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REPO RT
ON THE
MIASMAL FEVERS OF THE WEST.
TO THE
MEDICAL SOCIETY
OF THE
COUNTY OF WASHTENAW,
ANN ARBOR.
PUBLISHED BY THE SOCIETY.
,r-'\ ^
/?
         <d'-       ' '■'■'*










          ANN ARBOR,






PRINTED AT THE STATE JOURNAL OFFICE,
1839. 
 
CONTENTS.
Correspondence,                                            v

Chap.  I.                                                   1
Chap.  II. General remarks on classification,                   3
Chap.  III. Classification.                                    4

                          PART I.

Chap.  I. Simple miasmal fevers of the synochal grade,           7
        General remarks  on the different types of fevers,      lb
        Symptoms,                                         8
        Treatment,                         <               9
        Directions to be observed in fevers in general,        16
Chap.  II, Simple miasmal fevers of the synochus grade,          19
        Symptoms,                                        lb
        Treatment,                                        20
Chap.  III.  Simple miasmal fever of the typhoid grade,          29
        Remarks,                                         lb
        Symptoms,                                        "
        Treatment,                                        31

                         PART II.

Miasmal fevers complicated with organic lesions,               35
Chap.  I. Gastro-Enteritic Miasmal fever, or miasmal fever
         complicated with  inflammation of the alimentary
         canal.
        Symptoms,                                        2*
        Treatment,                                        40
Chap.  II. Hepatic Miasmal fever, or miasmal fever complicated
        loith inflammation of the liver.                       49
        Symptoms,                                        lb
        Treatment,                                        50
Chap.  III. Splenitic Miasmal fever, or miasmal fever compli-
        cated with inflammation of the spleen.                 52
        Symptoms,                                         lb
        Treatment,                                        "
Chap. IV. Pneumoniae miasmal fever, or miasmal fever com-
        plicated with inflammation of the chest.                55
        Symptoms,                                         lb
        Treatment,                                        56 
IV                      CONTENTS.

Chap. V.  Cephalitic Miasmal fever, or miaasmal fever com-
        plicated with inflammation of the brain and its me-
        ninges.                                            58
        Remarks,                                          lb
        Symptoms,                                         59
        Treatment,                                         60
Chap. VI, Miasmal fever, complicated with inflammation of
        the Spinal marrow and its membranes ganglia, and
        nerves.                                             64
        Symptoms,                                         lb
        Treatment,                                         65
Congestive Miasmal fever, or chill fever,                      66
        Symptoms,                                         lb
        Treatment,                                         68
A few general remarks,                                      69 
V
                    CORRESPONDENCE.

  At a meeting of the Medical  Society of the county of Washte-
naw, June, 1839—
  On motion of Dr. Cowles, the thanks of the society were presented
to the chairman of the committee appointed to investigate the autum-
nal fevers of 1838, for his able and scientific report.
  On motion of Dr. Taylor, the report was ordered to be published
by the Medical Society of the county  of Washtenaw.

                                    Ann Arbor, June, 1839.
  Gentlemen,
                The report having been accepted, has become the
property of the society;  and your right to dispose of it as seems to
you proper,  is acknowldged.  The  compliment you have so kindly
bestowed upon it, and your order to publish it are too flattering to
be passed over, without demanding in return the most devout thanks
for the  honor you  thus  shown me!    Some further claims will
will here be made with confidence upon your indulgence and gene-
rosity ;  viz: first, That  you will excuse  the desultory manner in
which some of this report is written, owing to its being done with
frequent interruptions, and  in such brief moments of leisure as  the
practising physician can have afforded him; and the determination
to be brief, has in some instances detracted from the force and perspi-
cuity of the sentiment.   That as  much matter  which was imme-
diately  useful, might be condensed in  as small a compass as possible
we have confined ourselves principally to the diagnostic symptoms
and treatment of the different  forms  of miasmal fever.   Three or
four hundred pages should be allotted to a work of this kind, in treat-
ing of the laws of malaria, its physical and moral  effects, and  the
etiology, the pathology,  the symptoms and treatment, of this family
of diseases,  and the  modifications produced by its influence on other
affections, occurring in the  malarious districts of the west.
  It has long been my intention to attempt something of this kind, and
if no abler  pen engages soon, in this difficult undertaking, I shall
attempt it the first favorable opportunity.  The space which such a
work offers, will leave room to carry out more in detail, the classi-
fication here adopted; and will give a  chance of adducing authority,
facts and arguments to  establish any  new views in the etiology,  pa-
thology, therapeutics, etc., pertaining to thes diseases.  The object
of making this announcement, is, to  take this occasion of request-
ing all  practitioners of the west, in whose  hands this may fall, to
communicate to me, as soon as convenient, such views upon any
controverted point, in relation  to these diseases, as experience and
observation  has confirmed them in.  Any thing new under the many
heads proposed to be discussed, will be deemed of great value ; and,
also, whatever goes to  establish or overthrow  any view which is
now deemed doubtful.    In making  this request, it is confidently
expected, the appeal will not be made in vain, so far at least, as the
members of our own society are concerned.   Not a few of you hava
•• 
VI .
CORRESPONDENCE.
spent many years in the prime of life, enduring all the privations
incident to new settlements, in a laudable devotion to the interests of
the afflicted; and it is not expecting too much, if we express an as-
surance that you  can contribute something, from your ample expe-
rience, for  the benefit of the profession at large.
  A  valuable hint from any source, will be duly appreciated and ac-
knowledged in the course of the work; and no pains will be spared
to make it in every way as useful to, the profession as possible.
                                              S. DENTON, 
 
 
REPORT
                     ON  THE

MIASMALFEVERS OF THE  WEST.
                  CHAPTER I.

To the  members  of the  Medical Society  of the
   county of  Washtenaw:

Gentlemen,—
                Your committee to whom was referred the
subject of the autumnal fevers of 1838, have had the same
under consideration, and beg leave to

                     REPORT:
   That if greater mortality attended the prevalence of the
endemic miasmal fever of 1838 in some sections of the county
than others, it was probably owing to  its greater prevalence
and to a more powerful influence of the endemic cause.  But
your committee are bound to acknowledge that too little atten-
tion is bestowed by practitioners  in general on the  different
pathological condition  of the system  that may exist in  different
seasons, and in  the same season in different individuals, as a
cause or consequence of miasmal fevers.  We are not for the
present going to espouse the doctrine held by a very large
and respectable class  of our  profession, viz: that all  fevers
are symptomatic of some organic lesion ; but thus far we will
say, in our opinion fevers are  much oftener complicated with
some structural  derangement than many suppose, and  the great
danger in all cases of miasmal fever, consists in the liability
of some viscus  or tissue  becoming implicated in the  course of
                            A 
2
the disease.   Some seasons, or  in  some places, the fever is
prone to fall with great violence on one organ, and  in others
upon another; and some individuals in  the same  season and
vicinity have, one viscus involved, and another patient another.
When a different viscusor tissue is implicated, however similar
the fever may appear in other respects, it is essentially a  dif-
ferent disease, and  requires a different  mode  of treatment.—
From  these considerations your committee  have come to the
conclusion that they could best subserve your interests by lay-
ing before you a brief synoptic treatise  of the miasmal fevers
of this country, classified according to  the different grades
under  which they appear, and by laying down in as  concise a
manner as possible the symptoms denoting the different or-
ganic lesion, and the modifications of treatment  adapted  to
each. 
3
                  CHAPTER II.
         GENERAL REMARKS  ON CLASSIFICATION
   Miasmatic fevers include one great family or class of
febrile diseases almost infinitely diversified in their symptoms.
and  running through a long scale of gradations  from the
nearly harmless tertian ague or quartan, to a fever of the
most alarming violence,  overwhelming the powers  of life in
a few hours.   As each of these intermediate grades demands
an appropriate modification of  treatment, it would seem  as if
we had an extended field for  study and experience before us,
to determine the grade ef fever in each particular  instance
and prescribe means adequate to a cure.  But the field is still
more enlarged when we add to the above, that every grade of
miasmatic fever from the mildest to the most malignant and
fatal, is extremely liable to produce or become somehow com-
plicated  with  an inflammation or congestion of some tissue
or viscus of the animal  economy.
   The importance of the organ implicated, and the degree of
inflammation or  congestion with  which the part is seized, is
of the utmost  importance in a practical point of view.  And
this is one of the  most  difficult  parts  of our  profession too,
owing to the obscure and very equivocal signs which denote
the consecutive local  malady, though it be in a vital part, and
disorganizing in its violence.
   The separate heads or different varieties under which mias-
matic fevers will now be considered, are founded  upon the
above premises, viz:  first, that miasmal fevers are of different
grades which is the foundation  of the first  division; and
second, that each  separate grade is  liable to be complicated
with organic lesions  or congestions.
                             a2 
4
                  CHAPTER III.
                    classification.
First,
   1. Simple Miasmal fever of the Synochal grade.
2. " do.	" " Synochus do,
3. " do.	" " Typhoid do.
Second,	
1. Gastro Enteritic	Miasmal fever
2. Hepatic,	do.
3. Splenitic,	do.
4. Pneumonic,	do.
5. Cephalitic.	do.
	REMARKS.
  This classification of miasmatic fever, though new, is not
introduced  for the purpose of laying the  foundation of any
novel theory of the etiology or treatment of fevers.   Perspi-
cuity is the object of this arrangement.   It is for the purpose
of rendering methodical what is now in a perfect jumble.—
These fevers appear under the greatest diversity  of grades,
from the most highly sthenic or synochal to the lowest asthe-
nic or typhoid, and each grade is obnoxious to complications
of phlogosis  or  congestions,  presenting the most  opposite
aspects and indications of cure;  and yet our books  treat  of
this  subject under one  general head, without making these
most palpable distinctions.    Hence, one set of physicians in-
sist that these fevers are always of the atonic, and others of the
entonic grade.  Some insist that they are  always idiopathic,
and others that  they are symptomatic of some primary local
affection.   One set dogmatically insist on one set of remedies,
and  the other upon another: one says that bleeding and the
anti-phlogistic regimen will cure all, and the other that it will 
5
kill all.   Much of this discrepancy arises from being wedded
to different theories, but more  from the fact  that one author
has written from the impressions received during  the preva-
lence of one endemic or epidemic during one season, and in
one locality ;  and another has treated the disease under differ-
ent circumstances, and each supposing that his limited expe"
rience will apply to all seasons and locations.
   A well arranged and  methodical treatise on the fevers ari-
sing from malaria, as they appear in the far west, is a deside-
ratum, and though perhaps a better classification  may here-
after be hit upon than the above, yet no arrangement extant is
so well calculated to systematize the practitioner's views rela"
ting to the true character of the  disease, and the  method of
treatment at the bed side of  the patient, as this  one; and if a
book were to  be  written, as voluminous as the importance of
the subject demands, all that is wanting is to amplify and carry
out into all of its details the present synopsis.   Extreme bre-
vity however  must be observed in the present  instance;  and
that as many practical  facts may be as  much condensed as
possible,  we  have stated little else than  the symptoms and
treatment in each grade and species, and all unnecessary ar-
gument and explanation is carefully avoided. 
 
7
                 PART  FIRST.

                     CHAPTER I.

General remarks on the different types of fevers.
    SIMPLE MIASMAL FEVER OF THE SYNOCHAL GRADE.

    Simple miasmal fever of whatever grade ;  that is, mias-
mal  fever unaccompanied by local disease, has one remark-
able diagnostic symptom that distinguishes it from the fevers
arising from  any other cause; and that is,  its obvious  and
uniform intermissions or remisssions.   When these intermis-
sions are shorter and less distinct and the cold stage less severe
at the accession of each  paroxysm, it is usually denominated
a remittent fever.  When the intermissions are longer and
perfect, and the paroxysm ushered in by a long or severe chill,
it is called  an intermittent fever  or fever and ague.  Any
thing which aggravates the last, has a tendency to  convert it
into a remittent or a continued fever; and whatever mitigates
the  other, converts it  into an intermittent fever, or effects a
cure.  If an  idiopathic inflammation occurs in one who has
been long exposed to  the influence of malaria, the attendant
fever is likely to shew a marked tendency to intermit.
   These fevers are said  to be quotidian,  tertian or quartan
according as the paroxysm recurs on  the second, third or
fourth days;   always  counting the day  on  which the  last
paroxysm occurred as one day.   The  tertian type is very
likely to become a double tertian.  It usually becomes double
after the patient has had two, or three, or more paroxysms every
other day. which  usually come on in the  A. M.  Then that
which should be the welfday is interrupted toward  night by
a slight paroxysm, which does not wholly leave the pattent 
8
until nearly morning, or  within a few hours of the morning
paroxysm which is much the harder of the two.   This then
leaves the patient in the P. M., in  what is called the intermit-
tent or fever and ague, and leaves a long intermission of about
eighteen or twenty-four hours duration, until the next evening
paroxism.   The intermission from the evening to the morning
exacerbation, is only of about four or six hours duration, and
from the morning to  the  evening  from eighteen to twenty-
four hours.  What by way of distinction is usually called the
remitting fever, is generally  marked by quotidian or double
tertian exacerbations.   In some instances in the remitting fever
we have double quotidian exacerbations and, as in the double
tertian, every  alternate paroxys:u  is  generally  much the
strongest.

                       SYMPTOMS.

