■'S&s AN INAUGURAL ESSAY ON THE YELLOW FEVER, AS IT APPEARED IN THIS CITY IN 1 7 9 5-.y^ SUBMITTED to THE PUBLIC EXAMINATION OF THE FACULTY OF PHYSIC, UNDER THE AUTHORITY OF THE TRUSTEES OF COLUMBIA COLLEGE, IN THE STATE OF NEW-YORK, WILLIAM SAMUEL JOHNSON, LL.D. Piefident, FOR THE DEGREE OF DOCTOR OF PHYSIC, On the 3 J of May, 1797. By ALEXANDER HOSACK, fun.'A.M. OF NEW-YORK. NEW-YORK: Printed by T. and J. SWORDS, Printers to the Faculty of Phyfic of Columbia College, No. 99 Pearl-ftreet. — I797.— / /£ct■.# Z^r^^t THE FOLLOWING PAGES ARE INSCRIBED TO Dofior JOHN BARD, AS A TESTIMONY OF SINCERE RESPECT FOR A MEDICAL PRACTITIONER WHO UNITES THE CHARACTER OF A LEARNED PHYSICIAN AND AN ELEGANT SCHOLAR, TO THAT OF AN ACCOMPLISHED GENTLEMAN; AND AS A TRIBUTE OF PERFECT ESTEEM, BY HIS VERY OBLIGED AND HUMBLE SERVANT, >s THE AUTHOR. PREFACE. JljEFORE the reader perufes the following differtatlon, I muft beg leave to inform him, that this is the firft attempt of a young man, 'inexperienced in writing, and is done only in compliance with the regulations of this Col- lege for conferring the degree of Dofior of Medicine. I have purpofcly avoided any inquiry as to the origin of the difeafe, or the chemical com- pofitlon of the matter or polfon producing it; referring the reader forparticulars upon thefe fubjecls to the more complete hiflory of the difeafe, as publlfhedby Doctor Bayley, Mr. Webster, and others; and have confined myfelf to a plain detail of the fymptoms, caufes, and cure of the difeafe, as far as fell under VI under my own obfervatlon, in my attendance at the New-York Hofpltal, and upon the private practice of DoElor Samuel Bard, and my brother DocJor David Hosack. If afinglefaEl, either new or ufeful, fhall be communicated, I fhall feel myfelf much gratified In having undertaken the tafk. A N . INAUGURAL ESSAY ON THE YELLOW FEVER. HISTORY. A HE yellow fever is known by a va- riety of names. By the French it has been denominated La maladle de Slam, from a country of that name in the Eaft-Indies, where it is fuppofed to have had its origin, and from whence to have been conveyed to diftant parts of the world. Sometimes they call it La fevre matelotte, from its attacking feafaring people and foreigners more readily than the natives of the coun- try in which it prevails. The Spaniards have 8 i'ave given it the name of votnito pre to, or the black vomit, which is one of its moft malignant and characxeriftic fymptoms. Some have called it the malignant fever— others the putrid bilious, and bilious remit- ting fever, &c. This difeafe firfr. appeared in this city about the year 1740; and, as I am informed by Doctor John Bard, who was at that time a practitioner, it mani- fefted the fame malignant fymptoms which characlerifed the late mortal epidemic.— In fome of the fouthern ftates it has been known to prevail at a much earlier pe- riod.* In 1791 it appeared again in New- York, and has been defcribed in a differ- tation published by Doctor Addoms. The epidemic I am now about to de- scribe, and which has univerfally received the name of yellow fever, firfl appeared about the middle of July, and continued until the weather became cold. The fea- fon, See Dr. Lining. 9 fon, during its prevalence, was very hot and moift. It raged with molt violence in thofe parts of the town adjacent to the caftern more, where the air is lefs pure, and the ground lower than in any other part of the city; which, confequently, muft, in fome degree, ferve as a refervoir for the filth of the upper parts of the city. It attacked perfons of all ages, adults more frequently than children, and males than females—foreigners more than the natives, or fuch of our inhabitants as had lived in warm climates.* Frenchmen and blacks B who * The same has been remarked in the West-Indies, and in the other parts of the United States, viz. that foreigners from northern climates were more susceptible of the disease than the native's. In support of this opinion, I beg leave to introduce the following extract of a letter from Doftor George Davidson to Doctor David Hosack, dated Fort-Royal, Martinique, September 23, 1796; in which he offers the following ingenious explanation of this fa&: " I have already mentioned the experiments made upon the atmospheric air here, with a view to ascertain the compo- sition of it. Those experiments have been frequently re- peated, in the presence of the late Do&or Charles Web- ster, of Edinburgh, Do&or Saunderson, of London, 10 who had lately arrived from the Weft-In- dies, were rarely the fubje&s of this difeafe, as they appeared to have been inured, and thence rendered infenfible to the operation of and Doctor Chisholme, lately. The result has shewn a much greater proportion of oxygene than what I could have conceived—no less than -^W of oxygene gas. It may, perhaps, tend to