Nervous Fever
“. . . nervous fever —
the endemic disease of the German literati.” [*]
Although references to “nervous fever” occur several times in this correspondence, the understanding of the disease at the time could vary widely depending on the physician (or patient) involved, and, like many medical definitions, could cover what was likely a variety of discrete illnesses or, especially, symptoms. [1] As will be seen, the qualifier “nervous” is to be understood primarily not as “excited, irritable, giddy” — though such in the form of anxiety, restlessness, and even delirium could indeed constitute an accompanying symptom — but rather as “medically of or relating to the nervous system, affecting the nerves.” The following publications provide a more or less representative selection of both succinct (no. 1) and lengthier (nos. 2–4) views of the illness from the period between 1750 and 1804.
(1) Robert Hopper’s succinct definition from his Compendious Medical Dictionary (1801); — (2) John Huxham’s classic essay from his book An Essay on Fevers (1750/82); — (3) William Buchan’s chapter from his book Domestic Medicine (1804); — (4) Synopsis and Extracts from Christoph Wilhelm Hufeland’s (Caroline’s physician’s) book on nervous fever (1799).
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(1) A succinct definition of the disease was provided in England in 1801 by Robert Hopper: [2]
Febris Nervosa. Febris lentis nervosa. The nervous fever. A variety of typhus mitior of Cullen, but by many considered as a distinct disease. It mostly begins with loss of appetite, increased heat and vertigo; to which succeed nausea, vomiting, great languor, and pain in the head, which is variously described by some like cold water pouring over the top, by others a sense of weight. The pulse, before little increased, now becomes quick, feeble, and tremulous; the tongue is covered with a white crust, and there is great anxiety about the praecordia. Towards the seventh or eighth day, the vertigo is increased, and tinnitus aurium, cophosis, delirium, and a dry and tremulous tongue, take place. The disease mostly terminates about the fourteenth or twentieth day.
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(2) Physicians at the time seem generally to have concurred that the classic treatment of the topic was that contained in the 1750 treatise on fevers by John Huxham. [3] What follows is his chapter on “nervous fever” from the 1782 edition of that essay. [4]
Of the slow nervous Fever
I Begin with a Description of the slow nervous Fever, which hath been very exactly taken from too many, who have fallen Victims to this insidious and dangerous Enemy.
The Patient at first grows somewhat listless, and feels slight Chills and Shudders, with uncertain sudden Flushes of Heat, and a Kind of Weariness all over, like what is felt after great Fatigue: This is always attended with a Sort of Heaviness and Dejection of Spirit, and more or less of a Load [heaviness], Pain, or Giddiness of the Head; a Nausea and Disrelish of every Thing soon follows, without any considerable Thirst, but frequently with urging to Vomit, tho’ little but insipid Phlegm is brought up.
Tho’ a Kind of lucid Interval of several Hours sometimes intervenes, yet the Symptoms return with Aggravation, especially towards Night; The Head grows more heavy, or giddy, the Heats greater, the Pulse quicker, but weak, with an oppressive Kind of Breathing. — A great Torpor, or obtuse Pain and Coldness affects the hinder Part of the Head frequently, and oftentimes a heavy Pain is felt on the Top all along the coronary Suture: This, and that of the back Part of the Head, generally attend nervous Fevers, and are commonly succeeded by some Degree of a Delirium.
In this Condition the Patient often continues for five or six Days, with a heavy pale funk Countenance, seeming not very sick, and yet far from being well; restless, anxious, and commonly quite void of Sleep, tho’ sometimes very drowsy and heavy; but although he appears to those about him actually to Sleep, he is utterly insensible of it, and denies that he doth so.
The Pulse, during all this Time, is quick, weak and unequal, sometimes fluttering, and sometimes for a few Minutes slow, nay intermitting; and then, with a sudden Flush in the Face, immediately very quick, and perhaps soon after surprisingly calm and equal; and thus alternately. — The Heats and Chills are as uncertain and unequal, sometimes a sudden Colour and Glow in the Cheeks, while the Tip of the Nose and Ears is cold, and the Forehead at the same Time in a cold dewy Sweat. — Nay it is very common, that a high Colour and Heat appear in the Face, when the Extremities are quite cold.
The Urine is commonly pale, and often limpid, frequently of a Whey-colour, or like vapid Small-beer, in which there is either no Manner of Sediment, or a Kind of loose Matter, like Bran, irregularly scattered up and down in it. — The Tongue, at the Begining, is seldom or never dry or discoloured, but sometimes covered with a thin whitish Mucus; at length indeed it often appears very dry, red, and chapped, or of the Colour of Pomegranate Rind; but this mostly at the State, or Close of the Disease; yet, however dry the Tongue and Lips seem, the Patient scarce ever complains of Thirst, tho’ sometimes of a Heat in the Tongue.
About the seventh or eighth Day the Giddiness, Pain, or Heaviness of the Head, become much greater, with a constant Noise in it, or Tinnitus Aurium, which is very disturbing to the Sick, and frequently brings on a Delirium. The Load on the Praecordia, Anxiety and Faintness grow much more urgent, and they often fall into an actual Deliquium [dissolving, melting away, fainting], especially if they attempt to sit up; Coldish Sweats suddenly come on in the Forehead, and on the Backs of the Hands (tho’ at the same Time there is too much Heat in the Cheeks and the Palms) and as suddenly go off. — If the Urine now grows more pale and limpid, a Delirium is certainly to be expected with universal Tremors and Subsultus Tendinum [twitching of the tendons]; the Delirium is seldom violent, but as it were a Confusion of Thought and Action, muttering continually to themselves, and faultering in their Speech: Sometimes they awake only in a Hurry and Confusion, and presently recollect themselves, but forthwith fall into a muttering, dozy State again.
The Tongue grows often very dry at the State, especially in its middle Part, with a yellowish List on each Side, and it trembles greatly when the Sick attempt to put it out. — When the Tongue at this Time grows more moist, and a copious Spitting comes on, it is always a very good Sign: — But where a Difficulty of swallowing, continual Gulping, or Choaking in the Throat supervene, it is a very dangerous Symptom, especially if attended with any Degree of a Singultus [hiccups].