   The synochal grade of miasmatic fever, like those of either
of the other grades, commences with a  cold stage after a few
hours of  languor, drowsiness, anxiety,  paia  in  the  head,
loins, &c.
  ■ The chills and rigors alternate with flashes of heat, until the
heat finally predominates.   The cold stage in  this is shorter,
and  is usually ushered in after fewer premonitory symptoms
than either of  the other grades.   The hot stage simulates the
synocha or true inflammatory fever.   The pulse is  full,  or
hard and strong, the skin intensely hot and flushed, especially
about the head and face, with increased sensibility to light
and sound; intense thirsting for cold water and severe throb-
ing pains  in the head and loins.   The tongue is covered with
a white fur, the bowels generally costive,  urine  scanty and
very high colored, and the  blood, when drawn, presents the
inflammatory buff
   Such are a few of the most prominent symptoms of this
grade of miasmatic  fever, and care has  been  taken to select
those symptoms  which most distinguish it  from the other 
9
grades.   It might be, and often is,  at first mistaken for simple
inflammatory fever; but at the end often or twelve hours, if it
be an intermittent, a profuse perspiration comes on, which, after
an hour or two's continuance terminates in a perfect intermis
sion. This intermission lasts until the next day, about one or
two hours later than the accession the day previous, if it be a
quotidian, but if a tertian, it passes over one entire day, and
recurs again on the  third day about one or two. hours  ear-
lier than on the day of the previous paroxysm.   If it be a
remittent, the hot stage continues until toward the next morn-
ing  (if  the exacerbations be quotidian,) and if tertian,  until
the  next morning but  one,  before much  abatement of the
fever ;  when a perspiration and a mitigation of all the patient s
sufferings  ensue.   This respite  is destined to be of but few
hours  duration, when another paroxysm comes  on, ushered
in by  a cold  stage  less severe  usually  than  the first, and
much less in intensity and duration than  generally  character-
izes the cold stage of an intermittent. The  pain in  the back
and lower extremities is generally more severe than in simple
inflammatory fever, so that it almost appears like a rheuma-
tism of the lower limbs.

                       TREATMENT.

   Whatever may be thought of blood-letting in simple mias-
 mal fever  in  either of the other grades, no physician in his
 senses, should hesitate a moment to use the lancet early and
 decisively  in this grade of fever.   If an  opportunity offers,
 bleeding should be had recourse to in the cold stage in prefer-
 ence to the hot stage, and the blood should  be  suffered to
 flow until the chills and rigors entirely cease, and  until a de-
 cisive impression is made on the system.   It should-then be
 stopped and the physician should wait to see if a full reaction
 comes immediately on  before he quits his patient, for if chills
 and rigors should again commence, though slightly, the arm
                               B 
10
should again be corded, and as much more blood taken as
is necessary to put an entire stop to the chills.
  If an opportunity does not offer  to bleed in the cold stage,
blood may be drawn in the hot stage, but should not in gene-
ral be resorted to in the sweating stage or during the apyrexia.
In either  case  no reference  should  be had to the quantity
drawn in this grade of fever, but a decisive impression must
be made amounting to faintness, if remittent, which sometimes
takes twenty ounces, and sometimes but five or six.
  A second bleeding must frequently be  had recourse to in
this grade of fever, and if it be practised, in order that the  full
benefit of it may be had with as little loss of blood as possible,
it should  be repeated within a few  hours of the first,  and
should be carried to the same extent with regard to the impres-
sion to  be  produced as mentioned  above.    If  the  second
bleeding be deferred until twenty four hours or  more; from
two to four  times  the quantity will be necessary that would
have been if resorted to in a few hours from the first blood-
letting.
   If from neglect in sending for a physician, or from  unskil-
ful practice, blood-letting has been deferred for several days,
it frequently becomes a difficult matter to decide upon the  pro-
priety of resorting to it, as also '.he extent to which it should
be carried;  for be it known, the directions contained  in the
last paragraph apply exclusively to the stage  of excitement,
including the first five or six days in cases of ordinary  vio-
lence, though this stage may be much shorter or longer  in
duration, as the fever is more violent and rapid; or milder and
slower in its progress.  If  several days have elapsed before
we sec the patient, and we learn from the history of the  case
that it has been a period characterised by a high state of feb-
rile excitement, and the proper remedies have not been pre-
scribed,  we should  be very suspicious that some organ has
become involved  ere this.   A careful examination must be im- 
11
mediately instituted ; the head, the chest  and the abdomen(
must each be submitted to the  most rigid scrutiny, and if any
organ is found implicated, as evidenced by the symptoms here-
after to be noticed under the proper head, the treatment must be
according to the suggestions then laid down ; but if no evi-
dences of a local disease are to be found, then the answers to
such inquiries as the following must guide  us.   Was the
malady slow in comparison to the  grade of the fever in run-
ning through its forming stage?   Had it  evidently reached
its acme, and is it now in the declining stage?   If clearly it
is in a declining stage, depletion should not be  used;  but if
not, it as certainly should,  without regard to the length of
time which has elapsed since the commencement of the  fever.
   Where much doubt exists whether the declining stage has
already commenced, it is better in this grade of fever  to try
the effect of one blood-letting.    It will be the safer course;
but in either of the other grades if doubt exists, it had  better
be omitted.
   Having carried  blood-letting to a sufficient extent, it will be
very uncommon for the bowels to resist the operation  of  ca-
thartic doses of the ordinary  size.   A dose of cremor  tartar
and jalap (preceded by  eight or ten  gr. calomel, or not, as
may be thought proper) should be given.
   In all cases, especially on exhibiting the first dose, an ene-
ma is better to be given  first ;  but if the stomach be irritable,
so as to endanger the  rejection of the cathartic dose, the
bowels should always be first thoroughly moved by one or
more injections.
   For this  purpose you may mix twenty grs. of jalap with
a little  molasses, and dilute  it with  a sufficient  quantity of
warm water or thin gruel, to fill a large syringe, or you may
use senna tea with epsom salts or common salt.   For the re-
mainder of the stage of excitement, the bowels should be  freely
opened by three or four motions per day, procured by means
                            b2 
12
of some gentle cathartic, as a few grains of jalap or cremor
tartar, seidlitz  powders, epsom salts with  senna and manna
or one drachm carb. of magnesia,  and one oz. castor oil inti-
mately mixed in a mortar,  with some agreeable syrup, and
given in divided doses, and, if convenient,  some lemon juice
and sugar may be added.   Any dose of this kind may be pre-
ceded once in a day or two by five or six grs. of calomel, and
the lower part of the bowels should also be evacuated every
day or two by enemata. The great object should be to produce
full cathars is without irritating the stomach and bowels as is
too often the case.  There is no class of medicines more ne-
cessary and nonembre abused in this disease, than cathartics.
   Many of the worst complications of this disease, with gas-
tric and enteritic  irritation and inflammation, are produced by
the improper selection and injudicious management of cathar-
tics.   Antimonial emetics and emeto-cathartics are very little
used now, by those who entertain a proper  horror of exciting
an inflammation of the mucous membrane of the stomach and
bowels;  for  this tissue* under  the  best  management,  is ex-
tremely liable to  become implicated, and when it does it gives
one of the worst features to  this disease.   Cathartics should
be given  during the day, that an opportunity may be afforded
at night for repose, aided by a Dover's powder.   During this
stage of excitement the refrigerant diaphoretics, such as nitre.
antimonials, muriate of ammonia, saline effervescing mixtures
&c, may be given.   The drinks may be cold water acidula-
ted with  lemon, currant jelly, or tamarinds.   The patient may
take milk and water, buttermilk  and water,  buttermilk pop,
water gruel, barley water, rice water &c; the three last, may
also be acidulated  and sweetened so as to be  palatable.  No
nourishment should be given but the drinks above mentioned,
during the "stage of excitement.  When the fever has  passed
its acme, or has  entered  on the stage of decline, the bowels
need not be moved so often; the refrigerant diaphoretics may 
13
be omitted, or given less frequently;  and the patient may be
allowed boiled rice, toast and  weak tea,  and finally veal tea.
Remittents, in their declining stage, often assume an intermit-
tent character; when  they should be treated as if they were  .
originally intermittent, and, as shall be he hereafter stated.—
But  if,  as is generally the- case  in this grade of fever, the
declining stage terminates gradually  in convalescnnce, no-
thing more need be done, but to allow an increase of more sub-
stantial  food, and gentle exercise in the open ait; tonics not be-  ->
ing required or of any use.   When a perspiration commences
at any time during the fever, bland tepid  drinks should be free-
ly administered, and  the perspiration encouraged, but more
especially in the stage of excitement of a remittent.  Butitfre"
quently happens that in the stage of decline, the sweating is too
profuse, in which case it would be improper to encourage it.
   It should be remarked here,  as a peculiarity in the fevers
of the country, that sweating is much more common during
the continuance of the fever, and without indicating any very
favorable change, than where most of us  have been in the
habit of practising in other countries.   Perhaps half of all
the fevers we witness here, not excepting the acute phlegma-
saj, are characterized by more or less  sweating  during the
whole continuance of the fever, and even before it has reached
its acme or sub-crisis.  The inexperienced are often deceived
by these sweats, and pronounce the fever nearly at an end or
 cured,  when it has yet to run a protracted and may be a dan-
 gerous course.  A sweat of this kind is not critical, and may
 be known very soon by its not being attended with a corres-
 ponding amendment of all the other symptoms; in which case
 no pains are necessary to encourage it, but on the other hand
 if it be critical, it should be pr omoted.
   If a remittent, instead of terminating in convalescence, runs
 into a  distinct intermittent, or fever and ague, or, if the disease
 is originally of this form, it  will become necessary to pre-
 scribe  some additional directions. 
14
  It must be kept in mind, that the directions about to be given
apply to intermmittents occuring under this particular grade,
viz: Simple miasmatic fever of the synochal grade. Though
these directions will apply  in  the main to intermittents of all
grades and complications,  the variations  in the treatment of
each being noticed under its respective head.
  If the fever be originally a distinct intermittent of the sy-
nochal grade, at least one copious bleeding and a liberal ex-
hibition of  cathartics, should  be premised; if,  on doing thus
much, the  patient feels well  during the intermissions,  free
from headache and pain in the back and limbs, skin, tongue
and pulse normal, and absence of thirst;  measures maybe
adopted  to  intercept the paroxysms.   But if the appearances
are not  as above  intimated, quinine or any other remedy to
break up the paroxysms must be delayed, and the antiphlogis-
tic treatment further persevered in.  It is in this grade of fever
that these precautions are particularly insisted on.   It  is not
indispensable, but it is better, to give our  cathartic doses
during  the intermission, and  just  a sufficient time previously
to. the anticipated paroxysm, to have the operation commence
about the time of its accession.   One very respectable writer
avers, that  equal  parts  of calomel, aloes and  rhubarb, given
in this way, will effect a cure  by the fifth or seventh paroxysm
and sometimes sooner, with  much less  liability to a relapse,
than by giving the barks or arsenic.
   There is much respectable testimony in favor of always
deferring the quinine, &c,  until the fifth or seventh exacerba-
tion ; when, it is said, the fever may be stopped with much less
risk of a relapse.  If quinine or  any of the other medicines,
as barks, arsenic  &c, be given without reference to the above
regulations, you  may,  it  is true, in most instances,  break up
the paroxysm, but the convalescence will be slow, and a relapse
almost certain, within one  or two weeks; and if this  incon-
siderate mode of breaking up the fever be persisted in, some
structural lesion  will  generally  follow.   But a still more 
15
serious consequence  of the too early  use of these medicines
is apt to follow, which is, that it converts it into a remittent,
or continued fever.
  This is by no means an uncommon  occurrence, and they
frequently turn out to be obstinate and protracted cases; mani-
festing in many instances  before their termination, signs of
local inflammation,  accompanied with a  fever of the typhoid
character.   When  it has been once determined  to stop the
intermittent, all experience will give  the preference to qui-
nine, over any other of the scores of  medicines  which  have
been  recommended.   It is almost an infallible medicine in
this disease; and notwithstanding  popular abuse, it is one of
the most harmless articles in the materia-medica.  It is doubt-
ful, if it ever fails to  cure, that the failure is not  attributable
to the existence of some organic derangement.
  From ten to fifteen grs. are always sufficient;  less than ten
will seldom answer, and more than fifteen are never necessary.
Here, one  exception  should be rrade; where opium mixed
with camphor &c,  has been given for the purpose of inter-
cepting or  mitigating the previous paroxysm, and the quinine
is given during the succeeding intermission ; in which case,
it almost always fails.  It should  be given one gr. per hour,
or two grs. every two hours;  commencing long enough pre-
viously to the chill, to give the quantity intended.  In double
tertians, the long intermission should be preferred.   Where a
relapse is to be apprehended, or where one is habitually sub-
ject to relapses of fever and ague, the following prescription
should be given in about ten days after the last day of fever:
                   12 grs. Quinine,
                   12 "    Rheubarb,
                     8 "    Aloes.
  Divide into twelve pills.  Take one four times per day.—
At the end  of about ten or fourteen days, the same quantity
should be again repeated;  or, it may be taken sooner, if the 
16
 patient has been much exposed to any exciting ca^use, or if he
 feels any of the premonitory  symptoms of the ague.   And
 so this prescription should be repeated during the months that
 the ague prevails, and until all liabitity to a relapse, or the
 susceptibility to the influence of the malaria, is overcome.—
 In this way business-men, whose time and health are of great
 importance, may continue to reside in malarious  districts and
 enjoy an immunity from attacks of the ague.
   Quinine had better be combined in general, with  small
 quantities of cathartic and deobstruent medicine. The unplea-
 sant effect which  it has on the head of corpulent persons and
 children may be thus avoided.
   Arsenic  is the  next article  of importance as a  febrifuge;
 and indeed it is the only one in the materia-medica worthy of
 consideration, as a succedaneum for the barks and quinine.—
 It is but little inferior to the quinine, where there is no irrita-
 bility of the stomach  and bowels.   From  one eighth to the
twelfth of a gr.  may be taken, from four to six times per day:
 being careful that  the bowels are  perfectly loose, and even
 then, it should  always be combined as we  have directed  in
 quinine.    In this way oedema and other unpleasant conse-
 quences are not likely to follow.   It is always necessary in
order to succeed, to give arsenic during two intermissions in
a tertian and three or four in a quotidian.

