siffc'KrtSiriiA'joXs;::".."' •: ■'■ ■ic'i.ift.'jeiiK'f'MivV •■ -••'l-tot'-W-!'; ".•", ■ ' *>-,£.*.? A v! ■■"•■ fi^iViv• ,•,.■ •■.•;-;"---v..-.;.iiV;''^.'<--: •A-!#l$ 'iST'iS''*-' ' '•''.■■'F:"'' ■■\!&l!v;,"1'.:'' :i /'".titx. J* .v'-1.'. ';:■ -':■•' ■■■:;-::>\iv'.•■.•;':+•■• ■ ■.. ■■?■'*% ':'*:'$%s NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service ~v. **&"*>-'%r ^-z. '/ V 0 ^? s^-^ "TrvHE obfervations contained in the following pages, were made during the time that I lived in Jamaica, or while I attended fome part of the army in America. The materials were collected between the years 1774 and 1782; and the prefent performance would have been offered to the public before this time, had I fooner found leifure to at- tend to the bufinefs of publication. The i'nfufficiency of Dr. Hillary's work, the moil efleemed book on the difeafes of the Welt Indies, and the only one with vi PREFACE. which I was acquainted while I remained in that country, furnilhed me with a motive for the undertaking ; a motive, which may be thought, perhaps, no longer to exift, as two treatifes have been publilhed lately by Dr. Hunter and Dr. Mofeley, exprefsly on the difeafes of which I have written. I might remark, that the prefent attempt, fuch as it is, was nearly completed before the trea- tifes to which I allude came to my hands. The views which they afford of fevers, as they differ from each other, fo they likewife differ from thofe which I have ventured to advance. I have weighed their merits maturely, and cannot fay that I difcover any information, which gives me caufe to change thofe opinions which I had formed, or which renders the publication of the prefent work PREFACE. vii unneceffary. I may obferve, that Dr. Hunter details, with candour and per- fpicuity, the mode of practice, which was followed by the molt refpectable medical people of Jamaica, at the time that I lived in the ifland. He perhaps prefcribes the bark in larger quantities, than was then cuftomary; but I do not perceive any thing in the plan of treat- ment effentially new; neither will Dr. Mofeley, though he purfues innovation with great eagernefs, be better able to eftablifh his claim to original difcove- ries. The plentiful and long continued purging, on which he places a confider- able (hare of his merit, has been a fa- vourite practice with numbers for many years paft; and the free ufe of the lancet, which he recommends fo much in fevers, was employed in feveral dinricls of viii PREFACE. Jamaica, before this author's name was known. Dr. Spence, a practitioner of fame eminence at Lucea, in the Weftern extremity of the ifland, wrote a pam- phlet (I believe in the year 1776) with a view to enforce its fafety and utility, in promoting the cure of the general clafs of febrife difeafes. The publica- tion was well received, and ferved to re- move the dread of the lancet, which fome people till then had falfely entertained. I have thus explained the motive v/hich induced me to write ; and I leave it to people of experience to judge of the manner in which I have executed the talk. I fhall only obferve, that, when I firft Intended to prepare my obferva- tions for the infpection of the public, I had no other defign than to mention PREFACE. ix ftich circumftances in the hiftory and cure of fevers, as did not appear to be generally known. Having fpent the earlier part of my life in fituations, which did not admit of a continued plan of ffudy, I had not till lately much ac- quaintance with the opinions of medical writers. About four years ago, when 1 found a fettled abode, I began occa- fionally to look into the works of the ancient phyficians. In examining Hip- pocrates, I difcovered fuch a fimilarity in the fevers of the Archipelago, with thofe of Jamaica, that I fufpended my de'fign of publifhing, till I fhould have given that author's writings a careful perufal. I foon was convinced that many obfervations, which I had confi- dered as my own, were actually known to this father of phyfic ; and though I x PREFACE. was probably difappointed in being an- ticipated in offering fomething new to the public, I was ftill gratified by the cpincidence of remark, that gave me a confidence in my accuracy which other- wife I durft not have afiumed. After I had carefully perufed the writings of Hippocrates, I confulted and compared fuch other of the Greek phyficians, as I was able to procure. I even defcended with a fimilar examination to the pre- fent times ; but as my collection of me- dical writers, particularly • of modern ones, is fmall, I have probably omitted fome who ought to have been men- tioned, or perhaps advanced obferva- tions as my own, which in reality be- long to others. If I have done fo, I muft be allowed to fay, that I have done it without confcioufnefs. PREFACE. xi It may appear, perhaps, that I have treated the opinions of great names with too little refpect; but if facts have at any time occurred to me, which contradict eftablilhed theories, I fhould hope that thefe facts will be examined before they are rejected. No medical authority ought to prevail over the cer- tain evidence of truth. I am not con- fcious of having mifreprefented, for the fake of a theory, the minuteft circum- ftance of what I have actually feen ;— if I have been miftaken in any inftance in forming conclufions, I fhall receive the correction of my inaccuracies with gratitude. CHAP. I. OF THE GENERAL CHARACTER OF THE REMIT- TING FEVER OF JAMAICA. AS it is perfectly well known, that fevers, which are eflentially in themftlves the fame difeafe, vary in their appearances, from difference of climate and feafon, it would be very fuperfluous to attempt any proof of what is fo generally acknowledged. Even Hippocrates, who lived more ihan two thoufand years ago, does not feem to have been unacquainted with this fact:. This induftrious phyfician, as we learn from many paflages in his works, not only vifited the various iflands in the j*Egean Sea; but travelled like- wife into various parts of the adjacent continents. The motive of his journevs, we are taught to believe, was principally to obferve the different fituation of places, and to mark their correfponding difeafes. He has defcribed very fully, in a curious and ufeful treatife, the effects of air and local fituation on the human frame; and in the hiftory of fevers, related in the books of Epidemics, has fddom forgotten to mention, not only the general conftitution of the feafons with re- fpec~l to difeafes; but likewife the nature of\the cli- mate, where his obfervations were more particularly made. The fpcciesof fevers, it is true, that are found in the writings of Hippocrates are extremely multi- plied; yet this author feems ftill to have been clearly of opinion, that difeafes, which are eflentially the fame, afllime, in fome rcfpccts, a different appearance in the ifland of Thafus, and at Abdera, on the contiguous 2 REMITTING FEVER coaft of Thrace. Obfervations to the fame effect- have been made by many others in different parts of the world; nor is the fact capable of being better il- luftrated in any country than in Jamaica; where a very fmall change of place, or the ordinary revolution of feaibns, are often obferved to influence in a high degree, the appearances of the common endemic of that ifland. But this obfervation,—that local fitua- tion and the change of feafons, are the caufe of varie- ties in the appearances of the fame difeafe, has been fo long known, that it is almoft unneceflary to men- tion it; nor would it have been repeated noW; unlefs to obviate any objections which might be made to the hiftory, that is given in the following pages, fhould it not be found exactly to correfpond, with that which has been obferved by others, who have lived in the other iflands of the Weft Indies, or in other parts of Jamaica; or perhaps even in the fame part of Jamaica, at a different period of time. It is prefumed, indeed, that the C\me fundamental diftinctions of fever obtain in every ifland within the tropics; yet the defcription that is given in this place, (it may not be unneceflary to mention), is affirmed to be ftrictly exact, only in the diftrict about Savanna la Mar, and that only for a fhort fpace of time: viz. from the year 1774- to the year 1778. The fever, that chiefly prevailed at Savanna la Mar during the period mentioned above, was ufually mild in its fymptoms, and more regularly remitting in its form than I underftood the endemic difeafe to be in moft other parts of the ifland. To what cir- cumftances in the local fituation this might be owin^, I do not pretend to determine. Savanna la Mar Is fituated clofe by the fea: its particular fcite, and the furrounding country to the diftance of feveral miles is perfectly level; whilft in confequence of its being open to the Tea on the eaft, it is vilited early, and con- ftantly by a folutary and refreshing breeze. There OF JAMAICA. " "3 is a fmall rivulet, indeed, which, lofing ltfelf almrtft entirely in mud, forms a morafs that partly furrounds it on the north. From vicinity to this morafs'the fitua- tion of Savanna la Mar has been fufpected to be un- healthy; but it is not fo in fact. The fea at high wa- ter, particularly in the fpring tides, overflowing the fwampy ground, contributes in a great meafure, pre- haps, to diminifli the more ufual noxious qualities of the marfh exhalation. The opinion of many eminent writers, however, is not altogether favourable to this idea; but there feems to be reafon to doubt, whether the opinion formed by thofe writers in this inftance, is die refult of accurate and careful obfervation; or if it is merely a fuggeftion of theory. I am inclined to the latter way of tlfinking, as I have never found the neighbourhood of./Salt-marihes, in the different parts of America that I -have had the opportunity of vifiting, * lefs healthful thai/i the reft of the country:—on the contrary, they wjbre frequently more fo. Before proceeding to a particular defcription of the fever, that chiefly prcrailed in the diftrict of Savanna la Mar, it may not be fuperfluous to give the outline of its character, that we may be the better enabled to trace its refemblance with the fevers of other climate?, and to determine its place in the general clafs of fe- brile difeafes. The common fever of Savanna la Mar, which, as I mentioned before, was ufually mild in its fymptoms, and regular in its form, feems to be properly ranked with thofe, that ftrictly fpeaking are called remitting. It is difficult to fix the boun- daries between remittents and intermittents, if a fixed boundary actually exifts. The paroxyfms of the fever of Jamaica are obferved, in many inftances, to termi- nate in more perfect remiflions than the paroxyfms of the endemic of North America, which is known to be fundamentally an intermitting difeafe. Hence au- thors generally are of opinion, that all the difference which appeaxs to take place in thofc fevers, depends B 2 4 REMITTING FEVER. merely on an accidental caufe: viz. on the greater or lefs beat of the climate. I fhall not be pofitive that it is not fo; yet I cannot help remarking that certain appearances incline me to be of opinion, that there fubfifts, between the endemic of Jamaica and the en- demic of North America, a difference, in fome degree, fixed and effential. I cannot pretend to afcertain the difference precifely; or to offer a conjecture about the modification of the morbid caufe in which it con- iifts; yet the following circumftances give reafon to, believe, that to a certain degree at leaft it actually takes place. The common fever of Jamaica, for in- flance, was not only difpofed to terminate of its own accord; but it was difpofed to terminate on certain critical days, often at an early period, and by figns of crifis too clear to be miftaken; neither did the Peru- vian bark, in the manner at leaft in which it was ma« naged, ever cut fhort its courfe with certainty. The endemic of America on the contrary often lafted long. It frequently, indeed, changed to another difeafe after a length of time; but no period could be affigned for its natural termination. The figns of crifis, it may likewife be remarked were fo obfcure as fcarcely to be diftinguifhcd with the clofeft attention; at leaft for my own part I will own, that after an experience of feveral years, and the greateft care in obferving the minuteft circumftances, I never yet was able to fay with confidence, that the endemic of America, parti- cularly in the northern provinces, was gone not to re- turn again, till the hour of its return was paft: nei- ther did the Peruvian bark, though its effects were fo equivocal in the fever of Jamaica, fcarcely ever fail of flopping the progrefs of this difeafe. To which we may add, that the complaint, which ftrictly fpeaking is called the intermittent, or ague and fever, can fcarcely be faid to belong to Jamaica; at leaft it was not known at Savanna la Mar. In the courfe of four years I did not once obferve it; and thofe, who had lived much longer at this place, affured 0* JAMAICA. 5 me they had never feen an inftance of it; unlefs in perfons who were newly arrived from aguifh coun- tries. This is a fact of fome importance, as it fhevi s to us, that though the proper intermittent is not the endemic difeafe of the country it is ftill capable of ex- ifting in the climate:—no weak argument, that, the two difeafes of which we have been fpeaking, actually do poffefs fome difference in the modification of the general caufe, though'we are unable to define'the pre- cife bounds and limits of it. The circumftances which I have mentioned might incline us to be of opinion, that the fever of Jamaica, and the common endemic of America are not exactly the fame difeafe; that is, that though they depend on the fame general caufe; yet that this caufe undergoes fome fixed and permanent modification in thofe different climates, fo that aneffential difference actually arife?. But though this really appears to be the cafe; yet I fnuft acknowledge, that the reigning epidemic of the (buthern provinces of America, often lofes its diftinc- tive marks of intermiflion in the hot months of fum- mer; whilft it approaches, in other refpects, fo near fo the fever of Jamaica, as to be diftinguifhed from it with difficulty. This was particularly the cafe atEben- ezer in.Georgia, in the year 1779, during the months of June and July. A cold fit was feldom obferved in this place; unlefs perhaps in the firft attack; lownefs, languor, head-ach, pain of the back and other difagree- able feelings remained even in the moft perfect remif- fions: the difeafe was likewife much difpofed to termi- nate of its own accord: on the ufual critical days, fre- quently by figns of crifis, that were far from being obfcure: yet though thefe refemblanees were (o very ftriking, the fever of Ebenezer was perfectly under the controul of Peruvian bark, which was not exactly the cafe with that of Jamaica. I muft remark, how- ever, that bark was ufed with a freedom in America, that I never thought of attempting in the Weft Indies. B 3 6 REMITTING FEVER, &C. But though it ftill may be thought doubtful by fome, whether the autumnal fever of aguifh countries, and the endemic fever of Jamaica are character!ftically different, or effentially the fame difeafe; yet it is hot fo difficult to trace a fpecific refemblance, between this fever of the Weft Indies, and the prevailing en- demic of the iEgean Sea. The fever defcribed in the Epidemics of Hippocrates has every ftriking feature of the difeafe which is the fubjeft of the following treatife. The general character is the fame; the courfe and mode of termination are often alike. If the du- ration is fometimes different, it is probably much ow- ing to the more decifive practice of the moderns: for though it remains uncertain, whether a remedy has yet been difcovered, which abfblutely tuts fhortthe fe- ver of Jamaica in the midft of its courfe ; yet no doubt remains, that there are various modes of treatment, which may, and actually do render the ordinary changes of the critical day, decidedly critical. The fevers of the iEgean Sea, as defcribed by Hippocrates, and of Minorca, as defcribed by the accurate Cleghorn, bear the neareft refemblance to the endemic of Sa- vanna la Mar. The fevers of Italy, of different parts of the continent of Afia, as defcribed by various wri- ters, as well as the fever of America, of which I have had perfonal experience, however obfcure their remit- lions, feem rather to be degenerated intermittents, than the difeafe defcribed in the following pages. But that I may not be thought to infift too much on this opinion, which few, perhaps, may confider as of much confequenceT I fhall relate the hiftory of the fever of Savanna la Mar, as accurately as I can, leaving it to others to determine, whether it mould be confidered as an intermittent degenerated into a remitting form» in confequence of the greater heat of the climate, or allowed to poffefs Something character! ft ic in its own nature. [ 7 ] CHAP. II. OF THE DIFFERENT TYPES OF PERIODICAL FE- VERS. A Knowledge of the types and periods of fevers-, though {o neceflary ,to be well underftood by thofe who pretend to cure the difeafe, has unfortu- nately been little attended to by the practitioners of Jamaica. In that country, I met with fome who were able to foretel the returns of the Angle tertian; but I met with none, and I have good reafon to be- lieve that there actually were few, who troubled them- felves about forms of greater complication. There were many, on the contrary, whoT blinded by theories of accumulated bile, ridiculed altogether the idea of this ftated regularity in the movements of nature. To enter into a difpute with fuch would be labour loft. The exiftence of a regular type in the fevers of the Weft Indies does not admit of a doubt, yet we muft not forget to mention, that thofe types are traced with greater difficulty in that country, where remiffions are obfcure, than in others, where every paroxyfm is uihered in by a cold fit. In Jamaica it is impoffible to follow them without the moft careful attention, or perhaps to attain a clear and fyftematic knowledge of them, without writing down and analyzing many of thofe cafes which occur in practice. I remember to have been imprefled with the idea, at a very early pe- riod, that one obfervation made by myfclf would in reality be more ufeful than twenty equally important in themfelves, which I only retained in my memory from reading. Convinced of this truth I ceafed to look for information in books, from the time that I arrived in the Weft Indies; but, trufting wholly to 8 types ete my own experience, wrote down minutely, in the pre- fence of the fick, the hiftory and cure of the moft im- portant cafes of fever that occured to me. At ftated times I reviewed that which I had done, and arranged under proper heads the moft ftriking circumftances, that I found recorded in my notes. Among other un- expected appearances I obferved a regularity and order in the types of fevers, of which at firft I had no idea. But though the laws of nature appeared to be fixed and ftable, in producing this varied but ftated regu- larity of form; yet a knowledge of thofe laws was not eafily attained. Two years were fpent, and not fewer than a hundred cafes were analyzed, before my views of the fubject were in any degree accurate. The la- bour, perhaps, was fuperfluous; there being many au- thors who have defcribed minutely every variety and every combination of type that has ever been obferved to take place. But as I had little knowledge of the writings of others at this period, I 'h -.11 content my- fclf in the firft place with relatmg the hiftory of types as they occurred to my own obfervation; at the fame time that I fhall not omit to take notice occaiionaliy of the more conftant peculiarities, which are found in authors of credit, who have praifLifiid in different countries. The influence of climate I may obferve is of confiderable effect in modifying the various formsj "The fingle tertian, the period cf which is forty- eight hours, is a form of fever that occurred frequently in Jamaic?, particularly in the dry arid healthy feafon. Its courfe was eafily traced, as the remiilions were often diftinct, and theaccefllonsfometimes diftinguifh- ed by a flight horror or fhivering. But though the above-mentioned type was by no means of rare occurrence at Savanna la Mar; yet the double tertian, with fimilar paroxyfms on r.!tcrr.ai.e days, was ftill more common, particularly in the rainy and fickly months. This form of fever, which feemed to confift of two fingle tertians, that ran a feparate PERIODICAL FEVERS. 9 and independent courfe, began ufually in the morning. Its hour of invafion was from eight to ten; and its acceffion was generally diftinguifhed by a cold fit. The paroxyfm, which for the moft part was regularly formed, declined after a continuance of eight or ten hours; -and the patient remained free from fever, not only during the night, but during the following day, till four in the afternoon, or later. A feverifh indif- pofition ufually came on then, which continued the whole or the greateft part of the night. A remilfion took place ; but it was foon fucceeded by a paroxyfm fimilar in its fymptoms, and manner of attack, to the paroxyfm of the firft day. This having declined to- wards evening, the patient, as formerly, was free from fever during the night and the day following. At the ufual hour, however, or more generally before it, a paroxyfm more diftinctly formed in all its parts, and more violent in degree, than the preceding one which correfponded with it, returned, and continued till morning. It fubfided; and was foon fucceeded by the paroxyfm of the fifth day, which declined, as formerly, after the ufual duration. Such was the general courfe and progrefs of the difeafe.—The fever of the odd day, which began forthe moft part in the morning, ufually returned later and later, and with decreafing violence every fucceeding paroxyfm; whilft the fever of the even day, which generally began in the afternoon or evening, as ufually returned earlier, and when this was the cafe, frequently encreafed in force. The fe- ver which came on in the morning generally began the difeafe. It was for the moft part a fever of com- plete and regular paroxyfms from the firft attack. The fever of the evening, on the contrary, was little more than an indifpofition in its beginning; nor was its time of appearing at all certain. It often was not perceived till the evening of the fourth day; fome- timcs not till later, neither was its continuance of a fixed duration. Sometimes it went on after the fever *lo TYPES OF of the morning had ceafcd; and in other cafes -it ter- minated, while the other purfued an uninterrupted courfe. The type, which was fo frequent in Thafus, and the other iflands of the ^Egean Sea, feems to be a fpe- ciesof the double tertian. Mention is made frequently of fuch a form in the Epidemics of Hippocrates; yet the double tertian of Hippocrates is directly oppofite, in fome refpects, to the type which I have juft now defcribed.— The evening fever generally began the difeafe in thofe iflands: hence the great exacerbations, and confequently the crifis were frequently on the even days. Such alfo appears to have been fome-, times the cafe in Minorca: yet Cleghorn acknow- ledges, that a type, fimilar to that which I have de- fcribed as^prevailing fo commonly at Savanna la Mar, was by much the moft frequent form of the above- mentioned ifland. It was alfo, I may add, frequent in the fouthern provinces ofNorlh America, particu- larly in the hot months of fummer and autumn. A quotidian type has been defcribed by almoft every author, who has written on thefubject of intermitting and remitting fevers: neither can it be denied, that forms of difeafe frequently occur, where the paroxyfm returns every day at the fame hour, with fymptoms fo nearly alike, that an ordinary obferver can perceive no difference. Yet Mr. Senac, an author of confi- derable eminence, boldly maintains, that a real quo- tidian type does not exift in nature. The queftion, perhaps, is not eafily determined. I can only men- tion from my own experience, that I have frequently feen fevers with quotidian exacerbations of fuch a kind, that there was no perceivable difference between them, either in fymptoms or in manner of attache; yet I muft like wife own, that thefe exacerbations were generally in the evenings; and that the difeafe was not in every refpect of a diftinet intermitting form. I have now mentioned thofe types that are moft PERIODICAL FEVERS. ir frequently met with in the fevers of Jamaica; yet be- fides thefe, there now and then occur others of more complicated and perplexing forms. Thus, I have fometimes feen at Savanna la Mar, a fever, which feemed to be compounded of a fingle tertian with a quotidian. In the fpace of forty-eight hours there were three feparate exacerbations, two of which were exactly alike, that it was impoflible to perceive a dif- ference; whilft the whole three followed each other in fuch an order of time, that to a fuperficial obfer- ver, there appeared to be only one long paroxyfm of thirty-fix hours or more. An example will make it more plain. On Monday, for inftance, the pa- roxyfm of a fever was obferved to begin about nine in the morning, preceded by fome degree of coldnefs arid fhivering. This paroxyfm was ufually violent in its firft attack : But declined gradually towards evening; though before it was gone off totally, another exacerbation commenced, which continued the whole of the night. This likewife abated on Tuefday morning; and the patient remained ap- parently free from fever till five in the afternoon or later. A paroxyfm then made its appearance, fimilar to the paroxyfm of the preceding evening. It ran over a courfe of fimilar duration, and fcarcely had abated on Wednefday morning, when a paroxyfm re- fembling that of Monday fucceeded it; which, as for- merly, declining towards evening, was foon followed by an exacerbation, that lafted till the morning of Thurfday. On Thurfday, as on Tuefday, there was no feyer till late in the afternoon; when the evening exacerbation returning at the ufual hour, proceeded in its ufual courfe. The tertian type, fimple, or varioufly compounded, is the form of fever, which prevails moft univerfally in all climates. The quartan in thofe countries were I have lived was rare; and the exiftence of a real quo- tidian, perhaps, is doubtful. To that compound, form, 19 TYPES OF which I have juft now defcribed, I ftiould be inclined to give the name of Semitercuin. It is exprefsly the difeafe, which I now find has been defcribed under this name by Hoffman ; but it is more difficult to de- termine exactly, if it is the Hemitritjeus of the an- cients. The Hemitritaean form is frequently men- tioned by Hippocrates; but his definition is too lo.fe to enable us to judj;e precifely of its nature. It is in faft impoffible to fay with certainty, whether it is to a type fimilar to that which I have defcribed, or to the extended and fubintrant paroxyfms of the double ter- tian, that he has applied the name. This laft, indeed, feems to have been the idea of many of the ancients, particularly of Celfus and Agathinus.—The phyfi- cians of the earlier ages, were lefs curious in minute diftinctions than their followers ; and probably applied the name of Hemitritaeus to thofe fevers, the pa- roxyfms of which were fimply of unufual duration, no lefs than to thofe that were of a complicated or com- pound nature. This actually appears to have been the cafe for a great length of time; but at laft, and not long indeed before the days of Galen, the fophif- tical genius of the profeffors of medicine, which exert- ed itfdf chiefly in things of little importance, mul- tiplied the types of fevers to an endlefs variety, and attempted to eftablifh diftinctions which have no ex- iftence in reality. Galen, who is copious in moft things, has difcuflld very fully the fubject of types in general, and defcribed particularly the nature of the Scmteitian at great length. But whatever credit may be otherwife due to the obfervations of this il- luftnous writer, it is evident that the defcription, in the prefent inftance, is merely the refult of theory. He has attempted, indeed, to illuftrate his opinion by an example ; but the cafe he has furnifhed us with, is conftantly varying its hour of attack; and if ac- curately examined, appears rather to be a triple tertian, properly fo called, than the form of fever that PERIODICAL FEVERS. 13 1 have defcribed above. After the Greeks we may next take afhort view of the Arabian phyficians, who, as they borrowed much of their knowledge from the writings of Galen, likewif; adopted his idea of the compound nature of the Semitertian. Avicenna, the moft eminent among them, has defined this form of difeafe withagooddealof precifion; but v/e do not find that he has added any thing very material to the opi- nions of his predeceffors. Galen indeed, had difcuf- fed the fubject fo fully, that, though fucceeding wri- ters fometimes changed names, they do not. feem in reality to have furnifhed much new obfervation. As we defcend to lefs remote times, Hoffman and Cleg- horn are the moft accurate of the moderns, on this fubject, who have yet come to my hands. The for- mer defcribes under the name of Semitertian the ex- prefs form of difeafe, that I met with in Jamaica; the latter refers this title to the extended and fubintrant paroxyfms of the double tertian. It is with unwilling- nefs that I differ in opinion from Cleghorn, who has thrown more light on the hiftory of periodical fevers, than perhaps, all the writers of his time : yet I cannot help obferving, that I never recollect to have met with an original Semitertian, fuch as that he has de- fcribed in his well-known treatife. I muft own, in- deed, that I have feveral times feen the morning fever of the double tertian anticipate, fo as to be mixed with the decline of the paroxyfm of the preceding evening; thereby producing a form of difeafe, that could only be diftinguifhed, by the moft careful attention, from one long paroxyfm of thirty hours or more : yet this ' was in fact, only a degenerated double tertian, the paroxyfms of which became accidentally mixed with each other. The types which I have defcribed above are all the varietie?, that I obferved in the fevers of the Weft- Indies; yet more extenfive experience might haves perhaps, brought to my knowledge ftill further com- *4 TYPES OF plications : forbefides the forms mentioned in the pre* ceding pages, I had the opportunity, in the fouthern provinces of North America, to fee feveral inftances of the triple tertian, properly fo called. In forty- eight hours there were three feparate paroxyfms; all of them differing from each other, but correfponding with others that followed.—They were eafily traced, as the acceftions in that climate were ufually diftin- guifhed by a cold fit. In Jamaica, on the contrary, complications and irregularities were marked with difficulty. The anticipation of type among other things occafioned confiderable perplexity. Thus the fingle tertian, whofe regular period is forty-eight hours, often completed its revolutions in forty-fix. But though the paroxyfms frequently returned one hour or even two hours fooner than the ufual time; yet thefe anticipations were feldom longer, unlefs the difeafe was of a malignant nature, or difpofed to change to a continued form. In either of thefe cafes anticipa- tions of twelve or fourteen hours were not uncom- mon. Of the different forms of fever the anticipa- tions of the fingle tertian were the longeft and moft remarkable. It was obferved, indeed, that the even- ing paroxyfm of the double tertian very generally re- turned before the ufual hour; yet this return was fel- dom more than an hour at once; nor did the time of invafion in the whole courfe of the difeafe, fo far as I have obferved, ever go beyond twelve at noon. The morning paroxyfm, on the contrary, frequently poit- poned; yet I have likewife obferved it fometimes to anticipate fix or eight hours at one time; by which means, it encroached on the paroxyfm of the preceding evening, and produced the difeafe which Cleghorn has diftinguifhed by the name of Semitertian. The ob- fervation of this fact "does not feem to have efcaped Avicenna. There undoubtedly are accidental circumftances, which have-fome effect in accelerating or retarding PERIODICAL FEVERS. t$ Che return of the paroxyfm for a fhort fpace of time; yet it would appear, upon the whole, that the caufe, why a fever anticipates or poftpones, depends upon' fbmething that is peculiar to the particular nature of the difeafe. Thus, a fever, which once begins to an- ticipate, generally goes on anticipating through a great part of its courfe; a certain proportion being frequently preferved between the anticipations of the different paroxyfms. This was particularly the cafe in the fingle tertian of America. The paroxyfms of the fevers of that country often anticipated to a cer- tain point, by fhort anticipations, which bore a re- gular proportion to each other; whilft they were fome- times likewife obferved to poftpone,- in the fame gra- dual manner, towards the termination. This feldcm happened in the fevers of the Weft Indier. The anticipations I have mentioned often occafion perplexity in tracing the types of fevers; yet the com- plications which arife in the progrefs of the difeafey have a ftill more confiderable effect in embarrafling the appearances of regularity. Fevers which begin as fingle tertian, of en continue fuch through the whole of their courfe; yet it fometimes likewife hap- pens, that complicating fevers make their appearance on the even days for inftance, and continue longer,. ©r terminate fooner then the original complaint, in fuch manner, as if their exiftence no way depended on it. To be able to diftinguifh thofe complications from the anticipations of a fingle type is frequently veryufeful, and a knowledge of it may, in general, be attained with a good deal of certainty. Thus for inftance, if the difeafe is moderate in its fymptoms,anu without fufpicion of malignity, the appearance of a paroxyfm twelve or fourteen hours before the ufual time, efpecially if there is no material difference in the r,r.ture of the fymptomsr gives reafon to fufpect that the premature return is in reality the complication of another fever. On the contrary, where the difeafe C 2 Ifj TYPES OF has betrayed figns of malignity, or where the fymp- toms differ from thofe of the former paroxyfms only in a greater degree of violence, there is then reafon to apprehend that this appearance is only an anticipa- tion. On the fubject of complication of type, fome curious obfervations may be found in the writings of Galen and Avicenna. The opinions of thofe au- thors, indeed, are often mixed with whimfical theo- ries ; yet in many refpects they are fundamentally true and highly interefting. It would be a matter of fome utility could we learn to foretel, from the nature of the types, the accidents that are likely to happen in the progrefs of the difeafe, or to form a probable conjecture of the event. Some- thing certainly may be gained if we obferre with at- tention. Thus I may rermrk, that I never found an- ticipations of one hour or even two to be of much confequence in the fevers of Jamaica, particularly ff they happened at an early period; yet if they were longer, or did not happen till after a long continu- ance of the difeafe, they often indicated an approach- ing crifis. On the contrary, where the paroxyfm an- ticipated twelve or fourteen hours at one time, there was always fufpicion of danger, at whatever period this might happen. It either indicated danger and malignity, or a difpofition in the fever to change to a continued form. Anticipating fevers were likewife obferved to be more difpofed to terminate of them- f.lves, and likewife to terminate more fpeedily, than thofe which fteadily preferved the fame hour of re- turn. This feems to have been known to the an- cients.—But farther, as anticipating types are gene- rally a fign of increafing violence, though of a more fpeedy termination ; fo the poftponing of the pa- roxyfm, has ufually been allowed to indicate a dife. f-, whofe violence has begun to decline. Such is the common obfervation; nor have I ever found it to be •therwife; unlefs in fome cafes of weaknefs and im- PERIODICAL FEVERS. 17 paired fenftbility, where the fatal paroxyfm did not come on till after the ufual hour of attack. I am afraid I may appear to many as unnecefl'arily minute, on a fubject, which is not in general confi- dered as of much importance; yet ftill I cannot for- hear to mention fome circumftances of connexion,. between the hour of invafion and the future type of the fever, which appear to be not only curious, but ufeful; and which, fo far as I know, have not been taken notice of by any preceding writer. Galen, it is true, boafts the knowledge of foretelling, from the appearance of the firft paroxyfm, the nature of the fu- ture type of the difeafe ; yet the hour of invafion is not included among the number of thofe figns, from which he has drawn his information. The rules, in- deed, which he has left us are not altogether without foundation; yet they are by no means to be depended on alone. They have, in fact, arifenfrom theories of bile and phlegm, rather than from accurate and careful obfervation. There is not, perhaps, any one crite- rion on this fubjuct that applies equally in every cli- mate. Thofe rules, which I thought I had difco- vered, are only local. They varied in the different parts of Jamaica, and in moft parts of America did not apply in any degree. Having adopted, on my arrival in the Weft Indies, the method of writing. down and analyzing fuch cafes of fever as came un- der my care, the difference of hour, at which fevers of a different type ufually commenced, ftruck me as a matter of no fmall curiofity. The fingle tertian,. for inftance, was conftantly remarked to begin in the forenoon, ufually between the hours of eight and eleven ; whilft thofe forms of difeafe, that were evi- dently quotidian, or ftill more continued as con- ftantly began in the evening, generally from four to eight. This feemed to be a. fixed diftinition; it is an important one; and fo far there was no ambiguity:. bnt it was extremely difficult, perhaps impoffible, ta- C3 lS TYPES OP difcover figns at an early period, which were capable of diftinguifhing the fever, which continued fimpie in its form throughout, or which became complicated at a certain period of its courfe. I have often made a fortunate conjecture; but I believe it would occafion embarraffment, rather than afford information, were I to attempt to defcribe thofe circumftances, which fometimes determined my opinion. They muft, in fact, be learnt from actual obfervation. I havejuft now mentioned, that it is extremely difficult to diftin- guifh the fingle from the double tertian, by the ap- pearances of the firft paroxyfm, when the morning fever of this laft form begins the difeafe; fo neither is it eafy to diftinguifh the double tertian from the quo- tidian, when the illnefs commences with the evening paroxyfm of that complicated type. This is a cafe, indeed, as far as my experience goes, rarely happens j yet where it does happen, the circumftances, with which the evening fever is ufually attended, mark a further diftinction. The quotidian commences ufu- ally by adiftinct and regular paroxyfm; the evening fever of the double tertian, for the moft part, only by 3 flight indifpofition. This connexion which I have juft mentioned, be- tween the hour of invafion and the type of the fever, was obferved conftantly at Savanna la Mar in Jamaica; but the fame rules did not by any means hold true in the different parts of the continent of America. The moft ufual hour of the invafion of the fingle tertian was twelve at noon in that country; though in fome cafes the paroxyfm came on fo early as ten in the morning, or fo iate as two in the afternoon. Of the other forms I cannot fpeak with any certainty. But befides the different hour of invafion of the different types, I muft likewife take notice of fome other circumftances, that feemed to be connected with the various forms. The duration of the pa- roxyfm for inftance, was ufually longer in the fingle tertian than in the doubh tertian, or quotidian; .andf PERIODICAL FEVERS. *9 of the double tertian, the paroxyfm of the morning was ufually longer than that of the evening; and be- fides being longer, was generally of greater violence, at leaft in the beginning of the difeafe, The cold fit was likewife more remarkable in the fingle tertian, than in the other forms of fever.—I do not fpeak of the quartan, of which I know but little. Of the bi- lious vomiting*, fo much infifted on by Galen as a diftinguifhing mark of the fingle tertian, I am at a lofs to fpeak pofitivcly. I can, indeed, affirm that I conftantly obferved fuch evacuations to be more fre- quent in the different forms of the tertian, than in thofe that appeared to be quotidian, or that approached nearer to a continued type. Such were the types of the fever of Jamaica, and fuch were the principal circumftances that appeared to be connedted with them. The types of fevers it may be obferved feem to be modified by climate; and there are not perhaps two different countries, or even diftricts of country, in which they are exactly alike. The hour of invafion of the fame form of difeafe was different in Jamaica, and on the continent of North America; neither does it appear to have been exactly the fame in Jamaica, and in the different iflands of the Mediterranean. The prevalence of certain forms in certain climates, and the various changes of the form according to the changes of the feafon, is a mat- ter of curiofity, and of considerable importance in the hiftory of the difeafe. In Jamaica for inftance, for one fingle tertian, there were at leaft three double ones; whilft in America, the fingle tertian bore the proportion of ten to one, perhaps, to all the other forms. In the higher latitudes of this country, the fingle tertian was almoft the only form which was feen, in the winter months and in fpring; yet in the fouthern provinces, particularly in the heat of fum- mer and fometimes in autumn, the double tertian, and even ftill more complicated types were by no means uncommon. 20 TYPES, &C I have thus endeavoured in. the preceding pages to defcribe the types of remitting fevers, as they oc- cured to my own obfervation. I have likewife at- tempted to compare my own descriptions with thofe of other authors; fo that the reader may, in fome de- gree, be able to attain a fyftematic view of this fpe-. cies of difeafe, as it appears in the different parts of the world. The labour I am aware will be reckoned fuperfluous by many; and a difcuifion on types, will probably be confidered as partaking too much of the fchool of Galen, v/ho is held in contempt by the wri- ters of the prefent day. I by no means contend lor the infallibility of Galen or the ancients; yet I can- not help believing, that though they have left us much falfe and fuperfluous theory, they have likewife left us many valuable obfervations, on the nature and progrefs of febrile difeafes, which the moderns feem to have neglected. Though the theory of Galen on the prefent fubject is probably ill founded, his obferva- tions are certainly exact; and from what I have my- felf feen, no affertions, which will convince me, that an intimate acqaintance with the types and periods- of fevers, is not an effential knowledge to the practi- tioner. It is, indeed, the firft ftep; and it is a ftep of fuch importance, that our future progrefs will neither be fatisfactory nor fate, unlefs it is properly under- ftood. I maybe allowed to fpeak from my own ex- perience. It fell to my lot to have the charge of men's lives at an early period of life. I had then no know- ledge of the types and periods of febrile difeafes, and I muft not conceal, that the method of treatment I purfued, and the returns of the difeafe fo often inter- fered, that though actual harm was feldom done, yet many opportunities of doing good were certainly loft. The patient, if he had the leaft penetration, could not,,- fometimes, avoid feeing, that, though I might be ac- quainted with the common routine of practice, I was ignorant of the nature and progrefs of the difeafe, from which I had undertaken to relieve him. [ 21 J CHAP. III. CRITICAL DAYS IN FEVERS- THE critical days, which are intimately connect- ed with the types and periods of fevers, come properly to be confidered in this place. The fubject is important, and though very fully difcuffed by me- dical writers, does not as yet appear to have been fa- tisfactorily explained by any one. If we attempt to trace the doctrine to its fource, we fhall find the firft mention of it in the writings of Hippocrates. The followers of this author's opinions are numerous ; and the endeavours, they have employed in attempt- ing to eftablifh his fyftem, have been ftrenuous and unremitting. But critical days have unfortunately afforded a field for controverfy in all ages ; and there ftill are many who maintain, and others who as con- finently deny the exiftence of any fuch power in af- fecting the termination of febrile difeafes. In the midft of this perplexity, a man who has had no expe- rience of his own is totally at a lofs, which way to turn. There are great names on both fides of the queftion, but clear and decifive evidence on neither. A detail, therefore, of fuch obfervations as promife to remove many of thofe circumftances of embarraff- men t, cannot fail of being ufeful, and I hope accept- able to the public. I am aware, indeed, that an at- tempt to explain a myftery, which has hitherto eluded the refearches of the moft eminent phyficians, will not probably efcape cenfure :—In'an obfcure man, per- haps, it may be deemed arrogant; neither is it alto- gether without hefitation that I undertake the difcuf- fion; though very unequivocal proofs of the truth of the principles on winch I proceed, arife from a view 22 CRITICAL DAYS of the cafes of fever which came under my care, dur- ing the time I lived in the Weft Indies. The prin- ciple on which the critical days in that climate depend,, appears from the facts found in the following pages to be indifputably eftablifhed; the deviations are fa- tisfactorily accounted for; and the fundamental rules,. it is prefumed, are fuch as may be extended to every climate on the globe. But, I fhall ftatein a few words the leading circumftances, which occurred to me on the fubject. If they afford not light enough to remove all the difficulties, it is hoped they may at leaft point out a road, by which thefe difficulties may in future be removed. It may not be improper to remark in the firft place, that I had heard of the doctrine of critical days in fe- vers before my arrival in the Weft Indies; yet I may likewife obferve, that it was a doctrine, which I had only heard of by name. I had no knowledge of it, and I foon found that the idea was treated with ridi- cule by practitioners, who very generally fuppofed1 the courfe of the fevers of Jamaica to be cut fhort by bark, or other powerful means. Influenced, perhaps* by the authority of older men, I found myfelf difpofed toacquiefce in the common opinion, that this doctrine was only one of the fanciful theories of the fchools; yet it was not long before I acquired a different view of the fubject. I foon obferved that fevers fometimes ceafed before a fingle grain of bark Was git.en; fometimes after a few dofes, and fometimes not: till after feveral ounces. The obfervation of this fact did not fail to undeceive me. Under the circum- ftances I mention, it would have been the height of obftinacy to have perfifted in believing, that the cure of the fever was in reality owing to die power of this celebrated remedy. But though it was foon evident, that the termination of theydifcafe depended on fome other thing than that which was generally fuppofed ; yet a confiderable time paft over, before I was able to determine what this fomething actually IN FEVERS. 23 Was, or before I was able to afcertain the laws which it obeyed. I foon difcovered, mderd, that fevers had a general tendency to terminate on particular days ; but it was not til! the year 1776, that I difco; ered the proportion thofe days bore to each other, or the fources of the many deviations, which occurred. The fubject formed to be important ;—and I felt an eagernefs to determine a queftion, which hitherto had been fruit- lefsly purfued. With this view I wrote down with care and attention every C2fe of fever which I met with in the year 1776 and 1777; and in looking over the memoranda fome time after, found, that the critical days bore to each other the following proportion: viz. of fixty c.fcs, which terminated favourably, ten ter- minated on the third, ten on the fifth, twenty on the feventh, ten on the ninth, five on the eleventh, three on the thirteenth, and two on the feventeenth. Of nine which terminated fatally, one terminated on the fixth, one on the feventh, fix on the eighth, and one on the tenth. Thefe fa XCRITICAL DAYS fion to make frequent ufe: viz. that a relapfe has a tendency to run over a courfe of duration equal to the original fever. This is confirmed by the autho- rity of Hippocrates; but I may alfo add, that not only thofe recurrences of fever, which are more pro- perly ftyled relapfes; but further, that in thofe in- fiances, where the difeafe undergoes any remarkable change in the nature of its fymptoms, the diforder is generally difpofed to continue for the fame length of time in this new form, as it had done in the former.. Thus a remarkable change of fymptoms on the fifth was followed, by a crifis on the ninth; fometimes,- perhaps, only by another change of fymptoms on the ninth, the final crifis not happening till after another period of five days. In like manner, a change of fymptoms on the feventh was often followed by a crifis on the thirteenth; or only, perhaps, by another change on the thirteenth, the difeafe completing ano- ther revolution of feven days before a final termina- tion. That fuch changes actually do take place at certain periods, not only thofe cafes of fever, which have come under my own care, but thofe related by Hippocrates, in the books of Epidemics, give fuffi- cient room to believe. Thus in every one cf thofe > inftances, where the hiftory is fo circumftantially de- tailed as to leave it in our power to trace the difeafe in its progrefs, it will conftantly be found, if the day of crifis deviates from the general rule, that a change of fymptoms, often an evident renewal of fever, had actually taken place at fome period of the courfe. In this manner, if the change of fymptoms of which I fpeak happened on an odd day, the odd days continued to be critical, as if no change had been; on the con- trary, if the paroxyfm of the odd day completed its courfe, the remiffion which followed was often more perfect than ufual:—a diftindt period was marked in the hiftory of the difeafe,—or in other words, there was an obfcure or imperfect rrifis. But on the IN FEVERS. 27 day following, which was an even day, a fever with a different train of fymptoms made its appearance, and tan over a courfe, for the moft part, equal in dura- tion to the former. If this change, or renewal of the difeafe happened on the fixth, a change or crifis was not expedted till the tenth, if on the eighth, not till the fourteenth. I have faid juft now, that relapfes were generally difpofed to run over a courfe of the fame duration as the original difeafe ; yet I muff like- wife remark, that they were fometimes alfo of fhorter continuance* Thus I have frequently obferved a change of the nature of the fymptoms on the feventh,. "—and a final crifis on the eleventh; the renewal of the difeafe, inftead of feven, being only of five days con- tinuance. The above circumftances are capable of explain- ing the ordinary deviations from the regular critical periods in the fevers of the Weft-Indies; but I can- not affirm with the fame certainty, that a fimilar ex- planation will be conftantly admitted in the long fevers of this country. I have however reafon to believe, that changes at the feptenary periods fre- quently take place here, and fometimes apparently difturb the critical periods of the difeafe. Thofe cafes which I have been able to trace with accuracy give ftrong proofs of it,—I fhall relate two or three of them to ferve as an illuftration. The firft, is that of a young man, who had been ill of a fever more than three weeks before I was called to him. Two days before I faw him; and after an evident abate- ment of the fymptoms, there happened a fudden and unexpected relapfe, or renewal of the difeafe. In- formed of this circumftance, I dated from the new attack, and calculated the critical days in the manner which has been fhewn above. Minute attention dif- covered the type, though it was only an obfcure one.—'It was Semitertian, or there was an exacer- bation every evening, with a more evident paroxyfm 28 CRITICAL DAYS on the alternate days. A crifis happened at the period? I had forefeen, but it was not final. A fever returned again in the evening, different however in type, as well as in fymptoms, from the preceding. It had iliftinct quotidian exacerbations and an imperfect crifis lappened on the feventh. But in twelve or fourteen liours, a coldnefs and fhivering marked a renewal of the old, or perhaps the invafion of a new difeafe. The fymptoms were not only different in their nature from the fymptoms of the former ; but they were likewife more violent in degree. TJie difeafe continued in this form for feven days, and the crifis, which at laft was only imperfect, was foon fucceeded by another renewal of fever, the beginning of which was marked by a fimilar degree of coldnefs and fhivering. The fymptoms of this were likewife different from the pre- ceding, but its form was the fame, and it ran over a courfe of equal duration. The feptenary revolutions were very plain in this cafe. I fhall relate another in which they were not fo clearly marked, though they certainly did ftill take place. Itisacafe of fever with nervous fymptoms. On the feventh a fediment ap- peared in the urine, fome drops of blood fell from th» nofe; anil the abatement of fever was very evident; yet it did not laft long. The difeafe recurred again on the eighth, and continued to increafe in violence till the fourteenth. A fediment then appeared in the urine, fome drops of blood fell from the nofe as be- •fore, there were two or three evacuations by ftool, which had been unufual in the preceding courfe of the difeafe; and from the whole appearances I could not kelp entertaining fome faint hopes of crifis. There Was indeed an evident alleviation of the fufferings; but it lafted but for a fhort time. Next day every ■fymptom was aggravated, and the powers of life feem- ed to fuffer a gradual diminution till the twentieth, when the patient died. I do not recollect any in- ft-ance of fever, where die revolutions were more ob* IN FEVERS.. 