1. Idiopathic Fevers

Several indications for the use of opium are offered in different varieties and conditions of fever. As a stimulant it is very useful in the low or typhoid state of fever, when the pulse is feeble, and the blood impaired. Not only is the circulation weak, but the cerebral centres also, in consequence either of the depressing effect of the cause, or of the depraved blood. Stupor or delirium does not. in these cases, constitute a contraindication, when the low muttering character of the latter, and the capability of being roused from the former, taken in connection with the general condition of the system, show that the brain is suffering rather from debility than from over-excitement. Indeed, opium, by stimulating the cerebral centres, often operates favourably in relieving the two conditions referred to. The tremors, subsultus tendinum, general uneasiness, occasional wakefulness, and other nervous disorder afford other indications for the use of opium, which is, in fact, among our best remedies in the typhoid condition of fever. By this expression I do not wish to designate a special febrile disease, as typhus or enteric fever, though these afford the best characterized type of the condition; but a peculiar state of febrile disease, which may attend any one of the idiopathic, and, indeed, even of the symptomatic fevers, and may be known, wherever it exists, by a feeble pulse, dryness and darkness of the tongue or a tendency to them, a dusky hue of the surface, and more or less of the nervous derangements just mentioned. It is seldom met with at the commencement of the special fever which it accompanies; and opium, therefore, is not usually indicated at that stage. The medicine may be combined with ipecacuanha when the skin is dry; and a little blue mass may often be added to the two, with a view to its stimulant influence on the various secretions. They should all be given, as a general rule, in these cases, in small doses frequently repeated. A favourite combination of my own, under these circumstances, consists of one-sixth of a grain of opium, the same quantity of ipecacuanha, and half a grain, or a grain of the mercurial pill, to be given every two hours. This is especially adapted to the condition as it occurs in enteric or typhoid fever. When opium, in cases of this character, increases stupor, delirium, heat of skin, dryness of mouth, or frequency of pulse, it is acting injuriously, and should be omitted. But when it quiets delirium, gives a disposition to natural sleep, lessens the frequency but increases the fulness and force of pulse, and moistens the skin, it is acting beneficially, and should be persevered in.

Without having the typhoid character, fevers are not unfrequently attended with nervous disorder, such as twitchings of the muscles, sudden startings, general uneasiness, restlessness, want of sleep, and sometimes slight delirium, which will often yield to a full dose of opium, with an equal quantity of ipecacuanha, or a proportionate amount of tartar emetic, given at bedtime. But, in determining as to the propriety of administering it in such cases, reference should always be had to the contraindications mentioned in page 736.

There is another condition of fever in which opium is strongly indicated, with a view to its stimulant influence, especially on the cerebral centres. I allude to the cold stage at the commencement of fevers, when it assumes a violent character, either simply of collapse, or of this with intense disturbance of the functions. Such a condition characterizes the onset of pernicious miasmatic fever; but it is also not unfrequently met with in other malignant fevers, as in malignant typhus, yellow fever, smallpox, erysipelas, etc.; and, in a less degree, in febrile diseases not malignant In the chill of common intermittent fever, the depression is often so great and so lasting as to call for the same treatment. In all these cases, the original depression is in the nervous centres. It is through them that the cause of the fever first acts, and, prostrating them by its shock, produces the general prostration as a secondary result Opium is obviously indicated by its highly stimulant action upon these centres; and is preferable to alcohol, because the excitement of the circulation which it produces is sooner over, and does not. therefore, continue forward into the stage of reaction, as the alcoholic stimulation Ardent spirits might equally excite the nervous centres, though even in this respect their operation is less favourable than that of opium: but they also endanger an increase of the fever to follow, which opium, properly used, does not. The latter medicine is. indeed, of the utmost importance in the condition now under consideration, and perhaps, on the whole, superior to all other remedies. It should always be given in full doses, being quite inadequate to the desired effect in small quantities. The only contraindication is an active congestion or inflammation of the brain; but, happily, this is comparatively rare under the circumstances referred to. In doubtful cases, great contraction of the pupil might add some weight to that of other symptoms marking the contraindicating condition of the brain; but alone it is of little value.

Still another condition common in fevers, and indicating the use of opium, is sickness at the stomach. When this does not depend on acute gastric inflammation, it will often yield promptly to opium or its preparations, administered by the mouth, the rectum, or endermically at the epigastrium.

The special fevers occasionally offer special indications for opium besides those mentioned. Thus, it is often useful in the enteric or typhoid fever, by putting a check to exhausting diarrhoea. and aiding in the suppression of hemorrhage from the bowel- in the advanced stage.

In smallpox it is very serviceable in the stage of maturation, and subsequently by moderating the irritative reaction of the disease of the surface upon the system generally. This it does by diminishing the susceptibility of the nervous centres, and consequently their power of receiving impressions from the surface, and transmitting them, in the form of irritation, to the heart, lungs, etc. The same remark is applicable to erysipelas; but caution is more necessary in this affection, not to aggravate any existing disposition to cerebral congestion.

In intermittent fevers, opium will often effect cures, and may be very beneficially resorted to in the absence of quinia, or as an adjuvant to that medicine. To be most efficient it must be given in the intermission, and so that it shall be in full action at the time of the expected return of the paroxysm. Its operation is strictly antiperiodic, and has already been explained under the indications for the use of opium. (See page 732.) Somewhat more than the medium full dose may be given in this case.