to be put in competition with it as a febrifuge. | ent day particularly worthy of notice, are those In effect, of the three species of cinchona used in the neighbourhood of Rome, and especially officinally in the present day, the lance-leaved, about the Pontine marshes, which have often pale or quilled bark (c. lancifolia), heart-leaved or yellow bark (c. cordifolia), and oblong-leaved or red bark (c. oblongifolia), the yellow, which, as we learn from Mutis and Zea, is the genuine febrifuge of Spanish America, and whose superiority to the rest has been abundantly proved in this country as well as on the continent of Europe, is very considerably less bitter and astringent than the red, and not more so than the pale bark it has less resin than the first, and less gum than the second. Dr. Cullen preferred the red, but Zea's communications upon the subject (Annal. de Hist. Nat., tom. ii., Madrid, 1800) were not then published; and Cullen was not in possession of the experiments by which the statement of the latter has been confirmed. Sir George Baker, as already noticed, found the red bark produce so much oppression and nausea, that he was obliged to discontinue its use. It affords, however, the largest portion of quinine.

:

In administering the bark, little needs to be added to the rules laid down by Sydenham, and copied in a preceding page. Dr. Home has sufficiently shown, not only that the best time for commencing the medicine is soon after the paroxysm, but that it should be discontinued some time before a recurrence of the cold fit, since, if persevered in till its accession, this fit is almost uniformly rendered more violent.(Clinical Experiments, 8vo., Edin., 1780.)

If in the proportion of half a drachm or two scruples to a dose, as recommended by Dr. Sydenham, or such other quantity as may sit without uneasiness on the stomach, it should not succeed, it should be tried in combination with some aromatic, or omitted altogether; and by no means be increased to the enormous quantities some practitioners have ventured upon, who seem to have conceived that they could force the system to yield to its powers, by the overbearing arms of weight and measure. It is singular that Borsieri should have so far lost sight of moderation, as to have prescribed occasionally from four to six drachms of the powder in a single draught. In the extremity of the yellow fever such doses have, indeed, been given, and perhaps with advantage; but opium and old port, in large abundance, have been given at the same

time.

been drained to carry off the decomposing an mal and vegetable materials that spread their aria cattiva, as it is called, over the whole of the Campagna. The disease hence produced is named, from its source, malaria. It is also found in like situations, and has the same name, about Syracuse, and other parts of Sicily. M. Rigaud de l'Isle has asserted, that the miasmic particles which infect the air in these places, are heavier than the air in its loftier and lighter strata, and may be separated from it. He has found an elevation of 300 yards, at the Pontine marshes themselves, a complete security from infection; and he proposes for those who reside lower to sift the air which they breathe, by wearing a fine silk gauze over the mouth and nostrils. (Mém. de l'Institut. Royale de France, March 24, 1817.) M. Brocchi has successfully employed the same remedy, and hence recommends sleeping under a fine moscheto-net in all places where intermittents are endemic.-Dello Stato fisico del Suolo di Roma, &c., Di G. Brocchi.)

*The possibility of hectic fever arising from marsh iniasm is a suspicion that may be disIt will also be judicious to abstain from the pensed with, as it is entirely destitute of founda. use of bark in every instance in which any of tion. There may be hectic fever in consequence the abdominal viscera appear to be labouring of visceral disease, that has originated during an under parabysmic enlargements, whether ante-ague, and has not yet been cured; but as for ma laria being ever itself the cause of hectic, the cedently to its employment or during its use opinion is groundless. Perhaps, with the excepand, in these cases, to alternate small doses of tion of remissions, hectic fever has no analogy calomel with whatever tonic may be found to whatsoever to what is commonly implied by reagree best with the system. [Yet, as the editor mittent fever. As a judicious writer has ob has already stated, the experience of Dr. El- served, "remittent fever may be considered as liotson proves, that the sulphate of quinine holding a middle rank, as to external character, between intermittent and continued fevers; but, may be given beneficially, whether such enlargements be present or not it has no power it chiefly prevails, and the cause whence it prinwith respect to its nature, the localities in which of preventing the cure of inflammation, nor cipally, if not solely arises, it bears a closer af does it interfere with antiphlogistic means.] finity to the former than the latter. It may be re Among the endemic intermittents of the pres-garded more properly as forming the mean degree

miasm, however, is the most common cause of the second, perhaps of the first species; though we shall presently find it probable that even here, and particularly in the second species, human contagion has also occasionally proved a cause, as it assuredly has in those cases of hectic fever, produced by perpetually attending upon, or sleeping with a consumptive patient.

