O. V. Lows. • ESSAYS ON THE AUTUMNAL AND WINTER EPIDEMICS. 
6; M. Low. BY JOHN ESTEN £OOKE M. D. PROFESSOR OB THE THEORY AND PRACTICE OF MEDICINE IN TRANSYLVANIA UNIVERSITY. 
* TRANSYLVANIA PRESS. PRINTED BY J. 0. MOKWOOl), PUIVTUII TO THE UNIVERSITY. jsmnsi...t 


(cOPY-RIOHT SECURED ACCORDING TO LAW.) 


ADVERTISEMENT. 
The following essays wer* originally published hi the Transylvania Journal of Medicine and the Associate Sciences. They are published in this form for the convenience of those who may choose to have them together They'are intended chiefly for the use of the students of Transylvania University. 


CONTENTS. 
An Essay on Autumnal Epidemics, Page 1 
An Essay on Winter Epidemics, - 09 
An Essay on Thfphus Fever, - 85 
An Essay on Cholera Infantum, i - 122 


O. M. Lonu. 
AN ESSAY ON THE AUTUMNAL DISEASES. 
In the first number of the Transylvania Journal of Medicine &c. I have endeavoured to give an outline of an attempt, since published,* to investigate the connexion between the remote causes and the symptoms of fever and of some other diseases, by inquiring into the effects of those causes on the body ; next into the effects of those effects, or new causes, and so on descending to the ultimate effects, the symptoms in question. In the present essay it is proposed to take a view of the origin of that cause which produces the autumnal diseases, of its effects on the system, and of the best mode of obviating them. 
Most of the remote causes of fever do not produce epidemic disease. Excessive fatigue, violent emotions of the mind, excessive stimulants, &c. do not operate upon such numbers as are affected during the prevalence of epidemics, nor are they confined in their operation to particular seasons of the year. Famine is capable of producing epidemic disease, but it is comparatively a rare occurrence ; whereas epidemics are annual in many parts of 
*A Treatise of Pathology and Therapeutics, by Jolm E. Cooke, M. D. &c. 


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Cooke ou Auluiitnal Discuses. 
the earth, so as to have given rise to the expression, the sickly season. Cold sometimes produces epidemic disease, but rarely except in conjunction with the cause of autumnal fever, as will hereafter appear. It is in hot weather, as the history of epidemic diseases shows, that almost all of them arise. 
The inquiry into the cause of these hot-weather epidemics, and the interesting questions connected with the subject, are of incalculable importance; inasmuch as this agent exerts a greater influence over the health of the human race than all the other causes of disease put together. This assertion will not be considered extravagant if, (as is believed to be completely established in the treatise above alluded to), this be also the cause of typhus fever, of plague, and, in conjunction with cold, of the winter epidemics which occasionally prevail in every part of the temperate climates. 
In attempting to investigate the origin of these diseases, the first circumstance that strikes the attention is, that they are particularly severe and frequent in hot climates. As we advance northward we find them less common and less violent ; and the colder countries rarely suffer from them. 
In temperate climates, the hot months arc the time of special sickness, the season in which epidemics arise. When raging with their utmost violence, the occurrence of frost or even of very cool weather, instantly checks their progress and soon puts an end to them. In tropical countries no season is exempt from their occasional appearance, and in some parts they prevail throughout the year. Heat therefore is essential to the prevalence of these diseases. 
Heat alone however, in the degree usual in the hottest climates, is not sufficient to produce epidemics. The dry season on the West coast of Africa is comparatively healthy. The inhabitants of the great deserts of that continent are not affected by these epidemics. The diseases of Egypt never spread into the neighbouring deserts occupied by the Bedouin Arabs. The West-India islands vary exceedingly with regard to health. Barbadoes is a healthy island ; Jamaica and Hayti arc very sickly. The latter arc five degrees farther north than the former. Our not? 


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test sehsons are, in many situations, the most healthy; and during the prevalence of an epidemic in hot weather, many places escape at a very short distance from those which suffer severely. These partial effects show the operation of a partial cause, while heat is general in its action. Heat alone is therefore not the cause of the epidemics of hot weather. 
Moisture is also necessary. The hot countries within the tropics, which are in general healthy during the hot and dry season, become sickly soon after the rains commence, and continue so throughout the wet season, and afterwards until the abundant moist ure is evaporated. As soon as this is effected, the health of the country is restored, except in those places which continue wet throughout the year. The rainy season and the sickly season arc synonymous terms. 
The very same may be said of the extensive country of the Southern and Western states of America. Wet summers are sickly, and dry summers are healthy except in the neighbourhood of marshes, ponds, or rivers. This was strikingly exemplified in the occurrences of the years 1822 and 1823. In the former, in most parts of the country, the summer was the dryest perhaps eycr known ; the latter one of the wettest. 
In the excessively dry summer of 1 822, the valley of the Shenandoah in Virginia was generally healthy. The few places which suffered are near marshy grounds, or rivers which in that arid season were almost dried up, leaving extensive flats covered With an abundance of the vegetables which grow in water, exposed to the action of the sun. The highlands below the Blue Ridge were likewise healthy, and the parts that suffered were on the marshy borders of the rivers. In Pennsylvania, about Harrisburg, the middle of July was wet and sickly; afterwards it became very dry, and the epidemic declined.* In Ohio the weather was so dry that "the Ohio river was lower than ever # known since the settlement of the country. The water was in most places nearly stagnant, resembling a long lake more than a river, and covered with a mucous scum or froth." The autumnal diseases did not 
•Medical Recorder. No. 21, p. 139. 


Cooke on Autumnal Diseases. 
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prevail in this year, but were "wholly confined to the neighbourhood of streams ;" and it was even observed " that those settlements located where the shores of the river were bold and not lined with a wide beach, were uniformly healthy, and vice versa."* On the other hand, in the year 1 823 the rains were excessive; in Pennsylvania, Maryland, Virginia, Ohio, Mississippi, and Alabama, and the autumnal epidemic was very severe in all these states. Even in the year 1822 a similar contrast was exhibited indifferent parts of the country. While Virginia, Pennsylvania and Ohio were (as already stated) dry and healthy, Kentucky and Mississippi were excessively wet, and very sickly. The summer was hot, the rains commenced early, and the epidemic made its appearance sooner than common, and was very severe. The same contrast is observable in different years in every neighbourhood. Thus, at Natchez the year 1816 was very dry and healthy, 1817 wet and sickly, 1818 dry and healthy, and 1819 wetter and more sickly than 1817. 
It is evident therefore that in dry seasons health is general, and in wet seasons sickness is general; that the sickly spots in dry times are near streams, ponds, or marshes; and that when one part of the country is dry and another wet in the same season, the dry part is healthy, except about streams, ponds, and marshes ; and the wet part sickly. 
It follows from the preceding statements that the concurrence of heat and moisture is necessary to the production of epidemic disease. But though necessary, they are not sufficient to produce them. Vessels at sea, or at a small distance from land, in the hottest climates, even in the rainy season, continue healthy if they be kept clean. Lind from experience of this, advises those who are able, to retreat to floating habitations during the sickly season. Instances have frequently occurred of a superabundance of moisture in hot weather being favourable to health. Pringle tells us that the neighbourhood of the towns of Brabant, in 1748, was inundated as a protection from the enemy, that the air" sensibly became more noxious upon letting off part of the water in 
•ML Journal Sic. No. 17, p. 106. 107. 


Cooke on Autumnal Diseases. 
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the beginning of summer, after the preliminary articles of peace were signed ;" and that the States of Holland being made sensible of this by the sickness which raged at Breda, gave orders to let in the water again, and to keep it up until winter. In the autumnal season of 1798 in Boston, the inhabitants living near a mill-pond in the town were sickly. This pond was often drained so us to leave the bottom exposed to the action of the sun. The water was ordered to he i etained constantly in the pond, and this being none, the fever ceased in that quarter. Excessive rains have often produced the same effect. ** Dr. Dalzilles, in his treatise upon the diseases of the negroes in the West-Indies, informs us that the rainy season is the most healthy at Cayenne, owing to the neighbouring morasses being deeply overflowed." In the island of Trinidad, the centre of which is a vast morass, an abundance of rain is salutary. Dr. Ferguson calls them preserving rains, because a deficiency is sure to be followed by sickness. He also says, " In the island of St. Lucia, the most unwholesome town of Castries, at the bottom of the Carenage, which is altogether embosomed in a deep mangrove fen, became perfectly healthy under the periodical rains." He further states that a year of uncommon drought is infallibly a year of pestilence to the greater part of the West-India colonies. Therefore a rainy year is healthy in the most of these islands. Lind makes the same statement of the island of Sardinia. 
Heat and moisture are therefore not sufficient to produce epidemic diseases. Something more is necessary ; and the additional requisite is easily discovered by attention to the situation and circumstances of the places most liable to these diseases. 
In the tropical countries, cities and stations which have been the graves of unnumbered thousands, are situated near marshes, or at the mouths, or on the banks of rivers, in flat countries which, in the rainy season, are inundated. In more temperate climates, similar spots are the seat of similar diseases in the summer and fall; as in Holland, and many parts of Italy ; and of our own country, as we may observe by looking around us in our own immediate neighbourhood. The marshes, the marshy borders of riven, 
r-nr. ». no. ur. 44 


Cooke on Autumnal Diseases. 
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the artificial morasses produced by building mill-dams, are spots noted for disease. 
On the other hand, places situated at a distance from marshes or low grounds are comparatively free from disease. It is unnecessary to cite cases in support of this ; the observation of every man will afford him evidence of its truth. 
Places formerly healthy have often been rendered unhealthy by an artificial morass, as is witnessed in every neighbourhood where a mill-dam is built ; and places in the neighbourhood of ponds or marshes, formerly unhealthy, have been rendered healthy by draining off the water. A multitude of examples of this might be cited. 
It has been objected to this doctrine that some marshy situations are generally healthy, and yet sometimes suffer; while others are generally sickly, yet sometimes escape. This objection is easily obviated. 
Marshy situations, generally healthy, have become sickly during a very dry season. A marsh covered deep with water, or a mill-pond well filled and exposing no marshy surface, may have produced no injury for years. A very dry season, by evaporating the water, and exposing the bottom to the action of the sun, renders the neighbourhood sickly. The effect of such exposure may be estimated by what has been said of the occurrence at Breda in 174 8, and at Boston in 1798. Senac mentions an instance in which the bottom of a pond was brought within the influence of the heat of the sun in a different manner with the same result. * Near the walls of a large city stood a very extensive and deep pond of water, which for forty years had served as a receptacle of all the filth from the houses and streets. As long as these putrid matters remained covered with water, they were productive of no mischief. But when they had so far accumulated as to rise above the surface of the water, a most malignant fever spread through the tract of country adjoining the city."* 
The same cause, dry weather, in different circumstances produces effects precisely opposite. A marshy spot, which has here- 
*Seuac on Fevers, translated by Charles Caldwell, M. D. &c. p. 20. 


Cooke on Autumnal Diseases. 
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tofore rendered a neighbourhood sickly, may be dried up, and the 
consequence is health, as certainly as if it were rendered dry by draining off tlie water. 
Very wet weather sometimes produces the same beneficial effects on marshy places ordinarily sickly, by covering them from the action of the sun. Of this several instances have already been stated, from Dr. Dalzillcs and Dr. Ferguson. 
Thus we find that excessive heat, by drying up the moisture in a marshy tract of country, will make it healthy; or by making a marsh of a pond formerly well filled, will produce unusual sickness. On the contrary, that excessive rain will fill a country hitherto dry and healthy, with marshy spots, and produce fatal disease ; or will cover from the action of the sun extensive marshes, and prevent the evil which would otherwise have followed. The marshy state of the soil, therefore, is necessary to the production of disease, and all the facts confirm the doctrine that marshes are the special seat of epidemic fevers. 
The following facts shed light on the connexion of that agent which is the cause of epidemic diseases, with this state of the soil. 
"Lancisius relates that thirty gentlemen and ladies of the first rank in Rome, having made an excursion upon a party of pleasure towards the mouth of the Tiber, the wind suddenly shifted, and blew from the south over the putrid marshes ; when twentynine were immediately seized with a tertian fever, one only ea caping."* 
Similar effects on a change of the wind blowing over marshy grounds, have been observed in many parts of this country; in Boston, New- York, Philadelphia, Baltimore, &c. The following striking instance occurred near Galliopolis on the Ohio river in 1796. Major Prior of the army, witnessed the rise and progress of the disease, and on a visit to Baltimore in the following year, made for Dr. Potter, Professor of the Theory and Practice of Physic in the University of Mar) land, a statement in writing from which the following is taken. — "As the garrison was severely afflicted 
*Lind on Hot Climate*, p. 21. . 


Cooke on Autumnal Diseases. 
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by this fever, I could but take great interest in it. The fever was, I think, justly charged to a large pond near the cantonment. An attempt had been made, two or three years before, to fill it up by felling a number of large trees that grew on and near its margin, and by covering the wood thus fallen with earth. This intention had not been fulfilled. In August the weather was extremely hot, and uncommonly dry ; the water had evaporated considerably, leaving a great quantity of muddy water, with a thick slimy mixture of putrefying vegetables, which emitted a stench almost intolerable. The inhabitants of the village, principally French, and very poor as well as filthy in their mode of living, began to suffer first, and died so rapidly that a general consternation seized the whole settlement. The garrison continued healthy for some days, and we began to console ourselves with the hope that we should escape altogether; we were, however, soon undeceived, and the reason of our exemption heretofore was soon discovered. The wind had blown the air arising from the pond from the camp; but as soon as it had shifted to the reverse point, the soldiers began to sicken : in five days half the garrison was on the sick list; and in ten half of them were dead."* 
The inference from these facts, that a vapour or gas, produced in marshy places, is the cause of the epidemic fevers of hot weather, is irresistible. Nothing but a vapour or gas can take the direction of the wind blowing over these places, and produce its effects in every quarter to which it is carried. 
Marshes during the heat of summer and autumn, when these diseases appear, abound in vegetable matter undergoing the process of decomposition, whence proceeds an abundance of gas. All the circumstances favouring the prevalence of epidemics, are such as peculiarly favour the decomposition of vegetable matter. Thus heat and moisture are both necessary ; but such a degree of heat as by drying up a marsh, puts an end to the decomposition of vegetable matter therein, puts an end also to the prevailing epidemic; or, such an abundance of moisture as, by covering the vegetable matter, and protecting it from the action of the sun, 
•Potter's Memoir on Contagion ; also Med. Recorder, No. 4, p. £27. 


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checks or puts an end to decomposition, produces the same effect. Further, as long as there remains any moisture in a marshy place, the greater the heat and therefore the more rapid the decomposition, the more violent the epidemic ; while frost, which puts an end to decomposition of vegetable matter, puts an end to the epidemic. 
There is therefore very strong reason to believe that the gas driven by the wind from marshy places, which is the cause of epidemic fevers, is the product of the decomposition of vegetable matter. 
This is corroborated by the occurrence of such diseases when vegetables in bulk, as potatoes, &c. are suffered to putrefy. The holds of vessels, particularly ships of war, contain large quantities of vegetable matter, such as peas, oatmeal, cocoa, flour, &c. in casks often not strong enough to prevent their contents from escaping. They also contain wood for fuel sometimes in great quantity, and quite green. Many instances are related of the air of the holds of ships becoming so impure that candles would scarcely burn in them.* The ship Regalia sailed from Guernsey for Africa in November 1814 and arrived in February 1815, full of troops in perfect health. In the latter end of June she took in a supply of wood for a voyage to the West-Indies, where she was about to convey a number of black troops. The wood was cut down and carried on board the same day ; and the quantity was such that after she had been in the West-Indies several weeks she was found still to have enough for a voyage to Europe. She sailed from Africa on the 1 8th July, and arrived in the West-Indies on the 24th August. The crew began to sicken in a fortnight after the wood was laid in. One died before sailing; two the day after: all but two were attacked on the voyage, and five out of twenty-one died. An officer and his wife, and the captain and his wife also died. Among the troops there was considerable mortality on the passage ; and after their arrival in the West-Indies, between the 24th of August and the 24th of October, one hundred and eleven of them were sent to the hospital with the flux, of whom fifty-three died. 
""Bancroft's Sequel, p. 232-3. 


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Cooke on Autumnal Diseases. 
At English-harbour, Antigua, this vessel was fumigated, and after three days' detention sailed to Barbadocs. During this short voyage three newly entered hands sickened ; one died, and two were sent to the hospital. On her arrival three more sickened, one of whom had lately entered, and one died. The hold was now ordered to be cleaned out. Every thing was taken out of it, and it was exposed to the concentrated heat of stoves, the hatchways being closed. About the time the cleansing commenced, of three men newly shipped, two sickened, of whom one died ; and the cook, upwards of fifty years of age, died. 
After having undergone a thorough cleansing, she sailed for Guadaloupewith a crew of French prisoners and their families out of the jails, one of whom had the yeJlovv fever, but no fever prevailed on board. 
This vessel, before this great quantity of green wood was shipped, was healthy. A fortnight after, sickness commenced, affected almost every body on board, killed about one third, and attacked almost every one who was shipped in place of those who had perished. After a thorough cleansing, she sailed with a crowd of prisoners taken out of jail, and no fever arose among them. 
These facts and many similar to them, abounding in medical works, confirm the inference, that a gaseous fluid, the product of the decomposition of vegetable matter abounding in marshes and other places, is the cause of epidemic diseases. 
This gas is dense or it would arise from the earth and not bo driven along its surface by the wind, as in the fever at Galliopolis above stated. Numerous facts shew that it is dense. Those persons who inhabit the lower stories of houses are much more liable to an attack of fever, than those who inhabit the upper ones. Low places, as dry ravines, dry ditches of forts, &c. are very dangerous places to occupy, and centinels who are posted in them are very liable to be attacked. 
The evidence therefore is positive, that a dense gas proceeding from marshy places, or driven from them by the wind, is the cause •f the epidemics of hot weather; and there is the strongest reason to believe that it is the product of the decomposition of vegetable matter. 


Cooke on Autumnal Diseases; 
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It would not be proper in treating this subject, to pass over in silence the objections made to the doctrine here advocated, in a paper read before the Royal Society of Edinburgh in 1 820 by William Ferguson, M. D. F. R. S. a gentleman of talents, great experience and extensive opportunities of observation. These circumstances are well calculated to give weight to what he advances, and accordingly his objections have been well received, which renders it more necessary to show that they are not well founded. Error in principle cannot fail to lead to error in practice.* 
Dr. Ferguson asserts " that putrefaction, under any sensible or discoverable form, is not essential to the production of pestiferous miasmata." In support of the opinion ** that the marsh poison cannot emanate from vegetable putrefaction," he asserts v that it is found most virulent and abundant on the dryest surfaces; often where vegetation never existed, nor could exist for the torrents, such as the deep and steep ravines of a dried water-course; and that it is never found in savannahs or plains, that have been flooded in the rainy season, till their surface has been thoroughly exsiccated; vegetation burnt up; and its putrefaction rendered as impossible as the putrefaction of an Egyptian mummy." 
In support of these assertions he brings forward several statements, which show that the cause in question is found in a number of places such as he describes, viz. very dry surfaces, as hill-sides, and plains which have become dry after having been flooded. These statements are admitted to be true; and they prove that the pestiferous gas is found in those places ; but it does by no means follow that it is never found in them until their surface has become ** exsiccated." There is a profusion of evidence to the contrary. Lind speaking of Senegal says, " This, as most tropical countries, has properly speaking only two seasons, the wet and the dry; the former is only of about four months continuance, and is the season of sickness," o^c. tt Soon after the rainy season began, a low malignant fever constantly spread itself 
•This paper was republished in the 13th No. of ten Phil. JonrnnU with marked encomium* by a distinguished physician. 


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among the Europeans." "The most mortal epidemic "however is that low malignant fever of the remitting kind, which rages only in the rainy season."* Nor is this at all variant from our own experience. Not to multiply instances, it is fresh in our recollection that in the extraordinarily sickly summer and fall of 1823, the plains of this country were so far from being exsiccated, that the roads were miry throughout the autumnal season from continual rains. This is more than sufficient to show the incorrectness of the assertions, that the malaria " b found most virulent and abundant on the dryest surfaces," and "is never found in savannahs or plains that have been flooded in the rainy season, till their surface has been thoroughly exsiccated" &c. 
It is evident then that all that is established, and that is not denied, is that the malaria was found on those particular spots mentioned ; and there is no difficulty in showing that in every case vegetable matter in a state of decomposition existed on the spot, or near enough to produce the effects observed. 
The cases in which epidemic disease appeared on plains that had been flooded and had become dry, shall first be considered. 
The English troops in the south of Holland suffered very much in the hot and dry summer and autumn of 1 794. They were encamped on "a levsl plain of sand, with a perfectly dry surface, ¦where no vegetation existed or could exist but stunted heath plants: on digging, it was universally found to be percolated with water to within a few inches of the surface" &c. 
Holland abounds in marshes, or rather it is a great marsh. Pringle speaking of two villages, one ten feet, the other fourteen above the subterranean water, mentions this as an extraordinary height in that country! In such a country, in so hot a summer, decomposition of vegetable matter must have taken place to a very great extent ; and the mere fact that the army was encamped on a plain of sand, with no vegetable but heath plants stunted by the drought of that year, is no argument against its sufferings being produced by a gas arising during the process of decomposition, 
*Lind on Hot Climates, p. 32, 41, 42, &c. tPringle on Dis. f>f the Army, p. 63. 


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in a country where there is not a hill to obstruct the passage of miasmata, and where marshes to produce them so abound, that they must be carried by every wind upon them. In 1810 another English army suffered in the same wuy in the same country. 
An English army was marching, in 1 809, through a dry country of considerable elevation, on the confines of Portugal. May had been very wet, and the weather had been so hot for several weeks as to dry up the mountain streams and had left stagnant pools of water among the rocks. In the ravines that had lately been water-courses, several regiments took up their bivouac for the sake of being near the stagnant pools, the water of which was " perfectly pure"; and several of the men were immediately after seized with remittent fever, and part of that portion of the troops were exclusively affected for some time. " The army advanced to Talavera through a very dry country, and in the hottest weather fought that celebrated battle which was followed by a retreat into the plains of Estremadura, along the course of the Guadiana river, at a time when the country was so arid and dry, for want of rain, that the Guadiana itself, and all the smaller streams, had, in fact, ceased to be streams anel were no more than lines of detached pools in the courses that had formerly been rivers; and there they suffered from remittent fevers of such destructive malignity, that the enemy and all Europe believed that the British host was extirpated." 
This statement certainly operates against Dr. Ferguson's doctrine. May was very wet, and the weather in the following months was very hot and the country had become very dry. During this time the army marched through a part of Portugal and Spain, and, except a small part of it which encamped in the "halfdried ravine," which was the bed of a stream, continued free from fever, until they were forced to retreat into the plains of Estremadura, along the course of the Guadiana, when that river audits branches had become msre lines of detached pools; and "there they suffered from remittent fevers of such destructive malignity" &c. This is precisely what occurs with us. When for want of rain the country is burnt up, as happened in many parts 3 


Cooke on Autumnal Diseases. 
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of this continent in 1 822, it is generally healthy. Few cases of fever occur except near ponds, marshes, and the streams which have become mere lines of pools ; and it is observed that the cases in such situations are very severe. If "one only condition be indispensable to the production of the marsh poison, on all surfaces capable of absorption," viz. paucity of water where it has previously and recently abouneled; if it be found only in plains that have been flooded in the rainy season, after their surface has been thoroughly exsiccated ; why was the English army healthy on their march until they arrived on the banks of the Guadiana, at that time a line of pools? and why was that part of the army alone affected during their march, which encamped in the bed of a stream which had also become a line of pools? why was that part affected which encamped where the surface had not yet become exsiccated, and why did those escape who remained on that which had ? why, in short, is sickness confined, in dry years, to the wet places near rivers &c? and why does it extend to every part of the country in wet years amidst continual rains which never allow the surface to dry? 
Several other places in Spain are mentioned as being very sickly, all of them on the banks of rivers. In that fertile country the spring of the year is very wet, the summer very hot. In such circumstances an immense amount of vegetable matter must be decomposed ; whenever and wherever it is going on the people are sickly, and that it is to be attributed to a gas produced during the process of decomposition is evident from the remarkable occurrence at Galliopolis before stated, and from a multitude of others similar to it. 
Dr. Ferguson states that the leeward shore of Guadaloupe for a course of nearly thirty miles, though the soil is remarkably open, dry and pure, and without marsh in the most dangerous places, is inconceivably pestiferous throughout the whole tract, and in no place more so than the sandy beach near high water mark. The name Guadaloupe is given to two islands having a very narrow channel of sea water between them. The leeward island is called Basse-terre, (or low-land,) from being very low and marshy; the other called Grand-terre, has also large marshes, as 


Cooke on Autumnal Diseases. 
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may be gathered from Dr. Ferguson's account of the situation of Point-au-Pitre, situated on the leeward shore of Grai:d-tcrre. 
Although then the soil be open, dry, and pure, it differs little in this respect from most of the West-India islands. Most of them are light and open, and have, notwithstanding, pestiferous marshes. In a space of thirty miles of low land, with rivers and marshes, in a hot country, decomposition of vegetable matter in abundance, must take place. The steep ridge of mountains to windward shelter it from the trade-wind which would carry off the gas produced on its surface, which therefore must abound; and it is not wonderful it should be " inconceivably pestiferous throughout the whole tract;" nor that the night la tul-wind, from the mountains to the shore, should carry it down to the latter, and render it particularly dangerous to remain on shore through the night. 
Dr. Ferguson mentions in a note an instance in England of a spot absolutely destitute of vegetation, which was nevertheless subject to fevers produced by marsh poison. " The point of Dungeness is a tongue of land appended to the great Romncy marsh, and consists of an extensive bank of shingle or gravel, so dry, loose and open, that, even during wet weather, horses sink in it nearly up to their knees. The forts and barracks are at least four miles from what may be called the main land, where the grass begins to grow ; yet was there no spot of that unwholesome tract of country more prolific of endemic fever during the hot summer and autumn of 1817, than these barracks." 
It is evident, that in so hot a season as that of 1817 is stated to have been, miasmata must have abounded in this extensive tract of marshy and unhealthy country ; and the access to the post at Dungcness being through it, every one passing and repassing was exposed to the operation of the unhealthy air. Moreover, the whole distance from the body of the marshy tract to the post being a flat surface, every wind which blew in that direction, must have carried the miasmata then abounding to the barracks. It is certain that in this, as in every other case stated by Dr. Ferguson, there was a marsh close at hand, in circumstances to produce 


16 
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the effect observed; and where there was no marsh near, as at Lisbon, there was no sickness. 
1 1 remains to explain the cases stated in which dry hills are sickly. Dr. Ferguson makes the following statement. 
" The beautiful post of Prince Rupert's, in the islandof Dominica, is a peninsula which comprehends two hills of a remarkable form, joined to the main land by a flat, and very marshy square isthmus to windward, of about three quarters of a mile in extent. The two hills jut right out on the same line into the sea, by which they are on three sides encompassed. The inner hill of a slender pyramidal form, rises from a narrow base nearly perpendicular, aliove and across the marsh, from sea to sea, to the height of four hundred feet, so as completely to shut it out from the post. The outer hill is a round-backed bluff promontory, which breaks off abruptly in the manner of a precipice above the sea. Between the two hills runs a very narrow clean valley, where all the establishments of the garrison were originally placed ; the whole space within the peninsula being the driest, the cleanest, and the healthiest surface conceivable. It was speedily found that the barracks in the valley were very unhealthy, and to remedy this fault, advantage was taken of a recess or platform near the top of the inner hill, to construct a barrack, which was completely concealed by the crest of the hill from the view of the marsh on the outside, and at least three hundred feet above it; but it proved to be pestiferous beyond belief, and infinitely more dangerous than the quarters in the valley within half musket shot below. In fact no white man could possibly live there, ard it was obliged to be abandoned. At the time this was going on, it was discovered, that a quarter which had been built on the outer hill, on nearly the same line of elevation, and exactly five hundred yards farther removed from the swamp, was perfectly healthy, not a single case of fever having occurred on it from the time it was built. These facts were so curious that 1 procured the surveyor-general of the island to m< asure the elevations and distances, and I have given them here from his report." 
In this case it is evident that the inner hill and the clean valley could not have been the surface which produced the cause of the 


Cooke on Autumnal Diseases. 
17 
fever; because the outer hill, separated only by a small valley from the inner, and manifestly as well adapted to the production of the cause of autumnal fever, was entirely free from it. It is evident that we must look to some other quarter for the source of the evil ; and we cannot for a moment be at a loss for this when we consider all the circumstances. 
There was a large marsh, three quarters of a mile in extent, to the windward of the hill. The gas generated in this marsli must necessarily have been driven up the ascent of the hill next to it, which was the inner hill, by the trade-wind which sets continually in that direction ; and surmounting its shoulders, have fallen from its density into the valley between the two hills; down which, being protected by the inner hill from the wind, it quietly glided into the sea, and did not reach the outer hill five hundred yards further removed from the marsh. 
Thus it was that the valley was found unhealthy; that the removal to the elevated position on the inner hill, only carried the men nearer to the source, to a situation in which the gas operated with full power as it commenced its descent into the valley; and that the outer hill was healthy because protected from the gas by the interposition of the valley, and by its distance. It is manifest, that if the troops near Galliopolis had been encamped on high ground, ascending gradually from the pond to the camp, that the gas would just as certainly have been forced along up it, and must have produced the same effect as it actually did on the level ground. 
An account somewhat similar to the above, of Prince Rupert's, is given of some high grounds near Port of Spain in Trinidad. The centre of the island is an immense marsh. The heights in question arise out of this marsh, and ascend gradually as they recede westward from it. Thus situated, the ges from the marsh is blown directly along up the ascent of these heights, and over them into the sea. » 
> 
The facts stated by Dr. Ferguson show, therefore, nothing more than that "malaria" i« found in some places in which vegetation has been burnt up, and in some elevated and dry situations; but its existence in every case mentioned is consistent with the 


18 
Cooke on Autumnal Diseases. 
doctrine advocated in this essay, there being in every instance ia which disease occurred, a source of the gas in question in the neighbourhood, viz. cither a marsh to windward, or pools of water; and therefore the conclusion, that putrefaction is not essential to the existence of "malaria," is so far from being legitimately drawn from these facts, that they confirm the opposite doctrine. 
Exsiccation, therefore, is not essential to the production of the endemic diseases of hot weather; and we find it the result of universal experience, in all times and places, tl at without the decomposition of vegetable matter these diseases never occur, and that a dense gas thence arising is the cause of them. 
Exhalations arising from putrefying animal matter, or from a mixture of animal and vegetable mattery have also been considered as capable of producing these diseases. Bancroft has however stated a number of facts which show decisively that such exhalations are not productive of epidemic fevers. He states that apprehensions having been entertained of danger to the health of the inhabitants of Paris from the offensive exhalations which proceeded from an old grave yard, nearly twenty thousand bodies, in different stages of putrefaction, were disinterred and removed. Much of this was done in the hottest weather, but no fever was produced. During the epidemic fever of 1 800 in Spain, ten thousand bodies were buried in one burying ground in Seville, and twelve thousand in three others. In the hot weather of the following spring, the earth which covered these bodies cracked open and suffered a foetid odour to exhale. In Cadiz the churches were more or less filled with putrid emanations from the same cause. In neither case did an epidemic follow. In an establishment for the manufacture of adipocire at Conham, near Bristol in England, the entrails and useless parts of many hundred carcasses were left to putrefy on the surface ofthe ground; and although the effluvia were very offensive to all employed in the manufactory, the health of no one was injured in the two years during which the establishment was continued. Dr. Gordon gives an account of the putrefaction of one thousand barrels of salted beef in one of the West India Islands without producing sickness 


Cooke on Autumnal Diseases. 
19 
in any person in the town or in the neighbourhood. The beef was entirely spoilt and thrown into the sea. It is the custom of many countries to manure their fields with fish ; but no epidemic, has been known to arise on such occasions. 
These cases constitute strong evidence that exhalations from putrefying animal matter do not produce epidemic disease. It is to be considered also that the quantity of animal matter lying on the surface ofthe earth is exceedingly limited; being eagerly devoured by a variety of birds, beasts, and insects, in constant pursuit of it. On the contrary that vegetable matter everywhere abounds, and particularly in those places in which epidemics appear. It is also to be considered that the gases arising during the putrefaction of animal matter arc exceedingly offensive ; and that in places in which a fever prevails, there is frequently little smell, and often none. There must therefore be, in such situations, a very small proportion of the gases which arise from putrefying animal matter; and it cannot be believed that so sm.dl a quantity produces the effects observed in epidemic seasons when corresponding effects are not observed when these gases are abundant. If an epidemic fever be produced by so small a quantity of these gases that they scarce can be perceived, what terrible consequences should follow when a town or neighbourhood is annoyed, as in the cases above stated, by a most offensive smell for months? 
Bad drinking water has also been considered by some as the cause of these epidemics. A single consideration will show the incorrectness of this opinion. Epidemics occur in hot weather particularly, and therefore nothing present throughout the year can be the cause of these diseases. 
It has been supposed that epidemic fevers arc produced by some influence of clay lands on the atmospheric air. If so, these diseases ought to continue throughout the year, whereas they appear only in warm weather. If it be contended that it requires a high temperature to enable the clay to act, the answer is, that at that temperature, in such wet soils as these clay lands generally are, miasmata arise from the vegetable matter. There is therefore present, a cause known to be capable of producing 


20 
Cooke on Autumnal Diseases. 
these diseases; and there is no ground for believing that clay lands have a special influence, the same circumstances on any other lands producing the same effect. 
It has been supposed that water below the surface of the earth and near to it, produces epidemics. The same objection that was made to the two last mentioned alleged causes, is equally opposed to this. When water is found a little below the surface of the earth, it is not in one season only but throughout the year; whereas epidemics appear chiefly at one season; or if there be a season in which this subterraneous water is not to be found, or is scarcer than common, it is in that very time when epidemics prevail, viz. in hot dry weather. Countries so situated as to have water within a short distance ofthe surface, are for the most part marshy, and hence, in dry warm weather, the cause of the diseases which prevail. 
A moist air has been by some considered a cause of epidemic disease. But in the moist climate of Holland wet summers, when the air is particularly moist, are the healthiest, and dry summers the most unhealthy.* 
Dryness of the atmosphere has also been considered a cause of these diseases. It has been alleged in support of this opinion, that the long prevalence of hot southerly winds, has at all times and nearly in every country, been occasionally productive of epidemic disease ; the mortality during an epidemic vastly increasing during a southerly wind, and on the recurrence of a north wind a correspondent diminution taking place, till the disease is extinct. This statement is true, and yet affords no foundation for the opinion that dryness of the atmosphere produces epidemic disease. Winds arc wet or dry, in every region, according to its situation with respect to the sea, or any large body of water; and on this account, in all the south of Europe and of Asia the south wind is not dry but moist. 
It is an unanswerable objection to this or any other condition ofthe atmosphere being alone the cause of the autumnal or hot weather epidemics, that while the former is general in its opemtion, 
•Pringle on the Diseases of Uie Army, p. 82, 184. 


Cooke on Autumneil Diseases* 
21 
the latter are partial in their appearance* being more violent in one place than another, desolating some spots, while others at a short distance escape altogether. So partial an effect cannot flow from a cause general in its operation. 
Thus while in Italy and other marshy countries of Europe, in the island of Sardinia, and in the West-Indies generally, dry weather produces violent epidemics; in some of the West-Indies, in Senegal, &c. it is healthiest in dry weather, and very sickly in the midst of incessant rains. la this whole country, the dryest years are the healthiest except in spots, and tliesc are the wettest spots in the country. 
A rarefied state of the atmosphere has been mentioned as a cause of epidemic disease. A number of morbid s^yiptoms have been experienced at the top of high mountains, and attributed to the rarefied state of the atmosphere in those elevated situations ; and it is argued that such symptoms must be produced whenever such a state of the atmosphere exists. True; but when does it exist on the surface of the earth at the ordinary level of human habitations? If this doctrine were true, elevated situations would be the most sickly and low ones the most healthy. It is liable also to the same insuperable objection with some of the preceding, that the phenomena are two partial for so general a cause. 
How totally inconsistent with the nature of any of these alleged causes, are the occurrences among the troops at Galliopolis? There the cause, from its density, took its direction from the wind, and its presence being ascertained by its effects, it was traced to the spot where it originated; to the windward of which its effects could not be observed. 
Comets have of late years been seriously proposed as the chief cause of epidemics. The absurdity of the idea will appear at once if we consider, that they appear in winter as well as in summer, while most epidemics occur in hot weather; that comets continue to appear as in former times, but the epidemics of Europe are much less violent since that continent has been better cultivated, drained, &c; that epidemics if produced by comets, ought to be universal in the earth, which is not the case; that epidemics aften occur before, often after, the appearance of comets, some* 
1 


22 
Cooke on Autumnal Diseases. 
times a whole year: now if they appear because of the approach of comets, they ought to he more and more severe the nearer these bodies come ; hut these diseases are often over heforc they approach nearest: if it be said that epidemics occur because of the going off of comets, then ou<dit the former not to appear before the nearest approach of the latter. 
It is evident therefore from all that has been said, that there is not sufficient ground for believing that the epidemic diseases of hot weather are produced by a arising from putrefying animal mattcr,or by bad drinking water, or by the influence of clay lands, or by subterraneous water, or by a moist airnlonc,orby a dry air alone, or by a rarefied state of the atmosphere, or by comets; but that we have abundant reason to believe that these wasting pestilences are the effects of a dense gas, the product of the decomposition of vegetable matter. 
The next question in the regular prosecution of this inquiry, relates to the effect of this agent on the human system. This has, however, been the subject of consideration in the paper before alluded to,* and need not be repeated here. Suffice it barely to state the substance of what is given on the subject in that essay. 
The agent in question, commonly distinguished by the name of miasmata, causes the blood of those who are exposed to its influence to be of a darker colour than common. Goodwin's experiments on the connexion of life with respiration show, that when the blood is dark-coloured, it does not stimulate the heart to as vigorous action as when it is of the usual colour; and therefore that under the influence of this dark-coloured blood, the action of the heart is weakened. Weakened action of the heart is actually observed always to occur in the commencement of autumnal diseases. This state of the heart necessarily and inevitably produces accumulation of blood in the vena cava and its great branches. Internal congestion or accumulation is also observed actually to occur in these diseases. Accumulation of blood in the vena cava cannot exist without extending into the large veins of the head, the liver, the stomach and bowels, and the kidneys; and 
•*Triin?ylvtiuia Journal of Medicine kc. vol. 1. p. 80, kc. 


Cooke on Autumnal Diseases. 
23 
consequently affecting all these parts. Universal experience shows that they are all affected in the diseases in question. From accumulation of blood in the interior and its consequent absence from the exterior, must also result paleness, shrinking and diminution of the temperature of the external surface; while the sudden presentation of an Increased quantity of blood to the heart, must excite that organ to increased action, if it be capable of it .at the time.* These effects are also observed to occur in connexion with the others, above stated, in the diseases produced by the agent in question. 
It appears therefore that this agent, miasmata, by rendering the blood dark-coloured, weakens the action of the heart; the consequences of which are weakness of the pulse, diminution of the bulk of the external parts of the body, shrinking of the features and of the skin, paleness and coldness of the surface; together with accumulation of blood in the vena cava and its branches, whence arises pain in the head, comatose affections, convulsions, delirium, disordered secretion of the liver, nausea and vomiting, want of appetite, disordered bowels and kidneys, the convulsive agitation of ague, and increased action of the heart, which produces increased colour, temperature, and bulk of the external parts. 
These symptoms, with some others arising from the same cause, constitute the paroxysm, viz. the cold and the hot stages of a fever: they are moreover the leading features, present in all autumnal diseases. Sometimes one part, sometimes another, is more affected; and these differences give rise to distinguishing names. These it is proper to retain for convenience, but we shall be led into error if we lose sight ofthe fact that the above are the leading features of every form. 
In the further prosecution of this subject, it is proposed to show that the same cause produces all the forms of autumnal fever; that in all of them the same internal state is produced, the same general train of symptoms or leading features occur, the same mode of treatment is required, and the same obstacles to effecting it, occasionally exist, and are to be overcome in the same way. 
•Transylvania Journal of Medicine &c. vol. I. p. 85. 86. 


