A treatise on the fevers of Jamaica, with some observations on the intermitting fever of America, and an appendix, containing some hints on the means of preserving the health of soldiers in hot climates. / By Robert Jackson, M.D. ; [Four lines of quotations]

CHAP. VII. OF PROGNOSTIC IN THE FEVERS OF JAMAICA.

TO be able to perceive at a distance, the approach of danger or returning health, is a knowledge highly satisfactory and useful to the physician; but it is a knowledge which is not easily attained: for to judge with certainty of the event of fevers, requires not only long and attentive observation, but a dis|crimination of complicated and ambiguous appear|ances, which does not depend always upon attention alone. The sagacious Hippocrates is generally con|sidered as the first, who laid the foundation of the science of prognostic; and we certainly must allow, that he has left us many important and valuable ob|servations on the subject; yet we may also add, that his decisions in many instances, are precipitate. Hippocrates seems generally to have placed too great confidence in signs separately considered, and to have formed his conclusions too often on the authority of single facts. Thus he has sometimes considered as fatal in themselves those signs, which in reality are only dangerous. The absolutely fatal signs in fevers are actually few in number. I am able to affirm, from my own experience, that people are sometimes restored to health after many of the usually reputed fore-runners of death are present. We have, in fact, as yet only an imperfect knowledge of prognostic in fevers; but the field is still open, and careful obser|vation, it is to be hoped, may enable us in time to supply the defects. I dare not venture to assert, that I have advanced beyond others in this necessary and difficult science; but I am disposed to flatter myself, that the following attempt to appreciate the marks of danger or safety in the fevers of Jamaica, may be

found in some degree useful. It contains the result of my own observations in that country; and though I am perfectly conscious that the rules are often defec|tive, yet I likewise know, that I have suggested some hints which have not been commonly observed, and which may help to direct those, who have not had much experience of their own.

Prognostic is such, as applies to fevers in general, or more particularly to the different species of the disease. The type or form, the general course and tenor of the disorders, and the general nature of the paroxysms often afford useful information. From the type alone, we do not often obtain much that is to be depended upon. Long and distinct intermissions are commonly accounted signs of safety; yet we fre|quently see instances of the single tertian proving fatal, while types of greater complication are often void of danger: in general, however, complicated types are 〈◊〉〈◊〉 and perhaps more commonly fatal than others. But though a knowledge of the type of the fever abstractedly considered, does not com|monly afford any material indication of danger or safety, yet the time of the return of the paroxysm is a subject, from which more may be learned. An an|ticipation of an hour or two, is seldom much to be regarded; yet an anticipation of ten or twelve is al|ways suspicious. It either indicates a latent malig|nity, or a tendency in the disease to change to a con|tinued form. The complication of another fever, or the doubling of type is by no means favourable; yet it is much less to be dreaded, than a long and an ir|regular anticipation. Anticipations have been gene|rally considered as signs of the increasing force of the fever; so the type which postpones, is usually be|lieved to indicate a disease, which is hastening to a fa|vourable termination: the effect however is some|times the contrary. I have myself seen some instances, where, in consequence perhaps of weakness and im|paired

sensibility, the return of the fatal paroxysm, though it probably ha•• commenced sooner, was not clearly perceived till after the usual hour of attack. But besides those indications of danger or safety, which may be drawn from the nature of the simple type, or from the hour of return of the paroxysm, the state of the paroxysms and remissions deserves likewise to be attended to. It was generally observed where the paroxysms were regular, and assumed a com|pleter form in the progress of the disease, that there was not generally much reason to dread an unfavourable event. Hopes of safety might likewise be entertained with still greater confidence, where the paroxysms, though more violent in degree, became more regular and distinct after the use of bark, wine and stimulants. On the contrary, it was always an indication of danger, where they became longer or lost the distinctness and regularity of their form, as the disease advanced in its progress. Changes from bad to good, in the course of the fever, also indicated more safety as the opposite changes indicated more danger, than if cir|cumstances equally unfavourable had continued from the beginning.

