Some fuch thing is wanting in these circumstances in malignant fevers with diffolved humours, both to prevent this gangrenous difpofition of the humours and sphacelation of the vifcera, as well as to fatisfy this vital indication which is most prevalent in them; but no medicine feems to anfwer; for thefe heating, ftimulating cordials only further diffolve the broken texture of the blood, and instead of relieving fweats, promote colliquative evacuations, and occafion fpafms and convulfions of the fibres. instead of restoring or preferving their tone. But in these circumftances, in malignant fevers with diffolved blood, the bark feems to be the only promising remedy: but this however, I should not have dwelt fo long upon at prefent, had I not known the bark to be given in this diftemper; to wit, about the height of the fever or state of the disease, when the fatal condition was just at hand, and that to the quantity of more than half an ounce of the powder in usual doses in a day's time; after which the perfon recovered, which would hardly have been the cafe in most other acute continual fevers, of the violence of this. I muft own this is but a fingle inftance, and not made with fufficient accuracy to determine fo important a point; and I know the dangerous confequence of drawing general rules from particular obfervations, the bane of phyfic, and reproach of human reafon: fo that I cannot any further recommend or condemn this practice, but think it for many cogent reasons highly worthy the further confideration of the skilful, on which account I could not pafs over this mention of it.

"But whatever may be the effects of the bark in this disease, yet I know it to be often neceffary and ufeful after it. There is a greater debility generally remains after the crifis, and the pulfe is weaker and lower, than after any disease I ever faw; the folids feem to have loft their elasticity, and the blood its due crafis. This makes purging, to prevent a relapfe, dangerous. At other times this fever, from an imperfect crifis, degenerates into a flow periodic fever of long continuance. In thefe conditions, feveral lofe their lives; but I have known others, who feemed to be in the like danger, to be faved by the bark: I have been VOL. I. D

informed by feveral judicious eye. witneffes, that this was the cafe of the foldiers and failors in the late American expedition; great numbers of whom died in this lingering condition after the fever.

"After the morbid humours are prepared or concocted, the next thing neceffary to be confidered, is the evacuation of them; in which three things are to be confidered. 1. When any artificial evacuation is neceffary to relieve or affist nature. 2. What kind of evacuations are most proper; and 3. The proper time

for these evacuations.

"As to the first, we must remember what we have above hinted; that about the time, when the yellowness appears, or about the state of the difeafe, the pulfe turns extremely weak and low, the debility is increased, and nature is unable to rid herself of any offenfive burden, at a time when she stands most in need of it: this is it, that makes artificial evacuations neceffary to affift the feeble efforts of languishing nature. It is true, the fole hopes of many, in these circumstances, are placed in cordials, to strengthen the body, as is the plaufible pretence: and evacuations are then dreaded above all things, on account of the debility, which it is feared they may increase. But the body is not to be strengthened, but by removing what weakens and oppreffes it, which feems to be here the diffolved ferous and bilious humours ftagnating in the capillaries, or thrown on the vifcera. And all these acute putrid fevers ever require fome evacuation to bring them to a perfect crisis and folution, and that even by ftools, which must be promoted by art, where nature does not do the business herself. On this account an ill-timed fcrupulousness about the weakness of the body is often of bad confequence in these urging circumstances, for it is that which feems chiefly to make evacuations neceffary, which nature ever attempts, after the humours are fit to be expelled, but is not able to accomplish, for the most part in this disease. And I can affirm, that I have given a purge in this cafe, when the pulfe has

* Una igitur alvi spontanea folutio atque perturbatio continuam febrem tuto ac perfecte judicat, &c. Fernel. Feb. cur. Method. c. 8.

been fo low, that it could hardly be felt, and the debility extreme; both one and the other being restored by it. Another thing which makes artificial evacuations the more neceffary now, is the diffufion of a new morbid matter through the blood, which caufes the icterus different from that which firft brought on the fever, when nature is almost overcome by the conflict with the first. Evacuations are likewife the more requifite at laft, if the neceffary ones have been neglected at first.

