AY OBSERVATIONS INTERMITTENT, REMITTENT & CONGESTIVE FEVER: 4 By THOMAS BARBOUR, M.D., PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN, IN THE MEDICAL DEPABTMENT OF KEMPER COLLEGE, ST. LOUIS, MO. PUBLISHED BY THE MEDICAL CLASS. SAINT" LOUIS: PRINTED BY DANIEL DAVIES Comer of Main and Olive streets. "Professor Thomas Barbouri " Sir, " Pursuant to the action of a meeting of the Students of the Medical Department of Kemper College, before whom your very able and interesting Lectures on the Intermittent, Remittent, and Congestive forms of Fever, were delivered, We were appointed a Committee, and instructed to ask of you a Copy, for publication in pamphlet form. " In the view of that body, the high excellence of the Lectures, on a subject touching so directly the people of the Mississippi Valley, makes it a matter of public interest, and we cheerfully add our voices to the call for its publication. "Be pleased to accept the assurances of the high respect with which we are> " Your fellow-citizens, "R.S.WILEY, 1 "J. R. POYNTER, | " D. O. GLASCOCK, [-Committee. " E. B. STRODE, | " H. NANTZ, J " Kemper College, December 12th, 1844." " To Messrs. Wiley, PoyntEr, Glascock, Strode, Nantz, Committee. " Gentlemen, "I received, to-day, your polite note, expressive of the desire of the Medical Class of Kemper College to have, for publication in pamphlet form, a copy of my lectures on Intermittent, Remittent, and Congestive Fever; and in reply to it, I beg leave, through you, to say, to the highly respectable and intel- ligent class which you represent, that, though I had not, at the time of the delivery of the lectures referred to, the remotest idea of their publication, as they desire it, on account of the value they are disposed to attach to them, I cannot, consistently with the relation I sustain to them, withhold my consent. "I am, Gentlemen, "Very respectfully, yours, &c, " THOMAS BARBOUR. "St. Louii, December 12tli, 1844." PREFACE. In the whole circle of medical science, there is no one subject which has excited so much interest, or which has commanded so much of the attention of the votaries of medicine, as that of Fever, in all its various modifications. From the very dawn of medical history, its paramount importance has been universally acknowl- edged ; and the best talents in every age have been devoted to the elucidation of its nature, and the discovery of its appropriate treat- ment; nor should we be surprised at this, when we reflect, how prevalent this scourge of the human family is, and that its course has ever been marked by the numerous victims that have fallen under its fatal power. When we consider how much has been written upon this fertile theme, it is a reasonable supposition, that, by this time, we should have arrived at some definite conclusions as to the nature of fever, and attained an accurate knowledge of the principles which should guide us in its treatment/ but that we have not, is clearly deducible from the great discrepancy of opinion which prevails, at the pres- ent day, among enlightened medical men, in relation to the true pathology and treatment of what are called essential fevers. The results of past researches have been, in an eminent degree, benefi- cial and encouraging, as false and absurd doctrines, and, of conse- quence, erroneo.us modes of treatment, have been successively abandoned, and superseded by more rational systems based on sound induction. Still we are bound to confess — humiliating as may be the acknowledgement — that, notwithstanding all the accumulated light of past ages, the subject of fever is yet involved in much obscurity. Judging, however, of our future advancement from the results of the past, we are encouraged to hope, that, through the inductive system which is now being applied to the investigation of medical science, at no distant period, as perfect a degree of knowl- 8 But the question, whether the matter of miasmata is organic or inorganic, though interesting in a speculative point of view, does not comport with the practical design of this brief treatise; 1 shall, therefore, leave the consideration of the nature of this oc- cult poison, to enquire through what channel it enters into the human system, and so affects it as to develope such diversified forms of fever. That it makes its primary morbid impression on the nervous system, does not admit of a rational doubt; but whether the skin, the mucous membrane of the stomach, or the bronchial lining, is the recipient point of that impression, is a question concerning which there is much difference of opinion. From the comparative insensibility of the skin; and from the fact, that the stomach is comparatively inaccessible, whilst the bronchial mucous membrane is constantly exposed to the action of the miasmatic poison with which the air of infected districts must be charged, we may reasonably infer, that the nervous filaments spread on that extensive surface must receive the primary im- pression, which, being communicated to the great nervous cen- tres, is ultimately radiated throughout the entire system, and so disturbs the healthy balance between the nervous and vascular systems, as to develope the forms of fever under consideration, by a series of actions which I will endeavor to explain. This leads me to enquire, what is the first link in the chain of morbid action, and what are the consecutive phenomena which constitute the pathology of intermittent fever? As has been stated, it is most probable that the primary impression of the peculiar cause of fever is on the bronchial lining, and that that impression is transmitted to the great centres of the nervous system. What is the immediate effect of that impression? A close observation of the mauifesiations which characterize the incipiency of every attack, makes it obvious, that it must be diminished nervous sensibility. That this is the case, seems to be conclusively demonstrated by the great languor and lassitude, anorexia, muscular weaknes.s, and the indisposition to mental and corporeal exertion which universally precede the full development of the fever. Diminished nervous sensibility must, therefore, be considered the first event in the series of morbid actions. The second event, I suppose to be morbid irritability of the nervous system, and, of consequence, an inequilibrium of nervous distii- 9 bution. Hence the internal organs become foci to which nervous influence tends; and the minute ramifications of nerves destined to the surface, and designed to control the action of the capillary vessels, cease to transmit their natural amount of stimulus which is essential to healthy capillary circulation, which