29 fcure than in the prefent cafe; yet they were ftill ca- pable of being traced. The next example I fhall mention is much clearer. It is an inftance of a bad fever, of no difcernible type in the beginning, in a man who v/as confiderably advanced in years. On the evening of the feventh there was fome obfcure temlency to crifis. The patient was not only eafier in his own feelings; but the eye and countenance, which had been confufed and clouded, brightened up, and a fmall fediment appeared in the urine. Yet thefe favourable circumftances were only of fhort duration. In the courfe of the day following, all the fymptoms recurred, and the difeafe acquired force till the evening of the thirteenth. The pulfe then began to rife, and continued rifing till the morning of die fourteenth, when a profufe fweat was followed. by a very diflinct crifis. But ftill this crifis was not final. The malignity of the difeafe, however, departed, and the complaint that remained, affuming a remitting form, totally difappeared after another pe- riod of feven days. I fhall only beg leave to relate another inftance of fever, which occured to me lately,. and which affords a very curious proof of feptenary. revolutions in febrile difeafes of long continuance A young man had been ill of a fever about a fort- night before I was called to him. At the time I firft few him, the fymptoms were very violent; but having abated confiderably in the courfe of a day or two, I began to entertain hopes of a fpeedy recovery. Thecomplaint was almoft entirely gone, when a new train of fymptoms unexpectedlymaking its appsarance,. raged with violence for a day or two, and then de- clined gradually as the other had done. I again look- ed for figns of crifis, when another acceffion on the, feventh from the former attack, brought ratters into ftill greater dan:er. Thefe fymptoms, though of a different n ;ture from the former, were violent in the beginning; but they foon began to abate, and hiicL D 3. 30 CRITICAL DAYS almoft disappeared, when the attack was once more renewed on the following feventh. In this manner the difeafe went through nine feptenary revolutions ; and it is fomewhat remarkable, that the fymptoms^ which marked the new acceffion, were always diffe- rent from thofe of the acceffion immediately preced- ing. In one, the diftinguifhing fymptoms were a morofe and ftern fullennefs, in another, delirium, tre- mors and fubfultus tendinum,—and in the third, co- pious liver-coloured ftools. Thefe were three times feverally repeated. It deferves, however, to be re- marked, that the period of the acceffions was fhort- &ntd before the termination of the difeafe. After it had continued nine weeks in the manner I have def- cribed above, there were two acceffions of five -days each; after which all traces of fever difeppeared. It is fufficiently plain from the facts which I have" mentioned in the preceding pages, that the more ufual irregularities in the order of the critical days, proceed* generally from overlooking the type in periodical fevers, or from neglecting to attend to feptenary, and* other revolutions, in fuch as approach more nearly to a continued form. Thefe are the general caufes of apparent irregularity; yet befides thefe, there are ftill fome others, which muft not be paffed over with-; out notice, as they occafionally have the effect of producing apparent deviations. Thus it often hap- pens, that a difeafe, which appears to be continued in the beginning,,changes to remitting after a certain duration. The change is ufually on an odd day, and on the day following the firft paroxyfm of the remit- ting form makes its appearance, the termination of which may be expected on an even day, if we date from the beginning of the illnefs, though ftill on an odd day, if we date, (as perhaps we ought to do) from the time this change in the circumftances of the difeafe took place. To this we may add, that thofe -complicating fevers, whichx happening at various dif- IN FEVERS 31 tances of time, fometimes terminate fooner, fome- times continue longer, than the original complaint, frequently difturb in appearance the general regu- larity of the critical periods of nature. It happens, perhaps, from a fimilar caufe, that a paroxyfm of an unufual kind fometimes terminates the difeafe, and apparently difturbs the regular periods of crifis This has occurred to me feveral times in practice; and it happened twice in my own perfon. The ordinary paroxyfm declined after the ufual duration; a new one fucceeded of uncommon violence, and very dif- ferent in its nature from the former. Its courfe was of long continuance, and it finally terminated the difeafe. The above facts enable us to explain fatisfactorily every circumftance, which relates to critical days in fevers, where the crifis is clear and decided ; yet I muft ftill own, that as I have fometimes met with fevers where marks of crifis were fcarcely perceptible fo it would be rafhnefs, in fuch cafes, to fpeak pofi- tively of the order of the critical days. The patient might, in fome meafure, be faid to wade through the difeafe; the changes from day to day being fo very fmall, that it required more difcernment than I can boaft of to mark them with precifion. . The obfervations I have related, and the rules I have attempted to eftablifh, for the better explana- tion of the doctrine of critical days in fevers, were formed at a time when I had no knowledge of the opinions of preceding authors. They may therefore better claim exemption from bias in favour of one fet of writers, or prejudice againft another. They arc indeed no more than an analyfis of facts, which were colle&ed with every poffible care, which are fufficiently circumftantial, and which fpeak beft for themferves. They contain, (if I do not view them with a partial eye,) fuch information, a3 may lead to a utisfactory explanation of this myfterious and long 32 CRITICAL DAYS difputcd doctrine.—I muft only beg leave to add, that though I have everywhere mentioned the pre- eminence of particular days in terminating fevers, yet it muft not be underitood, that this power de- pends on a particular quality of the days, merely as fuch. It depends more evidently on a certain number* of revolutions of the difeafe, in confequence of which, the fever from fomething we do not in the leaft un- derftand, feems difpofed to terminate finally, or to fuffer a change in its mode of action. This there- fore brings us to the conclufion,. that the critical pe- riods are improper calculated by the natural day. The doctrine, in fhort, can only be rendered confid- ent by attending to the periods of the difeafe, by Am- plifying complicated types, and by marking- thofe feptenary or other revolutions, which happening at different diftances of time, occafion an appearance of irregularity which does not exift in reality. Having related the refult of my own obfervations on critical days in fevers, I fliall now endeavour to bring under one point of view, the fubftance of what has been written on the fubject, by fome of the moft celebrated of the ancient, as well as modern phyficians.. That certain days, or that portions of time compre- hended in a {certain number of davs, had obviouflv a power of producing changes on the human frame, ap- pears to be an obfervation of high antiquity; hut as a medical doctrine, we are unable to trace it farther than the days of Hippocrates. Hippocrates has treated very fu'ly of the critical periods of fevers, in various parts of his works; and upon the whole, has amaffed a con- figurable body of information; though with lefs pre- cifion, perhaps, than has been generally imagined. The cafes of the Epidemics, which we naturally con- fider as the materials from which he formed his gene- ral doctrine, have fome obvious and great d..frct«. The date is feldom clearly afecrtained, and the .mode of calculating the time, does not fe«m to be fixed. 1C IN FEVERS. 33 as fever, for inftance, begins in the evening, or in the courfe of the night, the day following is generally reckoned the firft day of the difeafe, by this author.— But this is not all.—Some of the cafes are plainly re- lated from memory; and others are only parts of cafes, related by different perfons. This want of accuracy, where it is fcarcely poffible to be too cir- cumftantial, neceffarily breeds confufion, and pro- duces an appearance of irregularity, which docs not actually exift. Hence we find inconfiftency in the general dodtrine, as delivered in different parts of the works, which have been afcribed to Hippocrates; at the fame time, that there is a want of that circumftantial detail in the particular parts, from which only we can be enabled to form an opinion. I have read over with much attention the cafes of fevers, recorded in the Epidemics; but I frequently found myfelf unable to trace the difeafe in its progrefs. Though evidently fubject to periodical movements, it was not always in my power to lay hold of the type; yet wherever it was poffible to attain this exactnefs, I have the fatisfaction to add, that I conftantly found the move- ments of nature to be uniform. They were the fame in the iflands of the Archipelago, as in the ifland of Jamaica.—-If they appeared in fome inftances to be different, it was perhaps principally owing to this, that the Greek phyfician had left fome part of the dif- eafe undefcribed. From what I have juft now faid, we can have no hefitation in concluding, that the opinion of Hippo- crates, on the fubject of critical days, is neither pre- cife in any one part, nor confiftent in the whole. The doctrine, however, in its beft digefted form, is the following: viz. That odd days have a remarkable power in terminating fevers; but more particularly, that the great critical revolutions happen at quater- nary periods. Thus the moft eminent critical days, are the fourth, the feventh, the eleventh, the four- 34 CRITICAL DAYS teenth, the feventeenth and the twentieth. This is the general form of this Hippocratic doctrine; yet in this form, it bears contradiction to obfervations that are found in various parts of that ancient author** Works. The fifth and ninth are excluded by this arrangement, from the number of the critical days; though there are numerous examples of their great power, in terminating febrile difeafes. The doctrine of critical days, which appeared firft in a regular form, in the writings of Hippocrates,, found numerous and refpcctable advocates among the ancient phyficians. Diodes of Caryftus, Philotimusy Heraclides of Tarentum, &c. all bore teftimony to' the general truth of the obfervation; but their writ- ings being unfortunately loft, we are now ignorant of the particular facts and arguments, by which they attempted to fupport their opinions. Indeed, from the time of the Perfian invafion of Greece, till the Roman arms penetrated into Afia, a period of near four hundred years, we know of no oppofition to to this fundamental doctrine of the Coan Sage : But in the time of Pompey the Great, an author arofe* who endeavoured to eftablifh his own fame on the ruins of this favourite fyftem of his predeceffors. Afclepiades, who was a man of a bold and daring genius, not only rejected this apparently well founded doctrine of the ancients, but treated the idea of it with ridicule. His arguments are ingenious and acute; but they fall fhort of the truth. The pa- roxyfms or exacerbations, as he juftryobferves, fome- times change to the even days, and confequently the crifis: yet this, if properly underftood, does not def* troy the generality of the rules;---if the method of calculating the time, by the periods and revolutions* of the difeafe, be adopted, the difficulty is perfectly removed. But though this fact in reality, was not unknown to Afclepiades; yet it does not appear, that he underftood the application of it. I may addj that IN FEVERS. 3 £ he has precipiately rejected the doctrine, from the very circumftance which eftablifhes its reality. We do not meet with any thing very material, on the prefent fubject, between the time of Afcle- piades, and the days of Galen. There appears, in- deed, to have been many, who adopting the opinion, and copying the arguments of the eloquent Bethy- nian, denied altogether the exiftence of critical pe- riods in fevers; whilft others, recurring to the doc- trine of Hippocrates, maintained their reality with no lefs obftinacy. But we are now in a great mea- fure ignorant, if thofe writers attempted to fupport their opinions by any new facts, or new arguments. Among other misfortunes, we muft regret particu- larly, that the treatife of Aretaeus on fevers is loft. From what we know of this author's induftry we might have reafonably expected original information on the fubject in queftion. Galen, whofe fertile and exuberant genius left no path in phyfic unexplored, has written fully on this celebrated doctrine. He has profeffedly adopted the opinion of Hippocrates, and laboured much to ex- plain and confirm it; but unfortunately, he has oftener overwhelmed the fubject with diffufe and tedious reafonings, than illuftrated it by proofs from expe- rience and actual obfervation. Upon the whole, however, amidft much fuperfluous and unmeaning matter, we find not only ufeful information, but a more fyftematic arrangement of facts, than is any where to be met with. He has attempted to fix with more precifion the date of invafion ; he has eftimated with more accuracy the critical power of the diffe- rent days; and further, has hinted obfcurely, that the time will be calculated moft conveniently by the pa- roxyfms or revolutions of the difeafe. In fhort, this author, no lefs than Afclepiades, was fufficiently ac- quainted with the principal truths, which give con- fiftency to this doctrine; but it is evident, that he 36" CRITICAL DATS did not underftand the full extent of their application. He was conftantly biafled by the theory of a quater- nary period; as without this predilection,, it is not eafy to conceive, how he fhould have coniidered the fourteenth, as critical of tertians, where the parox- yfms happen on the odd days, and where the termin- ation, as he acknowledges, conftantly follows the folution of a paroxyfm. The latitude likewife which he affumes, in explaining the apparent irregularities, is much too great. If we are permitted to reckon either the beginning or the termination of a paroxyfm, as the critical period, according as it fhall beft fuit our theory, it is eafy to elude the moft pofitive tefti- monies of experience. Yet, notwithftanding thefe defects, the different tracts of Galen on this fubject, deferve to be carefully read. The facts they contain, though fometimes mifapplied, are often important; and though we are not always fatisfied with the rea- fonings of the author, we are aftonifhed at the amaz- ing mafs of learning and knowledge found in his works. There is little new information, on the fubject of critical days, to be met with in the writings of thofe Greek phyficians, who were pofterior to the time of Galen. iEtius Amidenus, indeed, brings into nar- rower com pafs the fubftance of the doctrines of his predeceffors. He mentions likewife, the moft ma- terial of thofe circumftances, which influence the deviations from the regular crifis ; but it is evident, that he has not fufficiently underftood their applica- tion. Alexander Frallianus, who was an excellent practitioner, and a man of long experience, pafles over this fubject without particular notice; and though Paulus of iEgina has detailed the opinions of Galen in a more compreffed form, than they arc found'in the ori^nal author; yet he has not added any new obfervations of his own. From the manner, indeed, in which he fpeaks, of the peculiar virtue o£ IN FEVERS. 37 the feventh and fourteenth, we fhould be apt to be- lieve, thatjie is not altogether free from prepoffeffion in favour of the Pythagorean numbers. It was reafonable to have expected information on the fubject of critical days, from the writings of the Arabian phyficians. The Arabians inhabit a country, were the periodical movements of natura are perhaps more clearly marked, than in our north- ern latitudes. Some diftricts of their country like- wife were famous for the fcicnces at an early period, though it does not indeed appear that much of this knowledge defcended in a direct channel to the Ara- bians of the prefent times. The Arabian phyficians, in many inftances, enriched medical practice with new forms of remedies; but they have for the moft part only adopted the theoretical doctrines of the Greeks, particularly of Galen. Avicenna, the moft famous among their phyficians, and undoubtedly a great man, has Galen conftantly in his eye: in fhort, he has done little more on the fubject of critical days, at leaft, than merely tranflate the opinions and argu- ments of the celebrated Greek. He attempts, indeed, to be more explicit in ascertaining the date of inva- fion; but he does not in fact, go much beyond his predeceffors;—hinting only obfcurely, that the cri- tical days ought to be calculated from the proper for- mation of the type, or the diftinct invafion of the fever. He has added, however, that the odd days, are properly the critical da)Softhe fingle tertian,and that the eleventh of courfe, obtains rank of the fourteenth in this difeafe. There are many authors, who have written on this fubject, fince the arrival offciencein Europe; but there are few that I have met with, who have thrown light on it from their own obfervations. The moft of them have borrowed the opinion from Hippocrates; and accordingly have attempted to efta- blifh the truth of it, on the facts which are found in E 3§ CRITICAL DAY'S. the writings of that author; facts, which, on enquiry, will fcarcely be found to be accurate enough to be made the bafis of a general doctrine. It would b« time ill fpent, to enter into a detail of the arguments of this numerous lift of writers ; who, in reality, have oftener attempted to fupport their opinions by the authority of Galen and the ancients, than by the facts which might have been found in their own ex- perience. From writers, however, of this defcrip- tion, it would be unjuft, not to feparate Hoffman, an author, who has related with candour the refult of his own obfervations, in a practice Qf forty years and upwards. The facts which Hoffman meotieas, throw confiderable light on the fubject; yet ftill they do not remove all the difficulty. They neither ena- ble us to form an eftimate of the power of the differ- ent critical days; neither do they at all affift us in comprehending the caufe of the deviations. There are probably other modern authors befides Hoffman, who have treated of the power of critical days in fe- vers; but, except Dr. Cullen, I have not met with any one, who has left any obfervations which deferve much notice. This celebrated phyfieian is a warm advocate of the ancient doctrine of critical days. He fubfcrib.es profeffedly to the arrangements of Hippo- crates ; though he acids likewife the refult of his own obfervation, in the various kinds of fevers of this country. The moft eminent of the ancient and the moft f/ftematic of the modern phyficians, all agree in a£. cribing to certain days a particular power in termi- nating; yet they do not fo perfectly coincide in the arrangement they have given of thofe 4ays, or in the caufes they have affigned for the particular pre-emi- nence. The inconfiftency of Hippocrates has, per- haps, b?en in fome meafure the fource of this diver - fity of opinion. In one place, this author has ranked the twentieth as the proper critical day in fevers; in fome others, this power is attributed to the twenty- IN FEVERS. $ty firft. That the tWenty-firft is properly the day of crifis, was the opinion of Archegenes and Diodes;, that it fhould be fo, is not inconfiftent with the ge- neral'principle of the Hippocratic doctrine; viz. the movements of a quaternary period. So far. is clear ;. but as it was obferved hy Hippocrates,, as well as by other authors, that the twentieth was ftill more fre- quently a day of crifis than the twenty-firft, a wpoa-Se^/c, on the fourteenth, Was introduced to account for this apparent deviation from the general rule. This idea of *p«9-8w/c, or accumulation of one period on ano- ther, which is mentioned in the writings of Hippo- crates, originated perhaps in the doctrine of Pytha- goras. It is adopted by Galen, and it appears in reality to be occafionally true; yet it can never be cortfidered as an eftablifhed principle in the move- ments of febrile difeafes. By means of fuch accu- mulation, however, Galen has attempted to eftablifhr the pre-eminence of the twentieth, which he con- fides as the real critical day of Hippocrates. That the twentieth—(not the twenty-firft) is actually the critical day of Hippocrates, is likewife decidedly the ©pinion of Dr. Cullen^ who, going a ftep farther than his predeceflbrs, endeavours to fupport his af- fertion by fome arguments, which are entirely new. This ingenious author hazards the bold conjecture, that the appearance of the twenty-firft, in the writings of Hippocrates, has arifen wholly from accidental error in the original manufcript: but with all due deference to fuch refpectable authority, I muft beg leave to fuggeft, that the twenty-firft occurs too fre- quently in thofe writings, which have been afcribed tb the Coail Sage, to give countenance to the opi- nion, that it owes its place, as a critical day, to care- lefs error. The other argument is more ingenious ; but perhaps not better founded. This writer has ventured to maintain, that the type of febrile difeafes changes to qnartan after the eleventh -x but I can fee 4-0 CRITICAL DAYS no good reafon for the fuppofition. Medical writers have repeatedly noticed inftances of crifis, on the thirteenth, and fifteenth ; even my own experience, narrow as it has been, furnifhes me with fufficient evidence, that crifis actually do happen at the above- mentioned periods. As thofe days, which have been chiefly confidered as critical, are now fuppofed to be fufficiently known, it will not be fuperfluous in the next place, to take a fhort view of the caufes, on which the particular pre-eminence has been thought immediately to de- pend. The quaternary period, which in reality is a period of four, and a period of three days fucceeding each other alternately, is the general principle af- fumed by ancient phyficians, to explain this arrange- ment. But if we continue to purfue the undifturbed movements of a quaternary period, we fhall bring the eighteenth and twenty-firft into the order of cri- tical days, rather than the feventeenth, and twentieth. The contrary is in fact the cale. To obviate there- fore this difficulty, or to reconcile obfervation with theory, a »poirtJi\ GENERAL REMOTE made its appearance. It extended in fome degree to the whole battalion ; but raged with particular vio- lence on the right, which bordered on low and fwampy ground. The approach to new and full moon never failed, even in this climate, to increafe the number of the fick; yet it deferves to be re- marked, that this increafe was always fmaller in pro-. portion, in that part of the battalion, which lay con- tiguous to the fwamp, where the difeafe was highly .epidemic, than in the other extremity of the encamp- ment, where it prevailed in a lefs degree. But ftill upon the whole, when the regiment moved from their ground, in the beginning of November, of a hundred cafes of intermitting fever, which were marked in the almanack, eighty were found to have commenced in the ufual period of invafion; that is, in the fecond and laft quarters of the moon. It is fomewhat remarkable, that relapfes were in a fmaller proportion. This regiment, fome parts of the me- dical hiftory of which I deferibe, embarked on an expedition for the fouthward in November, and ar- rived at its deftination in Georgia, in the latter end of the year. It remained in the fouthern provinces, and ferved every campaign till the capitulation at York-town. The fame train of obfervation was continued during this intervening fpace, and the fame influence of the moon feemed in general to prevail; but the notes having been loft, I cannot now exactly afcertain the degree in which this in- fluence took place. Of this, however, I am certain, that even in times of the greateft epidemic ficknefs, when the connexion was evidently weakeft, the num- ber of the fick was generally doubled in the periods approaching"to new or full moon. We cannot avoid concluding, from the facts which I have ftated above, that the approach to new and full moon, or fomething connected with that approach, may be juftly confidered as a powerful exciting caufe CAUSES OF FEVERS. 6"$ of fever. The circumftances, indeed, which I have mentioned, are fo clear and unequivocal as to leave little room for doubt: nor did 1 entertain any, till I found that the obfervations of Dr. Balfour, on this fubject, were fo ftrikingly different from mine. Ben- gal and Jamaica are diftant from each other; yet few people will be difpofed to believe, that fo great mo- dification of a general caufe has arifen folely from this diverfity of climate. Dr. Balfour muft fpeak for himfelf. For my own part, I can only fay, that what Ifaw I have related with truth. As I have told the manner in which the ideaarofe, with the manner in which the inveftigation was conducted, I leave the conclufion to be formed by the reader.. G3 [ 66 ] CHAP. V. THE PROXIMATE CAUSE OF FEVER. THEORIES of the proximate caufe of fevers, or more properly modifications of theories, are fo numerous, that a whole volume would fcarcely be fufficient to give any tolerable account of them. *' It is a tafk indeed which I fhall not undertake ; yet I hope it will not be altogether fuperfluous, to give a curfory view Of the principles, which have directed the conjectures on this fubject in different ages. The principles are, in fact, fewer in number than at firft fight they appear to be. Phyficians, ambitious of raifing their name and reputation, have fhown great induftry in multiplying and modifying opinions; yet it does not appear, that they have produced any great variety of theories, which are fundamentally diftinct. The ancients, who were little acquainted with ehemical principles, or with the qualities and pro- perties of the nervous fyftem, placed the proximate caufe of fevers in fome fignal fymptom of the dif- rafe, fuch as increafed heat, or abounding bile ; or en- tering ftill farther into the fields of fpeculation, ven- tured to attribute it to derangements in the perme- able canals of the body, or to affections of the hu- mours, or circulating mafs of fluids. Hence obftruc- tion of pores, plethora, error loci, lentor and vifcidity, or putrefaction of the humours, have all feverally, at different times, or by different authors, been con- fidered as the immediate or proximate caufes of this difeafe. The theories, which prevailed in the fchools till the beginning of the fixteenth century, did not often extend farther than to the cauf s which I have mentioned: but after that period, the difcovcries ojf CAUSE OF FEVER. 67 the famous Paracelfus opened a road to innovation in medical reafoning. The followers of this author, if not numerous, were enthufiaftic and vociferous. They indulged in the wildeft extravagance of con- jecture ; and their opinions, for a confiderable time, were combated with the authority of Galen, rather than with folid argument and accurate reafoning. At laft the difputes between Chemifts and Galenifts beginning to fubfide, the chemical theories became incorporated with the doctrines of the mechanic phi- lofophy, which were revived more than a century ago, and which ftill maintain fome influence in the common fyftems of phyfic. In the mean time hap- pened the important difcovery of the circulation of the blood ; butno immediate change, in themanner of ac- counting for fevers,enfuedimmediatelyinconfequence of it. Yet as from this period the refearches of phy- cians began to be conducted on a more extended plan, fome parts of the fyftem were brought into view, which had been formerly little attended to. The nervous fyftem, which had been in a manner overlooked for many ages, was now found to be of importance in the economy of the animal machine ; and authors foon began to confider it, as affording a probable feat for the proximate caufe of fevers. Among the firft of thofe authors, who viewed it in this light, we reckon Borelli and Dr. Cole ; the one of whom in Italy, the other in England, propofed much about the fame time, new and different opi- nions about the proximate caufe of fevers. Their conjectures, I muft confefs, are far from being pro- bable ;-—(that of the Italian is fcarcely ingenious) yet they deferve to be mentioned in this place, as being among the firft attempts to bring into view a part of the fyftem, which is very effential in enabling us to account for many appearances in febrile difeafes. It is commonly believed, that the nervous fyftem was not difcovered to be a part of material import- 68 THE PROXIMATE ance; either in the functions of health, or in the af- fections of ficknefs, till the laft century. This, in fact was generally the cafe-; yet I muft not omit to mention, that we meet with an expreffion in the writings of Hippocrates, viz. ■*<* o^«vt« » ntf/nmrm Mfi.*™, which might incline us to be of opinion that this phyfician was not altogether ignorant of the influence of the nervous power; and that he ac- tually confidered this principle of the confutation to be of much importance in ihe management and cure of difeafes. After Hippocrates, Van Hel* mont, under the whimfical appellation of Archeus, afferted more directly the dominion of the fentient principle. He has indeed applied its operations more particularly to affift him in explaining the theory of fevers; but it has been a misfortune that the opi- nions of this author have been generally lefs attended to, than perhaps they deferve: fo that it has been cuftomary to confider, the celebrated Hoffman as the firft, who fuggeftedthe idea, that the proximate caufe of fever depends on a derangement or affection of the nervous fyftem ; at leaft he is the firft, who de- livered a fyftem on the fubject, which can in any de* gree be confidered as rational and confiftent. It will not be an eafy tafk, to give a clear and diftindt view of that, which has been confidered by the ancients, as the proximate or immediate caufe of fevers. The language of the earlieft writers is not by any means precife in this refpect; and we fhall frequently, perhaps, have difficulty from the ambi- guity of expreffion, to diftinguifh from each other the definition, the remote and occafional, or the im- mediate and proximate caufe of the difeafe. The proximate caufe of a difeafe, it muft be remembered, is a caufe which conftantly and uniformly produces its refpective .complaint; and without which this complaint cannot even for a moment exift. It is, in fhort, the firft effential derangement, which the ac- CAUSE OF FEVER. 69 tion of this caufe produces in the frame of the fuf- ferer: but though we know this to be certainly true, yet we have made no progrefs in difcovering the na- ture of this derangement. The firft action of the caufe of fever is obfcure, and fome part of the de- rangement which it occafions, has hitherto probably palled over unnoticed, even by the moft accurate obfervers. If we attempt to give a view of the fucceffive conjectures, which, at different times, have been of- fered to the public concerning the proximate caufe of fevers, it will be ncceffary to begin with Hippo- crates. We may collect very clearly from the writings of this author, that an increafe of the heat of the body had afforded, to the ftill more ancient phyficians, the firft idea of the eflence or immediate, caufe of fevers. This feems to have been the idea of the moft ancient profeffors of medicine. Hippo- crates in fome degreefubferibed to it; yet this author feems likewife to doubt, if the fimple increafe of heat alone is fufficient to conftitute a proper fever, or that it can with propriety be confidered as the ef- fential proximate caufe of the difeafe. But though Hippocrates raifes this objection to the common opi- nion concerning heat, yet he ftill leaves us in doubt with regard to the opinion which we ought to adopt. His ideas are fluctuating and uncertain. We find in the different parts of his works, obftruction, ple- thora, miafmata or bile, all feparately confidered, as immediate caufes of fever. But fuch caufes, I may add, where they do take place, are in fact only more remote or diftant caufes. Neither miafmata, bile, nor obftruction, are circumftances on which the ex- iftence of fever invariably and neceffarily depends ; at leaft fuch caufes require to be in a certain ftate of modification, which is yet undefined, before they arc capeble of actually producing the difeafe. Bile bears a very confpicuous part in the Hippocratic 7« THE PROXIMATE doctrine of fevers. The fabric, indeed, which our author raifes on this principle, is fanciful,and inmany refpects, ill founded f yet, as modified by the fertile genius of Galen, it paffed on through a-fucceffionof many ages: nor is it, even now, altogether banithed from the language of practitioners. Sueh are the hints concerning the caufes offeveri| which I have been able to collect from the writings of Hippocrates. The expreffions are often obfcure or equivocal ; and we can fcarcely fay, that an opi- nion can be formed from them which deferves the name of a theory. The fucceffors of this great phy- fician were, perhaps too feniihJe of this defect; and therefore attempted to fabricate other opinions, which might be more explicrt and diftinct. Among the firft of thofe attempts, we may reckon the hypothecs of Diodes of Caryftus, a phyfician who lived at an early period, and who was highly efteemed by his contemporaries. Fever, according to this author, is not fo much a primary difeafe, as a fymptom of ferae other affection. Wounds, tumours, and many other accidental caufes, have certainty been obferved to give rife to fymptorris which have been ufbally deno- orinated fever ; yet neither wounds nor inflammations have been generally obferved to give rife to a propn fever. I will not however deny, that wounds, or in- flammations, occasionally prove exciting caufes df proper fever, where there is a ftrong drtpofition to the difeafe, exifting in the conftitution, at the time thofe accidents have happened. It does not appear that this, theory of Diodes gained much grouad with fucceeding writers; yet it was, perhaps, the caufe of introducing the diftinetion of primary and fymptomatic >nto the hiftory of fevers ; a diftinetion, which is frequently of confequence in practice. But I muft further add, that though the opinion of Di- odes is not admiffible in its literal meaning; yet, in a modified fenfe, it is notaitogcther without foundation. CAUSE OF FEVER. 71 The fymptoms of fevers are undoubtedly indications of a derangement of the body from its healthy ftate; but when we have faid this,'we can fay no more.— The nature of the derangement, which in its firft beginnings is not obvious to the fenfes, neither the andents, nor the writers, of the prefent age have, as yet, been able to afcertain. Not very long after Diocles, Erafiftratus, a native of the ifland of Cea* and phyfician at the court of An- tigonus, furnifhed a conjecture concerning the caufe of fevers, which is mentioned both by Celfus and Galen, and which appears to have originated in his anatomical refearches. As Erafiftratus directed his purfuits particularly to the fanguiferous fyftem: fo imprefled, perhaps, with an idea of the importance of that part of the body on which his thoughts bad been chiefly employed, he ventures to hazard the opinion, That the immediate caufe of fever depends on a certain error loci, or transfufion of the red blood into the arterial channels : and this, he moreover adds, proceeds from repletion.—The opinion originates from an anatomical error, and on that account need not detain us any longer. The next author, of whofe opinion on this fubject any diftinct traces have been tranfmitted to us, is Af- clepiades, the Bythinian, a man who feldbm treats the doctrines of his predeceffors with refpect. In his rage for innovation, Afclepiades attempted to change or modify the theories of thofe who had gone before him, in fuch manner, as to hope to impofe a conjec- ture on the world, which might, at leaft poffefs fome exterior claims of novelty. He allows with the moft ancient phyficians, that the infeparable fign of fever, or its eflential part, confifts in an excefs of heat; but having aaopted the doctrine of atoms, which was conveyed to the Greeks by Democritus of Abdera, he pretends to account for the difference of types by » a difference in the fize of the corpufcles, which he 72 THE PROXIMATE fuppofes to be formed by a combination of indivifible atoms. Thus we fee that obftruction in the per- meable canals of the body, in this writer's opinion, conftitutes the theory of the proximate caufe of fever: on which principle we may likewife conclude, that the modern doctrine of lentor and vifcidity has built its foundation. The author, whom I have laft mentioned, may actually be confidered as the original founder of the methodic feet. The principal tenets of this feet of phyficians have been tranfmitted to us by Celfus, Cto'be mentioned, from its being the firft attempt to ;bring this part into view, in accounting for febrile -difeafe. This hypothefis, however, though obvioufly -ill founded, enjoyed its day of fame. It was foon .followed by another conjecture, more ingenious in- •deed, but which was not fo generally attended to, as the preceding. Dr. Cole of Wbrcefter, towards the end of laft century, fuggefted an idea, that the proximate caufe of intermitting fevers depends on a laxity or debility of the brain and origin of the nerves. The fuppofition is not fo improbable ; but thefupcr- ftructure, which the author has raifed, is abfurd, and unfupported either by fact or probability. Yet, if xcej<*we MgM& Mundy, an author who offered a conjec- ture of a fimilar kind, in a work entitled Zio%pt>s**-oyt«, Borelli and Cole ate the only writers prior to the time of Hoffman, who confidered the nervous fy^em, as directly affording a feat for the proximate caufe of fevers. Hoffman, whom 1 have juft mentioned, was a celebrated profeffor at Halle in Saxony. He -flourifhed in-the earlier part of the prefent century, 80 THE PROXIMATE publifhed many volumes, and certainly poffeffes tire merit of having enlarged our views on the fubject of fevers. His theory of the proximate caufe is not only more ingenious, but certainly has more appear- ance of truth, than any other, which had been offered to the public at the -time it appeared. The e-*c*AyXL^asgLof fever confifts, in his opinion, in a fpafmodic affection of the nervous fyftem. It is a truth which few people will attempt to deny, that a fpafmodic ftricture of the furface of the body generally takes place in ordinary cafes of fever ; yet we muft perhaps alfo acknowledge with Dr. Cullen, that a fpafmodic ftricture is not certainly and uniformly the firft eC- fential part of a febrile difeafe. Some other thing is frequently obferved to precede the fpafm, which, in the opinion of the laft mentioned celebrated profeflbr, has a right to be confidered as a proximate and eflen- tial caufe. But as the theory of the proximate caufe, affigned by Dr. Cullen, is not only more plaufible and complete than any preceding one; but ftill in- creafing in popularity and fame, it will not be fuper- fluous, if we ftop to examine it with more attention- The remote caufes of fever, according to this author, are fedative powers, applied to the nervous fyftem, which diminifhing the energy of the brain, thereby produce a debility in the whole of the functions, and particularly in the action of the extreme veffels. Such, however, is at the fame time the nature of the animal economy, that this debility proves an indirect ftimulus to the fanguiferous fyftem ; whence by the intervention of the cold ftage and fpafm connected with it, the action of the heart and larger arteries is increafed, and continues to be fo, till it has had the effect of reftoring the energy of the brain, of exciting this energy to the extreme veffels, of reftoring there- fore their action; and thereby fpecially overcoming the fpafm affecting them: upon the removing of which, the excretion of fweat, and other marks of CAUSE OF FEVER. Si relaxation of excretories take place. This theory of fever holds out an appearance of great fimplicity, and of perfect connexion. I wifh we could fay that it had an equal claim to truth: but I am afraid it will be found, on a careful examination, to be no more in reality than an ingenious hypothefis, the leading prin- ciples of which can fcarcely be proved even to exift. I do not pretend to enter deeply into the difcuffion of theYubject; yet I cannot avoid reprefenting, in a few words, fome circumftances of difficulty in this au- thor's theory, which are not eafily reconcileable, either with reafon or obfervation. It might be doubt- ed, in the firft place, if the remote caufes of fever are actually of a fimple fedative nature; but at pre- fent I fhall admit that the firft principle, which is af- fumed by the profeflbr, is in reality a fact, and pro- ceed to enquire, if the reft of the doctrine is capable of being defended, even on this foundation. Itconfti- tutes the fum of Dr. Cullen's theory, as was men- tioned before, that the remote caufes of fever occa- fion debility, or diminifhed energy of the brain and nervous fyftem; that this debility neceffarily gives rife to fpafm, and increafed action of the heart and arteries ; which continuing for a certain length of time, finally removes the difeafe. Thus the different ftages of fever appear to follow each other as caufe and effect; and debility in the firft inftance, is fup- pofed neceflarily to give rife to reaction. Such a fup- pofition is not very obvious to reafon, and has not much fupport from the analogy of facts. It would be eafy to mention examples, .where the application of debilitating caufes as is not obferved to be follow- ed-by obvious reaction of the fyftem ;.but at prefent I fhall content myfelf with the familiar one of the ap- plication of cold. It is perfectly well known, that cold, when conftantly and uniformly applied to the body, even goes fo far as abfolutely to extinguifh the powers of life, in a part, or in the whole, without '82 THE PROXIMATE our being able to perceive any efforts on the part of nature to ftopthe pro°refs of this deftructive tenden- cy. From this we may fairly infer, that common de- bilitating caufes, at leaft while they continue to be applied in the f\ ne conftant and uniform manner, do not neceffarily excite the reaction of the fyftem: but I will even go farther, and venture to affirm, that fpafm and reaction do not neceffarily follow very great degrees of debil.ty, which appear to proceed from the -prefence of a febrile caufe. During the time I re- gained in America, I had frequent opportunities of witnefling the truth of this affertion. In the fouthern :provineesof that country, particularly in the furwner and autumnal months, the intermitting fever was ge- nerally epidemic in a high degree; but its geneHil caufe, which-was then fo abounding in the atmofphere, often injured the actions of i;fe, without producing*a regular train of operation; that ic, one part of the -difeafe appeared without'that mode of-action, which is fuppofed, by our author, .to be its neceflary effect. Thus, I have feen the moft extreme degrees of de- bility and lan^our in all the functions, continue even for eight or ten days, without our bjing able to dif- cover the'i'malleft marks of fpafm, or obvious reac- tion. This inactivity and langour fom-times vanifh- ed fuddenly ; and the body r:fumed its ordinary health and vigour, frequently without an evident caufe. On the next da v, however, or'pefhaps the ■day following; it, thcpatienc was furprksed with a re- gular paroxyfoi*of'fever. From this it appears vefy plainly, that if the immediate caufe of fever actually •confifts in debiIity,'this'debility neceffarily undergoes a peculiar, but hitherto undefined'fpecies of'modifi- cation, before it can be confidered as the caufe of the fubfequent'parts of the difeafe; a conceffion whiih leaves us perfectly in our former ftate Of uncertainty and ignorance. As it may be -concluded from the facts, which I CAU ,E OF FEVER. 83 have mentioned, that fpafm and reaction are not the neceifary confequences of the application of debilitat- ing caufes, either common or febrile; fo if we purfue our author's train of reafoning farther, we fhall not find his inductions to be very confiftent, or very con- vincing. If we are difpofed to grant, that the re- mote caules of fever actually diminifh the energy of the brain, it is not an obvious inference, that the circumftances of this diminifhed energy have the cer- tain effect of exciting the reaction of the fyftem. It appears, in fhort, like afcribing reft and motion to the fame power. But to fmooth the prominent fea- tures of this apparent inconfiftency, the ingenious author has thought fit to affume a principle!, the ex- iftence of which is very ambiguousin its enlarged fenfe, and very infufficient in its limited one. Dr. Cullen does not admit of the Italian principle of «KTo.s-«Te/«; he however afcribes effects to the vis na- turae medicatrix, which are not capable of being ex- plained mechanically. I mentioned before, that no efforts of nature are perceived to arife, under the uniform and conftant application of a debilitating caufe ; but though this is true, I muft likewife ob- terve, that when thefe debilitating powers, from any caufe whatever, actually ceafe to act, abate materi- al y in the intenfity of their action, orfuffer chano-e in its mode, before the vital principle is irrecoverably deftroyed, nature, which perilfts in continuing life and even ftruggles in attempting to maintain it^may then.be faid to ratfe efforts, which have a tendency to reftore the body to its ordinary health. This power, which to a certain degree, refills caufes of a destructive tendency and which endeavours to ref tore to their original ftate the derangements of the fyftem which have actually taken place, is only a 1L* mited degree of the vis naturae medicarrix. It is fn fho'-t, no more than an effort to continue the action of living; yet it is all, w'nch we fhall, at any time perhaps, be able to perceive. 84 THE PROXIMATE I have thus mentioned briefly fome objections, ta this celebrated theory of Dr. 'Cullen. The inge- nuity of the author is acknowledged to be great; the pains and labour, which he has bellowed in complet- ing his favourite doctrine appear likewife to be con- fiderable ; yet I cannot help remarking, that its de- fects are ftill fo obvious, that we are unavoidably obliged to be fatisfied with one of thefe conclufions: viz. either that the debility, which is fuppofed to be the caufe of fever, is of a peculiar but unknown kind; that it ceafes to act, or changes its mode of action from an accidental caufe, or from fomething in its own nature; or that a reaction arifes in the fyftem, from a principle of confcioufnefs of the deftructive tendency of this debilitating power. It is not con- fonant with the common laws of the animal economy; that reaction fhould arife in that part of the fyftem, where the debilitating.influence has been primarily and principally exerted. Suppofitions of this nature, are only fubterfuges, and no more in reality than myfterious ways of acknowledging ignorance. The opinions I have enumerated above are the principal ones, which have been advanced by medical writers, on the fubject of the proxi- mate caufe of fevers. Though numerous, they are all reducible to two general claffes; viz. either to conjectures, which are totally without foundationi or to circumftances, which are in fact only fymptoms or parts of the difeafe, fome of which are more, others lefs effential. The proximate caufe of fever, is i cer- tain peculiar ftate of the body, on which the difeafe, or the fubfequent parts of the difeafe, neceffarily de- pend. It ic, in fhort, the firft effential action of the febrile caufe; but this action is fo intricate and diffi- cult to be difcovered, that phyficians have fought for it in vain for more than two thoufand years. The ancients were fatisfied with the idea of preternatural heat, excited in the heart, and communicated, by CAUSE OF lTVEFt.' ' $$ means of the blood and fpirits, to the reft of the body. Hoffman, making a bold er ftep, intro luces a fpafmodic affection of the moving fibres; aul Dr. Culien, go- ing ftill farmer, lays the principal ftrefs. upon lan- guor and debility, or weakened action of the nervous energy. Increafed heat, fpafmodic ftrictpr: and marks of debility are generally prefent, in various degrees, inthedifterentftagesof fever; butdebility for the moft partprecedes the others ; and on this account, if equal- ly eflential, has a preferable right to be confidered as the firft part of the difeafe. There is ftill reafon to doubt if it actually is the firft. I have myfelf at- tended carefully to the manner in which intermitting fevers approach. The firft thing which I obferved in others, or what is ftill more to be depended upon, the firft thing I felt in myfelf, was ufually a difagree- abie, but a peculiar affection of the ftomach. The precife nature of this affection I am unable to define in words; but I knew it fo well by experience, that I always confidered it as a warning, (and it was fometimes the only warning, which I had,) of the approach of the paroxyfm. It was often accompa- nied by flatulence, and it fometimes preceded the firft feelings of the languor and debility, nearly the fpace of an hour. The obfervation of this fact has occured to me frequently; and I cannot avoid con- cluding, that it gives room to believe, that the de- bility, which is fo commonly the fore-runner of fever, inftead of being the firft and principal mode of ac- tion of the febrile caufe, is only a part of that action, —perhaps not the moft eflential. As Hippocrates appears at a very early period to have been perfectly fcnfible, that fomething befides a fimple increafe of heat was neceflary to conftitute a fever; fo we may now perhaps conclude, with equal reafon, that debi- lity has fome other circumftances combined with it, which we have not beenx able to difcern very clearly- 86" THE PROXIMATE. Having faid that there are not any of the numerous theories, which have as yet been offered to the public on this important fubject, in any degree fatisfactory, it might be expected, perhaps, that 1 had fomething of my own to bring forward, which might be more perfect, at leaft in my own opinion: but I willingly acknowledge, that I have no fuch pretenfions. After fourteen or fifteen years of careful obfervation, and daily reflexion on the phenomena of fevers, I am obliged to confefs, that my opinion ftill remains to be formed. The proximate caufe of this difeafe, is a fubject of a dark nature. It is fuch, perhaps, as our limited capacities will never develope. But though we defpair of ever attaining clear ideas of its fpecific nature, there are ftill fome ufeful circum- ftances connected with it, which we comprehend with clearnefs. We know, that the more general remote caufe6 of fevers, are certain invifible exhala- tions, fometimes more evidently arifing from marfhy grounds, fometimes more obfeurely diffufed in the air, and fometimes obvioufly proceeding from the bodies of our fellow creatures. We know, likewife, that thefe caufes which are unfriendly to the human conftitution, are varioufly modified and combined, and of various degrees of force or in various ftates of concentration; but we proceed no farther with cer- tainty. We are not able to afcertain the nature of thefe effluvia, and it is only by conjecture that we trace them in the channels by which they enter the body. The changes which they operate on the folids, fluids, or nervous fyftem, before their action becomes obvious, are totally unknown to us. We know, though the body lie expofed to exhalation, even in a concentrated ftate, that an appearance of difeafe is not, generally, the inflantaneous confequence. A fpace of time intervenes, various indeed according to circumftances, but always fuch as gives room to believe, that the caufe requires, and actually under- CAUSE OF FEVER. 87 goes a modification, before it is capable of producing a fever, or the paroxyfm of a fever. The circum- ftances connected with the approach of fevers, parti- cularly intermitting fevers, afford an illuftration of my meaning. The caufe of the difeafe, fo far from producing the fever immediately when applied to the body, often lurks for a confiderable time in the con- ftitution, without perceptibly injuring the ordinary actions of life. Sometimes it gives rife to affections, which are apparently very different from their real nature. Thus a perfon often languifhes for days, weeks, or even longer. The indifpofition fuddeniy and unexpectedly vanifhes: and the apparent reco- very of health is foon followed by a paroxyfm of re- gular fever. In other cafes again, the attack of the difeafe is fudden; and its formation from the begin- ning diftinct. This fact affords a prefumption, that, in confequence of a particular modification, which is only accomplifhed in a certain fpace of time, but the nature of which we do nor in th— leaft compre- hend, an aptitude is regenerated between the remote caufe of the difeafe, and the relative ftate of the body. When the ftate of the body, and the remote caufe ap- proach to, or arrive at a ftate of mutual correfpon- dence, the difeafe is produced. When this ftate, which I call an aptitude, is changed or deftroyed, the difeafe vanifhes, or fuffers a change of form. This is a fact, which cannot be difputed ; and it feems to be the extent of our knowledge, on the important fubject of the proximate caufe of fevers. I 2 t S8 ] CH A P. VI. OF .THE GENERAL HISTORY OF THE FIViR OF JAMAICA. IT. will not be improper to remark, before I begin to deferihe the hiftory of this fever, that though the endemic which prevailed at Savanna la Mar, not- withftanding much variety of forms and fymptoms, is confidered as only one and the fame difeafe, yet it may alfo be obferved, that the variety of thefe appearances is fometim.s fo great and remarkable as to occaiion confiderable perplexity to the practitioner. The fymp- toms and form of this endemic appeared, on a fuper- ficial view to be conftantly varying ; yet by attend- ing more clofely to the courfe, progrefs, and changes of the difeafe, thefe apparent irregularities vanifhed gradually, the-varieties being in fact only accidental, and often depending on very trivial caufes. The ana- lyfis gf the different cafes of fever, which came under my care, during the time that I lived in Jamaica, furnifhed me with this information. I formerly mentioned the manner in which my obfervations were conducted : I have only now to add, that I truft the method, which I adopted, has enabled me to give a more accurate hiftory of the fever of Jamaica, and to explain more fatisfactorily than has been done hi- therto the various fources of the many irregularities which are obferved to occur. I am perfectly fcnfible that my experience has been too limited, to give me hopes of rendering the prefent work complete; yet I would flatter myfelf, that it will not be altogether ufelefs : I totally difclaim theoretical opinions, and content myfelf with a plain narrative of facts; neither do I afpire to any higher praife, than care in obferving FEVER OF JAMAICA. 