Cooke on Autumnal Diseases. 
24 
It would be a repetition of what has been already said on the subject of the origin of autumnal epidemics, to go into a statement of facts concerning the cause of each of the different forms of these diseases. Suffice it to make some general statements, the truth of which every man who reads them, will be 'ready to attest; and which when brought to his recollection, will at once convince him that all the forms of autumnal disease, arise under the influence of the same cause. 
All these forms, intermittent and remittent fever, dysentery, diarrhoea and cholera, arise at the same time of the year and in the same circumstances and situations. They are all more severe in very hot climates; in temperate climates they all appear in hot weather, and decline in cool weather. Moisture as well as heat is necessary to the production of all of them.* Heat and moisture are not sufficient to produce any of them without the presence of vegetable matter. A single fact shall be stated to set this matter in a clear and strong light. Two vessels lay at the island of Bulama on the coast of Africa in the year 1792, during the rainy season. Some hundreds of men, women, and children were confined on board by the rain ; and the weather being hot, they soon became very sickly and numbers died. Within the small compass of these two vessels were to be seen all the forms of autumnal fever; remittents, some of them ofthe highest grade, destroying the patient in a day or two, intermittents, cholera and dysentery.! This fact is so striking as to convince, to constrain us to believe, that the same cause produces all the forms of autumnal disease. 
This cause produces the same internal state in all these affections. This is evinced by the weak pulse, the pale and shrunk surface and diminished temperature, observed in the first stage of all the forms. This state of the pulse and of the surface, indicates weakened action of the heart, which cannot exist without being followed by an accumulation of blood in the interior veins; and this internal venous congestion is known to exist in all the forms of autumnal disease. 
•Clcghom's Obs. on the Dis. of Minorca, see the whole 2nd chapter 4 Medical Repository of New-York, vol. L p. 475. 


Cooke on Autumnal Diseases. 
25 
The accumulation ofhlood in the vena cava and its brandies, existing in all the forms of autumnal disease and necessarily affecting the same parts in all, the same general train of symptoms or leading leatures occur in all these diseases. In the commencement of every one of them we observe the symptoms constituting what is called the cold stage of a febrile paroxysm. This stage, in all the forms, is generally followed by increased action of the heart, constituting the hot stage. The hot stage moderates more or less, or entirely subsides in a few hours. The remission or intermission is again followed by in creased action. The remission is sometimes very slight, at others so perfect that for some hours or even for a day the patient is flattered with a hope that his disease is at an end. This is the case in dysentery as well as in fever.* 
The parts principally affected are the back, the head, the breast, and the epigastrium. 
The pain in the back is often most severe in the cold stage, moderating as the fever rises. 
The head is very generally, perhaps universally, more or less disordered. Pain and confusion of intellect exist in every degree, from that in which they are little regarded, to one in which the patient is ungovernable or stupefied. 
The breast is the seat of oppression accompanied by efforts to get rid of it by full inspiration, with anxiety and great apprehensions of danger. 
Tie epigastrium is the seat of tenderness, from a degree so slight as not to be noticed by the patient till pressure is made, to an intolerable soreness and burning, accompanied by fruitless efforts to vomit. 
The discharges from the bowels are of various colours and consistence. Sometimes the bowels are obstinately constipated; at others there are frequent green or black discharges. 
The urine is of various colours from a deep yellow to a very dark and almost black, precisely such as is seen when dark coloured feces have long remained in a vessel of urine. 
•Cleghom's Ob 3. &c. p. 123. 236. 


Cooke on Autumnal Diseeises. 
26 
Every one of these symptoms has occurred in all the forms of autumnal disease that I have witnessed for twenty-five years past; and every practitioner of experience and observation will assent to the truth ofthe assertion as far as his experience extends. 
It is true that different cases are distinguished by one having a higher degree of this, and another of that symptom Some have a greater, and others a less degree of remission of febrile action every day. In some cases the bowels are very irritable so that large doses of medicine are required to produce evacuations; in others smaller doses will produce great effects. Sometimes the bowels arc so irritable and the secretion of bile so free, that without medicine bilious evacuations are as abundant as in others from the administration of cathartics. In some of these cases, after the ordinary contents ofthe bowels are passed off, the mucus which Hues them is discharged, at first in its natural state and finally more or less tinged with blood. This irritable state somelimes extends to the whole tract of the alimentary canal, and at others is confined to one or other extremity of it. 
These differences give rise to the distinguishing names, remittent, intermittent, diarrhoea, dysentery and cholera. But though the different forms are distinguished by them, they do not constitute the disease. Thus, that form in which the bowels are so irritable as to discharge first the ordinary contents of a greater or less portion of them, and afterwards mucus or bloody mucus, is called dysentery for the sake of distinction ; but it is evident that this symptom does not constitute the disease: besides this, there arc to be seen all those above mentioned as the leading features of autumnal epidemics. We even find in many cases that this symptom does not appear for some days after the others.* Before it appears the case is not to be distinguished from the general mass of cases of autumnal fever; and after its appearance, if by proper remedies it be speedily removed, the case cannot be distinguished from others in which the symptom never appeared,, and no man can by any means discover that it ever existed. 
The same may be said of every other form. Intermittents 
*Cleghorn's Obs. on the Pis. of Minorca p. 1. of Chap. v. 


Cooke on Autumnal Diseases.. 
27 
become spontaneously, or they may be made to become remittents, and remittents intermittents; dysentery becomes n remittent or intermittent, and remittents .and intermittents assume the character of dysentery; cholera becomes an intermittent or remittent, and vice versa. 
These statements are confirmed in every point by the testimony of Cleghorn and Pringle.* 
The same internal derangement ex'sting in all the forms of autumnal fever, and the leading features or symptoms, effects of this internal derangement, being the same in all, the same mode of treatment is proper in the whole of them; and the difficulties in prosecuting the treatment, arc the same, and are to be overcome in the same way. 
The remedies commonly used in the treatment of autumnal fever are bleeding, vomiting, purging, blistering, the warm bath, and tonics. 
In every case of fever in which the pulse is strong and tense, the good effects of letting blood arc manifest to all who have made the trial. In these cases it is often necessary to take blood to obviate immediate danger; and it is almost always advisable, in order to prevent the prostration of the system which follows excessive action of the heart and arteries. It should be carried to the extent of making a sensible impression on the colour ofthe countenance or on the pulse ; and should be repeated, so as to ensure the effect desired, the reduction of the violent action of the heart, without regard to the number of bleedings in the same day. I have frequently advised bleeding repeatedly in the same day when the pulse continued strong and tense, or when that state returned in a short time after being softened by the previous bleedings. 
In cases in which the pulse is not so strong, but still more so than natural, bleeding is often advisable when it may be and is dispensed with. It favours the operation of cathartic medicines, and is effectual, in a few minutes, in the reduction of a degree 
•Clefdiorn's Obs. on »he l)i«ra*es of Minorca p. 123. 130. 140. 151. 155. Pringle's Dis. ofthe Army, Part 111. Chap. 4, ' Chap. 6, t 3. 


Cooke on Autumnal Diseases. 
28 
of increased action, which may not with certainty be accomplished in hours or days by any other means. 
In cases in which the pulse is moderate or even smaller than common, bleeding is sometimes beneficial; particularly when the head or the bowels are affected with violent pain, or the lungs greatly oppressed. In these cases the patient is often pale, and there is some doubt ofthe safety of taking blood; hut if he can near the loss without the pulse sinking, he will be greatly relieved. In the commencement of an attack, if the pulse, though small and not strong, be somewhat slow and regular, aid be not varied by change of the position ofthe patient from a lying to a sitting posture, bleeding may be tried. If the pulse, which ought to be felt during the whole time, do not fail at all, the Needing may be continued. In such cases the pulse sometimes increases in force after a short time, sometimes even during the 
operation. A la Jv with intense pain in the head, pale cool skin, and weak 
pulse desired me to bleed her. Fearing to venture, I advised her to take a cathartic; it operated five or six times, but the pain continued. Still insisting on being bled, though much in the same state as in the morning, her wish was complied with and she was considerably relieved. Some time afterwards, she was attacked again in the same way. The pain was very severe, the skin pale and cool, the pulse weak but regular and slow, and not altered by rising and sitting up. About a pint of blood was taken from the arm, the pulse not lowering, and on taking off the ligature it was troublesome to stop the blood. She w r as about in a day or two. 
The affusion of cold water upon the whole ofthe body, or upon some principal part of it, as the head, is likewise a very effectual and speedy mode of reducing the action of the heart. Emetic medicines in nauseating doses arc another effectual moans of reducing increased action. 
Emetics are sometimes useful in autumnal fevers merely as an cvacuant. They discharge a quantity of bilious or other matter, which from the position and shape ofthe stomach, is sometimes retained for days, exciting great nausea. They are also useful 


Cooke on Autumnal Diseases. 
29 
in the forming state of fever: given in the approach ofthe cold fit, they often prevent it. In the access ofthe paroxysm of fever the patient sometimes is affected with a sense of suffocation and labours for breath. In these cases emetics are very useful in affording relief for tlie time. Administered in the fever so as to produce free vomiting they often break up the paroxysm, and there is no doubt but a fever may sometimes be cured by repeated emetics. They, however, produce injurious effects wlien administered in such a manner as to cause excessive purgii g of a serous fluid. Such a purging I have known terminate in death in two days, and the misfortune is that the cases in which emetics will act in this way, cannot with certainty be distinguished. 
Cathartics are the main depcndauce in the treatment of autumnal fever. They have generally been considered useful in proportion to the quantity of the discharges they produce ; and as any one ofthe class may be made to act on the bowels, it is too common an opinion that excepting calomel, one is nearly as good as another. Hence it is that physicians often prescribe a dose of calomel at night, and direct the patient, to take in the morning any thing he likes best to assist the operation. 
It cannot however have escaped the attention of men, of observation, that free purging sometimes gives little or no relief; that notwithstanding the most active employment of cathartics, the patient gradually sinks into stupor, with eyes suffused, &c. ; and that the symptoms produced by congestion or accumulation of the blood in the interior veins, are sometimes rapidly increased by the active operation of a single cathartic. Neither has it escaped tlieir observation, that in those cases in which cathartics are useless or injurious, the discharges are serous; and that all the unfavorable symptoms are at once mitigated by the discharge of consistent and dark-coloured matter from the bowels. 
There is no difficulty in explaining why evacuations of this nature produce greater benefit than serous discharges. We lmvc seen that in autumnal diseases there is an accumulation of blood in the vena cava and its great branches, producing disorder in the different parts with which those branches are connected. It is evident therefore that lessening this accumulation must have 
5 


Cooke on Autumnal Diseases. 
30 
the effect of alleviating the symptoms dependent upon it. The communication between the branches ofthe vena porta?, those of the venae hepaticae and the biliary ducts, is so free, that if either of them be injected, the others will be filled. It is manifest therefore that discharges from those ducts directly les«en the quantity of blood accumulated in those veins and in the vena cava, &c. and must, therefore, necessarily alleviate the effects flowing from that accumulation. On the other hand serous discharges are poured out by the capillary vessels opening upon the internal surface of the intestinal canal, and consequently proceed from the arterial system: such discharges it is well known weaken the pulse, which is a certain indication that the action of the heart is weakened; and weakened fiction of the heart is inevitably followed by increased accumulation of blood in the vena cava, &c. and consequently by an increase of the symptoms dependent upon or flowing from it. 
In the choice of a cathartic therefore, we should consider it indispensable that it be capable of producing evacuations from the biliary ducts, and that cathartic which best effects this purpose should be preferred to all others, unless some greater injury is liable to arise from its administration in sufficient quantity, than that under which the patient is suffering. 
From long and constant observation and from many experiments, I consider the medicines in common use as standing in the following order, in reference to their fitness to effect this object, the most effectual being first mentioned ; viz. calomel, aloes, rhubarb, jalap, scammony, colocynth, senna, calcined magnesia. Salts of all kinds, oil and gamboge are little adapted to this end. In some cases either of the three last mentioned will, in a degree, answer the purpose; but in general, particularly after free purging has been once or twice effected, oil only discharges what may be in the intestinal canal, and if there happen to be nothing there,, it frequentlyly passes off unaltered and unmixed with any thing; while gamboge and salts produce an immense serous discharge, at first coloured by the contents c" the bowels, but transparent if the medicine be continued. 
Calomel is slow in operation often requiring twelve hours: it 


Cooke on Autumnal Diseases. 
31 
does not operate frequently, but the discharges are large. It gripes little or none in general, and is perhaps the most effectual medicine known, in producing consistent discharges from the biliary ducts. 
Aloes resembles calomel in its operation more than any other vegetable cathartic docs. I have given a considerable dose of calomel for several days in succession, and to the same patient for as many more days the same number of grains of aloes ; and from the result of these and other experiments with rhubarb Bic. I am convinced that aloes is the best substitute for calomel, with reference to producing consistent bilious discharges. It resembles it in being slow to operate, in not operating more than once or twice freely, and in griping very little in general. A very strange idea prevails that the action of aloes is limited to the lower part of the bowels, and even to the rectum, and hence it is objected to as likely to produce haemorrhoids. This idea may have proceeded from the small dose commonly given, having usually no further effect than to unload the rectum. The same is however observable on giving almost any cathartic in a small dose. Calomel, rhubarb and occasionally jalap, act in the same manner. Aloes however, as well as the rest of these, in large doses operates more freely, producing several loose bilious passages. That aloes acts on the rectum alone is impossible, because it is very soluble in however dry a state it may be; and therefore must be in a situation to act immediately on being taken into the stomach: that it is brought into a fluid state in the stomach is evident when it happens to be thrown up a short time after being swallowed. The discharges produced by aloes are also more purely bilious and acrid than those produced, perhaps by any other; which certainly shows it acts on the upper part of the bowels and the liver. 
Rhubarb is the next, of the vegetable cathartics, to. aloes in its influence over the secretion of bile. In doses of five or ten grains it acts very much like the latter; but it is not quite so certain or effectual in producing consistent discharges. In large doses it produces a more abundant and liquid discharge. 
Jalap in small doses is less certain to operate than rhubarb. In 


32 
Cooke on Autumnal Diseases. 
large doses it is more active, the discharges being larger, and more liquid, but still of a cast decidedly bilious. 
Scammony is much more active than 'jalap, and much like it in its operation, but less nauseating. 
Colocynth is also much more active than jalap, but produces more nausea and griping. The infusion of senna is also very active, and produces more griping than jalap. The calcined magnesia produces similar thin discharges, except in small doses. 
Of these medicines calomel being the most effectual in producing discharges from the biliary ducts, and being also tasteless*, the dose small in bulk and weighty, whereby it is retained when other medicines are rejected, would be used to the exclusion of all others but for the danger of ptyalism. The necessity of limiting the use of this medicine, so far as to avoid this disagreeable effect of it, leads to the employment of different cathartics in conjunction with it. With this in view it is reasonable to believe that the medicines most similar to it in operation should be selected ; and after long and very particular attention to this subject, I am entirely persuaded that the best combination that can be devised to produce free, yet consistent evacuations from the liver, in most cases, is the following, viz. equal quantities of calomel, aloes and rhubarb, made into a mass for pills with water alone. Each pill may contain two grains of each of these medicines, and will not be large if nothing but water be used in mixing them. In general three or four such pills operate in eight or ten hours without nauseating or griping, and produce about three passages. 
If a patient be liable to be salivated, each pill may contain but one grain of calomel ; or this medicine may be entirely left out. There is, perhaps, no substitute for calomel equal to the aloes and rhubarb. In many cases this combination effects the object in view very well; but it is not as effectual in producing dark-coloured passages as when calomel is added to the other two, this addition ensuring the object when the aloes and rhubarb alone have failed. 
In some cases it is found that two, three, or four such doses do not operate on the bowels. In these cases it is necessary to in* 


Cooke on Autumnal Diseases. 
33 
crease the dose or use some more active ingredient than the rhubarb. Patients generally prefer the latter. With this view jalap may be substituted for the rhubarb in the preceding prescriptions: this combination is very active and produces very abundant dark bilious passages, of thinner consistence however. Jalap and rhubarb mixed, and used in place of cither singly in these prescriptions, form a very useful combination o r the qualities of the two: the compound is more active than the rhubarb alone, and less nauseating than jalap, the effect being a medium as to consistence. Sometimes jalap nauseates excessively; scammony may then be used instead of it. 
AH these combinations mix perfectly well with water alone, into a mass fit for pills. Some gentlemen who have used them, have complained of the bulk of the pills. On inquiry I found they had used some other ingredients, as flour, soap, &c. No addition is necessary. t 
Sometimes the patient is distressed with a burning produced by the acrid bile brought into the intestines by these cathartics, particularly by the pills of aloes, rhubarb and calomel. This is readily relieved by omitting the aloes. A small dose of magnesia will also relieve the burning in a short time: these medicines increase the fluidity of the passages, and thus render them less acrid. 
Even these active medicines sometimes fail : in these cases equal quantities of scammony and calomel may be used : 1 have sometimes found the addition of the eighth of a grain of tartarized antimony to each pill, very effectual. 
Avery active cathartic may be formed of calomel and tartarized antimony, or ipecacuana. The former is particularly valuable in the cases of children, inasmuch as the taste is so little offensive to them. This compou id has the advantage of contributing to relieve by reducing the pulse. The calomel ,may be given at a single dose, ai d the tartarized antimony in divided doses afterwards. It is to be observed however that the nausea which is apt to be produced by the last is very disagreeable ; and as the other mercurial cathartics mentioned, effectually answer the pur* 


34 
Cooke on Autumnal Diseases* 
pose, and in a more pleasant way, I have seldom used the antimcnials for a longtime. 
The object in going into this detail is not only to state the prescriptions which have been found best adapted to produce consistent passages from the bowels, but likewise to manifest how important a matter I conceive it to be, ever to have this object in view. I never consider a patient safe until he is brought to discharging freely from the biliary ducts; and if this can be effected pretty early and the discharges can be maintained, I consider him safe. 
The best time for giving a cathartic te a point of some moment. In order that the evacuations may be most serviceable in reducing the febrile action, the medicine should be administered in such a manner as to operate during the fever. They should therefore be given during the remission. It is always best to administer such a dose at once as will be pretty certain to effect the object in view. Thus, if it be found on trial that four pills given in the morning do not operate sufficiently, and that it becomes necessary to give a second or third dose; on the day following, it will be advisable to give six or eight at once if the patient will make the effort to swallow them. An effort is all that is required: six or eight pills can easily be swallowed at once, with a little attention. The best way is to hold a little water in the mouth, and pour the pills far back into the throat out of a dry spoon or wineglass. 
Under the daily operation of these medicines, the discharges from the bowels, at first of a dark brown, a black or a dark green colour, gradually become lighter in colour and finally yellow. During this process the symptoms also become more and more mild, and in almost every case they disappear by the time that the passages become yellow. The febrile action is carried off in most cases before this is effected ; but other effects of accumulation of blood in the vena cava and its branches, viz. derangement of the functions of the liver, the stomach, &c. continue. But as soon as this congestion is reduced so that the secretion of the liver becomes natural and healthy, the appetite returns: because 


Cooke on Autumnal Diseases. 
35 
the veins of the chylopoietic glands all contributing to form the vena portac which supplies the liver, these glands are all in like manner affected by accumulation of blood in the interior veins; and the same degree of fulness which produces a healthy secretion in the liver, produces the same in the stomach, and the appetite and power of digestion return with the appearance of natural-coloured passages. 
The patient is now convalescent, but the medicines should not be laid aside, unless indeed, as sometimes happens, the bowels become so open as not to require aid. If however he should not have one or two copious consistent passages in the day, he ought not to fail to procure them by a sufficient dose of the pills of aloes, rhubarb and calomel. Treated in this way patients rapidly recover and have a fine complexion very soon after rising from bed. It will not be questioned that a convalescent with a good appetite, recovers faster if he happen to have his bowels in such a loose and easy state as that abovementioned ; and if he have them not in this condition, can any thing be more certain than that bringing them into this state will promote his recovery? 
There are some symptoms which occasionally occur in these fevers, deserving of particular notice. One of these is stupor. When the pulse is strong, there is no question of the propriety of evacuations in this case, and therefore nothing further need be said respecting it. When however the pulse is moderate or weak, some maybe disposed to doubt the propriety of such remedies, and to rely on blistering and irritating applications to the. feet, &c. The effect however of a free evacuation of dark bilious matter in such circumstances, is surprizing. 
I was desired to visit a patient and found him affected with stupor and an uneasy feeling hi the abdomen. He had been ilia fortnight. His physician informed me that he had attempted in vain to purge him, that he had blistered the abdomen without advantage, and that he was now resting all hope of saving him oh a salivation. He was advised to return to his first plan and give him a large dose of scammony and calomel. He took half a drachm of each that night. Early next day we found he had 


Cooke on Autumnal Diseases. 
36 
had six large dark-green passages, and was much better. These medicines were continued and he rapidly recovered. 
Another man had been ill for some days. I found him in a stupor, unable to speak, and with a complexion of a dark yellow colour. On being asked if he felt pain, he made an attempt to put his hand to the pit of his stomach, but was not able to direct the effort properly. His pulse was somewhat strong .and full. With hesitation I ventured to bleed him: he was not relieved by it. The attending physician was advised to open his bowels effectually. This was done with scammony and calomel inconsiderable doses: the passages were free and black: next day lie was so much better as to be able to converse on his situation. The third day he was again found in a stupor and in extreme danger: his nurse had neglected giving him bis medicine, arid there had been no evacuation from the bowels. His brother then determined to remain with him. The same medicine operated well, the stupor disappeared immediately, and the course being continued he recovered. 
A man, seventy years of at^e, was affected with stupor, and had at the same lime hilious diarrhoea; the passages were of a dark green colour. His pulse was active. He took mercurial cathartics every day for about a week with marked benefit; and he perfectly recovered. The spontaneous discharges might have cured him; but as be was an old man, it was thought best to hasten his recovery by rendering them more copious. His son Dr. Sutton I. Harris of Frederick county Virginia, was attending to him at the same time. 
Stupor is a very common symptom in children who are affected with autumnal fever. When it is very considerable, tire child is said to have hydrocephalus interims. It is accompanied sooner or later, sometimes from the beginning, by enlargement of the pupils, insensibility of light and even blindness ; or by contracted pupils and great sensibility of light, with pain and convulsions. These symptoms, however, are all such as an accmulation of blood in the vessels of the head is capable of producing; such accumulation is present in autumnal 


Cooke on Autumnal Diseases. 
37 
fever, and is to be seen when the patient dies ; at the same time that an effusion of water is sometimes at least, not to be found; perhaps, rarely exists. "Dr. Quin has given a dissection of a child that died with all the symptoms of hydrocephalus interims, and yet nothing was discovered in the brain but a slight turgescence of its blood-vessels."* It appears also from Morgagni's account of the dissection of a great number of bodies, that accumulation of blood in the vessels of the head, sufficient to render them turgid, exists in almost every case in which serous effusion is found.! Lastly effusion of serum in great quantity sometimes occurs without the appearance ofthe symptoms attributed to it.J 
Inasmuch therefore as the symptoms relied on as evidence of the existence of serum in the cavity ofthe cranium, are such effects as increased fulness of the vessels of the brain and its coverings is capable of producing; as even when serous effusion is observed, increased fulness of the vessels of the brain is also present; and as in some cases, dissection shows that increased fulness of those vessels, but no serous effusion is present, it is evident that the former and not the latter is the cause of the symptoms in question, at least in most cases. 
This conclusion is strongly confirmed by the fact, that when there is a free evacuation of bilious matter from the bowels, the child is manifestly relieved of all the symptoms, and, this ceasing, they return again in a few hours, and again disappear on a repetition of the bilious evacuation. These marked changes, repeated in a short time, are entirely inconsistent with their depending on effusion as their cause, which cannot so suddenly be removed and return again: but it is perfectly consistent with dependance on an accumulation of blood in the vessels ofthe head, which can by such evacuations from the liver and therefore from the vena 
?Rush's works, vol. 3, p. 58. fMorgagni of the Seats and causes of Diseases, Let. I. art 26. — Let. 11. art. 9. 17. 20.— Let. HI. art. 4. 6. 14. 24. 26.— Let. IV. art. 4. IS. 19. 24. 28.— Let. V. art. 6.— Let. VI. art. 6.— Let. VII. art. 4. 9.— Let. X. art. 17. 19.— Let. XI. art. 2— Let. XXI. art. 7. 33.— Let. XXIV. art. 6.— Let. XXV. art. 10.— Let. XXXI. art. 2.— Let. XXXV. art. 16.— Let. LX. art. 2. 10. 12. tlbid. Let. I. art. 7.— Let IV. art. 3. 29. 35. 36. 6 


Cooke on Autumnal Diseases. 
38 
cava and its branches in the head, be reduced, and can return in a short time. 
The treatment of children in this situation, is precisely the same as that of adults. Bleeding ought not to be omitted if the pulse admit; but a copious discharge from the liver is the most effectual means of removing this affection of the head. Indeed so important is this evacuation, that, provided only the pulse be moderated by bleeding if necessary, by it alone the child will be saved, and without it perhaps nothing can save him. 
Convulsions sometimes occur in autumnal fevers. They sometimes accompany the last mentioned symptom. They occasionally appear in the commencement of an attack, sometimes in the course of it. Whenever they occur the patient should be freely bled if the pulse be strong and hard: but if soft, though full, bleeding is improper, and likewise if the pulse be weak. A lady riding out had a convulsion in her carriage. She was bled freely and vomited. She was next day able to return to town and desired me to visit her. Her pulse was full and very soft. She Wished to be bled. This was objected to, on the ground that the further weakening the fiction of the heart, would tend to increase the accumulation of blood in the interior veins, and very probably produce convulsion. She was purged with mercurial cathartics, and discharged black matter pretty freely. After continuing to do so four days, she prevailed on me to bleed her, and while the blood was running she was seized with a violent pain in the head, and fell into convulsions. The patient should therefore not be bled when the pulse is weak or very soft. While the convulsions continue it is exceedingly difficult to get him to take any thing: but by watching closely a Moment may be seized to pour down a solution of tartarized antimony. Half a scruple is not too much for an adult, but it should be instantly followed by large draughts of warm water, or tea, which the patient will drink when he will not swallow water, repeated without interval until the whole is thrown up. At the moment this is done, the patient becomes somewhat sensible, and not a moment should be lost in administering a dose of jalap and calomel. As the case ts urgent, and another opportunity may not occur for many hours 


Cooke- on Autumnal Disease*. 
39 
afterwards of repeating the dose, a large one should be given. In such cases, when called to patients who had been for many hours almost without interval convulsed* half a drachm of calomel and as much jalap has proved in a short time decidedly beneficial. After a free operation the patient is relieved, and the case proceeds as other cases of fever. 
As in individual cases, sometimes the head, sometimes the back, is more affected, so in some seasons these parts are affected in most of the cases. In 1 825 stupor or delirium or both, were common in adults. The children also had the same affection of the head, which ivas called hydrocephalus. In some sea* sons, in like manner, the back is principally affected, and the attention of the patient, and too often of the physician, is drawn away from the true nature of the case, and the disease often terminates fatally while efforts are making to relieve the affection considered merely as a local one. In both the one and the other the affection of the part, is but a symptom of the general disease. The part is no doubt affected, but the affection depends on the same cause with the other- symptoms, and stands or falls with them. The treatment therefore of these cases is the same with that of autumnal fever in general. I have not room to state facts here to establish this view of the nature and treatment of these affections, but state as the result of my observation and experience that these and all similar local affections, during the season of epidemic diseases, are to be most successfully treated as cases of autumnal fever. 
There are some other symptoms which occur in fevers of low grade. Fevers of the lowest grade of action are successfully treated in tke same way, except that bleeding is not admissible, ?md that instead of the affusion of cold water, that of warm or tepid water should be used. Cathartics are the main dependence; and when the action of the heart is very weak and quick, those cathartics which produce discharges of considerable consistence are more especially necessary. Such cathartics are considerably stimulant: it is however sometimes proper, and even occasionally necessary, to use stimulants with the cathartics; but rarolv after dark-coloured consistent passages have been procured. 


Cooke on Autumnal Diseases. 
40 
There is not a symptom belonging to these low fevers which is not carried off by such cathartics. 
In the year 1806 I had a patient in a low fever, with delirium, subsultus tendir.um, &c. whose life was by his friends despaired of, but under the daily operation of mercurial cathartic pills, he discharged black bilious matter, and recovered perfectly in two or three weeks, without any other medicine than occasionally an opiate with vol. alkali. 
In the year 1 808 I had a patient lying much in the same situatio 1, who was however excessively weak, and lay attempting to pick off spots which he supposed he saw on the bed-clothes. He was taking mercurial cathartics every day and discharging black matter, when he was one day visited by an elder physician, who advised that the cathartics had been carried too far and that he should take bark and wine. He however continued the cathartics and recovered without bark. 
In the year 1 816 I was desired to visit a patient of twelve years of age who was very ill: there was another of about the same age lying in the room, who was not very ill, and whom the family undertook to manage. On the second day however she likewise was put under my care. The one first mentioned took a cathartic every day without any objection from the family, it being admitted that she was dangerously ill; and in twelve days without any other medicine she was entirely well. 
The other took a cathartic, two mornings, and was so much better on the third that the family declined giving her any thing more. She was sitting up, but could not eat. On the next morning she was on the bed again, and on the morning following was compelled to return to taking medicine. In two or three days she was again sitting up, and the family again considered medicine unnecessary. In two days more she was compelled to begin again. By this time however she had become seriously ill. She continued taking mercurial cathartics alone, the discharges being excessively foetid. Not bearing in mind that their own interposition had been the cause of the length of her illness and fearing she would die, the family at length desired the aid of a physician, a relative of theirs, in consultation. He, using language 


Cooke on Autumnal Diseases. 
41 
very common on such occasions, observed that the practice had been very proper, hut that as she was in a typhous state, the cathartics should be laid aside and she should be stimulated. As the whole party were now opposed to my views, and particularly as it had been frequently declared by neighbouring physicians that continued purging was not necessary even in fevers of considerable action, and that in these fevers, on their own experience and that of writers of high authority, bark, &c. were proper, I was well satisfied that the point should be fairly tested. The patient was therefore, under my direction, most faithfully stimulated with brandy, wine, bark, blistering plaisters, &,c. for a week. She commenced this course weak and low enough; but at the end of the time mentioned she was decidedly weaker and lower; and her death was pronounced to be inevitable. In this state of things I protested against pursuing the stimulating plan any longer, and, no objection being made, 1 returned to the cathartic plan of treatment. She took a dose of rhubarb and calomel every morning, sufficient to operate two or three times until she perfectly recovered. She took nothing else except an anodyne occasionally at bed time. It is worth while to observe that these were the first patients I had in that family, and that I never had such difficulty in families in which the practice had been followed. The good effects silenced all opposition. 
In the same year I had nine patients in one family. The master had a high fever, was bled several times, purged freely and recovered. All the rest but one had fever of ordinary grade, requiring cathartics without bleeding, and recovered. The one excepted had a weak, quick, soft pulse, moderate heat of the skin, mild delirium and subsultus tendinum. Continued mercurial cathartics cured him also. One morning he was more delirious and had more subsultus tendinum and tremor than the day before. Having had my mind much engaged about this time, as above intimated, respecting the propriety of purging in these cases, I was very attentive to the effect of avery dose. Finding him with an increase of what are called nervous symptoms or symptoms of typhus, I was sitting observing him and reflecting on his case, when his mistress came in and said that she bad no* 


Cooke on Autumnal Disceiscs. 
42 
glected giving him the last dose of medicine left for him. This information settled the point, and the cathartics were continued daily until he was perfectly well. He took nothing else* A gentleman, in 1821, consulted mercspectirg his brother who lived so far off that I declined visiting him. He however undertook to give me daily information of his situation. He had been ill for some days and had been taking calomel and opium. He lay in a comatose state, with a weak quick pulse. Some pills of calomel, scammony and camphor were sent, with directions to give him four every two hours, until they should operate. Such were his brother's fears from a practice so different from. that which had been followed before, that he only ventured to give him two pills at a time. He took several doses before they* operated. The discharge was copious and black. He immediately after the first passage recovered from the stupor, and conversed with considerable animation. The mercurial cathartics were continued daily and he perfectly recovered. 
In the present summer, a negro girl, thirteen years of age, had a black tongue, delirium, hurried manner and respiration, anxious countenance, pain in the right side on full inspiration, dry cough, excessive soreness of the epigastrium, a pulse quick and varying in force very much in the course of the day; she was sometimes hot and sometimes so cold as to require hot applications to her abdomen and extremities ; she had such a disposition to watery passages that a small proportion of ipecacuana or of rhubarb with the calomel, made them very much so. Calomel alone, in doses of half a scruple, three or four times a day, rendered the discharges more consistent. After continuing this for several days,-she took aloes and calomel, of each ten grains, three or four times in twenty four hours, the rule being to repeat the d^se every three or four hours until the effect was produced. She continued this prescription for a week. The passages became more and more consistent, were black for several days, then green with a mixture of yellow, and finally yellow. She manifestly (mended every day. When she began, it was necessary to use hot applications to the feet &,c. once or twice a-day:,in a few days this was forgotten; she acquired composure; the delirium disappeared,, 


Cooke on Autumnal Diseases* 
43 
also the hurried respiration, the pain on inspiration and the cough, the soreness of the epigastrium, the blackness of the tongue, and •she had a great appetite. She took no other medicine and used no blistering plaister. 
In these low fevers hemorrhages from the stomach and bowels, with petechias on the skin, are not unfrcquent. These discharges sometimes appear in the commencement of the attack, sometimes in the course of it: they are often, perhaps generally accompanied by purple spots on almost every part of the surface. .Some of these are of a light purple colour; others of all the different shades to a deep purple. They arc of all sizes and of various shapes. When the cuticle is broken over one of the deep purple spots, black blood sometimes exudes. 
These discharges from the stomach and bowels, I believe to be the effect of congestion or accumulation of blood in the vena cava xind the neighbouring branches, because they almost invariably occur, as far as my experience extends, when the pulse is weak, and are often great when the temperature of the surface is reduced and the patient is pale ; which indicate weakened action of the heart and consequently accumulation of blood in the vena cava, &c. It is believed that they proceed from the liver, because tin* blood is just such as is contained in that viscus ; because the secretory vessels of the liver are naturally larger than those of any other gland, as is shown by the free communication between the bile-ducts and the vena porta? by injection ; because the secretory vessels of the liver, being veins, are more easily dilatable than those of the glands on the surface of the stomach and bowels, and therefore more readily suffer the blood to pass; and because when black blood is passing, there is little or no discharge, of the common kinds from the bile-ducts, and when the common bilious discharges return, or are restored, tlic discharge of blood alone ceases. 
Under this conviction I determined near seven ye.vrs ago to try the efficacy of such cathartics as those above mentioned, in haemorrhages from the stomach and bowels ; and such has been the result that I rely with entire confidence on the use of these medicines alone, in all such cases. 


Cooke on Autumnal Diseases. 
44 
I have a minute of one case cured by cathartics in 1822. During the autumnal epidemic of 1 823, I hadscvcral cases in which there was a discharge of black blood from the bowels, with purple spots on the skin of different sizes and shapes, some as small as a grain of wheat and others nearly as large as a dollar. In these cases the cathartic pills above mentioned were given so as to operate on the bowels, without any other medicine whatever, with the best effect. One of these cases only terminated in death: a child had been passing blood profusely for a week when I visited it, and was almost gone ; the purple spots were some of them as large as a dollar. No effort was made to save it, as the attendants had despaired of its living. 
In every autumnal season since 1823, excepting that of 1827 which was remarkably cool and healthy, similar cases have occurred in my practice ; and whether the haemorrhage appeared before any medicine was administered, which was generally the case, or during the administration of mercurial cathartics, these medicines alone were administered as being the best means of reducing that congestion or accumulation in the vena cava and its branches, of which the haemorrhage is the effect. 
The only exception to this was the employment of a blistering plaister in one case, which produced ho visible effect. The result on the whole is as follows. Not taking into consideration the child above mentioned, for whom nothing was done, in every instance the haemorrhage disappeared while taking the medicine. Four of these patients however, died, notwithstanding. A woman with such discharges from the bowels, took cathartics to a considerable extent, but without the slightest effect in producing proper discharges; she and her sister were both ill at the same time, in the same room ; the sister had no haemorrhage ; cathartics had not the desired effect on the bowels of either; but during the time in which they were daily administered, the haemorrhage lessened and disappeared, so as to bring the cases to a nearer resemblance than at first. As the cathartics had no effect in either case, I predicted to my friend Dr. Stribling, of Frederick county, Virginia, who visited them with me on the fourth day, fhe death of both, resting solely on the single circumstance of there 


Cooke on Autumnal Diseases* 
45 
being no operation whatever. They were at that time able to rise and sit up in bed, or to get out of bed without help. They both died within four days, without having had a single bilious discharge. 
In three other cases haemorrhage appeared in the course of the treatment. The cathartics were continued notwithstanding and the discharge of blood ceased in all of them; and the patients died some time afterwards, through gross neglect of directions, one of them by excessive eating during convalescence. Some of the cases in which the patients recovered were very remarkable. A young woman about twenty years of age had the autumnal fever about the last of July and first of August 1824. While recovering slowly, in consequence of unwillingness to take sufficient medicine, she was affected with an unusual tremor of the hands. On the 6th of August she had a discharge of dark blood from the nose and mouth. After spitting out the blood as completely as possible, it could be seen to flow into the mouth and moisten the whole surface, precisely as the saliva does. She took two cathartic powders. On the second day I found the medicine had had little or no effect on the bowels; the haemorrhage had increased ; a number of irregular purple spots of different sizes had appeared on her face and neck. She was very cold and pale. A blistering plaister was applied to the back of the neck. She took in the day and night four large cathartic powders. On the third day I found the medicine had operated but slightly. The haemorrhage from the nose and mouth continued, but was not as free as it had been: the discharges from the bowels were entirely of blood, black and fluid. She was in a cold sweat, with a low pulse. During the day and night she took more than a drachm of scammony and more than two drachms of jalap and as much aloes, made into fifty-two pills. 
On the fourth day I found that she had vomited twice in the night, and in the morning had had a very offensive passage, mixed with blood. She was still cold, pale, bathed in sweat, with a weak pulse, and lay on a very hot day wrapped in a very large thick blanket. Heft for her forty-eight pills, of aloes, rhubarb, and scammony. of each four scruples: four to be taken every 


46 
Cooke en Autumnal Diseases. 
hour. A small blistering plaister was applied to each leg. In this situation I was compelled to leave her till day; but she was nursed by ladies on whom I could completely rely for strict attention to the directions. On arriving at the house in the evening almost afraid to inquire about her, I was greatly relieved by finding her much better. The medicine had operated well four times; the passages were of a dark colour with little or nd blood. She had discharged no blood from the mouth since morning; the skin had become warm and dry. The blistering plaisters had drawn indifferently on one leg and well on the other. It may be observed that she had a blistering plaister on the second day also, but the haemorrhage continued. The medicine had not operated ; on this day it had operated well, and the haemorrhage ceased. This moreover was the only case in which blistering was employed in the last seven seasons. Twenty-eight pills of the same kind were left to be taken in the night. 
On the fifth day I found the operation had l>cen free; the passages not so dark. She looked much better. She took in the course of the day twenty-four pills of the same kind. She continued to take the cathartic medicines every day, in sufficient quantity to operate well, and in eleven days she recovered. She took no other medicine. During the last ten days she was once bled. This was the only case in which the patient wuS blistered, and it was done in order to avoid blame if she should die, as was expected, and not from any belief of the value of the remedy. From all my experience I was persuaded that she would recover if dark and copious passages could be procured ; and that without them she would die. 
A young marCwho had the fever in 1 824, while using mercurial cathartics with the usual effect of discharging bilious matter} with evident advantage, began to pass black blood in considerable quantity. His family was alarmed and requested me to visit him. When I arrived his physician was about giving him an opiate with a view to check the discharge. He was strongly urged to go on with his first plan, of evacuating: he did so, and the patient recovered without difficulty, and his health was unusually good for some time after. 


