On the other hand, there are in the Carolinas, many physicians who almost invariably commenced the treatment with venesection. Dr. Trent, of Richmond, Va., states that he bled in this disease more copiously than he had ever done before. He tells us that he took from many patients, with the happiest effect, from twenty-five to fifty ounces of blood at once, and sometimes repeated the detraction to nearly the same amount. The blood, he says, was always cupped and sizy.

In the cases that have occurred to myself, the lancet has been seldom required or admissible. I have employed it more than once experimentally, in my anxiety to give relief to pulmonic pain and dyspnoea. In some of these instances, a certain degree of advantage seemed, indeed, to have been gained, yet though I proceeded with much caution, and had selected the cases as not only appearing to be well adapted for the trial of this remedy, but as demanding a resort to it, the consequent prostration was in each of them alarmingly great, and difficult for the patient to recover from.

It is true that we have here a very unequal distribution of the circulating fluids the force of morbid vascular determination, too, is thrown upon organs of vital importance. Yet these local determinations are of peculiar character, and must be regarded as congestive rather than inflammatory.

"The fluids," says a northern writer, "are too stagnant to be drained off by venesection." Indeed, this local engorgement, of whatever set of organs, is often so tenaciously obstinate, that it does not seem to be affected, in any degree, by whatever subtraction from the mass of blood, while the general system is promptly depressed, and if great care be not taken, irrecoverably prostrated.

In some instances it has been proposed, on account of the difficulties which embarrass us, "to give cordials and open a vein at the same time." Yet, with all these efforts at obtaining the beneficial influences of bloodletting unalloyed by its injurious tendencies, the general result of the practice is not such as to encourage us to place any dependence upon it.

Of course I must not be understood as offering any objection to the use of the lancet in attacks marked by a predominance of the tokens of obvious inflammatory excitement. I have not a doubt that this was the general character of the epidemic in those localities whose resident physicians report the success of a free and bold resort to the antiphlogistic regimen in its full extent.

I have been much pleased with the effect of the early administration of an emetic, or an emetico-cathartic, where the case is seen at its commencement. A very common formula is the combination of tartarized antimony, or of ipecac, which I prefer, with calomel;-the domestic mixture of sal Epsom dissolved in a strong infusion of seneka or serpentaria with the same emetics, may also be used.

By the double action of these prescriptions we not only cleanse thoroughly the stomach and intestinal canal, a step which experience has shown to be of great importance, but we effect the paramount ob ject of creating a centrifugal tendency of the fluids and determining energetically to the surface. We thus most safely and effectually re

move the local congestions which constitute the most serious and characteristic portions of the disease, and restore the impaired equability of the circulation. This remedy, however, the emetico-cathartic, is obviously unsafe, and must not be trusted to in some of the more exquisite examples of early prostration and extreme muscular weakness. In such cases we resort at once, without previous employment of any means of depletion, to the moderately stimulating diaphoretics, under which head we find our second class of measures, when we have premised the emetic and cathartic. Of these, camphor, nitrous ether, the carbonate and acetate of ammonia are the best, and are made more beneficial by combination with opium, and especially with Dover's powder. The efficacy of all these will be much aided by pediluvium, and by the application of warm fomentations, poultices, and heat in various forms to the surface of the patient. Cataplasms with mustard must be laid over the chest, if pain or dyspnoea are present, and applied to the wrists and insteps. Epispastics are also of use here, by their double power as stimulants and revulsives; the back of the neck, if the head be affected; the sternum and epigastric region, if the lung or heart, or stomach suffer, should be selected for their application. There has been some dispute as to the preference due to the dry or moist form of heat, as the best to be resorted to in this disease. It is, I think, easy to decide. If the skin be dry, I prefer fomentations, or even the vapor bath; if moist, I prefer bottles of hot water, heated bricks, bags of hot salt, chaff, etc. Sweating will, in the greater number of cases, come on readily, but must be regulated. If too profuse, and kept up for too long a time, it may prove injurious and debilitating. We restrain it by substituting dry for moist applications, and removing some of the bedclothes, and changing cautiously the body linen of the patient; dry garments, carefully and well aired, being put on in place of those moistened by the cutaneous discharges.

