ARMY MEDICAL. LIBRARY WASHINGTON Founded 1836 Section' Number .. Form 113c, W. D.. 8. G. O. oro 3—10543 (Revised June 13, 1936) ^m A d^Jfc0^, TREATISE OF PATHOLOGY AND THERAPEUTICS. "—r~ BY JOHN ESTEN COOKE, M. D. 10FESS0R OF THE THEORY AND PRACTICE OF MEDICINE IN TRATS3Y* VAJJIJ UNIVERSITY. IN THREE VOLUMES. VOL. I.£ -/ LEXINGTON, KENTUCKY "1828." ADVERTISEMENT. It is but just to state that notwithstanding this work is published in Lexing- ton, the two first volumes (except the last forty or fifty pages) were printed in Winchester, Virginia, intheofficeof Mr. Samuel, H. Davis, to whose great 'care and attention I am indebted for the handsome dress in which they ap- pear. J. E. C. [C0py-IUGHT SECURED ACCORDING TO LAW -] TABLE OF CONTENTS. i - THE FIGURES DESIGNATE THE PARAGRAPHS, CHAPTER I. Introductory observations, 1—10; mode of investigating the ^ »subject 11—19; strictures on the theories of Hippocrates, Stahl, Hoffman, Boerhaave, 22—32; on that ofCullen, 33—36 on that of Brown, 37—39; on that of Rush, 40—46: observa- tions on the vis medicatrix naturae, 50—51; on the doctrine of sympathy, 52—78. CHAPTER II. Of the remote causes of disease, their mode of operating, and their effects on the system. The action of the heart measured by the pulse and the colour and temperature of the extremities, 81—83; remote causes of disease, 84; weaken the action of the heart, 85; abstinence from food a remote cause of fever, 86—87; produces weakened action of the heart, 88; fatigue a remote cause and produces the same effect, 89—90; external violence from a blow or a fall the same, 91; the depressing pas- sions the same, 92; want of rest or sleep the same, 93; stimu- lants of every kind used to excess the same, 95—96; strong tea and coffee the same, 97; intense application of mind the same, 98; cold reduces the action of the heart, 99—114; sudden death from drinking cold water, 115; Dr. Currie's opinion respecting this affection, with objections 117—127; Dr. Rush's opinion with objections, 128—129; proposed solution of the difficulty, 1.30—137; this effect of cold consistent with the general doctrine. 138; cold a remote cause of fever, 139. CONTENTS. ' CHAPTER III. The remote cause of the epidemics of hot weather, a dense gai arising from fermenting vegetable matter, 141—178; frequently attributed to exhalations from putrifying animal matter, 179— 195; to bad drinking water, 196; to the influence of clay lands, 197; to subterraneous water, 198—201; to moisture of the air, 202; to dryness of the air, 203—205; to a rarefied state of the air, 206; to the influence of comets, 207. CHAPTER IV. The same dense gas the remote cause of the epidemics of hot weather in the United States, the West Indies, and South Ame- rica, 211. CHAPTER V. 4 The same cause produces the epidemic diseases of Asia, of Africa, and of Europe, 447. CHAPTER VI. Answer to some objections by Dr. Ferguson, 535. CHAPTER VII. 4 Of the nature of the dense gas, the remote cause of the epi- demic diseases of hot weather in all parts of the earth, 582. CHAPTER VIII. Winter epidemics, called bilious pleurisy, pneumonia typhoides &c. the effect of the joint operation of miasmata and cold, 597__ 631; as regular in their appearance, when these causes concur, as autumnal fever amidst abundance of miasmata, 632—643. CHAPTER IX. Of the identity of all the forms of autumnal epidemic disease. 644. CONTENTS. CHAPTER X. Of contagion considered as a remote cause of fever, 699—721; of the contagion attributed to yellow fever, 722—757; of the contagion attributed to the plague, 758—800; of the contagion attributed to typhus fever, 801—842. CHAPTER XI. The plague arises, prevails, and declines in the very same circumstances in which hot weather epidemics in all parts of the earth arise, prevail and decline, and is therefore produced by the same remote cause, 843—939. CHAPTER XII. The typhus fever is also produced by the same cause, 940; arises in situations in which the dense gas, called miasmata, abounds, 941—948; corresponds with epidemic diseases of hot weather in the time of its rise, greatest height, and decline, and the same kind of weather is most favourable to the increase of them and it, 949—983; arises on board of ships at sea or in port in circumstances in which miasmata abound, 984—1027; the symptoms of typhus fever are the same with those produced by miSsmata, 1028—1046; typhus fever appears in company with diseases known to be produced by miasmata and they are mutu- ally convertible into one another, 1047—10($2; typhus fever therefore the autumnal or bilious fever of England, 1063; this conclusion confirmed by a variety of considerations, among others the acknowledgements of Trotter and Blane, 1064—1092. CHAPTER XIII. A few observations on the identity of autumnal remittents., typhus fever, and plague, 1093—1106. CHAPTER XIV. Of the unity of fever, U07—1118. CONTENTS. CHAPTER XV. Of a general epidemic constitution of the atmosphere, consider* ,ed as a remote cause of epidemic fever, 1119—1165. CHAPTER XVI. Some general remarks on the origin of epidemics, 1166—1200; CHAPTER XVII. Remote causes predisposing or exciting 1201—1203; some ad- ditional remote causes, 1204—1208, PREFACE. • The investigation of the manner in which the remote causes of disease operate on the human system in producing the symp- toms wepbserve, is one of the most important subjects that can engage our attention. This investigation has notwithstanding been so loosely conducted, that few principles are established, the explanations of the phenomena of fever by the most celebra- ted pliysicians have been so unsatisfactory, that at the present mo- ment there is no received theory, and we every day hear doc- trines directly opposed to one another, asserted with the utmost confidence of their being well founded. In this conflict of opinion, how are we to ascertain the truth? What are we to believe? Let us profit by the experience of o- thers. Less than two centuries ago,Natural Philosophy which now stands on a basis so firm, Avas as much embarrassed by contradic- tory doctrines as the science of Medicine now is. It emerged from this state by a method so simple, and so reasonable, that to hear it stated is all that is necessary to convince us of its propriety. It consists in making experiments and observations, and in draw- ing general conclusions from them, and admitting no objections against the conclusions, but such as are taken from experiments or other certain truths. This is the method of philosophizing of the great Newton; and one of the rules by which he and his associates were governed in their investigations, is, that proposi- tions drawn from the phenomena of nature "are to be deemed, notwithstanding contrary hypotheses, eiiher accurately or very nearly true, till other phenomena occur, by which they may be rendered more accurate, or liable to exceptions." Before this time natural philosophers (to use the language of one of them) "disregarding experiments, the only sure foundation IV PBKJi'At-i.'. whereon to build a rational philosophy, busied themselves in framing hypotheses for the solution of natural appearances;■ "whereas the philosophers of later times, laying ;iside those false lights, as being of no other use than to misguide the understand- ing in its searches into nature, betook themselves to experiments and observations, and from thence collected the general powers and laws of nature." This portrait of Natural Philosophy as it was, bears too strong a resemblance to the science of Medicine as it now is. Long since convinced that experiments and observa- tions are the only true foundation of knowledge, and that hypo- thesis is the ignis fatuus by which we are led astray, the author of the following pages has endeavoured, in the investigation of the changes produced in the system by the remote causes of disease,, carefully to adhere to the abovementioned method of philosophi- zing. How far he has done so, must be left to others to decide: every departure from it will no doubt be observed, and it i3 his wish that it should be; for if he knows himself, he desires that the, truth should prevail. It is not intended to say that this method has never been fol- lowed in medical writings. Its adoption by natural philosophers, together with its manifest reasonableness and.propriety, and the advantages that have grown put of it in relation to that branch of knowledge, have so influenced the minds of all literary men, that it has imperceptibly been more or less adopted in every depart* ment of science. But there is still mu,ch to be done in Medicine. There is still too much explanation founded on hypothesis, too much upon terms the precise meaning of which is not adhered to when they are used, and too much reference to unknown and un- defined laws in explaining the operations of the human system. It is sometimes urged that this method of philosophizing is on- ly adapted to what are called the exact sciences, that in medicaj investigations we cannot attain to such certainty, and that we must therefore be content with probability. It is replied, that although in prosecuting medical inquiries, the field of experiment is limited, that of observation is unbounded. If there be questions which we cannot decide because the truth on certain points is not ascertained, it is deceiving ourselves to tn^FACE. V come to a conclusion without it, and rest on conjecture or asser* tion. It is the better way, the only rational way to defer our decision; if we do not know, to say we do not; and immediately to resort to experiment and observation in order to settle them. As long as we continue to draw our inferences, and build our doc- trines on this foundation, we proceed with certainty. What is done is never to be done again: it is settled forever. But if through impatience of this slow way of investigating a subject, we fly to conjectufe, a door is opened at once destructive of the very object, settling the question: for, as every man can conjeeture, many conjectures are made, and contradictory doctrines are maintained, sometimes with a pertinacity only equalled by their absurdity. Although the investigation into the manner in which the r»-, mote causes produce the symptoms of disease, is, as the i_.. e convenient and forcible method of illustrating the subject, con- ducted in the following pages by inquiring into the effects of those remote causes, next into the effects of those effects, and so on de- scending to the symptoms, it is proper to state that this was not the course the inquiry actually took. The writer for many years had had his attention turned to this subject. Accustomed from the natural turn of his mind, as well as from the course of his education, to rest his belief on evidence alone, and to receive as true nothing not thus supported, he could not assent to theories built oh round assertion, without the sha- dow of evidence to support them. He could not therefore but reject the theory of QJullen, a mere pile of conjecture; nor that of Brown, overlooking the most palpable objections; nor even that of Rush, destitute of evidence to support a principal feature, that of sudden increase of excitability at the moment in which the ac- tion of stimuli has produced debility, and consequently exhaustion of excitability. In using this language respecting the productions of men of great genius, the writer only expresses that want of confidence in them, which has prevented medical men from re- ceiving any one of them as a satisfactory solution of the problem. In truth he can say that the time never was in which he received ^s true any of the theories abovementioned. H PRKFACE. Not satisfied however to practice empirically, his mind was of. ten turned to the consideration of the important questions invol- ved in the subject, and the long and solitary rides he was fre- quently called on to take, afforded opportunities for undisturbed reflection. The first question which pressed on his mind, related to the cause of the derangement of the functions of the liver in the au* tumnal diseases. The symptoms observed were very commonly, by the mass of people and by many physicians, attributed to su- perabundance of bile, and this as well as many other popular no- tions, was derived from high authority in former days. The obt vious relief afforded by a free discharge of bile, gave considera- ble countenance to the opinion; but the unanswerable objection was, that very often there is no bile discharged either from the stomach or the bowels, by the most active medicines, and the symptoms are more severe than in those cases in which there is an abundance of that fluid—and that a free secretion of bile is a most desirable object. It was evident then that the morbid symp- toms arc produced not by bile, but by the retained material of which bile is formed, viz. the blood in the liver. This led to the doctrine of congestion in that viscus being the cause of the disorder observed, a doctrine advanced by many late writers. It was very evident that this cause is capable of producing an increased secretion of bile, but the question arose, can it likewise produce a suppression of the secretfon? From what occurs in the mamma after parturition there is reason to believe it can. In that gland a certain degree of congestion or accumulation of blood produces increased secretion; a higher degree, such as pro-i duces hardness, suppresses secretion entirely. The next question was, how' are the other parts, the stomach, the head, Lc. affected? By sympathy, is the common answer; which, while it acknowledges an intimate connexion between these parts, conveys no precise idea of it, and contains no expla^ nationofits nature. Revolving in his mind the nature of this connexion, the thought struck him that congestion, or accumulation of blood cannot ex- ist in the liver, without extending into the vena cava, and its PREFACE. Vll great branches, the jugulars, the emulgent veins, and the inter- nal and external iliac veins; nor without producing an accumu- lation in all the veins leading into the liver, viz. in the veins of all the chylopoietic viscera. It was at once apparent that the same accumulation must affect the brain, and the stomach and bowels; and derange the functions of the latter, at the same time that it deranges those of the liver. Further reflection led to the observation that the same accumulation affects the kidneys and the uterus also. Considerable time was spent in tracing out the effects of this accumulation of blood in the vena cava and its branches, in the several parts in which they are situated. It was found that this cause is capable of producing pain in the head, vertigo, stupor, &c.; enlargement of the liver and pain in that part, increased secretion of bile, with nausea, Vomiting and purging; or suppressed secretion and constipation; and in the glands of the stomach, increased secretion with ravenous appe- tite, or suppressed secretion and consequent want of appetite, flatulence and acidity; together with derangement of other parts not necessary to particularize. An accumulation of blood in the interior veins was thus found to be capable of producing the symptoms preceding and accom- panying fever: it still remained to account for the increased ac- tion of the heart and arteries. Blood being the natural stimulus of the heart, it is evident that a sudden increase of the quantity poured into it, must produce increased action of that organ, if it be at the time capable of it. The sudden accumulation there- fore which takes place in the colds tage of fever, produces the increased action that follows; while the abovcmentipned affec- tions of the head, stomach, liver, &c. which precede fever, are the effects of gradual accumulation of that fluid in the vena cava, &x. The next question was, what is the cause of this accumulation? It had been observed that weakened action of the heart is always present in the commencement of these autumnal diseases, and that it is produced by all the remote causes of fever: and it was evi- dent that it must, whenever present, necessarily produce accu- mulation of blood in the vena cava, &c; and therefore that this is the cause. VUl PRfcFAOE. When the inquiry had reached this stage, the manuscript was copied for publication, in 1822. It was however subsequently determined to inquire into the nature of the remote causes, the manner in which they operate on the system, and into some doc- trines connected with this subject, viz. the identity of the forms of autumnal disease, the contagious nature of the yellow fever, and the contagious nature and origin of the typhus fever, and the plague. This addition, viz. the inquiry into the nature of the remote causes, &c. constitutes the first volume* The doctrines advanced have been familiar to my friends since the spring of 1822—To them I owe an apology for the delay of the publication. They had some reason to -expect it in 1822 or 1823. Want of experience in the difficulties of such an undertaking in the midst of constant occupation, is the only excuse that can be of- fered. The sole dependahce of a large family, until very lately, was on my exertions in the practice. This absolutely required attention to every call in a country-practice extending in one di- rection about twenty miles. The result of the exposure connected with unremitting atten- tion to such a practice, was bad health, in consequence of which it became necessary to seek a town-practice—At this period, in the beginning of 1822, it was expected that leisure would be af- forded for finishing the work for publication. Unexpected suc- cess in business however, and the prevalence of very severe au- tumnal epidemics, together with the addition proposed to the work, delayed the commencement of printing until the summer of 1826. The same causes rendered the progress in printing slow, it being found impossible to devote more time than sufficed to keep one hand at work. In the summer of 1827, the interup- tion produced by my election to the professorship of the Theory and Practice of Medicine in Transylvania University, caused a suspension of the work; and the occupations growing out of this new situation have rendered it impossible to complete it before the coming summer. The solicitations of many of the medical class have induced me to publish the two first volumes embracing Pathology and the treatment of Chronie Diseases, leaving the third volume containing the treatment of Febrile Diseases, to ap- pear in the course of the ensuing summer. PATHOLOGY AND THERAPEUTICS. CHAPTER I. Felix qui potuit rerum cognoscere causas. 1. Mankind have ever shown a strong inclination to discover the causes of natural phenomena; and from the remotest ages their ingenuity has been exer- , cised in the investigation of them. This propensity is not confined to the intelligent and the enlightened; even the stupid and the ignorant have their desire to know, and often their theories to explain the secrets of nature. 2. The inquiry into the origin and nature of the va- rious forms of disease which afflict the human race is especially interesting; seeing that the natural propen- sity is stimulated by the importance of the subject to our well-being, and to life itself. Physicians, who are continually called on to relieve the afflicted, and whose best endeavours in their behalf are often baffled, are especially interested in ascertaining the causes of the morbid appearances, and particularly the proximate 10 cause, " quae praesens morbum facit, sublata tollit, mu- tata mutat."* 3. They have accordingly shown, from the earliest times of which we have any record, the deep interest they feel in this subject. By their unwearied atten- tion, and by a multitude of observations, they had early made considerable discoveries respecting those causes which remotely influence the body in such a man- ner that disease is eventually produced ;l they had marked the phenomena that occur, and had laid down, with very considerable precision, those which indicate a favourable or an unfavourable termination ;2 and they had acquired a knowledge of many articles, ve- getable and mineral, of great efficacy in the treatment of diseases. 4. The intermediate causes, however, connecting links between the remote causes and the symptoms of disease, and particularly the proximate cause, escaped them entirely. Consisting in changes wrought in the body by the remote causes, they are not subject to ob- servation ; and the only course by which to acquire a knowledge of them, is that of rigid inference from known facts, and of argument built on those facts and inferences. Yielding, however, to the impatient de- sire, natural to man, at once to solve every difficulty, this slow but sure course was deserted; and medical writers had recourse to conjecture, and formed such hypotheses as they deemed consistent with known facts, and sufficient to explain the phenomena. * Which when present causes the disease, when taken away removes it, when changed changes it. i Celsus de Medicina, Lib. 3, cap. 23. Cum quibus fugere oportet solera, balneum, ignera, etc. 2 Ibid. Lib. 2, cap. 8. 11 5. Physicians in succeeding ages have too closely followed the example. Although they have multiplied their experiments and observations, and have in the course of ages accumulated an immense number of facts, and made many efforts to explain the pheno- mena of disease, it is thought little progress has been made; and a writer of some distinction says, " The real derangement in the system which produces the external appearances in fever, it must be owned, is not at all known."1 6. The theories of the moderns, like those of the an- cients, are founded on hypothesis or conjecture, and therefore have uniformly failed to give general satis iaction, for any length of time, in an age in which the Newtonian method of philosophizing has enlightened the mind of the public. Hence has arisen in some a kind of despair of ever seeing any satisfactory explana- tion of the phenomena of disease, and in others a con- tempt of all theory. Speaking of Senac's attempt to explain some of these phenomena, one writer2 says, " The physician who un- dertakes to account for the periodical recurrence and termination of the paroxysms of an intermittent, may be truly said ' to attempt the bow of Ulysses.' The matter is as much an arcanum naturae now, as it was in the days of the father of physic. Nor does it seem at all probable that the thick veil which has hitherto concealed it will be shortly removed." Some medical writers seem even to consider it a 1 Fordyce on Fever, Dissertation 1, p. 47- 2 C. Caldwell, IYI. D. Professor of the Institutes of Medicine and Cli- nical Practice in the Transylvania University. Note to ch. 9, book 1, of his Translation of Senac on Fevers. 12 mark of mature judgment to think theory of little im- portance.1 " Hinc factum est, non prorsus sine rationis specie, ut multis, cum medicorum, turn aliorum homi- num, persuasum sit, omnem theoriam medicam pror- sus vanam et futilem esse, et non modo non prodesse, sed revera multum nocere, animum nempe a vera no- titia, qua? sola, ut volunt, experientia discatur, ficta scientia, avocando."* 7. The same beautiful writer continues: "Verum enimvero non ideo concludere fas est nihil veri aut certi de theoria artis medicse unquam repertum iri," &c.f It would indeed be in the highest degree unbecoming, not only to sit contented under the slurs that have, with no sparing hand, been cast upon the profession, but even to pass upon ourselves the sentence, that we are but enlightened empirics, that we never can attain to such knowledge of the operations of the human sys- tem, under the influence of the causes of disease, as will direct us advantageously in our endeavours to ob- viate their effects. This indeed will not be done. Im- pelled by the innate propensity above alluded to (1), men will theorize, and the question is not whether we shall have a theory, or not; but whether we shall have a right one, or a wrong one. 8. Wrong theory leads almost inevitably to practice 1 Currie's_ Medical Reports, Vol. 1, p. lG5. 169. * Hence it has happened, not altogether without an appearance of reason, that many, as well physicians as other men, are persuaded, that all medical theory is altogether vain and futile; and is not only unpro- fitable, but indeed very injurious, in calling off the mind, by counterfeit science, from true knowledge, which can be acquired, as they think. from experience alone.—Gregorii Conspectus. Introd: p. 19. t But truly it,is not therefore just to conclude, that nothing true or certain concerning the theory of the medical art will ever be discovered Ibid. p. 19. 13 either directly injurious, or indirectly so, by it* men ness, whereby a mortal disease rages uncontrolled. The heating treatment of small pox is an instance of the former ; the treatment of a fever in Leyden by Syl- vius de la Boe is an instance of the latter. Resting on his theory that the fever was caused by an acid, he administered chalk to cure it, and being an influential man in the profession, his practice was followed, and two-thirds of the population are said to have died un- der the treatment. 9. It has indeed been said to be a matter of small importance what our theory is, if our practice be right. If our practice be right while our theory is wrong, it is accidentally right. The remedy has been discovered, as many have been, by chance; as the beneficial effect of cold water in fever by patients jumping into the sen from a ship ; or by some similar exposure. But if, in attempting to derive the same benefit from the affusion of cold water, we apply it without a correct theory of its action, we may kill our patients; as Dr. Currie of Liverpool, when about to show the good effects of the practice to a Russian surgeon, was very near doing with a patient by immersing him in cold water during a chill;' and as a follower of his in that practice actu- ally did in many instances by the affusion of water at improper periods.2 10. If a wrong theory be so injurious, and there is too much reason to believe that it lias slain multitudes (8. 9), theory is not a vain thing ((>), and it is a matter of the utmost importance to discover the true one. 1 Currie's Medical Reports, Vol. 1, ch. 7- 2 Ibid. Vol. 2, p. 358. 14 That there is a true theory it were absurd to deny. The remote causes of disease, operating on the human system, produce uniform effects. This must be the consequence of their operating in an uniform manner, and of the system's acting, under their influence, uni- formly according to certain laws by which it is go- verned. The exposition of this manner and of these laws, or a statement of the immediate effects of the remote causes on the system, and of the changes wrought in it in consequence of these effects, will show the whole connexion between the agents ascertained to be remote causes of disease, and their effects the symptoms ; and is the true theory. 11. In the following pages I shall attempt the in- vestigation of this connexion; or, a statement of the immediate effects of the remote causes on the system, and of the changes wrought in it in consequence of these effects. The course which, it is believed, the in- quiry must necessarily take to be successful, is stated in a few observations which follow. 12. Every phenomenon is the effect of some cause producing it; that cause was likewise produced by a second; that by a third; and so on, extending upwards in point of time of existence. This succession of cause and effect constitutes a chain of effects, or of causes, according as it is viewed in the descending or in the ascending line. 13. Each phenomenon is therefore, at the time of its appearance, the termination or last link of a chain o£ causes. That link of such a chain, which is nearest the phenomenon observed, which immediately produ- ces it, is the proximate cause ; those links more remote 15 from the phenemenon, are called its remote causes. The proximate cause, as well as every other link of the chain below the remote cause, is therefore an ef- fect of the remote cause. 14. Different effects may flow from one remote cause. In this case the chain of causes ascending from each effect, must terminate in that remote cause from which they all proceed. These chains of causes may not all continue distinct until they arrive at the remote cause, but may fall into one another, as they ascend, before they arrive at it. Thus a remote cause may produce a single effect, which may be the cause of another single effect, from which several effects may directly or indirectly proceed. 15. That link in which the ascending chains from several effects first coincide or unite, is the proximate cause of all those effects; for in the ascending line it is the nearest cause from which they all flow. Any cause more remote cannot be the proximate cause; any one nearer is the cause of only a part of the effects. 16. Different remote causes may produce the same effects ; and we often find them co-operating to pro- duce them. In this case it is plain that the descending chains from the different remote causes coincide at some point as they proceed downwards, and co-operate in pro- ducing some link of the chain. That link must be one from which all the effects proceed; otherwise, the re- mote cause, which co-operates to produce it, would be the remote cause of only a part of the effects. This may be the proximate cause (15), or it may be a link which produces the proximate cause. That is. IG that link in which the descending chains first meet, may be the same with that in which the ascending first meet, or the proximate cause (15) ; or the former may be the cause of the latter. 17. The proximate cause is an effect of all the re- mote causes (13. 15. 16); and therefore all the causes which produce it, are remote causes of its effects. IS. Applying these manifest truths and inferences to the phenomena of disease, the remote causes of fe- ver, and the whole train of symptoms proceeding from them, denominated a febrile paroxysm* with all the in- termediate links, constitute a series of causes and ef- fects ; the chains of effects descending from all the re- mote causes uniting in each symptom, and the chains of causes ascending from all the symptoms uniting in each remote cause. Every effect of the remote causes is one point of the series, one link of the chain; is the effect of the causes preceding ; is the cause of the effects succeeding. 19. Hence it is evident that, in order thoroughly to investigate the connexion between the remote causes and the symptoms of disease (11), we may inquire into the effects of the causes ascertained; next into the effects of those effects, or new causes; and so on, descending until we arrive at the ultimate effects, the symptoms in question: or, that we may inquire into the causes of the symptoms, and into the causes of those causes, and so on, ascending until we arrive at the remote causes; or, that these two modes may be combined, and that the agreement of the two in the same result is a strong confirmation of its truth. 20. Instead, however, of following this simple and 17 natural course, and bending their whole attention to the inquiry, in the descending line into the effect, or in the ascending line into the cause, of the successively ascertained points of the series of causes, and thus step by step dispelling the gloom in which the subject is involved; physicians have, as was before observed, resorted to hypothesis for aid to enable them to ex- plain the phenomena observed in disease. 21. Before we proceed in this investigation (19), we shall endeavour to state the principal hypotheses which have been proposed, and to show their insuffi- ciency. As most of the diseases which afflict man- kind are accompanied by fever, this state of the system has attracted special attention; and great efforts have been made to explain its phenomena. Chronic affec- tions have received comparatively little attention; and the opinions respecting them are vague and unsatis- factory. 22. The most ancient hypothesis we are acquainted with is that contained in the writings of Hippocrates; according to which health consists in the due propor- tion of the four humours of which the body was sup- posed to be formed; viz. phlegm, blood, bile, and black bile ; and disease in an undue proportion of the same; the evil consequences of which were guarded against by the care of a superintending principle. 23. When an undue proportion of the humours ex- ists, or when one is in excess, the superintending prin- ciple, according to this doctrine, excites a commotion, during which the blood is purified, the morbid humours discharged by the bowels, the bladder, or the skin, and, the purpose of the febrile commotion having been 3 1* effected, the inordinate action ceases, and health is restored. 24. This doctrine continued in high esteem in Eu- rope until late in the 18th century; and was without a rival until the 16th, when the Chemical Sect of Phy- sicians arose. According to their theory the fluids of the body are acid, or alkaline, and diseases are pro- duced by the preponderance of one or other of those states; and are to be cured by the adihinistration of medicines of the opposite character. 25. In the 17th century an attempt was made to apply mathematical and mechanical principles to the explanation of the phenomena of disease, and for a time attracted the attention of physicians. It was how- ever soon found that neither the science which relates to the properties and dimensions of inert matter, nor that which concerns the mutual attractions of the ele- ments of matter, is applicable to the explanation of the operations of the living body. These hypotheses were accordingly soon laid aside. 26. In the end of the 17th century the celebrated Stahl made an addition to the ancient doctrine. He believed that there is in the system a constant tendency to plethora; that this state and a bad state of the hu- mours are the causes of disease; and that the office of the presiding power, to which he, like his predecessors, attributed intelligence, is to produce the necessary eva- cuations, as well as to correct the bad state of the fluids. 27. The leading points of this ancient doctrine, the humoural pathology, are, a bad state of the fluids, to which Stahl added a constant tendency to plethora • 19 and a superintending intelligent principle, whose office was to correct the disordered state, by exciting com- motion, depuration, and evacuation. 28. It is defective in assuming, without proof, that the internal derangement consists in a disordered state of the fluids ; 2, in not showing how the disordered state or internal derangement is produced by the re- mote causes; 3, in not showing how this state pro- duces the symptoms of disease, particularly the in- creased action in fever; 4, in referring them to a pre- siding power which is not shown to exist. In other words, it does not trace the connexion between the remote causes and the symptoms of disease (19). 29. Some few years after Stahl's addition to the ancient humoural pathology, Hoffman proposed a the- ory, containing a number of the doctrines of the day; but in addition to them, he taught that health con- sists in a certain tone of the moving fibre, and disease in too great or too little tone; in spasm or atony. " Ex hisce autem omnibus uberius hactenus excussis, per quam dilucide apparere arbitror quod solus spas- mus et simplex atonia, sequabilem, liberum, ac pro- portionatum, sanguinis omnisque generis fluidorum motum, quibus excretionum successus et integritas functionum animi et corporis proxime nititur, tur- bando ac pervertendo, universam vitalem ceconomiam subruant ac destruant;" &c* It may be sufficient to * From all these considerations thus far copiously discussed, I think it clearly appears that spasm alone and simple atony, by disturbing and destroying the equable, free, and proportionate motion of the blood and of the fluids of every kind, on which the healthy condition of the excre- tions and the soundness of the functions of the mind and body immedi- ately depend, overturn and destroy the whole vital oeconoroy.—Cullen's First Lines, Preface, p. xxiv. 20 object to this doctrine that spasm and atony are symp- toms of disease ; effects of the remote causes ; and not themselves remote causes. 30. In the beginning of the 18th century, Boer- haave, a man of great genius, industry, and learning, intimately acquainted with all the systems from the time of Hippocrates, formed a theory of materials se- lected from every side, which was so well received, that his praises rung throughout Europe for a large portion of the 18th century. He attributed diseases to various states of the solids and the fluids; to a weak and lax, and to a stiff and elastic fibre ; to an acid acrimony, a spontaneous glue, and a spontaneous alkali in the fluids; to excessive and to defective circulatory motion; and to plethora. The diseases arising from each of these different states were to be cured by remedies tending to produce an opposite state of the system. It is needless to say a word respecting this system ; the absurdities to which it led may be seen in his Aphorisms.1 31. His theory of fever is, that some of the above and other remote causes produce the proximate cause.2 He is not, however, precise in stating the proximate cause. He says, " Whence it appears, that then (in the cold fit) the bloody humours do stagnate at the ends of the capillary vessels, and that there is notwith- standing at the same time some cause that irritates the heart."3 " So that the too quick contraction of the heart, with an increased resistance at the end of the capillary vessels, is sufficient to complete in us the idea of all acute fevers."4 " So that after a due examen of J Aphorisms 63. 64. 70, to 73. 85. 86. 2 Ibid. 583. 586. 3 Ibid. 577. * Ibid. 581. 21 the whole history of intermitting fevers it must be con- cluded, that their proximate cause is a viscosity of the arterial liquid, upon which succeeds any one of the causes of the two strong and quick contraction of the heart, and a resolution of what had been stagnated."1 He does not say whether the obstruction in the ca- pillary vessels, which is assumed to exist, produces di- rectly or indirectly the increased action, and he does not show that it does it in either way. 32. To these visionary doctrines, and to the mon- strous absurdities connected with them, of which a full specimen may be seeu in the works of Sydenham,2 and in the Aphorisms of Boerhaave,3 the language of Gre- gory is strikingly applicable: " Non est dissimulandum, theoriaj medicae scriptores hominum patientia multum abusos esse, et sibi aliisque, nuper et olim, miris inep- tiis impossuisse.* These theories have however been abandoned; and in their stead have been advanced several others, which have in turn attracted the attention, and divided the opinions of medical men. 33. Hitherto little notice had been taken of the re- mote causes of fever: Boerhaave mentions them, but does not show their operation on the system. Cullen, whose theory followed next, seems to have taken a more enlarged and comprehensive view of the subject than any of his predecessors. He pointed out the ef- 1 Aphorism 755. 2 Sec. 1, ch. i. art. 1. Sec. 1, ch. iv. art. 1. Sec. 1, ch. v. art. 2.3 4. 10. Sec. 2, ch. ii. art. 11. Sec. 6, ch. hi. art. 5. 3 Aphorisms 63. 64. 70, to 73. 85. 86. * It is not to be concealed that the writers of the theory of physic have greatly abused the patience of men, and have imposed on them- selves and others, lately and formerly, by wonderful absurdities.—Gre- gorii Conspectus. Introd. p. 19. 22 feet of the remote causes, viz. debility, and after show- ing, from the symptoms preceding a febrile paroxysm, and from the consideration that the remote causes are of a debilitating nature,2 that a state of debility ex- ists in the commencement of fever, he says,3 " It is therefore evident that there are three states which al- ways take place in fever; a state of debility, a state of cold, and a state of heat; and as these three states re- gularly and constantly succeed each other in the order we have mentioned them, it is presumed that they are in the series of cause and effect with respect to one another. This we hold a matter of fact, even although we should not be able to explain in what manner, or by what mechanical means these states severally pro- duce each other." Instead however of patiently in- vestigating the connexion he had observed between the different stages, whereby he might have disco- vered the manner in which the one produces the other, he contented himself with referring the matter to the old doctrine of a superintending power in the system,4 which ever since the days of Hippocrates had been the resource of physicians in their attempts to explain the phenomena of fever. 34. Apparently desirous, however, of avoiding the absurdity of the doctrine of a superintending intelli- gent principle, he calls it a general law of the animal (economy; but in the same paragraph,4 speaks of it as a power producing effects, viz. "many of the motions excited in fever." Considered in either light, referring to it those phe- nomena of fever, which the author admits he cannot explain, affords no information. 1 First Lines, xxxv. 2 ibid, xxxvi. 3 Ibid, xxxvii. * Ibid, xxxviii 23 Referring certain morbid symptoms to a general law of the system, of the nature of which no account is given, nor any account of the manner of its opera* tion in producing the effects, is no explanation^ It is perfectly obvious, a mere truism, that they happen by a general law of the animal oeconomy. The question is, Wfiat is that law ? In what manner are these phe- nomena produced ? Considered as a power there is no evidence of its existence. 35. This system is therefore defective in not ex- plaining the manner in which one stage produces another.1 (2.) The inability to explain being admitted,1 it is wrong in attributing the phenomena to a power,1 the vis medicatrix naturae, of the existence of which there is no evidence. (3.) It is wrong in attributing to that power effects, of the existence of which there is no evidence, viz. spasm of the extreme vessels.2 The evidence which Cullen offers, "the suppression of all excretions, and the shrinking of the external parts,"3 may be impu- ted not only "in part," but wholly "to the weaker action of the heart in propelling the blood into the extreme vessels."3 There is at any rate no certainty, and Cullen's own language, " there seems to be a spasm,"* shows a consciousness of the uncertainty of its existence. (4.) It is wrong in attributing the increased action to that effect of the supposed power, viz. to spasm of the extreme vessels,4 as to an intermediate cause; with- 1 First Lines, xxxviii. 3 Ibid, xliii. 3 Ibid. xl. ♦ Ibid. xli. 24 out producing any evidence that such spasm, suppo- sing it to exist, is capable of exciting increased action ; the doctrine beins left to rest on the common opinion of physicians.1 (5.) This theory is moreover defective in excluding stimulants from the list of remote causes. They are, undoubtedly, often remote causes of fever; by exci- ting the action of the heart and arteries too high to last, they indirectly produce the debility which pre- cedes fever.2 (6.) It is wrong in stating that the causes act on the nervous system primarily, and, thus diminishing the energy of the brain, produce debility. The remote cause, miasmata, produces effects on the system, viz. darkness of complexion and blackness of the blood, long before there is any diminution of the energy of the brain. On the contrary, it is often observed that persons just before an attack of fever are extraordinarily brilliant in their thoughts and lan- guage. The remote cause, cold, produces a manifest weak- ness of the action of the heart and arteries, long be- fore the energy of the brain is lessened. 36. The theory of Cullen is superior to the ancient theory of Hippocrates, in attributing the phenomena observed to a law of the animal oeconomy, instead of an intelligent superintending principle ; but of the mode of operation there is no more explanation in one than in the other: Cullen having referred to that law, as to a power producing the effects, without showing how they were produced; and having offered no evi- 1 First Lines, xxxix. 2 Ibid, xxxvii. and Rush, Vol. 3. p. 3, 25 dence of the existence of the only specified means of producing, or intermediate cause of the increased ac- tion, viz. spasm of the extreme vessels. That this state of these vessels exists, he does not show (35.3) ; how it was produced, he admits he can- not explain ;x how it produces the effect attributed to itj he does not attempt to say (35. 4). In short, he does not trace the connexion between the remote cau- ses, and the symptoms of fever (18. 19). 37. Brown taught that the life of man and other animals consists " in this property alone; that they can be affected by external agents as well as by cer- tain functions peculiar to themselves, in such a manner that the phenomena peculiar to their living state, that is their own functions, can be produced."2 This pro- perty is called excitability; and the external agents, exciting powers.3 The effect of the exciting powers acting upon the excitability, is to be denominated ex- citement.4 " Excitement, the effect of the exciting powers, the true cause of life, is, within certain boundaries, pro- duced in a degree proportioned to the degree of stim- ulus. The degree of stimulus, when moderate, pro- duces health; in a higher degree it gives occasion to diseases of excessive stimulus; in a lower degree, or ultimately low, it induces those which depend upon a deficiency of stimulus, or debility."5 " A is affected with a disease of debility, where the excitement has gone down to 10 degrees, the excita- bility mounted up to 70 degrees in the scale. What is 1 Cullen's First Lines, xxxviii. 2 Brown's Elements, x. 3 Ibid. xiv. * Ibid. xvi. 5 Ibid, xxiii. 4 26 to be done! By a proper use of high stimulants the 30 degrees of lost excitement may be restored, and as many of superfluous excitability discharged, and the excitement and excitability made to meet again at the middle point of 40. If the remedies are carried up to any degree betwixt 40 and 55, they have gone too far, and produced predisposition to sthenic diseases; if still farther, but not exceeding 70, they will have produced one or other of these diseases; but carried beyond 70, the diseases which their operation produces, are those of indirect debility."1 38. It follows from this doctrine that there is no other difference between sickness and health, than dif- ferent degrees of excitement; 2, consequently, that a man drinking wine so as to produce the highest de- grees of excitement, must have passed through one or other of the sthenic diseases ; 3, that a man, in pass- ing from a high state of excitement, in synocha for instance, to a low one, by letting blood, must pass through the state of health ; and, as excitement is ea- sily reduced by the loss of blood, that a man should be cured of a sthenic disease in a few minutes. 39. This doctrine also makes predisposition to sthe- nic diseases consist in increased excitement; whereas diminished excitement, sometimes in a remarkable de- gree, precedes even those diseases admitted by the au- thor to be sthenic; viz. synocha, catarrh, &c. It also considers disease as the direct effect of in- creasing or diminishing the exciting powers; diseases of excessive excitement proceeding from the former, and those of reduced excitement from the latter. In ' Brown's Elements, lxxi. note d. 27 opposition to this, however, diseases of the highest ex- excitement often follow the abstraction of exciting power; as in peripneumony, and dysentery from cold. In short, this doctrine overlooks the whole train of causes between the remote causes and the symptoms of disease. 40. Rush's theory of fever is, that the effect of the remote causes of fever is to produce debility; either by excess of stimulus first elevating the excitement of the system above its healthy grade, and afterwards re- ducing it down to that state which he calls debility of action; or, by abstraction of natural stimuli, reducing the system below its healthy grade of excitement.1 (2.) Debility being thus formed in the system, a sud- den accumulation of excitability takes place, whereby a predisposition is created to fever.2 (3.) Additional stimuli, or the common impressions which support life, sometimes become irritants, and readily add another link to the chain of causes which induce fever; and that is, depression of the whole sys- tem, or what Dr. Brown calls indirect debility.3 (4.) By the continued action of stimuli, reaction is induced, and in this reaction, according to its greater or less force and extent, consist the different degrees of fever.4 41. According to this theory, in those cases in which stimulants are the remote causes, (1.) Stimulants produce debility; which is followed by accumulation of excitability. (2.) Stimuli, additional or common, produce depres- sion. * Rush, Vol. 3, p. 3, 4. » Ibid. p. 5. « Ibid. p. 5. * Ibid. p. 6. 28 (3.) Stimuli, morbid or natural, continuing to act, produce reaction. (4.) Moreover, " the same remote cause is often de- bilitating, stimulating, and depressing;" or, to preserve the order in which the several stimuli are supposed to act (40), debilitating, depressing, and stimulating. (5.) And further," in certain fevers the remote cause sometimes excites convulsions in the blood vessels, (that is, fever,) without being preceded by preternatu- ral debility and excitability; and with but little or no depression of the system."1 42. If this were the case, the increased action would be the direct effect of the remote cause, and the same as the excitement of Brown (37). But there are no such short cuts as this in natural operations. The suc- cession of cause and effect is uniform. It is only be- cause of the rapidity of the operation that, in some cases, we do not perceive the different steps; which nevertheless occur in order. All that are inconsis- tent with that rapidity, and occur not then, are not necessary, and therefore never do; as nature does nothing in vain.2 It is evident therefore that, having proposed as links of the chain of causes, states of the system, which he himself admits are not essential to the production of fever, he has overlooked the true series of causes ex- tending from the remote causes to increased action of the heart and arteries. 43. Moreover, there is no real difference between the effect of stimulant remote causes, debility of ac- l Rush's Works, Vol. 3, p. 14. 2 Newton's first rule of philosophizing. 29 Hon, and the effect of stimuli additional or common, depression, or the indirect debility of Dr. Brown (39) ; because, 1, both states are the effect of stimuli; and even the very same stimuli; as is broadly admitted by Rush (41. 4) ; 2, the marks of the second debility or depression, " weakness of the limbs, inability to stand or walk without pain, or a sense of fatigue, a dry, cool, or cold skin, chilliness, a shrinking of the hands and face, and a weak or quick pulse," are the well known effects of the remote causes, often produced in a few minutes; and even of the abstraction of stimulus, as on the application of cold. Therefore these states are the same, and depression, as a separate step in the process, does not exist. 44. It is objected also that stimulants, additional or common, having produced depression (40. 3), conti- nuing to act, should continue to produce greater* and greater depression, and never produce reaction. 45. This inconsistency is the more striking when it is stated that the same remote cause sometimes acts as debilitating, depressing, and stimulating ; in other words, continuing to act on the same system, it first debilitates, next depresses, and lastly stimulates. It is manifest that a cause which debilitates will continue to debilitate, and that increased action will never take place without the intervention of some other cause.1 This cause, connecting the remote causes and the symptoms of fever, is the desideratum of all the sys- tems that have been offered to the world ; and Rush, like his predecessors, has resorted to hypothesis as a substitute for it. Boerhaave's Aphorisms, 36. 30 46. His hypothesis, that debility, the effect of the remote causes, is followed by sudden accumulation of excitability, so great that the common stimuli which support life are enabled to produce all that follows (40), is unsupported by evidence, is destroyed by his own admission that it does not always occur (41. 5), and therefore is not essential; and appears to have been invented to account for the occurrence of fever or increased action when there are present no other stimuli than the common impressions which support life. For rightly believing stimulus necessary to pro- duce action, and resorting to the common impressions which support life, when he perceived no other pre- sent ; particularly when a chill and fever is produced by going into cold water ; he found it necessary to in- vent a hypothesis to account for common stimuli pro- ducing increased action. 47. Darwin's theory rests on the same principle with the theory of Rush, that accumulation of excitability follows reduced action, and upon a sympathetic con- nexion supposed to exist between the different parts of the body. " When any parts, which are naturally excited into perpetual action by stimulus, become torpid or less active from decrease of that stimulus ; there first oc- curs a decrease of the activity of the parts next cate- nated with them." " There next occurs an accumulation of the senso- rial power of irritation in the parts which were torpid from defect of stimulus;" and " a similar accumula- tion of the sensorial power of association in the parts which were catenated with the former." 31 " Whence if the subduction of stimulus has not been too great, so as to impair the health of the part, the activity of the irritative motions returns, even though the stimulus continue less than usual; and those of the associate motions become considerably increased, be- cause these latter are now excited by the previous fibrous motions, which now act as strong, or stronger than formerly, and have also acquired an accumula- tion of the sensorial power of association." " But if the parts thus possessed of the accumulated sensorial powers of irritation and of association, be ex- posed again to their natural quantity of stimulus, a great excess of activity supervenes;" &C.1 The whole theory rests on the doctrines of accumu- lation of sensorial power following torpor, and of asso- ciated motions, expressions equivalent to increase of excitability following debility, and sympathy, particu- larly on the latter, so much that the author denomi- nated it the Sympathetic Theory of Fever. 48. These theories are defective in consisting too exclusively in attempts to account for the single symp- tom, increased action of the heart; and in the resort, in order even to do this, to the hypotheses of a vis me- dicatrix naturae, of sudden increase of excitability fol- lowing the debility produced by the remote causes, and of a sympathetic influence between distant parts. 49. With respect to the sudden increase of excita- bility, the impossibility of its occurring in a degree sufficient to produce the effects observed, has been already shown (41. 42. 46). 50. With regard to the vis medicatrix naturae, it is 1 Zoonomia; Theory of Fever. Sup. 1. 16. 2. 32 unquestionable-that the body is so constituted, that an injurious impression often gives rise to an action or to a series of actions, the tendency of which is to remedy the evil. Thus, excessive exercise wastes the fluids by exciting perspiration, but gives rise to desire for liquids, by the gratification of which the system is re- plenished. But to represent this law of the system as a power, and to attribute to it important operations, without showing how they are effected by it, is not a very satisfactory mode of explaining difficult things. 51. The truth is, in this as well as in every other case of the application of agents to the body, those agents themselves, the phenomena observed on their application, and the intermediate links, effects of the former and causes of the latter, constitute a chain of cause and effect (12. 17) ; and the interposition of any power is unnecessary. The intelligence displayed does not consist in exciting an action to remove the evil then present; but in so constituting the system origi- nally, that an evil impression made on it is the first link of a chain of causes, of which the last alleviates or removes the evil. 52. The doctrine of sympathy has no better foun- dation. Certain parts of the body, as the head, the liver, the stomach, are observed, in common, to be disordered together; so that when one is affected, the others seldom escape. To account for the simulta- neous appearance of these affections, it is said that they are produced by sympathy between the parts in question. In order to understand the answer, and to judge of its correctness, it is necessary to ascertain the precise idea intended to be conveyed by this term. 33 53. In common acceptation, sympathy signifies fel- low-feeling, or an affection felt by one person in con- sequence of the affection of another. When one is in distress, and we feel for him, we are said to sympa- thize with him ; but actual suffering of the person sym* pathizirtg is not included in the idea. If both are suf- fering, they are fellow-sufferers. Each suffers, but his suffering is his own. Now in the case of different parts of the body suffer- ing at the same time, it is obvious that their suffering is actual. Therefore they do not sympathize in the common acceptation of the word. 54. If the term be used in a sense different from that in whieh it is commonly received, it becomes necessa* ry to define the sense in which it is used. 55. The advocates of this doctrine have defined sympathy to be such a connexion or consent between different parts, that " a certain condition prevailing in the one part occasions a similar condition in the other." l As however the affections of the parts sym- pathizing are often dissimilar, others have extended the signification of the term so as to embrace the lat- ter also, and have given the name to such a connexion between distant parts, that when one is affected the other is likewise. A late writer has called it " the mutual influence of distant parts."2 56. Before we are at liberty, however, to attribute important operations to such influence of one part over another, it is absolutely necessary to show that it exists. What evidence of its existence is offered by the advocates of the doctrine 1 1 Cullen's First Lines kc. xliv. 2 Blane's Medical Logic,p. 113, 5 34 57. Whytt says, "besides this general consent which prevails throughout the whole body, there is a particu- lar and very remarkable sympathy between several of its organs, (the organs of the body,) by means of which many operations are carried on in a sound state; and pain, convulsive motions, and other morbid symptoms, are often produced in such parts as have no near con- nexion with those that are immediately affected. " To illustrate this I shall give several instances, be- ginning with the head, and taking the parts in their order downwards." The following are a few of them. 58. "Violent pains in the head, which have their seat most commonly in the membranes of the brain or peri- cranium, are frequently attended with a sickness at the stomach, and vomiting." "Light and noise are offensive both to the eyes and ears in severe headachs." "The ear is frequently pained when the fauces are inflamed." "A pain in the teeth often affects the cheek bone, one side of the head, the throat, and the corresponding ear." * "A disordered state of the stomach and intestines, with wind or noxious humours lodging in them, will sometimes so affect the brain as to deprive people of their reason. At other times the same causes will produce a vertigo, cephalaea, hemicrania, clavus hyste- ricus, palpitations, intermissions of the pulse, difficulty of breathing sudden flushings of heat, sweating, &c." 59. After giving many other instances in which he shows, as in those just mentioned, that certain parts of 1 Whytt on the Nerves and Nervous Diseases, p. 14 to 21 35 the body being morbidly affected, certain other parts are also frequently affected at the same time, he says, " Many other examples of sympathy, both in a sound and morbid state of the body, might be mentioned ; but the above will be sufficient at present, as \ shall have afterwards frequent occasion to touch on the same subject."1 60. Other writers treat the subject in the same way and seem to think, when they produce cases of simulta- * neous affection of different parts, that they produce instances of the influence of one part over another. It is however very evident that they are no more than ca- ses of the former, which the latter is introduced to ex- plain : and it does not by any means follow necessari- ly, that this simultaneous affection is produced by a sympathetic influence of one part over another; for it may be that these affections are the common effects of some cause operating simultaneously on the different parts affected. The question is, in which of these two ways do the affections occur together 1 61. The doctrine of a sympathetic influence of one part over another is beset with difficulties, and leads to absurd conclusions. 62. The introduction of this doctrine to explain the phenomena of fever, has led its advocates to fix upon the stomach as the seat of the primary action of the remote cause of fever, the most extensive in its opera- tion. It has been asserted, that intermitting fever ari- ses from a morbid impression made on the stomach, by the direct action of miasmata which enter by the mouth, the head and the liver being affected in conse- 1 Whytt on the Nerves and Nervous Piseases, p. 29, 36 quence of the influence the stomach exerts oyer them. But to this doctrine there are insuperable objections. 63. The remote cause, miasmata, does not produce its first effects on the stomach. It affects the colour of the blood of every person exposed to its operation; and with this, the colour of the skin, and of the pas- sages when under the operation of a cathartic, and of- ten without. The blood, the skin, and the passages, all become darker; the former and the latter often black. This is the case with those who are apparent- ly not at all affected, who are about their daily busi- ness and eating heartily. Any body, during the prevalence of an autumnal epi- demic of any severity, on taking a mercurial cathartic, and many without, will have black or green passages; or, if blood be drawn it will be found black. 64. The same remote cause often produces, before any disorder of the stomach is observed, other symp- toms which precede fever and have therefore been cal- led premonitory symptoms ; as listlessness, weakness, sleepiness, slight pain in the head, vertiginous affec- tions, &c. and all these in many cases in which the ap- petite continues good to the time of the attack. These symptoms preceding the affection of the stomach, it is very evident that the stomach is not the part first af- fected, and that they are not produced in consequence of an affection of that part, by means of its influence over other parts. 65. Moreover, many of the remote causes are of such a nature that the idea of their being taken into the stomach is absurd. A man exposed to a cold rain becomes chilly and a fever often follows : fear is ano- 37 ther remote cause of fever; also loss of blood, a fall or a blow. None of these however act directly on the stomach. They nevertheless produce nausea, and some of them with more certainty than miasmata. Thus bleeding largely will certainly produce nausea and often vomiting: a fall or a blow often produces the same. The disorder of the stomach in fever therefore, is not the direct effect of the remote causes acting on the stomach. 66. Inasmuch as the stomach is very often not the part first disordered, and as this disorder when produ- ced is not the effect of the direct action of the remote causes, it follows that the disorder of the head, liver, &c. is not the effect of a morbid impression on the sto- mach, by means of the sympathetic influence of the latter over the former. 67. A sympathetic influence of one part over another, implies a medium or channel of communication be- tween those parts. There is no part known to have influence over another, without a channel to convey that influence. The influence of the brain is convey- ed to the different parts of the body through the chan- nel of the nerves ; and if the free passage of that influ- ence through one of them be interrupted by ligature, vain is every effort to move the part supplied through that nerve. If this influence, so essential to the slight- est motion of every part, to the well-being of the body, and to life itself, be not able to pass without a channel of communication, the strongest presumption arises of the necessity of such a channel in every case of influ- ence of one part over another. 68. The advocates of the doctrine of sympathy, ful- 38 ly aware of this, have endeavoured to show that the nervous system is the medium.1 If this were so, (1.) When the brain is affected, all the other parts ought to be affected,2 and the affection ought to be in proportion to that of the brain ; (2.) Those parts which are intimately connected, ought always to suffer together ; (3.) They ought to suffer in proportion to the close- ness of the connexion. 69. But none of these inferences hold good : (1.) The brain suffers in every way, when many parts escape; and often those supposed to be most closely connected with it; and the affection of those parts which are affected at the same time, is not in pro- portion to that of the brain ; (2.) Those parts intimately connected, do not always suffer together; (3.) When they do, their suffering is not always in proportion to the closeness of the connexion. The nervous system cannot therefore be the medi- um. 70. This is admitted by a late writer who strenu- ously advocates the doctrine of sympathy. He says, "We find in some old anatomical books, an attempt to trace sympathies to the ramifications proceeding from the common trunk of a nerve ; but better obser- vation has proved that sympathies have little or no dependance on the connexion and distribution of nerves."3 1 Cullen*= First Lines &c. xliv, Whytt on the Nerves d 10 2 Whytt on the Nerves, p 11. J -^rves, p. i«. 3 Blane's Medical Logic, p. 145. 39 Convinced, however, of the absolute necessity of a medium, he says, "the medium of this communication is probably some imponderable fluid j"1 an admission that there is no known medium. 71. A medium being therefore necessary, and none provided, for the passage of sympathetic influence from one part to another, none such passes, and therefore none exists ; the only purpose for which it is suppoi sed to exist, not being effected. 72. There is evidently, therefore, nothing more than a simultaneous appearance of the affections in question (52. 60). Every thing more than this is assu- med. Whytt's instances show no more. Cullen only presumes the existence of the consent.2 Richerand as- serts a relation between certain parts, but acknow- ledges we know nothing of its nature. No one argu- ment is offered to prove the existence of sympathy. 73. Some have taken a more philosophical view of this subject, and have admitted that the term, sympa- thy, merely expresses the fact that there is a certain connexion between different parts, whereby when one is affected the other is likewise. According to this view, sympathy is the mere name of the connexion, and its nature is still a subject of investigation. Such however is the influence of names over the human mind, that we insensibly glide into the belief that we understand an operation when we have only given it a name.3 Thus, if we ask why is the head affected when the stomach is disordered, and are told it is by sympa- 1 Blane's Medical Logic, p. 143. 2 Cullen's First Lines &c. xliv. 3 Antiquum enim et usitatisaimum apud medicos est, sibi aliisque persuadere se rem intelligere, cum nomen tantum didicerint, novam- 10 thy, there is an appearance of an answer; but it is evi- dent we have learnt nothing; if we put the definition in place of the term. If we should answer the question by saying the head is affected by the connexion that exists between it and the stomach, no one would consi- der it a satisfactory solution. 