CJLINICAL REMARKS, ' ON FEVER ACCOMPANIED WITH PETECHIA, TYPHUS, AND ERUP- TIVE STATES OF THE SYSTEM,*, AS IT APPEARED lU GlLMANTOtf AM) V/Cnvri% • TM THE YEAR *' 1815. by da^id w. clark, a#d Villi am tenney. con'coro: tRitri'ED by George hcwcr. M«rch...t614. V f;)m *<>:$£ tt;*0-Z * # m 3 Clinical ftemftvlt& The mortality of the prevailing epidemic, pi Ting through different fections of the United States, which, wherever it appears, fills every breaft with confternationv and anxiety, and from its precurfors and on- ^ comitants, perhaps not being univeiially known in this vicinity and others, it is fel- dom recognized till by its ravages it pro- claims its genera. Thefe confiderations induce us to prefent to the putilic a fuccinct account o^fever as it appeared in Gilman#n and vicinity, with petechias, typhus, and eruptive ftates.of the fyftem, in the year 1813, >vith the method of treatment; being careful to ftate fajfts ex- plicitly, both as it refpe&s its precurfors, concomitants, and method of cure. For the fake of plainnefs and precifion, its diagnoftics will be divided into three dif- ferent ieta 1. When it attacked the brain. 2. When it attacked the kings. 3. When it feized upon the extremi- ties, and, in-the progrefs of the difeafe, fet- tled upon the brain, or lungs, or both. 4 CLINICAL REMARKS. I. When it attacked the brain, there was a fixed acute pain in the forehead and one or both eyes, accompanied with dilata- tion and contraction of the pupils, or they contracted almoft to a point, remaining nearly ftationary: this fymptom was juftly confidered highly alarming, which fooner or later, according to the violence of the difeafe, was fucceeded by a fuffufion, or of pain of the afterpart, attended with violent puliation of the" carotid and temporal arte- rleSj and exceflive heat of the head. Large depofitions of lymph fometimes fucceeded, generally, on the courfe of the former. The 'extremities were cold, efpecially the inferior —the fkin conftricRd, pale, and dry, ex- cept the face, which generally wore a florid hue; the pulfe at the wrifts feeble and irregu- lar, fometimes intermitting and quite im- perceptible, accompanied in moft cafes with a paralyfis of one fide, generally the left, the eye oppofite to which, the patient was unable to clofe: or to convey an idea which fhall not be miftaken, the pulfe dn one fide was confiderably full, while on the other it was fcarcely perceptible. Refpiration fmaH and anxious at firft, but foon became more laborious, till at length ftertor enfued; cold vigors darted down the back and loins,thencc CLINICAL REMARKS. $ over the body, attended with tremor of the whole fyftem, of the tongue in particular, when- attempted to be run out, which was moift, and covered with a whitith coat.—- The urine was high colored and fmall in quantity at firft, which fopn became pale, and, on Handing, depofited alargc quantity of coagulated lymph: naufea and vomiting accompanied generally from the commence- * ment; what was evacuated at firft was moft- ly a cold vifcid phlegm, which was foon fucceeded by that of a dark bilious cafrv— The countenance became diftorted/ and changed to a livid hue,attended in fome in- ftauces with double vifion.-A high ^jpliriurn. or ftupor ioon enfued,' and petechias or vi- bices appeared on the forehead, temples,and face, thence extending over the body, the fphinetors ani et vefica refufed to do their office; and though we often attempted to rouze the patient, profound coma prevailed, and they funk infenfible into the arms of death! 2. When it attacked the lungs, they com- plained of a fulnefs of the praacordia and ftomach, of naufea, and vomited, oreffayed to; ho.vever, but little was evacuated, and they appeared unable to inflate the kings.— A 2 6 CLINICAL REMARKS. Refpiration fmall and anxious as above, ac- companied with fighing, reftleffnefs, and often fhifting of place, which, toward the clofeofthe difeafe, when fatal, was attend- ed with fingultus.—Extremities cold and numb, with great proftration of ftrength, and depraved action of the fenfitive organs, and cold rigors as above delineated: the pulfe intermittent, fmall, and unequal in frequen- cy and ftrength; though in fome cafes it was.,confiderably accelerated and full: when this .occurred, theie was univerfaliy a fixed acute pain in the region of the fide or fto- mach, and to one unacquainted with its in- fidiousmmeanderings. would have indicted £he ufe of the lancet.