attention to regimen, to effect a cure. In the choice of the cathartic, the physician should be guided by circumstances. If he find nothing but febrile excitement, with or without a little redness of the fauces, he should prescribe sulphate of magnesia, or a combination of this with infusion of senna. Should symptoms of acid in the stomach be conjoined with the others, magnesia may be added to the saline cathartic. Should sallowness of the skin, yellowness of the tongue, or want of colour in the evacuations from the bowels, with oppression about the epigastrium, indicate hepatic congestion, and deficiency of hepatic secretion, the indication would be offered for some cathartic combination containing calomel; as three or four of the compound cathartic pills, a dose of calomel and jalap, or of calomel and compound extract of colocynth. The neutral mixture or effervescing draught, with or without small doses of tartar emetic, is usually the best diaphoretic, when the skin is hot and dry, and the pulse excited. Sometimes, however, when the action is of a feeble typhus-like character, or when a good deal of general soreness, as occasionally happens, is associated with the fever, ten grains of the pow der of ipecacuanha and opium, given at bedtime, will prove highly useful. Should the fever continue, the bowels ought to be kept regularly open by the saline cathartics, and the diaphoretics above mentioned given in the interval. Rest should be enjoined, all causes of excitement avoided, the diet should be exclusively vegetable, and no stimulating drinks whatever allowed.

Should inflammation in any important organ be developed, sufficient to affect the system, the case must be treated exactly as an ordinary phlegmasia of that organ.

In the infantile cases, especially in the infantile remittent, some modification of the treatment is requisite. Some recommend an emetic at the commencement of the disease. This may be useful when the stomach is loaded with undigested food; but, as a general rule, is not advisable. Perhaps the most effectual remedy in the early stage is a full purgative dose of calomel. This cathartic appears to exercise a peculiar influence over the disease. It is certainly more efficient than other medicines belonging to the same class, which operate on the bowels no less powerfully. I have often seen the disease yield immediately to a full dose of calomel, after having been ineffectually treated with magnesia, castor oil, salts, &c. For more than thirty years, I have habitually used this medicine in the irritative fever of children, have never seen it do harm, and have very frequently found it to put an immediate end to the disease. I believe that, if given early, it will generally produce this effect, and thus prevent the protraction of the fever in the remittent form. How it operates is a matter of conjecture. Perhaps it may do good by its powerful influence upon the liver, promoting a free secretion of bile, and unloading the portal circulation. Perhaps it may have a peculiar alterative effect. But the fact of its utility rests not upon theory, but experience. In order to avoid the sore mouth which, in some fever cases of children, it is liable to produce when long retained in the bowels, care should always be taken to administer some other cathartic, if it fail to operate freely in six or eight hours. From two to six grains of calomel, according to the age of the patient, three or four grains being the proper dose for a child during the third and fourth year, may be given in syrup or molasses, and followed, if necessary, in the time above mentioned, by a dose of castor oil or sulphate of magnesia. Should the bowels not be well evacuated in this way, the operation of the cathartic should be promoted by enemata. In cases of obstinate constipation, moderate doses of infusion of senna, with manna, fennel seed, and sulphate of magnesia, repeated at intervals of two hours, will be found very effectual. After the bowels have been freely opened, should the fever continue, it may be treated

with the neutral mixture, repeated every hour or two, in the dose of one or two fluidrachms, or, if the stomach be irritable, by a dose of the effervescing draught at the same interval. Along with the neutral mixture, when there is no sickness of stomach, small doses of antimonial wine, or of tartar emetic in aqueous solution may be used, the quantity being so regulated as not to induce vomiting or severe nausea. The spirit of nitric ether is also an admirable adjuvant, when there is much starting or twitching of the tendons. The warin bath is useful under similar circumstances. This treatment is especially applicable to the febrile paroxysm; but it may also be employed, with smaller doses, or longer intervals between them, during the remission. Should convulsions have occurred or be threatened, in addition to the sweet spirit of nitre and the warm bath, as above recommended, poultices made with bruised garlic and flaxseed meal or bread and milk should be applied around the feet, and the back should be bathed, along the spine, with brandy heated with garlic. It may sometimes be proper to take blood from the arm, or by leeches from the temples, and to make cold applications to the head; but these are by no means necessary in all cases. The practitioner must be influenced by the degree of arterial action, and the evidences of sanguineous determination to the head. Convulsions in children are often the result of mere nervous disturbance, and do not require the lancet. When, however, they continue beyond a few minutes, or show a disposition to return, especially if there be no reason to suspect spasm in the intestines, it will be safest to take blood.

Throughout the disease, the bowels should be kept daily opened. Magnesia, alone, or combined with one of the saline cathartics, as sulphate of magnesia, tartrate of potassa and soda, or phosphate of soda, will often be useful, not only as a laxative, but also as an antacid. Should the patient be feeble, it may be given with rhubarb. Sometimes it may be proper to repeat the calomel, though in smaller doses than at first. It would be especially indicated by whiteness or blackness of the stools. Under the same circumstances, if the alimentary canal should be delicate, blue mass may be substituted for the calomel.

