A
PRIZE   ESSAY
ON
BILIOUS  FEVER.
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BY
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LUNSFORD P. YANDELL, M. D.
PROFESSOR OF CHEMISTRV AND PHARMACY IM THE LOUISVILLE MEDICAL INSTITUTE.
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       LOUISVILLE, KY.




PRENTICE AND  WEISSINGER.




            1841. 
 
          A PRIZE ESSAY
                  ON

BILIOUS   FEVER.
Sanos sospitare agrosque sanare.
   Bilious Fever is a most prevalent disease in the valley of the
 Mississippi.  It is,  also, a most fatal disease.   It  carries off
 the 'infant at the breast, the old man, the tender  youth, the
 young man, and the  man in the prime and vigor of useful
 life.  It  is  the  Great  Destroyer in  all our  south-western
 States.   The best minds of the medical profession have been
 devoted to its study, and to the means of subduing it,  in  both
 hemispheres, and on both sides of the line ;  but yet it remains
 unconquered.  'We have ascertained,  pretty accurately,  the
 circumstances under which it takes its rise, and are general-
 ly agreed upon the name of its  imaginary cause; great im-
 provements have, also, been  made  in  the mode of treating
' it, and higher  success crowns the efforts of modern practi-
 tioners ;  but, despite all, it continues often to prove fatal, and
 in one of its forms, is still the terror of south-western physi-
 cians.

   Aetiology.—Nothing in regard to  Bilious Fever is better
 settled, than that the poison which generates it is  developed
 by the drying up  of ponds and water courses,  in a fertile re-
 gion of country, under an ardent summer and autumnal sun.
 Wherever  moisture  is  present  to co-operate  with  organic
                             1 
4
rnatter  in  warm weather, there is decomposition going on.
and there is found bilious disorder—especially by the bottoms of
streams or ponds recently exposed to the air and the sun, does
the poison of fevers seem to be eliminated.  The draining of
a mill-pond, if done late  in summer, or in the fall, hardly ev-
er fails  to spread miasmatic diseases far and wide among the
inhabitants of the  neighborhood.  The following is  an ins-
tance, in point, which has never been  published:—The pro-
prietor of a mill on a  small stream in Ohio was in the habit,
every year in early summer, when the waters became low, of
draining the pond,  by raising the flood-gate.   No injury  to
the health of his neighbors resulted, so long as the draining
process  was confined  to early summer: the inhabitants of a
village  bordering upon the stream were not particularly sub-
ject  to  fevers.  But  during a wet  summer, in 1839, as the
stream continued full, he was induced to  postpone  draining
the pond until late in August.   The  consequence was, that a
most  formidable fever  broke out  in the village, and prevailed
to an extent before unknown in it.  The owner of  the mill
was compelled to draw off the  water,  next spring, the pond
having been condemned as a  public nuisance, and the sum-
mer which followed was one of health in all the surrounding
neighborhood.
  The droughts  of our summers, by exhausting the  streams
and  exposing  the  deposits of organic  matter on their mar-
gins and in their beds, are known to all practising physicians
to be the almost certain harbingers of fever in some one of
its varied forms.   And in reviewing the record that we have
kept of  our cases of fever, we are able to trace nearly every-
one of them to the borders of some  pond or stagnant  stream.
Year after year, we find that our autumnal business has been
almost  wholly  confined  to  the vallies of the neighboring
creeks and rivers.
  In the neighborhood of Louisville, and particularly to the
South, lies an extended district of flat country dotted  all over
with ponds ; • it is called the "Pond Settlement." In the spring,
and during the early summer, this region is salubrious, for the 
5
ponds, as yet, are full of water.  But when they begin to be
exhausted in July, and  their beds send up exhalations under
the solstitial heats,  fever, in every shape, rarely ever fails to
attend.  If this district ever escapes this unwelcome visitant,
it is in a rainy season when the ponds are  kept full.  In  an
early day,  and, in  fact, until  within a late period, this city
was regarded as one of  the  most unhealthy places in the val-
ley of the Ohio; but such  has  been the beneficial effects of
draining and tillage,  that  it  would  now  compare,  in  the
healthfulness of its  citizens, with any other river town in the
West.  This is particularly  true of the central  and  densely
settled parts of the city.  The suburbs continue to be visited
by fever.  A  line might be  traced  around the  city marking
the limits of  the healthy atmosphere, and the point at which
malaria begins to assert its  authority.   Within certain limits
the air is pure, but   beyond these, on the three sides of the
town exposed to the miasms of the ponds, it is still unsafe to
reside.  The explanation  of these facts is easy.   The  inhabi-
tants  in the  interior are remote from  the source of the  poi-
son, and are, moreover, protected  by the intervening build-
ings ; whilst those  who dwell  on the frontier inhale  the poi-
son emitted  by the ponds  that  have  not yet been drained.
As the draining progresses the  boundaries of health are found
to be  sensibly and  rapidly extended, and  the  region upon
which the pestilential vapors have so long  rested, like a dis-
mal incubus,  promises to become, in a few years, under a ju-
dicious system of ditching and culture, one of salubrity and
great  value.  The  environs of Louisville only require to be
rid of the stagnant water which remains, to be rendered  as
healthy as Main street, which  was as often visited by malig-
nant fevers as they now are, while large ponds exposed their
filthy waters to the  sun, in quarters now covered by pave-
ments and houses.
  It is interesting and  instuctive to remark, how coincident
are all the  circumstances attending  the rise and  propagation
of bilious fever, in countries so remote  as Italy and the Val-
ley of the Mississippi.   In following the historian of the Cam- 
*
                            6