Frequently profuse Sweats pour forth all at once about the ninth, tenth, or twelfth Day, commonly coldish and clammy on the Extremities: Oftentimes very thin Stools are discharged; both the one and the other are generally colliquative [excessive liquid discharge, often debilitating] and very weakening. — However a warm Moisture of the Skin is generally salutary, and a gentle Diarrhoea frequently carries off the Delirium and comatose Disposition.
Now Nature sinks a-pace, the Extremities grow cold, the Nails pale or livid, the Pulse may be said to tremble and flutter rather than to beat, the Vibrations being so exceeding weak and quick, that they can scarce be distinguished; tho’ sometimes they creep on surprisingly slow, and very frequently intermit. The Sick become quite insensible and stupid, scarce affected with the loudest Noise, or the strongest Light; tho’ at the Begining strangely susceptive of the Impressions of either. The Delirium now ends in a profound Coma, and that soon in eternal Sleep. — The Stools, Urine, and Tears run off involuntarily, and denounce a speedy Dissolution, as the vast Tremblings and Twitching of the Nerves and Tendons are Preludes to a general Convulsion, which at once snaps off the Thread of Life. — In one or other of these Ways are the Sick carried off, after having languished on for fourteen, eighteen, or twenty Days; nay sometimes much longer.
All Persons grow deaf and stupid towards the End of the Disease (some extremely deaf) tho’ too quick and apprehensive at the Begining, insomuch that the least Noise, or Light, greatly offended them. — Many, from their immoderate Fears, seem to hurry themselves out of Life, where little Danger was apparent at the Begining; nay several will not suffer themselves to sleep, from a vain Fear of dozing quite away; and others from the vast Hurry, Anxiety, and Confusion, they are sensible of in it, or at their awaking. — Where the Deafness ends in an Impostume [separation of pus] of the Ear, it is generally a good Symptom; and so it is also when a Parotis [salivary gland] suppurates, or a large pustular angry Eruption breaks out about the Lips and Nose.
This is a Description, (tedious indeed, but pretty exact) of the slow nervous Fever in its most aggravated Circumstances: Wherein I have laid down the Symptoms in the Order in which they naturally come on; — and this I think should be always observed in describing any Disease. — It most commonly attacks Persons of weak Nerves, a lax Habit of Body, and a poor thin Blood; those who have suffered great Evacuations, a long Dejection of Spirits, immoderate Watchings, Studies, Fatigue, and the like; and also those, who have used much crude unwholesome Food, vapid impure Drinks, or who have been confined long in damp, foul Air; that have broken the Vigor of their Constitutions by Salivations, too frequent Purging, immoderate Venery [sexual indulgence], &c. — Whence I think it is evident, this Disease arises from a too relaxed State of the Solids, a poor weak Blood, and a Lentor [viscidity] and Vapidity of the lymphatic and nervous Juices: — The very Method of Cure shews this, which consists in mild, stimulating, attenuating, and proper Cordial, strengthening Diet and Medicines. — Hippocrates somewhere notes, that the successful Method of Cure shews the Nature of the Disease.
Let us now therefore endeavour to shew the properest Method of curing this Fever.
It was another Maxim of the great Hippocrates, that whoever knows the Nature of the Disease, knows the Method of Cure. — It is at least the indispensable Duty of every Physician, before he prescribes for his Patient, to consider well his Constitution, and the Nature of his Disease; for as Celsus elegantly says, Aestimatio causae saepe morbum solvit [A right judgment as to the cause often resolves a disease]. — And this is in no Case more necessary than in Fevers, in which the Time is short, and Experiments dangerous; Where the Disorder doth not attack with great Violence, it is better to wait a little, and observe the Motions of Nature, than be too precipitant. — But it is rare, that Physicians are called in at the very Begining of slow Fevers: Indeed they are often too far advanced, ‘ere they are consulted.
From the History of the slow nervous Fever I think it is very evident, that no great Evacuations are proper (especially Bleeding) particularly in Persons of originally weak and lax Constitutions, who are by far the most subject to it. — I have known a common Purge, injudiciously given at the Begining of this Fever, immediately followed by surprising Languors, Syncope [fainting], and a large Train of other ill Symptoms: However it may be necessary sometimes, even at the Begining, to cleanse the primae Viae [main digestive tracts], by a gentle Puke, a little Rhubarb, Manna, &c. if you give any Thing drastic, be assured your Patient will rue for it, and you will repent it. — And here I cannot but observe, that a mild Vomit may be given with much less Ruffle to Nature than a common Purge, and indeed is useful, nay necessary, where Nausea, Load and Sickness at Stomach are urgent; which frequently happen at the Attack of this Fever: — Clysters of Milk, Sugar, and Salt, may be injected with Safety and Advantage every second or third Day, if Nature wants to be prompted to stool.
The temperate, cordial, diaphoretic [having the power to increase perspiration] Medicines are certainly most proper in these Fevers; and a well regulated, supporting, diluting Diet is necessary: The latter of itself, judiciously managed, will go a great Way in the Cure, especially assisted by well timed and well applied Blisters, and a due Care to keep the Patient as quiet as possible, both in Body and Mind. But it should be noted that any strong Opiates are commonly very pernicious, however Want of Sleep and great Restlessness may seem to demand them. — Mild Diaphoretics, as Pulv. Contrayerv. comp. with a little Castor and Saffron, and small Quantities of Theriac. Andromachi, or Elixir Paregoricum, have much better Effects: which, by raising a gentle easy Sweat, or at least a plentiful Perspiration, calm the Hurry and Tumult of the Blood and Spirits, whence soft refreshing Slumber succeeds. Where the Confusion and Dejection of Spirits are very considerable, Galbanum or Silphium, with a little Camphire, should be added; and Blisters should be forthwith applied to the Neck, Occiput [back of head], or behind the Ears: and during all this a free Use of thin Wine-whey, some pleasant Ptisan [barley water], or Gruel, with a little soft Wine, must be indulged. Indeed the Patients, in this Case, should drink frequently: though such Quantities may not be necessary as in the ardent, or even putrid malignant Fevers; yet they should be sufficient to carry on the Work of Dilution, support the Sweats and supply the Blood with fresh and wholesome Fluids, in lieu of the vapid, acrid Latex [a milky white fluid], that is continually passing off. — And I think in this View a thin Chicken Broth also is of Service, both as Food and Physic, especially towards the Decline of the Disorder; and for the same Reason thin Jellies of Hart’s-horn, Sago, Panado [a paste of flour or bread crumbs and water or stock used as a base for sauce or a binder for forcemeat or stuffing], are useful, adding a little Wine to them, and the Juice of Sevile Orange, or Lemon.