If the strength seem to fail, our stimulants must be used more freely-the vol. alkali in large doses, from 5 to 10 grains every half hour or hour, with wine whey or brandy toddy; spts. nit. dulc., spts. turpentine, the tincture of cantharides, may be given alternately or in combination. I can set no limit to the administration of this class of remedies, but the excitement of a notable degree of reaction, which, being observed, will guide us in the future quantities to be exhibited; taking care, however, that the patient shall not suffer by their timid or inefficient amount, nor be allowed to retrograde by any sudden subtraction of dose.

Where the pulmonary congestion is intensely great, our task will be difficult. I scarcely know a case in which our ordinary medicines produce less effect-the lancet is inert. Fomentations and poultices, made irritating by mustard, must be applied assiduously about the chest. It will perhaps be advisable to resort to the spts. terebinth. in large doses, or to depend upon the free exhibition of camphor in sub

stance.

In the form of pneumonia typhoides, which so closely resembles the bilious pleurisy of the South, when the symptoms of gastric distress are combined and prominent, a mercurial cathartic should be first

prescribed, and the bowels kept afterwards moved for some time with a solution of sal Epsom in the infusion of seneka or serpentaria, as revulsive and sudorific. If the retching and vomiting are troublesome, and refuse to be controlled by the effervescing draught, lime-water, and mustard poultices to the epigastrium, I would advise opium, in small doses, and a blister to the scrobiculus cordis.

The mercurial treatment has been highly recommended by many writers, and among others in the very able Report of the Committee of the Massachusetts Medical Society, in 1810-11. If ever applicable, it must be under such conditions as we are now considering. Stokes speaks very favorably of it in his account of the Dublin epidemic; and I have seen it prove admirably beneficial. Many of the treatises upon this strange disease are filled with eulogies of opium; a remedy which seems to have been applicable at almost every stage, in every modification, and in every locality where it prevailed. Its full and free use has, in my own hands, been so universally required, and productive of so much relief and comfort to the suffering sick, as constantly to recall to my memory with sincere acquiescence in their propriety, the forcible expressions of the older writers concerning it, where they styled it, "divinum remedium! magnum Dei donum!” There is, indeed, no substitute for it; no second to it in the materia medica. It alleviates the oppressive dyspnoea so often present, promotes the expectoration of the thick, ropy mucus effused in the lungs, diminishes the anxiety and dejection of mind which harass the patient, often restores reason to the delirious, determines to the surface, gives new vigor to the circulation, and re-excites the nervous energy. It alone possesses the power to control the troublesome retching and vomiting sometimes present: to calm the incessant and insupportable restlessness of the sufferer, and procure for him a tranquil and quiet slumber, that most delightful solace of the sick and afflicted.

It was, as we are told, the only means found to be of any efficacy in the lethargic and other anomalous and malignant cases formerly described; and the doses which are affirmed to have been exhibited with advantage in such attacks, are prodigiously large. It is stated in the Massachusetts Medical Journal (vol. ii. p. 149), that from fifty to one hundred drops of the tinct. opii have been given every half-hour with success. In one case mentioned there, a scruple of solid opium was taken in the course of three hours; in another, forty-two grains in forty-eight hours. When deglutition was impracticable, the best results have followed its free exhibition in enemata.

In my own practice, these enormous amounts have never been required; I have obtained the most unequivocal benefit from the medi cine in the usual doses, freely but cautiously adapted, and repeated with a frequency proportioned to the exigencies of the case.

I have met, happily, with no example of the terrible modification affecting the throat with malignant inflammation, and termed "anginose." In these, it is advised to apply a blister to the front of the neck, which must be kept open and discharging. Besides this, and in addition to the other stimulants and diaphoretics above recom

mended, I should be disposed to employ, as in cynanche maligna, the infus. capsici, in free quantities, as a drink, and use it abundantly to wash the throat.

It is well to be reminded, that in this strange disease, it is never permitted to despair of our patient, recoveries being in considerable number recorded, from circumstances the most deplorable, and in deed, to all reasonable anticipation, absolutely hopeless. The convalescence is so slow, difficult, and irregular, as often to require unremitting continuance of our care and attention. We must subtract gradually from the amount of stimulants which have been given him, and substitute, in their stead, the more permanent tonics. Of these, each practitioner has his favorite. Arsenic is preferred by many of the New England physicians, and is, without doubt, highly serviceable. The muriate of iron is also spoken of as well adapted. I am in the habit of trusting rather to cinchona, combining it in infusion with serpentaria, to which I add a small proportion of carb. potass. and tinct. opii camphor.

