culi? Our author concludes these preliminary remarks by saying that, between nymphomania and nostalgia, which are placed by Dr. Cullen in his class locales, and in immediate succession as tc order, no further connexion can be traced than in their commencing letter; and upon this principle nosology and nonsense are as nearly allied. To call a vehement desire of revisiting our native home,' which is the definition of nostalgia, a local affection, would seem indeed totally inconsistent with any other notion than that of an obscure anticipation of organological or phrenological doctrine. PART IV. PRACTICE. CLASS I.-PYREXIAL AFFECTIONS. 333. Order 1. FEVERS. The general divisions, it will be observed, of the febrile order of diseases, are in the first place into intermittent and continued; the subdivisions being, of the intermittent, the tertian, quartan, and quotidian, with their several varieties and admixtures; and, of the continued, the inflammatory or synocha, the typhoid or low fever, and the synochus or mixed; to which is added in the nosology hectic fever. We shall not of course repeat the definitions which are given in the nosology, but proceed to remark generally and individually on symptoms, peculiarities, causes, diagnosis, prognosis, and modes of treatment. 334. Symptoms of intermittents.-Intermittent fevers are characterised by a decidedly marked cold stage, in which we find rigors, paleness, collapse, short and obstructed respiration, chattering of the teeth, trembling of the limbs, and rough or contracted skin called goose skin, with a general shrinking of the features, and a small and frequent pulse. These symptoms continue for a longer or shorter period, and are then succeeded by those of the hot stage, which however is at first of partial and irregular occurrence; and at length the heat becomes universally diffused, and is much above the standard heat of health. Fulness likewise takes the place of the previous collapse and shrinking; the pulse from being small becomes fuller and harder; pains are felt in different parts of the body and limbs; nausea and vomiting are not unfrequent; the urine is high colored, but small in quantity; the breathing is hurried; there is considerable headache and throbbing of the temples; confused perception and thought, and oftentimes delirium; the tongue now be comes covered with a white crust, and thirst prevails. After these symptoms have continued for some time a moisture breaks out on the forehead, face, and neck, which soon extends universally; and now the heat and thirst abate, the urine from being high colored and scanty comes to be more copiously discharged and to throw down a sediment, the pulse becomes more free and natural, the throbbing of the head subsides, the respiration becomes less labored, and in a word, all the functions are restored to their wonted condition. The whole of this process usually takes up from six to eight hours. We have above remarked that the tertian, the quartan, and the quotidian, are the most frequent VOL. XIV. types, as it is expressed, of intermittent fever By this is meant, that, in the case of the tertian,t forty-eight hours elapse from the commencemen of one fit of fever to the commencement of an other; that the period of the quartan is seventy two hours, and of the quotidian twenty-four The most common type is the tertian, which is the occasion of its being marked first in the nosology: this principally occurs in the spring. The quartan, which is the most severe form of ague, usually occurs in the autumn: this has generally the cold stage the longest, while the tertian has for the most part the longest hot stage. The subdivisions and intermixtures of types we need not, as above intimated, follow; but it is necessary to remark that, while the true intermittent or ague leaves the patient in the intervals of the fits quite free from febrile disorder, there is a form of fever which is neither properly intermittent, because it does not thus go off completely; nor properly continued, because the intervals are marked, but not with distinctness : this kind of fever authors have therefore agreed to designate remittent. It is further necessary to notice that these types of fever change, tertians and quartans become quotidians, and the quotidian falls into the remittent; and this change in the general way is rather favorable than not, inasmuch as it is for the most part from a severer to a milder form. Climate very much modifies the types and circumstances of intermittent and remittent fever, and the different seasons have likewise a considerable influence upon the types of the disorder. It is in countries where heat and moisture prevail conjunctively that the remittent form of fever is the most common. Agues often last, if not arrested by medical treatment, for some length of time, and often terminate without producing much organic mischief; but they occasionally give rise to chronic obstructions of the viscera by their continuance, more especially of the liver and spleen, enlargements of which last organ used formerly to be well known under the denomination of aguecakes; dropsy also is an occasional sequela of intermittent fevers; but these seem rather to be produced in an indirect way, and to follow upon primary derangement and chronic obstruction of the viscera. 