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UNITED STATES OF AMERICA
ME/>
WASHINGTON,  D. C.
GPO  16—67244-1
8001 
 
   $3*  The object of the following publica-
tion,  is to show  the  advantages  to  be  deriv-
ed from blood-letting, in the disorder on tvhich
it treats. 
SOME ACCOUNT
.:r
THE    FEVER
WHICH EXISTED IN BOSTON  DURING THE  AUTUMN
                 AND  WINTER
OF 1817 AND 1818.
WITH A FEW GENERAL REMARKS ON
TYPHUS  FEVER.
   By W. GAM AGE, Jr.  M.D.
FFMOW OF THE MASSACHUSETTS MEDICAL SOCIETT
       BOSTON:
PRINTED BY WELLS AND LILLY,
          1818. 
 
PREFACE.
 1 he following communication  was intended and prepared fof
the New-England Journal of Medicine and Surgery, but it was
presented too late for the last number.   Since that it has been
somewhat extended, and now its length precludes its admission,
intire,  into  the next number of that  work.  I am, therefore, in
some degree under the necessity of adopting this mode of publi-
cation.   It is, however, with some reluctance that I give to the
communication the  form of a  nook,  as  it has no pretensions to
more  than an essay oh the subject  to which it  relates.   The
principal object is to give to the public without delays the result
of a practice  in a formidable disease, which is not in common
use ; and particularly to  excite attention to the morbid changes,
which  this disease  effects  in those, who fall its victims.   The
cases presented are numerous, and  rather minutely detailed, be<
cause it is necessary, in order to form a proper estimation of the
value of the chief remedy  employed, to relate all  the  circum-
stances, which can have any influence, on the results.
   This subject, fever, demands a long and patient investigation.
It  is copious in new and interesting truths, whose development
would  furnish a volume, but before a thorough work can  be pro-
duced, a greater accumulation of facts is necessary than has yet
been obtained.  It  is hoped that the facts presented in the fol-
lowing pages will contribute to the elucidation of its  cause,  and
the improvement of the  treatment of this disease. 
4
   As I have before publickly appeared in favor of the practice of
 bleeding in other diseases, and as I again present myself its ad-
 vocate under circumstances where it has generally been forbid-
 den ; it may  not be improper on  this occasion to state, that my
 present favourable judgment of this practice is not the effect of
 preconceived opinions,  or a favourite theory ; nor is it recently
 formed ; but  on the contrary, it is the result of long experience,
 and it has been gradually matured.   This  practice was  com-
 menced  with great caution,  and  with  strong prepossessions
 against it.  But its salutary effects in some cases, and the morbid
 changes produced by acute disease, which I frequently witnessed
 by examinations after  death,  at  last wrought conviction that
 bloodletting was not only a highly valuable remedy, but an in-
 dispensable one.  It was in the next place to be ascertained, to
 what extent this remedy might be  used  with  safety and advan-
 tage ;  and this  part of the inquiry has been attended with much
 anxiety and  watching; the mind being  constantly operated on
 by the fear of doing too much or too little for the safety of the
 patient.   No situation is more trying  to the physician,  than
 when he sees the death of his patient inevitable, unless it can be
 averted by a remedy, the power of which has  not been  measured
 in the  disease which threatens the mischief.
   With respect to this question,  much  positive knowledge has
been gained, but there is still much to be done.  I am conscious
 that the way is an unfrequented one, and that great circumspec-
tion is required.  But it is a rule with me not to advance a  se-
 cond step till the first rest3 on firm ground.
                                                    W.  G. 
SOME ACCOUNT,  $c.
The fever, which was in some degree prevalent in
thistown in the last autumn and winter, ranks proper-
ly under the denomination of typhus, but it differed
in some respects from the usual appearance of that
disorder.  The principal symptom by which it was
distinguished from the common form of typhus, was
the primary, and often severe affection of  the head.
This symptom was truly characteristic, and appear-
ed to be the cause of others not very usual,  and
all together they gave a peculiar  aspect to the dis-
ease.  It might  with propriety have been denomi-
nated  brain  fever.   In many  instances  it bore  a
strong resemblance to that variety of typhus called
spotted fever.  It has not, indeed, in any instance
within my observation, exhibited that rapid progress
to a fatal termination, which has sometimes marked
that variety of the disease ; but some cases were ex-
tremely violent and distressing in their attack and
progress, and manifested, very early, a bad character.
Sometimes, indeed, it was mild, and yielded readily 
6
 to common remedies ; but a majority of the cases
 which came under my care were severe and trouble-
 some.  It did not, however, always discover its real
 character at its commencement; it  would appear
 mild at first, the  patient fancying nothing worse
 than a common cold; but in the mean time the dis-
 ease was insidiously creeping on, and  after a few
 days the situation of the unfortunate sufferer would
 be distressing and  hazardous.   But whatever may
 have been  its  aspect, it has been  under some cir-
 cumstances, very destructive of human life.
   The  disorder usually commenced  with  a chill
 and head-ach.  The  pain was sometimes  in the
 back of the head, but in most instances in the fore-
 head, and was accompanied with a sense of weight
 or great tightness  across the forehead.   In  a short
 time the patient felt pain  in the  back and limbs,
 sometimes an excruciating pain in some of the joints.
 In some cases  there was an extreme soreness  or
 painful sensibility to the touch over the whole body;
 in others a numbness, principally in the limbs, re-
 sembling that state in which the liirib is said to be
 asleep.—The state of the  skin varied.  In some
 cases the commencing chill was not followed by any
 excess of heat, but an unnatural coldness continued
 during almost the continuance of the  disease.  In
 others the excess of heat was constant, but the skin
 at the same time was moist,  and had its natural soft-
 ness.  In a majority of cases, there was one or two
regular paroxysms of heat in the twenty-four hours, 
7
and in the intermissions the temperature of the skin
was natural.
  The state of the circulations was not more uni-
form ; the pulse, however, was in most cases feeble
and small; in some greatly accelerated ; in  others
the pulsation did not exceed seventy or eighty in a
minute ; in a few instances it was intermittent.
   The strength  in some cases was greatly and im-
mediately prostrated ; in others the prostration was
inconsiderable till the disease had advanced.
   The tongue in some,  was slightly  coated  and
moist; in others thickly coated with a white  fur,
which was disposed to become brown if the disor-
der progressed.   In some it had  no fur,  but its
surface was brown, dry,  horny  and cracked.  In
some severe cases the appetite at first was not ma-
terially impaired, and the secretions not greatly di-
minished ; but in others, at the first attack, constant
nausea and vomiting were  distressing symptoms.
   In the progress of the disease, other symptoms
presented, as heaviness over the eyes, a dimness of
sight, anxiety, sighing and faintness,  extreme flatu-
lence,  universal  distress  and jactation,  delirium,
 stupor and insensibility ; distress in the chest com-
 monly about  the region of the heart, amounting in
 some instances  to positive and acute pain, difficult
 respiration and dread of suffocation.  These affec-
 tions of the chest in a greater or less degree were
 not unusual in the cases which occurred in October.
 It will appear that they were not the effects of in-
 flammation in that part of the body. 
8
   This must be considered only a very general out-
 line of the symptoms produced by this disease.  A
 more minute account is presented in the cases which
 follow.

                    CASE I.
   The patient, a lady aged thirty, of rather a gross
 habit,  had been a little indisposed for one or two
 days before the 8th October, on which day, at noon,
 she  was taken with  a  general  chill,  accompanied
 with a severe head-ach.   I  saw  her in the evening;
 an uncomfortable heat of the skin had followed the
 chill, and she complained of pain in her head, neck,
 back,  and extremities ;  her tongue was coated and
 pulse accelerated, one hundred  and twelve in a
 minute,  quick, but soft.   She took this evening an
 emetico-cathartic, and drank freely of balm tea.
  9th.  The medicine operated thoroughly, but she
 was not relieved.  Pain in the head more  severe ;
 eyes dull, skin too cool; there was distress about
 the chest, and  involuntary sighing : pulse one hun-
 dred and twenty, small  and feeble;  the throat in-
flamed and sore,  and  an extreme soreness  over the
whole  body rendered the least motion painful.   I
immediately took  from her a pint and a half of
blood , it was thin, uncommonly black, coagulated
slowly, but exhibited no buffy coat.  After this she
took an ounce of the sulphate of soda; and at bed
time had poultices made with vinegar applied to her
feet and the back of the neck, and took a pill con- 
9
sisting of two grains of calomel, and half grain of
opium.
   10th. Not materially better ; pulse  the  same ;
skin warm ;  the urine distressingly hot and scanty.
Repeated  the  bleeding to the amount of twenty
ounces ;  the appearance of the blood the same.
Directed a cathartic, the cold ablution, and the fol-
lowing recipe :
                R Subm. Hydrarg. gr. xij.
                Tart. Antim-
                Opii    -  aa gr. ij. M. f. pit. No. xij.
                cum. sol. mira. Nilot.  q. s.
One pill to be taken every four hours.
   Evening.  Symptoms the same,  except the head
and chest  seemed a little relieved.—Bleeding re-
peated to the extent of sixteen ounces.  The ap-
pearance of the blood the same.   She was a little
faint after the operation.
   11th. The acute pain of the head, and the  sore-
ness of the flesh diminished ; throat nearly well;
pulse moderated to one hundred and ten, and  more
elastic.  But she had a  restless night; sighs  con-
tinually, has nausea, and a sensation of sinking or
faintness at the pit  of the stomach; skin hot and
the eyes inflamed.—V. S. Twelve ounces extract-
ed ; blood more florid,  but in other respects  the
same.
   Evening. Said the bleeding in the morning gave
great relief;  the symptoms, however, are not mate-
rially  changed.   The bleeding repeated  to the
amount of ten ounces; the  back of the neck blis-
2 
10
tered.   The nausea attributed to the pills, they are
omitted.
   ] 2th. Had some sleep, and is better, except the
nausea.  To have an emetic, and at bed time eight
grains of calomel.   Pulse one hundred.
   13th. Better;  pulse  ninety-six.  The  emetic
operated favourably, and the calomel produced two
or three black, alvine discharges.—Cold ablution
and diluting drinks  continued;  calomel to  be  re-
peated at bed time.
   14th. In general,  much  the  same as yesterday.
Skin hot and dry.  To take the antimonial solution
after the following recipe :
                Be Tart. Antim. gr. iij. Aquae, font. §i. M.
Commence with ten drops,  and increase the dose
gradually.
   15th. The  smallest dose of the antimonial solu-
tion produced vomiting ;  it was, therefore, omitted.
Sleep disturbed by dreams.   Head not so well ; it
is dizzy, heavy and burthensome,  and seems not to
belong to the body; pulse ninety-four, strong; de-
sired to be bled  for the relief  of the head ;  twelve
ounces  of blood were  taken; it had  for the first
time, a thin  buffy coat upon  it.   Again blistered
the back  of  the  neck,  and  directed a  cathartic.
The calomel had affected the  mouth, and caused a
considerable flow of saliva.
   16th. Head in some degree relieved, and other
symptoms quite favourable ; pulse eighty-eight;
muscular strength very good; the head constantly
wet with cold water. 
11
  17th. Head not quite so well, other symptoms as
yesterday.   Got from the bed, and walked the floor
without difficulty.  Directed a cathartic on account
of the head.  Evening.   Had three copious alvine
motions, but the  head  is  worse; it has shooting
pains, principally over the right eye ball; dizziness
and ringing in the ears ; the  capacity to  think  is
lost, and the passing of time  cannot be realized.
Pulse ninety.   1  immediately took from her a pint
of blood ;  she fainted ; but this was to be attribut-
ed more to the length of time occupied in getting
the quantity from a bad orifice, than to the loss of
the blood.
  After this, convalescence was so rapid, that on
the 21st there were no remains of the  disease, and
she was out of  bed all day  without inconvenience.
  It appears that this patient lost in about nine days,
nearly  seven pints of blood ;  and she was, without
doubt,  indebted to the persevering  use of this re-
medy for her recovery.

