PHILADELPHIA COUNTY MEDICAL SOCIETY.
Meeting of December, 1849.
Dr. Jackson, (late of Northumberland,) President, in the Chair.
Discussion on the Powers of Quinine in Remittent Fevers.
Dr. Parrish remarked that, in the absence of the lecturer for
the evening, he would ask the attention of the Society to a subject
of much practical interest, in the hope of eliciting inquiry, and of
promoting discussion.
It is well known that, within a few years past, the practice of
administering quinine in the early stage of malarial fevers of the
remittent type, has become quite prevalent in those sections of
the United States where these fevers are most prevalent. The
idea is now extensively entertained, that remittent and intermittent
fevers are essentially the same disease, and that the absence of
distinct intermissions in the former, should not prevent the admi-
nistration of the remedy which is found so effectual in controlling
the latter. Hence, the physicians who hold to this opinion give
quinine in large doses, and with a view to its antiperiodic qualities,
in the remissions of a fever, for the purpose of preventing the
exacerbations, which are known to occur at particular intervals.
They do not wait until all febrile action has passed away, or until
a crisis occurs in the natural course of the fever, on the fifth,
seventh, or ninth day, or even later, but they commence at the
outset with this potent remedy, just as they would do if no fever
W’ere present, as in the intermission of an intermittent. In both
cases they would, perhaps, generally precede the quinine by a
brisk mercurial cathartic, and then attack it with quinine, in
the interval of the paroxysms, with a view to cutting short the
disease.
The results of this practice, as reported to us by many highly
respectable physicians of the west and south, whose experience
has been ample, is, that remittent fevers which, under the plan of
treatment formerly in vogue, were accustomed to run a protracted
course, and to assume a serious aspect, are brought to a rapid
termination, or converted, after two or three paroxysms, into the
intermittent type, and easily cured. They say, that so far from
the quinine increasing the heat, thirst, and sensorial disturbance
incident to fever, that it allays these, calms the nervous system,
and acts as a diaphoretic. Now, it is a point of great practical
interest, to know how far these observations of our brethren in
other sections correspond with experience here; and my object
in introducing the subject at this time is, to ascertain this.
For myself I can state that, in common with most of those who
hear me, I was educated in the doctrine, that in remittents we
must be very cautious of bark or quinine, while the least febrile
excitement is present.
The idea entertained here, by the most eminent medical teachers,
when I was a student, was, that in remittent the febrile excite-
ment must be reduced by the lancet and brisk purgation during
the early stages, and that tonics were only to be given after the
decline of the fever. Even my excellent father, who, as is well
known by many here, was more favorable to the use of tonics and
supporting treatment in fever than most of his contemporaries,
taught in his lectures that bark and quinine were not to be given
until the cleaning of the tongue, or the occurrence of critical
sweats indicated the approach of convalescence; except in cases
where malignant symptoms were developed, or where unusual
evidences of prostration existed,—and then the article was given
more for its general tonic properties, than with any prospect of
cutting short the fever.
Within the past few years, however, from the large amount of
testimony to the value of quinine in the early stages of remittent
which has reached us through the medical journals, I have been
induced to pursue this course, and have reason to be well satisfied
with it. I have found that quinine given in the early stage of a
remittent, after a free evacuation of the bowels by a mercurial
cathartic, and when a distinct morning remission was observable,
has had the effect of moderating the evening exacerbation, and,
by continuing it for a few days, of bringing the fever to a rapid
and favorable crisis. I have seldom given over 15 or 20 grains
in the remission, and in mild cases have found even less than this
to answer the purpose. Since adopting this plan I have not seen
any cases of protracted remittent, running on for three and four
weeks, and attended with tympanitis, subsultus tendinum, low
delirium, haemorrhage from the bowels, &c. Whether this fortu-
nate exemption is attributable to the mode of treatment adopted,
or to a diminished liability in our fevers of late years to assume
this form, I cannot positively say; though I am inclined to think
that the old plan of delaying the use of tonics may have contri-
buted to the production of these prolonged cases.
If the practice recently introduced by the practitioners of the
south and west, in the treatment of malarial fevers, be confirmed
by experience, and established as sound—it must be admitted that
a great step has been taken in practical medicine—diseases, once
the dread of the inhabitants of large sections of our country, will
be divested of much of their virulence, and be brought under the
control of remedial measures, while our science will have achieved
a grand triumph.
