sionally, when the heat is great, and the pain severe, cold water may be poured from a moderate height upon the head, held over a basin. At the same time, hot and stimulating pediluvia may be employed as revulsives. For the irritability of the stomach, the best remedies are those already mentioned; viz., the effervescing draught, cold carbonic acid water, or small portions of ice. Small doses of one of the salts of morphia are sometimes useful, in connexion with the draught, or with other medicines. When pressure over the stomach occasions much pain, leeches may be applied to the epigastrium, followed by warm fomentations or emollient cataplasms, unless the weight of these should render them too uncomfortable to the patient. Sinapisms are sometimes useful in the early stage.

When the fever begins to decline, and the second stage commences, febrifuge and depleting remedies must be abandoned, and, unless symptoms of convalescence are obvious, without suspending the mercurial treatment, measures should be employed for counteracting the inflammation of stomach, and supporting the strength of the patient. For the former purpose, I know nothing better than the acetate of lead, as recommended by the late Dr. Irvine, of Charleston, S. C. (Eclectic Repertory, x. 519.) This remedy is not appropriate to the febrile stage, nor was it employed in that stage by Dr. Irvine. The period for beginning with its use is when the heat of skin and frequency of pulse abate; while a yellow hue begins to show itself in the conjunctiva or face, and tenderness in the epigastrium indicates continued or increasing inflammation of the stomach. One or two grains should be given every hour or two, and the remedy continued until from thirty to forty grains have been taken. I have employed it in some bad cases, with the happiest results. In one of them, the matter ejected from the stomach had begun to assume the flaky character of black vomit; and yet the patient recovered. I confess, however, that my experience with it has not been sufficiently ample to justify a positive recommendation, upon that ground alone. We employ the remedy, with great advantage, as a local application to mucous inflammation, as in that of the rectum and urethra, when not attended with high vascular excitement; and this is the exact condition presented by the gastric mucous membrane, in the second stage of yellow fever. Besides, the astringent properties of the preparation may render it useful in preventing the black vomit, which is now admitted to be a sort of hemorrhage.

But the case should not be trusted to this remedy alone. The epigastrium should be covered by a large blister, and the same application may be made to the extremities, in order to support the system, and to direct excitement to the surface. Powdered acetate of morphia sprinkled upon the blistered surface, over the pit of the stomach, will sometimes be useful in allaying gastric irritability. The strength must be sustained by mild nutriment. The farinaceous drinks and weak animal broths, or a little milk and water, may be employed for this purpose. Advantage may sometimes accrue from the use of lime-water and milk, in the quantity of a tablespoonful of each every hour.

Should the system show signs of sinking, it will be necessary to employ tonics and stimulants, with a nutritious diet. Sulphate of quinia or the compound infusion of Peruvian bark, the mineral acids, capsicum, oil of turpentine, wine-whey, carbonate of ammonia, wine, brandy, egg-nog, milk-punch, strong animal broths or essences, are the chief means to be used; and from these selections and combinations must be made in accordance with the degree of prostration. None of them are specific. All that they can do is to support the strength of the system, until the disease shall spontaneously terminate. It is possible that the capsicum and oil of turpentine may be useful as alteratives to the mucous membrane of the stomach. Should any one of

these remedies occasion burning pain in the epigastrium, it must be omitted. Opium should be freely used, and may be combined with any one of them. The oil of turpentine with laudanum, or one of the salts of morphia, is a combination sometimes especially useful. Of the oil from twenty drops to half a fluidrachm may be given at once, suspended in water by means of gum arabic, and repeated every hour. Stimulating frictions should also be used in very prostrate cases. Should hemorrhage from the stomach or bowels occur, it may be met with acetate of lead, nitrate of silver, kino, and pure tannic acid, severally or in combination; and opium should be added to whichever of these remedies may be employed.

In the secondary fever, the treatment must be conducted upon general principles applicable to all febrile diseases; reference being always had to the strength of the system.

