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difficulty of going beyond general rules for the use of a remedy whose power is so much dependent upon the fluctuating state of the animal economy under disease, will be readily acknowledged. We must be guided by the evidence of local affection, by the nature, temper, and period of the disorder, and particularly by the actual effect produced by the operation; for, in different circumstances and persons, it will be borne with very different results, under symptoms apparently similar; hence the discordance of opinion, the applause and censure that have attached to this remedy, since the earliest eras of medicine. What I have seen certainly authorizes me to believe that early bloodletting may be extended to cases of fever, in which it has been generally considered at least equivocal, if not prohibited. In favour of its late employment, which must ever require great caution and discrimination, and which can only be justified under very pressing symptoms, I have nothing whatever to say beyond what is comprised in the maxim of Celsus, "Multa in precipiti periculo recte fiant, alias omittenda.”
In farther support of these observations, I might here adduce, were it necessary, many high and well-known authorities, ancient and modern, in behalf of blood-letting in fever. But such a review would far exceed my object, which is impartially to pourtray its effects in the disease in question, not to advocate its cause in fevers in general; certainly not the indiscriminate or incautious application of this remedy, in habits debilitated by disease, intemperance, long residence in warm climates, or in unhealthy situations;-far less to countenance its rash employment late in this disorder. On the contrary, I am well persuaded that its late or injudicious use in dangerous fevers, such as those I have been most conversant with in the West Indies, would infallibly accelerate the fatal catastrophe; but, in climates where the disease is far less rapid, and where, from experience of its nature and tendency; of its pressure upon some vital organ; or of the inefficacy of other modes of treatment, we have reason to apprehend that it will run on to a fatal termination unless relieved, we are certainly warranted in making the attempt; and the success with which it was made in some of the above instances alone, is, I conceive, sufficient to justify this conclusion.
In leaving to be weighed in the varying scale of opinion the above evidence in behalf of early blood-letting, as a remedy for fever, the inference that the reverse of this proposition has often been assumed from theory, and not from experience, will probably be allowed to have some influence with the most sceptical, when it is reflected, that they who have written in its favour
have practised what they recommend; while it is hardly to be supposed that the humanity of those who are against it would permit their giving a fair trial to a measure which they believed to be injurious. In this fever, unfortunately, the cold affusion was but seldom deemed admissible, from the frequency of pulmonary, or other topical congestions.
Without entering into the different views with which epispastics have been used, they were employed with their usual good effects in mitigating pain and local symptoms; and they often proved serviceable in relieving the head at a later period of the disease.
It is, I trust, every day becoming less necessary to say any thing of the ill effects of opium, bark, or wine, in the early stage of continued fevers; in the debility left by the disease, the latter proved a most valuable and grateful cordial.
In appreciating what has been said of the effect of venesection, it should be recollected, that, in all cases, purgatives were freely used at the same time.
It is now well understood, that the value of the latter class of remedies is not limited to the mere removal of the fecal contents of the bowels, but that they may be so managed as to obviate or relieve a tendency to topical congestions elsewhere; and also to produce a considerable effect upon the general system, by the increased quantity of fluids they cause the various glands and exbalent arteries to pour into the intestines.
Thus they become not only eminently subsidiary when bloodletting is proper, but more universally useful in diseases in general, in proportion as they are more uniformly applicable.
They were here considered not only indispensably requisite in the first instance, and assisted by enemas when necessary, but they were liberally exhibited throughout the disease; and very often the bowels could not be kept sufficiently active unless they were repeated day after day. Though not a new, it is a most important observation, that all uncertainty as to the full operation of this class of remedies can only be removed by inspection, without which the practitioner is very apt to be led to imagine that the patient, from his own report, or that of the nurse, has been sufficiently purged, when, at most, he may have had only two or three partial scanty dejections. There is another reason for this; purging, though oftener carried to an insufficient length, I have reason to believe, in some instances, has been pushed too far, and hence its due limits can only be ascertained by personal observation. While we are producing foul, dark, fetid evacuations, we may naturally expect that we are benefiting and relieving the patient; but when the bowels have been freely
cleansed, and the system does not require further reduction, to keep up a constant state of irritation, by purging, can only prove wasting and injurious.
On the other hand, by those that have not had much acquaintance with fevers, it is hardly possible to calculate the quantity of medicine sometimes required to overcome the torpor of the intestinal canal; the morhid accumulations that have been discharged, after repeated purgatives; and, in some cases, the speediness of their reproduction.
In tropical fevers, especially, I have seen very striking examples of the abatement of fever and delirium, after the operation of purgatives; and it is therefore of great consequence to be aware, that the febrile symptoms are often maintained, or renewed, by the retention of vitiated secretions, or other morbid contents of the intestines; as also of the quantity of dark coloured offensive matter that is often discharged, after the patient has been thought sufficiently purged, and its speedy reaccumulation, in some cases, in order to estimate the extent to which it may be necessary to persist in the use of evacuants.