                    CASE II.
   On the same evening, October the 8th, I was call-
ed to a labouring man, who was reported to be in
great  distress.    I found  him  in bed, complaining
bitterly of an extreme pain, which he said was fixed
in the most fleshy part of the thigh of the right ex-
tremity.  He had also pain in his head and back,
and a soreness of the whole body.  Began to be ill
towards evening; the indisposition commenced with 
12
 a severe chill, and was followed by great heat of the
 skin.  Pulse  one hundred in a minute, quick, and
 somewhat hard.  Had no objection to blood-letting.
 A vein was immediately opened, and a large  quart
 of blood taken from him.   The  following  day he
 was decidedly  better,  but  took a dose of the sul-
 phate of soda.  On the third day he took a second
 dose, and was very soon well.
   His expeditious recovery was owing chiefly, I ap-
 prehend, to the  use of blood-letting  so soon after
 the commencement of his disorder.*

                    CASE HI.
   Mr. K. a small spare man, and  sickly, began to
 be sick on the  21st October.   The disorder  com-
 menced  with a chill, which  was soon accompanied
 with head-ach,  pain in the back and limbs, particu-
 larly in the knee joints, and a soreness of the whole
 body.   He endeavoured to remove his indisposition
 by cathartics, pediluvium, and drinking warm teas;
 having little success with these means, and his head
 getting worse,  he had taken  from him ten ounces
 of blood.  I saw him  on the afternoon of the 23d.
 He thought his head better,  but the pain in the knee
joints was so acute, that the  least motion put him in
 torture.   He had also pain  in his back, and an ex-

  * It is to be understood, that when the quantity of blood taken, is
 designated by measure, beer measure is meant; when by  weight,
 avoirdupoise weight; taking it for granted, that a pint, beer measure, is
 a pound avoirdupois weight. 
13
treme degree of soreness and tenderness, so that he
could not bear to be touched ; even the motions ne-
cessary for respiration gave pain.   Skin unnaturally
cool; tongue thickly coated with a white fur; pulse,
small, feeble,  but soft, and not accelerated.  Di-
rected an emetic, to be followed by copious draughts
of warm teas, with the spirit of nitrous ether, and
warm fomentations to the whole body.
  24th. The distress somewhat relieved ; the skin
had acquired a  natural warmth ;  other symptoms
the same.—A  cathartic to be taken ;  the warm teas
and  fomentations to be continued; the nitre,  as it
is disgusting, to be omitted, and the calomel pills to
be given as in the first case.
  25th. Symptoms not materially changed.   The
same treatment to be continued.
  26th. In every respect worse ; continually rest-
less and groaning ; head-ach more violent; pain in
the knee joints more  acute; pulse, small, quick,
and feeble,  one hundred and twenty in a minute ;
skin below the natural temperature ; besides these,
which had appeared in some degree before,  a new
symptom presented in a formidable shape ; this was
a sense of great weight or oppression across the
chest, directly in the region of the heart.   For this,
he said, he must have immediate relief, or he must
die.   I proposed  bleeding;  he consented, and  I
took from him, at once, twenty-four ounces of blood.
It was quite black, thin, coagulated slowly, and had
a thin coat.  Relief  was  immediately  obtained. 
14
 Chest to be extensively blistered.—Evening. Symp-
 toms a little moderated ; pulse, one hundred and
 ten, but it has a double stroke, that is,  there were
 two strokes in the time of one, a strong  and a weak
 stroke, the latter following the other instantly ; the
 stronger only  was counted.   Bleeding repeated,
 eight ounces taken.  Pills caused nausea, they were
 therefore omitted ; six had been taken.
  27th. Better; pulse the same, except fuller.  His
 chief distress arises from flatulency this morning; an
 immense quantity of flatus continually passes up and
 down.  A cathartic of  calomel and rhubarb to be
 given.
   28th.  Flatulency abated ; head  painful and
 heavy ; heat of the skin above its natural tempera-
ture,  but at the  same time  moist; pulse one hun-
dred, pulsations  still double.—V. S. Twelve oz.
 The blood had a thick, buffy coat.
  29th.  Has pain in the head over the  eye balls ;
other symptoms better;  pulse ninety-six, pulsations
single.  But on account of the head performed V. S.
Took ten ounces of blood, and directed a cathartic
of rhubarb,  and super-tartrite of potass.
  30th. Bled freely from the nose in the night;
head relieved.
  31st.  Bled again from the nose.   Pulse eighty.
Convalescent.
  It had been my desire to  conduct this case to a
safe conclusion without resort to blood-letting.  The
patient's usual state of health had been very feeble, 
15
and on that account his  friends were opposed  to
this practice being  adopted with him.   But his
symptoms became so formidable that there seemed
to be safety in no other means.   The result has been
fortunate ; the patient's health, since his recovery
from the fever, has been better than for years  be-
fore.

                   CASE IV.
  The patient, a female ten years old, had been se-
verely sick at least four days.  The parents, under-
taking the  management of the disease,  had given
her an emetic, a cathartic, &c. &c.  She was, how-
ever, getting worse.  She  was delirious a greater
part of the night previous to my seeing her; com-
plained of severe pain in her head, neck and back;
had a paroxysm  of febrile  heat every day, com-
mencing about  evening,  and lasting seven or eight
hours.   Between these paroxysms  the  skin  was
cool, particularly the feet and legs  were cold.
Tongue coated,  and began  to  be dark  coloured ;
pulse accelerated, one hundred and forty in a mi-
nute, quick, and very small; the artery rigid, and
apparently to the touch no  bigger than  a thread.
Treatment.   V. S. performed, and  five ounces of
blood taken.  It was thin,  and very florid.  The
back of the neck was blistered, sinapisms applied
to her feet; warm applications to the extremities,
and  cold  water liberally to the head.   She took
cold drinks,  and the antimonial solution.  On the 
16
 second day of my attendance, her head was a little
 relieved, other symptoms  not much improved ;
 tongue getting quite dark.   The bleeding repeated
 to the extent of four ounces, and a calomel cathar-
 tic to be given.  Small doses of the  antimonial so-
 lution produced nausea and vomiting, it was, there-
 fore, omitted.  The third day she was much better,
 the pulse, however, remained small.
   The principal remedies used after this, were ca-
 thartics  and cold ablutions.  The eighth day she
 had no disease, the debility very moderate, appetite
 good, and she was soon well.

                    CASE v.
   The sister of the subject of the preceding case,
 thirteen years old, was sick with the same disease.
 She was attacked two days  later, but with equal
 severity.   Being bled sooner after its commence-
 ment, the disorder yielded more readily.   She lost
 twelve  ounces of blood at three  bleedings.   She
 was the first well.

                   CASE VI.
  October 26th, afternoon. I visited Mrs. C. a spare
 woman,  between fifty  and sixty years old.  She
 had been indisposed for several days, and quite sick
for the two days past.  She had pain in  her head
and  limbs, soreness of the flesh, dry  skin, furred
tongue, a pulse frequent,  small, and  feeble.  Had
taken physic twice, to evacuate the bowels, and had 
17
sweated herself by means of warm teas.  I directed
her an emetic.
  27th. She was not relieved by the emetic.   Said
that her head was tightly bound across the forehead,
and there was  a weight over the eyeballs.   Pulse
the same ;  flatulency  very troublesome.   Took
from her one pint of blood, had cold water applied
to her head; and warm poultices to her feet.
  28th. Head less painful,  but heavy and dizzy
has distress across the  chest; skin cold ; pulse  ir-
regular, each distinct, followed by two or three  in-
distinct pulsations.   Blistered  the chest  and back
of the neck, and  gave warm teas with the spirit of
nitrous aether.
  29th. Temperature  of the  skin restored; head
not quite so easy ; other symptoms much the same.
To take a cathartic  of rhubarb and calomel; and
after the operation, the calomel pills.   Nitre omit-
ted.
  30th. Symptoms worse.   Affection of the head
and the prostration of strength increasing ; tongue
dark, brown and dry ;  pulse no  better.  The sin-
gular character of the pulse had deterred me from
bleeding.   The state of the head seemed now to
demand it.   Venesection was performed, and eight
ounces of blood taken.  It was uncommonly black,
thin, and did not easily coagulate.  Evening.  Cer-
tainly no worse.  She was pleased with the effects
of the bleeding.   Repeated it to the amount of
four ounces.
3 
18
   31st. Better ; pulse regular, eighty in a minute/
but small.   To  drink  freely  of a solution of the
super-tarti ite  of potass, which was grateful to her.
   Nov. 3d. The symptoms seemed improving till
this day ; she complains that  her head is worse ;
has pain in her side, and sickness of the  stomach.
Gave an emetic  ; to be followed by a rhubarb ca-
thartic ; blistered the side.
   4th,  The emetic  vomited her ; had some black
alvine discharges,  and the side is  relieved.  But
the distress  in the head is severe,  and she has an
acute pain in the right eyeball.   V. S.  ten ounces
of blood  taken, and the back  of  the  neck again
blistered.
   6th. In some respects better ;  but the distress in
the head continued,  and the right eye  threatened
with a total  loss of sight; the left had been for ma-
ny years affected  with a cataract.  Bleeding re-
peated  to the extent of six ounces,  and the fore-
head blisteied.
   7th. Head a little better.   It ought  to be men-
tioned,  that there  had been, regularly  every day,
for five or six days past, a paroxysm of febrile heat,
which commenced at about six, P.  M. lasted from
five to seven hours, and subsided without  perspira-
tion.  It had begun  to diminish  in  length and se-
verity.
  The treatment after this, consisted principally in
the administration of cathartics, and in  repeatedly
blistering different parts of the head.  Finally, the 
19
disorder subsided, and the head and eye were re-
stored to their natural state.
  Had the bleeding been sooner repeated, at first,
the disorder would  probably  have been  less pro-
tracted, and attended with less danger in its progress,

                    CASE VII.
   October 27th.  I was called to see Mrs. —1.  She
had been a little indisposed two days ; complained
of pain in her head, back  and limbs; had smart
uterine pains, being seven months advanced in preg-
nancy ; pulse quick and small; skin  hot, tongue
coated, and the  strength prostrated.  Took from
her a pint  of blood, and directed a cathartic  dose
of senna and manna.
   28th. Uterine  pains removed ; other pains miti-
gated ; but the head is heavy, and bound across the
forehead.  Pulse small, contracted, intermits  after
every third pulsation ; skin cool, but dry ; secretions
diminished;  urine little in quantity, high coloured,
and painfully hot.  A cathartic dose of rhubarb and
calomel given, flaxseed tea and other diluting drinks.
The  bleeding was not repeated on account of the
intermission of the  pulse.
   29th.  Pulse and  head the same.   Blistered the
back of the neck, and gave the  submuriate of meiv
cury in small doses.
   31st.  Nothing has been gained the three last
days ;  head more painful  and heavy ; pulse the
same, still intermitting;  the mouth evidently affect- 
20
ed by the calomel, but no relief follows ; has two
paroxysms  of heat  regularly every  twenty-four
hoursi and the disorder is acquiring a more serious
aspect.   Under these circumstances, blood-letting
seemed the only remedy that could arrest its pro-
gress, and as its effect on the pulse in the preceding
case was pleasant, I had little hesitation in using it.
A pint of blood was, therefore, taken from the arm;
it was thin, coagulated reluctantly, and had a thin
buffy coat.  The intermission of the pulse ceased
while the blood was flowing, and did not return.
   November 1st. Better; pulse regular, and only
eighty-six in a minute, but the head is not right.
Took a  cathartic ;  the  soreness of the  mouth  is
troublesome.
   3d. Not so well this morning; the paroxysm of
heat more severe ; head heavy, pulse one hundred
and ten.  Repeated the bleeding to twelve ounces.
   In  a short time  after this, all febrile symptoms
disappeared, and she became very hearty.

                   CASE VIII.
   October 28th.  Mrs. K—e had been ill seven or
eight days with what she supposed a bad cold.  She
had taken an emetic, and two or three  cathartic
doses with teas, &c.  Her symptoms became  worse;
 she had  pain in her head and limbs, prostration of
 strength, and great restlessness; palpitation  of the
 heart, and  distressing flatulency ; skin dry, pulse
 quick and feeble ; tongue coated,  and beginning to 
21
have a dark colour.   V. S. Took one pint of blood,
which was very black, coagulated slowly, and had
no buffy coat.  Gave her a cathartic dose of rhu-
barb and magnesia, and allowed her to drink snake-
root tea.  The next day, not finding much improve-
ment, I bled  her another pint.   The cathartic had
produced some dark coloured stools, and the flatu-
lency was relieved.
   The third  day the head was relieved, but the pal-
pitation returned with violence.   Blistered the back
of the neck, repeated the cathartic, and allowed the
ammoniated alcohol in the snakeroot tea.
   During the succeeding eight days, the  disease
varied in its appearance.   In this time emetics, ca-
thartics, blisters,  and the submuriate of mercury,
were used as remedies.
   On the 12th day, the twenty-first since the com-
mencement of the disease, the patient was evidently
worse.  Had an acute pain in the right eye; accom-
panied with an increase of the heaviness and dizzi-
ness of the head.  The palpitation of the heart,
excessive flatulency, and  a sensation of fainting,
were constantly present.  The skin was harsh, and
rather hot; pulse one hundred,  quick and sharp ;
coat on the tongue of a dark brown colour.   Bled
her ten ounces,  and repeated  the  cathartic.  The
next day symptoms improved, and from this time
she gradually recovered. 
22
                    CASE IX.
   Mrs. —e, aged thirty, had been ill five or six day^
and taken much medicine.  Has pain in her  head,
over the eyeballs, and tightness across the forehead;
pain in her back and limbs ; prostration of strength;
restlessness, loss of sleep, &c.  Pulse feeble, small,
one hundred and twenty in a minute  ; tongue coat-
ed ;  has regularly, every day, towards evening, a
chill, followed by heat.   Bled her to the amount of
a pint, and gave a cathartic of the sulphate of Soda.
   2d day. Symptoms very little improved. Bleed-
ing repeated to the extent of twelve ounces.
   3d day.   Better,  except she had  distress in her
chest, and an  indescribably strange feeling in her
head.—Warm fomentations to the chest, and blister-
ed the back of the neck.
   4th day.  Blistered the chest, and repeated the
cathartic.
   6th day.  Symptoms improving.
   8th day.  She imagined it necessary to take wine
and food to  restore her  strength, and yesterday she
treated herself with roasted chicken,  cider,  and a
glass of cherry.  Pain  in the  head very much in-
creased ; took an emetic.
   9th day.  Had acute  pain  in the right eyeball,
and in the right side of  the head.  Pulse one hun-
dred and twenty, small.—Six ounces of blood were
taken from the arm, and the neck blistered,
   10th day. Pain in the  head  less acute, but com-
plained that it felt heavy;  she  lay  in a state of 
23
considerable stupor, and only replied to questions
in a low, muttering voice.   Gave her  a  cathartic
dose of rhubarb and calomel.
  11th day. Symptoms very little better; pulse
one hundred and twenty.   Bled her ten ounces.
  13th day. Repeated the  bleeding eight ounces.
  14th day. Better. After this, she rapidly recov-
ered, without the aid  of bark,  wine, or any thing
more stimulating, than common, simple diet.

                    CASE X.
  John Cross, aged twelve, had been ill four or five
days, and his friends  had administered to him an
emetic  and cathartic,  but  his disease  progressed.
Complained of pain in his head, back, and limbs,
chillness, loss of appetite, prostration,  &c.  Pulse
one hundred and thirty, small, quick, feeble; tongue
had a white fur upon it.   Bled him six ounces, and
directed the solution of tartrite of antimony.
   2d day.  The solution, in very small doses,  pro-
duced vomiting.  Head better; pulse one hundred
and twenty ; solution to be omitted ; a cathartic
dose of senna and manna to be given.
   3d day.  The symptoms continued the same ; re-
 peated the bleeding to four ounces.
   4th day.  Disorder seems disposed to continue ;
 same quantity of blood taken as yesterday.
   5th day. Symptoms all better; pulse one  hun-
 dred ;  tongue  cleaning;  appetite returning.  His
 recovery was soon complete. 
24
  In most of the preceding cases, the disease in its
commencement  was apparently  mild,  and it  pro-
gressed slowly.  In those which follow, it was more
sudden and violent in its onset.