74. There is a striking instance of this delusion in a work published by an eminent physician. After insis- ting on the retention of the term sympathy, on the ground that we must have some word to express what actually takes place in certain operations of the system, and if we reject this we must invent another, he says, " Some of the most striking phenomena, such as the translation and conversion of diseases, can in no o- ther way be explained:" * Whence it is fair to infer that he thinks this word, expressing only what actually takes place in certain operations, explains the nature of those operations. 75. The following is an instance in which no infor* que rem se credere invenisse, cum novum tantum rei antea bene no- tas nornen imposuerint. Caveant autem medici, caveant imprimis in medicine studium incumbentes, ne hoc modo sibimet ipsis dent verba, umbramque pro substantia captent. Gregor. Conspectus Medici- nae Theoret. Introd. p. 6. For it is an ancient and very common thing among physicians, to persuade themselves and other*, that they understand a thing, when they have only learned a name; and to believe that they have dis- covered a new thing, when they have only imposed a new name up- on a thing well known before. Physicians ho-jcever should take care, AND ES?ECIALLY THOSE WHO ARE EARNESTLY ENGAGED IN THE STU- DY OF medicine suoui.d beware, lest in this nay they deceive them- selves, AND GRASP THE SHADOW INSTEAD OF Til" SUBSTANCE. 1 Clane^s Medical I.^ic,p. 143. 41 mation is conveyed by explanations founded on the doctrine of sympathy. The connexion of the surface of the body with the kidneys is called by the same writer one of " the most striking and important exam- ples of sympathy."1 If we ask how is the secretion of the kidneys in- creased, when the perspiration is diminished; the an- swer is, by the sympathy between them; by the mu- tual influence of these distant parts on one another (55). What is there in this answer more than the as- sertion of a connexion by which the phenomenon oc- curs 1 of the nature of which we know nothing from the answer; while its very existence is only inferred from the fact which it is brought forward to explain. I need not say, this is not an explanation of the cause of the phenomenon. 76. With regard to the second branch of the ques- tion (60), are tliese affections produced by some cause acting simultaneously on the different parts; it is cer- tain that these symptoms occur in consequence of ex- posure to the action of certain remote causes of dis- ease ; and therefore each of them is an effect of the operation of the remote cause, or of some intermediate cause on that particular part (18). 77. The relation between the affections of the dif- ferent parts must therefore be that of cause and effect, or that of effects of a common cause. If one be the cause of the other, it must always precede ; if it some- times succeed the other, it cannot be the cause. If, therefore, in consequence of the action of certain cau- ses, two affections ordinarily appear together, the one 1 Blane's Medical Logic, p. 144. 6 42 or the other, indifferently, preceding, they are effects of a common cause. 78. In order to ascertain how and why these affec- tions occur together, the proper course is to inquire the cause of each, and to trace up the chain of causes from each to the remote causes (19). Thus shall we discover the relation they bear to one another, or the nature of their connexion, and the reason of their oc- curring together. 79. We have thus endeavoured to show that the re- mote causes and the symptoms of disease are the ex- tremes of a series of causes and effects; to point out the proper course of inquiry in investigating the con- nexion between them (19); to show that instead of prosecuting the inquiry in this way, physicians have had recourse to various hypotheses to enable them to explain the morbid phenomena; that these hypothe- ses are unfounded, at least to the extent assigned to them, and insufficient to explain the phenomena ob- served ; and therefore that the great problem, what are the connecting links between the remote causes and the symptoms of disease, is not yet solved. 80. I shall now attempt the investigation of this connexion, by inquiring into the effects of the remote causes; next into the effects of these effects, or new causes; and so on descending to the ultimate effects, the symptoms in question (19). CHAPTER II. OF THE REMOTE CAUSES OF DISEASE, THEIR MODE OP OPERATING, AND THEIR EFFECTS ON THE BODY. 81. The blood is the natural stimulus which excites the heart to action. "When we tie the two venae cava? so as to prevent the blood from arriving at the heart, the heart stops ; when we slacken our ligatures and let in the blood, it moves again ; when we tie the aorta, the left ventricle being full of blood will continue struggling, bending, turning up its apex, and contrac- ting incessantly and strongly, and will continue this struggle long after the other parts have lost their powers."1 Thus, when the entrance of the blood into the heart is prevented, it ceases to act; when the blood is let into it again, it acts again ; and when by tying the aorta, the blood is prevented from escaping from the heart, its continued presence produces continued ac- tion of that viscus. The blood is therefore the natural stimulus which excites the heart to action. 82. The action of the heart is measured by its ef- fect, the distension, which we call the pulsation of the arteries. If this be forcible, we judge that the heart acts strongly; if it be weak, we judge the action of the heart is weak. Bell's Anatomy, Vol. 1, p. 342. 44 83. The blood, sent to the remote parts of the sys- tem by the action of the heart, communicates colour and warmth to the surface and extremities. If the action be increased by exercise, or in fever, the coun- tenance is flushed; if it be diminished, or suspended, as in fainting, paleness and coldness ensue. The ac- tion of the heart therefore is also measured by the co- lour and temperature of the surface and extremities. 84. Experience has ascertained that certain exter- nal agents, some great bodily exertions, and some im- pressions on the mind, although they do not imme- diately produce disease, yet effect such an alteration in the state of the system, that morbid symptoms sooner or later appear. These are called remote cau- ses of disease in contradistinction to the immediate or proximate cause. 85. All the remote causes of disease, directly or in- directly, weaken the action of the heart. We shall adduce evidence of the truth of this, with respect to each remote cause as it is mentioned. 86. If a person be deprived of food for several hours longer than usual, various morbid symptoms appear, with febrile action. This I have personally expe- rienced many times. Dr. Currie, of Liverpool, relates the case of a gentleman who could not pass food into the stomach in consequence of a stricture of the lower part of the oesophagus. He died in four days after ceasing entirely from taking nourishment in any way. "The state of the pulse, as well as almost all the other symptoms, very nearly resembled the symptoms of the last stage of fever, when it terminates fatally."1 Mo- 1 Currie's Medical Reports, p. 211. 45 therby, and after him Parr, says, " when animals die for want of food, their death is not directly the conse- quence of hunger, but of a putrid fever." 87. These effects are sometimes produced on great numbers. There have been many instances of famine producing the death of thousands, with the symptoms usually appearing when other remote causes of disease operate extensively. It has accordingly been univer- sally admitted to be a remote cause of disease in coun- tries or cities, in which a dense population, in conse- quence of unfruitful seasons, or the devastations of war, have been deprived of subsistence. 88. If we abstain from food for several hours longer than usual, the action of the heart soon begins to de- crease ; and if the experiment be continued a whole day the pulse becomes very feeble, and the counte- nance pale, with a general feeling of excessive lan- guor, evincing weakened action of the heart (82. 83). 89. Excessive bodily exertion producing fatigue, is another remote cause of various morbid symptoms. This I have often experienced, and often observed in others. Those who on a sudden emergency exert themselves excessively, are very apt to be indisposed and feverish for some days afterwards, and in the au- tumnal season the fever is frequently very severe. 90. Violent exertion of the. body continued for a length of time, sends on the blood with such rapidity to the heart as to excite it to too great action (81), which soon unavoidably terminates in diminished ac- tion of that viscus, indicated, particularly when the exertion is very excessive, by a fluttering and feeble pulse (82. 83). 46 91. External violence from a blow or a fall produ- ces fever, and various morbid symptoms, besides the local symptoms proceeding from contusion. Blows have the effect of reducing the action of the heart in a remarkable manner. A violent stroke, not on the head only, but on any part of the body, will in an in- stant stop the action of the heart. Falls have the same effect precisely, it being immaterial whether a body be impelled against a man, or he against the body. I have seen a person who had fallen from a horse continue for some time with a feeble pulse, pale countenance, and yawning and stretching, as in the cold stage of fever. 92. The depressing passions, fear, grief, &c. have long been observed to produce various morbid affec- tions and to favour the attack of fever, rapidly promo- ting the spread of epidemics: they are therefore re- mote causes of disease. These passions weaken the action of the heart. High degrees of them suspend and even extinguish it. Lower degrees produce feeble pulse and paleness of the countenance, indicative of weakened action of the heart (82. 83). 93. Want of rest or sleep is a remote cause of dis- ease. The body when fatigued requires a certain time of inaction in order to recover its wonted vigour. If too little time be allowed for sleep, it becomes lan- guid, and the weakness of the pulse and paleness of the countenance indicate weakness of the action of the heart. 94. Several of these causes are frequently conjoined in their action. The depressing passions, want of 47 rest, and great fatigue, operate together upon many of those who are attending upon sick friends. In these circumstances it has often been observed that the con- fident, the fearless, the cheerful, and those who attend the sick from a sense of duty, escape, while the timid fall victims to the disease. 95. Stimulants of every kind used to excess are re- mote causes of fever. Fermented liquors used too freely are followed by a feverish state on the following day. This effect is observed at any time, and in any circumstances ; but if other remote causes be in ope- ration, their joint action produces a greater effect. Thus during the prevalence of an epidemic, many escape until they indulge in the use of wine, &c. to excess, when they are very liable to be immediately seized. 96. These stimulant drinks have a powerful effect in weakening the action of the heart. They stimu- late it to increased, which necessarily terminates in diminished action; and this, evident even after the first act of intemperance, shows itself much more clearly after repeated indulgences, by the general lan- guor, the paleness of the countenance, and the feeble- ness of the pulse (82. 83). 97. Strong tea produces considerable disorder and feverishness in many persons on the day following the use of it. In those who do not discover this effect immediately, it may be observed after a few days con- tinuing to drink tea more frequently in the day, and stronger than common. Strong coffee has a similar, but not so great an effect as tea. Strong tea remarka- bly excites the action of the heart of most people, and 4* the continued use of it rarely fails to produce weak quick pulse, and pale complexion (82. 83). 98. Intense application of mind is so generally as- sociated with other remote causes of fever, as want of rest, and sometimes with the use of stimulants, as strong tea, coffee, tobacco, opium, wine, or brandy, that some doubt might arise as to its efficacy in pro- ducing disease. Those however who have carried their application to great lengths for years, and who have abstained from the use of stimuli, have found, or may have observed, that they are incapable of devo- ting all of even the ordinary waking hours, for a length of time, without producing considerable disor- der of the system, with feverish heat. It is therefore of itself a remote cause of disease. Intense application produces in a striking degree the languor, paleness, and feebleness of pulse, which indicate weak action of the heart (82. 83). 99. Cold reduces the force of the pulse in a very short time, and paleness, coldness, and shrinking of the surface and extremities ensue, indicating weak- ened action of the heart (82. 83). 100. These are said by some to be only the first ef- fects of cold; and it is alleged that it soon after raises the pulse and the temperature of the body. 101. If indeed a considerable degree of cold be ap- plied to a healthy person, and in a few moments after be withdrawn, he will experience the last mentioned effects; but if the application of cold be continued, the pulse and the temperature will never rise as high as they were before the application. 102. The experiments of Dr. Currie, of Liverpool, 49 show in the clearest manner, that the continued action of cold reduces the pulse, and the temperature of the body. 103. With regard to the pulse, he says, it invaria- bly sunk from 85 and upwards in a minute, to 65 or 68; became firm, regular, and small; buj after being long in the bath, could hardly be felt at the wrist.1 104. With regard to the temperature; when a man is immersed in very cold sea water, the heat of his body is, in a minute or two, considerably reduced. If he continue in the water, his temperature after some fluctuations, during which it never rises to the height at which it was before immersion, rapidly decreases. 105. Currie states that a healthy man, twenty-eight years of age, with black hair and ruddy complexion, was immersed on four different days in sea water, at the temperature of 44 and 42 degrees. His tempera- ture fell 9 degrees in two minutes, on an average of the four experiments. After the first fall there was some rise, but not to the same temperature as before immersion by near 4 degrees on an average.2 106. This small rise is however only temporary; immersion in cold salt water, continued for some time, producing a rapid fall. Thus in the seventh experi- ment the heat sunk at first 11 degrees, and then mounted in the usual irregular way, and at the end of thirteen minutes had ascended to 92 degrees, within two degrees of its height before immersion. Here it stood for nineteen minutes, with little variation; at the end of that time it began to fall rapidly, though ir- regularly, and in three minutes was as low as 85 de- 1 Currie's Medical Reports, p. 152. 2 Ibid. p. 145 to 148. 7 50 grees; and it was not thought safe to push the experi- ment farther. In this experiment, when the heat sunk rapidly, Dr. Currie examined the motion of the heart, and found it feeble and languid.1 The same person who was the subject of the four first experiments, lost his heat in cold fresh water more gradually; but throughout the experiment it contin- ued to sink in a remarkably uniform manner.2 107. Now if this person, after having been im- mersed for half a minute or less, had jumped out of the water, there would have been an increase of the pulse and of the temperature. The conclusion is, that the effect of cold is to depress the pulse and tempera- ture ; and the rise of both is plainly the consequence of withdrawing the depressing power. This happens in the following manner. 108. The action of the heart being reduced, less blood is propelled into the arteries, and consequently it accumulates in the vena cava. On removing the cause of the depression, the cold water; the natural stimulus of the heart, the blood (81), being present in abundance, increased action immediately follows. Whereas when the cause of the diminished action is continued, the effect continues until the action of the heart almost ceases; and it becomes evident that by a little longer exposure it would cease altogether.3 109. The same occurs when cold water is dashed on a person. A boy eight years of age, strong and sturdy, had three basins of cold water poured on his head and shoulders. He felt a glow of heat after it. This occurred every morning for some days; but on » Currie's Rep. p. 152. 2 ibid. p# 157< 3 Jbid ^ ^ ^ 51 trying six basins, his temperature did not rise, but he became pale and even livid, and complained for some time of being cold. 110. Some experiments made by other medical gen- tlemen vary a little from those of Dr. Currie.1 In these " the strength of the arterial action was in all cases diminished by immersion in cold water; but its fre- quency was, with scarcely any exception, increased ; in many cases, from the combination of extreme weak- ness and rapidity, it was scarcely possible to count the number of the pulsations." This variation, far from weakening, gives force to the conclusion drawn from the experiments of Dr. Currie; the last described pulse being one of extreme debility. 111. Cold applications to'a small part of the body produce the same effect of weakening the pulse, and of course the action of the heart, in a minor degree. I know a lady, who, going into the kitchen to hurry dinner for some company, set to washing a «abbage in cold water, in which her hands and arms were im- mersed a short time: this exposure produced a chill in which of course the pulse was weakened, and there- fore the action of the heart. The following experiment was made on an uncom- monly strong stout boy of twelve years of age. He sat with his feet and ankles in water at the tempera- ture of 56 degrees, into which lumps of ice were put at the same time with his feet; the ice was not all melted at the close of the experiment. His pulse before im- mersing his feet beat 90 times in a minute, and mode- 1 Dr. Stork, of Bristol, England, and Doctors Spooner and McPon- nel, Edinburgh. See Rees's Cycloped. art. cold, 9th column. 52 rately strong. In the third minute there were 96 pul- sations ; 96 also in the fifth; 87 in the tenth; 82 in the fifteenth ; 78 in the twentieth. The pulse all this time, and for two or three minutes longer, was softer and weaker; towards the latter part requiring consi- derably more attention than at first in order to feel it. There was some fluctuation in the strength, but every little increase was followed by a decline, and on the whole there was a decided reduction in strength. There were 80 pulsations in the twenty-fifth minute, and they had become fuller and stronger; 83 in the thirtieth; 85 in the thirty-fifth, and decidedly weaker than ever; 84 in the fortieth; 81 in the forty-fifth; 84 in the forty-eighth; 88 in the fiftieth, increasing in strength again ; 80 in the fifty-fifth, declining again. His feet were then taken out and the pulse became slower, and very strong and full, every pulsation as if with an effort; from the fifty-fifth to the sixty-fifth, 74 to 76 pulsations in a minute; in the ninety-fifth mi- nute the pulsations were 75, and still full, flowing, and strong. The temperature was the same throughout. 112. The mode of the application of cold to the body makes no difference in the nature of its effects; exposure to cold air producing the same as that to cold water. The former, like the latter, reduces the pulse and the temperature of the body if continued; if withdrawn after a short exposure, the pulse and tem- perature rise. Cold air has very ready access to the neighbourhood of the heart by the lungs; in conse- quence of which people who are warm clothed, and exposed to a very cold air, are often severely affected before they are aware of it; the lungs not being sensi- 53 ble to any ordinary degree of cold. John Bell says, the heart feels, when it can be called nothing more than a punctum saliens, the slightest change of heat or cold.1 113. Cold applications internally to the stomach produce the same effects. Thus if a person drmk cold water when heated, the force of the pulse will imme- diately be reduced, and the whole body cooled. If the draught be free, and the person in good health, he will soon after feel a glow on the surface similar to that produced by dashing a basin of cold water over the body. If he continue to drink glass after glass, the pulse will be reduced, as by the continued appli- cation to the surface. In persons of less vigorous health the application to the surface is not followed by a glow, and even one basin of cold water is apt to produce chilliness. Such persons often object to drinking cold water when recommended to them, al- leging that it makes them chilly, and prefer for that reason putting a toast in it. 114. When cold applications are made to the scro- tum, that part contracts; this has been advanced as a fact indisputably proving that cold stimulates. This conclusion is founded on the assumption that contraction is a state of excitement, and it is argued, as excitement is the effect of stimulants, that cold is a stimulant. The foundation however is not sound. When the pulse is rendered feeble by continuing long in cold water, and the countenance is pale and even livid, and the body shaking with cold, the scrotum is rigidly contracted. This contraction is therefore no » Bell's Anatomy, Vol. 1, p. 339. 54 more excitement, or the effect of a stimulant, than the contraction of the rest of the skin, at the same time, or in the cold stage of fever. The foundation failing, the argument falls, and cold is not a stimulant. To those who may notwithstanding believe that con- traction of the scrotum is a state of excitement; it may be suggested that, admitting it to be so, an effect may be produced by an agent directly or indirectly: the agent may be the immediate cause ; or it may be the cause of some change, which is in turn the cause of the phe- nomenon observed. It is only by observation that we ascertain in which of these ways any effect is pro- duced. When therefore we see the scrotum contract on the application of cold, we are to inquire whether cold produces this effect directly, or indirectly by means of some change it produces. In inquiring into this point we must bear in mind that the direct effect of cold, in every way in which it is applied, is to dimi- nish action (102, &c.); 2, that cold increases action only indirectly (107). We should therefore be well supported were we to determine that the contraction of the scrotum, admitting it to be a state of excite- ment, is the indirect effect of the application of cold. The force of this argument will appear in a stronger light by contrasting the effect of heat with that of cold on the same part. Heat produces exactly the opposite effect of relaxing the scrotum. With the same propriety that it has been argued that cold is a stim- ulus, because it produces contraction of that part, we may conclude that heat is not, because it relaxes it. We know, however, that heat is a stimulant, and there- 55 fore we conclude, that, if what is called relaxation of the scrotum be a state of deficient excitement, it is an indirect effect of heat. So we know that cold reduces action ; and when we see this debilitating power pro- duce contraction, admitting this to be a state of ex- citement, we should conclude of course that it is indi- rectly produced. 115. In certain circumstances, chiefly of great heat and fatigue, a draught of cold water produces sudden death. Our harvest people in the midst of their la- bours sometimes die in a few minutes after a draught of water from a spring. The external application of very cold water in similar circumstances produces the same effect. Dr. Franklin says, " I once knew an in- stance of four young men, who, having worked at har- vest in the heat of the day, plunged into a spring of cold water; two died on the spot, a third the next morning, and the fourth recovered with great diffi- culty. A copious draught of cold water in the same circumstances is often attended with the same effect in North America."1 116. As many escape these effects who drink cold water and bathe in it, there is evidently something pe- culiar in the state of the persons injured by it. There are two opinions respecting the circumstances in which cold applications are fatal. 117. Dr. Currie contended that the danger arises from cold applications while the body is cooling after having been heated.2 He says, " In all the cases which I have consulted, as well as in those I have related, three circumstances are either expressed, or may be 1 Currie's Rep. p. 96. a Ibid. p. 81. 94. 56 clearly inferred: 1, the body had been previously heated beyond the temperature of health by exercise carried to fatigue ; 2, to this violent exertion a state of rest had succeeded; 3, a profuse perspiration had ta- ken place."1 118. The cases stated are surprisingly opposed to the doctrine advanced. The first circumstance men- tioned as occurring in these cases is correct; the se- cond is in every instance the reverse, excepting per- haps one. In the first case stated,2 a young man having been engaged for a long time in a most severe match at fives, after it was over sat down on the ground panting for breath and covered with profuse perspiration. He called for a pitcher of cold water just drawn from a pump in sight, held it in his hands for some minutes, but put it to his head as soon as he had recovered his breath, and drank a large quantity at once. He laid his hand on his stomach and bent forwards ; his coun- tenance became pale, his breath laborious, and in a few minutes he expired. In the second, after violent exertion at playing ball, neither the sweating nor fatigue having abated, the young man went into a cold wine cellar, drank, and died immediately. In the fourth, fifth, sixth, and eighth, it is manifest that the sufferers drank greedily immediately on reach- ing the water without waiting for " a state of rest to succeed." The seventh is of a mixed nature, but bears the same import.3 1 Currie's Reports, p. 83. 2 ibid. p# 81 3 IW(J> g3 57 119. Currie also quotes several instances in which great numbers suffered in the same way. He mentions one from Appian, in which the soldiers of an army, fatigued in battle and being very hot, drank greedily of the water of a fountain, and many died.1 He quotes another related by Gulielmus Tyrius: an army passing through a parched country at length ar- rived at a river, drank greedily, and many died.2 120. In the case of Alexander's army on the march through the desert of scorching sand, the very same thing occurred. Arrived, fainting under their toils, at the river Oxus, they immediately kneeled down and drank so intemperately, that Alexander lost more men here than in any battle he fought.1 121. In the case of Alexander himself, the same is most evident. He made a forced march through the defiles of Mount Taurus to save the city of Tarsus from being burnt by the Persians. " It was at the close of this extraordinary march, according to the tes- timony of all the historians, that the conqueror, ad- vancing into Tarsus at the head of his troops, co- vered with dust and sweat, and exhausted with long continued toil, stripped himself in the sight of his army, and plunged into the pure and cold waters of the Cydnus which runs through the city. The symp- toms that followed are described with sufficient mi- nuteness and precision. Vixque ingressi subito hor- rore artus rigere coeperunt: pallor deinde suffusus est, et totum propemodum corpus vitalis calor reliquit. Exspiranti similem ministri manu excipiunt, nee satis compotem mentis in tabernaculum deferunt. Q. Curtii, 1 Currie's Medical Reports, p. 84. 2 ibid. p. 85. 8 5S Lib. iii. cap. v."* Even in this ease of the applica- tion of cold water to a person, immediately on his ar- rival at a river from a long and rapid march, "co- vered with dust and sweat," and of course without in- terval, without time for rest, Dr. Currie makes the ex- traordinary supposition that he "must have been cooled, as well as debilitated, by excessive perspira- tion and fatigue."1 122. The only case which affords this doctrine any appearance of support, is related of two young men travelling on foot,2 who arrived about eleven o'clock in the forenoon "heated, but not fatigued," on the banks of the river Tweed. They stripped instantly and plunged in. The utmost refreshment followed. In the afternoon they proceeded sixteen miles further at a single stretch. The afternoon had been warm and they sweated profusely, but the evening was tem- perate and rather cool. They had travelled for some miles slowly, and arrived at the end of their journey stiffened and wearied with their exercise. The re- freshment experienced in the morning from bathing, induced one of them to repeat the experiment, and he went perfectly cool into the same river. " The con- sequences were very different. The Tweed which was so refreshing in the morning now felt extremely cold, and he left the water hastily. No genial glow suc- ceeded, but a feverish chill remained for some time, with small frequent pulse and flying pains over the * Having scarce entered the water, his limbs began to grow cold with a sudden rernbhng: then paleness spread over him, and the vital heat almost left h>s whole body. His attendants took him, like a dvine per- son, in their arms, and earned him, not properly in his right slnses, into his tent.—Currie's Med. Rep. p. 94 * Ibid. p. 94. 2 ibid. p. 98. 59 body. Warm liquids and friction brought on at length considerable heat, and towards morning perspiration and sleep followed." The next day he was extremely feeble, and it was several days before he recovered his usual vigour. 123. This case, unconnected with the others ad- duced, might be considered as favouring the doctrine that the danger arises from cold applications while the body is cooling after having been heated (117). But we are compelled to reject the idea; 1, because this is the only one of all the cases stated in which there was time to cool before the cold application was made; 2, because in Dr. Currie's tenth experiment, made to ascertain the effects of immersion in cold wa- ter, the same effects followed on the application of cold water to a person who had not been previously heated. 124. In this experiment, the bath stood in the open air j1 the temperature of the air was forty-one and an half degrees; that of the water forty degrees. A young man was immersed to the shoulders in this bath for thirty-four minutes. On coming out, notwithstand- ing the use of the warm bath, he began to shiver vio- lently, " became sick and very languid, a cold sweat covering his face, his pulse very quick and feeble. He was removed into bed, but passed a feverish night, and next day had wandering pains over his body, with great debility, resembling the beginning stage of a fever. By cordials and rest this went off."2 125. The identity of the effects of immersion in cold water, whether the subject of the experiment be pre- viously heated or not, is manifest (122. 124); and the 1 Currie's Medical Reports, p. 145. 2 Ibid. p. 158. 60 conclusion is irresistible, that the danger does not arise from the application of cold to a person becoming cool or losing heat, after having been heated to excess. 126. This erroneous principle has led to a corres- ponding inference. Dr. Currie considers it "per- fectly established, that there is no situation in which the application of cold to the body, whether to the sur- face or the stomach, is so safe, or in general so salu- tary, as when the heat of the body from whatever cause is preternaturally great, provided the body is not already in a state in which it is rapidly parting with this heat, and no disease has taken place in the general sensibility, or in the structure of any of the parts."1 127. This is a legitimate conclusion from the doc- trine advanced (117), but is contrary to the constant experience of this whole country; it being not un- common to hear of men in the harvest field, stop- ping to drink out of a spring and dying on the spot. In consequence of these terrible accidents, it has become a practice to wait a while in order to be- come cool before drinking, and experience has proved it to be the proper plan. 128. Dr. Rush on the other hand, from its being so common for people to suffer in this way from drinking cold fluids, while excessively heated, considered this circumstance essential to the production of the effect; and recommended strongly, that persons who are pre- ternaturally heated, and who will notwithstanding drink cold water, should first cool themselves by wash- ing the hands and face. He asserts that "by the use 1 Currie's Medical Reports, p. 87. 61 of these preventives, inculcated by advertisements pasted upon pumps by the Humane Society, death from drinking cold water has become a rare occur- rence for many years past in Philadelphia."1 That this circumstance, excessive heat, is not essential, is evident from the case of the young man above related (122), and from the tenth experiment of Dr. Cur- rie (124). 129. These dangerous consequences of cold appli- cations appear, therefore, when the body is greatly heated without subsequent cooling (115. 118. 121); when it is cool after having been heated (122); and also without its having been previously heated (124). There is something here inconsistent with the theo- ries of both Rush and Currie. 130. The solution of the difficulty rests on the prin- ciple above established (99 to 113), that cold applica- tions to the surface or to the stomach reduce the action of the heart. If these be made, for a short time, when the heart is vigorous, the reduction is quickly followed by increased action (107. 109); but if the action of the heart be already low, the additional reduction by cold applications is so great as to produce almost imperceptible pulse, and even its sudden extinction (9. 115). 131. On applying this principle we shall find it to explain every difficulty in the cases adduced. In those mentioned by Franklin (115), as well as in the cases stated by Dr. Currie (118 to 121), the persons had been already exposed to the extreme operation of a powerful cause of reduced action of the heart, ex- cessive fatigue (89. 90). * Rush's Works, Vol. 1, p. 195. 62 In the first case mentioned by Dr. Currie, the young man was excessively fatigued, and could not for some minutes drink for want of breath, and drank as soon as he had recovered it (118). The expressions,1 in the second, " nee sudore adhuc aut fatigatione remis- sis ;"* in the third, " et sudore respersus ac totus ma- didus et fatigatus ;"f in the fourth, " corporis totius ada- pertis poris madidus ;"J in the fifth, " exhausted with fatigue ;" in the sixth, " stooping down after severe la- bour to drink;" in the eighth, " exhaustis viribus et totus sitibundus ;"|| all show excessive fatigue, suffi- cient to produce diminished action of the heart in a very great degree. In the case from Appian (119), the soldiers were excessively fatigued in battle " et aestuantes,"§ when they drank of spring water greedily. In that from G. Tyrius (119), the soldiers were marching through an arid parched country, and of course were hastening forward with all expedition to get to water, (as was also the case with Alexander's army, of which a stri- king account is given from Q,. Curtius, by Currie,2) and were consequently greatly fatigued when they ar- rived on the banks of the river and drank abundantly. In the case of Alexander's army in pursuit of Bes- sus, across a desert forty-six miles in width, they ar- rived " fainting under their toils" on the banks of the river Oxus (120). Alexander himself, when he nearly 1 Currie's Medical Reports, p. 82. * Neither the sweat nor the fat is ue having as yet remitted. t And covered with sweat and all wet and fatigued. J Wet from the open pores of the whole body. j| With strength exhausted and excessively thirsty. {} Literally, waxing hot, boiling. a Note to p. 84. Medical Reports. 63 lost his life by leaping into the Cydnus, was "covered with dust and sweat, and exhausted with long conti- nued toil (121)." The four young men mentioned by Franklin (115) had " worked at harvest in the heat of the day," an exercise, from the custom of racing in the field, not inferior to any mentioned for violence. 132. In all these cases the vigour of the heart was reduced by continued violent action, the consequence of being vehemently stimulated by the torrent of blood forced into it by long and severe exercise (81.) In this reduced state, it is manifest that the application of a cause, as cold, of itself sufficient speedily to re- duce the action of the heart to a dangerous feebleness (124), must be very apt even to extinguish it. 133. On this principle there is no difficulty in explaining the case of the young man who after a day's journey on foot went into the Tweed (122). When he bathed at eleven o'clock in the forenoon, " heated, but not fatigued," the reduction of the ac- tion of the heart by the water, was just enough to make him feel more pleasant. When in the evening he was "stiffened and wearied," and had been com- pelled " to travel some miles slowly" from the fatigue of walking all day, the vigour of the heart was so re- duced, that, on the additional reduction produced by going into the water, the pulse became " small and frequent," and the patient complained of chilliness and nying pains over the body. 134. It appears then that in every case mentioned by Franklin and Currie (115. 131. 133), previously to the application of cold, fatigue had been suffered suffi- cient to reduce the action of the heart. (>4 135. Similar effects have followed the application of cold water for a short time, in cases in which the action of the heart was reduced, but not by fa- tigue. A patient of Dr. Currie's was taken out of bed, shivering in the cold stage of an intermittent, his pulse small and frequent, his extremities shrunk and cold, and cold brine was dashed over him. His breathing was in consequence for some minutes almost suspen- ed; his pulse at the wrist was not to be felt; the pul- sations of the heart were feeble and fluttering; a deadly coldness spread over the surface; and when respiration returned, it was short, irregular, and la- borious.1 136. Continued exposure to cold has the same ef- fect, when the action of the heart has not been previ- ously reduced. This appears from the tenth experi- ment of Currie (124), on a healthy young man (105). The action of the heart was in its natural state, but the immersion in very cold water continuing a very long time, the same effects appeared as on the appli- cation of cold for a shorter time to persons in whom the action of the heart had been previously reduced. 137. The same effects, therefore, proceed from a short exposure to cold, when the action of the heart has been previously reduced; as in the cold stage of fever (135), or by excessive fatigue (131); as from continued exposure, when the action of the heart has not been previously reduced (124). Consequently we must attri- bute the total or almost total extinction of the action of the heart in those cases, in which persons excessively fatigued have drank freely of cold water, or have been 1 Currie's Medical Reports, p. 43. 65 immersed in it, to the joint operation of the two cau- ses ; and may conclude, generally, that the evil effects sometimes observed to follow the sudden application of cold, arise from the operation of this powerful cause of reduced action of the heart, on systems in which the action of that viscus has been previously reduced; most commonly, but not exclusively (135), by exces- sive fatigue. 138. Thus it appears that every variety of the ope- ration of cold, is consistent with the general principle, that cold applications to the body lower the pulse and the temperature, and therefore reduce the action of the heart (82. 83.) 139. Cold is one of the most common, and is the most immediately active of the remote causes of fever; in many cases producing fever in a few hours, inde- pendently of the assistance of other remote causes ; as in the cases mentioned above from Currie (122. 124). 140. Most of the causes of disease yet mentioned are limited in their operation. Want of food, or fa- mine, has in many instances produced great mortality. Cold is very extensive in its operation, but its action is so painful that it is carefully guarded against; and few instances occur of epidemic disease from it alone. 9 CHAPTER III. OF THE REJIOTE CAUSE OF THE EPIDEMICS OF HOI WEATHER. 141. The inquiry into the cause of the epidemics of hot weather, and all the interesting questions con- nected with the subject, are of incalculable impor- tance. For thirty years the discussion has almost en- grossed the attention of the medical world. A multi- tude of facts, scattered through the writings of past ages, as well as a very great number ascertained by the care and attention of the present, have been brought to bear on the subject, and have thrown much light on it; but it seems notwithstanding, for a few years past, to be rather more unsettled than it was.' When facts abound, all that is wanting to ascertain the truth, is a careful induction of such inferences as clearly flow from them. I shall endeavour to proceed in attempting this investigation, cautiously yet firmly. 142. Hot weather in a large portion of the earth, is the time of the greatest mortality; and hot coun- tries are the special seat of epidemic diseases. Here alone they display all their terrors; as we travel north we find them less common and less violent; and the colder countries are comparatively healthy. 3 See the editorial remarks, No. 13, p. 1, of the Philadelphia Journal of Med. and Phys. Sciences; the paper of Ferguson to which they are prefixed; and Chapman on Epidemics, No. 16, p. 366, of the same Journal. 67 When raging with their utmost violence in the au- tumnal months, a stop is put to their further pro- gress by frost, and by the accompanying cool winds from the north, in those countries far enough north to enjoy this benefit: whereas within the tropics no sea- son is exempt from their occasional appearance, and in some parts they prevail throughout the year.1 Heat, therefore, is plainly essential to the existence of these diseases. 143. Heat alone, however, in the degree usual in the hottest climates, is not sufficient to produce epi- demics. Lind states that the dry season in Senegal, the hottest part of the year in that country, is healthy. The Arabs of the great desert of Africa are healthy; and the diseases of Egypt never spread into the neigh- bouring deserts occupied by the Bedouin Arabs.2 The West India islands vary exceedingly with regard to health. Barbadoes is comparatively healthy, while Jamaica and Hayti are very sickly. The latter are five degrees farther north than Barbadoes. Our hot- test seasons are, in many situations, often the heal- thiest ; the fore part of the summer is generally heal- thy ; 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 par- tial cause, while heat is general in its action. Heat alone is therefore not the cause of the epidemics of hot weather. 144. The hot countries within the tropics, in gene- 1 Lind on Hot Climates, p. 34. Hillary, p. 108. - Assalini, p. 66. Burkhardt's Travels, Quart. Rev. No. 41. p. 144. 68 ral healthy during the hot and dry season, become sickly soon after the rains commence. Lind, speak ing of Guinea, says, "This, as most tropical countries, has, properly speaking, only two seasons, the wet and the dry; the former is commonly of about four months' continuance, and is the season of sickness; whereas for many months in the dry season, most parts of this country are equally healthy and pleasant with any in the world."1 No sooner, however, do the rains set in than the ravages of disease commence, and con- tinue throughout the wet season, and afterwards until the abundant moisture' is evaporated.2 As soon as this is effected, the health of the country is restored, ex- cept in those places which continue wet throughout the year. The rainy season and the sickly season are synonymous terms.3 This agrees with what is observed in Europe and America. Dr. Wind, a Dutch writer quoted by Lind, States, that at Middleburg, the capital of West Zea- land, a disease generally reigns toward the end of August or the beginning of September, which makes its appearance after the rains which generally fall in the latter end of July, and is always most violent after hot summers.4 In this country precisely the same thing occurs. Hot and wet seasons are the most sickly; and dry seasons, though hot, are healthy. Thus the wet years 1804, 1821, 1823, were very sickly, and the very dry year 1822, healthy; and although in very dry seasons some places are very sickly, these are uniformly situa- J Lind on Hot Climates, p. 32. 2 ibidj p> 35j 37 .. Q » Ibid. p. 60. 68. 71. 4 Ibid p. 19. ■ 69 ted near water courses, or marshes; of this Harper's Ferry and Shepherdstown, on the Potomac river, are striking instances. Examples of this kind might easily be multiplied. Moisture, therefore, is also essential to the production of these diseases. 145. Heat and moisture, however, though both es- sential, 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, con- tinue healthy if they be kept clean. Many instances are mentioned of vessels in port, immediately on the appearance of disease among their crew, pushing out to sea with the effect of immediately stopping its pro- gress.1 Lind, from experience of this, even advises those who are able, to retreat to floating habitations during the sickly season.2 Instances have often occurred of a superabundance of moisture in hot weather being favourable to health. Pringle tells us that the air of Brabant, in 1748, when the neighbourhood of the towns had been inundated as a protection from the enemy, " sensibly became more noxious upon letting off part of the water, in the be- ginning 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 ra- ged at Breda, gave orders to let in the water again, and to keep it up until winter.3 In the autumnal season of 1798, in Boston, the in- habitants contiguous to a mill-pond in the town were very sickly. This pond was often drained of its water, 1 Lind on Hot Climates, p. 89. 132. 133. 2 Ibid. p. 118,120. 3 Diseases of the Army, p. 62. 70 so as to leave the mud and putrid substances exposed to the action of the sun. The selectmen were re- quested to order the water to be retained constantly in the pond; which being done, the fever soon ceased inthat quarter.1 146. Excessive rains have often produced the same effect. "Dr. Dazilles, 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 daply overflowed."2 Dr. Rush states in his account of the autumnal fever of 1795, in Philadelphia, that "on the 30th and 31st of August, there was a fall of rain, which suddenly checked the fever of the season, insomuch that the suc- ceeding autumnal months were uncommonly healthy."5 The same occurred in the county of Loudoun, Vir- ginia, in 1804. The summer of that year was the wet- test ever known by the jpeople then living; a severe epidemic followed; but on the low grounds of the Po- tomac, usually very sickly, which were that year al- most continually under water, the cases were much milder than on the upland. 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,4 because a defi- ciency is sure to be followed by sickness. He also says, "In the island of St. Lucia, the most unwhole- some town of Castries, at the bottom of the Carenajre, which is altogether embosomed in a deep mangrove i Medical Repository, Vol. 2. p. 466. 2 Rush's Works, Vol. 3. p. 108. 3 Ibid. p. 243. ■* Philadelphia Journal, &c. eVo. 13. p. 8. 71 fen, became perfectly healthy under the periodical rains."1 He further states, that "a year of stunted vegeta- tion, through dry seasons, and uncommon drought, is infallibly a year of pestilence to the greater part of the West India colonies."2 Therefore a rainy year is healthy in the West Indies generally. Lind makes the very same statement of the island of Sardinia.3 Heat and moisture are not therefore sufficient to produce epidemic diseases. 147. In order to ascertain what more is wanting, let us look into the situation and circumstance of those places most liable to these diseases. In the tropical countries, those spots where sick- ness prevails throughout the year, as Benin, New and Old Calabar, &c. are low and marshy.4 Those ci- ties and stations in Africa, Asia, and America, 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 become one vast morass. In more temperate climates, similar spots are the seat of similar diseases in the summer and fall. Such are the Campagna di Roma, and many other parts of Europe. Such, in the United States of America, are the rice swamps of the south, and the swampy countries of the sea coast from Delaware bay southward. If we look around us in our own immediate neighbourhood, we shall observe the same. The marshes, the river bottoms, rendered similar to marshes by the heat of summer, the artifi- 1 Philadelphia Journal, &c. No. 13. p. 8. 2 Ibid. p. 9. 3 Lind on Hot Climates, p. 21. 4 Ibid. p. 34. 120. 72 cial morasses produced by building mill-dams, are the spots noted for disease. Of this every neighbourhood affords instances. 148. On the other hand, places situated at a dis- tance from marshes or low grounds are comparatively free from disease. At the sickly settlement of Bencoolen, in Sumatra, very few of the English survived any length of time, until they built a fort on a dry elevated situation, at the distance of about three miles from the town, which afforded a tolerably safe retreat.1 The Dutch, at JSatavia, one of the most unhealthy spots on the earth, made an excellent road from the city to the mountains for the benefit of convalescents.* "The English, at Bombay, enjoy the benefit of ha- ving several rising grounds near them, from whence, during the rainy seasons, they may in safety behold the adjacent country covered with water."2 Lind mentions St. Thomas's mount, within nine miles of Madras, as the Montpelier of the English settlements in India, and calls it a paradise of health.2 He speaks also of "Monk's Hill, as affording a safe retreat from sickness in Antigua."3 Centreville, in Fairfax county, Virginia, is situated on elevated, dry, slaty land; it may be seen from a great number of places for many miles around. In the sickly autumn of 1821 there occurred, Dr. Lane of that place informed me, but two cases of fever in the town, although the sick in the neighbourhood, in which there are large streams and extensive low grounds, were so numerous, that he scarce had time to sleep. i Lind on Hot Climates, p. 60.152. 2 Ibid. p. 153. * Ibid. p. 148. 73 On inquiring into the source from whence these two persons could have derived the fever; one, Mrs. L., had spent three weeks at the house of a friend who lived near an old mill-pond, and was taken sick soon after returning home. The other was a paralytic fe- male who sat listening to our conversation. She sta- ted that there was a pond in her yard; that she was in the habit of sitting for hours together near a back door for the benefit of air, and that the wind was blow- ing immediately over the pond upon her, at the mo- ment she felt the chill which ushered in the attack. 149. Places formerly healthy, have often been ren- dered unhealthy by an artificial morass, as is witnessed in every neighbourhood when a mill-dam is built. Harrisburg, in Pennsylvania, situated between the Susquehannah river and a small creek, and extending nearly or quite from one to the other, afforded, in the year 1793, a striking example of this. In that year a dam was built across the creek in the rear of the town, whereby was produced a very extensive and shallow pond. In the autumn succeeding, a mortal fever pre- vailed in the town, which the people attributed to the pond ; and they insisted on having the dam removed. With some difficulty they succeeded; the pond was completely drained, and the town was as healthy af- terwards as it had been before. Lind states that the Arabs are in the habit of re- venging themselves on the Turks of Bassora, by break- ing down the banks of the river Tigris, with a de- sign to cover the neighbourhood with water; the con- sequence of which always is a mortal fever.1 * Lind on Hot Climates, p. 78. 10 74 150. Places in the neighbourhood of marshes, for- merly unhealthy, have been rendered healthy by drain- ing the marshes, and have again become unhealthy on suffering the drains to fill up. Dr. Lane informed me that the family of one of his friends had been remarkably unhealthy for years. In 1821 the autumnal fever began in this family very early. He told his friend that he considered an old mill-pond near the house as the source of the evil, and advised him to have it drained. It was done without delay; and as soon as the bottom became dry, the fa- mily became healthy, even before the sickly season had passed over. " Calcutta, built literally on a swamp on the east side of the Hoogly, and surrounded to this moment by immense lakes at a few miles distance, has, by the draining of that part of the city inhabited by Euro- peans, become as healthy as any country of the same latitude on earth. Ten miles below the city, where the country is not cleared, and the rapidity and rank- ness of the vegetation is suffered to infect the air, the jungle, or violent bilious fever, is sure to attack every one who comes for a time within its atmosphere; yet the old village of Fultah, while the Dutch had an es- tablishment there, was healthy, because the ground was cleared; since they have left it, it has become once more unhealthy."1 151. The evil consequences of continuing near a swamp are often experienced by the crews of ships, particularly in hot climates. " It was observed, that during the summer and autumn of 1765, when fevers 1 Lind on Hot Climates, p, 65. note. 75 raged at Portsmouth, and in such ships as lay in that harbour near the mud, the men who were in the ships at Spithead enjoyed perfect health."1 Lind says he was " informed by Mr. Martin, sur- geon of the Cataneuch, a Guinea trader, that when he was in Gambia river, in company with four other ships, the men, in one of those ships, were daily taken ill of fevers and fluxes, and several of them died delirious; while all the English in the other ships, and in the factories, were in perfect health : but upon removing that ship about half a league from her first anchorage, which was too near some swamps, her men became as healthy as those in the other ships."2 152. We find then that in all parts of the temperate zones, and between the tropics, marshes are particu- larly favourable to the production of fevers. 153. It is sometimes objected to this doctrine, that some marshy situations are generally healthy, and that others are generally sickly; also, that the former some- times suffer severely from epidemic fevers, while the latter sometimes escape. These are undoubted facts; but when investigated, instead of weakening, they are found to strengthen the doctrine. 154. Marshy situations, generally healthy, have be- come sickly during a very dry season. A marsh co- vered 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 ef- fect of such exposure may be estimated by what has ' Lind on Hot Climates, p. 118. 8 Ibid. p. 120. 76 been stated of Holland and Boston (145). Senac mentions an instance in which the bottom of a pond was brought into view in a different manner, but with the same result. " Near to 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."1 155. The same cause, hot weather, in different cir- cumstances, produces effects precisely opposite. A marshy spot, which has heretofore rendered a neigh- bourhood sickly, may be dried up, and the consequence is health. On the 23d of July, 1821, so great a quan- tity of rain fell in Fauquier county, in Virginia, that about twenty mill-dams were broken down in the course of the day and following night. The weather was afterwTards very dry. In a short time the mud left on the bottom of the ponds, was so dry that a spade could be thrust down into the large cracks, which appeared to extend to the very bottom of the accumulated sediment. During the time these ponds were drying, bilious vomitings and diarhoeas, and also some most violent cases of bilious remittent fever, oc- curred among the workmen employed in rebuilding the dams, and those who lived near. But after they became perfectly dry, it was universally observed that we never had had so healthy an autumn. 1 Caldwell's translation of Senac on Fevers, p. 20. 4 4 156. Very wet weather will produce the same bene- ficial effects on marshy places ordinarily sickly, by co- vering them from the action of the sun. Of this se- veral instances have already been given (146). Be- tween Winchester and Charlestown, in the valley of Virginia, is a remarkably large and deep spring, from which extends a low marshy piece of ground about a mile long, and perhaps one hundred yards wide. All around this marsh the people have been annually sub- ject to fevers in an unusual degree. In the very wet year 1823, however, the marsh being inundated, they almost entirely escaped. This is also exemplified by the measures adopted in Brabant, and in Boston, to obviate the effects of marshy spots (145). In these instances the inundation of the neighbouring marshes, put an end to the prevailing sickness. 157. The effect of a marshy soil is strikingly mani- fested when that state is only temporary. If a coun- try, ordinarily dry and healthy, in consequence of very wet weather, become marshy in hot weather, epidemic fever will certainly follow. This was exemplified in the years 1804, 1821, and 1823, in the country above and below the Blue Ridge. In these years, particu- larly in the first and last mentioned, the quantity of rain was unexampled in the memory of most per- sons ; as was also the general prevalence of autumnal fevers. 158. A gentleman living on the ridge land between the Opequon and the Shenandoah river, informed me that he had, for nineteen years before 1823, scarcely known what sickness in his family was. A neighbour had been in the habit for many years of watering his 78 meadow by small rills from his mill-race. Before this wet year, the quantity he could spare was very small, and not enough to make the ground wet. This year, however, it was quite marshy, and the road through it miry. The consequence was, a great number of per- sons died in the houses just around the meadow. 159. Thus we see that excessive heat, by drying up the moisture in a marshy tract of country, will make it healthy (155) ; or, by making a marsh of a pond for- merly well filled, will produce unusual sickness (154). On the contrary, that excessive rain will fill a country hitherto dry and healthy, with marshy spots, and pro- duce fatal disease (144. 157. 158); or, will cover from the action of the sun extensive marshes, and prevent the evil which would otherwise have followed (156). 160. AVe find, then, that the objections are founded on a partial view of the subject, and that all the facts confirm the doctrine that marshes are the special seat of epidemic fevers. 161. The following facts shed still more light on the subject. " 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 Ti- ber, the wind suddenly shifted, and blew from the south over the putrid marshes; when twenty-nine were im- mediately seized with a tertian fever, one only esca- ping."1 162. Lind, speaking of a settlement formed by the English on the island of Balambangan, near Borneo, says, " For a few months these people continued in i Lind on Hot Climates, p. 21. 79 perfect health; but no sooner did the monsoon change, than sickness made its appearance; and it raged with such violence that scarce one in ten survived this mon- soon." " The seasons of health and sickness are here regulated by the direction of the wind or monsoon; from October until April, during the northeast mon- soon, the wind comes from the sea, and the settlement is perfectly healthy; but from April until October, du- ring the southwest monsoon, the wind blows over the marshes, both of this island and of Borneo, and pro- duces fevers of a most malignant nature, which fre- quently cut off even the stoutest men in twelve or fourteen hours."1 163. A very fatal fever prevailed at Galliopolis, in Ohio, in the summer of 1796. Major Prior, of the army, witnessed the rise and progress of the disease. He visited Baltimore in September, 1797, and made for Dr. Potter the following written statement of the circumstances. "As the garrison was severely af- flicted 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 Au- gust 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 1 Lind on Hot Climates, p. 74. 75. 80 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 ex- emption heretofore was soon discovered. The wind had blown the air arising from the pond from the camp; but as soon as it shifted to the reverse point, the soldiers began to sicken : in five days half the gar- rison was on the sick list; and in ten, half of them were dead."1 Examples under each of the preceding heads might easily be multiplied. 164. 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. 165. It has been objected to this doctrine that the inhabitants of elevated situations are sometimes har- rassed with autumnal fevers. Thus, a fever prevailed in the year 1823 on a part of the Blue Ridge in Jef- ferson county, Virginia. At the western foot of this mountain flows the river Shenandoah. Between the river and the mountain there is some river-bottom land. The land is cleared and cultivated to the top of the mountain. That year was uncommonly wet and sickly throughout the valley of the Shenandoah. There are, moreover, a great number of obstructions in this river, made of stone, and passing obliquely downwards nearly to the oppo- 1 Potter's Memoir on Contagion; also, Medical Recorder, l. 52?. 81 site side, in order to throw the water to one side, and increase the depth of it for the improvement of the boat navigation. These obstructions have produced a number of shallow places, and marshy spots at the edge of the river. It is evident from this statement that the circum- stances are perfectly adapted to the production of the gas in question: and it is equally evident, that the relative position of the river and the mountain is such, that the westerly winds, which are prevalent through- out the autumnal season, must carry the gas arising from the marshy spots about the river, directly up the mountain; as it did in the cases just stated, upon those who were to leeward of the marshes (161 to 163). 166. Marshes, during the heat of the summer and autumn, when these diseases appear, abound in putre- fying vegetable matter, whence proceeds an abun- dance of gas. All the circumstances favouring the prevalence of epidemics, are such as peculiarly favour the putrefaction of vegetable matter. Thus heat and moisture are both necessary (142. 144); but such a degree of heat as, by drying up a marsh, puts an end to the putrefaction of vegetable matter therein, puts an end also to the prevailing epidemic (155) ; or such an abundance of moisture as by covering the ve- getable matter, and protecting it from the action of the sun, checks or puts an end to putrefaction (156), produces the same effect. Further, as long as there remains any moisture in a marshy place, the greater the heat, and therefore the greater the putrefaction, the more violent the epidemic : while frost, which puts an end to putrefaction, puts an end to the epidemic. S2 There is, therefore, very strong evidence that the gas driven by the wind from marshy places, which is the cause of epidemic fevers (163. 164), is the product of the putrefaction of vegetable matter. 167. This is corroborated by the occurrence of such diseases when vegetables in bulk, as potatoes, &c. are suffered to putrefy. The first cases of the fever of 1793, in Philadel- phia, originated at a wharf, on which, and into the ad- joining dock, had been thrown from the hold of a ship a quantity of coffee in a putrid state. The disease spread first through those alleys and streets which were in the course of the winds that blew across the dock and wharf w here the coffee lay in a state of pu- trefaction.1 168. " The holds of all vessels, particularly ships of war, contain large quantities of vegetable matter, in casks often insufficiently strong to prevent their con- tents from escaping; such as pease, oatmeal, cocoa, flour, sugar, and wood for fuel, and when united with a due proportion of humidity, so as to produce a given change by putrefaction, a gas is evolved, under a cer- tain degree of atmospheric temperature, highly detri- mental to animal life,"2 &c. Many instances can be produced of the air of the holds of ships becoming so impure that candles will scarcely burn in them.3 169. The ship Antelope arrived at Barbadoes in March. Immediately afterwards, when the inhabi- tants of Bridgetown were perfectly healthy, a fever appeared on board; there were one hundred and ten 1 Rush's Works, Vol. 3. p. 43. 109. 8 Bancroft's Sequel, p. 233. 3 Ibid. p. 232. 83 cases, of which thirty-one ended in death.1 In conse- quence of this she was cleaned out, when it was found that " a combination of the above vegetable substan- ces" (168), with the bark of green wood and chips in a state of putrefaction, occupied a considerable por- tion of the hold; and "those individuals who had hith- erto resisted the influence of this miasm, now suffered in clearing away a mass of highly putrid and offensive matter. Even some of the government slaves, who have ever been exposed on similar duties, employed here, experienced the noxious effects of this effluvium, and narrowly escaped by being sent to the hospital."2 170. The ship Childers arrived at Barbadoes on the 26th of August, 1816, with twenty-six sick; twenty- one had died in ten days. In the next four days there were twelve new cases; there were never less than three new cases in each of the five following days, when she was blown out to sea with only fifteen ef- fective hands.3 She arrived at Antigua, and was or- dered to be purified; when the hold of the ship was found to be in a most extraordinary state of filth, fer- mentation, and impurity.4 The seamen declared that on different occasions when they were sent there, the candles would not burn.5 After her purification she continued perfectly healthy, though she took many fresh hands on board.6 171. The ship Regalia left Guernsey in November, 1814, and arrived on the coast of Africa in February, 1815, full of troops in perfect health. She was em- ployed from that time until the latter end of June in i Bancroft's Sequel, p. 235. 2 Ibid. p. 233. 3 Ibid. p. 228. 229- * Ibid. p. 230. fi Ibid. p. 232. « Ibid. p. 231. 84 removing troops and stores from one post to another. At this time she took in a supply of green wood, which was " cut down and brought on board the same day,"1 in such quantity that after she had been in the West Indies several weeks, there was enough left for a voy- age to Europe.2 The ship was rather leaky.3 She sailed from Africa with black troops for Bar- badoes on the 18th of July, and arrived a little before the 24th of August. There was a considerable mor- tality on the passage. There were only seven hun- dred and fifty-three of these black recruits originally, who were distributed among four transports, the Re- galia and three others.1 After their arrival in the West Indies, between the 24th of August and the 24th of October, the Regalia sent to the hospital one hundred and eleven cases of flux, of which fifty-three proved fatal; the other three transports sent only one hundred and seventy-seven, of which only seventeen terminated in death.4 172. The crew began to sicken in a fortnight after the wood was laid in. One died before sailing; two the day after; the men continued to " fall ill" until all but two had suffered attacks, and five out of twenty- one died before her arrival at Barbadoes. A military officer and his wife died on the passage; the captain's wife after making the harbour; and the captain him- self immediately after*-* At English harbour, Antigua, she was fumigated, and after three days' detention re- turned to Barbadoes. During this short voyage three newly entered hands sickened; one died, and two were 1 Bancroft's Sequel, p. 218. 2 ibid. p. 224. 