 pagna di Roma, one cannot fail to be struck with the exact
 identity of the causes which have  desolated that  remarkable
 region, and are  traced everywhere in this country as exciting
 malarious diseases.  The Campania,  we learn from Roman
 history, was once a densely populated  and beautiful country—
 the site of the thirty cities of Latium with its dependant vil-
 lages.   It is now nearly a wilderness—a long series of wars
 with their Roman neighbors laid waste its fields, depopulated
 its villages, and exhausted the resources and energies  of the
 remnant of  its people.   As a consequence,  the  mountain
 streams, which industry had confined to  narrow channels
 spread unchecked over the low valleys, and  formed anew the
 lakes and pools which had long  been dried  up.   The pesti-
 lence followed quickly  on the  footsteps  of war, to complete
 the  work of desolation.   A poisonous atmosphere was gath-
 ered over the Campagna, and spread its baleful influence  far
 around.  Town and  village gradually disappeared, until the
 sites of many of them  could scarcely  be  distinguished.  The
 progress of depopulation was at first so slow as to be  almost
 imperceptible.  "The outskirts were thinned by fevers  which,
 returning at  the return of mid-summer or of autumn, grad-
 ually compelled the  inhabitants to retire  towards  the  centre
 of population,  or remove at once to more  elevated and  sa-
 lubrious situations.   By degrees the range of  the disease  ex-
 tended, drawing a narrower and still  narrower circle around
 the fated spot.  Years  might pass  away  before its hold  was
 made secure,  but its  violence was redoubled as it approached
 the centre, until one or two seasons were  sufficient to com-
 plete the work of destruction."*
  But the Campagna thus desolated by malaria revived, when
Rome, carrying  her  conquests beyond the confines of Italy,
 became the centre of a great  empire, and wealth, with all
 its attendants, flowed in upon her.  People revisited  its de-
 serted fields, and rebuilt the villages.   Its  streams were guid-
 ed once more into their  proper channels, and the stagnant
*New-York Review. 
7
pools  ceased to send  up  their noisome effluvia.   Luxuriant
harvests covered the  beds of exhausted marshes, and the vil-
las of some of  the first  citizens of Rome  crowned many of
the heights of the region where the pestilence  but  a few
years before had held undisputed sway. And in this prosperous
state the Campania continued, so long as Rome  remained the
seat of empire.  But with the removal of the Popes  to Avig-
non  commenced a new  period of decay.  The villas were
abandoned  to the  charge of indolent agents and slaves, and
fell gradually into  ruins.  Many of the villages were desert-
ed, and smitten by the reigning spirit of  luxury and effemi-
nacy, and  galled by  an  iron despotism,  all  lingered on in a
doubtful and precarious existence, until  the inroad of the bar-
barians completed  the ruin of the country.  The  population
of Rome itself dwindling down to seventeen thousand souls,
the Campagna was deserted, except by a few  miserable be-
ings who dragged  out an  existence of  thirty or forty years,
rarely ever reaching sixty.
  And thus, with the neglect of its culture, and the  accumu-
lation of water upon its surface, the Agro Romano sunk again
to the lowest point of desolotion.  The  facts are deeply inter-
esting to the medical philosopher.  It is seldom, indeed, that
we are ever able to trace more  satisfactorily the connexion
between  the phenomena of disease and their causes.   And it
is not the least interesting fact in  the history of this  country,
that, since the  removal  of the Papal Court to Rome  again,
there has been a gradual  improvement in  the salubrity of the
Campania—that event being followed by  the return  of labor-
ers to its  fields, and the draining of the Pontine marshes by Pius
the 6th.  That immortal  enterprise, the writer from  whom I
have quoted remarks, had it been followed up by the  draining
of other portions of the Agro Romano, might long since have
reclaimed it.   Enough was done  to show where the  evifl lay,
and to indicate the mode of removing it.
   The malaria, it is well  understood, is confined to  the low-
lands of the Campania.  High situations are exempt  from  it;
and it would  be easy, it is stated  by writers who have visited
                            1* 
8
it, to form a scale presenting, at different points of elevation,
the gradation of noxious,  bad, suspicious, passable, good, and,
finally, excellent air.   Monte Mario,  at the gates of Rome, is
healthy throughout the year. The village of St. Oreste, which
stands midway on the ascent of Mount Soracte, and yet is des-
olated by autumnal fevers, seems to be an exception.  "Here,
however, the peculiar structure of the mountain itself affords
an explanation of the variation.   It is a solid mass of nearly
naked rock, with but here and there a scanty growth of shrubs
and low wood to shelter it from the exhalations of the marshes
below."
  The unhealthy season  at Rome commences not until  to-
wards the middle of July.  The shepherds  remain with their
flocks through nearly the whole month of June, taking the  re-
mainder of this interim of good air to gain the mountains  by
slow marches.  By this time the smaller streams and shallow
pools  are dried up, and the  two rivers, the Anio and the Tiber
also load the air with noxious exhalations.   The degree of un-
healthfulness  of any particular season  depends in a great meas-
ure upon the  autumnal rains.  When these are  delayed  or
scanty,  the fever  obtains a stronger hold  and  spreads  with
greater rapidity.  But an early and great fall of water produ-
ces an immediate change in the atmosphere, not only cooling
but purifying it,  and by renewing the half-drained  streams
covers up the reeking sources of malaria.*
  I fear the reader will deem  that I  have devoted too much
space to the history and  physiognomy of a region so remote
from  the scene  of his professional labors.   All that I can say
is, that the interest of the subject has appeared to me to justify
the length of the details.  The Campagna  di Rome is  not
only famous for the malignity of its fevers, but as having been
longer the seat of febrile diseases than any locality of which  we
have  any authentic history.  Long before the time of Cicero
and Pompey, it had been desolated by the  poison  which con-
  *For these details concerning the Agro Romcno, I am chiefly indebted
to a spirited writer in the New York Review. 
9
stitutes the scourge of the magnificent valley of  the West.
And, after the lapse of more than twenty centuries, the same
malaria continues to hover over its  plains, and to walk in
darkness through its villages and cities.  The  Campania has
twice been rendered  salubrious by a wise system of drain-
ing and tillage ;  and twice has it been yielded back again to
the dominion of the pestilence.  Health has followed the foot-
steps  of industry, and, with the return of barbarism or indo-
lence, the waters have spread  over the plains unchecked, and
fevers have returned with all their pristine malignity.
  To all this we have many analogies at home.  I have cited
the case of the city of Louisville, where draining and cultiva-
tion have, in  a few years, introduced the most  favorable chan-
ges.  The clearing away of the forests, with a  consequent ex-
posure of a soil, rich in the remains of organic matter, to an
ardent sun,  on^the other hand,  has been a prolific source of
febrile disease in all  the south-western states; for  the barrier
which trees oppose to the spread of malaria has been remov-
ed from  the water courses, and  the noxious exhalations from
water, as well as from the virgin soil turned up by the plough,
have contributed to taint the  air.  Along all our streams dis-
ease is known  to have become much more prevalent, since
the shrubs and trees fringing their borders were cleared away.
I remember a beautiful country seat, in one of the Western
states, which lies near a small river that becomes  stagnant in
summer and autumn.   In early times, and while the river was
yet surrounded by a dense  forest, the locality  was one of the
most healthy in all that neighborhood.  A case of fever, for
some years after a large family settled  upon it,  was of rare
occurrence.  But as the  fields were extended and the forests
removed, the visits of this malady  became  more frequent.
The trees which once stood  between the dwelling and the
river have now  been  hewn away, and the winds,  laden with
the seeds of disease,  meet with no obstruction.  The place is
subject to autumnal  fevers of a  malignant type.  This is but
one of innumerable instances that  might be cited; but so fa-
miliar must  the observation  be to all practitioners, that it 
10
 would  be  superfluous to multiply examples.  The river to
 which I have just referred is quite noted for its insalubrity,
 and it is worthy  of remark, that it is also the  site of a great
 many mills.   From the point where  the first mill is erected,
 to the mouth of the river, hardly a healthy situation in the
 neighborhood of it can be found.
   Another fact, connected with  the  propagation of miasms,
 of the highest importance, is  their dependence for  transmis-
 sion upon the winds.   A house built upon the eastern, or the
 north-eastern bank of a river or pond, receives the prevailing
 winds after they  have swept  these sources of malaria, and
 will  be more unhealthy than one which  stands in a southern
 or westerly direction from such collections of water.  Houses
 so built as to expose  their open doors and windows to the
 breezes coming over stagnant water  or marshes,  are  more
 subject to fevers than those in the same  village, on the same
 street, which oppose their rear, with  closed entrances, to the
 wind.   This  is the  statement of historians with  regard to
 Rome, and it is the experience of all towns and villages where
febrile diseases have been generated by collections of stagnant
 water.  In Rome, we are assured, that the interposition of so
 slight a barrier to the poison, as a piece of guaze, spread over
 the window-openings at night, will protect the sleeping  in-
 mates; whilst those who sleep with their windows open, and
 without such defence, in the direction of the marshes, are al-
 most sure to be attacked by fever. In all parts of the Western
 country, situations to the  south  of streams, especially if ele-
 vated, are comparatively healthy ; those which lie as far from
the water, north,  being unhealthy. Situations east, and north-
east, are subject  to  fevers; and  the  explanation is found in
the fact, that the  south, and south-west winds are prevalent
 in summer and autumn, with an interchange, occasionally, of
 a breeze from the north-west, later in the season.
  If upon this branch of my subject I seem to have dwelt at
undue length, my apology is, that it involves principles of the
deepest importance  to the  community.   "Sanos  sospitare,
cegrosque sanare," I have adopted as my motto, and I hold  the 
11
 first to be, not less than the last, the duty of the  physician.
 The public health is a matter of such vast concern, that  one
 may well  be  pardoned for a little prolixity in the detail of
 facts which have an intimate bearing upon it.  And, if I am
 not greatly mistaken, I have indicated, in the history I have
 given of the rise  and propagation of malaria, the mode by
 which the  range of the diseases  it produces  may be greatly
 limited.  Let the hygienic precepts that they suggest be pro-
 perly  inculcated upon the people, and they will be more in-
 dustrious in removing the sources of miasmata.   Let them be
 taught that fever is  the sure penalty annexed to a residence
on certain  banks of water-courses, and that it may, with great
 certainty,  be  avoided by  selecting a site at  a distance from
 them, and it is not probable that they will persevere in violat-
 ing so obvious and salutary a principle.  It is not saying too
 much to assert, that, by the observance of the laws which ex-
 perience and observation have established on this subject—by
 planting and draining,  by cultivating the soil, and  by the se-
 lecting of proper sites for dwellings—half the fevers might be
 prevented which now afflict the country, and annually rob it
 of many of its best citizens. I speak with the greater earnest-
 ness in reference to these things, because,  while the truth of
all that I have said is generally known and admitted by med-
ical men, they do not appear to me  to have exerted them-
selves as they  might have done, to reform the people on these
points  of hygiene.  To my mind, it involves truths of  the
deepest practical import, and it  is only by impressing them
upon individuals and the public authorities that we can hope
for reform, and the improvement of the general health.
  I am aware that it is contended by some,  not without plaus-
ibility, that there is  no  specific cause of fever;  but that it is
excited by vicissitudes of atmospherical temperature, and by
 the chilling effects of the  vapors condensed  into fog by  the
coolness of the evening.  But the fact, that fever has a specific
type—as distinct and peculiar as small pox or measles—that
houses, in particular situations near water, are healthy, while 
12
others, not nearer, but  to the leeward,  are  unhealthy, both
being alike enveloped in the  fogs arising from the water—that
in places once  famed for their  insalubrity  health  has  been
brought about by draining, while the air continues  to be sur-
charged  with aqueous  vapor exhaled from  the neighboring
streams, as is strikingly true of a city to which I have already
alluded*—and  that the  draining of a mill-pond, by which the
quantity of atmospherical moisture in its  vicinity  is diminish-
ed, taints the summer and autumnal air in all the surrounding
region—all point to a specific cause.  And this  cause we con-
tinue to refer to marshes, or the exhalation of moisture from
a bed of putrifying organic matter; but we  are compelled to
admit, at the same time, that this poison has never been de-
tected by any  chemical test as a constituent  in the atmos-
phere of infected places.  Broschi directed a long  series of
cautious experiments  to the solution of  the problem; and in
the air of one of the most pestilential regions in the Campag-
na di Roma he  thought, by  his first analysis, he had detected
the miasmatic particles.  On renewing the experiments, how-
ever, and collecting  the vapor with new precautions, he was
unable to discover the  slightest trace  of either vegetable or
animal  matter.  Moschati  examined the air of some insalu-
brious rice-fields in Tuscany, from which it appeared that  it
contained albuminous flocculi, but the  nature  of  which he
could not determine.f   Prout, in  his Bridgewater  Treatise,
mentions that,  during the prevalence of cholera, in London,
he found the atmosphere to be increased in weight, and stead-
ily so, and the explanation of the fact he supposes to be, that
some gaseous body was diffused through the air of the city,
considerably heavier than the air it displaced ; but the charac-
ter, and even the existence, of this gas, was a matter of con-
jecture.  M. Rigand de ITsle made a series of experiments in

  * Louisville.
  fRecords of General Science, quoted by the American Jour, of Med.
Sci. for Nov. 1836. 
13
  the marshes ofLanguedoc with a view of detecting the poison
  of fever.   He condensed the dew upon glass, and, like Mos-
  chati, found flocculi possessing the  properties of animal mat-
  ter, but without being able  to prove that he discovered the
  miasm.*   A more laborious series of experiments were insti-
  tuted by Boussingault, with the same view, and  although  he
  detected organic  matter in  the vapor  over the  marshes,  he
  was not more successful than the preceding chemists in insu-
  lating the  peculiar  poison.  I will  only add, that such  has
  been the result of other investigations, instituted with a view
  to the discovery of this  most prevalent  but hidden poison,
'  which, as  we have  seen, is as rife and  as potent now, in the
  marshes around Rome,.as it was in  the  time  of Tacitus, and
  which all  that has hitherto been done by the hand of industry
  in our south-western  valley  has not  materially  abated—I
  ought, perhaps, rather to  say, that  the amount of cultivation
  in the West has only fully developed the poison, which a higher
  cultivation may subdue; and with this remark, I dismiss the
  first branch of my subject.

                     PATHOLOGY OF FEVER.

    This is one of the vexed questions  of the day.  It is not my
  intention to present a history of all the theories of fever which
  have been  proposed in the  various  ages of Medicine, much
  less to attempt an estimate  of their several  merits.  This I
  should deem a most unprofitable consumption of time;  and I
  shall therefore confine my remarks,-on this head, to the two
•  most  prominent of the modern theories, the anatomical theo-
  ry of Broussais, Louis, Bouillaud, Bretonneau,  &c,  and the
  congestive theory of Armstrong, Johnson, and others, pre-
  senting afterwards,  a view of the phenomena  of fever as they
  appear to  be successively developed.  I shall speak first  of
  the congestive theory.
*Ib. loc. citat. 
14
   According to Armstrong, the essential or proximate cause
 of fever consists in a  congestion of the internal veins of the
 body, and particularly those of the portal circle.  It was a
 belief expressed in his earlier writings, that, in the pathology
 of fever, the  right side of the heart would come to be the only
 structure worth studying.   The vena cava, in this view of the
 matter, is  the seat of the  primary morbid action.   The heart
 is enfeebled by the malarious poison, in consequence  of  the
 deteriorated  character of the blood, which has become black
 by the action of the miasm, and lails to supply the heart with
 its natural stimulus.  Hence it accumulates in the large veins
 for the want of power  in  the heart to  propel  it forward.
 Congestion,  in the view of those who  adopt the  hypothesis,
 is the great evil—the  causa sine qua non—which being  re-
 moved, the fever ceases.
   To this theory, whatever may be the arguments  in its favor,
 there is an objection that I  cannot help regarding as fatal to
 it—which  is, that the results of post mortem examinations do
 not reveal  such a condition of the  venous cavity.  In a large
 majority of cases subjected to the testof the anatomist's knife,
 the liver has  not been found in a state of congestion, or as ex-
 hibiting any  morbid lesion.   True, in nearly all fatal cases of
 fever, traces of congestion or of inflammation  are to be seen
 in some of the abdominal viscera; and often, also, in the or-
 gans of the chest and of the head.   But, so far as I have had
 opportunity to  compare  the histories of such cases, as given
 by the writers of all the conflicting  schools, I have not been
 able to discover, that deep congestion of the vena cava, or of
 the portal circle, is by any means a uniform appearance.  On
 this point,  the testimony of Dr. Bailly is very  full and strik-
 ing*   This eminent physician  visited Rome in  1820, 1821,
and 1822, for the express  purpose of studying the malignant

