BILIOUS FEVERS,

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.

OF THE CAUSES OF BILIOUS FEVERS.

FROM the numerous observations which have been made in different quarters of the world, there can be no doubt, that the cause of the fevers under consideration, is a miasma or exhalation, which issues from a marshy or putrid soil, or from putrefying vegetable and animal substances. The similarity in the season, situation, and soil, in the different countries and districts in which these kind of fevers prevail, and es|pecially the time of the year in which they are most epidemic and dangerous, concur in proving that how|ever symptoms may vary in different situations and constitutions, they arise from one common cause, and that cause is miasma.

This miasma is supposed to partake of the nature of the putrid source from whence it is derived, but what|ever its nature may be, it exists in the atmosphere over the soil or putrefying substances, from whence it arises in various quantities, and perhaps degrees of strength, according to the climate, season, temperature of the air, and quantity of putrid matter. Hence in tempe|rate climates in the hot season, it is in less quantity or in less strength, than in hotter climates with a similar soil. In hot climates also, the heat and impurity of the air, favours its operation, by inducing debility and pre|ternatural irritability in the animal system. In tempe|rate climates the difference between the temperature of Page  18 the air of the days and nights, render the body more especially liable to be affected by febrile miasmata.

Why these miasmata when diffused abroad in the at|mosphere of marshy districts, do not produce fever in all the inhabitants within the sphere of its influence, or why some are affected by it much later than others, can only be explained by supposing that it can only operate on relaxed, infirm, or debilitated constitutions, and that some debilitating cause must conspire with it, before it can produce any morbid effect in vigorous and robust constitutions. This appears to be confirm|ed by its effects on the emigrants from Ireland, which generally arrive in this country the beginning of Au|gust. Very few are affected with either the remitting or intermitting fever the first season, though numbers are with the dysentery, whereas very few of those that take up their residence in the suburbs of Philadelphia, escape it the second or third season after their arrival: but many are affected the first season of their arrival with infflammatory fever, especially if the season be dry and hot,—if wet and cool, the dysentery. This is also the case with persons who come to reside in the city, from the western and hilly parts of Pennsylvania.

Mud and stagnant water in every climate, possess the materials which give origin to the cause of this species of disease; but a combination of other circumstances is requisite to give it activity. Among the principal of the circumstances which give activity to this cause, may be reckoned the influence of a powerful sun. Hence some situations, which in the winter season are distinguished for no particular disease, are observed in the hot months to be most remarkably unhealthful.

There are few men whose observations are so circum|scribed, as not to know, that it is in the neighbourhood of swamps, mill-dams, and near the shores of fresh water rivers, that intermittents and remittents chiefly prevail; yet it deserves likewise to be remarked, that though a fever of one of these forms is most prevalent in such situations, no champaign or level country is en|tirely exempt from them, especially when wet sum|mers are succeeded by dry and sultry autumns.

Page  19Fresh cleared land in level countries, is rendered much more unhealthful for some time, than when co|vered with wood. The reason is obvious; the wood not only stops the progress of noxious vapours carried from a distance, but it also covers and protects the ground from the immediate action of the sun; in doing which it more than counterbalances the less free circu|lation of the air, or the greater dampness of the ground. Hence no opinion is more erroneous, than that the clearing a country of its woods, renders it healthful. Unless the grounds be drained and cultivated as well as cleared, the effect is likely to be the reverse.

FEBRILE MIASMATA Conveyed through the AIR to a considerable Distance.

IT would be a matter of utility could we determine which certainty to what distance from their source, the noxious effluvia of marshes extend. But this is a ques|tion which we can not expect to ascertain with precis|sion. It is not uniformly the same in all situations, depending perhaps on the concentrated state of the ex|halation, at its source, the obstacles it meets with in its progress, and the nature of the ground over which it passes, or to which it is directed. Dr. Jackson re|lates, that he has known their influence very remark|able at the distance of a mile and a half, on the top of an hill of very considerable elevation. (p. 412.)

The same author, as well as the experienced Lind, late physician to Haslar Hospital, remarks, that a space of time almost constantly intervenes, after exposure to the noxious effluvia of marshes, before the subsequent ap|pearance of fever. "This is not uniformly the same in all persons, owing sometimes perhaps to the state of concentration, in which the exhalation is applied to the body, or to the peculiar aptitude of the individual, to favour or resist its operation."—Both the last mentioned authors agree, that the fever seldom attacks in less than seven Page  20 days after exposure to the noxious effluvia, and Dr. Jackson says, that he oftner observed it to attack four|teen days after such exposure. (p. 415.)

The nature of this cause of fever, though it has long been a subject of enquiry remains still unknown.

From the greater violence of the fever produced by it, as well as the complexety, and often malignity of its symptoms in soils the most putrid, during the au|tumnal season, we infer that the exhalation is in the largest quantity, and has acquired a greater degree of power, or that the atmosphere with which it is mixed, is by some means deprived of its correcting power. But we have hitherto been able to proceed no farther, not|withstanding the aids which modern chemistry has fur|nished.

It has been supposed, (and the supposition was adopt|ed by the celebrated Dr. Cullen,) to possess a S•eptic Principle, but this alone is by no means sufficient, to ac|count for the very peculiar manner in which it affects the human race. Some other quality perhaps is there|fore connected with it, which cannot be brought under the inspection of our senses. But though the ingenuity of the human mind, has not hitherto been able to pene|trate the intimate nature of this cause of fever, we still have it in our power to trace its effects upon the human constitution.

We plainly perceive that a habitual exposure to it, is peculiarly unfriendly to the principle of life, and in a very remarkable manner, shortens the period of ex|istence. Hence, as recorded by Dr. Jackson, while fe|males born, and constantly residing in the the low lands of Georgia, have seldom been observed to live beyond the age of forty, males seldom exceed fifty, whereas Eu|ropeans or Americans from the northern states, who had arrived at manhood before they settled there, have sometimes lived to a very advanced age, though the majority of new settlers have died, of what is called a seasoning to the climate, the first or second year after their arrival.

Though these and other instances which will occur to every ones recollection, afford sufficient proofs of the Page  21 noxious quality and power of marsh effluvia, yet we are by no means instructed as to the manner by which it becomes so. It will therefore profit but little, to pro|secute the subject any farther.

Certain limits are unquestionably prescribed to human researches, on the present subject, beyond which, though fancy may take its slight, and theory make wide excur|sions, all is conjecture, obscurity, or profound dark|ness.

Floods of rain, by diluting and precipitating putrid exhalations, relieve from the remitting bilious fevers, common to marshy situations; but rain has no effect upon the yellow fever, except when joined with cold, or succeeded by frost.

1. IS THE BILIOUS FEVER, OR ANY OTHER VARIETY OF THE REMITTING FEVER OCCASIONED BY MARSH MIASMATA, OR THE EXHALATIONS FROM PUTRID, OR PUTREFYING VEGETABLES EVER CONTAGIOUS?

2. AND WAS THE YELLOW FEVER, WHICH OCCASION|ED SUCH DEPLORABLE MORTALITY IN PHILADEL|PHIA, IN THE SUMMER AND AUTUMN OF 1793, A D WHICH HAS APPEARED IN OTHER SEA-PORT TOWNS IN THE UNITED STATES OF AMERICA SINCE THAT PERIOD, ONLY A HIGHER GRADE OF THE BILIOUS FE|VER, GENERATED BY THE SAME CAUSES?

These are questions highly interesting to the inhabi|tants of this country, and as physicians of considerable respectability differ in opinion respecting them, and the public mind has been much distracted by the discor|dant opinions which have been published on the sub|ject; a desire of reconciling this difference, and of clearing it from the ambiguity in which different views have involved it, has induced me to undertake the troublesome task of collecting the sentiments and opi|nions of the most experienced writers on the subject, and is now my motive for submitting them to the in|spection of the public.

Page  22To these I have added a variety of remarks and ex|planatory notes.

How far these are calculated to determine those in|teresting questions, must be submitted to the judgment of judicious and impartial enquirers.

AN EXAMINATION OF THE EVIDENCES RESPECTING THE CONTAGIOUS NATURE OF INTERMITTENT & REMITTENT FEVERS

IT has been said that it is scarcely possible to open a practical book on medical subjects, without meeting with facts which establish the opinion, that fevers occasioned by the exhalations from putrid vegetables are contagious. The fevers generated by putrid cabbage, mentioned by Dr. Rodgers, and by putrid flax men|tioned by Dr. Zimmerman, were both of them con|tagious. Lancisi, Reverius, Bianchi, Cleghorn, Lind of Windsor, and Clark, have also been quoted in sup|port of this opinion.—All of which shall be noticed in the sequel.

That Dr. Rodgers of Cork, was deceived with res|spect to the origin of the fever which broke out at Wadham College, is rendered more than probable by the observations of the celebrated Lind of Haslar Hos|pital. This author informs us in his Essay on Fevers and Infection, page 290, that almost all the cases of fever which occur at academies and boarding-schools are derived from infection; and that most cases of low fever which occur in private families are derived from the same source. Dr. Cullen has expressed a similar opi|nion, which has been adopted by Robertson, Clark, Fer|riar, and a numerous host of authors of the first rate abilities.

Page  24Dr. Zimmerman appears to have confounded epide|mic with contagious diseases; nor should this be thought extraordinary, for notwithstanding his abilities and cha|racter, he has been frequently mistaken in his opinion respecting the remote causes of other diseases. Among other mistakes, he says the scurvy is propagated by con|tagion,* and that putrid fevers are occasioned by the exhalations from putrid animal substances, and the plague at Grand Cairo, by the stench from swarms of dead and putrid grasshoppers and locusts.†

Lancisi who was physician to Pope Clement XI. was so much mistaken in the real causes of diseases, that he ascribed the pestilence which prevailed more or less at Grand Cairo annually, to the effluvia of hemp and flax, which happened to be stored in granaries near that city, at a time when the disease was more general than usual; he has also ascribed a fever which depopulated one end of Rome, to the putrid effluvia from horses lit|ter or stable dung.‡

That the plague never originates in that way, but is derived from specific contagion, generated in the cities of the East, is clearly shown in Mead's Short Discourse on the Plague, published in the year 1721, and in Russel's treatise on the same, published in the year 1791. The other opinion of Lancisi, viz. that one end of Rome was depopulated by a fever, which originated from the putrid effluvia of horses litter, &c. Professor Rush has refused in the 2nd Vol. of the American Philosophical Transactions, page 211 and 212: These are his words. "Offal matters, especially those which are of a vegetable nature, should be removed from the Page  25 neighbourhood of a dwelling house. The dung of domestic animals, during its progress towards manure, may be excepted from this direction. Nature which made man and these animals equally necessary to each others subsistence, has kindly prevented any inconve|nience from their living together. On the contrary, to repay the husbandman for affording shelter to these useful and helpless animals; nature has done more: She has endowed their dung with a power of destroy|ing the effects of marsh exhalations, and of preventing fevers. The miserable cottagers in Europe who live under the same roof, and in some instances in the same room with their cattle are always healthy.* In Phila|delphia, fevers are less known in the neighbourhood of livery stables, than in any other part of the city. I could mention a family that has lived near thirty years near a livery stable, in a sickly part of the city, that has never known a fever but from the small pox or measles."

Dr. Zimmerman has indeed said, that "the effluvia from a little heap of flax has been known to occasion a malignant fever, which proved fatal to the family in which it began, and afterwards spread its contagion through a whole country." But it does not appear from this paragraph, whether he meant that the exha|lation from the flax, or the fever from the family spread its contagion through a whole country. This can only be determined by reference to the original, which I have not had an opportunity of examining, and it is seldom that a translation conveys the precise meaning of the author. He has not mentioned whether the disease, which he says was occasioned by the exhala|tions from the putrid flax, attacked a number at the same time, or in succession, as they came within the sphere of contagion, that is within six or eight feet of the patient, for it has been ascertained by Dr. Haygath of Chester, that even the contagion of the small pox is Page  26 innoxious at that distance, where a free circulation of air is preserved.

If the facts mentioned by Dr. Zimmerman were true, the human race might literally work out their salvation with fear and trembling, since none of woman born, could possibly survive one hot summer; for al|though, "a little heap of putrid flax," should be want|ing, there are always apples rotting on the ground, putrid cabbage in the garden, turnips, potatoes, onions, or other vegetables in vaults or cellars,—and bilge water on shipboard.

As to Dr. Rogers it appears evident that he did not know the difference between contagious, and epidemic diseases, for he has ascribed the former to causes which 〈◊〉 only produce epidemics or sporadics, and not con|tagious ones. The fevers which prevailed annually at Cork, he says were owing to the exhalations of the putrid blood from the slaughter-houses, particularly after the summer rains; whereas it is well known (for it has been often observed) that such diseases are com|mon in all damp situations in the autumnal season, where there are no slaughter-houses. The healthiness of the generality of butcher's families, is opposed to his opinion, as well as the healthiness of the manufac|turers of starch and indigo, where vegetable putrefac|tion greatly abounds, is to that of vegetable putrefaction occasioning malignant, much less contagious fevers in situations open to the free introduction of the surround|ing air. Unreflecting credulity,—like Shakespear's Glendower, is always ready to ascribe simple events to extraordinary causes. At my birth, says Glendower, strange phaenomena appeared; comets, eclipses, and rock|ing of the firmament. Percy to ridicule his vain credulity and self-sufficiency, answers, that all these phaenomena might also have happened at the birth of a kitten: Meaning that there could be no connection between such phaenomena, and the birth of mortals. Phy|sicians are too often apt to attribute the cause of things to some circumstance most obvious to their senses, or to some remarkable circumstance in, or phaenomenon which accompanies or preceeds any Page  27 disease; and for want of tracing all the circumstances to their source, mistake effects or coincidents for causes. Thus in the year 1699, when the yellow fever ceased upon the coming on of frost, because Roger Gill a preacher had offered himself some time before, as a sacrifice for the people, and soon after died, with others exposed to the contagion, it was generally ascribed to a special interposition of Providence, instead of being ascribed to the effect of frost, which was the physical cause of its suppression. I once saw a bodkin thrust through a hen's head, some of the balsam of Riga was applied, the hen walked about soon after, and appeared to recover by the virtue of that balsam. Another hen with a bodkin thrust through her head, to which no balsam was applied, did the same and detected the cheat.

A medical professor, says, that Dr. Lind ascribes the yellow fever to vegetable exhalations, but I can find no such sentiment in any of Lind's works. His words are (in his Treatise of Diseases of Hot Climates, page 119—5th Edition.) This fever in general proceeds from intense heat, and a peculiar unhealthfulness of the air, but he does not say how that unhealthfulness of the air is produced. What he has said respecting the effects of unwholesome air at Greenwich hospital in Jamaica, has no other reference to the subject, than that every kind of fever is ag|gravated by such air, page 179, 5th Edition. The fact is, that Dr. Lind was not acquainted with the source of this fever, but mistook it for a higher grade of the bilious remittent fever, rendered so by a peculiar unwholesomeness of the air; but unlucki|ly for these opinions, there are no instances of a bilious fever becoming contagious, nor one authen|tic instance where the disease under consideration ever occurred in any state of the atmosphere, without the concurrence of specific contagion.—For proof of this, I refer to the facts contained in Hillary's Diseases of Barbadoes, not to his speculative opinions; Gough's History of the Friends; to Dr. Mitchel's Let|ter to Dr. Franklin; to Lind on Infection; to Lin|ings Page  28 Account of its several occurrences at Charleston, in 1732, 1739—45 and—48, where it was each time traced to importation, and when some of the seasons in which it occurred, were both cooler and wetter than many which had intervened, or preceded them. The fact is, Lind knew nothing about the disease but from the report of others, otherwise he would not have pub|lished an extract of a letter from Dr. N. Smith to op|pose the opinion of its being contagious. (See his Essay on the means of preserving the health of seamen, &c.) If Lind was right in his opinion, the disease he speaks of could not be the same as the one which pre|vailed in the West India Islands, as well as in Philadel|phia, in 1793; for it was highly contagious in both places. And in the West Indies affected the natives, as well as foreigners. Not withstanding the positive manner in which the other, Dr. Lind, (now of Windsor) who was surgeon to a little sloop of war, in the service of the East India Company, has decided on the question, his opportunities were too unfavourable, and his obser|vations too limited to determine a question of this na|ture.

Dr. Cleghorn has said, that tertians have as good a right to be called contagious, as the measles or small pox, but as he has not mentioned any facts in support of his assertion, it can only be considered as mere mat|ter of opinion, derived perhaps from hearsay, or the Ipse dixit of some professor learned in antient error.

It would be mere waste of time, to employ my pen against such authors as Riverius and Bianchi. Works published when fair science was only beginning to dawn, claim compassion.

But Dr. Clark is a champion in the cause of conta|gion, over whom a victory would be honourable.

This author asserts that every form and variety of fever belongs to the same genus, and is occasioned by one and the same cause, viz. contagion, and that every form and variety is more or less contagious according to the situation, state of the atmosphere, and the consti|tution Page  29 of the person exposed to the exciting cause of the disease. Yet he acknowledges that, "They are seldom contagious, except when the air in the apart|ment of the sick, is saturated with animal effluvia."*

To prove the contagious power of remittents and in|termittents, he mentions the following particulars.

"The Grenville Indiaman which touched at the Island of Java, suffered greatly from the malignity of the air. A few were taken on board when the ship sailed from Batavia ill of a malignant fever, which spread by contagion at sea, and carried off great numbers. I visit|ed several (adds our author,) when she arrived at China, who were reduced to mere skeletons by the duration of the fever and the dysentery, both of which were most cer|tainly propagated by contagion."

From Dr. Clark's mentioning his having visited se|veral in this ship, after her arrival at China, it appears that he was not on board of her at the time he says "the disease spread by contagion at sea," of course he could not determine with certainty, whether the disease was contagious or not.

Dr. Lind on Diseases of Hot Climates, says, "a per|son may be attacked by a fever several days after ex|posure to the exhalations of marshy grounds. From comparing many instances of people, who have slept on shore during the sickly season, and which alone have been taken ill out of the whole ships company, then lying in an open road, it appears that some are imme|diately seized with sickness or delirium, many are not seized with any complaint till they have been on board for two or three days; several have been only slightly indisposed for the first five or six days; and in a few the symptoms of indisposition have not appeared before the tenth or twelfth day.† Hence the effects of the in|jury Page  30 received on shore from land air, may not appear till some time after the ship has been at sea,* or a con|tagion may be generated even at sea, from causes which it is sometimes difficult to ascertain."

Dr. R. Jackson in his late Treatise on the intermitting fever of America, assures us that fevers produced by the air of marshes, (or the exhalations from putrid ve|getable substances) seldom if ever make their attack in less than seven days after such exposure, and that some have been as long even as twenty days after such expo|sure, before the was fever completely formed.

To support the opinion which he appears to have adopted from Dr. Cleghorn, that common intermit|tents are contagious; Dr. Clark informs us, that an old lady with the palsy, who lived up three pair of stairs, in a situation where no marsh miasmata could reach her, was attacked with an ague, and as there was no source of marsh miasma, from whence it could have originated it must have been occasioned by contagion. But from whom she received the contagion he has not said.

From this case it appears that Dr. Clark thought, no case of ague could take place in any situation, or from any circumstance, unless the person affected had been previously exposed to marsh exhalation, or to the effluvia of a person labouring under the disease. A mistake which is unpardonable in an author, who pretends to write for the instruction of others.

The fact however is very different from what Dr. Clark has supposed, for there are a multiplicity of ob|servations upon record, which as well as my own ob|servations, convince me that intermittents often occur in situations excluded both from marshes and sick per|sons,Page  31 where patients, after being debilitated by any acute disease, fall into regular intermittents from ex|posure to the night air, when the dews are copious, or after a sudden change of weather from dry and hot to wet and cold.—Perhaps this was the case with Dr. Clark's patient who was debilitated by a chronic dis|ease. We are also told by Dr. Clark, that a decrepid and infirm gentleman, and his servant maid were both attacked by an intermittent, for which no cause could be assigned, but the visit of another maid servant from the country. He knew a child take the ague from be|ing much conversant with a person troubled with that disease—"And a man from only visiting a friend while sweating in a tertian." Since the year 1788, adds Dr. Clark, "I have seen six instances of agues communi|cated from one to another by contagion in the wards of the infirmary at New-Castle."

These may appear unequivocal proofs of the conta|gious nature of intermittent and remittent fevers, to persons not aware of the changes which the state of the mind, the situation of place, and the change of living, as well as the propensity to imitation, (which prevails in most diseases attended with nervous symptoms,) have upon the human body.

Here Dr. Chalmers observes for me, that when one person in a family sickens, and the disease cannot be removed in a few days, there is nothing more common than for some of the attendants to be affected in the same way; this gives an alarm to the neighbours, who conclude that the disease is contagious, though in ge|neral, there is nothing more foreign from the truth— for it is generally owing to the similarity of the consti|tutions which now prevails in consequence of climate and season, and to greater exposure than ordinary to the prevailing causes. This is particularly the case with nurses and other attendants who are deprived of their customary rest and food, when they expose themselves abroad after being debilitated by confine|ment in the warmer and more impure air of a sick-room.

Page  32From comparing that fever called by Dr. Clark* a remittent, and which Sennertus says began in Hungary and spread by contagion over Germany, with the camp fever described by Sir John Pringle, the hospital fever of Donnald Monro, the jail and ship fever of Lind, Roupe, Blane, Robertson, &c. and with the fever which prevailed in some of the American hospitals, and British prison ships in the years 1776, 1777, and 1778, &c. I am convinced that it was a typhus, or a con|tinued fever of a putrid tendency which originates from animal effluvia in a certain situation, and was propa|gated by contagion, and was not a genuine remittent, or any fever that was derived from the exhalations of vegetable putrefaction.

Dr. Ferriar, to whom in abilities and medical ac|quirements few are superior, entertains an opinion that "all infectious animal poisons, that of the hydropho|bia excepted, are formed originally from some morbid process in the living human body."

"It is true the putrefaction of dead bodies generates a poison, which is highly noxious when received into the human body by a wound, or any raw surface; but this poison does not seem to infect like that of fevers by exhalation. Its first effect unlike the other, is to oc|casion the death of the part where it is admitted.†"

"Noxious effluvia indeed frequently arise from pu|trefying animal substances in a certain state. Dr. Monro mentions a remarkable instance of this in his Treatise on the Dropsy, and some later examples are recorded by Mr. St. John. But it does not appear from these cases, that the noxious effluvia produced any symptoms re|sembling those of putrid or pestilential fevers; on the con|trary they acted by a direct stimulus, occasioning inflam|matory complaints, from which we may conclude that they are essentially different from febrile contagion.‡"

Page  33It is now generally admitted (for it has been esta|blished by accurate and repeated observations) that the effluvia from the living human body in certain situa|tions, whether affected by fever or not, become a poi|son capable of producing a disease in a healthy body which has the power of propagating its likeness to others, either from contact or near approach, or by means of other substances, which have been within the reach of the exhalations from the body of the sick.

If it were admitted, that a solitary example or two, have occurred of a fever occasioned by the exhalations of putrid vegetable substances, occasioning a fever to those who attended the sick, and from them to others, it will serve very little towards determining the ques|tion, unless it can be made appear, that the fever thus propagated, was marked by the characteristic symp|toms of either an intermittent or remittent, only diver|sified by season and constitution, &c.—For before any thing can be with certainty admitted as the efficient cause of an effect, that cause must not be occasionally, but constantly present whenever that effect is produced.

Though I believe the circumstances which I have already stated, and the arguments which I have advan|ced, are sufficient to convince every impartial enquirer, that the doctrine of the contagious nature of intermit|ting and remitting fever's, so long as they retain their genuine type or character, is erroneous; yet lest any doubt on the subject should remain, I will now proceed to detail the observations and opinions of a few authors of the highest credit, and most ample experience.

