DEP/DUA/1/17/12 (Normalised version)

Alexander Cameron

(1778)

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Intermittentis & Continuae

Allen Cameron.

Of disease to which this patient subjected little room for doubt.

Symptoms as detailed in case such that can have no hesitation in referring it to class of Pyrexia

And there when consider that no evidence of local affection must necessarily reduce it to order of proper fevers.

These Dr Cullen contrary to practice with respect to other orders, has divided into two sections.

How far with propriety however is I must own with me a very great question.

In first place term [Section] here appears very [exceptional].

[Section] a sufficiently proper [subdivision] of books, or of chapters by no means of classes & orders.

And when adopted amongst latter, is at least contrary to universal [practices] of every system.

With them proper fever very generally considered not as order but class of disease.

And then indeed with sufficient propriety may make general [distribution] of intermittents at least when put in contradictory [instances] either to cases of Continued or even Remittent

But must own that when diseases to be divided into few large classes, should be disposed with Dr Cullen to view fevers not as a proper genera class but merely as order.

In this light instead of considering intermittent as a section of the order, would view them merely as one genus of it.

And can see no greater impropriety in considering the intermittent fever as particular genus than the Nervous or Inflammatory fever.

For such a view countenanced given in great sameness occurring in all intermittents.

True indeed that with respect to type & appearance considerably diversity.

And particularly in what regards period of return of paroxysms.

The source from whence distinction of [genus] here principally almost solely drawn.

But to be observed that, in no other case by Dr Cullen at least is duration of affection considered as grounds of distinction among fevers.

And if were admitted with regard to intermittents might at least with equal propriety be adopted of the [continued].

This however would lead to division of continued fevers into many genera to which although admitted by other nosologists¹, he has given no place.

And on same principle on which he has formed other genera of fevers, may I imagine view intermittents, as merely one genus

And would consider quotidian. tertian. & quartan. types as giving foundation not for different genera but merely for different species.

While again would view species of Mr Sauvages & others as mere [illegible].

In this distribution less difficulty at least when consider on what trifling circumstances their different species have foundation.

May farther add that although quotidian tertian & quartan somewhat different in appearance, yet at least as much connected together as species of almost any other genera of disease.

To whole, one general cure very properly applies.

And indeed, if to subdivide intermittents into [genera], from differences in essential nature, & from diversity requisite in treatment, would [require] to be done, on other principles, than on obvious type.

Certain that in most cases less real difference between Tertian & Quartan both occurring in spring season than between tertians occurring in spring, & same taking place in autumn.

Or as is termed by vulgar who uniformly consider it as one Genus only the Ague.

On this ground then while refer disease of present patient to Class of Pyrexia & order of Fever would reduce it to genus Intermittent.

While however thus far little difficulty to encounter in investigation of genus disease cannot speak with same precision as to species

From description indeed given in case should be inclined to pronounce it of Quartan type.

But since patient came under our care, to this form has by no means corresponded.

And while sometimes intermission for two days on other occasions for one only & at third time, recurrence of fits every day.

This perhaps might be [urged] as additional argument for viewing all intermittents as constituting one genus only.

For otherwise should have been obliged to view patient as labouring under three different genera of disease.

[Transitions] however in this manner from one genus to another, where generally founded on natural distinction, can no means take place.

Types of intermittent however, every day observed to be subjected to change.

And indeed may be considered as rather uncommon as otherwise to find continuation for any length of time, in same form.

At common accession very generally [irregular]

And is at least vulgar expression to say that then intermittent not found.

If however irregular at commencement not less so at very advanced period.

And cannot even be considered as very fixed type about middle of course.

For though evidently either tertian or quartan yet often fits either anticipated or postponed.

And this may at least consider as approaching towards different type.

If then such irregularity even during short period of disease not to be wondered at when had subsisted so long as with present patient.

Without therefore referring it to any particular species must here be satisfied with general [name]

But in most cases of much less importance to settle name than nature

Here however a field [presented] to us on which in lectures of this kind cannot propose to enter.

That is [disquiet] respecting general nature of intermittent.

But without saying any thing on this subject may only observe that no reason to view present case as different from others.

And here also [presumption] of arising from [cause] by which intermittent very generally [induced].

That is marsh effluvia.

For are informed that occurred from exposure during night to moist atmosphere.

Is not indeed said, that then in [neighbourhood] of any remarkable marsh.

