TYPHUS SYNCOPALIS,
SMEBS®  UVVJEID&
OR THE
POTTED-FEVER  OF  NEW-ENGLAND,
AS IT
APPEARED IN THE EPIDEMIC OF 1823,
MIDDLETOWN,  CONNECTICUT.
BY THOMAS MINER, M. It  ^
  " Our knowledge in many branches of Natural History [and Medicine]
would be much less imperfect than it is, if many facts had not been sup-
pressed, either from a fear lest they should be thought  incredible, or from
that unreasonable incredulity which will not, even from the strongest testi-
mony, give credence to any thing that it cannot explain."
  " For my own part, I am contented to write faithfully what I have ob-
served, leaving every body afterwards to follow his own way at his peril."
  MIDDLETOWN, (CONN.)

PRINTED  FOR  THE AUTHOR.
1825. 
M04t
 tsar
 c.4. 
PREFACE.
  AS far as respects  endemic diseases, Middletown, from its first settle-
ment, has been one of the moBt salubrious stations in the United States; and
of the epidemics which, within the last twenty years,  have so extensively
visited New-England, it remained long exempt.  During the last five  years
however, it has experienced its full share of sickness, though in comparison
of the number and severity ef  the cases, the degree of mortality has been
unusually small; there being about one death in thirty cases, including both
the moderate and severe; and about one in fourteen op fifteen, if reference is
made to the severe cases only.  Except here and there a sporadic case, since
1815 or '16, the fever about to be described is new.  and never  prevailed
in this town as an epidemic, till 1822.  That season, our fevers assumed a
new form, entirely different from  regular Typhus, whether of the nervous
or  the putrid type, and consequently demanded a peculiar variation of
practice, especially in  the early treatment.  New diseases, without any as-
signable cause, occasionally have appeared in the most salubrious quarters
of  the globe,  and are no argument  against the general healthiness of any
particular station.
   In the year 1823, the disease which is the subject of the following sketch,
in a greater or less degree, prevailed in about a dozen towns in this vicinity.
It had a common character in all, though  in some  unimportant circum-
stances, there were considerable  variations.  In one or  two places, the
proportion of severe cases was much greater thas in this town; in others, it
was much less.  The same was the fact with petecchiae, eruptions, and per-
haps, stinging heat.  The author witnessed, this  season, cases of the epi-
demic  in ten or twelve different towns,  and noticed  that  all the patients
agreed in the peculiar affections of the brain and nervous system, and espe-
cially in their liability to gastric sinking; and that much difficulty existed in
all, of employing evacuants to any extent.   In some of the adjoining towns,
a few of the protracted cases, after they had assumed the form of common
typhus, tolerated a moderately free purging, and some of the milder bore it
in the  begining;  but in general,  as late as  the second or third week, it
was necessary to observe great caution in its  employment, or an alarming
or fatal sinking, or coma, would follow, or the milder cases  were converted
 into obstinate bilious-fevers.
   The fevers of the year  1822, as just observed, partook very much of the
 same character, and  were often  attended with alarming paroxysms  of
 subsidentia, though in general, they were  not so strongly marked, as in
 1823.   The year 1824, except some pneumonia and catarrh in the spring,
 was uncommonly healthy, till September; yet the scattered  cases were of
 the same diathesis, and suffered much injury from free purging, being gene-
 rally by that  process converted  into  factitious bilious-fevefs, and liable to
 extreme sinking at a critical  period.  The last four months of  the year, a
 number of cases occurred, which were attended with as great deficiency of
 vital power, from the very access  of the disease, as  any  of  the preceding
 season.   The cynanche and catarrh, which at the same time were so gene-
 rally prevalent among children, in the majority were light diseases, though in
 many instances, they were obstinate, and attended with severe  paroxysms
 of sinking.  The same remarks apply to the epidemic catarrh and pneumo-
 nia of the  first four months of  1825.  Petecchise have been more common
 than usual this present summer.
   Opportunities have frequently been presented, for  observing this  protei-
 form disease under almost every conceivable circumstance.   In former years.
 
IV
  jiany cases, in which no medication at all had been employed till the  pa-
  tient was actually dying, came under the inspection of the writer.  The ef-
  fect of almost every kind of treatment has also been carefully noticed.
   During the  prevalence of any malignant  epidemic, there will  now  and
  then be a case so rapid,  that by the time  a physician can be  obtained, the
  patient has sunk below the reach of all medication; and occasionally one i*
  so obstinate as not to yield, though every medicine produces its specific or
  operative effect; but in general, no severe disease admits of more speedy
  and certain success than the malady under consideration, provided the pro-
  per means are only employed early, energetically, and perseveringly.
   In common language} this epidemic has been generally called Typhus, though
  it varies essentially from all the fevers  which have received that appellation
  by  foreign authors.  This confounding  of names has led to  much confu-
 sion in practice, and it is apprehended, has been the cause of the fatal ter-
 mination of many cases; the proper treatment being  peculiarly  different
 from that of ordinary  nervous or putrid  fevers.   It will be observed however,
 that the fever under consideration may be blended with almost any other acute
 disease, and where it prevails, pneumonia, dysentery, or common typhus, or
 even influenza, will partake very much of the same character.  This is ex-
 emplified in the unexpected and fatal sinking, which of late years has  been
 so frequent in these diseases, in many parts of our country.
   This disease first appeared as an epidemic, in  Massachusetts, in 1806, and
 there has not probably been a year since, in which it has not existed some-
 where in New-England.  In Connecticut it has never prevailed, to any ex-
 tent, nearer than twelve or fifteen miles of the sea-shore*.
   It is of much importance in  medicine, that the history of such epidemics
 should be preserved.   Hoping that some other  pen might be employed, the
 author has delayed publishing this sketch, though it  was  compiled more
 than a year ago.  So much  time having already elapsed without the ap-.
 pearance of any publication, he was at last suspicious, if he did not commu-
 nicate to the medical public his remarks, all correct knowledge of the epi-
 demics which have lately  prevailed in the central parts of Connecticut,
 would soon be overlooked or forgotten.   Though the author has taken the
 utmost pains to be precise in his description, and to be minutely exact, and
 is under much obligation to several of  his friends, and more particularly to
 one  of them, for assistance, he is very apprehensive that no correct idea of
 the nature of this sinking fever, or of the operation of medicine in, allaying
 its symptoms, can be formed by any one, who is not already conversant  with
 the phenomena of malignant  diseases.   The pernicious effect  of free  eva-
 cuation, and the total inefficiency of ordinary supporting remedies, in or-
 dinary doses, can hardly be realized by any other than an eye-witness.
   Unfortunately, the gentleman who has unquestionably practised more in
 diseases of this description, than any other physician in the State, or probably
 in the United States, who has witnessed several thousand cases, and is every
 way pre-eminently qualified for the undertaking, is so entirely occupied in pro-
 fessional and other humane employments, as to allew him no  leisure to pre-
 pare for the press the results of his extensive observation and  experience.
 He therefore must excuse the dedication of this sketch to  him, as of all
 others, he will  be the best judge of the general accuracy of the statement,
 and of the propriety of the method of treatment.
  Eli Todd, M. D.  Physician to the Retreat for the Insane, at Hartford, is
 most respectfully requested to consider  this tract as inscribed to him, as an
 acknowledgment of his  very valuable suggestions upon  the symptoms and
 treatment of malignant diseases, and as a sincere, though imperfect testi-
 monial, of his universally acknowledged merits, as a philanthropist, a scholar,
 and a physician.
  JMddletown, (Conn.) July, 1825.                THOMAS  MINER.

  * For the history of its early appearance, the reader is referred to Dr. North
on Spotted Fever, to Dr. Strong's Dissertation, and to Dr. Fish's Dissertation. 
SKETCH
                         or THE

HISTORY  OF  THE  EPIDEMIC  OF 1823,

                           IN

          MIDDLETOWN, CONNECTICUT.
   Between the last of March, and the last of December 1823,
two of the physicians* had the care of more than a hundred and
seventy severe cases of Fever, in Middletown, Connecticut, which
went through their course, and required close and vigilant at-
tendance.  They also had the charge of more than a hundred and
eighty other cases of the same  sort, which, either from original
mildness,  or prompt treatment,  proved  to be  comparatively
slight.   The latter class of patients however, were so much in-
disposed, as to be unable to attend to their ordinary business, for
a period of  one or two weeks; though unlike the former, they
were not entirely confined to their  beds for  any considerable
time.  Out of these cases, being in the whole about three hundred
and sixty, twelve died; viz. six adults, and six children.  One
half of the mortality happened in November.  In the succeeding
month, the Epidemic terminated.  Persons of all  ages, from one
year old to seventy, and of both sexes, were the subjects of the
disease.  It  is  perhaps needless to remark, that  the following
statement applies more particularly to the severer cases, unless
the more moderate are distinctly mentioned.
  There were two varieties of  attack, the sudden, and the insi-
dious.   The most sudden attacks were the soonest relieved, pro-
vided the patients had prompt and  appropriate treatment; and
under such  circumstances,  the disease rarely exceeded  five or

  * Dr. Edward S. Cone and the author.  The patients  were principally
Br. Cone's, but were mostly visited by the author in consultation. 
                             6
^vcn days.  [See Appendix, Note l.J  In some of Ihe severest
cases, the disease arrived at its height on the third day, and under
careful management, the patient appeared subsequently to be free
from danger.  Not one,  this year,  that was  suddenly attacked,
died; the recovery, in most instances, being the evident conse-
quence  of the promptness and decision of the treatment, and of
the necessity which both patients and attendants felt, of following
prescriptions scrupulously.
  In the insidious cases, the subjects of the disease were affected
with the symptoms about to be described, in a mild degree, for a
greater  or less length of time, and many seemed to labour under
a kind of infatuation concerning the malady and existing danger,
and were almost invariably inclined,  for several days, to  ascribe
their  indisposition to some  other cause, than  the prevailing epi-
demic ;  and if, at the instigation of friends, a physician was called,
they could not be induced,  without  the greatest difficulty, to fol-
low any regular plan of treatment, till violent symptoms occurred,
sometimes as early as the third or fifth day, or more commonly,
as late  as the seventh.   A  few insidious  cases continued  two or
three weeks, before there was apparent danger.
   The whole number of deaths, this year, happened among the set
of insidious cases.  One of the adults died on the third day; one,
on the fifth; one, on the ninth; one, at the end of the second week ;
one, at the end of the third week; and one, on the fifth week.  Be-
sides, in one of  these fatal cases, the disease was complicated, at
first, with Dysentery ; in one, with Gout;  in  one, with a chronic
hepatic affection ; and two had hemorrhage from the lungs.  [See
Appendix, Note 2.]  The other  did  not substantially vary from
the common insidious cases.   Some  of the children  died at  the
end of a week; the others,  at the end of a fortnight.
   A few of the cases were complicated with Dysentery; some, with
Colic ;  two or three, with Cholera ; some, with Cynanche; some,
with cough or Pneumonia •,  two or three, with Rheumatism ; one,
with Gout; a few, with severe pain, and passive inflammation of
 some of the extremities.   The great  majority, however, had no
 apparent local affection, except of the brain, and of the parts that
 more directly sympathise with that organ.
   During the prevalence of this epidemic, chronic diseases nearly
 disappeared, and when they did exist, their acute paroxysms were
 invariably blended with  the prevailing epidemic.   For eight or
 nine months, it was difficult to find a case of acute disease,  that 
                              7
did not partake of the epidemic constitution, under whatever head
it might be nosologically classed.  Not  more than two or three
cases were, this season, attended with petecchiae.   In one of these,
they were very dark and prominent.   A marbled skin, efflores-
cences, and eruptions, appeared in many instances.   [See Appen-
dix, Note 3.]
   In nearly every instance, whether severe or moderate, the dis-
ease began with more or less pain in the head, especially about the
forehead.  Vertigo  was  also  a symptom almost universal.  In
some, a sudden faintness, dizziness, or sense  of extreme exhaus-
tion, so that the patient could neither sit nor stand upright, was the
first symptom.   In others, the attack resembled a severe concus-
sion of the brain, or a sudden stroke  of Palsy or Apoplexy.   In-
deed, every thing seemed to show that the brain and nervous sys-
tem were the primary seat of the disease.
   In almost every case, the skin was preternaturally cool, for  seve-
ral of the first days, and subsequently, in temperature, it never ex-
ceeded the standard of health, in more than three or four cases.
[See Appendix, Note 4.]   Even after it had been warmed by inter-
nal and external heat, in conjunction with stimulants, it was ever
liable  to become partially cold, as about the thighs, knees, legs,
arms,  hands and feet.  In the course of the  disease, more  espe-
cially in the worst cases, it was almost always so much benumbed,
 as to be insensible to an ordinary pinch or scratch, and while  in
 this state, incapable of being affected by common sinapisms and
 blisters.   This numbness was sometimes most prominent in one
 side, or even in  one leg or arm.  In  the latter stage however,
 there sometimes occurred periods of extreme susceptibility to the
 impression of rubefacients and epispastics ; but as a general rule,
 external applications, of ordinary strength, would  produce very
 little effect, till something like reaction had been effected.   Com-
 plete agues or rigors, this year, were very rare in any stage of the
 disease.   Commonly,  through the  whole  course  of the dis-
 ease,  the  surface,  though not dry or  husky, was seldom  much
 inclined to  spontaneous moisture.   [See Appendix, Note 5.]   In
 a few instances however, there was a morbid, drenching perspira-
 tion.  Sometimes, though rarely, the patient would complain of a
 general sensation of heat, though, to the feel of the attendants, he
 would be actually cold.  Is not the  heat,  which has  been  often
 said to occur in  some epidemics of this disease, either a transient
 flush, or the calor mordax, the stinging sensation merely, and not 
                              8
 the actual augmentation of thermometrical  temperature ?  If in-
 creased heat, and increased frequency of the  pulse, are a part of
 the definition of Fever, a great majority of the cases had no fever
 at all, but were merely an acute Neurosis.   At this day however,
 it is well known that these symptoms are often absent in irregular
 Pyrexia.   [See Appendix,  Note 6.J
   The countenance, in most of the severe cases, had a kind of leaden
 hue, with marks of anguish. In some, there were patches of a bright
 flush, intermingled with other patches that  were preternaturally
 pale.   In a few cases, the pupils of the eyes  were contracted, and
 in a few, dilated.   In some cases, the organs of sight and hearing
 were irritable in the extreme ; in others, they were equally torpid.
   There were two  prominent varieties of the tongue, the con-
 tracted and pointed, and the dilated and flabby.  The fur of the
 tongue  assumed every possible deviation from health, and was of
 every conceivable variety, except that it never had the appearance
 which is usually found  in Synocha.   In the course of the disease,
 red tongue was  rather more frequent than any other.  Two  un-
 common varieties of fur sometimes occurred, one of which  was a
 greenish slime, and the other a mucus,  varying in appearance,
 from moist brown sugar, to light colouredgpelasses.   The former
 was rare ; the latter, more common.   Most  of these varieties of
 tongue were  liable to  sudden changes in the  same patient.   In
 some of the protracted cases, there were aphthae.  A black tongue
 seldom  appeared, and two or three instances of it only were  no-
 ticed.   On the whole, the state of the tongue was of very little ser-
 vice in diagnosis, or prognosis.  In general, there was little  or no
 thirst; but sometimes it was urgent.   In such cases, it was gener-
 ally aggravated by cold  water, and  palliated  or  removed  by a
 persevering use of aromatics or alcohol.
  The stomach, on the one hand, was usually as torpid and  inac-
tive  as  a leathern bag, so that in many instances, the  patient
would choose scalding hot liquids; or  on the other, it was irrita-
ble in the extreme.   [See Appendix,  Note  7.]   The  change from
one to the other  of these  extremes,  was generally sudden, and
occasioned by slight causes, or took place  without any assignable
cause.   In the majority of the severe cases of sudden attack, un-
less the  violence of the disease was immediately subdued by verv
energetic practice, torpor prevailed for the first two days ; but  for
the succeeding three or five, the irritability would be so extreme.
that without the nicest and most careful  management, vomiting 
                              9
or retching would be incessant.  The matter ejected, generally
consisted of little more than the drink, or secreted mucus.  In a few
instances, it was greenish ; in a very few, dark coloured.   Though
in some instances this vomiting was very troublesome, yet there
was never any bile evacuated, except in two or three patients that
had long laboured under a cjhfonic hepatic  disease, or except as
the consequence of an ill-timed emetic or cathartic.  [See Appen-
dix, Note 8.]   Indeed, the vomiting  or nausea, in this disease,
seemed ordinarily to be entirely symptomatic of an affection of the
brain, or was obviously the effect of an emetic or  cathartic, the
sympathies   being  the  reverse  of sick-hcad-ache.   This  was
evinced by its being excited by raising or moving the head, or by
placing the patient in an erect posture, and relieved, by a recum-
bent position; and especially,  by blisters to the forehead, temples,
and more particularly, to the vertex.   Blisters to the region of the
stomach alone, though of some service, produced much less effect
in relieving this symptom.
   With the exception of the few cases that commenced with Diar-
rhoea, Cholera, or Dysentery, the  bowels were naturally torpid.
. [See Appendix, Note 9.]   Ischury, from mere torpor of the bladder,
was  much more common,  than in other  low typhoid diseases.
There was a  profuse discharge of urine in a few cases.  In general,
in common with ordinary low Typhus of the nervous type, there
was nothing  peculiar in the appearance of this excretion.   Indeed,
the excretions were never more offensive,  and usually  much less
so, through the whole course  of the disease, than in health; and
the alimentary canal was not disturbed by any thing which it con-
tained naturally.  The eructations and ejections of air had no pe-
culiar, disagreeable  odour, there was no fetor of the breath, and
in all stages, as well at  the bed-side of the dying, as at the access
of the disease, there was no febrile smell.  [See Appendix, Note 10.]
  The condition of the brain, in this disease, was usually very similar
to that state  which is produced by exposure to Carbonic-acid-gas?
or which is occasioned by excessive doses of some preparations of
Lead, or of certain essential oils, or of active and pure  narcotics.
In many cases it resembled concussion, or apoplexy, or palsy.   In
all the severe, and in a majority of the mild cases, there was from
the very access, before a particle of medicine had been taken, a
peculiar  deficiency of vital  energy in the brain, and the  whole ner-
vous system,  so that raising the patient into an erect posture, would
generally produce the same sort of vertigo, anxiety at the stomach,
                              2 
                               10
acceleration and irregularity of the pulse, nausea, and even faint-
ing, which result from a similar position after a great loss of blood.
Inalmost every instance, the patient was much more  comfortable
when the head was low ; and much inconvenience, and even dan-
ger, was almost invariably occasioned from any other  than a hori-
zontal posture.   [See Appendix, Note 11.]
  The  mind  was more  or less affected in every severe case.   In
the majority of such cases, after the patient was induced to apply
for medical advice, there was  a morbid fear, entirely independent
of any existing urgency  or danger of symptoms, and of any infor-
mation respecting sickness and death in the vicinity.  The public
were not panic-struck, as the deaths were so few, as to cause very
little alarm.*  Fear, therefore, was rarely a predisposing or exciting
cause in this town, though it evidently was, in some of the adjoin-
ing.   In some cases, there was a morbid clearness of intellect, at-
tended with incessant loquacity,  or there was  too great watchful-
ness, and extreme restlessness; both of which states were always,
sooner or later, followed by delirium or coma.  [See Appendix, Note
12.]   Nearly every case of delirium alternated with coma, but eve-
ry case of coma was not attended with delirium.  In some cases,
the delirium resembled  intoxication; in many, Hysteria;  and in
others, it was of the low muttering kind, such as is common in or-
dinary low fevers.  In some few cases, there was no other delirium