explain some difficulties which we meet with in the phenomena attending upon yellow fever, viz. why Europeans, or those from cold climates, of tense, rigid fibres, and in the prime of life, are the subjects of its attack. I suppose, what you will admit, that Europeans or Ame- ricans, from cold climates, have a more tense and firmer texture of fibres than Creoles, or those who have long re- sided here—cold tending to brace the habit and invigorate the body, and whilst it does so, increasing the appetite and digestive powers. Besides this connection between the stomach and surface, we also observe a remarkable sym- pathy between the stomach and lungs: whatever tends to invigorate the stomach, remarkably increases the action of the lungs, as we may perceive from what follows after a full meal and a few glasses of generous wine. Inspiration and respiration are increased; a greater quantity of atmospheric air is taken into the lungs, and a greater quantity of oxy- gene fixed in the blood: hence the irritability; a glow of genial heat diffused, and the circulation becomes more ra- pid. But as the atmospheric air in Europe contains a less proportion of oxygene, the quantity of it fixed will be proportioned to the necessities and calls of the system. It is, however, far different in those climates: before the ap- petite and digestive faculties are impaired, whilst the tone 11 of its caufe; but their exemption is, no doubt, more particularly to be afcribed to their temperate mode of life, and efpecially their freer ufe of vegetables; for it is cer- tain, that thofe who moil indulged in the ufe of animal food and fpirituous drinks were moll fufceptible of the difeafe. The fymptoms which marked the yel- low fever in its firft itage were, a general languor and heavinefs—depreffion of the fpirits, fbmetimes approaching to ftupor— difinclination to motion—a fenle of cold, and fhivering—acute pain in the head, efpe- cially above the eyes—pains in the back, and frequently extending down the extre- mities—the fkin was hot, dry, and much flufhed, not unlike the fcarlet blufh of an erilepelatous inflammation—the eyes were fuffufed and vigour of the system still continue, and also the cor- responding acrion of the lungs, a much greater proportion of oxygene being contained in the atmospheric air, will be fixed, and the irritability of the system increased; or, in other words, the system surcharged with oxygene. Hence the predisposition to fever." 12 fuffufed with water, and the veffels of the tunica adnata much diftended with blood: fo conftant were thefe laft fymptoms, that they may, in a certain degree, be confidered as chara&eriftic of the difeafe. The pulfe was, for the moft part, frequent, full, and hard—refpiration was proportionally quickened, attended with much anxiety, ftricture, forenefs, and frequently intenfe heat about the precordia—the tongue was foul, the appetite depraved, with naufea, vomiting, and not unfrequently pain about the region of the ftomach: thefe were among the firfr. fymptoms of the difeafe. The bowels were conftipated, unlefs the patient laboured under a diarrhoea at the commencement of the fever—the urine, in. this ft age of the difeafe, appeared, for the moft part, as in the firft; ftage of fevers in general, viz. high-coloured, and fmall in quanti'.y; in the laft ftage, when the fever had continued for fome days with violence, and 13 and the general mafs of fluids became changed, this excretion manifefted the fame alterations, becoming fometimes turbid, and at others yellow, as if tinged with bile. —Such are the fymptoms which generally appeared at the commencement of the dif- eafe, conftituting what I would call the inflammatory ftage, but differing from any inflammatory difeafe, inafmuch as in the former there was no particular part of the body which appeared to be exclufively the feat of inflammation. Where the difeafe terminated favourably, there was, for the moft part, an evident abatement of the above fymptoms in forty-eight hours; and in the courfe of five days the patients were generally freed from fever, but were left greatly debilitated by the violent operation of the poifon producing the difeafe, and the evacuationswhichbecame neceflary for the removal of the fever: even in thofe inftan- ces where blood-letting, the moft debilitat- ing ing of all evacuations, was not employed, the patient was fo reduced as to require all the refources, both of nature and of art, for his fupport. This ftage of the difeafe was rather marked by fymptoms of debility, yet accompanied with great irritability, fb much fo, that the leaft imprudence in diet, clothing, bodily exertion, or indulgence in converfation and company, would frequent- ly induce a return of fever. But where this abatement of the difeafe did not take place within the firft three days, a very