becomes almost entirely suspended on account of the constriction of the minute vessels. A third event now follows: a loss in the balance of the circulation, the blood being determined to the internal viscera, in consequence of the intimate relation which subsists between the nervous and muscular systems. A train of phenom- ena now arises which peculiarly characterizes an intermittent paroxysm: in proportion as the blood recedes from the contract- ed capillaries of the surface, and accumulates in the larger trunks and internal organs, the skin becomes cold, pale and contracted, and the pulse feeble and irregular; the patient complains of a sense of weight in the head, dull headache, and pain in the back and extremities; there is more or less confusion of the intellect; there is great muscular weakness, accompanied with irregular contractions, causing what is called shivering, or rigor, which may properly be regarded as a species of convulsions; and the patient yawns very frequently. The foregoing symptoms are obviously dependant upon congestion of the brain and spinal marrow. The lungs being engorged, there is a painful sense of oppression in the chest; the respiration is hurried and laborious, and the patient often sighs deeply. The heart's action being disturbed by the undue accumulation of blood on its right side, there is a painful sense of oppression about the heart; and the pulse is, most generally, very irregular, small, contracted — sometimes quick—at others, slow and oppressed. The chylo- poietic viscera, together with the spleen, being deeply congested, there is a sense of great oppression in the epigastric and hypo- chondriac regions, with nausea — sometimes bilious vomiting, and great thirst. The above phenomena, collectively, constitute what is called the cold stage of an intermittent paroxysm; the duration of which is various, according to several modifying circumstances, but chiefly to the various degrees of constitutional strength. Sooner or later, the excessive irritability of the nervous system becomes expended, and the brain and spinal marrow, which reg- ulate the action of all the vital functions, return to their normal 10 state of excitability, and the heart and general vascular system, down to the ultimate capillary vessels, by degrees, receive their natural supply of nervous stimulus, in consequence of which, the great central organ of the circulation is excited to more vigorous action, and enabled to disburden itself of the oppressive load under which it had labored; and the capillaries being relieved of their constriction, freely admit their usual currents; hence, a centrifugal movement takes place in the circulating fluid,'and full re-action is soon established. This constitutes the fourth important event in the series, by which, what is called the hot stage of an intermittent paroxysm is developed. A new train of phenomena now presents itself: the face, having been pale and contracted, becomes flushed and rather swollen; the general surface becomes hot and dry; the pulse is quick, tense and full; there is much thirst; there is increased pain in the head, back and extremities; the sensorial powers are more or less disturbed; the respiration is anxious and oppressed; the urine is scanty and very high colored, and the patient is exceedingly restless; sometimes there is great irritability of the stomach. The natural balance between the nervous and vascu- lar systems having been completely restored, and the vascular re-actioh consequent thereon having continued for a greater or less length of time, the excess of excitability, which always transcends a normal degree when the balance between the nervous and vascular systems is disturbed, becomes exhausted, and the febrile symptoms rapidly subside; and the third and last stage of the paroxysm is established by general perspiration, which, beginning upon the face and neck, gradually appears over the whole surface. This last event completes the series of phe- nomena which distinguish an intermittent paroxysm, and the patient is restored to a comparatively apyrexial state — the vari- ous functions of his body having resumed, in a greater or less degree, their natural action. Sometimes, though rarely, there is but one regular paroxysm, embracing the cold, the hot and sweating stages—after which, convalescence commences, and the system returns to a perfect state of health; most generallv, however, intermittents are subject to repeated revolutions of exacerbations and intermissions, which vary considerably in their duration. When the interval which intervenes between the be- ginning of one paroxysm and that of the succeeding one is twenty- 11 four hours, authors designate the type by the term quotidian; when the interval is forty-eight hours, it is called a tertian; and when seventy-two hours, it is called a quartan ague. The quar- tan type is exceedingly rare in its occurrence; the quotidian and tertian, especially the latter, are very common. The most usual form, both of the intermittent and remittent, in this country, is what is called the double tertian, being subject to quotidian par- oxysms, but each alternate one being the most severe. This division is certainly important in a practical point of view, as, by a close observation of the peculiar type, we can be better enabled to adapt our remedies to the prevention of succeeding paroxysms. The subject, however, admits of another division, which, being based on certain important pathological conditions, is, I conceive, of very great practical value; as a strict regard to it is very essential to the adoption of appropriate modifications of treat- ment. The division to which I refer, is into the simple, the in- flammatory, and the congestive forms of intermittent: the simple form usually occurs in individuals of healthy constitutions, in whom there is no weak point or local affection whatever. The characteristics of this form are general nervous irritability, followed by general simple excitement, during which there is a healthy balance of the circulation, in consequence of which there is no serious topical disorder. This form is almost always very regular in its course, and tends, spontaneously, to a favorable issue. The inflammatory form generally occurs in young and robust individuals, in whom there is some lurking irritation, especially in the mucous coat of the stomach or bowels, or in the coverings of the brain, more particularly the arachnoid. This form is characterized by a very severe cold stage, followed by a hot stage, in which the excitement is intense; the pulse being very full and bounding, the face flushed excessively, the skin hotter