  * When it is  generally known, that only one in twenty-five or thirty dies.
of those who labour under  this disease if it is properly managed,  it will be
divested of most of its terrors.  Besides, when it is  recollected, that evei.
the majority of these fatal  cases fall a sacrifice to their rashly tampering
with  emetics or cathartics themselves,  before a physician  is called, the
sense of danger will still be vastly lessened.  No  severe disease is so much
under the control of medication, in the great majority of cases, as Typhus-
syncopalis, if it is only taken in season, and managed with judgment and de-
cision.   Without the advice of a physician, no medication ought to be at-
tempted in cases of sudden attack, except warming the patient  with ex-
ternal heat and stimulating applications, and giving  him freely to drink of
hot aromatic infusions, such as sage, penny-royal or mint.  In the insidious
cases, or under predisposition, two tea-spoonfuls of compound tincture of
the bark in half a glass of wine, four times a day, is proper treatment, if a
physician can not be procured.   From the best calculation, when this dis-
ease  in 1823, prevailed the most, there never was, at one time, more  than
one person in a hundred, of the population, that was sick; generally, not one
person in a hundred and fifty.  The largeness of the number was owing to
the regular continuance of the disease in some part or other of the town,
and to the regular succession of cases for eight or nine months 
                             11
than what was manifested by a false estimate of the disease, the pa-
tient, when in the greatest danger, instead of showing any signs of
fear or apprehension, insisting that he was  but slightly sick.  In
most cases which received early and judicious medication, delirium
did not occur to any extent.
   Except where there are  convulsions,  or,  in  a very few in-
stances,  where  something  like maniacal  exertion appears,  or
when  the fever counterfeits Delirium-tremens,   the  affection
of the brain in this disease, (unlike many head-affections in Pneu-
monia-typhodes,  and  common  Typhus,)  rarely  produces  any
increased muscular strength; but  on the contrary,  it  usually
occasions great languor, and inability for muscular exertion, which
is more especially manifested when the patient is in an erect pos-
ture.  As has been before observed, this debility was a kind of
paralysis, and appeared to arise from  a partial extinction of the vi-
tal principle, more resembling the. effect of excessive doses of the
active and pure narcotics, or of a sudden and violent concussion o&
the brain, than the exhaustion of the latter stages of common fever.
The exhaustion or deficiency of vital  energy in both cases, appears
to be the same, and the same proportion of the living principle is
extinguished ; only,  at the end of protracted fevers, there is a  great
waste of the solids and fluids of the body, which, must be repaired
before much muscular strength is acquired..
   In many of the severe cases,  the patient  on  going to sleep,
would fall into a state,resembling Incubus, with difficult or partially
suspended respiration, which would require his being awaked as
often as once  every five minutes; and some could  not be allowed
to sleep longer at one time for several days, without their sponta-
neously  waking in  the most excruciating fright and distress, and
finding themselves greatly exhausted.
   During  the  progress  of  the  epidemic,  every variety  of
pulse occurred, except the strong and hard, and this often in the
same patient. In many of.the mild cases, and in most of the others,
till the period of fatal sinking, it was rarely so frequent  as in
health; but towards the close of life, in several of the fatal cases,
it was a hundred and twenty or thirty, and occasionally, a  hundred
and sixty in a minute.  In less than  twelve hours, it would some-
times vary in  frequency from forty,  to a hundred and thirty.  In
one instance, it was as slow as twenty-seven beats in a minute, and
in six or eight hours  varied to a hundred and thirty.  This patient
recovered so rapidly, that he was able to ride out  in a week from 
12
his first attack.  After the disease was  fairly  formed, whether it
was moderate or severe, an  erect or sitting posture would almost
uniformly accelerate the pulse forty or fifty beats in a minute, and
sometimes double its  frequency, besides producing considerable
irregularity.  In a  very  few cases, the pulse was a hundred and
twenty at the very  first attack.  The pulse alone, (as is the case
with the tongue,)  is a very deceptive guide in  this fever.  At
various times in the course of this disease, and even in the dying,
it would occasionally give a delusive feel of fulness and force, that
often deceived the very best judges respecting the danger, unless
attention was particularly directed to other symptoms.   [See Ap-
pendix, Note 13.]    In such  circumstances, in former epidemics,
bleeding has been seriously proposed by a  counsellor, while the
attending physician  knew the patient to be actually in articulo mor-
tis.  In other epidemics, in which this disease  was mistaken for
active inflammation of the brain, or  for Apoplexy, when the pa-
tient has been bled, death has ensued before the ligature could be
taken from the arm.  [See Appendix, Note  14.]  In most of the
worst cases, the circulation was daily so languid by turns, that the
extremities had a livid appearance,  and were often nearly pulse-
less.  One patient at least recovered, that was without pulse at
the wrist for several hours.  Some of the fatal cases were attended
with a very distressing palpitation of the heart.
   A very prominent symptom, which occurred in  some degree in
almost every instance, even of the mild cases, and probably  with-
out  an exception in all the severe, and happened  in  every stage,
sometimes constituting the first access of the disease, consisted of
paroxysms of subsidentia, or a death-like sinking sensation in the epi-
gastrium, that was described, sometimes as extreme distress, some-
times as a painful sense of vacuity and faintness, sometimes as trem-
bling or fluttering,sometimes as real  pain and anguish, and at others,
 was declared to be  utterly indescribable.  During the existence of
 these paroxysms,thecoolness and numbness of the skin, the lividness
 of the extremities, the feebleness of the pulse, and the indications of
 distress in the countenance, were much augmented.   Sometimes,
these paroxysms of sinking, were attended with palpitation, and of-
ten  with spasms;  though spasms, tremors and subsultus were not
uncommon in every stage.  In the  mild cases, these paroxysms of
 sinking, occurred regularly in the morning ; but in the severest,
 they were not confined to any particular hour of the day.  Singul-
 tus  was extremely  rare, /is also was indurated, inflated, or tympa-
 nitic abdomen.  [See Appendix, Note  15.] 
                             IS
  In many of those cases which were neglected, or treated  with
evacuants, or in which the early symptoms were not decisively and
fully met and subdued  by appropriate  remedies,  a peculiar and
somewhat different, and  usually irreparable sinking and exhaustion
occurred, after a critical effort, or in lieu of a crisis, on the third,
fifth, or more commonly, on the seventh day.  In a few case6, it
did not occur till the  end of the  second or third week.   Under
such circumstances, in  addition to the  sinking in common  with
other cases,  the  respiration was interrupted and peculiar, and
much resembled that  of the dying, or rather that of animals (as it
is described) after a division of the Par Vagum, the  inspirations
occurringonly at intervals of several seconds, and being  usually long
and full, while the expirations were so short, that the breath was
parted with instantaneously.   This critical sinking, in combination
with morbid  respiration, was often the first warning of danger to*
the patients and attendants, in the insidious cases,  and it was  al-
most invariably irremediable ; for, although every symptom could
be  met, for a time, to the full extent, and although the most decid-
ed operative effects of medicine could be produced, and life  often
be  prolonged for days, yet the weight of the disease could rarely be
lessened, and, in  one of the succeeding critical efforts, the  same
symptoms would  almost inevitably prove  fatal.  In other fatal
cases, the disease terminated in a deadly coma.  Paroxysms of co-
ma were periodical in some instances, as were those of sinking in
others.   The former description  of sinking and  anxiety, which
was principally referred to the epigastrium, in distinction from the
critical, may be termed ordinary sinking.   It was usually relieved
when taken in season, and treated with  energy.   [See Appendix,
 Note 16.]
   Haemorrhages were rare in this disease; but when  they did oc-
cur, they were mostly fatal.  One case  of  a  child which died on
the seventh day, was attended with symptoms of Chorea.   One or
two cases were seen  that resembled Deliriura-tremensv  [See Ap-
pendix, Note 17.]     Many  had  most of the usual symptoms of
 Hydrocephalus-internus.  Several retained their habitual  relish
for strong tea, snuff, and tobacco, through the whole course of the
disease.   Milk-porridge, or broth, was the food that generally sat
 easiest on the stomach.  In a few cases, there was a strong dispo-
 sition to eat heartily  of solid animal food.   In those in which this
 appetite was moderately  indulged,  it seemed to digest properly ;
 at any rate, it produced no sort of inconvenience. 
                              14
   In opposition to ordinary fevers, in this disease the symptoms wert
 generally much more urgent and severe in the morning, than in the
 afternoon or evening; that is, the patient was most dangerous during
 *he remission.  The reaction of the exacerbation in the afternoon,
 though it did not reach the standard of health, and could not even be
 considered as reaction at all in common fevers, made the  patient
 comparatively easy.   When there was a resolution of the disease at
 its outset, a relapse would infallibly supervene suddenly, upon any
 considerable irregularity of diet, exercise, etc. within the first week;
 but when the disease had once run its course, there were very few
 relapses during convalescence.  There were several  repeated at-
 tacks, after the most perfect recovery; and several of the patients
 had had the disease the preceding year.   [See. Appendix, Note 18.]
 Critical periods were most prominently observed. When a case was
 protracted longer than five or seven days, as in the last stage of
 almost every acute fever,  the disease  appeared, though still more
 liable to severe and fatal sinking  at the critical periods, not very
 unlike common low Typhus, in which delirium, tremors, subsultus,
 coma and sinking occur; and was not easily distinguished from it,
 especially by counsellors, who could not witness its whole course.
   The treatment, as respects degree, was almost as various as the
 number of cases;  but it was alike in kind, in all; and there was
 abundant evidence, of the necessity of avoiding every thing that
 might waste the vital powers.  This was more especially the fact,
 with respect to evacuations, which, if copious, invariably rendered
 the mild cases severe, and the severe ones, fatal.  Probably more
 than three-fourths of the fatal cases were the consequence of sponta-
 neous or factitious purging or vomiting. Emetics did not answer at
all, as the mildest would almost inevitably produce incessant vomit-
ing, which, if not controlled by very large doses of Opium, or by
great quantities of Laudanum by  enema, would end in exhaustion
 and death.  [See Appendix, Note 19.]   More than three quarters of
all the cases however, whether severe or moderate,  were at first
very slightly purged with Calomel, so  guarded  as  not to operate
before twelve or eighteen hours.   It was necessary to  manage lax-
atives with the greatest caution,  and very generally, to conjoin
them with Opium.  Calomel, accompanied with a diaphoretic re-
gimen, if retained on the stomach twelve hours without operating
by the bowels, in the light cases, would lessen, and often remove
 all the morbid action; yet, much more caution was  necessary in
 this  process, to ensure a resolution, than in  common Typhus. 
15
Nevertheless, more than two copious dejections never took place,
without the most obvious injury.  It is as safe to leave a wounded
artery to nature, as in this disease, to administer a cathartic, with-.
out directing its free operation to be instantly checked by Opium.
Those patients, who of their own accord attempted, at the outset
of the disease, to purge themselves, even with Castor-oil, provided
it operated more than once or twice, were commonly found by the
physician in little better than a dying state, and always required
the most  assiduous  exertions for  their recovery.  Several that
adopted this plan were seen, who could never be raised, and obvi-
ously sunk down and died, in consequence of it.  One patient wa6
seen, that sunk irretrievably, by a single operation of an enema.*
In about a fourth of those patients who had the disease in  its se-
verest form, a judicious physician would no more think, at first, of
vomiting or purging, than of employing those processes to mitigate
the struggles of the dying.  In several of the worst cases, cathar-
tics could not be made to operate, while  the patient was in the low-
est state, and there was not the least inconvenience, from having
nothing pass the bowels for a week; and in some of these, when the
patient was considerably better, the bowels spontaneously resumed
their natural action.  The proper time for evacuating the bowels
in the lowest cases, was indicated by tenderness  of the abdomen,
uneasiness, or slight pain, which showed that the torpor of the intes-
tines had ceased.   Under these circumstances, the discharges were
never indurated,  but were always  perfectly natural.  In many
cases, a single  enema, or a small quantity of Magnesia, or Rhu-
barb, or an aloetic pill, was necessary as an eccoprotic,  or at  far-
thest, as a laxative once in two or three days.  It is to be observed,
that the Opium should not be abstracted on account of the laxative
or any other article, but only  as the other symptoms admit.  On
the whole, the best way of evacuating the  bowels, appeared to be
produced,  by giving daily about a dram of Magnesia, and if neces-
sary, assisting it every other day by an enema.
   The opinion, that in this disease, and more especially in any of
the distinctly marked cases, purging would increase the suscepti-
bility to the impression of stimulants, was utterly unfounded.  The
morbid  action  could not be  changed, in  the severest cases, by
evacuants  and alteratives; it could  only be controlled by exciting