SPECIES I.

EPANETUS MITIS.

MILD REMITTENT.

The patient complains of drowsiness, and feels languid; is occasionally chilly, and afterward flushed, but without perspiration; for the skin is hot and dry, the thirst considerable, commonly with nausea and a total loss of appetite. In the course of the day, but usually towards the evening, the pulse quickens, the heat increases, and at length terminates in a sweat, which, however, is sometimes only partial, rarely free and copious, and never critical; for, on its ceasing, the skin is still dry and heated, and the pulse accelerated. Sometimes the exacerbation occurs about noon, and sometimes

PULSE REGULAR, THOUGH FREQUENT; DEBILITY in the middle of the night.

SLIGHT REMISSION DISTINGUISHED BY SWEAT-
ING, OR A CLOUD IN THE URINE.

If the disease be left to itself, the symptoms augment in severity daily; the head occasionabdominal viscus, gives proof of being loaded ally, but more generally the liver, or some other and oppressed, and the restlessness is intolerable; or a sudden cholera supervenes, and carries off the complaint by a salutary crisis.

THIS species occurs most frequently among persons of relaxed fibres, debilitated habits, and sedentary occupations; and is usually preceded by an irregular action of the alvine canal, flatulence, abdominal tension, dyspepsy, or some other affection of the viscera of the lower belly upon torpitude, or obstruction in some one or This species seems to be primarily dependant and is hence called by Professor Frank, as well in more of the chylopoetic organs, and generally the ensuing as in the present species, gastric yields to a course of active purgatives, among fever (De Cur. Morb. Hom. Epit., tom. i., § 50, which calomel ought to take the lead. These 99, 8vo., Mannh., 1792), intermittent, remittent, should be repeated two or three times a week, or continued, according to the type it assumes. and the intervals be filled up with mild diaphoIt occurs at all seasons of the year, but more fre-retics. The pulse will generally be found from quently in the autumn; the ordinary temperament of the season uniting with the patient's infirm state of health, and thus adding an exciting to a predisponent cause. Fatigue, cold, or long exposure to the rays of the sun, are also, at this time, powerful concomitants, and quicken the appearance of the disease.*

in the scale of periodic or marsh fevers, of which intermittent and yellow fever constitute the extreme points. A more intense operation of the febrific cause than is required for the production of intermittent fever engenders remittent, and the more violent the latter, the more remote is its character from that of intermittent; or, in other words, the less perceptible the remissions. That a more powerful action of the morbific cause is demanded for the production of remittent fever, is indicated by the circumstance, that when periodic fevers are prevailing in certain countries, the permanent residents are often observed to have the disease in the form of ague only, and the mortality among them is small; but strangers unhabituated to the climate and its diseases, suffer from remittents, with a proportionably greater loss of life. In more sickly seasons, remittents will be the prevailing form among both classes of persons; but strangers are more violently affected, and the mortality among them greater. Its affinity to intermittents is shown, too, by the tendency which it has to pass into that form, and inversely, by the proclivity of ague to assume the remitting type."-(Dr. Joseph Brown, In Cyclop. of Pract. Med., art. FEVER.) From such facts and reflections an argument might easily be deduced, which would shake very much the hypothesis of malaria, or marsh miasm, and the contagious principle of human effluvia, being capable of exciting similar fevers.-ED.