In enumerating those particular signs or symptoms, from which we are led to form a judgment of the event of the remitting fever of Jamaica, I shall con|sider in the first place the state of the pulse. The pulse is so differently affected by the same causes in different people, and individually subject to so many peculiarities, that conclusions formed solely upon this basis must ever be fallacious. Hippocrates, who has treated very fully of the other signs of prognostic, is totally silent on the subject of the pulse. He has mentioned the term, indeed, in several parts of his works; but it does not appear, that he had a perfect knowledge of the nature and indications of the pul|sations of the arteries. The subject was somewhat better understood before the time of Celsus: yet this

author does not believe, that any information could be drawn from the state of the pulse alone, which was in any great degree to be depended upon. Galen, who is generally diffuse on every subject, has treated very fully of the nature of the pulse. He has indeed multiplied distinctions to an amazing extent, and suggested combinations of endless variety; yet notwithstanding this apparent minuteness, there are still several important observations with respect to it, which have escaped him altogether. It is not many years ago, that Dr. Solano, a Spanish physician who practised at Antequiera, opened some new and cu|rious views concerning the pulse, and its various indications.

The detail of facts with which this writer has fur|nished us, is really wonderful, and the candour with which he has related them, independent of the testi|mony of several respectable authorities, engages us to give him credit. I had not heard of Solano's dis|coveries at the time I lived in Jamaica, and I do not find that I had ever taken notice of observations similar to those he has mentioned. I was able indeed, for the most part, to foretel from the nature of the pulse, even in the beginning of the disease, whether the fever would be of a continued or remitting form; but I did not discover any signs from it, which led me to form a judgment of the future mode of termi|nation. I may add, that I met not with any instances of crisis by haemorrhage; neither did I ever take no|tice of the rebounding pulse. The intermitting pulse occurred frequently, sometimes as a forerunner of death, sometimes as an attendant of favourable crisis: but I cannot say, that I observed that it ever presaged a future diarrhea. I shall however pass over the observations of others without further comment for the present, and content myself with relating those circumstances of pulse connected with danger or safety, as they occurred to my own observation in the

remitting fever of the West Indies. I must remark in the first place, that independent of peculiarities of constitution, a weak, a feeble and easily compressed pulse was generally a bad one: a pulse which was indistinct and small, or small and hard, particularly at a late period of the disease, or together with de|lirium or clammy sweats, indicated for the most part, the most extreme degree of danger. That species of pulse moreover, where the stroke was obscure, or felt with difficulty, was suspicious at all times; but it was particularly dangerous where accompanied with a wavering, a tremulous, a constantly creeping or vermicular motion in the artery. I am not certain that my meaning will be clearly understood; yet I believe that those who have once observed this tre|mulous and creeping pulse, will not easily forget the danger which it indicates. It often attended a fever of a malignant kind, where the nervous influence ap|peared in some degree, to be suspended.—But to pro|ceed: it is an observation so well known as to render any mention of it almost superfluous, that a frequent, an irregular, a fluttering and intermitting pulse com|monly indicates danger, sometimes approaching death: yet I must add, that an intermitting pulse sometimes attended the favourable crisis of a peculiar species of fever. It was observed, however, in such cases, that the pulse was not otherwise irregular, than by failing in its stroke at the end of every third or fourth pulsa|tion, neither was it generally found to be uncom|monly frequent. Some instances of this singular appearance occurred to me during the time that I remained in Jamaica: so that I was in some degree dis|posed to rank the intermitting pulse among the signs of favourable crisis, in a species of fever, the pre|ceding course of which had been distinguished by symptoms of a peculiar nervous affection. When I became acquainted afterwards with the observa|tions of Dr. Solano, I began to doubt whether the

