DEP/DUA/1/29/34 (Normalised version)

John Frazer

(1782)

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John Frazer.

Of general name of disease of this patient no room for doubt.

No hesitation in pronouncing that subjected to an intermittent Fever.

Of this distinctively marked paroxysms incontrovertible evidence.

But here, when inquire what kind of intermittent, more room for doubt.

For although in history of case said to be quotidian, yet well known that these not only intermittent, in which daily paroxysms.

Quotidian upon whole here, but a rare disease.

And some very [extensive] practitioners who even go so far as to assert, that have never met with such.

In state of case at time when came under our care, undoubtedly strong objections to supposition of Quotidian.

For although daily fits with same symptoms, & of same duration, & violence yet did not occur at same hour.

One day attacked at six, other at 8 o’clock.

In this then have what has been considered as distinguishing characteristic of double tertian.

For in that case patient supposed to labour under two distinct fevers.

Paroxysms of one recurring every second day at determined hour.

And of other on that day when if single fever only existed, there would be perfect apyrexia.

This however am inclined to consider as distinction, existing much more in theory than in practice.

Not indeed that fevers do not actually exist which from variety in nature of symptoms, & return of paroxysms may not be styled both double Tertian & double Quartans.

But hold this to be in nature in no degree different from Quotidian intermittent or other

And indeed in present case utmost that can be contended for is that Quotidian now converted into double Tertian.

For at beginning daily attacked with paroxysm at same hour. viz 12 o’clock.

And still though attacked at different hours no difference in fits.

From these circumstances then of sudden transition from one type of intermittent to another as well as from sameness in method of cure have long been inclined to think that whole should with propriety be considered only as one genus.

And certainly in reality nothing that can be called essential or generic distinction.

With regard to affection of present patient then hold it sufficient to pronounce that disease when came under care an Intermittent Fever.

Here however in judging of prognosis type as well as other particulars to be taken into account.

And have no doubt in asserting that present case more unfavourable than if were either regular quotidian or tertian.

This however not only unfavourable circumstance in case.

Is something against patient that has considerable degree of sickness both during cold & hot fits.

Still more that has never what can be called perfect apyrexia.

For pulse uniform considerable [quickness]

In so much that even during apyrexia seldom to be found under 100.

To this also to be added as an unfavourable circumstance the long continuation of disease.

For before coming under our care had subsisted even for space of 12 weeks.

Still more unfavourable that during period mentioned oedema swelling of legs had supervened.

Yellowness of complexion may be viewed in same light.

Here indeed from circumstances mentioned seemed to depend nothing on jaundice.

For not only are stools natural, but membrane of eye also unaffected.

May conclude therefore that does not here depend on any affection of liver, which intermittents but too apt to induce.

And probably to be ascribed to change in state of serum, particularly as exists in extreme vessels, or effused in subcutaneous cells.

But though thus a less important symptom than if yellowness from affection of liver, yet still unfavourable.

Same remark also applicable to emaciation & general debility.

Although these indeed occur in almost every intermittent when allowed to run on to any great length.

Upon whole then appears that many circumstances in present case unfavourable.

From this however far from pronouncing affection dangerous.

Of all fevers intermittent unquestionably most under our command.

Are acquainted with an artificial mode of cure which seldom at least [unsuccessful]

In so much that whatever may be case in other climates, here at least very rarely fatal.

Especially when occurring with one in prime of life, & in other respects of sound constitution.

Hence then although from circumstances mentioned above was apprehensive that case might prove tedious yet hoped in end to be able to accomplish cure

And this I think now in great measure at least affected.

For at last report patient had been upwards of eight days [without] what could be called fit.

This change for better have little doubt in asserting was affected by medicine here employed.

Which however will more particularly appear from short review of practice.

On first application for aid ordered an emetic for this patient.

Emetics in intermittents have long been employed & unquestionably useful on various grounds.

But particularly so as paving way for Peruvian Bark

With this intention chiefly was that had recourse to Emetics, in present case.

And as means of completely evacuating stomach ordered Ipecacuanha.

With view of obtaining full vomiting no Emetics better fitted.

And as preparation to Bark complete evacuation of stomach great objective to be aimed at

After due preparation, many disputes as to best mode in which Peruvian Bark can be exhibited.

Some consider it as most effective when given immediately before, others when exhibited immediately after paroxysm.

But in my opinion very little in either of these circumstances.

Proposition if not upon absurd, at [least] upon very uncertain hypothesis as to nature of complaint.

And inclined to think, that in every case, cure may be effected by introduction of certain quantity of Bark

Great objective therefore is to introduce this in such a way, as to be least distressing to stomach.

On this account unless where some peculiarities in case [preferable] to every other mode introduced in small doses during whole interval.

By this means obtained full effect of quantity of Bark employed with least uneasiness to patient.

And if should be continued for short time longer than absolutely necessary for cure this at least attended with no other inconvenience than small expense of Bark.

Here then ordered in doses of ℥I. to be taken every second hour.

From this mode of introduction no reason to think that quantity such as to give any unease at stomach.

While at same time by persisting in use till one ounce & half taken quantity introduced sufficient at least for stopping most intermittents.

While from vomit desired effect bark also product of no inconvenience.

And if had not affect of stopping fit produced at least change for [better]

Had effect indeed of suspending fits entirely only for space of two days.

But when afterwards returned not with same type as before

For in place of paroxysm every 24 hours now returned only once in 48.

Hence then in place of quotidian or rather double Tertian now converted into regular Tertian.

But what of still more consequence than change of type severity of paroxysms also diminished.

Although therefore quantity of Bark already taken seemed inadequate to cure yet for complete recovery seemed only to require farther continuation.

Ordered therefore that recourse should again be had to use & persisted in till taken to quantity of ℥ii.

By this means interval from fit obtained for considerable length of time.

Still however in return of a paroxysm had evidence that affection not entirely overcome.

With view therefore of effecting this as well as of preventing recurrence thought farther use of Bark still necessary.

Did not indeed seem now requisite to persist in use to same extent as formerly

Ordered therefore that should be regularly continued merely to quantity of ℥ii in day.

And under this, all return of paroxysms suspended for almost fortnight.

Still however could not consider disease as completely removed.

For although no fit yet frequent [attacks] of alternating heat & cold.

Could not doubt therefore that aguish disposition still remained.

From this consideration, at last report ordered, that should persist in single dose of Bark daily

At same time had recourse to another medicine in evening.

Use viz of White Vitriol under form of pills

This metallic sometimes had recourse to in intermittents after Bark has failed.

And though not always, sometimes at least with success.

In hopes therefore that here in conjunction with Bark will remove what remains of affection

And that no farther practices necessary for cure.

If such however are hereafter requisite must be accommodated to circumstances which shall then take place