In cases of a low form at the beginning, where reaction is deficient or altogether wanting, it will be necessary to use the means which are recommended in the last stages of ordinary cases. External stimulation by means of the hot bath and powerful rubefacients, tonics and stimulants by the stomach, and stimulating enemata of oil of turpentine, brandy, laudanum, &c., must be employed. I should generally prefer for internal use, in such cases, the oil of turpentine and sulphate of quinia. The latter remedy may be given in large doses, as much even as from five to ten grains every two or three hours, until some effect may appear to have been produced. Cases of this kind, however, too frequently bid defiance to medicine.

In New Orleans, the practice of giving large doses of quinia, very early in the disease, is asserted by some to have been attended with great success. According to Dr. Fenner, it was first introduced in the epidemic of 1841 by assistant surgeon Charles McCormick and Dr. A. J. Wedderburn; and has been since extensively employed. From fifteen to thirty grains of sulphate of quinia are given at once, sometimes uncombined, sometimes in connexion with opium or a mercurial cathartic or both, and with various accessory treatment, according to the particular views of the practitioner. Sometimes the quinia is repeated, in the same or smaller doses. The febrile action is said to subside very speedily, and the patient frequently to enter almost immediately into convalescence; but, in other instances, though the primary fever may be apparently cut short, and the secondary fever prevented, yet the disease marches steadily onward to black vomit and a fatal issue, as in violent cases treated in the ordinary mode. (N. O. Med. & Surg. Journ., v. 208.) In the comparatively mild epidemic of 1847, the quinia practice was found so satisfactory as to have been very extensively adopted in New Orleans; but in the very severe one of 1853 it was less successful; and the late Dr. Hester, editor of the N. O. Med. & Surg. Journ., stated in the last number of that journal put forth under his supervision (vol. x. p. 404), that it had not proved satisfactory to those who employed it in the latter epidemic. In the preceding number (x. 279), he made the following statement. "In the commencement of the present epidemic, the advocates of large doses of quinia soon found that this article when given in sedative doses, failed to accomplish a cure, although the febrile symptoms gradually gave way to its use."

Dr. H. R. Frost, of Charleston, S. C., has found the chlorate of potassa an excellent remedy in the febrile stage of the disease. After having freely evacuated the bowels, he gives the chlorate in the quantity of three or four drachms in divided doses during the twenty-four hours, employing at the the same time, when necessary, leeches to the temples, and iced-water to the head. (Charleston Med. Journ. and Rev., viii. 182.)

Throughout the treatment, especial attention should be paid to the thorough ventilation of the apartment, and to the preservation of personal clean

liness by a frequent change of linen, and of the bedclothes. All excrementitious matter should be immediately removed.

It is proper to state, before leaving the subject of the treatment of yellow fever, that some practitioners, especially in the French West Indies, have been in the habit of relying upon the mildest measures; trusting rather to the resources of the system, aided by the removal of noxious influences, than to any strong remedial impressions. In the first stage, demulcent beverages, chicken water with a little nitre, or other weak ptisans, perhaps a small bleeding when the excitement is great, a little magnesia now and then, fomentations or poultices to the abdomen, or a few leeches to the epigastrium, and the warm bath; in the latter stages, preparations of bark, mineral acids, camphor injections, &c., constitute the routine of the treatment; and it has been asserted that the success of the plan is little if at all short of that of the more energetic methods usually employed.

The prevention of the disease is even more important than its treatment. In relation to individuals, when circumstances prevent their leaving the place in which the disease prevails, they should select a residence in the highest and healthiest spots; should sleep preferably in the highest part of the house; should avoid the night air; should abstain from fatiguing exercise, exposure to alternations of temperature, and excesses of all kinds; should endeavour to maintain a cheerful and confident temper; should use a nutritious and wholesome but not stimulating diet; and, if compelled to enter any spot in which the atmosphere is known to be infected, should take care not to do so when the stomach is empty, or the body exhausted by perspiration or fatigue. Attempts to guard against the disease by low diet, bleeding and purging, or the use of mercury, are futile, and even worse than futile. The feebler the system, the less is it able to resist the entrance of the poison, or its influence when absorbed.