3 Ibid. p. 226. * Ibid. p. 219- 85 sent to the hospital. On her arrival three more sick- ened, one of whom had lately entered, and one died.1 173. The hold was now ordered to be cleaned out: every thing was taken out, and the hold was exposed to the concentrated heat of stoves, the hatchways be- ing closed. About the time this was commenced, of three men newly shipped, two sickened, of whom one died; and the cook, upwards of fifty years of age, sick- ened and died.2 174. After having undergone the above thorough cleansing, " she sailed from Guadaloupe, crowded to a very great degree with French prisoners and their fa- milies from the jails, under the most dangerous cir- cumstances to health, with a case of yellow fever ac- tually dying on board the day before she left Basse- terre roads, but without communicating any such fever to the unfortunate passengers."3 175. This vessel, before this great quantity of green wrood was shipped, was healthy (171). A fortnight after sickness commenced, affected almost every soul 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. 176. These facts, and many more abounding in medical works, confirm the inference, that a gaseous fluid, the product of the putrefaction of vegetable mat- ter (166) abounding in marshes, and other places (167 to 175), is the cause of epidemic disease's. 177. This gas is dense, or it would arise from the 1 Bancroft's Sequel, p. 220. 221. a Ibid. p. 222. 3 Ibid. p. 223. 86 earth and not be driven along its surface by the wind (161 to 163). Numerous facts show that it is so. Domestic animals first feel the effects of its presence in the air. Those persons who inhabit the lower sto- ries of houses, are much more liable to the attack of an epidemic fever, than those who inhabit upper sto- ries. Dr. Ferguson in his essay on marsh poison says, "According to official returns during the last sickly season at Barbadoes, the proportion of those taken ill with fever, in the lower apartments of the barracks, exceeded that of the upper by one-third throughout the whole course of the epidemic.'" He also says, that "the deep ditches of the forts, even though they contained no water, and still more the deep ravines of rivers and water courses, abounded with the malarious poison. At Basseterre, Guada- loupe, a guard-house placed at the conflux of the in- ner and outer ditch of the fort, infallibly affected every white man with fever that took a single night guard in it; and the houses that were built in the ravine of the river Aux Herbes, (a clear rapid mountain stream that runs through the town,) or opposite to its ' bou- chure,' proved nearly as unhealthy as the guard-house above mentioned."1 178. The evidence, therefore, is positive, that a dense gas proceeding from marshy places, or driven from them by the wind, is the cause of the epidemics of hot weather (161 to 163. 177); and there is the strongest reason to believe, that it is the product of the putrefaction of vegetable matter (166 to 176). 179. These diseases have also been frequently at* 1 Philadelphia Med. and Phys. Journal, No. 13. p. 18. 87 tributed to exhalations arising from putrefying animal matter, or from a mixture of animal and vegetable matter. Bancroft has, however, stated a number of facts which seem decisive that such exhalations are not productive of epidemic fevers. 180. He states that complaints having been made of offensive smells from an old grave yard in the midst of Paris, it was determined to remove the mass that had accumulated in the course of ages, so as to re- duce the yard to the level of the neighbouring streets. Nearly twenty thousand bodies, in different stages of putrefaction, were disinterred and removed. In the course of this operation, the men were sometimes sud- denly thrown down by the concentrated vapours which escaped from bodies penetrated by the spades; but notwithstanding, no fever was produced, though much of this was done in the hottest weather. 181. During the epidemic fever of 1800, in Spain, there were buried in one of the burying grounds of Seville ten thousand bodies, 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 ema- nations from the same cause. In neither instance did an epidemic follow.1 182. The philanthropic Howard, in his work on Lazarettos, says, " The governor, at the French hos- pital at Smyrna, told me, that in the last dreadful plague there, his house was rendered almost intolera- ble by an offensive scent, especially if he opened any 1 Bancroft on Fevers, p. 95. &c 88 of those windows which looked toward the great bu- rying ground, where numbers were left, every day, unburied; but that it had no effect on the health of himself or his family. An opulent merchant, in this city, likewise told me that he and his family had felt the same inconvenience without any bad consequences."1 183. An instance is given of a man, his wife, and two sons, living ten years in good health in a room under the anatomical buildings of St. Bartholomews. The adjoining passage had in it a number of tubs for the maceration of bones; and other rooms of the cel- lar, communicating with it, contained large excava- tions for receiving the refuse of the anatomical rooms. In consequence of this state of things, the whole place was constantly filled with a close cadaverous smell. The whole family spent the day and slept in this con- fined and noisome place. The man was constantly occupied in the dissecting rooms, cleaning bones and handling the most putrid matters. He always en- joyed good health, as did the rest of the family.2 184. Several other strong cases are mentioned of putrid exhalations from manufactories of glue and catgut, from boiling blubber in a very offensive state; from manuring fields extensively with quantities of fish, and from the manufacture of adipocire, without the production of fevers among the workmen. In an establishment for the last purpose at Conham, near Bristol in England, the entrails and useless parts of many hundred carcasses were left to putrefy on the surface of the ground; and though the effluvia were very offensive to all employed in the manufactory, the 1 Bancroft on Fevers, p. 97. 2 Ibid. p. 420. 89 health of no one was injured in the two years the establishment was continued.1 185. If such exhalations were capable of producing epidemic fevers, every severe battle should be followed by one in the neighbourhood in which it is fought; particularly as the bodies of the slain are often left to putrefy on the surface of the earth. It is alleged in- deed, that they have arisen in such circumstances.2 As, however, they often do not, there must be some other cause in action in those cases in which they do. What this is may be gathered from the situation of those places in which armies are often posted, and battles often fought, viz. in the neighbourhood of a river or of a swamp for the sake of the support afforded by them; or of besieged cities on large rivers, sometimes pur- posely surrounded with inundations (145). 186. This may be illustrated by the following state- ment of Pringle, and answer of Bancroft. The former states from Forestus, that " a malignant fever broke out at Egmont, in North Holland, occasioned by the rotting of a whale that had been left upon the shore."3 The latter observes that Egmont is nearly surrounded by marshy or low grounds, and to the miasmata from these he attributes the fever; " because whales have not been found capable of producing such effects in later times, and because fevers from marsh effluvia constantly fall under our observation." In support of the former reason, he refers to an account by Dr. Gordon of a whale which putrefied at the island of Santa Cruz, without producing any evil effect.1 1 Bancroft on Fevers, p. 422. 2 Pringle on Diseases of the Army, p. 320. 3 Ibid. p. 321. 12 90 187. Here is strong ground for believing that exha- lations from putrid animal matter do not produce epi- demic disease. The fever at New London, in Con- necticut, in 1798, has however been very confidently attributed to this cause. 188. The situation of that city is " elevated, with scarcely any low grounds to generate marsh mias- mata."1 The disease originated within a kind of paral- lelogram, formed by four or five stores, containing large quantities of fish imperfectly cured, and within that space and one hundred yards from it, in several direc- tions, it mostly prevailed. Within that space nothing was observed more than in the other parts of the town, except a large quantity of imperfectly cured codfish stored in bulk.2 In one store only, fifty quintals were found in a state of fer- mentation, and emitting a very disagreeable odour. In addition to this foul matter, another account states that there was a very offensive privy belonging to the house in which the fever first appeared ;3 and also a parcel of damaged clams which were thrown from the same house.4 189. The weather was excessively hot. The sum- mer of 1798 exceeded in temperature, both as to in- tensity and duration, any season in the knowledge of the oldest inhabitant. The average of forty-seven ob- servations of a thermometer, in the open air in a northern shade, at different hours from midday to five P. M. was within a very small fraction of 88 de- grees. The lowest mentioned was 78, the highest 97 3 Medical Repository, New York, Vol. 2. p. 402. 2 Ibid. p. 408. 3 Ibid. p. 405. « Ibid. p. 4^2. 91 degrees. It was also unusually dry and calm for five or six weeks in succession, with the exception of only a few nights.1 To the effluvia arising from the operation of this excessive heat on the codfish, the fever has been pretty generally attributed. 190. It is however to be inferred from the expres- sion above quoted (188), that New London has some low grounds whence marsh miasmata are of course, in hot weather, evolved. The fever broke out also near the wharves; and on the wharf adjoining the house in which the first cases appeared, there was " a heap composed chiefly of the dung of cattle, with the sweep- ings of the decks of vessels," . m5 . 1?96 • 1797 •„ mQ cury in the thermometer ) was, in July, .... 83° 88° 90° 94° in August, 93° 89° 82° 96° The hottest year, 1798, was the most sickly; two thousand and eighty-six died. The year 1795, which in one month approached the temperature of that year, was next in sickliness. The evil was increased in 1798 by the very heavy rain in the middle of Au- gust, followed by a considerable increase of the tem- perature already high (228). "In 1795 the weather was warm and moist, but there was but very little rain. In 1798 the weather was not only much warmer, but was accompanied with sudden and heavy rains."2 231. At the south end of Seneca Lake, in New- York, there is a valley six miles long and one wide, lying in the same direction with the lake. Three miles of this valley are, during the months of April and May, for the most part covered with water, in consequence of the lake being at its greatest height. As the waters of the lake subside, the very rich soil is left covered with aquatic plants and animals. At this spot, I. W. Watkins, who gives the account,3 formed a settlement in 1795 with about twenty men. " As the heat of the season increased, they successively grew sick." During the season the same fever was very prevalent over that region, particularly in the * Medical Repository, Vol. 2, p. 307. 2 Ibid. p. 308. 3 Ibid. Vol. 3, p. 359. 15 114 neighbourhood of ponds and marshy grounds. It was called Lake fever, and produced an universal yellow- ness over the body. It has been less prevalent since that year, which was remarkably warm and sultry. 232. " Between the years 1792 and 1796, a gentle- man began to erect a furnace and forge in the moun- tains, a few miles above Haverstraw, for which pur- pose he erected a dam across a large stream of water, and overflowed a large tract of land: he built small houses around it for his labourers, and was carrying on his work with vigour until autumn, when the heat of the weather dried his pond, and soon after his la- bourers were generally attacked with a very malig- nant fever, which was so mortal that most of them died; the remaining few fled, and since that time the work has been neglected on that account."1 233. " In the year 1797 several mills were erected in the town of Greenfield, and county of Saratoga, during the winter and spring, that caused much land to be overflowed with water, which in summer became dry. The ensuing autumn most of the inhabitants were attacked with a fever" which " proved very ma- lignant." " It was attended with the same symptoms that characterize the present yellow or malignant fe- ver in the city of New-York, except that many who died of it did not vomit; and of those who did some vomited black, and others did not. The succeeding years the new ponds were emptied every May, and not filled until fall, and these malignant fevers visited them no more."1 234. In the neighbourhood of the medicinal spring i Medical Repository, Vol. 10, p. 240, by Dr. J. G. Scott. 115 called the Rock Spring, in Saratoga county, New- York, is a vast quantity of low, flat, moist land; the spring is in a valley, the bottom of which is a swamp, through which slowly flows a considerable stream. The surrounding inhabitants are visited every season with a fever, that proves very mortal. 235. " In the year 1804, a gentleman from New- York, improving a plantation up the North river as high as West-Point, on the east side, in the neigh- bourhood of some newly-erected mills, was under the necessity of discontinuing his work on account of a highly malignant fever that originated and prevailed in that place. And I can substantiate by as good medical authority as this city (New-York) can afford, that at least one of his people died of the same disease as the yellow fever of New-York."1 236. On the Raydeross creek, which flows easterly through the county of Saratoga, in New-York, are a number of mills, the ponds of which cover a great deal of the adjacent land. The vegetation on each side of the creek is very luxuriant. Soon after the erection of the dams belonging to these mills, very mortal fevers made their appearance. " It was not uncommon to see families consisting of ten persons, lose three or four of their members in the course of one warm season." The owners of the mills were with some difficulty induced " to open the dams and draw off the water during the sickly months. The consequence was a restoration of health to the inha- bitants ;" and, " although intermitting and remitting fevers do still prevail, they are not marked with their former malignity."2 3 Medical Repository, Vol. 10, p. 241. 2 Ibid. Vol. 12, p. 131. 116 237. " The village of Waterford is situated at the confluence of the Hudson and Mohawk rivers, on a flat which terminates about 150 rods west of the Hudson, in a rise of ground that runs parallel with that river to the north." This village " has generally been re- markable for its salubrity. In the summer of 1805, a small quantity of water had been suffered to collect and stagnate in the centre of the village; an accumu- lation of filth of various kinds had prevented it from being drained as usual from the ground." Early in September, persons occupied near this pond were at- tacked by violent fevers. " There was scarcely a, per- son who was in the habit of frequenting the vicinity of this pond, but was in some degree affected by its exhalations. About twenty persons were violently seized with fevers similar to the above, all of which could be traced to this source." There had also been erected, in the summer of 1804, a mill-dam across the branch of the Mohawk adjoining the village. This dam set the water back into a creek, which in the summer had always been dry. The trees, &c. during the summer of 1805, pro- tected this pond from the sun. In the winter of 1805, the trees were cut down for fire wood. In the sum- mer of 1806, the sun had free access to the pond, and of about fifty persons residing near the bank of this creek or pond, not one escaped an attack of bilious remitting or typhus fever, and most of them were sick during the whole season. Many of those further off were also affected, but not so severely; and they reco- vered more easily and more perfectly.1 1 Medical Repository, Vol. 12, p. 132, by Dr. Steams. 117 238. In Orange county, New -York, there is a tract of land near the Wallkill, lying lower than the outlet of the river, and therefore subject to inundations, and almost always wet and marshy. There are many thou- sand acres of rich land thus situated. The country adjoining has been famous for its unhealthiness ever since it was settled. A company undertook to drain this land, but few constitutions were found capable of long enduring the malignity of its atmosphere, and very few withstood it many weeks. " The temptation of liberal pay draws to this unwholesome region a crowd of hardy labourers." Some of the most sturdy are overpowered in a few days; and almost all in a few weeks.1 239. Bald Eagle valley, in Pennsylvania, is low and generally flat. Near to Bald Eagle creek, which runs through the valley, are many ponds of stagnant water. From the settlement of the valley, the ponds contin- ued full, and the inhabitants healthy, until 1797. The trees had been gradually cleared away; the ponds be- came filled with trees, rubbish, and putrid substances; and being exposed to the rays of the sun, were nearly dried up towards the end of that summer, and sent out a very unpleasant smell. The consequence was, in the hot years 1797, '98, and '99, a fever which killed often in forty-eight hours, and had every symptom mentioned in the accounts of the yellow fever in Phi- ladelphia and New-York. In the year 1797 it was as fatal in Milesborough, on Bald Eagle creek, accord- ing to the number of inhabitants, as it was in Phila- delphia in 1793. A large pond of water stood near 1 Medical Repository, Vol. 14, p. 11, by Dr. Cole. 118 the town. The water formerly shaded by the trees, was now exposed to the sun, and the season being very dry and warm, was in a great measure dried up. The pond abounded with putrefying vegetables, and the stench was great; few in the town escaped sick- ness of the most malignant kind, which continued through August and September. The pond has since been drained off, and the inhabitants are as healthy as usual. The year 1799 was very dry. The mercury in the thermometer stood often as high as 95 degrees, and one day in the shade as high as 99 degrees. This sea- son the symptoms were much the same as in the two preceding, only more violent. " The black vomiting was characteristic."1 240. In the rich state of Ohio there is a great num- ber of streams, on the borders of many of which are those extensive plains called prairies. They extend from the bank of the stream to a second bank at va- rious distances from the first; and the ground is often lower at the foot of the second bank than it is near the stream, in consequence of which the water stagnates in the plain. These plains are covered with a luxuriant growth of grass and weeds, which in the autumn and winter fall, and in the heat of the ensuing summer rot so com- pletely, that the leaves which fall or are blown into low places, often entirely disappear before the next fall of the leaf. The air of this country is very moist. Fevers prevail almost exclusively in the low tracts of country, and for the most part along the streams,2 1 Medical Repository. Vol. 4, p. 105, by Dr. Harris. 2 Ibid. Vol. 10, p. 6, by Dr. P. Harrison. 119 241. In 1800 the summer was unusually dry until about the middle of August, and the waters unusually low. During this time it was tolerably healthy at Chilicothe, on the Scioto, and in the neighbouring country. About the middle of August it rained so as to raise the streams over their banks. Shortly after, a fever prevailed in Chilicothe, and in the settlements on the Scioto and its tributary streams, which abated in October.1 242. The spring of 1801 was very wet; the rains were frequent and violent until the first of June. From that time until the latter part of August it was dry, and intensely warm. There were seasonable rains in September and October, and the heat was as intense in September as in any of the summer months. The fever began early in July on Deer creek, and soon after on the Kinnakenic, and the Blackwater, and on the Pickaway plains; and finally reached the high banks and Chilicothe.1 243. In the spring and summer of 1807, there were three freshets in the Ohio river; the low lands were covered with water, and many crops of corn and grass were destroyed by it. In every direction there was a profusion of vegetable matter in a moist state. In June ophthalmia was very common: by the middle of July intermittent and remittent fevers were common; and in August the fever was general all along the river for several hundred miles.2 244. Marietta is situated on the rich bottomsof the Ohio river; and the Muskingum river flows through 1 Medical Repository, Vol. 10, p. 6. 2 Ibid. Vol. 11, p. 345, by Dr. S. P. Hildretb. 120 it. The Ohio river was in the summer and autumn of 1822 lower than it was ever before known to be. The water was in most places nearly stagnant, resem- bling a long lake. The shores were lined for several rods in width with aquatic plants and grass, as early as the month of June, although in common seasons they are not seen sooner than August or September. A disagreeable smell arose from these putrefying ma- terials along the shore of the river, which was per- ceived by every one in the morning and evening, and at all times of the day by those inhabitants of the high grounds who approached the river.1 The fever in that summer was confined to the neigh- bourhood of streams, the bottoms of which, thus laid bare, exposed to the action of the sun a great mass of vegetable matter, while the upland, destitute of mois- ture, continued healthy. Those settlements, also, in which the shores were bold and there was no wide beach to the river, were healthy.2 245. In the year 1823 the whole country was de- luged with rain in the months of June and July. The rains ceased the last of August, and the weather was dry for the remainder of the season. The weeds grew to the height of fifteen or eighteen feet; many fields of corn were entirely destroyed by the wet, and many fields of wheat lost after having been reaped. {The epidemic of this year was not, as in 1822, con- fined to the vicinity of water courses, but infested the uplands as well as the valleys. Even some districts in the Alleghany mountains were visited with inter- i Phil. Journal, &c. No. 17, p. 107, by S. P. Hildretb, M. D. 2 Ibid. p. 106. mittent and remittent fevers. The only part of the state, east of the Scioto river, that remained healthy, was a district of country embracing New Connecticut, and extending in that direction from Lake Erie to the Ohio river; where it was very dry, and the inhabi- tants entirely escaped fevers.1 The disease continued to rage through the month of October, and was only suppressed by the heavy frosts in the beginning of November.2 246. New Design, a village about fifteen miles from the Mississippi, stands on high ground, but is sur- rounded by ponds. In 1797 the yellow fever carried off fifty-seven out of two hundred inhabitants. Dr. Watkins, who gives the account, had seen the yellow fever in Philadelphia.3 247. Louisville, in Kentucky, stands on an elevated bank of the Ohio river, but on very flat land exceed- ingly rich. The neighbouring country is also rich and level; particularly a low flat district of land called Pond settlement, which commences in the town itself, stretches in a south-west direction about twenty miles, and is six or eight miles wide. On this tract of land are numerous ponds and marshes, and it is clothed with the most luxuriant vegetation. The annual rise of the Ohio river in the winter and spring, usually of about twenty-five feet at Louisville, brings down a great deal of vegetable matter, which, when the water subsides in May or June to the low water mark of summer, is left, on the surface lately inundated, exposed to the action of the sun. 1 Philadelphia Journal, &c. No. 17. p. 112. a Ibid. p. 115. 3 Medical Repository, Vol. 4, p. 74. 16 122 There is a small stream which empties into the ri ver immediately at the town, where there are some wharves and the chief landing place for boats. The bottom and banks of this creek, after the subsidence of the water in June, are generally very foul and muddy. On this creek about a mile from the town is a mill and a pond. In the town there were, in 1821 and 1822, at least eight ponds. 248. The summer and fall of 1819 and 1820 were remarkably dry; little rain had fallen in the spring and early summer months; the ponds in and near the town were dried up before the first of July in each year. Even in the pond district of country there was little or no stagnant water. The river was low in both years. Both of these very dry years were remarkably healthy. 249. During the spring and summer of 1821 there was an immense quantity of rain: the ponds were all overflowed, and the earth thoroughly saturated with water. The summer was warm, and the winds were from the south-west, sweeping over the pond district. This district is thinly settled, but suffered severely in this year; and the town also, especially the skirts of it. Those who lived in the suburbs nearest the ponds suffered earlier, and more severely than those who inhabited the central part of the town. 250. In the spring of 1822 there was " an almost unprecedented quantity of rain, and during June, July, August, and September, an unusual succession of heavy and continued showers. The rain, though it fell in excessive abundance and in heavy torrents, seemed to have no effect in cooling the atmosphere. There was a closeness and sultriness of atmosphere 123 proving very oppressive during the summer months, which with little or no abatement continued through the night as well as day." The fever commenced earlier in this year than in 1821, and was more severe and unmanageable. The pond district suffered first, and afterw ards the town; the south-west part being first affected.1 251. The eastern end of the state of Tennessee is a rough niountainous country, and is extremely healthy; intermittent and remittent fevers being rare, except on the large rivers. Part of the western end of the state adjacent to Kentucky, is equally broken, and enjoys an atmosphere not less salubrious. The south-west of the state is level and fertile. Dispersed over the country are numerous ponds, es- pecially near the mountains. From the flatness of the surface, the waters run off slowly, and in some places stagnate. In the heat of summer, fevers, intermittent and remittent, sometimes of a very aggravated form, prevail.2 252. Natchez is situated on the east bank of the Mississippi, in north latitude 33 degrees 31 minutes, from one hundred and fifty to two hundred feet above the surface of the river at low water. The shore forms a high precipice, which excludes the view of the river. ^The surface is very undulating, with a gradual but irregular declivity for about three miles eastward to St. Catharine's creek. " It is sufficiently remote from any swamp on the same side of the river not to be affected by its exhalations. The soil is a 1 Philadelphia Journal, &c. No. 15, p. 1, by J. P. Harrison, M. D. 2 Ibid. No. 3, p. 50, by VVm. Lea, M. D. 124 rich black mould. Bilious fever was common in the summer and fall, of which occasionally there were a few cases of the highest grade, but previously to the year 1817, the inhabitants were not afflicted with an epidemic fever." 253. After the termination of the last war, there was a rapid increase of population. Many improvements were made, buildings erected, and arrangements made and partially executed, to reduce to a convenient le- vel the irregular surface of the site of the town. By this means ponds were formed in many parts of the town, and the natural course of the water being stop- ped, cellars in the low places were often partly filled; the back yards of many houses also, being thrown be- low the level of the street, were often wet and became the receptacle of much filth of every kind. 254. The year after the peace, 1816, was very dry and healthy. The next year, 1817, was wet and sickly. The year 1818 dry and healthy. The year 1819 wet- ter and more sickly than 1817. The following table, taken from the one given by Dr. Perlee, will place the whole in a clear light at one glance. The rain is stated in 225th parts of an inch. Rain from the 1st of May till the Mean temperature, June to Deaths. last of August, four months. September, four months. 1816 1961 79£° no eoidemic. 1817 3285 77° abouHSOO. 1818 1919 761" ■>• no epidemic. C number not mentioned ; 1819 5862 773° . 21 162 small fraction above 75 degrees; more than five de- grees lower than our hot summers.1 328. The first considerable autumnal epidemic af- ter 1804, occurred in the year 1821. The spring and summer of that year were not remarkable until to- wards the end of July. In the latter part of that month, an extraordinary quantity of rain fell in the course of two days. In the upper part of Fauquier county about twenty mill-dams were w ashed away, and the whole country was deluged by the most incessant torrent of rain for about twenty-four hours, that I ever witnessed. An incredible quantity of every kind of vegetable mat- ter, logs, brush, hay, wheat in the straw, &c. was left here and there on the banks of the streams. The whole country was perfectly saturated with water, the swamps were all full, and there was a great deal of water standing about in the low grounds. 329. The county of Fauquier is near sixty miles in length, and from twenty to thirty in breadth. The up- per half is mountainous; the lower is comparatively level, and in many places flat. A number of large streams pass through it, and there is a considerable proportion of wet land, particularly in the south-east part, in the Marsh. 330. After the great rain abovementioned, the weather was hot and very dry throughout the season. In the upper half of the county, there was for a short time, in the immediate neighbourhood of the mill- ponds, a number of cases of autumnal fever, some very severe; but as soon as the bottoms of the ponds became dry, there was scarce any sickness in the coun- 1 Medical Recorder. No. 1, p. 142. 163 try (155). In the lower half, however, and in the county below, still more flat and marshy, the most terrible epidemic prevailed. 331. The same rain, and succeeding dry warm weather, produced the same deadly epidemic in the neighbouring counties, Loudoun, Fairfax, Prince Wil- liam, and Culpepper. It produced an epidemic also in the southern and the south-eastern part of the state;' and no doubt in other parts of which no ac- count has been published. 332. In the midst of the distress produced in almost every part of the counties abovementioned, a tract of country of fifty or sixty miles square, there were a few striking exceptions. The upper part of Fauquier county was one, and Centreville was another (148). Between the situation of this village and that of Dum- fries, in the neighbouring county of Prince William, and the consequences in both, there was a strong con- trast. Dumfries is situated near an extensive marsh: in consequence of the great rain in July it also had many ponds in and about it. It was stated at the time that there were only three persons who escaped an attack of the autumnal fever in that season. 333. Surry county, Virginia, lies adjoining the south side of James river; on the west it has a creek; on the south the Black-Water swamp; and on the east another creek. The banks of James river are very high for the most part; but there are three creeks be- sides those already mentioned, extending from three to five miles into the county, besides several small in- lets of much less extent. There is a great deal of 1 Medical Recorder, No. 19, p. 420, and No. 17, p. 73. 164 marshy land about these creeks. There are also a number of mills, with extensive ponds subject to be- come dry in the heat of summer. In the middle and southern sections of the county are several large swamps. Some of the situations immediately on the river are sickly, but most of them are the reverse. The middle of the county is very sickly. 334. The latter part of the summer, and the whole autumn of 1820, were unusually sickly; but on the ap- proach of winter it became healthy. The summer of the year 1820 was very dry. 335. In 1821 the spring was backward; the latter part wet. The summer was hot, with refreshing show ers until the first week in August; from which time until the third of September the weather was very dry. On that day there was a violent wind, with tor- rents of rain, which kept the earth wet until October. The weather was unusually warm for the season, and very dry and sultry in October, until which time there were not many cases of bilious fever; but between the first and tenth of that month the cases increased very rapidly, and became more violent.1 336. In the same autumnal season the yellow fever prevailed in the cities of Alexandria and Norfolk; neither of these towns had suffered severely from epi- demic disease for almost twenty years. 337. The city of Alexandria, in the district of Co- lumbia, stands on sandy ground considerably above the level of the river. It has, however, a very swampy piece of ground above and below, and very 1 Medical Recorder, No. 17, p. 73, by W. H. Fincb, M. D. 165 near to it. From 1795 to 1800, it was difficult to wade through either of them; and the lower part of the southern swamp was impassable or nearly so, the Potomac river covering the greater part of it at high tide. It had, however, been protected in some mea- sure from the water of that river and the adjoining creek by causeways, and had been partly drained by very large ditches ; insomuch, that about 1800, it was enclosed and used as a grazing ground. A branch of the swamp at the upper end, formerly extended around what was then the back of the town, at a short dis- tance west of the market-place. It is now dry, and streets or causeways are extended across it. The wa- ter that runs down through this hollow way, from a considerable extent of ground, passes through trunks placed at the bottom of the causeways. Great rains not having sufficient vent by these trunks, the water rises and forms a kind of pond for a short time, leav- ing, as it slowly drains off, the filth, &c. brought down from above, spread over the surface of the low ground. Behind the town at a very short distance, there is a considerable range of hills; betw een it and the town is a corresponding range of rather low ground. In wet weather, the whole was^formerly miry and the resort of millions of plovers. The water from this ground vents itself by a small stream near West-End, through a swampy piece of ground, into Hunting- creek. 338. Thus situated, Alexandria has frequently suf- fered from epidemics, particularly in 1793 and 1803. In the former year a severe bilious fever prevailed; in the latter the yellow fever: in both those years the 166 summer was hot and dry. From 1803 to 1821 there was no considerable epidemic in this city; the sum- mers in that interval were cool and healthy (327). 339. In the year 1821 this town suffered very much from the yellow fever. After the last of July the sum- mer was very dry and hot. I ascertained from parti- cular examination and inquiry, which was the sole ob- ject of the visit, that the fever prevailed, with the ex- ception of one spot, on the borders of the low ground west of the market house, and along the side of it to the river; along the wharves, some of which were then unfinished; at the lower edge of the town, and at West-End. 340. The spot above excepted is in the heart of the town; ten or fifteen persons died near the inter- section of Fairfax and Prince streets. On inquiring into the cause of this very partial effect, I learned that a person living in one of the houses in Fairfax- street, had had an old well cleaned out, and the filth was thrown into a narrow alley passing in the rear of the lot. In a short time, the people who lived near could not keep their windows open on account of the smell. Complaints were made, and orders given for its removal; it was dofte, however, in a very dilatory manner. There was but one cart employed, and there were twenty-seven loads of this offensive matter, which of course was for several days continually in agitation. The middle of this square is low, and many years ago was often under water for a considerable time. When I visited it, the smell continued to be very perceptible. In the house, from the yard of which the filth was thrown, there died three or four persons; in several 167. adjoining houses, from one to three. In a house al- most immediately opposite to the one first mentioned, two died; near it one ; and at the south-west corner, at the intersection of the above named streets, two or three died; in all about twelve persons. Among them were some of the worst cases that occurred in town, and every one but one within fifty or sixty yards of the mass of filth in the alley. 341. It is probable that such a change has taken place in the situation of the low grounds about Alex- andria, as to render its health dependant on a different state of the weather from that which formerly influ- enced it. The summer of 1803 was dry ; at that time the low grounds were still considerably marshy, in which state a dry summer would be most likely to pro- duce an epidemic. In 1821, however, when there was a great fall of rain in July, followed by hot wea- ther, an epidemic prevailed; and in 1822, which was very dry, the town was healthy. This would indicate that the low grounds have become dryer, and require wet weather to produce an epidemic; and this change in those grounds is very probable, inasmuch as in 1800 they had become sufficiently dry for a pasture. 342. The yellow fever raged in Norfolk in 1800. The ground on which the city stands is a sort of peninsula. " The line which marks out the boundary of the town on the side next the river, comprehended originally more water than land on that side of the main street." In some places the wharves are advan- ced upwards of an hundred yards into the river, as far as this boundary line. That part of the city where the fever chiefly prevailed, stands entirely on made 168 land, reclaimed by sinking log pens and filling them chiefly with green pine saplings, which are slightly covered over with earth or gravel. In some places large openings are left for docks: in others, wharves are formed next the channel of the river, while the in- terior parts are covered with water. Through the whole of this wooden fabric, the water of the river penetrates. There are also some places left in their ancient state, and consequently have become equiva- lent to sunken places, and are the receptacles of all kinds of filth. " In these ponds, or rather sinks of putrefaction, though sixty yards or more from the ri- ver, the tide ebbs and flows through the open texture of the adjacent reclaimed ground." At low water they are not dry, but are the resort of hogs in hot weather. In addition to these circumstances, a short time be- fore the fever commenced, a cargo of spoiled West India fruit was picked over, and the greater part thrown into a pile, and left until after the occurrence of some cases. 343. Rains had been very frequent in June and July; but instead of cooling the air, it was observed that they were invariably followed by more intense heat. For more than two months after the 25th of June, the inhabitants of Norfolk lived, in an atmos- phere heated above 85 degrees of Fahrenheit, some- times as high as 94 and 95 degrees, but very frequently upwards of 90 degrees. " Such a long tract of in- tensely hot weather, is not, we believe, within the re- membrance of any person now living in this place." The fever appeared close to the abovementioned ponds. Two young men in a vendue store, at the 169 spot where the oranges and limes lay, died among the first. 344. For several days in the last of July and first of August, the weather was cooler than before ; and there was a temporary suspension of the disease. The weather became steadily hot again about the sixth of August, and continued so throughout that month. The disease returned with the hot weather, and con- tinued with unabated violence to the end of the month. On the 30th there was a considerable fall of rain, fol- lowed by three or four days of cool weather, with a brisk northerly wind. On the fourth of September, the thermometer stood at 60 degrees. Attacks of the fever were less frequent: but this might partly be ac- counted for by the reduced number of persons liable to take the fever. About the middle of the month it again became sultry, and a number of young persons who had hitherto escaped were attacked.x On the fifth of October a deluge of rain fell, accompanied by a very high wind from the north-east; the weather became suddenly cold, and in a few days not a ves- tige of the yellow fever was to be seen in Norfolk. The weather became hot again about the middle of the month, the thermometer standing at 80 degrees in the shade. Several persons who had returned to the city, and some strangers, were attacked, and some fell victims to the fever.1 Here is strong proof of the cor- respondence between the minute variations of the dis- ease, and the varying state of the weather; and proper care would soon put us in possession of abundance of testimony to the same amount (214. 219). 1 Med. Repos. Vol. 4, p. 329, by Drs. Selden and Whitehead. 22 170 345. The fever again prevailed in 1801. The spring was extremely cold and late; frequent rains in June, and a cloudy sky, kept the weather cool. It varied from 70 to 87 degrees until the last week, when the weather became serene and intensely hot, followed by occasional rains. This weather continued until the 23d of August. Diarrhoea and dysentery began to appear in June, and increased as the summer advanced. Du- ring the month of August, some cases of yellow fever were reported to have occurred about the wharves. On the first of September the weather became ex- tremely hot, calm, and serene. Not a cloud was to be seen for eleven days; during which time the mer- cury in a thermometer, fixed in a passage with a free circulation of air, in a part of the town well ventilated, and not crowded with houses, frequently rose to 94 degrees, and was seldom below 90 degrees in the hot- test part of the day. At ten o'clock at night, during this time, it was found several times standing at 90 degrees. Under these circumstances, the "intestinal fever entirely disappeared;" and by the seventh or ninth of the month, the cases of yellow fever had become so numerous as to deserve the name of an epidemic, and to rouse public apprehension.1 346. The lower part of this country, about Nor- folk, is an uniform plain, intersected by rivers and creeks of tide water. The whole country is univer- sally unhealthy. The inhabitants show the effects of a pernicious atmosphere. A thin sallow appearance is more common than we have ever observed in any 1 Medical Repos. Vol. 6, p. 247, by Drs. Selden and Whitehead. 171 other part of the world, even in the hottest climates; and they are commonly tormented with agues one half the year, and scarcely ever get clear of the appear- ance of them.1 347. The yellow fever prevailed in Norfolk in 1821 also. On the 20th of July a vessel arrived in the har- bour from Guadaloupe; and after " having dischar- ged her cargo at an upper wharf, her bilge water was pumped out on the dock between Southgate's and Warren's wharves, which was found to be so pu- trid and offensive, as to render it expedient that the doors and windows of a neighbouring house should be closed." Notwithstanding this precaution, every in- dividual of the family, seven in number, were taken sick, except the master of the house, who was from home when the bilge water wras pumped out. Two of the family died. A clerk in a warehouse, about the same distance, fifteen or twenty yards, from the vessel with the other house, sickened and died. A young man who assisted in pumping the vessel, and a boy who had frequently been about her at the time, both died. 348. To this bilge water the disease, which pre- vailed throughout that fall in Norfolk, was principally attributed, on the ground of the facts stated, and on that of the fever not having prevailed for many years before in that town. The cargo of this vessel was rum, molasses, and su- gar. The drainings of such a cargo, Dr. Ferguson says, " creates a stench that is absolutely suffocating to those unaccustomed to it; yet fevers are never 1 Med. Repos. Vol. 5, p. 430, from Barnwell's Phys. Investigations. 172 known to be generated from such a combination."1 It is moreover admitted that bilge water had been fre- quently discharged at the wharves with perfect safety; indeed it cannot be doubted that it is every year done in many instances. It is therefore admitted, that a certain state of the atmosphere was necessary to give effect to the insupportable stench of the water in this case. Let us then inquire into the state of the at- mosphere in Norfolk at that time. 349. The spring had been backward and wet, and the summer set in very warm in June, and the disease appeared in August. The first cases appeared as above stated near a very filthy dock; but within a few days after, the disease also appeared in a very dirty lane, crowded with people in the lowest circumstances, mostly Irish recently emigrated, very intemperate, and dirty in their manner of living. It was very near the dock, and had another very filthy one on its other side. The last mentioned receives all the offal of the neisrh- bourhood, and at low tide is bare and exposed to the action of the sun for a considerable distance from its head. The fever extended gradually around the head of the dock last mentioned ; it appeared also in a block of wooden buildings under which the tide flowed, and equally unclean with those in the lane above men- tioned. In a very short time it embraced that whole section of the town, and was almost exclusively con- fined to it. 350. The disease was more or less violent as the thermometer rose or fell. No very material change, however, occurred until the third of September, when * Philadelphia Journal, &c. No. 13, p. 14. 173 there was a hurricane from the north-east, shifting af- ter a short time to the north-west, and accompanied by torrents of rain. The water of the river rose above the wharves, and covered all that part of the town in which the disease prevailed. This moderated the dis- ease considerably, but towards the end of the month it began to increase, but was of a milder character; but there were some bad cases in October among those who returned from the country too soon.1 351. It is evident from this statement that the cir- cumstances of the town were precisely such as have in a thousand instances produced such a fever; that in the time of its rise, August; the manner in which it appeared in different places in the flat part of the city, about the docks ; its limitation to the foul and crowded part of the town; its prevalence through the summer; the check from the hurricane; its increase after the storm, that having occurred early in the season when the heat was still considerable; and in its cessation only when the weather became cold, it corresponds precisely with the fevers every where occurring in such situations in a warm climate. Its revival after the hurricane particularly shows what was its real cause. The whole foul atmosphere of the town must, on that occasion, have been driven far away; and the cause must have been regenerated from the same filthy docks, alleys, &c. saturated with water during the hurricane, but in a milder degree on account of the lateness of the season. 352. The very same weather, first wet and then hot and dry, produced a very similar fever in all parts of 1 Medical Recorder, No. 17, p. 60. 174 the state of Virginia, and in many other states (328, &c.) ; and the yellow fever prevailed at the same time in Alexandria and in Wilmington, North Carolina (322. 339). It is evident, therefore, that the fever would have occurred here also, if the vessel above- mentioned had not arrived. 353. It is very probable the nausea, &c. produced by the stench, so deranged the system as to bring on a fever in persons already on the verge of an attack; but that it could do no more is evident, from what Ferguson states, and from the admission that bilge water has often been pumped out at Norfolk without injury to any body. 354. As to the circumstance of the absence of the fever from Norfolk for a number of years before 1821, it will be remembered that the summer seasons for many years before had been very cool, and unusually free from epidemic diseases, except in the extreme south in the wet summers 1817 and 1819 (254). 355. In Philadelphia, cited because we have such ample accounts of the epidemics that have prevailed in it, " from 1805 when it last threatened to assume an epidemic character," "yellow fever was met with in a few sporadic cases only, which seldom attracted much notice." From 1812 " yellow fever became a stranger to us (in Philadelphia) even in a sporadic shape, and as it disappeared, a kind of interregnum ensued, in which no disease showed itself with vio- lence or to great extent. A period of unexampled health existed, especially during the cool summers of 1814 and 1815. In the summer of 1818 diseases be- gan to assume a more exalted character, and two well 175 marked oases of yellow fever occurred. In 1819 the summer diseases exhibited a still nearer approach to their former state, and were of more frequent occur- rence." Twenty-four cases of yellow fever occurred. In 1820 the fever was still more violent.1 356. From 1805 until 1818 then, the summers were uncommonly healthy; and from the table of the tem- perature of the summers in Philadelphia, published in the Medical Recorder,2 it appears, that the mean tem- perature of June, July, and August, of the twelve years, was 75 degrees 7 minutes ; whereas, in the se- ven years from 1793 to 1799, inclusive, in the four hottest of which the yellow fever was epidemic, and in the three coolest of which there were a few cases, the mean temperature of the same months was 80 de-* grees 12 minutes. The coolness of those summers was so remarkable that attempts were made in the public papers to ac- count for it; and among other hypotheses advanced, it was alleged to be the effect of the immense islands of ice which about that time were frequently met with off the coast in summer time. 357. When the autumnal fever in Philadelphia be- gan again to show marks of violence, the same thing was observed to occur in various parts of Virginia,. Pennsylvania, and Maryland.3 About the same time the summers became hotter than they had been for many years. In " a condensed view of the greatest heat" which occurred at Ilarrisburg, Pennsylvania, in the years 1819, '20, '21, and '22, it is stated that 1 Jackson on the malignant fever of 1820 in Philadelphia. Philadel- phia Journal, &c. No. 2, p. 319. 2 Medical Recorder, No. 1, p. 142. 3 Ibid. No. 21, p. 126, by Dr. Agnew. 176 the thermometer stood at and above 80 degrees in each of the months from May to September, inclu- sive, excepting the month of May, 1820, in which it is said it stood at 80 degrees. In 1819 and 1820 it was sometimes as high as 95 degrees.1 358. It is evident from this statement why Norfolk, as well as other parts of Virginia, Maryland, and Pennsylvania, was exempt from severe epidemics in the cool years abovementioned, and why it suffered when the summers became hot again. In the same year, 1821, Wilmington, in North Carolina, also suf- fered from the yellow fever (322). Alexandria, in the district of Columbia, experienced the same misfortune; in the latter, as in Norfolk, there had been no appear- ance of the disease since 1803. 359. The valley of the Shenandoah lies between the Blue Ridge and the North Mountain, and is per- haps twenty miles wide. The northern branch of the Shenandoah, about forty-five miles from the Potomac, crosses the valley from the North Mountain towards the Blue Ridge, and at a short distance from the lat- ter turns, and flows along the foot of the mountain into the Potomac at Harper's Ferry. Near the middle of the valley the Opequon creek passes along nearly parallel with the Shenandoah, and likewise empties into the Potomac. 360. This valley and the adjoining mountains af- ford an excellent field for observing the effect of dif- ferent kinds of weather in producing epidemics. In it there is almost every variety of soil and situation. A vein of slaty poor land, several miles wide, extends l Medical Recorder, No. 21, p. 126. 177 from one end to the other, through which the Opequon creek passes. East of this lies an exceedingly rich tract of land, extending to the Blue Ridge, through which the Shenandoah flows. In this tract there are extensive plains, still so wet as to retain the name of Marsh, as the Long Marsh, &l. West of the Opequon hills there is another tract of good land, extending some miles to the hilly country at the foot of the North mountain. In this there are also plains of considera- ble extent, which retain the name indicating that they were formerly marshy. These different tracts are long and narrow, extending lengthwise in the valley. There are some considerable streams which empty into the Opequon or the Shenandoah; and on most of these streams there are many mill-ponds. The She- nandoah has a great number of marshy spots about it in dry weather, produced by obstructions made in it with a view to throw the water to one side, and im- prove the boat navigation (165). There has been as great a variety in the seasons from 1822 to 1826, as in the situation of the different parts of this valley. 361. The year 1822 was so dry throughout the sum- mer that the grass was entirely bleached, and in many places the corn also, as effectually as it would have been by the severest cold of winter. This drought prevailed also in the neighbouring states of Maryland, and the central part of Pennsylvania.1 This year was remarkable for general health. 362. The year 1823 was the wettest season since 1804 (324). This was a very common observation among those who remembered the latter. The whole 1 Medical Recorder, No. 21, p. 140. 141, 23 178 country was wet throughout the summer, meadows became marshes, and the roads were generally miry. The weather was also warm. Sickness was as general in this year as health had been in the preceding. Scarce a family escaped; and many families were all sick. The occurrences of the autumnal season bore a striking resemblance to those of 1804. In some houses, in both years, I found not an individual able to provide for the youngest chil- dren, except at particular times of the day when the fever remitted, and then of course with great inconve- nience and suffering. Every bed was occupied, some by two or three persons, and it sometimes happened when one fainted, that there was not another able to give assistance. 363. To this general prevalence of health in 1822, and of sickness in 1823, and also in 1821 (328), there were some striking exceptions, which remarkably sup- port and confirm the general doctrine (178). Harper's Ferry was sickly in 1821 and in 1822, but healthy in 1823. Shepherdstown, on the Potomac, was sickly in every one of the three years; as was also Waterford, in the neighbouring county of Loudoun. 364. Harper's Ferry is a village situated in the ob- tuse angle formed by the junction of the Potomac and Shenandoah, on a very narrow slip of land, perhaps fifty or sixty yards wide, between a high and steep hill or mountain, and the water. The latter part of the summer of 1821, it was above stated, was very dry, and the bottoms of the two rivers were exposed to the heat of the sun for a length of time. The water in a canal which supplies the public works was very low. 179 and an attempt was made in the heat of the weather to clean it out. Numbers of the men sickened in the very act. This town was also sickly in 1822, for the same reason. In that dry year the bottoms of the ri- vers were more exposed than in the year before. In the year 1823, however, Harper's Ferry was compara- tively healthy; and it was observed that the rivers were fuller than they had been for some years. The rain which fell in 1821 was all, or nearly all, before the last of July. In 1823 it rained throughout the sum- mer (362). 365. Shepherdstown is situated on the Potomac also, and suffered in 1821 and 1822 with Harper's Ferry, and from the same cause, the exhalations pro- ceeding from the bottom of the river. It differed, however, from that place in being very sickly in 1823 also. This town stands on the bank of the Potomac, and through it, nearly at right angles with the course of the river, runs a small stream which supplies some mills in the town. Immediately back of the town, the ground through which this stream passes is low, and in wet weather marshy. Thus in dry hot summers the inhabitants suffer from the exhalations from the bottom of the river, and in wet years from the adjoin- ing marshy ground. 366. Waterford is situated on the east side of the Ketockton creek, partly on a low ridge running nearly parallel with it, and partly on the flat between the ridge and the creek. This is a sluggish stream in that part of its course, running through a low flat piece of ground abounding with vegetation. There is a dam 180 across it some distance above the town; and below the dam in summer time, the water is so low, that the bed of the stream is little more than a succession of ponds. Between the creek and the town, which is a very short distance, there is also a mill-race, itself very low in hot weather; and some ponds where brick have been made. Thus situated, Waterford is in wet seasons sickly, on account of the exhalations from the whole surface of the low grounds ; and in dry seasons, on account of those from the bed of the creek, the brick yards, and the race. The mill-pond may have some effect also, in hot dry summers, as it lies south- west from the town. 367. Thus excessive rain produces in dry places sickness (362. 158), and in wet places health (364. 156) ; while excessive drought produces in dry places health (361), and in wet places sickness (364). 368. In the year 1824 the weather in July was very hot and very wet; almost every day there was a heavy shower, and the weather notwithstanding continued warm. In the midst of this weather the fever made its appearance, a month earlier than in the preceding year, and there were great apprehensions of a still more severe epidemic. After July, however, the wea- ther became very dry, and continued so for the rest of the season, and the sickness abated, except near marshes, ponds, and streams. 369. In 1825 the weather was also dry, and the country generally healthy. About marshes and ponds there were some very severe cases. A family who lived on a small farm, which had been generally heal- thy, were attacked, every one of them, in the month 181 of September, and five out of eight died. The symp- toms were of a high grade; one had hemorrhage from the bowels; several, invincible constipation. There was in the barn-yard of this farm, a pond for the purpose of watering the cattle. The year 1S24 was dry, except in July; 1825 was more so, and this pond was reduced almost to dryness. The bottom was a mass of filth, nearly black, which had been col- lecting there for years. It was between south and west of the house, and very near it; and almost the whole family were about it every day, some to take care of the horses and others to milk the cows. 370. The year 1826 has also thus far been dry in the greater part of the valley. Some parts have had heavy rains, but the waters have been very low. The months of May and June were excessively hot. In these circumstances the usual fever began very early in some places near the Shenandoah. May was very sickly. A remarkable change occurred in the weather in July. It became very cool, and has con- tinued so until this time, September. The weather is unusually cool and pleasant. Near the water courses the sickness continues to be considerable. Harpers Ferry is suffering very much. Those parts of the country not near water are healthy. 371. On Mill creek, in Berkeley county, there is a mill-pond, which had been for many years gradually filing until a large part of it had become shallow. The immediate neighbourhood suffered considerably in the summer and autumn for a number of years, but particularly in the dry seasons for some years back. In 1825 the people around it suffered excessively, as 182 they did in other similar places. In 1826, the mill having been burnt, the water was let off, and the shal- low part of the pond has been all summer firm dry land, and not a person has been ill in the neighbour- hood. 372. The town of Winchester is situated on a re- markably level piece of ground, extending above half a mile between two hills, and upon the hills. Through the middle of the flat, from west to east, runs a stream of lime-stone water. In former years the whole of the flat on both sides of the stream was a marsh. At that time the town was unhealthy, and great numbers of children were sick every summer. Of late years the low places have been gradually filled up. Some of the streets have been paved, the bed of the run en- larged, and the sides for the most part walled up, so that no water is suffered to stagnate in any part of it. From the large spring which is the source of the stream, an abundance of water is conducted by sub- terraneous pipes to every part of the flat, and to some parts of the high ground, and the streets have so uni- form a descent that the waste water from the hydrants has free course to the stream running through the cen- tre of the town. By this means the gutters are easily washed, and this is frequently done. Much of the ground near the stream, for half a mile west of the town, is still marshy. Along the sides of the rising ground on each side of the stream, and about the spring, are several large dwelling houses. 373. In the excessively hot year 1822 (361), in the hottest part of the summer, the stream which runs through the town \yas cleaned out and regulated in 183 the manner abovementioned. While this work was going on, the water was turned into the adjoining street, which is nearly parallel with the general course of the stream. The street was covered from side to side in some parts, but the water was very shallow. Every Saturday evening the water was turned back into the bed of the stream, and again into the street on Monday morning. Thus the street, the bed of the stream, and the mud thrown out on its banks, consti- tuted an abundant source of miasmata. The town was that year sickly, particularly along the stream. In one house on the stream, and near the dirtiest part of the street, there were a number of sick persons, and two died. 374. In 1823 the summer was very wet as before stated (362), and the country sickly; but the town was very healthy. The streets were kept remarkably clean, the gutters cleaned and washed out frequently, and the weeds in the back streets pulled up and thrown into the middle of the street, where the hot sun and passing wagons soon destroyed them. The marshy ground also above the town was covered with water, and less exposed to the sun. 375. In 1824 the streets were regulated, and the side ways in some places raised so as to render them uniform, and to carry the water regularly onward to the stream. In consequence of this, however, the course of the water was in some places checked, and ponds were formed (253). In the south-west and north-east parts of the town this was particularly the case. In these two quarters there was much more sickness than in the other parts of the town, 184 376. The year 1825 was unusually sickly in Win- chester. The weather was very hot in the former part of the summer, and very dry throughout. The marsh west of the town was just firm enough to bear a light person picking his way through it. There is a mill in the edge of the town on that side, and the water being deficient in quantity, the miller employed a number of men to clean out the race. This was done in mid-summer, and a considerable quantity of water- grass which had obstructed the passage of the water, and of marsh mud, lay exposed to the action of the sun for half a mile along the race. In addition to this, the seine had been several times dragged in a large pond at the head of the marsh, and a great quan- tity of the same grass drawn to the bank. A gentle- man living in one of the houses near the pond, had also had two or three men employed for several days in pulling out the grass, which was so tangled together that a boat was filled in a short time. They carried out and threw on the bank of the pond a great num- ber of boat-loads. 377. That side of the town next to the marsh was the most sickly, but the inhabitants of the houses along the side of the marsh were the greatest suffer- ers. The inhabitants of one of the houses suffered severely, for some time before those of the others were affected. This house was immediately at the head of the marsh, and directly in line with it and the mud and grass on the side of the race. It was observed by some of the inhabitants that the wind, during the time in which this house suffered alone, blew directly up along the race and over the marsh upon the house, 185 378. The other houses were situated on the small hills along the edge of the low ground, twro or three hundred yards distant from the race, and on the side of it; so that the wind blowing up the stream, carried the miasmata along in front of the houses, but at some distance from them. The wind changed on a Friday evening, and blew directly across the marsh and the race upon the hou- ses that had hitherto escaped; and a medical gentle- man living on the spot, I was informed by the person who gave me some of the most interesting of these particulars, immediately on observing it, predicted that the disease would appear in those houses by Monday morning. On Monday the prediction was verified ; and one of those families suffered so severely that they retreated to the town for safety. 379. The spring of 1826 was unusually dry, and ex- cessively hot. The weather was hotter in May than I ever knew it to be. In that month the usual en- demic commenced with great violence, and continued through the month of June. In July we had a num- ber of extremely heavy rains, followed by very cool weather. These rains were very partial; one of them, so heavy as to inundate Water-street, did not extend three miles from town. This immediately checked the disease : the weather continues cool and remarka- bly pleasant, and very healthy. 380. Since the cool weather commenced in July, except some persons who have been out in the neigh- bouring country on the river, and at similar places, and some who reside in a low, wet quarter of the town, I have had no bad case but in two houses. 