The Project Gutenberg eBook of Medical Inquiries and Observations, Vol. IV (of 4), by Benjamin Rush

Footnote:

[9] This extensive district is continued, from the city of Philadelphia, along the Delaware, but is not subject to its government.

AN INQUIRY
INTO
THE VARIOUS SOURCES
OF THE USUAL FORMS OF
SUMMER & AUTUMNAL DISEASE
IN THE UNITED STATES,
AND THE MEANS OF PREVENTING THEM.

I. To enumerate the various sources of the usual forms of the summer and autumnal disease in the United States. And,

To render the application of those means as extensive as possible, it will be proper to mention, under the first head, all those sources of summer and autumnal disease, which have been known to produce it in other countries, as well as in the United States. They are,

1. Exhalations from marshes. These are supposed to be partly of a vegetable, and partly of an animal nature. They are derived from the shores of creeks and mill ponds, as well as from low and wet grounds; also from the following vegetable substances in a state of putrefaction.

2. Cabbage. A malignant fever was produced at Oxford, by a putrid heap of this vegetable some years ago, which proved fatal to many of the inhabitants, and to several of the students of the university at that place.

3. Potatoes. Nearly a whole ship's crew perished at Tortola, by removing from her hold, a quantity of putrid potatoes.

9. Coffee. “About the time,” says Dr. Trotter, “when notice was taken of the putrifying coffee on the wharf at Philadelphia, in the year 1793, a captain of a man of war, just returned from the Jamaica station, informed me, that several vessels laden with the same produce came to Kingston, from St. Domingo. During the distracted state of that colony, this article, with other productions, had been allowed to spoil and ferment. The evolution of a great quantity of fixed air, or carbonic acid gas, was the consequence; and in these vessels, when opening the hatchways, such was its concentrated state, that the whole of the crew, in some of them, were found dead on the deck. A pilot boarded one of them in this condition, and had nearly perished himself [10].”

11. Cotton which had been wetted on board of a vessel that arrived in New-York, a few years ago, from Savannah, in Georgia.

14. Old books, and old paper money, that had been wetted, and confined in close rooms and closets.

15. The timber of an old house. A fever produced by this cause is mentioned by Dr. Haller, in his Bibliotheca Medicinæ.

16. Green wood confined in a close cellar during the summer months. A fever from this cause was once produced in this city, in a family that was attended by the late Dr. Cadwallader.

17. The green timber of a new ship. Captain Thomas Bell informed me, that in a voyage to the East-Indies, in the year 1784, he lost six of his men with the scurvy, which he supposed to be derived wholly from the foul air emitted by the green timber of his ship. The hammocks which were near the sides of the ship rotted during the voyage, while those which were suspended in the middle of the ship, retained their sound and natural state. This scurvy has been lately proved by Dr. Claiborne, in an ingenious inaugural dissertation, published in Philadelphia, in the year 1798, to be a misplaced state of malignant fever. Dr. Lind mentions likewise the timber of new ships as one of the sources of febrile diseases. The timber of soldiers' huts, and of the cabins of men who follow the business of making charcoal in the woods, often produce fevers, as soon as the bark begins to rot and fall from them, which is generally on the second year after they are erected. Fevers have been excited even by the exhalation from trees, that have been killed by being girdled in an old field.

23. The matters which usually stagnate in the gutters, common sewers, docks, and alleys of cities, and in the sinks of kitchens. A citizen of Philadelphia, who had a sink in his kitchen, lost a number of cats and dogs by convulsions. At length one of his servants was affected with the same disease. This led him to investigate the cause of it. He soon traced it to his sink. By altering its construction, so as to prevent the escape of noxious air from it, he destroyed its unwholesome quality, so that all his domestics lived in good health in his kitchen-afterwards.

24. Air emitted by agitating foul and stagnating water. Dr. Franklin was once infected with an intermitting fever from this cause.

25. A duck pond. The children of a family in this city were observed, for several successive years, to be affected with a bilious remitting fever. The physician of the family, Dr. Phineas Bond, observing no other persons to be affected with the same fever in the neighbourhood, suspected that it arose from some local cause. He examined the yard belonging to the house, where he found an offensive duck pond. The pond was filled with earth, and the family were afterwards free from an annual bilious fever.

26. A hog-stye has been known to produce violent bilious fevers throughout a whole neighbourhood in Philadelphia.

Fevers are less frequently produced by putrid animal, than by putrid vegetable matters. There are, however, instances of their having been generated by the following animal substances in a state of putrefaction.

6. A large bed of oysters. The malignant fevers which prevailed in Alexandria, in Virginia, in 1803, and in Southwark, adjoining Philadelphia, in the year 1805, were derived from this cause [11].

8. Privies. The diarrhœa and dysentery are produced, oftener than any other form of summer and autumnal disease, by the fœtor of privies. During the revolutionary war, an American regiment, consisting of 600 men, were affected with a dysentery, from being encamped near a large mass of human fæces. The disease was suddenly checked by removing their encampment to a distance from it. Five persons in one family were affected with the yellow fever in Philadelphia, in 1805, who lived in a house in which a privy in the cellar emitted a most offensive smell. No one of them had been exposed to the foul air of Southwark, in which the fever chiefly prevailed in the autumn of that year. Three of them sickened at the same time, which obviated the suspicion of the disease being produced by contagion.

There are several other sources of malignant fevers besides those which have been mentioned. They are, exhalations from volcanoes, wells, and springs of water; also flesh [12], fish, and vegetables, eaten in a putrid state; but these seldom act in any country, and two of them only, and that rarely, in the United States.

The usual forms of the disease produced by miasmata from the sources of them which have been enumerated are,

In deriving all the above forms of disease from miasmata, I do not mean to insinuate, that sporadic cases of each of them are not produced by other causes.

In designating them by a single name, I commit no breach upon the ancient nomenclature of medicine. The gout affects not only the blood-vessels and bowels, but every other part of the body, and yet no writer has, upon that account, distinguished it by a plural epithet.

The four last of the forms of disease, that have been mentioned, have been very properly called intestinal states of fever. They nearly accord, in their greater or less degrees of violence and danger, with the first four states of fever which occupy the blood-vessels, and in the order in which both of them have been named. I shall illustrate this remark by barely mentioning the resemblance of the yellow fever to the dysentery, in being attended with costiveness in its first stage, from a suspended or defective secretion or excretion of bile, and in terminating very generally in death, when not met by the early use of depleting remedies.