and dryer than usual in simple intermittents, and the thirst very ardent, together with severe pain in the head, back and extremities. The third, or sweating stage, is, generally, imperfectly developed, and throughout the Avhole intermission the patient complains of more or less headache, thirst, and restlessness, and the pulse continues quicker and tenser, and the skin hotter and dryer than usual in the intermission. The congestive form occurs, generally, in persons of naturally 12 feeble constitutions, or in those who are debilitated from any cause. If, under either of the above conditions, there should exist any fixed irritation about the brain, the lungs, or the abdo- minal viscera, the point of irritation will become a fixed centre of attraction, to which the circulating fluid will be unduly deter- mined; in consequence of which, the healthy balance of the circulation will be very greatly disturbed, and internal congestions induced, at the expense of the superficial capillary circulation, from which ensues the form under consideration, and which is characterized by a protracted cold stage, and imperfectly devel- oped hot stage. During the cold stage, which is of unusual duration, the patient complains of a sense of weight or oppression in the head; deep-seated headache or giddiness; the respiration is very anxious, hurried and oppressed; there is more or less oppression experienced in the epigastric and hypochondriac regions, accompanied with a sense of internal heat and restless- ness; the pulse is weak, irregular, and oppressed; and the whole surface is exceedingly cold and shrunken. During the hot stage, which is always imperfect and very slow in its development, the system continues to be more or less oppressed; the breathing is rather quick and laborious; the pulse is rather frequent and small; the surface is moderately and partially warm, the extremities being cooler than the head or trunk, and there is dull pain in the head, back and extremities, and the patient complains of much thirst, sense of burning in the stomach, and restlessness. This form much more frequently occurs in the course of the disease, after several revolutions have been passed, than at the com- mencement. The treatment of intermittent fever next demands our atten- tion, and I shall consider it with special reference to the patho- logical conditions above adverted to; that is, I shall notice the modifications of treatment most appropriate to the simple, the inflammatory, and the congestive varieties. The simple regular intermittents are exceedingly mild, and require but little attention, comparatively; there being no serious disorder in any of the important functions, and there, conse- quently, being a strong natural tendency to spontaneous termina- tion, they can, most generally, be easily and early conducted to a favorable issue. 13 There are two important indications to be fulfilled in the management of all the forms of intermittent fever; the first is, to conduct the patient through the paroxysm by relieving, as much as possible, his unpleasant sensations; and the second is, to adopt such measures during the intermission, as will interrupt the course of the disease, and secure the patient against the recur- rence of t*he paroxysms; the first is palliative, the second curative. The object to be aimed at in the cold stage of the paroxysm, is to equalize the circulation by the application of such means as are calculated to aid the reactive powers of nature, and promote the determination of blood to the surface; by which the internal organs are relieved of their congestion. Fo/ this purpose, it is generally sufficient to confine the patient to bed; have him well covered with warmed blankets; apply hot bricks, or bottles filled with hot water, to the extremities and sides; administer a full dose of laudanum or paregoric, and give warm drinks freely, as sage or eupatorium tea. These measures, almost always, in simple cases, speedily induce full reaction, and the develop- ment of the hot stage. It now becomes important to moderate the excitement—to obviate local inflammations, which are always liable to occur under high vascular reaction, and to procure an early and perfect intermission. With these views, it is generally sufficient to place the patient in a well-ventilated apartment; have him lightly covered; administer a seidlitz powder, or an effervescent senna draught, to evacuate the bowels; have him repeatedly sponged with tepid vinegar and water, and give cold acidulated drinks. The above means usually induce a speedy resolution of the hot, and the supervention of the sweating stage. During this stage, all that is necessary is, to promote the perspi- ration, if only partial, by the use of warm drinks, as sage, balm, elder blossom, or eupatorium tea; and, if excessive, by changing the patient's bed clothes and linen, and by giving moderately cold drinks, as rice-water acidulated with citric acid, or elixir vitriol. The third stage being completed, and the system having re- turned to an apyrexial state, the treatment during the intermis- sion, and which is designed for the radical cure of the disease, demands our special attention. The Peruvian bark, and its valuable preparation, sulphate of quinine, stand pre-eminent among the remedial agents which have been used for the radical 14 cure? of intermittents; and surely, when judiciously used, are justly entitled to our highest confidence. Much difference of opinion, however, prevails among authors in relation, 1st, to the necessity of a preparation of the system previous to the use of this potent remedy; 2d, to the most proper period of the disease; and 3d, to the most proper time of the intermission, for its administration, in order to obtain its greatest prophylactic power. According to my experience, there is no necessity for preliminary prepara- tion; whenever the intermission is complete, that is, when the pulse is soft, slow and regular, the skin moist and cool, the tongue moist and not very heavily coated, and when there is little or no headache — under such circumstances, the sulphate of quinine will, almost always, arrest the course of the disease after two or three paroxysms. If the tongue is much furred, and there are other evidences of vitiated secretions, especially the biliary, it is proper to administer a mild mercurial purgative, say 10 grs. of calomel combined with 10 grs. of rhubarb, some time during the intermission. When I deem it necessary to exhibit such a purgative, I usually do so at bed-time, and confine the use of quinine, generally, to the forenoon. It is rarely necessary to repeat purgative medicines in