89 the appearances of the difeafe, and truth in relating the appearances which I have feen. Before proceeding to give a particular hiftory of the different varieties of the endemic fever of Jamaica, it will not be improper to mention the more general fymptoms, which diftinguifh the difeafe, and to trace an outline of the courfe, which it has been commonly obferved to purfue: and I may remark in the firft place, that though debility is ufually confidered as the firft fign of an approaching fever ; yet, if we attend minutely to all the circumftances of invafion, it will not generally be difficult to perceive, that a difagree- able, though undefcribable affection of the ftomach, takes place previous to the fmalleft perceptions of languor or debility, which are commonly only imme- diate fore-runners of coldnefs and fhivering. This coldnefs, which was obferved to be various in dura- tion, as well as in degree of force in the fevers of this country, was fucceeded by flufhings of heat al- ternating with the cold, and increafing gradually till the heat at laft prevailed. The hot fit, which was likewife of various duration and of various force, had many n;w fymptoms joined with it, the principal of which were fuch as fhewcd an increafed circula- tion, or an irregular determination of the blood to , the different parts of the body. This hot fit, and the difturbances connected with it, according to cir- cumftances, continued for a longer or fhorter fpace of time; at laft fweat breaking out on the head and breaft, extended itfelf gradually to the extremities, and accomplifhed after a certain continuance, either a total remiffion of the fever, or a confiderable abate- ment of the violence of the fymptoms. It is almoft unneceflary to mention, that this remiffion or abate- ment of fymptoms was of longer or fhorter duration, and more or Lfs complete in fevers of different forms. An aggravation of fymptoms fucceeded to the re- I 3 <)0 HISTORY OF THE miffion; but it was ufually obferved to begin with- out preceding coldnefs, and frequently without marks of preceding languor or debility. The hot fit now ran high, and all the fymptoms were frequently more violent than they had been obferved to be in the firft paroxyfm. Sweat at laft made its appearance, fol- lowed in moft cafes by a remiffion, lefs perfect in- deed, than the preceding one, but ftill diftinct enough to be clearly traced. In this manner things went on for a longer or fhorter fpace of time, the paroxyfms ufually increafing in violence, and the remiffions be- coming fometimes more, though in general lefs per- fect, as the difeafe advanced in its progrefs. I may further obferve, that there was occafionally a change of the type, fometimes a change of the nature of the fymptoms in the courfe of the illnefs; and that, where either of thefe were the cafe, the difeafe was ufually of longer continuance; at the fame time, that the order of the critical days was difturbed in confe* quence of thefe changes. The.refemblances,which I have mentioned above, were found in all the different fpecies of the remit- ting fever of Jamaica ; but from caufes, which were not always perceived, and which fometimes appeared to be very accidental, the difeafe was diftinguifhed in a part, or in the whole of its courfe, by the preva- lence of a train of fymptoms of fuch a particular na- ture, as jgave occafion to the diftinctions of inflam- matory, nervous, malignant, putrid or bilious; the feparate hiftories of which I (hall now relate more circumstantially. FEVER OF JAMAICA. 91 SECTION I. OF FEVER DISTINGUISHED BY SYMPTOMS OF IN- FLAMMATORY DIATHESIS. THE variety of fever, which I fhall defcribe firft, is that, where the inflammatory diathefis prevailed in different degrees. Where this diathefis was moderate, the difeafe was ufually of the leaft complicated form, as well as of the leaft dangerous nature, of any of the fevers of Jamaica. The pa- roxyfms were generally regular, and complete in all their parts, and terminated, for the moft part, by a copious fweat, in a perfect remiffion : the pulfe was full, ftrong, and regular; without uncommon hard- nefs or tenfion; whilft the heat of the fkin, though fometimes great in degree, was generally free from that burning pungency, fo common in fome other /pedes of fever. It was lefs removed, in fhort, from; a fimple increafe of the natural warmth. I may fur- ther remark, where this moderate degree of inflam- matory diathefis characterized the genius of the dif- eafe, that the danger was feldom great; and that the termination or crifis was generally regular and final. But though this degree of the inflammatory diathefis was frequently obferved to be a fign of fafety, and of regular crifis : yet it alfo often happened, where the diathefis prevailed in excefs, that the fymptoms of ex- citement ran unufually high,and that a ferious danger threatened life. The pulfe, in fuch cafes, was not only frequent during the paroxyfm, but it was like- wife, quick, hard, and vibrating ; the heat was often intenfe ; the internal functions and the various fe- cretions, were confiderably difordered ; at the fame time, that a very obftinate fpafmodic ftricture pre- vailed on the furface of the body. The remiffion which followed, for the moft part, was obfcure; th* 92 HISTORY OF THE pulfe frequently retaining a preternatural quicknefs and hardnefs; whilft there was generally a confider- able degree of febrile heat on the fkin. The fymptoms, which I have juft now mentioned indicate different degrees of the real inflammatory diathefis ; but befides actual fymptoms of real in- flammatory diathefis, there were likewife found fevers, with the appearances of a fimilar difpofition, though the real genius, of the difeafe was in reality of a dif- ferent nature. It is of importance in practice to dif- tinguifh thofe ambiguous appearances ; but it is not always eafy to do it with certainty. We may re- mark, however, that the apparent inflammatory dia- thefis was ufually accompanied with marks of great irritability, and fometimes with marks of violent ex- citement during the paroxyfms ; while languor and great depreflion of fpirit were frequently perceived to attend the remiffions. The pulfe, which at one tjme was hard, irregular, and quick, at another was frequent and low, and funk under a fmall degree of preffure. The heat of the body was not always great, yet it was pungent,—and left a difagreeable fenfation on the hand : the fecretions were often ir- regular ; the countenarice was confufed, clouded and overcaft, the eye was fad, and fometimes appeared as if it were inflamed ; the feelings were unpleafant to the patient himfelf: there was great irritability of temper; and the ftate of the fkin im-reffed us with the idea, that there was a ftrong fpafmodic ftricture prevailing on the furface of the body.—The above are the principal circumftances, which were ufually prefent in the different ftates of inflammatory fevers; yet thefe circumftances were fometimes fo varioufly complicated and combined with others, that the ac- curate difcrimination of them muft be left, in moft cafes, to the obfervation of the individual himfelr. Thofe different ftates and degrees of the inflam- matory diathefis, which I have defcribed above, were INFLAMMATORY FEVER. 93 fometimes general throughout the whole of the body, not affecting one member more remarkably than an- other ; fometimes they were partial or feemed to be connected with a principal affection of a particular part : and where this was the cafe, the local affec- tion, and the general diathefis of the fyftem, ufually had a mutual correfpondence with each other. Thus, where the inflammation affected the fubftance of the liver or lungs, the general Inflammatory diathefis was ufually in a moderate degree ; while the higheft ex- cefs of general vafcular excitement often accompanied inflammations of the membranes of thofe organs. But though inflammation of membranes was often accompanied with a high degree of general inflam- matory diathefis; yet there were likewife fome. kinds of thofe local inflammations which communicated only a low, or an ambiguous degree of their diathefis to the general fyftem : fuch are fome of thofe inflam- mations, which occafionally affect the furface 6f the alimentary canal, and which appear, in general, to be of the eryfipelatic kind. SECTION II. • F FEVER WITH SYMPTOMS OF NERVOUS AF- FECTTON. THE endemic fever of Jamaica, was not oftener diftinguifhed by fymptoms of general inflam- matory diathefis, than by circumftances of nervous affection. The beginning of this form of the difeafe, was often characterized by a high degree of that difagreeable affection of the ftomach, as alfo by much of that languor and debility, which are commonly fore-runners of fevers in general. To thefe fymp- .toms fucceeded a flight degree of chillinefs, followed 94 SYMPT0M5 OF by a hot fit, which often continued long, but feldom ran high. The pulfe was fmall, frequent, and eafily comprefled. It varied with change of pofture;-~ and fometimes was fo much affected when the patient was raifed upright, as totally to difappear ; the heat of the body was feldom great; the fecretions and ex- ertions were generally irregular, and the internal functions were much difordered. The mind was ufually affected, affected however in various degrees, and in various ways. Sometimes there was a lively de- lirium, fometimes the delirium was low and defoond- ing ; and, as the one or other of thefe was the cafe, the appearance of the eye and countenance was chearful or fad. The tongue was fometimes moift, fometimes dry, but feldom very foul; thirft was irregular, naufea was frequent, and the ftate of the ftomach was generally very irritable. There was likewife, in moft cafes, deep and heavy fighing, and, unlefs in times of pre- ternatural excitement, a very urcommon degree of defpondency. The above Were the principal fymr*. toms of the nervous fever of Jamaica. The. parox- yfms in this difeafe feldom exceeded twelve hours in duration ; while the termination or abatement, was ufually diftinguifhed by feveating, though feldom by fuch fweatings as extended completely to every part of the body. The remiffions were not by any mecns perfect: the headrach, and other difagreeable feelings ufually abated; but figns of languor ftill continued, and marks of fpafmodic ftrifture for the moft part re- mained on the furface of the fkin. I may further obferve, that as the paroxyfms generally increafed in violence, in the progrefs of the fever ; fo it was very feldom that the remiffions put on an appearance of greater diftinctnefs, as the difeafe approached to its termination. Such is the general hiftory and the progrefs of the difeafe, which might be diftinguifhed by the name of the nervous fever of Jamaica: but befides thofe cir- NERVOUS FEVER. 95 cumftances, which I have mentioned above, others were fometimes found attending it, which, though lefs regular and conftant, deferve ftill to be taken no- tice of. Thus the firft ftage of the paroxyfm, inftead of the more ufual appearances, was occafionally dif- tinguifhed by fits, which appeared to be of the epi- leptic kind. Thefe fits in fome cafes were fucceeded by a lively delirium, in others by ftupor or infenfi- bilify. The delirium, which was a common fymptom of this difeafe, ran high in feveral inftances; though it more generally amounted only to an abfence of thought, or difficulty of recollection. It is a circum- ftance of fome curiofity likewife, that inftead of a paroxyfm, confifting of different parts in a certain order of fucceffion, there was fometimes a total ftupor and infenfibility, which continued for a determinate fpace of time, without even being fucceeded by ob- vious marks of fever: whilft the time of the paroxyfm, in other cafes, was diftinguifhed by fuch a degree of tremor and mobility, as nearly approached to the difeafe known by the name of St. Vitus's dance. And further, befides thefe ftrange and irregular ap- pearances, fpafms and excruciating pains in different parts of the body, in many inftances, were the lead- ing, indeed almoft the only fymptoms of the difeafe. It is not only curious, but it-is indifpenfably necef- fery in the conduct of our practice, to obferve with attention the various modes of action of the caiife of fevers, and to eftimate with precifion the various combinations. The caufe of fevers, in exerting its principal action On the nervous fyftem, fometimes produces excitement, fometimes occafions depreffion; effjets opposite to each other in their nature. Ex- citement rnd depreffion are two general and oppofite modes of .cfion; yet befides thefe we often obferve others, which do not belong wholly to* the one or the other, but v/hich feem to be compounded of both, in a manner we do not very well comprehend. This 96 SYMPTOMS OF caufe of fever likewife, which acts in directly oppo- fite ways, appears alfo to exert its action more pow- erfully at different times on one part of the fyftem than on another ; that is, it acts fometimes more im- mediately on the brain, or reafoning faculty, fome- times more directly on the nerves, or moving powers of the body. It may even be obferved further, that all thefe modes of action, which are preferved diftinct at one time, are combined in various degrees at an- other. Thuc, where the caufe of fever >acts by pro- ducing excitement, lively delirium in various degrees is.the confequence; while languor, ftupor, and in- fenfibility naturally follow the oppofite mode of ac- tion. Low delirium, tremors, ilartings, &c. are pro- bably owing to a compound effect. Both modes of action fucceed each other rapidly; or perhaps both modes are actually prefent at the fame time, though probably in different degrees, in the different por- tions of the brain. This fact at leaft is certain, that obvious depreffion is often combined with figns of great irritability. It is a remark likewife of confider- able importance, that the natural functions are lefs difordered, where the caufe of the difeafe acts upon the nervous fyftem internally, or principally difturbs the intellectual powers, than where this action is ob- vioufly external: the pulfe is then more regular, though often obfcure ; the difpofition to faint is not fo great; mufcular mobility is lefs remarkable, and local pains are felt lefs acutely. On the contrary, where this caufe acts externally, or chiefly affects the moving p >wers, the difpofition to faint in changing pofture is more remarkable; tremors, flattings, &c. are more common; appearances, in fhort, are more fluctuat- ing and often more alarming. It is a matter not lefs ufeful than curiousto diftin- guifh the different fpecies of delirium in fevers, to trace the different combinations, and to mark the ap- parently trivial caufes, which excite, or which fome- NERVOUS FEVER. 97 times remove thofe derangements of the'reafoning fa- culty. It is a remark, which has been often made, that' while one delirious perfon in fever appears only to be in better fpirits than ufual, another, or perhaps the fame perfon in another paroxyfm of the fame dif- eafe, is outrageous or perfectly furious. A third is low and languid, abfent and inattentive, or, with a fixed look of vacancy, does not feem to be otherwife deranged, than by requiring greater time to recollect himfelf. To which we may add, that there are fome, who talk coolly on things in general; but who cannot bear mention of fome particular fubje£ts. SECTION III. OF FEVER IN WHICH ARE DISCOVERED SIGNS OF MALIGNITY. THE feverof Jamaica, as diftinguifhed by figns of inflammatory diathefis, or by circumftances Of nervous affection, prevailed principally at Savan- na la Mar; yet befides the above forms of the dif- eafe, there fometimes likewife occurred others, which fhe wed marks of peculiar malignity. It is difficult to define precifely in words the character of the dif- eafe, which I now attempt to difcribe; its diferimi- nating marks, not confifting fo much in one or two fymptoms, as in a certain affemblage of circumftances; refiding chiefly in the ftate of the eye and counte- nance of the patient, and conveyed with difficulty in verbal defcription. I may remark, u\ the firft place, that there was feldom any thing very particu- lar in the manner of invafion of this fpecies of dif- eafe. The cold fit was rarely violent in degree, though it was often of long continuance: neither djd the hot K 98 OF MALIGNITY fit ufually run high, in the common acceptation of the word, though it was fometimes attended with circum- ftances peculiarly difagreeable. The pulfe varied re- markably. It was obfcure, or fcarcely to be felt in fome ; in others it was ftrong, though unequally fo; the artery, in many inftances, being hard and con- tracted, with a peculiar vibration in the ftroke. Af- ter thefe fymptoms and others, which are ufual in this ftage of fever, had continued for a longer or fhorter time, fweat began to make its appearance on the head and breaft, which extending itfelf gradually to every part of the body, was at laft followed by a remiffion, tolerably perfect for the moft part, though there ftill remained fome ftrange and unpleafant fenfations. It does not appear that there is any thing very uncom- mon in the fymptoms, which I have hitherto taken notice of: thofe which follow are more characterlftic. The ftate of the eye and countenance, afford the fureft figns of the malignity of the difeafe ; but there is dif- ficulty in difcriminating thofe appearances. The face is not unufually flufhed in fevers; but, in the prefent cafe, the countenance exhibits fomething elfe befides an appearance of fimple flufhing. It is likewife grim, dark and overcaft, with fuch marks of confufion and diftrefs, as if the patient were agitated by fome re- fentful paffion. The eye is fad and defponding; and the whole appearance, in fhort, indicates fuch a ftate of mind, as we fhould be difpofed to ftyle malignant. It is in fuch a ftate of the countenance as I have def- cribed, that the character of this fpecies of fever chiefly refides ; yet befides this, fome other circum- ftances frequently attend the difeafe, which are lefs ufual in ordinary fevers. The paroxyfm for inftance returned, for the moft part, much fooner than the regular period, always with greater violence, and fometimes with new and alarming fymptoms. It de- clined in twelve or fourteen hours; but the remiffion was lefs perfect than the preceding one; the next re- IN FEVERS. ()<) turn of fever, which was likewife much earlier than the ftated hour, was often ufhered in by convulfions, and the time of it occupied by ftupor or coma. The tongue was likewife irregularly moift or dry. If dry, it was generally covered with a black fcurf; if moift, with a thin glutinous coat, through which the red furface fhining obfcurely, prefented an appearance of a leaden colour. In this cafe the mouth abounded with a ropy faliva. But befides the above fymptoms, there were alfo violent twitchings in the flomach and bowels, fuddenfqueamifhnefs, faintnefs, anxiety, reft- leffnefs, frightful dreams, diftreffing apprehenfions, and frequently after the fecond paroxyfm, a particu- lar crouded eruption (not unlike iron-burnt blifters,) on the upper lip, which for the moft part fpread to- wards the nofe. 1 ne type of this fever, it may be further remarked, was ufually of the fingle tertian kind, generally anticipating by long anticipations. In moft inftances this malignant difpofition was dis- coverable at the very beginning ; yet in others, no fymptoms of a doubtful nature made their appearance till after the third revolution. SECTION IV. OF FEVERS IN WHICH ARE OBSERVED SYMP- TOMS OF A PUTRESCENT TENDENCY. WE meet with the term putrid fever, or fever with putrefcent tendency, in the writings of almoft every author who has treated of the difeafes of hot climates: but though this expreffion is fo much the common language of practitioners, I cannot he\$p obferving, that a remitting fever, with fymptoms of a fpecific putrefaction, did not once occur to my K 2 IOO SYMPTOMS OF A obfervation in the ifland of Jamaica, during the time that I lived in that country. I muft however add, 4that though a remitting fever fpecifically.putrid is ac- tually a rare difeafe; yet I do not attempt to deny, that a putrefcent tendency is frequently prefent inthe primse viae, in a very confiderable degree ; and that marks of it are fometimes difcoverable, even in the general fyftem, at a late period of the illnefs, when the vigour of life has abated, and the powers of cir- culation have begun to fail. This however is fo ac- cidental and uneffential, that it is only in compliance with the general language of medical people, that I think it neceffary to defcribe a difeafe, where thefe (fymptoms are obferved to prevail. The tendency to putrefaction, which was obferved in the fever of Ja- maica, fometimes begins inthe primae viae; and from the primae vire was communicated to the reft of the fyftem; fometimes it remained confined to the limits of the inteftinal canal, throughout the whole dura- tion of the diforder; in which cafe iflatulence, ructus, anxiety, naufea and thicft were the fymptoms which were chiefly troublefome: -the belly likewife was ge- nerally loofe, at the fame time that the ftools were dark and fetid. But where this tendency was com- municated from the primae viae to the reft of the body, or othewife made its appearance .in the general fyftem, a form of difeafe arofe diftinguifhed by the following fymptoms. If the tendency to putrefaction appeared at an early period, the heat of the fkin made a more d fegreeable impreffion on the hand, than was ufual in fame other fevers ; the fkin itfelf was likewife for the moft part, dry and conftricted ; the thirft \was"ir- regular, fometimes intenfe, fometimes from local af- fection of the fauces, apparently little increafed.— The appearance of the eye was often fad ; fometimes it gliftened with unufual brilliancy; fometimes itfeern- ed to be inflamed. The countenance was generally flufhed, often particularly confufed, and of a grim PUTRESCENT FEVER. IOI and clouded afpect. I have however frequently ob- ferved, where fymptoms of putrefcency difcovered themfelves at a late period of a fever, the preceding courfe of which had been diftinguifhed by circum- ftances of nervous affection, that the bloom of the complexion was uncommonly fine and delicate. To the above fymptoms might be added, great irritabi- lity of temper, general uneafinefs of fenfation, and diforder in all the functions of the body. When the fever affumed this appearance, paroxyfms and remif- fions were generally obfcure and irregular. The fe- ver indeed often fubfided in a fmall degree; but the future remiffions generally became lefs diftinct, as the difeafe proceeded in its courfe. The tongue af- fumed different appearances, at different periods and in different perfons. In fome it was moift, in others parched and dry. It was not univerfally foul, at leaft it frequently happened, that the edges were clear and beautifully red in their colour.. The lips likewife were fometimes fmooth, and of a cherry-like appear- ance ; at the fame time that the gums were inflamed and fpongy, as they ufually are in fcurvy : the pulfe likewife was fmall for the moft part; but it was irre- gularly fo. I fay noth ing of the difpofition to faint in erect pofture, which though generally enumerated among the figns of putrid fevers by authors, does net in fact appear to conftitute a criterion of the difeafe. K3 lot OF FEVERS WfTH SECTION V. OF FEVERS ACCOMPANIED WITH AN WCREASEJ) SECRETION OF BILE. THOSE fpecies of fevecs, which I have men- tioned above, feem to affectthe general fyftem, or every part of the body nearly alike ; but befides thefe, we fometimes meet with others, which are diftinguifhed by local affections, or increafed deter- minations to particular parts in a degree fo remark- able, as to pcrfonate very exactly a peripneumony, a hepatitis, or inflammation of the -bowels; the accom- panying fever being at the fame time fo flight, as fcarcely to be confidered as a primary affection. As an accident fimilar to thefe local affections of the liver or lungs, we may reckon an increafed fecrer tion of bile. The caufe of fever, from circumftances which we do not always perceive, fometimes acts with particular violence on the biliary fyftem, in con- fequence of which the fecretion of bile being preter- naturally increafed, a difeafe arifes, which without much impropriety may be called bilious. But though this irregular action of the morbid caufe, on the bi- liary fyftem, frequently gives rife to bilious appear- ances in the fevers of Jamaica; yet thefe appearances are in fact often owing to'caufes more accidental, and more remote than even this. Naufea and vo- miting are among the common fymptoms of fevers in every country; but they are particularly frequent in thofe of the Weft-Indies. It is well known that a continuance of naufea, or that a repetition of the action of vomiting, increafes the deteimination, not only to the ftomach, but likewife to the parts which are near to it. Hence the fecretion of bile is pre- ternatural' v increafed fecondarily by the ordinary ef- fect of vomiting, and bilious appearances become a SECRETION OF BIUE. IOJ neceflary confequence of this accidental fymptom of the difeafe. In thofetwo manners, viz. tn confequence of the irregular action of the morbid caufe on the immediately biliary fyftem, or from a fecondary ef- fect in confequence of its action on the ftomach, the the'bilious fever may, m fome refpects, be confidered as a difeafe of nature j but befides this, it often ori- ginates from -ovtr own treatment, viz. from the re- peated ufe of emetics, or of cathartics, which are vio- lent in their operation. The accidental appearance of bilious vomitings, inthe fevers of hot climates, fur- niftied medical authors with a pretence of forming a new theory, and of directing the mode of practice to a particular view. Influenced by this appearance, they affume it as a fact, that a vitiated quality, or a redundant quantity of bile conftitutes the eflentizl caufe of the difeafe ; and on this foundation adopt the plan of repeated evacuating, both upwards and downwards ; a practice Which evidently increafes the fecretion of the bile. Hence, a difeafe, or the fymp- tom of a difeafe, arifes wholly from this mode of treat- ment ; and the removal or cure of it is afterwards attempted by a perfeverance in the means, which ori- ginally gave rife to it:—of this I have feen numerous examples. I have now defcribed the remitting fever of Ja- maica, as characterifed by fymptoms of a different appearance. I may further remark, that where thefe fymptoms were unmixed with each other, there was little difficulty in the diftinetion, and little embarrafl- ment in planning or executing the indications of cure: but it fometimes alfo happened, that the different fpe- cies, which 1 have defcribed feparately, was fo per- plexed and complicated, that it appeared uncertain to which kind the difeafe properly belonged; or to which view the practice ought to be principally di- rected. Symptoms of putrefcency, for inftance, were often combined with fymptoms of apparent inflam- 104 0F FEVERS &C. matory diathefis; as fevers with nervous affection, or putrefcent tendency, were fometimes accompanied with marks of peculiar malignity. It happened often likewife, that the nature of the difeafe fuffered a total change after a certain duration ; or that a fever with one train of fymptoms ceafed, whilft another with a different train began. It would be a matter of no fmall importance, were we able to afcertain the various caufes, which influ- ence the various appearances of the fame difeafe; but this knowledge is not eafily attained:—much of it indeed lies beyond the reach of our comprehenfion. We may however remark, that the feafon of the year ufually has fome effect on the diathefis of the fyftem, and often on the type and form of the fever. Thus, in the dry feafon, though the remiffions are not always more perfect, the type is commonly more fimple, and the general diathefis is oftener inflammatory. In the rainy months, on the contrary, remiffions are more perceivable, but the type is more complicated, and the general diathefis of the fyftem has a ftronger ten- dency to putrefcency, often with a mixture of fymp- toms of nervous affection, fometimes with fymptoms of a malignant nature. The ftomach, bowels, and biliary fyftem likewife fuffer more in this feafon than in the drier months of the year. But befides this difference, which arifes from feafon, we alfo find very conftant effects from local fituation. Thus in hilly countries there is generally more of the inflammatory diathefis, with more frequent determination to the head and lungs, and lefs obvious remiffions, than in flat and champaign countries, where the ftomach and biliary fyftem fuffer in a more peculiar manner., C 105 J CHAP. VII. QF PROGNOSTIC IN THE FEVER-3 OT JAMAICA. TO be able to perceive at a diftance, the approach of danger or returning health, is a knowledge highly fetisfactory and ufeful to the phyfician ; 'but it is a'knowledge which is not eafily attained: ;for to judge with certainty of theevent pf fevers, requires not only long and attentive Obfervation, but a dif- crimination of complicated and arribiguous appear- ances, which does not depend always upon attention alone. The fagacious Hippocrates is generally con- fidered as the firft, who laid the foundation of the fcience of prognoftic ; and we certainly muft allow, that he has left us many important and valuable-ob- fervations on the fubject; yet we may alfo add, that 1iis decifions in many inftances, are precipitate. •Hippocrates feems generally'to have placedtoo great confidence in figns feparately confidered, and to'have (formed his conclufions too often on the authority of •fingle facts. Thus he has fometimes confidered as fatal in themfelves thofe figns, Which in reality are ■only dangerous. The abfolutely fatal figns 'in fevers are actually few in number. I am able fto affirm, from my own experience, that people are fometimes reftored tohealth after many of the ufually reputea •fore-runners of death are prefent. We have, in fact, as yet only an imperfect knowledge of prognoftic in •fevers; but the field is ftill open, and careful obfer- vation, it is to be hoped, may enable us in time to •fupply the defects. I dare not venture toaflert, that •I have advanced beyond others in this neceffary and difficult fcience; but I am difpofed to flatter myfelf, that the following attempt to appreciate the marks of danger or fafety in the fevers of Jamaica, may be J06 PROGNOSTIC IN THE found in fome degree ufeful. It contains the refult of my own obfervations in that country; and though I am perfectly confcious^that the rules are often defec- tive, yet I likewife know, that I have fuggeftedfome hints which have not been commonly obferved, and which may help to direct thofe, who have not had much experience of their own. Prognoftic is fuch, as applies to fevers in general, or more particularly to the different fpecies of the difeafe. The type or form, the general couffe and tenor of the diforders, and the general nature of the paroxyfms often afford ufeful information. From the ' type alone, we do not often obtain much that is to be depended upon- Long and diftinct intermiffions are commonly accounted figns of fafety; yet we fre- quently fee inftances of the fingle tertian proving fatal, while types of greater complication are often void of danger: in general, however, complicated types are fufpicious—and perhaps more commonly fatal than others. But though a knowledge of the type of the fever abftractedly confidered, does not com- monly afford any material indication of danger or fafety, yet the time of the return of the paroxyfnris a fubject, from which more maybe learned. An an- ticipation of an hour or two, is feldom much to be regarded ; yet an anticipation of ten or twelve is al- ways fufpicious. It either indicates a latent malig- nity, or a tendency in the difeafe to change to a con- tinued form. The complication of another fever, or the doubling of type is by no means favourable; yet it is much lefs to be dr^ded, than a long and an ir- regular anticipation. Anticipations have been gene- rally confidered as figns of the increafing force of the fever ; fo the type which poftpones, is ufually be- lieved to indicate a difeafe, which is hafteningto a fa- vourable termination : the effect however is fome- times the contrary. I have myfelf fecn fome inftances, where, in confequence perhaps of weaknefs and im- FEVERS OF JAMAICA. 107 paired fenfibility, the return of the fatal paroxyfm, though it probably had commenced fooner, was not clearly perceived till after the ufual hour of attack. But befides thofe indications of danger or fafety, which may be drawn from the nature of the fimple type, or from the hour of return of the paroxyfm, the ftate of the paroxyfms and remiffions deferves likewife to be attended to. It was generally obferved where the paroxyfms were regular, and affumed a com- pleter form in the progrefs of the difeafe, that there was not generally much reafon to dread an unfavourable event. Hopes of fafety might likewife be entertained with ftill greater confidence, where the paroxyfms, though more violent in degree, became more regular and dittinct after the ufe of bark, wine and ftimulants. On the contrary, it was always anindicrtion of danger, where they became longer or loft the diftinctnefs and regularity of their form, as the difeafe advanced in its progrefs. Changes from bad to good, in the courfe of the fever, alfo indicated more fafety as the oppofite changes indicated more danger, than if cir- cumftances equally unfavourable had continued from the beginning. In enumerating thofe particular figns or fymptoms, from which we are led to form a judgment of the event of the remitting fever of Jamaica, I fhall con- fider in the firft place the ftate of the pulfe. The pulfe is fo differently affected by the fame caufes in different people, and individually fubject to fo many peculiarities, that conclufions formed folely upon this bafis muft ever be fallacious. Hippocrates, who has treated very fully of the other figns of prognoftic, is totally filent on the fubject of the pulfe. He has mentioned the term, indeed, in feveral parts of his works; but it does not appear, that he had a perfect knowledge of the nature and indications of the pul- fations of the arteries. The fubject was fomewhat better underftood before the time of Ctlftis: yet this Io8 PROGNOSTIC IN-THE author does not believe, that any. information could be drawn from the ftate of the pulfe alone, which was in any. great degree to be depended upon,, Galen, who is generally, diffufe on every fubject,.has treated very fully of the nature of the pulfe. He ha* indeed multiplied, diftinctions to an amazing extentj ind fuggefted combinations of endlefs variety; yet notwithstanding this apparent minutenefs, there are ftill feveral important obfervations with refpect to itj which have efcaped.him.altogether. It is not many years ago, that Dr. Solano,.a Spanifh phyfician whq practifed at Antequiera, opened fome new and cu- rious views concerning the pulfe, and its various indications. The detail of facts with which this writer has-fur- nifhed us, is really wonderful, and the candour with which he has related them, independent of. the tefli*. mony of feveral refpectable authorities, engages us to give him credit; I had not heard of Solano's dif- coveries at the time I lived in Jamaica, and I do not find that I had ever taken notice of obfervations fimilar to thofe he has mentioned. I was able indeed, for the moft part, to foretel from the nature of the pulfe, even in the beginning of the difeafe, whether the fever would be of a continued or remitting form; but I did not difcover any figns from it, which led me to form a judgment of the future mode of termi- nation. I may add, that I met not with any inftances of crifis by haemorrhage ; neither did I ever take no- tice of the rebounding, pulfe. The intermitting pulfe occurred frequently, fometimes as a forerunner of of death, fometimes as an attendant of favourable crifis: but I cannot fay, that I obferved that it: ever prefagi.d a future diarrhea. I fhall however pafs over the obfervations of others without further comment for the prefent, and content myfelf with relating thoffl circuraftar.ces of pulfe. connected with danger or fafety, as they occurred to my own obfervation in the FEVERS OF JAMAICA. IO9 remitting fever of the Weft Indies. I muft remark in the firft place, that independent cf peculiarities of constitution, a weak, a feeble and eafily compreffed pulfe was generally a bad one : a pulfe which was~ indiftinct and fmall, or fmall and hard, particularly at a late period of the difeafe, or together with de- lirium or clammy fweats, indicated for the moft part, the moft extreme degree of danger. That fpecies of pulfe moreover, where the ftroke was obfcure, or felt with difficulty, was fufpicious at all times; but it was particularly dangerous where accompanied with a wavering, a tremulous, a conftantly creeping or vermicular motion in the artery. I am not certain that my meaning will be clearly underftood; yet I believe that thofe who have once obferved this tre- mulous and creeping pulfe, will not eafily forget the danger which it indicates. It often attended a fever of a malignant kind, where the nervous influence ap- peared in fome degree, to be fufpended.—But to pro- ceed : it is an obfervation fo well known as to render any mention of it almoft fuperfluous, that a frequent, an irregular, a fluttering and intermitting pulfe com- monly indicates danger, fometimes approaching death: yet I muft add, that an intermitting pulfe fometimes attended the favourable crifis of a peculiar fpecies of fever. It was obferved, however, in fuch cafes, that the pulfe was not otherwife irregular, than by failing in its ftroke at the end of every third or fourth pulfa- tion, neither was it generally found to be uncom- monly frequent. Some inftances of this Angular appearance occurred to me during the time that I remained in Jamaica: fo thatl was in fome degree dif- pofed to rank the intermitting pulfe among the figns of favourable crifis, in a fpecies of fever, the pre- ceding courfe of which had been diftinguifhed by fymptoms of a peculiar nervous affection. When I became acquainted afterwards with the obferva- tions of Dr. Solano, I began to doubt whether the HO PROGNOSTIC IN THE intermiffion of pulfe, which I had met with in the fevers of Jamaica, might not have been a fign of ap- proaching diarrhea, which had not occurred to my notice, rather than a fign of proper crifis, as I had formerly imagined. I remained in this uncertainty till lately, that fome inftances of this fymptom hap- pening at the termination of fevers in this country, have helped to confirm me in the opinion which I entertained before. I found in thofe cafes to which I allude, that the pulfe intermitted after every third or fourth ftroke on the day, on which I expected the crifis. The intermiffion of the pulfe was not of fuch a nature as indicated approaching death; I there- fore looked watchfully for a diarrhea, but no diarrhea enfued. It muft be confefled, indeed, that one of the patients feemed to be much diftreffed with gripes and flatus; but being deprived of the power of fpeech we could not obtain any accurate idea of his feelings: and no evacuation actually took place, till the day following, before which time the intermiffion had dis- appeared altogether.—Befides the above, there are fome other figns of pulfe which have their particular indications ; but they are fo generally known, that it will not be neceffary to enlarge on the fubject. I fhall therefore only obferve further, that changes from better to worfe in the ftate of the pulfe, as the dif- eafe advances in its progrefs, are bad, while the op- pofite changes are favourable*, yet I muft likewife add, that in thofe cafes of favourable change, it will be neceffary todiftinguifh carefully the pulfe of coma, from the pulfe of returning health.—-The difference. is fometimes fcarcely to be known, except from the attending fymptoms. Next to the ftate of the pulfe, I fliall mention thofe appearances of the tongue, which, together with other concomitant circumftances, frequendy afford figns of the mildnefs or malignity of the difeafe. Though we do not expect that the tongue mould be FEVERS OF JAMAICA. Ill of a healthy afpect, during the continuance of a fever; yet where it is dry only in a moderate degree, or where it is covered with a fmooth and whitifh coat, the difeafe for the moft part, is void of malignity, though not always of danger. On the contrary, where it is immoderately dry, or dry and black, the indications of danger are great, and I may add, ftill 'greater where a white flimy and glutinous fubftance covers its furface. This flimy ftate of the tongue was often feen at an early period, and as far as my experience goes, conftantly - indicated malignity. To the above we may add, a fodden or parboiled ap- pearance of the tongue, which was not of lefs dan- gerous import than the preceding. But befides thofe obvioufly unhealthy afpects of the tongue, its appear- ance in fome inftances was not different from its na- tural ftate, except in a certain lividnefs of colour. This was conftantly fufpicious, and if not fatal, was always extremely dangerous. The danger indicated by the tongue, when it is intenfely dry, rough, crack- ed, or ulcerated is generally known; but I muft not omit to mention, that when from a dry and unheal- thy ftate, it turns moift fuddenly, or affumes its na- tural appearance, whilft the other figns of favourable crifis did not fhew themfelves at the fame time, a change of the mode of action of the febrile caufe is indicated,—and generally a dangerous one.—I fay nothing of palenefs and tremor, as thefe fymptoms only indicate certain ftates of general or particular debility of the nervous fyftem. Vomiting is another of the alarming, and fome,r times of the dangerous fymptoms of the fevers of the Weft-Indies. If this fymptom continues during the remiffion of the fever, without material abatement, there is reafon to dread its conf quences ; but if it vanifhes or abates in a very material degree at the decline of the paroxyfm, it does not deferve to be fo particularly regarded. The practice however t« TI2 PROGNOSTIC IN THE which it leads is often ferious. Vomiting is fup- pofed by moft practitioners to indicate emetics; but the indication is fallacious, and the practice is often pernicious. During'the time that I lived in Jamaica, I had frequent opportunities of feeing vomitings ren- dered continual by the repeated ufe of emetics, which before this treatment, appeared to be only accidental fymptoms during the paroxyfm of the difeafe. I therefore at laft became cautious of purfuing this view, and have reafon to believe, that if I did not oftener do good than others, I feldomer increafed the danger. But befides the degree and frequency of the vomiting, the nature of the matters thrown up may likewife furnifh indications of the danger or fafety of the fever. The various kinds of bilious vo- mitings have been fully explained, and the danger of each has been fo particularly pointed out by many writers, efpecially by Hippocrates, that I pafs over the fubject without further notice, confidering it un- neceflary to repeat the obfervations of others. I muft however remark a more uncommon kind of vomiting, which fometimes happened in the fevers of Jamaica, add which I believe has hitherto efcaped the notice of obfervers. The vomiting to which I allude in this place, is a vomiting of a clear and ropy liquor, in which are often found fwimming flakes of a darker coloured mucus. This appearance was chiefly obferved, where the remiffions were indiftinct, and the fweats partial and incomplete. It conftantly afforded an indication of danger, and I feldom found that the ufual remedies were effectual in reftraining it. Vomitings of black and vitiated matters are com- monly known to be of the moft dangerous import,—* fucceeded by obfcure hickupings, they are often fore- runners of death. Yet though this is generally true, I muft not at the feme time omit to mention, that I have feen feveral inftances of recovery where black vomiting had prevailed for fome time; and other FftVERS OF JAMAICA. 113 cafes which give 'me room to conclude, that hickup- ings are not conftantly fatal. I take the prefent oppor- tunity to remark, that hickup was fometimes only a diftinguifhing fymptomof the difeafe, which increafed or declined with the paroxyfm ; and that in other in- ftances it attended the favourable crifis of fevers, the preceding courfe of which had been characterifed by fymptoms of nervous affection. This fpecies of hickup was generally alarming in degree, and equally inexplicable with the intermitting pulfe, which I mentioned above as fometimes attending a favourable termination. It often continued the fpace of twenty- four hours, in fpite of all that could be done by me- dicine. Next to the indications of vomiting, I fhall enu^ merate fuch as may be drawn from the prefence or abfence of thirft. Immoderate and unquenchable thirft has always been reckoned an unfavourable fymptom in fevers. It is fo undoubtedly, yet I have frequently feen very extraordinary degrees of it conr tinuing for a length of time, without particular dan- ger. Befides the defire for liquid in general, there is often an unconquerable longing for drinks of a particular kind;—a feeling which ought always to be attended to, and frequently complied with.—The defire for cold water is fometimes ravenous.—I have known it not only fatiated with fifety, but even with good effects. But though this immoderate thirft is juftly reckoned a bad fymptom in fevers ; yet an in- difference for liquid, with a dry tongue, and other marks of internal heat, is ftiil worfe. It has indeed been generally confidered as fatal; but here we ought to diftinguifh, whether it proceeds from local affec- tion of the tongue and fauces, or from a gent.ral failure of the powers of life. In the one cafe it is a mortal fign, in the other it can only be faid to be danger-jus. The andents, particularly Hippocrates and his L 3 IF4 PROGNOSTIC IN THE commentator Galen, have treated fo fully of the in- dications of evacuations downwards, that I fhould be able to do little more than to copy their obferva- tions. There is one fpecies of evacuation, however, which they do not appear to have defcribed very ex- plicitly, and which I have often obferved to be at- tended with great danger*. This is the frequent, fmall and ineffective excretion, and more particularly*' copious ftools, which refemble dirty water, efpeciahy if accompanied with tenfionof the hypochondria and abdomen. Medical writers have been long accuftomed to form a prognoftic of the event of fevers, from puftular or fcabby eruptions about the mouth : but the fign is ambiguous, arid cannot be depended upon, with- out many limitations. 1 fhall however relate that which has occurred to my own obfervation, without troubling myfelf about the opinions of others. And I remark in the firft place, that an eruption about the corners of the mouth, and near the lips, Which comes forth freely, and foon turns into a fcab, particularly if it does not appear till after the third revolution of the difeafe, affords a general fign of fafety, at leaft il affords a fign that the complaint has attained the height Of its violence. On the contrary, an eruption which fhews itfelf at an earlier period, which is crouded, and makes its way with difficulty, or which refembles iron-burnt blifters rather than puftules pro- perly fo c'llcd, particularly if it is on the upper lip, and fpreads towards the nofe, affords a general indi- cation of danger and malignancy.—Small and imper- fect eruptions likewife are frequently a fign of a te- diouc dfczfe. The ftate of animal heat is another of thofe cir- cumftances, which may be confidered as affording an indication of the nature and event of fevers. Where the heat of the body, in the remitting fever of Jamaica, was equally diffufed to the extremities, TEVERS OF JAMAICA. 11^ or not differing from an increafed degree of natural warmth, the difeafe was ufuallymild, without particular danger or malignity; but where acrid, fiery and pun- gent, though perhaps not much increafed in degree, danger was apprehended with reafon, particularly if the warmth was not extended equally to every part of the body. In the remiffions of thofe fevers, which were diftinguifhed by fymptoms of nervous affection, or, as is more commonly believed, putrefcent ten- dency, the heat of the body was often feveral degrees below the ftandard of health. The fymptom was alarming,but it was not in fact of much confequence. This diminution of the heat of the body, during the remiffion, was not by any means a rare occurrence; but befides this, there was fometimes obferved a de- gree of coldnefs, during the favourable crifis of ner- vous fevers, of a very fingular and extraordinary kind. In fome inftances this coldnefs was not infe- rior in degree to that of a perfon dying, or actually dead ; yet a diftinetion was perceived without diffi- culty. It was not accompanied with marks of ftric- ture on the furface of the body, at the fame time that the pulfe was generally foft, regular and full. Next to the ftate of animal heat it will not be im- proper to confider the indications of the various kinds of fweats. The figns of a favourable fweat are commonly known. Where that excretion was fluid, warm and univerfal, particularly where accom- panied with a foft, full and expanding pulfe, calm and eafy refpiration, general relief from fymptoms of dif- trefs, with a cheerful eye and countenance, we might in general prefume on fafety of the difeafe, often on its favourable termination. On the contrary, where the fweat was cold, clammy and partial, particularly where the pulfe became or continued frequent, fmall and tenfe, with anxiety, reftleffnefs and difturbed re- fpiration, a circumfcribed flufhing, a greafy hue of the countenance, or a wild and dejected appearance I iS PROGNOSTIC IN THE of the eye, the fituation was then alarming :•—"death, in fhort, was feldom far off. There is, however, an obfervation with regard to this fubject, which I muft not omit to mention. Authors, with one confent, have confidered cold fweats as certain mortal figns in fevers ; but there appear to be exceptions to this ge- neral rule. I met with feveral inftances, while I re- mained in Jamaica, where univerfal fluid fweats, of an extraordinary degree of coldnefs, accompanied the crifis of the difeafe. I was much alarmed when this appearance firft occurred to me, but my fears foon vanifhed, as I found that the pulfe became flower and fuller, that the refpiration became calm and eafy, and particularly that the eye and countenance acquired fuch a cheerfulnefs and ferenity, as are ufual at the fa- vourable termination of fevers. To the figns of prognoftic, which I have men-. tioned above, I fhall add thofe which are indicated by the general ftate of the vital powers, or by the more particular affection of parts, which are of imme-. diate importance to life. Among the firft of die af- fections of the vital organs, we fhall confider fuch in- dications as arife from a difturbed ftate of refpiration. A frequent, a hurried and unequal refpiration, (I do not fpeak of that which depends on primary affection of the lungs), is juftly confidered as a fign of a bad difeafe. This is more certainly the cafe, where ac- companied with deep and heavy fighing. Frequent fighing was a common fymptom in the fevers of Ja- in aic£, where the powers of life were deprcfled; and though not abfolutely a mortal fign, it conftv.ntiy in- dicated danger. Next to the ftate of refpiration, I fhall mention the ftate of the intellect, or reafoning faculty, which often afforded fome prognoftic of the event of the fever. Delirium, I obferved before, was a common fymptom in the remitting fever of Jamaica.' Where it vanifhed or abated as the .paroxyfm declined, it was fejdojqa, FEVJfRS OF JAMAICA. II7 found *o be of material confequence. On the con- trary, where it continued during the remiffion undi- minifhed in degree, it was a fymptom of the moft fe- rious nature. I mentioned in a former part of this treatife, that the caufe of fever appeared to act on the brain and nervous fyftem, in two general and oppo- fite ways; that is, by occafioning excitement or de- preffion. Of thefe two modes of action, depreffion was the moft dangerous; unlefs where the excite- ment ran uncommonly high. But though I obferved, that there are only two general modes of operation, viz. excitement and depreffion ; yet I muft alfo add, that the modifications are numerous,and very varioufly combined. Among the moft dangerous and alarm- ing fpecies cf the derangements of the intellect, we might reckon a ftern fullertoefs, an unmanageable fu- rioufnefs, picking the bedcloaths, tracing figures on the wall, and fuch other inftances of perverted judg- ment. Stupor and fufpenfion of the nervous influ- ence, as we might term it, were likewife greatly to be dreaded : unlefs they fhewed themfelves only during the time of the paroxyfm, they were generally fata), more certainly fo, if they followed convullions. As nearly conne£ted with delirium, we fhall now confider other difturbed ftates of the functions of the brain, viz. the ftates of reft and watching. We do not expect that fleep fhould be found and undif- turbed in fevers; yet we have been accuftomed to think favourably of the difeafe, where the patient is refrefhed by it. On the contrary, total want of reft, or unrefrefhing flumbers, conftantly indicate danger. There is, however, an aftonifhing diver- fity of conftitution in this refpect, that mufl always be taken into the account in forming an opinion, Want of fleep was obferved to give rife to delirium in fome perfons very fpeedily ; others fupported it for a great length of time, without any appearance of delirium or fpafmodic affection. An appearance o# I iS PROGNOSTIC IN THE fleeping, without actually enjoying the comforts of fleep is well known to be a dangerous fymptom; yet it is not by any means a mortal one. Anxiety and reftleflhefs, are often referred to the ftomach ; but reftleffnefs and jactitation, as depending on the ftate of the nervous fyftem, were likewife frequent, and generally dangerous fymptoms. Tremors of the tongue and of the hands were common appearances in fevers, with marks of nervous affection ; but I have likewife met with inftances, where the whole body fhook, when any motion was attempted, not otherwife than it does in paralyfis or chorea fancti viti. Startings and fubfultus tendinum were not un- common ; and they were juftly confidered as indica- tions of danger ; fometimes as forerunners of con- vulfion. A difpofition to faint, even actual faint- ing, was frequent in the fevers of this country. It was always dangerous, though perhaps lefs fo, than other fymptoms which were lefs alarming, particu- larly if it fuffered increafe and diminution with the paroxyfms and remiffions of the difeafe. But befides' thefe fymptoms, which indicate diminifhed energies, or irregular action of the nervous influence, we may likewife obferve, that the fphincter mufcles fre- quently lofe their power of contracting, particularly in the advanced periods of fevers. Thus perfons fometimes can only lie upon their back, the eyes and mouth are half open, the powers of fpeech and fwal- iowing are impaired or loft, and urine and ftools pafs off without confeioufnefs or againft their will. It is unneceflary to remark, that thefe are all fymptoms of the moft extreme danger. If they proceed from a general and uniform diminution of the powers of life, we may juftly confider them as fatal; if they are only produced by a certain mode of action of the febrile caufe, and are remarkably increafed during the paroxyfm, or aggravated by peculiar circumftances of conftitution, Ave fhall find many inftances of re- FEVERS OF JAMAICA. 110, covery. Thus, I have often feen people recover, who could neither fpeak nor fwallow ; who did not appear even to diftinguifh objects, and who were un- able to retain their urine and ftools ; or who were not confcious when they paffed ; yet I do not pre- tend to have met with any of thefe fortunate events, where thefe alarming fymptoms were the confequence of uniform diminution, or general extinction of the vital principle. From the figns which I have enumerated, fepa- rately and collectively confidered, we may in general be able to form fome prognoftic of the nature and event of the fevers of Jamaica. If to thefe we add thofe indications, which may be taken from the ftate of the eye and countenance, we may attain a ftill more fatisfactory knowledge. It is an obfervation which I have conftantlyjound to be true, that where the eye and countenance were ferene and cheerful, the difeafe was void of any latent malignity, though it might be otherwife of a dangerous nature. On the contrary, where the appearance of the eye was fad, watery, inflamed, or uncommonly gliftening ; where the countenance was of a dreary hue, downcaft, dark and clouded; and fometimes where it was of a beau- tiful blooming colour, which was not natural to the patient, there was always reafon to fufpect danger. But though a ferene and cheerful eye and counte- nance are generally indications of fafety, I muft not at the fame time omit to mention, that it fometimes happens in beginning mortifications, or in imperfect or unfavourable crifis, that the eye and countenance affume, for a fliort time, this flattering appearance of ferenity and compofure, though the hour of death is actually approaching faft. The indications from tha eye and countenance are of the greateft importance, in enabling us to form a judgment of the event of fevers ; but little of this knowledge is, in fact, com- municable in words. It muft be drawn, in a great meafure, from our own obfervations. 