Baglivi, (who united great sagacity and indefatiga|ble industry, with sound judgment,) published his Ob|servations on the prevailing Diseases of Rome in the year 1696, in which he informs us, that remittents were endemic and exceedingly malignant during the summer and autumnal months along the shores of the Tiber, and the low grounds of the antient Latium, which was in a manner a desert, overrun with impu|rities, and that in several parts, particularly about Ostia and Porta, the air was so unwholesome, that if any citizen went out and remained there all night, and then Page  34 returned to town, he was soon after seized with a dan|gerous fever, commonly called "the Bad Air Fever." This fever differed very much both in its symptoms, and method of cure from the fevers that spring from other causes.—It was relieved by blisters and cordial medicines, but aggravated by blood-letting, &c. Bag|livi however had no suspicion of its being contagious, otherwise he would have mentioned it.

Baron Vanswieten tells us, that "double tertians, which imitate continued fevers, and which are often epidemical are not contagious, though they are often attended with exanthemata, gangrenous blotches on the surface of the body, swellings of the parotids and other symptoms of malignity." This he exemplifies by an account of the epidemic fever of 1756, occasion|ed by the noxious effluvia of marshes. "Many visited the sick at different times; and many of the sick were removed to families in health at some distance from the sphere of the effluvia, and not an instance occurred of its being communicated by contagion."*

The celebrated Lind has given an account of a re|mitting bilious fever, which was very epidemic and malignant in several parts of England in the autumn of 1765, accompanied in many cases with yellowness of the eyes and skin; but instead of imputing it to conta|gion, he expressly says, the number of the cases, and the violence and complexity of the symptoms marked as it were the nature of the soil. At Portsmouth its symptoms were bad, worse at Kingston, and still more violent and dangerous at a place called the Half-way-House, where the situation is remarkably low and damp." That this was only an intermittent diversified in its symptoms, and modefied by season and soil, ap|pears evident from its continuing to appear a consider|able part of the ensuing winter in the form of a quartan ague, and from its yielding to the bark in large doses when it most resembled a continued fever.

Page  35Dr. Black, on the Human Species, asserts, that "though fevers of the intermittent and remittent type are the endemics of all hot countries, and are generally epidemic in certain situations and seasons, yet they are not contagious, except the sick be crowded together in places from whence fresh air is excluded." He adds that "this circumstance as well as the remissions which occur only once in these fevers, in the course of twenty-four hours distinguishes them from the continued fever which has two exacerbations, and perceptible though slight remissions, twice within the same period. An ir|refragable proof that they are derived from a different source and belong to a different genus."

Similar remarks may be seen in the 1st Vol. of Dr. Cullen's First Lines of the Practice of Physic. (Vol. I. sect. 29th.) In none of the works of the last mentioned illustrious author, is there the least intimation of inter|mittents or remittents being contagious; and surely a man of Dr. Cullen's reading, experience and observa|tion, would not have omitted a circumstance of such importance, if he had thought them so. His words are, "* The remote causes of fevers are chiefly conta|gions or miasmata, and miasmata are the cause of inter|mittents, and contagions of continued fevers, strictly so called. Drs. Gardner and Clark, though both stre|nuous advocates for the doctrine of the contagious power of those fevers, acknowledge that they only be|come so when the air in the apartment of the sick is confined and saturated with animal effluvia." Dr. Zimmerman has delivered a similar opinion respecting the contagious power of the dysentery.

The extraordinary and adventurous Bruce, informs us in his Travels, (Vol. 3d. page 360, 8vo. Dublin Edition) that "Bilious fevers are often epidemic along the Coast of the Red Sea, from Sues to Babel Mandel, and often prove mortal in three days; but he makes no mention of their being contagious. These like Page  36 other remittents, yield to the bark, but it must be given in a different manner from that employed in Europe."

The bilious intermitting fever described by Dr. Ray|mond, which prevails in the autumn universally in the Islands of Zealand and the neighbouring coast of Zealand, he says, from a variety of facts is well known not to be in the least contagious. Physicians who attend the sick, and other people who live in the same house with them, are never siezed with the same complaint, unless they have been previously exposed to the same cause.*

Dr. R. Jackson in his Treatise on the Intermitting Fever of America, says "the exhahalations from swamps were a fruitful source of fevers to the British troops, not only in the southern states, but at Kings|bridge on York Island, in the year 1778 and —9; but remarks, that "none of these were contagious." (page 88.)

Dr. Hunter was of opinion that none of the fevers which occur within the Tropics, are contagious, and that when contagion is imported, then it is soon ex|tinguished.

Dr. Wade in a paper on the Prevention and Treat|ment of the Disorders of Seamen and Soldiers in Ben|gal, written in the year 1791, declares that "during his residence in Bengal, though fevers and dysenteries were often epidemical, they never exhibited any ap|pearance which could excite a suspicion of their being contagious."

Dr. Ross, one of the members of the College of Phy|sicians of Philadelphia, also informs us that he was at Bossorah on the Euphrates in the year 1776, when a bilious remittent prevailed there, which was unusually mortal, but was in no instance contagious.

Dr. Chisholm in his Treatise on the Pestilential Fe|ver which prevailed at Grenada in the spring of 1793, remarks that "he had never in any instance known the endemic bilious fever to be contagious."

Page  37Along the flat and swampy grounds of Maryland, Virginia, the two Carolina's, and Georgia, especially where an extensive surface of putrid soil is exposed to the scorching rays of a blazing sun, bilious remittents are periodically epidemic, and amazingly malignant; but there is not one well authenticated instance of their being contagious.

We are told by Mr. Townsend in his Travels through Spain, that a bilious remitting fever prevails at Car|thagena every autumn, in consequence of its proximity to an extensive marsh on its east side called the Alma|jor, which occasions great mortality; but that it differs in no respect from the bilious fevers of other countries, excepting that putrid and nervous symptoms sooner take place, than in colder climates with purer air.

Dr. D. Ramsay, whose authority is unexceptionable, remarks in his Sketch of the Climate of South Caro|lina, that the bilious fever differed from the yellow fe|ver in not being contagious. Dr. Rush has given an Account of the Bilious Remittent Fever, which was more than usually prevalent in the southern and eastern parts of the city and district in the year 1780, which was occasioned by the water that had been permitted to overflow, and stagnate upon the low grounds between the conflux of the two rivers, from the neglected state of the drains and banks. This fever was attended with extremely distressing symptoms, but it did not bear blood-letting, nor is there a hint expressed of its being contagious.

Dr. Buel has published an Account of a Bilious Fe|ver, that was epidemic at Sheffield and the country adjacent, to a large extent of marshy ground and stag|nant water, in the autumn of 1793, 1794 and 1795, which in some cases appeared to be malignant. This fever he ascribes to marsh exhalations, but has made no mention of its being contagious, which he certainly would not have omitted, if he had ever observed any thing of the kind.*

Page  38The experienced Doctors Taylor and Hansford, in their Account of the Bilious Fever which prevailed at Norfolk in the summer and autumn, of the year 1795, deny that it was contagious.

The physicians of New York, who have written on the malignant yellow fever, which prevailed in that city in the year 1795, and destroyed the lives of near one thousand of the inhabitants; are decidedly opposed to the opinion, that bilious fevers are contagious, as is evident from their denying that the yellow fever was contagious; which they supposed was only a higher grade of the common bilious fever, which prevails there more or less at the same season every year, and which they ascribe to the effluvia of the mud and stagnant water of the flats and docks.

Although Doctors Gardner and Clark, and a few other authors assert, that the bilious remitting fever, arising from marsh miasmata is contagious, they ac|knowledge before it becomes so, "It must be in some measure altered in its nature by unfavourable situation, and the impure air of crowded wards."*

Lind, (of Haslar) whose opportunities of making ob|servations were confessedly great, though perhaps some|times too much hurried by the duties of his station to be always accurate, observes "that tropical remittents are the most dangerous and difficult to manage, yet these are not contagious, unless when accompanied with dy|sentery, and the sick are crowded together." This is an important fact, and distinguishes this fever from the nervous or putrid fever. In those febrile epidemics and endemics from marshy situations, the remissions are also more perceptible and synchronous, than in those from animal contagion.†

Here we have an acknowledgment from some of the ablest, and most learned of the advocates for the doctrine of the contagious power of intermittents and remittents, Page  39 that "(they are not naturally or necessarily contagious, but may become so after they have in some measure changed their nature."

This is certainly in effect giving up the point, for a disease changed in its nature, is no longer the same that it was originally, but a new disease. If they are not changed in their nature, and are contagious, they must propagate a fever of the same character and type with themselves. But every case of fever which originates from febrile contagion, exhibits the type and character of the typhus or continued fever, with nervous or pu|trid symptoms.

When the attendants on patients with an intermitting or remitting fever are attacked with a fever of a conti|nued type, and nervous or putrid symptoms, it implies, not that those fevers are contagious, but that a conta|gious matter has been generated, accumulated, and ren|dered active, in consequence of the situation and circum|stances of the sick: For it has been often experienced, that contagion has been generated in consequence of the confinement of healthy persons in situations where the air is confined till it becomes saturated with the effluvia issuing from their bodies, which are thereby converted into contagion. But this contagion produces a fever of a continued type, and an assemblage of symp|toms which distinguish it from every other genus, and propagates a fever of the same type and assemblage of symptoms from one to another. But remittents do not produce their likeness to persons exposed to their influ|ence; therefore as remittents they are not contagious.

To conclude, if fevers become contagious and are communicated from one to another, the disease caught being similar to the one from which it took its origin; it may be inferred that they depend upon a specific and unaltered contagion,—but if a person takes a fever from another, different from the original disease, it shews that a specific contagion has been generated, en|tirely different from that by which the original disease was produced.

That a contagion may be generated by persons la|bouring under intermittent or remittent fever in con|fined Page  40 and unventilated situations, I do not pretend to deny, but I contend that the contagion so generated is of a specific kind, entirely unconnected with the in|termittent and remittent fever, otherwise it would oc|casion in those exposed to it, a fever of an intermittent or remittent form; but instead of this it always occa|sions a fever of a continued form capable of being com|municated in succession from one to another.

That the contagion generated by patients labouring under the recited diseases is not connected with those species of fever, but entirely independent of them ap|pears to be rendered certain from the very same kind of contagion being frequently generated in similar situa|tions, by persons entirely free from every kind of fever.

How the exhalations from the living human body in a confined portion of the atmospheric air become a poison, capable of generating a disease in a sound body, distinguished by a particular assemblage of symptoms, I do not pretend to know; but the fact is unques|tionable.

Recent and accurate observations have not only con|vinced me, that febrile contagion is always derived from the living human body, in situations deprived of a due proportion of oxygen or pure air; but that the con|tagion is rendered more virulent and deleterious in pro|portion to the extent and duration of the heat to which people in such situations are exposed. This is confirmed by the Account of the Origin of the Yellow Fever, which appeared in the Island of Grenada, in the be|ginning of the year 1793, published by Dr. Chisholm. And of that on board the Busbridge, East Indiaman,* in 1792. Noxious effluvia indeed frequently arise from putrid animal substances in confined situations. Dr. Monro mentions a remarkable instance of this, and some later examples are recorded by Mr. St. John. But it does not appear from these cases, that those noxious effluvia produced any symptoms resembling those of putrid or pestilential fevers: On the contrary, Page  41 they acted as direct stimulants, and occasioned inflam|matory affections, which were not preceded by symp|toms of debility, and which are, entirely different from the effects produced by febrile contagion.

Let us now advert to the question, relative to the malignant fever being only a higher grade of the com|mon bilious fever which derives its origin from the ef|fluvia of marshes or putrid vegetable matter. Though it be difficult to convey precisely in words a description of the symptoms which distinguish the one disease from the other; their discriminating marks not consisting so much in one or two symptoms, as in a certain assem|blage of several, yet when the whole of the symptoms of each are compared jointly and severally, the difference is exceedingly clear and evident.

The malignant yellow fever is distinguished at its commencement, from the worst cases of the bilious re|mitting fever, by the suddenness of its attack, shortness of the cold stage, greater severity of pain in the fore|part of the head and eyes, which are also more fre|quently inflamed and watery in the former, than in the latter; and especially by the costiveness or dysenteric state of the bowels, the excretion of bile, which is a constant symptom in the bilious fever of hot climates being as invariably deficient at the beginning of the malignant yellow fever; the remissions are also more obscure, and the skin more dry. The debility in the animal functions is greater, the stricture about the pre|cordia more distressing, the countenance more flushed, of a deeper purple colour, and exhibits the appearance of greater misery and distress. Dr. Jackson observes, that though the yellow fever appears variously in per|sons of different constitutions or diatheses, from its first accession, it may generally be distinguished from the endemic remittent of the country, not only by the ob|scureness of the remissions, but likewise by a certain ex|pression of the eye and countenance, with something unusually disagreeable in the feelings, of which words convey an imperfect idea.

Page  42The malignant yellow fever which prevailed last in Philadelphia, differed very considerably from the usual remitting fever in not shewing any disposition to puke, except when excited by medicine, before the end of the second, and often not before the beginning of the fourth day.

The remarkable irritability of the stomach in the former, which comes on, in the majority of cases (when the disease is permitted to run an uninterrupted course) about the third or fourth day, in consequence of which a constant nausea and retching to vomit, brings up every thing as soon as it enters the stomach, and is accompanied with a burning heat, and sense of soreness, deep and frequent sighing and restlessness, distinguish the yellow fever very materially at this period from the bilious remittent.

The bilious colour of the skin, and the coffee ground, or black vomitings, which frequently occur in the ad|vanced stage of the disease, may when they both occur, be considered as decided and unequivocal marks, which distinguish this disease not only from the bilious but from every other form of fever except the plague.

But the yellow fever does not differ from the bilious fever, only in the circumstance of contagion, and in the aspect and severity of its symptoms; it differs from it also by its symptoms being rendered worse, by some of the remedies which are most efficacious in the cure of the bilious fever.—Nor are these the only circum|stances in which these fevers are dissimilar: The bilious fever occupies more especially marshy districts, where the inhabitants reside at a considerable distance from one another, and invades a number at the same time; its cause being mixed with a considerable portion of the atmosphere, and its influence sometimes extending more than a mile from its source; it is also more or less endemic in such situations at the same season annu|ally.

Whereas the yellow fever never appears among the the inhabitants of marshy countries in temperate cli|mates, but in such climates, when it does occur, is al|ways confined to sea-port towns, where, on its first oc|currence Page  43 it has always been traced to one contracted spot near to some wharf, or foul vessel.—If it originated from the same cause as the bilious remittent, every part of the town, where it occurs, would be alike subject to the disease, at the same time, or within a few days of each other.—Some would be seized in the north and south, some in the east and west, the centre and cir|cumference, at the same time; but instead of this, the malignant yellow fever every time that it has occurred in this city, (and it has occurred only five times in|cluding the present year, in the course of the present century, and once before, that we have any account of on record or have learned from popular tradition,) has always made its first appearance in one circumscrib|ed point, and first affected a few individuals who resided near, or transacted business at that particular point, while every other part of the city has continued perfectly heal|thy, until the disease has had time to spread itself by contagion. From those circumstances, it is evident that the seeds of the disorder do not float in, or mix with the atmosphere to any extent, but must be sought for in some other source.

If we go down to the meadows and marshes on the flats of the Delaware and the Schuylkill, and look for it among the diseases, which exhalations engender, it is not there. Imagination, and her whimsical daugh|ter, Theory, have created something in those places, which they have called its likeness; but, the Sallow Imp of the marshes, is the offspring of different parents, and differs essentially in its character from the jaundice-eyed fiend, which extends its destructive sway by con|tagion. If we look for it, in the effluvia from the gut|ters of the streets, the heaps of unmolested dirt, in the alleys and lanes, the mud and litter with which the wharfs and water street is too often encumbered, it still eludes our search. If it was the offspring of the last mentioned sources, the market women, the farmers, and all those that transact business in market street, and especially all that reside in the narrow and dirty and crowded alleys, would be subject to the mighty destroyer every summer.

Page  44That the malignant yellow fever, is a species of fever belonging to a genus, essentially different from that of the bilious remitting fever, is farther supported by the au|thority of the majority of those authors, that have had the best opportunities of acquiring information on the subject.—To save the trouble of transcribing the passages which support this opinion, the reader is referred to the works of Warren, Desportes, Schote, Hume, Blane,* Mosely,† Jackson,‡ Chisholm, and Bryce.§

Dr. Chisholm, after comparing the malignant yellow fever, (which was epidemic at the port and town of St. George, in the island of Grenada, in the year 1793, some months previous to its appearance in Philadelphia.) with the endemic bilious fever of the islands, concludes thus,¶ "If we may be allowed to draw a conclusion with respect to the diagnostic of this disease, from the remote and proximate causes, from the symptoms, and from the dissections, I apprehend we must consider it as truly pestilential, and differing from the plague, strictly so called, only in not always exhibiting all the symptoms that are peculiar to that malady."

The cases annexed to Dr. Chisholm's book, demon|strate, that the fever which prevailed at St. George's, was essentially the same, as that, which afterwards pre|vailed at Philadelphia. I purposely reserve the result of my enquiries into the origin, and causes of the ma|lignant yellow fever, for a separate treatise, which I am preparing for publication.

A DESCRIPTION OF THE BILIOUS REMITTING FEVER, AS IT USUALLY APPEARS IN PHILADELPHIA, IN SUMMER AND AUTUMN.

IN this fever though there is not a com|plete intermission or cessation of the febrile symptoms, there is an abatement or remission more or less evident once in the course of every twenty-four hours.

This fever after being preceded for a day or two, and sometimes much longer by a disagreeable sense of languor and debility, usually attacks between eight and eleven o'clock in the morning with a chilly fit, which after a longer or shorter duration, is accompanied with or succeeded by the following symptoms. Alternate sensations of cold and heat, darting and thrilling through the back and limbs, acute pain in the fore part of the head, back and limbs, yawning, stretching, restlessness, constant thirst, dryness and clamminess of tongue, mouth, and fauces, flatulency, nausea, and frequent at|tempts to puke, sometimes bringing up bilious matter, and sometimes voiding it by stool. In many cases the cold stage is accompanied with cholera; in others, espe|cially when the fever attacks persons of a phlogistic diathesis, or strongly disposed to local inflammation, it Page  46 is attended with costiveness. In these cases however the patient generally has a call to the chair before the commencement of the second paroxism. The urine during the cold stage is pale, copious and crude; but as soon as the hot stage is established, and during its height it becomes high coloured, and during the remission appears thick and cloudy and sometimes de|posits a brick-coloured or brownish mucous sediment. During the continuance of the hot stage, there is al|ways a sense of tightness and uneasiness about the tho|rax and stomach, and more or less frequency and uneasiness in respiration. As the hot stage advances the pulse (which during the preceding stage was low, small, quick, contracte•, and irregular) becomes freer, fuller, stronger; the temporal and carotid arteries throb; the face becomes suffused with a scarlet blush; the muscles of the face diminished during the cold sta•e, now be|come larger than in health; the s•in shrunk, rough, pale and dry before, now becomes distended and smooth. The sickness and propensity to puke so constant and distressing during the cold stage, and also during the conflict between the cold and the hot stages, before the latter becomes completely established, now ceases; and about four o'clock in the morning sometimes two or three hours sooner, but oftner an hour or two later, all the feverish symptoms begin to remit and continue to decline till the hour of the first attack: Then the same process is again renewed and the fever runs the same course as the preceding day; and so on every day till it entirely ceases, becomes an intermittent or degenerates into a continued form.

After the second paroxism, and sometimes after the first the fever is seldom preceded by a cold stage, but comes on with sense of languor, restlessness, flushings of heat, an increase of thirst, and some nausea, or fla|tulence at stomach, and the fever generally continues moderate till four or five o'clock in the afternoon, when it becomes more violent and continues in that state till the morning. In some cases this fever is worse every second day. It also sometimes makes its first at|tack in the evening. In those cases the paroxisms are Page  47 generally longer, and the remissions more obscure than when it attacks, or when its paroxisms are renewed in the morning.

In some cases at the beginning of the fever, stomach sickness accompanied with vomiting and discharges of bile from the bowels is so predomninant, especially in children whose systems are extremely irritable during the season when remittents prevail, in consequence of the summer's heat, and often from the effects of teething, that many physicians, have supposed, that a redundancy and depraved state of that fluid was the principal cause of the fever, and in infants have confounded it with the cholera infantum: This is, however, a very great error, for vo|miting, by whatever means excited, if often repeated, with violent efforts, scarcely ever fails of forcing bile from the biliary ducts, and sometimes in enormous quantities. An extraordinary secretion of bile in this fever, and in every other, is the effect of great irrita|bility of the stomach, in conjunction with a defect of power in the circulating vessels on the surface of the body; the consequence of which is, a preternatural de|termination to the vena cava, liver, &c. and of course the cretion of an extraordinary quantity of bile in a given time.

During the exacerbation of the fever, there is always more or less, head ach, and pain in the back and limbs, and in many cases delirium, accompanied with much restlessness. The face and eyes also appear more tur|gid and lively; the tongue appears at first whitish and moist, or lightly tinged with a streak of yellow. But when the fever has continued for several days, with an increase of debility, it becomes covered with a dark, brown, tough and dry crust. In some cases, great pro|stration of strength is visible from the beginning, in others, it decreases gradually in the course of the fever. The thirst varies with the rise and fall of the fever, a bitter taste is common; a diarrhoea is more frequent than costiveness—the colour of the urine varies with the rise, progress, and decline of the paroxism: At the commence|ment of the paroxism it is pale, thin and copious, at the height it is high coloured, scanty and cloudy, at the de|cline Page  48 it is still high coloured, but very turbid, and lets fall a sediment; the heat of the skin, also varies with each stage the of paroxism.

When the disease has continued for several days with encreasing debility, it is common for the skin and eyes, to become heavy dull and yellow, and the countenance to appear ghastly. In those circumstances, the pulse is always weak and exceedingly quick, and the mind af|fected with delirium of the low kind, commonly called typhomania.—When the disease has continued without abatement, and especially when the prostration of strength has become very considerable, the symptoms frequently become so much diversified in different patients, that the inexperienced, are apt to suspect them to labour under different diseases; some are costive, others have a con|stant diarrhoea; some are chilled by every passing gale, while others are refreshed by the coldest air; the skin of some is constantly parched with heat, while others are as constantly bathed in sweat.—But symptoms com|mon to almost all at a late period of disease, are a low, quick pulse, ghastly countenance, sunk eyes, continual heat and restlessness, with sickness, faintness, and pro|stration of strength, at the usual time of the accession of every fresh paroxism; and this sickness, and increase of debility, generally lasts from morning till evening, and frequently all night, particularly, every second or third day; after which, there is generally some abatement of these distressing and alarming symptoms for some hours.—If the debility still continues to increase, the the pulse becomes weaker, lower, smaller, quicker and more irregular, through every stage of the paroxism, and the remissions become no longer discernable, except by greater prostration of strength, anxiety and restless|ness at one time of the day, (generally about noon) than another. The days on which this fever usually terminates in health, are the 5th. 7th. 9th. 11th. and 13th. These are also the days on which the remissions are most manifest. When this fever terminates favoura|bly, the remissions become more distinct, accompanied with a warm moisture on the skin, and a copious sedi|ment in the urine, an intermission then succeeds, and Page  49 strength gradually returns. In many cases it terminates unfavourably without the aid of art, but in the present improved state of medicine, few die of this fever when judiciously treated. When this fever proves mortal, and the strength is nearly exhausted, the patient, as in the last stage of other fevers, lies altogether upon his back, and frequently slides to the foot of the bed; in this condition, he has always more or less twitching of the tendons at the wrist, and is affected with low deli|rium, in which he mutters incoherently to himself.— His tongue, his teeth, and lips are covered with a dark coloured, sordid crust: His tongue trembles when thrust forth for inspection; his eyes appear dull and stupid; his sensibility, which in the early state of the disease was too acute, is now the reverse; his hearing becomes impaired; he doses with his eyes and mouth half open; he sees objects indistinctly, and clouds ap|pear to hover round him; a stupid insensibility pervades all his faculties; the sphincters lose their retentive power; the faeces and urine pass off involuntary; and as if lamenting his hopeless condition, tears steal down his ghastly face; the pulse falters, and only moves in tremors, losing, on the slightest pressure, all motion; a cold and clammy sweat bedews his torpid limbs, his fingers, his nails, his lips grow purple, his respiration becomes interrupted, by a collection of phlegm, occa|sioning a peculiar rattling in the trachia, vulgarly called the death rattle, frequently interrupted by hiccup. These symptoms are generally followed soon after by death.

