire to stand idle by as long as the fire is smouldering, and to take no measure to extinguish it until it has burst into flame, nay, not until the flame has spread from the floor to the ceiling, and from the ceiling to the roof. We may not be able to see a single spark, but if we see the smoke and feel the heat, we know that there is fire somewhere, and that however concealed at present it will soon make itself visible enough, and that it will consume not only the structure in which it originates, but others with which it may come in contact if it be not put out. With equal certainty we know that fever, though apparently mild in the commencement, will excite inflammation in vital organs, and that that inflammation, if it be allowed to establish itself, will place the fabric of the body in the most imminent danger. The physician, in the first stage of fever, armed with his lancet, is to his patient what the fireman with his engine, before the flames have had time to kindle, is to a building that has taken fire. At this early stage, the former can check inflammation with almost as much ease and certainty as the latter can prevent the flames from bursting out. On the contrary, the physician who is called to treat inflammation in the later stage of fever is in the position of the man who arrives with the apparatus for saving the house when its stories have been already consumed and its roof has fallen in.

Bleeding in fever cannot be performed too early. The very first moment of excitement, could that be discovered, is precisely the moment when the employment of this powerful remedy would produce the greatest effect. The earlier the bleeding, the greater will be the impression made upon the disease, and the less upon the patient; or, the more effectually will the inflammatory action be stopped by the loss of the smallest quantity of blood.

When inflammation has actually come on, there is then not a moment to be lost; that inflammation must be stopped; the accomplishment of this object is the great end which the practitioner should aim at in every thing he attempts; until he has done this he has done nothing; until he has done this he ought to give neither sleep to his eyes nor slumber to his eye-lids; until he has done this he ought to feel that there should be no rest for himself, because there is no safety for his patient. Until the inflammation is subdued blood must be taken; be the quantity it may be necessary to abstract, in order to accomplish this object, what it may; be the bleedings it may be requisite to repeat what they may; the vein must be allowed to flow, and it must be opened again and again until this object is secured. If this golden opportunity be allowed to escape, and this object be not obtained, the risk is most imminent. During this early period the physician is master over the disease; if he allow it to pass away without obtaining the victory, the disease becomes master over the physician. From that moment his control over it is gone. Never can he regain his lost advantage. Fever is a process that advances with a step as steady as time, and like time it never retraces a step. At a subsequent period its progress may be sometimes retarded, and now and then it may be weakened; but, after the lapse of a few days, this is all which the most complete success is then capable of accomplishing.

Mere relief of inflammation is nothing; to render a severe inflammation a less severe inflammation is to do nothing; because the less severe inflammation may be fatal just as certainly as the more severe: the inflammation must be subdued, or the case, if not wholly lost, becomes dangerous and doubtful.

The abstraction of blood must be carried to the extent of subduing the inflammation: there is no other limit to the quantity to be taken but that which is adequate to subdue the inflammation. To attempt to measure the quantity by drachms or ounces is wholly vain; because, if the remedy be properly employed, the quantity will vary in every individual case. To take an ounce more than the subdual of the inflammation requires is injurious; to take an ounce less is still more pernicious; to take the quantity necessary to accomplish the object, and no more, is to use the lancet—that powerful instrument, so dangerous in rash hands, and no less dangerous in weak, with the discernment and decision of a master. He who with a knowledge which gives and which justifies boldness and decision, is able thus to employ this great remedy, is a skilful physician, who has derived from study and experience the best fruit they can yield: he who has not yet reached this perfection of his art, (and who among us can pretend to the attainment?) must still go on to observe and to learn.

The object to be accomplished then is clear; that means of obtaining it are known; and when these means are promptly, boldly, and effectually employed, what is the result of experience? That after all, the quantity of blood it is necessary to abstract is not large. The tendency of the preceding observations is not to countenance frequent and large abstractions of blood in fever, but to save the blood of the patient, by taking the due quantity at the proper time. Smaller bleedings will subdue febrile than pure inflammation. Febrile inflammation, as has been so often stated, is a modified inflammation, the modification consisting in less activity in the vascular system and greater depression in the nervous. Whence a moderate bleeding will make an impression upon febrile inflammation which can be equalled in pure inflammation only by a large bleeding. He who takes away sixteen ounces of blood in fever adopts a bolder and more decisive practice, and brings more effectual relief to his patient, than he who abstracts thirty ounces of blood in some other forms of inflammation; and he who takes away six ounces of blood in one febrile case, does more than he who takes away sixteen in another. But the question never can be whether the bleeding should be small or large: that is nothing. The thing to be considered is the condition of the organs, the state of the system; not the ounces of blood to be taken, nor the number of periods at which it is to be removed. Abstract blood to the subdual of the inflammation—that is the rule; abstract blood at the very commencement of the inflammatory action; if you are in time to do it, at the very commencement of the febrile excitement. Then little blood will be lost, and the patient will be safe. And when this is done, nothing of importance remains to be done. The practitioner who has been thus active in the commencement will be idle during the future progress of the disease. Daily as he repeats his visit he will find that his interference is not required, and will admire to see with what ease a disease of frightful power is disarmed, and rendered innoxious, if it be attacked in infancy, and not neglected or trifled with until it be nurtured to maturity, and allowed, at last, to put forth unchecked the strength of that maturity.

If, after the abstraction of sixteen ounces of blood at the commencement of the attack, the vascular excitement be not completely subdued, in the course of three or four hours the same quantity must be again taken; and if, the next morning, that excitement continue, it will probably have already passed into inflammation; and, therefore, the vein must be once more opened, and the blood allowed to flow until the pain, wherever seated, be entirely removed. To check the disease, instead of subduing it, does not in the least diminish its future strength, and, by weakening the powers of life, it even hastens the period of mortality. Nothing is more common than the appearance of typhoid symptoms, on the second or third day after bleeding has done nothing but lessen the inflammatory action; whereas, had it been carried somewhat, and generally only a little, farther, the patient would have been convalescent at the very period when his danger becomes most imminent. In cases where general bleeding produces a decided impression on the inflammation, but does not stop it, cupping, or even leeches, will often complete what the lancet commenced.

