Or fevers of the remitting kind accompanied with bi|lious evacuations, prevail more universally than any other kind, and although they are not so dangerous, or mortal, as pestilence or typhus, yet from the uni|versality of their sway, and the frequency of their oc|currence they destroy greater numbers in a course of years, than any other kind or form of fever.
During, or soon after the periodical rainy seasons of the torrid zone, especially where the soil is moist and Page 2 unsheltered from the parching rays of a vertical sun, and abounds with putrefying vegetable and animal sub|stances. Fevers of a remitting type with reternatural excretions of bile, often occasion mortality almost equal to that of the Asiatic plague.
This fever not only destroys the majority of new settlers in such situations, but renders •he constitutions of those who escape with life, infirm the remainder of their days.
In many parts of Europe, particularly where the si|tuation is flat, and the soil moist, this fiend stretches his baneful scepter over the sickening land, the whole autumnal season.
Along the Tyber in Italy, and on the flat grounds of Hungary in Germany, where the summers are long, and the heat extreme, bilious remitting fevers are the most fatal in the catalogue of diseases. Holland, which is little better than an extensive morass, though situ|ated so far north, is periodically visited by the bilious fever. It also extends its sway to many parts of Eng|land and Ireland. Nor is the continent of North America exempt from its baneful power.
Throughout all the low grounds from Canada to Florida, this distemper infests the country at stated periods.
That the bilious fever is only a variety of the inter|mitting fever, altered in its aspect and symptoms by climate, season, soil, and the sensible qualities of the atmosphere, &c. is rendered certain, from its prevailing in similar situations and states of the weather in all countries.
Thus, in the low grounds of some of the Provinces of Germany, those fevers which owe their origin to the effluvia derived from a moist and putrid soil, appear in the form of simple tertians, or distinct quotidians, while in Hungary where the ground is more level, and the atmosphere almost motionless for want of hills to con|duct the winds, the fever produced by the same ex|halations, appears in the form of a remittent, with ma|lignant symptoms and excessive bilious evacuations, which in its progress, unless speedily relieved by na|ture Page 3 or art, degenerates into a state of extreme debility, and displays symptoms exactly like those of the most malignant typhus, or putrid fever as it is commonly called, occasioned by contagion.
In Italy, a fever the same in kind, but differing in degree of violence, often appears in the shape of a double tertian, or irregular remittent, and is often at|tended in its progress with pitechiae or purple spots, and apthous ulcerations in the mouth and fauces.
In Holland the same occasional or efficient cause, produces a fever with distinct intermissions every, or every third day.
In Ethiopia, and in all that tract of country from Sues to Babel Mondel, it gives the disease the semblance of the pestilence in its most malignant form.
In America, as well as in other countries, the fevers which are occasioned by the air of marshes, or the effluvia of putrefying vegetable or animal substances, are amazingly influenced in their aspect and symptoms, by the soil, situation, climate, season; and by the pre|ceding and present qualities of the atmosphere, and the customary mode of living of the inhabitants.
In the nothern states, fevers from the recited cause, are seldom epidemic, though cases of remitting fever are by no means rare in those states, in marshy situa|tions during the autumnal months, but they mostly ap|pear in the form of intermittents. In the middle states remittents with bilious evacuations are very common, but seldom very complicated or malignant, except when the preceding spring and summer have been moist and sultry. Neither dry and hot, or wet and cool sum|mers, have been observed to render this kind of fever either general or malignant: On the contrary, when it does occur after such seasons, it is generally con|nected with an inflammatory diathesis, and requires blood-letting and purging, repeated as often as the symptoms resume any appearance of violence, as well as the strict observance of the antiphlogistic regimen, to reduce it to its natural and simple form. But in Vir|ginia, North and South Carolina, and Georgia, where the heat is more intense, and the soil more putrid, along Page 4 the shores and ouzy banks of large rivers and ponds of stagnant water, particularly after the rice harvest in September and October, when an extensive surface of moist soil is exposed to the piercing rays of the sun, a fever of the remitting kind is generated, which exhibits symptoms of alarming debility and malignancy; and yet, there is not one instance on record, of this fever however malignant and mortal it may have been to the persons affected by it, ever being contagious, or of having communicated a fever distinguished by the same assemblage of symptoms, from one person to another.