  * When patients are mentioned as teen, it* iff meant in consultation, and
they are not included in the three hundred and sixty caws, the immediate
►subjects of this 6ket«h. 
                             16
and supporting the vital powers by stimulants, and such articles as
appear to have an immediate action on the brain and nervous system.
  If by vigorous treatment, the system could be raised in a day or
two, to a mercurial, or purging, or  vomiting point, the victory
might be considered as already gained, and there was very seldom
any need of either of the processes of vomiting,  purging, or ptya-
lism afterwards.   [See Appendix, Note 20.]  As a general rule
in this epidemic, it might be affirmed of cathartics, with the ut-
most certainty, juvantper casum, nocent per se.  In every instance,
the mildest forms of the disease were rendered severe and unman-
ageable, by free purging or vomiting.  If they did not sink, which
was usually the fact, they became factitious-bilious fevers, which
were obstinate and unmanageable.  [See Appendix,  Note 21.]  In
a few bad cases, in which a slight  mercurial action was excited,
it was of no sort  of service; and in such cases, if irritable, stran-
gury from Cantharides only distressed the patient.
  Opium was the most important remedy in the severe form of this
disease, and was, in such cases, regularly administered from  the
very first visit.  A few cases imperiously required half an ounce of
the tincture in an hour, or half a dram in substance, in the course
of twelve hours, before the urgent symptoms could be controlled ;
and even some cases required a dram in the same time.  All these
patients recovered.  In nearly every fatal case of this year, there
were circumstances to prevent a free use of medicine.  The whole
of those patients, whose symptoms were promptly met with Opium, in.
variably  recovered.   Opium enough, assisted by external applica-
tions, would command every peculiar symptom, with as much cer-
tainty, as any effect can be promised from medicine, except the ex-
treme  sinking, after a critical effort, in a neglected, or ill-ma-
naged case ; and even in this forlorn state, it always mitigated much
of the anxiety and distress, and prolonged life.   Many other arti-
cles, however, were very useful in the course of the disease.
  Alcohol was highly beneficial in some cases, and  required to be
employed freely  in many, but it seemed not to be equally adapted
to all, and on  the whole, was of much less importance than Opium.
Wine seemed totally unfit for the severer cases.  [See Appendix.
Note 22.]   Lytta and Capsicum internally, were very serviceable
in the torpid cases, but were entirely unmanageable, and greatly in-
creased the irritability of most of those which were previously irri-
table.   Arsenic, (Fowler's Mineral Solution,) was  highly service-
able when the head was very much affected, and the  stomach at 
17
the same  time torpid.  In some irritable cases it answered well.
but it was necessary to adjust the dose very accurately, in order to
have its full effect on the one hand, and not offend the stomach on
the other.  In these cases however, it agreed better than any thing
else, except Opium, or perhaps Alcohol and aromatics.   Delirium
resembling mania, was occasionally relieved by tincture of Stra-
monium, combined with tincture of Opium.  Camphor and Ammo-
nia answered a good purpose in the more moderate cases, but were
worse than nothing in most of the severe.   Ether was of no service
for permanent support, but was occasionally very useful during the
sinking paroxysms.  The same was the fact with Peppermint, and
other essential oils.   Oil of Turpentine  was not used internajly.
[See Appendix, Note 23.]  Cinchona, and the other vegetable  bit-
ters and tonics, did not the least good in the severe cases.  They
were too slow in their action  to  produce a perceptible effect, till
after a crisis, or  in the protracted stage of such cases, as assumed
the form of common Typhus.  After convalescence commenced,
they were often useful to assist in retaining the ground which had
been gained, and to accelerate recovery.   In these instances, if
the stomach was irritable, Sulphate of Quinine was preferable to
any other preparation of Cinchona.  [See Appendix, Note 24.]
   In all the varieties of this disease, internal medicines were great-
ly assisted by external  applications, which were adjuvants tha't
could never, with safety, be omitted.  When it was practicable, the
early use of the  hot-bath was of great service, and it was much to
be regretted, that it could not be oftener employed in the first
stage.  Warm or tepid bathing, was rather injurious.   The water
should be  so hot, as to make as strong an  impression as can be
borne, without danger of scalding.  When strong, and at the same
time quick rubefacients were required, bottles of hot water, heated
bricks  or wood,  hot spirits, Mustard,  Liquor of Ammonia, Capsi-
cum, and Oil of  Turpentine, were important agents.  Epispastics
of Cantharides would produce no effect,  in many cases, till  the
skin had been first excited in this way; but as soon as the suscep-
tibility of the patient was raised, by internal and external means, to
the blistering point, the  freest  application and repetition of them,
was attended with the  most  obvious beneficial effects.  They
were more especially useful to the shaved vertex, forehead, tem-
ples, spine, epigastrium and  extremities.   In  every  case,  (the
very mildest are  not with safety excepted,) the forehead, and in the
severe, the vertex  should be immediately blistered.  Shaving  the
                              3 
                             18
head, and blistering it early, is more serviceable than any other ex-
ternal application.  Torpor of the bladder almost invariably yield-
ed to sinapisms, or more especially, to blisters on the inside of the
thighs.   So sensible were those patients who had their reason, of
the beneficial effect of blisters, that they frequently begged to have
them repeated.   To one patient, more than twenty blisters, and to
another, more than thirty were applied during the course of this
disease, and evidently with the greatest advantage.   Oil of Tur-
pentine, warmed, and confined to prevent evaporation, was the speed-
iest epispastic,  and was of much benefit in coma.   In a very few
cases, there supervened such a  peculiar irritation in  the latter
stage, that blisters required  to be repeated with caution,  on ac-
count of strangury, as this symptom, in irritable cases, sometimes
increased the morbid action.  It always lessened it, in cases of
torpor.  In no other disease is it so essential to distinguish coun-
teracting, from coinciding agents.  But after all,  in the severest
forms of the disease, Opium, Alcohol, Arsenic, aronuntics, and exter-
nal applications,with no other medication, might be depended upon.
   In the mildest cases, after cautious  purging  with Calomel, the
prescriptions were almost negative ;  such as  to  avoid vegetable
acids, cold water, muscular exertion, an erect position for any con-
siderable length of time, much purging, and various other hurtful
measures.  Numbers of cases  might be stated, in which the pa-
tients, while labouring under an apparently moderate disease, from
a false idea that they should gain strength by sitting up, have pro-
duced the most dangerous paroxysms  of vertigo and sinking, some
of which, have been followed by death. Many of the severest cases
did not admit of being moved from their beds for several days;
since the slightest motion, or change of position, was liable to pro-
duce a severe paroxysm of sinking, and increase the exhaustion to
such a degree, as to require hours to regain  the ordinary strength.
Some slight cases might be trusted to aromatic, bitter  infusions,
alone; others, to Camphor and Ammonia.   In several of these, no
Calomel, or Opium, or Alcohol, or  any  active  medicine, was
needed or employed, provided all hurtful measures were studious-
ly avoided.  In many, a blister to the forehead, Serpentaria, Cam-
phor and Ammonia, Compound tincture of Cinchona, and  Opium
in very small quantities, were all that were required.
   Profuse sweating from external heat was useless in the mild, and
inefficient, or injurious in the worst form of the disease, unless em-
 ployed at the very access; and in this stage, it could rarely be 
19
used with convenience.   By the time a physician is called, it is
generally too late for sweating to be  of much  service; though,
when employed very early in cases of sudden attack, it is  some-
times capable of breaking up the disease, especially in the torpid
variety.  Under such circumstances, it ought generally to be tried.
[See Appendix, Note 25.]  The duration, severity, and mortality
of this  disease, depend more than any  other, upon  the early
management.
  On the whole, it must be repeated,  the  epidemic afforded the
most decisive evidence, in favour of the efficacy of a free use of
Opium, when employed in season, for  the  removal of coma, and
other atonic affections of the brain.   When the early  treatment
was  efficient, there was sometimes a  resolution in twenty-four
hours, or the disease rarely lasted longer than five or seven days;
but when the practice was so timid and inert, as only partially to
meet the symptoms, if the patient did not immediately sink, it was
generally protracted somewhat in the form of common Typhus,
fourteen, or twenty-one days, and in some few cases, four  or five
weeks.   [For other particulars concerning principles and practice,
see Essays on Fevers, etc. especially those parts of the work
which treat of the irregular varieties.]
  This epidemic, very obviously, was not common Typhus, as that
term  is intended to include the nervous and putrid fevers  of the
older authors.  What then was it ? It has been questioned whether
it was nosologically the  same as the Hartford Spotted-Fever of
1809 ; and by those who did not witness the disease, even whether
that epidemic differed essentially from common Typhus, or Ner-
vous-Fever.—The peculiar and extreme deficiency of vital ener-
ay in the brain and nervous system, from the  very access  of the
disease, without any appreciable reaction during the whole course—
the early urgency of the symptoms—the constant liability to cold-
ness  of  the extremities,  and  numbness of the skin—its degree of
insusceptibility to the action of strong rubefacients and blisters—
the peculiar  distressing and death-like sinking in  the  epigas-
trium__the craving of hot liquids—the alternation of extreme
torpor and excessive irritability of the stomach—the great liability
to sudden and irremediable sinking—the  respiration resembling
that of animals in which the Par Vagum has been divided—the im-
mediate exhaustion produced by an erect position—the delirium
resembling intoxication, (when neither Alcohol,  Opium, nor  any
other medicine had been used,)—the extreme variableness and ir- 
20
regularity of the pulse, particularly its occasional deceptive fulness
and force, when the patient is in the most alarming state of exhaus-
tion—the very rapid progress of the disease—the impunity, at least,
with which the most extraordinary doses of Opium  were bornej
(which must be acknowledged  by all, from the unparalleled suc-
cess of the practice, whatever may be realized of its necessity and
advantage by those who did not watch the whole progress of the
cases,)—[See Appendix, Note 26.] the injurious effects of free eva-
cuations, whether spontaneous or factitious—the general ineflicacy
of all medication to gain a hair's breadth upon the disease, when,
from neglect or bad management, the patient had once sunk down
at a critical period, though perhaps the same degree of exhaustion
might  not have  been  very  alarming  at  the crisis of any other
ordinary fever, and though individual symptoms might be capable
of material palliation—the absence of febrile smell, and indeed, of
any uncommon fetor of the excretions—all mark the identity of the
disease with the Hartford Spotted-Fever of 1809, and evince its
diversity from common Typhus or Nervous-fever.   From these
considerations, it is believed, no one will hesitate to admit that this
disease, at least as respects the severest and most  sudden cases,
was genuine Spotted-fever, and  that it was essentially  different
from common Typhus.  Indeed, the two  diseases differ so much,
especially during several of the first days, that the best treatment
of common Nervous-fever, would prove fatal in every severe  case
of Spotted-Fever.   With the utmost confidence it is asserted, that
by the experienced, they might be always discriminated, and there-
fore should never,  at this late  day, be mistaken, or  confounded
together.  It is true, that in  a great majority of the cases of this
year, the disease was less violent, and more manageable than the
Spotted-Fever of 1809, and indeed, than it was this same season
in several adjoining towns.   The only difference appears to  be,
that the mild and insidious cases, were in  a  much greater propor-
tion, this year, than formerly.  The cases of sudden attack, were
identically the same as those of 1809, and all the others were clear-
ly varieties of the same epidemic.   But this is a point of difference
which existed to  an equal degree between several of the different
cases of both epidemics.  Why may there not be prominent varie-
ties of Spotted-Fever,  as well as of common Typhus, Yellow-fe-
ver,  Cynanche-maligna,  Pneumonia-typhodes, Dysentery,  etc.?
[Set Appendix, Note 27.]
   This disease, however, was peculiarly distinguished from even 
21
other, by the early paroxysms of sinking that attended it, by the
entire absence of the stage of reaction, which is so essential to or-
dinary fevers,  and by the great effect which Opium had in miti-
gating all the dangerous symptoms of every stage, but more espe-
cially, irritability, delirium and coma.  In every instance, except-
after the fatal sinking of a critical  period, provided a sufficient
quantity could be swallowed, or received and retained by enema,
(which latter, in some few cases, was the best way of administer-
ing it,) it seemed to be invariably capable of obviating the symp-
toms in question.
   In common Typhus, whether of the nervous or putrid type, even
after a critical sinking, we can,in general,not only call the remaining
excitability into action, but as is evident, actually  produce a new
secretion of vital power.  But this can rarely  be done, after the
critical  sinking  of the worst cases  of Spotted-fever.  If there-
fore, we have not produced an early change, or begun thorough-
ly with  a much more  energetic course, than similar symptoms, in
ordinary Typhus would demand,  or even justify, our prospect of
success is  small.  It is the sudden  attacks of  the severest cases,"
which rouse all  our energy, and usually make us even more suc-
cessful  in this disease, than  in ordinary fevers.  [See Appendix,
Note 28.]
   To conclude,—Typhus-syncopalis or the Spotted-fever, when
neglected or injudiciously  managed, is among the most deadly
maladies which  a mysterious  Providence  permits  to scourge
the human race.  When taken in season, and  treated with deci-
sion and judgment, few diseases yield with so  much certainty to
* proper conrse of medication. 
APPENDIX.
NOTES.
   1. In every malignant epidemic, a few instances aw liable to occur,
in which the vital principle is so immediately extinguished, that the pa-
tient is in a moribund state before the physician can be called. , A ww
such were seen in former years, and one or two in 1824.  bucn appa-
rently hopeless cases, however, should not be forsaken,  as the powci*
of life sometimes rally, after all hope of life has ceased for hours,   u
patients have been previously well supported, they will  usually revive
after an apparently deadly coma has continued  for a great length  oi
time.                                                         c
   2.  Hemorrhage from the lungs,  or rather the free discharge  oi a
frothy matter of a pink-colour, or of a mucus tinged with blood, with-
out pain, or scarcely any cough, is one of the most fatal symptoms that
can occur ; yet it may be the  first, and only cause of alarm to the by-
standers.
   3.  The  author  has  seen carbuncles two  or three  inches  in di-
ameter,  in the latter  stages of this disease,  and also has known the
carbuncle to  be the earliest symptom that was noticed.  Swelling of
the parotid glands, phlyctaense, vibices, petecchiae, ecchymoses, etc. oc-
casionally occur.  A few cases began with extreme pain  and passive in-
flammation in the extremities.  Pestilential buboes are almost the only
conceivable external affection that is not occasionally met with in these
epidemics.  It is quite unfortunate that a single symptom, (petecchiae,)
 and one too, which is wanting in a great majority of the cases,  should
have been seized upon, to give the odious and deceptive name of Spot-
ted-fever, as that name has been applied by European writers, to a very
different kind of fever.   Indeed, petecchiae may  appear in diseases of a
very different character ;  and often in porphyra-haemorrhagica, sea-
scurvy, and other chronic complaints which are unattended with fever.
Small  vesicular eruptions, attended with troublesome  itching,  have
been very common in all our late epidemics.
   4. Nothing  is more fallacious than the statements of nurses concern-
ing heat.  The true standard, is that of a  healthy person  lying com-
fortably in bed.  Those who  are about the sick, and  interrupted in
their sleep, have often cold bands which are very sensible to the least
change, or even to no  change of temperature  in the  patient.  The
same remarks will often apply to the hands of the physician.  In what
is called stinging heat, the real temperature is perhaps most frequently
below the healthy standard.   Transient flashes of heat with  a  flushed
countenance, are however, common in  some of these epidemics.
   5.  In 1824, the patients  were very frequently inclined to sweating 
23
two or three times every twenty-four hours.  Cold sweats during par-
oxysms of sinking are not a rare occurrence.
   6.  In some of  the most  deadly forms of the disease, there is very
little  apparent derangement of the  functions of the skin, tongue,  ali-
mentary canal, or pulse, except during the daily paroxysms of sinking.
   7.  The distinction between extreme irritability and extreme torpor,
is well illustrated in  Cynanche, when in some cases, Capsicum is the
best and the most grateful  topical  application ; in others, it seems to
set the throat on  fire.   Strangury,  excited by Cantharides, will occa-
sionally very much increase irritability, though in torpid cases, it is a
very valuable counteraction.
   8.  It is the easiest thing imaginable to convert almost any fever of
the nervous  type, which is not so  low as to sink immediately under
evacuations, into a bilious fever, with irritable stomach, tympanitic ab-
domen, diarrhoea, or hemorrhage, by injudicious  emetics and  cathar-
tics.   Indeed, the bilious-fevers of this region, which are seen at the
present day, are  almost universally factitious, being the obvious result
of hyper-emesis  or hyper-catharsis, in originally nervous fevers, or in
mild  spotted-fevers.
   9.  Within the  last two years, three or four cases have been met with,
which if  they had occured on the eastern continent, would unques-
tionably have been considered as genuine specimens of the Spasmodic-
Cholera of India.  They  all recovered under the use of Opium, the
hot bath, and external stimulants.
   10. In a few cases, there was a slight mercurial fetor, .which,  with
the effluvia from blisters, sinapisms, etc., might possibly be mistaken
for the ordinary febrile smell; but generally, the air appeared to be
completely free from the least unpleasant taint.
   11. Exceptions to the danger of an erect posture  sometimes occur,
though they are very few  in this disease ;  but in one case, the patient
could not lie down, without feeling as if his feet were in the air,  and his
body  hanging from them with the  head  downwards.  He was very
speedily  relieved by shaving his head and blistering it freely.
   12. The symptom of morbid clearness of intellect, is perhaps more
dangerous than delirium.   It was very common in the fever of 1824,
and continued till nearly the last of several fatal cases.
   13.  It was curious to see how completely strangers were liable to
be deceived by the pulse.   In many of the  worst cases, except during
 the paroxysms of sinking, or when the patient was dying,  and in  some
instances, in both of these states, judging from this symptom alone, no
disease would be inferred to  exist.  Counsellors,  unless they stay by
the patient  twenty-four hours,  almost always judge incorrectly of the
danger.  Though a bad state of the skin, pulse, and tongue,  are always
unfavourable, yet it cannot be  too often enforced, that a state of these
functions, nearly natural, often exists  in the worst cases of this epi-
demic.
   14.  It would be easy to state a  number of cases which  sunk from
bleeding, when the disease first appeared in this State, and was mistak-
en for active phrenitis.   They are facts of universal notoriety.   The
author has known repeatedly of venesection in the milder  forms of
these epidemics  ; but it not only produced  paroxysms of sinking, but
rendered the cases obstinate and  protracted.  In every severe  c; se
free bleeding, as  also free vomiting and purging, is almost certain death. 
24
   15. The symptoms of tumid abdomen and hemorrhage were mote
 common in 1824.   But it must be  recollected that  free  purging  was
 more common, as the cases were not generally so immediately sinking
 in the first stage.  Tumid abdomen in fevers, most probably, is always
 caused by excessive purging, or spontaneous diarrhoea, not seasonably
 checked.
   16. It is  necessary to make further comment upon the two kinds of
 subsidentia, or sinking, or Vabattement. as it is called by the French, as
 they are but little understood, and can never be realized by  those who
 have not witnessed this disease in its severest form.  These sinkings are so
 common, as to be properly reckoned among the diagnostics of ordinary
 cases. These symptoms have been the cause of much of the applause,
 and much of the reproach, that have prevailed, concerning what is usual-
 ly called the stimulating practice.  The objections have almost uniformly
 come from those who have had little or no experience of the disease in
 its worst and most sinking varieties. In the paroxysms of ordinary sub-
 sidentia, the patient is sure to find relief by an efficient use of aromatic
 drinks, essential oils, Alcohol, Ether, or Opium, assisted by external
 stimulants ;  and in the more urgent cases, there is no other mode of relief.
 The patient must use them freely, or he sinks for ever.  The author is
 confident, that no instance of recovery from this disease, in the severest
 form, can be produced under an opposite method of treatment.  In the
 more obstinate paroxysms, the quantities of some of these articles, that
 are not only borne with impunity, but that are imperatively demanded,
 are incredible to a stranger to such sinking cases.   Every patient feels,
 and every bystander sees, their salutary effect.  It is necessary to keep up
 this effect by the same article^ regularly  and frequently administered,
 though in much less doses than during the paroxysm, which may pre-
 vent its return in any alarming degree.  In moderate cases, those fits of
 sinking when left to themselves, do not at first, destroy life, but each
 succeeding one reduces the vital powers so much, that a paroxysm of
 critical sinking soon  supervenes,  that instantly jeopards life.  When
 this critical sinking does occur,  the most decided practice is necessary
 to prevent instant death ;  and in defiance  of every exertion, in the ma-
jority of cases, it is believed, it finally proves fatal.   Lifs may usually
 be prolonged for hours, and sometimes days and weeks, but the system
 has received such a shock, that ultimate recovery is rarely to be expect-
 ed.  However, it is always our  duty to support the patient as long as
 possible ; and we succeed often  enough in producing a new secretion of
 vital power, to prove, that desperate cases should never be neglected,
 and at the same time, to demonstrate the salutary effects of medicine
 in palliating, even when it  cannot remove disease-  Those  who are
 ignorant of  the extreme malignity of the disease, in  general  attribute
 death in those cases to the medication.  If a physician suffers his pa-
 tient to die in one of these paroxysms, he loses no reputation ; but if
 with the most exquisite skill and  judgment, he prolongs life  for days
or weeks, and the case finally fails, he is almost sure of being censured
for his practice.  When sporadic cases of this fever first occur, they are
generally mortal, and the patient is usually said to die of aft of apoplexy,
of angina-pectoris, of hydro-thorax, of organic affection of the heart, or
of some such fatal disease. He does often die, before sufficient reaction is
produced to show that he laboured under a febrile disease.  No fever re-
quires greater nicety in adapting the treatment to the symptoms of in- 
V
                                2h