A due impression having been made upon the inflammation by bleeding, the subsequent treatment should consist of purgative medicines, given to the extent of producing three, or at most four stools in the twenty-four hours: beyond that number no advantage is obtained by purging; more frequent evacuations, indeed, weaken the patient, but not the disease. The best purgatives consist of one or two grains of calomel, with six or eight of rhubarb, repeated every night, or every other night, and followed the next morning by two drachms, or half an ounce of castor oil, or by the common senna draught. Cold sponging, if the skin be hot; acidulated drink, if there be thirst; perfect quiet, a dark room, a silent nurse, affording prompt attendance, with a noiseless step, a cheerful countenance, and no words—this, together with three tea-cups full of thin arrowroot or gruel, in the twenty-four hours, given in divided portions, at intervals of about two or three hours, comprises all else that will be required, or that will be useful, until the period of convalescence.

Such is the simple, but most efficient treatment appropriate to the common fever of London and its neighbourhood (and I do not speak of the treatment proper for any forms of the disease as it exists elsewhere, and which I have not seen) in its ordinary degree of severity.^[35]

Suppose, however, the proper treatment not to have been applied; suppose the case to have been neglected or mismanaged; either not to have been seen at all, or to have been too much contemned; suppose the pain in the head to have been not severe; that no complaint was made of it; or that giddiness only was felt; that the skin was not burning hot, but moderately warm; that the pulse was neither strong, nor bounding, nor hard; but of moderate strength, and soft; that the mind was tolerably distinct, and the restlessness not great: why should blood be drawn? what indication is there for the employment of so violent a remedy in so mild a case? No symptom is prominent; no symptom is urgent; the case will do well.

Such is the view that would be taken by the great majority of practitioners of this kind of case, and their treatment, without doubt, would be correspondingly inert. And this is the true origin, in many cases, of typhus symptoms; of adynamic fever. The disease is allowed to take its own course; and the product of every fever, at a certain stage of its process, is adynamia: the physician does not perform his office; the disease advances; the restlessness increases; there is no sleep; delirium comes on; muscular tremor begins to be perceptible; the pulse rises; the sensibility diminishes; and stupor, if it be not already present, is close at hand. And now the disease, it is sufficiently obvious, is severe; now, it is admitted, it calls for a powerful remedy; and, now for the first time, the lancet is thought of. But the bleeding relieves no symptom; it increases some; the progress of the inflammation is not checked; the adynamic symptoms are more fully developed; the patient is more prostrate, and the fever, in all respects of a worse character: the inference is, that bleeding is a most inefficient and dangerous remedy in fever; and this inference is deduced from experience; those who draw the conclusion, judge from what they see; they disclaim reason; they pretend only to understand and to respect the lessons of experience.

I appeal to the attentive observer, whether this be not a faithful history of the progress and termination of hundreds of fever cases; whether such a history may not be recorded as of daily occurrence; whether what has been stated be not commonly the view, the practice, the result, and the lesson.

I will not appeal to the different history that belongs to cases that are differently treated. But I do earnestly appeal to the pathology that has been stated; that, at least, is experience, and it teaches a lesson, which it is worse than foolish to despise or to forget. Every symptom just enumerated, has been detailed over and over again in the cases that have been laid before the reader: inspection after death must have made the conditions of the organs, as indicated by those symptoms, familiar to his mind. Of what avail can bleeding be, when the patient is brought into the condition which first excites alarm, in the case here supposed? The blood is no longer in its vessels; it is beneath the membranes, or in the ventricles, or at the base of the brain; the inflamed capillaries have done their work upon the cerebral substance and upon its membranes; and have left proof enough of their activity, in the thickening of the one, and the softening or the induration of the other. What can blood-letting do in this state of the organs? What can shaving the head, and applying cold do? What can blisters do? What can purgatives do? And above all, what can wine do? Nothing can be done; at least, nothing effectually or certainly.

If there be still pain, if the sensibility be little diminished, if the pulse be not very quick and weak, it may yet be possible to check the further progress of the inflammation; to prevent the disorganization of the brain from advancing; but the means to accomplish this, must now be tried with the most extreme caution: perhaps, in the whole compass of medical practice, there is no case which requires a nicer discrimination than this, when it has arrived at this point. The abstraction of a few ounces of blood may stop the inflammatory action of the vessels before they have produced such a change of structure as is incompatible with life, and such as the powers of life cannot repair. But if the abstraction, even of this minute quantity of blood, at this point of the inflammatory process, do not put a stop to that process, the remedy will co-operate with the disease, to depress the powers of life, and will deprive the patient of what chance of recovery he might otherwise have had. To decide in a case which requires such nice discernment, and in which, even with the best discernment that can be exercised, the event must always be so doubtful, is a task which few physicians, who understand the nature of it, find either easy or agreeable.

But instead of bleeding, the proper remedy may possibly be the very reverse: it may be requisite to afford a stimulus. The change of structure produced by the inflammatory process may not have proceeded to such an extent as to be absolutely incompatible with life; but the powers of life maybe so exhausted by the inflammatory excitement that, unless aid be brought to them, they will be overpowered, and sink: afford them appropriate aid, and they will rally, and, although slowly, ultimately repair the lesion which the organs have sustained.