different and more malignant train of fymptoms ap- peared, partaking more of the fymptoms of the laft ftage of putrid fever, as defcribed by Huxham and Cullen. In the laft ftage of the difeafe, the pulfes funk, became more frequent, irregular, and fometimes intermittent: the perfon would lay continually on the back, with the knees drawn up, and the body finking toward the bottom or foot of the bed; the breathing became *5 became proportionably more difficult; and the cruft which had formed on the tongue became of a black colour, which change alfo took place on the lips and teeth; the yellow- nefs became more general over the body, attended with cold clammy fweats; the vomiting now became more frequent and copious; in fome inftances patients have vomited inceffantly, and in aftonifhing quantities; and what was brought up re- fembled the grounds of coffee: this, for the moft part, was considered as a fatal fymp- tom: there were, however, feveral inftan- ces of recovery after this had taken place to a confiderable degree.* It is worthy of remark, * The opinions, as to the nature and origin of the black matter vomited up, are very numerous and different. Some have supposed it to be part of the stomach; but we must entirely reject this idea, when we consider the enormous quantities which patients sometimes throw up. The most probable opinion is, that it is bile imperfectly formed. [See Saunders on the liver. ] Here I beg leave to quote the words of Doctor Jackson, who, from dissection, has formed the same opinion: after opening the abdomen, &c. and no- ticing the appearance of the viscera, he says, " The liver i6 remark, that when the vomited liquor ac- quired this black colour, a diarrhoea fome- times followed, in which there was a dif- charge of a fimilar fort of black matter, but more refembling tar or molaffes. The flo- rid colour now left the eyes, and they be- came yellow and funk. The functions of the brain and nervous fyftem were alio very much deranged: the patient was attacked with delirium, attended with fubfultus ten- dmum, and fbmetimes a perfeclt ftupor, with a convulfive kind of fighing. The fpeech began to faulter and tremble. The patient and spleen were generally enlarged in size; the colour of the liver was often of a deeper yellow than that of any other of the abdominal viscera; while the texture of the spleen was frequently less firm than it is found to be in its natural state. The gall-bladder, for the most part, was moderately full, but the bile it contained was black and thick. The biliary ducts were likewise enlarged, and mo- derately filled with the same sort of bile which was found in the gall-bladder; while the very blood-vessels of the li- ver bore the marks of uncommon distension. In the ca- vity of the stomach, likewise, there was usually more or less of a dark coloured liquor, similar to what had been thrown up in the last stage of the disease." 17 patient appeared very uneafy, and fhewed a difpolition to leave the bed. Sometimes a deceitful tranquility appeared, and by fome was fuppofed to be a favourable fymptom; but the patient, upon getting afleep, was much agitated. The ftools and urine be- came black, very ofFenfive, and difcharged involuntarily: in fome inftances there was an entire fuppreffion of urine: the extremi- ties became cold, but the heat ftill continued about the ftomach: blood was difcharged from the mouth, nofe, ears and eyes, and from thofe parts of the fkin where blifters had been applied. Sometimes blood was effufed in the cellular membrane, appear- ing in the form of mortification—petechiae appeared about the neck and breaft—vibi- ces, or livid fpots, came out upon the body, particularly upon the abdomen—the per- fpiration became very foetid—the eyes fhone like glafs—hiccough and muttering came on, and were followed by death. C Dotfor i8 Dodlor Rush, in his hiftory of the yellow fever as it prevailed in Philadelphia, has taken notice of buboes and carbuncles as among its fymptoms. I do not know a fingle inftance where theie fymptoms have occurred in this difeafe in New-York. In the Weft-Indies thefe fymptoms are not uncommon, as would appear from the fol- lowing extract of the before-mentioned letter, which I have introduced, as it ferves to eftablifh the fimilatity of the yellow fever to the plague.