335. Causes.-The predisposition to be affected by the exciting causes of ague are, weakness of body, whether constitutional or induced by large evacuations; unwholesome diet; long watching; exposure to the cold and damp of a night air; mental depression; and, in fine, whatever tends to debilitate or derange the frame. And it is to be observed, that this predisposition is increased by habit, that is, a person having once had the disorder is more likely afterwards to have it excited by its particular and specific source, or perhaps to fall into it in consequence of exposure to cold and damp, or subjection to circumstances which are generally regarded as merely circumstances of predisposition, but which some consider actual excitants of the disorder. We may further remark that this law of habit is different from that which applies to the continued forms of fever, especially those which manifestly acknowledge a specific poison as their F source; for the effect of these is rather to lessen than increase predisposition, an individual being much less obnoxious to their influence after having once been the subject of them. This in some cases is carried almost to the extent of complete insusceptibility to a second attack. Respecting the actually exciting causes of intermittent fevers, or agues, we may refer to what has been advanced in our introductory remarks (see par. 290); in which it will be seen that a difference of opinion prevails on this head, some supposing that a particular poison engendered from the decomposition of marshy lands is absoutely necessary for the production of ague, or even remittent fever; while others contend that, so far from marsh miasm being necessary to the excitation of intermittent, we have no evidence that such poison ever operates, or even exists. In addition to what has been advanced on this head, we shall here beg leave to introduce the remarks of a modern and luminous writer, Dr. George Gregory, to whom we shall become more indebted for quotations and extracts as we proceed in our disquisition. The great and important occasional cause of intermittents, says Dr. G., are the effluvia arising from marshy grounds, and called by physicians marsh miasmata. It is certainly a curious fact that this pathological principle, so obvious and so important in its practical tendency, should have been unknown, or at least unnoticed by the older medical authors. Sydenham seems to have had a glimpse of it, but he could not have seen it in its true light, for in his fifth chapter he attributes agues to the ebullition of spirits and viscid juices. Lancisci is the original writer on marsh miasmata. His treatise is entitled De Noxiis Paludum Effluviis. We are not, however, yet acquainted with all the circumstances upon which the production of ague depends. It is presumed, however, that the miasmata arise from the combination of earth and moisture with putrescent vegetable matter. Moisture alone, though ever so abundant, will not produce ague; for it is a rare disease at sea, even upon the foggy banks of Newfoundland. When the marsh is covered by water, agues are less frequent. Of the exact nature of these miasmata we are ignorant, but some points have been noticed with regard to them to which it will be proper to advert. The most elevated parts of a marsh being always the healthiest, it is imagined that the miasmata are comparatively heavier than the atmospheric air. There is reason too to believe that they cannot be wafted by currents of air to any great distance from the spot where they were generated, but on this point some differences of opinion have lately prevailed. The calm months of the year being the most productive of agues, it is reasonable to suppose that the miasmata are most powerful when concentrated, and that diffusion by a brisk wind renders them comparatively inert. Culture and proper draining prevent their formation, and hence it is that intermittent fevers, are so much less frequent in England at present than they formerly were. A very short exposure to the exhalation of a marsh is sufficient to affect the system. Travelling through the Pontine marshes has often been fol lowed by an attack of ague. There is considerable diversity in the period which elapses between exposure to marsh miasmata, and the invasion of the disease. It sometimes does not exceed a few days, but there is reason to believe that the latent period has occasionally extended to several weeks or even months. But, though it cannot be disputed that marsh miasmata are the most frequent and important existing causes of intermittent fevers, still it would be impossible to deny that it has others. Febrific miasmata may unquestionably arise, under particular circumstances, from almost any soil. Persons residing in very healthy parts of London are occasionally attacked by intermittent fever. In the time of Sydenham, agues were common in every part of