lfWu3& UNITED STATES OF AMERICA ^ . . FOUNDED 1836 WASHINGTON, D. C. Bl9574 EXTRACTS FROM A REPORT OF THE MASSACHUSETTS MEDICAL SOCIETY, RESPECTING A DISEASE COMMONLY CALLED y SPOTTED OR PETECHIAL FEVER, WHICH HAS WITHIN A FEW YEARS BEEN EPIDEMIC IN VARIOUS PARTS OF NEW-ENGLAND. Montreal PRINTED BY NAHUM MOWER. 1812. THE alarm excited the last Winter in the Eaflern Town- ships of this Province in consequence of the prevalence of the Spotted or Petechical Fever, and the recent occurrence of several cases of the same disorder in this city ; has induced the publishers to lay before the public, the following Extracls from a Report of a Committee of the Massachusetts Medical Society. The extreme length of the original Communication, has pre- vented us from republifhing it entire ; we have therefore selecled such parts asJ+-thought to be of the most general util- ity. Convinced of the importance of communicating to the public whatever might be deemed useful, relative to this subjecl, and as early as poffible, we have given it in this form, which will be found to describe the general nature of the disease and the requisite mode of treating it. ■it 4? ■>§< ■ty^4%^^^fyfy*fyi&i(p-x»-4fr *|"-4t^11 *&*&<■*&$* ^^-^^^^sHM^1 NATURAL HISTORY OF THE DISEASE. A HIS difeafe has been of various degrees of feverity •, in a large proportion of cafes very mild ; in fome, fevere, and in a few deftroyed life suddenly, like the plague. The communications, which have been made to the committee, relate chiefly to the difeafe in its graved forms. The hif- tory which they give must therefore be underflood as relat- ing moftly to the fevere cafes ; and they are not furnifhed with the means of making all the difcriminations which could be wished. They are however informed that in the milder cafes the fymptoms differed only in degree, not in kind. The invafion of the difeafe is generally fudden and vio- lent. In its courfe all the funftions of the body are more or lefs interrupted, and often fome of them are entirely fuf- pended. The fubjeft of it is feized in the midft of his ufu- al labour or occupation, and oftentimes is ftruck down fud- denly, almoft as by a ftroke of lightning. The firft symp- toms are various, fuch as local pain or paralyfis, delirium ol- eoma, and rarely fpafms or convulfions. The difeafe often commences with fhifting pains. The patients fuddenly feel a pain in one joint or one limb, often in a finger or toe, in the fide, ftomach,foack, neck, or head. Sometimes the fenfation is like the flinging of a bee, fre- quently it » mod excruciating pain, which at once arrefts ., MEDICAL COMM UN ICATfONS. and commands the whole attention. Tins pain moves from place to place without lofing its violence, generally ap- proaching the head, and is often confined to one fide of the body. It is faid that the left fide is more frequently affect- od than the right. The head is more frequently firft affect- ed with pain than any other part ; and when not affected at the firft moment, it almoft invariably becomes fo in a fliort time. The pain in the head is oftentimes intolerably fevere, fo that it is compared to the beating of hammers upon the part ; and the patient fays he fhall become crazy, if it con- tinues. Partial lofs of fenfibility and paralyfis are, in other cafes, the firft fymptoms, and often occur in the courfe of the dif- eafe, when they do not in the beginning. The powers of fight are affected in various degrees from a flight dimnefs-. to abfolute blindnefs. In like manner the fenfibility of the fkin and parts fubjacent is diminifhed, fo that a limb be- comes numb or feels as if it had been afleep. The otlicr organs of fence have not been noticed to undergo fimilar af- fections. In the mufcles of various p.-.rts, naralvns has been ocacfionally obferved ; as in thofe of one hand or foot, and of tentimes in thofe fubfervient to deglutition. In fome cafes hemiplegia has occurred at the commencement ; and it is particularly worthy of remark that often the qrrateft weight of difeafe falls on one fide of the body ; iniomuch that not only the voluntary mufcles but the vafcular fyftcm ' has been much more affected on one fids than on the other. Not very rarely the difeafe commences with delirium ; and very frequently this fymptom follows a violent pain in the head in a very early ftage of the difeafe. The dcliriun is often mild -, in fbme cafes however, where it is attended MEDICAL COMMUNICATIONS. -3 with flufiied face and eyes, great heat in the head, and vio- lent pulfation of the carotid arteries, it produces a fury, which is fcarcely to be reftrained. In a few inftanccs the patient has become blind and raving within half an hour af- ter the attack. Stupor and coma, likewife convulfions and fpafms occa- fionally attend the accefs of the difeafe ; but they are more frequent in its later ftages. In whatever form the difeafe commences, there Suddenly enfues great proftration of ftrength, In fome inftances the patient is defcribed as almoft immediately falling down un- der the weight of difeafe. This proftration is accompanied or followed by univerfal or partial chills •, the {km becomes dry and pale, or mottled like one who has been long, in the cold, eyes glafly, nofe contracted, the face fublivid, with palenefs around the mouth, and the countenance exprelfive of the utmoft anxiety and diftrefs, or its features diffoived with a lofs of all character and expreflion ; the whole body becomes cold, respiration very laborious, efpecially in child- ren, puifes very fmall and feeble, fie v.- at the commence- ment but fhortly very frequent. Jf there be neither coma nor delirium, the fpirits are very much dejected, the pati- ent fullers extreme fclicitude and anxiety, with apprel.cn- fions of death, frequent fighs, reflleffnefs and agitation. He complains of oppreftion and faintnefs, with undefcrib.:- ble diftrefs about the praecordia and a fcnf.tion of fullnefs at the ftomach. Frequently eructation, naufea, and vomit- ing enfue, and alfo fainting in the early ftages of the dif- eafe •, and the vomiting occasionally becomes inccfiunt, cm- barraffmg and defeating every effort to give ieilef >v internal medicies, while it exhnufts the patient- 6 MEDICAL COMMUNICATIONS. The different ftages of this difeafe and the duration of each are not very accurately diftinguifhed by moft of thofe, who have made communications to the committee. Doubt- lefs this is becaufe disaphorcfis has commonly been eftab- liihed at an early period of the difeafe, which has been fol- lowed by a mitigation or a fubfidence of the fymptoms. How far this diaphorefis has been produced by art alone, and whether there be not a natural tendency to this termin- ation, may be matter of doubt. It is generally reprefented as the effect of art ; but it is remarkable that the efforts for this purpofe fliould have been very generally fuecefsful, if there is not any natural tendency to its production. By fome however it is noticed, that the fymptoms of the firft ftage, fuch as have been defcribed, become modified in the courfe of from eight to twenty-four hours. Within that period fome have died. But ordinarily, except where the powers of life are to much exhaufted, the fymptoms of the second ftage fupervene. The pulfes become more full and regular, the fkin becomes warm, countenance flufhed, and in plethoric fubjects efpecially, even red and florid ; refpi- ration short and very difficult from a fenfe of fullnefs in the kings, but more regular than in the early periods of the dif- eafe ; eyelids fwollen and eyes flaring, with a throbbing pain in the head ; light diftrefles and noife irritates ; and great reftleffnefs, general anxiety and frequently delirium enfue. In a large proportion of cafes thefe fymptoms have ail fub- fided, and the difeafe has terminated within three days ; of- ten in one. Even in cafes where the attack has been very violent, and the powers of life almoft overwhelmed at firft, the patkut h;:s fo far recovered as to be verv comfortable in MEDICAL COMMUNICATIONS. 7 three or four days, fuffering only a flight debility. In many cafes, however, while.the feverity of the difeafe has abated, it has neverthelefs continued under a milder afpect, and exhibited the lefs equivocal characters of typhus •, under which circumftances the termination has rarely been fatal. To this remark exceptions have been noticed in May, and the early part of Jnne. Relapfes have occurred in many inftauces with the fame fymptoms as in the original attacks ; they have rarely if ever been followed by death. Among the varieties of the difeafe, the following is given as a description of fome cafes which have occurred efpecial- ly among females. " Univerfal deadly coldnefs ; fkin white as polilhed marble and fmooth ; countenance perfectly •placid •, not one diftorted mufcle ; pulfe in the wrift im- perceptible -, motion of the heart fcarcely to be felt ; refpi- ration vifible only by gafping, and that not frequent •, and as it were only a ftep between this imperfect ftate of life and death." Even from this ftate of deadly ftilluefs patients have been reftored to life and health. As has been already mentioned, fome die in the early ftages of this difeafe. A few are taken off fuddenly in ten or twelve hours •, others in twenty-four, thirty-fix, or forty- eight hours from the firft fymptom of the diforder. Death rarely occurs after the third day ; indeed fome of thofe prac- titioners, who have been moft converfant with the difeafe, confider their patients fafe if they pafs through the firft twenty-four hours without any mortal fymptoms. The following is a defcription of the termination of the difeafe in cafes, in which it was fatal within two days. Af- ter the fymptoms of the fecond ftage, as defcribed above, hare continued from fix to ten hours, the fkin becomes pale & MkDlCAL COMMUNICATIONS. und cold ; pulfes very quick, fmall and irregular ; refpira- tion lefs hurried, but very laborious ; countenance fallen ; the folids flaDcid ; the petechial foots of dark color, violet cr livid, fuddenly appear on the fuperior extremities, and immediaiely over the whole body. At length confufion of mind with conftant drowfinefs, inability to fwallow, refpira- more freqent and more laborious, with flutteeing ptilfe, an- nounce the immediate approach of death. From the various defcriptions of the difeafe which have been furnifhed them, the committee have endeavoured to give a general view of its symptoms, their courfe and order. Every fympton is not to be obferved in every cafe ; on the contrary there is gereat Variety in the fymptoms, and it is faid that there is great variety alfo sn the order in which' they occur. In this general view it has been impoflible to de'fcribe all the variety of afiections with all their clrcomftances, fnch as are more or lefs frequently obferved in this difeafe. It may therefore be ufeful to prefent the moft important fymp- toms in an uncombed view ; and in doing this it may be neceffary to repeat in fome iriftances what has already been ftated. The face and eyelids are often fwollen ; and in fome caf- ca the face is fwollen and black like that of a perfon ftran- gulated, The eyes are moftly defcribed as being deprived of their natural luftre, dull and glafly, or red and watery, with the pupil, fometimes contracted, more frequently di- lated. Sometimes the pupils are feen to vibrate from one extreme to the other. The eyes are alfo defcribed as ap- peannmg more brilliant than usual, with a wild penetrating ftare j and it is faid that this fbee of the eyes is fometimes MEDICAL COMMUNICATIONS. 9 noticed feveral hours before the patient is aware of any morbid affection. The ienfation3 in the head are various ; such as dizzi- nefs, vertigo, pain ; throbbing, fevere, excruciating pain •, arid ftricture acrofs the forehead and eyes. Thefe ferifa- tions are often followed and fometimes accompanied by de- lirium. The delirium has all the varieties obferved in other acute difeafes, from that which is mild and light, and in- deed little elfe in coherence of ideas, to that which is low and muttering, or that which is violent with rage. Coma as well as delirium is of frequent occurrence, and is even more common in the late Images of fevere cafes. There are inftances, efpecially in adult males, in which confeiousnefs remains to the laft unimpaired, although the iffue be fatal. There are alfo other fymptoms which appertain to the animal fyftem 5* the following are particularly noticed. Numbnefe or total infenfibility and paralyfis in a larger or fmaller portion of the body, which occur often in the firft ftage of the difeafe, and continue through its whole courfe, and even after other fymptoms have fubfided ;—a fenfe of laflitude and wearinefs ; forenefs of the flefii, efpecially in children ; and fpafms which frequently occur, and fhifr. fuddenly in the fame manner as the pain does from part to part -a fometimes refembling histeric fpafms, fometimes oc- cafioning the head to be drawn back as in opisthotonos. The refpiration is much and varioufly aftl'ded -, in gene- ral it is difficult. Cough rarely occurs* and the 'difficulty * This piirase is used in the sense i>iv*n t0 lt b>' Bichat—under this division he comprehend, the brain, and its dependant organs- viz.