"The next thing to be confidered, is the kind of evacuation to be promoted; the most beneficial I have always found to be procured by lenitive cholagogue purges. Sanctorius indeed tells us, that the matter of malignant fevers is discharged by infenfible perfpiration, which is the general aim of physicians to obtain in these kinds of fevers, in which they feldom confider that hardly any putrid continual fever comes to a perfect crisis by fweats alone.* But in this particular fever, whenever any yellowness, even in the eyes, appears, we are entirely frustrated in our expectation of obtaining any relief from diaphoretics, in order to carry it off. This icterus proceeds from a matter which feems to be too vifcid to pass off through the narrow pores of the skin, and never goes off entirely and perfectly by any ways whatever, whether the contrivance of nature or art, that ever I could obferve, but by a turbid yellow lateritious urine or loofe ftools. The fame obfervation is confirmed by Hippocrates, who adds to these falutary discharges, in an icterus coming on a fever, a plentiful bleeding at the nofe (Epidem. l. 1. § 3.) Nay the fever itself, when little or no yellowness appears, is hardly to be carried off entirely without purging; for when this indication is neglected, when it first offers (all changes being generally fudden,) the fever returns with exacerbations, like the putrid fever coming after an imperfect expulfion of the variolous matter in the small-pox; and as often proves mortal in this cafe, as in any other. It is true we do fometimes fee the fever brought to an apyrexy without purging, when accompa

* Fernel. Feb. cur. Method. c. 8.

nied with little or no yellowness, but very feldom when it is; but even then the crifis is imperfect, and the distemper is fubject to frequent and severe relapses; and often degenerates into a flow periodic and long continued fever, which gradually waftes and confumes the body, when this neceffary rule of practice is not rightly complied with in time."*

THE following obfervations were found on a loose paper in the book from whence the preceding pages were taken. They are the production of Dr. Kearsley, fen. a physician of great respectability then refident in Philadelphia.

"TH

"HE yellow fever in Virginia feems well described by Dr. Mitchell, but it differs from that which appeared in Pennsylvania at the fame period of time in the following particulars.

* The following Note occurs in Miller's Retrospect, vol. 2. p. 367. " Dr. JOHN MITCHELL, who was mentioned in a former chapter, as having come from England to Virginia early in the last century, appears to have been a man of observation, acuteness, and enterprise, as well as of learning. His refidence in Virginia was chiefly at Urbanna, a small town on the Rappahannock, about feventy-three miles from Richmond. He was a great botanist, and seems to have paid particular attention to the Hybrid productions. He wrote an useful work on the general principles of Botany, and containing descriptions of a number of new genera of plants, which was published in 4to. in 1769. He also wrote, in 1743, an Essay on the Caufes of the different Colours of People in different Climates,' which was fent over to Mr. COLLINSON, and published in the Philofophical Transactions, vol. xliii. p. 102-150. Besides these, he published an Efay on the Preparations and Ufes of the various Kinds of Pet-Afb. Philofophical Tranfactions, vol. xlv. p. 541-563; and a Letter concerning the Force of Electrical Cobefion.' Philofophical Transactions, vol. li. p. 390. See Pulteney's Sketches of the Progress of Botany, &c. vol. ii. p. 278, &c. It is believed the fame man was the author of the Map of North America, published in 1755, which he accompanied with a large Pamphlet, entitled, The Contest in America;' and foon followed by another pamphlet, entitled, The prefent ftate of Great-Britain and North America,' 1767. See American Husbandry, &c. vol. i. p. 285.

6

1. Wandering pains like thofe attending a rheumatic fever, but much more fevere, were generally much complained of from the first, by those who had the disease in Pennsylvania. These are not mentioned by Dr. Mitchell.

"2. A very great anxiety with ficknefs and pain of the stomach, attended with an exceffive convulfive vomiting, which no medicine would fcarce relieve. This appeared on the first or fecond day, but more commonly on the third, when it was generally fatal, by bringing on hiccough, inflammation of the ftomach and vifcera, with a large discharge by vomit, of a black atra-bilious matter like coffee grounds, mixed with a bloody lymph, or coagulated blood; which frequently put a period to the patient's life; though fome recovered under this symptom, by an early discharge of this black matter by ftool.

"3. The atra-bilious humour, as Dr. Mitchell calls it, was highly acrid, yet not fo vifcid as that in Virginia; which gave it a more easy paffage through the biliary ducts; and being thereby more easily pumped up by the convulfive reachings of the ftomach; hence by its greater acrimony it rendered this symptom more violent and fatal, than it seems to have been in Virginia."