the metropolis. To the great attention which is now paid to the sewers we are probably in a great measure indebted for the present healthiness of the town, and particularly for our exemption from ague. The occasional occurrence of the disease, therefore, at a distance from marshes, is not to be a matter of surprise. Agues prevail extensively in certain districts where there are no marshes; but then it will always be found that there is something equivalent to a marsh. There is either a subsoil of such a nature as does not allow water to penetrate easily through it; or there is a great extent of wood impeding thorough ventilation and the action of the sun's rays; or there is total inattention to drainage and culture. In one or other of these ways we may be able to explain the prevalence of ague in the uncultivated parts of America, and in many parts of Italy, particularly the neighbourhood of Rome, Naples, and Syracuse. These peculiarities of soil are not merely the occasion of agues, but they serve to modify the characters of continued fever, and of any other febrile disease which may happen to occur in the district. They give a tendency to exacerbation and remission in the symptoms of the fever; and it is not improbable that many cases of what might be considered genuine remittent fever from marsh exhalations, are in fact cases, of common continued fever from cold modified by peculiarities of soil. We may add that there is still much that is obscure with respect to the actually producing causes of intermittents; these forms of fevers, after having been almost unknown in the metropolis for many years, have within these few past months been comparatively frequent here; a fact which should seem inconsistent with the notion of marsh miasmata, which generally obtains; indeed there is every reason for the inference that much of disease-creating and disease-modifying circumstance has reference to atmospherical variations which have hitherto been altogether undetected excepting in their effects. 336. Prognosis.—In Britain, and in other countries in the north of Europe, agues are for the most part unattended with any immediate danger; but the disorder is apt, as above inti mated, under unfavorable circumstances, or injudicious treatment, to give rise to visceral obstructions, and their consequences. In some parts of Africa agues are diseases themselves of great danger, without reference to their interme diate consequences; and in all cases we may say of the disorder, that its prognosis will be greatly regulated by climate, soil, and season. When the fits are of short duration, and regular recurrence, a speedy or an interrupted solution of the malady may be looked for; but when they are of long continuance, and accompanied with structural derangement, or even of very violent affection of function, the disorder is likely to continue for some time, and its termination in health will be doubtful. 337. Treatment.-The obvious indications are to abate the violence of the fit; and, when the fit has subsided, to endeavour at preventing its That is, Take of subcarbonate of ammonia eight grains, liquor of acetate of ammonia three fluid drachms, syrup of orange peel two fluid drachms, water one fluid ounce for a draught. When the hot stage is fully set in, saline and cooling medicines are called for, with acidulated drinks; and now it will be proper likewise to give diaphoretics, of which one of the best, when the irritation runs very high, is a small dose of tartarised antimony, as in the following formula: R Antimonii tartarizati gr. . Aquæ puræ f. 3iss. Fiat haustus. That is, Take of tartarised antimony one-sixth of a grain, and water a fluid ounce and a half, for a draught; or a solution of half a scruple of nitre (potassæ nitras) may be administered in a draught of water; or the common saline draught, either in a state of effervescence, or when the effervescence is over. The effervescent saline draught is made by mixing a scruple of carbonate of potass (salt of tartar) dissolved in a fluid ounce of water, and sweetened by sugar, with half an ounce of lemon juice, or, what is quite as good, fifteen grains of the concrete citric acid. Some practitioners give opium in the hot stage, to the extent of from thirty to sixty drops of the tincture, about half an hour after its accession; others recommend a fluid drachm of sulphuric ether for the same purpose of shortening the fit, abating its violence, and hastening perspiration. Bleeding too has been recommended, especially where the irritation of the hot fit runs high, or the inflammatory diathesis is conspicuous. Saline purgatives may at this time also be exhibited should constipation accompany heat; and there is no better aperient on these occasions than from half an ounce to an ounce of Epsom salts (magnesia sulphas) dissolved in camphorated mixture. In short, the treatment of the hot stage of intermittent fevers is pretty nearly the same as the treatment of continued fever, marked by irritative or inflammatory excitement; and to heat in the cold stage, and cool in the hot stage, are the plain indications