—the nerves and voluntary muscles, so far as they are dependant on the brain. v> 10 MKDSCAL COMMUNICATIONS. of respiration has not commonly appeared to arife from an inflammation of the lungs. In two cafes, however, fymp- toms of pneumonia have arifen, and in one of them the ex- iftence of that affection was demonftratcd after death.* The actions of the heart are very feeble in this" diseafe ; about its region that there are often very diftreffing fenfa- tions, defcribed as death-like feelings. Thefe feufations are Occasionally relieved by fpc nt.incous vomiting, and pcflibly they mav have fome connection with die gaftric region. In a few mild cafes the pulfes are little altered ; but commonly they are very feeble, and except at the commencement, fre- quent. It is faid 'at they fometimes denote more ftrength in the fyftem than it is found to poflefs. They are fometimes hard ; more often they are intermittent, and irregular both in force and frequency ; they are remarkably variable, fo that in the courfe of an hour, and indeed in much lefs time, they change from quick to flow, from ftrong to feeble, and vice versa ; at the acceflion of delirium early in the difeafe, they have been obferved to undergo a fudden acceleration from fixty or feventy to one hundred and twenty, and even to one hundred and fifty in a minute. The pulfation of the carotids is often very confiderably greater than that of the radial artery. The phenomena of the fkin have received conflderable at- tention ; feme of them have given to this difeafe its vulgar name. In the early ftages the fkin is perhaps invariably di y i at a later period fpontaneous fweats have broken out * These ca--es are specially noticed, because we are told that this disease has prevailed on the borders of Lake Champlain, in Vermont, and also in Montreal and its vicinity ; ana that in those places it has taen combined with pneumonic infiamatipjj. MEDICAL COMMUNICATIONS. 11 on the head, cheft, and fuperior extremities. A doubt has been exprefTed whether univerfal fweating would not occur without aid of art. In a few cafes which have occured in Bofton and it3 vicinity there has been obferved a great ten- dency to this evacuation, and it has very readily becora** profufe. Doubtlefs there have been cafes in which it was very difficult to excite diaphoresis, but in many it has been fufficicent to put the patient in bed, and give him a cup o* any wrarm liquid. The. fweats are faid to have an offen- five and peculiar odour ; it is fetid •, but this does not feem to defcribe it fuflieiently. It has been compared to the fmcll which arifes from a dead rat within the wainfcot of a room. It has alfo been compared to the fmell of a mercurial fore mouth. In many cafes the fkin is faid to be remarkably fmooth j but this is not an univerfal rppeara'nce. The spots on the fkin are of various defcriptions. They occur in all ftages of the difeafe ; lefs frequently however on the firft than on the fubfequent days. Frequently a rafli or miliary eruption only appears, or a few blotches on the infide of the elbow, and other fimilar parts : ana it has been fuggefted that thefe may be produced by the mode of treat- ment ufually adopted. The blotches are florid, or red and fiery. An appearance like meafles has alfo been noticed, and likewife veficles and puftules, which have been compar- ed to the vaccine and variolous eruptions. In fome cafes thefe fpots and eruptions have appeared at fucceflive periods two or three times in the courfe of the difeafe. The vefi- cles and puftules are very frequently torn by fcratching ; aft-r which or without being torn they are commonly fol- lowed by fcabs of a brown color ; but occafionaliy they ar-j 1H MEDICAL COMMUNICATIONS. followed by ulcerations which do not heal until after recov*. ry. Thefe affections of the fkin are often attended with itching ; and independent of them, itching very frequently occurs, efpecially on the third day, when the fymptoms be- come more favourable at that time. This itching is fore- times extremely violent, fo that the patient will almoft tear up his fkin in endeavouring to alleviate it. All thefe affec- tions are frequently noticed at the time when die more im- portant fymptoms abate, or fubfide. In a few inftances, veficles containing a bloody fluid oc- cured in the county of "Worcefter. Thefe veficles were compared to blood blifters, and were about the fize of a brge pea ; they appeared in various parts of the body and limbs; in a few days they broke, discharged a bloody fluid, and feabbed over. In one cafe, in which the attack was very violent, blifters refembling thofe produced by cantha- rides appeared on the fecond and third day on the breaft and on one foot. They were about five inches in length and nearly one in breath. On the fourth day from the°at- tack, fome of thofe on the breaft and that on the foot 1,< - came black and dry, and the ft in was fphacelated. The efchers with due treatment left clean ulcers, which healed without difficulty. The appearance of petechia- and vibices has been notic- ed. They occur in comparatively few caf.;s of the difeafe. They are of worfe portent in proportion as they are more- dark coloured. They do not however always occur in fatal cafes, nor are they confined to fuch cafes. It isnoteafy to determine in how large a proportion of fubjeds the fcin is affiled with fpots and eruptions. Un- der the obfervatiorf of feme gentlemen, thowels are rarely coloured by natural, healthy bile until the third day. In two cafes we are told that dyfentery fupervened in an ad- vanced ftage of the difeafe •, but it was cf fhort duration. Patients fometimes complain of fo renews of the throat ; and on infpection, the fauces are found very red, but not fwol- len in any part. The fenfation of forenefs is often juft be- low the fauces where the parts cannot be feen. Aphthae have been occafionally obferved. In moft cafes the urine has not been very different in its appearance from that in health, but the quantity has been lefs. Strangury has been ranked among the occafional fymp- toms ; but a queftion may be permitted whether this has not been produced by the remedies employed. Th$re is an irregularity in the courfe of the fymptoms in this c'ifc lie, and fo alfo in their duration. Blindnefs con- tinues from half an hour to twenty hours ; fevere pain in the head, and delirium from four to twenty hours ; deep coma from fix to twelve hours, and even from the beginning to the end of the difeafe, efpecially in children, s In a few inftances flight affection of the parotid glands have been obferved, but in general, glandular fweliings have not been noticed by our correfpondents. In fome cafes fweliings have occured on the joints and lirhbs. Thefe have been very fore to the touch, and their appearance has been compared to that of the gout. The parts fo affected feel as MEDICAL COMMUNICATIONS. lo if they had been bruifed. The fweliings arife on the- fmafi- ; er as well as on the larger joints, and are often of a purple colour. Thofe on the fmall joints efpecially fometimes dif- appear as the difeafe approaches its crifis. It is not ftated that the difeafe of the whole fyftem ever fubfides when thefe local affections take place* By fome praditioners the in- !' flammation in thefe cafes is called eryfipelatous, and proba- bly with juftice. In a few inftances purulent difcharges from the ears have been no deed* They have not been accompanied by any re- markable change in the courfe of the difeafe. In a finall number of cafes the difeafe has been followed by deafnefs, from which the patients have not fpeedily recovered. Two perfons were affeded in this way in the year 1808 at Am- herft, and their hearing has not yet been reftored. By fome of our correfpondents it is said that recovery from this difeafe has been rapid, and the fubfequent ftate of health as good as ufual. But the exceptions to thefe re- marks are certainly numerous. The attack of this difeafe has been defcribed as fudden and violent ; but there are cafes in which the qrdinary fymptoms occur in a flight degree, and increafe gradually for hours and even for two or three days before the difeafe becomes very ferious. We may alfo add in this place that in fome parts of the country there were many perfons who exhibited fome of the fymptons of the difeafe, fuch a? local pain, and numbnefs, but who were not fo much affeded as to be confined. In general our correfpondents do not recognize this dif- eafe as having before occurred under their notice. Two gentlemen believe that they have in the ce-rrfe of many years U MEDICAL COMMUNICATIONS. f«en a few cafes of the fame charader. Six or eight cafe's occured in Amhcrft in 1808. The replies to our queftions refpeding the diagnofis arc | not very full. It feems to be generally believed that the ; difeafe is to be diftinguifhed only by attending to the com- j bination and courfe of the fymptoms. One gentleman ftates that the moft general characteriftics arc " univerfal proftra- tion of ftrength, and a depraved adion of the fenfitive organ." It is very generally agreed that this difeafe is not contagi- ous. Neither very young infants nor aged perfons have been i'o fubjed to this fever as perfons in middle life. In one town nearly all thofe affeded were between eighteen and thirty years of age ; but the fame remark was made elfewhere. By fome gentlemen it is remarked that females are more fubjed to the difeafe than males ; and this Was true in Worcefter, the only town from which we have received a ,■ lift of the fick. Yet one gentleman ftates that it attacks more efpecially the moft healthy and robuft, male and fe- male. Women in different ftages of pregnacy have had fe- vere attacks and have done well; but they have not all been fo fortunate. Blacks are not exempted from the difeafe. To this part of cur report, which with a few alterations is the fame as it was when read to the counfellors at their - meeting on the fecond of May, we have now to add ; that in cafes of this difeafs which have occured fince the middle . of April, as obferved in Bofton and Lancafter more pabcu- larly, fome change has been noticed in the fymptoms. Dif- charges of bile from the ftomach, and foulnefs of the llomach and bowels, have beep me more common ; and fo nlfo have MEDICAL COMMUNICATIONS. 17 hardnefs of the pulfe and heat on the furface of the body. In many of thefe cafes the bile has appeared in undue quan- tity and much altered in its charader ; its confiftence very thick and tenacious, and its colour dark. In feveral fatal cafes at Lancefter, and in two not fatal, a dark matter was thrown up, which was called " black vomit." Whether this matter wak tire fame called by that name in the autum- nal fevers of warmer climates, the committee are not aflured. It appears alfo that in various parts of the commonwealth the common typhus is much more frequent than ufual at this feafon of the year •, appearing in many inftances with its ordinary fymptoms ; but in others with a charader more c,r lefs refembling the difeafe which we have defcribed. PROPORTION OF FATAL CASES. Refpeding the proportion of fatal cafes, the committee have not the means of making any accurate ftatement. It would be very ufeful to obtain from each town in which the epidemic has appeared, the number of its inhabitants,—the length, of time during which the difeafe has prevailed,—the number of perfons who have been affeded by it,—the num- ber of thofe to whom it has proved fatal,—and the average number of deaths in the correfponding^ periods of other years. The committee will ftate as much as they have yet learned relative to this branch of the fubjed ; refpeding winch they have made fome efforts to obtain more informa- tion. At the firft appearance of this difeafe in the county of Worcefter, a verv large proportion of thofe affeded with k died at an early period of the difeafe. Since it has extend ol more widely, its violence has dimifhed, and the propor- c :.S MEDICAL COMMUNICATIONS. tion of deaths has become very fmall. So it is reprefented by our correfpondents generally ; the following are the par- ticulars given by feveral of them. In 1808 the difeafe was feen at Amherft ; and of fix cafes three were fatal. In the prefent year at Cambridge- ] 'port, four perfons died.