                   CASE XI.
  November 8th. John Bright, about thirty, a me-
chanic, was taken about noon; with severe chill, and
pain in his  head to  such  a degree as to oblige him
to quit his work and go to bed.  I was called to
him in the evening; he was groaning in agony with
the pain in his head ; said it would burst, and  he
would submit to have it  opened to  obtain relief.
The seat of the pain was in the forehead,  and the
top of the head.  He had also pain in his back, and
limbs, particularly the knee joints ; sickness at the
stomach ; and prostration of strength ; pulse one
hundred, quick, small and hard ; countenance pale,
and expressive of anguish.  He consented to  be
bled, and when I had taken one quart of blood  from
him, he begged me to proceed, it gave so much re-
lief to  his head.  I took eight ounces more,  when
his pulse was affected.   The blood was dark, not
disposed to coagulate, and had no buff.  A cathartic
dose of  senna and manna to be given ;  diluting
drinks, and the head to be bathed with  cold water.
  9th. Pain in the head did not subside so much
that he could sleep till  towards morning, when he
rested  a  little.  Cathartic operated well.   Symp-
toms generally mitigated.  Bled him to  the amount
of twelve ounces only.   Blood the same aspect. 
25
  10th, 9 A. M. Had  a restless night;  pain in his
head severe  ; had great distress in the right side of
the thorax.  Pulse eighty,  full, quick ; skin cool;
tongue thickly coated.   Took from him  one pint
of blood.  Blistered the back of the neck, and gave
him a cathartic.
   11th. Head and chest relieved.  Cathartic had
not operated well.   Had severe pain in the bowels.
Warm fomentations  to be applied to them, and ca-
thartics  repeated  till  the  bowels  are  evacuated.
This was not accomplished  till evening, after which
they were easy.
   12th.  Countenance  anxious, head  not entirely
easy ;  had heat last night,  and  was  restless  till
towards morning.   Pulse  seventy-five, slow,  full,
strong.—Took from him twelve ounces of blood,
and gave him another cathartic.  The blood had a
thick coat of fibrin.
   13th. Much better ; can sit up; wishes to re-
move  from his present lodgings ;  is  permitted.
Walks down two pair of stairs, rides some distance,
walks up two pair,  with no  other inconvenience
than a  little  fatigue.
   After this, he took a cathartic and  was immedi-
ately convalescent.
   On the 22d of the same month, he took to him-
self a wife,  and commenced a journey of several
hundred miles.
                       4 
26
                   CASE XII.
  The patient, a girl of sixteen years old.  She was
suddenly taken  ill with a chill, and sickness of the
stomach ; this was soon followed Hby severe pain in
her head  and back,  and an aching of the limbs.
She took an emetic, which operated powerfully up
and down, and used pediluvium, but all without re-
lief.   When I saw her she had been ill about twenty
hours ; complained  much of  pain  in her  head ;
countenance swollen and crowded with blood; pulse
one hundred twenty-six, quick, small, feeble ; said
she  was cold  and  extremely  weak.  Blood-letting
was recommended, and twenty four ounces large,
were immediately taken from the arm.  It was quite
black,  and did  not readily coagulate, and had no
buffv coat; she took a  cathartic dose of the sul-
phate of  soda.
  2d day. Much better ; head relieved, pulse one
hundred and ten ;  but the disease was evidently not
subdued.   Repeated  the bleeding,  and  sixteen
ounces more of blood were taken.
  3d day. The  first object that struck my sight on
entering the chamber, .»as my patient sitting at the
fire; countenance  bright  and  natural ; symptoms
of disease nearly gone; pulse one hundred ; tongue
cleaning : health was soon restored without farther
medical aid. 
27
                  CASE XIII.
  November. Mr. H., forty years old, was suddenly
seized with the symptoms of this  disorder ; they
manifested much violence, especially the pain in
the head.   Very soon after the attack, he was bled;
One quart of blood was taken from him at once.
He was immediately relieved, and with the assist-
ance of one or two cathartics,  the disease was speed-
ily and  entirely removed.

                   CASE XIV.
   November. John E. a lad eleven years  old, in
the same house with the above case, was  violently
seized  with this  disorder.  Pain in the  head and
limbs very distressing; tongue coated, pulse  one
hundred and twenty in a minute, quick and feeble.
He was bled immediately after the attack; eight
ounces of blood were  taken.  He afterwards  had
an emetic, and the  two following days a cathartic
each day  ; and was then convalescent.

                    CASE XV.
  December. The patient, amiddle aged working wo-
 man, was obliged to take to her bed in consequence
 of inability to continue her labour.  She began to
 be ill at noon ; I saw her in the evening ;  she  com-
plained that she was tired,  had pain in her head
 and back, and a feeling in her head when she raised
 it from the pillow,  which she could not describe ; 
28
 pulse not much accelerated, but feeble,  and easily
 compressed; tongue coated with a dense white fur
 on each side, but natural in the middle ;  skin of its
 natural temperature.  These were suspicious symp-
 toms, though their aspect was  not  at  present very
 bad.  I advised her to be bled ; and  immediately
 took from her arm, twenty-four ounces of blood,
 and gave her one  ounce of the sulphate of soda.
   2d day, 10 A. M.   Symptoms much  the  same.
 Repeated the  bleeding to the same quantity.
   3d day.  Symptoms mitigated, but not subdued.
 Repeated the  bleeding to a pint.
   4th day. Still better. Took an ounce of the sul-
 phate of soda, and was soon well.
   Other cases of  a similar nature might be added.
 The five last cases were  unquestionably indebted
 to blood-letting for the sudden check  to the pro-
 gress of the disease.   In  the two first  of the five,
 the symptoms, in their commencement; were very
 formidable, and no hope of a favourable issue could
 be entertained, unless  a strong impression could be
 made at once.
  In the cases, which follow, the disease was not en-
tirely arrested by blood-letting, but I think it will
appear that the patients owed their final recovery
to this remedy.

                  CASE XVI.
  The  patient, a female aged about thirty-five.
From the best account which could be collected, she
had been sick about four days.  At the time of my 
29
visit she was very ill.  She lay on the bed in a state
of extreme prostration, and apparent stupor, groan-
ing incessantly with the distress she suffered from
the pain in her head,  and  the aching of the whole
body.   The pain was seated principally in the fore-
head, and crown of the head.  When roused to
speak,  she said it  was indescribable, but  seemed
most like an immense weight, which  would crush
her to the earth ; and this sensation was accompa-
nied with a constant and violent throbbing.   Her
pulse was not  much accelerated, but it  had no
firmness, and was easily obliterated by the pressure
of the finger.   Tongue coated with a dense white
fur upon each edge ; the middle, about one third of
its surface, was red, quite dry and rough.  The skin
had about its natural temperature.  Under these
circumstances, blood-letting, to my apprehension,
was the only means of relief.  Twenty-six ounces
of blood were, therefore, immediately taken from
a vein in the arm.   A cathartic dose of senna and
manna directed, and the constant application of cold
water to her head.
   2d day, 10 A. M.  Her head,  she said was easier
for a short  time after the  bleeding  last  evening,
but it soon returned as severe  as ever ; she had no
rest, but was groaning all night.   Repeated the
bleeding to twenty-four ounces.  Blistered exten-
sively the neck and back.  Evening.   Not materi-
ally better.  Took sixteen ounces  more of blood.
Cold water continued to her head. 
30
   3d day. Slept a little; head easier; tongue brown
in the middle, but moist ; pulse one  hundred  and
twelve.   But she complained of distress across the
chest, and sickness at the stomach.  Takes nothing
but cold water.  This  calm was not to be trusted.
Twelve  ounces of blood  were taken.   Evening.
Was quite faint after the bleeding.  Chest and stom-
ach relieved ; but the head was heavy, and throbbed.
The application of cold water continued.
   4th day. Symptoms not so favourable as yester-
day ; pain in the head returned with almost its form-
er severity.  Stomach sick ; pulse  one hundred
and twenty, quick, small, feeble ; tongue dry, quite
dark coloured,  and cracked in  the middle.  Skin
warmer than usual.—Bled her twelve  ounces, and
gave a cathartic dose of the sulphate of soda, to
be assisted by an enema.  6 P. M.  Pain not quite
so great as in the morning.  Repeated the bleeding
to eight ounces.
   5th day. Pain in  the head abated,  but it feels
large, heavy and dizzy.  She is  occasionally deliri-
ous.   Pulse the same ;  coat on the tongue peeling
off, and leaving a  raw surface.  The cathartic of
yesterday operated once only.   A dose  of  Jalap
and calomel to be given.   The  head  to be shaved
that  the cold water may be more directly applied.
Evening.  No materia] change.
  6th and 7th days. She was comparatively easy ;
some of the time slightly delirious, but seemed at
least to be no worse. 
31
  8th day.  Pain in the head came on again severely
about midnight; complained bitterly of the pain
in her head; distress at the pit of the stomach, and
an aching of the lower extremities.   Pulse one hun-
dred and twenty ;  tongue  dry,  skin rather warm.
Bled her ten ounces.—6 P. M. Symptoms much
the same.   Repeated the bleeding eight ounces.
  9th. Symptoms milder; head, she says, feels more
like her own, and  objects appear more natural  to
her.  Bowels to be moved by an injection, and the
cold water  continued to her head.
  14th day. The  symptoms had appeared to  be
mild the four last days, pain in the head abated, and
our anticipations were favourable.   To-day the  as-
pect is less  flattering ;  had a restless night, pain and
dizziness of the head distressing ; pulse quick and
small, and  one hundred and twenty in a minute,
skin hot and dry.  Bled her six  ounces ;  gave a ca-
thartic and again blistered the back of the neck.
  After this day, the symptoms continued mild for
five or six days ; they then subsided, and the patient
recovered rapidly.

                  CASE XVII.  .
  Patient, a lad sixteen years old.  Visited him De-
cember 19th, 4 P. M. He had been sick about eight
days, confined to his bed the most part of that time.
He had been bled  once to the  amount probably of
eight ounces; had  taken some medicine, principally
a mixture of the spirit of nitrous  aether, and the 
32
wine of antimony :  but his symptoms had been get-
ting  worse.   He complained  of pain in his head,
principally in his forehead; pain in his back and
limbs ; weariness and aching of his extremities ;
pulse one hundred and  twelve, quick  but soft;
tongue thickly coated, the coat in the middle of the
tongue brown and dry ; skin rather warm,  but not
dry ;  that of the head very  hot.  The  treatment
commenced with removing all stimulating  articles
both of medicine and diet.  Twelve ounces of blood
were taken from the arm ; and  the constant appli-
cation of cold water directed  to his  head, and the
cold ablution to the body, when the  heat was on.
   20th,  9 A. M.  Symptoms continue  the  same.
Repeated the bleeding fourteen  ounces, and direct-
ed a cathartic.
  21st.  Some amelioration of the disease.—V. S.
Twelve ounces of blood taken.
  22d. Was quite faint after  the bleeding yester-
day ;  but when this was removed, he found himself
much easier.  Had a good night: pain in his head
very much diminished ; pulse one hundred ; feels
bright, and delighted with his improved state.  But
he had a paroxysm of heat in the  afternoon, and
was not so well in the evening.—Advised bleeding
immediately, but he was disposed to  defer it.
  23d. Does not feel so happy as yesterday morn-
ing.   Pain and heaviness returned in the head; pulse
one hundred and twelve, and he has  more heat and
restlessness.   Disappointed that he  does not con- 
33
linue to mend,  loses his confidence in blood-letting,
and declines having it again tried.  Directed a ca-
thartic ; blistered the back of his neck, and  con-
tinued the cold water.
   24th. Disease progressing.   Pain in the head in-
creased, accompanied Avith an increase of heat and
restlessness ; pulse one hundred and twenty, tongue
more coated, of a darker aspect, and dry; urine
scanty and very thick.—Consented to be bled, and
sixteen ounces  of blood were taken.
   25th. Symptoms mitigated, but not so much so
as on the twenty-second.  Cathartic to be repeated,
and the subm. of mercury to be given in small doses.
   26th. No improvement since yesterday morning;
the pain in the head and the heat continue unabated.
Pulse one hundred and twenty ;  tongue and urine
the same,—V. S. Eight ounces of blood were taken.
   27th. The heat abated after the bleeding yester-
day, but returned again in  the night, and continues,
notwithstanding the constant application  of  cold
water.  Repeated  V. S.  Eight ounces of blood
were taken.
   28th. The symptoms a little moderated.  Re-
quests that the  bleeding may  be repeated,  so great
was  the relief  which he  experienced from it yes-
terday. V. S.  Eight ounces of blood taken.  Had
two  or  three alvine motions by  the calomel; it is
to be omitted.
   29th. Pain in the head and heat very much  di-
minished ; coat on the tongue peeling off.
                       5 
34
   31st. Seemed to be doing well till the last eve-
 ning, Avhen the pain in the head returned with vio-
 lence, and the  heat of the skin  was great.  These
 symptoms have not diminished this morning.  V. S.
 Eight ounces of blood extracted.   Bowels to be
 evacuated ; cold water  continued.
   January 1st. Had a quiet night; very little pain
 in the head this morning,  and the heat very mode-
 rate.
   2d.  Head still remains comparatively easy, but he
 complains of pain  in his 4>ack  and aching of the
 limbs, is restless, and the skin  continues hot and
 dry.—Consultation  in the  evening.   It was agreed
 to give him the following :
                R  Subm. Hydrarg. gr. xij.
                  Pulv. Ipecac. - gr. vj.
                  Opii    -   gr. ij. M. f. Pil. No. xij
                   cum. sol. M. Nilot. q. s.
 One pill to be given every six  hours;  forehead to
 be blistered.
   3d.  Symptoms continue ;  pain in the head in-
 creased ; pulse one hundred and twenty, quick, and
 somewhat hard  ; skin hot and dry.—Consultation at
 noon.  Agreed not to bleed more.  Pills continued.
  4th. Symptoms the same.  Pills omitted, and a
 cathartic dose of rhubarb  given.
  These symptoms continued with very little vari-
ation, for fiye or six days longer.  During this time
no remedies were used except the cold ablution and
occasionally a cathartic.   The head now seemed to
be liberated,  but the back and lower extremities 
35
were still affected.  A distinct paroxysm of heat
returned every day, but it gradually became weaker
and shorter.  Much benefit seemed to be obtained
by often bathing and  rubbing the back along  the
whole spine with cold vinegar ; at least this opera-
tion gave the patient much  satisfaction.  All the
febrile  symptoms gradually  diminished; but  did
not entirely subside till about the end of this month;
after which he regained his accustomed health with
rapidity.
   This case appeared to me to be  one of those, in
which the  disease might have been arrested at the
commencement by blood-letting.   It is more diffi-
cult to procure such a result after the diseased habit
is fixed, and some morbid change effected.
   Had I used the remedy more boldly,  when the
patient came under my  care,  or even  followed up
the impression made after  the third bleeding, the
 course of the  disease  might probably have been
 shortened.  But something must often be  yielded
to the timidity of friends,