Here no reference is made to the commonly received doctrine, that ordinary remittent fevers spring from the influence of marsh miasm, or malaria. Thus, as Dr. J. Brown has stated, remittent is

ninety to a hundred strokes in a minute; but, as soon as it sinks below this, and the heat and dryness of the skin have yielded to a general softness, columbo alone, or combined with sulphuric acid, will easily complete the cure; though the disease not unfrequently runs on for ten days or a fortnight.*

THE REMITTENT FEVER OF INFANCY, which is generally ascribed to worms, does not essentially differ from the present, regard being had to the greater irritability in early life. Worms, there can be no doubt, are sometimes the cause of this infantile fever, but perhaps rarely; and there is no instance on record of their having been traced in the bodies of those who have fallen victims to it. Dr. Hunter expressly declares, that he has often searched in vain. The ordinary cause is crude accumulations in the first passages, whence the digestion proceeds imperfectly; there is great general irritation, with considerable languor: the belly becomes tumid and often full of pain; the food is nau

the endemial fever of warm climates; but it is also met with in temperate regions, and in our own country, especially in seasons of unusual heat, and in those parts of it where, under ordinary temperatures, agues are prevalent.-Cyclop. of Pract. Med., art. FEVER.-ED.

* Prescribe six grains of calomel, which are to be followed by an active cathartic, and a mixture composed of four grains of tartarized antimony and eight ounces of camphire mixture, three tablespoonsful of which are to be given every fifth hour. As soon as the tongue becomes clean, the skin natural, and some impression is made on the disease, the fourth part of the following mild aperient mixture, given three times a day, will complete the cure:-R. Magn. sulph. 3vj, infus. gentianæ comp. zvj, acid. sulph. dil. 3j; ft. mist. -ED.

seated the head is hot, heavy, and often comatose; as though there were water in the ventricles, which is sometimes suspected, though without foundation: the skin is pale or livid, with occasional flushes in the cheeks. It is a singular fact, that, if the exacerbation or increase of fever take place in the night, there is wakefulness and perpetual jactitation; if in the daytime, drowsiness and stupor.*

SPECIES II.

EPANETUS MALIGNUS.

MALIGNANT REMITTENT.

PULSE SMALL, HURRIED, irreguLAR; DEBILITY
EXTREME OFTEN WITH SIGNS OF PUTRES
CENCE.

EXTREME debility may be inferred from the symptoms of great weakness and irregularity of the voluntary motions; weakness of sensa tion; weakness and wandering of the mind; weakness of the pulse and of respiration; coldness and shrinking of the extremities, and a tendency to faint in an erect posture; nausea, vomiting, and a total disinclination to nourishment; difficult deglutition, depending upon an atony of the muscles of the fauces; involuntary excretions, depending upon an atony or paresis of the sphincters.

Dr. Butter recommends as an aperient, small doses of neutral salts, and, when the bowels have been opened, nitrate of potash; or, if there be considerable irritation, the extract of hemlock. Generally speaking, however, there is such a sluggishness in the peristaltic action of the bowels, as well as in the intestinal secernents, that neutral salts will not answer the purpose; and, in consequence, rather add to the irritation than carry it off. And hence, much stronger purgatives should be employed from A putrescent state of the fluids may be dethe first; as calomel, resin of jalap, or gam-termined from the following symptoms-pulse boge dissolved in milk; and it may be safely prognosticated, that, till this plan is had recourse to, the disease will in most instances maintain its ground, if it do not make a fearful advance. But with a course of brisk cathartics, in conjunction with perfect quiet, good ventilation, and light nutritive food, it will usually give way in a week or fortnight.‡

"By infantile remittent fever is now commonly understood a species of fever to which children from one year old, up to ten or twelve, are very subject, characterized by one or more daily exacerbations and remissions, by pain of the belly, and sometimes also of the head, and by an unnatural state of the alvine discharges."-Dr. Joy, Cyclop.

of Pract. Med., art. FEVER.

quick and tremulous; heat of the surface sharp and pungent, giving to the finger a peculiar tingling for some minutes afterward; the skin parched, or soaked with sordid, fetid sweat; the smell offensive to a considerable distance; the breath hot and fetid; the mouth aphthous; the tongue clammy, fetid, livid, greenish-black; the lips swollen, puckered, cracked, and purple; the urine brown or blackish, and offensive; black discharge, often in profuse quantity, from the stomach; the stools blackish, colliquative, very offensive, parted with profusely and insensibly; the mind wandering; twitching of the tendons; swelling and tension of the belly petechial spots, vibices, and hemorrhages from different parts, without proofs of increased in

symptoms:

In this insidious and often fatal form of dis-petus.* ease, the first indication is to remove all causes of This species may be traced under four va irritation, and to unlock the intestinal and cuta-rieties, each sufficiently marked by its own neous secretions. For this purpose, to the means mentioned above may be added the employment of small doses of ipecacuanha, alone or combined with rhubarb; say one or two grains of the former, with some three or four of the latter, administered once or twice a day for a few days, according to the exigencies of the case; the neutral salts will also be found useful. In a form of

a Autumnalis.
ß Flavus.
y Ardens.

