SOME ACCOUNT OE THE PREVAILING EPIDEMIC IN THE NORTH- 
WEST, VARIOUSLY DESIGNATED, BUT USUALLY 
POPULARLY DENOMINATED 
“SPOTTED FEVER.” 
A Paper Rear Before the Illinois State Medical Society, May, 1864. 
,T. ADAMS ALLBN, AT. X)., LL. X)., 
Prof. Prin. and Prac. Med. and Clin. Med., Rush: Med. College; Formerly Prof, 
etc., in the Indiana Med. College; Late Prof., etc., in the Med. Beg't of 
the University of Michigan; Ex-President of the State Med. 
Society of Michigan, etc. 
The peculiar severity and remarkable prevalence of the epi- 
demic popularly called Spotted Fever, and the great anxiety 
which manifestly prevails, Jto glean from every quarter infor- 
mation with regard to its nature, and especially its treatment, 
must be ray apology for trenching upon the limited time of 
the Society by a brief paper upon the subject. 
The writer claims as large an experience in this form of dis- 
ease as has probably fallen to the lot of any living member of 
the profession, as it has happened to have been his fortune to 
pass through as wide a spread and devastating epidemic of it, ORIGINAL COMMUNICATIONS. 
as any with which medical history acquaints us.* Limited in 
range, compared with Asiatic Cholera, Yellow Fever, or the 
Plague, nevertheless, by its intensity and mortality, in the 
particular districts which it attacks, the writer does not hesi- 
tate in saying that it is vastly more to be dreaded in any com- 
munity than either of the forms of disease mentioned. 
In the present paper the writer must premise the regret that 
tire, which is no respecter of persons, destroying his residence 
and its contents, in the spring of 1851, spared not his memo- 
randa of this terrible epidemic which devastated many parts 
of the State of Michigan during the years 184Y, 8, and 9. A 
record of numerous cases, in their onset, progress, and post, 
mortem,*■ was thus unfortunately destroyed. The impression 
left upon the writer’s mind, deepened as it has been by fre- 
quent observations since that time, is too profound to depend 
upon any manuscript aid. Not less than live States of the 
North-West have recently been visited by this mortal disorder. 
A very little light is better than none in a dark place, and it 
is not hazarding too much to say that no man as yet so well 
understands the “ Spotted Fever,” as to be incommoded by 
the slightest additional information on the subject. 
Of the Spotted Fever very little is found in the text-books, 
and our own observation is, that of the various monographs 
on the subject, but few, if any, reflect the personal experience 
of their writers.f Even the name is a subject of dispute— 
stat nominis umbra. 
The diagnosis is comparatively clear to any one with even 
slight experience—unfortunately the reliable therapeutics puz- 
zle and confound the most expert. Most remarkable as an 
epidemic, yet it often occurs sporadically, and in the latter 
case the diagnosis usually is—congestion of this, that, or the 
*The number of cases personally observed by the writer, was not less than 
» thousand, and probably many more than that number. 
f Several monographs have appeared on the subject, wherein the writers 
speak boldly, although they confess to have seen not more than a half dozen, 
eases. ON SPOTTED FEVER. 
other organ, more frequently the brain. As though the term 
congestion explained anything! 
In observing the phenomena presented, we may premise 
that they simulate the toxicological—we can scarcely resist the 
belief that they are caused by a specific materies morbi, which 
the popular opinion readily conjectures to be a contagious prin- 
ciple, yet by careful observation we become convinced that this 
materies morbi must have been generated within the system 
by the agency of external causes. The causes without—the 
poison generated within. According to the writer’s observa- 
tion, it is more likely to occur in winters with a variable tem- 
perature—where a few days of intense cold are rapidly fol- 
lowed by days of thaw, mud, and rain. Neither uniformly 
cold nor warm weather are so likely to engender it. But oth- 
er influences unquestionably co-operate. It does not seem 
always confined to a particular season. We have seen cases 
in the wet basements of Chicago, and they have, according to 
the best authority, occurred in military camps in damp locali- 
ties, irrespective of, or connected with “malarious” influences: 
Here and there, wherever the “grand array” of the Union has 
been dispersed, it has manifested itself, oftentimes vaguely 
denominated Cerebro-Spinal Meningitis, or “ Congestive Fe- 
ver,” according as the reporter was, or was not, familiar with 
the peculiarities of the disease. 