                  CASE XVIII.
   February 3d, noon.  I was called to see Mrs. L.
 a slender woman of infirm health.  She  was pros-
 trate on her bed, and complaining in piteous groans,
 of a violent pain and a sense  of an immense weight
oppressing her head ; the pain  was  seated in the
forehead,  and over the  eyeballs ; complained also
of great weakness, pain in her back, and aching of 
                      36
her limbs;  distress at the pit  of the stomach, and
nausea ; coldness and weariness.  Pulse one hun-
dred and thirty-two, small, quick,  feeble ; the coat
on the tongue already had a dark brown colour.  1
learned that she had been complaining of her head
for ten or twelve days past, and had been quite  un-
well ; that  with great exertion she went  abroad on
the second instant, and while absent, the pain in her
head suddenly increased to its present excess.  She
fainted,  and was  carried home very  ill.   Under
these circumstances, the prognosis  could not be
very favourable ;  the  disorder had continued so
long, and acquired an aspect  so formidable, that  a
mitigation  of the distress  was the most to be anti-
cipated.  The treatment commenced with bleeding,
twenty ounces of blood were taken from the arm ;
it was very black, did not coagulate for some time,
and formed no buff.   A  cathartic dose of senna
and manna  to be given ; the lower extremities  and
the body to be made warm by jugs of hot water ;
and cold water to be applied  to the head.
  4th. Cathartic  operated  well ;  the  nausea  and
distress at the stomach were so great, that she beg-
ged for an emetic ;  she had it about six P. M.  was
thoroughly evacuated, but obtained no  relief.  Dis-
tress in the head and at the stomach continued all
night; it does not abate, but its severity causes con-
tinual sighing and groaning.   Pulse one hundred
and thirty six; coat on the tongue dark brown, and
dry about the middle.   Urine  in small quantity, 
37
but deposits a large reddish sediment.—Repeated
the bleeding to the same quantity ; the blood  had
the same appearance.   Blistered largely the back
of the neck ; gave a cathartic of jalap and calomel;
warm fomentations to the pit of the stomach, kc.
   5th. She was faint for some  time after the bleed-
ing yesterday.  The acuteness of the pain in the
head abated, but it is extremely heavy and burthen-
some.  Had a short paroxysm of heat last night,
but the temperature of the skin is natural except
that of the head, which is constantly  very hot; the
wet cloths  applied  to it are heated  with  great ra-
pidity.  Stomach the same, accompanied with  pain
in  the left side.  A large blister to be raised  over
these  parts.  The cathartic did  not operate well;
senna tea to be given.  The mouth evidently affect-
ed by calomel, and  it  now appeared  that she had
taken, on the first and second, two doses of cathar-
 tic pills, in which there  were twenty  grains of  calo-
 mel, and the bowels were only slightly moved.  In
 the dose given yesterday, there were ten grains of
 calomel, quite enough in all to effect the system.
 Evening.   Head more painful; mouth very  sore
 from  the calomel; stranguary produced from the
 vesecatories.  Stomach still in great distress.—Bled
 her twelve ounces, and allowed her to take the  spirit
 of nitrous aether, a tea spoonful every three hours
 in flaxseed tea.
    6th. Accidental symptoms relieved.  Pain in the
 bead not so acute.   Cathartic operating this morn- 
38
ing.   Evening.   Pain in the head distressing; pulse
one hundred and thirty-six ; tongue, &c. the same.
V. S. Twelve ounces of blood extracted.  Nitre
omitted.
  7th. Better this morning.   Evening.   Not so
well.   V. S.  Ten ounces of blood taken.
  8th. Her state the same as yesterday.  Evening.
V. S. Took six ounces of blood, and blistered the
left side of the head, in which the pain was the most
acute.
  9th. Head  more calm, but the stomach very sick,
and in great distress.   Bowels  to be evacuated by
magnesia  and enemas.   Evening.   Stomach re-
lieved.
  10th. Pain  in the head returned  this morning;
pulse one hundred and twenty, more  firm than it
has been; appearance of the tongue unfavourable ;
skin has more heat than  usual.  V. S.  Only  five
ounces of blood were taken in consequence of a
bad orifice ; the patient had no convenient vein for
bleeding.  Evening.   Head easier.
  11th. Head in great distress  again; cannot en-
dure the least  motion ; pulse one hundred and twen-
ty eight.   Attempted to bleed, and obtained seven
ounces of blood.  Gave a cathartic,  and again blis-
tered the back of the neck.   Evening.  Bowels
evacuated ; head less painful.
  12th. Head in pain ; pulse one hundred and twen-
ty, quick and hard.  V. S. four ounces taken.  Six
P. M.  Had a paroxysm of heat this afternoon: 
39
head and pulse the same.   V. S. Eight  ounces ot
blood obtained.
  13th. Had a good night, and is quite bright this
morning ; head comparatively easy, but not entire-
ly free from pain ; can move herself with facility ;
pulse one hundred and twelve ; tongue begins to
clear.
   14th. Head  more 'painful  to-day.  V. S. Four
ounces taken.  Cold water to be re-applied.
   15th. Still worse.  Tongue dry again; pulse  one
hundred and twenty.   V. S. Eight ounces taken ;
blood has a buffy coat.  Back of the neck re-blis-
tered.
   16th. Seems better; tongue cleaning; asked for
cider and beef tea; indulged.   Pulse one hundred
and twelve.
   17th. Has some pain in  the left eye, but in other
respects about the same.   Took senna and  manna.
   18th. Pain in the eye increased ; has pain also in
the back of the head.  V. S.  Five ounces of blood
extracted.  To be blistered  behind  each ear. It
ought to have been, mentioned, that the urine  had
become sufficiently copious and clear.
   19th. Pain in the head increased, and has changed
 its place.  It now shoots from  the left eye, to
the back of  the head,  and  is very distressing.
 Pulse one hundred and twenty, quick  and small.
The tongue had  been moist, and its foul coat nearly
cast off;  its cuticular coat has now become  dry,
 and of a brown colour even to its tip.   V. S. Took 
40
 eight ounces ol blood.  Seven, P. M.  Pain still se-
 vere, though not so bad as in the morning.  Re-
 peated the bleeding to the same amount.   The cold
 water to the head very grateful.
   20th.  The same process seems to be going on in
 the back of the head,  as has just terminated in the
 forehead.  This now  has become  the seat of the
 pain, and the heat of that part is so excessive, that
 it can be kept supportable only by a constant change
 of the wet cloths upon which it lays.   She had  a
 chill  this morning,  followed  by a sense of great
 heat; but to the hand of another her skin was quite
 cool.  Pulse  one  hundred  and  twenty, quick :
 tongue as  yesterday ; urine  again deficient, and
 thick, with a reddish  sediment.   V.  S. and took
 twelve onnces  of blood.  Gave a cathartic.   Six,
 P. M. No material change.   V. S.  Six  ounces of
 blood extracted.
  21st. Symptoms mitigated a little.
  22d.  Complains of a violent throbbing in the
 back of the head ; the old pain in the  side and dis-
 tress at the stomach has returned.  Bowels  to be
 moved by a cathartic  dose of rhubarb and an ene-
ma ; hot fomentations  to the side and stomach, and
 a blister  upon  each arm.  Evening.   Vomited se-
 veral times after the enema was given.   Took pep-
 permint in hot water to relieve the stomach.  Had
 two copious alvine evacuations, and the  distress at
 the stomach subsided.
  23d. Seemed a little better. 
41
  24th. Throbbing and heat returned in the head ;
and likewise the pain in the side and distress at the
stomach.  V.S. Four ounces taken.  Blistered the
side and back of the neck.
  25th.  Strangury again  from  the  vesicatories.
Throbbing in the head  still severe*   V. S. Four
ounces extracted.
  26th and 27th.  Symptoms more favourable.
  28th. The patient very much worse.  It seemed
that she had yesterday  several cold chills, and at
twelve last night, commenced a smart paroxysm of
heat, accompanied with severe pain in the left  side
of  the  head, ear, face and teeth ; aching of the
limbs, distress in the chest, difficulty of breathing,
restlessness and jactation.   Pulse one hundred thir-
ty-six ; tongue  black, coated again to the tip.   Im-
mediately performed V. S. and took twelve ounces
of  blood.  Six P. M. had a slight paroxysm at two
o'clock, but has been quite easy since the bleeding.
   March 1st. Some pain continues in  the ear, face
and jaws.  Had a slight chill this morning, followed
by  a  little heat; pulse  one hundred  and twenty,
quick. V. S.  Six ounces taken.  Blood does not
readily coagulate, and has the buffy coat.
   Various applications were made to relieve this
pain about the  face, among which were blisters be-
hind  the ear,  and on the  side of the face.   We
gave opium one night, but with unpleasant effects.
The pain gradually subsided,  and other symptoms
  emed to be improving for four or five days.   But
                         6 
42
 again  her  nights became restless, and the febrile
 symptoms  were increasing.  On the ninth, she com-
 plained of  an acute pain in the left side of the head
 and eyeball; pulse one hundred  and ten, quick ;
 tongue dry and brown,  V. S.  Six ounces of blood
 were extracted.
   These pains  then subsided, and the febrile symp-
 toms seemed so much abated, that a little wine was
 allowed.  Six  glasses in  all were taken from the
 tenth to the fourteenth, when the febrile symptoms
 were again  increasing; head heavy and stupid, with
 pain across the forehead ; pulse  one hundred and
 twenty, quick ; tongue dry and brown.   The mis-
 chief was attributed to the wine.   It was laid aside.
 Bowels well  evacuated, and the cold water applied
 to the  head.   She took oatmeal  gruel, and  cold
 water with  magnesia ; the  latter was  the  most ac-
 ceptable drink.  There seemed to be some amend-
 ment till the  eighteenth,  when the febrile parox-
 ysms became longer and more depressing ; and on
 the twenty-first, she had severe pain in the head and
 other unpleasant symptoms.  Six ounces of blood
 were extracted.
  On the twenty-second, she was much better ; pain
 subsided, pulse  ninety-six, fuller than it had been ;
 she was bright,  relished food, and flattered herself
 with a  speedy recovery.  But the unfortunate wo-
 man was now exposed to the noise and turbulence
of a delirious husband, and for two days and nights
had no repose.  She suffered from agitation of mind
.»«■ 
43
 and  became herself almost deranged.  Her head
 became painful and the febrile paroxysms more se-
 vere, and a relapse was threatened.   Six ounces of
 blood were taken from her; she was blistered about
 the head, and took a cathartic.  She was relieved
 in a  measure,  and hopes  were entertained  that
 nothing worse would follow.  Some pain continued
 in her head, and the pulse remained small and quick.
   On the  thirty-first,  the pain in the head had in-
 creased, and the pulse was very small.  Bled her
 six ounces.
   April 1st, 9 A. M.  The  deterioration  was nol
 checked.  She had completely relapsed, with vio*
 lent pain, principally in the  right  side of the head,
 where it had not been  before since the commence-
 ment of her  disorder.   She laid  with her mouth
 half open, and  complained  of being very  stupid,
 having great lassitude, weariness and soreness of
 the  limbs.   Tongue dry and brown ; pulse one
 hundred and twenty, quick, and very small,  like a
 thread.  Here life  was again  in great hazard, and
 nothing promised relief, but the old remedy.   I bled
 her to the amount of six ounces, and  blistered the
 forehead, and the  back of the  neck.  Evening
 Symptoms  the same.   Repeated  the bleeding to
 the same extent,
   2d. Symptoms nearly  the same.  Pulse fuller^
and larger.  Repeated the  bleeding to six ounces,
Evening. No material change.  Bleeding repeal
ed to four ounces, 
                       44
   3d. Symptoms more flattering; stupor and pain
abating; pulse  larger,  one hundred and ten in a
minute.—V.  S.  Six ounces  of blood  extracted.
Evening.   Great heat on the skin, and head more
painful.  Took four ounces more of blood.
   4th. A little better in the  morning.  Gave  her
ten grains  of calomel  as  a  cathartic.   Evening.
Bowels  not moved.   The febrile  paroxysm  ran
high.   Had great pain in her head, at the pit of the
stomach, and in one leg, and  complains of numb-
ness in the other limbs.  Repeated the bleeding to
six ounces,  and the calomel six grains more.
   5th. A little better. Had three alvine discharges,
assisted  by  sulphate of soda.
   6th. The same as yesterday.  The mouth  is af-
fected by the calomel.
   After the ninth, the head  was quite  liberated,
but the inflammatory action continued in the spinal
marrow, and the common symptoms  of fever were
exhibited in the trunk.   Two exacerbations occur-
red every twenty-four hours,  with intermissions of
about two hours between them.  Generally at the
evening paroxysm a severe pain came on in the epi-
gastrium, and the umbilical region, to relieve which,
a variety of means were tried.  A gentle cathartic
afforded the greatest degree of mitigation.   A suffi-
cient dose, therefore, of the Pilula aloes et myrrhoe,
was taken  every night,  to produce  one or two al-
vine motions the  next morning.  The appearance
of the discharges was natural.  This pain returned
only occasionally after the ninth. 
45
  The affection of the trunk continuing about the
aame, notwithstanding the frequent application of
the cold ablution, particularly  to the back, the te-
pid bath was used on the thirteenth.  She was put
into it three nights in succession, but  deriving no
apparent benefit,  farther trial was declined.
   May 1st, The febrile symptoms had  nearly sub-
sided, and health seemed about to be restored, when
a severe inflammation  of the lungs commenced, ac-
companied with cough,  acute  pain, and many of
her former symptoms.   She is obliged again to sub-
mit to farther evacuations, blistering, &c. &c.
   The  inflammatory  action in this case was un-
commonly obstinate;  it  would seem to be  subsid-
ing, but at the moment that a hope began to be in-
dulged, that it would decline as in other  instances,
when relief was  obtained, its increase would  be
manifest.  Thus, no less than four distinct accessions
of  the disease occurred.  That they  were the ef-
fects of the spreading and augmentation of the in-
flammatory action, is proved by  the fact, that the
symptoms were in each instance reduced within the
bounds of present safety by bleeding,  and the pa-
tient allowed another  chance for existence.
   The cause of the protracted course of this case,
was probably the diseased action having become fix-
ed and extensively spread  before the treatment
commenced.  I am aware that it will be attributed
by some, to the mode of treatment.   To such a
supposition, I oppose  what I confidently believe tg 
46
 be the fact, that with any other treatment, at present
 known, sudden death would have  been  certain.
 The result of the other cases may also be adduced;
 in these the same effect ought to have been produc-
 ed, were• the supposition  well  founded.   On the
 contrary,  farther experience as to the safety of a
 free use of this remedy, will probably enable us,
 not only to arrest a destructive termination of this
 disease, but to bring even bad cases to a favourable
 and expeditious conclusion.