It is observable, the Sick are never so easy, as whilst they are in a gentle easy Sweat; for this soon removes the Exacerbations of Heat, Hurry, &c. — But profuse Sweats should never be encouraged, much less attempted by very strong heating Medicines, volatile alcalious Salts, Spirits, &c., especially in the Begining, or Advance of the Fever; for they too much exhaust the Liquidum vitale, and are followed by a vast Dejection of Spirits, Tremors, Startings of the Tendons, and sometimes end in Rigors, cold clammy Sweats, Syncope, or a comatose Disposition. — Sometimes irregular, partial Heats and Flushes succeed, with great Anxiety, Restlessness, Delirium, Difficulty of Breathing, and a vast Load and Oppression on the Praecordia; so as to incline the less cautious Observer to think there may be something peripneumonic [tending to inflame the lungs] in it: — but even here beware of Bleeding, for you will find the Pulse very small and unequal, though very quick: Not only the Weakness and Fluttering of the Pulse contraindicate Bleeding, but also the pale, watery, limpid Urine, which is commonly attendant. These Symptoms denote the Load, Anxiety, and Oppression on the Praecordia to be from the nervous Orgasm, not from a peripneumonic Obstruction, or Inflammation: The Breathing in this Case, though thick and laborious, is not hot, but a Kind of sighing, or sobbing Respiration, nor is there many Times any Kind of Cough concomitant; so that this is really from some Degree of Spasm on the Vitals, not from Inflammation. — And this is very manifest in hysteric Paroxysms.
Here therefore the nervous cordial Medicines are indicated, and Blisters to the Thighs, Legs, or Arms. — I commonly use the following Bolus and Saline Draught. [Prescription of ingredients in abbreviated Latin]
These, or the like, I order every 5th, 6th, or 8th Hour, and a temperate cordial Julep, Spiritus volatilis aromat, or foetidus may be now and then given out of thin Wine, or Cyder-whey, or, which is in many Cases better, out of thin Mustard-whey; which, without any more pompous Apparatus, is not a contemptible Medicine, especially for the Poor. These gently stimulate the torpid Vessels, and raise their oscillatory Powers; they attenuate the Humors, and dilute them, and by these Means promote easy relieving Sweats, which soon carry off the Erethism [an abnormally high degree of irritability or sensitivity or excitability], as the Ancients called it. — The Saline Draught, prepared as above, is much more apt to pass by the Pores of the Skin than when made with Salt of Wormwood, which rather moves through the urinary Passages. — When I assert, from repeated Experience, the Use of the above described Draught in asthmatic Cases, any one may easily judge of its Efficacy in these.
But to return, this Difficulty of Breathing, Anxiety and Oppression, many Times precede a miliary Eruption, which often appears the seventh, ninth, or eleventh Day of this Fever, and sometimes later: — Indeed great Anxiety and Oppression on the Praecordia always precede pustular Eruptions of any Kind, in all Sorts of Fevers. — Every one must know how ill-timed and improper Bleeding would be on such an Occasion, when the greatest Care should be taken not to retard Nature’s Operation in this particular, which is many Times compleatly critical: On the contrary it should be promoted by soft, easy Cordials, proper Diluents and the like; and to these sometimes a little Theriaca Andromachi [a therapeutic mixture containing up to 60 different potions, tonics, plant and animal parts and used as a generic cure-all], or Elixir Asthmaticum [paregoric, originally an elixir for asthma consisting of honey, licorice, flowers of Benjamin, opium, camphor, oil of aniseed, salt of tartar and spirit of wine], should be added; which not only tend to calm the universal Uneasiness commonly complained of, but also very effectually promote a Diaphoresis, or breathing kindly Sweats, with which the miliary Eruptions freely and easily advance.
But however advantageous these commonly are, profuse Sweats are seldom or never so, even though attended with a very large Eruption; for I have known two or three Crops of miliary Pustules succeed one another, and large Sweats, long continued, with no Manner of Relief to the Patients; nay of very great Detriment, as they reduced them to an extream Degree of Weakness. — In Truth these large Sweats are much more commonly symptomatical than critical, and the consequent Eruption is very often the mere Symptom of a Symptom; for the miliary Glands of the Skin appear very turgid, and mimic a Rash upon profuse Sweating, even in the most healthy.
In such profuse, colliquative Sweats, I have very frequently given a little generous red Wine, (diluted somewhat, if necessary) with the greatest Advantage; it presently moderating the Sweats, supporting the Patient, and keeping up also the miliary Papulae, if they happen likewise to attend. — Celsus advises Vinum austerum meraculum in morbo cardiaco [Sharp wine slightly diluted for a disease of the heart], which I take to have been a Species of nervous Fever with colliquative Sweats. — Towards the Decline of the Fever, where the Sweats are abundant and weakening, I moreover give small Doses of the Tincture of the Bark with Saffron and Snake Root, hereafter described, interposing now and then a Dose of Rhubarb to carry off the putrid Colluvies [effluvia], in the first Passages; which withal makes the Remissions, or Intermissions, which frequently happen in the Decline of nervous Fevers, more distinct and manifest, and gives a fairer Opportunity for Preparations of the Bark. — I generally give it, about this Time, out of the saline Draughts made with Salt of Wormwood and Juice of Lemons, which makes them much more effectual. I am persuaded this Method will shorten these Fevers, even those with miliary Eruptions, which too often run on to an exceeding great Length, and are frequently attended with dangerous Relapses, — I have more than once known Patients sink under this Fever, after having been kept in a sweating Method for five or six Weeks together, and after having gone thro’ three or four successive Crops of miliary Eruptions (as they are called) they all the while melting away, and weltering in their own Sweat, and the Bed rotting under them.
