disease; and this is the entire sum and substance of our knowledge of the matter-just as easily packed in a nutshell as blown out into an empty balloon.

ARTICLE III.

INTERMITTENT FEVER.

It is hardly necessary to enter at any considerable length into the details of the treatment appropriate to the simple intermittent form of periodical fever. The management of simple chills and fever has been, to a very great extent, taken out of the hands of medical men, and intrusted to those of the patients themselves and their friends. This management consists almost exclusively in the use of the sulphate of quinine, with occasionally, perhaps, a simple or a mercurial purgative. The quinine is usually given during the intermission, and in various doses, from one or two to eight or ten grains.

Amongst persons constantly residing in malarious localities, intermittents frequently become obstinate, irregular, and protracted. In these cases, and in the simple forms, when the latter resist the influence of quinine, various substitutes for this substance have been made use of. Amongst these, the most important are arsenic, and some of the bitter vegetables, Cornus Florida, or dogwood, chamomile, thoroughwort, and so on. There is no doubt at all of the anti-periodic property of arsenic; and in those cases to which I have referred, it may sometimes be used with advantage. So, an infusion of one of the vegetables just mentioned will occasionally be found more efficacious in arresting the paroxysms than even the bark itself; and when the disease does not yield to its usual remedy, it is well to employ them.

In regions where marsh fevers are extensively prevalent, there are many remedies and modes of practice, besides those already mentioned, which acquire a popular celebrity. Most of them produce a pretty sudden and powerful impression either upon the mind or the body, and in this way they frequently break up the disease. I shall mention particularly only one other remedy, and that is opium. This substance has been a good deal used in the treatment of periodical fever, and there seems to be no doubt of its great value. The following interesting account of its action and effects is by James Lind, who for a long period during the last

century was a careful and extensive observer of periodical fever. His testimony in regard to its advantages is so emphatic and decided that I feel bound to introduce it. The history of his experience is thus related. Having given a dose of opium in an obstinate case of ague, on account of some accidental symptom, to the great relief of the patient, he concluded to try the remedy more extensively. "Having at that time," he says, "twenty-five patients laboring under intermitting fevers, I prescribed an opiate for each of them, to be taken immediately after the hot fit, provided the patient had any inquietude, headache, or similar symptom subsequent to the fever. The consequence was that nineteen in twenty-two received immediate relief; the other three had no occasion to take it.

Encouraged by this success, I next day ordered the opiate to be given during the hot fit. In eleven patients out of twelve to whom it was thus administered, it removed the headache, abated the fever, and produced a profuse sweat, which was soon followed by a perfect intermission. Since that time, I have prescribed an opiate to upwards of three hundred patients laboring under that disease. I observed that when given during the intermission, it had not any effect either in preventing or mitigating the succeeding fit; when given in the cold fit, it once or twice seemed to remove it; when given half an hour after the commencement of the hot fit, it generally gave immediate relief.

"The effects of opium, given in the hot fit of an intermitting fever, are these: First, it shortens and abates the fit; and this with more certainty than an ounce of bark is found to remove the disease. Second, it generally gives a sensible relief to the head; takes off the burning heat of the fever, and occasions a profuse sweat. This sweat is attended with an agreeable softness of the skin, instead of the disagreeable burning sensation which usually affects patients sweating in the hot fit, and is more copious than in those who are not under the influence of opium. Third, it often produces a soft and refreshing sleep to patients before harassed with fever, from which they awake bathed in sweat, and in a great measure free from complaint.

"I have always observed that the effects of opium are more uniform and constant in intermitting fevers than in most other diseases, and are then more quick and sensible than those of most other medicines. An opiate thus given, soon after the commencement of the hot fit, by abating the violence and lessening the duration of

the fever, preserves the constitution in a great measure uninjured. Since I have used opium in agues, a dropsy or jaundice has seldom attacked any of my patients in these diseases.

"In cases where opium did not immediately abate the symptoms of the fever, it never augmented their violence. On the contrary, most patients reaped some benefit from an opiate given in the hot fit; and many of them bore a larger dose of opium at that time than at any other. Even a delirium in the hot fit is not increased by opium, though opium will not remove it. If the patient be delirious in the fit, the administration of the opiate ought to be delayed till he recovers his senses; an opiate will then be found to relieve the weakness and faintness which commonly succeed the delirium."