Cooke on Autumnal Diseases. 
47 
Uterine haemorrhage is not an uncommon occurrence in severe autumnal epidemics. In women not pregnant it is most apt to occur if the attack of fever be within a few days after the periodical discharge has ceased. In them it is no disadvantage. In pregnant women there is such a disposition to haemorrhage ia epidemic seasons, that abortion is a common occurrence in severe attacks. 
There ought to he no hesitation in administering the cathartic medicines above mentioned, in consequence of these haemorrhages. f had long ago ascertained that there is nothing in the state of pregnancy to render cathartics improper. In 1819 I was called to see a lady said to have been in labour three days. I found her suffering very severe pain in the abdomen with considerable intervals of ease. The pain was accompanied by severe straining, and the head of the child was in consequence forced down pretty low, but the os tincae was not at all dilated. The pain was about the middle of the abdomen, and the straining was accompanied by an expression of uneasiness in the countenance, such as is produced by a griping. I judged the affection to be a bilious colic, and gave her a large dose of calomel, which operated well, discharged deep green bile and entirely relieved her for several hours. The mercurial cathartics were actively employed for three days, when she was perfectly relieved and dismissed her midwife. In a few days afterwards, however, she was delivered after a very short labour from which she recovered well. 
This has long been my practice in pregnant women requiring the use of cathartics: and when it was ascertained that these medicines are the best that can be given in haemorrhages, it wasconcluded that in the haemorrhages of pregnant women they must be equally beneficial. In the space allotted to this essay there is not room to enlarge on this subject. In the work above referred to, ample evidence is offered of the perfect safety of cathartics in these cases, and the great benefit to be derived from them.* Suffice it here to say that active cathartics, such as are above described, arc effectual in removing uterine haemorrhages, whether 
Pathology and Therapeutics, paragraphs 2127. 2160. 


48 
Cooke on Autumnal Diseases. 
in the impregnated or the unimprcgnated state, whether the patient have fever or not. For near seven years I have given nothing else, and have uniformly found them successful in a very remarkable dcgTto. 
The difficulties frequently in the way of effecting the great object in all autumnal fevers, a free evacuation from the biliary duels, are now to he mentioned. These are a great disposition to serous discharges from the bowels, sometimes without the administration of medicine, and sometimes in consequence of it; difficulty of operating upon the bowels, apparently arising from insensibility to the action of medicines; and extreme irritability of the stomach, in consequence of which almost every medicine is rejected as soon as swallowed. 
The disposition to serous discharges is readily overcome by the use of calomel and aloes, or calomel alone. *By the addition of aloes less calomel is required to effect the purpose, or it is effected in a shorter time. The combination is usually given in the form of a pill; in consequence of which it is sometimes rejected by the stomach. This may often be remedied by administering it in the form of a powder, which, as the dose is small, may be taken in jelly or any thing of similar consistence; not mixing it, on account of the nauseous taste, but laying the powder on a small portion of jelly, and covering it with another. If this be rejected, the dependance is on calomel alone, and it is one that will not fail. Ten grains of calomel with or without aloes, two, three or four times a-day according to the urgency of the case, will in a day or two produce a marked effect on the discharges: they will become darker and more consistent. There is almost no danger of exciting ptyalism during the continuance of the thin discharges, and therefore there ought to be no hesitation in administering the calomel until dark and consistent discharges are obtained. If the case is urgent, from a scruple to a drachm should be given at once, in order to obtain the desired effect as speedily as possible, and repeated according to the necessity of the case. 1 have known physicians who would not hesitate to give a patient ten grains three or four times a day for one or more days, but were unwilling to give more than ten. and under any circumstances would 


Cooke on Autumnal Diseases. 
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not consent to give more than a scruple, at once. It is obvious, however, that half a drachm given at one dose will not have any more effect in exciting ptyalism, than if it be given in three doses jn the course of the day: it will moreover have a better opportunity of producing its cathartic effect, when given at once than in several portions at different times. If therefore it he ascertained by trial, that the patient requires three doses a-day to produce discharges from the biliary ducts, it is at least as safe to give the whole at once. 
I visited a patient, about thirteen years of age, in consultation with a neighbouring physician, who had abundant watery passages. He had taken a scruple of calomel with a little ipecacuana, and a dose of calomel alone before his physician was called in. I urged the continuance of the latter without addition. He took a scruple three times a-day for two days. No alteration having taken place, which was very unusual, a change of the medicine was strongly urged; and the physician and the mother insisted that no such change of the appearance of the discharges as was> anticipated, would ever take place. The calomel however was given that night, and next morning the discharges were "consistent, green, and copious. It was so managed notwithstanding, before I visited him, as to reduce the morning dose to half the quantity, and by the middle of the day the discharges had again become watery. The plan of treatment once broken into, was not resumed, and, as I predicted at the moment, he died, in about thirty hours. 
This was in very hot weather. Soon afterwards a girl of nine?, years of age was attacked in a similar manner, and became a patient of mine. She took immediately half a scruple of calomel and repeated it every hour until the discharges became black and consistent. She took five doses: so considerable a quantity of calomel was given under apprehensions of a result similar to the preceding one; and the day after the discharges became black and consistent, a mixture of rhubarb and calcined magnesia, of each ten grains, was substituted for the calomel, in hopes it would answer the purpose of keeping them up. It succeeded very well, and she took two more such doses in the following days, and speedily recovered. 


Cooke on Autumnal Diseases. 
50 
Children take pills badly, and therefore it is difficult to give them aloes, which cannot well he given in any other form on account of the taste. I have very rarely used magnesia, even in the small quantity above mentioned, in such cases. In general rhubarb nlor.c has been preferred when the quantity of calomel previously used has been considerable; if not, rhubarb and calomel. Sometimes I have however, found it necessary to give them aloes in powder with the rhubarb; and would eilways prefer giving that medicine when the calomel is omitted, if they can take pills. 
With regard to patients in general, as soon as the evacuations" become consistent, and are not followed by thin discharges hr the after-part of the day, the pills of aloes, rhubarb and calomel 1 may be used Instead of the latter alone. If the discharges again become thin, the rhubarb should be left out. If after a few daysthis prescription is found to be not sufficiently active in the common dose, and the patient be unwilling to take a larger one, it will be necessary to substitute jalap or scammony for the rhubarb: the former however is preferable. If the patient prefer the latter, as he advances to a healthy state it will often be found too active, and he should return to the rhubarb and aloes, with or without calomel according to circumstances. These medicines being continued so as to produce two copious consistent passages every dt'ty, the patient will rapidly recover without any other medicine. 
Cases sometimes occur in which the bowels discover great insensibility to the action of such medicines as are best adapted to produce discharges from the biliary ducts. In every epidemic we occasionally meet with them; and the difficulty thence arising, forms a principal feature of some epidemics. 
Simple difficulty of operating on the bowels can, perhaps in every instance, be overcome: but it sometimes requires very strenuous and persevering efforts. In such cases the patient should, as soon as his situation is discovered, lose blood if the pulse admit of it, take a full dose of calomel, and every hour or two afterwards half a dozen pills of aloes and jalap or scammony. The more the patient can take the better, for this reason; that Ihe extent of the difficulty is not known, and, the patient being in danger, it cannot be determined what is to be the result to 


Cooke on Autumnal Diseases. 
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him, until an operation is effected. In such a case, the patient a near relative, of great importance to his connexions, taken very ill in an epidemic season of which the difficulty in question was the principal feature, was bled and took a dozen pills at once, of aloes, jalap and calomel: finding next morning, that the medicine had not operated, it was evident no time was to be lost. He took twelve pills every hour until he had taken sixty, when they operated copiously several times. The difficulty continued great throughout and the quantity of medicine necessary to operate, gradually declined, in ten days, to two dozen pills in the day: and for three weeks afterwards he averaged two dozen a-day. It is obvious in this case, which ended well, that if the patient had commenced with what might be considered in common a full dose of the pills, and had repeated it even twice in the day, that days would have elapsed before the quantity found necessary to operate, could have been taken. Further, that the six dozen pills it was found, on trial, necessary to operate, would not have acted if given in smaller doses and at longer intervals. The common rate of administering would therefore, in all human probability, have failed to save this patient. 
This plan is effectual and safe. It is safe, because if the case turn out less obstinate than VM feared, as soon as the difficulty is overcome, we can stop without any apprehension of an excessive and exhausting discharge, as readily occurs from the use of those medicines which produce watery passages; and if it prove very obstinate, we have lost no time, but are exerting ourselves in a way that is almost sure, to succeed. Indeed I have never known it fail. 
In a series of epidemics from 1822 to 1826 inclusive, fruitful of these cases, this prescription never failed when the medicinewas retained. It sometimes however, requires considerable resolution to persevere, as the following case shows. A gentleman in 1826, very ill, was attended by my friend Dr. McGuire of Winchester, Virginia, who, aware of this feature of the prevailing epidemic, commenced very actively. The medicine, however, failed entirely. His great anxiety for his friend induced him to request me to visit him. We agreed entirely and gave him various 


52 
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medicines in great quantity, for three days without effect. Some idea may be formed of the difficulty by the fact that he took in one night five drachms of scammony. On the fifth morning, some of the friends under great alarm, urge d the use of milder medicines. Too much had been already yielded, and time had been lost in trying everything that was thought likely to effect the object. Magnesia and rhubaib, oil and infusion of senna had passed unchanged through his bowels. We therefore agreed to tell the patient that nothing but a determined effort on his part, to swallow whatever was given him, offered any prospect of safety. He commenced without delay and took six pills of aloes, scammony and rhubarb, ten grains of each, every hour, night and day. On the third day the medicine operated and the discharges were bilious. In this time he took a dose or two of calomel in addition to the pills. The necessity of continuing the medicine did not cease; but the quantity necessary to operate gradually declined, until in a fortnight two or three pills produced as much effect as ten or twelve dozen had at a former period. He recovered perfectly in a short time. 
In the course of the autumnal season of 1826, so many cases of this kind occurred as to stimulate every one engaged in the practice to the utmost exertion of his faculties, in order to accomplish that which all admitted to be essential, bilious evacuations. Every cathartic medicine and various combinations were tried. It is certain that those who relied on saline medicines and infusion of senna, &c. were particularly unfortunate in the termination of their cases. Oil passed unaltered. Infusion of senna did the same. Rhubarb and calcined magnesia passed off with the precise appearance that would be observed on mixing water and those medicines together, viz. a watery red fluid with a white sediment. Gamboge and calomel purged the patient excessively and produced alarming exhaustion. Jalap alone succeeded when the patient could retain it in large quantities. In two cases in the preceding year it passed through the bowels unaltered. The conviction of the sure dependence to be placed in the pills of aloes with jalap or scammony, was the result of experience gained in 1826 and subsequently, and they were not 


Cooke on Autumnal Diseases. 
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selicd on in these two cases, although they were used among other medicines. Jalap was the medicine relied on, and failed, as above mentioned, entirely and the patients both died. Scammony succeeded in the cases in which it was relied on entirely, if the patient could retain it; but it was not used often enough to decide the point, whether it would not sometimes pass unaltered. Thejjills themselves were sometimes seen among the discharges; but that is the case when they succeed very well. They have never been known as others above mentioned to pass off alone; but have eventually succeeded in producing bilious discharges in every case in which they were retained. 
The third difficulty mentioned as frequently encountered in the treatment of autumnal diseases, is irritability of the stomach, in consequence of which most medicines arc rejected and have no opportunity of operating on the bowels. In some cases there are incessant and violent efforts to vomit for days together, or even until death. Indeed death is inevitable in this situation if a free discharge of bilious matter cannot be effected, or does not spontaneously occur; and when this is abundant, the relief is most remarkable. 
When this state of the stomach discovers itself by the rejection of the pills of aloes, rhubarb and calomel, or by frequent efforts to vomit, it is best to Lake an effectual step at once. The patient should take without delay a large dose of scammony and calomel, or calomel alone if the former be not at hand, (which however ought not to be, when lives are placed in our hands). It is better to do that at first which will in all probability become necessary at last, with the disadvantage of an increase of the disdisease and apprehensions from a number of small and ineffectual doses retained. This is a step I never have yet repented taking. It is one I never knew do harm, and it scarcely ever fails to do good. As soon as an effectual operation is established, the irritability is, for the most part, gone, and the case proceeds as others do, sometimes moderate doses succeeding very well, at others 
large doses being required for a considerable time. This is best exemplified by cases. 
I was called to sec a patient who had been making efforts to 3 


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vomit for more than four days: as frequently occurs in these cases nothing was thrown up. She had had no passage from the bowels. She was bled and took immediately a scruple of calomel, and every two hours afterwards, ten grains of scammony, drinking very hot water alone after the medicine. This operated in aomc hours, the vomiting ceased and the case proceeded as usual. This was a case in which nothing had been given, and there was no reason from any circumstances to apprehend an obstinate state of the bowels. In other cases, from previous fruitless efforts to move the bowels, or from a knowledge of the character of the prevailing epidemic, we infer that more active steps arc necessary. 
In a case in which the stomach was very irritable, and for several days efforts had been made to move the bowels in vain, the patient took a drachm of scammony and as much calomel at once, in powder mixed with sugar and water, (which was preferred to syrup because the latter would form with it a more adhesive mass, whereby the stomach would have more power over it, to reject it); and was directed to drink very hot water after it for some time. It operated once or twice in about twelve hours and produced such discharges as were desired. It was followed by scammony and aloes in pills given repeatedly during the day: at night? the stomach being still irritable and retaining with difficulty an insufficient quantity of the pills, the same dose of scammony and calomel, one drachm of each, was given. In twelve hours it operated well several times, the stomach retained without difficulty a sufficient quantity of scammony and aloes to operate freely, and this medicine alone being continued day by day, the patient perfectly and speedily recovered. 
Sometimes scammony and calomel is rejected by the stomach, and then the dependance is on calomel alone. This however is not often the case : in the autumnal season of 1 826 (a season so remarkable, in Winchester Virginia, for every kind of difficulty in the treatment of the epidemic fever, that a good history of it would constitute a most interesting paper), that combination was found superior to any other, except perhaps the compound extract of colocynthand calomel; and this extract (it will be remembered) is from colocynth, aloes and scammony. 


Cooke on Autumnal Diseases. 
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When it is found necessary to rely on calomel alone, it is to be remembered that the patient's life is staked on the issue. Time should not be lost in insignificant efforts: every dose fruitlessly administered renders the situation of the patient more alarming, because it is propelling him towards ptyalism (the only bar to the administration of this medicine in sufficient quantity to cure every autumnal fever); and thereby cramps the subsequent efforts of the physician, through fear of the consequences. As much therefore should be given at once as it is reasonable to believe will succeed; and a judgment should be formed from what has already been done and from the character of the epidemic. I have in these circumstances given with the best effect a drachm of calomel. It produces a copious, tenacious or viscid discharge, of a deep green or nearly black colour, and affords the most marked relief: in short, it producos the same effect in these desper rate cases that a common dose produces in a common case. It very frequently happens however that a physician will not venture, as he terms it, to give so large a dose; but will not hesitate much to give ten grains every two or three hours until the patient has taken as much. It is however most evident that by this procedure the risk is incurred without obtaining the full benefit of the cathartic operation. It is also to be obsorved that such practitioners will not hesitate to persist for days in repeating small doses, until they far exceed the quantity which, given at once, would have completely succeeded ; for it is to be remembered that one or two large doses, often so completely remove the irritable stale of the stomach, that tlie case may afterwards be managed without calomel, aloes being substituted for it in combination with jalap, &c. 
It is exceedingly rare to find a patient require more than a dose ar two of the size above mentioned to effect the object in view. It sometimes, however, fails. In the autumnal season of 1 826, a robust young woman, sixteen years of age, was suddenly and violently attacked. Being called immediately, I found her with an uncommonly dark bilious and anxious countenance, great soreness of the epigastrium and excessive irritability of the stomach. After several fruitless trials in operate on the bowels, the modicine 


Cooke on Autumnal Diseases. 
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having been thrown up, she took a drachm of calomel: as this did not operate in^pmc hours she took another, and repeated the dose until in the course of the twenty-four hours she hud taken 
four. These had a most excellent effect, and I considered her safe. The next day however, as she had taken a larger quantity of calomel than I had ever given in a day, and as the discharges had been very consistent and black, she took jalap and crem. tartar all day: it had however not the least effect, and at night she began to vomit and threw it all up. She then took a drachm of calomel and repeated it until she had taken five in the course of the night and morning, with the same line effect in producing abundant bilious discharges, and with remarkably good effect on the symptoms generally. Still more uneasy from apprehensions of ptyalism, I gave her on the following day crem. tartar alone. I was led to this by some experience of its remaining better on the stomach than most medicines, and was less afraid of its producing watery passages in consequence of the extreme viscidity of those of the day before. She took it all day as before, and at night commenced vomiting and threw it all up. My fears of the consequence of continuing to give the only medicine which offered any prospect of saving her, held my hand ; and she continued to vomit until death relieved her. I reproached myself on her account afterwards, and felt conscious that fear of a remote and uncertain evil had induced me to stand and see her die, without doing for her all I might have done. I was convinced she would not have died, had the calomel been continued; and subsequent experience in my own practice and that of my friends, has confirmed the conviction. 
A girl of much the same robust habit was attacked in a very similar manner. She had excessive soreness of the epigastrium and hypochondria, incessant disposition to vomit, and threw up every thing that was taken into the stomach. She was the patient of my friend John P. Spindle M. D. now of Tennessee. He made great efforts for five days to operate on the bowels, but without any good effect, except on the fifth day, when he gave her four doses of calomel, containing above three drachms. This produced copious, dark and bilious passages. Next day, fearful 


Cooke on Autumnal Diseases. 
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of the consequences, he gave her sundry medicines without cak> mcl, and varied them in every possible way for three days, without the least success. He then desired me to visit her. She was lying on her back and could not turn on her side on account of the soreness across the epigastrium, and vomited every thing she swallowed. Being of very full and vigorous habit of body, having had no operation on the bowels for nine days, except on the fifth, and having symptoms of a very high grade of autumnal fever, it required no prophetic spirit to tell that she would die if not relieved. Nine days trial clearly showed that it would be folly to persist in efforts with any thing but calomel. The result of the fifth day's efforts made it evident that common doses would not succeed: above three drachms had been given before any good effect was produced: to give less, would be to give what must certainly be repeated in order to succeed, and to give any was folly if we were not determined to succeed. We therefore, after bleeding her, which the state of the pulse still admitted, gave four drachms at once. At night, eight or ten hours afterwards, the medicine not having operated, the dose was repeated: Next day she discharged at least two gallons of thick bilious matter. We gave her no more medicine, but a continued discharge, in sufficient quantity, was kept up from the bowels by the use of the juice of a species of cherry which was very laxative, and strong rose-leaf tea* She recovered perfectly in a few weeks, ar.d is now well. 
It cannot be questioned that this practice would be followed, but for the fear of the injurious effects on the mouth. But is the bare apprehension of t he most dreadful salivation more terrible than certain death? Surely not. I have never yet met with a family, who did not urge the use of the calomel, when the case was plainly stated to them (as has been my practice in the very few cases in which such treatment was necessary); nor a patient who would not rather run the risk than die. The son of a friend of mine was very ill. Many trials plainly showed that nothing but calomel would remain on his stomach, excepting only croton oil which among other remedies was tried in 1826: of this medicine he took a whole bottle in a few days with partial effect. When this was all used and no more to be had in time, his case 


Cooke on Autumnal Diseases. 
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was stated to his father. He was told, what indeed he fully apprehended with all that saw the boy, that he could not live unless an operation could be effected, and that in effecting this by the sole medicine that could do it, there was a risk of producing terrible mischief. He urged me to make every effort and run the risk. The boy naturally thin and delicate, was by this time very much emaciated. He took two scruples of calomel, which it was known from the effect of previous medicines and the general character of the epidemic, was not more than enough to operate. It produced two passages. The same dose was continued for seventeen days, except that on one day he took a drachm. There were two or three passages daily, consistent and bilious. He recovered and was unusually fat and hearty afterwards. 
Tlie risk of salivation in these extreme cases is less than is supposed. I have never known a patient in the circumstances above stated as absolutely requiring some energetic mode of procedure, to be badly salivated after taking the largest dose. The patient first mentioned, who died, had not the slightest degree of affection of the mouth. The second had a small mercurial ulcer on the inside of the cheek when I first saw her: this was considerably increased afterwards, but soon healed by the frequent application of a weak solution of the sulphate of copper in water, which is the most effectual application I have ever met with. The boy had also a small ulcer in the same place : the same was gently applied to it with a soft mop frequently in the day, and it did not increase. The worst case of ptyalism that ever occurred in my practice (I mean in cases in which I had the entire control of the patient) occurred in the year 1816. The patient, with irritable stomach and bowels almost immoveable, took calomel with other medicines in common doses frequently repeated for a week, without producing any evacuation. She took in the week about an ounce of calomel. She recovered and suffered no lasting inconvenience however. lam now entirely persuaded that a fourth of the quantity given on the first day would have operated well and would not have salivated her. 
If a person in an ordinary attack take a very large dose it will very likely salivate: but in the circumstances mentioned. 


Cooke on Autumnal Diseases. 
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the same cause which renders the system less sensible to the action of mercury in one part, renders it less so in the other; so that if it take an uncommon dose to operate on the bowels, it takes more than common to act on the mouth. I have even known salivation cured by purging with calomel alone. Miss W. in Winchester Virginia was a patient of my friend Dr. M c Guire. Being extremely ill, a consultation was desired and the doctor requested me to visit her. She had been taking medicines for several days but had thrown up every thing, so that calomel had been for a day or two the whole dependancc. She had taken as much as half a drachm in the day, but had had no operation from any thing. She was pale, the pupils were dilated, she was restless and a little delirious, her stomach rejected every thing, even water; she had also a sore mouth, and the saliva was abundant. Our views agreed perfectly: we Were persuaded that she would speedily die unless soon relieved by free evacuations from the biliary ducts, that she could not bear the loss of any blood to aid the operation, that no medicine could be retained for a moment butcafomel, that what had been given was not sufficient, for the best of reasons, it had not operated, and therefore, that she must take larger doses or die; and although, to take larger doses while her mouth was sore, appeared to be a hazardous measure, we concluded it was the only course, and we must risk our reputation for her benefit as she reposed her confidence in us. Accordingly we gave her a drachm; it operated well, the discharges were of a deep green colour: the same dose was repeated with the same effect every day for a week, except one day when she took somewhat more; at the end of which time she could sit up and eat, and every appearance of soreness had ceased in the mouth. 
I have been led to the statement of these extraordinary cases by a sense of duty. It has been said "thousands die tof medicable wounds": thousands of thousands, lam fully persuaded, die of fevers that might be cured. I have known many perish for want of free bilious discharges, whom a small increase of the ordinary quantity of medicine would have saved. This would in all 


60 
Cooke on Autumnal Diseases. 
probability have occurred in the case stated p. 373, but for the active cathartic there mentioned. If cases so violent as to require drachms of calomel to effect an operation, terminate with the same success when that operation is effected, as milder cases, how nrmny people die for want of a proper operation who might be saved by a single drachm? 
When a physician unfortunately finds himself engaged in so difficult a case, the question before him is this: is the end in view necessary to the recovery of the patient? all our experience is in the affirmative. The question next is, has the patient taken a sufficient quantity ? Certainly not to operate : he must then take more; the purpose must be effected or death will follow. If a case occur in which the common cathartic produces no effect, no one hesitates to increase the dose next day. , Physicians in general continue, in such cases, to make attempts day by day, with doses considerably larger than common, and repeated several times in the day; and when they succeed in their efforts, they congratulate themselves and the patient, and consider very justly that they have saved his life: but when they fail, what is the fair inference, but that the patient has lost his life because they have failed to operate upon his bowels? And why should they fail with the means of success in their hands? 
I would however wish that the reader should particularly understand that it is not intended to recommend large doses of calomel or of any other medicine in common cases. On the contrary I have always endeavoured to accomplish the object in view with as small a quantity of calomel as possible ; and in the great majority of cases succeed with from five to ten grains a-day. But in cases in which common means have been found to fail and the patient's life is suspended on the issue, I should hold myself criminal not to give such doses as, from all the circumstances of previous failure and the general character of the epidemic, in my best judgment I believe will succeed. 
It is further to be particularly remembered that of the desperate cases under consideration, no one has terminated unfavorably in which the medicine has been given to the extent of operating *>n the bowels and sustaining that operation ; that every case has 


Cooke on Autumnal Diseases. 
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terminated in death in which this was not done : and that in no case of the kind, has salivation occurred, equal to what is frequently produced by smaller doses frequently repeated, and not operating well. 
It will be observed that salivation is spoken of in this essay as an evil to be avoided. Many consider a patient safe as soon as Ihis affection of the mouth appears. This opinion is however erroneous. The safety of the patient depends, not on producing ptyalism, but upon daily evacuations of consistent bilious matter. Without the latter, in cases of any violence, the patient will die even in a state of salivation; having them he will get well without it. In those cases in which calomel alone, or even a larger proportion of that medicine is necessary to procure the proper evacuations, the appearance of salivation is to be dreaded as a serious obstacle in the way. If the difficulty in moving the bowels should not give way when it appears, the patient's situation is a very dangerous one. In the cases stated p. 395, 397, if the affection of the mouth had increased to such a degree as to prevent the continued administration of the calomel, the patients must have died. 
Some attempts have lately been made to show that means much milder than even the common mercurial practice of the country are all-sufficient in the treatment of our autumnal fevers. This doctrine may safely be left to the test of experience. It Can only influence the minds of young men commencing practice, and it is very certain that the experience of a single epidemic in the South and Southwest will show them its total unsoundness. 
Blistering plaisters arc by some practitioners very commonly used to excite the system when the pulse is weak and the patient's extremities are frequently cold. This is entirely unnecessary. The application of hot cloths and the administration of the mercurial cathartic .tt the approach of the cold state or as soon as it is perceived, are sufficient to carry it off in almost every case in which a blistering plaister can be of service. I have often administered in extreme cases of this kind a large dose of calomel with the effect of raising the pulse and rendering the skin warm and soft. Visiting a patient with two physicians in consul-9 


Cookk on Autumnal Di$6tUCS. 
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tation, we found him with cold surface, marbled with livid spots, and with dim vision: my friends seemed to think his case hopeless; they had found extreme difficulty in operating on his bowels throughout the treatment, and the scanty passages were black: they were advised as the best means of rousing him to give him a drachm of calomel: this was done, and in a very short time the Improvement in every symptom was so striking as entirely to satisfy them, although they were startled at the proposition when first made. No other remedy whatever was employed to rouse him. 
Blistering plaisters are frequently applied to the back of the neck to relieve a pain in the head. This symptom depends on the accumulation of blood in the vessels of the head, and is often most severe when the pulse is weakest; in which case it is obvious that the accumulation of blood in the vena cava extends to the veins ofthe head. Evacuations from the biliary ducts therefore, are the best means of relieving and will be found effectual, and without them blistering will not avail; or if the pain is removed, it is but for a few hours. 
Tonics are thought by many to he indispensible in the treatment of autumnal fever. He however who tries the plan of using such cathartics as produce consistent evacuations from the bowels, daily until the discharges become natural in colour &x. will be convinced that tonics are utterly unnecessary. With the return ofthe secretion of the liver to a healthy state, that of the glands of the stomach is abundant ; the patient's appetite is sharp, and he rapidly recovers his strength. I have not given a tonic of any kind in any stage of remittent fever for more than ten years. 
In the treatment of the other forms of autumnal fever, inasmuch as they are all the effect of the same cause, accumulation of blood in the vena cava and its branches, the same object should be kept steadily in view, viz. lessening that accumulation by evacuations from the biliary ducts. 
The treatment of intermittent fever, is precisely the same with that of remittents, excepting only that in the former, attention is required to put an end to the chills. The only peculiarity in the treatment of intennittents consists in an endeavour to prevent the action 


Cooke on Autumnal Diseases. 
63 
ofthe heart from sinking into the low state preceding every exacerbation, and the consequent accumulation of blood in the vena cava and its branches. It is evident that when thus accumulated within and crowding on the heart, the blood, the natural stimulus of that organ, is presented to it in unusual quantity, and the hot must necessarily follow the cold stage, if the heart be capable of increased action. The violence of this finally subsides, and the blood, lately filling the arteries and the veins of the surface, retires to the interior veins and again accumulates there, as in the first cold fit. If the accumulation within be prevented from increasing to its utmost degree; if the blood while accumulating, can be sent forward, so as to prevent the degree of fulness ofthe vena cava &c. existing in the cold stage, thut stage is moderated or prevented, and with it the following exacerbation is also moderated. This has been effected in various ways, for the most part empirically. Among the vast number of popular remedies for intermittent fever, perhaps every successful one acts in this way. Such are running, walking or riding a short time before the access ofthe cold fit, stewed drams at the same period ofthe disease, and a great variety of others, the effect of which is obviously to promote the diffusion of the blood towards the surface. Among medical men the same is usually effected by emetics, by bark, by laudanum or opium, and in obstinate cases by a salivation. The former are administered a little before the access of the cold fit, and the effect of each is obviously to promote the action ofthe heart, whereby the accumulation in a very great degree, and consequently the accompanying symptoms, arc prevented. Salivating acts in the same way. The mercurial action is remarkably uniform and durable, and the action ofthe heart, while under its influence, in general is not allowed to sink down into the low state observed in the cold fit. 
Seeing then that the object to be effected in the treatment of intermittent fevers, is to support the action of the heart when low, and reduce it when high, as well as to evacuate through the liver from the vena cava &c.,it some years ago occurred to me that the pills before mentioned as effectual for the latter purpose, being *.omposed of stimulant cathartic medicines, which often excite the 


Cooke on Autumnal Distant s. 
64 
system considerably, would answer for the former purposes also , • that by giving them after the fever, two hours before the next « >ld fit was expected, they would by exciting the action ofthe heart, tend directly to prevent the accumulation of blood in the interior veins, and that by the time the fever began to rise, the evacuations produced by them would contribute to keep it down. This idea has been fully tested and the practice founded on it, has been completely successful. 
During the great epidemic of 1 823, in which clearly marked tertians with most severe agues, were very common in the country around Winchester in Virginia, this method failed in only two cases; in neither of which a fair trial was made. In one the ague was removed, but the patient ceasing to take the medicine while the discharges from the bowels were still black, it returned as was predicted. In the other, the ague being violent and the case having occurred before the good effect of the mode of treatment was so manifest as it afterwards was, opium and camphor, in doses of two grains of the former and five of the latter, were substituted for the pills. Five such doses were taken in five days, before the recurrence of the ague was prevented. 
In subsequent years similar success has followed the administration of this medicine in this way, insomuch that no other remedy has been employed in my practice, except in a case of extreme violence, in which the agitations of the body were so extraordinary that it was deemed proper to prevent if possible another fit, which was done with the saturated solution of arsenic ; a medicine which I had used for twenty years with almost invariable success, when the plan of treatment above described was adopted. Five drops of the saturated solution to an adult is the proper dose in most cases, to be repeated three times in the twenty-four hours immediately preceding the period of the expected chill or ague, and the last dose but a short time before it. Two or three drops are enough for feeble and reduced persons. A large dose purges and sometimes vomits. The superiority of the mode of curing by cathartics consists in this, that the cause of the symptoms, accumulation of blood in the vena cava &c. is removed, and with it those effects of that fulness, enlarged vis.eera, 


Cooke on Autumnal Disease?. 
65 
©edematous swellings, &c. which, when bark, quinine or arsenic is used, sometimes remain. 
After the recurrence of the ague or chill is prevented, the disease is not to be distinguished from a remittent fever: it is a remittent and is to be treated as above stated. 
Dysentery is another form of autumnal fever, to be treated in every point as such a fever. After bleeding when the pulse admits of it, the continued administration of mercurial cathartics in such manner as to produce free discharges from the biliary ducts, as far as my experience extends, never fails to remove the disease, if continued in the manner above described in the treatment of remittent fever. The symptom which distinguishes dysenteric from other cases of autumnal fever, is removed in a day or two, in general, and the case is then not to be distinguished from any other case of autumnal fever ; and is to be treated as. such in every respect. The same difficulty in operating on the bowels :uid the same irritability of the stomach are sometimes met with in these, as in other cases of autumnal fever, and are to be overcome in the same way precisely. 
A mulatto girl, twelve or thirteen years of age, had, for a whole week, taken every variety of cathartic medicine that an anxious desire for her recovery suggested, and without the least advantage. She had not in that time a single discharge from the bowels, other than the small discharges of bloody mucus from the rectum. Her groans were incessant and in the highest degree distressing: her death was considered inevitable. As her stomach retained every thing she took after the first two or three days, I determined to make a regular continued effort to operate on her bowels with large dotes of jalap alone, as she had taken as much calomel as was thought safe to give her. She commenced immediately with a drachm, and took as much every hour until she had taken four drachms, when it operated: the passages were a dark green, large and very consistent. As long as the discharges continued free, she was almost entirely easy ; but after three or four passages, they became small, and the pain began to return. Without delay she began again to take the same doses: there was no operation after «he recommenced, until she 


Cooke on Autumnal Diseases. 
66 
had taken four more drachms of jalap, when the same kind of discharges appeared as in the first instance, and continued until she had had three or four, during which time she was again easy. As they dwindled, the pain returned. She then commenced a third time and took three drachms, when the operation. became free, and continued for a week moderately, and she perfectly recovered. Several cases similar to this occurred in the same year, 1816, when the dysentery was epidemic in Fauquier County, Virginia. Not one of these cases ended unfavorably, provided mercurial cathartics were given in sufficient quantity to effect a free bilious discharge from the beginning. Not one ended favorably in which this was not done. I knew one instance in which the patient died under free and continued discharges produced by Epsom salts ; and another in which ihe patient had been relieved by large doses of rhubarb and calomel, and was convalescent, but by the administration of an opiate the discharges from the bowels were arrested and the patient died in three days. 
A young man had been taking a variety of cathartics without an effectual operation. He required large doses and could not retain enough of any ofthe ordinary medicines to operate. Infusion of senna passed through him apparently unchanged; oil did the same. He used half a pound of senna in the day for several days, besides other medicines. Two dozen pills of jalap, aloes and calomel, containing a drachm of each barely operated ; but when they did, they afforded relief from the tenesmus &c If he could have taken more of them, they would have put an end to the disease : this he could not do in consequence of the state of his stomach, which whenever they were pushed farther, rejected the whole. In this state having been ill a fortnight, he took a drachm of calomel and half a drachm of scammony which operated moderately: he next day and the day after, took a drachm of each which produced copious dark coloured passages. These were kept up day by day, with aloes and jalap, which he was now enabled to retain, and he recovered beyond the expectations of almost any that saw him. 
Emetics have been highly recommended in dysentery. They 


Cooke on Autumnal Diseases. 
?rr 
nre useful in several respects, as in remittent fever, but the evacuations above described are indispensible in serious cases. Ipccacuana is perhaps the best emetic in these cases. If after operating it act on the bowels, or if it act on the bowels without vomiting, and the action be kept up, the patient will seldom fail 
to recover. Until the year 1816 I never met with any difficulty in the treatment of dysentery with ipecacuana alone. In the summer and fall of that year this disease was epidemic in Fauquier County Virginia ; the ipecacuana could not be retained by the stomach in doses of a single grain, and I was compelled to have recourse to mercurial cathartics. The case stated p. 403 with others similar to it, occurred in that year. The ipecacuana had been laid aside some time, when I was requested to visit a negro man about twenty-five years of age. He had taken various medicines; oil, &c. &c. for several days, but without relieving him; and apprehensive of his death his master had had him carried from the house to a quarter not far off. As I rode up his groans were distinctly heard at some distance. The idea of trying the ipecacuana in this case suddenly occurring, he immediately took ten grains in a little water, and with such effect as I can never forget. In five or ten minutes he was perfectly easy. Three doses often grains each were left for him, with directions to take one at, night, in the morning, and at noon; and if he should at any time feel more pain &c. to take one immediately. On the third day he had seventy grains of the same divided into three doses; the object being to give as much as could be retained. On the fourth day he had four doses, each twenty grains; on the fifth, six doses ; on the eighth six, each twenty-five grains. After the fifth day I did not see him. The medicine operated freely every day, discharging deep green matter, and the patient recovered. 
The treatment during convalescence has been already stated. In treating of the cure of remitting fever. 
Cholera is another form of autumnal discaso. It 16 needless however to go into the treatment of this disease here. It has been show v in a former paper in this journal, that the cholera of adults and the cholera infantum is the same disease. The object in view in both, as in all the forms of autumnal fever. i«to procure free eraeoa* 


Cooke on Autumnal Diseases. 
68 
tions from the biliary ducts; which being effected, the patient is greatly relieved, and by a continuation of the evacuations, cured. How this is to be effected, may be seen in the paper on cholera infantum, as well as in the cases stated p. 387 which may be considered as cholera. A single case of this disease in an adult shall be stated. 
A man of thirty-five years of age called me up one morning early, in very hot weather. I found him vomiting and purging most violently: he had been all night in this situation, discharging an immense quantity of serous fluid. He was exhausted, his pulse very feeble and surface cold and pale. He took immediately a drachm of calomel; and very hot water or tea after it whenever he desired to drink. The vomiting in a short time ceased; in twelve hours the passages were green, in eighteen they were black; they were kept up next day with pills of aloes, calomel and rhubarb: on the third morning I found him sitting up at worJ;, making shoes, though very weak. The discharges were continued, and he perfectly recovered in a remarkably short time. 
I have thus given the result of my experience in all the forms of autumnal fever. It is the fruit of twenty-five years attentive observation of these diseases. Mercurial cathartics are the dependance, the indispensible remedy. Of this there is no question among the great mass of the physicians of this country, as for as it respects the treatment during the fever; but some, perhaps many, think that when the fever is gone, the patient should be supported with some kind of tonic medicine. Let the trial be made. Administer such medicines as produce free bilious evacuations from the beginning, avoiding salts, &c. which produce exhausting serous discharges, and when the patient arrives at that point at which tonics are deemed necessary, let him take aloes, rhubarb and calomel in such quantity as to produce two or three copious and consistent passages every day, and if he docs not improve faster and gain a keener appetite than is usually produced by tonics, continue to use the latter. 