Dr. W. Jewell said he was an advocate for the early employ-
ment of quinine in fevers. In intermittent forms he preferred
decided doses, and in remittent types he did not invariably confine
his practice to grain doses. For several years he had been accus-
tomed to administer quinine in the ordinary forms of autumnal
fevers, without waiting for a complete intermission of the paroxysm.
He had not witnessed any bad results therefrom. He would not
venture, however, to advocate its use where there were signs of
local congestions, or during a high state of inflammatory excite-
ment; in such instances, the introduction of quinine, from its
therapeutic properties, is contraindicated. An abatement of the
more violent symptoms of febrile excitement would be an indica-
tion, with him, for the admission of quinine into the system. By
this course he had often witnessed the cutting short of fever.
He believed it to be a safe mode of practice. Of one thing he
was certain, that he cured his cases of fever in a much shorter
period now, than he did years ago, when he depended upon the
free and frequent use of the lancet, and a complete intermission of
the paroxysm, before he ventured to prescribe quinine. He seldom
encountered those protracted and obstinate cases of slow conva-
lescence, with a tedious train of nervous symptoms, and an almost
insurmountable prostration of the nervous energy, often terminat-
ing in visceral obstructions, with which he had been familiar in
the early years of his experience as a practitioner. Then it was
that he bled day after day, during the paroxysm, until he had
entirely subdued the fever; but of late years his mind and prac-
tice had undergone a change, so that his lancet lay rusting in its
case, for want of frequent use in fevers.
He believed that we were too timid in the treatment of fevers
by quinine; and he was glad to find that the employment of the
article, without waiting for a perfect and distinct remission,
was gaining friends. If the practice was not a favorite one
now, he thought it would become so hereafter. As for his expe-
rience, it was decidedly in its favor; nor had he witnessed those
distressing effects upon the stomach and pulse, which had been
attributed to its use, during the prevalence of fever. The approach
of tinnitus aurium and partial deafness he looked upon as an indica-
tion of its influence upon the nervous system, but by no means a
dangerous result. But he would not recommend its indiscriminate
use in fevers ; like other therapeutic agents, it required the exer-
cise of judgment and discretion.
In the administration of large doses of quinine in intermittent
fevers he had had some experience. It was not a new practice to
him. In 1825, the late Dr. J. Snowden, of this city, was accus-
tomed to treat his intermittents with decided doses of quinine.
His usual habit was, after free purging, to administer during the
intermission 10 grains of the article at one time, and was very
successful in the treatment of his cases. The same practice had
been adopted by other practitioners. He (Dr. J.) had followed
in the same path, and instead of prescribing quinine in one
grain doses each hour, during the intervals of the paroxysm,
he directed five grains every two hours, until 10, 15 or 20 grains
had been taken, according to the peculiar temperament or con-
dition of his patient. This practice, with him, had been very
successful.
He had often continued the use of the quinine in intermittents,
during the prevalence of the fever, without inconvenience to the
patient, and he considered the practice a much safer one than
many had been disposed to believe it. He would be happy to Lear
the experience of others on this subject.
Dr. Bell, in reference to the alleged novelty of giving quinine
in the paroxysm of remittent fever, remarked, that it did not require
a person to have attained a very advanced age to be able to
witness a circle of medical doctrines, in which-the old were
revived as novelties. The practice described by Dr. Parrish is
not, by any means, new or recent. Drs. Clark and Lind,—the
first in his work on the Diseases which prevail on Long Voyages,
&c.; and the second on the Diseases of Warm Climates, speak of
the use of the bark during the exacerbation of the fever—not as a
matter of speculation, but of good practice. These authors wrote
more than three-quarters of a century ago. Others might be cited
to the same purport. In Italy the practice has been long a familiar
one.
Dr. Bell, when remittent and intermittent fever, with their con-
gestive complications, prevailed around Philadelphia, twenty-
seven and twenty-eight years ago, had, from his connection with
the Philadelphia Dispensary, of which he was one of the physi-
cians for more than twelve years, an opportunity of seeing much
of these fevers. He gave, in some cases, various preparations of
cinchona during the paroxysmal stage of remittent fevers, but
without satisfactory results. When the blue mass, or calomel,
was directed in alternation with the bark, better effects ensued.
Dr. B. said that, to hear some persons, one would suppose
learning and experience to be incompatible with each other, and
that a knowledge of the opinions of the best writers on a disease
was a disqualification for treating it successfully. That some read-
ing was of service, however, he had the means of proving to his
professional brethren in his published lectures on the Practice of
Physic, in which, when speaking of the treatment of congestive
fever, he took some pains, and he believes not without success, to
show his readers that this disease, which to most of them seemed
to be new, had been in fact fully described, and its correct treatment
laid down in various works, some of them, perhaps, on their own
shelves. A reference to these would have taught them that, under
the name of pernicious or malignant intermittents and remittents,
were described their congestive fevers. Torti, among others,
recommended and gave the bark in sub-continued fever of a
malignant character.
