ART. III. Observations on Congestive Fever. By THOMAS BARBOUR, M. D., of Pulaski, Tennessee.

In the brief investigation of the interesting subject of the present paper, it is not my intention to consider the accidental cases of congestive disease, dependent on sporadic causes; nor those congestive superventions which are incident to every form of fever, but to confine my observations to that peculiar modification of febrile disease which is characterised from its very incipiency, by strongly marked symptoms of deep internal congestion, and a great oppression of the powers of life; in other words, that affection which is denominated in the south, pure congestive fever. The frequency of its occurrence, and the fatality attending it in the southern portions of the United States, concur to render it worthy of the most serious consideration of the profession; and demand from every practitioner, who has had good opportunities for observation, the results of his experience, which may serve in some degree to lessen the fatality of this destructive malady, by contributing to the improvement of its treatment. Having had numerous opportunities during the last four years, of witnessing this disease, and in some instances, in its most malignant form, in what is called the Tennessee Valley, in North Alabama, I indulge' the hope that a few observations, principally with the view of pointing out the best method of treatment, will not be altogether unacceptable to the profession, and especially to medical men residing in the south, whose painful duty it may often be to observe, and to treat it.

I will cursorily notice, 1st, the etiology-2d, the pathology-and 3d, the symptoms of genuine congestive fever; then detail the plan of treatment which I have found the most efficacious.

In regard to the causes of this form of fever, as indeed of all other forms of what is called essential fever, but little is certainly known. Its almost universal occurrence in localities which are favourable to the production of malaria; its co-existence with all the common varieties of miasmatic fever;— and all of its distinguishing phenomena clearly demonstrate the identity of cause, and that that cause must be some powerful and concentrated poison, generated by the decomposition of organic matter.

It requires but a superficial observation of the phenomena of this disease, to be convinced that this cause, whatever it may be, makes its primary impression upon the nervous system; and that all of its characteristic symptoms are the immediate sequences of diminished nervous sensibility. The suddenness of the attack, the numerous indications of nervous derangement, and the rapidly fatal tendency of the disease, conclusively show, that the brain and the whole nervous system, the main springs of life—are almost overwhelmed in the very first assault of the enemy.

The impression made upon the nervous system is proportionate to the intensity of the poison applied; and the effects on the constitution are vari

ous according to the relative force of vital resistance; hence, whenever it prevails, there is every gradation of the disease from slight manifestations of congestion, to the most malignant cases, in which the vital forces are completely empowered. This leads me to the consideration of the pathology of congestive fever, which I will point out in a few words.

The whole nervous system being oppressed by a powerful morbific poison. as necessary consequences, all of the vital functions over which it presides, as respiration, circulation, secretion, &c., become greatly impaired; the capillary circulation throughout the entire system becomes much impeded; and there is a centripetal movement in the circulating fluid, in consequence of which the pulse becomes weak, and the general surface cold and contracted; whilst the internal organs become gorged with blood.

The phenomena dependent upon internal engorgements, are various according to the seat and extent of the congestion. When the brain is the chief seat of congestion, the countenance appears contracted, oppressed, and besotted; there is pain or giddiness, or a sense of heaviness in the head; and there is a strong tendency to coma and insensibility. When the lungs and heart are principally congested, there is great præcordial oppression; the respiration is short, hurried, and oppressed; and there is generally a peculiar livid appearance in the face; the pulse is irregular and oppressed; and there is general coldness of the surface. When the abdominal viscera are the chief seats of congestion, there is a sense of great heat and oppression in the region of the stomach, attended with great thirst, and a constant disposition to retching and vomiting; there is also indescribable restlessness; sometimes the bowels are torpid; but most generally they are very loose-thin, serous discharges passing off in enormous quantities, which contribute rapidly to prostration and death. Autopsic examination usually reveals the true source of all the foregoing symptoms. The various organs are found more or less gorged with blood; which was the cause of their oppression and embarrassment during life.