AN ESSAY ON WINTER EPIDEMICS. 
f » a former essay I have endeavoured to point out the origin of the cause which produces autumnal diseases, its effects on the system, and the* best mode of obviating them. In the present it is proposed to investigate the causes which produce winter epidemics, and to make a few general observations on the treatment. 
In a neighbourhood in which miasmata abound, the whole population is more or less exposed to their influence, and the effects appear in various degrees. Perhaps none escape without having their blood rendered darker in colour, or without becoming more or less sallow; some lose their appetite; others in addition to this have a loathing of food, and a disposition to vomit; many have furred tongue; many, green or dark passages; some have occasional chilly feelings and pains in different parts of the body. AH these occur in many persons who are able to attend to their business regularly, and escape severe illness. 
These morbid symptoms, in various degrees, continue to affect the whole population throughout the autumnal season* Numbers are becoming ill every day, and at the moment of the access of cold weather, many are still on the verge of an attack* When winter appears the production of miasmata ceases, and the violent winds of that season disperse all that remain in law spots. The cause ceasing to operate, the effects gradually disappear, but not instantly ; for we meet in every period of cold weather, with cases in which green or black discbarges from the stomach and bowels, and other effects of miasmata, appear.* 
•Since the publication of the essay on autumnal disease*, 1 have had several conversations on the subject with gentlemen who find a diificulty in fall* ad- mitting the dependant* of tbow diseases on mmwaaU. Tbeir dovbu srafc 19 


CoOKt on Winter Epidemics, 
70 
When winter sets in there is another remote cause of fever in operation, and in neighbourhoods in which miasmata abound, the population is at the same time under the influence of both these 
from observing th;tt cases of autumnal fever appe&r at a considerable distance from sources of miasmata. We conceive that one point at least on this subject is settled ; that every man's experience has brought him to the conclusion, that autumnal fever is certain to prevail in the heal of summer along the borders of marshy grounds, not cover- ed with water so as to prevent the full action of the snn. Wherever such a 3 lot is formed by the regulation of streets in a town, by the building of a null- am, or in any other way, provided the water does pot cover the surface from the full action ofthe sun, there, in hot weather, autumnal fever prevails. When- ever this marshy state is done away by draining, by filling with earth, by cover- ing with water, or by excessive drought in the heat of summer, the fever cease*. The presence of both heat and moisture is shown to be necessary by the failure of the fever to appear in cool countries until hot weather, and by its disappear- ance in cold weather; as well as by its failure to appear in hot countries until the rains set in, and its disappearance as soon as the country becomes dry after -|he rains or inundations cease. * " It cannot be admitted as an objection to this known truth, that cases of (ever occur at a distance from marshes or the" borders of streams. Whatever these may be attributed to, it remains absolutely certain that whenever heat and moisture co-operate on vegetable matter, there fevers arise. The circumstances accompanying the appearance of these diseases, show further in the most striking manner, that they are the effect of a cause produced by the co-operation of heat and moisture on vegetable matter, and driven bj the wind on those who sutler. The single instance of the occurrence at Oallio- Jiolis,* shows this in the clearest manner : but there are thousands of instance* o prove it. This position is just as certain as that first stated. The occur- rence of cased of fever in such situations that it is asserted this cause cannot be present, is no proof that the latter does not produce those cases which occur where it is nresent. 
With regard to the cause of those cases which occur in elevated situation*, it is to be borne in mind that those who dwell in such places, are not subject to fe- vers unless there are sources of miasmata in the neighbourhood. The hills of the island of Madeira are not subject to such fevers. They are so precipitous that no marshy surface can exist. Ihe same may be said of the Canaries, of JWoiitsrrat, of Nevis, and much the same of Bermuda and St. Christopher's. On the contrary, those hilly situations iti which the disease appears, are uniform- ly in the neighbourhood of sources of miasmata. Dr. Ferguson, in an essay in Which he endeavours to establish this very point, that miasmata are not the cause of autumnal fevers, has brought forward a number of instances in which, they appear on elevated situations : but there is not one stated in which a source of miasmata does not exist in the neighbourhood, and in such a direction that the prevalent winds (the trade-winds') carry them towards the hill. In one in- stance of two hills, the one nearest the marsh was the seat of disease, and ano- ther live hundred yards further off, and sheltered by the former, was entirely It is evident therefore that miasmata produce the fevers near marshes and the borders of streams : and when we see fevers precisely of the same nature, occur- line at the same time at some distance from these sources of miasmata, it is nut reasonable to say they are not produced by them ; particularly when this agent is of sir h a nature that it must be carried forward by the wind, and ob- 
•Trail. Jour. vol. 1. p. 345. flbid. vol. 1. p. 354. 


Cooxr on Winter Epidemics. 
Vf 
uemote causes. Even in the course of the autumnal season, 
fever is often induced in persons under the influence of miaa mata, by exposure to cold, sometimes during sleep in cool nights, or by neglecting to change wet cloths. It is evident therefore, that when a population is under the influence of miasmata, the co-operation of cold will produce a continuance of the epidemic through the winter months. 
Cold, in addition to its influence on the action of the heart, whereby it produces fever,* has a local operation upon the part to which it is immediately applied. It is known that when cold is applied for some time to any external part of the body, it produces redness and swelling, which often amount to severe inflammation. In like manner when applied to the fauces and to the lungs, it often produces inflammation in those ports. Fevers accompanied by these local affections, are distinguished by appropriate names. Fever with such a local affection of the lungs or pleura is called pneumonia or pleurisy. 
When therefore cold produces fever with such local affee* ttons, or pleurisies, in persons who are under the influence of miasmata, 
servation alone can determine the distance to which it is capable of being car- ried in force sufficient to produce effect. At least it lies on the objectors to •how that this cause, which produces the fever nearer its source, does not produce it when it appears further oil in the direction in which we know it is passing. It is frequently objected that the chemists have not yet been able to discover in ; difference between the atmosphere of marshy ground and that of more ele- vated and healthy situations. But we know there is a difference ; we experi- ence its fatal effects ; it has even been a matter of common observation for hun- dreds of years, that those who are exposed to a current of air from niarxhe ground are sure, to suffer, and means have been resorted to to avoid it with v.- re. it advantage. Shall we then deny the evidence of our senses because cln in, try is not yet perfect? shall we say a gaseous fluid does not exist when we have evidence of its effects before our eyes, because chemists have not yet been able to discover the nature of that fluid . ! because they have not yet been able to point out a chemical test of its presence ? Were not those who saw dogs ex; ire in the celebrated Italian gsotto,. certain of the presence of a deleterious agent In the air of that place before the chemists had discovered a test of the presence of carbonic acid gas? Would they have credited an> one who should have flft) nied its existence because they had not yet been able to point out such a test r How were they certain of its i resence? They knew it only by its deleterious effects. So we, though we have not yet been able to discover the relations of the gaseous fluid called miasmata to other gaseous fluids, on which alone rests the knowledge, of a chemical test of its presence, are nevertheless certain of it» existence by its effects ; viz. by observing that in whatever direction it is ca rr-ed by the wind, it produces certain effects which disappear when it psjnssj lobe- earried there. Tran. Journ. Vol. 1. p. 79, ic-. 


Cooo on Winter Epidemics. 
72 
bilious symptoms, the effects of miasmata, likewise ap* pear, and the disease is called bilious pleurisy. Bilious pleurisy therefore, as well as the cases of fever which occur in winter, is the effect of the combined operation of miasmata and cold. 
The effect of the cold of winter therefore, upon a population under the influence of miasmata, is to produce a continuation of cases of the autumnal epidemic through the winter months, together with cases of bilious pleurisy m those who are. so exposed to cold as to have a local inflammation produced in the lungs. It would follow from this exposition of the manner in which winter epidemics are produced, that they should appear in places in which miasmata abound, that they should prevail most in winters following autumnal seasons in which miasmata abound, and that the bilious symptoms in the winter epidemic should correspond in violence with those of the preceding autumnal epidemic. The truth of these inferences and of the general doctrine of the dependance of these winter epidemics, as well as those of the summer, on miasmata, is fully supported by the following statements. Bilious intermitting fevers are very prevalent during the autumn in the level countries near the sea coast of North Carolina. They also prevail near the rivers for some distance 
above the low lands." "Those intermitting fevers disappear as the cold weather sets in, but they are frequently succeeded by fevers of a different type, that are more fatal. Those fevers of the colder season are commonly attended by symptoms of partial inflammation, whence they are denominated pleurisies of the eyt or of the head; at other times they affect the side. In those several forms they are equally dangerous." "It commonly attacks people who have been afflicted by intermitting fevers during the summer and autumn. It appears chiefly, perhaps only, lit those places where people are subject to intermitting fevers % in low sunken grounds, and along the banks of rivers. In the beginning of winter, in the year 1792, that fever was very fatal in Martin county, near the river Roanoke; the river had lately been very low, and much of the muddy bottom and other 


Oooke: on Winter Epidemics, 
73 
grounds usually covered by water, had been exposed to the sun. The pain was then in the head. In the year 1794, ten or twelve men, the heads of families, adjoining one another, died of that complaint in December, on the river Neus. They had lived near the beginning of the high grounds on the north-east side of the river. There had been a dry season, and the winds were generally from the south-west. The other inhabitants of the adjacent country, except on that narrow strip by the river, enjoyed good health. In the year 1 792, to the best of my recollection, in the beginning of winter, this pleurisy in the head, as it was called, was endemic near Matamusket, in a settlement where the land is rich but very low, and much of it covered with water."* 
Greenville is a small town on the south side of Tar river, built on a pleasant spot of considerable elevation, and nearly insulated by the river and two branches on the east and west sides of the town. The land on the north side of the river is low, broken by ponds, and subject to be overflowed during a fresh, which occurs five or six times a year, to such an extent 
as to cover the low land half a mile from the banks. The miry state of the branches, in many places, renders them dangerous to cattle. South of the town, and nearly a mile distant, is a mill-pond, the dam of which was broken during the summer, by which means a considerable extent of its bottom, &c. was exposed to a hot sun for nearly two months. The land between the town and this pond, is mostly under cultivation. July, August, September and October were distinguished, as usual, by the prevalence of bilious fevers: however, the fevers of this year were more particularly marked.' 
In February, March and April a fever proved very mortal in town and country. Some physicians called it bilious peripneumony. The attack was made by chill or ague: before this was entirely worn off, a pain of the head, breast, side', or back, seized the patient, and frequently several of these symptoms at once, increasing in violence as the fever came on, and during its progress. 
tMedjcaJ Repository, Vol. 2, p. 156, by ti. Williamson, M. O. 


Cookk on Winter Epidemics, 
74 
The pain in the side was accompanied by a cough and expectoration of bloody matter.* In the 7th volume of the Eclectic Repertory, we hare an account by Dr. Davis, of Columbia, in South Carolina, of a winter epidemic which commenced in that town in November, 1815, immediately after the common bilious fever. It prevailed in other parts of the state also, and "the most swampy situations, margins of rivers, and places most subject to the endemial autumnal bilious fevers, suffered most severely from the epidemic." In the same paper, Dr. Trent, of Richmond, in Virginia, in a letter to Dr. Davis, gives an account of an epidemic in the winter of 1815 in that city. " A highly bilious character sometimes 
attended it. The patient not only throwing off* a great deal of vitiated bile, but becoming very yellow. The liver was sometimes the part on which the disease spent its force. A very frequent form of the disease was that of bilious pleurisy." The winter of 1814 was very severe in Fauquier and the neighbouring counties of Virginia. The snow was unusually deep. An epidemic prevailed in the winter. In reply to a request made to a friend, Dr. Withers of Warrenton, for information on the subject, he wrote, "In Fauquier the epidemic was most prevalent and fatal in the marsh, about Woodside's; the face of the country is low and very wet. There were some. cases on Tinpot (run). They generally complained of paia about the thorax ; the blood when drawn was sizy ; stools dark green ; expectoration saffron coloured. There were cases without pain in the thorax; there was pain occasionally in the head and limbs; some complained of the toes only. There were not more than two or ti ree c*ases in my practice, above the road leading to Fayettesville." The country above that road is high and hilly. The very same parts of the country were most affected in the autumnal epidemic of 1821. The same disease was excessively severe along the Potomac and Rappahannoc rivers^ a country peculiarly liable to autumnal diseases. 
In Philadelphia, in the winter following the great epidemic 
•Medicul Repository, Vol. 5, p. 137, by Dr. G. Pillson, 


Cooke on Winter Epidemics. 
75 
of 1 ?9S, it was observed that the symptoms of yellow fever appeared in combination with those of pneumonia* 
Dr Rush, speaking of the diseases of that winter, says, "But the diseases of the winter had a peculiarity still more extraordinary; and that was, many of them had several ofthe symptoms of the yellow fever, particularly a puking of bile, dark coloured stools, and a yellow eye." He further mentions several cases of pneumonia, in which appeared symptoms of yellow fever; as yellowness ofthe eyes, dilatation ofthe pupil, and redness of the eyes in the degree common in yellow fever. 
Dr. Griff itts attended a patient in pneumonia who had universal yellowness of the skin. 
In the year 1794 there were many cases of yellow fever. "The cold weather in October checked the fever, but did not banish it from the city. It appeared in November, and in all the succeeding winter and spring months." The winter was moderate. There was an uncommon mortality in the months of January, February and March, 1795. 
In 1795 there were some cases of yellow fever, and the different forms of autumnal fever were of a pretty high grade. "The winter was uncommonly moderate. There fell a good deal of rain, but little snow." " Catarrhs were frequent." Several cases of bilious malignant fever appeared in March and April. 
In 1 796, August. September and October were uncommonly healthy. The winter was in general healthy. During the spring, though cold and wet, no diseases of any consequence occurred.* 
In the autumn of 1 797 the yellow fever prevailed in Philadelphia, and "was succeeded by scarlatina, catarrhs, and bilious pleurisies in the months of November and December of the 
* Vol. 3, p. 244. Vol. 4. p. 3. It is proper to observe, that in the edition of 1 81 8 of Rush's Works, there is an error in inserting 1 796 for 1 795, in the passage, "*» The winter of 1796 was uncommonly moderate,** Vol. 3. p. 243, as will ap- pear on comparing this pasrage with one in the next page, vis. " The weather jn December was extremely cold," &c. There is another in inserting 1 797 for 1796, at the commencement of the account of the fever of 1797, Vol. 4. p. 3, as will appear on comparing that passage with the ciuxuicncenioot of theac- .<annt «f the fey« of 179 ft. 


fe 
Cooke on Winter Epidemics, 
same year." The diseases of February and March were catarrhs 
and bilious pleurisies. In 1798 a most violent yellow fever raged in Philadelphia* The diseases of November and December were highly inflammatory. A catarrh was nearly universal. The weather in December was extremely cold. About the middle of January the weather moderated, but "the weather was very cold, and bilious pleurisies were common during the latter part of February." It was still cold in the first half of April, and diseases, though fewer than in winter, were still bilious and inflamma- 
tory. The yellow fever again prevailed in 1799. There is no men- 
tion of the health of the city in November and December; but in January the cold was not so great as common. Catarrhs, cynanche trachealis, and bilious pleurisies were prevalent in every part of the city. A few cases of yellow fever occurred likewise during this month. March was unusually healthy, and the weather warm in April, and the city as healthy as in March. 
In the autumn of 1 800 in Philadelphia there were in September twenty-one cases of yellow fever in Spruce-street, between Front and Second streets, all in the neighbourhood of putrid exhalations ; but the city in general was so healthy, while other cities suffered, that Rush endeavours to account for it. 
The months of November and December were uncommonly healthy. " The month of January was intensely cold. In February it became more moderate. The diseases during these two months, were catarrhs and a few pleurisies. In March and April there fell an unusual quantity of rain." A few mild cases of scarlatina anginosa appeared in these months. 
In autumn 1801 the city was healthy. No winter epidemic but the measles. 
In 1 802 there was a considerable number of cases of yellow lever. No mention of the diseases of November and December, but the weather in January was uniformly cold, and in February there was a thaw; and the diseases of both these months were catarrhs and bilious pleurisies. The latter appeared in a tertian type. 


Cooke on Winter Epidemics, 
77 
Tn the autumn of 1803 the city was sickly. In January following the weather was clear and cold, with deep snows and rain, and was healthy. In February there was a deep snow, followed by several very cold days ; there was also a fall of snow in March, followed by an uncommon degree of cold. Catarrhs and bilious pleurisies were very common during both these months. In the beginning of April the weather was cold and rainy. Bilious pleurisies were still the principal diseases which prevailed in the city. 
In 1 804 there was less sickness than usual in the forepart of the autumn, but in October intermittents were very common between Eighth-street and the Schuylkill. The winter was uncommonly cold and tempestuous; and during January, February and March, there was a number of bilious catarrhs and pleurisies. 
Dr Rush has given no account of the winter diseases afterthis year, and very few notices of the autumnal. He says, however, that "Dr. Huxham and several other physicians describe bilious fevers in open winters, and particularly after a sudden thaw has succeeded a great frost."* This is precisely what I have uniformly observed. Bilious pleurisies are most frequent in the beginning of winter, when there are cold rains and the ground is wet and cold, and towards the end of winter, when there is a general thaw, very often brought on by rains; while during the uniform cold weather of mid-winter, when the earth is dry, and it snows instead of raining, it is much more healthy. They occur also in very cold weather. It is evident from the preceding statements, that winter epidemics prevail in situations in which miasmata abound in the autumnal season; that they occur in winters following those seasons particularly favourable to the production of miasmata, and that they do not occur in winters following healthy autumns; that the symptoms manifestly indicate that they are the joint effect of miasmata and of cold ; and that those symptoms of the winter epidemics which originate in miasmata, correspond in grade 
* Rush's Works, vol. 4, p. 103, front Huxham on air aud epidemic die. v. 1, p. 19. It 


78 
v^ookc oh winter CjOieiemtcs. 
with those of the previous autumnal epidemic. It appears also that many of the cases have no other symptoms than those common in autumnal epidemics, the operation of the cold being sufficient to produce a fever, as frequently happens in the autumnal season, but not to produce its peculiai local effects on the lungs. 
There are, therefore, in winter epidemics some cases in which the symptoms of catarrh or pneumonia are the mostpromitent; and some in which they are not to be seen, the case heing without hesitation called a bilious fever or yellow fever. Wherefore it is evident that winter epidemics are the effect of the joint operation of miasmata and cold. 
These winter epidemics have been mentioned by several authors, and yet have been very little adverted to by physicians. They are nevertheless regular in their appearance, insomuch that it is not difficult to predict with as much certainty a winter as a summer epidemic. If, for instance, we have much rain in summer, and the weather be warm, autumnal fevers are sure to appear in considerable number. So, if after an autumn abounding in miasmata the winter be very cold, as in 1814, or wet, a winter epidemic may confidently be expected. 
Svdenham gives an account of one of these in the winter of 1075.. In the summer and fall of that year, numbers were destroyed by an epidemic fever and dysentery ;* and the winter epidemic commenced with the first cold moist weather. "In 1675 the season having continued occasionally warm, like summer, till towards the end of October, and being suddenly succeeded by cold and moist weather, a cough became more frequent than I remember to have k'>own it at any other time; for it scarce suffered any one to escape, of whatever age or constitution he w«>re, and seized whole families at once. Nor was it remarkable only for the numbers it attacked, (for every winter abundance of persons are afflicted with a cough,) hut also on account of the danger which attended it. For as the constitution, both now and during the preceding autumn, eminently tended to produce the epidemic fever above described, and as there was now ne 
*gydcnhuius's Works, Sec. 5, eh. 1. 


Cooke on Winter Epidemics, 
79 
other epidemic existing, which by its opposition might, in some measure, lessen its violence, the cough made way for, and readily changed into the fever. In the mean while, as the cough assisted the constitution in producing the fever, so the fever on this account attacked the lungs and pleura, just as it had affected the head, even the week preceding this cough; which sudden alteration of the symptoms occasioned some, for want of sufficient attention, to esteem this fever an essential pleurisy or peripneumony, though it remained the same as it had been during this constitution. 
"For it began now, as it always did, with a pain in the head, back, and some of the limbs; which were the symptoms of every fever of this constitution, except only that the febrile matter, when it was copiously deposited in the lungs and pleura, through the violence of the cough, occasioned such symptoms as belong to those parts. But nevertheless, as far as I could observe, the fever was the very same with that which prevailed to the day when this cough first appeared ; and this likewise the remedies to which it readily yielded plainly showed."* 
Cleghorn, in his valuable work on the diseases of Minorca, which island is the seat of violent autumnal epidemics, gives a particular account of very fatal winter fevers appearing about November, and almost depopulating some corners of the island. They begin 4 * commonly like a i ague fit, with shivering and shaking, Hying pains all over the body, bilious vomitings and purgings," &c. "the most part of the sick being seized with stitches in theirsides,strikiug upwards to the rlavicle,and shoulder blade,"t &c. Beside some abatement of the fever common -every morning, on the third day or beginning of the fourth, there was frequently a great remission, sometimes a totiil cessation of every violent symptom, so that the sick were thought to he out of danger; but on the fourth or fifth, a delirium, Sac. carried off the patient in a day or two.J 
» 
Though Cleghorn states that the most part of the sick had 
•Sydenhams's Works, Scc.s,ch. 5. tCleghorn's Diseases of Minorca, p. 242. t' hul ' P- &&¦•- 


Cooke on Winter Epidemics, 
80 
stitches in the sides, &c. it is plain from what he says in the be* ginning of the chapter, that many of the sick had no symptoms of the kind. He says, "The anniversary epidemical fevers of 
Minorca may be divided into two classes, which at present, for distinction sake, we shall call the summer and winter fevers. The former break out in June or July, and cease about January, or somewhat sooner. The latter seldom appear before November,"* &.c. It is plain from this statement, that of the cases actually occurring in the winter, some resemble so nearly the summer fevers as not to be distinguished from them, and he calls them summer fevers ; while others have the additional symptoms of pain about the chest, &c. with expectoration, and even of these, some, on dissection are found without any affection of the lungs or pleura.t It is this latten class that he describes as the winter fever. 
These extracts show, that in Europe, as well as in America, winter epidemics occur in such situations, and at such seasons, as to make it evident that they are the joint effect of miasmata and cold, and the continuance of the autumnal epidemics; or, as Sydenham says, the very same fever which prevailed to the day when the cough Jirst appeared. 
It is obvious from the preceding statement that in winter epidemics, there is no essential difference between those cases which are and those which are not accompanied by inflammation in the thoracic cavity. In all the cases bilious symptoms appear, and in those in which pneumonic inflammation occurs, it is only an additional symptom, and the bilious symptoms correspond in grade with those of the preceding epidemic ; witness the observation of Rush, stated above, that yellowness of the eyes and skin, and redness of the eyes in the degree common in yellow fever, occurred in cases of pneumonia in the winter following an autumnal season in which yellow fever prevailed. The bilious symptoms are of every grade which miasmata produce in autumnal seasons. Nausea, vomiting, diarrhoea, constipation, furred tongue, green and black discharges from the sto 
•Cleghoru's Diseases of Minorca, p. 238. tlbid. p. 250. 


Cooke on Winter Epidemics. 
81 
thach and bowels, yellowness of the skin and eyes, violent headach and backache, the tertian form, the depressed state observed in autumnal epidemics, subsultus tendinum, &c. are all to be seen in winter epidemics, with and without pneumonic inflammation. 
In addition to these, some of the sick have severe pain through the thorax, difficulty of breathing sometimes extreme, and cough sometimes attended by expectoration and sometimes not. These symptoms have caused this disease to be called a pleurisy ; and when there is no pain in any part of the thorax, but a severe one in the head, as in every other respect the latter cases resemble the former, the people of some parts of the country have tailed the latter pleurisy in the head. 
The pain in the side and cough are not however always the effect of inflammation in the thorax. Both these symptoms frequently accompany a state of congestion in the liver and parts connected with it,* when there is no inflammation in the thorax. Cleghorn mentions a case in which he believed the patient to have died of pleurisy. He 'expectorated freely from the sixth to the twelfth day of his illness. On examination however after death his lungs and pleura were found to be sound.! Cough and pain in the side are frequently observed to accompany a state of congestion in the liver and parts connected with it, in chronic cases when there is no suspicion of inflammation in the thorax. In these acute cases the symptoms are precisely the same, except that they are more severe and sometimes accompanied by strong pulse. 
The remedies required in those cases of the winter epidemic in which the symptoms are the same with those of the autumnal fever, are the same precisely with those proper in the treatment of the latter. There is not a single particular in which a difference can be stated : it is needless therefore to do more than refer to the essay on this subject in the commencement of this volume. § 
With regard to those cases in which there are catarrhal or 
'Trans. Jour. Vol. 1. p. 82. fCUghorn'i Ob*, on the Dis. of Minorca, p. 246. 


Cooke on Winter Epidemics, 
82 
pneumonic symptoms, it is necessary in addition to the treatment called for by the bilious symptoms, to make use of remedies suited to remove the inflammation of the lungs. These are chiefly bleeding, and blistering. 
The excessive pain in the side or breast, sometimes occurring in this disease, together with the cough and difficulty of breathing, seem to call for bleeding freely. Notwithstanding however the pressing necessity on account of these symptoms, the pulse is in many cases so low as absolutely to forbid the loss of blood; and many instances have occurred in which the physician, induced by the extremity of the sufferings of the patient, has been tempted to open a vein with consequences so manifestly injurious as to cause the remedy to be reprobated by many people. The propriety of bleeding however is to be determined by the pulse in every case; and there are cases in which all other remedies will fail to save the life of the patient without this; of which the following statement will evince' the truth. 
A man, who lived in a house noted for the number of its inhabitants who had been affected by autumnal fevers, was attacked in very cold weather in the month of February succeeding the very sickly autumnal season of 1823, with bilious pleurisy. He had a most violent pain in the side, excessive and almost incessant cough, and his pulse was strong, hard and tense. He was directed to be bled every day until the pulse should become soft and moderate, and to take a mercurial cathartic every day. This "he did for four days, when fearing to proceed farther on such general directions, he desired me to visit him. 
On the fifth day he still had a hard pulse, with pain in the side and severe cough. His passages were nearly black. He was, bled immediately, ar d the same cathartics continued. This was done daily for three days more, when he was directed as before, to lose blood every day until his pulse should be reduced, and to continue the cathartics. 
On the twelfth day I was again called. He had been bled exery d;iy except one. In the forepart of this (the twelfth) day, he had lost half a pi.-it of blood. His pulse was still hard and tense, his cough excessive and almost incessant. I took twentyfour 


Cooke on Winter Epidemics. 
83 
« 
ounces of blood, and gave him the same general directions with regard to bleeding, and likewise cathartics, his discharges being still very dark-coloured. 
He was bled three times more in the next three days, and continued the cathartics until the thirtieth day. On the eighteenth day from the last bleeding, being in the neighbourhood I called to see him, and found him perfectly well, having been walking about for several days. The only remedies used in this case, besides those mentioned, were a blistering plaister to 'the side on the twelfth day, an anodyne sudorific on one occasion, an emetic of ipecacuana on another, and two ounces of syrup of squills. The effect of these remedies was so inconsiderable, that no one of them was repeated ; and the whole treatment consisted in bleeding and purging daily. This man enjoyed a state of health decidedly better after this attack, than he had experienced for some time before. 
Blistering also affords decided advantage when the pulse is weak and will not admit of bleeding. In such a state of things a blistering plaister and a cathartic which discharged from the bowels a quantity of green matter, I have seen produce the most surprising relief. 
Blistering however will not afford more than temporary relief, and often not that if the pulse be strong, as was evident in the case stated above. If therefore the pulse require it, the patient should be bled, anil the blistering deferred until, by repeated bleeding if necessary, the action of the heart is reduced ; and then if the pain continue, blistering will produce marked effect. 
In those cases however, above referred to, in which the pain and cough are not the effect of inflammation in the thorax, blistering will be of little service. Produced by congestion of the liver and parts connected with it, they are to be removed by lessening or removing that co> gestion; viz. by evacuation from the liver. Ii this as in all other cases, congestion is most effectually relieved by evacuations from the vessels immediately concerned. 1 i this ca«e blistering cannot reach the part, but evacuations from the biliary ducts produce the most decided benefit: 


Cooke on Winter Epidemics, 
84 
and as in all cases of this winter epidemic there is congestion of the liver &c, as well in those cases in which there is inflammation in the thorax, as in those in which there is none, cathartics which evacuate from the liver are of service. In the former case they are indispensible aids, in the latter the chief dependance. A friend of mine, Dr. John C. Green of Loudoun county Virginia, was remarkably successful in treating the fatal winter epidemic of 1814-15. His practice was to give the patient jalap with a small quantity of tartarized antimony, so as to vomit once or twice and afterwards purge. The discharges were green, or dark-coloured, and by continued evacuations of this kind he informed me he saved all but. two of thirty-one patients. 
The practice in the winter epidemics may therefore be summed up in a few words. The fever is to be treated as an autumnal fever when there is no local affection or inflammation of the lungs: and when there is, In addition to the remedies required in the former case, the patient must be treated as for pleurisy. He must be bled if the pulse will admit of it, and have a large blistering plaister applied as near as possible to the seat of pain in the thorax, as soon as the pulse is reduced if the pain continue; or if the pulse do not admit of bleeding, he should be blistered immediately. 


AN ESSAY ON TYPHUS FEVER. 
The remote causes of the epidemic diseases which occasionally hurry, in a short time, thousands of the human race to the grave, have long been deeply interesting subjects of consideration with physicians. Although violent disputes have agitated the medical world respecting the origin of these diseases, and in some measure still agitate it, great progress has been made in the last thirty years. The question of the remote cause of yellow fever may be considered as settled, although there are some few who hold on to the belief that it is propagated by a specific contagion ; somewhfit in the manner of the physicians of Europe in the time of Harvey, of whom not one, it is said, above the age of forty, admitted the truth of the doctrine of the circulation of the blood. 
The question respecting the nature ofthe remote cause of typhus fever is still unsettled. Obscurity rests upon it. It is proposed in the following essay to investigate this subject. 
It is perhaps universally believed in England that the remote cause of this disease is a specific contagion, and very many in this country have adopted the opinion. It is proposed to show in the first place that this doctrine is erroneous, and that a specific contagion is not the remote cause of typhus fever. 
Contagion is a matter generated by a diseased body, capable, on application to a healthy body, of producing in it the same morbid state, and of causing it to produce contagious matter of the same kind. 
Some contagions remain adhering to the surface which generates them: others are volatile, as we conclude from the circumstance of their producing their specific effect without the contact of the healthy with the sick person. Volatile contagions 12 


86 
Cooke on Typhus Fever. 
produce their effect in a manner unknown,' but' without contact with the sick, or with anything visibly proceeding from them; but as we know that by approaching near to a person affected wi'h the small-pox, a person who has never had it, will be affected with that disease, we are entirely persuaded that something passes from the sick, and affects 'him who is exposed to its influence. This unknown effluvium we call a volatile contagion, because it flies through the air from one to another. 
As it is very easy to avoid contact with diseased persons, very few people, comparatively, are affected by the fixed contagions; and because very many people are attacked by epidemic fevers, and most of them without having been in contact with the sick, and many of them without having even seen them, these diseases, if popagatcd by contagion, must be propagated by a volatile contagion. 
What evidence have we of the existence of volatile contagion ? None, hut that which arises from observing certain effects, which we cannot account for in any other way, than by attributing them to an invisible cause which we distinguish by this name. We see for instance, that the symptoms of a disease never appear in a person, without his having been in the presence of someone affected with that disease; and that they arc invariably the consequence of being in the presence of a person so affected, without regard to circumstances. Thus, the symptoms of small-pox never have been known to appear in any one without his having been in presence of a person affected with that disease,* and invariably appear when a person is so exposed. Wherever the sick go, they carry the disease; and it never appears where they do not go.* We therefore conclude that something emanating from such diseased person, affects those who go near them. — Obviously then, we have no right to conclude that a disease is produced by a volatile contagion, vhrn it does not appear in those who go . into the presence of the 
•Excepting when the disease is produced by inoculation, in which case the fixed contagion of small-pos is carried to the person uliuctoil, and inserted into his flesh. 


Cookb on Typhus Fever. * 
87 
sick. On the contrary, perceiving that the only evidence of contagious nature that wo can have, is wanting in this disease,, we must conclude that it is not contagious. 
Sometimes the circumstances are such as to mislead those whip decide hastily or do not examine closely. Thus we often sec persons in good health become sick on going near to those who are ill; but we. shall* often be wrong in our decision, if we pro* ¦ounce the disease contagious in every such case. There is a cause for every disease; and that cause is, or has been, in operation when we see the effects appear. The cause may originate in the sick, or in the circumstances in which they are situated. In order todpeide the question, the sick and the circum* stances should be separated. If when the sick are removed from the circumstances, the disease appears in those who go into their presence, we may conclude that the cause proceeds from them. If, on the contrary, the disease docs not appear in those who go where the sick are; .but does appear in those who go where the circumstances are, we surely are compelled to conclude that the disease is produced by a cause which does not emanate from the sick; but by one which arises in those circumstances.* 
•This error of attributing a disease to a cause emanating from the sick, be- cause those who go among the sick an; attacked, has frequent ly been commit- ted. Those who go into [daces in which the yellow fever is prevailing, arc very apt to be attacked: it does not however follow necessarily that the cause of this disease emanates from the sick, or is a specific contagion ; it may be ua agent arising in the circumstances in which the sick are situated. If wo were to admit the mere fact, that the disease is the consequence of going- whero people are lying sick, as evidence that the disease is produced by a causoema. nating from their bodies, we should be compelled to admit that the common autumnal remittents and intermittent* arc contagious. On thil very ground indeed, Cleghorn asserts that "these tertiau fevers have as good a right to bo called contagious, as the measles, small-pox, or any other disease ; for although in that season, there certainly is a peculiar disposition in the air to affect num- bers in the same way, yet those who are much conversant among she sick are most liable to catch the listemper." It is evident that he overlooked the, truth, that another cause may be produced, in the circumstances in which the sick are situated: and we now know, from the fact that this disease arises, wherever and whenever heat and moisture are co-operating upon i lead vege- table matter, and ceases when that co-operation ccnsc?j and nctcT appears 


Cooke on Typhus Fever. 
88 
There is another test of the contagious nature of a disease. If a disease be propagated by a volatile contagion, those who are in attendance on the sick must take it; this being the only circumstance which convinces us of the contagious nature of the disease. These attendants having been affected must in like manner communicate the disease to their attendants; these to others, and so on until the disease becdmes universal, unless by some means or by some law regulating its action, it is checked in its operation. This check is provided, and consists in the incapacity of volatile contagions to produce disease more than once in the same person. Thus, the small-pox cannot affect the same person more than once. The operation of this check is to render those who have had a contagious disease secure from a second attack, and to enable them to attend the sick and cut off the communication with those who have not been affected, and arrest the progress of the disease. Without this restriction, a contagious disease would be perpetual also: for, as soon as a person should recover, he would be liable to be attacked again, .and the whole world would be filled with distress. 
There is however no universal and perpetual disease, and it 
when this operation is not going on ; and likewise from the fact that the disease appears in that direction chiefly, almost entirely, in which the wind blows from the spot in which this operation is going on, that an agent is produced in those circumstances, which is the cause of the disease; and we further know that a specific contagion emanating from the sick' is not the cause, from the following decisive test. Separate the sick from the circumstances in which the disease arises and observe the result : where the sick are now situated, we may go with perfect safety : where the circumstances are we cannot ; the dis- ease is still produced in those who venture into them, if not an individual be there, if it be on a desert island. 
The same is true of the yellow fever. This disease never appears in Phila- delphia unless the medium temperature of the atmosphere at three o'clock P. M. in June, July, and August, is above 80° of Fahrenheit's thermometer, and •locs appsjjr whenever that state ofthe atmosphere exists through those months. Observe now what occurs in that city and in New York, upon removing the sick Irom the circumstances in which the disease makes it's appearance. The inhabitants of that district of the city in which this occurs, have been removed and the district enclosed by a fence and guarded. He however who passes that tence, does it at the ; » ril of his life. He who follows the sick to heir new habitations, and mixes freely with them is unhurt. 


Cooke on Typhus Fryer. 
89 
therefore follows that all diseases propagated by a volatile contagion are so restricted in their operation, that they cannot affect the same person repeatedly: and from this it immediately follows, that those diseases that are not so restricted in their operation, that is, -those by which we are liable to be repeatedly affected, are not propagated by a volatile contagion. 
It has been said that «ome diseases are contagious in certain circumstances of confined air &c. If there should be such a disease, it must become universal and perpetual in those, circumstances, unless the contagion which propagates it, be restricted in its operation in the way before mentioned; that is, unless it be incapable of affecting the same person repeatedly. There is however no disease universal and perpetual in the circumstances mentioned ; and it follows that all diseases propagated by a volatile contagion in certain circumstances, arc so restricted that they cannot affect the same person repeatedly; and consequently those diseases not restricted, viz. those by which we are liable to be repeatedly affected, are not propagated by a volatile contagion. 
These are therefore additional marl.3 whereby we can at once decide whether a disease is or is not contagious. One is, if we are repeatedly liable to have a disease, it is not propagated by a volatile contagion. Another is, if a disease be propagated. by a volatile contagion, it will spread until it becomes universal, unless its progress be checked by cutting off the communication between the sick and those who are liable to have the disease, by means of those who are not liable to it, in consequence of having had it already. 
All the characteristics which have been mentioned are found in the small-pox. 
It is never produced without approaching the sick, or applying the contagion procured from them. 
In persons placed near the sick it is invariably jiroduced.* 
It invariably spreads from the sick to those who are exposed to it,* without regard to circumstances. 
•In some very rare instances it is not thus produced ; but this is no excep- tion to the principle, because these persons are not liable to have the disease in 


Cooke on Typhus Fever. 
90 
It would spread universally unless stopped by cutting off the communication between the sick and the well who are liable to take it. 
We are not liable to be repeatedly affected by it. We therefore believe that in this disease, something passes from the sick which affects the well, and this we call contagion. 
Let us apply these principles in the investigation of the subject ofthe contagious nature of typhus fever. 
It is proper that it be understood that typhus is. called by various other names in the works of the English, Scotch, and Irish physicians. Dr. Currie speaks of typhus or jail fever.* He says in his Medical Reports, tt When the term fever is used in the present work without any adjunctive, it is the low contagious fever that is meant. This is the typhus of Dr. Cullen; the contagious fever of Dr. Lind; febris inirritativa of Dr. Darwin. In popular language it is generally called the nervous fever; and when particular symptoms appear, the putrid fever." "This is the common fever of England," &c? v Doubtless, the typhus or low contagious fever, is the prevailing fever of this island ai>d of Europe."t "It is the epidemic of all our great towns, of our jails, hospitals, manufactories," &c.§ 
Dr. Pringle says he has observed the same fever which arises in crowded hospitals arise in crowded barracks and transport ships, and that it is the same called in England the jail distemper, and is incident to every place ill-aired and kept dirty.|| 
any way, not even by inoculation. The test therefore holds good to all of the human race who arc liable to the disease. 
• Curries Medical Reports, p. 23. t Ibid. p. 27. | Some of our writers have undertaken to say that typhus fever is never ob- served In this country, and that it is peculiar to the British Islands. This quo- tation shows that Dr. Currie entertained no such idea. Moreover Trotter in his Medicine Nautica mentions that the French ships captured on the first of June 1794, were overruu with typhus. He therefore did not consider it a dis- ease peculiar to England; and no man ever had better opportunities of obser- ving. 
i Curries Med. Reports, p, 48. 
|| Pringle on the Diseases of the Army, p. 289, fifth Edition, Quarto, Lon- don. 
• 


Cooke on Typhus f 'ever. 
91 
Thus we find that the common fever of England epidemic in 
the great towns, the typhus, the jail -fever, the hospital fever, the ship fever, the putrid fever and the nervous fever are the 
same; insomuch that Dr. Currie designates the disease by the term fever without any adjunctive. 
Although the typhus fever has been so generally, or rather universally, considered as contagious, it has not one characteristic of a contagious disease. 
It is produced in certain circumstances, without the introduction of sick persons, or any communication with them or any thing connected with them. The following statements from Currie, Lind, Pringle, and Trotter, fully establish this position. They all believed, it is to be remembered, in the contagious nature of the typhus fever, and therefore no suspicion can exist that the facts were distorted to uphold .a theory. The latter had better opportunities of observation than almost any other person that can be mentioned. • 
Dr. Currie, a decided advocate for the contagious nature of the disease, speaking of a typhus fever which originated at Canterbury, says, " On considering every thing, this cause may reasonably be traced to the crowded and uncomfortable state of their barracks: to the gradual operation of foul air arising from this circumstance, the predisposition to disease is more immediately to be imputed, and finally the contagious fever itself."* "It (typhus) is usually produced in situations where there is a want of cleanliness, and more especially of ventilation ; and when produced, it is propagated by contagion."f . 
" Dr. Lind informs us", that .in a frigate which sailed from North America, with a healthy crew, a malignant fever broke out before her arrival in England, during very bad weather, which affected a considerable number of the men, and of which the surgeon's mate, boatswain, and some others, died." "Thus," he remarks, "a seasoned sound crew became infected, as it 
* Carrie's Med. Reports, p. 396. 
tQuere, What need of contagion to propagate it? Could, not that which produced the first case, produce the subsequent cases? 


