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MEDICAL INQUIRIES
AND
OBSERVATIONS.

BY BENJAMIN RUSH, M. D.
PROFESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINE, AND OF CLINICAL PRACTICE, IN THE UNIVERSITY OF PENNSYLVANIA.
IN FOUR VOLUMES.
VOL. III.
THE SECOND EDITION,
REVISED AND ENLARGED BY THE AUTHOR.
PHILADELPHIA,
PUBLISHED BY J. CONRAD & CO. CHESNUT-STREET, PHILADELPHIA; M. & J. CONRAD & CO. MARKET-STREET, BALTIMORE; RAPIN, CONRAD, & CO. WASHINGTON; SOMERVELL & CONRAD, PETERSBURG; AND BONSAL, CONRAD, & CO. NORFOLK.
PRINTED BY T. & G. PALMER, 116, HIGH-STREET.
1805.

CONTENTS OF VOLUME III.

OUTLINES
OF A
THEORY OF FEVER.

As many of the diseases which are the subjects of these volumes belong to the class of fevers, the following remarks upon their theory are intended to render the principles and language I have adopted, in the history of their causes, symptoms, and cure, intelligible to the reader.

I am aware that this theory will suffer by being published in a detached state from the general view of the proximate cause of disease which I have taught in my lectures upon pathology, as well as from its being deprived of that support which it would receive from being accompanied with an account of the remedies for fever, and the times and manner of exhibiting them, all of which would have served to illustrate and establish the facts and reasonings which are to follow upon this difficult and interesting inquiry.

I shall not attempt to give a definition of fever. It appears in so many different forms, that a just view of it can only be given in a minute detail of all its symptoms and states.

In order to render the theory, which I am about to deliver, more simple and intelligible, it will be necessary to premise a few general propositions.

I. Fevers of all kinds are preceded by general debility. This debility is natural or accidental. The former is the effect of the sanguineous temperament, and exists at all times in many constitutions. The latter is induced,

1. By such preternatural or unusual stimuli, as, after first elevating the excitement of the system above its healthy grade, and thereby wasting a part of its strength, or what Dr. Brown calls excitability, and Darwin sensorial power, afterwards reduces it down to that state which I shall call debility of action. Or,

2. It is induced by such an abstraction of natural stimuli as to reduce the system below its healthy grade of excitement, and thereby to induce what Dr. Brown calls direct debility, but what I shall call debility from abstraction. This general debility is the same, whether brought on by the former or the latter causes. When induced by the latter, the system becomes more excitable than when induced by the former causes, and hence an attack of fever is more frequently invited by it, than by that state of debility which succeeds the application of an undue portion of stimulating powers. To this there is an exception, and that is, when the remote causes of fever act with so much force and rapidity as suddenly to depress the system, without an intermediate elevation of it, and before sufficient time is given to expend any part of its strength or excitability, or to produce the debility of action. The system in this state, is exactly similar to that which arises from a sudden reduction of its healthy excitement, by the abstraction of stimuli. This debility from abstraction, moreover, is upon a footing with the debility from action, when it is of a chronic nature. They both alike expend so much of the quality or substance of excitability, as to leave the system in a state in which irritants are seldom able to excite the commotions of fever, and when they do, it is of a feeble nature, and hence we observe persons who have been long exposed to debilitating causes of both kinds, often escape fevers, while those who are recently debilitated, are affected by them, under the same circumstances of exposure to those causes.

That fevers are preceded by general debility I infer from their causes, all of which act by reducing the excitement of the system, by the abstraction of stimuli, or by their excessive or unusual application. The causes which operate in the former way are,

1. Cold. This is universally acknowledged to be a predisposing cause of fever. That it debilitates, I infer, 1. From the languor which is observed in the inhabitants of cold countries, and from the weakness which is felt in labour or exercise in cold weather. 2. From the effects of experiments, which prove, that cold air and cold water lessen the force and frequency of the pulse.

2. The debilitating passions of fear, grief, and despair.

3. All excessive evacuations, whether by the bowels, blood-vessels, pores, or urinary passages.

4. Famine, or the abstraction of the usual quantity of nourishing food.

The causes which predispose to fever by the excessive or unusual application of stimuli are,

1. Heat. Hence the greater frequency of fevers in warm climates, and in warm weather.

2. Intemperance in eating and drinking.

3. Unusual labour or exercise.

4. Violent emotions, and stimulating passions of the mind.

5. Certain causes which act by over-stretching a part, or the whole of the body, such as lifting heavy weights, external violence acting mechanically in wounding, bruising, or compressing particular parts, extraneous substances acting by their bulk or gravity, burning, and the like[1]. The influence of debility in predisposing to fevers is further evident from their attacking so often in the night, a time when the system is more weak than at any other, in the four and twenty hours.

II. Debility being thus formed in the system, by the causes which have been enumerated, a sudden accumulation of excitability takes place, whereby a predisposition is created to fever. The French writers have lately called this predisposition “vibratility,” by which they mean a liableness in it to be thrown into vibrations or motions, from pre-existing debility. It is not always necessary that a fever should follow this state of predisposition. Many people pass days and weeks under it, without being attacked by a fever, by carefully or accidentally avoiding the application of additional stimuli or irritants to their bodies: but the space between this state of predisposition, when it is recent, and a fever, is a very small one; for, independently of additional stimuli, the common impressions which support life sometimes become irritants, and readily add another link to the chain of causes which induce fever, and that is,

III. Depression of the whole system, or what Dr. Brown calls indirect debility. It manifests itself in weakness of the limbs, inability to stand or walk without pain, or a sense of fatigue, a dry, cool, or cold skin, chilliness, a shrinking of the hands and face, and a weak or quick pulse. These symptoms characterize what I have called in my lectures the forming state of fever. It is not necessary that a paroxysm of fever should follow this depressed state of the system, any more than the debility that has been described. Many people, by rest, or by means of gentle remedies, prevent its formation; but where these are neglected, and the action of stimuli, whether morbid or natural, are continued,

IV. Re-action is induced, and in this re-action, according to its greater or less force and extent, consist the different degrees of fever. It is of an irregular or a convulsive nature. In common cases, it is seated primarily in the blood-vessels, and particularly in the arteries. These pervade every part of the body. They terminate upon its whole surface, in which I include the lungs and alimentary canal, as well as the skin. They are the outposts of the system, in consequence of which they are most exposed to cold, heat, intemperance, and all the other external and internal, remote and exciting causes of fever, and are first roused into resistance by them.

Let it not be thought, from these allusions, that I admit Dr. Cullen's supposed vires naturæ medicatrices to have the least agency in this re-action of the blood-vessels. I believe it to be altogether the effect of their elastic and muscular texture, and that it is as simply mechanical as motion from impressions upon other kinds of matter.

That the blood-vessels possess muscular fibres, and that their irritability or disposition to motion depends upon them, has been demonstrated by Dr. Vasschuer and Mr. John Hunter, by many experiments. It has since been proved by Spallanzani, in an attempt to refute it. Even Dr. Haller, who denies the muscularity and irritability of the blood-vessels, implies an assent to them in the following words: “There are nerves which descend for a long way together through the surface of the artery, and at last vanish in the cellular substance of the vessel, of which we have a specimen in the external and internal carotids, and in the arch of the aorta; and from these do not the arteries seem to derive a muscular and convulsive force very different from that of their simple elasticity? Does not it show itself plainly in fevers, faintings, palsies, consumptions, and passions of the mind[2]?”

The re-action or morbid excitement of the arteries discovers itself in preternatural force, or frequency in their pulsations. In ordinary fever, it is equally diffused throughout the whole sanguiferous system, for the heart and arteries are so intimately connected, that, like the bells of the Jewish high-priest, when one of them is touched, they all vibrate in unison with each other. To this remark there are some exceptions.

1. The arteries are sometimes affected with great morbid excitement, while the natural functions of the heart are unimpaired. This occurs in those states of fever in which patients are able to sit up, and even to walk about, as in pulmonary consumption, and in hectic fever from all its causes.

2. The heart and pulmonary artery are sometimes affected with great morbid excitement, while the pulsations of the arteries on the wrists are perfectly natural.

3. The morbid excitement of the arteries is sometimes greater on one side of the body than on the other. This is obvious in the difference in the number and force of the pulsations in the different arms, and in the different and opposite appearances of the blood drawn from their veins, under equal circumstances.

4. The arteries in the head, lungs, and abdominal viscera are sometimes excited in a high degree, while the arteries in the extremities exhibit marks of a feeble morbid action. Fevers attended with these and other deviations from their common phenomena, have been called by Dr. Alibert, altaxiques. They occur most frequently in malignant fevers.

While morbid excitement thus pervades generally or partially the sanguiferous system, depression and debility are increased in the alimentary canal, and in the nervous and muscular systems. In the stomach, bowels, and muscles, this debility is occasioned by their excitement being abstracted, and translated to the blood-vessels.

I shall now endeavour to illustrate the propositions which have been delivered, by taking notice of the manner in which fevers are produced by some of its most obvious and common causes.

Has the body been debilitated by exposure to the cold air? its excitability is thereby increased, and heat acts upon it with an accumulated force: hence the frequency of catarrhs, pleurisies, and other inflammatory fevers in the spring, after a cold winter; and of bilious remittents in the autumn, when warm days succeed to cold and damp nights. These diseases are seldom felt for the first time in the open air, but generally after the body has been exposed to cold, and afterwards to the heat of a warm room or a warm bed. Mild intermittents have frequently been observed to acquire an inflammatory type in the Pennsylvania hospital, in the months of November and December, from the heat of the stove rooms acting upon bodies previously debilitated and rendered excitable by cold and disease.