The public also have important duties in this complaint. Letting alone the vexed question of quarantine, we may insist on the necessity of establishing hospitals in healthy situations, of removing as far as possible all sources of noxious effluvia, of correcting such effluvia where known to exist by fumigations with chlorine, and finally, in our northern cities, where the limits of the infected neighbourhoods are often well defined, of removing the inhabitants from within these limits, and excluding the entrance of others by the temporary erection of fences across the streets or avenues. In places where the residents have become exempt from the disease by habitual exposure to the cause, it will be sufficient to remove and exclude strangers and children from the infected districts.

Article IV.

ENTERIC FEVER.

Syn-Typhoid Fever.-Typhus mitior.-Nervous Fever.-Abdominal Typhus.-Common Continued Fever.-Entero-mesenteric Fever.-Dothinenteritis.-Follicular Enteritis.

This is a common febrile affection, presenting a considerable diversity of symptoms, yet having in general a certain recognizable character, and probably constituting, in all its forms, one and the same disease. It is the ordinary endemic fever of Europe, and of those portions of the United States in which the miasmatic or bilious fevers do not prevail, and is more or less mingled with the latter within their own special limits. Indeed, the probability is that it belongs to the whole human family, and is to be found in all

inhabited regions. Though long known in its different forms, its identity in these forms was not clearly perceived until after the researches of Louis, which, by determining its anatomical, in connexion with its exterior character, gave us the means of recognizing it under every variety of aspect.

The nomenclature of this disease is unsettled and perplexing. By some writers it is denominated continued or common continued fever; but this term is not sufficiently distinctive; as other fevers, equally common in many situations, are equally continued; and, in fact, English authors generally confound under the title two affections, which are probably quite distinct; namely, the disease under consideration and proper typhus fever. The name of typhoid fever, applied to the disease by Louis, and now much in use, is, I think, still more unfortunate. Independently of the fact, that the complaint is not essentially typhoid, and that it very often runs its whole course without any symptom analogous to those which characterize typhus fever, there is the strong objection, that any other febrile affection may equally assume the typhoid form; so that a mere epithet, applicable to a common condition of disease, is thus appropriated to a distinct complaint, and must inevitably lead to frequent misconceptions. Bilious fever, yellow fever, the plague, the 'different exanthematous fevers, and all the phlegmasiæ may become typhoid, as well, though not, it is true, as frequently as the one in question. It is highly desirable, therefore, that the name should be abandoned, though there is reason to apprehend that it has already taken root too deeply to be easily eradicated. There can be no doubt that the affection, denominated typhus mitior by the older writers, was very often that which we are now considering; but the name is objectionable, as implying only a difference in degree between this and true malignant typhus. Nervous fever is less inappropriate than either of the preceding titles; as the disease is pre-eminently marked by nervous disorder, and the cases to which the name has been applied have probably in general belonged to it. But almost all fevers, indeed we may say without qualification, all fevers are attended with some degree of nervous disorder; for this enters into the very definition of the term fever; and the title, therefore, is not sufficiently distinctive. Dothinenteritis (from 800, pustule, and Tepov, intestine) was a name conferred on the complaint by Bretonneau, and was intended to express the eruptive character of the intestinal affection which distinguishes it. Follicular enteritis had the same origin. Both are objectionable upon the score, that they consider as essentially the disease what is a mere attendant, though a very common one. I propose the title of Enteric fever with some diffidence. It has the same basis as the Entero-mesenteric fever of M. Petit, but has the advantage over it of greater simplicity. It is merely intended to express the fact, that this fever is distinguished from all other idiopathic fevers by the frequency and extent of intestinal disease. Other fevers are attended occasionally with disease of the bowels; this almost always, if not essentially. The intestinal affection is as characteristic of this disease as the eruption is of smallpox.