As a farther illustration of the necessity of a physician knowing
the history of the treatment of a disease which comes before him,
Dr. B. adverted to the strange ignorance manifested by a physician
of a Parisian hospital a few years ago, in his prescribing large
doses of quinine for acute rheumatism. This gentleman began his
experiments as if he had been the first to adopt the practice; over-
looking or ignorant of the trials of Haygarth and other English
physicians so many years before, on this point. A little literature
might have saved the lives of some of the patients of the Parisian
doctor, and the credit of the profession.
Our wonder at the administration and favorable reports of the
good effects of quinine in the hot stage of periodical fevers will
be abated if we look on this medicine in another light than as a
tonic. It is a difficult task to classify medicines, with reference
to either their physiological or therapeutical effects; and hence,
while we can criticise existing arrangements, we find it difficult
to offer better ones. If we must designate the operation of quinine
in disease by a single term, that of sedative seems the most
appropriate. Its power of allaying febrile irritation, in which
disturbance of the nervous system is the chief element, cannot be
doubted. That with this effect it should, also, when given in
disproportionately large doses, exert narcotic and even toxical
properties, is only what we must look for from nearly all articles
of the vegetable kingdom which wre are accustomed to use as
sedatives. Be this as it may, Dr. B. expressed his belief that the
admission of the sedative operation of quinine would go farther to
harmonize the pathology of the fevers and other diseases, and its
use in them, than a belief of its stimulating or tonic effects. As
a mere stimulant it utterly fails us. As a tonic proper, in diseases
in which there is simple asthenia and anemia, without nervous
complication, it is equally unsuccessful. Indirectly, it seems to
display a tonic operation by allaying and removing the nervous
disorder and excitement, which kept the functions in a disturbed
state, and produced indirect debility in consequence.
Our confidence in the administration of large doses of quinine
in periodical fevers, and of its use in the paroxysmal period, will
be increased by a knowledge of the fact, that this practice is now
one of common recourse in southern Europe, in Algeria, and in
the United States, by physicians who would seem to have been
led to it without any prior concert or formal interchange of
opinions.
Arsenic, the febrifuge effects of which are readily suggested by
the mention of quinine, is another example of the difficulty of
classifications of the Materia Medica. It is commonly spoken of
as a tonic, and as such it is prescribed in periodical fevers ; but
its operation in these diseases is not explicable by regarding it in
this light. Like quinine, its chief therapeutical action is on the
nervous system ; and like quinine, also, its action is more evidently
tranquillizing than exciting; and hence its use is admissible in
states of excitement of the nervous and even bloodvessel system,
in which mere stimulants, and common tonics, too, containing the
bitter and astringent principles, would be injurious. This remark,
of course, applies to the administration of arsenic in small doses,
short of any toxical effects, which last would include not only
lesions of tissue and poisoning of the blood, but the milder degree
of emaciation and anasarcous effusion. From the time of Fowler to
the present day, the safety and good effects of arsenic in intermit-
tent fever are familiar to English and American physicians; but
it is only of late years that the same favorable opinions of this
medicine are beginning to be entertained in France. For a time,
under the dominion of the Broussain theory, arsenic was dreaded
as a poison, the use of which was denounced under all circum-
stances. Dr. B. has himself heard Broussais in his lectures speak
of it in these terms. Now, however, we find that, through the
exertions of M. Boudin, and other medical officers of the French
army, arsenic has been used to a great extent among the troops,
as respects the number of the patients.
It would seem, from official returns., that not only is the safety,
but also the efficacy, of the practice proved. In this last respect
it is alleged to be superior even to quinine. Thus, while the mean
duration of the cases of intermittent fever treated by quinine is
stated to have been thirty days, that of those in which arsenic was
administered was twenty-two days; and that while the relapses
after the quinine were somewhat more than twelve per cent., those
after arsenic were but a little more than three per cent.*
*Dr. Bell, at the meeting of the Society, gave the general results of the
use of arsenic in intermittent fever as above. He has since added the nume-
ral returns of the comparative merits of this medicine and quinine to the
manuscript report of his remarks.