—" We have had a return of the yellow fever during the months of July, Auguft and September, much more violent than I ever recollect feeing. The rainy fea- fon fet in very late, and the weather proved, during thefe three months, remarkably warm and fultry. The difeafe commenced early in July, and was not only contagious, but attended with peftilential fymptoms. Buboes appeared in feveral patients, who, however, recovered; and I have feen feve- ral 19 ral inftances of the anthrax and peftilential carbuncle. One patient evidently funk from a carbuncle on his elbow, the haemorr- hage from which could fcarcely be fiippref- fed by pledgits dipt in diluted vitriolic acid; and two others alfo appeared upon the foot and ankle of the fame patient. I am at prefent attending a medical gentleman who has above fifty carbuncles upon his body. The difcharge has reduced him, but he is recovering. The appearance was firft a red unequal erysipelatous appearance upon the fkin; in the centre appeared an elevated fpot, which gradually changed to black, burft, and difcharged a blackifh bloody ichor, and left behind it a deep pit. Upon other parts a white puftule appeared, which, after burfting, difcharged pus and bloody ferum, and pitted in the fame manner. The back, loins, and upper part of the thighs were principally affected." PREDI5- 20 PREDISPOSING CAUSE. PREDISPOSITION is that ftate of the body not of itfelf capable of producing the difeafe, but rendering the body more fufcep- tible of the exciting caufe. In order to pro- duce yellow fever, it is necenary that the body fhould be in fuch a ftate as to receive the action of the exciting caufe. This ftate appears to be a peculiar irritability in the fyftem, by whatever means- induced. Upon no other principle can we explain the rea- fon why the contagion does not affect every perfon within its atmofphere, and why the attendants of the fick are not always at- tacked. The caufes which produce predif- pofition in the body, for the moft part, are, i ft. Fear, which poffeffes great power in debilitating the body, and hence rendering it more irritable. Upon this principle we may 21 may account for the good effects of the dif- ferent preventives which many were in the habit of ufing; fuch as the wearing a fmail quantity of camphor, vinegar, &c. con- ftantly about the body, infpiring them with a certain degree of courage. The ufe of tobacco was fuppofed to have a good effect in counteracting the difeafe, probably from its poffefling more ftimulus than the matter of contagion. 2d. Heat, efpecially expofure to the di- rect rays of the fun, was a common caufe, as it aflifted the ftimulus of contagion in bringing on indirect debility. Fire alfo ren- dered the contagion more active. To prove this we notice, that a great majority of thofe that were infected were fuch as, from the nature of their occupations, were much expofed to the heat of the fun and fire. 3d. Fatigue, whether induced upon the mind or body, and from whatever fource. 4th. Grief. Perfons who attended friends or 22 or relatives in this difeafe were not unfre* quently feized during their attendance. 5th. Excefs in venery, and other evacua- tions, fuch as bleeding and purging, aided by fear, which caufed fome perfons to adopt thefe means in order to prevent the opera-* tion of contagion, 6th. Cold; accordingly fuch as had been previoufly much heated, upon getting themfelves wet, drinking largely of cold water, or expofing themfelves to a ftream of cool air, were readily attacked with the difeafe. 7th. Intemperance in eating or drink- ing : taking either too large or fmall quan- tity of improper food; or a fcanty allow- ance of common diet. EXCITING 23 EXCITING CAUSE. DISEASE is brought on by the action of the exciting caufe, after the body is rendered capable of receiving the contagion by the action of the predifpofing caufe. The yel- low fever being a contagious difeafe, it muft undoubtedly depend upon the action of a poifon either generated or introduced into the body. This matter, or poifon, is generally acknowledged to be exhaled from animal and vegetable fubftances in a ftate of putrefaction: but, as there is a great con- trariety of opinion upon this fubject, I fhall purpofely pafs it over, referring the reader to the works of Lavoisier and others.— There are alfo many different opinions as to the mode in which this contagion acts upon the body in producing the difeafe. Some have fuppofed that it enters the fyf- tem ,24 tern by the ftomach—fome that it enters by the lungs—and others, that the body re- ceives it by the pores of the fkin. All thefe opinions have their advocates ; but by whichever palfage it is communicated to the fyftem, whether by the ftomach, the lungs, or the pores of the fkin, it is certain, that, in common with the matter of fmall- pox, meafles, lues venerea, the venom of the rattle-fnake, &c. it produces a violent irritation throughout the whole fyftem. Its firft operation I confider to be upon the nervous fyfiem: hence the violent pains of the head, back, and extremities of the body —hence the ficknefs of ftomach and vo- miting—hence the fenfation of cold and conftridtion upon the fecreting and excret- ing veffels. Such an irritation upon the nervous fyftem, with an interruption to the fecretions and excretions, are neceffarily followed with a quickened circulation. The