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even if it be only hard, and there be great tendency to Gen. III. inflammatory congestion in any of the larger organs, as a
Spec. II. the head, the chest, or, as is far more common, the nus flavus.
Yellow stomach, the spleen, and the liver, we cannot well be too
fever. bold both in bleeding and purging; and the plan laid down by Dr. Rush is by no means an exaggeration of what ought to be pursued. It may be, that eight-andforty, or even four-and-twenty hours are the whole we have to work in; and unless we can, so to speak, stifle or lay prostrate the sensorial power, and thus completely . break down the inflammatory diathesis by debilitating
and relaxing the living fibre or solidum vivum, rather than by diminishing the moles movenda, the organs mostly affected will in all probability become gangrenous in a day or two, the oppressed blood vessels will give way, and we shall have a chlorotic or livid skin, cold extremities, black vomit, and all the other apparitors of death, before the tamer plan of aperients and diaphoretics could have time to produce the slightest impression on the system. Generally speaking, it will be best to bleed in an erect position, for the sensorial excitement, which is what we are chiefly to aim at, is best cut down by syncope, which an erect position will soonest induce; and we may, hence, save the expense of several subsequent bleedings.
Dr. Pym speaks with a very just discrimination upon this subject, in observing that while the Bulam fever, or the disease in its most violent attack, is relieved by free venesection, the yellow fever, more properly so called from the brighter hue on the surface, or, in other words, that which is slighter in its incursion, will not often endure the lancet. Dr. Musgrave's statement seems to oppose this assertion, for he distinctly tells us that “ blood-letting in both forms is our sheet-anchor; the only pillar on which we can securely rest any hope of extensive success.” The Antigua fever seems to have exhibited great severity in most instances, and hence called for a courageous course of practice with perhaps few exceptions. Yet the following paragraph proves that
Gen. III. it did admit of exceptions, and softens down almost to
unanimity a clash of opinion and practice which after nus flavus. all is more ostensible than real; “ we have repeatedly," Yellow
says he, - with success, taken upwards of forty ounces of fever.
blood at one bleeding. With equal success we have in several cases renewed the bleeding up to the third, and even the fourth time; but, generally speaking, those which require such reiterated evacuation evince an obstinacy NOT LIKELY TO ADMIT OF A FAVOURABLE RESULT UNDER ANY MODE OF TREATMENT. IT MUST ALSO BE REMEMBERED, THAT EVERY ONE WHO APPLIES FOR ASSISTANCE IS NOT ALIKE ABLE TO BEAR THIS LIBERAL DEPLETION." It only needs to be observed further that the bowels were emptied, as they ought to be, by calomel or jalap, or some other active purgative; the head was shaven, and cold ablution preferred ordinarily to cold affusion, because of the fatigue endured under the latter. Bark was then instantly given, and, where the stomach would bear it, in the powder. Mercury, with a view of exciting salivation, was seldom tried, and not relied upon. In effect, in the milder cases it was not wanted for this purpose, and, in the more urgent, there was no time for its
use. Mercury be- There can be no doubt, however, of its being highly neficial when discrimi
advantageous, in a great multitude of cases, and of genately used. neral benefit in various forms of this destructive epide
my. For whether we contemplate the fever as local or unrestrained, as consisting in violent universal excitement, or, according to M. Broussais, in an inflammation of the mucous membrane of the stomach or duodenum irritating the bile-ducts, and the liver itself by sympathy; whether as threatening congestion to any of the larger organs, or actually accompanying congestion ; there is no medicine which, primâ facie, affords a better prospect of relief than mercury, from its general action on the excernent system, as well as its specific action on the intestinal canal, and the salivary glands. It must, however, be admitted that it is only under a particular condition and tone of the vascular frame, that it can at
any time be employed with good effect; and hence not Gen. II.
Spec. II. only is a sound judgement constantly demanded in its application, which indeed is a requisite that ought ever nus flavus.