Has there been an abstraction of heat by a sudden shifting of the wind from the south-west to the north-west or north-east points of the compass, or by a cold night succeeding to a warm day? a fever is thereby frequently excited. These sources of fever occur every autumn in Philadelphia. The miasmata which exist in the body at that time in a harmless state, are excited into action, in a manner to be mentioned presently, by the debility from cold, aided in the latter case by the inaction of sleep, suddenly induced upon the system.

Again: has the body been suddenly debilitated by labour or exercise? its excitement is thereby diminished, but its excitability is increased in such a manner that a full meal, or an intemperate glass of wine, if taken immediately after the fatigue is induced upon the body, excites a fever: hence the frequency of fevers in persons upon their return from hunting, surveying, long rides, or from a camp life.

But how shall we account for the production of fever from the measles and small-pox, which attack so uniformly, and without predisposing debility from any of its causes which have been enumerated? I answer, that the contagions of those diseases seldom act so as to produce fever, until the system is first depressed. This is obvious from their being preceded by languor, and all the other symptoms formerly mentioned, which constitute the forming state of fever. The miasmata which induce the plague and yellow fever, when they are not preceded by the usual debilitating and predisposing causes, generally induce the same depression of the system, previously to their exciting fever. Even wounds, and other local irritants seldom induce fever before they have first produced the symptoms of depression formerly mentioned. I shall presently mention the exceptions to this mode of producing fever from contagious miasmata and local injuries, and show that they do not militate against the truth of the general proposition that has been delivered.

It may serve still further to throw light upon this part of our subject to take notice of the difference between the action of stimuli upon the body predisposed by debility and excitability to fever, and their action upon it when there is no such predisposition to fever.

In health there is a constant and just proportion between the degrees of excitement and excitability, and the force of stimuli. But this is not the case in a predisposition to a fever. The ratio between the action of stimuli and excitement, and excitability is destroyed; and hence the former act upon the latter with a force which produces irregular action, or a convulsion in the arterial system. When the body is debilitated, and its excitability increased, either by fear, darkness, or silence, a sudden noise occasions a short convulsion. We awake, in like manner, in a light convulsion, from the sudden opening of a door, or from the sprinkling of a few drops of water in the face, after the excitability of the system has been accumulated by a night's sleep. In a word, it seems to be a law of the system, that stimulus, in an over-proportion to excitability, either produces convulsion, or goes so far beyond it, as to destroy motion altogether in death.

V. There is but one exciting cause of fever, and that is stimulus. Heat, alternating with cold[3], marsh and human miasmata, contagions and poisons of all kinds, intemperance, passions of the mind, bruises, burns, and the like, all act by a stimulating power only, in producing fever. This proposition is of great application, inasmuch as it cuts the sinews of the division of diseases from their remote causes. Thus it establishes the sameness of a pleurisy, whether it be excited by heat succeeding cold, or by the contagions of the small-pox and measles, or by the miasmata of the yellow fever.

To this proposition there is a seeming objection. Cold, sleep, immoderate evacuations, and the debilitating passions of grief and fear (all of which abstract excitement) appear to induce fever without the interposition of a stimulus. In all these cases, the sudden abstraction of excitement destroys the equilibrium of the system, by which means the blood is diverted from its natural channels, and by acting with preternatural force in its new directions, becomes an irritant to the blood-vessels, and thus a stimulating and exciting cause of fever. When it is induced by cold alone, it is probable so much of the perspirable matter may be retained as to co-operate, by its irritating qualities, in exciting the fever.

VI. There is but one fever. However different the predisposing, remote, or exciting causes of fever may be, whether debility from abstraction or action, whether heat or cold succeeding to each other, whether marsh or human miasmata, whether intemperance, a fright, or a fall, still I repeat, there can be but one fever. I found this proposition upon all the supposed variety of fevers having but one proximate cause. Thus fire is a unit, whether it be produced by friction, percussion, electricity, fermentation, or by a piece of wood or coal in a state of inflammation.

VII. All ordinary fever being seated in the blood-vessels, it follows, of course, that all those local affections we call pleurisy, angina, phrenitis, internal dropsy of the brain, pulmonary consumption, and inflammation of the liver, stomach, bowels, and limbs, are symptoms only of an original and primary disease in the sanguiferous system. The truth of this proposition is obvious from the above local affections succeeding primary fever, and from their alternating so frequently with each other. I except from this remark those cases of primary affections of the viscera which are produced by local injuries, and which, after a while, bring the whole sanguiferous system into sympathy. These cases are uncommon, amounting, probably, to not more than one in a hundred of all the cases of local affection which occur in general fever.

In my 4th proposition I have called the action of the arteries irregular in fever, to distinguish it from that excess of action which takes place after violent exercise, and from that quickness which accompanies fear or any other directly debilitating cause. The action of the arteries here is regular, and, when felt in the pulse, affords a very different sensation from that jerking which we feel in the pulse of a patient labouring under a fever.

This irregular action is, in other words, a convulsion in the sanguiferous, but more obviously, in the arterial system.

That this is the case I infer from the strict analogy between symptoms of fever, and convulsions in the nervous system. I shall briefly mention the particulars in which this analogy takes place.

1. Are convulsions in the nervous system preceded by debility? So is the convulsion of the blood-vessels in fever.

2. Does debility induced on the whole, or on a part only, of the nervous system, predispose to general convulsions, as in tetanus? So we observe debility, whether it be induced on the whole or on a part of the arterial system, predisposes to general fever. This is obvious in the fever which ensues alike from cold applied to every part of the body, or from a stream of cold air falling upon the neck, or from the wetting of the feet.

3. Do tremors precede convulsions in the nervous system? So they do the convulsion of the blood-vessels in fever.

4. Is a coldness in the extremities a precursor of convulsions in the nervous system? So it is of fever.

5. Do convulsions in the nervous system impart a jerking sensation to the fingers? So does the convulsion of fever in the arteries, when felt at the wrists.

6. Are convulsions in the nervous system attended with alternate action and remission? So is the convulsion of fever.

7. Do convulsions in the nervous system return at regular and irregular periods? So does fever.

8. Do convulsions in the nervous system, under certain circumstances, affect the functions of the brain? So do certain states of fever.

9. Are there certain convulsions in the nervous system which affect the limbs, without affecting the functions of the brain, such as tetanus, and chorea sancti viti? So there are certain fevers, particularly the common hectic, which seldom produces delirium, or even head-ach, and frequently does not confine a patient to his bed.

10. Are there local convulsions in the nervous system, as in the hands, feet, neck, and eye-lids? So there are local fevers. Intermittents often appear in the autumn with periodical heat and pains in the eyes, ears, jaws, and back.

11. Are there certain grades in the convulsions of the nervous system, as appears in the hydrophobia, tetanus, epilepsy, hysteria, and hypochondriasis? So there are grades in fevers, as in the plague, yellow fever, small-pox, rheumatism, and common remitting and intermitting fevers.

12. Are nervous convulsions most apt to occur in infancy? So are fevers.

13. Are persons once affected with nervous convulsions frequently subject to them through life? So are persons once affected with fever. The intermitting fever often returns with successive springs or autumns, and, in spite of the bark, sometimes continues for many years in all climates and seasons.

14. Is the strength of the nervous system increased by convulsions? This is so evident that it often requires four or five persons to confine a delicate woman to her bed in a convulsive fit. In like manner the strength of the arterial system is increased in a fever. This strength is great in proportion to the weakness of every other part of the body.

15. Do we observe certain nervous convulsions to affect some parts of the nervous system more than others, or, in other words, do we observe preternatural strength or excitement to exist in one part of the nervous system, while other parts of the same system exhibit marks of preternatural weakness or defect of excitement? We observe the same thing in the blood-vessels in a fever. The pulse at the wrist is often tense, while the force of the heart is very much diminished. A delirium often occurs in a fever from excess of excitement in the blood-vessels of the brain, while the pulse at the wrist exhibits every mark of preternatural weakness.

16. Is there a rigidity of the muscles in certain nervous diseases, as in catalepsy? Something like this solstice in convulsion occurs in that state of fever in which the pulse beats but sixty, or fewer strokes in a minute.

17. Do convulsions go off gradually from the nervous system, as in tetanus, and chorea sancti viti? So they do from the arterial blood-vessels in certain states of fever.

18. Do convulsions go off suddenly in any cases from the nervous system? The convulsion in the blood-vessels goes off in the same manner by a sweat, or by a hæmorrhage, frequently in the course of a night, and sometimes in a single hour.

19. Does palsy in some instances succeed to convulsions in the nervous system? Something like a palsy occurs in fevers of great inflammatory action in the arteries. They are often inactive in the wrists, and in other parts of the body, from the immense pressure of the remote cause of the fever upon them.

From the facts and analogies which have been mentioned, I have been led to conclude that the common forms of fever are occasioned simply by irregular action, or convulsion in the blood-vessels.

The history of the phenomena of fever, as delivered in the foregoing pages, resolves itself into a chain, consisting of the five following links.

1. Debility from action, or the abstraction of stimuli. When this debility is induced by action, it is sometimes preceded by elevated excitement in the blood-vessels, from the first impressions of stimuli upon them.