Dr. Drake says of opium in the treatment of malignant intermittents: "Of its great value no physician of experience, in those diseases, can entertain a doubt. If there be no diarrhoea, however, it is not necessary to administer it throughout the intermission, but reserve it for the last dose of the sulphate, before the approaching chill. The quantity in which it is then given, is often entirely too small, and much better fitted to simple intermittents, in which the susceptibilities of the system are lively, than to those in which they are greatly reduced. In such a state of the system, three or four times as much as would be required in an ordinary ague, is not a large dose. I have met with many physicians who had a just appreciation of this state of the system; but with none who carried the practice logically deducible from it, so far as Dr. Merriman and Dr. Henry, of Springfield, Illinois. It has grown into a settled opinion with those gentlemen, that a moderate quantity of the sulphate, combined with a large quantity of opium, is the very best practice. Hence through the early periods of the intermission, they do little or nothing; but three or four hours before the chill, administer a bolus of four grains of opium and eight grains of sulphate, which, as they affirm, scarcely ever fails. Dr. Henry has even found that dose of opium, without the other medicine, successful. Dr. Jayne pursues the same practice, but generally limits the opium to two grains."

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To prevent the occurrence of relapses, I know of no means of any value, except an occasional use of the bark; a careful regulation of the diet and exercise, so as to keep the system in as vigor

Lind on Hot Climates, Phila. ed., p. 236.

Dr. Drake on the Diseases of North America, vol. i. p. 776.

ous a tone as possible; and an avoidance of the night air, and of all the ordinary exciting causes of disease. There is only one means certainly to be depended upon, and this consists in a removal beyond the influence of the malarious poison.

For the removal of the various remote consequences of the disease which have already been enumerated, no very particular rules can be given. The local engorgements of the liver and spleenespecially of the latter-so long as they are simple engorgements, without any fixed change of structure, are to be met by the means already indicated, particularly by quinine, paying attention at the same time to the state of the bowels and secretions. When these engorgements have been so long continued and so often repeated, as to result in chronic structural alterations, only palliative effects can be looked for from remedies. The headache and other cerebral troubles, which sometimes follow the disease, and which seem to be connected with a kind of nervous erethism, may generally be removed by shaving the head and keeping it cool; by quiet and rest; and a careful regulation of all the organic and animal functions. Neuralgic affections are to be treated upon the same general principles. There can be but little doubt, that a free and persevering use of cold water, externally and internally, with a plain but substantial diet, and active exercise in the open air, would constitute the best possible treatment in many of these cases. The best special remedy for the anemic condition which the disease frequently leaves behind it consists in the different preparations of iron.

[The cachexia produced in those who had been affected with the fever of the Isthmus, was found to require quinine and iron in tonic doses, often for a period of two months after the febrile paroxysms had wholly ceased, before the patients were regarded as well enough to be discharged.

At the Bellevue Hospital, New York, for the last year or two quinoïdine or chinoïdine has been gradually taking the place of quinine, in the treatment of fever and ague. So far, it is thought to be equally efficacious as an antiperiodic; and is substituted on account of its comparative cheapness. Although it must be given in doses two or three times larger than the quinine, still the substitution sensibly diminishes the expenses of the apothecary's department, in so large a hospital.]

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CHAPTER XI.

DEFINITION.

THERE is so wide and various a range in the forms of periodical fever that it is very difficult to frame any definition of it which shall possess the necessary brevity, and at the same time be sufficiently comprehensive to include all the essential features of the disease. I can come no nearer the fulfilment of these conditions than in the following endeavor.

Periodical fever is an acute affection, occurring at all periods of life; much more common in the white than in the negro race; confined to certain geographical localities, and prevailing most extensively, as an annual endemic, in marshy and uncultivated regions, and along low-lying and luxuriant alluvions; mostly confined in temperate climates to the latter part of the hot season of the year; immediately excited, in many instances, by the ordinary occasional causes of acute disease, such as exposure and excesses; dependent for its essential cause upon a poison called marsh miasm. or malaria, the nature and composition of which are unknown; generally sudden in its access, commencing with a rigor or chill, which is succeeded first by febrile excitement, and then by general perspiration; these successive phenomena constituting the three stages of what is called the paroxysm of the disease; this paroxysm having a tendency to recur, or to repeat itself, more or less regularly, at certain definite periods, and after certain intervals, these intervals constituting the remissions or intermissions of the fever; the paroxysms and intervals being in an immense majority of instances either diurnal or bi-diurnal in their recurrence; the symptomatic phenomena constituting these periodical stages, varying very widely in their intensity and combinations, thus giving rise to numerous fluctuating and diverse forms of disease; the simpler varieties attended with but little immediate danger, and continuing from a few days to an indefinite period of time; the graver and pernicious forms dangerous in their tendency, and