  DIRECTIONS  TO BE OBSERVED IN FEVERS IN GENERAL.

   As this little  essay would be defective without a few words
of general direction for the management of the patient, which
will apply to all grades of this fever, and in fact to all fevers,
some brief  rules will be offered in this place.
   A room as retired and airy as the case will admit of, should
 be selected for the patient.  If possible, the nearest and dear-
est friend of the patient should take the sole charge of  him,
and the management of the prescriptions.   To this one only, 
17
should the physician give his directions, and get the history
of all the symptoms since his last visit.
   The neighbors and friends generally, must not be permitted
to enter the room.  Their kind solicitude for the sick, should
never prompt them to come within his hearing.   His atten-
dant can inform the patient who have inquired after him, and
who have been good enough to present any thing for his com-
fort, or offer their services to wait on him.
   The person who  has the charge of the patient, must choose
the time out of the twenty-four  hours, when he is the most
quiet and free from  pain, for his own repose, which is  gene-
rally from midnight until eight  or nine in the morning;  for
during this time, the  patient should be disturbed as little as
possible;  and where  it is not contra-indicated,  he should be
under the influence of an anodyne.   During  this time,  the
patient should be left in charge of some quiet,  careful person
who is agreeable to him, with instructions to hold no conver-
sation, but  to do all that  is possible to dispose  him to perfect
quietude.   The patient should be taught to take all his medi-
cine and  drinks without  rising up in bed.  When lying on
his back, the attendant should put his hand under his occiput,
and  tip his head a little forward.   In this way,  he can swal-
low with as much ease as in any  other position.  The sick
person had better  hold the cup or spoon in his own hand.  A
bed-pan should always be used to save the fatigue of getting
up and down.  The room should be kept dark and well ven-
tilated, and the most scrupulous cleanliness observed.  The
patient's linen should be often changed. Every cup and spoon
as soon as used for medicine or drinks, should be taken imme-
diately out of the room  and washed.   In hot weather, the
room may  be kept  at an agreeable temperature during the
heat of the day, by often mopping or sprinkling the floor,
unless some existing pulmonary affection should seem to for-
bid it.  The bed-clothes should  be as light and  few as possi-
                            c 
18
ble during  the  stage of excitement, and  until the fever has
passed the  acme, when  more clothes should  be used.  The
extremities should be examined often by the attendant and kept
as warm as the rest of the surface, by using external heat, fric*
tion, sinapisms &c, if necessary.  When there is much heat of
the skin, the patient should be sponged  over often with some-
thing coli   Where the heat is not so great, and warm spong-
ing is more agreeable to the feelings of the patient, that should
be practised two or three times in the twenty-four hours.  This
occasion should always be  taken to  use considerable friction
all over the surface, with the hand or a coarse cloth.   If from
stupor, or any other reason, the patient does not attend to it,  the
attendant should change his position occasionally in bed.   He
should always arouse him from a disturbed orjethargic sleep,
but not from a quiet one, even to give him medicine or drinks,
unless it is too protracted.   In summer he must lie on straw
or a mattrass, without blankets or comforters over it.   Straw
pillows should always be preferred, especially if the  head be
at all effected.  These remarks would have been omitted at
this time, if it were not for their acknowledged importance,
and from knowing how very often such rules are disregarded.
The truth  is, leaving the necessary  pills  or powders  is but a
tythe  of the physician's duty.  All acknowledge the impor-
tance of good nursing, but in order to secure  it, the physician
must see to it.  The best part of the house should be selected
and regulated  before he leaves the patient, and some one in
particular must be chosen to take charge of the  directions,
and the croakers and gossips forbidden the apartment, and if
 possible expelled from the  premises. 
19
                    CHAPTER  II.

 Simple Miasmal fever of the synochus grade.

                      SYMPTOMS.
   This grade of fever may generally be distinguished at
its accession, from its premonitory or forming stage occupying
a greater space of time, than the one just described.  Several
days  are frequently  taken  up by equivocal  premonitory
symptoms, before the cold  stage commences.  Such as a bad
taste in the mouth, a sense  of weakenss and uneasiness in
the lower limbs, and a slight  headache and back ache, are fre-
quently noticed toward night or every  other night, for seve-
ral days, without attracting much attention.  The cold stage
is not marked by great violence, but is protracted  in its dura-
tion.   Transient  flashes of heat commence, alternating with
the chills and rigors;  but much more time elapses before  the
heat predominates, than in the  preceding grade.   The skin
is redder than natural in the more  aggravated cases, though
not so much  flushed, or so hot as in the preceding grade.  In
some instances the skin is paler than natural, but not so shrun-
ken and ash-colored as in typhus.
   The fur upon the tongue is  white, and frequently slimy,
accompanied with a very bad taste  in the mouth.    This fur
frequently becomes dry very soon, and of a dark brown along
the centre, or all over the  surface.  The urine is red,  and
 diminished in quantity. The arterial action is much increased
 in frequency and force.   But though  the fever sets in, in its
 severer forms, with a degree of vascular reaction, and general
 strength, little short of that in the synochal grade ; yet, both
 the grade of fever and general powers  of life, soon wane and
                    *       c2 
incline  to  the low or typhoid state.   If delirium occurs du-
ring the  exacerbations, it is not of so violent a kind as in the
synochal grade, neither does the patient experience much in-
tolerance of light and sound,  unless there is some cerebral
inflammation present.  There is generally flatulence or more
irritability of the stomach  in this than in the former variety,
and  the patient is more peevish and morose.  Much the lar-
ger .share of the miasmal  fevers  which occur in this section
of the country are of  this  grade.  It,  in fact, includes all, ex.
cept such as are of the inflammatory grade, or such as are
marked by typhoid symptoms from the commencement.
   In the simple form of this  fever; that is, when it is not
connected with local  inflammation  to any extent,  the inter-
missions and remissions are very distinct and perfect, leaving
the patient to suppose  he is quite  recovered.  The sweating
is generally profuse, and leaves the skin cool and soft.
   The intermittents that occur in this  grade of miasmatic
fever are such as frequently allow of the patient's being about
and attending to his business during the  whole of the inter-
mission.   The  paroxysms are generally tertian, except in
the latter part of summer  or autumn, when they are most apt
to  be double tertian or quotidian.

                      TREATMENT.

   Almost every thing that has a medicinal property, has been
recommended by some one, as a certain cure for this form of
ague, as it is popularly called; beside which, a great variety
of charms, amulets, &c, have had their day of favor.
   This form of the disease affords a large field for the enter-
prise of the quack and nostrum-monger.   The  most opposite
modes of cure  have  been recommended, and  have  shared
equally the popular confidence.   Others again, recommend
to let it run until it wears itself  out, a3  it is called.   Very 
21
many, in miasmatic districts, adopt this latter expedient, after
spending considerable sums for nostrums, and after swallow-
ing a great variety of useless and disgusting quack remedies.
This disease, above  all others, will often admit with impu-
nity, of the  most opposite and improper modes  of treatment,
or of no treatment whatever.
   Blood-letting is not  generally  necessary  in this  grade of
simple intermittent.  It may  be used to advantage, however,
in persons of very sanguine and phlethoric temperaments, or
where the bowels are not moved by the usual amount of ca-
thartic medicines.  When resorted to, it had better be in the
cold stage ;  if not then, in the hot stage ;  but it should not be
used  in the  sweating stage, and  seldom during the apyrexia.
The  bowels should be freely evacuated, as directed  at page
eleven.  When the intermissions become perfect, denoted by
freedom from pain in the head, a clean tongue, no thirst, uni-
versally cool and moist skin, &c, the barks or quinine may
be given as recommended at  page fifteen.   These  febrifuges
are often used without these precautions.   As soon as it is as.
certained that the disease is an intermittent,  barks, &c, are
immediately exhibited during the apyrexia, and it must be
acknowledged that in most cases, this treatment is successful.
The hurry of the physician's business, and the impatience of
the sick, have led to  much indiscriminate practice in tljis dis-
temper.  But whoever practises extensively in this way will
fail in some instances in breaking up  the disease, by the ac-
customed quantity of bark, quinine or arsenic;  relapses will
be more common in his wake, and he will have the mortifica-
tion of converting some fevers that were  intermittent at first,
into a remittent or continued fever ; and of aggravating some
incipient local inflammations which were hitherto latent.
 Some very respectable  physicians and authors, who have wit-
nessed the ill effects of such hurried and indiscriminate prac-
tice, recommend waiting till  the fifth  or  seventh paroxysm 
22
before attempting to stop the fever, and administer well chosen
cathartics Sec, in the mean time, as often at least, as every par-
oxysm.   At this time, it often stops of its own accord; but if
not, it may be checked by  the usual remedies.    If there be
no urgent necessity of putting an immediate stop to an inter-
mittent,  it will be better on the  whole to put off  giving qui-
nine, arsenic &c, long enough to administer proper cathar-
tics, and have  them ODerate about the time of the expected
paroxysm, for  a few times; or at least long enough to  have
the intermissions  perfect and free from heat of the skin,  pain
in the head and  back, and  fur on the tongue, thirst, &c.   If
any one should choose to adopt this plan, a few exceptions to
this rule should  here be  insisted on.  If the patient be  very
old and  debilitated, it should generally be stopped  as  soon
as possible; for  such  subjects  are frequently  carried off
very suddenly, especially by a quotidian.   If it  be a young
child, and especially if it cause  convulsions, as it very  often
does, the necessity for putting an immediate stop to it, is para-
mount to all other considerations.    These convulsions  in
children  generally  occur about the commencement  of the
sweating stage, but in a few rare instances they have occurred
in the cold stage.   These covulsions generally cause great
alarm, but  experience proves there is little ground for appre-
hension ; for among all the cases we have witnessed and heard
of in  this section of the country, amounting probably to  seve-
ral hundreds, we do  not  recollect of but one or two instances
where it proved  fatal.   If the cold fit threatens to produce a
miscarriage, as it sometimes does, we should make no delay ■
and above all, should parturition take place during the  exist-
ence of  an intermittent, it should be immediately intercepted ;
for the  next paroxysm  succeeding a confinement has  often
caused a very unexpected  prostration, and  in several instan-
ces has proved  fatal.
   Ten or twelve grs. quinine, combined with rhei and  aloes 
23
as before recommended, or an equivalent of some other febri-
fuge, should be given in ten  days after  the last exacerbation,
to insure the patient against an early relapse. Those who have
frequent relapses, and those who undertake to wear out the
ague, often suffer severely from visceral organic derangements,
as a consequence.  Disease of the spleen, liver,  mesenteric
glands, general anasarca or effusions in the abdomen, or thorax,
are the most common.  Though wearing it out, as it  is called,
terminates favorably in a majority of cases, yet out of a great
number, some wrill result as above stated.
   In the April number of the Edinburgh Medical  and Sur-
gical Journal for 1827, a valuable paper was published, which
was communicated by Doct. Mackintosh, on the subject  of
bleeding in the cold stage of intermittents.  His  views have
been republished more at large, in  his very  valuable book
entitled  " Principles of Pathology  and Practice  of Physic,
by John Mackintosh, M. D."  His attention seems first to have
been called to the use of the lancet in the  cold stage of inter-
mittents, from his views of the  pathology of the disease, as
derived from a vast number of dissections.  Subsequent  ex-
perience confirmed his views in the pathology and treatment.
 These  suggestions coming from such high authority, com-
 manded the early attention of the faculty throughout Europe
 and India, and  whoever has been resolute enough to divest
himself of his old  prejudices,  and give it a fair  trial, seems
no less pleased than astonished at its success.
   He recommends opening a large orifice as soon as the cold
 stage has fairly commenced ;  the blood flows sluggishly at
 first, but, as the venous engorgement  becomes lessened,  the
 blood springs in a rapid stream from  the arm.   If you  are
 successful in opening a good  orifice,  generally  by the time
 twelve or sixteen ounces are drawn, and often much sooner,
 the painful  cold sensations, and shaking  give  way to an
 agreable  sensation  of  warmth.    By  this means also  the 
24
hot and sweating stages are entirely  intercepted,  or greatly
mitigated  in their violence and duration.  If the next par-
oxysm commences with a chill of much intensity, a vein
should be  opened as before, but if, as is generally the case, the
next chill  is but very slight, the lancet need not be used ; for
the hot and sweating stages will be correspondingly mild, if
the bed-clothes be properly regulated; and thus the intermittent
will be cut short in a few days, by keeping the  stomach and
bowels properly  regulated by the use  of cathartics, &c.   It
is  often, however proper and  necessary, to give a few grs.
of quinine, to subdue  the slight febrile paroxysms which
remain, in order to perfect  the  cure. Among the most obvious
advantages to be  derived from blood-letting in the cold  stage,
are—
   1st.  The injury which in many cases results from the con-
tinuance  of the  venous engorgement,  which so  constantly
leads to organic diseases, is avoided.
   2d. The danger, proceeding either from the want of suffi-
cient re-action, or from  its excess, is also avoided.
   3d. It mitigates the present paroxysm very much, in all its
stages, and frequently cuts it short entirely, j
   4th. If  subsequent paroxysms occur, they are manifestly
lighter, and they  will generally cease entirely, after a few fits,
without the use  of the barks,  quinine  or arsenic; but if  it
does become necessary  to use them, the system is found to be
increased in is susceptibility to their favorable impression, and
relapses are much less  frequent.
     Such is  a condensed statement of  the views of Doct.
Mackintosh, and those who  advocate  the same treatment;
but it is much too brief to do him justice, and the reader  is
earnestly  recommended to peruse his book for a more  gene-
ral understanding of the subject.
   We have not been backward in giving these new views of
Doct. Mackintosh a trial, as in fact, we feel bound to do in all 
25
cases coming from so respectable a source, and backed up by
such an array of unimpeachable testimony, and as far as our
limited experience will enable us to judge, we are compelled
to think very favorably  of his statements.   In most of the
cases in which we have tried  it, the bowels were too tumid or
costive, or the tongue was too much loaded, or there was too
much  uneasiness in  the head to render  the  use of quinine
strictly proper.   In these cases the bleeding in the cold stage
was of manifest  advantage, by lessening the  severity of that
particular fit and mitigating the intensity of the subsequent
ones, and in several cases the paroxysms ceased soon, without
the use of quinine or arsenic, which  we are  sure would not
have taken place, if it had not been from the  bleeding.
   The cases that were bled have not relapsed yet, though
several were on  hand at the time, who were cured in the or-
dinary way, and most of these have relapsed  once and some
twice.   More recently still, we were applied to by a patient,
who, to use his own  words, "could not make the ague stay
cured by the use of quinine."  The first cold stage after this,
we opened a vein as soon as the cold stage had fairly com-
menced ; when about eleven ounces  were drawn, the chills
ceased and the hot stage was less  painful and shorter  than
common.    On the third day about the same  hour, the  cold
stage again recurred, and the drawing of  about eight or nine
ounces of blood intercepted the entire paroxysm, and he went
the remainder of the day about his business, affirming that he
felt perfectly well.  Though this patient  was ono, who peo-
ple generally would  say had no blood to spare, yet he ex-
perienced not the least ill effects from its loss, but has enjoyed
his health and strength ever since, and has  had no  relapse
though he thinks if he had taken quinine, it would have re-
lapsed several times, and his  health would  have  been less
perfect than it now is. 
26
  The remittents of this grade, require but a slight modifica-
tion in their treatment  from that in the preceding grade.   If
an early opportunity should offer of blood-letting in the  cold
stage, it should hardly  be omitted;  but as in most instances it
does not, we  must be guided in this particular by other cir-
cumstances.  If the patient is not very sanguine and pleth-
oric, and if on a  careful investigation, there appears to be
no  local  inflammation,  or no determination which seems  to
threaten  it, it will not be necessary to bleed, except, when the
bowels will not move  freely on giving the patient his accus-
tomed dose of physic.  When this  happens,  the medieine
should not be much increased in quantity, but  an adequate
bleeding will correct the evil.  The antiphlogistic treatment
and other matters, must be regulated as was recommended in
 the stage of excitement in the synochal grade.   The remis-
 sions  should be encouraged, by  giving tepid  drinks &c,
 during the sweating  stage.   By  this means,  we make the
 remissions more perfect and  longer,  which is always desira-
 ble ;  and if they become more distinct and longer at the end
 of each paroxysm, we shall have  reason to hope that it will
 soon terminate in an  intermittent, if not before, soon after it
 enters on the declining stage.
    It has been recommended by some, to give quinine in large
 doses during the remissions.  If it be admissable at all,  it can
 only be so under a very favorable combination of circumstan-
 ces.  It is improper to give it during the sweating stage, even
 in an intermittent; for the sweating stage is as much a part of
 the exacerbation, as the cold or hot stage.  Now if the apy-
 rexia following the sweating stage be perfect, the patient free
 from restlessness and pain, skin cool over the entire surface,
 no febrile heat, acrimony, or dryness  about the chest or arm-
 pits, and free from thirst, tongue natural, then  without doubt
 quinine may be given with little danger of  injury.   But the 
27
time that  elapses, if any, after the termination of the sweat-
ing stage, and the accession of the next paroxysm, is gene-
rally very brief, too brief to do much good with  quinine, if
it has the  right  tendency.  Let us inquire, what is quinine
given for, in intermittents ? Is it given for any other purpose
than to  intercept the paroxysm ?   If it fails in  this, does it
do any good ?   Is it expected to intercept the next paroxysm
of a remittent, by those who recommend it?   If the apyrexia
is not sufficiently long and perfect to entitle it to the name of
an intermittent, quinine cannot be given with much prospect of
benefit;  and injury very often results from it.  It sometimes
happens, after all the violent and more urgent symptoms of
the disease have abated, and we are  expecting it to terminate
in convalescence, about the seventh, eighth, or ninth  day,
that from some  cause, hard  to  determine, a remnant as it
were, of the fever,  holds on, and assumes a more continued
and slightly typhoid form, characterized sometimes, byr rather
disagreeable and profuse  sweats, a slight delirium by turns,
and a little subsultus, and a dark tongue.
   Such appearances should prompt the practitioner  to the
most  scrutinizing search for some local malady,  which may
have  been hitherto latent,  or which may just now be forming,
and if any such local disease be found you are referred to the
proper  head for the  treatment.   If not, we have little to ap-
prehend as to the final result, though the case may be a pro-
tracted one.    If these symptoms  become  of a decidedly
typhoid  character,   the treatment  recommended  under the
next head will be suitable, but if not we may keep the  bow-
els quietly  open, and the extremities warm, allow more bed-
clothes, leave off the nitre, antimonials.  &c, and  give more
nourishment,  if his  stomach will admit of it; use considera-
ble friction of the skin ; check the sweats with a cloth dipped
in  strong salaratus  water, camphorated spirits,  or alchohol,
d2 
28
and applied to the skin by friction, as often as the sweating
becomes profuse.   Procure rest at  night by a Dover's pow-
der, or  if inclined to be a little  comatose, apply  a blister to
the back of the neck. 
                          29





