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of weakness. Nothing can be more fallacious than such symptoms, whether they regard the duration or degree of the disease. It is in the first instance but a weak debility which they indicate: towards the close of the fever, indeed, this spurious weakness becomes real, but the present argument interferes not with the sequelæ of fever. The object is to establish a general principle, to ascertain the primitive essence of the disease. In the last stage, nothing can be less equivocal than the prostration of every mental and bodily power, nothing more awfully indicative of a wasted and worn-out fabric. But it will shortly be demonstrated that this is not a primitive state, but a subsequent consequence, often induced by mismanagement or neglect.
While thus contending for the necessity of teaching and treating fever pathologically we wish not to reject the light of symptoms during life; both sources of knowledge may and ought reciprocally to illustrate each other. The veracity of the inward consequence may rectify the deceptiveness of the outward sign, and the character of the outward sign may indicate the inward state. When we are convinced that the inward consequence generally indicates excitement, to know that the outward symptom so often indicates debility cannot authorize the inference that the cause of both is weakness. The existence of an inflammatory product after death is incompatible with the existence of continued debility during life, and it matters not how far the living symptoms savoured of weakness, the dead result is a sufficient proof that the symptoms were fallacious and that the weakness was imaginary. It is true that patients labouring under fever do not die at every stage of the disease, and that the same opportunities are not given to trace the workings of internal action, with that precision with which every change of symptom can be noted. We cannot positively pronounce upon the moment when moderate vascularity becomes excessive, when excessive vascularity passes into inflammation, when inflammation terminates in ulceration or effusion. But it is nevertheless true that a thorough knowledge of diseased appearances after death, in every variety of case and constitution, of type and temperament, will form a key to the proper understanding of symptoms during life, without which their indications must have a greater tendency to mislead than to guide ; and he who has watched with cautious observation the various symptoms which various forms of fever have assumed during various stages of their course ; he who has journalled these symptoms with sufficient accuracy to render them available for future reference, and who at last has inspected the bodies of his dead, comparing and elucidating what he discovers upon inspection with the daily history of his symptoms, will in a short time be sufficiently qualified to pronounce upon what is going on within, by watching what is going on without, and to contend with internal disease as scientifically and as successfully as though his patient were translucent, and he could witness with his own eyes the covert operations of the malady.
• 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.–Smith, p. 397.
Since, therefore, the internal consequences of fever are inflammatory, since the external signs of fever often indicate weakness more than inflammation, since the inward consequences of fever never can deceive, and since its outward effects often do, symptoms must be esteemed as no more than the expressions of an interior agent, and safe only as far as they faithfully communicate to the spectator the operations which this agent internally carries on.
As the first question of importance in the investigation of this disease is . in what does it consist ?' the second question is how should it be treated' --what remedies are best adapted for its cure? The first question is preparative to the second, and when a proper solution has been furnished to the one the other can neither be difficult to comprehend, nor answer. He, who fears debility as the foe of life, will not be violently inclined to pursue such measures as are calculated to weaken the constitution, while he, who has the fear of inflammation rather than of debility constantly before his eyes, must look upon all kinds and degrees of excitement as doubtful, if not dangerous.
The treatment proposed by each will depend upon the views of each as to the character of the existing evil, and as to the nature of its future consequences. If fever be debility, and if the danger which attends it depend upon the degree of this debility, it is obvious that, as a general principle, such treatment as might tend to increase this debility would be highly injudicious ; whereas, if fever be essentially a disease of excite ment, and if the danger it occasions depend upon the extent of this excitement, it must be admitted that, as a general principle, such remedies as are opposed to excitement must hold out the surest prospects of relief. The following extracts will accordingly show that we are no better agreed upon the treatment than upon the nature of this affection.
• The first principles of my practice thus appearing to be as generally received as they had before been rejected, it only remains for me to detail the remedies which I have employed; and with respect to these, too, I might be even more brief, from having little to add to the list of remedies in typhoid Fevers, which may be found at the 18th page of my “Treatise on Fever,” published in London, A. D. 1814, as well as in my " Medical Reports from the Cork-street Hospital ;" but, that as these publications may not be in the hands of the reader, some recapitulation of those remedies themselves; and my reasons for recommending them, supported as I have been by all my subsequent experience, may be permitted. They may be arranged according to their relative importance in the treatment of fever, in the following order, viz. IN MIXED FEVER.