—The eyes appeared languid, and funk in their orbits; the nofe dry, and the noftrils contracted; the tongue drier than above defcrit.d, covered at itc. apex, and on the fides, with a whitifh coat, while the roots and middle appeared of a dirty brown or yellow color; fordes collect- ed on the J;ps and teeth the fourth or fifth day; petechia or ecchymofis appeared on various parts of the body; the urine, as above defcribed, accompanied with dyfuria; large floculi of coagulated lymph floated on its furface, in which a fmall quantity of CLINICAL REMARKS. cruor was vifible, and on (landing, emitted a difagreeable fetor in fome cafes: delirium, if any, was very moderate, and for the moft part the intellectual functions remained un- impaired to the laft-----Thofe who failed, generally Ianguithed till the feventh or eighth day before death clofed the truly folemn and diftrefsfui fcene! 3. When primarily the extremities, and in the progrefs of the difeafe, the brain or lungs, or both, became affected, its charac- teriftics were flight; fhifting pains in'va- rious parts of the body, as the fingers, wrifts, elbows, hips, knees, heels, toes, &c.-Thefe were not always prefent in the fyftem, nor were they fevere; but were attended with a fenfe of heat and weaknefs, and had been confidered as rheumatifm by the patients, they having been troubled with them for a confiderable lapfe of time previous to con- finement: naufea and vomiting likewife at- tended: the pulfe and refpiration as above, though in fome mild cafes there was but lit- tle alteration. A fcarlet eruption made its appearance perhaps in one cafe in fire only, whofe puftules were diftinct, and contain- ed a fmad quantity of limpid ferum, which, on bebg difchargsd^ foaled kindly, though 8 CLINICAL REMARKS. in fome inftanc ? they maturated, fphacelat- ed, and caft off; the appearance of which was conical: thefe laft difcharged a fanious matter, and feldom healed till the patient was convaKkenc. Petechias or vibices made their appearance in fome cafes previous to confinement, and were difcernible after the patiet. > were able to walk their room. A ibrencis of the throat, hyfteria, and hypo- choffclriafis, were frequent concomitants: urine and difuria as above. Teretes were almoft always prefent in the primae vise, and in children feerr.ed to demand imme- diate attention; but were treated as of minor ^confeqaence,.excepting in one cafe; and though this did not prove mortal, yet it was very troublcfome and lengthy. Tumors fometimes occurred in various parts; and on being opened, difcharged good pus, and healed kindly.—The appetite but little al- tered in fome oafes, though generally there was a loathing of food.-Deafnefs in a num- ber.occurred, which was of a temporary nature : fleep difturbed; and, after taking of repofe, in many there was an uncon- fcioufrtefs of it. In fome cafes the patients were feized with fyncope and diarrhoea; in thefe the proftrajioji-of ftrength almoft ex- CLINICAL REMARKS. 9 ceeded belief: the vital energy appeared to have forfaken the fyftem, the eyes were glaffy, and the pupi's greatly contracted, the extremities cold, and the puliation gone at the wrifts, and the fyftoie and diaftolc of the heart fcarcely perceptible.—In one cafe the patient was attacked with pain in one finger, which progrefTed to the brain, obferving the courfe of the inferior cubital nerve, fimilar to aura epileptica, and11 was foon accompanied by the firft mentioned concomitants. This foon terminated: fa- tally. The paroxifm In fome obferved a con- fiderable degree of. .'regularity, though not generally. The duration of the difeafe was matter of uncertainty; a few days, in fome mild cafes, terminated it, while in others five or fix weeks were neceflary to effect a cure. The firft three or four hours, after the attack, were confidered very precious to the patients; and the importance of the ob- ject will be our justification, if we urge the immediate call of a phyftcian acquaint- ed with the difeafe, a ftrict compliance with his prefcriprions, and perfeverance, let the concomitants be what they may; as they 10 CLINICAL REMARKS. fcre frequently reftored when from appear- ances paft all hope. We find ouriclves loft in conjecture, and utterly unable to give^a fatisfactory reafon for thefe fudden tranfitions from highhealth to a ftate truly deplorable and highly alarm- ing; but death to. us does not appear to take place in thefe violent cafes from a ftate of inflammation or putrefaction in the fys- tenvbut from a fudden proftration of the excitability or vital energy. The method of cure purfuedby us, was, I. To remove the torpor of the ftom- ach, • 2. To cleanfe the ftomach by a liberal life of emetics. 3. To remove the torpor of the capil- lary veffe's, by ftimulants, external heat, and friction,' producing a free perfpiration, thereby reftoring the excitability or vital energy. 4. To obviate various other concom- itants, with fuch medicine as each particu- lar case in our judgment required. The medicine we were in the habit of tiling were—Ipecac, zincum vitriolat.—Rad. ferpt. virg. feneka, Valeriana, rhei, Colombo — Cantharides, calo. gm. camphor, opii.