120 PROGNOSTIC, &c. I do not pretend that the figns of prognoftic, which I have enumerated in the preceding pages, are by any means complete, if referred to fevers in general; but I at the fame time believe, that they are lefs defec- tive, if applied more directly to the remitting fever of Jamaica. They were collected at a time when I was not much acquainted with books : and, on that account, I am induced to offer them to the public with more confidence; particularly, as I find that the indications, to which I have principally trufted, appeared in the fame light to fome authors, who are univerfally confidered as careful obfervers, and who practifed in climates, in many refpects, fimilar to that of the Weft Indies. I have difcriminated, as far as was in my power, between the doubtful and more certain appearances of danger or fafety; and I hope I have no where advanced any thing, which has a tendency to miflead the uninformed. I may add, that general knowledge in prognoftic goes no farther than a very rude outline, which individuals muft fill up from their own experience. There are, in fact, few figns in fevers, which are abfolutely decifive in them- felves ; and as thefe figns are often varioufly com- bined, fo they muft be Separately and collectively ef- timated. It is only from confidering accurately the refult of the whole, that we can be enabled to fpeak with confidence. x CHAP. VIII. #F THE DIFFERENCE BETWEEN A CRISIS AND SIMPLE REMISSION. IT is certainly a matter of fome importance, to be able to diftinguifh between actual crifis and the fimple remiffion of the fever of Jamaica; but it is a matter about which the practitioners of that country did not feem much to«concern themfelves. A differ- ence undoubtedly exifts, and the marks of it appeared to me clear and unequivocal in moft inftances. It was otherwife in the intermitting fever of America. In the pure intermitting fever of that country, I fome- times gueffed luckily ; but 1 cannot fay pofitively, that I ever difcovered figns on which I could depend with abfolute certainty, that the fever was gone, not to return again, till the hour of return was paft. In this difeafe, on the contrary, I fhouldmot expect to be deceived once in a hundred times. Much of this information, however, is too minute to be intelligi- bly explained in words, and therefore can only be ac- quired by actual obfervation. I in: U attempt to enumerate the principal of thofe figns, fron which we may be enabled to attain fome knowledge of the difference between actual crifis and temporary remiffion : and in the firft place I remark, that the tongue was ufually rough and dry, even dur- ing the moft perfect remiffions of the endemic fever of Jamaica. If it therefore happened, that it affum- ed a fmooth and moift appearance at the end <-f a pa- roxyfm, there generally was reafon to believe that the fever was gone, not to return again. This prcftn-p- tion was ftill ftronger, where its edges acquired the cherry-like colour of health ; and particularly where the coat, with which ic was ufually covered, xhewed M 122 OF A CRISIS AND a difpofition to loofen and feparate. It muft however be remarked, that though thefe appearances of the tongue afforded a common mark of the termination of fevers, they did not by any means afford a decifive one. Inftead of crifis, they fometimes only indicated a change in the mode of action of the febrile caufe ; they were, in fhort, in fome cafes only forerunners of fymptoms of nervous affection, or marks of a change from a continued to a remitting or intermit- ting form. Such are the prefumptions of actual cri- fis, which might be drawn from the appearances of the tongue, where the tongue happened to be remark- ably changed from its natural appearance in the pre- ceding courfe of the difeafe. But it alfo fometimes happened in cafes of the fingle tertian, where the pa- roxyfms were flight, and the remiffions long and per- fect, that the tongue was fo little altered by the pre- fence of the fever, as not to afford any certain crite- rion between the remiffion and actual crifis. In fome fevers likewife of a malignant kind, the tongue was , fometimes fmcoth and moift, even red and clear on the edges, whilft the difeafe was advancing rapidly. This, however, fo fer as I have feen was conftantly. connected with a particular ftate of the ftomach, viz. with naufea, or with vomitting of a vifcous liquor. Signs of crifis taken from the pulfe alone, were not in general much to be depended upon in the fe- vers of Jamaica; yet, together with other circum- ftances, the ftate of the pulfe might often help us to decide in doubrful fituations. Changes from bad to better, if no fvmptoms of comatofe affection appeared at the fame time, were generally confidered as indicat- ing crifis, or tendency to. crifis ; yet it will be lefs expected, perhaps, that I fhould rank the intermit- ting pulfe among the-figns, which indicate a favour- able ternin.ition of the difeafe. So e inftances of this have occured to me, both in the Weft-I^diegjand in England; but though I mention the feet, I con- kf± ni'-felf unable to offer an explanation of it. SIMPLE REMISSION. I2J Th? ftate of the fkin affords marks more decifive of the total or temporary abfence of fever, than the ordinary ftate of the pulfe. When the fweat, which in the preceding remiffions had been partial aiid im- perfect, became copious, fluid, univerfal and of long continuance, there was generally a prefumption of crifis. But independent of the nature of the fweat, there is fomething in the ftate of the fkin, fomething in the impreffion which it makes on the hand which feels it, very different when the fever has only remit- ted, and when it has terminated finally. Though it . may be difficult, perhaps impoffible, to mark this diftinetion precifely in words ; yet it is eafily known to thofe, who accuftom themfelves to obferve minute circumftances with attention. There was, in fact, no indication of that fpafmodic ftricture on the fur- face, which had been obfervable in the former remif- fions, and we might fay, that the body was perfpir- able, even in the extreme parts. It is a circumftance likewife not a little curious, that the heat of the body, during a crifis, particularly in thofe fevers, which had principally affected the nervous fyftem, was fome- times fo much below what it ufually is in health, as to be really alarming. In fome inftances, I have found the extremities to be not lefs cold, than if the patient had been actually dead; yet this coldnefs was of 1 jch a nature, as to be diftinguifhed without much - difficulty from that which precedes death. The above is only a very imperfect hiftory of thofe figns, which actually diftinguifh the crifis of fever from a,fimple remiffion. There are ftill fome others, not lefs to be depended upon, perhaps, but which cannot be fo eafily reduced to diflinct defeription.—— ' Among thefe, we may reckon unufual evacuations upwards or downwards, found and refrefhing fleep, wh re watchfulnefs had prevailed through the preced- ing coarfe of the difeafe, return of natural appetites, decreafe ot thirft, loofening of fcabby eruptions, and M % 124 0F A CRISIS AND above all, a certain expreffion of chearfulnefs in the eye and countenance, which though not to be defined in words, conveys to the mind of the obferver, a ftrong conviction of what is going forward. This brighmefs of the eye was well known to Hippocra- tes, as a falutarv fign in fevers; but though it gene- rally affords a very decided indication of a favourable event; yet we muft be careful to diftinguifh from it that clear and glafiy appearance, which the eye fome- times acquires previous to death* [ «* ] CHAP. IX. THE GENERAL CURE OF FEVER. BEFORE I attempt to offer rules for the treat- neot of the remitting fever of Jamaica, it will be proper to confider in'the firft place, how far the cure of the difeafe is the work of nature, and how far it already has been, or hereafeer may be ace >m- plifhed by the exertions of art. The queftion Is im- portant, and till its limits are defined, we cannot hope to eft*bii:h rules of practice on a firm bafis, or to conduct a mode of treatment on a confiftent plan. It will be neceffary however, before entering farther into this fubject, to confider the power of the vis medicatrix naturae :—a principle, which under one name or other, has influenced the views of medical men from the earlieft records of phyfic, till the pre- fent times. SECTION I. OF THE VIS MEDICATRIX NATURE. IT is an opinion, which feems either to have been exprefsly avowed, or tac^ly acknowledged in eve- ry dgz of the world, that a fever is a combat or ef- fort of nature, to remov •: from the fyftem the derange- ments of a morbid caufe; or in other words, to re- ftore a dife .fed body to its ordinary health. It was lon^ believed, that the powers of the conftitution m ide an attempt to concoct the crude and undigested humours;—uid finally to expel the n from the body. But this mode of reafoning is found to be unfatisfac* M 3 I 0.6 THE GENERAL tory: and, fome late authors have adopted the idea, that nature directs her efforts towards effecting a fo- lution of fpafm, on the prefence and obftinacy of which the difeafe has been thought, in fome meafure, to depend. It will be a hard tafk to reconcile this difference of opinion, or to fay which is the right one. There are plaufible arguments on both fides of the queftion; and neither fuppofition, perhaps, is accurately true. The coction of humours (as it may be called) is often apparently connected with evident approaches towards a relaxation of fpafmodic ftricture; and increafed difcharges by the different ex- cretories, are obvioufly attendants of its actual folu- tion. Yet though this is certainly true, it ftill is not clear, that either the coction of the humours, or the folution of the fpafm, is the real effect of a regular mechanic operation of the powers of nature, attempt- ing by this means to overcome the deftructive ten- dency of the difeafe. It is even more probable, that the coction of the humours, or folution of the fpafm ate only circumftances of accident, occafionally con- nected with certain ftates of action of the morbid c.mfe; but which do not arife from the regular defign of nature to accomplifh this purpofe. I juft now ob- ferved, that there is a difference of opinion about the mode of operation, which nature employs to combat the effects of the difeafe; but I may add, that no body, as far as I know, attempts to deny the exiftence of fuch a principle in the conftitution of the frame, as difpofes it to reftore its own health by a certain train of regular efforts. On the firft view of the fubject, indeed, there are many circumftances which give countenance to the opinion. The relief which often follows hemorrhage, fweat and other evacuations in unufual quantity; and ftill more, the relief, which attends the eruption of the fmall pox, or the appear- ance of gout on the extremities, undoubtedly affords a ftrong prefumptive argument, that nature raifci CURE OF FEVER. I 27 fome active and generally well directed efforts, which remove from the body a caufe that difturbs the ordi- nary functions of health. But though the above cir- cumftances are commonly known, and may be fup- pofed to afford an argument in fupportofthis opinion; yet the fact may pe.haps admitof another explanation, while there are other appearances, connected with the fubject, which render the exiftence of this regular defign of nature very queftionable. When I fay, that I cannot readily allow the vis medieatrix naturae, (in the fenfe in which it is generally underftood), to be an eftablilhed principle in the conftitution of the frame, I am aware, that I incur an imputation of 4tt. prefumption. An opinion, venerable from an- tiquity, and fupported by many plaufible arguments, .might be thought to be fecure from the attacks of a man, who has no profeffional reputation to boaft of: yet as no defire of novelty has induced me to fabricate a conjecture on a dark fubject, fol humbly hope I may be indulged in my attempt to explain an important truth. The fanction of two thoufand years, and the authority of the names who fupport this doctrine, are formidable opponents; yet I truft I may be able to prove, that the vis medieatrix naturae does not, as is commonly believed, reftore the health of the body by one general and uniform mode of operation ; or that our difeafes are not removed in confequence of a regular defign in the mechanifm of the frame. I fhall relate the fact from which I have been led to form this conclufion; for the refutation or confirma- tion of which, I require no other indulgence than a candid enqiirv. I have juil: now declared, that fever, or the caufe of fever, is not combated and finally overcome by a regular train of active efforts, or a vis medieatrix na- turae: and I muft obferve in proof of it, that there were many of the fevers of the Weft-Indies, where the difeafe, or the paroxyfm of the difeafe, vanifhed or 128 THE GENERAL declined, without any exertion on the part of nature being perceiveable. The powers oi life, during this period, were in fome degree fufpended. T he patient, who could only be faid not to be actually d .ad, was totally infenfible to every object that was near to him; and often did not feel the irrkation of acrid fubftances that were applied to him : yet after a certain conti- nuance in this ftate, he began to refumehis powers of fenfation and motion; and the difeafe at laft fub- fided or vanifhed, though the efforts of nature were not difcovered ; nay, though the vital powers were fometimes in a ftate fo weakened, as to be apparendy very little capable of effort. This fact, which the moft fuperficial obferver could not eafily overlook, furnifhes fufficient reafon for doubting of the very exiftence of a vis medieatrix naturae ; a doubt which is further corroborated, by obferving the manner- in which death frequently approaches in the fevers of Jamaica. It is known, that the fufferings of the pa- tient are fometimes alleviated for a fhort time before death. This alleviation, wherever it does take place, happens conftantly at the expected period of crifis. The caufe of it has generally been attributed to the vis medieatrix naturae; that is, to a laft effort of the powers of life ; but I have weighed carefully all the circumftances connected with tire phenomenon, and cannot readily affent to the opinion. To indulge in conjectures, is contrary to the principles I profefs ; yet I muft fuggeft, that a fever, or the paroxyfm of a fever, terminates, ftrictly fpeaking, from a hidden fomething in the nature of the febrile caufe, from fomething which ceafes to act, or which changes its mode of action after a certain duration.- I do not pretend to explain the manner in which this happens. I only add, that the fact is fupported by probabilities. It was frequently obferved, in fuch cafes cf fever as terminated fatally, that there was actually a period of time, generally the period immediately preceding a CURE OF FEVER. I29 decided fatal termination, where the real prefence of difeafe was perceived with difficulty. The patient, however, was unable to recover. Death happened in a very few hours, and it feemed to enfue in fuch cafes, from one of the following caufes, viz. either from the mechanifm of a part of vital importance being deftroyed; from the powers of nature being too much exhaufted to continue life ; or perhaps ftill oftener, from the recurrence of the difeafe, in another form, fpeedily putting a period to exiflence, while the vital principle was in this weakened ftate. But though the circumftances, which I have mentioned, afford grounds for believing that a fever, or the pa- roxyfm of a fever, is not actually removed from the body, fole! y by the efforts of a vis medieatrix naturae; yet if we dmofe to proceed further in the inveftiga- tioiii it will be no difficult tifk to involve this opinion. which has hitherto been confidered almoft as facred, in ftill greater perplexity. If we admit of the exifl- ence of a vis medieatrix naturae, it will not be eafy to conceive, how a fever, which has once been expel- led from the body, fhould return again in a given time, or how the alternate paroxyfms of the double tertian, for inftance, fhould be of fuch differen* duration or of fuch di fferent decrees of violence in the fame per- fon; neither cm we uoderftand, how a fever of one kind fhould laft only feven days, another fourteen, and another twenty, or longer:—circumftances which hap- pen daily, withouttheleallapparentconnex-ion with the innate vigour of conftitution. We ftullbe equally puz- zled likewife, if we attempt to explain on the fuppofi- tion of this principle, how a fever fhould continue, while the powers of the conftitution are vigorou? and ftrong, and ceafe when they are apparently exhaufted. The above are well known facts, and do not leave any room to doubt, that the termination of fever, or of the paroxyfin of fever, depends on fome other principle befides the mere efforts of the vis medicatri* 13© THE GENERAL naturae. Whether this refides, as was hinted before, in a hfdden modification of the nature of the caufe, which ceafes to act, or changes its mode of action af- ter a certain duration ; or whether, combined with this, the conftant but imperceptible changes, which are continually going on in the fyftem, deftroy in the frame of the individual, that particular ftate of apti- tude to the febrile caufe, in which the difeafe confifts, We cannot determine with certainty ; yet it would be obftinate to maintain any longer, that the cure of fe- vet is owing to general and well directed efforts of nature, expelling a morbific matter or overcoming a prevailing fpafm. It is true, that an obvious folution of fpafmodic ftricture, or the appearance of a morbid matter on the lefs important parts of the body, ufually attend the favourable termination of fevers ; yet thefe circumftances are, in fact, attendants rather than caufes of crifis. I do not deny, that increafed dis- charges by different outlets, fometimes moderate the violence of fever during its continuance, as well as attend its final folution; yet it has not, nor perhaps can it ever be demonftrated, that this proceeds from a regular defign of nature. The hints which have been thrown out in the pre- ceding pages, give room forfuppofing thatthevisme- dicatrix naturae, in the fenfe in which it is ufually underftood by medical writers, is only a principle of doubtful exiftence in the conftitution of the frame ; yet though this is certainly true, I do not pretend to deny, that the animal machine is endued with a power, which refifts, in feme meafure, the derangements of a deftroying caufe, and which perfifts to a certain de- gree in continuing the action of living. The gene- ral nature of the caufe of fever, or the nature of its various modifications is a myftery, vv'^.ch we do not as yet know. We only know, that when prefent in ^ a certain ftate of vigour and activity, it deranges or diiturbs the actions and functions of the f/ilem j—« CURE OF FEVER. I3I while we likewife know, that ic does not always dif- turb every action or every function in the fame de- gree. It has occurred too often to have efeaped the moft fuperficial obfervation, that where one part of the body fuffers particularly, the others are often re- lieved in proportion. We frequently in this manner obferve, that general fever is duninifhed by the ap- pearance of local pain; or, on the contrary, in- creafed by its removal. It likewife often happens from the fame principle, that where the ftomach and biliary fyftem fuffer much, there is lefs diforder in the other parts: and on the other hand, that Where thefe fufferings are removed or mitigated, the general fever runs higher, and often continues high, till the feme, or other local affections, are again produced. Thu?, though we are totally ignorant of the intimate nature of the caufe of fever, we ftill perceive very plainly, that it either poffeffes fomething in its own nature, or accidentally meets with fomething in the conftitu- tion of the individual, which determines it to affect the different parts of the body in an unequal degree. It ufually exerts its greateft force upon parts, which are preternaturally weakened by the general influ- ence of climate, feafon, fituation, or o :her accidental caufes. Hence bilious appearances are common in the hot months of hot climates, pneumonic affection in cold and dry weather, greater degrees of vafcular excitement among the temperate and more active races of men; while fymptoms of nervous affection prevail among the luxurious and enfeebled. The above, with other fpecies of the increafed action of the caufe of fever on a particular part of the body, depend wholly, perhaps, on circumftances of acci- dent ; yet it has fo happened, that thofe irregular de- terminations have unfortunately been confidered as the efforts, which nature employs to expel from the body a caufe, which difturbs the economy of health. I (hail not, at prefent, go fo far as to contend, that * 132 THE GENERAL thefe determinations are not, in fact, intentions of nature; but fhall only beg leave to fuggeft, if they actually are intentions, that it is mere chance which determines whether they are falutary or fatal. It is a trutfi which nobody will deny, where the force of the difeafe is accidentally directed to an "organ of excre- tion, or to a part of little importance to life, that the reft of the body is often proportionally relieved, and even that a recovery of general health is fometimes the confequence ; yet the contrary is the effect, where the functions of the part, upon which the force of the fever has been thus accidentally diverted, are of im- mediate importance to the action of living. The Gout, a difeafe, the caufe of which bears no very re- mote analogy to the ca fe of fever, may be adduced as affording an illuftration of this truth. The proxi- mate caufe of gout, is equally hid from us as the proximate caufe of fever. We know, however, that the one equally with, the other, has a tendency to de- ftroy life. We likewife know, that there is a power or principle in the conftitution, which to a certain degree refifts deftruction. The nature of this power, however, is unknown. We are not only in the dark with regard to its nature; but we can only form con- jecture? about the part where it principally refides.—. We, however, cl< arly perceive its force and activity to be different in different parts of the body. We may next be allowed to remark, that where the caufe of gout is in a certain ftate of modification, tumults, (which properly enough may be termed re-action), arife in the fyftem, and go on to continue till this cauf. or hurtful matter finds an outlet from the body, or a lodgment on one particular part. The outlets from the body are numerous: the parts dh which the gout feems principally to fix its feat, are the extre- mities, where the power of refiftance is fmalleft.—— The vital principle, how-over, becomes weaker as man advances in years; and the caufe of the diforder CURE OF FEVER. 133 feems then frequently to find accommodations in parts, which are lefs remote from the fources of life. This more efpecially is the cafe, where tone and vigour have been preternaturally weakened. Hence the fto- mach, the bowels, fometimes the brain, and even the heart itfelf fuffer from the immediate action of this difeafe, in the latter periods of life. But though no perfon perhaps will deny, that the caufe of gout finds readieft accommodation, (if I may fo apply the term) in thofe parts of the body, where the vital powers are naturally weak, or have been accidentally weak- ened from various caufes ; yet we may add, that it is likewife removed from the parts, on which it has' been thus fixed, by fuch applications as excite their active powers; or, in other words, which call forth the local re-action of the fyftem. We may alfo ob- ferve, that tumults arife in the general fyftem, in confequence of this repreffionor repulfionofthe mor- bid caufe from a particular part; and that they do not in general ceafe, till an outlet is opened, or ac- commodation found in fome other parts of the body. The above appearances, occur daily in the hiftory of gout. They feem to bear a ftrong analogy to thofe irregular determinations, which frequently take place in fevers, and their caufe perhaps is the fame. We do not perceive any other law by which they can be explained, than the natural or adventitious ftate of activity of the powers of life, which refill deftruction with unequal force in the different parts of the fyf- tem : fo that we fhall be obliged to conclude, that thofe fufferings, which have hitherto been flyled the efforts of nat ire, are in reaiity more of the paflive, than of the active kind. The circumftances which I have now mentioned, combat the very exiftence of the opinion, which has been commonly received with regard to the vis me- dieatrix naturae. I have hinted, that the extent and limits of that principle are narrow, and that the fa- *34 THE GENERAL lutary effects are accidental. I fhall next endeavour to fhew, that they cannot, without danger, be made the bafis of the general plan of cure in febrile dif- eafes. The talk is important, but the attempt may be thought prefumptuous, as an opinion, contrary to that which I advance, has obtained almoft the uni- verfal confent of mankind. I have no defire of changing names, or of making diftinctions, where there is in fact no difference. I perfectly acquiefce in retaining the word vis medieatrix naturae, pro- vided it is limitted to a certain mode of re-action, or to" a power in the conftitution of refilling deftruction unequally in its different parts, in confequence of which, irregular detenninations fometimes prove fa- lutary by accident; yet I muft add, that if we mean to denote by this term a fyftem of laws, which have the beft directed tendency to remove from the body a caufe which deftroys health, and endangers life, the opinion has a verv uncertain foundation. There are few perfons fo ignorant, or fo blindly devoted to the doctrines of «t«/T6*p«T«/« as not to own, that the ufual- ly reputed efforts of nature, are often ill directed, fometimes pernicious : in fhort, that they are obvi- oufly the caufes of death. The truth of this obfer- vation cannot be denied^ and unfortunately it obliges the advocates of the vis medieatrix naturae, to grant the conclulion, that the laws of the principle are im- perfect. The works of the author of nature, as far as our limited knowledge can trace them, are univer- fally without defect, if examined according to the plan on which they have been originally formed. If they appear otherwife, it becomes us to hefitate, before we decide. We may not have comprehended the fundamental principle of the defign; but we revolt from the idea, that the execution would be left im- perfect, had it been intended by the Author of our being, that the medianifm of the frame would be fuch, as fhould oppofe and remove, in the moft CURE OF FEVER. 135 effectual manner, the derangements of the morbid caufe. Defect and imperfection can have noplace in the works of the Almighty. Had it actually been in the original defign of our Creator, that the hu- man body fhould be provided with a fyftem of the beft concerted laws for reftoring its health, when de- ranged by the numerous caufes of difeafes, as it is impious to fuppofe, that thofe laws could be defec- tive; fo we may reafonably conclude, that the effects of fevers would not then have been fatal. We find however, that fevers, as well as ©ther difeafes, are fatal to people of all ages and defcriptions: and that nature's intentions of cure, if they really are inten- tions, are often deftructive to herfelf. I need fcarce- ly remind the reader of examples of their pernicious tendency. Vomitting, fweating, increafed difcharges by ftool, &c. are generally confidered as the falutr.ry efforts of nature: but inftances are numerous, where the excefs of thofe evacuations have obvioufly proved the caufes of death. In the fame manner, abfeefles, which in the remote parts of the body, fome- times attend, and even fometimes perhaps influ- ence the favourable termination of fevers; in the brain, or in other organs of importance, are no lef6 certainly the caufe which deftroys life. In both in- ftances the defign of nature, if it can be called a defign, is the Tame. The force of the difeafe being turned principally upon one part, the reft of the body is in a great meafure relieved from its fufferings ; - but the health and ftructure of the part are hurt or deftroyed by the change; and it depends wholly upon the accidental importance of the organ, upon which this diverfion has been made, whether death or re- covery is the confequence. Thus it often happens, that the reputed indications of nature prove the im- mediate caufes which deftroy the exiftence of the in- dividual ; a faft not reconcileable, with the infinite power and wifdom of the Author of our being. N 2 1$6 THE GENERAL I have infinuated, that the efforts of nature are uncertain and precarious. They depend on acci- dental determinations to different parts of the body; and I may add, that if we endeavour to inveftigate the caufe, which directs the mechanifm of the frame, to adopt one fpecies of effort, or one mode of deter- mination in preference to another, we fhall not per* haps be able to find any other, than a difference in the ftates of the powers of life, which refill deftruc- tion with unequal degrees of force in the different parts of the body. Where there is the leaft refift- ance, either from the natural or accidental circum- ftances of the conftitution, there the difeafe moft ob- vioufly exerts its greateft force. Hence we are fufficiently warranted to conclude, that though the fvruflure of the human body is perfect with refpect to every orrpofe for v/hich it is intended, being only endu d with a principle, which refifts deftruction, or psrfifts in continuing life to a certain degree ; yet that it is extremely cL-feftive, if we confider it as a machine furnifhed with a fyftem of laws, which have an invariable and well directed tendency to re- ftore health by the moft judicious and rational efforts. The reftoration of health, in confequence of this re-adtion, or irregular determination which takes place in the fyftem, is only a circumftance of acci- dent. The fkiil of man fometimes fucceeds, where the efforts of nature have obvioufly failed. SECTION II. 0F THE GENERAL INDICATIONS OF CURE IN FEVERS. THE vis medieatrix naturae, has been hitherto efteemed a principle of much importance in the cure of febrile difeafes. I have attempted to ex- CURE OF FEVER. 137 plain its real limits and extent; but am afraid I may not have done it fatiifactorily. A tumult which, properly enough perhaps, may be termed a reaction of the fyftem, evidently takes place in confequence of the application of a morbid caufe ; but there feems to be little reafon for believing, that this reaction points out the beft method of cure, or wholly by itfelf accomplii'hes this important bufinefs. But though the reputed efforts of nature are thus defec- tive in accomplifhing the cure of fevers; yet I do not deny, that there is a general tendency in fevers, or in fhe paroxyf.n of fevers, to terminate in a given time, often by a fixed and regular mode of termina- tion. We do not, however, by any means compre- hend the caufe upon which this depends. From the fimilarity in the progrefs and termination of epidemics, as well as from the fleadinefs with which various forts of fevers puifue their courfe, in fpite of the moft oppofite modes of treatment, we are l;d to con- clude, that there is fomething peculiar in the modi- fication of the caufe, which influences the duration of the difeafe. This at prefent, is unknown ; perhaps is a knowledge which we cannot attain ; yet if we take pains to obferve the courfe of fevers wi.h atten- tion, we may difcover fome .rules of practical ufe. We know that one fpecies of febrile difeafes, obfti- nately purfues its courfe, notwithftanding every en- deavour to oppofe it; while another is fo totally under our management, as to be flopt fhort at pleafure with almoft infallible certainty. It thus happen?, that the intermittent is perfectly under our controul. Over the continued, and even over the remitting fever of Jamaica, I am afraid, we fhall be obliged to confefs, that we poffefs no very certain power.—But I fha!i examine this fubject more particularly. When I firft arrived in Jamaic;-, in the year 1774, I found that the practitioners of that country« very generally believed, that the couife of the ordi- N 3 1$ THE GENERAL nary endemic fever was checked with great certainty by the powers of Peruvian bark. This opinion, in- deed, is found in every medical book, and it appeared frequently, on the firft view of the fubject, to be well founded. No great fpace of time, however, elapfed before fome circumftances were obferved, Which prefented the matter in a different light. I found in many inftances, that bark was given in the firft remiffion, or on the fecond day of the difeafe; in others, it was not given till the third remiffion, or till the fixth day from the beginning of the complaint; and in fome again^ the* fever difappeared altogether before a fingle grain of this remedy had been admi- niftered. I was particularly exact in marking the time or the period of the difeafe, at which the bark was begun to be given, as alfo the quantity which was taken upon the whole. The refult was notfuch as might have been expected. Notwithftanding the mod oppofite modes of treatment, the difeafe ap- peared to terminate or change about the fame periods in almoft every patient. This fact was confirmed in numerous inftarce? ; and it feems to afford a very un- equivocal proof, that bark, in the quantity in which it is commonly pn.fcribed in the Weft Indies, has not the effects which are ufually afcribed to it. I do not, however, infer, that this remedy may not be ca- pable, with more deciiive modes of management, of effecting all'that has been expected from it. I had not, during the time that I remained in Jamaica, any conception that the ftomach could have retained, or that it would have been fefe to have ventured upon the quantities of bark, which I afterwards gave to others, or took myfelf in the intermitting fever of America, Two fcruples or a drachm,every two hours, is in feet only a fmall dofe. To this under dofe, during fhort remiffions, we might perhaps impute the failure of that remedy in the fevers of the Weft Indies. That this actually is the cafe, is confirmed CURE OF FEVER. 13$ in fome degree, by an inftance which I find recorded among my notes. A young man was feized with a fever, about the middle of Auguft, which fhewed marks of great violence from the beginning. Bark was given early, and in larger quantity than cuf- tomary. The laft paroxyfm of the difeafe, was ir* fome meafure fufpended, in confequence of this pro- ceeding ; yet, except that the marks of external fever were obfcure, the patient remained, as ufual, uneafy and diftreffed, till the period at which the crifis was expected; when the marks of final termi- nation fhewed themfelves diftinctly. This is the only cafe I met with, where the paroxyfms of the fever of Jamaica were ftopt, or fufpended by the bark; or where external marks of fever vanifhed without evident figns of crifis. It affords only a doubtful proof of the power, which this remedy has been fuppofed to poffefs, of abfolutely cutting fhort the courfe of the endemic of that country. But though the bark was feldom efficacious in abruptly cutting fhort the courfe of this difeafe, it is no more than juftice to remark, that it is a remedy which was almoft every where fafe, and that it was ultimately ufeful in promoting the cure. It imparted in moft inftances, where it was employed, a degree of tone and vigour to the fyftem—a certain fomething to the con- ftitution ; in confequence of which, the crifis, which we fhould have expected to be only partial or imper-r feet, became decided and final. I have fuggefted thofe few remarks, with regard to the virtues of Peru* vian bark in the common endemic of Jamaica ; if its effects are fo very doubtful in this difeafe, we have no reafon to expect, that they will be more cer- tain in fevers of a more continued kind. Befides bark, the power of which appears to be very precarious, other remedies have been employee! by phyficians, with the view of cutting fhort the courfe of fevers,—Antimony, under one form or I40 THE GENERAL other, has been celebrated for this intention, fince its firft introduction into medicine. James's Powder is the moft famous, and perhaps the moft effectual antimonial preparation, which, as yet, has been of- fered to the public. I am ferry to fey, that I had not an opportunity of making proper trial of it, in the fevers of the Weft-Indies ; but I can add, that the emetic tartar was often found to be dangerous, fcarcely ever effectual in cutting fhort the courfe of the difeafe, unlefs given at an early period, or before the fever had affumed a proper form. Its vittues, as a febrifuge, were heightened by the addition of opium and camphire, I am forry alfo to remark, that I can- not fpeak with confidence of the virtues of James's Powder, in the intermitting fever of America. Eme- tic tartar was frequently employed, but it did not by any means anfwer the expectations which jvere enter- tained of it. I acknowledge, that it might be fo managed, as apparently to prevent the return of a particular paroxyfm; but the inftances, where it com- pletely removed the difeafe, were fo rare, that I do not confider it as poffeffed of very eminent virtues. I have had frequent opportunities, fince my return to Britain, of trying James's Powder in the conti- nued fevers of this country ; and the refult of my experience inclines me to believe, that this remedy, when given at an early period, has fometimes actu- ally carried off the difeafe. It appeared likewife, when exhibited near the critical periods, to render the crifis more complete; but I have little caufe for thinking, that it ever cut fhort a fever in the midft of its courfe. Thus it appears, that thefe two cele- brated remedies,—bark and the various preparations of antimony, are, in fact, lefs effectual in cutting fhort the courfe of febrile difeafes, than has been com- monly fuppofed ; I cannot, however, abandon the idea that the purpofe, which has been expected from thefe remedies, may ftill be obtained by other means. CURE OF FFVER. I4I Galen mentions fome inftances, where he extinguifh- ed the fever by copious evacuations : authors men- tion many, and I have myfelf feen fome, where drink- ing plentifully of the coldeft water, produced the fame effects. The alternate ufe of warm and cold bathing occafions great changes in the ftate of the conftitu- tion : and from the trials, which I have made of thefe applications, I do not entertain a doubt, that they may be fo managed, as to (horten very materially the du- ration of foyers. I do not however promife, that they are capable of being fo conducted, as infallibly at once to flop the difeafe in its progrels. This can only be accomplifhed by thofe great and remarkable changes, which deftroy a certain aptitude, in the ftate of the fyftem, to the morbid caufe, in which the dif- eafe is fuppofed to confift. But I muft at the fame time confefs, that as we neither know the nature of this aptitude, nor the particular nature of remote caufes, fo every attempt of cure on this plan, as it muft be at random, cannot be adopted without danger. It is a view, therefore, which will not be profecuted with fafety, while our knowledge of the nature of morbid caufes, and of the laws and ftrudture of the human frame, is fo imperfect. It is evident from the facts which I have related in the preceding pages, that we cannot fafely trufl the cure of fevers to thofe tumults, or irregular de- terminations in the fyftem, which are ufually flyled the efforts of nature : neither does it appear, that we can depend on the efficacy of any one remedy, we are yet acquainted with, as poffeffed of the power of abruptly cutting fhort their courfe. We ftill how- ever perceive, that thefe difeafes have a general ten- dency to terminate in a given time and fteadily to go through a tegular progrefs, in fpite of the greateft exertions of art. If we review the practice which med.cal people have followed in fevers, from the days of Hippocrates to the prefent times, we meet with fuch contradictory methods of treatment, as render 142 THE GENERAL it impoffible to avoid pronouncing, that if one man had actually faved life, another's endeavours feemed as if intended to deftroy it: yet few authors have ventured to offer the fruits of their labours to the public, without previoufly boafting more fuccefsful methods of cure, than were known to their prede- ceffors. Hence, if we are not fometimes difpofed to doubt their veracity, we can hardly avoid concluding) that their practice had been feeble, and of fmall effect. We lament, with reafon, that medical facts are fre- quently of little value: nay, that they oftener mifleadj than guide us in the way to truth. An overfondnefs for ourfelves is, perhaps, more the caufe of this, than real want of candour; the natural propenfity of the human mind to flatter itfelf, difpofing us to attribute cures to remedies, which were adminiftered near the critical periods of the difeafe; while twenty inftance^ where fimilar treatment produced no apparent effect* are infenfibly blotted from the memory. This at leaft was die cafe with myfelf. I flattered myfelf in many inftances, that I had actually faved life :— I now find, on maturer reflection, that I had in reality dons -no material good. Thus it frequently happens, I believe, that practitioners boaft of cures, to which they have no right; at the fame time I am convinced, that they are frequently charged with deaths, of which they are innocent. The life of man does not appear to depend upon fo fmall a matter, in febrile difeafes, as is generally imagined; and is not often prcferved or endangered by the routine of common practice. It is not always eafy to know exactly the real effects of treatment; neither has the ro;y the powers of life ; while we likewife know, that there is a principle in the mechanifm of the frame, which refifts deftruction to a certain decree. We alfo know, that the caufe of the difeafe differs in de- gree of force ; and that it is differently modified ac- cording to various circumftances; as we likewife ob- ferve, that the principle of life, or power of refiftance, is different in activity, in the different parts of the body. To thefe two powers, viz. the force of the morbid caufe and the powers of the conftitution our views in practice muft be principally directed. Hence we may eftablifh a genera1 rule, that wherever the force of the morbid caufe is weak ; at the fame time that the powers of life in the general fyftem, and particularly in the organs of vital importance, are 144 THE GENERAL ftrong and active, we have nothing more to do than to look on. On the contrary, where the caufe of the difeafe is of unufual force, or where the powers of life are preternaturally weak, our interference ought to be fpeedy, bold and decided. In other words, we leave the bufinefs chiefly to nature, or take it entirely out of her hands. It is this which a practitioner muft firft deteemine, when called upon to give his affiftance to a patient labouring under a fever. If the powers of the conftitution appear to be equal to the tafk, our interference would be officious, and perhaps might prove hurtful. If affiftance is neceffary, it ought to be our principal aim to render it complete ; but in profecuting this view, we meet with muchdifficulty and impediment. We are not yet acquainted with any one remedy, which has a certain and infallible power of cutting fliort fevers in the midft of their Courfe. It is not therefore abfolutely in our power to take the bufinefs entirely out of the hands of nature. We can, in fact, go no farther, than to oppofe her pernicious efforts ; or to obviate the fatal tendencies of the difeafe. The fatal tendencies of the difeafe, are varioufly modified, and the means by which they muft be obviated, are fometimes directly oppofite. . Two general modes, however, of the fatal action of fevers may in moft inftances be difcovered. The caufe of the difeafe, in one cafe, exerts its influence on the fources of life and motion ; in the other, the ftructure of an organ of lefs importance is deftroyed, and death happens only from a fecondary effect. There is pe hap. no fundamental difference in thefe different modes of action; yet the indications of cure, Which arife from this view, are totally oppofite. In the firft inftance, it is neceffary to excite, and tofup- port the general powers of life: an indication of very great extent. In the other, it is fometimes neceffary to diminifh the general reaction of the fiyf-em; to obviate irregular determination, and to oppofe with vigour the tumultuary efforts of nature. C *4S ] CHAP. X. •F THE PARTICULAR CURE OF THE FEVER OF JAMAICA. I SHALL begin this fubject with obferving, that the fever, which prevailed in the diftrict of Savanna L Mar, was naturally a difeafe of the remitting kind; yet circumftances were fometimes connected wi.h it, in fuch a manner as prevented it from afluming its proper form. To remove thofe circumftances, which thus mafked or concealed the real genius of the difeafe, was confidered as the firft ftep towards a cure. The accomplifhment of this purpofe, however, was fometimes difficult; neither could it always be effect- ed by the fame means. Thus it happened frequently in cafes, where there was excefs of-xcitement, or a high degree of inflammatory diathefis, that the re- miffions where fcarcely perceptible; as it was likewife obler ed, that where there was a want of reaction, the paroxyfms were K.f.en languid and obicure. In the one cafe, the remiffi ns dife; vered themfelves in con- feq r and opium, giv.n in pre ty large doles, and repeated frequently. Raniiii 11, at ie;.ft a great abatement in.the violence of symptom?, was gtneially the consequence of this plan oi treatment); particularl , if affifted by the plen- tiful dilution of watery liquors, by warm ba.hing and by larae glyfters of fimple water. It is iliperfluous to mention the ufe of blifters in cafes o! local affec- tion ; but it will be lefs expected, that ihi:. remedy fhould be recommended in fevers, where there is an excefs of the general inflammatory diathefir-.—I can, however, bear tcftim; ny to its efficacy. I he manner by whicli blilie.s produce their effects, is not yet agreed opon among a thors; neither do I pretend to throw a: y new- light up.11 the fubject; but I would beg leave to fuggeft, .hat the mode of affording re- lief in the prefent, at leaft, did net feem to be much FEVER OF JAMAICA *47 unlike the effect of local affections, in confequence of which the violence of fevers is fometimes obferved to fubfide. I purfued the above method of procuring remiffi.'n in thofe fevers, where there was real inflammatory diathefis prevailing in excefs ; bat it fo happened, that the figns of this diathefis were fallacious appear- ing in fome inftances to be prefent, though the real genius of the difeafe was actually of a dirfe en: m- tu'e; a circumftance, which occafioned a difference of management in conducting the method of cure. Exceffive evacuations were not only unfafe in f ch cafes, but in general had not any powerfal effects in difpofing the difeafe to affume a remit ing foul. Bleeding, however, was often found to be neceffary, though it was f Mom requifite to repeat tke opera- tion. The good effects which were ob erved to fol- low the ufe of cathartics, were not in general very renrarkable; yec it was proper, in moft inftances, to open the body freel/ ; for which pu pole, no u>rm of medicine, with which I am acquainted, anfwered better than a folu.ion of falts with a frmll por.ion of emetic tartar, and fomerimes with the addition of la.i- danum. In cafes of local pain, blliters applied near the feat of affection were always of eminent fervice ; and in cyfes of general irritability, they v/ere oten equally ufe.ul, when applied to the back part of the head and neck. A po -vder compofed of nitre, cam- phire, ene:ic tartar and opium, was likewife em- ployed with fucce's ; b jt the libe al ufe of warn bath- ing, was ftill more to be depended upon. No per- fon, perhaps, will refufe cmentto the method of pro- ceeding, v/hich I have hitherto recommended ; but when 1 mention a free and bold ufe of cold bathing, even in an early fta-e of this feve , I do not expect the fame conce'.fion. To da'h cold water on the head and fh oulders of a perfon in a fever, has an ap- pearance of rafhaefs and haza d. I can, however, O 2 I48 PARTICULAR CURE OF THE produce the teftimony of repeated experience for the fafety of the practice, no lefs than for its fuccefs in procuring remiffion ; and fhall therefore confider it a duty to recommend it warmly to the public. Wher- ever it was employed,—and the cafes in which it was t ied were numerous, a calm and equable perfpiration, additional tone and vigour, with great abatement of irritability, were conftantly obferved to enfue. The paroxyfm' and remiffions were generally dif- tinet in the beginning of fevers, where the nervous fyftem was principally affected; but often became lefs fo, as the difeafe advanced in ics progrefs ; a ciicum- ftance which did not arife oftener from the nature of the complaint, than from the common method oftreat- menr. Bleeding was often difpened With in the fe- vers of the Weft-Indies; but vomiting and purging were indulged in with fieedom. The diftinetion of paroxyfm and remiffion was fometimes evidently ren- dered ©bfeure by this practice ; while it was like- wife obvioufly reftored again, by the ufe of wine and cordials, which excited the powers ef life. In this fpecies of difeafe, evacuations were feldom ne- ceffaiy; feldom indeed ad 1 iffible in a great extent. Bleeding unlefs under particular circumftances, was torally impr per. Cathartics were fometimes dan- gerouf, and antimonial vomits often funk the patient irrecoverably. Bliftering, on the contrary, even at an earl period, was generally of fervice; a> alfo were opiates, and a judicious ufe of the warm bath; but cold bathing with fait water, was, of all others, the remedy of the moft powerful effect. I do not pre- tend to fay, that it abfolutely flopped the courfe erf" the eve ; but I can fay with .'ruth, that ii generally reftored th<■ diftinetion of paroxyfm and remiffion, diminifhed irritability, and imparted a degree of tone and vigour to the fyftem, which was juftly confidered as a fign of fafety. To procure remiffion in fever, diftinguifhed by a prevalence of the putrefcent tendency, is not in everv FEVER OF JAMAICA. 149 Inftance an eafy talk. A remitting fever, with marks bf fpecific putrefaction, is n't a difeafe of common occurrence in Jamaica; but a fever with figns of pu- trefactive tendency, mixed with fymptoms of great irritability, or a high degree of malignity, is not alto- gether iai'0. From the corrplicated nature of the dif- order, the indications of core are often diffic: It and perplexed. Bleeding is uni/erfally condemned ; more, I believe, from theory than from actual obfervation. It was, and perhaps ftill is, a fafhionablemode of rea- foning, to impuie the languo s and other marks of debility, which are common in the fevers of the Weft- Indies, tJ a putre cent tendency in the fyftem. Such fymptoms however are in feet more generally the attendant^, or diftingu'fhing figns of fever?, w here the nervous fyftem is affected. In fuch caf.s, bleeding is obvioufly hurtful; in the one of which we now treat, (where fuch a difeafe actually exift?,) it is not onlv a remedy of fafety, but of very eminent fervice, p/evious to the application of cold, particularly pre- vious to cold bathing, which may be ufed with free- dom and boldnef;. Cold bathing, indeed, is the remedy on which we muft principally depend. There aie others which do g-'od occafionally; but this i - the only one I know, whichhas any very con- fiderable effect in changing the nature of the difeafe. Thee is a general rrle in the practice of medicine, which requires to be particularly remembered in thofe complicated fpecies of feve", viz. that as the indica- tions of cure are often c; aba raffed; to the appear- ances, which principally p io: to danger, are firft to be attended to; while the plan of cue, -bich we de- termine to-be the moft prope", muft be followed up with vigour and resolution. We ought always to bear in mind, that in dangerous and difficult cafes feeble remcf .o, or even powerful ones timidly ufed, are or little avail. Odd bathinj, employed with ti- midity, failed of doing good in foa.e inftances. I O 3 I £6 PARTICULAR CURE OF THE met with no example, where the boldeft ufe of it did harm. It was feldom, I muft again repeat, that it did not fueceed in obviating irritability, in checkirig the putrefcent tendency, and in imparting to the fyftem that degree of tone and vigour, in which fafety is obferved to confift. The method of procuring remiffion, in thofe fevers which were diftinguifhed by local affections, or ir- regular determinations to particular parts, was nicefj and fometimes difficult. Bleeding was frequently proper, efpecially, if there fubfifted at the fame time marks of a general inflammatory diathefis: but it was feldom fufficient wholly to accomplifh the bufinefs. However, together with a judicious management of warm bathing, it greatly heightened the good effects of blifters, the remedy on which the principal de- pendence was placed. ]ji fevers which were accom- panied with uncommon pain of the head, I have fometimes found it ferviceable to apply cold to the part affected ; die feet being at the fame time immerfed in warm water, and blood flowing by a large orifice from the arm. I alfo frequently obferved, that the general fever ran higher, though it likewife more certainly affumed its proper form, in confequence of bleeding, bliftering, and the removal of local pain. In thofe fevers, where bilious appearances were the effect of accidental, irregular determination to the ftomach or liver, the remiffions were often obfcure : neither did the method of treatment, which was gene- rally adopted, feem to be well calculated to bring forth the natural, genuine appearance of the difeafe. Bilious appearances, it muft be owned, fometimes vanifhed, while the type of the fever became more diftinct after the exhibition of an emetic or brifk cathartic ; yet there is caufe to doubt if this depended on the evacuation of bile. It might be faid, with more truth, perhaps, that the action of the emetic, by exciting the powers of the ftomach and biliary fyftem, effected a change in the irregular determina- FEVER OF JAMAICA. 