 dividual cases than this, as some  of them are  very slight, and requite
 only moderate practice.  The charge of indiscriminate practice is ut-
 terly groundless, and the general  inference that is attempted  to be
 drawn from particular cases, is  entirely unwarranted.   From a con-
 versation of a few minutes with  any intelligent physician, it is easy to
 ascertain, whether he has ever witnessed the whole progress of a very
 malignant epidemic.    If he has not, or  has only superficially viewed
 sporadic cases, or if he has only seen the disease in its mildest form, or
 in the intervals of the paroxysms of sinking, all his analogies will fail
 him.  How a patient can sink irretrievably, sometimes on the first day
 of his disease, from a single emetic, cathartic, venesection, or enema,
 or even a draught of cold water, when at the same time, he might pro-
 bably have been restored under proper treatment, is utterly incompre-
 hensible, to such as  have not repeatedly witnessed their effects.  And
 on the other hand, it is equally mysterious, how doses of medicine, that
 in ordinary cases might  endanger life, may be given  with  the  utmost
 safety,  and the most prominent advantage.  It is equally incredible,
 that some cases may be trusted a week without the bowels  being mov-
 ed, and not only so, but that the slightest eccoprotic, if it could be made
 to operate, might destroy life.  The fact that coma, and other typhoid
 affections of the brain, are more  surely  relieved by  Opium than any
 other remedy, is equally incomprehensible.  However, no facts in me-
 dicine are better known by the truly experienced,  or are supported by
 more substantial testimony.
   17.  Several cases  occurred in  1824,  that  counterfeited delirium-
 tremens.
   18.  In 1824, two women were delivered, one of them of a dead
child, during a severe  attack of this disease.   The mothers, and the
 living child, ultimately did well.   Several gravid women passed through
 the disease, in both seasons, without its  producing abortion.   Several
infants, of a few weeks old, have had  Sinking-typhus, within the last
 two years.
   19.  In some few cases under peculiar circumstances, where torpor
 prevailed, emetics of Zino and Ipecacuanha, in skilful  hands, have suc-
 cessfully roused the system; but then it  often requires a dram of each
 to operate.   Small doses  are worse than  useless.   Emetics combined
 with Calomel,  have sometimes  a favourable effect in the beginning of
mild cases, but they require  extreme caution in any case  of sinking-
 fever.  The epidemics of different years, vary very much, as respects
the safety of emetics, and much depends upon the preponderance of irri-
tability  or torpor ; and much, whether the attack is insidious or sudden.
In sudden and violent cases, emetics and cathartics, at first, are utterly
inadmissible.
   20. It is very certain that no instance of intoxication took place this
year, from the use of Alcohol; but in  former seasons, when any thing
like  it was supposed  to occur, it is stated that the patient was free from
danger, and that  all medicine might be soon abstracted.  Of this the
writer is merely informed by friends, and is somewhat skeptical;  as he
never saw intoxication, or had the least reason to suspect it, in a fever,
in a single instance.   Such cases,  therefore, are of very rare occurr
rence.  The coma  and delirium, though so often mistaken for intoxi-
cation, are symptoms  of the disease,  and when taken  early, almost
                                4 
26
infallibly yield to Alcohol and Opium, in sufficient quantities.   These
symptoms are often mistaken by superficial observers, for intoxication,
vvhen no Alcohol, Opium, or stimulant of  any  kind, has been adminu-