* At that place there were fix fe- . . vere calls, but a much larger number which were mild. ] Under the infpedion of one phyfician in the county of Worcefter there occurred two deaths in one hundred and thirty patients ; under that of another, one death in up- wards of fifty patients j and under another in the fame county, one death in nearly one hundred patients. In a ftatement of ninety-one cafes in the town of Barrc nine are marked as fatal. It is mentioned in the fame ftate- ment that there were thirty-nine other cafes, the iffue of which is not mentioned ; but from fome circumftances it may be inferred that none of them were fatal. APPEARANCES AFTER DEATH. The advantages, which arife from the examination of dead bodies, have been exceedingly confpicuous in the in- veftigation of this difeafe. From this fource have been ob- tained fads of great importance in illuftrating the nature of the complaint, and pointing out the propriety of certain modes of treatment, which the fymptons indicated in a lefs diftind manner.. It is a fubjed of regret that the examina- tions of thofe, who have fallen vidims to this difeafe, have not been more general. All thofe, which have been care- fully detailed, arc fubjoined. We have fatisfadory reafons * One adult and three children ;-who were sick 17, 29. 30 and' 42 hours. MEDICAL COMMUNICATIONS. 19 to believe that the morbid appearances in thefe correfpond- ed with thofe of fome other cafes, which have not been ful- ly communicated. The cafes here given have principally occured in the neighbourhood of Bofton, fo that the com- mitte are able to vouch for their accuracy. This is alfo ef- tablifhed by the remarkable coincidence in the moft impor- tant circumftances noticed. We fhall now give a general ftatement of the moft com- mon, and the remarkable morbid phenomena, leaving the comparative frequency of the particular appearances to be obferved in the cafes introduced hereafter. EXTERNAL APPEARANCE. Soon after the patient expires, and in fome inftances a. fliort time before, the fkin affumes a formidable livid colour. This appearance is either generally diffufed over the flcin, or elfe it exifts in fpots, commonly of an irregular form, but occafionally rounded. The lividity is more remarkable at firft on the anterior parts of the fubjed, efpecially on the fore part of the face, neck and fhoulders, than afterward ; for it gradually fubfidea from thefe to the pofterior parts of the trunk. Wherever the cuticle has been removed by vefication the fkin is. almoft black and often covered by fluid blood. On the other hand the petechiae, which exlfted during life, become paler, veficles or phlyctenae, eruptions and rednefs of the tunica conjunctiva difappear. HEAD. When the cranium is feparated from the dura mater this membrane ufually difcharges a confiderable quantity of blood. As foon as the dura mater is cut through, a quanti- 2) MEDICAL COMMUNICATIONS. ty of ferous fluid commonly cfcapes from under it, and the w!:cb furface between the dura mater and tunica ar.ich- noides is found to be quite moift with the fame fluid. This is not always tranfparent like water, but fometimes quite rod coloured. The longitudinal finus is filled with blood, and when wounded difcharges a very great quantity of thij fluid, which pours into it from the cerebral veins. Having rmfrd the dura mater, we difcover an extraordinary fullnefs of die veins on the fuiface of the brain, if the longitudinal finus is ftill entire. This appearance however cranes ac- cording to the duration of the difeafe. Li tliofr, who have pcrifhed within t'r^ fpace of twelve hours from the firft in- vafion, the large blood veffels are cxceilively crouded, while in theft, of twenty-four hours continuance or longer the minute veflels are more aiftind ; and the other appearance-, wc are ro defcribe, are more confpicuous, in proportion to die duration of the difeafe. The tunica arachnoides and the pia mater are remarkably altered in appearance by the effuuon of an opaque fubftance between them, which may b? called coagulated lymph, or femi-purulent lymph. TIds fubftance is frequently of the ycllcwifh colour of pus, with a coniiftence between the tenacity of lymph and the .fluidity of pus. At other times we fee it poffeffed of the afped of well characterized lymph. This effufion accompanies the courfe of the veffels very generally. In no inftance of die duration above mentioned have we feen it wanting in this fituation, while it is always very irregularly diffufed in the other parts. The fpace between the thin membranes con- tains alfo a confiderable quantity of ferous fluid. The two hemifphere of the brain adhere to the dura mater, near the longitudinal finus, and to each other with fo much ftrength, MEDICAL COMMUNICATIONS. 21 as often to require a laceration or incifion through the fub- ftance of the brain, in order to arrive at the corpus callofum.' The medullary fuhftance exhibits a great number of bloody points at the fedions of the veffels, while the cortical part feems paler than ufual. The lateral ventricles alway con- tain a notable quantity of water. This varies of courfe. Sometimes thefe cavities may be feen greatly enlarged, and at others with not more than three or four times the quan- tity often found in healthy brains. The plexus choroides is often thicker and harder than natural, but always very pale from maceration in the effufed water. The membrane at- tached to the plexus exhibits very confiderable alterations from its healthy tranfparency to a ftate of morbid thicknefs and opacity. The membranes at the bafis prefent the fame appearances as at the vertex of the brain, A large quantity of ferum is found there ; and an effuficn of coagulated lymph in mafs has been witnefsed in the fame part. THORAX. The heart generally exhibits fome appearance of difeafe. In everv inftance the fmall veffels on the furface of the cr- n-an are beautifully injeded : the external coat is fometimes the feat of a depofition of lymph, and even the inner lining and valves are occafionally altered from their healthy tex- ture. The right and left cavities ufually contain a fmall quantity of black blood, quite fimilar in appearance and n/aantity ; and even the aorta has been feen gorged with the fame dark coloured fluid. The ftrudure of the lungs is not commonly deranged. Thefe organs are of a light and healthy colour on the fore part •, while the pofterior or lower parts are difcolourcd by the blood which fir'-s into them. Their «>i MEDICAL COMMUNICATIONS. fubftance contains a very variable proportion of blood, de- pendant no doubt, on certain eircumftances accompanying the ceffation of life. It feems that when the lungs are full of blood the liver is flaccid, and when the lungs are empty the liver is large and turgid. In one cafe the cavity of the thorax was the feat of very confiderable difeafe. The heart was inflamed and exhibited a large thick flake of yellow lymph on its anterior face. The-pleura of the right fide, both of the ribs and lungs was covered with the fame fub- ftance, but more nearly approaching pus in its confidence ; and the cavity of the pleura contained a very large quantity of half formed pus. The colour of the lungs externally was an ill-looking purple, and die pleura over them feemed to be fhrivelled and adhered to the diaphragm. Their con- fiftence was uniformly firm in this cafe, owing perhaps to the large quantity of blood they retained. ABDOMEN. The contents of this cavity have fcarccly fhown anv marks of difeafe. Its opening is not attended with fo unpleafant impreflions on the organ of fmell as in moft other difeafes. The coats of the ftomach are generally free from the flight- eft morbid appearance ; but in a fingle inftance, the laft, which occurred in the vicinity of Bofton, the mucus coat was in a ftate of very uniform inflammation, and the veins were vifible through the peritonasal covering. The contents of the ftomach are not ufually remarkable ; yet they have fometimes a refemblance to coffee-grounds, or more nearly to brown foup ; while in other cafes they confift of green- ifh mucus ; each without any offenfive odour. The duode- num and the whole tr,\d oi fmajl and large inteftines are in I MEDICAL COMMUNICATIONS. 23 a healthy ftate. The latter commonly contain a confidera- ble quantity of fecal matter. The liver and fpleen are dif- tended in very various degrees, as we have already intimat- ed and are quite free of any morbid change, unlefs we ex- cept an extreme livid color. The gall bladder is generally full of bile, which is fometimes of a dark color and ropy confiftence. The pancreas and kidneys prefent nothing ex- traordinary. The bladder is commonly full of urine. The mufcular fubftance as well as all other parts, which are filled with and exhibit the color of the blood, is of a liv- id appearance, fuch as is not witneffed in other difeafes. This fluid has therefore neceffarily a very dark hue. It it commonly accumulated in the cerebral veffels ; and is in moderate quantity in the vense cav?e and cavities of the heart. After having flowed out it often coagulates. The coats of the blood veffels are not altered from their healthy ftate, if we except the change, which has been defcribed as exifting on the outer furface of the veins of the brain. The lateft period after death when any of thefe fubjeds has been examined was from twenty to twenty-four hours ; at which time, there was a lefs offenfive odor exhaled from the body than during life, and there were no figns of the commencement of putrefadion. THE MODES OF TREATMENT WHICH HAVE BEEN ADOPTED, AND THEIR EFFECTS. Thofe evacuations which arc ordinarily made in the com- mencement of acute difeafes have been thought hurtful in this. Blood-letting has not been frequently pradifed by the gentlemen, to whom wc are indebted for comraymica- U MEDICAL COMMUNICATION?'. tions. They have been deterred from this pradice by the opinions they have entertained refpeding the difeafe ; and by the reports of fome of thofe, who had had previous op- portunities of obfervation on the fubjed. Some cafes how- ever have occurred in which the lancet has been employed with benefit. Thefe will be particularly noticed in the re- marks which the committee will make on this head. Cathartics have been thought injurious till the third day of the difeafe •, but enemas have fometimes been adminifter- ed on the fecond day, when fpecially indicated, without in- jury. In general emetics have alfo been thought injurious on die firft and fecond days ; but in this refped the caution has not been fo univerfally regarded. Efpecially in cafes " where ficknefs at ftomach has feemed to arife from a pri- or indifpofition in that organ rather than from a morbid af- fedion induced by the difeafe," it is faid emetics have been found ufeful. It is faid alfo that where the vomiting has been frequent, yet only white mucus and the liquids recent- ly fw allowed have been ejeded, emetics have not afforded relief. When medicines of this defcription have been ad- miniftered opium has been given afterwards. The pradice which has been by far the moft generally purfued, and confidered of primary importance, is to pro- duce early and long continued fweating. In many cafes, efpecially mild ones, this has been very eafily affeded ; in fome fevere cafes it has been very difficult. The means which have been adopted for this purpofe are very minutely detailed. The remedies are internal and external. The internal remedies employed have not generally been thofe now moft commonly direded to produce diaphorefis in fe- vers, fucli as ar.dmonials ; and widch appeur to excite the MEDICAL COMMUNICATIONS. 