In its incursion it does not appear to select those debilitated 
by previous disease, in preference to the robust. It selects no 
particular age or sex, neither are any exempt. Nor does it 
seem to be influenced materially by localities—those upon the 
highlands, and those upon the lowlands—the rich and the poor 
are quite impartially seized. And yet there is a feature of 
causation which is generally to be noticed as common—the 
variable hygrometricand thermometric condition of the atmos- 
phere. This is a point worthy of consideration in its physio- 
logical relations, and gives a glimpse of the real nature of the 
disease. ORIGINAL COMMUNICATIONS. 
The Attack.—The modes of attack are various, and yet ail 
coincide in representing a potent influence upon the nervous 
system. More commonly this is manifested by distinct rigor 
gradually passing to general coldness, absence of pulse in the 
extremities, and coma, very like that of pernicious remittent, 
and this, it may be, without marked local symptoms. At oth- 
er times pain is the prominent symptom—pain more frequent- 
ly in the occipital or nuchal region, but very often in other 
parts of the head, in the shoulders, trunk, hips, or extremities. 
This pain is usually sharply circumscribed, but this is not in- 
variably th*e case. It becomes more and more intense, until 
the patient grows delirious, apparently from its severity, and 
then ultirnates in coma, after which, the disease takes the same 
course as when ushered in by a chill. Or it may speedily be 
replaced by the rigor. The suddenness of the attach, and 
rapid progress to grave symptoms are very characteristic. The 
delirium which ensues upon the pain, or which supervenes up- 
on the coma, is of the most violent character, with incessant 
jactitation and often vociferous and incoherent cries. 
The Eruption.—Sometimes at the very outset, but usually 
not until the lapse of several hours—from three to twenty- 
four—there occurs a peculiar discoloration or eruption upon 
the surface, but this is exceedingly variable in its form. Some- 
times it consists in simple petechial points, and again of dark 
discolorations of large surfaces, like ecchymosis, or rather the 
subcutaneous extravasation of purpura. More frequently there 
is no elevation of the cutis, but occasionally there are eleva- 
tions of the epidermis like bull®, with thin, dark, sanious 
contents. Sometimes it approximates the mulberry rash of 
typhus, and again it is said by some of my correspondents to 
look like the eruption of measles. I have never seen it take 
the latter appearance. The form of the eruption, although 
from its frequency is derived the popular designation of the 
disease, is not diagnostic. Mainly the evidences oresented by 
it are those of a diffluent disintegrated state of the blood. 
Yet I have fancied the prognosis was modified, as in many ON SPOTTED FEVER. 
245 
* 
eruptive diseases, by the brightness or lividity of the eruption. 
The eruption or discoloration is not invariably present. 
Innervation.—Among the most remarkable symptoms may 
be mentioned persistent tonic contraction of the muscles of the 
back of the neck, sometimes deepening into opisthotonos; 
convulsions, paralysis of the extremities, particularly of the 
arms, and also of the optic and auditory nerves—the auditory 
oftenest,—remarkable soreness of the surface and joints to 
touch or motion. 
There may be intolerance of light and sound, but oftener 
the special nerves involved are paralyzed. While there is the 
most excruciating hyper-sesthesia of the general surface, the 
fingers may be placed on the cornea with no flinching by the 
patient. Rarely the muscles of articulation and deglutition 
are paralyzed. Hemiplegia is not infrequent, or the paralysis 
may be confined to a single extremity. Strabismus, unequal 
size of the pupils, twitching of the facial muscles, etc., etc., 
are incidental symptoms. 
The Pulse, at the outset, is small, thready, tremulous, irreg- 
ular, soft, and speedily lost at the wrist. On the occurrence 
of reaction, or remission, it increases in fullness and force. 
About always during the primary stage, it is slow, but during 
reaction it runs up to 120 or 150. 
The Skin is, in most cases, dry as well as cold, but in per- 
haps twenty-five per cent, it is moist. In all instances, it is 
variable at different hours of the day. 