The variety in the forms and grades of the summer and autumnal disease, in different seasons, and their occasional changes into each other in the same seasons, are to be sought for in the variety of the sensible and insensible qualities of the atmosphere, of the course of the winds, and of the aliments of different years.

II. The means of preventing the different forms of disease that have been mentioned, come next under our consideration.

Happily for mankind, Heaven has kindly sent certain premonitory signs of the most fatal of them. These signs appear,

I. Externally, in certain changes in previous diseases, in the atmosphere, and in the animal and vegetable creation.

1. The first external premonitory sign that I shall mention is, an unusual degree of violence in the diseases of the previous year or season. Many proofs of the truth of this remark are to be met with in the works of Dr. Sydenham. It has been confirmed in Philadelphia, in nearly all her malignant fevers since the year 1793. It would seem as if great and mortal epidemics, like the planets, had satellites revolving round them, for they are not only preceded, but accompanied and followed, by diseases which appear to reflect back upon them some of their malignity. But there is an exception to this remark, for we now and then observe uncommon and general healthiness, before the appearance of a malignant epidemic. This was the case in Philadelphia, previously to the fevers of 1798 and 1799. I have ascribed this to the stimulus of the pestilential miasmata barely overcoming the action of weak diseases, without being powerful enough to excite a malignant fever.

2. Substances, painted with white lead, and exposed to the air, suddenly assuming a dark colour; and winds from unusual quarters, and unusual and long protracted calms, indicate the approach of a pestilential disease. The south winds have blown upon the city of Philadelphia, ever since 1793, more constantly than in former years. A smokiness or mist in the air, the late Dr. Matthew Wilson has remarked, generally precedes a sickly autumn in the state of Delaware.

3. Malignant and mortal epidemics are often preceded by uncommon sickness and mortality among certain birds and beasts. They have both appeared, chiefly among wild pigeons and cats in the United States. The mortality among cats, previous to the appearance of epidemics, has been taken notice of in other countries. Dr. Willan says it occurred in the city of London, between the 20th of March and the 20th of April, in the year 1797, before a sickly season, and Dr. Buneiva says it preceded a mortal epidemic in Paris. The cats, the doctor remarks, lose, on the second day of their disease, the power of emitting electrical sparks from their backs, and, when thrown from a height, do not, as in health, fall upon their feet [13].

4. The common house fly has nearly disappeared from our cities, moschetoes have been multiplied, and several new insects have appeared, just before the prevalence of our late malignant epidemics.

5. Certain trees have emitted an unusual smell; the leaves of others have fallen prematurely; summer fruits have been less in size, and of an inferior quality; and apples and pears have been knotty, in the summers previous to several of our malignant autumnal fevers. Dr. Ambrose Parey says, an unusually rapid growth of mushrooms once preceded the plague in Paris.

II. The premonitory signs of an approaching malignant epidemic in the human body are,

1. A sudden drying up, or breaking out of an old sore; fresh eruptions in different parts of the body; a cessation of a chronic disease, or a conversion of a periodical into a continual disease. Of this there were many instances in Philadelphia, in the year 1793.

2. A peculiar sallowness of the complexion. This was observed to be general in Philadelphia, previous to the yellow fever of 1793. Dr. Dick informed me, that he had observed the same appearance in the faces of the people of Alexandria, accompanied in some cases with a yellowness of the eyes, during the summer of 1793, and previous to the appearance of a violent bilious fever on the banks of the Potomac.

3. I have observed one or more of the following symptoms, namely, head-ach; a decay, or increase of appetite; costiveness; a diminished or increased secretion of urine; a hot and offensive breath [14]; constant sweats, and sometimes of a fœtid nature, or a dry skin; wakefulness, or a disposition to early or protracted sleep; a preternaturally frequent pulse; unusual vivacity, or depression of spirits; fatigue and sweats from light exertions; hands, when rubbed, emitting a smell like hepar sulphuris; and, lastly, a sense of burning in the mouth; to be present in different persons, during the prevalence of our malignant epidemics.

The means of preventing the different forms of our summer and autumnal disease come next under our consideration. I shall first mention such as have been most effectual in guarding against its malignant form, and afterwards take notice of such as are proper in its milder grades. These means naturally divide themselves again,

Where flight is practicable, it should be resorted to in every case, to avoid an attack of a malignant fever. The heights of Germantown and Darby have, for many years, afforded a secure retreat to a large number of the citizens of Philadelphia, from their late annual epidemics. It were to be wished our governments possessed a power of compelling our citizens to desert the whole, or parts, of infected cities and villages. In this way the yellow fever was suddenly annihilated in Providence, on Rhode-Island, and in New-Haven, in Connecticut, in the year 1805. But the same power should rigorously prevent the removal of the sick, except it be that class of them which have neither homes nor friends. The less the distance they are carried beyond the infected atmosphere, the better. The injury sustained by conveying them in a jolting carriage, for two or three miles, has often been proclaimed in the reports of our city hospitals, of patients being admitted without a pulse, and dying a few hours afterwards.

In leaving a place infected by miasmata, care should be taken not to expose the body to great cold, heat, or fatigue, for eighteen or twenty days, lest they should excite the dormant seeds of the disease into action.

But where flight is not enforced by law, or where it is not practicable, or preferred, safety should be sought for in such means as reduce the preternatural tone and fulness induced in the blood-vessels by the stimulus of the miasmata, and the suppression of customary secretions. These are,

1. A diet, accommodated to the greater or less exposure of the body to the action of miasmata, and to the greater or less degrees of labour, or exercise, which are taken. In cases of great exposure to an infected atmosphere, with but little exercise, the diet should be simple in its quality, and small in its quantity. Fresh meats and wine should be avoided. A little salted meat, and Cayenne pepper with vegetables, prevent an undue languor of the stomach, from the want of its usual cordial aliments. The less mortality of the yellow fever in the French and Spanish West-India islands than in the British, has been justly attributed to the more temperate habits of the natives of France and Spain. The Bramins, who live wholly upon vegetables, escape the malignant fevers of India, while whole regiments of Europeans, who eat animal food, die in their neighbourhood. The people of Minorca, Dr. Cleghorn says, who reside near gardens, and live chiefly upon fruit during the summer, escape the violent autumnal fever of that island. The field negroes of South-Carolina owe their exemption from bilious fevers to their living chiefly upon vegetables. There is a fact which shows, that not only temperance, but abstinence bordering upon famine, has afforded a protection from malignant fevers. In a letter which I received a few months ago, from the Rev. Thomas Hall, chaplain to the British factory at Leghorn, containing an account of the yellow fever which prevailed in that city, in the summer and autumn of 1804, there is the following communication. “Of the rich, who live in large airy houses, there died but four persons with the fever. Of the commodious, who live comfortably, but not affluently, there died ten. Of the poor, who inhabited small and crowded rooms, in the dirty and confined parts of the city, there died nearly seven hundred. But of the beggars, who had scarcely any thing to eat, and who slept half naked every night upon hard pavements, not one died.” From the reduced and exhausted state of the system in these people, they were incapable, if I may be allowed the expression, of the combustion of fever. Persons reduced by chronic diseases, in like manner, often escape such as are acute. Six French ships of the line landed 300 sick, at St. Domingo, while the yellow fever prevailed there in the year 1745, and yet no one of them was infected by it [15].