  *Traitie Anatomico—Pathologique des Feivres Intermittentes, Simples
et Pernicieuses.  Paris, 1825. 
15
fevers of that country.   He has recorded the histories of thir-
ty-six fatal cases of what he  terms malignant intermittents,
but which, in this country, would be called congestive fever.
They exhibited, in their progress, every mark of deep conges-
tion.  Many of them terminated  in twenty-four hours.  The
bodies of the patients were of  an icy coldness.   Some of
the victims  were comatose  almost from the beginning, and
others were foolish, like men intoxicated.  In some, there was
complete prostration of the muscular powers; but others were
able to walk about their rooms onty a few hours before death.
In all, great coldness of the surface was present—a general
shrinking of the features and extremities—the pulse was not
to be felt at the wrist,  and, now and then, not even in the ca-
rotids:—in all of which we  trace the strongest resemblance
to the character of our own congestive fever.
   Of the thirty-six fatal cases recorded by Dr. Bailly,* the au-
topsy discovered arachnitis in 25 ;  in  19, gastro-enteritis; in
18, splenitis ; in 3, diffluent spleen, and in 3, ruptured spleen ;
in 13, cephalitis; in 7,  gastritis;  in 7, enteritis; in 5, altera-
tions of the liver, of which, one was by inflammation, two by
congestion, and two by putrilaginous  softening.   Pneumoni-
tis, pericarditis, peritonitis,  and  inflammation in other  parts
were detected in many cases.  From these  statistics we see,
that the tissue which suffered most frequently was the  arach-
noid  membrane.   If, however, we add the seven cases of gas-
tritis to the nineteen of gastro-enteritis, we  have  twenty-six
cases in which the stomach suffered.  In every instance, in-
flammation in some  part of the contents of the abdomen was
discovered.   In thirty out of the thirty-six cases,  there was
inflammation of the brain, or of its arachnoid membrane, con-
joined with inflammation in some part of the digestive canal.
The  liver was found in abnormal condition in but five of the
whole number, and congested in  but two.
   I will not undertake to affirm, that  the experience  of all
•Quoted by Dr. John Bell. Lectures. Phila. 1840.
                        2 
16
writers on this subject is equally unfavorable to the conges-
tive theory.  Dr. Davis, for example,  says, "dissection  has
shown that the organs  primarily affected are the  liver and
the spleen.  In subjects who have expired of this disease, even
in the  early stage, these viscera have always appeared  to be
materially altered in their structure."*  Cleghorn says, "I
have examined the bodies of nearly a hundred persons who
perished in these fevers, and constantly  found one or other of
the adipose parts in the lower belly (the cacol, mesentery, co-
lon, &c.)  of a  dark black complexion,  or totally corrupted;
the vesica fellea full  and turgid, and the stomach  and intes-
tines overflowing with bilious matter:  the spleen larger and
sometimes weighing  four or five pounds, and so excessively
soft and rotten, that it had more the appearance of coagulated
blood wrapt up in a membrane, than of any organical part."f
Still, I  cannot refrain from  remarking, that the  statistics fur-
nished by  Bailly  appear to my mind to amount, as  regards
that theory, to an experimentum crucis.   If congestion be the
foris et origo of fever, how could it have  been absent in so
many of these cases?  And if present, to hurry on the cases to
the catastrophe, how are we to account  for the disappearance
of it, so soon after death?   If the liver  bear so  much of  the
onus of febrile  disorder,  as is maintained by the advocates of
the congestive doctrine, why do we find it,  at the end of the
worst cases, so often in a sound condition?  Is not the infer-
ence irresistible, that, being sound, it is guiltless of the mis-
chief, either as the primary cause, or as  involved secondarily,
and contributing to maintain the morbid action?
   In Dr. Bailly's cases, the spleen, of all the organs, gave the
most frequent  proofs of congestion ; for in twenty-three ca-
ses out of the  thirty-six, it was in this state, or in a state of
congestion conjoined with inflammation.  The congestion, in
a few instances, had progressed to  the  point  of breaking up
the tissues of that organ.  Dr. Shapter,  in the Library of
Practical Medicine, also testifies to the frequency of lesions of
*On the Walcheren Fever.
tDiseases of Minorca. 
17
the spleen in fatal cases of intermittent feVer.  According to
all the authorities, indeed, this organ appears to be singularly
often affected.  But it were easy to show, I think, that this
condition of the spleen is  a consequence, and not the cause,
of the febrile commotion.  Who, for example, has not seen
cases of enlarged spleen  without fever?   This viscus occa-
sionally becomes so much increased in size, in consequence of
repeated attacks  of ague, as almost to fill up the abdominal
cavity. And yet it is well known, that with all this congestion
of the organ, iever is by no means  the invariable attendant.
That it sometimes is, will not be denied; and that such a con-
dition of the spleen adds to the  difficulty of curing intermit-
tents, all physicians have experienced. But it is as well known,
that the chills may be checked, and  temporarily, if not per-
manently,  cured, while the spleen  maintains  its unnatural
size.  The two parts of'the argument then, are, that the spleen
may be enlarged without  exciting fever; and that where they
are conjoined,  the fever may  be relieved without  removing
the congestion of the spleen.   And  a distinct argument is,
that the spleen is not invariably found in a diseased state at
the close of congestive fevers.  Why it should  be often so  is
easily explained.   During the chill, which precedes all fevers,
the blood is accumulated in great quantities in the  spleen by
the very nature of its circulation.   This organ  is of a pecu-
liarly loose, spongy, and  vascular texture.   In  intermittent
fever the febrile reaction is very great, and  the engorgement
of the spleen returning  with every  paroxysm, in the end, its
structure can hardly fail to become altered.   The  morbid state
thus induced in it, as an altered condition of any other organ,
will react  upon the irritated  nervous system,  and become,
secondarily, the means of keeping  up the morbid commotion.
In  like manner, congestion of the liver becomes a source of
mischief, as must local  lesions  in whatever important organ
existing.
   According to this view of the subject, it is unphilosophical
to regard hepatic congestion as the cause of fever, and, con-
sequently,  to address all our remedies to the liver. 
18
   I shall next inquire whether, by the same course of reason-
 ing, gastro-enteritis, arachnitis, &c.  are  not excluded as the
 essential cause of fever.  Some of these lesions attend all fatal
 cases of the disease, according to the experience of every pa-
 thologist, and probably contribute largely to the fatal termin-
 ation.   But do they not very often  occur independently of
 fever, and run their course without developing that disease?
 Is it not a matter of daily  observation, that gastritis, and in-
 flammation of the intestines may exist, and yet every pathog-
 nomonic symptom of bilious  fever be absent?  In dysentery,
 cholera, gastritis, diarrhoea, ccc.  the  symptoms are specific,
 but not those of miasmatic fevers.  Arsenic or the other irri-
 tating poisons excite gastro-enteritis;  but in such cases there
 are not the regular, well-marked paroxysms of fever.  In dys-
 pepsia the stomach is often in a state of sub-acute inflamma-
 tion ; yet this inflammation is far from developing an  inter-
 mittent or remittent fever.   Fever and such local lesions co-
 exist; but  these points  of  irritation,  however they may ag-
 gravate and perpetuate  the fever, cannot be  regarded as the
 cause of it.
  The following facts are equally unfavorable to the hypoth-
 esis under consideration : the irritation produced by introdu-
 cing a catheter will sometimes excite  a chill,  followed by fe-
 ver, which may be repeated for several days: I have seen a
 severe paroxysm of fever developed  by keeping a tent in an
 irritable ulcer on the side for an hour, which could not have
 been distinguished  from a  regular  intermittent.  The shock
 of a cold bath has been followed by a chill and fever, which
 recurred at the same hour the next day.  Bad cases of stric-
 ture and retention of urine  are pretty  uniformly attended by
 the phenomena of intermittents, so that we have a class of
 what are called urinary  fevers. Richter cites a case in which
 the irritation of worms brought on the disease.  The suppres-
sion of the catamenia and  of other habitual  discharges has
been known to excite it. Shapter mentions the  case of a girl
nine years  of age,  in which a true  tertain was clearly refer-
rible to fright.  In all  these  cases the fever is, indisputably, 
19
quite  independent of gastric or intestinal irritation, and the
facts show that an intermittent may arise and persist without
such a cause.
  We are assured, that "every system  and every organ in
the body may be, and frequently is, diseased during the course
of fever;" and it is even probable that in a great majority of
cases, "death is  the  result of one or many local inflamma-
tions."*  But there is no constancy,  no uniformity either in
the seat or extent of the local disease.  In one, we  find the
intestinal canal  healthy; in  another,  the same  parts present
extensive disorganizations; and yet the symptoms  in both,
during life, were the same.   Or we find, in other cases, the
lungs  inflamed,  arachnitis,   or rupture of the  spleen; and
in others, find all these organs in a healthy state.  But if, as
held by the advocates of the gastric theory, fever were a mere
exponent of  the inflammatory condition of the stomach and
intestinal canal, we should as uniformly find such local lesions
after the death of febrile patients,  as we find disorganization
of the lungs in death from pulmonitis;  which,  we have seen,
is far from being the fact.  Nor is this all, for we may have
several patients  presenting  different symptoms, and  yet on
examination, post mortem, find the same  morbid changes in
all.   In one, the phenomena  of typhus  may be present; in
another, this condition may be slightly marked; in a third, it
may be absent;  and yet, in  every one, we shall trace  the
same local lesion.  Do we find, here, any  of that constancy
which subsists  between cause and effect?   We have similar
symptoms excited by diverse  lesions ; and various phenomena
excited by similar organic changes.  To say that in such ca-
ses the fever  is symptomatic of the local lesion, would be ab-
surd.   "A child," says Stokes, "is exposed to the contagion of
smallpox; for sometime nothing particular is  observed; he
then gets ill and feverish, and this is followed by an eruption
of variolous  pustules.   Here we have  a local disease conse-
quent upon a circumstance  affecting the whole system, and