The expense of procuring quinine, and the great extent to
which it is adulterated, gave increased importance to the question
of a good and cheap substitute for this invaluable medicine.
The President of the Society (Dr. S. Jackson, formerly of
Northumberland) was asked his opinion, as he had practised
twenty-five years in a region of fevers; he gave it, and has since
written it with amplification as follows:—
If any one reads this little paper, let him bear in mind that the
writer intended to note so much only as would indicate his gene-
ral principles of treatment; and that he confines his observations
to the fever as he has known it in Northumberland or Philadel-
phia, and to such cases of this as consist of open and free reaction.
The remittent koinomiasmatic fever is a purely inflammatory
disease in all times and places, having no tendency whatever to
the typhus or typhoid, nor any possibility of being changed into
either of these, in any of its stages. If there is no actual inflam-
mation present, there is yet always a tendency to form it, pro-
vided the excitement be high or unequally directed. In all cases
therefore of open free reaction, the first indication is to abstract
all stimulant and tonic matter, whether medicinal or dietetic, till
the fever is solved or changed into a perfect intermittent: those
cases excepted which are protracted into a state of great debility,
or such as are sometimes supervened by hemorrhage, congestion,
or some other dangerous debilitation; and even here bark and
animal food are inadmissible.
Bleeding, general or local or both, is nearly always necessary,
or at least useful, particularly in children, in whom there is a
determination to the head that will soon end in convulsions or
inflammation and effusion. The state of the head in young persons
will often indicate a repetition of this remedy; but of this we shall
say more in our progress.
Purges ought to be mild, and given in divided doses. If you
are called in the morning, and this remedy is necessary, give oil
or Epsom salts, the latter with magnesia, either of them to be
assisted by enemata, so as to relieve the bowels before the exacer-
bation. This may be expected from one to four o’clock, and you
must have it met by small doses of tartar emet. one sixteenth to
one twelfth of a grain, largely diluted, every half hour. It is now
very desirable that the physician should be there with his lancet;
but if this be impossible, the patient must go on with his tart,
emet. and hope for a bleeding on the following day. An intelli-
gent nurse might determine whether cups might not, in the phy-
sician’s absence, be applied to the nucha. Cases sometimes occur,
however, in which blood may be drawm from the arm in the morn-
ing; and others are sometimes met with that absolutely require
either bleeding or cups, so great is the febrile cephalalgia.
Cold water must be poured on the head during the exacerbation
in great abundance, if there is much heat or pain therein. Let
the patient hold his head over a wash-tub, and let'cold water be
poured thereon slowly and from a height of three or fouu feet, but
in a very small stream long continued. If the body be generally
hot, it must be sprinkled or sponged with cold water, or with
warm water, to either of which a little vinegar may be added.
The pouring of cold water on the head, like bleeding, is particu-
larly important in children, on account of their cephalic predis-
position. Above all things, be careful that the feet are warm.
Now, it is ten to one if the purging do not go on during the
afternoon; and as the principal irritation thereof is passed during
the morning, the continuance of it during the afternoon, as a mild
diarrhoea, will help to weaken the fever. But should it not cease
as the remission approaches, you must omit the tart, emetic; and
if the patient be debilitated, and headach do not prevent, you may
give some op. with ipec. and determine their action to the skin by
sudorific tea. The purging ought to be stopped when there is a
reasonable hope of an approaching perspiration. Op. is often a
blessed medicine in this fever; but it must be generally given so
as to sweat off its own intrinsic bad properties, or rather its inap-
propriate effects. But alas for the fever patient whose opium
acts as an irritant.
Now it is needful to prepare for a loose state of the bov’els the
coming morning. Give then, to an adult, from 5 to 15 grs. cal.
at late bed time, preliminary to a dose of oil as early in the morn-
ing as possible, thus being careful that the irritation of purging
be administered during the remission. If the bile be healthy and
sufficient, or green and not offensive, you may give a small dose
of oil at night instead of the calomel; but the least suspicion of
hepatic derangement must be met by the mercury, and calomel is
infinitely better than the blue mass.