25 CApi.lb.ry veffels without increafing the adions of the heart or large veffels cither in force or frequency. Preparations of antimony particularly feem not to have been at all tried ; but ipecacuanha, which refembles in its operation the prep- arations of that mineral, has been employed very fuccefsful- ly by fome in combination with opium. In general the internal remedies adminiftered in this dif- eafe with a view to produce fweating have been thofe called cordials. The external remedies have been warmth and moifture, and futh articles of clothing as would more effec- tually confine both. The following is a fummary of the di- rections commonly given on this fubjed. The patient is firft put into a warm bath, or his feet are bathed in warm water ; then, being well rubbed, he is to be laid in bed between blankets, and bed cloaths added in - proportion to his fenfations, or to his adual temperature when his fenfibility is very much diminifhed. Around him are to be placed bottles of hot water, or billets of wood heated in boiling water and wrapped in flannel -, or he is to be wrapped in flannel wrung out of boiling water ; fina- pifrns are applied to the feet; and he is to fwallow fre- quency fome warm liquid of the defcription given above, preferring to ufe the weakeft which appears adequate to the particular circumftances of the cafe. The articles mofk, commonly employed for this purpofe are hot infufions of the leaves of mint, penny-royal, and other fimilar plants, winc-whey, wine and water, wine, brandy and other ardent fpirits more or lefs diluted, camphor, fulphuric ether and opium. It is not generally thought ufeful to excite profufs fv/eating. To this there appears to be a very confiderable tendency, when moifture is once produce! on the fkin ; and D 26 MEDICAL COMMUNICATIONS. fome very judicious praditioners have thought it neceffary to check this great evacuation by wiping and rubbing the fkin with warm dry cloths. But it has been thought very important to maintain the perfpiration in a moderate degree for a length of time proportioned to the feverity of the cafe ; that is from twenty to forty hours, and even longer in fome inftances. To maintain this procefs not only cordials, but < noarifnment is given, uich as the patient's ftomach can, 1 bear •, which in many cafes is ftrcng foup. tinder this treatment moft commonly the violent fymp- toms and not very rarely all the appearances of difeafe have iuhfided. When relief has thus been obtained the diapho- refis muft not be fucldenly checked, nor muft the patient be haftily moved from his bed. The flcin fhould be allowed to dry gradually, or if very much loaded with moifture fliould feec]u~r:tly be Wiped and rubbed ; but the patient fhould not be removed nor the bed cloaths fliifted till the third day. The adminiftration of the articles mentioned has been f eg-dated not merely with a view to promote diaphorefis. They are alfo thought neceffary to excite the adions of the heart and large veflels and to produce warmth. In propor- tion to the neceflity of the cafe, the ftrength and quantity of thefe articles have been increafed or diminifiied. In ma- ny cafes very mild cordials aflifted by external heat and cloathing have been found fufficient to effect the'purpofes defired ; in others the moft bold and liberal ufe of the ftrongeft cordials has been thought neceffary ; they have been borne in very large quantities, and it is faid that life ha? appeared to depend on their effecls. In admhdftering medicines of this defeription the quantity has not been re- garded ; the practitioner has meafured the ufe of them on- MEDICAL COMMUNICATIONS. 1? ly by their effeds. In cafes of extreme coldnefs, great tor- por and frequent vomiting ardent fpirit has been given un- diluted ; and when it would not remain on the ftomach if given cold, it has been made hot. Under fuch circum- ftances a quart of brandy has been given in twelve hours. It fhould however be noticed that fome of our correfpond- ents who have been very converfant with the difeafe proteft ftrongly againft this liberal ufe of cordials ; and believe that much injury has been produced by them. In the lethargic ftate, which is, it is faid " the death ftate of the difeafe, un- ieis a fpeedy change be produced," tindure of opium has been thought eminently ferviceable. In cafes which have been thought defperate fifty to a hundred drops of this tinc- ture adminiftered every half hour " have almoft invariably removed the lethargy." When deglutition has been render- ed impofiible by paralyfis opium has been adminiftered in enemas with the moft falutary effeds. In cafes of fpafms alfo opium has been given in large dofes* with the moft happy confequences. Arfenic has not been very much employed by our corre- fpondents, and its effeds are not particularly flared. In n-eneral if its ufe is mentioned, it is with approbation. to ' ^ Two gentlemen have adminiftered the ufual preparation cf this article in the convalefcent ftate, and they think it has been beneficial. At the fame time that cordials have been employed in- ternally, and heat to the general furface of the body, cold water, fnow, and ice have been applied to the head, Thefe applications have been made, when there was violent pain * In one cafe a feruple was given in the courfe of three hours.; i« another forty-two grains in forty-ei^lit hours. iiri MEDICAL COMMUNICATIONS. in that part with heat and fiufhed face, and when there waa violent delirium. The cold applications have in thefe cafea afforded great comfort to the patient, and have mitigated or removed thofe very important fymptoms. Sulphuric ethcr dropped on the head and allowed to evaporate, has produc- ed fimilar good effeds. Vefication on the back of the neck, or on the head, fore- head, and temples has like wife been followed by moft im- portant good effeds, not only in relieving the complaints about the head, but in abating other violent fymptoms of the difeafe. Vefication over the ftomach. has been very dtccefe- fully employed to check inceffant vomiting ; and, generally, to remove the morbid irritability of that organ. The bark of the officinal cinchona lias been thought too flow in its operation to effed any change in the early move- ments of this difeafe, when fevere ; but after die firft dan- ger has been over, that and fimilar remedies have been em- ployed with fome benefit. But preparations of iron* have appeared to one gentleman to produce a better effed during convalescence than cinchona. In fome cafes when apparently grown defperate, one gen- tleman found the warm bath a remedy of the higheft value. Preparations of quickfilver, particularly the fed muriate, have been exhibited in this difeafe in ihe fame manner, ;.;■■ they are given in this country in variou■; other acute difeafes. They have been more or lefs employed by various phyfi- cians j but particularly by a gentleman at Worccfter. Oth- er articles, fuch as have been mentioned, were alfo admin- iftered by this gentlemen ; but where life was not immeui- diately threatened thefe preparations were more particularly * This gentleman gave GiifEth's myirh mixture. MEDICAL COMMUNICATIONS. «§ relied on. His mode has been to " aclminiftcr diligently" from the beginning fubmuriate of quickfilver combined with camphor and ipecacuanha, and with fo much opium as to prevent any powerful cathartic effeds from the medicine. This mode has been purfued until a flight affedion of the falivary fyftem ha? been produced. The fuccefs attending this pradice certainly was not exceeded by that of any other ; and, while purfuing it, the very liberal ufe of cor- dials has not commonly been found neceffery* THE committe have now reported every thing of impor- tance relative to the difeafe lately epidemic in the county of Worcefter and clfewliere within this commonwealth, fo far as they have been able to obtain information an that fubjed. They will here add fome brief notices RESPECTING THE SAME DISEASE IN OTHER PLACES. The appearance of this difeafe in the county of Worcef- > -r was not the commencement of its recent prevalence in our country. It is obvioufly the fame which occured in Medfield in 1806, of which an account was publifhed a- mong the medical papers of the fociety. It is unneceflary to recite the defcription there given. Since the month of March 1807 the fame difeafe has been epidemic in fome parts of the ftste of Connedicut, In that month « it appeared in the city of Hartford, and foon after in the town of Windfor. From that time to the prefeut it has .made it appearance at various times in various places in the counties of Hartford and Litchfield. Cafes have oc- curred in almoft every month of the year ; but it has gene- 30 MEDICAL COMMUNICATIONS. rally been moft prevalent in the laft winter and the fpring months. We are not fenfible of any variation in the feafons Sufficient to have given rife to this new form of dife..fe. "The winters preceding the fpring of 1806—7, when the difeafe firft appeared, had been, as ufual of late years, open and mild. The winter of 1808—9 was unufually fevere. The local fituations of the towns, in which* the difeafe has been moft prevalent, arc various. While fome of them are Situated upon the bordes of rivulets, and and interfeded by Small ftreams never know to emit unhealthy vapours ; oth- ers are placed upon high hills and bleak ridges, and have been ranked among the moft healthy in New England.*" It appears that this difeafe has exhibited in Connedicut con- siderable variety of charader in different places and in dif- ferent years. It would be interefting to notice ail the circumftances ob- icrved there which have not been remarkrd in this ftate. But this report will not give room for fuch notices. This difeafe is faid to have prevailed during the pre font feafon in fome parts of the of New-York and Vermont and of the province of Upper Canada. It is reported that in diefe two laft mentioned places fymptoms of pneumonic affedion have in many cafe? attended the difeafe. The committee have not yet been able to obtain fedsfedcry in- ormution from thofe quarters. * An inaugural dissertation on the disease termed petechial or spotted fever, by Nathan Strong, jun. of Hartford. P-'inted by Peter b. Gleason, 1810. The committee ha* e derived their information respecting this epidemic in Connecticut from this dissertation, from a ivper by E:. Samuel Woodward published in the New York Medi- cal Repository, and from the private letters of respectable physicians MEDICAL COMMUNICATIONS. 31 ON THE NAME AND CHARACTER OP THIS DISEASE. THE committee now beg leave to make fome remarks on the name and charader of the difeafe, which is the fubjed of their report. This difeafe has been called fpotted or petechial*' fever The name has been confidered improper by moft medical men, who have had occafion to remark upon the fubjed. It is however true that to fimilar epidemics, that is to epi- demic fevers refembling this in the appearance of petechiae, the name of petechial fever has been given. Two opinions have been maintained on this head. The one that the pe- techiae are primary, or effential to the difeafe in the fame manner as the eruptions in fmall pox and meafles, to the difeafes, which bear their names. The other opinion is that they are fecondary, or Symptomatic ; that they may or may not occur in various difeafes, and that they are produced in confequence of fome peculiar ftate, into which the fyftem is brought not by any fpecific adions, but by adions common to various difeafes. The first opinion is adopted by Buferius, one of the moft induftrious and learned of compilers. He difcuffes the fub- jed very fully,f aHd ftates the reafons for his opinion. Of * It is conjectured bv Hoffman and others that this terra is deriv- ed from the Italian word pedecbio. But Bursenus suggests that it mav be derived from pesth, because these spots were first noticed m the plague. Burserius had traced back the history of these spots in Italy only to Fracasiorios. But his suggestion derives considerable force from this circumstance ; that Iograssia, who, according to vVii- lan, noticed these spots in Italy a hundred years before Frapstonus, and probably before any one else, called them fetnaat. Irdlan on cutaneous diseases, Vol. i. p. 47°« ■+ Institutions of Medicine translated by Brown—Vol. iii. P- 226. Chapter on the Petechiae or petechial disease. His arguments are not here stated at largo ; but the Hioft important par.s of tbtra aic >i\en. S-e the work. 32 MtDIUAL COAirVi UN NATION?. thefe the principal are, I. That, when petechiae prevail epi- demically in any place, they are found on many perfons without fever or any other preceding difeafe. II. That the diSeaSe has a great tendency to the fkin, So that although in a Sew perfons who have the fever they do not appear, yet that they do in the great majority of inftances. III. That the Sever has a great variety oS charader So that the petech- iae be SuppoSed to depend on the Sever, but on the contrary the Sever on the petechiae. IV. That the petechiae appear at various periods oS the diSeaSe. V. That the eruption when perfed in its charader gives relief, and " that in con- Sequence of it alone, without any other fenfible excretion, the difeafe is entirely refolved." The committee have ftated the opinion and reafons of Burferius, becaufe they have not Sound any other author, who So decidedly adopts the firft opinion, and engages So fully in its fupport as he does. In aafwer to his firft reafon it may be ftated that, al- though he quotes feveral writers in its fupport, the circum- ftance he menions has not been noticed by many, who are confidered the moft eminent practical writers. That how* ever petechiae may have appeared at tho/e times without Se- ver will not be denied, Since they often appear at other times without fever, or certainly without any considerable Sever. Such petechiae arc deScribed by the very accurate "Willan ;* but he does not remark that they occur more Srequentiy while fevers are epidemic which are accompanied by petech- iae. So far as is known to the committee petechiae with- out fever have not been Seen here during the late epidemic. * On cutaneous t'i .