The fever, in its favourable iffue, would fometimes terminate in a tedious quotidian or tertian ague; and in fome.instances in hypocondriafis. A termination by sweat was an occurrence fo rare as never to be expected. Bruce has mentioned a dangerous bilious diarrhoea attending occafionally the conclufion of the fever. I never observed this circumstance in any case under my notice. A favourable crifis occurred on the second and third days on feveral occafions, when medical affiftance had been early administered: but it took place generally within five or feven days, although it was fometimes protracted fourteen days.

The termination of the disease by death, occurred most frequently on the fourth or fixth days. But while many perfons died in the courfe of twelve, eighteen, twenty-four, and thirty hours, others lingered till the thirteenth and fourteenth days. The fatal clofe of the fever exhibited very different appearances, according to its violence and the previous mode of treatment. Clark and Balfour have ascribed the termination in death of bilious fevers generally to morbid congestions. It is very probable their opinions are juft. I obferved the following fymptoms attending this diftreffing period: Hæmorrhages-acute pains-delirium-mania and violent convulfions accompanied the last hours of fome. But the greater number, whom I saw, glided almost infenfibly out of life. ADIEU.*

Although the ingenious and amiable author of thefe valuable letters has embraced the doctrine of the contagious nature of the yellow fever, yet it must be remembered that it was then a doctrine which had never been opposed; from my intimate acquaintance with him I have little hesitation in believing, that had his life been spared, he would have become a powerful advocate for the oppofite opinion.-Editor.

(To be continued.)

For the Philadelphia Medical Museum.

An Account of the SALUTARY EFFECTS of LIGATURES in the laft Stage of a violent Cafe of Yellow Fever. By JAMES STUART, M.D. of Philadelphia.

EPTEMBER 23, 1798, S———— S― a young woman of this city, aged twenty years, and of a found conftitution, was feized with very violent fymptoms of the epidemic then prevailing. When I first visited her, fhe loft by my direction, twenty ounces of blood from the arm; after which fhe took dofes of ten grains of calomel and ten grains of jalap, every three hours until they operated. Large and frequent doses of calomel joined with mercurial frictions, and occafional bloodlettings were then prescribed; fo that by the twenty-feventh of the month and the fourth from the attack, she had loft seventy or eighty ounces of blood; had taken one hundred grains of calomel, and twelve ounces of the strongest mercurial ointment had been rubbed in on the extremities without any good effect. On the twenty-feventh debility was great,-fhe fighed much,was very restlefs,---complained of an intolerable fenfation of burning in the ftomach, and was haraffed with repeated and frequent efforts to vomit, without difcharging any thing except mucus, white flakes, and the liquids laft taken in. Blisters were now applied to the epigastric region, and to the upper and lower extremities, which were removed in about ten or twelve hours afterwards, when the cuticle was found distended with a yellow coagulable lymph, that preserved its form without any foreign fupport.

On the morning of the twenty-eighth the vomiting still continued; the lower extremities were cold, and the pulse almost imperceptible: fingultus was at times very diftreffing: the

pulfations of the heart and carotid arteries were fo violent, as to be perceptible to the eye in the motion of the bed-clothes. This laft fymptom fuggefled to me the propriety, if not the neceffity, of farther blood-letting; while extreme debility and an almost evanefcent pulfe as ftrongly forbade it. In this dilemma, anxious for the recovery of my patient, and forfaken by the great mafters in our art, I tied a ligature on each arm, near the middle of the humerus, tight enough to impede the return of the blood in the veins, and not fo tight as to ftop the faint pulfations of the arteries. The veins were not turgid in less than fifteen minutes. Shortly afterwards, the fingers became violently contracted with convulfive fpafms; the wrifts were foon drawn into confent, and the patient complained that they were much affected with pain. Apprehending the fpafms might become more general, the ligatures were removed, and in ten minutes the fpafms were relaxed alfo. The ligatures were again applied and relaxed with exactly the fame effects, so that in ten minutes, I now could with the greatest ease and certainty convulfe and relax the fingers at pleasure. This alternate application and removal was continued for nearly two hours, while the pulfe was perceived to grow gradually stronger; the pulfations of the heart and carotid arteries became more tranquil; the anorexia and vomiting was lefs and lefs frequent; anxiety declined, mufcular ftrength increafed, the extremities, with these changes, refumed their natural heat; and I had the pleasure to hear from my patient fhe was much relieved. I, now thinking it unneceffary to continue the ligatures, repeated the calomel and frictions alone. On the fucceeding night fymptoms of ptyalifin appeared, and on the twenty-ninth of the month, and the fixth of the difeafe, she became convalefcent.