& Asthenicus.

Autumnal Remittent
Yellow Fever.

Burning Remittent.
Asthenic Remittent

The AUTUMNAL REMITTENT is that which so this complaint, the late Dr. Ed. Miller, of New-frequently shows itself in our own country, in York (Medical Writings, N. York, 1824), recom- the season from which it derives its name, with mended small doses of calomel combined with opium; this practice may often be useful where a strong tendency to assume the tertian or cerebral determination and vascular fulness are

absent.-D.

In France, infantile remittent fever is treated as a species of gastro-enteritis. That the secretions from the mucous surface of the alimentary canal are in a depraved state, is a fact generally admitted; but whether in consequence of inflam mation, is a disputed point. Dr. Joy expresses his belief, that medicines which slightly increase and modify those secretions, will usually be attended with more success than the sole employment of directly antiphlogistic measures. -(Cyclop. of Pract. Med., art. FEVER.) cases, Dr. Hamilton combined calomel with In very obstinate opium and antimony. On the other hand, Dr. Clarke, after the exhibition of an emetic, and one or two active purgatives, prescribes bark. The editor has seen, in the public services with which he has been connected, many cases of this fever; and the practice which he has the most favourable

the

double tertian type: or, in other words, with striking exacerbations every other day, or, where the double tertian is imitated, every day, the exacerbations commencing at noon, and the duration being usually under twelve hours; intervals consisting of remissions, which, however, are not always very clearly determined. Where the double tertian type prevails, and the patient has to labour with two distinct sets of tertian exacerbations, it is obvious that one of

James's powder, and a cathartic mixture, followed opinion of, consists in giving at first calomel and by small doses of rhubarb and the hydrargyrum cum cretâ.-ED.

*No writer has given a better account of the fluids in their putrescent state than Dr. Dyckman. -See his Dissertation on the Pathology of the Human Fluids, New-York, 1814.-D.

these must take place every day, as it must occur in the remission of the other. Consequently, this variety is often mistaken for a quotidian remittent. But a little attention will point out the real nature of the disease. For, while the one set will usually be found distinguished from the other by evincing some difference in its duration or its violence, both will be distinguished from the quotidian by the time of their attack, which is at noon, while the quotidian attacks in the morning; and by the comparative brevity of the paroxysm, which is always under twelve hours, while that of the quotidian runs on towards eighteen.

any other obstruction takes place in a large organ, there is instantly a disturbance in the balance of the circulating fluid; and a disturbance which, in so irritable a state of the general system as we are now contemplating, can rarely exist without fever, or a tendency to fever.

There is no question that this general disturbance of the balance of the circulating fluid and increased excitement of the digestive organs may terminate in actual inflammation in some part of these organs, and especially in their mucous membrane:* and hence those pathologists who regard fevers of all kinds as consisting in inflammation, contemplate the reThe perfect apyrexy which takes place in mittent before us as an enteric, or gastric phlegthe interval of intermittent fevers, gives the masia: but this, as we have already had occonstitution a full power of recovering its energy casion to observe, is rather to denominate it and recruiting its sensorial supply; and hence from its result than from its essential nature, there is great difficulty in accounting for a re- and to make the cause and effect change places: turn of the paroxysm: I mean in cases in which a remark which will apply to yellow fever, as the patient is removed from the miasmic atmo-well as to the present variety. sphere; for otherwise, the cause that com- All this mischief is apt to occur in autumns menced the disease will be present to continue of temperate climates, that are peculiarly dry, it. Habit may possibly effect this after a re- and uniform in the range of the thermometer. currence of several paroxysms; but this will But it often happens that even in the most temscarcely apply to the second, in which no habitperate and healthy climates, like our own, the can, with great strictness of language, be said to have taken place. In remittent fevers, however, something of this difficulty is removed; for the constitution, even during the remissive interval, is still struggling with disease, and has not an opportunity of recovering its sensorial power.

