18 



PRACTICE OF MEDICINE. 



determination to the brain characterizes the commencement of reac- 

 tion in this variety ; and inordinate affection of the hver and mucous 

 surface, the more advanced stages. 



Congestive, or MaligJiant remittent. — This is one of the severest 

 and most fatal of endemic fevers. As its name impHes, the disease 

 is of a malignant type from the commencement. The great danger 

 here is, that when the patient is raised, perhaps with great effort, out 

 of the paroxysm, the practitioner may regard it as incipient con- 

 valescence, and neglect the precautions necessary to ward off the 

 next, which may prove fatal. 



Anatomical characters, — Inflammation of the stomach and bowels 

 is perhaps the most frequent lesion. The glands of Brunner are 

 often much developed, but Peyer's glands are unchanged. The 

 membranes of the brain are sometimes inflamed, and "sometimes 

 there is congestion. The liver is often enlarged, more or less sof- 

 tened, and, according to Dr. Stewardson, of a bronze or slate colour. 

 The spleen is also enlarged and softened. 



Complications. — Gastro-cluodenitis is among the earliest compli- 

 cations of remittents ; in the more advanced stages, dysentery occa- 

 sionally comes on. Diseases of the liver and spleen are common 

 attendants on remittents. Determination of blood to the brain 

 often occurs early in the more severe forms. In temperate climates, 

 remittents are frequently associated with bronchial or pvlmonary 

 affections. 



Treatment. — In the mild form, before reaction comes on, and 

 when there are no indications to forbid its administration, an e7netic 

 is generally very useful. After its full operation, a large dose of 

 calomel, or calomel and opium, may be given, and an action be pro- 

 duced on the bowels by purgatives and cathartic enemata. These 

 means being repeated until morbid secretions and ffecal accumula- 

 tions are removed, bark or quinine may be prescribed, if the re- 

 missions are distinct, and there be no signs of cerebral or gastric 

 inflammation. When a paroxysm of great violence has been sub- 

 dued, and there is danger that the next may prove fatal, recourse 

 should be had to the sulphate of quinia, no matter how short or im- 

 perfect the remission may be. The quantity must be sufficient to 

 bring the system under its influence before the next paroxysm. The 

 remedy should be continued yntil two daily paroxysms have been 

 prevented ; after which the patient may be considered safe. In some 

 cases, where the patient's strength will admit of it, moderate bleeding, 

 in the stage of excitement, will shorten the disease, and render the 

 remissions more perfect. During reaction, in the early exacerba- 

 tions, frequent doses of James' poivder with calomel, or tartarized 

 antimony, given in repeated doses, will oftentimes promote a favour- 

 able termination. The effervescing draught is considered by some 

 authors as particularly applicable to bilious remittent fever. When 