24 186 One of these was situated within thirty or forty steps of a marshy spot, about thirty yards in length, and half as wide, in such a manner that the south-west wind passed over it into the doors and windows. I had urged the subject on one of my friends in the neighbourhood, predicting evil from its continuance. Of the family exposed, as above mentioned, every white person, three in number, who spent the day at home, were taken sick; one was an obstinate case. Not one of those who spent the day at the shop on the main street had an attack. There was no other dwelling house exposed as this was to the same cause. In the other instance, a similar spot, twenty or thirty yards square, was situated immediately back of the house to the south-west. The back buildings extend to the west, and face the south; so that effluvia blown from the spot, strike the back buildings on their front, and enter them, or are directed to the principal build- ing. Every white person in this house, consisting of six, except one who was away five or six weeks below the Ridge, was more or less sick; two of the cases were very obstinate. The back buildings of this house completely protect the house north of it from these exhalations. The fa- mily on the south side of it have suffered severely for several years back; not one of them has escaped, and most of them have been very ill, some more than once. This year and the last they escaped, and I have attri- buted it to their having become habituated, or sea- soned, to the influence of those exhalations. The other family came to town last year, and were then frequently sick. 187 381. The city of Baltimore is situated on the north side and the west end of an inlet of the Patapsco, called the Basin. The stream called Jones's Falls flows from north to south through the city, and empties into the Basin. Along the lower part of this stream, particularly on the east side, the land is very flat. To the west, along the side of the Basin, and around its head, the ground is also very flat. At a short dis- tance south of the town flows the Patapsco, separated from the Basin by a narrow slip of high land. The banks of this river are marked with inlets, which are exposed at low water to the action of the sun. A lit- tle south-west of the town there are extensive brick- yards, and the land between the city and the river in that direction is flat and inclining to a marshy state. On the eastern side of Jones's Falls, is situated a con- siderable extent of flat, moist ground, on which stands that part of Baltimore called Fell's Point, which was originally detached from the city. Between the mouth of Jones's Falls and the Point, there was formerly a deep cove, and the adjoining land on the west side of that stream was formerly quite marshy, and inter- sected by creeks, which are now filled up. Extremely long wharves have been extended into the water; which were generally built with logs, like pens, or log houses, and the enclosed space was filled with chips, shavings, and all kinds of offal, with a thin covering of earth or gravel; and even this was sometimes omitted. Thus whole streets in the flat part of Baltimore, on which a dense population resides, are a mass chiefly of vegetable matter, which of course in the hot wea- ther is in a state of fermentation. Even in winter of- 188 fensive air sometimes escapes when the outside cover of this mass is broken through.1 382. This flat ground along the Basin and Jones's Falls, is very unhealthy. Severe bilious fevers are frequent there; it is the principal seat of the yellow fever, and cases of the latter sometimes occur, when the other parts of the city to the north-west remain quite healthy.2 The north-western part of the city is high and dry, and very healthy. Dr. Potter, in his excellent Memoir on Contagion, says, " No case of the yellow fever ever did originate in West Baltimore, above Hanover-street, beyond the sphere of the exha- lations from the docks, wharves, or made ground. I defy the whole population of the city to produce a so- litary exception."3 383. In the year 1797 the yellow fever prevailed in the flat parts of the city above described. Previous to the 17th of September the fever had been confined to them, and to those persons who lived in the higher parts who frequented them. On that day a strong south-east wind began to blow, and the fever immedi- ately appeared among the inhabitants of the north- west part of the town. In 1800 several instances of this kind were noted, " and the principle became so familiar that the increment of cases was calculated with tolerable accuracy, by observing the variation of the winds."3 384. The cove abovementioned is so situated that all the filth conveyed into it by the west, north-west, and south winds, must remain to stagnate and putrefy. J Medical Recorder, No. 10, p. 215. 2 Ibid. No. 10, p. 217. 221. 8 Ibid. No. 4, p. 532. Potter's Memoirs. 189 " There can be no egress by any but a north-east wind, and this cannot act, for the Point is a barrier which effectually obstructs the wind from that quarter." In the year 1800, by the prevalence of the north and east winds, which continued a great part of the summer, the bottom of this cove was left bare for some weeks previous to the prevalence of the fever of that year. The disease began on the borders of this cove, and its progress could be traced through the streets in what- ever direction the winds blew. The effect was so great on those who were very near, that the labour- ers employed in filling up its northern shore were compelled to relinquish the work early in the sum- mer (364).1 385. The summer of the year 1819 was unusually dry and sultry in Baltimore. The heat was extremely oppressive, not only from its intensity but its duration. August was for the most part clear and hot; and the prevailing winds were from the south and east. The yellow fever prevailed in the lower part of the city; and along the water two or three miles below town, for several weeks before a single case occurred in town. In the latter it appeared late in July along the docks, and in extremely foul alleys. It made its appearance at the extremity of Fell's Point, in a street running along the water, almost exclusively formed of shavings without even a stratum of earth upon them. Soon after, in consequence of the disagreeable smell arising from this mass of putrefying shavings, com- plaint was made, and the police ordered it to be co- 1 Medical Repository, Vol. 4, p. 355. Address of the Medical Fa- culty to the Mayor of Baltimore. 190 vered with earth. Three men from a healthy part of the town, were employed to do this; in a few days they were all attacked by the yellow fever and every one died (364. 383). The disease continued to prevail, and almost every individual who did not leave the affected part of the city, suffered an attack. A violent and long contin- ued storm from the north-east occurred in the latter part of September. The number of cases was in- creased for a few days, but the weather was rendered cool by it, and the disease gradually subsided after the first of October.1 386. The most striking evidence of the truth of the general doctrine is afforded by the occurrences of this summer in Baltimore. At a meeting of the Medical Faculty on the 9th of September, it was unanimously declared, that excepting some cases that had occurred on a wharf, on which there was a very foul alley hea- vily complained of as a nuisance, that they did not be- lieve a single case had originated west of Jones's Falls. " They likewise declared without a dissenting voice, that four-fifths of the city was at that time more healthy than it had been at the same season for several years." That this should be the case in an elevated dry and gravelly spot, such as the original soil of Baltimore is, is perfectly consistent with the doctrine here advo- cated. 387. On the Eastern Shore of Maryland, in the year 1793, "after a spring unusually wet, and during a summer as uncommonly hot, the bilious remitting fe- ' Medical Recorder, No. 10. p. 214, by J. Revere, M. D. 191 ver became epidemic." Some of the sick died with the black vomit.1 388. The lower part of Dorchester county, Mary- land, consists entirely of low land, with a large tract of swamps and marshes. The water in these places usually continues plentiful all summer, but in the sum- mer of 1800 it was nearly all dried up. About the 10th of August a severe epidemic commenced and contin- ued until November. There were some cases of yel- low fever. The same fever prevailed also in the fol- lowing year.2 389. Wilmington, in Delaware, is situated on a hill, about one hundred and nine feet above the level of the tide; between two creeks, the Brandy wine on the east, and the Christiana on the west; which flow into the Delaware river, distant about a mile and a half in a south-easterly direction. South-east of the town there is a considerable quantity of marshy land; and on the western side of the Christiana there is an ex- tensive marsh, which had been continually inundated until the spring of 1798, when it was drained. From the middle of July in this very hot and dry year, this marsh became extremely offensive; one hundred acres of mud covered with decaying vegetables being ex- posed to the action of the sun. There were also some very filthy docks in the town. On the northern side of the town there is a small vale in which there are tan-yards, breweries, &c. 390. An intelligent gentleman, who resided in Wil- mington during the fall of 1798, informed Dr. Vaughan. 1 Medical Recorder, No. 4, p. 529- Potter's Memoir. 2 Medical Repository, Vol. 5, p. 345, by Dr. Mace. 192 that he observed one morning a fog arise from the marsh below the town, and passing gradually over the creek, settle on the lower part of the town, and branch round into the south-eastern parts, and the vale on the north. " He repeated his observations frequently, and always observed the same phenomena." The course which this fog took, shews very plainly the di- rection in which the dense gas, arising from the pu- trefying vegetable matter in the marsh, was drifted; and these very parts were those to which the yellow fever was in that year almost entirely confined.1 391. The yellow fever did not prevail in Wilming- ton in 1793 and 1797. The marshes below the town were about that time very wet and miry. The sum- mers of 1793 and 1797 were rather wet,2 which state of the weather was unfavourable to the production of miasmata in a wet marsh : but the year 1798 was ex- cessively dry and hot, more so than 1793 or any year since, and therefore was well adapted to produce them in abundance. 392. In Christiana village and its neighbourhood, the disease also occurred in 1798. The first case was in the Welsh-Tract swamps; the second, adjacent to an extensive marsh; three persons in succession died out of one house. In September the disease was ge- neral and truly alarming. It appeared in Newcastle, and along the Delaware for some distance. 393. That part of the county of Delaware, in Penn- sylvania, which lies on the river Delaware, is very flat and was originally wet marshy land. Though by great t Medical Repository, Vol. 3, p. 368, by Dr. Vaughan. a Rush's Works, Vol. 3, p. 119- Vol. 4, p. 5. 193 care it has been drained and protected by banks from the water, there are many stagnant pools, creeks, and inlets, abounding with vegetation. In the year 1823 there were frequent light showers, with very warm weather, and the winds generally from the south and south-west, passing immediately over the marshes below, along the banks of the Delaware. In this year the autumnal fever was very severe. In the year 1824 the rain frequently fell in torrents, washing off the filth of every kind from the surface of the ground, and overflowing the pools and marshes. The weather was remarkably cool and pleasant, with the wind from north-west. In consequence of the marshes and pools being en- tirely inundated, and in July, August, and September, repeatedly washed out, there were very few cases in the low grounds; but in the higher parts of the coun- try the autumnal diseases prevailed.1 394. In the autumn of the years 1820 and 1821 the river Schuylkill was " two feet lower than usual, and consequently a large number of logs and stumps, which had long been buried in the river, were exposed, to- gether with much vegetable matter." In the former of these very dry summers, the autumnal epidemic made its appearance along the margin of the river; in the latter, it appeared also at some distance from it.2 395. The same disease prevailed along the Susque- hannah in 1819. The river was very unusually low. About one-fourth of the stream at one of the ferries, above a sand bar, was entirely stagnant, and the sur- 1 Medical Recorder, No. 30, p. 217, by R. Dutton, M. D. 2 Philadelphia Journal, &c. No, 6, p. 356, by W. Harris, M. D. 194 face was covered with river grass and a green gluti- nous mass. Of seventy-three persons residing at the ferry and near it, only three escaped sickness.1 396. The city of Philadelphia has also suffered se- verely from pestilence. It has its offensive docks, its foul sewers, its filthy and confined alleys, and low pla- ces and ponds in its suburbs. Some idea may be form- ed of the evil that may spring from these sources, from the following extracts from a paper by Dr. Samuel Jackson.2 397. Hodge's dock has been for some years gradu- ally filling up ; at low water it is at present uncovered nearly in its whole extent, and a large mass of mud is thus exposed to the action of the sun and air. Two culverts or tunnels discharge their contents into the dock. On the wharf, south of the dock, there formerly stood a large frame building, which had been used for packing and storing hay, of which considerable quan- tities had fallen into the dock at different times, and when the store was burnt down about two years since, some hundred weight were thrown into the dock.3 398. Pegg's run may be considered as an open sewer, passing through the closely built parts of Penn township, Spring Garden, and the Northern Liber- ties, to the river Delaware. Excepting during heavy rains, or immediately after them, the stream is barely sufficient to carry along, with a sluggish current, the mass of offensive substances that compose it; for in fact it seems more like liquid mud than water. By the erection of a bridge across Pegg's run at New Market- 1 Philadelphia Journal, &c. No. 6, p. 356, note. 2 Ibid. No. 2. 9 Ibid. p. 344. 195 street, a stagnating pool was formed from two to three hundred feet in length, twelve to fifteen in width, and three in depth.1 399. These unquestionably are sources from which droceed pestiferous effluvia; but there are other cir- cumstances in the situation of Philadelphia, which have been too much overlooked in considering the sources of the cause of the epidemics which have afflicted this city. There is on its northern edge a large mar- shy run, called Gunner's run, separating the village of Kensington from the Northern Liberties; and on the southern border, lies a marshy tract of land, called the Neck, between the rivers Delaware and Schuyl- kill, and extending from the city to their junction. That exhalations from these have considerable influ- ence over the health of the city is manifest from the following considerations. 400. It appears from a passage in Rush's works, that bilious fevers were for many years confined chiefly to Southwark, which lies next to the marshes below the town. Some physicians mentioning, about the year 1778, the appearance of bilious remittents in the middle and northern parts of the city, Dr. Clark- son, who began to practise in Southwark in 1761, said they had been long familiar to him, and that he had met with them every year since his settlement in Phi- ladelphia.2 The cause of their more general diffusion appears from a passage in Caldwell's Memoirs. An old and celebrated physician of Philadelphia informed the doctor, that, "previously to the Revolutionary 1 Philadelphia Journal, &c. No. 2, p. 355. 2 Rush's Works, Vol. 4, p. 230. 196 war, the city was surrounded from east to west by a range of forest timber, which protected it from the ex- halations discharged by the marshes of the neck, and by the more distant shores of the Schuylkill. This timber fell a sacrifice to the rapacious hands of the British army, in the winter of 1778, since which time the city has been more generally pervaded by bilious fever than had been the case in former years."1 " The yellow fever prevailed in the neighbourhood of Spruce-street wharf, and near a filthy stream of water which flowed through what is now called Dock- street, in the year 1762. Some cases of it appeared likewise in Southwark. It was scarcely known in the north and west parts of the city." In 1765 an inter- mitting fever was epidemic in Southwark.2 In the year 1780 the bilious fever prevailed as an epidemic in Southwark, and in Water and Front streets, south of Market-street.3 It is remarkable (says Rush,) that Southwark was nearly the exclusive seat, not only of the bilious or break-bone fever of 1780, but of the inter- mitting fever of 1765 and of the yellow fever of 1805.4 The yellow fever of 1797 was confined chiefly to the district of Southwark and the village of Kensington for several weeks.3 It also appeared early in Ken- sington, in 1798,6 and in the Northern Liberties, in 1802.7 Gunner's run is between these two. 401. On the one hand, we cannot conceive of any thing better calculated to produce disease than the filthy state of Pegg's run, and of other places in 1820 (397. 398); and the consequence was, a mortal sick- l Caldwell's Memoirs, p. 38. 2 Rush's Works, Vol. 4, p. 230. * Ibid. p. 238. * xbid. Note. 5 Ibid. p. 4. • Ibid. p. 40. 7 Ibid. p. 80. 197 ness; more so indeed than in 1793, the proportion of deaths being greater. If, however, so great a nuisance within the city produced only one hundred and twen- ty-five cases,1 what possible state of things, in that respect, could produce the death of four thousand persons 1 402. On the other hand, when we consider the po- sition of the marshes of the neck, south of the city; the great heat of the summers from 1793 to 1799 ; the prevalence of the south winds in summer, which Dr. Rush says " have blown upon the city of Philadel- phia ever since 1793, more constantly than in former years,"2 and which of course have driven the exhala- tions directly upon it; in connexion with the fact, that in that part of the town next to the marshes, bilious diseases were common before they were known in the other parts, in which they have made their ap- pearance in consequence of the destruction of a wood which formerly sheltered them; and that it is still, in general, the first, and sometimes exclusively affected by epidemics; the inference is irresistible, that mias- mata from this quarter are chiefly instrumental in pro- ducing these diseases. 403. This inference is strongly supported by another consideration. Dry weather is most favourable to the production of miasmata from marshes, the sun having thereby a better opportunity of acting on the vegetable matter. In such situations, therefore, the most violent epidemics arise in the hottest and dryest summers; and this we shall find, on a comparison J Philadelphia Journal, &c. No. 2, p. 335. « Rush's Works, Vol. 4, p. 113. 198 of the different epidemics, is what actually occur- red in Philadelphia. 404. The following table will serve to show this; as well as the general dependance of yellow fever, on the joint operation of heat and moisture on vegetable matter, or the filth of cities. The account of the tem- perature is taken from the Medical Recorder;1 the minutes of rain, from Rush's Works. Before the first of August. After the first of August. Medium tem-• :jniUire, June, July, August. Deaths. 1793 Rainy.a Drv. particularly in Sept. and Oct.6 82deg. 2 m. 4,000. 1794 No account, and therefore presumed to be not remarkably wet or dry. No account, do. 79deg. 2 m. Afew deaths about dirty pla-ces and the ponds of the subutbs. Rush. 1795 Heavy rains in the last of July and first of Augusts 79 deg. 2 m. Some deaths in July, check-ed by heavy rains which carried away bridges, buildings, he. Rush. 1796 Rainy. May and June uncommonly wet.d Very dry. 79 deg. 4 m. Few cases. Rush. 1797 But little rain. Rainy.e 80 deg. 7 m. 1000 or 1100. Rush. 1250. C. Kvans. 1798 Very dry/ Dry.g 81 deg. 8 m. 3500. 1799 No account. Very dry .A 81 deg. 1000. 1800 Very wet.t Unusual quantity 28tli and 30th August.i 77 deg. 77 deg. 7 m. Some cases confined to one •■pot. Rush. 1801 Wet in March and April, afterwards ve-ry dry.j Considerable quantity on 4tb August../ Very lew cases. 1802 Rather wet.it No account. 77 deg. 2 m. About 200. 1803 Rather dry.i Little account. 79 deg. 3 m. Yellow fever slightly. 1804 Rainy .m No account. 74 deg. 7 m. Uncommonly healthy. 1805 Exceedingly dry.n Very dry.n 79deg. 7 m. 75 deg. 7 m. of the whole 300 or 400. 1806 to 1817 No account. No account. During part of the time, un-exampled health, especially in the cool «ummers '14, '15.o 1 No. 1, p. 142, by Cadwallader Evans. a Rush's Works, Vol. 3, p. 119. b Ibid. p. 87. c Ibid. p. 242. d Ibid n 2477. 253 534. Thus it appears that in every region of the earth the epidemics of hot weather are produced by miasmata arising during the putrefaction of vegetable matter. Some objections, however, have lately been advanced against this old doctrine, with such appear- ance of strength as to induce some to waver in their belief.1 These objections, it is due to the importance of the subject to examine. "> Philadelphia Journal, &c. No. 13, p. 1, No. 16, p. 365. CHAPTER VI. ANSWER TO SOME OBJECTIONS. 535. In a paper read before the Royal Society of Edinburgh, Dr. Ferguson has controverted the doc- trine advocated in the preceding pages with much ap- parent strength. On a close examination of the cases he has stated, it will nevertheless appear, that they all support the doctrine he opposes. 536. Dr. Ferguson asserts that "the marsh must cease to be a marsh in the common acceptation of the word, and the sensible putrefaction of water or vegetables must alike be impossible before its surface can become deleterious;" and infers from a narrative of facts, going in his opinion to support this assertion, " that putrefaction, under any sensible or discoverable form, is not essential to the production of pestiferous miasmata."1 537. The facts may be arranged under the two fol- lowing heads: 1. "That it (the marsh poison,) is ne- ver found in savannahs or plains that have been flooded in the rainy season, till their surface has been tho- roughly exsiccated, vegetation burnt up, and its pu- trefaction rendered as impossible as the putrefaction of an Egyptian mummy."2 2. " That it is found most virulent and abundant on the driest surfaces; often where vegetation never existed, nor could exist for 1 Philadelphia Journal, &c. No. 13, p. 2. 2 Ibid. p. 13. 255 . the torrents, such as the deep and steep ravines of a dried water course."1 538. In support of the first he makes the following statements. " The first time that I saw endemic fe- ver, under the intermittent and remittent forms, be- come epidemic in an army, was in the year 1794y when, after a very hot and dry summer, our troops, in the month of August, took up the encampments of Rosendaal and Oosterhout, in South Holland. The soil in both places was a level 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, which, so far from being at all putrid, was perfectly potable in all the wells of the camp."2 The army in 1799 " remained the whole autumnal season in the most pestiferous portion of that unheal- thy country, without suffering in any remarkable de- gree from the endemic fever;" but "the preceding summer had been wet and cold to an unexampled de- gree; during the whole of the service we had constant rains, and the whole country was one continuous swamp, being nearly flooded with water." "In the year 1810, a British army at Walcheren, on a soil as similar as possible, and certainly not more pestiferous, but under the different circumstances of a hot and dry preceding summer, instead of a wet and cold one, suffered from the endemic fever of the coun- try to a degree that was nearly unprecedented in the annals of warfare."3 1 Philad. Journal, &c. No. 13, p. 13. 2 Ibid. p. 2. » Ibid. p. 3. . 256 539. These and some other cases are admitted to be facts; but what do they prove 1 Nothing more than that the pestiferous gas is found in these places after the surface has been flooded and has become dry ; not that it is never found in savannahs or plains that have been flooded, until their surface has been thoroughly exsiccated, vegetation burnt up, and its putrefaction as impossible as that of a mummy. There is a pro- fusion 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 continu- ance, and is the season of sickness,"1 &c. " No sooner the rains fall, than this long parched crust of earth and clay (forming the bottom of the dried-up rivers,) gradually softens, and the ground, which before had not the least smell, begins to emit a stench, which in four or five weeks, becomes exceed- ingly noisome. At this time the sickness is generally most violent,"2 viz. three months before the end of the rainy season, which lasts four months. " But the diseases most fatal to Europeans are fluxes and fevers. The latter make their appearance in the rainy season."3 " Soon after the rainy season began, a low malig- nant fever constantly spread itself among the Euro- peans."3 " The most mortal epidemic, however, is that low malignant fever of the remitting kind, which rages only in the rainy season."4 1 Lind on Hot Climates, p. 32. 2 Ibid. p. 37. 3 Ibid. p. 41. 4 Ibid. p. 42. 257 " The season of their appearance is during the rains, and for some short time after they have ceased."1 " On the 18th of May it rained the whole day; and the rain continued, with but short intervals, until the beginning of October. In the month of June almost two-thirds of the white people were taken ill." "Its attack was commonly in the night, and the patients, being then delirious, were apt to run into the open air. I observed them frequently recover their senses for a short time, by means of the heavy rain which at that time fell upon their naked bodies."2 " Of these not one was taken ill till after the rains began."* Some idea may be formed of the thorough soaking of this whole country, for the whole time of the sickly season, from the following passages. " The quantity of rain which falls during the wet season is almost in- credible. By observations made at Senegal, 115 inches depth of rain were found to fall in these four months; a quantity equal to that which falls in England during the space of four years."4 "We were, as I have already observed, thirty miles distant from the sea, in a country altogether uncultivated, overflowed with water, surrounded with thick impenetrable woods, and overrun with slime."5 540. Nor is this at all variant from our own expe- rience. Not to multiply instances, it is fresh in our recollection, that, in the year 1823, more sickly by far than any other for nineteen years back, the plains of this country were so far from being exsiccated that the roads were often miry, and that they were kept continually wet by repeated rains. Two cases men- 1 Lind on Hot Climates, p. 47. 2 Ibid. p. 49- a Ibid. p. 50. * Ibid. p. 33. * Ibid. p. 51. 33 258 tioned already are strongly in point (150. 330). As long as the old pond in the former continued wet, the family was sickly; but as soon as it was thoroughly dried, they became healthy amidst sur- rounding sickness. So also in the latter, as soon as the bottom of the pond was quite dry, sickness was at an end. In short, the result of my observation for twenty-three years is, that if there be much rain in summer, (where vegetation abounds,) sickness soon after commences; if the weather be hot and dry, the disease continues until the country be perfectly dry, when the new cases become less frequent and it be- comes more healthy, except in spots, viz. the places still wet, not the parts exsiccated. 541. Pringle speaking of the low countries says, "The country bordering on the lower part of the Maes is not only unhealthful on this account, but by reason of floods from the smaller rivers, lies all the winter under water, and continues damp throughout the summer. The moisture and corruption of the air were much increased by the inundations which had been made about the fortified towns since the com- mencement of the war, and sensibly became more noxious on letting off part of the water, in the begin- ning of summer, after the preliminary articles of peace were signed. For these grounds, which were once entirely covered, being now half drained and marshy, filled the air with moist and putrid exhalations."! " This sickness was much greater near Breda and Bois-le-Duc than at Eyndhoven, which lay at a much greater distance from the inundations and other mar- shy grounds."i 1 Pringle on Diseases of the Army, p. 62. 259 " Those who lay farther from the water and were only annoyed with the natural moisture of the coun- try and the heat of the season, had both fewer and milder fevers." Thus, though the sickness was general, those who were near the marshes suffered by far the most both in number and violence of the symptoms. The Greys cantoned at Vucht, a village within a league of Bois- le-Duc, surrounded with meadows, either then under water or but lately drained, were the most sickly. Roth's and Rich's dragoons, w ho also lay near the in- undations, were likewise very sickly. Johnson's regi- ment of foot at Nieuland, where the meadows had been floated all winter and were but just drained, re- turned sometimes above half their number.1 This is more than sufficient to show the incorrect- ness of the position (537), that the malaria "is never found in savannahs or plains that have been flooded in the rainy season, till their surface has been tho- roughly exsiccated," &c. 542. In support of the second position (537), " that the malaria is found most virulent and abundant on the driest surfaces, often where vegetation never ex- isted, or could exist," he makes the following state- ment, and others as striking. " The beautiful post of Prince Rupert's, in the island of 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 1 Pringle on the Diseases of the Army, p. 65. 260 which they are on three sides encompassed. The inner hill of a slender pyramidal form, rises from a narrow base nearlv perpendicular, above and across the marsh, from sea to sea, to the height of four hun- dred 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 nar- row- clean valley, where all the establishments of the garrison were originally placed; the whole space with- in 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 infi- nitely more dangerous than the quarters in the valley within half musket shot below. In fact no white man could possibly live there, and it was obliged to be aban- doned. At the time this was going on, it was disco- vered, 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 I procured the surveyor-general of the island to measure the elevations and distances, and I have given them here from his report."l 1 Ferguson's Essay, Philadelphia Journal, &c. No. IS, p. 10. 261 543. These statements are admitted to be true; but they only prove that the " malaria" was found in those places. They do not prove the general posi- tion, that the driest places are those in which we find it most virulent and abundant. On the contrary, the multitude of instances already stated show the re- verse, and an instance directly opposed to it in point of fact is mentioned by Dr. Ferguson in the very case above recited (542), on which he rests, in part, as proof of his assertion. If the gas is so virulent and abundant on one hill, it is not to be found on the other; and it is found on that hill nearest the marsh. 544. It is clear then that all that is established, and that is not denied, is that the malaria was found on those particular spots mentioned; or, that it is some- times found on dry plains after they have been flooded, and on dry hills. Had not these cases been brought forward, the inference we have drawn (178) would have rested unquestioned on the multitude of facts of a directly opposite character that have been stated, as well as on those which must occur to every one from his own reading and experience. These cases can only be considered then, as long as they continue un- explained, at the most, in the light of exceptions to the general rule; and should we be able to show that putrefying vegetable matter existed on the spot, or near enough to produce the effects observed, the cases are no longer exceptions—they confirm the general rule. 545. This we shall now show to have been the fact in every instance mentioned, and first of those which occurred in Holland (538). Pringle, speaking of this country, has the following 262 observations.1 " Great part of the United Provinces, with Dutch Brabant, from Grave downward along the Maes, being likewise low and wet, is subject to the same distempers with the flat part of Flanders. But the air is worst in Zealand, as that province is not only low and watery, but surrounded with the oozy beaches of the eastern and western Scheld, and the most mar- shy parts of the country ; so that almost every wind, except from the sea, adds to its native moist and un- wholesome exhalations. All this tract of the Netherlands being little higher than the level of the sea, or the rivers that pass through it, was once so much exposed to inundations from floods and high tides, that till dykes and drains were made, it was one large morass; and even now, after incredible labour, the country is liable to be overflowed by extraordinary floods and other casual inlets of water." Speaking of two villages, the one ten, the other four- teen feet above the subterranean water, he mentions it as an extraordinary height in that country.2 Here is cause enough on our ground. Here de- composition of vegetable matter takes place to a very great extent; and the mere fact that the army was en- camped on a naked plain of sand, is no argument against its sufferings being produced by a gas arising during the process of putrefaction, in a country where there are no hills to intercept the passage of mismata, and where marshes to produce them so abound, that, as Pringle says, almost every wind adds to its native moist and unwholesome exhalations. The more per- 1 Pringle on the Diseases of the Army, p. 2. 2 Ibid. p. 63. 263 feet the dryness of the spot, the more fatal the disease; because the same intense heat that rendered it so, operates at the same time on the surrounding marshes, mud, &c. 546. The justice of this explanation may be tested by referring to the Bahama islands. They are low and flat like Holland; and " seem to have been formed, if external appearances may be trusted, from an accu- mulation of shells or small calcarious grains of sand."1 But the soil is remarkably thin, and they have no ri- vers depositing mud and forming morasses. They are also, in perfect accordance with the doctrine support- ed in these pages, remarkable for health; whereas, "if paucity of water, where it has previously and re- cently abounded,"2 be the cause of epidemics " in cli- mates of high temperature," here we ought to find them as frequent and violent as in Holland ; indeed, more so, as the heat is so much greater, and the rains so very abundant (435). 547. The occurrence of sickness in Holland in 1810 (538), is explained in the same way; and the exemp- tion in 1799 is perfectly consistent with our doctrine, the superabundance of water which made "the whole country one continuous swamp," and the unexampled coolness being both calculated to prevent putrefaction to any great extent. 548. The next case mentioned occurred in Portu- gal. "In June the army advanced again towards Spain, in a healthy condition, during very hot wea- ther. The army was still healthy, certainly without 3 Edwards's Hist. West Indies, Vol. 4, appendix by M'Kennan 2 Ferguson, p. 16. 264 endemic fever, and marching through a singularly dry rocky country, of considerable elevation, on the con- fines of Portugal. The weather had been so hot for several weeks as to dry up the mountain streams ; and in some of the hilly ravines, that had lately been wa- ter courses, several regiments took up their bivouac, for the sake of being near the stagnant pools of water that were still left amongst the rocks. The staff offi- cers who had served in the Mediterranean, pointed out the dangerous nature of such an encampment; but as its immediate site, amongst dry rocks, appeared to be quite unexceptionable, and the pools of water in the neighbourhood perfectly pure, it was not changed. Several of the men were seized with violent remittent fever before they could move from the bivouac the fol- lowing morning; and that type of fever, the first that had been seen on the march, continued to affect that portion of the troops exclusively for a considerable time. Till then it had always been believed amongst us, that vegetable putrefaction (the humid decay of vegetables,) was essential to the production of pesti- ferous miasmata; but, in the instance of the half-dried ravine before us, from the stony bed of which (as soil never could lie for the torrents,) the very existence even of vegetation was impossible, it proved as pesti- ferous as the bed of a fen. The army advanced to Talavera through a very dry country, and in the hot- test 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, 265 in fact, ceased to be streams, and were no more than lines of detached pools in the courses that had for- merly been rivers; and there they suffered from re- mittent fevers of such destructive malignity, that the enemy and all Europe believed that the British host was extirpated."l 549. This case certainly operates against Dr. Fer- guson'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 " half- dried ravine," which was the bed of a stream, contin- ued free from fever until they were forced to retreat into the plains of Estremadura, along the course of the Guadiana, when that river and its branches had become mere lines of detached pools, and " there they suffered from remittent fevers of such destructive ma- lignity," &c. 550. This is precisely what occurs with us. When for want of rain the country is burnt up, as happened in 1822, and almost in as great a degree in 1825, and again in the present year, 1826, 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 situa- tions are extremely severe (364 to 366. 370. 511). 551. If " one only condition be indispensable to the production of the marsh poison, on all surfaces capa- ble of absorption," viz. " paucity of water, where it has previously and recently abounded;" if it be found 1 Philadelphia Journal, &c. No. 13, p. 4. 34 266 only in plains that have been flooded in the rainy sea- son, after their surface has been thoroughly exsicca- ted ; why was the army healthy on their march until they arrived on the banks of the Guadiana, a line of pools 1 and why was that part of the army alone af- fected during their march, which encamped in the bed of a stream which had also become a line of pools 1 Why are autumnal fevers general in wet years, amidst continued rains which never allow the surface to dry 1 (362. 539. 540) ; and why in the dry years is the sick- ness confined to the wet places near rivers, &c.1 (363 to 366). 552. The bare hilly country near Lisbon, where the foundation of the soil, and of the beds of the streams is rock, with free open water courses among the hills, is a very healthy one; but the Alentejo land, on the other side of the Tagus, though as dry superficially, being perfectly flat and sandy, is as much the re- verse as it is possible to conceive. The breadth of the river, which at Lisbon does not exceed two miles, is all that separates the healthy from the unhealthy re- gion ; and the villages or hamlets that have been placed along the southern bank of the Tagus, for the sake of navigation, are most pestiferous abodes. The sickly tract, however, is not confined to the immediate shore of the river. Salvaterra, for example, about a mile inland, is a large village and royal hunting resi- dence in the Alentejo, which is always reputed to be very healthy till the beginning of the autumnal season, when every person, who has the means of making his escape, flies the place. In their superstitious fear, the inhabitants declare, that even the horses and other 267 animals would be seized with fever if left behind, and therefore they always remove the royal stud. The country around is perfectly open, though very lowr, and flooded with water during the whole of the rainy season ; but at the time of the periodical sickness, it is always most distressingly dry, and exactly in propor- tion to the previous drought, and consequent dryness of soil, is the quantum of sickness."1 553. The nature of the country about Lisbon is pre- cisely such as would lead to the conclusion that it is a healthy country, if health depend on the absence of putrefying vegetable matter. Though water abounds in the spring, it cannot stand in pools. But if paucity of water following abundance be the only indispensa- ble condition of the production of disease, why is not this country as sickly as the equally elevated and rocky neighbourhood of Port of Spain, mentioned by Dr. Ferguson in the same essay, or the hill at Prince Rupert's (542). 554. With respect to the Alentejo land, there is certainly nothing peculiar in its circumstances. It is a flat low country, lying between two rivers, near their mouths, having several cross cuts from one to the other, and to the sea, and abounding with moisture in the forepart of the summer. It is evident that a large village and a royal hunting residence implies a plenty of vegetation in the proper time for it, and al- though very arid at the time the sickness takes place, there is no reason for believing that the malaria arises at the season of the year when vegetation is actually burnt up. Oh the contrary, in the progress of vege- 1 Philadelphia Journal, &c. No. 13, p. 5. 268 tation to perfect dryness, decomposition must take place as the heat of the weather increases, and it is manifest that gases must be produced. Moreover, in such situations there always is much filth and vegeta- ble matter about the banks of the rivers, and more or less of marshy ground, the exhalations from which must have free access to every part of so flat a spot as this is. 555. The same may be said respecting the country around Cividacl Rodrigo. " It is situated on a rocky bank of the river Agueda, a remarkably clear stream; but the approach to it on the side of Portugal is through a bare, open, hollow country, that has been likened to the dried-up bed of an extensive lake; and upon more than one occasion, when this low land, af- ter having been flooded in the rainy season, had be- come as dry as a brick ground, with the vegetation ut- terly burned up, there arose fevers to our troops, which for malignity of type could only be matched by those before mentioned on the Guadiana"1 (548). The gases which are produced during the progress of ve- getation to perfect dryness, rest on this flat hollow country, and gently glide down to the beds of the ri- vers, the lowest places, on one of which the city, is situated. 556. The same was experienced at Corea, a town on the banks of the river Alagon, " with this addition clearly demonstrated, that no spot of the pestiferous savannah below the town, was so much to be dread- ed as the immediate shores of the river." To this the same explanation may be given. If ever * Philadelphia Journal, &c. No. 13, p. 6. 269 decomposition of vegetable matter take place, it must occur in a flat country, with abundant rains in the spring, followed by excessive heat, and " the pestife- rous savannah below the town" was a most suitable place for the evolution of miasmata. 557. In the case of the post at Prince Rupert's, it is evident that the inner hill and the clean valley could not have been the surface which produced the cause of the fever; because, almost universally, such " heights of the purest soil" are healthy, as in Barbadoes, and other islands of the West Indies (439.440), and at Lis- bon (552); and because at this very post, 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 quar- ter for the source of the evil. 558. In order to discover this, we must recal to mind that the pestiferous gas is dense, resting in the lowest places, and driving with the wind (178). With regard to the latter property, independently of its be- ing a necessary consequence of its nature, as a dense gas, the evidence afforded in the statements respecting the fever on Fort Hill, and in Back-street, Boston (223. 224) ; Cliff-street, New-York (229) ; and at the cantonment of the United States troops at Gallio- polis, Ohio (163), leaves no room for doubt. 559. In the case now under consideration there was a large marsh, three-quarters of a mile in extent, to the windward of the hill. The gas generated in this marsh must necessarily have been driven up the ascent of the hill next to it, or the inner hill, by the trade- 270 wind which sets continually in that direction, and sur- mounting its shoulders, fell from its density into the valley between the two hills; down which, being pro- tected by the inner hill from the wind, it quietly glided into the sea, and did not reach the outer hill five hun- dred 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 to a place in which the gas was more abundant than in the valley ; because, after passing the shoulders of the hill, though its density would dispose it to descend to the lowest part, it must, by the impulse given it by the wind, be somewhat more mixed with the common air between the hills; and that the outer hill was quite healthy because pro- tected from the gas by the interposition of the valley, and by its distance. 560. " Port of Spain, Trinidad, the capital of the island, is situated very near the great eastern marsh, with which it is in direct communication, by a mar- ginal line of swamp along the seashore. It cannot be called a healthy town, but it is very far from being uninhabitable. On the right are some covering heights, which rise out of the marsh at one extremity. These, unlike the site of the town, which has been built on marshy or alluvial ground, are composed of the purest and most healthy materials, (pure limestone, the pu- rest and the best in all the West Indies,) yet have they proved a residence deadly and destructive in the great- est degree to all who venture to inhabit any part of their diversified surface. No place, however elevated, or sunk, or sheltered, or walled in, gives securitv 271 against the exhalations from below; only it has been distinctly ascertained, that these prevail with more or less malignity, exactly in proportion to the elevation of the dwelling. The lower, consequently nearer the marsh, the better. The tops of the ridges are unin- habitable. On the highest top, at an elevation of four hundred feet, and farther removed from the marsh than the town itself, a large martello tower was built to defend the place. It possessed a fine temperature, but proved so dangerous a quarter that it was obliged to be abandoned. Not even a Creole mulatto Spa- niard could sleep in it with impunity for a single night, after a course of dry weather."1 561. Dr. Ferguson has said nothing of the direc- tion of the trade-wind in relation to " the great east- ern marsh," the towrt, and the hills. Taking, how- ever, Tanner's new and excellent map for a guide, the town is situated in the northwest corner of the island. On the left the coast runs a little east of south; on the right directly west, forming a cape running out from the main body of the island to a considerable distance. The covering heights to the right, men- tioned by Dr. Ferguson, are on this neck of land. They rise out of the great eastern marsh, which is of course to windward. Thus situated, the gas from the marsh is blown di- rectly along up the ascent of these heights, and over them to the sea. 562. The effect of wind blowing miasmata up a hill, was strikingly exemplified in 1798 at Fort Hill, Bos- ton, and on the Blue Ridge, in Virginia, in 1823, &c. 1 Philadelphia Journal, &c. No. IS. p. 10. 272 (558. 165). A remarkable instance is also stated in the Medical Repository of New-York.1 Brewton-IIill, two miles below Savannah, in Georgia, has ever been a dangerous place of residence in the summer and fall. " The house is on the edge of a lofty hill, perhaps fifty feet above the level of the river, distant a third or half a mile, and the intermediate space is a rice-field. It has no protection, and the forms of disease are in the most concentrated and active state." 563. It is manifest, that if the troops at Galliopolis (163) had been cantoned 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. And it is as evident, that, in this way, the gas ascended the sloping heights at Fort Hill; those of the Blue Ridge, in Virginia; of Prince Rupert's, and of Port of Spain. 564. This is illustrated and confirmed by what was observed at English harbour, in Antigua. A range of fortified hills surrounded the dock-yard. Monk's hill rises perpendicularly above the marshes to the height of six hundred feet. The ridge is about one hundred feet lower, and slopes backwards from the swamps. The men who stood guard in the night among the marshes below Monk's hill, were frequently seized with furious delirium, and died in a few days. Not a single case of fever of any kind occurred to those in- habitants of Monk's hill who were not obliged to sleep out or stand guard below.2 At the ridge, three hun- 1 Vol. 10, p. 360, note. 2 See the same in Lind on Hot Climates, p. 149. 273 dred feet above the marshes, the artillery soldiers (se- venteen in number,) never were on any of the night guards, but every man suffered an attack of the ordi- nary remittent. At the barrack on the top of the ridge, at the height of five hundred feet, and still farther re- tired from the marshes, there scarcely occurred any fever worth notice. Those on the perpendicular hill escaped, while those on the hill sloping backwards from the swamp, suffered. It is evident that, in the former case, the perpendicular form of the hill pre- vented the ascent of the gas, which must have been driven around the base; whereas, in the latter, the gradual slope of the hill facilitated the ascent.1 565. "The leeward shore of Guadaloupe, for a course of nearly thirty miles, under the shelter of a very high steep ridge of volcanic mountains, never felt the sea- breeze, nor any breeze but the nightly land wind from the mountains; and though the soil, which I have often examined, is a remarkably open, dry, and pure one, being mostly sand and gravel, altogether and po- sitively without marsh in the most dangerous places, it is inconceivably pestiferous throughout the whole tract, and in no spot more so than the bare sandy beach near the high water mark. The coloured people alone ever venture to inhabit it, and when they see stran- gers tarrying on the shore after night-fall, they never fail to warn them of their danger. The same remark holds good in regard to the greater part of the lee- ward coast of Martinique/'2 &c. 566. The name Guadaloupe is given to two islands 1 See Johnson, Vol. 2, p. 113, for similar instances. a Philadelphia Journal, &c. No. 13, p. 19. 35 274 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 may be gathered from Dr. Ferguson's account of the situa- tion of Point au Pitre, situated on the leeward shore of Grand-terre. Although then the soil be open, dry, and pure, mostly sand and gravel, it differs little in this respect from most of the West India islands. Most of them are light and open, and have, notwithstanding, pesti- ferous marshes. In a space of thirty miles of low land, with rivers and marshes, in a hot country, de- composition of vegetable matter, in abundance, must take place. Sheltered from the trade-wind which would carry it off, the gas produced on its surface must abound; and it is not wonderful it should be "inconceivably pestiferous throughout the whole tract;" nor that the night land wind, from the moun- tains to the shore, should carry it down to the latter, and render it particularly dangerous to remain on shore through the night. The same remark holds good of the leeward coast of Martinique, this island having also its basse-terre.1 567. The facts stated, (545 to 566), therefore, only show that "malaria" is found in certain places where vegetation has been burnt up, or does not exist; but its existence there has been shown, in every instance, to be consistent with the origin and nature of the sras laid down in the preceding pages, and the presence of a source of it, sufficient to produce the effects ob- 1 Lind on Hot Climates, p. 85. 275 served, pointed out: and therefore the conclusion that putrefaction is not essential to the existence of " ma- laria," is so far from being legitimately drawn from them, that they confirm the opposite doctrine. 568. To support the doctrine that putrefaction is not essential to the production of pestiferous mias- mata, Dr. Ferguson endeavours to show that where vegetable putrefaction is self-evident," it is not produc- tive of disease and death similar to what emanates from the marsh poison." He alleges that in West India sugar ships, where the drainings of the sugar mixing with the bilge water of the hold, creates a stench that is absolute- ly suffocating to those unaccustomed to it, fevers are never known to be generated.1 To this assertion we cannot, it is true, at this distance reply, by ad- ducing a case or cases of these effects proceeding from the putrefaction of that precise kind of vege- table matter; but we have stated cases at large, in which there is the most unquestionable evidence that vegetable matter of other kinds in a state of decompo- sition, on ship-board, does produce such effects (168 to 175). We have further shown that a mass of mat- ter, similar to that which forms a marsh, in a pile in a city, produces the same effects (340). We have shown that a mass of vegetable matter, on a larger scale, but equally circumscribed, in a state of decomposition, produced corresponding effects. The fever in the cantonment at Galliopolis manifestly proceeded from the gas arising from the pond; the troops having escaped entirely until the wind blew directly over it, 1 Philadelphia Journal, No. 13, p. 14. 276 and in five days after that occurrence one half the sol- diers being sick. This pond was partly filled with fallen trees ; and at the time of the raging of the fever, contained " a great quantity of muddy water, with a thick slimy moisture of putrefying vegetables" (163). 569. With great confidence, of support, he refers to the effect of dung heaps in every part of the world. Heaps of dung, literally, have in this country very lit- tle vegetable matter in them. But we have frequently read accounts of families being destroyed almost en- tirely by fevers, which were by the physicians attri- buted to a decaying hay-stack, or some such object near the house. The following facts occurred in my own family. In the fall of 1821, when the season was uncom- monly healthy in VVarrenton, Fauquier county, my family w as unusually sickly. Few escaped entirely ; two were quite sick. This excited some surprise un- til we adverted to the following circumstance. The garden had just been inclosed ; the land was not rich, and about two hundred cart loads of manure were put on about one-third of an acre. The weather after July was excessively dry, and the pumpkin vines, &c. which were very luxuriant, died. These dead vines, an exuberant crop of weeds, &c. were piled against the fence to rot for manure. The pile, eighteen feet long, five feet high, and projecting about three feet from the fence, was about fifty feet southwest of the back door. 570. The same thing, it is highly probable, occurs very much oftener than people are aware of in the fall of the year, and is passed over without notice because 277 every body is sick; a reason we have often heard given by unthinking people, for not believ ing a marshy situa- tion unhealthy. A family near the house of a friend of mine, fed a number of large hogs in a small yard before the house with a profusion of cut grass; the filthiness of the yard was such, that it was difficult to get to the house. Of this family in that fall three men died with the worst symptoms, as hemorrhages, &c. It is true that they lived near a stream of water; but it was large, the banks were dry, and this family suf- fered much more than their neighbours in the village. 571. With the same view (568) the doctor endea- vours to showr, that where vegetable putrefaction abounds there is little or no sickness. " Thus at the town of Point au Pitre, Guadaloupe, which is situated aiiiidst some of the most putrid marshes in the world, the stench of which is almost never absent from the streets, the [dace was far from being uniformly unheal- thy. Strangers, however much they might be annoyed by the smell, often resorted to it with impunity. No more was its first outpost Fort Louis, where the waters are so stagnant and putrid, that it is even more offen- sive than at Point au Pitre ; but at fort Fleur'D'Epee, the farthest outpost, at the extremity of the marshes, where they approach to the state of terra firma, where little or no water is to be seen on the surface, and no smell exists, there cannot be supposed a more deadly quarter, and all white troops consider their being sent there as an equivalent to a sentence of death. It ought to be noted that the marshes of all these three posts are overgrown with the thickest underwoods, and rankest aquatic vegetation of every kind." 278 572. "A fact of the same kind has been observed in the island of Tobago. The principal fort and barrack of the colony has been placed immediately to leeward of the Barcolette swamp, within the distance of less than half a mile, and the strong ammoniacal stench of its exhalations, even at that distance, often pollutes the barracks; but these are so far from producing fe- ver at all times, that when I visited the white garrison there, they had been more remarkably exempt from that form of disease for several years than any other troops in the West Indies."' 573. Of the same cast is the account of " the town of New-Amsterdam, Berbice, situated within short musket shot to leeward of a most offensive swamp, in the direct tract of a strong trade-wind that blows night and day, and frequently pollutes even the sleeping apartments of the inhabitants with the stench of the marshes, yet it had produced no endemic fever worthy of notice, even amongst the newly arrived, for a period of months and years previously to my visiting that colony." 574. With regard to the stench, it is well known that when vegetable matter is designedly placed in circumstances favourable to decomposition, and when this is rapidly going on, as in a mass of bruised ap- ples, or peaches, in the process of making brandy, or in a beer tub, there is little or no smell. On the con- trary, in consequence of the fermentation of certain vegetables, or of animal matter, an offensive gas is produced before decomposition can be perceived to have begun. x Philadelphia Journal, No. 13, p. 9. 2 Ibid. p. 13, note. 279 We know, also that the dense gas which produces the evil has no smell (195); and that the strong smell- ing gases are not dense. Therefore, the strong smell in those places least affected, is no proof of the degree of decomposition going on there ; nor.of the presence of the dense gas, the known cause of the disease. 575. From the face of the account it is evident, that in all these places the exemption from sickness rested on the abundance of water preventing the action of the sun on the marshes ; and from the extreme unheal- thiness of that post, where " the marshes approached to the state of terra firma, and little or no water was to be seen on the surface," it is evident that as soon as the marshes were brought into a state favourable to putrefaction, and before exsiccation had taken place, the pestiferous gas was produced. 576. The same is shown by the effect of an uncom- monly dry summer on the health of one of these very places. Dr. Rush says, " Dr. Gordon informed me that five hundred persons died of the yellow fever in Berbice, between July 1804, and May 1805, during which time there fell not quite three inches of rain. The earth in this case was every where dry and parched"1 (430). It is to be remembered that the rains are very abundant in that^ country (420. 426). It is very evident that this extreme drought, in so hot a country, was precisely the weather most favourable to the production of miasmata in " a most offensive swamp" (573). It is the very weather which always produces severe epidemics near marshy places (436 1 Rush's Works, Vol. 4, p. 111. 280 to 438); and it is to be observed, that the severest cases, in these dry seasons, occur near streams and marshy places. 577. It may also be observed, that as the account of Dr. Gordon and Dr. Frost (430. 431) enables us to explain the difficulty Dr. Ferguson found in recon- ciling this case to the doctrine of the production of endemic fever, by a gas arising from putrefy ing vege- table matter; so Dr. Ferguson's account enables us to explain the difficulty Dr. Rush found on the other extreme, of the occurrence of endemic disease in (as he supposed,) the absence of moisture and putrefac- tion. 578. The same is manifest from the case of Trini- dad (560). In that island, " almost all swnmpy, and the centre of which may be called a sea of swamp, where it always rains at least nine months in the year, if it only rained eight, or if at any time there was a cessation of the preserving rains, the worst kind of remitting fevers were sure to make their appearance."1 Is it not manifest that exsiccation never occurred in such " a sea of sw amp '!" 579. If we suppose such a marsh to be exsiccated, it is evident that it will, in becoming so, pass through the state best calculated for putrefaction, and that this will precede exsiccation. In countries far enough north, as Spain, or sufficiently elevated, as Abyssinia, to be rendered cool by the rains in the forepart of the summer, the absence of heat delays the appearance of sickness, sometimes even until the general aspect of the country be dry. On the contrary, in countries like 1 Philadelphia Journal, &c. No. 13, p. 8. ^ 281 Senegal, hot in the extreme, very soon after the rains begin, sickness appears. The appearance of disease, therefore, though sometimes delayed till exsiccation takes place, often occurs without it; but never without the circumstances favouring decomposition of vegeta- ble matter, even when it begins immediately after the fall of the rains. Lind says, "the first rains which fall in Guinea are commonly supposed to be the most unhealthy ; they have been known in forty-eight hours to render the leather of the shoes quite mouldy and rotten,"1 &c. 580. A very strong argument against the doctrine of Dr. Ferguson is, that the autumnal fever often ap- pears on board of vessels at sea. Of this, instances have already been given (168 to 175). On board of the Busbridge, Indiaman, on a voyage from England to the East Indies, when the ship had arrived near the line, the yellow fever broke out.2 On board the Ge- neral Green also, which vessel left Newport, in New- England, in June, and sailed to the Havanna, the yel- low fever broke out at sea.3 A remarkable case is stated in one of the late journals, of a violent fever breaking out in a ship ; in consequence of which the attention of her officers was turned to having her cleansed, when several boat-loads of very offensive matter were discovered in her hold underneath a plat- form of boards, very similar to marsh mud. 581. In these cases it is very evident that the con- dition of Dr. Ferguson does not take place, viz. pau- city of water where it has lately abounded (551); and 1 Lind on Hot Climates, p. 35. ? Medical Recorde/, No. 4, p. 541. 9 Ibid. p. 533. ,36 282 it is as plain that the same mass of corruptible mat- ter was present, as in many others already stated (340). 582. Exsiccation, therefore, is not essential to the production of the endemic diseases of hot weather; and these never occur without the decomposition of vege- table matter; and we find it the result of universal ex- perience, in all times and places, that putrefaction of vegetable matter is the conditio sine qua non of the presence of these diseases, and that a dense gas thence arising is the cause. Note. The following case should have been mentioned before; but this part of the work was printed in the midst of incessant engagements during a severe epidemic, and the passage was overlooked. It should have been inserted between 545 and 567; it is therefore noticed here. Dr. Ferguson mentions in a note an instance in England of a spot ab- solutely 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 Romney 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 bar- racks 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 unwhole- some tract of country more prolific of endemic fever during the hot sum- mer 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 Dungeness being through it, every one passing and repassing was exposed to the opera- tion 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 pro- duce the effect observed : and where there was no marsh near, as at Lis- bon, in Bermuda, &c. (439), there was no sickness. CHAPTER VII. OF THE NATURE OP THE GAS, AND ITS IMMEDIATE EFFECTS ON THE HUMAN SYSTEM. 583. The nature of the dense gas, which bears the name of miasmata, is not an uninteresting subject. If we could ascertain it, effectual means might be de- vised to counteract its influence. The following con- siderations are offered on the subject. The elementary parts of vegetable matter are car- bon, oxygen, and hydrogen: a few contain azote, but these are not often met with in marshes. The gase- ous combinations which may arise from the decompo- sition of vegetable matter and the re-union of these elementary parts, are carbonic acid gas, carburetted hydrogen gas, and hydrogen gas. Of these, the two latter are light and fly off immediately. The former is the only gaseous product of putrefying vegetable matter, dense enough to remain on the surface of the earth, and to drive with the wind. If azote should arise in any case, it is not dense enough for this. The carbon is capable of combining with hydrogen in a different proportion from that which occurs in the car- buretted hydrogen gas, and also with the azotic gas; but these compounds are only observed during certain processes of the laboratory. 584. A dense gas arising from putrefying vegetable matter, being the cause of the diseases observed in 284 the neighbourhood of marshes ; and the carbonic acid gas being the only dense gas known to arise in such circumstances, we are led to infer that the carbonic acid gas is the cause in question ; and the truth of the inference is strongly supported by a comparison of the properties of the gases, of the circumstances in which their effects appear and disappear, and of the nature of these effects. 585. Both these gases are denser than the atmos- pheric air, so as to remain at the lower part of it, and to drive with the wind along the surface of the earth. 586. " Dr. Dalzelle says he once checked a bilious fever by spreading twelve barrels of lime over a piece of marshy ground, from whence the exhalations which produced it were derived."1 The carbonic acid gas has a strong disposition to combine with lime; it unites with it in preference to the alkalis. 587. The unknown gas does not produce its effects across water, unless it be in great force, and at very short distances. Lind recommends living on the wa- ter in very sickly countries to escape it. Some fami- lies in Philadelphia, in 1793, escaped the disease en- tirely by living in vessels in the river.2 Dr. Ferguson says, " it is certainly lost and absorbed by passing over a small surface of water."3 The carbonic acid gas readily unites with water. 588. " Mercurialis relates, (says Dr. Mead,) that the plague in Venice was augmented by burning a large quantity of infected goods in the city."4 He also states, that after making the same experiment in the i Rush's Works, Vol. 4, p. 131. 2 Ibid. p. 130, Pringle, p. 57. 3 Philadelphia Journal, &c. No. 13, p. 18. ■■ Mead's Treatise on the Plague, p. 120.- 285 last plague at Marseilles, the disease spread every day more and more through the city.1 Large fires, Dr. Hodges states, were made in all the streets of London for three days together, in the time of the great plague; and there died in that week many hundred more people than in the week prece- ding, although the disease was on the decline.2 The effect of these fires was the production of an immense quantity of carbonic acid gas; and from the extent, ir- regularity, and narrowness of the streets of London, at that time, there was little opportunity for its imme- diate dispersion. 589. A wood, or thick growth of bushes, inter- posed between a marsh and a dwelling house, saves the inhabitants from the effects that would follow but for the interposition. It is impossible that a gas should be unable to pass through the trees with the wind which brought it thus far. It is manifest that it is arrested by the wood; and the fact of the carbonic acid being consumed by the wood, completely accounts for the salutary effects of its interposition. 590. It is a matter of common observation, that the blood drawn from persons who have been exposed to the exhalations arising from marshes, is darker than usual. It is often nearly black, even in those persons who are not ill, the darkness being in proportion to the degree of exposure. In Goodwyn's excellent treatise on "the connexion of life with respiration," he says, " It has been shown already, that when the same air is breathed several times, or when it is retained in the lungs longer than 1 Mead's Treatise on the Plague, p. 132. 2 ibid. p. 131. 