mild intermittents. I am con- vinced that much injury has been done by the use of frequently repeated active cathartics in these cases, by which, gastric and intestinal irritation is excited; and simple, often converted into complicated cases. Under favorable circumstances, that is, where the intermission is complete, it is best, most generally, to avoid the use of evacuant medicine altogether, excepting some cooling aperient, as a seidlitz power, during the hot stage, until the paroxysms are arrested, when a mild mercurial purgative should be administered once or twice, in order to improve the secretions, and thus render a relapse less liable. In regard to the period of the disease when the quinine should be administered, I do not hesitate to state that we should never permit a perfect intermission to pass by without availing ourselves of the prevent- ive power of this valuable tonic. Some, as the late Dr. Eberle, for whose character and opinion I have the highest respect, urge', that it is preferable to postpone the use of quinine until after the' fifth or seventh paroxysm, as, when thus exhibited, relapses are much more uncommon. According to my observation, all simple cases can generally be arrested by it after the second or third 15 paroxysm, with but little tendency to relapse, if the system is kept under its influence for several days after the last; and in all cases of a serious character, it is highly dangerous to delay its use, on account of the visceral congestions and inflammations which are apt to occur in consequence of repeated paroxysms, during which the internal organs become more and more embarrassed, because reaction becoming more imperfect, the disgorgement of the organs becomes less after each successive exacerbation; hence the patient is apt to pass into the congestive condition heretofore spoken of, or inflammation being established in the seats of congestion, he may ultimately be destroyed by excess of excitement. These observations are designed to apply especially to intermittents, as they occur in the southwest, where the very mildest form is prone, if neglected or mismanaged, to assume the inflammatory, or congestive character. The next point to be determined is, at what time, during the intermission, should quinine be exhibited, in order to obtain its greatest powers? My experience leads me to this conclusion: if the intermittent is simple, the intermission complete, and the recurrence of the paroxysms regular, it is decidedly preferable to postpone the administration until within two or three hours of the expected paroyxysm; then, to give a large dose, say from 10 to 20 grs., combined with from 10 to 20 grs. of Dover powder, and, at the same time, have the patient well covered in bed, make hot applications to the extremities, and give warm sage or ginger tea to drink. This combination I regard as highly valuable, it being calculated to fulfil all the prominent indications; the opium tending to allay morbid irritability; the ipecac, to lessen any excitement which may exist in the vessels, and act gently on the skin, the functions of which are usually considerably disor- dered; whilst the full dose of the quinine braces up and gives tone to the nervous system, and, by the peculiar impression which it makes, tends, in a powerful degree, to interrupt the chain of morbid action peculiar to this disease. Since I have adopted this practice, I can confidently say, that very few of the cases which have come under my observation, during the last ten years, have continued beyond the second or third paroxysm, and a very small proportion has been subject to relapse. If the case is more severe, the paroxysms irregular, and especially if there is a tendency to the congestive form, I think it 16 highly important to take advantage ot the earliest favorable opportunity to give the quinine, and to repeat it frequently throughout the whole intermission. Under such circumstances, I generally admister 5 grains of quinine combined with 5 of Dover powder, and repeat every three hours—increasing to 15 or 20 of each during the last two or three hours of the intermis- sion. As auxiliary to the above, as in the simple regular form, external heat should be applied, and warm drinks, as sage or ginger tea, should be freely allowed; and in urgent cases, sina- pisms should be applied to the extremities two or three hours before the expected paroxysm, in order to avert it. In the treatment of the inflammatory form, a decidedly antiphlogistic course is pre-requisite to the use of quinine or any other remedies usually administered with the view of radical cure. If the pulse is quick, very tense and full, the skin hot and dry, and there is much thirst and headache, blood should be drawn from the arm until a decided impression is made upon the constitution, after which, should there be strong indications of cerebral disturbance, or gastric or enteric irritation, cups should be applied to the temples, the back of the neck, or between the shoulders, to the epigastrium, or over any part of the abdomen, according to the seats of local affection. Having bled, and cupped, if deemed advisable, the bowels should be effectually evacuated by some mild purgative, as 10 grains each of calomel and rhubarb, after which, if necessary, a little cold-drawn castor-oil, or infusion of senna and manna should be administered. The mercurial purga- tive should be repeated every other night, so long as the excite- ment continues unabated, and the secretions, especially the biliary, vitiated in appearance. As auxiliary to the above, the patient should be repeatedly sponged with tepid vinegar and water, or if the excitement is very high, we should make use of an occasional tepid affusion; he should be allowed the free use of cold acid drink, and if there should be much gastric irritability, the spirit of mindererus, or effervescent draughts made with citric acid and soda. The above measures, especially if the general blood-letting is decisively adopted during the hot stage, are generally sufficient to allay the febrile excitement, and induce a more perfect intermission, manifested by a slower and softer pulse, a cooler and more moist skin, and a great abatement of the cerebral and gastric symptoms. As soon as this favorable change 17 takes place, quinine should be administered, with the view of arresting the disease. I usually give 5 grains each of quinine and Dover's powder, and repeat every three hours during the absence of excitement, taking the precaution to enlarge the dose to 10 grains each towards the close of the intermission, so as to make a strong impression upon the nervous system. During