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diff --git a/58861-0.txt b/58861-0.txt new file mode 100644 index 0000000..707185d --- /dev/null +++ b/58861-0.txt @@ -0,0 +1,9216 @@ +*** START OF THE PROJECT GUTENBERG EBOOK 58861 *** + + + +Note: Project Gutenberg also has an HTML version of this + file which includes the original illustrations. + See 58861-h.htm or 58861-h.zip: + (http://www.gutenberg.org/files/58861/58861-h/58861-h.htm) + or + (http://www.gutenberg.org/files/58861/58861-h.zip) + + + Images of the original pages are available through + Internet Archive. See + https://archive.org/details/b21935142_0003 + + + Project Gutenberg has the other three volumes of this work. + Volume I: see http://www.gutenberg.org/ebooks/58859 + Volume II: see http://www.gutenberg.org/ebooks/58860 + Volume IV: see http://www.gutenberg.org/ebooks/58862 + + +Transcriber's note: + + The ligature oe has been marked as [oe]. + + Text in italics has been enclosed by underscores (_text_). + + The symbol hand pointing has been marked as [hand]. + + + + + + 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. + + _page_ + + _Outlines of a theory of fever_ 1 + + _An account of the bilious yellow fever, as it appeared in + Philadelphia in 1793_ 67 + + _An account of the bilious yellow fever, as it appeared in + Philadelphia in 1794_ 355 + + _An account of sporadic cases of bilious yellow fever, as they + appeared in Philadelphia in 1795 and 1796_ 435 + + * * * * * + + + + + 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. + + [1] Cullen's First Lines. + +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]?" + + [2] First Lines, sect. 32 of the chapter on arteries. + +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. + + [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._ + +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. + + [4] See the Comparative View of the Diseases of the Indians and of + Civilized Nations. Vol. I. + +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, diarrh[oe]a, 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. + + [5] Inaugural dissertation, entitled, "An Attempt to disprove the + Putrefaction of the Blood in Living Animals." + +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]. + + [6] Epidemics, book iv. + +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. + + [7] Treatise on the Cold Bath. + +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]." + + [8] Treatise on Inflammation. chap. I. 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 diarrh[oe]a. 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, +diarrh[oe]a, 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 diarrh[oe]a 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. + + [9] Account of the Intestinal Remitting Fever of Bengal. + +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. + + [10] On Dropsies, vol. II. + +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. + + [11] Essay on the Spasmodic Affections in India, p. 53, 54, 55. + +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. + + [12] Vol. II. Dublin edition, p. 262. + + [13] Praxis Medica, lib. xviii. cap. i. + +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." + + + + + 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 96-1/2. 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. + +In some constitutions, the miasmata were at once a remote, a +predisposing, and an exciting cause of the disease; hence some persons +were affected by them, who had not departed in any instance from their +ordinary habits of living, as to diet, dress, and exercise. But it was +more frequently brought on by those causes acting in succession to each +other. + +I shall here refer the reader to the principles laid down in the outlines +of the theory of fever, for an account of the manner in which the system +was predisposed to this disease, by the debility induced by the reduction +of its excitement, by action and abstraction, and by subsequent +depression. Where a predisposition was thus produced, the fever was +excited by the following causes, acting directly or indirectly upon the +system. Where this predisposition did not exist, the exciting causes +produced both the predisposition and the disease. They were, + +1. _Great labour_, or exercises of body or mind, in walking, riding, +watching, or the like. It was labour which excited the disease so +universally among the lower class of people. A long walk often induced +it. Few escaped it after a day, or even a few hours spent in gunning. A +hard trotting horse brought it on two of my patients. Perhaps riding on +horseback, and in the sun, was the exciting cause of the disease in most +of the citizens and strangers who were affected by it in their flight +from the city. A fall excited it in a girl, and a stroke upon the head +excited it in a young man who came under my care. Many people were seized +with the disease in consequence of their exertions on the night of the +7th of September, in extinguishing the fire which consumed Mr. Dobson's +printing-office, and even the less violent exercise of working the fire +engines, for the purpose of laying the dust in the streets, added +frequently to the number of the sick. + +2. _Heat_, from every cause, but more especially the heat of the sun, was +a very common exciting cause of the disease. The register of the weather +during the latter end of August, the whole of September, and the first +two weeks in October will show how much the heat of the sun must have +contributed to excite the disease, more especially among labouring +people. The heat of common fires likewise became a frequent cause of the +activity of the miasmata where they had been received into the body; +hence the greater mortality of the disease among bakers, blacksmiths, and +hatters than among any other class of people. + +3. _Intemperance_ in eating or drinking. A plentiful meal, and a few +extra glasses of wine seldom failed of exciting the fever. But where the +body was strongly impregnated with the seeds of the disease, even the +smallest deviation from the customary stimulus of diet, in respect to +quality or quantity, roused them into action. A supper of twelve oysters +in one, and of but three in another, of my patients produced the disease. +Half an ounce of meat excited it in a lady who had lived, by my advice, +for two weeks upon milk and vegetables, and even a supper of sallad, +dressed after the French fashion, excited it in one of Dr. Mease's +patients. + +4. _Fear._ In many people the disease was excited by a sudden paroxysm of +fear; but I saw some remarkable instances where timid people escaped the +disease, although they were constantly exposed to it. Perhaps a moderate +degree of fear served to counteract the excessive stimulus of the +miasmata, and thereby to preserve the body in a state of healthy +equilibrium. I am certain that fear did no harm after the disease was +formed, in those cases where great morbid excess of action had taken +place. It was an early discovery of this fact which led me not to conceal +from my patients the true name of this fever, when I was called to them +on the _day_ of their being attacked by it. The fear co-operated with +some of my remedies (to be mentioned hereafter) in reducing the morbid +excitement of the arterial system. + +5. _Grief._ It was remarkable that the disease was not excited in many +cases in the attendants upon the sick, while there was a hope of their +recovery. The grief which followed the extinction of hope, by death, +frequently produced it within a day or two afterwards, and that not in +one person only, but often in most of the near relations of the deceased. +But the disease was also produced by a change in the state of the mind +directly opposite to that which has been mentioned. Many persons that +attended patients who recovered, were seized with the disease a day or +two after they were relieved from the toils and anxiety of nursing. The +collapse of the mind from the abstraction of the stimulus of hope and +desire, by their ample gratification, probably produced that debility, +and loss of the equilibrium in the system, which favoured the activity +of the miasmata in the manner formerly mentioned[14]. + + [14] Outlines of a Theory of Fever. + +The effects of both the states of mind which have been described, have +been happily illustrated by two facts which are recorded by Dr. +Jackson[15]. He tells us, that the garrisons of Savannah and York-Town +were both healthy during the siege of those towns, but that the former +became sickly as soon as the French and American armies retreated, from +before it, and the latter, immediately after its capitulation. + + [15] Treatise on the Fevers of Jamaica, p. 298. + +6. _Cold._ Its action, in exciting the disease, depended upon the +diminution of the necessary and natural heat of the body, and thereby so +far destroying the equilibrium of the system, as to enable the miasmata +to produce excessive or convulsive motions in the blood-vessels. The +night air, even in the warm month of September, was often so cool as to +excite the disease, where the dress and bed-clothes were not accommodated +to it. It was excited in one case by a person's only wetting his feet, in +the month of October, and neglecting afterwards to change his shoes and +stockings. Every change in the weather, that was short of producing +frost, evidently increased the number of sick people. This was obvious +after the 18th and 19th of September, when the mercury fell to 44° and +45°. The hopes of the city received a severe disappointment upon this +occasion, for I well recollect there was a general expectation that this +change in the weather would have checked the disease. The same increase +of the number of sick was observed to follow the cool weather which +succeeded the 6th and 7th of October, on which days the mercury fell to +43° and 46°. + +It was observed that those persons who were _habitually_ exposed to the +cool air, were less liable to the disease than others. I ascribe it to +the _habitual_ impression of the cool night air upon the bodies of the +city watchmen, that but four or five of them, out of twenty-five, were +affected by the disease. + +After the body had been heated by violent exercise, a breeze of cool air +sometimes excited the disease in those cases where there had been no +change in the temperature of the weather. + +7. _Sleep._ A great proportion of all who were affected by this fever, +were attacked in the night. Sleep induced what I have called debility +from abstraction, and thereby disposed the miasmata which floated in the +blood, to act with such force upon the system as to destroy its +equilibrium, and thus to excite a fever. The influence of sleep as a +predisposing, and exciting cause was often assisted by the want of +bed-clothes, suited to the midnight or morning coolness of the air. + +8. _Immoderate evacuations._ The efficacy of moderate purging and +bleeding in preventing the disease, led some people to use those remedies +in an excess, which both predisposed to the disease, and excited it. The +morbid effects of these evacuations, were much aided by fear, for it was +this passion which perverted the judgment in such a manner, as to lead to +the excessive use of remedies, which, to be effectual, should only be +used in moderate quantities. + +The disease appeared with different symptoms, and in different degrees, +in different people. They both varied likewise with the weather. In +describing the disease, I shall take notice of the changes in the +symptoms, which were produced by changes in the temperature of the air. + +The precursors, or premonitory signs of this fever were, costiveness, a +dull pain in the right side, defect of appetite, flatulency, perverted +taste, heat in the stomach, giddiness, or pain in the head, a dull, +watery, brilliant, yellow, or red eye, dim and imperfect vision, a +hoarseness, or slight sore throat, low spirits, or unusual vivacity, a +moisture on the hands, a disposition to sweat at nights, or after +moderate exercise, or a sudden suppression of night sweats. The dull eye, +and the lowness of spirits, appeared to be the effects of such an excess +in the stimulus of the miasmata as to induce depression, while the +brilliant eye, and the unusual vivacity, seemed to have been produced by +a less quantity of the miasmata acting as a cordial upon the system. More +or less of these symptoms frequently continued for two or three days +before the patients were confined to their beds, and in some people they +continued during the whole time of its prevalence in the city, without +producing the disease. I wish these symptoms to be remembered by the +reader. They will form the corner stone of a system which I hope will +either eradicate the disease altogether, or render it as safe as an +intermitting fever, or as the small-pox when it is received by +inoculation. + +Frequent as these precursors of the fever were, they were not universal. +Many went to bed in good health, and awoke in the night with a chilly +fit. Many rose in the morning after regular and natural sleep, and were +seized at their work, or after a walk, with a sudden and unexpected +attack of the fever. In most of these cases the disease came on with a +chilly fit, which afforded by its violence or duration a tolerable +presage of the issue of the disease. + +Upon entering a sick room where a patient was confined by this fever, the +first thing that struck the eye of a physician was the countenance. It +was as much unlike that which is exhibited in the common bilious fever, +as the face of a wild, is unlike the face of a mild domestic animal. The +eyes were sad, watery, and so inflamed, in some cases, as to resemble two +balls of fire. Sometimes they had a most brilliant or ferocious +appearance. The face was suffused with blood, or of a dusky colour, and +the whole countenance was downcast and clouded. After the 10th of +September, when a determination of blood to the brain became universal, +there was a preternatural dilatation of the pupil. Sighing attended in +almost every case. The skin was dry, and frequently of its natural +temperature. These were the principal symptoms which discovered +themselves to the eye and hand of a physician. The answers to the first +questions proposed upon visiting a patient, were calculated to produce a +belief in the mind of a physician, that the disease under which the +patient laboured was not the prevailing malignant epidemic. I did not for +many weeks meet with a dozen patients, who acknowledged that they had any +other indisposition than a common cold, or a slight remitting or +intermitting fever. I was particularly struck with this self-deception in +many persons, who had nursed relations that had died with the yellow +fever, and who had been exposed to it in neighbourhoods where it had +prevailed for days and even weeks with great mortality. I shall hereafter +trace a part of this disposition in the sick to deceive themselves to the +influence of certain publications, which appeared soon after the disease +became epidemic in the city. + +In the further history of this fever, I shall describe its symptoms as +they appeared, + +I. In the sanguiferous system. + +II. In the liver, lungs, and brain. + +III. In the alimentary canal; in which I include the stomach as well as +the bowels. + +IV. In the secretions and excretions. + +V. In the nervous system. + +VI. In the senses and appetites. + +VII. In the lymphatic and glandular system. + +VIII. Upon the skin. + +IX. In the blood. + +After having finished this detail, I shall mention some general +characters of the disease, and afterwards subdivide it into classes, +according to its degrees and duration. + +I. The _blood-vessels_ were affected more or less in every case of this +fever. I have elsewhere said, that a fever is occasioned by a convulsion +in the arterial system[16]. When the epidemic, which we are now +considering, came on with a full, tense, and quick pulse, this convulsion +was very perceptible; but it frequently came on with a weak pulse, often +without any preternatural frequency or quickness, and sometimes so low as +not to be perceived without pressing the artery at the wrists. In many +cases the pulse intermitted after the fourth, in some after the fifth, +and in others after the fourteenth stroke. These intermissions occurred +in several persons who were infected, but who were not confined by the +fever. They likewise continued in several of my patients for many days +after their recovery. This was the case in particular in Mrs. Clymer, +Mrs. Palmer's son William, and in a son of Mr. William Compton. In some, +there was a preternatural slowness of the pulse. It beat 44 strokes in a +minute in Mr. B. W. Morris, 48 in Mr. Thomas Wharton, jun. and 64 in Mr. +William Sansom, at a time when they were in the most imminent danger. Dr. +Physick informed me, that in one of his patients the pulse was reduced in +frequency to 30 strokes in a minute. All these different states of the +pulse have been taken notice of by authors who have described +pestilential fevers[17]. They have been improperly ascribed to the +absence of fever: I would rather suppose that they are occasioned by the +stimulus of the remote cause acting upon the arteries with too much force +to admit of their being excited into quick and convulsive motions. The +remedy which removed it (to be mentioned hereafter) will render this +explanation of its cause still more probable. Milton describes a +darkness from an excess of light. In like manner we observe, in this +small, intermitting, and slow pulse, a deficiency of strength from an +excess of force applied to it. In nearly every case of it which came +under my notice, it was likewise tense or chorded. This species of pulse +occurred chiefly in the month of August, and in the first ten days in +September. I had met with it formerly in a sporadic case of yellow fever. +It was new to all my pupils. One of them, Mr. Washington, gave it the +name of the "undescribable pulse." It aided in determining the character +of this fever before the common bilious remittent disappeared in the +city. For a while, I ascribed this peculiarity in the pulse, more +especially its _slowness_, to an affection of the brain only, and +suspected that it was produced by what I have taken the liberty elsewhere +to call the _phrenicula_, or inflammatory state of the internal dropsy of +the brain, and which I have remarked to be an occasional symptom and +consequence of remitting fever. I was the more disposed to adopt this +opinion, from perceiving this slow, chorded, and intermitting pulse more +frequently in children than in adults. Impressed with this idea, I +requested Mr. Coxe, one of my pupils, to assist me in examining the state +of the eyes. For two days we discovered no change in them, but on the +third day after we began to inspect them, we both perceived a +preternatural dilatation of the pupils, in different patients; and we +seldom afterwards saw an eye in which it was absent. In Dr. Say it was +attended by a squinting, a symptom which marks a high degree of a morbid +affection of the brain. Had this slowness or intermission in the pulse +occurred only after signs of inflammation or congestion had appeared in +the brain, I should have supposed that it had been derived wholly from +that cause; but I well recollect having felt it several days before I +could discover the least change in the pupil of the eye. I am forced +therefore to call in the operation of another cause, to assist in +accounting for this state of the pulse, and this I take to be a spasmodic +affection, accompanied with preternatural dilatation or contraction of +the heart. Lieutaud mentions this species of pulse in several places, as +occurring with an undue enlargement of that muscle[18]. Dr. Ferriar +describes a case, in which a low, irregular, intermitting, and hardly +perceptible pulse attended a morbid dilatation of the heart[19]. In a +letter I received from Mr. Hugh Ferguson, then a student of medicine in +the college of Edinburgh, written from Dublin, during the time of a visit +to his father, and dated September 30th, 1793, I find a fact which throws +additional light upon this subject. "A case (says my young correspondent) +where a remarkable intermission of pulse was observed, occurred in this +city last year. A gentleman of the medical profession, middle aged, of a +delicate habit of body, and who had formerly suffered phthisical attacks, +was attacked with the acute rheumatism. Some days after he was taken ill, +he complained of uncommon fulness, and a very peculiar kind of sensation +about the præcordia, which it was judged proper to relieve by copious +blood-letting. This being done, the uneasiness went off. It returned, +however, three or four times, and was as often relieved by bleeding. +During each of his fits (if I may call them so), the patient experienced +an almost total remission of his pains in his limbs; but they returned +with equal or greater violence after blood-letting. During the fit there +was an intermission of the pulse (the first time) of no less than +thirteen strokes. It was when beating full, strong, and slow. The third +intermission was of nine strokes. The gentleman soon recovered, and has +enjoyed good health for ten months past. The opinion of some of his +physicians was, that the heart was affected, as a muscle, by the +rheumatism, and alternated with the limbs." + + [16] Outlines of a Theory of Fever. + + [17] Vergasca, Sorbait, and Boate in Haller's Bibliotheca Medicinæ, + vol. iii. also by Dr. Stubbs in the Philosophical Transactions, + and Riverius in his treatise de febre pestilenti. + + [18] Historia Anatomica Medica, vol ii. obs. 405, 418, 423, 510. + + [19] Medical Histories and Reflections, p. 150. + +I am the more inclined to believe the peculiarity in the pulse which has +been mentioned in the yellow fever, arose in part from a spasmodic +affection of the heart, from the frequency of an uncommon palpitation of +this muscle, which I discovered in this disease, more especially in old +people. The disposition, likewise, to syncope and sighing, which so often +occurred, can be explained upon no other principle than inflammation, +spasm, dilatation, or congestion in the heart. After the 10th of +September this undescribable or _sulky_ pulse (for by the latter epithet +I sometimes called it) became less observable, and, in proportion as the +weather became cool, it totally disappeared. It was gradually succeeded +by a pulse full, tense, quick, and as frequent as in pleurisy or +rheumatism. It differed, however, from a pleuritic or rheumatic pulse, in +imparting a very different sensation to the fingers. No two strokes +seemed to be exactly alike. Its action was of a hobbling nature. It was +at this time so familiar to me that I think I could have distinguished +the disease by it without seeing the patient. It was remarkable that this +pulse attended the yellow fever even when it appeared in the mild form +of an intermittent, and in those cases where the patients were able to +walk about or go abroad. It was nearly as _tense_ in the remissions and +intermissions of the fever as it was in the exacerbations. It was an +alarming symptom, and when the only remedy which was effectual to remove +it was neglected, such a change in the system was induced as frequently +brought on death in a few days. + +This change of the pulse, from extreme lowness to fulness and activity, +appeared to be owing to the diminution of the heat of the weather, which, +by its stimulus, added to that of the remote cause, had induced those +symptoms of depression of the pulse which have been mentioned. + +The pulse most frequently lessened in its fulness, and became gradually +weak, frequent, and imperceptible before death, but I met with several +cases in which it was full, active, and even tense in the last hours of +life. + +_Hæmorrhages_ belong to the symptoms of this fever as they appeared in +the sanguiferous system. They occurred in the beginning of the disease, +chiefly from the nose and uterus. Sometimes but a few drops of blood +distilled from the nose. The menses were unusual in their quantity when +they appeared at their stated periods, but they often came on a week or +two before the usual time of their appearance. I saw one case of a +hæmorrhage from the lungs on the first day of the fever, which was +supposed to be a common hæmoptysis. As the disease advanced the +discharges of blood became more universal. They occurred from the gums, +ears, stomach, bowels, and urinary passages. Drops of blood issued from +the inner canthus of the left eye of Mr. Josiah Coates. Dr. Woodhouse +attended a lady who bled from the holes in her ears which had been made +by ear-rings. Many bled from the orifices which had been made by +bleeding, several days after they appeared to have been healed, and some +from wounds which had been made in veins in unsuccessful attempts to draw +blood. These last hæmorrhages were very troublesome, and in some cases +precipitated death. + +II. I come now to mention the symptoms of this fever as they appeared in +the _liver_, the _lungs_, and the _brain_. From the histories which I had +read of this disease, I was early led to examine the state of the +_liver_, but I was surprised to find so few marks of hepatic affection. I +met with but two cases in which the patient could lie only on the right +side. Many complained of a dull pain in the region of the liver, but very +few complained, in the beginning of the disease, of that soreness to the +touch, about the pit of the stomach, which is taken notice of by authors, +and which was universal in the yellow fever in 1762. In proportion as the +cool weather advanced, a preternatural determination of the blood took +place chiefly to the lungs and brain. Many were affected with pneumonic +symptoms, and some appeared to die of sudden effusions of blood or serum +in the lungs. It was an unexpected effusion of this kind which put an end +to the life of Mrs. Keppele after she had exhibited hopeful signs of a +recovery. + +I saw one person who recovered from an affection of the lungs, by means +of a copious expectoration of yellow phlegm and mucus. But the _brain_ +was principally affected with morbid congestion in this disease. It was +indicated by the suffusion of blood in the face, by the redness of the +eyes, by a dilatation of the pupils, by the pain in the head, by the +hæmorrhages from the nose and ears, by the sickness or vomiting, and by +an almost universal costive state of the bowels. I wish to impress the +reader with these facts, for they formed one of the strongest indications +for the use of the remedies which I adopted for the cure of this disease. +It is difficult to determine the exact state of these viscera in every +case of bilious and yellow fever. Inflammation certainly takes place in +some cases, and internal hæmorrhages in others; but I believe the most +frequent affection of these viscera consists in a certain morbid +accumulation of blood in them, which has been happily called, by Dr. +Clark, an _engorgement_ or choaking of the blood-vessels. I believe +further, with Dr. Clark[20] and Dr. Balfour[21], that death in most cases +in bilious fevers is the effect of these morbid congestions, and wholly +unconnected with an exhausted state of the system, or a supposed +putrefaction in the fluids. It is true, the dissections of Dr. Physick +and Dr. Cathrall (to be mentioned hereafter) discovered no morbid +appearances in any of the viscera which have been mentioned, but it +should be remembered, that these dissections were made early in the +disease. Dr. Annan attended the dissection of a brain of a patient who +died at Bush-hill some days afterwards, and observed the blood-vessels to +be unusually turgid. In those cases where congestion only takes place, it +is as easy to conceive that all morbid appearances in the brain may cease +after death, as that the suffusion of blood in the face should disappear +after the retreat of the blood from the extremities of the vessels, in +the last moments of life. It is no new thing for morbid excitement of the +brain to leave either slender, or no marks of disease after death. This, +I have said, is often the case where it exceeds that degree of action +which produces an effusion of red blood into serous vessels, or what is +called inflammation[22]. Dr. Quin has given a dissection of the brain of +a child that died with all the symptoms of hydrocephalus internus, and +yet nothing was discovered in the brain but a slight turgescence of its +blood-vessels. Dr. Girdlestone says, no injury appeared in the brains of +those persons who died of the symptomatic apoplexy, which occurred in a +spasmodic disease which he describes in the East-Indies; and Mr. Clark +informs us, that the brain was in a natural state in every case of death +from puerperile fever, notwithstanding it seemed to be affected in many +cases soon after the attack of that disease[23]. + + [20] Vol. i. p. 168. + + [21] Treatise on the Intestinal Remitting Fever, p. 125. + + [22] Outlines of a theory of fever. + + [23] Essay on the Epidemic Disease of Lying-in Women, of the years 1787 + and 1788, p. 34. + +I wish it to be remembered here, that the yellow fever, like all other +diseases, is influenced by climate and season. The determination of the +fluids is seldom the same in different years, and I am sure it