But besides, that this a circumstance, which might not have [claimed] attention of patient and that are not informed of contrary have sufficient grounds for conjecture, in account given us.

For may readily suppose that when moisture exhaled from earth, & again condensation in great quantity containing nearly same noxious matters as [extracted] from marshes.

And probable that effluvia of marshes differs principally from others, not so much from nature of exhalation as from greater abundance.

Here however that quantity great, are fully warranted to conclude from account given in case.

Before leaving consideration of nature of patients disease another circumstance to be taken notice of.

That is cough to which now subjected.

May occur as query whether this to be looked upon as belonging to intermittent or not.

Certain that intermittent greatly diversified from combination & conjunction with other affections.

And not uncommon to find paroxysms attended with eruptions, inflammation, etc but much more with Nervous affections.

Such then may here suppose to be case with cough.

And to this some countenance given from increased severity of cough during intermittent paroxysm.

But when again [consider] other [illegible] led to different view.

To be observed that since commencement has been a constant affection.

That while disease of very long duration, this has subsisted only for short space of ten days.

And that then took origin from manifest exposure to cold.

From all these considerations then view it as accidental catarrh unconnected, with the intermittent.

After delivering this opinion as to name & nature of affection no great reason I imagine for being much alarmed as to termination.

Prognosis indeed in every case of intermittent cannot be favourable.

In certain warm climates, where large marshes, may perhaps be considered as one of most fatal diseases.

There, even by few paroxysms, patient cut off in same manner, as in other fevers.

And indeed if [affective] measures for cure omitted on first intermittent often happens that second cannot be obtained.

Such however, by no means appearing, which put on in any part of this countenance.

Even in those parts of country where most prevalent is by no means considered as a dangerous disease.

And vernal intermittent in particular by [many] looked upon rather as [salutary] than [otherwise].

How far this the case however is a matter of great doubt.

Probably no other foundation for it than that occurs in constitution, where [proceeding] to affection of more dangerous tendency is wanting

But that of itself has any influence [either] as removing or preventing other diseases see no foundation for supposition.

And although very far from being disposed to rank it among dangerous diseases yet equally little inclined to consider it as a salutary affection.

But whatever may be opinion of general nature, present case rather more unfavourable than common.

For has already been subjected to this complaint for space of many months.

Is not the product of spring, but an autumnal intermittent of last year.

And has continued to greater or lesser [degree] during whole of winter season.

And that too notwithstanding use of those remedies which most affective in removal of this complaint.

Has indeed at times been in great [measure] entirely free from affection.

And particularly after treated for this [disease] in the Royal Infirmary².

Then however, as on other occasions, in no long period returned.

And since came under our care [although] some alleviation of affection yet by no means complete cure.

Hence then however much natural tendency of disease may be favourable however much [illegible] in general be under our command by use of proper medicines, yet must look upon present as obstinate case.

And when this happens although not by itself fatal yet often lays foundation for most dangerous affection.

Particularly those depending on obstruction & scirrhous of different viscera.

In case before us then, neither grounds for flattering ourselves with speedy cure, nor can consider affection as entirely without danger.

Yet notwithstanding continuation have hitherto at least no indication either of scirrhous or any other threatening symptom.

And besides that affection has formerly yielded to [medicine] season, also now more favourable for cure.

May then at least expect that shall be able if not to affect radical cure, at least to obtain same temporary cure, as formerly.

And even to rid patient of disease till again exposed to action of exciting causes.

That is to state of atmosphere charged with effluvia which particularly occurs during autumnal months.

Before leaving prognosis may perhaps be expected that should say something of cough.

Not impossible that may yet turn out most dangerous part of affection.

And by no means rare to find Phthisis, beginning in manner not more threatening.

Consider it, however, as have done, in light of accidental catarrh has not hitherto been object of attention.

And am in hopes that with regard to it no measures will need to be taken.

Hitherto therefore practice has entirely been directed with view to intermittent

And without fresh occurrence is intention to continue on same plan

Of measures therefore already taken & afterwards proposed come next to speak.

And here as waved inquiry respecting general nature of intermittent fever, shall say nothing as to general plan of cure.

May only remark, that in all cases of proper fever, cure may be viewed as conducted on one of two great principles.

Either endeavour viz to conduct to favourable natural termination or to induce artificial.

On former plan endeavours totally [employed] on mitigation of symptoms & cure must necessarily be slow.