  *Stokes' Lectures, p. 409.
                            2* 
20
in this, as in local ulcerations attendant  upon  typhus, the
local lesion is secondary.  We might as well argue  that the
pustules were the cause of the symptoms in one case, as to
say that the ulceration of the intestines was the  cause  of the
other."*
  Finally; the well known effect of bark in intermittent  fe-
ver seems  to  me fatal to the doctrine of the physiological
school.   If we  possess in any remedy a specific for any dis-
order, it is  this  article in recent cases of ague and fever.  And
yet bark is a tonic,  a stimulant, and  in  genuine  gastritis
would be  as   mischievous, as  in  intermittent  fever it  is
known to be salutary.  How is it to be explained, that recent
and acute gastritis is subdued by a remedy proved to be per-
nicious  in  other phlegmasia^ ?   I confess that  the analogies
cited by Broussais and his followers do not strike me as true.
Chronic opthalmia,  diarrhoea,  and  blennorrhagia, caused by
stimulants, bear little resemblance  to the inflammation that
occurs during the progress of fever in the mucous membrane
of  the stomach.
   The  true account of the phenomena appears then,  to be,
 that  the repetition and excessive amount of the local conges-
tions occurring in  the cold stage of fevers, give rise to a hy-
 perasmic condition of the  affected organs.  This condition,
frequently excited, leads, at last, to local inflammations. New
 local inflammations  are  set up in various organs, and these,
 which, in the beginning, were only the effect of the disease,
 become, by reacting on  the system, the cause of its continu-
 ance^   And hence, it appears,  that in almost all cases of fe-
 ver, there  is a  combination of the  essential and the sympa-
 thetic fevers—the essential, the  result of the first cause—the
 impress of malaria upon the nervous system—and the sym-
 pathetic, the result of the local lesions which arise  during its
 course.  So that, in the treatment  of this  disease,  we are to
 bear in mind,  not only the phenomena which seem  to grow
 out of a general disturbance of the nervous system, but those
   *Stokes. Od. cit. p. 414.
   fib. 
21
local inflammations also, which, springing up in its progress,
serve to perpetuate  the fever.   We thus obviate the danger
of death from the violence of the local affections, as also, the
disturbance resulting from sympathetic irritation;  whilst we
reduce  the disease to a state  of  the greatest simplicity, in
whice quinine or bark may  be given to arrest it.   Upon the
fact,  that,  these  local lesions being removed,  the accompa.
nying fever often speedily subsides, Broussais chiefly  founded
his  doctrine.  But it has  been shown that this was a hasty
generalization.   The true explanation of the fact is, that by
subduing the local inflammation, we remove a focus of irrita-
tion, which opposed the salutary operations of nature.*  Af-
ter a few paroxysms of fever, we  have ample reasons to sus-
 pect such local complications, and it  is then found too late to
 rely upon quinine alone even in intermittents.  Whether the
 inflammation be  in  the  viscera of the abdomen,  the thorax,
 or the cranium—and  we have seen that all are occasionally
 involved—it constitutes a part of the morbid chain,  and calls
 for a corresponding complexity of treatment.  The  antiphlo-
 gistic  alone is not sufficient,  as in  pleuritis; nor that alone
 which acts upon the system.
    The poison producing fever seems to exert its first  influence
 upon the nervous system.  The nerves of the cerebro-spinal
 axis are  first disturbed.   Hence the  langour, head-ache, dul-
 ness, loss of apetite, disturbed sleep, and general malaise, the
 precursors  of an attack of fever.   The  nervous system is
 marked  by a peculiar  law—that of periodicity, or  intermis-
 sion.f  It is active, and reposes by turns.  Repose  is  essen-
 tial to its  health.  Intermission being  an attribute of the tis-
 sue which sustains the first morbid impression, the same char-
 acter  is stamped upon the disease.  All  essential fevers ex-
  hibit this tendency, and in  one type, the intermission is com-
  plete.   All diseases located in the  nervous system are inter-
  mittent, notwithstanding that the  cause may be permanent.
*Stokes, Op. cit. p. 416.
fDr. John Bell's Lectures, p. 550. 
22
A spicula of bone, for example, irritating the  brain will ex-
cite epilepsy recurring at distant  intervals, though the irrita-
tion be always present.  And, in like manner, coma, catalep-
sy and hysteria recur periodically, while  the cause of irrita-
tion may be  some permanent  organic lesion.  In fever,  the
system of nerves controlling animal  life being depressed, all
parts of  the system—the skin, the  viscera, and all the organs
of circulation—are disturbed with it.  For it is not mere de-
pression  of action; it is action also  perverted.  Congestions
of the viscera, abdominal, thoracic, and cerebral, occur, which
changes  of temperature,  irregularities  of all sorts, fatigue,
etc., especially favor; and these congestions being  repeated,
to be followed, still, by violent  reaction, lesions at length are
established in  some  system of  organs, and become indepen-
dent foci of irritation,  reacting upon the  cerebro-spinal axis,
and  increasing  and  perpetuating the morbid commotion.—
That  the intestinal canal should become most frequently the
seat of these local inflammations would  be inferred a priori,
if post mortem examinations  had not  established  the  fact,
from the  circumstance  of the extreme excitability of this tis-
sue,  and that  it is peculiarly  under the  influence of aerial
vicissitudes, of mental emotions, of fatigue,  and of food and
drink. All  these, in fact, become the exciting causes of fe-
ver,  when the nervous system is laboring under the effects
of malaria.  They often hasten the attack of which the  pre-
monitory symptoms  had  been for some  days in existence;
and by irritating the digestive apparatus they favour conges-
tions and inflammation in that system*.
  Thus,  to recapitulate, we  have   two classes of  phenomena
conjoined in fever: the first, irritation of  the nervous system
induced by the impress of malaria; the second, congestion or
inflammation of some  part, most  commonly  the mucous lin-
ing of the stomach and intestines, or of some of  the associ-
ated organs, but  often, also, of the lungs, and of the brain
and its membranes.  In the chill,  the nervous system is de-
pressed, and with it  the  action of the suffering organs  falls
below the healthy standard.  Reaction  follows the chill, and 
23
the diseased  organs also reacting, irritate the nervous system
still  further,  and  excite  the heart  to more  violent action.

                        TREATMENT.

  In  the access of fever it is impossible to say what type it
will assume.  Remittent fever may be converted into an in-
termittent,  by good management, in favorable cases, and in-
termittents often degenerate into  the remittent form, or even
assume the character of the formidable congestive type.  In
the same family, we  meet with  all the grades, from the mild
intermittent to the congestive.
  Dr. Cartwright  assured  the  writer of this  paper,  that, in
the  yellow fever  which  prevailed in Mobile,  New Orleans,
and Natchez, in 1839, if,  in the forming stage  of the disease,
viz; within  an hour or two  after the access of the chill, ten
grains  of sulphate of quinine were administered in a single
dose, it often had the effect of arresting the fever or convert-
ing it into  a mild and tractable form.*  The  same is true of
the common intermittent; but, as in yellow fever, the reme-
dy  must be administered  before the case is complicated by lo-
cal inflammations.   It was only while  the fever  was form-
ing that  the quinine  possessed  the power of subduing it;
and it is only  after the first few  paroxysms, that this article
can be  relied on, singly,  in chills and  fever.   After a few of

  *Dr. Johnson in his work on Tropical Climates reports a similar prac-
tice as having been pursued by La Fucute, with singular success, in a
malignant fever of Andalusia. "His  plan," he remarks, "was to  force
the patient, if possible, to swallow six or eight ounces of bark within
the first forty-eight hours of the disease.  At the village of Los Barios,
a few miles distant, from St. Roque, ninety patients took the bark within
the  first eight hours of the fever, of whom none died, excepting one
man carried off by a gouty affection.  Of eight patients to whom it was
administered between the eighth and tenth hour, all recovered.  Of five
who began between the twelfth and twenty-fourth hour, three recovered
and two died.  Of twenty who did not take it till the second day, thir-
teen recovered and seven died.  Of seventeen who waited till the third
or fourth day, eight recovered  and nine died.   And lastly, out of eighty
persons who made  no use of the bark, but took other remedies, only
twenty-two recovered and fifty-eight died." 
24
these commotions, it has been seen, the viscera become invol-
ved in disease demanding other treatment.  In confirmed cas-
es,  purgatives must  be superadded to the bark or quinine;
and, not unfrequently, venesection, local and general, becomes
necessary  to subdue the local inflammations.   Of the propri-
ety of the last named remedy,  the physician will judge from
the violence of the paroxysm,  the amount of local pain com-
plained of, and the evidences, on examination, of inflamma-
tion in any organ.  Dr. Stokes urges,  with great  emphasis,
the  importance of such an  examination of all the regions of
the body.   " Here, gentlemen," he observes, " let me entreat
of you to  lay this down for  yourselves as  a rule  never to be
departed from,  that before you  prescribe the slightest medi-
cine you first make an accurate and perfect survey of the state
of the  viscera.  The whole nicety of treatment," he con-
tinues, "turns  on this.  If the case be one of the  essential
kind, we know the remedy which  will answer,  if not in all,
at least in the majority of cases.  If it be symptomatic, your
treatment must be directed to the removal of the local lesions."*
Quinine, aided, if complications exist, by moderate bleedings,
and an occasional cathartic, of which calomel is the best, will
not often fail to check intermittent fever.  But the disease is
known to  be peculiarly apt to return again, on any slight ex-
posure or  indiscretion of the patient, and,  after  repeated re-
currences, to induce  an anoemic condition  of the system.  It
becomes almost a  law  of the economy, and  although often
checked by quinine, as frequently  appearing again under the
most  trifling irregularities.  Such  cases are  familiar  to all
practitioners in miasmatic districts of country.   Continuing,
at intervals, through  the winter, they break out in the spring,
and persist during the summer.  In such cases, bark and qui-
nine cannot be depended  upon; and, as in all similar states of
the sanguineous system, in which the blood appears to be de-
generated from a  healthy condition and to  be deficient in red
globules, the preparations of iron exert the  happiest influence.
*0p. cit. 
25
Trousseau developes this principle fully in his recent treatise
on Materia Medica.  Dr. Stokes, also, gives his testimony to
the value of iron, in such  conditions of the system.  I have
relieved many of these obstinate cases of intermittent by the
carbonate  of iron, combined with a vegetable  bitter.  The
ferro-cyanate of iron, however, is the form which seems to be
best adapted to these cases.  Stokes esteems the introduction
of Prussian blue  as a great  improvement  in  medicine.  He
gives it in doses of from a "scruple to half a dram, three  times
a day."
  The only other remedy of which I shall speak in simple in-
termittent  is arsenic, which,  according to M'CulIock, Sir Gil-
bert Blane, and others, may be used in some cases where bark
has failed.   This, Sir Gilbert found, was the fact in the  fever
which afflicted the British troops during  the Walcheren ex-
pedition.   In the fevers of young subjects who can with diffi-
culty be brought under the  influence of  quinine or bark, I
have often  used  Fowler's solution  with  satisfactory results.
But where quinine can be given, and is borne by the patient,
it is superior to all  other  remedies  in recent cases; and has
this advantage over arsenic, that it is uniformly harmless. Ca-
ses are on  record, in which  patients, who had used  arsenic,
fell into bad health, became  weak, emaciated, and presented
a remarkable  derangement of the  digestive organs, after re-
covery from the fever.  Stokes relates instances of irremedia-
ble mischief from the long-continued use of this remedy. Such
have never occurred in my  practice; but the experience of
so  able a practitioner should induce  caution in  others.   The
dose of quinine commonly prescribed may be increased with
advantage. Dr. Stokes prefers ten grains at a. dose, once a
 day, to the same quantity in smaller doses during the day.   I
 remember an  interesting  case, which goes to the same point,
 I had a patient, a  young  man from Alabama,  who, having
 had a severe attack of pleuritis in  the winter, fell  into chills
 and fever in the spring.  He tried the quinine in doses of one
 and two grains, and with them  succeeded in  checking the
 disease ; but it still returned.  In one of the paroxysms, per- 
26
haps the second of a third relapse,  I gave him sixteen grains
at a single dose, in the height of the  chill.  Warmth was
soon restored; sweating came on without any well-marked
febrile  paroxysm;  and the chills left him to return no more.
I have  alluded to a condition of the system, induced by re-
peated  attacks  of  intermittent fever, in which the prepara-
tions of iron exert  an excellent influence, but I should leave
the subject very incomplete without a reference to those vis-
ceral obstructions that are so  likely to arise in the progress of
this disease, and which, in fact, constitute one of its chief sour-
ces of danger.  Dropsy is a well known consequence  of such
obstructions, and it has lately become  a matter of remark,
that tubercular consumption  is frequently developed in per-
sons whose health  has suffered from  long continued intermit-
tents.  The danger of so formidable a disease should cause us
to redouble our diligence to subdue the  fever while yet in its
recent  and tractable  stage.   In chronic  cases the  patient
should, if possible,  seek  a change of air, avoiding localities
where  malaria abounds; and, for the  rest, should adopt all
those measures which are calculated to restore the deranged
viscera to  healthy action, and impart tone and vigor to the
system.  For fulfilling the latter indication some  practitioners
prescribe sulphate  of copper,  in preference to the salts of iron,
combining it either with quinine or some astringent bitter.
In such cases, almost every thing depends upon  the care and
discretion of the patient, and  without his faithful co-operation
relapses will continue to take  place, and, at  length, some of
the dreaded sequelae will make their appearance, in spite of
all  the resources of the physician.
   Intermittent fever, now and then, assumes a form in south-
ern climates, in which  other modifications  of treatment be-
come necessary.  I allude to what  is called in this  country,
congestive fever, but  which seems to have been long ago de-
scribed by writers under the name of  "malignant intermit-
tent."   Alibert gives an accurate description of  congestive
fever under the title  of "algid"  intermittent.  From the de-
scriptions given by Senac, Lancisci, Lind, Pringle and Cleo-- 
27
 horn as well as by Bailly more recently, of these intermittents, it
 is clear to my mind, that they are identical with the formida-
 ble fever of our region.  A more graphic account of our con-
 gestive fevers could not be found than that'contributed  by
 surgeon  Shields in Johnson's work on  Tropical  Climates.
 "The patient,"  he says, "on the first attack frequently falls
 down and is insensible during the  paroxysm, his body cover-
 ed with cold clammy  sweats, except at  the pit of the stom-
 ach, which always feels hot to the palm of the  hand; the
 pulse is small  and quick.  The  length of the paroxysm va-
 ries from six to eighteen hours, and  was generally succeeded
 by cold rigors,  very often low  delirium, preparatory to the
 next stage or  paroxysm of the fever.   The intellectual func-
 tions now become impaired, the patient not being at all sensi-
 ble of his situation or of any particular ailment.  If the pa-
 tient be asked how he  is, he commonly  answers 'very  well,'
 and seems surprised at the question.  This is a very  danger-
 ous symptom, few recovering in whom  it  appeared.  A great
 proportion changed in  a few days to a bright yellow, some to
 a leaden color;  other cases terminated fatally,in a very rap-
 id manner,  too,  without the  slightest alteration in that res-
 pect.  Generally,  however, the  change  of  color  indicated
 great danger.   In  some a purging of vitiated bile occurred ;
 in a great many a torpor prevailed throughout the intestinal
 canal; rarely did any  natural fasces appear spontaneously."
  Lind describes the following case as a malignant  intermit-
 tent,  which  answers  fully  to the  symptoms of congestive
 fever:

  "A young gentleman  was seized  with a  fit of an  ague, and
 in half an hour became delirious, then comatose, and  at length
 speechless.  Finding him in this state, I ordered a blister  to
 be applied to his back,  and a cordial julep with salt  of harts-
 horn to be poured by degrees  into  his mouth.  In two hours
afterwards, upon  recovering his senses so  as to swallow with
ease, I ordered him two ounces of  tinture sacra, and then as
soon as the fever and sweat had abated, without waiting for
 the complete  effect of the purge, half a dram of bark every
four hours.  He  began the use of the bark three hours  after
                            3 
4
                            28

 he  had taken the tinct. sacra; but before he had taken five
 drachms  of it, he was seized with  a second  fit, and in like
 manner became  delirious, comatose, and  speechless.  Sinap-
 isms were applied to his feet, and other irritating applications
 used, until the fever was terminated by a plentiful sweat.—
 Thus,  having, twice narrowly  escaped  dying  in  the  fit, a
 dram of  the bark was ordered to be taken punctually every
 hour.  He soon  took two ounces of it, which had so happy
 an effect, that the fever left him entirely, and he was quickly
 restored to perfect health."*

   I will add one case  more of algid fever,  as given  by Dr.
 Bailly.  The subject of it was a man set.  60 years, of thin
 habit of body, but healthy up to the  time of the  attack,  18th
 August.

   "He had a paroxysm of the common kind, which went off in
 a  sweat.   On the 19th he was brought to the hospital, and
 had a return of the  fit, in which he  complained  much of in-
 ward heat.  Expression anxious; the features were in a man-
 eer flattened on  the bones of the face; the complexion was
 natural;  look  heavy.   Evening: decline of  the  fit,  skin
 moistened  with  a viscous  and cold sweat; pulse  small and
 frequent; agitation general; pain at the epigastrium ; tongue
 red, but moist—no thirst.  (Half an ounce of bark.)  Through-
 out the night the  skin was moist.  Patient vomited the bark.
   "On the 20th of August, in  the morning, there was a  re-
 mission of fever,  the pain had disappeared, and  the counte-
 nance was tranquil.  About noon, a fresh paroxysm came
 on, and although a great heat succeeded the chill, the extrem-
 ities remained cold, and  the skin was covered with livid spots.
 On the 21st, general  calm, but  the extremities still cold; pulse
 small and  frequent.   Towards noon, there was a return  of
 fever, preceded by chill; exacerbation of the preceding symp-
 toms. The patient does not feel the coldness; he is in a meas-
 ure  benumbed and  torpid.  (Bark:  an ounce to  be  taken
 through the night.)
  22d. Skin less cold;  pulse small and frequent; a viscous
 sweat over the whole body; look heavy.  (Two  ounces  of
 bark.)   At 10  o'clock, return of the paroxysm ;  pulse not to
 be felt at the arm; beats  140 at the  crural artery.   An icy
coldness of the extremities; abdomen flattened, even con-

 *Essay on diseases incidental to Europeans, in Hot Climates, &e. 
29
cave, its parieties applied as it were to the spine ; pain of the
stomach, agitation, anguish;  the patient who has never lost
his understanding, is in a state of torpor, which barely allows
of his  answering any question.   The  complexion is natural.
(Twelve leeches applied to  the epigastrium; blisters to the
arms ;  bark, three ouuces in powder  to be taken during the
night.   He has vomited the bark.)
  "23d, A well  marked  remission.  Towards nine o'clock,
return  of the cold, which is like  that of marble; pulse imper-
ceptible, artery beats 144 at the thigh.  Pain of the stomach
more  intense; anxiety,  great torment, eyes sunken.   The
cold, which hitherto had been  confined to the extremities, ex-
tended to the shoulder and the pelvis.  The head was cool,
the thorax and abdomen not of their natural temperature ;
thighs icy like  the legs.   Evening; same state;  he did not
feel  the cold  of his  legs, but was aware when touched by
another that the  skin of the  latter was  warmer than his.
Pain of the stomach incessant.  Lies on the back.   Death at
3, A.  M."

   I will now briefly compare the  history of congestive fever
 with  the description of these cases.   Dr. Russel  thus writes
 of this fever:*

   "There is nothing  in the first chill or fever  calculated to
 alarm; but the second or third  may indicate the greatest dan-
 ger.   The chill is  not generally very distressing, but the ex-
 citement upon reaction is excessive—the pulse is full, frequent,
 and resisting;  the skin  hot; pain in the head  intense; the
 eyes often red; thirst for  cold  drinks urgent;  violent throb-
 bing of the  carotids—in fine every  symptom of a most ma-
 lignant fever is present.  Upon  the decline  of fever, a pro-
 fuse,  cold, clamy sweat breaks out, but affords no relief.  The
 pulse  rapidly sinks, becoming sometimes imperceptible,  lne
 whole surface is cold and shrunken, but especially the face,
 criving to the countenance a ghastly expression.  Great dis-
 tress,  referred to the  chest  and  epigastrium;  oftentimes a
 burning  heat, and superadded  is a restlessness, which the pa-
 tient  cannot  control.  Respiration  hurried and  difficult.  In
 some cases constant vomiting,  or repeated ineffectual efforts;
 in others, hypercatharsis, which usually ensues  after the ex-
 hibition of a hydragogue.  The strength of the patient is of-
* Transylvania Journal, vol. 6, p. 90. 
30
ten astonishing—he is able to rise at pleasure from his bed-
to change his position from place to place; in fine, to control
every muscle of his frame."

  The following is a case of congestive fever, reported by W.
J. Johnson in the first volume of the Southern Med. and Surg.
Journal:  About sunrise on a morning in August, 1835, a ne-
gro man, aged  30, was attacked  with pain  in the head and
shivering.  He  was ordered to bed, and wraped up warm,
and a bowl of hot sudorific tea was given him.   Patient com-
plained no more, and lay  in bed  perfectly  calm and quiet;
breathing laborious;  eyelids  open, and eyes  fixed; made no
reply when spoken to; extremities cold and clammy; pulse
slow and struggling.  Death in  a few hours.
  The same writer details the particulars of another case:


  "A boy at school, set. 14,  in the midst of apparent good
health,  was seized with congestive fever in such a degree
that he was thought to be  dying.  He  was bled, and vomited
—half-digested chesnuts were thrown up.   Cups were used,
with sinapisms to his extremities, and a blister to the neck.
He continued in a state of collapse.  By the use of calomel,
enemas, cupping, and stimulants, a large  quantity of dark, vi-
tiated, offensive bile was brought away from the  bowels.  Af-
ter this,  he became sensible and  expressed  himself  better.
Reaction was considerable, and the antiphlogistic  plan was
pursued for several days.   His friends entertained the strong-
est hopes of his  recovery, when  on a sudden he complained of
acute pain in the head—went delirious, and seemed foi some
time to be  laboring under an  attack  of  phrenitis.  These
symptoms were attended with convulsions and other nervous
symptoms.   Blisters were  re-applied to the head and behind
the ear; but notwithstanding this, he went in a fatal collapse,
from  which he  never  recovered.  The pupils  of his  eyes
were widely dilated, insensible to light; picking at the bed
clothes; low, muttering delirium ; incoherent   speech; sub-
sultus tendinum; involuntary evacuations, were the symp-
toms which closed the scene."