When the breath is sour, small doses of bicarbonate of soda or bicarbonate of potassa should be given, from four to six times a day, dissolved in water or carbonic acid water. The latter salt should be preferred when the urine is very scanty, in consequence of the diuretic properties of the saline compounds of potassa.

Should the abdomen be painful or tender, it should be covered with an emollient cataplasm; and sometimes leeches and blistering may be necessary. In cases accompanied with vomiting, teaspoonful doses of lime-water and milk, mixed in equal quantities, and given every hour, are often very serviceable. In the same cases, aromatic poultices, or weak sinapisms should be applied over the stomach; and it may become necessary to give an anodyne enema. There is usually so much aversion to food that it is difficult to induce the child to take nourishment of any kind. This is an indication of nature which should not be slighted. In the early stages, very little food is required, and that of the lightest character. Solution of gum arabic, in the proportion of an ounce to a pint, is generally sufficiently nutritive for the first day or two, while the fever is high; and it has the advantage that, having little taste, the child will take it freely for drink, especially if it be made cold with a little ice. Barley, arrow-root, tapioca, sago, &c., may be given in the liquid form, when something rather more nutritious is required; and rennet whey is a good article of diet under similar circumstances. Milk and water, together with farinaceous substances, may be employed in small quan

tities as the disease advances, and at last, it may become necessary to support the strength by animal broth or jellies. Care, however, should always be taken to give nothing that can irritate the stomach or bowels. Cold water should be given frequently throughout the fever, and nothing is more grateful to the patient.

During convalescence, the bowels, if disposed to constipation, should be kept open by the mildest laxatives, or by enemata; and the greatest caution should be observed, in relation to the diet, not to allow indigestible articles of food, nor to permit too great an indulgence of the now sharpened appetite. On the other hand, if the patient is left feeble and without desire for food, and especially if he sweat copiously at night, it may be proper to administer the mineral acids, or simple bitters.

Article II.

MIASMATIC FEVER.

Under this name are included all the forms of fever resulting from the influence of marsh miasmata. For an account of the nature of this agent, as far as known, the circumstances of its production, the situations in which its effects are experienced, and the manner in which it operates, the reader is referred to the dissertation on the causes of disease in general. (See page 153.)

Of the different cases of fever which originate in this cause, some are intermittent, some remittent, and some so little variable in their course that they might, with as much propriety as almost any other instances of febrile disease, be considered as continued. But it is not in type or form only that these fevers differ. Some are characterized by a sthenic or vigorous grade of action, such as is usually denominated inflammatory; others have a low or typhoid tendency, especially towards their close; and others again are from the commencement decidedly adynamic, asthenic, or malignant. In the last section are included the cases now frequently denominated congestive. But all these varieties are essentially the same disease, modified by the degree of intensity in the cause, by the peculiar susceptibilities of the patient, or by some previous or coexisting morbid influence. They are in fact as much one disease as are the different varieties of smallpox, measles, or scarlet fever.

They exhibit this identity of nature, in the first place, by their interchangeable character. The intermittent, for example, sometimes becomes remittent, the remittent often ends in the intermittent, and those cases which may be considered as continued always, if of sufficient duration, exhibit a tendency to remit, and in the end sometimes to intermit. Indeed, the paroxysmal form appears to lie at the foundation of all of them; and, though it may sometimes be concealed by superadded phenomena, generally becomes evident upon a careful examination. Even the different grades show a disposition to run into one another. The inflammatory may become typhoid; and the lowest and most malignant cases often leave behind them a tendency, which, after the system has regained its energies, exhibits itself in the production of an intermittent or remittent of the ordinary kind. Again, in all the forms of miasmatic fever, there is a disposition to affect especially particular organs, as the spleen, liver, and stomach. All of them, moreover, occur at the same season, in the same situations, and even in the same family; one individual being affected, perhaps, with one form, a second with another form, and a third with still another. Thus, in the same family, there may be, in the

same season, a case of ordinary intermittent, one of remittent, and one of malignant or congestive fever.

I shall treat of them under the divisions of 1. intermittent fever; 2. remittent fever, and 3. pernicious, malignant, or congestive fever, which may be either intermittent or remittent. As the cases which might deserve to be called continued exhibit, as before stated, during their course, if sufficiently protracted, a tendency to the remittent form, they may without impropriety be ranked in the second section. It will be understood that I do not include yellow fever among the miasmatic fevers. If resulting from a miasm at all, this disease is certainly not one of the effects of the ordinary marsh miasms. All the varieties of miasmatic fever occur most frequently, and, as original affections, almost exclusively, in the latter part of the summer and in autumn. When they appear in the winter or spring, it is generally as returns of former attacks. Still, there are occasional cases of bilious fever, in its different forms, occurring in the latter seasons, without previous disease. In these, the tendency may be supposed to have lurked in the system, derived from exposure to the miasm during summer or autumn, and to become evident upon the application of some exciting cause; though it is not impossible that, in spring or early in summer, the heat may sometimes be sufficiently great, and sufficiently protracted, to cause the evolution of miasmata in a dilute, and comparatively inefficient form.