The Tongue is more or less enlarged and flabby, with in- 
dentations of the teeth upon its edges. It is pale and rapist, 
with a coating of a pale ash or white color, passing to yellow 
or brown, but it does not present distinctive symptoms. 
Nausea and Vomiting are occasional, but not constant 
symptoms ; the matters thrown up being the normal contents 
of the stomach, or, in bad cases, decomposed blood, bile, mu- 
cus, etc. 
The Bowels are variable. Some cases are natural, in oth- 
ers, there is obstinate constipation, and in others still, severe ORIGINAL COMMUNICATIONS. 
diarrhoea, with discharges of grumous and offensive matters. 
The Respiration is ordinarily laborious and irregular, sigh- 
ing and perhaps stertorous, or hissing through the clenched 
teeth; more frequent than normal while consciousness con- 
tinues, out becoming slower with advancing coma. 
The Urine is generally scanty, smoky, albuminous, depos- 
iting a plentiful sediment, intermixed with ropy mucus and 
disorganized blood corpuscles. In some instances I have 
knowm it abundant and of lo}v specific gravity. 
The Second Stage.—The first stage may terminate in death 
in a few hours, or, after an interval of from six to twenty-four 
hours, there may occur a marked remission of the symptoms 
—a very deceptive remission—leading both the physician and 
patient to believe the difficulty pretty much over. Superven- 
ing upon the remission rapidly, or it may be upon a gradual 
awakening from the comatose state, there will be intense feb- 
rile excitement, great heat of the surface, rapidity and strong 
tension of the pulse, arterial throbbings, flushed face, turgid- 
ity of the conjunctiva, with extreme thirst, etc. This is liable 
to be attended with the highest grade of delirium, and frantic 
muscular jactitation, requiring several attendants, perhaps, to 
keep the patient in bed. 
The delirium may, after a while, merge again in coma, ap- 
parently from utter exhaustion, or it may gradually moderate 
in violence and pass into the low muttering character, with 
subsultus, etc., the patient supine, with the extremities fixed, 
and painful to touch or motion ; or in some cases turned rather 
to the prone position, with, in either case, the posterior mus- 
cles of the neck fixed rigidly, drawing the head strongly back- 
ward. Occasionally it is drawn laterally backwards, but is 
always in a state of rigid immobility. 
In this stage the bowels are inactive, and the urine either 
scanty or wholly retained. The skin is hot, but not infrequent- 
ly reeking with an offensive perspiration. Irregular or partial 
siveats are common. Convulsions, paralysis, pain or other 
evidences of central nervous disorder are largely aggravated. ON SPOTTED FEVEK. 
Latek, may pass on with irregular febrile phenomena, into 
the low, lingering typhoid stage, stretching over even forty or 
sixty days, before the establishment of a tedious convalescence. 
The low fever which so often supervenes upon severe attacks 
of the Asiatic Cholera much resembles it. 
The patient may die in this stage, or 
From the outset there will be presented intermingled symp- 
toms, according to the involvement of particular organs in 
secondary lesion. The lungs are especially liable to severe 
or even fatal disorder. So much so indeed as, by the gravity 
of its manifestations almost entirely to mask the original dis- 
ease, Dr. Condie, in a note to the American edition of Wat- 
son’s Practice, includes a description of this form under the 
head of Typhoid Pneumonia, but it is unnecessary to say that 
the disease described is but the one now under notice, with 
secondary pulmonary complication. 
Ulceration of the throat, the writer has observed as a com- 
plication in several cases—the destruction of tissue proceeding 
to an alarming extent. Erysipelas is the most frequent and 
dangerous of complications. It is easily kindled upon the 
slightest abrasion of the surface, and often, without such a 
nidus, attacks the face and neck, extending to the scalp, or 
more rarely seizing the extremities. This erysipelatous affec- 
tion is apt to be exceedingly destructive to the part attacked, 
giving rise to foul sloughing sores, rapidly wearing out the 
patient by exhaustion. Some of our friends who have observ- 
ed this frequent concurrence of erysipelas, have been so struck 
by it as to be led to believe the disease essentially an erysipe- 
latous inflammation of the Cerebro-Spinal tissues, as also of 
those organs secondarily involved. 