  I will not multiply instances;  but I cannot forbear express-
ing my belief, that any physician who will carefully compare 
31
what he has seen of congestive fever with the histories given
by European, and especially Italian writers, of the malignant
intermittents of miasmatic regions, will come  to the conclu-
sion, that the two diseases are identical.  In the congestive
fever of the South, therefore, I conclude that we have  the
algid fever of Alibut—the  pernicious or malignant intermit-
tent of Senac, Lancisi, Lind, and other old writers on the  dis-
eases of  the tropical climates.   It is proper, however, to re-
mark, that remittent as well as intermittent fever is subject
to degenerate into this malignant type, and in treating of the
cure I have not  pretended to distinguish between them, re-
garding them all as modifications of bilious fever.  Conges-
tive fever, I  have said,  calls for a modification of the treat-
ment usually  successful  in the simple  remittent or intermit-
tent.  That modification  has been introduced by the practi-
tioners of  the  Valley of the Mississippi, and if judiciously
adopted  and  pursued, promises to rob this fever of a large
share of its terrors.  It consists in the cold water dash, as in
cases of asphyxia, and in liberal doses of sulphate of quinine.
The latter remedy given  in the forming stage of the disease
will often convert it  into a simple  intermittent.   It is to be
given in ten  grain  doses, and repeated  according to circum-
stances.   Of the  application of cold water in asphyxia of such
fevers, with signal success, we are in possession of much  tes-
timony  from practitioners in various parts of the South-west.
Among the first to  adopt the practice, I believe, was Drs.
Fearne and Erskine, of Huntsville, Alabama; but without be-
ing acquainted with the results of their experiments, Dr.  Ad-
dams, of Cynthiana, Kentucky, resorted to it, with the hap-
piest results, in  the  asphyxiated stage of cholera.   Dr. Rus-
sel, in the article referred  to, has recorded some highly inter-
esting and instructive cases of recovery from congestive fever
under the use of the cold dash.  I cannot better illustrate  the
practice  than by  transcribing some of these  cases.
   His second case was that of a man whom he found in  the
greatest state of restlessness, complaining of a sense of exces-
sive internal heat.
                          3* 
32
   "His pulse  was barely  perceptible, skin cool and wet with
sweat, respiration impeded and  frequent; there had been no
evacuation from his bowels, notwithstanding  he had  taken,
according to the estimation of his friends, sixty grains  of cal-
omel. This being the third case I had seen, and my confidence
in the efficacy of cold water being unbounded, I without delay
made the application.  As usual, the relief was instantaneous,
and so agreeable was it to the patient, that for the remainder
of the time he was confined, he kept  by  his bed side a  vessel
of water which  he used at his pleasure  according to the sug-
gestion of his feelings.   Reaction was thus completely estab-
lished, and with mild cathartics  and quinine he  was entirely
restored  to health."

  Dr. Erskine details the particulars of  a case, the subject of
which was found in  the third paroxysm of  regular  inter-
mittent fever  of the tertian form, which had been neglected.
The cold, clammy surface, feeble pulse, great restlessness and
precordial  distress were  present, as in  all  such cases.  Cold
well-water, rendered colder by the addition of table-salt, was
dashed on the naked surface.   He feel asleep soon after being
put to bed, and had ten or twelve hours  rest.  Reaction  was
complete next morning, pulse slower and fuller; no return of
the clammy sweat.  "He  recovered  in  a few  days upon the
use of bark, with occasional doses of mild aperient medicine."
  A second case reported by Dr. Erskine is one of algid inter-
mittent.   The subject, a female, had the symptoms of simple
intermittent; but in the second paroxysm, symptoms of a ma-
lignant character occurred.  A cold, clammy sweat appeared
on the extremities, accompanied  with great restlessness  and
anxiety,  for  which Dr. E.  at first  tried sponging with cold
water, as  the friends objected to the cold  dash; but the pa-
tient growing much worse in twelve hours,  he had recourse
to the affusion.  When he resorted to it, the extremities were
cold and shrivelled, pulse feeble, features contracted; great
restlessness was  present, with considerable alienation of mind.
The water was poured  on her body from a pitcher, and being
wiped dry  she was put to bed, where she slept for an hour or
two.  The cold sweat  was then  found  to be returning,, and 
33
the cold water was  again applied.   The renewal  was found
necessary three or four times.  A few doses of calomel  and
quinine completed the cure.
  The last case reported  by Dr. Russell is in the language of
Dr. Fearn, and is highly instructive:


  "Sylvia, a favorite mulatto servant, belonging to Dr. David
Moore, was attacked with  intermittent fever on  the 11th of
September.  I saw her on the morning of the 16th, and found
her in the following condition :  Her whole body shrunk, cold,
and bathed in a  clammy perspiration—skin  shrivelled, as if
she had been for some time immersed in water.  The extrem-
ities were of a marble coldness—some restlessness, and occa-
sional sighing,  but  without any distinct pain ;  mental facul-
ties unimpaired ;  pulse scarcely perceptible at the wrist, and
beating 130 in a minute;  tongue  moist; cold drinks alone
were craved;  every thing warm or stimulant was loathed.   I
was informed that the first paroxysm had gone off in the usual
manner, with perspiration, and  was followed  by  a complete
intermission.  On the 13th, a second paroxysm came on; the
extremities continued cold for some time  after the body was
hot, and the fever did not give place to an entire intermission,
as it had done two days previously.   On the 15th some fever
continuing, an emetic of ant. tart,  was administered.  It op-
erated well, but not inordinately, both as an  emetic and ca-
thartic.  The fever subsided rapidly, perspiration came on,
and continued through the night, increasing in quantity, and
assuming a more  cold and clammy  character, until she was
reduced  to the situation in which I found her next morning."

   Cold affusions were ordered, to be repeated every two hours,
but  as the prescription was  left to be executed by  the over-
seer, the physician found, in the evening, that the bath had
been given but twice, and that the situation of his patient was
in no way improved.  On his visit in the evening the affusion
was again made,  and by next morning the danger  had pass-
en.   She had slept well—warmth was restored.   Quinine and
bark, with mild laxatives, were the only remedies subsequently
used.  The paroxysm  did not return, and the convalescence
was rapid.*
"Trans. Jour. Med. loc. eit. 
34
   To the efficacy of the cold affusion in the collapsed state of
 congestive fever, I will only add the testimony of Dr. Keller,
 of Alabama.   He says :

   "I have  seen it tried often, and in two-thirds of the cases it
 proved entirely  successful.  One  case  I recollect—that of a
 favorite servant; the family had despaired of her life, and had
 removed her to  an adjoining room to die.  She  was  entirely
 pulseless, and had been so for hours; the cold dash was applied
 twice in an hour, and in three hours  the excitement was so
 great as to require the free  use of the lancet—in a few days
 she was as well as ever."   He adds :  "If cold water fails to
 excite in this stage, you may consider the case of your  pa ■
 tient hopeless."

   Dr. K. has found it far more effectual in rousing the system
 from the state of asphyxia, or collapse, than the most power-
 ful stimulants.
   It is curious to remark, how exactly  this is in analogy with
 the action of the same remedy in asphyxia from other causes.
 In poisoning with the mephitic gases, and in cases of drown-
 ing,  or of syncope from the  effects of lightning, cold water in
 the form of affusions is well known to be the most  efficient
 remedy.  The same  is also  true of poisoning by opium; and
 late experiments go to prove that in the asphyxia induced  by
 an over dose of hydrocyanic acid it is the most certain restor-
 ative.  So  that,  on this point, we seem to have arrived at a
 general truth—to have established a great and valuable prin-
 ciple ; and  if future  researches should  confirm it, cold water
 will  become the remedy in all aphyxiated conditions of the
 system, whether induced by lightning,  the noxious gases,  an
 over dose of arsenic or prussic acid, or  occurring in  fever or
 cholera.  The experience of Dr. Addams in the collapse of
 cholera has already been alluded to, and his paper on  the sub-
ject contains the history of a number of cases of the highest
 interest,  to which,  as being  analagous to cases of congestive
 fever in the same stage, I will refer more in detail.
  His first  case is that of a man aged 30, of robust constitu-
 tion.  He had been affected  with  choleric symptoms  for four 
35
 or five days.  Collapse supervened on the fifth.  His skin was
 icy cold and bathed in perspiration—pulse nearly impercepti-
 ble,  breathing  oppressed, tongue  cold, spasms, eyes  sunk,
 "countenance collapsed."   Vomiting, and watery discharges
 from his bowels copious and frequent.   Recovered under  the
 cold water affusions, with a few doses of calomel and quinine.
   Case 2d.—A little boy, aged 11, had  all the above describ-
 ed symptoms.   Other remedies failing to excite, the cold affu-
 sion was applied, once and again;  reaction occurred, and he
 got well.
   In the third case the termination was fatal, the patient, a
 woman, aborting, and sinking twenty days after her attack.
 The cold water recovered her from the state of collapse, and
 her death was clearly the consequence  of the abortion.  The
 child had been dead for several weeks,  from appearances in-
 dicated.
   The next case  was one  of deep collapse.  It terminated
 favorably.  The cold water was  repeatedly  applied,  always
 restoring warmth and exciting the pulse.
   Dr. A. refers  to many cases treated  successfully  by other
 physicians  in the same  way.  After free depletion  by vene-
 section, purgatives and emetics,  he deems  the remedy inap-
 plicable.*
   It would  be difficult, I think, to find in the annals of Medi-
 cine, more  unequivocal testimony to the efficacy of any  re-
 medial agent, than has here  been  brought forward in favor of
 affusions of cold  water in the asphyxia of congestive fever.   I
 shall  add nothing to  these  details which already, perhaps,
 have been sufficiently extended.
   Before taking leave of the  treatment of congestive fever, I
 will allude briefly  to the views of a late writer on the subject.
 Dr. Hardin, of  Kentucky,  reported some  cases in the first
 volume of the Louisville Journal of Medicine and Surgery,
 marked by certain peculiarities, which terminated fatally.  In
a late number of the Western Journal of Medicine and Sur-
 gery he has  extended  his remarks,  and has added two fatal'
*Trans. Jour. Med. vol. 8, p. 61. 
36
 cases which exhibited the same peculiarity.  This peculiarity
 consisted in copious evacuations from the bowels of "mucus,
 as green as wheat, inodorous, exceedingly acid, and incapable
 of communicating any tinge to water."  He treated these ca-
 ses in the usual way, with calomel, v. s. blisters, ipecacuanha,
 pulv. antimon. &c.   Gangrene of the mouth and gums came
 on, with fatal symptoms of collapse.   He regards the green,
 mucus discharges as pathognomonic, and  insists, that when-
 ever they appear, calomel is poisonous, inducing  with fatal
 certainty gangrene  of the mouth.   In such cases he  applies
 sinapisms to the whole extent of the spine, upon the principle
 of arousing it  to  action, and thereby invoking secretion from
 the abdominal viscera. And this practice appears to have suc-
 ceeded  admirably in his hands.   He relates the histories of
 several  remarkable cases, and states that he has had  much ex-
 perience in the application of the remedy.   The following is
 the sixth case in Dr. Hardin's paper:

  "Sept. 1st. 1838, I was requested to visit a  youth aged 12
 or 13 years, of good constitution,  who had been sick some
 twelve  days.  Symptoms—expressed himself  as being free
 from pain ; tongue dark red and very dry;  skin rather hot;
 pulse  too frequent and sufficiently full; restlessness very con-
 siderable.  He had been in a similar condition from the com-
 mencement of the  attack;  had taken 25 grs.  calomel every
 night, with rhubarb on the following morning  when the cal-
 omel  failed  to operate.  Discharges represented as having
 been consistent and bilious  from the beginning.  The  same
 treatment was continued for one night longer.
  "Sept. 3d.  Gangrene of the gums apparent; surface cool;
 pulse small, weak and frequent; alvine evacuations represent-
 ed as  being still consistent and bilious; but upon inspection
 were found to be a dark green mucus.   Spinal irritation with
 mustard seed was used every twelve  hours,  and the bowels
 moved with rhubarb.  Under  this treatment the patient re-
covered, but was  considerably  endangered for  some days by
gangrene and hemorrhage from the gums."*

  In all cases of this  fever (congestive) of ordinary violence,
*See No. xiv. of this Journal. 
37
 Dr. H. found the respiration laborious, with feeble radial pul-
 sation, cool surface and extremities, and an intolerable sense
 of weight at the epigastrium.  He  had  in  vain attempted to
 rouse the circulation by synapisms and warmth to the  ex-
 tremities ; but, applied to the spine, they have produced mark-
 ed  advantage.  The extremities grew warm, the praecordial
 distress is removed; in other words, the balance of the circu-
 lation is restored.  Besides the irritation over the spinal cord,
 Dr. H. gave rhubarb as a purgative ; but no calomel.  He re-
 lies upon the sinapisms, aided by ten grains of Dover's pow-
 der and five grains of camphor, to prevent the paroxysm.
   I have gone somewhat fully into an explication of Dr. Har-
 din's  practice,  because it is novel, and involves a principle
 which, if confirmed, will prove a highly important one.  That
 there are cases in which calomel is unequivocally pernicious, may
 well make those pause who use this remedy, indiscriminately
 and perseveringly, from the beginning to the close of bilious
 fever in all its grades.  If Dr. H. has hit upon the distinctive
 feature of such cases, he has discovered a  most valuable fact
 in practical medicine.  I can only add that he is a gentleman
 of excellent moral character, whose accuracy and faithfulness
 in the statement of facts may be fully relied on.   And in the
 present  case he  reports, that his experience  has  extended
 through  two years, and that he  has tested the practice in a
 multitude of cases.
  In support of the liberal  use of quinine which I have pro-
 posed, much testimony may be adduced.  I have referred to
 the remark of Dr. Cartwright concerning its utility in the ac-
cess of yellow fever.   Dr. Perrine, twelve years ago adminis-
tered  the medicine in such  doses as to amount to a  dram in
a single intermittent.*  Dr. Monette, both in the American
Journal of the  Medical Sciences, and in  the Western Journal
of Medicine and Surgery has given his favorable opinion of
the practice.  Dr. Drake says he has been in the habit of giv-
ing it in doses often  or fifteen grains.f Dr. May reports some
  * Western Journal of Medicine, vol. xi.
  tlb. 
                           38