Cooke on Tophus Fever. 
92 
would appear, from the closeness or damp below, occasioned by 1 fie hatch-way being kept, shut."* 
Pringle says he has often seen this fever arise in crowded hospitals, barracks, and ships; tind gives numerous instances.t Trotter, who, from his situation as physician to the Channel fleet of England in the latter part of the last century, had an opportunity of observing the disease more extensively than almost any other man has ever had, abounds with evidence on this as well as every other point involved in this discussion. Although a confirmed believer in contagion as the cause of typhus fever, he states many cases in which it appeared on board of shjp" at sea, where it was impossible to trace it to any contagion carried on board. He states that it appeared on board the Nis;er, the Glory, the Edgar, the Pompee, the Saturn, the Magnificent, &c and expressly says of each these or similar words, "Its origin could not be exactly traced ? " &c.j; and lest it should be supposed that no great care wastaken to discover the manner in which the disease was introduced, it is proper to remind the reader that all the fleet believed the disease to be contagious; that Trottcrsaysthat a captain who would gladly meet the cemv would turn pale on being told that the fever had broke out on board his ship; that he himself and all the surgeons were constantly on the look-out to prevent the introduction of any thing which could give rise to the disease; and, if a few dirty boys had entered on board a ship, whether they were sick or not, a fever occurring soon afterwards was sure to be attribifted to them, as confidently as if they had been known to carry contagion in their clothes. Notwithstanding all this care and anxiety to discover the manner in which the contagion was introduced, it is declared it could not in many instances be traced. 
In some cases it was acknowledged there was not even a ground of suspicion that the disease was introduced by contagion ;§ and in others that it was generated on board. ]| 
•Rett's Cyclopedia, article Contagion. 
tPri'cleonthe Dis. ofthe Army, p. ft, 25, 63, 287. $ Trotter's Medicina Xautica, vol. I, p. 153, 160; vol. 3, p. 63, 64, 147, 159. 167. tlbid. Vol. 3, p. 60, 151. || Ibid. p. 154, 157, 162. 


CoOtt on Typhus Feter, 
93 
Dr. Trotter, on a full view of these striking facts, although a decided contagionist, as every man in England then wan, makes the following observation: "It is very certain that this fever is generally spread by contagion; but it is equally certain, that it frequently arises in places where there could be no suspicion of communication with infected persons or clothing."J Considering how perfectly Dr. Trotter, and the English physicians generally, rested in the opinion of the contagious nature of the typhus fever, how perfectly destitute they were even of a suspicion of its fallacy, what great attention he paid to the subject, making the most minute inquiries into the manner in which the disease appeared to be introduced into every vessel, stronger or more satisfactory evidence cannot be desired, that typhus fever originates in certain circumstances, without the introduction of the sick, or of any thing connected with them. In persons placed near the sick the typhus fever is very often hot produced. Very few of those who arc near them, attending upon them, are affected with the disease, in proportion to the whole number exposed. 
The writings of the British physicians are full of facts which Establish this point incon testa bly. 
Dr. Currie in his letter to Dr. Clarke published in his Medical Reports, makes some remarkable statements respecting the Liverpool work-house, which place this matter in a strong light. This was a very large building, containing sometimes 1400 per* 'sons, which in the course of the year received from 12 to 18,000 patients. Every person who went into this building entered by a small door at which stood a porter. The person who occupied this post at the time the letter was written, had been in it for several years, and though continually exposed to the operation of any contagion that might be proceeding from the sick who entered, had escaped entirely. The patients proceeded from the door to certain apartments, one for each sex, where they were stripped and washed, and had a change of cloths; and there they remained until the 
•Trotter*! Medkriaa Nautica, vol. I, p. *$*. 
13 


Cooks on Typhus Fever. 
94 
apothecary made his daily visit. Of the people who were employed in this service, some in the course of years, were sick. Moreover all the persons who were admitted, awaited the visit of the apothecary in these two washing rooms;, and he decided who had and who had not fever. The patients in fever were put into a ward, or large division, by themselves, and the others were sent to two other divisions of the house; one called the Lock Hospital for females, and the other the Children's Nursery. In ten years the fever did not appear in the Lock Hot* pital, although almost every person in it must have been in company with the fever patients in the receiving and washing rooms, while waiting for the daily visit of the apothecary: and in the same length of time, there was one season in which a number of the children were affected with fever, and one only; although in addition to the exposure to contagion, if it exist, in the receiving and washing rooms, there was another exposure so remarkable as to excite the surprise of Dr. Currie himself; and enough not only to do that, but to have convinced him that the danger 
of approaching the sick is imaginary. 
He states that the children were allowed to run about the house; and that at the hours of meals, as was very natural in children, they collected in great numbers towards the bottom of the stairs, near the door of the eating room. While Dr. Currie was one day examining the stairs, which he thought badly constructed, a patient in fever was carried in and passed up the stairs within three or four feet of every child on them, and muck nearer to some. He was so struck with the exposure and the danger, as he conceived, in consequence of his believing in the contagious nature of the disease, that he immediately counted the number of the children and found exactly eighty-three, on the stairs. He also mentioned the circumstance to the nurses, apparently conceiving that if ought not to be allowed; but they considered it a light matter, as what might happen every day. " Though no clear instance of injury arising from such occurrences" he says, "can be brought, I have always deprecated the circumstance which leads to them; ai d in conjunction with ethers of my brethren, urged in the parish committee, the pronriety 


Cooxs on Typhus Fever, 
95 
of having a distinct passage to and from the fever wards. Various consultations were held on this point; but the structure of the building rendering such an alteration impossible, without entirely defacing the front, the want of any actual proof, or even" appearance of injury from using the common stair case, cooled our zeal." The plan was finally given up. On one occasion a fever prevailed among the children and sixty-seven were sick: what proportion to the whole number this was we are not informed. We are however assured that this was caused by the introduction of the children of a poor family, some of whom had the fever, the children having been sent to the nursery without changing their clothes and with some degree of fever upon them. It must be observed however, that this was said after the occurrence of the fever among the children, by men who were fully persuaded that the disease was contagious, not with a view to decide the question of contagion, for that was no question with them, but to account for the contagion getting access to the children: and they do not assert that the children who were alleged to have introduced the fever, had the disease at the time, but that they had some degree of fever upon them; such a degree as escaped the observation of a man whose special business it was, to take care that a disease believed to be contagious, was not introduced among the other inhabitants of the establishment. This is said too, when in the same letter it is stated that two of the nurses have each of them a child actually living with them in the wards, and going out to school in the day. These children appeared neat, clean, and healthy, though they slept in the very centre of the patients every night. Lastly with reference to the nurses; they were often and sometimes for a considerable time in contact with the sick, and exposed to the undiluted exhalations from their skin and lungs; and notwithstanding this great exposure, all tha,t is alleged is, that in the course of ten years several "have caught the contagion"; that is to say, several had a fever: for it was the fever that was observed, and the supposed cause is evidently used in place of the alleged effect. Accordingly (as might very reasonably be expected) "experience" (says Dr. Ci- rie) "taught . them to estimate even this hazard very lightly; and it N in fact 


Cooke em Typhus Fever, 
96 
as easy to get a nurse for the fever wards, as a servant for any other part of the house." What is very remarkable is the statement that, in the year 1801s the master and mistress and a young woman were taken sick and died ; which circumstances occasioned great agitation. But, it is stated, they died at different times, and the master of the house had never been in the fever wards, the mistress but seldom, and they lived in a part of the building very remote. Trotter's Medicina Nautica abounds with evidence on this subject. He mentions numerous instances, entirely too many to quote hero, in which people having this disease were carried! among a ship's crew without spreading it. The following is a specimen of these : speaking of the Charon hospital-ship, he says "We had in that hospital many malignant cases of typhus, and come deaths, yet no infection was ever spread there."* The following is a striking instance: he says, "We know of nothing that can propagate this fever, but exhalations front the body. But a patient in typhus was sent from the Venerable to the hospital-ship, with a fetor about him, that exceeded any thing Of the kind which ever came within my knowledge. After being 
washed and shifted, it still continued; and was perceived at a considerable distance. He died in a few days; yet nobody was it fected from him, either in his own ship or our hospital. "t It would be easy to multiply quotations from Trotter in support of this position ; but w hat has been already stated is abundai.t evidence that in persons placed near those who have the typhus fever, the disease is very often not produced, or rather seldom is produced. 
It is proposed next to show that the typhus fever never spreads even in the presence ofthe sick, without the concurrence of an impure atmosphere. 
This will appear to be true from considering the circaon* sti; c~s in which it is produced, and the result or consequence of separating the sick from those circumstances. This disease ¦rfthown to be most prevalent in the confined habitations ofibe 
•TiwJer s Med. Nantica, vol. l,p. 179. See also p. 109, 164, 130, tltrSea vol. t, p. 60, for similar passages. tlbid. p. 175. 


Cooke on Typhus Fever* 
97 
poor in the most filthy parts of cities. Dr. Currie makes some really frightful statements respecting these habitations, and moreover informs us that the streets in which the fever prevails most have numerous collections of standing water, and in those streets which are *ot drained and in which piles of every kind of filth are allowed to collect, the fever prevails most. Ferriar in his Medical Histories makes similar statements. Remove the sick from those neighbourhoods in which these sources of fever are so abundant, and the disease ceases. Remember the account of the Liverpool work house. From twelve to eighteen thousand patients are carried into it, in the course of the year, from these very streets abounding in moisture and filth, and though the fever wards are in the very centre ofthe building and cannot be entered hut through the common staircase, crowded every day with children, yet no single instance has occurred of the contagion (that is the fever) spreading from them to the other parts of the house. 
41 It to clear from the collected observations of Dr. Hay garth, and of those active and experienced physicians whose cocrespondence 
he has published, not to mention the experience which fever wards have lately afforded, that in a large airy and clean apartment, Jew or none even ofthe moat intimate aitesuiants catch the disease, where the patient labours under infectious fever. The nurses themselves, exposed to the effluvia of the excrements, and perpetually near and often in contact with the sick, nevertheless hardly ever receive infection."* On the one band, in the confined air ofthe miserable dwellings of the poor, situated in filthy and undrained streets, the lever is produced and constantly kept alive, although so many thousands are annually seat into the work house. On the other, in the purer air of this establishment, it is forever expiring; end wore it not for the thousands annually sent into it, would cease entirely. ' 
> 
It is therefore evident that this disease docs not spread in pieces into which the sick are introduced, without the coacurrencc 
•RSCsftCyelepedia, article Contagion. 


Cooke on Typhus Fever. 
93 
of circumstances which have been shown to be capable of 
producing the disease: and when, therefore, we see the disease spread In such circumstances, after the introduction of a sick person, it is not a fair inference that the cause proceeds from the sick; seeing that the circumstances without the sick can produce the disease, and the sick without the circumstances cannot. 
Moreover, if typhus fever were propagated by a volatile contagion, it would become universal if its progress were not arrested by cutting off the communication with those in health, by means of persons not liable to be attacked in consequence of having had the disease. There is however no idea entertained of any person's not being liable to repeated attacks, and no attempt made by means of any such persons, to insulate the sick; and yet the disease does not spread until all in a city are affected. Therefore likewise we conclude that typhus fever is not propagated by a volatile contagion. 
Lastly, this is a disease to which we are repeatedly liable; and hence also we conclude that it is not propagated by a volatile contagion. 
We find therefore that typhus fever is destitute ofthe characteristics of a contagious disease, viz. that of affecting a person only once; and that of spreading until it become universal, even in the circumstances favorable to its extension, unless stopped by insulating the sick. Moreover typhus fever often appears in such circumstances, that it is admitted by contagionists that there is not the slightest suspicion of communication with the sick, and it is evidently impossible in some of the cases, from their own statements, that there could have been any: in persons placed near the side, the disease is very often not produced, and it never prevails without the presence of those circumstances which are sufficient at 
anytime to produce it. But the ground of our belief in the propagation of a disease by a volatile contagion being, that it is produced by exposure to the sick, without any other possible means of accounting for the phenomena, and never without inch exposure, we are in this case ennrelv destitute of it, and 


Cooks on Typhus Fever, 
99 
must conclude that typhus fever is not propagated by a volatile contagion. 
, It is next proposed to show that the remote cause of typhus fever is toe dense gas arising during the decomposition of vegetable matter, commonly called miasmata. 
. Jn support of this doctrine it will be shown that the typhus fever arises in those situations in which miasmata abound, and in which in all parts of the earth miasmatic fevers are produced ; that in the timeof its rise and fall, its greatest height and lowest declension, it corresponds with miasmatic fevers, and that the same kind of weather is most favourable to the increase of both; that typhus fever on board of ships, at sea or in port, arises in circumstances in which miasmata abound; that the symptoms of typhus fever are the very same with those observed in fevers known to be produced by miasmata; that typhus fever appears in connexion with miasmatic fevers; and that they are mutually convertible into one another. 
It is proposed in the first place to show that the typhus fever arises in situations in which miasmata abound. The first evidence I shall offer is from Dr. Carrie's account of the diseases of Liverpool. He tells us that the town of Liverpool having been harrassed by typhus fever, the magistrates called in the physicians, to give their opinion of the measures it was advisable to take to improve the health of the city. The physicians, he informs us, took the matter into consideration and presented a full report on the subject, in which they took a view of the causes of the uncommon sickness of the two years preceding that time, and of the measures necessary to prevent its recurrence. In speaking of this subject they complain of the want of cleanliness in the streets, and mention ground within the liberties of the city which was not drained. They state that for twenty years before there had been collections of standing water ano of filth of every kind in a part of the town which they named and that that part of the town had been infested with low fevers, especially in the autumnal months. 
These low fevers, occurring in situations where miasmata mutt abound in hot weather, and in the very season, the antumnal, 


. Cooke en Typhus Fever. 
100 
when they are known to abound in such places, and therefore so manifestly produced by miasmata, are culled by Dr. Currie without hesitation or question typhus fever. This he does not only in the general declaration before mentioned, that typhus fever is the common fevor of England, the epidemic Of all the great towns, but he calls this particular fever, typhus fever. Thus he states in two several tables respecti.ig the health of Liverpool, the number of cases of fever, which were carried into the Dispensary in the same month: in one table the word fever is used, in the other typhus fever; in both places the same number of cases is stated. 
. 
It is evident from this statement that the miasmatic fevers Which arose amid these stagnant waters and filthy places, were called typhus fevers by Dr. Currie. , Dr. Currie mentions a case in which a regiment billetted in Liverpool, and paraded and mounted guard in a fort on the banks of the river. The general guard-room was a very dirty and confined place, and had under it a cellar, which had been full of water in the winter, but was at the time in which the fever appeared, half evaporated and sending forth offensive exhalations. IrT this state of things, the typhus or jail fever broke out in June and spread rapidly. 
He mentions another typhus fever which broke out in a regiment in barracks at Gosport. This is a town on the West side of Portsmouth harbour in the South of England. The land around this harbour is low and damp, and intersected with creeks. The ague and fever frequently prevails there and sometimes dysentery in the autumnal season. This fever commenced in May, progressed through July, and, though great efforts were made to suppress it, it continued through August and September, and ceased in November. 
Manchester in England is situated between two rivers. Some ofthe streets were not drained at the time alluded to in the statement to be made. Dr. Ferriar tells us in his Medica! Histories t^at the fever generally prevalent in this town and neighbourhood, iti which it is evident miasmata mnst have abounded whenever the temperature was sufficient to produce 


Cooke on Typhus Fever. 
101 
them, was a mild typhus. He expressly says " During the late epidemic it was observed that the fever prevailed most in streets which were not drained, or in which dunghills were suffered to accumulate" &c. 
We have then, in these statements made by men who believed firmly in the contagious nature of the typhus fever, the most unequivocal evidence that typhus fever arises in situations in which miasmata abound in warm weather. 
The next thing proposed to be shown is, that in the time of its rise and fall, its greatest height and its lowest declension, typhus fever corresponds with the miasmatic fevers of other countries. The reverse of this is confidently asserted: it is said that typhus fever is a disease of cold weather particularly; and that it disappears in hot weather. There is however on this point, as well as on the whole subject of typhus fever, a strange inattention to facts. 
The following table shows at a glance that typhus fever is not a disease particularly of cold weather; that like all miasmatic fevers in temperate climates, it increases as the autumn advances ; is at the highest in that season of the year, and declines on the coming of cold weather, and that it is particularly severe in the hottest weather, 
» 
14 


Cooke on Typhus Fever. 
102 
A TABLE, showing the Number of Fevers admitted on the Books of the Liverpool Dispensary, from the first of Janna-j 1780, 1o the last uf December, 1796, inclusive; distinguishing the Numbers admitted every Year,* and each Month of every Year. 
Year. Jan. Feb. March. April. May. June. July. August. SepCr. QcCb''r.\Nov > r. Dec'r. 1780 160 125 179 173 168 183 191 150 129 186 150 133 1781 130 146 180 200 187 154 157 127 167 I 234 208 223 1782 268 265 231 292 , 148 159 120 140 143 I 182 150 158 1783 210 158 184 207 ; 222 212 286 227 265 ! 316 i 257 273 1784 170 t 194 245 247 232 225 270 230 266 i 247 369 297 1785 235 j 268 296 294 219 J 87 173 180 186 250 244 182 1786 I 191 ; 166 216 244 202 155 159 188 j 169 211 167 197 1787 * 259 ' 209 301 234 313 356 255 192 ' 218 234 283 326 1788 236 174 213 255 253 245 271 311 258 341 315 295 1789 319 176 338 323 391 205 j 184 162 ! 212 214 204 208 1790 176 j 248 337 294 281 247 ! 343 ! 270 310 340 355 269 1791 253 247 277 230 233 240 266 248 300 ! 344 ! 335 371 1792 359 j 361 ! 269 278 , 26i 237 23ft | 223 211 330 | 212 174 1793 174 209 j 221 ; 259 j 237 i 334 199 197 338 ; 305 ¦ 224 228 1794 157 230 , 383 280 j 337 j 305 291 245 303 j 230 258 ¦ 326 1795 152 266 j 546 I 204 I 234 | 230 248 159 196 239 317 180 1796 197 161 ! 266 ! 242 ; 288 I 176 203 182 254 I 329 153 247 3683 3602 4682 4266 4206 3850 3852 3431 3925 4592 4201 4087 •The right-hand column, stating the whole number of oases in each j ear, is omitted as having no bearing on the subject. 


Cooke on Typhus Fever, 
103 
From this table it appears that typhus fever is not peculiarly a disease of cold weather. Under the name of each month is stated the whole number of the cases of typhus which occurred in that month for each of seventeen years ; and at the bottom, the whole that occurred in that month for the whole seventeen years. The smallest of the sums-total in the table, excepting one, is under February, and the next under January. The whole number for the three winter months exceeds the whole number in the three summer months by only a very few cases. 
This fever, like our autumnal epidemics, is sometimes followed by a winter epidemic precisely in the same circumstances. But 
notwithstanding this, the smallest number of cases in a single month occurred nine times in December, January and February; and only six times in June, July and August; and in four of these six, the number in the winter months was but a very few cases above that in the summer. On the other hand, the highest number in the year occurred only once in December and once, in February;and once also in June and once in July. These statements show in the most pointed manner that this disease is not peculiarly a disease of cold weather. 
But this is not all: It is not only not peculiarly a disease of cold weather, but it is particularly a disease of hot weather, and like all miasmatic fevers in temperate climates, increases as the autumnal season advances, is at the greatest height in that season, and particularly severe or malignant in the hottest weather, and declines on the approach of cold weather. 
All this is shown by the table. The lowest total-number in the table is under August; it increases from above 34 hundred in that month, to above 39 hundred in September and near 4C hundred in October, and declines in November to 42 hundred, and to near 41 hundred in December. 
This agrees with the increase and decrease of our autumnal epidemics. 
In some ofthe years the autumnal increase is small in comparison with others, but it is invariable. There is a difference in every year, and the uniformity of the increase, however inconside* Sable in seme years, shows the operation of an uniform principie; 


Cooke on Typhus Fever. 
104 
just as theappearance of a few bilious cases in the autumnal season here, is a minor degree of the operation of the same cause-that sometimes produces an epidemic. 
This doctrine does not rest however on this table alone. Trotter and Currie mention many instances of epidemic typhus commencing in" warm weather, increasing through the autumn, and declining on the approach of cold weather. Currie says the dysentery appeared in July 1801 in Liverpool, and afterwards the typhus fever raged with great violence. In August, September and October, there were fifteen hundred deaths, nine hundred above the usual number. In September six hundred and tea died. 
The physicians of Liverpool, in the report to the magistrates already mentioned, allege the necessity of dr aining and cleaning the streets, because in their damp and filthy state, low fevers infested those parts of the town in the autumnal months especially. 
Dr. Ferriar states that the weather was wet and warm in the summer and autumn of 1794, and that it was even a burning summer; and the typhus fever was unusually prevalent at the time. A bilious colic had raged among all ranks of people before the fever prevailed. The fever was at the same time prevalent in many parts of England, and in the fleets of Engkv d and France. 
Miasmata in these circumstances must have abounded: it is, impossible that it should be otherwise. 
Dr. Currie mentions an epidemic typhus in the town or city of Canterbury in England. This town is situated in a low wet place ; the summer was excessively hot. The epidemic com. menced about the last of July, it prevailed through August ar.d September, and the last case occurred on the 21st of October. The fever was accompanied by dysentery, the cases of which 
were very numerous. On the first of June 1794, an English fleet captured most ofthe. 
ships of a French fleet. That year was excessively hot. The* French ships were very sickly, the typhus fever prevailing on board. The crews were la: ded at Plymouth and Portsmouth. The situation of these two places is such that it is impossible nrt* 


Cooke on Typhus Fever. 
105 
asmata should not abound in warm weather. Portsmouth in the hot summer of 1764, Lind says, was very much harassed by a miasmatic fever of high grade. During the continuance of the French in this situation, in this hot summer, there was a vast mortality among them, as well as among the militia who guarded] them. In one place above three hundred died in four mouths, that is, in July, August, September and October. 
This body of evidence shows, in the strongest manner, that typhus fever prevails most in hot seasons, that it increases with the increasing heat, and declines on the coming of cold weather. There is however in some instances a winter epidemic following the autumnal, precisely as in ourepidemics. That this is the e£ feet of cold operating on persons affected previously by miasmata, is evident from the identity of the symptoms in the typhus of winter and our bilious fever of winter; as well as from the fact that these winter typhus fevers occur in cold weather after sickly autumnal seasons. We have not time to dwell longeron this subject, but it may be illustrated by a single case. 
In the year 1 794, the summer of which was very hot, the number of cases of typhus in August was 245,* in September 303, October 290, November 258: here then is a rise front August to September and a gradual decline in October and No* vember. In December however, there was an increase to 32$ eases on the coming of very cold weather. In the more settled weather of mid- winter the number of cases fell down to 152ia January; and in February, but particularly in March, there was a great increase. This winter and spring were colder than had been experienced in England for a long scries of years, sbvs Dr. Currie.t The number of cases in December was 32ft and in March 546. 
This is precisely what occurred in 1814-15 in this country and in Virginia. In January snow covered the ground two feet deep and lay a long time, a most unusual thing; and the consequence was a very fatal epidemic in the latter part of winter. 
The next thing proposed is to show that the typhus fever, 
•See the table, p. 74. 
tCurric's Med. Reports, p. iM t 


Cooke on Typhus Fever. 
106 
which appears on board of ships in port or at sea, arises ia circumstances in which miasmata abound. 
There can be no question of this with regard to the ships in port, inasmuch as these harbours are almost all in the mouths of small rivers in a flat country. With regard to ships at sea, we have seen, when discussing the question of the origin of autumnal fevers on board of ships, that they abound in tilth chiefly of vegetable matter.* They carry a vast quantity of wood, of vegetable substances of various kinds for food, and we know that the air of vessels is often so impure that lighted candles appear dim and sometimes the light goes out. In these circumstances, we have seen that miasmatic fevers of every form make their appearance.! Miasmata then abound in these circumstances, and in these very circumstances typhus fever arises. With regard to the temperature of the atmosphere when the fever appears on board of ships at sea, Trotter mentions a great number of instances in which it arose in hot weather. It is to be observed also that the temperature of the interior of a ship 
is always higher than that of the atmosphere without. The erowdofineu, the number of caudles continually burning, the fires that are necessarily burning in the hottest weather, all tend to produce this state; and we are told that on board the Immortalite, when the thermometer in the shade stood at 72° "the medium heat between decks, when the watch below, were in bed, was 84°"J 
In the hot summer of 1794,§ when the mercury in the thermometer in the latter part of June stood at 80° in the shade, the typhus fever was general in the English, French and Portuguese fleets in the English Channel; and in the summer of 1779 the same occurred on board the French and Spanish fleets ofFPlymouth.|| 
The French ships, a number of which were taken by the English in 1794, Trotter says, were extraordinarily dirty, and 
* Transylvania Journal Vol. I, p. 317. + Ibid. p. 3fi2. % Trotter's Med. ISiuit. vol. 3, p. 98. 
t Ibia vol. I, p. 78, 79, 89 and 197 compared, fl Ibid. p. 205, QOtei 


Cooke on Typhus Fever. 
107 
great numbers ofthe seamen perished.* The English suffered less, because extraordinary care was taken to clean and ventilate 
every ship.t 
The report of one ofthe surgeons, Mr. Gillespie, for Julyj shows the influence of high temperature in increasing the disease. He says, "The approach ofthe solstice and the ennicula, seemed to have considerable influence on the spreading of the complaint; as notwithstanding the precautions used many were attacked with it."J 
The correspondence between the effect of the high temperature ofthe summer of 1794 by land and by sea, is worthy of particular attention. The same high temperature which produced an epidemic typhus fever on board the English and French fleets at sea, also produced an increase and continuance of the* mortality among the French prisoners after they landed,§ upon their guard composed of English militia,§ an unusual number of cases in Liverpool (see the table), and an epidemic typhus fever at Manchester:|| and there can be no reasonable doubt that it was general in England in that hot summer, as was, Lind says, a similar fever which prevailed in the very hot summer of 1765 in Portsmouth. 
Dr. Trotter mentions many instances of this fever breaking out in single ships in the summer .and autumnal months.ll Several of these ships are mentioned as having been particularly dirty and leaky. 
* Trotter's Med. Naut. Vol. 1, p. 76, 77. 
tlbid. Vol. 3, p. 80. Vol. 1, p. 84, 86, 94. % Ibid. Vol. 3, p. 90. } Ibid. Vol. 1, p. 84. || Sec Ferriar's Medical 4listorics, p. 231. The passage runs thus; "In the summer and autumn oil 794 the usual epidemic fever" (which he says in p. 81 is a mild typhus) "became very orevalcnt among the poor in some quarters of the town, particularly after a bilious colic had raged among all ranks of people. To the ordinary causes of fever were now added it he influence of a burning summer, succeeded by very wet, bntyet warm weather," &c. Compare this with the passage, quoted a few lines above, from Mr. Gillespie, respecting the effect of the increase of the temperature of the weather in increasing the disease. • 
TTrottcr's Med. Nautica, v.ol. 1, p. 135, 136, 137, 155, 165, 167, 178; vol. % ? S> 26; vol. 3, p. 59, 2 15, 


Cooke on Typhus Fever, 
108 
The typhus fever was sometimes epidemic in winter In the fleet as on land. This was the case in March and April 1 800, when the weather was cold, tempestuous and rainy ;* and likewise in the same months in 1801. t It appeared at the same season in a number of ships not in fleet.§ The symptoms were, "a combination of the symptoms df typhus with pneumonia"; || that is, the disease consisted of the symptoms of the typhus fever as it appeared in summer, with the addition of those pneumonic symptoms produced by cold. There is probably more of the winter epidemic at sea than on land, for this obvious reason: when the weather is bad at sea, there is a greater necessity for turning out to save the ship; whereas on land, almost every body at such times is housed. Sailors therefore must suffer more in winter than lands-men. , 
It is evident from these statements that typhus fever appears on hoard of ships at sea or in port, in circumstances in which miasmata abound, and at those times in which miasmatic fevers appear. Excepting the month of March, in which when the disease appeared, it is stated that the weather was cold, tempestuous and rainy, the greater part of the instances in which the /ever appeared, occurred in the summer and autumn. 
It is now to be shown that the symptoms of typhus fever, as stated by the British writers, are those which we every year see produced by miasmata. 
These symptoms, as stated by a considerable number of surgeons in the army and navy of England to Dr. Currie, but chiefly to Dr. Trotter, are the following. 
The disease frequently commences with a dull headach with restlessness and shivering, pains in the back and all over the body, foul tongue, and great prostration of strength. The headach gradually becomes more acute, the temperature of the body increasi'ig gradually till it attains a very considerable height, and frequently there is delirium in the fever. The eyes are sometimes blood-shot. 
•Trotter's Med. X.i-it. vol. 3, p. 160, to 174, 221. tlbid. p. 194 to 209. 
?Ibid, vol. 1,p.57 to 67, -210; vol. », p. 14, 17, 21, 147; vol. 3, p. 60, 63, 453,155. fllbid. passim. 


The pulse varies from a very weak and rapid, to a fell, strong and hard stroke. This, strange as it may seem to those who consider this as a peculiar disease in which the pulse is always weak, is nevertheless a fact The frequent occurrence of cases with hard and strong pulse in the midst of those with weak pulse, shows that the same cause produces both; and this connected with the identity of thesymptoms in other respects, manifestly indicates that they are one disease. Indeed the question of difference seemed not to have arisen in the minds of these surgeons, and they therefore, speaking of it as typhus fever, state unequivocally that the pulse was sometimes hard and apparently oppressed. With the headach and other affections of the head which often accompany pain in that part, there is nausea and vomiting, great anxiety, feel tongue, and parched tongue. The discharges from the stomach and bowels are frequently bilious; those from the stomach sometimes green, and those from the bowels green, dark, sometimes black, and often very offensive.* 
The skin in very hot summers becomes yellow. This is noticed by several surgeons, and in several years. One of the surgeons in his alarm apprehended that the yellow fever had been introduced, the ship having spoken a vessel from the West Indies and perhaps sent a boat on board. Trotter however relieved his apprehensions, tolling him that it frequently occurred; and that he had often seen the eyes, the skin, and the urine as deeply tinged by bile in typhus, as he ever saw it in the yellow fever in the West Indies. He observes also that this symptom was particularly remarked in the warm summer of 17944 Trotter mentions a variety of symptoms occurring in the last stage of a mortal attack of typhus fever, of which I have seen all but one or two unimportant ones in our autumnal fevers, when patients were not properly evacuated; and those that 1 have not seen, others have ; so that every symptom occurs in 
•Hamilton on Purgatives; Darwin's Zoonomia, vol. 2, p. 490; Ferriar's Med. Hist. p. 71. 
*TrotUrs Med. Naut. vol. 1, p. 259; vol. 3, p. 215, 215. 15 
109 
Cooke on Typhus Fever, I 


connexion hlemora 
Cooke on Typhus Fever. 
110 
our fevers. Among these are mentioned in 
rhages, intolerable stench of the breath and excretions; the skin By or yellow, petechias, vibices, vomiting of black matter, the ach rejecting every thing immediately as swallowed,* &c. his is a perfect picture of the fatal cases of our autumnal fevers, particularly when the patient has not been well evacuated ; when from the violence of the case, or from the timidity of the practitioner, the patient lies without a sufficient discharge from his bowels. Typhus fever has also its winter epidemics,} in which the symptoms are those which have already been mentioned, witk the addition of such as are produced by the action of cold on the thoracic viscera, viz. pneumonic symptoms. This 4s what we see every year occur in our miasmatic diseases: they are likewise frequently followed by winter epidemics, in which the symptoms are those observed in the miasmatic fevers of the autumnal season, which are the very same observed in typhus, as has just been shown, together with the same additional symptoms in the thorax proceeding from cold, also observed in winter typhus.J 
Sit is next proposed to show that typhus fever appears in comny with miasmatic diseases, and that they are mutually convertible 
into one another. 
Dr. Ferriar, in his Medical Histories, tells us that he has seen cholera converted into typhus. He also states that dysentery and diarrhoea are often converted into the same fever. He mentions also an epidemic bilious colic, in the same season with an 
epidemic typhus fever.§ 
Pringle states that hospital fever, that is typhus,]| and dysentery appeared together. Few escaped he says, for however mild or bad the flux was, for which the person was sent to the hopital, the fever almost surely supervened.! He states that an English 
•Curries Medical Reports, p. 25, 310, 388 ; Trotter's Med. Naut. vol. 1 , p. MO, 109, 255,266, 274. 281 ; vol. 2, p. 58; vol. 3, p. 55, 102, 161, 154, 209, 215,218. 
fSec Transylvania Journal of Medicine, vol. l,p. 537. JTrolter's Med. Naut. vol. 3, p. 157, 191, 193; Kerriar's Med. Hist. p. 70. jFerriar's Mcd, Hist. p. 138. IJSecp. 62. ITPringle's Diseases of the Army, p. 25, 34. 


army, which had been exposed in the autumnal season to miasmata in Holland, being on the voyage home in November, some of the men were taken ill with remitting fever, which was soon by the crowded state of the vessel converted into jail-fever,* that is, typhus.? Perriar states that in one case, in which a typhus fever was unusually protracted, the* fever assumed the form of an intermittent.}; Dr. Gomez, a physician to the Portuguese fleet, in a letter to Dr. Currie of Liverpool, mentions a case in which a typhus fever was converted into a dysentery .§ Trotter abounds with evidence of this kind. He speaks o a ship landing a number of men, after a voyage, ill with typhus and dysentery. In another case a considerable number of persons ill with flux and typhus fever, were received on bOard the hospital-ship from one of the fleet.|| He speaks often of the typhus fever putting on the intermittent form, which, he says, showed it was on the decline ;T and this very observation shows mat the case was of so frequent occurrence that he had founded 
a rule upon it. He speaks of cases of typhus assuming a bilious remittent form.** He says that he has seen a family in which the father had an obstinate tertian, while the mother and part of the children had typhus fever. He states that he lias constantly remarked, when typhus prevailed on board of ships, that intermittents and remittents occasionally appeared, and when the proportion of the latter increased, he considered it as a mark that the epidemic was on the decline. 
The following quotations show this matter in a strong light. Speaking of one ship, he says "There were a larger number of bad cases in typhus, ague, and dysentery, than come usually to a naval hospital at one time. From the same transport and in the same regiment, were brought people ill of the three disr eases just mentioned."!? 
"It is not easy (he says) to trace those circumstances, which 
•Pringle's Diseases of the Army, p. 39. t See p. 62. 
$Ferriar'i Med. Hist. p. 82. ?Carrie's Med. Reports, p. 335. 
(|T rotter's Med. Naut. vol. l,p. 58; vol. 2, p. 14. INbid. vol. 1, p. 66,70, 18^ ••laid. ». 82, 84, 187, 18B» ttlbid. vol. 1 , p. 192. 
11 1 
11l 
Cooke en Typhus Fever, 


Cooke on Typhus Fever. 
112 
occasionally convert an intermittent or remittent fever into a continued type, (or typhus,) and vice versa.* There must bowever be something in their disposition very much alike ; for wherever we find typhus affecting a number of people at a time, we also find cases of the remittent and intermittent form."? These statements of facts, by men all of whom believed typhus fever to be propagated by a specific contagion, are abundantly sufficient to show that the fever called typhus end miasmatic fevers, including all the forms, intermittents, cholera, cohc, diarrhoea and dysentery, arise together under the operation of the same circumstances, and are convertible into one another. 
It appears evident from these statements that typhus fever bears the same relation to intermittents, cholera, colic, diarrhcea^ and dysentery, that our remittent fever bears to the same. Even the chronic diseases in which typhus terminates, are the same with those in which our autumnal fever sometimes terminates. Ferriar says "In particular seasons dropsy succeeds most cases of typhus," and mentions that this was unusually common in 1792.J 
It has now been shown that typhus fever arises in situations in which miasmata must abound in hot weather; that in the time of the rise and decline of this fever it corresponds with miasmatic fevers of temperate climates, and that the same kind of weather is favourable to; the increase of both; that the symptom?: of typhus fever are the same with those of autumnal fever; that typhus fever appears in company with miasmatic dis» eases; and that they arc mutually convertible into one another. Whence H is evident that typhus fever is produced by mi as-, mata. 
The typhus fever though commonly called a continued fever is in reality a remittent. Cullen even admits it. He doubts 
•The single consideration, that intermittents are convertible into typhus, strongly indicates, indeed clearly shows the miasmatic origin of the latter. If the fever be first an intermittent and then a typhus fever, its erigia is eat- changed; the typhus fever originated in miasmata* 
tTrotter's Med. Naut. vol. 1, p. 311 
JFerriar's Med. Hist. p. 152, 23*. 


US 
Cookk on Typhus Fever. 
whether in forty years he ever saw a continued fever properly speaking. Hesays that there are almost always daily exacerbations and remissions in the most continued fever;* wherefore he makes remissions and exacerbations a' part of his definition of continual fevers. 
This being the case, it is apparent that the typhus fever of England bears the same relation to the intermittents, dysenteries &c. which, according to the declaration of Trotter &c. arise in company with it under the operation of the same circumstances, that the remittent fever of more southern regions bears to the intermittents, dysenteries, &c arising in company with it, under the operation of the very same circumstances: and as the intermittents, dysenteries, &c. of England, are the same diseases with the intermittents, dysenteries, &c. of those southern regions, differing only in degree of violence, it is evident that the remittent of England viz. typhus fever, is the same disease with the remittent fever of those regions, differing only in degree* 
Typhus fever therefore is the common autumnal fever, or remittent bilious fever of England. 
This conclusion is supported by a variety of considerations. 
1. The argument of Cullen, that remittents and intermittents are the same disease, because they arise from the same origin, prevail together in the same places, and at the same time of the year, and are convertible into one another ;T ii equally strong in favour of the identity of typhus fever and intermittents, these also arising from the same origin, prevailing together in the same places and times, and being convertible into one another. 
2. Epidemic fevers are classed by Cullen under the head of typhus fever, which, from the situation in which they appeared, and the names given them by authors as descriptive of them, evidently were miasmatic diseases. Such are the epidemic diseases 
•Synopsis Nosologic, tic. Tom. ii, p. 66, Nota. "Fere semper in febribus maxime continuis, exacerbationes et remissioncs, etiam quotidio, satis mani- festos observavi." 
?Cullen's Nosology, Vol. 2., p. 54. 