The abdominal viscera sometimes experience the full force 
of the morbific influence, but in greater part are comparative- 
ly little disturbed. Epistaxis, hsematorrhoea, hsematemesis, 
and hsematuria are occasionally present to a dangerous extent. 
Sequela.—Among the sequela we note deafness, blindness, 
partial or complete paralysis of motion, tuberculosis, albumin- 248 
ORIGINAL COMMUNICATIONS. 
uria. Albumen is about invariably present in the urine of the 
tardily convalescent, or ultimately fetal cases of long continu- 
ance. Marasmus in both children and adults, and phthisis in 
the latter, are especially common. The constitution seems 
broken down, and perhaps years elapse before the surviving 
patient recovers his original vigor. 
Post Mortem.*—With regard to jpost mortem appearances, 
there has been much apparent discrepancy of description. The 
explanation of this discrepancy is found easily in the fact that 
death may result in any stage of the disease. It thus becomes 
quite difficult, at times, to discriminate the incidental compli- 
cation from the primary original affection. 
If the patient die in the first stage, within a few hours from 
the attack, there may be very few signs of local change. The 
Blood will be found settling to dependent portions, and with a 
loose, gory, diffluent clot. There will be found stasis of blood 
in the capillaries of the Cerebro-Spinal meninges, particularly 
of the pia-mater and dura-mater, rarely of the arachnoid. The 
superficial vessels of the convolutions will be distended, and 
those upon the walls of the venticles likewise full, presenting 
here and there spots like ecchyrnosis, though more florid in hue. 
Sections of the cerebral substance will show a similar condi- 
tion of the blood vessels, as manifested by large red points on 
cutting across them. The medulla oblongata, spinal menin- 
ges, and cord, at the upper part, will exhibit similar appear- 
ances. The stasis of semi-dissolved blood is so considerable 
that both the gray and white tissues gain a pinkish tinge. 
More or less circumscribed softening is found, usually in- 
volving the cortical substance of the cerebrum, the inferior 
surface of the cerebellum, and the floor of the lateral ventri- 
cle. In fine, a lessening of the firmness and density of the 
whole mass is evident on careful inspection. Effusion of dis 
colored serum into the cavities is present, now and then, to a 
large amount. 
■-The post mortem appearances here described, are those fully confirmed by 
the writer’s own dissections. ON SPOTTED PEVEK. 
249 
If the case has run on to high reaction, all the results of in- 
flammation may be present. In this case the arachnoid is apt 
to be thickened, and with loss of its transparency. In the 
exuded matters are found pus and lymph corpuscles, or the 
exuded lymph forms a quasi membrane, loose, creamy, and 
readily broken down, upon the surface, or along the course, of 
the large vessels. The greatest quantity is at the base of the 
brain, and always at the optic commissure. It is also stated 
to be found on the corpora quadrigemina, the medulla oblon- 
gata, and around the third pair of nerves, where they pene- 
trate the arachnoid membrane. Wherever the exudation takes 
place it is likely to be stained by the dissolved hssmatin. 
In the spinal region, the morbid changes affect mainly the 
meninges, the substance showing little modification of struc- 
ture—the most observable being softening. The exudation, 
discoloration, and Softening are most noticeable about the roots 
of the cervical nerves. The thoracic and abdominal lesions 
present nothing distinctive. Where the lungs become involv- 
ed, there are the ordinary evidences of stasis of blood and 
effusion, or where the later stage is reached, the usual results 
of inflammation. The same remark may be made of the in- 
testinal tube. 
Here rests the case, so far as my own examinations have 
extended, and so far as those made, by others, which have fall- 
en under my notice, have been concerned. To my own mind 
the morbid anatomy thus far developed, is altogether unsatis- 
factory. The advances of modern Physiology indicate a still 
further exploration of the cadaver, which I confess not to have 
made, and am at this time only consoled in not having made, 
by the concurrent failure of other inquirers on this subject, 
and by the still more cogent reflection that probably if the 
examination had been made it would have proved scarcely 
more than negative.* But on this point hereafter. 
