8 Tertianus triplex. Triple tertian. y Tertianus impar. Double unequal tertian. of the other; and the mission. 8 Tertianus duplicatus. A single tertian with two Duplicate tertian. • Quartanus duplex. Double quartan. (Quartanus triplex. Triple quartan. Quartanus duplicatus. Quartanus triplicatus. alone. type, it is often serviceable to the general health, and carries off many disorders of other kinds Dr. Fordyce affirms (On Fever, Diss. ii., p. 16), that he has seen it of considerable use in curing or alleviating chronic rheumatism, habitual indigestion, cutaneous eruptions, protracted inflammations, epilepsies, and hysteria. And his assertion is corroborated by other authorities.(Salmuth, cent. ii., obs. 14; Ephem. Nat. Cur., dec. iii., ann. iii., obs. 30.) It is to this kind of remedial fever that Professor Frank gives the name of depuratory.-(Op. cit., tom. i., p. 48.) The duration of intermittents is of great uncertainty. The vernal agues generally disappear with the advance of summer; the autumnal are more obstinate, and especially the paroxysms on the reg-quartan. Where they have remained long, and ular day of attack, the have become habitual, even their removal must intervals being of or- be attempted with great caution; for, when dinary duration. abruptly suppressed, they have been known to The paroxysms of the lay a foundation for a host of other maladies, one set occurring in often of a more fatal description, as paralysis, the intermissions of various visceral affections, and even sphacelus. the other, and evin- Ludolf gives an instance of an eight-day ague cing a difference of (anetus erraticus octanus) continuing for eighteen duration or of vio-years; yet this was probably a double quartan; lence with an inter- while we have abundant examples of a conval on the third day tinuance of the regular quartan for nine (Eph. Nat. Cur., dec. ii., ann. viii., obs. 45), twelve Consisting of a single (Avicenna, canonum i., lib. iv., tr. i., cap. vi.), quartan with regularly-eighteen (Madai, Von Weekselfiebern, sect. 144), returning paroxysms; twenty (Eph. Nat. Cur., dec. iii., ann. ix. and while each of the x., obs. 51), twenty-four (Marcellus Donatus, intervening days is lib. iii., cap. xiv., p. 291; Pontanus, De Febr. marked with a slighter Conel., lib. viii.), and thirty years (Binninger, or separate attack. obs. cent. v., N. 64; Wierius, obs., p. 37), and Consisting of a single one instance of its lasting for not less than fortyIt quartan with two par- eight years.-(Gabelchover, cent. vi., obs. 74.) oxysms on the regular is in this species, therefore, that we chiefly meet day of attack: the in- with those congestions in the spleen which are tervals being of ordi- called ague-cakes, as also with scirrhosities in nary duration. the liver, pancreas, and other abdominal organs, Consisting of a single which by Bonet, Swalwe, Senac, and other quartan with three par- writers, have been regarded as causes of the oxysms on the regular disease, but by Van Hoven, and most pathol day of attack: the in-ogists of the present day, excepting, perhaps, tervals being undis- Cruveilhier, are more correctly resolved into turbed, and of ordinary duration. Having thus distinctly noticed the several species and chief varieties of intermittent fever, I shall proceed to offer a few remarks upon its general history and medical treatment. effects. Schenck gives a case of congenital quartan. or in which it appeared in an infant immediately after birth (Obs., lib. vi., N. 36); and Paullini another, in which though not strictly congenital, it appeared in very early infancy. (Cent, i obs. 94.) But such examples are rare. Among Whenever the accession of an intermittent is other singularities, I may observe, that the ac violent, be its type what it may, it is sometimes cession has sometimes been so violent as to attended with very alarming symptoms, as syn-destroy the patient in the course of the first cope, apoplexy, vehement spasms over the whole paroxysm, of which an instance will be found system, or a coldness or torpor which threatens in Senac (Von Weekselfiebern, b. ii., cap. vi. death. Yet, when not violent, nor of very while, at other times, it has been so slight and long duration, especially when of the tertian rapid, that the entire paroxysm has run throngh * It once occurred to Dr. Joseph Brown to seeing very feebly, for eighteen hours, at the end of a person die in what appeared to be the cold stage which he expired, his intellect having been of a first fit of ague. Heat applied in various clouded till within a few minutes of his dissolu modes, ammonia, ardent spirits, ether, and other tion. The principal morbid appearance discovered tient lay as cold as marble, and shivering violently, had a lobulated appearance, and was gorged with without any pulse at the wrist, and his heart act-blood.-Cyclop. of Pract. Med., art. FEVER.-ED. its course in a minute.