IN TYPHOID FEVER.
Yeast or Barm.
Tepid, or Cold Affusion.
Peruvian Bark. James's Powder. Many other remedies may, no doubt, be occasionally employed with advantage for the relief of the symptoms which accompany peculiar forms of epidemics, or such as are produced by extraordinary idiosyncrasies. But these, according to my experience are more frequently applicable than any others, in the treatment of our common indigenous fever.
The beneficial effects of the four first articles of this list of remedies in the treatment of fever, it is no longer necessary to insist on, for they are no longer denied. For the same reasons, too, I need not, as on former occasions, enter more fully into explanation, why blood-letting has not a place in this list. When, however, I come to speak of topical bleeding, 1 shall have to state, that under the pestilential form which our epidemic fevers have assumed since the year 1823, I have found it advisable to employ even this partial evacuation more sparingly and cautiously than in my first publications on fever I felt justified in recommending.
With respect to Peruvian bark too, which I have here added to the list of remedies for typhoid fevers; although, on former occasions, I stated, that “ I had not found it necessary for the cure of the continued fevers in Dublin,” I have now to observe, that, under the growing malignity of these distempers, I have employed some preparations, especially the sulphate of quina, with obvious advantage, even in cases which did not parlake of tendencies to remittent or intermittent forms; in such tendencies, however, the usefulness of that remedy was most manifest.'—Stoker, p. 111-113.
The general reception of his practical principles, which Dr. Stoker alludes to in the preceding extract, is thus described
"The views taken' both of the nature and treatment of fever, by Dr. Burne, entirely accord with those which may be found stated in my medical reports from the Fever Hospital, as well as in my separate essays on that subject. And as (when speaking of his denomination of Fever) I have already remarked, this leaves, I think, no reasonable doubt of the epidemic Fevers of London baving lately become more typhoid or adynamic, than they had formerly been. It is further satisfactory to me to find, that the treatment which I had long since adopted and recommended in our typhoid fevers, has been found suitable to the prevention and cure of those in London ; and that, too, in proportion as they have acquired more of that form, with which I was best acquainted.'-p. 110-111.
Now, to put the reader in possession of Dr. Burne's plan of treatment we shall quote the following passage-" Although the judgment here wants the assistance of experience, the very great and unaccountable debility and listlessness, with the other signs, indicate very evidently the threatening of an attack of fever. It is of much importance for the physician to see his way clearly ; for if he should attribute this obstinate attack to any other than its just cause, and be induced to abstract blood he will inflict an injury it is not always easy to repair. The abstraction of blood does no good, and it will now and then be succeeded by a gradual alarning sinking of the powers of life, from which the patient may never recover. Should the pain in the head be so severe (it rarely is) as to tempt the practitioner to draw blood, let the quantity be small and its effects be observed some hours after it has been abstracted ; because patients will appear to bear bleeding at the moment, while in a few hours its injurious effects will be manifest.” See a practical Treatise on the Typhus or Adynamic Fever, by John Burne M. D. London. 1828. p. 200—1.
If, then, the sentiments of Doctors Stoker and Burne so entirely correspond, and if Doctor Stoker considers these sentiments generally adopted throughout London, merely because Doctor Burne has re-echoed them, we beg to disabuse Dr. Stoker's fancy with the few passages from the work of Doctor Smith, physician to the only exclusive hospital for Fever within London; and although we feel it a harsh and invidious undertaking to lower an author in his own esteem, by narrowing the limits of his influence, we do feel it, at the same time, to be a duty to the public and to the profession, to the advancement of truth and the promotion of sound medical knowledge, to place landmarks around the Doctor's territory that he may hereafter know it to be forbidden ground, should the boundary again be ever overstepped.
One would think that the following paragraph was penned as an antidote to the very passage above given :• 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.'--p. 382.
Both authors are describing what ought to be done at the very opening of the disease, yet the one talks of bleeding as at the very best a most precarious resource, while the other labours for utterance to express its importance !
• 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