*At the meeting of the State Society, before -which this paper was read, it 
was stated that certain recent dissections showed commencing fatty degenera- 
tion of the kidneys. In so far this confirms the writer’s present views. 250 
ORIGINAL COMMUNICATIONS. 
It is proper to remark, that whilst in about every case 
there is on post mortem some visual evidence of local disease 
of the cerebro-spinal region, nevertheless, in very many, this 
evidence is very slight, and in some it is inappreciable. The 
disease is capable of killing the patient speedily or slowly, 
and yet leaving behind no trace of its footsteps. Here, as 
elsewhere, the facts teach that the immediate molecular 
changes, upon which life and death depend, are intrinsically 
beyond the sphere of our aided or unaided observation. 
We necessarily infer their existence, precisely as we infer 
the reactions of a chemical mixture, by observation of results, 
and of things which we can see, and handle, and weigh. 
HecbjEmial Cases.—ln common with many other potent 
influences which suddenly strike down the powers of life—the 
cause, or causes of this terrible disease may produce, at once, 
necrsemial symptoms, so profound that particular manifesta 
tion of the special “ proximate cause” will not take place. The 
diagnosis here is really not of much, if of any, importance. 
Malignant typhus, small pox, scarlatina, rubeola, diphtheria, 
Asiatic cholera, erysipelas, pernicious remittent, uraemia, etc,, 
are severally capable of producing the same condition. In 
this case, an overwhelming cause acts especially upon the 
cerebro-spinal centre, and secondarily upon other organs. The 
blood from the beginning is poisoned, and scarce living, and 
death may ensue from this poisoning, or later, from the local 
changes in the brain and cord, or in some instances, from in- 
volvement of other vital organs. Probably all observable 
lesions are truly secondary. 
Diagnosis.—The only forms of disease with which this is 
liable to be confounded are, pernicious remittent, (“ congest- 
ive”) fever and typhus, nevertheless, as there is no limit to 
human absurdity, one medical journalist claims that all these 
noted cases are but malignant scarlatina ! Such absurdity of 
speculation exhibits itself in too clear a light to need effort at 
controversy. Yet it may be observed that in the progress of 251 
ON SPOTTED FEVER. 
pernicious remittent and malignant typhus, cerebro-spinal 
changes often occur, which render the diagnosis impossible; 
and this may not be deemed unfortunate, because at the same 
time it is unnecessary. Since enlightened medical men have 
ceased to regard diseases as entities, and no longer rely upon 
routine treatment, the diagnosis of names has yielded place to 
the search for causes and conditions, and treatment has been 
placed upon a broader and more certain basis. 
Those who carefully notice the peculiar disturbances of the 
nervous system and muscular apparatus in this affection, can 
not fail to see that they are exceedingly rare in the so-called 
congestive fever of malarious districts. There is no periodic- 
ity about it. It can not be merely a severer form of that 
fever for it occurs in districts indiscriminately, where that fever 
is known and where it is not. It occurs at a season of the year, 
mainly, when notoriously, pernicious remittent loses its viru- 
lence, and indeed, is scarcely everpresent, save in cases which 
have been especially liable to attacks of periodical disease, and 
whose constitutions have been broken down by previous illness. 
Briefly, the paralysis of special sensation and voluntary 
motion ; the hyperesthesia of the surface and joints, or more 
remarkably, of circumscribed localities; the opisthotonos and 
convulsions ; the petechias and vibices ; the absence of perio- 
dicity, notwithstanding marked remissions; the locality and 
times of occurrence; the sequela; these and many other par- 
ticulars, to be seen by the seeing eye, distinguish the disease 
from “ Congestive Fever,” with no difficulty or uncertainty. 
The influence of quinia is wonderfully diagnostic. In per- 
nicious remittent it is prompt, powerful, and certain—it is the 
remedy, with all others ignored. In the disease under review, 
it is scarcely noticeable in effect, and wholly unreliable, nay, 
comparatively worthless as a remedy. The “ Congestive Fe- 
ver ,” bows beneath its potent influence at once—the “Spotted 
Fever” scorns its impression. 
Practically, the physiognomy of the disease is as diverse as 
the lineaments of strangers. 