With this brief view of the pathology, I pass on to the consideration or the symptoms of congestive fever. The premonitory symptoms, which are, generally, of short duration, are those which commonly precede other forms of fever, such as languor, and lassitude, a sense of weariness, and general uneasiness, loss of appetite, and disturbance of the stomach and bowels. Next to these succeed chilly sensations-alternated by flashes of heat, soon after which the patient has a regular paroxysm, characterised by a protracted cold stage-the system, most generally, being unable to recover its natural temperature before the occurrence of the second paroxysm.

The type of this fever corresponds with the double tertian of the old authors, being subject to quotidian paroxysms, but on each alternate day, to an increased aggravation of the symptoms. Thus on the third and the fifth days, the paroxysms are usually very severe, and followed by a protracted cold stage, from which the system reacts very feebly. The anxiously

looked for hot stage is rarely or never fully developed, even in what might be called mild cases. But instead of it, the temperature of the whole surface is greatly diminished and irregular-the extremities being much colder than the trunk. The pulse becomes exceedingly weak and quick; the respiration is short, hurried, and difficult; the patient complains of a painful sense of heat, and weight in the epigastrium, accompanied with insatiable thirst; there is uncontrollable restlessness; the patient tosses himself from side to side, and often rises up, as if to relieve the oppression of the lungs; there is either pain, or giddiness, or sense of weight in the head; and the countenance looks contracted, pale, anxious, and often livid; the tongue is generally moist; and the bowels in a large majority of cases are loose, and the dejections serous.

The above sketch presents a tolerably correct delineation of the symptoms of ordinary congestive fever, as they present themselves at an early period of the disease.

They are, however, subject to considerable modification, according as the brain and spinal marrow, the lungs, or the abdominal viscera are the chief seats of congestion; the most prominent symptoms in each case being particularly referable to the chiefly engorged organs.

If the condition above detailed is not soon removed by the recuperative efforts which nature makes to throw off the oppressive load under which she is labouring, aided by proper remedial agents, there is a rapid tendency to total collapse. This usually occurs either on the third or the fifth days, when, as has been remarked, the paroxysms are unusually severe. This condition is marked by all the symptoms, which indicate profound congestion. The extremities, and, indeed, the whole surface, become as cold as ice; the whole body is bathed with cold clammy sweat; the skin loses its elasticity, resuming, very slowly, its natural situation, when pinched up; the pulse is very quick, and scarcely perceptible; the thirst is insatiable; and there is uncontrollable anxiety and restlessness; the respiration becomes shorter, more hurried, and oppressed; and there are strong marks of diminished sensibility; as a disposition to lethargy, and even to coma, with great muscular prostration. If unchecked, these symptoms increase with a rapid pace, and soon terminate in death.

But congestive fever does not always follow the regular course above described. Sometimes, instead of suffocated excitement, after the first or second regular paroxysms, there is full and violent reaction, and the stage of excitement continues for twenty-four, thirty-six, or forty-eight hours, with little or no remission, when the system, seeming to be exhausted by the violence of the excitement, rapidly sinks into collapse.

This modification generally occurs when there are internal inflammations, as indicated by pressure over the epigastrium, the right hypochondriac region, or over some portion of the bowels.

In other instances, the first regular paroxysm is succeeded by the strongest mark of deep congestion, and complete collapse of the powers of nature.

So far as my observation has extended, this last modification almost universally occurs either in aged persons of feeble or broken down constitutions; or in those who have debilitated themselves by the use of harsh purgatives, or by the use of a too common remedy among southern planters, the emetocathartic, salts and tartar, which most generally causes great gastric and intestinal irritation, which induces a rapid fluxionary movement in the circulating fluid towards the chylopoietic viscera, which causes inequality of the circulation, and rapidly prostrates, by the copious serous discharges which

ensue.

We now come to the most important part of our subject-the treatment of the different modifications of congestive fever. What are the leading indications in the treatment of this disease, founded on the pathological views which have been taken of it? There is a perfect unanimity in the opinions of medical men, that the great objects at which we should aim in the use of therapeutic means, are-1st, to restore the lost balance of the circulation;-2d, to relieve the engorged organs; and 3d-to restore the suspended secretions.

