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This item is filmed at the reduction ratio checked below/ Ce document est film6 au taux de reduction indiquA ci-dessous. 10X 14X 18X 22X 26X 30X y 12X 16X 20X 24X 28X 32X The copy filmed here has been reproduced thanks to the generosity of: La Biblioth^ue da la Villa da Montrtel L'exemp*.*'s.v3a(*t,jt.<' .Si^\ f !^ -■■■;*'■ f'HE alarm exuted the kit JVtnter in the Eafiern Town* ships of this Province in consequence of the prevalence of the Spotted or Petechical Fever^ and the recent occurrence of several cases of the same disorder in this city ; has induced the publishers to lay before the public^ the follotvlng Extracts from a Report ofaCoh^mitteeofihiMirssachusetts Medical Society. The extreme length of the original Communicatioh: has pre^ ^ vented tts from ripahlifhrng it entire; VDe have th&efcire selsSied such parts as is thought to be of the most general util- ity. Convinced of the importance of communicating to the public whatever might be dtemed useful- relatiiie to this subje£iy and as early aspojftble, we have given it in this form, which will be found to describe the general nature of the disease emd the requisite mode of treating it* ..- -.«*i niii PM ^ rn TowH» nee of the urrence of s induced Extracts Medical : has prC' _ fhefefgre teral util- 'ng to the 'e to this t his form f ire of the NATUIIAL HISTORY OF THE DISEASE. This aifeafc has been of various degrees of feverity \ \n a lairge proportion of cafes very mild j in.fothe, fevere,- and in a few deftroyed life suddenly, like the plague. The communications, which have been made to the committ^ee, relate chiefly to the difeafe in its gravpft forms. The hif- tory «rhich they give must therefore be underftood as relat- ing moftly to the fevere cafes •, and they ire not furniftrtd with the means of making all the difcrlminations which could be wished. They are however infotined that itt the milder cafes the fymptoms differed only in degree, not in kind. The invafion of the difeafe is generally fudden and vio- lent, In its courfe all the frnaions of the body ate more or lefs interrupted, and often fome of them are entirely fuf- pended. The fubjed of it is feized in tlie midft of his ufu- al labour or occupation, and oftentimes is ftruck down fud- denly, almoft as by a ftroke of lightning. The firft symp- toms are various, fuch as local pain or paralyfis, delirium or coma, and rarely fpafms or convulfions. ' The difeafe often commences with fhifting pains. Tlic patients fuddenly feel a pain in one joint or one limb, often in a finger or toe, in the fide, ftomach, back, neck, or head. Sometimes the feniation is like the dinging of a bee, fre- quently it is moft excruciating pain, which at once arrefts 4. ■Wj- ■■I teJ J 4 MEDICAL COMMCTNrCATIONS. and commands the whole attention. This pain moves from place to place without lofing its violence, generally ap- proaching the head, and is often confined to one fide of the body. It is faid that the left fide is more frequeirtly afFe£t- ed than the right. The head is more frequently fird afFee mufcles of various parts, paralyfis has been dcacfionally obfcrved j as in tliofe of one hand or foot, and of tentimes in thofe fubfervient t,o deglutition. In fomc cafes hemiplegia has occurred at rlic commcnceracnt ; and it is particularly worthy of reniai:!; that often the gvcattA weight of difcafe falls on one fide of the body j infomuch that not only the voluntary mufcles but the vafcular fyfl;em has been much more affeaed on one fide than on the otiier. Not very rarely the difeafe commences with delirium; and very frequently this fymptom follows a violent pain in die head in ct very early flagc of the rT.afe. The ilelirium is often milu ; ia fome cafes however, v.'hcrc it is attended "'^^T'. M KDIC A L COM M L'MCATlOXS. ovcs from orally ap- fide of the rtljrafFe^l- irft affea- ifle«Sled at in a flicrt 3ly fev?re, upon the , if it con- }\cv cafes, )f the dif- powers of t dimn^fs [ity of tiie I limb be- rhe other [imilar af- : has been foot, and In fomc cnt J- and : gvcatcA i.nfomuch ar fyil;eni he otiier. lelirium j It pain in delirium attended with fluflied face and eyes, great heat in the head, and vio- lent pulfation of the carotid arteries, it produces a fury, which is fcaTcely to be reftraijied. Ih a few inftances the patient has become blind and raving within half an hour af- ter the attack. Stupor and coma, likcwife convulfions and fpafms occa- fionally attend the accefs of the difeafe ; but they are more frequent in its later ftages. In whatever form the difeafe commences, there fuddenly cnfues great proftration of ftrength. In fome inftances the patient is defcribed as almoft immediately falling down un- der the weight of difeafe. This proftration is accompanT'd or followed by univerfal or partial chills ; the flcin becomes dry and pale, or mottled like one who has been long in the cold, eyes glafly, nofe contrafted, the face fublivid, with palcnefs around the mouth, and the countenance exprefllvc of the utmoft anxiety and diftrcfs, or its features diflblvc- with a lofs of all charafter and cxpreflion •, the whole body becomes cold, respiration very laborious, ef|»ecially in child- ren, pulfes very fmall and feeble, flow r.t tlie commence-, ment but fliortly very frequent. If there be neither coma nor delirium, the fpirits are very much dejeded, th;: pati- ent fufFers extreme folicitude and anxiety, with apprel.en- fions of death, frequent fighs, reftlciTiicfs and ai^itation. He complains of opprcftion and faintnefs, with undefcriba- blo cliftrefs about the praecordia and a fcnfatioii cf fuUncfs nt the ftomach. Frequently cruftation, naufea, rmd vomit- li'.g enfue, and alfo fainting in the early ftngcs of the uii- n{e ; and the vomiting occasionally becomes incclTant, tm- l)arrafRng and defeating every t ftbrt to give vdicf by ititcvnal medicies, while it exhaufts the jx'tknt. .^f f i i MKDiCAt COMMUNICATIOXS. The ilifFerent ftages of this difeafe and the duration of , each are not very accurately diilinguiflied by. moil of thofc, ii^ho liave made communications to the committee. Doubt- lefs this is bccaufc disaphorcfis has commonly been edab- lifhed at an early period of the difeafe, which has been fol- ..rlpwed by a mitigation or a fubfidcnce of the fymptoms. . IJow far this diaphorcfis has been produced by art alone, and whether there be not a natural tendency to this terr-iin- vfirtion, may be matter of doubt. It is generally reprcfented as the efFeft of art j but it is remarkable that the efforts for this purpofe ihould have been very generally fuccefsful, if ^cre.is' not any natnral tendency to its produdlion. By fome however it is noticed, that the fymptoms of the ifirft (lage, fuch as have been defcribed, become modified iij the courfe of from eight to twenty-four hours. Within that period fome have died. But ordinarily, except where tlie powers of life are to much cxhaufted, the fymptoms of tiie second ftage fupervene. The pulfes become more full and regular, the (kin becomes warm, countenance fluflied, and in plethoric fubjefts cfpccially, even red and florid ; refpU " ration short and very dilficult from a fenfe of fullnefs in tlie lungs, but more regular than in the early periods of the dif- eafe ; eyeliJs fwollen and eyes flaving, with a throbbing pain iu the head i light diftrelles and noife irritates j and great reftlefliiefs, general anxiety and frequently delirium enfue. In a large proportion of cafes thcfe fymptoms have ail fuh- (ided, and the difeafe has termir..-.ted within three days i of- ten in one. Even in cafes where the attack has been very violent, and the powers of life almofl: overwhelmed at liril, the patient has fe far recovered as to be very conJortablc ia "~*'**~^i^ • ^m Juration of )ft of thofc, 9e. Doubt, been cftab- as been fol- fymptoms. ' art alone, this terr-iin- reprcfenteH c efforts for iccefsfui, if in. toms of the modified in Witliin that : where tlie toms of tlie ore full and luflied, and >rid ; refpl- hiefs in the > of the dif- a throbbing itates ; and tly delirium lave all fuh- c days ; of- is been very led at liril, [iifortablc in MEDICAL COMMUNICATrONS. t tliree olr four day», fuflfering only a flight debility, th mimy cafes, however, while the feverity of the difeafe has alMted, it has neverthelefs continued under a milder afpe£V, and exhibited the lefb equivocal charaflers of typhus •, uftder which circumitances the termination has rarely been fataK To this remark exceptions have been noticed in May, and the early part of June. Relapfes have occurred in many inftauces with the fame fymptoms as in the original attaclcs ; they have rarefy if ever been followed by death. Among tfie varieties of the difeafe, the following is givert as a defcriptioti of fome cafes which have occurred efpecial- ly among females. " Univerfal deadly coldnefs ; flcin white as poliflied ma'rWe and finooth j countenance perfeftly placid ; not otte diftorted mtifcle ; pulfe in the wrift im- perceptible ; motion of the heart fcarcely to be felt ; refpi- tation vifible only by gafpmg, and that not frequent ; and as it wei'e oitfy a ftep between this imperfeft ftate of life and deatJj." Even from this ftate of deadly ftilluefs patients have been reltored to life and health. As has been already Wrentioned, fome die in the early ftages of tJiJs difeafe. A few are taken off fuddenly in ten or twelve hours i others in twenty-four, thirty-fix, or forty* eight hours from the firft fymptom of the difbrder. Death rarely occurs after the third day ; indeed fome of thofe prac- titionerSi who have been moft converfant with the difeafe, confider dKir patients fafe if they pafs throXigh the firft twenty-four hours without any mortal fymptonis. The following is a defcriptioin of the termination of the difeafe in cafes, in which it was fatal within two days. Af- ter the fymptoms of the fecond ftage, as defcribed above, have continued from fix to ten hours, the (kin becomes pale \ n f M ed as ap- enetrating fometimes MEDICAL COMMUNlCATfONS. 9 iiotLced dveni hours liefore ftW pattest iti ajwuNre of any morbid aftiction. The ftfufations in the head are various ; &uch ns dizai- ne(3, vertigo, paiu i tluobbiug, fc-verc, cxcxuciutlng pain ■, aud Aridjurc acrofs tlie forehead and cyc8. Tla-re fcnl'a- tions are often followed and foinctitnes accompanied by de- lirium. T h^ delirium has all tiic varieties obfcrved in other acute difeafcr., £rom that which is mild and liglit, and in- deed little cJfe in (oliercnce of ideas, to that which is lev/ aad muttering, or that whicli is violent with rage. Com* as well as delirium is of frequent occurrence, and is even groore common in tlie Jatc ftagcs of fcverc cafes. There arc ittftaijcas, efpcctally in adult maks, iti which confciousuafe jemains to tlte Jail unimpaired, altliough the ifTuc be fata]. ■ Thexe jyre iUfo oUier fymptoms whidl appertain to tliy auim^l fyftem j* the following ^irc particulajrly npticcd. INumbnefs or total iufenfibility and parjilyfis in a larger or fnialler portiqn Oif the body, wJiich occur often in the firft ftage of the difeafe, and continue through its whole courfe, and even after other fymptoms have fubCded ; — a fenfe of laflitude and wearinefs ; forenefs of the flefli, efpecially x4 cliildren ; and .fpafms which frequently occuf, and fhift fuddenly in the fame manner as the pain does from part to part i fometimes refemhUug histeric fpafms, fometimes oc* cafioning the head to be drawn back as in opisthotonos. The refpiration is much and varioufly affcdicd ; in gene- ral It is difficult. Cough rj^rely occurs, and the difficulty * Tins phrase is u»ed in the sense given to it by Bichut— under this division he comprehends the brain, and its dependant organs— viz.