This is precisely the condition, and perhaps it is the only condition, under which stimuli are really beneficial in fever. Whenever such remedies are indicated, the vascular action is weak, and there appears to be a want of due supply of arterial blood to the brain. Of all stimuli, wine or brandy is the best. If it be doubtful whether a stimulus can be borne, or will prove beneficial, a few ounces of wine may be administered. It will soon be manifest whether it be the appropriate remedy. If the restlessness, the heat, the delirium increase under its use, it will be obvious that it cannot be borne; if, after some hours, no perceptible impression be made upon any symptom, it is seldom of the least service, given to any extent, or persevered in for any length of time. If it be capable of doing any good, some improvement in the symptoms is commonly perceptible in a few hours after it is first administered. Sometimes that improvement is sudden and most striking; more commonly it is slight, slow, but still easy to be seen. If the pulse become firmer, and especially slower, the tremor slighter, the delirium milder, the sleep sounder, the skin cooler, and, above all, if the sensibility increase, and the strength improve, it is then the anchor of hope. It will save the patient if it be not pushed too far, and if it be withdrawn as soon as excitement is reproduced, should that happen, which it often does.

No certain indication for the administration of wine can be drawn from one or two symptoms alone: neither from the state of the pulse, nor of the skin, nor of the tongue; neither from the tremor, nor from the delirium. There is an aspect about the patient, an expression not in his countenance only, but in his attitude, in the manner in which he lies and moves, being, in fact, the general result, as well as the outward expression of the collective internal diseased states, that tell to the experienced eye when it is probable that a stimulus will be useful. Depression, loss of energy in the vascular system, as well as in the nervous and the sensorial, indicated by a feeble, quick, and easily compressed pulse, no less than by general prostration, afford the most certain indications that the exhibition of wine will be advantageous: and if the skin be at the same time cool and perspiring, the tongue tremulous, moist, or not very dry, and the delirium consist of low muttering incoherence, these symptoms will afford so many additional reasons to hope that it will prove useful. On the contrary, if the skin be hot, the eye fierce or wild, the delirium loud, noisy, requiring restraint, and the general motions violent, it is as absurd to give wine, as to pour oil upon a half-extinguished fire, with the view of putting out the yet burning embers.

When wine is indicated, but does not produce a decided effect, brandy may be substituted. I have seen no benefit arise from giving either in large quantity. When the condition is really present in which alone it can be useful, a moderate quantity will accomplish the only purpose it can serve. In every other condition, wine may be administered to any extent, (and I have given half a pint every hour) until the stomach return it, by vomiting, without the slightest impression being made upon the disease, or any, or scarcely any, upon the system. The malady is in possession of the seat of sensibility; it has destroyed the organ; it has abolished the function: what advantage can result from the application of stimuli? The spirit that could feel their impression, and answer to it, is gone: organs destroyed by overstimulation, cannot be regenerated by the application of additional stimuli: the apparatus is broken; the wheels are clogged; the obstruction lies in that part of the mechanism in which the main power that works the machinery is generated; that obstruction cannot be removed; the movements of the machine must cease. Even when the case is not thus utterly hopeless, wretched is the physician whose only dependence for the safety of his patient is in wine.

These considerations ought not to make us desponding, or inert, even under the worst circumstances, as long as the case is not absolutely desperate; but they ought to impress deeply and indelibly upon the mind of the practitioner who has the first charge of a fever patient, that the disease must be conquered in the very first days, or it will conquer, and that there are no means by which that conquest can be rendered sure or probable, but that afforded by the lancet.

Very much the same observations apply to the exhibition of opiates. There is a condition of the system in which an opiate puts a stop to a state of exhausting agitation and restlessness; procures tranquil sleep; lessens delirium, and operates most favourably on all the symptoms. This may be when the skin is cool and perspiring; the tongue moist, or not very dry; the delirium low, and the pulse and the patient weak. No kind of opiate in any form in which it can be administered ever proves in the least degree beneficial whenever the skin is very hot, the tongue very dry, or the general motions and actions of the patient are violent.

Now and then the powers of life rally unexpectedly and wonderfully: they throw off a load which appeared to have oppressed them totally and for ever. It is therefore the duty of the medical attendant to be always at hand until the termination even of the most desperate case, and carefully to watch every change that takes place; for changes may suddenly occur which may give him a clue to bring in invaluable assistance. He may be suddenly called upon to give a stimulus; he may be suddenly called upon to check re-excited and inordinate action. To describe in words the countless variety of circumstances under which it may be necessary that he should take very unexpected and decided measures, and not a few of which may demand of him clear discernment and nice discrimination, is quite impossible: he can acquire the power of performing the most difficult and arduous duty he has undertaken only by studying the disease, and by rendering himself perfectly familiar with the principle of its treatment.

When the inflammatory action has proceeded unsubdued and has terminated in some change of structure, probably accompanied with copious effusion, as indicated by the symptoms detailed under the cases illustrating cerebral affection, advantage is sometimes obtained by affecting the system with mercury. In this condition of the brain it is not easy to bring the system under the influence of mercury; when it can be accomplished, the patient is commonly, though not invariably, snatched from death. In several instances I have known this treatment successful under apparently the most hopeless circumstances. When the success is most complete, the convalescence is invariably tardy, and often appears to be doubtful; the mind for a long time remains feeble, infirm, and almost fatuous; and, as in the two cases recorded by Pringle, though such patients recover of their fever, it is long before the nervous and the sensorial systems are restored to a sound state. The best mode of exhibiting mercury is in the form of a pill, consisting of two grains of calomel with half a grain of opium, given every three, four, or six hours.

3. To a fever which is severe from the commencement the preceding observations apply with double force. Then, if the most powerful remedies are not immediately employed, and if they are not brought to bear at once upon the severe symptoms in the completest combination, the case is wholly lost. The delay of an hour is pregnant with danger; the delay of a few hours places the efficacy of any measures that can be taken in great uncertainty; and the delay of a day or two renders their most vigorous application utterly useless. Whereas, knowing, as we now know, the condition of the organs upon which the severity of every case depends, and knowing remedies appropriate to that condition of sovereign efficacy, exceedingly few of such cases would be lost were these remedies employed with due vigour at the commencement of the attack. The typhoid symptoms with which it is commonly thought such cases commence would never appear. The patient would be convalescent, or at least would labour only under a mild form of fever at the period when, without these remedies, his condition would be hopeless. The practitioner ought never for a moment to forget that it is in the power of early and active treatment to deprive these severe cases of all their severity and, consequently, of all their danger; but that, after the lapse of a day or two, all human skill will be exerted in vain.