Latter where succeeds by giving more expedient termination is often means of saving patient

But neither in every case admissible nor where tried does it always succeed.

Both one and other very frequently the case with respect to those febrile diseases where no intermission.

But in genus of intermittent seldom that circumstances of case such as to render [attempt] at least, to artificial termination inadvisable.

And as have already remarked, is in but few cases, that from proper [persistence] & due care, attempts do not at length succeed.

Was then on this principle that here intended to aim at cure.

With view to artificial termination of Intermittent certain that no medicine more powerful than the different tonics.

Particularly different articles belonging to this tribe which manifest qualities, as bitters, astringents, or aromatics.

All those properties to very considerable degree discovered, in Peruvian Bark

And as far as experience of practice in general yet goes, can have no doubt in asserting that is most powerful article with this intention hitherto discovered.

Am far however from looking upon it as only means by which intermittent may be stopped.

Even inclined to think, that in some instances, affection may be removed, by other articles where this fails.

And no doubt that Peruvian Bark has at one time succeeded although formerly employed in same case without success.

From these different circumstances then led at least on some occasion to trial of other medicines.

And here as Peruvian Bark formerly used & as nothing urgent in the [disease] looked on case as no improper object for [trial]

Was on these grounds that at first put patient on use of Allium or Garlic

Previous to this indeed will observe that prescribed an Emetic.

And with respect to Emetics may remark that a peculiarity occurs in case before us deserving attention.

Cannot indeed consider it as very singular that no operation produced by Ji of Ipecacuanha.

Although with most patients even less quantity will produce some affect.

But probable that although had here been given to much greater extent no affect would have followed.

For on inquiry informed that patient had before taken largest doses of strong emetics without any sensible operation.

And this not merely on vague & [illegible] account given by patient himself but on authority of Gentleman who attended to his case when a patient in the Infirmary.

Whether this however from peculiar occurrence in disease or in constitution cannot pretend to say.

Yet probable that rather consequence of latter cause.

At least in general intermittents do not render operation of Emetics more difficult.

But whether from one or other equally disappointed us of intention which had in view from operation of emetic here

That was to cleanse stomach of patient so as to facilitate action of other remedies.

Same affect indeed, as here wished from emetic might perhaps have been obtained from purgative.

But these difficultly exhibited in such a manner as fully to empty intestines without evacuation from system in general.

And in cases of intermittents, in general at least, is unquestionably unfavourable.

Thought it therefore more advisable to give trial to medicine without preparation.

And began with use of Allium neither from own experience of affects, nor knowledge of principle on which operates.

But from authority which lately [illegible] considered it at least as a medicine deserving trial.

Such a trial was given it in instance before us.

And although seemed to have some [affect] on paroxysm yet at last obliged to desert it as inadequate to producing cure.

From this trial however would be far from pronouncing it of no use.

For to be remembered that here even Bark itself had failed.

Still therefore inclined to look on it as a medicine to be judged of from farther [illegible]

Yet can have as little hesitation in saying that present trial rather against it as otherwise.

On [disappointment] with the garlic before [making] other trials thought it most advisable to have again recourse to the Cinchona or Peruvian Bark.

And although had not formerly been means of radical cure yet hoped that might now affect it.

For although may perhaps assert that in all circumstances efficacy very great yet no doubt that operation influenced by many different particulars.

Especially by condition of atmosphere in which patient kept, whether from [season] or situation.

And by mode of administration.

Now, with respect situation is in same circumstances as formerly.

An inhabitant of this city, and as far as disease will permit engaged in employment of chairman³.

Edinburgh a situation by no means giving [product] to intermittent

Is very far from being a frequent disease as [illegible] of this city.

Still less are obstinate intermittents ever observed to take [illegible] here.

And indeed case before us did not originate in Edinburgh.

In this circumstance then patient now as well as formerly far situated.

And for affection in present state is by no means against him that now walks about streets in place of being confined to an hospital.

For advantage of exercise as aiding cure of this disease well known

And indeed while affection gives natural disposition to [indolence], exercise in different forms [enjoined] as mode of cure.

But while some advantage from this particular still greater from change of season.

Often happens that when intermittents cannot be cured in spring will yet of themselves ease in summer months.

And after easterly winds which in general prevail during May, have ceased, season [may] always be viewed as becoming gradually more favourable to cure till autumn.

While from these two particulars might now have greater expectation, have already remarked that by another particular also influence of Peruvian Bark affected.