Drinks should be milk warm, because they promote the kindly
operation of the purgatives and tart, emetic; and if the ungovern-
able and silly patient will have cold water, let it be given in very
small doses. Large cold drinks often bring on colic, and their
transient sedation is always followed by reaction demanding
another draught. Milk warm drinks are known to quench thirst
better than cold, whether in sickness or health. But here the
reader reclaims—“a cold drink is often followed by a free per-
spiration, the effervescing cold draught determines directly to the
skin, and often most wonderfully composes a sick stomach: see
what Dr. Wood says in his Practice of Medicine.” ’Tis true
that a large cold drink will sometimes be followed by a temporary
sweat, but not often; and if it be indulged in after the perspiration
has begun, it is positively hurtful, particularly in bodies greatly
debilitated. The Riverian draught is a useful medicine, if given
in a state of brisk effervescence, and to patients who are not dis-
posed to flatulence; but query—who is to give it? From three
to ten are sick in the same house and there is one worn-out nurse,
and most likely an ignorant and clumsy one, who has hardly-
recovered from her own sickness, and who is so oppressed with
duties, that the “very grasshopper is to her a burden”—I could
wish Dr. Wood to see this woman go round among the patients,
salt of wormwood in one cup and lemon-juice in another—I think
he would find her an unfortunate and clumsy chemist. As to the
neutral mixture, which is the same thing in a vapid state, you
might as well give the washings of your teacups and saucers.
No—tart. emet. with warm drink is the divine remedy in this
fever. You cannot give it judiciously without doing good—you
cannot withhold it without doing ill. It is like the Philosophy
intended by Horace which he thought would profit all sorts of
people;
zEque pauperibus prodest locupletibus seque,
/Eque neglectum pueris senibusque nocebit.
Now by this mild treatment, assisted by many coadjuvants not
necessary to name, as I am writing for the learned only and not a
full treatise for them, nature will bring many deadly cases of fever
to a safe and early crisis, or change them into a salutary inter-
mittent. The most important part of the physician’s office, is to
watch the state of the head, for this is the seat of danger. Bleed-
ing, with leeching the head or cups to the nucha in the very
beginning of the exacerbation, must be repeated in many cases
more than once, and the pulse must be kept under the sedative
influence of tart. emet. Of this the dose may be gradually
increased to one fourth of a grain; but be careful not to maintain
a continual nausea, for this will bring both the medicine and
physician into disgrace. Nor is this nausea necessary to the
febrifuge operation of the tartar as may be learned from Lind,
Chapman, Fordyce and others.
When at last you seem to have done all that can be done by
bleeding, purging, tart, emetic, and yet the fever continues without
any evidence of a coming solution, the patient becoming debilitated
without a proportional subduction of fever, there is no doubt some
local inflammation, most likely in the gastro-intestinal membrane,
possibly in the meninges. But wherever it is, small doses of
calomel must be given—not to salivate, for this would be a hor-
rible thing, but merely to bring the system under the slightest
influence possible. I have already said that calomel is to be pre-
ferred to the slow, feeble, uncertain, and often adulterated blue
mass. Now as soon as the green bile begins to flow, you may
hope for an amelioration of all the symptoms. But while the
calomel is doing its part in the above state of things, the remedy
which stands pre-eminent is the cold shower bath. If a common
apparatus be not at hand, let the patient sit down in a common
wash-tub and let a bucket of cold water be thrown over his head
and shoulders; then let him be dried and put between blankets,
taking some sudorific drinks as camphor tea or vinegar whey. In
some cases this process may be preceded by a dose of op. and ipec.
This bathing may be repeated every day, in the beginning of the
exacerbation if the strength suffices—in the height of it, should
the patient be weak; and be assured that it has happily terminated
many cases of fever that threatened to run into the lowest state.
Now this method of bathing may be used earlier in the fever with
great advantage, but it is after evacuations have been pursued for
some days that it proves pre-eminently salutary.
Protracted Cases.
When the physician is called late or some untoward circum-
stances occur when he is called early, the case may be protracted
into a state of great danger. Then supervene the symptoms
unfortunately called typhoid. The debility is great, the heat little,
the tongue dry and red, the teeth uncovered—dentes retecti* the
feet cold, the head sweating. These symptoms, I say, have been
unfortunately called typhoid. Tis true they afford the likeness of
typhus, but the disease is still an inflammatory remittent and it
will not bear the identical treatment of typhous fevers. In the
above state of the system, bark, quinine, bitters, snakeroot, are
advocated by many: I venture to discard them all, but particularly
the bark and quinine—the best of remedies when properly used,
the very worst when abused. Nor wrould I give one particle of
animal food, not even chicken water, as long as the fever is
continued.
* This symptom I do not recollect seeing noted except by Persius. Sat.
Ill—101.