-(Reil, Memorab. Clin., voli., Fasc.) The character of the intermittent seems in a considerable degree to depend upon the age or idiosyncrasy of the individual, and the temperament of the atmosphere. We find, also, that variations more usually take place in the quotidian than in any other type, which we should, perhaps, ascribe to its occurring more frequently in early life, when the frame is more irritable; and to the debility which the constitution suffers from this type, above that of any other, in consequence of the greater length of its paroxysms, and the greater brevity of its intervals, by which means the prostrated strength of the system has no time to rally. | to particular cases, and, in the other, to the general disease. In plethoric habits, the head was greatly oppressed with a tendency to delirium In those of a nervous and irritable disposition, the intermittent was connected with spasms and twitchings of the tendons. And those disposed to rheumatism, had acute arthritic pains. The state of the atmosphere, and the general character of the season, Dr. Reynolds has forgotten to notice; but we see evidently, and indeed he himself allows, that they give a typhous impression to the epidemic; which, from the same, or from other causes, is also peculiarly distinguished by the easy victory it yielded to the use of the bark, as that of the preceding year was distinguished by its obstinate resistance to this medicine. In this metropolis, from causes which have not been handed down to us, and which, in- If we ascend a year higher, or to 1780-1, we deed, do not appear to have been traced at the shall meet with an equal diversity of symptoms. time, intermittent fevers were more than ordi- "These fevers" (intermittents), says Sir George narily frequent from the year 1781 to 1785: Baker, "were in general no other than the and the remarks I have just made apply in an common ague; but in the more inland counespecial manner to all these. As a single ex- tries of England, they were often attended with ample, let us select those of 1782, as described peculiarities extraordinary and alarming. For by Sir George Baker and Dr. Reynolds, in an the cold fit was accompanied by spasm and article drawn up by the former, with an admira-stiffness of the whole body; the jaws being ble combination of learning and liberality, sound critical judgment, and inquisitive research. "The type of the fever of 1781-2," says Sir George, "was either tertian or quotidian; the former being more common in the first part of the winter; the latter, from the middle of February to the end of June. With respect to the former, NOTHING OCCURRED to my observation which is worthy of notice"-(Med. Trans., vol. ii., art. xiii.) On the latter, Dr. Reynolds communicated to him the following information :The quotidian fevers were irregular in their invasion, and uncommon in their appearance; and no cases resembled each other, except in very few circumstances. The first attack generally commenced with a horror; but the subsequent paroxysms, though often beginning with a sense of cold, were chiefly without horror. The intermission was short, and seldom perfect. The symptoms were very severe, and in many cases dangerous, and leaned strikingly to a typhous form. Great and sudden oppression of the head, anxiety, depression of spirits, a dry, parched tongue, yet less covered with hardened| mucus than might be expected; a pulse low, quick, and intermitting; bowels variable; urine dark-red and clear, without any sediment, constituted the ordinary signs. Many had a low muttering delirium; two or three a laborious respiration; a few spasms and twitchings of the tendons: aphthæ appeared occasionally and one patient exhibited symptoms of violently acute rheumatism. The bark was universally successful; and, "I was as much pleased,” says Dr. Reynolds, "with its present efficacy, as I was in the year 1781 mortified by its extraordinary want of power. Half the quantity of it which I used on that occasion was sufficient on this." In other words, idiosyncrasy and atmospheric temperament were both peculiarly visible, and gave a peculiar character, in the one instance, fixed, the eyes staring, and the pulse very small and weak. In many cases, delirium was added to spasm, under both which symptoms the patient laboured quite to the end of the paroxysm. And though the senses returned when the fever subsided, yet a convulsive twitching of the extremities continued, even in the intermissions, to such a degree, that it was not possible to distinguish the motion of the artery at the wrist. This fever had every kind of variety: and, whether at its first accession it were a quotidian, a tertian, or a quartan, it was very apt to change Trom one type to another. Sometimes it returned two days successively, and missed the third, and sometimes it became continual. I am not informed that any died of this fever while it intermitted. It is certain, however, that many country people, whose illness had, at its begin ning, pit on the appearance of intermission, becoming delirious, sunk under it in four or five days. It is a remarkable fact, and very well attested, that in many places, WHILE THE INHABITANTS OF THE HIGH GROUNDS WERE HARASSED BY THIS FEVER IN ITS WORST FORM, THOse of the subjacENT VALLEYS WERE NOT AFFECTED BY IT. The people of Boston and of the neighbouring villages, in the midst of the Fens, were in general healthy, at a time when this fever was epidemic in the more elevated situations of Lincolnshire: and other examples of a like kind have already been noticed.