The authorities quoted by Dr. Rush, of its being contagious in other parts of the world, shall be exa|mined in the course of these observations.
From the influence of climate and situation upon the constitutions of the inhabitants, it is reasonable to expect, that a diversity in the treatment of the same disease would be requisite. The suggestions of reason are in this instance, supported by the observations of authors of the most extensive experience and sagacity; among these may be mentioned, Baglivi, Ziminerman, Pringle, Tissot; and of more recent date, Lind, Bruce, and Jackson.
That diseases the same in kind, differing only in de|gree, require not only a treatment differing in degree, but in kind, we learn from the medical writers of dif|ferent countries.
Thus we are informed, that the inhabitants of France bear bleeding without injury, and often with evident benefit, in almost every form of fever that occurs there; while in Italy it is thought to do injury in almost every case of fever. Emetics, and other evacuants, agree with the constitutions of the Germans, while sudorifics and cordials suit best to animate and warm the phleg|matic Hollander.
Blisters, volatiles, aromatics and wine, are of use in the remissions of the fevers that prevail in the autumnal season in the south of Europe, as well as in the southern states of America, during every period of the disease. But in the northern states they are seldom admissible, Page 5 till the vigor and tension of the arterial system has been reduced by blood-letting, purging, refrigerating drinks, and abstinence.
Physicians should therefore always compare the cli|mate and soil of the country where an author has been in habits of making his observations, with those of his own, before he submits to be governed by his rules or advice.—Unless he does this, he will be at a loss to know whether the practice of the author he may have occasion to consult, will apply to the diseases where he resides or not.
It also requires great caution as well as discernment, to avoid being misled by the plausible theories of spe|culative and fanciful authors. For instance, who, after reading in one of those authors, that every fever owes its existence and continuance to a state of debility; that it is aggravated by debilitating powers, and that purgatives of every species are debilitating powers, would venture to employ a medicine of this class, in the cure of any kind of fever? Yet in hot climates, where extreme and constant heat, and a variety of other circumstances, are said to be constantly conspiring to encrease the supposed cause of the disease (debility,) there is nothing more common, nothing more benefi|cial, than the frequent employment of mild purges in remitting bilious fevers.
Or who that reads, that a convulsive state of the ar|teries is the proximate cause of every fever, whether, pestilential, typhus, intermittent, or remittent, and that copious blood-letting and purging are the best remedies in one variety of fever arising from the same origin, viz. stimulus with all the other varieties, would hesitate to employ the same remedies without measure or re|serve, in every form that can possibly occur.
Intermittent and remittent fevers, as well as fevers accompanied with local affections, are greatly influen|ced, not only by the climate and soil, but by the season and sensible qualities of the atmosphere.
Sir John Pringle remarks, that "In Holland towards June, (a healthy month;) Inflammatory fevers begin to recede, and that bilious remitting and malignant Page 6 fevers often succeed, and continue throughout the sum|mer and autumn, until the return of winter, when in|flammatory fevers recommence; the seasons and dis|eases interchanging and running into each other."
Dr. Monro relates, that "The first time he saw much of the remitting fever in Germany, was about the end of June, soon after the army took the field. At that time the remissions were short, and the fever partook much of the nature of the common inflammatory fever, and most of the sick were cured by blood letting, and other antiphlogistic remedies.
"After the middle of June, the fever did not partake near so much of the inflammatory nature as before;— the remissions became much more evident, and it was attended much oftner in the beginning with bilious vomitting and purging, and in some few the disorder turned to a dysentery.
"A few had it changed into a continued putrid fever, from the wards in one of the hospitals being too much crowded—and in some few it terminated in regu|lar agues. In November several were taken ill of the remitting fever in the garrison of Bremen, which mostly ended in a regular intermittent, the endemic distemper of the place."