intermission of pulse, which I had met with in the fevers of Jamaica, might not have been a sign of ap|proaching diarrhea, which had not occurred to my notice, rather than a sign of proper crisis, as I had formerly imagined. I remained in this uncertainty till lately, that some instances of this symptom hap|pening at the termination of fevers in this country, have helped to confirm me in the opinion which I entertained before. I found in those cases to which I allude, that the pulse intermitted after every third or fourth stroke on the day, on which I expected the crisis. The intermission of the pulse was not of such a nature as indicated approaching death; I there|fore looked watchfully for a diarrhea, but no diarrhea ensued. It must be confessed, indeed, that one of the patients seemed to be much distressed with gripes and flatus; but being deprived of the power of speech we could not obtain any accurate idea of his feelings: and no evacuation actually took place, till the day following, before which time the intermission had dis|appeared altogether.—Besides the above, there are some other signs of pulse which have their particular indications; but they are so generally known, that it will not be necessary to enlarge on the subject. I shall therefore only observe further, that changes from better to worse in the state of the pulse, as the dis|ease advances in its progress, are bad, while the op|posite changes are favourable: yet I must likewise add, that in those cases of favourable change, it will be necessary to distinguish carefully the pulse of coma, from the pulse of returning health.—The difference is sometimes scarcely to be known, except from the attending symptoms.

Next to the state of the pulse, I shall mention those appearances of the tongue, which, together with other concomitant circumstances, frequently afford signs of the mildness or malignity of the disease. Though we do not expect that the tongue should be

of a healthy aspect, during the continuance of a fever; yet where it is dry only in a moderate degree, or where it is covered with a smooth and whitish coat, the disease for the most part, is void of malignity, though not always of danger. On the contrary, where it is immoderately dry, or dry and black, the indications of danger are great, and I may add, still greater where a white slimy and glutinous substance covers its surface. This slimy state of the tongue was often seen at an early period, and as far as my experience goes, constantly indicated malignity. To the above we may add, a sodden or parboiled ap|pearance of the tongue, which was not of less dan|gerous import than the preceding. But besides those obviously unhealthy aspects of the tongue, its appear|ance in some instances was not different from its na|tural state, except in a certain lividness of colour. This was constantly suspicious, and if not fatal, was always extremely dangerous. The danger indicated by the tongue, when it is intensely dry, rough, crack|ed, or ulcerated is generally known; but I must not omit to mention, that when from a dry and unheal|thy state, it turns moist suddenly, or assumes its na|tural appearance, whilst the other signs of favourable crisis did not shew themselves at the same time, a change of the mode of action of the febrile cause is indicated,—and generally a dangerous one.—I say nothing of paleness and tremor, as these symptoms only indicate certain states of general or particular debility of the nervous system.

Vomiting is another of the alarming, and some|times of the dangerous symptoms of the fevers of the West-Indies. If this symptom continues during the remission of the fever, without material abatement, there is reason to dread its consequences; but if it vanishes or abates in a very material degree at the decline of the paroxysm, it does not deserve to be so particularly regarded. The practice however to

which it leads is often serious. Vomiting is sup|posed by most practitioners to indicate emetics; but the indication is fallacious, and the practice is often pernicious. During the time that I lived in Jamaica, I had frequent opportunities of seeing vomitings ren|dered continual by the repeated use of emetics, which before this treatment, appeared to be only accidental symptoms during the paroxysm of the disease. I therefore at last became cautious of pursuing this view, and have reason to believe, that if I did not oftener do good than others, I seldomer increased the danger. But besides the degree and frequency of the vomiting, the nature of the matters thrown up may likewise furnish indications of the danger or safety of the fever. The various kinds of bilious vo|mitings have been fully explained, and the danger of each has been so particularly pointed out by many writers, especially by Hippocrates, that I pass over the subject without further notice, considering it un|necessary to repeat the observations of others. I must however remark a more uncommon kind of vomiting, which sometimes happened in the fevers of Jamaica, and which I believe has hitherto escaped the notice of observers. The vomiting to which I allude in this place, is a vomiting of a clear and ropy liquor, in which are often found swimming flakes of a darker coloured mucus. This appearance was chiefly observed, where the remissions were indistinct, and the sweats partial and incomplete. It constantly afforded an indication of danger, and I seldom found that the usual remedies were effectual in restraining it. Vomitings of black and vitiated matters are com|monly known to be of the most dangerous import,—succeeded by obscure hickupings, they are often fore|runners of death. Yet though this is generally true, I must not at the same time omit 〈◊〉〈◊〉 mention, that I have seen several instances of recovery where black vomiting had prevailed for some time; and other