1^1 tion, which had formerly taken place to thofe parts. It was generally obferved, where good eftects did not follow the firft exhibition of remedies of this kind, that harm was ufually the confequence of a fecond. Vomiting, in fhort, was often rendered continual, and the diftinetion of paroxyfm and remiffion was ap- parently deftroyed, in confequence of the operation of violent emetics. Instructed by repeated examples of their hurtful effects, I at laft fcarcely ever em- ployed antimonial vomits ; even the lafeft kinds were ufed with caution. If it appeared, at any time, that the action of vomiting, would be ferviceable, camo- mile tea, or at fartheft a few grains of ipecacuana were generally thought fufficient for the purpofe. When this bufinefs was finifhed, a draught of cor- dial flimulating liquor, which had a tendency to pro- mote a diaphorefis, was next adminiftered. By this mode of treatment, efpecially if ablifter was applied at the fame time to the region of the liver, I have the fatisfaclion to add, that the bilious appearances for the moft part vanifhed, and, if care was taken to fupport a determination to the furface, feldom ever returned during the continuance of the fever. Dif- ferent feafons, and different fituations of country were particularly diftinguifhed by correfponding determi- nations. Thus a tendency to the bowels and biliary fyftem was chiefly remarkable in the autumnal months, and in low and champaign countries; the head and breaft were oftener affected in the winter months, and in hilly fituations. I obferved before, that it is the firft object in the cure of fevers, to remove thofe circumftances, or accidental ftates of the body, which hinder the dif- eafe from afluming its proper form. Thus, to pro- cure remiffion, appeared univerfally to be the firft bufinefs in the cure of the fever of Jamaica; the next, and a very important one, is to prevent the re- turn of the paroxyfin. If we knew a remedy, which t£2 PARTICULAR CURE OF THE could be depended upon to accomplifh this purpofe with certainty, the cure of the difeafe would be eafy ; but the Peruvian bark,, which almoft infallibly flops the courfe of intermitcing fevers in ail countries, does not feem fo indifputably to poffefs the fame power over the ufual ende-nic of the Weft Indies, lam forry to own, that my knowledge on this fubject, is not altogether fatisfactory. At the time I left J <.maica I did not entertain a doubt, that the endemic of the diftrict, where I refided^ poffeffed fomething in its own nature which decidedly determined its duration. It was ufually obferved to terminate on a critical day, generally by very evident iign's of crifis, and without feeming to be materially effected in its courfe, by the various and oppofite modes of treatment! which were fometimes purfued. .But though this was true for the moft part, yet the fuperior efficacy of the very large dofes of bark, which I afterwards ventured to give in the intermitting fevers of North America, obliges me to fpeak with hefitatior, when I mention the powers of that remedy. It is probable that bark, with the fame management, might have had the fame effects, in the fever which prevailed at Savanna la Mar, as in that which is commonly epidemic in Georgia and the Carolinas ; yet no doubt remains, that as commonly employed in Jamaica, it has no right to be confidered as a rem.dy, which abruptly cuts'fhort the courfe of the difeafe. In every cafe where it w?s tried, (except one) it did not feem to do more than give a degree of tone and vigour to the fyftem, to excite a certain ftate of inflammatory dia- thefis, in confequence of w'rich, the crifis was ob- ferved to be more perfect and complete, though it did not perhaps actually happen at an earlier period. Thus I am difpofed to conclude, from all the expe- rience which I have had, that bark is not gen.reily carried farther, in the cure of the remitting fever of Jamaica, than merely to fupport the tone and vigour FEVER OF JAMAICA. t^$ •f the powers of life. If we truft to it for more, in dofcs of two^fcruples or a drachm given every two hours, we fhall certainly be deceived. Having mentioned the different methods of treat- ment, by which it was attempted to procure remif- fion in the endemic fever of Jamaica, and having likewife endeavoured to afcertain how far we can go inpreventing the return of paroxyfms, it only remains to detail fome particulars in the management of the plan of cure, where the different fpecies of fevers were diftinguifhed by a peculiar train of fymptoms. It was obferved in general, that fevers, with a mode- rate degree of inflammatory diathefis, feldom re- quired our interference. The difeafe, after a certain duration, terminated ufually of its own accord. After 1 had gained fome experience of the general courfe of fevers, I ufually allowed thofe, in which I did not perceive marks of danger, to go on their own way, that I might better difcover thofe periods, at which the difeafe was naturally difpofed to terminate. Thus where the paroxyfms continued regular and diftinct, the remifiions perfect, and the vigour unimpaired, nothing material was attempted to be done. On the contrary, where the paroxyfms were long, or lefs diftinJ$ greater efficacy. It was, however, found to mode- rate the violence of local pain, particularly the vio- lence of the head-ach, and to be not altogether with- out effect, in retarding the ufual rapid progrefs of the difeafe. It has hitherto been thought neceffary, indeed almoft indifpenfible, to empty the firft paffages in this fpecies of fever; but time is fhort, and the good which accrues from fuch evacuations, is not very certain, and often not effential. It was, therefore, thought fufficient to truft this intention, for the moft part, to laxative glyfters; after the employment of which, (bleeding havingbeen premifed in fuch quan- tity as was deemed proper,) the patient was wafhed clean, and bathed in warm water, in as complete a manner as the circumftances of fituation would per- mit. It is needlefs to mention, that this was done with a view to increafe mobility of fyftem, and to remove fpafmodic ftricture from the extreme veffels of the furface; in confequence of which, greater be- nefit was expected from the application of cold falt- water, which was daihed fuddenly from a bucket on the head and fhoulders. This practice may appear hazard6us, to thofe who argue without experience; but I can vouch for its general fafety, and bear tefti- mony to its»good effe<5ts. Sweat, with perfect relief from all the feelings of anxiety and diftrefs, was ge- nerally the confequence of this mode of treatment. If employed within the firft twelve hours from the attack, it feldom failed of removing all the fymptoms of danger: or of effecting a total and complete change in the nature and circumftances of the difeafe; but if the progrefs was more advanced, though the fame rule of practice might ftill be proper, the execution required more boldnefs and decifion. It is only pof- fible to judge from the circumftances of the cafe, at this period, of the neceffity or propriety of bleeding, and of emptying the lower inteftines by means of glyfters; but when this bufinefs fliall have been ac- If6 YELLOW FEVER. complifhed, in fuch manner as may be deemed right, or conducive to the main view, it will be advifeable to fhave the head, to bathe the whole body in warm water, and inftantly to dafh cold water from a bucket on the head and fhoulders. I have even fometimes, where there was an appearance of greater obftinacy,1 ventured to wrap the whole body in a blanket foaked in fea water, or water in which was diflblved a large portion of fait. If anxiety was great, or naufea and vomiting troublefome, I have alfo obferved benefit from the application of a blifter to the epigaftric re- gion. Opiates, joined with remedies which had a tendency to determine to the furface, were found to be ferviceable ; and wine, with a fupply of frefh and cool air, in moft cafes,_ was highly neceffary. This method of proceeding will, perhaps, be thought un- warrantable; but. I can fpeak confidently of its fafety j and I may farther add, that unlefs fome decided fteps are taken to change the nature of the difeafe, during the continuance of this ftage, our future endeavours to do good, will generally be in vain. I have hitherto promifed fuccefs in the cure of this fever, with a good deal of confidence; but if it fhould fo happen, that we are not called to the patient till the yellow- nefs has fpread over the whole of the body, or till the black vomiting has begun to make its appearance, the profpedt, I muft confefe, is then very dark. The ordinary refources of our art are feeble ; and if good can be done at all, it can only be done hy means, which in the common opinion of practitioners, bor- der on rafhnefs. In this hitter ftage of the com- plaint, fo great a degree of torpor overwhelms the powers of life, that remedies do not produce their ufual effect, and our labour is often the fame, as if we attempted to refufcitate a corpfe. I have, how- ever, feen inftances of fuch unexpected recoveries from the moft hopelefs ftate in fevers, that I feldom totally defpair as long as life remains. I know that YELLOW FEVER. I 77 death may be prevented, even after black vomiting has appeared with all its terrors, if a remedy can be found powerful enough to excite the action of the extreme veffels, and to recall the determination to the furface of the body. For this purpofe, I have employed alternately warm and cold bathing with ■* .■* fuccefs. I have even wrapt the body, as I mention- " ed before, in a blanket, foaked in water, in which a large portion of fait was diflblved, or which had been fteeped in brandy or rum, enjoining at the fame time the liberal ufe of wine, or even more powerful cor- dials. I have heard of fome well-attefted inftances, where plentiful draughts of rum and water, have checked the vomiting, and apparently faved the lives of patients, after the medical people had given them up for loft. I have now mentioned the method of cure which I purfued in the yellow fever of Jamaica; and I muft be allowed to add, that the general indication ap- pears to be confirmed by a view of the hiftory and progrefs of the difeafe, as alfo by confidering the ap- pearances which are found after death. It was ob- ferved in the preceding pages, that the circulation became languid at a certain period in the courfe of this fever, and that the determination was, in fact, turned upon the internal parts, particularly upon the alimentary canal, and biliary fyftem. To fupport, therefore, or to recall the determination to the fur- face, where it had begun to retire, was the princi- pal aim which was kept in view. It was purfued with vigour; and, I have the fatisfaclion to add, fre- quently with fuccefs. I am afraid that the means may be thought hazardous; but I have never yet per- ceived from them, even a momentary harm. I fhall not therefore ceafe to recommend them, till I find that others have tried them fairly, and found them dangerous or ineffectual. 178 YELLOW FEVER. & SECTION II. IN the preceding pages, I attempted todefcribe the difeafe, which has been ufually regarded as the proper yellow fever of the Weft indies, detailing at 7 the fame time, the particular fteps of a method of ^ej cure, which I have caufe to believe, was followed $fS with more than ordinary fuccefs. I now proceed to confider another fpecies of diforder, which frequently makes its appearance among people newly arrived in hot countries, and which, from fome ftriking marks of affinity, I have been induced to rank as a fpecies, or variety of the former. Yellownefs, indeed, is not by any means common to it, and black vomiting is actually rare ; yet paroxyfms and remiffions are fcarcely diflinguifhable, and the difference between it and the preceding, is perhaps, in fact, only acci- dental. I remarked before, that this fpecies of difeafe, as well as the yellow fever, properly fo called, appears but rarely among thofe who have refiued any length. of time in tropical climates. It was obferved to begin, as fevers ufually do, with difagreeable affec- tion of the ftomach, with languor, debility, and pain of the head. The horror of fhivering, fo common in the commencement of febrile difeafes, was feldom great in degree; but it often lafted long, and fome- times was accompanied with unufual feelings. The pulfe was generally fmall, frequent, and eafily com- preffed; the eyes were watery, muddy, or inflamed ; the features were confufed, and the countenance was fometimes flufhed : the thirft was feldom great; and the heat of the fkin was ufually moderate ; but a deep and heavy fighing, a hurried refpiration, with an inconceivable diftrefs and anxiety about the pr,e- cordia, gave ftrong indications of the nature of the complaint.—In fome inftances I have known fudi YELLOW FEVER. I 79 fevere and excruciating fpafms, as,.in fome meafure feemed, to fufpend the ordinary functions of life. In twelve hours, or lefs, there was often fome abatement in the violence of thofe fymptoms; but . feldom fuch material relief, as, with any degree of juf- tree, could be called a remiffion. The fkin became * cool, and fometimes moift ; yet there fcarcely ever was any fweat. The pulfe became fuller, and often lefs frequent; the reftleffnefs and anxiety were fome- times fenfibly diminifhed; and the local pain often abated; but this refpite was neither long, nor of cer- tain duration. In a few hours, all the fymptoms . returned with aggravation. The eyes became more muddy ; the countenance more confufed; the head- ach, and other pains increafed, together with fenfa- tions of anxiety, and reftleffnefs, hurried refpiration, and deep and heavy fighing. The pulfe was now more frequent, fmaller and harder; the thirft was increafed, with naufea, and fometimes with vomiting. The vomiting was feldom bilious : it was not often, indeed, that the matter thrown up, was altered from what had been drank, unlefs by having acquired an additional degree of ropinefs.—To the above fymp- toms was fometimes added an obftinate coftivenefs, fometimes fuch a degree of purging and griping, as might eafily be miftaken for proper dyfentery. As the difeafe advanced in its progrefs, the abate- ment of the violence of fymptoms, which at firft was fometimes percdved towards the mornings, became gradually lefs and lefs perceptible, and at laft was fcarcely to be diftinguifhed; The anxiety and reft- leffnefs were now particularly diftreffing; the fkin was fometimes dry, though oftener moift, and in point of heat below the ordinary temperature of health; while it gave the idea to the perfon who felt it, as if there was a powerful fpafm fubfifting on the furface. I may likewife remark in this place, that a beautiful red colour of the cheeks, together with a fmooth- l8o YELLOW FEVER. nefs and cherry plumpnefs of the lips, was frequently obferved towards the latter periods of the difeafe. Yellownefs, as was mentioned before, was feldom feen, unlefs in the very laft ftage of the illnefs ; and vomiting of black, or even bilious matter was ex- tremely rare. There was, however, at all times, a great difpofition to faint, with more or lefs of a cer- tain fpecies of low delirium. The courfe of this fpecies of the difeafe, was lefs rapid, than the courfe of that which terminates in black vomiting ; the termination of the one being often protracted to the eighth or ninth day, that of the other feldom exceeding the fourth or fifth. The marks of crifis, as was obferved before, were rarely difcoverable in the firft fpecies of the yellow fever. They were likewife obfcure in the prefent, and I cannot pretend to fpeak with confidence, of the in- fluence of critical days. Where the termination was favourable, the pulfe became gradually ftronger, and lefs confined in its ftroke ; the fkin likewife became fofter, while the impreffion, which it made on the hand that felt it, communicated an idea that the cir- culation was more vigorous, and the fpafm on the furface lefs obftinate; the eye and countenance like- wife brightened up; the anxiety and reftleffnefs va- nifhed or decreafed, and fome appetite for food re- turned ; but it was often difficult to mark the point of time precifely, at which this change took place.— It may be obferved likewife, where the termination was fatal, that death approached in two different ways» A patient, apparently poffeffed of vigour, was fometimes fuddenly feized with coma or convul- fions, and died unexpectedly ; but it happened more frequently, that the powers of life were gradually and flowly cxtinguifhed; the pulfe became weaker and more confined in its ftroke; while the natural heat and circulation retired by degrees from the furface and extremities of the body. YELLOW FEVER. l8l The cure of this fpecies of the difeafe, though by no means eafy, was lefs difficult upon the whole than that of the former. Inftead of the torpor and infen- fibility, which prevailed in the latter periods of the proper yellow fever, the mobility of the nervous fyf- tem was fo much increafed in the prefent fpecies of difeafe, that remedies feldom failed of producing fen- fible effects : and wherever remedies produce effects, it generally is in our power to manage the bufinefs in fuch manner, that fome good may arife. It may be obferved in the firft place, with regard to the cure, that bleeding, which frequently was ufeful in the former fpecies, was generally hurtful in the prefent; and that inftead of retarding, it oftener accelerated the progrefs of the difeafe. Emetics were employed very commonly by the practitioners of the Weft Indies, in this as in other cafes of fever; but I cannot help remarking, that languor and debility, frequently yellownefs, and fometimes a continual vomiting, which no remedies could reftrain, were often the con- fequence of antimonial emetics of fevere operation ; and I have no doubt in faying, that the approach of death was actually haftened, in feveral inftances, by this method of treatment. Laxatives were occa- fionally of fervice; but the ftronger purgatives were frequently hurtful. Bfifters were often extremely beneficial ; but it requires care and difeernment to apply them in the proper circumftances, fo as to reap the full advantage. Opiates were fometimes ferriceable, and bark and wine, in moft inftances, Were remedies of great value ; but the principal truft Was placed in warm and cold bathing ; which, under proper management, feldom failed of anfwering every expectation completely, or fpeedily, of removing the chief fymptoms of danger. Sometimes it appeared to cut fhort the courfe of the difeafe abruptly. R I©*2 YELLOW FEVER. SECTION III. I HAVE now defcribed two fpecies of a fever, which feems to be, in fome degree, peculiar to the natives of northern regions, foon after their ar- rival in the Weft-Indies'. In the one, a determina- tion to the alimentary canal and biliary o'rgans, with marks of putrefcent tendency in the general mafs of fluids, was difeoverable at an early period ; in the other, the brain and nervous fyftem were more par- ticularly and principally affected; while the fpecies, cf which I now attempt to give fome account, ex- hibited ftrong marks of vafcular excitement, with a very high degree of the apparent inflammatory dia- thefis. This wa§ more irregular in it ♦ appearances and more complicated in its nature, than the others. The marks of inflammatory diathefis were generally very apparent in the beginning ; but they ufually gave way or became complicated in the latter ftages, with fymptoms of putrefcency or nervous affection. In defcribing the hiftory of this difeafe, it may not be fuperfluous to remark, that there is feldom any thing particular in the fenfations of debility and hor- ror, which precede the formation of the paroxyfm. The hot fit was generally obferved to run high; the heat was often intenfe; the pulfe, which was quick, frequent and irregular, vibrated often in an uncommon manner, and wrtto\.an ufual degree/of force; the thirft was fometimes immoderate',"Torne-^ times not greatly increafed ; the countenance was" flufhed ; the eye glifter.ed, and appeared frequently to be in.fome degree inflamed ; the figns of excite- ment were in general uncommonly high ; yet the difpofition to faint was fometimes hidden and unex- pected. It deferves farther to be remarked, that blood drawn from the arm did not commonly exhi- bit the ufual buffy appearance of real inflammatory YELLOW FEVER. 183 eiathefis ; and though times of aggravation and al- leviation were often difcernible; yet they did. not happen at regular and ftated periods. It was obferved frequently, that many of the lead- ing circumftances fuffered a material change, about the third day of the difeafe. The fymptoms of high inflammatory diathefis, which prevailed in the begin- ning, became- mixed, more or lefs, with fymptoms of putrefcency, or nervous affection. Delirium made its appearance; fometimes it ran high, with ftartings and fymptoms of violent excitement; fometimes there was a low and muttering incoherence with marks of languor and debility. The gums turned red and fpungy, and fometimes bled; the thirft was frequently intenfe, the tongue dry, with vomiting and fevere retching ; yet vomiting of bilious or vitiated matters was a rare occurrence. The above fymptoms gene- rally went on to increafe, during the fpace of fix or feven days, about which period the powers of life either yielded to the difeafe, or figns of recovery be- gan to appear: the marks of crifis, however, were feldom diftinct and final ; neither was the influence of critical days fo much to be depended upon as irt the common remitting fever of the country. It was mentioned above, that the nature of this foyer was more complicated than that of the two for- mer; fo the indications of cure are likewife more dif- ficult and perplexed. If we proceed on the firft ob- vious view of the difeafe, we {hall often do irreparable mifchief by copious ,and repeated evacuations; yet there will not be lefe danger, on the other hand, if, •regardlefs of the prefent degree of excitement, we in- dulge freely in the ufe of ftimulant?. It is neceffary to obferve a middle courfe ; and I muft confefs, that it is fometimes difficult to do any thing, without doing harm. Bleeding was frequently employed in the cure of this d'.feafe, and in moft cafes, it was a ufeful remedy, though lefs perhaps from its own 184 YELLOW FEVER. eftects merely, than from paving the way to other more powerful applications. It i?, however, capa- ble of being eafily carried to excefs ; and ought not to be trufted to wholly for the removing of the irri- tability, and high degree of excitement, which pre- va:ls fo generally in ~the beginning of this difeafe. After bleeding, emetics and cathartics are employed very freely. I have always profeffed myfelf an ene- my to the practice of giving emetics in the fevers of Jamaica; yet, I muft confefs, that antimonials were not only fafer, but of more particular fervice in this, than in any other fpecies of fever, where I have feen them tried. Among the great variety of forms which have been recommended by practitioners, for the purpofe of emptying the firft paffages, I have not found any one anfv/er fo well, as a thin folution of the fal-catharticum, given at different intervals, with a fmall portion of emetic tartar, and fometimes with the addition of laudanum. The operation of this remedy was extenfive. It might be fo managed, as to promote naufea or vomiting, fweat, or moderate evacuations downwards; at the fame time that it proved very powerfully fedative. I may likewife add, that I have fometimes found benefit from nitre, camphire and opium, given in pretty large dofes, and accompanied with plentiful dilution. But though thefe remedies were often ferviceable, and contributed in many cafes to moderate the high degree of irrita- bility, yet the chief dependence of the cure was.much better trufted to cold bathing. After the furface of the body had been fumciently relaxed, by the previous ufe of warm bathu:g and fomentations, the effects of cold bathing were wonderful. The exceffive irrita- bility was moderated or removed, and the powers of life were invigorated in a very Angular manner in confequence of it. I have attempted in the preceding pages, to give a fhort view of a difeafe, which has not, I believe, YELLOW FEVER. l8^ been hitherto very accurately defcribed by authors' or treated with much fuccefs in practice. It is a difeafe of a continued kind; and, as I faid before, in fome degree peculiar to the natives of northern lati- tudes, foon aftertheirarrival in the tropical climate?. I cannot help thinking, that it may be eafily diftin- guifhed, even in the firft hours of its attack, from the intermitting or remitting fever, which is the common endemic of hot countries: but I muft at the fame time add, that this diftinetion does not refide in the prefence or abfence of one individual fymptom.. The ftate of the pulfe, indeed, conveys information,. that the difeafe is not of the kind which has paroxyfms and remiffions : yet this information can only be ob- tained from a knowledge and actual comparifon of the two difeafes :—I do not pretend to defcribe it in words. The ftate of the eye and countenance, was likewife obferved to be ftrongly defcriptive of the na ure of the difeafe; as alfo were the deep and heavy fighing, the hurried refpiration, the anxiety and reft- leffnefs, with a certain uncomfortablenefs of fenjation, which no words can exprefs ; but I confefs myfelf, at the fame time, perfectly at a lofs to fix on any one fingle fymptom, which appearing, at an early period, difcriminated it with certainty from all other fevers. 1 have defcribed it under three diftinct and feparate forms; but I muft alfo add, that they may fometimes be found to be more complicated with each other, rfun they appear to be in the above defcription.. R j C iW] CHAP. XII. INTERMITTING FEVER OF AMERICA. " HAVING endeavoured in the preceding treatife,, to give a more accurate hiftory of the endemic fevci of Jamaica, than is met with in books, and I am difpofed to flatter myfelf, having pointed out a more fuccefi-ful method of cure than that which has been generally pui fucd ; I fhall now add a few obfervations on the intermitting fever of America; a difeafe, in which my experience has been tolerably extenfive. The frequent occurrence of intermitting fevers in •very climate, together with the full and ample man- ner in v.hich the difeafe has been treated of by many learned and ingenious wrieis, excufes me from en- tering into a minute and lull difcuffion of the fubject. I fhall therefore employ only a few pages in attempt- ing to illuftiate particulars in the hiftory or" the dif- eafe, which have been foperficially noticed; or to ex- plain fern . points of treatment, which, though not new, I have ventuied to carry farther than is ufual in com- mon practice. As I had the opportunity of attending to the hiftory of the intermitting fever in feveral of the fouthern provinces of the Continent of North Ame- rica, I fhall fiiil mention the more conftant and ge- neral coarfe if the difeafe, and arierwards point out thofe circumftances of peculiarity, which feemed to arife from the difference of climate, or from the influ- ence of the feafon of the year. I fhall likewife occa- sionally take notice of the general ftate of health of the fcoo^s who ware tmtloyed on the fame expedition, INTERMITTING FEVER, &C. 187 though I muft alfo add, that I can only pretend to trace the progrefs of the fever with accuracy, in the regiment in which I had the honour to ferve. I fhall attempt, in the firft place, to give an accurate defcription of the paroxyfm of an intermitting fever, marking as carefully as I can, the order of fucceffion, in which the fymptoms moft ufually appear. We are taught by the defcriptions of moft writers, to con- fider languor and debility as the firft feeling or firft effential fymptom in the paroxyfm of an intermitting fever; but I cannot avoid remarking, that an unuf ual affeaion at ftomach,a flatulence,—in fhort, fomething difagreeable, which I cannot eafily define, but which was accompanied in many cafes with head-ach, and fometimes with drovvzinefs, preceded every fenfation of languor or debility in moft cafes, where my obfer- vations were made with fuch care that they could be trufted to. I may alfo farther obferve, that, as foon as this languor or debility began to be perceived, the veins began to fubfide, the nails turned pale, and at laft blue ; the fkin of courfe was dry and conftncted; and there was fometimes an evident diminution of heat, particularly of the heat of the extremities. To thefe fymptoms was often added, a difagreeable kind of yawning, with ftrong fenfations of wearinefs, and an irrefiftible inclination to ftretch the limbs. A 'fenfation of cold was now felt in the back, as if water ran down upon it in feparate ftreams. It foon va- nifhed, indeed; but fuddenly returned again in a more violent decree; in which manner it went on, ceafing for aninftant, and then recurring with aggravated vio- lence, till the whole body became at laft affeaed with rigour or Awing, accompanied, in a more efpecial manner, with chattering of the teeth. The coldnefs having now arrived at its acme, or higheft point ot inteniity, glowings of heat were^erceived1 inthe inter- vals between the rrgor^or.fucceffions. Thefeglowings grew gradually ftrbnger, and-continuing for a greater 188 INTERMITTING FEVER length of time, at leaft banifhed every fenfation of cold. The heat, which now fucceeded, was often much above the temperature of health;, marks of fe- ver fometimes ran high; the veins became full; the face was flufhed, and the furface of the body bore marks of diftenfion. The duration of this ftate was uncertain: fometimes it did not continue the fpace of one hour, fometimes it lafted four or five. A damp- nefs at firft began to appear on the forehead and brea'ft, which extending itfelf gradually to the extremi- ties, was at leaft formed into a fweat; -in confequence- of which, the fev, r gradually fubiided, and the body returned nearly to its natural ftate. The above are the moft ufual fymptoms of the pa- roxyfms of an intermitting fever. I have defcribed them in the order of time in which they moft ufually ap- pear. I muft however remark, that fymptoms are fometimes obferved different from thofe which I have now taken notice of; as alfo, that the order of fuc- ceffion, which I have mentioned, is not, by any means fixed and invariable. It is impoffible to deny the common obfervation, that languor or debility is a ge- neral and early fymptom in almoft every fpecies of fever ; but it is likewife certain, that there are many inftances, where it is not in our power to perceive its actual prefence. It is therefore precipitate to con- clude with Dr. Cullen, that all the future phseno-* mena depend upon this, as their eflential and original caufe. There may frequently be deception in at- tempts to defcribe the fituation of othur.'.; but that which we feel ourfelves is more to be trufted to :— and I can affirm, that I have often felt f nfetious of cold in my own perfon, previous -to every feeling of languor or debility; previous, I might even fome- times fay, to any peicepnble deviation from a ftate of health. But beftde?', that the exiftence or perception of languor and debility, does not feem to be effen- tial to the exiftence of a paroxyfm of intermitting OF AMERICA. 189 fever, I may likewife add, that I have feen inftances, particularly in the hotmonths of fummer, where the whole of this difeafe paffed over, without the leaft perceptible degree of a previous cold fit. It happen- ed fometimes alfo, that during the continuance of the paroxyfm, there was fcarcely any obfervable diforder in the pulfe, or any material figns of external fever. The tumult and uneafinefs, which terminate in moft cafes by fweat, went off in fome by urine or flool, or perhaps declined in others, without the appearance of any preternatural evacuation. In like manner it was commonly obferved, in the difeafe diftinguifhed by the name of partial intermittent, that there was not any perception of cold, nor increafe of heat; no diforder in the pulfe, or preternatural evacuation ; in fliort, not a fymptom, which charaaerizes the ge- nius of the difeafe, except local pain, which continu- ing for a certain time, difappears, and then returns again at a ftated hour. To this we may add, that there are various inftances, where the whole duration of a complaint, which indifputably depends on the caufe of intermitting fever, is occupied by a coma- tofe difpofition, by convulfions, or even by tetanic affeaion. If we therefore confider thefe phenomena attentively, we lhall find little caufe to believe, that the moft ufual fymptoms of the intermitting fever, are fymptoms without which the difeafe cannot exift; or that they are mutually the caufe and effea of each other. The order of fucceffion I have obferved is not fixed invariably; and cafes are numerous, where thofe fymptoms, which fome authors have confidered as abfolutely eflential, do not appear at all. This fea is certain; and we may fafely conclude from it, that the main hinge of aaion in a paroxyfm of fever has not been yet difcovered. The vital and natural funaions are varioufly af- feaed, not only in different people, but in the fame perfon, in the different ftages of a paroxyfm of the IpO INTERMITTING FEVER fame fever. The pulfe, in the firft approach, is of- ten remarked to be flower than natural, fometimes it is more languid and weak. It foon however becomes more frequent, though it continues for the moft part fmall and contraaed, till the latt-r ftage of the cold fit. It then ufually acquires ftrength and fome de- gree of fulnefs, fometimes greater frequency and hardmefs; but as the fweat begins to flow, the hard- nefs and frequency abate, while the fulnefs increafes; fo that it returns by degrees nearly to its natural ftate* The difagreeable affection of ftomach, (which I for- merly obferved was fometimes the firft perceptible fyo eoom of a paroxyfin of the intermitting fever) in- c: e< fes frequently to naufea or retching, fometimes to feverc and continual vomiting; which does not * ceafe till fweating has become general all over th* body. The refpiration, which in the beginning o£ the paroxyfm, is ufually flow, and fometimes inter- rupted with fighing, in the progrefs of the hot fife Becomes frequent, laborious and high. It often hap- pens, likewife, that there is more than ordinary dul- nefs of perception in the mental faculties in the firfts approach of the fever ; while this is often fucceeded by extraordinary acutenefs in the more advanced" ftages, particularly during the continuance of the hot fit. But though it is only during this period thats excitement and dhtirium are obferved to be common; yet inftances are not wanting, where derangement of\ intellect is among the firft fymptoms of the difeafe^ and where it continues among the principal through- out the whole of the courfe. To the above appear- ances we may add, that the urine, which is thin and pale in tho firft ftage, becomes high coloured in the progrefs of the hot fit; and as the fweating advances,. thick and turbid, frequently with the addition of a copious lateritious fediment. I remarked formerly, in treating of the remitting fever of Jamaica, that certain hours of attack were OF AMERICA. I9I in a very "peculiar manner conneaed with the dif- ferent types or forms of that difeafe; but I cannot pretend to far, that the fame rules were obferved to hold good, with any degree of certainty in the inter- mitting fever of America. Single tertians, indeed, began moft ufually about twelve ; though there were likewife many inftances where they came on fo early as ten" in the morning, or fo late as two in the after- noon. The other forms were ftill lefs regular. It was alfo taken notice of, that anticipations were common in the fingle tertian of Jamaica; as alfo that they were irregular and long. In America they were ftill more frequent; but feldom exceeded one or two hours at once. They often, however, pre- vailed to a certain acme, or point in the difeafe, ob- ferving a regular interval of time in their progrefs. It fometimes likewife happened, that the type poft- poned o-radually, till the complaint difappeared finally, This, however, was much more rare than the other. Having mentioned, in the preceding pages, fome general refemblances of the intermitting fever of Ame- rica, I fhall next trace its peculiarities in the dif- ferent provinces, in which the regiment to which I belonged, had the fortune to ferve. I may obferve, in the firft place, that I joined the firft battalion of the 71ft regiment, on York Ifland, in the beginning of the fummer 1778. Few of the men were then fick; neither did the number increafe materially^ till towards the latter end of June. The intermitterits, which appeared previous to this period, were gene- rally fingle tertian; and of perfectly eafy treatment. In the month of July, a dyfentery,'oPa very particular kind, became epidemic, and the fporadie intermittent inftantly vanifhed. The ftools in this complaint were numerous and bloody, the griping were fevere, but there was feldom any very material diforder in the pulfe. The difeafe did not often terminate in lefs than feven days; fometimes it-Continued a I92 INTERMITTING FEVER fortnight or longer. The ordinary treatment was" very rarely of benefit; yet the complaint was of a nature fo little dangerous, that I do not recollea a fingle perfon who died of it. It difappeared totally about the beginning of Auguft, or rather changed into an epidemic intermittent, the type of which was ufually fingle tertian. The paroxyfms of this fever were regular, the intermiffions were diftina ; and its nature was fofar from being obftinate, that I fcarcely met with an inftance which refitted the Peruvian bark, where that remedy was given in fufficient quantity. This fever continued highly epidemic during the months of Auguft and September. The frequency of new attacks was confiderably diminifhed in the month of Oaober ; yet fuch as happened then, were generally accompanied with dangerous and alarming fymptoms. Relapfes were common. But though the intermitting fever of this ifland was epi- demic in a confiderable degree, it was not by any means of a fatal nature. If negkaed in the begin- ning, foundation was fometimes laid for obftinate complaints ; but the difeafe was not fatal in its proper form to any one patient, who remained with the regiment. I cannot fpeak with certainty of the iffue of a few of the worft cafes, which were fent to the General Hofpital, on the breaking up of the encamp- ment in the month of November. The regiment was then embarked in tranfports, on an expedition to the fouthward. The fick were colkaed into one fhip, which, after a ftormy and tedious paffage, arrived with the reft of the fleet at Savanna, in Georgia, in the latter end of December. The voyage had an excellent effect on the health of the men. Out of a hundred and twenty convalefcents, who embarked at New York, in the month of November, not a man died ; and there only remained two, who were unfit for the fervice of the field, on the day of our arrival in the Savanna river. During the months of January, OF AMERICA. 193 February and March, the battalion of the regiment in which I ferved, was a total ftranger to ficknefs. It was employed in longand almoft continual march- ing, till the latter end of April, when, encamping at Ebenezer, on the Savanna river, the intermitting fever foon made its appearance, and fpreadfo rapidlv, that before the end of June, very few remained, not only in this regiment, but even in the garrifon, who had notfuffered more or lefs from this raging difeafe. It was commonly remarked in the hiftory of this fever, that the type during the month of May, was ufually fingle tertian, till the fifth or fixth day ; after which, paroxyfms were often obferved daily, though generally unequal in force and duration : that is, the difeafe changed about this period, to a double tertian form. But though this was obferved to be the cafe, during, the greateft part of May, the type of the fever was ufually double tertian, or quotidian, from its very commencement, in the month of June. The difeafe was then of the moft ardent kind. The pa- roxyfms were feldom ufhered in by a cold fit; and the remiffions, for the moft'part, were very ind;ftin& and imperfea. The heat of the weather was excef- five, during the greateft part of the month ; and ftran^e and alarming fymptoms occurred freqox,u?/ in the courfe of the difeafe. In fooie cafes a comatofe difpofition, approaching to apoplexy, or rigid fpafms, refembling a perfea tetanus, occupied the greateft part of the paroxyfm ; in others there were various local pains, deliria, bilious vomitings or purgings, with a multitude of other afrecticr.s, which appeared on a fuperficial view to conftitiue the whole of the complaint. Yet thefe fymptoms declining afterfone continuance, recurred again at a ftated hour, and were finally removed, or at leaft fufpended, by the Peruvian bark. I left the garrifon of Kbenezer in the beginning of July, and went direaiy to Savanna, where the fame epidemic prevailed, though in a de- S 194 INTERMITTING FEVER gree of lefs frequency, and with fymptoms of a lefs a arming nature than at the above-mentioned place. At Savanna, it ufually retained marks of diftinCt in- termifiion, and its type was often of the fingle tertian kind—in iiiort, it was fimilarto the fever of Ebenezer in the month of May. From Savanna, I went to Beaufort in the beginning of Auguft. The fever, which ufually prevails at this feafon of the year, in all the fouthern provinces of North America, was then epidemic among the troops who were flationed on this ifland. The type, however, was ftill more com- monly fingle tertian here, than at Savanna. The be- ginning of the paroxyfms was likewife more gene- rally diftinguifhed by a cold fit; and theintermiffions, for the moft part, were more perfea and diftina. In a few cafes, indeed, marks of malignity were dif- coverable ; yet the difeafe, upon the whole, was not of a fatal nature, or of obftinate cure ; though unlefs fpeedily checked by bark, it often degenerated into dyfentery or dropfy, which were not only removed with difficulty, but in the circumftances under which we laboured, were often-of very precarious iffue. This epidemic was ftill acquiring force, when the outpofts were fummoned to the defence of Savanna. Its progrefs was, in fome meafure, fufpended during the aaive fervice of the fiege. The enemy, however, had no fooner retired from before the place, than a fever begin to rar-e with violence, which carried off prodigious numbers,'particularly of the foreign troops. It was obferved in the hiftory of the preceding year, that few were attacked afrefh with the intermitting fever on York Ifland, fo late as the months of Oaober and November; but it was likewife remarked, that, where the difeafe happened at thofe period, the fymp- toms were oftener malignant or dangerous. The lame was in for^e reflects the cafe at Savanna. The fever, which made its rppearance after the fiege, was *( an alarming and violent kind. Marks of diftina OF AMERICA. I95 intermiffion were feldom difcoverable, delirium was a common fymptom, fpafmodic affeaions were feme- times violent, and the courfe of the diforder \vv;., ge- nerally rapid. The rage of this epidemic ceafed in December ; but relapfes continued to return occa- fionally, during the following winter ; which was an unufually fevere one in that fouthern latitude. There likewife ftill remained fome dyfenteric com- plaints, which refilled every mode of treatme.it that could be devifed. They yielded however to the re- turn of the warm weather, affifted, in no f.nall degree perhaps, by theaaive fervice of the fiege of Charlef- town. The recovery, indeed, was fo complete, that, in the beginning of June, the whole of the regiment arrived at Camden in perfea health. The firft bat- talion was fent to occupy a poft at the Cheraws on the river Pedee. The diftance is feventy-five miles ; yet fuch was the fpirit and aaivity of the men, that they performed the march in three days, without fatigue or inconvenience. An open field, between four and five hundred paces from the bank of the river, was chofenfor the encampment of this battalion ; while a fituation perfeaiy dry and cleared of wood, but nearer to the bank, was rcferverps happened to ferve, we may be enabled to form fome idea of the chancres, which are more conftantly pro- duced by feafon and climate, or which arife accident- ally from the particular effbas of local fituation. In the fpring and beginning of iummer, the fingle ter- tian was the moft ufual type of the endemic of Ame- rica, in every province which the regiment viliied; — the paroxyfms were diftina, and the intermiffions were generally perfea. In the months of June, July and Auguft, double tertians were common, and in fome fituations banifhed every fimpler form. As the weather turned cool, the fingle tertian refumed its place ; fo that any other type was fcarcely ever feen. But befides the above changes of type, which in fome degree followed the changes of feafon, dyfentery or dropfy frequently made their appearance in the months 200 INTERMITTING FEVER of Auguft, September and October, alternating with, or fucceeding the intermittent; while fevers of a bad and uncommon kind .ere by no means rare in the months of Oaober and November. I have thus obferved in a cur ory manner the more general changes of the intermitting fever, as influ- enced by change of feafon. I may alfo remark, that befides l'eafon, climate had a confiderable efFha in modifying the appearances of the dife fe. It thus happened, that the tvpe was generally fingle tertian on Yoik Ifland, even in the heat of aimmer; in fpringand winter other forms were rarely feen. In Georgia, the fingle tertian was the p:evading form, only in the winte.f and ipring. In fumme-, and fome part of autumn, double tertians were common; and types of ftill greater complication frequently made their appearance during this period, in fo.ue par icular fituations of the province. Dyientery dropfy and dan- gerous fevers were likewife more frequent here in the autumnal months, than they were found to be in the neighbourhood of New York ; while the courfe of intermittent, as long as the form was regular, was mo:e fpeedily checked by Peruvian Bark in Georgia,, than in the more northern latitudes. The prevailing type of the climate of South Carolin-j, vvas fingle ter- tian, even in the oimfner and autumn; yet where the forms of the difeafe was in-a high ftat. of concentra- tion, as at the Cheraws, the type was ouen fo cm- plicated that remiffions were fcarcely discernible. The tendency of the endemic of this province, to deg:ne- late into dyfemery or dropfy in he autumn,, was like- wife lefs remarkable than in Georgia. The danger- ous fevers of Oaober and :N ovember were alio fewer in number; though ftill more /requent, and more for- midable than in the province ol New York. The province of Virginia lies about half.vay between New York and Savanna; and the general effeas of its cli- mate, on the common endemic ot the country,, cor- OF AMERICA. 201 refoonded with its local fituation.—Deviations from the tertian type, were more frequent than at the one place, lefs fo than at the other. It appears from what has been faid above, that the fingle tertian is the proper fundamental type of North America. It undergoes, as we have feen, a regular change and alteration, in confequence of the ordinary changes of the feafons, as alfo in confequence of the effeas of the various climates of the different pro- vinces of that extenfive- continent: but befides thefe changes, which are more general and certain, we like- wife find, that the accidental circumftances of local fituation often produce very remarkable effc-as. In this manner, though the type of the fever which pre- vailed on York Ifland, was properly fingle tertian; yet double tertians, and even more complicated forms, were not by any means rare, in a part of the batta- lion which lay contiguous to a f.vamp. The real nature of the endemic fever of Georgia, is, perhaps properly of the intermitting kind; ^et remiffions were often fcarcely perceptible at Ebenezer; which is fitu- aied im i.ediately on the bank of the river Savanna, and which, in fome degree, is furrounded by creeks of frefli water. It may not be improper to remark with regard to Ebenezer, that few places in America have been obferved to be more unheaithi'ul; though fuch a conclufion piobably would not be drawn from a general view of us fiiuition. It occupies a fandy eminence of confide; able elevation, and pofl'effes a confiderable environ of cleared ground. At Sa- vanna, which is fituated twenty-five miles nearer the mouth of the river, there were likewife many in- ftances of deviation from the fingle tertian type, but ftill fewer than at Ebenezer. The fever lhcewife was generally of a lei's dangerous kind. The obvi- ous appearances of the two places did not afford fuf- ficient reafon for forming this conclufion. The fitu- ation of Savanna would have probably been thought 202 INTERMITTING FEVER to be the leaft favourable to health. Though elevated and dry, and poffeffing a wider environ of cleared ground than Ebenezer; yet a fwamp on the right and left, v/ith a river and rice fwamps in front, threat- ened great ravage from intermittents. That they were lefs formidable than might have been expeded, was probably in a greater meafure owing to the bluff or fend bank being higher than the fituation of the town, and intercepting, in fome degree, the exhala- tions from the river and great fwamps. I obferved on a former occalion, that the figns of crifis, in the remitting fever of Jamaica, were generally clear and unequivocal. I muft now own, that I have not been able to attain certainty, on this head, in the intermitting fever of America. In fe- vers of a fingle tertian type, the intermiffions were frequently fo perfed and complete, that it was not eafy to fay what was wanting to conftitute perfea health: even in the hot months of fummer, where the remiffions were extremely obfcure, I often found it difficult to form an opinion to which I could confi- dently truft ; as it happened frequently, that thofe figns, which I had been difpofed to conf.der at one time as marks of final c;ifir, proved in the event only to be indications of more diftina intermiffion, or of fome change in the nature of the fymptoms. Kaving_given a fhort view of the hiftory and pro- grefs of the intermitting fever of America in the pre- ceding pages,"! fhall now proceed to offer a xbw ob- fervations on the manner of treatment. And I may obferve in the firft place, that the intermitting fever is not in general a difeafe of a dangerous nature. If treated with decifion in the beginning, it is for the moft part removed very fpeedily and very certainly ; though if attacked with feeble remedies, it often con- tinues long, and not feldom lays the foundation of complaints which eventually have an unfavourable termination. The intermitting fever fometimes proves OF AMERICA. 203 fetal from the adual violence of the fymptoms of the paroxyfm, though the danger more generally arifes from a tendency to degenerate into dyfentery or drop- fy, or to form vifceral obitruaions. But befides the danger, which arifes from the aaualtbrce, or from the more tedious effbas of the difeafe, we-often find a charaaer of peculiar malignity, in the intermittents of fome feafons and fome fituations, which d;_ferves to be particularly attended to. Malignity is a word of a vague meaning ; and on different occafions is dif- ferently applied. In the prefent inftance, I refer the term to a peculiar charaaer of the difeafe, exprefled by a certain ftate of the eye and countenance of the the patient. It was fometimes obferved, that the countenance of the patient was flufhed; but at the fame time dark and overcaft; or that it was of a greafy and dufky appearance, with a look of flernnefs and defpondence in the eye. Thofe appearances, particu- larly where a white glutinous covering appeared on the tongue, were conftantly indications of concealed or lurking danger. They occurred often at Ebene- zer and the Cheraws, and I had the misfortune to learn from experience, that whenever they occurred, time ought not to be fpent in the frivolous prepara- tions, which are ufually thought neceffary to precede the giving of bark. If we judge it not to be proper. in any cafe to venture upon the ufe of bark, before the body has been fufficientlv prepared by emetics and cathartics, we fhall too often meet with inftances where the courfe of the difeafe will be finifhed be- fore thefe preparations are completed. It has hap- pened oftener than once to myfelf, that the fatal pa- roxyfm commenced before I had gone through the ufual routine of preparation, which at that time I thought indifpenfably iuceffary, before I attempted to cut fhort the courfe of the fever by means of its Well known fpecific. Having premifed fo much with regard to the ge- 204 INTERMITTING FEVER neral nature of the difeafe, I fhall now add a few obfer- vations about the management of thofe remedies which have been moft ufually employed; fome of which appear to be fuperfluous; while there is only one of them which has a right to be confidered as ef- fcaual. It is a common and obvious remark, that the intermitting fevers of the fame feafon fhew a ge- neral tendency to run over a fimilar courfe, though the modes of treatment may be fometimes direaiy oppofite. As I had often taken notice of this fact during the time that I remained in America, I began to fufpea that the changes, which I had been accuf- tomed to attribute to treatment, were in reality owing to a difpofition in the nature of the difeafe, which was little affeaed by the ordinary prefcriptions. But that I might in fome degree afcertain the truth of this fufpicion, I feleded thirty cafes of fever, which had commenced within twenty-four hours of each other. This experiment was made at Ebenezer, in the month of May; where the difeafe, though highly epidemic, had not yet difcovered any figns of malignity; fo that danger was not apprehended from a delay of a few da'ys. I claffed thofe thirty cafes in three divifions, without paying regard to the nature of the fymptoms of any individual cafe. To one I prefcribed a repe- tition of emetics, at fuch intervals as were judged proper; for another, cathartics of various kinds, or managed in various manners; while I left the third wholly tc»its own courfe. I watched the progrefs of the difeafe attentively for the fpace of eight days, and cannot pretend to fay, that I obferved any material difference in the changes or appearance of thofe cafes, which were treated in fo different a manner. The type, which was generally fingle tertian at the com- mencement of the d'forder, changed for the moft part to double tertian or quotidian, after the fecond or third paroxyfm ; though not in a different proportion, as far as I could judge, in thofe which were left OF AMERICA. 