  oi  In so many fevers is it necessary to keep the bowels free,  and
in so many diseases is the weight of morbid action lessened  by a strong
impression on the alimentary canal, it is no wonder that physicians, inex-
perienced in sinking diseases, with the  greatest difficulty, can realize
the inconvenience arid hazard  of active cathartics in this  fever.   Iu
sinking  cases, the effect is obvious and  immediate; but  it require!
repeated trials,  before a physician is  ready to allow,  that the  bilious
cases, which usually sink at the end of a week or fortnight, are factitious,
and of his own creation.  Comment, en effet,  n'o-til pas vu que, dans
plusieurs cas,non sexdmont la maladie a ete exasperee, mais mime suscitie
par let  moyens  curatifs, et que Vanomalie des symptoms suivit celle du
traitement ?  The great hazard  of free  purging in  this disease,  only
shows that it is a powerful agent when it is indicated in others, and is an
argument for its use, when properly applied.   Agents that are liable to
do no harm, seldom do much good in medicine.
  22. From  being in the habit  of commanding the urgent symptoms
with Opium, to the extent of one, two, or three grains, every hour or
half hour, during the severest paroxysms of sinking, and afterwards keep-
ing up its effects by one grain, every two or three hours, or even a grain
or more every hour in  extreme cases, the author has  generally been
able to dispense with the vast quantities of Alcohol, that are requisite
upon a  different plan ; though now and  then a  case requires it,  in as
large a  quantity as the stomach can retain.  It is rare that more than a
pound-of diluted Alcohol  is administered in  twenty-four  hours,  and
usually  much less.  When the stomach is very irritable, hot infusions
of Cloves, Cinnamon, or other aromatics, are  frequently preferable to
Alcohol.   In a few instances, wine, porter, and bottled cider, are  pro-
perly substituted for  diluted Alcohol.   Food  reguhrly  administered,
such as a spoonful or two of broth or  milk  porridge,  every hour or
half hour, is as necessary as medicine, in  the lowest cases.  Opium by
enema  is often necessary to check diarrhoea and other symptoms, but is
generally a very poor substitute in urgent cases, unless there is  uncon-
trollable vomiting, for the usual method of taking it in substance into the
stomach.   In many cases, large quantities of Alcohol, and even of Opi-
um, might be  dispensed with,  if the patient  had not been sunk by
emetics, or cathartics, or Calomel, or other preparatory means, which
might be highly proper in regular typhus or nervous-fever.  The
Ipecacuanha and neutral salt in Dover's Powder,  are  injurious in all
severe  cases.  Antimonials, and the common  neutral  salts, are out of
the question.   The truth is, the disease is so urgent in its violent form,
that not only is the stage of reaction wanting, but also  there is no ne-
cessity  nor time for preparation.  The exhaustion must be attacked im-
mediately, by such means as will produce a new secretion of vital power,
Some gentlemen, from having only read the author's essay upon the re-
solution  of  fevers, have made very great mistakes, in attempting to
apply the  treatment which is proper for regular nervous or putrid fe-
vers  only, to the disease now under consideration.   If they had  read
the 6th, 10th, 11th, and 14th Essays with attention, they  would have
*eenthe outlines of the principles and practice, in irregular fever*   To 
27
consider and treat this disease as ordinary nervous-fever, is often a fa-
tal mistake.   As the second,  or preparatory stage, [see the author's
essay on Stage, in essays on fevers,] for practical purposes, is entirely
wanting in  all malignant fevers of the  nervous type, [see Essay on
Type,]  the  preparatory process, so indispensable  in most other dis-
eases, is therefore, both unnecessary and pernicious.  Except to obvi-
ate some peculiar symptom, emetics, in comparison  with slow and mo-
derate purging with Calomel, are very indifferent practice, even in ner-
vous fever, and since blood-letting has been laid aside, antimonials are the
most fatal of all kinds of treatment, which are ever adopted in our late epi-
demics.   They change the whole aspect of the disease, and make it a
very different thing from what it would otherwise have been.  Active
cathartics, (and even  any cathartic  at all, for several of the first  days;
in the worst  cases,) are scarcely less exceptionable.  It must not be
forgotten that this  disease, very evidently is  neither excited  nor  aggra-
vated, by any thing that is naturally found in the alimentary canal in its
usual quantity.  There is  less reason to suspect morbific matter in this,
than in any other  fever.
   23.  In some  years,  Oil of Turpentine  internally, has been found
serviceable in torpid cases ;  but it  is usually rather unmanageable in
those which are irritable.  It may be given by  enema, in doses of a
dram, with a dram or two of laudanum, every four or six hours, in
coma.   Ether by  enema is proper in such cases.
   24.  Cinchona is peculiarly  adapted to putrid-fevers ;  it is of but  lit-
tle service in  the purely nervous, if they have not been previously pre-
pared  by Calomel; and unless there are aphthae, or symptoms of the
alimentary canal that demand  astringents, or unless  the  fever assumes
the form of common Typhus,  it is of no service in this disease, till the
stage of convalescence.  Where the stomach  is not irritable, it may be
given in immense doses, and suddenly abstracted without any percepti-
ble effect.  Sulphate of Quinine will not irritate from its bulk, but this
is probably  its only convenience.   It is apt to produce a sense of con-
striction in the stomach, when given in large doses.  No peculiar be-
nefit from it, in preference to other preparations of Cinchona, except
in irritable cases, has been seen in the acute stages of any disease, be-
side intermittents   and  remittents.    The author  is  fully convinced,
that in these latter diseases, it is nearer a specific than any other medi-
cine.  Four or six grains a day, are serviceable in many cases of slow
convalescence.  But in most  other cases except intermittents and re-
mittents, the ordinary preparations of the Bark appear to  be preferable,
provided the  stomach is not too irritable to retain them.  It has proba-
bly had as repeated and fair trials in this town as any where, and this is
the result of the experience here, concerning the Sulphate of Quinine.
It would seem to be by no means a complete substitute for Cinchona, in
ordinary cases, though from its  great concentration, and its being so
easily taken in the form of pill, it is a very  important article.
   25.  Whether there is more  irritability,  or a greater disposition to
diaphoresis, or whether the disease  is more frequently insidious in its
attack, or from whatever cause, it is certain  that sweating is less effica-
cious now, than it  formerly is  said to have been.  In  certain  circum-
stances it is very exhausting  and ought not to be promoted after the
patient is thoroughly wanned.   Sweating from external heat, and warm
aromatir drinks, is all that should ever be attempted to be done, m case? 
28
of sudden attack, before medical aid is obtained.   Vomiting or purging
should never be hazarded before a physician is called, when such an epi-
demic prevails, as it usually produces such sinking as to aggravate the
disease, and often endangers life.
  26. Notwithstanding the extreme malignity, (by which term is meant,
whether the fever is of the nervous or putrid type, a peculiar deficien-
cy of vital power, and consequent insusceptibility to the curative action of
ordinary medicines, in ordinary doses,) the practice in this disease was at-
tended with a success, scarcely paralleled in the annals of medical histo-
ry.   For seven months, there was a constant succession of cases, nearly
one  half of which required very energetic  treatment, and several  of
them the strongest practice which is ever admissible ;  and there were
but six deaths  among them.  The public scarcely knew that there was
an epidemic prevailing, the knowledge of it being mostly confined to the
families and connexions of the sick ; and they could not realize the ex-
tent and danger  of the malady.  There had been nothing very uncom-
mon in  the season, during the spring and summer, though it was perhaps
rather more variable than  usual;  but from the eighteenth of Septem-
ber, to the  latter part of December, the weather was remarkably cold.
The chilly, dark,  unpleasant  weather of November, in which month
six died, though it did not materially increase  the number of cases,
seemed to aggravate the symptoms, and to add to the severity of the dis-
ease. The extreme heat of summer, when the mercury of the thermo-
meter is above 90°, is equally unfavourable.   For a general rule, it is
evident, that the variations of the barometer, thermometer, and hy-
grometer,  have  little or no effect upon our epidemics, except as to the
exciting causes of individual cases, and the modification of such cases as
already exist.   Why the epidemic constitution is more inclined to Pneu-
monia,  or to Cynanche, or to  Spotted-Fever, or to common Typhus,
in one year than in another, has never yet been ascertained.  Mete-
orological  tables, have hitherto thrown no light upon any thing but the
exciting causes,  except in miasmatic diseases.   It is well known, that
the same  exciting cause  produces various  diseases,  according to the
 epidemic constitution, or prevailing diathesis.  It is worth remarking,
 that every sudden change  from warm to cool, invariably proved inju-
 rious to the sick, and vice versa, during the whole prevalence of this
 epidemic.
   27. All  typhoid diseases,  at times,  have a strong disposition to run
 into each other, and are often blended together.   If therefore, any one
 is  disposed to consider this epidemic as common Typhus, or  Nervous-
 Fever, blended  with Spotted-Fever, the author is not inclined to dispute
 concerning the name, provided it is not allowed to deceive with respect
 to  the practice,  and to induce the physician to adopt a treatment, which
 might be proper for common Typhus.  The epidemic constitution, or
 general diathesis, was decidedly that of Spotted-Fever, and every acute
 disease was tinged with it, and partook of the same common- character.
 This sinking-fever, is certainly described, as an epidemic, by no system-
 atic writer that is usually  read in America.  For aught that is known, it
 was never noticed till it appeared in  Massachusetts, in  1806.  The
 nearest approach to Spotted-Fever to be  met with in any foreign  au-
 thor, commonly found in our libraries, is in the statement of some cases
 to Johnson's Journal,  No.  12.  undw  the  head of Puerperal-Fever. 
29
Some of those cases, which are said to have affected men as well as women,
were certainly very nearly allied to the Spotted-Fever of New-England,
if not identically the same.  The Cholera of India is perhaps a variety
of this disease, supervening upon some derangement of the hepatic sys-
tem.  The author has elsewhere expressed his opinion, that the  local
affection  of the Spotted-Fever of New-England, is  a typhoid inflamma-
tion of the brain,  sui  generis; and that  it might properly be named
Phrenitis-typhodes.  He sees  no  reason to change his views.   Signs
of  inflammation, it is true,  have not always  been detected by dissec-
tion ; but from the authority of the great Baron Larry,  they cannot  al-
ways be seen, even after the most obvious symptoms of [active] inflam-
mation.  Morbid  Anatomy is usually very fallacious, in exhibiting the
causes of disease  and death.   It only shows their effects with certainty.
At  the present day, every one knows, that in deaths from excessive loss
of blood, whether spontaneous or factitious, the same turgescence and
distention of the vessels and membranes of the brain exists, that is usual-
ly found  after the most decided cases of inflammation.
  28.  It would be a piece of affectation to pass  in entire silence, the
great excitement  which  Sinking-Typhus, in common with every  other
malignant epidemic, has at different times produced in  the public  mind.
The various  and  clashing opinions upon this subject, among those who
are strangers to Sinking-Typhus, or who have rarely seen a case  of it,
are well known ; and more obloquy and abuse have been cast upon the
physicians, who have extensively and skilfully practised in this disease,
than in any other that has appeared in our country,  the Yellow-Fever
not excepted.  This ferment may be traced to several combined causes.
   First—Many Physicians are extremely  reluctant in acknowledging
themselves to be  unacquainted with any subject that materially concerns
their profession,  or in allowing that others  have had  more extensive
experience in any important branch than themselves.  They who have
not practised extensively in malignant epidemics, can never realize how
essentially diseases of the same name and nosological character, vary in
their malignant, from their milder and more common form, and how the
effects of medicines vary in these different  circumstances.
   Secondly—The  most malignant diseases in kind, are sometimes s©
slight in degree, (Plague, Yellow-fever, and  Cynanche, for instance,)
that they are often known to  yield under very inert practice, under im-
proper practice, and sometimes to  recover spontaneously.
   Thirdly—Much  confusion arises from names, almost every acute fe-
brile disease at the present day,  being  usually called  Typhus,  a term
which was formerly restrained to nervous, or putridfevers.  But we now
find Cullen's Synochus,  (the fevers of the sub-putrid type,) the Spotted-
fever of New-England,  Pneumonia-typhodes, Cynanche-maligna, ner-
vous-fever, putrid-fever, &c. all frequently mentioned  under one  name,
and considered as a mathematical unity, so that when we hear that  a per-
son at a distance  is labouring under Typhus, or the fever, we have only
to  guess what  is  the real disease.  No judgment therefore from a given
 name, can be formed of the propriety of any given method of treatment.
 Since  then Typhus is  used  as  a generic name,  we ought to inquire,
 what species is meant.   Is it nervous-fever, putrid-fever, bilious-fever,
sinking-fever, &c. should be the question,  if we would expect any thing
like a definite  answer. 
so
   Fourthly—A great difficulty arises from mixing in a desultory manner,
 and without a fixed plan, various and opposite modes of practice.   Dis-
 credit is thus brought upon all; for no one has had a fair trial.   V hen
 a practitioner is called to a sinking case, his first attempt is  usually, to
 rouse the system with external and internal stimulants.   Alter the imme-
 diate  danger from the sinking is overcome, he next thinks of clearing
 the stomach and bowels, as he would  in many other fevers, by  an active
 emetic or cathartic.   If the disease is Typhus-Syncopahs, in its severe
 form  he will then  be sure to sink the patient again.  This requires more
 stimulants, and  the patient is alternately stimulated and  reduced,  till  a
 fatal coma or sinking ends the scene.   Excitants have been used beyond
 all bounds, the  patient is lost, and the practice brought  into disrepute,
 and clamour raised against stimulants.   The truth is, no one course has
 been properly followed, and closely adhered to,  but the patients have
 sunk irretrievably, under a vacillating and heterogeneous intermixture
 of exciting and  reducing agents. It must never be forgotten, that this is a
 new disease, and not described, at  least systematically, by any foreign
 author.
   Fifthly—The false notion of the necessity of evacuating the contents
 of the alimentary canal, whether they are morbid or healthy,  or  whe-
 ther there are any specific indications for this process or not, or whatever
 may be the general condition or diathesis  of the patient, or the  idea that
 such evacuations are always necessary to increase the susceptibility to
 stimulants and tonics, and rouse the vital energies of the patient, or the
groundless theoretical apprehension that the continued use of stimuli, in
 acute  atonic diseases, will occasion dangerous excitement, or will be lia-
 ble to produce  what is called indirect debility, because  such might be
 the effect in health, are generally urged in justification of such a course,
 by those who have not the  most positive experience  to the contrary,
 even in the severest and most threatening cases. Every urgent case, is ir-
 retrievably lost under such treatment, however freely excitants and to-
 nics may be employed in the end.  When the attack is mild and insidi-
 ous, the real danger is usually misapprehended, till violent symptoms are
 produced by an ill-timed emetic or cathartic, or till the final sinking of
 a critical period ; and then, however much a free  and decisive use of
 stimulants may  palliate the symptoms, yet the patient is  often incapable
 of being raised ; and in this set of cases likewise,  death too often  is the
 ultimate result.
  Both these sets  of cases are therefore adduced  by the skeptical, in
 evidence of the inefficacy of stimulants ; and their supposed injurious or
noxious effects,  are subsequently inferred by the observation of a  third
 set of cases, which commence in nearly the same manner as the second,
 but which in  reality are so moderate,  as to recover under a mere
placebo treatment, or no treatment, or even in dtfiance of a moderately
depleting and evacuating course, without the aid of  any  kind of stimuli.
  It is believed however, that much the greatest difficulty arises, from
the theoretical speculations of gentlemen, who have never witnessed any
very malignant cases through their whole course.   A casual visit in con-
sultation, can afford but a faint idea of the general train of symptoms, or
of the powers and  effects of a proper course of medication.   [See the
 author's Essay  on  Experience, in  essays  on fevers, and othef.
 MEDICAL SUBJECTS.] 
31
  To sum up all in a few words—The public mind is principally agita-
ted, and the dispute is  chiefly carried  on, by two descriptions of physi-
cians ; by those practitioners who have not witnessed the disease in its
most malignant form, and by those who have never adopted and pursu-
ed any regular course  of treatment.  Hot-Typhus,  or the sub-putrid
type,  [See Essay  on  Type,] often wears itself out, and the  patient
recovers occasionally under any practice ; but there is not an instance
to be found, in the annals of medicine, of a malignant epidemic of the
nervous type, being successfully treated by any other plan than that of
A  REGULAR EXCITING AND  SUPPORTING COURSE OF MEDICATION.  This
is the only treatment which has ever succeeded, and met the approbation
*»f all the able  practitioners, from  Hippocrates to the  present day. 
32
            NOSOLOGICAL,  MISTAKES.

   Sporadic cases of Typhus-syncopalis are rarely recognized by such
as have not met with this fever as  an epidemic.   They are therefore
almost always called by a wrong name, and considered as being some
other disease.   The list of morbid affections to which  Sinking-typhus
has been supposed to belong is large ; yet  it would be easy to specifj
cases, in which it has been called by each of the following names.
   Affection of head and stomach, Angina-pectoris, Apoplexy, Cholera,
Colic,  Convulsions, Debility, Delirium-tremens, Gall-stone or  Spasmo-
dic-Jaundice, Hydrocephalus-internus,  Hydro-thorax, Hypochondrias,
Hysteria, Intoxication, Marasmus, Palsy, Palpitation,  active Phrenitis,
Quick-consumption, Rheumatism, Sick-head-ache, Sun-stroke, Syncope,
Tetanus, Typhus,  (meaning either bilious-fever, nervous-fever,  or
putrid-fever,) Uterine-disease, Vertigo, &c. &c. &c.
   Notwithstanding these numerous mistakes, the diagnostics of no disease
are more  precise and  definite,  than  those  of Typhus-syncopalis.
Though sometimes rather difficult to be traced at a single visit, yet  by
careful watching through its whole course,  (except when the patient
fails in the first paroxysm,) there will always be found a certain combina-
tion of symptoms, that cannot leave  the least doubt in the mind of a
physician, who has the slightest talent at discrimination. 
S3
             ADDENDA.—August 29,  1825.


        l^XSCELLANSOUS  REMARKS.
   Typhus-syncopalis has continued to be the prevailing disease, and
there have not been more than one or two weeks at a time since March^
18123, in which it has not been noticed ; though occasionally for months,
the number of cases on hand has been so small, that the aggregate of the
population was quite healthy.  Except in the cold autumn of 1823, and
in the excessively hot summer of  1825,  when in July the mercury for
several days was  many hours above 90°, the degree  of mortality has
boon less, than in any other severe disease,  to which this section of the
country h liable.   The cases of sudden and  violent  attack \my  very
little, either  in their general appearance or  appropriate treatment, in
different seasons or years;  bul the insidious cases,  in different \ears,
and according to the complaints with which they are frequently blend-
ed previous to the accession of paroxyms  of sinking, often assume a
very diversified appearance,  and  occasionally admit of  a considerable
diversity of practice.
   Peteccbia;  have been very common the  present yar.  A swelling
and soreness  of the gums, mouth  and throat, sometimes followed by a
severe  thrush, have been seen where not a particle of mercury had
been employed.   Among children more especially, a spurious reaction
of only a few hours, with stinging heat, has  occasionally appeared ; but
generally, the coldness and languor soon returned.   Several torpid in-
sidious cases have been broken up by acrid emetics ;  and in some others
of the same kind, Calomel  and Opium have done equally well, and in
two  or three days have removed  the disease.  In some neighbouring
towns, but not in this, the first attack has been so violent that no medi-
cation has made any  permanent impression,  and some patients  have
been seen that have died within three days—one, in ten hours.  Several
of the insidious cases of the present year have been  unusually pro-
tracted, and have assumed somewhat the appearance  of chronic com-
plaints, the paroxysms of sinking occurring in a severe degree  only
once every seven days, though there was generally a moderate and ob-
vious subsidentia every morning,  or rather, every forenoon.   Such
CHj.es have been occasionally protracted,  especially under inefficient
treatment, eight or ten weeks, and some of  them  have  proved  iatal.
In no disease is it so necessary to  meet every symptom  instantly_;  and,
the paroxysms of sinking when periodical,  should okays be anticipat-
ed" by such means  as will tend to prevent them.   In one point of view,
Typhus-syncopalis differs from every other fever, and that is in the de-
cree of severity of the  most distinctly marked cases.   As Darwuis.ud of
Cvnnnche,it  admits of every gradation, from a flea-bite  to the Plague.
More than half the cases are usually so mild as to require but  very
slight medication, provided  ;.I1 injurious measures are avoided.
  Typhus-syncopalis may  he defined, A Ncrcous-fe-jer* in which the