286 usual, there is a gradual diminution of the dephlogis- ticated air, (oxygen gas,) and an increase of fixed air (carbonic acid gas.") " When the dephlogisticated air is thus diminished, the ordinary change of colour which the blood undergoes in the lungs, will be also diminished, till at length it will pass through the pul- monary veins with the same black colour as when it entered into the arteries." " I forced a considerable quantity of air into the lungs of a small dog, whose sternum had been re- moved, and confined it there by a tight ligature round the trachea: the blood continuing to circulate through the lungs in this state, began immediately to put on a shade of brown in the trunks of the pulmonary veins; and in less than two minutes it became very black."1 The same experiment was tried on toads and lizards with the same result. The dark colour of the blood, therefore, takes place when an increased quantity of the carbonic acid gas is present, as completely as under the influence of marsh miasmata. 591. The effect of carbonic acid gas directly ap- plied in a confined situation, is to " produce at first a sense of uneasiness, then chilliness, sickishness, and a kind of head-ache, which ushers in loss of sense, a fixedness of the eyes, a rigidity of the whole body, a ghastly countenance, a small, frequent, and irregular pulse, feverishness,"2 &c. These are effects very commonly observed in per- sons exposed to the operation of marsh miasmata. J Goodwyn on the Connexion of Life with respiration, p. 66. 67. 2 Motherby's Dictionary, Carbo. 287 592. A very large proportion of carbonic acid gas in a confined place extinguishes a lighted candle and destroys animal life. So also does the gas which produces endemic fever. See the case of the Childers (170), in the hold of which ship the seamen declared candles would not burn, upon many occasions, when they were sent into it. The same thing occurred in the case of the ship of war General Green, on her voyage to Havanna. 593. To sum up the whole, the unknown gas is dense, and arises from putrefying vegetable mat- ter (178). The carbonic acid is a dense gas arising from pu- trefying vegetable matter, and the only one known to exist. The miasmatic diseases are most prevalent in the afterpart of the summer, showing the abundance of the unknown gas. At the same time carbonic acid gas abounds, in consequence of the profusion of dead and decaying vegetable matter. The unknown gas drives with the wind. Carbonic acid gas does also. The unknown gas, according to Dr. Dalzelle's ac- count, is absorbed by lime. Carbonic acid gas has a strong disposition to com- bine with lime. The unknown gas is readily absorbed by water. Carbonic acid is readily absorbed by water. Large fires in great number in a town, increase the effects arising from the unknown gas. Carbonic acid gas is produced in immense quantity by them. 288 The unknown gas is arrested by a wood, and pre- vented from producing its effects beyond it. Carbonic acid gas is consumed by a wood, and thus effectually arrested. The unknown gas changes the blood of those ex- posed to its influence to a brown, and finally to a black. Carbonic acid gas does the same. Carbonic acid gas produces a sense of uneasiness, chilliness, sickishness, head-ache, &e., a small, fre- quent, and irregular pulse, feverishness, &c. (591). The unknown gas also produces a sense of uneasi- ness, &c. &c. The unknown gas extinguishes lighted candles, and destroys animal life suddenly. Carbonic acid gas does the same. 594. Admitting then the existence of a dense gas, the product of putrefying vegetable matter, other than the carbonic acid gas; there are two gases thence arising, one known, the other unknown ; both denser than the atmospheric air; both producing the same effects; both driven by the wind along the surface of fhe earth, so as to make their effects visible at a con- siderable distance ; and both arrested by the interpo- sition of a wood between the source whence they pro- ceed and a distant object, whereby the usual effects are prevented. It is moreover impossible that the un- known gas can arise from vegetable matter in a state of decomposition, without the presence of carbonic acid gas; so that the former never exists without having along with it, in the latter, a cause capable of producing every effect attributed to it. It would therefore be a violation of Newton's first 289 rule of philosophizing to admit the existence of any other than the carbonic acid gas. This gas is there- fore the cause of the autumnal diseases. 595. The effect of this gas we have seen is to ren- der the blood brown, and finally black (590). This black blood does not stimulate the heart as the flo- rid blood does. In his experiments on the respira- tion of different animals, Goodwyn says, " he attended carefully to the changes in the colour of the blood, and in the corresponding contractions in the left auri- cle and ventricle of the heart; and in all the exam- ples observed, that when the blood which passed into the left auricle was florid, the auricle and ventricle contracted strongly, and the circulation went on as in health; but when the blood began to put on a shade of brown the contractions were diminished, and when it was black the contractions ceased, although the au- ricle was distended with blood,"l &c. Thus, weakened action of the heart is the conse- quence of respiring the dense gas arising during the putrefaction of vegetable matter. 596. The general doctrine is not implicated in the discussion respecting the nature of the dense gas, known by the name of marsh miasmata (583, &c). Whatever be the nature of this gas, it renders the blood brown, and finally black, which thereby becomes less stimulant to the heart (595). Nor is this effect confined to this dense gas; any gas arising from pu- trefying vegetable matter, has the same effect of weak- ening the action of the heart, if prevented from flying off, or if retained so as to be respired. Dr. Beddoes 1 Goodwyn on the Connexion of Life with respiration, p. 72 to 81. 37 290 says, " he never saw an instance in which a lowered atmosphere did not at the moment quicken the pulse, while it weakened the action of the heart and arte- ries." * But this gas, being the only one dense enough to rest on the surface of the earth, is the only one ac- tually present when the effect is produced. J Darwin's Zoonomia, Vol. 2, p. 479. CHAPTER VIII. ORIGIN OF WINTER EPIDEMICS. 597. Although autumnal epidemics cease, for the most part, with hot weather, it is not unusual for the first cold weather to produce an increase of the num- ber of cases; and they continue to occur throughout the winter, sometimes in considerable numbers. Thus, in the epidemic in the neighbourhood of Portland, Maine (213), Dr. Barker attended " in July six cases, in August sixteen, in September twenty-five, in Octo- ber twenty-four, in November nine, in December eight. in January fifteen, in February six."l 598. It is evident from the increase of cases on the access of cold weather, or on sudden changes to colder weather; and from some of the symptoms being such as are commonly produced by cold; that this remote cause has considerable influence in producing these fevers. But that cold alone is not the cause is ob- vious, when we reflect that they are sometimes mild and not very prevalent in the coldest winters; and that the reverse sometimes happens in comparatively mild winters. Some other remote cause is therefore in operation; and it will appear from a consideration of the state of the persons attacked on the access of cold weather, from the symptoms, and from the 1 Medical Repository, Vol. 3, p. 365. 292 topography of the places in which these cases occur, that they are produced by the joint operation of mias- mata and cold. 599. The effects of the remote cause miasmata are paleness or sallow ness, black blood, black and green discharges from the stomach and bowels, &c The whole of these effects do not appear in all exposed. Some are ill; others complain only of chilliness, pains in different parts, &c.; others feel pretty well, but have little or no appetite; others, in addition to want of appetite, feel a loathing; or, if there be no loathing, the stomach is so irritable that on eating a meal it is soon after rejected ; all are more or less sallow; some who are apparently well have black tongues; blood drawn from persons not indisposed is nearly black ; the serum is yellow; the discharges from their stomachs and bowels are frequently green or black, particularly if a mercurial cathartic be taken. 600. It is certain, therefore, that the whole popula- tion of a neighbourhood exposed to miasmata, is under the influence of this remote cause of disease and af- fected in various degrees. Numbers are on the verge of an attack at every period of the autumnal season, and are still so at the moment of the access of cold weather. The process of putrefaction, and the pro- duction of miasmata, thereupon ceasing, the cause ceases to operate, and the effects gradually disappear. This, however, takes time; and although most of those thus influenced escape, particularly those lightly af- fected, all do not, and we meet with cases in every pe- riod of cold weather, in which the effects, black blood, green or black discharges from the stomach and bow- els, are observed. 293 601. In seasons in which miasmata abound, greater numbers are on the verge of an attack throughout the fall, and also at the time of the access of cold weather, and for some time after. In the course of the autumnal season, fever is often induced in persons under the influence of miasmata, by exposure to cold, sometimes during sleep in cool nights, or by neglecting to change wet clothes. If, while the population are still under the influence of miasmata, the access of cold weather be sudden, or the weather be severe, the operation of cold being general, greater numbers must necessarily suffer an attack; and this is particularly the case in winters fol- lowing seasons in which miasmata abound. 602. According, therefore, to the degree of expo- sure to cold, some have simple bilious remittent or intermittent fever, with the precise symptoms which occurred in the autumn; while in others catarrhal or pneumonic symptoms also appear. Even in those cases in which the disease is considered as pneumonia, the lungs are often not affected. Cleghorn dissected se- veral bodies dead of pleurisy, as he thought, and found the pleura sound.1 In some cases, however, pneumo- nia is unquestionably present, together with the clearly marked symptoms of the autumnal disease preceding. 603. It is manifest from this statement that these winter diseases occur in persons exposed, while under the influence of miasmata (600), to the action of cold; and that the symptoms observed are those produced by miasmata, in connexion with more or less of those produced by cold. Wherefore they are the effects of the joint operation of miasmata and cold. 1 Clcghorn's Diseases of Minorca, p. 247- 294 fJ04. It is manifest that the symptoms produced by the one or the other cause, must predominate in pro- portion to the power of the predominant cause. Thus, of persons influenced equally by miasmata, those most exposed to the action of cold will experi- ence most of its peculiar effects, catarrh or pneumo- nia. The same holds good, as well when applied to different years, as to individual cases. In those win- ters following autumnal epidemics in which we are most exposed to cold, that is, in which the weather is most severe, catarrhal and pneumonic affections pre- dominate ; while in the mild winters, the cases are al- most free from them, the symptoms being almost en- tirely those of the preceding autumnal epidemic. Thus in the w inter of 1814, which was very severe, the snow being two feet deep in this country, the pneumonic symptoms predominated, and the disease was very mortal. All the symptoms of autumnal fever were, however, also present, viz. besides the ordinary symp- toms common to fever in every form, green and black discharges from the stomach and bowels. In the re- markably mild winter of 1823, the catarrhal symptoms were common, but pneumonia did not occur in more than a single instance in my practice. The cases were almost uniformly bilious remittent, with all the symptoms as strongly marked as in the autumnal season. The winter of 1824 was the mildest ever known in this country in the memory of the living; the ground was not frozen except during one week in February, perhaps the whole winter. In consequence of this the streets were very muddy, and the feet of those whose 295 business called them out, were frequently wet the whole day. Bilious cases of high grade were com- mon. In the beginning of February the weather was very cold for one week. This caused a great increase of the number of sick, and almost universally a cough and oppression of the breast were added to those symptoms which appeared previously; but no case of pneumonia occurred in my practice. 605. These cases sometimes continue to occur through the winter. As some persons continue under the influence of miasmata through the autumn, and fall into fever on the accession of the action of another remote cause, cold; so others, better protected, or more careful against cold, continue in the same state through the winter, until, on some sudden exposure. fever is produced. 606. In confirmation of this explanation (603), we find such winter epidemics occur frequently in the north, after summers particularly calculated to pro- duce miasmata; as in the case of Portland (213) ; or in southern countries where disease from miasmata is common every year, on the occurrence of unusually cold weather; or, as in the north, even in winters of or- dinary severity, after autumns in which an uncommon quantity of miasmata is produced. It is further con- firmation of its correctness that these winter epide- mics, both in the north and in the south, occur in situa- tions in which miasmata are known to abound. 607. The following cases illustrate all these parti- culars (597 to 606), as well as the general doctrine of the dependance of these winter epidemics, as well as those of the summer, on miasmata. 296 608. In the autumn of 1798 a severe epidemic pre- vailed in Portland, Maine, and continued throughout the winter; the particulars of which have been already stated (213. 597). 609. " 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 ri- vers 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 symp- toms of partial inflammation, whence they are deno- minated pleurisies of the eye or of the head; at other times they affect the side. In those several forms they are equally dangerous." " It commonly attacks peo- ple who have been afflicted by intermitting fevers du- ring the summer and autumn. It appears chiefly, perhaps only, in those places where people are sub- ject to intermitting fevers, in low sunken grounds, and along the banks of rivers. In the beginning of win- ter, in the year 1792, that fever was very fatal in Mar- tin county, near the river Roanoke; the river had lately been very low, and much of the muddy bottom and other 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 fa- milies, 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 fhe winds were generally from the south-west. The 297 ©ther inhabitants of the adjacent country, except on that narrow strip by the river, enjoyed good health. In the year 1792, 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 lowr, and much of it covered with water." * 610. Greenville is a small town on the south side of Tar river, built on a pleasant spot of considerable ele- vation, 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 extent as to cover the low land half a mile from the banks. The miry state of the branches, in many places, ren- ders 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 a con- siderable extent of its muddy bottom, &c. was exposed to a hot sun for nearly two months. The land be- tween the town and this pond, is mostly under culti- vation. July, August, September, and October, were distinguished, as usual, by the prevalence of bilious fe- vers : however, the fevers of this year were more par- ticularly 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, 1 Medical Repository, Vol. 2, p. 156, by H. Williamson, M. D. 38 298 and frequently several of these symptoms at once, in- creasing in violence as the fever came on, and during its progress. The pain in the side was accompanied by a cough and expectoration of bloody matter.1 611. In the 7th volume of the Eclectic Repertory, we have an account by Dr. Davis, of Columbia, in South Carolina, of a winter epidemic which commen- ced in that town in November, 1815, immediately af- ter the common bilious fever. It prevailed in other parts of the state also, and "the most swampy si- tuations, margins of rivers, and places most subject to the endemial autumnal bilious fevers, suffered most severely from the epidemic." 612. 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 some- times the part on which the disease spent its force. A very frequent form of the disease was that of bilious pleurisy." 613. The winter of 1814 was very severe in Fau- quier and the neighbouring counties. 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 pain 3 Medical Repository, Vol. 5, p. 137, by Dr. G. Pillson. 299 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 three cases 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 Imost affected in the autumnal epidemic of 1821. The same disease was excessively severe along the Potomac and Rappahannock rivers, a coun- try peculiarly liable to autumnal diseases. 614. In Winchester the autumnal epidemic of 1822 was followed by a winter epidemic. A snow storm in February covered the earth a foot deep. This, with cold north-east winds and rain in the last of that month and first of March, produced considerable sickness. The symptoms were such as are common in the au- tumnal season, bilious passages, &c. together with catarrhal symptoms. I met with one case in which these symptoms rose by degrees to that grade of the disease which has been called peripneumonia notha. 615. In the fall of 1823 the town was healthy; and the whole winter remarkably so. I met with but one case of bilious pleurisy; in which there was a violent cough, pain in the side, with remarkably dark bilious countenance, and black passages for a fortnight. This case occurred in February, very near to a mill-pond, in a house noted for the number of sick persons in it in every autumnal epidemic. 616. In the fall of 1824 the town was sickly; and the beginning and end of the winter, particularly Fe- 300 bruary, March, and April, were very sickly. Catar- rhal affections were common; but in most cases the disease was a bilious remittent of high grade. The discharges wrere generally black, and nausea common. In one instance the stomach was excessively irritable, and the discharges by vomiting, as well as those from the bowels, w ere perfectly black. After some days of evacuation by mercurial cathartic pills, finding the stomach still discharging black matter, though aware of the effects of emetics in autumnal diseases of high grade, I ventured to give fifteen grains of ipecacuana. The patient vomited about thirty times, and it requi- red considerable* efforts to stop the operation. 617. In the fall of 1825 the town was also very sickly; and the forepart of December, and after the middle of January, the winter was sickly. The wea- ther, particularly in the latter part of the winter, was very severe. There was a number of cases of pneu- monic inflammation, with bilious symptoms, and dark green discharges. 618. In 1826 the weather in the latter part of the summer was cool and pleasant (379), and an epide- mic appeared late in the season. It was, however, very severe. In addition to the regulations of the streets by public authority, above alluded to (375), there were some pathways raised a foot or two above the level of the street, for the convenience of passing across the flat wet ground between the main street and the next street west of it. This was done in the spring of this year. The south-west quarter of the town, in consequence of these things, had several ponds in it from one to six inches deep. The houses mentioned 301 before as having suffered from such wet spots, are in that quarter. The disease prevailed very generally along this flat ground on both streets. Of the whole number of cases, nine-tenths occurred in this south- west quarter, and along the stream that passes through the town. The disease has much abated for some time; but already (middle of November,) have bilious pleurisies made their appearance, after a very cold rain and wind. The discharges are of a black, or bottle green colour. In one case now under my care, the patient was bled freely, and completely relieved from the pain in the thorax and the difficulty of breathing, and has been some days passing black bile. It would be im- possible for any one to discover in her at this time, any other symptoms than those of autumnal fever. In another case, after the pain in the side and the cough were removed, the dark passages, and other symptoms of the autumnal epidemic, continued; and among others, a remarkable difficulty of operating on the bowels. I have observed precisely the same in former winter epidemics. 619. In Philadelphia, in the winter following the great epidemic of 1793, it was observed that the symp- toms of yellow fever appeared in combination with those of pneumonia. r 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 of the symptoms of the yellow fever, par- ticularly a puking of bile, dark coloured stools, and a 302 yellow eye." He further mentions several cases of pneumonia, in which appeared symptoms of yellow fe- ver ; as yellow eyes, dilated pupil, and redness of the eyes in the degree common in yellow fever. Dr. Griffitts attended a patient in pneumonia who had universal yellowness of the skin.1 620. In the year 1794 there were many cases of yel- low fever.2 " The cold weather in October checked the fever, but did not banish it from the city. It ap- peared in November, and in all the succeeding winter and spring months." The winter was moderate.3 There was an uncommon mortality in the months of January, February, and March, 17954 (608 to 614). In 1795 there were some cases of yellow fever, and the different forms of autumnal fever were of a pretty high grade.5 " The winter was uncommonly moderate. There fell a good deal of rain, but little snow." " Ca- tarrhs were frequent." Several cases of bilious ma- lignant fever appeared in March and April.6 In 1796, August, September, and October were un- commonly healthy. The winter was in general heal- thy. During the spring, though cold and wet, no dis- eases of any consequence occurred.7 In the autumn of 1797 the yellow fever prevailed in 1 Rush's Works, Vol. 3, p. 102. 2 ibid, p 199, &c. 3 Ibid. p. 201. * Ibid. p. 232. 5 Ibid. p. 242. 6 Ibid. p. 243. 7 Vol. 3, p. 244. Vol. 4. p. 3. It is proper to observe, (hat in the edition of 1818 of Rush's Works, there is an error in inserting 1796 for 1795, in the passage, "The winter of 1796 was uncommenly moderate," Vol. 3, p. 243, as will appear on comparing this passage with one in the next page; viz. " The weather in December was extremely cold," &c. There is another in inserting 1797 for 1796, at the commencement of the account of the fever of 1797, Vol. 4, p. 3, as will appear on com- paring that passage with the commencement of the account of the fever of 1798. 303 Philadelphia, and " was succeeded by scarlatina, ca- tarrhs, and bilious pleurisies in the months of Novem- ber and December of the same year." The diseases of February and March were catarrhs and bilious pleurisies.1 In 1798 a most violent yellow fever raged in Phila- delphia. The diseases in November and December were highly inflammatory. A catarrh was nearly uni- versal. The weather in December was extremely cold. About the middle of January the weather mo- derated, but " the weather was very cold, and bilious pleurisies were common during the latter part of Feb- ruary." It was still cold in the first half of April, and diseases, though fewer than in winter, were still bi- lious and inflammatory.2 The yellow fever again prevailed in 1799. There is no mention 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 like- wise during this month. March was unusually heal- thy, and the weather warm in April, and the city as healthy as in March.3 In the autumn of 1800 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 suf- fered, that Rush endeavours to account for it.4 1 Rush's Works, Vol. 4. p. 39- 2 Ibid. p. 55. 3 Ibid. p. 63. 4 Ibid. p. 64. i 304 The months of November and December were un- commonly healthy.1 " The month of January was in- tensely 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 scar- latina anginosa appeared in these months.2 In autumn 1801 the city was healthy. No winter epidemic but the measles. In 1802 there was a considerable number of cases of yellow fever. No mention of the diseases of No- vember 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 ter- tian type.3 In the autumn of 1803 the city was sickly. In Jan- uary 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 dis- eases which prevailed in the city.4 In 1804 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 1 Rash's Works, Vol. 4, p. 65. 2 Ibid. p. 69. 3 Ibid. p. 83. « Ibid. p. 91. 305 tempestuous; and during January, February, and March, there was a number of bilious catarrhs and pleurisies.1 621. D.\ Rush has given no account of the winter diseases after this 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."2 This is precisely what 1 have observed uniformly. 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. 622. The fever which prevailed in Portland, Maine, in the autumn of 1797 (213), continued through the winter until March.3 The fever of the autumn of 1798, in the same place, continued till February (597).. 623. Bethlehem township, Connecticut, four or five miles square, is ridged into hills running due north and south. There are six of these ridges, and in each valley there is a stream of water. The soil is very fertile. It was settled in 1730, and continued healthy until 1750. In 1748 a man built a dam across the central valley, in order to kill the timber on a piece of flat ground containing about fifty acres. The ground 1 Rush's Works, Vol. 4, p. 95. 2 Ibid. p. 103,from Huxham on air and epidemic dis. Vol. l,p. 19- 3 Medical Repository, Vol. 2, p. 150. 39 306 continued covered until the spring of 1750. The wa- ter was then let off, and was followed by a pestilence, which carried off a number of the most robust inhabi- tants. The summer was a very hot one. 624. As few of the physicians, and still fewer of the people, thought the ponded swamp the cause of the disease, ten years after what the old people called the first great sickness, the same low ground was again overflowed. After the letting out of the water in 1760, another wasting sickness began in the month of No- vember, and carried off about forty inhabitants; this was called a malignant pleurisy.1 625. From this it appears, that, as the cause in every autumnal epidemic falls short of producing the disease in numbers, though it produces in every one a greater or less approach to it; it may fail of produ- cing evident disease in any, but may leave the whole population on the verge of it, and produce, by the co- operation of cold, an epidemic in the winter and spring. 626. It is not a valid objection to this doctrine, (that the winter is but the continuance of the summer epi- demic, derived from miasmata, and continued by the co-operation of cold;) that many are taken sick in high places where miasmata do not abound. It is certain that miasmata are so far diffused as to produce some effect even in those who live at some distance from marshes. During the epidemic of 1823,1 did not bleed a single person for indisposition of any kind, or how- ever slight, in the town of Winchester, which was then very healthy in comparison with the neighbourhood, whose blood did not resemble in blackness and con- 1 Medical Repository, Vol. 1, p. 523, Rev. A. Backus. 307 sistence the blood of those who suffered attacks of fe- ver in the country. The winter epidemic then, although like the sum- mer, it is most prevalent in low places; because there the two remote causes, cold and miasmata, co-operate in full force ; is found in high situations in greater pro- portion than the summer diseases, because, although one remote cause, miasmata, is there weak, the other one, cold, is as strong as in the low places. 627. There are two causes operating; the one con- fined for the most part to low places, the other general. While the former operates alone, the sick are chiefly found in low places. When the latter begins to ope- rate, its action not being confined to low places, but extending with equal power to high situations, the proportion of the sick must be increased in them. If the power of miasmata in low places be to the same in high situations as four to one, the number of the sick in the former will be, to those in the latter, as four to one. If the power of the other cause, cold, be represented by the number two; as it acts on all alike, the joint effect on the low places will be as six, and on the high as three. Thus, although a greater num- ber are still sick in the low places, there is a great- er proportion in the high. 628. It is evident from the preceding statements, that winter epidemics prevail in situations in which miasmata abound in the autumnal season (608 to 611. 613. 614. 616 to 620. 623. 624); that they occur in winters following those seasons particularly favoura- ble to the production of miasmata (608 to 611. 614. 616 to 620. 624) ; and that they do* not occur in win- 308 ters following healthy autumns (615. 620, in 1796, 1800, 1801); that the symptoms manifestly indicate that they are the joint effect of miasmata and of cold (612 to 619. 620, in 1794, 1795, 1797, 1798, 1799, 1802, 1803, 1804) ; and that those symptoms of the winter epidemics which originate in miasmata (599), correspond in grade with those of the previous autum- nal epidemic (614 to 620). It appears also that many of the cases have no other symptoms than those com- mon in autumnal epidemics (612 to 619. 620, in 1794, 1795, 1799), the operation of the cold being sufficient to produce a fever, as frequently happens in the au- tumnal season (601), but not to produce its peculiar local effects on the lungs. There are, therefore, in winter epidemics some cases in which the symptoms of catarrh or pneumonia are the most prominent; and some in which they are not to be seen, and the case is without hesitation called a bilious fever, or yellow fe- ver (620, in 1794,1795,1799) ; and even in those cases in which, at first, the symptoms of pneumonia are most prominent, if these be removed by prompt measures, the symptoms originating in miasmata (599) remain, and the disease is not to be distinguished from an au- tumnal or bilious fever (618). Wherefore it is evi- dent that winter epidemics are the effect of the joint operation of miasmata and cold. 629. It is evident from the whole preceding account, .that catarrhs and pleurisies are found prevailing to- gether as the result of the same cause (614 to 620), the latter being the effect of a higher degree of power in the cause. Catarrhs are frequently epidemic, when there are few pleurisies (604. 620, in 1800). 309 630. As, in some cases which were deemed to be pleurisies, it has been found, on dissection, that the pleura was sound; so in many cases called catarrhs, or colds, from the cough and other symptoms, the lungs are not affected, and there is no expectoration. The cough is violent, but entirely dry; and all the other symptoms show that the disease is the effect principally of miasmata; as in the following case of a child of seven years of age. The sole symptoms were pain in the stomach, diarrhoea, rapid decline in colour and flesh, violent cough without the slightest expecto- ration. Ten grains of calomel produced black passa- ges, and relieved all the symptoms surprisingly. The cough ceased. The relief was so great, that nothing more was done for a day or two, and the symptoms returned. The same remedy again produced the same discharges, afforded the same marked relief, and soon carried off the disease. This was one of a great num- ber of cases in the winter of 1824 (604). 631. These epidemics, with catarrhal or pneumonic symptoms, have been sometimes called influenza. Dr. Pillson, speaking of the winter epidemic mentioned above (610), says, " From information I am led to think that the same combination of symptoms appear- ed on this river in the year 1789 or 1790, and was then known by the indeterminate name of influenza.'" 632. These winter epidemics have been mentioned by several authors, and yet have been very little ad- verted to by physicians. They are nevertheless re- gular in their appearance, insomuch that it is not difficult to predict with as much certainty a winter as 1 Medical Repository, Vol. 5, p. 140, note. 310 a summer epidemic. If, for instance, we have much rain in summer, and the weather be warm, autum nal fevers are sure to appear in considerable number So, if after an autumn abounding in miasmata the win- ter be very cold, as in 1814 (604), or wet, a winter epidemic may confidently be expected. 633. Sydenham gives an account of one of these in the winter of 1675. In the summer and fall of that year, numbers were destroyed by an epidemic fever and dysentery ;l and the winter epidemic commenced with the first cold moist weather. " In 1675 the sea- son having continued unusually warm, like summer, till towards the end of October, and being suddenly suc- ceeded by cold and moist weather, a cough became more frequent than I remember to have known it at any other time ; for it scarce suffered any one to escape, of whatever age or constitution he were, 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,) but also on ac- count of the danger that attended it. For as the con- stitution, both now and during the preceding autumn, eminently tended to produce the epidemic fever above described, and as there was now no other epidemic existing, which by its opposition might, in some mea- sure, lessen its violence, the cough made way fof, 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 1 Sydenham's Works, Sec. 5, ch. 1. 311 of the symptoms occasioned some, for want of suffi- cient attention, to esteem this fever an essential pleu- risy or peripneumony, though it remained the same as it had been during this constitution. For it began nowr, 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, ex- cept only that the febrile matter, when it was copious- ly deposited in the lungs and pleura, through the vio- lence of the cough, occasioned such symptoms as be- long 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 ap- peared; and this likewise the remedies to which it readily yielded plainly showed."1 634. Sydenham also mentions a fever, which he had found to prevail from the beginning of winter to the beginning of spring, and calls it the winter fever.2 He likewise mentions " a fever, attended with several pe- ripneumonic symptoms, which arises every year to- wards the beginning, but more frequently at the close of winter." This he calls bastard peripneumony.5 Though he describes these as different fevers, it is evi- dent from his language, as well as from the symptoms, that they are one. He says, speaking of the winter fever, " if there be much morbific matter, it occasions such a fever as we have described under the head of the bastard peripneumony. But if there is only a small quantity of morbific matter, it only produces the symptoms I proceed to enumerate."2 635. He mentions also another fever, which he calls ] Sydenham's Works, Sec. 5, ch. 5. 2 jW(|. p. 538. s Ibid. p. 267. 312 a new tever. When he was first called upon in this fever, he " esteemed it the same kind of distemper as the bastard peripneumony," "with this difference only, that this fever was sometimes not attended with those symptoms which characterized and distinguished that disease," viz. peripneumonic symptoms.1 His reason for believing it to be a new fever, is given in these words; "but in the beginning of summer, which sea- son commonly terminated those peripneumonic fevers, this fever still continued; whence, soon perceiving my error, I was fully persuaded that this fever was to be referred to a new constitution."1 636. It is evident that this is no sufficient reason for reversing a judgment founded on the identity of the symptoms ; and that the first opinion was correct. It is also evident from the quotation above (634), that the common winter fever, and the bastard peripneumony, differ only in degree. The identity of all three will appear at once from the following statement of the symptoms of each. Bastard Peripneumony. Alternate paroxysms of heat and cold. Giddiness and acute pain in the bead, when the cough is most trou- blesome. Cough, pain in the thorax, difficult respira- tion. Blood resembling pleu- ritic blood. Urine turbid and very red. Winter Fever. The same. Pain in the head and limbs, and universal rest- lessness. Generally a cough, but respiration not so diffi- cult. The same. The same. Not mentioned. 1 Sydenham's Works, p. 54-1 Pulse much the same as in health. The new f',ver of 1685. The same. Frequently pain in the head and limbs. Generally a cough, with other symptoms of mild peripneumony. The same. Not mentioned. The same 313 637. The identity of the whole is here apparent. It is further shown by the direction given by Sydenham, in his treatment of both the winter fever1 and the new fever,2 that if difficulty of respiration, or violent pain in the head on coughing, show a tendency to bastard peripneumony, " the patient is to be carefully treated according to the method laid down in our discourse on that disease."3 638. Sydenham says little of the weather, but states that the new fever commenced " as soon as it began to thaw in February, 1685." Webster states that the preceding summer was hot and dry.4 Such a summer, in so flat and wet a country as England, must have produced abundance of miasmata; and the weather in the following February was, in these circumstances, precisely such as we have seen is calculated to pro- duce a winter epidemic (604. 620, in 1802. 621). 639. It is evident, therefore, that these fevers, pre- vailing at the same time, differed only as the different cases of our winter epidemics differ, viz. some have more and some less of the peripneumonic symptoms. The former are well described in his account of the bas- tard peripneumony ; the latter in the account of the winter fever. But, differing only in the degree of the affection of the thorax, there is no propriety in con- sidering them as different diseases. 640. The summer of 1685 also was hot and dry, and an epidemic prevailed in England. Sydenham says that the fever w hich commenced in February con- tinued to prevail in summer, the peripneumonic symp- toms being slighter as the w eather became warmer. i Sydenham's Works, p. 540. 2 Ibid. p. 546. « Ibid. p. 540. 546. 4 Webster's History of Pestilences, Vol. 1, p. 205. 40 314 When the fever began in February, he considered it " the same kind of distemper as the bastard peripneu- mony," and the correctness of the opinion is evident from what is stated above (636). When the sum- mer came on, the peripneumonic symptoms having disappeared, he found that the remaining symptoms identified the disease with the summer fever. Hence, also, it is obvious that the only difference between the summer and winter epidemics, is the addition of the peripneumonic symptoms to the latter. 641. Cleghorn, in his valuable work on the diseases of Minorca, which island we have seen 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 "commonly like an ague fit, with shiver- ing and shaking, flying pains all over the body, bilious vomitings and purgings," &c. " the most part of the sick being seized with stitches in their sides, striking upwards to the clavicle, and shoulder blade,"1 &c. Be- side some abatement of the fever common every morn- ing, on the third day, or beginning of the fourth, there was frequently a great remission, sometimes a total cessation of every violent symptom, so that the sick were thought to be out of danger; but on the fourth or fifth, a delirium, &c. carried off the patient in a day or two.2 In one person, whom he believed to have died of a pleurisy, the lungs and pleura were found on dissection to be sound. He expectorated freely from the sixth to the twelfth day of his illness.3 1 Cleghorn's Diseases of Minorca, p. 242. 2 Ibid. p. 246. 3 Ibid. p. 250. 315 642. Though Cleghorn states that the most part of the sick had stitches in the sides, &c. it is plain from what he says in the beginning of the chapter, that many of the sick had no symptoms of the kind. He says, " The anniversary epidemical fevers of Minor- ca 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,"1 &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 that even of these, some, on dissec- tion, are found without any affection of the lungs or pleura. It is this latter class that he describes as the winter fever. 643. These extracts show that in Europe, as well as in America, winter epidemics occur in such situa- tions, 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 Sy- denham says, the very same fever which prevailed to the day when the cough first appeared. 1 Cleghorn's Diseases of Minorca, p. 238. CHAPTER IX. IDENTITY OF THE AUTUMNAL EPIDEMIC DISEASES. 644. From the identity of the cause of autumnal epidemics, we infer the identity of these diseases. We shall not, however, rest the doctrine on this inference alone, but consider the question at large. 645. In the first stage of every fever the action of the heart is diminished. This is sooner or later followed by increased action, which after some hours more or less moderates or subsides. These two states of the system, the cold and the hot stage, constitute a pa- roxysm of fever. 646. On the degree of the cold stage is founded the division of autumnal fevers into intermittents and re- mittents. Both these arise in the same circumstances of heat, moisture, &c. Few epidemics occur in which either is exclusively observed; one predominates, but some of the other almost universally appear also. In many cases it is difficult to say whether the fever is strictly remittent or intermittent. Remittents often become intermittents; and intermittents remittents. The change from one to the other sometimes occurs in the same person more than once. These are there- fore one disease. 647. All, it is believed, have concurred in this deci- sion. Cullen's language is very striking: "Remit- 317 tentes enim, quse dicuntur, ex eodem principio, mias- mate nempe paludum, ac intermittentes, oriuntur; iis- dem in locis, et eodem anni tempore, utraque simul epidemice grassatur; utraque iisdem prorsus remediis sanatur; et ssepissime in eodem homine idem, qui vi- detur, morbus, nunc intermittentis, nunc remittentis typum exhibet. Morbi idcirco, causis, sanatione, et typo simillimi, ncc ad ordinem, nee ad sectionem di- versam distrahendi erant."1 648. Epidemics vary exceedingly in the violence of the two stages constituting a paroxysm of fever. In some the cold stage is very severe and long continued, and the hot stage comparatively moderate. In others, the former is almost unnoticed, while the latter is very severe. The depression is in some cases so great that the patient dies in the cold fit. In others the increased action is such that death ensues in the height of the hot stage, with symptoms of apoplexy. The causes which produce either peculiarity in a few cases, in some years are sufficient to make it a common occurrence; just as the cause which some- times produces a single instance, or a few cases of yel- low fever, is sometimes sufficient to make it general. Thus, we have had in some counties in Virginia, in 1820 and 1821, an epidemic in which many died in 1 Culleni Synopsis Nosologiae Methodicae, Tom. 2, p. 56. For those (fevers) 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 inter- mittent, another while of a remittent. These diseases, therefore, being very like in their causes, in the cure, and in their form, are not to be drawn asunder to different orders or sections. 318 the first cold stage;' and authors mention epidemic intermittent apoplexy, epilepsy, &c.2 As, in the individual instances, no one would con- ceive that the disease w as any thing more than an ag- gravated degree of one or other of the stages of the prevalent fever; so, when these cases become more numerous, it would be unphilosophical to consider them different diseases, because they occur in greater numbers. 649. Both intermittents and remittents vary in vio- lence, from an affection so slight as to be little regard- ed, to one so great as to acquire the appellation of malignant; and these higher degrees of morbid action take place when those circumstances, in which mias- mata are produced, exist in greater force, viz. when the temperature of the atmosphere is unusually high, and moisture and filth abundant. 650. The yellow fever occurs, in hot countries, in situations, in which, in cooler countries, common re- mittents and intermittents would appear (436). In cool situations in hot countries, as on the elevated rid- ges above the places where yellow fever appears, com- mon remittents and intermittents prevail at the very moment that yellow fever is raging below (564.) Ma- lignant tertians become mild by removing the patient to a situation in which the cause is less powerful ;3 as from the neighbourhood of a marsh to a high and dry situation. On the other hand, mild cases become ma- lignant when the sick are carried to a situation in 1 Medical Recorder, Vol. 5, p. 417, by J. R. Lucas, M. D. 2 Cullen. Nosol. Vol. 2, p. 49. 50. Tertiana carotica, tertiana epi- leptica. Bruce. Rees's Cyclopedia, Sennaar. 3 Lind on Hot Climates, p. 132.133. 139. 319 which the cause is more powerful. Thus, Lind, speak- ing of Greenwich hospital in Jamaica, unfortunately built near a marsh, says, " The effects of this unhealthy situation were, that when a patient was sent thither with only a mild intermitting fever, this mild indisposi- tion was often changed into a malignant fever, a bloody flux, or some other mortal distemper. The yellow fever often reigned there, attended with the most pro- fuse evacuations of blood by vomiting, stools, and even by every pore of the skin, when no such symptoms oc- curred in patients whose cases had been similar, and who were permitted to remain in their ships."1 The same author says, " It is a common observation that those who have had obstinate agues in England or Holland, almost constantly suffer a relapse when they arrive on the coast of Africa."2 651. In the United States the yellow fever always makes its appearance in places noted for the preva- lence of the ordinary autumnal fever ; and in the same circumstances which produce the latter (221. 226. 246. 252, &c. 305, &c. 309, &c. 316, &c. 320. 336, &c.) It appears only when the cause of the or- dinary grade of fever is in greater force than com- mon. The gas which produces autumnal fever being the effect of the operation of heat on moist vegetable matter, the quantity is of course proportioned to the degree of heat where the latter abounds. In very hot summers the quantity produced must therefore be greater than common, and the grade of their effect, autumnal fever, higher. This is what we find actu- ally occurs. In the forepart of a very hot season, the 1 Lind on Hot Climates, p. 131. 2 Ibid. p. 54. 320 temperature is as high as it is in any part of common seasons; therefore in the forepart of such seasons the grade of autumnal fever is as high as the highest in common seasons; and, as the season advances, the grade advances also, and the highest grades appear. Before the cause has acquired that degree of force necessary to produce yellow fever, bilious fever is com- mon. It gradually becomes more and more violent, as the weather becomes more and more favourable to the production of the common cause. If from any cause the production of miasmata be checked, the vio- lence of the fever moderates; and this moderation appears not only in the comparative mildness of the new cases, but often in the melioration of the symp- toms of the old. This change takes place whether the check proceed from frost, from cool weather with- out frost,1 or from effectual draining, or filling up ponds, as occurred at Galliopolis2 and at New-York (226. 228); the effect on the fever being the same from lessening the force of the cause on the spot, as from removing the sick to a place where it exists in less force (650). 652. In the rise of the epidemic, the nature of the fever becomes a subject of warm contention; some de- claring it yellow fever, others asserting it is only the ordinary fever rendered more malignant by the in- x C. Caldwell, M. D. now Professor of the Institutes of Medicine, &c. in the Transylvania University, in a letter to the editor of the New-York Medical Repository, vol. 7, p. 149, respecting the yellow fever of 1803 in Philadelphia, says, "After the tenth of October the disease was no longer spoken of as a thing dangerous or alarming; and before the twentieth there was scarcely a case of it existing in the city. Contrary to the experience of former years, it terminated entirely be- fore the occurrence of black frost." 2 Potter's xMemoir, Medical Recorder, No. 4, p. 528. 321 ereased heat of the weather. At length, however, all admit it is the yellow fever. Even after this is universally admitted, at a little distance from the chief sources of miasmata, even in the higher parts of the same city, cases of the ordinary grades of bilious fever are common.1 Nay, it is im- possible to decide in the first hours of an attack, whe- ther the disease is of the ordinary grade of bilious fe- ver, or will turn out to be yellow fever; many cases of the latter ending in the former, after a violent com- mencement ; and many pronounced ordinary bilious fever terminating with all the symptoms of malignant yellow fever.2 Not only do both exist at one time, under the ope- ration of one cause, in different parts of the same city, but of those in the very heart of the most sickly part, some have only the ordinary grade of bilious fever; and this is sometimes the case even with nurses who have attended some of the worst cases: they have been carried sick from the bedside of the dying, and have had nothing more than an ordinary bilious fever.3 1 Dr. Caldwell, in the same paper, says, "As the fever receded from the low ground and malignant atmosphere of Water-street, it became more and more mild and manageable; till its evanescent shades in Se- cond-street were, in many instances, much lighter than the common re- mittent of the country." Rush, in one of his volumes, speaks of a physician, Dr. Sayre, vol. 4, p. 31, who had but fifteen cases of the yellow fever in one of the years in which it prevailed in Philadelphia, ■and accounts for it by observing that his practice did not extend to that part of the city in which the dis- ease prevailed. In 1821, in Alexandria, those who lived in the high and dry parts of the town seemed to be perfectly easy. No cases occurred in those parts except in one spot stated elsewhere (340). 2 Rush's Works, Vol. 4, p. 7!Y 86. 88. Potter's Memoir. 3 A case of this kind was reported regularly, and published in one of the numbers of the New-York Evening Post in the fall oi 1822. Simi- 41 322 Throughout the whole course of the epidemic, warm disputes often occur respecting the nature of particu- lar cases; plainly showing not only the impossibility of making any intelligible distinction between them except the grade; but, as grades are almost as nume- rous as the cases of fever, even of fixing upon that grade which shall bear the name. 653. In the country, as in the cities, when the cir- cumstances productive of the cause of autumnal fever are in great force, the fever becomes malignant, and cases often occur not to be distinguished from the yel- low fever. Dr. Potter has in his memoir on conta- gion given some cases. We have ourselves seen in the country cases more malignant than such as have been shown to us as yellow fever; death occasionally taking place in twenty-four or forty-eight hours from the attack. There is no recorded symptom of yellow fever that does not occasionally occur, in some years frequently, in the epidemics of the country, in the neighbourhood of marshes, ponds, and rivers. A pa- tient of mine in the fall of 1824, who had formerly had the yellow fever, was struck with the sameness of the symptoms and appearance with those which occurred on the former occasion. In every considerable epi- demic, cases occur with more or less of the following symptoms; petechias, hemorrhages from the gums, stomach, bowels, and a black discharge which does not stain yellow, but, on being shaken about in a white vessel, part adheres to the sides with the precise ap- lar to this is the fact, that natives of hot climates have bilious remittent fever of a mild grade, under the operation of the same cause and at the same moment that strangers have yellow fever. 323 pearance that coffee grounds treated in the same way would produce; together with excessive vomiting from the beginning, without discharging any thing but what happens to be swallowed; a burning pain in the sto- mach ; black or purple blood, and a deep yellow or dark brown colour of the skin; coma, or delirium; and before death, perfect coldness of the limbs, of which the patient is often not sensible, sometimes for forty-eight hours, and after death, livid marks about the abdomen and back. 654. A family of twelve persons occupied a dwel- ling-house on Mill-creek, a branch of the Juniata river, in Pennsylvania, in 1805. The summer was very dry, the waters extremely low. All but one of the family were ill, five died, and in three of the latter, for several days before death, blood " oozed out from the extre- mities of the vessels through the cuticle, and stood in minute drops all over the face, chest, arms, &c. and when wiped off, no traces from whence it issued could be discovered by the closest inspection; but after death, a small livid spot appeared wherever there had been amy exudation of the sanguineous fluid."1 I have often endeavoured to discover the part of the mouth from which the blood exudes in autumnal fevers, but without success. It appears to flowr into the mouth from all parts as the saliva does. 655. Cases of autumnal fever, with black vomit, have frequently occurred in the country and the smaller towns.2 The following case occurred near AVinchester in the summer of 1826. The account was given to me by an eye-witness. There was a J Medical Repository, Vol. 10, p. 1. 2 Ibid. Vol. 8, p. 374. 324 chill and fever, with extreme restlessness throughout; continual fever; death occurred at the close of the twelfth day; the body was much swelled; was per- fectly black; a dark bloody fluid ran out of the nose, mouth, and eyes; and there was so much in the coffin that it ran out through the joints. 656. Physicians who have had an opportunity of seeing the yellow fever in the cities, have declared it to be the same disease with the severe autumnal fe- vers of the country. Dr. Speed of New-Orleans, in a letter to Dr. Mitchell of New-York, says he is fully persuaded from observations made in Washington city, in Norfolk, in Kentucky, in New-Orleans, from 1795 to 1802, that the yellow fever is but a higher de- gree of the common autumnal fever of the country.1 Many physicians have made similar declarations2 (221. 233 to 285. 387). 657. The identity of the yellow fever and the com- mon autumnal fever is further shown by the fact, that when the yellow fever prevails in the cities, the com- mon autumnal fever in the country, as well as in the cities (652), is very prevalent and of a very high grade ; showing the operation of a cause general in its action, as in 1793 (149. 338. 404), and in 1821 (329 to 336). Moreover, such cases as have of late years been called yellow fever have often occurred in the cities. Dr. Ramsay says they have occurred in several sum- mers in Charleston when the yellow fever was not epidemic.3 Dr. Prioleau, who had long practised in 1 Medical Repository, Vol. 9, p. 259. 2 Potter's Memoir, Medical Recorder, No. 4, p. 530. 3 Medical Repository, Vol. 4, p. 217. 325 the same city, informed Dr. Dickson that no sum- mer passed in which he had not seen such cases.1 Dr. Warren, of Boston, made a similar statement (221). These severe cases were treated like the rest, and now, that a new name is given them, the impossibility of dis- tinguishing them remains. Dr. Dickson, in his account of the yellow fever in Charleston, in 1817, says, "At the beginning of the attack, every physician, however great his intelligence, was often liable to be deceived. Hence, it became at last the general rule, to treat all cases, attended with any the slightest suspicious cir- cumstances, as yellow fever, and it was impossible to devise abetter mode of conduct."2 658. This identity is farther shown by the fact, that each at times assumes in its course the form of the other. Dr. Ramsay, in his account of the yellow fe- ver of 1804 in Charleston, South Carolina, says, "Ne- glected intermittents frequently terminated in the yel- low fever." " Several cases of clearly marked yellow fever terminated in low nervous fevers,"3 &c. This has been observed frequently (652). Pringle gives an extract from a communication made him by Dr. Huck, who was engaged in the En- glish expeditions against the French and Spanish West Indies, about the middle of the last century, which very strongly confirms this doctrine. " Even in the most ardent and worst kinds of the yellow fe- ver, I think a paroxysm may generally be perceived once in four and twenty hours ; for the patient is com- monly worst towards the evening, or at night. And l Philadelphia Journal, &c. No. 6, p. 264. 2 Ibid. No. 6, p. 252. ' Medical Repos. Vol. 8, p. 365. See Med. Record. No. 4, p. 536. 326 if the yellow fever was to be distinguished, in its be ginning, from the common remitting or intermitting fever which was so fatal to our army, it was only by all the symptoms running higher, and by a greater de- gree of the fever when one might have expected freer remissions. Both fevers began with nearly the same symptoms; sometimes, though rarely, with a shiver- ing. But whenever the fever ran high with burning heat, violent pains of the head and loins, profuse sweats without relief, redness and burning pains of the eyes, inflamed countenance, watchfulness, anxiety, oppression and burning pains about the pr&cordia, frequent vomitings of green or yellow bile, or (what I think was rather worse,) a constant retching to vomit without bringing up any thing, or vomiting the drinks only, one might then almost certainly foretell the yel- lowness ; and if this appeared on the second, third, or fourth day, the disease was generally mortal. I have often seen patients labouring under most of these symp- toms immediately relieved by early evacuations, and the fever brought to intermit. Nay, I have more than once seen this fever with all these symptoms carried off by bleeding and exhibiting, within a few hours from the first attack of the disease, a medicine which ope- rated pretty briskly both by vomit and stool; and I have known some of these very patients, who were so well as to go abroad on the second or third day after, and who continued well for four or five days, but on committing some error, such as exposing themselves too much to the sun, were again seized with the same symptoms, and died on the fourth or fifth day, with their skin tinged of a deep yellow or copper colour. 327 Hence I am apt to think that these are different de- grees of the same disease, and that it sometimes de- pends upon the manner in which the patient is treated in the beginning, whether he shall have the yellow, or only a remitting or intermitting fever."1 659. Here we see the common autumnal fever and the yellow fever 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 a common in- termittent or remittent, another while that of the yel- low fever. The diseases, therefore, being most simi- lar in cause, form, and mode of cure, ought not to be draw n asunder to different orders or sections (647). 660. In autumnal epidemics, nausea and vomiting are common symptoms. In some cases they are ex- cessive. They are often accompanied by purging; and in many instances after some vomiting, the nausea goes off, and the purging remains alone. These af- fections are called cholera and diarrhoea. They are, however, only aggravated degrees of single symptoms, common, with many others, to these, and the great mass of cases in which only the usual degrees of these symptoms occur. To call them, therefore, different diseases, would be just as reasonable as to consider the pain in the head or back, when particularly se- vere, as different diseases. 661. In many cases the purging becomes more and more frequent and painful, and the discharges from the bowels smaller and smaller; and these symptoms, * Pringle on the Diseases of the Army, p. 197, note. 328 if neglected, sometimes continue until the efforts to discharge become almost incessant and intolerable, and, the contents of the bowels being entirely evacua- ted, the most violent exertions only discharge the mu- cus of the lower end of the intestines, generally mixed with blood. In some cases, throughout the disease a portion of green acrid bilious matter is discharged, mixed with the blood and mucus. Scybala are not more frequent in these, than in the mass of cases that occur at the same time, in which tenesmus is not pre- sent. This distressing affection has also acquired a distinct name, dysentery, but is not a distinct disease. 662. These affections of the stomach and bowels are met with in epidemics of every grade, and occur in the same places, and at the same time, with those cases in which the stomach and bowels are not much affected. Each occasionally assumes the form of the others, and, like the other symptoms of autumnal fe- ver, suffers a periodical remission and exacerbation. Of this there is an abundance of evidence in the best authors. 663. Cholera morbus, diarrhoea, dysentery, and ter- tian fever, are every where mentioned as occurring to- gether in Cleghorn's account of the diseases of Mi- norca. He says, "And 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."1 3 Cleghorn's Obs. on the Diseases of Minorca, p. 130. See the whoU: second chapter for similar statements. Phil. Jour. &c. No. 6, p. 250 251. 329 664. " The cholera morbus sometimes hath its regu- lar 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; nor is it uncom- mon for dysenteric fevers to put on the form of ter- tians ; and for the fits of tertians, to be regularly ac companied by gripes and stools." 665. "It is remarkable that both dysenteries and tertians, without any manifest cause* are sometimes more universal and severe in one part of the island in one year, than another; and often seem, as it were, to attack particular families with uncommon severity; whilst others in the same place, the same circumstan- ces and way of life, escape. Those, however, who live in low vallies, or near stagnating corrupted wa- ters, are commonly the greatest sufferers."l 666. In his account of tertian fevers he says, " Some- times one or two symptoms of the fit predominate with such violence that the rest are obscured, or altogether eclipsed. Hence we so frequently meet with hemi- cranias, choleras, dysenteries, and chincoughs, return- ing regularly at stated periods."2 He speaks of cho- lera morbus occurring in tertian fever ;3 of tertian fe- ver terminating (as Hippocrates tells us) in dysentery, &c. ;4 and says that fevers, in the course of which vomiting, purging, bleeding of the nose, colliquative sweats, or the like come on, " sometimes are immedi- ately changed into mortal dysenteries; sometimes they 1 Cleghorn's Observations on the Diseases of Minorca, p. 123. a Ibid. p. 146. 3 Ibid. p. 151. * Ibid. p. 155. 12 \ 330 become continual tertians, and run out to a great length,"1 &c. Speaking of relapses he says, "It is not uncommon for a looseness to come on in the room of a relapse."2 He says dysenteries begin in three ways, like a simple diarrhoea,3 or with a fever,4 or a griping :5 but in which ever way they begin, " in pro- cess of time, the case comes to be pretty much the same."6 667. Speaking of the cure of cholera, Cleghorn says it must be managed according to the method of Hippocrates, lately described more fully by Syden- ham, by anodynes, &c.; but "if feverish complaints, or fixed pain in the belly or sides come on, after the eva- cuation is stopped, (as is frequently the case) it will be necessary to bleed and keep the belly open."7 He had said before, speaking of tertians, cholera, and dy- sentery, that if one is suppressed, the other ensues (664); and this treatment is well adapted to the cure of a fever. He also says, " When the cholera morbus re- turns periodically, like a tertian, it must be cured as these fevers are,"8 &c. 668. Speaking of the cure of dysentery, he says, " When they begin like a simple diarrhoea without fe- ver or fixed pains in the belly, the first thing to be done, is to empty the intestines of their acrimonious contents as soon as possible,"9 &c. But when the dysentery began with a fever, or with a griping (666), he " confided principally in the early use of the anti- phlogistic method," bleeding repeatedly, and using 1 Cleghorn's Observations on the Diseases of Minorca, p. 158. Mbid. p. 214. 3 Ibid. p. 225. 229. 4 Ibid p. 225. * Ibid. p. 226. 6 Ibid. p. 227. 7 Ibid. p. 223. 3 Ibid. p. 224. 9 Ibid. p. 229- 331 emollient injections, and fomentations, and plenty of mild diluent drink, shunning opium as much as possi- ble.1 As soon as the fever was somewhat abated, he endeavoured to procure discharges from the bow els; first by the gentlest cathartics, and " proceeding by degrees to the more active, till the end proposed be ob- tained."2 He says, "The great similitude there is in many respects between tertian fevers and dysenteries, induced me frequently to make use of the bark in the last named disease ; when the fever and gripes were regularly exasperated, either every day or every other day at stated periods, it has often effectually put a stop to both,"3 &c. Here we see dysentery and many cases of cholera morbus treated in the same manner with tertian fever. 669. Sydenham speaking of the epidemics of Lon- don, says, " This fever, which had continued the whole year, made great devastation in the beginning of July, 1675, but at the approach of autumn it began to strike in upon the bowels, appearing sometimes with the symptoms of a dysentery, and at others with those of a diarrhoea; though sometimes it was free from both, and rather seized the head, and caused a kind of stu- por." He further says, "the gripes were generally supposed to have destroyed the numbers that died at this time, whereas in reality their death was rather to be ascribed to the fever, for such as attended the sick during this autumn knew how much the fever pre- vailed ; so that both the dysentery and the diarrhoea ought rather to be accounted symptoms, than essential and original diseases."4 1 Cleghorn's Observations on the Diseases of Minorca, p. 231. a Ibid. p. 232. « Ibid. p. 236. * Sydenham's Works, p. 201. 332 670. Morton's evidence is to the same amount. He says in the autumn of 1666, that, with the autumnal fever, diarrhoea and dysentery were very prevalent; and that " a remission and exacerbation of the gri- pings, looseness, and other tormenting symptoms, were plainly observed to return duly on every other day." Whence (he says) he clearly discerned that these were but symptoms, and the fever was the primary disease.1 671. Pringle says, "The bilious disorders begin about the decline of summer, and become epidemic in autumn, appearing earlier, more general, and with worse symptoms, in proportion to the heat of the sea- son, 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."2 " The heat and moisture of the air appear to be no less the chief remote and external cause of the dysen- tery, than of the autumnal remitting and intermitting fevers,"3 &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 oc- casional or exciting causes. For in the end of sum- mer, or in autumn, when any number of men are ex- posed 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 1 Medical Repository, Vol. 1, p. 53. 2 Pringle on the Diseases of the Army, p. 168. 3 Ibid. p. 251. 