In some cases, this fever is protracted from one to four weeks; in others, it terminates in a perfect inter|mission in as many days, especially when properly managed. Cold and clammy sweats are almost infalli|ble signals of approaching death, in every stage and pe|riod of the disease.

The whole of the prognosis may be thus summed up. Tone and vigour, or a moderate degree of that state of body, distinguished by the name of inflammatory diathe|sis, without local affection, afford the surest signs of Page  50 safety: Whereas general failure of the powers of life, or irregular determination to organs of importance, are the most certain signs of danger.

The season of the year, and state of the weather, with respect to dryness, or moisture, as well as local situation, have considerable effect in varying the symp|toms, and in determining the mildness or violence of this fever. In marshy and wet situations, and dry sea|sons, the cases which occur about the latter end of sum|mer and beginning of autumn, are generally attended with greater debility, and have much more obscure and imperfect remissions; the general diathesis of the sys|tem, has also a greater tendency to putrefaction, mixed with nervous affection, and sometimes with symptoms of a malignant nature.

The stomach, bowels, and biliary system, suffer more under these circumstances than at other times. When the summer and autumn have been wetter and cooler than usual, the fever at its commencement, generally partakes of an inflammatory nature, but the remissions at first are very imperfect, and with difficulty discerned, yet with proper management they soon become distinct and complete.

DIAGNOSTICS.

THE remitting fever, is distinguished from the typhus, or continued fever, by the remissions being more dis|tinct, and by having only one remission in the course of every twenty-four hours, whereas the remissions in the typhus, though perceptible only to those who pay particular attention to symptoms, occur twice in every twenty-four hours. It also differs from the typhus at Philadelphia, in being more constantly attended with evacuations of bile, by vomit and stool. It is produced by a very different cause, and is not like that disease, contagious: In these respects it also differs from the yel|low fever of the West Indies, as well as in the excre|tion Page  51 of bile, though it often resembles that disease, in occasioning a yellow colour of the skin and eyes of the patient. From the semi-tertian, it differs in no essen|tial respect, excepting in the violence of its symptoms; the remissions in most cases of each, being one day more perfect than another.

CAUSES WHICH PREDISPOSE TO THE REMITTING FEVER

THE persons most subject to this fever, are the relaxed and debilitated, the delicate and infirm: Persons thus circumstanced, exposed to the occasional or efficient causes of the intermittent fever, contract a remittent, that is a fever of the same nature as an inter|mittent, only differing in degree, in consequence of the difference in constitution and predisposition.

In all cases of this fever in order to ascertain whe|ther it partakes most of the inflammatory, or nervous diathesis, the state of all the functions of the body should be carefully examined; for by the prevailing diathesis as indicated by the symptoms, our treatment of the disease ought to be regulated.

If the pulse be either rapid, strong and full, or even low and hard, or tense, we may be assured that the disease partakes of an inflammatory nature, and more especially if accompanied with pain of any particular organ.

But where the pulse is weak and soft, however fre|quent or quick, and there is a corresponding debi|lity in the animal functions or voluntary muscles, a contrary diathesis is always prevalent.

The pulse however though generally a good index of the state of the arterial system, is sometimes so much affected by passions of the mind, by the state of respi|ration and by local affections that we may be misled, if we trust to it, without comparing it, with other cir|cumstances inseparable from the disease.

Page  53By attending to the state of the stomach, and of the muscles subservient to the will, together with the state of the brain, and comparing the condition of each with the pulse, we may generally form a proper estimate of the state of the disease.

In forming a judgment of the state of the vis vitae from the sensible heat of the body, much caution and discernment are requisite; for, although an increase of sensible heat always follows an increased circulation of the blood, it does not always depend upon the force with which it is impelled by the heart, but is often owing to the obstruction of perspiration, whereby the heat is prevented from passing off. Nor is the quick|ness of the pulse an index of power in the system, but the reverse, excepting when joined with fulness or hardness.

PROGNOSIS.

THE prognostics in this as in other fevers, must be derived from our knowledge of the causes of death in febrile disorders in general.

These in the present form of fever are to be deter|mined by the state of debility, and the degree of disor|dered action present in the several functions of the body.

The symptoms which denote a great degree of de|bility in the animal functions, are

1st. Weakness in performing the voluntary motions, and swooning when in an erect posture.

2d. Imperfect sensations.

3d. Typhomania or delirium, accompanied with great debility.

4th. Those which denote a great degree of debility in the natural functions, are foulness and dryness of the tongue, gums, and fauces; great loss of appetite; distension of stomach; insatiable desire for acids and cold water; involuntary stools and urine, &c.

Great debility in the vital functions, is denoted by the lowness, smallness, or emptiness and quickness of Page  54 the pulse; hurried, and interrupted respiration; op|pression at the precordia; restlessness; deep, and fre|quent sighing; sunk and inanimate appearance of the eyes and countenance, &c.

With respect to the fluids, danger is denoted by pe|techiae, or the eruption of livid or purple spots; effu|sions of blood under the cuticle; bloody and brown coloured urine; profuse and obstinate diarrhoea; pro|fuse, weakening, colliquative, or clammy sweats, ac|companied with coldness of the extremities, &c.

BEFORE I proceed to the treatment of this fever, it may not be improper to add that cases of remitting fever frequently occur, especially in the early part of summer and latter part of autumn, in which inflam|matory symptoms or marks of high arterial action are predominant; this happens especially when a consider|ably long period of very warm weather is succeeded by heavy rains, and a sudden change of temperature in the atmosphere. While the atmosphere continues either uniformly dry and warm, or uniformly wet and cool, fevers are very rare; of this we had striking ex|amples in the hot and dry summer of 1782, and the wet one of 1788.

The pulse in such cases is not only frequent during the paroxism, but it is likewise quick, hard, and vibra|ting; the heat is often intense; the internal functions, and the various secretions are considerably disordered, and the whole surface of the body appears dry and rough.

The remission that follows for the most part is ob|scure, the pulse frequently retaining, a preternatural quickness and hardness, and the skin still retaining a con|siderable degree of febrile heat. In these circumstances, the excretion of bile is an unusual symptom, and the patient is inclined to be costive, till after the preter|natural and strong action of the arteries, is reduced by depleting remedies. In these cases the head and back sufferes more severely, than when it appears in any other form.

Page  55In this climate, contrary to what occurs within the Tropics, rainy summers and autumns, though they do not occasion the remissions always to be more perfect and visible, they render the type more simple, and the diathesis oftner inflammatory.

In hot and dry seasons on the contrary, especially from the beginning of August, to the middle, and some|times to the latter end of September, the fever is usually blended with symptoms of a nervous kind, and parti|cularly accompanied with bilious evacuations.

In these cases the mind is much seldomer affected during the exacerbations, than in the former: Some|times, however the patient is affected with lively and unruly delirium, sometimes the delirium only amounts to a slight incoherence in the train of ideas, or a mo|mentary suspension in the power of recollection.

The paroxisms in this variety of the fever seldom ex|ceed eighteen hours, and in some cases are finished in twelve, and the remissions are distinguished by more or less perspiration, though this seldom extends completely to every part of the body. The remissions in those cases, which are accompanied with copious evacuations of bile, though more perfect than those, in which the phlo|gistic diathesis is predominant, are by no means com|plete; the head-ach and other disagreeable feelings usually abate, but signs of languor, and of imperfect solution, are still observable, in the tongue, pulse and skin.

The paroxisms frequently increase in violence, in the progress of the fever, and the remissions become less distinct. In children the first paroxism, is sometimes introduced with an epileptic sit, and in many of such young subjects, it is common for the febrile action to be determined, particularly to the brain; and to terminate in hydrocephalos internus: This is more particularly the case in the early part of summer, when cold weather is succeeded by sudden and intense heat.

In some cases, particularly in persons addicted to free living, instead of a paroxism, consisting of different parts, in a certain order of succession, there is sometimes an entire stupor and insensibility, which continues for a Page  56 determinate space of time, accompanied with evident signs of fever, especially with flushing in the face, and full pulse; while in others during the whole period of each paroxism, and especially previous to the exacerba|tion, a tremor and agitation of the limbs are constant.

In debilitated constitutions, each succeeding paroxism generally returns sooner than the regular period, always with symptoms of great distress, and sometimes with new and alarming ones; it generally declines at the begin|ning in twelve or fourteen hours, but each succeeding remission becomes less distinct, except when obviated by the rules of art.

The fevers which occurred at Philadelphia, in the autumn of 1794, (the spring and fore part of the sum|mer of which had been preceded by a great deal of rain,) were generally double tertains, the paroxism be|ginning one day in the forenoon, the next in the after|noon. In the cases that became dangerous, or difficult of cure, the paroxisms were gradually anticipated half an hour, or an hour every day, till the fever became an obscure remittent, resembling the typhus, or fever of a continued type. In those cases in which the pa|roxism came on later every day, the disease in a few days became a regular intermittent.

In the central parts of the city, this fever was a rare occurrence; but in the suburbs and the southern and western parts of the city it was, to a limitted degree epi|demic. But from the notes which I kept of the state of the weather and diseases of that season, it appears that on the 1st. of September, there were twenty cases of simple intermitting fever, to one of remittent.

Several cases of remittent with bilious puking occur|red on the 16th. Three cases of double quotidian came under my care, i. e. two paroxisms came on eve|ry day, one in the forenoon and one the evening, but the symptoms were always more violent every third day. The water in the ponds which had been constantly full of water, on each side of pine and lombard streets began to diminish rapidly about the middle of the month. On the 19th. a sudden change of the wind to N. W. reduced the thermometer 17°. Immediately after Page  57 this change in the temperature of the air, almost every family in the vicinity of those ponds were attacked with tertian, or quotidian fevers. On the 26th. I visit|ed sixteen patients, with distinct intermissions.

Ten cases remittent, with inflammatory symptoms, and three with bilious evacuations. Intermittents and remittents, continued prevalent till after the middle of October; but as the season grew colder, they either de|clined or became combined, with topical inflammations.

EXTRACTS from my NOTES on the WEATHER and DISEASES of the year 1795.

THE spring and summer of the year 1795 were agreeable, cool, and frequently refreshed with rain. Torrents of rain fell all the first week of August, the wind N. E. and occasioned remarkable freshes, which occasioned great injury to the agricultural interest. Not a case of remittent came to my knowledge before the 16th of this month: From this time till after the middle of October, intermittents and remittents were only sporadic.

All the ponds, ditches and hollows about the city, continued full of water, from July till after the 10th. of September, a proof that much rain had fallen within that period: About the middle of the month heavy dews began to fall, and several cases of remittents occurred, accompanied with bilious discharges. Seve|ral cases of cholera also occurred at the same time. On the 16th of September, the proportion of intermittents to that of remittents, was ten to four.

By the 17th. the water in the ponds and ditches had diminished considerably, and presented a moist and pu|trid surface to the sun.

Frost was observed for the first time this season, early in the morning of the 23d. The cold weather has begun to give an inflammatory complexion to the intermittents, which have lately occurred in southwark and the extremities of the city. The weather became Page  58 mild on the 24th. and continued so till the 4th. of Octo|ber, two days excepted, on one of which a considerable quantity of rain fell.

On the 5th. of October it became so cold, as to ren|der fires necessary.

The proportion of remittents, to that of intermittents, was three to one; but cases of neither were very nu|merous.

From the 6th. to 12th. the weather was calm and mild; after rain which fell on the 11th. the wind chang|ed to N. W. and became cool and pleasant; on the 13th. it again became calm and sultry, 14th. cloudy; 15th. heavy rain: remittents were now more general than they had been any part of the season, and were for the most part accompanied with strong and quick action of the arteries. Blood-letting soon after the commence|ment of the fever, to a second, and sometimes to a third time, from ten to fourteen ounces at a time, was some|times found requisite to procure a perfect intermission. From the 14th. to the 20th. the weather was exceed|ingly variable.

Ice appeared on the gutters, in the morning of the 18th.

On the 21st. I had several cases of intermittent, but only one of remittent fever.

EXTRACTS from my NOTES on the WEATHER and DISEASES, of 1796.

THE measles, the scarlatina, the tussis ferina, the small pox, and the mumps, were all prevalent at the same time in the month of April, and in some in|stances in the same family.

The winter and spring, till May, had been remark|ably cold: The weather in May, variable and generally cool.

June till the 17th. was almost constantly wet.

From the 21st. of June, to the 1st. of July, the wea|ther was fair.

Page  59A few cases of intermittents occurred about the end of the 1st. week in July.

August 1st. Intermittents had not increased in number.

Weather cold and variable from 1st. to 9th. Sultry from 9th. to 15th. 15th. cloudy and remarkably cold, continued cold till 20th.

The remainder of the month, sultry, with frequent showers.

The whole of August remarkably healthy; inflam|matory cases most prevalent.

The first case of remittent, that occurred in my prac|tice this season, was on the 8th. of September. Inter|mittents were considerably numerous.

After the middle of September, cases of remittent fever, became more numerous, but were generally mild.

Page  60

The preceding returns demonstrate that the bilious remitting fever very seldom becomes epidemic in Phi|ladelphia, though sporadic cases occur annually at the same season.

Nor have I ever met with a case of bilious, or any other form of fever, occasioned by the air of the city, or of the marshes which has communicated a fever to the nurses, attendants, or physicians.

A register of the weather and diseases of the present year, I reserve for my intended publication on the Malignant Yellow Fever.

OF THE TREATMENT.

IN order to the successful treatment of this fever, the first thing to be attended to is the re|moval of the remote causes, or those circumstances which gave it birth. Removal therefore to a dryer situation and purer air, is next to indispensible.

The next step is to attempt by the most efficacious means to obtain an intermission as speedily as possible after the attack of the fever, that the Peruvian bark may be administered to the best advantage.

With this view, we are to consider how far the vio|lence of the fever on its first attack, will admit of blood letting and the antiphlogistic regimen, always retaining in memory, that so long as the inflammatory symptoms are evident, which is always the case when the pulse is strong and full, or quick and hard, or tense, however small and low it may feel, and the skin continues hot and dry, the tongue white and moist, the pain in the head, back, or limbs violent, blood letting is not only a safe, but a necessary remedy, a Sine qua non, which ought not to be dispensed with.

The success which attended blood-letting in some cases of yellow fever, connected with local affection in the autumn of 1793, and an opinion which has since been conceived or adopted by some of the physicians of Philadelphia, that all fevers depend on the same proxi|mate cause, differing only in degree, however produced; and that they are all inflammatory at the beginning, Page  [unnumbered] has induced several physicians to transfer the fame prac|tice to the kind of fever, under consideration. In cases also purely in ammatory, blood has been drawn to an astonishing quantity, without any apparent injury, but in every case as far as I have been able to obtain infor|mation, it has proved injurious and in some cases fatal when the disease was not attended with inflammatory symptoms, or when th•se were partial and slight.

In a great number of patients however with a fever of a remitting form, connected with an in inflammatory diathesis (which frequently occurs in the fore part of summer, and the latter end of autumn) I have frequently found it requisite to take away ten or twelve ounces of blood every day to a fifth time, and in a few cases where the pulse was very quick and hard, I have opened a vein with advantage twice a-day, and I believe it ought to be a rule in all such cases, to bleed more or less accord|ing to the violence of the symptoms, without regard to the period of the disease, or the name which others may think proper to call it. I must at the same time observe, that where purging and antimonials are freely employed, they will in many cases even when inflam|matory symptoms are predominant, supercede the necessity of being so very lavish of human blood.

I have learned by frequent experience the truth of Dr. Balfour's observations, that all laxative and pur|gative medicines as well as injections, are very uncertain in their operation, and frequently disappointment us, so long as any considerable degree of fever is present. The period therefore at which fevers shew a tendency to remit, should be carefully watched, and purgatives administered on the first signs of a remission—And when these are not evident, still the usual period of remission is to be preferred for that purpose. At this time they will generally operate and evacuate the bile, secreted and accumulated during the exacerbation, which is the first and indeed, an indispensible requisite in the cure of these fevers.

Mercury is so effectual for this purpose and at the same time attended with so little hazard, that it may be with propriety stiled the key of the hepatic system.

Page  63Mercury has been for several years employed as a purge of superior efficacy in bilious fevers, by several respectable physicians in Europe as well as in the East and West Indies, particularly by Dr. Gilchrist, Pringle, and Hamilton. And it was employed by the late Dr. Huck Saunders in the cure of intermittents, in which the bark failed; but, the discovery of its efficacy in the cure of malignant and contagious fevers when employed so as speedily to affect the salivary glands, was reserved for Dr. C. Chisholm, who first employed it for that purpose in the year 1791.* How far it will have the same effect in cases of the fever under consideration, re|mains still to be determined by future observations;— but from its effects in cases of obstinate intermittents, when given in small and repeated doses internally, or employed by friction externally, till it occasions saliva|tion, there is every reason to expect it will have the same effect in cases of bilious remitting fever.

Dr. Clark, in his Observations on Diseases of Long Voyages, gives the following account of the efficacy of mercury in violent cases of fever. Vol. I. page 182. edit. 2d. "I have had much experience of the supe|rior efficacy of calomel, conjoined with opium, in tak|ing off irritability of stomach, and in opening the bow|els: And therefore in all dangerous remitting fevers, attended with vomiting, burning heat, and pain at stom|ach, I would recommend the pills, No. 4.† Two to be taken immediately, and one to be repeated every half hour, till the pain abates. After this their operation is to be assisted by glisters, fomentations, and in very urgent cases, by the use of the warm bath.

"When the irritability of the stomach, is by these means removed, all bilious and corrupted humours should be carried off by a solution of salts, in a decoc|tion of tamarinds, or an infusion of sinna, &c." In a note at page 183, Dr. Clark adds, "The yellow fever Page  64 of the West Indies, and that of Senegal, have been re|presented to be always beyond the power of medicine; but I have little doubt, that the fatality of the worst kind of fever, may be obviated by a practice similar to that above mentioned." In such cases, he also recom|mends "A hundred drops of laudanum in an emol|lient glister; the patient to be put into a warm bath, and when removed to bed, eight or ten grs. of calo|mel to be given in the form of pills, with opium, if the anodine glister has not removed the vomiting, the ope|ration of the pills to be promoted by purgative glisters, and as soon as the bowels are opened, to throw in the bark, in the most liberal manner, without loss of time."

Dr. Balfour, who practised medicine twenty years in different parts of the East Indies, gives the follow|ing testimony in favour of the use of mercury in fe|vers. (Treatise on Putrid Pestilential Remitting Fevers, published in 1790, page 109.) "Calomel in a decree, superior to any other medicine, I am acquainted with, possesses the property of loosening and detaching the mucus of the intestines: It requires, in general from six to ten hours to effect this perfectly, and operates best when the patient lies quietly in bed. A proper dose to an adult, is from six to twelve grs. and this dose must be repeated from three to six times, or as often as the state and contents of the intestines may require, at the beginning of the disease, and afterwards occasionally, as it may seem to be required, by the fulness of the bowels and the state of the contents." When the mu|cus is loosened by the calomel, Dr. Balfour, prescribes a solution of salts, with a very small portion of emetic tartar, to be given in divided doses, every morning after the calomel, at the beginning of the disease. After this process, he prescribes the liberal use of the bark, &c.

Dr. Wade, also a physician of considerable experi|ence, who practised in the East Indies, after delivering an opinion, that the fevers of that climate, depend upon a vitiated state of the mucus of the intestinal canal, and recommending active purgatives for the removal of their cause, adds, "As the disease does not always arise from the quantity or quality of grosser matters in the Page  65 stomach and intestines, or from any portion of vitiated bile and other secretions, which the utmost power of the usual purgatives can effect, we must have recourse to such as are active, and better calculated to remove the complaint. It may be deemed particularly fortunate, that the purgatives which prove most successful in fe|vers, are as mild in their operation, as they are certain and powerful.

"From two to ten, or more grs. of calomel, with a greater proportion of any of the other articles, form a dose of the utmost safety. These doses should be re|peated every second night, or if the symptoms are pressing, every night, as long as any thing offensive shall remain to be discharged from the bowels."*

"It may be received as a general rule, that the mer|curial laxative be given at night, and the medicines necessary to promote its effects, early next morning, as well as in the course of the day. The more those symptoms called putrid, or nervous are present, is the use of mercurial purgatives indicated.

"Mercury exhibited, in the yellow fever, black vomit, &c. to as to affect the mouth, has uniformly proved successful." Edin. Med. Com. for 1793, Vol. 18.

Dr. Blane, in his Observations on the Bilious Remit|tent Fever of Hot Climates, remarks, that "when the fever appears to be kept up by a fresh accumulation of bile, the repetition of evacuants is necessary, and ca|lomel will be found to answer remarkably well as a purgative, its stimulus being so extensive as to loosen, and bring away bile, when the saline purgatives had failed of having that effect; and it will be still more effectual for this purpose, if given alone, in a dose, from five to ten grains, and followed some hours after|wards by some other purgative." (Observations on Diseases of Seamen, page 392, &c.)

In obstinate and protracted intermittents, that resisted the power of the bark, it was the practice of the late Dr. Thomas Bond, at the Pennsylvania Hospital, to put Page  66 the patient under a slight course of mercury, after which the bark generally succeeded. And we are informed by Dr. Blane that Dr. Huck Saunders assured him, that he had frequently cured agues, in which the bark had failed, by putting the patient on a course of mercury, and afterwards returning to the use of the bark. (Page 428 of Dr. G. Blane's Observations, published in 1785.)

Dr. Chisholm first discovered the efficacy of mercury in 1791 in a contagious fever which he at first mistook for the hepatitis, in the cure of which its efficacy had been for a considerable time established, not only in the East Indies, but in England, as appears from the 9th. Volume of the Edinburgh Medical Commentaries. In the yellow fever at Grenada in 1793, he also experi|enced its superior efficacy. Dr. Gilchrist, (as appears from the Edinburgh Essays and Observations, Physical and Literary, Vol. III. page 498) more than fifty years ago, entertained the most decided opinion of the vir|tues of mercury in the low state of fever, connected with inflammation. Dr. Gilchrist's discovery has since been followed and improved upon by several physicians of acknowledged merit. But he whose penetration makes the first discovery or improvement, and removes inju|rious prejudices, is entitled to the greatest share of gra|titude and applause.

Dr. Gilchrist's practice was afterwards applied to the liver disease in the East Indies, and from an apparent analogy, being applicable to bilious fevers, it has since been a remedy in the hands of almost every practitio|ner. Consequently as a medicine in those kinds of diseases, it is not entitled to the distinguished name of a New Remedy.

As the chief objects of attention in the majority of cases in this fever (when debility and bilious evacua|tions are the most prominent symptoms) are the con|tents of the stomach and intestines; upon the patient's first complaint, before the paroxism of the fever has formed, or while the patient perhaps only complains of alternate heats and chills, the contents of the stomach Page  67 should be immediately evacuated, either by an emetic, cathartic, or by a purging glister. But if the pain of his head be violent, blood-letting should always be premis|ed, unless great prostration of strength should forbid it.

The next step towards procuring a remission, is to open the pores of the skin. This in the beginning of the disease, where my observations have principally been made, is best accomplished by the following draught, repeated every second or third hour, with plentiful warm dilution of the antiphlogistic kind.

℞ Aq. Ammon. Acetat. ʒij vel ℥ss Aq. hord. vel simp. ℥i Tart. Emet. gr. 1/6 vel ¼ Sach. Alb. ʒij M. f. haust.

Experience teaches us that antimonials are particu|larly useful in the early period of this fever, especially when there is the least tendency to an inflammatory dia|thesis, which is always the case when the pulse at the wrist is tense, and the throbbing in the temporal and ca|rotid arteries strong.

In cases however where there are are no evidence of such diathesis, but where the prostration of strength is very considerable, they are not only useless, but inju|rious, as they have a tendency to counteract the small degree of power still remaining, and which can only be augmented by cordial and nutritive remedies.