The choice of purgatives was not restricted in the present fever, where the stomach was so retentive: jalap and calomel was the purge most frequently employed, and, upon the whole, perhaps, the most efficacious. The latter was found a valuable addition to other cathartics, but it was seldom exhibited with any farther view, as the biliary system was little affected, and chronic visceral derangement, as a consequence of fever, rare.
Dr Fordyce, and other eminent practitioners, have observed that medicines of this class, when combined, occasion less sickness and pain, and are more certain in their operation, than when taken singly; a remark in which I beg fully to coincide. A mixed purgative, I am clearly of opinion, operates more effectually, and, at the same time, more easily, and in a smaller dose, than any remedy of this description individually.
Upon the whole, although, from their general and extensive utility, purgatives claim a great superiority in the treatment of various diseases, and of fever in particular, yet their value ought not to derogate from the efficacy, nor supersede the use of other agents; for, in the severer forms of fever, we find that bloodletting, purging, and the cold affusion, greatly, and mutually, assist each other.
Clifton, February 1816.
On the Malignant Fever which prevailed at Gibraltar in 1813, and its Treatment by Blood-letting. By J. HUMPHREYS, Assistant-Surgeon, Royal Artillery.
THE THE Bilious Remittent Fever, which has long been prevalent in Gibraltar during the summer months, assumed a malignant form in the month of August 1813. As this disease has proved so very destructive in this fortress for the last two years, exciting a peculiar interest in every class of society here, and has been subject of alarm to the greater part of Europe, I beg to transmit the following observations for insertion in the Edinburgh Medical and Surgical Journal.
My object in submitting a few remarks on so important a subject to the consideration of the medical world, is to recommend blood-letting and the depleting system; and to shew that this mode of treatment, instead of producing deleterious effects, and adding to the already existing debility, according to the opinion generally entertained by the medical officers in this garrison, is, on the contrary, attended with instantaneous relief of the distressing symptoms, and the extreme prostration of strength, and at once cuts short the disease, as will appear by the cases which I shall subjoin, and which came under my own immediate treatment.
On the first appearance of the fever in 1813 in its aggravated type, a report was spread, and generally believed, that it was contagious; the garrison was immediately placed in a state of the strictest quarantine, and families became so exceedingly alarmed from a supposition of its being highly so, as to shut themselves up, refusing admittance even to their friends. I do not, however, concur in this opinion, and hope to shew, in a satisfactory manner, by many instances which I shall adduce, that no contagion existed. The disease, at its commencement, attacked persons in different parts of the town at the same time, who were very remotely situated from each other, and those who shut themselves up, and considered themselves secure, being perfectly insulated, were attacked as readily as those who mixed indiscriminately with the people as usual; shewing clearly that the disease was produced by general local causes, acting on the whole population of the place, and not imported, of which no satisfactory assignable source has ever been traced; nor do I VOL. XIĮ. NO. 46.
think it probable that contagion is of that peculiar nature, as to shew itself in different years precisely at the same season, having lain dormant and inert nine months of the year, and then burst forth to commence its devastating influence.
The local causes which appear to me to have given rise to this so much dreaded and formidable disease, are principally the following: The excessively crowded population of the place; the houses and sheds being literally huddled together in so limited a spot, without arrangement, and of the worst construction; the doors and windows being generally on the same side of the apartments, so as to preclude a free access of air and ventilation; and among the lower orders of Portuguese, Spaniards, and Jews, these dwellings are usually shut up during the whole of the day, from sunrise to sunset, consequently, on their return, they must breathe a very impure air, almost wholly deprived of its oxygen the immense collection of animal and vegetable matters, arising from so great a population, during the dry summer months, remaining stagnant from May till the end of August, and which become roused into action at the end of the autumnal season by the partial rains, when the quantity of water is not sufficient to propel them through their respective drains, which are too narrow for their evacuation, being frequently choked and bursting. At this season, also, the heavy night-fogs, succeeded by a parching sun, occasion exhalations extremely noxious and unwholesome. To these may be added the peculiar situation of the town, which is on the western foot of a steep rock, 'about 1400 feet in height, running nearly north and south, the air remaining nearly stagnant during the prevalence of the easterly winds, which continue with but little variation the whole sum
Having enumerated such of the local causes as I conceive to be the leading and most prominent, in aggravating the bilious remittent fever, which we here witnessed in the years 1813 and 1814, I shall now proceed to state some striking examples.
A lady, an officer's wife, residing in the Moorish Castle, which is considerably above and out of the town, never left the castle, and was so alarmed that she would not allow any individual to approach her; and after the fever had existed five weeks or more, she fell ill and died of it; her husband, who was constantly at her bed-side during her illness, escaped the disease.
Similar precaution had been taken by the Ordnance storekeeper, Robert Pringle, Esq. who had adopted the most rigid quarantine for more than three weeks, yet he did not escape. As his was the first case where I ventured to deviate from the common mode of treating the disease, and as it terminated suc