It remains to say a word or two relative to the modification of the more powerful remedies, as the prominent affection may have its seat in the brain, the lungs, or the intestines.

The treatment in a cerebral case of moderate severity has been already sufficiently explained. Blood must be drawn to the subdual of the inflammation, and if blood be abstracted early, two, or at most three, moderate bleedings will be all that will be required.

But when the attack commences with severe cerebral affection, the bleeding must be proportionally large, and early as it is copious. A bleeding adequate to subdue a moderate, will be utterly inert in a severe degree of cerebral disease. I give, as a specimen of what may be sometimes required, the case of Dr. Dill. I saw my friend at the very commencement of his attack, and was, therefore, able to carry into effect what I conceive to be the proper treatment with due promptitude and vigour. I saw him before there was any pain in the head, or even in the back, while he was yet only feeble and chilly. The aspect of his countenance, the state of his pulse, and the answers he returned to two or three questions, satisfied me of the inordinate, I may say the ferocious, attack that was at hand. Having taken an emetic without delay, as soon as its operation was over, blood was taken from the arm to the extent of twenty ounces. During the night, severe pain in the limbs, especially in the loins, and intense pain in the head came on. The blood that was taken on the preceding evening was not inflamed. Early in the morning he was again bled to the extent of about sixteen ounces, with great diminution, but not entire removal of the pain: the pain not lessening, towards the afternoon he was again bled to the same extent: the pain was now quite gone; the blood from both these bleedings was intensely inflamed. During the night the pain returned, and, in the morning, the eyes were dull and beginning to be suffused, while the pulse continued slow and intermittent, and the respiration suspirious; but the face was blanched, and the pulse, in addition to its other characters, was weak. Instead of opening the vein afresh, twelve leeches were applied to the temples; these very much relieved, but still did not entirely remove the pain; for this reason, he was cupped to the extent of sixteen ounces: this operation afforded very great relief, and he continued easy until the following evening, when the pain returned, and he was again cupped on the temples to the same extent. Immediate relief followed this second operation; but, unfortunately, the pain returned with great violence towards evening, and it was now impossible to carry the bleeding any farther. Within twenty-four hours, it was plain that typhoid symptoms in abundance would be present, for the fur on the tongue was becoming brown, and there was already slight tremor in the hands. No more blood could be taken with any prospect of advantage, nor even with safety; yet, without the aid of some powerful remedy the case was lost.

The whole scalp was now enveloped in ice, but so intense was the heat of the head that it was melted in a few minutes, and the clothes, steeped in the evaporating lotion, dried with extraordinary rapidity. Neither of these expedients produced the least perceptible effect.

What was to be done? Recourse was had to a measure the efficacy of which is but little known and less appreciated; a remedy the power of which is second only, if, under some circumstances, it be not even superior, to that of the lancet; a remedy which can never supercede the lancet nor dispense with it, but which, when added to it, forms by the combination a treatment so powerful and efficacious that it might render death, from the acutest cerebral inflammation, as rare as recovery is at present.

This remedy is known by the name of the cold dash. It consists of pouring a column of cold water upon the head in a continued stream from a height of from six to ten feet. The mode of applying it is as follows. The patient is seated in a large tub; a table is placed at the side of the tub upon which a man stands, and at as great an elevation as his arms can reach, pours upon the naked head of the patient a steady but continued stream of cold or iced water, from a watering-pot without the rose. The stream is made to fall as nearly as possible upon one and the same spot. At first the elevation must be slight, for the shock is too violent if the stream be poured at once from the highest point. There is a record, that in the East, where ingenuity so long laboured for tyranny to invent the most exquisite modes of torment, the victim was placed with his bare head under a small stream of cold water which was so directed as to fall unceasingly upon one spot. In this instance cruelty was cheated of its object by its ignorance of the mode in which its expedient operated. The device was well adapted to kill but not to produce pain, for insensibility must soon have put an end to suffering.

Employed as a remedy, there is no degree of burning heat which the animal economy is capable of producing, no intensity of vascular action, and no violence of pain that can resist its continued application. Sooner or later, usually in from ten to twenty minutes, the heat, though most intense, disappears, the skin becomes cold, the face pallid, the features shrunk, while the pulse is reduced to a mere thread, and the pain of the head, however violent and intolerable, entirely ceases. After the patient has been wiped dry, which he should be as rapidly as possible, and placed in bed, the symptoms may soon return in all their violence; the same process will again remove them, and as often as the former recur the latter must be repeated. Three or four repetitions will commonly suffice to subdue the most intense cerebral affection. In the case of Dr. Dill, the relief it brought was instantaneous and most complete. From a state of intense suffering it rendered him perfectly easy, and from a state of imminent danger, safe. I had no anxiety about him from the moment he came out of his tub, although it was necessary to pass him through the same ordeal three times; but he himself having tried this remedy on his sister, having in her case witnessed its efficacy, and now felt it in his own, was extremely desirous that it should be repeated as soon as he was conscious of any return of pain. In consequence of its application, together with the copious depletion that preceded it, at the period when under ordinary treatment, the most exquisite typhoid symptoms would have been present, he was convalescent.^[36] If we consider how powerful the abstraction of caloric must be by every fresh current of water that falls upon the head, to what a mere thread the minute external blood-vessels must be constringed, and consequently to what an extent the internal must be affected, we shall not wonder at its efficacy. Powerful as the cold affusion is when exhibited in its ordinary mode, yet the impression it makes upon the brain, compared with the effect produced by this remedy, may be said to be what the application of six leeches to the temples is to the abstraction of thirty ounces of blood.