varied +with the weather in the disease which I am now describing. Dr. Jackson +speaks of the head being most affected in the West-India fevers in _dry_ +situations. Dr. Hillary says, that there was an unusual determination of +the blood towards the brain, after a _hot_ and _dry_ season, in the +fevers of Barbadoes in the year 1753; and Dr. Ferriar, in his account of +an epidemic jail fever in Manchester, in 1789, 1790, informs us, that as +soon as frost set in, a delirium became a more frequent symptom of that +disease, than it had been in more temperate weather. + +III. The _stomach_ and _bowels_ were affected in many ways in this fever. +The disease seldom appeared without nausea or vomiting. In some cases, +they both occurred for several days or a week before they were +accompanied by any fever. Sometimes a pain, known by the name of +gastrodynia, ushered in the disease. The stomach was so extremely +irritable as to reject drinks of every kind. Sometimes green or yellow +bile was rejected on the first day of the disease by vomiting; but I much +oftener saw it continue for two days without discharging any thing from +the stomach, but the drinks which were taken by the patient. If the fever +in any case came on without vomiting, or if it had been checked by +remedies that were ineffectual to remove it altogether, it generally +appeared, or returned, on the 4th or 5th day of the disease. I dreaded +this symptom on those days, for although it was not always the forerunner +of death, yet it generally rendered the recovery more difficult and +tedious. In some cases the vomiting was more or less constant from the +beginning to the end of the disease, whether it terminated in life or +death. + +The vomiting which came on about the 4th or 5th day, was accompanied with +a burning pain in the region of the stomach. It produced great anxiety, +and tossing of the body from one part of the bed to another. In some +cases, this painful burning occurred before any vomiting had taken place. +Drinks were now rejected from the stomach so suddenly, as often to be +discharged over the hand that lifted them to the head of the patient. The +contents of the stomach (to be mentioned hereafter) were sometimes thrown +up with a convulsive motion, that propelled them in a stream to a great +distance, and in some cases all over the clothes of the by-standers. + +Flatulency was an almost universal symptom, in every stage of this +disease. It was very distressing in many cases. It occurred chiefly in +the stomach. + +The _bowels_ were generally costive, and in some patients as obstinately +so as in the dry gripes. In some cases there was all the pain and +distress of a bilious colic, and in others, the tenesmus, and mucous and +bloody discharges of a true dysentery. A diarrh[oe]a introduced the +disease in a few persons, but it was chiefly in those who had been +previously indisposed with weak bowels. A painful tension of the abdomen +took place in many, accompanied in some instances by a dull, and in +others by an acute pain in the lower part of the belly. + +IV. I come now to describe the state of the _secretions_ and _excretions_ +as they appeared in different stages of this fever. + +In some cases there was a constipation of the liver, if I may be allowed +that expression, or a total obstruction of secretion and excretion of +bile, but more frequently a preternatural secretion and excretion of it +took place. It was discharged, in most cases, from the stomach and bowels +in large quantities, and of very different qualities and colours. + +1. On the first and second days of the disease many patients puked from +half a pint to nearly a quart of green or yellow bile. Four cases came +under my notice in which black bile was discharged on the _first_ day. +Three of these patients recovered. + +2. There was frequently, on the 4th or 5th day, a discharge of matter +from the stomach, resembling coffee impregnated with its grounds. This +was always an alarming symptom. I believed it at first to be a +modification of vitiated bile, but subsequent dissections by Dr. Physick +have taught me that it was the result of the first stage of those morbid +actions in the stomach, which afterwards produce the black vomit. Many +recovered who discharged this coffee-coloured matter. + +3. Towards the close of this disease, there was a discharge of matter of +a deep or pale black colour, from the stomach. Flakey substances +frequently floated in the bason or chamber-pot upon the surface of this +matter. It was what is called the _black vomit_. It was formerly supposed +to be vitiated bile, but it has been proved by Dr. Stewart, and +afterwards by Dr. Physick, to be the effect of disease in the stomach. + +4. There was frequently discharged from the stomach in the close of the +disease, a large quantity of grumous blood, which exhibited a dark colour +on its outside, resembling that of some of the matters which have been +described, and which I believe was frequently mistaken for what is +commonly known by the name of the _black vomit_. Several of my patients +did me the honour to say, I had cured them after that symptom of +approaching dissolution had made its appearance; but I am inclined to +believe, dark-coloured blood only, or the coffee-coloured matter, was +mistaken for the matters which constitute the fatal black vomiting. I +except here the black discharge before-mentioned, which took place in +three cases on the first day of the disease. This I have no doubt was +bile, but it had not acquired its greatest acrimony, and it was +discharged before mortification, or even inflammation could have taken +place in the stomach. Several persons died without a black vomiting of +any kind. + +Along with all the discharges from the stomach which have been described, +there was occasionally a large worm, and frequently large quantities of +mucus and tough phlegm. + +The colour, quality, and quantity of the _fæces_ depended very much upon +the treatment of the disease. Where active purges had been given, the +stools were copious, f[oe]tid, and of a black or dark colour. Where they +were spontaneous, or excited by weak purges, they had a more natural +appearance. In both cases they were sometimes of a green, and sometimes +of an olive colour. Their smell was more or less f[oe]tid, according to +the time in which they had been detained in the bowels. I visited a lady +who had passed several days without a stool, and who had been treated +with tonic remedies. I gave her a purge, which in a few hours procured a +discharge of fæces so extremely f[oe]tid, that they produced fainting in +an old woman who attended her. The acrimony of the fæces was such as to +excoriate the rectum, and sometimes to produce an extensive inflammation +all around its external termination. The quantity of the stools produced +by a single purge was in many cases very great. They could be accounted +for only by calling in the constant and rapid formation of them, by +preternatural effusions of bile into the bowels. + +I attended one person, and heard of two others, in whom the stools were +as white as in the jaundice. I suspected, in these cases, the liver to be +so constipated or paralyzed by the disease, as to be unable to secrete or +excrete bile to colour the fæces. Large round worms were frequently +discharged with the stools. + +The _urine_ was in some cases plentiful, and of a high colour. It was at +times clear, and at other times turbid. About the 4th or 5th day, it +sometimes assumed a dark colour, and resembled strong coffee. This colour +continued, in one instance, for several days after the patient recovered. +In some, the discharge was accompanied by a burning pain, resembling that +which takes place in a gonorrh[oe]a. I met with one case in which this +burning came on only in the evening, with the exacerbation of the fever, +and went off with its remission in the morning. + +A total deficiency of the urine took place in many people for a day or +two, without pain. Dr. Sydenham takes notice of the same symptom in the +highly inflammatory small-pox[24]. It generally accompanied or portended +great danger. I heard of one case in which there was a _suppression_ of +urine, which could not be relieved without the use a the catheter. + + [24] Wallis's edition, vol. i. p. 197. + +A young man was attended by Mr. Fisher, one of my pupils, who discharged +several quarts of limpid urine just before he died. + +Dr. Arthaud informs us, in the history of a dissection of a person who +died of the yellow fever, that the urine after death imparted a green +colour to the tincture of radishes[25]. + + [25] Rosier's Journal for January, 1790, vol. xxxvi. p. 380. + +Many people were relieved by copious _sweats_ on the first day of the +disease. They were in some instances spontaneous, and in others they were +excited by diluting drinks, or by strong purges. These sweats were often +of a yellow colour, and sometimes had an offensive smell. They were in +some cases cold, and attended at the same time with a full pulse. In +general, the skin was dry in the beginning, as well as in the subsequent +stages of the disease. I saw but few instances of its terminating like +common fevers, by sweat after the third day. I wish this fact to be +remembered by the reader, for it laid part of the foundation of my method +of treating this fever. + +There was in some cases a preternatural secretion and excretion of +_mucus_ from the glands of the throat. It was discharged by an almost +constant hawking and spitting. All who had this symptom recovered. + +The _tongue_ was in every case moist, and of a white colour, on the first +and second days of the fever. As the disease advanced, it assumed a red +colour, and a smooth shining appearance. It was not quite dry in this +state. Towards the close of the fever, a dry black streak appeared in its +middle, which gradually extended to every part of it. Few recovered after +this appearance on the tongue took place. + +V. In the _nervous system_ the symptoms of the fever were different, +according as it affected the brain, the muscles, the nerves, or the mind. +The sudden and violent action of the miasmata induced apoplexy in several +people. In some, it brought on syncope, and in others, convulsions in +every part of the body. The apoplectic cases generally proved fatal, for +they fell chiefly upon hard drinkers. Persons affected by syncope, or +convulsions, sometimes fell down in the streets. Two cases of this kind +happened near my house. One of them came under my notice. He was supposed +by the by-standers to be drunk, but his countenance and convulsive +motions soon convinced me that this was not the case. + +A coma was observed in some people, or an obstinate wakefulness in every +stage of the disease. The latter symptom most frequently attended the +convalescence. Many were affected with immobility, or numbness in their +limbs. + +These symptoms were constant, or temporary, according to the nature of +the remedies which were made use of to remove them. They extended to all +the limbs, in some cases, and only to a part of them in others. In some, +a violent cramp, both in the arms and legs, attended the first attack of +the fever. I met with one case in which there was a difficulty of +swallowing, from a spasmodic affection of the throat, such as occurs in +the locked jaw. + +A hiccup attended the last stage of this disease, but I think less +frequently than the last stage of the common bilious fever. I saw but +five cases of recovery where this symptom took place. + +There was, in some instances, a deficiency of sensibility, but, in +others, a degree of it extending to every part of the body, which +rendered the application of common rum to the skin, and even the least +motion of the limbs painful. + +I was surprised to observe the last stage of this fever to exhibit so few +of the symptoms of the common typhus or chronic fever. Tremors of the +limbs and twitchings of the tendons were uncommon. They occurred only in +those cases in which there was a predisposition to nervous diseases, and +chiefly in the convalescent state of the disease. + +While the muscles and nerves in many cases exhibited so many marks of +preternatural weakness, in some they appeared to be affected with +preternatural excitement. Hence patients in the close of the disease +often rose from their beds, walked across their rooms, or came down +stairs, with as much ease as if they had been in perfect health. I lost a +patient in whom this state of morbid strength occurred to such a degree, +that he stood up before his glass and shaved himself, on the day on which +he died. + +The mind suffered with the morbid states of the brain and nerves. A +delirium was a common symptom. It alternated in some cases with the +exacerbations and remissions of the fever. In some, it continued without +a remission, until a few hours before death. Many, however, passed +through the whole course of the disease without the least derangement in +their ideas, even where there were evident signs of a morbid congestion +in the brain. Some were seized with maniacal symptoms. In these there was +an _apparent_ absence of fever. Such was the degree of this mania in one +man, that he stripped off his shirt, left his bed, and ran through the +streets, with no other covering than a napkin on his head, at 8 o'clock +at night, to the great terror of all who met him. The symptoms of mania +occurred most frequently towards the close of the disease, and sometimes +continued for many days and weeks, after all other febrile symptoms had +disappeared. + +The temper was much affected in this fever. There were few in whom it did +not produce great depression of spirits. This was the case in many, in +whom pious habits had subdued the fear of death. In some the temper +became very irritable. Two cases of this kind came under my notice, in +persons who, in good health, were distinguished for uncommon sweetness of +disposition and manners. + +I observed in several persons the operations of the understanding to be +unimpaired, throughout the whole course of the fever, who retained no +remembrance of any thing that passed in their sickness. My pupil, Mr. +Fisher, furnished a remarkable example of this correctness of +understanding, with a suspension of memory. He neither said nor did any +thing, during his illness, that indicated the least derangement of mind, +and yet he recollected nothing that passed in his room, except my visits +to him. His memory awakened upon my taking him by the hand, on the +morning of the 6th day of his disease, and congratulating him upon his +escape from the grave. + +In some, there was a weakness, or total defect of memory, for several +weeks after their recovery. Dr. Woodhouse informed me that he had met +with a woman, who, after she had recovered, could not recollect her own +name. + +Perhaps it would be proper to rank that self-deception with respect to +the nature and danger of the disease, which was so universal, among the +instances of derangement of mind. + +The pain which attended the disease was different, according to the +different states of the system. In those cases in which it sunk under +the violence of the disease, there was little or no pain. In proportion +as the system was relieved from this oppression, it recovered its +sensibility. The pain in the head was acute and distressing. It affected +the eye-balls in a peculiar manner. A pain extended, in some cases, from +the back of the head down the neck. The ears were affected, in several +persons, with a painful sensation, which they compared to a string +drawing their two ears together through the brain. The sides, and the +regions of the stomach, liver, and bowels, were all, in different people, +the seats of either dull or acute pains. The stomach, towards the close +of the disease, was affected with a burning or spasmodic pain of the most +distressing nature. It produced, in some cases, great anguish of body and +mind. In others it produced cries and shrieks, which were often heard on +the opposite side of the streets to where the patients lay. The back +suffered very much in this disease. The stoutest men complained, and even +groaned under it. An acute pain extended, in some cases, from the back to +one or both thighs. The arms and legs sympathized with every other part +of the body. One of my patients, upon whose limbs the disease fell with +its principal force, said that his legs felt as if they had been scraped +with a sharp instrument. The sympathy of friends with the distresses of +the sick extended to a small part of their misery, when it did not +include their sufferings from pain. One of the dearest friends I ever +lost by death declared, in the height of her illness, that "no one knew +the pains of a yellow fever, but those who felt them." + +VI. The _senses_ and _appetites_ exhibited several marks of the universal +ravages of this fever upon the body. A deafness attended in many cases, +but it was not often, as in the nervous fever, a favourable symptom. A +dimness of sight was very common in the beginning of the disease. Many +were affected with temporary blindness. In some there was a loss of sight +in consequence of gutta serena, or a total destruction of the substance +of the eye. There was in many persons a soreness to the touch which +extended all over the body. I have often observed this symptom to be the +forerunner of a favourable issue of a nervous fever, but it was less +frequently the case in this disease. + +The _thirst_ was moderate or absent in some cases, but it occurred in the +greatest number of persons whom I saw in this fever. Sometimes it was +very intense. One of my patients, who suffered by an excessive draught of +cold water, declared, just before he died, that "he could drink up the +Delaware." It was always an alarming symptom when this thirst came on in +this extravagant degree in the last stage of the disease. In the +beginning of the fever it generally abated upon the appearance of a moist +skin. Water was preferred to all other drinks. + +The _appetite_ for food was impaired in this, as in all other fevers, but +it returned much sooner than is common after the patient began to +recover. Coffee was relished in the remissions of the fever, in every +stage of the disease. So keen was the appetite for solid, and more +especially for animal food, after the solution of the fever, that many +suffered from eating aliment that was improper from its quality or +quantity. There was a general disrelish for wine, but malt liquors were +frequently grateful to the taste. + +Many people retained a relish for tobacco much longer after they were +attacked by this fever, and acquired a relish for it much sooner after +they began to recover, than are common in any other febrile disease. I +met with one case in which a man, who was so ill as to require two +bleedings, continued to chew tobacco through every stage of his fever. + +The convalescence from this disease was marked, in some instances, by a +sudden revival of the venereal appetite. Several weddings took place in +the city between persons who had recovered from the fever. Twelve took +place among the convalescents in the hospital at Bush-hill. I wish I +could add that the passion of the sexes for each other, among those +subjects of public charity, was always gratified only in a lawful way. +Delicacy forbids a detail of the scenes of debauchery which were +practised near the hospital, in some of the tents which had been +appropriated for the reception of convalescents. It was not peculiar to +this fever to produce this morbid excitability of the venereal appetite. +It was produced in a much higher degree by the plague which raged in +Messina in the year 1743. + +VII. The _lymphatic_ and _glandular system_ did not escape without some +signs of this disease. I met with three cases of swellings in the +inguinal, two in the parotid, and one in the cervical glands: all these +patients recovered without a suppuration of their swellings. They were +extremely painful in one case in which no redness or inflammation +appeared. In the others there was considerable inflammation and but +little pain. + +In one of the cases of inguinal buboes, the whole force of the disease +seemed to be collected into the lymphatic system. The patient walked +about, and had no fever nor pain in any part of his body, except in his +groin. In another case which came under my care, a swelling and pain +extended from the groin along the spermatic cord into one of the +testicles. These glandular swellings were not peculiar to this epidemic. +They occurred in the yellow fever of Jamaica, as described by Dr. +Williams, and always with a happy issue of the disease[26]. A similar +concentration of the contagion of the plague in the lymphatic glands is +taken notice of by Dr. Patrick Russel. + + [26] Essay on the Bilious or Yellow Fever, p. 35. + +VIII. The _skin_ exhibited many marks of this fever. It was +preternaturally warm in some cases, but it was often preternaturally +cool. In some there was a distressing coldness in the limbs for two or +three days. The yellow colour from which this fever has derived its name, +was not universal. It seldom appeared where purges had been given in +sufficient doses. The yellowness rarely appeared before the third, and +generally about the fifth or seventh day of the fever. Its early +appearance always denoted great danger. It sometimes appeared first on +the neck and breast, instead of the eyes. In one of my patients it +discovered itself first behind one of his ears, and on the crown of his +head, which had been bald for several years. The remissions and +exacerbations of the fever seemed to have an influence upon this colour, +for it appeared and disappeared altogether, or with fainter or deeper +shades of yellow, two or three times in the course of the disease. The +eyes seldom escaped a yellow tinge; and yet I saw a number of cases in +which the disease appeared with uncommon malignity and danger, without +the presence of this symptom. + +There was a clay-coloured appearance in the face, in some cases, which +was very different from the yellow colour which has been described. It +occurred in the last stage of the fever, and in no instance did I see a +recovery after it. + +There were eruptions of various kinds on the skin, each of which I shall +briefly describe. + +1. I met with two cases of an eruption on the skin, resembling that which +occurs in the scarlet fever. Dr. Hume says, pimples often appear on the +pit of the stomach, in the yellow fever of Jamaica. I examined the +external region of the stomach in many of my patients, without +discovering them. + +2. I met with one case in which there was an eruption of watery blisters, +which, after bursting, ended in deep, black sores. + +3. There was an eruption about the mouth in many people, which ended in +scabs, similar to those which take place in the common bilious fever. +They always afforded a prospect of a favourable issue of the disease. + +4. Many persons had eruptions which resembled moscheto bites. They were +red and circumscribed. They appeared chiefly on the arms, but they +sometimes extended to the breast. Like the yellow colour of the skin, +they appeared and disappeared two or three times in the course of the +disease. + +5. Petechiæ were common in the latter stage of the fever. They sometimes +came on in large, and at other times in small red blotches; but they soon +acquired a dark colour. In most cases they were the harbingers of death. + +6. Several cases of carbuncles, such as occur in the plague, came under +my notice. They were large and hard swellings on the limbs, with a black +apex, which, upon being opened, discharged a thin, dark-coloured, bloody +matter. From one of these malignant sores a hæmorrhage took place, which +precipitated the death of the amiable widow of Dr. John Morris. + +7. A large and painful anthrax on the back succeeded a favourable issue +of the fever in the Rev. Dr. Blackwell. + +8. I met with a woman who showed me the marks of a number of small boils +on her face and neck, which accompanied her fever. + +Notwithstanding this disposition to cutaneous eruptions in this disease, +it was remarkable that blisters were much less disposed to mortify than +in the common nervous fever. I met with only one case in which a +deep-seated ulcer followed the application of blisters to the legs. Such +was the insensibility of the skin in some people, that blisters made no +impression upon it. + +IX. The _blood_ in this fever has been supposed to undergo a change from +a healthy to a putrid state, and many of its symptoms which have been +described, particularly the hæmorrhages and eruptions on the skin, have +been ascribed to this supposed putrefaction of the blood. It would be +easy to multiply arguments, in addition to those mentioned in another +place[27], to prove that no such thing as putrefaction can take place in +the blood, and that the symptoms which have been supposed to prove its +existence are all effects of a sudden, violent, and rapid inflammatory +action or pressure upon the blood-vessels, and hence the external and +internal hæmorrhages. The petechiæ on the surface of the skin depend upon +the same cause. They are nothing but effusions of serum or red blood, +from a rupture or preternatural dilatation of the capillary vessels[28]. +The smell emitted from persons affected by this disease was far from +being of a putrid nature; and if this had been the case, it would not +have proved the existence of putrefaction in the blood, for a putrid +smell is often discharged from the lungs, and from the pores in sweat, +which is wholly unconnected with a putrid, or perhaps any other morbid +state of the blood. There are plants which discharge an odour which +conveys to the nose a sensation like that of putrefaction; and yet these +plants exist, at the same time, in a state of the most healthy +vegetation: nor does the early putrid smell of a body which perishes with +this fever prove a putrid change to have taken place in the blood before +death. All animals which die suddenly, and without loss of blood, are +disposed to a speedy putrefaction. This has long been remarked in animals +that have been killed after a chase, or by lightning. The poisonous air +called _samiel_, which is described by Chardin, produces, when it +destroys life, instant putrefaction. The bodies of men who die of violent +passions, or after strong convulsions, or even after great muscular +exertion, putrify in a few hours after death. The healthy state of the +body depends upon a certain state of arrangement in the fluids. A +derangement of these fluids is the natural consequence of the violent and +rapid motions, or of the undue pressure upon the solids, which have been +mentioned. It occurs in cases of death which are induced by the excessive +force of stimulus, whether it be from miasmata, or the volatile vitriolic +acid which is supposed to constitute the destructive samiel wind, or from +violent commotions excited in the body by external or internal causes. +The practice among fishermen, in some countries, of breaking the heads of +their fish as soon as they are taken out of the water, in order to retard +their putrefaction, proves the truth of the explanation I have given of +its cause, soon after death. The sudden extinction of life in the fish +prevents those convulsive or violent motions, which induce sudden +_disorganization_ in their bodies. It was observed that putrefaction took +place most speedily after death from the yellow fever, where the +commotions of the system were not relieved by evacuations. In those cases +where purges and bleeding had been used, putrefaction did not take place +sooner after death than is common in any other febrile disease, under +equal circumstances of heat and air. + + [27] Outlines of a Theory of Fever. + + [28] See Wallis's edition of Sydenham, vol. i. p. 165. vol. ii. p. 52, + 94, 98, 350; De Haen's Ratio Medendi, vol. ii. p. 162. vol. iv. p. + 172; Gaubii Pathologia, sect. 498; and Dr. Seybert's inaugural + dissertation, entitled "An Attempt to Disprove the Doctrine of + Putrefaction of the Blood in Living Animals," published in + Philadelphia in 1793. + +Thus have I described the symptoms of this fever. From the history I have +given, it appears that it counterfeited nearly all the acute and chronic +forms of disease to which the human body is subject. An epitome, both of +its symptoms and its theory, is happily delivered by Dr. Sydenham, in the +following words. After describing the epidemic cough, pleurisy, and +peripneumony of 1675, he adds, "But in other epidemics, the symptoms are +so slight from the disturbance raised in the blood by the morbific +particles contained in the mass, that nature being in a manner +_oppressed_, is rendered unable to produce _regular_ symptoms that are +suitable to the disease; and almost all the phenomena that happen are +_irregular_, by reason of the entire _subversion_ of the animal economy; +in which case the fever is often _depressed_, which, of its own nature, +would be very high. Sometimes also fewer signs of a fever appear than the +nature of the disease requires, from a translation of the malignant +cause, either to the nervous system, or to some other parts of the body, +or to some of the juices not contained in the blood; whilst the morbific +matter is yet turgid[29]." + + [29] Wallis's edition, vol. i. p. 344. + +The disease ended in death in