Where the body is exposed to miasmata, and a great deal of exercise taken at the same time, broths, a little wine, or malt liquors, may be used with the fruits and garden vegetables of the season, with safety and advantage. The change from a full to a low diet should be made gradually. When made suddenly, it predisposes to an attack of the disease.

2. Laxative medicines. Hundreds, perhaps thousands, of the citizens of Philadelphia were indebted for their preservation from the yellow fever to the occasional use of a calomel pill, a few grains of rhubarb, or a table-spoonful of sweet, or castor oil, during the prevalence of our late pestilential fevers. Even the air of Batavia has been deprived of its poisonous quality, by means of this class of medicines. A citizen of Philadelphia asked a captain of a New-England ship, whom he met at that island, how he preserved the whole crew of his ship in health, while half the sailors of all the other ships in the harbour were sick or dead. He informed him, that it was by giving each of them a gentle purge of sulphur every day.

3. A plentiful perspiration, or moderate sweats, kept up by means of warm clothing and bed-clothes. The excretion which takes place by the skin, is a discharge of the first necessity. I have never known an instance of a person's being attacked by the yellow fever in whom this discharge was constant, and equally diffused all over the body. Its effects are equally salutary in preventing the plague. So well known is this fact, that Mr. Volney informs us, in his Travels into Egypt, that the common salutation at Cairo, during the prevalence of the plague, is, “Do you sweat freely?” For the purpose of promoting this excretion, flannel shirts or waistcoats worn next to the skin have been found more useful than linen. As the perspiration and sweats, which are thus discharged in a pestilential season, are often unusual in their quantity, and of a morbid quality, clean body-linen or flannel should be put on every day, and where this is not practicable, that which has been worn should be exchanged every morning and evening for that which has been exposed during the previous day and night, in a dry air.

4. Blood-letting. In addition to the authorities of Dr. Haller and Dr. Hodges, mentioned in another place [16], in favour of this remedy, I shall subjoin a few others. Dr. Mitchell, in his Account of the Yellow Fever which prevailed in Virginia, in the year 1741, informs us, that it was often prevented in persons who were under the influence of its remote cause, by the loss of a few ounces of blood. It was formerly a practice among the physicians in St. Domingo, to bleed whole regiments of troops as soon as they arrived from France, by which means they were preserved from the malignant fever of the island.

During the short visit paid to this city, in the year 1798, by Dr. Borland, a respectable physician of the British army, he put into my hands the following communication. “In the beginning of August, 1797, 109 Dutch artillery arrived at Port au Prince, in the Bangalore transport. The florid appearance of the men, their cumbersome clothing, and the season of the year, seemed all unfavourable omens of the melancholy fate we presumed awaited them. It was, however, thought a favourable opportunity, by Dr. Jackson and myself, to try what could be done in warding off the fever. It was accordingly suggested to Monsieur Conturier, the chief surgeon of the foreign troops, and the surgeon of the regiment, that the whole detachment should be blooded freely, and that, the morning after, a dose of physic should be administered to every man. This was implicitly complied with, a day or two after, and at this moment in which I write, although a period of four months has elapsed, but two of that detachment have died, one of whom was in a dangerous state when he landed. A success unparalleled during the war in St Domingo! It is true, several have been attacked with the disease, but in those the symptoms were less violent, and readily subsided by the use of the lancet.

“The crew of the Bangalore, on her arrival at Port au Prince, consisted of twenty-eight men. With them no preventive plan was followed. In a very few weeks eight died, and at present, of the original number, but fourteen remain.”

All these depleting remedies, whether used separately or together, induce such an artificial debility in the system, as disposes it to vibrate more readily under the impression of the miasmata. Thus the willow rises, after bowing before a blast of wind, while the unyielding oak falls to the ground by its side. It is from the similarity of the natural weakness in the systems of women, in the West-Indies, with that which has been induced by the artificial means that have been mentioned, that they so generally escape the malignant endemic of the islands.

A second class of preventives of malignant fever are such as obviate the internal action of miasmata, by exciting a general or partial determination to the external surface of the body. These are,

1. The warm bath. I have known this grateful remedy used with success in our city. It serves the treble purposes of keeping the skin clean, and the pores open, and of defending what are called the vital organs from disease, by inviting its remote cause to the external surface of the body.

2. The cold bath, or cold water applied to the external surface of the body. Ulloa, in his travels through Cuba, tells us the Spaniards make it a practice, when partially wetted by the rain, to plunge themselves, with their wet clothes on, into the first stream of water they meet with afterwards, by which means they avoid taking the fever of the island. Where this cannot be conveniently done, the peasants strip off their clothes, and put them under a shelter, and receive showers of rain upon their naked bodies, and thus preserve themselves from the fever. Dr. Baynard has left it upon record, in his treatise upon the cold bath, that those persons who lived in water-mills, also watermen, bargemen, and fishermen, who were employed upon the river, and in dabbling in cold water, were rarely affected by the plague in London, in 1665, and that but two persons died with it on London bridge. The water carriers at Cairo, Mr. Volney says, uniformly escape the plague; and Dr. Chisholm informs us, that those negroes in Demarara who go naked, and are thereby disposed not to avoid showers of rain, are never affected with the fever of that country.

3. Washing the body, every morning and evening, with salt water. A whole ship's crew from Philadelphia was preserved by this means from the yellow fever, some years ago, in one of the West-India islands, while a large proportion of the crews of several ships, that lay in the same harbour, perished by that disease.