Cold applications to the head, and evaporating or iced lotions, are useful in mild cases; they may keep up the effect produced by this in the more severe, but to hope to control the latter by their aid alone, is to expect to coerce a giant, by twisting around his arms a spider’s thread.

II. Of the Modification of Treatment in Thoracic Affection.

Fortunately, there is a remedy nearly as powerful and efficacious in intense thoracic affection, as blood-letting and the cold dash are in the cerebral. In the severe bronchial affection of fever, blood-letting is of little avail. It seems to have scarcely any control over the peculiar affection of the lining membrane of the bronchial tubes, or even over the inflammation of the substance of the lung, which so often accompanies the intense form of thoracic disease. It weakens the patient, without making a decided impression upon the disease. Laennec states that the pathology of pneumonia could scarcely be learnt under his practice; for that he treated the disease, not by blood-letting, but by tartar emetic; and that all his patients recovered. I thought this one of the exaggerated statements in which medical writers sometimes delight to indulge; but it immediately occurred to me that this remedy might prove exceedingly efficacious in the bronchitis of fever. Its efficacy has surpassed my expectation. It seldom fails if exhibited with promptitude and decision. The mode in which it is most efficiently administered, is in doses of two grains, dissolved in an ounce of water, and repeated every second, third, fourth, or sixth hour, according to the severity of the case.

In the slight bronchial affection, which is so constantly present in fever, nothing is required but the mucilage of gum-arabic, or a little of the almond emulsion now and then, with the tincture of hyosciamus, or two or three grains of the compound powder of ipecacuanha, to allay the irritation of the cough. The inflammation of the mucous membrane, when slight, spontaneously subsides.

No remedy at all comparable in efficacy to the preceding has yet been discovered for the inflammation of the mucous membrane of the intestines, which forms so constant and formidable a part of the organic affection of fever. General bleeding has but little influence over the disease. If employed early and with due activity, it will prevent the affection from occurring, but, when once it has supervened, large bleedings are out of the question, and even small and repeated bleedings are not as effectual as leeches. In severe cases, the abdomen should be covered with leeches, and they should be re-applied daily, until the pain and tenderness are gone, or, at least, have become slight, for it is often impossible entirely to remove the tenderness. The abdomen should be covered with a poultice as soon as the leeches fall off. Afterwards, the application of a linen rag, moistened constantly with the oleum terebinthinÆ, keeps up the effect produced by the leeches, and, when the affection is slight, may supersede their use altogether.

When the purging is considerable, five grains of the hydrargyrum cum cretÂ, with five of the pulvis ipecacuanhÆ compositus, given every night or every night and morning, often checks it; if this remedy fail, a stronger opiate may be exhibited, and sometimes an anodyne enema may be administered with great advantage. If there be constipation, one or two drachms of castor oil is the proper laxative. Active or irritating purgatives are highly injurious.

When blood is mixed with the stools or there is considerable hÆmorrhage from the intestines, every thing that can irritate the mucous membrane must be carefully avoided. The mineral acids sometimes appear to check the discharge. The infusion of roses rendered stronger by the addition of a few drops of the sulphuric acid, is a convenient mode of administering such medicines, and the efficacy of the draught is sometimes improved by the addition of a drachm of the tincture of hyosciamus. It is not uncommon for copious discharges of blood to alternate with constipation. In this case the mildest laxative must be administered with caution. The powers of life are sometimes so prostrate, that three or four stools, excited by purgative medicines, are sufficient to exhaust them. A tea-spoonful of castor oil, repeated at intervals of six hours, is all that should be attempted. Now and then a stimulant has a greater effect in checking the hÆmorrhage than an astringent, and then the oleum terebinthinÆ is the best remedy.

IV. We have spoken of a fever still more intense

even than this, severe as it is, under the name of the intensest form of fever. And of this, the same may be said as was stated of the mildest, that there is little or nothing to be done. As far as regards the treatment, the two extremes of fever, the mildest and the most intense, meet, for in the first no remedies are required, and in the second, none are of any avail. In these latter cases, there is no remedy and no combination of remedies yet known, capable of affording effectual aid. The abstraction of the smallest quantity of blood is fatal: the application of the cold bath is out of the question; the warm bath is inert; the vapour-bath affords rather more prospect of benefit; but the proper remedies, if any exist, remain to be discovered.

When a person has swallowed a certain quantity of laudanum, there are remedies which are capable of counteracting the poison and of saving the patient. When he has swallowed a larger dose, provided it amount to a certain quantity, no remedies will avail, excepting the application of the stomach-pump. Unless the poison be promptly expelled from the system, adopt with the utmost vigour the best-concerted expedients which the medical art can supply, the patient will die. A person afflicted with the intensest form of fever, is in the condition of a person who has swallowed this large dose of poison. When a pump is invented, capable of extracting his poison from the brain, he may be saved.

Little modification is required in the treatment of scarlet fever. The most important difference between continued fever without and with an eruption, is the greater predominance of nervous affection in the former and of inflammatory affection in the latter. Accordingly, in scarlatina there is not only a greater tendency to inflammation than in ordinary fever, but the inflammation which is set up in the febrile circle of organs approximates more to the character of pure inflammation. There is greater vascular action, with less nervous and sensorial depression. The consequence is, that blood-letting may be carried to a greater extent, and will be attended with still more decided and more certain efficacy than in ordinary fever. After a decided impression has been made upon the vascular excitement by general bleeding, the application of ten or twelve leeches to the throat is of sovereign efficacy. If scarlatina be treated in this manner on the second day, or sometimes even on the third, though it commence with exceedingly severe symptoms, yet the patient will be convalescent in the course of three or four days.