•: cases Vol. i. p. 45.3. and following. MEDICAL COMMUNICATIONS. 33 in anSwcr to the .fecond it is the remark of a large pro-1 portion of pradical writers that petechiae do riot appear in nearly all the cafes of thofe epidemics in which they are no- ticed. It is alfo remarked by moft of thefe writers that the frequency of their appear nice depends Very much upon the ■■treatment of the difeafe. Both thefe remarks appear to be confirmed by Willan.* The third reafon or argument It is obvious may he ftated with equahforce on the other fide ; inaSmuch as petechias appear in Severs of a great variety of charader. From vari- ous considerations we do not believe it can have any, cer- tainly not much weight on either Side •, but iS any, the leSs in Savour oS the opinion oS BurSerius when taken in connec- tion with his fourth reaSon. For by this is appears not on- ly that the conftitutiohal affedion has not any peculiar cha- rader, but that the period, at which the (pots appear, is ex-- tecdingly variable and uncertain. Although this may be true in Some degree as to Small-pox, mealies, &C. it is not true of them at all in the fame extent as Burferius ftates it to be with refped to petechia;. Petechia may appear from the firft to the eleventh day of the diSeaSe, and even later. The Sad which he ftates in his fiSth and laft reaSon is ex- preSsly denied by moft pradical writers on this Subjed, whom the committee have had an opportunity to conSult. Sennertus ftates that petechias are rarely critical; or rare- ly appear at the time oS the erifis ; but avers that they arc commonly Symptomatic. He believed that petechia belong to malignant fevers.f Riverius alSo ftates that they arc * On purpura contagiosa. f " Febtes petechials ad malignas pertineant." Opera—Vol. :, p. 200. Lugduni 1650. His use of the term malignant mav be learnt :n his works—and viii he noticed in a subsequent part of the; report, E 31 MEDICAL COMMUNICATIONS. fometimes critical, fometimes Symptomatic ;* but does not fay which charader they moft frequently bear. Burferiui however makes a diftindion, fimilar to that we have ftated, between thofe which are primary and thoSe which are criti- cal ; for he confiders both the critical and Symptomatic, Secondary ; and agreeably to this diftindion it is obvious that neither Sennertus nor Riverius confider petechia; in any caSe, as he does, primary. Sydenham certainly uid net know the petechial Sever, as a Specific diSeaSe ; and ifellini,1 Fr. Hoffman,2 Lientand,3 Stoll,1 Culleiv' Selle,6 and many later writes oS good repu- tation,7 who have Spoken of petechia;, confider them not only as fecondary, but moftly as fymptomatic. Willan does not expreSsly difcufs this queftion, as the nature of his work does not feem to require it ; but his opinion very obvioufly is that petechiae are only fymptomatic in the fevers in which they occur. He treats it as a point not contefted, although he refers to Burferius.8 As regards the epidemic under our confideration the com- * Opera p. 450. Lugduni 1679. 1 De urinis et pulfilms, de febribus, & c. Lugduni 1717. a Hoffman treats of the true petechial fevers ; but he leaves no doubt as to his opinion in this point. " Exanthamata veteres generali de- nominatione has dicunt maculas.----Ab aliis autem exanthematibus praeter figuram in eo difcrepant, quod non niodo fine omni ardore, fine pruntu, cutis elevatione, afperitate et exulceratione prodeant, fed' et ut plimmum fine levamine." Med. Rat. Syft. Vol 4 p. *58. Ve- net. 1730.—Itching has commonly been remarked here to accompa- ny the eruption. ' 3 Synopiis univerfepraxeos medicae. Vol. 1. p. a;. paris, ,770i 4 Aplionfmi de ftonbus p 151. Paris, anno fee. Reipub. Gall. 5 Ye"er-; morboium. Alfo firft Lines of the pradice of Phvfic 6 Rudimenta Pyretologuie methodicac pp. 177-8. Berolim 1780. we^a" Dl&' °nC °f the ^^ W°rks °f authority viich 8 Willan ftates that petechiae have been noticed not only in acute, but in various chronu difeafes.. On cutaneous difeafes, Vol. 1. p. 471. -i MEDICAL COMMUNICATIONS. S3 mittee have adopted the fecond opinion ftated above, viz. that the petechia are fecondary, for the following reafons. I. The cutaneous affedions which occur in this difeafe are very various ; fuch as red fpots only, miliary eruptions, blotches, veficles, puftules and rardy purpura or petechiae. II. In a very confiderable proportion of cafes there are not difcovered either fpots or eruptions. Indeed if we ex- cept fome flight appearances on the infide of the elbow- joint, and in fimilar places, which very probably are to be attributed to fweating, fuch fpots and eruptions are com- paratively rare. III. Thefe Spots and eruptions appear at very uncertain periods of the difeafe, and are of very uncertain duration. IV. Although in fome inftances it has been remarked that relief accompanied the appearance of thefe fpots and eruptions, this has not been noticed by the majority of thofe converfant with the difeafe. It feems however to be true that in this difeafe there has been a tendency to increafed adion in the fkin ; which is evinced by the Sweats,* by the various Spots and eruptions, and by the itching. This laft has very often taken place at the crifis •, and in general an increafed and free adion of the cutaneous veffels has been attended with relief to the internal and more noble organs. In confirmation of the opinion we have adopted it may be added that in Connedicut « thefe fpots, which in 1806-7 marked almoft every cafe, in 1808-9 were rarely obferved."f * Although the fweats may not have occurred fpontaneoufly, yet in many cafes when excited they have very readily become prof ufe. T Strong's differtation, p. n.-Tlratthe difeafe there was the fame whtch hafoccurred here whl not be doubted on ™W*S™*£ fcription with Strong's. We may remark that out s -s d awn entire- ly from thofe of petlbnal obferverf, and, tnougn muca :.«>- n.-, u - 3d MEDICAL COMMUNICATIONS. What is this diSeaSe ? To this queftion the committee Seei themfelves bound to reply ; this they attempt with-dif- fidence. In this difeafe are difcovered the fymptoms of fever ; fe- bris of Cullin ; fever as defcribed by Dr. George Fordyce.* Thefe Symptoms are disproportionate in different parts of the fvhfem ; and generaJly are ftcii moft violent in the an- nual fyftcn , or in the brain and its dependant organs.f 'feaeSe Symptoms are alfo Said to-be irregular in their courSe and order ; by which is meant that their-courSe-and order- are neither the Same in all the Subjeds oS the diSeaSe, nor the firme as in ordinary fevers. - To :befe remarks may be added that, agreeably to the ftatement heretofore given, there'exifts-in this difeafe in- flammation of the internal organs, particularly on the mem- branes, and efpecially within the cranium ; in the fevere cafes of the difeafe always within that cavity. Occafionaily: inflammation is alfo found on the membrane coyereing the heart, and lining the pericardium; and fefij frequently on the pleura. General- inflammation combined with fever is noticed by Fordyce, and he defcribes the fymptoms attending fuch combination. The principal Symptom he mentions, as showing the exiftence of inflammation under thefe circum- ftances, is hardnefs of the pulfe ; to which however he adds that blood drawn under proper precautions* is covered with a buff, or .a coat of coagulable lymph without red particles. copied from it in any particular. This remark we make that more con- fidence may be placed m the firmlarity which is noticed in the difede. * Differutions on fever. f See note page 9. t The committee do not think it neceffety to mention here thefe tdS''0™' "°r exp,anatl0n v-'di known of this appearance cafl- MEDICAL COMMUNICATIONS. 37 Hardnefs of the pulfeand this appearance of the: blood'-' have not commonly been noticed in this difeafe ; particu- larly not in thofe perfons, wh'ofe bodies have been examin- ed after death, We may therefore- infer that a combination of fever and "inflammation, fuch as Fordyce has defcribed,' has not commonly exifted in this difeafe, The fymptoms will perhaps authorife an opinion that the inflammation is erysipelatous.* The appearances on exam- i. irtation after death do not difagree with this opinion, They do i. fome inftances afford to it a ftrong confirmation. The fubftances of the diSeaSed parts has not been Sound thicken- ed, or carnified •, nor do the inflamed SurSaces exhibit a , bright color. The exudations are coagulable lymph, Serous and purulent fluids. The lymph is not, as in phlegmonous inflammation, white and SemitranSparent ; but approaches to pus both in color and confiftence. In caSe IX. in the thorax were exhibited all the circumftances here deScribed. Now we are told by Mr. Hunter that when eryfipelateus inflammation occurs in circumScribed cavities " it hardly produces adhefions, and when it Suppurates the Suppuration takes place firft."p In confirmation it may be added that, when external inflammations occur in this diSeaSe, they are eryfipelatous ; at leaft in moft Such caSes. The Sollowing then may be ftated as general inferences. This difeafe is fever combined with internal inflammation ; and the inflammation is commonly eryfipelatous. Yet this * Several of our correfpondents have compared this difeafe to cy- nanche maligna, in which the inflammation is eryfipelatous ; and this comparifon they have made without appearing to have thofe views of the character or the difeafe which we now prefent. f On the blood, inflammation, &c. Vol. T. p. 232. Philadelphia. edition, 1796. ^ce the whole Section. 38 MEDICAL COMMUNICATIO.NS. charader of the inflammation applies to individual cafe* more or leSs perSedly. In fome recent cafes efpecially the inflammation has approached more nearly to the phlegmo- nous ; and perhaps in none is it purely eryfipelatous. It is Srequently oS a charader imtermediate between the two. It is Surther to be remarked that this inflammation has been moft conftantly Sound within the cranium. Is inflam- mation in this cavity common to all cafes oS Sever ? This opinion has been entertained by Some praditiorers ; and it has oS late been particularly Supported by two teachers of medicine.* The pofitive evidence that Such inflammation has oSten been Sound to have exifted in caSes oS Sever is ve- ry considerable. But the evidence that fuch inflammation is often wanting is irrefiftible.f It appears that inflamma- tion has often been found in the other great cavities in fub-, jeds dead of fever, and not at the fame time within the cranium. Sometimes it is found in one cavity only ; fome- times in two of them at once, and at other times in all three, We well know that inflammation is often feen externally during fever. But in many cafes of fever there has not been difcovered any inflammation either during life, or af- ter death. It is therefore proper to infer that fever, in the fenfe in which we ufe the term, is not dependent on inflam- mation. When the two difeafes exift together they are to be confidered as in combination, without having any necef- fary dependence on each other. We are now led to this queftion. Have thofe fevers in which fuch inflammations occur been diftinguifhed by any '"* Dr. Ploucquet, Profeflbr of medicine in the univerfity of Tubin- gen ; and Dr. Ciutteibuck, Lecturer in London, ^ee Ciutteibuck on rever ; and for the doctrines of Ploucquet fee Bcddces on fever as connected with inflammation. t See Bcddoes' refearches. MEDICAL COMMUNICATIONS. 