When the means already prescribed, fail of in|ducing an evident remission, the fever is generally kept up by a fresh accumulation of bile in the gall blad|der or ducts of the liver. When this is the case, there is generally a sense of weight or uneasiness about the hypochondria. In these circumstances a repetition of evacuants is requisite, and calomel as recommended by the sagacious Dr. Blane (a living author in high esti|mation) is generally sound to answer remarkably well as a purgative, its stimulus being so extensive, as to loosen and bring away bile as well as hardened faeces, when the saline purgatives have failed of that effect. "The calomel has been found most effectual for this purpose when given during the remission, in a dose of Page  68 from five to ten grains, followed five or six hours after by a glister, or some mild purgative."

This being effected, antimonial are to be again ad|ministered in small doses, and if there be no inflamma|tory symptoms present, an anodine, combined with an antimonial, and a little of the saline mixture should be given every night at bed time.

℞: Suc. Limon. ℥ss. Sal. Alk. Veget ʒss. Tart. Emet. gr. ¼. Tinct. Opii. gtt. XL. Aq: Com: Sacharat ℥iss. m. f. haust.

The principal point of management, after an evident remission is obtained, is to administer the Peruvian bark to the best advantage.

Whatever may be the case in tropical climates, more or less remission is always necessary in this part of the world, especially at an early period of the disease, be|fore this medicine can be administered with success, or even safety.

When the remission is prevented by excess of debi|lity in the arterial system, which may generally be dis|covered from the weakness of the pulse, and great pro|pensity to faint, or become sick at stomach upon being raised up; blisters as well as a more cordial regimen are absolutely necessary, and in general produce a favourable effect.

The bark should be administered during every remis|sion, in as large doses as the stomach can retain, without occasioning much oppression or sickness.

It is best in substance, but when it cannot be taken in that manner, it may be made into a strong decoction, in conjunction with a little Columbo root and serpenta|ria: Should the stomach reject it in this form, we ought without delay, to have recourse to it in glisters, with the addition of a little laudanum. In this way, from two to four drachms of bark, with ten or fifteen drops of laudanum should be administered every two hours, mixed with a tea cup full of panada or sowl broth, till the return of the fever, during the exacerbation of which an antimonial mixture is again to be made use of.

Page  69When considerably weakened by the paroxism, a little wine, especially old port, on account of its astringency and tonic effect, should be occasionally joined with the bark, or a little of it given after every dose.

Wine however is seldom proper, or even safe in large draughts, in the early stage of this fever, except in those cases when the prostration of strength is very evident and alarming.

In every case, where the remission is obscure or im|perfect, and no local affection, or inflammatory symp|toms are discoverable, the most probable means of affording relief, is to excite a universal sweat. This is not only an imitation of nature, but is founded on reason and experience, for it is by sweating, that the sit of an intermittent is terminated; this however should be at|tempted by gentle soothing means, and not by strong stimulating, and heating medicines and regimen.

For this purpose, the following composition, given at the height of the paroxism, is frequently effectual.

℞: Aq. Ammoniac: acetat: ʒij. vel. ℥ss. Tart. Emet. gr. ss. Tinct. Opii. gut. XV. vel. XX. Aq: Cin: simp. ℥iss. Sach. alb. q. s. f. haust.

To coincide with the same intention, and to render the effect of the above composition more certain, plentiful and warm dilution is necessary: And I have generally found an infusion of serpentaria, sage, or some other mild aromatic, preferable to farinacious decoctions, or vinous mixtures. The application of warm moisture to the surface of the body, renders the effect of the reme|dies already mentioned still more certain. This may be performed by bathing the feet and hands in warm water, or by fomenting the thighs, legs, and arms, with warm stupes; these operations have the effect of bringing on a general relaxation on the skin, of diminishing irrita|tion and delirium, and of inducing sleep.

But before we make use of pediluvia and warm fo|mentations in this fever, we should be well assured that the strength of the pulse and velocity of the circulation are not already too great, otherwise instead of obtain|ing Page  70 the end for which we use them, we shall find if the heat of the water exceeds 98°, they will have a contrary effect, because of the stricture induced on the exhalents by the heat, which not only stimu|lates the solids, but distends the fluids. The pulse must however be raised several degrees above the healthy state of action, otherwise no sweat will flow.

Some patients are troubled with incessant puking previous to the accession of every fresh paroxism, and are sometimes so debilitated and reduced by it, as to threaten immediate danger. In these cases after having immersed the feet and legs in water as warm as can be conveniently borne, from 30 to 40 drops of liquid lau|danum should be taken in a draught of peppermint julep, or combined with an effervescent mixture of ve|getable alkali and lime juice, and should be repeated after every evacuation, till it have the desired effect. If the stomach reject the laudanum immediately after it has been taken, a double quantity mixed with a little aromatic infusion or tea, should be thrown into the bowels frequently. If this should fail, or should not be submitted to, flannels wrung out of hot spirits of wine or brandy, and covered with powdered spices, such as cinnamon, alspice, and cloves, or ginger, and black pepper, should be applied to the stomach, feet, and wrists; or they may be rubbed with oil of cloves, lau|danum, and sweet oil, and covered with heated flannels. When chilly sensations prevail, these applications are nearly equal to blisters. Blisters to the thighs however may be applied at the same time when the case is urgent; and in alarming cases, a blistering plaister should always be applied to the stomach.

As puking frequently precedes or accompanies every fresh paroxism, and is attended with a sensible diminu|tion of vigour in the several functions of the body, and takes place nearly at the same hour every day, or every second day; it may generally be prevented by giving the patient from twenty-five to forty drops of Thebaic tincture, in any mild and palatable cordial draught, two hours before the expected paroxism, and especially if blisters be applied to the wrists or legs at the same time.

Page  71When the case is not so urgent as to threaten imme|diate death, the feet and hands may be plunged into cold water to increase their irritability, before the ap|plication of heat and other stimuli.

In many cases incessant vomiting cannot be restrained by any means till the circulation is restored to the sur|face, and perspiration takes place. For this reason we are advised by Dr. Jackson to take the patient out of bed, dash cold water over his head and shoulders, re|turn him to bed, and to give him a cordial anodine draught, with warm aromatic and palatable drinks. These means he informs us (and my own experience confirms the truth of his information) generally occa|sion a calm and equable perspiration, with great abate|ment of irritability, and frequently a complete inter|mission of the fever; and by keeping up a determina|tion afterwards to the surface by means of diaphoretics, diluting drinks, and a blister to the liver, bilious eva|cuations seldom become troublesome during the remain|ing course of the fever.

I have also frequently seen the stomach settled by small and repeated draughts of hot lime juice punch, while the patient's feet and legs were fomented with flannels wrung out of warm water.

Where lime juice cannot be readily obtained, for making the effervescent neutral mixture, the following powder may be substituted.

℞ Sal. Alk. vegetab. fixat gr. x. Pulv. Chrystal. Tartar ℈i Sach. Alb. ʒss M. (f. Ch. No. j.)

By throwing this powder into a glass of water, an effervescent neutral mixture, is instantly formed.

In the generality of cases in this fever, it is of much importance to prevent the patient from becoming cos|tive, and frequently to carry off the bilious matter which is constantly secreted; otherwise the Peruvian bark, the remedy on which we chiefly depend for the cure, cannot be given to effect. On the contrary, if given when bilious and other acrid and excrementitious matters abound, it generally occasions spasmodic affec|tions, or distentions of the stomach and intestines; adds Page  72 to the feverish heat, and often occasions a foulness of the tongue and fauces, and sometimes brings on de|lirium.

Moderate and frequent evacuations by stool, under these circumstances, instead of weakening the patient, sensibly refresh and strengthen him, in proportion as the aggravating cause of irritation and distress is re|moved from the bowels.

But as bilious, and other excrementitious matters originate and accumulate from debility and relaxation, as soon as they are removed by the recited means, their recurrence should be as much as possible prevented by the free use of the bark, and such drinks and aliment, as are found upon trial, to agree best with the patient. The application of a blister to the region of the liver, is a most invaluable remedy for this purpose.

Where however, there is great lowness, and disposi|tion to swoon upon rising; glisters should be employed instead of purgatives, when occasion requires. In these circumstances, copious evacuations are generally in|jurious.

In all cases attended with symptoms of evident debi|lity, and ineffectual re-action in the vascular system; blisters ought always to be employed without delay, the earlier after the attack, the better. The excitement produced in the centre of the nervous system, the com|mon sinsory, by their stimulating power, is conveyed to every part of the system, and new vigour is given to every function. That the power and action of the heart, as well as the voluntary muscles, depend in a great measure on the excitement, and power of the sensorium, is clearly demonstrated, by its cessation immediately after the cardiac nerves have been divided.

Though the first effects of blistering is to stimulate, excite, and invigorate, the discharge which follows, is debilitating in proportion to the quantity discharged, after the inflammation produced by the blister has sub|sided. For this reason, when our view in the employ|ment of blisters, is to excite and invigorate the circu|lating powers, and not to relax and debilitate, the sur|face excoriated by the blister, should be healed as Page  73 speedily as possible, or fresh inflammation excited by some irritating ointment.

I believe, from some trials I have seen, that it would be advisable, as one part heals, to apply a blis|ter to another, for the purpose of keeping up succes|sive excitement, till an intermission takes place.

When from increasing debility, neglect, mismanage|ment, &c. the disease assumes a continued form, (which is very common in low damp situations, when the weather is very hot, sultry, and calm,) the most stre|nuous and persevering efforts should be made to invi|gorate the whole system. For this purpose, in addition to the successive application of blisters, (one of which in dangerous cases should always be applied to the back part of the head and neck, or, if much affected with nervous delirium, over the centre of the head;) the best of wine should be given in different forms, in pa|nada, in whey, and by itself, observing always to regu|late the quantity, by the state of debility present, and its effects upon the pulse, and brain.

Strong decoctions of bark and serpentaria, should also accompany the use of wine, and may be given now without regard to remissions. If the stomach rejects or loaths it in every form, it should be employed in glisters.*

Page  74In cases accompanied with great debility, tremors of the hands, typhomania and watchfulness, symptoms common in the latter stage of this, as well as of the putrid fever, from contagion; opium is at present a favourite prescription with many physicians, but they are by no means agreed with respect to the doses, or periods of repetition.

Doctor Cullen, who paradoxically says, it possesses both a stimulant and sedative power, advises it in large doses, and to be repeated only once in six or eight hours, while others, less influenced by theory, perhaps, direct it in small and repeated doses, in conjunction with vinous drinks. In this way it is a remedy of su|perior efficacy, in all cases accompanied with low, weak pulse, and failure of the vital powers; and especially in all cases attended with typhomania and subsultus ten|dinum.

When any difficulty occurs in distinguishing the weak pulse from the strong one, we are assured by Dr. Dar|win (in his Zoonomia, Vol. 2d. page 301,) that "it may generally be ascertained by counting its frequency. For when an adult patient lies horizontally in a cool room, and is not hurried or alarmed by any circumstance, nor stimulated by wine or opium, the strong pulse sel|dom exceeds 118 or 120 in a minute; and the weak pulse is generally not much less than 130, and often much above that number. Secondly, in sitting up in bed, or changing the horizontal, to an erect posture, the weak pulse is immediately quickened 10 or 12 pulsations in a minute, which is not the case in the strong pulse, when the patient has rested after the exer|tion of rising."

It has long been known to physiologists, that sensa|tion and voluntary motion, depend upon a certain power or function of the brain; but it is a discovery of modern date, that, though the muscular fibres of the heart, are endowed with a certain degree of inherent power, they are still for such action as is necessary to the motion of the blood, very constantly dependent on a nervous pow|er transmitted into them from the brain, which influ|ences, and modifies the actions of the heart: This is Page  75 evident from the motions of the last mentioned organ immediately ceasing, upon dividing the cardiac nerves. A force is therefore supposed to be constantly exerted in the brain during life, which is extended to the fibres of the heart, as well as to every other part of the body.

It is evident to the most superficial observer, that the sensibility, and irritability of every part of the body, are rendered less susceptible of impressions, by the use of opium.

In all cases of pain arising from any cause, except that from inflammation, it is a sure and never fail|ing palliative, and generally succeeds in procuring sleep, if given in doses sufficiently large to overcome the irritations present in the system, or to allay the ex|quisite irritability.

The best method of ascertaining the manner in which any medicine operates, is in the first place, to observe the ultimate effect, and then to go back step by step as far as possible to the primary cause: The first cause has in no instance been discovered demonstratively; but in tracing secondary causes, we may proceed with to|lerable certainty: Agreeably to this plan, I have endea|voured to ascertain the effects of opium upon the living body; and have found its first effect, is uniformly that of increasing the temperature of the body. As from the sensible qualities of this substance it cannot act like heat, by uniting with, and increasing the temperature of other bodies, it must act by increasing the cause of heat, but as the heat of the body is always in propor|tion to the strength, or the rapidity with which the blood circulates through the vessels, nothing can in|crease the temperature of the body, which does not at the same time augment the rapidity of the circulating blood. The increase of heat takes place soon after tak|ing opium, which must therefore be owing to the sti|mulus of the opium upon the heart and vessels, by sym|pathy from the nerves of the stomach, or through the intervention of the brain.

When there is great determination to the head, ac|companied with ferocious delirium and great restlessness, Page  76 neither wine nor opium should be employed. The most serious consequences have arisen, from the intem|perate use of cordials in such circumstances. Here bleeding, and blistering the head, and sedatives, are indicated; but when the pulse is low and quick, accom|panied with convulsive motions of the muscles of the limbs, two or three grains of opium, joined with eight or ten of Sal. Am. Vol. made into a bolus, with con|serve of roses, ought to be given at bed time; and five or six grains of the volatile salts, with five or six drops of laudanum every two or three hours in the day time, followed by a large draught of a strong decoction of bark and snake root, sangree, or wine whey.

In the last recited circumstances, genuine Madeira wine is the most agreeable, as well as the most effectual cordial that can be employed; and may be given with|out restriction day and night, till the subsultus and tremors give way, and the pulse feels fuller and more vigorous. Some of the cases which are the most un|manageable and fatal, are those in which there is a spontaneous diarrhoea.

In every instance therefore, when the diarrhoea is so profuse as to debilitate, an attempt should be made to restrain it.

This in general is most effectually done, by taking a small dose of tincture of opium, with two or three table spoonfuls of the chalk mixture, of the London Dispen|satory, five or six times a-day, and the confictio opiata, at night.

It often happens, that the patient cannot be prevailed upon to take the above medicines: In such cases a few drops of tinct. opii. in a little wine mulled with the yelk of an egg, cinnamon and sugar will have the same effect, and is much more grateful to the patient.

The hiccup is most effectually relieved by opium and aether, and the application of a blister to the stomach.

The most suitable and agreeable aliment is sago, panada, chicken broth, or beef tea; with the addition of more or less wine, according as the debility is greater or less.

Page  77When wine raises the pulse, and invigorates the sys|tem, without inducing delirium, it is right to persist in giving it; but when it occasions or increases delirium, restlessness and heat, it ought instantly to be discon|tinued. The intention of giving wine, is to increase and support the powers of the system; not to heat, ir|ritate, and prevent sleep.

In general, if the bark be given freely in the time of the remissions, there will seldom be a necessity to give much wine, during the first week of the fever, and seldom afterwards, to exceed one pint of Madeira or port, or a bottle of claret, in twenty-four hours.

In cases, where coma, or lethargic symptoms come on, besides the cordials already mentioned, a blister should be applied to the coronal future, and sinapism to the feet.

When the fever is entirely subdued, and the patient in a state of convalescency, he should still continue the use of wine, or porter, and a nourishing invigorating diet. He should also frequently take moderate exer|cise in the open air in suitable weather, observing to accommodate his dress, to the changes of the weather, and to his debilitated condition.

To promote a more speedy recovery, it will be pro|per to make use of an infusion of cort. Peru. or rad. Columb. in water with the addition of a little of Hux|ham's tinct. cort. or old brandy, with the daily use of the cold shower, or plunging bath, and a dose or two of some agreeable composition, with sal. mart. or flor. martial. If the stomach remains weak and dyspeptic, brandy and water, will be a preferable drink, to either wine or porter. Oedematous swellings are apt to fol|low this fever, when it has been long protracted.

These, where no tumefaction and obstruction of the liver or spleen are discoverable, generally give way to exercise, and regular, generous, but not intemperate living. When they do not, diuretics ought always to be combined with tonics.

Ten or fifteen grains of pearl ash, taken two or three times a-day, in a draught of the following bitter infu|sion, generally answers this purpose equal to any other.

Page  78 ℞ Rad. Gentian Co•tus ʒij. Cort. Aurant. ℥ss. Sem. Coriand. ℥ss. Aq. Com. lbiss. coquend. ad lbj. & colend.

If this fails, the digitalis or powder of Squills alter|nated with chalybeate pills should be substituted; and if the swellings still gain ground, recourse should be had to mercurial frictions, repeated every night till the mouth becomes affected, which should be kept in that state for three or four weeks at least; the strength of the patient being supported at the same time with suit|able aliment.

If oedematous swellings increase, or prove tedious, boluses containing two three grains of sal martis, or ten or fifteen of flores martiales with the addition of some agreeable aromatic, may be taken several times a-day, in conjunction with a cordial and invigorating regimen. The tinctura ferri muriata of the London Pharmacopaea, is a very efficacious preparation, and may be taken several times a-day in doses of from ten to twenty drops in any agreeable draught.

AN ACCOUNT OF THE FEBRILE DISORDERS WHICH PREVAILED IN SHEFFIELD IN THE STATE OF MASSACHUSETTS, IN THE YEARS 1793, 1794 AND 1795. EXTRACTED FROM A LETTER OF WILLIAM BUEL, PHYSICIAN AT SHEFFIELD, TO E. H. SMITH, PHYSICIAN AT NEW YORK.

BEFORE entering directly on the subject of the disorders, which prevailed here in 1793, 1794 and 1795, I shall mention some circumstances relative to the face of the country in the Town of Sheffield.

The river Housatonak runs in a serpentine course through this town, from North to South. Upon the banks of the river, on each side, is an extent of intervale, or meadow land, averaging on both sides at about a mile in breadth. The greatest part of this intervale is overflowed at the time of the thawing away of the snow, in the spring; and sometimes, by large and sudden freshets, at other seasons. The nature of the soil, in general, is such, that, very soon after the water is off, the land is dry and fit for tillage. It is, however, much interspersed with coves and marshes; in the former of which the water remains stagnant a considerable part of the summer, and in many of them perpetually; of the latter there are not many upon this river, but there are some which remain such, through the season.

Beside the Housatonak, there are two other consi|derable streams, running through part of this town, Page  80 which unite and empty into that river. Upon each of these streams are large tracts of low, marshy lands; great part of which is overflowed by freshets, and is never perfectly dry.—There is (which is very mate|rial) a mill-dam, on each of these streams; and the two dams occasion the overflowing of several hundred acres of the low lands. As summer advances, and the ponds fall, considerable parts of these lands are left uncovered by the water; more or less, according to the drought of the summer. In both of these ponds are large quantities of timber and other vegetable matters, which in hot weather, are always in a state of putrefaction. This state exists in an increased degree as the substances become more exposed to the action of the sun. The foetor occasioned by this putrefying mass is such, in hot weather and when the water is low, as to be extremely offensive to the smell, at the distance of many rods.

The inhabitants of this town, who live in the vicinity of these marshy and drowned lands, have, as would naturally be expected, been always subject to remittent and intermittent fevers, from its first settlement. It is, however, generally remarked by the old people, that these disorders have of late years, until the three last decreased, owing, probably, to the clearing, or par|tial draining, of the lands.

Although, the disorders which have prevailed in this town, for two or three years past, are owing un|doubtedly, principally to these local causes; yet it is not improbable, that some predisposition to them was occasioned by a general constitution of the air. To ascertain this point, with any degree of precision, we ought to have before us an accurate history of the wea|ther, for several years past. Even then it would, per|haps, be impossible; as it ever has been found a diffi|cult matter to trace any connection between the mani|fest qualities of the air, and the effects of a general constitution of it, favourable to disease. As I am un|able, either from minutes, or memory, to give any account of the weather, I shall leave the matter un|attempted.

Page  81In the year 1793, during the season in which such complaints usually appear, intermittents and their con|comitants were more frequent than they had been for many years before. In September and October, there were a few scattering instances of bilious fevers.

Early in the spring of 1794, inflammatory com|plains, chiefly of the pneumonic kind, were unusually prevalent. They were soon succeeded by intermit|tents; which were more frequent than they had been the year before. Nothing peculiar attended them; and they continued to occur pretty often through the summer.

Towards the last of July, the bilious, or, as it is called here, the pond-fever, began to make its appear|ance; principally about the South Pond, one of the mill-ponds beforementioned, and near the Canaan line. There were some s•attered instances about the North Pond: and a few, which were at such a distance from both, that they were, probably, occasioned by the stag|nant water about the great river, the Housaconak. But the disorder was chiefly confined to the vicinity of the South Pond. The influence of this pond appeared to extend about one mile and a half from its borders. Within this place there are about 150 inhabitants; and about 80 of this number were affected with the fever: part of them inhabitants of Sheffield, and a part of Canaan. Among those who were sick, there were five or six instances of mortality. There were not more than ten or twelve persons who had the disorder in other parts of the town. From these there was but one death; and that in a case complicated with pregnancy, and eventually with phthifis pulmonalis. People continued to be attacked with this fever through the months of August, September, and a part of October.

The disorder was, probably, in all respects, what is termed a bilious remitting fever. It began with an ague fit; intense pains in the back, head, and limbs, soon succeeded by thirst, dryness of the skin, &c. con|tinuing without much variation •8 or 20 hours: a slight moisture then broke out upon the skin—••dom Page  82 a profuse sweat; a degree of remission of the fever, and abatement of the pains, then ensued, and continu|ed till about the time of day of the first attack, when another exacerbation of fever commenced, with symp|toms similar to the first. If the disease was left to itself, the remissions would sometimes become shorter and more imperfect, as the paroxisms were repeated, until it grew to be nearly or quite a continued fever. A diarrhoea, and sometimes dysenteric symptoms were added to the rest. Most of those who died were at|tended with a preternaturally lax state of the bowels; which in several instances, might properly be called dysenteric. The tongue was, from the first, covered with a white sur. After three or four days, a black stripe began to appear; extending from the root, towards the extremity; and gradually spreading as the the disorder advanced, till the whole tongue assumed a black appearance. Even the teeth and gums were sometimes covered with this black fur; and in some patients who afterwards recovered.

In the treatment of this disorder, evacuation of some kind, is undoubtedly necessary in the early stage of it. Venesection generally produced a temporary relief from the violence of the pain, and was, probably, when the constitution was firm and robust, and the habit ple|thoric, frequently useful; but it did not appear to me to be important as a curative remedy. Emetics some|times did well; and where there was a great degree of nausea, I thought them useful. But purging, with ca|lomel and jalap, was the mode of evacuation I prefer|red, and generally practised; and the remedy which of all others appeared to be most advantageous in the early stage of the disease.

It is unnecessary for me to say any thing more, in this place, than the assiduous purging, in the beginning, and a plentiful use of the bark, after the remissions had become such as to make it admissible, were the essen|tial parts of the management of this disorder.

So strong was the tendency to disorders of this kind, that people continued in some instances to be affected with intermittents, or fever and ague, through the Page  83 winter. These were frequent in the spring, but with no peculiarities, and yielding to the common remedy with the usual facility.

During the month of August 1795, I was in the county of Ontario, in the western part of the state of New York. There was, at that time, a disorder pre|valent there, of the same nature with that which I found rise in Sheffield, on my return, and which I am about to describe. It was chiefly existent in the neighbour|hood of stagnant waters, and in situations similar to those places, in this town, to which the disease was most confined. The treatment required was, of course, the same.

On my return to Sheffield, which was the 5th. of September, I found a number of the inhabitants, about the North Pond, afflicted with a fever, which began to appear about three weeks before. The people first at|tacked were those who lived nearest to the pond; whole families of whom were down at once. Numbers con|tinued to be taken daily, chiefly within the vicinity of this pond, or within three quarters of a mile of its bor|ders, till about the middle of October; after which time there were few instances of new attacks. In this time, i. e. from the 10th. of August to the 20th. of October, of about 200 (which is not far from the num|ber of persons living within three quarters of a mile of some of the borders of this pond) not less than 150 were affected with more or less of this disease; out of which number, but one person died, and that an aged man, previously debilitated and disordered.—The number affected with this fever, in all other parts of this town, did not, I believe, exceed thirty. Of these, three died: one, an aged woman; the other two, preg|nant women, of whom one died in the fever, the other suffered an abortion, and died some months after, dropsical.