                   CASE XIX.
  February 27th. The patient, a lady, Miss----,
 had been for many days indisposed with a cold and
 severe cough,  and had suffered much  with headach.
 She had endeavoured to remove these affections by
 cathartic medicines, squills, &c. &c. But as the
 cough and headach increased, and her lungs began
 to suffer with pain and soreness,  she  asked  advice.
 This  was on the twenty-fourth.   She  was  bled;
twelve ounces of blood were extracted from the
arm.  The next day took a cathartic,  and was much
better.  The morning  of the twenty-seventh, she
was so well, (there was still, however, some pain in
her head,) that she intended going abroad in the af-
ternoon.   She took a light dinner, but very soon
after was attacked with a severe  and  general  chill
and shivering.   This, some time after, was followed
by a considerable heat  of the skin, severe pain in
the head, across the forehead; a stricture across the 
47
chest, and pain in the shoulders, so as to render res-
piration distressing;  pain in the back, and aching ol
the limbs, accompanied with a numbness and prick-
ing sensation.   She had attempted to get relief by-
bringing on perspiration; but her distress increased
to a degree insupportable.  I saw her at about ten
P. M. She was greatly agitated, almost to delirium,
begging to have an immense weight removed from
her head.  The pain in her head, she said, was in-
describable ; that in her shoulders very acute, and
accompanied  with  a frequent  cough,  nausea, and
retching.   Her skin had more than its natural heat,
tongue slightly coated, pulse one hundred, quick,
depressed.  The artery seemed as if sunken deep-
ly among soft parts,  making little resistance to the
finger.
  All hot things were immediately removed except
from the feet,  which were  cold.  I took twenty-
four ounces of blood from the arm, and she was a
little faint; had the head, shoulders, and chest con-
stantly bathed  with cold vinegar,  and allowed
nothing to be taken  but cold and simple drinks.
  28th, 9 A. M.  She was quiet a short time after
the bleeding; the cold applications were very grate-
ful, and she rested a little.  Had,  however, some
delirium towards morning, and the symptoms were
nearly as bad as last evening, especially the pain in
the head, in which there was a  throbbing so violent,
that she compared it to blows from a mallet.  The
nausea on the  stomach continued, and occasionally
i 
48
she vomited, which she was very desirous of doing.
The skin was cool, tongue more coated with a dense
white fur ; pulse one hundred and ten.   The bleed-
ing was repeated to twenty  ounces ; the  cold  ap-
plications  continued, and she had an emetic.   Six
P. M. The emetic operated thoroughly, after three
full doses  of Ipecac, and the tart rite of antimony
had  been taken.   The nausea  and retching, how-
ever, were not removed, and the effect was so pros-
trating and distressing, that she was hardly sensible
to any other pain.  An enema was given, and  hot
fomentations  applied to  the  epigastric  region.
Cold water to the head.
  March 1st, 9 A. M. More comfortable ; pain in
the shoulders and chest  removed; stomach  more
calm.  The enema produced  two or three alvine
discharges.  Pain in the  head less violent, particu-
larly if it be kept perfectly  still.   Skin cool, pulse
one hundred and ten, the  same character ; the coat
on the tongue dark at the roots;  urine scanty  and
thick.   Bleeding  repeated to twelve ounces.   Six
P. M. Nausea returned in the  afternoon ; rubbing
the back with cold vinegar  seemed to relieve it.
Complains of a  pain in  the left side, and  has a
troublesome cough.   Other symptoms the  same.
V. S. Ten ounces of blood taken.  The back of
the neck and the side to  be extensively vesicated.
  2d. Seems to be much  better ;  can  bear moving
very well; pulse one hundred, still, however, quick
and  unresisting.   The vesicatories have very little 
                       49
effect; to be continued.   Seven P. M. Much the
same, except the cough is troublesome.
  3d, 10 A. M. Symptoms all worse; was restless
the first part of the night; at about  midnight had
a severe shivering, followed by  an increase of the
pain  in the head, delirium,  pain in the shoulders,
left side, and groin ; accompanied with cough, nau-
sea and retching.   Pulse one hundred and twelve,
quick, but unresisting;  head very hot, other parts
of the body cool, feet  cold ; tongue red, and dry
in the middle.  Took from her immediately sixteen
ounces of blood ;  it  coagulated slowly, and was
buffy.  The side was blistered, the neck only slight-
ly irritated; vesicatory  to be renewed.  Bowels to
be evacuated by an enema.  Cold water to the head;
artificial heat to the body and limbs.   Seven P. M.
A little relieved ; was faint after  the bleeding in the
morning,  but she has had some slight chills since
noon. Craves ice; is indulged.  Pulse  the same
as in the morning.—Repeated the bleeding to eight
ounces.
   4th. Had a very  uncomfortable night  from the
strangury caused  by the blisters, sickness  at the
stomach, and a sinking faintness ; a table spoonful
of wine was given in the night, with a little pep-
permint ;  she  thought it  made her  head worse;
which she says feels immensely large, crowded and
dizzy, but  is  quite free from pain  unless  moved
quickly.  Tongue entirely  clean and moist, but
its surface is pale, and  as smooth as if polished.
/ 
50
 Pulse feeble and small.  Declines taking any thing
 except magnesia and water, made cold with ice.
   4th.  Had a more comfprtable night;  strangury
 removed, but a soreness remains in the hypogastric
 region,  and a frequent cough produces great pain
 in that  part.   Head as yesterday ; pulse one hun-
 dred and sixteen, quick, skin  warm ; tongue the
 same.   Bowels to be evacuated ; warm fomenta-
 tions to the hypogastrium ; cold water continued to
 the head.   Six P. M. Symptoms much  the  same,
 except  a sinking at the  stomach, and flatulence.
 Had two alvine discharges.   In consequence of the
 great distress of the stomach, she took a tea spoon-
ful of brandy in cold water.  Allowed it to be re-
 peated with great care.
   6th. Stomach, bowels and cough  relieved; but
her head still feels unnatural, large, and dizzy, and
occasionally throbs with violence.   Had taken only
two tea spoonfuls of brandy.  Six P. M. A very
considerable change for the  worse ;  had a chill at
noon, and has been cold since ; pain in the head re-
turned, accompanied with slight delirium, sickness
and a sensation  of sinking at the  stomach.   Pulse
one hundred and  sixteen,  quick ; tongue dry and
brown, but  as smooth as it has been.   She had taken
two more tea spoonfuls of brandy very much dilut-
ed with  water.   It  is to be entirely  omitted.  To
remove  these symptoms, it was deemed necessary
to bleed again.  Six  ounces  of blood  were taken.
10 P. M. She bore the  loss well and  seemed  to be 
51
benefited.  Four ounces more were taken from the
same orifice.   It was very thin, did not coagulate
for some time, and then had a thin coat of fibrin.
   7th.  Was  tolerably comfortable through the
night, but complains much of her head this morn-
ing ; it feels  immensely large and  heavy ; cannot
realize that it is her own ; if moved,  it throbs vio-
lently.   Pulse one hundred and twelve.   Had the
head shaved, and a vesicatory, sufficient to cover its
whole surface, applied. Six P. M. Head thoroughly
blistered ; but it throbs more constantly than in the
morning ; sickness of the stomach returned.  Had
a chill at noon, and has been very cold since ; she
is with difficulty kept warm by bottles of hot  water
and other heating applications.  But notwithstand-
ing this  coldness,  she craves incessantly ice-cold
drinks,  which she often throws from her  stomach.
I again directed brandy to be put into her drink ;
hot fomentations to the epigastrium, and heat to the
extremities, &c.
   8th. She was in  great distress all night;  the vom-
iting ceased,  but  the sensation of sinking  at the
stomach returned to  such a degree, that she sup-
posed herself dying, and was willing to be released
from her present  sufferings.  She  took hot  wine,
peppermint,  and the ammoniated alcohol, but the
stomach rejected  them ; the puking  gave  relief.
Her head is very much in the state it was yesterday
morning.  Six P. M.  Stomach a little better ; she
is slightly delirious, or more properly  may be said 
52
 to be highly excited.  Complains of no pain ; pulse
 one hundred and twenty.  Brandy and all stimulat-
 ing substances forbidden.  She had taken  exactly
 one ounce of brandy since the last evening, but re-
 tained very little.
   9th.  Talked all night incessantly ; complains that
 her head is dizzy,  and  throbs ; pulse  the  same ;
 tongue still has that polished smoothness, except on
 one side is a deep ulcer,  and she complains that its
 whole surface is raw.  The back of the neck to be
 again  blistered.   Bowels  to  be evacuated.    Six
 P. M.  Delirium  continues.   Sleep to  be procured
 by laudanum.  The  cold water to be  re-applied to
 the head.
   10th. Her stomach rejected the laudanum, and
 the vomiting returned whenever she  attempted to
 take any thing.  Six P. M.  Calm and  easy.
   11th.  Slept three or four hours last night; but
 the delirium still continues ; complains of her head
 and stomach.   A blister to be raised upon each arm.
 Six P. M. Delirium increased at noon,  and she took
 one grain of opium,  which in a short  time  caused
 her to vomit.  She is more  calm, and is to take no-
 thing except mild liquids.
  12th.  Had a quiet night, and slept some.  But
 this morning she  had  a cold chill, accompanied with
 a violent pain in the  head,  distress at the stomach,
 and in the throat; she is perfectly calm  and rational,
but in great distress.   Pulse one hundred and twen-
 ty.  Took  from her immediately,  six  ounces of 
53
blood.   Evening. Very easy and calm.   Pulse the
same.
  13th. Quite calm and easy all  night.  Thinks
her head  feels better.  Pulse  one hundred  and
twelve ; skin  of its natural temperature ; tongue
the same  as on the ninth.   Head to be  kept con-
stantly wet with cold water.
  14th. Complains more of her head this morning;
the least  motion produces throbbing ;  pulse one
hundred and twenty.   Bowels to be evacuated by
medicine.  Six  P. M.   Had quite a hot  flush  at
noon,  head and stomach  in great distress. V. S.
Six ounces of blood taken.  The bowels were thor-
oughly evacuated.
  15th. Symptoms  milder.  Evening.   Has had a
slight  delirium all day.  She takes nothing except
a pleasant solution of the super-tartrite of potass.
A blister to be raised behind each ear.
   16th. Night  pretty  calm.   Complains of her
head and  stomach.   Evening.   Heat  at noon ;
head and stomach worse; delirium cpntinues ; pulse
one  hundred and twenty.   Bled her six  ounces.
   17th. Better, but has some delirium.   Cold wa-
ter to the head continued.
   18th. Symptoms improving ; pulse one  hundred
and  twelve ; tongue begins to discover some of its
natural papillae upon its edges ; they are, however,
very small and pale.   Some inclination  for food is
manifested, and chicken broth allowed. 
54
  19th.  Seems to be doing  well.  Evening.  Had
a febrile paroxysm at noon ; is much excited, and
complains of the throbbing in the head.—Bled her
four ounces.
  20th, 21 st, and 22d. Moving on favourably ; takes
nourishment, and sleeps tolerably well.
  23d. Complains of her head to-day.  Bowels to
be  evacuated.   Evening.   Head still aches, and
she says she does not feel so well.   Pulse one hun-
dred and sixteen.   Bled  her six ounces.
  24th.  Quite comfortable ; bears getting up well,
and takes nourishment with  a good relish ; such as
chicken broth, &c. &c.   Begins to-day with the de-
coction of quassia.
  I now flattered  myself that  the  restoration  of
my patient was nearly accomplished.  The disease,
indeed, was not removed, the head was not liberated,
the pulse remained at one hundred and eight or one
hundred and twelve, and there was an exacerbation
of the febrile symptoms at least once every twenty-
four hours.  But as the symptoms had so far yield-
ed, it  was to be expected they would continue to
subside.   We were allowed to indulge this hope
for four or five days.  But on the twenty-ninth, the
prospect was not  so favourable.  The preceding
night  had been restless and  uncomfortable ; she had
sickness at the  stomach, and considerable  pain in
the head, accompanied  with deafness and dizziness.
Gave her a cathartic of rhubarb and calomel, and
blistered the back of the neck. 
55
  30th.  The cathartic operated well, but relief was
not obtained.   The pain in the head, and the sick-
ness of the stomach increased ; pulse one hundred
and twenty, quick and small.  Took from her six
ounces of blood,  and directed two grains of calo-
mel combined with a very little opium, to be given
every six hours.
   31st.  Sickness  and pain  diminished;  pulse the
same.
   April 1st.  Symptoms all worse ;  a relapse had
taken place,  marked  with  all the severity of the
first attack.  Had a severe and protracted chill, ac-
companied with great pain and numbness in the
forehead and back of the head ; nausea and vomit-
ing.   The chill was soon followed by heat, aching
and numbness of the limbs, pain in the back, side,
and epigastrium; pulse one hundred and twenty,
quick, very small, and sharp.  The  membrane of
the tongue had been smooth  and  somewhat rigid ;
it was now brown and dry.  Blood-letting was again
resorted to ;  eight ounces of blood were taken ; it
was very thin, coagulated slowly, and was coated
with a thin buff.  Subm. Hydrarg. continued.  Eve-
ning.   Very little mitigation.   V. S.  Bled four
ounces.
   2d. 9 A. M.  Symptoms  a little moderated,  ex-
cept the pain in  the epigastrium, which at times
was very  severe.  Repeated the bleeding to six
ounces. Evening.  No material improvement,  V. S.
Four ounces of blood taken. 
56
  3d. The night passed comfortably, and she was
a little better.  The brown colour disappeared from
the tongue ; pulse one  hundred and twelve.  The
pain  still continued occasionally in the epigastrium.
Bowels  evacuated by an enema ; discharge quite
black.   Twenty grains of the Submur.  Hydrarg.
had been taken ; the mouth was not affected.  I di-
rected four grains to  be given twice a day, for the
double purpose of affecting the mouth and the bow-
els.   Evening.  Symptoms the same.
  4th. Suffered great distress last night in the head,
and at the pit of the stomach, accompanied with
vomiting ; took an opiate, but thought it increased
her misery.  These symptoms continue this morn-
ing.   Took from her six ounces  of blood, re-blis-
tered the back of the neck, and the epigastrium ;
continued  the subm. Hydr.  Evening.  Very free
from pain.
  5th. Had some rest.  The pain  in the  epigastri-
um returned ; she took two tea  spoonfuls of the
camphorated tincture of opium with some benefit,
The  pain and sickness  returned this morning with
great distress in the head.  Repeated the bleeding
to six ounces.  Bowels evacuated  by an enema;
discharge  dark green.   Subm. Hydr. continued.
Evening.  Quite easy till three P. M. when the pain
returned with the usual febrile paroxysm.
  6th. Had a bad night in consequence of the pain
in the epigastrium,  which moved also into the um-
bilical region.  Was not relieved by the paragoric, 
57
which was rejected by the stomach.   Bowels to be
evacuated by an enema.   Mouth a little affected by
the calomel; forty-four grains in all had been taken;
not to be repeated.  Head easy.  Evening.  Pain
in the bowels relieved by the evacuation, but return-
ed again towards  night.  Attempted to retain  ca-
thartic medicines, but, after being down two hours,
they produced vomiting.  Opiates, she  insisted, in-
creased her distress.
   7th. Had some  rest; pain nearly subsided,  but
the stomach will  retain nothing.  Head  remains
quiet.   Blistering  to be renewed over  the epigas-
trium.
   8th. The vomiting subsided, and she  slept some
hours during the night;  but had  a chill, followed
by heat towards morning,  and  the pain in the epi-
gastrium and the vomiting  returned.
   The stomach remained in this state, with intervals
of rest, for four days longer.  The sickness was at-
tempted to be allayed by a  variety of  means.
Sometimes opium  seemed to do good, and some-
times a little  brandy and water would be retained ;
but, generally, any stimulating article seemed to in-
crease the affection.   If any thing did good, it  was
the mild  bitter decoctions,  such as wormwood,
camomile flowers,  and quassia.  Every attempt to
evacuate the bowels, either by medicine or an ene-
ma, invariably produced vomiting.  On the thir-
teenth she was very comfortable ; bore  getting up
well,  and took food with a good appetite.  Pulse
                        8 
58
one  hundred and eight,  soft, elastic.   Tongue be-
gan to show its papillae,  red  and prominent at the
tip.   The head continued comfortable.   The bow-
els had not been  evacuated for some days, except
partially by  enemas.  This opportunity was im-
proved to  introduce rhubarb into  the stomach, in
small doses in pills at convenient intervals, for the
purpose  of producing  a  thorough motion.   But
when about twenty-four  grains  had  been  taken, the
vomiting returned with  great violence.  It lasted
till the evening of the fourteenth, when after a large
quantity of pea-green matter had been ejected, it sub-
sided.  The fifteenth and sixteenth  days  were very
comfortable.   Sat up half  an hour on the sixteenth.
She was not so well on the seventeenth, had  some
headach, and a febrile paroxysm, accompanied with
sickness.  The smooth,  thickened, whitish  coat,
which had covered the tongue,  had cracked, and
presented a number of deep  ulcerations, which
gave much trouble.  The bowels were put in mo-
tion by an enema.
  Things remained  very much in this state till the
twenty-sixth.   A febrile  paroxysm returned every
day,  for the most  part accompanied with sickness ;
some days the sickness  was  considerable.  There
was, however, a gradual improvement.  The tongue
healed ; the strength and appetite increased, &c.
  On the twenty-sixth, the bowels  began to move
without assistance, and the evacuations were large
and natural.  The febrile paroxysms shortened, the 
59
sickness nearly subsided :  pulse one hundred, soft,
full, and  elastic ; tongue  getting natural.   After
this there was a rapid improvement; the sickness
entirely subsided ; appetite good, and the stomach
digested meat and bread with great facility.
   The principle restorative  articles, which  have
been administered, are the simple bitter decoctions,
the juices of meat, and the bland articles of  food.
Wine, and other stimulants,  were not  agreeable,
and were very apt to produce sickness.
   May 1st.  Since  the last notice, wine  is taken in
small quantities, and the muscular strength is re-
gained with rapidity.
   The sickness of the stomach in this case is so se-
vere, that it requires some  particular notice.  Dis-
turbance of the stomach had not been an unusual
occurrence in other cases,  and  in another  part of
this paper, I have attributed this affection to the
 state of the brain in this  disease.  In the onset of
 this case,  it probably arose from the same cause.
 But after the relapse, the  sickness  was  more con-
 stant, and often violent,  and seemed  to arise from a
 more local affection  of the alementary  canal.  It
 did not  seem to be owing  to inflammation, in the
 coats of the stomach, or intestines ; the usual symp-
 toms of such a state were not present.—For there
 were long intervals  of rest from  the  nausea, in
 which time food was grateful, and borne well on the
 stomach. Still it  appeared  to be the effect of in-
 flammation :  opiates  did  not relieve it, but often 
60
 caused stricture and distress ; stimulants, though
 they seemed to afford a little relief,  when the ex-
 haustion was great, on the whole aggravated the
 evil.   It appeared to me that the difficulty was  in
 the caliac plexus and ganglions.  1st. The pain in
 the epigastrium arose from the same cause  as the
 sickness, and the patient uniformly referred the pain
 to the  place of this nervous plexus.   2d.  The pain
 and sickness usually occurred by  paroxysms, with
 other febrile symptoms, and  they were  the most
 successfully relieved by the same means which re-
 lieved  the other symptoms.   3d. The secretions
 from  the liver were  morbid.  4th.  The  bowels
 could not endure the least disturbance ; and any
 attempt to move them, either by medicines or ene-
 mas, produced distress and  vomiting.  5th. The
 pain and sickness declined with the  other febrile
 symptoms, and the  stomach and intestines were im-
 mediately able to perform their natural  functions
 with vigour.  Positive evidence cannot be obtained
 as to the above point, but whatever were the cause
of the  vomiting, it  essentially aided in reducing in-
flammatory action.
  The extent of bleeding in the two  last cases will
to some appear excessive ; but there was no alter-
native.  I should not have dared to have taken the
risk of the patient's life, and  left  the disease to it-
self, short of any one of the evacuations of blood.
It is not probable that it would be often necessary
to carry the remedy  to the same extent.   It does 
61
 not appear,  however, to have been in any way in-
jurious ;  and life, in my opinion, could  not  have
 been sustained short of this extent  of bleeding ;
 unless, possibly, by repeating the operation at short-
 er  intervals  in the  first stage of the disease, the
 course of it might have been shortened, and the less
 quantity  in the end been necessary to affect a cure.
 These were  extreme cases ; there symptoms  were
 precisely those presented by the patient, who was
 the subject of Examination first.  In case nineteenth
 they were even  more  extreme  at the  commence-
 ment ; they were of  that description, which usually
 kills in from five to ten days.  In such cases, I will
 venture the assertion, life never has been sustained,
 except by the same means.  The laws of their pro-
 gress, therefore, and  the extent of means necessary
 to affect a safe termination, cannot well be compar-
 atively estimated.
   It will be perceived,  that in the management of
 this  disorder, I have placed a  chief reliance on
 blood-letting,  and from the character and result of
 the cases  here presented, it will, I think, be readily
 granted,  that my confidence  was  not misplaced.
 From the first of October  to the  fiist  of April, I
 treated nearly forty  cases of this disorder,  all of
 which, except one, which was very mild,  required
 the  use of the lancet  to a greater or less extent.
Every  case has terminated fortunately.*  It is not