4. Anointing the body with oil. The natives of Africa, and some American Indians, use this preventive with success during their sickly seasons. It has lately been used, it is said, with effect in preventing the plague. Its efficacy for that purpose was first suggested by no oilman having died of that disease during four years, in which time 100,000 people perished with it in Egypt. Oliver, in his Travels into that country, says the men who make and sell butter, are equally fortunate in escaping it.

5. Issues, setons, and blisters belong to this class of preventives of malignant and bilious fevers. Issues, according to Parisinus, Florentinus, Forestus, and several other authors quoted by Diemerbroeck, have prevented the plague in many hundred instances. Paræus says, all who had ulcers from the venereal disease, or any other cause, escaped it. Dr. Hodges owed his preservation from the plague in London, in 1665, to an issue in his leg. He says he always felt a slight pain in it when he went into a sick room. Dr. Gallaher ascribed his escape from the yellow fever of 1799 to a perpetual blister, which he applied to his arm for that purpose. Dr. Barton favoured me with the sight of a letter from Dr. James Stevens, dated January 12, 1801, in which he says he believed Dr. Beach (formerly of Connecticut) had been preserved from the bilious fever by a seton in his side. He adds further, that Dr. Beach had been called to attend the labourers at the Onandoga salt springs, in the state of New-York, ninety-eight of whom out of a hundred had the bilious fever. Of the two who escaped it, one had a sore leg, the other what is called a scald-head. The discharge from the sores in each of them, as well as from the doctor's issue, was more copious during the prevalence of the fever, than it had been at any other time.

A third class of preventives of malignant fever, are such as excite a general action, more powerful than that which the miasmata are disposed to create in the system, or an action of a contrary nature. These are,

1. Onions and garlic. All those citizens who used these vegetables in their diet, escaped the yellow fever in 1793. The greater exemption of the natives of France from this disease, wherever they are exposed to it, than of the inhabitants of other European countries, has been ascribed in part to the liberal use of those condiments in their food. The Jews, it has been said, have often owed to them their preservation from the plagues which formerly prevailed in Europe. It is probable leeks and onions, which to this day form a material part of the diet of the inhabitants of Egypt, were cultivated and eaten originally as the means of obviating the plagues of that country. I have been at a loss to know why the Author of Nature, who has endowed these vegetables with so many excellent qualities for diet and medicine, should have accompanied them with such a disagreeable smell. Perhaps the reason was, kindly to force them into universal use; for it is remarkable their smell in the breath is imperceptible to those who use them.

2. Calomel, taken in such small doses as gently to affect the gums. It preserved most of the crew of a Russian ship at Plymouth, in the year 1777, from a fever generated by filth in her hold. In a letter which I received from Captain Thomas Truxton, in the year 1797, he informed me, that an old and respectable merchant at Batavia had assured him, he had been preserved in good health by calomel, taken in the way that has been mentioned, during the sickly seasons, for upwards of thirty years. The mortality of the fevers of that island may easily be conceived of, when I add, on the authority of a physician quoted in Sir George Staunton's Account of his Embassy to China, that one half of all new comers die there on the first year of their arrival.

Our principal dependence should be placed upon those two preventives under this head. There are several others which have been in common use, some of which I believe are hurtful, and the rest are of feeble, or doubtful efficacy. They are,

3. Wine and ardent spirits. They both prevent a malignant fever, only when they excite an action in the system above that which is ordinarily excited by the miasmata of the fever; but this cannot be done without producing intoxication, which, to be effectual, must be perpetual; for the weakness and excitability, which take place in the intervals of drunkenness, predispose to the disease. Agreeably to this remark, I observed three persons, who were constantly drunk, survive two of our most fatal epidemics, while all those persons who were alternately drunk and sober, rarely escaped an attack of the fever. In most of them, it terminated in death.

4. Tobacco. Many hundreds of the citizens of Philadelphia can witness, that no benefit was derived from this weed, in any of the ways in which it is commonly used, in the late epidemics of our city. Mr. Howard says it has no effect in preserving from the plague.

5. Camphor suspended in a bag round the neck, and rags wetted in vinegar, and applied to the nose. These means were in general use in the fever of 1793, in Philadelphia, but they afforded no protection from it. It is possible they had a contrary effect, by entangling, in their volatile particles, more of the miasmata of the fever, and thus increasing a predisposition to it.

A fourth class of the preventives of malignant fevers are certain substances which are said to destroy miasmata by entering into mixture with them. Two persons, who were very much exposed to the causes of the fever in 1798, took each of them a table spoonful of sweet oil every morning. They both escaped the fever. Did the oil, in these cases, act by destroying miasmata in the stomach chemically? or did it defend the stomach mechanically from their action? or did it prevent the disease, only by gently opening the bowels? It is certain the fat of pork meat protects the men who work in the lead-mines of Great-Britain from the deleterious effects which the fumes of that metal are apt to bring upon the stomach and bowels, and that a poisoned arrow, discharged into the side of a hog, will not injure him, if it be arrested by the fat which lines that part of his body.

The vapour which issues from fresh earth has been supposed to destroy the miasmata which produce malignant fevers, by entering into mixture with them. Most of the men who were employed in digging graves and cellars, and in removing the dirt from the streets of Philadelphia, in 1793, escaped the fever of that year. In the new settlements of our country, it is said, the poison of the rattlesnake is deprived of its deadly effects upon the body, by thrusting the wounded limb into a hole, recently made in the earth. The fable of Anteus, who rose with renewed strength from the ground after repeated falls, was probably intended to signify, among other things, the salutary virtues which are contained in the effluvia which issue from fresh clods of earth.

3. There are many facts which show the efficacy of the volatile alkali in destroying, by mixture, the poison of snakes. One of them was lately communicated to the public by Dr. Ramsay, of South-Carolina. What would be the effect of the daily use of a few tea spoonfuls of this medicine in a liquid form, and of frequently washing the body with it, during the prevalence of pestilential epidemics?