various ways. In some it was sudden; in +others it came on by gradual approaches. In some the last hours of life +were marked with great pain, and strong convulsions; but in many more, +death seemed to insinuate itself into the system, with all the gentleness +of natural sleep. Mr. Powell expired with a smile on his countenance. Dr. +Griffitts informed me that Dr. Johnson exhibited the same symptom in the +last hours of his life. This placid appearance of the countenance, in the +act of dying, was not new to me. It frequently occurs in diseases which +affect the brain and nerves. I lost a patient, in the year 1791, with the +gout, who not only smiled, but laughed, a few minutes before he expired. + +I proceed now to mention some peculiarities of the fever, which could not +be brought in under any of the foregoing heads. + +In every case of this disease which came under my notice, there were +evident remissions, or intermissions of the fever, or of such symptoms as +were substituted for fever. I have long considered, with Mr. Senac, a +_tertian_ as the only original type of all fevers. The bilious yellow +fever indicated its descent from this parent disease. I met with many +cases of regular tertians, in which the patients were so well on the +intermediate days as to go abroad. It appeared in this form in Mr. Van +Berkel, the minister of the United Netherlands. Nor was this mild form of +the fever devoid of danger. Many died who neglected it, or who took the +common remedies for intermittents to cure it. It generally ended in a +remittent before it destroyed the patient. The tertian type discovered +itself in some people after the more violent symptoms of the fever had +been subdued, and continued in them for several weeks. It changed from a +tertian to a quartan type in Mr. Thomas Willing, nearly a month after +his recovery from the more acute and inflammatory symptoms of the +disease. + +It is nothing new for a malignant fever to appear in the form of a +tertian. It is frequently the garb of the plague. Riverius describes a +tertian fever which proved fatal on the third day, which was evidently +derived from the same exhalation which produced a continual malignant +fever[30]. + + [30] De Febre Pestilenti, vol. xi. p. 93. + +The remissions were more evident in this, than in the common bilious +fever. They generally occurred in the forenoon. It was my misfortune to +be deprived, by the great number of my patients, of that command of time +which was necessary to watch the exacerbations of this fever under all +their various changes, as to time, force, and duration. From all the +observations that were suggested by visits, at hours that were seldom +left to my choice, I was led to conclude, that the fever exhibited in +different people all that variety of forms which has been described by +Dr. Cleghorn, in his account of the tertian fever of Minorca. A violent +exacerbation on even days was evidently attended with more danger than on +odd days. The same thing was observed by Dr. Mitchell in the yellow fever +of Virginia, in the year 1741. "If (says he) the exacerbations were on +equal days, they generally died in the third paroxysm, or the sixth day; +but if on unequal days, they recovered on the seventh." + +The deaths which occurred on the 3d, 5th, and 7th days, appeared +frequently to be the effects of the commotions or depression, produced in +the system on the 2d, 4th, and 6th days. + +The remission on the third day was frequently such as to beget a belief +that the disease had run its course, and that all danger was over. A +violent attack of the fever on the 4th day removed this deception, and, +if a relaxation had taken place in the use of proper remedies on the 3d +day, death frequently occurred on the 5th or the 7th. + +The termination of this fever in life and death was much more frequent on +the 3d, 5th, 7th, 9th, and 11th days, than is common in the mild +remitting fever. Where death occurred on the even days, it seemed to be +the effect of a violent paroxysm of the fever, or of great vigour of +constitution, or of the force of medicines which protracted some of the +motions of life beyond the close of the odd days which have been +mentioned. + +I think I observed the fever to terminate on the third day more +frequently in August, and during the first ten days in September, than it +did after the weather became cool. In this it resembled the common +bilious remittents of our city, also the simple tertians described by Dr. +Cleghorn[31]. The danger seemed to be in proportion to the tendency of +the disease to a speedy crisis, hence more died in August in proportion +to the number who were affected than in September or October, when the +disease was left to itself. But, however strange after this remark it may +appear, the disease yielded to the remedies which finally subdued it more +speedily and certainly upon its first appearance in the city, than it did +two or three weeks afterwards. + + [31] Diseases of Minorca, p. 185. + +The disease continued for fifteen, twenty, and even thirty days in some +people. Its duration was much influenced by the weather, and by the use +or neglect of certain remedies (to be mentioned hereafter) in the first +stage of the disease. + +It has been common with authors to divide the symptoms of this fever into +three different stages. The order I have pursued in the history of those +symptoms will render this division unnecessary. It will I hope be more +useful to divide the patients affected with the disease into three +classes. + +The _first_ includes those in whom the stimulus of the miasmata produced +coma, languor, sighing, a disposition to syncope, and a weak or slow +pulse. + +The _second_ includes those in whom the miasmata acted with less force, +producing great pain in the head, and other parts of the body; delirium, +vomiting, heat, thirst, and a quick, tense, or full pulse, with obvious +remissions or intermissions of the fever. + +The _third_ class includes all those persons in whom the miasmata acted +so feebly as not to confine them to their beds or houses. This class of +persons affected by the yellow fever was very numerous. Many of them +recovered without medical aid, or by the use of domestic prescriptions; +many of them recovered in consequence of a spontaneous diarrh[oe]a, or +plentiful sweats; many were saved by moderate bleeding and purging; while +some died, who conceived their complaints to be occasioned by a common +cold, and neglected to take proper care of themselves, or to use the +necessary means for their recovery. It is not peculiar to the yellow +fever to produce this feeble operation upon the system, It has been +observed in the southern states of America, that in those seasons in +which the common bilious fever is epidemic "no body is quite well," and +that what are called in those states "inward fevers" are universal. The +small-pox, even in the natural way, does not always confine the patient; +and thousands pass through the plague without being confined to their +beds or houses. Dr. Hodges prescribed for this class of patients in his +parlour in London, in the year 1665, and Dr. Patrick Russel did the same +from a chamber window fifteen feet above the level of the street at +Aleppo. Notwithstanding the mild form the plague put on in these cases, +it often proved fatal according to Dr. Russel. I have introduced these +facts chiefly with a view of preparing the reader to reject the opinion +that we had two species of fever in the city at the same time; and to +show that the yellow fever appears in a more simple form than with +"strongly marked" characters; or, in other words, with a yellow skin and +a black vomiting. + +It was remarkable that this fever always found out the weak part of every +constitution it attacked. The head, the lungs, the stomach, the bowels, +and the limbs, suffered more or less, according as they were more or less +debilitated by previous inflammatory or nervous diseases, or by a +mixture of both, as in the gout. + +I have before remarked, that the influenza, the scarlatina, and a mild +bilious remittent, prevailed in the city, before the yellow fever made +its appearance. In the course of a few weeks they all disappeared, or +appeared with symptoms of the yellow fever; so that, after the first week +of September, it was the solitary epidemic of the city. + +The only case like influenza which I saw after the 5th of September, was +in a girl of 14 years of age, on the 13th of the month. It came on with a +sneezing and cough. I was called to her on the third day of her disease. +The instant I felt her pulse, I pronounced her disease to be the yellow +fever. Her father was offended with this opinion, although he lived in a +highly infected neighbourhood, and objected to the remedies I prescribed +for her. In a few days she died. In the course of ten days, her father +and sister were infected, and both died, I was informed, with the usual +symptoms of the yellow fever. + +It has been an axiom in medicine, time immemorial, that no two fevers of +unequal force can exist long together in the same place. As this axiom +seems to have been forgotten by many of the physicians of Philadelphia, +and as the ignorance or neglect of it led to that contrariety of opinion +and practice, which unhappily took place in the treatment of the disease, +I hope I shall be excused by those physicians to whom this fact is as +familiar as the most simple law of nature, if I fill a few pages with +proofs of it, from practical writers. + +Thucydides long ago remarked, that the plague chased all other diseases +from Athens, or obliged them to change their nature, by assuming some of +its symptoms. + +Dr. Sydenham makes the same remark upon the plague in London, in 1665. +Dr. Hodges, in his account of the same plague, says, that "at the rise of +the plague all other distempers went into it, but that, at its +declension, it degenerated into others, as inflammations, head-ach, +quinsies, dysenteries, small-pox, measles, fevers, and hectics, wherein +the plague yet predominated[32]." + + [32] Dr. Hodge's Account of the Plague in London, p. 26. + +During the prevalence of the plague in Grand Cairo, no sporadic disease +of any kind makes its appearance. The same observation is made by +Sauvage, in his account of the plague at Alais, in the province of +Languedoc[33]. + + [33] Sed hoc observatu dignum fuit, omnes alios morbos acutos, durante + peste siluisse, et omnes morbos acutos e pestis genere suisse. + Nosologia Methodica, vol. i. p. 416. + +The small-pox, though a disease of less force than the plague, has often +chased it from Constantinople, probably from its being in a declining +state. But this exclusive prevalence of a single epidemic is not confined +to the plague and small-pox. Dr. Sydenham's writings are full of proofs +of the dominion of febrile diseases over each other. Hence, after +treating upon a symptomatic pleurisy which sometimes accompanied a slow +fever, in the year 1675, and which had probably been injudiciously +treated by some of those physicians who prescribe for the name of a +disease, he delivers the following aphorism: "Whoever, in the cure of +fevers, hath not always in view the constitution of the year, inasmuch as +it tends to produce some particular epidemic disease, and likewise to +reduce all the cotemporary diseases to its own form and likeness, +proceeds in an uncertain and fallacious way[34]." It appears further, +from the writings of this excellent physician, that where the monarchy of +a single disease was not immediately acknowledged, by a sudden retreat +of all cotemporary diseases, they were forced to do homage to it, by +wearing its livery. It would be easy to multiply proofs of this +assertion, from the numerous histories of epidemics which are to be found +in his works. I shall mention only one or two of them. A continual fever, +accompanied by a dry skin, had prevailed for some time in the city of +London. During the continuance of this fever, the regular small-pox made +its appearance. It is peculiar to the small-pox, when of a distinct +nature, to be attended by irregular sweats before the eruption of the +pock. The continual fever now put on a new symptom. It was attended by +sweats in its first stage, exactly like those which attended the eruptive +fever of the small-pox[35]. This despotism of a powerful epidemic +extended itself to the most trifling indispositions. It even blended +itself, Dr. Sydenham tells us, with the commotions excited in the system +by the suppression of the lochia, as well as with the common puerperile +fever[36]. Dr. Morton has left testimonies behind him, in different parts +of his works, which establish, in the most ample manner, the truth of Dr. +Sydenham's observations. Dr. Huxham describes the small-pox as blending +some of its symptoms with those of a slow fever, at Plymouth, in the year +1729[37]. Dr. Cleghorn mentions a constitution of the air at Minorca, so +highly inflammatory, "that not only tertian fevers, but even a common +hurt or bruise required more plentiful evacuations than ordinary[38]." +Riverius informs us, in his history of a pestilential fever that +prevailed in France, that "it united itself with phrenitis, angina, +pleurisy, peripneumony, hepatitis, dysentery, and many other +diseases[39]." + + [34] Vol. i. p. 340. + + [35] Vol. i. p. 352. + + [36] Vol. ii. p. 164. See also p. 1, 109, 122, 204, 212, 233, 274, 355, + 358-9, and 436. + + [37] De Aere et Morb. Epidem. p. 33, 34. + + [38] Page 285. + + [39] De Febre Pestilenti, vol. ii. p. 95. + +The bilious remitting fever which prevailed in Philadelphia, in 1780, +chased away every other febrile disease; and the scarlatina anginosa +which prevailed in our city, in 1783 and 1784, furnished a striking proof +of the influence of epidemics over each other. In the account which I +published of this disease, in the year 1789, there are the following +remarks. "The intermitting fever which made its appearance in August was +not lost during the month of September. It continued to prevail, but with +several peculiar symptoms. In many persons it was accompanied by an +eruption on the skin, and a swelling of the hands and feet. In some it +was attended with sore throat, and pains behind the ears. Indeed such was +the prevalence of the contagion which produced the scarlatina anginosa, +that many hundred people complained of sore throats, without any other +symptom of indisposition. The slightest exciting cause, and particularly +cold, seldom failed of producing the disease[40]." + + [40] Vol. i. + +I shall mention only one more authority in favour of the influence of a +single epidemic upon diseases. It is taken from Mr. Clark's essay on the +epidemic disease of lying-in women, of the years 1787 and 1788. "There +does not appear to be any thing in a parturient state which can prevent +women from being affected by the general causes of disease at that time; +and should they become ill, their complaints will probably partake of the +nature of the reigning epidemic[41]." I have said that the fever +sometimes put on the symptoms of dysentery, pleurisy, rheumatism, colic, +palsy, and even of the locked jaw. That these were not original diseases, +but symptomatic affections only of the reigning epidemic, will appear +from other histories of bilious fevers. Dr. Balfour tells us, in his +account of the intestinal remitting fever of Bengal[42], that it often +appeared with symptoms of dysentery, rheumatism, and pleurisy. Dr. +Cleghorn and Dr. Lind mention many cases of the bilious fever appearing +in the form of a dysentery. Dr. Clark ascribes the dysentery, the +diarrh[oe]a, the colic, and even the palsy, to the same cause which +produced the bilious fever in the East-Indies[43]; and Dr. Hunter, in his +treatise upon the diseases of Jamaica, mentions the locked jaw as one of +its occasional symptoms. Even the different grades of this fever, from +the mildest intermittent to the most acute continual fever, have been +distinctly traced by Lancissi to the same marsh exhalation[44]. + + [41] Page 28. + + [42] Page 132. + + [43] Observations on the Diseases in Long Voyages to the East-Indies, + vol. i. p. 13, 14, 48, 151. vol. ii. p. 99, 318, and 320. + + [44] Lib. ii. cap. v. + +However irrefragably these numerous facts and authorities establish the +assertion of the prevalence of but one powerful epidemic at a time, the +proposition will receive fresh support, from attending to the effects of +two impressions of unequal force made upon the system at the same time: +only one of them is felt; hence the gout is said to cure all other +diseases. By its superior pain it destroys sensations of a less painful +nature. The small-pox and measles have sometimes existed together in the +body; but this has, I believe, seldom occurred, where one of them has not +been the predominating disease[45]. In this respect, this combination of +epidemics only conforms to the general law which has been mentioned. + + [45] Hunter on the Venereal Disease, introduction, p. 3. + +I beg pardon for the length of this digression. I did not introduce it to +expose the mistakes of those physicians, who found as many diseases in +our city as the yellow fever had symptoms, but to vindicate myself from +the charge of innovation, in having uniformly and unequivocally asserted, +after the first week in September, that the yellow fever was the only +febrile disease which prevailed in the city. + +Science has much to deplore from the multiplication of diseases. It is as +repugnant to truth in medicine, as polytheism is to truth in religion. +The physician who considers every different affection of the different +systems in the body, or every affection of different parts of the same +system, as distinct diseases, when they arise from one cause, resembles +the Indian or African savage, who considers water, dew, ice, frost, and +snow, as distinct essences; while the physician who considers the morbid +affections of every part of the body (however diversified they may be in +their form or degrees) as derived from one cause, resembles the +philosopher who considers dew, ice, frost, and snow, as different +modifications of water, and as derived simply from the absence of heat. + +Humanity has likewise much to deplore from this paganism in medicine. The +sword will probably be sheathed for ever, as an instrument of death, +before physicians will cease to add to the mortality of mankind, by +prescribing for the names of diseases. + +The facts I have delivered upon this subject will admit of a very +important application to the cure, not only of the yellow fever, but of +all other acute and dangerous epidemics. I shall hereafter assign a final +cause for the law of epidemics which has been mentioned, which will +discover a union of the goodness of the Supreme Being with one of the +greatest calamities of human life. + +All ages were affected by this fever, but persons between fourteen and +forty years of age were most subject to it. Many old people had it, but +it was not so fatal to them as to robust persons in middle life. It +affected children of all ages. I met with a violent case of the disease, +in a child of four months, and a moderate case of it, in a child of but +ten weeks old. The latter had a deep yellow skin. Both these children +recovered. + +The proportion of children who suffered by this fever may be conceived +from a single fact. Seventy-five persons were buried in the grave-yard of +the Swedish church in the months of August, September, and October, +twenty-four of whom were children. They were buried chiefly in September +and October; months in which children generally enjoy good health in our +city. + +Men were more subject to the disease than women. Pregnancy seemed to +expose women to it. + +The refugees from the French West-Indies universally escaped it. This was +not the case with the natives of France, who had been settled in the +city. + +It is nothing new for epidemics to affect persons of one nation, and to +pass by persons of other nations, in the same city or country. At +Nimeguen, in the year 1736, Deigner informs us, that the French people +(two old men excepted), and the Jews, escaped a dysentery which was +universal among persons of all other nations. Ramazini tells us, that the +Jews at Modena escaped a tertian fever which affected nearly all the +other inhabitants of the town. Shenkius says, that the Dutch and Italians +escaped a plague, which prevailed for two years in one of the towns of +Switzerland; and Dr. Bell, in an inaugural dissertation, published at +Edinburgh, in 1779, remarks, that the jail fever, which attacked the +soldiers of the duke of Buccleugh's regiment, spared the French prisoners +who were guarded by them. It is difficult to account for these facts. +However numerous their causes may be, a difference in diet, which is as +much a distinguishing mark of nations as dress or manners, will probably +be found to be one of them. + +From the accounts of the yellow fever which had been published by many +writers, I was led to believe that the negroes in our city would escape +it. In consequence of this belief, I published the following extract in +the American Daily Advertiser, from Dr. Lining's history of the yellow +fever, as it had four times appeared in Charleston, in South-Carolina. + +"There is something very singular (says the doctor) in the constitution +of the negroes, which renders them not liable to this fever; for though +many of them were as much exposed as the nurses to the infection, yet I +never knew of one instance of this fever among them, though they are +equally subject with the white people to the bilious fever[46]." + + [46] Essays and Observations, Physical and Literary, vol. xi. page 409. + +A day or two after this publication the following letter from the mayor +of the city, to Mr. Claypoole, the printer of the Mail, appeared in his +paper. + +"SIR, + +"It is with peculiar satisfaction that I communicate to the public, +through your paper, that the AFRICAN SOCIETY, touched with the distresses +which arise from the present dangerous disorder, have voluntarily +undertaken to furnish nurses to attend the afflicted; and that, by +applying to ABSALOM JONES and WILLIAM GRAY, both members of that +society, they may be supplied. + MATTH. CLARKSON, + _September 6th, 1793._ _Mayor_." + +It was not long after these worthy Africans undertook the execution of +their humane offer of services to the sick before I was convinced I had +been mistaken. They took the disease in common with the white people, and +many of them died with it. I think I observed the greatest number of them +to sicken after the mornings and evenings became cool. A large number of +them were my patients. The disease was lighter in them than in white +people. I met with no case of hæmorrhage in a black patient. + +The tobacconists and persons who used tobacco did not escape the disease. +I observed snuff-takers to be more devoted to their boxes than usual, +during the prevalence of the fever. + +I have remarked, formerly, that servant maids suffered much by the +disease. They were the only patients I lost in several large families. I +ascribe their deaths to the following causes: + +_1st._ To the great and unusual debility induced upon their systems by +labour in attending their masters and mistresses, or their children. +Debility, according to its degrees and duration, seems to have had the +same effect upon the mortality of this fever that it has upon the +mortality of an inflammation of the lungs. When it is moderate and of +short duration it predisposes only to a common pneumony, but when it is +violent and protracted, in its degrees and duration, it predisposes to a +pulmonary consumption. + +_2dly._ To their receiving large quantities of impure air into their +bodies, and in a most concentrated state, by being obliged to perform the +most menial offices for the sick, and by washing, as well as removing +foul linen, and the like. + +_3dly._ To their being left more alone in confined or distant rooms, and +thereby suffering from depression of spirits, or the want of a punctual +supply of food and medicines. + +There did not appear to be any advantage from smelling vinegar, tar, +camphor, or volatile salts, in preventing the disease. Bark and wine were +equally ineffectual for that purpose. I was called to many hundred people +who were infected after using one or more of them. Nor did the white +washing of walls secure families from the disease. I am disposed to +believe garlic was the only substance that was in any degree useful in +preventing it. I met with several persons who chewed it constantly, and +who were much exposed to the miasmata, without being infected. All other +substances seemed to do harm by begetting a false confidence in the mind, +to the exclusion of more rational preservatives. I have suspected +further, that such of them as were of a volatile nature helped to spread +the disease by affording a vehicle for miasmata through the air. + +There was great mortality in all those families who lived in wooden +houses. Whether this arose from the small size of these houses, or from +the want of cleanliness of the people who occupied them, or from the +miasmata becoming more accumulated, by adhering to the wood, I am unable +to determine. Perhaps it was the effect of the co-operation of all three +of those causes. + +I have said, formerly, that intemperance in drinking predisposed to the +disease; but there were several instances of persons having escaped it +who were constantly under the influence of strong drink. The stimulus of +ardent spirits probably predominated over the stimulus of the miasmata, +and thus excited an artificial fever which defended the system from that +which was epidemic. + +I heard of some sea-faring people who lived on board their vessels who +escaped the disease. The smell of the tar was supposed to have preserved +them; but, from its being ineffectual in other cases, I am disposed to +ascribe their escape to the infected air of the city being destroyed by a +mixture with the water of the Delaware. + +Many people who were infected in the city were attacked by the disease in +the country, but they did not propagate it, even to persons who slept in +the same room with them. + +Dr. Lind informs us that many persons escaped the yellow fever which +prevailed in Pensacola in the year 1765, by retiring to the ships which +lay in the harbour, and that when the disease had been taken, the pure +air of the water changed it into an intermitting fever[47]. The same +changes have frequently been produced in malignant fevers, by sending +patients infected with them from the foul air of a city, into the pure +air of the country. + + [47] Diseases of Warm Climates, p. 169. + +Persons confined in the house of employment, in the hospital, and in the +jail, escaped the fever. The airy and remote situation of those buildings +was probably the chief means of their preservation. Perhaps they derived +additional security from their simple diet, their exemption from hard +labour, and from being constantly sheltered from heat and cold. + +Several families, who shut up their front and back doors and windows, and +avoided going out of their houses except to procure provisions, escaped +the disease. + +I have taken some pains to ascertain, whether any class of tradesmen +escaped the fever, or whether there was any species of labour which +protected from it. The result of my inquiries is as follows: Three +butchers only, out of nearly one hundred who remained in the city, died +with the disease. Many of them attended the markets every day. Two +painters, who worked at their business during the whole time of the +prevalence of the fever, and in exposed situations, escaped it. Out of +forty scavengers who were employed in collecting and carrying away the +dirt of the streets, only one was affected by the fever and died. Very +few grave-diggers, compared with the number who were employed in that +business, were infected; and it is well known, that scarcely an instance +was heard of persons taking the disease, who were constantly employed in +digging cellars. The fact is not new that grave-diggers escape malignant +fevers. It is taken notice of by Dr. Clark. + +It was said by some physicians in the public papers, that the +neighbourhood of the grave-yards was more infected than other parts of +the city. The reverse of this assertion was true in several cases, owing +probably to the miasmata being diluted and weakened by its mixture with +the air of the grave-yards: for this air was pure, compared with that +which stagnated in the streets. + +It was said further, that the disease was propagated by the inhabitants +assembling on Sundays for public worship; and, as a proof of this +assertion, it was reported, that the deaths were more numerous on Sundays +than on other days; occasioned by the infection received on one Sunday +producing death on the succeeding first day of the week. The register of +the deaths shows that this was not the case. I am disposed to believe +that fewer people sickened on Sundays, than on any other day of the week; +owing to the general rest from labour, which I have before said was one +of the exciting causes of the disease. From some facts to be mentioned +presently, it will appear probable, that places of public worship, in +consequence of their size, as well as of their being shut up during the +greatest part of the week, were the freest from miasmata of any houses in +the city. It is agreeable to discover in this, as well as in all other +cases of public and private duty, that the means of health and moral +happiness are in no one instance opposed to each other. + +The disease, which was at first confined to Water-street, soon spread +through the whole city. After the 15th of September, the atmosphere of +every street in the city was charged with miasmata; and there were few +citizens in apparent good health, who did not exhibit one or more of the +following marks of their presence in their bodies. + +1. A yellowness in the eyes, and a sallow colour upon their skin. + +2. A preternatural quickness in the pulse. I found but two exceptions to +this remark, out of a great number of persons whose pulses I examined. In +one of them it discovered several preternatural intermissions in the +course of a minute. This quickness of pulse occurred in the negroes, as +well as in the white people. I met with it in a woman who had had the +yellow fever in 1762. In two women, and in one man above 70, the pulse +beat upwards of 90 strokes in a minute. This preternatural state of the +pulse during the prevalence of a pestilential fever, in persons in +health, is taken notice of by Riverius[48]. + +[48] "Pulsus sanorum pulsibus similes admodum, periculosi."