333 fevers begin to be frequent in camp whilst the dysentery still subsists; that the first symptoms are often simi- lar, such as the rigors and disorder 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 dysen- tery ; 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 primae viae." * 672. Of the people who were for months shut up in the ships Hankey and Calypso, at the island of Bula- ma, on the coast of Africa, " Some had regular inter- mittent fever of various continuance, from a few weeks to several months: others had a violent fever, which terminated favorably or fatally in one, two, three, four, five, or six days; or, which lingered out, after its first violence, as many weeks : some had diarrhoea and dy- sentery, &c. and all these varieties happened on board the same ships, without any obvious difference in the exposure of the individuals to the causes of disease. Yellowness of the skin was a common appearance in the sick; and some of those who died at Sierra Leone (on their way to England) had black vomit; and this symptom also appeared at Bulama in the latter part' of the season."2 673. Dr. Hildreth, in his account of the epidemics of 1822,1823, in Marietta, Ohio, says, " In the months of September and October, dysenteries were very pre- valent ; and in many instances, alternating with inter- mitting fever in the same subject."3 1 Pringle on the Diseases of the Army, p. 253. * Med. Repos. Vol. 1, p. 475. a Philad. Jour. &c. No. 17, p. 113. 334 Dysentery often commences with symptoms of di- arrhoea, as almost every physician has experienced.1 674. Dysentery corresponds in grade with the fever which it accompanies. In the cooler regions of the earth it is comparatively mild; in the tropical regions, where fevers are of the highest grade, it is a mortal distemper (650). In this climate, where fevers under the influence of an unusually hot sun are sometimes highly malignant, the symptoms of dysentery corres- pond. " In the summer of 1797, (says Dr. Potter,) at Baltimore, the symptoms of dysentery were gra- dually commuted for those of a yellow fever of the deepest die. From the middle of June until the last of July, a time of intense heat and reiterated torrents of rain, the dysenteric form of fever pervaded Fell's Point. In August, the rains having ceased, and the weather continuing unusually hot, the dysenteric symp- toms failed until they were lost in the unequivocal cha- racters of the yellow fever."2 675. The cholera infantum is the cholera morbus of children. The distinction implied in the term, in- fantum, is of late date. It is not used by Sydenham, Boerhaave, Cleghorn, or Cullen. Sydenham mentions children being affected by cholera morbus. Cleghorn does the same repeatedly; thus he says, "about the end of that month the cholera morbus carried off many children."3 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 they in- x Currie's Medical Reports, p. 261. 2 Potter's Memoir, Medical Recorder, No. 4, p. 537. 8 Cleghorn's Observations on the Diseases of Minorca, p. 130. 335 tended to include the vomiting and purging of chil- dren under the general title of cholera morbus. 676. The cholera appears in situations favourable to the production of autumnal fever. The cities of the south are more subject to the ravages of autumnal fever than those of the north. The same is true re- specting the prevalence of cholera infantum. Those cities which from their low and marshy situation are remarkably subject to the former, are likewise to the latter. In cities, those parts most favourable to the production of fevers, such as dirty alleys, and filthy suburbs in the neighbourhood of marshy inlets, wet places produced by regulating streets, &c. are also most productive of cholera infantum. If a city by cleaning and draining be preserved from the former disease, it is likewise from the latter. In one quarter of the town of Winchester, a few years ago, there was a large pond made by regulating the streets, &c. (375). In the autumnal season there was a great number of cases of fever, and of cholera infantum, in the immedi- ate neighbourhood of the pond. It was filled up, and since that time there has been very little of either in that quarter. When the whole town was little better than a marsh, numbers of children died of bowel com- plaints (372). Since it has been rendered dry by draining and filling up with stones and earth, it has become more healthy. , 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 the physicians in cities to children in this disease, and it 336 is advantageous to them if the air of the place to which they are carried be purer than that of the city ; but if the place of their retreat be near marshes, they are not benefited by the change. Dr. Rush says that two out of the only three patients he ever lost, of those who were sent into the country, were carried into the im- pure air of the marshy neck below Philadelphia. In the island of 3Iinorca, noted for the annual pre- valence of autumnal fever of high grade, the cholera infantum also regularly makes its appearance. Cleg- horn mentions the occurrence of this disease in every year which he spent in that island. 677. Cholera infantum and autumnal fevers both appear in hot weather. If the weather be temperate, they are both moderate; if hot, they are both aggra- vated. If hot weather come sooner than common, they both appear earlier than usual. When the wea- ther becomes cold, they both decline. In cities in which bilious fevers of high grade annu- ally 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 autum- nal fever prevails; and they cannot be taken 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 prema- turely are of an attack of fever. 678. Dr. Jackson, in his account of the malignant or yellow fever of 1820, in Philadelphia, says, " In the past summer and autumn, diseases assumed the gene- ral symptoms which they possessed in the former epi- demic periods of 1793, 1797, 1798. Cholera morbus 337 and infantum were very prevalent; bilious and remit- tent fevers, from which our city had been for several years nearly exempted, were common diseases; and dysentery, which had become a rare disease in Phila- delphia, was of frequent occurrence, and very difficult to manage."' 679. Dr. Rush, in his inquiry into the causes and cure of this disease, says, " Its frequency and danger are always in proportion to the heat of the weather." This is said respecting its prevalence in the city of Philadelphia; and it is ascertained, from observation of the thermometer during twenty-five summers (404), that, in that city, the frequency and danger of autum- nal fever also, is proportioned to the same circum- stance, the heat of the weather.2 Both these forms of autumnal disease are, in that city, the effect of the miasmata produced by the action of heat on the ex- tensive low grounds of the Neck. On the contrary, in elevated and dry countries nei- ther remittent fever nor cholera infantum appear, un- less there be some wet weather. This I have con- stantly experienced in a remarkably elevated village and neighbourhood in which I resided for some years. 680. Cleghorn, in his account of the diseases of Mi- norca, says that the young children, towards the end of June, are attacked with vomiting, purging, and periodical fever, and in July tertian fevers appear among people of all ages.3 681. In 1745, "June was scarce ended when the tertian fevers and cholera morbus began, and increa- 1 Philadelphia Journal, &c. No. 2, p. 319. 2 Med. Record. No. l, p. 140. 8 Cleghorn's Observ. &c. p. 121. 43 338 sing daily according to custom, came to their greatest degree of frequency in September; from which they gradually declined,"1 &c. 682. In 1746, "The chincough had no sooner disap- peared than a periodical fever, accompanied with vo- miting and purging, took its place, which proved alike fatal to many children during the summer."2 "In July the tertian fevers broke out as usual, and their violence being augmented by the excessive heat of the season, many persons died suddenly about the seventh day of the distemper; but the cold weather of Septem- ber prevented their becoming so general and continu- ing so long as they commonly do; for about the end of October they gave way to catarrhs and quartan agues."3 683. In 1747, " 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 ter- tians became universal. Besides, towards the end of June the diarrhoea, dysentery, and tenesmus broke out and raged violently for some weeks."3 Here observe the cholera commenced a month earlier than common, as did also the tertians, diarrhoea, and dysentery. 684. " The ensuing summer (1748) proved very un- healthy to the children, many of them dying of the cholera morbus, and periodical fevers," &c. " The ter- tians began in July and finished their annual career about the end of November; many persons died sud- denly during the dog-days and about the equinox. In ' Cleghorn's Observations on the Diseases of Minorca, p. 127. a Ibid. p. 129. 8 Ibid. p. 130. 339 the mean time dysenteries prevailed in Ciudadella,"1 &c. The month of July in this year was extremely hot and sultry.2 These quotations strikingly show not only the ge- neral dependence of tertians and of cholera morbus on the same kind of weather, but the intimate con- nexion of both with its variations. 685. It has been argued that the same cause cannot produce both cholera and autumnal fever, because the former appears somewhat earlier in the season than the latter. In answer, it may be observed that the tendency of the argument, founded on the appearance of the fever and of cholera in 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 pro- duced the fever. The truth, however, is, that mias- mata, the cause arising out of the circumstances above- mentioned, are produced before the appearance of either autumnal fever or cholera. The first warm weather occasions an evolution of gas from moist and filthy spots. It is stated by Dr^Jackson, in his ac- count of the fever in 1820, in Philadelphia, that bub- bles 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. The argument, therefore, is sustained; and the force of the objection falls before 1 Cleghorn's Observations, &c. p. 133. 2 Ibid. p. 110. 310 the foct, that the cause of autumnal fever exists before the appearance of cholera infantum; while the depen- dence of both on the same cause, miasmata, is shown by tljc 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 usual1 (678). 686. The correctness of this view of the subject is further shown by the occurrence of autumnal fever in some children, at the same time that others have cho- lera. Cleghorn speaks of many children dying of cho- lera morbus and periodical fever. Some have " vomit- ing, purging, and periodical fever" (680), or " a perio- dical fever accompanied with vomiting and purging" (682) ; while others have a periodical or remittent fe- ver, without either (684); all of which every physician of experience must have had many opportunities of observing. The occurrence of remittent fever in cliildren, with or without disordered stomach and bowels, shows the presence of the cause of the com- mon autumnal remittent fever; unless it be shown that remittent fever in a child is a different disease from remittent fever in an adult; or, that a remittent fever accompanied by disordered stomach and bowels, is a different disease from a remittent fever which is not so accompanied. The whole difficulty consists, therefore, in the fact, that children are more easily affected than adults ; but this is not always the case, the tertian fever of adults and cholera infantum sometimes making their appear- ance at the same time (681). * Philadelphia Journal, &c.No. 6, p. 250. 251. 341 687. In cholera infantum there is a regular febrile exacerbation in the evening. Generally the fever only remits, but in the autumnal season of 1821, when al- most every fever in my practice was an intermittent, in cholera also there was a stretching and coldness of the surface. Dr. Rush says, since the prevalence of the yellow fever in Philadelphia, the cholera infantum requires bleeding to cure it, in some cases as often as twice or thrice. Cleghorn also mentions that the cho- lera is accompanied by a fever (680. 682. 684). Sometimes the diarrhoea ceases, and the fever then increases considerably ; and if the former return, the latter moderates again. In the former case the dis- ease is not to be distinguished from a common autum- nal fever; and in both, there is as complete a conver- sion of one into the other, as in the case of the remit- tent and intermittent (647). I have also seen dysen- teric symptoms appear in cholera, so marked that the case was pronounced dysentery by one who had not seen the patient before. 688. My own experience corresponds entirely with the preceding. All these affections arise in the same circumstances, of season and situation, and are found continually prevailing together. Few epidemics are entirely without cases with dysenteric symptoms. In some seasons, they occur in the great bulk of the cases. The autumnal fever often commences with such symp- toms. Sometimes they are not so considerable as to give name to the disease ;l at other times they become more and more severe, and attract the chief attention of the patient and the physician, and the disease as- 1 Pringle on the Diseases of the Army, p. 64. 342 sumes the name of dysentery. The symptoms are still, however, the same with those of autumnal fever, ex- cept the griping and tenesmus; but these afford no better foundation for making it a distinct disease than the vomiting does. The sole difference is, that in the former the lower part of the intestinal canal is principally affected; in the latter, the upper part. In the extreme cases of the former, dissections show that the lower end of that canal, from the coecum to the rectum, is purple or black ;l in those of the latter, the upper end is affected in the same way; while the w hole tract is more or less in like manner affected in both the former and the latter, in common with the great bulk of the cases which occur in company with them. If the mere difference of the part affected constitute a different disease, we must have more names intro- duced into the nosological list. In June, 1825, I had three cases of dysentery, that is, with the symptoms, nausea, griping pain, small discharges, bilious, mu- cous, and bloody; and on the administration of mer- curial cathartic medicines, there were dark, green, or black passages, followed by entire relief. At the same time there were three cases of nausea, griping pain high up in the intestines, and no discharges; but on the administration of similar medicines, there were similar discharges, followed also by entire relief. In these different cases the only difference was the part affected with griping pain. Sydenham has two pas- sages which show that the same had often occurred in his practice.2 Dysenteric symptoms sometimes come 1 Pringle on the Diseases of the Army, p. 245. - Sydenham's Works, Sec. 4, ch. iii. 1. 7. 343 on in the progress of a fever, and the disease would of course be called dysentery, by one who had seen it for the first time in that stage (687). Sometimes when the case is taken early, and well treated with mercurial cathartics, the affection scarcely arises to such height as to acquire the name; or even if considerable, it is quickly removed, and from that time no person can possibly distinguish the disease from the common au- tumnal fever by any existing symptom. 689. The same in substance is true of the cholera and diarrhoea. In 1825, among other cases in the au- tumnal epidemic, a woman who had been almost con- tinually vomiting for four days, was bled and took twenty grains of calomel, and after a few hours some doses of scainmony. She did not vomit after that day, and the case progressed precisely as the other cases did, and were not to be distinguished from them. In another season a man had about twenty passages in one day. He took twenty grains of calomel; the discharges became black, consistent, and were reduced to a small number, and the progress of the case was the same with other cases of autumnal fever; the symptom, diarrhoea, having entirely disappeared. These are instances of cases which frequently occur. 690. All these forms of disease therefore, cholera, diarrhoea, dysentery, and tertian fever, arising from the same origin,1 prevailing together in the same places,2 and at the same season of the year,3 being cured by the very same remedies,4 and very often the same dis- i'665. 671. 672. 673. 676. 2 663. 671. 672. 673. 6?6. 678. 680 to 684. 3 663. 665. 666. 669. 671. 672. 673. 677. 680 to 684. * 667. 668. 671. 344 ease in the same man, one while exhibiting the form of one, and another that of another of them -,1 and be- ing therefore most similar in cause, in form, and in the cure, ought not to be separated and classed as differ- ent diseases (647). 691. It appears from the preceding pages that weak- ened action of the heart is the effect, directly or in- directly, of the remote causes of fever. This, there- fore, is a link of the chain of causes and effects ex- tending from the remote causes to the symptoms of fever (18). This conclusion is confirmed by the fact long since ascertained, that all fevers are preceded by weakened action of the heart.2 692. We have inferred the identity of all the forms of autumnal fever from the identity of the remote cause (644, &c). It is a fair inference, that a cause, ope- rating on beings constituted alike, produces effects in every part of the world of the same nature; and, when we perceive differences in grade only, that they are to be attributed to difference in the force of the cause, or in its power over individuals arising out of consti- tutional difference ; particularly when we perceive all the varieties which exist in the different epidemics of the earth, produced in every epidemic, in every country. 693. We infer the same from observing that this re- mote cause, although in different climates and circum- stances of various degrees of force, operates, in all pla- i 664. 666. 669. 671. 673. 674. 685. 650. 2 Boerhaave's Practical Aphorisms, 563. Cullen's First Lines, xxxiv. xlvi. Darwin's Theory of Fever, Supplement, 1. 1. 6. Rush's Works, Vol. 3, p. 3. 4. 345 ces alike, in producing the effect, weakened action of the heart (691). This identity of effect in all, unques- tionably shows that the remote cause is operating alike in all, and confirms us in the belief that its ultimate or remote effects, the symptoms constituting the disease, will be the same. 694. We infer the same from the identity, in all these fevers, of this new cause, weakened action of the heart, produced by the same remote cause. If we in- fer identity of the ultimate effects from the identity of the remote cause, and the justice of the inference is confirmed by observing that it is so far correct, we more confidently infer their identity from the identity of a cause nearer than the remote cause. 695. It may perhaps be objected to this inference, that weakened action of the heart precedes variolous fever also, and therefore the identity of the autumnal fe- vers cannot be inferred from their being all preceded by this state of the system. It is replied, that weak- ened action of the heart uniformly produces certain effects called fever (691). Even when this cause is produced by a peculiar remote cause, the variolous virus, it produces its proper effect, fever, modified b\ certain effects peculiar to the remote cause. As weak- ened action of the heart, produced by this remote cause, uniformly produces corresponding effects, a fe- ver sui generis ; so, when produced by another remote cause, miasmata, we infer it will as uniformly produce a corresponding disease. Thus, as the confluent and distinct small-pox, proceeding from one remote cause, the mildest following inoculation with virus procured from a case the most malignant, are one disease ; so. 44 346 fevers, the mildest and most malignant, proceeding from one remote cause, miasmata, are also one. 696. We infer the same identity from observing that the degree of the symptoms is proportioned to the degree of the remote cause: as the latter, in pro- portion to the advance of the season, increases in force, the former become more and more severe; so that all the grades, from the mildest to the most malignant, are seen in one season under the operation of the same cause (651). 697. We infer the same from all the different grades appearing in all the same varieties of form, viz. inter- mittents, remittents, dysentery, cholera, and winter fever, or pneumonia typoides.1 698. Thus the identity of the remote cause, of the intermediate cause, and of the effects, and the propor- tion of the effects to the remote cause, all combined, constitute a mass of evidence incontrovertibly show- ing the identity of all the autumnal or hot weather epidemics. 1 644 to 687, but particularly 648 to 650. 658. 674. 678. 679. Also 608 to 622, particularly 619. 620. CHAPTER X. OF CONTAGION, CONSIDERED AS A REMOTE CAUSE OF FEVER. 699. Contagion has also been enumerated among the remote causes of fever. 700. Contagion is a matter produced by a diseased body, capable, on application to a healthy body, of producing in it the same disease, and of causing it to produce contagious matter of the same kind. 701. It is either fixed or volatile. The former pro- duces its effect only by contact with the sick, or by inoculation; such is the vaccine virus, the syphilitic, &c. The Jatter produces its effect in a manner un- known, but without contact with the sick, or with any thing visibly proceeding from them. 702. As all the contagions known to produce their appropriate diseases by contact with the sick, or by inoculation, are very sure in their operation; and as contact is easily avoided, the diseases thus propagated must be very sure to affect those exposed, and at the same time must extend to very few. 703. It is evident, therefore, that diseases can be extensively and rapidly spread by volatile contagion only. 704. The contagion attributed to the plague has by some been considered as fixed. But this is entirely inconsistent with the rapid progress of that disease, 348 the numbers affected, and the escape of so many ot those who are most exposed by frequent contact with the bodies of the sick (700. 701). The fixed conta- gions, moreover, take effect only when the skin of the part to which they are applied is broken, or when ap- plied to a very delicate and moist surface: and they produce in that part a local affection, and the system is secondarily affected. It is not, how ever, pretended that the plague is propagated only when the skin is broken. Finally, the local affections in plague appear chiefly in those parts of the body which do not come in contact with the sick; and in a very great propor- tion of the cases, particularly in all the worst cases which terminate in death in a few days, do not appear at all. The plague, therefore, cannot be propagated by a fixed contagion. Accordingly we find that the allegations of the most eminent authors respecting the plague, are founded on the idea of its spreading by a volatile contagion. The same may be observed of other epidemic diseases, as the yellow fever, and the typhus fever. It is by a vo- latile contagion, therefore, if by any, that these epide- mic diseases are propagated, and the whole tenor of the preventive means indicate it. It is a volatile con- tagion, therefore, which we have in view in the follow- ing observations. 705. It may be here observed, that it follows as a consequence of the origin of hot weather epidemics, as well as of those of the winter, that they are not con- tagious. The propriety of that rule of philosophizing, that " more causes of natural things are not to be ad- mitted, than are both true and sufficient to explain the 349 phenomena," will not be contested. Now, waving for the moment the consideration of the truth of the doc- trine of the propagation of these diseases by contagion, it is enough, that the agent, which we have shown to be the cause of these diseases, is not only sufficient to explain the phenomena observed, but contagion is not. Dr. Caldwell in his memoirs has well observed, "that the yellow fever will in two or three weeks over- run an extent of city, which the small-pox will not pervade in twice as many months. To what cause (he continues) can such a remarkable difference be owing 1 Certainly to this, that the small-pox is propa- gated only by contagion from the sick to the well, a source of disease which most persons have it in their power to avoid; while yellow fever is spread by a vi- tiated, or what I shall here term a malignant atmos- phere, which being a common medium has access to every one."! We shall not, however, rest the question on this inference alone, but discuss the subject on its own merits. 706. When a person in good health is placed near one affected with morbid symptoms, and becomes af- fected in the same manner, the question arises, how was the disease produced in the second 1 707. If with all our care we can discover no cause ; if we find that in all the varying combinations of cir- cumstances that have occurred for ages back, the mor- bid symptoms in question never appeared without the presence of a person previously affected in the same way; and that they are, in every change of circum- stances, the invariable consequence of being present i Caldwell's Memoirs, p. 100. 350 with a person so affected; the disease appearing where- ver the sick go, and never where they do not; we are led to the conclusion, that the circumstances which produce the cause, exist in the affected person, and we are induced to suppose, that the person in health is influenced by something invisible passing from the sick; and this invisible influence we call contagion. The belief in the existence of volatile contagion, is therefore a hypothesis resting for support on its fitness to explain the spreading of a disease, and our inability to discover any other cause. That it is no more will appear, if we consider that we have no evidence what- ever of the actual existence of volatile contagion. We know nothing of it; we only infer its existence from the single circumstance of the spreading of the disease. 708. If however we find that the disease is not the invariable consequence of being in presence of a sick person; that it never follows unless this exposure be made in certain circumstances; and that in these cir- cumstances it arises, whenever they occur, without the presence of the sick; we are entirely destitute of the only ground on which we can rest the hypothesis of contagion (707). 709. Further, if, in these circumstances, we at length discover a cause capable of producing the symptoms observed, heretofore invisible in consequence of being an aeriform fluid; if these symptoms uniformly appear in such circumstances, that this cause must be present, and in no other, the question is at an end; the cause of the first case is manifestly the cause of all that follow. 710. If a disease be propagated by a volatile conta- 351 gion, the attendants must take it; for if they do not, we are destitute of the only ground on which the hy- pothesis of contagion rests (707. 708). They must communicate it to their attendants ; these to others; and so on, until the disease become universal. 711. The only thing which prevents this result, is a law of the system, impressed on it by the Creator, with all others necessary to the continuance of the race of man. This law is, that the system is so little dis- posed to be affected by volatile contagion, that, except very rarely, it produces no effect on a second applica- tion or exposure. By means of attendants exempt from its action, in consequence of having previously suffered, the communication between the sick and those in health who are still liable, is cut off, and the progress of the disease arrested. Without this restric- tion it would not only be universal, but perpetual. 712. It is therefore absolutely necessary to the very existence of the human race, that the volatile conta- gion by which a mortal disease is propagated, be in- capable, in general, of affecting the same person re- peatedly. 713. However weak a volatile contagion may be, if it be capable of producing sickness, the attendants of the sick must be affected; this, as we have before stated (710), being the only ground we have for be- lieving it to exist; they will communicate it to others; and so on, until it become, unless restricted as above (712) from affecting the same individual repeatedly, universal and perpetual. 714. It has been asserted that there are volatile contagions which only act in certain circumstances; as in the presence of foul air, or of a certain tempera- ture. The belief in the existence of a volatile conta- gion so limited, must rest on the same ground with those not limited (707). If it exist, it must, through the attendants of the sick, spread until it become, un- less restricted as above (711. 712. 713), universal and perpetual in those circumstances. 715. As there is, however, no such universal and perpetual disease, even with the limitation in the pre- ceding paragraph, the consequence is, that all the vo- latile contagions are so restricted in their operation that they cannot affect the same individual repeatedly. From this it follows directly, that no disease not so re- stricted, or to which we are repeatedly liable, is pro- pagated by a volatile contagion. 716. It has however been said that a volatile conta- gion, acting only in certain circumstances, need not ne- cessarily affect all in those circumstances. It is not, it is said, the mere presence of foul air which gives effect to the contagion ; that a change is to be effected in the body, to prepare it for the action of the contagion; that until this be done, the latter is inert; and if the system be able to resist the action of foul air, so that this change be not accomplished, the person escapes. 717. It may be answered, this change must be a morbid one ; foul air produces no other; and as a mor- bid change in the state of the system must be followed by corresponding effects, there is present a cause for the morbid phenomena, the hypothesis of contagion loses its sole support, and falls to the ground (707). 718. A disease, therefore, to which we are repeatedly liable, is not propagated by a volatile contagion (715). 353 719. If a disease be propagated by a volatile conta- gion, it will spread until it become universal, unless it be stopped by insulating the sick, by means of those who are not liable to it, in consequence of having al- ready been affected (710. 711). 720. If a disease be propagated by a volatile con- tagion in certain circumstances only, it will spread un- til all in those circumstances are affected, unless it be stopped by insulating the sick by means of those, who, having had it, are not again liable to be affected (714). 721. We shall find all these characteristics of con- tagion in the small-pox. 1. We are not repeatedly liable to be affected by its contagion (718); 2, it would spread universally, unless stopped by insulating the sick as above (719) ; 3, in persons placed near the sick, the disease is almost invariably produced; 4, it is never produced, under any circumstances, (except- ing by inoculation, see 704,) without a near approach to persons affected with the disease; 5, it invariably spreads from the sick, without regard to circumstan- ces. We therefore believe this is a contagious disease, Of the contagion attributed to yellow fever. 722. It is still believed by some eminent physicians, that yellow fever is propagated by a peculiar conta- gion. Let us try its claim to the character of a con- tagious disease by the principles above laid down. 723. We are liable to repeated attacks of this dis- ease. Dr. Rush, speaking of the yellow fever of 1793 in Philadelphia, says, " Cases of re-infection were very common during the prevalence of this fever." In the year 1794, in which there was but little of the disease, 45 354 he met with four cases, the subjects of which had had the fever in the year before.1 Dr. Potter, in his memoir on contagion, states that he has himself had this disease three times. Mr. Doughty, a British surgeon who served eight years in the West Indies, mentions " the case of the 85th regiment, which suffered dreadfully from the con- centrated form of yellow fever in Spanish town in 1805. The next season they escaped it entirely in Fort Augusta, but again in 1807 they were nearly an- nihilated in Kingston. At the latter time and place, Mr. Doughty himself was at the brink of the grave from an attack of the yellow fever, though seven years previ- ously, he asserts that he had it in its concentrated form in the same town."2 Dr. Dickson, in a communication to Dr. Johnson respecting the yellow fever of 1808, in Mariegalante, says, " Many of the old, as well as the new troops were seized with the fatal fever; indeed the worst cases were second attacks."3 We are then liable to repeat- ed attacks of this disease, and therefore it is not propa- gated by a volatile contagion (718). 724. If the yellow fever were propagated by a vola- tile contagion, unless stopped by insulating the sick by means of attendants not liable to be attacked, in consequence of having once had the disease, it would become universal (719) ; and if propagated by a con- tagion acting only in certain circumstances, unless stopped as above, it would continue to spread until all in those circumstances were affected (720). But no * Rush's Works, Vol. 3, p. 88. 217. 2 Johnson on Tropical Climates, VoL 2, p. 87- 3 Ibid. p. 199 355 attempt is made to insulate the sick in this manner, no person being thus exempt from repeated attacks, and the disease does not spread until all, even in the circumstances favourable to it, are affected. There- fore, also, it is not propagated by a volatile contagion. 725. Numberless facts support this conclusion. 1. Great numbers who are near the sick, attending on them, escape the disease entirely. 2. It often is, and may at any time be produced by certain circumstances, without the presence of persons previously affected. 3. When the sick are carried out of these circumstan- ces, or removed beyond the influence of the «ause there generated, no person who approaches them is affected. 726. Great numbers who are near the sick, attend- ing on them, escape entirely. A multitude of instances of this might be stated. The following are from Dr. Jackson's account of the yellow fever of 1820 in Phi- ladelphia.1 727. " The family of Hays (in which occurred the first case reported to the board of health,) occupied a single room. It consisted of himself, wife, and three children, who all shared the same bed during his ill- ness." " The other tenants of the house, the neigh- bours, and his acquaintance, frequently visited him while sick, find a number of persons assembled at the house to attend his funeral. Not an individual thus exposed, sickened," &c. 728. A rigger contracted the disease at Walnut- street wharf, sickened and died. Two families occu- pied the house, the individuals of which had to pass through where this man lay sick, in going in and out 1 Philadelphia Journal, &c. No. 3, p. 25. 356 of the house. The neighbours also were frequently with him. No one took the disease from him, though the alley was at that time very filthy and offensive. 729. Another man, who took the disease at the same wharf, had a family of ten persons. The alley in which he lived is narrow, confined, and filthy; the house small and close. No one of the family or neigh- bours, however, were affected. 730. In the case of a lad, who lay in a garret with a single window, the disease displayed the worst fea- tures of malignity. Seven or eight persons were al- most constantly employed in the room with him, and the night previous to his decease, some one of them was incessantly occupied in frictions of his body. No sickness appeared among them. There are more in- stances to the same amount in that paper. 731. Dr. Ferguson, in his essay on marsh poison, states, that it often happened that the soldiers belong- ing to the barracks at Monks-Hill, Antigua, who in perfect health mounted guard in the night, among the marshes at the foot of the hill, were seized while standing sentry, and when carried back to the bar- racks expired with the black vomit in thirty hours from the attack. And notwithstanding this, not a single case of yellow fever, nor of fever of any kind, occurred among those of the inhabitants of Monks-Hill, who were not obliged to sleep out of the garrison, or to ^ take the duties in the marshes below. 732. This disease often is, and may at any time be produced by certain circumstances, without the pre- sence of persons previously affected. 733. The memoir of Dr. Potter affords abundant 357 evidence that it often appears in situations in which there is no possibility of its having been received from a sick person. " Mr. Ellicott, in his journal (of a voyage down the Ohio, in November, 1796,) is so explicit and intelli- gent on this subject, that no reasoning can shake his statement. His words are these: * I arrived at Gal- liopolis at eleven o'clock in the morning. This village is a few miles below the great Kenhaway, on the west side of the Ohio river, situated on a high bank; it is inhabited by a number of miserable French families, many of which, this season, fell victims to the yellow fever. The mortal cases were generally attended with the black vomit. This disease certainly originated in the town, and in all probability, from the filthiness of the inhabitants, added to an unusual quantity of animal and vegetable putrefaction in a number of small ponds and marshes within the village. The fever could not have been taken from the Atlantic states, as my boat was the first that descended the river after the fall of the waters in the spring; neither could it have been carried from New-Orleans, as there is no communica- tion at that season of the year, from the latter to the former of these places; moreover, the distance is so great, that a boat would not have time to ascend the river after the disorder appeared that year in New- Orleans, before the winter would set in." 734. Dr. Potter received a more particular account of the same fever from major Prior of the army, who witnessed the rise and progress of the disease, which is given above (163); some particulars not there rela- ted are stated here. The sick generally died with 358 black vomit; they were often yellow before death, and almost always afterwards. As some decisive measure became necessary to save the rest of the troops, a ditch was cut, what little water remained was conveyed off, and the whole surface covered with fresh earth. Not a man was seized with the worst form of the disease after the work was finished: and the sick were not a little benefited ; for they generally recovered, (though slowly,) because the fever became a common remit- tent, or gradually assumed the intermitting form. Frost put a period to the fever in every form. 735. The following "is equally explicit as to the in- digenous origin of yellow fever. 'At a village called New-Design, fifteen miles from the Mississippi, and twenty from St. Louis, containing about forty houses, and two hundred inhabitants, in the summer and au- tumn of 1797, the yellow fever destroyed fifty-seven of the inhabitants, or more than one fourth. No person had arrived at this village from any part of the coun- try where the disease had prevailed, for more than twelve months preceding its appearance.' Dr. Wat- kins resided in the village at the time, and having seen the disease in Philadelphia, testifies to the facts." 736. Dr. Potter also mentions some cases of yellow fever, which occurred in a house near Baltimore in September, at a time when that city and the adjacent country were remarkably healthy. Struck with the circumstance, he examined the premises narrowly, and discovered that the cellar contained water which had remained there from the first week in June, the country having been then inundated with rain. The cellar being useless was closed, and the only vent for 359 the gas arising from it, was through the floor, which was open in several places. At his solicitation, the survivors were removed, and convalesced from that time. " But the tragedy did not end here. The owner of the house, anxious to retrieve its character, hired two men to empty the cellar." They ripped up the floor and drew off the whole of the water in one day, by means of a pump. In a few days after they both sickened, and died with the usual symptoms of yellow fever, hemorrhages, yellow skin, petechia?, and one with the black vomit. 737. The same writer says, during the embargo in 1808, when no foreign sail whitened our waters, in August the yellow fever commenced its ravages at Fell's Point. 738. This disease has even been produced at sea, in circumstances in which there was not the slightest ground to doubt its generation on board the ship. 739. The United States ship-of-war General Greene sailed from Newport, in Rhode-Island, on the third of June, 1799. At sea the yellow fever broke out. The fever did not exist at Newport before the ship sailed. That town is too far north for the appearance of the yellow fever, except in very hot summers ; or so soon in the year in the hottest. The ship touched no where, and had no communication with any vessel, until she arrived at Havanna after the appearance of the disease. 740. " The Busbridge, Indiaman, sailed from Eng- land for Madrass and Bengal on the 15th April, 1792; on the 26th of May she crossed the line in 26 degrees west longitude. The mercury ranged from 80 to 86 360 degrees. The weather was very sultry, with frequent rains. In this state of things the yellow fever broke out, although she touched at no port, nor had com- munication with any vessel."1 741. A fever with hemorrhages, or oozing of blood through the cuticle, so as to stand in minute drops on the face, arms, and chest, occurred in Pennsylvania in 1805 (654) ; a fever with every symptom of yellow fe- ver, including black vomit, originated near a number of ponds in the hot years 1797, 1798, and 1799, in Bald Eagle valley, Pennsylvania (239); fevers with similar symptoms occurred in 1797 and 1804 in New- York (233. 235) ; and many other instances have been mentioned in the preceding pages (655). 742. It is stated in the seventh volume of the Me- dical Repository, in an account of the yellow fever of 1803 in New-York, that " A large proportion of the epidemic consisted of instances in which an indivi- dual only was attacked in the midst of a family, the members of which assiduously attended the patient without contracting the disease. Many aged and very young persons, whose condition imposed confinement in their houses, without the occurrence of any prece- ding case in their families, were attacked with the dis- ease in its most virulent form. Multitudes also took the disease, who had not previously approached any sick person, any suspected vessel, or any fomites al- leged to be imbued with contagion. One person was attacked in the debtors' prison, who for three months before had not been beyond its walls; and no person was previously, or subsequently, affected with the disease."2 * Med. Becorder, No. 4, p. 526, &c. 2 Med. Repos. Vol. 7, p. 183. 361 743. It is evident from a passage in Cleghorn's Ob- servations on the Diseases of Minorca, that cases of yellow fever occurred in that island in hot summers. Speaking of the dangerous cases of the autumnal fe- ver, he says, " But the utmost danger is to be appre- hended, if a few drops of blood fall from the nose : If black matter, like the grounds of coffee, is discharged upwards or downwards : If the urine is of a dark hue, and a strong offensive smell: If the whole skin is tinged with a deep yellow, or any where discoloured with livid spots or suffusions:'" &c. These cases were as truly cases of yellow fever, as those mentioned as having occurred almost every year in company with the cases of common autumnal fever in Charleston, Boston, Philadelphia, and the West Indies (221. 413. 657. 658). 744. The yellow fever of 1793, in Grenada, was at- tributed by Dr. Chisholm to contagion derived from the crew of the ship Hankey, who had been almost ex- terminated by that disease at Bulama, an island on the coast of Africa. The circumstances under which that fever broke out, show unequivocally that it ori- ginated among the crew and passengers of that ship, and another, the Calypso. They sailed from England with a crowd of passengers to make a settlement at Bulama. There were no inhabitants on that island, but it belonged to the Canabacs, who resided on a neighbouring one. After some difficulty they pur- chased the island; but the rainy season coming on, and there being no kind of accommodation on shore, the passengers and crew determined to continue on 1 Cleghorn's Observations on the Diseases of Minorca, p. l6l. 46 362 board until the rainy season should cease ; and to pro- tect themselves from the weather, they covered over the decks of the ships. In this crowded state, two hun- dred and seventy-five men, women, and children, be- sides the crews, were confined together, in the rainy season, in a tropical climate, on board two vessels, adapted by the covering over their decks, in an ex- traordinary manner, to give effect to the cause of fever. It is proper to mention that there was another very small vessel, but she was used as a despatch boat for various services, and had none of the passengers on board. In these circumstances, diarrhoea, dysentery, intermittent and remittent fever, and yellow fever, with black vomit, appeared, and carried off great numbers (672). 745. To this abundant evidence it is needless to add more. Suffice it to say, if any dependence is to be placed in the description of yellow fever by the medi- cal gentlemen of the cities; if any is to be placed in the decisions of the physicians of the country, founded on a comparison of cases occurring in their practice with these descriptions, and the occasional advantage of seeing for themselves, on their visits to the seaports j fevers occasionally occur with the symptoms of yellow fever, including the black vomit, in situations in which it is impossible to believe the disease did not originate on the spot. For my own part, no inconvenience was experienced from a visit to Wilmington in 1798, to Alexandria, in the district of Columbia, in 1803, and again in 1821, during the prevalence of that disease in those places. In the last instance the visit was made for the sole purpose of inquiring into the origin. 363 &c. of the disease. In the course of three days every part of the town, particularly where the fever was most prevalent, was minutely examined. On ap- proaching for the first time the bedside of a patient with yellow fever, the recollection of the earnestness with which my friends had withstood my intention, (representing it as a rash and needless risk of life,) as well as of the fate of the unfortunate Yalli, at that time much talked of, unavoidably made an impression on my mind. But a confidence that the disease is not contagious, founded on the body of evidence be- fore the public, supported me, and in a few moments I was perfectly at ease; for on beholding the patient, inquiring into the symptoms, and examining the dis- charges, it was evident that there was no greater dan- ger from contagion than had been encountered before the visit, having left behind me in the country more strongly marked cases of the same kind. This patient was visited repeatedly every day until she died, and once after death. No inconvenience was experienced from the exposure during this visit. 746. We have then unquestionable proof, that the yellow fever often is, and may at any time be produced in certain circumstances without the presence of per- sons previously affected. 747. When the sick are carried out of these cir- cumstances, or removed beyond the influence of the cause generated in them, no person who approaches them is affected. 748. This position is fully established by number- less instances, in which, when the sick are brought out of situations favourable to the spread of the disease, 361 into » pure air, the disease is not propagated ; no one in the pure air being affected by the presence of the sick. Experience has long since shown, that the dis- ease, when carried from a city into the pure air of a neighbouring village, does not spread; nay, that in the very city in which its fatal ravages are felt, there are parts in which, if a sick person be carried into them, the disease will not spread. 749. In Alexandria in 1821 the high and dry parts of the town were healthy, excepting one small spot (340); the sick were frequently carried into these parts and the disease did not extend, so that the people in them expressed a confidence that there was no danger from such occurrences. Dr. Potter, in the memoir abovementioned, challenges the whole population of Baltimore to produce a single instance of the disease spreading " in West Baltimore above Hanover-street," from one of the hundreds and thou- sands of those, who after breathing the pestiferous at- mosphere in the lower parts of the town, and sicken- ing there, were carried into the upper parts. In the Medical Repository it is stated that during the preva- lence of the yellow fever in 1803 in New-York, many who had fled from the city were attacked with the dis- ease and died, in all the surrounding country and towns, without communicating it in a single instance.1 750. The event of the case of the General Greene (739) is direct proof. " It became necessary in this disabled condition of the crew to return to the United States, and on the 27th of July the frigate arrived at a Medical Repository, Vol. 7, p. 183. See also Medical Recorder, \o. 10, p. 213. No. 13, p. 160. 162. No. 33, p. 5. 9. 365 Newport. She was subjected to an entire unlading; the sick with all their clothes were sent to the hospi- tal. Mark the end of this disaster; neither the citi- zens (who could not be entirely excluded from inter- course with the crew,) nor the attendants of the hos- pital contracted the disease." 751. The case of the Regalia transport is one of the strongest that ever occurred (171, &c). While, with a crew perpetually sick, and dying in such num- bers as to require continual recruiting, she was tra- versing the West India seas in every direction, and leaving sick persons at every port, no fever was com- municated to any person by the sick she sent ashore in any one place. This made such an impression on the mind of Dr. Ferguson that he expresses himself thus. " I am aware how much I have been favoured by circumstances, and what a different interpretation the facts I have collected would have borne, had the present epidemic that now afflicts the islands broken out in the ordinary course of seasons a year earlier, at the time the Regalia was here; my task would then have been a much more difficult one, for these (facts) instead of assisting me to elicit the truth in the manner I have done, would in that case have been turned to the confirmation of error, and the perpetuation of the delusions, in regard to imported contagions."1 752. We find therefore that the yellow fever does not possess the characteristics of a contagious disease, viz. that of affecting a person but once; and that of spreading until it become universal, even in the cir- cumstances favourable to its extension, unless stop- ped by insulating the sick (718. 719. 720). 1 Bancroft's Sequel, p. 239- 366 Moreover, great numbers placed near the sick, at- tending on them, escape entirely (727, &c.); it is produced in certain circumstances, whenever they oc- cur, without the presence of any person previously af- fected with the disease (732, &c.); and when the sick are carried out of these circumstances, or removed be- yond the influence of the cause generated in them, no person who approaches them is affected (747, &c). We must therefore conclude that the yellow fever is not propagated by a volatile contagion. 753. In opposition to a conclusion resting on such strong grounds, the doctrine of the contagious nature of the yellow fever rests solely on the appearance of the disease after a sick person has been introduced into a town, and on the rapid spreading of the disease. 754. As to the first, it has been shown that the dis- ease has originated in certain circumstances without the introduction of the sick (732 to 745). Therefore there is a cause independent of communication with them, or of contagion derived from them ; and that this cause is a gas, produced in such circumstances, is evi- dent from the effect of exposure to a wind blowing over the places in which those circumstances exist (162. 163. 223. 224. 229. 317. 383. 390. 402. 431. 432), as well as from the effect of cutting off the source of it by draining, filling up, overflowing, &c. (224. 226. 228. 441). 755. It is also well known that this disease very often does not follow the introduction of the sick (747 to 751). Therefore such introduction is not alone sufficient to produce it. It is further known, that it never spreads after the introduction of the sick into 367 a town, unless the town be in a foul state, and the temperature be very high. Now, these are the very circumstances in which the disease has been shown to have originated (754). Consequently the gas produced in these circumstances is the cause ; and the introduc- tion of the sick is not. 756. The rapid spreading of the disease is the other ground alleged in support of its contagious nature. There is nothing in this circumstance to indicate the nature of the cause; all that we can infer from it is that the cause is extensive in its operation. The gas wbich arises in the circumstances in which this disease always appears, is capable of being applied to any number of persons at one moment; nay, if they be in the direction of the wind blowing over the spot in which those circumstances exist, and there be no obstruction, it cannot be avoided (163). It is there- fore better adapted to the rapid production of the dis- ease, than contagion; any contagion ascertained to exist, as the variolous, being incapable, as is well known, of affecting a person at the distance of twenty feet. The former indeed is capable of the rapid pro- duction of the disease, and contagion is not (705). 757. There is evidently, therefore, no foundation for the doctrine in either of these circumstances; nothing to produce a doubt of the correctness of the conclusion that the disease is not contagious. Of the contagion attributed to the plague. 758. It is perhaps generally believed by physicians, that the plague is propagated by a peculiar contagion. It is nevertheless entirely destitute of the characters tics of a contagious disease. 368 759. The plague affects the same individual repeat- edly. Dr. Russel, in his account of that disease in Alep- po, in 1760, 1761, and 1762, says, "In the plague, contrary to what happens in the small-pox, persons are liable to be aftected more than once; not only at long intervals, and in different climates, but in the same town in the course of the same pestilential sea- son. This fact, which has been doubted formerly by some physicians, and by others expressly contradicted, has been long established on the best authorities."1 760. Out of 4,400 cases which Dr. Russel treated in the years 1760, '61, and '62, there were twenty- eight instances of persons who had it twice in that time. It was impossible, he says, to obtain satisfac- tory information respecting the number of those who had had it in former years: the last plague was eigh- teen years before; some were too young to remember; the accounts of others, who said they had, were for the most part too vague to be depended on. He saw none who had it more than twice, but was credibly informed of persons who had it three or four times. 761. That the proportion of those who had this dis- ease a second time, to those who withstood the influ- ence of the cause after the first attack, was really greater than what is above stated, will appear if we consider, first, that their number should be compared, not with the whole number of cases, but with the num- ber of persons who recovered. Some judgment may be formed of this from some expressions of Dr. Rus- sel. He says before the middle of June, in 1761, a 1 Russel's account of the Plague in Aleppo, p. 180. 369 small proportion recovered. An instance is given of three only recovering out of sixty-eight; another of about the same number out of sixty or seventy j1 and another of only one out of forty.2 This was the last of March. From the middle of June to the first of Oc- tober it was less fatal; and from the middle of Octo- ber to the end of the year hardly one third recovered.3 From the middle of August, 1762, a very small pro- portion of those affected recovered. 762. If we consider further the restriction of the term re-infection to those cases only in which the pa- tient had perfectly recovered, and when the symptoms of the second disease seemed as manifestly to proceed from recent infection as those which had attended the first, we shall have reason to believe that the propor- tion was still greater. 763. The great bulk of the cases occurred in the six weeks after the first of June. There were few re- coveries before the first of that month. The conva- lescence was slow, extending generally to four weeks; the danger of taking the disease ceased comparatively in July, the disease rapidly declining after the middle of that month; very few therefore had time perfectly to recover, so that " the symptoms of the second dis- ease should as manifestly proceed from recent infec- tion as those which had attended the first." In ease CIX it is laid down, that if a person has a running bubo, a second attack in the time must not be consi- dered as a re-infection, but as a relapse. A great many of those who recovered had, for some time after, running buboes; and all of those who were again at- 1 Russel's Treatise, p. 26. 27. 2 Ibid, append, p. viii. 3 Ibid. p. 41. 17 370 tacked were excluded. Dr. Russel admits the diffi- culty of deciding betw een a relapse and a re-infection, and only puts down in the latter class those manifest- ly belonging to it. What is a relapse during conva- lescence but a renewed attack 1 Names do not alter facts. The return of the disease, with all its symp- toms, is proof of renewed action of the cause ; and is sometimes indeed more severe than the first attack. 764. If therefore we consider the small proportion of the recoveries, the exclusion of all who relapsed, and of all who had had it in former plague seasons, we shall find the proportion of those who have second or third attacks in plague, not less than in other fe- vers. Thus, you would seldom find a man who had had in one season a second distinct attack of bilious fever, after having perfectly recovered from the first. In the fall of 1823, for instance, which was more sickly than any other for nineteen years before, I have no recollection of any such second attack; and never knew or heard of a third or fourth. But if we extend our views to past years, we shall find many who have had it before. Dr. Russel had, therefore, full ground for saying that the plague is a disease by which per- sons are liable to be affected repeatedly. Therefore it is not propagated by a volatile contagion (718). 765. If this disease were propagated by a volatile contagion, unless stopped by insulating the sick, by means of attendants not liable to be attacked in con- sequence of having once had the disease, it would be- come universal (719); and, if propagated by a conta- gion acting only in certain circumstances, unless stop- ped as above, it would continue to spread until all in 371 those circumstances were affected (720). But no at- tempt is made to insulate the sick in this manner, and the disease does not spread until all, in the circum- stances favourable to it, are affected.1 Therefore it is not propagated by a volatile contagion. 766. Abundance of facts support this conclusion, which shall be arranged under three heads. 1. In persons placed near the sick the disease is very often not produced. 2. The disease is produced by certain circumstances without the presence of the sick. 3. It does not spread in presence of the sick without the concurrence of these circumstances. 767. In persons placed near the sick, the disease is very often not produced. The following facts are from Dr. Russel's treatise on the plague. 768. In the family of the Neapolitan consul, the consul himself and six or eight others died. The wi- dow of a Neapolitan gave constant attendance on all these without any bad consequence.2 769. A French surgeon took the disease and died. He was attended by his partner, by a priest, and by two servants, of whom the priest only took it.2 770. A young Greek, whose constant occupation was to nurse the sick, and assist the buriers of the dead; and "a Grecian woman, exceedingly corpulent; who having affectionately nursed her husband, during his illness, and two of her daughters, who both died of the plague, continued afterwards to expose herself with uncommon courage, in the assistance of all the sick in the neighbourhood;" both escaped.2 1 In Aleppo there were in the year 176l about 12,000 sick of the plague. The population was about 230,000, near 20 times as many. 2 Russel's Treatise, p. 7- 372 771. The superior of the Terra Santa convent was* taken ill and died; and the other fathers, as the con- vent had shut up at the same time with the European merchants in the beginning of February, having no suspicion that the disorder could be the plague, com- municated freely with him at the beginning of his sick- ness. When the certain marks of the plague were discovered, the fathers were much frightened, but all of them escaped.1 772. The porter at a public house, his son, and bro- ther, died of the plague. The former was searched repeatedly by the attendants and by Dr. Russel, for tumors, and neither of them, nor of four Armenians who by turns attended the sick, was affected.2 773. A Jew banker died on the third day of his ill- ness. None of several female attendants constantly employed about him took the disease.3 774. " It is remarkable, that before the middle of June (1760) it was rare to find more than one person sick in one family, even in the houses of the meaner class; and the attendants employed about the sick so often escaped, that the people were too often led to believe it was not the true plague."3 Nevertheless, at this very time the disease was so fatal that almost all that took it died (761). 775. In the beginning of August a rabbi who kept a school for boys was taken ill. Dr. Russel found him surrounded by above a dozen of his scholars, besides several women and children of the family, of all whom none took the disease except his wife, who fell ill with- in eight days after him and recovered. The man him- self died on the sixth of August.4 1 Russel's Treatise, p. 7- 2 Ibid. p. 17- 3 Ibid- p. 19. * Ibid. p. 24. 373 776. " In the fourth week of July, 1762," (when the plague was rapidly declining,) " died Padre Carlo, of the Terra Santa convent. He had voluntarily devo- ted himself to an attendance on the affected ever since the spring of 1760, and had indeed exposed himself with uncommon resolution in the exercise of the most humane, as well as the most dangerous offices about the sick. I have often had occasion to meet with him in the course of my visits, and have sometimes found him, when the ordinary attendants were not in the way, employed in supporting the sick in his arms while they sat up in bed to take their medicine."1 111. A Jewish girl died of the plague on the tenth of May. The family consisted of twelve or fourteen persons, including four or five other children, most of whom had frequented the chamber and communicated with the sick girl during the three first days. She had also been constantly nursed by one woman and two men, but all escaped.2 778. In the great harems the disease seldom spread much ; of perhaps above forty females not more than four or five being infected.3 779. Russel says that when shut up, as is practised by Europeans generally, he continued to issue medi- cine to the sick who went in crowds to his dwelling, and when he wanted to examine the eruptions, he brought the patients within four or five feet by means of a stairway that passed by one of the windows of the house in which he was confined. If we consider the great dread of the disease entertained by Euro- peans, and the obligation and necessity the doctor was 1 Russel's Treatise, p. 55. 2 Ibid, appendix, p. xx. 3 Ibid. p. 62. 374 under not to risk the health of those confined with him, and the odium he would have incurred by doing ?my thing likely to introduce the plague, of which his expressions show he was very sensible, it is evident that, although he considered the disease contagious, his experience had taught him he was perfectly safe at the distance of only four feet from the sick. 780. Assalini, in his account of the plague in Egypt, says, " I have seen a great number of persons who have been attacked by the epidemic, after having had communication with others who were already sick; and I would have adopted the conclusion, that it was to contagion they ought to attribute their disease, if I had not also seen a much greater number who contin- ued to enjoy good health, in spite of the most decided communication."] 781. He says that the quarantine near Cairo was continually eluded by the people and the soldiers with- out producing any bad effect. He mentions three sol- diers who went from a neighbouring fort to Cairo, and died of the plague two days afterwards. They had intercourse with more than sixty persons, but not a symptom of the plague followed in any of them.2 782. A native practitioner was employed by the French at Jaffa, and opened the buboes indiscrimi- nately. " For several years he had attended such in- habitants of Jaffa as were attacked by the plague, and he used no precaution whatever to preserve him- self from this complaint, nor to avoid contact."3 783. In Egypt the plague uniformly begins to de- cline in June, and ceases generally about the last of 1 Assalini, p. 17- 2 Ibid. p. 18. 19 3 Ibid. p. 20. 375 that month. The popular belief is, that it ceases altogether on St. John's day, and immediately af- terwards the clothes of the many thousands that have died during the plague, are handled, bought, put on, and worn without any apprehension of danger; and though these consist of furs, cotton, silk, and woollen cloths, which are stuffs supposed to be most reten- tive of the infection, no accident happens to those who wear them.1 It is however known, that although the plague declines fast in June, and generally ceases about the last of the month, yet it sometimes continues until the middle of July.2 It is evident, therefore, that even before the plague ceases, there is the most per- fect safety in freely handling and wearing the clothes of the dead. 784. Dr. Russel also gives an extract from a book published in 1665 by Kemp, in which it is stated, that " in the ending of the last great sickness (1625), the people went promiscuously one among another, and the houses were quickly filled with inhabitants, and fresh comers out of the country, and yet no infection followed." Also during the siege of Bristol, about twenty years before (1665), hundreds died every week of the plague ; but as soon as the city was taken, "the soldiers made no great difference of quartering in any houses, or coming into any company, and the inhabi- tants returned to their forsaken dw ellings at one gate, whilst the pestilence went out at the other, and hath not hitherto returned again."3 785. Hodges, in his account of the plague in Lon- 1 Russel's Treatise, p. 266, note. Extract from Bruce's travels. 2 Ibid. p. 266, and note. 3 Ibid. p. 272, note. 376 don in 1665, says, " The houses which before were full of the dead, were now again inhabited by the living; and the shops which had been most part of the year shut up, were again opened, and the peo- ple again cheerfully went about their wonted affairs of trade and employ, and even, what is almost beyond belief, those citizens who were before afraid even of their friends and relations, would, without fear, ven- ture into the houses and rooms where infected per- sons had a little before breathed their last: nay, such comforts did inspire the languishing people, and such confidence, that many went into the beds where per- sons had died, even before they were cold or cleansed from the stench of the disease."1 This occurred "early in November," and the dis- ease, so far from increasing, as it must necessarily have done if it had been contagious, rapidly declined, and soon ceased. In the week ending on the third of November, 1414 persons died; in the week following, 1050 died; in the second week after, 652 died ; in the third week, 333 died; and 210 in the week ending on the first day of December.2 786. The disease is produced by certain circum- stances without the presence of the sick (766). The plague frequently appears on board of ships in the course of their voyage from the ports of the Levant to those of France and Italy. 