—■ 01 ricini, piperit, pulegii, cinnamo.—Spt. CLINICAL REMARKS. ii rther vit. fal foda, tart.—Cort. eleuth. nux mofchata, wine, brandy, &c. accord-* ing to the particular fituation, age, fex, condition, and violence of the attack. Or our method and application of cure may be comprehended in the following or- der, viz. By removing the torpor of the ftomach, by ftimuli, preceding the ufe of emetics, with camphor, brandy, &c; by removing the morbid matter from the ftom- ach, by a liberal ufe of emetics, of ipecac. zincum vitriolat., &c. which at the fame time determined the fluids from the center to the circumference of the body; by re- moving the torpor cf the capillary vefllls with the affiflance of external heat, friction &c; to anfwer which intention, finapifms were dii ected o be applied to the feet; bricks, after being heated, were partially quench- ed in vinegar, and placed to the feet, knees, hips, &c. and, ifneceffary, flies fteeped in vinegar were ufed by friction, &c. by keeping up a healthy and regular perfora- tion by a free ufe of camphor, feneka. fer- pentaria virginiana, &c. after the operation of the emetics, by cold applied and vefica- torics to the head and breaft to prevent coma, extravafations, aad depofitions on It CLINICAL REMARKS. thefe important organs, if the heat of the head was exceflive; for which purpofe linen cloths, folded thick, and after being rm- merfed in cold water, or vinegar, or vine- gar and fait, were applied to the fame; and iy epifpaftic to the forehead or nape of the neck; and if there was danger of ex- travafations on the lungs, they were ap- plied to the breaft; and, by obviating all the other concomitants that appeared, with fuch .medicine as the judgment directed. In cold weather, it was ncceflary to pre- vent the emetics from taking the motion of the bowels; as a fmall operation funk the patient extremely; for which purpofe, an anodyne was generally adminiftered; but, in cafes where the brain was primarily af- fected, we give it as our opinion that they bad better have been omitted, as in fome cafes they appeared to increafe the comatofc ftate. Would it not anfwer a more valu- able purpofe toadminifter an enema, with which a generous quantity of liq. lauda- num was combined ? The bo a els were generally kept clofed until the fymptoms were broken, or till the third or fourth day, when cathartics were dire&ed; thofe whofe operation was CLINICAL REMARKS. 13 mild, caufing little irritation, were ex- hibited. It was neceffary, in fome cafes, to pre- fcribe emetics to the fourth, fifth, or fixth time, or more; and after we thought the ftomach perfectly cleanfed,there would often remain a feverifh heat and irritability in the fyftem, for wThich it was difficult to aflign a reafon, the patient remaining flatu. quo, till by the exhibition of another emetic^he achan of the prima? vise, viz. the feptic ac{d, was expelled, the heat and irritability gone; after which the patient was foon able to go about his ufual avocation, paying very par- ticular attention to his diet, being careful not to overload his ftomach.—Relapfes in ? number of inftances occurred; and, in fotne cafes, might be faid to be in confequence of inattention on the part of the parents, to the above directions, and expofure to cold. In Gilmanton, of thofe who failed, the principal part were, in their origin, affec- tions of the brain; and, on our arrival, had become comatofe, a ftate much eafier to prevent than to remove; but two or three died in confequence of the lungs being the part primarily affected, one of which we were indulged with an examination; this b 14 CLINICAL REMARKS. patient we did not fee till the third or fouTth day after the attack.—We were informed a number of emetics had been adminiftered, none of which operated with much force. On laying the contents of the thorax open to view, fmall air veficles appeared in the mediaftinum, fome of which were ruptur- ed, and an extravafation of blood on the ojlirernum: the funerior part of the left lobe of the lungs, of a dark color; in the lobules of which, the air veficles were blown up, ruptured and contorted in the middle; while in the inferior extremity no veftige of air veficles, blood veffels, &c. could be difebvered, by reafon of extrava- fation; and when cut, would fink even with the furface of the water; the inferior portion of the right were nearly natural as to cokr, the air veficles blown up and rup- tured through the whole celular fubftance. On the external furface of the liver, bright yellow fpots or depofitions' of bile were vifible, fome of which were more than an inch in length. ;>The gall-bladder did not contain an over proportion "of bile. The diaphragm was of a livid or dark brick color.