"In June 1762, the remitting fever began to appear again among the troops at Natzungen, and continued to be frequent through the summer and autumn. The greatest part terminated this year in regular agues, mostly in tertians, and were cured by the bark, whereas the year before, very few terminated this way."
(This is a clear proof of the influence of climate and soil upon the constitution, and of the power of consti|tution in modifying disease.) "Most of those ill of this fever, had a yellowish colour of the countenance, which went off with the fever; in some more observa|ble than in others; in general it was slight; some few become yellow all over."
Dr. Pringle has also taken notice of this yellowness sometimes occuring in cases of remitting fever, and re|marks, that it was found more frequent during the first campaign, than afterwards.
Page 7Dr. Lind, the most experienced physician of the pre|sent age in febrile diseases, relates, that "The years 1765 and 1766, were distinguished by an uncommon appearance of intermitting and remitting fevers in most parts of England, one obvious cause of this was the unusual frequency of the easterly wind, (which con|trary to what it is in America is always dry and hot in that climate.)
"The year 1765 was remarkable, not only for the long continuance of easterly winds, but also for an ex|traordinary degree of heat: In the month of August, the thermometer was often as high as 82° in the mid|dle of the day. This considerable addition of heat, to|gether with the want of refreshing rains, greatly spread this fever, increased its violence, and in many cases changed its form.
"The violence of the fever, with its appearances in an intermitting, remitting, or a continued form, mark|ed as it were the nature of the soil.—In Portsmouth, its symptoms were bad, worse at Kingston, and still more violent and dangerous in a street called the half|way-house, where the situation of the houses are low and damp.
"A constant pain and giddiness of the head, were the most inseparable and distressing symptoms of this disease: some were delirious; and a few vomitted up a quantity of bile, and in all, the countenance was yel|low. The universality of this fever, together with its uncommon symptoms, were at first alarming; but when the lancet was withheld, and the bark given ple•tifully in large doses few died.
"The disease decreased with the heat of the weather, and in the winter appeared chiefly in the form of a quartan ague*."
We learn from the Observations of Dr. R. Jackson in his treatise on the Fevers of Jamaica, that the season of the year has considerable effect upon the diathesis of the system, and consequently upon the type, or form of Page 8 the fever, even within the tropics. Thus in the dry season (from December to April) though the remissions are not always more perfect, the type is commonly more simple, and the general diathesis more inflamma|tory. In the rainy months, remissions are more distinct, but the type is more complicated, and the general dia|thesis has a strong tendency to putrescency, and often with symptoms of nervous affection. The stomach, bowels and liver, likewise suffer more in this season than in the dryer months of the year. Besides this difference which arises from season, we also find very constant effects from local situation. Thus in hilly dis|tricts there is more of the inflammatory diathesis, with more frequent determination to the head and lungs, and less distinct remissions than in flat and champaign countries, where the stomach and biliary system suffer in a remarkable manner."
This effect of season and soil, is still more remarkable in the intermitting or remitting fever of the United States of America. In the spring and beginning of summer, the double tertian or remitting fever, is the most usual type of fever in the marshy tracts, and low grounds, in every part of the Union, and the remissions are short and imperfect.
In the months of August and September, and part of October, quotidians, and fevers with very imperfect and obscure remissions are more prevalent than any other forms or types. As the autumn advances, single tertians and remittents, with inflammatory symptoms become most prevalent.
Besides the changes, produced in the type and symp|toms of fevers produced by the air of marshes, or the effluvia of putrefying vegetable substances by the change of season, and the condition of the soil, climate has a considerable effect upon it—For on York-Island, the type is generally, even in the heat of summer, single tertian. In Georgia, the single tertian is the prevailing type only in the winter and spring.