irritating matter of itfelf is fufficient to 25 to produce this effect; but the fuppreflion of perforation, the confined ftate of the bowels, and efpecially the retention of bile of an uncommonly acrid quality, muft alfb unqueftionably have a fhare in adding to this irritation and increafed action. CURE. HAVING ftated the fymptoms and caufes of the difeafe, we are next to confider the indications of cure, which appear to be, Firft, To prevent the further operation of the poifon producing the difeafe. Secondly, To procure a fblution of the inflammatory ftage of the fever. Thirdly, To counteract the putrefcent ftate of the body, as defcribed in the fecond ftage of the difeafe. And, D Laflly, 26 Laftly, To reftore the tone of the fyftem when the preceding indications are ac- complished. Firft, To prevent the further operation of the poifon producing the difeafe. To this end it is neceftary that the patient be removed from the atmofphere in which he took the difeafe, and placed in a Situation where he may enjoy a pure, free air: all articles capable of conveying the contagion mould be immediately removed from the body, fuch as clothing, &c. in place of which there mould be clean dry clothing, bedding, &c. Secondly, To procure a folution of the inflammatory ftage of thefever. It isnecef- fary to moderate the increafed action c-f the fyftem, and to remove, as far as poftible, every other fource of irritation. To evacu- ate immediately the poifon from the body, when once introduced, is as impoffible as to eradicate the matter of fmall-pox, meafles, or 27 or any other difeafe produced by fpecific con- tagion. In the treatment of yellow fever, as in that of the fmall-pox, if the analogy be a juft one, the bufinefs of the phyncian appears to be, to moderate the action of the poifon producing the difeafe, and, at the fame time, to remove every circumftance which can aggravate its operation upon the body. With a view to diminifh the increafed ac- tion of the fyftem, evacuations of different kinds were employed. Some practitioners had recourfe to blood-letting, followed by purging and fweatlng ; and others trufted entirely to the two latter. With refpect to blood-letting, my obfervation has been, that the promifcuous ufe of the lancet was very injurious and unfuccefsful. In the New-York hofpital it was frequently em- ployed, but in the majority of cafes the difeafe terminated fatally; yet, in fome few inftances, where the conftitution was uncommonly plethoric, and the determina- tion 28 tion to the head more violent than ufual, I have obferved good effects follow the lofs of a moderate quantity of blood. But, gene- rally fpeaking, blood-letting was attended with pernicious confequences. The fame has been confirmed by the obfervations of feveral of our moft resectable practition- ers. The more common and fuccefsful practice was, i. To procure a free evacuation from the bowels. The purgative medicines which were employed Were many and va- rious. By fome, calomel and jalap were prefcribed, and, in the beginning of the dif- eafe , with good effect. Others adminiftered a mixture of rhubarb and magnefia with cinnamon or mint-water. This alfo anfwer- ed well in many cafes, where the ftomach was irritable, and rejected the former me- dicines. But the medicine which was the moft fuccefsful, and acquired the greateft reputation, was the Glauber's falts, given in 29 in warm diluting drinks. The dofe was. generally from one to two ounces, diffolved in a pint of gruel made of Indian meal, and given in divided dofes until it operated freely; the patient at the fame time drink- ing freely of gruel or chicken water, to promote its operation. Salts, exhibited in this form, for the moft part fat well on the ftomach: they were expeditious in their operation, and, in many inftances, pofTeffed the additional advantage of relaxing the fkin and inducing perfpiration, efpecially where the patient drank largely during their operation. But when the ftomach was fo much irritated as immediately, to re- ject every thing taken into it, recourfe was then had to glyfters, compofed of vinegar and water, quickened by the addition of a fmall quantity of molaffes : thefe fcarcely ever failed to produce the intended effect. 