the use of the above combination, the patient should drink freely of warm sage, balm or eupatorium tea, which, by acting gently on the skin, enables the quinine to be better borne; if the quinine cannot be borne, that is, if it causes much headache or excitement of the pulse, a strong infusion of serpentaria should be substituted for it, until we procure a complete intermission.. In the congestive modification, in which the cold stage is usu- ally very protracted, and the hot stage imperfectly developed, the system continuing more or less oppressed in consequence of the great inequality of the circulation, it is highly important to aid nature in her efforts to throw off the oppressive load under which she is struggling, by the use of means calculated to invite the circulation to the surface; and when the lost balance is restored, to guard the system against the recurrence of the paroxysms, which, in feeble, debilitated constitutions, are apt to be followed by fatal consequences. If called to a patient during the cold stage, a full dose of laudanum or paregoric, say from 40 to 60 drops of the former, and from one to two drachms of the latter, should be immediately administered; the patient's extremities should be placed in a hot salt or mustard bath, and permitted to remain 20 or 30 minutes, after which, they should be well rubbed, and warm mustard plas- ters applied to them, and continued on until the skin is decidedly inflamed; a bag of hot salt, or a bottle of hot water, should be ap- plied over the epigastrium, and repeated until reaction is induced; the patient should drink freely of hot sage, ginger, or serpentaria tea; and 5 grains each of calomel, camphor, quinine, and Dover's powder, should be administered every two or three hours until reaction ensues. If the reaction is imperfect, that is, if the skin is only moderately and partially warm, if the pulse is quick, rather small and irregular, and there is a sense of internal heat and oppres- sion, we have the best evidences that can be afforded of suffocated excitement; to remove which, it is highly necessary to abstract blood very cautiously. The plan I generally adopt is, to place B 18 the patient's extremities in hot water, made more stimulating' with salt or mustard, the lower in a tub deep enough to extend to the knees, the hands and fore-arms in a basin held by an assistant: I then open a vein, and keep my fingers upon the opposite pulse; if the pulse flags, and the patient grows sick and faint, I close the orifice immediately, and administer a little wine or brandy, and continue the means already stated, to promote reaction, and sustain the system. If, however, the pulse rises and becomes regular and fuller, which it most generally does under such circumstances, I cautiously continue the abstraction until the pulse becomes pretty well developed-—the rapid effects of which are, a,,generally warm skin, and a great relief of the internal sense of oppression. To aid the general blood-letting, it is sometimes necessary to apply cups over the chief seats of congestion, and follow them with large sinapisms, and allow the patient to drink freely of warm sage or serpentaria tea. If reaction becomes fully established, and the excitement is only moderate, all that is necessary is, to sponge the surface occasionally, with tepid vinegar and water, let the patient have moderately cold acid drinks, and administer mild, alterant and aperient medicines, with the view of evacuating the intestines of their vitiated contents, and improving the various secretions; for this purpose, I generally use the following combination: — Blue mass, 3 grs.; rhubarb, 3 grs.; ipecac, \ to 1 gi\, or, if the alvine discharges are rather thin, 5 grs. of Dover's powder. This com- bination should be repeated every six or eight hours, until the excitement is subdued, and the biliary secretion properly excited. If, however, after reaction has taken place, the excitement should be very violent, as is the case sometimes, it is highly important to reduce it, in order to obviate the supervention of inflammation in the organs which have been so lately gorged with blood, and of course greatly weakened; for this purpose, tepid affusion should be applied, minute portions of calomel and ipecac, say 1 gr. of the former and from £ to 1 gr. of the latter, should be administered every two hours. These means are generally sufficient to mod- erate the febrile excitement; but, if they prove inadequate, cups should be freely applied over the chief seats of congestion; or we may venture to draw blood from the arm to a moderate extent, taking care to stop the operation upon the slightest manifestation of failure in the pulse. This precaution is always very necessary, 19 on account of the great liability to collapse, after previous congestion, by which the vital powers are considerably weakened. If, under the use of the above measures, the vascular excite- ment is sufficiently lowered, manifested by a softer and slower pulse, and a cooler and more soft skin, the system should be brought under the influence of quinine as soon as possible; with this view, from f> to 10 grs. of this salt, combined with 5 grs* of camphor, and the same quantity of Dover's powder, should be repeated every three hours during the intermission; and about two or three hours before the expected paroxysm, the quinine and Dover's powder should be increased to 20 grs, each, and large sinapisms should be applied to the extremities, and one over the whole abdomen. This energetic course of treatment very rarely fails to prevent the recurrence of the paroxysm. Most practitioners in the United States are opposed to the use of quinine in such large doses as I have recommended, upon the ground that it is calculated, when thus exhibited, to aggravate the disease, by increasing the excitement, and ultimately super- inducing local inflamations. My observation leads me to believe that such serious consequences rarely occur. I have been in the habit, for ten years past, of giving it in the doses above stated, and I do not recollect one single instance in which there was decided detriment from it, provided the system was in the proper condition to receive it. My impression is, that its action upon the animal economy is very similar to that of opium, and that, like the latter, large portions are more decidedly sedative. This view of its modus operandi was first suggested, I believe, by Dr Thomas Fearn, of Huntsville, Alabama; and of its correctness I am entirely satisfied, from close observation of its effects' Whenever I feel doubtful as to the propriety of administering it, and still feel disposed to