Farinaceous diet and vegetable soup ought to be administered
in small, frequent doses; and if stimuli are needed, wine whey,
wine and brandy largely diluted, sweet sp. of nitre, carb, ammon.
in julap. But when the tongue is dry and red, the sp. of turpentine
is the best of all remedies and should be given in doses of 20 drops
to 40 every two hours in mucilage or simply floating on cold
water. Blisters to the surse and nucha are of great service in this
state and they ought to be drawn between the scapulae, if there is
any tendency to the lungs. Here moreover they act charmingly
on the brain and thus do a double duty.
I need not remind the experienced practitioner how much good
he may do by the use of opium, but if I had the leisure and it were
necessary, I would “ cudgel his brains” with respect to the turning
of its operation on the skin. Combined with ipec. and given at
bed time with warm camphor tea, it will procure sleep and some
perspiration in the morning. A non-critical and partial swTeat is
not injurious in this as in typhous fevers ; it affords, like issues in
other diseases, an outlet to inflammatory action.
This process continued nightly, you will find at last that the
morning mador is indicating that nature, with your skilful aid, is
about to solve the whole disease and prepare the patient for quinine.
You will find him gaining a little every day, the pulse becoming
slower, the countenance brighter, the tongue moist, the exacerba-
tion daily less severe; till finally at your nocturnal visit, say mid-
night, you find a softness over the whole body with a fuller and
slower pulse—this is the first time to think of quinine. This
patient who has been in dubio for several days and has kept you
continually uneasy, you visit the next morning at the dawn and
find that he has happily turned the goal. Now give him a dose
of op. or paregoric; and then two grs. of quinine every hour till
lie has taken from 12 to 16 grs. and the whole trouble is over—
you have saved the life of a fellow creature, or rather the Science
of Medicine has done it for you.
Tis vain for Dr. Forbes or Dr. Anybody to say that nature per-
formed the cure. Nature sickened the man, nature- brought him
to the very brink of the grave; and there she would have left him,
had she not been persuaded, importuned, or compelled, by your
skill in medical science. Nature cure such cases! As well might
you say that she cures a crevasse of the great Mississippi because
she first made the breach and then afforded the mud wherewith to
stop it. Nature acts by an organic necessity and requires to be
aided by the means which a world of physicians have happily
discovered. Hippocrates said the physician was the servant of
nature; could he now see what physicians do, he would say that
she is their servant.
Nature cures no mortal disease; that physicians cure many, we
do certainly know; and we ought never to do this without feeling
thankful for the means, as they certainly came down from Heaven.
The cures of mortal diseases have become so common that they
are not estimated, and the blessings we confer are not appreciated
even by ourselves. Pious men give thanks at table that they have
something to eat and say grace, the Friends hold a silent pause;
in both which there is a twofold gain, “they kill two birds with
one stone,” they return thanks and acquire a wonderful appetite
by delay. Now I should like to see this practice fairly carried out
and a grace said or a pause made over every dose of bark. How
different from this is their practice!—the ungrateful men make
angry faces and complain that it is bitter and sticks in their
teeth.
The patient has now passed the crisis and he is fortified for the
present by the 14 grs. quinine against any return of the fever and
against an impending intermittent, which he was poorly able to
bear. He is not however free from an almost imperceptible fever
arising from a little inflammation somewhere ; but this will gra-
dually wear away without bringing the system into sympathy and
hence the old favorite, chicken broth, may be given and a little
quinine or bark must be given every day in divided doses.
As to the use of quinine or bark during the continuance of fever,
I must say of them as did Baglivi—remedium dam,nabile et per-
niciosum. Bark was given us for a specific purpose—the cure of
periodicity and not for the cure of fever. Epicurus taught as we
learn from Lucretius L. IV.—821 et seq. that our bodily organs as
eyes and ears were not made for their present uses ; but that when
made, they found something to do and brought themselves into
use. Were this philosopher to metempsicose into the body of
some modern physician, he would probably teach, that having
found bark beneficial in ague, he would therefore use it. This I
believe is not orthodoxy in the present age. We must believe that
Heaven gave the bark for the cure of periodicity as certainly as
we believe that the eye was made to see with or the ear to hear
with. It was not given to cure inflammation, obstruction, dropsy,
or fever—therefore it does harm in this fever till nature assisted
by the physician or the physician assisted by nature, removes
these, or digests them so far that their floating morbosity seeks
the pores, the kidneys, or the bowels.