* It is * Sir Gilbert Blane, Select Dissertations, p. 111, 8vo., Lond., 1822. In order to form a correct judgment of this part of the subject, we should have been informed of the state of the weather, not merely in respect to temperature, but quantity of rain that fell in the different places alluded to. ations, while it ceases in lower ones, will admit of The occurrence of ague sometimes in high situ. explanation on principles already noticed in a preceding note.-ED. likewise singular, and worthy of notice, that, in many families, the female servants were nearly exempted from a disease which very few male servants, especially the labourers in the open air, escaped. But the distinguishing character of this fever was its obstinate resistance to the Peruvian bark; nor, indeed, was the prevalence of the disease more observable, than the inefficacy of the remedy. Though the quantities of the bark usually given were exceeded, the fit was apt to return, rarely altered, either with respect to the time of invasion, or the intenseness of the symptoms; and just as if no means had been used to prevent it. A drachm of the bark in powder was frequently administered every second hour, without averting the fit." In casting our eyes over the great diversity of medicines that have been employed for the cure of intermittents,* we shall find that, innumerable as they are, they may be arranged under two general heads, tonics and antispasmodics; as though, long before the time of Dr. Cullen, his two principles of the disease, debility and spasm, had been uniformly admitted and acted upon. The antispasmodics, consisting chiefly of stimulants, sedatives, and relaxants, have been confined to the term of the paroxysm, with a view to weaken and shorten it; and the tonics, consisting principally of bitters and astringents, have been employed throughout the intervals, with a view of fortifying the system against a recurrence of the attack. In discussing the medical treatment of intermittent fevers, it will be sufficient to limit ourselves to these two indications. or four times in succession. And he assures us that he has very frequently seen obstinate intermittents removed by this powder, and without any relapse. The practice, however, has not been equally successful in other hands; not even when capsicum has been given in a much larger quanti ty, or exchanged for ammonia, treacle-mustard (clypoela jonthlapsi), or black or white pepper, the latter of which is only the former denuded of its outward tunic, mixed up with brandy or Hollands. They have all, indeed, sometimes answered, but the result is uncertain; and, as was long ago observed by Van Swieten, if the medicine do not succeed upon a full dose, and especially when combined with ardent spirit, it will often extend its influence to the hot fit, and greatly exacerbate it; and not unfrequently convert an intermittent into a continued fever. Upon the whole, therefore, this plan is not to be recommended, however varied. The least pernicious material is the ammonia; but then it is also the least effective. A large draught of cold water has been not unfrequently had recourse to for the same purpose, and also, in a few instances, with success. The object is, by taking it about half an hour before the cold fit is expected, to excite a strong reaction and powerful glow over the entire system against the time when the cold fit returns, and thus to preoccupy the ground; and, by disturbing the regularity of the type, to subdue the intermittent altogether. But this plan has, perhaps, more frequently failed than the preceding and when the shivering or horripilation produced by the cold water has not been followed with a stimulant effect, as in delicate habits more especially, it has often continued so long as to run into the term of the febrile cold fit, and very considerably to increase its power. Ballonius relates a case in which it proved fatal.