cases which give me room to conclude, that hickup|ings are not constantly fatal. I take the present oppor|tunity to remark, that hickup was sometimes only a distinguishing symptom of the disease, which increased or declined with the paroxysm; and that in other in|stances it attended the favourable crisis of fevers, the preceding course of which had been characterised by symptoms of nervous affection. This species of hickup was generally alarming in degree, and equally inexplicable with the intermitting pulse, which I mentioned above as sometimes attending a favourable termination. It often continued the space of twenty-four hours, in spite of all that could be done by ••••|dicine.

Next to the indications of vomiting, I shall enu|merate such as may be drawn from the presence or absence of thirst. Immoderate and unquenchable thirst has always been reckoned an unfavourable symptom in fevers. It is so undoubtedly, yet I have frequently seen very extraordinary degrees of it con|tinuing for a length of time, without particular dan|ger. Besides the desire for liquid in general, there is often an unconquerable longing for drinks of a particular kind;—a feeling which ought always to be attended to, and frequently complied with.—The desire for cold water is sometimes ravenous.—I have known it not only satiated with safety, but even with good effects. But though this immoderate thirst is justly reckoned a bad symptom in fevers; yet an in|difference for liquid, with a dry tongue, and other marks of internal heat, is still worse. It has indeed been generally considered as fatal; but here we ought to distinguish, whether it proceeds from local affec|tion of the tongue and fauces, or from a general failure of the powers of life. In the one case it is a mortal sign, in the other it can only be said to be dangerous.

The ancients, particularly Hippocrates and his

commentator Galen, have treated so fully of the in|dications of evacuations downwards, that I should be able to do little more than to copy their observa|tions. There is one species of evacuation, however, which they do not appear to have described very ex|plicitly, and which I have often observed to be at|tended with great danger. This is the frequent, small and ineffective excretion, and more particularly copious stools, which resemble dirty water, especially if accompanied with tension of the hypochondria and abdomen.

Medical writers have been long accustomed to form a prognostic of the event of fevers, from pustular or scabby eruptions about the mouth: but the sign is ambiguous, and cannot be depended upon, with|out many limitations. I shall however relate that which has occurred to my own observation, without troubling myself about the opinions of others. And I remark in the first place, that an eruption about the corners of the mouth, and near the lips, which comes forth freely, and soon turns into a scab, particularly if it does not appear till after the third revolution of the disease, affords a general sign of safety, at least it affords a sign that the complaint has attained the height of its violence. On the contrary, an eruption which shews itself at an earlier period, which is crouded, and makes its way with difficulty, or which resembles iron-burnt blisters rather than pustules pro|perly so called, particularly if it is on the upper lip, and spreads towards the nose, affords a general indi|cation of danger and malignancy.—Small and imper|fect eruptions likewise are frequently a sign of a te|dious disease.

The state of animal heat is another of those cir|cumstances, which may be considered as affording an indication of the nature and event of fevers. Where the heat of the body, in the remitting fever of Jamaica, was equally diffused to the extremities,

or not differing from an increased degree of natural warmth, the disease was usually mild, without particular danger or malignity; but where acrid, fiery and pun|gent, though perhaps not much increased in degree, danger was apprehended with reason, particularly if the warmth was not extended equally to every part of the body. In the remissions of those fevers, which were distinguished by symptoms of nervous affection, or, as is more commonly believed, putrescent ten|dency, the heat of the body was often several degrees below the standard of health. The symptom was alarming, but it was not in fact of much consequence. This diminution of the heat of the body, during the remission, was not by any means a rare occurrence; but besides this, there was sometimes observed a de|gree of coldness, during the favourable crisis of ner|vous fevers, of a very singular and extraordinary kind. In some instances this coldness was not infe|rior in degree to that of a person dying, or actually dead; yet a distinction was perceived without diffi|culty. It was not accompanied with marks of stric|ture on the surface of the body, at the same time that the pulse was generally soft, regular and full.