interesting cases in which it acted benignly in such doses.  In
his own person he used fifteen grains of quinine, during the
fever, which left him while taking it.  "I passed the day," he
says,  "without  the recurrence of fever;  was affected  with
some degree of stupor, ringing in  my ears and deafness; but
with  no other uncomfortable sensation.   A dose of calomel
taken about 8 o'clock, A. M.,  brought off evacuations of the
consistence  of black clotted blood."*  He  recovered, using
quinine in smaller doses, with calomel and rhubarb.  Dr. May
found that given in the febrile paroxysm, it uniformly redu-
ced the pulse.   Such is J;he  experience of  Dr. Thomas Fearn,
also, who gives a striking case in the 9th volume of the Tran-
sylvania Journal of Medicine.  The patient labored under bil-
ious fever, having had repeated attacks  of intermittent fever
in former years.  It was in the advanced stage of the disease,
and Dr. F. believed his patient  would die in the next parox-
ysm.   He gave quinine in doses of thirty-two grains at the oc-
currence of the apyrexia, but while the  pulse was still a hun-
dred in the minute.  In an hour there  was a diminution in the
frequency of the pulse—"the invariable effect,"  he  remarks,
"of a large dose of quinine."  Another dose-of the same size
administered in an hour was attended with a still further re-
duction of the pulse, and a "ringing inthe ears."   A third dose
was given, making ninety-six grains in three doses.  The pa-
tient  recovered, Dr.  Fearn's ordinary dose of quinine  is
twenty grains.f
  From all this—and  it were easy to add much to the same
effect, if time and space permitted—it is clear, that quinine is
to be regarded rather as a sedative than  a  stimulant, conform-
ing, thus, in character to opium,  which  stimulates  in  small
doses, but in large doses calms and subdues nervous and arte-
rial excitement.  Quinine,  consequently,  may be administer-
ed as well in the remissions, as in  the intermissions of fever.
This is the conclusion, at least, to  which the writer of this
essay has come, and the practice he would  earnestly  recom-
*Transylvania Journal, vol. x
fTransylvania Journal, vol. x. 
39
mend to the consideration of the profession.  This preparation
of bark appears to be a febrifuge, in the true acceptation of
the  term—preventing the chill, and moderating and abridging
the  paroxysm of fever.  I would give it at the access of fever,
while the  disease Was yet in  its forming stage, and I would
watch the earliest remission,  and  administer a dose of ten or
fifteen grains, with a  view  of converting the subsidence into
a complete intermission.  And from all the experience I have
had, as well  as from  what others have  written concerning
this practice, I am convinced that it is the best mode of treat-
ing fever.   In  saying this, however,  I am far from meaning
to convey the impression,  that, in  the treatment of fever, I
should rely exclusively upon quinine,  or upon it  in conjunc-
tion with all the  remedies heretofore enumerated.  I mean
simply  to say, that I am constrained  to regard it as a most
important  improvement upon the system  too generally con-
fided in—that of purgatives and the lancet.
   Of the  lancet I have already spoken.  It should  be used
wherever  we  have  reason  to suspect  local  lesions,  and it
should be  employed, also, in cases of excessive  arterial ac-
tion  to  obviate  the  danger of such  lesions.   But I should
deem it a  useless waste of time to dwell upon the value of a
remedy, the indications for  which are so familiar to  the pro-
fession.  That it has  been abused, and that it may be carried
to excess, no one can question, any more than that it is impe-
riously called for in  many cases of fever.  Marshall Hall has
well  described a morbid state to which excessive venesection
gives rise.   We see it in the nervous  irritation, the throbbing
temples, headache, &c. with which females suffer who have
been the subjects of profuse uterine haemorrhage.  But in de-
scribing the circumstances which should regulate the employ-
ment of the lancet, I should be  but repeating what is fully
and clearly laid down in every standard  work which treats of
 fever.  Nor shall I dwell  at greater length upon the value of
local bloodletting, which, by the universal consent of the pro-
fession, is placed at the head of the means for subduing local
inflammations.   Leeches are more  eligible under certain cir-
cumstances, but  cupping  is  to be  preferred in a majority of
                             4 
40
cases, as being more under our command, and enabling us to
adapt the bleeding to the  violence of the affection.  I esteem
the general use of this measure  by the  profession one of the
greatest improvements in the practice of this country.  As a
mean of controlling local disease, it exceeds in power all other
remedies, at  the same time that its  action is immediate and
clear, and its application attended with  but little pain.  It is
never to be> omitted  where the disease shows a disposition
to fix upon particular organs.
   It is difficult to speak of purgatives in fever without enter-
ing into discussions and details which would extend  this essay
beyond  all reasonable limits.  I  shall, therefore,  confine my
remarks  to a  few  points  upon  which my experience en-
ables me to speak  with  confidence.  I will not institute a
comparison between  the value  of  cholagogue  and  hydra-
gogue cathartics, nor  dwell  upon  the fact, so  universaHy
admitted, that the procurement of  dark,  consistent  evacu-
ations is  a most favorable circumstance in cases  of bilious
fever.  Neither shall I stop to inquire in what way the pur-
gatives,   usually  styled bilious, exercise their curative influ-
ence—whether by promoting the secretion of the liver, or by
removing the local lesions of the alimentary canal which are
known to maintain febrile excitement.   The statement of a
few facts, however, bearing on  this  point, may  be proper.
First, then, it  would seem to be unphilosophical  to address
our remedies  exclusively to an organ which post mortem ex-
aminations have proved to be frequently free from  disease ;
and equally so to  infer,  that, because purgatives act  benefi-
cially, they do so by disgorging the liver of its vitiated bile.
That calomel, which exerts a decided influence on  the liver,
is a most valuable remedy in fever, I  freely admit; nay, I am
ready to maintain, that it is indispensable in the management
of the fevers of the Misssisippi Valley.   But it does not ne-
cessarily follow, that it relieves  the  patient by its action on
the liver, which may be in a healthy  condition.
  The second  fact upon  which I would lay a good deal  of
stress is,  that calomel, which may stand  for the class  of pur-
gatives,   has been proved by  many experiments to  be quite 
41
the opposite of a stimulating, or irritating medicine,  when
applied to inflamed surfaces.  In the person of the patient of
Dr. Beaumont, this  fact was clearly established.  When the
stomach of Saint Martin was seen to be red and dry,  and he
had no appetite, a few grains of calomel introduced through
the orifice in  the abdomen had the effect, in a short time, of
removing the hypercemia,  and allaying  all the symptoms of
gastric disturbance.  The  same remedy we apply to external
surfaces in an inflamed condition.  We give it in dysentery
with  advantage, where the large intestines are known to la-
bor under inflammation.   It is a remedy of most unequivocal
value in croup, the  essential feature of which  is high inflam-
mation.  We give it in cases of excessive gastric irritability,
where no other  medicine  can be retained, and we find it to
check and relieve the vomiting and nausea.  But why multi-
ply examples?  All the facts connected with the operation of
calomel prove it to be a sedative, allaying gastric  irritation,
favoring sleep  in the sick and watchful, curing a bad cough,
and relieving the heat and  pain of gonorrhea.  That such is
its character no physician can doubt who  has watched  its ac-
tion upon young children,  and seen it induce sleep like an
opiate.  And as a sedative no doubt it is, in part, that it brings
relief to the febrile  patient.   Acting directly upon the inflam-
ed surfaces, it removes one of the  conditions by which  the
febrile action is perpetuated.  But the liver and other abdom-
inal viscera  being  often  though not uniformly in  a state of
congestion, it relieves this state of things by promoting their
secretions.   Calomel, therefore, is well retained as one of the
most efficient remedies in fever, although we reject the theory
of hepatic congestion upon which it has been used to so great
excess.
   In point of activity there  is no great difference between a
large and a small  dose of calomel.   The  article is nearly in-
soluble, one  part  requiring  two thousand parts  of water to
dissolve  it,  and, consequently,  when administered in large
quantities, much of it passes unchanged, but partially altered
  n chemical  composition,  as I have  observed.  I have known
a patient to  take sixty grains of  calomel,  and have but a sin- 
42
 gle  moderate passage  from it;  and a week afterwards have
 known the  same  individual to  be  purged six  times  by  ten
 grains of this medicine.  Of course, his system was in a differ-
 ent  condition at the two periods; although the difference was
 not  manifested by the  symptoms, for he was  laboring under
 diarrhea each time.  But all physicians must have remarked,
 that the effects of this medicine  are by no means  proportion-
 ed to the dose of it, and that one or  two grains of  it will often
 excite the bowels quite as freely as  a  scruple.   Some writers
 maintain, that it  is  more likely to  irritate the stomach and
 bowels in small than in large doses.
   If these views be  correct, very  large doses of calomel, to
 say the least, are unnecessary.  It is  also unphilosophical,
 upon these principles, to increase the dose with the evidences
 of intestinal torpor, and to depend upon  curing the disease by
 purging from the liver.  If a dose of ten or twenty grains fail
 to operate, it is a proof that the remedy is not in  harmony
 with the  prevailing state  of the  system.  The  excitement
 may require  to  be moderated;  and, then, v. s., cold  water,
 tart. emet. or ipecac, in small doses, will cause the purgative
 to act well.   Often its action will be promoted by combining
 it with quinine.  In favor of this practice I might cite  much
authority.  It may be found in all the American  journals of
 medicine.  By the use of the latter  article in large doses, the
 system may be brought into a condition  in which a few grains
 of calomel will  produce  satisfactory purging. And finally,
 according to the experience of  Dr.  Hardin, in one condition
 of the spinal cord, the stimulation of sinapisms, applied along
 its course, will promote the desired operation. Far, therefore,
 from relying  upon calomel alone, I cannot too  strongly insist
 upon aiding its salutary action by the lancet, when indicated
 ■^by cupping, and leeches—by cold water, copiously used,
externally andinternally—by quinine,given so as to anticipate
the paroxysm, and to shorten it—or by the application of ex-
citants,  in the apyrexia,  or remission,  to the spinal column,
as the state of the patient may point to  the propriety  of one
or the  othe'r  of  these measures. I am  sure  we  have  relied
quite too  exclusively upon this  potent remedy in the  treat-
ment of our fevers. 
43
  A few years ago it was the practice to hasten the operation
of calomel, when slow, by the administration of the neutral
salts or castor oil.   Dr. Rush, it is well known, used calomel
and jalap combined, in doses of ten grains each.  But since
the appearance of epidemic cholera in this country, and prob-
ably even a year or two earlier, a disposition  to serous evac-
uations has been remarked, in our fevers, which such purga-
tives promote.  Hence, for a number of years, they have been
pretty universally discarded.   But  this feature in the fevers
of the  South is  gradually disappearing, and the saline  purga-
tives may be restored to favor.  As less likely to  excite wa-
tery purging, aloes, rhubarb,  extract of the juglans cinerea,
and scammony, are both adapted to cases in which there is a
proneness  to such evacuations.  These are to be administered
in from eight to twelve  hours after the calomel, should  this
fail to act in that time, and must be repeated, if the first dose
is not  sufficient.  But  here, again, I must bear my testimony
against that practice, which consists in repeating dose after
dose of such articles, without any attempt at bringing the sys-
tem into a state favorable to purgation.  Incredible doses of
jalap,  rhubarb,  scammony and aloes are sometimes given in
fever without purging  the  patient.   In such cases the liberal
use of cold water will  frequently relax the bowels, especially
if it be aided by the abstraction of a little blood, or by minute
doses of tartar  emetic.   And  where the stomach  is so irrita-
ble as  to reject all medicines,  nothing will be found so soon
to quiet it as the cold bath, and the liberal use of ice. I prefer
giving a dose of calomel at  bed-time, and securing its action
by  suitable adjuvants next day; and then  waiting till even-
ing before repeating it.  Some hours are necessary to enable
it to exert its whole beneficial influence  upon  the system;
and once in the four-and-twenty hours is as often as it  has
been my practice to exhibit it.  At the  same time, I will not
undertake to say, that there may not be cases in which it is
proper to administer it more frequently.  But I  greatly fear,
that by those who hold, that the only way  of curing fever is
to purge from the liver, it has often been pushed too far; an
error which has contributed to excite great prejudices against 
44
it in the public mind, and to give a class of empirics a tempo-
rary advantage over the regular practitioner.   The danger of
ptyalism—very  great  in  children—is  not to  be  forgotten
where it is necessary to give calomel day after day for a long
time.  Nor should we  lose sight of the  fact,  that there are
morbid states which particularly favor this mischievous ac-
tion of the medicine, and that many constitutions  are pecu-
liarly susceptible to it.
  If, therefore, there be danger in large  doses—danger of sal-
ivation, and of fatal gangrene of the mouth—and  if small do-
ses  are as active, but not so likely to salivate, as large ones,
why should we persist in the employment of the latter?  If
we  can avoid the  danger, and at the same  time accomplish
our object, by combining the calomel, or by varying our rem-
edies to suit the varying indications of the disease, nothing is
plainer, than that the moderate use of this formidable remedy
is alike a matter of duty and good policy.
  Of the subordinate remedies called for in the cure of fevers,
I shall not speak at great length.  I do not estimate the value
of emetics  highly, nor consider them as admissible in cases of
gastric irritability, which symptom I have seen them seriously
aggravate.  Upon the  whole, unless there are irritating in-
gesta to  be removed, I  am not sure that we should lose much
by  rejecting them in the treatment of our fevers.   Yet, while
I express this as the result of my own experience, I must ad-
mit that high authority can be found for the use of them.   I
well remember the success of the late Dr. Wilson Yandell,
one of the earliest practitioners of Tennessee, whose uniform
practice it was to administer an emetic, in the first stage of
the attack.  He held,  as Rush also maintained, that by this
course he frequently cut short the fever, or, at least, rendered
it  more mild and manageable.   Graves says, tartar emetic
frequently succeeds in cutting short, or removing febrile symp-
 toms, and it is evidently one of  his favorite remedies in those
cases of typhus,  where there is undoubted evidence of deter-
 mination of blood to  the head, producing  headache, loss of
 sleep, and delirium. But this admirable author truly remarks,
 what must  have struck all  physicians  of observation, that 
45
every epidemic is peculiar and distinct in its nature, and that
each, consequently, requires  a peculiar mode of treatment.
The fevers which have prevailed  in the Valley of the Missis-
sippi for the last fourteen or fifteen years have  been marked
by a tendency to congestion, in some seasons, and, in others,
by an irritability of the stomach,  forbidding the use of emet-
ics.  This, I am persuaded, is the general experience of the
physicians of this region of country.   I have long been con-
vinced, that emetics exerted a most  baneful influence in the
case of the excellent physician above  alluded to, whose prem-
ature death was occasioned by an attack of autumnal fever,
in which  he took tartar emetic  more  than once.  After the
operation of the last dose, his disease assumed  the formidable
congestive type.   But I entertain a  very different opinion of
the virtues of cold water, as a drink and external refrigerant,
in the hot stage of the disease.  Indeed, I could hardly  speak
too  warmly in praise of it,  whether the comfort it gives to
the patient be regarded,  or the effect it exercises  in moder-
ating the violence of febrile action.  Yet I do not think it ad-
missible to dwell upon a remedy the  virtues of which all prac-
titioners are beginning to admit, and which must become the
most  popular of all our remedies for fever.  Cold water is
hardlv to be ranked among  the  subordinate means for con-
trolling febrile action.  It deserves, rather, to be classed among
the most  efficient of the measures.   Fortunately, it is one
most consonant to the  feelings of the  patient.  The history
of practical medicine affords not  a few  instances in which pa-
tients have  recovered, by violating the precepts of misguided
practitioners, and indulging freely in the use  of cold water.
Ice  is even more grateful than  cold water  from the spring,
and in cases of great  gastric irritability is one  of our best
remedies.   Great is the  relief I have  often witnessed, in such
cases, from allowing the patient  to swallow little pieces of IT
every few minutes.  In  cholera  infantum and dysentery, as
well as fever, I  have repeatedly seen it allay nausea and vom-
iting in the promptest manner.
   While  on the  subject of cold water  I will mention, that I
have experienced admirable effects from the cold dash in ca- 
/
46
•
 ses of fever marked by obstinate determinatrons to the brain.
 The patient is to be placed in the hot bath, and while in this
 situation  cold  water is to be poured on his  head from the
 mouth of a pitcher, or the spout of a coffee-pot.*
    Opium may be given  in the cold stage of intermittent fever
 without  aggravating  the fever, and with the good  effect  of
 abridging the cold paroxysm.    _^~/
   Blisters are indicated  in fevers under a variety of circum-
 stances, but it is particularly as stimulants, in the latter stage,
 or as revulsives, where local determinations occur,  that they
 are to be used; and in such conditions their effect is often
 most salutary.  Who  has not seen them  relieve the  pain in
 the head, chest, or abdomen,  sometimes  persisting after  free
 depletion, like  a  charm?  No  doubt  they are often applied
 too early, in which case  they increase the febrile excitement.
 They are not to be resorted to until after the violence of the
 disease has been subdued by evacuants.   If, afterwards, locaJ
 affections are manifest they are to be  employed, unless cup-
 ping should be more clearly indicated.
   The pulvis ipecac, compos., as a diaphoretic, may be employ-
 ed in the advanced stage of fever; and the pulvis antimonial-
 is is admissible at an  earlier  period.   Tartar emetic in  mi-
 nute doses, with a view  to diaphoresis, is a favorite prescrip-
 tion with many able practitioners.
   But having pointed out the cardinal remedies in the cure
 of fever, I shall not attempt to enumerate the details of treat-
 ment ; but shall only add, in  conclusion,  that much of  the
 success of our remedies will depend upon the time of adminis-
 tering them, the fidelity with which their operation is watched
 and promoted, and the care with which  the comfort of the
 patient is preserved.  Stillness,  repose, a darkened but well
 ventilated chamber, all things, in a word, {hat mitigate  his
 Siguish, contribute to  his restoration, and in the worst cases
 may be pronounced necessary to recovery.

praSceS°UthW00d Smith °n Fev^ for full details of the efficacy  oftfn.