venture upon it, I invariably give large doses combined with Dover's powder or ipecac; it may be, that the Dover's powder may so far influence its action as to enable the system to tolerate it, when it otherwise could not. In all the forms of intermittent, whether simple, inflammatory, or congestive, it is proper to continue the use of quinine for several days after the disease appears to be arrested, in order to guard against relapse; and as the secretions, especially the biliary, are most generally disordered, mild alterant and aperient medi- cines should be administered occasionally, until the tongue be- 20 comes clean, and the alvine discharges assume a healthy aspect; for this purpose, I give 5 grs. of blue mass and 10 grs. of rhubarb, every second or third night; and, on the following day, if neces- sary, a little castor-oil, or senna and manna infusion. In addition to these simple precautionary measures, the patient should, for some considerable time, avoid exposure in damp, chilly weather; and if of weak constitution, ought to wear flannel next the body, on account of the morbid sensibility of the skin to the impressions of cold in all such individuals. Intermittents not unfrequently become chronic, and continue to recur, in some cases, after regular, in others, after very irre- gular intervals, for a long time, notwithstanding the diligent use of all the means commonly adopted to eradicate them. The pathological conditions on which the chronic form depends are very different, and should be carefully discriminated, as the treatment must be modified accordingly. In some cases, there is no evidence of visceral disorder or disease; still, the paroxysms continue to recur, after regular or irregular intervals, the inter- missions being so perfect, and the general health so little affected by them, that the patients are generally not only able to go about, but to attend to their usual avocations. From these circum- stances, it is obvious, that the periodical return of chill and fever must be dependant upon a habit of the nervous system, acquired by a frequent repetition of the same diseased actions. When dependant on this cause, it is necessary to make a new impres- sion upon the nervous system in order to interrupt this disagreea- ble, chilly habit; for this purpose, I would recommend large doses of quinine, to be repeated three or four times during the inter- mission, together with active, but agreeable exercise of the mind and body. The influence of the mind, in arresting this disease, has ever been acknowledged, and every practitioner must have met with interesting illustrations of its power, when judiciously directed, to avert an expected paroxysm. I generally advise such patients to clothe themselves warmly, and take an interest- ing tour, if compatible with their situations, on horseback, or in a pleasant vehicle, as circumstances may indicate. The change of scenery and of associations, incident to travelling, exerts a salutary revulsive influence by which the mind is diverted from bodily afflictions ,and directed to pleasing objects of reflection; whilst the change of air, of diet, and of habits, and the exercise' 21 are well calculated to improve the secretions, promote digestion, and invigorate the whole system. If travelling does not comport with the situation of a patient, or if it proves unavailing, I would advise the use of the cold shower-bath every morning, and to be repeated about two hours before the expected paroxysm. This is a safe and valuable remedy; its remote effect is that of a powerful general tonic; its immediate effect is a comfortable reaction about the time the chill usually comes on. The most common conditions, however, on which chronic intermittents depend, particularly in more southern latitudes, are enlargements and indurations of the liver or spleen, which are frequently associated with jaundice or dropsy. Cases dependant upon these conditions are exceedingly numerous in unhealthy localities in the south, where patients, with pale, sallow com- plexion, bloated face, cedematous feet, and obvious enlargement of the liver or spleen, are often seen engaged in their ordinary occupations, although subject to frequent returns of their chill. The most important indication to be fulfilled, in the treatment of these cases, is, to remove the visceral disease. For this purpose, the following combination will generally prove sufficient, if aided by long-continued counter-irritation: blue mass, 3 grs.; ext. hyosciamus, 3 grs.; aloes, 1 to 2 grs., made into two pills, and given every morning and night, at first, and afterward, every night, or every other night. Counter-irritation should be kept up by means of tartar emetic ointment, a seton, or what I have used with a very good effect, a liniment, composed by dissolving half an ounce of camphor in an ounce of spirits of turpentine, and adding 30 or 40 drops of croton oil. If the above combination appears to be inadequate to the resolution of the visceral disease, I would recommend the following: —Protoiodide of mercury, h gr.; ext. hyosciamus, 2 or 3 grs.; aloes, 1 gr., to be given in the form of pill, morning and night—gradually increasing the proportion of the protoiodide up to 2 grains, twice or three times a-day. The next indication to be fulfilled is, to invigorate the system by the, use of suitable tonics; for this purpose, the sulphate of quinine combined with the arsenite of potash, is preferable to all others; of the former, 3 to 5 grains, and of the latter, from the 15th to a 20th of a grain should be given twice or three times during the day, and the patient should drink freely of sarsaparilla tea. Under the influence of the above measures, the enlargement or indura- 22 tion of the liver or spleen will, in a large majority of cases, become resolved, the secretions greatly improved, and conval- escence established. II.