Next to the state of animal heat it will not be im|proper to consider the indications of the various kinds of sweats. The signs of a favourable sweat are commonly known. Where that excretion was fluid, warm and universal, particularly where accom|panied with a soft, full and expanding pulse, calm and easy respiration, general relief from symptoms of dis|tress, with a cheerful eye and countenance, we might in general presume on safety of the disease, often on its favourable termination. On the contrary, where the sweat was cold, clammy and partial, particularly where the pulse became or continued frequent, small and tense, with anxiety, restlessness and disturbed re|spiration, a circumscribed flushing, a greasy hue of the countenance, or a wild and dejected appearance

of the eye, the situation was then alarming:—death, in short, was seldom far off. There is, however, an observation with regard to this subject, which I must not omit to mention. Authors, with one consent, have considered cold sweats as certain mortal signs in fevers; but there appear to be exceptions to this ge|neral rule. I met with several instances, while I re|mained in Jamaica, where universal fluid sweats, of an extraordinary degree of coldness, accompanied the crisis of the disease. I was much alarmed when this appearance first occurred to me, but my fears soon vanished, as I found that the pulse became slower and fuller, that the respiration became calm and easy, and particularly that the eye and countenance acquired such a cheerfulness and serenity, as are usual at the fa|vourable termination of fevers.

To the signs of prognostic, which I have men|tioned above, I shall add those which are indicated by the general state of the vital powers, or by the more particular affection of parts, which are of imme|diate importance to life. Among the first of the af|fections of the vital organs, we shall consider such in|dications as arise from a disturbed state of respiration. A frequent, a hurried and unequal respiration, (I do not speak of that which depends on primary affection of the lungs), is justly considered as a sign of a bad disease. This is more certainly the case, where ac|companied with deep and heavy sighing. Frequent sighing was a common symptom in the fevers of Ja|maica, where the powers of life were depressed; and though not absolutely a mortal sign, it constantly in|dicated danger.

Next to the state of respiration, I shall mention the state of the intellect, or reasoning faculty, which often afforded some prognostic of the event of the fever. Delirium, I observed before, was a common symptom in the remitting fever of Jamaica. Where it vanished or abated as the paroxysm declined, it was seldom

found to be of material consequence. On the con|trary, where it continued during the remission undi|minished in degree, it was a symptom of the most se|rious nature. I mentioned in a former part of this treatise, that the cause of fever appeared to act on the brain and nervous system, in two general and oppo|site ways; that is, by occasioning excitement or de|pression. Of these two modes of action, depression was the most dangerous; unless where the excite|ment ran uncommonly high. But though I observed, that there are only two general modes of operation, viz. excitement and depression; yet I must also add, that the modifications are numerous, and very variously combined. Among the most dangerous and alarm|ing species of the derangements of the intellect, we might reckon a stern sullenness, an unmanageable fu|riousness, picking the bed cloaths, tracing figures on the wall, and such other instances of perverted judg|ment. Stupor and suspension of the nervous influ|ence, as we might term it, were likewise greatly to be dreaded: unless they shewed themselves only during the time of the paroxysm, they were generally fatal, more certainly so, if they followed convulsions.

As nearly connected with delirium, we shall now consider other disturbed states of the functions of the brain, viz. the states of rest and watching. We do not expect that sleep should be sound and undis|turbed in fevers; yet we have been accustomed to think favourably of the disease, where the patient is refreshed by it. On the contrary, total want of rest, or unrefreshing slumbers, constantly indicate danger. There is, however, an astonishing diver|sity of constitution in this respect, that must always be taken into the account in forming an opinion. Want of sleep was observed to give rise to delirium in some persons very speedily; others supported it for a great length of time, without any appearance of delirium or spasmodic affection. An appearance of