2. Having procured copious and free evacuations from the bowels, the next ob- jea 3° ject appeared to be to relax the furface of the body, and induce free perfpiration. In fome inftances this falutary difcharge came on immediately after the bowels had been emptied, and was readily continued by tak- ing plentifully of warm drinks; but, for the moft part the febrile fymptoms continued violent, the fkin remained hot and dry, the pains ftill diftrening, and it became necef- fary to have recourfe to more active means to induce fweatlng. For this purpofe many fudorific medicines were employed. Some pradtitioners ufed emetics, and others fmall dofes of James's powders, and the different preparations of antimony. Vomiting, in this difeafe, I have generally obferved to be of dangerous tendency. It may, perhaps, not be amifs, when the difeafe nrftdifcovers itfelf, and is attended with much ficknefs and vomiting, to empty the ftomach freely, by means of an infufion of chamomile flowers: but the exhibition cybernetics I con- fider 3* fider to be highly dangerous and improper. I believe I have feen fome cafes in which the death of the patients could be afcribed to no other caufe than the inceftant vomit- ing brought on by an emetic given in the commencement of the difeafe. But the moft certain and fuccefsful means were, to wafh the whole furface of the body with cold vinegar and water, and immediately after covering the patient with blankets— to adminifter fuch medicines as poffefs the effect of bringing on fweating: of thefe the fpiritus mindereri and faline draughts of Riverius fucceeded well, more efpecially if the warm drinks were continued, fuch as the infufion of fnake-root, gruel, toaft water, tamarind water, lemonade, &c. Thefe were much aided by applying to the feet of the patient a warm brick, fteeped in vinegar and covered in a flannel cloth wet with vinegar or fpirits: the fteam, thus emitted and diffufed through the bed, had a won- 32 a wonderful effect in foftening the fkin and exciting fweat, efpecially where the cold wafhing had been previoufly employed.— Some practitioners have preferred the prac- tice of plunging the patient feveral times in a cold bath, and violently darning the body with cold water. But limply wafh- ing the patient with cloths dipped in cold vinegar and water, was found much pre- ferable to immerfion, both becaufe it more effectually diminifhed the heat of the fyf- tem, and was lefs fatiguing to the patient. Experiments have proved, that repeatedly wiping and wafhing with water, in the or- dinary way in which the operation is per- formed, diminifhes the heat feven or eight degrees more than fimple immerfion, or dafhing it over the body with pails. The practice of cold bathing in fevers of this type is not a new one, but was very commonly employed at Breflaw, in Silefia; 33 Silefia;* and of late years has been very fuccefsfully applied in the Weft-Indies,f as well as in different parts of Europe, where difeafes of this type prevail. Professor Gregory, of Edinburgh, and Doctor Currie, an eminent phyfician at Liverpool, have alfo prefcribed it with great advantage in the low typhus fevers of thofe cities. But its great fuccefs in the New-York hofpital, as employed by Doctor Samuel Bard, and in the private practice of my brother, have fully con- vinced me of the propriety of its^ufe. It is alfo proper to remark, that where the phyfician was not called to the patient in the firft ftage of the difeafe, and putrid fymptoms had appeared, and the patient had become much debilitated, the cold bath was injurious; and from the abufe of cold bathing, by employing it in the laft ftage E of * SeeDE Ha en's Ratio Medendi. $ Doftor Jackson on the Diseases of Jamaica. 34 of the difeafe, it has fallen into difrepute with fome practitioners. But as the abufe of a thing is no argument againft its ufe, I repeat my obfervation, that in the firft or inflammatory ftage of the difeafe, it was one of the moft ufeful remedies that was employed. When the cold bath had been thus made ufe of, and immediately after followed by the fpiritus mindereri or faline mixture, with plentiful dilution, it rarely failed to produce fweating in the courfe of fifteen minutes; and when once induced, it was eafily continued by the re- petition of the fudorific medicines and drinks, until a folution of the fever was obtained. In fome inftances where the patient refufed his drink and medicines, or, from the careleffnefs of the nurfes, they had not been fupplied as frequently as was proper, and the perfpiration had been fup- preffed, it became neceffary to repeat the cold bathing, which feldom failed to pro- cure 35 cure a return of the fweating. By the con- tinuance of this difcharge an abatement of all the fymptoms took place: it appeared to operate as a fpecific in the difeafe; the pulfe in a fhort time became moderate; the heat of the fkin diminifhed; the pain in the head and back, before- fo diftreffing, was alfo relieved; the ficknefs of ftomach and vomiting were removed; and, in the courfe of two or three days from the attack, the patient had little elfe to contend with but mere debility. Thirdly, In thofe cafes where the phyfi- cian was not called in the early ftage of the difeafe, where the bowels were not freely emptied, and perfpiration had remained fuppreffed, with a continuance of the fever, a more diftreffing train of fymptoms appeared, as defcribed in the fecond