2. An increase of their excitability.

3. Stimulating powers applied to them.

4. Depression. And,

5. Irregular action or convulsion.

The whole of the links of this chain are perceptible only when the fever comes on in a gradual manner. But I wish the reader to remember, that the same remote cause is often debilitating, stimulating, and depressing, and that, in certain fevers, the remote cause sometimes excites convulsions in the blood-vessels without being preceded by preternatural debility and excitability, and with but little or no depression of the system. This has often been observed in persons who have been suddenly exposed to those marsh and human miasmata which produce malignant fevers. It sometimes takes place likewise in fevers induced by local injuries. The blood-vessels in these cases are, as it were, taken by storm, instead of regular approaches.

I might digress here, and show that all diseases, whether they be seated in the arteries, muscles, nerves, brain, or alimentary canal, are all preceded by debility; and that their essence consists in irregular action, or in the absence of the natural order of motion, produced or invited by predisposing debility. I might further show, that all the moral, as well as physical evil of the world consists in predisposing weakness, and in subsequent derangement of action or motion; but these collateral subjects are foreign to our present inquiry.

Let us now proceed to examine how far the theory which has been delivered accords with the phenomena of fever.

I shall divide these phenomena into two kinds.

I. Such as are transient, and more or less common to all fevers. These I shall call symptoms of fever.

II. Such as, being more permanent and fixed, have given rise to certain specific names. These I shall call states of fever.

I shall endeavour to explain and describe each of them in the order in which they have been mentioned.

I. Lassitude is the effect of the depression of the whole system, which precedes fever.

The same cause, when it acts upon the extremities of the blood-vessels, produces coldness and chills. This is obvious to any person, under the first impression of the miasmata which bring on fevers, also under the influence of fatigue, and debilitating passions of the mind. The absence of chills indicates the sensibility of the external parts of the body to be suspended or destroyed, as well as their irritability; hence when death occurs in the fit of an intermittent, there is no chill. A chilly fit, for the same reason, seldom occurs in the most malignant cases of fever. It is sometimes excited by blood-letting, only because it weakens those fevers to such a degree, as to carry the blood-vessels back to the grade of depression. Coldness and chills are likewise removed by blood-letting, only because it enables the arteries to re-act in such a manner as to overcome the depression that induced it. It has been remarked, that the chilly fit, in common fevers, seldom appears in its full force until the patient approaches a fire, or lies down on a warm bed; for in these situations sensibility is restored by the stimulus of the heat acting upon the extremities of the blood-vessels. The first impressions of the rays of the sun, in like manner, often produce coldness and chills in the torpid bodies of old and weakly people.

Tremors are the natural consequence of the abstraction of that support which the muscles receive from the fulness and tension of the blood-vessels. It is from this retreat of the blood towards the viscera, that the capillary arteries lose their fulness and tension; hence they contract like other soft tubes that are emptied of their contents. This contraction has been called a spasm, and has improperly been supposed to be the proximate cause of fever. From the explanation that has been given of its cause, it appears, like the coldness and chills, to be nothing but an accidental concomitant, or effect of a paroxysm of fever.

The local pains in the head, breast, and bones in fever, appear to be the effects of the irregular determination of the blood to those parts, and to morbid action being thereby induced in them.

The want of appetite and costiveness are the consequences of a defect of secretion of the gastric juice, and the abstraction of excitement or natural action from the stomach and bowels.

The inability to rise out of bed, and to walk, is the effect of the abstraction of excitement from the muscles of the lower limbs.

The dry skin or partial sweats appear to depend upon diminished or partial action in the vessels which terminate on the surface of the body.

The high-coloured and pale urine are occasioned by an excess or a deficiency of excitement in the secretory vessels of the kidneys.

The suppression of the urine seems to arise from what Dr. Clark calls an engorgement, or choaking of the vessels of the kidneys. It occurs most frequently in malignant fevers.

Thirst is probably the effect of a preternatural excitement of the vessels of the fauces. It is by no means a uniform symptom of fever. We sometimes observe it, in the highest degree, in the last stage of diseases, induced by the retreat of the last remains of excitement from every part of the body, to the throat.

The white tongue is produced by a change in the secretion which takes place in that organ. Its yellow colour is the effect of bile; its dryness is occasioned by an obstruction of secretion, or by the want of action in the absorbents; and its dark and black colour, by a tendency to mortification.

It will be difficult to account for the variety in the degrees and locality of heat in the body in a fever, until we know more of the cause of animal heat. From whatever cause it be derived, its excess and deficiency, as well as all its intermediate degrees, are intimately connected with more or less excitement in the arterial system. It is not necessary that this excitement should exist only in the large blood-vessels. It will be sufficient for the purpose of creating great heat, if it occur only in the cutaneous vessels; hence we find a hot skin in some cases of malignant fever in which there is an absence of pulse.

Eruptions seem to depend upon effusions of serum, lymph, or red blood upon the skin, with or without inflammation, in the cutaneous vessels.

I decline taking notice in this place of the symptoms which are produced by the debility from action and abstraction, and by the depression of the system. They appear not only in the temperature of the body, but in all the different symptoms of fever. It is of importance to know when they originate from the former, and when from the latter causes, as they sometimes require very different and opposite remedies to remove them.

It remains only to explain the cause why excess in the force or frequency of the action of the blood-vessels should succeed debility in a part, or in the whole of the body, and be connected for days and weeks with depression and preternatural debility in the nerves, brain, muscles, and alimentary canal. I shall attempt the explanation of this phenomenon by directing the attention of the reader to the operations of nature in other parts of her works.

1. A calm may be considered as a state of debility in the atmosphere. It predisposes to a current of air. But is this current proportioned to the loss of the equilibrium of the air? By no means. It is excessive in its force, and tends thereby to destroy the works both of nature and art.

2. The passions are given to man on purpose to aid the slow and uncertain operations of reason. But is their action always proportioned to the causes which excite them? An acute pneumony, brought on by the trifling injury done to the system by the fatigue and heat of an evening spent in a dancing assembly, is but a faint representation of the immense disproportion between a trifling affront, and that excess of passion which seeks for gratification in poison, assassination, or a duel. The same disproportion appears between cause and effect in public bodies. A hasty word, of no mischievous influence, has often produced convulsions, and even revolutions, in states and empires.

If we return to the human body we shall find in it many other instances of the disproportion between stimulus and action, besides that which takes place in the excitement of fever.

3. A single castor oil nut, although rejected by the stomach upon its first effort in vomiting, has, in one instance that came within my knowledge, produced a vomiting that continued nearly four and twenty hours. Here the duration of action was far beyond all kind of proportion to the cause which excited it.

4. A grain of sand, after being washed from the eye, is often followed by such an inflammation or excess in the action of the vessels of the eye, as to require bleeding, purging, and blistering to remove it.

Could we comprehend every part of the sublime and ineffable system of the divine government, I am sure we should discover nothing in it but what tended ultimately to order. But the natural, moral, and political world exhibit every where marks of disorder, and the instruments of this disorder, are the operations of nature. Her influence is most obvious in the production of diseases, and in her hurtful or ineffectual efforts to remove them[4]. In again glancing at this subject I wish it to be remembered that those operations were not originally the means of injuring or seducing man, and that I believe a time will come when the exact relation, between cause and effect, or, in other words, the dominion of order shall be restored over every action of his body and mind, and health and happiness again be the result of every movement of nature.

From the view I have given of the state of the blood-vessels in fever, the reader will perceive the difference between my opinions and Dr. Brown's upon this subject. The doctor supposes a fever to consist in debility. I do not admit debility to be a disease, but place it wholly in morbid excitement, invited and fixed by previous debility. He makes a fever to consist in a change only of a natural action of the blood-vessels. I maintain that it consists in a preternatural and convulsive action of the blood-vessels. Lastly, Dr. Brown supposes excitement and excitability to be equally diffused over the whole body, but in unhealthy proportions to each other. My theory places fever in excitement and excitability unequally diffused, manifesting themselves, at the same time, in morbid actions, depression, and debility from abstraction, in different parts of the body. No new excitement from without is infused into the system by the irritants which excite a fever. They only destroy its equal and natural distribution; for while the arteries are in a plus, the muscles, stomach, and bowels are in a minus state of excitement, and the business of medicine is to equalize it in the cure of fever, that is, to abstract its excess from the blood-vessels, and to restore it to the other parts of the body.

II. I come now to apply the theory which I have delivered to the explanation and description of the different phenomena or states of fever.