The miasmata which produce malignant fevers often exist in an inoffensive state in the body, for weeks, and perhaps months, without doing any harm. With but a few exceptions, they seldom induce a disease without the reinforcement of an exciting cause. In vain, therefore, shall we use all the preventives that have been recommended, without,

1. Heat and cold. While the former has excited the yellow fever in thousands, the latter has excited it in tens of thousands. It is not in middle latitudes only that cold awakens this disease in the body. Dr. Mosely says it is a more frequent exciting cause of that, and of other diseases, in the island of Jamaica, than in any of the most temperate climates of the globe. It is this which renders cases of yellow fever, when epidemic in our cities, more numerous in the cool months of September and October, than in July and August. For the purpose of avoiding this pernicious and universal influence of cold, the clothing and bed-covers should be rather warmer in those months, in middle and northern latitudes, than is agreeable, and fires should be made every morning and evening in common sitting rooms, and during the whole day, when the weather is damp or cool. They serve, not only to prevent the reduction of the excitement of the blood-vessels, by the gradual and imperceptible abstraction of the heat of the body, but to convey up a chimney all the unwholesome air that accumulates in those rooms during a sickly season. By these precautions, I have known whole families preserved in health, while all their neighbours who neglected them, have been confined by a prevailing autumnal fever.

4. Fatigue from amusements, such as fishing, gunning, and dancing, and from unusual labour or exercise. The effects of fatigue from this cause have been already noticed [17], in the maids of large families being the only persons who die of the fever, in consequence of their having performed great and unusual services to those branches of the family who survive them, while nurses, who only exercise their ordinary habits in attending sick people, are seldom carried off by it.

6. Partaking of new aliments and drinks. The stomach, during the prevalence of malignant fevers, is always in an irritable state, and constantly disposed to be affected by impressions that are not habitual to it.

8. The entire cessation of moderate labour. This, by permitting the mind to ramble upon subjects of terror and distress, and by exposing the body to idleness and company, favours an attack of fever. A predisposition to it, is likewise created by alternating labour and idleness with each other.

9. The continuance of hard labour. The miasmata which produce malignant fevers sometimes possess so much force, that the least addition to it, even from customary acts of labour, is sufficient to excite the disease. In this case, safety should be sought in retirement, more especially by those persons whose occupations expose them to the heat of fires, and the rays of the sun, such as hatters, smiths, bricklayers, and house and ship carpenters. The wealthy inhabitants of Constantinople and Smyrna erroneously suppose they escape the contagion of the plague, by shutting themselves up in their houses during its prevalence. They owe their preservation chiefly to their being removed, by an exemption from care and business, from all its exciting causes. Most of the nobility and gentry of Moscow, by these means escaped a plague which carried off 27,000 persons in that city, in the year 1771, and many whole families in Philadelphia were indebted for their safety to the same precautions in the year 1793. Confinement is more certain in its beneficial effects, when persons occupy the upper stories only of their houses. The inhabitants of St. Lucia, Dr. Chisholm says, by this means often escape the yellow fever of that island. Such is the difference between the healthiness of the upper and lower stories of a house, that, travellers tell us, birds live in the former, and die in the latter, during the prevalence of a plague in the eastern countries.

All the exciting causes that have been enumerated should be avoided with double care three days before, and three days after, as well as on the days of the full and change of the moon. The reason for this caution was given in the account of the yellow fever in Philadelphia in the year 1797.

To persons who have retired from infected cities, or countries, it will be necessary to suggest a caution, not to visit them while the malignant fever from which they fled prevails in them. Dr. Dow informed me, in his visit to Philadelphia in the year 1800, that the natives and old citizens of New-Orleans who retired into the country, and returned during the prevalence of the yellow fever in that city, the year before, were often affected by it, while all such persons as did not change their residence, escaped it. The danger from visiting an infected city is greater to persons who breathe an atmosphere of a uniform temperature, than one that is subject to alternate changes in its degrees of heat and cold. The inhabitants of Mexico, Baron Humboldt informed me, who descend from their elevated situation, where the thermometer seldom varies more than ten degrees in the year, and visit Vera Cruz during the prevalence of the yellow fever in that city, are much oftener affected by it than the new comers from the variable climates of European countries. But the habits of insensibility to the impressions of the miasmata of this disease in one country, do not always protect the system from their action in another. The same illustrious traveller informed me, that the inhabitants of the Havannah who visit Vera Cruz, and the inhabitants of Vera Cruz who visit the Havannah, are affected in common with strangers with the fever of those places.

I shall take leave of this part of our subject, by adding, that I am so much impressed with a belief in the general, and almost necessary connection of an exciting cause with a yellow fever, that were I to enter a city, and meet its inhabitants under the first impressions of terror and distress from its appearance, my advice to them should be, “Beware, not of contagion, for the yellow fever of our country is not contagious, nor of putrid exhalations, when the duties of humanity or consanguinity require your attendance, but BEWARE OF EXCITING CAUSES!”

In the mild grades of the summer and autumnal fevers of the United States, the means of prevention should be different from those which have been recommended to prevent the yellow fever. They consist of such things as gently invigorate the system, and thus create an action superior to that which the miasmata have excited in it. The means commonly employed for this purpose are,

1. Cordial diet and drinks; consisting of salted meat, and fish, with a moderate quantity of wine and malt liquors. Dr. Blane says, the British soldiers who lived upon salt meat, during the American war, were much less afflicted with the intermitting fever than the neighbouring country people; and, it is well known, the American army was much less afflicted with summer and autumnal fevers, after they exchanged their fresh meat for rations of salted beef and pork. Ardent spirits should be used cautiously, for, when taken long enough to do good, they create a dangerous attachment to them. A strong infusion of any bitter herb in water, taken upon an empty stomach, is a cheap substitute for all the above liquors where they cannot be afforded. The Peruvian bark has in many instances been used with success as a preventive of the mild grades of the summer and autumnal fevers of our country.

2. An equable and constant perspiration. This should be kept up by all the means formerly mentioned for that purpose.

3. Avoiding certain exciting causes, particularly great heat and cold, fatigue, long intervals between meals, intemperance, and the morning and evening air, more especially during the lunar periods formerly mentioned. Dr. Lind says, the farmers of Holdernesse, in England, who go out early to their work, are seldom long lived, probably from their constitutions being destroyed by frequent attacks of intermitting fevers, to which that practice exposes them. Where peculiar circumstances of business render it necessary for persons to inhale the morning air, care should be taken never to do it without first eating a cordial breakfast.