ftage of the difeafe, and required a different mode of practice: few patients, however, reco- vered from this ftage of the difeafe. Where 36 Where the ftomach was much difturb- ed with ficknefs and vomiting, which was one of the moft dangerous fymptoms, the faline draught was exhibited in the effer- vefcing ftate; and, in fome inftances, yeafl was employed with advantage, followed with nourifliing antifeptic drinks, as milk- punch, lemonade, porter diluted with wa- ter, &c. Snake-root-tea, where it fat well upon the ftomach, appeared to poffefs moft advantages \\\ this ftage of the difeafe, in- afmuch as it procured a free determination to the furface of the body, independent of its antifeptic properties; but where the fto- mach rejected every thing, recourfe was had to blifters, applied immediately over the region of the ftomach, and, in fome in- ftances, with the moft happy effects. Spi- rituous fomentations, applied to the lower extremities, efpecially where they were followed with perfpiration, in many in- ftances gave relief to the ftomach, and rendered it more retentive. Where 37 Where the bowels were in a coftive ftate, purgative medicines were given to the patient; at the fame time injections were employed, compofed of vinegar and water, with the addition of molaffes, and repeated every hour until they produced the defired effect. When the functions of the brain and nervous fyftem were much difturbed, as indicated by delirium, fubfultus tendinum, reftlefmefs, &c. finapifms, compofed of rye-meal, vinegar, and muftard, applied to the foles of the feet, blifters to the an- kles, to the infide of the thighs, and to the head, in fome few inftances procured re- lief.—In this ftage of the difeafe fome prac- titioners had recourfe to bark, wine, and the tonic treatment in general; but the plan I have obferved to be attended with moft fuccefs in addition to the medicines and treatment related above, was to fup- port the patient's ftrength, by the mildeft nourifh- 3« nourishment, and fuch as was the leaft ftimulating to the fyftem, viz. foups, com- pofed of a great proportion of vegetables, fago, milk-punch, with a fmall quantity of fpirits or brandy, merely fufEcient to render it grateful to the ftomach. In ad- dition to this mode of treatment, great at- tention was paid to the removal of every external fource of irritation, by frequent changes of linen and bedding, by frequent- ly wiping the body with cloths dipped in fpirits or vinegar, removing every offen- five matter from the room, and by correct- ing the atmofphere around him, by the explofion of gun-powder, fprinkling vine- gar over his bed, and through the room, and procuring a free circulation of frefh air. Fourthly, Having, by the means above enumerated, procured an entire folution of the fever, it remains to reftore the ftrength of the fyftem. In the ftage of the difeafe alluded 39 alluded to under the laft indication, while a degree of fever remained, an active tonic or ftimulating plan of treatment was found injurious; but, when a perfect folution of the difeafe was obtained, and the patient la- boured under mere debility of body, tfn3 mode of treatment was not only admiffible* but, in many inftances, the patient's ftrength.was fo completely exhaufted, that the moft reftorative medicines and diet be- came neceffary. In this ftate of body re- courfe was had to the bark, ferpentaria, the different bitters, mineral acids, and theufual medicines prefcribed with this intention, viz.wine, porter, milk-punch, &c. The diet employed with moft advantage confifted chiefly of vegetables: fago, tapioca, indian and oat-meal gruel, rendered palatable by the addition of wine, were, for the moft part, grateful to the patients—were fiiffi- ciently nourishing, and, being of a more antifeptic quality, were found lefs hazard- ous 40 ous than the ufe of animal food. When animal food was' employed, it was in the form of foups, with a large proportion of vegetables, ^or calves-feet jelly, with the addition of wine: in this form it became lefs exceptionable. . But folid animal food was very commonly injurious, retarding the recovery of the patient, and in many inftances producing a return of the difeafe; it was therefore very generally prohibited during the convalefcent ftate of the patient, The drinks employed with moft benefit, and which were found moft grateful to the Sick, were wine and water, milk- punch, porter, &c* Such was the difeafe, and fuch the mode of treatment, as far as has come within my knowledge. THE END. Beek -taken apart. Leaves deaoldlfled vlth magnaslum bloarbenate* Resetted en linen oords. New all-rag end paper signatures* Unbleaohed linen hinges* Rebound In quarter unbleaohed linen* Fabrlane paper sides* Carolyn Herten & Associates 430 West 22nd Street New York, Nov Tork 10011 February, 1977 ,-• HORTi