It is not probable that much advantage would be derived from the detail of numerous cases to illustrate the modification of treatment, and the circumstances under which particular remedies should be chosen. A few are subjoined as specimens of the ordinary extent to which bleeding may be carried, and of the usual conditions under which wine may be exhibited, and of the results, when favourable, produced by each remedy.

Mary Ann Hunt, Æt. 24, servant. Admitted on the 14th day of fever: attack commenced with shivering, succeeded by heat, nausea, and head-ache; until last night, has had no stool for five days. At present, no pain of head or chest; much pain of limbs; sleeps well; severe pain over the epigastrium, increased considerably by coughing and by pressure; tongue thickly coated with a whitish-yellow fur, through which the papillÆ appear large and prominent; much thirst; no appetite; no stool to-day; skin warm; catamenia regular; pulse 135, of good strength.

V.S. ad ?xxvj. Haust. SennÆ Sal. quam primum. Acid. Mist. pro potu. Mist. Acet. Amm. C. 6t q. h.

15th. Pain of limbs quite gone; that of epigastrium also entirely removed; no tenderness on the fullest pressure; tongue more clean; less thirst; several stools; slept well; skin cool; pulse 84, soft. Blood in both basons very buffy. Cont. med.

16th. Continues quite free from pain; tongue nearly clean; two stools; skin cool, moist; pulse 88. Pt. med.

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

22d. Sat up yesterday and the day before, since which the skin has become more warm, the pulse more quick, and the tongue more loaded, but there is no local pain, and the bowels are open.

23d. Pains of limbs returned; slept ill; tongue loaded at root; pulse 110.

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

26th. Pains gone; skin cool and moist; tongue the same; two stools; pulse 100.

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

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

41st. Dismissed cured.

Eleanor Welby, Æt. 21, servant. Attacked four days ago with chilliness, shivering and pain of head. At present, pain of head gone; mind distinct; little or no sleep; eyes suffused and injected; no uneasiness of chest nor cough; throat sore, with difficult deglutition; tenderness of abdomen on pressure; tongue loaded on body with white fur, extremely red at edges and tip; lips and teeth sordid; some thirst; bowels regular; pulse 129, of good strength, yet easily compressed; efflorescence of skin of dark red colour, approaching to a dusky hue. V.S. ad xvj. Hirud. viij. gutturi. Ol. Ricini, ?iij. quam primum. Mist. Acid. pro potu.

6th. No uneasiness of head; slept ill; eyes suffused and injected; face swollen; still complains of soreness of throat, which is undiminished; tongue moist; teeth sordid; lips sordid and cracked; less thirst; three stools; pulse 120, firm; blood very sizy and cupped. Rep. V.S. ad ?xiij. et Hirudines viij. gutturi. Pt. Med.

7th. Expression of countenance more natural; face less swollen; more sleep; throat greatly relieved; deglutition quite easy; no tenderness of abdomen on full pressure; tongue more clean and moist; lips and teeth less sordid; pulse 111; eruption less distinct. Haustus SennÆ Sal. c. m.

8th. No uneasiness of head, throat, or abdomen; sleep natural; tongue beginning to clean, much less red; pulse 114; skin exfoliating.

9th. Convalescent.

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

Mary Jones, Æt. 33, married. Three days ago attacked with shivering, succeeded by glows of heat, severe pain in the back and lower extremities, with much head-ache. At present, pain of head severe, especially over the forehead; mind distinct; scarcely any sleep; no uneasiness of chest; some cough; abdomen tender on pressure; tongue not much loaded; some thirst; no appetite; one stool; pulse 108, of some power.—V.S. ad ?xvj. Ol. Ricini, ?iij. q. p. Mist. Acid. pro potu.

Hora 3tia, p. m. Pain of head diminished since the bleeding, but by no means removed; much pain of back; some of abdomen; pulse 112, strong, full, sharp, and not easily compressed. Blood with firm and thick buff. Rep. V.S. ad ?xvj. statim. Pulv. Aper. Mit. h. s.

4th. After the second bleeding last night, the pain was entirely removed: she slept well, and the pain continued absent until this morning, when it returned with great severity, or rather violence. She was bled to the extent of fourteen ounces with immediate and great relief: blood in both cups with firm buff and proportion of crassamentum large: at present, the head is quite free from pain; there is scarcely any pain in the back; no tenderness of the abdomen; tongue loaded in middle with white fur, moist at edges, of natural colour; four stools; pulse 120, weak.—Pt. med.

5th. No return of pain in the head; that of back continues; slept ill; tongue much more clean and quite moist; four stools; pulse 120, weak; skin warm and damp. Omit. pulv. Pt. alia med.

6th. Pain of head returned with great severity last night, for which she was bled to the extent of four ounces with only temporary relief; no sleep on account of the severity of the pain; skin hot; entire scalp extremely hot; face pallid; nothing unnatural in the appearance of the eye, and no intolerance of light; pulse 120, sharp, but easily compressed; tongue loaded with white fur; thirst; four stools; buff on blood pretty firm.

C. C. ad ?x. nuchÆ. CamphorÆ, gr. v. c. Extract. Hyosci. gr. iij. 6ta. q. h. Pulv. Aper. Mit. h. s. Lotio frigida capiti raso.

7th. Pain of the head entirely removed since the cupping, and has not since returned; slept well; face continues very pallid; tongue loaded with white fur in middle; very pallid; pulse 120, of good strength; feels quite easy, but very weak. Cont. PilulÆ. Capt. Haust. QuininÆ Sulph. 6ta. q. h.

8th. No return of pain in the head; some in loins; scarcely any sleep; tongue the same; four stools; pulse small and extremely weak. Pt. Med. omnia. Capt. Vini Albi, ?iv. in dies.

9th. Free from pain in the head, back, and every organ; scarcely any sleep; much restlessness; delirium; countenance pallid and sunk; feels very weak; tongue the same; four stools; pulse 120, not so weak as yesterday. Pt. Med. Vini Albi ad ?viij.