sleeping, without actually enjoying the comforts of sleep is well known to be a dangerous symptom; yet it is not by any means a mortal one. Anxiety and restlessness, are often referred to the stomach; but restlessness, and jactitation, as depending on the state of the nervous system, were likewise frequent, and generally dangerous symptoms. Tremors of the tongue and of the hands were common appearances in fevers, with marks of nervous affection; but I have likewise met with instances, where the whole body shook, when any motion was attempted, not otherwise than it does in paralysis or chorea sancti+viti. Startings and subsultus tendinum were not un|common; and they were justly considered as indica|tions of danger; sometimes as forerunners of con|vulsion. A disposition to faint, even actual faint|ing, was frequent in the fevers of this country. It was always dangerous, though perhaps less so, than other symptoms which were less alarming, particu|larly if it suffered increase and diminution with the paroxysms and remissions of the disease. But besides these symptoms, which indicate diminished energies, or irregular action of the nervous influence, we may likewise observe, that the sphincter muscles fre|quently lose their power of contracting, particularly in the advanced periods of fevers. Thus persons sometimes can only lie upon their back, the eyes and mouth are half open, the powers of speech and swal|lowing are impaired or lost, and urine and stools pass off without consciousness or against their will. It is unnecessary to remark, that these are all symptoms of the most extreme danger. If they proceed from a general and uniform diminution of the powers of life, we may justly consider them as fatal, if they are only produced by a certain mode of action of the febrile cause, and are remarkably increased during the paroxysm, or aggravated by peculiar circumstances of constitution, we shall find many instances of re|covery.

Thus, I have often seen people recover, who could neither speak nor swallow; who did not appear even to distinguish objects, and who were un|able to retain their urine and stools; or who were not conscious when they passed; yet I do not pre|tend to have met with any of these fortunate events, where these alarming symptoms were the consequence of uniform diminution, or general extinction of the vital principle.

From the signs which I have enumerated, sepa|rately and collectively considered, we may in general be able to form some prognostic of the nature and event of the fevers of Jamaica. If to these we add those indications, which may be taken from the state of the eye and countenance, we may attain a still more satisfactory knowledge. It is an observation which I have constantly found to be true, that where the eye and countenance were serene and cheerful, the disease was void of any latent malignity, though it might be otherwise of a dangerous nature. On the contrary, where the appearance of the eye was sad, watery, inflamed, or uncommonly glistening; where the countenance was of a dreary hue, downcast, dark and clouded; and sometimes where it was of a beau|tiful blooming colour, which was not natural to the patient, there was always reason to suspect danger. But though a serene and cheerful eye and counte|nance are generally indications of safety, I must not at the same time omit to mention, that it sometimes happens in beginning mortifications, or in imperfect or unfavourable crisis, that the eye and countenance assume, for a short time, this flattering appearance of serenity and composure, though the hour of death is actually approaching fast. The indications from the eye and countenance are of the greatest importance, in enabling us to form a judgment of the event of fevers; but little of this knowledge is, in fact, com|municable in words. It must be drawn, in a great measure, from our own observations.

I do not pretend that the signs of prognostic, which I have enumerated in the preceding pages, are by any means complete, if referred to fevers in general; but I at the same time believe, that they are less defec|tive, if applied more directly to the remitting fever of Jamaica. They were collected at a time when I was not much acquainted with books: and, on that account, I am induced to offer them to the public with more confidence; particularly, as I find that the indications, to which I have principally trusted, appeared in the same light to some authors, who are universally considered as careful observers, and who practised in climates, in many respects, similar to that of the West Indies. I have discriminated, as far as was in my power, between the doubtful and more certain appearances of danger or safety; and I hope I have no where advanced any thing, which has a tendency to mislead the uninformed. I may add, that general knowledge in prognostic goes no farther than a very rude outline, which individuals must fill up from their own experience. There are, in fact, few signs in fevers, which are absolutely decisive in them|selves; and as these signs are often variously com|bined, so they must be separately and collectively es|timated. It is only from considering accurately the result of the whole, that we can be enabled to speak with confidence.