REMARKS ON THE

INTERMITTENT AND REMITTENT FORMS OF FEVER.

BY JNO. F. PETHERBRIDGE, M.D., OF ANNE ARUNDEL COUNTY, MD.*

HAVING had, for some years past, considerable experience in the treatment of the intermittent and remittent forms of fever, and having, with uniform success, pursued a course somewhat different from the one generally adopted, I have thought it might not be altogether uninteresting to the readers of the "Medical and Surgical Journal," to see a brief statement of the plan which I have followed.

In order that the subsequent remarks may be fully appreciated, I would premise that my practising district embraces the lower part of Anne Arundel and the upper part of Calvert counties. A single glance at the map will give a clear idea of its geographical situation. It will be seen to constitute a part of the narrow strip of land running down between the Chesapeake bay on the one side, and the Patuxent river on the other. Thus located, it might be presumed that the situation would be sickly, especially during the autumnal months. And such was the case to a very great degree some ten or fifteen years since. But, owing to the changes which have taken place in the general face of the country, and the alterations which have been effected in the habits of the people, the health of the locality has improved so much, that we do not at this time consider it by any means a sickly one; or at least not near as much so as others similarly exposed.

The diseases with which we have to contend, are those which generally prevail in alluvial situations. For it will be borne in mind that a large portion of our lands is of this character. In the summer, we have diarrhoea, dysentery, and all the modifications of bowel complaints; in the fall, commencing the middle or

*This article also came to hand too late for our last number. We shall be pleased to hear from our friend, the doctor, frequently.

EDS.

the last of August, and continuing until the first heavy frost, and for ten days or a fortnight afterwards, we have the whole tribe of diseases which have been generally supposed to owe their origin to malaria, the intermittent, remittent and the well-defined congestive fever; and scarcely have these disappeared from amongst us before winter introduces the pneumonia biliosa, a disease which, with us, requires almost as much skill and energy as the congestive fever itself.

But it is, as the caption of our article indicates, upon the intermittent and remittent fever, we propose to offer a few remarks.

Thoroughly educated in what may with propriety be designated the calomel school; taught to believe that the liver is the great source of all the diseases to which mortality is heir, and that calomel is the catholicon by which they are to be overcome, we commenced our professional career, with strong prejudices against every thing that savored of the Broussaic school. But we had been practising but a short time, before we were convinced that however applicable the views we had learned might be to diseases of other climates, they were entirely unsuited to the diseases with which we had to contend. The red tongue, the incessant retching and vomiting, the insatiable thirst, with the tenderness and pain of the epigastric region, so clearly designated the stomach and not the liver as the seat of disease, that the most obtuse intellect could not possibly misunderstand.

But perhaps it is proper to remark here that we have been informed by physicians of great skill and observation, that it has only been since the passing of the cholera through the land, that our fall diseases have assumed a gastric character; that prior to that period, they were entirely different from what they now are, in their pathological indications; and that no form of treatment so rapidly arrested them in their progress, and so successfully relieved them as hydrar submurias in large and repeated doses. So different is the state of things at present, that but for the entire confidence we have in the judgment and the representations of these gentlemen, we could scarcely give credence to an assertion of this character; for we positively aver that in the hundreds of cases which have fallen under our observation, we have never

found it necessary in a single instance to resort to this mode of procedure. But viewing them as consisting in gastritis or at most in gastro duodenitis, we have adopted therapeutics in accordance with the same.

If we can see our patient in the early stage of the disease, we invariably bleed during the period of excitement, after which we apply from ten to fifteen cupping glasses over the region of the stomach, duodenum, &c., abstain from all medicines, direct our patient to eat ice "ad libitum," and with the view of extinguishing the excitement as rapidly as possible, we have vessels filled with ice, placed under the hands, so that he may freely play with the same. By these means, we pretty generally succeed in converting what would otherwise be a remittent into an intermittent, and thereby secure to ourselves a more favorable opportunity than we otherwise could have, for the administration of the agent upon which we place our chief reliance in arresting the progress of the disease. It should have been remarked that our remittents almost invariably assume either the simple or the double tertian form; the latter most generally. And if the paroxysmal character of the disease is not overcome, the patient will soon have a dry, chapped tongue, constant fever, great prostration of strength, a low, muttering delirium, and the whole train of symptoms constituting what has been called the typhoid state. To prevent this truly deplorable state, the materia medica, in furnishing us with quinine, gives us what approximates as nearly to a specific as it is possible for us to find in the science of therapeu tics. But, unfortunately, the intrinsic value of this agent has seldom been fully appreciated, on account of the manner and the quantity in which it has been given. It is true that frequently in the dose of two and three grains every two or three hours, it will suffice in the mild intermittent. But when the disease is one of considerable violence, and where there is danger of the anticipated paroxysm, placing the patient almost if not entirely beyond the reach of the science, such a course is for all the world as was wont to be said by the professor of the theory and practice of medicine in the University of Maryland, like attempting to beat down the rocks of Gibraltar with the grains of mustard VOL. II.-No. 1. 4