10th. Slept ill; much restlessness and delirium; frequent and deep sighing; severe pain in the lower extremities recurring in paroxysms; she says the pain is as if some one were rending her limbs from her; tongue white, moist; four stools; pulse 110, weak; takes and relishes her wine. Statim capiat Haustus Anodynus, c. Liq. Opii Sedativi, gtts. xl. Augt. Vini Albi, ad ?x. Cont. alia med.

11th. Long and tranquil sleep after the draught; less delirium; no sighing; no return of pains in the limbs; mind perfectly distinct; “feels greatly better;” countenance much more animated; tongue the same; pulse 108, more strong and firm, but still easily compressed. Cont. Med. Rept. Haustus Anodynus hora decubitus.

12th. Slept well all night; “feels very much better to-day;” no return of pain; complains only of sense of lowness; pulse 96, weak. Pt. Med. omnia.

13th. Continues to improve in all respects.

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

18th. Continues steadily to improve. Pt. Jus. Bov. lbj. in dies. Vini Albi, ?vj.

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

33d. Free from complaint. Dismissed cured.

In this case bleeding was carried to the utmost extent to which it could be carried with safety, and rather beyond it; but it was one of those cases in which less was to be apprehended from the bleeding than from the disease.

Frances Jacob, Æt. 17, destitute. Four days ago seized with nausea, vomiting, headache, and other febrile symptoms. At present, much pain of epigastrium, which is extremely tender on pressure; throat sore; deglutition very painful; much vertigo; scarcely any headache; no sleep; mind confused through the night; some pain of chest on full inspiration; cough, with viscid copious sputa; very considerable dyspnoea; aspect of countenance leaden-coloured and oppressed; skin warm, of a dusky, unhealthy red colour; tongue very red, not much loaded; bowels constipated; pulse 135, tremulous and indistinct. Abradat. Capillitium. Hirud. viij. faucibus externis. Postea Empl. Emoll. Empl. LyttÆ nuchÆ. Inhal. Vap. Aq. Calid. Garg. c. Borat SodÆ. Ol. Ricini ?iij. q. p. Pulv. Aper. Mit. h. s.

5th. No pain of head; no sleep; mind confused; much low talkative delirium; still uneasiness of chest on full inspiration; throat less painful; deglutition more easy; dyspnoea and cough the same; abdomen tender; tongue unchanged; four stools; pulse 120, feeble and indistinct; skin covered universally with very unhealthy red, dusky efflorescence. Pulv. Aper. Mit. h. s. Mist. Camphor, ?iss. c. Tt. Hyosciami, ?j. et Ammon. Carbon, gr. x. 4ta. q. h. Vini Albi, ?vi. in dies.

6th. Much delirium; some sleep; skin of same colour; rather more sensible to-day; says she has no pain of head, but sense of severe soreness all over her; much cough; four stools; pulse 120, weak. Pt. Med. et Vin.

7th. Slept well; less delirium; “feels much better;” countenance greatly improved; skin more warm; colour much more natural; throat still painful; deglutition difficult; some tenderness of the epigastrium on full pressure; scarcely any over the abdomen; tongue red at edges, brown and dry in middle; much thirst; three stools; pulse 108, soft, not very weak; lips and mouth surrounded with an herpetic eruption; skin not abraded, but covered with soft scab. Pt. Med. omnia.

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

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

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

14th. Complains more of pain of epigastrium, which is considerably tender on pressure; other symptoms the same. Catap. Sinap. epigast. Pt. alia.

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

18th. Convalescent.

24th. Dismissed cured.

Margaret Skey, Æt. 37, married. Five days ago attacked with sense of cold, shivering, and heat, together with pains in the bones. At present complains of pain in small of back; no headache; no pain of chest; some cough; no tenderness of abdomen; tongue white and dry; much thirst; bowels constipated; sleeps tolerably; pulse 112. Haust. SennÆ Sal. q. p. et c. m. Rep. Mist. Acid. pro potu.

6th. Abdomen very tender; tongue red; four stools; much thirst; skin warm; face flushed; pulse 100, easily compressed. Hirud. x. abdom. Postea Catap. Emoll. Rep. alia.

8th. Much delirium through the night; considerable muscular tremor; pain of abdomen gone; tongue tremulous, but not much coated; much thirst; four stools; pulse 100, weak; frequent shivering. R. QuininÆ Sulph. gr. ij. Aq. Rosae, ?j. M. Sit Haustus, 6tis. q. h. sumendus. Jus. Bov. lbj. in dies. Rep. alia.

10th. No sleep; mind confused; two stools passed in bed; urine in bed; respiration laborious; pulse 90, weak. Alcohol (brandy) ?iv. ex Aqua per diem. Pt. Med.

13th. Slept better; less delirium; two stools not passed in bed; pulse 96.

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

17th. Strength again rather diminished; tongue rather brown; much thirst; pulse 100; no pain. Pt.

21st. Little change, excepting that the tongue is more brown, dry, and tremulous; pulse 108, extremely feeble; mind distinct; no delirium; two stools. Aug. Alcohol ad ?vj.

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

24th. Countenance much more animated; tongue more clean, quite moist, still brown towards root; pulse 110. Pt.

25th. Countenance still more improved; tongue more clean; no longer brown; pulse 102, weak.

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

27th. Gains strength. Alcohol ad ?iij.

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

45th. Has been gradually, though very slowly gaining strength; tongue now clean; appetite good; bowels regular (Low Diet); 2 ozs. meat daily.

52d. Dismissed cured.