— the nerves and voluntary muscles, safir as tliey are depcndan* on tlie brain. B f , I " III 10 MEDICAL COMMUNICATIONS. of respiration has not commonly appeared to arifc from ati inflammation of the lungs. In two cafes, however, lymp- toms of pneumonia have arifen, and in one of them the ex- iftence of that affection was demonftrated after death.* The actions of the heart are very feeble in this diseafc j about its region that there are often very diftreffing fenfa*- tions, defer ibed as death-like feelings. Thefe fenfations are occafionally relieved by fpontaneous vomiting, and poffibly they may have fome connei^aon witli the gailric region. In a few mild cafes tKfe pulfes are little altered ; but commonly they are very feeble, and except at the commencement, frc quent. It is faid that they fometimes denote more flrength in the fyftem than it is found to ipofkfs. They are fometimes liflrd ; more often they are intermittent, and irregular both ill force and frequency ; they 3 re remarkably variable, fo that in the courfe of an hour, and indeed in much lefs time, they change from quick to How, from ftrong to feeble, and vice versa 5 at the acceffion of delirium early in the difeafc, they have been obfcrvcd to undergo a fudden acceleration from fixty or feveiity to one hundred and twenty, and even to one hundred and fifty in a minute. The pulfation of the carotids is often very ccnfiderably greater than that of the radial artery. The phenomena of the flcin have received confiderable at- tention ; fome ol them have given to thit, difcafe its vulgar name, In the early ftages the flcin is perhaps invariably dry } at a later pcviod fpontapeous fwcats have broken out ^ * 1 hesc cases are specially noticed, because we are told that this dirciise has prevailed on the borders of Lake Champlain, in Vermont, and also in Montreal and its vicinity ; and that it '.hnse places it has Is«en combinec! v/ith pneumonic incarnation. MEDICAL COMMUNICATIONS. U on the head, cheft, and fuperior extremities. A doubt has been exprefled whether univerfal fweating would not occur without aid of art. In a few cafes which have occured in Bofton and its vicinity there has been obferved a great ten- dency to this evacuation, and it has very readily become profufe. Doubtlefs there have been cafes in v^hich it wai very difficult to excite diaphoresis, but in many it has been fufficicent t^ put the patient in bed, and give him a cup Oi any warm liquid. The fweats are faid to have an often- five and peculiar odour ; it is fetid ; but this does not feem to defcribe it fufficiently. It has been compared to the fmell which arifes from a dead rat within the waiafcot of a room. It has alfo been compared to the fmell of a mercurial fore mouth. In many cafes the flcin is faid to be remarkably fmooth ; but this is not an univerfal appearance. The spots on the (kin are of various defcriptions. They occur in all ftages of the difeafe ; lefs frequently however on the firft than on the fubfequent days. Frequently a rafh or miliary eruption only appears, or a few blotches on the infide of the elbow, and other fimilar parts : and it has been fuggefted that thefe may be produced by the mode of treat- ment ufually adopted. The blotches are florid, or red and fiery. An appearance like meaflcs has alfo been noticed, and likewife veficles and puftults, which have been compar- ed to the vaccine and variolous eruptions. In fome cafes thefe fpots and eruptions have appeared at fuccefllve periods two or three times in the couxfe of the difeafe. The vefi- cles and puftules are very frequently torn by fcratoliing ; after which or without being torn they are commonly fol - lowed by fcabs of a brown color -, but occaiionally they are \ -, ■\\ \\ i \i ■■f.i i. 1 I !l H MEmCAL COMMUNICATIONS. followed by ulcerations which do not lieal until after recov- ry. Thcfe alTecHons of the {kin are often attended with itching ; and independent of them, itching very frequently oceursj especially on the third day, when the fyinptoms be- come more favourable at that time. This itching is forae- tipics cstremcly violent, fo that the patient will almoft tear up his luiii in endeavouring to alleviate it. All thefe afFec- tionaare frequently noticed at the time when the more im- portant fymptoms abate, or fubfide. In a fcT^ inftances, veficles containing a bloody fluid oc- cured in the county of Worcefter. Thele veficles werii compared to blood blifterg, and wura ak)ut the fizo of a large pea ; they appeared in various parts of the body and limbs ; in a few days they broke, discharged a bloody fluid, ?nd fcabbed over. In one cafe, in which the a^ttaek was very violent, blifters refembling thofe produced by caiitfea- rides appeared on the fccond and third day on the breaft and on one foot. They were about five inthes in length and nearly one in breath. On the fourth day from the at- tack, fome of thofe on the breaft and tliat or the foot be- came bljick and dry, and the fkm was iphacelated. Tiie efchers with due treatment left clean ulcers, which healcit v.'itliout difficulty. The appearance of petcchiae and vibicc^ has l>een noric- ed. They occur in comparatively few caL-s of the difcafe. They are of worfe portent in proportion as they are mere dark coloured. They do not however always occtir ia faul cafes, nor are tl\cy confined to fucli cafes. It is not eafy to determine in how l:;rgc a proportion of fubjects the fkin is afFefted with fpots and eruptions. Un- der the obfervation of fome gentlemen, they liayc been very g'-3;c:rrrr:: MEDICAL COMMUNICATIO.NJS. 13 rare. Oiie rcmireks that in eigkty caies, among \thkh twen- ty were very fevetej he had feeii 6nly fowr inftances in which fpotsor eruptions of airy kind had taken phce ; and he adds that thefe had not been the woflt cafe-8 undet his car*?. Another eftimates the proportions of cafes, in wliich there had been difeovercd fortie of the affsiftions which we have defcribed, to be two thirds of the whole. He includes, however, very flight affeaions, which have often difappcar- ed in a few hours. Defquamations of the cuticle, ind more raWly adcmat- ousfweliings of -the extremities, have occurred at the ter- mination of the difcafe. The tongue is ufually moift and vrhke through the whole difeafe, when it terminates within tliree or five days. When •i continues longer, the tongue becomes darker coloured, yellow or brown. It is fometimes very clean and red. There is feldom any remarkable thirft ; in a few caf^s it lias not been at all greater ^han natural. Some patients liave a defire for cold water, but not for any other liqtiid. The appetite is diminiihed, but it is not alv/ays fo entirely dedroyed as in moft other acute difeafcs. Children particu- larly fometimes exprefs a ftrong defire -for food. Nor arc The powers of digeHion always lufpended fo entirely as In moft other febrile difeafes. Voraiting very frequently oc- curs, but in the firft few weeks in which the difeafe prevail- ed, bile was very rarely thrown up. The matters ejeaed from tlie ftomach were commonly the articles recently fvral- lowtd and ?. ropy mucus. Yet at all times there has been difcharged by fome perfons a dark green liquid ; and in fome inftances a liquid of a blueilli colour. u J f: mmm 14 MEDICAL COMMUNICATIONS. The bowels are commonly very quick, and arc not readi- ly excited to aftion, efpecially on the firft days of the di^ cafe. When difcharges are made from tlie bowels on thofe days, they are commonly of a dark, green colour, and to curfory obfervation referable tar. It is faid by one gentle- man that the difcharges from the ftomach and bowels are rarely coloured by natural, healthy bile until the third day. In two cafes we are told that dyfentery fupervencd in an ad- vanced ftage of the difeafe -, but it was of fhort duration. Patients fometimes complain of forenefs of tlie tliroat ; and on infpeftion, the fauces are found very red, but not fwol- len in any part. The fenfation of forenefs is often juft be- low the fauces where the parts cannot be feen. Aphthae have been occafionally obferved. Ill mod cafes the urine has not been very different in iw appearance from that in health, but the quantity has been lefs. Strangury has been ranked among the occafional fymp- toms ; but a queftion may be permitted whether this has not been produced by the remedies employed. There is an irregularity in the courfe of the fymptonis iii this difeafe, and fo alfo in their duration. Blindnefs con- tinues from half an hour to twenty hours ; fevere pain in the head, and delirium frorxi four to twenty hours ; deep coma from fix to twelve hours, and eveii from the beginning to the end of the difeafe, efpecially in children. In a few iaftanccs flight aflcdion of liie parotid gbnds have been obferved, but in general, glaiuliilar fwcllings have not beer, noticed by our correfpondents. In fome cafes iwclllngb ]iAve occured on tl»e joints and hml>s. Tlicfe have been very lore to the touch, r.nd their appearance has been wmparcd to that of the j;ou':. 'Th'i parLs lb afitiSled feel as if they ha( cr as well colour. 1 appear as i that the di local affedl flammatiei bly with ji In a fev been notic< markable ( number of from whic pcrfons we herft, and By fome from this < health as g marks are < The atta and violent fymptoms i for hours a becomes vt in fome pq, exhibited fl pain, and r to be confii In genei eafe as ha^ gentlemen 1 -*»«*"«»l ^tf MEDICAL COMMUNICATlbNS. 15 not readi- of the di^ :l8 on thofo ur, ami to »ne gentle- bowels are : third day. d in an ad- t duration, iroat ; and t not fwol- xn juft be- Aphthac erent in its f has been onal fymp- ler this has mptonis ill idnefs con- ere pain in urs ; deep ; beginning otid glands •llings have fome cafes Thcfe have :c has been accl fed as if they had been bruifed. The fwelHngs afife on the fmall- cr as well as on the larger joints, and are often of a purple colour. Thofe on the fntiall joints efpecially fometimes dif- appear as the difeafe approaches its crifis. It is nst ftated that the difeafe of the whole fyfterti ever fubfides when thefc local affedions take place. By fome praditioners the in- flammation in thefe cafes is called eryfipelatous, and proba- bly with juftice. In a few inftances purulent difcharges from the ears have been noticed. They have not been accompanied by any re- markable change in the courfe of the difeafe. In a fmall number of cafes the difeafe has been followed by deafnefs, from which the patients have not fpeedily recovered. Two pcrfons were affefted in this way in the year 1808' gt Am- herft, and their hearing has not yet been reftored. By fome of our correfpondents it is said that recovery from this difeafe has been rapid, and the fubfequent ftate of health as good as ufual. But the exceptions to thefe re- marks are certainly numerous. The attack of this difeafe has been defcribed as fudden and violent •, but there are cafes in which the ordinary fymptoms occur in a flight degree, and increafe gradually for hours and even for two or three days before the difeafe becomes very ferious. We may alfo add in tliis place tliat in fome pi^rts of the country there were many perfons who exhibited fome of the fymptons of the difeafe, fuch as local pain, and numbnefs, but who were not fo mueh afFeded as to be confined. In general our correfpondents do not recognize this dif- eafe as having before occun-ed tinder their notice. Two gentlemen believB that they hr e in tlie courfe of many ve^s \ ffl m m M EDIC A L CO M M UiN IC ATiON«. Six -or eight caics I I ifeen a few cafes of the fame idbara^Uu' occured in Anilieeft in 1808. The .replies to ■out queftions c«fpe6ling the diagneiiri« arc not very full. It feema to be geoeralJy believed that (die liave had fe- not all been e difeafe. V alterations jrs at tlieir add ; that : the middle acre pat'cu- toms. Dif- thc ItoraacK fo alfo hive MEDICAL COMMUNICATIONS. 