of nature. Some practitioners administer, immediately before the accession of the cold stage, an emetic, with a view of producing such an impression upon the system as to interfere with the full development of the febrile action, and some give tincture of opium at this time, with the same intention; so that it will be recollected that opium is given by different individuals, both in the cold and hot stages. For the purpose of accomplishing the second indication, viz. preventing the disorder's recurrence, remedies are had recourse to in the intermission, and of these emetics, purgatives, Peruvian bark, arsenic, and forcible impressions made upon the nervous system, are the principal. For an emetic, a scruple of the sulphate of zinc may be given, dissolved in water; and the purgatives at this time of the apyrexia should be rather of the resinous than saline kind. A fluid ounce of the compound decoction of aloes, with the same quantity of infusion of senna, will make a good aperient draught, and when decided marks are present of obstructed viscera, or disordered condition of the alimentary and intestinal canal, mercurials may be joined with the purgatives that are administered, and by the exhibition of them the system will be better prepared for bark or arsenic. Five grains of blue pill at night, succeeded in the morning by the abovenamed purgative draught, and these repeated two or three times in the course of the week, will constitute a good preparative or accompaniment of bark, which given without these deobstruents, as they would be called by the Boerhaavians, might, while it cures the complaint, tend to facilitate the visceral infarctions above referred to. Bark should for the most part be given when the system is entirely free from pyrexia; it may be administered in drachm doses every third or fourth hour, or even oftener if the stomach will bear it; so that several doses may be exhibited during the intermission; the following draught may be substituted. R Extracti cinchonæ resinosi grs. xv. That is, Take of extract of bark fifteen grains, compound tincture of bark two fluid drachms, syrup of orange peel one fluid drachm, decoction of bark a fluid ounce and a half; for a draught. As an excellent substitute for bark in those large quantities, the modern concentration of it, beginning now to be well known under the name of the sulphate of quineric, may be administered with much advantage. Of this two grains may be given instead of the bark powder or draught, made into a pill with a small quantity of crumb of bread, or thick mucilage; or it may be made into a draught with water and two or three drops of the diluted sulphuric acid. The medical practitioner, who has not hitherto been in the practice of employing this medicinal, will often be surprised at its prompt efficacy, both in intermittent fevers, and in other cases where considerable quantities of bark are indicated, but where the stomach is scarcely able to receive the necessary quantity in the form of powder, decoction, or extract. It should be observed that, when the extract of bark is employed with a view of giving the medicine in large doses, the resinous extract, or that made with spirit, is much superior to the aqueous, as by the action of the spirit a part of the bark is taken up which is not soluble in water. When arsenic is administered to cure intermittent (which for the most part is more efficacious, at any rate, than the old forms of bark), the liquor arsenicalis of the London Pharmacopoeia should be employed. This is an arseniate of potass, and often proves promptly and decidedly efficacious in preventing the recurrence of the febrile paroxysms. It may occasionally be employed with tincture of opium in the dose of five minims of the foriner to three or four of the latter. Under proper management, says a modern author, arsenic will be found to be the most generally useful of all the medicines which have been recommended in the treatment of agues. The best mineral substitute for it is the sulphate of zinc, which is largely employed in the fenny counties of England. It is given in doses of one or two grains three times a day, and is very highly spoken of. A strong impression made upon the imagination of the patient will sometimes break in upon the habit of the disorder, and at once dislodge the malady, which shall have seemed reluctant to give way to the common remedies. Charms have often proved efficacious; and it is not necessary to say that their operation is upon the principle now adverted to. While the secretions are kept in good order by the administration of purgatives and mercurials, to which, by the way, the taraxacum (dandelion) may be occasionally added with advantage; a generous diet, and the moderate use of wine, will be found requisite during the absence of the paroxysms. These too are good preventives of the malady, especially after a patient has been the subject of an attack. Remittent fevers are to be treated upon the same general principles with intermittent and continued. These are types of fever which, as above intimated, are very common in counties where there is a combination of heat and marshy exhalations, or humid atmosphere. Their varieties, from endemial causes, and local circumstances, and constitutional peculiarities, are almost endless. They are, however, for the most part characterised by an excited or disturbed state of the biliary functions, and on this account especially call for medicines which act as an emulgent to the liver; but we shall have further to speak on this head, when considering that form of disease which has been termed yellow fever. 