The disease, this year, put on a different form to what it did the last. It might, with more propriety be called an intermittent, than a remittent fever; though it was very different from a common fever and ague. Page  84 It began, like other fevers, with an ague fit, attended with pains in the head, back and limbs. The duration of this part of the paroxism was uncertain. It was succeeded by a hot fit, whose duration was, in different persons, from six to forty eight hours. A remission, and, sometimes, nearly or quite, a perfect intermission, then came on; but whose duration was as irregular and uncertain as was that of the paroxism before. After the first, the paroxisms were not generally ushered in by a regular ague fit; only some slight chills were felt; and these were irregular, both in degree and continuance. The length of the next succeeding paroxisms and intervals could, by no means, be calculated for, from the pre|ceding, so completely irregular was this disorder. The fever evidently tended to an intermittent form; but it could neither be called quotidian, tertian, quartan, nor by any other name used by authors to distinguish the different species of intermitting fevers. The pains in the head, limbs and back, were very fevere, particu|larly in the latter, which were so universally intense, that the symptom might almost be considered as charac|teristic of the disorder. In the primae viae, flatulency was nearly a constantly attendant and very troublesome symptom. Evidences of an increased secretion and ex|cretion of bile, were generally present through the disease, but were particularly observable in the conva|lescence. Some degree of yellowness of the skin, which was almost universal, indicated a reabsorption of this fluid, and a deposition of it upon the skin. This yel|lowness was in two instances which I saw, very intense. A slight degree of delirium was very common, during the height of the fever. The appearance of the tongue was much the same that it was last year.

My method of treating the fever of this year, was similar to that which I employed the last year.—Pur|ging, in the beginning, and afterwards a plentiful use of the bark, appeared to me to be the most successful way of managing it. In extreme cases, particularly, a free and full exhibition of bark, wine and laudanum, seemed the only means of salvation. It was absolutely necessary that the patient should be thoroughly purged, Page  85 previous to the use of stimulants, otherwise the bark, wine, or laudanum, would have very pernicious effects. I saw several instances, at the westward, where, by too early a use of these medicines, the fever was changed into a continued form, attended with a constantly dry and yellow skin, comatose symptoms, &c. One of the instances of extreme yellowness, which I have men|tioned, was of this kind, and at the westward. I re|moved this symptom, and recovered the patient, by giving repeated doses of calomel and jalap, some per|spirative medicines, and afterwards the bark, wine, &c. Each purge in this case, lessened the degree of yellow|ness very apparently. The other instance of intense yel|lowness, which I saw, was in this town, in the case of the pregnant woman, whom I have mentioned to have died in the fever. This woman's fever never had distinct intermissions. Several slight attempts were made to administer the bark; but it would not do. Perhaps my timidity in the evacuants, on account of her situa|tion, was injurious to her.

The Bark did not suspend the paroxisms, in this disorder, in as short a time as it does in common inter|mittents; but, if the patient was properly prepared, and the use of it was persevered in, it never failed to have the effect.

Purging was probably useful in a twofold way: First by carrying off the superfluous bile; which was evident|ly secreted and excreted in a preternatural quantity: Secondly, by reducing the sthenic diathesis, which was perhaps always present in the early stage of the dis|order.

It is true, that those whose fever was suspended by the bark, were subject to frequent relapses, and to a long and lingering state of convalescence. This drew an odium upon that medicine; and many were indu|ced to believe that it was owing to the use of it that people were so long in recovering, and of course, that it was improper. I am convinced, however, from very attentive observation, that those who did not take the bark, but suffered the fever gradually to wear away, as it sometimes would, were equally subject to those Page  86 inconveniences. Indeed this seems to be the nature of the disease, The old people in this town, who recollect the times when disorders of this kind have prevailed here before, and when the bark was not at all used, inform me that those who were afflicted with them, were a long time in recovering.

It seems that in all cases, when patients have got rid of the fever, either by means of the bark, or other|wise, there remains an increased disposition to the for|mation and excretion of bile, and that this humor ac|cumulates in the primae viae, till it first destroys the ap|petite and occasions nausea, and then excites a sponta|neous discharge by stool or vomiting, or a relapse of fever, or both. A continuance in the use of some lax|ative medicine, after a recovery, has a tendency to prevent these effects; and, if strictly attended to, would probably prevent them, and perhaps obviate the disposition to relapse entirely.

In reflecting on phenomena of this kind, the human mind is anxious to fix on something satisfactory as their causes. Specific contagion, I am convinced, was in no instance which came under my observation, either here or at the westward, the cause of the propagation of the disorder. That marsh effluvia, to whose action the in|habitants of some parts of this town are subject, is the exciting cause, and is necessary to the production of the disorders in question, is beyond any manner of doubt. This is evident from their existing only where this influence extends. But something more is want|ing; otherwise we cannot account for their prevailing in some years, and not in others. Every circumstance relative to the ponds * and marshes in this town, has ap|parently Page  87 been the same for many years past; and yet very little of this form of disease has appeared, for ten or twelve years back, until the two last. We must ei|ther suppose a peculiar constitution of the atmosphere, occasioning a predisposition to these disorders, and co|inciding with the local cause, or marsh effluvia; or that the marsh effluvia itself is, by some peculiarity of the at|mosphere, wrought up to a higher pitch of virulence, and thus produces a higher degree of disease. I am in|clined to admit the latter supposition, as I am convinced that the fevers which have prevailed here for two or three years past, and the common intermittent fever, are the same, only differing in degree. I have seen all degrees, from the mildest form of intermittent, to the most extreme of bilious remitting fever. It is impossi|ble to say where the line of division shall be drawn. The disease this year seems to have formed a connecting link between intermittent and bilious fever; and were I to name it, I would call it a bilious intermittent. Should the intermittent fever, in its usual form, prevail next year, the disorder may be said in the three years, to have been in regular gradations run through.

EXTRACT OF A LETTER FROM DR. THEODORE JOHNSON OF EASTON, TALBOT COUNTY, TO THE AUTHOR, DATED MAY 16TH. 1794.

"BEFORE I give you a detail of the diseases which prevailed with us last summer and autumn, it may not be improper to give you some idea of the situ|ation of Talbot, and a description of the season which preceded the sickly one, as it is a well known fact, that a predisposition to certain diseases, are frequently ge|nerated in one season, and the diseases produced in another.

This county is bounded on the west by the Chesa|peak, and is variously intersected by perhaps, as great a number of rivers and large creeks, as any in the Union, some of which extend for many miles into the country eastward, and are fresh some miles from their source. The country near the bay side in general is much the most healthy, but (as you will readily con|ceive,) is much the most affected by winds. The easterly and north-easterly winds, passing over the un|healthy parts of this peninsula, usually take up and carry the seeds of fevers with them; insomuch that when these winds prevail, the bay side is often as sickly as any other part of the country.

Last spring was very wet, and the months of May and June were marked by the excess, both in fre|quency and quantity of rain; in consequence of which Page  89 the crops of hay, &c. were larger than has been known for many years.

Part of July and August, was uncommonly warm.

We had comparatively few cases of fever in July, but early in August more people than I ever knew, com|plained of different degrees of indisposition, from a sense of lassitude to an intermittent fever. I really thought the remitting bilious fever (if it may be so called) was also more frequent, and more malignant, than I had ever seen it before. In some cases the vomiting was so violent, as to bring away large quantities of blood from the extremely relaxed exhalents of the stomach. I had one remarkable case of this kind, which termi|nated favourably: I have no unequivocal proofs that this fever was contagious, but am inclined to think it was, when it run into the typhus type, and exhibited symptoms of malignancy.

The dysentery most generally occurs here in autumn, when fevers of various types abound. It does not always keep pace with the autumnal fevers, yet I am disposed to think it only a different modification of the same dis|ease, as they are often very much intermixed, and gene|rally happen at the same season, and both appear to be derived from miasmata.

Last year there did not appear to be any great uni|formity, in the appearance of the dysentery, with the fevers that prevailed; but I rather conceived it was more influenced by diet, and the sensible qualities of the atmosphere.

May not the action of cold, or some error in diet, co-operating with miasmata and other sedative causes, occasion the disease to fall with more force upon the bowels, than the rest of the system, without the influ|ence of which, it would have assumed the common type of an intermittent? Or would you call this a sym|tomatic affection? I am confident I once took a true idiopahic dysentery, from getting extremely wet and cold, on being previously indisposed, at a time when autumnal fevers were rife, which always impressed Sydenham's idea very strongly upon my mind."

EXTRACT OF A LETTER FROM DRS. TAYLOR AND HANSFORD, TO THE AUTHOR, RELATIVE TO THE REMITTING FEVER WHICH OCCURS AT NORFOLK, ON THE CHESAPEAK BAY IN VIRGINIA, AND THE ADJACENT COUNTRY.

THE country around Norfolk is low land, mostly within twelve feet of the level of the sea, inter|sected in all directions with salt-creeks and rivers, the heads of which form swamps and marshes, and fenny grounds covered with water in wet seasons. Wherever it is not cultivated, the land is covered with large tim|ber and thick underwood. The vicinity of the sea, and the salt-creeks and rivers, occasion a constant moisture and warmth of the atmosphere, insomuch, that although under the same latitude a hundred miles up the coun|try, deep snows and frozen rivers are very common during the winter, yet here we consider such occur|rences as extraordinary; for these reasons, the spring is very early ushered in, sometimes so early, that many trees are in bloom about the latter end of February; from this time, however, till the end of April we are subject to cold rains, piercing winds, and sharp frosts.

About the middle of May, the weather becomes sul|try, with some cool days, occasioned by the change of winds to the north and north-east: At this period all the diseases of the winter begin to decline, and the Page  91 whole country is universally healthy (except here and there a trifling vernal intermittent which scarce requires the application of medicine) till the middle or latter end of June, when diarrhoeas and dysenteries appear among the children, mostly with those under two years old, though not absolutely confine I to such.

In some years the diarrhoea is almost universal, at|tended for the most part with an irritation of the stomach, and an irregular fever of the intermittent kind: After the proper evacuations, we apply bark in large quantities, joined to the most approved astringents and anodynes, gum kino, opium, spec. e•scord. &c. and when the stomach will not bear a sufficient quan|tity of bark, we throw it up in glisters repeatedly, for many days together, and this we have learnt, by ex|perience, to be the only mode which can be depend|ed on.

In July, the heat of the weather increases; but dur|ing the whole of this month and the greatest part of August, there are no diseases at all, at least none which can be called epidemic. On the approach of the au|tumnal months, intermittents begin to appear through|out the country.

It is not our province here to recapitulate the seve|ral opinions concerning the cause and nature of those fevers, nor yet to divide them into numberless species and genera. We have never been able to distinguish any other difference in the nature of intermittents, than that which constitution, climate, and manner of living give rise to; those causes will divide them into perfect, imperfect, or remittent: The several termina|tions of them which we frequently observe into con|tinued, putrid, or nervous fevers, will be found to arise from the same causes, and under those simple terms we shall proceed to treat of intermittents in all their stages.

Those which occur earliest in the season are uniform|ly of the mildest kind, and yield soonest to the proper medicines. Among the labouring and temperate class of our citizens, whose diet is simple, whose hours are regular, and whose use of spirituous liquors is sparing, Page  92 those fevers are perfect intermittents, generally of the tertian kind, and though not confined particularly to any age or sex, yet are most frequent among the younger class, the females and the children; they are in wet seasons almost general among those of the latter description in country places, and in low fenny ground. They yield immmediately to proper evacuations, and the use of the Peruvian bark, and seldom outlast the autumna• months, even without the assistance of any art: Sometimes, however, in relaxed habits, they ter|minate in jaundice, enlarged spleen, anasarca, and death. We shall not be particular upon this sort of in|termittents, because they are in nothing different from those which prevail in all countries similarly situated.

Among that class of citizens, whose hours are more irregular, and whose use of wine and luxurious food is more frequent, those fevers, though still retaining the intermittent, quotidian, and tertian form, are neverthe|less impefectly so; a great degree of heat, quickness of pulse, and debility remain during the whole time, which may be called intermission, with partial or total loss of appetite. Here intermittents begin to put on an ap|pearance, which we think very different from those of any other country; they are preceded by a chilliness, which commonly seizes the patient when he thinks himself in perfect health. Head-ach, great thirst and heat soon follow, in many instances delirium, vomit|ing, diarrhoea, and large discharges of bile;—about the fifth, seventh, or twelfth hour the patient is reliev|ed by profuse sweat, which continues with the afore|mentioned heat, quickness of pulse, and debility, till the next paroxism. These are generally of the ter|tian kind, and return regularly if no medicine is used, from nine to fourteen days, when they will com|monly terminate altogether, or degenerate into a slight quotidian, which allows the patient to walk about, and when the cold weather approaches, for the most part, leave him altogether.

People of the latter description are more rarely the subjects of intermittent fevers than those who live in a plain manner; and if proper evacuations are made, and Page  93 the bark administered with perseverance, and attention to the stomach and first passages, the disease may al|most certainly be cured after the third paroxism, and very often even a second is prevented.

We have always experienced cathartics to be the safest and most effectual evacuations in those kinds of fevers; and if the patient has an irritated stomach with costiveness, emetics are not only inadequate and unne|cessary but dangerous. We frequently find great dif|ficulty in making the stomach bear a sufficient quantity of cathartic medicines to procure the desired evacua|tions: when this is the case, laudanum and aqua men|thae, or extract. thebaic. are administered an hour or two before the purge, which generally causes the latter to remain, and though the opiate retards the operation, it does not ultimately prevent it, or render it less pow|erful. •fter this we proceed to the use of the bark during the intermissions, and without regard to mea|sure, give it as profusely as the stomach will permit, and in the most powerful form, beginning with the powder, and occasionally using the decoction, the ex|tract, and cold infusion. It too often happens, that the stomach will not bear the medicine at all, in which case we give large quantities of the decoction or infusion by clysters; and we can venture to assert, when those clysters are retained in sufficient quantity, the effect is equal to that produced by any other mode of adminis|tering it. During the paroxism, we find great relief procured, by making the patient drink plentifully of a strong infusion of serpent. virgin. to which, when the symptoms are very painful, we add laudanum in suffi|cient quantity to procure the patient perfect ease. These last medicines, particularly the serpent. have a visible power of shortening the paroxyism, and will rarely disagree with the stomach. The use of opium, its safety and advantage in those cases, we presume to be well known; therefore we shall decline making any observations upon it, except that we have not found it (as has been asserted) capable per se, of curing inter|mittents. It has been advised to give it in conjunction with the several preparations of bark, where the irrita|ble Page  94 state of the stomach will not bear the cort. alone. This expedient will succeed, if the quantity from time to time be increased, and is often used with success, though it invariably occasions great distress to the pa|tient when the fever leaves him, by inducing an h•sle|rical or hypochondriacal sensation, which if it does not amount to pain, the patient will tell you his feelings are far worse than if it did.

The use of this medicine to prevent the passage of the bark by stool is known to every one; but we think the gum. kino for general use much better, and more permanent in its effects.

At the accession of those fevers there is frequently a full hard pulse, inflamed eyes, a sense of fullness in the breast, and sometimes a sharp pain in the side, re|sembling that which attends inflammatory fevers. These circumstances have often led practitioners, and others who are not acquainted with the climate, to bleed the patient; an expedient, which if it does not produce a tendency to putrefaction, invariably fixes the fever so firmly, that the cure becomes afterwards exceedingly difficult.

When no medicines are given at all, we have obser|ved before, that the fever for the most part will decline of itself on the ninth or fourteenth day, or degenerate into a slight quotidian, and sometimes a quartan; this is, however, not always the case.

If no medicine has been given, or if the disease has been improperly treated by bleeding, or by too great evacuations, otherwise by forbidding the use of wine, &c. the fever sometimes becomes remittent.

In the town we have also many of these fevers, which though clearly belonging to the class of intermittents, appear in the form of remittents; because, there is an evident tendency to decline of the fever at a parti|cular time, once in twenty-four hours, every other day, or every fourth day, and all the diagnogstic symptoms are precisely the same as they are in distinct intermit|tents, making allowance for age, sex, and constitution; nor do the means of cure differ, though variously ap|plied.

Page  95In the town, throughout the months of September and October, many of the inhabitants are seized with fevers, which begin with chilliness, a sense of fulness in the stomach, followed by pains throughout the limbs, neck, back, and hips, great heat and prostration of strength, which proceed and terminate as before de|scribed, under the term of imperfect intermittents. But others who are attacked in the same manner, par|ticularly robust and plethoric habits, or those who are accustomed to drink a great deal of wine, porter, &c. and take plentifully of luxurious food, have a greater sense of heat, more pain in the limbs, and much more oppression and debility—are extremely restless, some|times with delirium, and great thirst; and when the period of intermission of the fever should arrive, viz. the ninth or twelfth hour, are but partially relieved, that is, the sense of heat is not so great, the delirium and restlessness are somewhat abated, and there are some few strokes difference in the pulse; and when there is nausea and vomiting, those likewise partly cease to torment the patient, but the prostration of strength, pain in the limbs, &c. with the dry skin, still remain: Here the evacuation by cathartics should be attempted without delay, and the period of the remission (which though obscure, lasts several hours) employed in ad|ministering bark in every possible form, without regard to the quickness of pulse and dry skin; wine should be given in large quantities, and on the return of the pa|roxism, the patient should drink profusely of an infusion of serpentar. with wine.

When this plan is followed with perseverance, the patient almost always recovers, though the paroxism, or properly speaking, the violent hours of the fever, may return once or twice; but if this is neglected, af|ter the second return, the fever puts on • malignant and putrid type, and often ends in death.

We have sometimes found it impracticable to make the patient keep the bark in any form, or by any mode of giving it; when this is the case, the disease is always dangerous, and the only expedient we have left is the use of wine and serpentar. and we have so many times Page  96 experienced the advantage of this last medicine, by giving it in a large quantity, that we cannot help earnestly recommending it to the notice of every prac|titioner.

It is a medicine, though of known efficacy, very much neglected, at least the proper administration of it; like the bark, it cannot be given in too large a quantity, when the stomach will bear it. The fevers of the latter description are less common than the others.

When the disease begins to yield to the medicine, a profuse sweat comes on; the pulse grows full, slow, and soft; the sense of heat and pain in the limbs, back, hips, and neck abate and gradually subside; the patient has a desire to ear, and in a few days he feels nothing but a debility, which is far from being so great as the violence of the disease would give cause to sus|pect, and a very little time restores him to perfect health and vigour.

When it is about to terminate unfavourably, there is an increased irritation of the stomach, with vomiting of cystic bile, mixed with tough mucus, attended in some cases with diarrhoea, the pulse grows smaller, quicker, and intermits, or rather seems at times to re|treat from the finger while feeling it; the countenance falls, the eyes become glossy, the tongue black and dry, the teeth cemented over with a black mucilaginous substance, cold extremities, and death; the pulse, however, is never to be depended upon in the termi|nation of these fevers; it is sometimes so hard, full, and regular, even at the moment that every other symptom evinces the approach of death, that inexpe|rienced practitioners would be often induced to bleed or evacuate when the patient is expiring.

When continued fevers from intermittents take place, they are generally confined to relaxed, debilitated, or debauched habits; they are far from being common with us, and as in every other country, they either ter|minate on the twenty-first day, or lengthen out into what are called nervous fevers, we shall neither treat of this stage of the disorder, or pretend to point out a mode of cure, for whatever may be the predisposing Page  97 cause, the disease is invariably the same, and requires the same mode of tretament in every country. We must, however, take notice of one effect which some intermittents produce, viz. a debility or affection of the optic nerve, so as to render the patient perfectly blind, till the bark and other tonics, have removed the fever, when those patients recover their sight with health.

AN ABSTRACT OF THE OPINIONS AND PRACTICE IN FEBRILE DISEASES, OF PHYSICIANS OF DIFFERENT COUNTRIES, &c. WITH OCCASIONAL REMARKS &c.

HIPPOCRATES, (who practised medi|cine in Greece, about four hundred and fifty years before the Christian aera, and who was the first that we have on record, that reduced the healing art to any kind of system) has described a bilious fever, under the title of typhus,* which he says invades, when the bile is moved through the body when the dog star arises in the summer time. In this disease immediately an in|tense burning was felt, together with an acute fever; and immediately the strength was exhausted, with a weakness and heaviness of the body, and such an impo|tency of the legs and arms that they were of no use to the patient. He also remarks that the belly was dis|turbed with violent gripings, and evacuations of offen|sive excrements. The remedies recommended by this celebrated and venerable physician in the cure of this fever, were cold, and thin suppings, black austere wine, or if that disagreed, white austere thin wine. He also Page  99 advises the application of linen cloths dipt in cooling liquors to those parts of the body where the greatest heat is principally perceived*

This extraordinary physician collected together the signs that occur and appeared to be characteristic of every disease that came under his notice, and by com|paring them with what he observed in a natural state of health, estimated the danger in proportion to the degree that those signs of disease departed from a state of health. If the physicians since his time had been content to have learned the treatment of diseases from a faithful obser|vation of the effects of remedies instead of puzzling their heads with researches into their intimate causes, the healing art would not have been subjected at this time to the opprobrium of a conjectural art.

Erasistratus, a physician distinguished for certain in|novations in the treatment of diseases, two hundred years later than the Coan sage, Asclepiades and his dis|ciple Themison, who practised medicine with reputa|tion at Rome a few years before the introduction of Christianity into the world, were all enemies to blood-letting in fevers. Believing the disease to depend upon a straitness of the minute or extreme vessels of the body, and especially on the surface, their practice was to prohibit the use of all kind of aliment for the first three days, and to drench the patient with copious draughts of water to relax and render the vessels per|meable.

Hippocrates remarks that one should open a vein in acute diseases, if the disorder appears violent if the patient is in the vigour of his age, and the strength at that time is also considerable†

Serapion who made his appearance about the same period as Erisistrates, was the founder of the empyric sect, as the latter was of the methodic. His followers were numerous, and many of them respectable; but we have no account of their practice in the fever under Page  100 consideration. The summary view of Celsus, or the accidental fragments in the volumnious works of Galen, furnish only imperfect information. Contentions how|ever, ran high between the Dogmatists and Empirics, the former of whom, were chiefly guided by reasonings; and generally misled by the erroneous philosophy of the age in which they lived, while the latter trusted solely to experience.

Celsus, who lived in the reign of Tiberius, says, "Blood-letting is required when the fever is violent, and the body looks red, or the veins swell, and appear full."—Celsus however, makes no mention of venae|section, where he treats of the cure of an ardent fe|ver, by which term the antients understood a disease similar in almost, or perhaps in every respect, to the malignant yellow fever of the West Indies of pestilen|tial origin, as appears from the description of the symp|toms, and period of its termination, given in Hippo|crate's Epidemics, the substance of which, is delivered in Vanswieten's Commentaries, Vol. 7th. p. 96.

In continual fevers, with symptoms denoting inflam|mation, it was the practice of Galen, who left Perga|mos and settled in Rome about the year 160, to bleed the patient till he fainted, with the view of extin|guishing the fever at once. In this kind of fevers, he expressly advises blood-letting and the drinking of cold liquors. But he has made no mention of blood-letting, in intermittent or remittent fevers.

Neither Aetius, nor Paulus Aegineta, who lived after Galen: The latter in the 7th. century, and has given an analysis of the opinions and practice of the prolix com|mentator of Hippocrates, make any mention of opening a vein, either in the remitting, or ardent fever, as they term the synochus.—But Aroeteus, a cotem|porary of Aetius, treating of the cure of a syncope, the beginning of which he pronounced an ardent fever; recommends venaesection, when the syncope proceeds from too great a quantity of blood, and some consi|derable inflammation appears about the liver, or pre|cordia. He however subjoins, that "much less blood ought to be evacuated, than upon other occasions, Page  101 because the least error committed in this respect, may be of fatal consequence."

Avicenna, the Arabian, who practised medicine at Ispahan, the capital of Persia; and compiled a Treatise on Diseases, from the works of Galen, in the 10th. century. His theories are those of Galen: In the ge|neral conduct of the cure, he follows him closely. He is indeed more reserved with the lancet, while he is not always consistent with himself, in the manner of employing it.