* The next division of antispasmodics, which have been directed against the paroxysm, and especially against the rigour with which it makes its onset, is sedatives and of these the chief have been opiates, which, when given in the form of laudanum, in a dose of from thirty to forty drops at the commencement of the chill has, in many cases of intermittents, been highly beneficial; diminishing the duration of the stage, and moderating its symptoms. Dr. Trotter says, that he practised this plan with general advantage in an epidemic intermittent that altacked the Vengeance, one of the Channel fleet under Lord Howe; and adds, that, "if the first dose of opium did not produce a sensible relief It was a favourite practice with Bergius to anticipate the cold fit, constituting the accession of the paroxysm, by pungent stimulants, in the hope that, if he could successfully combat this first stage, he should gain a complete victory, not only over the individual paroxysm, but over all future incursions. His favourite medicines for this purpose were garlic, mustard-seed, and capsicum. And he boasts of having, in numerous instances, completely succeeded, with each of these; though he admits that the mustard-seed answered best in vernal intermittents, but did not, in general, prove sufficient for the autumnal quartans. The Indian practitioners, I may here observe, employ chakka or ginger, and sometimes the sison ammi for the same purpose, and Dr. Chisholm has occasionally succeeded with scallions.-(Clim. and Dis. of Trop. Coun., &c., 1822, p. 53.) Bergius, however, placed his chief reliance on the capsicum, six grains of which he was in the habit of giving, combined with two scruples of bay-berries in * Op., tom. i., p. 193. Venesection has been powder, "incipiente primo rigore ;" and of re-stage, and of preventing the hot stage, or lessening recommended as a means of shortening the cold peating it every day, at the same hour, for three its duration and violence. Dr. Mackintosh, in his work on the Practice of Physic, is in favour of such treatment. On the other hand, Dr. Stokes rather disapproves of venesection in the cold stage though he admits that it is beneficial in removing the symptoms of congestion about the chest and abdomen.-(Edinb. Med. and Surg. Journ, 1829.) Dr. Elliotson has never seen a case of ague which required venesection in the cold stage.-Lect. at Lond. Univ., Med. Gaz., 1832, p. 2.—En. * Intermittents are sometimes cured merely by diet and regimen. Of twenty-three patients sent to the hospital la Charité, for the purpose of testing the efficacy of the misletoe (Îlex aquifolium), M. Chomel states that the disease ceased immediately in seven of them, although no medicine was administered.-See Mem. de l'Acad. Royale de Med., vol. iii.-D. and exhilaration of spirits in half an hour, he re-usual practice, so as not to regulate the hot and peated it, and never found it necessary to go sweating stages, but to anticipate the cold fit. beyond a second dose."* Sir Gilbert Blane ad- And we may still farther add to the ingredients verts to the same plan, as pursued at Walcheren of the medicine a full dose of ammonia with great during the English expedition to that island, and advantage; for, it is in this form, if in any, that with an equal success.† we can employ stimulants with a certainty of doing little mischief, and very nearly a certainty of considerable benefit. In the case of a quartan in St. Thomas's Hospital which had lasted two years, Dr. Fordyce determined upon this plan; and prescribed a full dose of Dover's powder, with a sweating draught of carbonate of ammonia, two hours before the paroxysm was expected. It succeeded perfectly. A profuse perspiration anticipated the period of the cold fit, and hereby entirely prevented it; bark was next given freely, and this obstinate ague was cured in a few days.-(Edinb. Med. Comm., vol. vi., p. 359.) We have already seen, however, that there is some cause or other, probably the peculiar temperament of the atmosphere at the time, that baffles or one occasion the remedy that has best succeeded on another. And hence opium has often failed in other intermittents in every form, but especially when given in the cold fit. And owing to this diversity of effect, Dr. Lind thought it most useful in the hot fit; and asserts that, if administered to the extent of twenty or fiveand-twenty drops of laudanum half an hour after the beginning of the hot fit, it produced the advantage of shortening and moderating the heat, calmed the anxiety and headache, which are usual concomitants, expedited the sweating stage, made the paroxysms more regular, and sometimes stopped the fever altogether. Other physicians have commenced with relaxants; and where these are selected, the antimonial preparations are to be preferred to ipecacuanha. They tend more directly towards the surface, and, where it is useful to excite vomiting, which is often the case, they act sooner, and maintain the action longer, and hence make a double effort to accelerate the sweating stage. The antimonial preparations differ chiefly from each other by having the reguline part of the antimony they contain in a more or less fusible state; and their operation will very often vary according to the quantity or quality of the acid they meet with in the stomach; and hence the different effect of the same preparation in different persons, and even in the same person at different times. Whatever be the relaxant or sudorific employed, it should be assisted by plentiful potations of warm diluents, and by placing the patient between the blankets instead of in the sheets of his bed: for, I have already had occasion to observe, that upon these auxiliary means depend, in many instances, the accomplishment of the object we have in view, without which the most urgent diaphoretic exerts itself to no purpose.