Though a gentle Diarrhoea is sometimes of manifest Service towards the End of this Fever, crude, thin, colliquative Stools are very far from being so, but sink the Sick surprisingly fast: Where they are livid, or of a Kind of lead Colour, whatever be the Consistence, it is a dangerous Appearance.
There is no Evacuation of a more favourable Portent than a pretty free Salivation, without Aphthae [ulcers on the tongue]; where this happens, with a kindly Moisture of the Skin, I never despair of my Patient, however weak and stupid he may seem: — Indeed the Deafness many Times makes the Sick, at the Close of the Distemper, appear much less sensible than they really are; not but that many, under these Circumstances, escaping the Grave, degenerate into mere Idiots.
Under any of these Evacuations plentiful, supporting diluting Nourishment is absolutely necessary to keep up the Spirits, and repair the Loss of the daily wasting Juices, and mend the remaining: Indeed, when the Patients are too heavy and stupid, they should be very frequently prompted to it; for it is even altogether as necessary as Medicine.
We have very seldom any Thing compleatly critical in this Fever; in many Cases only Time itself seems to wear it off. The Urine is scarce ever concocted, but crude, pale and thin thro’ the whole Course of the Disorder, and frequently much too profuse; sometimes indeed, after the Exacerbations, or in the Sweats, it is higher coloured, but without Sediment, small in Quantity, and commonly greasy as it were.
It seems to me evident, that too great a Lentor of the lymphatic and most exalted Juices of the Body, is one of the conjunct Causes of slow nervous Fevers; and I conceive, that as the Serum, when once coagulated by feverish Heat, never resolves into any Fluid fit for the Uses of the animal Economy, but turns into an acrimonious Putrilage; so the ropy, stagnant Lymph corrupts by Degrees into a putrid Ichor [a thin watery or blood-tinged discharge], which must be discharged from the Body by its common Outlets, or some artificial Drains. Though the Pores of the Skin, and the salival Ducts, are found in general to be the most advantageous Ways; yet it often partly runs off also by the Intestines and urinary Passages. — Now though these Discharges are many Times very profuse, it is found by Experience, they are not to be too hastily suppressed, without causing a very dangerous Translation of the morbid Matter on the vital Parts: A sudden Check of the Sweats being most commonly attended with convulsive Rigors, vast Uneasiness and Oppression on the Praecordia, Syncope, &c.; — as Nausea, Sickness at Stomach, Colics, and a Delirium are the common Effects of potent Astringents prematurely administered. — Nay the Blisters in this Case are not to be hastily dried up; the more they discharge generally so much the better; and even if they ulcerate somewhat, it is commonly no unfavourable Symptom; for though it may shew the Acrimony of the Humor drained off, it is a Proof that Nature hath Strength enough to expel it: — So that, when the first Blisters begin to heal up, others should be applied to other Parts; for it is not merely from the Stimulus, but also from the Drain they make, that they are serviceable. — The large angry Pustules, that often break forth at or after the State of this Fever, and frequently ulcerate and run largely, are a Kind of natural Blisters, which give vent to the putrid corrosive Ichor, and sufficiently indicate one Way of giving Nature Relief.
Upon the whole then, where any of these Discharges are very immoderate, they may be prudently restrained, but not repelled; and therefore cold Air, cold Linnen, cold Liquors, or a cold Regimen, are greatly improper. — And yet to be always labouring by very hot Cordials, volatile alcalious Salts, and very hot Air to raise Sweats, and to continue them is really melting, not mending your Patient. And as to a vast Number, and repeated Eruptions, of the white and red miliary Pimples, they not only shew the Quantity of the Disease (as we call it) but many Times also the wrong Measures of the Physician. Do we succeed the better for throwing out a vast Number of the Small-pox by a very hot Regimen? And yet the latter bids much fairer for a compleatly critical Discharge than the former. — And I appeal to all experienced Physicians, whether ever they saw large and profuse Sweats of any Service in the Small-pox, or Measles: I am sure I have very many Times found them highly detrimental.
I have been the larger on this Head, as I am fully persuaded, the common Method of treating miliary Fevers by very hot, sweating Medicines, and Regimen hath been the Bane of Thousands. — In a Word, whether in miliary Fevers, or the slow nervous without Eruptions, the sole End of Medicine should be to assist Nature in her Operations and support her under them; but in such Manner as may comport with the general Laws of the animal Economy; promoting by Art, where the Discharges are deficient by Nature, or restraining when profuse and inordinate; taking Care at the same Time never to pervert, in any particular Disease, any particular Crisis, which by just Observation, and long Experience, hath been found regular, constant and salutary, but always to favour it. — Thus, to give an Instance in the Fever now treated of; when a Diarrhoea happens too profuse, it may be restrained by a gentle cordial Opiate, as Theriaca Andromachi, or the like, which by quieting the Irritation, and promoting the cuticular Discharge, moderates the Flux; for gentle, easy breathing Sweats are always found advantageous. — To stop it at once, by very strong Astringents, is to prevent Nature’s Endeavours, as they tend to prevent both Stool and Sweat. — But whoever will be more fully informed of the Method of treating the slow nervous Fevers, may consult a late judicious Treatise of Sir Richard Manningham on the Febricula, &c.
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(3) From the approximate period during which Caroline herself allegedly suffered from nervous fever, see William Buchan’s remarks in his chapter on the disease from 1804: [5]
Of the Slow or Nervous Fever
Nervous fevers have increased greatly of late years in this island [Great Britain], owing doubtless to our different manner of living, and the increase of sedentary employments; as they commonly attack persons of weak relaxed habit, who neglect exercise, eat little solid food, study hard, or indulge in spiritous liquors.