In summer and part of autumn, double tertians are common; and types of a still more complicated kind frequently make their appearance in certain situations Page 9 of all the southern states. Dysentery, dropsy, and fe|vers accompanied with malignant symptoms, are like|wise more frequent in the southern, than in the eastern or middle states; and the course of the fever in the former in general, is more certainly checked in its early stage by the Peruvian bark, than in the latter.
Virginia lies about half way between New-York and Savannah, and the general effects of its climate on the common endemic of the country, corresponds in a great measure with its local situation. Deviations from the tertian type are more frequent here than in New-York, but less so than in Georgia.
SPORADIC CASES of remitting fever occur at Phila|delphia, in the spring, and early part of summer. Du|ring those seasons, they are generally accompanied with inflammatory symptoms, and the remissions are very imperfect and obscure for the first three or four days, after which they become more evident, and in a few days more, unless prevented by improper treatment or conduct, change to complete intermittents, which are readily removed by the use of the bark.
In the cases which occur in the vernal and summer seasons, bilious symptoms are seldom observable, ex|cept at the accession of the fever, or with those symp|toms which usher it in.
Nausea and occasional puking, are common at the accession of every species of fever, whether inflamma|tory, nervous, or intermitting: Under these circum|stances more or less bile is generally ejected, but as this is merely the effect, and not the cause of the vomiting, and as the evacuation of bile in any form or variety of remitting fever, is only a symptom, and not a cause of the disease, there is no propriety in naming the fever bilious, in which it only occasionally and under parti|cular, or accidental circumstances becomes a predomi|nant symptom. With the same propriety it might be denominated inflammatory in those cases where the pulse is strong and quick, the skin hot and dry during Page 10 the exacerbations, though the remissions be regular and distinct.
In both forms the fever is derived from the same occasional cause, miasmata, operating on constitutions, differing only in diathesis.
The paroxisms of pure intermitting fevers are always finished in less than twenty-four hours;—so likewise in remitting fevers, though the hot and sweating stages of the paroxism do not entirely cease before the expiration of twenty-four hours from the accession of each pa|roxism; they always suffer before that time, a consider|able abatement or remission of their violence; and at the same period every day, or every other day, a paroxism is in some shape renewed, which runs the same course as before.
When it happens, and in certain circumstances this is often the case, especially in an advanced state of this fever, that the remission is imperfect, is perhaps with|out sensible perspiration, and that the returning parox|ism is not marked by the most usual symptoms of a cold stage, but chiefly by the aggravation or exacer|bation of a hot stage, it is difficult to distinguish the disease from that species of fever denominated typhus, occasioned by contagion, or human effluvia.—But if these have passed from an intermitting or remitting form, to that of a continued one, and still shew some tendency to become intermittent once a-day, or at least every second day, and there is no foundation to suspect exposure to contagion or human effluvia, and if they have but one paroxism in the course of twenty-four hours, they certainly ought to be considered and treated as remittents. For "Continued fevers which arise from contagion, shew little tendency to become intermittent or remittent, in any part of their course, and especially after the first week of their continuance, and have pretty constantly an exacerbation, and remission twice in the course of every twenty-four hours."*
Page 11Two circumstances diametrically opposite in their nature, appear to occasion the remitting fever, to assume a continued form, viz. a phlogistic diathesis, and a de|fect of power in both the nervous, and vascular systems, —•n the one state, the actions produced in the circu|lating vessels are preternaturally strong and quick, in the other they are preternaturally weak and irregular.
Inflammatory topical affections are very apt to occur during the season when remittents and intermittents are prevalent, upon any sudden change of weather to a colder state; particularly after rain has continued for three or four days, which is very common at, or soon after the autumnal equinox. In these cases, the re|missions of pain and fever are more observable every morning, than when they occur in winter or spring; which evinces that they are either connected with the cause of common intermittents, or that the constitutions of people are disposed, at that season to take on an in|termittent or remittent form, notwithstanding the pre|sence of the stimulus of inflammation.
When the small pox becomes prevalent, either in the natural way or by inoculation at the same season, the fever with which it is accompanied frequently as|sumes the remittent form. And even the malignant yellow fever which prevailed in 1793, did the same in numerous instances, though it had few symptoms in other respects like those of a common remittent, and differed from it essentially in its origin, nature, cause, and manner of attack.