Yellow to be present, but much important time is often lost in preparing the system for its remedial introduction. In Ot
Other remethe case of ENTONIC or strong vascular action, it is ne dies usually
employed cessary first of all to lower, and in the case of ATONIC or before or in weak vascular action, to raise the living power to the conjunction: proper standard before ptyalism can be obtained, which is the grand test of its having taken effect : and hence, to accomplish the former, bleeding, purgatives and cold affusion, must be first called upon to exercise their respective powers; and in the latter case, tonics and cordials; upon which last ground, Swediaur tells us that the most efficacious plan of treatment consists in giving calomel and columba, in doses of thirty-five grains each, five or six times a day*. It is truly said, indeed, by the advo. cates for mercury, that such other remedies are all valuable adjuvants; and this is so far from being denied by to which
many those who are hostile to the use of mercury, that they ascribe the affirm, on the contrary, that the benefit ascribed to this
whole bemedicine, when it has once obtained a sway over the system, ought rather to be attributed to these adjuvants themselves; which would have proved still more beneficial, had they been left to their own power and intention alone. Mr. Gibson, who is a strenuous advocate Estimate of for the use of mercury upon the principle now adverted its salutary to, very candidly admits both these causes of impedi- rious effects. ment. “In hotter climates”, says he, alluding to the debilitating province of Guzzaret, “the PHLOGISTic state of Gibson. the system is adverse to the introduction of mercury: but the prudent abstraction of blood happily reduces it to that standard, which is most favourable for its action. In India, however, in fever, the disease in which this is most speedily to be desired, the same means would, but in very few cases, be admissible : for the DEBILITY IS SO GREAT and instantaneous, as well as the tendency to pu
• Nov. Nosol. Meth. Syst. 1. 28.
Gun. III. tridity, that only in the robust new-comer is it, if ever,
:. to be hazarded. It would seem that DEBILITY AND THE & E. malignus flavus. PLETHORIC SYSTEM, ARE EQUALLY INIMICAL TO THE SPE
CIFIC MERCURIAL ACTION. If the patient is fortunately fever.
invigorated sufficiently to give the mercury influence, and BEFORE ANY ORGAN ESSENTIAL TO LIFE IS INJURED, by the strictest nursing and attention afterwards the recovery is almost certain, all morbid action yielding from the moment ptyalism is brought on."*
Even in cases, however, in which the mercurial action is fortunately excited, the same intelligent writer tells us that he has frequently met with a very serious evil resulting from the mercury itself; for such, says he, is at times the profusion of the ptyalism when once induced, that the most disagreeable consequences succeed, and the convalescence is long and precarious; on which account he laments that we have no criterion to determine how far
we may proceed with the mercurial process, and when Bancroft.
we ought to stop. Dr. Bancroft advances much farther than this, and asserts that not only has the salivation retarded the convalescence, and produced very troublesome affections of the tongue, mouth and throat, with other ill consequences, thus acknowledged by its advocates, but that the salivators, even when they have been free from these evils, have not been more successful than other practitioners; and he particularly alludes to the admission of Dr. Rush, who was not unfriendly to the mercurial mode of treatment, that " in the City Hospital (of Philadelphia), when bleeding was sparingly used, and the physicians depended chiefly upon salivation, MORE
THAN ONE-HALF DIED of all the patients who were ad-, Jackson. mitted.”+ For like reasons Dr. Jackson speaks with as
little satisfaction of the same practice, not only upon his own experience but even upon that of Dr. Chisholm himself. Alluding to the high recommendation of mercury by the latter, he observes, “the detail of his testimonies
* Edin. Med. and Surg Journ. Vol. xi.
does not warrant a conclusion so favourable ; for the Gen. III. proportion of mortality in the detachment of Royal Ar- Spe
BE. maligtillery upon whom this practice is supposed to have been nus flavus. first tried, has perhaps scarcely ever been exceeded in a cel tropical climate. Further, it is a common observation that, where salivation actually takes place in continued fevers, it seldom shows itself till the violence of the symptoms has evidently abated : hence a suggestion arises that the appearance of salivation is only an indication of the departure of disease :--no proof exists that the operation of the mercury is the cause of this departure. Such are the remarks which occurred in reviewing different modes of treatment in the hospitals of St. Domingo; to which it will not be superfluous to add an experiment made at the Mole in August 1796 by Mr. Lind, Surgeon to Jamaica. Out of fifteen cases of fever put under the care of Mr. Lind, on the first day of the disease and treated with the utmost attention, five died; in three of whom salivation actually took place; five recovered, in whom no salivation took place; in the other five, who also recovered, salivation was evidently established; but, as is usual, not till the violence of the symptoms had begun to abate. Out of four who were put under his care on the second day of the disease, no one died; but one only was affected by the mercury; one brought to the hospital on the third day of the illness, died : mercury was employed, but no salivation took place; one, on the fourth, likewise died, without marks of salivation ; one, on the fifth-the salivation was established, but the disease proved fatal. In none of the above cases were less than ten drachms, and in most not less than two ounces of strong mercurial ointment rubbed into the legs and thighs, with the employment of all other means which seemed calculated to promote the expected effect."* The question, therefore, to say the least of it, is still Hence the
c question still open; and, admitting all that can be said in favour of 1.
* History and Cure of Fever, Part. 1. Ch. XI. pp. 293, 294.