Causes. Nervous fevers may be occasioned by whatever depresses the spirits, or impoverishes the blood; as grief, fear, anxiety, want of sleep, intense thought, living on poor watery diet, unripe fruits, cucumbers, melons, mushrooms, &c. They may likewise be occasioned by damp, confined, or unwholesome air. Hence they are very common in rainy seasons, and prove most fatal to those who live in dirty low houses, crowded streets, hospitals, jails or such like places.
Persons whose constitutions have been broken by excessive venery, frequent salivations, too free an use of purgative medicines, or any other excessive evacuations, are most liable to this disease.
Keeping on wet clothes, lying on the damp ground, excessive fatigue, and whatever obstructs the perspiration, or causes a spasmodic stricture of the solids, may likewise occasion nervous fevers. We shall only add, frequent and great irregularities in diet. Too great abstinence, as well as excess, is hurtful. Nothing tends so much to preserve the body in a sound state as a regular diet; nor can any thing contribute more to occasion fevers of the worst kind than its opposite.
Symptoms. Low spirits, want of appetite, weakness, weariness after motion, watchfulness, deep sighing, and dejection of mind, are generally the forerunners of this disease. These are succeeded by a quick low pulse, a dry tongue without any considerable thirst, chillness and flushing in turns, &c.
After some time the patient complains of a giddiness and pain of the head, has a nausea, with reachings and vomiting ; the pulse is quick, and sometimes intermitting; the urine pale, resembling dead small-beer and the breathing is difficult, with oppression of the breast, and slight alienations of mind.
If towards the ninth, tenth, or twelfth day, the tongue becomes more moist, with a plentiful spitting, a gentle purging, or a moisture upon the skin; or if a supuration happens in one or both ears, or large pustules break out about the lips and nose, there is reason to hope for a favourable crisis.
But if there is an excessive looseness or wasting sweats, with frequent fainting fits; if the tongue, when put out, trembles excessively, and the extremities feel cold, with a fluttering or slow creeping pulse; if there is a starting of the tendons, an almost total loss of sight and hearing, and an involuntary discharge by stool and urine, there is great reason to fear that death is approaching.
Regimen. It is very necessary in this disease to keep the patient cool and quiet. The least motion would fatigue him, and will be apt to occasion weariness, and even faintings. His mind ought not only to be kept easy, but soothed and comforted with the hopes of a speedy recovery. Nothing is more hurtful in low fevers of this kind than presenting to the patient’s imagination gloomy or frightful ideas. These of themselves often occasion nervous fevers, and it is not to be doubted but they will likewise aggravate them.
The patient must not be kept too low. His strength and spirits ought to be supported by nourishing diet and generous cordials. For this purpose his gruel, panada [a paste of flour or bread crumbs and water or stock used as a base for sauce or a binder for forcemeat or stuffing], or whatever food he takes must be mixed with wine according as the symptoms may require. Pretty strong wine-whey, or small negus [a beverage of wine, hot water, sugar, lemon juice, and spices] sharpened with the juice of orange or lemon, will be proper for his ordinary drink. Mustard-whey is likewise a very proper drink in this fever, and may be rendered an excellent cordial medicine by the addition of a proper quantity of white wine. [6]
Wine in this disease, if it could be obtained genuine, is almost the only medicine that would be necessary. Good wine possesses all the virtues of the cordial medicines, while it is free from many of their bad qualities. I say good wine; for however common this article of luxury is now become, it is rarely to be obtained genuine, especially by the poor who are obliged to purchase it in small quantities.
I have often seen patients in low nervous fevers where the pulse could hardly be felt, with a constant delirium, coldness of the extremities, and almost every other mortal symptom, recover by using in whey, gruel, and negus, a bottle or two of strong wine every day. Good old sound claret is the best, and may be made into negus, or given by itself, as circumstances require.
In a word, the great aim in this disease is to support the patient’s strength, by giving him frequently small quantities of the above, or other drinks of a warm and cordial nature. He is not however to be overheated either with liquor or clothes; and his food ought to be light, and given in small quantities.
Medicine. When a nausea, load and sickness at the stomach, prevail at the beginning of the fever, it will be necessary to give the patient a gentle vomit. Fifteen or twenty grains of ipecacuanha [containing an emetic alkaloid extracted from ipecac root, often prepared as a syrup] in fine powder, or a few spoonfuls of the vomiting julep, [7] will generally answer this purpose very well. This may be repeated any time before the third or fourth day, if the above symptoms continue. Vomits not only clean the stomach, but by the general shock which they give, promote the perspiration, and have many other excellent effects in slow fevers, where there are no signs of inflammation, and nature wants rousing.
Such as dare not venture upon a vomit may clean the bowels by a small dose of Turkey rhubarb, or an infusion of senna and mauna.
In all fevers, the great point is to regulate the symptoms, so as to prevent them from going to either extreme. Thus, in fevers of the inflammatory kind, where the force of the circulation is too great, or the blood dense, and the fibres too rigid, bleeding and other evacuations are necessary. But in nervous fevers, where nature flags, where the blood is vapid and poor, and the solids relaxed, the lancet must be spared, and wine, with other cordials, plentifully administered.
It is the more necessary to caution people against bleeding in this disease, as there is generally at the beginning an universal stricture upon the vessels, and sometimes an oppression and difficulty of breathing, which suggest the idea of a plethora, or too great a quantity of blood. I have known even some of the faculty deceived by their own feelings in this respect, so as to insist upon being bled, when it was evident from the consequences that the operation was improper.
Though bleeding is generally improper in this disease, yet blistering is highly necessary. Blistering-plasters may be applied at all times of the fever with great advantage. If the patient is delirious he ought to be blistered on the neck or head, and it will be the safest course, when the insensibility continues, as soon as the discharge occasioned by one blistering-plaster abates, to apply another to some other part of the body, and by that means keep up a continual succession of them till he be out of danger.