17 hardnefs of the pulfo and heat on the furfacc of the body. In many of thcfe cafes the bile has appeared in undue quan- tity and much altered in its charafter ; its confiftence very thick and tenaciousi and its colour dark. In fevcral fat;il cafes at Lancefter, and in fwo not fatal, a dark matter was thro^*^n up, which was called " black vomit." Whether this matter was the fame called by that name in the autum- nal fevers of warmer climates, the committee are not alTarcd. It appears alfo that in various parts of the commonwealth the common typhus is much more frequ'.nt than ufual at this feafon of the year ; appearing in many ihftances with its ordinary fymptoms ; but in others with a charadler more or lefs refembling the difeafe which we have defcribed. PROPORIION OF FATAL CASES. Refpefting the proportion of fatal cafes, tlie committee have not the means of making any accurate ftatement. It would be very ufeful to obtain from each town in which the epidemic has appeared, the number of its inhabitants, — the length of time during which the difeafe has prevailed, — the number of perfons who have been afFe£l:ed by it, — the num- ber of thofe to whom it has proved fatal, — and the average number of deaths in the correfponding periods of other years. The committee will ftate as much as they have yet learned relative to this branch of the fubjeft ; refpecling which they have made fome etiorts to obtain more informa- tion. At the firft appearance of this difeafe in the county of Worcefter, a very large proportion of thofe affc(£led with it died at an early period of the difeafe. Since it has extend- ed more widely, its violence has dimiflicd, and the proper- c ■1 ^ ), I H I h i \ _,<«fta»»^ ««»*,>m«a**ip«»^ 'f certain in a lefs examina- ;afe, have sen care- y reafcns to believe tliat the morbid appearances in thefc corrcfpond- ed with thofe of fome other cafes, which have not been ful- ly communicated. The cafes here given have principally occured in the neighbourhood of Bofton, fo that the tom- mitte are ?ble to vouch for their accuracy. This is alfo ef- tablilhed by the remarkable coincidence in the mail impor- tant circumftances noticed. We fhall now give a general ftatcment of the tnod com- mon, and the remarkable morbid phenomena, leaving the comparative frequency of the particular appearances to be obferved in the cafes introduced hereafter. EXTERNAL APPEARANCE. Soon after the patient expires, and in fome inftanccs a fliort time before, the (kin aflumes a formidable livid colour. This appearance is either generally diffufed over the Ikin, or elfe it cxifts in fpots, commonly of an irregular form, but occafionally rounded. The lividity is more remarkable at firft on the anterior parts of the fubjea, efpecially on the fore part of the face, neck and (boulders, than afterward •, for it gradually fubfides from thefe to the pofterior parts of the trunk. Wherever the cuticle has been removed by vefication the flcin is almoft black and often covered by fluid blood. On the other hand the petcchiae, which exifted during life, become paler, veficles or phlyctenae, eruptions and rednefs of the tunica conjunctiva difappear. HEAD. When the cranium is feparated from the dura mater tliis membrane ufually difcharges a confidcrable quantity of blood. As foon as the dura mater is cut through, ;i quanti- 2J MEDICAL COMMUNICATIONS. ty of f.-rous fluid commonly efcapes from under it, and tijc wliol.; furfa-v'c between the dura mater and tunica arach- noides is found to be cjuitc moift with tlie fame fluid. This li not uhviys trjulpmcnt lik^ water, but fometimcs quite - red coloured. The longitudinal finus is filled with blood, and wlicn wounded difchargcs a very great quantity of this fluid, w'liijh pours into it from the cerebral veins. Having raifed the duia mater, wc difcovcr an extraordinary fuUncfs of the veins on the furface of the brain, if tlie longitudinal finus IS ftill entire. This appearance however varies ac- cording to the duration of tlie difeafc. In tlujft-, who have piriflicd within the fpace of twelve hours from the firft in- vafion, the large blood vcfle^c ire execflively erouded, while m thofe of twenty-four hours continuance or longer the minute vefTeis are more difliind j and the other appearances, we are to defcribe, are more confpieuous, in proportion to the duration of ih? difeafe. The tunica arachnoides and the pia mater are remarkably altered in appearance by the efFufion of an opaque fubftance between them, which may b:: called coagulated lymph, or femi-purulent lymph. This fubftance is frequently of the yellowifh colour of pus, with a confiftence between the tenacity of lympli and the fluidify of pus. At other times we fee it pofltfl'cd of the afpea cf well charaaerized lymph. This effufion accompanies the courfe of the vcfllls very generally. In no inftance of the duration above mentioned have we feen it wanting in this fituatjon, while it is always very irregularly diflufed in the other parts. The fpace between the thin membranes con, - tains alfo a confiderable quantity of ferous fluid. The two hemifphere of tlie brain adhere to the dura mnter, near the longitudinal fmus, and to each other with fc much ftrongth, \:M' ^•^i™*^!** ■:^.')ff^^f''*f^iitfi^til. MEDICAL COMMUNICATIONS. fl 08 often to require a laceration or incifion through the fub- ftance of the brain, in order to arrive at the corpus t jllofum. The medullary fuLitance exhibits a great number of bloody points at the fcdione of the veflels, while the cortical putt feems paler than ufual. The lateral ventricles alway con- tain a notable quantity of water. This varies of courfe. Sometimes thefc cavities may be feen greatly enlarged, and at others with not more tlian three or four times the quan- tity often found In healthy brains. Tlie plexus choroides is often tliicker and hardor than natural, but always very pale from maceration in the efFufed water. The membrane at- tached to the plexus exhibits very confiderable alterations from its healthy tranfparency to a ftatc of morbid thicknefa and opacity. The membranes at the bafis prefent the fame appearances as at the vertex of the brain. A large quantity of ferum is found there ; and an effufion of coagulated lyn.ph in mafs has been witnefsed in the fame part. I ' THORAX. The heart generally exhibits fome appearance of difeafe. In every inftance the fmall veflels on the furface of the or- gan arc beautifully injcded : the external coat is fometimes the feat of a depofition of lymph, and even the inner lining and vahres are occafionally altered from their healtliy tex- ture. The right and left cavities ufually contain a fmall quantity of black blood, quite fnnilar in appearance and quantity ; and even the aorta has been feen gorged with the fame dark coloured fluid. The ftrufture of the lungs is not commonly deranged. Thefe organs are of a light and healthv colour on the fore part -, while the pofterior or lower parts arc difcoloured by the blood which fnlic into them. Their" n. \\ If MEDICAL COMMUNICATIONS. ' -f fubilance contains a very variable proportion of blood, dc- pcmlant no doubtj on certain circumllances accompanying the ccfTation of life. It fecms that when the lungs arc full of blood the liver is flaccid, and when the lungs are empty the liver is large and turgid. In one cafe tlje cavity of the thorax was the feat of very confidcrable difcafe. The heart was inflamed and exhibited a large thick flake of yellow lymph on its anterior face. The pleura of the right fide, both of the ribs and lungs was covered with the fame fub- ftancc, but more nearly approaching, pus in its confidence ; and the cavity of the pleura contained a very large quantity of half formed pus. The colour of the lungs externally was an ill-looking purple, and the pleura over tliem fecmcd io be (hrivellcd and adhered to the diaphr.igm. Their con- fidence was uniformly firm in this cafe, owing perhaps to the large quantity of blood they retained, ABDOMEN. The contents of this cavity have fcarcely fliown any marks of difeafe. Its opening is not attended with fo unplcafant imprcflions on the organ of fmell as in mod other difeafes. The coats of the ftoniach are generally free from the flight- ed morbid appearance; but in a fingli indancc, the lad, which occurred in the vicinity of Bodon, the mucus coat was in a date of very unifprm inflammation, and the veins were vifible through the peritonical covcyitig. The contents of the domach are not ufually remarkable 5 yet they have fomctiiner. a refemblauce to coflt'e-grounds, or more nearly to brown foup ; wliile in other cafes thty confid c' ^^ivcun ifh mucus ; each without any ofi^enfive odour. The duode- !Jum and the wliolc tivi\ of fmall and large iatefcines are in _-*»■ J*<««B--WW- MEDICAL COMMUNICATIONS. t^ a healthy ftatc. The latter commonly contain a confidcra- ble quantity of fecal matter. The liver and fplccn are dif- tended in very various degrees, as wc have alltrady intimat-' ed and are quite free of any morbitl change, unlefs we ex- cept an extreme livid color. The gall bladder is generally full of bile, which is fometimes of a dark color and ropy confiftence. The pancreas and kidneys prefent nothing ex- traordinary. The bladder is commonly full of urine. The Jr-nfcul;ir iuWtance as well as all other parts^ which arc filled wi^^b md exhibit the color of the blood, is of a liv- id .pivf.arante, fach as is not witnefled in other difeafes. This fluid has therefore necefl'arily a very dark hue. It it commonly accumulated in the cerebral veflels j and is i» moderate quantity in the vena: cava; and cavities of the heart. After having flowed out it often coagulates. The coats of the blood veflels are not altered from their healthy ftate, if we except the change, which has been defcribed as exifting on the outer furface of the veins of the brain. The lateft period after death when any of thefe fubjefls has been examined was from twenty to twenty-four hours } at which time, there was a lefs offenfive odor exhaled from the body than during life, and there were no figns of the commencemeiu of putrefaction. THE MODES OF TREATMENT WHICH HAVE BEEN ADOPTED, AND THEIR EFIECTS. Thofe evacuations which are ordinarily made In the com- zr.eucement of acute difeafes have been tlicught hurtful in this. Clood-letting has not been frequently praiflill'd by the gentlemen, to wliom we are indebted for connnuuica- I i rJ 1 1, '■ 24 MEDICAL COMMUNICATlOxNS. I / :if' I iions. They have been deterred from tliis pradice by the opinions they Iiavc entertained refpefting ths difeafe ; and by the reports\)f fome of thof^-, who had had previous op- portunities of obfervation on the fubjed. Some cafes how- ever have occurred in which the lancet has been employed with benefit. Thefe will be particularly noticed in the re- marks which the committee will make on this head . Cathartics have been thought injurious till the third day of tlie difeafe ; but enemas have fometimes been adminifter- cd on the fccond day, when fpecially indicated, without in- jury. In general emetics have alfo been thought injurious on the firft and feconJ days •, but in this refpe£t the caution has not been fo univerfally regarded. Efpecially in cafes « where ficknefs at ftomach has feemed to arife from a pri- or indifpofition in that organ rather than from a morbid af- feftion induced by the difeafe," it is faid emetics have been found ufeful. It is faid alfo thnt where the vomiting has been frequent, yet only white mucus and the liquids recent- ly fvvallowed have been eje£l:ed, emetics have not afforded relief. When medicines of this defcription have been ad- miniftcred opium has been given afterwards. The practice which has been by far the moft generally purfued, and confidered of primary importance, is to pro- duce early and long continued fweating. In many cafes, efpecially mild ones, this has been very eafily affedled ; in fome fevere cafes it has been very difficult. The means which have been adopted for this purpofe are very minutely detailed. The remedies are internal and external. The internal remedies employed have not generally been thofe now moft commonly direcT;cd to proJuce Jiaphorefis in fe- versi fuch as antimonials ; and which appear to excite the 'ii- RiKDICAL COMMUNICATIONS. 