20$ entirely to Nature, or which were treated in the man- ner which has been mentioned above. It deferves however to be remarked, that the paroxyfms were ufually milder, more regular and diftina after the repeated ufe of carthartics; as alfo that bark fucceeded more fpeedily and more certainly after a repetition of antimonial emetics. Where bleeding is judged to be proper or necef- fary in the cure of the intermitting fever, the circum- ftances are generally fuch as require that it precede every other in order of time. Bleeding was often found to be ufeful in particular cafes. It moderated the violence of fymptoms, and feemed not to be with- out effed in removing a certain ftate of the fyftem, which refifted the fuccefsful operation of the bark ; but I muft likewife add, that there was feldom occa- fion to employ it in the fouthern provinces of Ame- rica. It was blamed by fome as increafing the dif- pofition to relapfe: of this, however, I can fay nothing from my own experience; and as I am difpofed to be- lieve, that the lofs of a moderate quantity of blood, / feldom does material harm in this difeafe; fo I havei reafon to think, that it is feldom neceffary in warm < climates, particularly in the hot months of fummer or autumn. Emetics have been employed in the cure of inter- mittents for a long time paft. There are many prac- titioners, who confider there ufe as indifpenfable ; and fome have pretended, that the cure of the difeafe, in its earlier ftages, may be trufted to this remedy alone. Emetic tartar, fo managed as to operate at the hour of the fever's return, was fometimes found to prevent the accefs of a particular paroxyfm; but though obliged, from want of bark, to have recourfe to this method of treatment in numberlefs inftances ; my experience does not fupply ,me with a fingle one, where I could pofitively fay, that it abfolutely cut fliort the courfe of the difeafe. Relapfes, I muft T 206 INTERMITTING FEVER confefs, difappeared frequently in confequence of the praaice; but they likewife difappeared frequently, where nothing at all was done : fo that 1 cannot help being of opinion, either that the real effeas of emetics havebetn miftaken, or that the proper modes . of managing them are not generally known. I muft not however omit to mention, that emetics are occa- fionally of great fervice, and that antimonial emetics efpecially obviate the effe£ts of inflammatory dia- thefis, and on particular occafions facilitate the fuc- cefsful operation of the _bark. They are likewife feldom followed by thofe dangerous effeds which frequently arife from the employment of them in fevers of Jamaica; though I certainly fhould advife that they be ufed v/ith great caution in the fouthern provinces, in the fummer and autumn, where the re- mifiions of the fever are obfcure. Cathartics have likewife been much employed by praaitioners in the cure of intermitting fevers; and in few cafes, perhaps, can be omitted with fafety. They certainly poffefs very remarkable effeas in rendering the form of the difeafe regular and diftina; but they do not feem to be endued with a particular power of cutting fhort its courfe.—The circum- ftances of the cafe can only point out die propriety or advantage of the various remedies of this clafV. The above are the ufual modes of evacuation, which moft praditioners confider to be indifputably neceffary previous to the exhibition of bark. I muft however remark, that cafes fometimes occurred in the fouthern provinces, particularly in the hot months of fummer, which only admitted of thofe evacuations in a fmall degree. Inftead of the diftind and regular paroxyfms, which were expeded to follow the ufe of emetics Or cadiartics, the difeafe was fometimes obferved to affume a languid and continued form, in confequence of fuch treatment, while it likewife in feme inftances recovered the diftindion of paroxyfm OF AMERICA. 207 and remiffion,by means of applications v/hich excited the tone and vigour of the fyftem; particularly by means of exercife in cooler air, or accidentally by ex- pofure to rain. Peruvian Bark is the chief remedy, upon which we now depend, for the cure of intermitting fevers. It is a remedy, which like others, has undergone fomereverfes of reputation, fince its firft introdudion into Europe; and, though its efficacy is now fully acknowledged, perhaps over-rated by Englifh peti- tioners, it does not feem yet to have gained the fame general credit with other European nations. The French ufe it with caution, and many of the Germans are ftill its enemies. It has been accufed even by fome of the Englifh "writers, of failing in the cure of intermittents; and blamed by many of occasioning complaints more dangerous in their nature than thofe it was intended to remove. I was early aware of thefe objeaions, and watched narrowly that I might ^ difcover its real effeds; and am warranted in faying, j that it has every ri?;ht to be confidered as a feed lie in ague and fever; while it is totally free from the im- putation of occafioning dyfentery, dropfy, or'voeeral obftruaion. Thofe complaints were always moft frequent, where this remedy had been the moft fpar- ingly employed. But though I have mentioned that bark is both a fafe and efficacious remedy in the cure of intermit- ting fevers, I muft alfo confefs, that it is only ren- dered fo by particular modes' of management. It is probable that much of the bark, which is now im- ported into England, is either in fome fhape adulte- rated, or naturally inferior in quality to what it had been informer times ; as v/e often read of cures ef- fected by a fingle drachm in the laft century, which we fhould fcarcelv now expect from an ounce. Three or four ounces feldom failed of checking the progrefs of the moft formidable fevers of America; one or T 2 2o8 INTERMITTING FEVER two frequently did not produce any fenfible effed. Being perfedly convinced of the truth of this obfer- vation, I generally gave bark in cafes, where the circumftances were judged proper for its exhibition, in dofes of two drachms ; which I direaed to be re- peated every two hours during the abfence of the fever: By this mode of treatment the difeafe was oftm fo completely conquered, that the patient was frequently capable of returning to his duty in the fpace of feven or eight days. Time ought not to be fpmtin frivolous preparations, or difeafes attacked with feeble remedies, where the health of foldiers is concerned. The fpeedieft cures are generally the beft; and I have had many opportunities of wit- nefling more health and ftrength gained during eight days in the field, than I fhould have expected from a month's eafe in an hofpital, affifted by the beft advice of the phyficians. The above-mentioned quantity of bark, for the moft part, was fufficient to effed a cure in ordinary cafes of the difeafe ; but where danger appeared to be threatening, the dopes were often increafed to half an ounce, or even more. In fome cafes of obftinacy, indeed, accompanied with a fluggiftinefs of conftitution, I obferved no other rule in the quantity than fuch as proved difagreeable to the ftomach, or excited a tumult in the fyftem. The method was often fuccefsful ; and I mayobferve in general, that two ounces taken at five or fix times, and in the fpace of eight or ten hours, were often more effectual, than double the quantity in fmall dofes, and at long intervals. If the large dofes of bark, which I have recommended, fhould appear to any one to be dangerous or unneceflary; I may add, that I have myfelf frequently taken an ounce at once; while I have likewife obferved the cure to be tedious and uncertain with the moderate dofes of ordinary practice. I may farther remark, that this remedy was often rejeaed by the ftomach, and in fome cafes OF AMERICA. 209 paffed off almoft inftantly by flool ; yet that the courfe of the fever feemed to be no lefs efteaually checked by it, than when fuch effeds did not occur. The quantity of bark, which I frequently pre- ferred in the intermitting fever of America, may appear to be greater than neceffary : fo the time at which it was fometimes given, may alfo appear to be premature. Bark was feldom given in the fevers of the fpring and beginning of fummer, unlefs in cafes of relapfe, till after fufficient evacuations had been premifed. In the autumnal months, where figns of malignity and danger were difcovered, the firft inter- miffion was often laid hold of: neither was it uni- formly deemed neceffary, to premife the evacuation's of vomiting or purging* In relapfes I feldom let pafs the opportunity which the firft intermiffion af- forded ; by which means, thofe who were fubjea to the returns of this difeafe, were rarely returned in the reports of the fick. Where bark was given in fuch quantity, and in fuch manner as I have mentioned above, it generally was fuccefsful in checking the progrefs of tbe difeafe ; yet I muft not omit to obferve, that inftances fome- times occurred, where it totally failed of this effed', under every mode of management that could be de- vifed. It would be ufeful to afcertain thofe circum- ftances exaaiy; but this is a tafk v/hich I cannot promife to perform. It was however remarked, that where the inflammatory diathefis prevailed in very evident degree, bark was frequently given without fuccefs: and owing to this caufe, perhaps, it was lefs to be trufted to in the fpring, (unlefs in cafes of relapfe), than in the hot weather of fummer and au- tumn. But befides the obvious marks of inflamma- tory diathefis, there appeared to be other conditions of the frame unfriendly to the fuccefeful operations of bark. The exaa nature of thefe, indeed, was perceived with difficulty ; yet I have often obferved 2IO INTERMITTING FEVER them to be conneaed with fome of the following cir- cumftances; viz. with a fmall and hard pulfe, or wrtif a pulfe where the ftroke was obfcure or without ex- panfion, and where a creeping or vermicular motion was obfe,ved in the ftate of the1 artery; to which was fometimes added, a conftriaed ftate of the fkin, a clammy moifture on the furface of the body, with- out figns of free perfpiration, and together with a fuf- penfion or irregular aaion of the nervous influence* In the ftate defcribed above, bark alone was often fiVen in great quantity, without producing any fen- le effea. It fometimes fucceeded where antimo- nials, opiates and other antifpafmodics were joined with it; but blifters applied to the back part of the head and neck, were ferviceable above all other re- medies in removing thofe circumftances, whatever they were, which flood in the way of its fuccefsful operation. In fome cafes which had proved obftinate to every other means, the difeafe difappeared imme- diately afeer their application; and in every one where they were employed, ceafed any longer to re- fill the bark. Bark alone undoubtedly has a right to be confidered as a fpecific in the cure of the in- termitting fever, but its virtues are occafionally im- proved by the addition of aromatics, chalybeates, and particularly by a certain proportion of fnake root. It was a pradice with fome of the country people of Carolina, to attempt the cure of the intermitting fever by means of Virginia fnake root, given in dofes of two fcruples or half a drachm. I made a trial of that remedy in feveral inftances ; but did not find that it was fuccefsful. Joined however with the Peruvian bark, in the proportion of two drachms to an ounce, it was often obferved to produce very ex- cellent effeas. The cures were more complete and more permanent. There was not only lefs tendency to relapfe, but dyfenteries and dropfies were more rare, after I was fortunate enough to adopt this mode OF AMERICA. 211 of praaice, than they had been during the preceding years. There have been many different conjeaures about -•—-the mode of the bark's operation in the cure of in- termitting fevers; but none of them afford a fatisfac- tory explanation of the fubjea. Bark is evidently bitter, aftringent and aromatic; but how it becomes fpecific in intermittents, in a degree fo fuperior to all other bitters, aftringents and aromatics, is a myf- tery we cannot eafily comprehend. It obvioufly poffeffes a power of giving tone and vigour to the powers of life ; and often communicates to the fan- guiferous fyftem, a certain ftate or difpofition, known by the name of inflammatory diathefis. Thus it is ufually obferved, that where the nervous frame is weak and delicate, bark rarely failed of cutting fhort the courfe of the difeafe, and its fuccefs in fuch cafes, is preceded, for the moft part, by apparent changes in the general diathefis of the fyftem. If ftrength, fulnefs, and vigour of pulfe follow the em- ployment of bark, the fever frequently difappears; but if thofe figns are wanting, it is not poffible to form any certain judgment of the future efted. In like manner, if figns of inflammatory diathefis con- tinue to prevail during the courfe of the difeafe, bark fometimes changes it to a continued fever; but fel- dom checks its progrefs effedually. From thefe faas, which I have often feen verified, I am difpofed to conclude, that bark is only to be confidered as an accidental fpecific in the cure of intermittents, and that its faiutary effeds probably may be explained from the change, which it occafions in the relative ftate of the body. That bark is fo often fuccefsful depends, we may prefume, on the intermitting fever being fo often conneaed with an attonic ftate of the fyftem ; from which caufe it probably arifes, that it is fo much more effeaual in fummer and autumn, in warm weather and in warm climates, than in the 212 INTERMITTING FEVER oppofite. circumftances. But though an at tonic ftate of the fyftem is frequently conneded with intermit- ting fever, it is not conftantly fo ; hence the difeafe is not invariably removed by thofe proceffes which excite tone, or give rife to the inflammatory diathefis. Exceffive evacuations and other caufes, by which the body has been reduced to the laft ftate of debility, have oftetrinterrupted .the couife of an intermittent. So that we have everysreafon to conclude, that bark is only relatively fpecific,*in as much as it deftroys certain circumftances of aptitude, whch are effentially conneded in particular fituations with the exiftence of the difeafe. In this manner, voyages, journeys, new purfuits, or new modes of life, frights, the aaive fervice of the field, or the hardfliips of fieges have often removed intermitting fever, which had refitted the ordinary aids of medicine. I obferved in a former part of this treatife, that it was feldom a matter of much difficulty to flop the courfe of the intermitting fever of America; but I muft now add, that it was always difficult, fometimes impoffible to fecure the patient againft any future return of the difeafe. Bark, though much celebrated for this purpofe, did not feem to prevent a relapfe with the fame certainty with which it flopped the courfe of the fever, when adually prefent. It deferves however to be remarked, that where bark had been o-iven at regular intervals after the difeafe difappeared, the paroxyfms in the relapfe were, in general, not only flighter, but had ufually more of the inflamma- tory diathefis joined with them, while the complaint fhewed more difpofition to terminateof its own accord, after a few revolutions. It is univerfally known, that the powers of bark feldom fail in the cure of inter- mitting fevers, where given in fufficient quantity ; yet I muft alfo obferve, that its virtues do not feem to extend farther than to a temporary fufpenfion of the paroxyfms. That bark does not elimenate or OF AMERICA. "21$ deftroy the aftual caufe of the difeafe, appears plainly from this faa, that relapfes are frequently the confe- quence of thofe circumftances, which occafion debi- lity, or which counteraa the effeas of this tonic remedy. To which we may add, that though relapfes are often of a different type from the original fever, yet, as tiiey generally happen on an even day from the fuppreffion of the paroxyfm, there can be little room to doubt that the old complaint again refumes its courfe, though it probably, in the mean time, lofes feveral of its original fymptoms. It is a fea likewife which we ought not to omit mentioning, but which in general, does not feem to be much attended to, that fome periods are more remarkable for the re- lapfe of intermitting fevers than others. I obferved before, that relapfes almoft conftantly happen on the even days. I now add, that the moft remarkable of thefe days are the fixth, the eighth, twelfth, four- teenth, twentieth, twetiry-fecond, twenty-eighth, and thirtieth. The fourteenth is remarkable for re- lapfes above all the others. Next to it we may rank the twelfth, twentieth, and twenty-fecond; unlefs in times of very prevailing ficknefs, where the fixth and eighth" often come in for a great fhare. If we take pains to examine the particular circumftances of the patient, and attend to the nature and degree of the prevailing epidemic, we may often be enabled to form a tolerable conjedure with regard to the moft pro- bable period of return. Having therefore acquired from obfervation fome general ideas of the different propenfities to relapfe in different fituations, and in different fubjeas, I ufually began to give the bark in quantity, and to ufe other precautions on the fifth, after the fuppreffion of the paroxyfm, in cafes where there were the ftrongeft fufpicions of a fpeedy return ; while thih, was delayed till the eleventh, nineteenth, or twenty-feventh in others, in proportion to the different degrees of healthinefs. This praaice was 214 INTERMITTING FEVER continued for the fpace of three days, or till the fuf- picious period was paft. But I muft further remark, that befides the propenfity, which was obferved in fevers to return at the periods above-mentioned, the approach to the newand^full moon was likewife found to be conneded with relapfes in a very remarkable manner. Independent therefore, of the precautions, which were ufed at the feptenary periods, the ap- proach to new and full moon was conftantly at- tended to. If the above directions were carefully complied with, we might in general prevent the difeafe from proving fatal, or from injuring the conftitution ma- terially, though I muft at the fame time confefs, that we could in reality do little more than preferve the patient in a valetudinary ftate, till cool weather, a change of fituation, or fuch a change in the manner of life as excited the adive powers of the conftitu- tion, contributed their part to effea a permanent eftablifhment of health. Being perfeaiy convinced of the truth of this obfervation, I generally remitted the men to the regiment, to be put upon the lift of duty, as foon as I was certain that the courfe of the difeafe was aaually ftopt. The praaice at firft fight may appear harfh ; but I have found it to be falutary. Exercife, even fome degree of exertion, promotes the recovery of health. Habits of floth and indo- lence are fpeedily contraaed in hofpitals: the military ardour is gradually extinguifhed, and bodily ftrength is recruited more flowly than in the field, under every difadvantage of fatigue or inclement weather___Of the truth of this I have had ample experience. I have now pretty fully defcribed the method of cure, which I purfued in the intermitting fever of America. I am not ignorant that other plans have been adopted, and other remedies employed by others ; but as I have not had experience of any, except that which I have mentioned, I do not reckon myfelf OF AMERICA. 2 15 qualified to furnHhany remarks on the fubjed. Bark, indeed, is fo fafe, and at the fame time fo effeaual, that I fhould be flow in recommending any other re- medy, where this can be procured in fufficient quan- tity. The flrongeft proofs of its value arife from a comparative view of the mortality of the intermit- tino- fever, in different regiment?, which were em- ployed on the fame fervice, bu which were treated indifferent manners by their refpeai/e fu rgeons.— The Heffians were all of them inveterate enemies to the bark; and there were ever fome of the Britifh furgeons who employed iz very fparingly. The mor- tality' among the troops trufted to the care of thofe, was uniformly in great proportion. There was a Heffian regiment, the fituation of which I had the opportunity of knowing exaaiy, thai loft one third of its men by this difeafe and its effeas, during one year's fervice in Georgia. There were Britifh regiments alfo, which loft more than a fourth ; while there were otheus, which did not loe a twentieth." The whole of thefe iegiments were engaged on the fame fervices ; they were all alike foreigners in America ; and there appeared to be no obvious caufe fo: fo great a differ- ence in the degree of mortality, excep; a difference in the management of the bark. Bark was fcarcely ever employjd in one cafe ; in another it was ufed with tirnhhty; whilft it was given with the earlieft opportunity,' and in quantifies far exceeding the ufual praaice in the third. I have defcribed, in the preceeding page?, the me- thod which I adopted in the cure of the intermitting fever of America, whilft that fever preferved its dif- tina md proper form. I have likewife mentioned the beft means I am acquainted with, of guarding againft its return ; and it vrill not be improper in the next place, that I add a few remarks on fome of its moft ufual and formidable effeas. The intermitting fever of America fhewed a ftrong difpofition f Zl6 INTERMITTING FEVER change into a fpecies of dyfentery, or a purging and griping at particular feafons of the year, and more efpecially in particular local fituations. Dropfy was likewife a frequent effba of this complaint, and ob- ftruaions of the vifcera were not by any means un- common, where the intermittent, from neglea or other circumftances, had been allowed to go on in an uninterrupted courfe. The changes from intermitting fever to dyfentery, and from dyfentery to intermitting fever, were fo fre- quent in the months of Auguft and September, that thofe difeafes feemed evidently to depend on the fame general courfe; affuming at different times the one or the other form from caufes which we could fel- dom afcertain. In thofe cafes of dyfentery the ftools were uncommonly copious and watery, and remiffions and exacerbations frequently appeared at regular pe- riods ; but though the cure was often attempted by the bark, it did not in general fucceed. I muft begin with acknowledging, that I fhall not be able to give a complete or accurate hiftory of the progrefs and final termination of this fpecies of dy- fentery, into which the intermitting fever is fo much difpofed to degenerate; as I fhall likewife only have it in my power to mention the general methods of cure, which were purfued in the earlier ftages of the difeafe. Where it was found that a cure could not be accomplifhed in a reafonable time in the field or regimental hofpital, dyfenteric patients were generally removed to places v/here they could meet with better accommodation; fo that the difeafe in its latter ftages has feldomer fallen under my obfervation. I muft obferve in the firft place, that this fpecies of dyfentery had no right to be confidered as an in- feaious difeafe. It appeared in faa to be no more than an intermitring fever, which, from fome caufe or other excited its principal force on the alimentary ca- nal. Remiffions and exacerbations were generally OF AMERICA. 217 obfervable in the one difeafe, as well as in the other in the earlier ftages; yet thefe appearances became gradually lefs and lefs remarkable, and the/e appeared at laft marks of permanent affeaion of the midlines. The fkin now became dry and harfh, the flefli wafted, and the bowels were uncommonly irritable, particu- larly where the prickly heat had retired from the fur- face; the difeafe was now evidently fupported by the exiftence of permanent local affeaion. With regard to the cure of this fpecies of com- plaint I have little to obferve, which is not generally known. Bark was fometimes employed to check its courfe; yet I muft confer, that bark alone was fel- dom found to be fuccefsful. Where there were no marks of an aaual inflammatory ftate of the ftomach and bowels, it fucceeded better when joined with aromatics, powder of camomile flowers, and particu- larly with fnake root. Laxatives were prefcribed frequently, and feemed often to be proper. They were however mo.e ufeful where fome other thing was joined with them, which had the quality of de- termining to the fkin. Opium in varfoiis forms was a common remedy ; and often a ufeful one before the^e were marks of permanent affeaion of the in- teftines. Ipecacuanha, or fuch preparations of anti- mony as promoted the evacuations by the fkin, were frequently combined with it. The great objea which I purfued in this difeafe was to reflore and fopport a free perfpiration, to diminifh the irritability, and to ftrengthen the tone of the alimentary canal. I was difpoied to expea benefit from warm bathing, fric- tions, &c. but the fituation in which we were placed did not admit of a trial of them. Exercife was pro- per, and even fome degree of exertion. Change of air was ferviceable in many cafes, well feafoned food in fome, and wine in others. The above plan was p'-.rfued in the beginning of the complaint with tole- rable fuccefs ; but if it failed, or could not, from the 2 1$ INTERMITTING FEVER circumftances of the fervice, be properly executed, the difecfe then loft the remitting form, the body became iean and exhaufled, the ftools blood}', with a very irritable ftate of the bowels. In fuch cafes there w..s often ulceration, various degrees of inflammation, or obltruuions in the coats of the inteftines. Blifters applied to abdomen or loins, and kept open, were often ferviceable; medicated glyfters, varied according to the nature and feat of the affeaion, were likewife of benefit; and in the latter ftages I have feen much good from the employment of ftrong aftringents. In illuftration of this 1 fhall mention the cafe of an officer, who was attacked with this fpecies of dyfen- tery, foon after the fiege of .Savanna. Every thino;, which the medical people of the garrifon could fug- geft was put into execution, without much benefit. The difeafe continued through the whole of the winter without material abatement; the-flefh wafted, the fkin becamedry, with fuch other fymptoms as are ufual- in this complaint. In the month of March, a perfon of the country recommended the decoaion of the bark of a tree, (probably of the fpecies of the Simarouba,) which appeared to be poffeffed of a con- fiderable fliare of aftringency. It checked the purging and griping inftantly ; fo that the difeafe ceafed for the fpece of three weeks. The appetite was good, the ftools copious, and in fome degree lienteric. The griping and even purging at laft returned ; the decoaion was repeated, but had not the fame effeds. Other arlringents, the extraA of logwood, terra ja- ponic?, &c. checked ir for a fhort time, but no mate- rial ground was gained. He died in the month of May. Dropfy fucceeding, and fometimes alternating with intermitting fever, was not by any means a rare ap- pearance in America, particularly in fome feafon?, and in feme fituations. The fwellings generally pre- vailed in evervpart of the body. They were ufuaily OF AMERICA. 2 1^ leucophlegmatic, though I have alfo feen feme in fiances of tympanitis; a difeafe which was commonly frp- pofed to proceed from improper management of tiie bark. With regard to the cure of dropfical complaint, I have little to obferve which is not generally known. It confifted not only in evacuating the v/a^or, but in communicating to the fyftem fuch a degree of tone and vigour as refifted farther accumulation. With this view exercife, and even fome degree of exertion, was proper: wine, even more ftimulating liquors, high feafoned food, frictions and v/arm clothing, were ferviceable. I fhould likev/ife have been dif- pofed to exped benefit from fea bath in? ; but I can- not venture to fay, that I have ever made a propcr trial of it. Blifters were alfo ufeful; not only as occafioning a difeharge of the water!;, but as excising the aaion of the vafcular fyftem. Air.ong. the nu- merous clafs of diuretics, there is not any one, which has fo powerful effeds as cantharides, in fubftance or in tindure; and among the corroborants, I fhould be inclined to give the preference to chalybeate?, Colombo root, and Peruvian bark. It may not be improper to mention in this place, that I have feen fome inftances where a general anafarca has been completely cured by the accidental fiipervening of convulfions. Obftrudions of the abdominal vifcera are like- wife reckoned among the common effeds of inter- mitting fevers. They are frequently attributed to the early or improper ufe of bark ; but appear in fad generally to arife from the long continuance of the difeafe. I cannot add any thing to the manner of treating them that is not known to every one. U 2 [ 220 ] CHAP. XIII. A GENERAL REVIEW OF THE PRACTICE OF PRE- CEDING AUTHORS IN FEBRILE DISEASES. HAVING defcribed the method of cure, which I followed in the remitting fever of Jamaica, tne yellow fever and intermitting fever of America ; it will not, I hope, be deemed fuperfluous to give a fliort fketch of the general principles, which have di- reaed the praaice of phyficians in febrile difeafes, from the days of Hippocrates, till the prefent times; a fubjea of which I have not yet feen a conneded view. There is reafon to believe that the fcience of medicine made confiderable progrefs in different parts of the world, particularly in Egypt, at an early p3riod ; but diftina records of the art, prior to-the age of Hippocrates, are either loft, or fo blended with the writings which are affigned to that author, that we do not know how to diftinguifh them. The praaice of Hippocrates in fevers, has been accufed of being feeble and inert; and it is certain, that many of the moft effeaual remedies of modern times, were unknown to that venerable phyfician; yet if we take the pains to eftimate candidly the whole mode ©f proceeding, we fhall be forced to acknowledge, that its effects were lefs inadive than has been gene- rally imagined. The mode of treatment adopted by the Coan Sage, feems not only to have done evident o-ood, but fometimes to have aaually cut fhort the courfe of the difeafe. Sweating at an early period, the moft effeaual means we yet know of cutting off the courfe of fevers, was employed frequently by this author; and though antimonials were then unknown, yet feveat, excited by a fimpler procefs, was often obferved to produce very decifive effeds. Hippo- REVIEW OF PRACTICE, tkc. 22T crates, indeed, has been lefs circumftantial in the detail of remedies than we could have wifhed. He has however related the dietetic part very diftindly. Flis rules are always judicious, and his regimen fometimes of fuch efficacy, as evidently to operate very confiderable changes in the ftate of the fyftem. It appears frequently to have been his aim to at- tempt to exterminate the fever in its early periods, or to endeavour to cut fhort its courfe abruptly, by dired or indired oppofition to its proximate caufe : yet this idea was not purfued beyond a certain po.r.t. Afier the fourth day had pai'fd, Hippocrates ufually co;uented himfelf with fupporting the general powers of life with proper diet and nourishment, allowing nuu.Lj after that period to perform the work her own way: in other words, to complete the bufinefs by the flower operations of codion and crifis. Thefe tv/o views, viz. the attempts to cut fhort the difeafe abruptly in its beginning; or in the ]ate periods, the codeavours to fupport the powers of life, till the na- tural termination might arrive, comprehend the ge- neral rule:; of pradice followed by this celebrated phy- fician : and I much doubt if the modern-, notvri'-.b- ftandin"- all their pvetenfions, have aduaUy difco- vered any other indications more d.cifive, though I willingly allow, that they h::ve .made great improve- m-n: , in the mode of executing thofe I have men- tioned. At Laft, I acknowledge for my own part, that I am r»': yet acquaint d v'uh any mode 01 treat- ment, by which the natural courfe of a continued, or even obfeurely remitting fever can certainly be pre- vented, after the firft days of the difeafe are p: ■ ;— thai: is, after a diftind formation of the type; before that b.;poened, the fweating procefs jfc frequently foc- cefsful. ' But though the attempt to cut fhort the dife-.fe in its beginnini, or to fupport the nov/ers of life in the later periods, comprehend this anther's general rule of praaice ; yet we laid ccnf.derable 22 2 REVIEW OF PRACTICE diverfity in the manner of accomplifhing thefe dif- ferent purpofes. The man* iv«vt<6)C, or an atten*pt to counteraa the derangements of morbid caufes, may be confidered as the firft general maxim, which was eftablilhed in the cure of difeafes. Hippocrates has this maxim conftantly in his eye, and endeavours by various means, according to a fuppofed diverfity in the mode of adion, to cut off the immediate exift- ence of fever. In this manner the prefence of heat and bile, or the fuppofition of obftruded perfpiration, have feverally furnifhed him with different indica- tions. His ideas however are not precife; fo that his praaice frequently fluauates between conjeaure and experiment. If the difeafe does not yield to one mode of treatment in a given time, he frequently paffcs to its oppofite much at random. The doarines of Hippocrates acquired fuch gene- ral credit, in every part of the world where they were known, that we do not remark any material innova- tions in die cure of fevers, till the time of Erafiftra- tus; a fpace of near two hundred years. The inter- vening period, indeed, was diftinguifhed by philofo- phers, who employed their time in inveftigating the ftrudure and economy of the human frame, as well as by phyficians, who improved the art of ' medicine by the invention of new remedies. Plato, Ariftotle and Theopbraftus were the moft eminent of the for- mer; Petro is chiefly diftinguifhed among the lat- t'.r. (i) This author, as we find recorded both by Celfus and Galen, attempted to extinguifh a fever by copious drenching with cold water; foon after which, he nourifhed his patient with wine and ftrong foods, a cuftom which was in fome degree imitated by Clophantus. Hints, however, of the firft of thofe praaices are found in the writings of Hippocrates^ fo that we may juftly confider Erafiftratus, as the firft who departed fo far from the principles of the Coan Sage, or who arrived at fo high reputation, as to be rW Febrile diseases. 223 regarded by pofterity as the author of a new method of curing difeafes. I mentioned in a former part of this treatife, the opinion which Erafiftratus enter- tained concerning the caufe of fevers. All that we know of his pradice may be comprifed in a few words. Erafiftratus was every where the inveterate enemy of bleeding. He was likewife the author of a certain plan of abftinence, which, with a little modification from Afclepiades and Themifon, made a eonfpicuous figure in the annals of phyfic for feveral fucceeding ages. Herophilus, who lived much about the fame time with Erafiftratus, acquired alfo high reputation in the medical world ; but unfortunately we have it not in our power to give a particular detail of his dif- coveries. Soon after the period I have mentioned, the fcience of medicine was divided into three diftind branches ; viz. as the art is employed to remove dif- eafes by diet, by drugs, or by manual operation. Serapion likewife, who is confidered as the author of the empiric fea, made his appearance not long after this divifion of the profeffion into feparate branches. His followers were numerous, and many of them were refpeaable; but we are not enabled to give a diftina account of their praaice on the fubjea of fevers. The fummary views of Celfus and Pliny, or the accidental fragments in the volu- minous works of Galen, furnifh only impeded in- formation. Contentions, however, ran high between dogmatics and empirics, the former of,whom were chiefly guided by rcafonings, as the latter trufted folely to experience. The Greeks, for many ages, were the only people We are acquainted with, who cultivated the feiences with induftry. For near five hundred years they were almoft exclufively the profeffors of the healing art. The Romans were cautious of admitting the refinements of learning into their ftate; and had •«42 REVIEW OF PRACTICE nearly attained the height of their glory, before they willingly received phyficians into their city. Afcle- piades the Bithynian, the contemporary and friend of Pompey and Cicero, appears to be the firft, who practifed medicine at Rome with any degree of re- putation. This author left his native country, with the defign of inflructjng the Roman youth in the arts of eloquence ; an acquirement, which was held in high eflimation among that warlike people; but not fucceeding in this purfuit, according to his wifhes, he foon difcovered, that the profeffion of me- dicine offered a fair opening for the exercife of his talents. The ftate of the art, indeed, was then pe- culiarly propitious to his undertaking; the former fame of Hippocrates being divided between Erafif- tratus and Herophilus, and fome authors of the em- piric feet. Afclepiades was two difcerning not to perceive, that new doctrines could not fail of drawing followers, and too enterprizing not to attempt to carry this purpafe into execution. He probably, in the firft place, read over all that had been'written by former phyficians; the moft effential parts of which,, he felccted with a good deal of art, and fo modified as to form a fyftem, which appeared to be complete, and which exhibited upon the whole, confiderable appearances of novelty. If we take the pains to trace his opinions to their fources, we fhall find that Democrites or Epicurus furnifhed him with his phi- lofophy, that Hercdicus fuppiieu him with the hints of bathing, friction, and geftation, that the plan of abftinence, or fading for three days, was learnt from Erafiftratus; and that Petro and Cleophantus in- structed him in the practice cf giving cold water, and of allowing greater indulgence in the ufe of wine.— But though the authors I have mentioned furnifhed Afclepiades with the hints of his doctrines and prac- tice; yet we may obferve, that he has always mo- delled thefe after his ov/n fafhion, and carried them IN FEBRILE DISEASES. 225 farther than had ever been done by their original in- ventors. It was remarked above, that the profeffion of medicine was divided into different fects before the time of Afclepiades ; yet, as far as we can judge from the imperfect information which has been tranf- mitted to us, this author was the firft, who deferves the name of an active phyfician. Previous to the time of this enterprizing Bythynian, medical men trufted the cure of fevers chiefly to the efforts of nature; and were only folicitous about the mode of death. Afclepiades, affuming a bolder principle, en- deavoured to cut fhort the fever in the midft of its courfe : and it is reafonable to fuppofe, that by flep- ping fuddenly from the extremes of torture to the higheft gratification of the appetites, fuch changes were effected in the ftate of the fyftem, as probably fometimes accomplifhed the purpofe. Such were the general views of this author. It may not be im- proper to add a few remarks on fome of the remedies which he employed. It is impoffible to fix the date, when friction and warm bathing were firft numbered ampng the affift- ances of the phyficians. 1 hey appear, however, from the teftimony of Celfus, to have been ufed with caution by the ancients. Afclepiades not only in- dulged in them with freedom, but fo conducted the management cf bathing, that it might be juftly con- fidered as a luxury of the higheft elegance. Gefta- tion, another of the gymnaftic remedies employed by this author, even in an early period of ardent fever, is an experiment of a ftill bolder and more defperate kind; and fuch as fucceeding writers with one voice feem to have condemned :—perhaps without examin- ation or fair trial. I am fenfible that the opinion, which I am to offer on this fubject, is not likely to meet with general approbation ; but the opportunity which I enjoyed, during the late war, of ferving with a regiment, which was almoft conftantly in the 2 26 REVIEW OF PRACTICE field, enables me to confirm the truth of it by ample experience. The good effeds of geftation or tra- velling, even in awkward conveyances, were very obvious in almoft every ftage and fituation of the ardent bilious fever ; but I fhall relate fome inftances of its fuccefs, which appear to preclude all poffibility of doubt. At Ebenezer in Georgia, at a feafon, when the thermometer, in the coolcft part of the lioufe, often flood at ninety-fix, and even fometimes rofe above it, I was feized with the ardent bilious fever, which at that time made dreadful ravage among the troops. For fix or feven days I did not once fhut my eyes ; my thirft was great, yet every fort of liquid, which i could procure, wis naufeous; the diftindion of paroxyfm and remiffion was no longer perceivable ; the pulfe, at the wrift, was neither un- commonly frequent nor ftrong ; but die pulfation of the defcending aorta was fo great, as to fhake the whole frame; anxiety and reftlefsnefs were in- tolerable : in fliort, the torment was fo exceffive, that human nature could fcarcely fuffer more. The fituation was precarious; and without much re- flexion I indulged the defire of being carried to Sa* vanna; though the diftance w;> not lefs than twenty- five miles. An open carriage, the only conveyance which the country afforded, was provided for the pur- pofe; and I was put into it, in a verv feeble and diftreflcd condition. Fortunately the day was cloudy, and cooler than ordinary. The roads were likewife foft and fandy. Though the carriage was very de- feaive, the motion was no ways unpleafant; and I had not travelled two miles before I felt a wonderful increafe of vigour. It rained heavily about halfway, and before I reached Savanna, I was drenched to the (kin. The effeds which might have been expeaed, did not follow. Inftead of being hurt, 1 was fur- pi izingly benefited. I walked into the houfe with ftrength and firmnefs, eat fomething without diflikc, IN FEERILE DISEASES. 227 and flept found the following night; in fhort, obtained a perfea remiffion of the fever. This is a ftrong inftance of the good effects of travelling in fevers ; yet it is only a folitary one. I fliall add another, which places the fact on a ftill firmer bafis. I men- tioned in a former part of this treatife, that while the 71ft regiment lay at the Cheraws, the endemic of the country prevailed among the men in a moft un- ufual degree. The difeafe was often without diftine- tion of paroxyfm and remiffion; the anxiety and reftlefsnefs were intolerable, bilious vomitings and purgings were frequent, and exceffive. While near two hundred men were in this fituation, an order arrived for abandoning the poft. It being impoffible, as we were fituated, to provide waggons to tranfport fo great a number of fick, about forty of thofe who were leaft likely to be foon fit for fervice were fent down the river in boats. Of the particular fate of this party I cannot fpeak with certainty ; but I have the fatisfaction to add, that not a man died of thofe who retired to Camden by land ; aud that after the third day, fcarcely a fever was left, which had not aflumed a regular intermitting form. This appears at firft fight almoft an incontrovertible proof of the febutary effeas of geftation; but I/muft not at the fame time omit to mention, that benefit alfo probably refulted from a change, which accidentally happened in the ftate of the weather. The weather, (which, during the time we remained at the Cheraws was uncommonly hot,) became unexpeaedly cool after the march was begun; together with rain, feem which the fick men had nothing to fhelter themfelves. This inftance of expofure to rain furnifhes a proof of a fea of much importance. It is generally believed that petting wet with rain is hurtful to a perfon in health. It is no lefs commonly fuppofed to be cer- tainly pernicious in ficknefs ; but the contrary ap- pears to be fometimes the cafe. I have feen the happieft effeas from the application of cold, even 22 8 HEVIEW OF PRACTICE from getting accidentally wet with rain in many in- ftances, befides the prefenc. Increafe of tone and vigour was generally the confequence ; and life was evidently protraded, fometimes perhaps faved, by accidents, or modes of treatment, which, in the com- mon opinion of mankind, would have been reckoned the caufes of death.—But though I have mentioned the accidental good effeas of geftation, and even of expofure to rain in different ftates of the ardent fe- ver ; I fhall not be fo paradoxical, as to recommend fuch experiments in common praaice. I muft how- ever be allowed to obferve, that we have little caufe to be afraid of their pernicious effeas. Motion and travelling, as far as my experience goes, were con- ftantly hurtful in cafes of local pain and inflammation; or in derangement of intellea ; but, on the contrary, conftantly ferviceable in anxiety and reftiefsnefs, de- pending on the ftate of the ftomach ; as alfo in af- feaions of the biliary fyftem. I mentioned before, that Afclepiades praaifed me- dicine at Rome with great reputation. He propa- gated his doarines with a good deal of fuccefs; but fuch i?, and ever has been the fate of our conjeaural art, that no fyftem has yet preferved its credit undi- minifhed foi1 any length of time. The views of phy- fician?, with regard to difeafes, had hitherto been va- rious and complex; even fevers had been often con- fidered, by the,fame perfon, as depending on differ- ent caufes. Themifon, a pupil of Afclepiades, at- tempted to remedy the perplexity which neceflarily arifes from this inftability of arbitrary conjeaure ; and endeavoured to reduce all the diforders, to which the human body is liable, to two general claffes;— viz. to thofe which arife from an increafed degree of ftridure, or its oppofite affeaion, preternaturalTaxityf to which he afterwards fubjoined fome complaints, which appeared to partake of the nature of both.— The idea of fimplifyinr difeafes did not probably arife IN FEBRILE DISEASES-. 229 in the mind of Themifon, till the latter period of his life; on which account, perhaps, the dodrines were left in fome meafure unfinifticd; and it is to Thefla- lus, who lived in the time of Nero, that we are in- debted for completing she methodic fyftem, and for enlarging the bounds of its femj. Soranus likewife added to its credit. It is a misfortune, which v/e muft regret, that except Ccelius Aurelianus, there is not one of the many authors who were ottached to the tenets of this feet, whole works have efeaped the wreck of accident or time. This only remaining author appears to have copied, by his own cenfoflion, jalraoft literally from Soranus. It does not belong to this place "to enter deeply into the tenets of the fed, with regard to difeafes in gene- ral; but leads to views of fome importance in the theory and treatment of many diforders. It proceeds on the fuppofition of circulation in all parts of the body; and with a little latitude may be fuppofed to comprehend the affbaions or the animated folid Or tontraaile fibre. Fever is confidered by the writers of this fyftem, as a difeafe of the clafs of ftridure; and if we had authority to add fpafmodic, we might believe, the methodics had difcovered a very impor- tant phenomenon in the hiftory of febrile difeafes.— J3ut this fome may think is granting them too much. If we take the trouble to trace their dodrine, re- feeding the caufe of fever, to its fource, we fliall find the; the hints of it are forth bed exprefely by Afcle- piades,'who perhaps ..borrowed his id-.as on the fub- jed feo:n Erafiftratus, or even from Hippocrates—■ But as ftriaure, affigned by the writers of the me- thodic fea as the caufe of fever, is not perhaps radi- cally different from the obftruaion of prec Jing au- thor:;; fo we do not find much material difference in their manner of conduaing the cure. The followers of Hippocrates, Erafiftratus and Themifon proceeded equally on the idea of reftoring permeability in die 230 REVIEW OF PRACTICE minuter canals of the fyftem; a purpofe which they conceived would be belt affeaed by certain proceffes of attenuation and relaxation. Thus Hippocrates diluted plentifully, and gave nourifhment only fpar- ingly, during the firft days of a fever. Erafiftratus enjoined a general abftinence, Afclepiades prefcribed a term for the duration of the abftinence; while The- mifon limited it fo rigidly to the fpace of three days, that the praaice was diftinguifhed by the name of diatriton, as its followers were known by that of dia- tritarii. This idea of diatriton conftituted an objea of much importance in the fyftem of the methodic phyficians. It direaed all their movements, and is the only view, which can properly be called their own. The mode of application of the remedies of preceding authors was occafionally modified by this foa; but except that which I have juft mentioned, we do not difcover much that is fundamentally new. It may not be improper in this place to take notice of the praaice of cold bathing in fevers, which was introduced at Rome in the infancy of the methodic fed; and which afterwards*acquired great celebrity in different parts of the world. The Emperor Au- guftus, who for the greateft part of his life was af- flicted with ill heab.h, was at laft attacked with a complaint of fo obftinate a kind, that the ufual ap- plications did not afford him any relief. Warm bath- ing and all that train of remedies had been tried in vain. The Emperor was fenfible of his defpe;at= fituation; and his phyfician Antonius Mufz, baffled in all his attempts, ventured, though apparently at great hazard, to prefcribe the cold bath. The health of Auguftus was unexpectedly reftored by it; and the phyfician was highly honoured, and amply re- warded. It is a misfortune that we do not know the fpecific nature of the difeafe, under which the Em- peror laboured; but we have reafon to conclude, from the circumftances which attended the cure, that it IN FEBRILE DISEASES. 23 I was a fever of a bilious remitting kind; perhaps com- plicated with catarrhal affection, and wafting of the body. But though the fuccefs of cold bathing, in the inftance I have mentioned, waSmuch greater than expectation; yet the remedy did not long retain its credit. It was foon afterwards employed In the cafe of Marcellus, a youth of great hopes, and prefump- tive heir to the empire; but the event proving un- fortunate, it fell fuddenly into difrepute,---probably without fufficient caufe. We find however that Cel- fus, in lefs thin half a century, afterwards ventured to recommend it in a certain fpecies of the flow or hectic fever; though Charmes, a phyfician of Mar- feilles, appears actually to be the firft who rendered the ufe of the remedy general. Galen employed it frequently with great freedom and boldnefs. The Arabians, particularly in. peftilential difeafes, went ftill farther than the Greeks or Romans; and we prefume, from the fact recorded by Bufbequius, that it was fometimes prefcribed at Conftaniinople, even fo late as the fixteenth century. I do not know that it has been often tried in Europe, fince the revival of the medical feiences in the Weft. I mentioned in a former part of this treatife, that I had employed it frequently in the fevers of Jamaica; I now add, that I have ventured upon it in the fevers of this country with fo great fuccefs, that 1 fhould expect the moft beneficial effects might refult from a proper manage- ment of it. (2) We are indebted to Celfus, who lived in the time of Tiberius, for preferving many of the opinions and pradices of preceding phyficians, which other- wife would probably have been loft. This author, not lefs remarkable for candour, than for the elegance and perfpicuity of his manner of writing, does not feem to have been blindly devoted to the tenets of any particular fea. He has favoured us with valuable extraas from the works of the moft celebrated dog- 232 REVIEW OF PRACTICE mat'cs; he has likewife taken notice of the moft re- ma <;tMe opinions and pra<:'.ices of the Lmpir;c3, v/i. .out orr.itting to mention the innovations of Af- clepLdes and Tnemif >n. With regard to his par- ticular merlc as a phyfician, we may obferve that he every were difcovers an excellent judgment, and that his praftice is generally decided without being rafh. So great have been the ravages cf rime or accident among the writings of the early phyficians, that it is fcarcely poffible altogether to avoid error, in at- tempting to trace the various revolutions in medical practice, pror to the time of Galen. From that downwards we are enabled to give a more certain and better conneded view of thefubjea; there being few of the principal writers of this latter period, who have not been preferved entire. When Galen came firft to PvOme, which was in the time of the Emperor Antoninus, the pradice of medicine was chi lly in the hands of the followers of the methodic fyftem. The praetice of diatriton, or abftinence for three dap was then in high fafhion, not only with the profeffed pupils of Theffalus, but even with the few remaining adherents of Erafiftratus. Galen every where declares himfelf its inveterate enemy ; and often tranfgreffes the bounds of liberality and decency, in his attempts to turn it into ridicule. His ov/n endeavours are exprefsly exerted to revive and cftablifli the principles of Hippocrates ; and to com- plete thofe parts, which the want of time or the want of experience of his mafter had left impe;fe-t. He poffeffed uncommon fertility of genius, a great flow of language, and a judgment by no means deficient; ver, fro.n a fophiflical fpirit of philofophi/.ing, he frequently fo cntan.Jed his opinions with theorerical diftindions, that his views are often uncertain, and fometimes embarrafli:..;. The principle with which he fets out is diredly to oppofe the aaual exiftence IN FEBRILE DISEASES. 