The management of the convalescence is one of the most difficult parts of the treatment and one of the most unsuccessful, not because there is any thing which requires to be done, nor because there is any disease which prevents recovery, but because the patient is considered as well when he is only convalescent. Of the great tendency there is to relapse during the whole of this period few medical men are sufficiently aware, and the unprofessional attendants on the sick are totally ignorant of it. For a long time the brain, the bronchi, and the intestines remain so irritable that the slightest excitement is capable of renewing the diseased action which has recently subsided; but without excitement of some kind, that renewal never takes place. It is the duty of the physician and the nurse to guard the patient from such excitement, which they may always do completely; so that whenever there is a relapse, the physician, or the nurse, or both must be in fault: as long as they perform their duty with judgment and firmness there is no such thing; but this part of their duty which is extremely simple, they cannot be induced to believe to be of importance: no one who has not seen death happen over and over again from the neglect of it will believe it, and even those upon whom melancholy experience has impressed the truth most strongly, constantly allow themselves to be surprised at the slightness of the excitement by which, and the advanced period of the convalescence at which relapse may happen. It is not easy for a nurse to resist incessant importunity and even reproach; and there are suspicions to which a physician is subjected, which, when he sees that they are entertained, it requires some moral courage to enable him to bear. Without doubt he deserves the worst that can attach to him if he allow the caprice, or the impatience, or the injustice of his patient, or any earthly consideration to induce him to swerve from the faithful discharge of the duty he has undertaken. The unreasonableness of the convalescent, should be considered and treated as the delirium of the preceding stage.

The mismanagement of the convalescence consists chiefly in allowing the patient to rise too early from bed, and to take solid food too soon and in too large a quantity; and these are by far the most frequent causes of relapse. Were I to place on record all the instances I have seen of fatal relapse from these two causes alone, the list would be frightful. Many patients, the very day they become convalescent, think they ought to be allowed to get up. They feel well, they think they are so; they earnestly declare that they are so. They are impatient of bed; they imagine it keeps them weak: “if you would but allow me to rise how thankful I should be; how much more it would refresh and strengthen me than any thing that can now be done.” Such is the language which is constantly addressed to the physician in the early period of convalescence, and if he be weak enough to yield to it and allow his patient to rise, it is a chance if he ever rise again. The most cautious and experienced physician sometimes finds himself deceived, falling into the same error with his patient, and thinking him stronger than he is. Whenever this happens, the physician has great reason for self-reproach, because he ought to allow no risk to be run. Often, however, in private practice, the physician is allowed to have no control whatever over the management of the convalescence—he is dismissed as soon as the patient is out of apparent and urgent danger; dismissed hastily, often to be more hastily recalled to witness the death of him whom every one thought to be well.

But if merely rising from bed at too early a period occasion the death of great numbers, eating heartily of solid food is a still more frequent and certain cause of it. The appetite is generally keen immediately after fever has subsided: if animal food be allowed as soon as the appetite craves for it relapse is sure to be produced. Often and often have I seen fatal cerebral and abdominal inflammation excited in a few hours after the commission of this error. I do not expect, by any language at my command, to communicate to others my own conviction of its danger. I know that such a conviction can be produced in no one who has not an opportunity of observing the convalescence of large numbers; and I know that no one who has such an opportunity can be without it.

There are three conditions under which this danger is peculiarly imminent. First, when the disease has been unusually severe and protracted. The more intense the fever and the longer it has lasted, the more are all the organs enfeebled, and the longer do they retain the irritability of weakness, In this state, anything beyond the gentlest stimulus will induce vascular excitement, which will rapidly pass into inflammation.

Secondly, when the disease was severe in the commencement, and has been promptly subdued by active treatment. Whenever copious bleeding brings on a precocious convalescence, that convalescence is invariably uncertain and infirm. It is always steady as long as it is properly protected, but it has not strength equal to its apparent health: it is as tender and fragile as it is sensitive: the least noxious agent impresses it; the least stimulus overpowers it. The patient is suddenly relieved from a load that oppressed him; the organs react with preternatural vigor; they have enough to do to sustain the reaction of the system: stimulate them still further by animal food and wine, and they will be sure to be over done; and this artificial excitement will be as fatal as the excitement of disease. It can be of little consequence to the patient whether he die of malaria or of chicken.

Thirdly, when the disease was slight in the commencement and through its subsequent progress, but the convalescence proved tardy and imperfect. In this case, animal food and wine are pernicious and highly dangerous, and often prove more fatal than a severe form of fever. Nothing is advantageous or safe for such a patient but perfect rest and quiet and the blandest farinaceous diet.

I have now laid before the reader all that I have been able to learn of this frequent and most formidable disease. I am conscious that some of the views which have been exhibited are opposed to the prevalent doctrines of the day, and that some parts of the treatment recommended must appear to many unnecessary and hazardous. But since I have suggested no doctrine which has not been deduced from a long and careful study of the phenomena, and recommended no practice which has not been derived from large experience, I trust that the former will not be rejected without examination, nor the latter condemned until its failure have been witnessed. I have opposed with earnestness, perhaps some may think with vehemence, certain opinions and modes of practice which I conceive to be pregnant with evil; but as I have never intended the slightest reproach or blame to the advocates of the doctrines I condemn, so I shall feel truly grateful to any one who will point out any mistake into which I may have fallen. Those who have studied this disease with the best success are the most sensible how much remains to be done to render our knowledge of it perfect and our treatment of it effectual. Many are the dark spots that still remain upon this part of the field of knowledge; many are the labourers that must work long and skilfully before they are removed; while, if the successful investigation of medical science in general contribute largely to the well-being of man, the successful study of this branch of it must be pre-eminently beneficial. It is computed that upwards of one-half of the human race perish by this fell disease in one or other of its forms: when this fact is coupled with the truth disclosed by the annexed tables, which shew at what age this malady is most prevalent and fatal, we become duly impressed with the importance of labouring to render our knowledge of this dreadful disease complete, that we may lessen, as far as possible, the suffering of our common nature, and extend to its utmost limit the term of human life, too brief when most protracted, but constantly cut short by this great enemy of our race, just as adolescence is ripening into manhood.