stant and oppressive nausea; the skin being moist and cool, and the pulse frequent and thready. In others, there is diarrhoea, or it may be dysentery, with intense tormina and tenesmus, and numerous dejections of muco-sanguineous or sero-sanguinolent matters. Meteorism and hiccup precede death. I saw a strong and healthy man who lay constantly on his side with his hands immersed in iced water, making little or no complaint except that if he removed his hands, or if the water became warm, uncontrollable vomiting came on. His pulse was full, soft, and regular; the invading chill had been severe; his face was somewhat flushed; he died on the 5th day. Such cases were frequent in that neighborhood, as I was informed. The physician who attended him was similarly attacked a few days after, and died in the

same way.

4th. The necræmial. I use this phrase after Williams, not knowing better how to denote the form in which the blood seems to have lost its vitality at once, poisoned. There is little or no suffering in these cases generally. The patients sink rapidly into collapse. The skin is often very cold, whence the phrase "algid," applied to them. Hort gives two such instances in which death took place in less than twelve hours from the commencement of the chill, in stout, robust men. The first is described as showing "a chill increasing in intensity without any respite until it terminated in the icy coldness of death. The nervous system was completely overwhelmed and paralyzed, except a feeble internal action of the blood vessels, and equally feeble respiration." The second is spoken of as "attacked with the same symptoms, but dying two or three hours sooner."

In the ordinary cases of all these varied forms, the symptoms above recited are of course more pronounced during the exacerbation. If the type be intermittent, they may, indeed, disappear in the apyrexia or subside entirely. In a case of the third variety, where the determination was to the bowels, dysenteric, of quotidian recurrence, there was in the intervals little or no discomfort; but the patient sunk and died on the third day.

Autopsy.-1. In the cerebral cases, it is almost always found upon examination that some effusion has taken place within the ventricles or at the base of the brain. Clots of blood have been found in the cerebral substance.

2. Of the thoracic form we have from Holmes a description: "The abdominal viscera and contents of cranium were in a healthy state; the skin around the whole chest was discolored by extravasated blood; the vessels of the heart were deeply engorged with blood, the auricles and right ventricle were filled; the lungs bled as if a sponge had been cut that was soaked in blood; the whole blood of the body seemed to have found a common reservoir in the thorax."

3. Of the abdominal. Boling, of Alabama, tells us "that the internal heat of the viscera was greater than he had ever found it in any other disease; not only extremely disagreeable, but almost insupportable to the hand." Lewis found in one instance "the whole internal surface of the stomach of a dark red and the mucous coat softened." Ames says: "There is always some evidence of inflammation in the

large or small intestines." In 8 out of 11 examined in Mobile, by Lewis, "the mucous coat of the stomach was much softened, giving way under very little force; of a dull pearl color with the exception of here and there a deep red patch very circumscribed; in 2 of the 8 it was thickened, raised, and pulpy, coming off before the nail or scalpel-handle like a thick gelatinous or stringy mucus."

I have no record of any post-mortem examination in the fourth class of necræmial cases, as contradistinguished from the other varieties. Pathology.-If it were not for the frequent intermittence and marked remission of this condition of congestion, we might ascribe all the phenomena simply to "intoxication" or poisoning of the blood. As Prof. Draper has shown the dependence of the capillary circulation upon the quantity and healthy state of this fluid and its capacity to act by affinity upon the internal surface of the vessels, it is evident that any morbid change or impairment of these qualities will affect and impair its motivity, more or less, to complete stagnation. But there are two objections to the sufficiency of this explanation: 1st. The facts that such congestions occur and prove fatal when no malarious influences are present; and, 2d. The intermission of all the phenomena, and their recurrence, even in aggravated violence, the subject having been removed from the source of malaria, and having received no additional dose. The action of the cause, whatever that may be, cold, perhaps, in one case, malaria in another, the matter of contagion in a third, paralyzes the extreme organs of circulation, the capillary vessels. These, it is evident, must be in a living and susceptible condition in order that they may act or be acted on by the blood, which may or may not be poisoned, but which cannot pass along inanimate tubes, or passes along slowly and with obstruction through tubes whose vitality is impaired. The functions of these minute vessels are more or less completely suspended. The tissual elasticity and contractility of the arteries tend to impel their contents and empty them, while the veins and parenchymatous structures are engorged. Hence the congestions we are speaking of. But there are obvious reasons in the nature of the cerebral and pulmonary circulation to render the lungs and brain the ready seats of this engorgement, and all casual attacks will, I think, be found either cerebral or pulmonary. I have seen two impressive examples of the latter; both of them occurring at the end of winter, in February and March. One, a young man, sat down to breakfast in good health, but began to complain of pain in the chest and dyspnoea, which increased in intensity until with some chilliness and irremediable prostration he died-in about six hours. The second, a lady suffering under slight catarrhal fever, rose about six o'clock in the morning, and while dressing became chilly with shivering. These symptoms were followed by dyspnoea, and her physician was sent for. I saw her with him about mid-day-and she died three hours after. In these cases all the resources of art to relieve local determination of seemingly passive character-simply congestive-were exhausted, but in vain.