I have said in my sixth proposition that there is but one fever. Of course I do not admit of its artificial division into genera and species. A disease which so frequently changes its form and place, should never have been designated, like plants and animals, by unchangeable characters. The oak tree and the lion possess exactly the same properties which they did nearly 6000 years ago. But who can say the same thing of any one disease? The pulmonary consumption is sometimes transformed into head-ach, rheumatism, diarrhœa, and mania, in the course of two or three months, or the same number of weeks. The bilious fever often appears in the same person in the form of colic, dysentery, inflammation of the liver, lungs, and brain, in the course of five or six days. The hypochondriasis and the hysteria seldom fail to exchange their symptoms twice in the four and twenty hours. Again: the oak tree has not united with any of the trees of the forest, nor has the lion imparted his specific qualities to any other animal. But who can apply similar remarks to any one disease? Phrenitis, gastritis, enteritis, nephritis, and rheumatism all appear at the same time in the gout and yellow fever. Many observations of the same kind might be made, to show the disposition of nearly all other diseases to anastomose with each other. To describe them therefore by any fixed or specific characters is as impracticable as to measure the dimensions of a cloud on a windy day, or to fix the component parts of water by weighing it in a hydrostatic balance. Much mischief has been done by nosological arrangements of diseases. They erect imaginary boundaries between things which are of a homogeneous nature. They degrade the human understanding, by substituting simple perceptions to its more dignified operations in judgment and reasoning. They gratify indolence in a physician, by fixing his attention upon the name of a disease, and thereby leading him to neglect the varying state of the system. They moreover lay a foundation for disputes among physicians, by diverting their attention from the simple, predisposing, and proximate, to the numerous, remote, and exciting causes of diseases, or to their more numerous and complicated effects. The whole materia medica is infected with the baneful consequences of the nomenclature of diseases, for every article in it is pointed only against their names, and hence the origin of the numerous contradictions among authors who describe the virtues and doses of the same medicines. By the rejection of the artificial arrangement of diseases, a revolution must follow in medicine. Observation and judgment will take the place of reading and memory, and prescriptions will be conformed to existing circumstances. The road to knowledge in medicine by this means will likewise be shortened; so that a young man will be able to qualify himself to practise physic at as much less expence of time and labour than formerly, as a child would learn to read and write by the help of the Roman alphabet, instead of Chinese characters.

In thus rejecting the nosologies of the schools, I do not wish to see them banished from the libraries of physicians. When consulted as histories of the effects of diseases only, they may still be useful. I use the term diseases, in conformity to custom, for, properly speaking, disease is much a unit as fever. It consists simply of morbid action or excitement in some part of the body. Its different seats and degrees should no more be multiplied into different diseases, than the numerous and different effects of heat and light upon our globe should be multiplied into a plurality of suns.

The advocates for Dr. Cullen's system of medicine will not, I hope, be offended by these observations. His immense stock of reputation will enable him to sustain the loss of his nosology without being impoverished by it. In my attempts to introduce a new arrangement of fevers, I shall only give a new direction to his efforts to improve the healing art.

Were it compatible with the subject of the present inquiry, it would be easy to show, that the same difficulties and evils are to be expected from Dr. Darwin's division of diseases, as they affect the organs of sensation and motion, and as they are said to be exclusively related by association and volition, that have been deprecated from their divisions and subdivisions by the nosologists. Diseases, like vices, with a few exceptions, are necessarily undisciplined and irregular. Even the genius of Dr. Darwin has not been able to compel them to move within lines.

I return from this digression to remark that morbid action in the blood-vessels, whether it consist in preternatural force and frequency, or preternatural force without frequency, or frequency without force, constitutes fever. Excess in the force and frequency in the pulsations of the arteries have been considered as the characteristic marks of what is called inflammatory fever. There are, however, symptoms which indicate a much greater excess of irritating impressions upon the blood-vessels. These are preternatural slowness, intermissions, and depression in the pulse, such as occur in certain malignant fevers.

But there is a grade of fever, which transcends in force that which produces inflammation. It occurs frequently in hydrophobia, dysentery, colic, and, baron Humboldt lately informed me, upon the authority of Dr. Comoto, of Vera Cruz, in the yellow fever of that city, when it proves fatal in a few hours after it attacks. In vain have physicians sought to discover, by dissections, the cause of fever in those cases, when followed by death, in the parts of the body in which it was supposed, from pain and other symptoms, to be principally seated. Those parts have frequently exhibited no marks of inflammation, nor of the least deviation from a healthy state. I have ascribed this apparent absence of disease to the serous vessels being too highly excited, and thereby too much contracted, to admit the entrance of red blood into them. I wish these remarks to be remembered by the student of medicine. They have delivered me from the influence of several errors in pathology; and they are capable, if properly extended and applied, of leading to many important deductions in the practice of physic.

I shall now briefly mention the usual effects of fever, or morbid excitement in the blood-vessels, when not removed by medicine. They are,

1. Inflammation. It is produced by an effusion of red particles of blood into serous vessels, constituting what Dr. Boerhaave calls error loci. It is the second grade of fever, and, in fevers of great violence, does not take place until morbid excitement has continued for some time, or has been reduced by bleeding.

2. Secretion, or an effusion from rupture, of the serum of the blood, constituting dropsies.

3. Secretion of lymph or fibrin, forming a membrane which adheres to certain surfaces in the body.

4. Secretion of pus, also of sloughs.

5. An effusion by rupture, or a congestion of all the component parts of the blood.

6. Gangrene from the death of the blood-vessels.

7. Rupture of blood-vessels, producing hæmorrhage.

8. Redness, phlegmon, pustules, and petechiæ on the skin, and tubercles in the lungs, and on the liver and bowels.

9. Schirrus.

10. Calcareous and other earthy matters. Both these take place only in the feeble and often imperceptible grades of morbid action in the blood-vessels.

11. Death. This arises from the following causes.

1. Sudden destruction of the excitability of the blood-vessels.

2. A disorganization of parts immediately necessary to life.

3. A change in the fluids, so as to render them destructive to what are called the vital organs.

4. Debility, from the exhausted or suspended state of the excitability of the blood-vessels.

All these effects of fever are different according to its grade. Dr. Blane says fevers are rarely inflammatory in the West-Indies; that is, they pass rapidly from simple morbid excitement to congestion, hæmorrhage, gangrene, and death. This remark is confirmed by Dr. Dalzelle, who says the pneumony in the negroes, in the French West-India islands, rarely appears in any other form than that of the notha, from the arteries in the lungs being too much stimulated to produce common inflammation; but such is the force of morbid excitement in hot climates, that it sometimes passes suddenly over all its intermediate effects, and discovers itself only in death. This appears to have taken place in the cases at Vera Cruz, mentioned by baron Humboldt.

All the different states of fever may be divided,

I. Into such as affect the whole arterial system; but with no, or very little local disease.

II. Into such as affect the whole arterial system, and are accompanied at the same time with evident local disease.

III. Into such as appear to pass by the arterial system, and to fix themselves upon other parts of the body. I shall call these states of fever misplaced.

I. To the first class of the states of fever belong,

1. The malignant. It constitutes the highest grade of morbid diathesis. It is known by attacking frequently without a chilly fit, by coma, a depressed, slow, or intermitting pulse, and sometimes by the absence of pain, and with a natural temperature or coldness of the skin. It occurs in the plague, in the yellow fever, in the gout, in the small-pox and measles, in the hydrophobia, and after taking opium and other stimulating substances. Dr. Quier has described a pleurisy in Jamaica, in which some of those malignant symptoms took place. They are the effect of such a degree of impression as to prostrate the arterial system, and to produce a defect of action from an excess of force. Such is this excess of force, in some instances, in this state of fever, that it induces general convulsions, tetanus, and palsy, and sometimes extinguishes life in a few hours, by means of apoplexy or syncope. From its being accompanied with these symptoms, it has received the name of adynamique by Dr. Alibert. The less violent degrees of stimulus in this state of fever produce palsy in the blood-vessels. It probably begins in the veins, and extends gradually to the arteries. It seems further to begin in the extremities of the arteries, and to extend by degrees to their origin in the heart. This is evident in the total absence of pulse which sometimes takes place in malignant fevers, four and twenty, and even eight and forty hours before death. But there are cases in which this palsy affects both the veins and arteries at the same time. It is probably from this simultaneous affection of the blood-vessels, that the arteries are found to be nearly full of blood after death from malignant fevers. The depressed, and intermitting pulse which occurs in the beginning of these fevers perhaps depends upon a tendency to palsy in the arteries, independently of an affection of the heart or brain.

This prostrate state of fever more frequently when left to itself terminates in petechiæ, buboes, carbuncles, abscesses, and mortifications, according as serum, lymph, or red blood is effused in the viscera or external parts of the body. These morbid appearances have been ascribed to putrefaction, and the fever has received, from its supposed presence, the name of putrid. The existence of putrefaction in the blood in a fever is rendered improbable,

1. By Dr. Seybert's experiments[5], which prove that it does not take place in the blood in a living state. It occurs in the excretions of bile, fæces, and urine, but in this case it does not act as a ferment, but a stimulus only upon the living body.

2. By similar appearances, with those which have been ascribed to putrefaction, having been produced by lightning, by violent emotions of the mind, by extreme pain, and by every thing else which induces sudden and universal disorganization in the fluids and solids of the body. The following facts clearly prove that the symptoms which have been supposed to designate a putrid fever, are wholly the effect of mechanical action in the blood-vessels, and are unconnected with the introduction of a putrid ferment in the blood.

Hippocrates relates the case of a certain Antiphillus, in whom a putrid bilious fever (as he calls it) was brought on by the application of a caustic to a wound[6].

An acute pain in the eye, Dr. Physick informed me, produced the symptoms of what is called a putrid fever, which terminated in death in five days, in St. George's hospital, in the year 1789.

Dr. Baynard relates, upon the authority of a colonel Bampfield, that a stag, which he had chased for some time, stopped at a brook of water in order to drink. Soon afterwards it fell and expired. The colonel cut its throat, and was surprised to perceive the blood which issued from it had a putrid and offensive smell[7].