--_De Febre +Pestilenti, p. 114._ + +3. Frequent and copious discharges by the skin of yellow sweats. In some +persons these sweats sometimes had an offensive smell, resembling that of +the washings of a gun. + +4. A scanty discharge of high coloured or turbid urine. + +5. A deficiency of appetite, or a greater degree of it than was natural. + +6. Costiveness. + +7. Wakefulness. + +8. Head-ach. + +9. A preternatural dilatation of the pupils. This was universal. I was +much struck in observing the pupil in one of the eyes of a young man who +called upon me for advice, to be of an oblong figure. Whether it was +natural, or the effect of the miasmata acting on his brain, I could not +determine. + +It will be thought less strange that the miasmata should produce these +changes in the systems of persons who resided constantly in the city, +when I add, that many country people who spent but a few hours in the +streets in the day, in attending the markets, were infected by the +disease, and sickened and died after they returned home; and that others, +whom business compelled to spend a day or two in the city during the +prevalence of the fever, but who escaped an attack of it, declared that +they were indisposed, during the whole time, with languor or head-ach. + +I was led to observe and record the above effects of the miasmata upon +persons in apparent good health, by a fact I met with in Dr. Mitchell's +history of the yellow fever in Virginia, in the year 1741. In that fever, +blood drawn from a vein was always dissolved. The same state of the blood +was observed in many persons who had been exposed to the miasmata, who +discovered no other symptom of the disease. + +A woman whom I had formerly cured of a mania, who lived in an infected +neighbourhood, had a fresh attack of that disease, accompanied by an +unusual menstrual flux. I ascribed both these complaints to the action of +the miasmata upon her system. + +The smell emitted from a patient, in a clean room, was like that of the +small-pox, but in most cases of a less disagreeable nature. Putrid smells +in sick rooms were the effects of the excretions, or of some other filthy +matters. In small rooms, crowded in some instances with four or five sick +people, there was an effluvia that produced giddiness, sickness at +stomach, a weakness of the limbs, faintness, and in some cases a +diarrh[oe]a. I met with a f[oe]tid breath in one patient, which was not +the effect of that medicine which sometimes produces it. + +The state of the atmosphere, during the whole month of September, and the +first two weeks in October, favoured the accumulation of the miasmata in +the city. + +The register of the weather shows how little the air was agitated by +winds during the above time. In vain were changes in the moon expected to +alter the state of the air. The light of the morning mocked the hopes +that were raised by a cloudy sky in the evening. The sun ceased to be +viewed with pleasure. Hundreds sickened every day beneath the influence +of his rays: and even where they did not excite the disease, they +produced a languor in the body unknown to the oldest inhabitant of the +city, at the same season of the year. + +A meteor was seen at two o'clock in the morning, on or about the twelfth +of September. It fell between Third-street and the hospital, nearly in a +line with Pine-street. Moschetoes (the usual attendants of a sickly +autumn) were uncommonly numerous. Here and there a dead cat added to the +impurity of the air of the streets. It was supposed those animals +perished with hunger in the city, in consequence of so many houses being +deserted by the inhabitants who had fled into the country, but the +observations of subsequent years made it more probable they were +destroyed by the same morbid state of the atmosphere which produced the +reigning epidemic. + +It appears further, from the register of the weather, that there was no +rain between the 25th of August and the 15th of October, except a few +drops, hardly enough to lay the dust of the streets, on the 9th of +September, and the 12th of October. In consequence of this drought, the +springs and wells failed in many parts of the country. The dust in some +places extended two feet below the surface of the ground. The pastures +were deficient, or burnt up. There was a scarcity of autumnal fruits in +the neighbourhood of the city. But while vegetation drooped or died from +the want of moisture in some places, it revived with preternatural vigour +from unusual heat in others. Cherry-trees blossomed, and apple, pear, and +plum-trees bore young fruit in several gardens in Trenton, thirty miles +from Philadelphia, in the month of October. + +However inoffensive uniform heat, when agitated by gentle breezes, may +be, there is, I believe, no record of a dry, warm, and stagnating air, +having existed for any length of time without producing diseases. +Hippocrates, in describing a pestilential fever, says the year in which +it prevailed was without a breeze of wind[49]. The same state of the +atmosphere, for six weeks, is mentioned in many of the histories of the +plague which prevailed in London, in 1665[50]. Even the sea air itself +becomes unwholesome by stagnating; hence Dr. Clark informs us, that +sailors become sickly after long calms in East-India voyages[51]. Sir +John Pringle delivers the following aphorism from a number of similar +observations upon this subject: "When the heats come on soon, and +continue throughout autumn, not moderated by winds or rains, the season +proves sickly, distempers appear early, and are dangerous[52]." + + [49] "Sine aura, usque annus fuit."--_Epid. 3._ + + [50] Letter from Sir John Bernard to Dr. Floyer, p. 233. + + [51] Vol. i. p. 5. + + [52] Diseases of the Army, p. 5. of the 7th London edition. + +Who can review this account of the universal diffusion of the miasmata +which produced this disease, its universal effects upon persons +apparently in good health, and its accumulation and concentration, in +consequence of the calmness of the air, and believe that it was possible +for a febrile disease to exist at that time in our city that was not +derived from that source? + +The West-India writers upon the yellow fever have said that it is seldom +taken twice, except by persons who have spent some years in Europe or +America in the interval between its first and second attack. I directed +my inquiries to this question, and I now proceed to mention the result of +them. I met with five persons, during the prevalence of the disease, who +had had it formerly, two of them in the year 1741, and three in 1762, who +escaped it in 1793, although they were all more or less exposed to the +infection. One of them felt a constant pain in her head while the disease +was in her family. Four of them were aged, and of course less liable to +be acted upon by the miasmata than persons in early or middle life. Mr. +Thomas Shields furnished an unequivocal proof that the disease could be +taken after an interval of many years. He had it in the year 1762, and +narrowly escaped from a violent attack of it this year. Cases of +reinfection were very common during the prevalence of this fever. They +occurred most frequently where the first attack had been light. But they +succeeded attacks that were severe in Dr. Griffitts, Dr. Mease, my pupil +Mr. Coxe, and several others, whose cases came under my notice. + +I have before remarked that the miasmata sometimes excited a fever as +soon as they were taken into the body, but that they often lay there from +one to sixteen days before they produced the disease. How long they +existed in the body after a recovery from the fever I could not tell, for +persons who recovered were, in most cases, exposed to their action from +external sources. The preternatural dilatation of the pupils was a +certain mark of the continuance of some portion of them in the system. In +one person who was attacked with the fever on the night of the 9th of +October, the pupils did not contract to their natural dimensions until +the 7th of November. + +Having described the effects of the miasmata upon the body, I proceed now +to mention the changes induced upon it by death. + +Let us first take a view of it as it appeared soon after death. Some new +light may perhaps be thrown upon the proximate cause of the disease by +this mode of examining the body. + +My information upon this subject was derived from the attendants upon the +sick, and from the two African citizens who were employed in burying the +dead, viz. Richard Allen and Absalom Jones. The coincidence of the +information received from different persons satisfied me that all that I +shall here relate is both accurate and just. + +A deep yellow colour appeared in many cases within a few minutes after +death. In some the skin became purple, and in others black. I heard of +one case in which the body was yellow above, and black below its middle. +In some the skin was as pale as it is in persons who die of common +fevers. A placid countenance was observed in many, resembling that which +occurs in an easy and healthful sleep. + +Some were stiff within one hour after death. Others were not so for six +hours afterwards. This sudden stiffness after death, Dr. Valli informs +us, occurred in persons who died of the plague in Smyrna, in the year +1784[53]. + + [53] Experiments on Animal Electricity, p. 90. + +Some grew cold soon after death, while others retained a considerable +degree of heat for six hours, more especially on their backs. + +A stream of tears appeared on the cheeks of a young woman, which seemed +to have flowed after her death. + +Some putrified in a short time after their dissolution, but others had no +smell for twelve, eighteen, and twenty hours afterwards. This absence of +smell occurred in those cases in which evacuations had been used without +success in the treatment of the disease. + +Many discharged large quantities of black matter from the bowels, and +others blood from the nose, mouth, and bowels after death. The frequency +of these discharges gave rise to the practice of pitching the joints of +the coffins which were used to bury the dead. + +The morbid appearances of the internal parts of the body, as they appear +by dissection after death from the yellow fever, are different in +different countries, and in the same countries in different years. I +consider them all as effects only of a stimulus acting upon the whole +system, and determined more or less by accidental circumstances to +particular viscera. Perhaps the stimulus of the miasmata determines the +fluids more violently in most cases to the liver, stomach, and bowels, +and thereby disposes them more than other parts to inflammation and +mortification, and to similar effusions and eruptions with those which +take place on the skin. There can be no doubt of the miasmata acting upon +the liver, and thereby altering the qualities of the bile. I transcribe, +with great pleasure, the following account of the state of the bile in a +female slave of forty years of age, from Dr. Mitchell's History of the +Yellow Fever, as it prevailed in Virginia, in the years 1737 and 1741, +inasmuch as it was part of that clue which led me to adopt one of the +remedies on which much of the success of my practice depended. + +"The gall bladder (says the doctor) appeared outwardly of a deep yellow, +but within was full of a black ropy coagulated atrabilis, which sort of +substance obstructed the pori biliarii, and ductus choledochus. This +atrabilis was hardly fluid, but upon opening the gall bladder, it +retained its form and shape, without being evacuated, being of the +consistence of a thin extract, and, within, glutinous and ropy, like soap +when boiling. This black matter seemed so much unlike bile, that I +doubted if there were any bile in the gall bladder. It more resembled +bruised or mortified blood, evacuated from the mortified parts of the +liver, surrounding it, although it would stain a knife or probe thrust +into it of a yellow colour, which, with its ropy consistence, seemed more +peculiar to a bilious humour." + +The same appearance of the bile was discovered in several other subjects +dissected by Dr. Mitchell. + +The liver, in the above-mentioned slave, was turgid and plump on its +outside, but on its concave surface, two thirds of it were of a deep +black colour, and round the gall bladder it seemed to be mortified and +corrupted. + +The duodenum was lined on its inside, near the gall bladder, with a +viscid ropy bile, like that which has been described. Its villous coat +was lined with a thick fur or slime, which, when scraped or pealed off, +the other vascular and muscular coats of the gut appeared red and +inflamed. + +The omentum was so much wasted, that nothing but its blood-vessels could +be perceived. + +The stomach was inflamed, both on its outside and inside. It contained a +quantity of bile of the same consistence, but of a blacker colour than +that which was found in the gall bladder. Its villous coat, like that of +the duodenum, was covered with fuzzy and slimy matter. It moreover +appeared to be distended or swelled. This peculiarity in the inner coat +of the stomach was universal in all the bodies that were opened, of +persons who died of this disease. + +The lungs, instead of being collapsed, were inflated as in inspiration. +They were all over full of black or livid spots. On these spots were to +be seen small vesicles or blisters, like those of an erysipelas or +gangrene, containing a yellow humour. + +The blood-vessels in general seemed empty of blood, even the vena cava +and its branches; but the vena portarum was full and distended as usual. +The blood seemed _collected_ in the _viscera_; for upon cutting the lungs +or sound liver or spleen, they bled freely. + +The brain was not opened in this body, but it was not affected in three +others whose brains were examined. + +Dr. Mackittrick, in his inaugural dissertation, published at Edinburgh in +the year 1766, "De Febre Indiæ Occidentalis, Maligna Flava," or upon the +yellow fever of the West-Indies, says, that in some of the patients who +died of it, he found the liver sphacelated, the gall bladder full of +black bile, and the veins turgid with black fluid blood. In others he +found the liver no ways enlarged, and its "texture only vitiated." The +stomach, the duodenum, and ilium, were remarkably inflamed in all cases. +The pericardium contained a viscid yellow serum, and in a larger quantity +than common. The urinary bladder was a little inflamed. The lungs were +sound. + +Dr. Hume, in describing the yellow fever of Jamaica, informs us, that in +several dead bodies which he opened, he found the liver enlarged and +turgid with bile, and of a pale yellow colour. In some he found the +stomach and duodenum inflamed. In one case he discovered black spots in +the stomach, of the size of a crown piece. To this account he adds, "that +he had seen some subjects opened, on whose stomachs _no marks of +inflammation_ could be discovered; and yet these had excessive vomiting." + +Dr. Lind has furnished us with an account of the state of the body after +death, in his short history of the yellow fever, which prevailed at +Cadiz, in the year 1764. "The stomach (he says), mesentery, and +intestines, were covered with gangrenous spots; there were ulcers on the +orifice of the stomach, and the liver and lungs were of a putrid colour +and texture[54]." + + [54] Diseases of Warm Climates, p. 125. + +To these accounts of the morbid appearances of the body after death from +the yellow fever I shall only add the account of several dissections, +which was given to the public in Mr. Brown's Gazette, during the +prevalence of this epidemic, by Dr. Physick and Dr. Cathrall. + +"Being well assured of the great importance of dissections of morbid +bodies in the investigation of the nature of diseases, we have thought it +of consequence that some of those dead of the present prevailing +malignant fever should be examined; and, without enlarging on our +observations, it appears at present sufficient to state the following +facts. + +"1st. That the brain in all its parts has been found in a natural +condition. + +"2d. That the viscera of the thorax are perfectly sound. The blood, +however, in the heart and veins is fluid, similar, in its consistence, to +the blood of persons who have been hanged, or destroyed by electricity. + +"3d. That the stomach, and beginning of the duodenum, are the parts that +appear most diseased. In two persons who died of the disease on the 5th +day, the villous membrane of the stomach, especially about its smaller +end, was found highly inflamed; and this inflammation extended through +the pylorus into the duodenum, some way. The inflammation here was +exactly similar to that induced in the stomach by acrid poisons, as by +arsenic, which we have once had an opportunity of seeing in a person +destroyed by it. + +"The bile in the gall-bladder was quite of its natural colour, though +very viscid. + +"In another person, who died on the 8th day of the disease, several spots +of extravasation were discovered between the membranes, particularly +about the smaller end of the stomach, the inflammation of which had +considerably abated. Pus was seen in the beginning of the duodenum, and +the villous membrane at this part was thickened. + +"In two other persons, who died at a more advanced period of the disease, +the stomach appeared spotted in many places with extravasations, and the +inflammation disappeared. It contained, as did also the intestines, a +black liquor, which had been vomited and purged before death. This black +liquor appears clearly to be an altered secretion from the liver; for a +fluid in all respects of the same qualities was found in the gall +bladder. This liquor was so acrid, that it induced considerable +inflammation and swelling on the operator's hands, which remained some +days. The villous membrane of the intestines, in these last two bodies, +was found inflamed in several places. + +"The liver was of its natural appearance, excepting in one of the last +persons, on the surface of which a very few distended veins were seen: +all the other abdominal viscera were of a healthy appearance. + +"The external surface of the stomach, as well as of the intestines, was +quite free from inflammation; the veins being distended with blood, which +appeared through the transparent peritonium, gave them a dark colour. + +"The stomach of those who died early in the disease was always +contracted; but in those who died at a more advanced period of it, where +extravasations appeared, it was distended with air. + "P. S. PHYSICK, + "J. CATHRALL." + +I have before remarked, that these dissections were made early in the +disease, and that Dr. Annan attended a dissection of a body at +Bush-hill, some time afterwards, in which an unusual turgescence appeared +in the vessels of the brain. + +Thus far have I delivered the history of the yellow fever, as it affected +the human body with sickness and death. I shall now mention a few of +those circumstances of public and private distress which attended it. I +have before remarked, that the first reports of the existence of this +fever were treated with neglect or contempt. A strange apathy pervaded +all classes of people. While I bore my share of reproach for "terrifying +our citizens with imaginary danger," I answered it by lamenting "that +they were not terrified enough." The publication from the college of +physicians soon dissipated this indifference and incredulity. Fear or +terror now sat upon every countenance. The disease appeared in many parts +of the town, remote from the spot where it originated; although, for a +while, in every instance, it was easily traced to it. This set the city +in motion. The streets and roads leading from the city were crowded with +families flying in every direction for safety to the country. Business +began to languish. Water-street, between Market and Race-streets, became +a desert. The poor were the first victims of the fever. From the sudden +interruption of business they suffered for a while from poverty as well +as from disease. A large and airy house at Bush-hill, about a mile from +the city, was opened for their reception. This house, after it became the +charge of a committee appointed by the citizens on the 14th of September, +was regulated and governed with the order and cleanliness of an old and +established hospital. An American and French physician had the exclusive +medical care of it after the 22d of September. + +The disease, after the second week in September, spared no rank of +citizens. Whole families were confined by it. There was a deficiency of +nurses for the sick, and many of those who were employed were unqualified +for their business. There was likewise a great deficiency of physicians, +from the desertion of some, and the sickness and death of others. At one +time there were but three physicians who were able to do business out of +their houses, and at this time there were probably not less than 6000 +persons ill with the fever. + +During the first three or four weeks of the prevalence of the disease I +seldom went into a house the first time, without meeting the parents or +children of the sick in tears. Many wept aloud in my entry, or parlour, +who came to ask for advice for their relations. Grief after a while +descended below weeping, and I was much struck in observing that many +persons submitted to the loss of relations and friends without shedding a +tear, or manifesting any other of the common signs of grief. + +A cheerful countenance was scarcely to be seen in the city for six weeks. +I recollect once, in entering the house of a poor man, to have met a +child of two years old that smiled in my face. I was strangely affected +with this sight (so discordant to my feelings and the state of the city) +before I recollected the age and ignorance of the child. I was confined +the next day by an attack of the fever, and was sorry to hear, upon my +recovery, that the father and mother of this little creature died a few +days after my last visit to them. + +The streets every where discovered marks of the distress that pervaded +the city. More than one half the houses were shut up, although not more +than one third of the inhabitants had fled into the country. In walking +for many hundred yards, few persons were met, except such as were in +quest of a physician, a nurse, a bleeder, or the men who buried the dead. +The hearse alone kept up the remembrance of the noise of carriages or +carts in the streets. Funeral processions were laid aside. A black man, +leading or driving a horse, with a corpse on a pair of chair wheels, with +now and then half a dozen relations or friends following at a distance +from it, met the eye in most of the streets of the city, at every hour of +the day, while the noise of the same wheels passing slowly over the +pavements, kept alive anguish and fear in the sick and well, every hour +of the night[55]. + + [55] In the Life of Thomas Story, a celebrated preacher among the + friends, there is an account of the distress of the city, in its + infant state, from the prevalence of the yellow fever, in the + autumn of 1699, nearly like that which has been described. I shall + insert the account in his own words. "Great was the fear that fell + on all flesh. I saw no lofty or airy countenance, nor heard any + vain jesting to move men to laughter. Every face gathered + paleness, and many hearts were humbled, and countenances fallen + and sunk, as such that waited every moment to be summoned to the + bar, and numbered to the grave." The same author adds, that six, + seven, and sometimes eight, died of this fever in a day, for + several weeks. His fellow-traveller, and companion in the + ministry, Roger Gill, discovered upon this occasion an + extraordinary degree of christian philanthropy. He publicly + offered himself, in one of the meetings of the society, as a + sacrifice for the people, and prayed that "God would please to + accept of his life for them, that a stop might be put to the + contagion." He died of the fever a few days afterwards. + +But a more serious source of the distress of the city arose from the +dissentions of the physicians, about the nature and treatment of the +fever. It was considered by some as a modification of the influenza, and +by others as the jail fever. Its various grades and symptoms were +considered as so many different diseases, all originating from different +causes. There was the same contrariety in the practice of the physicians +that there was in their principles. The newspapers conveyed accounts of +both to the public, every day. The minds of the citizens were distracted +by them, and hundreds suffered and died from the delays which were +produced by an erroneous opinion of a plurality of diseases in the city, +or by indecision in the choice, or a want of confidence in the remedies +of their physician. + +The science of medicine is related to every thing, and the philosopher as +well as the christian will be gratified by knowing the effects of a great +and mortal epidemic upon the morals of a people. It was some alleviation +of the distress produced by it, to observe its influence upon the +obligations of morality and religion. It was remarked during this time, +by many people, that the name of the Supreme Being was seldom profaned, +either in the streets, or in the intercourse of the citizens with each +other. But two robberies, and those of a trifling nature, occurred in +nearly two months, although many hundred houses were exposed to plunder, +every hour of the day and night. Many of the religious societies met two +or three times a week, and some of them every evening, to implore the +interposition of Heaven to save the city from desolation. Humanity and +charity kept pace with devotion. The public have already seen accounts of +their benevolent exercises in other publications. It was my lot to +witness the uncommon activity of those virtues upon a smaller scale. I +saw little to blame, but much to admire and praise in persons of +different professions, both sexes, and of all colours. It would be +foreign to the design of this work to draw from the obscurity which they +sought, the many acts of humanity and charity, of fortitude, patience, +and perseverance, which came under my notice. They will be made public +and applauded elsewhere. + +But the virtues which were excited by our calamity were not confined to +the city of Philadelphia. The United States wept for the distresses of +their capital. In several of the states, and in many cities and villages, +days of humiliation and prayer were set apart to supplicate the Father of +Mercies in behalf of our afflicted city. Nor was this all. From nearly +every state in the union the most liberal contributions of money, +provisions, and fuel were poured in for the relief and support of such +as had been reduced to want by the suspension of business, as well as by +sickness and the death of friends. + +The number of deaths between the 1st of August and the 9th of November +amounted to four thousand and forty-four. I shall here insert a register +of the number which occurred on each day, beginning on the 1st of August, +and ending on the 9th of November. By comparing it with the register of +the weather it will show the influence of the latter on the disease. +Several of the deaths in August were from other acute diseases, and a few +in the succeeding months were from such as were of a chronic nature. + + died. | + August 1 9 | + 2 8 | + 3 9 | + 4 10 | + 5 10 | + 6 3 | + 7 12 | + 8 5 | + 9 11 | + 10 6 | + 11 7 | + 12 5 | + 13 11 | + 14 4 | + 15 9 | + 16 7 | + 17 6 | + 18 5 | + 19 9 | + 20 7 | + 21 8 | + 22 13 | + 23 10 | + 24 17 | + 25 12 | + 26 17 | + 27 12 | + 28 22 | + 29 24 | + 30 20 | + 31 17 | + September 1 17 | + 2 18 | + 3 11 | + 4 23 | + 5 20 | + 6 24 | + 7 18 | + 8 42 | + 9 32 | + 10 29 | + 11 23 | + 12 33 | + 13 37 | + 14 48 | + 15 56 | + 16 67 | + 17 81 | + 18 68 | + 19 61 | + 20 67 | + 21 57 | + 22 76 | + 23 68 | + 24 96 | + 25 87 | + 26 52 | + 27 60 | + 28 51 | + 29 57 | + 30 63 | + October 1 74 | + 2 66 | + 3 78 | + 4 58 | + 5 71 | + 6 76 | + 7 82 | + 8 90 | + 9 102 | + 10 93 | + 11 119 | + 12 111 | + 13 104 | + 14 81 | + 15 80 | + 16 70 | + 17 80 | + 18 59 | + 19 65 | + 20 55 | + 21 59 | + 22 82 | + 23 54 | + 24 38 | + 25 35 | + 26 23 | + 27 13 | + 28 24 | + 29 17 | + 30 16 | + 31 21 | + November 1 13 | + 2 21 | + 3 15 | + 4 15 | + 5 14 | + 6 11 | + 7 15 | + 8 8 | + 9 6 | + ---- | + Total[56] 3881 | + + [56] In the above accounts there is a deficiency of returns from + several grave-yards of 163. + +From this table it appears that the principal mortality was in the second +week of October. A general expectation had obtained, that cold weather +was as fatal to this fever as heavy rains. The usual time for its arrival +had come, but the weather was still not only moderate, but warm. In this +awful situation, the stoutest hearts began to fail. Hope sickened, and +despair succeeded distress in almost every countenance. On the +_fifteenth_ of October, it pleased God to alter the state of the air. +The clouds at last dropped health in showers of rain, which continued +during the whole day, and which were succeeded for several nights +afterwards by cold and frost. The effects of this change in the weather +appeared first in the sudden diminution of the sick, for the deaths +continued for a week afterwards to be numerous, but they were of persons +who had been confined before, or on the day in which the change had taken +place in the weather. + +The appearance of this rain was like a dove with an olive branch in its +mouth to the whole city. Public notice was given of its beneficial +effects, in a letter subscribed by the mayor of Philadelphia, who acted +as president of the committee, to the mayor of New-York. I shall insert +the whole of this letter. It contains, besides the above information, a +record of the liberality of that city to the distressed inhabitants of +Philadelphia. + +"SIR, + +"I am favoured with your letter of the 12th instant, which I have +communicated to the committee for the relief of the poor and afflicted of +this city. + +"It is with peculiar satisfaction that I execute their request, by +making, in their name, on behalf of our suffering fellow-citizens, the +most grateful acknowledgements for the seasonable benevolence of the +common council of the city of New-York. Their sympathy is balm to our +wounds. + +"We acknowledge the Divine interposition, whereby the hearts of so many +around us have been touched with our distress, and have united in our +relief. + +"May the Almighty Disposer of all events be graciously pleased to protect +your citizens from the dreadful calamity with which we are now visited; +whilst we humbly kiss the rod, and improve by the dispensation. + +"The part, sir, which you personally take in our afflictions, and which +you have so pathetically expressed in your letter, excites in the breasts +of the committee the warmest sensations of fraternal affection. + +"The refreshing rain which fell the day before yesterday, though light, +and the cool weather which hath succeeded, appear to have given a check +to the prevalence of the disorder: of this we have satisfactory proofs, +as well in the decrease of the funerals, as in the applications for +removal to the hospital. + +"I have, at your request, this day drawn upon you, at sight, in favour of +the president and directors of the Bank of North America, for the sum of +five thousand dollars, the benevolent donations of the common council of +the city of New-York. + +"With sentiments of the greatest esteem and regard, + + "I am, sir, + "Your most obedient humble servant, + + "MATTH. CLARKSON. + + _"Philadelphia, Oct. 17, 1793._ + _"Richard Varick, mayor of the city of New-York."