The celebrated Sydenham (who, by the by, was a very erroneous philosopher) misled by vague and erro|neous notions, respecting influential constitutions of the atmosphere (which he ascribed to some secret and inex|plicable alteration in the bowels of the earth, or to the influence of the planets;*) held an opinion that the reverse of what I have assigned, took place when the Page 12 small pox or plague prevailed: "For these," says he, "either banished all other diseases, or compelled them to wear their livery; that is, they assumed their type, and leading symptoms, and required the same kind of treatment:—An opinion totally incompatible with facts and later observations. An author of more modern date, from confounding epidemics derived from con|tagion, with those from season, and soil, has also fallen into the same error."
It has been, and is still the opinion of several phy|sicians of respectability, not only in Philadelphia, but also in Baltimore, New York, and Boston, that the contagious yellow fever which has prevailed during the summer and autumnal months, in several of the sea|port towns of America, since the year 179•, is the same in kind, differing only in degree with the common bi|lious remittent; and because the season was dry, and uniformly warm when it prevailed at Philadelphia in 1793; its contagious quality was ascribed to that cause, and when it prevailed at New York in 1795, because the weather was remarkably wet at that time, it was as preposterously ascribed to that circumstance.
It is not only rational to suppose, but many facts favour the opinion, that when no other disease appears in the place where a contagious disease prevails, that the season or sensible qualities of the air, or exhalations from the soil at that time, are not favourable to the ge|neration of the diseases usually endemic at that season. It is impossible that the contagion should have the ef|fect of banishing them, as it can have no effect upon the quality of the air, to any extent from the bodies of those with the disease. Facts relative to the state of the weather at New York in the autumn of 1795, and at Philadelphia the present year, viz. 1797, which were wetter and cooler than many preceding seasons had been, as well as those contained in almost every mo|dern medical author, establish this.
It is merely owing to a change in the sensible qua|lities of the air, or to the removal of the various efflu|via, or impurities with which it is occasionally mixed, that one epidemic succeeds or takes place of another, Page 13 and not to the influence of one epidemic over another. For example: In the warm and impure air of autumn, when intermittents prevail, pleurisies are rare, but on the approach of winter the intermittents decline, and pleurisies increase. Is this owing to the influence of the one disease over the other, or is it owing to a change in the sensible qualities of the air? That fe|brile diseases derived from contagion, and those from marsh effluvia, often prevail in the same place, and at the same time, is known to every person acquainted with medical history. Even Sydenham has recorded instances, (though they contradict his doctrine of occult causes) of several diseases different in kind, being epi|demic in the same place at the same time *. Change of season always banishes some kinds of disease, and fa|vours the generation and propagation of others. This is so simple and obvious, that none but a man wedded to the most extravagant theory, would have looked into the bowels of the earth, or up to the stars for the cause.
When however I reflect that philosophy was only beginning to emerge from gothic darkness, in which it had long been sunk, at the time Sydenham published his observations; I am willing to make due allowance for his errors:—But the present aera, when philosophy has arrived at a state of improvement, which approaches to perfection, such errors are not entitled to the same toleration.
I shall now transcribe a few remarks from other au|thorities, which will remove every doubt, that two con|tagious diseases, different in kind, may prevail in the same place at the same time. Examples of this kind are mentioned by the experienced Dr. Lind, in his Ob|servations on the Diseases incidental to Europeans in Hot Climates, page 126, 5th Edit: And Russel on the Plague, at page 24 and 48, relates that the remitting fever prevailed at Aleppo in August 1760, when the Page 14 plague was on the decline, and in November 1761, the plague and the small pox prevailed there at the same time.
Mertins in his History of the plague at Moscow in 1771, at page 186 gives similar examples.