---On removing the external tegu- ments of the brain, there appeared fmall CLINICAL REMARKS. l> fpots or cxtravafations of Wood under the fagittal future on the dura mater, and effu- fions of lymph on the fmall folds of the veflels of the pia mater, at their extremi- ties where they anaftomize with, the veins, thv glandular part nearly natural, while fmaii dark fpots appeared in the mcdullares. Owing to the latenefs of the hour when no- tified, we made but a fuperficial examin-.. ation, as the friends of the deceafed were collected to perform the fepulchral rites. However, nothing which would have pre- vented his recovery was difcovered in the, examination of the brain. In affections of the lungs, the patient generally languifhed till the feventh or eighth day, if they proved mortal: of the brain, thofe who failed, died from four to eight-and-*forty hours'from the firft attack. We have been frequently afked, Is there nothing to prevent the approach of this truly alarming diforder? To which we now reply, that a regular and warm diet, a tem- perate ufe of ardent fpirits, avoiding all ex- tremes, with the ufe of flannel next the {kin univerfally,' being carefui to keep the feet dry and warm, and the head cool, are as good prophylactics as occur to our minds, 10 CLINICAL REMARKS. It is i'.kewife neceffary to keep the fyftem free from worm's, efpecially in children. Would not emetics be of fcrvice?—We obferved, that in damp, ftormy weather, or when the wind was eafterly, new cafes were more frequent, and the fick were, generally worfe: on the contrary, in clear weather, and the wind to the weftward,thcy were better, and in the moft defperate cafes thefe' was a revival, and few new ones oc- curred. Generally fpeaking, the land was of a fouthern declivity, and adjacent to water, where the diforder raged with the moft violence. As the fpring advanced, the fever as- sumed a pneumonic type, which was foon fucceeded by that of a typhus ftate; the principal part were cafes mild in degree, and yielded to the foregoing method of cure in a few days: however, we combined tart, antimony wirh the ipecac, and have been in the habit of exhibiting the gm. camphor in fubftance and in large dofes. —We would obferve, that although calo- mel is too flow in its operation to be truft- ed to in violent cafes at firft, yet we have found it to he a regular and powerful ftimu- lant; and when it has been exhibited by CLINICAL REMARKS. 17 us, combined with gm. opii, et camphor or ipecac, it has anfwered many valuable pur- poics, and in thofe patients where a ptya- lifm enfued, it was confidered a favorable omen. Cinchona was inadrniflible in fub- ftance; but in the form of Huxham's tinc- ture, in lengthy cafes attended with typhus, great benefit was experienced from its ufe; likewife a ftrong decoction v\as combined with liq. laud, and yeaft for enemas in cafes of violent diarrhoea. The following is a ftatement of our treat" ment of a few of the numerous cafes which occurred in the year 1813. CASE I. Jpril 26.—Mrs.----, of -\ flendcr con- ftitution, aged about 50, after doing the wafhing of her family, complained of a pain at the ftomach, and took a moderate dofe of fpts. camphor, was inftantaneoufly feized with an involuntary diarrhoea which was very fetid, not having any command of the bowels. On our arrival, found her fu ik very low, the pulfe about 120, and carce- ly perceptible; the countenance langud the pupi s contracted, and exceffive heat of tlie 15 2 18 CLINICAL REMARK ». head; the extremities being cold. Immedi- ately adminiftered an emetic, which operat- ed powerfully, and caufed two motions of the bowels. Applied an epifpaftic to the forehead and nape of the neck, and direct- ed to apply flies with vinegar by friction to the extremities, finapifms to the feet, and bricks prepared to the hips, knees, and legs; at the fame time directed the head to be kept wex with cold vi ^ar and fait: after the operation of the emetic, the patient took ol. cinnamo., or fpt. camphor, or a decoc- tion of rad. ferpt. virg., once in thirty min- utes, and occafionally a fmall dofe of elix. aft h mat. Atril 27.—Were informed the diarrhoea had fubfided, the pulfe about 100, the fkin moift; continued the medicine as the day before, except in not being given fo orten, with the addition of powders compofed of gm. opii. et camphor, which were directed to be adminiftered once in four hours. April 28.—The patient about the fame; continued the medicine; a longer fpace of time intervening. April 29--Patient about the fame, except the pulfe, which were about 95 ; medicine continued. CLINICAL REMARKS. 19 April 30.-Patient about the fame, pulfe 82 ; gave a cathartic of rhei, fal. tart. and. fern. anis.: continued the medicine as be- fore, except the elix. afthmat. and grri\opii. May 1.-Pulfe about 80 ; the patient con- valefcent; directed rhei and fal. tart, to be given in a ftate of efferveicence. May 2.