114 
Cooke on Typhus Fever, as' * 
of Egypt which prevail most in the hottest weather and never at tor the marshes and lakes are dried up; the epidemic fevers likewise of Senegal, Hungary, Trent, Cologne, Warsaw, Leipsic, Cremona, Petersburg, Silesia, &c. all of which are so situated as to make it evident that they are liable to miasmatic diseases; some indeed are celebrated for them. 
3. Cullen mentions under the head of typhus fever, the putrid fever of Macbride, the putrid catarrhal fever of 1 768, the putrid bilious fever of 1749, and the putrid nervous fever of 
1770, described by De Mertens. 
These terms, putrid and bilious, were formerly used to designate the autumnal fevers of tow countries.* 
4. Lind gives an account, from the journal of a surgeon who sailed up some of the rivers of Guinea, of a fever which prevailed in the month of June in a town in 1 2 degrees north latitude. "Their sickness could not be well characterized by any denomination commonly applied to fevers; it however approach^ 
ed nearest to what is called a nervous fever (or typhus, see p. €4), as the pulse was always low, and the brain and nerves seemed principally affected."t * «t> 
Cullen has also placed under the head of typhus, a fever called Febris Senegallensis, and refers to the London Medical Observations, 11. 21, for an account of it. He therefore concurs with the surgeon above mentioned, in considering the fever of the West Coast of Africa, a typhus. Lind himself calls it a low malignant fever.J This fever however occurs in the rainy season, is ofthe remitting kind, and besides delirium, coma, sunk pulse, and a train of nervous symptoms, is accompanied by 
bilious vomiting and purging, and yellowness of the skin.? 
It therefore originated amidst abundance of miasmata, and bad the symptoms observed in fevers produced by that remote cause; and was therefore the ordinary miasmatic fever of that 
country. Cullen himself has placed the same fever under the head of tertians also, viz. Febris remittens regionum calidarum. 
• See Primrle on the Diseases of the Army, p. 73, 168, 188. 
t Lot* on Hot Climates, p. 49. $ Ibid. p. 4?, 


Cooke on Typhus Fever. 
110 
$. In the year 1765 in Portsmouth in England, and in the 
neighbourhood, the summer being very hat, a violent fever prevailed, in which yellowness ofthe skin was a common symptom, with others which we observe in our autumnal fevers. This was called by Lind the autumnal fever of England. In the year 1794, in the very same place, the summer of this year also being very hot, a very violent fever prevailed with the 
same symptoms, and among others, as occurred in 1766, there was yellowness of the skin. This fever Trotter calls typhus.* The identity ofthe two is palpable. 
6. Another circumstance which shows the identity of typhus and miasmatic fever is, that physicians who come from England to this country, call our autumnal fevers typhus fever. Even those who formerly studied in Edinburgh, and their students, frequently do the same. Some years ago a physician from Ireland settled about a dozen miles from the place of my residence. In the following autumnal season he had a fever and requested my aid. He was advised to take a mercurial cathartic every day, with the assurance that he would soon be well. He was 
startled at the mention of such a course in his disease, which he pronounced typhus fever. It was the autumnal fever every where then prevalent. 
7. The identity of the cause of autumnal fever and typhus is so obvious that Dr. Trotter is himself led to the conclusion, that these diseases have a common origin; but, what shows in a very strong light the propensity of the British physicians to believe in contagion, he concludes that dysentery and tertian fever arc produced by the imaginary contagion of typhus fever. He says, "We have now seen in the Vengeance, the contagion of typhus, brought on board by two men, extend throughout a ship's company: and in the space of four months, indifferent subjects produce continued, remittent and intermittent forms of fever, fn Jjord Moira's transports, something of the same kind occurred, with the addition of dysentery. To these I might add other facte 
• Trotter's Mod. Naat. Vol. 1, p. 84. 


Uff 
Cooke on Typhus Fever. 
in confirmation, from almost every ship which I have attended under a general contagion." 
These facts numerous as can be desired, prove beyond question or reasonable doubt, a common origin ; that they are produced by the same cause. What that cause is, cannot bft doubted by those who see these fevers arise under the influence of what proceeds, in hot weather, from stagnant waters and pilot of filth, or dung-hills as they are called, in the outer edges of cities, and disappear by filling up those places, or covering them with water, or by drying them up, or by draining them, or on the coming of cold weather. In short, the conclusion is inevitable that something produced in these circumstances is the cause ; and that that agent is a gas, is equally certain when we consider the circumstances of the case at Galliopolis in Ohio, viz. that the fever appeared net until the wind blew over a neighbouring filthy pond upon the troops of the United States cantoned there, that it commenced with great violence immediately after the wind began to blow on them, and moderated and almost ceased on filling the pond with earth.* 
Sir Gilbert Blanc draws a similar erroneous conclusion. He observed the yellow fever arise on board of ships precisely in the same circumstances that give rise in northern regions to typhus fever. He therefore attributes them to the same cause, and ascribes them both to the contagion of typhus. He therefore calls the yellow fever typhus icterodes; that is, typhus with yellowness ofthe skin. 
It is admitted that they are produced by the same cause. But we know that yellow fever arises in company with cases of common remittent fevers, with intermittents, with diarrhoea, with dysentery. We know that intermittents and dysenteries do not proceed from contagion of typhus, but can be produced with a plenty of water, in very hot weather, on any spot where vegetable matter is to be found; and when in full operation-, destroyin 'hose subject to the action ofthe agent thus produced, the 
•Transylvania Journal Vol. 1, p. 345. 


Cooke on Typhus Fever. I 
117 
whole can be controlled by carrying off or covering up the water. We know that they proceed from miasmata. Therefore also does yellow fever; and the specific contagion of typhus fever is unnecessary to account for any effect observed, and is therefore imaginary. 
Blanc endeavours to obviate this argument by alleging that the yellow fever produced by miasmata, and that on shipboard, are different diseases. But this attempt is a desperate one. For, it is evident that even on shipboard miasmata abound, not only from the quantity of vegetable matter on board and the Kh temperature of the holds of ships, but from the occurrence •c of diseases known to be produced by miasmata on land. 
Moreover the yellow fever produced on board of ships is not to be distinguished from that arising on land. The physicians from the West Indies who were in Philadelphia in 1793, and subsequently in other cities in other years, acknowledge the identity of the yellow fever of our cities with the yellow fever of the West Indies; and Blanc himself destroys his own allegation by admitting that the yellow fever of Philadelphia of 1703 was the real yellow, fever, alleging that the contagion was carried to Philadelphia from the West Indies. 
This point is however settled by the occurrences on board of the two ships Hankeyand Calypso at Bulama. There, on shipboard, arose the yellow fever, together with dysentery, intermittent fever &c. The latter we know, as has been stated frequently, arise from miasmata, because we can produce them at any time in hot weather with sufficient water, and remove them by carrying off the water in any way. Therefore as these diseases and yellow fever arc evidently produced by the same cause, even to the satisfaction of both Trotter and Blanc, at least on that point, the typhus icterodes is also produced by miasmata. 
Notwithstanding the strength ofthe evidence on this subject, rendering it evidently impossible that the remote cause of typhus fever can be a specific contagion produced by the bodies of those who are suffering under this disease, there is a case of great notoriety which has been confidently represented 16 


118 
Cooke on Typhus Fever. 
Us settling the question of the -contagious nature of this disease. The case alluded to is that of the sickness which occurred during the sessions at the Old Bailey in London in 1750. A few years ago no one could argae this question without being 
told of this case, and it is still occasionally mentioned. It is however very remarkable that the bare facts of this affair show that, whatever else might have been the cause, it could not possibly have been contagion. 
The court sat in a room crowded to the utmost by great numbers who were attracted by the desire of hearing the trial of an officer, who was charged with murder in consequence of having killed another in a duel. The trial continued all day. The house was very close, as it was cold weather though in May, a cold piercing wind blowing at the time. In a short time the air of the house became excessively N offensive, as is very common on similar occasions. 
In this state of things a number of persons, viz. the Lord Mayor, the judges and jury, and some other persons on the left hand of the Lord Mayor were, a few days after, taken ill, and a number died. Those on the right of the Lord Mayor escaped. The body ofthe people were not affected. This sickness was, and is even now by some, confidently ascribed to contagion introduced by prisoners awaiting their trial in the house. 
To this it is objected, I, that the prisoners are known not to have been sick; it is expressly so stated: 2dly, the persons affected were twenty-five feet from the prisoners, and those who were nearest to them were not attacked : 3rdly, it is known that even the contagion of small-pox cannot affect a person at that 
distance. 
These are circumstances which are totally inconsistent with the nature of contagion; and if we look a little into some others, 
we may find little difficulty in explaining the manner in which the disease was produced. 
It Iras been mentioned that the crowd rendered the air ofthe house very offensive. In consequence of this, a window was raised on the left side of the house. It was a wide one and the air was piercing. The judges on that side faced this window, 


Cooks on Typhus Fever. I 
119 
and the cold air blew immediately upon them. Therefore they, being next to the window and receiving the full impression of the cold air in a heated state, suffered; while those on the other side of the house, and the people below, over whose heads the wind blew, escaped. This explanation of the cause is given by Bancroft and is perfectly rational. But whether it be received or not, although such effects would at anytime almost inevitably follow such exposure to cold in so heated a state as these men were in, it cannot be believed that contagion from people who were not sick, produced disease, not in those close 
to them and almost in contact, but in those who were at twice the distance which would secure them from the contagion of 
small-pox. 
his lastly proposed to make some observations respecting the treatment of typhus fever. Little or nothing can be added to what has been already said on this subject in the essay on autumnal fevers in the first volume of this journal.* The following 
case will perhaps be considered interesting, on account of the quantity of medicine required to move the bowels. The symptoms were those of what has been called the typhoid type 
of fever, and manifestly indicated that the patient was fast progressing into full formed typhus; and there is every reason to believe that if the disease had not been arrested, he would have died with the most aggravated symptoms of typhus fever. During the present winter a member ofthe medicatclass hadi an attack of fever, and after a fortnight's continuance under the care of an able physician, was apparently recovering. Ho however suffered a relapse; and in consequence of some other engagement of his physician I was desired to visit him. 
He had fever, with something of a hurried manner of speaking; but nssAfciag very remarkable in the symptoms. He was 
surprised at the proposition to purge him, but submitted. He took several cathartics of aloes, calomel and 'rhubarb daily, without much effect. He was after several days observed 
? Transylvania Journal of Medicine &c. Vol. I, p. 377 to 384. 


Cooke on Typhus Fever. 
120 
to be s6mewhat delirious, his tongue acquired a black colour,-and he had some subsultus tendinum. , 
In this situation, having had no passage from three very large doses ofthe medicines above mentioned, his room-mate was desired to give him a drachm of calomel and a drachm of scammony at once. He did it with great apprehension* but found him manifestly benefitted by the operation that followed. He took for a week or ten days following, from half a drachm to a drachm of each of those medicines daily, and recovered per-fectly, with an extraordinary appetite, without one particle of any other medicine. 
I shall close this subject with expressing entire conviction that more patients will recover by the use of cathartics alone, provided they be so managed as to operate in (he way proposed, viz. so as to produce consistent passages, than by any other mode of treatment whatever; and that the most unsuccessful practice is that which excludes cathartics altogether) relying on tonics and stimulants) 
On the subject of regimen nothing has been said in the essay on autumnal fever; and therefore a few observations here will not be improper. 
Sick persons should unquestionably be kept in a well ventilated room, but a current of air should not be allowed to pass, over them. This may be effected without difficulty, by suspending a curtain in such a manner as to turn aside the air flowing into the room through a door or window. It may be done very conveniently, even when there is a strong current of cold and damp air, by letting the window curtain hang down in such a manner as to direct the current to the floor, entirely below the level ofthe patient in bed. In this way, even in winter, the cold air may be let in to ventilate the room* while the tempera* ture is kept up by a fire. 
The air of the room should be of a moderate temperature^ such as is agreeable to people in health. The patient ought not to be covered with more bed-clothes than is agreeable to him. 
The patient should drink only when he desires i^ and hit 


Cooke on Typhus Fever. 
1 2 1 
drink should be of the temperature most agreeable to him. Cold water is in general most desired. Some object to the use of it while taking calomel. I will only state on this subject the result of my observation* In twenty-five years I have never debarred a patient from the use of cold water and ice in fever", notwithstanding the use of calomel; and have never seen one instance of evil arise from it. I have had patients who took a drachm of calomel at once, and ate ice all day after it, (and this more than once,) who were not salivated at all, and who suffered no perceivable inconvenience from it, but recovered a perfectly good state of health in a short time. My family has coiv sisted of fifteen or twenty persons, almost every one of whom has in the same season taken calomel, and used cold water at pleasure without ever asking a question about it, and without any known evil consequence. 
The patient should never be urged to eat. His appetite being gone and digestion impossible, to eat is to introduce into his stomach a mass to ferment and incommode him, sometimes to kill him. If he take any thing in fever, it should be well made chicken-water, or a similar fluid made with becf&c. but absolutely without any flour to thicken it. When the patient is kept from eating and purged in the way above mentioned, day by day, without interval, he will have almost invariably within twenty four hours ofthe time when his passages become natural in colour and smell, a good appetite. He ought then to have a nourishing diet, mild that it may not excite him, and fluid that it may pass easily along and not oppress him; such as mush and milk, soup with a little mutton or any tender meat well boiled. / 
/ 


AN ESSAY ON CHOLERA INFANTUM. 
It is proposed in the following essay to give a brief view of the pathology and treatment of Cholera In fen turn. Correct pathology is necessary to successful practice; and although many valuable papers have been written on this subject, it is thought that medical writers have too easily admitted a variety of agents as remote causes of this disease, and have not sufficiently turned their attention to that one which alone is the cause of its prevalence as an epidemic. This disease moreover is so extensively prevalent in the South and West, that it is a subject of prime importance,, particularly to young practitioners just entering upon the theatre of life, to have a clear conception of the remote cause chiefly operating, the internal derangement thereby produced, and the most effectual mean* of removing it and the symptoms arising out of it. To these three points the attention of the reader is particularly invited. 

This disease has been attributed to teething, to eating fruit, to worms> to cold, and to heat. 
That the process of dentition cannot be the cause of this 
epidemic is evident from the following considerations. l,ChhV dren are teething throughout the year, while cholera is almost entirely confined to one part of it ; 2, Many have it in the season for its appearance who are not teething; some before the process commences, others after it is over. This process is however very irritating, and no doubt contributes, when conjoined with the principal cause hereafter to be mentioned, to increase the fever present in this disease. 
Eating freely of the fruits which abound in summer, has no 


123 
better claim to be considered the cause of this epidemic Cholera Infantum is more fetal in cities where fruit is comparatively scarce, than in the country where children eat as much as they please. In a family in which I practised for a number of years, the successive children were all affected with cholera, notwithstanding that there was the utmost pains taken to keep them from fruit. On the contrary, my own family has suffered very little from this disease, although the children have been allowed to eat as much fruit ha they pleased. For some years we occupied a house, the garden of Which Was an acre of ground containing a great variety of fruits in abandonee, to which five small children, white and black, had every year free access, and commenced on the currants, gooseberries, plumbs, &c. before thfey were ripe. 
Fruit and other articles of diet, frequently of the most simple and nutritious kind, such as are totally 3 incapable of producing disease, and such as the child has in numberless instances used with the greatest advantage, are often charged with producing cholera. But when acidity and vomiting or purging take place after eating sach things, it is an evidence of the derangement of the stomach previously subsisting. It 
is in this case as in dyspepsia; eating some acescent article of diet is often charged with producing the disease, whereas the acidity and eructation are the consequence ofa morbid condition of the stomach, without which the food would have been digested as formerly. 
It is not intended to say that some fruits have not a laxative Operation on the bowels of children: but this, when produced, is no more the cholera, than a like operation produced by magnesia. In. both cases, if the child he at the time in health, no other symptoms of cholera are produced than the disturbance ofthe bowels, and perhaps of the stomach: the internal derangement, the effect of the remote cause, out of which the symptoms spring, does not here exist. If the child be at the time under the influence ofthe remote cause of cholera and ofthe internal derangement resulting from it, fermentation is apt to take place in a mass of acescent food, because the stomach is 


124 
disordered; but in consequence of this disorder not appearing until after the food is taken in, the latter is erroneously supposed to be the cause of the disease. Cholera has likewise been attributed to worms. In many cases however it is certain that none of these exist in the bowels: and in others in which they were present, the disease has continued after they have been expelled. There is another reason however, which operates with equal force against the pretensions of all agents which are present at every period of the year. The disease is epidemic in one season only, and therefore must be the effect of some cause then arising, 
Cold has no better pretensions to be considered the cause of this epidemic, which is especially a disease of hot weather. Cold may even be managed so as to benefit a patient in cholera. In certain circumstances it increases the symptoms by co-operating with the principal cause in increasing that internal derangement from which they spring; but cold alone never produces such an epidemic. 
Excessive heat has also been considered as the remote cause of cholera. But although it is unquestionably true, that hot weather is the season in which it is epidemic, it is to be observed that this disease is not always most prevalent in the hottest summers. The summer of 1 821 was, in the upper part of Fauquier county in Virginia, after July, uncommonly hot and dry, insomuch that tlie grass and even the Indian corn was burnt up; it was nevertheless uncommonly healthy. The same occurred in Minorca in the year 1749. The drought according to Cleghorn was so great that the harvest failed; in some parts "they scarcely reaped as much corn as they had sown." At the same time it was excessively hot in Juue, and "the weather there had seldom been felt so excessively hot and sultry as this year in July; the quicksilver rising daily above the 80th degree of the thermometer, and never falling below the 79th, even in the •night-time, till the rains which fell in the latter part ofthe month had cooled the air."'* The medium height of the mer- 
*CJcghoru's Obs. on the Diseases of Minorca, p. 117. 


125 
4 
» 
• 
cury in the thermometer was in July of this year, about one degree and a half greater than it had been in the six summers Cleghorn spent in the island. But notwithstanding this excessive heat, he says tt in June and July there were some specimens ofthe summer diseases, but so few that' they scarcely deserve to be called epidemical;"* while in the preceding summers, one of which was not as hot as usual, the cholera was very fatal. 
There is evidently therefore something more than heat necessary to the production of this disease. What this is may readily be discovered by attending to the circumstances in which the disease appears in different situations. 
With this view let us minutely examine the state of the weather in the different years that Cleghorn passed in the island of Minorca. I know no work which contains so exact an account ofthe weather and diseases for so many years in succession, as the valuable work of that writer on the diseases of that island. 
The following table represents the state of the weather and the diseases in each year from 1744 to 1 "M 9 inclusive. The quantity of moisture in the first four months is stated separately from that in the second four, because the latter has more effect on the epidemic of the year than the former, in consequence of falling in the warm weather. The figures and fractions under the head of temperature represent the medium heat ofthe weather during the months of June and July. 
•Cleghorn's Obs. on the Diseases of Minorca, p. 134.. 


120 
Moisture in the Ist 4 months. 
Much rain till tlu> middle of April. 
18 days of rain a of heavy rain 1 of floods of rain. 
'24 days of rain 5 of heavy rain, 5 of floods of rain. 
hot till 
September, but afterwards 
very cool. 
77 3-31 
23 days of rain, 10 of heavy rain, 
18 days o' rain, 3 of heavy rain, 6 of floods of ruin. 
extreme- 
ly hot from 
May till the mid•Ue of 
1 of 
Hoods of rain. 
September. 
77 10-31 
40 days lldavs extreme- 
of rain, of ram, |i\ hot 15ofhea- loi hea- j and sal- 
ty rain, v> rain, try in •2'of 3 of July ioodl I floods of 
Mf rain. rain. I 77 |C>-3l 
14 days [In May, June dry 
of ran, June, k | and very sof hea- Jolj, 10 I hot: July 
vy rain, I days«j| I seldom so 2o( j rain, 4 I extrenie- 
to Klsof heavy r'n ly hot k r»n. 3 floods sultry of rail 78 12-31 
Great drought ; short harvest 
>o. 
in the td 4 months 
very dry. 
13 days of rain 1 of hea- ' vy rain 
6 of floods of rain. 
13 days of rain, 5 of floods of rain. 
I CIUjK> raturc. 
July not as hot as usual. Au gust very hot and sultry. 
hot and sultry. Au trust exces- 
sively so. 75 14- 1. 
the middle of 
Diseases. 
Cholera began in the end of June. Tertians numerous in July, but not so universal or malignant in Aug. and Sept. as they commonly are. Dysentery began after middle of Sept. and was general k malignant 
"June was scarce ended when the tertian fevers and cholera morbus began _ increasing daily according to custom, came to their great est degrecof frequency in Se >. from which they gradually declined"— a 
"Thecluncough hid no 'sooner disappeared than a j>eriodicai lever accompanied with vomiting ti:id purging took its piace, which : roved alike fatal to many children during the summer." In July the tertian fevers broke out as usual, and their violence being augmented by the rxcc«?ive heat of the season, many "tr-nns died, tec. the cool weather in Sept. prevented their becoming so .-enerdl or continuing so Ion;; as common. 
"The extraordinary heat of May ushered ill the summer diseases somewhat sotfner than usual : for about the end of that month, the cholera morbus carried oh" many children, and in June the tertians becan.i" universal: besides towards the end of June the diarrhoea dysentery and tenesmus broke out and raged violently for some weeks." 
The summer proved very unhealthy to the children, many of them dying of cholera morbus and :>erioilical lever, kc. The tertians began in July and finished about the end of November. Dysenteries prevailed in C'iudadella 
C leghorn left Minor- a early in August, "to June and July there were some specimens of the summer diseases, but so few thuf they scarcely deserve to be called epidemical" 
1744 
1745 
1746 
1747 
1748 
174!' 


rj7 
• 
These statements from Cleghorn show in the clearest manner, what was before admitted, thai heat is essential to the prevalence of cholera as an epidemic. Thus, it does not commoace until the hot weather of June and July in general; end when the weather is unusually hot e;trlicr in the year, it makes its appearance earlier, as in the hot mouth of May 1747. But it likewise shows that heat, though a circumstance essential to the prevalence of this epidemic, and therefore to the existence ofthe cause of it, is not itself the cause. It will be observed that the medium heat of June and July in the years 1746, 1747 and 1748 is almost the same, the highest and lowest varying only half a degree, and that of 1749 is nearly a degree higher than the highest of them; vet we find that the latter was much the healthiest of all these years. It was even much more healthy than the year 1745, in which year the medium temperature of the two months June and July, was very nearly 
three degrees lower than in 1749. 
The same statements show also what additional circumstance is necessary to the production of this epidemic. The different years mentioned differ not so much in heat as in moisture. Though the former differs but little, there is a great difference in the latter; and on comparing the different summers together, we find that the wettest were the most sickly. Thus, 1748 was somewhat cooler thnnl 749, but much wetter and much more sickly; and 1745, considerably cooler but much wetter than 1749, was likewise much more sickly. Furthermore, when we compare those vcars that were both hot and wet, we find the cholera in proportion to both: thus the year 1745 .\as hot arid wet, and sickly, but the three following years were hotter and wetter and more sickly in proportion. 
From these facts, it is evident that cholera infantum depends on some cause arising out of this combination of heat and moisture; and when this is considered in connexion with the additiona] facts which appear on the face ofthe above statement, viz. that cholera and tertians prevail together in every year; that when one appears earlier, the other dors also; both in tin sequence ofthe earlier appearance of that f omhi; alior of Ik at and moisture whirli produce* them both, H in 17 17; a' d b;-'ly that when there is a considerable deficiency of moi-ture, neither 


128 
tertians nor cholera are very prevalent, notwithstanding the heat of the weather is extreme, as in 1749, it is very evident that they both depend on the same remote cause arising out of this combination of heat and moisture; vis on miasmata. 
The opinion that heat alone is the cause of cholera has perhaps derived its chief support from the authority of Rush, who says "Its frequency and danger are always in proportion to the heat of the weather." We have however shown from the best authority, for such Cleghorn certainly is, that the frequency and danger of this disease are not always in proportion to the heat of the weather. This observation of Rush's is the result of his experience in Philadephia ; and it is conceded that in that city the rule holds good. It is to be observed however, that the very same is true respecting the prevalence of the autumnal fever in that city ; it having been ascertained, from observation of the thermometer during twenty-five summers, that in that city the "grade and frequency" of autumnal fever is always in proportion to the same circumstance, the heat of the weather. It has however been ascertained from a multitude of observations in all parts of the world, that autumnal fever is not caused by heat alone, but by miasmata proceeding from vegetable matter undergoing decomposition; aid the reason of these diseases seeming in Philadelphia to depend on the grade of heat alone, is that there i&a large body of marsh near it, from which, whenever the temperature of 
the atmosphere is high enough, miasmata in abundance are evolved. This dependence of the two diseases on the same state of the weather in Philadelphia tends directly to the same conclusion, that cholera and autumnal fever are produced by the same remote cause, miasmata. A variety of considerations eoifirm this conclusion. 
The cities of the South are more subject to the ravages of cholera infantum than those ofthe North, as they likewise arc to autumnal fever. Those cities, which, from their low and marshy situation, are remarkably subject to fevers, are also to cholera. In cities, those parts most favourable to the production of fevers, such as narrow dirty alleys, and filthy suburbs in the neighbourhood of marshy inlets,, brick-yards, standing water produced by regulating streets, &c. are also 


129 
most productive of cholera infantum. If a city by draining, cleaning, &c. be preserved from the former disease, it is likewise freed from the latter. The town of Winchester in Virginia, is situated on a level spot which was originally marshy, and still has a stream of water running through it. In process of time the marshy grounds have been filled up with earth, the bed of the stream has been made deeper and wider, so as to carry off a much greater quantity of water than it formerly did, and the whole town has become drier and cleaner. In consequence of this change, the town has become much more healthy. I have been informed by several females who have raised families there, that some years ago great numbers of children died with bowel complaints. Of late years however comparatively few cases of this disease occur. In one quarter however, in consequence of some regulation of the streets, a pond was made; and a considerable number of cases of feVer and of cholera infantum occurred in the immediate neighbourhood ofthe pond. It was filled up with clay, and there has been little or none of either since that time, in that quarter. 
This disease appears also in the country in places favourable to the production of autumnal fever; as about mill-ponds, near water-courses, marshes, and low grounds. Country air is recommended by city physicians in this disease; and it is an advantage to children, if the air of the place to which they are Carried is purer than that of the city. But if the place of retreat be near marshes, the infants are not benefited by the change. Dr. Rush tells us that of the only three patients he ever lost, of those who were sent into the country, two had Hben carried into the impure air of the marshy neck below Philadelphia. 
In cities in which autumnal fevers annually prevail, children are in such danger from cholera, that great numbers are carried into the country, to spend in a pure air the time during which the autumnal fever prevails; and they cannot betaken back with safety until that time be- past. If they return during that period, they are in danger of an attack of cholera, or of a relapse, just as those adults who return prematurely are from an attack of fever. 
We have seen from Cleghorn's statements that in the island 


ISO 
of Minorca, cholera and tertians appear together in the same situations, and circumstances of weather; that which produces, hastens, or delays the one, producing, hastening, or delaying the other. It appears further from the representations of the physicians of Philadelphia, that the variations in the weather produce the same effect on the grade of the two diseases. Dr. Rush, in bis inquiry into the cause and cure of this disease, states "that since the prevalence of the yellow fever in Philadelphia after the year 1793, the cholera infantum has assumed symptoms of such malignity as to require bleeding to cure it. In some cases two or three bleedings are necessary for that purpose." It will be remembered that for about ten years after 1793, the autumnal fever was also more malignant than it had been for a long time in Philadelphia, in consequence ofthe great heat ofthe summers of those years. Dr. Jackson, in his account of the malignant or yellow fever of 1820 in the same city, says " In the past summer and autumn diseases assumed the general symptoms which they possessed in the former epidemic period of 1 793, 1 797, and 1798. Cholera morbus and infantum were very prevalent; bilious and remittent fevers from which our city had been for several years nearly exempted, were common diseases; and dysentery*, which had become a rare disease in Philadelphia, was of frequent occurrence, and very difficult to manage."* 
It has been objected that the same cause cannot produce both cholera and autumnal fever, because the former appears somewhat earlier in the season than the latter. 
It may be observed in reply, that the tendency ofthe argument, founded on the appearance of the fever and cholera m the same situations and in the same kind of weather, is to show, that both depend on a common cause arising out of those circumstances; and, that the force of the objection rests on the presumption, that, as the fever appears later than the cholera, the cause; of the fever could not have existed when the cholera commenced, or it would likewise have produced the fever. The truth however is, that miasmata, the cause arising out of the circumstances above mentioned, are produced before either 
*Phil. Jour. Med. and Phys. Sci. 2. 31 P. 


131 
autumnal fever or cholera become epidemic. The firef warm weather produces an evolution of gas from moist and filthy spots. It is stated by Dr. Jackson, in his account of the fever of 1820 in Philadelphia, that bubbles of air were seen constantly disengaging from the half-fluid mud in some of the confined alleys of that city as early as in May. I have myself seen the same even earlier in the season. The argument therefore is sustained, and the force of the objection falls before the fact, that the cause of autumnal fever exists before the appearance of cholera infantum; while the dependance of both on the same cause, miasmata, is shown by the correspondence of both, in the number of cases and in grade, with the increasing power of that cause, as the season advances, or when it is hotter, or when it comes earlier than usual. 
The correctness of this view of the subject is further shown by the occurrence of autumnal fever in some children, precisely such as also occurs later in the summer, at the same time that others have cholera, showing manifestly at the earlier period the presence and the operation of miasmata. 
We inquire next into the nature of the internal derangement produced by this remote cause. 
The cause of this epidemic being the same with that which produces autumnal fever, the operation on the system must be the same, and the inter, ml derangement the same. This we have shown in a previous paper* to be an accumulation of blood in the vena cava and its great branches; and that it exists in cholera infantum is evident from the symptoms observed in the disease. 
It is strongly indicated by the pale and bloodless appearance of the little patient, as well as by the shrunk state of the surface generally, particularly observable in the Ftollowness of the eyes. It is manifestly the cold stage of the disease, and although there is not often a chill observed, yet it is sometimes manifest. The following passage is taken from my note-book. " This fall (1821) our bilious fevers have almost all been intermittent; and I have distinctly observedin the children in cholera,a 
•See p. 24, &c, 


132 
stretching accompanied with coldness, which may well be called a chill." 
This state is also evinced by the fact that this disease is almost universally accompanied by fever. We indeed often find the patient cool and pale; but there is notwithstanding, a regular evening exacerbation. Dr. Rush on the subject 01 cholera says" It sometimes begins with a diarrhoea, which continues for several days without any other symptom of indisposition; but it more frequently comes on with a violent vomiting and purging, and a high fever." "The fever is of the remitting kind, and discovers evident exacerbations, especially in the evenings." Cleghom's testimony is of the same import. He says "Towards the end of June the young children are attacked with a vomiting and purging and periodical fever,&LC."* "The chin-cough had no sooner disappeared'than a periodical fever accompanied with vomiting and purging took its place," &c.t Fever being therefore almost universally present in cholera, and every fever being preceded by a cold stage in which the blood retires from the surface and consequently accumulates in the interior veins, this state of accumulation in the 
interior veins exists in cholera. 
The same accumulation is evinced also by the presence of its known effects on the head, stomach, and liver. 
The head is always more or less affected ; stupor or disposition to sleep is common; pain in the head, frequent; convulsion, and apoplectic symptoms not uncommon. 
The secretion of the liver is disordered: that gland is often Sensibly enlarged; there is sometimes an excessive flow of bile from it; at other times there is such an engorgement of the veins constituting the liver, that secretion is suspended, and the discharges from the bowels, when they are somewhat coexistent, are whitish or what is called clay-coloured. 
The disordered state of the stomach is likewise the effect of the same accumulation, as will appear from the following coisidorations. 
From the able experiments of that great physiologist, Spalbv 'Sard, it appears that when the common articles of food are. 
immersed in gastric juice no fermentation takes place, care 
•Clefchorn's Obs. on the Dis. of Minorca, p. 121, tlbid. p. 129. 


133 
being taken to preserve the vessel in which the experiment is made, in a proper degree of heat;* and that this fluid even corrects putrefaction when it has commenced in meat, &c. t When however, instead of the gastric juice, saliva or water was used to moisten and cover the mass, the experiment in every other respect being conducted precisely in the same 
way, "the mixtures began, some sooner and others later, to emit air-bubbles, which soon increased in frequency and size; the surface of the liquor was covered with froth, which continued as long as any air was generated. During this time the mass swelled greatly, the intestine commotion was manifest, and the substances immersed being made specifically lighter by the air-bubbles that adhered to them and the increase of bulk, rose to the surface of the fluid."! 
The conclusion is, that the gastric juice is that which restrains the disposition to fermentation, natural to the usual articles of diet in the situation in which they are placed, as to heat and moisture, in the stomach; and that when every mark of fermentation which took place in the experiment of Spallanzani, above mentioned, appears in the stomach, they must proceed, as in that experiment, from the absence of the gastric juice. 
The deficiency of gastric juice in this case is the consequence of the interruption of the functions of the glands which secrete that fluid, by the same engorgement of the vessels constituting them, that interferes at the same time with the secretion of bile. The accumulation of blood in the veins of the liver, cannot fail to extend to those of the stomach which pour their blood into them; and when therefore the functions of the former are interrupted, those of the latter ought also to be. 
The vomiting and purging result from the action ofthe fermented mass on the stomach and bowels, as well as from the increased sensibility and irritability of the alimentary canal, proceeding from the same accumulation in all the interior veins and small arteries entering into them. We know of no case in which the presence of an increased quantity of blood 
rlbid. cclvi,fcc. 
•Spallanrani's Dissertations, vol. 1, ccxxxvi. llbid. ccxxxiv. 18 


134 
in the small vessels of a part does not render it more sensible to impressions. The accumulation of blood in the interior, is the cause of another symptom in this disease; viz, the tumid state of the abdomen, notwithstanding the great discharges from it. These discharges themselves are another effect of the same cause. The load of blood in the liver and in all the viscera, producing an obstruction to the free entry of that fluid from the minute arteries into the corresponding veins, there is a great press upon every point by which a part of their contents may pass: those minute vessels therefore which carry off a transparent fluid to lubricate the internal surface of the stomach and bowels, not being obstructed by any thing in their course, now pour an increased quantity of serous fluid into the alimentary canal, which is ejected from them upwards or downwards according to circumstances. 
We have now considered the subject of the remote cause which produces this epidemic, the internal derangement resulting from its operation, and the symptoms arising out of it. We have seen that the remote cause is the same with that which produces the autumnal fever, that the internal derangement is the same, and the symptoms if attentively considered, will be found to be essentially the same. 
Cases of both cholera and autumnal fever in children, occur at the same time, and there is in both, fever with evening exacerbations and morning remissions or intermissions. 
In both, the head is affected with pain and stupor, and convulsions frequently occur. 
There is in both a want of appetite, nausea, and griping. 
In tbe autumnal or bilious fever, the nausea is occasionally attended by vomiting, and if a cathartic dose of calomel be given, the discharges from the bowels are green, dark, or black. 
In Cholera Infantum the nausea increases until it terminates in vomiting or purging of bilious matter and of a thin flu id, sometimes coloured by bile, sometimes without colour; and if a cathartic dose of calomel be given, the very same kind of .passages are produred as in the other case. 
Moreover, under a continuance of the mercurial cathartic medicines, those cases which commence with vomiting and 


135 
purging, even of a watery colourless fluid, lose their peculiar Symptoms, and assume those of the cases which did not begin with either vomiting or purging; insomuch that no one on the second or third day could possibly, from the existing symptoms, distinguish them, or say which case commenced with vomiting 
or purging, and which did not. The remote cause of cholera and autumnal fever being the same, and the \itcrnal derangement thereby produced being likewise the same, it follows that the same object should bo held in view in the treatment of both, vis. the reduction or re^ moval of the accumulation of blood, or congestion, in tbe interior veins, from which spring all the symptoms observed. This is effected by means of discharges from the liver. The commu-niCation between the branches of the vena portae, those of the venae hepaticae, and the biliary ducts, is so free, that if either of them be injected, the others will be filled. It is manifest therefore, that these ducts constitute an outlet from those veins, and consequently from the whole of the great interior veins; and that free and continued evacuations from the former will in the most direct manner lessen accumulation of blood in the latter. 
In perfect accordance with this view of the subject it will be found, that the main dependance for a cure of this disease is on purging, so managed as to produce evacuations from the liver, and continued daily, as in autumnal fever, until health be restored. The same consistent bilious evacuations are neressary in both: how to effect them, is the whole difficulty in those cases in which there is extreme irritability of the stomach and bowels, and the difficulty is the same in both children and adults: Cholera infantum is the same precisely with the cholera morbus of adults. The distinction implied in the word infantum is of late date, it is not used by Sydenham, Bocrhaave, Cleghorn, or Cullen. Sydenham mentions children being affected by cholera morbus. Cleghorn does the same in very many passages. Boerhaave in his Aphorisms, and Cullen in his First Lines, do not mention children at all in their account of cholera ; whence it is evident that they intended to include the vomiting and 
purging of children under the general title of cholera morbtuv- The recover? of the patient depend in«j upon a free discbarge from the bowels of dark-coloured, green, or yellow matter of . 


