1942. In the advanced stages of continued and inflammatory Fevers, Opium, if judiciously exhibited, is productive of the greatest benefit; but its administration requires much caution and circumspection. "When," observes Dr. Copland,% "the disorder of the sensorium outruns the other symptoms; when, by vena?section or topical bleeding, or by alvine evacuants and refrigerants, the general and local symptoms are relieved, but the delirium still continues; when to this are added tremors, sub-sultus tendinum, and unrestrained evacuations; when there has been at first high vascular excitement, and large evacuations have been required to guard the brain or other organs from mischief, and wild delirium has followed; if the patient has previously been in a delicate or nervous state; if he has been addicted to an excessive use of spirituous or vinous liquors, particularly the former; if the habits of the patient and his occupations have been such as to inordinately excite and exhaust the sensorium; or if the anxieties, toils, or debaucheries of life have previously injured his health, and more especially the state of nervous energy; - in these several circumstances, should opiates be resorted to, in the advanced progress of typhoid and of synochoid fever that has passed into the nervous or typhoid state." The mode of exhibiting opiates in these cases is a matter of no small importance. In many cases one or two grains of solid Opium may be given, either alone or with Camphor and Nitrate of Potash. The combination with Camphor is to be preferred, when there is much adynamia, and no inflammatory determination to the brain. When the bowels are much disordered, Ipecacuanha may be added to these. In some constitutions, Morphia is preferable to solid Opium. Dr. Graves * speaks highly of a combination of Opium and Tartar Emetic in the Delirium of Fever. He also observes that you will often succeed in procuring sleep, by administering Opium in the form of enema, where you would fail of bringing it on by an opiate administered by mouth. On the subject of Opium in fever, the observations of Dr. Christison are most judicious. "Opiates," he observes, "are chiefly useful in two states: when there is sleeplessness without delirium, or tendency to stupor; and when there is restless delirium, in concurrence with a soft pulse, and the general signs of exhaustion. In either case, the criterions which are favourable to their employment, are a pulse compressible and not jarring, no great flushing of the face, freedom of the conjunctivae from particular injection of vessels, and a soft tongue, neither very much loaded, nor very dry and brown. In most circumstances where opiates are serviceable, they disagree if too often repeated. The best signs of their administration having been judicious are quiet sleep, with refreshment on awaking, and a moister state of the tongue. If they produce more delirium, or no refreshment, notwithstanding that sleep was their immediate effect, or if the tongue become more dry and brown, they should be abandoned." (See also next section.)

* Medical Problems, op. cit. Lib. of Med., vol. i. p. 111.

Dict. Pract. Med., vol i. p. 1035.

1943. In Typhus Fever, the indications for Opium are the same as noticed in the preceding section. Dr. Graves, however, has supplied us with another caution, which merits especial attention. After remarking that a contracted state of the pupil is often present in Typhus Fever, he observes, " Whenever, in attending a case of fever, you meet with a contracted state of the pupil, even in a slight degree, although your patient may be restless and greatly in want of sleep, beware of Opium, I have often," he continues, " seen it tried, and I think scarcely ever without more or less injury to the patient. When Opium is administered in the advanced stage of fever, with symptoms of cerebral derangement, and a tendency to contraction of the pupil, you will find that the pupil which has been moderately contracted to-day will be greatly contracted to-morrow, and that the patient will soon sink into an irrecoverable state of coma. The contracted state of the pupil may exist in the extreme and most marked form in Typhus Fever, without being necessarily accompanied by headache and delirium; the patients are restless, and in a state of remarkable nervous excitement; but they answer questions, not unfrequently, in a tolerably clear and rational manner, and many of them distinctly affirm that they have no pain in the head. These circumstances may deceive the unwary; but the experienced practitioner, who has witnessed many such cases, will feel that a fatal termination is threatened. Under these circumstances, Opium in every shape is injurious; and even Tartar Emetic fails in controlling or diminishing the pernicious effects of the Opium. This is somewhat remarkable, as the combination of Tartar Emetic and Opium seldom fails in relieving cases similar in all respects, except the symptom of contraction of the pupil" In a subsequent part of this valuable lecture, Dr. Graves suggests a combination of Opium and Belladonna, when the above symptom is present, the latter counteracting the power of the Opium, in inducing or aggravating contraction of the pupil. He quotes some cases in which the combination was given with apparent advantage, but the subject requires further investigation. In the advanced stages of the fever, Opium should be combined with Camphor, wine, and other stimulants.

* Clin. Lect., vol. i. p. 115. Lib. of Med., vol. i. p. 186.

Dub. Journ. of Med. Sciences, July 1, 1838.

1944. In Intermittent Fevers, Opium is a valuable adjunct to other measures, although incapable itself of effecting a cure. Its employment is as old as Galen; but, in modern times, was reintroduced by Dr. Trotter,* and was warmly advocated by Dr. Lind. He states, that if given in the intermissions, it had not the least effect, either in preventing or mitigating the succeeding paroxysm; that when given in the cold fit, it once or twice removed it; but that when administered half an hour after the commencement of the hot fit, it generally afforded immediate relief. When thus given, he observed the following effects to ensue: - 1. It shortened and abated the fit with more certainty than an ounce of bark. 2. It generally gave sensible relief to the head, took off the burning heat of fever, and occasioned a profuse sweat. 3. It often produced a soft, refreshing sleep, from which the patient awaked, bathed in sweat, and in a great measure free from all complaints. He further considered, that when thus given during the paroxysm of fever, it not only produced present relief, but rendered the patient less prone to liver disease, dropsy, &c. I cannot speak of its efficacy when administered in the hot stage; but, if administered in a full dose (T. Opii exl.) at the commencement, or even during the presence of the cold stage, I have seen it, in numerous instances, >operate almost like a charm in cutting it short; and although it did not appear to shorten the subsequent hot stage, it appeared in many instances to mitigate its severity. So perfectly aware of this were the soldiers during the Peninsular War, that Dr. Joseph Brown * states, that at the first appearance of the cold stage, they applied in most cases for " an ague draught," which consisted of exl. T. Opii and 3j. of Ether. Lind found that in children, rubbing the spine with an embrocation of equal parts of soap liniment and T. Opii, at the approach of the cold stage, often prevented the paroxysm. In Hay Fever, Mr. White Cooper speaks highly of Tr. of Opium in doses of gutt. ij. - iij. every two hours for three times, followed by one drop every two hours till the discharge from the eye and nose diminishes. The treatment should be continued at longer intervals for three or four days.

* Medicina Nautica.

On Fevers and Infections, 8vo, 1763.

1945. In Small-Pox of a mild character, Opium is generally uncalled for; but in severe or confluent cases, when there is much nervous irritability, intense itching of the skin, sleeplessness, and, in the advanced stages, alarming convulsions, Opium in a full dose may be given, taking care to prevent it constipating the bowels, or affecting the head. It is best conjoined with Tartar Emetic.