                   CHAPTER III.

 Simple  Miasmal fever of the typhoid grade.

                       REMARKS.
  Though this grade of miasmal fever occurs perhaps but
seldom, as a primary  fever,  and  disconnected with  local
lesions, yet there are some reasons for assigning to it a sepa-
rate position in this arrangement.
  It is a fever of a  distinct grade, giving rise to a peculiar
set of general symptoms, and  though some viscus or tissue is
almost always  affected, yet some things  in reference to the
treatment, are common, and but little modified on account of
the local phlogosis.   And again ,the signs which indicate the
seat  of the  local affection, are sometimes so  obscure  and
equivocal, that little more can be done than prescribe for the
general symptoms.
  Though it generally occurs as a second stage or sequel of
one of the other grades, or is preceded by a longer or shorter
period of fever of the synochal or synochus grades, yet when
the  typhoid grade  of fever does set in, it  is as distinct  in its
character, and requires as much peculiarity of treatment, as
any other species or variety of fever whatever.

                       SYMPTOMS.
  This grade of fever  is so easily recognized, that no one is
likely to mistake it; in fact, all the relatives and friends who
are permitted to  look in upon the  patient, have  discernment
enough, to see at once,  that the fever, as they say, "has run
into a typhus;"  and so near does it simulate the true typhus, 
30
that it would be impossible for a physician to pronounce that
it was not, by the existing symptoms, without calling  to his
aid the  history of the case, or the prevailing epidemic.—
Hence, typhoid is by far the most significant cognomen  that
could be given to this grade of miasmal fever.  The patient
has a quick, feeble pulse; great prostration, delirium or coma,
usually  a brown or black and dry tongue, black sordes about
the teeth, difficulty of protruding  the tongue, picking at the
bed-clothes, subsultus  tendinum, calor mordax, difficult deglu-
tition, involuntary evacuations and stupor. He replies to your
questions with reluctance, and his answers are short, peevish
and sarcastic;  profuse, hot or clammy sweats,  sometimes
bedew nearly the whole surface, but are frequently confined
to the head,  chest and neck; dark grumous blood  sometimes
oozes from the gums, the  breath is  offensive, skin pale and
shrunken, great alteration of the features and voice, and great
muscular weakness,  epistaxis and dizziness; and  vertigo  if
compelled to sit up.   It is  frequently from a week  to ten
days, before the milder of the typhoid symptoms mentioned
above, make their appearance, having been preceded by feb-
rile symptoms, usually of the  synochus grade.   But under
more aggravating exciting causes, as in the paludal districts
of the tropical  regions, or in a very hot and  dry season in
temperate regions, where a quantity of low ground usually
covered with water,  is exposed to a hot sun, in the immediate
vicinity of a large population as was the case with  Dexter,
by draining the mill-pond  in the autumn of 1828;  some
cases usually occur,  marked by  the more malignant of the
above symptoms,  making their onset with great impetuosity
and with little, or no previous stage of  the synochus grade.
   Symptoms like the above, with more or less violence, often
 continue for a week, or even ten or twelve days, and terminate
 in death or  a very gradual recovery, with a protracted conva-
 lescence. 
31
                      TREATMENT.

  In the first place, make yourself acquainted with the his-
tory of the  case.    Is it a recent attack, or has it passed
through some days of the synochus  grade ?  Then put your
patient under a rigid examination for local inflammations and
congestions, according to the diagnostic symptoms hereafter
mentioned.   Examine his extremities on every visit yourself,
and order bathing,  frictions, sinapisms  or external warmth.
&c, as the case may require. Examine the bladder often, and
if it does not discharge its contents freely as it often docs not,
pass the catheter.  Examine the hips and sacrum, to see that
no ulcers are formed from too constant pressure, and vary his
position frequently, by bolstering him in different positions.
    If it be a recent case, do not let the apparent debility de-
 ceive you.  What has become of the strength and power that
the patient was so recently endowed  with ?  Has it been ex-
hausted by violent and protracted febrile excitement, or are
the powers of life pent up or  weighed  down  by  some over-
whelming cause.?  If the latter, has he been  in this state of
 oppression so long, that  the system  will not rally, or react,
on taking off some of the load ?  Apply your ear or a stethe-
scope over the heart, and see if it be not laboring with more
strength, than the pulse of the wrist would seem  to indicate.
   If on these considerations you can have any  well grounded
suspicions that depletion should be used, by all means make
a trial of it.   If you are not sure of its necessity, still under
proper  precautions,  it can be tried  as safely as any remedy
whatever.  Open a vein, and keep  your finger on the pulse
of the other wrist, and if the pulse does not grow  weaker,
and above all, if it rises, you may be sure you arc  right.—
If the pulse appears to  flag, after a  small bleeding, order a
little warm wine, external warmth, and friction, and examine
your patient again  after the lapse of an hour; for  perhaps 
32
the system  is not past re-action,, but is slow to do so, from
having endured the load so long.  Then if you find reaction
is taking place, you may cord the arm and let more blood.-—
By managing in this way, you will sometimes, in the course
of a few hours get a copious bleeding,  and have a  free and
comDaratively active state of the circulation ;  when but a few
hours previously, you might be induced  to believe, the patient
was ready to sink from actual debility.   In this way, it is not
uncommon, for the graver typhoid symptoms to be changed to
the milder, or  perhaps to the synochus.   In the cases which
admit of bleeding, cathartic medicines, which procure copious
evacuations should be used ; though  irritating purges should
be avoided, for fear of producing inflammation of the mucous
membrane of the alimentary canal; a disease most likely to
become complicated with the fever, and which it should  be
our chief purpose to avoid.
   When you have decided  on  not bleeding any more, or on
not bleeding at all, and  become convinced that you  have not
to direct your attention to any local affection, there is not much
to be  done, but to attend to your patient's comfort, and most
urgent wants, and s'.and  ready to meet any untoward symptom
that may show itself.  In the  milder cases, your chief care
should be, not to injure your patient by too much officiousness,
but trust greatly to the  vis medicatrix natura.  The whole
contents of the stomach and bowels, should be expelled by
an enema, followed  with a  few grs.  of  calomel,  and  all
worked off by castor oil, mixed either with carbonate of mag-
nesia,  or turpentine, as may be preferred.   After this the
bowels should be moved perhaps twice a day, with some gen-
tle aperients, and enemata, but so as to be sure  that none of
the contents,  are allowed to accumulate, and not pass off—
The antiphlogistic means as previously recommended, should
in the main be used, excepting the nitre, antimonials, etc.—
An agreeable temperature should be preserved over the entire 
33
surface  and extremities, by means  already  mentioned.   If
profuse sweats occur, stimulating frictions of mustard, capsi-
cum,  alcohol, camphorated spirits, solution of sal. aratus. or
some  of the mineral acids, or the pulv. cantharides and vine-
gar, may be frequently used, and if demanded, some internal
stimulants  may be tried, as wine-whey,  with or without a
little aqua ammonia, mulled wine, milk punch, lemon punch,
or wine and water.   If these agree with  the  stomach without
increasing  the thirst,  drynesss of the tongue, and fauces, and
restlessness, they may be continued and increased, if necessary,
not otherwise. It is said by some, that strong beer or porter, par
ticularly if alternated  with good yeast, may be freely adminis-
tered  in some instances, where  there is much thirst and dry-
ness of the mouth, with evident advantage, and when the pa-
tient  will bear nothing else stimulating.   Some,  are  in  the
habit of recommending  barks and  quinine;  but where a
stimulant is necessary, good madeira, or claret, wine is best.  It
is cheaper and more agreeable.  In some extreme sinking cases
brandy is used to advantage. A strong decoction of capsicum
or  capsicum  in substance,  is sometimes  given in extreme
cases, and  in  some instances, with  more  evident advantage,
than  any other stimulus.   When the patient begins to arouse
from this stage of decline, the stimulants must be withdrawn.
 It is  seldom advisable to  give bitters, or stimulants  during
 convalescence, or more nourishment than the stomach craves.
Errors of  this kind, often produce disagreeable diarrhoea,  and
 other unpleasant consequences.  In the early settlement of
this county, the  miasmal fevers were characterized by a much
 greater adynamic tendency than now;  and when  not com-
plicated with too much local disease, repuired the  early use
of stimulants, and they were even nsed sometimes very freely,
 when local blood-letting,  fomentations,  and  counter-irritation
 were going on at  the same time, to  remove a local  inflam-
 mation.
                              E 
34
  So strong was this tendency to "run down," as it was called
that few patients were permitted to remain twenty-four hours.
after the first attack in our autmnal fevers, without forth proof
brandy by his side.   In a great number of instances, it was
early and freely administered; so much so that  some, who
never made use of it  when  well, and  even delicate  females,
took from  a pint to a  quart, every twenty-four hours for seve-
ral days in succession, with an indefinite quantity of bark and
quinine added.  This treatment at the time did seem to be the
only safe  course, and a number of sudden and  unexpected
deaths took place  apparently from a neglect of it.
   Such is said  to be the tendency of the autumnal fevers in
some of the newer parts of onr state at this time, and the treat-
ment adopted there by some physicians, is much as has been
stated above.   But it has been several  years, since our mias-
mal fevers in this section, have seemed to call for such treat-
ment, and if we were again called on to witness such cases we
will not now pretend to decide, how far our views and treat-
ment might be  changed according to some suggestions made
at page thirty-one. 