autumnal months are checkered with sudden vicissitudes of heat and cold: and the pools and rivers are suddenly inundated with equinoctial rains, overflow their banks, and cover a wide surface of land with stagnant water. And the animal frame has hence to contend against the dangers of invisible damps, and abrupt changes of temperature, as well as against solar excitement: all which become occasional causes of fever, operating upon a state of body already predisposed to its influence.

There is no perplexity in accounting for a greater tendency to febrile affections in the autumn than in any other quarter of the year: and this, whether we allow the operation of a specific febrile miasm from marshes or not. And hence, even without the existence of When the animal frame has for some months febrile marsh miasm, we see sufficient causes been exposed to the stimulus of a high atmo- for a more frequent appearance of fever in the spheric temperature, and not unfrequently, per- autumn than in any other season of the year: haps, to that of the direct rays of the sun, all whence, indeed, one reason for its appearing i its organs become relaxed and debilitated. The warm seasons in fleets that are cruising at a nervous energy is diminished, or, in the lan- considerable distance from ports, as has beer. guage of Dr. Cullen, is in a state of collapse; justly observed by Sir William Burnet. But a general languor and inertness prevail over in many districts, perhaps even in some spoevery part of the system, and most of the func-radic cases, we have reason to believe that marsh tions are performed feebly and laboriously. And miasm does co-operate, and itself form the rehence, if debility be the first stage of the proxi- mote cause; and more especially where such mate cause of fever, this part of the cause is cases are frequent, the residence a lowland, continually present. But this is not all: the and the season hot and rainy. Dr. James Johncalorific rays of the sun act more powerfully upon some organs than upon others; and most of all upon the liver. The liver is hence in a state of perpetual irritation; and an unusual proportion of bile is secreted, a part of which is very generally absorbed and carried into the circulation; and, in tropical climates, so large a part as to form one of the causes of that tawny hue, by which the skin is there characterized and as the greater proportion of the surplus often passes off by the bowels, we see an obvious foundation laid for that variety of diarrhoea which we have already described under the epithet of bilious. The liver, moreover, becomes weakened and torpid in proportion to its degree of excitement, and hence more disposed to congestion; and where congestion or VOL. I.-A a

*The frequency of increased vascularity and ulceration of the mucous coat of the intestines in fever, has been amply proved by dissection.-See particularly Broussais Phlegm. Chroniques; Andral's Clinique Médicale, tom. i.; and Bright's Reports of Med. Cases, p. 178 et seq., 4to., Lond.,

1827.-ED.

On the Bilious Remittent of the Mediterranean.

The occurrence of remittent and intermittent fevers in ships, far distant from marshy countries, may appear at first to furnish an argument against the doctrine of malaria, or marsh miasm, being always concerned in the production of such disof the latter view would remind their opponents orders; but those writers who maintain the truth of the malaria frequently issuing from the bilge. water, in which the decomposition of vegetable substances is going on.-ED.

rejects whatever is introduced into it. Generally speaking, the stomach, from this symp tom, suffers more than any other organ; and, along with the sickness, we have often a very troublesome and debilitating looseness, which resists every attempt to check its course Sometimes, however, the bowels are costive from torpor, and the stomach is but little affected.

son makes a like distinction between the causes of the ordinary endemic fevers of the east. "The fever in question," says he (bilious remittent), "frequently arises from atmospheric heat, or rather atmospheric vicissitudes, deranging the functions, or even structure, of important organs; and is, as Sir James M'Grigor supposes, sympathetic of local affection. Where marsh miasm is added, which is generally the case, then we have the endemic of the place, modified by the peculiar nature of the effluvia, and from which we are not secured but by local habituation to the cause."—(Influence of Trop-insidiously hold on for upwards of three weeks, ical Climates, &c., 3d edit., p. 105.)