  * How far the pneumonic affection in case eighteenth, is to be con-
sidered connected with, and a part of the first disorder, it is not easy
to determine  ; the patient, however, is in a fair way to recover from
that attack. 
62
pretended that none of these cases would have re-
covered without blood-letting.   But it is believed,
that more than one third would have died, and some
of the remainder  been in great hazard.  This as-
sertion is  made with  the greater confidence, as I
witnessed  some cases  which baffled the powers of
other remedies.  Their symptoms were precisely
of the same character and  degree of violence, as
in some of those, which  yielded to blood-letting.
Other means of cure,  indeed, were not neglected,
but the effect, must, I think, be attributed to this re-
medy.   The principal remedies used, besides blood-
letting, were,—1st,  deprivation of all food and sti-
mulating substances.  This  contributes to the same
end as blood-letting. 2d.  The cold ablution.  This
is not only very grateful to the patient,"  but proba-
bly aids very much in diminishing the  severity of
the symptoms.  3d. Vesication.   From the receiv-
ed opinion of the modus  operandi of this remedy,
much was expected  from  it;  frequent use  was
made of it in the bad cases, and it  probably did
good.  I avoided, however,  for the most part,  this
operation  upon the head,  as I  thought quite as
much gained by the application of cold water.   4th.
Cathartics.  These are important aids  in most va-
rieties of typhus.   I cannot say, however, that they
had any very positive effect in diminishing the
symptoms of the  variety at present under consider-
ation.   5th. Emetics  were used  occasionally, and
to  obviate some accidental inconvenience.  They 
63
did not appear, in any other way, to be beneficial.
6th. The  tartrite of antimony in  solution.  This
could seldom be retained, in very  small doses, but
even then it did not appear to have the least effect.
The contrary,  however, has  been evident in other
varieties of typhus.   7th. The same  may  be  said
of  calomel as an alterative.  Even when salivation
was effected, the symptoms of the disorder  did not
appear to  be in the least mitigated.
   Blood-letting, then, was, without doubt, the prin-
cipal agent in effecting the cure in the above cases;
and it appears to me to be the appropriate  remedy
for typhus fever.   This is not my first essay with
the lancet in typhus ; I have before had  reason  to
value highly its efficacy in this disease, though I
have not been obliged to use it to the same extent.
I can,  therefore, recommend  it with the  greater
confidence, as a safe and efficient remedy in this
disorder;  at least, it is as much  so in  this, as in the
lung fever.  It is not  pretended that it will cure
every case, under any circumstances ; but it is in
many instances the only means which can allay the
disorder and give the patient a chance for  life.   It
will, even in severe  attacks,  often completely ar-
rest the progress of the disease, and put the patient
in a state of immediate convalescence.  But placing
it on the same footing as to efficacy  and certainty,
it still holds important advantages over other means,
two of which  only 1 shall state.   1st. The  debility
of the patient, treated with this remedy, i* much 
64
 less at the termination of the disorder,  though the
 loss of blood may have been considerable, than if
 treated in the common way.  2d. The  senses of
 the patient are rarely affected, and that state of in-
 sensibility and  suspense  between life  and  death,
 which, in severe cases,  forms the  crisis of the dis-
 ease, does not occur. '* There is no marked crisis in
 cases treated by  blood-letting.   The disorder gra-
 dually diminishes, till it entirely disappears.
   In the employment of this remedy, some regard
 is to be had to the end to be accomplished.  It is to
 be presumed  that no man would  use  blood-letting
 in any disease, unless he were convinced that inflam-
 mation, or a state  approaching to  it, were present.
 With this conviction, his object would be to subdue
 this state, or at least so far to diminish  the inflam-
 mation, that life would not be in danger.  But it is
 frequently said  of bleeding, that it did  no good,
 even where it would seem to have been indicated,
 and it is sometimes charged with the unfortunate re-
 sult of the disorder.  In such cases the quantity of
 blood abstracted, the circumstances under which it
 is done, as it regards the  violence of the disease,
 and the progress it had made, are seldom taken into
 the account.   It does no  good to  bleed a little
 when the  inflammation is violent,  and seated in a
vital organ.  This would be like attempting to ex-
tinguish a large fire with a cup of water.   If we do
not arrest the progress of the inflammation, we may
 as well do nothing, for death will as certainly ensue 
65
as if nothing had been done.  For instance, in a
case of severe pneumonia,  or  in a case of croup,
in which so much mischief had not already taken
place by delay, that restoration was impossible, sup-
pose we bleed to half the extent, or two thirds suf-
ficient to subdue the inflammation, it is obvious that
the result would be just as fatal as if no blood had
been taken ; a little delay only might be effected ;
and it is just as obvious that no part of the mischief
should be attributed to the remedy.  The urgency
of the symptoms should guide  us, and the quantity
of  blood which the patient may lose, or the number
of times we bleed, is not so much to be regarded,
as the effect produced on the disease, at least while
the symptoms  indicate so much violence, that death
may  ensue.   The inflammation will be reduced
within the limits of probable safety much  short of
danger from the loss of blood.
   In  typhus fever, the inflammation, which is pre-
sent,  I apprehend to be the cause of danger.  Some-
times it is so violent as in  a few hours to destroy
the functions of life.   In other cases, such derange-
ment may be produced, that order cannot be restor-
ed.   Such cases are not within  the control of any
remedy.  But there are several reasons why blood-
letting may not be successful in this disorder, even
in cases  which might be  subjected  to  its  power.
The first is, delay in  employing this remedy.  It
will readily be perceived that a disease of so much
violence as were some of the preceding cases, and
                       9 
66
in which the brain is so deeply involved, as is  dis-
covered by the examination of those, who have fall-
en victims to the  disorder, would require  prompt
and decisive  treatment.  But  besides the  danger
from procrastination, the first attack is the favour-
able time to make a strong impression on the  dis-
ease, and if possible to suspend it  entirely.  An
inflamed part  returns  to  its natural state more
readily if the inflammatory  action be checked
at its onset, than after a diseased habit is establish-
ed.
   Another is  making  too long  intermissions be-
tween  the repetitions  of the  bleedings.  For the
same  reason  that it is proper to bleed early,  it
is desirable  to take  the necessary  quantity as
fast as the patient can bear it.   This cannot al-
ways  be conveniently done at one  bleeding, but,
till it is done, the disease will be progressing.
   A third reason  why blood-letting may not cure
this disease is, because it is not carried to  a suffi-
cient extent.