                     PART  II.

  Miasmal fevers of the different grades  irilh
                  organic  lesions.

                        REMARKS.

   This is by far the most important and interesting  part of
our subject.   It is  a key to all the discrepancies and contra-
dictions in theory and  practice, that have filled our  schools
and  books,  till of late, with  such irreconcilable jargon  on
miasmal fevers, and have left the physician to feel humbled
in many instances,  at his impotence at the bed side of his
patient.  It  has been much the fashion hitherto, to ascertain
first, if your fever be a remittent, for instance, and if so, pre
scribe  for the name of the disease.   You consult one author'
whose experience has been confined to one locality, and sea-
son, where the most active cathartics, antimonials and nitre
were found  of the utmost service.   Now this author did not
know  enough to tell  you, that in his practice, all his bad cases
were accompanied with cerebral  inflammation,  and it was
what he had carefully to avoid in  his milder ones. Your own
practice may have been for some years; among miasmal fevers
of precisely this variety, and  consequently you  have become
much attached to, and confident  in the  use of  similar reme-
dies.   But now you change your location, or  the disease
appears at length in yonr old neighborhood, complicated with
gastretis or  enteritis.   Still, it is  obviously enough,  a remit-
ing fever, and the  active cathartics, antimonials, nitre,  &c.
are prescribed, as usual.   The physician becomes alarmed at
the mortality of the epidemic, and  the inertness of his reme- 
                           3(3

dies, and in short,  nearly  all his  case3 that were  originally
bad, prove fatal, and his cases that appeared mild at first, and
which he expected to discharge  cured in a few days, run a
protracted and painful course, and recover after a tedious con-
valescence.   In another locality, or another season the fever
pioduces  consecutive  hepatic,  or pulmonic derangements,
anil'phlogosis,  each of which demands  a  radical difference
of treatment.   Nor must  the physician  expect to  meet with
those prominent and  well  marked symptoms, to point  out
the seat of a consecutive inflammation,  which distinguish
them in the phlegmasia? proper.  It is a little surprising on
examining this subject with this particular view, that nearly
all the books, from the oldest to the latest,  abound with instan-
ces of nearly every viscus and tissue at different times, having
been the seat of disorganizing inflammation, (as shown by
post-mortem examinations,)  without the most able  and expe-
rienced attending physicians having had the  least suspicion
of its existence.   This is owing to the fact, that the attention
of the faculty has been so little called to the  consecutive in-
flammation in what are called idiopathic fevers, and to the
obscurity of the signs which indicate its presence.
  It is always advisable when any epidemic changes in some
of its symptoms, if you are  not positive of the nature of  the
change, to embrace the earliest opportunity for a post-mortem
examination,  and thus enable yourself at once to account for
the novel  phoenomena  of the malady,  by detecting the ana-
tomical lesion.   These local affections occur but  seldom in
the  synochal  grade, more  frequently in the synochus grade,
but much the most frequently in the typhoid  grade of mias-
mal fever. 

                    CHAPTER I.

  Gastro-Enteritic  Miasmal fever,  or  miasmal
fever complicated  with inflammation of the ali-
 mentary canal.

   This is by far the most common phlogosis, that we have to
 contend with in these fevers, and the pathognomic symptoms,
 are not always palpable, especially in the typhoid  grade ;
 where it may exist to an alarming degree, and yet, that stun-
 ned or apathetic  state, under which the whole system seems
 to be laboring, prevents the developement of such symptoms
 as would, under any other circumstances, point out the nature
 and extent of the malady.  It is a fatal error to suppose, that
 pain and tenderness are always to be met with, in consecutive
 abdominal inflammations, especially when the fever is of the
 typhoid grade.   Neither is it an easy matter, to point out the
 precise seat of the inflammation, because gastretis, enteritis,
 peritonitis &c, have many signs  in common, and  because
 more  parts  than one  are usually implicated  at the same
 time.

                       SYMPTOMS.

   The patient most commonly lies on  his back, with his
knees drawn up, and when pressure is made on the abdomen,
he complains of soreness, or if from stupor, he is not inclined
to speak, he evinces signs of pain, by knitting his brows and
showing other symptoms of uneasiness.  There is generally
an increase of heat over the abdomen, and often at the same
time a damp  coldness about the face and forehead.   Intense 
38
thirst for cold drinks, and frequent vomiting, if the inflamma-
tion be in the stomach, or upper part of the bowels. And if in
this part, fluid or other substances that are taken on the sto-
mach, are soon rejected, but sooner if they be warm.  Bile is
generally ejected, and the patient experiences temporary relief
after vomiting.  The tongue is red  about the.edges and tip,
and in  many  instances the redness extends over the entire
surface, presenting a skinned  appearance.  It  often  becomes
dry and brown along the centre, and  chapped.  There  is
soreness about the fauces and difficult deglutition. The abdo"
men is fuller than natural, and distended by gas.  A gurgling
noise is often heard in the bowels,  especially after drinking-
If the inflammation  be confined to the lower  part of the in-
testines, many of the above symptoms will not present them-
selves.   There is  generally frequent mucous or oily stools,
in some instances diarhoea, sometimes a little mucous streaked
with blood; in other instances watery, billious, and  acrid de-
jections, a hollow appearance about the  eye, and great mus-
cular prostration.   Faint and sinking turns just  before, or at
the time of any thing passing the bowels, is an  indication of
enteritis.   The least peristalic motion of the bowels, even to
expel a little gas, sometimes produces a sense of  fainting, and
the patient calls for camphor and volatile salts and asks to be
fanned.   It would be very unfortunate to mistake such symp-
toms, for pure debility, and thereby pursue  the  wrong treat-
ment, as it must almost of necessity prove fatal.
   In the more advanced stages of the disease, copious  liquid
evacuations mixed with dissolved blood,  or large quantities of
blood but little mixed, pass from the  bowels producing rapid
exhaustion of strength.  These are  accompanied  with the
most alarming sinking turns, and in some cases, with profuse,
cold, clammy  sweats, threatening immediate dissolution.
    If  the  inflammation be seated in  the duodenum,'there is
generally a puffy feel over the part:  and the whole surface 
39
 of the body, but more especially the skin about the face and
 neck, becomes jaundiced.   This  icteroid appearance, fre-
 quently occurs without  the  least disease of the liver, or ob-
 struction of the biliary ducts, as bile is found in its usual quan-
 tity in the  evacuations from the stomach and bowels.
   Children from six months to  five or six years old, are pecu-
 liarly liable to exhibit many of the above  symptoms, accom-
 panied with a fever of the synochus grade constituting, what
 is called infantile  remittent.   Although the  affection is not
 necessarily of miasmatic origin, yet the pathological condition
 of the abdomen,  and the proper  treatment,   are  so  anala-
 gous,  that  it was  deemed  expedient to allude  to it  in this
 place.   The distension and irregularity of the child's bowels
 variable appetite, picking at its nose and  lips, starting in its
 sleep &c.,  often induce the friends to believe that the child has
 worms, the poor little sufferer is drenched with every thing in
 the house "good for worms," and every croaker and gossip in
 the neighborhood, kindly  prescribes her  "sure  cure," but,
 contrary to all their expectations, the child grows worse ! and
 after thus converting  a very mild  disease into a formidable
 one, a physician is sent for in time to  be " in at the  death."—
 It is,  perhaps, now, more than the doctor can do, to undeceive
 them.   They inform him very gravely that " the child has
 worms!"  that they "have  given the  most active  medicines
 they have, and they have sent for him to see if he  had some-
 thing more powerful to expell them."   It is seldom we meet
 in practice with a more frequent, fatal, and yet inveterate delu-
 sion than this.  If you will kill the child with drastic medi-
 cines. " for worms," all  is well; but  if you save the child
 without " expelling the worms," they  never feel exactly satis-
 fied about it.   If  it were not for depriving these worm doc-
 tresses of so much of their consequence in the world,  could
almost  wish that there was not a worm in existence. 
40
                      TREATMENT.