-REMITTENT FEVER. The remittent form of fever next demands our consideration. If the intermittent and remittent forms of fever be, as has been stated, of the same essential nature, and dependant upon the same peculiar cause, why are their general phenomena and causes so materially different? The light of pathology exhibits to us a very- satisfactory solution of the question. It teaches us the important lesson, that, though the nature of the primary morbid impression made upon the nervous system, by the common cause, is the same in both, the ultimate effects are widely different. It is obvious, from all the symptoms which mark the forming stage of a remittent, that there is, in the first place, diminished nervous sensibility; and, secondly, abnormal irritability; in conse- quence of which conditions, there is manifested, first, a depression of the vital forces, and consecutively an irregularity in their move- ment, from which arises a loss in the balance which naturally exists between the nervous and vascular systems. So far, the pathology of intermittent and remittent agree; hence, the initial symptoms are almost identical. The forming stage of remittents is, however,. of short duration; the chilly sensations are very soon alternated by flushes of heat, and in a short time full febrile re-action is established—manifested by a full, frequent and sometimes tense pulse, hot and dry skin, flushed face, considerably increased pain in the head, back and extremities, great thirst, furred tongue,, it being yellow or brown, nausea, sometimes bilious vomitino-__a sense of oppression in the epigastric and right hypochondriac regions, and, in the severest cases, by a decidedly yellow tino-e of the sclerotic coat of the eye, and of the general surface—the urine being of a deep yellow color. This stage of excitement corresponds with the hot stage of an jntermitterft paroxysm, and is dependant upon the same processes 23 of nature, but its course differs from it materially; instead of ter- minating, as the hot stage of an intermittent usually does, in a few hours, in free perspiration, and a perfect intermission, it con- tinues, in a more intense degree, for a much greater length of time, and only abates, remits, for a few hours, during which, there is slight moisture on the skin, it still continuing warmer, and the pulse quicker and tenser than natural. This slight remission hav- ing continued three, four, or five hours, without any previous cold stage, the fever again rises, until it equals, or exceeds, the violence •of the first paroxysm; and, continuing for an indefinite period, again declines, or remits. In this way, successive exacerbations and remissions continue to occur, until the fever either terminates in a perfect crisis, and convalescence, or assumes a more malig- nant form, and becomes more continued in its course. What, then, are the pathological conditions on which the important differences in. the general phenomena of the above modifications of fever are dependant? In intermittents, if simple, although there is full vas- cular re-action during the hot stage, the excitement is simple and general; that is, the circulating fluid is equally distributed through- out the whole system, there being no undue quantity in any one part, and consequently no irritated action in the capillaries of any part, external or internal; hence, in a short time, excitability be-^- comes exhausted, and the system returns to a comparatively apy- rexial state. In remittents, on the contrary, there is, from the very commencement, some fixed seat of irritation, or inflammation, most generally, in the mucous coat of the stomach or bowels; in the coverings of the brain, especially the arachnoid; in the liver, and sometimes in the bronchial lining. These local irritations or in- flammations, serve as permanent centres of attraction, by which the balance between the nervous and vascular systems continues to be disturbed, and consequently vascular excitement sustained. Having cursorily noticed the chief cause of difference between a simple intermittent and remittent, let us, in the next place, enquire into the causes by which a simple becomes converted into a malig- nant, and more continued form of remittent. A careful observation of the external manifestations during life, and of the morbid appearances revealed to us after death, conclu- sively demonstrates that the important change is dependant upon a progressive increase in the extent and grade of inflammation in the vital organs. If the locai inflammation i« in -liyht degree 24 and of limited extent, the fever, generally, proceeds with regu- larity, and tends to a favorable crisis, usually about the ninth day. If, however, we should perceive, at each successive exacerbation, a decided aggravation of the symptoms, we may predict, with unerring certainty, that the inflammation is advancing. In all cases of a severe character, whilst all the structures referred to, as being the almost exclusive seats of disease in this form of fever, may be implicated in some degree, inflammation, generally, great- ly predominates in one, and the most prominent symptoms are chiefly referable to that point. If the brain and spinal marrow are principally involved, the patient complains either of considerable pain in the head, or giddi- ness, or a painful sense of heaviness in the head ; he suffers much pain in the back and extremities; there is great restlessness, and dis- turbance of the sensorial faculties, amounting frequently to violent delirium; there is painful intolerance of light and sound; the scalp is preternaturally hot; the carotids beat with unusual force; the face is flushed; the countenance expressive of much anxiety, and the pulse is quck and tense — sometimes quite full. If the inflam- mation advances, sooner or later, a new train of symptoms set in, indicative of disorganization; the pain in the head, back and ex- tremities ceases; insensibility increases; there is increased rest- lessness, low muttering delirium, subsultus tendinum, involuntary discharges; certain indications that inflammation has done its work of destruction, and that the great nervous centres are suffer- ing from its morbid products. If the mucous coat of the stomach be principally involved, there is pain and a sense of oppression in the epigastrium; tenderness on pressure; nausea, and frequent bilious vomiting; the tongue is loaded with a yellow fur on its surface, whilst its tip and ed^es are vividly red; there is great thirst for cold and acid drinks, a°nd there is a sense of burning in the stomach; the pulse is usually quick, small and tense; the bowels are generally torpid, at first- the urine scanty, turbid, and very highly colored. The brain becoming sympathetically involved, we have, in addition to the above, the symptoms of cerebral inflammation. If the mucous coat of the intestinal tube be the chief seat of inflammation, there is great pain in the bowels; tenderness on pressure over the bowels, most frequently over the ileoccecal por- tion ; preternatural heat over the whole surface of the abdomen- 25 the tongue is intensely red on its edges and tip, whilst its surface is covered with a dirty yellow fur, which sometimes becomes brown or black; the bowels are sometimes, at first, rather torpid; they, however, soon become very loose, the dejections being serous, mucous or bloody; in the worst cases, the abdomen becomes tympanitic; the