That stimuli are sometimes necessary, I do not question ; but
they are the choice of evils, and such only ought to be used as
produce a transient effect. Bark, bitters, and animal food, are
most persistent in their effects, never failing to aggravate or cause
inflammation. The writer cannot distinctly remember what mis-
chief he did with bark on first setting out in life, as 38 years have
since rolled by, sweeping away many reminiscenda; but within his
clear recollection, he has seen enough in the practice of others, to
make him confident in his opinion and stubborn as Cato—
“ tenacem propositi virum.” He does certainly remember giving
it the first two or three years of his practice: but of this he has
no pleasant recollection; and lie must have abandoned it on
account of its inutility or the mischief it did.
Let the reader bear in mind, that I am treating of remitting
miasmatic fever which cannot in my opinion be ever changed into
typhus; this last is a specific disease and bears a very different
relation to animal food and bark—a fact which alone might prove
the natural discrepancy.
But how is it, you inquire, that many eminent physicians have
used bark with safety and advantage in these very fevers ? Have
a little more patience and I will patiently tell you. The remittent
and intermittent fevers are from one cause and ever ready to be
converted into each other, but particularly the remittent into the
intermittent. Now it is a fact that some remittents have, from
the onset, very severe exacerbations ending in almost perfect
intermissions. This is particularly the case in those whose exacer-
bations are worst every third day. Now in these cases there is a
strong tendency to periodicity, to the forming of an intermittent,
and hence the bark, if given in the sweating stage of the exacer-
bation, as practised by Clark and others, expends its stimulation
on the skin, while its antiperiodic effects are valid in preventing
or mitigating the next day’s fever. In fact the remittents wherein
the bark is found useful, are mere intermittents somewhat masked,
hence bark is the appointed and heavenly remedy.
Thus quinine has sometimes been found to extinguish yellow
fever; now this disease has been considered as allied to malig-
nant intermittents from the peculiar remission on the third
day; and in epidemics wherein this alliance is considerable, the
quinine may sometimes prove fortunately useful. In malignant
remittents there is known to be a distinguished tendency to inter-
mission, and here it is therefore admissible.
In this disease, the very prostration which renders all these cases
alarming, prevents that local inflammation that resists the just
and salutary operation of the bark, in cases milder but more phlo-
gistic. In fine, it is inflammation present or to come, conjoined
with a fever essentially inflammatory, that prevents the proper
operation of bark. In typhus fevers, this medicine may be used
by an experienced hand, though they be attended by some inflam-
mation ; so it may be used in gout and rheumatism, but not with
safety if an active phlogosis is on the increase.
In southern lands, there are many cases, and sometimes nearly
whole epidemics, wherein there is very little inflammation and
wherein too, the disease is characterized by a feeble circulation and
an almost paralysed state of the whole man : here there is no fear
of inflammatory action, hence the tonic powers of bark may raise
the system above congestion, and its peculiar virtues may destroy
the periodicity. Blessed medicine—which does more, through the
ingenuity of physicians, than would seem to have been first in-
tended. Among many proofs of this operation of bark in the
South the reader may find some of the strongest in a paper by
Dr. Wm. M. Boling on the fever of Alabama, Jlmer. Jour. Med.
Scien. New Series, Vol. xii. 18.
But even in Southern climates bark cannot always be used with
safety—witness the testimony of Mosely and Hillary, in the West
Indies, and Johnson in the East, as well as many other authorities
that might be adduced. Mosely, in treating of the remittent fever
of the West Indies, says, 4dh ed. Lond. 1803,—“ if the fever be a
recent one, and has a tendency to a remittent, (he is now speaking
of intermittents,) the premature use of the bark impedes the secre-
tions, causes strictures in the capillary vessels, and fixes immovable
obstructions in the brain. This I have so often seen that I wonder
at writers not observing more caution in advising bark early in the
remission of fevers,” p. 192. He enumerates in p. 193 the evils
that come from giving bark in remittent fever when there is any
tendency to inflammation.” He declaims, p. 190 to 193, against the
giving of bark till the body is fully prepared for it by evacuations,
and before the intermissions are perfect. To the improper use of
bark in intermittent and remittent fevers, he imputes dementia,
insanity, inflammations, and various obstructions.
Dr. James Johnson lost all his patients in the remittent fever of
Bengal, till he abandoned the bark, and took to bleeding and calo-
mel. He says, “it was with a trembling arm and a palpitating
heart that I first opened a vein.” See Johnson on “ the endemic
fever of Bengal,” and above all attend to his necrotomic phenomena.
By the way it must be conceded that Dr, Balfour used bark in the
same fever after evacuations; but he had to confess after some
years, that obstructions of the liver w’ere very frequent, and proba-
bly existed in all cases, that hence he would recommend mercury
so as to effect the mouth.