39 peculiar charader, So as to be Specially denominated by pro- feffors of medicine ? The committee believe that this quef- tion may be anfwered in the affirmative, and that the con- sideration oS it will not be uSeleSs. By inverting the terms we Shall find an anSwer in an ob- servation made by Baglivi. " Quae nobis videntur malig- nae a viScerum phlegmone aut eryfipelatode fiunt."* This is the Sum oS a dodrine, which Subsequent observations and reSearches appear to have confirmed. The term malignant has been very loofely applied ; and its tffe has been juftly reprobated by Sydenham and many • others. Yet there is one description of fevers, to which it has been mote peculiarly appropriated. It is true that the beft writers are very oSten conSuSed in the endeavor to dif- tinguifh peftilential, and putrid and malignant Severs. To engage in the consideration oS all their diftindions and all their conSufion would lead the committee too Sar Srom their objed. They believe however it will be uSeSul, in order to determine the true charader oS the epidemic under their consideration, and to compare it with diSeaSes heretoSore de- Scribed, to point out thoSe Symptoms which have been con- sidered evidences of malignity in fevers. They are the fol- lowing : I. Great disproportion in the violence of the fymptoms, compared with each otner. II. Some peculiarity in the charader of the fymptoms when compared with thofe called by the fame name, as they occur in ordinary difeafes. III. Remarkable imbecility, and proftration of all the powers of the body, or of certain of them, without any * Opera—p. 51. 4© MEDICAL COMMUNICATIONS. manifeft caufe ; occurring at the very commencement of the diSeaSe, or after it has continued a Sew days with mild Symptoms. IV. Pains in any or every part oS the body, Sometimes fixed, but often fhiSting ; in the limbs Severe, as iS they had been bruiSed or broken ; with tolling and twifting. V. Extreme pain in the head ; the greafteft Solicitude and perturbation oS mind, watching and delirium ; or ftu- por, coma and lethargy. Imagination very much difturbcd and memory weakened. VI. The countenance very much altered, lofing its uSual Spirit and expreffion ; Sometimes entirely natural. Face of- ten livid and leaden coloured. VII. Eyes red, or dull and cloudy.; dimneSs of fight and blindnefe. Ringing and hiffmg in the ears ; deafneSs. Taftc .and Smell depraved. VIII. Tongue rough, dry and dark ; mouth bitter ; Some- tomes with anSaliable thirft, Sometimes without any. IX. PulSe Srequent, Small, weak ; everi in beginning ex- tremely Small and Srequent -,* variable and intermittent. X. Heat Sometimes great, but oStener leSs than in other febrile affedions. Extremities oSten very cold. XL Urine Similar to that in health, eSpecially in the firft days oS the diSeaSe ; Sometimes thin, without Sediment; or if there be any fediment it is often€ark coloured, more like an excrementitious fubftance than like the ufual fediment. XII. Matters difeharged from the ftomach and boweli often livid, black or green, or otherwise unnatural. XIII. Scanty and Srequent Sweats about the Sorehead and neck only ; Sometimes profufe over the whole body. minimi !f£ interdurn in huius febrIs »n"io pulsns formicanti similis, minimus et Irequeotissiraus. Sennertu?. MEDICAL COMMUNICATIONS. 41 XIV. Red, livid, afti-coloured and black Spots on the neck, back, breaft, arms and legs ; various puftules '; Car- buncles, parotids and buboes, which laft do not readily Sup- purate. This deScription is taken Srom the works of Sennertus* and Riverius, medical writers of diftinguifhed reputation in the fixteenth and fevcnteenth centuries. Subftquent wri- ters agree in the fame, efpecially Bellini and Fred. Hoffman. One charader however which they all give to this fever ia that it is contagious. In this refped certainly our epidemic does not accord with their defcription ; but it is well known how imperfedly this fubjed of contagion has been under- ftood ; and indeed how imperfedly it is uhderftood by ma- ny writers at the prefent day. The committee are unwilling to multiply references feny farther than is neceffary to eftablifh the charader x>£ thofe fevers which have been moft diftindly confidered as malig- nant. This charader does not feem to have been clearly dif- tinguifhed by many modern writers. It has however been particularly recognized by Selle in his Rudimenta Pyretolo- giae Methodicae ~i and perhaps more diftindly by Pinel. The former comprehends fevers of this defcription under an order in which he denominates them febres atactae ; the latter adopiting the fame term calls them in this own lan- guage fievres ataxiques vu malignes. Thefe are compre- hended in his noSological Syftem under the fiSth other of primitive fevers. The epithet which Selle Subftifuted for malignant, and which i» adopted by the French profeffor, * Sennertus terminates his description iiuhesc words. Et ut haec ooncludamus, nihil fere malifcst, quod non interdum in hisce febribus appareat ; ac quo magis extra omnia tuta apparent, ed mugis intui omnia s'ict tvrhau et mutate. Op. Vol. 3. p. if.;- F 42 MEDICAL COMMUNICATIONS. expreffes that the leading charader of the difeafes under that order is irregularity. One fhort defcription of ataxic fevers is this ; " fevers diftinguifhed by anomalous and ir- regular affedions of the nervous fyftem, occafioned by any caufe either moral or phyfical which affeds the nervous principle,"* Another is the following j " The true cha- rader of the fever of this order is to prcfent a continual a- berration and perverfion of the fenfibility, which appears at one time deftroyed, at another exalted to the higheft degree ; and of which the alteration is manifefted by nervous fymp- toms, that vary inceffantly, fucceed each other and alternate : without any fixed order, and proceed in a manner the moft incoherent."f The committee will not engage the attention of the coun- ; fellors in inquiring to which of the genera of Pinel's order of ataxic fevers our epidemic belongs ; whether all the in- dividual cafes may be distributed among thofe genera, or whether a new genus muft be conftituted. They have been led incidentally into Some noSological inquiries, or into a Confldention oS names ; but theSe inquiries and considera- tions have not been their ultimate objed. This objed has been to fliow by what Symptoms the diSeaSe called malignant fever has been known ; and, although difeafes have many times been called malignant without proper discrimination, * Dictionnaire de medecine par—Jos. Capuron. f This description is taken from a note by Renauldin, in his trans- lation from the German to the French of Dressing's treatife upon di- agnostics, p. 21. The.committee regret the impossibility of procur- I mg Pinel's nosography, where no doubt they would find his difinition exactly laid down. They have acquired the knowledge of his system only from his medcanr (Unique, and from the writines of <=ome of his rujus. MEDICAL COMMUNICATIONS. 43 that the epithet has by fome of the beft praditioners been appropriated to thofe oS a certain deScription. It appears then that the leading circumftances, which diS- tinguifh Such Severs, are the Sollowing -, viz. great proftra- tion oS ftrength ; affedions of all thoSe fundions belonging to, or immediately eonneded with the brain ; and great ir- regularity in the fymptoms, their courfe and order. The committee proceed now to inquire whether experi- ence has confirmed the obfervation of Baglivi; that is, whe- ther it has been found that inflammation of the internal vif- cera is combined with fever in thofe cafes, where fever has the characters above mentioned. The appearances after death in fubjeds of fever have been much more regarded by the Germans and French, than arjftong the Englifh and Americans. But the works of the writers on the continent of Europe are not very com- monly found in this country •, and many of them, which might be confulted with great advantage, arc not in our hands. For this however we are in fome meafure compen- fated by two recent publications in England, to which we have already referred ; an inquiry into the feat and nature of fever by Clutterbuck, and refearches concerning fever a; eonneded with inflammation by Beddoes. The former of thefe writers, endeavouring to fliow that fever was depen- dent on inflammation within the cranium, gives us many obfervations in confirmation of this opinion- Beddoes has many more obfervations induftrioufly colleded from very extenfive reading, in which he fhows inflammation in vari- ous parts of the body to be combined \yith fever ; and alfo others in which''nb fuch inflammation was discovered. Neither of thefe wkers certainly had any idea of fhewing 4-1 MEDICAL COMMUNICATIONS. that it is eSpecially in Sever oS the deScription called malig- n.-nt that Such inflammations are Sound. But it is impofli- ble to look into their works with this idea in the mind, and not be ftruck with the evidences, which are Surnifhed by them of its truth. In fome cafes of fuch inflammation the nature of the difeafe is not mentioned ; but wherever it is mentioned, or wherever the history of the difeafe is given, it is found to belong to Pinel's order of fievrcs ataxiques ou malignes. The committee might here introduce the vari* ous evidences to which they refer ; but this would be to extract the moft valuable parts of the books they have men- tioned. To thefe books therefore they beg to call the at- tention of the cou:: fellers.* In addition to the evidence * See Ciutt. rburk on fever Vol. I. p. 168.—The following* remarks may r,*-. nude on. his r:fcreates. ifencti 3cr.iuhl.iet. I ib IV. Sect. i. Obs. 34. the cases are not suf- fer,er.iv dctnied to dt-teimme die character of the diseases. Obs. 44- ni ?mt epistle ar. 4 and 6. contain cases probably ataxic. In the one was found samous matter in the tympanum-in' the other brain diseased. Epist. vn. art. %. ataxic fever ; brain diseased. Other cases in the same epistles might be noticed, but they are not clearly stated or frequently intermediate, the eryfipelatous character pre- dominating. It probably alfo happens that in fome caSes Sever termin- ates in local inflammation ; and perhaps inflammation in Se- ver. Undoubtedly in Some caSes the one diSeaSe commences alone, and the other Supervenes and combines with the firft* —This is very common in malignant epidemic Severs ; and hence the patient does not at firft, perhaps not for Some day9, appear to be affected with a Severe diSeaSe ; when Suddenly there enSues great proftration of Strength with fymptoms of cerebral affection. Intermittent fevers are not prevalent among us ; and probably owing to that circumftar.ee we attend lefs to re- miflion in' fever than phyficians in moft other climates, who arc in the habit oS /liftinguifhing the paroxyfms oS fever. The committee have not any information reSpecting the general character oS tlie diSeaSe under consideration in theSe reSpects. It would Seem however from Some caSes com- municated to us and from cafual remarks that it has remif- f.ons, although they may not be -f -~j ~cTood, '■which is fuperfluous in the head, without pro- ducing a Sudden'proftration in the Syftem, before it has time to be benefited by the removal oS the preflure. Here the head and the other parts of the body are to be confidered as in Some meaSufe disjointed. If a vein be opened in the arm, it will not relieve the head, except throught the medium of the general circulation ; and the heart and veffels will Suffer in a large proportion to the benefit received, and for a few moments before any benefit is "received. The effeds dur- ing thoSe moments may be fatal. If the 'quantify taken be not enough to give any relief, or if it be more than is necef- fary for relief, the injury to the' fyftem may be Such as to produce death. But if a vein be opened, which immediate- ly communicates with the cerebral