                    CASE.
   A physician requested me to look at a  patient
of his and give my advice as to  the propriety of
bleeding in her case.   She lay  on the bed in- a
state  of great prostration;  groaning continually
from the distress  she suffered principally from the
pain  in  her  head.   The pain  in  her  head, she
said, was indescribable, and she also had pain in her 
67
side, and a general uneasiness.  Her tongue  was
dry, and  red  in  the  middle, and coated  with a
dense  white  fur  on each  side.  Pulse from  one
hundred to one hundred and ten, feeble, depressed,
but quick.  She  had  been  ill from  three  to  five
days.  It  was  a very  bad  case of the prevailing
fever.   I  advised the  gentleman to bleed,  but at
the same time, gave it as my opinion, that it would
do no good, unless it were followed up boldly  and
expeditiously ; and that nothing  essential would
be gained by one or two,  even copious bleedings.
He agreed with me that she must in  all probabili-
ty die,  unless something that would  have a deci-
sive effect were done.   He therefore, concluded to
try blood-letting, and abstracted from her arm,  that
evening, from twenty-four to twenty-eight  ounces
of  blood.   The patient  expressed  her sense of
relief,  particularly in  her side.  The  next morn-
ing, perhaps ten  ounces more were taken.  The
third day  four ounces more; the disease progress-
ing. This treatment was then relinquished.  The
medical attendant  tried,  I believe,  every other
means, which the art  suggested, such  as constant
vesication to the head, &c. &c.  but the event  was,
as I predicted; the patient died.  The morbid ap-
pearances after death are presented in Examination
first.   It  is very  plain that two  or three small
bleedings  could have  little effect in  reducing  the
inflammation that existed in this ca?e. 
68
   No  general  rule  can be prescribed, as to  the
quantity of blood that should  be lost,  as this must
depend upon the degree and extent of the inflam-
mation, and upon the ability of the  injured part,
to return  to its  natural  state.   One  object   was
kept constantly in view,  in the  treatment  of the
preceding cases; it was, to reduce the inflamma-
tory action within the bounds of probable safety.
If the  inflammation yielded before the patient had
lost a  great quantity of blood, the bleeding  was
continued, till it was subdued, and a cure  effected.
But if it did not  entirely yield,  and much blood
had been lost, I ceased to  bleed so soon as the  dan-
ger was not imminent, and trusted to time and other
means for the rest.   The time  the  disease   had
continued, was not regarded.   If, after having been
once reduced, the disease  again increased so  as to
put existence  at  hazard,  I  again  resorted to  the
remedy but with more caution.  This was done as
often as the disease threatened to get the advantage,
and the result proved the practice  to  be  correct,
at least, so far as it  regarded safety.  In cases
seventeen,  eighteen and nineteen, it was necessary
continually to act on the defensive; not a bleeding
was performed with  an expectation of immediate-
ly terminating the inflammatory state.  The indi-
cations, which guided me in my opinion as to  the
necessity of repeating the bleedings, were princi-
pally the state of the head and that of the pulse.
These two symptoms taken conjointly could scarce- 
69
ly deceive me.  The quantity of blood taken at a
time depended on existing circumstances.  Bleed-
ing, ad  deliquium, is no guide for the limitation
of this operation in adults.  They will  faint much
sooner from a certain  inexplicable impression on
the nervous system, than from the loss of blood.
   Another reason  why  blood-letting may not be
successful in this disease, arises from the practice
of giving stimulants under the notion  of  support-
ing the patient's strength.  But to bleed  and give
stimulants, is undoing with one hand, what we do
with the other.   This will not appear  strange  to
those, who  believe  inflammation  to be the cause
of the phenomena.   If it be necessary  to  give
stimulants as leading  remedies,  it cannot, at the
same time, be proper  to bleed.   If stimulants  be
given,  blood-letting  had better be omitted; for
this reason, that bleeding in this disease, seems to
 render the system more susceptible to the action
 of stimulants.  I reason in this way ;  a degree of
 inflammation exists in the spinal marrow  and the
brain, sufficient to interrupt their functions ; hence
follows the  general prostration, in which the stom-
 ach partakes.  Stimulants act  through  the me-
 dium  of the  stomach, but while in this  state of
 prostration, it is not so susceptible of being excited,
 and stimulants  put into  it will  of course  have
 less effect on the  system.  But bleeding relieves,
 in a degree,  the inflamed spinal  marrow, and in
proportion to this relief, it performs its office, and 
70
  the stomach receives its share of its influence, and
  is in  the  same  proportion  renovated ; stimulants
  will of course  have more effect, excite the heart
  into greater action, and do more mischief, than the
  bleeding did good.  I have uniformly found that
  any of this class of medecines were injurious  in
  the cases,  which 1 have treated, and  if taken to any
  considerable extent before  the head was free and
  the pulse in nearly  its  natural state, a  relapse
 would follow, the more or  less severe, according
 to the degree of disease remaining at the time.  I
 found it necessary, therefore, to use them very cau-
 tiously and to relieve only some  accidental symp-
 tom.   In the convalescent state  of my  patients,
 tonics or stimulants were  quite  unnecessary, un-
 less the disorder had continued a  long time.
   It seems indeed a little  paradoxical that a mode
 of treatment, so diametrically opposite to  the one
 I have recommended, should be sometimes, appa-
 rently successful.  If blood-letting be the proper
 practice, it would seem  that  an opposite mode
 should be destructive.   But it is a  fact, that pa-
 tients with  this disease do sometimes get well not-
 withstanding  great  quantities  of stimulants are
 taken into their stomachs,  and the cure is ascribed
 to  their  efficacy; but  I  have good grounds for
 believing that those, who get well with stimulants,
would get well without them.  That we may un-
derstand why stimulants are not always destructive
in typhus fever,  it is necessary to attend to the 
71
phenomena, presented in a case, which is allowed
to run an unimpeded course, or which no curative
means are  used to arrest.  In such a case the first
symptoms,  which strike our attention are gene-
rally, prostration of  muscular strength,  lassitude,
pain in the head, back and limbs; impaired men-
tal  energy; disturbance and  for  the most  part
acceleration  of the  circulations;  diminution of
the secretions, loss  of appetite, increase  of  heat
upon the surface, &c. &c.   These symptoms get
daily worse  and worse ; the prostration increases,
and is soon  accompanied  with delirium,  stupor,
insensibility.  The patient now presents a horrid
spectacle of stupid madness;  the  powers of the
system are almost suspended ; he is trembling be-
tween life and death, and the balance  is turned
by a breath, to either side.  In this state he may-
lay for many hours  and perhaps days.   But the
event is sometimes fortunate.   Why is it so ? Dur-
ing this state of suspense the heart partakes of the
general  depression;  its action becomes languid,
the  determination  of the blood to  the inflamed
spinal marrow is diminished; the immoderate ac-
tion in that part, therefore, ceases, and if it has not
suffered too  great an injury, this  organ will gra-
dually  return  to  its  natural  state,  its  functions
be performed,  and  consequently  the powers  of
the whole system  will be  renovated.   Precisely
the same set of morbid phenomena may be wit-
nessed, when the disorder is  treated with stimu- 
72
feints, only their progress is more rapid if stimu-
lants be given from its commencement.  The sys-
tem soon becomes so prostrated  as to be insensi-
ble to the action of stimuli, and then recovery may
take place by the  same process as that above de-
scribed, but if it does take place,  it will be in de-
fiance of the remedies.
   The chief objection to blood-letting in typhus
is the debility  with which the patient is  suppos-
ed to be suffering.  He  is unable to support him-
self in  an  erect  posture, and  he  has  a quick
and small pulse.   These  are  supposed to be the
effects of weakness.   With  the  same propriety
might  the  incapacity to  move,  produced  by a
compression  of the brain from  a  blow  on  the
head be  called debility.   Or with  equal  truth
might the loss  of  muscular power and the quick
and feeble pulse  manifest  in a fit of intoxication
be  attributed to debility.  That  the  prostration
is not owing to  debility might be known from the
following considerations.   1st. It is often sudden,
taking place  immediately after the febrile attack,
and the patient from full health and activity is fix-
ed almost immoveablv to his bed;  and when  it is
not so sudden, no causes have existed, which could
have produced real weakness  to a twentieth  part
of the  extent of  the  prostration.   Has he been
subjected  to great depletions or long starvations ?
People in this situation are less liable to fever than
those in full vigor.   2d. The real debility is great 
73
er at the subsidence of the disorder  than  at  its
commencement, but the prostration is  materially
less.  The debility then fancied to exist in  fever,
is  only apparent.  The depression of  muscular
strength, the effect of inflammation and disturbance
of the nervous system, has caused the mistake.
The phenomena of inflammation  have  been con-
founded with the effects of weakness.
  The utility  of any remedy in disease is best
tested by experience ; and, ceteris paribus, its adop-
tion should depend upon its  comparative success.
But we sometimes have another source, by  which
we are enabled to estimate the  value  of certain
modes of  practice.  This  source  is the morbid
changes effected by  the  disease, which are dis-
covered to us after death.   If such changes  point
to causes, which may be relieved by certain known
remedies,  such remedies should  be employed  in
such  disease.  Were  it  generally known, that
typhus fever was the effect  of violent  inflamma-
tion, -in an  important organ,  bleeding  would  be
considered by  most physicians a  valuable remedy
in that disease.
  The morbid changes produced by the variety
of typhus under consideration, amount,  I think, to
strong evidence, that its phenomena were the ef-
fects of inflammation in the brain and   the spinal
marrow.  This evidence I shall present, but before
giving an account of these appearances,  I will take
the  liberty  of advancing  an  opinion  respecting
the  cause of idiopathic fever, which I  have for
                      10 
74
some time entertained, and which is  the  result of
much  investigation and experiment.  It  is this,
that the cause of the  phenomena,  which,  collec-
tively constitute that disease denominated fever, is;
inflammation of the medulla spinalis, in which the
brain is often  more or  less involved, though not
necessarily to produce  the characteristic symptoms
of the disease.  It is not convenient at  this time
to discuss the subject  at large, and  I shall state
very  generally only some  of the reasons,  which
have influenced  me to  adopt this opinion.
   1st.  In fever we find the same  phenomena pre-
sent, as in other disorders,  where local  inflamma-
tion is known to exist.   Hence it is  philosophical
to infer that inflammation is present  in fever, and
that it is the cause of the phenomena in  that dis-
ease, unless it can be shown, that such phenomena
can be produced by  other  causes.   2d.  Fever is
understood to be a disorder of the whole system ;
and every organ is supposed to suffer in nearly an
equal degree.   If then  it be true, that the pheno-
mena of fever are the  consequence  of inflamma-
tion, it must follow that every organ in the body
is in an  inflamed state, or that this general  suffer-
ing is the effect of inflammation in  some  organ,
which has a very intimate  connexion  with • all  the
rest, and more than a common influence over them.
  Now, during the  existence  of the disease, we
have no evidence that every organ is thus locally
affected, and by examination  after death,  we do
not discover that such had been their  state. In fact, 
75
in a great number of dissections after death by fever,
every organ has been found in a sound  state,  ex-
cept the brain and the spinal  marrow.  Hence we
must conclude,  that the general derangement of
the system  in  fever is the consequence  of  the
affection of some  one  organ,  on  which the rest
have an intimate dependence.
  3d. I have said, that in many cases, only two organs
have been discovered to be  certainly diseased after
death by fever ; the brain and the medulla spinalis.
But the brain may be inflamed and not produce the
phenomena essential to  fever.  In fact, it  has not
that intimate connexion with all the  other  organs,
 necessary to cause that general sympathy with its
 own derangement.   We have left then only the
 medulla spinalis, and we are thus led  to this part as
 the seat  of  the mischief.   But has this  such  a
 general  and controlling influence over every other
 organ of the  system ]  To  those  unacquainted
 with modern discoveries in physiology, an  affirma-
 tive answer may appear  extravagant.   But the
 point has been settled by repeated experiments.
 Those of Le Gallois have long been before the pub-
 lick.  He even inferred that  the medulla  spinalis
 was the  source of life to  the trunk.  Dr. A. P.
 Wilson Philip has controverted this  conclusion of
 Le Gallois, and contends that the muscular system
 has its power independent of the nervous system.
 But with respect to the independent function of
 the spinal marrow, and its  powerful influence  over
 the other organs, they do not disagree.   I  Have re 
76
peated many  of  the  experiments of Le  Gallois,
and the result has been a conviction, that the func-
tion of the medulla spinalis is  independent of that
of the brain, and that  this  function  is of vital  im-
portance to the other  organs.   But  another  ques-
tion  is to  be settled.  What evidence have we
that the spinal marrow is  in an  inflamed  state in
fever ? Without adducing at this time the evidence
we might draw from the phenomena of the disease
and from analogy,  I  shall mention only  the  ap-
pearances, which  are  exhibited by this part after
death by fever.  In six cases which I have exam-
ined,  the following phenomena  were exhibited.
1st. An uncommon quantity of an aqueous fluid was
found in  the spinal  canal,  surrounding the spinal
marrow and in contact with the  pia mater, which
is its immediate covering.
  2d. The  medullary  substance  itself had an  un-
natural hardness, and the spinal marrow, even after
its membrane was dissected away, had almost  the
firmness  of a  cord, and would  resist very hard
pressure.   These appearances I  take to be proofs
of previous inflammation.
  This is certainly not the natural state of the spi-
nal marrow, and these phenomena have not existed
in a number of cases  which I have examined, of
patients who died of other diseases.
  With this view of the subject,  the cause of the
several varieties of continued  fever, might be ex-
plained ;  but I shall only remark, that in simple fever
it is probable,  that the inflammation is for the most 
77
part confined to the spinal marrow.  In typhus, the
inflammation is more intense, and the brain is sooner
or later involved.  In the present variety, the brain
seemed to be primarily and  principally affected.
   The three cases of dissection which  follow, ex-
hibit the morbid changes produced  by this disease
in the brain and spinal marrow.  They  appear to
me to be the effects of inflammation in those parts.