136 
Ihft consistence, if the passages he already of this description, they should be continued; and if small and griping, as they very often are, they should be rendered more free by a mercurial cathartic. Parents often attribute the weakness of the patient to the purging, but after a free operation, children feel much stronger. 
In treating this disease we meet with the same difficulties that oppose us in treating the autumnal fever, and all the combinations of cathartics, necessary in the latter, are likewise necessary in the choleva. Calomel and rhubarb in equal quantities, often operate in the most desirable manner: if they do not act sufficiently, jalap of* scammony may be tried instead of the rhubarb: if the passages produced by this compound be too thin and serous, a mixture of scammony or jalap, with rhubarb and calomel may be used. Calcined magnesia issome- Paes used to quicken the operation of calomel, but it is too apt produce thin passages. 
Five grains of calomel with the same quantity of either of the other medicines mentioned, is a suitable dose for children of eight or ten months. It will sometimes be found however that a number of such doses will be required in the day to operate freely ; and in all cases, the physician after having decided correctly as to the object in view, ought to effect it. 
The free consistent discharges being continued daily, they gradually approach to a natural state, in colour and smell, and when this takes place under the influence of mercurial cathartics, the child, perhaps invariably, shows every mark of return* ing health. 
We have thus far, in speaking of the treatment of cholera, had in view those cases in which the discharges are still bilious, as they very often are in the commencement. The physician however often finds that they have become, or have from the beginning been thin, serous and profuse. The child sometimes •ommences with discharges of this kind from the stomach, some' times from the bowels; and whether the one or the other be first affected, the other is soon disordered, and sometimes they are both affected from the beginning. 
In this case the object is the same, to procure as speedily at possible consistent discharges from the liver, and to continue 


137 
them. . Calomel is better adapted to the end in view than any known medicine ; inasmuch as it is weighty and the dose small in bulk, and therefore cannot easily be rejected ; and it is likewise, least apt of all the cathartics to produce watery passages, and most effectual in producing consistent discharges from the liver. Five grains of calomel every twelve hours, almost invariably effect the desired alteration in the passages in twentyfour, thirty-six, or forty-eight hours. This is so certain that, in critical circumstances arising out of difference of opinion with another practitioner, 1 have ventured to predict under the treatment proposed, with calomel alone, the passages would in fortyeight hours become black; and the prediction was verified by the event, although there had been no other than serous, colourless passages for many weeks. 
It sometimes happens that the calomel alone does not purge the patient: the thin discharges cease entirely, but no others appear. In this case it becomes necessary to add rhubarb, jalap, or scammony to the calomel. Five grains of one or other of these medicines with the same quantity of calomel, is the best prescription in this state of tilings. Rhubarb is preferable, being more like calomel in its action than either of the others; but sometimes it does not operate, and we are driven to the use of some more active medicine. Scammony is preferable to jalap because it nauseates less and is more active. 
As soon as consistent passages are established, the copious thin discharges cease: it frequently happens that not one is observed after the first consistent evacuation. After the passages become consistent and coloured, the treatment of the patient proceeds exactly in the same manner as if they had been so from the beginning; which case has been already considered. 
The proportion of calomel may be diminished after the coloured evacuations appear. If the quantity taken to effect the change have been considerable, it is sometimes prudent to omit the calomel entirely: but, if the passages become thin and watery in consequence of the omission, it is necessary to return to the use of that medicine. There is some risk of ptyalism; but 
it is better to run the risk than to let the child die. Ptyalism has never occurred but once in my practice in this disease: the 
« 


138 
case was an extremely severe one,' and I fully believe would have terminated in death under less active treatment. «* * 
The above-mentioned doses are of a proper size for children eight or ten or twelve months old. The youngest, even those of one or two weeks, take two or three grains of calomel with or without as much rhubarb; and I have even found it necessary to give scammony at that early age. 
The medicine failing to operate it often becomes necessary to repeat the dose in a few hours, sometimes till even half a dozen arc taken in one day; and in some cases, days elapse before a free purging can be established. In children, as in adults, the size of the dose necessary to act on the bowels differs very much in different cases; some of four or five months requiring ten 
grains of calomel. 
With regard to the time of giving the medicine, when the case is not urgent it is best to wait until bed-time, as it scarcely ever fails to qniet the bowels so much that the child sleeps, sometimes all night. So striking is this effect of a dose of calomel, or of calomel and scammony, tlu.l parents have very often inquired if there was not opium in the powder. 
Such is the relief often obtained in recent cases from the first operation, that the fears of the parents are c.uieted so entirely that they are apt to think it unnecessary to give another doee. The medicine must however be continued daily until the passages become entirely natural in colour, cosistence, and smell. 
In July 1816, 1 read Cheyne's essay on Atrophia Ablactatorum. I tried his doses of half a grain of calomel every^four hour*, and found them very often effectual, purging the patient well and bringing off green and black matter. Relieved, by the efficacy of these small doses of calomel, from the fear of producing ptvaslism, which had occurred in one remarkably obstinate case mentioned above, 1 ran into the very common error of using the prescription in every instance that occurred; but soon found there were cases that would not so easily yield. On inquiring 1 found the passages in these cases were not changed and that nothing green or dark had been discharged; and on increasing the dose of calomel, or giving a dose of scammorry or rhubarb and calomel, the proper operation was effected, the passages becoming green or dark, and by continuing the diecharge 


139 
the patient recovered. These small doses therefore are successful when they act on the bowels in the way above mentioned, and not without. There are indeed some slight cases in which they check the discharge for some lime, or perhaps entirely, and do not operate on the bowels in the way above represented as necessary. In these cases the recovery is not perfect, the child showing manifest marks of indisposition, and very generally relapsing in a short time. 
The diet may be any thing that the child desires and can retain. Milk and water sweetened, and thickened milk also sweet ened, are as proper as any thing else. Thickened milk is made by pouring into milk boiling briskly, a thin mixture of milk-and flour without lumps, and stirring the boiling milk while the mixture is poured into it, and for a short time after. 
Having found the course of treatment above recommended entirely successful for many years, a few observations will suffice with respect to other remedies. 
Bleeding is rarely strictly necessary, but blood might be drawn with advantage in many cases in which it is not attempted. Dr. Rush says in this disease children sometimes require bleeding two or three times. 
Vomiting has been often recommended, but I have very rarely used it. Though emetics have unquestionably been administered with advantage, they sometimes increase the watery purging: to be useful they should operate quickly. They are chiefly beneficial in driving the blood to the surface, and thus lessening the accumulation in the interior veins. Calomel which has so beneficial an influence in other respects, is often serviceable in this way likewise; and has this decided advantage over every other medicine operating in this manner, that the extension of its operation to the bowels is desirable. 
Blistering has been greatly commended, and no doubt has considerable effect in quieting the excessive irritability of the stomach. But this remedy also I have for many years laid aside, inasmuch as the object in view can be more pleasantly and certainly effected by the same remedies that are necessarily employed as evacuants. 
Anodynes are unnecessary. In an hundred instances, as was before observed, the mercurial cathartic given at bed-time has 


140 
relieved the disagreeable sensations of the child so perfectly that it has fallen asleep at once. Tonics I have never found necessary when purging was properly conducted. I formerly used them externally and internally, but with very little apparent benefit. When purging with mercurial cathartics is conducted as above recommended, the patient recovers appetite, colour, and strength so fast, as to render it obvious that tonics are unnecessary. In some cases however the child is excessively debilitated and emaciated when application is made, sometimes in consequence of entire neglect and sometimes of improper treatment. Even in these cases the same plan is the best I have ever tried. A few years ago I was called to see a child who had been for many weeks affected with this disease. She had been treated with every thing but calomel. She was excessively emaciated, so that 
the skin of her extremities could be folded around them: tenesmus harassed her, as well as repeated vomiting and purging, every day, of a colourless thin fluid. She took two grains of calomel which immediately vomited her: smaller doses were then given, half a grain at a time, with about a grain of prepared chalk or white sugar to give some bulk to the dose; of these she took five or six every day: they produced in the course of forty-eight hours black passages, as was predicted, a circumstance alluded to before: they were continued daily for five weeks, producing every day consistent discharges of various colours: the dose was found not always sufficient to purge, and she took on one occasion as much as five grains of calomel at once. She took no other medicine. Her recovery was steady from the beginning and perfect in the time mentioned: she became uncommonly fat and hearty. 


On the Use % of Cold Water in Fever. 
JL HE treatment of fever is a mbject of immense importance to the human race. Millions annually experience from this disease suffering of almost every kind; and even if saved from death, many are saved to experience the destruction of their happiness from the loss of friends, the derangement of their affairs, and the shattered state of body and mind often following the devastations of a febrile disease. The best mode of cutting short this terrible enemy of man, or of evading the force of the storm, has long exercfted the ingenuity of physicians; and it will not be questioned that he who shall devise the most effectual and the most agreeable plan of treating fever, will deserve well of his fellow-beings. It is not to be doubted that the plan generally pursued, or rather the principles now acted on in this country, when carried into operation at a sufficiently early stage of the disease, are very effectual in the relief of the sufferings of the patient, and in saving him from a fatal termination of them. Yet, the writer thinks, a powerful remedy has been too much neglected and even undervalued, although it is recommended as much by its pleasant effects as by its efficacy. It is proposed in the following remarks to show that the use of cold water in fever is an effectual, safe and agreeable remedy. 
This remedy, for it richly deserves the name, may be used with excellent effect either internally or externally. Its external use was strongly urged upon the attention of physicians many years ago by Dr. Currie of Liverpool, in his Medical Reports. His attention had been turned to the subject by some means, and he has gathered from many quarters, the strongest testimony of its good effects in fever; and made, himself, extensive trial of its effects with the roost happy result. 


On the Use of Cold Water in Fever. 
146 
In one of his early experiments he had eight cases of fever: on seven he tried the pouring of cold water and they all recovered: in the eighth case, for a reason given, he did not use the remedy and it ended in death.* A subsequent experiment was a very remarkable one.* A regiment quartered near him was attacked in June with the common epidemic fever of England. Dr. Currie was requested to give his aid to the surgeon of the regiment. He found fourteen patients in fever, of whom one was in the twelfth and another in the fourteenth day of the disease. There were a number of bad symptoms in the cases which had been on hand eight days or more; such as petechia*, pain in the head with stupor, low delirium and bleeding at the nostrils. There were afterwards other bases to the a* mount of fifty-eight in all. The cold water from the sett at the side of the fort was poured over the naked bodies of these men, and all recovered, except the two who had been sick, one twelve, the other fourteen days; and in neither of these cases was the remedy employed. They were supposed to be too far gone. In twenty-six of these cases the fever was immediately terminated by the remedy. And what is quite as remarkable is, that when the disease was in full progress, in the middle of June, the regiment was mustered and marched 
down to the sea-side, and made to bathe regularly for some time, with the effect of completely preventing any further attacks. There was not a single case afterwards.t 
The same practice was successful in the treatment of cases of fever in the Liverpool Infirmary. In a great number of cases the disease was cut short by the affusion of water on the first and second days; and several instances occurred of the same complete solution of the disease, when the remedy wa6 delayed until the third day, and even the fourth; but this was not common 4 
The following cases show the method of using the remedy and its decisive effects in fever. 
* ('time's Med. Reports, Vol. 1, Chap. 11. f Ibid. Chap. 111. + Ibid. Chap. V. 


On the Use of Cold Water in Fever. 
147 
A young man, 19 years of age, a pupil in the Infirmary, was attacked with fever. Dr. Currie saw him on the fourth day of his illness. He directed a bucket of cold water to be poured over him. This was at noon. The fever disappear, edand a profuse perspiration broke out. "At five in the afternoon he was again seized with feverish rigors, followed by heat, thirst and headach as before. An hour afterwards, the hot stage was established; his heat was 100 degrees, his pulse 100. The same quantity of cold water was again poured over him, and with similar effects. His pulse fell immediately to Bo, and became more full; his heat became natural. The following night he took twenty drops of laudanum and slept well." This was on the 17th of the month. 
"On the 18th at noon his pulse was 96 and soft, his skin moist, but a little above the natural heat. His tongue was a little furred, and his head ached: he also complained of thirst; the heat at the axilla was 100 degrees. The same remedy was again applied. He was greatly refreshed by it. The pulse fell to 90, the skin became cool, the thirst went off, and all the feverish symptoms vanished." 
"On the 19th his pulse was 88, his heat natural, the thirst and headach were gone, and his appetite improving. The affusion was repeated for the last time at six o'clock in the 
evening." 
"On the 20th his pulse was 78 and soft, his tongue clean, and his appetite further improved. He had still some remains of debility on the 21st, but on the 22nd he was free of complaint. This patient during his fever took no medicine but the effervescing mixture, the dose of laudanum excepted. The affusion was used four times." 
In another case, a woman 57 years of age "had the usual symptoms, headach, pain in the back and loins, and thirst: her tongue was furred, and her eyes heavy: her pulse 96, her heat 101 degrees. The affusion of cold water was performed at noon. In a few minutes afterwards the heat under the tongue was 98 degrees, the pulse 80." This was on the third day of the disease. Toward evening the fever re. 


148 
On the Use of Cold Water in Fever. 
turned with rigor and the usual consequences. As soon as the hot stage was established, the water was used, and the fever disappeared. The next day, in the fever, the water was again used twice, at noon, and in the evening; and on the third day the same was done, and the fever returned no more. " This patient used no other remedies but an enema, and after it an opiate every night." 
A man, aged 44, about 72 hours after the attack, with pulse beating 100, temperature 104 degrees, had pain in the back and head particularly severe. The water was poured over him, and in ten minutes, his pulse was at 90, temperature at 100 degrees; he was entirely relieved of the pain in the head and back; and was greatly refreshed. In the evening the exacerbation ofthe fever was severe, and the headach returned with violence. At four in the morning he used the remedy of his own accord, and at nine was in a gentle perspiration, the tongue moist, the pulse 84, the skin cool, and the pains of the head and back entirely gone. In the afternoon there was a slight return of fever, the affusion was repeated, and he had no return of fever. In another case with the usual symptoms of fever, the cold affusion was first applied on the 7th day, with the usual effect. The affusion was repeated the same day, and on the next, 
and on the third day the fever was completely removed. 
A young lady in the 7th or Bth day of typhus had three or four gallons of cold brine thrown over her at six in the evening, the time of the greatest exacerbation. To assuage the burning sensation of the hands and temples, those parts were frequently sponged with vinegar. The effects of the affusion were as striking as usual in the immediate relief of the symptoms; and on every return of the fever it was repeated, and on the 7th day she was entirely free from the disease.? 
Dr. Currie used at first fresh water, afterwards fresh water with vinegar, and lastly a saturated solution of sea-salt in water. Salt water, he says, is more refreshing to the patient, and he thinks safer. "Persons immersed in sea-wa- 
* Carrie's Med. Reports, Vol. 1, Chap. V. 


On the Use of Cold Water in Fever. 
149 
ter, and especially in saturated brine, for some time together, preserve the lustre of the eye and the ruddiness of the cheek, longer than those in fresh water, of an equal temperature, and such persons exhibit the vital reaction stronger when removed from it."* 
Some other cases stated by Dr. Currie are so very remarkable, and the writer from his own experience has such reason to credit them, that he is persuaded a condensed statement of them will be worth the attention of the reader. 
Dr. Currie was requested to visit a patient on the 12th or 13th day of his disease. He was sunk down in bed in low delirium, insensible to surrounding objects ; and had subsultus tendinum. His pulse was feeble and so frequent as scarcely to be counted ; petechias covered his body ; he was affected with diarrhoea, and passed his urine and stools involuntarily. His respiration was tolerably free ; he could take nourishment ; and his heat was steadily and considerably greater than natural. 
He was too weak to be taken out of bed, and therefore the surface of his body was washed with towels dipped in cold vinegar and water. Anodynes were used to stop the diarrhoea, and procure sleep. Yeast was also directed, a pint daily, with broth and gruel mixed with wine for his food. 
The exacerbations were marked by a deep flush extending over his face and neck. On every appearance of this symptom, his mother was directed to repeat the ablution of his body with vinegar and water. This was done eight or ten times in the twenty-four hours, and was always followed by abatement of febrile agitation, and generally by sleep. 
In forty-eight hours a dawn of recollection appeared, and the involuntary discharges ceased. In eight'days more he was out of all danger. t 
A boy of 16, of a healthy habit of body, after a few days of indisposition was seized with a long continued and very 
violent shivering fit, quickly succeeded b 
increase 
* Carrie's Med. Reports, Vol. i, Chap. VI. ? Ibid. Vol. 2, Chap. I. 
9ft 


On the Use of Cold Water in Fever. 
150 
of temperature- He had intense shooting pains in his head, sickness and oppression at the pit of the stomach, great uneasiness in the loins, extreme prostration of strength, and distressing soreness over the whole body. On the 7th day from the cold fit abov ementioned, his hearing had become very acute; his sight also; he was in a delirium, talking and singing loudly; his pulse was 120, his temperature 108 degrees; his skin parched and dry. Notwithstanding the high temperature he had complained of the cold air, and the cold water had not been used. In the condition just stated he was taken out of bed, at 8 o'clock in the evening, and a pailful of cold water poured over his body. He was greatly distressed at it, and wept bitterly, but being conveyed to bed, in a few minutes his pulse had fallen to 100, his heat was sensibly diminished, and his mind became calm and clear. He drank a glass of warm wine and water, and in about half an hour fell into a deep sleep in which he continued nearly eight hours. 
The next morning, his skin was moist and cool, pulse 96 and firm, thirst gone, pains removed, countenance cheerful, intellect composed and collected. 
In the course of the day he became feverish and his body was sponged with cold vinegar and water. He slept soundly and perspired gently that night, and awaked in the morning refreshed and free from fever. He soon perfectly recovered.* 
A boy of 11 years of age with the usual symptoms of fever, on the 4th day had cold water poured over him and repeated the same evening. It had the usual decided good effect. He used the cold water twice on the following day; and on the 6th day, while the nurse had stepped out, feeling an increase of temperature, he poured a pitcher of cold water over himself in bed. He was removed to a dry bed, slept soundly that night, and awaked in the morning quite free from fever. 
The only medicines prescribed in this case were the saline mixture and small doses of Columbo.t 
* Curries Med. Reports, Vol. 2, Chap. I. t Ibid. Vol 2, Chap. 111. 


On the Use of Cold Water in Fever. 
151 
This case and a number others were furnished by W. P. Dimsdale, M. D. of London, who says in his observations appended to the cases, that "in all, the good effects have been strikingly manifest, and in no instance has the disease terminated fatally after the use of this remedy." 
The following is too remarkable an account to withhold from the reader. In the month of May 1800, the Cheshire regiment, in barracks at Gosport, was attacked by the common epidemic of England, which spread rapidly. The sick were treated in the usual way for two months. " During that time thirty of the men were seized with the infection, and in few or no instances was the disease stopped by the emetics or antimonial sudorifics. The fever ran from thirteen to seventeen days, and in some cases to three or four weeks." — "The contagion continued to spread in spite of all our endeavours. At length we had twenty-five in the hospital together, in the different stages of the disease. 
"Finding none of the usual means successful in arresting the fever, I had recourse to the affusion of cold water; this was towards the end of July." In the first case in which the remedy was tried, the water was poured on the patient on the second day, with the usual good effects. "In the evening the fever returned; I threw the water again over him with the same happy effect. He had a good night's rest; the next morning he was free of fever, and he was dismissed cured, on the third day from his admission. 
"Pleased with this success, I immediately adopted the same practice in nine other cases of fever, from the first to the fifth day of the disease, with equal benefit. In six other cases, from the sixth to the tenth day of the disease, I followed the same practice: in three of these with complete and nearly immediate success, having used affusion only thrice with each." — "In the three other cases sensible relief was obtained, and they all recovered in the end, but the disease ran its course." 
Through the months of A ugust and September many newcases of fever occurred. "These were watched narrowly, the cold 


On the Use of Cold Water in Fever. 
152 
affusion invariably used, and in general on the second day. The effects were similar to those related of the case first mentioned; the success was invariable." In one of these cases the patient was taken to the hospital in the evening of the second day of the fever, "with the usual symptoms, but in the severest form. An emetic was administered, and the affusion deferred till morning. The emetic operated well, but his night was extremely restless, his headach particularly acute, and delirium came on with great violence. It was necessary to employ force to keep him in bed. In the morning of the 21st (the third day of fever) I found his heat had arisen to the uncommon height of 107 degrees, and his pulse was 125. The cold affusion was employed; he screamed from the severity of the shock; but, on returning into bed, he appeared much refreshed, was perfectly sensible, and said that he thought himself well. On examining about ten minr utes after the affusion, the heat was found to be 100 degrees, the skin moist, the pulse 110. He slept for nearly four hours in perfect tranquillity. In the evening the fever returned. The affusion was repeated with similar benefit. He slept the greater part of the night. Next morning the fever returned once more. The remedy was once more applied, and the disease was subdued. lie was dismissed from the hospital on the 29th." 
" From the end of July to the 31st of October, I employed the cold affusion in sixty-four cases. In sixty of these I arrested the disease, having seldom occasion to use the remedy more than twice or thrice, and in no one case more than four times. In the other four cases, (all of which are alluded to in the course of this narrative,) the disease being advanced, was not stopped by the remedy, though the patients ultimately recovered." 
This account was communicated to Dr. Currie by James Marshall, Surgeon of the regiment.* 
Dr. Currie received a number of statements from surgeons of the English navy who used this remedy in various parts of 
• Curries Med. Reports, Vol. 2, Chap. 111. 


On the Use of Cold Water in Fever. 
153 
N. 
? 
the world. Several African surgeons adopted it with success. Mr. Wilson, the surgeon of the Hussar employed it with extraordinary success in the treatment of the yellow fever which appeared on board that frigate in 1795. The sick were landed on their arrival at Halifax in June and placed in tents. —He bled generally iii an hour after the accession of the hot stage, then gave a solution of tartar emetic, and administered the cold affusion always in cases of delirium, which it immediately removed, inducing tranquillity and sleep. Of eighty-three cases Mr. W r ilson did not lose one. 
Mr. Magrath, surgeon of the Amphion, in a letter to Dr. Currie wrote thus: "I have now put this remedy to the test of accurate trial in upwards of an hundred cases of typhus, differently modified by climate and season and diversity of constitution, sometimes complicated with catarrhal symptoms and sometimes with affections of the bowels, not only in the English Channel, but in the Baltic Sea, and in the increased temperature of a southern latitude; and with invariable success. When employed in the first stage of fever, it frequently happens, that a single application is sufficient, and 1 have always observed, that it is more powerfully efficacious, in proportion as it is early resorted to, and that if neglected till the morbid catenation is strongly formed, the fever frequently resists the cold affusion for some time." The same gentleman wrote three years before this to Dr. Trotter on the same subject. He says in that letter, "Indeed, invariable success has attended my endeavours ever since I began to adopt this practice on a large scale.' I''l'' 
The following account of the treatment of the epidemic fever of the West Indies is very remarkable. 
The Ganges arrived at Port-Royal, Jamaica, on the 24th November, 1801, in remarkable health. A'malignant fever was then prevailing among the shipping: many of the merchantmen were nearly unmanned by it. Soon after her arrival it broke out on board the Ganges and spread rapidly. Mr. Nagle, the surgeon, determined to have recourse to the 
* Jtfedicina Naut. Vol. iii, p, 237. 


154 
On the Use of Cold Water in Fever. 
affusion of cold water. As soon as the morbid heat fairly indicated the accession of fever, he poured a quantity of sear water on the patient from the head downward; generally two or three bucketfuls. After the patient was put to. bed he gave him in general eight or ten grains of calomel and four or five of pulvis antimonialis, and a plenty of diluent drinks. When the water was thus used on the first or even second day it operated like a charm. All the feverish symptoms were removed and the patient fell asleep; and on awaking two or three passages from the calomel served to carry off every remaining irritation. Commonly the fever did not return; but if it did, the bathing was repeated as might be required. There were one hundred and twenty cases from November to July, in all of which the cold affusion was used, and two only were lost. One of these had been ill of a violent inflammation of the knee, and was in a reduced state when he was taken ill with the fever; and the other was of a weekly habit and consumptive tendency. In the last of the two the water was not used in the early stage of the disease.* 
The same mode of practice was followed with success in the 17th century in Persia, and in the 18th in Abyssinia.t 
Cases have frequently occurred in which the patient in delirium runs into the rain or jumps into the sea with the effect of entirely carrying off the fever and delirium. Dr. Currie mentions the case of Capt. S. of Liverpool, who in a delirium jumped out of his cabin window in the Irish Channel and was twenty miuutes in the Sea. He was taken up perfectly calm and speedily recovered.^ He relates also, on the authority of Morandi, physician at Venice, "That some sailors at Constantinople, in the phrenzy of the plague, have thrown themselves into the Sea, and it is said that on being taken out, they have recovered."! 
He quotes also a work of Dr. Cockburn, physician to the fleet about the beginning of the 17th century, in which the author says that such things frequently happen to sailors in 
* ( nrrie's Med. Reports, Vol. 2, Chap. IV. t Ibid. Vol. 2, Chap. V. t Ibid. Vol. 1, Chap. XVII. 


Cooke On the Use of Cold Water in Fever. 
155 
a delirium, and if they are not drowned, "they sweat plentifully and shake off their fever."|| Other cases of a similar kind are stated.lT He quotes the following from Monsieur Desgenettes. "An artilleryman, who had two buboes and an anthrax, (charbon) made his escape from the Lazaretto of lioulak, on the day of his being admitted, and in a violent delirium precipitated himself into the Nile. He was taken up about half an hour afterwards, below Embabeth, by the people of that village, and he afterwards perfectly recovered."* 
It seems scarcely necessary to say that this remedy ought only to be used when the patient has a hot, dry skin. Partial moisture which does not relieve the patient ought not to prevent the use ofthe remedy; but a free, general perspiration affords much relief and so reduces the fever, that the remedy is obv iously not called for when it exists-. Dr. Currie was near destroying a patient by the use of the cold affusion in the cold stage of fever ;§ and Dr. Ord was himself very nearly destroyed by the use of the remedy at an improper time, and in another attack was apparently saved by it when used at the proper period, viz. in the hot stage. He intimates plainly that he had seen many men destroyed by the application of cold water in the cold stage of the disease, but speaks in the strongest terms ofthe use of it in the exacerbation of the fever.t 
One thing should not be omitted. Dr. Curries experience convinced him that the use of this remedy is not forbid by the circumstance ofthe patient's being in a state of salivation, if that should be the case. In speaking of one of his first experiments, he mentions that he abstained from the use of the cold affusion in a case in which the patient laboured under ptyalism; and adds, "I was not then aware that this last circumstance formed no objection agaipst the cold affusion," &.c.% Dr. Ord, also, says, that in his own person while in salivation he employed it without injury.t Of the correctness of this the writer is entirely persuaded from repeated ob- 
1( urrie's Med. Reports, Vol. 2, ( 'hap. IV. Ibid. Vol. 2, Chnp. V. • • Ibid. Vol. % Chap. I. ¦f Ibid. Vol. 2, <hap. V. t Ibid. Vol. L Chap. 11. Ilbid. Vol. l.Chap. VII. 


On the Use of Cold Water in Fever. 
156 
servation of the use of cold water externally, as well as internally, not only without injury, but with manifest advantage. 
tSome physicians prefer the use of tepid water for the same rpose, and there seems to be an opinion that there is someing contradictory in the two modes of practice, and that the statements of those who use the tepid and of those who use the cold water, are inconsistent. This, however is not the case.. If water of the temperature of 92 degress or even less, which Dr. Currie calls tepid water,* be thrown over a patient in fever, his temperature must be lowered in two ways: first, by the positive abstraction of heat, inasmuch as the tepid water is many degrees lower in temperature than the patient in fever; secondly, by the evaporation which commences - immediately after the water passes from off the body, which is greaterafter the use of tepid than of cold water. 
Even if the patient be immersed in the tepid bath, the reyrluction of his temperature must go on rapidly until it will be reduced too low, if he be continued long enough in the bath; as the writer has often witnessed in boys in the heat of summer, when the water is quite warm. 
tThe truth of this is evident from the consideration that a in, at the temperature of 100 degrees or more, immersed a bath of 92 degrees must loose heat rapidly. There can be no question that his temperature will very soon descend to 98 degrees, the usual grade in health; and that nothing can prevent the reduction still lower, unless there be some provision of the living body to guard against it. There is a provision of this kind, so that it is a common saying that the living body is capable of sustaining its temperature at 98 degrees in every vicissitude of the temperature of the climate in which we live. This is in a great measure true, but must be qualified. The observations on which the rule is founded are all made on men immersed in atmospheric air. The rule te re fore only extends to those who are in this situation. It jst not be extended to persons immersed in a different flu- 
• Med. Reports, Vol. 1, C hap. IX, X, 


On the Use of Cold Water in Fever. 
157 
id, as water. There may be something in the nature of the latter fluid, which prevents the rule from holding good; and there is something. Thus, the air we live in conducts heat from the system very slowly; water does the same very rapidly. A man therefore would be disagreeably affected by \ water at a temperature at which in the air he would feel too 
warm. The heat of his body by the latter at 92 degrees, would not be carried off as fast as would be pleasant — by the former it would be taken off so rapidly as to sink it in a short time several degrees. Tepid water therefore as well as cold, reduces the temperature of the system and therefore may be used with good effect in fever, though it will not produce so immediate and striking benefit. It may, however, be sometimes used when it might appear hazardous to employ cold water; as when the patient is so low that a fear might arise that the latter would prostrate him irrecoverably. 
The internal use of cold water is likewise beneficial in the hot stage of fevers. It cannot be used to such extent as to put an end to a paroxysm so manifestly as the affusion of cold water over the whole external surface; but it is efficient in proportion to the extent to which it can be applied, and is the highest gratification a person in fever can enjoy. It would be easy to cite many instances in which patients who had been forbidden to drink cold water in fever, on having their longing desires gratified have fallen into a profound sleep, and have been greatly benefitted. And why they should not be, would be difficult to tell. Nature dictates to man the use of water as his common drink, and it issues from the earth for his use in all the habitable parts of the globe. The desire for it is particularly great when the body is heated; and children who cannot speak their wants, often show their eagerness for water by stretching towards it with cries, when it is brought near them. The desire for water is as great when the body is in the heat of fever, as when heated in any way, and should by no means be denied unless there be evidence of its bad effects. Of this there is none. AH 
91 


On the Use of Cold Water in Fever. 
158 
ages have used cold water in fever, and it has been rejected by a few only, comparatively speaking. Hippocrates says, " If any one is sick, he should use for drink vinegar and honey, in winter indeed warm, hut in summer cold ; and even water and honey, and water if he has much thirst." Galen, in commenting on this, says, " But seeing that fire is warm and dry, and On that account fever also, water, which cools the body and also moistens it, is greatly opposed to the nature of fever. And indeed fevers seem to be instantly extinguished by it when given at the proper time. This indeed has been abundantly declared in the books of the method of cure; but now also the sum of 
the matter shall be stated. When, therefore, there shall be a fever, with the strength continuing, you will not only not hurt if you give cold water, but you will greatly benefit the patient. The draught of cold water may be as full as the sick man is able to drink without breathing."* 
Hippocrates was mucht more backward in the use of this remedy than Galen. He objects to its use in pleurisies, preferring vinegar and honey, or honey and water, and now and then a little water. Galen, in commenting on this passage shows that his views were different. After reciting several things which cold water, Hippocrates says, cannot do, and which he conceived were necessary to be done in order to the cure, Galen says, " Nobody ever used cold water to effect these purposes. But nevertheless other physicians, and even Hippocrates, use it: but he less, they more freely. For because they, being led into error, use other drinks with bad effect, they fly back to water, which has no remarkable bad effect, nor indeed active power." — He attributes the bad 
•"Qinini autem ipnis calidus et sirens sit, atque ob id etiam febris, aqna fe- bris natnnt ruaxime rontrnria est, qua* corpus turn refrieerat, tnm humectat. Et sane ab ea tempestive data febres protinns extinpui videntur. Dictum sa- ne abnnde in libris rnethodi medrndi • sed et nunc rei summa dicetur. Qimm ersro febris fuerit, constantibus viribus, non solum non laedes si frisridaa dederis, vrrum it mapnonere proderis. Potio autem friinda? hujusmodi tanta sit copia, quantum fririd* aquae a-eeripse inspirando haurire possit." Opera Hippocra- tu Coi et GalenU Tom. XI, Fol. 30, 11. t "In hoc ersro exhibitionis «conu« baud est similis, ouod velis febrem CxHn- euere frigida affatin atque ad laborantu usque tatietaUm epota. n 


On the Use of Cold Water in Fever, 
159 
effects often observed, to the physicians, directing too much wine in the water of the patient —and relates the following anecdote. " When I was every day administering to a certain sick old man wine and water, one of these physicians being present and observing me dropping a very little wine into the water, smiled and said that the sick man did not drink wine, but only saw it; not properly understanding that the proportion of the mixture of wine and water which is given for pleasure, is one; and that which is administered for utility another."* He speaks of the improper use of cold water in the following manner. " But that the drinking of water in the beginning of the accessions, is injurious, (which he (Hippocrates) has declared in these words, but if a person shall drink it at any time when his feet are cold, it will hurt him much more in all these respects) is one of those things which are known and conceded by all. When therefore is water proper to be drank? When the sick person will use drink alone, refusing the fluid part of a decoction of barley."t 
Hippocrates, though cautious in the use of cold water as a drink in some diseases, as in pleurisies,! in others used it freely. He says indeed that "if any one use cold drink inconsiderately, it brings on spasms and a rigor;"! ana-tms we know to be true: but we know equally well that the considerate use will put an end to fever. In this respect it agrees, with all powerful remedies, which are injurious in some conditions of the system though beneficial in others. Hippocrates himself says, "In a bilious fever, which returns every day, and is accompanied by bitterness of the mouth and vomiting, and a heaviness in the lcins and legs, on that day on which 
# c " Qnum ieritur seni cuidam ssgrotanti quotidie vinum aquosum exhiberem, quidam ex huiusmodi medic is praesens, me vini minimum aquae ipsi instillan- tem contemplatus, risit, xrtrrumque vinum non bibere, sed duntaxat cernere dixit ; non sane intellieens mixtionis vini, quod gratia voluptatis datur, ad aquam, aliam esse symmetriam, et aliam ejus, quod ad utilitatem ministratur." 
t Ibid. Tom. XI, Fol. 103, 104. 
X This is taken from Hoffman, and no doubt is correctly stated, though from some cause his references do not aspee with the copy to which the writer has access. Hoffman. Opera Omnia, Tom. I, Fol. 469. 


On the Use of Cold Water in Fever. 
160 
the fever holds the patient he should take as much cold water as he will drink."§ 
In the treatment of typhus fever Hippocrates says, "In the first days let the patient abstain from the bath; anoint him with wine and warm oil in his bed; let him abstain from meats; give him thin and cold draughts." — "But if vehement thirst from the heat press him, when you have administered much drink, make him vomit, and do this two or three times. And when the heat continues, apply old linen dipped in cold water, to the part in which he says he burns most."* 
Celsus is very clear in his directions ort this subject. He says, " But if an ardent fever parches the patient, no draught of medicine is to be given; but he is to be* cooled in the accessions with oil and water, which are to be mixed with the hand until they become white; he is to be kept in that chamber in which he can breathe a free and pure air; neither is he to be stifled with much clothing, but is to be barely covered from view by the lightest. Vine leaves dipped in cold water may likewise be placed upon his stomach. Nor indeed is he to be harrassed with too much thirst. He is to be fed later, that is, after the third day ; and is to be well anointed before meat with the same.|| If an humour has collected in the stomach, he is to be made to vomit when the paroxysm is on the decline; then cold herbs or an apple should be given, something which is agreeable to the stomach. If the stomach continue dry, the fluid p; r: of a decoction of barley, or of wheat, or of rice, with which fresh fat has been boiled, is therefore to be given. But when the disease is at its greatest height, certainly not before the fourth day, when there has previously been a great thirst, cold water is to be supplied copiously, that he may drink even beyond satiety; 
and when the stomach and prascordia are now full beyond 
t "In febre biliora, quae hominem quotidie corripit, et oh hma rum. jnn^itur, et vomitio juncta,et ad Jumbos rruraque ea die qua febrls detinft, quantum guis bibere volet, aquam friuidaw sumere o|*>rtet." This is also fro Koffman, s.ime work, p. 471. * 'inporr.tef", of Internal Aifections, Chap. XII, 7tb Vol. of the work be- fore c noted. H Viz. Oil and water mixed as before mentioned. 


On the Use of Cold Water in Fever. 
161 
measure, and sufficiently cooled, he ought to vomit. Some indeed do not require vomiting; but use the cold water itself alope, given to satiety, as a medicine. When either is done, he is to be covered with much clothing, and so disposed that he may sleep. And generally, after long thirst and watchfulness, after complete satiety, after the heat is removed, sound sleep comes on, in which a great sweat is poured out; and that is a most prompt relief; but in those persons, however, in whom besides the heat, there are no pains, no swelling of the praecordia; nothing prohibiting, either in the thorax, or in the lungs, or in the fauces; there has been no ulcer, no looseness, no flux of the belly. But if any one in a 
fever of this kind coughs slightly, he is not troubled with vehement thirst, nor ought he to drink cold water; but it is to be cured in that manner in which it is directed in \>ther fevers."* 
This practice of the Fathers of Medicine was followed in succeeding ages, with little if any serious opposition until the commencement of the 18th century, when Boerhaave opposed the use of cold *vater in fever. He says, "The patient ought to drink plentifully of watery, soft, gentle, somewhat 
acid liquors, rather hot than cold, though he should covet the 
* '"-'ivero aniens febris cxtorret, nulla uiedicamenti danda potioest; sed in Ssis aocessionibus oleo et aqua refri rerandus est, qnse miscenda mann sunt, mcc albescant; co conelavi tenendus, quo inn I turn et purum aerem trahere possit ; nequc niultis vestirnentis stranxulandus, sed aduiodum levibus tnntum velandus est. Possimt c tin in super stom ichuin imponi folia vitis in aqua fri- gida tincta. Ac ne siti quidem ninii i vexandus est. Alendus maturius est, id est, i die tertio; et ante cibum iisdem perumrendus. Si pitiiita in stomacho coiit, inclinata jam accessione, voinere cogendus est; turn danduin frr-Miun olu viut nomtuu, ex iis, quae stomaeho conveniunt. Si siccus mane* stom a- chus, protinus vel ntisanaS, vel alica?, vel oryzae creator dandtis est, cum quo re- cen* ideps poctsj sit. < 'urn vero in suniino increinento morbus es(, utique non ante 
quartum diem, magna siti antecedente, friirida aqua copiose pracstandu est, Ht bibat etiam ultra satietateiu; et cum jam venter et praecordia ul- tra mod u in repleta, satisiaie refriirernta sunt, vomerc debet, i Qui- dam ne vomitum quidem exigent; sed ipsa aqua friujida tantum, ad satie- tatem data, pro medicamento ntuntiir. I'bi utrmnlibct factum est, multa Teste operiendus est, et collocandus, tit dormiat. Fereque post tantrum sitim et vu-iliam, post mult am satietutem, post infnctum c ilorem, plenus soiuims venit, per quern in.rens sudor effunlitur: MqiM praes«.ntissimiim auxiliimi estl sed in iis tamen, in quibus praeter anlorein, nnlli dolores, nullus nraecordiorura tumor nihil prohiben*, vel in thorace, vel in pulmone, vel in faacibos- non Sucus, non dejectio, non pronuviuni alvi fuit. -i ijiiis nul.em in huiusmodi fe- bre leviter tussit, is ne<;uc vehement! siti ronfli"tatur, ne<pie bibere aqaum fri- gidam debet; sed eomodo curundu- est, ao in ceteris fehribas pr iecinitur. w Cclsusdc Meditina, Lib. HI. Chap. VII, 2. 


162 
On the Use of Cold Water in Fever. 
contrary, as most times happens."* To this he was led by his theory, as is evident from the whole article, and from Van Swieten's commentary on it. But at this very time the use of cold water as a drink in fevers was so universal and was carried so far along the shores of the Mediterranean Sea, that the practice acquired a special name, Diata Aquosa. In Germany, too, some years later than Boerhaave, Hoffman was very decided in favour of drinking cold water in fever. He has an entire chapter on the subject, of eight folio pages. He attempts to demonstrate its utility from the structure of the body, from the nature of the blood, and from the experience of its good effects. He cites ancient and modern physicians 
as speaking in its favour. % He says Ramazzini spoke of the snow which fell on the 
mountains of warm countries, as a singular provision of Divine goodness for the health of the inhabitants. 
He quotes Alpinus as saying, "In continual, very burning fevers, all physicians are accustomed to exhibit large draughts of cold water, because it concentrates the native heat, so that the thirst and heat immediately cease; thence the whole body is strengthened, the disease is dissipated by the water drank, and generally the drinking of cold water excites the most profuse sweats, sometimes bilious vomitings, take place, ant ometimes copious discharges from the bowels, and it excites abundant urine It is wonderful how such a remedy overcomes these fevers. For these fevers are finished by the excretions which water excites."t 
In the treatment of Cholera Aretaeus directs "that it should not be suppressed in the beginning, but that the discharge of the vitiated humours should rather be promoted, by taking tepid water frequently in small quantities. 
Afterwards if the bowels are in pain and the feet cold, he 
• Boerhaave's Practical Aphorisms, 743. * "In continentibus febribus vehemcnter aestuosis, medici omnes largum po- tum aleidae aquae exhibere suescunt, quia calorem nativum concentrat, ut stntim inde sitis et calorcesset; roboratur inde totum corpus, aqua epota di- geritur morbus, et plerumque lnrpissiroos sudores frieidae aquae potus suscitat, nonnunquam vomitus biliosi faint, et aliquando per alvum copiosi profluunt et nrinara copiosam excitnt. Mirabile est, quomodo tale prnesidium has febre* cxpugnet. Nam excretionibus, quas aqua suscitat, hae febres finiuntnr." 