The intestinal state of our summer and autumnal disease requires several specific means to prevent it, different from those which have been advised to defend the blood-vessels from fever. Unripe and decayed fruit should be avoided, and that which is ripe and sound should not be eaten in an excessive quantity. Spices, and particularly Cayenne pepper, and the red pepper of our country, should be taken daily with food. Mr. Dewar, a British surgeon, tells us, the French soldiers, while in Egypt, carried pepper in boxes with them, wherever they went, to eat with the fruits of the country, and thereby often escaped its diseases. The whole diet, during the prevalence of intestinal diseases, when they are not highly inflammatory, should be of a cordial nature. A dysentery prevailed, a few years ago, upon the Potomac, in a part of the country which was inhabited by a number of protestant and catholic families. The disease was observed to exist only in the former. The latter, who ate of salted fish every Friday, and occasionally on other days of the week, very generally escaped it. In the year 1759, a dysentery broke out in the village of Princeton, in New-Jersey, and affected many of the students of the college. It was remarked, that it passed by all those boys who came from the cities of New-York and Philadelphia. This was ascribed to their having lived more upon tea and coffee than the farmers' sons in the college; for those cordial articles of diet were but rarely used, six and forty years ago, in the farm houses of the middle states of America. I mentioned formerly that the cordial diet of the inhabitants of our cities was probably the reason why the dysentery so seldom prevailed as an epidemic in them.

Another means of preventing the dysentery is, by avoiding costiveness, and by occasionally taking purging physic, even when the bowels are in their natural state. A militia captain, in the Pennsylvania service, preserved his whole company from a dysentery which prevailed in a part of the American army at Amboy, in the year 1776, by giving each of them a purge of sea-water. He preserved his family, and many of his neighbours, some years afterwards, from the same disease, by dividing among them a few pounds of purging salts. It was prevented, a few years ago, in the academy of Bordentown, in New-Jersey, by giving all the boys molasses, in large quantities, in their diet and drinks. The molasses probably acted only by keeping the bowels in a laxative state.

As the dysentery is often excited by the dampness of the night air, great care should be taken to avoid it, and, when necessarily exposed to it, to defend the bowels by more warmth than other parts of the body. The Egyptians, Mr. Dewar says, tie a belt about their bowels for that purpose, and with the happiest effects.

II. I come now, according to the order I proposed, to mention the means of preserving whole cities or communities from the influence of those morbid exhalations which produce the different forms of summer and autumnal disease, and, in particular, that which is of a malignant nature.

As the flight of a whole city is rarely practicable, it will be necessary to point out the means of destroying the morbid miasmata.

1. Where the putrid matters which emit them are of a small extent, they should be covered with water or earth. Purchas tells us, 500 persons less died of the plague the day after the Nile overflowed the grounds which had emitted the putrid exhalations that produced it, than had died the day before. During the prevalence of a malignant fever, it will be unsafe to remove putrid matters. A plague was generated by an attempt to remove the filth which had accumulated on the banks of the waters which surround the city of Mantua, during the summer and autumnal months [18]. Even a shower of rain, by disturbing the green pellicle which is sometimes formed over putrid matters, I shall mention in another place, has let loose exhalations that have produced a pestilential disease.

2. Impregnating the air with certain effluvia, which act either by destroying miasmata by means of mixture, or by exciting a new action in the system, has, in some instances, checked the progress of a malignant fever. The air extricated from fermenting wines, during a plentiful vintage, Vansweiten tells us, has once checked the ravages of a plague in Germany. Ambrose Parey informs us, the plague was checked in a city in Italy by killing all the cats and dogs in the place, and leaving them to putrify in the streets. Mr. Bruce relates, that all those persons who lived in smoky houses, in one of the countries which he visited, escaped bilious fevers, and Dr. Clark mentions an instance, in which several cooks, who were constantly exposed to smoke, escaped a fever which affected the whole crew of a galley. The yellow fever has never appeared within the limits of the effluvia of the sal ammoniac manufactory, nor of the tan-pits in the suburbs of Philadelphia, nor has the city of London been visited with a plague since its inhabitants have used sea-coal for fuel. But other causes have contributed more certainly to the exemption of that city from the plague for upwards of a century, one of which shall be mentioned under our next head.

3. Desquenette tells us, the infection of the plague never crosses the Nile, and that it is arrested by means of ditches, dug and filled with water for that purpose. Dr. Whitman has remarked, that the plague never passes from Abydos, on the Turkish, to Mito, on the European side of the water of the Dardanelles, which forms the entrance to Constantinople. The yellow fever has never been known to pass from Philadelphia to the Jersey shore, and the miasmata generated on the east side of the Schuylkill rarely infect the inhabitants of the opposite side of the river. Many persons found safety from the plague of London, in 1665, by flying to ships which lay in the middle of the Thames, and, it is well known, no instance of yellow fever occurred in those Philadelphia families that confined themselves to ships in the middle of the Delaware, in the year 1793. But three or four, of four hundred men, on board a ship of war called the Jason, commanded by captain Coteneuil, perished with an epidemic yellow fever, in the year 1746, at St. Domingo, in consequence, Dr. Desportes says, of her hold being constantly half filled with water [19]. I have multiplied facts upon this subject, because they lead to important conclusions. They show the immense consequence of frequently washing the streets and houses of cities, both to prevent and check pestilential fevers. What would be the effect of placing tubs of fresh water in the rooms of patients infected with malignant fevers, and in an atmosphere charged with putrid exhalations? Their efficacy in absorbing the matter which constitutes the odour of fresh paint, favours a hope that they would be useful for that purpose. I have mentioned an instance, in the Account of the Yellow Fever in Philadelphia, in the year 1797, in which they were supposed to have been employed with evident advantage.

4. Intercepting the passage of miasmata to the inhabitants of cities. Varro, in his Treatise upon Agriculture, relates, that his namesake Varro, a Roman general, was in great danger of suffering, with a large fleet and army, from a malignant fever at Conyra. Having discovered the course of the miasmata which produced it to be from the south, he fastened up all the southern windows and doors of the houses in which his troops were quartered, and opened new ones to the north, by which means he preserved them from the fever which prevailed in all the other houses of the town and neighbourhood. Mr. Howard advises keeping the doors and windows, of houses which are exposed to the plague, constantly shut, except during the time of sunshine.

Several other means have been recommended to preserve cities from malignant fevers during their prevalence, which are of doubtful efficacy, or evidently hurtful. They are,

5. Strewing lime over putrid matters. Dr. Dalzelle says, he once checked a bilious fever, by spreading twelve barrels of lime on a piece of marshy ground, from whence the exhalations that produced it were derived [20]. A mixture of quick lime and ashes in water, when thrown into a privy, discharges from it a large quantity of offensive air, and leaves it afterwards without a smell. As this foul air is discharged into the atmosphere, it has been doubted whether the lime and ashes should be used for that purpose, after a malignant fever has made its appearance.