  If the patient is in a condition to take any nourishment, he
must be confined exclnsively to that which is bland and  mu-
cilaginous, as, arrow-root, sago, tapioca, blanc-manger, etc.—-
He must be confined to cooling mucilaginous  drinks, acidu-
lated, or not, as he prefers.
  Bleeding, cupping or  leeching,  blistering  followed  by
large bran fomentations, &c, must be had recourse to in their
turn,  and  according to the exigency of the case.   Bleeding
should be  more frequently resorted  to, and  carried to much
greater extent in these  cases, than  the  general  symptoms
would seem to warrant.   There is no error  so often made in
general practice, as to mistake the low symptoms consequent
on a consecutive  inflammation of the mucous  membrane of
the alimentary  canal, for real or  pure debility.  This leads
to the use of stimulants and tonics,  instead  of  free depletion,
general and local counter-irritation, fomentations, and copious
mucilaginous injections of flax-seed  tea,  etc.   The contents
of the stomach and bowels should be thoroughly  expelled
if possible, and with the least irritating medicines.   For this
purpose the patient should first be put under the influence of
a large anodyne; then five or six grains of calomel, followed
in two hours with repeated doses of castor oil, and carbonate
of magnesia, (see page thirty two,) will be found the best for
this purpose; still repeating, if necessary, the opium, so as to
insure an  operation  without pain or irritation.   After this the
bowels should be carefully moved about  once or twice in the
twenty-four hours, by some such mild means as above stated,
assisted by proper enemata.   In cases of very frequent acrid
or bloody stools, or  in any case where there is too much loose-
ness  of the  bowels, you should be careful to clear them  tho-
roughly ;  but in the most cautious and  gentle manner  pos-
sible ; and prevent accumulations in future, by using the same 
41
means as often  as  necessary  for  that  purpose,  but  not  of-
tener.   Next to this, repose is what the bowels most need,
and this they must have, or all other means are useless.  For
this purpose, opium is our main  dependence, and should be
used without stint.   It is a great error to suppose that opium
is unfavorable to the operation of cathartics, in cases where
there is much irritation of the alimentary canal: for in many
such  instances, it is a powerful and indispensible adjuvant.—
Any  cathartics, without the use of opium, which may be ex-
hibited, will oftentimes produce sickness  of the stomach, tor-
mina, and frequent  watery dejections, attended with no relief;
whereas, if the patient be kept steadily under the influence of
opium, the same cathartics will  procure one  or two large,
consistent evacuations, with evident relief to the patient, and
without pain.  Opium  and calomel,  one gr. each, in a pill,
may  be given every one, two, three, or four hours, as the na-
ture of the case demands.  If this is not sufficient, or if opium
is contra-indicated in such large doses, acetate of lead  may be
used  to any extent,  combined with opium in the proportion of
three or four gr. of the former, to one of the latter. This will
seldom fail  in arresting  the frequent discharges.   When the
stomach is irritable, and sometimes when it is not, these  medi-
cines given by injections, are found to do  much the best.   For
this purpose, a  large  tea-spoon full  of  laudanum, in half a
tea-cup full of thin starch, may be  injected immediately after
every stool.   The quantity of fluid  should be small  at first,
to insure its retention, but may be afterwards increased.   To
this injection the lead  may be added  if necessary.
   In some  instances, where frequent watery stools are diffi-
cult to restrain, and there is but little fever, it will be  found
advisablo to put your laudanum and lead in a strong decoction
of logwood for an injection. This last is  more easily  retained
than either  of the others, and has more power over bad  cases.
 One  powerful means of overcoming too  frequent evacuations,
                               F 
42
 and one too much neglected, is the use of iarge injections of
 starch or flax-seed tea.   When the patient feels inclined  to
 have something pass his bowels, a flax-seed tea injection ad-
 ministered, with, or even without a little laudanum added, will
 generally composo  him at once.   There are very few  cases
 where  repose and quietude  may not  be procured  for the
 bowels, by the use of the calomel and  opium  pill, aided by
 flax-seed tea injections, if the latter are administered as often
 as once in from two to four hours, with or without a little lau"
 danum, as is necessary,   Hot bran fomentations should gene-
 rally be used in the mean time, even though there may be lit-
 tle or no perceptible  tenderness from pressure.  After keeping
 the bowels quiet in this way for a day or two, it is generally
 no very hard matter  to procure one or two large and consist-
 ent stools, per day, by the use of oil and magnesia, or oil and
 turpentine, (if there  is not much fever  and acute inflamma-
 tion.)   It sometimes  happens in these cases however,  to be a
 very difficult task, to get any cathartic, to do any thing more
 than operate, by procuring small fluid stools, the very state of
things above all  others, which we wish to avoid.    A very
good article  in such cases, is  pulverized brimstone, or well
 washed sulphur. A tea-spoon full should be given about once
in four hours.  It is more likely to procure a consistant evac-
uation in twenty-four  or thirty-six hours without any small wa-
tery ones, than any  other article in the materia-medica,  and
it leaves the bowels  more disposed to quietude.  Pulverized
charcoal makes a tolerable substitute  for sulphur,  or it may
be alternated with it, by giving a tea-spoon full at a time.—
Charcoal is of especial benefit where  you wish  to add the
powers of an absorbent or antiseptic, to that of a cathartic.—
It is frequently given in conjunction with yeast.
  One thing should  be always borne in mind,  in giving ca-
thartics in these cases of whatever kind, and this is the opium
and injections, and even astringents, if they are used,  should 
43
be steadily  persevered  in;  as  well when the cathartics are
being given, as at «ny other time.  Care should be taken not
to discontinue the flax seed enemata too  soon, on the bowels
bpcoming a little more quiet.
  Balsam of copavia, or oil of turpentine, mixed with castor oil,
in the proportion of one part of the former, to three or four of
the latter, has been much extolled by some, as a cathartic in
some cases, but especially where the inflammation is  not very
acute.   This might seem incompatible with  the previous in-
junction, to give nothing stimulating or irritating; but experi-
enceproves, that a small tea-spoon full of turpentine, and a ta-
ble-spoon full of cold pressed castor oil, simmered in a little
sweet-milk and sugar,  (with  which  it mixes,) is one of the
best aperients that  can  be given in these cases.   The quan-
tity  can be increased, if thought necessary, as the  above is a
moderate dose.   This  may be  given instead of the oil and
magnesia.   In all  cases, where the stomach or bowels are in
this  state, all nitre, antimonials, muriate of ammonia, acetate
of ammonia, &c, should be carefully withheld.   Eberle  re-
commends, that where the alimentary canal becomes irritated
by the use of  the  above articles, or by  irritating  cathartics,
producing tormina and frequent watery stools, the following
medicine should be given aided  by mucilaginous drinks:—
               Calomel gr. j
               Pulv.  Ipecac, gr. vij.  M.
   Divide into eight equal parts, and give one every half hour
or hour."
   The above is found to bo an  excellent prescription in such
cases.   The extreme sinking turns which are apt to accom-
pany this disease in its declining stage, consequent upon pro-
fuse or bloody dejections, and accompanied generally, by co-
pious clammy sweats, must be met, with as much promptitude
as possible.    External warmth and  irritating frictions, sina-
pisms over a creat part of the extremities, and all that can be
                           v2 
44
done by external means, must be done.   Internally, you may
give wine or brandy, or hot wine or brandy toddy, ammonia,
sul. ether  saturated with camphor, thirty or forty drops every
hour  or  two, red pepper  tea, quinine  in  liberal doses, &c,
but, where wine is sufficient,  it is preferable.   Care should
be taken not to use these articles longer than is necessary, and
not to place too much reliance on them; but direct your  atten-
tion  to the pathological condition of the  alimentary canal,
and the abdominal 7iscera, and  to the use  of such means
for their cure as have been heretofore  pointed out, and such
as your own good sense can devise.
   When the stomach is  very irritable, and  apt to reject its
contents often, (except where  some retching proceeds from a
phrenilis, as is sometimes the case) you may make the attempt
if you like, to allay it, by  a large dose of clear laudanum, or
opium and cal.  two or three grs. of each, in  a pill; denying
the patient every thing to  be taken on the  stomach until this
produces its effect; then by keeping up this  strohg anodyne
impression, and proceeding with  caution,  letting the  patient
tako but little iced or cold drinks at a time,  you may get on
without any further difficulty.  If, however, you are satisfied
that there is any irritating  ingesta in the stomach, some warm
water, camomile or weak  boneset tea, should be premised, so
as to get a full discharge from the stomach first.
   The anodyne should be always given  immediately after
vomiting.   If howevor, this should be rejected, or if from any
cause, you are satisfied that such  will be the result, you may
always put the system under  the  influence of opium, just as
well by injections.  After having bled and cupped, if neces-
sary,  and  prescribed a mustard plaster, or a blister followed
by fomentations, your main reliance should be on anodyne in-
jections, to get  the system under its full influence, then keep
it up,  by the small calomel and opium pill of equal parts, care-
fully  excluding ev.ry thing else  from the stomach,  except  a 
45
spoonful of cold water, occasionally, measured out in a spoon
with a few small lumps of ice, if nt hand.   Even this, had
better sometimes beheld in the  mou'.h and spit  out without
swallowing, as nothing is of so  much  importance as repose
to the stomach,  when in a highly irrritahle  condition;  and
this cannot be procured in many instances, without withhold-
ing every thing from the stomach,  even  for several days.—■
Before commencing with anodyne injections, as full a cathar-
tic operation  should be procured as possible, by enemata first,
and these should be repeated  from time  to time,  as often as
is necessary.   Then after quieting the  bowels with anodyne
injections, you may throw up as much water, milk and water,
thin starch, strained water-gruel,  etc., as is necessary to sup-
ply the system with sufficient fluids and nourishment.  This
may be continued, if the stomach remains  irritable, for several
days ; the stomach being denied every thing in  some instances,
and in others, nothing being admitted but the opium and calo-
mel pill.   In short when the system requires the operation
of any medicine, and from any cause it cannot well be admit-
ted through the stomach, it can be given with just about the
same advantage by the rectum.
    Any of the cathartics,  as aloes,  rheubarb,  jalap, salts,
and senna, &c.;  any of the anodynes,  or  antispasmodics,
 any of the tonics, stimulants or astringents, as quinine, brandy,
or wine, acetate of lead, &c.; diluents  and nourishment, as
beef or  chicken tea,  in addition to  what has been  before
named, and in fact, almost every article in  the materia medica,
 if properly prepared, may be given by the rectum, in about
the same quantity, and with about  the same certainty, that
each will have its specific operation, as if given by the stomach.
In fact, in all instances, where there is great irritability of the
stomach, whether from gastretis, enteritis, or any other cause,
injections are of the utmost importance 
■16
  In instances of great irritability, of the stomach, and vomi-
ting, from whatever cause, the patient generally suffers much
from thirst and dry skin.   Drinks are rejected before they
can enter the circulation, and  though  the patient  swallows
ever so much fluid, it is instantly rejected, and he still suffers
from the most tormenting thirst.   In all  cases,  of this kind, if
you order an injection of a pint or more of thin starch, warm
water,  or water gruel, every two, three, or four hours, accord-
ing to the urgency of the symptoms, the thirst  will be allayed
and the skin  bedewed with a gentle moisture.  Whoever has
witnessed the suffering from constant vomiting, thirst, jactita-
tion, dry hot  skin, etc., always  consequent upon acute gastri-
tis, and some  cases of enteritis, will appreciate  this announce-
ment very highly;  as there  are few diseases without  this
remedy, in which  the  patient  suffers  more, and few if it be
properly used, in which they suffer less.
   The intermittents which occur, complicated  with irritation
of the alimentary canal,  have  a fever of the synochus grade
generally.  If on a careful inspection, the inflammation seems
to bcbut very slight, you need not always delayr the giving of
the quinine, until every vestige of it is overcome.
   You should procure a  bleeding in the cold stage if possible
first, and repeat it with the next cold stage, if necessary, then
topical  bleedings and  counter-irritation, &c,  should be pre-
mised, if the  nature of the case seems to require it.  Then, if
the intermissions are  perfect,  no thirst,  no  heat of the skin
about the abdomen, no irritation evinced by  the pulse,  and
tongue not loaded, you may prescribe  the usual quantity of
quinine, largely diluted  in some cooling mucilaginous beve-
rage, taking care to keep the bowels open.   But, it sometimes
happens that  the paroxysms are perfectly regular, as to time,
and duration  ; and terminate in a profuse but hot sweat, with-
out leaving the patient during  the  intermission perfectly  free 
47
from restlessness, thirst, &c, skin on the body a little too hot,
the pulse a little corded, the abdomen perhaps a little tumid,
meteorism, and watery dejections or costivtness, and a loaded
or polished tongue.   If under any  of  these  circumstances,
the physician regards the case as a simple intermittent of the
synochus or synochal grade, and prescribes  his quinine, or
other febrifuges of this class,  he  may or mayr not intercept
very easily the intermittent paroxysms, but the local irritation
will become augmented, aud deeper seated ; the fever will
become remittent or  continued, and after several days.it is
likely to become of the typhoid grade,  and run a protracted
and dangerous course. Such is the origin and history of some
of the most fatal cases that have occurred in  this section  of
Michigan.
   But the consecutive  inflammation of the  mucous mem-
brane of the alimentary canal, consequent upon miasmal fever
cannot be much protracted without converting the  fever into
the continued  form, and typhoid grade.   One reason why we
have so much of this grade of fever in  the autumn and fore-
part of winter, to deal with, is that  the examination of the
early spmptoms is not sufficiently minute and  discriminating;
the incipient phlogosis is  not  detected, and early subdued or
guarded against, and it insiduously steals on, until it produces
this grade of  fever, when, although the inflammation is  pro-
bably aggravated, yet. the typhoid grade of fever, so  subdues
or  locks  up the sensibility of the whole  system,  that the
symptoms which would indicate its presence  in an original
inflammation of this tissue are seldom present.
   This last fact should be kept constantly in mind, in making
our diagnoses;  not only when this tissue is inflamed, but
where any other tissue or viscus is presumed to be implicated.
   It is a matter of the first importance in the recovery from
this disease, that the  most rigid abstemiousness from every
article calculated to irritate the stomach  and bowels be obser- 
48
ved, until the patient  is far advanced in his convak'scence.—
Relapses and chronic  irritations are very apt to follow these
attacks, and in  many instances the bowels are more or less
bloated for six or twelve  months afterwards.

* 
49
                     CHAPTER II.

   Hepatic   Miasmal  fever,  or miasmal fever
complicated  with inflammation of the  liver.

                       SYMPTOMS.
   When this organ is diseased in miasmal fever, the symp-
toms in many respects are not unlike those, when gastritis is
present, as nausea, vomiting, thirst &c.   But the pulse is not
usually so weak and small,  neither is  vomiting produced so
soon by injesta, nor is muscular weakness so great as in gas-
tritis.  The skin and conjunctiva are icteroid in most instan-
ces, though not always, as in inflammation of the mucous coat
of the  duodenum, but, it  can  be  distinguished from the lat-
ter, by there being  little or no healthy bile in  the evacua-
tions from the  stomach and  bowels.  If the liver be acutely
and much affected, the stomach ejects no bile, and the stools are
of a clay or ash color. The  urine is scanty  and high colored.
There is generally a sense  of weight, fullness and pulsation,
in the  right hypocondrium,  a little pain  in the right shoulder,
and  uneasiness in lying on  the left side.  Pressure under or
over the  short ribs, produces a sense of  soreness or pain.
   There is apt to be a little cough without any other symp-
toms of bronchitis.    This cough,  produces an increased  un-
easiness or pain in the side,  and a disposition to vomit.
   The tongue is not much  furred at first, but finally a dark
red list extends over the centre to the dorsum and soon turns
black.   Towards the termination of this variety of fever, es-
pecially if it has not been thoroughly treated  from the com-
mencement, the liver strives to relieve  itself by throwing off
a large quantity of black, thick, tar-like bile, or blood, which
                          G 
50
passes by the bowels.  This is no doubt a critical discharge,
and should be regarded favorably, and encouraged by full ca-
thartics.  This is almost the only hope when the liver has
been violently implicated, and proper treatment neglected.—
This  discharge from the liver is likely to be preceded or fol-
lowed by sinking turns, resembling those mentioned in enteri-
tis, which requires the use of cordial stimulants,  warm wine
and milk, or wine and water, at the same time you use full ca-
thartic doses to  carry off the offensive matter.
   We must be careful however in this as in all  other cases
of consecutive inflammations, that we do not wait for all those
symptoms to present themselves before we apprehend the true
nature  of the case; for  in truth but very few of the above
signs are present, and these but in their faintest degree, espe"
cially when the fever is typhoid;  and yet the local affection
may be of disorganizing violence.

                      TREATMENT.

   After having used general and topical depletion, (if not con-
tra-indicated) blistering, fomentations, &c, and put the patient
on such a course, as the grade of fever indicates, calomel is
our main remedy.   From ten to twenty grs. should be given
every four or  five hours, and should be persevered  in, until
ptyalism is produced, or until the liver discharges bile copi-
ously.    If there is much irritation of the stomach,  as there
usually is, opium should be combined with  the calomel, and
effervescing draughts  exhibited to allay it.   If the  calomel
does not keep the bowels sufficiently open,  other aperients,
enemata, &c, should be had  recourse to, in sufficient quanti-
ties for the purpose.
   Some physicians, after having witnessed the great benefits
derived from  the use of large doses  of calomel, in the hepa-
tic variety of miasmal  fevers, have blindly  recommended  it
in all cases.    The  physicians of southern latitudes, where 
51
these  fevers are  generally hepatic, have done much toward
propagating this popular error.  But in this latitude, there are
several other organs, either of which are as likely to be dis-
eased as the liver, and perhaps the mucous membrane of the
alimentary canal much more  likely,  and in which nothing
could be more preposterous and injurious than such enormous
doses of calomel. 
52
                   CHAPTER III.

   Splenitic   Miasmal fever,  or  miasmal fever,
complicated icith inflammation of the spleen.

                       SYMPTOMS.