_ + +It is no new thing for bilious fevers, of every description, to be +checked or subdued by _wet_ and _cold_ weather. + +The yellow fever which raged in Philadelphia in 1699, and which is taken +notice of by Thomas Story in his journal, ceased about the latter end of +October, or the beginning of November. Of this there are satisfactory +proofs, in the register of the interments in the friends' burying-ground, +and in a letter, dated November 9th, old style, 1699, from Isaac Norris +to one of his correspondents, which his grandson, Mr. Joseph P. Norris, +politely put into my hands, with several others, which mention the +disease, and all written in that memorable year in Philadelphia. The +letter says, "It has pleased God to put a stop to our sore visitation, +and town and country are now generally healthy." The same disease was +checked by wet and cold weather in the year 1741. Of this there is a +proof in a letter from Dr. Franklin to one of his brothers, who stopped +at Burlington, on his way from Boston to Philadelphia, on account of the +fever, until he was assured by the doctor, that a thunder gust, which had +cooled the air, had rendered it safe for him to come into the city[57]. +Mr. Lynford Lardner, in a letter to one of his English friends, dated +September 24, 1747, old style, after mentioning the prevalence of the +fever in the city, says, "the weather is now much cooler, and those under +the disorder revive. The symptoms are less violent, and the fever +gradually abates." + + [57] From a short note in the register of the interments in the + friends' burying-ground, it appears that the fever this year made + its first appearance in the month of June. The following is a copy + of that note: "12th of the 6th month (O. S.), 1741, a malignant + yellow fever now spreads much." Besides that note, there is the + following: "25th of the 7th month (O. S.), 1741, many who died of + the above distemper were persons lively, and strong, and in the + prime of their time." + +I have in vain attempted to procure an account of the time of the +commencement of cold weather in the autumn of 1762. In the short history +of the fever of that year, which I have inserted from my note book, I +have said that it continued to prevail in the months of November and +December. The register of the interments in the friends' burying-ground +in those months confirms that account. They were nearly as numerous in +November and December as in September and October, viz. in September 22, +in October 27, in November 19, and in December 26. + +The bilious remitting fever of 1780 yielded to cool weather, accompanied +by rain and an easterly wind[58]. + + [58] Vol. i. + +Sir John Pringle will furnish ample satisfaction to such of my readers as +wish for more proofs of the efficacy of heavy rains, and cold weather, in +checking the progress and violence of autumnal remitting fevers[59]. + + [59] P. 5, 56, 180, and 323. + +From the 15th of October the disease not only declined, but assumed more +obvious inflammatory symptoms. It was, as in the beginning, more +necessarily fatal where left to itself, but it yielded more certainly to +art than it did a few weeks before. The duration of it was now more +tedious than in the warmer weather. + +There were a few cases of yellow fever in November and December, after +the citizens who had retired to the country returned to the city. + +I heard of but three persons who returned to the city being infected with +the disease; so completely was its cause destroyed in the course of a few +weeks. + +In consequence of a proclamation by the governor, and a recommendation by +the clergy of Philadelphia, the 12th of December was observed as a day +of thanksgiving throughout the state, for the extinction of the disease +in the city. + +It was easy to distinguish, in walking the streets, the persons who had +returned from the country to the city, from those who had remained in it +during the prevalence of the fever. The former appeared ruddy and +healthy, while the latter appeared of a pale or sallow colour. + +It afforded a subject of equal surprise and joy to behold the suddenness +with which the city recovered its former habits of business. In the +course of six weeks after the disease had ceased, nothing but fresh +graves, and the black dresses of many of the citizens, afforded a public +trace of the distress which had so lately prevailed in the city. + +The month of November, and all the winter months which followed the +autumnal epidemic, were in general healthy. A catarrh affected a number +of people in November. I suspected it to be the influenza which had +revived from a dormant state, and which had not spent itself, when it +yielded to the predominance of the yellow fever. This opinion derives +some support from a curious fact related by the late Mr. Hunter of the +revival of the small-pox in a patient, in whom it had been suspended for +some time by the measles[60]. The few fevers which prevailed in the +winter were highly inflammatory. The small-pox in the natural way was in +several instances confluent; and in one or two fatal. I was prepared to +expect this inflammatory diathesis in the fevers of the winter; for I had +been taught by Dr. Sydenham, that the diseases which follow a great and +mortal epidemic partake more or less of its general character. But the +diseases of the winter had a peculiarity still more extraordinary; and +that was, many of them had several of the symptoms of the yellow fever, +particularly a puking of bile, dark-coloured stools, and a yellow eye. +Mr. Samuel D. Alexander, a student of medicine from South-Carolina, who +was seized with a pneumony about Christmas, had, with a yellow eye, a +dilated pupil and a hard pulse, which beat only fifty strokes in a +minute. His blood was such as I had frequently observed in the yellow +fever. Dr. Griffitts informed me that he attended a patient on the 9th of +January, in a pneumony, who had a universal yellowness on his skin. I met +with a case of pneumony on the 20th of the same month, in which I +observed the same degrees of redness in the eyes that were common in the +yellow fever. My pupil, Mr. Coxe, lost blood in an inflammatory fever, +on the 18th of February, which was dissolved. Mr. Innes, the brewer, had +a deep yellow colour in his eyes, on the fourth day of a pneumony, on the +27th of the same month; and Mr. Magnus Miller had the same symptom of a +similar disease on the 16th of March. None of these bilious and anomalous +symptoms of the inflammatory fevers of the winter and spring surprised +me. I had been early taught, by Dr. Sydenham, that the epidemics of +autumn often insinuate some of their symptoms into the winter diseases +which follow them. Dr. Cleghorn informs us, that "the pleurisies which +succeeded the autumnal tertians in Minorca, were accompanied by a +vomiting and purging of green or yellow bilious matters[61]." + + [60] Introduction to a Treatise on the Venereal Disease, p. 3. of the + American edition. + + [61] Page 273. + +It belongs to powerful epidemics to be followed by similar diseases after +they disappear, as well as to run into others at their first appearance. +In the former case it is occasioned by a peculiar state of the body, +created by the epidemic constitution of the air, not having been changed +by the weather which succeeded it. + +The weather in March resembled that of May; while the weather in April +resembled that of March in common years. A rash prevailed in many +families, in April, accompanied in a few cases by a sore throat. It was +attended with an itching, a redness of the eyes, and a slight fever in a +few instances. The small-pox by inoculation in this month was more mortal +than in former years. However unimportant these facts may appear at this +time, future observations may perhaps connect them with a similar +constitution of the air which produced the previous autumnal epidemic. + +The appearance of bilious symptoms in the diseases of the winter, excited +apprehensions in several instances of the revival of the yellow fever. +The alarms, though false, served to produce vigilance and industry in the +corporation, in airing and purifying such houses and articles of +furniture as belonged to the poor; and which had been neglected in the +autumn, after the ceasing of the disease. + +The modes of purifying houses, beds, and clothes were various. +Fumigations of nitre and aromatic substances were used by some people. +Burying infected articles of furniture under ground, and baking them in +ovens, were used by others. Some destroyed all their beds and clothing +that had been infected, or threw them into the Delaware. Many +white-washed their walls, and painted the wood-work of their house. I did +not conceive the seeds of the disease required all, or any of those means +to destroy it. I believed _cold_ and _water_ to be sufficient for that +purpose. I therefore advised keeping the windows of infected rooms open +night and day, for a few days; to have the floors and walls of houses +well washed; and to expose beds and such articles of household furniture +as might be injured by washing, upon the bare earth for a week or two, +taking care to turn them every day. I used no other methods of destroying +the accumulated miasmata in my house and furniture, and experience showed +that they were sufficient. + +It is possible a portion of the excretions of the sick may be retained in +clothes or beds, so as to afford an exhalation that may in the course of +a succeeding summer and autumn, or from accidental warmth at any time, +create a solitary case of fever, but it cannot render it epidemic. A +trunk full of clothes, the property of Mr. James Bingham, who died of the +yellow fever in one of the West-India islands about 50 years ago, was +opened, some months after they were received by his friends, by a young +man who lived in his brother's family. This young man took the disease, +and died; but without infecting any of the family; nor did the disease +spread afterwards in the city. The father of Mr. Joseph Paschall was +infected with the yellow fever of 1741, by the smell of a foul bed in +passing through Norris's Alley, in the latter end of December, after the +disease had left the city. He died on the 25th of the month, but without +reviving the fever in the city, or even infecting his family. + +The matter which produced the fever in both these cases, had nothing +specific in it. It acted in the same manner that the exhalation from any +other putrid matters would have done in a highly concentrated state. + +In a letter from Dr. Senter of Newport, dated January 7th, 1794, I find +the following fact, which I shall communicate in his own words. It is +introduced to support the principle, that the yellow fever does not +spread by contagion. "This place (says the doctor) has traded formerly +very much to the West-India islands, and more or less of our people have +died there every season, when the disease prevails in those parts. +Clothes of these unfortunate people have been repeatedly brought home to +their friends, without any accident happening to them." + +I feel with my reader the fatigue of this long detail of facts, and equal +impatience with him to proceed to the history of the treatment of the +fever; but I must beg leave to detain him a little longer from that part +of the work, while I resume the subject of the origin of the fever. It is +an interesting question, as it involves in it the means of preventing the +return of the disease, and thereby of saving the lives of thousands of +our citizens. + +Soon after the fever left the city, the governor of the state addressed a +letter to the college of physicians, requesting to know their opinion of +its origin; if imported, from what _place_, at what _time_, and in what +_manner_. The design of this inquiry was to procure such information as +was proper to lay before the legislature, in order to improve the laws +for preventing the importation or generation of infectious diseases, or +to enact new ones, if necessary for that purpose. To the governor's +letter the college of physicians sent the following answer: + +"SIR, + +"It has not been from a want of respect to yourself, nor from inattention +to the subject, that your letter of the 30th ult. was not sooner +answered; but the importance of the questions proposed has made it +necessary for us to devote a considerable portion of time and attention +to the subject, in order to arrive at a safe and just conclusion. + +"No instance has ever occurred of the disease called the _yellow fever_ +having been generated in this city, or in any other parts of the United +States, as far as we know; but there have been frequent instances of its +having been imported, not only into this, but into other parts of +North-America, and prevailing there for a certain period of time; and +from the rise, progress, and nature of the malignant fever, which began +to prevail here about the beginning of last August, and extended itself +gradually over a great part of the city, we are of opinion that this +disease was imported into Philadelphia, by some of the vessels which +arrived in the port after the middle of July. This opinion we are +further confirmed in by various accounts we have received from +unquestionable authorities. + + "Signed, by order of the college of physicians, + + "JOHN REDMAN, _President_. + + "_November 26th, 1793._ + "_To the governor of Pennsylvania._" + +Dr. Redman, the president of the college, Dr. Foulke, and Dr. Leib, +dissented from the report contained in this letter. I have been +necessarily led to continue it in the present edition of this work, not +only because all the other members of that body still retain their belief +of the importation of the fever, but as a reason for republishing the +facts and arguments in support of its domestic origin. + +I have asserted, in the introduction to the history of this fever, that I +believed it to have been generated in our city; I shall now deliver my +reasons for that belief. + +1. The yellow fever in the West-Indies, and in all other countries where +it is endemic, is the offspring of vegetable putrefaction. Heat, +exercise, and intemperance in drinking (says Dr. Lind) _dispose_ to this +fever in hot climates, but they do not produce it without the concurrence +of a remote cause. This remote cause exists at all times, in some spots +of the islands, but in other parts even of the same islands, where there +are no marsh exhalations, the disease is unknown. I shall not waste a +moment in inquiring into the truth of Dr. Warren's account of the origin +of this fever. It is fully refuted by Dr. Hillary, and it is treated as +chimerical by Dr. Lind. They have very limited ideas of the history of +this fever who suppose it to be peculiar to the East or West-Indies. It +was admitted to have been generated in Cadiz after a hot and dry summer +in 1764, and in Pensacola in 1765[62]. The tertian fever of Minorca, when +it attacked Englishmen, put on the usual symptoms of the yellow +fever[63]. In short, this disease appears, according to Dr. Lind, in all +the southern parts of Europe, after hot and dry weather[64]. + + [62] Lind on the Diseases of Hot Climates, p. 36 and 124. + + [63] Cleghorn, p. 176. + + [64] Diseases of Hot Climates, p. 123. + +2. The same causes (under like circumstances) must always produce the +same effects. There is nothing in the air of the West-Indies, above +other hot countries, which disposes it to produce a yellow fever. Similar +degrees of heat, acting upon dead and moist vegetable matters, are +capable of producing it, together with all its various modifications, in +every part of the world. In support of this opinion, I shall transcribe +part of a letter from Dr. Miller, formerly of the Delaware state, and now +of New-York. + + "_Dover, Nov. 5, 1793._ + +"DEAR SIR, + +"Since the middle of last July we have had a bilious colic epidemic in +this neighbourhood, which exhibits phænomena very singular in this +climate; and, so far as I am informed, unprecedented in the medical +records, or popular traditions of this country. To avoid unnecessary +details it will suffice at present to observe, that the disease, on this +occasion, has assumed, not only all the essential characters, but +likewise all the violence, obstinacy, and malignity described by the East +and West-Indian practitioners. If any difference can be observed it seems +here to manifest higher degrees of stubbornness and malignity than we +usually meet in the histories of tropical writers. In the course of the +disease, not only extreme constipation, frequent vomiting, and the most +excruciating pains of the bowels and limbs, harass the unhappy patient; +but to these succeed paralysis, convulsions, &c. and almost always +uncommon muscular debility, oppression of the præcordia, &c. are the +consequence of a severe attack. Bile discharged in enormous quantities +constantly assumes the most corrupted and acrimonious appearances, +commonly æruginous in a very high degree, and sometimes quite +atrabilious. + +"The inference I mean to draw from the phænomena of this disease, as it +appears in this neighbourhood, and which I presume will also apply to +your epidemic, is _this_, that from the uncommon protraction and +intenseness of our summer and autumnal heats, but principally from the +unusual drought, we have had, since the middle of July, a near approach +to a _tropical_ season, and that of consequence we ought not to be +surprised if tropical diseases, even of the most malignant nature, are +_engendered_ amongst us." + +To the above information it may be added, that the dysentery which +prevailed during the autumn of 1793, in several of the villages of +Pennsylvania, was attended with a malignity and mortality unknown before +in any part of the state. I need not pause to remark that this dysentery +arose from putrid exhalation, and that it is, like the bilious colic, +only a modification of bilious fever. + +But further, a malignant fever, resembling that which was epidemic in our +city, prevailed during the autumn in many parts of the United States, +viz. at Lynn in Massachusetts, at Weatherfield and Coventry in +Connecticut, at New-Galloway in the state of New-York, on Walkill and on +Pensocken creeks in New-Jersey, at Harrisburgh and Hummelstown in +Pennsylvania, in Caroline county in Maryland, on the south branch of the +Potowmac in Hardie county, also in Lynchburgh and in Alexandria in +Virginia, and in several counties in North-Carolina. In none of these +places was there a suspicion of the disease being imported from abroad, +or conveyed by an intercourse with the city of Philadelphia. + +It is no objection to the inference which follows from these facts, that +the common remitting fever was not known during the above period in the +neighbourhood of this city, and in many other parts of the state, where +it had usually appeared in the autumnal months. There is a certain +combination of moisture with heat, which is essential to the production +of the remote cause of a bilious fever. Where the heat is so intense, or +of such long duration, as wholly to dissipate moisture, or when the rains +are so great as totally to overflow the marshy ground, or to wash away +putrid masses of matter, no fever can be produced. + +Dr. Dazilles, in his treatise upon the diseases of the negroes in the +West-Indies, informs us, that the _rainy_ season is the most healthy at +Cayenne, owing to the neighbouring morasses being _deeply_ overflowed; +whereas, at St. Domingo, a _dry_ season is most productive of diseases, +owing to its favouring those degrees of moisture which produce morbid +exhalations. These facts will explain the reason why, in certain seasons, +places which are naturally healthy in our country become sickly, while +those places which are naturally sickly escape the prevailing epidemic. +Previously to the dissipation of the moisture from the putrid masses of +vegetable matters in our streets, and in the neighbourhood of the city, +there were (as several practitioners can testify) many cases of mild +remittents, but they all disappeared about the first week in September. + +It is worthy of notice, that the yellow fever prevailed in Virginia in +the year 1741, and in Charleston, in South-Carolina, in the year 1699, in +both which years it prevailed in Philadelphia. Its prevalence in +Charleston is taken notice of in a letter, dated November 18th, O. S. +1699, from Isaac Norris to one of his correspondents. The letter says, +that "150 persons had died in Charleston in a few days," that "the +survivors fled into the country," and that "the town was thinned to a +very few people." Is it not probable, from the prevalence of this fever +twice in two places in the same years, that it was produced (as in 1793) +by a general constitution of air, co-operating with miasmata, which +favoured its generation in different parts of the continent? But again, +such was the state of the air in the summer of 1793, that it predisposed +other animals to diseases, besides the human species. In some parts of +New-Jersey, a disease prevailed with great mortality among the horses, +and in Virginia among the cows, during the autumn. The urine in both was +yellow.--Large abscesses appeared in different parts of the body in the +latter animals, which, when opened, discharged a yellow serous fluid. +From the colour of these discharges, and of the urine, the disease got +the name of the _yellow water_. + +3. I have before remarked, that a quantity of damaged coffee was exposed +at a time (July the 24th) and in a situation (on a wharf and in a dock) +which favoured its putrefaction and exhalation. Its smell was highly +putrid and offensive, insomuch that the inhabitants of the houses in +Water and Front-streets, who were near it, were obliged, in the hottest +weather, to exclude it by shutting their doors and windows. Even persons, +who only walked along those streets, complained of an intolerable +f[oe]tor, which, upon inquiring, was constantly traced to the putrid +coffee. It should not surprise us, that this seed, so inoffensive in its +natural state, should produce, after its putrefaction, a violent fever. +The records of medicine (to be mentioned hereafter) furnish instances of +similar fevers being produced, by the putrefaction of many other +vegetable substances. + +4. The rapid progress of the fever from Water-street, and the courses +through which it travelled into other parts of the city, afford a strong +evidence that it was at first propagated by exhalation from the putrid +coffee. It was observed that it passed first through those alleys and +streets which were in the course of the winds that blew across the dock +and wharf, where the coffee had been thrown in a state of putrefaction. + +5. Many persons who had worked, or even visited, in the neighbourhood of +the exhalation from the coffee, early in the month of August, were +indisposed afterwards with sickness, puking, and yellow sweats, long +before the air of Water-street was so much impregnated with the +exhalation, as to produce such effects; and several patients, whom I +attended in the yellow fever, declared to me, or to their friends, that +their indispositions began exactly at the time they inhaled the offensive +effluvia of the coffee. + +6. The first cases of the yellow fever have been clearly traced to the +sailors of the vessel who were first exposed to the effluvia of the +coffee. Their sickness commenced with the day on which the coffee began +to emit its putrid smell. The disease spread with the increase of the +poisonous exhalation. A journeyman of Mr. Peter Brown's, who worked near +the corner of Race and Water-streets, caught the disease on the 27th of +July. Elizabeth Hill, the wife of a fisherman, was infected by only +sailing near the pestilential wharf, about the 1st of August, and died at +Kensington on the 14th of the same month. Many other names might be +mentioned of persons who sickened during the last week in July or the +first week in August, who ascribed their illnesses to the smell of the +coffee. + +7. It has been remarked that this fever did not spread in the country, +when carried there by persons who were infected, and who afterwards died +with it. During four times in which it prevailed in Charleston, in no one +instance, according to Dr. Lining, was it propagated in any other part of +the state. + +8. In the histories of the disease which have been preserved in this +country, it has _six_ times appeared about the first or middle of August, +and declined or ceased about the middle of October: viz. in 1732, 1739, +1745, and 1748 in Charleston, in 1791 in New-York, and in 1793 in +Philadelphia. This frequent occurrence of the yellow fever at the usual +period of our common bilious remittents, cannot be ascribed to accidental +coincidence, but must be resolved, in most cases, into the combination of +more active miasmata with the predisposition of a tropical season. In +speaking of a tropical season, I include that kind of weather in which +rains and heats are alternated with each other, as well as that which is +uniformly warm. + +9. Several circumstances attended this epidemic, which do not occur in +the West-India yellow fever. It affected children as well as adults, in +common with our annual bilious fevers. In the West-Indies, Dr. Hume +tells us, it never attacked any person under puberty. It had, moreover, +many peculiar symptoms (as I have already shown) which are not to be met +with in any of the histories of the West India yellow fever. + +10. Why should it surprise us to see a yellow fever generated amongst us? +It is only a higher grade of a fever which prevails every year in our +city, from vegetable putrefaction. It conforms, in the difference of its +degrees