In pursuance to the fuccefs attending this my first experiment, with a view more fully to afcertain the effects of ligatures on the circulatory fyftem, I began, on the feventh of December, 1798, fome experiments on my own person,

At ten o'clock A. M. after breakfasting sparingly, my pulse was unufually hard, and at feventy-fix in the minute; a liga

ture was tied on each thigh; in ten minutes, my pulfe was perceptibly lefs hard; in twenty, much fofter and the pulfations increased in number to eighty-eight; at half past ten, foft and ftill at eighty-eight; I became languid and fleepy, and the ligatures were removed; in ten minutes afterwards the pulfe was fuller and fell to eighty-four; in twenty, the fame; in half an hour, at eighty and full: in an hour still the fame.

It is much to be regretted that numerous engagements, have as yet, prevented my pursuing thofe experiments far enough, to place the effects of the remedy in confideration beyond the pale of scepticism; yet it is confidently hoped even these may be fufficient to recommend a trial of that, which promises fuccour to the fufferings of man at a period when art generally fails in her refources, and his sympathising fellows overwhelmed with defpair, confign him to his fate!

Mr. Kelly of Leith attempted to fhorten the cold ftage of intermittents, by fufpending the circulation in a part of the arterial fyftem, by means of ligatures on the extremities, and in a number of cafes very happily fucceeded. He fuppofes the application of the Tourniquet, "increases the velocity and momentum of the circulatory fyftem." That it does, when applied as he used it, tight enough to obftruct the motion of the blood in the arteries of the extremities, must be evident; but it is equally obvious, and a fact which has never before been properly appreciated, that an obstruction to its return to the heart by the veins, while the arteries remain free to act, must be attended with a revulfion from, and confequently a diminution of action in, the heart and larger arteries.

The foregoing experiments, therefore, fhew,

ift. That ligatures on the extremities, when only strait enough. to obftruct the blood in the veins; reduce the pulse, and diminifh the excitement, precifely in the fame manner that bloodletting does.

2d. That excitement is the fame in every different system in the animal machine, as was fully exemplified in the convulsions

of the mufcular fyftem, which fucceeded the decline of exceffive action in a portion of the arterial fsystem.

3d. That a tranflation* from one fyftem to another, or from one to another part of the fame fyftem, eafily takes place.

4th. That there is in fome states of fever, a concentration of excitement, and an accumulation of blood in the heart and larger veffels, while the pulfe and circulation on the extremities are languid and deficient.

5th. That the debility of the voluntary functions in the malignant state of fever, is occafioned by a fulness of the larger veffels of the brain, producing compreffion in the origin of the nerves, and by a partial interruption of the circulation in the fmaller order of blood vessels interfperfed between the fibres of the mufcles, on which those functions depend.

6th. and laft. That ligatures, by detaining the fluids from the heart and larger veffels, and by accumulating them in those of the extremities, may fo tranflate and dispose of the excitement, as to prove a most invaluable remedy in fome states of fever where bloodletting would be inadmiffible.

"In febre," fays Sauvages, "vires cordis et arteriarum multúm increfcunt ; aft illicò vires ftomachi, vires artuum, vires imaginationis, attentionis ad negotia moralia minuuntur, venus filet; in foporofis morbis infarctum eft cerebrum ant cerebellum, conatus cerebri & meningum intenduntur, verum ea molimina dependent à viribus cordis ; ergo vires cordis fæpiùs intenduntur, ut in apoplexia; cæteri verò artus, cætera fenfuum organa fluido nerveo defraudantur." Nofolog. Tom. I. pag. 78. fect. 344.

cr

+ "Sic in agonem ducentibus," fays the author before quoted, " licet conatus interni fint vehementiffimi, ut patet ex interni caloris intenfitate, tamen pulfus eft debilis, feu exilis et mollis, quia maxima pars virium abfumitur intra cor et majora vasa, nec nifi pars eorum exigua fuperftes ad arterias minores pertingit, in quibus explorari poteft." Vid. Nofolog. Tom. I. pag. 77. fect. 340.