Dr. Desportes takes notice that a fish, which he calls a sucker, affected the system nearly in the same manner as the miasmata of the yellow fever. A distressing vomiting, a coldness of the extremities, and an absence of pulse, were some of the symptoms produced by it, and an inflammation and mortification of the stomach and bowels, were discovered after death to be the effects of its violent operation.

Even opium, in large doses, sometimes produces by its powerful stimulus the same symptoms which are produced by the stimulus of marsh miasmata. These symptoms are a slow pulse, coma, a vomiting, cold sweats, a sallow colour of the face, and a suppression of the discharges by the urinary passages and bowels.

Error is often perpetuated by words. A belief in the putrefaction of the blood has done great mischief in medicine. The evil is kept up, under the influence of new theories, by the epithet putrid, which is still applied to fever in all our medical books. For which reason I shall reject it altogether hereafter, and substitute in its room.

2. The gangrenous state of fever; for what appear to some physicians to be signs of putrefaction, are nothing but the issue of a violent inflammation left in the hands of nature, or accelerated by stimulating medicines. Thus the sun, when viewed at mid-day, appears to the naked eye, from the excess of its splendour, to be a mass of darkness, instead of an orb of light.

The same explanation of what are called putrid symptoms in fever, is very happily delivered by Mr. Hunter in the following words: “It is to be observed (says this acute physiologist) that when the attack upon these organs, which are principally connected with life, proves fatal, that the effects of the inflammation upon the constitution run through all the stages with more rapidity than when it happens in other parts; so that at its very beginning, it has the same effect upon the constitution which is only produced by the second stage of inflammation in other parts[8].”

3. The synocha, or the common inflammatory state of fever, attacks suddenly with chills, and is succeeded by a quick, frequent, and tense pulse, great heat, thirst, and pains in the bones, joints, breast, or sides. These symptoms sometimes occur in the plague, the jail and yellow fever, and the small-pox; but they are the more common characteristics of pleurisy, gout, and rheumatism. They now and then occur in the influenza, the measles, and the puerperile fever.

4. The synochus state of fever is known by a full, quick, and round pulse without tension. The autumnal bilious fever and colic, also the gout, often appear in this form.

5. There is a state of fever in which the pulse is small, but tense and quick. The patient, in this state of fever, is seldom confined to his bed. We observe it sometimes in the chronic rheumatism, and in pulmonary consumption. The inflammatory state of this grade of fever is proved from the inefficacy of the volatile tincture of guaiacum and other stimulants to remove it, and from its yielding so suddenly to blood-letting. I have called it the synochula state of fever.

6. There is a state of fever inclining more to the synocha, than what is called the typhus, or low chronic state of fever. I have called it the synochoid state of fever.

7. The typhus state of fever is generally preceded by all those circumstances which debilitate the system, both by the action and abstraction of stimuli. It is known by a weak and frequent pulse, a disposition to sleep, a torpor of the alimentary canal, tremors of the hands, a dry tongue, and, in some instances, by a diarrhœa. These symptoms occur most frequently in what is called the jail, the ship, and the hospital fever. I heard of it in a few cases in the yellow fever of 1793, and all writers take notice of cases of the plague, which run on into a slow fever that continues 30 or 40 days. I have seen it succeed the common bilious fever, pleurisy, and influenza. It has been confounded with the malignant state of fever, or what is called the typhus gravior; but it differs widely from it in being accompanied by a feeble excitement in the blood-vessels, from a feeble stimulus, and by the usual signs of debility from abstraction in every other part of the body.

From the accession of new stimuli, or an increase in the force of former ones, this typhus state of fever sometimes assumes, on the 11th, 14th, and even 20th days, the symptoms of the synocha state of fever. It will be useful to remember this remark, not only because it establishes the unity of fever, but because it will justify the use of a remedy, seldom prescribed after the disease has acquired that name which associates it with stimulating medicines.

The common name of this state of fever, is the nervous fever. This name is improper; for it invades the nervous system by pain, delirium, and convulsions much less than several other states of fever. To prevent the absurd and often fatal association of ideas upon the treatment of this state of fever, I have called it, from its duration, the low chronic state of fever. I have adopted the term low, from Dr. Butter's account of the remitting fever of children, in order to distinguish it from states of fever to be mentioned hereafter, in which the patient is not confined to his bed. This new name of the typhus or nervous fever establishes its analogy with several other diseases. We have the acute and the chronic rheumatism; the acute and chronic pneumony, commonly called the pleurisy and pulmonary consumption; the acute and chronic inflammation of the brain, known unfortunately by the unrelated names of phrenitis, madness, and internal dropsy of the brain. Why should we hesitate, in like manner, in admitting acute and chronic fever, in all those cases where no local inflammation attends?

8. The typhoid state of fever is composed of the synocha and low chronic states of fever. It is the slow nervous fever of Dr. Butter. The excitement of the blood-vessels is somewhat greater than in the low chronic state of fever. Perhaps the muscular fibres of the blood-vessels, in this state of fever, are affected by different degrees of stimulus and excitement. Supposing a pulse to consist of eight cords, I think I have frequently felt more or less of them tense or relaxed, according as the fever partook more or less of the synocha, or low chronic states of fever. This state of fever occurs most frequently in what are called the hectic and puerperal fevers, and in the scarlatina.

9. The hectic state of fever differs from all the other states of fever, by the want of regularity in its paroxysms, in which chills, fevers, and sweats are included; and by the brain, nerves, muscles, and alimentary canal being but little impaired in their functions by it. It appears to be an exclusive disease of the blood-vessels. It occurs in the pulmonary consumption, in some cases of lues, of scrophula, and of the gout, and after most of the states of fever which have been described. The force of the pulse is various, being occasionally synochoid, typhoid, and typhus.

10. Intermissions, or the intermitting and remitting states of fever, are common to all the states of fever which have been mentioned. But they occur most distinctly and universally in those which partake of the bilious diathesis. They have been ascribed to the reproduction of bile, to the recurrence of debility, and to the influence of the heavenly bodies upon the system. None of these hypotheses has explained the recurrence of fever, where the bile has not been in fault, where debility is uniform, and where the paroxysms of fever do not accord with the revolutions of any part of the solar system. I have endeavoured to account for the recurrence of the paroxysm of fever, in common with all other periodical diseases, by means of a natural or adventitious association of motions. Dr. Percival has glanced at this law of animal matter; and Dr. Darwin has explained by it, in the most ingenious manner, many natural and morbid actions in the human body.

11. There is a state of fever in which the morbid action of the blood-vessels is so feeble as scarcely to be perceptible. Like the hectic state of fever, it seldom affects the brain, nerves, muscles, or alimentary canal. It is known in the southern states of America by the name of inward fevers. The English physicians formerly described it by the name of febricula.

These eleven states of fever may be considered as primary in their nature. All the states which remain to be enumerated belong to some one of them, or they are compounds of two, three, or more of them. Even these primary states of fever seldom appear in the simple form in which they have been described. They often blend their symptoms; and sometimes all the states appear at different times in the course of a fever. This departure from a uniformity in the character of fevers must be sought for in the changes of the weather, in the casual application of fresh irritants, or in the operation of the remedies which have been employed to cure them.

To the first class of the states of fever belong the sweating, the fainting, the burning, and the cold and chilly states of fever.

12. The sweating state of fever occurs in the plague, in the yellow fever, in the small-pox, the pleurisy, the rheumatism, and in the hectic and intermitting states of fever. Profuse sweats appeared every other day in the autumnal fever of 1795 in Philadelphia, without any other symptom of an intermittent. The English sweating sickness was nothing but a symptom of the plague. The sweats in all these cases are the effects of morbid and excessive action, concentrated in the capillary vessels.

13. The fainting state of fever accompanies the plague, the yellow fever, the small-pox, and some states of pleurisy. It is the effect of great depression; hence it occurs most frequently in the beginning of those states of fever.

14. The burning state of fever has given rise to what has been called a species of fever. It is the causus of authors. Dr. Mosely, who rejects the epithet of yellow, when applied to the bilious fever, because it is only one of its accidental symptoms, very improperly distinguishes the same fever by another symptom, viz. the burning heat of the skin, and which is not more universal than the yellowness which attends it.

15. The cold and chilly state of fever differs from a common chilly fit, by continuing four or five days, and to such a degree, that the patient frequently cannot bear his arms out of the bed. The coldness is most obstinate in the hands and feet. A coolness only of the skin attends in some cases, which is frequently mistaken for an absence of fever.

Having mentioned those states of fever which affect the arterial system without any, or with but little local disease, I proceed next to enumerate those states of fever which belong to the

II. Class of the order that was mentioned, in which there are local affections combined with general fever. They are,

16. The intestinal state of fever. I have been anticipated in giving this epithet to fever, by Dr. Balfour[9]. It includes the cholera morbus, diarrhœa, dysentery, and colic. The remitting bilious fever appears, in all the above forms, in the summer months. They all belong to the febris introversa of Dr. Sydenham. The jail fever appears likewise frequently in the form of diarrhœa and dysentery. The dysentery is the offspring of marsh and human miasmata, but it is often induced in a weak state of the bowels, by other exciting causes. The colic occasionally occurs with states of fever to be mentioned hereafter.

17. The pulmonary state of fever includes the true and bastard pneumony in their acute forms; also catarrh from cold and influenza, and the chronic form of pneumony in what is called pulmonary consumption.