Nearly the same features separate it from “ maculated 252 
ORIGINAL COMMUNICATIONS. 
typhus.” It is not a severer form of typhus disease, because 
it is rarely developed under those known circumstances which 
develop the latter. The nervous manifestations at the outset 
are wholly diverse; the mode of attack and progress of the 
cases are dissimilar, save that in some cases a low fever fol- 
lows the secondary lesions ; but well marked, and indeed 
some of the severest, cases are arrested, and convalescence 
occurs, without any such secondary fever. 
The eruption, or rather extravasation of dissolved blood be- 
neath the skin, is wholly unlike the maculae of typhus, or the 
roseolar spots of typhoid. Such extravasations do not consti- 
tute the peculiar eruption of typh disease. Typh fevers are 
the creation of ochlesis, of bad ventilation, tilth, and improper 
food. This clearly depends on meteorological influences, en- 
tirely apart from the accumulation of human beings in crowd- 
ed places ; independent of decomposing organic matter ; inde- 
pendent of confined air. It attacks equally all ages, from the 
infant to the veteran—the out-door laborer and the lady in the 
parlor. 
Presenting some symptoms in common with typh diseases, 
its history and physiognomy are as diverge from them as “bil- 
ious remittent” from “yellow fever.” 
Its diagnosis only becomes difficult from them in that ne- 
cnemial condition, before alluded to, when these and a vast 
number of other malignant diseases are merged in common 
manifestations, by the overwhelming nature of the causes pro- 
ducing them. 
Prognosis.—The proportionate mortality in the early peri- 
ods of this, as of other pestilential epidemics is something 
frightful to contemplate ; but there always remains this well- 
established fact that under about any respectable, or even so- 
called active, treatment, the fatality steadily diminishes with 
time, and the later cases are quite controllable. Its primary 
mortality in proportion to the number seized, is unsurpassed 
even by Asiatic cholera. 
Therapeutics.—lt would be a happy circumstance if the ON SPOTTED FEVER. 
treatment were as satisfactorily determined as even the char- 
acter of the disease. Unhappily this is not the case—but 
much can be done, and many lives thereby saved, which neg- 
lected would have been lost. This is a truth which charlatans 
and pretenders are ready to take advantage of, and all ears 
are speedily stunned by the praises of particular remedies and 
methods whicii they go around braying about. “ Specifics'" 
for it are as plentiful in every city, village, and hamlet as ap- 
plicants for offices after a Presidential election—but, alas, they 
fail miserably in the trial. 
Under the writer’s own observation has come treatment 
which ought to make all classes of created things—from an- 
gels to jackasses—weep. We have seen men try to bring on 
a crisis—the death-crisis—which we have elsewhere exposed, 
by bloodletting. Others attempt the same thing by emetics 
and mercurial purges. Steaming is perhaps the most popular 
plan of producing exhaustion of the feeble remaining powers 
of life. We have seen long trains of wagons returning through 
Michigan onud from the hemlock woods, a score or more of 
miles away, laden with the precious branches, (Birnam’s wood 
coming to Duusinane,) greeted as Oriental pilgrims coming 
from Mecca. 
I have known fifty grains of morphia given within a dozen 
hours to a boy of fifteen, to relieve him from the terrible pain 
and suffering, with no avail, save that death followed. 
Incalculable quantities of brandy and quinine, of capsicum 
and carbonate of ammonia, have been poured into the stom- 
achs of the comatose; and there is no measurement, of the 
amount of turpentine and other irritants, which have been 
thrown up, per rectum. The surface has been parboiled, roast- 
ed, cauterized. What have we not seen done? 
There is no limit to human credulity—there is no bound to 
human assumption. The most trivial remedies have been 
ushered into notice, and temporary repute, under the loosest of 
professional hypotheses—fortunate only in that they have re- 
placed destructive methods. ORIGINAL COMMUNICATIONS. 
Flimsy chemical analogies, mixed with apochryphal fer- 
ments. have floated sundry inert substances into use, which 
luckily convert the sin of commission into the less odious sin 
of omission. Satisfactory treatment remains to be discovered. 