25 laplllary veflels without iiicreaGng the iftions of the heart of large veflcls either in force or frequency. Pteparations of antimony particularly feem not to have been at all tried ; but ipecacuanha, which refembles in its operation the prep" wations of that mineral, has been employed very fuccefsful- ly by fome in combination with opium. In general the internal remedies adminiftered in this dif- calc with a view to produce fwcating have been thcfe called cordials. The external remedies have been warmth and moiflure, and fuch articles of clothing as would more effec- tually confine both. The following is a fummary of the di- fe£lit)ns commonly given on this fubjeft. The patient is firfl put into a warm bath, or his feet are bathed in warm water ; then, being well rubbed, he is to be laid in bed between blankets, and bed deaths added in proportion to his fenfations, or to his aftual temperature when his fenfibility is very much diminifhed. Around him are to be placed bottles of hot water, Oi billets of wood heated in boiling water and wrapped in flannel ; or he is to be wrapped in f anriel wrung out, of boiling water ; fma- pifms are applied to the feet j and he is to fwallow fre- quently fome warm liquid of the defcription given above, preferring tc ufe the weakeft which appears adequate to the particular circumftances of the cafe. The articles moft commonly employed for this purpofe are hot infufions of the leaves of mint, penny-royal, and other fmiilar plants, winc«-whey, wine and water, wine, brandy and other ardent fpirits more or lefs diluted, camphor, fuiphuric ether and opium. It is not generally thought ufeful to excitt. profufc fweating. To this there appears to be a very confidcrablu tendency, when moifture is once produced on the (km j arti|^ X) V ;i J ■• 'I id MEDICAL COMMUNICATIONS. h iome very judicious praftitioners have tliought it neceflary to check this great evacuation by wiping and rubbing the ikin with warm dry cloths. But it has been thought very important to maintain the perfpiration in a moderate degree for a length of time proportioned to tlie feverity of the cafe j that is from twenty to forty hours, and even longer in fome in (lances. To m;?.intain this procefs not only cordials, but jiourillmient is given, 'jch as the patient's ftomach can bear -, which in many cafes is ftrong foup. Under this treatment mod commonly the violent fymp- toms and not very rarely all the appearances of difeafe have fubfuled. When relief has thus been obtained the diapho^ refis muft not be fuddenly checked, nor muft the patient be ^aRily moved from his bed. The fkin fliould be allowed to dry gradually, or if very much loaded with moifture fliould frequently be wiped and rubbed i but the patient fhould not be removed nor the bed cloaths (hifted till the tliird day. The adminiftration of the articles mentioned has been regulated not merely with a view to promote diaphorefis. They ?re alfo thought neceflary to excite the anions of the heart and large veffels and to produce warmth. In propor- tion to the neccffity of the cafe, the ttrength and quantity uf thefe articles have been increafcd or diminiflied. In ma- ny cafes very mild cordials alBftcd by external heat and tloathing have been found fufficient to cfftO. the purpofes defired •, in others the moil bold and liberal ufe of the ftrongeft cordials has been thought neceflary ; they have been borne in very large qu mlitics, and it is faid that life has appeared to d<'pend on their efFefts. In adminiftering hicdicines of this del'crlption the quantity has not been re- garded ; the pvaciitioner has meafurcd the ufe of them on- i MEDICAL COMMUNICATIONS. 27 ly by their effefts. In cafes of extreme coldnefs, great tor- por and frequent vomiting ardfnt fpirit has been given un- diluted i and when it would not remain on the ftomach if given cold, it has been made hot. Under fuch circum- ftances a quart of brandy has been given in twelve hours. It fhould however be noticed that fomc of our correfpond- ents who have been very converfant with the difeafe proteft ftrongly againil this liberal ufe of cordials ; and believe that much injury has been produced by them. In the lethargic ftate, which-I^s;, it is faid « the death Itate of the difeafe, un- lefs a fpeedy change be produced," tincture of opium has been thought eminently ferviceable. In cafes which have been thought defperate fifty to a hundred drops of this tinc- ture adminiftered every half hour « have almofl invariably removed the lethargy." When deglutition has been render- ed impofliblc by paralyfis opium has been adminiftered in enemas with the moft falutary efFeas. In cafes of fpafms alfo opium has been given in large dofes* with the moft liappy confequences. Arfenic has not been very much employed by our corre- fpondents, and its efFefts are not particularly ftated. In general if its ufe is mentioned, it is with approbation. Two gentlemen have adminiftered the ufiial preparation of this article in the convalefcent ftate, and they think it has been beneficial. At the fame time that cordials have been employed in- temally, and heat to the general furface of the body, cold water, fnow, and ice have been applied to die head. Thefc applications have been made, when there was violent pain * In one cafe a fcrupie was given in tlic couifc of three hours ; in inotluT forty two graiua in forty-eight hour?. ¥. '1Z^' /| 38 MEDICAL COMMUNICATIONS. I in that part with heat and fluihecl face, and when there was violent dcUrium. The cold applications have in thcfe c?fc» afforded great comfort to the patient, and have mitigated or removed thofe very important fymptoms. Sulphuric etlier dropped on the head and allowed to evaporate, has produc- ed fimilar good effefts. Vefication on the back of the neck, or on the head, fore- head, and temples has likewifc been followed by mofl im- portant good effects, not only in relieving the complaints about the head, but in abating other violent fymptoms of the difeafe. Vefication over the ftomach has been very fuccefs- fully employed to check inceflant A'omiting ; and, generally, to remove the morbid irritability of that organ. The bark of the officinal cinchona has been thought too flow in its operation to efFe£t any cliange in the early move- ments of this difeafe, when fevere ; but after the firft dan- ger has been over, that and fimilar remedies have been em- ployed with fome benefit. But preparations of iron* have appeared to one gentleman to produce a bettor efFcdl during convalefcence than cinchona. In fome cafes when apparently grown defpcratc, one (rcn- tleman found the warm bath a remedy of the highcll value. Preparations of quickfilver, particularly tlie fubmuriatc, have been exhibited in this difeafe in the Hiinv" manner, as they are given in tliis country in various otliev vicute difealcs. They have been more or lefs employed bv various plivfi- cians •, but particularly by a gentleman at Worceflcr. Oth- er articles, fuch as have been mentioned, were alfo admin- iftered by this gentlemen ; but where iii'c was not imnicdi- diately threatened thefe preparations were: mfnc particularly * This gontleiTian gave GiiffitVs nr/irh mixture. ■■?^ ^ MLDICAL COMMUNICATIONS. S« m relied on. His mode has been to " adminifter diligently" from the beginning fubmuriate of quickfilver combined with camphor and ipecacuanha, and with fo much opium as to prevent any powerful cathartic effeds from the medicine. This mode has been purfued until a flight affedion of the falivary fyftem has been produced. The fuccefs attending this praftice certainly was not exceeded by that of any other ; and, while purfuing it, the very liberal ufe of cor- dials has not commonly been found neceffery. THE committe have now reported every thing of impor- tance relative to the difeafe lately epidemic in the county of Worcefter and eifewhere within this commonwealth, fo far as they have been able to obtain information on that fubjeft. They will here add feme brief notices RESPECTING THE SAME DISEASE IN OTHER PLACES. The appearance of this difeafe in tlie county of Worcef- ter was not the commencement of its recent prevalence in our country. It is obvioufly the fame which occured in Mcdfield in 1806, of which an account v,-as publifhcd a-.- niong the medical papers of the fociety. It is unncceflary to recite the defcription there given. Since the month of March 1807 the fame difeafe has been epidemic in fomc parts of the ibtc of Conucd:icut. In that month " it appeared in the city of Hartford, and foon after in the town of Wind for. From that time to (he prelent it has made it appearance at various times in various places in the counties of Hartford and LitchijelJ. Cafes have oc- curred in almofl every month of the year ; but it has gene- ¥^ 30 MEDICAL COMMUNICATIONS. rally been moft prevalent in the laft winter and the fpring months. We arc not fenfible of any variation in the feafons fuflicient to have given rife to thia new form of difeafc. The winters preceding the fpring of 1 806 — 7, when tlie difeafe firft appeared, had been, as ufual of late years, open and mild. The winter of 1808 — 9 was unufually fevere. The local fituations of the towns, in which the difeafe haa been moft prevalent, are various. While fome of them are fituated upon the hordes of iivulets, and and interfered by fmall ftreams never know to emit unhealthy vapours ; oth- ers are placed upon high hills and bleak ridges, and have hccn ranked among the moft healthy in New England.