   It is not often easy to mistake, when this organ is diseased
in miasmal fever, unless when there is  considerable  stupor
and insensibility, in consequence of a typhoid grade of fever.
But, it is by far the most common, for the spleen to be inflamed
in the synochus grade, and  the fever intermittent.   There is
almost always pain in the position of the spleen, and running
up into the left shoulder.  You can feel the spleen distinctly,
on examining  with the hand, enlarged and hardened.  The
tongue is frequently smooth and polished, which  leaves but
little doubt, that there is some gastro-intestinal irritation ac-
companying it.

                      TREATMENT.

   The usual general and topical depletion, counter irritation,
&c, with other antiphlogistic means, must be used, to the ex-
tent that seems necessary.   The fever treated according to its
grade.
   If the fever be intermittent,  as it most  commonly is, and
the intermissions perfect, it is not always necessary to put off
giving the quinine, until the local disease is entirely removed;
in fact, each succesive paroxysm often increases the local diffi-
culty,  do what you will to remove it, until the quinine be
given  and the exacerbations of intermittent,  intercepted.—
 Quinine may be given with impunity, when there is more in- 
53
flammation of the spleen, than any other organ.   The same
rule should govern us here,  however, as in other local affec-
tions, about giving the quinine, viz :  the intermissions of fe-
ver must  be perfect.   If the ordinary quantity does not stop
the paroxysms, you must not continue it.   Iodyne has been
much recommended in chronic affections of the spleen.  Mu-
riate of ammonia has probably more reputation in removing
affections  of the spleen, in conjunction with the other neces-
sary general and local means than any other article now in
use in this country.  Eberle puts great confidence in it, and
recommends  that it be given, if intermittent fever exist, in
combination with quinine, in the proportion of twenty grs. of
the former to two of the latter; and continued thus  liberally
after the quinine is no longer necessary.   It should be given
in some emulsion.
Thus—  Muriate ammonia?,   oz. ss.
          Pulv. ext. glycyrrh,  oz. i
          Tart, antimonii      gr. j
          Aq.  fontanae,        f oz. vjii M, ft. S.
   Take a table spoonfull every four hours during the day.
   Blue pill, or small doses of calomel, so as to affect the gums
is frequently recommended and generally resorted to, but ex-
perience can testify but little  in its favor.  Physicians in the
East Indies, who have much experience in treating diseases of
the spleen, have discarded mercurials in any form.  Some of
the preparations of iron, generally the sul., combined with ca.
thartics, are now extensively used there, both by the native and
European physicians, in  chronic diseases of this organ.   In
Bengal, there  is a preparation much in use called the,: spleen
mixture."
          Pulv. jalap,
           Pulv. Rhei.
          Pulv. columba?,
          Pulv.  zinziberus, 
54
          Potassce supertartratis, aa oz. j
          Ferri sulphatis,       dr. ss.
          Tinct. sennse,         dr. iv
         Aq. Mentha? sativte,  f. oz. x misce.
   Give one ounce and a half at 6 A. M. so as to have it ope-
rate about twice actively per. day.   This is sufficient in very
chronic cases, where a slow cure only can be expected; but
in more active  cases, the  same quantity should be again re
peated at  11  A. M., so as to get  four  or more evacuations
daily.   This mixture should be continued about ten days, and
then, alternated for four or five days with eight grs. comp. ext.
colocynth, with two grs. gamboge, in  pills at bed time,  and
in the A. M. at seven, twenty drops tinct.  ferri. muriat. in a
wine-glass of water, with dr. i tinct. gentian comp.   This last
dose should be repeated again at  eleven.   In this way the
medicines should be alternated until the cure is complete. 
55
                   CHAPTER  IV.

  Pncumonitic miasmal fever, or miasmal fever
complicated with inflammation of the chest.

                       SYMPTOMS.

  No part of the year is exempt from a liability to this disease
becoming complicated  with  pneumonic  inflammation; but
our spring months, and latter part of autumn, and fore part
of winter,  seem the most liable to it.  It is not always easy
to decide exactly upon the precise seat of the thoracic phlogo-
sis, after  settling in our own minds that it actually exists.   It
may be in the pleura, larynx,  trachea, bronchia, or parenchy-
ma of the  lungs;  or, more than one of those organs may be
simultaneously affected;  but  owing to  the obscurity of the
symptoms in consecutive  inflammations  generally, and espe-
cially,if the sensibilityof the whole system is subdued by a
typhoid grade of fever, it will not be safe to attempt tomake
out a very accurate diagnosis.  It is of more importance gene-
rally, in a practical point of view, to distinguish a bronchitis,
than either of the others, and fortunately it is most easy to do
so.  This is usually preceded by the nose and frontal sinuses,
being a little affected, as by a cold, a sense of tightness about
the chest, and the cough increasing the pain in the  head.—
There is a sense of tightness about the chest, with some cough,
a little expectoration of starch-like mucous, lips purple, instead
of being red, as in other pectoral affections; countenance pale,
except now and then a transient circumscribed flush on either
of the cheeks.   Bronchitis  is  frequently brought on, late  in
these fevers, by not increasing the bed-clothes and tempera-
ture of the room,  on  the fever having passed its acme; and 
56
 not  adopting  the proper precautions on the coming on of a
 cold rain-storm, &c.
   On the least pneumonic symptom showing itself, it should
 ^ad us to a careful  investigation,  and a full estimate  of all
 the appearances,  being careful to attach  due importance to
 the slightest indications of thoracic phlogosis.   Even  a cir-
 cumscribed  red or purple  spot on either cheek, or about the
 chest, should lead to suspicion, that all is not right, for some
 of our most celebrated physicians assert, that these appearan-
 ces invariably denote some pneumonic derangement.   A fur-
 ther enumeration of the symptoms is useless,   It is only ne-
 cessary to recollect  all the signs that "denote any idiopathic
 pectoral derangement, and make a due allowance for their
 modification, on account of the local disease being consecu-
 ive, and  more especially if the grade of fever  be typhoid.

                       TREATMENT.

   The slight  catarrh or bronchitic symptoms accompanying
 the  intermittents, do not usually demand much  attention ;
 though it is well to investigate their extent, and watch care-
 fully their progress.   Intermittents may be intercepted with
 quinine, in these mild cases, and the catarrh may receive some
*attention  at the same time, or afterwards, if it continue.
  But where the least catarrhal or bronchitic symptoms occur,
 in a fever of greater violence, or a  lower grade, or where
 they denote a deeper seated affection of any of the organs of
 th^thorax, even in an intermittent, they should receive prompt
 and indefatigable attention.
   Bleeding, if not decidedly contra-indicated;  cupping, blis-
 tering, or other counter-irritation,  &c, must all be  had re-
 course to.  Opium, calomel and ipecac, one gr. each, every
 four or six hours, or oftener, according to the urgency of the
 case, so as to allay the present irritation, and produce ptyalism i
 antimonials,  mucilaginous  drinks, and  diaphoretics must be 
57
used in their proper place.  Care should be taken to keep the
apartment ©f the right temperature, and if bronchitis exist
some proper inhalations will be of service.
   If the bronchial tubes become obstructed, an emetic of ipe-
cac, boneset, or lobelia, should be used, though apparently in
the last stages of the fever.
   If the patient be very much prostrated,  he can be support-
ed during the operation,  with warm stimulating drinks.  The
signal benefits derived from the use of emetics in the  last
stages of fever, especially of the typhoid grade,  where bron-
chitis  has been present, has  induced  many to  recommend
them, with but little or no discrimination, and especially with-
out seeming to notice whether any pneumonic affection de-
manded them or not, when, in truth, they can seldom be ad-
missible under any other circumstances. • These last observa-
tions apply  exclusively to  the treatment of the local disease,
and you must refer to the observations on the treatment under
the proper grade of fever, in this as in all other local diseases,
which are here treated of for general directions. 
58
                    CHAPTER  V.

   Cephalitic  Miasmal fever,  or miasmal fever
complicated with inflammation of the brain  and
its meninges.

                       REMARKS.

   An attempt will not be made here to point out the distinct-
ive symptoms  which indicate the precise seat  of the inflam-
mation.  It is frequently as much as is practicable, to say in
which of the three  principal cavities, the  local difficulty is
situated, viz: whether in the  abdomen, thorax, or cranium,
without attempting to designate the precise tissue, as the seat
of a consecutive inflammation.
   It will not be necessary to point  out the symptoms which
denote the  presence of an idiopathic  cerebral inflammation,
nor of an acute inflammation of the head, which occurs nearly
simultaneously with the accession of the fever.   These cases
are sufficiently obvious to a common observer.   It is the con-
secutive inflammation insiduously stealing on, in the advanced
stages of the disease, when usually the  sensibilities of the
system are torpid, from a typhoid grade of fever, that it is so
difficult, and yet so important, to detect.   Persons engaged in
directing   and managing an extensive business, intellectual
persons, and such as live by an exertion of their mental pow-
 ers, are more prone to affections of the brain in miasmal fever,
 than the common laboring classes, who lead comparatively,
 an animal existence.   Precocious youth, and children, are
 also  more than  liable others to this complication of disease. 
59
                       SYMPTOMS.

  The first symptoms generally noticed  in the approach of
consecutive phrenitis, are, an increased heat about the head,
throbbing of  the carotid and temporal arteries, pulse small
and quick, fugitive pains  in the muscles and joints, torpid
bowels, and an uneasy sensation at the precordia.
   At first the patient may be troubled with coma vigil, but
soon the coma becomes more profound, and by turns  he falls
into a deep unquiet sleep, from which it is difficult to arouse
him perfectly; and when he is aroused, he is lost or frightened,
cross and  peevish, and perhaps falls out with  his old  friends,
and adopts new ones.  He reposes with his  eyes rolled  up
under the upper eye-lids, and  sometimes a little open.  The
uneasiness and pain  in the head increases; if you direct the
patient to  shake his head, he is loth to do so, and it increases
the suffering.  He sighs often, breathes hurriedly,  loathes
food, sickens  at the stomach on a sudden change of posture,
tosses his  arms about, and  occasionally presses  one hand on
the head,  knits his brows suddenly, grinds his teeth, and if a
child, bites the cup or spoon.   His temper is irritable, coun-
tenance changes suddenly from flushing to paleness, and looks
heavy and exhausted.   The eyes are more sensitive to light;
sometimes but one, but generally both the pupils a little con-
tracted, hearing more acute, but sometimes more obtuse.—
There is a little unsteadiness or trembling of the  hands, and
if you take hold of them when he is sleeptng, or is not noti-
cing you  will find them rather firmly shut and a little unyield-
ing in the joints of the hand and elbows.   These appearances
are sometimes confined to one hand only.
   The above symptoms often make  their approach by the
most  imperceptible  degrees,  occupying sometimes  several
days, and keep on  increasing if not arrested, until cerebral
inflammation, or  oppression is too  obvious to be mistaken.—
                           h2 
60
Some physicians refer all, or nearly all the symptoms deno-
ting consecutive cerebral inflammations  to sympathy,  than
which, no error  can evince greater ignorance oftentimes, of
the true pathology  of the case.  If symptoms of bronchitis
comes on or any other pulmonary affection, after a fever's run-
ning several  days,  no physician  thinks  of  referring  it to
sympathy, and the same may be said of enteritis ;  or if symp-
toms of enteritis supervene  upon inflammation of the lungs,
or vice versa, nothing is  said about  sympathy ;  or if symp-
toms of the latter affections supervene upon an original phre-
nitis, it commands  the  immediate attention of all.   But if
symptoms denoting an approaching affection of the brain,
shew themselves, when any other disease is  present, many
physicians stupidly  refuse to  prescribe, with  reference to a
threatened or incipient sub-acute  phrenitis, but blindly  attri-
bute the new symptoms to sympathy.  Such opinions are real-
ly  too preposterous to require a serious refutation.

                      TREATMENT.