233 of fever; he next recommends to remove, at leaft to avoid an increafe of thofe caufes which give rife to the difeafe. Thefe ideas are drawn from the writings of Hippocrates, and are fuch as no perfon will dif- pute : but, as the caufes of fever are fuppofed, both by Hippocrates and Galen, to be many and various, fo the indications of cure often require to be executed in different, and fometimes in direaiy oppofite man- ners. This neceffarily gives rife to confufion ; and entangles the praaitioner in the mazes of doubt and conjecture ; to obviate which, as much as poffible, the learned commentator of Hippocrates has thought fit to divide fevers into three general kinds, viz. ephemeral, continued, ^and heaic or habitual; the caufes of v/hich he fuppofes to be fo little analogous to one another, as to demand particular management in the method of cure. We look in vain for new views, or material im- provements in the management of fevers, in the writings of thofe Greek phyficians who followed Galen. Oribafius profeffedly is no more than a col- feaor of the opinions and praaices of other men ; and Aetius, on the prefent fubjea, does not afpire to much higher fame. There are, indeed, few of his obfervations, which may not be found in the volumes of Galen, or fome preceding writer ; yet he feems generally to have comprehended what he wrote. He digefted the knowledge which he found in books wfthcare and judgment; and gives an arrangement fo clear and perfpicuous, that the perfon may derive information from Aetius, who would be overwhelmed and loft in the prolixity of Galen's difcuffions. From thofe writers, however, who trod implicitly in the footfteps of Galen, we muft be allowed to fe- parate Alexander of Tralle, a-phyfician who lived in the fixth century. This author wrote his book on fevers at a very advanced age; and though the trea- tife perhaps does not contain many idsas, which may X 3 234 REVIEW OF PRACTICE not, in fome fhape or other, be found in the'writings of his predeccffors, yet the obfervations have the ap- pearance every where of having originally arifenfrom aaual experience. The language, which is concife, clear and perfpicuous, is wholly his own. The am- biguous circumftances of difeafes are more accurately diferiminated than in any preceding work which has defeendcd to the prefent times ; and though the man- ner of accounting for things may be fometimes erro- neous, yet it has had little influence on the praaical indications, which are almoft unexceptionably judi- cious. As Alexander of Tralle wrote at a time of life when fame muft have bein indifferent to him, and to a friend, whom he was more folicitous to in- ftrua than to amufe with the fplendour and variety ©f his learning, we have an additional caufe to give our confidence to his obfervations. His manner is candid and ingenious ; and the treatife before us may be confidered by the praaical phyfician, as the moft valuable of the «remains of the ancients. Judicious cautions are every where interfperfed, and confider- able changes in the management of remedies are fometimes attempted ; but the praaice of giving opiates in a certain ftate of fever"is the only praaice of this author, which has any title to be called in- novation. Paulus is the next phyfician of note, who lived after the days of Galen. He was born in the ifland of Aegina, and travelled over many countries. It is probable that he was fufnciently acquainted with every difcovery, which bad been made by his prede- ceflbrs ; yet Galen, on the fiilsjea of f ver, is the au- thor whofe works he has principally followed. His book on fevers, indeed, contains all the material doc- trines and obfervations of that voluminous v/rite r; And thofe who dread the labour of encountering the prolix and fophiflical difquifitions of the commentator t)f Hippocrates, may find a very diftind analyfis IN FEBRILE DISEASES. Itf of his opinions and praaices in the treatife of Paulus Aegineta. Having endeavoured in the preceding pages to give a fhort view of the methods which were ufually pur- fued by the moft eminent of the Greek phyficians, in the cure of fevers, it will be neceffary in the next place to take fome notice of the improvements ctf their immediate fucceffors, the Arabians. This talk will be foon performed; the Arabians have not in reality opened any views inthe curative indications erf" febrile difeafes, which were unknown to their prede- ceffors ; or which require that we fhould fpend long time in endeavouring to explain them. The medical fcience evidently drew its origin from the Eaft ; yet it was alfo foon reConveyed to the countries from whence it fprung, with improvements and additions from the genius of the Greeks. We learn from Herodotus, that Democedes, a native of Crotone, who had ftudied medicine in the ifland of Aegina, far excelled all the phyficians of the Perfian court, even fo early as the time of the firft Darius; though the court of this Prince probably could boaft of all the fkiil, both of AfTyria and of Egypt. Clefias fometime after was held in great eftirnation by Ar- taxerxes; and the invitation, which was held out to Hippocrates by the Perfian monarch, indicates very clearly, that the Greeks, even then, were more famed for medical fkiil than the inhabitants of the Eaftern countries. The iflands and fnores of the Mediter- ranean feem through the whole hiftory of medicine, to have produced the greateft number of phyficians. Crotone and Cyrene were famous for feveral ages : and Alexandria, at a later period, rofe into great cele- brity. Students flocked to it from every part of the world ; it was even neceffary that every one, who afpired to wealth or reputation in phyfic, fhould fpend fome time in this celebrated feminary. It was owing perhaps, in fome degree, to the vicinity of 236 REVIEW OF PRACTICE this illuftrious fchool, that the.province of Syria en- joyed at one 'time, a confiderable fhare of learning and learned men. The works of the moft eminent of the Greek phyficians were tranflated into the dialea of the Syrian country, in the feventh and eighth centuries; by which means they were pro- bably, in fome meafure, propagated in the Eaft : though we alfo are informed by Abulpharage, an Arabic writer, who had; preferved many curious anecdotes of private hiftory, that the doarines of Hippocrates were planted in the Chorafan, at a ftill earlier age, by the phyficians, who followed in the train of Aurelian's daughter, who was married to Sapores king of Perfia: nor is it improbable, that thefe doarines were ftill more generally diffufed through the Perfian dominions, by the alliances of friendfhip, as well as by the long wars, which were afterwards carried on between the Greek empire and the celebrated Khorrou Pawiz. But though the in- habitants of Syria and Irak were an enlightened na- tion, at an early period ; their neighbours, the Ara- bians, who afterwards attained fo great a name in fcience no lefs than in war, remained long in a ftate of illiterate ignorance. Before the eftabiifhment of iflamifm, there fcarcely was a native Arab, who could either write or read. The little genius they poffeffed was chiefly exerted in compofing verfes, or in colour- ing a rhetorical harangue. They appear, indeed, to have acquired fome pradical knowledge of the mo- tions of the heavenly bodies ; and it is likewife reafonable to fuppofe, that they had the feme fkiil in medicine, as is common to favage nations ; but there is no reafon to believe, that they, as yet, had made progrefs in the medical art, confidered in a fcientific view. Hareth, a native of Tayef, who lived in the time of the prophet, and who feems to have been in habits of intimacy with that fingular man, is the firft of the Arabs, whofe name is recorded among the IN FEBRILE DISEASES. 23^ phyficians of the Eaft. This perfon, who acquired fome knowledge of medicine at Nifabour, and other places in the Chorafan, returned home after fome time, with great wealth, and no fmall fhare of fame. He pradifed among his countrymen with much re- putation ; but how far he fpread the light of fcience among them is uncertain. The Saracens advanced rapidly in conquefts and the eftabiifhment of their faith; but we do not hear any thing of their pro- grefs in the healing art, till the ninth century. Syrians a:ul Perfians, generally of the Jewifh or Chriftian religion, laboured fometimes for the warlike Arabs in the fervile occupation of curing difeafes, at leaft we do not know that any of the Saracens attained much eminence in medical fcience, till the tranfla- tions of Honain and his pupils laid open to them the treafines of the Greeks. We are ill qualified at this period to judge of the merit of thefe tranflations. But if we may be allowed to form conclufions, from the ufe which has been made of them, we fhall not, per- haps, be difpofed to entertain a very high opinion of their accuracy. In many inftances, the later Ara- bian phyficians have expreffed the ideas of Hippo- crates and Galen only very loofely; and in fome few cafes, perhaps, have not very clearly comprehended their meaning. But, as the later Saracens were feldom fkilled in any language except their ownj the original tranflators are probably alone blameahlc for the whole of thefe mi flakes. The medical authors, who wrote in the Arabic language between the ninth and fifteenth centuries, and, who ftill lie concealed in the lefs acceffible drefe of their native country, are almoft innumerable : nei- ther are thofe, who have been introduced into the common acquaintance of Europeans few in number, or fmall in volome, If I poffeffed a complete Series, even of thofe who are commonly known in Europe, the examination I have entered upon might be drawn 238 REVIEW OF PRACTICE out to a confiderable length; but as I have no hopes of obtaining that foon, 1 fhall content myfelf with giv- ing fome idea of the Arabian fyftem of praaice in fevers, from the works of Avicenna, the moft emi- nen: and beft known of the Oriental phyficians. An ex- amination, indeed, of one of the writers of this nation may, in a great meafure, render an inquiry into the others unneceflary. Thofe, at leaft whom I have feen, do not differ materially from one another; or perhaps effentially from the Greeks who went be- fore them. The canon medicine, the principal work of Avicenna, exhibits a fyftematic view of the whole art of medicine, theoretical as well as praaical. I have read over with care all that relates to fevers; and though there is little, perhaps which may not ul- timately be traced to Galen or Hippocrates; yet the author Has not copied fervilely from either of them. He is more foil and particular tiian the one; lefs pro- lix and tedious than the odier. I muft however re- mark', that the diftij»aions and divifions, which he has attempted to introduce into the hiftory of fevers, are not only unneceflary, but aauaily ferve to em- bar: afs the indications of cure. His general theo- ries are thofe of Galen. In the general condua of the cure, he tread; in the footfteps of the fame mafter. He appears, indeed, to be more fearful of the lancet; while he is not perhaps always judicious, or confiftent with himfel , in the manner o; employ- ing it. On the contrary he has admitted cool air ra- ther more freely, and has perhaps carried cold drink even to a bolder length, than bad been done by the Greeks. Cool air, cold dnn!:, and even the external application of cold, may be reckoned among the moft effeaual remedies in the fevers of hot climates ; and this author has conduaed the management of them, in a luxurious, elegant and efficacious manner. But though the works of Avicenna furnifh a general view of the praaice of the Arabian fchoel of phyfic, it is ftill in fome degree a defeaive one. As he has not IN FEBRILE DISEASES. 235 fornifhed us with a detail of the cafe of an individual, we are not able to judge precifely of his powers of difcerning the difeafe, or of his decifion in the manner of treating it. The medical fcience, which after the taking of Alexandria was little cultivated by the flothful Greeks, or barbarous nations of the Weft, fprungup •. ith new vigourin the province of Syria, in Irak and Arabia; and followed every where in the train of the Saracen conquerors. Extending with their arms over the northern coafts of Africa, it foon found its way into Spam; and, even fo early as the eleventh cenrury, was conveyed to Salernum in Italy, by Conftantinus Africanus, a native of Carthage, who had lived long in Afia, ani who v/as well acquainted with the lan- guage and medical knowledge of the Orientals. The Arabians were the firft who opened the fources of che- miftry; they alfo made great improvements in the art of forgery, and even defcribed fome complaints which in earlier ages were not taken notice of but they de- parted but little ftom the fyftem of the Greeks in the management of febrile difeafes. After the fall of the Roman empire the genius of learning made no ex- ertion in Eorope foe a very long period of time. The native European flothfully acqiiefced in the im- perfed knowledge of Arabian wiiters, which was obtained from che inelegant, and perhaps often un- faithful tranflations of the Jews, who, for a confider- able time, were no contemptible profeffors oi the medical art. But, though fome part of the knowledge of the Arabian phyficians was communicated, in this manner to the nations of the Weft, in the eleventh and twelfth centuries ; yet a part of the fixteenth paf- fed over, before it was poffible to trace any marks of improvement. Commentaries were written wimout number; but, for many years, there fcarcely was an individual in all the feminaries of Europe who dared to think for himfelf. It has been cuftomary to date 140 REVIEW OF PRACTICE the revival of fciences in the Weft from the taking of Conftantinople, by which the ftores of Greek lite- rature were in fome degree opened to the world. The language of Galen began then to be more generally underftood, and the writings of Avicenna fell rapidly into neglea; yet the advantage which accrued to medicine from the change, does not appear to have been great. The mind was exercifed in a wider field of learning ; but it was ftill in chains to the authority. of the ancients. The opinions of Galen and Hippo- crates were copied, recopied and commented upon by hundreds ; but there were very few who ventured to ufe any judgment of their own. Among the moft cele- brated of the followers of Galen we may reckon F er- ne! i us, Foreftus, Lommius and Sennertus, men of confiderable talents, but who were to Jcrupuloufly devoted to the principles of their mafter, to open a new road in the praaice of the art. This was re- ferved for Paracelfus, who early in the fixteenth cen- tury ventured to attack the opinions of his preri ecef- fors, and the authority of Galen. Paracelfus poffeffed aconfommatefhare of affurance, together with know- ledge of remedies which were n^t generally known at that time. He acquired fome acquaintance with the chemical difcovcries of the Arabians, in the courfe of his various travels, and applied in praaice what he had learned, on his return to his native country. He defpifed the authority of the regular phyficians, em- ployed lemedies with great boldnefs, and often with lingular fuccefs. This fuccefs was even very pro- bably exaggerated by report; and there appear to have been mane, who followed him impliedly; while others cheered themfelves in modifying and improving his idea>. Under this h(i view v/e may ran:c Van Hebnont, a perfon, who effeaed a very material innovation in the manner of curing febrile difeafes. Van Helmont poifefibJ c.-nficfevable learning; but difcovered, at the fame time fuch marks of warmth and enthwiufm of IN FEBRILE DISEASES. 241 .genius, as diminiflied his credit with contemporary and fucceeding practitioners. The terms which he employs, are fometimes ridiculous; and his reafonings are frequently disfigured with fancy and whim ; yet his ideas are generally important, and often well founded. The archaeus of this author does not differ materially from the fentient principle (r* sv»p^a>vr») of Hippocrates ; and perhaps comprehends the whole idea of the vis medieatrix naturae of the moderns. Van Helmont proceeds to the cure of fever on the important principle of exciting, or calling forth the powers of life, to exterminate an offending caufe ; fo that we may aaually confider him as the firft, after Afclepiades, who attempted to take the bufinefs wholly out of the hands of nature. He difregards the pro- ceffes of coaion and crifis; ind makes a decided ef- forc to cut the dieafe fhort at an early perLd. He is likewife an enemy to bleeding, pirging, vomiting, and the various evacuations which had been employed by his predeceffors, attempting to accomplish his par- pofe folely by the means of fwea", and infenfible per- foration.' 'Fhe fuccefs of his praaice was fo great, that he deems the man unworthy the name o: phyfician wh:> fuffers a fever to exceed the fourth day; a degree of fucce s, which all the powers of antimony have not yet en-ibied us to boaft ot. 'Flie circulation of the blood having bean proved inconteftably about the middle of the laft c.ntury, hopes wee reafonably entertained, that lire healing art would be benefited by the difcovery. It does net however appear that medical men, for fome time at leaft, either argued more clearly, or pradifed more fucce • f .iiy. The advocates o; the galenical and che- mical fehol-> had giadaally app.oached to each other; fo thac the dodrines and pradices of thofe c intend- in* parties wcrj no-./ ioienfibly blended together. S°r-:i:nes the me mVde of thinking predomin ited, fo.aeames tiie uther; bu: chemical principle- every 2„|_2 REVIEW OF PRACTICE where gave fcope to the imagination, which often in- dulged in the wildeft extravagance of conjedure. Among the number of thofe conjedurers, who ar- rived at much eminence and fame, we may reckon Sylvius de le Bae, who lived in the end of the laft century, and introduced a confiderable innovation in *he manner of treating fevers. His theories are ge- nerally known. They appear to be totally deftitute of foundation ; yet unfortunately are the ground- work of all his pradical indications. His principal view confifts, in regulating the mixtures of bile and pancreatic juice. He likewife lays fo great a ftrefs upon the nature of the occafional caufe, as gives rife to doubt and ambiguity. Thus he fometimes pre- feribes acids, though oftener aromatics, volatiles, and opiates. But as we poffefs fome cafes, which he ap- pears to have healed, in the Leyden hofpital, with all his fkiil 2ni attention, we are enabled with more certainty t) form a judgment of the particular merits of his praaice. It has not any claim to extraordinary fuccefs ; yet it is evidently innocent of the great harm which fome later authors have imputed to it. In fhort, if we except opiates, we may confider the reft or" his remedies as very feeble and ineffeaual. During the time that Sylvius flourifhed in Hol- land, a new theory of fevers was offered to the public in England by Dr. Willis, the celebrated author, to whom we are fo much indebted tor bringing into view the importance of the nervous fyftem, in the economy of the human frame. It does not however appear, that this writer's theory ever extended far, or that it was the caufe of much innovationin praaice. The method of treatment, which was generally adopted in the fevers of England, at the time when Sydenham began to fludy medicine, confifted prin- cipally in bleeeding, in vomiting with antimonials, in evacuating the inteftinal canal by means of glyfters or gentle laxatives; and, in the latter periods of the IN FEERILE DISEASES. 243 difeafe, in attempting to raife fweat by hotter alexi- pharmics. In the firft conftitution of feafons def- cribed by this author, viz. the years 1661,-62,-63,- and 64, we do not find any material deviation from this general plan of cure ; which was the plan fol- lowed by Willis, and other contemporary phyfician'?. In the next conftitution, viz. the years 1667, 68 and part of 69, Sydenham forces himfelf on our obferva- tion by an attempt to effect a very important inno- vation. The fever which prevailed during the laft mentioned years was generally of long duratioo. it was ufually accompanied with profufe fweatings, and often diftinguifhed by petechial eruptions. Cordie.l^, and hot regimen were fometimes obferved to cut fliort its courfe abruptly; yet dangerous fymptoms were ftill more frequently the confequence ot this ftimulating mode of treatment, than a favourable ter- mination. The fagacious Sydenham, inftruaed by repeated experience of the bad effeas of this common method of cure, adopted a contrary one; which he purfued with boldnefs, and apparently with great fuc- cefs. It may not be improper to obferve in this place, that our author is not to be confidered as the inventor of the antiphlogiftic method of treating fevers. The ancients, particularly the Arabians, carried the cooling fyftem ftill farther than the mode ns. About this time however it had fallen into general neglea ; and Sydenham undoubtedly poffdfes the merit of reftoring it; more perhaps from his own obfervation, than from a knowledge of what had been done by bis predeceffors. Part of the year 1669, the years 1670,-1671 and 1672, form another conftitution of feafons, according to this author's arrangement of difeafes. The epidemic affumed a different appear- ance from the former. It was chiefly diftinguifhed by fymptoms of dyfenteric affeaion. Our author, however, ftill adhered to the outlines of the antiphlo- giftic plan ; and treated the difeafe fuccefsfiilly with 244 REVIEW OF PRACTICE bleeding, and the repeated .ufe of laxatives. The meurou of treatment, which he adopted, admits of a remark. In the former epidemic, the profufe fweat- ings were checked; in the prefent, the inteftinal evacuations were encouraged ; in one cafe he ap- peared to promote, in the other to thwart the inten- tions of nature ; praaices fo oppofite that we can- not eafily reconcile them. The next conftitution, viz. the years 1673,-74 and 75 difcovered a fever With a new train of fymptoms, and in Sydenham's opinion of a very different race. It was principally diftinguifned by pleuretic and rheumatic affbaions, by coxa" and ftupor. The general antiphlogiftic pi.ciice was ftill perfiftcd in; and the whole of the cure was trufted to difcretional bleeding, bliftering the back part of the head and neck, with the repeated employment of glyfters. The hotter diaphoretics were cautioufly avoided. In the year 1684, this diligent obferver imagined he difcovered the appear- ance of a fever of a perfeaiy new and unknown kind ; a fever accompanied with more or lefs derange- ment of intelfea, and many other fymptoms of ner- vous affeaion ; the fpecies of difeafe, perhaps, which nofologifts have diftinguifhed by the name of Ty- phus. But though this fpecies of fever was fuppofed by our author, to be extremely different in its nature from any that he had yet feen, we do not however perceive, that this idea fuggefted to him any material difference in the mode of treatment. From the fhort view which has been given of Sy- denham's praaice in fevers, it is eafy to perceive the fife and progrefs of the method of cure which he adepted. Antiphlogiftic proccfles were carried to a greater' length by the ancient?, than the moderns have yet dared to rifk. But there is little reafon to fup- \\)\'e, that Sydenham owed the ideas of the alterations which he introduced to information from preceding writers. His pradice bears every where authentic IN FEBRILE DISEASES. 245 marks of having arifen from his own obfervation.— The moft common termination of fevers, is by fweat- ing or increafed perfpiration ; a fault obferved by Van Helmont, and which furnifhed that author with the idea of profecuting the cure of the difeafe wholly on this plan. The praaice feems to have been early adopted in many parts of Europe ; and it even conti- nued in general reputation in England, at the time that Sydenham began his medical ftudies. Sweating undoubtedly is often beneficial, and may be confi- dered, upon the whole, as the moft certain means of exterminating the caufe of fevers; yet bad effeas of- ten refulted from it—then probably more owing to the manner in which it Was conducted, than to the real hurtfulnefs of the thing itfelf, viewed in the light of a general remedy. Sydenham, who does not ap- pear to have difcriminated between the aaual effeas of fweating and the effeas of the manner of exciting it, condemns the praaice in general terms, and paffes to an oppofite method of treatment with a good deal of boldnefs. It has ever unfortunately been the fate of phyfic, like every other conjeaural art, to pafs from one extreme to its oppofite by large ftrides; and thus, even the fagacious Sydenham, who had feen the bad effects of treating remedies in fevers with much of the inflammatory diathefis, was induced to .employ antiphlogiftic proceffes in thofe fpecies of dif- eafe, which we fhould be difpofed to believe do not Well admit of them. The new, or nervous fever, in the opinion of the practitioners of the prefent age, could not well bear the plentiful evacuations preferi bed by this author; at leaft, we may fafely afiirm, that fuch evacuations are not by any means neceffary.— But 1 fhall difmifs this fubject with obferving, that the practice of Sydenham, if we except the article of hleeding, can only be confidered as feeble, and as of- ten infignificant. His remedies fometimes, perhaps, obviate the fatal tendency of fymptoms; but are nqt Y 3 246 REVIEW OF PRACTICE capable Of having any decided effects on the natural courfe of the difeafe. I may like wife add, that his practice is directly at war with the principle of his theory. If fever is confidered an effort of nature to exterminate fomething hurtful from the conftitution, bleeding and thofe evacuations, which diminifh the powers of life, are not the proper means of effecting this purpofe. But the truth is, the practice of Sy- denham was his own; his theory was that of the times in which he lived, formed from a mixture of the doctrines of Van Helmont, Campanella and Dr. Willis. It may not be fufpected, perhaps, from the remarks- which I have made on the practice of Sydenham in fevers, that I do not confider him as the author of fo much effential improvement, as has been generally imagined. I muft however acknowledge, that he deferves the higheft praife for the accurate and well difcriminated hiftory of acute difeafes, which he has left us. The deferiprions are complete, and the cir- cumftances fo peculiarly chofen, that the difeafe itfelf is aaually before the eyes of the reader. Thefe are the great, and as yet the unrivalled excellencies of Sydenham ; but in admitting fuch effential differences in the caufe of epidemics as he has done, he neceffa- rily leads us to embarraffment, and often leaves the praaitioner in a ftate of uncertainty. The difeafe defcribed by Sydenham, in the various conftitutions of feafons between the years 1661 and 1685, fhews external marks of confiderable diverfity ; yet I muft confefs, that I fee but little reafon for fuppofing, that thefe appearances arife from caufes which are totally and fundamently diftina. The fever of Sydenham, in all its form?, is in fea the common endemic of England. Circumftances however often arofe then, and ftill arife, which modify the general caufe in fuch a manner, that the difeafe appears at one time with fymptoms of inflammatory diathefis, at another with IN FEBRILE DISEASES. 247 fymptoms of nervous affeaion, and at another, with a general difpofition to affedions of particular organs. Thefe modifying caufes, which are more general or part;cular, more obvious or obkruer, often continue for a certain train of feafons, and influence very ma- terially the charader of the reigning epidemic. The general caufe of the fe/er is in reality one and the fame, yet I muft alfo acknowledge, that the modifi- cations are evidently many and varioue, and often very remotely different from each other. Chemical principles for fome ti.ne paft, had the principal fhare in enabling; medical writers to account for the phenomena in fevers ; but about the end of laft century, the mechanical philofophy was ao-ain revived, and being incorporated with the dodrines of the chemifts, the laws, and various derangements of the human frame, were then explained on the princi- ples of hydraulics, or chemical mixture. The au- thors who adopted this mode of reafoning were nu- merous, and fome of them were of great eminence; but at prefent I fhall only take notice of one of the greateft of them, the celeb rated Boerhaave, who formed a fyftem, which was confidered as the moft perfea that had hitherto been offered to the public. The doarines of this author acquired uncommon fame. They foon extended over all Europe, and, in- deed, ftill prevail in the greateft part of it. But though Boerhaave has prefented us with a methodical explanation of the phenomena in fevers; and has detailed the method of cure with clearnefs and pre- cifion ; yet we do not find, that he has furnifhed much that is new and original in praaice. He is every where cautious, and in moil inftances judicious; though he has committed a principal error in forming indications of cure, from a fuppofition of lentor and vifcidity; a caufe the very exiftence of which we have every reafon to doubt. Durine- the time that Boerhaave flourifhed in Hoi- . 248 REVIEW OF PRACTICE land, indeed before this author bad arrived at much reputation, Profeflbr Stahl, at Halls in Saxony, pro- pofed fome new opinions, which acquired confiderabfe fame, and which have been confidered, in fome man- ner, as forming a peculiar fyftem. The leading principle of this author, as is confefled by all, admits only of a feeble and inaaive pradice. I might even add, that it frequently leads to a pernicious one. Thofe tumults, or fufterings, which pafs by the name of the efforts of nature, are extremely deceitful; and have obvioufly, in many inftances, a deftruaive tendency. I mentioned before that they are trufte^ with danger ; yet Stahl, proceeding on this prin- ciple, boafts extraordinary fuccefs in the cure of the petechial fever, which prevailed in moft parts of Saxony towards the end of laft century. In a review of thofe authors, who have written on febrile difeafes, it would be unjuft to omit men- tioning Hoffman, contemporary with Stahl, and pro- feflbr in the fame univerfity. The aaual alterations v/hich this author has introduced into the cure Ojf fevers, are not perhaps very great in themfelves; yet his important difcoveries, in regard to its theory, entitle him to great confideration. The moft of the remedies, which he employed, are found in the writings of his predeceflorsj or contemporaries; yet they were not, perhaps, always prefenbed by them with the fame intentions. The theory of Hoffman opens a road for the trial of antifpafmodics, merely on the footing of antifpafmodics ; a dafs of remedies of much importance in the cure of febrile diforders. In praaice, Hoffman is more decided than Stahl; and his views, perhaps are more extenfive than thofe of Boerhaave. He is likewife uncommonly candid; and has furnifhed us with a great variety of hiftories, which ferve in many cafes to illuftrate the nature of the d'feafe. The antiphlogiftic method of treating fevers, the IN FEBRILE DISEASES. 249 ground-work of which was laid by Sydenham, and improved by Boerhaave, prevailed in moft parts of Europe, without material alteration, till near the pre- fent times. Bliftering with cantharides, which had been employed with caution, and which was even fufpeaed of deleterious effeas by many, was intro- duced into praaice in the end of the fixteenth cen- tury, aad about the beginning of the prefent began to be, as employed, a common remedy in many fpe- cies of fever : its good effeas were often obvious, and, according to the prevailing mode of reafoning, were fuppofed to arife from a quality which can- tharides were believed to poffefs, of attenuating the blood. This mode of operation is no longer admitted; but the remedy ftill retains its credit. Few people pretend that blifters are poffeffed of fpecific powers in fhortening the courfe of fevers ; yet every one al- lows, that they obviate many fymptoms of dangerous tendency, and that they often difpofe the difeafe to affume it proper form. In fevers, accompanied with local affection, their beneficial effeas are univerfally acknowledged ; and, even in many cafes of general irritability, they often produce very fortunate changes. But I muft obferve, with regard to this, that much depends on managment, and the mode of application. In local affeaions the local application is moft effec- tual ; in cafes accompanied with much general iirir tability, the back part of the head and neck ought, perhaps, to be preferred to others. I have thus fre- quently feen in fevers, where there was much general irritability, that blifters applied to the extremities evidently aggravated the difeafe; while I have alfo obferved, thlit they as certainly diminifhed the hard- nefs and frequency of the pulfe, and difpofed the patient to reft, Where they were applied to the back part of the head and neck. There is another remedy • that I fliall take notice of before leaving this fubjea, which poffeffes ftill higher reputation than blifters. 2^0 REVIEW OF PRACTICE Antimonial preparations have been employed occa- fionally in fevers for many years paft ; but they did not gain eftablilhed credit in this country, till within thefe thirty years. The difcovery of the famous powder of Dr. James appears to have been the caufe of a confiderable innovation, in the manner of treat- ing febrile difeafes. The pradice of Boerhaave did not go farther than to obviate fymptoms of fatal tendency ; it left the difeafe to purfue its own courfe.. Dr. jamts affumed a bolder ground, and promifed to cut fhort the fever abruptly by means of his powder. There are many who ftill tread in his footfteps ; I acknowledge, as I have hinted before, that their at- tempts may be often fuccefsful in the early ftages of the iflnefs, or often ufeful towards a critical period. I cannot however believe, that this powder, or any preparation of antimony with which we are yet ac- quainted, poffefles the power of abruptly terminating a fever wherever it is employed ; at leaft, to effect this requires a management of which I confefs myfelf ignoiant. The effeds which Dr. James promifed from his powder, others have attempted to obtain from emetic tartar ; but I have reafon to think with inferior feccefs. the wonderful power, which the Peruvian bark is obferved to poffefs, in fufpending the courfe of inter- mittents, has led the practitioners of the prefent times to employ it, with the fame views, in fevers of various denominations. But after what I have faid of 'the uncertainty of its effeds in checking the courfe of the remitting fever of Jamaica, it will be needlefs to repeat here, that I do not expea to find it of much efficacy, in (hortening fevers of a more continued kind. I muft, however confefs, that, even in many of thefe, it is a remedy of great value. It fupports, in a very eminent degree, the tone and vigour of the powers of life. Opium has been prtferibed cccafionally in fevers IN FEBRILE DISEASES 2^1 ffor along time pad ; but it is only oflate years, that it has been recommended, as a general remedy in fome particular fpecies of this difeafe. The pradi- tioners of the Weft Indies, prefcribe opium with more freedom, than is generally done in England. It is frequently employed to mitigate fymptoms ; and in fome fituations which were very alarming, I have gi/en it in very large quantity with unexpedted good effeas. In the f[ow fevers of this country I have frequently had recourfe to it; and, combined with antimonials and camphire, have found it to be a re- medy, of great value. Opium in general was more cordial than wine. In cafes of defpondence and diftrefs it gave a confidence to the mind, and im- parted a pleafureablenefs to the fenfations above all other remedies. In fhort, it appeared often, not only to be inftrumental in conducting the difeafe to a favourable termination, but it enabled the patient to pafs through it with comfort to himfelf. I have mentioned in the preceding pages, the moft eminent of thofe authors, who have written on the cure of fevers ; giving at the fame time fuch extrads from their works, that the reader, who has not the opportunity of confulting the originals, may be enabled to form fome idea of the fucceflive changes, the improvements, and oftener perhaps the corrup- tions, which have arifen in the method of treating febrile difeafes, from the eariieft records of the art to the prefent times. The apparent changes are more numerous than the real ones ; while the moft oppofite modes of treatment do not often appear to have much perceptiole effed on the event. The cure of fever has been hitherto purfued on two gene- ral and oppofite views, viz. on the idea of exciting the powers of life, by means of heating and ftimulating remedies ; or of dimini filing the reaftion of the fyftem by evacuations and other antiphlogiftic proceffes. The above extreme of thofe direaiy oppofite modes 252 REVIEW OF PRACTICE of treatment have approached gradually to each other, or been varioufly combined by different praaitioners. It cannot however fail of appearing ftrange to a perfon, who views the fcience of medicine in a philo- fophical light, to hear one fet of men afferting that the proper cure ©f fever Confifts in exciting the powers of life, or in enabling nature to expel the dif- eafe by force; while another,with no lefs confidence, maintains that the plan of moderating or diminifhing increafed aaion is that which ought alone to be pur- fued. From fuch contradiaory affertions we cannot eafily avoid concluding, either that the moft oppofite means produce the fame effba, or that nature has a prefcribed mode of proceeding in fevers, which ordi- nary medical affiftance is not powerful enough to controul. There are many eminent praaitioners, who have been confcious of this truth. The candid Sydenham himfelf acknowledges, that thofe, whom he treated with all his fkiil and attention, and who pof- feffed all the comforts that affluence could afford, did not often fare better than the poor, who were only fparingly furnifhed with neceflaries, and who met with little affiftance from medicine. I have myfelf feen many examples of the fame kind. Sometimes I purfued the ufual methods of cure with, care and perfeverancc; fometimes i left the bufinefs almoft entirely to nature, and I cannot fey, that the dif- ference of the event gives me much caufe to be vain. But though I may appear to be feeptical with regard to the effeds of common practice, I ftill cannot help being of opinion, that we may arrive at a high de- gree of perfedion in the management of febrile dif- eafes. So fanguine, indeed, are my expeaations, that 1 cannot eafily forgive myfelf, when the event of this difeafe happens to be unfortunate. The remitting fever of Jamaica is not a difeafe by anv means devoid of danger; yet I fhould not be fatisfied with myfelf, from the view which I now have of the fubjea, if I IN FEBRILE DISEASES. 2^3 loft one patient in fifty. I own indeed that tins is a degree of fuccefs, which neither 1, nor perhaps an/ other man has yet attained. I muft however add, that I have not always had the liberty of doing what I wifhed to do; neither have I always dared to ven- ture upon what I judged not proper to be done. The prejudices of patients in fome cafes, and ohe idea of refponfi-bility in others, confine us to the beaten track, though we may be confcious in ourfelves that it never can lead us to our cbjed. If thefe obHacks were removed, a man who will aa with decifion, may promife almoft any degree of fuccefs in the remitting fever of the Weft-Indies, in conftitutions which are free from habitual complaint?. The conftant fluctuation which has hitherto pre- vailed in the opinions of phyficians concerning the caufes of fever, and in their pradiccs with regard to its cure, oblige -us to think doubtfully of the real progrefs of the healing art. Hippocrates was allowed to have pradifed with more fuccefs than his prede- ceffors. Afclepiades was believed by many to have been ftill more fortunate than Hippocrates ; yet the road which he purfued was totally different. Galen, who reviewed and improved the fyftem of the Coan fage, rofeto great eminence, and marked out the patb^ of medical pradice for many centuries. The doc- trines of Paracelfus fhook his authority; and thefe in their turn gave way to newer modes of thinking. In this manner there have been fuch perpetual revolu- tions in the modes of treating febrile difeafes, that we can fcarcely avoid concluding, that little or nothing of the matter is yet known with certainty. Medical writers have wandered from conjeaure to conjedure, for more than two thoufand years ; and we do not yet perceive any profpea of thefe conjeaures beinj nearer to an end. Z f *ss 3 APPENDIX. CONTAINING SOME HINTS WITH REGARD TO THE MEAN'S OF PRESERVING THE HEALTH OF SOLDIERS SERVING IH HOT CLIMATES. HWING treated pretty fully of the remitting fever of Jamaica, and intermitting fever of A nenca, I fhall now offer a few thoughts on the va- rious means of pveferving the health of foidiers in warm climates; taking the liberty at the fame time to fuggeft fome ideas, which might perhaps be ufe- fuliy attended to by thofe who fuperintend the medical eftabiifhments of the army. The climate of the Weft-Indies has been fatal to the European conftitution, even fince its firft difco- very by Columbus. To the armies and navies of England it he.r, been particularly deftruaive. The fad fare of the troor>s who went on the expedition to Carthagena will be long remembered; neither will the lofs fuftained ar the Havannah, Martinique and Gaudaloupe foon be forgotten; while the deftruction, occafioned by the effeds of climate at St. Lucia, St. Juan, and even in Jamaica, during the late war, is 'ftill frefh in our memories. As it appears from a comparative view of the mortality of the troops em- ployed in thefe different fervice?, that we have pro- fited but litde by the experience of our former rhif- fortunes, it might probably be fuppofed, that the great itcknefs, obferved on thefe occafions, has aau- ally arifen from the irremediable effeds of climate, or unavoidable hardships of fervice in hot countries ; but there is reafon to believe that this is not wholly die cafe. I will venture to aflert, nor fhould I ex- pea to meet with difficulty in proving, that much 2 5»" APPENDIX. ©f it has proceeded from the inexperience or inatten- tion of thofe who conduaed the expeditions, or from fuch errors in the medical departments as might have been eafily obviated. It is fuperfluous to obferve, that the health of the foldier is an object of principal importance jn enfuring the fucceffes of war. We have many inftances of expeditions apparently well concerted, which have failed from the exceflive fick- nefs of the troops: and too many proofs of this fick- ■nefs-proceeding from a negled: of fuch precautions* as might hr/e contributed to the preservation of 1 ubo. I have accuftomed myfelf to look at this fo ject for more than fifteen years. I have .turned it o;ren in my mind, and cannot difcover that much jodicious attention has yet been paid to it. We can- not often perceive that health has been an object of coniiderarion, in fixing the permanent flations of troops; or that it has been much regarded in choofing encampments in the field. Exercifes, which mi^ht inure the body to hardlhips, have not been fufhci- ently enforced; and fuch forts of diet, and fuch modes of life, as might obviate the danger of difeafes, have been little attended to; while the beft regulations for * foeedy and decifive plan of cure do not appear to have been adopted. I fhall be obliged, in tracing this fubjea, to advance fome ideas which are contrary to the opinions of fome celebrated authors, which combat popular prejudices, or which interfere with the views of interefted men. I may be reckoned pre- fumptuous perhaps in cenfuring freely; but I am confcious that I do nt>t advance any thing which has »ot truth for its foundation. It has frequently been the praaice, in times of war, to fend new railed regiments to ferve in the iflands. of the Weft-Indies;xand though the injudici- oufhefs of the praaice has long been difcovered, it does not yet appear to be difeontinued. During the late war there were feveral corps fent out to tfiofe APPENDlk. 2£7 eowntries newly recruited, the confequence of which was, that though not a man died by the fword; yet in the fhort fpace of two years, there fcarcely was a foldier left. A great part of this dreadful mortality undoubtedly arofe from the climate; yet fome fhare of it feems likewife to have proceeded from the par- ticular circumftances of raw undifciplined troops.— Men newly enlifted in England, are generally of grofs and full habits, and too often accuftomed to ir- regular and diflipated modes of life. Under fuch circumftances, a fudden tranfition to a hotter air, joined with full meals, and the habitual indolence of a paffage at fea, cannot fail to produce a plethoric ftate of the body, which is often rendered dangerous by the incautious ufe of ftrong liquors, or the ordi- nary exertions required in performing military exer- x:ifes, under the influence of a powerful fun. I do not pretend to infinuate that thofe are the caufes of remitting fever, but I am very fenfible at the fame time that they are caufes which occafionaliy aggravate its danger, and which even fometimes accelerate its appearance. In foldiers who have been inured to a military life, fuch change of climate operates with dimini.-hed effea. The bulk of the fluids is per- haps duniniihed by a continuance of lefs full living ; while the tone aird elafticity of the moving powers are increafed by habits of exercife and exertion — The difpofition to commit excefles is likewife reprcf- fed by the rigour of difcipline; and the mind acquires a phiiofophical nrmnefs from long fervice, which not only contributes to the prefervation of health, but which enables the individual to fuftain with fortitude the attack of difeafes. In pafling from a cold to a hot climate, the firft thing that occurs to be confidered, is tee effea pro- duced by the fimple increafe of heat en the horo-n frame. Expamion of the fluids, and c-nihquent ful- nefs of theveflcls is-conftantly obferved toulce place Z3 25 8 APPENDIX. from fuch :i change, frequently however accompanied wuh diminiflied energy of the moving powers, par- ticularly where heat is combined with dampnefs of the air. To obviate therefore this natural effea of heat is the firft general objea to be attended to, in tranfporting troops to the tropical climates. The Englifh, from the conftitution of their bodies, and ftiil more perhaps from their manner of living, fuffer more from thofe fudden changes than fome other European nations. The French and Spaniards are not only lefs grofs conftitutionally, but eat likewife lefs animal food, and drink their liquors greatly more diluted, than the natives of England. They do not probably owe more to medical affiftance than the Englifh ; yet they are known to efeape better from dangerous difeafes ; and their fafety I might add has been remarked to bear fome proportion to the differ- ent degrees of abftemioufhefs, which they are known to obferve. An idea prevails with the generality of people, who vifit warmer or more unhealthy climates, that it is neceffary to eat and drink freely, as a fecu- rity againft the attacks of endemic fevers ; but a very narrow obfervation wjll ferve tofhew, that good living, as it is called, has no fuch effeds; and we may even foon perceive, unlefs blended by long eftablifhed prejudices which flatter our appetites, that it adually is attended with pernicious confe- quences. The moft abftemiou?, fo far as I have ob- ferved, efeaped the beft, not only from the attacks, but particularly from the danger of difeafes. With regard to the diet of a folditr, ferving in a hot cli- mate, I fhould be difpofed to believe, that one fpare meal of animalhood would be perfedly fufficient in twenty-four|: and if it were eafy to alter eftablifhed cuftoms, it would be moft proper, perhaps, that it were made inthe cool of the evening. Coffee, or tea for breakfaft might likewife be fubftituted with ad- vantage in place of the ordinary allowance of rum ; APPENDIX. 2$9 but this I muft confefs would be a dangerous expe- riment, Our foldiers have been fo long accuftomed to confider this gratuitous allowance of rum as their right, that no man could anfwer for the confequences of with-holding it. The praaice certainly is perni- cious, and the man, who firft introduced it into the army, did no good fervice to his country. I do not deny that a judicious ufe of fpirits might be of benefit occafionally: neither do I pretend to fay, that, even the hardeft drinking can be confidered as a general caufe of fevers ; but it would not be difficult to pro- duce evidence, that hard drinking aggravates the violence, and increafesthe danger of the difeafe, when it happens to take place; while I cannot perceive much reafon for concluding, that the ufe of fpirituous liquors has ever been produaive of general good to the army, particularly in warm climates. But as I have juft mentioned, that fpirituous liquors have little claim to be confidered among the number of thofe things, which contribute to the prefervation of health : fo I may add, with perfea confidence, that the allow- ance of rum granted to foldiers, has done much harm by ruining difcipline, and ,good behaviour. If it is with-held for one day, difcontent immediately begins to ftiew itfelf among the men. If with-held for any length of time, complaints fometimes rife to a ftate of mutiny, and defertions become numerous. But befides this, that foldiers feldom perform extra-duty with alacrity, unlefs they are bribed with a double allowance of liquor. A double allowance, drank un- diluted, as is generally the cafe, is frequently fuffi- cient to produce fome degree of intoxication. I need not mention the difafters to which an intoxicated army is expofed. Difafters of a very ferious nature have aauallv happened from this caufe, and they might have'happened oftener had the enemy been always vigilant, and bold enough to have feized the opportunity. ^ a6o APPENDIX. A deal might be faid on the fubjea of abftemiouf- nefe. Moderation both in earing and drinking is ef- fentially necefiary to the health of troops newly ar- rived in hot climates ; but a truth fa obvious need not be enforced by many arguments. The example of the French and Spaniards afford a very convinc- ing one. I: is kno.vn to every medical perfon, that the fevers cf hot climates are generally m ft danger- ous in full and plethoric habits. It ought to be an objea of attention therefore to obviate this caufe of mortality, by means of fpare living, and the cautious ufe of ftimulating liquors : but foldiers have little felf command, and feldom refill the gratification if their appetites. Hence it becomes the duty of thtir offi- cers to enforce their compliance with what is proper, and to preclude them, as much as is poffibie, from :he means of obtaining what is pernicious; bui this re- quires great vigilance and attention, and often geeat feveritv. It is not enough that foldurs are obliged to eat in meffes. The officers ought daily to infpeft their meals, and inflia penalties where they obferve trartfgreffion?. And further, as it is a matter of much importance to preferve troops in a ftate of health fit for aaion, and as the courfe of fevers is often un- commonly rapid in the Weft-Indies, it would be pro- per, perhaps, that the furgeon reviewed the men daily. The diilart approach of tlie difeafe would be fre- quently difcovered by this means, and the danger of it might probably be fomerimes averted by timely af- fiftance. Before men appear in the fick-repons, die fever is often confiderably advanced in its progrefs. Befides the alterations which might be made in the diet of troops, on their arrival in hot climates, fome changes in the mode of cloathing might, perhaps, be likewife adopted for the fake of eafe and convenience, if not for purpofes of real ufe and economy. Round white hats would be the moft proper covering for the head; and dowlas might be fubftituted with advan- APPENDIX. 26l tage in room of the thick cloth, of which the coats of foldiers are ufually made. There can be no groundsfor fuppofing, that a foldier will not fight as well in dowlas as in fcarlet; and there is certain proof that he v ill perform duties, which require exertion, whh greater fafety and effea, as thenaiurc of hiscloathing willpre- ferve him cooler by fome degrees. But though fuch al- terations may be hinted, there is little room to believe that they will be attended to. In the prefent rage for military fhew, it will be a difficult talk to con- vince men to lay afide an uniform, which adds fo much to the brilliancy of the appearance. Much ftrefs feems at prefent to be laid upon the drefs of the foldier, and 1 do not pretend to argue, that it is a matter of perfea indifference. It has certainly very often had vifible effeas upon the enemy; but thefe effeas have oftener proceeded from a knowledge of the charader of the troops who wore it, than trom any thing formidable in the uniform itfelf. But to leave this fubjea of drefs, I fhall only obferve, that a flannel or cotten wrapper would be more ufe- ful to a foldier, ferving in the Weft-Indies, than a blanket; and perhaps the expence of it would not* be much greater. It would ferve for his covering in the night, and would fecure him againft the effeas of cold, where occafions obliged him to go out. I fhall endeavour in the next place to point o ;t fome of thofe benefits, which may be derived to health, from habits of daily exercife. This is an objea of the greateft importance, but unfortunately it is an cbjea very little attended to in ihe Britifh army. It appears, indeed, to be little regarded in moft of the armies of modern Europe. I fhould incur a charge of prefumption, perhaps of ignorance, did I attempt to point out the exercifes which are the moft proper for the forming of foldiers. Thofe only which contri- bute to the°prefervation of health, belong to this place. I may however remark, that the effential part of the 2?fe APPENDIX. art of difcapl&iing troops, confifts in imparting fentj. ments of heroifai and virtue to the minds of the men, in improving the exertions of their limbs, and in acquir- ing knowledge of the correfpondence of then exer- tions when called into aaion. If I duift take fo gieat a liberty, I fhould be inclined to fay, that oar ordinary exercifes are flat and infipid in their nature; that they occaii n no exertions, and excite no emulation: they neither improve the active powers of the body, nor inure the foldier to bear fatigue and hardfhip. The Romans, who owed more to the difcipline of their armies than any nation on earth, were extremely ri- gorous and perfevering in their exercifes. They prac- tifed their foldiers in every fpecies of fervice that might occur; fo that nothing at any time happened with which they were unacquainted. Aaual war was in reality a time of relaxation and amufemerrt to the f ldie: s of this warlike people, who appear to have been trained for the fervice of the field, as horfes are for hunting or the co ufe. The Romans were not only fentible of the advantages which thofe habits of exercife procured them in aaion; but had al b the penetration 10 difcover, that they were eminently for- viceable in the prefervaiion of health. The word's cf Vegetius are remarkable. " Rei milicari-. periri, plus quatidiana ai morum exercilia ad fanitatem mili- tum putaverunt prcdeffe, quam medicos." I made the fame remark during the time that I attended a regi- ment in America, without knovring thai it was fup- ported by fo great authority. I obferved, when the men veie in the-field, fometimes even complaining of hardfhip ar,d farigue, that few were reported in the lift of the fic.'c : when removed to quarter?, or en» camped for any length of time in one place, the hof- pitai was obferved to fill rapidly. This obfervation was un.fo;rnly verified, as often as the experiment was repeated. An idea, has been long entertaifted, that the Euro- APPENDIX. 2% rppean conftitution cannot bear hard labour in the fun, or perform military exercifes with fafety, in tho hot climates of the Weft-Indies. Hence a plan has been fuggefted, and in fome degree I believe adopted, that regiments forving in thofe countries, be furnifhed' with people of colour to do the drudgery of the fol- diers. But this appears to be an innovation which ought to be admitted with extreme caution. It will evidently ferve to increafe floth and idlenefs, and un-. lefs the perfons of colour can perform the military duty in the field, their fervices will go but a fliort way in preferving the health of the troops. A fol- dier, notwithftanding he may have received the King's* pay for twenty years or more, remains in fome de-: gree a tyro till his betdy has been inured to fatigue,- and prepared to bear without danger the effeas of the climate, in which he may he deftined to ferve. This is a part of the military difcipline, indeed, no lefs neceffary than a knowledge of the ufe of arms ; and though it is a part of it, difficult to be accom-*. pliihed, there is ftill room to believe, that it may be •ffeaed, even in the fo much dreaded climate of Ja- maica. It is a common opinion, that the fatigues of an aaive campaign in the Weft-Indies, would.be fatal to the health of the troops.; hut the opinion has . been aflumed without fair trial. The exertions of a fingle day have often been hurtful. This was fre- quently the cafe in America, where the foldiers had remained for fome time in a ftate of reft 4 but bad effeas from the greateft exertions, in the hotteft weather of fummer, were extremely rare in that country, after the campaign had been continued for a- few days. But that I may not feem to reft an opi- nion of fo great importance on a bare analogy, I fhall beg leave to obfervei, that young European planters undergo greater fatigues, and remain daily expofed for a longer time to the heat of the fun, than would fidj to die lot of foldiers in the-aaual fervice of the 26*4 APPENDIX. field. I might likewife further confirm the opinion, that an Englifhman is capable of fuftaining fatigue in the Weft-Indies, equally well with the African, or the native of the iflands, by mentioning a journey which I once performed myfelf. I lived about four years in Jamaica, during the greateft part of which I believed that death, or dangerous ficknefs, would be the confequence of walking any diftance on foot; but I afterwards learnt that this apprehenfion was vain. I left Savanna la Mar in the year 1778, with the defign of going to America; but having em- barked in a hurry, and forgot a material piece of bufinefs, I found a neceflity of being put afhore, after having been two or three days at fea. I was landed at Port Morant, in St. Thomas's in the Eaft, from which I went to Kingfton by water, where learning that there was a veffel at Lucca, in the Weftern ex- tremity of the ifland, nearly ready to fail for New- York, I fet out direaiy, that I might not lofe the ^ppportunity of a paffage. My finances not being in a condition to furnifh horfes, I left Kingfton on foot, about twelve o'clock, and accomplifhed a journey before it was dark of eighteen miles. I did not find I was materially fatigued and ftill perlifting in my refolution, travelled a hundred miles more in the fpace of the three following days. It may not be im- proper to remark, that I carried baggage with me, equal in weight to the common knapfack of a foldier. 