* The most important season, nevertheless, for medical operation, is in the intermission of the paroxysms: since, however successful we may be in moderating the febrile attack, it is rarely that we can depend upon any plan which may then be adopted, to prevent a recurrence of the fit. The opinion of mankind seems to have concurred in most ages, in regarding debility as either the proximate or predisponent cause of intermittents, since almost the only medicines that have been brought forward to guard against the recurrence of their periodic attacks have The most efficacious practice which I have been TONICS, with the sensible qualities of bitterwitnessed, consists in uniting relaxants withness or astringency, or of both. opiates; and, where this joint effort is pursued, ipecacuanha may answer as well as any of the preparations of antimony. We cannot have, for this purpose, a more useful medicine than Dover's powder; and it should be commenced with much earlier than is consistent with the In what way these act upon the moving fibre at any time, and particularly in the diseases before us, we cannot say with any degree of precision. The tone of the moving fibre depends unquestionably in some degree upon the state of the fibrous material itself, but perhaps in a much greater degree upon the state of the nervous influence. We have great reason for believing, that astringents, in producing tone, act upon the fibrous material itself, for we find them operating in like manner upon animal fibres both in a living and a dead condition. But whether, as Dr. Cullen conjectures, it be the The administration of opium to arrest the invasion of intermittents, is one of long and extensive use in the United States. It is largely indebted for its popularity to the authority of Sir Gilbert Blane. Sixty or eighty drops of laudanum, blended with a few drops of sulphuric ether, or of aqua ammonia, are often administered a short time previous to the invasion of the cold chill. Many * Dr. Elliotson conceives, that in the cold stage, physicians will testify to the efficacy of this treat- the plan of surrounding the patient with hot air ment, and few be disposed to question its efficacy, would be better than putting him into the warm even in plethoric subjects. Plethora and local con- bath, as is sometimes done. Air in any quantity. gestion however should always be considered, and and of any temperature, may be conveyed under bloodletting may sometimes be found an important the bedclothes by means of something like an inpreliminary measure. Dr. Gallup (Epidemic Dis-verted funnel, a tube, and a spirit-lamp. Dr. Ellieases of Vermont) strongly condemns the use of opium in every form of intermittent fevers.-D. + Select Dissertations, &c., p. 105, Lond., 8vo., 1822. Dr. Elliotson has given opium with very great success; yet, says he, "if I found great congestion of the head or other parts, I would order bleeding in preference to opium." otson has also a favourable opinion of the usefulness of friction. The warm drinks which are given, he thinks, should not contain wine or brandy, as such stimuli would be likely to increase the subsequent hot stage, bring on delirium, and cause congestion and inflammation of the head and internal organs.-ED. part of bitters alone to act upon the nervous power or living principle, and especially in the very singular manner in which he represents them as acting, is a different question; and the present is not the place for entering upon it. sician to his holiness, pointed out, in express terms, the time and proportion in which the bark was to be taken. Unfortunately, the time stated was frigore febrili incipiente, "at the commencement of the cold fit:" and it being administered in this manner, with only temporary benefit, to the Archduke Leopold of Austria, a year or two afterward, it immediately fell into great discredit with a very large and learned part of the medical community of Europe; and a most acrimonious warfare was instantly waged in every quarter on the subject, in which the combatants on both sides seemed more desi rous of victory than of truth. If we contemplate the brain and spinal marrow as the sources of nervous energy, we can readily conceive that the component parts of these organs, as well as of any other, may be invigorated by medicines that have a peculiar influence on their structure; and that consequently, such organs may be rendered capable of distributing the nervous