   Bleeding should be had recourse to if  possible; and here
some general directions  with regard to blood-letting in con-
secutive inflammations, will be given.  If the inflammation
comes on, and is detected before the fever has passed its  ac-
me, the same freedom with the lancet should  be  used,  as in
idiopathic inflammations ; that is, bleed from a large orifice,
and copiously, so as to produce syncope once,  twice, and per-
haps thrice, in quick succession.   In this way a  more endu-
ring impression can be made on the system, with  a much less
expenditure of blood, than from a small orifice and at longer
intervals.  If the fever has pa.ssed its acme, it becomes a much
more delicate question, to decide upon the propriety of blood-
letting, and the extent to which  it should be carried.  If the
strength of the patient does not seem too  much exhausted,
and if you apprehend considerable violence of the local dis- 
61
ease, (after  making due allowance for the slightness of the
symptoms in such cases)  you  had better by all means, let
blood, but in a very different manner from the mode of doing
so in other cases.   The orifice  should be less, and frequent
small bleedings must be  taken ;  their effects closely watched,
and the  vis vitce of the system supported,  if necessary, by
warm wine  and water,  or green tea and  other cordial stimu-
lants, aided  by stimulating frictions,  sinapisms,  &c, to in-
crease the centrifugal tendency of the circulation, and call off
the blood as it were, from the part affected.   It is sometimes
almost impossible to open the bowels freely,  and keep them
so without blood-letting, when the brain is diseased.   But if
the disease has run too long, and the patient's strength has be-
come exhausted,  and if on  listenin g,  the  heart's action is
weak with the pulse,  bleeding would do an irreparable injury
But when bleeding is  necessary,  and is not used, you  will
lose all of the most happy effects that would otherwise follow
from the use of cathartics, calomel to affect the constitution,
anodynes, diaphoretic's,  fomentations, cupping and blistering.
Cupping or leeching should generally follow venesection,
for a  short time,  before resorting to blisters, which  should
always be followed by  fomentations, if the  disease is where
they can be conveniently applied.
   In diseases of the brain, great pains must be taken to keep
the bowels  freely open  ; purging next to blood-letting is the
most powerful  means for  overcoming this disease, and  must
be carried to the extent  of five or six free evacuations daily.
 If much apprehension  exists of bringing on inflammation of
the mucous  membrane of the bowels, such articles as will ope-
rate freely,  and with the  least irritation,  must be used, as a
few grs. of calomel followed by oil and magnesia, or magesia
and rheubarb. The bowels must be kept freely open, not  only
during the whole of the disease, including  the  stage of de- 
62
cline, but also during the convalescence.  Be careful to keep
up a warmth and a free circulation in the extremities; sina-
pisms to  the feet and knees, blisters to the legs and inside of
the thighs, to the back of the neck and arms, &c, will be of
service.   The head should be kept elevated, and very cool,
with ice  or evaporating lotions.    Care should be taken in
using ice, etc. not to get the  pillows and bed-clothes wet, by
the dripping of the water.   The pillows and clothes should
be often changed and dried.   Without this  precaution, you
are likely to bring on a bronchitis, which must greatly en^
hance  the patient's danger.   Time out of mind, a complica-
tion of bronchitis with cerebral inflammation, has been looked
upon as almost necessarily fatal.   The room should be free
from light and noise, and all  general conversation  forbidden.
The patient should be with but one person at a time, and that
should be one whom he likes, and who can  influence him to
be quiet, and keep his mind from dwelling too  much on  his
business or other exciting topics. He should not be disturbed
from a calm sleep for any thing  whatever.    But great care
should be taken to distinguish betwixt a calm quiet sleep, out
of which the patient will arouse easily, and feel  refreshed,
and one which is too deep, disturbed, or profound, and  out of
which it is difficult to arouse him, and from which, he awa-
kens exhausted and lost.   For from the latter  kind of sleep
he should always be aroused; few things are of more injury,
than to suffer the patient to continue long in such  a sleep.—
Antimonials, and nitre, if not contra-indicated,  and diaphore-
tics may be  used, but opium is Drohibited,  except  after very
free depletion and evacuations,  the  bowels being perfectly
open, a little Dover's powders may be used to  advantage.—
Calomel in small doses, or the blue pill, may be used, so as
to produce a slight effect, but not full ptyalism.   Some think
that digitalis in substance, in decisive doses, can  be used to 
63
advantage, say 1-2 gr. of the  powdered  leaves, every two
hours, till the paient is brought fully under its influence.
   One writer in the Medico-chirurgical review-says, that
green tea  used after proper evacuations, has a powerful influ-
ence in subduing cerebral  irritation. 
64
                   CHAPTER VI.

   Miasmal fever,  complicated with inflamma-
tion of the Spinal marrow  and its membranes,
ganglia, and nerves.

                       SYMPTOMS.

   These organs are extremely liable to  become implicated
in miasmal fevers.   Great pain and uneasiness in the back
of the  neck, increased  by pressure, with shooting pain and
soreness of the upper  extremities,  indicates inflammation in
the cervical portion;  or pain in the loins, with great uneasi-
ness and soreness of the lower extremities, and flinching from
tenderness, on pressing that portion of the spinal cord, indi-
cates an inflammation of the medulla spinalis in the lumbar
portion.
   Sometimes  great soreness is felt on  pressure, throughout
the whole length of the spine in  these fevers, and if this  be
accompanied  with great soreness and pain in the extremities,
especially in the course of the nerves,  you will suspect that
the spinal marrow is  extensively  implicated.  These pains
are to be distinguished from rheumatism, from there being
little or no swelling of the joints.   The patient is apt to com-
plain of an uncomfortable and uneasy feeling about the dia-
phragm and stomach;  he occasionally gapes, and his breath-
ing is variable and uneasy.  We occasionally notice other
symptoms, especially in females, which simulate hysteria, and
and which are apt to  encourage the physician and friends;
but without any good  reason, as  experience proves.    The
above symptoms accompany either the intermittent, remittent, 
65
 or continued forms of miasmal fever of the synochus and ty.
 fhoid  varieties, and claim a due  share  of the physician's
 notice.

                       TREATMENT.

    The treatment should be bleeding, if admissable, cupping,
 leeching, blisters, sinapisms, fomentations, &c, over the whole
 length of the spine, or co-extensive with the inflammation ;
 rubbing the  limbs  along the course of the principal nerves
 with the hand, accompanied with as firm a pressure  as the
 patient can bear, and anodynes to procure rest.  This in ad-
 dition to  what is recommended under  the grade of fever
 which accompanies it, is sufficient to give a correct idea of the
 necessary treatment.
    In the intermittent form and synochus grade of fever, we
 have a great variety of what some have called anomalous, and
 others masked intermittents.   Little doubt can exist of their
 miasmatic origin, as they are confined to the same districts of
 country usually, with the ague.   They alternate with it,  and
 are generally cured by a slight modification of the  treatment
 recommended in intermittents.  They consist of every variety
 of  neuralgia,  tooth-ache, ear-ache, amaurosis, nervous head-
 ache, spasmodic cough, and mania.   These affections  gene-
 rally shew themselves in quotidian paroxysms, and last about
 the same length of time, that a fit of the fever and ague does,
 leaving the patient pretty clear from suffering during the in-
 termission.  The exacerbations are likely to be more irregu-
 lar than the ague.
   Quinine and arsenic are  of as much importance in these     *
 as in  the true intermittent.    But, as in other cases of inter-
mittents, it is necessary that the intermissions be perfect, and
care must be taken  to investigate the seat and extent of any
lesion, as spinal,  cerebral, ganglionic, or  gastric, that may
i 
66
exist, and remove  it, or, subdue it in a great measure, before
giving the quinine or arsenic.  Some have attempted  to in-
tercept the paroxysms of miasmatic neuralgia,  with brandy,
opium and camphor, hot bath, sweats, &c, and  though these
are sometimes successful, yet, they generally do nothing more
than defer it for  a  few hours, and at most but a few days.—
If the neuralgia be connected with much  inflammation  of
the superior portion of the spinal marrow, particular caution
should be taken to  subdue it, before giving tonics or stimulants.
as one case  has been witnessed in  Ann Arbor,  where  by a
neglect of this precaution, the inflammation extended to the
brain, and proved fatal.   It is seldom advisable after deciding
on giving the quinine, or arsenic, to carry it farther than you
would in the  ague,  and if that quantity does not remove  it,
you should turn your attention to investigate more particular-
ly the seat of the local irritation, that keeps it up, and direct
your remedies accordingly.
    CONGESTIVE MIASMAL  FEVER, OR CHILL FEVER.

  To carry out the plan as commenced, it is necessary to add
one more  species of miasmal fever, which,  it is conceived,
will complete  a pretty full account of all the different forms
under which this fever has occurred,  since the settlement of
this county.   This  disease used to prevail more or less eve-
ry autumn, from the year 1826, up to about four or five years
ago; since which period, but little has been heard of it.

                       SYMPTOMS.

   It was a quotidian intermittent, and commenced  like any
other ague of  that variety, with this slight difference at first,
which never attracted the attention of the patient, or his friends 
67
viz : The chill would commence  as usual, and with it coma.
The hot stage was not well developed, the extremities remain-
ed below the natural temperature, and about the body, the heat
was a little increased;  the countenance was pale, lips &c,
livid, coma continued, pulse weak.   The sweating stage was
imperfectly  defined,  as there was  more or  less of sweating
from the commencement, but after a more  profuse sweating,
during which the coma continued, the patient would get up'
and go  about  his business; the whole exacerbation  having
occupied about the same length of time, that quotidians do in
general.  During the sweating,  and for some time after, the
skin on the hands looked as if it had been sometime immersed
in  water, or as if it had been par-boiled, it  was so corru-
gated and bleached.
   The patient remained  very  comfortable  during the inter.
missions, and the next day, about two hours later than the day
previous, another paroxysm would come on, with less appa-
rent violence, than many of  the most harmless cases of ague,
but the want of reaction, or a  full developement of the hot
stage, remained the same, coma more profound, and continues
some hours longer than the day  previous.    But thecoma
gradually subsides, and at length the patient gets up again,
and goes about as before, until the accession of the  next fit,
when the coma is more profound and still more  protracted
than the other.   In this way it goes on until about the sixth
paroxysm, the patient remains  comatose through  the whole
intermission.  When the disease arrives  at this  stage, the
next exacerbation is the last,  for the patient never arouses
from the profound stupor into which this throws hirn, and he
dies in twelve or twenty-four  hours.   The patient, or his
friends  seldom became alarmed, until the  lethargy was so
protracted that it forced itself upon their attention ; they, all
the while, supposing he had only the ague,  and was  inclined
to sleep a little too much.  In  this way, the case in many in-
stances was suffered to run  on, up to the last paroxysm,  or
                          i2 
68
last but one, before calling medical  aid, when, according to
the mode of treatment then adopted, it was too late to save
the patient,
   During the years in which this species of fever continued(
a number died every autumn, the majority of whom,  were
past the middle age of life.

                      TREATMENT.

   If the case was seen by the physician, whilst yet the in-
termission between the coma and the next cold stage was suf"
ficently long to administer the requisite quantity of quinine
and have it take effect,  it never failed  to check it.   If seen
thus early, it was just as tractable as any other variety of ague.
It freqently happened, that the patient was not seen till  six or
eitrht hours previous to the exacerbation, which it was but too
evident would place  him beyond recovery.   To intercept the
anticipated paroxysm, becomes  now the engrossing object. It
is evident, if we had as much again time as we have, none
of it must be lost, in giving  cathartics  or emetics, to prepare
the patient for the exhibition  of quinine.   After estimating
the time we have left us, we commence, by giving such quan-
tities of quinine every  half hour, or  hour, as  will use up
twenty or thirty grs. before the next fit.  This we generally
combined with large doses of calomel and capsicum;  brandy,
sinapisms, stimulating frictions over the whole surface,  exter-
nal  warmth, or a hot bath, were used as the time drew near
for the next exacerbation.   Opium should always be avoided,
as counteracting the  effects of quinine.   This practice gene-
rally proved successful, even though the time was very short.
   Where tbe physician  was  called in earlier, the disease
yielded without any extraordinary measures, so  that they
were prompt and efficient; and  in this way many have re-
covered, without appreciating  their danger,  and thinking
lightly of the physician's solicitude. 
69
            A FEW GENERAL OBSERVATIONS.

  It is sometimes difficult to decide in the incipient stages of
a consecutive inflammation, precisely, which organ, or tissue
is affected, or which is likely to become the seat of the disease,
but it is not difficult for a practitioner of much medical  acu-
men, who is on the alert, to refer the disease to its proper re-
gion, viz:  the abdomen, thorax,  or cranium, in the forming
stages of the complaint.
  Thus, if after the fever is fairly formed,  there still exists
much irritability  of the stomach,  or  great anxiety for  cold
drinks,  tongue red about the edges, or elivated papillae,  or
a burgling noise in the abdomen, after drinking,  or  a  little
more fullness in this region than natural,  or frequent watery
stools, we must at once direct our attention to  this region; and
before the local disease is much  advanced, a slight deviation
from our regular course in the original fever is all that is ne-
cessary.  The antimonials  and nitre must be withheld, and
the drinks should all be mucilaginous, the bowels kept  open
with  oil and magnesia, frequent and anormal evacuations re-
strained ; external fomentations, large mild enemata, etc., will
be sufficient to stop its  progress.
  If  ever  so slight catarrhal symptoms appear, they should
receive immediate attention.   Does the  patient breathe as if
there was too much mucous in the bronchia? ?   Is the cheek
a little flushed ?  Has he a slight cough ?  Does he hawk  up
and spit more than  natural ?   Are the lips livid, and does  he
repose with his mouth a little open, and are the ala nasi con-
tracted,  &c?   On the  first  appearance of these symptoms, a
light emetic, followed  by antimonials and Dover's powder, 
70
cupping, blisters, and keeping the temperature of the room
uniform, and a little elevated, added to  the general treatment,
will check its further advance.
 Does the pain in or over the orbits of the eyes increase, with
a little more sensibility to light and sound?   Do the carotid
and temporal  arteries beat with increased  violence ?  Is he
watchful, &c?  The room should be kept dark and still, the
head  elevated, and evaporating lotions applied; the  bowels
moved more briskly with cremor tartar, and jalap, and a blis-
ter applied to  the neck.   This will be  found  sufficient in an
incipient, or threatened case of cerebral inflammation, in ad-
dition to the  treatment required in that particular grade of
fever.
  But these slight indications of local phlogosis, are too often
suffered to pass unnoticed at first,  or without receiving that
attention, which their importance demands, until  the part is
deeply involved.  This cannot continue long,  (no adequate
means being  used  for its  removal) without  involving other
organs;  every part of the system being more liable to be-
come implicated in a fever, especially if it be  of a low grade.
Hence we often see the  contents  of more than  one of the
principal cavities, inflamed at the same time. This adds greatly
to the danger, and requires diligence on the part of the phy-
sician, and such a nice modification of  the treatment  hereto-
fore laid down, as his good sense must  suggest.   But we are
occasionally called to witness cases still more  deplorable, viz:
where the  visceral inflammation  has  been suffered to take
still deeper root, and spread wider, till  the  contents of the
abdomen, thorax and head are all three involved.   Very few
recover from this complication of disease.  Here the task of
the physician becomes a painful one.   He can do little more
than stand by a silent observer, for the brief period usually
allotted to such  unfortunate patients.   Still  you  should not 
71
abandon the case in despair, but do what you can in the qui-
etest way possible  for his comfort, and support the waning
life of the body, by such means as are in  your power, and
for the rest, trust to the mysterious, but sometimes  succssful
operations of nature.
FINIS. 
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