Dr. Maximillian Plinta has published an Account of the Scarlet Fever and Hooping Cough, being preva|lent at Elangen in the year 1790, at the same time with an epidemic small pox. Diseases of various description also came under the notice of several physicians in Philadelphia, during the prevalence of the malig|nant yellow fever in 179•. Several cases of small pox came under the care of Dr. Deveze, and Dr. Duffield, at Bush Hill hospital, which were sent out of the city previous to the eruption, from suspicion of their having the malignant yellow fever.
Several cases of the same kind came under my own notice: A Mr. Quinton from New England, died of the small pox, at Mrs. Newark's in Spruce street at the time, when two of her other lodgers had the yellow fever.—Several cases of quotidians and tertains came under my care in different parts of the city, and in the suburbs, where the contagion never reached.
The same disease prevailed in the summer and part of the autumn of 1794, at Fell's Point, adjoining Balti|more; at which time the small pox also became epide|mic, as appears by the report of the Committee of Health, and a letter from Dr. Buchannan, dated Octo|ber the 11th, 1794, published in the Gazette of the U. S. October, 6th 1794.
Dr. Monson, in his account of the yellow fever which prevailed at New Haven in 1794, says the scarletina prevailed at the same time, and that a greater number of persons were affected with the scarletina, than with the yellow fever; see his letter to Noah Webster, Esq. page 179 of Webster's Collection on Bilious Fevers.
In the present year also, I saw several cases of scarlet fever, and of the small pox, in the same part of the city where the malignant fever was most prevalent, and one case of the latter, in the same chamber with two other patients, ill of the malignant fever.
Page 15From this statement it appears, that all that can with propriety be understood by an epidemic constitution of the atmosphere, is, that it is rendered more capable of retaining miasmatic effluvia and contagious matters, at one time than another, or that it renders the human body more susceptible of contagious, as well as more liable to febrile diseases from other exciting causes, at one time than another. From the facts on record re|specting the plague, it appears that a certain range of temperature is requisite for the contagion, by which it is propagated, to operate: Hence it would appear that the pestilential contagion is attached to, and rendered volatile to a certain extent, by a certain quantity of ca|loric or matter of heat, or is attenuated and diffused by the action of sensible heat, like water converted into va|pour, so as to be specifically lighter than the air near the surface of the ground. This opinion appears to be confirmed, from the effects of excessive heat, as well as by •hose of frost: The one rendering it more light and volatile, so as to rise too high to have any effect; the other detaching the caloric, and letting the contagious parti|cles fall to the ground, &c.
Whether the effluvia with which the atmosphere of cities is occasionally replenished from the various sources of nature, and art, can have the effect of rendering any kind of contagion more active and deleterious, or not, I am not prepared to determine; but it is reasonable to suppose a circumstance of this kind, by diminishing the purity of the atmosphere; renders it sooner saturated with the contagious particles, and cannot fail of rendering the human body more easily affected, and the disease more dangerous when it does take place.*
Page 16This explanation of epidemic constitutions of the air, being less visionary than that of Dr. Sydenham, and sup|ported by a greater number of facts, and observations, is the one I have adopted, and the one that I recom|mend to the attentive examination of the reader.
It has become fashionable in this city, to call every fever bilious, that occurs in the summer and autumn, whether accompanied with a preternatural secretion and effusion of bile or not. This is certainly very objec|tionable, as it has a tendency to mislead, all who are go|verned by names, instead of the symptoms of diseases; nausea and some puking sometimes occur at the acces|sion of every kind, or variety of fever, and more or less bile is at that time generally evacuated; but as this is merely the effect of the cold stage of the fever, and the condition of the system at that time, and not the cause of the fever; the impropriety of denominating it from that circumstance must be obvious, especially, as that is not a constant, but accidental symptom of the fever. On the other hand, if it be denominated a phlogistic or asthenic remittent, according to the diathesis desig|nated by the symptoms, the young practitioner, will not be so liable to mistake the true indications, and will employ those means warranted by the experience of ages, for the reduction of excessive action, or the support of declining strength, as symptoms may in|dicate.