seed. Here, if we would rescue our patient, if not from the grave, at least from a long and protracted illness, the remedy must be prescribed in the dose of fifteen or twenty grains. And from years' experience in thus administering it, we hesitate not to affirm that all who will thus prescribe it, will never be induced to abandon the course. This, then, is the plan we pursue, if the disease is one of considerable mildness, and the return of the paroxysm or the excerbation is not expected for some time after the use of our depletory remedies, we direct a mild laxative. But if the disease is one of violence, and the paroxysm or the exacerbation is expected in the course of three or four hours, we never concern ourselves about unloading the bowels, but direct our efforts to the destroying of the periodicity of the disease. And not until after this has been accomplished, do we administer some mild aperient. We are convinced that the routine practice, of purging the patient for days before administering the quinine, is radically wrong. In every instance it keeps up the irritation. upon the gastro enteric membrane, and by debilitating the patient, only renders the system more liable to the recurrence of the disease. If the physician can see his patient during the excitement of the first paroxysm, and will freely use his lancet, his cups and ice, and four hours before the expected return, will administer the tonic in doses of twenty grains, in a large majority of cases —at least eight out of ten-it will be unnecessary for him to combat with the second. He will have the satisfaction of cutting short, in a few hours, a disease, which, under a different mode of treatment, would require his attention for one, two, three weeks or more, and then have the mortification of seeing his patient with a salivated if not a sloughed mouth.

With propriety the question may be asked, if the administration of so large a dose of quinine is not directly at variance with the pathological views laid down? If the stomach is in a state of inflammation, will not this agent have a direct tendency to increase the same? Reasoning "á priori," would conduct us to such a conclusion. But such, however, is not the case. Vividly is the recollection upon our mind, when we were induced for the first time to make the experiment. The individual had been sick

for some time; the case was rapidly passing into the typhoid state; the dry, red, glazed tongue-the certain precursor of this state-was before our eye; and the certainty that the next paroxysm would either result in death, or render the case almost unmanageable, compelled us to make an effort to prevent its return. The tonic was administered, and, to our inexpressible delight, the disease was arrested, and in a short time our patient was convalescent. Since then, we have invariably, after the abstraction of blood, either generally or locally, or both, directed the tonic to be taken; and if we can succeed, as we generally do by the administration of a scruple dose, four hours before the expected paroxysm, in producing the buzzing in the ears-tinnitus aurium -which characterizes the full effect of the agent, we feel perfectly safe. We are assured from repeated observations, that with this sensation, there will be a profuse perspiration, indicating an entire breaking up of the diseased action.

We would remark that we prefer giving the quinine in solution, and instead of using the elixir of vitriol for the purpose of suspending it, we use one of the vegetable acids, generally the tartaric. We dissolve the twenty grains in a tablespoonful of water, and add the dry tartaric acid, until the solution becomes transparent. We prefer the vegetable acids as being less irritating in the event of their being slightly in excess; indeed, when we cannot get a distinct intermission for the administration of the tonic, and have to give it during the remission, we prefer making the solution slightly acidulated.

Sometimes it is the case, the paroxysm or the exacerbation comes on an hour or two sooner than was anticipated, and not being able to foresee this, the quinine has not been administered sufficiently early to produce its specific influence in time, in this case the second paroxysm is developed; but by guarding against it at the next period, by giving the tonic sufficiently early to produce the tinnitus aurium, we at once put a stop to it. As before stated, from three to four hours is the period we prefer.

Briefly, and in a desultory manner, such is the course we pursue in the treatment of these diseases; and we have the satisfaction of knowing that of some hundreds of cases including the in