There are no specifics—there are no antidotes. Yet experi- 
ence points to somethings which seem to have done some 
thing—perhaps,post hoc ergo propter hoc, after all. 
And, first, we rank external stimulants—rubefacients and 
artificial heat. Whatever will powerfully stimulate the sur- 
face, especially along the spine and the extremities. This not 
from any vague idea of internal “ pressure,” or “ congestion,” 
to be overcome by “determining to the surface,” but for pro- 
moting tissue changes in this most accessible of the excretory 
organs, and thus awakening energy of the circulation, and 
immediately excretion of effete matters, and renewal ot blood 
The rubefacient becomes thus a general stimulant. With cap- 
sicum and mustard, ammonia and terebinthinates, pungent oils 
and friction, the means are abundant enough, and the practi- 
tioner can take his choice. But, let it be observed, to be useful 
the action of the surface must be awakened, and not merely 
irritated. Persistency, and yet caution not to destroy the tis- 
sue, must be the cardinal points in view. Direct heat from its 
ultimate sedative impression, is a more questionable remedy. 
The hot water or vapor bath speedily exhausts—still, when 
the surface is dry and rigid, these may be employed for a short 
time only. The alcoholic vapor bath is better. 
A potent stimulant is the application of ice for a few mo- 
ments and then the alternation of hot epitheras—this alterna- 
tion to be frequently repeated. The intense local pain, so 
often present in the primary stage, may occasionally be con- 
trolled by full doses of morphia internally, but usually the 
amount required is so excessive as to prove dangerous of itself. 
Under these circumstances the hypodermic injection will be 
found of greater advantage. But from the puncture there is 
always danger of erysipelas. The same remark applies to ON SPOTTED FEVER. 
255 
vesicants—primarily of excellent service, secondarily there is 
danger of sloughing sores. The slightest abrasion of the sur- 
face is to be looked upon with fear. 
Internally stimulants and restoratives, boldly, but with due 
regard to their ultimate effect. Thus the alcoholic stimulant 
of whatever sort, when acting at all, is quite disposed to pro- 
duce the sedative or anaesthetic effect, cheeking tissue meta- 
morphosis, hence the disappointment so often experienced on 
its administration during the cold stage, or in necrsemial cases. 
If given, it is better combined with arterial stimulants—capsi- 
cum, piperin, monarda, etc. Etheriai preparations, ammonia, 
etc., answers well in some cases. 
In the writer’s experience the Tincture of Cantharides in 
full, and what to some would seem inordinate, doses has been 
found the most valuable of internal stimulants. Of this, (a 
‘proved preparation,) from twenty to forty drops may be given 
every hour until reaction ensues, or strangury supervenes. 
The occurrence of strangury, so far from being dreaded, is to 
be hailed as an omen of the most favorable import. It may 
be but a coincideuce, but it is fortunately an invariable one, 
that the patient in whom this symptom occurs, from this or 
any other cause, gets well. This interesting fact, observed 
more than fifty years ago in the history of this same disease, 
seems to us to let in a glimpse of light upon the therapeutics. 
It is not the strangury which cures, but the awakening of the 
nervous system and of the excretory energy, which this symp- 
tom incidentally manifests. The favorable result may be se- 
cured without the induction of strangury. 
Where there is any appearance of erysipelas, or where there 
are any evidences of dissolution of the blood, as shown by the 
deep, livid shade of the spots, or by passive haemorrhages, the 
Muriated Tincture of Iron should be simultaneously admin- 
istered. Coinciding with the general effect of the Cantharides, 
it seems to especially prevent further destruction of the blood 
and to facilitate its repair. Besides it lessens the liability to 
injury of the kidneys, and moderates strangury. Ten, twenty, 256 
ORIGINAL COMMUNICATIONS. 
or more, drops of the Tincture of Iron may be given with each 
dose of the Cantharides, and the mixture well diluted in some 
convenient vehicle. 
Other stimulating diuretics which we have tried have thus 
far proved less useful in our experience, but we favor further 
experiment on the point. 