of violence and danger, to season as well as climate, and in this +respect it is upon a footing with the small-pox, the measles, the +sore-throat, and several other diseases. There are few years pass, in +which a plethoric habit, and more active but limited miasmata, do not +produce sporadic cases of true yellow fever in Philadelphia. It is very +common in South and North-Carolina and in Virginia, and there are facts +which prove, that not only strangers, but native individuals, and, in one +instance, a whole family, have been carried off by it in the state of +Maryland. It proved fatal to one hundred persons in the city of New-York +in the year of 1791, where it was evidently generated by putrid +exhalation. The yellow colour of the skin has unfortunately too often +been considered as the characteristic mark of this fever, otherwise many +other instances of its prevalence might be discovered, I have no doubt, +in every part of the United States. I wish, with Dr. Mosely, the term +_yellow_ could be abolished from the titles of this fever, for this +colour is not only frequently absent, but sometimes occurs in the mildest +bilious remittents. Dr. Haller, in his pathology, describes an epidemic +of this kind in Switzerland, in which this colour generally attended, and +I have once seen it almost universal in a common bilious fever, which +prevailed in the American army, in the year 1776. + +I cannot help taking notice, in this place, of an omission in the answer +to the governor's letter, by the college of physicians. The governor +requested to know whether it was imported; if it were, from _what place_, +at _what time_, and in _what manner_. In the answer of the college of +physicians to the governor's letter no notice was taken of any of those +questions. In vain did Dr. Foulke call upon the college to be more +definite in their answer to them. They had faithfully sought for the +information required, but to no purpose. The character of their departed +brother, Dr. Hutchinson, for capacity and vigilance in his office, as +inspector of sickly vessels, was urged without effect as an argument +against the probability of the disease being imported. Public report had +derived it from several different islands; had chased it from ship to +ship, and from shore to shore; and finally conveyed it at different +times into the city, alternately by dead and living bodies; and from +these tales, all of which, when investigated, were proved to be without +foundation, the college of physicians composed their letter. It would +seem, from this conduct of the college, as if medical superstition had +changed its names, and that, in accounting for the origin of pestilential +fevers, celestial, planetary, and demoniacal influence had only yielded +to the term _importation_. + +Let not the reader reject the opinion I have delivered because it is +opposed by so great a majority of the physicians of Philadelphia. A +single physician supported an opinion of the existence of the plague at +Messina, in the year 1743, in opposition to all the physicians (33 in +number) of that city. They denied the disease in question to exist, +because it was not accompanied by glandular swellings. Time showed that +they were all mistaken, and the plague, which might probably have been +checked, at its first appearance, by their united efforts, was, by means +of their ignorance, introduced with great mortality into every part of +the city. This disposition of physicians to limit the symptoms of several +other diseases, cannot be sufficiently lamented. The frequent absence of +a yellow colour, in this epidemic, led to mistakes which cost the city +of Philadelphia several hundred lives. + +The letter of the college of physicians has served to confirm me in an +opinion, that the plagues which occasionally desolated most of the +countries of Europe, in former centuries, and which were always said to +be of foreign extraction, were of domestic origin. Between the years 1006 +and 1680, the plague was epidemic fifty-two times all over Europe. It +prevailed fourteen times in the 14th century. The state of Europe, in +this long period, is well known. Idleness, a deficiency of vegetable +aliment, a camp life, from the frequency of wars, famine, an uncultivated +and marshy soil, small cabins, and the want of cleanliness in dress, +diet, and furniture, all concurred to generate pestilential diseases. The +plagues which prevailed in London, every year from 1593 to 1611, and from +1636 to 1649, I believe were generated in that city. The diminution of +plagues in Europe, more especially in London, appears to have been +produced by the great change in the diet and manners of the people; also +by the more commodious and airy forms of the houses of the poor, among +whom the plague _always_ makes its first appearance. It is true, these +plagues were said by authors to have been imported, either directly or +indirectly, from the Levant; but the proofs of such importation were as +vague and deficient as they were of the West-India origin of our +epidemic. The pestilential fevers which have been mentioned, have been +described by authors by the generic name of the plague, but they appear +to have originated from putrid vegetable exhalations, and to have +resembled, in most of their symptoms, the West-India and _North-American_ +yellow fever. + +I shall resume this interesting subject in another place, in which I +shall mention a number of additional facts, not only in support of the +domestic origin of the bilious yellow fever, but of its not spreading by +contagion, and of course of its being impossible to import it. I shall at +the same time enumerate all its different sources, and point out the +means of destroying or removing them, and thus of exterminating the +disease from our country. + +With these observations I conclude the history of the epidemic fever of +the year 1793. A few of its symptoms, which have been omitted in this +history, will be included in the method of cure, for they were discovered +or produced by the remedies which were given for that purpose. + +[Hand] The following page begins an account of the states of the +thermometer and weather, from the 1st of January to the 1st of August, +and of the states of the barometer, thermometer, winds, and weather, from +the 1st of August to the 9th of November, 1793. The times of observation, +for the first three months are at 7 in the morning, and 2 in the +afternoon; for the next five months they are at 6 in the morning, and 3 +in the afternoon. From the 1st of October to the 9th of November, they +are as in the first three months. + + _January, 1793._ _February, 1793._ + +----+---------+----------------------+---------+---------------------+ + | | Therm. | Weather. | Therm. | Weather. | + | D. | 7h | 2h | | 7h | 2h | | + +----+----+----+----------------------+----+----+---------------------+ + | 1 | 27 | 30 | Cloudy. | 9 | 26 | Fair, hazy. | + | 2 | 30 | 41 | Fair, cloudy. | 25 | 34 | Rain, ditto. | + | 3 | 30 | 33 | Cloudy, rain. | 33 | 37 | Cloudy, fair. | + | 4 | 38 | 41 | Rain, cloudy. | 25 | 46 | Cloudy, fair. | + | 5 | 35 | 42 | Fair, cloudy. | 36 | 44 | Cloudy, ditto. | + | 6 | 33 | 47 | Cloudy, fair. | 35 | 46 | Cloudy, rain. | + | 7 | 38 | 51 | Fair, fair. | 36 | 40 | Cloudy, fair. | + | 8 | 32 | 49 | Fair, ditto. | 28 | 44 | Cloudy, ditto. | + | 9 | 33 | 48 | Hazy, fair. | 42 | 50 | Rain, fair. | + | 10 | 38 | 51 | Fair, ditto. | 38 | 40 | Cloudy, fair. | + | 11 | 35 | 48 | Fair, clouds. | 19 | 27 | Fair, cloudy. | + | 12 | 31 | 42 | Fair, ditto. | 20 | 28 | Snow, cloudy. | + | 13 | 28 | 42 | Fair, ditto. | 22 | 31 | Cloudy, snow. | + | 14 | 25 | 27 | Hail, snow, sleet. | 27 | 39 | Cloudy, fair. | + | 15 | 32 | 37 | Clouds, mist. | 18 | 40 | Fair, ditto. | + | 16 | 37 | 39 | Rain, ditto. | 29 | 42 | Cloudy, ditto. | + | 17 | 37 | 45 | Rain, snow, fair. | 44 | 48 | Rain, ditto. | + | 18 | 32 | 52 | Fair, ditto. | 39 | 49 | Cloudy, fair. | + | 19 | 37 | 48 | Fair, ditto. | 31 | 41 | Cloudy, rain. | + | 20 | 33 | 47 | Hazy, cloudy. | 52 | 53 | Rain, fair. | + | 21 | 36 | 47 | Cloudy, fair. | 37 | 49 | Fair, ditto. | + | 22 | 27 | 32 | Fair, ditto. | 29 | 34 | Fair, ditto. | + | 23 | 22 | 37 | Fair, ditto. | 22 | 34 | Snow, cloudy. | + | 24 | 30 | 39 | Cloudy, ditto. | 54 | 59 | Rain, cloudy. | + | 25 | 30 | 41 | Fair, hazy. | 34 | 35 | Cloudy, ditto. | + | 26 | 31 | -- | Fair. | 35 | 43 | Rain, mist. | + | 27 | 23 | 38 | Fair, cloudy, snow. | 43 | 43 | Rain, cloudy. | + | 28 | 35 | 45 | Cloudy, fair. | 14 | 26 | Fair, ditto. | + | 29 | 29 | 37 | Fair, ditto. | | | | + | 30 | 22 | 23 | Snow, hail. | | | | + | 31 | 25 | 32 | Cloudy, fair. | | | | + +----+----+----+----------------------+----+----+---------------------+ + _March, 1793._ _April, 1793._ + +----+---------+----------------------+---------+---------------------+ + | | Therm. | Weather. | Therm. | Weather. | + | D. | 7h | 2h | | 7h | 2h | | + +----+----+----+----------------------+----+----+---------------------+ + | 1 | 20 | 38 | Fair, ditto. | 45 | 70 | Cloudy, fair. | + | 2 | 31 | 51 | Hazy, cloudy. | 47 | 71 | Fair, ditto. | + | 3 | 48 | 63 | Rain, fair. | 56 | 80 | Fair, ditto. | + | 4 | 43 | 61 | Hazy, ditto. | 51 | 72 | Cloudy, fair. | + | 5 | 51 | 52 | Rain, fair. | 53 | 61 | Cloudy, rain. | + | 6 | 32 | 50 | Fair, ditto. | 60 | 76 | Misty, fair. | + | 7 | 36 | 62 | Fair, ditto, clouds. | 51 | 65 | Fair, ditto. | + | 8 | 54 | 60 | Cloudy, rain. | 46 | 74 | Fair, ditto. | + | 9 | 26 | 41 | Fair, ditto. | 55 | 71 | Fair, cloudy. | + | 10 | 29 | 51 | Fair, ditto. | 50 | 56 | Fair, ditto. | + | 11 | 43 | 55 | Rain, ditto. | 37 | 63 | Fair, ditto. | + | 12 | 40 | 43 | Cloudy, ditto. | 54 | 62 | Cloudy, rain, fair. | + | 13 | 38 | 39 | Cloudy, fair. | 49 | 62 | Fair, ditto. | + | 14 | 26 | 44 | Fair, ditto. | 50 | 70 | Fair, ditto. | + | 15 | 32 | 59 | Fair, ditto. | 45 | 55 | Rain, cloudy. | + | 16 | 52 | 62 | Cloudy, fair. | 46 | 62 | Cloudy, fair. | + | 17 | 51 | 72 | Cloudy, fair. | 48 | 67 | Fair, clouds, fair. | + | 18 | 58 | 69 | Hazy, cloudy. | 52 | 66 | Cloudy, fair. | + | 19 | 53 | 59 | Fair, ditto. | 52 | 75 | Fair, ditto. | + | 20 | 42 | 61 | Fair, ditto. | 52 | 49 | Rain, cloudy. | + | 21 | 41 | 43 | Rain, cloudy. | 44 | 47 | Cloudy, ditto. | + | 22 | 31 | 47 | Fair, ditto. | 43 | 46 | Rain, cloudy. | + | 23 | 35 | 57 | Fair, ditto. | 42 | 63 | Fair, ditto. | + | 24 | 37 | 50 | Fair, ditto. | 44 | 68 | Fair, ditto. | + | 25 | 35 | 59 | Fair, ditto. | 45 | 65 | Cloudy, ditto. | + | 26 | 47 | 54 | Cloudy, rain. | 53 | 57 | Cloudy, rain. | + | 27 | 43 | 51 | Fair, cloudy. | 47 | 46 | Rain, ditto. | + | 28 | 33 | 45 | Fair, clouds, fair. | 44 | 54 | Rain, cloudy. | + | 29 | 34 | 57 | Fair, ditto. | 40 | 59 | Fair, ditto. | + | 30 | 41 | 58 | Cloudy, fair. | 40 | 65 | Fair, ditto. | + | 31 | 42 | 61 | Cloudy, fair. | | | | + +----+----+----+----------------------+----+----+---------------------| + _May, 1793._ _June, 1793._ + +----+---------+----------------------+---------+---------------------+ + | | Therm. | Weather. | Therm. | Weather. | + | D. | 7h | 2h | | 7h | 2h | | + +----+----+----+----------------------+----+----+---------------------+ + | 1 | 45 | 69 | Foggy, cloudy. | 53 | 61 | Rain, showery. | + | 2 | 52 | 73 | Fog, clouds, fair. | 54 | 64 | Clouds, showers. | + | 3 | 60 | 63 | Rain, ditto. | 55 | 62 | Cloudy, rain, fair. | + | 4 | 60 | 80 | Fair, ditto. | 54 | 60 | Rain, do. cloudy. | + | 5 | 55 | 56 | Cloudy, ditto. | 58 | 72 | Cloudy, fair, rain. | + | 6 | 47 | 58 | Cloudy, fair. | -- | 71 | Cloudy, rain. | + | 7 | 50 | 68 | Cloudy, fair. | 68 | 78 | Fair, ditto. | + | 8 | 59 | 78 | Cloudy, fair. | 65 | -- | Fair, ditto. | + | 9 | 61 | 79 | Foggy, fair. | 70 | 88 | Fog, fair. | + | 10 | 65 | 71 | Rain, hazy. | 74 | 90 | Fair, ditto. | + | 11 | 55 | 75 | Cloudy, fair. | 76 | 90 | Fair, ditto. | + | 12 | 61 | 76 | Cloudy, rain. | 75 | 88 | Fair, showers. | + | 13 | 57 | 78 | Fair, ditto. | 74 | 81 | Cloudy, rain. | + | 14 | 59 | 83 | Fair, cloudy. | 63 | 77 | Fair, ditto. | + | 15 | 60 | 71 | Fair, ditto. | 63 | 82 | Fair, hazy. | + | 16 | 50 | 69 | Fair, ditto. | 67 | 85 | Fair, ditto. | + | 17 | 48 | 74 | Fair, ditto. | 74 | 89 | Fair, showers. | + | 18 | 61 | 81 | Cloudy, fair. | 73 | 88 | Fair, ditto. | + | 19 | 65 | 85 | Fair, rain. | 77 | 91 | Fair, ditto. | + | 20 | 65 | 87 | Fair, ditto. | 79 | 88 | Fair, rain, fair. | + | 21 | 68 | 86 | Fair, ditto, clouds. | 75 | 85 | Cloudy, rain. | + | 22 | 72 | 80 | Clouds, gusts. | 58 | 78 | Cloudy, fair. | + | 23 | 94 | 79 | Cloudy, fair. | 58 | 78 | Fair, ditto. | + | 24 | 58 | 75 | Fair, ditto. | 60 | 79 | Fair, ditto. | + | 25 | 52 | 70 | Fair, cloudy. | 67 | 74 | Cloudy, rain. | + | 26 | 61 | 66 | Rain, ditto. | 66 | 69 | Cloudy, rain. | + | 27 | 68 | 84 | Cloudy, fair. | 68 | 80 | Cloudy, fair. | + | 28 | 70 | 68 | Fair, clouds, rain. | 71 | 85 | Cloudy, fair. | + | 29 | 57 | 62 | Cloudy, rain, clouds.| 77 | 88 | Cloudy, ditto. | + | 30 | 54 | 57 | Cloudy, rain. | 74 | 90 | Fair, ditto. | + | 31 | 54 | 60 | Clouds, ditto. | | | | + +----+----+----+----------------------+----+----+---------------------+ + + JULY, 1793. + +-----+------------+-----------+-------------+--------------------+ + | | Barom. | Ther. | Winds. | Weather. | + | | 6 3 | 6 3 | 6 3 | | + |Days.|A. M. P. M.|A. M. P. M.|A. M. P. M.| | + | | | | | | + | 1 |30 0 29 9| 77 88 | W W |fair. | + | 2 |29 8 29 7| 77 81 | W |fair, showers. | + | 3 |29 9 30 0| 74 80 | E E |cloudy. | + | 4 |30 1 30 0| 70 83 | E SW |cloudy, fair, rain. | + | 5 |30 0 29 9| 76 90 | NW SW |fair, ditto. | + | 6 |29 9 29 9| 78 91 | SW SW |cloudy, thunder. | + | 7 |29 9 30 0| 73 88 | NE NW |fair, clouds. | + | 8 |30 1 30 1| 72 85 | E E |cloudy, fair. | + | 9 |30 0 29 8| 73 81 | S SW |cloudy, ditto. | + | 10 |30 0 30 0| 70 84 | W NW |fair, ditto. | + | 11 |30 0 30 0| 74 88 | NW NW |fair, clouds. | + | 12 |30 1 30 2| 70 84 | N N |fair, ditto. | + | 13 |30 1 30 0| 68 83 | NW NW |fair, ditto. | + | 14 |30 0 30 0| 65 80 | N Calm |fair, hazy. | + | 15 |30 0 29 9| 66 75 | SW SW |cloudy, ditto. | + | 16 |29 8 29 7| 70 83 | W W |rain, fair. | + | 17 |29 8 29 9| 68 81 | NW NW |fair, ditto. | + | 18 |30 0 30 0| 66 86 | W SW |fair, ditto. | + | 19 |29 9 29 9| 75 85 | SW W |fair, cloudy, rain. | + | 20 |30 0 30 0| 72 87 | W NW |fair, ditto, shower.| + | 21 |30 1 30 1| 70 86 | NW NW |fair, ditto. | + | 22 |30 0 30 0| 72 87 | SW SW |fair, ditto. | + | 23 |30 0 30 0| 73 91 | SW SW |fair, cloudy. | + | 24 |29 9 29 9| 75 89 | Calm W |cloudy, fair. | + | 25 |30 1 30 1| 71 83 | NW NNW |fair, ditto. | + | 26 |30 2 30 2| 63 82 | N NE |fair, ditto. | + | 27 |30 2 30 1| 64 81 | S calm S |fair, cloudy. | + | 28 |30 1 30 0| 72 85 | Calm NNE |cloudy, fair. | + | 29 |30 1 30 1| 74 85 | SSE NE |cloudy, ditto, rain.| + | 30 |30 1 30 0| 73 86 | S SW |cloudy, fair. | + | 31 |29 9 29 8| 76 80 | SSW SW |cloudy, rain, fair. | + +-----+------------+-----------+-------------+--------------------+ + + AUGUST, 1793. + +-----+------------+-----------+-------------+--------------------+ + | | Barom. | Ther. | Winds. | Weather. | + | | 6 3 | 6 3 | 6 3 | 6 3 | + |Days.|A. M. P. M.|A. M. P. M.|A. M. P. M.|A. M. P. M. | + | 1 |29 95 30 0| 65 77 | WNW NW |cloudy, fair, | + | 2 |30 1 30 1| 63 81 | NW SW |fair, fair, | + | 3 |30 6 29 95| 62 82 | N NNE |fair, fair, | + | 4 |29 97 30 0| 65 87 | S SW |fair, fair, | + | 5 |30 5 30 1| 73 90 | SSW SW |fair, fair, | + | 6 |30 2 30 0| 77 87 | SW W |cloudy, fair, | + | 7 |30 12 30 1| 68 83 | NW W |fair, fair, | + | 8 |30 1 29 95| 69 86 | SSE SSE |fair, rain, | + | 9 |29 8 29 75| 75 85 | SSW SW |cloudy, fair, | + | 10 |29 9 29 9| 67 82 | W SW |fair, fair, | + | 11 |30 0 30 0| 70 84 | SW WSW |cloudy, cloudy, | + | 12 |30 0 30 0| 70 87 | W W |fair, fair, | + | 13 |30 5 30 0| 71 89 | SW W |fair, fair, | + | 14 |30 0 29 95| 75 82 | SW SW |fair, rain, | + | 15 |30 0 30 1| 72 75 | NNE NE |fair, cloudy, | + | 16 |30 1 30 1| 70 83 | NNE NE |fair, fair, | + | 17 |30 1 30 0| 71 86 | SW SW |fair, fair, | + | 18 |30 1 30 1| 73 89 | calm SW |fair, fair, | + | 19 |30 1 30 0| 72 82 | N N |fair, cloudy, | + | 20 |30 1 30 12| 69 82 | NNE NNE |fair, fair, | + | 21 |30 15 30 25| 62 83 | N NNE |fair, fair, | + | 22 |30 3 30 35| 63 86 | NE SE |fair, fair, | + | 23 |30 25 30 15| 63 85 | calm S |fair, fair, | + | 24 |30 1 30 1| 73 81 | calm calm |cloudy, rain, | + | 25 |30 1 30 1| 71 66 | NE NE |rain, gr. rain, | + | 26 |30 15 30 2| 59 69 | NE NE |cloudy, cloudy, | + | 27 |30 2 30 2| 65 73 | NE NE |cloudy, cloudy, | + | 28 |30 2 30 15| 67 80 | S calm |cloudy, clearin. | + | 29 |30 16 30 15| 72 86 | calm SW |cloudy, fair, | + | 30 |30 1 30 1| 74 87 | calm SW |fair, fair, | + | 31 |30 0 30 0| 74 84 | SW NW |rain, fair. | + +-----+------------+-----------+-------------+--------------------+ + + SEPTEMBER, 1793. + +-----+------------+-----------+-------------+--------------------+ + | | Barom. | Ther. | Winds. | Weather. | + | | 6 3 | 6 3 | 6 3 | 6 3 | + |Days.|A. M. P. M.|A. M. P. M.|A. M. P. M.|A. M. P. M. | + | 1 |30 0 29 30| 71 86 | calm SW |fog, fair, | + | 2 |29 75 29 8| 73 86 | SW SW |fair, fair, | + | 3 |30 0 | 60 | NW N |fair, fair, | + | 4 |30 15 30 15| 55 75 | W W |fair, fair, | + | 5 |30 15 30 1| 62 80 | SE S |fair, cloudy, | + | 6 |29 97 29 95| 70 89 | WSW W |fair, cloudy, | + | 7 |30 0 30 0| 65 77 | WNW NW |fair, fair, | + | 8 |30 1 30 1| 64 70 | calm calm |cloudy, cloudy, | + | 9 |30 0 30 0| 66 80 | SE NW |rain, fair, | + | 10 |30 0 30 0| 64 72 | N NNE |fair, cloudy, | + | 11 |30 1 30 0| 62 72 | NNE N |cloudy, fair, | + | 12 |29 96 29 9| 58 76 | NW NNW |fair, fair, | + | 13 |29 95 30 0| 57 72 | NW N |fair, fair, | + | 14 |30 0 30 5| 58 79 | NW NW |fair, fair, | + | 15 |30 0 29 97| 65 80 | N S |fair, fair, | + | 16 |29 9 29 | 70 84 | S SW |cloudy, fair, | + | 17 |29 8 29 85| 66 67 | N N |cloudy, cloudy, | + | 18 |30 3 | 44 | N |fair, | + | 19 |30 4 30 35| 45 70 | calm SW |fair, fair, | + | 20 |30 3 30 15| 54 69 | calm SE |hazy, hazy, | + | 21 |30 0 29 0| 59 78 | calm |cloudy, fair, | + | 22 |30 0 30 0| 63 83 | calm |cloudy, fair, | + | 23 |30 1 30 1| 62 80 | calm SE |cloudy, cloudy, | + | 24 |30 2 30 2| 65 70 | NE ENE |cloudy, fair, | + | 25 |30 15 30 0| 61 68 | NE NE |cloudy, cloudy, | + | 26 |29 8 29 7| 58 79 | N N |cloudy, fair, | + | 27 |29 7 | 64 | NW NW |cloudy, fair, | + | 28 |30 5 30 15| 54 73 | NW NW |fair, fair, | + | 29 |30 3 30 3| 56 74 | NE ENE |cloudy, fair, | + | 30 |30 35 30 3| 57 75 | calm SW |foggy, fair. | + +-----+------------+-----------+-------------+--------------------+ + + OCTOBER, 1793. + +-----+------------+-----------+-------------+--------------------+ + | | | | | | + | | Barom. | Ther. | Winds. | Weather. | + | | | | | | + | | 7 2 | 7 2 | 7 2 | 7 2 | + |Days.|A. M. P. M.|A. M. P. M.|A. M. P. M.|A. M. P. M. | + | 1 |30 15 30 5| 64 80 | SW SW |cloudy, fair, | + | 2 |29 9 30 5| 70 72 | W NNW |cloudy, fair, | + | 3 |30 2 30 15| 50 72 | W SW |fair, fair, | + | 4 |29 75 29 7| 59 72 | SW W |cloudy, cloudy, | + | 5 |30 0 30 1| 58 66 | N N |fair, fair, | + | 6 |30 3 30 3| 43 66 | NE W |fair, fair, | + | 7 |30 45 | 46 | calm |fair, | + | 8 |30 6 30 6| 53 68 | N N |fair, fair, | + | 9 |30 5 30 4| 53 70 | NW NW |fair, fair, | + | 10 |30 2 30 2| 49 74 | E NW |fair, fair, | + | 11 |30 0 29 85| 51 74 | W W |fair, fair, | + | 12 |29 6 29 55| 58 64 | SW NW |rain, rain, | + | 13 |29 85 29 9| 49 69 | NW NW |fair, fair, | + | 14 |30 5 30 0| 52 76 | SW SW |calm, fair, | + | 15 |29 75 29 8| 56 54 | SW N |fair, rain, | + | 16 |30 0 30 0| 37 53 | NNW N |fair, fair, | + | 17 |30 1 30 1| 37 60 | NE NE |fair, fair, | + | 18 |30 1 30 1| 41 62 | NW NW |fair, fair, | + | 19 |30 0 29 9| 51 66 | N N |cloudy, fair, | + | 20 |30 0 30 0| 44 54 | NW N |fair, fair, | + | 21 |30 0 30 2| 49 59 | N NW |fair, fair, | + | 22 |29 6 29 5| 51 65 | NW NW |fair, fair, | + | 23 |29 8 29 8| 47 60 | W W |fair, fair, | + | 24 |30 3 30 4| 36 59 | W NW |fair, fair, | + | 25 |30 4 30 3| 46 71 | S S |cloudy, do. h-w. | + | 26 |30 2 30 2| 60 72 | calm SW |cloudy, cloudy, | + | 27 |30 3 30 3| 44 44 | NNE NNE |cloudy, cloudy, | + | 28 |30 2 30 1| 34 37 | N N |cloudy, cloudy, | + | 29 |29 85 29 85| 28 44 | NNW NW |fair, fair, | + | 30 |30 1 30 1| 28 49 | calm SW |hazy, hazy, | + | 31 |30 15 30 2| 42 45 | calm NNE |cloudy, rain. | + +-----+------------+-----------+-------------+--------------------+ + + NOVEMBER, 1793. + +-----+------------+-----------+-------------+--------------------+ + | | Barom. | Ther. | Winds. | Weather. | + | | 7 2 | 7 2 | 7 2 | 7 2 | + |Days.|A. M. P. M.|A. M. P. M.|A. M. P. M.| A. M. P. M. | + | 1 |30 1 30 1| 40 41 | NNE NE |rain, cloudy, | + | 2 |30 3 30 25| 32 49 | NNE NE |fair, fair, | + | 3 |30 1 30 0| 43 56 | calm SW |cloudy, cloudy, | + | 4 |29 8 29 9| 55 67 | SW SW |cloudy, fair, | + | 5 |30 15 30 1| 50 64 | NE NE |rain, rain, | + | 6 |29 8 29 65| 63 67 | S S |cloudy, cloudy, | + | 7 |29 8 29 8| 44 64 | calm SW |fair, fair, | + | 8 |29 8 29 85| 43 56 | SSW SW |fair, fair, | + | 9 |29 9 29 95| 42 64 | SW SW |fair, fair, | + +-----+------------+-----------+-------------+--------------------+ + + + OF THE METHOD OF CURE. + +In the introduction to the history of the fever, I mentioned the remedies +which I used with success, in several cases which occurred in the +beginning of August. I had seen, and recorded in my note book, the +efficacy of gentle purges in the yellow fever of 1762; but finding them +unsuccessful after the 20th of August, and observing the disease to +assume uncommon symptoms of great prostration of strength, I laid them +aside, and had recourse to a gentle vomit of ipecacuanha, on the first +day of the fever, and to the usual remedies for exciting the action of +the sanguiferous system. I gave bark in all its usual forms of infusion, +powder, and tincture. I joined wine, brandy, and aromatics with it. I +applied blisters to the limbs, neck, and head. Finding them all +ineffectual, I attempted to rouse the system by wrapping the whole body, +agreeably to Dr. Hume's practice, in blankets dipped in warm vinegar. To +these remedies I added one more: I rubbed the right side with mercurial +ointment, with a view of exciting the action of the vessels in the whole +system, through the medium of the liver, which I then supposed to be +principally, though symptomatically, affected by the disease. None of +these remedies appeared to be of any service; for although three out of +thirteen recovered, of those to whom they were applied, yet I have reason +to believe that they would have recovered much sooner had the cure been +trusted to nature. Perplexed and distressed by my want of success in the +treatment of this fever, I waited upon Dr. Stephens, an eminent and +worthy physician from St. Croix, who happened then to be in our city, and +asked for such advice and information upon the subject of the disease, as +his extensive practice in the West-Indies would naturally suggest. He +politely informed me, that he had long ago laid aside evacuations of all +kinds in the yellow fever; that they had been found to be hurtful, and +that the disease yielded more readily to bark, wine, and, above all, to +the use of the cold bath. He advised the bark to be given in large +quantities by way of glyster, as well as in the usual way; and he +informed me of the manner in which the cold bath should be used, so as to +derive the greatest benefit from it. This mode of treating the yellow +fever appeared to be reasonable. I had used bark, in the manner he +recommended it, in several cases of sporadic yellow fever, with success, +in former years. I had, moreover, the authority of several other +physicians of reputation in its favour. Dr. Cleghorn tells us, that "he +sometimes gave the bark when the bowels were full of vicious humours. +These humours (he says) are produced by the fault of the circulation. The +bark, by bracing the solids, enables them to throw off the +excrementitious fluids, by the proper emunctories[65]." + + [65] Page 223. + +I began the use of each of Dr. Stevens's remedies the next day after my +interview with him, with great confidence of their success. I prescribed +bark in large quantities: in one case I ordered it to be injected into +the bowels every four hours. I directed buckets full of cold water to be +thrown frequently upon my patients. The bark was offensive to the +stomach, or rejected by it, in every case in which I prescribed it. The +cold bath was grateful, and produced relief in several cases, by inducing +a moisture on the skin. For a while I had hopes of benefit to my patients +from the use of these remedies, but, in a few days, I was distressed to +find they were not more effectual than those I had previously used. Three +out of four of my patients died, to whom the cold bath was administered, +in addition to the tonic remedies before-mentioned. + +Baffled in every attempt to stop the ravages of this fever, I anticipated +all the numerous and complicated distresses in our city, which +pestilential diseases have so often produced in other countries. The +fever had a malignity and an obstinacy which I had never before observed +in any disease, and it spread with a rapidity and mortality far beyond +what it did in the year 1762. Heaven alone bore witness to the anguish of +my soul in this awful situation. But I did not abandon a hope that the +disease might yet be cured. I had long believed that good was +commensurate with evil, and that there does not exist a disease for which +the goodness of Providence has not provided a remedy. Under the +impression of this belief I applied myself with fresh ardour to the +investigation of the disease before me. I ransacked my library, and pored +over every book that treated of the yellow fever. The result of my +researches for a while was fruitless. The accounts of the symptoms and +cure of the disease by the authors I consulted were contradictory, and +none of them appeared altogether applicable to the prevailing epidemic. +Before I desisted from the inquiry to which I had devoted myself, I +recollected that I had, among some old papers, a manuscript account of +the yellow fever as it prevailed in Virginia in the year 1741, which had +been put into my hands by Dr. Franklin, a short time before his death. I +had read it formerly, and made extracts from it into my lectures upon +that disease. I now read it a second time. I paused upon every sentence; +even words in some places arrested and fixed my attention. In reading the +history of the method of cure I was much struck with the following +passages. + +"It must be remarked, that this evacuation (meaning by purges) is more +necessary in this than in most other fevers. The abdominal viscera are +the parts principally affected in this disease, but by this timely +evacuation their feculent corruptible contents are discharged, before +they corrupt and produce any ill effects, and their various emunctories +and secerning vessels are set open, so as to allow a free discharge of +their contents, and consequently a security to the parts themselves, +during the course of the disease. By this evacuation the very minera of +the disease, proceeding from the putrid miasmata fermenting with the +salivary, bilious, and other inquiline humours of the body, is sometimes +eradicated by timely emptying the abdominal viscera, on which it first +fixes, after which a gentle sweat does as it were nip it in its bud. +Where the primæ viæ, but especially the stomach, is loaded with an +offensive matter, or contracted and convulsed with the irritation of its +stimulus, there is no procuring a laudable sweat till that is removed; +after which a necessary quantity of sweat breaks _out of its own accord_, +these parts promoting it when by an absterging medicine they are eased of +the burden or stimulus which oppresses them." + +"All these acute putrid fevers ever require some evacuation to bring them +to a perfect crisis and solution, and that even by stools, which must be +promoted by art, where nature does not do the business herself. On this +account an _ill-timed scrupulousness about the weakness of the body_ is +of bad consequence in these urging circumstances; for it is that which +seems chiefly to make evacuations necessary, 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 case, when _the pulse has been so low, that it could +hardly be felt_, and the _debility extreme_, yet _both one and the other_ +have been _restored by it_." + +"This evacuation must be procured by _lenitive chologoque_ purges." + +Here I paused. A new train of ideas suddenly broke in upon my mind. I +believed the weak and low pulse which I had observed in this fever, to be +the effect of debility from a depressed state of the system, but the +unsuccessful issue of purging, and even of a spontaneous diarrh[oe]a, in +a patient of Dr. Hutchinson, had led me not only to doubt of, but to +dread its effects. My fears from this evacuation were confirmed, by the +communications I had received from Dr. Stevens. I had been accustomed to +raising a weak and low pulse in pneumony and apoplexy, by means of +blood-letting, but I had attended less to the effects of purging in +producing this change in the pulse. Dr. Mitchell in a moment dissipated +my ignorance and fears upon this subject. I adopted his theory and +practice, and resolved to follow them. It remained now only to fix upon a +suitable purge to answer the purpose of discharging the contents of the +bowels. I have before described the state of the bile in the gall-bladder +and duodenum, in an extract from the history of a dissection made by Dr. +Mitchell. I suspected that