INTERMITTENT FEVER.
Syn.-Fever and Ague.

This disease is characterized by febrile paroxysms, recurring at stated times, and by the absence of fever between the paroxysms. The intervening period, from the end of one paroxysm to the commencement of the next, is called the intermission or apyrexia; the whole period occupied by one paroxysm, and the succeeding intermission, is called the interval.

The type of the fever has reference to the length of the interval. There are three ordinary types; the quotidian, tertian, and quartan. In the quotidian, the paroxysm recurs every day, with an interval of about twenty-four hours; in the tertian, every other day, with an interval of forty-eight hours; and in the quartan, every third day, with an interval of seventy-two hours. The inventors of the two latter names considered the two nearest paroxysmal days with the intervening day or days, as constituting one period, and thus counted every paroxysmal day twice in the succession. Other types are mentioned by authors; such as the quintan, sextan, septan, and octan, the last occurring at intervals of a week; but they are all very rare; and there are probably few physicians who have seen any one of them.

The regular types above mentioned are liable to numerous diversities. The quotidian is sometimes double, having two paroxysms every day. There is a double tertian, with a daily paroxysm, but occurring at different periods, or with different characters, on successive days; the paroxysms of alternate days exactly corresponding with each other. Thus, on the first and third day, the paroxysms may take place in the morning, and correspond with each other in grade and character; while on the second and fourth day, they shall occur in the afternoon, and in like manner correspond with each other, but differ from those of the two other days. It thus appears that two tertians are going on at the same time, but at different periods of the twenty-four hours. Sometimes there are two paroxysms in one day, and none in the next. This variety is distinguished by the name of duplicated or doubled tertian. The triple tertian

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has two paroxysms every other day, and one in the intervening day; that is, three instead of one in forty-eight hours. The double quartan is the variety in which, out of three days, two have each one paroxysm and the other none; the triple quartan, that in which there is a paroxysm every day, but the three successive paroxysms differ from each other, while they correspond respectively with the three which follow. Other varieties are mentioned by writers, as the tripled and quadruple tertian, the doubled and tripled quartan, &c. &c.; but these distinctions are mere refinements, of no practical value, and exceedingly rare in nature, if, indeed, they have any other foundation than in the imagination of observers. Of all the varieties above enumerated, the double tertian is the only one which often occurs. It is said that cases have been noticed, in which the paroxysms are altogether irregular. These are distin guished by the title of erratic intermittents.

SYMPTOMS.-Each paroxysm of an intermittent, when quite regular and fully formed, consists of three stages; viz., the cold, the hot, and the sweating stage, which usually succeed each other in the order mentioned. Very often, the paroxysm is preceded by the ordinary preliminary symptoms of fever, such as feelings of languor or weariness, general uneasiness, stretching, yawning, &c. (see page 87); and occasionally these feelings, with perhaps some pain in the head and back, impaired appetite, and a scarcely observable degree of febrile excitement, constitute the whole apparent disease for several successive paroxysms. A person is seized with the above symptoms, or something like them, which after a few hours pass off, almost without notice, and are perhaps quite forgotten, until upon their recurrence the next day, or the day after, or upon a third occasion at the same interval, and each time with increased severity, the patient is reminded of the preceding attacks, and finds himself, or is informed by his physician that he is labouring under intermittent fever. Attention to these imperfectly formed preliminary parox ysms is important; as the disease may be arrested by the adoption of proper measures at this early stage, and much subsequent inconvenience and discomfort spared the patient. Sometimes, however, the first regular paroxysm seizes the patient in the midst of apparently good health, and without warning.

Cold Stage. After some yawning, stretching, &c., the patient experiences sensations of chilliness, especially in the limbs. These increase, and gradually spread over the whole body, becoming often severe and distressing. Not unfrequently, the chilliness seems to run in longitudinal lines, as if little streamlets of ice cold water were trickling down the trunk. Along with this, the patient experiences shivering or trembling; rapid and successive shudders run through the frame; the teeth often chatter, sometimes loudly; and the bedstead is occasionally shaken with the violence of the involuntary movements. These tremors, in connexion with the sensation of cold, are technically denominated rigors. The body often feels cold to an observer, especially the hands, feet, nose, ears, and cheek; but this is by no means uniformly the case. Sometimes the surface is hotter than in health, even when the patient experiences a feeling of severe cold.

In connexion with the sensation of coldness, the surface is pale and contracted, and not unfrequently presents the rough appearance known under the name of goose-flesh, which is owing to the projection of the sebaceous and capillary follicles, while the proper tissue of the skin shrinks. From the same cause, the hair sometimes bristles, as in fright. The hands are shrunken, the features contracted, the countenance pale, and the lips and ends of the fingers often purplish, or somewhat livid.

Though the tongue is pale and moist, there is often thirst; all disposition for food is lost; and occasionally nausea, and vomiting of food, mucus, or