338. Continued fevers.-The student, by turning to the nosology, will perceive that Dr. Cullen's system recognises three forms of continued fever; out it will be right to take these, as all other di visions in medicine, merely as arbitrary or conventional, and to recollect that, although the definitions are as accurate as definitions can be, the practioner must expect to find endless varieties and modifications. We shall in this section, as we have done in that devoted to intermittents, first treat of the general symptoms of fever, then of their causes, prognoses, diagnoses, and ma nagement. Symptoms of continued fever.-Lassitude, languor, and anxiety, followed by rigors, which are again succeeded by partial, and at length universal, heat; indeed, the history of a paroxysm of intermittent fever is, in some sort, a description of continued fever; but, for the most part, there is in these last more of animal depression and sensorial disturbance than is the case in intermittent fever. A very great prostration of strength also, in the general way, marks the commencement of continued fever, though in respect to the degree of this symptom there is found very great variety, and in some cases the powers seem rather obstructed or oppressed than actually exhausted; indeed, this particular may be received as one of the differences between positive debility and the peculiar debility of fever-that in the latter there is an indisposition to exert power-while in the former there is the inclination without the ability. The pulse in fever becomes more frequent than in health, and it wants also the freedom of health; it is oppressed, and if the fever be what is called inflammatory, or marked from the onset by very high excitement of the vascular system, there can be recognised a hardness as well as obstruction about its beats; this hardness, however, is more conspicuous when the fever is what is called symptomatic, that is dependent upon actual inflammation of some one organ. It should be observed that the symptoms of continued fever, especially of the fevers that are met with in this country, are often of gradual and almost imperceptible invasion. You cannot always draw the line of demarcation between health and disease; the patient is often unwell rather than positively ill for some days; and the young and inexperienced practitioner must not condemn himself for being less skilful and observant than others, should he fail to anticipate the full formation of unequivocal fever, from having seen the patient during the time and circumstances now referred to. When, however, there is continued languor and depression, especially if it be attended with confusion of thought and general difference of perception from what is the case in health-when these symptoms are accompanied by an altered state of pulse, by pains of an obscure and wandering kind about the limbs, by sighing, or hurried or obstructed breathing, by a peculiarity in the expression of the countenance, especially of the eye, this last organ being sometimes dull and dim, at other times morbidly sensible to the light; and the vessels of the tunica conjunctiva injected with red blood-when in addition to these symptoms the tongue becomes furred, the skin hot, shrivelly, and dry, the urine scanty and high colored, and the bowels torpid or irregular, we may be pretty certain that fever is about to establish itself; and the particular nature of the fever will be usually designated by the prominence of one or two characteristic marks; thus in the plague, which according to Dr. Cullen's classification would be a typhus gravior, the most marked of all the early symptoms is the extreme prostration of the strength, and the staggering of the individual attacked, and in the course of the malady buboes become its characteristic; while, in the yellow fever of the West Indies, typhus icterodes, the yellow color of the skin, the buboes, derangement, and the black vomit, are the prominent features of the distemper. 339. Causes of continued fever.