6. Mr. Quiton Morveau has lately proposed the muriatic gas as a means of destroying miasmata. However effectual it may be in destroying the volatile and foul excretions which are discharged from the human body in confined situations, as in filthy jails, hospitals, and ships, it is not calculated to oppose the seeds of a disease which exist in the atmosphere, and which are diffused over a large extent of city or country. Mr. Morveau ascribes great virtues to it, in checking the malignant fever in Cadiz, in 1801, but from the time at which it was used, being late in the autumn, there is more reason to believe it had run its ordinary course, or that it was destroyed by cold weather.

7. The explosion of gunpowder has been recommended for checking pestilential diseases. Mr. Quiton Morveau says, it destroys the offensive odour of putrid exhalations, but does not act upon the fevers produced by them.

8. Washing the floors of houses with a solution of alkaline salts in water, has been recommended by Dr. Mitchell, as an antidote to malignant fevers. As yet, I believe, there are no facts which establish the efficacy of the practice, when they are produced by exhalations from decayed vegetable and animal substances in a putrid state.

9. Large fires have sometimes been made in cities, in order to destroy the miasmata of pestilential diseases. They were obviously hurtful in the plague of London, in the year 1665. Dr. Hodges, who relates this fact, says, “Heaven wept for the mistake of kindling them, and mercifully put them out, with showers of rain.”

I cannot conclude this head, without lamenting the want of laws in all our states, to compel physicians to make public the first cases of malignant fever that come under their notice. The cry of fire is not more useful to save a city from destruction, than the early knowledge of such cases would be to save it from the ravages of pestilential and mortal epidemics. Hundreds of instances have occurred, in all ages and countries, in which they might have been stifled in their birth, by the means that have been mentioned, had this practice been adopted. But when, and where, will science, humanity, and government first combine to accomplish this salutary purpose? Most of our histories of mortal epidemics abound with facts which show a contrary disposition and conduct in physicians, rulers, and the people. I shall mention one of these facts only, to show how far we must travel over mountains of prejudice and error, before we shall witness that desirable event. It is extracted from the second volume of the Life of the late Empress of Russia. “The Russian army (says the biographer), after defeating the Turks, on entering their territories were met by the plague, and brought it to their country, where the folly of several of their generals contributed to its propagation, as if they thought by a military word of command to alter the nature of things. Lieutenantgeneral Stoffeln, at Yassy, where the pestilence raged in the winter of 1770, issued peremptory orders that its name should not be pronounced; he even obliged the physicians and surgeons to draw up a declaration in writing, that it was only a spotted fever. One honest surgeon of the name of Kluge refused to sign it. In this manner the season of prevention was neglected. Several thousand Russian soldiers were by this means carried off. The men fell dead upon the road in heaps. The number of burghers that died was never known, as they had run into the country, and into the forests. At length the havoc of death reached the general's own people: he remained true to his persuasion, left the town, and went into the more perilous camp. But his intrepidity availed him nothing; he died of the plague in July, 1771 [21].”

III. Let us now consider, in the last place, the means of exterminating malignant and other forms of summer and autumnal disease, by removing their causes. These means are,

1. The removal or destruction of all those putrid matters formerly enumerated, which are capable of producing fevers. Many of the institutions of the Jewish nation, for this purpose, are worthy of our imitation. The following verses contain a fund of useful knowledge upon this subject.—“Thou shalt have a place without the camp, whether thou shalt go forth abroad; and shalt have a paddle upon thy weapon, and it shall be when thou wilt ease thyself abroad, thou shalt dig therewith, and shalt turn back, and cover that which cometh from thee; for the Lord thy God walketh in the midst of thy camp to deliver thee, therefore shall he see no unclean thing in thee, and turn away from thee.” Deuteronomy, chapter xxiii. verses 12, 13, and 14. “But the flesh of the bullock, and his skin, and his dung, shalt thou burn with fire without the camp.” Exodus, chapter xxxix. verse 14. The advantages of thus burying and removing all putrid matters, and of burning such as were disposed to a speedy putrefaction, in a crowded camp, and in a warm climate, are very obvious. Their benefits have often been realized in other countries. The United Provinces of Holland hold their exemption from the plague, only by the tenure of their cleanliness. In the character given by Luther of Pope Julius, he says, “he kept the streets of Rome so clean and sweet, that there were no plagues nor sicknesses during his time.” The city of Oxford was prepared to afford an asylum to the royal family of Great-Britain from the plague, when it ravaged London, and other parts of England, in the year 1665, only in consequence of its having been cleaned, some years before, by the Bishop of Winchester. In a manuscript account of the life of Doctor, afterwards Governor Colden, of New-York, there is the following fact. It was first communicated to the public in the daily gazette of the capital of that state, on the 30th of October, 1799. “A malignant fever having raged with exceeding violence for two summers successively in the city of New-York, about forty years ago, he communicated his thoughts to the public, on the most probable cure of the calamity. He published a little treatise on the occasion, in which he collected the sentiments of the best authority, on the bad effects of stagnating waters, moist air, damp cellars, filthy shores, and dirty streets. He showed how much these nuisances prevailed in many parts of the city, and pointed out the remedies. The corporation of the city voted him their thanks, adopted his reasoning, and established a plan for draining and cleaning the city, which was attended with the most happy effects.” The advantages of burning offal matters, capable by putrefaction of producing fevers, has been demonstrated by those housekeepers, who, instead of collecting the entrails of fish and poultry, and the parings and skins of vegetables, in barrels, instantly throw them into their kitchen fires. The families of such persons are generally healthy.

2. In the construction of cities, narrow streets and alleys should be carefully avoided. Deep lots should be reserved for yards and gardens for all the houses, and subterraneous passages should be dug to convey, when practicable, to running water, the contents of privies, and the foul water of kitchens. In cities that are wholly supplied with fresh water by pipes from neighbouring springs or rivers, all the evils from privies might be prevented by digging them so deep as to connect them with water. Great advantages, it has been suggested, would arise in the construction of cities, from leaving open squares, equal in number and size to those which are covered with houses. The light and dark squares of a chequer-board might serve as models for the execution of such a plan. The city of London, which had been afflicted nearly every year for above half a century by the plague, has never been visited by it since the year 1666. In that memorable year, while the inhabitants were venting their execrations upon a harmless bale of silks imported from Holland, as the vehicle of the seeds of their late mortal epidemic, Heaven kindly pointed out, and removed its cause, by permitting a fire to destroy whole streets and lanes of small wooden buildings, which had been the reservoirs of filth for centuries, and thereby the sources of all the plagues of that city [22]. Those streets and lanes were to London, what Water-street and Farmer's-row are to Philadelphia, Fell's-point to Baltimore, the slips and docks to New-York, and Water-street to the town of Norfolk.