pulse is generally small, tense and contracted. The brain sympathizes early with muco-enteritis, especially ilei- tis; hence, there is usually severe head-ache, chiefly referable to the forehead ; and in bad cases, delirium, at first violent, afterwards of a low muttering character, supervenes. If the liver be principally implicated, and there is much san- guineous engorgement, there is a painful sense of weight and oppression in the epigastrium and right hypochondrium, severe headache and early delirium, the sympathy between the brain and liver being very great; constant nausea and vomiting — not of bile, but of the ordinary contents of the stomach; the tongue is moist, and but slightly coated; the bowels are generally very torpid; the urine highly colored with bile, and the skin, sooner or later, assumes an intensely yellow color. The hepatic compli- cation most generally occurs in the more southern latitudes, and, where it is associated with a high grade of muco-gastritis and duo- dinitis, constitutes the very worst form of remittent fever, denomi- nated, from the deep yellow tinge the skin assumes, yellow fever. Having rapidly glanced at the external manifestations, as evi- dences of internal inflammation, let us, in the next place, briefly refer to those more unequivocal evidences, the morbid appearances exhibited after death. If the brain has been the chief seat of inflammation, we discover unusual vascularity in the brain and its coverings, especially the pia mater; the arachnoid is generally thickened and opaque; the substance of the brain, when cut, exhibits numerous red points — and it is changed in its consistence, being sometimes softer, at other times harder than natural; there is more or less effusion into the ventricles, and between the membranes, the fluid being sometimes thin straw-colored serum, sometimes bloody, and at other times gelatinous or purulent, as between the arachnoid and pia mater. When the mucous coat of the stomach and bowels has been the seat of inflammation, it exhibits the strongest marks of increased 26 vascularity, thickening, or ulceration in various degrees. This last lesion occurs most frequently in the lower part of the ileum. When the liver is chiefly implicated, we usually discover strong marks of sanguineous engorgement; the gall bladder is distended with vitiated bile; and the substance of the gland is, frequently, softer than natural. In considering the treatment of remittent fever, I will notice that which is appropriate to the simple form first, then that which is adapted to the prominent modifications referred to. It should be remembered, that, in this form of fever, there is fixed irritation, or acute or subacute inflammation in one or more of the structures already adverted to, superadded to that peculiar condition of the nervous system which essentially characterizes the febrile state; and that, .of consequence, there is permanent vascular excitement, and derangement of the secretions ; hence, the important indica- tions are, to subdue vascular excitement; to remove the local affections, and to improve the secretions. These purposes can, generally, be easily effected in a large majority of the ordinary cases which occur in our country. During the accession of fever, the patient should be placed in a well ventilated apartment, and be lightly covered; mild aperients should be occasionally adminis- tered ; cold acid drinks ought to be allowed; the whole surface should be repeatedly sponged with tepid vinegar and water; and the diet should be rigidly antiphlogistic, as gum Arabic solution, rice water, rice or corn-meal gruel, well boiled. As the bowels are, almost always, torpid, and loaded with vitia- ted matters, in the commencement of all cases, practitioners uni- versally agree, that purgatives constitute an essential part of the treatment of remittent fever. The chief reliance is placed, by most, on this important class of remedial agents; and especially on mercurials variously combined, on account of the prevailing impression that the functions of the liver are universally deranged- It is true, that mild, but efficient purgatives, are indispensably necessary throughout the whole course of remittent fever; but I apprehend that much detriment has been occasioned by the too earnest desire of some physicians to secure a " clean house," by the repeated use of active cathartics. With this view, it is a com- mon practice, particularly in the south, to administer very large portions of calomel, combined with aloes, calocynth, jalap or other active articles of the class, and follow them up with saline and 27 other medicines, so as effectually to wash out the intestinal canal; and this plan is pursued, with more or less activity, throughout the course of the fever. When it is remembered, that the mucous membrane of the stomach and bowels is almost always irritated or inflamed, it cannot be doubted but that such active measures must prove highly prejudicial in a large majority of cases. If only irritation exists, it is sure to be converted into inflammation; and if inflammation already exists, it will be, inevitably, greatly aggra- vated. Of the correctness of this observation, we have but too many melancholy proofs, exhibited under a course of active pur- gative medicine, such as red and dry tongue, great abdominal tenderness, and copious serous, mucous or bloody discharges; conditions which, in my opinion, arise, in most cases of severe character, from the too-anxious wish of practitioners to purge the system of a disease, which, being determinate in its course, will oftener be more effectually eradicated by lenient than by violent means. The important indications to be fulfilled by purgatives, are the dislodgement of the irritating contents of the alimentary canal, and the improvement of the secretions. If these objects are attained, the fever generally yields very rapidly under the influence of sim- ple auxiliary remedies. It is, in my opinion, rarely necessary or proper, in remittent fever, uncomplicated with cerebral inflamma- tian, to deplete the system by active purgation. If active depletion is indicated on account of high vascular excitement, it is far pre- ferable to draw directly from the currents of the circulating fluid, than to do so by increasing intestinal irritation, which must nec- essarily render the case more tedious and more dangerous. In the ordinary remittents of this country, I usually administer, at night, three or four pills, consisting of two grains of calomel, two or three of rhubarb, and one-fourth or one-third of a grain of ipecac. These 1 find, generally, sufficient to procure two or three