—Puife from 75 to 80; directed a decoction from rad. Colombo and lig. quaf- fia to be taken occafionally. "5 CASE II. Mrs.------, aged about 35*, of a good conftitution,was attacked with fever July ; 9 —were informed, that the firft knowledge the family had of her illnefs, was a derange- ment; found her comatofe, adminiftered an emetic, compofed of ipecac, and tart. ant. in a liberal dofe, which did not operate; in 20 minutes repeated it again, which not op- erating, 4 grs ofvit zinci. was given; at the fame time thefe were adminiftered, gave faturated tinct. camphor freely to the patient —having taken about one ounce of ipecac. judged it prudent to defift—nothing of con« fequence was evacuated from the ftomach upward; but the difcharge from the bowels was profufe, and very fetid—countenance languid and funk—pulfe feeble, being about £0 CLINICAL REMARKS. 100, and irregular—extrc r/ities cold—pu- pils contracted: applied an epifpaftic to the forehead, and directed cantharides to be ufetfby friction, &c. A decoction of ferpt. was adminiftered in liberal dbfes every thir- ty minutes; eff piperit. and elix. camphor, as occafion reqjired. July 20.—;The operation of the bowels had confiderably abated, the comatofe ftate ftili i%maining—applied an epifpaftic to the afterpart of the head—directed powders, compofed of gm. opii., cam. and ipecac, to be adminiftered every four hours, and a decoction of rad. valeri. and feneka, as oc- cafion required—the pulfe about the lame, July 21 .—The diarrhoea had fubfided— other fymptoms as* yefterday. Continued the medicine as before, with the addition of ol. cihnamo. occafionally—pulfe from 90 to 9 j. July 22.-—Comatofe ftate abating* the bowels clofed, the pulfe about the fame; continued the alterative powders,ferpt. with the addition of foda, July 23.-Patient Mafter---«&,, aged about 13, of a good COnftitution, complained of a load at the ftomatfyand eiratic pain. His father called for and received an emetic, which operated favorably; and in the after part of the fame day we were Informed by him* he believ- ed that his fon would efcape a fever; how- ever,^fter having eaten a bowl of bread. and milk at even, he foon complained of a _ load and preffure in the region of the ftom- :> ach. We were called about midnight; found him in a convulfive and, comatofe -- ftate; gave an emetic; no operation of con- fequence enfued; and though-every endeav- or was ufed for his recovery,, he died the day following. In giving this plain and conci.fe, but faithful narrative, we have avoided, as much as poflible., the technical terms made ufe of by medical authors and the fraternity; choofing, with our united endeavors, to be ufeful to many,' rather than to be under- ftood but by a few;, and if this fhall be the means of doTeminatir!| a knowledge of the difeafe, its iymptoms, and method of cure, to one town, fociety, family, or perfon, or be the inftrument in the hands of Provi- dence of the reftoration of health to one or CLINICAL REMARKS. * S3 more of the human family, our intentions will be amply remunerated* *■ A GLOSSARY TO THB FOREGOINi Achan, septic acid Aura epileptica, a sensation, as rf a blast of cold air pscending from the extremities to the bttrt and head ^ An,.ocfyne, a medicine to ease pain Anastomize, the communication of vessels with one * another Concomitants, attendant symptoms Corrta, an inclination to sleep Cruor, thick, red part ok the blood Convalescent, recovering of heat:* Capillary vessels, small blood vessels on the surface Cathartic, medicines which cause the motion of the Cclular, consisting of little cells or cavities [bowels Dilatation, to enlarge Delirium, a disorderly motion of the animal spirits Dysuria, difficulty and pain in discharging the urine Diastole, the dilatation of the heart Deposition, stagnant Diaphragm, a muscle which divides the trunks of*? the body into two cavities # Dura mater, a thick laganbrane which surround^ the brain ™ * Diagnostics, are those signs of a disease which are apparent, and distinguish it from others Ecchymosis, marks and spots in the skin Extrata.sation^ the fluids of the body when out of EJp'usisn, pouring forth ? t?^Lv •v, CLINICAL REMARKS. Flrtuli, fl.'ke* Ge?irra, thnt which makes itself known Hysteria, mrvmis con;plaints, ir spasmi Lypickondnaih, a difficult digestion, attended wtfl- vapors Lyfnp/i. the transparent or watery part of the blood Lvbules, the separate lobes of the lungs «* Mediastinum, the mtmbrane in the middle of the Nausea, sickness [breast Petechia, redN^purple spots Pupils, the sight of the eyes Paroxism, a fever fit Peroration, sweating Pia mater, the innermost covering of the brain Pneumonic, tending to an affection oi the lungs Ptecordia, the forepart of the region of the thorax Prima via, the firbt passages Precursors, what g