On the Use of Cold Water in Fever. 
163 
advises that the belly should be irritated by a warm ointment. But if bilious humours are discharged from the bowels, and a vomiting of bile still remains, with nausea, anxiety, loss of strength, he desires that two or three cups of cold water be drank to bind the belly, that the retrograde course of the humours may be prohibited and the burning stomach be cooled."* 
Caelius Aurelianus also advises in the Cholera that cold water should be taken at intervals. 
Alexander Trallianus prohibits cold applications externally, but writes that "drinking cold water suits better than any thing else, and may be drank a little at a time; if there is very great weakness, a little wine may be added." He says that "cold water is especially useful, if bilious matters are discharged from the stomach and the bowels; if the sick person has vehement thirst and a foul tongue; if the weather is warm, the sick person be a young man, ahd has used warmer things."t 
Hoffman speaks of his own experience thus: "We ourselves firmly testify ofthe very salutary effect of cold drinks in ardent bilious fevers, as they are called, in bilious synocha, and also in that catarrhal synocha, which in the past year raged here and elsewhere, likewise in the continual and double tertian, from our own long and attentive experience." — " \nd wonderful indeedit seems, why cold water, or any cold diluent drink, should powerfully promote sweating. But when every thing in the body is burning with internal heat, and the intestine motion ofthe sulphureous parts is most vehement, cold drink taken in not only moderates the same, but being 
* u Praecioit enim, ne in principio supprimatur, sed potius promoveatur hu- morum vitiosorum exitus, sorbendo aqaam tcpidam assidue, sed paucam. De- in si torqucntur intestina et pedes frie/escunt, alvum irritandam esse calido on- guento monet. Si autem biliosi humores per inferiora dejecti, biliosus tamen vomitus ad hue adsit, cum fastidio, anxietate, virium lapra, volt, ut frieidae aquae cyathi duo, ant tres propinentur, ad ventris adstrictionem, quo retroera- dus humorum cursus prohibeatur et stomachus aniens refrisreretur." 1 "Sed pota aqua friridn maximc omnium convenit, quae paullatim bibatur j si virium snmma imbecillitas, panim vini addendum." "Turn utilem esse fri- gidam, si biliosa per alvum et vomitum eperunttir ; si a eg er vehementer sitit et linyuam scabram habet; si aestas fuerit, aeger jnvenn et caJidiori victij rfrimum nstrj." 


On the Use of Cold Water in Fever. 
164 
warmed by the heat ofthe interior it relaxes the fibres and subcutaneous canals, so that a very abundant sweat breaks out. But this effect is greater and more certain, if refrigerants, acid and nitrous, are given at the same time .with a sufficient quantity of water."| "Wherefore we the more reprehend, and think reprehensible, that perverse custom of 
certain physicians as well as attendants, who, when a raging heat distresses the patient, in fevers, even in the exanthemata, the small pox, the measles, the scarlet fever, and also the synocha, wholly deny cold drink to the sick, and give them nothing but warm tea or coffee, cover them up and overwhelm them, moreover in warm beds. For they do nothing else with these things but increase the anxiety, waste the strength, bring on restlessness," tStc.t 
Cold water has also been used with excellent effect in dysentery. Hoffman says on this subject; "From which by analogy we may justly conclude that in that nearly allied bilious affection ofthe intestines, in which with almost intolerable tormina and tenesmus, bilious and bloody matters are very frequently discharged, cold watery drink is not less profitable, even for the same reasons. Of which very salutary effect of cold drink in dysentery, experience moreover very abundantly testifies. Thus Diemerbroeck, Obs. xxix, makes mention of a desperate dysentery cured by cold drink." He mentions another case from the same author and adds; "We ourselves testify from experience, that diluent drinks, 
t "Vosmet ipsi de siliiberrimo hoc potns fri idi effectu, in febribus sic dictis bihosis ardentibus, in synocha biliosa, nee non catarrhali ilia synocha, quae elapso anno hie et alibi grnsMta, item in tertiana continua et dupliei, ex lon- gn et attenta nostra experientin, confirm itius testamur." "fit min>m utique videtur, cur frigida aqua, nut frigidus alius diluens notu*, sudorem movent va- li.lc. Sed übi aestu interno uruntur in cor^ore cuncta et intestinus partium sulphurearum motus est vehementissimus, friiridus intus susceptus potus eun- dera non modo attemperat, sod et colore intcrius tepefactus, fibras et canales subentan^os laxat, ut sudor erumpat largissimus. T into matris vero et certius hie resnondct effectus, si sudicienti aquae quantituti indantur simul refrigeran- tia, ncida et nitrosa." t "Quo magis semper improba vimus et improbandum censemus, ilium perver- tum, turn medicorum quorundam, turn adstantium morem, gui urgente morda- ci aestu, in febribus, exmthematicisetiam, variolosa, morbillosn, purpuracea, nee non synocha, aegris frigidum potum penitus denegant, ac nisi calidum in- fusi thee, ;tut decocti caffee, concedunt, eosque praeterea tricliniis et lectis calidis inchidnnt atquo obruunt. Ifis enim nihil aliud officiant, guam ut anxi- etates augeant, vires exsolvant, inquietudines accersant ;" &c. 


On the Use of Cold Water in Fever. 
165 
as whey, milk and water, butter-milk, simple water, or the milder mineral water, (vis. aquam Selteranam, aut Swalbacensem,) have been especially advantageous in the dysenteric disease."* > 
Hoffman cautions against the use of cold drink when the interior of the body is in a raging heat and the body is bathed in sweat; when the animal (economy is greatly disturbed by vehement anger; when, with severe spasms and pains of the stomach and bowels in the paroxysm, there is coldness of the extremities, and hard and irregular pulse; when there are signs of internal inflammation; when the patient is very old* and when the strength fails from long continued indisposition; and when in women, especially from a defect of the natural periodic discharges of blood, there is a fear of a cachexy.t 
The testimony already adduced is sufficient to show the great advantage to be derived from the use of cold water externally and internally. Many physicians of this country are in the habit of allowing their patients cold water to drink, but the external use is not so common. A physician of Maryland, who was a few years ago Governor of the State, whose name is not now recollected, had experienced such advantage from a rather unusual way of exhibiting cold water in dysentery, that he published in the newspapers an account of his success, recommending its general adoption. He gave large injections of cold water. 
It would scarcely be proper after so many statements, to withhold the experience of the writer on this subject; as it might be inferred from his silence that the practice recemmended was taken up merely from reading. It shall b/; given 
* "Ex quibus jam recte per analogiam concludendum ; in iJlo cholcrico ad- modum amni intestinorum affectu, quo cum intolerandis fere torminibus ac te- nesmo, biliosa, et omenta dejicinntur ereberrime, non minus proacuam eats frigidum aquosum potum, easdem etiam ob causas. De quo saluberrimo effec- tu frigidi potus in d vsenteria, überius praeterea testator experientia. Sic D{- emerbroeck, Obs. XXIX, ateminit dysenteriae desperatae, potu frigido sana- tae." "Nos ipsi testamur exporti, dfluentes potus, ut lactis serum, lac lymph- •turn, ebutyratum, aquam simplicem, aut mineraletn leniorem, Selteranaal scilicet, aut flwalbacensem, in dysenterico morbo profuisse eximie." t The above extracts are all from the last chapter of the first vnlatae of Hoffmaa>« Work-. M 


166 
On the Use of Cold Water in Fever. 
in few words. In the severe epidemic of 1804, in Virginia, the writer was twice attacked, once, violently; the fever was accompanied by delirium. He used cold water freely at the same time that free evacuations were going on from the administration Of calomel and tartarized antimony. He administered it in many other cases the same year, and in every year from that time. His patients have never in the autumnal diseases been debarred the use of cold water and even ice, when their heat and thirst led them to desire them. They have used them at pleasure, and frequently he has sent a basket of ice to a patient whom he wished to use it. No evil has arisen from the practice; but on the contrary it has been so obviously useful that many who had great prejudices against the practice, have been led by observation of its safety in the case of others, to use it themselves when attacked; so that even those physicians, who, in the commencement of the discussion, which the adoption of the practice is sure to excite in most places, opposed the use of cold water even as a drink, have been compelled to allow it to their patients. 
His experience in the external use of cold water is not so great, though it has been considerable. Some years ago a stout boy of about four years of age sleeping in the room, waked him up by his groaning. On examination he was found to have a very high fever: his pulse was strong and the temperature excessively high. He was instantly washed from head to foot with a towel dipped in water, until he' became cool. In a few minutes he was fast asleep and had no return of the fever. 
A summer or two since, on visiting a sick lady in the country, an infant was observed by the writer, while passing through the room to the patient's, to have a very high fever and to show considerable marks of distress. His temperature was uncommonly high, his face very red, his respiration rapid and accompanied by a noise indicating great uneasiness. His father was advised to take him out of bed, place him on the floor and pour water over his whole body. He did 6o immediately, and on returning after conversation with 


On the Use of Cold Water in Fever. 
167 
the patient, he was observed lying at his case, cool, quiet, and amusing himself. 
In the autumnal season of 1826, there were so many sick in the town of Winchester, Virginia, in which the writer then resided, that he* would not leave the town. Those in the country who notwithstanding this refusal chose to depend upon him, were treated in the following manner. They were directed to use the cold affusion in the height of the fever and to repeat it at every return of the paroxysm, and to use the common cathartic remedies as usual. The epidemic was very severe; many died in town and country; and yet, of the patients treated in this manner not one died, although in one or two cases the fever was accompanied by convulsions. Finally, it is proper to state, that the writer has never seen any bad effect from the use of cold water externally or internally, during the use of mercurial cathartics. He is entirely satisfied from twenty-eight years experience that it does not in any way endanger the patient; that it does not render him more liable to be salivated; but on the contrary that in salivation it is advantageous to the patient to wash his mouth often, and his jaws externally, and to drink as freely as his inclination arising from heat, leads him to desire it. 




REMARKS ON SPASMODIC CHOLERA. 
JYo DISEASE has attracted so much of the public attention in America, within the present century, as the Cholera, except perhaps the winter epidemic, called in many places the typhus fever, of 1812 to '1815. The alarming manner in which it arrests its victims, the rapidity with which it runs its course, and the striking symptoms which accompany the death of the patient, fasten on the minds of those who witness them, and produce a strong sense of the uncertainty of life ; and the important questions, What is the cause of this terrible disease? and What is the best way of treating Hi are continually proposed to those who are supposed capable of giving satisfactory answers. In the 4th vol. of the Tran. 


Remarks on Spasmodic (Jliolcra. 
ifo 
journal the writer endeavoured to show that this disease arises in the same combination of circumstances which gives rise to our ordinary autumnal diseases.* This conclusion was drawn from the facts stated in the account of its appearance in various places in the neighbourhood of the Caspian sea, and on various rivers which empty into it. 
It appears that the disease commenced in 1830, in June. at a port at the southern extremity of that sea, and appeared at different points of the coast farther and farther north as the summer advanced, and broke out at its.northern extremity, at Astrachan, situated at the mouth of the river Volga, in the latter end of July, six hundred miles from the port at which.it commenced in June; and that it appeared at different points on the Volga and its branches, still more and more north as the summer advanced, commencing at Moscow in the middle of Septcmber.t The whole country around the Caspian sea is very flat and marshy, as well as the region through which the Volga flows. The disease was not a stranger in this region. It had appeared several times before 1830 at Astrachan. In the summer of 1829 it prevailed at a number of places on the Volga, and other rivers, and the manner of its prevalence, according to some of the statements, strikingly resembled that of autumnal fever. Thusat-Orenburg, on one of the rivers emptying into the northern end of the Caspian sea, the cholera appeared on the 26th of August. It increased slowly for a fortnight, but after the 9th of September more rapidly. From the 9th to the 25th of September there were fifty-seven cases; from the 25th to the 30th. seventy-five cas.es; from October Ist to the 21st, six hundred and fifteen cases; from October 21st to November 20th, three hundred and fifty-three cases; when it ceased entirely. This accords very much with the manner in which a common autumnal fever arises, increases and declines. The? district of country about Orenburg in which the disease prevailed. 
£ See Remarks, Vol. iv, p, 425., tjbid. Vol. ivj pp. 431 432. 


Hemarks on Spasmodic Cholera. 
17i 
was about two hundred and forty miles by two hundred in extent. It commenced, as above stated, in the latter part of August, and by the 23d November it was every where extinct. This is stated in the same sentence in which it is said thajt the disease continued in some places as late as the 6th of February* — which shows that there was very little of it after cold weather appeared. In this particular, its continuance in some places after cold weather, this disease is on the same footing with all the autumnal diseases; cases of Which not unfrequently occur in considerable numbers in winter.t For a more particular account of the prevalence of cholera in that region, the reader is referred to the remarks in the 4th volume of this journal.]: The conclusion drawn from the facts thus stated, that it appears and prevails in the same circumstances wtth autumnal fever, is most amply supported by a profusion of testimony on our own continent.. 
During the past summer it has prevailed at various places in which the different forms of autumnal disease annually appear — and those cities which have been frequently ravaged by the severest autumnal epidemics, have this summer and autumn suffered from cholera — and those parts of these cities which suffered most from the former, have experienced most from the latter. The reports of a number of physicians who visited the places afflicted in order to ascertain the cause of the disease, afford evidence that it arose in low, filthy and damp places, precisely in such circumstances as are most favorable to the production of fever. In Montreal the part of the city most afflicted was extraordinarily dirty, and low and wet; and one of the statements represents the appearance of cholera as a common occurrence in that town. In the city of New- York, the low, wet and dirty parts of the town, where the yellow fever formerly raged, were most afflicted. Philadelphia, Baltimore, Washington City, Alex- 
*Ibid. p. 430. tSee Cleghorn's Dis. of Minorca, pp. 138, 242. tlbtd. p. 425, &.c. Rush's Acct. of the fevers of Phil. 1794, 95, &c. 


Remarks on Spasmodic Cholera. 
173 
andria and Norfolk, all of which places formerly suffered from yellow fever, and often from severe autumnal fevers, were afflicted with cholera; and the latest accounts represent the mortality as very great in the towns on the Mississippi. 
The disease has also appeared along the rivers, on the canals, and at many places near small streams and ponds. The steam-boats on the western waters have suffered severely. It is stated that some have lost near thirty persons in running from below to the upper country; and that as many as three have died in the short run from Cincinnati to Louisville. Many boats on this account were laid up. 
In passing through a part of Virginia in which autumnal fevers are frequent and severe, the writer found that the cholera had made its appearance in places well adapted to the production of the former. On the canal near Harper's Fer- . ry, on the Maryland side of the Potomac river, a considerable number of deaths had occurred from cholera. At Halltown, a very small village ou a sluggish stream in the rich low grounds of the Shenandoah, the disease had taken off a . number of persons; as many as five in one house, the garden of which extended down to the banks of the stream. At Leesburg also,and in its neighbourhood, on Goose-creek, there were several cases. 
These fac's show that the disease appears in places suitable to the production of autumnal fever, . while its appearance at the very season in which the latter prevails, shows thnt the one arises in the same combination of circumstances that give rise to the other. 
The common cholera is one of the forms of autumnal disease, all of which arise, prevail and decline, under the influence of the very same circumstances. Not only dd^they arise and decline together, but one form of autumnal disease may and often does, spontaneously, change into another; and all of them can readily be made to assume one form by proper treatment. Thus, diarrhoea, dysentery, or cholera, may easily be made to assume one form, in which the patient is 


Remarks on Spasmodic Cholera. 
173 
discharging bilious matter daily, and the distinctive signs are so entirely lost, that no one can distinguish the patient who commenced with cholera from him whose first symptoms were dysenteric; nor either from him who had no other symptoms from the beginning but those of bilious fever. 
The appearance of these different forms of autumnal disease under the influence of the same kind of weather, has been long observed, as well as their changing from one to another, in the same illness. Cleghorn says, " About the time when the tertians begin, the Cholera Morbus, Rash, and Essere, become frequent and epidemical in a lesser degree." After mentioning also diarrhoeas, dysenteries, and tenesmus, he says, " There seems to be a near alliance amongst all the diseases above mentioned. Those who have the rash or essere, to a great degree, are very liable to tertian fevers; on the other hand, in the paroxysms of tertians, these cutaneous eruptions are apt to break out. The Cholera Morbus sometimes hath its regular periods like a tertian, as the paroxysms of tertians are frequently attended with a cholera. Sometimes a tertian is changed into a dysentery; or a dysentery becomes a tertian; and when one of these diseases is suppressed, the other often ensues;" &c* He says, "June was scarce ended when the tertian fevers and cholera morbus began; and increasing daily according to custom, came to their greatest degree of frequency in September; from which time they gradually declined, and seldom appeared after the winter solstice."t This was in 1745. In 1747, he says, "The extraordinary heat of May ushered in the summer diseases somewhat sooner than usual. For about the end of that month the cholera morbus carried off many children, and in June the tertians became universal. Besides, towards the end of June, the diarrhoea, dysentery, and tenesmus, broke out and raged violently for some weeks."{ 
It is evident from these considerations that cholera is a form of autumnal disease dependant upon the same circumstances, 
*CJeghorn's Diseases of Minorca, p. 123, and 158. tlbid. p. 127. Jlbid. p. 130. 21 


174 
Remarks on Spasmodic Cholera. 
and therefore produced by the same cause as autumnal fevers. In the past summer and fall cholera has been uncommonly prevalent through the country; and preceded that grade which has been called spasmodic cholera, in places in which the latter made its appearance; showing the presence of the cause which commonly produces cholera and other forms of autumnal disease, in the very places in which spasmodic cholera appeared. The cases of cholera, moreover, for weeks before the appearance of spasms, were remarked to be very severe, and to require uncommon efforts to save the patient; and when at length the cases of cholera with spasms did occur, it was found impossible to distinguish in the commencement between those cases in which spasms afterwards appeared and those in which they did not. And as when the proper mode of treatment is adopted in the commencement, spasms do not appear, there is ground to conclude that the appearance or non-appearance of spasms, in severe cases, depends upon the treatment, and not upon any difference in the nature of the different cases. 
The identity of the spasmodic cholera with that which is commonly unattended by spasms, is further shown by the fact, that the former when arrested in its course by the use of calomel, like the latter is converted into a bilious fever: that is to say, that the patient, in those cases in which there is every reason to believe that he is rapidly advancing to the spasmodic state, and even in those in which spasms have occurred, by the simple change of the passages from a thin and light coloured or transparent fluid to a green or black viscid substance, produced by calomel, often by a single dose, is placed in the condition of a person in ordinary autumnal fever; insomuch that the two cases cannot be distinguished by a person who sees them for the first time after the patient in cholera has been brought into the state spoken of; and the one has as good a chance for ultimate recovery as the other. 
It may be alleged that the spasmodic cholera seizes the patient in some cases, without the least warning. This however cannot be received as true without clear testimony, and 


Remarks on Spasmodic Cholera. 
175 
there is good reason, in the very nature of the affection, to believe that no person can arrive at such a pitch of disease without such previous symptoms as plainly mark a state of congestion, which is certainly present in every case of cholera. It is certain that of those who have been equally exposed to the cause of cholera, some have had the diarrhoea, — which has been called a premonitory symptom, but which is more properly a symptom of the disease itself — while others have had fulness of the head, numbness ofthe hands, and other symptoms indicative of the operation of congestion on the brain. The former is of so marked a character that it is not easily mistaken — while the latter are easily confounded with uneasy feelings, frequently experienced. When therefore the former appear, the patient is said to have premonitory symptoms; but when they do not, though the latter are present, he is said to be without them. 
It may be supposed that the state of collapse in cholera makes an essential difference. The writer has not been able to perceive any difference between this state of the patient, in this disease, and the state of one who is dying of congestive bilious fever — that is, autumnal fever in which the congestion is so great and lie condition of the patient so prostrated, that he cannot be relieved from the one, or roused from the other. 
It has been said that the spasmodic cholera appears in all places and seasons, without regard to situation or weather. This is certainly not the fact. It has appeared in cold weather, in some places: but warm weather is the time in which it almost universally prevails. In Moscow it is stated to have prevailed in the winter: but as above stated, it commenced in that city in September. Its occasional prevalence in the winter, is, however, no objection to the doctrine, that the agent which causes it is produced in warm weather. The same may be said of the common autumnal fever, and of every epidemic disease which depends upon hot weather for its origin. The epidemic disease which formerly ravaged Europe, then called the plague, almost uniformly commenced in 


176 
Remarks on Spasmodic Cholera. 
warm weather, increased with the increasing heat of the season, was most severe in hot dry summers in the moist countries of England and Holland, and declined at the approach of winter.* And yet this disease occasionally prevailed in winter. Cleghorn in his account of the diseases of Minorca, after attributing the fevers of that island to the hot weather, and the uncommonly early appearance of the fevers in 1747 to the uncommon heat of the month of May, says that the same fevers appeared in winter.t Dr. Rush mentions that the severe autumnal fevers of Philadelphia sometimes appeared in the winter. And every practitioner of experience in this country has met with fevers in the winter not to be distinguished from those which he treated in the preceding fall. It is evident therefore that the occurrence of cholera sometimes in winter, is no objection to this disease being produced by the same cause which produces autumnal fever. 
As to its appearance in mountainous regions, there is no testimony for it known to the writer. An attempt was made to show that the disease was carried to Orenburg from some towns on the sea ofAral in Asia, by the caravans which passed thence to the former city. The route lay through the mountains of Persia, but it could not be shown that the disease had existed in this mountainous country. The disease appeared at Tirllis in Georgia, which is high up in the country from the Caspian sea, but it is situated on a river — and when it was prevailing to a very serious extent in this city, the inhabitants retired to the neighbouring high grounds, and the disease soon ceased among them. -^ 
It is sometimes asked, if the same cause produces both bilious fever and spasmodic cholera, why should the latter prevail more especially at the present time, and so generally? Whatever force there is in this objection, operates just as much against the doctrine that the other forms of autumnal disease are all produced by the same cause. We conclude 
•Ses a paper on this subject in the 3d Vol. ofthe Tran. Journal of Mcd, p. 553, tDis. of Minorca, Chap, vi, p, 238; 2d edition, London. 


Remarks on Spasmodic Cholera. 
177 
that intermittents and remittents, dysentery, diarrhoea, and cholera are all the offspring of the same deleterious agent, for three reasons. The first is, they all appear in the same season, are aggravated by increase of temperature, and decline in moderate, and cease for the most part in cold weather. The second is, that those who are exposed to the same combination of circumstances, to the same marsh air, or even to the foul air produced in the narrow compass of a ship's hold, experience the different forms mentioned; some having one and some another, and sometimes every form which can be mentioned being at once exhibited in a single ship's crew. The third is, that while these different forms are prevailing, the same individual is often affected first with one and then with another of them. Thus one will have a remittent; and afterwards an intermittent; and finally perhaps dysentery; or the reverse. And some may commence with cholera and end with fever, and the reverse. These things are unquestionable, and have long been observed and recorded by medical writers of the most established credit.* Dr. Cullen argues in the following manner, for the identity of remittent and intermittent fevers. "For those which are called remittents, arise from the same origin as intermittents, viz. marsh miasmata; both rage together epidemically, in the same places, and at the same time of the year; both are cured entirely by the same remedies; and very often the self-same disease which is seen in the same man, one while exhibits the form of an intermittent, another while of a remittent. These diseases, therefore, being perfectly alike in their cause, in the cure, and in their form, are not to be separated under different orders or sections."t 
Dr. Pringle uses the same argument to show that fevers and dysentery are of like nature. He sdys, "The bilious disorders begin about the decline of summer, and become epidemic in autumn, appearing earlier and more genera], 
'SeeCleghorn's Dis. of the Island of Minorca, the whole 2d chapter: also Chap, iii, p. 158. rCulleni Synop. Tom. 2, p. 46. 


Remarks on Spasmoilic Cholera. 
178 
and with worse symptoms, in proportion to the heat of the season, and to the moisture of the ground and climate. Although of different forms, they are of a like nature, and may be reduced to two heads, viz. fevers and fluxes."—" The heat and moisture of the air appear to be no less the chief remote and external cause of the dysentery, than of the autumnal remitting and intermitting fevers," &c. — " Hitherto we have seen how similar the causes are of the remitting and intermitting fevers, and of the bloody flux. Nay, the affinity extends even to the occasional or exciting causes. For in the end of summer, or in autumn, when any number of men are exposed to night damps and fogs, especially after a hot day, or lie upon wet ground, or in wet clothes, part of them will be seized with that kind of fever, and part with this flux; and perhaps a third sort will have a disorder compounded of both. Add to this, that those fevers begin to be frequent in camp whilst the dysentery still subsists; that the first symptoms are often similar, such as the rigors and disorders of the stomach; that the remitting and intermitting fevers of a more malignant kind have sometimes ended in a bloody flux; that such countries as are most subject to these autumnal fevers, are likewise most liable to the dysentery; and that the analogy continues even as to the method of cure, in so far as the principal part of it consists in clearing the prima? viae. Upon the whole, the nature of the two distempers appears so much alike, that at first sight Sydenham seems to have expressed himself justly, when he called this flux, 4 the fever ofthe season turned upon the bowels.'"* The sole difficulty in the way of his yielding his entire assent to this conclusion of his own argument, was the erroneous opinion that dysentery is contagious. This not being in our way, we must conclude with Sydenham, and with Pringle, hut for this error, that they are the same disease, differing only in unessential particulars. 
The passage already quoted from Cleghorn shows that the cholera also arises in the same circumstances with fever and 
•Pringle's Dis. of the Army, Part 111, Ch. iv; and Ch. vi, t 3. 


Remarks on Spasmodic Cholera. 
179 
dysentery, and that the same patient at different periods of the same attack has the symptoms of the different forms, and by the same mode of argument we arrive at the same conclu* sion, that this also is the same disease differing only in unessential particulars. The same is equally true of spasmodic cholera. The latter, it has been shown, arises in the same circumstances with autumnal epidemics, and is convertible into bilious fever. This rests not on the observation of one alone. It has been observed by many. Dr. Brown, of Sunderland in England, where the spasmodic cholera was very fatal, says in a letter to Dr. James Johnson and Dr. Tweedie, "In this sketch of the general progress of disease, during the autumn, I have classed together things which, because differing in name, are by many supposed to be essentially different, cholera and fever. The relation between these two genera of disease, is as close as possible. If a man is attacked with vomiting, purging, and collapse, and succumbs to these symptoms, he is said to die of cholera; if the disorder of the system is eliminated, as it were, by the discharges from the intestinal canal, he is said to recover from it; but if neither of these events occur, his state becomes one of fever, not distinguishable from that affection unpreceded by choleric symptoms. The first case which Dr. Daun saw, on his arrival here, he said he could not distinguish from typhus, — the discharges had ceased, and it had passed into the febrile state."* This the writer has himself witnessed. A patient in cholera who is successfully treated, is frequently brought into a febrile state, and while he lies discharging bilious matter, his case cannot be distinguished, by any marks known to the writer, from a case of bilious fever. 
This being the case, it is evident that th,e objection above stated, is as valid against the identity of any form of autumnal disease with the rest, as of spasmodic cholera. Though we are entirely convinced, from the identity of the cause of all of them, and from the identity of the morbid change 
*See Dr. Brown's letter in Vol. IV, p. 573, of the Tran. Journal of Med. <see. 


180 
Remarks on Spasmodic Cholera: 
wrought in the system, whereby they change from one to another in the same case, that they are all the same disease, 
differing only in unessential particulars, yet can we not say why in some years there are more intermittents than remittents, 
or in some years more dysenteries than fevers without dysenteric symptons, or in some more cases of cholera. 
It has been very generally supposed that the symptoms of spasmodic cholera are peculiar. This however is not the case. There is not one, that the writer has seen or heard mentioned, which has not occurred in other forms of autumnal disease. 
In all the forms of autumnal disease there exists congestion in the interior veins. In high grades of these diseases the congestion is very great. This interferes with the secretion of the liver and often entirely suppresses it. Absence of bilious discharges therefore is to be expected in all autumnal diseases of high grade, and is not by any means peculiar to spasmodic cholera. 
Congestion cannot exist in such degree as to suppress the secretion of bile without at the same time more or less affecting that of urine. Hence the latter is high coloured and scanty in autumnal diseases generally, and is sometimes entirely or nearly suppressed. This therefore is not peculiar to spasmodic cholera. 
The colourless discharges are not a rare occurrence. The writer has often had to contend with this symptom in autumnal fever. Cleghorn mentions it frequently in his account of the fevers of Minorca.* 
The colliquative sweats, with extreme coldness ofthe surface, the writer has also seen in autumnal fever. Dr. Lucas of Alabama, in his account of the epidemic of 1820 in Brunswick county, Va. says, " There was not only no increase of heat of the skin in those attacked, but a preternatural coldness; a cold, clammy and profuse perspiration overspread the body; &c. many, feeling perfectly well, would be 
?See pp. 146, 151, 157, 214, 224. 


Remarks on Spasmodic Cholera. 
181 
attacked, and in a few hours, and sometimes in a few minutes, would be in the most extreme state of prostration, without evident cause."* In the autumnal season of 1821 similar symptoms occurred in the commencement of the attack, together with a purple hue, in the neighbourhood of Centreville, near Alexandria, D. of Columbia, as I was then informed by Dr. Lane. Cleghorn also mentions colliquative sweats, with vomiting and purging in tertian fevcrs.t Many of the spasmodic twitches are very similar to subsultus tendinum, which is not an uncommon symptom, and the severer spasms have often occurred in autumnal fevers and diarrhoea.^ The purple hue of the dying and the dead, partial or general, perhaps every man of experience has seen in the close of congestive fevers. 
Holding these opinions, the writer has not seen any reason to depart from his ordinary mode of treating the disease. The first case of severe cholera he was called upon to treat during the past autumn, occurred about the last of August, or first of September. The patient was seized with vomiting in the night and next day was visited. He was then discharging from the stomach a .thin, colourless fluid; and from the bowels thin yellowish passages. He took twenty grains of calomel, and in a short time after thirty more, and before night forty more. The next morning no change having been discovered in his discharges, he was bled, the pulse being full, and took sixty grains of calomel. This dose was given every five or six hours, until he had taken four such on the second day. Every dose was given by the writer himself, in consequence of observing no change in the discharges. On the third morning, he took the same quantity of calomel, and was bled a second time, the pulse being full. At 12 o'clock no change having occurred* or rather the discharges having become more colourless, he took the same 
•Ses Med. Recorder, No. 19, p. 420. iCleghorn's Dis. of Minorca, pp. 157, 158. 
tBee ct. Cartwright's account of the Epidemic of 1822, in Monro Co. Miss. in the 98th No. ef the Med. Recorder, p. 666- 


Remarks on Spasmodic Cholera* 
182 
dose. In the afternoon he was found discharging a fluid entirely transparent; showing that the calomel had not yet acted on the liver, so as to produce any visible effect. The writer had for many years relied on calomel alone to produce the desired effect of free secretion of bile. He had never before seen sixty grain doses fail, and believes he never saw 
any occasion to repeat the dose, the first having always accomplished the object.* In the present case it was obvious that this dose was insufficient, and by the same process of reasoning which had formerly led him to increase from twenty to thirty, to forty, and finally to sixty grains, he was now led to conclude that he must increase the quantity, or let the patient die. He was still warm enough, but looked badly, and his countenance shewed great anxiety. In this situation he took one hundred and twenty grains at once. 
In the morning he was discharging thick black matter from the bowels. His stomach was perfectly quiet. He took sixty grains of calomel, and in the forenoon twenty small aloetic pills. These kept up a tolerably free discharge of black matter. 
The next morning (the fifth) he took the same. The sixth he took the pills alone. The discharges having become rather light coloured, he took, on the seventh morning, the calomel again, sixty grains, and the same number of pills. On the eighth, the discharges being still thick and dark coloured, end quite copious, he took twelve pills without the calomel. On the ninth found him out of bed — gave him no medicine. On the tenth found him easy in his bowels, and with} good appetite, and the same forenoon he was in the streets. He took no medicine but what is here mentioned. During the whole time, be took, at pleasure, ice in small bits, and thought it contributed greatly to check the disposition to vomit. He was not salivated in the slightest degree. 
This case clearly indicates that the cause of cholera was acting with unusual force in the production of that disease. 
•See Remarks on this subject in Vol. IV of Tree. Med. Jew. pp. 447,448. 


Remarks on Spasmodic Cholera, 
183 
Soon after the recovery of the patient, the writer went to the eastward, and on his return about the first of November, found that one or two deaths had occurred in Lexington with the symptoms of spasmodic cholera. There were five deaths only. The persons who died all lived or worked in the lower part ofthe town, or a little out of town, on the borders of a small stream. The cases were clearly marked. The patient in the collapse appeared as if inclined to dose, and yet as sensible of his danger, and answering questions correctly — sometimes roused by the spasms, or by the necessity of discharging from the bowels — the fluid bore a strong resemblance to rice-water — he was cold, with little or no pulse, and of a blueish cast over the whole body. One of the five cases the writer was called to, and saw him about four or five hours before his death. He had had diarrhoea two or three days — and had had frequent discharges and severe spasms for ten hours before he was visited. It is no reproach to the medical profession not to save a dying man. There should be no more surprise at the great proportion of the deaths of those who never call for assistance till the last moment, in cholera, than in any other form of autumnal disease. And who would expect to cure a person in bilious fever who had allowed the disease to progress until his pulse was gone, and the coldness and purple hue of death had seized upon him? It being evident that little or nothing was to be done in cases in which the disease had progressed so far as in the above, an effort was made, and very successfully, to turn the attention of the citizens to the first symptoms of the complaint. Hand bills were circulated by public authority, throughout the city, containing advice as to the symptoms by which the first approach of the disease might be ascertained, and as to the proper treatment. This advice was furnished by different physicians of the city, by request of the public authorities. The following was sent by the writer in reply to that request, and was published together with advice received from other physicians. 
" I have received your note requesting me to give you in 


184 
Remarks on Spasmodic Cholera. 
writing my opinion in relation to " the preventive treatment* of the cholera. I take it for granted that you wish to have such information as will enable the public at largo to judge of the approach of the disease, and to arrest its progress in 
any case in which its first symptoms may be observed. 
"The first indications of the disease are, disordered state of the stomach and bowels and often of the head, frequently overlooked by the patient; as want of appetite, costiveness, some uneasiness in the stomach or bowels, and dizziness or uncomfortable feeling in the head. These are common, however, to every form of autumnal disease. They may all be removed by a mercurial cathartic; to be repeated, if, during the operation, the discharges from the bowels are observed to be green or dark coloured. The common pills of rhubarb, aloes and calomel, much used in town, will answer this end as well as any thing else. 
"A further advance towards the cholera is the appearance of a looseness of the bowels in almost every case, not at all alarnrng to those who are not informed on the subject. This is the period of the disease in which the symptoms are so marked that the most uninformed can distinguish them; and it is the period in which medicine is sure to relieve, if given early. 
"The tendency of the disease is to more and more loose discharges from the bowels, of a lighter and lighter colour, until they become transparent or whitish. The appearance at last is such that they have been called, very generally t rice-water discharges. 
" The object of the patient should be to procure green or black discharges. If this be done he is safe. To effect this object, calomel alone has ever been my dependance: and I have never yet known it fail if given in due time and quantity. 
" Every one who has a looseness of the bowels at this season ought to consider himself as tending towards cholera. If neglected, he knows not how soon it may increase to such extent as at once to prostrate him. — My opinion is that 


Remarks on Spasmodic Cholera. 
185 
every person in this situation should take thirty grains of calomel at once. If the discharges do not become green or black in twelve hours, he should repeat the dose, and the same in the same case in twelve more. But generally the first will do. If so, the green or black discharges should be kept up for a few days, by the pills above mentioned. If however, after having taken the first or second dose of calomel, the looseness increases, he should increase the dose. It is best to double it, at once. 
"The discharges are to be observed closely. Some have deceived themselves and their physician by calling that an operation of the calomel, which was the mere discharge common in the disease. The distinction is in the colour alone. It is never the effect of the calomel, unless green or dark. 
"It is a common practice to add opium to the calomel. I am persuaded that the effect of this is often bad; and that it is never necessary in the loose state above spoken of — that is, never necessary in the "preventive treatment." 
" As your inquiry is confined to "the preventive treatment," I say nothing of the advanced stages of the disease; and the rather because in such cases the attending physician will of course direct. 
"If the Committee in their inquiry had more in view in their expression of treatment," than is supposed in these remarks, and looked to the conduct of persons in good health, it may be observed that the most powerful exciting causes of the disease are exposure to cold, to wet, great fatigue, late hours, intemperance in eating as well as drinking — and therefore that comfortable clothes, warm feet, keeping dry, avoiding excessive exertion of body or mind, retiring early to bed, and temperance in eating and drinking, are to be considered as preventives." 
These directions the reader will observe were intended to call the attention of the public to the first obvious symptoms, which no man could mistake, and to suggest a remedy which would effectually control them. Independently of the advantage of arresting, by this means, many cases in the early 


186 
Remarks on Spasmodic Cholera. 
stage of the disease, the attention of people was called to the true nature of the diarrhoea with which many werea£ 
fected, and advice was sought without delay. 
In these cases the patient was found generally to be discharging, sometimes very copiously, a thin yellow fluid from the bowels, without, for the most part, much uneasiness ornausea, and sometimes with some tendency to spasm. The object being to procure a free secretion of bile, calomel was resorted to as the best remedy. No effort was made by the writer to arrest the discharge by opium. Former experience had shown that less than sixty grains of calomel will seldom effect the purpose in ordinary cases of cholera, in this climate.* The experience of the present year, in the case above stated, had shown that this was not likely to be enough. The statements of physicians of high standing in Philadelphia, Washington City, &c. in their communications, indicated the same. They generally found themselves under the necessity of repeating the small doses they commenced with, until the patient had taken from sixty to one hundred and fifty grains in the day. Convinced, therefore, that ordinary doses would not be found sufficient, and urged by the fear of the increase of a disorder, the rapidity of whose course was not to be trifled with, the writer deemed it most adviseable to prescribe at once that quantity which it was likely the patient would be compelled to take in order to effect the object in view, a free discharge of bile from the bowels. He therefore directed in every case, except in one or two in which the patient was not pressed by the diarrhoea, one hundred and twenty grains of calomel at once. The effect of this quantity was in general to purge moderately, once or twice; the discharges being uniformly thick, and green or black. In some cases the effect was barely to arrest the diarrhoea. There was no further discharge for the whole day, and on the morning of the next, a dose of castor oil, or pills of rhubarb, aloes and calomel, as the patient pleased, being administered, 
•See p. 135, ike. and Vol. IV, p. 447, of Tran. Med. Joer. 


Remarks on Spasmodic Cholera. 
187 
green or black discharges followed. In some cases the patient would not take the whole advised, but preferred thirty, forty, or sixty grains. In these cases, perhaps in every one, the dose was repeated, sometimes more than once before a discharge was obtained, and the uneasiness and nausea 
continued, and sometimes was increased, as is not uncommon under the influence of insufficient doses. By repetition however, the object wa* effected, but it is believed never without the necessity of taking the full amount of the dose first recommended, and never so speedily and with such relief from the symptoms. 
As soon as this first object was effected, the patient was found to be, as before stated, precisely in the condition of one in bilious fever discharging the same bilious matter, and the case was thereafter treated precisely in the same way. That is to say, he was purged every day with mercurial cathartics in such a manner as to procure bilious passages, until the discharges became natural in colour, consistence, dec. This was effected by the pills above mentioned, and in some cases, by ordinary doses of calomel followed by oil in such quantity as merely to ca. » off the bile, and not to purge actively. 
The only case in which the patient was salivated under this treatment, was that of a young man who took a grain of opium with ten grains of calomel, a short time before the administration of the first dose above mentioned, of one hundred and twenty grains. In this case also, greater difficulty than common was experienced in moving the bowels day by day, after the discbarges became bilious. The salivation was not very considerable, however. But this slowness of the bowels is so often the result of the use of opium, that, in the opinion of the writer, it is not adviseable to use it when it can be dispensed with. How far it may be necessary in the severe pain of the spasms, he will not pretend to decide, not having had a case in which the disease reached that stage, except the one mentioned above, which he saw but four or five hours before death, after the spasms had ceased, 


? 
188 
Remarks on Spasmodic Cholera. 
and the patient was lying cold, blue, almost without pulse, and occasionally discharging the rice-water fluid. From the 
experience which he has had, however, (which at the same time he acknowledges to be comparatively small,) in the treatment of cases in that state in which without spasms of any consequence, the patient was purging freely, sometimes with vomiting, and sometimes vomiting without purging, he is entirely persuaded that it is, in such cases, unnecessary and injurious.