*" It appears that tJiis difeafe has exhibited in Connefticut con- fiderablc variety of charaifter in different places and in dif- ferent years. It would be intereftiiig to notice all the circamftances ob- ferved there which have not been remarked in this ftate. But this report will not give room for fuch notices. This difeafe is faid to have prevailed during the prefent feafou in fome parts of the of New-York and Vermont ami of the pi;ovince of Upper Canada. It is reported that in thcfe two laft mentioned places fymptoms of pneumonic affeiflion have in many cafes attended tlie difeafc. The committee have not yet been able to obtain fatisfaftory in- formation from thofe quarters. m * An inatiguiid d'lsseri/ttlon on llie disea>!e termed petechial, or spotted fever, by Natlian Strong, jun. of Ilartforcl. Primed by Peter .B. Glcason, 1810. The conimittee have derived their information respecting iliis epidemic in Connecticut from tliis (!if:sertairon. from a p^ipcr by Dr. S;imut:) Woodward pubhslied in the New York Medi- cal Repository, and fiom llic private IciierD of lespeclMble pliysicians in that Itale. ...... ^ ^ ^ *** ^'~"'^^. MEDICAL COMMUNICATIONS. 31 ON THE NAME AND CHARACTER OF THIS DISEASE. THE committee now beg leave to make fome remarks on the name and character of the difeafe, which is the fubjeft of their report. This diftafc has been called fpotted or petechial* fever The name has been confidered improper by moft medical men, who have had occafion to remark upon the fubjedl. It is however true that to fimilar epidemics, that is to epi- demic fevers refembling this in tlie appearance of petechiae, the name of petechial fever has been given. Two opinions have been maintained on this head. The one that the pe- techiae are primary, or effential to the difeafe in the fame manner as the eruptions in fmall pox and meafles, to the difeafes, which bear their names. The other opinion is thrt they are fecondary, or fymptomatic ; that they may or may not occur in various difeafes, and that they are produced in confequence of fome peculiar ftate, into which the fyftem is brought not by any fpecific anions, but by adions common to various difeafes. The first opinion is adopted by Buferius, one of the moft induftrious and learned of compilers. He difcuiTes the fub- jed very fully,t and ftates the realbns for his opinion. Of * It is conjectured by HofFman and others that this term is deriv- ed from the Italian word pedechie. But Burserius suggests that it may be derived from />(■ j/ir, because tliese spots were first noticed in the plague. Burserius had traced back the liistory of these spots in Italy only to Fracasiorius. But his suggestion derives considerable force from this circumstance ; that Ingrassia, who, accoiding to W'ii- laii, noticed these spots in Italy a hundred years before Franstorius, and probably before any one eke, called them pcsiuias. IViilan on cutaneous diseases, Vol. i. p. 470. t Institutions of Medicine translated by Biown— Vol. iii. p aaC. Chapter on the Petechiae or petechial disease. His arguments are not here stated at large ; but the molb important ii.iiis of thtm are given. See the work. 93 MEDICAL COMMU NIDATIONS. thefe the principal arc, I. That, when petechiae preva! epi- demically in any place, they are found on many pevfons without fever or any other preceding difeafe. II. That the difeafe has a great tendency to the {kin, fo that although in a few perfons who have the fever they do not appear, yet that they do in the great majority of inftances. III. That the fever has a great variety of character fo that the petech- iac be fuppofed to depend on the fever, but on the contrary the fever on the petechiae. IV. That the petechiac appear at various periods of the difeafe. V. That die eruption when perfedk in its chara. 4:3. and following. .dgidb )rev'a'. efJl- ly pcrfbns That the Ithough in ippear, yet III. That !ie petech- e contrary iac appear : eruption lat in con- excretion, reafone of :r author, ngages fo that, al- t circum- , who ?re rhat how- 'itliout fc- :her times ble fever. Willan ;* "requewtJy 7y petech- liae with- epidemicv MEDICAL COMMUNICATIONS. ss In anfwer to tl>e fecond It is die remark of a large pro- portion of prai^ical writers that pctechiae do not appear in nearly all the cafes of thofe epidemics in which they are no- ticed. It is alfo remarked by )nofl; of thefe writers that the frequency of ihcir appearance depends very much upon the treatment of the difcafe. i3oth thcfe remarks appear to be confirmed by Willan.* The third rcafon or argument it is obvious may be dated with equal force on the other fide 5 inafmuch as petechiw appear in fevers of a great variety of chara£ler. From vari- ous confideratioiij'we do not believe it can have any, cer- tainly not much weight on either fide j but if any, the lefs in favour of the opinion of Burfcrius when taken in connec- tion with his fourth teafon. For by this is appears not on- ly tliat the conftitutional affection has not any pecuhar cha- r-jwftcr, but that the period, at which the fpots appear, is ex- ceedingly variable and uncertain. Although this may be ■•'■'jc in fome degree as to fmall-pox, meafles, &c. it is not irut of them at all in the fame extent as Burferius ftates it I be with refpcA to peten the conn- ives no doubt general! de- anthematibus jmni ardore, )rodcant, fed p. 3j8. Ve- to accompa- Paris, 1770. lib. Gall. afPhyiic. :rolini 1789. hority which nly in acute, ol. I. p. 4-1. mittce have adopted tlje fccond opinion dated above, viz. that the pet?chi;v are focondary, for ^hation. f See BcJdoes' reft. arches. >' lual cafn; scially the phlegmo- atous. It I the two. tation has m Is inflain- rer ? Thi» rs ; and it cachers of lammation ever is ve- lammation inflimma- Les I jbr v'ithin the ly ; fome- 1 all three, externally :e has not ife, or af- /er, in the on inflam- hey are to any ncccf- fevers ia ed by any y of Tubin- jtterlnick on on Rver aS MEDICAL COMxMUNICATIONS. 39 peculiar charafter, fo as to be fpeciaJly denominated by pro- feflbrs of medicine ? The committee believe that this quef- tion may be anfwered in the affirmative, and that the coiv- fideration of it will not be ufelefs* By inverting the terms we fliall find an anfwer in an ob- fcrvation made by Baglivi. " Quae nobis videntur malig- nae a viicerum phlegmone aut eryfipelatode fiunt."* This is the fum of a do£lrine, which fubfequent obftlVations and refearches appear to have confirmed. The term malignant has been very loofely applied ; and its irfe has been juftly reprobated by Sydenham and many others. Yet there is one defcription of fevers, to which it has been mote peculiarly appropriated. It is true that the beil writers are very often confufed in the endeavor to dif- tinguifh peftilential, and putrid and malignant fevers. To engage in the confideration of all their diftinftions and all their confufion would lead the committee too far from their objeft. They believe however it will be ufeful, in order to determine the true charafter of the epidemic under tlieir confideration, and to compare it with difeafes heretofore de- fcribed, to point out thofe fymptoms which have been con- fidered evidences of malignity in fevers. They are the fol- lowing : I. Great difproportion in the violence of the fymptoms, compared with each other. II. Some peculiarity in the character of the fymptoms when compared with thofe called by the fame name, as they occur in ordinary difeafes. III. Remarkable imbecility, and prollration of all the powers of the body, or of certain of them, witliout any * Or^h—p. 5 T. 4& MEDICAL COMMUNICATIONS. w manifefl: eaufe ; occurring at the very .commencement of the difeafe, or after it has continued a few days with mild fyraptoms. , . • . IV. Pains in any or every part of the body, fometimcs fixed, but often fl>ifting ; in the Hmbs fcvere, as if they had been bruifed or broken j with toffing and twilling. V. Extreme pain in the head j the greaftcll folicitude and perturbation of mind, watching and deHrium ; or ftu- por, coma and lethargy. Imagination very much difturbcd and memory weakened. VI. The countenance very much altered, lofmg its ufual fptrit and exprcffion j fometimes entirely natural. Face of^. ten livid and leaden coloured. VII. Eyes ted, or dull and cloudy ; dimnefs of fight and blindnefs. Ringing and hifling in the ears ; deafnefs. Taftc and fmeli depraved. VIII. Tongue rough, dry and dark ; mouth bitter ; fomc* times with infatiable thirft, fometimes v/ithout any. IX. Pulfe frequent, fmall, weak ; even in beginning ex- tremely fmall and frequent ;* variable and intermittent. X. Heat fometimes great, but oftener lefs than in other febrile afFe«ftions. Extremities often very cold. XI. Urine fimilar to that in health, efpecially in the iirft days of the difeafe ; fometimes thin, without fecliraent j or if there be any fcdiment it is often dark coloured, more like an excrementitious fubftance than like the ufual fcdiment. XII. Matters call tlie at- bc evidence wing remarks :s are not sqf- scascs. Ob's. und certainly ien from tlie un», and so e referred to n oi its nicm- : — MorgRgni i.iligiiant. In re mere fh in :ntly ataxic ; g'li remarks i>cc3 were hI- s here. - ame the one was rain discatid. rases in rhc \f stated £.0 u5 1 was found ataxic fovnr^ Cluttcrbadt igle, Donald :ing that the have died of MEDICAL COMMUNICATIONS. 45 fijrniihed by thofe writers they will arfd only the foUowitJg. This i» fuch as rends to ihew that in malignant fe^er in- flamination occurs in the parts withm the cranium. Pincl in his meJicine cHniquc gires twenty-eight cafes of Ataxic ferer, and forty-nine cafes of fevers of different char- afters. Nineteen cafes of ataxic fever terminated fataHy and fourteen of the bodies were examined. Nine of the otlier cafes were fatal and five were examined. Of the fourteen in every one there were dlfeafed appearances within the cranium precifely fimilar to thofe difcovered here j of the five not one had fimilar appearances, nor any other appearances of difcafe within the cranium. This too conforms to Pinel's general remarks on the fame fubjeft ; and is fupported by further evidence in a difieration " fur les fievres ataxique fporadique et adynamique continue, S:c. par. A. B. Deflains," a pupil of Pincl. In four cafes, the only ones examined, the appearances correfponded exacftly with our's. The account, which is publifhed among the papers of the Society oi a fever at Geneva, (hew that that difeafe was the fame >vhich has prevailed here. It is there faid that Qn examination after death the blood vefTels of the brain v/ere turgid ; but that in other refpefts both the brain and the other vifcera were found natural. Beddoes gives an abftra£t of another account of the fame epidemic by Dr. Matthe. According to' his account the fame congcftion only was found in three children, who died of tiiis difeafe fev?r ; but it appears thai four of them confine this remark expressly to malignant fe\ er ; one to peitchial fever, one to typhus, and one tu yellow fever, probably a'l of them ataxic. In a very large proportion of the cases collected by Reddoes in wliich the bram was found diseased, tht fevers wore ataxic. He al- so gives some cases of similar fever* in wliich other viscera were diseased. i 4§ MEDICAL COMMUNICATIONS, in Icfs than twenty-four hours. But he reports alfo that hi an adult, who died on the fixth day, the following changes had occurred in the brain j viz. " veffels of the meninge* (Irongly infarcted, a bloody-gelatinous fluid fpread over the whole brain, liquid in the ventricles, choroid plexus deep red i at the posterior part of the lobes and interiorly puri- form matter without alteration of the texture of the brain ; the same at the thalamus nervorum opticorum and extend- ing along thefe neves and an inch into the cavity of the fpine i cerebellum very foft." , ^t Medfield alfo there was noticed, in three cafes only, turgescence of the cerebral veflcls ; but in two other cafes, more obvious proofs of difeafe within the cranium were dif- covered. In like manner in case XIV. which occured at Charlestown, turgescence yf the veins only was difcovered en examining the brain. But in this cafe, in thofe fimilar at Medfield, and in moft of thofe at Geneva, the difeafe had not continued twcnty-fuur hours. Now it is not ftraining. the fads too far^ when the whole are taken in tonnedion to believe that in thefe cafes inflammation had commenced, although there had not yet occured any fuch organic elFedls as to demonftratc this perfeftly. „ . There is indeed anotlier explanation of the llatc of fome, who have died thus fuddenly and in whom there has been found only diftenfion of the cerebral vcflels j this is tliat they are apoplectic, or die from the fudden preflure on the brain. The appearances during life in fome of thefe cafes accord with this explanation. The fymptoms in cafe XIV. and in many others, were very ftrikingly fip^ilar to thofe of apoplexy. . . , « MEDICAL COMMUNICATIONS. 