787. Captain Chataud's vessel which was believed to have introduced the plague into .Marseilles, in 1720, left the coast of Syria on the 31st of January, before the plague broke out there, and had a clean patent. 1 Russel's Treatise, p. 270. 2 Ibid. p. 276. 377 On the voyage the disease broke out, and he lost seve- ral of his crew. The fact is unquestionable; but Dr. Russel endeavours to show they received the contagion before they left Syria. He observes that the plague broke out there soon after her departure; that the dis- ease generally lies lurking some time in the place be- fore it occasions alarm, but was rife in the maritime towns of Palestine and Syria from the month of March; and that three vessels with foul patents arrived at Mar- seilles a few days after the arrival of captain Cha- taud.1 It must be admitted that there was small pro- bability of the crew being affected by contagion (ad- mitting it to exist) when they left the coast the 31st of January, a time when there is never much of the dis- ease in that country; when it was not known to exist at the time; when it was not "rife" until about two months after; and when we consider the very large pro- portion of those who escape even when they nurse the sick (768, &c). There is another source insinuated. He put into Tripoli to repair some damages sustained by bad weather; and after repairing them took in some merchandise and some passengers. It is not said the disease prevailed at Tripoli, and the clear presump- tion consequently is that it did not, or it would have been mentioned in an argument to support the conta- gious nature of the plague. The passengers unques- tionably were not sick at the time, or they would not have been received; but soon after one of them fell sick and died. " Two of the sailors employed to throw the corps overboard desisted at the desire of the pilot, and the rest of the ceremony was performed * Russel's Treatise, p. 218. 48 378 by the rest of the Mahommedan passengers." " With- in a few days the two sailors who had handled the corps were taken sick and died. At Cyprus the ship put her remaining passengers on shore, and made a very short stay. Soon after her departure from that island, a third sailor and the surgeon died of an ill- ness of a few days' duration." " Some time after this three more sailors fell sick, and there being no surgeon on board, the vessel put into Leghorn, where the three sick men died, and the physician and surgeon of the Laznretto declared the disease to be a malignant pes- tilential fever."J It is remarkable here that the death of the sailors was attributed to handling the dead body, although the surviving passengers who were engaged likewise in committing it to the deep, and who more- over attended to the sick man before death, escaped. Now it is admitted that the risk from handling the bo- dies of those who have died of the plague is inconsi- derable ; the danger is in being about the sick. The other passengers, therefore, should have taken it, and the sailors have escaped; and as the former did not, the latter, who were less exposed, could not. It could not have proceeded from the goods, because they were put on board long before the plague broke out, and because entire bales are not said to be noxious, the danger arising from unpacking them. This source is therefore not hinted at. The disease must there- fore have originated among them, as, we know, pesti- lential fevers have very often done ; especially in bad weather at sea, as was the case here; and as occurred in the case of the General Greene on her voyage from > Russel's Treatise, p. 222. 223. 379 Newport to Havanna. In this case, the people of Ha- vanna had a plausible ground for alleging that this ship introduced the fever from Newport; and if it had happened, that a case of the fever had also appear- ed at Newport a few days after her departure, the ad- vocates of the contagious nature of yellow fever would have rested great weight on it (739). 788. It appears from Assalini's account of the plague in Egypt, that, at the period at which it broke out, it could not be imputed to contagion introduced, because the English fleet so strictly blockaded the coast that no vessel had been able to enter. In consequence of this, the advocates of contagion were reduced to the necessity of attributing it to goods which since the preceding year had been left infected in the magazines of Alexandria and Aleppo.1 If we compare this supposition with what has been already stated respecting the sale of the clothes of the dead, even before the disease had fairly ceased, we shall dis- cover at once its absurdity, and be compelled to admit that the plague was generated on the spot. 789. That certain circumstances are necessary to the existence of the plague, is evident from its uni- formly increasing and decreasing with the increase and decrease of the temperature of the season in Lon- don ;2 and from its uniformly declining and ceasing in the month of June in Egypt.3 Russel, though he be- lieved the disease to be contagious, repeatedly asserts this. He says, " The state of the air instrumental in propagating the plague, varies in its degree of power, as also in its duration."4 Again, " Should ever that 1 Assalini, p. 15. 2 Russel's Treatise, p. 276. 3Ibid. p. 266. 4 Ibid. p. 273. 380 state of air, without the concurrence of which the con tagion of the pestilence never spreads, or ceases to act, be discovered,"1 »(Mr>.©ioxc5f-'MX'Ci"^*>»CO»-OTP^^'MTl*Xi>-CO t0©*O*C©"'1<©X'— ©*-0C0 — **O©- © r>- © © 5 lO oiO'rr©Tt,",!!?,coco©coi>« "''-*F-i(M»j>»'^fx «5 i-Hi-hi-((N(^(M(^C0(MCO(M(M^(J>ICO(?>(^ °- i^oo^o^oi^coios^ocor^^x©^ < t-H » a ^ co © © liJ^lOQO^QOCCi'rf'OXNHOSOiflH ©29£©©*5T|S5<:sc5<:2,tt©,^^cMt^ locoo^i^xciioco — i^icu5r^ioioc5 ©'-i^co^io^r^xci©^—c^coi'ic^ QD QD QD QC OD 3D Of) (T T Y) ~ C r£ ~* ~ -^ ~ XXXXXXXXXXCtCiCi© i- r>» i> «> i^. t^. j^ <> <- i- <-. r^ ^ i- ih» *- IN 35 *o CO CO CO CM $ CO CO © © Ol © to CM CM X © CM © © CO CO s CO c3 o 457 952. That typhus fever is not peculiarly a disease of cold weather, will appear from a very slight inspec- tion of this table. Under the name of each month, is given the whole number of the cases of typhus which occurred in that month for seventeen years. Of these sums total, the smallest in the table, except one, is under February, and the next under January; and the whole number for the three winter months, December, January, and February, for seventeen years, viz. 11,372, exceeds that of the three summer months, June, July, and August, viz. 11,133, only by 239 cases; an average of only four or five to the month. In looking through individual months, it will be ob- served that the smallest monthly number of cases, in any one of the seventeen years, occurred, notwith- standing the severe winter epidemics which greatly increased the number of cases in the winter months, nine times in December, January, and February; and only six times in June, July, and August. In four of these six also, the winter and summer months were almost even; in 1781, January exceeding August only three cases ; in 1785, December exceeding July only nine cases; in 1786, February exceeding June only eleven cases; and in 1789, February exceeding August fourteen cases. On the other hand, the highest num- ber occurred in December only once; in February, once ; and in June and July each once. 953. Typhus, like all miasmatic fevers in temperate climates, increases as the autumn advances, is at the highest in that season of the year, and declines on the approach of cold weather; and, like them, is particu- larly severe or malignant in the hottest weather. 458 The lowest number of cases in the above table in under August; it increases from 3431 in that month, to 3925 in September, and to 4592 in October; and declines in November to 4201, and to 4087 in De- cember. This agrees with the increase and decrease of our autumnal epidemics. The only difference in the time is, that the autumnal epidemic of England, typhus, commences a little later, and continues somewhat later in the year than ours. Thus, ours commences in August, so that there is a perceptible increase of sickness in that month. In England it does not begin till the month after. Ours is at the height generally in September, sometimes in October, as in Philadel- phia in 1793: in England it is at the height generally in October, sometimes in November, as in 1784,1790, and 1795, in Liverpool. In some of the years, as in 1780, 1782, and 1783, this autumnal increase is small in comparison with what it is in others; but though sometimes small, it is invariable, and the uniformity shows the operation of an uniform cause; as the occurrence of bad colds only, in some winters, shows a minor degree of the operation of the same cause, which sometimes produces pleurisies; or as the occurrence of a few bilious cases shows a mi- nor degree of the operation of the same cause, which in some years produces an epidemic. 954. There are many instances mentioned by Trot- ter and Currie of an epidemic typhus commencing in warm weather, increasing through the autumn, and declining on the approach of cold weather. Currie, speaking of the sickness in Liverpool in the fall of 459 1801, says, the dysentery appeared in July; the scar- latina an^inosa soon afterwards, which spread widely in August; and lastly, the typhus fever burst its usual boundaries, the habitations of the poor, and occasion- ed general alarm. "In the months of August, Sep- tember, October, and the greater part of November, 1801, the degree of sickness in Liverpool was unex- ampled in the history of the town." " In the months of August, September, and October, there were up- wards of fifteen hundred deaths in Liverpool, making an excess of nine hundred above the usual number. In September alone, the deaths amounted to six hun- dred and ten."1 955. The physicians of Liverpool, in their report to the corporation, allege the necessity of draining certain streets, because to them, " the low fevers, which in the autumnal months especially infest these streets, are principally to be imputed" (941). 956. Dr. Ferriar, speaking of the health of Manches- ter, says, "In the summer and autumn of 1794, the usual epidemic fever (a mild typhus 946) became very prevalent 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 the influence of a burning summer, suc- ceeded by very wet but yet warm weather."2 Miasmata here certainly abounded, and there can be no doubt that in any other country this would have been called an autumnal or miasmatic fever. 957. Dr. Currie gives us a particular account of an J Currie's Medical Reports, p. 262. 2 Ferriar's Medical Histories, p. 231. 460 epidemic at Canterbury, from a letter to him from the surgeon of a regiment of horse-guards (the Blues) stationed there. " A short account of the regiment previous to the breaking out of the fever will be necessary ; as it will be seen that the modification of typhus which took place was peculiar. " The Blues went to Canterbury, in October 1803, in the healthy state which that old corps generally enjoys. In the months of November, December, and January following, a good many cases of fever had appeared, and several died of it; and I have been in- formed by my very intelligent assistant, Mr. Peach, that it was from that combination of typhus and pneu- monia, which has been denominated pneumonia ty- phoides."x 958. The epidemic commenced on the 28th of July 1804. A patient was brought to the hospital, and died on the 30th. On the 11th of August another formi- dable case of typhus appeared; the patient died on the 14th. Six other cases speedily followed. " In Sep- tember our situation became alarming in the extreme; nearly a fifth of the regiment were on the sick list. In particular, there were thirty-three cases of fever, and six of dysentery." In consequence of this state of things, the regiment was encamped on the fifth of September. After the middle of this month the dis- ease declined, and the last case occurred on the 21st of October. The decline of the disease is attributed to the whole regiment bathing every day after the 12th of September; but it is plain, that, in leaving the town, 1 Currie's Medical Reports, p. 393. 461 they removed* from the cause existing there, which at the same time was producing among the inhabitants of Canterbury the same disease. 959. This town is situated in a rich valley on the banks of the river Stour, which, in that part of its course, separates into several branches, forming five or six islands. This situation is calculated to pro- duce miasmata in hot weather, and would lead us to expect an epidemic such as occurred. 960. It is to be observed that it commenced at the time when epidemics from miasmata usually commence, was at its greatest height in that month (September) in which they usually are, and declined and termina- ted when they usually decline and terminate. The summer of 1804 was very hot in Europe. 961. It is further to be observed that this fever was accompanied by dysentery, the cases of which were very numerous; there having been sixty cases of fever in the regiment, in the whole time, from the 28th of July to the 21st of October; whereas there were twen- ty cases of dysentery from about the 12th of September. 962. It is evident, therefore, from the situation of the town, from the time of the rise, the height, the de- cline, and termination of this epidemic, and from the number of cases of dysentery accompanying it, that miasmata in abundance were present. 963. After the great naval engagement of the first of June, 1794, between the English and French fleets.. the French prisoners were landed, and confined in the neighbourhood of Portsmouth and Plymouth. They were in a very sickly state when they landed, having been confined for the whole time that they were at sea in ships remarkably dirty, and ill ventilated. 462 964. The situation of the two ports above mention- ed is such that they must abound in miasmata in the proper season. The situation of Portsmouth, on the low island of Portsea, has been already noticed (523), and the prevalence there, in the hot summer of 1764, of a miasmatic fever of high grade. Plymouth is, next to Portsmouth, the most considerable harbour for ships of war in England. It is situated at the mouth of two rivers. 965. In this situation of things, in the hot summer of 1794 (956), there was a vast mortality among these prisoners; nor was it confined to them : " the Mid- dlesex militia who did the duty of guard over them were affected, some of whom died."1 " I have been told that 338 Frenchmen died at Forton alone in less than four months."] 966. These prisoners were landed about the middle of June, and these four months therefore extended through that time precisely in which miasmata abound, wherever there are sufficient sources of them in hot weather. The abundance of marshy grounds, filth, &c. about these seaports is unquestionable. The weather was unusually hot. In June the thermome- ter stood at 80 degrees towards the end of the month, in the shade.2 "In the beginning of July the weather continued sultry to an uncommon degree."3 August also was uncommonly warm in England.4 " The weather during the months of October and November was mild as to temperature, but thick and hazy, with much rain, and hard gales of wind from the south- 1 Trotter, Medicina Nautica, Vol. 1, p. 84. 2 Ibid. p. 78. 3 Ibid. p. 79- 4 Ibid. p. 89 and 197 compared. 463 west.'" This weather was calculated, in every re- spect, to put an end to a miasmatic fever. 967. We have seen that autumnal epidemics are frequently followed by winter fevers, the effect of the joint operation of miasmata and cold (597, &c). Ty- phus fever is also followed by winter fevers, in which the symptoms are " a combination of typhus and pneu- monia" (957). In autumnal epidemics the number of the sick, after declining as the temperature of the season declines, increases again as it becomes very cold. In mid-win- ter-or the settled cold weather, the sickness again de- clines ; but, in the breaking up of the winter, during the cold wet weather, it increases again. In this part of the world, the decline of the autum- nal fever is in October and November. The com- mencement of the winter epidemic is in December or January. January and February, or the latter part of the former and forepart of the latter, is the time of its declension; and the last of February and March, the time of its renewal. It declines again as the wea- ther settles, and sometimes in the hot, dry month of June, there is scarce a case in the country. The same occurs in other parts of the earth. In Minorca the same was observed by Cleghorn, who gives a very full account of the " winter fevers" of that island3 (641. 642). So alsoj in the autumnal or mias- matic fever, the plague of Aleppo, the same occurred. Russel says, " About the middle of November it seem- ed to me to decrease ; but from the beginning of the ' Trotter, Medicina Nautica, Vol. 1, p. 104. 2 Cleghorn's Observations on the Diseases of Minorca, chap. vi. 464 fourth week, till the 20th of December, it certainly in- creased, particularly among the christians."1 This is plainly shown by. the weekly bills of mortality, from the second of November to the fourth of January.' Nov. 1st week, 2d,week, 3d week, 4lh week. Dec. 1st week, 2d week, 3d week, 4th week, 5tb week. Burials 13T 116 124 167 166 156 166 105 99 The same also occurred in the plague in 1665 in London; as may be seen by reference to the table (888); and also in 1636.2 968. Precisely the same occurs also in the typhus fever. After the decline a winter epidemic often com- mences, in which the disease is a combination of Jhe symptoms of typhus fever, with pneumonia or catarrh ;3 and all the changes common in miasmatic fevers, the table shows, occur in typhus. After the time of the greatest height in the autumnal season, there was, on the coming of cool weather, a decline in the number of cases in November or December in sixteen of the years. In one (1787) the decline did not occur till January. In five years the decline continued without inter- ruption till some time in mid-winter: but there was an increase in the number of cases in the winter of twelve years of the seventeen, viz. 1781, '82, '83, '85, '86, '88, '89, '91, '93, '94, '95, '96. This increase was at its height in December in six years: it continued till January in five years, viz. in the winters of 1781-2. '82-3. '85-6. '86-7. '88-9, and '95-6. From the time of the greatest height in those twelve 1 Russel's Treatise on the Plague, p. 41. 2 Ibid. p. 276. 3 Currie's Medical Reports, p. 393. Trotter, Medicina Nautica, passim. 465 years, the number of cases declined till some time later in the winter. The lowest declension occurred in January five times; in February five times ; in March once. From the lowest declension in mid-winter there was, in every instance, an increase towards the breaking up of the winter, and in the unsettled weather of the spring. It commenced in February seven times; in March nine times; and in April once. From this time there was a decrease before the au- tumnal season, but not so uniform as in winter; be- cause the occasional very hot weather in the summer months, as in June 1794, when the thermometer was at 80 degrees, produces an increase out of order; ex- traordinary heat in a moist climate abounding with vegetation, always producing extraordinary sickness. 969. The connexion between the summer and win- ter epidemics, the consequence of the co-operation of cold with miasmata in producing the latter, is more apparent and striking, by attending to the correspon- dence between the number of cases in the commence- ment of cold weather and the breaking up of win- ter, with the number of those in the autumnal months immediately preceding. It will be seen on inspecting the table (951), that in every instance in which the number of cases in December, January, February, or March, was much greater than common, the number in the preceding autumnal season corresponded. Thus, in the winter of 1781-2, the number of cases was considerably greater than in the preceding years; and the number in the autumn of 1781 was greater than in the autumn of 1780. So also, a greater num- 59 466 ber than common in the autumn of 1788, (October), was followed by an unusual number in January 1789; an unusual number in the autumn of 1791, by an unusual number in the following winter generally ; the same in September and October 1793, by the same in Febru- ary and March 1794; and the same in the autumn of 1794, by the same in the following December, Febru- ary, and March. 970. The variations in the different seasons, as ex- hibited above (table 951), would be more striking if the excess in the winter months, from winter epidemics, were thrown off. This is proper in order to place the subject in the clearest point of view. Thus, in this country there is no question but that the annual sickness is caused by miasmata, and the month of September is ordinarily the time of its height. But if we were to form an estimate of the comparative sickness of the different months from what occurred in the years from 1806 to 1817, we should greatly err. The autumnal seasons of those years were unusually healthy (327), and in one of the winters, 1814-15, occurred the most mortal epidemic ever known in this country. If then, we were to form an estimate of the comparative sickness of the different months from what occurred in those years, the excess of the month of September would be greatly reduced, and the pro- portion of the winter months increased. In order, therefore, to set the matter in the true light, we must throw off the excess from the winter months of 1814- 15; as we propose to do with respect to the winter epi- demics which occurred in the seventeen years men- tioned in the table of typhus fever in Liverpool (951). 467 971. AVinter epidemics occurred in eight years of the seventeen; viz. in 1781-2. 1784-5. 1786-7. 1787- 8. 1788-9. 1790-1. 1791-2. 1794-5. A small increase of cases in the course of the winter occurred also in 1782. '83. '89. '93. and '95. If we divide the number of cases in,December of the other nine years, viz. 1783, by nine, we shall have the average number for that month, when there is no win- ter epidemic. If we multiply this average number by seventeen, we shall have the number of cases that would have occurred in December, according to the ordinary rate of decline of the autumnal epidemic, where no winter epidemic interfered to increase it, viz. 3368 cases. In the same way we shall obtain for the month of January 2937 cases; for February 3094; for March 4176; for April 4053; and for May 4068. The total numbers for the seventeen years (table 951), will then stand thus. Jan. Feb. March, April, May, June, July, Aug. Sep. Oct. Nov. Dec. 2937 3094 4176 4053 4068 3850 3852 3431 3925 4592 4201 3368 Or, to show the whole course of this epidemic more perfectly, its rise in the commencement of the autum- nal season, its progress as that season advances, and its decline on the approach of cold weather, we will place the months in an order somewhat different; thus, Aug. Sep. Oct. Nov. Dec. Jan. Feb. March, April, May, June, July, 3431 3925 4592 4201 3368 2937 3094 4176 4053 4068 3850 3852 972. These variations are strikingly shown by ano- ther view of the subject. The greatest monthly num- ber of cases in the year occurred the following number of times in each month ; 468 In Jan. Feb. Mar. April, May, June, July, Aug. Sep. Oct. Nov. Dec 013211101421 Or, arranging the months according to the course of the epidemic, it will stand thus; Aug. Sep. Oct. Nov. Dec. Jan. Feb. Mar. April, May, June, July, 014210132111 Here the preponderance in favour of the autumnal season is striking, as well as the influence of the cold wet weather of March. 973. These variations in the different seasons are in some years more remarkable than in others, as in the following instances. Aug. Sep. Oct. Nov. Dec. Jan. Feb. Mar. 1783 227 265 316 257 273 170 194 245 1789 162 212 214 204 208 176 248 337 1790 270 310 340 355 269 253 247 277 1794 245 303 290 258 326 152 265 546 1796 182 254 329 153 247 974. The following are instances of autumnal epi- demics, not followed by such an increase of the num- ber of cases in winter, as to deserve the name of win- ter epidemics. Aug. Sep. Oct. Nov. Dec. Jan. Feb. Mar. 1784 230 266 247 369 297 285 268 296 1785 180 186 250 244 182 191 166 216 1792 223 211 330 212 174 174 209 221 1793 197 338 305 224 228 157 230 383 1795 159 196 239 317 180 197 161 266 975. The' effect of hot weather on the number of ca- ses of typhus was remarkably displayed in the year 1794. In June the temperature nearly equalled that of the tropics, the mercury in the thermometer being as high as 80 degrees in the shade (966) ; and the num- 469 ber of cases was somewhat higher than in any of the autumnal months. In the same year, the weather in October and November was mild in temperature, and there were hard gales of wind (966) ; and in those two months the disease declined. 976. The effect of cold weather following a season in which miasmata abound, is also shown by the con- trast between the number of cases in the winters of 1794-5, and 1795-6. The summer of 1794 was un- commonly hot, and the winter and spring following were colder than had been experienced in England "in a long series of years."1 The number of cases in December was unusually great, and in March there were very many more than occurred in any of the se- venteen years of the table (951). In September, October, and November, 1795, the number of cases was above the average for seventeen. years, but the winter and spring following were the mildest experienced in England " in a long series of years;"* and the number of cases was considerably smaller. Sep. Oct. Nov. Dec. Jan. Feb. Mar. In the autumnal season, and > ^ ^ 26g 32g 1M 26& ^ very cold winter of 1794, $ Id the autumnal season and > „3g 3n 18Q m m 26& very mild winter of 1795, ) 977. The very same effect produced, as above sta- ted, in England in the very cold winter of 1794, was experienced from the same cause some years ago in this country. The winter and spring of 1814-15, will be long remembered in Virginia for the fatal fever which then prevailed. The winter was extremely ' Currie's Medical Reports, p. 234. 470 cold; the snow lying two feet deep on level ground, a very unusual thing. 978. Another particular may perhaps be worth mentioning. The variations in the time of the com- mencement and of the height of the epidemic typhus in England, are the same as they are in the miasmatic epidemics of this country. Sometimes one summer month and sometimes another is most healthy; and sometimes one and then another month of the autumn is most sickly. Thus, June with us is generally most healthy; but sometimes July is very healthy : Septem- ber is generally most sickly, but sometimes October exceeds it; as in 1793 in Philadelphia (406). In England, the table shows that although the num- ber of cases in August is on an average the smallest, yet the minimum occurred in June seven times, in July twice, and in August eight times, in seventeen years. The greatest number of cases, in the totals of the autumnal season, occurred in October; in the individual years, it occurred in September twice ; in October ele- ven times; in November four times. 979. It is observable, that although the number of cases of typhus in England rises and falls in the dif- ferent seasons precisely as our miasmatic fevers do, of which some remarkable instances are given above (954. 958), yet there is on the whole not so great a difference between the different months as there is with us. This arises out of the difference between the cli- mate of that country and of this, and the excessive crowding in the habitations of the poor of that country. 980. In this country the spring is usually wet. As 471 soon as warm weather comes, we have a few bilious remittents, and in May there is sometimes a conside- rable number of cases. June is however generally very dry, and the country is often parched, the grass appearing sometimes quite dead. At this time the country is very healthy. In the latter part of July and August we generally have a good deal of rain; sometimes very much. Soon after the wet weather sets in our epidemics commence, and are in propor- tion, for the most part, to the quantity of water that falls, as the heat of the climate is always considerable. If the rains fall earlier than usual, the sickness com- mences earlier (368). It appears then that we have a sickly time when- ever we have rain in hot weather; and this indeed would follow of course from what has been already established on that subject. Our exemption in June, therefore, is for want of rain in that month ; and it is plain, that if we had continued wet weather through- out the summer as in England, we should have con- tinued sickness as they have. 981. In England the surface of the country is rather flat, often marshy, fertile, and abounding with vegeta- tion. The climate is very moist, the rains gentle and very frequent. In the towns, accumulations of filth, ponds of water, and undrained streets, are more com- mon than with us; the evil consequence of these things not being so obvious in that temperate climate, they are permitted to exist to an extent, which, in this part of the world, would be followed by mortal epidemics (340. 375). The circumstances necessary to the pro- duction of miasmata exist therefore more uniformly 472 through the summer with them than with us, and the consequence is a greater uniformity in the number of the sick; but the autumnal increase in England re- sembles ours in being much greater when the heat of the weather is unusually great. Thus, in Liverpool there were nine hundred deaths more than usual in the very hot summer of 1794. 982. In the winter the proportion of cases is some- what greater in England, on account of the excessive crowding in the habitations of the poor. In epide- mics universally admitted to be the effect of miasmata, the number of cases is much greater in confined pla- ces, as in the crowded houses of seafaring people about the wharves of cities, and in those of the poor in the alleys. In such places, for want of ventilation, the air, by repeatedly breathing it, becomes impure; and the gas, which we have given some reason to be- lieve is the cause of autumnal fevers (583), is produced in abundance. This is the only known human efflu- vium, generated by healthy bodies, capable of produ- cing noxious effects, or dense enough to remain where it is generated; and, whether the argument respect- ing the nature of miasmata be considered as con- clusive or not, it is clear, that, on the grounds sta- ted by Beddoes (596), the effect of miasmata must be increased by the confinement and consequent impurity of the air. 983. This is observed to be the case in this climate, where every effort is made to obtain a free circulation of air, and where even in winter, in many parts of the country, open doors are often seen. In many places in England the confinement and 473 consequent impurity of the air is almost beyond be- lief. Dr. Ferriar, in his Medical Histories, mentions houses in blind alleys almost entirely excluded from light and air; also a range of cellars of four rooms, the two centre rooms being completely dark, and the fourth ill lighted, and ventilated chiefly through the others, and containing four or five beds each. From the accounts of Ferriar and Currie these almost in- credible things are common (831). If the effect of miasmata is increased by crowding, in hot countries where fresh air is necessary to im- mediate comfort, and where consequently it is eagerly and continually sought after, how much more must it be in these miserable abodes; particularly in winter, when want of fuel compels the poor to keep close. 984. The typhus fever on board of ships at sea or in port, arises in circumstances in which miasmata abound (940). Typhus fever is very common on board the guard- ships, receiving-ships, and hospital-ships, stationed in the different harbours of England; and in ships at sea in northern regions. The situation of the two principal harbours of Eng- land, Portsmouth and Plymouth, has been already mentioned (964). Chatham, another principal station of the navy, is situated in the county of Kent, a considerable part of which is low flat land, with many marshes. The great Romney marsh, a vast tract of rich wet land, occu- pies the most southern part of this county. Sheerness, not far from Chatham, is surrounded by 60 474 marshes: at this place there was an establishment of sick-quarters for sailors.1 Deal is also a seaport of Kent; off which is the ship-road called the Downs. The existence of mias- mata there is evident, not only from the flatness and marshy state of that county, but from the complaint of Trotter of the agues that were carried on board the fleet from Deal hospital.2 There are a number of others of less importance, at or near the mouths of rivers, which in that flat part of the island are very marshy. The whole of them are precisely such places as those, which, in southern countries, abound with miasmata, and are the seat of miasmatic diseases. 985. The ships for receiving and guarding the im- pressed men, and the hulks, on board of which the crews of ships of war are confined during the time those vessels are under repair, are not only exposed to the action of miasmata arising from the abovemen- tioned sources, but are themselves so filthy as to be- come sources of the same morbific gas. In the best disciplined ships, a great deal of filth is unavoidable, from the crowding together of such a number of men in a small compass. But in guard-ships, &c. often excessively crowded, the difficulty is vastly greater. Ships-companies are often two or three months in a hulk much smaller than the ship they came out of; " during this time, much of the etiquette of discipline is laid aside, because the present confined and nasty state of the hulk renders personal cleanliness imprac- ticable,"3 &c. 1 Trotter, Medicina Nautica, Vol. 1, p. 312. 2 Ibid. p. 313. 3 Ibid. Vol. 3, p. 298. 475 986. It is therefore perfectly obvious that miasmata abound in these vessels ; and in them typhus fever is so common, that they are continually referred to as the source of almost all the fevers that appear on board the fleets of England. Trotter says of receiving ships, " We trace infec- tious fevers (typhus 801) more frequently to them than to all other sources; witness the account given by some of the Orion's people. Besides the new raised men sent from tenders, all recovered men from hospitals are sent hither till their ships return to port, or till they are otherwise disposed of." * Speaking of ten- ders, he says, "These vessels being partly fitted as a prison, for security, are not the best calculated for health."1 987. Ships of war, though under better discipline, are so filled with matters liable to putrefaction, are so crowded, not only with men but with live stock for the use of the crew, and are so constructed, as to re- quire all possible attention, and great and systema- tic exertion of absolute authority to keep them free from the impure air continually generated in them. 988. Of the quantity of substances capable of fer- menting which are contained in ships of war, the fol- lowing extract of a letter of Mr. Neale, surgeon, will give some idea. " The holds of all vessels, parti- cularly ships of war, contain large quantities of vege- table matter, in casks often insufficiently strong to pre- vent their contents from escaping, such as pease, oat- meal, cocoa, flour, sugar, and wood for fuel, and when united with a due proportion of humidity, so as to pro- 1 Trotter, Medicina Nautica, p. 254. 476 duce a given change by putrefaction, a gas is evol- ved,"1 &c. • 989. The writer observes, that the casks are often not strong enough to prevent their contents from esca- ping. Some idea may be formed of the quantity sometimes scattered about, in rough weather at sea, from the following passage from Trotter. " The Co- lossus was the flag-ship of rear-admiral Pole, and sail- ed with the unfortunate squadron under the command of Sir H. C. Christian, which was obliged to return from contrary winds and severe weather, after being eight weeks at sea in February." " The low er-deck ports could not be opened during this time; and from the motion of the ship, and water shipped in the gales, the provisions and other articles had been spread about the hold, to the quantity of forty or fifty ton, accord- ing to captain Grindall's report, before the ballast was exposed. The consequence of this was the produc- tion of an atmosphere in the hold and well, unusually foul; no doubt, owing to the fermentation of the pro- visions, and the decomposition of the moisture. The officers and seamen employed in clearing the hold, were grievously afflicted with swellings about the sub- maxillary glands, and violent opthalmias; and were obliged to be relieved by others during this duty. Sometimes there was a necessity for standing fast, for some days, that the noxious vapour might be ex- pelled."2 Though in this case an extraordinary quantity of these vegetable matters was loose in the hold; yet it is frequently the case, that a quantity lies scattered 1 Bancroft's Sequel, p. 233. 2 Trotter, Med. Naut. Vol. 1, p. 167. 477 about, sufficient to produce so great a degree of impu- rity of the air of the hold, that candles will not burn there.' 990. " There is no situation where so large a num- ber of human beings is confined in so small a space as in a man-of-war."2 There are moreover numbers of live stock. " Nothing" says Trotter, " has been so offensive on the decks of our ships as pig-sties."s A vast number of candles are also continually burning in the different parts of ships; from many of which daylight is for ever excluded. In consequence of these things the temperature of a ship's hold is very high. It is stated by Mr. McCor- mick, surgeon of the Immortalite, that when the ther- mometer in the shade stood at 72 degrees, " the me- dium heat between decks, when the watch below were in bed, was 84 degrees."4 Trotter says, " The bread room is so hot, that there is scarcely a ship that does not condemn a quantity of cheese three or four times a year."5 He says, " 1 con- sider the bread room of a ship, from its present pent up condition, the number of lights so frequently burn- ing in it, and the noxious effluvia issuing from cheese, &c. as a species of volcano that is constantly throwing out pestiferous fumes to shorten and weaken life."6 991. In addition to all this, the construction of ships is necessarily such as to retain the dense gas ari- sing from all these sources. A great number of peo- ple live in those parts of the ship which are below the 3 Bancroft's Sequel, p. 232. 2 Trotter, Med. Nautica, Vol. 1, p. 274. 8 Ibid. p. 279. * Ibid. Vol. 3, p. 98. 5 Ibid. p. 279. f Ibid. p. 288. 478 surface of the water. Others have the benefit of air by means of the gun-ports in fine weather; but in the boisterous northern Atlantic, this is, often for weeks, an advantage they cannot enjoy. Every night, too, all is shut up. Trotter, speaking of a new arrangement on board of some ships, says, without the store-rooms and wings being arranged in this form, it is difficult to ventilate a ship below. 992. From this statement it is very evident, that vi- gorous and persevering exertions are necessary to keep ships free from the foul air continually produced by the various causes above mentioned. To induce all to make these exertions is impossible. Trotter, after all his efforts, (from 1793 to 1799), to induce those con- cerned to attend to these things, says, in the latter year, "At this moment the internal economy of many (ships) in the fleet, differs as much as the features of their officers."1 993. We shall now notice the instances in which typhus fever appeared on board the fleets of England, France, and Portugal, in the Channel; as well as those in which it occurred on board of single ships; and show, in those cases in which the situation of the ship is men- tioned, that abundant sources of miasmata were pre- sent ; and that the times of its appearance were those in which miasmatic fevers appear. 994. On the first of June 1794, the English took a number of French ships of war, and found them very sickly. " The Sans Pared had particularly suffered. This 1 Trotter, Medicina Nautica, Vol. 3, p. 150. 479 ship sailed from Brest, in a squadron, six weeks ago, with a complement of a thousand men on board; many perished in the early part of the cruise, and an hun- dred ill of the fever were sent into a corvette, whose guns were taken out for the better accommodation of the sick, to be carried to port."1 "The Northumberland was next in point of sick- ness ; but the others were more or less infected with typhus fever."2 These ships were "dirty to an ex- treme degree." "It was told me" says Trotter, "that the lower-deck ports (of the Sans Pared,) had never been opened from leaving the harbour till the day of action."x The weather was remarkably warm; the thermome- ter stood at 80 degrees in the latter part of June (966). Here was abundant cause for the existence of mi- asmata; extreme filth, moisture enough, and exces- sively hot weather, with great crowding, and no ven- tilation to carry off the foul air as it was generated. The fever continued to affect the French after they landed. Their situation on shore w as unhealthy, and numbers died. The fever ceased in October (966). 995. The English ships did not escape. They were however kept much cleaner than the French ships. But as it is impossible to keep vessels perfectly clean, on account of the crowd on board, their construction, &c. (990. 991), the excessively hot weather produced among them also a considerable number of cases. In some of them, Trotter does not say how many, yel- lowness of the skin occurred.3 The surgeon of the » Trotter, Medicina Nautica, Vol. 1, p. 76. 2 Ibid. p. 77. 3 Ibid. Vol. 3, p. 218. 480 Majestic, Mr. Gillespie, in his report for July, ob- serves, " The approach of the solstice, and the cani- cula, seemed to have considerable influence on the spreading of the complaint; .as, notwithstanding the precautions used, many were attacked with it."1 996. Great efforts were made on board the English ships to get rid of the disease; " the decks were kept clean, and the whole inside whitewashed;" the bed- ding and clothes of the men were constantly aired; "fires were kindled in pots in the hold, well, and bread room; stoves in the orlop, cabletiers, and fore and after cock-pits. Care was taken that the circulation of air through the wings should not be interrupted; and, besides the common windsails, two stunsails were fitted for the fore and main hatchway, so that every corner below was pure and completely perflated by the air; some of these sails were kept trimmed du- ring the night, so as to counteract the effects of the heat when the ports were down."2 By these strenuous exertions in cleaning, drying, and ventilating the ships, the disease was-checked, but cases continued to occur,3 and in the course of the summer eight hundred sick were sent on shore to Haslar hospital.4 Under the date 27th of September, it is stated that the fever was at an end.5 The fleet was cleared of sickness earlier than usual by sending on shore all the new cases as they occurred.6 997. The correspondence between the effect of the high temperature of the summer of 1794 by land and by sea, is worthy of particular attention. The same •1 Trotter, Medicina Nautica, Vol. 3, p. 90. 2 Ibid p 80 3Ibid.Vol.l,p.86.94. * Ibid. p. 84. * Ibid. p. 97.' «lbid.p.94. 481 high temperature which produced an epidemic fever on board the French and English fleets at sea, also produced an uncommon number of cases of typhus in Liverpool (951 table), a great mortality at Portsmouth (963, &c), an epidemic typhus at Manchester (956); and no doubt the effect was general, as in 1764 (524). 998. The Portuguese squadron which was attached to the English Channel fleet, suffered severely with ty- phus fever in the same year, 1794. These vessels were very dirty and badly ventilated. Trotter speaks of the contrast between them and the English ships in very strong terms.1 They arrived in the Channel in August, and on the 16th, when he visited the squadron, the fever had already made its appearance.2 On the 23d of September he visited fhese ships again, and found them all sickly, and the typhus prevailing among them,3 and increasing fast.4 In consequence of this state of things they sailed for Plymouth in October, to refit and purify. " The Eu- rope, a third-rate in ordinary, was allotted to them for an hospital, and fitted accordingly (in October); but from the numbers daily taken ill in all the ships of the squadron, she became so crowded, in the space of three weeks, that no room was left to receive more." In consequence of the extent of the sickness, Admiral de Valle requested Trotter to meet the physician to Plymouth hospital. He not appearing, Dr. Mein, of the Caton hospital-ship, attended. " There were at this time on board the Europe, five hundred people in * Trotter, Medicina Nautica, Vol. 1, p. 05. 2 Ibid. p. 91. 92. 3 Ibid. p. 95. 4 Ibid. p. 96. Note. At the bottom of tlve last page the reference should have been to the first Vol. instead of the third. 61 482 different stages of the fever." " The orlop-deck being full in every corner, from its very imperfect ventilation was literally pestiferous. The smell was intolerable,"1 &c. This fever continued to prevail as a winter epi- demic, but they so far recovered as to sail for Lisbon in February, leaving three hundred sick.2 999. An English army under Lord Moira embarked in October or November 1793, and sailed towards the coast of France; but not being able to land, they re- turned to England in the end of December very sick- ly with fevers and dysenteries.3 These troops were of course exposed for some time, at the place of embarkation, to the miasmata always present in such places at that time of the year. The complement of three transports was crowded into two, and they were extraordinarily dirty; inso- much that "the soldiers themselves imputed their ill- ness to the crowded dirty transports, and the confine- ment during bad weather." Every circumstance was calculated to produce the effect that followed. Exposure to miasmata in the low seaports, and afterwards excessive crowding in transports at that time of the year, October and No- vember, when miasmata abound, particularly in the heated holds of transport ships (985 to 991), follow- ed by bad weather at sea in December, could not fail to produce such disease. The presence of miasmata is not only a fair infe- rence from the circumstances, but is manifest from the presence of miasmatic diseases in company with ty- 1 Trotter, Medicina Nautica, Vol. 1, p. 99. 2 Ibid. p. 101. 3 Ibid. p. 191. 483 ]»hus fever. " There were a larger number of bad cases in typhus, ague, and dysentery, than come usu- ally to a naval hospital at one time."! 1000. " The combined fleet of French and Spa- niards, when off Plymouth, in summer 1779, were overrun with a contagious fever (typhus 801), which made them leave the Channel."2 1001. In the summer of 1793, the fever appeared on board the Orestes brig lying at Plymouth.3 1002. In June 1795 a typhus fever appeared on board the Prince.4 In July it appeared on board the Orion. It affected principally, perhaps entirely, land- men lately received. They had been confined on board a receiving-ship so crowded that they could not hang up a hammock, and " they conceived their dis- eases to have been caused by sleeping on the deck." The process described above (996) was executed on board this ship, and no fresh case of fever appeared afterwards.5 1003. It is frequently mentioned in Trotter's work, that landmen especially are liable to be attacked by typhus on board the ships of war, and that the disease is often confined to them, the old hands escaping alto- gether. It is evident from the state of things on board these vessels, described above (984 to 992), that the air of the hold, &c. is always more or less impure, and that, whenever the exertions to purify it are re- laxed, it is considerably so. To this the sailors, who have been long on board, have become familiarized, insomuch that it produces on them less effect than on l Trotter, Medicina Nautica, Vol. 1, p. 192. 2 Ibid. p. 205, note, 3 Ibid. p. 178. 4 Ibid. p. 135. B Ibid. p. 136. 137. 484 those lately entered who have been accustomed to a purer air. This is no more than what is every day observed with respect to the effect of the air of certain islands, on those accustomed to a purer state of the at- mosphere. Those who visit these islands, are certain to feel the effects of it, to pass through a seasoning, to suffer an attack of the fever produced by miasmata, when in force. So those who accustomed to a purer air, enter on board a ship of war, particularly in warm weather, are likely to suffer an attack of fever. As the fever in the islands is, for the most part, confined to new comers, and does not affect the acclimated ex- cept in very hot seasons ; so the typhus on board these ships is often confined to the men lately entered, and the old hands escape. Of this the Medicina Nautica affords a considerable number of instances. 1004. In June 1796 a fever appeared on board the Niger. She lay at Spithead; the only circumstance mentioned, leading to a knowledge of her situation, is, that seven of the men returned from Haslar hospital relapsed.1 1005. In September typhus fever appeared on board the Glory. The hold of this ship "was extremely foul, and had not been cleared when the fever made its ap- pearance."2 The means employed to subdue it were those before described. The fever extended to thirty- seven persons, and all the cases being sent on shore, and no new case occurring after the twenty-ninth, the ship was clear of the fever by that day.3 1006. The case of the Colossus has been mentioned already (989). Some time after the period mentioned 1 Trotter, Med. Nautica, p. 155. 2 Ibid. p. 167. 3 ibid. p. l6l. 485 in the former notice she w as fitted up for a cruise off Ushant, from which she returned on the sixth of Octo- ber after an absence of seven weeks.1 She must there- fore have sailed about the eighteenth of August, and the fitting up must have been in the heat of summer. While she was repairing in Ph mouth harbour, in July and the forepart of August, the typhus fever broke out three or four times among her crew, composed entirely of raw Irish landmen. It was kept down by sending the sick on shore immediately on being attacked, and by airing the ship well. Towards the end of the cruise off Ushant, viz. about the last of September, the fever appeared again ;2 and between the sixth of October, when she arrived, and the last of that month, she sent on shore thirty cases of typhus. After the first of November no new case appeared.3 In this case the ship was foul; and the time of the rise and of the cessation of the fever corresponds with the time, when, in like circumstances in this or any southern climate, a miasmatic fever would have arisen and have ceased. The want of uniformity in the pro- gress of the fever, in this and other cases on board of ships of war, is to be attributed to the efforts made to clean, to dry, and to ventilate them; and also to send- ing the sick on shore. ^ 1007. In the same years, 1794, '95, and '96, instan- ces of typhus fever occurred on board of ships, in those seasons of the year in which the winter epidemics ap- pear on land, and with the precise symptoms observed 1 Trotter, Medicina Nautica, Vol. l,p. 162.163. 2 Ibid. p. 164. 8Ibid. p. 165. 4S6 at the same time on land, viz. " a combination of the symptoms of typhus with pneumonia."1 These will be stated hereafter. We shall now inquire into the situation of these ships as to exposure to miasmata, in the autumn pre- vious to the winter in which they were afflicted. 1008. A number of ships are mentioned by Trotter as afflicted with typhus fever in the winter of 1793-4. The Russel and Invincible in the last of December landed a number of men ill with this fever.2 The Rai- sonable had been long at sea in bad weather. In Jan- uary she landed upwards of an hundred ill of typhus and dysentery. Previous to this she had landed at one of the Western Isles one hundred and seventy.2 The Gibraltar sailed in November from Plymouth, and after a cruise of some weeks in stormy rainy wea- ther, she was obliged to return to port, and landed a number of cases of flux and fever.3 In the last of February the London sent some cases of typhus to the hospital.4 In March the Valiant, the Caesar, and the Leviathan, landed a considerable num- ber of cases of typhus; fifty cases w ere sent in the second week of the month from the Valiant alone, and five cases in one day from the Caesar.5 In March a fever of uncommon malignity prevailed on board the Hebe.6 In the last of March the typhus appeared on board the Robust and Colossus ;7 about the first of April on board the Africa ;° and in the course of the month on board the Arrogant.8 3 Trotter, Medicina Nautica, passim. 2 ibid. Vol. 1, p. 57. 3 Ibid. p. 58. 4 Ibid. p. 59. r> Ibid. p. 6l. 6 Ibid. p. 60. 7 Ibid. p. 63. 3 Ibid. p. 67. 487 In April the fever on board these ships was on the decline ; in some of them extinct.1 On the first of May the whole fleet was in perfect health.2 1009. It is apparent on the face of this statement, that the fever prevailed most in the beginning and the breaking of winter; and in the interval between, the cases were comparatively few. Thus, in the four ships first mentioned, the disease appeared in December. A few are mentioned on the 23d of February on board the London, but it was in March that the fever be- came general. This corresponds with the periodical increase and decrease in that year on land; thus, in Liverpool, in November 1793, there were 224 cases entered on the register of the dispensary; in Decem- ber, 228; in January 1794, 157; in February, 230; and in March 338 cases (951, table). 1010. With respect to the situation of these ships, a few particulars only are mentioned respecting some of them, but we know generally that war was declared by the French early in 1793, and the presumption is that the ships were not in the best order as to cleanli- ness after lying by for years. They were moreover through the following months fitting up in port; the crowds of sailors suddenly collected together, and not yet brought to order, produced a vast deal of filth ; and in every way their situation was such as, we have shown, to expose them to the action of miasmata. Trotter, speaking of the sickly state of one of the ships, says, it "was too much the case with other ships at the beginning of the war. The hurry and bustle which take place at the early stage of all armaments, have produced similar disasters among new levied men."3 » Trotter, Med. Naut. Vol.1, p. 66. *lb. p. 69. 3Ib. Vol. 2, p. 143, 488 1011. This view of the state of these vessels is con- firmed by the particulars we have found scattered through Trotter's narrative of the health of the fleet. The Hebe frigate was always remarkably leaky in her upper works; and it is observable that the fevers on board this ship were " of uncommon malignity" (1008). The crew of the Robust and Colossus (1008), were living at the time that the cases occurred among them in a hulk, of which they complained, Trotter says, with justice; as she was left " in a very wet and dirty condi- tion by the ship's company that had occupied it before."1 The decks and beams of the Arrogant (1008), were remarkable for their moisture. " This uncommon dampness was probably very much owing to the spot where she lay in ordinary, which was surrounded with swamps."2 Her crew was newly raised. These circumstances show such great inattention to the situation of the ships, that it is highly probable that all were much in the same condition. 1012. The typhus fever appeared on board the Ven- geance in January and February, 1793. This vessel had been a guard-ship at Chatham. In the beginning of January she was to proceed to Portsmouth fully manned; and received four hundred men additional to carry to the fleet. The passage was long; the weather rainy and boisterous.3 The men were of course, from the crowd, and the weather, very much confined. The disease affected very few of the able seamen,4 and was almost confined to the new 1 Trotter, Medicina Nautica, Vol. 1, p. 63. 2 Ibid. p. 68. 3 Ibid. p. 186. 4Ibid. p. 210. 489 raised men, Irish landmen (1003), the dregs of jails in the Metropolis.1 Two hundred of these men were from the frigate Nemesis. She had been employed for two months in carrying new raised men between Sheerness and Spithead, and sometimes as a receiv- ing-ship at the Nore; there were seldom less than two hundred men on board, besides her complement, most of them landmen very badly clothed. Captain Ball was very attentive in using means for cleaning and ventilating, and with great success. Mr. Fleming, the surgeon, says, "No fever appeared in my time. But in February she became so sickly, that her whole crew were sent to Haslar hospital."2 It is unnecessary to repeat the observation that these circumstances were calculated to produce mi- asmata, and the corresponding diseases. That they did so, is manifest from the circumstance here also mentioned by Trotter, that some cases of the remit- tent and intermittent type were observed.3 1013. In January 1790, the Gorgon of 44 guns ar- rived at Portsmouth with a number of troops on board from Chatham.4 While she lay in the harbour a fe- ver prevailed among the soldiers; but not one of the seamen was affected.5 The fever had prevailed at Chatham when they were embodied. The situation of that place is such that miasmata abound in the au- tumnal season, and it is to be presumed that these men must have been there in that season as they were embodied there. As landmen, moreover, exposed to the air of the hold of a ship (1003), especially as 1 Trotter, Medicina Nautica, Vol. 1, p. 187- 2 Ibid. Vol. 2, p. 21. 3 Ibid. Vol. l,p. 187. 4 Ibid. p. 209. 5 Ibid. p. 210. 62 490 they occupied the lower-deck, in which situation they were most exposed to the dense gas called mias- mata, it is not w onderful they were sickly ; nor that the seamen, who were acclimated (1003), and moreover had that situation in which miasmata would be least likely to reach them, and in which they were nearer the pure air, should escape. 1014. The typhus fever prevailed on board the Pow- erful, while cruising off Ushant, from the first of Octo- ber to the last of December. In October there were twenty cases, November seven cases; "towards the end of December and beginning of January, there were sixty-eight cases." A dysentery accompanied the fever towards the last. Dr. Trotter, with the surgeon, attributes "the in- crease latterly to wet decks, confined air, the scuttles being shut, and the decks leaking above, during stor- my weather."1 These circumstances were well cal- culated to produce a winter epidemic among men un- der the influence of miasmata; as these, from the time when it began, October, and the accompanyihg disease, dysentery, undoubtedly were. On comparing this fe- ver with that which prevailed in Liverpool (951), we find a remarkable coincidence. 1796. In the Powerful. In Liverpool. October 20 cases. 329 November 7 153 December A great increase. 247 1015. In March 1797, the typhus fever prevailed on board the Minotaur. No circumstances of her situa- tion are mentioned.2 1016. In March the typhus fever appeared on board * Trottei, Medicina Nautica, Vol. 2, p. 14. 2 Ibid. p. 17. 491 the frigate La Nvmphe. About the end of the month she landed seventeen sick at Plymouth, and sailed for Spithead. The surgeon there left her, about the mid- dle of May. His successor did not join her till two months afterwards (in July1), who found the fever still prevailing, and it was the beginning of September be- fore it was completely extirpated."2 No circumstan- ces are mentioned respecting the situation of this ves- sel in the autumnal season of 1796, nor of her state as to cleanliness. The fever however commenced at one of those periods of the year remarkable, by sea and land, for the appearance of typhus. Its continuance is not surprising when we consider the situation of all ships of war, requiring the strictest discipline and con- tinual care in cleaning, and ventilating, in connexion with the circumstances of the anarchy Trotter states to have prevailed on board early in May, and that of her surgeon having been absent for two months in the hot weather. The extermination of the fever was effected as ear- ly as the first of September by the means before sta- ted (996), of thoroughly cleaning, drying, and ventila- ting the ship, and by sending on shore every case as it occurred. 1017. In April and May 1797, the typhus fever ap- peared on board the frigate La Pique. She had been lying during those two months in Plymouth harbour, undergoing repair. The fever affected the landmen alone.2 None of the old hands were seized3 (1003). 1018. In the summer (June or July,) 1797, ten ca- 1 Trotter, Medicina Nautica, Vol. 2, p. 58. 2 Ibid. p. 21. 3Jbid. p.24. 492 ses of typhus occurred among the landmen on board the London1 (1003). 1019. The typhus fever prevailed on board the Sa- turn early in March 1799.2 No cases appeared after the 12th of May.3 In the forepart of this time, pre- vious to the 16th of April, she was at sea, in weather cold for the season, with sharp easterly winds; after that in Cawsand bay. The crew were not remarka- ble for cleanliness,4 and before she sailed the men indulged to excess in intoxication, and were in the ha- bit of lying in exposed places, even .when the decks were wet. After her arrival they again indulged in drinking to excess. They also laboured very hard from the 29th of April to get the ship ready to put to sea as soon as possible; they did not sleep more than four hours, and some of them were not in bed more than one hour in the twenty-four. They were also much exposed to getting wet at this time. The ship too was very dirty, and full of lumber. This was in May. These men were exposed to a variety of remote causes of fever, and under these circumstances the fe- ver increased rapidly.5 1020. A typhus fever appeared in December and January in the Edgar. The ship leaked much in the upper works, and the people were constantly wet.6 This state of the ship must have given rise to the pro- duction of miasmata in warm weather, and under the joint operation of this remote cause, and of the cold and wet weather, was produced the fever, which "seem- ed combined with both pneumonic and catarrhal symp- > Trotter, Medicina Nautica, Vol. 2, p. 26. 2 Ibid. p. 147. 3 Ibid. p. 149. 4 Ibid. Vol. 3, p. 55. 5 Ibid. Vol. 2, p. 147,148. 6lbid. Vol. 3, p. 63. 493 toms; and, in some, assumed the form of dysentery." It affected half the ship's company. 1021. On the 26th of September 1799, the Uranie frigate arrived from her station off Brest on account of a general fever on board.1 This frigate was leaky in her upper works.2 See the effect of this in a pre- ceding case (1011). October sixth the Captain arrived in Cawsand bay, having typhus fever on board. She had experienced much bad weather, and was also leaky in her upper works.3 Mr. Farquhar, the sur- geon, in his report for May, says, " During the winter some typhoid cases were constantly in his list, without showing a disposition to spread much ; some cases of dysentery are also mentioned to have discovered them- selves. Twenty-five in both complaints are the num- ber for May."4 The general disposition to fever nearly disappeared as the warm and settled summer weather approached.5 1022. In the end of December 1799, the typhus ap- peared on board of the Caesar, during strong gales, with rain, sleet, and snow.6 In March and April 1800, it was general in the fleet,7 the weather being cold, tempestuous, and rainy ;• as the weather became settled it declined.9 1023. In December, and in January 1801, the ty- phus fever appeared on board of several ships,10 the crews of which had lived in hulks." In March and April 1801, it was again general in the fleet.12 * Trotter, Medicina Nautica, Vol. 3, p. 59. a Ibid. p. 151. 3 Ibid. p. 153. 60 * Ibid. p. 160. s Ibid. p. 69. 6Ibid. p. 155, 7 Ibid. p. 160. 162. 163. l'64. 166. 169. 174. 221. 3 Ibid. p. 233. 9Ibid. p. 69. wIbid. p. 130. 186. 191. 192. " Ibid. p. 188. 18Ibid. p. 194 to 209. 194 1024. In addition to the causes commonly acting at this time of the year, a scarcity of food pressed hard on the poor, and drove numbers into the naval service, " who seemed to have entered to prevent themselves from starving: many of these have been invalided as unfit objects for the service." " Depressed in mind by their distresses, worn down by poverty and want of food, and half naked, these unfortunate beings had been crowded into the dark and confined decks of ten- ders."1 Here is a combination of some of the most powerful remote causes of fever, and considering their general action, abundantly sufficient to produce the general fever which prevailed in the fleet. 1025. About the first of June 1802, the Malta was commissioned in Portsmouth harbour; and while lying there fitting, and completing the crew, on the twelfth of July the typhus fever broke out violently and sud- denly; many patients having yellowness of the skin, as in miasmatic fevers.2 1026. The Donegal was commissioned at Plymouth in August, and fitted out with great expedition and fatigue. Towards the end of that month and the be- ginning of September, typhus fever appeared. She sailed on the second of October, when the fever cases became more frequent. She went to Torbay early in November, and sent on shore about twenty cases, and the rest recovered on board. 1027. It is evident from these statements that the typhus fever appears on board of ships at sea, or in port, in circumstances in which miasmata abound, and at those times in which miasmatic fevers appear. Ex- 3 Trotter, Medicina Nautica, Vol. 3, p. 194. 2 Ibid. p. 215. 495 cepting the month of March, much the greater part of the instances in which the fever appeared, was in the summer and autumn. It was general in the hot sum- mer of 1794 in the English, French, and Portuguese fleets; in the summer of 1779 in the French and Spa- nish fleets off Plymouth; and at no other time of the year is it mentioned as having been general, but in March and April, 1800 and 180L The reason why the fever is more prevalent at this period of the year by sea than by land, is, that the people are infinitely more exposed to the weather by sea. On land in bad weather, all, who can, avoid the weather. By sea, that is the very time when the greatest exertions are ne- cessary, and the men are much more exposed than at any other time. The equinoctial gales in March, therefore, produce a general fever if the sailors are under the influence of miasmata. 1028. The symptoms of typhus fever as state*d by British writers, are those produced by miasmata (940). This will need no further evidence than the following extracts. 1029. Dr. Currie, of Liverpool, has published in his Medical Reports a letter from Mr. Marshall, the sur- geon of the Cheshire regiment of militia, respecting a typhus fever which prevailed among the men while in barracks at Gosport. The following is the statement of the symptoms observed. " The first symptoms were a dull head-ach, with restlessness and shivering, pains in the back and all over the body, the tongue foul, with great prostration of strength. The head-ach became gradually more acute; the heat rose to 102 and 104 degrees, and in one instance to 107 degrees; and in 496 general the restlessness increased to delirium, parti- cularly in the night."' 1030. Dr. Currie himself, speaking of a fever which prevailed at Stapleton, says, "The fever was evidently typhus in a malignant form. In such patients as I ex- amined, there were head-ach, dull, and sometimes blood-shot eyes, much disturbance of the functions of the mind, great prostration of strength, and very gene- rally petechias. The pulse was not very strong; in frequency it ran from ninety to one hundred and twen- ty in a minute; the skin was dry ; the heat varies in different patients."2 In another place he mentions a dull red suffusion of the adnata.3 1031. Dr. Trotter, in his Medicina Nautica, has published the reports of a number of surgeons of the English Channel fleet, made to him as physician of that fleet. 