The healing art, after the surrender of Alexandria, was little cultivated by the slothful and dispirited Greeks, but it sprung up with fresh vigour, in Syria and Arabia, and being extended with the conquests of the Saracens, it was introduced into the northern coast of Africa, and from thence was introduced into Spain and Italy.

After the fall of the Roman Empire, the genius of learning made no exertion in Europe, for a very long period of time. The Europeans were content, with the imperfect knowledge they could glean from the writings of Avicenna.—And part of the 16th. century passed over, before any real improvements were made in the treatment of fevers.

Among the most celebrated of the followers of Galen in the 16th. century, were Fernelius, Forestus, Lom|mius, and Sennertus; men of considerable talents, but too strongly attached to the opinions of their mas|ter, to exercise their own judgments to the best ad|vantage.

Lommius in particular, we are assured by Dr. Pat|terson, (in his Remark's on Dr. Rush's Works,) re|commended the use of blood-letting in the beginning of fevers in adults, and in whom vigour naturally abounds; but he reckoned it dangerous to repeat it in the exacerbation, or height of the paroxism.—When the patients strength is not much exhausted, but purely a little diminished, with lowness of spirits; venaesec|tion is neither to be entirely omitted, nor the quantity of blood drawn, to be copious. The length of the intervals is to be regulated by the strength of the pa|tient, Page  102 and the violence of the disease. In great weak|ness however, the lancet is to be entirely withheld, estimating this condition principally from the situation of the vital powers; while considerable caution is to be used in judging from the pulse, as it is liable to be affected by a variety of circumstances, which are often totally unconnected with the disease. The quan|tity to be drawn, should depend upon the result of a comparison between the disease, and the strength of the patient.

In a violent fever, if the patient's strength be not im|paired, Lommius advises a liberal evacuation of blood, and justifies the practice of Galen, of bleeding, in such cases till the patient faints, on the principle that the sudden depletion brings the patient directly to a state, different from what he had been in just before, whilst he may be revived from the syncope, by refrigerating means.

Botallus, who also lived in the 16th. century, car|ried blood-letting to still greater lengths, especially in pestilential fevers, in which he asserts, as quoted by Sydenham, that he found no speedier, and safer re|medy in pestilential disorders, than copious and sea|sonable bleedings; in all his patients, which were ex|ceeding numerous, both at the siege of Rochel, at Mons, and at Paris.

Sydenham himself had a high opinion of copious and repeated blood-letting in the plague, as well as in all inflammatory disorders; but he prohibits it in every form of the autumnal intermitting fever, even when concealed at the beginning, under the mask of a con|tinued fever.

"Autumual intermittents when the constitution is epidemic usually appear about June, but otherwise not till August, or the beginning of September, and very rarely in the following months. It is likewise to be noted, that it is a difficult matter at the first ap|pearance of intermittents, especially of those that are epidemic in autumn, to distinguish them exactly; be|cause at this time they are accompanied with a con|tinued fever; and for some time afterwards, unless Page  103 great attention be given, nothing more than a remis|sion can be discovered; but by degrees they perfectly intermit, and put on a form entirely agreeable to the season of the year." (Swan's Sydenham, p. 55.)

"Frequent experience has taught me," adds Dr. Sydenham, "that it is very dangerous to attempt the cure (of autumnal intermittents) by purging; unless in a way hereafter mentioned, and especially by bleeding. For in tertians, particularly in a very epidemic constitu|tion, if bleeding does not prove a present cure, it pro|longs the disease even in young, strong, and otherwise healthy subjects; but aged persons, after having long struggled with it, are destroyed thereby. What has been observed of bleeding, holds also of purging, with this difference only, that the latter is less dan|gerous, unless it be frequently repeated." (Page 59.) Boerhaave and Vanswieten have both adopted the same opinion. (Com. Vol. 7th.)

In treating of the epidemic diseases, from the year 1675 to 1680, the same author observes, that "though tertians and quotidians, after a fit or two may seem en|tirely to intermit, yet they frequently afterwards de|generate into a kind of continued fevers, and only come to a remission on those days that promised an inter|mission, &c. In this case I seize the opportunity of the remission, though it be ever so short, and give the bark more liberally during that interval, than when the in|termission is perfect" (Page 310.)

The most common termination of fevers, is by sweat|ing; this fact was observed by Van-Helmont, and fur|nished him with the design of prosecuting the cure of the disease, entirely on that plan. This practice ap|pears to have been early adopted in many parts of Europe, and was in general reputation in England, at the time Sydenham engaged in practice. Syden|ham having observed the bad effects of heating medi|cines, employed indiscriminately for this purpose, was induced to employ antiphlogistic processes, and espe|cially venaesection, which he carried to a considerable extent, particularly in fevers accompanied with an in|flammatory Page  104 diathesis, or connected with local inflam|mation.

But as it is the fate of the healing art, as well as every other, that depends upon opinion, to pass with large strides from one extreme to its opposite. Syden|ham frequently employed his depleting remedies, in cases which later and more numerous observations, demonstrate that they were improper. His practice was always at open war with his principles; for if the fever as he believed, is an effort of nature to exter|minate something hurtful from the constitution, bleed|ing and those evacuations, which diminish the powers of life, are not the proper means of effecting this pur|pose. In admitting such essential differences in the cause of epidemics, he also necessarily leads us into embarrassment, and often leaves us in a state of uncer|tainty; the fevers which he supposes to be essentially dif|ferent, and occasioned by different constitutions of the atmosphere, is in fact the common endemic of London, and the adjacent country, diversified as in other places by the season, soil state of the weather, constitutions of the inhabitants, and idiosyncrasies of individuals. Cir|cumstances arise in all countries, which modify the ge|neral cause of intermittent fevers, hence the disease ap|pears at one time with symptoms of in••ammatory dia|thesis, at another with symptoms of nervous affection, and at another with a general disposition to affections of particular organs.

Baglivi, who published his Observations on the Dis|eases of Rome, in the year 1696, says, that "The air at Rome, which is hemmed in by seven hills, is na|turally moist and impure, particularly in autumn, when the days are extremely hot, and the nights cool, and accompanied with heavy dews. At this season, the air is also much impregnated with the exhalations from the low moist ground, and the waters which wash the soil in its vicinity. That city is also much infested with unwholesome winds from the south, south-west, and south-east. The air is sometimes so prodigiously hot, as to exhaust all the moisture of the soil, and to occasion fevers of a very dangerous kind; the Hemi|tritaiae Page  105 of Galen, in which symptoms resembling apo|plexy, were common. The air is particularly impure and unwholesome, near the flat grounds along the Ti|ber. But all the parts of the city, which stand high, and are thick settled, with a prospect to the north or east, and are a considerable distance from the Tiber, are healthful. In the Campagnia di Roma, which is surrounded by a ridge of mountains in every direction, excepting a tract which extends towards the Mediter|ranean, the air is so impure in autumn, when the south wind prevails, that if the inhabitants of the city happen to remain there only one night, and then re|turn to the town, they are soon after seized with a fever accompanied with malignant symptoms, called the Foul Air Fever. In this fever, cordial and vinous me|dicines, and blisters, are very beneficial, but bleeding is extremely pernicious."

About the beginning of the present century, when every department of science, had arrived at a consider|able degree of improvement, there appeared in the writings of Stahl, of Hoffman, and of Boerhaave, three new and considerably different systems of physic, which for a considerable time had, and still in many parts of Europe, have a considerable share in directing the treat|ment of diseases.

Trusting much to the efforts of the animal system, which they supposed were conducted with constant at|tention and wisdom: Stahl and his disciples have in ge|neral, proposed only very inert and frivolous remedies, and are extremely reserved in the use of blood-letting, vomits, &c. in fevers.

The celebrated Boerhaave, who was professor of the theory and practice of physic, in the University of Ley|den; in his Aphorisms concerning the knowledge, and cure of intermittents, particularly at Section 762, ex|pressly says, "Hence blood-letting in these fevers, is in itself generally prejudicial, otherwise it may be of service by accident, or in some cases, as may be, like|wise a thin and strict diet."

On this Aphorism, his learned and experienced commentator, the Baron Vanswieten makes the follow|ing, Page  106 among other remarks; "Since blood-letting is so efficacious a remedy in quieting the too great violence of a fever, as we said before, many physicians have been likewise of opinion, that it may be of great use in the cure of intermitting fevers; and some have even believed, that these fevers might be removed only by repeated blood-letting. But since it was demonstrated under the preceding Aphorism, that all evacuations if violent and repeated, are prejudicial because they weaken, so the same is true likewise of blood-letting."

IN the System of Medicine of Dr. Hoffman, late pro|fessor at Hall in Saxony, published at Geneva in the year 1761, since translated by the late Dr. Lewis, and published by Dr. Duncan; we have the following ob|servations on intermittents and remittents, &c. Vol. 1st. p. 55, 56, &c.

"In the uncommonly hot and dry summers and autumns of 1726, 1727 and 1728, a variety of ano|malous, malignant intermittents were epidemic almost throughout Germany. Some suffered one, some two sits a day. In some they were at first continual, and changed on the 3rd. or 4th. day into intermittents; in others they intermitted at first, and changed afterwards into dangerous continuals. In some there were exces|sive evacuations of bilious and pituitous matter, both upwards and downwards, in others constant sweats, and faintness, during the remissions or intermissions. Some complained, during the fever, of heat and cold at the same time. Young persons were sometimes highly delirious in the paroxism; the aged sleepy: All com|plained of an anxiety and painful pressure about the region of the stomach; a dull pain of the loins, feet and head, and in the time of intermission, a pain in the nape of the neck, scapulae, and along the spine. At length pustles breaking out on the face, or purple mi|liary eruptions on the body, all the symptoms abated. if a sorbutic miliary fever was joined, the disease Page  107 proved of longer continuance; if the eruptions were white, it was generally fatal.

"These fevers were most frequent in marshy places; to persons of an irregular life, or weak constitution; after bleeding, strong purgatives, immoderate passions; and to women on the approach of the monthly period. Freedom of perspiration, openness of the bowels, avoiding cold moist air and unwholesome foods, were the surest preservatives. Some recovered in a fort|night; with others the disease lasted a month. Very few died, unless from some great mismanagement.

GENERAL METHOD OF CURE.

1. "In the beginning of the disease, small doses of nitre were given, both in the paroxisms, and in the intermissions, along with some agreeable simple wa|ters, to which were added a few drops of spir. nit. dulc. or the mineral anodyne liquor. The common drink was water gruel, with lemon juice and lemon peel, or reduced with almonds, into the form of an emulsion.

2. "The belly, where costive, was loosened by glisters of water-gruel, with cammomile flowers, oil of almonds, and common salt, and potions of mana and cream of Tartar. In some persons, rhubarb answered better.

3▪ "A sweat was promoted at the end of the pa|roxisms, where nature was too weak to effect it with|out assistance, by saturated diaphoretic mixtures, mix|ed with equal quantity of the anodyne liquor, and a few drops of volatile aromatic spirits.

4. "When, by these means, the fever had abated, and changed into a true intermittent, it was successfully treated as such. In some cases, the bark was given at the beginning, after a gentle emetic, along with casca|rilla, nitre and calx of antimony.

"In these fevers strong purgatives, and emetics did harm. Bleeding, acrids, sudorifics, and all hot me|dicines Page  108 were apt to change the single intermittents into double, or into continual fevers. Mild evacuants were serviceable.

"When vomiting, restlessness, and coolness of the ex|tremities were urgent, a gentle diaphoresis was pro|moted by the mineral anoydine liquor, mixed with a few drops of volatile spirits, distilled oil of mace, or a small quantity of the extract of saffron, and warm di|luting drinks."

SIR JOHN PRINGLE observes, that, "Though all moist countries are subject to intermittents, yet if the mois|ture be pure, and the summers are not close and hot, the fevers will mostly appear in a regular tertian form, and be easily cured. But if the moisture arises from stagnating water, in which plants, fish, and insects die and rot, then the damps being of a putrid nature, not only occasion more frequent, but more dangerous fe|vers, which oftener appear in the form of quotidians, or double tertians, than, in that of single ones.

These marsh fevers are not only apt to begin with little remission, but after intermitting for some days, to change again into continual fevers, with putrid and malignant symptoms.

It is also remarkable how they vary with the season; for however frequent, violent, or dangerous they have been in the decline of summer, or beginning of autumn, when putrid exhalations are most abundant, yet before winter, they are reduced to a small number, become mild, and generally assume a regular tertian form.

The first kind were observed in the campaign of the year 1747, to prevail near the inundations in Dutch Brabant; the next were those of Zealand; of the 3d. degree, were those in the lines of Bergan-op-Zoom; and the mildest sort, were such as were most frequent in the cantonments around Eyndhoven, in villages ren|dered moist by plantations, and subterraneous water.

Page  109At the height of the epidemic it appeared, that both intermittents and remittents, by extending or doubling their paroxisms, frequently changed into a continued, putrid and dangerous form, and that most of those that were lost, died in this way. But in general the mor|tality was not in proportion to the number of the sick, nor to the alarming nature of the symptoms. Although the distemper was violent, yet it yielded to medicine; and no kind of acute disorder seemed to require it more. One of the most unfavourable circumstances, was the proneness to a relapse, the danger of which was great|est during the hot weather, less in the decline of autumn, and least of all after the frosts began.

Frequent relapses brought on visceral obstructions, which made the intermittents more obstinate and ir|regular, and terminate in a dropsy, or jaundice. (p. 182,) &c.

Fifteen hundred patients, the greatest part with the dysentery, and a number of wounded men, being crowded together in a hospital, 3 leagues from Ha|nau, vitiated the air, and gave rise to a still more alarming distemper, viz. the jail or hospital fever; the common effects of foul air from crowds and animal corruption. (p. 22). This fever, and the dysentery grew daily worse. Few escaped, for however mild or bad the flux was, for which the person was sent to the hospital, this fever almost surely supervened.

The petaechial spots, blotches, tumifaction of the pa|rotids, frequent mortifications, contagion, and the great mortality, sufficiently shewed its pestilential nature.

Of fourteen mates employed about the sick, five died; and excepting one or two, all the rest had been ill and in danger. The hospital lost near half of the patients; but the inhabitants of the village having first received the flux, and afterwards this fever by contagion, were almost entirely destroyed.

One general hospital being established at Newied, the sick were removed from their several quarters, and carried down the Rhine to that place; where by the change of the air, those from Feckenheim were at first relieved, but the rest who were mixed with them caught Page  110 the infection, which the following circumstance ren|dered still more general and fatal. For orders coming soon after to remove all the sick from Germany to Flanders, they were embarked in Bilanders, and con|veyed by water to Ghent.* During this voyage, the fever having acquired new force by the confinement of the air, by the mortification and other putrid effluvia, it became so virulent, that above half the number died in the boats, and several of the remainder soon after their arrival.

The resemblance of this hospital fever, to the true plague was further evinced, by the following memora|ble incident.† A parcel of old tents being sent on board the same Bilanders with the men, were used by them for bedding: These tents, in order to be re|fitted were put into the hands of a tradesman at Ghent, who having employed 23 Flemmish journeymen about the work, lost 17 of them by the distemper, though they had no other communication with the infected."

From these observations, and from the frequent no|tice taken of the supposed contagious effects of the dy|sentery, it is manifest that Sir John Pringle never ob|served the remitting or intermitting fever to be propa|gated by contagion; on the contrary, he expressly says, the circumstance of the dysentery being contagi|ous, shews that it is essentially different from these fevers.

Sir John Pringle is of opinion from the symptoms and contagious nature of the pestilential fever, which occur|ed in the Imperial army in Hungary, A. D. 1566, de|scribed by Sennertus, (p. 254 Edit. 6th.) that it was a compound of the bilious and hospital fever, taking its rise in the camp, but acquiring its high degree of ma|lignity Page  111 and contagious quality, from the foul air of the places in which the sick were crowded.

In his Observations on the treatment of the bilious remitting, and intermitting fevers of marshy countries, Sir John Pringle remarks, that "In most cases, it was necessary to open a vein, either upon the first attack, or the next day, if there was no intermission. But re|peated bleedings, unless upon evident marks of a fixed inflammation were so far from producing the desired effect, that they seemed to render the fever more ob|stinate. It ought also to be remarked, that the rule about bleeding regards the soldiers only, and not the natives, whose constitutions were different from the sol|diers, who were not only young, but robust and san|guine. And even among the soldiers, bleeding was seldom necessary upon a relapse, as the fever then ap|peared without inflammation, and as a regular inter|mittent.

An antimonial emetic generally rendered the inter|mission more distinct. The marsh fever, during the hot season, being more apt to run into double parox|isms or to change into a continued form, than to re|main regularly intermittent, it was necessary after due preparation to stop it in the first fair intermission. And for this purpose, the bark was found to be no less specific in those parts than at home—and there was no security against relapses, unless the patient took an ounce of the bark in powder, once every ten or twelve days throughout the autumn. The most effectual way to make a soldier continue the use of the bark, is to mix it with equal parts of brandy and water." Page 109, & sequent.

MOST of the fevers of Minorca* make their first appearance in the shape of a true simple, or double Page  112 intermittent tertian. The cold sit seldom lasts above an hour or two; and as it goes off, some bilious matter is commonly discharged by vomit or stool. Then fol|lows an intense heat over the whole body, which raises the mercury in the thermometer to the 103d or •04th degree: And lastly, a profuse sweat puts an end to the paroxism. The apyrexy is tolerably complete, though for the most part the patient complains of a disagree|able taste, loss of appetite, head-ach, and pain in the small of his back, and pit of his stomach upon a full inspiration. The pulse during the intermission is almost natural: in the fits it varies according to their predo|minant symptoms: When they are attended by acute pains in the praecordia, it becomes small and obscure, so as to indicate greater weakness than there really is: on the other hand, when drowsy lethargic symptoms come on, it often resembles that of a person in full health, though the sick is in the utmost danger. The urine, whether made in the time of the paroxism or interval, is always clear, frothy, and of a deep red co|lour, without any separation. Blood drawn from a vein is most commonly florid like scarlet, without any sizey crust: the serum is sometimes tinged with yellow, but oftner red like the lotura carnium, and in great quantity. Sometimes the serum and crassamentum re|main united in a lax gelatinous mass.

As the fever advances to its height, the coldness and shivering which usher in the paroxisms become less, or intirely imperceptible: in which case a cholera mor|bus, or acute pains in the back or limbs, often supply their place: frequently the shiverings are intermixed with flushings of heat. In the mean time, the parox|isms themselves become longer, and bring on more formidable symptoms; such as head-achs, raving, sopors,Page  113 apoplectic fits, bleeding at the nose, cough, difficulty of breathing, palpitation of the heart, irregularity of the pulse, sickness and anxiety, pain about the upper orifice of the stomach, vomiting and purging; heat, tension, pain and pulsation in the abdominal viscera; subsultus tendinum, and an infinite variety of other com|plaints, which do not entirely cease with the sweat, that carries off the paroxism; so that the apyrexy is not only shortened, but rendered more obscure.

Besides, it often happens, during the second, third, fourth, or fifth period, that the tertian becomes double, though at first it was simple: Or if it was double from the beginning, the weaker fit continues, without any intermission, till the stronger comes on, and both being blended together, the disease puts on the appearance of a semitertian, having one very long fit, with a short interval every forty-eight hours. Sometimes a double tertian degenerates into a triple tertian, two fits instead of one happening on the odd days.

It must likewise be observed, that, in the progress of the fever, the regular order of the periods is frequently disturbed, by the paroxisms changing their hour of invasion, and attacking, unawares without any previous cold. Nor are anticipating fits always a bad sign, or those which postpone a good one, as some authors in|sinuate; on the contrary, the first frequently shew the strength of nature, as the others do her weakness.

After this manner these proteform distempers con|tinue to vary their shape in every period, and to pro|duce longer, more fevere, or more frequent paroxisms, till they arrive at their height; about which time the fits and intervals are often so confused, that they are scarcely to be distinguished: nevertheless, if death be not speedily the consequence of this confusion, they commonly again put on a more simple or regular form, and, after one or more slight paroxisms, go away of their own accord.

Those fevers which come to their height in the third period, terminate in the fourth or fifth period. Those which come to their height in the fourth period, terminate in the fifth or sixth. And those which come Page  114 to their height in the fifth, terminate in the sixth or seventh. When the most vehement paroxisms happen on the odd days, the crises will be on the odd days: When they happen on the even days, the great changes of the distemper will likewise be on the even days.

If the fever increases to the seventh period, it proba|bly will not cease before the ninth: But it rarely hap|pens that intermitting or remitting tertians run out to so great a length. Yet I have seen every year a few of the continual kind, which began with great mild|ness, and increasing by slow degrees, broke out vio|lently in the third or fourth week; and soon after ended in intermittents; though some of them have conti|nued without any considerable interval, for six or seven weeks.

In the cure of tertians, the symptoms of the parox|isms are more to be regarded than the types of the periods; for caeteris paribus, simple, double, triple, in|termittent, and remittent tertians, together with the semitertians, all require the same sort of treatment.

With regard to bleeding it has been warmly debated among both antient and modern authors where it ought or ought not to be used in tertian fevers. Much has been wrote on both sides; but the question appears to me too general to admit of a positive answer. CELSUS* has justly observed that

For my own part, when I was called early enough, in the beginning of these fevers I used to take away some blood (unless there was a strong contraindica|tion) from people of all ages; namely, from robust Page  115 adults ten or twelve ounces; from others a smaller quantity in proportion to their strength and years. And farther, if a violent head-ach, and obstinate deli|rium, and great heat or pains of the bowels were urgent, within a day or two, I repeated the bleeding. By which seasonable evacuation the vehemency of the paroxisms is somewhat diminished; the apyrexies be|come more compleat; the operation of emetics and cathartics is rendered safer and more successful; and the terrible symptoms, which often make their appear|ance about the height of the distemper, such as raving sopor, difficulty of breathing, inflammations of the abdo|minal, viscera, &c. are either prevented or mitigated.

But if before I was called, the fever had already con|tinued some time, and the mass of blood appeared to be too much melted down, or inclinable to a putrid dissolution, which is often the case, during the extreme hot weather, about the fourth period of the distemper, and is readily known by the great alteration of the patient's looks and his sudden loss of strength; or if the first paroxisms of the disease were attended with profuse evacuations, whether by vomiting, purging, sweating, or a haemorrhage from the nose: In all these circumstances, I either omitted the bleeding entirely, or took away a very small quantity, though some im|portunate symptoms might seem to require a much larger evacuation.

But when bleeding is allowed to be necessary, it is asked at what particular time of the periodical revolu|tion it ought to be performed? The ancients* be|lieved that

When I first became acquainted with these diseases, the uncommon violence of their symptoms induced me to lay the principal stress of the cure on evacuations; and to have recourse to frequent bleeding upon ac|count of the inflammations of the viscera; endeavour|ing at the same time by repeated cathartics to discharge the corrupted humours from the intestines: but when experience had convinced me that the bark was both a safe and effectual remedy in these circumstances, I then plainly perceived that such profuse evacuations were unnecessary if not prejudicial; and of late years, as I seldom omitted to bleed and purge once or twice, I rarely repeated either operation oftener.

In semitertians and remittents, which approach to the nature of continual fevers, I give a cathartic early in the morning of that day on which the symptoms are most moderate; hastening the operation with glysters (if occasion requires) so that it may be finished before the middle of the day, about which time the patient commonly grows worse. In true simple and double tertians there is generally an interval every morning, in which the purgative may be administered, but that Page  117 which succeeds the worst fit, is the most proper, as it is more calm, and continues longer than the other.

Proper evacuations being premised, if possible, within the first four or five days of the distemper, I carefully examine the condition of the patient, during the third revolution, and determine accordingly in what manner it will be necessary to proceed. If the paroxisms of that revolution be neither longer, nor attended with more threatening symptoms, than those of the second: if the patient preserves his strength, bears his illness easily, and signs of concoction appear in the urine, I frequently trust the whole business to nature, which commonly terminates the fever about the fourth or fifth revolution, and, for the most part, with an increase of some of the natural evacuations; so that sweats, cloudy or thick urine, and bilious stools often super|vene, and sometimes a spontaneous efflux of spittle, or a copious expectoration of pituitous matter.