  * No theory  leads to more exceptionable practice than that, which supposes
jinkins-typhus  to he origuiall,/ a gastric diso^e.  This In* l.ceu the cause ol the
death of hundreds, and com ertcd hundreds of mdd into tedious and protract. J
«-t»es, and into  spurious bilicus-fevers.   Those physicians who avoid much vomit-
ing or purlin-,  and know how t<- use Opium etfii-.u-ntly in suhslauce, or t-y ene-
ma, arc sefdom  much  troubled with vomiting,  and rarely mistake it tor a ^.sli;r
or bilious-fever.                                          .,
  CSee Essay an Type, and Ess=:.y on Stage, in Essaxs ow Fevers- 
34
sta*e of no-chon is wanting, the torpid or funning stage and the stage
of "exhaustion bf.'ng b'cn I.hI  together, attended with pain in the head and
vcrlig), and puroxysi-K  f gastric sinking;  and for the most part, with
a co-Jl skin and a slow pulse, and an absence of all febrile smell.   1\-
tecchiie, eruptions, ecchyuioses, general effusion of the capillaries, co-
nn, delirium, palpitation* interrupted respiration, numbness and insus-
ceptibility to the action  of  ordinary rubefacients  and epispastics,  and
sinking after evacuations,  are much more  common than in any other
febrile disease.  By attending to these symptoms, it may be more easily
distinguished than any other continued fever.   Coma  or delirium may
sometimes be so severe or so protracted, as to overwhelm or disguise
every other symptom ;  or  the attack may be so violent as to destroy
life in'a few  hours ;  and in these circumstances, in sporadic cases there
may be, with the inexperienced,  some hesitation as to the nature  and
name of the complaint;  but on the whole, there is less liability to mistake,
than in the diagnostics of any other acute fever with which we are in the
habit of meeting, in the  ordinary course of practice.  Dysentery, Cho-
lera,  Cynanehe, Catarrh,  Cough,  Pneumonia,  Measles, Rheumatism,
Gout,  and  even common Typhus,  are often complicated  with it;  yet
there is always some prominent symptom by which it may be determin-
ed, when the general affection of the systemia that of Typhus-syncopalis.
        CASE OF MRS.  C----- B-----, ^ETAT. 25.
  This patient, from some cause or other, was habitually costive, sel-
dom having a discharge from the bowels oftener than once a  week.
Previous to her attack  in the present instance, nothing had passed the
bowels for live days, during which time, she was engaged in attendance
upon a sick sister, whose case proved  fatal.  Most of this time, she
sat  up during the  night.   For the last two days, she  was unques-
tionably in a state of predisposition, as she complained of loss  of ap-
petite, languor, indisposition for exertion, vertigo,  and various other
symptoms usually called hysterical, such as quick transition from laugh-
ing to crying, without adequate cause, etc.
  July 6th, 1825. About 8  o'clock, A.  M. while  collecting vegetables
in the garden, she was suddenly seized with extreme vertigo, complete
blindness and deafness, with  greJt distress and faintness referred to the
epigastric region, upon which she immediately fell to the ground, in a
state  very near to perfect  insensibility.  On being carried into the
house, the surface was observed to be very cold and pale, and there
were the  strongest marks of distress in the countenance.  The by-
standers  immediately  applied tincture  of Camphor  to the face, and
smart friction was made, both with the hand and flannel, to the back
and extremities.   Under this treatment she soon recovered from her
insensibility, but was at the same time, seized with a  most excruciating
pain in the loins, and the lower part of the abdomen.  This was  so
extreme, that she incess mtly cried out for Opium ; and when some of
the tincture was obtained, she would not wait for it  to be dropped  or
measured, but insisted  upon taking instantly, and unmixed, a quantity,
which to the judgment of the attendants, must have been about half a
fluid ounce.  Her customary physician being absent, and some miles
distant with othar patients, she  waited, without medical aid, about an
hour after taking this dose, but as it made no sensible impression, and 
35
then- wti«no  relief, but indeed  rather  a  gradu-,,1 augmentation of the
p 1:11 and distress, she requested  that another  practitioner  should be
called in.  On his arrival, he directed an  enema of nearly four fluid
drams  of tincture of Opium, in a little warm Witter, together v.ilh
the  application  of strong  sinapisms to  the bowels, and llorsc-r;.<lish
leaves  dipped in hot water to the extremities.   After waiting mother
hour without  any perceptible mitigation  of the pain, and the, physician
who had already visited her  being  engaged professionally elsewhere,
another was  now called.   This jr-ntleman supposed all the symptoms
which had thus far occurred, were the mere result of a audden t rolcpsvs
uteri, and under this notion, he very strongly disapproved of the mea-
sures that had been taken,  and on the score of the Opium particularly.
he  excited considerable agitation and anxiety, both of  the patient, and
the  bystanders.  According  to hie  views (as subsequently stated) the
introduction of a pessary was to be the most important means of relief.
Notwithstanding this opinion however, he  prescribed twelve drops of
tincture  of Opium, every four hours, and twenty of Spirit of Ammonia
every  two hours, and departed.   In another hour, the  customaiy fa-
mily physician arrived.   At this time,  according"to the statements of
the patient, and' attendants, there was still very little mitigation of the
pain.  The pulse  was quick, and gaseous, (or in ether words, soft and
weak, with considerable apparent fulness,) and  as infrequent as fifty-
five in  a minute.   The temperature, though declared not to  be near so
low as  it had been, still fell considerably short of the natural standard.
The countenance  was motley, being principally very pale,  but with a
few livid patches; the lips  were livid;  the tongue was much con-
tracted and pointed, and its surface  was shrivelled, and somewhat red
der than natural.  There  was no thirst, though the patient lay with the
mouth  open.  The respiration was  hurried and laborious, and resem-
bled that of a person who had just been making violent bodily exertion.
Another enema of half a fluid ounce  of  Tincture of Opium in a little
warm water, was immediately administered, and three grains of Opium,
in conjunction with half a fluid ounce of Spirit, and the same quantity of
hot  water, were taken into the stomach.   As the external applications
had produced  no apparent effect, the Mustard was removed from  the
abdomen, and a plaster of the cerate of Lytta (of the  P. U. S. A.) of at
least forty-eight inches surface, was applied in its stead, and Horse-radish
loaves  dipped in hot  water, were renewedly applied to the  whole ex-
tremities.  Two grains oi  Opium  in pill  were directed to be taken
every two hours subsequently, and a hot mixture of one part Spirit  and
two parts water, was advised ad libitum.   About 3  o'clock  P. M.  the
patient had become much easier, but still was not entirely  free from
pain.  The frequency of  the puNe was  a little  increased, but still it
was preternaturally slow, being about sixty in a minute ;  the tempera-
ture was restored to  near  the natural  standard,  and  the whole surface,
was thickly sprinkled over, with dark-coloured petecchise ;  the respi-
ration was less laborious, but was still unnatural.  There was no change
in the tongue, but the patient h id once   vomited a small  quantity of a
transparent liquid, of a light  crass-green colour.  A slight  degree of
talkative delirium had taken place, and on  inquiry, a considerable sense
effaintness and distress  was complained of, at the stomach.   An epis-
pastic was now applied to the forehead, and another large one, between
the  shoulders ; and in addition to what the patient wjs already taking
internally, a mixture often  minims of the liquor of the Arsenite  of  Po-
fassa, and forty of (hetinctura of Opium, was directed at every  inter- 
36
mediate hour between the pills.   The Horse-radish leaves were again
renewed to the extremities.  The  epispastic  upon the abdomen had
not yet produced any perceptible effect.   During the evening, rube-
facient effects began to be produced,  by all the  external applications ;
but with the exception of a considerable itching of the surface, there
was no appreciable change of symptoms.  The medication heretofore
specified, was directed to be continued through the night.
   July 1th. This morning  the patient was found free from pain,  ano
perfectly rational.  The pulse remained stationary, the surface was of
a natural temperature, the petecchiae of a florid colour, the tongue  wa«
dilated and flabby, with the upper surface  covered with a loose, slimy,
dirty fur, and the edges and  under surface livid ; there  was no (hirst,
and no irritability of the stomach, but still a great sense of distress  and
sinking was complained of in the epigastric region, which  was uni-
formly a^ravated by the slightest motion of the head.
   At this time, both sides of the head wore shaved, and large epispas-
tics were  applied, and likewise another epispastic, over the stomach.
The saaie internal medication, that was directed the night previous,  was
continued, with the variation only of assigning a regular period for the
administration of the Spirit, of which  a table spoonful of a mixture  one
pirt Spirit, and  two parts  of bread-water, was  directed to be  given
every in' '.rme liate fifteen  minutes,  between  the  doses of the  other
medicines.   During this  day, and the succeeding night, the symptom*
were kept pretty well at bay by this course, except that the patient vo-
mited twice toward morning.
   July 8th. The patient tolerably comfortable.   An epispastic was ap-
plied to each wrist.  Both  the day and  the night  passed  in  a pretty
uniform state.
   July 9th. This morning, the symptoms still  pretty much at a stand.
The patient and her friends were now solicitous to have a  discharge
from the bowels,  and though the abdomen was  perfectly soft,  and
equally free, both  from distension and uneasiness, yet the physician
yielded to their solicitations, and permitted a laxative enema of decoc-
tion of Tansey with common salt and Mel issos, to be employed.   In
about an hour this came away, but with only a slight discharge of fcecal
matter.   Epispastics were  at  this time  applied to the ancles, but in
other respects, the same medication as heretofore was continued.
   July 10th. This day the symptoms continued stationary, till the  lat-
ter part ofthe  night; and consequently, the medication was unchanged.
   July llth. The  fifth day of the disease.  This  morning the  pulse
was found  much more frequent, being a little  upwards  of a hun-
dred in a minute.   The skin was  again considerably cooler, and the fur
of the tongue was loose.  There  was distressing singultus, and rejec-
tion of every liquid taken into the stomach.
   At this time, as this change was considered a-? a critical effort, all me-
dicine was discontinued, except a pill consisting of two grains of Opium,
every two hours.  Common tea, and simple chicken broth, very hot,
were allowed often, in tea-spoonful doses,  and the patient was enjoined
to refrain as far as possible from all talking,  and all motion, particularly
ofthe head, as moving this part had hitherto invariably occasioned faint-
ness, siokness, and sinking  at the stomach.   Under this course, a con-
siderable improvement of all the1 symptoms was  found at 7 o'clock P.
M the pulse was less frequent and more full, the skin was warmer, the
teugue was clear from fur, though quite red, the singultus and vomiting 
37
worn gone, and  the patient had  had some quiet and refreshing sleep,
The niy;ht passed tolerably well under the same course.
  July \2th.   To all appearance, the patient was now pretty free from
disc ise.   The interval between the pills was protracted to three hours ;
and two fluid drams of the compound tincture  of Cinchona, were di-
rected every two hours.   Improvement continued through the day and
night.   Toward morning, there  was  some   manifestation  of  re-
turning appetite, and food sat well.   Milk-porridge was  allowed, with
Crackers  soaked in Tea, Coffee, or Brandy and Water,  and likewise a
little Cod-lish, soaked soft and picked tine.
   July l8f/i. Symptoms nearly stationary.  A laxative enema, prepa-
red as the previous one had been, was now employed.  This  soon ope-
rated twice  pretty freely, and occasioned considerable  faintness, and
increased weakness.   On this account, an extra pill of two grains of Opi-
um was gi.ven.  The regular pills and tincture  were continued  as  the
day before.  This day and night, on the whole, passed tolerably well.
   July \±th. The interval between the pills, was this day lengthened
to tour hours.  The tincture was continued as usual.  The patient was
aow ;>ble to take sufficient food, and to sit up in bed.  Passed  the
whole twenty-four hours well.
   July Ibth. Still improving.  Took only four  ofthe pills, this day.
   July 16th. The patient now able to walk about her room.  Discon-
tinued both the Opium and the compound tincture of Cinchona, and in
their place substituted a  tea-spoonful of an aromatic tincture of Gentian,
in a glass of  wine, every four hours.  During  convalescence,  a great
number  of minute Carbuncles made their appearance,  which  did  not
disappear entirely, under about a fortnight.*
          CASE OF MISS L—- S-----, jETAT.  16.
   This patient was in a state of predisposition, for about a week, during
which time she complained of languor,  indisposition for exertion, head-
ache,  pain of the limbs, nausea, occasional vomiting,  and diar; hcea.
For the last twenty-four hours of this period, both the body and the limbs
wore thickly covered with distinct, but dark-purple petecchiae.  In the
course of this  time, the patient, of her own accord, had taken one ca-
thartic of Aloes with Canella, which operated but moderately ; and the
day previous to the attack of her disease, another of Sulphate  of Soda,
which operated freely.
   July 8th, K:25. About one o'clock, P. M. after drinking  freely  of
Lemon-punch, which contained only a very small quantity of Spirit, she
was suddenly seized with great distress, and sense of faintness and sink-
ing in the epigastrium, followed immediately by the most extreme pam
iiTthe lower part ofthe abdomen, much resembling that  of parturition,
but far more severe.   Upon the  occurrence of these symptoms, the
whole body and limbs quickly became cold,  and insensible to  the most
powerful  irritants and rubefacients, the countenance pale, sunken, and
glnstly, the lips livid, the tongue contracted and pointed, but without
fhr, the respiration interrupted, and resembling  that of a  person jn»r
beginning to recover from asphyxia.  There was likewise violent deli-

  * This patient had an attack ofthe sxme diseWfc, i& Marah 1325, equally severe,
which yielded to uimilar treatment. 
                                38

rum  and complete inability to swallow, but notwithst Hiding this general
con lit.ori, the pulse w is perfectly natural in all respects
  Oo account of the inability to  swallow,  no  internal remedy could be
employed.   An  enema, consisting of half a  fluid ounce of tincture of
Opiu n, diluted with a little hot Brandy and water, was immediately ad-
ministered ; frictions  were thoroughly and persevenngly employed ;
and after their discontinuance, the whole  body and extremities  were
covered with Huse-radish leaves, previously dipped in hot water.
  In the course of two or thrae hours, there was an obvious  mitigation
of all the symptoms, though no individual of them had disappeared.  De-
glutition, though difficult, was now no longer imposMtde,  but yet the
muscles concerned in this process, seemed  to be partially p.iralytic, and
wh-ui any effort w:is made to swallow, they acted irregularly and con-