1032. The surgeon of the Uranie, Mr. Perkins, re- marks, in his account of a typhus fever on board of that ship in September, " this fever had two kinds of attack, or orders of symptoms ; differing only perhaps in the particular constitution of the patient. " The first is attended by violently increased action, with seemingly great determination of blood to the head, with strong and distressing pulsation of the ca- rotids and temporal arteries; full distended counte- nance ; tunica conjunctiva inflamed; eye-lids heavy and tongue large; hard and apparently oppressed pulse, universal pains, hot skin, tinnitus aurium. " In the other, the animal functions are evidently im- paired ; the features are shrunk, and the whole coun- 1 Currie's Med. Reports, p 310. 2 Ibid. p. 388. 3 Ibid. p. 25 497 tenance expressive of a dejection of mind, in some in- stances amounting to terror; great pain and heavi- ness over the eyes; pain in the small of the back; anxiety; tongue small and white; nausea; skin dry, but not unusually warm; sometimes giddiness and imperfect vision; pulse small and quick: costiveness precedes both attacks."1 1033. Mr. Farquhar, surgeon of the Captain, says, " The symptoms are severe head-ach, and giddirfess, sickness or pain at the stomach, sensation of cold in the back and loins, great weakness, and general unea- siness over the body; the eyes and countenance de- jected. These complaints are succeeded by frequency of the pulse and hot skin; the tongue becomes foul and dry, and the patient is frequently seized with deli- rium. The belly is in general regular, though some have had a troublesome diarrhoea."2 1034. Mr. Carruthers, surgeon of the Malta, says, " The men on the attack were instantly seized with nausea; uncommonly violent head-ach ; syncope; las- situde over the whole body; yawning; tongue and lips and fauces much parched; pulse low, quick, and unequal; great anxiety, with cold clammy sweats. Vomiting was urgent in some, but diarrhoea did not accompany it, as I have before seen. Some of the patients had involuntary crying, and shedding of tears, like nervous or hysterical women."3 Many of the sick had yellowness of the skin, insomuch that he suspect- ed that the yellow fever had been introduced by com- munication with a sickly ship from the West Indies.3 i Trotter, Medicina Nautica, Vol. 3, p. 151. 2 Ibid. p. 154. «Ibid. p. 215. 63 498 In commenting on Mr. Carruther's observation/ Trotter says, " The disease is not of the kind allu- ded to. Icterus is not an unfrequent symptom in ty- phus ; it was particularly remarked among our seamen in the warm summer of 1794." * In another place he says, " I have often seen the eyes and skin, with the urine, as deeply tinged by the bile in typhus, as I have remarked it in the yellow fever of the West Indies."2 1035. Mr. Gray, of La Nymphe, says, " The symp- toms of this fever were cold shivering alternated by heat; head-ach ; pains of the back, knees, shoulders, and breast; sickness at stomach; pulse weak and fre- quent ; tongue foul; thirst; loss of appetite; dejec- tion of spirits; and great debility."3 1036. Mr. Dunn, of the Circe, says, " Some of our best men became daily affected in a similar manner; want of appetite, nausea, a foul tongue, some degree of tension of the skin, with costiveness, were the most observable appearances."1 1037. Mr. Kenning, of the Invincible, says, " They complained of chills, nausea, and head-ach: one had a severe pain over the left eye, which lasted for a few hours, and then shifted to the other, and so on alter- nately."5 1038. Mr. Johnstone, of the Saturn, says, " Sick- ness at stomacji, and a peculiar pain of the abdomen were common attendants of this disease : but neither diarrhoea, dysenteric symptoms, or constipation were observed."6 1 Trotter, Medicina Nautica, Vol. 3, p. 218. 2 ibid. Vol. 1, p. 259 3 Ibid. Vol. 2, p. 58. 4 Ibid. Vol. 1, p. 80. 5 Ibid. Vol. 1, p. 109. 6Ibid. Vol. 3, p, 55. 4 499 1039. Mr. Mc Arthur, of the Belleisle, says, "When it proved fatal, it happened as early as the fourth or fifth day. In these cases, I understand, there was an acute pain of the abdomen from the first attack, which remitted a few hours before death."1 " Nearly all the seamen's wives suffered from the disease; in whose constitutions it first appeared b> sore throat, determination to the head, and amenor- rhoea."2 The last symptom is very common in some of our epidemics. 1040. The attack is sometimes ushered in with ver- tigo, palpitations of the heart, delirium, and convul- sions ;3 and sometimes instant death occurs.4 "The sensation of cold on the surface of the body, in some cases, continues for a length of time ; but in others wears off in a few hours, and is alternated with heats, that seldom produce moisture on the skin and sweating. The skin itself soon acquires a sallow hue, and is dry and shrivelled. The sensation of cold is not however a constant attendant of the accession; I have seen many where no rigor was perceptible."3 1041. With regard to the state of the contents of the bowels, Trotter says, " The stools are commonly offensive ;"5 and in Hamilton's cases, though the men- tion of the colour, r jail fever (typhus 801), and mentioned as "a fever of a malignant kind, and very mortal"2 (1085. 1086). 1101. This fever was accompanied by petechial spots, blotches, parotids, and frequent mortifications ;s and sometimes by " suppurations of the parotid, or axillary glands."4 His description of the "eruptions" strikingly corresponds with that of the eruptions in the plague (924). " There is a certain eruption, which is the frequent, but not inseparable attendant of the fever. This is a petechial efflorescence, that is some- times of a brighter, or paler red, at other times of a livid colour, but never rises above the skin." " The nearer they approach to a purple, the more they are to be dreaded. In a few cases, instead of spots, I have observed purple streaks and blotches, which per- haps are still a worse symptom. The petechiae will sometimes not appear till after death,"5 &c. (914). 1.102. Pringle, we have seen, alleges that the au- tumnal remittent and hospital fever, jail fever, or ty- phus, are different diseases, and yet shows that their 1 Pringle on the Diseases of the Army, p. 193.194. 2 Ibid. p. 287. 3 Ibid. p. 25. 65. 4 Ibid. p. 298. 313. fi Ibid. 296. 297- 526 origin is the same (1086), as well as the symptoms (1094 to 1101); so likewise, although he alleges there is a difference between the hospital fever and the plague, be asserts they have a similar cause and like symp- toms. He says, "though the hospital fever may differ in specie from the true plague, yet it may be account- ed of the same genus; since it seems to proceed from a similar cause (1099), and is attended with the like symptoms"1 (1101), 1103. It is evident from this account, that the au- tumnal remittent fevers in very hot, dry, and calm summers in marshy countries (1094), pass into that grade of epidemic disease that has been called pesti- lential ; and the pestilential, in circumstances uncom- monly favourable to the production of epidemic dis- ease, into the plague, as admitted by Prosper Alpinus (1099). An expression of Diemerbroek's conveys a similar idea. The spotted fever prevailed in 1635 at Nimeguen, and it continued to become more malig- nant, " donee in apertissimam pestem transiret," until it passed into, or increased into the most undisguised plague.2 1104. This increase of the symptoms of the prevail- ing fever until it became an undisguised plague, is evident from Sydenham's and Morton's account of the plague in London, in 1665 (932 to 937). Sydenham would not positively affirm that the fever in the fore- part of the summer and the plague were the same; but says he knew by experience that they had the same symptoms (933). Morton speaks more positively, and 3 Pringle on the Diseases of the Army, p. 320. 2 Webster, History of Pestilence, Vol. 1, p. 184. 527 says, that the autumnal fevers (he calls them synochas,) when not properly treated, degenerated into malig- nant and fatal fevers, and sometimes from the begin- ning were distinguished by all the symptoms of the plague (937). 1105. The identity of these diseases is further shown by the fact, that disputes frequently arose concerning the real nature of an epidemic (930. 931). An au- tumnal disease becoming violent was called pestilen- tial ; the symptoms by degrees becoming more and more malignant, some at length called the fever plague; others denied, and the dispute was frequently settled, not by any distinguishing symptoms that could with confidence be referred to, but by reference to the ori- gin of the fever. If it could be shown to arise from some local cause, as it was not admitted by any people that the plague originated with them, it followed that the disease was not the plague. Thus, "in the year 1694, a fever broke out at Rochfort in France, which on account of the malignant symptoms and great mor- tality, was believed to be the true plague." But when the disease was found to have arisen from some mar- shes, over which the wind " had long blown" on the town, the idea of its being the plague was abandoned.1 1106. These diseases, therefore, originating in the same situations and seasons, and passing insensibly into one another, so that disputes continually occur respecting the name of the disease, not only in the commencement, but in the progress and decline, are evidently one and the same disease, differing only in grade. * Pringle on the Diseases of the Army. p. 323. CHAPTER XIV. UNITY OF FEVER. 1107. Typhus fever originating in miasmata (1060), and being a remittent fever (1061), the distinction be- tween continual and intermittent fevers does not exist in nature, and there is but one fever; a truth long since proclaimed by Rush. 1108. Cullen has three genera of continual fevers. His two first are Synocha and Typhus. In synocha the pulse is strong, frequent, and hard, and the heat much increased;! in typhus, the pulse small, weak, and for the most part frequent, and the heat little increased, with disturbance of the functions of the mind.2 But seeing that a fever is not always in its whole course either one or the other, and therefore cannot be refer- red to either, he has inserted a genus,3 Synochus, un- der which he arranges all fevers which in the begin- ning were synocha, in progress, and towards the end typhus.4 1 Synocha. Calor plurimum auctus; pulsus frequens, validus, et du- rus; urina rubra; sensorii functiones parum turbatae. 2 Typhus. Morbus contagiosus. Calor parum auctus ; pulsus parvus, debilis, plerumque frequens; urina parum mutata; sensorii functiones plurimum turbatae ; vires multura iraminutse. 3 Cum plures febres nee inflammatoriae nee nervosae ex omni parte sint, neque idcirco vel ad Synocham vel ad Typhum farile referenda?; genus Synochi, cujus typus hisce regionibus frequens conspicitur, hie inserui. Synop. Nosol. Cullen, Tom. II. p. 78. 4 Synochus. Morbus contagiosus. Febris ex synocha et typho com- posita, initio synocha, progressu et versus finem typhus. . 529 1109. Tt is to be observed, that the very fact of the synocha becoming typhus shows their identity; as a remittent becoming an intermittent shows the identity of these. It is evident that in a synocha continuing a considerable time and ending in death, the vigour of the system must gradually yield, and the pulse become small and weak, and the powers of the mind be dis- turbed. In this state the disease according to the de- finition has become typhus; but the patient surely has not a different disease ; it is the same he had from the beginning; it is the synocha which has reduced him to this low condition; the change is in him ; and the dif- ference in him is, that his heart is no longer capable of the same vigorous action that was observed in the beginning. Thus Morton, speaking of Cromwell's case and his father's, expresses himself in the follow- ing manner: " The synocha, in both cases, as the pow- ers of nature gave out, turning to synochus, with de- lirium, spasms, and other symptoms of high malignity."1 1110. It is further to be observed, that this change depends on the treatment. The malignant symptoms appear in bad cases if proper evacuations are neglect- ed (1044.1084); and almost never if they are employ- ed. After their appearance, proper evacuations pro- duce surprising benefit. The change depending on the treatment, the diffe- rence is an accidental, not an essential one. 1111. In order to determine to which genus a given case of fever belongs, synochus having no symptoms of its own, the first question is, are the symptoms those 1 Morton's Summary, &c. Medical Repository, Vol. 1. p. 51. 67 530 of synocha, or those of typhus 1 In either case, there is a second question. 1112. If the fever be synocha, the question is, will it continue so, or end in typhus 1 If it continue so, the fever is synocha; if it end in typhus, the fever is sy- nochus. But the appearance of the symptoms of ty- phus depending on the treatment (1110), whether they appear or not is accidental. A difference depending on an accidental circumstance, is not an essential, and therefore cannot constitute a generic difference. A synocha, therefore, which ends in typhus, and one which does not, do not belong to different genera; or Synocha and Synochus are one and the same. 1113. If the fever be typhus, the other question (1111) is, has it been so throughout, or was it in the beginning synocha 1 If not synocha at first, the dis- ease is typhus. As the question, was the disease in the beginning synocha or not 1 rests on the point whe- ther the pulse was strong, hard, and frequent, or not, the only doubt that can exist on the subject is, whether the pulse was sufficiently strong, hard, and frequent, to entitle the disease to be called synocha. If so, it is synochus; if not, typhus. The question whether the disease is synochus or typhus, rests therefore on the degree of the strength, &c. of the pulse, which is not a generic difference. Indeed, as grades of strength, &c. are infinite in number, if difference of grade con- stitute generic difference, there are an infinite number of genera. There is therefore no generic difference between Synochus and Typhus. Cullen himself ac- knowledges he cannot accurately distinguish between them, and is doubtful whether they ought to be consi- 531 dered different; and to which of the two, if they are made different, to refer the synonymes of authors.1 1114. We have before seen (1112) that between sy- nocha and synochus, there is no difference; and now that between synochus and typhus there is none. Therefore there is none between synocha and typhus ; and all three are one and the same. 1115. The British writers seem to have fallen into this view of the subject. Currie calls typhus the com- mon fever of England, the epidemic of all the great towns, &e. (801); and in the list of diseases at the Liverpool Infirmary (942) he mentions the number of fevers in one place, and the same number under the head of typhus fever in another place, both for the month of September 1790, indicating that all the fe- vers were typhus. Trotter speaks of typhus, times without number, in his Medicina Nautica; but never, I think, of synocha or synochus. On the contrary, in the report of the surgeon of the Uranie it is said, that the fever (typhus) had two kinds of attack, differing perhaps on account of the constitution of the patient. In the one, the pulse was hard, &c. (1032). Trotter makes no objection to this, although he is in the habit of making observations freely on the reports present- ed to him. This clearly indicates that he habitually 1 Inter Typhum tamen et Synochum limites accuratos ponere non possum; et an re vera pro diversis generibus habenda, vel, positis di- versis, utri eorum Synonyma auctorum referenda sunt, dubito. Synop. Nosol. Cullen, Tom. II, p 79- Nevertheless I cannot state the exact limits between Typhus and Sy- nochus ; and indeed I doubt whether they are to be considered different genera, or, being reckoned different, to which of them the Synonymes of authors are to be referred. 532 confounded what Cullen calls synocha and synochus. with typhus. 1116. Not only is there no foundation for the diffe- rent genera of continued fever, but there is none for the distinction between continued and intermittent fevers. 1117. Sydenham says that the intermittent fevers of London, of 1661, &c. were converted into continued fevers by the use of heating medicines, if given before the declension of the disease.1 The former Cullen classes with intermittents; the latter, with synochus. Morton says the continued changed into the intermit- tent form. He says, " The continued fever with which I was first affected, turning into a quotidian, and then into a tertian intermittent,"2 &c. Pringle says that in hot summers the autumnal intermittents in Hol- land became continued fevers, particularly when pro- per evacuations were not used.3 Here then intermit- tents become continued ; and continued, intermittent. 1118. Cullen's argument for the identity of remit- tent and intermittent fevers (647), is therefore equal- ly applicable here ; and continued or remittent and in- termittent fevers are the same disease. There is there- fore but one fever. 1 Sydenham's Works, p. 65. 2 Medical Repository, Vol. 1, p. 51. 3 Pringle on the Diseases of the Army, p. 14. CHAPTER XV. OF A GENERAL EPIDEMIC CONSTITUTION OF THE ATMOS- PHERE, CONSIDERED AS A REMOTE CAUSE OF FEVER. 1119. Epidemics have also been attributed to a ge- neral epidemic constitution of the atmosphere. Sy- denham's writings are full of this doctrine, but he doubts whether a pestilential constitution of the air be alone sufficient.1 Physicians in succeeding times have had recourse to the same mode of accounting for the prevalence of epidemics; and to this day, although the doctrine of the dependance of epidemics on mias- mata rests on evidence too strong to be shaken, there is a disposition to attribute them to a secret or un- known constitution of the atmosphere, at least so far as may be necessary to explain the occurrence of epi- demics in circumstances in which it is supposed that miasmata cannot be present. 1120. This doctrine is frequently mentioned in the Medical Journals of this country, and is supported at some length in a paper published in the Philadelphia Journal of the Medical and Physical Sciences. 1121. It is there said, the epidemic of 1822 "is as- cribed by some to excessive heat; by others, to the combined influence of heat and a superabundance of rain; by a third class, to heat and a long continued 1 Sydenham's Works, p. 77- 534 drought; and by a fourth, to the influence of certain topographical situations, because in those situations the complaint has proved unusually severe."1 1122. In opposition to this it is contended that epi- demics, as to mere existence, are " independent of all local and perceptible causes, a certain degree of tem- perature alone excepted;" and that they are produ- ced by " a general epidemic constitution of the atmos- phere."2 1123. In support of this doctrine, it is alleged that the epidemic of 1822 prevailed in almost every section of the United States; but that in relation to the sensi- ble qualities of the atmosphere, a very striking variety and even contrast prevailed in different sections ; and that, " in point of topographical position, many places equally sickly are perfectly dissimilar."1 1124. In particular, it is alleged that "in Pennsyl- vania, Maryland, and some parts of Virginia, the tem- perature of the summer has been moderate, and the drought unprecedented, yet there the epidemic has prevailed. " In the Carolinas and Ohio, there has been nothing peculiarly remarkable in the season, heats and rains having been in their ordinary proportion, yet there, in like manner, the disease has been prevalent. "Kentucky has been inundated by rains, and the season has been hot, and there we have also had to encounter the epidemic. "Louisiana, Mississippi, and Alabama, appear to have enjoyed their ordinary season, yet in some parts ! Philadelphia Journal, &c. No. 10, p. 314. 2 Ibid. p. 315. 535 heretofore found healthy, they have experienced a most fatal epidemic. " To the condition of things in Indiana, Illinois, and Missouri, similar remarks are equally applicable." 1125. It is further alleged, that "in some of the At- lantic states, it has been confined almost exclusively to the dry and hilly grounds, the low, flat, and humid tracts of country having for the most part escaped. " In the states of the West the reverse of this is true; the hills being more healthy, and the low grounds of wa- ter courses the theatre of disease. Yet, under all these different circumstances the complaint is the same." 1126. On these grounds it is concluded, " In relation to its mere existence, then, our epidemic would seem to be independent of all local and perceptible causes, a certain degree of temperature alone excepted. By those causes it is modified, but not created." 1127. The question is next proposed, "To what cause, then, is its existence to be attributed l" The an- swer is, "To a general epidemic constitution of the at- mosphere." " What is the nature of this constitution, or whence it is derived, is entirely unknown to us;" but " by looking into the general history of epidemic diseases, we find that in different ages and countries, this atmospheric constitution has occurred at irregu- lar periods, continued an indefinite length of time, and at last disappeared, without disclosing any vestige of the cause of either its rise or its decline." 1128. It is admitted, however, that "local exhala- tions from the surface of the earth necessarily co-ope- rated with the constitution of the atmosphere. With- out the exhalations the disease could not have existed: 536 nor could that cause alone have given rise to it. It was the result of the conjoined operation of both."1 1129. However plausible this argument may at first view appear, there is nothing in the situation or cir- cumstances of the countries mentioned, inconsistent with the doctrine contended for in the preceding pa- ges; and nothing to justify the inference that epide- mics are "independent of all local and perceptible causes, a certain degree of heat alone excepted." 1130. It is stated that in Pennsylvania, Maryland, and some parts of Virginia, the temperature of the summer was moderate, and the drought unprecedent- ed, yet there the epidemic prevailed (1124). 1131. This unqualified statement would lead to the belief, that the epidemic was general in these coun- tries. This, however, was not the case. 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 al- most dried up, leaving extensive flats covered with an abundance of the vegetables which grow in water, ex- posed to the action of a hot sun. Such are Harpers- Perry and Shepherdstown (364. 365). The highlands below the Blue Ridge were likewise healthy, and the parts that suffered were on the bor- ders of the rivers: thus, in the country along the Rap- pahannock river from Port-Royal to Tappahannock, a considerable extent of country where marshes on the river side abound,2 this dry summer was unusually sickly.3 1 Philadelphia Journal, &c. No. 10, p. 316. 8 Ibid. No. 12, p. 277. 3 Ibid. p. 287 537 1132. Of the diseases in Maryland, in 1822,1 have no account. 1133. In Pennsylvania, in the neighbourhood of Harrisburg, it rained on eight days in the first half of July; on the fifth there was a good deal of rain. In this month the dysentery prevailed in Hanover, and appeared in Paxton, both east of Paxton-creek; and the fever was increasing along that creek, and the river Susquehannah, and in the town between the two. From the middle of July to the middle of Septem- ber there was no rain. In August "the earth had be- come exhausted of moisture, and the streams were drying up;" in September the earth was "like a brick," and the creeks and rivers were nearly dried up. This drought checked the autumnal diseases. On the 31st of July the epidemic was extending but not fast; and on the sixth of A ugust was abating consi- derably, excepting in some valleys, particularly in Fishing-Creek Valley. The town was comparatively healthy in August and September.1 1134. The autumnal diseases did not therefore pre- vail in Virginia and Pennsylvania, except about wa- ter-courses ; and in the latter, although there was con- siderable sickness early in the season, there having been some rains in July, nevertheless, weeks before autumnal epidemics in general are at their height, it had considerably abated, and in some places almost disappeared before the middle of August. 1135. It is stated that in Carolina and Ohio there was nothing particularly remarkable in the season, " heats and rains having been in their ordinary pro- 1 Medical Recorder, No. 21, p. 139, &c. by Dr. Agnew. 68 538 portion;" yet there, in like manner, the disease has been prevalent (1124). 1136. Of the former I have no information ; but in the latter, 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"1 (244). The epidemic of this year, so far from prevailing in Ohio, was " wholly confined to the neighbourhood of streams," and it was 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"2 (244). 1137. It is stated that Kentucky was inundated with rains, and the weather was hot, and there also the epi- demic prevailed (1124). Both parts of this statement are correct (250). 1138. It is stated that in Louisiana, Mississippi, and Alabama, the season was an ordinary one; and yet in some places, before then healthy, they experienced a most fatal epidemic (1124). 1139. By turning to the account of the epidemic in Mississippi in 1822, it will be found that that season was not an ordinary one ; but just such an excessively wet one, as occurred in Kentucky in the same year, and that the event was precisely the same, a severe epidemic (308). 1140. Of Louisiana I have no information ; but in Alabama, there was a higher flood in the river Ala- bama than had been known for many years,3 and therf 1 Philadelphia Journal, &c. No. 17, p. 107. 2 Ibid. p. 106. a Ibid. No. 18, p. 262. 539 can be little doubt that in all this flat country, about the lower part of the river Mississippi, the same ex- cessive rains occurred. Of the effect in Alabama in 1822 nothing is said, but the following year, also very wet, was very sickly1 (313). 1141. Of Indiana, Illinois, and Missouri, nothing specific is stated. 1142. Let us now contrast the effects of this dry year with those of the exceedingly wet year 1823. In the latter the rains were excessive in Pennsylvania, Maryland, Virginia, Ohio, Mississippi, and Alabama; and the autumnal epidemic was very severe in all those states (245. 255. 313. 362). In particular, it was very sickly in every part of the valley of the Shenandoah, excepting where the river was full and there was no marshy ground. Thus, Harpers-Ferry, which suffered most severely in the year 1822, when the bottom of the river was exposed, in 1823, when the banks were full, was remarkably healthy (363). In Ohio, the upland and the hilly country, which escaped in the dry season, 1822, suffered excessively in the wet year 1823; the fever prevailed even in some districts of the Alleghany mountain (245). 1143. It is evident, therefore, that in dry seasons health is general, and in wet seasons sickness is ge- neral; that the sickly spots in dry times are near streams or marshes; and that when one part of the country is dry and another wet in the same seasons, the dry part is healthy, except about streams and mar- shes, and the wet part sickly. 1 Philadelphia Journal, &c. No. 18, p. 263, &c. 540 1144. It is alleged that in some of the Atlantic states the epidemic was confined to the high and hilly grounds, while the low, flat, and humid lands escaped; and that in the Western states the reverse was ob- served, the hills being more healthy, and the low grounds on the banks of the rivers being sickly. 1145. Why the hills of the West were healthy, and the low grounds sickly in 1822, we have already seen (244); it was because this hilly country was exces- sively dry, and the sickness was confined to the mar- shy spots on the rivers. With regard to the Atlantic states, we know that in this part of them the hilly country w as healthy, as in the West, and for the same reason ; the country was burnt up. In the valley of the Shenandoah, in 1822, the corn, in August and ear- ly in September, was bleached to the roots by the drought (361). On the contrary, in the humid coun- try along the Rappahannock river, in the Northern Neck of Virginia, it was at the same time very sickly (1131). The hills and the low grounds of the Atlantic states and of the West fared, therefore, alike in this dry year: they did so likewise in the following wet year, 1823. In the latter the hills of the West suffered severely (245); and in this valley the cultivated parts of the western side of the Blue Ridge also suffered (165). 1146. It is evident from the preceding observations, that every case mentioned is in perfect accordance with the doctrine of the dependance of epidemic fe- vers on the concurrence of heat and moisture in ope- ration on vegetable matter; and that there is not one which supports the doctrine that epidemics are " in- 541 dependent of all local and perceptible causes, a cer- tain degree of temperature excepted." On the con- trary, that rains are indispensably necessary to the production of a general epidemic in these countries; and in the absence of rains the epidemic is limited to the moist spots about the sides of rivers, and, as it were, located in them (244. 364. 365. 366). More- over, as epidemic diseases always prevail where the circumstances are favourable to the production of mi- asmata, and never where they are not; as they even appear in that particular quarter to which the exhala- tions from a marshy spot are driven by the wind, and do not appear in other directions (161 to 163); and as they cease when, by draining, by overflowing, or by filling up a marshy place, the source is cut off, the ge- neral state of the atmosphere meanwhile continuing the same, it is evident that their appearance depends entirely on the presence of miasmata, and not upon a general constitution or state of the atmosphere. 1147. Independently of this argument, the doctrine of the production of epidemic diseases by a general epidemic constitution of the atmosphere, is destroyed by the single fact that the alleged cause is general, the effects partial. In 1822, Ohio, Pennsylvania, and Virginia, were generally healthy; and Kentucky and Mississippi un- healthy. In the three former states, though they were generally healthy, wet places were very sickly. Shepherdstown and Harpers-Ferry, in Virginia (364. 365), and some situations on the Ohio river (244) suffered most severely. In 1821, Fairfax county, in Virginia, and almost all 542 the neighbouring country, far and wide, suffered se- verely from an epidemic fever. Centreville, however, escaped with only one severe case; there were two, but one was brought from the country (148). In the same season, the upper part of Fauquier county escaped by the destruction of almost every mill-dam, and the consequent drying up of almost every mill- pond in the country (330). A number of similar ca- ses have been stated in the preceding pages. Effects so partial cannot proceed from a general constitution of the atmosphere. 1148. If to avoid this difficulty, it be alleged that the co-operation of exhalations from the surface of the earth is necessary to give effect to the epidemic constitution of the air, and that the partial effects ob- served are the consequence of the exhalations being local; it is evident that the admission of the necessity of exhalations to the existence of epidemics, destroys the very foundation on which the existence of the un- known constitution of the atmosphere rests. For if exhalations are necessary, they are always present, and it is on the presumption of their absence that the necessity of calling in the aid of a general epidemic constitution of the atmosphere is founded. 1149. The doctrine of the dependance of epidemics on a general epidemic constitution of the atmosphere is therefore unfounded (1146. 1148). 1150. This language originated when little atten- tion was paid to the remote causes of disease, and then it was not improper: it was at that time an unknown constitution of the atmosphere which produced epi- demics ; it is now a known constitution. 543 1151. The concurrence of heat and moisture in operating on vegetable matter being necessary to the production of epidemics, it is evident that the epidemic constitution of the atmosphere, that is the constitution or state of the atmosphere which produces an epide- mic, must vary according to the circumstances of the country. 1152. In warm countries the epidemic constitution of the atmosphere is that state which lets fall abun- dant rains. Thus, in the United States, but more particularly in the middle, southern, and south-west- ern states, the abundant rains of 1823 produced a general epidemic; those places only being excepted, in which, by the superabundance of water, the vegeta- ble matter was entirely protected from the action of the sun (255. 313. 362. 364.) 1153. In 1822 this constitution was not general. It prevailed in Kentucky, and produced a severe epide- mic (250); but in Ohio, in Virginia, in Maryland, and in Pennsylvania it did not, and health was general in those states (244. 361.) So in 1817 this constitution prevailed in Mississippi, in Louisiana, and in Carolina, and a severe epidemic followed in those states (254. 309. 320). In 1819 the same constitution prevailed, and the same consequence followed in Mississippi, Alabama, and Louisiana (254. 305. 306. 307. 310); while in Kentucky the oppo- site constitution prevailed ; it was very dry, and there was little or no sickness (248). In 1821 the same con- stitution prevailed in Kentucky, Virginia, and Penn- sylvania, and another epidemic was the consequence (249. 330). 544 1154. The dependance of these epidemics on this constitution of the atmosphere is strikingly shown by the decline of the epidemic in the opposite state of the air; as in Pennsylvania in 1822 U133); also in 1821 in the upper part of Fauquier in Virginia (330); and in Frederick county in the same state in 1824 ,368). 1155. In cool and moist countries, the constitution of the atmosphere which produces epidemics is a high temperature of the air. Thus, in England, generally very moist, a hot summer is sure to produce a general epidemic; as in 1765, and in 1794 (524. 963, &c). 1156. In countries in which there are deep wet mar- shes, the constitution necessary to produce epidemics is a very dry as well as hot one. Thus, in Trinidad, and most of the West India islands, where almost all the towns are near marshes, often very deep and wet, in seasons of great drought epidemics prevail. The same is true of the island of Sardinia (525). 1157. No one state of the atmosphere, therefore, is an epidemical constitution in every country, or even in every part of any country. That which produces disease in the highlands, does not in the low and wet grounds; one constitution is epidemical in cool coun- tries, another in warm; and in consequence of peculi- arity of situation, that which is epidemical in one hot country, is not in another. Thus, in Senegal a wet season is sickly; in the West Indies a dry one: be- cause the first is an open extensive country; the lat- ter, for the most part, small islands with deep marshes near the principal towns; whence, moisture abound- ing, a wet constitution of the atmosphere is not epide- mical ; but a dry one is. No instance can be produce*I 545 of an epidemic in the north of Europe, or of America, which was not preceded by a hot summer; or of a ge- neral epidemic in the West Indies, not preceded by a dry one; or of one in the middle and south-western states of America, without much rain. 1158. With regard to the irregular periods at which epidemics return, they correspond precisely with the pe- riods at which heat and moisture concur in operating on vegetable matter; and the time of their continu- ance is precisely the time of the continuance of such concurrence ; and their disappearance depends on its cessation. 1159. Thus, when they concur, an epidemic ap- pears, and continues until the heat fails on the coming of winter, as generally happens in temperate climates; or until the moisture is entirely evaporated in the midst of summer, as sometimes occurs in this country, and every year in Egypt and Syria, and in Senegal; or until abundance of rain covers the vegetable matter from the action of heat, as sometimes occurs in wet seasons in low countries ; and is sometimes the effect of design to put an end to an epidemic. 1160. The language of physicians on this subject implies that an epidemical constitution continues some- times for several years, and is independent of the changes of weather. This, however, is entirely desti- tute of a foundation in truth. Several instances have been given of the most abrupt changes from health to sickness, not only in different years in continuity, but in the same year. 1161. Thus, in the neighbourhood of Portland, in Maine, the summers of 1797 and 1798 were hot and 69 546 wet, and sickly ; that of 1799 rainy and coo', and heal- thy ; that of 1800 hot and dry, and sickly fthere are marshes in the neighbourhood); and that of 1801 cool and rainy, and healthy until the last of August; and dry and sultry, and sickly in September (213. 214). Here the epidemical constitution continues two years, disappears in the third, returns in the fourth, and does not appear again until late in the fifth; and all these changes perfectly correspond with the changes in the sensible qualities of the atmosphere (1126). 1162. The most abrupt changes from sickness to health, and from health to sickness, occurred also in the following instances, the epidemic always appear- ing with the concurrence of heat and moisture, and disappearing on the failure of such concurrence. In Ohio, 1822 was very dry and healthy, and 1823 very wet and sickly (244. 245); in Kentucky, 1819 and 1820 very dry and very healthy, 1821 and 1822 very wet and very sickly (248 to 250); in Natchez, 1816 very dry and healthy, 1817 wet and sickly, 1818 dry and healthy, 1819 remarkably wet and sickly (254), 1823 very wet and sickly (255), 1825 wet and sickly (265); in New-Orleans, 1817 wet and sickly, 1819 much wetter and more sickly (309. 310) ; in the valley extending along the western side of the Blue Ridge, through Virginia, Maryland, and Pennsylva- nia, 1822 excessively dry and very healthy, 1823 ex- cessively wet and very sickly (361. 362), 1824 wet and sickly in July, dry and healthy afterwards (368), 1825 dry and healthy (369), 1826 dry and generally healthy (370); and lastly, in Philadelphia there were remarka- ble changes from sickness to health, and from health 547 to sickness, from 1793 to 1817, in all of which the pre- sence or absence of the epidemic constitution mani- ' festly depended on a certain temperature (404, &c). 1163. The influence of local causes is strongly marked in the cases stated in the following passages, viz. 149. 151. 156. 158. 163. 216. 218. 219. 224. 226. 229. 232 to 239. 244. 253, &c. 311. 317. 340. 364. 365. 366. 373 to 380. 383. 386. 393. 400, &c. 1164. Stronger evidence cannot be desired, that that constitution or state of the atmosphere which produces epidemics, is not "independent of all local and perceptible causes, a certain degree of tempera- ture alone excepted" (1126); and that it has not oc- curred " at irregular periods, continued an indefinite length of time, and at last disappeared, without dis- closing any vestige of the cause of either its rise, or its decline" (1127). 1165. The truth of the doctrine, that the presence of miasmata constitutes the epidemic constitution, is set in a strong and clear light by the fact, that the ca- ses in which local causes are efficient in the produc- tion of epidemics, confirm the general principle, mois- ture in these cases being supplied by the nature of the place in which the epidemic appears. CHAPTER XVI. SOME GENERAL REMARKS ON THE ORIGIN OF EPIDEMICS. 1166. We shall now make some general observa- tions on the origin of epidemics, which could not well be introduced before without interrupting the course of the argument. 1167. These diseases have been attributed, we have seen, to an unknown epidemic constitution of the at- mosphere, or such a state of the atmosphere as pro- duces epidemics, to contagion, and to miasmata, or the joint operation of miasmata and cold. 1168. The assertion of the dependance of epidemics on an unknown epidemic constitution of the atmos- phere, is a mere acknowledgement of ignorance of the real cause, contains no doctrine, and proposes no cause for the effects observed. 1169. The only agents proposed as the causes of these effects, are contagion and miasmata, the latter alone, or in combination with cold. 1170. The doctrine that contagion is the remote cause of epidemics, rests on the single circumstance of the disease appearing after communication with the sick. Not to repeat, that if propagated by contagion they would never stop until all were af- fected (710), nor that they want the characteristics of a contagious disease (718, &c); nor that they often com 549 mence without communication with the sick (732, &c. 786, Sec 819, &c), and often do not appear after com- munication with the sick (747, &c. 767, &c. 806, &c.); suffice it to say, that this argument would prove that intermittents are propagated by contagion. 1171. Thus, in Brucetown, in Frederick county, in Virginia, in the autumn of 1823, almost every indi- vidual in the town had an attack of the intermittent or remittent bilious fever, and several died. A relation of one of those who lay sick a considerable time and at length died, hearing of his illness, rode eighty miles to his assistance. He attended him night and day for a week or ten days. He at length returned home, when the season was quite healthy, and soon after, within a few days, had a violent attack of bilious fever. As the servants were also sick, a white girl was hired. She arrived there perfectly well, and in two days was taken sick. She had a violent ague, which returned on the third day, and on the fourth she insisted on be- ing carried away. A woman and all her family were sick. Four female relations in succession went, front a distance, to nurse the family. One after the other,. they were taken sick and carried off. A gentleman had a severe attack. A sister came to his assistance. He recovered. She went home, sickened and died. It is evident from this, that there is the same reason for believing that our common intermittents and re- mittents are contagious, as for believing it of any epi- demic disease. 1172. This opinion indeed was entertained by phy- sicians before the dependance of intermittents on mi- asmata was so fully established as it now is. Cleg- 550 horn says, " These tertian fevers have as good a right. to be 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 numbers in the same way, yet those who are much conversant among the sick are most liable to catch the distemper."1 1173. It is evident, therefore, that intermittents in this respect stand upon the same ground with other epidemic diseases; and that that which is considered as the effect of contagion, viz. the spreading of the disease, is no evidence of any thing more than the ge- neral operation of the cause, whatever that may be. 1174. There are some cases, however, so strongly urged as evidence incontrovertible of the contagious nature of certain diseases, that it may be proper to no- tice them in passing. 1175. Russel mentions the following occurrence as evidence of the contagious nature of the plague. " In the plague of Moscow in 1771, the populace, who had been prohibited from paying the accustomary last du- ties to the dying and the dead, rose tumultuously in a religious phrenzy, and broke into the hospital, and other places where the infected were lodged ; restored the religious ceremonies about the sick; kissed their departing friends; and would not permit the bodies to be buried, as before, without the city. The insurrec- tion was quelled in a few days, but much mischief was produced by this concourse of a distracted people. ' Tot hominum sanorum, aegrotorumque concursu, con- tagio aucto, mille et ducenti ultraque singulis diebus 1 Cleghorn on the Diseases of Minorca, p. 121, note. 551 . moriebantur.'1 The insurrection happened the fif- teenth of September, in the first part of which month the mortality from seven hundred daily, rose gradually to one thousand. Merten's Observ. p. 84, Vindibon. 1778."2 1176. There was, however, no greater increase of the number of deaths in this case than is common in epidemic fevers at that time of the year, in every coun- try in which they appear. September is precisely that month in which, in most temperate climates, epidemic diseases gradually arrive at their greatest height, af- ter which they gradually decline on the approach of winter; as this plague at Moscow no doubt did, inas- much as this disease uniformly declines at that time of the year in countries of moderate temperature (854). Sydenham, speaking of the plague in 1665 in London, its great height in August, and great decline in No- vember, says it seldom appears at any other season of the year.3 1177. The disease which caused the death of a number of persons in London, at the sessions at the Old Bailey in May 1750, has been very confidently at- tributed to contagion; but the occurrences were ut- terly inconsistent with the production of the disease by' such a cause. Even the variolous contagion, it is well ascertained, affects only those who are very near to the sick; but the persons who suffered on this oc- casion were far beyond the reach of any known conta- gion, viz. about twenty-five feet from the persons who were supposed to have carried the contagion into 1 By the concourse of so many men in health with the sick, the con- tagion being increased, more than twelve hundred died every day. 2 Russel on the Plague, p. 250, note. 3 Sydenham's Works, p. 77. 552 court. Moreover, most of the persons who were at- tacked were at the farthest end of the court-room, while those immediately around the prisoners are not represented as having been affected. Lastly, the sin- gular circumstance of almost every one who was at- tacked being on the left side of the room, and in ele- vated seats, points to some other cause than one which, if it exist, must extend alike to all around. It is plain enough, therefore, that the cause of this disease could not have been contagion; what it was, is as plain from the statement of Bancroft.1 1178. The court was excessively crowded to hear the trial of a captain in the navy for killing another in a duel. The trial was very long, and the house was so close that the air became in a short time exceed- ingly offensive; and although the weather was cold, a cold piercing east wind then blowing, the room was very warm. A window was therefore opened on the left side of the house, and a current of cold air for- cibly rushed in, and, the window being much higher than the heads of the people on the floor, passed over them to those who were more elevated, and therefore exposed to its action. Hence the number affected on the left side of the house. Such exposure to cold air, when the person is much heated, has often produced violent fever. 1179. Another case represented as evincing incon- trovertibly the propagation of fever by contagion, is that of the Hussar frigate. Blane calls it an experi- mentum cruris. He says, " There are well attested examples of its being communicated from one ship to ' Bancroft on Fevers, p. 443. 553 another in the middle of the ocean. As exhalations of the soil are here out of the question,'any one such fact may be considered as an experimentum crucis, in- contestably establishing the principle, and upon this alone the whole merits of the case might be rested."1 He then refers in a note to three cases, of which that of the Hussar is one. 1180. This language implies that similar instances of the communication of fever had frequently occurred on land, but that the force of the inference from them had been evaded under the pretence that miasmata had produced the effect; that here however none could be supposed to exist, and therefore that the occurrence of the disease on board this ship is an experimentum crucis. Both these positions are true if this case be such a test; that it has frequently happened on land, that patients in yellow fever, carried into companies of people at a distance from the place w here the fever prevailed, communicated it to them; and secondly, that the miasmata alleged to be the cause of the fever in such cases, could not have existed on board the Hussar. But they are both untrue. First, it is well known that thousands of instances have occurred of yellow fever having been carried into villages adjoining cities where that disease prevailed, without communi- cating it to an individual. This is so notorious in this country, that it would be a waste of time to quote ca- ses to show it. Secondly, so far from its being cer- tain that the Hussar could not have had miasmata in her hold, such was the foul state of the English ships at that period, that the contrary is almost certain. i Blane's Medical Logic, p. 258. 70 554 1181. Admitting the facts as stated in this case to be true, that after taking a French ship, the yellow fever prevailed on board the Hussar, the occurrence is not of such a decisive character as Blane represents it to be ; it is not an experimentum crucis. To make it such an experiment, incontestably establishing the doc- trine, the absence of every other cause must be cer- tain. Blane shows he was fully aware of this, when he says the occurrence took place in the middle of the ocean, where exhalations* of the soil are out of the question. It is however well known that this disease has often appeared on board of ships at sea, which have not had communication with any other ship, or any place where the yellow fever prevailed; as in the case of the Busbridge on her voyage from England to the East Indies (740), or of the General Greene on her voyage from Newport, Rhode-Island, to Havan- na (739). Blane himself asserts that this fever origi- nates on board of ships on long voyages.1 To make this case such a test, it ought to have been shown that the circumstances, which give rise to this fever on board of ships at sea, did not exist on board the Hus- sar. This has not been done, and therefore this is not an experimentum crucis. 1182. There are moreover some circumstances con- nected with this transaction that completely destroy its claim to be such a test. There were two English vessels in company, the Hussar and the Thetis, which captured two French vessels, the Raison and the Pre- voyante. The Hussar took the Raison, but received on board none of the crew that were sick. The The- 3 Blane's Medical Logic, p. 24$. 555 tis took the other ship. The latter was more sickly than the Raison, both on the voyage and after their arrival at Halifax; but the Thetis escaped the fever entirely.1 1183. The case of the Regalia has a much better claim to be considered in that light. It is asserted by Blane that the fever originates on board of ships at sea, but he also contends that it is propagated by con- tagion. The first is admitted; the second denied. To put the question to the test, a yellow fever patient is carried from one ship to another, say the Hussar; the disease soon after spreads on board that vessel. But inasmuch as both ships are in the same climate, and the disease, if it appear in both, must of course make its appearance in one of them first, and as the circumstances admitted on all sides to be capable of originating the fever may have existed in both, a ques- tion arises whether they have been excluded or not. Nothing certain being known on that subject, and it being certain from the known state of ships in general (168, &c), and from the climate in which the fever appeared, that those circumstances may have existed, the experiment cannot be deemed conclusive, and we must resort to a new one. 1184. Such an one was made on board the Regalia, in circumstances entitling it to be considered as com- pletely an experimentum crucis, as any experiment of the kind can be. She had suffered most severely for a long time; her crew was perpetually sick, and dying in such numbers as to require continual recruiting, and while traversing the West India seas in every di- ' Bancroft on Fevers, p. 496.497- 556 rection, she was leaving sick persons at every port (171, &c. 751). Her hold was at length cleaned out perfectly, and thoroughly dried by means of stoves heated very hot, the hatchways being closed. After having been thus thoroughly cleaned out, she sailed with a crowd of prisoners from the jails of Guadaloupe, and with a patient on board dying of yellow fever the day before she left Basseterre roads, but no fever was communicated to any of the passengers (174). In this case the circumstances in which the fever originates were entirely removed by the thorough cleansing of the vessel. The contagion, if it exist, was then introduced, but no effect followed, therefore no cause was there present, and contagion does not exist. 1185. Considerable stress has been laid on the prevalence of the plague in Malta, in 1820, and it has been urged very strongly as establishing the doc- trine of the contagious nature of that disease, inas- much as that island is almost a bare rock, without rivers or morasses. 1186. The evidence on which rests the belief that the plague was introduced and propagated by conta- gion, is as follows. A vessel arrived from Egypt with the plague on board on the 28th of March. She was received into quarantine, and the crew were taken to the Lazaretto, situated in a small island in the middle of the harbour, where the captain and his servant sick- ened in a day or two after being received, and died with symptoms of the plague. On the sixteenth of April the first case appeared in one of the principal streets of Valetta; the person affected was the daugh- 557 ter of a shoemaker. From that time till the 17th of May eight persons are mentioned as having been af- fected, and all died but one; and all belonging to the house or very intimate with the family, and often with them during their sickness. After that time it spread widely. 1187. I have not seen the work of Dr. Faulkner, but the reviewer says, " The first position, or the in- troduction of the contagion from the vessel to the shore, our author fails to prove by direct evidence. The current report at Malta was, that one Salvator Borg, a shoemaker, having purchased a piece of linen on board the San Nicholo, introduced the fomites into his own family, whence it radiated afterward to other persons. Dr. Granville has since .stated that this was authenticated as a fact, under the authority of Sir Thomas Maitland's despatches, and other official pa- pers."1 1188. There is no evidence here that can be relied on to prove any thing: a current report, or a despatch of a government officer founded on it, is not evidence. If there had been any attainable, Dr. Faulkner, con- sidering his object in writing, and the opportunity he had for the investigation, would have discovered it. 1189. Admitting, however, the statement as true, the contagion, if it exist, must have been introduced by the man himself, or by the linen. He himself is not stated to have been attacked until eighteen days after his daughter; it could not therefore have been introduced by contagion proceeding from himself (700); and therefore, if at all, must have been intro- duced by the linen. 1 Medico-Chirurgical Review, Vol. 1, p. 590. 558 1190. When, however, we consider the facts stated respecting the unreserved distribution of the clothes of the dead, immediately on the cessation of the plague in Egypt, and that they are worn by thousands with perfect safety, it is impossible seriously to believe that this piece of linen could have been the means of pro- ducing the mischief (783). It is most evident, that if the plague could thus easily be introduced into a town, the European cities of the Mediterranean coast and islands would be perpetually harassed by that dis- ease, inasmuch as they continually trade to the Le- vant, and the common practice of smuggling must an- nually introduce into them many articles in the same way with the linen abovementioned. 1191. As to the occurrences after the sixteenth of April, there is nothing more in them than what is seen every year in the prevalence of the autumnal diseases. They must commence somewhere; they do so at some point where the cause is at the time most efficient, and of course all that are near and all that approach are liable to be attacked. 1192. There is one circumstance rested on with considerable confidence, but with little propriety. The Augustine convent was situated in a remarka- bly healthy, spacious, airy part of the town, and the inhabitants had, from the very beginning, observed the greatest caution in shunning communication with the public. " It was at length, however, infected, in consequence of one of the servants, who was caterer by occupation, having, in disobedience of public or- ders, gone into a very contaminated part of the town, called the Manderaggio, and purchased infected 559 clothes. Shortly after his return he made full confes- sion of the circumstance, when one of the brotherhood belonging to this convent, out of compassion, imme- diately volunteered to attend him, placing himself, at the same time, in strict quarantine with the patient. Both nurse and patient immediately fell victims to the disease, but no other individual under the same roof was ever assailed."1 1193. This case certainly affords but equivocal sup- port to the doctrine of contagion. The inhabitants of a large house " in a peculiarly healthful, spacious, and airy part of the town," avoid all communication, from the very beginning, with the public, and of course more particularly with the sickly part of the town; the lan- guage seems to intimate that they were shut up (771); one only went into a very sickly part of the city, and purchased infected clothes, and shortly after returning confessed what he had done. Another of the inhabi- tants, together with the one who had exposed himself to the cause of the disease in one of the most sickly parts, went into strict quarantine, (where is not said,) and both died. All who continue in the spacious airy house escape, notwithstanding that the contagion is alleged to have been carried in ; one who exposed himself in the town, and another, who went into strict confinement with him, only died. 1194. It is certain therefore that the evidence of- fered here in support of the doctrine of contagion is entirely insufficient. Indeed the work itself affords positive evidence to the contrary. On the subject of 1 Medico-Chirurgical Review, Vol. 1, p. 591. 560 frictions with oil, Dr. Faulkner says, " There were so many instances of persons living in the closest inter- course with the infected, who escaped without the use of oil, and so few well attested cases of persons having come into actual contact with pestiferous matter who were protected by oil alone, that I cannot hesitate to conclude, that the opinion of its possessing any inde- pendent or certain prophylactic efficacy, is destitute of foundation."1 This single sentence contains evidence, that in very many instances persons living in the closest intercourse with the sick escaped; and that in some well attested cases, persons who had even been in actual contact with pestiferous matter, escaped ; the latter using fric- tion with oil as a preventive, on which, however, Dr. Faulkner's experience led him to place no reliance. 1195. Let us now examine into the situation of this island, and the state of the weather in which the dis- ease arose and declined. The island of Malta is a freestone rock, which has been quarried in order to build houses, immense forti- fications, &c. until the face of the island, "when view- ed in perspective, resembles an extensive stone-cut- ter's yard."2 A great part of the island is a barren waste, but the soil of the inhabited part is rich, though very shallow; seldom above a foot in depth. There are three spots on the habitable part which may be termed marshy or moist.2 There are no rivers, but some excellent springs, and an aqueduct leading to Valetta.3 1 Medico-Chirurgical Review, VqJ. 1, p. 594. 2 Ibid. p. 587- 3 Rees's Cyclopedia. 561 In the spring rain falls in considerable quantity, sometimes in torrents. In summer the thermometer ranges from 75 to 85 degrees in the shade. 1196. It is evident from this account that there are some marshy places; that the holes in the rock made by quarrying must, in wet years, form numerous small ponds, as in such a broken rocky piece of ground I have seen. It is certain that iri a wet year, such a surface must produce miasmata in abundance; and, considering the shallowness of the soil* not more than a foot to the rock, that a hot summer must soon ex- haust the moisture, stop the production of miasmata, and consequently put an end to the disease produced by them. Accordingly we find that the plague on this occasion broke out in April and May,1 spread very ra- pidly, and was decidedly checked by the seventeenth of July.2 This state of things is much the same with what occurred in Aleppo in Syria: there also there were heavy rains early in the spring, and great heat and drought in the summer; and in very wet springs the plague appeared, spread rapidly, and declined in July and August (885. 886). 1197. It is manifest, therefore, that the evidence of- fered by Dr. Faulkner is not sufficient to show that the plague is propagated by contagion; indeed that there is nothing new in it, nothing but what has been often brought forward, viz. the occurrence of the dis- ease in some after having communicated with the sick, at the same time that it is alleged, in the very same work, that numbers who communicated with the sick, and some who were in actual contact with the pesti- » Medico-Chirurgical Review, Vol. 1, p. 590. a Ibid. p. 592. 71 562 ferous matter, entirely escaped. It is moreover evi- dent, that it derives all the force it has from the sup- posed absence of the circumstances favouring the pro- duction of miasmata, this being rested on as strong ground in support of the doctrine. But there is nothing in the circumstances inconsistent with the de- pendance of the disease on miasmata; and the time of the rise and the decline, viewed in connexion with the nature of the surface, the spring rains, and the summer heat, correspond so entirely with the occur- rences in similar circumstances in Aleppo, as clearly to point to miasmata as the cause. 1198. If this is the case when this epidemic is con- sidered almost without reference to any other, how much stronger is the argument, when we take into view the circumstances in which the plague has ap- peared, prevailed, and declined in other countries. We have seen that on the continent of Europe, in England, in Egypt, and in Aleppo, the concurrence of heat and moisture is necessary to the existence of the plague (854. 864. 865. 887). The conclusion stands on such strong ground, that nothing less than a case clearly made out, of the prevalence of the disease in the absence of such concurrence, can shake it. In this instance at Malta, this is so far from being done, that there is a certainty that in every year miasmata are produced, and that in a very wet year they must abound until the country is dried up by the heat of summer; moreover, the disease prevailed precisely at that pe- riod of the year when they were most likely to have been abundant, and ceased precisely at that time, when, from the shallowness of the soil and the heat of the climate, the production of them must have ceased. 563 1199. It is evident, therefore, that of the cases al- leged as experimenta crucis of the truth of the doctrine of the contagious nature of epidemic diseases, none af- ford ground of conviction of the truth of that doctrine. 1200. Finally, when we consider that in temperate regions, all these epidemics arise in hot weather and decline in cold weather (142); in wet countries ap- pearing in hot, dry weather, and not appearing in cool, wet weather (505. 507. 524. 538); and in dry countries appearing in hot, wet weather (245. 249. 250. 362), and not appearing in dry weather (244. 248. 361); that in hot, dry countries, they appear in wet seasons, and cease when the country becomes dry (484); that in hot, wet countries, they arise in dry seasons, and cease in wet; in very marshy countries the hottest and dryest seasons being the most sickly (437. 441. 525); and that when entirely dried up they become healthy (330. 865. 887) ; it is evident that the concurrence of heat and moisture is the sine qua non, the indispensable condition of their appearance: and when we further consider, that in these circum- stances a vast quantity of gas is continually produced, and that the effects observed, viz. the morbid symp- toms, appear in those who are in the direction of the wind blowing over these sources of miasmata, and not in those who are not in that direction (163), it is evi- dent that the cause is a vapour or gas arising in those circumstances ; and the perfect emptiness of the pre- tensions of contagion to be the cause is shown by the fact, that the effects are seen wherever that cause, mi- asmata, is produced, and wherever it is carried, and no where else. CHAPTER XVII. REMOTE CAUSES ARE PREDISPOSING OR EXCITING. SOME ADDITIONAL REMOTE CAUSES. 1201. The remote causes of fever have been distin- guished into predisposing and exciting causes. The same cause is however sometimes predisposing, some- times exciting, and sometimes both. The distinction therefore does not relate to the nature of the cause, but to the order of the operation. 1202. The predisposing are those whose operation disposes to disease, that is, gradually leads to or pro- duces disease. The exciting are those which imme- diately cause it. But as the latter, if first in action, may not have immediately excited, but would have led along to disease ; and the former, if in action after the other, would have immediately produced it; and fur- ther, either would, if the other had not acted at all, have finally produced disease, it is evident that the exciting causes only fill the measure of internal de- rangement, which produces the symptoms in question. 1203. The remote causes may also be divided into those which operate upon great numbers, and those which may operate on individuals only. The former produce epidemic disease, such as miasmata, cold, and in some instances hunger or famine. The latter pro- 565 duce single cases, which are called sporadic cases; such are fatigue, intemperance, &c. 1204. We have now seen that all the known re- mote causes of fever weaken the action of the heart, and that weakened action of the heart precedes every fever (691). Weakened action of the heart is there- fore one link of the chain of causes extending from the remote causes to the symptoms of fever (18); and all those causes which produce this link of the chain, are themselves remote causes of fever; inasmuch as all those causes which produce it, are remote causes of its effects (17). 1205. Excessive venery, therefore, which remarka- bly weakens the action of the heart, is a remote cause of fever; it has indeed been enumerated by many au- thors as a very active cause of fever during great pes- tilence. 1206. Excessive evacuations also weaken the action of the heart and are remote causes of fever; and they also have been enumerated as such by authors. 1207. Abstraction of accustomed stimuli weakens the action of the heart, and is a remote cause of fever. Tobacco is a stimulus to the use of which some are so much accustomed, that the privation leaves them very languid; and Trotter mentions this privation as predisposing sailors to an attack of typhus fever.1 1208. The excessive action of the heart and arte- ries in fever, may be mentioned among the causes of weakened action of the heart. Excessive action how- ever induced, soon terminates in weakened action, proportioned to the previous excitement. It seldom 1 Trotter, Medicina Nautica, Vol. 1, p. 202. 566 happens that a fever lasts longer than twelve hours without the action of the heart moderating.1 Some- times, but rarely, it continues with great violence for several days with little remission; but when it does finally sink, it is into a very low and dangerous state of feebleness. We next proceed to inquire into the effects of weak- ened action of the heart. 1 Cleghorn's Observations on the Diseases of Minorca, p. 140. KND OF VOLUME 1 %