Nor do we find any clearer explanation of the facts in the reference to the nervous theory of intermittent fever. Prof. Jones, of Ga., tells

us that the action of the malarial poison is attended by marked diminution of the solid constituents of the urine. He has also discovered that the same poison "either directly or indirectly destroys the colored blood corpuscles." If the brain and nerves be affected by the necræmial intoxication, how can we comprehend the sudden relief during the apyrexia? It does not suffice here to take refuge in the dogma that "the life of the cerebro-spinal nervous system is periodical," as accounting for the periodicity of these fevers by their assumed radication in that system. The same primary symptoms present themselves in the other and more continuous forms of fever; the congestion; the chill; the pains; pandiculation, &c. Our best hypotheses upon all these topics must be confessed to be nothing more than ingenious conjectures. Treatment.-There are certain general principles that apply to all the forms, yet admit of modifications adapted to each. Nothing is so important or efficient as quina here, our best and truest specific. How it acts would be most difficult to explain; we know whither its efficacy tends. It affects in some peculiar manner the nervous system; it acts upon the brain. This is its obvious and characteristic function, and in this regard we may entitle it a narcotic. "It is," says Drake, "a calmant, a tranquillizer;" yet it disturbs in its own special method. Quininism, is, if we may trust our sensations, a state of irritation; the subject is restless, excited. It seems to restore the impaired activity, the "polarity" of the torpid cerebro-spinal axis, and thus arouse the dormant functions, which all depend upon sensorial activity. It is affirmed to influence the urinary excretion, and thus promote the elimination of effete and injurious elements. It is not, prominently, a stimulant to the circulation; if Mendenhall has found it increase, others affirm that they have known it diminish the frequency of the pulse. It dulls the hearing and dims the sight. It is accused of producing coma, diarrhoea, abortion. On looking over the catalogue of poisonous effects ascribed to it, one is struck with their resemblance to the symptoms of " pernicious fevers." Yet it requires most reckless administration of inordinate doses to do injury with it. Holmes' minimum dose was 18 grains, his maximum 80. Maillot gave, in a cerebral case, a potion containing 40 grains, and an enema containing 60. I speak of the disulphate of quinine, usually prescribed. Bazire, of Martainville, died from the effects of 900 grains; his wife recovered with difficulty, having taken 300. I have known 60 grain doses repeated thrice within the 24 hours, and an ounce to have been once given in the same course of time. These doses seem to be unnecessarily, wastefully, dangerously large. From 10 to 30 are quite sufficient in any case. In general I prefer to repeat smaller quantities more frequently, as from 5 to 10 grains every hour. I am persuaded that this remarkable drug presents the seemingly incompatible qualities of acting with great rapidity, and of reaching slowly its maximum point of action. Holmes places this at as great a distance as 18 hours. When the patient does not swallow or cannot retain it, we may use a double amount as an enema. Cathartics are considered also as generally applicable by many practitioners; I would except cases in which free diarrhoea and extreme prostration were

prominent. In all others it may be well to employ the mercurial, or, if the patient be feeble, turpentine, so as to procure a derivative and revulsive effect upon the bowels, which may be aided by irritating

enemata.

Counter-irritants should be applied extensively; heat, mustard, and epispastics. The hot bath, when the skin is cold and shrunk, should be followed by assiduous friction with acids, or hot alcoholic spirits.

In the cerebral cases, the lancet has been used sometimes with good effect. Dr. Wootten gives two successful instances. Leeches have been applied to the temples and the mastoid processes with benefit; ice and cold affusion have proved serviceable.