That is by mode of administration.

Here however as do not know how formerly given can say nothing of it.

But from [ability] of Gentleman by whom practice conducted can be no doubt that given with every advantage.

Can only then speak of mode in which now to be given.

And here into general question respecting mode of administration as being a [field] very extensive cannot propose to enter

May only remark that whole may be referred to these particulars.

What respects, form, quantity & time of administration.

With regard to form little doubt that as given in substance operates more affectively than in any other way.

With regard to quantity what necessary not determined by any fixed standing.

Can seldom however expect to remove an intermittent by less than an ounce

And may in general remark that less to be dreaded from over-dose than from not giving it to sufficient extent.

For while in former case inconvenience which can arise but slight & easily obviated.

[Latter] subjected us to every evil which can [illegible] from continuation of [this] disease.

In these two particulars however much less dispute among practitioners than with respect to third viz time of exhibiting.

On first introduction of Cinchona was imagined that from giving it at improper time greater evils produced.

And even that accurate observer Dr Sydenham ascribes sudden death of several patients to that circumstance.

Now however no doubt that these observations proceeded on mistake

And that mode which he condemns if not useful at least safe.

Yet still practitioners very much disposed to confine use to a pyrexia or intermission.

If however doctrine lately contended for & practice employed by Dr Millar well [founded] this perhaps not requisite.

And even without giving credit to all that he maintains yet still from what every day done in continued fevers may I think conclude that no necessity for intermission during paroxysms.

Has lately been contended that very particular advantage from administration immediately before the fit.

And in this way in direct opposition to injunction of Dr Sydenham is now frequently thrown in to quantity of ℥p or ℥VI in space of hour immediately before fit

No question that this done with [impunity]

And that from this mode of administration disease often cured.

Yet [pretended] superiority, as far as my observation goes, much more founded on theory than experience.

When thus given in nine, cases out of ten, fit immediately succeeding will go on as if had not been taken.

Often indeed, without using any more, following fits will be stopped.

And therefore [concluded] as advantage of this practice that when does not cure disease more expediently, yet saves Peruvian Bark.

This advantage however certainly of no very great consequence in private practice.

And besides [when] first fit not stopped seldom that first quantity trusted to.

When trusted to, practice will not unfrequently be [illegible] in cure.

When not quantity of Cinchona as [quality] as in any other way.

Besides this, this mode of administration liable to inconvenience as does not always agree with stomach.

Even supposing it then most efficacious yet cannot look upon it, as preferential in ordinary cases.

And upon whole look upon best method to be frequent repetition in small doses

Taking for example to extent of ℥p or Jii at distance of one two or three hours according to circumstances

In this manner beginning use immediately after paroxysm.

And if should not have affect of stopping next, yet continue with intermission

This mode directed with present patient

Not however advising repetition of doses oftener than [thrice] in day.

This in ordinary cases should not have been inclined to advise.

But was here intention, if should be found necessary, to make comparison between gradual & quick method of exhibition.

If however, which am hopeful may be the case, shall in present method cure patient, any farther trials superseded

But if from use of Cinchona as at present given, are disappointed have next thought of giving trial to some of mineral tonics.

Particularly Cuprum Ammoniala. Vitriol. Caeruleae or Mercury Corrosive Sublimate

For certain that by all these in different circumstances the disease has been cured.

Two first deservedly held in high esteem among tonics.

Latter not indeed in general considered as possessing any such power

But have been informed, on what I reckon good authority that by certain practitioners in some of fenny counties of England, used with great success in cure of Intermittent.

And is on such authority that here suggest it.

If after want of success with present trial one or more of these also ineffective is intention again to return to use of Peruvian Bark

And in place of employment in slow & [gradual] manner now done to exhibit in large doses immediately before paroxysms.

Thus at least some opportunity of judging of comparative efficacy to present mode.

Trials however now suggested probably [more] [than] shall have opportunity of [making]

And would hope more than will be [necessary]

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Explanatory notes:

1) Nosology is the branch of medical science dealing with the classification of diseases. Individuals referred to in the case notes as nosologists were commonly those who had published nosological, or classificatory, medical texts.

2) The Royal Infirmary of Edinburgh, established in 1729.

3) Occupation involving transporting people around the city in a sedan chair. A common occupation in cities such as Edinburgh with narrow winding streets which could not accommodate a horse and carriage.