But if the paroxism on the fifth day be evidently the longest and most fevere that has happened; if it be at|tended with any doubtful or dangerous symptoms; if the sick become giddy, feeble, and languid; in these cases, without delay, I have recourse to the bark; and the same evening, as soon as the sweats have procured a remission, I order two scruples or a drachm of it in powder to be given every two or three hours, or every hour and a half, so that five or six drachms may be taken before next day at noon, with as little interrup|tion to their sleep as may be; and the assistants are strictly enjoined to comply punctually with these direc|tions, lest if this interval escape, we should not after|wards have a favourable opportunity of giving a suf|ficient quantity of the medicine, as the fits about this period of the disease are wont to become double, sub-intrant, or continual. Yet it is not always in our power to put an immediate stop to the fever by this means: On the contrary, do what we can, it will of|ten proceed in its career, and, in spite of all our at|tempts, run obstinately on to the seventh or ninth day▪ But the great advantage which accrues from the early Page  118 use of the bark, is, that it invigorates the powers of the body, it prevents or removes the dangerous symp|toms, and in tertians, which of their own accord would continue to the end of the second week or longer, it brings on a crisis sooner, and with much less distur|bance. In short, to use the expression of one of the greatest promoters of medical knowledge in this age*,

DR. HUXHAM in his Essay on Fevers, remarks that "Sometimes quotidian, semi-tertian and tertian fevers, are very rife and cotemporary with epidemic pleurisies, and peripneumonies; as particularly in† 1744;—The cold season, in some constitutions, bracing up the fibres so high, and condensing the blood into such a degree of viscosity, as to bring on these inflammatory fevers on taking cold, or other accidents; whilst, on persons of a more lax system of nerves and fibres, and more weak watery humours, it only raised the powers of the oscil|latory vessels so high, and warmed the blood so much, as to carry off the ill consequences of deficient perspi|ration, and ropy heavy juices, by repeated fits of a re|gular Page  119 intermittent.—Thus we often see persons of low spirits, and a leucophlegmetic habit of body, raised in|to a feverish disposition by the use of warm invigorating medicines, chalybeates, &c. And if this turn of nature, be well managed, it generally ends in their perfect recovery. If you can change a slow nervous fever into a regular intermittent, you soon cure your pa|tient.

"It is commonly noted, that if the fever, from a re|gular tertian, runs into a semi-tertian, or quotidian, or greatly anticipates the time of the regular paroxism; a remittent, or continual fever is forthwith the conse|quence.—And this is too often effected by a very hot regimen, or a too hasty use of the bark. Indeed we very frequently see that quotidians, and double tertians, (which, by the bye, are oftentimes the same thing) will not bear the bark, at the beginning; till the saline draughts, proper diluting attenuants, and in some cases, bleeding, purging, and vomiting have been made use of. In truth, I never think it prudent, in such kinds of intermittents, to give the bark, in any form, till af|ter four or five paroxisms at least, and after having drawn more or less blood from persons pretty much inclined to the plethoric; and this method is more es|pecially to be observed in vernal agues.

If an intermittent runs into an inflammatory con|tinual fever, bleeding and a gentle cool purge will soon reduce it to its type.

But as some intermittents are apt to run up into an inflammatory fever, far the greater number, especially in the autumnal season, are disposed to sink into low irregular remittents, putrid or slow nervous fevers. It is not a very rare thing to find a quotidian fall into a tertian, thence into a quartan, and at last end in a dropsy; and this particularly in some seasons and places. This evidently shews that the fibres grow more and more enervated and the blood very vapid and watery. Even vernal tertians, which oftentimes cure themselves in a favourable season, prove many times exceeding obstinate in wet, rainy summers, and the patients are exceeding apt to relapse on the slightest occasions: This Page  120 was particularly observable in the wet, cold summers of 1734 and 1735.*

Perhaps it is the winter-cold, bracing up the fibres, that commonly puts a stop to agues in that season; for it hath been noted, that they are often very stubborn in a warm moist winter.

Improper evacuations by bleeding and purging, an unwholesome, gross glutinous diet, vapid ropy drinks, as stagnant heavy water, foul beer, and the like, ren|der these agues very anomalous, obstinate and dange|rous, and make them frequently degenerate into ma|lignant, putrid, or slow nervous fevers; otherwise they end in dropsies, jaundice, or universal obstructions of the viscera of the abdomen, and frequently in diseases of the genus nervosum. In a word whatever takes down the spring of the fibres too much, and weakens the crasis of the blood, will be productive of these mischiefs; and this especially, when due perspiration is frequently interrupted by cold damp air, want of due exercise, gross heavy slimy diet, as fish, lettuce, cucum|bers, and other watery insipid fruits, which are known to suppress the perspiration greatly.

These observations then evidently shew the necessity of using a warm, invigorating, attenuating regimen in the cure of agues, which affect persons of a lax ha|bit of body, and a poor thin blood; in a particular manner when a wet, foggy atmosphere prevails. Un|der such circumstances the cortex of Peru, however good and carefully chosen, frequently proves ineffectu|al, unless assisted with proper alexipharmacs, as rad. serpentar. virgin. Contrayerv. myrrh, camphire, &c. After four or five paroxisms, warm chalybeates may be added with very great success. But never be too hasty in giving the bark, or chalybeates, where the patient hath a yellow cast of the countenance, a tense abdomen, and a very costive habit of body. In which case mer|curial, saponaceous deobstruents with rhubarb, aloetics, Page  121 regenerate or soluble tartar, should be premised; nay they may in some cases be very conveniently joined with the bark.

THE eminent Morgagni, President of the University at Padua, remarks that "In malignant and epidemical fevers, it is not of so much importance to counteract the fever, as it is to counteract that malignant quality which is joined thereto; and which is, to the great in|crease of the difficulty in such a counteraction, almost peculiar in every constitution.

And certainly, unless you endeavour to overcome this malignant quality for the most part; you do the same thing, as if you should endeavour to overcome a fever, which had its origin from the bite of a viper, by antife|brile remedies; without paying any regard to the poi|son infused; to make use of the same example, which I perceive, from the history of the royal academy of scien|ces at Paris*, the celebrated Du Quesnay has made use of also.

For which reason, we ought the more to give thanks to the providence of Almighty God, that, in so very great an obscurity, and variety, of cases, it has favoured us with a remedy, the powers of which, in overcoming some dangerous fevers at least, is proved by experience; though the method in which it acts is somewhat ob|scure; I mean the Peruvian bark.

For this remedy, although some of these fevers seem to have one kind of malignity joined with them, and some another; as appears from the external causes and symptoms; can nevertheless counteract the one and the other equally; and subdue their malignity; as I have learned both from my own observations, and those of others.

Nor was the matter which has begun to be thrown out of the blood, either upon the skin, or about the Page  122 joints, by any means repugnant to the salubrious effica|cy of the bark; not even when repelled inwards, from thence, by the force of the external cold.

For a very eminent cardinal was cured by the bark of a malignant fever, into which he had fallen, in con|sequence of such a repulsion; as I have written to you on a former occasion:* And that very famous man Haller was also cured thereby of a very violent fever, which had come upon him in consequence of a gout being thus repelled; and which was attended with an erysipelas of the face likewise: and this he relates in the remarks that he has made upon the hundred and fifty-second disputation, among those which he has col|lected and published, as "contributing to the history and cure of diseases."

For it is past a doubt, that these things are not so much to be attended to, as this which I then spoke of; I mean, whether the fevers are periodical: that is, whe|ther they are wont to have an intermission, or a remis|sion at least; so as to afford us room to hope, that, by a timely and proper use of the bark, both the fevers themselves, and their attendant malignity, will be over|come.

Nor does the bark only overcome what is febrile; but even that which is not febrile; so that it does but recur periodically: although this effect is not so gene|ral, when the disorder is without any manifest fever: and as we have already said, that this has been observ|ed, so we might now also confirm it by a more recent, and more clear observation of Stephanus Weszpre|mus; I mean, of an equally severe, and obstinate, he|micrania being overcome by the same remedy, after having been already exacerbated every fourth hour, for two weeks together; and not having remitted till after two hours.

And if this observation, which was made and pub|lished in the year 1756, could have existed fifty years before; when I at length with difficulty put to flight Page  123 that very severe hemicrania, which returned every day at the same hour, by the prescription of a number of different remedies; I should certainly have made use of none more readily, and perhaps more successfully than this; notwithstanding I had been ignorant of the mode in which it produces its effects.

And I could wish the malignant and epidemical fe|vers, whereof we had begun to speak, were all perio|dical, as they are almost all of them joined with a various and obscure force of malignity; we should then have in this cortex a medicine, which, although we might be ignorant in what manner it operates, we might nevertheless try with a reasonable hope of suc|cess.

But they are very often synochae, or continual fevers; and such as, if you dissect the bodies of those who have been carried off by them, either show nothing, as I have said in the beginning, which discovers the peculiar nature, and situation, of the principal dis|ease; or show considerable and evident injuries of the viscera indeed, but such as, if you compare them with those symptoms that have been observed in the patients while living, you will naturally conceive to have been produced by some other latent and principal disease.

That is to say, by way of example, an inflammatory fever of the viscera, after dissection, shows the viscera to have been inflamed, whether it is benign, or malig|nant; but in the living patient if it he benign, it is alle|viated by repeated blood-lettings: If malignant, it be|comes worse, and is very soon fatal.

The cause of the difference is another principal dis|ease being joined to it; as in that fever at Roan de|scribed by the celebrated Malouin, which, about the end of the year 1753, carried off a great number, in a very short time, in that place.

For by reason of the malignant acrimony of the mat|ter which irritated the stomach and intestines, that in|flammation was at length produced, which was found in those viscera, and was already degenerated into a gan|grene: the other internal parts being unhurt, and par|ticularly Page  124 those of the head; which otherwise had been troubled with a pain, that arose from a consent of parts, and increased every day so as to bring on a delirium.

The college of physicians at Roan, therefore, pru|dently and usefully determined, that the inflammation was not then to be attended to; as it either did not exist in the beginning, or arose accidentally in the pro|gress of the disease: but that every method must be taken to eliminate that very acrid matter from the first passages; for from this, if it were left within, a per|manent irritation is much more to be feared, than a transient one from purgative remedies, especially when they are of a milder kind."

AN ABSTRACT of Dr. TISSOT's HISTORY of the EPI|DEMIC BILIOUS FEVER at LAUSANNE*, in the year 1755.

OBSERVATIONS ON THE BILIOUS FEVER WHICH OC|CURRED IN A VOYAGE TO THE EAST INDIES, IN THE YEAR 1766, BY DR. BADENOCH, (Published in London Med. Ob|serv. Vol. 4th, p. 156.)

"JULY 16th. 1766, we came to an anchor to lee|ward of the Island of Joanna, (in the Eastern Ocean, near the north end of Madagascar, where the ships of the East India Company usually stop in order to wood and water.) The sick, chiefly scorbutics, to the num|ber of about 40, were sent on shore to remain during our stay. The carpenters, coopers, and several others likewise slept on shore. July 21st. we left that Island, most of our scorbutics being recovered. During the remainder of that month, we were becalmed in sight of the Island. From the beginning to the 10th. of August, most of those who had slept on shore were attacked with bilious and remitting fevers of a bad sort. Few, if any of the other people of the ship, were seized with them, from which it did not appear to be in|fectious.

EXTRACTS from DR. FORDYCE's* DISSERTATIONS on FEVERS, published in 1794—5.

"A fever is a disease which no knowledge of the structure of the human body, as far as it is at present known, no knowledge of the properties of the fluids, as far as they have hitherto been investigated, no know|ledge of the action of the moving parts, as far as they have hitherto been observed, could give the smallest ground of supposition, that this disease could never have existed. In showing its history, therefore, observation of the disease is to be entirely adhered to, without any reasoning why, or how any thing in it takes place, or without any theory, as it has been called. It would be just as fruitless, at least for any useful purpose, as if a geographer were not to describe a country, but reason why a hill should be placed in one region, a valley in an other; why one shore is rocky, another sandy; instead of actually giving the situation of the hills and valleys, the rockyness or sandyness of the shores.

A great many more fevers begin between eight in the morning and eight in the evening, than take place between eight in the evening and eight in the morning. There is a remarkable difference; according to the au|thor's observation, at least ten fevers take place between eight in the morning and eight in the evening, for one that takes place between eight in the evening and eight in the morning.

It is to be remembered, that the history of fever should be given as it arises from observation, and not from any supposition. It is not therefore pretended to be understood, why this difference of proportion should take place. Some have supposed that the sun's passage over the meridian has an effect, but there does not appear to be any ground for this, because the num|ber of first attacks of fever, which take place at noon, or near it, are not remarkably greater than those which Page  186 take place two or three hours sooner or later. In short, fever is a disease, the whole of the appearances of which have been in no ways accounted for.

It has often been supposed that the redundancy of bile constituted an essential part of the attack of fever; whereas it is a mere accident. If the pancreatic juice had been blue, and had any particular taste or smell, and the bile had been colourless, insipid, inodorous, or as much so as the pancreatic juice is, in that case, what|ever has been said of the redundancy of bile as en essen|tial part of the attack of fever, would have been said of the pancreatic juice. It is clear that no experiment hi|therto made public has shown that any bile was ever contained in blood vessels, excepting in case of jaun|dice, and that, therefore, there can be no redundancy of bile, excepting as much as can be contained in the biliary ducts, and gall bladder. Much more than this is thrown out by twenty times in the attack of a simple fever in half an hour. Therefore, the bile thrown out is a consequence of the sickness, exactly in the same manner as it is a consequence of the sickness arising from the agitation in a ship at sea, and is not at all to be taken farther than as a mere accident in the attack of fever. The loss of appetite encreases, and the nausea and vomiting take place so instantly at the beginning of fever, that they can hardly be conceived otherwise than as an affection of the stomach itself.

All the causes, to which fevers can be ascribed from observations, are, certain substances applied to the bo|dy, as floating in the at•osphere, or applied in a fluid form to some part of the body. Sudden exposure to cold. Moisture in the atmosphere. Moisture of the cloaths, or other covering of the body. Indigestible food, or other substances affecting the intestinal canal. Sudden rising of the passions of the mind attended with anxiety. But it happens frequently, that fevers arise without any of these circumstances having been known to precede them. They are then to be referred to marsh effluvia or to contagious but invisible matter.

Of the particular secreted fluids which have been thought from their redundancy, or alteration of proper|ties, Page  187 to be causes of fever, bile has been the most fre|quent.

The ancients, whose knowledge of the properties of the matter of the body was very superficial, and de|pended solely on the external view, on which hypothe|ses were founded, supposed that the fluids consisted of red blood, phl•m, bile, and black bile, as is well known to those who have looked into their writings, and that to a redundancy, or alteration of the qualities of these, diseases were principally owing, and this idea has con|tinued down to the present day. Bile is conspicuous from its colour and taste, its colour is varied by sub|stances that it meets with in the intestines. This dif|ference of appearance has made it be considered still of great importance in disease. But modern enquirers have shown that it is a fluid secreted only by the liver, is not at all contained in the blood-vessels, but formed out of the substances which constitute the blood. There cannot, therefore, be any redundancy of bile in the blood-vessels because generally there is no bile con|tained in them at all. Bile may, however, and some|times does get into the blood-vessels. When it does, being capable of passing through all the secretory or|gans, it soon shows itself in all the secreted fluids, by giving them a colour, and converting them into a yel|low dye, and by tinging all the surfaces of the body that are exposed to the eye, of a yellow colour. When this happens, fever is never known to be produced, or to have followed, or taken place more frequently than in any other state of the body. Bile, therefore, when it does get into the blood-vessels, never can be accounted a cause of fever.

When the secretions of those glands which open in|to the intestinal canal are increased from any cause, the secretion of bile is increased along with that of the pancreatic juice, mucous, &c. When these encrease considerably, they are evacuated upwards or down|wards. Bile being the only conspicuous one, from its colour and taste, has often been attended to while the others have been neglected. There is •o evidence that in these cases the liver secretes a larger proportion of Page  188 bile than the other glands of the intestines their fluids. However that may be, apparently there is a great quan|tity of bile thrown out.

There is no instance upon record, nor none the au|thor ever knew, where fever more frequently took place after such increased secretion and evacuation than in any other circumstance. In that sickness, for example, which is produced by the agitation of a ship, vast quan|tities of bile are often secreted, and evacuated, yet there is no instance of fever taking place; in consequence therefore, bile getting into the blood-vessels, or secret|ed in any quantity, cannot be admitted as a cause of fe|ver. When so much has been said by many authors of great eminence about bilious fever, is their authority to be thrown aside entirely? Certainly no authority but that which rises from observation and experiment can ever be allowed in true science. It would be great pity to rob patients of their consolation in being bilious or nervous, but medicine is a science which never can be comprehended without much study, considerably more than can ever be given to it by persons following other occupations.

It happens not uncommonly, that there is no crisis takes place after the first attack of a fever, but a second attack takes place before the first paroxism is much di|minished, so that the disease at first puts on the appear|ance of a continued fever. In this case, the subsequent attacks are often in the fore part of the day, or if they should come on at the time of the ordinary returns of a continued fever, which are in the evening, they observe the tertian type; in either of which cases, we may ex|pect in a tertian period or two, first an imperfect crisis, followed gradually with more perfect ones, till all the crises are at last complete. When the crises are very imperfect at first, they almost always grow gradually more perfect, until it often happens, that they become so perfect, as not to leave behind the least vestige of the disease.

In a temperate or cold country, when the patient is strong, and there are only slight remissions at the be|ginning of an intermittent, or it puts on the appearance Page  189 of a continued fever, excepting that the exacerbations do not take place in the evening, it is not necessary to give great nourishment, yet some is absolutely necessary. The Greek physicians appear plainly not to have allow|ed any food or drink whatever on the first days. This seems improper, for if no watery fluid were exhibited, the proportion of fluids in the body would probably be too much diminished by the vapour which flies off from the lungs and other external surfaces of the body, and by the necessary evacuations. Accumulation of sea salt could not take place if neither food nor drink were thrown into the body; but common sal ammoniac and phosphoric ammoniac are continually forming by pro|cesses which seem rather to decompose than to produce blood or other fluids, and would be accumulated. Yet these might not be detrimental, as water might be form|ed by the same decomposition, so as to render their so|lutions equally dilute.

Neither the solids nor fluids of a living body are sub|ject to putrefaction; yet some portion of the fluids or solids, or both, seem to verge so near putrefaction, as to be converted into mucilaginous matters which are constantly washed off by watery secretions. Were the quantity of water diminished, they might not be carried off, but go still farther on to putrefaction, producing salts and vapours which might be pernicious. On this ac|count it may be necessary to throw watery fluids in this case of the disease into the blood-vessels.

When the remissions and intermissions of the fever are very imperfect, or when the disease at the beginning puts on the appearance of a continued fever, only that the exacerbations do not take place in the evening, perhaps it is not necessary that much chyle should be formed, because when the intermissions become more perfect, there will be time for food of greater nourishment to be digested, without interfering with the paroxisms of the disease; nourishment may therefore be out of the ques|tion at this time of the disease.

Remarks on those remedies which appear not to have a beneficial effect.

Page  190"The first of these is evacuation by bleeding; a power|ful remedy in many diseases, but in a regular tertian intermittent, it has not the least effect in preventing the paroxism from taking place, rendering it more regular, inducing more perfect crisis, or rendering the intermis|sions more perfect.

There seems to be a great error in the view of reme|dies employed in fever; practitioners frequently making no distinction between those used to cure the disease itself, and those employed to remove accidents that have arisen in it, although such distinctions are extremely necessary to be made. If, for example, in the course of a tertian, a pleurisy should happen to arise, taking away a quantity of blood would be a powerful remedy for the pleurisy, but although the pleurisy were removed, the intermittent tertian would go through its course just as if no blood had been taken away, except|ing that the patient would be rendered weaker.

Those who are uninformed in medicine expect that diseases are to be cured by violent remedies and suddenly. The attention of by-standers is often drawn to practi|tioners who employ strong acrid medicines. This has frequently induced those practitioners who are least ac|quainted with the real history of disease to use the most violent medicines in their apparent effects, supposing that they would also be the most efficacious in curing the disease, while practitioners really well informed, find it often much more proper to leave diseases to go through their natural course, while they are careful not to let slip an opportunity of employing a remedy that is efficacious in carrying them off.

Purgatives have often been employed in regular ter|tians, with a view to carry off certain humours supposed to occasion the disease. But it has been found on the other hand that purgatives have re-produced the dis|ease, after it has been carried off by other remedies, and that excepting in so far as they prevent costive|ness, and the use of stimulating ones, to assist the ac|tion of sudorific remedies, they tend to render the disease longer in its paroxisms and the crises less per|fect,

Page  191Evacuation, either by bleeding or purging, is hurtful, in so far as it weakens the patient, and renders him less able to bear the repetitions of the paroxisms, and on this account are improper, although not so highly pre|judicial as in continued fever, for in the intermissions there is time for food to be digested, so as to replenish the blood-vessels."

An ABSTRACT of DR. PATTERSON's REMARKS, pub|lished at London-Derry, in the year 1795.

"SEVERAL authors of considerable credit, both ancient and modern, have maintained with Dr. Rush, that malignant distempers are caused by the effluvia from corrupted vegetables; and this opinion they a|dopted from a belief, that these kind of effluvia, acting as a ferment, produced a putrescent state in the fluids of the human body. But it appears from experiment, that the vapour of putrefying vegetables, instead of being a septic, is a strong antiseptic matter, and pre|serves animal substances by the fixed air which it contains*.

It has, indeed, been properly remarked, that ridicu|lous, if not dangerous doctrines have been proclaimed, founded on deductions from some of these experiments, namely, That, in the time of a prevailing pestilence, dead animals should be thrown into the streets and roads, to fill the atmosphere with a putrid smell; and that in an epidemic season, nothing is better or more salutary, than for one to smell, three times a day, either a necessary-house or a sheep-house†.

Page  192The effluvium, which exhales from a mass of putre|fying vegetables, consists in a mixture of fixed air, in|flammable air, vital air, and phlogisticated air. To this mixture of various airs, some part of the principles of the plant, namely, the oil and the acid, are superadded; being not totally decomposed, although the vegetable itself be so, but merely volatilized by the putrefactive process. Inflammable air abounds in those places where vegetables are rotting in heaps; and marshes furnish it in great quantity, from whence it has been character|ised by the name of marsh inflammable air; but, in the latter case, it is extremely liable to decomposition, and to pass into the state of phlogisticated air*.

This ready decomposition of inflammable air is par|ticularly observable in the diminution of common air by phlogistic processes, in which a true inflammable air is first produced, and in its nascent state, as Priestly terms it, is immediately decomposed, previous to the phlogistication of common air—But for the manner in which this is accomplished, I must refer the reader to Priestly's Works on Air, vol. ii. p. 266, and the suc|ceeding pages; and in the 1st vol. p. 127, it is shown, that the volatile effluvium emitted from putrefying sub|stances is phlogiston, loaded with that matter which contributes to affect the nostrils with the sense of smell. Hence we may conclude, that the exhalations from putrid vegetables, and from marshes, which may be supposed to injure the atmosphere, and extend their influence to any distance, consist principally of phlo|gisticated air.

Besides this product of plants in general, certain kinds yield, during putrefaction, a particular sort of air, of a very foetid smell, resembling the hepatic odour. This species of vegetables is found to contain sulphur and volatile alkali, which uniting, form a sulphureous ammoniacal air, inflammable and highly offensive; Page  193 furnished plentifully by onions, radishes, &c. and still more abundantly by cabbages*.

The observation of Lancisi, that steeped flax and hemp are productive of what he calls a camp-fever, has been copied by many writers as well as Dr. Rush. It is an observation, however, which should be received with caution. For although the effluvia are extremely offensive, in this country, where prodigious quantities of flax are watered annually, and in warm weather, I never could trace our fevers to this source. The ty|phoid† fever, it is true, to which this kingdom is liable, appears to be most prone to commence about the same time of the year. But the flax-water cannot reasonably be accused of procreating the disease; because, many years ago, when the culture of flax was little known in Ireland, the fever was observed to arise about the same season‡.