When pain is dangerously intense, or convulsions occur, 
chloroform or ether may be carefully administered by inhala- 
tion ; and we should very much like to try here, as we have 
not yet had an opportunity, the Protoxide of ISTitrogen, or 
‘‘laughing gas.v Theoretically, and by analogy of its use in 
other cases, we are inclined to believe it would be found an 
invaluable remedy. Its energetic stimulating power would 
probably favor speedy reaction. 
We have not noticed any especial advantage from quinia in 
the first stage, although we have given it in doses varying 
from a couple of grains to half a dram every hour. The stim- 
ulating effect of the small dose is inappreciable; the sedative 
and diaphoretic effect of the large dose is objectionable. But 
when the deceptive remission occurs, we have fancied some 
benefit was gained by several full doses, at intervals of one or 
two hours—the sedative effect seemed to lessen the severity of 
the subsequent exacerbation, although we have found that a 
hundred grains thus given, would not prevent its access. 
Please observe, that while the writer thus ignores quinia as 
a curative agent of cardinal value, as some believe it, in pure 
cases of Spotted Fever, he is ready to admit the great proba- 
bility of its superior efficacy in the management of cases mod- 
ified by the so-called malarious influences. The same remark 
may be made with regard to the arsenical preparations and 
other “anti-periodics.” v 
On the occurrence of the remission, or the conclusion of the 
first period, something appears to be gained by relieving the 
bowels with a moderately stimulating cathartic, particularly 
when the cold stage has left behind it decided engorgement of 
the portal system. By this means the ensuing exacerbation is 257 
ON SPOTTED FEVER. 
ameliorated, and the tendency to pass afterwards into a low 
form of fever is sensibly lessened. We usually, for this pur- 
pose, combine calomel with gamboge, rhubarb, and soap, 
which operates freely but not violently in six or eight hours. 
Beyond this or some milder cathartic, we have rarely found it 
useful to employ purgation. The patient can not be cured by 
attempts to turn him inside out with either emetics or cathar- 
tics. 
If during the stage of excitement which now follows, 
the xirine becomes tolerably free and charged with its solid con- 
stituents, the patient may be reckoned safe, but if it is suppress- 
ed the case is one of extreme danger. 
The practitioner is apt to be deceived by the apparent ex 
citement, and hence to resort to excessive anti-phlogistic mea- 
sures, but this is a dangerous error* Collapse impends, almost 
momentarily, and it is indispensable to be on guard. Saline 
diuretics, very moderate doses of the usual sedatives, and per- 
haps anodynes may be used ; but bleeding, vomiting, and 
purging are out of the question. Ablutions with cold water, 
or the tepid bath, or showering the head, we have found in 
this case even more useful than in the similar stage of remit- 
tent. When in doubt, our own experience teaches us to say, 
stimulate even here. At all events hold up the great powers 
of life by careful restoratives and abundant fluid nutriment. 
Destructive changes will thus be prevented; the liability to 
collapse lessened, and the tendency to tedious low fever with 
doubtful final result, abated. 
But better do nothing than to do mischief. Discussion of 
the low fever and the various sequela occasionally met with, 
ensuing upon the attack, is not within our present purview. 
The treatment is comparatively clear and simple. Incidental 
local complications will modify each case, and the patience of 
even the most skilled practitioner will be severely taxed by 
the tedious prolongation. But the indications are so palpable 
and unmistakable that they need not command further notice 
in this place. 
2-von. xxi.-no. vj 258 
ORIGINAL COMMUNICATIONS. 
One or two remarks and this already too long extended 
paper will be brought to a close. The term Cerebro-Spinal 
Meningitis now generally accepted as designating “Spotted Fe- 
ver” is objectionable, in that it conveys the idea that the disease 
is essentially an inflammation of the parts indicated, which is 
clearly not the fact. 
The phenomena indicate the presence of a blood poison, 
prominently (but not invariably or exclusively,) affecting the 
cerebro-spinal meninges. 
There is reason to believe that this blood-poison is generat 
ed within the body itself, by concurrence of external causes 
influencing especially the physiologically vicarious, yet collab- 
orating organs, the skin and the kidneys. 
There is reason to believe that elimination of that poison, 
and consequent cure, is to be sought among those agents 
which especially impress these great emunctories. 
At all events, mere stimulants or antiphlogistics fail!