power in greater abundance, or of producing it in a more elaborate perfection. And we can also readily con- In our own country, the bark began to beceive, that such effects may be produced by both come popular about 1655. In 1658, Mr. Unbitters and astringents, as well as by medicines derwood, an alderman of the city of London. that possess some other sensible qualities, though died while using it, and was instantly reported these are the most obvious in their operation. to have fallen a sacrifice to its power; and so But should we, with Dr. Cullen, affirm that the prejudicial was the effect of this rumour, that same bitter, employed in the same proportion, Cromwell, who was attacked with an ague in produces both tone and atony, energy and de- the same year, was suffered to languish and at bility; that it both cures the gout and occa-length to die without an exhibition of the bark, sions it; that, employed for a certain time it effects the former, and, after such time, the latter; and should we beyond this affirm, with him also, that the nervous energy is not the production, but an inherent power, of the brain; that it admits neither of increase nor diminution; is changeable in its state, but unchangeable in its essence; becomes excited and collapsed, or rises and falls in its energy, but experiences nothing of the decomposition or recruit of every other part of the living frame around it; we should travel into a labyrinth of incongruities, and only enlighten ourselves with a will-o'-the-wisp. Dr. Cullen's system, like himself, is a work of no ordinary stamp; it is full of immortality, but mixed up with weak and perishable materials. Of the remedies appertaining to the one or the other of the two divisions we are now considering, those of astringents and bitters, the cinchona, or Peruvian bark, which unites both qualities in itself, is on every account entitled to our first attention. This valuable medicine, which some practitioners are apt to despise or think lightly of in the present day, has never been altogether without its opponents; and there are many facts respecting its operation, which, if not altogether anomalous, are of very difficult solution. Peruvian bark, according to the authority of Don Joseph Villerobel, a Spanish physician noticed by Badus, was first brought to Spain in the year 1632; but here, as in every other country, it had for a long series of years to encounter the prejudices of the medical profession; and consequently was very rarely made use of, and unquestionably would have sunk into oblivion but for the activity of the Spanish jesuits, who continued zealously to recommend it, and to import large quantities of it from their brethren in South America. Through these means, it was at last recommended by Pope Innocent X., in 1661, as a medicine perfectly innocuous and salutary; and a Schedula Romana, drawn up under the sanction of the phy his physicians being afraid to make a trial of it, in consequence of the fatal accidents that had so lately accompanied its use: in the words of Morton (Pyretolog., p. 17), "nondum vires corticis in hoc veneno subigendo, saltem hic loci, comprobatæ erant." In England, therefore, as well as on the continent, there was a great conflict of opinion. Dr. Prejean, who both preceded and succeeded Dr. Harvey as president of the College of Physicians, appears openly to have advocated its employment in 1658, according to facts adverted to by Sir George Baker in his admirable article on intermittent fevers (Med. Trans., vol. m., art. xiii.), from which these hints are chiefly drawn up. Dr. Brady, professor of physic at Cambridge, appears equally to have counte nanced it; as does Dr. Willis, according to his own statement: while Dr. Morton professed himself inexperienced upon its virtues, and Dr. Sydenham was decidedly adverse to its use. Sydenham, however, was a man of reason and liberality. His prejudices, and especially those derived from the hypothesis, that a fever is a fermentation in the blood, raised by nature to throw off some peccant matter at the surface, and which ought not therefore to be checked in its course, however wise it may be to moderate it in its violence, were all at arms against the use of the bark under any circumstances: and the mischievous effects to which he had been an eyewitness in some instances, and its total inertness in more, gave a sanction to suspicion, if it did not justify hostility. But he was determined to watch it for a still longer period, through all its variable effects, and to abide by the result when fairly cast up. He soon became sensible that it was, in most cases, a powerful engine; that in many instances, it was highly serviceable; and that, in those in which it failed, the miscarriage was rather to be ascribed to some error in handling it, than to a want of power in the drug itself. Sydenham had sufficient ground for this last conclusion. The mode in which it was, at this |