47 from Pinel's remarkj inflammation in the brain has been found in all cafes of ataxic fever i and the other viscera have been inflamed in fevers, which were not of that def- cription. This certaLily has not yet been made to appear ; but the committee are difpol'ed to confider this dodrinc as nojt materially incorrc^jt. . -jlf fome caf<38 occur which come under the defcription of ataxic fever, and in which not the bruin but the other vif- ccra are found to hav« been iiiflamed, an explanation m^y be found; by reference to tlie laws of fympathy. ; In cafes of tliis defcription the inflammation has more commonly been found in the addominal than in the thoracic vifcera ; and it is well known that morbid fympathy is more commonly re- marked between thofe vifcera and the brain than between the thoracic viscera and the fame organ. But the commit- tee do not wilh to urge this doftrine too faf . It is certain that in a vaft many cafes of ataxic fever the brain has been ■found difeafed ; and on the other hand that whete the brain has been found difeafed the fever has commonly been ataxic. ,But the fame conne-xion fometimes, although much left generally, has been found between fever of this defcription and local afi'eftions within the thorax and abdomen. The fubje£l mufl; be confidered as under invefl:igation, but cer- tainly not yet made perfeftly clear. To elucidate It arc waiting numerous accurate obfcrvations on the living and on die dead. Obfervations fufilciently numerous can be made only by the joint labours of many. But let every- one recoiled how many valuable obfervations already niade are loft to us, and what is worse, fcrve oftentimes only to perplex us, becaufc they have been recorded imperf«aiy and inaccurately. i- 1 *9 WEDICAL COMMUNICATIONS. Tht applicatiM of the ioaiitm, which iaw he« ftatco*, to ihe epidemic under our confulcration is duly general. In «xamifting individaal cafes we find great variety cf cliarac- ter. It 13 probablft that there have occurred cafe* of purr ferer, fjrnochus and typhus, both mitior and gravior ; cafoi of fever complicated with inflammation of the brain j *rtd Cafes of fuch inflammation alone, not combined with fevers Perhaps we fhould add that in fome cafes the fa^s fh.w on- ly a great turgefcftrtcc of the cerebral rcflels, not accompa- nied with inflammation. The inflammation alfo has raried In its charaAer, and has been phlegmonous, cryfipelatons, 6r frequently intermediate, the eryfipelatous charaaet pre- 'dominaiing. ;,...; It probably alfo happens thdt m fome cafes fcrer Wrt^ln- aies in local inflammation ; and perhaps inflammation in fc- Ter. Undoubtedly In fome cafes the one difcafc commences alone, and the other fupcrvenes and combines with the firft. —this is very common in malignant epidemic fctets ; and hence the patient does not at firft, ptrrhaps riot for fome day*, appear to be affcfted with a fevere difeafc ; when fuddcniy there enfucs great proftration of ftrcngth with fymptdms of cerebral afFe£!Hon. Intermittent fevers arc not prcvaTdht "'among us ; trnd probably owing to that circumftance we attend lefs to re- milKon in fever than pliyficians in moft 6ther ciftnaJcs,who arem tl.e Rahit of ' diftlnguifhing tliC fti'r6xyfm5 of fever, llie cojnraittee ' ha\'e not any information refpefting (he gcncr;d characVer of the difeafc -nndef fconfider^ion in tliefc rcfpca^. It would foem however from fhmc cafes com- inunicated to us and from cafnal remarks that it has remif- fions, alilAough ihcy may not be of atiy regular type 3 h il : tiSi^-i. MEDICAL COMMUNICATIONS. 49 fomc inftanccs there Is rcafon to fiifpca that thcfe rcmiflions have amounted ahnoft to intcrmlirions. Where the fever has had periods of rcmifTion or intermilTion, thcfe may have been lefs obfcrved bccaufc the fymptoms of inflammation have continued.* CAUSES* Rcfpc-aing the prcdlfpofing caule of this difeafe the com- mittee cannot offer any remarks that are fatisfaftory to thcmfelvesk The following circumlhnces only vire knovr rcfpcding it ; vizi that it has been in operation fince the tvinter of 1806, to the prefent time ; that its operation, extends over a very confiderable portion of country ; tJiat after ceafing to operate in one part of the country it commences its aft Ion in another > that the portions of country in which it produces its effe£ls are very various as to foil and elevation ; that the feafons in which it is pro- duced have been of different charafters as to temperature and moifture ; and that it has been moft powerful from midwinter till the latter part of fpring. The fuggelUont that bad grain has been in any mcafurc Influential in pro- ducing this difeafe are not corroborated by any evidence be- fore the r^mmittee* Shall wc with Sydenham confefs our Ignorance, by referring the prcdifpofmg caufe to fome fe- cret peculiarity in the confliitution of the atmofphere ? Something more is known refpc£Hng the exciting caufes. Thefe are the fame which operate in all cufcs, when epi- tlcmics prevail which are not contagious. Krrors in diet, cxpofure to fudden changes of temperature, or to damp air, fatigue, watching, axlety of mind, and in fliort any caufe, • See Fordyce on irregular intermittents. G * ^-*^''*--i^ to MEDICAL COMMUNICATIONS, I which in a time of health will produce a flight derangemctit in the fyftem, will during the cxiftence of epidemic which is not contiguous, operate as an exciting caufe. In other Wonds tlie prcdifpofing caufe affefls all, or a certain portion of, the members of the community in fuch a way, as that whenever the ordinary fundlions of the fyftem are interrupt- ed, in any confiderable degree, fuch pcrfons become aflfi:£led wltli the prevailing difcafe. It is in confcquence of fSitigue •and anxiety that the attendants on the fick often become af- fc£led with the prevailing epidemic *, but in fuch cafes the difcafe h often thought to be produced by contagion.* The committee do not make thefe remarks merely in con- formity to general principles entertained by them, altliough that conformity exifts ; they are founded on the obferva* tions of their correfpondents. The committee have gone as far in analyzing the difeafe, as fafts will warrant them. They will not add any thing refpeding tlie proximate caufe j for that would engage them in the inveftigation of die proximate caufes of fever and inflammation, fubjefts which have more frequently been difcuiTed, than illuftrated. Refpe£ting the caufes of fymptoms they may have occa* fioh to make fome remarks in co. lering the method of treatment ; they wifh not to make any, which have not for their object immediate praftical utility* METHOD OF TREATMENT. A few remarks will be made introduftory to the indica* tlons of cure ; but thefe will be ftated, and the means of fulfilling them briefly pointed out •, and then the difl^crcnt * See A Jara's Iiuiuiry into the laws of Epidemicsi. f^" MEDICAL COMMUNICATIONS. §1 irangement imic which In other ain portion ay, as that : interrupt- ne affefled I of fatigue become af> h cafes the ion.* cly in con- I, altliough e obferva-* he difeafe, any thin^ Id engage ;s of fever icntly been have occa* method of ive not for he indica* means of e different remedies to be employed and the circumftancei, which (hould regulate their employment, will be more particularly confidcred. In fome cafes of this fever the Immediate deftru£lion of life is threatened in the firft ftage, in confequencc of pref- fure upon the bruin. This prelVure is produced hy congef. tion of blood in that part. In other cafes life is threatened by inflammation of the membranes covering the brain and lining its cavities, ac- companied by a more flight congeftion. This inflammation may deftroy life in confequence of the irritation communi- cated to the whole fyftcm by the affedion of fo important an organ ; but more commonly by the effufion, which it occaHons, producing preflure on the brain. Thefe dangers are increafed by the combination of fever with inflammation, by which the fyflcm is rendered Icfs able to produce a natural cure, and which cmbarrafles the phy- Ccian in adapting remedies to the difeafe. There is in ad- dition fome rilk of life from the fever alone ; but this is not confiderable. In a llrge proportion of cafes the dangers, which have been difcribed, do no exift at all, or onlv in a flight degree. Wlien congefl:ion in the brain exifts, the firft indication is to diminiih the quantity of blood in that part. This is to be effefted if poflible by inducing contraction in the vcf- fcls of the head, and dilatation in thofe of tlie tiunlf; and ex- tremities. For this purpofe cold applications are to be made to the head, and thofe which are warm and moiil to the body j and at the fame time, if there be great deprcffion of ftrength, very mild cordials may be adrainiftercd. Where Uk \. £S MEDICAL COMMUNICATIONS. however the preflare on the brain ig very great, blood fliould be drav.ii from the jugular vein. When there cxifts inflammation within the cranium, witli- out any confidcrablc preflure, thefirft indication is to dif- rufs the inflammation, fo as to leave the patient affefted with fimple fever. This indication it is difficult to fulfil j for although wc feparate the difeafcs in our own minds, and although in a certain fenfe they have diftinft cxiftenccs, yet they are combined in one and the fame fyftcm, and proba- bly -are modified each of them by the other. "We may in- deed fometimes relieve both at once, but wc may alfo, while wc relieve the one, increafe the danger of the other. To fulfil this indication the fame remedies may be adopted, as ftated above to relieve congellion ; and, in addition, the forehead, the back of the neck, and even the whole head ihould be bliftered. Bleeding however fhould not be readi- ly praiflifcd in this cafe, unlefs tlie inflammation approach the phlegmonous charaftcr ; nor will it often be admilfible in this cafe to ufe cordials. Preparations of quickfilver, will alfo be ufeful in attending to other indicationgf will be beneficial with regard to this. The fecond indication is to interrupt thofe a6tlons which belong to the fever, fo as to reflore the anions of healtli. This indication will oftentimes be fulfilled