my want of success in discharging this bile, +in several of the cases in which I attempted the cure by purging, was +owing the feebleness of my purges. I had been in the habit of +occasionally purging with calomel in bilious and inflammatory fevers, and +had recommended the practice the year before in my lectures, not only +from my own experience, but upon the authority of Dr. Clark. I had, +moreover, other precedents for its use in the practice of sir John +Pringle, Dr. Cleghorn, and Dr. Balfour, in diseases of the same class +with the yellow fever. But these were not all my vouchers for the safety +and efficacy of calomel. In my attendance upon the military hospitals +during the late war, I had seen it given combined with jalap in the +bilious fever by Dr. Thomas Young, a senior surgeon in the hospitals. His +usual dose was ten grains of each of them. This was given once or twice a +day until it procured large evacuations from the bowels. For a while I +remonstrated with the doctor against this purge, as being disproportioned +to the violence and danger of the fever; but I was soon satisfied that it +was as safe as cremor tartar or glauber's salts. It was adopted by +several of the surgeons of the hospital, and was universally known, and +sometimes prescribed, by the simple name of _ten_ and _ten_. This mode +of giving calomel occurred to me in preference to any other. The jalap +appeared to be a necessary addition to it, in order to quicken its +passage through the bowels; for calomel is slow in its operation, more +especially when it is given in large doses. I resolved, after mature +deliberation, to prescribe this purge. Finding ten grains of jalap +insufficient to carry the calomel through the bowels in the rapid manner +I wished, I added fifteen grains of the former to ten of the latter; but +even this dose was slow and uncertain in its operation. I then issued +three doses, each consisting of fifteen grains of jalap and ten of +calomel; one to be given every six hours until they procured four or five +large evacuations. The effects of this powder not only answered, but far +exceeded my expectations. It perfectly cured four out of the first five +patients to whom I gave it, notwithstanding some of them were advanced +several days in the disease. Mr. Richard Spain, a block-maker, in +Third-street, took eighty grains of calomel, and rather more of rhubarb +and jalap mixed with it, on the two last days of August, and on the first +day of September. He had passed twelve hours, before I began to give him +this medicine, without a pulse, and with a cold sweat on all his limbs. +His relations had given him over, and one of his neighbours complained to +me of my neglecting to advise them to make immediate preparations for +his funeral. But in this situation I did not despair of his recovery, Dr. +Mitchell's account of the effects of purging in raising the pulse, +exciting a hope that he might be saved, provided his bowels could be +opened. I now committed the exhibition of the purging medicine to Mr. +Stall, one of my pupils, who mixed it, and gave it with his own hand, +three or four times a day. At length it operated, and produced two +copious, f[oe]tid stools. His pulse rose immediately afterwards, and a +universal moisture on his skin succeeded the cold sweat on his limbs. In +a few days he was out of danger, and soon afterwards appeared in the +streets in good health, as the first fruits of the efficacy of mercurial +purges in the yellow fever. + +After such a pledge of the safety and success of my new medicine, I gave +it afterwards with confidence. I communicated the prescription to such of +the practitioners as I met in the streets. Some of them I found had been +in the use of calomel for several days, but as they had given it in small +and single doses only, and had followed it by large doses of bark, wine, +and laudanum, they had done little or no good with it. I imparted the +prescription to the college of physicians, on the third of September, and +endeavoured to remove the fears of my fellow-citizens, by assuring them +that the disease was no longer incurable. Mr. Lewis, the lawyer, Dr. +M'Ilvaine, Mrs. Bethel, her two sons, and a servant maid, and Mr. Peter +Baynton's whole family (nine in number), were some of the first trophies +of this new remedy. The credit it acquired, brought me an immense +accession of business. It still continued to be almost uniformly +effectual in all those which I was able to attend, either in person, or +by my pupils. Dr. Griffitts, Dr. Say, Dr. Pennington, and my former +pupils who had settled in the city, viz. Dr. Leib, Dr. Porter, Dr. Annan, +Dr. Woodhouse, and Dr. Mease, were among the first physicians who adopted +it. I can never forget the transport with which Dr. Pennington ran across +Third-street to inform me, a few days after he began to give strong +purges, that the disease yielded to them in every case. But I did not +rely upon purging alone to cure the disease. The theory of it which I had +adopted led me to use other remedies to abstract excess of stimulus from +the system. These were _blood-letting_, _cool air_, _cold drinks_, _low +diet_, and _applications of cold water_ to the body. I had bled Mrs. +Bradford, Mrs. Leaming, and one of Mrs. Palmer's sons with success, early +in the month of August. But I had witnessed the bad effects of bleeding +in the first week in September, in two of my patients who had been bled +without my knowledge, and who appeared to have died in consequence of +it. I had, moreover, heard of a man who had been bled on the first day of +the disease, who died in twelve hours afterwards. These cases produced +caution, but they did not deter me from bleeding as soon as I found the +disease to change its type, and instead of tending to a crisis on the +third, to protract itself to a later day. I began by drawing a small +quantity at a time. The appearance of the blood, and its effects upon the +system, satisfied me of its safety and efficacy. Never before did I +experience such sublime joy as I now felt in contemplating the success of +my remedies. It repaid me for all the toils and studies of my life. The +conquest of this formidable disease was not the effect of accident, nor +of the application of a single remedy; but it was the triumph of a +principle in medicine. The reader will not wonder at this joyful state of +my mind when I add a short extract from my note book, dated the 10th of +September. "Thank God! out of one hundred patients, whom I have visited +or prescribed for this day, I have lost none." + +Being unable to comply with the numerous demands which were made upon me +for the purging powders, notwithstanding I had requested my sister, and +two other persons to assist my pupils in putting them up; and, finding +myself unable to attend all the persons who sent for me, I furnished the +apothecaries with the recipe for the mercurial purges, together with +printed directions for giving them, and for the treatment of the disease. + +Hitherto there had been great harmony among the physicians of the city, +although there was a diversity of sentiment as to the nature and cure of +the prevailing fever. But this diversity of sentiment and practice was +daily lessening, and would probably have ceased altogether in a few days, +had it not been prevented by two publications, the one by Dr. Kuhn, and +the other by Dr. Stevens, in which they recommended bark, wine, and other +cordials, and the cold bath, as the proper remedies for the disease. The +latter dissuaded from the use of evacuations of all kinds. This method of +cure was supported by a letter from Alexander Hamilton, Esq. then +secretary of the treasury of the United States, to the college of +physicians, in which he ascribed his recovery from the fever to the use +of those remedies, administered by the hand of Dr. Stevens. The +respectable characters of those two physicians procured an immediate +adoption of the mode of practice recommended by them, by most of the +physicians of the city, and a general confidence in it by all classes of +citizens. Had I consulted my interest, or regarded the certain +consequences of opposing the use of remedies rendered suddenly popular by +the names that were connected with them, I should silently have pursued +my own plans of cure, with my old patients who still confided in them; +but I felt, at this season of universal distress, my professional +obligations to _all_ the citizens of Philadelphia to be superior to +private and personal considerations, and therefore determined at every +hazard to do every thing in my power to save their lives. Under the +influence of this disposition, I addressed a letter to the college of +physicians, in which I stated my objections to Dr. Kuhn and Dr. Stevens's +remedies, and defended those I had recommended. I likewise defended them +in the public papers against the attacks that were made upon them by +several of the physicians of the city, and occasionally addressed such +advice to the citizens as experience had suggested to be useful to +_prevent_ the disease, particularly low diet, gentle doses of laxative +physic, avoiding its exciting causes, and prompt applications for medical +aid. In none of the recommendations of my remedies did I claim the credit +of their discovery. On the contrary, I constantly endeavoured to enforce +their adoption, by mentioning precedents in favour of their efficacy, +from the highest authorities in medicine. This controversy with my +brethren, with whom I had long lived in friendly intercourse, carried on +amidst the most distressing labours, was extremely painful to me, and was +submitted to only to prevent the greater evil of the depopulation of our +city by the use of remedies which had been prescribed by myself, as well +as others, not only without effect, but with evident injury to the sick. +The repeated and numerous instances of their inefficacy, in some of the +most opulent families in the city, and the almost uniform success of the +depleting remedies, happily restored the public mind, after a while, from +its distracted state, and procured submission to the latter from nearly +all the persons who were affected by the fever. + +Besides the two modes of practice which have been described, there were +two others: the one consisted of _moderate_ purging with calomel only, +and moderate bleeding, on the first or second day of the fever, and +afterwards by the copious use of bark, wine, laudanum, and aromatic +tonics. This practice was supported by an opinion, that the fever was +inflammatory in its first, and putrid in its second stage. The other mode +referred to was peculiar to the French physicians, several of whom had +arrived in the city from the West-Indies, just before the disease made +its appearance. Their remedies were various. Some of them prescribed +nitre, cremor tartar, camphor, centaury tea, the warm bath, glysters, and +moderate bleeding, while a few used lenient purges, and large quantities +of tamarind water, and other diluting drinks. The dissentions of the +American physicians threw a great number of patients into the hands of +these French physicians. They were moreover supposed to be better +acquainted with the disease than the physicians of the city, most of +whom, it was well known, had never seen it before. + +I shall hereafter inquire into the relative success of each of the four +modes of practice which have been mentioned. + +Having delivered a general account of the remedies which I used in this +disease, I shall now proceed to make a few remarks upon each of them. I +shall afterwards mention the effects of the remedies used by other +physicians. + + + OF PURGING. + +I have already mentioned my reasons for promoting this evacuation, and +the medicine I preferred for that purpose. It had many advantages over +any other purge. It was detergent to the bile and mucus which lined the +bowels. It probably acted in a peculiar manner upon the biliary ducts, +and it was rapid in its operation. One dose was sometimes sufficient to +open the bowels; but from two to six doses were often necessary for that +purpose; more especially as part of them was frequently rejected by the +stomach. I did not observe any inconvenience from the vomiting which was +excited by the jalap. It was always without that straining which was +produced by emetics; and it served to discharge bile when it was lodged +in the stomach. Nor did I rest the discharge of the contents of the +bowels on the issue of one cleansing on the first day. There is, in all +bilious fevers, a reproduction of morbid bile as fast as it is +discharged. I therefore gave a purge every day while the fever +continued. I used castor oil, salts, cremor tartar, and rhubarb (after +the mercurial purges had performed their office), according to the +inclinations of my patients, in all those cases where the bowels were +easily moved; but where this was not the case, I gave a single dose of +calomel and jalap every day. Strong as this purge may be supposed to be, +it was often ineffectual; more especially after the 20th of September, +when the bowels became more obstinately constipated. To supply the place +of the jalap, I now added gamboge to the calomel. Two grains and a half +of each, made into a pill, were given to an adult every six hours, until +they procured four or five stools. I had other designs in giving a purge +every day, besides discharging the re-accumulated bile. I had observed +the fever to fall with its principal force upon such parts of the body as +had been previously weakened by any former disease. By creating an +artificial weak part in the bowels, I diverted the force of the fever to +them, and thereby saved the liver and brain from fatal or dangerous +congestions. The practice was further justified by the beneficial effects +of a plentiful spontaneous diarrh[oe]a in the beginning of the +disease[66]; by hæmorrhages from the bowels, when they occurred from no +other parts of the body, and by the difficulty or impracticability of +reducing the system by means of plentiful sweats. The purges seldom +answered the intentions for which they were given, unless they produced +four or five stools a day. As the fever showed no regard to day or night +in the hours of its exacerbations, it became necessary to observe the +same disregard to time in the exhibition of purges: I therefore +prescribed them in the evening, at all times when the patient had passed +a day without two or three plentiful stools. When purges were rejected, +or slow in their operation, I always directed opening glysters to be +given every two hours. The effects of purging were as follow: + +1. It raised the pulse when low, and reduced it when it was +preternaturally tense or full. + +2. It revived and strengthened the patient. This was evident in many +cases, in the facility with which patients who had staggered to a +close-stool, walked back again to their beds after a copious evacuation. +Dr. Sydenham takes notice of a similar increase of strength after a +plentiful sweat in the plague. They both acted by abstracting excess of +stimulus, and thereby removing the depression of the system. + +3. It abated the paroxysm of the fever. Hence arose the advantage of +giving a purge in some cases in the evening, when an attack of the fever +was expected in the course of the night. + +4. It frequently produced sweats when given on the first or second day of +the fever, after the most powerful sudorifics had been taken to no +purpose. + +5. It sometimes checked that vomiting which occurs in the beginning of +the disease, and it always assisted in preventing the more alarming +occurrence of that symptom about the 4th or 5th day. + +6. It removed obstructions in the lymphatic system. I ascribe it wholly +to the action of mercury, that in no instance did any of the glandular +swellings, which I formerly mentioned, terminate in a suppuration. + +7. By discharging the bile through the bowels as soon and as fast as it +was secreted, it prevented, in most cases, a yellowness of the skin. + + [66] In some short manuscript notes upon Dr. Mitchell's account of the + yellow fever in Virginia, in the year 1741, made by the late Dr. + Kearsley, sen. of this city, he remarks, that in the yellow fever + which prevailed in the same year in Philadelphia, "some recovered + by an _early_ discharge of _black_ matter by stool." This + gentleman, Dr. Redman informed me, introduced purging with + glauber's salts in the yellow fever in our city. He was preceptor + to Dr. Redman in medicine. + +However salutary the mercurial purge was, objections were made to it by +many of our physicians; and prejudices, equally weak and ill-founded, +were excited against it. I shall enumerate, and answer those objections. + +1. It was said to be of too drastic a nature. It was compared to arsenic; +and it was called a dose for a horse. This objection was without +foundation. Hundreds who took it declared they had never taken so mild a +purge. I met with but one case in which it produced bloody stools; but I +saw the same effect from a dose of salts. It sometimes, it is true, +operated from twenty to thirty times in the course of twenty-four hours; +but I heard of an equal number of stools in two cases from salts and +cremor tartar. It is not an easy thing to affect life, or even subsequent +health, by copious or frequent purging. Dr. Kirkland mentions a +remarkable case of a gentleman who was cured of a rheumatism by a purge, +which gave him between 40 and 50 stools. This patient had been previously +affected by his disease 16 or 18 weeks[67]. Dr. Mosely not only proves +the safety, but establishes the efficacy of numerous and copious stools +in the yellow fever. Dr. Say probably owes his life to three and twenty +stools procured by a dose of calomel and gamboge, taken by my advice. Dr. +Redman was purged until he fainted, by a dose of the same medicine. This +venerable gentleman, in whom 70 years had not abated the ardour of +humanity, nor produced obstinacy of opinion, came forward from his +retirement, and boldly adopted the remedies of purging and bleeding, with +success in several families, before he was attacked by the disease. His +recovery was as rapid, as the medicine he had used was active in its +operation. Besides taking the above purge, he lost twenty ounces of blood +by two bleedings[68]. + + [67] Treatise on the Inflammatory Rheumatism, vol. i. p. 407. + + [68] Dr. Redman was not the only instance furnished by the disease, in + which _reason_ got the better of the habits of old age, and of the + formalities of medicine. About the time the fever declined, I + received a letter from Dr. Shippen, sen. (then above 82 years of + age), dated Oxford Furnace, New-Jersey, October 13th, 1793, in + which, after approving in polite terms of my mode of practice, he + adds, "Desperate diseases require desperate remedies. I would only + propose some small addition to your present method. Suppose you + should substitute, in the room of the jalap, _six_ grains of + gamboge, to be mixed with ten or fifteen grains of calomel; and + after a dose or two, as occasion may require, you should bleed + your patients _almost_ to death, at least to _fainting_; and then + direct a plentiful supply of mallows tea, with fresh lemon juice, + and sugar and barley water, together with the most simple, _mild_, + and nutricious food." The doctor concludes his letter by + recommending to my perusal Dr. Dover's account of nearly a whole + ship's crew having been cured of a yellow fever, on the coast of + South-America, by being bled until they fainted. + +But who can suppose that a dozen or twenty stools in a day could endanger +life, that has seen a diarrh[oe]a continue for several months, attended +with fifteen or twenty stools every day, without making even a material +breach in the constitution? Hence Dr. Hillary has justly remarked, that +"it rarely or never happens that the purging in this disease, though +violent, takes the patient off, but the fever and inflammation of the +bowels[69]." Dr. Clark in like manner remarks, that evacuations do not +destroy life in the dysentery, but the fever, with the emaciation and +mortification which attend and follow the disease[70]. + + [69] Diseases of Barbadoes, p. 212. + + [70] Diseases in Voyages to Hot Climates, vol. ii. p. 322. + +2. A second objection to this mercurial purge was, that it excited a +salivation, and sometimes loosened the teeth. I met with but two cases +in which there was a loss of teeth from the use of this medicine, and in +both the teeth were previously loose or decayed. The salivation was a +trifling evil, compared with the benefit which was derived from it. I +lost only one patient in whom it occurred. I was taught, by this +accidental effect of mercury, to administer it with other views than +merely to cleanse the bowels, and with a success which added much to my +confidence in the power of medicine over this disease. I shall mention +those views under another head. + +3. It was said that the mercurial purge excoriated the rectum, and +produced the symptoms of pain and inflammation in that part, which were +formerly mentioned. + +To refute this charge, it will be sufficient to remark that the bile +produces the same excoriation and pain in the rectum in the bilious and +yellow fever, where no mercury has been given to discharge it. In the +bilious remitting fever which prevailed in Philadelphia in 1780, we find +the bile which was discharged by "gentle doses of salts, and cream of +tartar, or the butternut pill, was so acrid as to excoriate the rectum, +and so offensive as to occasion, in some cases, sickness and faintness +both in the patients, and in their attendants[71]." + + [71] Vol. i. + +Dr. Hume says further upon this subject, that the rectum was so much +excoriated by the natural discharge of bile in the yellow fever, as to +render it impossible to introduce a glyster pipe into it. + +4. It was objected to this purge, that it inflamed and lacerated the +stomach and bowels. In support of this calumny, the inflamed and +mortified appearances, which those viscera exhibited upon dissection in a +patient who died at the hospital at Bush-hill, were spoken of with horror +in some parts of the city. To refute this objection it will only be +necessary to review the account formerly given of the state of the +stomach and bowels after death from the yellow fever, in cases in which +no mercury had been given. I have before taken notice that sir John +Pringle and Dr. Cleghorn had prescribed mercurial purges with success in +the dysentery, a disease in which the bowels are affected with more +irritation and inflammation than in the yellow fever. Dr. Clark informs +us that he had adopted this practice. I shall insert the eulogium of this +excellent physician upon the use of mercury in the dysentery in his own +words. "For several years past, when the dysentery has resisted the +common mode of practice, I have administered mercury with the greatest +success; and am thoroughly persuaded that it is possessed of powers to +_remove inflammation_ and _ulceration_ of the intestines, which are the +chief causes of death in this distemper[72]." + + [72] Vol. ii. p. 342. + +5. It was urged against this powerful and efficacious medicine, that it +was prescribed indiscriminately in all cases, and that it did harm in all +weak habits. To this I answer, that there was no person so weak by +constitution or a previous disease, as to be injured by a single dose of +this medicine. Mrs. Meredith, the wife of the treasurer of the United +States, a lady of uncommon delicacy of constitution, took two doses of +the powder in the course of twelve hours, not only without any +inconvenience, but with an evident increase of strength soon afterwards. +Many similar cases might be mentioned. Even children took two or three +doses of it with perfect safety. This will not surprise those physicians +who have been in the practice of giving from ten to twenty grains of +mercury, with an equal quantity of jalap as a worm purge, and from fifty +to a hundred grains of calomel, in the course of four or five days, in +the internal dropsy of the brain. But I am happy in being able to add +further, that many women took it in every stage of pregnancy without +suffering the least inconvenience from it. Out of a great number of +pregnant women whom I attended in this fever I did not lose one to whom I +gave this medicine, nor did any of them suffer an abortion. One of them +had twice miscarried in the course of the two or three last years of her +life. She bore a healthy child three months after her recovery from the +yellow fever. + +No one has ever objected to the _indiscriminate_ mode of preparing the +body for the small-pox by purging medicines. The _uniform_ inflammatory +diathesis of that disease justifies the practice, in a certain degree, in +all habits. The yellow fever admits of a sameness of cure much more than +the small-pox, for it is _more_ uniformly and more highly inflammatory. +An observation of Dr. Sydenham upon epidemics applies, in its utmost +extent, to our late fever. "Now it must be observed (says this most acute +physician) that some epidemic diseases, in some years, are uniformly and +constantly the same[73]." However diversified our fever was in some of +its symptoms, it was in all cases accompanied by more or less +inflammatory diathesis, and by a morbid state of the alimentary canal. + + [73] Vol. i. p. 9. + +Much has been said of the bad effects of this purge from its having been +put up carelessly by the apothecaries, or from its having been taken +contrary to the printed directions, by many people. If it did harm in any +one case (which I do not believe) from the former of the above causes the +fault is not mine. Twenty men employed constantly in putting up this +medicine would not have been sufficient to have complied with all the +demands which were made of me for it. Hundreds who were in health called +or sent for it as well as the sick, in order to have it in readiness in +case they should be surprised by the disease in the night, or at a +distance from a physician. + +In all the cases in which this purge was supposed to have been hurtful, +when given on the first or second day of the disease, I believe it was +because it was not followed by repeated doses of the same, or of some +other purge, or because it was not aided by blood-letting. I am led to +make this assertion, not only from the authority of Dr. Sydenham, who +often mentions the good effects of bleeding in moderating or checking a +diarrh[oe]a, but by having heard no complaints of patients being purged +to death by this medicine, after blood-letting was universally adopted by +all the physicians in the city. + +It was remarked that the demand for this purging powder continued to +increase under all opposition, and that the sale of it by the +apothecaries was greatest towards the close of the disease. I shall +hereafter say that this was not the case with the West-India remedies. + +It is possible that this purge sometimes proved hurtful when it was given +on the fifth day of the disease, but it was seldom given for the _first_ +time after the third day, and when it was, the patient was generally in +such a situation that nothing did him either good or harm. + +I derived great pleasure from hearing, after the fever had left the city, +that calomel had been given with success as a purge in bilious fevers in +other parts of the union besides Philadelphia. Dr. Lawrence informed me +that he had cured many patients by it of the yellow fever which prevailed +in New-York, in the year 1791, and the New-York papers have told us that +several practitioners had been in the habit of giving it in the autumnal +fevers, with great success, in the western parts of that state. They had +probably learned the use of it from Dr. Young, who formerly practised in +that part of the United States, and who lost no opportunity of making its +praises public wherever he went. + +I have only to add to my account of that purging medicine, that, under an +expectation that the yellow fever would mingle some of its bilious +symptoms with the common inflammatory fevers of the winter and first +spring months, I gave that purge in the form of pills, in every case of +inflammatory fever to which I was called. The fatal issue of several +fevers in the city, during the winter, in which this precaution had been +neglected, convinced me that my practice was proper and useful. + +It is to be lamented that all new remedies are forced to pass through a +fiery ordeal. Opium and bark were long the objects of terror and +invective in the schools of medicine. They were administered only by +physicians for many years, and that too with all the solemnity of a +religious ceremony. This error, with respect to those medicines, has at +last passed away. It will, I hope, soon be succeeded by a time when the +prejudices against _ten_ and _ten_, or _ten_ and _fifteen_, will sleep +with the vulgar fears which were formerly entertained of the bark +producing diseases and death, years after it had been taken, by "lying in +the bones." + + + OF BLOOD-LETTING. + +The theory of this fever which led me to administer purges, determined me +to use blood-letting, as soon as it should be indicated. I am disposed to +believe that I was tardy in the use of this remedy, and I shall long +regret the loss of three patients, who might probably have been saved by +it. I cannot blame