Symptoms, Course, &c.-The disease sometimes begins abruptly by a chill, followed by the usual symptoms of fever; but, as it occurs in this country, it more frequently comes on insidiously, and increases gradually, so that it is often impossible to fix the precise point of commencement. The patient is uncomfortable, and complains, perhaps, of weariness, general uneasiness, soreness or numbness of the limbs, and often of a little headache; the skin is somewhat heated, the face flushed, and the pulse accelerated; the tongue, if examined, is found to be very slightly coated with a thin whitish fur; the appetite is impaired though not quite extinguished; and these symptoms continue, with a slowly increasing intensity, but with a tendency to daily remis

sion, for several days, sometimes even for a week, before the patient feels himself sufficiently ill to take to his bed. Frequently, during this period, slight chilliness alternates with febrile sensations; though it sometimes happens that the patient complains of no chill whatever, and distinct rigors or shivering are rare. When the disease is completely formed, the chilliness ceases, and does not return, unless, perhaps, at the commencement of some incidental inflammation. There is also not unfrequently, during this inchoative stage, some looseness of bowels, amounting often to diarrhoea; and, when this is not the case, there is generally an extraordinary susceptibility to the action of cathartic medicine, which operates in much smaller doses than usual, or, if given in the full dose, produces more than the usual effect.

The disease, being now fairly under way, exhibits the ordinary phenomena of fever; such as frequency of pulse, heat and dryness of skin, flushed face, pains in the head, complete loss of appetite, thirst, and great general weakness. But the symptoms are also somewhat peculiar. The pulse, though sometimes but moderately accelerated, not exceeding 90 or 100 in the minute, and of considerable fulness and strength, is in other instances, and especially in females, very frequent, small, and compressible, often amounting to from 110 to 120 or more. The flush in the face is of a somewhat more purple tint than in most other cases of fever; and, when it is absent, there is not unfrequently a dusky hue of the complexion, with a certain heaviness or dulness of expression, which may be very slight in some cases, but is very striking in others. Headache, in some degree, is very seldom absent; and not unfrequently it is the chief subject of complaint. The patient also often experiences pains in the back or limbs, and sometimes has a feeling of universal soreness, as if bruised, or greatly fatigued. Sometimes there is much restlessness, with want of sleep. A characteristic symptom is, in many instances, the occurrence of bleeding at the nose, which, however, is generally slight, and no otherwise important than as a sign. In very many cases, a tendency is observed in the febrile symptoms to remission, sometimes daily, sometimes twice a day; and occasionally the exacerbations subside with slight perspiration; though this is much less frequent and more sparing in enteric, than in bilious or miasmatic fevers.

These symptoms continue with little other change than a gradual increase, for several days. The pulse becomes more frequent and less strong; the. skin acquires a heat and aridity which are often described as acrid or pungent; the obtuseness of countenance and duskiness of complexion deepen; the tongue remains slightly covered, or coats itself with a thicker fur, in either case showing a tendency to dryness or clamminess, and often appearing red at the tip and borders; the stomach, though often retentive, is sometimes irritable; diarrhoea is not unfrequent; transient pains are often felt in the abdomen, increased by pressure, especially in the right iliac region; and a slight degree of tympanitic distension in the bowels is discovered upon percussion, with a gurgling sound upon pressure by the hand. A cough frequently sets in, either dry, or accompanied with a slight mucous expectoration; and the physical signs of bronchitis are detected by the stethoscope. The urine is sometimes little changed, sometimes scanty, high-coloured, and offensive. Such is the course of the disease, until about the seventh or ninth day from the time of complete formation.

Other symptoms are now superadded. The tongue, previously moist or clammy, often becomes quite dry, and assumes a brownish colour. Deglutition is sometimes painful or difficult. The abdomen is obviously distended, so as frequently to present a convex outline from the ensiform cartilage to the pubes, when the patient is on his back, and upon percussion, sounds hollow or tympa