^sTron^'epispastics  were  now applied  to  the  forehead,  between
the shoulders, and  to  the  epigastric region ;  and the rubefacients
to  several  parts  of the body,  were renewed.   Forty mtmins  of
tincture of Opium, and ten of the  liquor  of the Arsenite of Potassa,
ware directed every two hours, and at every  intermediate hour, two
fluid  drams of officinal  Alcohol,  in  some hot  liquid.  In  addition,
Ginger mixed with hot Spirit  and water, and tincture of Camphor dilut-
ed with hot water, were administered in considerable quantities, as they
 could be got down.
   Through the remainder ofthe day,  there was a moderate, but gradu-
al  and regular alleviation of  symptoms, till about 10  o'clock,  P. M.
when a very irritable state ofthe stomach  suddenly took place, accom-
panied with extreme epigastric sinking and distress, greatly hurried and
panting respiration, very weak, soft, and small pulse, as frequent as  a
hundred and forty beats in  a minute, together with a cool, moist, and
 flabby skin.
   The tincture of Camphor,  the officinal Alcohol, and the Spirit, were
 now omitted, and two grains of Opium  in pill, were given at every inter-
 mediate hour, between the regular doses of tincture of Opium  and li-
 quor ofthe Arsenite of Potassa.   Epispastics were applied in addition,
 to the.ancles.   Under this course, all  vomiting soon ceased ; there was
 quiet and refreshing sleep, consisting of short naps, from which the pa-
 tient was easily roused, and the night  passed comfortably.
   July 9th. This morning, thera was  considerable mitigation of all the
 symptoms ; the temperature  was nearly as high as natural, the counte-
 nance was brighter, the epigastric distress and sinking were gone, the
 mind was tolerabfy steady, the pulse slower and fuller,  the  tongue co-
 vered with a light bro vn fur in the middle, and red at the edges, and
 <he patecchiae ware beginning to disappear, (as often happens under such
 a course of treatment,) but there was such torpor of the bladder, as to
 occasion a total inability to void urine.
   For the last mentioned symptom, strong epispastics were  applied to
 the inside of the thighs ; but in other respects, the same medication that
 was employed the night before, was continued.  The,day passed com-
 fortably, and with some further mitigation  of all the symptoms ; but as
 the torpor ofthe bladder still continued, an enema of decoction of Tan-
 sey and Ginger, to which was added common salt, was  administered in
 the evening.  This came away during the night, but without any fcecal
 discharge of any consequence from the bowels, though with a free eva
 cuation of urine.
    July \0th. This morning there was no  material change in the. symp- 
39
toms.  The patient, however, was full as well as the day before.  The
»leep had been quiet and refreshing, and the patient was easily roused
by the slightest means.   One or two additional epispastics were now
applied, but no change was made in the internal remedies.  As during
this day and night, the symptoms continued at bay, no change was made
in the medication, except the addition of two small epispastic^ to the arms.
  July 1 If/*. This day and night, no change of any consequence in the
symptoms, and of course the  same medication continued.
  July 12th. Till the evening of this day, there was no material change
either in the symptoms of the case, "or the medication.   During the
evening, it being the early part ofthe fifth day ofthe disease, great ir-
ritability  ofthe stomach suddenly took  place, and all liquid medicines
were rejected.  The surface immediately became considerably cooler,
the pulse as frequent as a hundred and twenty in a minute, the respira-
tion hurried, and a profuse sweat took place.   At this time, two grains
of Opium in pill, were directed every hour, and every thing else was in-
terdicted, till the stomach should become composed, which happened in
the course of the night.  After this, the pill was given  only every two
hours, anfl at the intermediate hour, a small quantity  of Spirit and wa-
ter was allowed,  and a little common Tea made very strong.
   July 13th. This morning, the patient was much better,  the skin wa«
nearly ofthe natural temperature and softness, the pulse was less fre-
quent, the stomach perfectly settled, and  the tongue fast losing its fur.
At this time, the interval between the  pills  was lengthened to  three
 hours, and half way between, two fluid drams of compound tincture of
Cinchona, were directed.  During this  day and night, there was con-
siderable improvement.
   July 14th. The patient still improving.   The pills were now  given
only every four hours, and the compound tincture of Cinchona, halfway
 between.   Food was taken with considerable relish, and in considerable
 quantity.
   July 15th.  This day took only four pills, and then discontinued them
 entirely.  No further medication, except a little of the tincture necess i-
 ry.   Convalescence was subsequently rapid.
          CASE OF MR. R---- F-----, ^TAT. 23.
  This patient, for several days previous to the attack of his disease, had
complained of languor and weakness, and had been pretty much desti-
tute of appetite. "During this period of predisposition, he took two ca-
thartics, one of which was Sulphate of Soda. -  This operated freely, on-
ly the day before he was seized.   The night immediately  previous to
his attack, he spent in watching with a patient,  sick of the prevailing
epidemic.
  >July Wth, 1825.  While walking in the street, between 12 and lo  -
clock P. M. he suddenly observed to a companion, that he felt as it in-
toxicated, and almost instantly fell to the ground.   He  was immediately
carried into a house, and medical  aid was called.   On the arrival of the
physicians, which was about 1 o'clock, P. M. the patient was still in  a
state of entire  insensibility ;  and  his condition, to the eye of a bystand-
er resembled a person labouring under a serious Apoplexy ;  or  more
exactly  one recovering from a state of Asphyxia from drowning.   The
surface was pale and cold, and covered with a clammy sweat;  the eyes 
40
  weTe fixed ;  respiration was slow and interrupted, a»d seemed as if cm
  ried oh entirely by mere voluntary exertion ; pulsation at the wrist was
  barely perceptible, and there was total inability to swallow.
    After wiping, and thoroughly rubbing the skin, epispastics were im-
  mediately applied to the forehead, sides of the head, and between the
  shoulders ; and nearly the whole  of the  body and extremities,  were
  covered with smapisms.   As no tincture of Opium was at hand, an tuie-
  ma, consisting of a fluid ounce of Oil of Turpentine, mixed with the
  9ame quantity of Oil of Olives, was immediately administered.
    In about two hours, the skin was raised nearly to its natural tempe-
  rature and softness, and the pulse acquired so much force, that its beats
  were easily ascertained to be about fifty in a minute.   There was now
  no stupor, but considerable delirium  had taken its place.   The  eyes
  had  a fixed  and vacant stare,  but when the patient was spoken to, he
  immediately  raised himself with a frightful expression of countenance,
  somewhat resembling that of a  rabid person.   There was, at the same
  time, considerable deafness.
    A mixture  of thirty minims of tincture of Opium, thirty of strong tinc-
  ture of  Lytta, and three ofthe  liquor of the Arsenite of Potassa,  was
  now directed to be given every  two  hours, and  at  the intermediate
  hours, a pill consisting of a grain and a half of Opium, with two grains
  of Calomel.  Spirit and water were prescribed for drink.   During most
  of the remainder of the day, and the subsequent night, there was vio-
  lent delirium, but,
   July 1 lth, at 8 o'clock,  A. M. the  patient was found  free from this
 symptom, though in its stead, there was a great sense of distress  and
 sinking in the epigastrium.  The pulse  was now very soft, weak, and  fre-
 quent, the skin cool, and both  the  body and extremities  covered with
 petecchiae, of rather  a florid colour.  The countenance  was at  the
 same time pale and sunken, the tongue was pale, and of a bloodless ap-
 pearance, and coated with a thick but slimy and dirty fur.
   At this time, an epispastic was applied to each wrist,  an  occasional
 Use of Camphor, and a free use of Spirit was directed, and the Opium,
 both in substance and tincture, with the liquor ofthe Arsenite of Potas-
 sa, as heretofore specified,  was continued.  The tincture  of  Lytta,  and
 the Calomel, were however abstracted, the former on account of a copi-
 ous and exhausting diuresis, which it had evidently produced ; and the
 latter, because it was now deemed injudicious,  and believed  never to
 have been  indicated.   Neither of these articles appears  to have be.-n
 proper in this  case.   At 8 o'clock, P. M. the patient was again delirious,
 and much  inclined  to  coma, but the  epigastric sinking  and distress'
 seemed to  be  somewhat less.   The  pulse was very weak and soft,  and
 the tongue as  last specified.
   The Spirit, and the  Opium  in substance, were continued as hereto-
 fore,  but the dose of the tincture of Opium, was increased to forty mi-
nima, and that ofthe liquor ofthe Arsenite of Potassa, to ten minims ; and
 an epispastic was applied to each ancle.
  July 12th: This morning, no material change perceived in  the symp-
toms.   Additional, but  small epispastics, were applied  to  the legs and
arms, but in other respects, the same medication was continued.  In the
course ofthe day, considerable strangury took place.
  July 13th. This morning, the symptoms still stationary.  New epis-
pastics were applied to the inside ofthe thighs and arms, but the same
medication, in  other respects, was continued.  At evening  there was
pain in the bowels, which was soon followed by an urgent diarrhoea  ten
or twelve discharges happening in the course ofthe night.though four ex- 
41
 tra pilU of Opium, of two grains each, and three enemata of four erains
 of Opium in powder, were given during this time.  This quantity of Opi-
 uu, kept  the  patient from  sinking under these profuse evacuations.
 .Judging from the effects of Calomel in other cases, it is believed that
 the diarrhcea was to be ascribed to that article, which, it will be recol
 lected, was used  at the commencement  of  this  case.  Through this
 night, the patient was generally wakeful, but when he did sleep  he
 sweat profusely ; in consequence of which, the skin became considera-
 bly cooler than it was before, though the tongue became clean, and the
 delirium disappeared.
   July Uth. This morning, the patient was found in an extremely lan-
 guid and weak state, but at the same time free from most ofthe uneasi-
 ness, which had hitherto attended his disease.  The diarrhoea had aba-
 ted, but was not entirely gone.   The same internal  medicines  were di-
 rected that, had been regularly employed the day previous, and an ene-
 ma of four grains of Opium  in  powder, was directed after  every dis-
 charge from the bowels that might take place.  Two only were needed
 before evening.  During this day, the skin became nearly of the natu-
 ral warmth, the tongue became clean, but was very  red ;  and the pulse
 was about 80, in a minute.   The night was passed  comfortably, under
 the same course.   No opiate enema was needed.
   July 15th. This morning there was considerable improvement in the
 general condition ofthe patient, and he was considered so free from dis-
 ease, that the  tincture of Opium, and the liquor ofthe Arsenite of Po-
 tassa, were omitted, and half a fluid ounce of the compound  tincture of
 Cinchona, was directed in their  stead.   The same medication in other
 respects was continued, and the day and night passed well.
   July 16th. The patient still improving.  The intervals  between the
doses of Opium, were now protracted to three hours, and the same was
 done  with respect to the doses ofthe compound tincture of Cinchona.
   July 17th. Still improving.  The same medicines continued, but at
 intervals of four hours.
   July 18th. Still better.  The same medication,  but at intervals of 6ix
 hours.
   July 19th. Still better.  All  the medicines hitherto employed, were
 now abstracted, and the patient was put upon a mixture of  one dram
 of Cinchona in powder, with a glass of wine, four tin es  a day.   The
 petecchiae are not yet entirely  gone, though they are  new fast disap-
 pearing.   The patient now has a good appetite, walks out, and is rapid-
ly recovering his  wonted strength.   Discharged.
           CASE  OF  MISS A---- C----, iETAT. 30.
   This patient had for a long time laboured under Ayer's Dyspeptic or
 Hepatic Marasmus ;  and for several days previous to the attack of her
 disease, had been more or less in attendance, both night and day, upon
 sick friends, beside labouring unusually hard the day in n ediateh preced-
 ing, in  washing.   On that day, she took (without advice) a common ca-
 iharticdose ofthe tincture of Aloes and Myrrh, but it produced no ope-
 ration upon the bowels.
  July 15th, 1825, in the morning, she was suddenly attacked with pain
 in the heel, which by paroxysms, was extremely violent.   During the
remission of this pain, she had hysterical delirium, with incessant loqua-
city, and alternate laughing and crying, without adequate cause.  There
vyasno cnedira*;on at all till 5 o'clock, P.  M. when her physician airiv- 
42
ed.   At this time,  her cheeks were of a deep livid colour, while the
rest of her face was pretcrnaturally pale ; the skin was pretematurally
cool, and rather dry ; the tongue was covered with a slight thin fur, and
ws>s contracted and pointed ;  the respiration was like that  ot a person
who had been making violent bodily exertion ; the pulse  was weak and
soft, and about fifty beats in a minute.   Strong epispastics were imme-
diately applied to the forehead, between the shoulders, and on each
wrist,  Horse-radish leaves dipped in hot water,  were applied to the
feet and legs, and forty minims of tincture of Opium, five of the liquor of
the Arsenite of Potassa, and five of strong Spirit of Pepper-Mint, were
given every two hours.  Hot Spirit and water, and hot tincture of Cam-
phor and water, were given ad libitum.   In this way, about half a pint of
Spirit was taken in the course of twenty-four hours.   Under this medi-
cation,  the patient became much more comfortable, and continued so for
the remainder ofthe day and night.  The sleep was moderate and easy.
the temperature ofthe skin rose nearly to its natural warmth  ; the pulse,
though still weak, was as frequent as seventy-five in a minute ;  all pain
was gone, the delirium was  much less,  the  tongue remained as the day
before, but there was so great torpor ofthe bladder, that the patient was
entirely unable to void urine by voluntary effort.
  July tGth. This morning, the symptoms  were  found much  as they
had been during the evening and night.  Epispastics  were applied to
the inside ofthe thighs, for the relief of the torpor ofthe bladder ; but
in other respects, the same medication was continued.   During the day,
the symptoms  continued pretty much at bay, and before evening, the
torpor ofthe bladder was relieved.  During the night, there was con-
siderable restlessness, and more delirium.
  July 11th. This morning, the tongue was dark red, much dilated and
flabby, and destitute of fur, the skin was considerably cooler, there was
a profuse  and exhausting sweat, the pulse was soft and weak, and  about
a hundred and twenty in a  minute.  Epispastics were  now applied to
each ancle, and two fluid drams of officinal Alcohol,  diluted with a lit-
tle hot water, were directed to be taken every  hour, in  addition to the
previous course.  Through the day, the symptoms remained nearly sta-
tionary.   In the evening, there was considerable epigastric  sinking.  At
this time, an extra dose of two grains of Opium in pill, was administer-
ed.  During the night, there  was but  little epigastric  sinking.  The
other symptoms remained stationary.
  July 18th. This morning, no new symptoms, and the previous ones,
were much at bay.   The same medication was continued.  Till twelve
o'clock, >I. the patient remained  comfortable, and without change of
symptoms.  At this time, there was  a severe paroxysm, of epigastric
sinking, but without any material change in the condition  of the pulse,
tongue, or skin.  A large epispastic was now applied to the  epigastrium,
and an  enema of three fluid drams of tincture of Opium mixed with  a
little hot  water, was administered.   The  same  medication, in  other
respects,  was continued.   Th>  afternoon  passed  more comfortably.
About  9 o'clock, P. M. there  was an  increase of the delirium, with in-
cessant loquacity, which lasted about an heur and a half.  Between 10
and 11  o'clock, P. M. she suddenly sunk into a deep coma, which was
mistaken by the attendants for fainting.   At this time, the skin was cold,
and drenched with sweat, the lips were purple, the respiration was in-
terrupted, and resembled that which is entirely voluntary; there whs
effusion into the bronchia?., throbbing or palpitation of the  carotids, and
other large arteries, but the pulse, though  seemingly full  on a superfi-
cial examination, was extremely weak  and soft.  An immediate  appli- 
43
  c;rtion of Mustard was made to the thorax, frictions were  vigorously-
  employed, and Horse-radish leaves  dipped in hot water, were applied
  to the extremities, but all with little or no  effect.   Life continued  till
  about 1 o'clock, A. M.   Just before death, there were two or three
  slight convulsions, which lasted a few seconds only.*


  CASE OF  MARK  MORTIMER LEAVENWORTH, jETAT.  25.
    This patient was naturally a person of slender constitution and rather
  feeble health.   Having an early taste for literature and science, he was
  originally designed for an academical education, which however, he
  was prevented from obtaining by a disease ofthe eyes, a semi-paralysis
  ofthe optic  nerve,  which was brought on by close application to studv.
  He had been  engaged for about three  years in the study of medicine,
  and was only waiting for the expiration ofthe legal time, in order to be
  admitted to  the degree  of M. D.   Immediately previous to  the time of
  his sickness he was the pupil of Samuel B.  Woodward, M. D. of Weth-
  ersfield, Connecticut, in whose practice he  had  witnessed several cases
  ofthe disease  with which he was so soon to be seized.
    On the 8th  of July, he made a visit  toMiddletown, Connecticut, and
  was invited  to remain a  short time, as an assistant to  one of  the phy-i
  cians of that place, who  had more cases ofthe epidemic under his care.
  than he could well do justice to alone.
    Tuesday,  July 12th,  1825. After about three days attendance upon
  the  sick in  this place, he complained about 9 o'clock A. M. of pain in
  the bowels, which was  soon followed  by a  free liquid discharge, that
  produced great languor and sense of weakness.  Two fluid drams of
  camphorated tincture of Opium, obviated these symptoms, and prevent-
  ed any further evacuations from the  alvine canal.  About  12  o'clock
  M. while visiting a patient, he was suddenly seized with great vertigo,
  accompanied with faintness or sinking at the stomach, which were spee-
  dily relieved  by three or  four fluid  drains of compound  tincture of
  Cinchona.   Upon this,  he immediately rode home, and soon after ate
  with much relish, a full dinner.  The  vertigo, and faintness  or  sinking
  at the  stomach, occurred at intervals through the afternoon, and con-
  fined  him to the house, but not to his bed.   The paroxysms, however,
  were readily relieved by a little Brandy and water.   During the whole
 of this time,  the pulse, tongue, countenance, and skin, exhibited no ap-
  preciable deviation, from their customary, healthy  state.  Towards
 evening he walked out a few rods, but was seized with faintness, which
 caused him  to return and take to his bed, from which it is believed, he
 never  arose without assistance.  In the evening he took a cup of tea, a
 little Brandy and water, and a single grain of Opium, which greatly re-
 lieved the vertigo, and  epigastric faintness  or sinking, the only symp-
 toms of which, at this time, he complained.   During the night,  he took
 moderately of Brandy and water, or of compound tincture of  Cinchona,
 as often as these symptoms occurred, and invariably, with  material re-
 lief.   There was but little sleep, and that much interrupted.
   Wednesday, July IMh.  In the course, of this morning, there was dou-
 ble vision, the  vertigo und epigastric faintness or sinking became much