I have been more sensible of the advantage of blistering in this than in any other disease. Blistering-plasters not only stimulate the solids to action, but likewise occasion a continual discharge, which may in some measure supply the want of critical evacuations, which seldom happen in this kind of fever. They are most proper, however, either towards the beginning, or after some degree of stupor has come on, in which last case it will always be proper to blister the head.
If the patient is costive through the course of the disease, it will be necessary to procure a stool, by giving him every other day a clyster of milk and water, with a little sugar, to which may be added a spoonful of common salt, if the above does not operate.
Should a violent looseness come on, it may be checked by small quantities of Venice treacle, or giving the patient for his ordinary drink the white decoction. [8]
A miliary eruption sometimes breaks out about the ninth or tenth day. As eruptions are often critical, great care should be taken not to retard nature’s operation in this particular. The eruption ought neither to be checked by bleeding nor other evacuations, nor pushed out by a hot regimen; but the patient should be supported by gentle cordials, as wine-whey, small negus, sago-gruel with a little wine in it, and such like. He ought not to be kept too warm; yet a kindly breathing sweat should no means be checked.
Though blistering and the use of cordial liquors are the chief things to be depended on in this kind of fever; yet for those who may choose to use them, we shall mention one or two of the forms of medicine which are commonly prescribed in it.
In desperate cases, where the hiccup and starting of the tendons have already come on, we have sometimes seen extraordinary effects from large doses of musk frequently repeated. Musk is doubtless an antispasmodic, and may be given to the quantity of a scruple three or four times a day, or oftener if necessary. Sometimes it may be proper to add to the musk a few grains of camphire, and salt of hartshorn, as these tend to promote perspiration and the discharge urine. Thus fifteen grains of musk, with three grains of camphire, and six grains of salt of hartshorn, may be made into a bolus with a little syrup, and given as above.
If the fever should happen to intermit, which it frequently does towards the decline, or the patient’s strength should be wasted by colliquative sweats, &e. it will be necessary to give him the Peruvian bark. Half a drachm, or a whole drachm, if the stomach will bear it, of the bark in fine powder, may be given four or five times a-day in a glass of red port or claret. Should the bark in substance not sit easy on the stomach, an ounce of it in powder, may be infused in a bottle of Lisbon or Rhenish wine for two or three days, afterwards it may be strained, and a glass of it taken frequently.
Some give the bark in this and other fevers, where there are no symptoms of inflammation, without any regard to the remission or intermission of the fever. How far future observations may tend to establish this practice, we will not pretend to say; but we have reason to believe that the bark is a very universal febrifuge [antipyretic], and that it may be administered with advantage in most fevers where bleeding is not necessary, or where there are no symptoms of topical inflammation.
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(4) Finally, in 1799 Caroline’s personal physician during part of her stay in Jena, Christoph Wilhelm Hufeland, published a book specifically on nervous fever, Bemerkungen über das Nervenfieber und seine Complicationenen, in den Jahren 1796, 1797 u. 1798 (Jena 1799).
See the announcement of the book that same year in England: [9]
Review of Dr. Christoph Wilhelm Hufeland, Bemerkungen über das Nervenfieber, &c., &c. in den Jahren 1796, 1797, und 1798 (1799), 199 pages. Observations on the Nervous Fever and its Complications, in the Years 1796, 1797, and 1798. The principal object at which the learned author aims in this volume is, to describe the proceedings and the spirit of the Clinical institution at Jena, in the treatment of this disease; to furnish young practitioners with just ideas and principles concerning the cure of this nervous fever, so generally prevalent in our times; and, finally, to place the important doctrine of complications, which has been confused so much by Brunonianism, in a proper point of view, in which he, in our opinion, has been completely successful.
In his introduction, Hufeland remarks that the regnant character of diseases over the past few years is to be described as nervous or, using more recent language at the time, asthenic, the primary cause being atmospheric in nature, relating both to shorter- and longer-term changes in the weather as well as to changes or disruptions in the chemical constitution of the atmosphere, which in its own turn results in an epidemic nature of the regnant character (i.e., the meaning of “epidemic” is not necessarily associated with a transferal of pathogens from person to person). [10] He stresses especially the effects of barometric readings, though (5–7)
one cannot deny that the epidemic character also derives from the condition of the other dietary [broadly understood] influences on people if such have a deficient disposition, primarily with respect to diet [narrowly understood], emotional disposition, clothing, lifestyle, and activities.
Among more recent diseases, nervous fever, Hufeland maintains, has been and continues to be the more prominent, concerning the general character of which he refers the reader to John Huxham’s essay (“still a masterpiece” [9]; see above). Nervous fever, he maintains, seldom occurs all of a sudden, being presaged instead for several days ahead by fatigue, listlessness, a heavy head, frequent chills, a lack of appetite, an excited pulse, and uneasy sleep, sometimes also by other forms of fever, even inflammatory, all of which then transition into nervous fever, whose true character is demonstrated by the inefficacy or even detrimental effects of remedies used against the initial symptoms, by an increase in headaches, an increasingly weakened nervous system, a quicker and weaker pulse, and increasing muscular weakness.
The three diagnostic indicators include: (1) problems with the senses and nervous system and the attendant functions; (2) contradictory symptoms; (3) instability of the primary symptoms, of pulse, respiration, urine, skin flaking, etc. Primary symptoms include especially a weak, quick, unstable, but occasionally almost normal pulse, frequent chills, a sense of stricture or cramping of the skin, occasionally isolated sweating or unstable temperature on parts of the body, flushes of heat (sometimes abiding and severe), dryness of tongue with no sense of thirst, tightening of tendons, being startled, trembling, other convulsions, including convulsive laughing and crying, headaches, deafness, a ringing in the ears, delirium often right from the beginning, often mild though also frenetic chest cramps, and side stitches. Less frequent symptoms include petechia (a small reddish or purplish spot containing blood that appears in skin or mucous membrane), heat rash, sometimes lymphatic blisters.