18. The eruptive state of fever includes the small-pox, measles, erysipelas, miliary fever, chicken-pox, and pemphigus.

19. The anginose state of fever includes all those affections of the throat which are known by the names of cynanche inflammatoria, tonsillaris, parotidea, maligna, scarlatina, and trachealis. The cynanche trachealis is a febrile disease. The membrane which produces suffocation and death in the wind-pipe is the effect of inflammation. It is said to be formed, like other membranes which succeed inflammation, from the coagulable lymph of the blood.

20. The rheumatic state of fever is confined chiefly to the labouring part of mankind. The topical affection is seated most commonly in the joints and muscles, which, from being exercised more than other parts of the body, become more debilitated, and are, in consequence thereof, excited into morbid and inflammatory action.

21. The arthritic or gouty state of fever differs from the rheumatic, in affecting, with the joints and muscles, all the nervous and lymphatic systems, the viscera, and the skin. Its predisposing, exciting, and proximate causes are the same as the rheumatic and other states of fever. It bears the same ratio to rheumatism, which the yellow fever bears to the common bilious fever. It is a fever of more force than rheumatism.

22. The cephalic, in which are included the phrenitic, lethargic, apoplectic, paralytic, hydrocephalic, and maniacal states of fever. That madness is originally a state of fever, I infer, 1. From its causes, many of which are the same as those which induce all the other states of fever. 2. From its symptoms, particularly a full, tense, quick, and sometimes a slow pulse. 3. From the inflammatory appearances of the blood which has been drawn to relieve it. And, 4. From the phenomena exhibited by dissection in the brains of maniacs, being the same as are exhibited by other inflamed viscera after death. These are, effusions of water or blood, abscesses, and schirrus. The hardness in the brains of maniacs, taken notice of by several authors, is nothing but a schirrus (sui generis), induced by the neglect of sufficient evacuations in this state of fever. The reader will perceive by these observations, that I reject madness from its supposed primary seat in the mind or nerves. It is as much an original disease of the blood-vessels, as any other state of fever. It is to phrenitis, what pulmonary consumption is to pneumony. The derangement in the operations of the mind is the effect only of a chronic inflammation of the brain, existing without an abstraction of muscular excitement.

23. The nephritic state of fever is often induced by calculi, but it frequently occurs in the gout, small-pox, and malignant states of fever. There is such an engorgement, or choaking of the vessels of the kidneys, that the secretion of the urine is sometimes totally obstructed, so that the bladder yields no water to the catheter. It is generally accompanied with a full or tense pulse, great pain, sickness, or vomiting, high coloured urine, and a pain along the thigh and leg, with occasionally a retraction of one of the testicles. It exists sometimes without any pain. Of this I met with several instances in the yellow fever of 1793. I include diabetes in this state of fever.

24. The hydropic state of fever, in which are included collections of water, in the lungs, cavity of the thorax, cavity of the abdomen, ovaria, scrotum, testicles, and lower extremities, and usually preceded, and generally accompanied with morbid action in the blood-vessels. That dropsy is a state of fever, I have endeavoured to prove in another place[10]. Nineteen dropsies out of twenty appear to be original arterial diseases, and the water, which has been supposed to be their cause, is as much the effect of preternatural and morbid action in the blood-vessels, as pus, gangrene, and schirrus are of previous inflammation. This has been demonstrated, by the late Dr. Cooper, in a man who died of an ascites in the Pennsylvania hospital. Pus and blood, as well as water, were found in the cavity of the abdomen. It is no objection to this theory of dropsy, that we sometimes find water in the cavities of the body after death, without any marks of inflammation in the contiguous blood-vessels. We often find pus, both in the living and dead body, under the same circumstances, where we are sure it was not preceded by any of the obvious marks of inflammation.

25. The hæmorrhagic state of fever, in which are included discharges of blood from the nose, lungs, stomach, liver, bowels, kidneys and bladder, hæmorrhoidal vessels, uterus, and skin. Hæmorrhages have been divided into active and passive. It would be more proper to divide them, like other states of general fever, into hæmorrhages of strong and feeble morbid action. There is seldom an issue of blood from a vessel in which there does not exist preternatural or accumulated excitement. We observe this hæmorrhagic state of fever most frequently in malignant fevers, in pulmonary consumption, in pregnancy, and in that period of life in which the menses cease to be regular.

26. The amenorrhagic state of fever occurs more frequently than is suspected by physicians. A full and quick pulse, head-ach, thirst, and preternatural heat often accompany a chronic obstruction of the menses. The inefficacy, and even hurtful effects, of what are called emenagogue medicines, in this state of the system, without previous depletion, show the propriety of introducing it among the different states of fever.

I have designedly omitted to take notice of other states of general fever accompanied with local disease, because they are most frequently combined with some one or more of those which have been mentioned. They may all be seen in Dr. Cullen's Synopsis, with their supposed respective generic characters, under the class of pyrexiæ, and the order of fevers. We come now in the

III. And last place, to mention the misplaced states of fever. The term is not a new one in medicine. The gout is said to be misplaced, when it passes from the feet to the viscera. The periodical pains in the head, eyes, ears, jaws, hips, and back, which occur in the sickly autumnal months, and which impart no fulness, force, nor frequency to the pulse, are all misplaced fevers. There are, besides these, many other local morbid affections, which are less suspected of belonging to febrile diseases. The nature of these states of fever may easily be understood, by recollecting one of the laws of sensation, that is, that certain impressions, which excite neither sensation nor motion in the part of the body to which they are applied, excite both in another part. Thus worms, which are not felt in the stomach or bowels, often produce a troublesome sensation in the throat, and a stone, which is attended with no pain in the bladder, produces a troublesome itching in the glans penis. In like manner, the irritants which produce fever in ordinary cases pass through the blood-vessels, and convey their usual morbid effects into a remote part of the body which has been prepared to receive them by previous debility. That this is the case, I infer further, from fevers being called back from their misplaced or suffocated situations, by creating an artificial debility in the arteries by the abstraction of blood. This is often done in muscular convulsions, and in several diseases of the brain.

Under this class of fevers are included

27. The chronic hepatic state of fever. The causes, symptoms, and remedies of the liver disease of the East-Indies, as mentioned by Dr. Girdlestone, all prove that it is nothing but a bilious fever translated from the blood-vessels, and absorbed, or suffocated, as it were, in the liver. This view of the chronic hepatitis is important, inasmuch as it leads to the liberal use of all the remedies which cure bilious fever. Gall stones and contusions now and then produce a hepatitis, but under no other circumstances do I believe it ever exists, but as a symptom of general or latent fever.

28. The hæmorrhoids are frequently a local disease, but they are sometimes accompanied with pain, giddiness, chills, and an active pulse. When these symptoms occur, it should be considered as a hæmorrhoidal state of fever.

29. The opthalmia, when it occurs, as it frequently does in sickly seasons, with a quick and tense pulse, and pains diffused over the whole head, may properly be called an opthalmic state of fever.

30. The tooth-ach, and

31. Ear-ach, when they arise from colds, and are attended with great heat, a quick and tense pulse, and pains in the head, are odontalgic and otalgic states of fever.

32. The apthæ, from the pain and fever which attend them, are justly entitled to the name of the apthous state of fever.

33. The symptoms of scrophula, as described by Dr. Hardy, in his treatise on the glandular disease of Barbadoes, clearly prove it to be a misplaced state of fever.

34. The scurvy has lately been proved by Dr. Claiborne, in his inaugural dissertation, published in the year 1797, to arise from so many of the causes, and to possess so many of the symptoms, of the low chronic and petechial states of fever, that I see no impropriety in considering it as a state of fever.

35. The convulsive or spasmodic state of fever. Convulsions, it is well known, often usher in fevers, more especially in children. But the connection between spasmodic affections and fever, in adults, has been less attended to by physicians. The same causes which produced general fever and hepatitis in the East-Indies, in some soldiers, produced locked jaw in others. Several of the symptoms of this disease, as described by Dr. Girdlestone, such as coldness on the surface of the body, cold sweats on the hands and feet, intense thirst, a white tongue, incessant vomitings, and carbuncles, all belong to the malignant state of fever[11]. By means of blood-letting, and the other remedies for the violent state of bilious fever, I have seen the convulsions in this disease translated from the muscles to the blood-vessels, where they immediately produced all the common symptoms of fever.

36. The hysterical and hypochondriacal states of fever. The former is known by a rising in the throat, which is for the most part erroneously ascribed to worms, by pale urine, and by a disposition to shed tears, or to laugh upon trifling occasions. The latter discovers itself by false opinions of the nature and danger of the disease under which the patient labours. Both these states of the nervous system occur frequently in the gout and in the malignant state of fever. It is common to say, in such cases, that patients have a complication of diseases; but this is not true, for the hysterical and hypochondriacal symptoms are nothing but the effects of one remote cause, concentrating its force chiefly upon the nerves and muscles.