veffels, Such as the exter- nal jugular Vein, the preflure is immediately removed Srom the head, and the general relieS is Such as to counteract all the evils oS loSs oS blood to the Syftem. From the foregoing confiderations, which have been ftat- ed briefly as the nature and importance of the fubjed will admit, it appears that there may be two, and thofe very dif- ferent ftates of the fyftem in this difeafe, in which it may be proper to let blood. The firft is when there is phleg- monous inflammation, or fuch as approaches near'v tn that H £8 MEDICAL COMMUNICATIONS. charader, affeding the brain and its membranes. Here if the fymptoms be not violent, other remedies may fufficc •, but if they are, if the pain in the head be fevere, iS the func- tions oS the whole animal Syftem be very much interrupted, and at the Same time the fkin be hot and the pulSe hard, the cafe is dangerous ; we have then to apprehend that fuch effeds will be produced within the cranium as will deftroy life, before we can arreft the difeafe by other remedies. In this cafe, the violence of the inflammation muft be reduced by bleeding. It is not comparatively very important from what part the blood is taken for this purpofe. It would however be beft to take it from the jugular vein, becaufe that communicates immediately with the veffels of the part affeded ; and probably a given quantity of blood,- drawn from that vein, vould afford more relief than if drawn from the arm. When from any caufe that vein cannot be open- ed, the operation may be performed on the temporal artery. From whatever veffel the blood is taken a large orifice fhould be made, that the effed may be as fudden as poffible, fo that a fmaller quantity may fuffice. Probably from ten to twen- ty ounces would be fufficient in most cafes. The fecond cafe, in which blood fhould be evacuated, is that which has already been defcribed, in which the brain is fuffering preflure from the fullnefs of its veffels. Here it is very important that the blood be drawn from the external jugular in preference to a vein in the arm, for reafons which have alfo been fuggefted. The orifice in this cafe alfo fhould be large, that the relief may be as immediate as poffi- ble. At the fame time it is important to avoid producing faintnefs, that the general fyftem may not fuffer too much, before it has derived the benefits of the operation. Several MEDICAL COMMUNICATIONS. S9 attentions may prevent this effed. Cold applications fliould be made conftantly to the head and face during the bleeding to excite contradion of the veffels in that part, and thus fup- ply blood to the reft of tlie fyftem ; thofe cordials, whofe adion is Sudden and tranfient, fhould be adminiftered at the Same time iS any SaintneSs be perceived •, and in this caSe the flow of blood fhould be ftopped until the SaintneSs has Subfided ; then if relieS is not obtained, the evacuation fhould be continued.* With theSe precautions the blood fhould be allowed to flow until it is obvious that Some relief is obtained. To maintain the advantage which has been thus procured, other remedies fhould be immediately employed, Such as will fhortly be noticed. To adduce authorities in Savour oS blood-letting in this diSeaSe would be uSeleSs ; for authorities may be quoted on both fides. Sydenham lamented the ufe of the word malig- nant, as defcriptive of any fpecies of fever, and faid that it had occaffioned more deaths than the Sword. He believed that this flaughter was occasioned by the uSe of alexiphar- mics, which had been confidered appropriate to malignant difeafes, while evacuations were too much negleded. On the other hand, Huxham and many others thought that Sy- denham was influenced by prejudice in transferring his prac- tice in inflammatory difeafes to thofe, which were malig- nant, and in which the ftrength oS the Syftem was proftrat- ed by a Secret cauSe. Perhaps their differences of opinion may be explained iS that adopted by the committee be cor- red. * It has not been very commom here to open the external jugular. vein, but the operation is very fimple. The preffure is made by the thumb of the operator placed on the vein where it paffes near the. maftoid mufcle juft above the clavicle. $0 MEDICAL COMMUNICATIONS. When the vifceral inanimation [5 phlegmonous or nearly fo, it is. well agreed that bleeding may be very adv-r.tage- oufly inftituted. When it is purely eryfipelatous, and in. addition to the weaknefs produced by the Sever, there oc- curs the peculiar proftration, which, accompanies inflamma-, tiou oS this charader, it may Sometimes be neceffary even, to exhibit powerful cordials for a. SeaSon, left death Should-: bs produced by Sudden SaintneSs. But if this proftration- be caufed by great preflure on the brain, death muft fhortly c.n- Sul. Here it is not " a pack on the back" which muft be: removed ; it is a pack on the head,, which is not only too. heavy to be borne, but whoSe. preflure deftroys in great meaSure thoSe properties in the living Syftem on which wc operate tp excite more vigorous adion. In Such acaSe. it is not inconfiftent to open.tlie jugular vein, wliile we exhibit even the moft powerSu! cordials. In caSes where it is not neceffary or might be injurious to. let blood frqm a large vein, the head may derive fome relief from cupping or leeches. The former is the moft expedi- tious mode oS local bleeding, and is therefore preferable. EMETICS. Emetics are adminiftered in the comrnencment oS Sever for two purpoSes. The one to produce an evacuation of any offenfive Subftances in the ftomach. The other to pro-, dupe a ftrong impreffion on that organ, and in conSequence of the Sympathy, between .that and all other parts of the fyf- tem to effed a change in all the organic adions.* By this * For organic adions, or actions of the organic fyftem fee the di- vilions of i„ jut before referred to. Generally the organic fyftem comprehend, all parts of the body except the brain and pans de- pendant on it as to functions. ' MEDICAL COMMUNICATIONS. 61 change the motions of the difeafe are interrupted. With both intentions they are often very advantageoufly employ- ed. For the firft purpofe they fliould be employed in this difeafe, whenever the fymptoms of offenfive fubftances in the ftomach are perceived. For the Second: they are too of- ten inadequate, and the uSe of them for that purpofe fhould be avoided, becaufe they occupy important time which can- not be redeemed. It is however in proportion to the vio- lence of the cerebral affedion that, emetics are contra-indi- cated. When this affedion is flight, they may be ufeful for the fecond purpoSe mentioned, and they fhould be; more readily exhibited, iS they are at the Same time in any degree indicated on account. oS the firft Such are the Suggeftions which the committee venture to offer on this head ; but their opinions are not absolutely fixed, and they wifh that they may be teftcd by clinical observations. CATHARTICS. Cathartics are either Such as produce copious fluid dis- charges Srom the bowete ; or Such as occafion only a dis- charge of the feces with comparatively very little fluid. In the firft caSe the fluid is Surnifhed Srom the liver and pan- creas and from the inteftinal mucus membrane. In this cafe a determination of blood takes place to the abdominal veffels, or, thofe veffels in confequence of increafed adion receive more blood. In the fecond cafe perhaps the Same effed takes place, but to an extent very much leSs. Thofe cathartics, which produce the effeds firft mentioned arc called draftic, and purgative ; thofe, which produce the fecond, are called laxatives and eceoprotics. Certain draftic cathartics, as particularly thofe which are refinous, increaSc M MEDICAL COMMUNICATIONS. the adion of the abdominal veffels generally more than oth- ers, and alfo increafe the adion of the veffels over the whole body. In mofl cafes of this diSeaSe draftic cathartics cannot be employed with advantage. The general Syftem is weakened by their operation much more than the head is relieved. An exception fhould be made however of thoSe caSes, in which the inflammation approaches the phlegmonous char- ader, and in which the Sanguiferous Syftem is not yet over- powered in conSequence of preflure on the head. In theSe caSes draftic cathartics, combined with fubmuriate oS quick- ' Silver, may be exhibited ; Sor here their effeds are Salutary in conSequence both oS their weakening the Syftem generally, and thereby diminifhing the violence oS adion, and oS the determination of blood to the abdomen, by which it is di- 1 minifhed in the head. It is propofed to combine the fub- muriate with the draftic cathartics, on account of the good '; effeds it may have on the whole fyftem, at the fame time that it affifts in producing an effed on the bowels. It is al- fo ufeful becaufe it ads on the whole canal from the fto- mach downwards, which effed is not fo perfedly produced by moft ether cathartics. It does alfo aflift in producing a determination blood to the abdomen, and does not at the ^ feme time produce a fudden increafe in the general adions of the fanguiferous fyftem, as the refinous cathartics often do. 1 Laxatives may be more generally employed in this difeafe, for at all times the fyftem is difturbed if fveces are allowed :o continue in the inteftines for any very unufual length oS time ; and the diSeaSe may invade the Syftem at a moment, j when it is already Suffering under an incumbrance oS this Sort. If the bowels are coftive, an enema fhould be ad- ' ! r f MEDICAL COMMUNICATIONS. 63 miniftered on th© firft, or at fartheft on the fecond day of the difeafe, and this more particularly, if the bowels make unavailing efforts to relieve themfelves. When they are at the invafion as free as ufual, medicines may be given, which will gradually promote their adion ; for they are very much difpofed to be flow in their operations in this difeafe. For this purpofe it is beft to employ fubmuriate of quickfilver in Small doSes, frequently repeated, becaufe that medicine will at the fame time be producing other good effeds on the whole fyftejn, as will be hereafter mentioned. Where bleeding is to be employed, both emetics and cathartics fhould be omitted until after that operation. HEAT AND COLD. The committee will not engage in the contefted queftions refpeding the effeds of hot and cold applications to the body ; they do not hazard contradidion in afferting that great benefit may refult Srom Such applications. In this o- pinion they are Supported by abundant experience ; for they feel affured that in cafes, winch have terminated fuccefsful- ly, and in which none of thefe evacuations juft now difcuf- Sed, have been made, relief has been moft commonly deriv- ed from fuch applications. Under this defcription of cold and hot applications the committee mean to include thofe remedies, which reduce the temperature although not cold themfelves, fuch as ether, when allowed to evaporate from the furface ; and thofe, which produce or retain heat, al- though not hot themfelves, Such as fridion, and woollen coverings. When the head is hot, and even whenever it is not cold on the furface, cold water, ice, and ether may be applied to. e4 MEDICAL COMMUNICATIONS. a with great benefit. Whatever be the rndde of operation, it is certain thai Such applications; occafion a comradfon of the blood veffels m the part, to which they are made ;' and in this cafe they caufe the head to be freed from preflure, and the reft of the fyften to receive the blood, which it of- tentimes wants. So far as fuch remedies produce .an effeds they are far preferable to bleeding ; as it is better to heal a difeased limb than to amputate it. "When they are not com- ^ pctent to entire rfeli'efj they will very much affift both dur- ing and after blood-letting. In a large proportion of the cafes of this diSeaSe the tem- perature of the furface of the body, and particularly on the limbs, is reduced. In fuch cafes, and even when the tern- I perature of the body is natural, great advantage is derived j from warm and moift'amplications to the furface. Such ap- plications increase the fulnefs of the veffels of the fkin ', and i as the extent is great,1 they operate powerfully in relieving the preflure of Wood in the head. They alfo produce dia- phcrefis and perhaps fome benefit is obtained from this eva- cuation -, but this effed, as it appears to the committee, is much lefs important than that above mentioned. The mode of making fuch applications has been defcribed in ftating the method of treatment which has very generally been a- dopted in the county of Worcefter. One caution is how- ever neceffary j viz. that the furface be not fo much heated, as to increafe to undue violence the general adions of the Sanguiferous Svitem.