1 do not know that fo great a journey was ever per- formed on foot by an European, in any of the iflands of the Weft-Indies ; not fo much I ana convinced from inability, as from idea that fuch exertions are dangerous. But as it appears from the above fea, that the European conftitution is capable of fuftain- ing common military fatigues in the climate of Ja- maica ; fo I may add that it ought to be a principal objea of military difcipline, that foldiers be praaifed with frequent marching, and the performance of Appendix. 26$ *mer exercifes of exertion, if it is aaaally meant that they fhould be ufeful in.times of war. The late of battles, I might obferve, depends oftener on rapid movements, in which the aaivity of the limbs is concerned, than on the expert handling of arms, which is acquired by the praaice of the manual. I obferved formerly, that abftemioufnefs and temperance were among the beft means of preferving health, or obviating the danger of the difeafes to which troops are liable on their firft arrival in hot climates ; but the rules of temperance are little regarded by Englifh foldiers at any time, and almoft conftantly tranfgreffed wherever extraordinary labour is required of them. To fuch caufes of excefs, joined with the great heat of the fun, we may perhaps impute many of the bad effeas of marching, or of moderate fatigue in ths Weft-Indies. In the journey which I have juft now mentioned, I probably owe my efcape from fick- nefs to temperance and fpare living. I breakfafted on tea about ten in the morning, and made a meal of bread and fallad, after I had taken up my lodging for the night. If I had occafion to drink through the day, water or lemonade was my beverage. In the year 1782,1 walked between Edinburgh and London in eleven days and a half; and invariably obferved, that I performed my journey with greater eafe and pleafure, where I drank water, aud only breakfafted and flipped, than when I made three meals a day, and drank wine, ale, or porter. In the fol- lowing fummer I carried the experiment farther. During the months of July and Auguft, I travelled in fome of the hotteft provinces of France. I ge- nerally walked from twenty-five to thirty miles a day, in a degree of heat lefs fupportable than the common heat of Jamaica, without fuffering any material in- convenience. I breakfafted about ten o'clock on tea, coffee or fyrup of vinegar, made a flender meal of animal food in the evening, with a great proportion A a 2rjfS APPENDIX. of fallad and vegetables; but never drank the wealctft wines without dilution. The great refrefhment which I found from fyrup of vinegar and water, con- vinces me, that the Romans had go©d caufe for mak- ing vinegar fuch an eflential article among the pro- vilions of their armies.—The ftate of luxury and our depraved appetites, unfortunately do not fuffer it to be adopted by the Englifh. I ought perhaps to make an apology to the reader for introducing my own experience on the prefent occafion : but I muft add, that I have only done it, becaufe it enables me to fpeak from conviaion, that an Englifh foldier may he rendered capable of going through the fevereft military fervice in the hotteft iflands of the Weft- Indies, and that temperance will be one of the beft means of enabling him to perform his duty with fafety and effea. I mentioned before, that the military exercife of. the Englifh army is ill calculated to excite a fpirit of emulation among the men. It is in fea confidered only as a piece of drudgery, in which there are few who have any ambition to excel. It has little effea' in improving the aaivity of the limbs, or hardening the conftitution of the body; fo that it may better fuftain hardfhip and fatigue. But feeble as its effeas- ure in the view of increafing exertion, or preferving health, it is generally almoft intirely discontinued when troops arrive in hot climates ; a prad^tice, which has arifen from a fuperficial and miftaken view of the fubject Sloth and indolence are the bane of a fol- dier in every climate ; exercrfe and aaion are the greateft prefervatives of difcipline and of health. It would be reckoned prefumption in me, and it does not belong to this place to point out thofe exercifes which might be proper for the forming of foldiers. But every one knows that walking, running, wreft- ling, leaping, fencing and fwimming, are often called into aaual ufe in the praaice of war. Thefe: arc APPENDIX. 267 foch exercifes likewife as excite emulation, and are praaifed wich pleafure by theindividual. They harden the body, increafe the power of the limbs, and by furnifhing the officer with a view of the different degrees of aaivity, may often enable him to place his men in the ranks, according to the uniformity of their exertions ; a more ufeful mode of arrangement in time of aaion, than uniformity of exterior form.- I may acli in this place, that fea-lvihing will be ex- tremely ufeful in rnejft cafes, in increafing the vi&our and prefervhv; the health of foldiers ferving in warm climates. 1 here no doubt will occur many cafes, in which it is improper ; but in general it may be employed with great benefit. I chiefly impute it to this caufe, that I did not experience a fingle clay's indifpofition, during the four years that I lived inv Jamaica. It has been known for many ages, that the ceufe of intermitting and remitting fevers, the moft for- m'.d'-'.bie difeafes of hot climates, owes hQ origin to exhalations from fwampy and moift grounds. It oftei happens likewife, that thole low and fwampy grounds are the moft acceffible parts of a coaft, or that towns and fettlements have been placed near them^—to at- tack or defend which falls to the lot of the foldier. It not being therefore in the power of a military commander to remove the natural di fad vantages,, which I have mentioned ; it is only in his power to fliew his judgment and attention, by applying the beft remedies to obviate their effbas. It is certainly an objea of the utmoft confequence to preferve troops in a ftate of health fit for aaion : and no perfon will deny, that every care ought to be employed in choofing the beft fituations for quarters, or even' temporary encampments, that the nature of the duty will permit. We learn from experience that fevers are little known in rough and hilly countries, where Water flows with a rapid courfe; while we likewife A a 2 268 APPENDIX. know, that they are common in low and champaigs countries, where water ftagnates, or 'has only a fluggifh motion i independent of which, thofe fitua- tions which are in the neighbourhood of fwamps, or near the oozy banks of large rivers, have always been obferved to be particularly liable to fuch difeafes. If therefore the circumftances of the fervice do not for- bid, no room can be left to doubt about the propriety of flationing troops in the mountanous or hilly parts of a country;. while I may likewife add, that where neceflity confines them to the plain, the fea fhore will in general be found to be the moft eligible. But- befides the ^bove general charaaer of local fituations there are likewife fome fubordinate circumftances, which deferve to be particularly attended to in choofing the ground of encampments. It is very commonly- believed that high and elevated fituations are the moft uniformly proper for this parpofe; but this in fea is not, by any means, a general rule. A high and dry fituation does not contain any thing hurtful in itfelf j but it is more than others expofed to the effluvia which are carried from a diftance. It is the peculiar nature of exhalations to afc.-nd as they proceed from their fource; in confirmation of which truth I have had feveral opportunities of witnefling, that this caufe of difeafe was carried to rifing grounds in a ftate of great aaivity; while it apparently paffed over the plain or vallies which lay contiguous, without pro- ducing any material effeas. From the knowledge of this fea we are furnifhed with this obvious re- mark, that it will be proper to interpofe woods or rifing grounds to the progrefs of thofe noxious va- pours ; or where fuch natural advantages do not exift, it might be ferviceable to burn a chain of fires in a temporary encampment, or even to raife a parapet wall to over top the barracks, where neceflity re- quires a more permanent ftation.-----It would be a matter of utility, could we determine with any cer- APPENDIX*- 2%. tamty to what diftance from its fource, the noxious effluvia extend; but this is a queftion which we can- not hope to afcertain very exaaiy. It is not uni- formly the fame in all fituations, depending on the concentrated ftate of the exhalation at its fource, the obftacles it meets with in its progrefs, and the nature of the ground over which it paffes, or to which it is direaed. I have known its influence very remark- able at the diftance of a mile and a half, on the top of a hill of very confiderable elevation. The conveniences of trade have often tempted eo- lonifts to place their towns on the banks of rivers. without regard to the healthfulnefs of the fituation.-- The choice of fuch fpots, injudicious as it evidently is, has been greatly approved of, and warmly recom- mended as preferable to others for the encampment of troops, by a very celebrated medical authority. Sir John Pringle confiders the banks of large rivers es extremely proper for this purpofe, on account of a free circulation of air; but I am forry to obferve, that Sir John Pringle's opinion on this occafion appears to have arifen from his theory, rather than that his theory has arifen from obfervation. We have aaual experience of the unhealthfulnefs of the muddy banks of large rivers in hot climates; and we have little caufe to dread difeafes, which originate from confined air in America, the Weft-Indies, or perhaps in any country where troops are employed in the field. I have juft now obferved, that the banks of large rivers, in the opinion of Sir John Pringle, afford the moft eligible fituation with refpea to healthinefs for the encampment of troops. I may add, that the fame author has likewife recommended open grounds for this purpofe, in preference to woods; and that the fame favourite idea, viz. a free circulation of air, has influenced his advice. I will not contend, that open, dry and cultivated grounds may not be prefer- able to o-rounds covered with wood, where the heat A a 3 270 APPENDIX. of the climate is moderate ; but I have no doubt in afferting, that encampments on lands, the woods of which have been newly cut down, as is generally the cafe in times of war, are of all others the moft un- healthful. I have myfelf feen feveral examples of it. Perhaps it is in a great meafure owing to this caufe, that new countries are generally fo fatal to the firft fettlers; as alfo, lhat troops fuffer fo remarkably in carrying on the fieges of places which are furrounded by woods : it being conftantly obferved, that effluvia from moift lands, when firft expofed to the aaion of a powerful fun, are always highly pernicious. The Romans, whofe obfervations on fubjeas which relate to war, may be oppofed with confidence to the authority of the moft celebrated moderns, were fully fenfible of the advantages of encamping under the fhelter of wood. We learn from Vegetius, that their armies reforted to the cover of a wood, not lefs carefully, than that they avoided the vicinity of fwamps or marfhes. There are in 'reality various circum- ftances, which contribute to render fuch, fituations both healthy and agreeable. If troops are encamped in the body of a wood, the noxious effluvia, which may be carried by the winds from neighbouring fwamps, are ftopt in their progrefs; the lofty fhadp of the trees preferves the air cool and more refrefh- ing than the atrnofphere of the open country; while we know from experience, that moift and fwampy lands do not fend forth their noxious vapours, in any re- markable degree, unlefs where they are aaed upon by the heat of a powerful fun. I fhall only further obferve, with regard to the caufe of intermitting and remitting fevers, that a fpace of time almoft conftantly intervenes between expofure to the noxious effluvia, and the fubfequent appearance of the difeafe. It is not indeed uniformly the fame in all cafes, appearing to depend not only on the concentrated ftate in which the exhalation is APPENDIX. 27S applied to the body; but on the general aptitude of the individual, and the various occafional or exciting caufes, which facilitate or refill its operation. It was in a few inftances only, that I faw the difeafe appear before the feventh day. It was oftener the fourteenth, twentieth, or even longer. Upon the" whole I may remark, that feptenary periods has a confiderable power in influencing theJame of its appearance. Having offered a few obfervations in the preced- ing pages, on the diet, exercifes and choice of the quarters or encampments for troops in hot climates ; I fhall now add a few hints refpeaing medical care and management. It will probably be fuppofed, that no attention with refpea to this fubjea has been omitted. Regiments are provided with furgeon?, and armies have always been furnifhed with ample hof- pital eftablifhments. But this perhaps is not enoogh. It is neceffary that the duties of thefe ftations be well executed, as well as v/ell defigned. The office of furgeon to a regiment is an office of truft and of pri- mary importance; the appointment to it, however, does not feem in general to be fufficiently attended to. The furgeoncies of regiments, till lately, were allowed to be bought and fold; in confequence of which abufe, little oilier qualification, came to be re- quired, than the command of the purchafe money. Thus it often happened, that young men, who had attended acourfe of anatomical leaures, or walked the rounds of an hofpital f :>r a few months, came at once to be en rufted with thecare of the 1 i ves of fix or feven hundred foldiers, who, as they are raifed and maintained at a great expencc, deferve, on the fcore of economy, independent of every other confideration, to be well taken care of. It would be fuperfluous to ufe any arguments to prove the prodigality of committing the care of a regiment to men, who have not had profeflional experience in any country, and who are totally unacquainted with the difeafes of the countries 272 APPENDIX. to v/hich they are frequently fen'. If we are difpofed' to believe that there is any thing in medical treatment, we can fcarcely avoid making the conclufion, that many lives are loft from this caufe. It muft not be underftood, that I mean any thing direfpeaful to the furgeons of the army, by tin's infinuation. I know that a regiment is an excellent fchool for medical knowledge; and that the beft praaidoners have occa- fionally appeared in the army; but I wifh ftrongly to inculcate the propriety of obliging candidates for this office, to produce evidence of their qualification*, be- fore they are admitted to fuch an important tried. It is not enough, that a ycung man, who offers himfelf to take charge of the health of a regiment, fh.uld know to perform an operation with dexterby. Hand- ling a knife in reality is the leaft part of a regimental furgeon's duty. The office of phyfician is his daily employment, to execute which properly, both years and experience are requited. It certainly ought there- fore to be an ot;jea of concern wbh thofe who are entrufted with the office of fuperintending the medi- cal appointments of the army, that the candidates for fbrgeoncies be cbliged to fubmit to fuch trials, as may in fome degree afford proofs of their abilities. It would be a proper regulation, perhaps, that no man be permitted to propofe himfelf for the furgeoncy of a regiment, before he has arrived at fuch an a^e, as may have furniihed him with general experience; and furLher, that he give teftimony of aaual abilities' by the ireatment cf difeaes in an hofpital, under the infpeaion of an able phyfician, to whom the du.y will be p'tferibed to examine the mode of praaice with rigour. A trial of this fort might be better trufted to than the recommendatory It■ tor of a profeflbr; or even the diploma of Oxford or Edinburgh. There is not anything chimerical in the propofal. Nohfeo- in fhort is more praaicable; but it is fcarcely to be expcaed, diat men of talents and education will give* APPENDIX. 2 73 themfelves fo much trouble, that they may be admit- ted into a fervice which holds out few ad vantages. Thfc falary of regimental furgepns is fmall; and it is per- haps no paradox to fay, that this is a caufe of great expence to the nation. The bare fubfiftence, which the fervice affords, furnifhes no inducement for men of abilities to enter, at leaft to remain any length of time in the army, which unfortunately has been con- fidered in no other light, than as a place, where fur- geons may pafs their noviciate; but which they are generally difpofed to leave, as foon as they are quali- fied to execute the duty properly. Medical know- ledge is gained only by experience but independent of medical knowledge, an acquaintance with the ha- bits, charaaers and difpofitions of foldiers is a matter ©f fo great importances that old furgeons, even of in- ferior abilities as medical men, have generally been obferved to have a proportionably fmall lift of fick in their refpecjtivecorps. Thequalities that are principal- ly required in a regimental furgeoru exclwfive of medi- cal learning and knowledge, are acutenefs in difcern- ing the charaaers and difpofitions of men, and above all, boldnefs and decifion in the application of reme- dies. Life is often loft in unhealthy climates, by the dilatorinefs and timidity of common praaice. Having mentioned juft now, that there appears to be a remiffnefs in examining the qualifications that are requifite for the office of regimental furgeon, I might perhaps, with equal juftice, extend die re- mark to the appointments in the general hofpital.—• The power of appointing phyficians or furgeons in the hofpital, has generally been lodged with the com- manders in chief, and I might fay, without tranfgref- fino- the bounds of truth, that merit has not aiways been the beft claim for promotion. It would be in- vidious to be more particular in cenfuring what is pafled. It is only hoped, that the fubjea will be en- quired into, and fuch remedies applied, as will pre- 2 74 APPENDIX. elude fimilar abufes in future. The general hofpital has ever been a heavy article in the expences of war; and if it were fair to form an opinion of the whole, from the part which I have feen, I fhould not heu- tate in declaring, that the eftabiifhment is in a great meafare fuperfluous. I have no doubt, in obtaining the fuffrages of people of experience, that general hofpiuils are ruinous to military dtfcipline ; that they peoinote floth and indolence, the worft difeafe ta wench a foldier is liable, and that they extin<*uiih very fpeedily the ardour for the fervice of the fichJ.— There is in fact no exaggeration in the affertion, that the mail, who has fpent two or three months in a ge- neral hofpital, is lefs of a foldier than when he was firft recruited. It is only I may add by habits of ex- ercife, even by toils and fatigue, that men at laft at- tain the properties of good foldiers: while it is only by conftant praaice of fuch difeipline, that they are preferved in a ftate fit for the performance of their duties. Thefe active qualities are fosedilv extin- guished by the habits of floth and indolence, which prevail in general hofpitals; but betides this, it is likewife certain, that cures are often there protraaed' to months, which might have been accomplifhed in the courfe of a few days, if circumftances would have permitted the men to remain with their regiment^.—■ Regimental furgeons have many inducements to exert themfelves in reftoring their men fpeedily to health, which ait only with feeble power on thofe who have the management of general hofpitals. The former likewife poffefs fome advantages, of which the latter. are deftitute. They know the habit and difpofition* of the patient; they fee the difeafe in its firft begin- nings, and are enabled to feize the moft favourable moments for aaing with decifion. The above are confiderations, which ought to make us backward in removing fick foldiers to general hofpitals; I may add, that fuch is the nature of military difeafes, that APPENDIX. 27^ there does not, perhaps occur one cafe in twenty, which might not be treated properly by the furgeon of the regiment, if attention, and a very little expence were beftowed in providing neceffary accommodation. But befides that, the difeafes of foldiers are feldom of fuch a kind, that they might, not be treated properly by regimental furgeons, if government were at the expence of fupplying a few conveniencies. I may farther obferve, that together with the in- dolence naturally attached to general hofpitals, and uniformly hurtful to military difciphne, there is often > aaual danger to life, by removing men in critical fituations, or by the neceffary intermiffion of medi- cal affiftance, where continual and vigorous exer- tions are required The difeafes of hot climates, particularly the fevers of the Weft-Indies, are pften moft acute and rapid in their courfe. The fur- geon of a regiment perceives the approach of danger, and, fenfible that his fituation does not enable him to dojuftice to his patient, determines to remove him to the general hoiipitak But time is loft before this can be accompiiihed. It is feldom that any thing is done after it is deemed proper to fend a fick man away; neither does it commonly happen, th&C any thing material is attempted on the day on which lie is received. Thus one day at haft, fometirr es two? are completely loft in cafes, where every momentjs of confequence. Time is precious in the fevers of hot climates; and the deciiion or neglea of an hour often determines the fete of a patient. It is an obfervation, which cannot fail of.having frequently occurred to people who have ferved any time in the army, that it would be a very great ad- vantage to the fervice, if fick foldiers could always be taken care of by the refpe£tive furgeons of the regiment. I have endeavoured to fhew, that the plan is pra.L.cable and eafy; and I may further add, that the expence neceffary for fuch an arrangement, Ij6 APPENDIX. would not amount to one third of what is ufually {pent in general hofpital eftablifhments. If this idea were adopted, nothing more would be required, than that proper lodgings, proper provifions, and a fuffi- cient fupply of medicines, were furnifhed for the fick ; that the furgeon of the regiment be well qua- lified for his flation ; and that an infpeaor be ap- pointed for a certain portion of troops, to take care that the duty be well and diligently executed. By this means a general hofpital, as far as regards me- dical treatment, might be abolifhed, or at leaft greatly abridged. Where fighting was expeaed, extra-fur- gical affiftance would ftill be neceffary. Such an iufpeaion of regimental hofpitals, as that I have men- tioned, feems to be perfoaiy fufficient for the care of the health of an army, in ordinary occafions. The greateft precautions, however, ought to be taken, that theinfpeaion does not degenerate into a nominal duty. The infpeaor ought to vifit the different quarters, examine minutely into every article of the management of the hofpitals, and order that general reports be publifhed annually ; and that fome mark of approbation be bellowed upon thofe furgeons, who appear to have executed their duty with the greateft diligence and ability. It ought to be a concern of government, however, that no perfon be appointed to infpea regimental hofpitals, who is not well ac- quainted with the difeafes of the climate, in which the troops happen to ferve. —»-» NOTES. CHAP. I. THOUGH I have defcribed the endemic fever of Jamaica as diftinctiy as is in my power ; yet as I have often obferved that we attain more ac- curate ideas from the detail of a particular hilioey than from general defeription, I fhall feicct from my notes two or three cafes which may ferve to give a clearer .view of the different fpecies of the difeafe. And in the firft place I fhall dcferibe an inftance <-f fever, which was diftinguifhed through the whole .of its courfe by fymptoms of the general inflammatory diathesis. (i) Lennox, a foldier of the 5oth regorient, a~ed 40, of a firm and compaa habit of body, was feized on the 3d of December, between eight and nine irr the morning, with a flight horror or {V.verina;, pre- ceded and accompanied by other ufual marks of fever. The fymptoms of coldnefs and fhivering went oft in the courfe of eight or ten minutes. A hot fit fuc- ceeded, with a good deal of head-ach, hurried refpi- ration, confiderable thirft, a ftronr;, full, and frequent pulfe. After a conbnuance of four or-five ho:.'.:-*, fweat began to appear on the head and brea'l, which extending gradually to the extremity's brought vvich it a tolerable diftina remiffion of tho fever. 2. 'Fhe fever, appeared to be gone off very c.. n;i t 'v b • ten o'clock at night." Th? patient rd!„u *«. Ji.iag 2 NOTES. the night, and continued in this fame ftate of eafe till about five o'clock in the evening. He then became uneafy and reillefs, with head-ach and a flight feverifh heat. 5. The feverifh indifpofition declined in the courfe of the night. He became eafier towards morn- ing and about feven might be faid to be in a ftate of remiffion. About nine a paroxyfm commenced, fimi- lar to the paroxyfm of the firft day, though with a ftill flighter degree of horror and fhivering ; the hot fit ran ftill higher, with much head-ach, thirft, and a ftrono- vigorous pulfe. The fweating at laft made its appearance, and the violence of the fever declined : there ftill however remained fome degree of head- ach, pain of the back, and thirft, with an averfion to food, and a more than natural frequency of pulfe. 6. Rolled tolerably ; but ftill is not free from head- ach and pain of the back : the tongue is dry and foul, and the coat which covers it is fmocth, but of confi- derable thickncfe, and of a cream colour. About four in the evening the paroxyfm of a fever made its appearance, fimilar, in fome degree, to the paroxyfm of the fourth, but of a much greater degree .of vio- lence. It continued for eight hours, and declined gradually towards morning. 7. There were no per- ceivable marks of fever at feven in the morning. A little after nine, however, a paroxyfm commenced, fimilar, in every refpea, to the paroxyfm of the fifth. 8. About three in the afternoon a paroxyfm began fimilar to the paroxyfm of the fixth, but • ftill more violent. It declined after the ufual duration, and was fucceeded on the ninth by another paroxyfin fimilar to that of the feventh. The remiifion which fucceeded appeared to be ftill more perfea than any of the preceding ; the fweat was even more copious, and the pulfe became fofter and more expanded after it than it had hitherto done. 10. A paroxyfm re- turned about half paft tv/o, fimilar to the paroxyfnj of the eighth, but not lefs violent in degree. It termi- NOTES. 3 nated, however, in a more fluid and univerfal fweat; the pulfe and the ftate of the flcin returned perfectly to what they were in health ; the mucous coat fep.i- rated from the tongue ; the eye and countenance af- fumed their natural ferenity, and unequivocal marks of final crifis appeared on the morning of the eleventh. The above cafe is an inftance of the doublt tertian ; the fever of the even day terminated the difeafe ; and the pulfe through the whole courfe was vigorous and ftrong, or marks of inflammatory diathefis, in a mo- derate degree, were conftantly prefent. (2) Henley, a foldier of the 6.0th regiment, was feized on the 6th of May, about five in the evening, with a naufea,, or unpleafant affe_t,on at ftomach, marks of great languor and debility, a fli.oit feJing of coldnefs and horror, a very weak and frequent pulfe, head-ach, pain of the back, and other fynp- •toms which are ufual i,i the acceffion of fevers. After a continuance of ten or twelve hours, thefe fymptoms were fo far gone off, that the patient was confidered to be in a ftate of remirfion. 7. The exacerbation of the fever returned again about the fame hour in the evening'at which it had firft come on, though without marks of preceding coldnefs or fhiverim;. The pulfe was fmall, obfcure, and extremely frequent; the heat of the body was not increafed very mate- rially ; the thirft was only in a moderate degree, but th^re was much naufea, an averfioii to food, a difpo- fition to faint in an ereeet pofture, deep and heavy /igbin *, tremor of the tingue, and a fed and defpond- ing ftate of the eye and countenance. 8. The fymp- toms of fever abated towards morning, and a remif- fion, though by no means a diftina one, took place. The pulfe became fomewhat flower and more ex- panded ; the fighing and anxiety abated a little, and there was evidently a ftate of greater eafe ; though tiaere ftill remained marks of great debility, and figns Bb 2 4 - NOTES. of fpafmodic ftriaure on the furface of the body. The heat was lower than it ufually is in health. About five in the evening the fymptoms, which had prevailed in the former paroxyims, returned again, but with confiderable aggravation. The head was affbaed with delirium, and there was a confiderable degree of tr-emor and darting. 9. Eafier in the morning, tnoughthe rem i foon was in no degree more complete than the former. About the ufual hour in the even- ing the fame fymptoms returned with aggravation. 10. The renr.i'fion as the former; the heat of the body below natural; the pulfe obfcure and frequent; trie ngns of debility very great. The exacerbation returned again at the ufual hour ; the paroxyfm ap- peared to be fomewhat more violent ; the delirium was higher, the heat greater, and the pulfe acquired rather more fliength and fulnefs. 11. Eafier in the rrK.rnhier, with a remiffion in every refpea as complete a v e former ; the pulfe diftina, and rather more ex- panded ; and, upon the whole,an appearance of rather more 'vigour. The paroxyfm was renewed in the e/ening as ufual. 12. Remiffion in the morning raher more complete : more vigour in the pulfe. The exacerbation as ufual. 13. In the morning, iiiftead of the ufual remiffion, there appeared marks of-a complete and final crifis j the fighing, which had been troublefome throughout the courfe of the. difeafe, vanifhed ; the eye and countenance affumed t'vir ufual ferenity and ch.eei fulnefs ; the pulfe be- came flower, fofter, and more expanded; and the tongue parted with its coat or covering. The r.bove »s an inftance of fever with fymptoms of ner- vous affedion. (3) Sergeant Negli, on the 2d of November, about eight in the morning, was feized with horror, fliiv'tring, and other Symptoms, which are ufual in the acceiiion oj fevers. The hot fit did not run very NOTES. 5 high, and before evening the paroxyfm was confi- derably abated. 3. This patient is now in the ftate of remiffion, the hert of the body is not greater than natural; but the cafe feems to be attended with feme,. fymptoms which are not very common in the fevers of this country. The countenance is clouded, dark, and grim ; the appearance of the eye is fad and defponding ; and he expreffes an uneafinefs in his feelings which is not eafily accounted for. 4. The paroxyfm returned about four in the morning. It was greatly more violent than the preceding ; and" though it might be faid to remit very completely, if we judge by the heat of the body and ftate of the pulfe; yet there ftill remained fome uncommon and unpleafant feelings. The eye and countenance were not only dark and defponding, but the tongue was covered with a flimy mucous coat, through which the red furface appeared obfeurely ; there were ftrange and unaccountable twitchings of the ftomach and Bowels, difturbed fleep, frightful dreams, and fore- boding apprehenfions. 5. A paroxyfm came on this evening near twelve hours fooner than it was ex- peaed. After expreffing an eafinefs at ftomach, and throwing up fome matter of a dark colour, he was fuddenly feized with a ftupor and infe nihility, from which he could not be roufed by all the applications of art. He died in about fixteen hours. This cafe affords an inftance of fever with marks of a peculiar malignity. The appearances of danger were fudden and unexpeaed ; and, as it was among the firft in- ftances of the kind which I had feen, I was difap- pointed, and in fome degree confounded at the event.. (4) Thomfon a young man aged twenty, after more than ufual exercife in the heat of the fun, was feized with ficknefs, fhiverings, and other figns of fever, about nine o'clock in the morning of the 3J of February. The pulfe was hard, frequent, and* B b 3 6 ' NOTES. irritated ; the eye was fad, and fometimes gliftening} the countenance flufhed, but rather dark and over- eaft; the refpiration hurried; naufea was troublefomej with a good deal of anxiety and reftleffnefs. The parox} feei continued long, and did not indeed go ofF very perfoaiy at laft. 4. Refted but indifferently; is now fomewhat eafier, though the remiffion is far from being perfea ; the thirft is confiderable; the tongue dry and foul, the ftomach loathes all forts of food ; and he feems to be much diftreffed with flatus and ruaus ; the ftools are dark-coloured and foetid; the pulfe is more frequent than natural, hard and ir- ritated, and the flcin is only partially moift. 5. An exacerbation of fever happened about nine in the morning. The^fymptoms were of the fame kind as in the firft paroxyfm, only fomewhat more violent in degree. The anxiety at ftomach was particularly diftreffing,and there appeared ftill more evident marks of putrefcent tendency in the alimentary canal. 6. An tmeafy night: an impcrfea and obfcure remiffion : the gums redder than they naturally are: the eye has a gliftening appearance, and the countenance is ftill confufed and clouded : the tongue is dry ; the thirft great; and ruaus and flatus are very diilreffing: the pulfe ftill irritated and quick : there is not any very remarkable difpofition to faint in an erea pof- ture : the ftools foetid. 7. The exacerbation returned about the fame hour as on the fifth, and with ftill greater aggravation : die fymptorrs of diftrefs in the ftomach and bowels were particularly alarming; rrith naufea, niaorofe belchings, and large watery foetid ftools. 8. Somewhat eafier in the morning, though the remiffion can only be faid to be obfcure. 9. The exacerbation happened r t the fame hour as on the: feventh, and continued for nearly the fame length of time. 10. Inftead of obfcure remiffion, marks of final crifis are now evident; the puife is returned nearly to its natural ftates the eye and NOTES. 7 Countenance have affumed their ufual ferenity; the fkin is moift, and gives no marks Of remaining fpaf- modic ftriaure; the anxiety and ruaus have ceafed ; and the ftate of the ftomach and bowels appears to be almoft natural. The above is an inftance of fever, in which there were very evident figns of pu- trefcent tendency in the alimentary canal; even fome obfcure marks of its progrefs in the general fyftem, complicated, however, with an irritated ftate of the vafcular fyftem, or fuch fymptoms as might be con- fidered as belonging to the apparent inflammatory diathefis. (6) Cunningham, a failor, aged twenty-five, was feized on the 5th of July, about five in the evening, with ficknefs, fhiverings, head-ach, and the other ufual figns of the remitting fever of the country. Its more diftreffing fymptoms were naufea and vomiting. 6. The remiffion is tolerably diftina; but there is ftill a good deal of head-ach, thirft, and figns of debility ; the tongue is dry, and the pulfe^is more frequent than natural. The paroxyfm 'returned about five in the evening with increafed vio- lence, accompanied with fevere retching, and copious vomiting of bilious matter. 7. Better in the morn- ing ; the vomiting has ceafed, and the remiffion is tolerably diftina. The exacerbation returned at the ufual hour, with the fame diftinguifhing fymp- toms of copious bilious difcharges. 8. Remiffion in the morning as ufual; the exacerbation in the even- ing as the preceding, with diftreffing and fevere vo- miting. 9. The ufual remiffion in the morning. The paroxyfm likewife recurred in the evening about the ufual time, but'not with the ufual fymptoms. Inftead of vomiting of bilious matters, there was fome degree of delirium, tremors, ftartings, and other fymptoms of nervous affeaion. 10. Thefe fymptoms remitted in the morning, but there ftill 8 NOTES. remained figns of great irritability and weaknefs. The fame train of fymptoms returned again in the evening: the delirium and tremors were ftill in a higher degree ; the pulfe was fmall and frequent ; and there was occafionally a great difpofition to faint in an erea pofture. n. Better in the morning, though there are not yet any marks of crifis. The exacerbation returned again in the evening, with fymptoms fimilar to thofe of the preceding paroxyfm. 12. Remiffion in the morning fimilar to the former. Exacerbation in the evening rather more violent. 13. Remiffion as the former ; the pulfe however ap- pears to be rather fuller than it has been fince this change happened in the circumftances of the difeafe. The paroxyfm returned at the ufual hour ftill more violent, though with greater marks of vafcular ex- citement. 14. Evident marks of crifis : the tongue begins to part with its covering ; the eye and coun- tenance appear clear and animated ; the pulfe is flower and fuller ; and the ftate of the fkin does not give any indication of exifting fpafmodic ftriaure. This cafe prefents an inftance of fever, the firft part of the courfe of which was diftinguifhed by uncom- mon bilious difcharges during the time of the pa- roxyfms ; the latter part of it by affeaion of the ner,- vous fyftem. NOTES. 9 CHAP. II. I. As I mentioned before that we attain more ac- curate ideas from the detail of particular cafes than from general hiftories ; I therefore relate the method of cure, which was purfued in thofe examples which are defcribed in the fixth chapter. i. Lennox.— On the 4th of December, or fecond dayof the difeafe, the folution of falts with a fmall por- tion of emetic tartar was given by a wine glafs full at a time, till it operated plentifully. 5. Some powders of nitre and camphire. 6. Two fcruples of bark were given every two hours during the remiffion, with an injuriaion that the nitrous powders be repeated dur- ing the time of the paroxyfm. Ii. The above plan was perfifted in till marks of crifis appeared. Not more than one ounce of bark was given during all the remiffions. 2. Henley. 7. The ufual folution of falts was given, but without any addition of emetic tartar. It operated plentifully. 8. The bark was begun this morning, with injunaions that it be adminiftered every two hours during the remiffions. g. A blif- ter was applied to the back of the head and neck, with a bolus of camphire, opium, and valerian. Wine was ordered, together with the bark, as foon as the remiffion fhould begin to appear. This plan was perfifted in till the crifis arrived, which was on the 13th. 3. Negli. The patient was purged on- the 3d with the ufual folution of falts, to which was added fo confiderable a portion of emetic tartar, that it like- wife operated by vomit. 4. Bark was given in the fO NOTES. ufual quantity, and at the ufual intervals. 5. As foon as the fever came on, blifters were applied to the head, and likewife to the legs; but they produced no perceivable effea. The patient died, and probably fell a facrifice to the difeafe, from my not having early enough perceived the malignity of its nature. 4. Tbompfon. 4th, The folution of falts with eme- tic tartar was adminiftered in the prefent cafe as it had be. n done in the others. It operated plentifully, but bad no material effea upon the difeafe. 5. Sa- line draughts in the flate of effervefcence were given frequently. Bark and wine were ordered in the re- miffion?, with as much lemonade as the patient chofe to d ink. 9. Glyfters or cold water, impregnated with fixed air, were employed two or three times widi apparent benefit. 10. '1 he bark, wine, and la- line draughts were given liberally, yet notwithftand- ing, the difea e feemed to complete its natural courfe* 5. Cunningbem.---6. The naufea and vomit- ing were fo diftreffing in the firft paroxyfm, that, in compliai.ee with the patent's eariieft entreaties, I con.'eiited ■:b give an erne ic. 7. The fymptoms were aggravated, and the emetic wa« repeated but without advantage. 9. An.-cynec were given during the pa- rex)im veidi valine draughts in the aa of effervef- cence. They m •derated the vomiting but did not enti.ely temove it. Biifters were applied to the head and legr.; ba .< and wine were given in confiderable quantity; but the difeaie continued till the 14th with- out material alteration. NOTES. XI CHAP. III. r. As the cold bathing, which I have fo ftrongly recommended in the cure of fevers, has an exterior appearance of being a rafh and hazardous remedy, I fhall relate fome cafes which may enable the reader to judge more precifely of its real effeas. Cold-bath- ing I may remark, appears to have been occafionally employed by the Greek and Roman phyficians, after the time of the Emperor Auguft us ; but I was only a young man when I went out to the Weft-Indies, and cannot pretend to fay that I v/as acquainted with the writings of thofe phyficians, or thai I poffeffed much knowledge of difeafes, except the little that could be retained from a curfory hearing of univerfity feaures. The firft hints of this praaice were there- fore accidental, and arofe from a converfation I had with the mafter of the veffel, in which I went paf- fenger. This perfon commanded a tranfport in the war 1756, and was prefent at the fiege of, the Ha- vannah. As he was talking one day of the ftate of die fleet, he mentioned accidently, that fome mefi were fent aboard of his fhip ill of fevers; feveral of whom, he obferved, jumped into the fea during the dilirium which attended the paroxyfms of the difeafe. Some of them, as might beexpeaed, were drowned; but the moft part of thofe who were recovered from the waves appeared to be greatly benefited by the ducking. The faft, which, from the veracity of the man, I thought I could depend upon, ftruck me ftrongly, and I refoived, in my own mind, to bring it to the teft of experiment as foon as an opportunity fhould offer: neither was it long after my arrival in Jamaica, that I had occafion to vifit a failor whofe fituation feemed to juilify fuch a trial. The poor 12 NOTES. » man was aboard of a fhip, which lay at anchor about a mile from the fhore. He hid been ill two days ; the delkium ran high; his eyes were red and inflam- ed; his refpiration was hurried; he was anxious and refllefs in a high degree, whilft together with thofe marks of excitement, he was occafionally languid and difpofed to faint. His fkin being dirty furnifhed an oftenfible excufe for trying this remedy. But it was previoufly thought proper to draw fome blood from the arm; which being done, fome buckets of fait water were daflied on the fhoulders. He was now laid in bed: a copious fweat enfued, fucceeded by a diftina remiffion, and a total change in the nature of the fymptoms. The fuccefs I met with in this in- ftance was more than I had expeaed ; I was there- fore encouraged to try the fame mode of bathing in a perfon who came under my-care fome weeks there- after, and who had been ill of a fever fix or feven days. This patient had been bled and bliftered;--- emetics and cathartics had been likewife employed, and bark had been given in the ufual manner, for the three laft days. The fever, however, had now in a great meafure loft its type. The man was low and languid; his eyes were dim; his vifion indiftina ;—- his pulfe was fmall and frequent, and, when the head was raifed from the pillow, not to be felt. Though it did not appear that he could reafonably be expea«d to live long, I ftill wifhed to get him conveyed to the deck, that a trial might be made of the effeas of cold bathing; but the fituation was fo ticklifh, that I felt fome uneafinefs in fetting about it. At laft he was lifted through the hatch-way in a blanket, though I muft confefs that I was not without apprehenfions that he might die under my hands. Some wine was then poured down his throat; and he was fprinkled with cold fait water, as he lay on the deck. Ap- pearing to be fomewhat invigorated by this procefs, he was raifed up very gently, and feveral buckets of NOTES. 13 the fea-water were dafhed about his head and fhoul- ders. He was then laid in bed; the pulfe foon became large and full. I left him in a copious fweat, and ■Was agreeably furprfed next day to find"him fitting on the deck, to which he had walked on his own feet. I fliall only mention another inftance of the good ef- feas of cold bathing in the fevers of the Weft-Indies, which is perhaps more dccifive than either of the for- mer. A boy, aged fourteen, had been ill of a fever feven or eight days. Nodiing. had been omitted, in f>oint of treatment, which is ufual tobedo.ie in iimi- ar cafes. Bark and wine had been carried as far as could be ferviceable, or even fafe; yet death feemed to be approaching faft. The fuccefs of cold bathinj, in fome inftances fimilar to the prefent, fo far ex- ceeded my expeaation that I was induced to make trial of it in the cafe before me, though I was not altogether without apprehenfions that death might be the confequence of the attempt. The bufinefs, how- ever, was accomplifhed without accident; and next day the boy was able, not only to fit up in bed, hut even to walk over the floor. After inftances fo ^unequivocal as the above, it would.be fuperfiuous to mention any others. I fnnll only add, that I have tried the remedy, in various fituations, alwey-, with fafety, generally with aftonifhing fuccefs; fo that I cannot forbear recommending it even at an early pe- riod, in the fevers of the Weft-Indies. It commu- nicates tone and vigour to the powers ot life, and di- minifhes irritability in a degree far fuperior to all other cordials or fodatives. The bathing was mar. -grd in the following manner: the water, v/hich va> re- quired to be of a refreihing degree of coolnefe, was generally dafhed by means of a bucket on the head and fhoulders. It was likewife found that its good effeas were heightened, in fome cafes, by previous bleeding and by the previous ufe of warm bathing. This may feem a raJi praaice to thofe who argue 14 NOTES. without experience ; but, fetting afide the authority of the ancients, we find it confirmed by the example of a perfon who was not a phyfician, and who, theie- fore may be fuppofed to be lefs under the influence of a favourite opinion from which he might be led to difguife the truth. Bufbequius, who was fent on an embaffy to Soliman the Great, was obliged to travel to Amafia, where the Sultan then fojourned. In his return home he was feized with a continued fever, and very feverely harraflbd by it. The difeafe gained fo much ground during the journey, -that he found it neceffary to flop at Conftantinople eo attend to the recovery of his* health. The praaice which was adopted to effea this may appear to be fingular, and by many, perhaps, will be thought to be hazardous and rafh. He mentions, that, after enjoying the luxury of warm bathing, he was fuddenly fprinkled with cold water. His words are, " Idem, fcilicet, Quaquelbenus me a balneo exeuntem frigida perfun- debat, quae res etfi erat molefta, tamcn magnopere juvabat." ( Iter. Conftant. p.") His phyfician, Qua- quelbenus, who feems to have been a man of excel- lent judgment and careful obfervation, had probably learnt the practice in his travels in Afia, as it does not appear to have been commonly known in Europe at that time. NOTES. *5 CHAP. IV. I. But befides thefe teftimonies of phyficians, in favour of the practice of drenching with cold water, the memoirs of Daron Trenck furnifh us with a cu- rious and very convincing proof of the efficacy of this remedy, in extinguiib.ir._r, almoft like a charm, the violence of a burning fever. The Baron, when ill of a fever in the prifon at Madgcborough, unfortu- nately broke the pitcher which contained his daily allowance of water. The fever was violent, and he fuffered the rn^ft inexpreffiblc torments of thirft, for the fpace of twenty-four hours. When the ufual fupply was brought to him next day, he feized the pitcher with eagernefs, and drank the water with fuch avidity, and in fo great quantity as is fcarcely cre- dible. The confequence was a total removal of the difeafe. To this I might add an inftance, which hap- pened to myfelf at Savanna in Georgia, in the y.ar J/79- In the exceffive hot weather of the iron h of July, I was feized with the endemic of the country, in a more violent degree than was commonly feen. In the third paroxyfm of the difeafe, my defire for cold water was ravenous. A pitcher cf it was drawn from the pump, which I drank off inftantly without the leaft abatement of the thirft. The draught was repeated in a few minutes, in quantity not lefs than a quart. The thirft v/as ef b.ftually quenched, and the fever feemed to vanifh. But though the fever appeared to be extinguifhed a? it were by a charm ; yet the ftomach and hypochondria became diftended, yellownefs of the eye and countenance fucceeded, with a confiderable degree of debility which remained for two or three days. I muft, however, remark with regard to this cafe, that the effeas were not the feiiie aa^they have been ufually reported to be by 16 NOTES. authors. The fever was extinguifhed ; but neithep vomiting, fweat, or any other fenfible evacuation enfui J. The ancient?, I may further obferve, feem to have adminiftered cold drink only in the advanced ftate of fever, when figns of coaion began to ap- pear; in which cafe, it is impoffible to form a certain opinion of its pfecife fuccefs. That cold water may be employed with effea, it is neceffary that the thirft be intenfe, perhaps that it be purpofely provoked, and that it be fully and completely fatiated. If managed in this manner, it probably will not often fail of extin- guishing the fever ; yet I muft not omit to mention, that unlefs it is managed with a great deal of caution and judgment, it may alfo often irrecoverably extin- guifh the powers of life.' 2. In fupport of this opinion, I fhall mention ft cafe, which fell under my own obfervation about a twelvemonth ago. I was called to a young man, a failor, ill of a fever of a very dangerous and alarming kind. It was the eighth day of the difeafe before I faw him. He had not been hitherto in the leaft be- nefited by any thing that was tried ; neither did any remedy which I could think of, though employed with almoft defperate boldnefs, in any degree check the progrefs of the difeafe. The power of fpeech was loft, and even fwallowing was performed"with difficulty; the eye was languid, nay almoft without motion ; the countenance was ghaftly; and many livid fpots, fome of them nearly the fize of a fix-pence, made their appearance on different parts of the body. I propofed bathing, and the friends of the young man, coniidering the fituation as defperate, confented that I fhould make a trial of it; more, perhaps, to comply with my defire, than from expeaation of any benefit that might refult from it. But in fetting about it, it unfoitunately happened, that an utenfil proper for the purpofe could not be procured, fo that NOTES. 17 we were compelled to be contented with a general fomentation. This was applied in as complete a manner as circumftances would permit. A blanket was foaked in warm fait water, and the body was wrapped in it from head to foot. In a fhort time the fkin became foft and warm, fweat began to flow ; the eye and countenance began to refume their anima- tion, which had been almoft extinguifhed, the pulfe rofe ; fwallowing was performed with lefs difficulty ; and next day the colour of the fpots was evidently brighter. So far the change was favourable ; but a regular fupply of wine and cordials having been nc- gfeaed during the following night, the pulfe funk, and things returned nearly to their former fituation. The fomentation was again repeated, in confequence of which the extremities and furface of the fkin be- came warm and moift, an effea which was no fooner produced, than the blanket was fudd.uly removed, and the face and breaft, particularly, were fprinkled with cold water, in which a large portion of felt was diffolved. The cold had the effea to caufe the patient to fhrink at the firft, yet in a fhort time be appeared to be refrefhed very remarkably. The powers of life grew gradually ftronger ; though the marks of crifis were not very evident for feveral de.ye. To the above I might add fome other inftances, v/h^re effeas Were fimilar; but I avoid fwelling the notes to too great extent, by entering into particular details. I fliall therefore only obferve in general, that cold "bathing was ufually of fervice. ft imparted general tone and vigour to the powers of life, and by increaf- ing the activity of the vafcular fyftem, probably fometimes rendered the crifis complete, where it na- tural iy would not have been fo ; but I cannot venture to fay that 1 ever carried it fo far that the difeafe could be faid to be precipitately extinguifhed by it. Cc 3 I x'8 1 NOTES TO THE CHAPTER UPON YELLOW FEVER. (fl)TN compliance with the language of medical J_ authors, I have defcribed the following difeafe under the name of Yellow Fever, though I am per- foaiy fenfible, that the appellation is not by any means proper. There are fome inftances of the difeafe perhaps where yellownefs does not at all appear, and in no one does it ordinarily fhew itfelf till the latter ftages. I know alfo that moft of the praai- tioners of Jamaica confider it only as an aggravated fpecies of the remittent; the common endemic of hot climate?. It appeared to me I muft confefs in a dif- ferent light ; but I fliall attempt to deferibe the two difeafes accurately, and leave it to the reader to judge for himfelf. It may not however be improper in this place to take notice of the opinion of Dr. Mofeley. Dr. iVlofelcy has lately written a treatife on this difeafey and endeavoured to perfuade us that it is no other than the Kucroc, or ardent fever of the ancients. But the yellow fever ofthe Weft-Indies,by Dr. Mofeley's own confeffion,is in fomemanner peculiar to ftranger* ne.vly arrived in tropical climates. The k«kto« we are informed, made its appearance in the iflands ofthe Archipelago, and on the coafts of the contiguoui continents jindifuiaunateJy among men and women, NOTES. 19 natives or foreigners : in fea it has not, as far as I can perceive, any claim to be confidered as a diftinft fpecies of difeafe. If I rightly underftand the fpirit of Hippocrates, or the defeription of the ftill more accurate Aretaeus, k«v '■■■ '"> It-