3. Where the different forms of summer and autumnal disease arise from marsh exhalations, they should be destroyed by drains, by wells communicating with their subterraneous springs, or by cultivating upon them certain grasses, which form a kind of mat over the soil, and, when none of these modes of destroying them is practicable, by overflowing them with water.

I have met with many excellent quotations from a work upon this part of our subject, by Tozzetti, an Italian physician, from which, I have no doubt, much useful information might be obtained. The Rev. Thomas Hall, to whom I made an unsuccessful application for this work, speaks of it, in his answer to my letter, in the following terms. “It is in such high estimation, that the late emperor Leopold, when grand duke of Tuscany, caused it to be re-printed at his own expence, and presented it to his friends. The consequence of this was, it influenced the owners of low marshy grounds, in the neighbourhood of the river Arno, to drain and cultivate them, and thereby rendered the abode of noxious air, and malignant fevers, a terrestrial paradise.”

4. The summer and autumnal diseases of our country have often followed the erection of mill-dams. They may easily be obviated by surrounding those receptacles of water with trees, which prevent the sun's acting upon their shores, so as to exhale miasmata from them. Trees planted upon the sides of creeks and rivers, near a house, serve the same salutary purpose.

5. It has often been observed, that families enjoy good health, for many years, in the swamps of Delaware and North-Carolina, while they are in their natural state, but that sickness always follows the action of the rays of the sun upon the moist surface of the earth, after they are cleared. For this reason, the cultivation of a country should always follow the cutting down of its timber, in order to prevent the new ground becoming, by its exhalations, a source of disease.

6. In commercial cities, no vessel that arrives with a cargo of putrescent articles should ever be suffered to approach a wharf, before the air that has been confined in her hold has been discharged. The same thing should be done after the arrival of a vessel from a distant or hot country, though her cargo be not capable of putrefaction, for air acquires a morbid quality by stagnating contiguous to wood, under circumstances formerly mentioned.

All these modes of removing the causes of malignant and yellow fevers, and of promoting strict and universal cleanliness, are of more consequence in the middle and northern states of America, than in countries uniformly warm, inasmuch as the disease may be taken as often as our inhabitants are exposed to its sources. In the West-Indies, a second attack of the yellow fever is prevented by the insensibility induced upon the system, by its being constantly exposed to the impressions of heat and exhalation. After a seasoning, as it is called, or a residence of two or three years in those islands, the miasmata affect the old settlers, as they do the natives, only with mild remittents. Nearly the same thing takes place at Madras, in the East-Indies, where, Dr. Clark says, the exhalations which bring on bilious fevers, colic, cholera, and spasmodic affections in new comers, produce a puking in the morning, only in old residents. But very different is the condition of the inhabitants of the middle and northern states of America, in whom the winters prevent the acquisition of habits of insensibility to the heat and exhalations of the previous summers, and thus place them every year in the condition of new comers in the West and East-Indies, or of persons who have spent two or three years in a cold climate. This circumstance increases the danger of depopulation from our malignant epidemics, and should produce corresponding exertions to prevent them.

In enumerating the various means of preventing and exterminating the malignant forms of fever, it may appear strange that I have said nothing of the efficacy of quarantines for that purpose. Did I believe these pages would be read only by the citizens of Pennsylvania, I would do homage to their prejudices, by passing over this subject by a respectful and melancholy silence; but as it is probable they will fall into the hands of physicians and citizens of other states, I feel myself under an obligation to declare, that I believe quarantines are of no efficacy in preventing the yellow fever, in any other way than by excluding the unwholesome air that is generated in the holds of ships, which may be done as easily in a single day, as in weeks or months. They originated in error, and have been kept up by a supine and traditional faith in the opinions and conduct of our ancestors in medicine. Millions of dollars have been wasted by them. From their influence, the commerce, agriculture, and manufactures of our country have suffered for many years. But this is not all. Thousands of lives have been sacrificed, by that faith in their efficacy, which has led to the neglect of domestic cleanliness. Distressing as these evils are, still greater have originated from them; for a belief in the contagious nature of the yellow fever, which is so solemnly enforced by the execution of quarantine laws, has demoralized our citizens. It has, in many instances, extinguished friendship, annihilated religion, and violated the sacraments of nature, by resisting even the loud and vehement cries of filial and parental blood.

While I thus deny the yellow fever to be the offspring of a specific contagion, and of course incapable of being imported so as to become an epidemic in any country, I shall admit presently, that the excretions of a patient in this disease may, by confinement, become so acrid as to produce, under circumstances to be mentioned hereafter, a similar disease in a person, but from this person it cannot be communicated, if he possess only the common advantages of pure air and cleanliness. To enforce a quarantine law, therefore, under such a contingent circumstance, and at the expence of such a profusion of blessings as have been mentioned, is to imitate the conduct of the man, who, in attempting to kill a fly upon his child's forehead, knocked out its brains.

From the detail that has been given of the sources of malignant fevers, and of the means of preventing them, it is evident that they do not exist by an unchangeable law of nature, and that Heaven has surrendered every part of the globe to man, in a state capable of being inhabited, and enjoyed. The facts that have been mentioned show further, the connection of health and longevity, with the reason and labour of man.

To every natural evil the Author of Nature has kindly prepared an antidote. Pestilential fevers furnish no exception to this remark. The means of preventing them are as much under the power of human reason and industry, as the means of preventing the evils of lightning and common fire. I am so satisfied of the truth of this opinion, that I look for a time when our courts of law shall punish cities and villages, for permitting any of the sources of bilious and malignant fevers to exist within their jurisdiction.

I have repeatedly asserted the yellow fever of the United States not to be contagious. I shall now mention the proofs of that assertion, and endeavour to explain instances of its supposed contagion upon other principles.

AN INQUIRY INTO THE VARIOUS SOURCES OF THE USUAL FORMS OF SUMMER & AUTUMNAL DISEASE IN THE UNITED STATES, AND THE MEANS OF PREVENTING THEM.

AN INQUIRY
INTO
THE VARIOUS SOURCES
OF THE USUAL FORMS OF
SUMMER & AUTUMNAL DISEASE
IN THE UNITED STATES,
AND THE MEANS OF PREVENTING THEM.