The convalescent should wear flannel next his skin for some time. His clothing should be carefully adapted to the season, and he should avoid, with especial prudence, all exposure to moisture, and to sudden alternations of temperature.

SYMPTOMATIC FEVERS.

Having gone through, in sufficient detail, the consideration of the idiopathic fevers, properly so called, I proceed to make a few observations upon those which deserve, by way of distinction, to be regarded as symptomatic or consecutive. I enter upon this topic, which will not occupy us long, the more willingly, on account of the opportunity afforded us of marking the obvious differences which so widely separate the two classes. We will thus be satisfied, I think, better than by the most labored argument, of the practical absurdity of confounding these two modes of febrile disorder; the one obviously connected with local injury, derangement, or irritation, of whose existence, and the influence exerted by it, in the production of the constitutional disturbance, and their necessary mutual connection and dependence, there are the most clear, and pointed, and unequivocal proofs; the other, inferred to be similarly connected with, and dependent upon a like irritation or derangement, whose seat and nature are both matters of obscure conjecture; and this inference merely founded upon a doubtful and disputed analogy.

Symptomatic fevers may be divided into the continued and intermittent; none of them assuming, so far as I know, a fairly remittent type. They may arise from causes, both external and internal. They may, in both forms, be connected with the same local excitement; and in such cases, the continued will be found to precede the intermittent; the former being connected with recent injuries and acute inflammations, the latter taking its origin in chronic and subacute phlegmasiæ, and organic affections doubtfully classed among the

phlegmasiæ, and supervening upon old ill-cured external wounds and injuries. The former is hence frequently denominated inflammatory fever; the latter is better known as hectic fever-the fever exquisitely of irritation.

With Inflammatory symptomatic fever we are familiar, as following within a short period wounds of the soft parts, fractures of bones, injuries of the head, violence done to a joint. Whether or no there is any pathological circumstance wanting, as some have been disposed to contend, which should induce us to withhold the title of fever from the disturbance of the system in instances of this kind, is not as yet perhaps absolutely decided. We have here, however, beyond dispute, all the common phenomena which go to constitute the ordinary definition of fever. The hot, dry skin, flushed and turgid face, suffused and red eye, anxious countenance, tongue red and coated with fur, stomach uneasy and irritable, great thirst, headache, languor, muscular debility and weariness, with occasional delirium, and a pulse frequent and tense and abrupt, form a picture which cannot fail to be at once recognized. Here the exclusive humoral system is inapplicable, and Stevens's views as to the morbid condition of the circulating fluids seem out of place. What proof have we of any incipient change in the blood? Nothing of the kind is even pretended. This is the history, too, as well of the febrile affections connected with internal inflammation, as with external injury. It is a description not only of the consequences of a severe wound, but of the state of the general system in pleurisy, rheumatism, and sorethroat. It may in both become of paramount consequence, and perhaps deserve to be regarded as even more important than the local affection. Yet its nature will be modified to a certain extent by the seat of the local excitement, and by the circumstances in which the subject is placed. In gastritis proper, for instance, and enteritis, we have a low and weak febrile condition, the pulse being small and feeble, and the nervous system prostrated; in phrenitis and rheumatism, on the other hand, the pulse is full and bounding, and the strength less impaired. In erysipelas we have either a synochal or typhous fever, to use the phrase of Cullen, according as the eruption occurs in a robust or invalid constitution, and in the country or in a crowded hospital. It would be altogether superfluous to discuss here the progress and treatment of this form of symptomatic fever. We shall have to speak separately of its numerous modifications, in detail, as we proceed through the long catalogue of maladies, of whose history it constitutes an essential part, whence the appellation, pyrectic; and we shall then lay down such rules for its control or management, as shall seem demanded in each particular instance.

HECTIC FEVER.

Some notice may, however, be taken here, without impropriety, in a general way, of hectic, or the intermittent symptomatic fever. It is not