How are we to attain these desirable objects? The discrepant views which have been entertained, and the great diversity of agents which have been applied to fulfil the plain indications of treatment, clearly show that, however well the pathology may have been understood, great uncertainty has existed in regard to the treatment.

Under circumstances favouraexperience, points out the This practice, I know, is upon pathological grounds,

ble to its adoption, reason as well as ample propriety of general, and topical bloodletting. strongly condemned by some; and others, who approve it, adopt it with a trembling hand. Why? Because the patient may have a feeble, quick pulse, and a cold skin, and other marks of prostration. But if we reflect upon the important lesson taught by the pathology of this disease, we must be convinced that the above symptoms do not arise from actual debility, but only from engorgement of the internal organs, which, most generally, are not, at first, structurally diseased, but only oppressed by the undue quantity of blood forced into them. The cautious abstraction of blood under such circumstances, unquestionably promotes reaction, by diminishing the load under which the heart and other vital organs are labouring. General bloodletting is altogether inadmissible in some conditions;-for example, it would be highly detrimental in aged persons of feeble or broken down constitutions; in persons of very intemperate habits; also in the advanced periods of any cases,-because, in all of these, the powers of life are generally at a low ebb, and most probably, the loss of blood by venesection would preclude the possibility of reaction.

But suppose a practitioner is called, at an early period, to a patient of generally good constitution and health, and under the meridian of age, and finds him suffering with all the symptoms of suffocated excitement, already noticed, surely, if he had ever witnessed the good effects of bloodletting

under such circumstances, he would not hesitate to draw blood cautiously. Nor would he ever incur any risk if he follows this simple rule; open a good orifice, and keep the fingers carefully applied on the opposite pulse, and if the pulse becomes weaker, stop the operation instantly, and if necessary, administer some diffusible stimulant. If, however, the pulse rises, and becomes fuller and more regular, as it often does, continue the operation until the pulse becomes well developed. When this effect is produced by bloodletting, there generally ensues a rapid improvement in all the symptoms, in consequence of the reaction of the system.

Bloodletting is particularly indicated in those cases where high excitement continues for two or three days after the paroxysm, with little or no abatement. Under such circumstances, it is certainly one of the best means we possess to lower excitement, and cause a perfect remission, during which we can make use of such remedies as are calculated to prevent the recurrence of a severer paroxysm, which would, most probably, be followed by collapse.

When general bloodletting is considered inadvisable, free cupping should be substituted. Cups should be applied along the whole course of the spine, over the chest, over the epigastrium, over the right hypochondriac region, or over the bowels, according as the indications of internal congestion predominate in one or other of those situations. The revulsive influence exerted by this operation, often acts very beneficially. Having bled or cupped as circumstances indicated, it is important to attend to the condition of the alimentary canal. The stomach is, generally, very irritable, and the patient complains of great thirst, and heat in the epigastrium; to relieve which, a large sinapism should be applied over the stomach, and small portions of cold water, or iced lemonade, or small quantities of ice, should be given; these are exceedingly grateful; they lessen the burning heat and thirst; and often compose the stomach. If they fail, cups should be applied over the epigastrium, and if necessary a large blister should follow them. These combined means rarely fail to tranquillise the stomach. The bowels are sometimes torpid, when the evacuations are either claycoloured, or of a muddy or tarry colour-conditions which indicate either a suspended, or a greatly vitiated secretion. Most frequently, however, the bowels are very loose, and the discharges serous, with a great quantity of small black particles in the bottom of the vessel containing them, resembling coffee grounds. This appearance is attributed by most southern practitioners to the oxydizement of the mercury which is so plentifully administered in the form of calomel. My own impression is that it is the result of morbid secretion from the liver and bowels. If the bowels are torpid, and the dejections are unnatural, the best combination I know of is, five grains of calomel, five grains of rhubarb, and one half grain of ipecacuanha, made into two or three pills, and given every four or six hours, so as gently to evacuate the intestines once or twice in the course of the day. Some prac