               EXAMINATION I.
   Mrs. T.,  examined about ten hours after death.
   The dura mater was in  the  natural state.  The
vessels on the surface of the brain were turgid with
blood.  The whole surface was covered  with a thin
serous fluid. This fluid was contained between the
tunica arachnoides and the pia mater.   The first
membrane  being raised from the latter into nume-
rous cells, some large and extensive, others small.
When one  of these was wounded, the fluid issued
out, and discovered a communication between se-
veral of them, but it was not general.  The whole
quantity of fluid could not be ascertained, but it was
judged to be from two  to  three ounces from the
surface of the brain.   The tunica arachnoides seem-
ed to be thickened, and two  or three small portions
of coagulable lymph were discovered upon its ex-
ternal face.  The brain was hard and so tough, that
it permitted the pia mater to  be  stripped from its
convolutions, without the least derangement of its
substance,   the  surface  still  remaining  smooth.
When cut  with a sharp  knife, numerous  bloody 
78
points presented  in  the medullary substance.  It
did not collapse ; the  relative situation of  each
part seemed to be maintained ; the parietes of the
lateral ventricles did  not touch each other, but they
presented themselves large cavities, and contained
a little water.  The plexus choroides was as colour-
less, as if it had been a long time bleached in water;
it seemed to be thickened, and was formed into nu-
merous cells or vesicles, containing a thin fluid, and
resembled,  in some  degree, a  bunch  of  grapes.
Each  cell seemed  to be distinct.  The parts con-
nected with the  lateral ventricles were as distinct
and as beautifully displayed, as  if they had  been
made  of wax.  The  corpus  callosum, the  septum
lusidum, and the fornix had such a degree of tough-
ness, as to bear rude  handling without giving way
in the least. The Thalami  nervorum  opticorum
had some  appearance of waste and irregularity of
surface, as if corroded in spots.  The  optic nerves
were  shrunk and  very hard.  The infundibulum
was open from the third ventricle to the sella turcica,
but the pituitary  gland was shrunken to a very
small, hard  substance, and  occupied  a  very small
space in the bottom of the sella turcica, which other-
wise was  empty.  The firmness of the brain  in-
creased as it approached the crura cerebri; the pons
varolii and the medulla oblongata were remarkably
hard and elastic.  After their membi anes were strip-
ped off, which  was  done  with great  facility, and
without the least mutilation  of the medullary sub-
stance, they could bear very considerable pressure 
79
and handling without being defaced or having their
natural forms altered.  The corpora pyramidaha
and olivaria, together with other elevations and de-
pressions, would remain distinct and beautifully dis-
played.  The medulla spinalis had an equal degree
of hardness : it was  like a cord,  and resisted very
firm pressure.  The  cervical portion only was  ex-
amined in this case.   The spinal canal contained
much serous fluid, surrounding the medulla spinalis.
It continued to ooze  out for some time, and seemed
to come from the deep parts of the  canal.  The
cerebellum  has not  been mentioned ; it was  not
much harder in this case than is natural.
  The chest and  abdomen were  examined. The
left lung afforded evidence of its having been in-
flamed.   A portion of this lung, about the  size of
two hen's eggs, in the neighbourhood of the seat of
pain,  when  she was  living, had become thickened
and hard ; when it was  cut into,  globules  of pus
were discovered.  The lungs were in other respects
sound.  The stomach and other abdominal viscera
were sound, and exhibited no marks of having been
inflamed.
  This case was the last examined in the order  of
time.   It is put down first, because a more particu-
lar account was taken of  its morbid  appearance,
than in the cases which follow.

              EXAMINATION II.
  P. K., examined about fifteen hours after death.
  The tunica arachnoides in this case, was raised
by an  aqueous fluid in the  same manner, and about 
80
the same degree as in the preceding.  The superior
parts of the brain, perhaps, were not quite so hard,
but the parts  about the ventricles were equally
firm and tough.  The pons varolii, the medulla ob-
longata, and the medulla spinalis were in the same
state, and after their membranes were stripped off,
could be handled with nearly as much facility, and
with as little injury as a muscle.   The cerebellum
in this case partook of  the general hardness.   An
aqueous fluid was found in the spinal canal in this,
precisely as in the preceding case.
  The thorax and abdomen were examined, but not
the least mark of recent inflammation could be dis-
covered.   The heart and  lungs  were sound ; the
inner coat of the stomach, and the other abdominal
viscera had not apparently suffered from recent dis-
ease.  I saw the subject of this examination twice
during her sickness.  Her symptoms appeared  to
be of the same character as those of the first  case
of this paper.

               EXAMINATION III.
  ----, examined  about twelve hours after death.
  The appearances in the head in  this case  were
very similar to those in the last.   The  presence of
an aqueous fluid over the surface of the brain, in
the plexus  choroides, and in the spinal canal, was
observed.   The  condition  of the  several parts  of
the brain was the same ;  the cerebellum  was very
firm and tough.  The dorsal portion of the medul-
la and spinalis was examined ;  it was unnaturally 
81
hard, but the degree of hardness was less than that
of the cervical portion.
  I did not see the subject of this examination be-
fore her death,

  Every one in the least acquainted with anatomy,
knows that the condition of the  above brains, inde-
pendent of the presence of the aqueous fluid, is not
that of a healthy  brain.   The brain in its natural
and healthy state, is quite soft, pulpy, and is handled
with difficulty,   But in these there was a wonder-
ful degree of hardness and toughness,*  and even
when  the  membranes were dissected  away, they
could be handled with great facility, and without
so much as soiling the fingers.  I have  examined
the brains  of a great variety of subjects, who have
died of very different diseases, and I never witness-
ed, (except in cases of typhus fever) any thing like
the above  state, except in two instances of subjects,
who died in consequence of frequent epileptic fits,
accompanied with some of the phenomena of fever.
In these two cases, the brains were remarkably hard
and tough.  No  uncommon  quantity  of aqueous
fluid, however, was present.   The  condition of the
medulla spinalis in these two instances, was not no-
ticed.

  * This hardened state of the brain, though it has sometimes been
noticed, has not been, I suspect, sufficiently recognized as the effect of
inflammation in that organ. But  it will hardly admit of a question.
The same thing is witnesse din the lungs and other viscera arising from
the same cause. It is probable that many  brains have been reported
to be sound, which were really in this condition.
                    *** 11 
82
  To what process shall we ascribe  this extraordi-
nary change from the natural condition of the brain,
but to that of inflammation, or a process in the sub-
stance of the brain itself similar to that which takes
place in the capillary system  of other parts when
inflamed ?
  The presence of the aqueous fluid  would alone
have excited strong suspicion of the previous exist-
ence of inflammation.  In fact, it is nearly conclu-
sive,  that inflammation had  been present in  the
membranes or in their immediate neighbourhood.
But there seems to be no other adequate cause for
the change which had been effected in the brain, than
inflammation.  The phenomena of the disease ought
to lead us to suspect the presence of inflammation,
and the result of the treatment which  has seemed
the best suited to control the disease, should add
weight to such an opinion.

  Many of the phenomena which this disease ex-
hibited, are not common  in fever, and their expla-
nation is to be sought in this  primary  and general
affection of the  brain.  The almost  constant  ab-
scence of  heat, noticed in most  of the cases,  ap-
peared to be owing to a less quantity being generat-
ed than in health.   The brain, it  has  been ascer-
tained, has considerable influence in the production
of heat in the trunk.  But whether this influence
be direct, or whether it be through the medium of
the lungs, and the diminution of the heat be owing to
the disturbance of their functions  with respect to 
83
the change of the blood, cannot be positively as-
serted.  It is well known that the  par vagum, or
eigth pair of nerves, is largely distributed to the
lungs,  and that they are seriously affected by any
injury to these  nerves.   They have their origin in
the medulla oblongata,  in which we have seen much
diseased alteration, and from  which these nerves
would be very likely to suffer.   Hence the distress
in the  chest, complained of in some of the cases,
might  be owing to  the injury which these nerves
had sustained.  Might not also the uncommon black-
ness of the blood be, in some  measure, attributed
to  the imperfect manner  in which  its  change was
effected in the  lungs ?  In cases of fever, in  which
the brain  was not primarily affected,  the venous
blood  has been almost  as florid as the arterial.
   The distress in the thorax, I suspected at first, to
be owing to inflammation in that part.  But  exam-
inations after death  showed that this  was not the
cause  in every case.   A  respectable physician in-
formed me that a patient, to whom he was called in
a late  stage of this fever, and too  late to do any
material good,  complained bitterly of this distress
in  the chest, and he understood that she had done
so from the  commencement of her disorder,   But
upon  examination after death, not the least mark
of any previous disease was discovered in the tho-
rax.   He was not permitted to examine the head,
but he was satisfied that there  was the seat of the
 disease.  The  patient, who was the subject of Ex 
84
 animation second, complained to me of great distress
 jn the chest, which,  she  said, had been very con-
 stant ; but there  was no evidence after death, that
 any inflammation had existed in that part.   In some
 cases there was, indeed, acute  pain in  the side,
 which was undoubtedly the effect  of inflammation
 in that neighbourhood.  The stomach,  likewise,
 suffers from any injury to the par  vagum, and we
 may probably refer to this cause the great disturb-
 ance of the stomach  in this disease, manifested by
 flatulence, pain, sinking, nausea, &c, and not to any
 local alteration in that organ.  The stomach, how-
 ever, is generally affected by any  considerable in-
 jury done to the brain.
  Other phenomena were present, which were com-
 mon to this and other varieties of typhus.   They
 admit of an easy explanation on the principle, that
 they were the effects of  inflammation of the  brain
 and spinal marrow.   The inflammation of the latter
 organ, I am persuaded, is the cause of  the pheno
 mena common to the  several  varieties of continued
 fever; and. however different may  be their aspect?
 from the simultaneous affection of some other or-
 gan, the pathognomonic,  or those symptoms which
 entitle the disorder to be denominated fever,  arise
 from the inflamed state of the medulla spinalis.  If
 this view be correct, it will give to the character  of
 fever the same degree of singleness and precision,
and to its medical treatment the same definiteness,
as is obtained in other local affections.   One objeet 
85
will be kept steadily in view, and  this will be to
subdue the inflammatory action existing in the spi-
nal marrow; and when this  is accomplished, the
disorder will subside.
                     NOTE.
   Since the preceding pages were written, I have
read the work of John Armstrong, M.D. on Ty-
phus Fever.  He is an ingenious and able advocate
for the practice of blood-letting in typhus; and his
book ought to have the candid  attention of every
physician.  I do not,  however, mention it on this
occasion for the purpose merely of commendation ;
I wish to advert to one point, among others, in the
view here presented of this  disease, in which I do
not agree with the author.  He divides the progress
of the disorder into three stages;  first, the stage of
depression ;  second,  excitement; third, collapse.
These  stages may often be  distinctly observed in
typhus, if the course of the disorder be unimpeded,
and the division is unquestionably of much practi-
cal utility.  But it does not appear to me, that the
last stage must so necessarily take place, as he seems
to represent.  The mild forms  of fever usually
terminate without it;  and  that variety  which he
denominates the  simple typhus, does not always run
into this stage even when little is done in the use of 
86
curative means.   The  severer  forms of this disor-
der, or what he calls the inflammatory typhus, may
Often be reduced to the simple form, and a resolu-
tion be effected without a collapse.  In my opin-
ion it should be the great object of medical treat-
ment, to prevont this stage of the disease ; and this
may usually  be effected by the timely  use of the
lancet.  I have successfully employed blood-letting
at the moment that a collapse seemed inevitable ;
and when the state of the pulse, and of the sensorium
indicated almost the presence of this stage of the dis-
order.   But after a small bleeding the senses have
brightened, the blackness and dryness of the tongue
diminished, and the pulse reported a more favour-
able state  of the internal movements.  If, however,
a collapse be  fully established, I agree with  Dr.
Armstrong, that the lancet should not be used.   In
fact no remedies will avail much then, and life or
death will depend on  the extent of the previous
mischief.
FINIS. 
 
 
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