The thoracic variety has proved most indomitable of all. The course most strongly advised is the administration of a quick emetic of mustard and salt; external friction and irritants; stimulant purgatives, such as turpentine, in large doses, by the mouth and enema; the hot bath; laudanum, brandy, and ether. This last article was most depended on in the algid fevers which assailed the French army during their occupation of Rome in 1848-49. If at hand, I would experiment on these desperate cases with electricity and galvanism, nitrous oxide gas and chloroform; both by inhalation, and in free amount, taken internally at the commencement of the attack.

In the abdominal we have far more to hope. I have seen the sulphate of quinine given alone in doses of 8 and 10 grains, in the gastric variety above described, promptly and permanently relieve the patient, changing his whole condition, and arresting his disease within a very few hours. In the diarrhoeal or dysenteric, large doses of opium do good service. Hort succeeded in one such in giving relief with 8 grains in substance. Anodyne enemata are also useful, and the warm bath a good adjuvant.

The necræmial, "algid," "pernicious" forms of malarious fever require the prompt administration of our highest order of stimulants, internally and externally, brandy and ether in no timid quantities; combined, of course, as in all the other varieties, let it be distinctly understood, and as of the most universal application and highest importance, with free doses of quinine, without which all other treatment is nugatory or uncertain.

Convalescence from congestive fever is always slow and vacillating, and should be aided by tonics, of which the infusion and tincture of cinchona, and the preparations of iron, are the best; and by generous diet, change of air, and exercise, carefully adapted to the patient's strength.

COUNTRY FEVER.-This is a title given familiarly in the cities of the South, and especially in frequent use in Charleston, South Carolina, to a modification of bilious or malarious fever, originating in transient exposure to the intensely concentrated malaria of the low country; as by sleeping a night or two upon a rice plantation during the summer and autumnal months. The sudden heats of spring sometimes develop it as early as May; nay, I have known instances originate from special exposure in April. Experience shows that such an

attack is attended with some peculiar hazards, and there has been much speculation as to the obscure cause of such additional malignity being occasioned by a removal during the latent period to a city atmosphere. The difficulty is increased by our knowledge of the fact that a like aggravation of the danger of the endemic remittents of the west, as Flint and others inform us, results upon similar removal to the healthy uplands, from low miasmatic spots, during the same interval of incubation. And I have myself observed, while residing in that most salubrious of all regions, which lies among the mountains of North Carolina, along the valley of the Saliko, that cases, which were developed there, after exposure in the malarious districts, either of the east or west, from Tennessee, Carolina, or Alabama, presented the same peculiar features. The progress of the attack is irregular, and the remissions uncertain, both in time of occurrence and duration, as well as in degree. The type is exceedingly complicated, obscure, and confused. A rapid succession of unexpected or accumulated exacerbations, the herosthesis of the ancients, annoys and distresses, and wears out the patient.

The prognosis in this variety of fever is unfavorable in a large proportion of instances, and the rate of mortality considerable. The strength yields rapidly under the sub-intrant exacerbations so quickly following each other, each more prostrating than its predecessor.

The treatment must be prompt and decided. Our best dependence, from the very commencement, is upon the combination of the mercurial with sulphate of quinine, in efficient doses. Ten grains of each may be given at first, and half the quantity at intervals of two hours, until the bowels are moved, when the calomel may be omitted, persisting with the quinine until quininism has been induced, which must be kept up for 72 hours at least, for fear of a return of the attack; the proclivity to such relapse being very great.

In the meanwhile, determinations to important organs must be met by the active but prudent employment of the revulsive and palliative measures already recited in detail.

To this general history of remittent fever in its several modifications, I will add here a notice of "the MOUNTAIN FEVER of California," as I find it denominated by Dr. Ewing, who describes it in a well-written paper in the St. Louis Medical and Surgical Journal for March, 1855.

"On my way to California," says Dr. E., "I encountered a peculiar form of fever, assuming the remittent type; its locality is the high mountainous regions; I have never known a case occur below the altitude of 7,000 feet above the level of the sea. The first cases that I saw were at or near the South Pass of the Rocky Mountains, and they are met with even in the mines of the mountains." The symptoms were faintness or languor, extreme weariness, a feeling of hunger, as if there was a vacuum in the stomach; the eyes were hot and heavy, with twitching of the cilia and of the muscles of the face;* there was excruciating neuralgic pain throughout the whole body, with deap-seated aching in the extremities and back; a dull headache, and sometimes epistaxis. The pulse was for awhile somewhat fre