Let us hear what Hillary says of the remittent fever of Barbadoes.
By bleeding, emetics, and saline drafts, the fever “ was generally
carried off by a critical sweat on the seventh or ninth day; or in
some few it came to intermit regularly after that time, and then was
soon cured by the bark, given with saline drafts. Though these
irregular, ingeminated fevers often remitted and sometimes seemed
to intermit, yet if the bark was given too soon in the disease, before
it inZer/mV/ed regularly, (as I have more than once seen,) it gene-
rally caused the fever to become continual and mail moris”
There are some dangerous diseases that admit of two general
methods of cure—one by debilitation and the other by tonics.
These will forever exercise the ingenuity of man, and give abun-
dant occasions of vehement contention, while both parties have
truth and reason on their side. But we are now treating of the
fever in Pennsylvania, and therefore it would be well to consider
what some Northern physicians of great reputation have said.
Pringle says, part III. ch. IV. sec. V. “the cure of the camp
fever, (he means the remitting and intermitting fevers,) depends
chiefly upon evacuations and a low diet: the bark is useful when
there are complete intermissions” Descanting on venesection, he
says,—“ a person unacquainted with the nature of this disorder, and
attending chiefly to the paroxysms and remissions, would be apt to
omit this evacuation, and to give the bark prematurely, which
might bring on a continued inflammatory fever. Rush’s edit. p. 178.
Now mark well—this great man used bleeding, purging, and
abundant doses of tartar emetic, thus preparing the system for a
complete intermission. At p. 182, he says—“I come next to the
bark, and shall observe, that these fevers have often such fair re-
missions and even with a breaking of the water, as might persuade
a physician unacquainted with their nature, that they would always
yield to this medicine; but he would be often disappointed. Whether
it be that some inflammation hinders the bark from taking effect, or
that these quotidians are not true intermittents, (as not being of a
tertian or quartan form,) certain it is that they can seldom be safely
stopped by it. For though the paroxysms have disappeared under its
use, yet having so often seen the breast affected or a lurking fever
remain after giving the febrifuge, at last I made it a rule to attempt
the cure without it, or at least to delay it till, in the convalescent
state, the patient required it only as a strengthener.”
In page 186, when treating of a w’orse form of remitting fever
which he calls the marsh fever, he says, “ it was necessary after
due preparation, to stop it in the first fair intermission.” And Dr.
Rush in his note p. 182, says—“ in the bilious remittents of the
U. States, of the first, second, and sometimes of the third grade, the
bark is ineffectual in curing them.”
In p. 183, however, Pringle confesses, that when evacuations did
not bring the fever to a crisis and the exacerbations wrere becoming
worse, he gave bark, beginning “two or three hours before the swTeat
ended.” Giving the bark during the sweating stage, if it was
necessary, was a most prudent measure and accords with what we
have said above. The stimulation is sweated off and the antiperi-
odic virtues remain. But Pringle took to the bark in these cases
as a last resort, after his approved treatment had failed.
Donald Munro, Vol. II. 88 and 89, 2nd ed. says—“In the years
1761 w’hen the fever came to remit, we were obliged for the most
part to continue the diaphoretics ; for although the disorder put on
a remitting form, the bark had very little effect in stopping it, unless
when the fever changed into a regular quotidian or tertian form.”
And again he says, “ We tried the bark in various forms in many
cases where the patient had been blooded and purged in the begin-
ning, and had used the cooling medicines, and where the remissions
were very clear, yet it had no effect in removing the disorder,
except in a few cases wherein the paroxysms assumed a tertian form.
For the most part, it made the patients more hot and feverish and
we left it off, as it was in danger of changing the remittent into a
continued fever.
Now maik what I said above—that when the bark succeeds in
remittent fever, it must be when there is a strong tendency to run
into the intermittent form. Now see here what Munro says page 90—
“ I have observed that in some seasons, it has a remarkably good
effect, while in other seasons it rather seems to increase the heat
and fever. In general the more distinct the remissions are, and the
more the fevers of the season tend to perfect intermittents, the better
effect the bark has.”
The above are some of the best authorities, they were the instructors
of my youth and I turn to them with pleasure—many others might
be adduced, but time and space are wanting; moreover it is an
invidious task to quote book after book which the reader is more
likely to know than the present writer. Vivo Roma said Baglivi
in excuse of his opinion: the present writer may say in palliation of
his ignorance, annos viginti quinque Northumbria vixit—that he lived
25 years in the Ultima Thule of medical science.