The contradictory or opposite relationship between pulse and the other symptoms, Hufeland maintains, demonstrates the nature of the illness, namely, great weakness. That is, the weaker the pulse, the more severe the overheating, delirium, and various topical pains and problems; the stronger the pulse, the weaker such symptoms. The same applies to the remedies. Anything causing excitation or strengthening tends to ameliorate heating, the quickened pulse, and other symptoms. For example, the more a person’s powers and strength are dissipated by the progress of the illness, the more did wine (a “fortifier”) tend to cool and calm the patient.
Amid these symptoms, the two main forms of nervous fever now emerge, namely, (1) elevated and (2) diminished irritability, both of which, of course, require different treatment. Unfortunately, these forms are not always clear cut, resulting in faulty treatment; indeed, the two forms can even alternate in a single patient without any discernible reason why such is happening.
Symptoms unique to the recent epidemic include catarrhal and rheumatic problems that in part precede and in part accompany the course of the illness, including aching in the limbs, head cold, a sore throat, especially severe, often dry, cramping coughing, pleural pain and an inflammation of the lungs.
The cases of nervous fever Hufeland treated lasted anywhere from six to eight weeks, often with severe aftereffects such as fatigue or, especially, a quickened pulse lasting sometimes for several months.
As for the epidemics during the years in question, the prognosis in virtually all cases of nervous fever was extremely difficult to determine. Despite the presence of sobbing, bloating, unstable pulse, fainting spells, “floccillation” (the aimless picking at bedclothes by a patient with delirium, dementia, fever, or exhaustion), difficulty in swallowing, involuntary urination and evacuation, and similar otherwise severe signs — certain patients nonetheless did not die. On the other hand, the patient’s overall condition could be quite tolerable and yet still end in sudden death. Crises during the illness were similarly inconsistent. Occasionally nothing unusual or critical was discernible during recovery with respect to the timing or disposition of bowel evacuations, though such improvement was often incomplete and laborious. On the other hand, occasionally quite critical days with evacuations, sweats, and urination were clearly discernible during periods of improvement, whereas the previously mentioned “incomplete” crises seemed to be more frequent, including with the presence of pustules around the lips, heat rash, boils, and abscesses. Twice Hufeland found instances of diarrhea, and during the highest crisis a case of stinking loose stools, in connection with which a quickening of the pulse was discernible, though the patient then felt stronger and more sprightly.
Hufeland then discusses the cure, which is divided into three categories: (1) treatment of the nervous fever as such; (2) treatment of symptoms; and (3) treatment of complications. What follows is his section on treating the nervous fever as such during the years in question (18–52):
First of all the fundamental (proximate) cause of the malady needs to be treated and eliminated. Such consisted in weakness and anomalic functioning of the entire nervous system. These demanded the use of excitatory, fortifying, effectively nourishing, though also antispasmodic and narcotic agents.
Instead of proceeding empirically here, the application was made according to the following considerations.
Some of the vivifying agents could and indeed had to be engaged for every patient without exception. Such included the ongoing enjoyment of purified (often renewed) dry air. (Although we had no opportunity to test such, I am convinced that the artificial admixture of oxygen or dephlogisticized air would have been extremely salutary.) Furthermore, moderate warmth and then frequent washing of the entire body, especially of the extremities, with warm water, admixed with soap, wine, brandy, and on occasion also a bit of spirits of camphor. Such served not only to ease skin cramps, but also to enhance strength generally, in which latter regard, however, the degree of excitatory admixture had to be determined according to the varying degrees of weakness.
With respect to the other agents, however, one had to consider carefully the doubly varying condition of weakness, namely, whether it was associated with an elevated or diminished capacity for irritability, something one could determine not from the preceding causes, but rather only from the current phenomena and careful experimentation. It may be noted, e.g., that all the customary dispositional stimulants etc. had extremely fast and strong effects; that the pulse was fast and easily altered; that wine and other warming stimulants made the attacks worse, the pulse and breathing faster, and the instances of delirium stronger. Here the weakness was associated with elevated irritability. If such were not present, if the patient lay in an indifferent, insensate, or even soporific stupor, whereby nothing, not even the things or objects most interesting to him, made any impression on him, and in which wine brought about no change in the pulse, then the weakness of one of diminished irritability.
In the first case, the gentlest stimulants, in the second, the strongest and most volatile had to be used, though no universally applicable dose could be determined; in the latter case, a steady increase both in the quantity and choice of increasingly strong stimulants was necessary until one could discern that the pulse changed for the better (the excessively slow pulse getting more brisk, the excessively brisk and uneven pulse getting calmer and stronger, the weaker getting fuller and more powerful), and that attacks of delirium, sleepiness, and cramps lessened, in which regard occasionally extraordinary quantities of stimulants were necessary, so that in one case no improvement was discernible until, within a twenty-four hour period, 2 pounds of good Rhine wine, 2 ounces of cinchona, 1 scruple of camphor, an equal amount of musk, and 30 drops of laudanum liquidum had been consumed, and stimulating mustard plasters applied. [case history] . . .
By contrast, in the second case (weakness with diminished capacity for irritability), the gentlest degree of stimulation had to be chosen, and here the determination of the suitable dose and even more so the choice of agent was often even more difficult, since a certain idiosyncrasy made it impossible for the patient to tolerate not only any stronger degree, but also the specific properties of a dose of a given agent. Here a dose of the sort described in the preceding case history would have killed the patient through the exceedingly vehement reaction it would have excited; hence the quantity of agents had to be diminished for a time, and milder varieties chosen as long as one could yet discern an excessively vehement agitation of the pulse, increased delirium, an increase in nervous irritability, convulsions, heat, and colliquative evacuations. The sign that one had attained the correct remedy consisted in no longer noticing the attacks described above, the pulse coming closer to a healthy condition and becoming stronger without becoming too fast or powerful, the colliquative evacuations lessening, the extreme irritability and mobility of the nerves, especially of the mind (delirium) lessening, and sufficient additional calmness emerging amid fortified energy. — Between these two extremes — the highest degree of elevated irritability, on the one hand, and stupor, on the other, there was a whole array of intermediate degrees requiring an equal number of modifications and intermediate degrees of stimulants, all of which, however, one could determine according to the same principles and phenomena. — Once one had commenced on the cure in this fashion, that is, provided the initial efficacious impetus toward a more energetic and regular functioning of the nervous system, one had to continue in the same vein, except that among those with whom one had to begin with weaker stimulants, one had to increase such to the extent they were not yet having the desired effect and the fortified strength lost its excessive capacity for irritability; by contrast, where because of insensate lack of irritability one had to begin with the most powerful stimulants, one similarly had to lessen those to the extent an increasing capacity for irritability rendered their effects excessively vehement, and for just that reason only weaker stimulants could maintain the desired efficacy. — Once the patient’s strength had been sufficiently stimulated through this method, and once the capacity for irritability had approximated its natural functioning level enough to tolerate the more astringent fortifying agents, the latter, too, then had to be added in order to confirm and complete the cure.