-On this head we must refer to our proem, as we did in the case of intermittent fever, where it will be seen that a difference of opinion still prevails on the excitants of the febrile state, one party supposing that no case of genuine fever of any continuance can have place without the operation and influence of a certain morbific poison which is peculiar to itself; another going to the opposite extreme of supposing that contagion is a mere imaginary power, and, while it is supposed to operate so as to communicate the malady, that the communication has, in point of fact, been from the air and circumstances of the place; while a third, and moderate party, think that we have sufficient evidence for the existence and operation of a poison in fever, but that the action of this poison is not, so to say, abstract and exclusive, that is, does not display its effects independently of the soil and atmosphere, and other circumstances of place, and that the disorders themselves, in which this poison is engendered, and by which they are propagated, may originate at times spontaneously. All parties, indeed, acknowledge that some distempers are directly and absolutely dependent upon a specifically exciting cause, and the disputes in some measure resolve themselves into the extent or limitation of this specific causation; whether, for instance, the plague of the Levant, and the yellow fever of the West Indies, originate and are communicable in the same manner as are small pox and measles. As considerable importance is attached to this enquiry, we shall in the present place add to the remarks made in the preliminary portion of the present article, the following quotation from Dr. Gregory, which, in our judgment, contains as clear and distinct an account of the subject in dispute as any we have met with. After speaking of cold and atmospheric alternations of temperature as causes of the febrile state, Dr. Gregory, the author to whom we now refer, goes on to say Continued fever, however, has another and a very important exciting cause, which frequently operates where neither cold nor alternations of atmospheric temperature can be suspected, as where fever attacks persons shut up in close rooms with others laboring under the disease. When fever appears under such circumstances, it is said to have its origin in contagion. A number of the most important doctrines in the science of pathology are closely associated with the subject of contagion. From the earliest periods at which it became an object of enquiry this has been acknowledged, but the investigation is obscure and difficult, and has proved a source of endless controversy. Many of the disputed points in medicine are interesting only to the man of science, but the doctrines of contagion are of general interest, because involving practical considerations of the highest importance. Without attempting to clear up all the difficulties in the way of the enquiry, I shall be satisfied with a brief enumeration of its leading positions, and of the principal points in dispute. 1. Attempts have been made to throw discredit on the doctrine of contagion as the cause of fever, by showing that it was for a long time either unknown to or discredited by physicians. It is certainly a curious fact that, for the first dawnings of information concerning it, we are indebted, not to Hippocrates or Galen, but to ancient poets and historians. Thucydides, in his account of the epidemic fever or plague that raged in Athens during the Peloponnesian war, shows that he understood contagion in the sense in which we now use the term; noxious matter from one body producing a similar disease in another. In Plutarch's life of Pericles, we read that, whilst that commander was laying siege to the city of Epidaurus, a distemper prevailed in his army, which not only carried off his own men, but all that had intercourse with them. Livy, in the account of a camp fever which affected the armies of the Romans and Carthaginians at the siege of Syracuse, distinctly states that it was propagated by contagion:- Postea curatio ipsa et contactus ægrorum vulgabat morbos.' Virgil and Lucretius employ the term contagion to express the manner in which a disease of sheep spread among the flock. Medical writers were for the most part very inattentive to contagion, until the time of Sydenham, in whose work (sect. ii. cap. 2), a distinct reference to contagion may be met with. Boerhaave and the followers of his school were very incredulous on the subject of contagion. Their ideas about it too were very imperfect and confused, from the circumstance of blending the notion of contagion with that of marsh miasmata. Dr. Huxham, Dr. Lind, and Sir John Pringle, are the great original writers on contagion, particularly on that of continued fever. Since their time the subject has undergone the most rigid examination, and, as we have said, has given rise to the most discordant opinions. 2. Much confusion has been introduced into the subject of contagion by the employment of the term infection, and by the different acceptations in which contagion and infection have been taken. This has been increased from the want of proper attention to the distinction between common contagion and specific contagion. Of this last kind are small-pox, measles, the plague, and syphilis. Diseases which, occasionally produced by contagion, are yet sometimes owing to the operation of other causes, are said to arise from common contagion; of this kind are catarrh, erysipelas, ophthalmia, and typhus. The laws of common and specific contagion are in many respects similar, but they have also their points of difference. 3. In the last paragraph, that has been as |