   *In each ofthe preceding cases, much injury was invariably produced by mo-
 ving or raisin* the h^'ad, while the  patient was in the lowest state.  Epigastric
 sinki'ig- was the certain consequence.  In general,  the  head was not  shaved ant
 Mistered sufficiently early.   \s this process is attended with trouble, it is usualV
 defcrre 1 so lonx as not to produce it? lull effect. In the worst rases, all the mot'
efficient means  diould be employed, with the loa=t possible delay. 
44
worse, and there was total inability to raise, or even  move the  head,
without great aggravation of these symptoms.   The pulse was still  na-
tural, as  respects  frequency and force, but had  become  quick ;  the
skin was also natural, both as  respacts temperature and moisture ;  but
the tongue  had become flabby and p-de, and was covered with a thin,
light coloured fur ; and the respiration was like that of a person who
had just been making considerable bodily exertion.
  It was now judged necessary to enter upon a regular course  of medi-
cation, and the patient was accordingly put upon one  grain of Opium
every two hours,  with  three  fluid  drams of  compound tincture of
Ginchona, and about the same quantity of Brandy suitably diluted, eve-
ry hour.   A little wine was  occasionally taken  at the pleasure of  the
patient.
   During this day, the symptoms were much less perfectly controlled,
than they had been the night previous.  Towards evening, and through
the night, there was considerable disposition to  vomit, with occasional
retching, for which about four extra pills of Opium, each consisting of
two grains, were taken at irregular intervals, and uniformly with great
relief.  During the night there was but little sleep, and that imperfect
and unrefreshing.
   Thursday, July 14th.  Double vision, vertigo,  and epigastric  faintness
still continue,  but with some  abatement, especially of the last.  The
pulse, skin, and tongm>, are much as the day before, but the respiration
is nearly natural.  During  the  regular morning aggravation of symp-
toms,  epispastics were applied to the  forehead, and the sides of  the
head.  The aam- quantities of Opium and  Alcohol, that were  used  the
diy before, were continued.   In the afternoon, without any apprecia-
ble change in the external symptoms, the  patient felt more comforta-
ble, but on account of a slight uneasiness in the  bowels, a casual medi-
cal visitor advised a laxative enema.  Instead  of this, one of a dram or
tw> of laudanum was given, which instantly relieved.  Although  there
was neither fulness nor  hardness of the abdomen, even in the slightest
degree, but on  the  contrary, a perfectly soft,  and rather  lank  state,
yet some hours afterwards, this advice, at the  wish of the patient,  was
complied with,  and a decoction of Tausey and Ginger, to which  was
added a little  common  salt and lard,  was administered.  About  this
time, from the suggestion of a counsellor of much experience,  and good
judgment in such ca>os, an aromatic  infusion of Gentian,  was substi-
tuted for water, for the  purpose of  diluting the compound tincture of
Cinchona,  and instead  of the Brandy and water, a table spoonful of a
mixture of equal parts, Brandy, Lime-water,  and boiled milk was  em
ployed.  As after some hours, the same uueasiness in the bowels re-
turning, and no evacuation having taken place, another enema, prepar-
ed in  the same manner as the first, but with  the substitution of a fluid
ounce of Castor Oil  for tb« lard, was administered.  About half an
hour from  this time, there were two moderate evacuations, which were
imnediitely followed by a considerable increase of vertigo,  and  epi-
gastric faintness, troublesome palpitation of the heart, aorta-descendens,
and carotids, great restlessness, and slight delirium, together with a dif-
ficulty of retaining any thing upon the stomach.   On the occurrence of
thea-i  symptoms, an enema of two fluid  drams of tincture of Opium
diluted with a  little tepid water, was immediately  administered, an
epispastic  was applied to the region of the stomach, and the regular
dose of Opium  was  increased  from  one grain, to a  grain and a half.
On account ofthe  irritability ofthe stomach,  it was necessiry to  omit
the compound tincture of Cinchona, and the aromatic bitt«r infusion.
and to get  down the mixture of Brandy, Lime-water, and boiled milk. 
45
a? the stomach  would receive it, but without any regularity.   During
the night, several extra pills of Opium, of two grains each, were given
at irregular  intervals, as  the urgency  of symptoms  required.  Under
this course, there was a considerable abatement ofthe immediate urgency
of the symptoms, and upon the whole  the patient  slept considerably
more, than tor any night previous, though the naps were short, and the
patient was easily roused.
  Friday, July  15th. This morning the patient was better than the eve-
ning preceding, but not so well as the morning previous.  The verti-
go was  still considerable,  and  there  was total  inability to  move the
head, without great  augmentation of it.   There  were, however, only
occasional paroxysms of epigastric faintness, and  these very moderate.
Troublesome palpitation  of the heart, aorta-descendens, and carotids,
occurred occasionally, always accompanied with  considerable restless-
ness.  The skin was cool, and very sweaty, and the pulse was soft and
feeble, and as respects frequency, it fluctuated between 80 and 110.
   A grain and a half of Opium was  now given, every two hours ; and
every fifteen minutes, a table-spoonful ofthe mixture of Brandy, Lime-
water,  and  boiled-milk.    Nourishment hitherto, though  taken with
considerable freedom, had been given rather irregularly.  Chicken
broth had been tried, but milk-porridge was preferred.  A table-spoon-
ful ofthe latter was now  directed to be invariably taken after  each dose
of the Brandy mixture, and frequently a table-spoonful of  Coffee, wai
allowed in addition.   During this day, in consequence of special exa-
cerbations of the vertigo, palpitation,  and restlessness, three enemata,
each consisting of two fluid drams of tincture of Opium, and two ex-
tra pills of Opium of two grains each, were necessarily administered,
each of which produced the  most obvious  relief of the symptoms for
which they were employed,  for the space  of two  hours.   This day
there was so great torpor ofthe bladder, as to prevent a voluntary dis-
charge  of urine, but when the catheter was employed, this  excretion
w-is  found to be natural,  both  in appearance and quantit}'.   As extra
doses of Opium  wore so  often necessary,  in order to meet urgent
symptom*,  it was this evening judged expedient to  increase the regu-
lar close (which was given every two hours,) to two grains ;  and on
account of a disrelish for the taste of Brandy, old Spirit was substituted,
and a mixture was made,  of two parts Spirit, one part Lime-water, and
one  part boiled milk, which was likewise given in doses of a table-spoon-
ful, and followed by the  same quantity of milk-porridge, and occasion-
ally  the same of Coffee    The night passed much more comfortably
than any previous one. since  the commencement ofthe disease.  The
sleep during the whole twenty-four hours, was less than natural, but
more quiet and refreshing than it had ever been before.  It was still
necessary, however, to  keep the  head  low, and motionless.  During
the dav and night of the  15th, the patient vomited but twice.
   S'/turday, July 16th. This morning, the symptoms  were more at bay,
and the patient more comfortable,  than any morning since the attack.
During  the customary apyrexial aggravation of the forenoon,  beside
restlessness  and  palpitation,  there was  some delirium.  An enema of
two  fluid drams of  tincture of Opium,  was immediately administered,
the whole top of the head was shaved, and a strong epispastic was ap-
plied.   The. enema not  proving sufficient, two extra pills of Opium,
of two grains "acb, were  given, before the  restlessness and palpitation
were obviated.   When the epispastic  began to produce its effect upon
the surface, the delirium  speedily disappeared.   In the afternoon, there
was a very obvious mitigation  of all the symptoms, and the patient was
still more  comfortable, than in the morning.  For the first time  since 
46
 the attack, the patient was now carefully lifted to anothei bed.  This
 produced a considerable aggravation  of the vertigo, and a recurrence
 of the epigastric distress  and palpitation,  for which, there was given
 with  speedy relief, an extra pill of two grains of Opium, and an enema
 of two fluid drams of the tincture.
  Sunday, July  nth. This  morning, the symptoms in  general were
 alleviat-.-d still further, than on tli3 morning previous, though there wa*
 still  inability to  move  the head without troublesome  vertigo.  The
 regular forenoon deterioration required this day, for its relief,  two  ex-
 tra pills of Opium, of two grains each   At this time, it was judged expe-
 dient to enter upon the use of the Liquor of the Arsenite of Potassa,
 as a  supportive  and  invigorating agent, and  accordingly two  minims
 were given with every regular dose of Opium.  Otherwise the course,
 both as respects  medicine and nourishment, which had bien pursued
 for the two days previous, was continued.  The night passed as com-
 fortably as any one since the attack, if not more so.
  Monday, July \8th. This morning,  as for three mornings preceding,
 there was a mitigation ofthe symptoms, in comparison with most ofthe day
 previous.  The  forenoon aggravation however, required two extra pills
 of Opium, of two grains each.  During the day, some uneasiness in  the
 bowels was complained of.   On examination,  the abdomen was found
 to be still free from hardness, fullness or tenderness, but on the contra-
 ry, it was  actually  soft and  lank.   An  enema  of  two fluid drams
 of Opium, entirely obviated all complaint.   This day passed* comforta-
 bly, as there was less vertigo, palpitation, and restlessness, than usual.
 Toward evening, the patient was again removed to another bed, which,
 as usual,  occasioned  a recurrence of  troublesome symptoms, viz. ver-
 tigo, palpitation and restlessness,and rendered another enema of two fluid
 drams of  tincture  of Opium, and an extra pill of two grains, necessary,
 before the patient could be rendered  as comfortable as before.   In  the
 course ofthe afternoon vomiting happened once, and  that not long after
 a dose of the Liquor of the Arsenite of Potassa.   As the patient confi-
 dently ascribed  this  effect to that  medicine, though  probably  without
 reason, it was  judged expedient to discontinue it.  The night  passed
 comfortably, and without any extra doses of medicine.   The regular
 course was continued unchanged.
  Tuesday, July  19th. This morning  the patient was much as  on the
 preceding.  For the purpose of anticipating and preventing the usual
 forenoon aggravation, an  enema of two fluid drams of tincture  of Opi-
um, was given early,  and with the desired effect.  No extra pills were
found necessary.   About noon, the patient was visited for the. first time
during his sickness by his father who lived at a distance.   The agitation
pro luced by this meeting,  rendered another  enema of two fluid drams
of tincture of Opium  necessary, in order to allay the increased vertigo,
p ilpit ltion and restlessness.   The regular medication was continued  un-
changed.   This  night, for  the first time,  was bad attendance.  The
wit~h>r slept, and of course was irregular, and repeatedlv neglectful, in
administering both  food and medicine, and finally left the house where
tli • p itient was,  before either the nurse or the family were up.
  ll'rdmsday, July 20th. The patient was worse this morning,  than on
rmv morning since the fifteenth.  From that time to  the present,  the
pulse  hid  varied  in frequency, from eighty, to a iiundred and twenty, in
a m-nuie,  and hid been soft and weak.  The  skin had been somewhat
cooi -r thin natural, and rather more sweaty than was desirable.  The
quantity of si ^ep for the twenty-four hours together, on the whole,  had
bee:- b-~ than m health, but it consisted of *!io;-f, quiet, and app irentlv 
                               47

refreshing naps, from which the patient was easily  ronsed.  If suffer-
ed, however, to continue more than about ten minutes,  they became
laborious, and seemed to produce fatigue and exhaustion.   During this
period, the tongue had gradually assumed a thin, but close,  sordid, and
brown fur, which, however, was  uniformly moist.   No  special thirst
had been complained of.  The aggravation of symptoms at the present
time, consisted in increased  vertigo, palpitation, and restlessness ; in
reduced temperature of the skin ; and in an increase ofthe frequency
ofthe pulse, to about a hundred and thirty in a minute.   An extra pill
of three grains of Opinm, and an enema  of three  fluid  drams of the
tincture, were given in the course of the forenoon, with the effect of
restoring the  patient, very nearly if not  entirely,  to the situation in
which he was, the day previous.   During the day, it was judged expedi-
ent to take some  measures towards moving  the bowels, not because
there were any further indications for this step from the  condition of
the bowels themselves, but merely from the length of time they had
remained unmoved.   In reference to this point, simple water was sub-
stituted for the Lime-water  in the Spirit mixture, and about a scruple
ofthe Carbonate  of Magnesia was given at a dose, three times, at nearly
equal intervals, during the day.   As however, the  patient  complained
in each instance,  after taking it,  of considerable uneasiness  in the stc-
mach, and as  there was an increase of  the vertigo, languor, and restless-
ness, during, the afternoon, contrary to the usual course ofthe disease,
and as the tongue was gradually becoming more flabby, and as the edges
from which the fur was now beginning to be removed, were more pale
than at any time previous, it was on the whole judged expedient, to re-
linquish the Carbonate  of Magnesia, before it should produce any  eva-
cuation, and to add ten minims of strong Spirit of Pepper-Mint, to each
dose ofthe Spirit mixture, and likewise to administer an enema of two
fluid drams  of tincture  of Opium.  The latter part of the day, the
patient was as comfortable as usual, till just at evening  another aggra-
vation of symptoms was produced, by changing the shirt.   This  ren-
dered another extra  pill, of two grains of Opium, necessary, and another
enema of two fluid drams of the tincture.   About  11  o'clock, P.M.
the patient was consigned to the care of the attendant for  the night, iu
as favourable a condition as had  been usual, at that  time,  for  several
days.   About 1  o'clock, A. M.  a physician,  who slept in an adjoining
chamber, was called, on account of a slight discharge of blood from the
ureflira, in consequence of the introduction of the catheter, which had
still continued to  be necessary, though it had always been performed by
the patient himself.   This  symptom being explained to the satisfaction
of the  attendmt, the general condition of the patient was examined.
Unexpectedly, the  pulse was now found to be very small, weak, and
■soft, and as frequent as  a hundred and sixty in a minute,  the beat  being
peculiarly short  and quick.   The  temperature was soon considerably
reduced,"the  countenance became sunken, there was increased vertigo,
and a confusion of mind, almost amounting to delirium.  An extra pill
of Opium, of two grains, was immediately given ; and the regular dose
was increased to  three grains.  The Spirit and  nourishment, were con-
tinued as heretofore.
   Thursday, July 21st. This morning, the patient was in  a very low
state ; but in  comparison with the latter part ofthe  night, somewhat im-
proved.  Two grain- of Opium, were now given every two hours ; and
at every intermediate hour, forty minims ofthe tincture, in  conjunction
with five minims of spirit  of Cinnamon.  Two additional  epispastics.
were applied to the sides of the head.   Through the day, the symptom?
remained nearly  stationary.  At evenimr. the patient was in a very low 
48
state.   During the night,  he vomited several times; after which, for a
few moments,  there would be furious delirium.   During the whole
time, there  was great restlessness and jactitation.   Toward  morning.
there was a kind of epileptic tremor;  after which, and about sunrise,
   Friday, 22d July, dissolution took  place.
                              REMARKS.

  In connexion with the statement ofthe preceding case, it ought to be remarked,
that from the fact that Mr. L. had a physician constantly by  him,  his symptoms
were barely met and obviated as they occurred, but were rarely or never antici-
pated and prevented, which is always necessary to insure a favourable crisis in
the bad cases.  At any rate, the treatment was always a little behind the progress
of the case.  It is  not however very probable,  that he could by any means have
been saved, considering the slender uess of his previous health, the feebleness of his
constitution, and the severity of his disease.  Notwithstanding these circumstan-
ces, so powerfully were  the symptoms met,  between the third day and the ninth,
that strong hopes were entertained  of his recovery.   Indeed, most of the time
from the attack to the final sinking on the ninth dty,  a physician not conversant
with the disease, on a call of ten minutes, would have been liable to form a very
erroneous judgment ofthe real danger of the case, on account of the  promptness
with which the symptoms were met, and the degree with which they  were capa-
ble of being controlled.   On close inspection, a considerable number of petecchiae,
were visible on the face and neck, but they were not so prominent as  in many other
cases.  This case, as well as the preceding, occurred in the hottest season ever
known in this climate.  In spite of every effort to preserve a comfortable tempera-
ture, in the rooms of the sick, the mercury of the thermometer stood from 90° to
94°, several hours every day, for a great part of the month of July, 1825.
  It may be proper further to remark, that in so much of the preceding cases, as oc-
curred from the 8th to the 12lh of July, 1825, great assistance was received, in mak-
ing out this report, from the very accurate minutes made on the spot by our deceased
friend, who for that short time, proved to be a very valuable assistant to  the  at-
tending physician.
  Since the.prevalence ofthe present epidemic in this and the  adjoining towns, it
has proved very fatal to  the medical profession. Dr. Warner at Haddam,  Mr.
Leavenworth in this City, Dr. Catlin, at Durham, and Dr. Ward, at Berlin, hav«
all fallen victims.
  Previous to printing the addenda, the following letter was received from that
veteran practitioner and author, the venerable James Thatcher, M.D.A. A.S.
of Plymouth, Mass. the friend and medical  associate of Brooks and Eustis,
under Washington, and author of the American Dispensatory,  and ofthe
American Modern Practice, &c. &c.  &c.
  Thomas Miner, M.D. Middletovvn,  Connecticut.
                                        Plymouth, August 18th, 1825.
             Dear Sir,
    Through your  politeness, I have been favoured with your ingenious
pamphlet on  T'ijphm-Sijncopalis, for  which I beg leave to  proffer  my  re-
spectful acknowledgments.  Not  having been fully satisfied with any trea-
tise on that formidable disease, I commenced the perusal  of yours with pe-
culiar interest and solicitude.  From a knowledge ofthe medical character
ofthe author, my expectations were such as to excite a particular attention
to every sentence, and permit me to indulge my feelings, by expressing niv
unqualified praise and approbation.  Your just description ofthe disease iii
its various forms, and judicious mode of treatment, afford  me a peculiar sa-
tisfaction, and I hope the book will be extensively circulated, both on ac-
count ofthe author, and the instruction which it cannot fail to impart to
the young and inexperienced practitioner.   I shall take pleasure in putting
it into the hands of my neighbouring physicians, and presume it will escarr
the  hand of criticism to unjustly bestowed on a former occasion.
                      I am with much respect,
                            Your obedient servant,
                                             JAMES  THATCHER 
 
NATIONAL
4145434 4
NLM041424344