by the treatment alreadly propofed. In addition, preparations of quickfilver may be exhibited, until an cfleft is produced on the mouth. In fomc cafes emetics may alFtft in attaining the purpQl'c here propofed. The third indication is to fupport the flrcngth of the pa-r ticnt V. hiie going through the difcafc. To which end all cvacaiitions fliould be avoided, whkh are not abfolutely neceflary, i-.nlefs there i? good rcafyi: to believe, that the dif* ll-: :i',,^jf MEDICAL COMMUNICATIONS. W eafc may thereby be cured, or materially dimrhlfhcd. Alfo fuch nourifliment fliould be given as the ftomach wUl bear with eafe. The fourth Imlication is, when the difeafe has fubfidcd, to reflore vigor to the Iv'ftcm cxhaufted by the fatigue of unufual exertions, by unufual evacuations and by want of nourifliment. This indication is to be complied with by adminiftcring tonics and nourifliment ; at the fame time all exertions, which cannot very cafily be borne, fhould be a- roided. Each of the remedies mentioned, and fuch others as may be deemed important will now be feparately confidcred. EVACUATIONS. It has been the praftife of almoft all phyficians to make fome evacuations from the body, in the commencement of acute difeafes. It would feem that experience muft have been in favor of this pradice, or it would not have been fo univerfally adopted. As to the mode of evacuation and the extent to which it ftiould be carried, there are no doubt va- rious opinions. But in ataxic or malignant fever, many phyficians have thought aU evacuations injurious, while oth- ers have advifed them to be very profufc. It is certainly true tliat evacuations muft not be wantonly or indifcriminl ately prefcribed in this difeafe; but when they are made for certain definite objedts, and regulated in their extent by a regard to thofe objeds, they may be highly beneficial. The objeds to be had in view will be ftatcd under the heads pl the particular evacuations. BLOOD-LETTING. "Die effeds of this evacuation are not always the fame, ,ind the mode in whivh it operates is not well agreed upon. . i PA At. s; $4 MEDICAL COMMUNICATIONS. It has been fuppofed to Icflen the actions by removing a ftl- mulus. By taking away the ftimulus of didention, when that exists, it may operate generally to leflen action. But vfhen the veflels do no.t fufF^r greater uiftention, than they bear with eafe, taking away blood from thern has been fup- pofed to increafe their aflion. The explanation which has been given of this effeft will be ftated. Xhe blood veffeU always contract to their contents, fo that they ^re always precifely lull. Their elasticity con- ^ntly tend^ to make them enlarge their capacity,* and tl^eir contj^ftion is produced by tl^eir mi^fcwlar power. "WliCn Mood is drawn from the vcflels, this power is exer- cifed at the expenfe of the reft of the fyftem. The effefls vary ibmewhat according to the mode of drawing blood. if it be drawn from a large veflel, in a full ftream, the vef- fels are obliged to a^ fudd^;jly j whereas if the blood flow fixun a fmaU veflel, and flo'v^ly, the cpntradtion of the veflTeU is more gradual, s^nd an efle£l more la fling, but lefs power- ful and immediate, is produced. The confequence of tliil exertion of the blood veflels is to diminiih the ftrength of the fyftem, and leflen the force of action in other parts of the body ; more efpecially in any portion of the fanguifer- ous fyftem, which is undergoing inordinate a£l:ion. Hence the cfliefts of bleeding, when phlegmonous inflammation exifts in any important part of the fyftem. When tlie veflels act feebly, when the pulfe is fmall and frequent, blood-letting in general is not admiflTible upoji the • Perhaps this is not true as to particular ve/TcIs when very ex- traordinary diftevied ; but it is true as to the L'ood vefleU generally in any ftate in v'jich they can all be at the fame time ; tor uiey can- not all at one time be lb extraordinarily diltended ; there is never liifltcien^ blood in the body for this purpofe. See Fordyce's pra<5ticc of phyfic, part I. article ^h^'i -vrffcls, for tlie doctrines here ftated. MEDICAL COMMUNICATIONS. Ity,* and principles, which hare been laid down. ITicre is however at Icaft one exception to this rule. If under thefe circum- ftances, as regards the aftion of the reffels generally, there exift a local plethora, or what has been called congeftion in any part, letting blood from the veffels fo affeiled may be- come neceflary. This fomctimcs occurs in the vcflels of, the tunica conjunftiva, and by dividing them that part is relieved. When fo fmall a quantity of blood is effiifed, as is neceflary in this cafe, tlie fyftem does not fufFer from the lofs, and it relieved by the removal of the local difeafe. But when it is a larger part and when larger veflels are afiefted in this way, the lofs of the blood, which is drawn to relieve them, may produce too much weaknefs in the fyftem. In tliis cafe the danger from the local afFedion, and from the lofs of blood to the fyftem muft be carefully weighed ; and it is only, when the former danger is great and imminent, that the evacuation can be authorized. The committe beg indulgence while they confider more minutely the eflre£ls of congeftion in the brain. It fome* times happens that a determination of blood takes place to the head from caufes, which the committee prefume not to afcertain. The arteries going to the brain throw the blood upon that part fafter, than it can be carried off by the veins ; or the veins ceafe to carry oiF the blood as faft as ufual, al* though the quantity which is brought be not unduly ihcrcaf'- ed. In whichever way it happens, the veffels become fo full, that they cannot cohtraft with fufficicnl force to relieve themfelves from the mafs of blood which they contain. In confcquence the brain fuffers from preflure ; its funftiong are more or lefs interrupted ; the mufcles of refpiration, which arc known by experiment to be influenced by the cc \' ?f f^'i 56 MEDICAL COMMUNICATIONS. rcbral fyftem, are partially paralyzed ; the mechanical of^ fice, which belongs to tliem, is not performed ; the lungs do not receive their ufual fupply of frefli air ; the blood does not undergo its ufual changes in the lungs from the action of the air j the left ventricle of the heart and the whole bo- dy is fupplied with blooJ. more or lefs nearly refembling that, which is ordinarily found only in the veins of tlie bo- dy and in the pulmonary arteries ; erery part of the body U in confequence weakened ; and if relief be not flibrtly ob* tained, death enfues.* In proportion to the power of the caufe thefe effe£ts take place in a greater or lefs degree. In circumflances fuch as have been defcribed the patient lies comatofe or convulfed ; the respiration is diftrefled, ftertorous as in apoplexy, or anxious, feeble and convulfive like that of an animal in an exhaufted receiver, the circular tlon is very Imperfedlly pcrform«k, the whole body is cold, more cfpecially the extremities, the fkin becomes grim, and livid, particularly in the face ; or when the preflure is moft fudden and violent the face fwells and becomes almoft black, and the refpiration and whole appearance is like that of a perfon who is ftrantrulatcd. Under thefe circumftances, in proportion to the violence of the cafe, different remedies are applicable, for here " dif- ference in degree conftitutes difference in kind." When the preflure is great, if a blood veffcl be opened, arid evacu- ation do no relieve the preffure, it finks the patient. The vcffels, in the trunk and extremities, must contraft to their contents, and by tliis exertion the little remaining ftrength of the fyftem is exliaufted. But if the preflure on the brain is relieved, the refpiration becomes free, and the whole ma- hi * See Eitliat on life and dcatli. ■ .i< Pl | l . .1 1, , ^- ■:,JJ««Sl'*«>- MEDICAL COMMiJNICATtONS. sf chine begins to perform its cdftomary motions. The imme- didte danger is. averted, the fenfibility and irritability, whicK wtrt dmoft loft, ite now recovered, the drcuiatioris become', more itegular, and remedies can be applied to complete the cure. Whatever may be the ftrength of the fyftem, it cah better bear thtf removal of the fuperfluous blood in the head* than it can bear the interruption of its fundions, arifing from the pireflure of that blood. The objeft is to take off that blood, Mrhich Is ftipcrfluous in the head, without pro- ducing a fudden proftratron in the fyftemi before it has time to be beneHted by the removal of the preflure; Here the head and the other parts of the body are to be confidered as in fome meafure disjointed. If a vein be opened in the arm, it wiU not relieve the head, except throiight the medium of the general circulation ; and the heart and veflels will fuffer in a large proportion to the benefit received, arid for a few moments before any "lenefit is received; The efiefts dur- ing thofe moments may be fatal. If the quantity taken be not enough to give any relief, or if it be more than is necef- fary for relief, the injury to the fyftem may be ,fuch as to produce death. But if a vein be opened, which immediate- ly communicates witli tlie cerebral veflels, fuch asrthe exter- nal jugular vein, theprelTureis immeuiately removed from the head, and the general relief is fuch as to counteratl all the evils of lofs of blood to the fyftem. From the foregoing confidcratlons, whJcIi I-.aVe been ftat- fed briefly as the nature and im{)ortance of tiie fubjeft wiU admit, it appears that tlicre may be two, and thofe very dif» ferent ftates of the fyftem in this difeafe, in which it may tc proper to let blood. The firft is when there is phleg- inanoit, inflammation, or fuch as approaches nearly to that H ■\- i\ s! it J, / i i I ffi: 'lO ttn MEDICAL COMMUNICATIONS. chdtafter, affefking the brain and its membranes. Here if • the fymptotris be not violent, other remedies may fuffice j but if they arc, if the pain in the head be feve^, if the fun^ tions of the whole animal fyftem be very much interrupted, and at the fame time the flcin be hot and the pulfe hard, the cafe is dangerous } we have then to apprehend that fuch effe^s will be produced within the cranium as will deftroy life, before we can aireft the difeafe by other remedies. In this, cafe, thie violence of tlie inflammation muft be reduced by bleeding. It is not comparatively very important from what part the blood is taken for this purpofe. It would however be belt to take it from the jugular vein, becaufe that communicates immediately with the vefFels of the part aflfefted ; and probably a given quantity of blood, drawn from that vein, would afford more relief than if drawn from the arm. "Wlicn from any canfe that vein cannot be open- ed, the opeAtion may be performed on the temporal artery. From whatever veflfcl the Wood is taken a large orifice (hould be made, that the effeft may be as fudden as poffible, fo that a fmaller quantity may fuffice. Probably from ten to twen- ty ounces would be fufficient in most cafes. The fecond cafe, in which blood Ihould be evacuated, is that which has already been defctibed, in which the brain is fufFcring preiTure from the fuUnefs of its veflels. Here it is very important that the blood be drawn from the externa! jugular in preference to'a vein in the arm, for reafons which have alfo been fuggefted. The orifice in this cafe alfo (liould be large, that the relief may be as immediate as poffi- ble. At the f;ime time it is important to avoid producing faintnefs, that the general fyftem may not fufFer too much, before it has derived tlie benefits of the operation. Several MEDICAL COMMUNICATIONS. «• attentions may prevent this effeft. Cold applications (hould be made coflftafltly to the hiad and face during the bleeding to excite contraftion of the veflels in that part, and thus fup- ply blood to the reft pf the fyftepi j thofe cordials, whofe a£tion is fudden and tranfient, fhould be ^dminiftered at the &n»e time if any faintnefs be perceived ; and in this cafe l^e flow of Wood'ftiould be ftcq)ped until the faintnefs has fubfided ; Acn if relief is not obtained, the evacuation fbovildbe cbntinued.