In consequence, the symptoms have often a close resemblance in both cases, so much so indeed, that when both diseases co-exist, it is sometimes found difficult to distinguish them. "The occurrences," says Dr. O'Halloran, "which preceded the appearance of the epidemic of Barcelona, in 1821, correspond with the old and recent observations on a similar subject in other countries; it almost invariably happening that the YELLOW FEVER of Spain is preceded by unusual diseases of various form and force; more particularly by BILIOUS REMITTENTS, which are not unfrequently so aggravated and MALIGNANT, that physicians themselves do not venture to define the lines of demarcation between them and the avowed epidemic."—(Remarks on the Yellow Fever of the South and East Coasts of Spain, &c., 8vo., 1823.)

The violence of the symptoms is commonly in proportion to the violence of the incursion; but not the duration of the disease: for I have often seen a fever that commenced mildly and

while another that commenced with great severity, and threatened the utmost danger, has softened its aspect in a week, and entirely quitted the patient in a fortnight. The exacer bation ordinarily takes place at noon, or early in the afternoon, and consists in an increase of heat and pulsation, for there is rarely any preceding chill, and as rarely any salutary moisture when the heat diminishes. The early part of the night is hence peculiarly restless, and no part of it tranquil: the patient dozes perhaps for a few minutes, but without being sensible of sleep, and talks incoherently while dozing; the images before him being partly furnished from dreaming and partly from delirium. And even during these snatches of unquiet slumber, he is perpetually turning from side to side in quest of ease, which no position affords him. Every symptom is obstinate; laudanum rarely produces sleep, and no sudorific, perspiration; the coolest and most refreshing drink is rejected from the stomach; and if looseness tease the bowels, it is retained, as already observed, with great diffi culty. It is hence of little importance what nourishment is offered, and every preparation seems almost equally to fail in supporting the strength of the system. In effect, the debility increases with every fresh exacerbation; and if no favourable change take place before the fourteenth or fifteenth day, there will always be reason for alarm. The progress of this disease is admirably described by Professor Frank (De Cur. Morb. Hom. Epit., tom i., sect. 100, 8vo., Mannh., 1792), under the name of febris continis gastrica, the remittent form being with him, as with Dr. Cullen, a section of the continued fever.

There is still, however, a difficulty in determining why the type of any fever, hereby produced, should be remittent rather than intermittent or continued; and why its declinations should imitate one form of intermittents rather than another. Pathology has its mysteries as well as every other branch of science; and let the man who would accuse us of ignorance, because we are incapable of explaining these secrets of nature, first tell us, to adopt the language of Sydenham, "why a horse reaches his full growth at seven years old, and a man at twenty-one? or, why some plants flower in May, and others in June? If," continues he, "the most learned men are not ashamed to make an open avowal of their ignorance upon these points, I cannot acknowledge myself blameable if I modestly forbear reasoning In the case of a young lady in her seventeenth upon a subject quite as difficult, and perhaps year, whom I lately attended, the attack was altogether inexplicable. At the same time I slight, and no serious evil was at first apprehendam persuaded, that the progress of nature is as ed. The pulse was about ninety in a minute, certain and regular in these cases as in any and rather small; the bowels were relaxed, the others, and that the quartan and tertian inter-motions bilious, and the stomach suffered from mittents are as subject to the natural laws, and nausea. as much governed by them, as any other occurrences whatever."

The autumnal remittent commences with lassitude, a general soreness over the body, yawning, inquietude, and most of the other concomitants of a febrile incursion. As some of the larger organs have been more affected by the influence of the season than the rest, we find them giving way in proportion. Hence the head is sometimes severely tried with pain or heaviness; the bowels are overloaded with bile, or the stomach is exquisitely irritable, and

A gentle emetic seemed to afford some relief to the stomach, and a dose of rhubarb and calomel to the bowels; but the fever continued, with a daily and increasing exacerbation, for the most part at mid-day or soon after. The stom ach again became irritable and sick, and the sickness was again connected with a diarrhea, but the stools were colourless and watery, and nothing was rejected from the stomach but the diluent food that was swallowed. The skin was now very hot and dry, the pulse from a hundred to a hundred and twenty strokes in A minute, the nights were passed in perpetual