37. The cutaneous state of fever. Dr. Sydenham calls a dysentery a “febris introversa.” Eruptions of the skin are often nothing but the reverse of this introverted fever. They are a fever translated to the skin; hence we find them most common in those countries and seasons in which fevers are epidemic. The prickly heat, the rash, and the essere of authors, are all states of misplaced fever. “Agues, fevers, and even pleurisies (says Mr. Townsend, in his Journey through Spain[12]), are said often to terminate in scabies, and this frequently gives place to them, returning, however, when the fever ceases. In adults it takes possession of the hands and arms, with the legs and thighs, covering them with a filthy crust.” Small boils are common among the children in Philadelphia, at the time the cholera infantum makes its appearance. These children always escape the summer epidemic. The elephantiasis described by Dr. Hillary, in his account of the diseases of Barbadoes, is evidently a translation of an intermittent to one of the limbs. It is remarkable, that the leprosy and malignant fevers of all kinds have appeared and declined together in the same ages and countries. But further, petechiæ sometimes appear on the skin without fever. Cases of this kind, with and without hæmorrhages, are taken notice of by Riverius[13], Dr. Duncan, and many other practical writers. They are cotemporary or subsequent to fevers of a malignant complexion. They occur likewise in the scurvy. From some of the predisposing, remote, and exciting causes of this disease, and from its symptoms and remedies, I have suspected it, like the petechiæ mentioned by Riverius, to be originally a fever generated by human miasmata, in a misplaced state. The hæmorrhages which sometimes accompany the scurvy, certainly arise from a morbid state of the blood-vessels. The heat and quick pulse of fever are probably absent, only because the preternatural excitement of the whole sanguiferous system is confined to those extreme or cutaneous vessels which pour forth blood. In like manner the fever of the small-pox deserts the blood-vessels, as soon as a new action begins on the skin. Or perhaps the excitability of the larger blood-vessels may be so far exhausted by the long or forcible impression of the remote and predisposing causes of the scurvy, as to be incapable of undergoing the convulsive action of general fever.

With this I close my inquiry into the cause of fever. It is imperfect from its brevity, as well as from other causes. I commit it to my pupils to be corrected and improved.

“We think our fathers fools, so wise we grow.
Our wiser sons, I hope, will think us so.”

Footnotes:

[1] Cullen's First Lines.

[2] First Lines, sect. 32 of the chapter on arteries.

[3] Perhaps there is no greater enemy to the life of man than cold. Dr. Sydenham ascribes nearly all fevers to it, particularly to leaving off winter clothes too soon, and to exposing the body to cold after it has been heated. These sources of fever, he adds, destroy more than the plague, sword, or famine.—Wallis's edition, vol. I. p. 357.

[4] See the Comparative View of the Diseases of the Indians and of Civilized Nations. Vol. I.

[5] Inaugural dissertation, entitled, “An Attempt to disprove the Putrefaction of the Blood in Living Animals.”

[6] Epidemics, book iv.

[7] Treatise on the Cold Bath.

[8] Treatise on Inflammation. chap. I. 8.

[9] Account of the Intestinal Remitting Fever of Bengal.

[10] On Dropsies, vol. II.

[11] Essay on the Spasmodic Affections in India, p. 53, 54, 55.

[12] Vol. II. Dublin edition, p. 262.

[13] Praxis Medica, lib. xviii. cap. i.

AN ACCOUNT
OF THE
Bilious Remitting Yellow Fever,
AS IT
APPEARED IN PHILADELPHIA,
IN THE YEAR 1793.

Before I proceed to deliver the history of this fever, it will be proper to give a short account of the diseases which preceded it.

The state of the weather during the first seven months of the year, and during the time in which the fever prevailed in the city, as recorded by Mr. Rittenhouse, will be inserted immediately after the history of the disease.

The mumps, which made their appearance in December, 1792, continued to prevail during the month of January, 1793. Besides this disease there were many cases of catarrh in the city, brought on chiefly by the inhabitants exposing themselves for several hours on the damp ground, in viewing the aërial voyage of Mr. Blanchard, on the 9th day of the month.

The weather, which had been moderate in December and January, became cold in February. The mumps continued to prevail during this month with symptoms so inflammatory as to require, in some cases, two bleedings. Many people complained this month of pains and swellings in the jaws. A few had the scarlatina anginosa.

The mumps, pains in the jaws, and scarlatina continued throughout the month of March. I was called to two cases of pleurisy in this month, which terminated in a temporary mania. One of them was in a woman of ninety years of age, who recovered. The blood drawn in the other case (a gentleman from Maryland) was dissolved. The continuance of a tense pulse induced me, notwithstanding, to repeat the bleeding. The blood was now sizy. A third bleeding was prescribed, and my patient recovered. Several cases of obstinate erysipelas succeeded inoculation in children during this and the next month, one of which proved fatal.

Blossoms were universal on the fruit-trees, in the gardens of Philadelphia, on the first day of April. The scarlatina anginosa continued to be the reigning epidemic in this month.

There were several warm days in May, but the city was in general healthy. The birds appeared two weeks sooner this spring than usual.

The register of the weather shows, that there were many warm days in June. The scarlatina continued to maintain its empire during this month.

The weather was uniformly warm in July. The scarlatina continued during the beginning of this month, with symptoms of great violence. A son of James Sharswood, aged seven years, had, with the common symptoms of this disease, great pains and swellings in his limbs, accompanied with a tense pulse. I attempted in vain to relieve him by vomits and purges. On the 10th day of the month, I ordered six ounces of blood to be drawn from his arm, which I observed afterwards to be very sizy. The next day he was nearly well. Between the 22d and the 24th days of the month, there died three persons, whose respective ages were 80, 92, and 96½. The weather at this time was extremely warm. I have elsewhere taken notice of the fatal influence of extreme heat, as well as cold, upon human life in old people. A few bilious remitting fevers appeared towards the close of this month. One of them under my care ended in a typhus or chronic fever, from which the patient was recovered with great difficulty. It was the son of Dr. Hutchins, of the island of Barbadoes.

The weather, for the first two or three weeks in August, was temperate and pleasant. The cholera morbus and remitting fevers were now common. The latter, were attended with some inflammatory action in the pulse, and a determination to the breast. Several dysenteries appeared at this time, both in the city and in its neighbourhood. During the latter part of July, and the beginning of this month, a number of the distressed inhabitants of St. Domingo, who had escaped the desolation of fire and sword, arrived in the city. Soon after their arrival, the influenza made its appearance, and spread rapidly among our citizens. The scarlatina still kept up a feeble existence among children. The above diseases were universal, but they were not attended with much mortality. They prevailed in different parts of the city, and each seemed to appear occasionally to be the ruling epidemic. The weather continued to be warm and dry. There was a heavy rain on the 25th of the month, which was remembered by the citizens of Philadelphia, as the last that fell for many weeks afterwards.

There was something in the heat and drought of the summer months which was uncommon, in their influence upon the human body. Labourers every where gave out (to use the country phrase) in harvest, and frequently too when the mercury in Fahrenheit's thermometer was under 84°. It was ascribed by the country people to the calmness of the weather, which left the sweat produced by heat and labour to dry slowly upon the body.

The crops of grain and grass were impaired by the drought. The summer fruits were as plentiful as usual, particularly the melons, which were of an excellent quality. The influence of the weather upon the autumnal fruits, and upon vegetation in general, shall be mentioned hereafter.

I now enter upon a detail of some solitary cases of the epidemic, which soon afterwards spread distress through our city, and terror throughout the United States.

On the 5th of August, I was requested by Dr. Hodge to visit his child. I found it ill with a fever of the bilious kind, which terminated (with a yellow skin) in death on the 7th of the same month.

On the 6th of August, I was called to Mrs. Bradford, the wife of Mr. Thomas Bradford. She had all the symptoms of a bilious remittent, but they were so acute as to require two bleedings, and several successive doses of physic. The last purge she took was a dose of calomel, which operated plentifully. For several days after her recovery, her eyes and face were of a yellow colour.

On the same day, I was called to the son of Mrs. M'Nair, who had been seized violently with all the usual symptoms of a bilious fever. I purged him plentifully with salts and cremor tartar, and took ten or twelve ounces of blood from his arm. His symptoms appeared to yield to these remedies; but on the 10th of the month a hæmorrhage from the nose came on, and on the morning of the 12th he died.

On the 7th of this month I was called to visit Richard Palmer, a son of Mrs. Palmer, in Chesnut-street. He had been indisposed for several days with a sick stomach, and vomiting after eating. He now complained of a fever and head-ach. I gave him the usual remedies for the bilious fever, and he recovered in a few days. On the 15th day of the same month I was sent for to visit his brother William, who was seized with all the symptoms of the same disease. On the 5th day his head-ach became extremely acute, and his pulse fell to sixty strokes in a minute. I suspected congestion to have taken place in his brain, and ordered him to lose eight ounces of blood. His pulse became more frequent, and less tense after bleeding, and he recovered in a day or two afterwards.

On the 14th day of this month I was sent for to visit Mrs. Leaming, the wife of Mr. Thomas Leaming. I suspected at first that she had the influenza, but in a day or two her fever put on bilious symptoms. She was affected with an uncommon disposition to faint. Her pulse was languid, but tense. I took a few ounces of blood from her, and purged her with salts and calomel. I afterwards gave her a small dose of laudanum which disagreed with her. In my note book I find I have recorded that “she was worse for it.” I was led to make this remark by its being so very uncommon for a person, who had been properly bled and purged, to take laudanum in a common bilious fever without being benefited by it. She recovered, however, slowly, and was yellow for many days afterwards.

On the morning of the 18th of this month I was requested to visit Peter Aston, in Vine-street, in consultation with Dr. Say. I found him on the third day of a most acute bilious fever. His eyes were inflamed, and his face flushed with a deep red colour. His pulse seemed to forbid evacuations. We prescribed the strongest cordials, but to no purpose. We found him, at 6 o'clock in the evening, sitting upon the side of his bed, perfectly sensible, but without a pulse, with cold clammy hands, and his face of a yellowish colour. He died a few hours after we left him.