* With diefe precautions die blood ihould be allovired to flow until it is obvious that fome relief is obtained. To maintain the adi^antage whidi has been thus procured, other remedies ihould be imoaediately employed, fuch as will ihordy be noticed. To adduce authorities in favour of blood-letting in this difeafe would be ufelefs } for authorities may be quoted on both fides. Sydenham lamented the ufe of the word malig- nant, rs defcriptive of any fpecies of fever, and faid that it had occaflioned more deaths than the fword. He believed that this flaughter was occafioned by the ufe of alexiphar- mics, which had been confidered appropriate to malignant difeafes, while evaluations were too much negle£Ved. On the other hand, Huxham and many others thought that Sy- denham was influenced by prejudice In transferring his prac- tice in inflammatory difeafes to thofe, which were malig- nant, and in which the ftrength of the fyftem was proftrat- cd by a fecret caufe. Perhaps their differences of opinion may be explained if that adopted by the committee be cor- rcft. M 1 I K : 4 »'^^ • It has not been very cotnmom here to open the external jugular, vein, but the operation is very limple. The preffure i4 made by the thumb of the operator placed on the vein where it pafles near the niaftoid mufcle juil above the clavicle. V.'t i| 60 MEDICAL COMMUNICATIONS. When the Tifceral iflammation is phlegmonous or nearly fo, it is welj agreed that bleeding may be very advantage^, oufly inftitutcfl, When it is purely eryfipelatous, and in addition to the weaknefs produced by the fever, there oc- curs the peculiar profttation, which accompanies inflamma^ tion of this charafter, it may fometimes be neceflary even to exhibit powerful cordials for a fcafon, left death IhouW be produced by fudden faintnefs. But if this proftration be caufed by great preffure on the brain, death muft (hortly en- fue. Here it is not « a pack on the back" which muft be removed j it is a pack on the head, which is not only too heavy to be borne, but iwhofc preflure dcftroys in great meafure thofe properties in the living fyftem on which we operate to excite more vigorous aftion. In fuch a cafe it is not inconfiftent to open the jugular ycin, while we exhibit even the moft powerful cordials. In cafes where it is not necelTary or might be injurious to let blood from a large vein, the head may derive fome relief from cupping or leeches. The former is the moft expedi- tious mode of local bleeding, and is therefore preferable, EMETICS, Emetics are adminiftered in the commencment of fever for two purpofes. The one to produce an evacuation of •ny oflFenGvc fubftances in the ftomach. The other to pro- duce a ftrong impreffion on that organ, and in confcquence of the fympathy between that and all other parts of the fyf- tem to efFea a change in all the organic aftions.* By this .! MEDICAL COMMUNICATIONS. «, ,t '^T '" ^'"^'- Po' *< f-ond ,I.e, arc oTof Which .he co.„u„„ven.„.„„ror..^tr:: *e.r cp,„,„„, a„ „„. abfolu.ely fixed, a„d U«y „!' * d«y n.ay l^e .efted by clinical obferva,ia«. ^ *" CATHARTICS. CaAanics are either fuch aa produce copious fl«id dif charges from the bowels ., or Aich as nr„r , charge of the f.ces with c'ompalTlte :^ t,"; f/ 7' .he firft ca^e *e fluid i. f„r„ifl,ed froL J 'Z ^a ^ creasand fro™ the iuteftinal mucus membrau, l/Z, cafe a de,erm,„atio„ of blood takes place to the abdom-^ vefl-ds, or, thofe velTels i„ co„fe,u=nce of i„c,eafed alo^ rece.ve »,„re blood. I„ the fecond cafe perhaps the fe™ eifea .alee, place, but to a„ extent ver, mU lefs. Tio" caAarfcs. which produce the eircfts firft mentioned are caUed drafttc, and purgative , thofe, which produce the fccond, are called laxatives and eceoprotics. Certain draftic cad,art.cs, a, particularly thofe which a,« reCnous. incrcafe I ■ 1? C 1 '1 ■ill i ■V ♦*-'* a9 MEDICAL COMMUNICATIONS. the ikaiott of the abdominaV-veflel* gercrolljr more tlmi'otli- ers, and alfo incaafc the aftion of t^:^ Tdfeltover the wftbfc ,hody. ■ ^-^-^i-'t .H^ In rood cafes of this difeafe dwftic C9th»nics «v»not be employed with advantage. The general fyftcm is weakened by their operation much more th^o the head i* relieved. An exception ihould be made however of thofe cafes, in which the inflanunation approaches the phlegmonous char- aaeiv and in which the fonguifcrous fyftem is not yet over- powered in coofcquence of preffure on the head. In thefe icafcs draftic cathartics, combined with f\daJ3uriate of quick- ittrer, may be exhibited ; for here tlieir efttas are falutary in ismfequence both of their weakening the fyftem generally, and thereby diminiihing the violence of aftion, and of the determination of blood to the abdomen, by which it is di-. minifhed in the head. It is propofed to combine the fub- muriate witli the draftic cathartics, on account of the good efFe£ls it may have on the whole fyftem, at tlie fume timr tlut it aflifts in producing an effed on the bowels. It is al- fo ufeful becaufe it afts on the whole canal from the fto- mach downwards, which effcd is nOt fo perfeaiy produced by moft other cathartics. It does alfo affift in producing a determination biood to the abdomen, and docs not at tlie fame time produce a fudden incr^afc in the general attions of the fanguiferous fyftem, as the refinous catliartics often do. Laxatives may be more generally employed in this difeafe, for at all times tlie fyftem is difturbed if faeces are allowed to continue in the inteftines for any very unufuai length of time ; and the difeafe may invade the fyftem at a moment, when it is already fufferuig under an incumbrance of tlii;* fort. If tlie bowels are coftive, an enenvi ftiould be ad- m I thevdhbk . ■)' c^not be weakened s relieved. axkSf in K)U3 fchar- : yet over- In thefc : of quicfc- falutary in generally, md of the h it is di<- e the fub- "the good fame time . Itisal- m the flo- produced roJuciug 3 not at the ral attions s often do. hi» difeafe, re allowed il length of a moment, ice of tlii* uld be ad- MEDICAL COMMUNICATIONS. 9$ miniftcrcd on the firft, or at farthift on th« fecoml day of the difeafe, and this more particularly, if the bowels make unavailing cflbrts f relieve thcmfelves. When they arc at the invafion as free as ufual, medicines may be given, which will gradually promote their aftion i for they art very much difpofed to be flow in their operations in this difeafe. For this purpofe it is beft to employ fubmuriatc of quickfilver in fmall dofes, frequently repeated, becaufe that medicine wifl at the fame time be producing other good effefts on the whole fyftem, as will be hereafter mentioned. Where bleeding is to be employed, both emetics and cathartics fhould be omitted until after that operation. HEAT AND COLD. The committee will not engage in the contefted queftions refpeaing the efFeas of hot and cold applications to the body } they do not hazard contradiaion in aflerting that great benefit may rcfult from fuch applications. In this o- pinion they are fupported by abundant experience •, for they feel affured that in cafes, which have terminated fuccefsfu!- ly, and in which none of thefe evacuations juft now difcuf- fcd, have been made, relief has been moft commonly deriv- ed from fuch applications. Under this defcription of cold and hot applications the committee mean to include thofe remedies, which reduce the temperature although not cold themfelvcs, fuch as ethfr, when allowed to evaporate from the furface j and thofe, which produce or retain heat, al- though not hot themfelvcs, fuch as fridion, arid woolJen coverings. When the head is hot, and even whenever it is not cold on the furface, cold water, ice, and ether may be^ipplicd to {\ m i; r-H S4 MEDICAL COMMUNICATIONS. a 111 . it with great benefit. Whatcrcr be the nSodc of operation, it is certain that fuch applications occafton a contra£lion of the blood veflels in the part, to which they are made ; and in this cafe they caufe the head to be freed from preiTure, and the reft of the fyften to receive the blood, which it of- tentimes wants. So far as fueh remedies produce an eiFe£l, they are far preferable to bleeding ; as it is better to heal a difcased limb than to amputate it. When they are not com-* petent to entire relief, they will very much affift both dur- ing and after blood-letting. In a large proportion of the cafes of this difcafc the tem- perature of the furface of the body, and particularly on the limbs, is reduced. In fuch cafes, and even when the tem<* pcrature of the body is natural, great advantage is derived from warm and muift applications to the furface. Such ap- plications increase tlie fulnefs of the veflels of the fkin ; and as the extent is great, they operate powerfully in relieving the prcflure of blood in the head. They alfo produce dia- phorefls and perhaps fome benefit is obtained from this eva- cuation ; but this effeQ, as it appears to the compiittee, is much lefs important than that above mentioned. The mode of making fuch applications has been defcribcd in ftating the method of treatment which has very generally been a- dopted in the county of Worcefter. One caution is how- ever neccflary ; viz. that the furface be not fo much heated, as to iricraafe to undue violence the general anions of the fanguifcrous fy(iem.— A pleafant warmth and a gentle moif- ture of the (kin are fufiicieiit. There is not any part of the treatment of ataxic or malign'.int fever, in which practition- ers are fo univerfally agreed, as in this of promoting diapho^ tcHs. It is alfo agrce 70 MEDICAL COMMUNICATIONS. 'X ) zemoved, and any confiderable remiflion of fcTcr takes place. Oii this point the committee hare not been able to learn fafficiently the refults of experience in the late epidemic. By fomc refpcAable phyGcians the cinchona has not been diought ufeful. In Hmilar difcafes the practice recom- mended has been found very beneficial. One very refpe£l- able phyfician thought chalybeates particularly ferviceatlc tmder the circumftances defcribed. Another who lias dif- tinguifhed himfelf by his Judicious treatment of thi? difcafe, ftates that the preparation, commonly called Fowler's folu- tion of arfenic, has fulfilled veiy perfeftly rfie indications onder the fame circumftanccs. We have recently received a confirmation of this opinion from another very refpeftable fource. Thefe obfervations jannot be Rated as conclufive, but deferve attention. Arfenic was employed in the early ftage of the difeafe at Medfield in i8o5, with apparent benefif, and has been ufed m various inftances fincc, as it is faJd, not without advan- tage. But the committee are not acquainted with fo many and fo accurate obfervations on tliis fubjcft, as to enable them to form an opinion refpe Committee. %