In Germany, people seem to concern themselves very little about the danger supposed to arise from the effluvia of steeped flax. Nor do I find, as far as I have been able to search on the point, that this kind of effluvia has been charged with generating malignant diseases in Aegypt, a country early noted for its great cultivation of flax, and remarkable for a hot climate. On the contrary, the pestilential diseases, to which Aegypt is obnoxious, have been imputed to other causes, namely, to the annual inundation of the Nile, and the hot winds from the deserts§.

As to the celebrated instance of putrid cabbages re|lated by Rogers, by which so many writers have sup|ported their hypotheses, it should be considered, that Page  194 when a malignant fever breaks out in a seminary, work|house, or manufactory, the persons interested are at great pains to find out some pretence for fixing its ori|gin on another cause than that to which it is really due; and generally pitch upon something known •o have emitted a disagreeable smell in the neighbourhood.

Another source of illusion is, that in our endeavours to account for epidemical disorders, we are apt to lay hold of every perceptible difference which we discover in the air, or situation of places that are attacked, from those that are free; and often, without duly examin|ing and considering these diversities, conclude that we have detected the cause, which is perhaps involved in inextricable difficulty.

It does not appear, that in the West-Indies, the ut|most care in clearing and draining swampy grounds, nor the setting in of cool winds, will prevent the recurrence of the yellow fever amongst troops. For we find from Dr. Chisholm that, although the best means were used, yet they did not preclude a fever of this kind, which began in Grenada in September, from returning the December following, with a•l its formidable and des|tructive symptoms. Neither does it appear, that it un|dations producing marshes ought to be accused of ex|citing the yellow fever; because Dr. Balfour's observa|tions shew us, that this disorder occurs at Banaris and other places in Bengal, not less than three hundred miles distant from the reach of tides.

These are confirmed by other observations: We find, from the 9th volume of the Transactions of the Bata|vian Society, that a fever, which carried off nearly one seventh part of the inhabitants, prevailed in Rotterdam, after draining some marshes in the neighbourhood of that city. •nd Dr. Jackson says, that the fever at Sa|vanea La-Mar, in Jamaica, which is situated in a level country, and partially surrounded by a morass, was more mild in its symptoms, than in most other parts of the island. He, therefore, thinks that the neighbour|hood of salt marshes is not so prejudicial to health as has been imagined; on the contrary, he believes it to be a healthy •••••tion, especially respecting its disposi|tion to generate •ebrile affection.

Of the effluvia from putrefying animal substances.

IF Dr. Ru•h be earnest in imputing the generation of fever to the exhalations from putrefying vegetables, he is on the other hand disposed to think, "it is much less common for the effluvia of putrid animal matters to produce fevers. How seldom do we hear of them in the neighbourhood of slaughter-houses, or of the work shops of skinners or curriers?*"

Together with the several kinds of air which the ex|halations from putrid vegetable matter contains, that from animal putrefaction is composed of a species of alastic fluids, called ammoniacal air and sulphureous ammoniacal air. These airs are imflammable and very foetid; and phlogisticate the atmosphere at least equal|ly as the effluvium from vegetable putrefaction. They also contain certain volatilized substances, denominated oily, which modify their influence, according to the nature of the matter from whence they proceed. And although they are active, and emit a considerable stench, yet I so far concur with Dr. Rush, that I cannot assent to the doctrine of some writers, who conceive, that they constitute the miasmata which generate contagious dis|eases. Like putrid vegetable effluvia, I believe they are proper vehicles of contagion; and, therefore, are not principles, but accessories only. Or, in the language of the systematic, to whom Dr. Rush seems attached, every impurity of air diminishes its stimulus; and con|sequently impure air, or air blended with impure mat|ters, without doubt debilitates, and produces asthenic diathesis, which prepares the body for the operation of contagion.

That slaughter-houses yield a considerable quantity of putrid animal effluvium, is certain; especially in places circumstanced as Cork is, in this kingdom. It is built on islands situated in a deep valley, and sur|rounded by several branches of the river Lee. These islands were naturally marshy, and subject to be over|flowed by spring tides, until the ground was raised by art. The rest of the marshes, both on the east and west, Page  196 are periodically covered by those tides; and, in the intervals, putrid vapours are exhaling from them. Continued ridges of hills, on which the suburbs are built, bound this vale on the north and south.

In the north and south suburbs, the slaughter-houses are numerous; the blood and odure from which are received in vast pits, where they are suffered to putre|fy, and emit such noisome steams as corrupt even the most wholesome breezes that pass over the city; and, upon great rains, these c•ss-pools discharge, by the declivities of the hills, their foetid contents into the river. Nor is this source of impure air confined to these places; for great quantities of filth and offals croud the streets, and particularly the close confined alleys and lanes where that description of people reside, whose circumstances are peculiarly adapted to foster and propagate febrile contagion.*

That we seldom hear of fevers being particularly prevalent in the neighbourhood of the work-shops of skinners and curriers, and, I would add, in that of tan-yards, is not at all surprising. The processes, which the hides undergo in the hands of the tanner, prevent the putrid fermentation; and, consequently, the genera|tion of that kind of effluvium favourable to the action of contagious miasmata, is primarily opposed. The smell issuing from tan-yards (which by the bye, very much resembles that from steeped flax) however offen|sive, seems to be very different from that which is emitted from putrefying animal substances; and pro|bably is owing to principles which do not adequately phlogisticate the air. If this be the case with respect to tan-yards, certainly the work-shops of those trades|men, skinners and curriers, who receive the skins al|most entirely freed from the corruptible parts, will be still less chargeable with being the source of contami|nating effluvia.

Several facts tend to prove, that very foul animal effluvia will not excite fever, without the concurrence Page  197 of specific contagion. Two men travelling on foot in the county of Kent, were assaulted near a town on the road with an extremely loathsome stench, which they imagined arose from animal putrefaction, and which continued to offend them for the space of two hours. The sky was clear without the least cloud; and, from the direction of the wind, this vapour could neither come from the unwholesome air of Sheppey island, nor from the muddy banks of the river Thames or Med|way, nor from the Rhumney marshes. Yet these men neither grew sick at the time, nor experienced any future inconvenience from this foetid exhalation.

The offensive smell, proceeding even from the excre|mentitious discharges of patients confined with non-fe|brile diseases, does not occasion pure fever. In a bilious colic, the evacuations both upwards and downwards, have been so intolerably offensive, as to produce sto|mach sickness and retchings in one case, and giddiness, vomiting, and tremor, in another; yet fixed fewer does not appear to have been the consequence in either.

Many instances have occurred, in which thousands of dead bodies have been left to putrefy on the field of battle, without causing putrid fever; and it is well known, that in no case has the origin of this disease been traced to the effluvia of subjects in a dissecting room. Nor have fevers been observed to originate, or to rage more severely, in houses surrounding grave|yards, in the middle of large towns, though the stench of the bodies accumulated in such receptacles, is often intolerably offensive.

In the cases which have been brought to shew, that infectious effluvia arise from putrefying bodies, it does not appear that they produced any symptoms resem|bling those of pestilential fever; on the contrary, they acted by direct stimulus, exciting inflammatory com|plaints; from which it may be inferred, that they are essentially different from febrile contagion.

I may now fairly conclude, that pestilential fever is not generated by marsh miasma, by the effluvia from stagnant water, nor by the exhalations from putrid vegetable nor animal substances.

Page  198That the yellow fever at Philadelphia did not arise from the effluvium of the rotten coffee, is an inference strongly corroborated by the facts and reasoning con|tained in the preceding section.

But that the disease was really imported from the West-Indies by means of three vessels, the •melia, Sans Culottes, and Flora, appears to be rendered almost cer|tain from the judgement and accuracy with which it was traced to its former source. It was at first con|fined to a few persons in that part of Water-street con|tiguous to the suspected vessels, and from thence was propagated to other parts of the city, proceeding with the greatest violence through its proper channels—close unventilated lanes and alleys.

The College of Physicians, three only excepted, con|firms this opinion. "No instance," say they, "has ever occurred of the disease called the yellow fever, havin• been generated in this city, or in any other parts of the United States, as far as we know; but there have been frequent instances of i•s having been im|ported, not only into this, but into other parts of North America, and prevailing there for a certain period of time; and from the rise, progress, and nature of the malignant fever which began to prevail here about the beginning of last •ugust, and extended itself gradually over a great part of the city, we are of opinion, that this dise•se was imported into Philadelphia by some ves|sels arriving in the port after the middle of July.*"

This declaration of the College, if it required any support, is materially strengthened by the testimony even of one of the dissentients, Dr. Redman. the pre|sident. For we are told by Mr. Carey, that from this physician's notes it appears, that, when the yellow fe|ver occurred in Philadelphia, in 1762, it was introduced by a mariner, who arrived ill with it from the Ha|vannah, and who, having taken lodging, communicated the disease to the family where he resided, from whence it spread by contagion to other parts of the city.

Page  199The citizens, therefore, (notwithstanding what Dr. Rush and others of the faculty endeavoured to incul|cate) having good grounds to believe, that, on the late occa•ion, the malady was of foreign original, could not be actuated, as the Dr. alleges, by mere prejudice.

Moreover, on the presumption that the fever was en|gendered by the effluvia from either vegetable or an|imal substances putrefying upon the wharfs, how are we to explain its appearing in Kensington, where those miasmata could not reach undiluted, about the same time that Dr. Rush was called to visit Dr. Hodge's child near the supposed cause of infection?—On such a presumption, the cotemporary visitation of the disease in Kensington and Water-street is inexplicable. But on the ground of its being imported from the West-Indies, that occurrence may be accounted for in a sa|tisfactory manner, by alleging that some of the sailors, passengers, or articles from tainted vessels made their way to Kensington very soon after their arrival in port. The fact indeed is, that some Danish sailors and other persons, who had been in the neighbourhood of the infected places, carried, the fever to that village; and, that these people caught the disease by contagion, we must continue to believe, until we have better reasons for ascribing its origin to the damaged coffee, than those we are yet furnished with on the affirmative side of the question.

The same opinion is entertained by a well-known and justly celebrated professor, Dr. Duncan, who is very conversant in medical inquiry, and who writes thus: "Indeed, when we consider, that it is on all hands allowed, that the disease after making its appearance, was propagated only by contagion, it seems much more probable, that the contagion itself was imported, than that it originated in Philadelphia; especially when we reflect, that at the time of its first appearance in that city, and for many months before, it had raged with great severity in different West-India islands, from whence there were frequent arrivals at Philadelphia."

Page  200Nay, further—In the histories of the yellow fever, furnished by the best authors, we find included the same symptoms, as those which Dr. Rush accounts cha|racteristic of the disease*. We find the flow pulse, called by him the sulky, and by one of his pupils the undescribable pulse—we find the indications of determi|nation to the head—we find the bilious affections—we find costiveness—we find childhood not exempt—and we find the peculiar rapidity of progress. Can we, then, at all doubt the identity of the Philadelphia fever with that which prevails in the West-Indies?—And if the same, why might it not have been imported from these islands into that city?

The great difficulty, or in general the impossibility, of tracing the contagious stream to the particular spring from whence it issues, has caused much con|fusion and contrariety of opinion respecting the ope|ration of infectious effluvia. Dr. Rush, for instance, imputes the germination of the Philadelphia fever to exhalations from putrid vegetable or animal substances; whilst he attributes its successive production to the ef|fects of contagion. But an infectious, or morbid efflu|vium, emitted from the living body, must contain some elementary principle, differing from any composing that which arises out of dead vegetable or animal mat|ter. This being the case, to say that miasma and con|tagion produce one and the same disease, would be say|ing that two dissimilar causes, acting on the like sub|jects, bring forth a similar effect; which would be al|ledging a physical absurdity.

On the contrary, as there is good reason for supposing pure fever to be an idiophatic disease, engendered by its own proper cause, which cause must consequently be uniform; and, as the epidemic under consideration is evidently a pure fever; it follows, that it must have originated from an infectious fomes derived Page  201 from a febrile system. A different opinion leads to the diversification of fevers, which has done infi|nite mischief, particularly amongst the troops in the West-Indies in the last war.* In this particular, we derive considerable support from Dr. Rush's book, p. 40; for it is there maintained, that the proximate cause of the yellow fever, and of all other fevers, is the same. The identity of the proximate cause, then, being admitted, fever must consequently be a primary disease of a specific nature. That the bilious remitting fever, in whatever part of the world it takes place, is radically the same, Dr. Gardner thinks manifest from numerous observations; and Dr. Cullen seems confi|dent, that in every species of contagious fever, except the exanthematous, the contagion is essentially one matter.†

Although we can but seldom ascertain the birth place of a spreading contagion, yet, as researches on this head have been sometimes successful, we may from thence presume, that zeal and perseverance, in our state of knowledge, would be attended with farther advantages. With respect to the plague, Sennertus avers, that whole families and towns have been infected with it, from the venom which had been pent up in clothes and beds for the space of many years. The variolous contagion will remain latent even in linen during several weeks, and sometimes for a number of months. Febrile con|tagion, which is less investigated, and which is seem|ingly a more fugitive thing than either the pestilential or variolous poison, has been known to reside in a gar|ment several weeks.

Contagion sometimes will adhere with an extraor|dinary pertinacity even to seasoned wood‡; for although Page  202 a sickly vessel has been well fumigated with the vapour of tar, yet the seeds of a malignant fever have broke out after some time in the same vessel, and the disease has been thence conveyed into others. And thou h•all the sick from the tainted vessels were removed—though these vessels and crews were kept remarkably well ven|tilated and clean—yet the infectious venom remained long lurking in the timber.

No place is better calculated for discovering the source and progress of contagion, than the navy. An infec|tious malady can be more strictly traced in fleets, or in a number of different ships, than in towns and villages, "as all the ships which compose a squadron, are under the same influence of diet and climate, the circumstan|ces of the men being likewise in other respects for the most part similar." Hence a contagion may often be|gin in a secret manner, and spread itself unsuspected over a town or village; while in a fleet of ships its commencement and extension become more apparent, from its confinement to one or more vessels.

From the retentive disposition of goods and ships, few people have suffered oftener than the Philadelphi|ans, by the importation of the contagion of the yellow fever from the West-Indies through those mediums. Along with other instances on record, I beg leave to call the reader's attention to the following: "A gen|tleman dying at Barbodoes (some years before 1761) his wearing apparel and linen, packed up in a chest, were sent to his friends at Philadelphia, where, upon opening the chest containing those tainted vestures, the family was taken ill; and the clothes being unluckily hung abroad to be aired, they presently diffused the contagion of this yellow fever over that town; by which the gentleman who furnishes me with this relation," says Lind, "was an unhappy sufferer, and of which fever two hundred died*."

Page  203That the fomes of the yellow fever may remain in all its vigour for a considerable time, even in these islands, we have indubitable proof. Three months after this fever had entirely ceased in Haslar hospital, two nurses, lodging in the same chamber, were seized with fevers, and both became yellow; one died, the other recovered. By a strict examination, it was discovered, that they had concealed some shirts and clothes be|longing to the infected men from America*.

When a nurse is seized, or when two or three per|sons in a family are attacked with a fever, it is imputed solely to cold, fatigue, grief, or the like debilitating causes; which seem to act no otherwise, than by strongly disposing the constitution to receive and ani|mate the taint. And when such a disease appears in a boarding-school of boys or girls, the calamity is often ascribed to causes which are not in the least accessory. Of this Dr. Lind relates an instance; and I have been able, more than once, to trace very virulent contagions to those kind of places.

As the phlogisticated state of the air depends upon the separation of one of its constituent parts, whereby the remainder becomes capable of keeping suspended the contagious matter; it has been conceived, that, if this state of the air be restored to its former purity, by adding to it that portion of which it had been deprived by the pulmonary and cutaneous functions, its powers of elective attraction will be altered, and that which was before held suspended, will now be precipitated. This precipitation of the morbid mephitis (conjectured to be in some cases in the form of powder) being depo|sited upon certain substances qualified for receiving it, is supposed to constitute what authors have agreed to call a fomes.

Page  204From some facts, however, it appears that the conta|gion is not soon, if it be at any time entirely, separated from the phlogisticated air. Upon visiting the cells where some men were confined with contagious diseases, Mr. Howard's clothes became so impregnated with the effluvium, that he was obliged to expose himself to the open air on horseback; and the vinegar, to which he was always accustomed to smell, became likewise so saturated as to be intolerably offensive*. An atmos|phere charged with a peculiar odour, well known to those conversant in the small-pox, surrounds patients in that disease, even before the eruption of the pustles; and clothes, which are long retained about the sick, pre|serve the same odour a considerable time.

This theory enables us to account for a number of facts—why combustion injuries the air in an epidemic constitution—why the upper strata of air in a room are pure, while the lower are vitiated—why ventilation is not of itself sufficient to purify tainted places and sub|stances—why fomites are more virulent than the efflu|via fresh from the sick, &c.

Dr. Clark, who has been already quoted, declares, that he is convinced both from his own experience, and from the information he rec•••••••om others, that the remitting fever is every where the same, and ••+quires the same treatment*. Although he thinks, t••t the genus of this fever does not require bleeding; yet, as this evacuation had been so generally recommended by eminent physicians, particularly by Drs. Huck and Cleghorn, he was induced to open a vein during the first paroxism in three patients. The consequence was, the first did not bear the evacuation, his pulse flagged, and he was very delirious in the ensuing fit. The other Page  205 two, who were seized suddenly with delirium, returned to their senses on performing the operation; but before fire or six ounces of blood were taken, they became faint, and the feverish paroxism ran higher than in those who did not suffer the evacuation. For the future he resolved to be very cautious in blood-letting; and, since that period, he laid it asude in every fever in warm climates, both at sea and on shore, unless accompanied with topical inflammation.

In cold and temperate climates, indeed, he grants that venaesection may sometimes have a good effect; at least taking away some blood in the beginning of a fe|ver, he •hinks cannot be attended with great danger. It may likewise be used at the commencement of warm weather, when many of the fevers are so mild as to re|quire almost no other cure, than to cleanse the primae viae, and to produce an equable perspiration by relax|ants. But when a person has continued a short time in a warm climate, he pronounces that blood-letting is extremely detrimental. "I have frequently been in|duced to try it," says he, "when it seemed to be strong|ly indicated by great drought, head-ache, flushed coun|tenance, and oppressed pulse; but I seldom ever saw it answer any good purpose."

Dr. John Hunter found, that blood-letting did no good even in those cases which seemed to require it most, and, if copious or repeated, was always hurtful; and that too where it seemed necessary to bleed freely on account of pulmonic inflammation. Dr. Balfour also, whose principal dependence, as before observed, is placed on other means, advises bleeding, but to be joined with blistering, provided they be indicated by the violence and obstinacy of the local affection, especially when seated in any vital or important part; attending at the same time to the precautions, mentioned already, for preventing the bad effects which are apt to follow the evacuation*.

Page  206In this point, then, until I have good reasons for the contrary, I must concur with the objectors (to Dr. Rush's practice) who contended, that bleeding was unnecessa|rily copious, and proved often destructive; that many of the indispositions, and much of the subsequent weak|ness of persons, who recovered after the free use of the lancet, might be ascribed to it; and that the blood-let|ting was prescribed indiscriminately, without paying sufficient regard to age, constitution, or the force of the disease. Beside, with the boasted efficacy of both the favourite remedies, purging and bleeding, how shall we reconcile the following confession? "Under every mode of treatment, it (the fever) seemed disposed after it was completely formed to run its course."

DR. WADE, in a medical paper published in 1793, is of opinion, that "the ideas entertained of the origin of fevers in warm climates, are probably erroneous, and that they may be deemed universally to originate in those latitudes from the bowels and their contents. From this persuasion, he relies chiefly on purgatives for the cure.

Venaesection, he regards as always a dangerous reme|dy, never to be employed previous to the operation of purgatives, even in the most inflammatory fevers.

He trusts the cure of all species of fever, to copious intestinal evacuation."

CONCLUSION.

FROM a review of the preceding Observations and Abstracts, it appears, that the remitting or bilious fever as it is commonly called, is only a variety of the intermitting fever, occasioned by an invisible matter, (known to exist only from its effects) derived from dead vegetable and animal matter, in a state of putre|faction; that it is distinguished by an evident remission or abatement, but not a total suspension or cessation of all the febrile symptoms once in the course of every twenty-four hours, most commonly in the morning, and a renewal and increase of the same before the evening; differing in this as well as other circumstances, from the typhus, or continued fever, occasioned by human contagion, in which there is almost always an exacer|bation or increase of the fever later in the evening.— That the nearer it approaches to or resembles the in|termitting type, the greater is the prospect of safety. That the paroxisms are prolonged and intermissions pre|vented, or rendered imperfect, by two opposite cir|cumstances, viz: by a phlogistic diathesis, and by pre|ternatural depression of strength.

That this kind of fever is not contagious or commu|nicated from one person to another, and that it differs from the malignant yellow fever, not only in that re|spect, but in its causes, nature and symptoms, as well as in the remedies requisite for its cure; as must be strikingly evident to every one that is capable of tracing effects to causes and will take the trouble to read the account of its origin and progress in Grenada in the year 1793, previous to its appearance in Philadelphia, published by Dr. Chisholm, and recollects that it had not made its appearance in Philadelphia for the space of thirty-one years before, though the summers had frequently, during that period, been as warm and dry, and some of them more so, and the streets and wharves Page  208 more replete with putrefying matters, and the air with the additional exhalations from the deep trenches and muddy docks, the receptacles of every kind of filth and impurity, as well as from the stagnant water of the suburbs and adjacent marshes, sources which had neither a local habitation or a name in 1793—And that the fever was occasioned by foreign contagion last summer, a committee of the College of Physicians has furnished the legislature of this state with ample and unequivocal evidence.

It also appears from the abstracts of the opinions and practice of different physicians, that no general or in|fallible rule can be established with regard to blood-letting in remitting fevers derived from marsh mias|mata; for we find some of the same authors that re|commend this remedy at one period of the disease or at a particular season, condemn it at a different season, or at a different period, or in a different situation.

General and indiscriminate recommendation or in|terdiction of blood-letting, besides being inconclusive, have been too often founded upon some favourite but uncertain hypothesis instead of being derived from ob|servations of its effects in different constitutions, and under different circumstances.

That blood may be drawn when certain circum|stances are present in every kind and variety of fever, if not with advantage, yet certainly without injury, no one conversant with medical facts will deny. The dif|ficulty is to know those circumstances when they are present, and the quantity of blood requisite to be drawn to produce the greatest possible advantage. Symptoms are the only guides we have to this knowledge; but the symptoms which conduct to this knowledge can only be distinguished by men of accurate observation and extensive experience.

Great diversity of opinion also unfortunately exists among the physicians in the West-Indies, as well as in this country, respecting the effects of blood-letting in the malignant yellow fever, owing in a great measure I believe to its having been employed, too indiscriminate|ly, too lavishly, too frequently, or at too late a period Page  209 of the disease, the nature and progress of which had not been sufficiently attended to. My experience and ob|servations in the year 1793, as well as last year, war|rant me in affirming, that I found blood-letting not only a safe, but an indispensable remedy in every case connected with unequivocal symptoms of inflamma|tion; such as acute pain in the head, stomach, or bow|els, and hard, tense, chorded or contracted pulse, whe|ther it felt small or full, and especially if those symp|toms continued without very sensible abatement more than twelve or fourteen hours.

On the other hand, I have always observed that it increased the debility, and accelerated the fatal termi|nation of the disease, in almost every case which com|menced with great prostration of strength, extreme anxiety and oppression and sense of weight about the epigastric and hypochondric regions, accompanied with a small, quick, irregular pulse, little alteration of heat on the surface, hurried and interrupted respiration, frequent and deep sighing, dejection of mind and con|stant restlessness, and especially, if those symptoms con|tinued without sensible and distinct abatement, more than eighteen or twenty-hours.

I have also seen blood-letting, when employed in the remissions, where the symptoms were by no means alarming or unfavourable in appearance, bring on faint|ings, and convulsions, and in some instances, death.

It can not therefore, be too often repeated, that it requires that judgment which can only be acquired by extensive experience and attentive observation, to en|able a physician to distinguish the circumstances which require or justify the employment of a remedy which seldom fails of doing either good or harm.