—A pleaSant warmth and a gentle moil- fare of tli2 fkin are Sufficient. There is not any part of tlie-»' Ireatr..':r-.t of ataxic or malignant fever, in which pradition- ers are fo univerSally agreed, as in this oS promoting diapho- refio. Ic i'j alio agreed th;t the Sweating fliould be continu* MEDICAL COMMUNICATIONS. Gi ed for a confiderable length of time, to obtain from it all the benefit it can afford. On this point there has perhaps been an extravagance in the opinions entertained. But no doubt gentle diaphorefis may be continued for twenty-four or even for forty hours with advantage. It is neceffary during this time, to watch the patient that he may not become too warm, and that he may not be too much exhaufted. Pro- fufe Sweating is to be moft carefully avoided. VESICATION. The utility of veficating the head, or the parts near it, is very highly eftimated by all, who have adopted this pradice. To derive Srom it all the advantages it can afford, this prac-. tice fhould be inftituted in the very earlieft ftage of the diS- eaSe. In every caSe, where the Symptoms of affedion of the brain are of confiderable violence, the head fhould be imme- diately Shaved. This renders it more eafy to abftrad heat from the head, where that is neceffary. When it is not, or when it has already been done, a larger or fmaller portion of the head fhould be immediately veficated. While cold applications arc made to the head, the back of the neck, the f irehead and temples may be veficated. It is important to produce the vefication as fpeedily as poffible ; for this pur- r )fe the ftrong tindure of cantharides fhould be well rub- bed upon the parts to be bliftered until a very confiderable rednefs is produced ; the plafter of cantharides fhould then be applied, and the part fhould frequently be examined, left in the tolling about of the patient the plafter be removed. Advantage may be derived from bliftering the extremities alfo, when the vafcular adion is feeble, and the flcin cold. Under this head may alfo be recommended ft nap ifms and rubefacients to the feet, and other parts of the eytr-ml*;.-*. I 65 MEDICAL COMMUNICATIONS. PREPARATIONS OF QUICKSILVER. In reporting the mode oS treatment, which has been a- dopted by their correspondents, the committee mentioned the uSe, which has been made oS the Submuriate of quickfil- ver. In caSes where life is immediately threatened, this re- medy cannot be relied on to avert the danger. But in cafes of lefs feverity, or where the moft urgent fymptoms are re- moved by other remedies, this is of great value. It may be exhibited in dotes of one to three grains, once in two to fix hours, until it produces an effed on the bowels ; the doSes nuy then be diminished, or exhibited leSs Srequent, and it may be combined with Small dofes of ipecacuanha and opi- um. In this manner it may be continued, until an effed is produced on the mouth. This effed fhould not be allowed to increaSe to any violence, but fhould be maintained in a very low degree, until all Symptoms oS diSeaSe have Subfided. The utility of this pradice has been fuflieiently tefted by experiment. It is the fame which is found ufeful in many other acute difeafes. It need not be employed to the excul- \ fion of any remedies, which are immediate in their effeds, and which the urgency of the cafe may require. The committee prefumes that they fhould not promote < the ufe of this remedy by difcufiing the mode, in which it j gives relief. They confider it, when affeding the fyftem, as an alterative ; an alterative not of the fluids of the body, but of the actions of the minima vafcula. It is therefore direded to fulfil the fecond and third indications. When the fubmuriate is not eafl'iy borne by the ftomach, or when it is too flow in its effeds, the ointment of quick- filvcr may be applied to the external Surface of the body, and to the parts which have been veficated. A drachm may be \ MEDICAL COMMUNICATIONS. , G7 -. ubbed on the fkin once in every three or Sour hours until Sufficient effed is produced. CORDIALS. Under this name are comprehended thoSe articles, of which the effeds are immediate or nearly So, which produce warmth in the ftomach and over the whole bodv, and which increafe in force and frequency the adions of the heart and large veffels. Refpeding the utility oS Such articles in the difeafe un- der conficferation there has been a divifion of opinion among praditioners oS medicine. There is perhaps a popular bias in favour of their administration. Their effeds are obvious, often comfortable for the moment, and, under certain cir- cumftances, Salutary. When liberally and indiscriminately adminiftered in this difeafe, they are very injurious by increaS- ins the force with which the blood is thrown on the head, or other parts in which there exift either inflammation or congeftion ; and they are injurious by Suddenly increafing the heat and the vafcular adions generally, and thus unne- eeffarily exhaufting the energy of the fyftem by impofing on it ufelefs labour. The very liberal uSe of cordials has been very fully tried during the laft three years in Connecticut, and alfo during the early part of the Spring in the county of Worcefter. The committe have reaSon to believe, that a confiderable pro- portion of the moft judicious praditioners in thofe places are now fully convinced, that this pradice is highly injuri- ous- This is the cafe with fome, who had adopted and for a time continued it with the moft Sanguine expedations of benefit, and probably with fome of thofe, on whofe commu* nications our former ftatement was founded. MEDICAL COMMUNICATION'S. There are however Occafions, on which Cordials may bt adminiftered in this diSeaSe with advantage. At the time when the adions of the fyftem are almoft arrefted in confe- quence of preffure on the brain, cordials may be required to keep the heart in motion. The patient is ready to faint, and if the adions ceafe for a moment death may enSu'e. At fuch a time we muft net hefitate to Sollow the didates oS nature, and excite increafed adion at any hazard, until we can gain time to adopt more effedual meaSures. It is pof- fiblc even that by cordials adminiftered under Such circum- fhrices we may excite the cerebral veffels to ftronger con- tradions and thu; relieve the brain ; but the chance is much greater, that by the liberal exhibition oS Such articles we Shall increafe the flow to the he.icfe while by diftention we leffen the power oS the veffels there to contrad. In this way either Sudden death, or effufiens and more diftant, but Scarcely Ms certain injury is produced. The careSuI exhibition of cordials may even be neceffan at the very moment, while we are letting blood. However abfurd this may appear to thcorifts, the pradice is not in- confiftent. An attempt has already been made to explain theneceffityofit. In difeafes. much more flight we fre- quently apply heat to the feet,, and abftrad it from the head ; a pradice which except froin habit would feem e- qually abSurd. In the late ftages of this difeafe, wheri evacuations can no longer be made with advantage and when the energy of th, fyftem is very much exhaufted, cordials may be ufeful Here it is true they muft be ufed without regard to quanti- ty, and b, measured only by effeds. Yet care fhould be MEDICAL COMMUNICATIONS. SS taken that thofe effeds be not great. Adion muft indeed be maintaitied at any expenfe, for without adion life will Soon ceafe ; but it muft be remembered that life may be maintained by very feeble adion, and that we defeat our own objed, when we increafe the adion beyond the power to fupport it. In all caSes the mildeft cordials competent fhould be em- ployed. External applications, So Sar as they can be Substi- tuted for cordials* are always to be preferred. Tonics alfa are to be employed in preference, when it i6 not neceffary to produce an immediate effed. Under this head perhaps fome remarks Should be made on the ufe of opium. The committee will offer a few and thofe only which are pradicah If the patient is Cool, opi- um is ufeful in the early ftage of the difeafe when attempt- ing to produce diaphorefis ; its property of producing this effed is well known. It is alfo uSeSul at that time, when there is great morbid irritability with toffing about, where- by the benefit oS other diaphoretics is prevented. The doSes required for theSe pUrpoSes may Sometimes be large j but in general they fhould be Small and repeated until they pro- luce the effeds defired. The committee cannot reftrain :he apprehenfion that Some of the evils attributed to this lifeafe have been aggravated, iS not Sometimes produced, by ihe too liberal uSe of opium and ardent Spirit. In caSes of violent SpaSms, aSter blood-letting, large dofes of opium arc unequivocally neceffary. Such cafes are however rare. TONICS. The bark of the officinal cinchona may be adminiftered as Soon, as the immediate danger from preffure on the brain U 70 MEDICAL COMMUNICATIONS. amoved, and any confiderable remiffion of Sever takes ph-.cc. On this point the committee have not been able to learn i Sufficiently the reSuIts oS experience in the late epidemic. By Some reSpedable phyficians tlie cinchona has not been ifeought uSeful. In fimilar difeafes the practice recom- mended has been Sound very beneficial. One very reSped- able phyfician thought chalybeates particularly Serviceable | under the circumftances defcribed. Another who has dif- tinguifhed himfelS hy his judicious treatment of this diSeaSe* ftates that the preparation, commonly called Fowlers Solu- tion of arfenic, has fulfilled very perfectly the indications under the Same circumftances. We have recently received a confirmation of this opinion from another very reSpedable Source. Thefe obfervations cannot be Sfeted'as conclusive, but deferve attention. Arfenic was employed in the early ft.^ye of the difeafe at Medfield in 1806, with apparent benefit, and has'been uSed m various inftances fince, as, it is faid, not- without z6.v;m- j tage. But the; committee are not acquainted with fb many and fo accurate observations, on this Subject* as to enable them to form an opinion refpeding it ; nor are they Satis- fied,, under what head it Should be ranked, if its effeds are fiLutaiT. DIET. j The general rule refpediug diet in acute difeafes applies j to tliat under consideration. This rule is to Supply the fto- 1 mach with the moft nutricious food it can digeft without labor to itfelf or irritation to the reft of the fyftem. It may indeed be neceffary to make feme exceptions to this rule \ in the firft days of acute difeafes, at a time when evacua- j dons are ufually made 5 but this exception it is not very mt- MEDICAL COMMUNICATIONS. fl portant to regard, as in fevere difeafes the ftomach will not bear much food at that time, agreeably to the conditions ftated above. In this diforder it is faid, that the appetite and powers of digeftion are often greater; thari in moft oth- er acute difeafes. On the appetite we cannot place full re- liance in a difeafe, in which the fenfibility is So varioufly and irregularly affeded. But when the powers of digeftion ap- pear fully adequate to the purpofe, not only the ufual fari- naceous nutriment, but even animal decodions, broths and Soups J may be given with advantage* It muft not how- ever be forgotten that the fyftem can bear rather lefs nour- ifhment, than the ftomach would be capable of digefting, more eafily, than it can bear the irritation and fatigue, pro- duced by loading the ftomach with a greater quantity of food, than it can eafily convert into chyle. In fuggefting their ideas reSpeding the mode of treatment the committee haye Sometimes gone into detail, and have Sometimes given only very general opinions. The reaSons for So doing will probably appear obvious to the counfellors. One of them was their defire to curtail as much as poffible a report, which has extended to a greater length, than had originally been contemplated. The committee are fully fenfible that much might now be added, and that mucli might be amended. THOMAS WELSH, } JAMES JACKSON, > Committee. JOHN C. WARREN, ) Eojlon, June 20th, 181c. HeX Hist. VJX XI o C)