None of the cases which I have mentioned excited the least apprehension of the existence of a malignant or yellow fever in our city; for I had frequently seen sporadic cases in which the common bilious fever of Philadelphia had put on symptoms of great malignity, and terminated fatally in a few days, and now and then with a yellow colour on the skin, before or immediately after death.

On the 19th of this month I was requested to visit the wife of Mr. Peter Le Maigre, in Water-street, between Arch and Race-streets, in consultation with Dr. Foulke and Dr. Hodge. I found her in the last stage of a highly bilious fever. She vomited constantly, and complained of great heat and burning in her stomach. The most powerful cordials and tonics were prescribed, but to no purpose. She died on the evening of the next day.

Upon coming out of Mrs. Le Maigre's room I remarked to Dr. Foulke and Dr. Hodge, that I had seen an unusual number of bilious fevers, accompanied with symptoms of uncommon malignity, and that I suspected all was not right in our city. Dr. Hodge immediately replied, that a fever of a most malignant kind had carried off four or five persons within sight of Mr. Le Maigre's door, and that one of them had died in twelve hours after the attack of the disease. This information satisfied me that my apprehensions were well founded. The origin of this fever was discovered to me at the same time, from the account which Dr. Foulke gave me of a quantity of damaged coffee which had been thrown upon Mr. Ball's wharf, and in the adjoining dock, on the 24th of July, nearly in a line with Mr. Le Maigre's house, and which had putrefied there to the great annoyance of the whole neighbourhood.

After this consultation I was soon able to trace all the cases of fever which I have mentioned to this source. Dr. Hodge lived a few doors above Mr. Le Maigre's, where his child had been exposed to the exhalation from the coffee for several days. Mrs. Bradford had spent an afternoon in a house directly opposite to the wharf and dock on which the putrid coffee had emitted its noxious effluvia, a few days before her sickness, and had been much incommoded by it. Her sister, Mrs. Leaming, had visited her during her illness at her house, which was about two hundred yards from the infected wharf. Young Mr. M'Nair and Mrs. Palmer's two sons had spent whole days in a compting house near where the coffee was exposed, and each of them had complained of having been made sick by its offensive smell, and Mr. Aston had frequently been in Water-street near the source of the exhalation.

This discovery of the malignity, extent, and origin of a fever which I knew to be attended with great danger and mortality, gave me great pain. I did not hesitate to name it the bilious remitting yellow fever. I had once seen it epidemic in Philadelphia, in the year 1762. Its symptoms were among the first impressions which diseases made upon my mind. I had recorded some of these symptoms, as well as its mortality. I shall here introduce a short account of it, from a note book which I kept during my apprenticeship.

“In the year 1762, in the months of August, September, October, November, and December, the bilious yellow fever prevailed in Philadelphia, after a very hot summer, and spread like a plague, carrying off daily, for some time, upwards of twenty persons.

“The patients were generally seized with rigours, which were succeeded with a violent fever, and pains in the head and back. The pulse was full, and sometimes irregular. The eyes were inflamed, and had a yellowish cast, and a vomiting almost always attended.

“The 3d, 5th, and 7th days were mostly critical, and the disease generally terminated on one of them, in life or death.

“An eruption on the 3d or 7th day over the body proved salutary.

“An excessive heat and burning about the region of the liver, with cold extremities, portended death to be at hand.”

I have taken notice, in my note book, of the principal remedy which was prescribed in this fever by my preceptor in medicine, but this shall be mentioned hereafter.

Upon my leaving Mrs Le Maigre's, I expressed my distress at what I had discovered, to several of my fellow-citizens. The report of a malignant and mortal fever being in town spread in every direction, but it did not gain universal credit. Some of those physicians who had not seen patients in it denied that any such fever existed, and asserted (though its mortality was not denied) that it was nothing but the common annual remittent of the city. Many of the citizens joined the physicians in endeavoring to discredit the account I had given of this fever, and for a while it was treated with ridicule or contempt. Indignation in some instances was excited against me, and one of my friends, whom I advised in this early stage of the disease to leave the city, has since told me that for that advice “he had hated me.”

My lot in having thus disturbed the repose of the public mind, upon the subject of general health, was not a singular one. There are many instances upon record, of physicians who have rendered themselves unpopular, and even odious to their fellow-citizens, by giving the first notice of the existence of malignant and mortal diseases. A physician, who asserted that the plague was in Messina, in the year 1743, excited so much rage in the minds of his fellow-citizens against him, as to render it necessary for him to save his life by retreating to one of the churches of that city.

In spite, however, of all opposition, the report of the existence of a malignant fever in the city gained so much ground, that the governor of the state directed Dr. Hutchinson, the inspector of sickly vessels, to inquire into the truth of it, and into the nature of the disease.

In consequence of this order, the doctor wrote letters to several of the physicians in the city, requesting information relative to the fever. To his letter to me, dated the 24th of August, I replied on the same day, and mentioned not only the existence of a malignant fever, but the streets it occupied, and my belief of its being derived from a quantity of coffee which had putrified on a wharf near Arch-street. This, and other information collected by the doctor, was communicated to the health officer, in a letter dated the 27th of August, in which he mentioned the parts of the city where the disease prevailed, and the number of persons who had died of it, supposed by him to be about 40, but which subsequent inquiries proved to be more than 150. He mentioned further, in addition to the damaged coffee, some putrid hides, and other putrid animal and vegetable substances, as the supposed cause of the fever, and concluded by saying, as he had not heard of any foreigners or sailors being infected, nor of its being found in any lodging-houses, that “it was not an imported disease.”

In the mean while the disease continued to spread, and with a degree of mortality that had never been known from common fevers.

On the 25th of the month, the college of physicians was summoned by their president to meet, in order to consult about the best methods of checking the progress of the fever in the city. After some consideration upon the nature of the disease, a committee was appointed to draw up some directions for those purposes; and the next day the following were presented to the college, and adopted unanimously by them. They were afterwards published in most of the newspapers.

Philadelphia, August 26th, 1793.

The college of physicians having taking into consideration the malignant and contagious fever that now prevails in this city, have agreed to recommend to their fellow-citizens the following means of preventing its progress.

1st. That all unnecessary intercourse should be avoided with such persons as are infected by it.

2d. To place a mark upon the door or window of such houses as have any infected persons in it.

3d. To place the persons infected in the centre of large and airy rooms, in beds without curtains, and to pay the strictest regard to cleanliness, by frequently changing their body and bed linen, also by removing, as speedily as possible, all offensive matters from their rooms.

4th. To provide a large and airy hospital, in the neighbourhood of the city, for the reception of such poor persons as cannot be accommodated with the above advantages in private houses.

5th. To put a stop to the tolling of the bells.

6th. To bury such persons as die of this fever in carriages, and in as private a manner as possible.

7th. To keep the streets and wharves of the city as clean as possible. As the contagion of the disease may be taken into the body, and pass out of it without producing the fever, unless it be rendered active by some occasional cause, the following means should be attended to, to prevent the contagion being excited into action in the body.

8th. To avoid all fatigue of body and mind.

9th. To avoid standing or sitting in the sun; also in a current of air, or in the evening air.

10th. To accommodate the dress to the weather, and to exceed rather in warm, than in cool clothing.

11th. To avoid intemperance, but to use fermented liquors, such as wine, beer, and cyder, in moderation.

The college conceive fires to be very ineffectual, if not dangerous means of checking the progress of this fever. They have reason to place more dependence upon the burning of gunpowder. The benefits of vinegar and camphor are confined chiefly to infected rooms, and they cannot be used too frequently upon handkerchiefs, or in smelling-bottles, by persons whose duty calls to visit or attend the sick.

Signed by order of the college,
WILLIAM SHIPPEN, jun.
Vice president.
SAMUEL P. GRIFFITTS,
Secretary.

From a conviction that the disease originated in the putrid exhalations from the damaged coffee, I published in the American Daily Advertiser, of August 29th, a short address to the citizens of Philadelphia, with a view of directing the public attention to the spot where the coffee lay, and thereby of checking the progress of the fever as far as it was continued by the original cause.

This address had no other effect than to produce fresh clamours against the author; for the citizens, as well as most of the physicians of Philadelphia, had adopted a traditional opinion that the yellow fever could exist among us only by importation from the West-Indies.

In consequence, however, of a letter from Dr. Foulke to the mayor of the city, in which he had decided, in a positive manner, in favour of the generation of the fever from the putrid coffee, the mayor gave orders for the removal of the coffee, and the cleaning of the wharf and dock. It was said that measures were taken for this purpose; but Dr. Foulke, who visited the place where the coffee lay, repeatedly assured me, that they were so far from being effectual, that an offensive smell was exhaled from it many days afterwards.

I shall pass over, for the present, the facts and arguments on which I ground my assertion of the generation of this fever in our city. They will come in more properly in the close of the history of the disease.

The seeds of the fever, when received into the body, were generally excited into action in a few days. I met with several cases in which they acted so as to produce a fever on the same day in which they were received into the system, and I heard of two cases in which they excited sickness, fainting, and fever within one hour after the persons were exposed to them. I met with no instance in which there was a longer interval than sixteen days between their being received into the body and the production of the disease.

This poison acted differently in different constitutions, according to previous habits, to the degrees of predisposing debility, or to the quantity and concentration of the miasmata which had been received into the body.