The rest of Hufeland’s section of treating the nervous fever itself consists in an explication of the agents to be used to attain these ends. Such include:
(1) volatile stimultants (excitantia), with a discussion of their ingredients and variations as well as their external use (e.g., washing, foot baths, full-body baths; aromatic herbs, clysters);
(2) fixed tonic fortifying agents that promote an enduring elevation of energy; such seemed to have more efficacy toward the end of the fever than at the beginning, though such is not always the case;
(3) dietary considerations for the same purpose, namely to promote an enduring elevation of energy;
(4) narcotics, including valerian, musk, camphor, emetics, narcotics in the narrower sense (capable of “weakening the nerves, though especially the sensitivity of the mind/soul”), including opium.
Hufeland then transitions into a more specific discussion on treating symptoms and complications (65–164), including (1) catarrhal-rheumatic (65–130), (2) gastric (69–130), (3) inflammatory (130–60), and (4) putrid (160–64). His final section (165–99) contains case histories.
Notes
[*] “Medical and Physical Intelligence,” The Medical and Physical Journal etc., ed. T. Bradley and A. F. M. Willich, 1 (March–July 1799), no. 11 (April 1799), 206, in an obituary for Professor Frederick Albrecht Charles Gren of Halle (1 May 1760–26 November 1798). Illustration from Christophe Schmid [Christoph von Schmid], La guirlande de houblon (1836), Oeuvres choisies, vol. 4, new ed. (Tours 1867), plate following p. 262. Back.
[1] For example, although Schiller is variously said to have died of consumption (tuberculosis), kidney disease, diverticulitis, or heart disease, The Gentleman’s Magazine 95 (1805) May, 493, reports that he died “of a nervous fever,” and The Monthly Magazine 19 (1805), 531, similarly had him dying of “nervous fever,” albeit in Vienna rather than in Weimar. Back.
[2] A Compendious Medical Dictionary Containing an Explanation of the Terms in Anatomy, Physiology, Surgery, Practice of Physic, Materia medica, Chemistry, &c., &c., 2nd ed. (London 1801), s.v. Febris nervosa. Back.
[3] John Huxham, An essay on fevers, and their various kinds, as depending on different constitutions of the blood: with dissertations on slow nervous fevers; on putrid, pestilential, spotted fevers; on the small-pox; and on pleurisies and peripneumonies (London 1750). As will be seen below, Caroline’s own personal physician when she came down with such a condition, Christoph Wilhelm Hufeland, will himself reference Huxham’s study. Back.
[4] An Essay on Fevers, to which is now added, a dissertation on the malignant, ulcerous sore-throat (London 1782), 74–92 (chap. 7) (orthography as in original). Back.
[5] Domestic Medicine: or, a valuable treatise on the prevention and cure of diseases by regimen and simple medicines (Leominster 1804), here 126–30 (chap. 19). Back.
[6] “Mustard whey: Take milk and water, of each a pint; bruised mustard-seed, an ounce and a half. Boil them together till the curd is perfectly separated; afterwards strain the whey through a cloth.
This is the most elegant, and by no means the least efficacious method of exhibiting mustard. It warms and invigorates the habit, and promotes the different secretions. Hence, in the low state of nervous fevers, it will often supply the place of wine. It is also of use in the chronic rheumatism, palsy, dropsy, &c. The addition of a little sugar will render it more agreeable.
The dose is an ordinary tea-cupful four times a-day” (p. 454). Back.
[7] “Vomiting julep: Dissolve four grains of the emetic tartar in eight ounces of water, and add to it half an ounce of the syrup of close July-flowers.
In the beginning of fevers, where there is no topical inflammation, this julep may be given in the dose of one table-spoonful every quarter of an hour till it operates. Antimonial vomits serve not only to evacuate the contents of the stomach, but likewise to promote the different excretions. Hence they are found in fevers to have nearly the same effect as Dr. James’ Powder.
This is a proper drink in acute diseases, attended with, or inclining to, a looseness, and where acidities abound in the stomach or bowels. It is peculiarly proper for children when afflicted with sourness of the stomach, and for persons who are subject to the heartburn. It may be sweetened with sugar, as it is used, and two or three ounces of simple cinnamon water added to it.
An ounce of powdered chalk, mixed with two pints of water, will occasionally supply the place of this decoction, and also of the chalk julep” (p. 435). Back.
[8] “White decoction: Take of the purest chalk, in powder, two ounces; gum Arabic, half an ounce; water, three pints. Boil to one quart, and strain the decoction” (p. 426). Back.
[9] “Retrospect of German Literature,” The Monthly Magazine, part 2 for 1799 (July to December), vol. 8 (London 1800), no. liv (January 20, 1800), 1096. Back.
[10] See “State of Diseases in London from the 20th of August to the 20th of September 1799,” The London Medical and Physical Journal, 2 (1799) 6 (August) 408–15, here 412:
To this contagious fever alone [“the typhus, or contagious malignant fever”], Dr. Cullen ought to have applied the denomination of typhus mitior: he has improperly comprised under it the slow or nervous fever described by Husham and Gilchrist, which may rather be considered as a specifies of hectic, and is not received by infection. Back.
Translation © 2013 Doug Stott