myself for not having used it earlier, for the immense +number of patients which poured in upon me, in the first week of +September, prevented my attending so much to each of them, as was +necessary to determine upon the propriety of this evacuation. I was in +the situation of a surgeon in a battle, who runs to every call, and only +stays long enough with each soldier to stop the bleeding of his wound, +while the increase of the wounded, and the unexpected length of the +battle, leave his original patients to suffer from the want of more +suitable dressings. The reasons which determined me to bleed were, + +1. The state of the pulse, which became more tense, in proportion as the +weather became cool. + +2. The appearance of a moist and _white_ tongue, on the first day of the +disease, a certain sign of an inflammatory fever. + +3. The frequency of hæmorrhages from every part of the body, and the +perfect relief given in some cases by them. + +4. The symptoms of congestion in the brain, resembling those which occur +in the first stage of hydrocephalus internus, a disease in which I had +lately used bleeding with success. + +5. The character of the diseases which had preceded the yellow fever. +They were all more or less inflammatory. Even the scarlatina anginosa had +partaken so much of that diathesis, as to require bleeding to subdue it. + +6. The warm and dry weather which had likewise preceded the fever. Dr. +Sydenham attributes a highly inflammatory state of the small-pox to a +previously hot and dry summer; and I have since observed, that Dr. +Hillary takes notice of inflammatory fevers having frequently succeeded +hot and dry weather in Barbadoes[74]. He informs us further, that the +yellow fever is always most acute and inflammatory after a very hot +season[75]. + + [74] Diseases of Barbadoes, p. 16, 43, 46, 48, 52, 122. + + [75] Page 147. + +7. The authority of Dr. Mosely had great weight with me in advising the +loss of blood, more especially as his ideas of the highly inflammatory +nature of the fever accorded so perfectly with my own. + +8. I was induced to prescribe blood-letting by recollecting its good +effects in Mrs. Palmer's son, whom I bled on the 20th of August, and who +appeared to have been recovered by it. + +Having begun to bleed, I was encouraged to continue it by the appearance +of the blood, and by the obvious and very great relief my patients +derived from it. + +The following is a short account of the appearances of the blood drawn +from a vein in this disease. + +1. It was, in the greatest number of cases, without any separation into +crassamentum and serum, and of a scarlet colour. + +2. There was in many cases a separation of the blood into crassamentum +and _yellow_ serum. + +3. There were a few cases in which this separation took place, and the +serum was of a _natural_ colour. + +4. There were many cases in which the blood was as sizy as in pneumony +and rheumatism. + +5. The blood was in some instances covered above with blue pellicle of +sizy lymph, while the part which lay in the bottom of the bowl was +dissolved. The lymph was in two cases mixed with green streaks. + +6. It was in a few instances of a dark colour, and as fluid as molasses. +I saw this kind of blood in a man who walked about his house during the +whole of his sickness, and who finally recovered. Both this, and the +fifth kind of blood which has been mentioned, occurred chiefly where +bleeding had been omitted altogether, or used too sparingly in the +beginning of the disease. + +7. In some patients the blood, in the course of the disease, exhibited +nearly _all_ the appearances which have been mentioned. They were varied +by the time in which the blood was drawn, and by the nature and force of +the remedies which had been used in the disease. + +The effects of blood-letting upon the system were as follow: + +1. It raised the pulse when depressed, and quickened it, when it was +preternaturally slow, or subject to intermissions. + +2. It reduced its force and frequency. + +3. It checked in many cases the vomiting which occurred in the beginning +of the disease, and thereby enabled the stomach to retain the purging +medicine. It likewise assisted the purge in preventing the dangerous or +fatal vomiting which came on about the fifth day. + +4. It lessened the difficulty of opening the bowels. Upon this account, +in one of my addresses to the citizens of Philadelphia, I advised +bleeding to be used _before_, as well as after taking the mercurial +purge. Dr. Woodhouse informed me that he had several times seen patients +call for the close-stool while the blood was flowing from the vein. + +5. It removed delirium, coma, and obstinate wakefulness. It also +prevented or checked hæmorrhages; hence perhaps another reason why not a +single instance of abortion occurred in such of my female patients as +were pregnant. + +6. It disposed, in some cases, to a gentle perspiration. + +7. It lessened the sensible debility of the system; hence patients +frequently rose from their beds, and walked across their rooms, in a few +hours after the operation had been performed. + +8. The redness of the eyes frequently disappeared in a few hours after +bleeding. Mr. Coxe observed a dilated pupil to contract to its natural +size within a few minutes after he had bound up the arm of his patient. I +remarked, in the former part of this work, that blindness in many +instances attended or followed this fever. But two such cases occurred +among my patients. In one of them it was of short continuance, and in the +other it was probably occasioned by the want of sufficient bleeding. In +every case of blindness that came to my knowledge bleeding had been +omitted, or used only in a very moderate degree. + +9. It eased _pain_. Thousands can testify this effect of blood-letting. +Many of my patients whom I bled with my own hand acknowledged to me, +while the blood was flowing, that they were better; and some of them +declared, that all their pains had left them before I had completely +bound up their arms. + +10. But blood-letting had, in many cases, an effect the opposite of +_easing_ pain. It frequently increased it in every part of the body, more +especially in the head. It appeared to be the effect of the system rising +suddenly from a state of great depression, and of an increased action of +the blood-vessels which took place in consequence of it. I had frequently +seen complaints of the breast, and of the head, made worse by a single +bleeding, and from the same cause. It was in some cases an unfortunate +event in the yellow fever, for it prevented the blood-letting being +repeated, by exciting or strengthening the prejudices of patients and +physicians against it. In some instances the patients grew worse after a +second, and, in one, after a third bleeding. This was the case in Miss +Redman. Her pains increased after three bleedings, but yielded to the +fourth. Her father, Dr. Redman, concurred in this seemingly absurd +practice. It was at this time my old preceptor in medicine reminded me of +Dr. Sydenham's remark, that moderate bleeding did harm in the plague +where copious bleeding was indicated, and that in the cure of that +disease, we should leave nature wholly to herself, or take the cure +altogether out of her hands. The truth of this remark was very obvious. +By taking away as much blood as restored the blood-vessels to a morbid +degree of action, without reducing this action afterwards, pain, +congestion, and inflammation were frequently increased, all of which were +prevented, or occurred in a less degree, when the system rose gradually +from the state of depression which had been induced by the great force of +the disease. Under the influence of the facts and reasonings which have +been mentioned I bore the same testimony in acute cases, against what was +called _moderate_ bleeding that I did against bark, wine, and laudanum in +this fever. + +11. Blood-letting, when used _early_ on the first day, frequently +strangled the disease in its birth, and generally rendered it more light, +and the convalescence more speedy and perfect. I am not sure that it ever +shortened the duration of the fever where it was not used within a few +hours of the time of its attack. Under every mode of treatment it seemed +disposed, after it was completely formed, to run its course. I was so +satisfied of this peculiarity in the fever, that I ventured in some cases +to predict the day on which it would terminate, notwithstanding I took +the cure entirely out of the hands of nature. I did not lose a patient on +the third, whom I bled on the first or second day of the disease. + +12. In those cases which ended fatally, blood-letting restored, or +preserved the use of reason, rendered death easy, and retarded the +putrefaction of the body after death. + +I shall now mention some of the circumstances which directed and +regulated the use of this remedy. + +1. Where bleeding had been omitted for three days, in acute cases, it was +seldom useful. Where purging had been used, it was sometimes successful. +I recovered two patients who had taken the mercurial purges, whom I bled +for the first time on the seventh day. One of them was the daughter of +Mr. James Cresson, the other was a journeyman ship-carpenter at +Kensington. In those cases where bleeding had been used on the first day, +it was both safe and useful to repeat it every day afterwards, during the +continuance of the fever. + +2. I preferred bleeding in the exacerbation of the fever. The remedy here +was applied when the disease was in its greatest force. A single paroxysm +was like a sudden squall to the system, and, unless abated by bleeding or +purging, often produced universal disorganization. I preferred the former +to the latter remedy in cases of great danger, because it was more +speedy, and more certain in its operation. + +3. I bled in several instances in the remission of the fever, where the +pulse was tense and corded. It lessened the violence of the succeeding +paroxysm. + +4. I bled in all those cases in which the pulse was preternaturally slow, +provided it was tense. Mr. Benj. W. Morris, Mr. Thomas Wharton, jun. and +Mr. Wm. Sansom, all owe their lives probably to their having been bled in +the above state of the pulse. I was led to use bleeding in this state of +the pulse, not only by the theory of the disease which I had adopted, but +by the success which had often attended this remedy, in a slow and +depressed state of the pulse in apoplexy and pneumony. I had moreover the +authority of Dr. Mosely in its favour, in the yellow fever, and of Dr. +Sydenham, in his account of a new fever, which appeared in the year 1685. +The words of the latter physician are so apposite to the cases which have +been mentioned, that I hope I shall be excused for inserting them in this +place. "All the symptoms of weakness (says our author) proceed from +nature's being in a manner oppressed and overcome by the first attack of +the disease, so as not to be able to raise regular symptoms adequate to +the violence of the fever. I remember to have met with a remarkable +instance of this, several years ago, in a young man I then attended; for +though he seemed in a manner expiring, yet the outward parts felt so +cool, that I could not persuade the attendants he had a fever, which +could not disengage, and show itself clearly, because the vessels were so +full as to obstruct the motion of the blood. However, I said, that they +would soon find the fever rise high enough upon bleeding him. +Accordingly, after taking away a large quantity of blood, as violent a +fever appeared as ever I met with, and did not go off till bleeding had +been used three or four times[76]." + + [76] Vol. ii. p. 351. + +5. I bled in those cases in which the fever appeared in a tertian form, +provided the pulse was full and tense. I well recollect the surprise with +which Mr. Van Berkel heard this prescription from me, at a time when he +was able to walk and ride out on the intermediate days of a tertian +fever. The event which followed this prescription showed that it was not +disproportioned to the violence of his disease, for it soon put on such +acute and inflammatory symptoms as to require six subsequent bleedings to +subdue it. + +6. I bled in those cases where patients were able to walk about, provided +the pulse was the same as has been mentioned under the fourth head. I was +determined as to the propriety of bleeding in these two supposed mild +forms of the fever, by having observed each of them, when left to +themselves, frequently to terminate in death. + +7. I paid no regard to the dissolved state of the blood, when it appeared +on the first or second day of the disease, but repeated the bleedings +afterwards in every case, where the pulse continued to indicate it. It +was common to see sizy blood succeed that which was dissolved. This +occurred in Mr. Josiah Coates, and Mr. Samuel Powel. Had I believed that +this dissolved state of the blood arose from its putrefaction, I should +have laid aside my lancet as soon as I saw it; but I had long ago parted +with all ideas of putrefaction in bilious fevers. The refutation of this +doctrine was the object of one of my papers in the Medical Society of +Edinburgh, in the year 1767. The dissolved appearance of the blood, I +suppose to be the effect of a certain action of the blood-vessels upon +it. It occurs in fevers which depend upon the sensible qualities of the +air, and in which no putrid or foreign matter has been introduced into +the system. + +8. The presence of petechiæ did not deter me from repeating +blood-letting, where the pulse retained its fulness or tension. I +prescribed it with success in the cases of Dr. Mease, and of Mrs. Gebler, +in Dock-street, in each of whom petechiæ had appeared. Bleeding was +equally effectual in the case of the Rev. Mr. Keating, at a time when his +arms were spotted with that species of eruptions which I have compared to +moscheto-bites. I had precedents in Dr. De Haen[77] and Dr. +Sydenham[78], in favour of this practice. So far from viewing these +eruptions as signs of putrefaction, I considered them as marks of the +highest possible inflammatory diathesis. They disappeared in each of the +above cases after bleeding. + + [77] Ratio Medendi, vol. ii. p. 162. vol. iv. p. 172. + + [78] Vol. i. p. 210, and 264. + +9. In determining the quantity of blood to be drawn, I was governed by +the state of the pulse, and by the temperature of the weather. In the +beginning of September, I found one or two moderate bleedings sufficient +to subdue the fever; but in proportion as the system rose by the +diminution of the stimulus of heat, and the fever put on more _visible_ +signs of inflammatory diathesis, more frequent bleedings became +necessary. I bled many patients twice, and a few three times a day. I +preferred frequent and small, to large bleedings, in the beginning of +September; but towards the height and close of the epidemic, I saw no +inconvenience from the loss of a pint, and even twenty ounces of blood at +a time. I drew from many persons seventy and eighty ounces in five days; +and from a few, a much larger quantity. Mr. Gribble, cedar-cooper, in +Front-street, lost by ten bleedings a hundred ounces of blood; Mr. +George, a carter in Ninth-street, lost about the same quantity by five +bleedings; and Mr. Peter Mierken, one hundred and fourteen ounces in five +days. In the last of the above persons the quantity taken was determined +by weight. Mr. Toy, blacksmith near Dock-street, was eight times bled in +the course of seven days. The quantity taken from him was about a hundred +ounces. The blood in all these cases was dense, and in the last, very +sizy. They were all attended in the month of October, and chiefly by my +pupil, Mr. Fisher; and they were all, years afterwards, living and +healthy instances of the efficacy of copious blood-letting, and of the +intrepidity and judgment of their young physician. Children, and even old +people, bore the loss of much more blood in this fever than in common +inflammatory fevers. I took above thirty ounces, in five bleedings, from +a daughter of Mr. Robert Bridges, who was then in the 9th year of her +age. Even great debility, whether natural or brought on by previous +diseases, did not, in those few cases in which it yielded to the fever, +deprive it of the uniformity of its inflammatory character. The following +letter from Dr. Griffitts, written soon after his recovery from a third +attack of the fever, and just before he went into the country for the +re-establishment of his health, will furnish a striking illustration of +the truth of the above observation. + +"I cannot leave town without a parting adieu to my kind friend, and +sincere prayers for his preservation. + +"I am sorry to find that the use of the lancet is still so much dreaded +by too many of our physicians; and, while lamenting the death of a +valuable friend this morning, I was told that he was bled but _once_ +during his disease. Now if my poor frame, reduced by previous sickness, +great anxiety, and fatigue, and a very low diet, could bear_ seven_ +bleedings in five days, besides purging, and no diet but toast and water, +what shall we say of physicians who bleed but once? + +"_October 19th, 1793._" + +I have compared a paroxysm of this fever to a sudden squall; but the +disease in its whole course was like a tedious equinoctial gale acting +upon a ship at sea; its destructive force was only to be opposed by +handing every sail, and leaving the system to float, as it were, under +bare poles. Such was the fragility (if I may be allowed the expression) +of the blood-vessels, that it was necessary to unload them of their +contents, in order to prevent the system sinking from hæmorrhages, or +from effusions in the viscera, particularly the brain. + +9. Such was the indomitable nature of the pulse, in some patients, that +it did not lose its force after numerous and copious bleedings. In all +such cases I considered the diminution of its frequency, and the absence +of a vomiting, as signals to lay aside the lancet. The continuance of +this preternatural force in the pulse appeared to be owing to the +miasmata, which were universally diffused in the air, acting upon the +arterial system in the same manner that it did in persons who were in +apparent good health. + +Thus have I mentioned the principal circumstances which were connected +with blood-letting in the cure of the yellow fever. I shall now consider +the objections that were made to it at the time, and since the prevalence +of the fever. + +It was said that the bleeding was unnecessarily copious; and that many +had been destroyed by it. To this I answer, that I did not lose a single +patient whom I bled seven times or more in this fever. As a further proof +that I did not draw an ounce of blood too much it will only be necessary +to add, that hæmorrhages frequently occurred after a third, a fourth, and +in one instance (in the only son of Mr. William Hall) after a sixth +bleeding had been used; and further, that not a single death occurred +from natural hæmorrhages in the first stage of the disease. A woman, who +had been bled by my advice, awoke the night following in a bath of her +blood, which had flowed from the orifice in her arm. The next day she was +free from pain and fever. There were many recoveries in the city from +similar accidents. There were likewise some recoveries from copious +natural hæmorrhages in the more advanced stages of the disease, +particularly when they occurred from the stomach and bowels. I left a +servant maid of Mrs. Morris's, in Walnut-street, who had discharged at +least four pounds of blood from her stomach, without a pulse, and with +scarcely a symptom that encouraged a hope of her life; but the next day I +had the pleasure of finding her out of danger. + +It was remarked that fainting was much less common after bleeding in this +fever than in common inflammatory fevers. This circumstance was observed +by Dr. Griffitts, as well as myself. It has since been confirmed to me by +three of the principal bleeders in the city, who performed the operation +upwards of four thousand times. It occurred chiefly in those cases where +it was used for the first time on the third or fourth day of the disease. +A swelling of the legs, moreover, so common after plentiful bleeding in +pneumony and rheumatism, rarely succeeded the use of this remedy in the +yellow fever. + +2. Many of the indispositions, and much of the subsequent weakness of +persons who had been cured by copious blood-letting, have been ascribed +to it. This is so far from being true that the reverse of it has occurred +in many cases. Mr. Mierken worked in his sugar-house, in good health, +nine days after his last bleeding; and Mr. Gribble and Mr. George seemed, +by their appearance, to have derived fresh vigour from their evacuations. +I could mention the names of many people who assured me their +constitutions had been improved by the use of those remedies; and I know +several persons in whom they have carried off habitual complaints. Mr. +Richard Wells attributed his relief from a chronic rheumatism to the +copious bleeding and purging which were used to cure him of the yellow +fever; and Mr. William Young, the bookseller, was relieved of a chronic +pain in his side, by means of the same remedies. + +3. It was said, that blood-letting was prescribed indiscriminately in all +cases, without any regard to age, constitution, or the force of the +disease. This is not true, as far as it relates to my practice. In my +prescriptions for patients whom I was unable to visit, I advised them, +when they were incapable of judging of the state of the pulse, to be +guided in the use of bleeding, by the degrees of pain they felt, +particularly in the head; and I seldom advised it for the _first_ time, +after the second or third day of the disease. + +In pneumonies which affect whole neighbourhoods in the spring of the +year, bleeding is the universal remedy. Why should it not be equally so, +in a fever which is of a more uniform inflammatory nature, and which +tends more rapidly to effusions, in parts of the body much more vital +than the lungs? + +I have before remarked, that the debility which occurs in the beginning +of the yellow fever, arises from a depressed state of the system. The +debility in the plague is of the same nature. It has long been known that +debility from the sudden abstraction of stimuli is to be removed by the +_gradual_ application of stimuli, but it has been less observed, that the +excess of stimulus in the system is best removed in a _gradual_ manner, +and that too in proportion to the degrees of depression, which exist in +the system. + +This principle in the animal economy has been acknowledged by the +practice of occasionally stopping the discharge of water from a canula in +tapping, and of blood from a vein, in order to prevent fainting. + +Child-birth induces fainting, and sometimes death, only by the _sudden_ +abstraction of the stimulus of distention and pain. + +In all those cases where purging or bleeding have produced death in the +yellow fever or plague, when they have been used on the first or second +day of those diseases, I suspect that it was occasioned by the quantity +of the stimulus abstracted being disproportioned to the degrees of +depression in the system. The following facts will I hope throw light +upon this subject. + +1. Dr. Hodges informs us, that "although blood could not be drawn in the +plague, even in the smallest quantity without danger, yet a _hundred_ +times the quantity of fluids was discharged in pus from buboes without +inconvenience[79]." + + [79] Page 114. + +2. Pareus, after condemning bleeding in the plague, immediately adds an +account of a patient, who was saved by a hæmorrhage from the nose, which +continued _two_ days[80]. + + [80] Skenkius, lib. vi. p. 881. + +3. I have before remarked that bleeding proved fatal in three cases in +the yellow fever, in the month of August; but at that time I saw one, and +heard of another case, in which death seemed to have been prevented by a +bleeding at the nose. Perhaps the uniform good effects which were +observed to follow a spontaneous hæmorrhage from an orifice in the arm, +arose wholly from the _gradual_ manner in which the stimulus of the blood +was in this way abstracted from the body. Dr. Williams relates a case of +the recovery of a gentleman from the yellow fever, by means of small +hæmorrhages, which continued three days, from wounds in his shoulders +made by being cupped. He likewise mentions several other recoveries by +hæmorrhages from the nose, after "a vomiting of black humours and a +hiccup had taken place[81]." + + [81] Essay on the Bilious or Yellow Fever of Jamaica, p. 40. + +4. There is a disease in North-Carolina, known among the common people by +the name of the "pleurisy in the head." It occurs in the winter, after a +sickly autumn, and seems to be an evanescent symptom of a bilious +remitting fever. The cure of it has been attempted by bleeding, in the +common way, but generally without success. It has, however, yielded to +this remedy in another form, that is, to the discharge of a few ounces of +blood obtained by thrusting a piece of quill up the nose. + +5. Riverius describes a pestilential fever which prevailed at +Montpellier, in the year 1623, which carried off one half of all who were +affected by it[82]. After many unsuccessful attempts to cure it, this +judicious physician prescribed the loss of _two_ or _three_ ounces of +blood. The pulse rose with this small evacuation. Three or four hours +afterwards he drew six ounces of blood from his patients, and with the +same good effect. The next day he gave a purge, which, he says, rescued +his patients from the grave. All whom he treated in this manner +recovered. The whole history of this epidemic is highly interesting, from +its agreeing with our late epidemic in so many of its symptoms, more +especially as they appeared in the different states of the pulse. + + [82] De Febre Pestilenti, vol. ii. p. 145, 146, and 147. + +An old and intelligent citizen of Philadelphia, who remembers the yellow +fever of 1741, says that when it first made its appearance bleeding was +attended with fatal consequences. It was laid aside afterwards, and the +disease prevailed with great mortality until it was checked by the cold +weather. Had blood been drawn in the manner mentioned by Riverius, or had +it been drawn in the usual way, after the abstraction of the stimulus of +heat by the cool weather, the disease might probably have been subdued, +and the remedy of blood-letting thereby have recovered its character. + +Dr. Hodges has another remark, in his account of the plague in London in +the year 1665, which is still more to our purpose than the one which I +have quoted from it upon this subject. He says that "bleeding, as a +preventive of the plague, was only safe and useful when the blood was +drawn by a _small_ orifice, and a _small_ quantity taken at _different_ +times[83]." + + [83] Page 209. + +I have remarked, in the history of this fever, that it was often cured on +the first or second day by a copious sweat. The Rev. Mr. Ustick was one +among many whom I could mention, who were saved from a violent attack of +the fever by this evacuation. It would be absurd to suppose that the +miasmata which produced the disease were discharged in this manner from +the body. The sweat seemed to cure the fever only by lessening the +quantity of the fluids, and thus _gradually_ removing the depression of +the system. The profuse sweats which sometimes cure the plague, as well +as the disease which is brought on by the bite of poisonous snakes, seem +to act in the same way. + +The system, in certain states of malignant fever, resembles a man +struggling beneath a load of two hundred weight, who is able to lift but +one hundred and seventy-five. In order to assist him it will be to no +purpose to attempt to infuse additional vigour into his muscles by the +use of a whip or of strong drink. Every exertion will serve only to +waste his strength. In this situation (supposing it impossible to divide +the weight which confines him to the ground) let the pockets of this man +be emptied of their contents, and let him be stripped of so much of his +clothing as to reduce his weight five and twenty or thirty pounds. In +this situation he will rise from the ground; but if the weights be +abstracted suddenly, while he is in an act of exertion, he will rise with +a spring that will endanger a second fall, and probably produce a +temporary convulsion in his system. By abstracting the weights from his +body more gradually, he will rise by degrees from the ground, and the +system will accommodate itself in such a manner to the diminution of its +pressure, as to resume its erect form, without the least deviation from +the natural order of its appearance and motions. + +It has been said that the stimulating remedies of bark, wine, and the +cold bath, were proper in our late epidemic in August, and in the +beginning of September, but that they were improper afterwards. If my +theory be just, they were more improper in August and the beginning of +September, than they were after the disease put on the outward and common +signs of inflammatory diathesis. The reason why a few strong purges cured +the disease at its first appearance, was, because they abstracted in a +_gradual_ manner some of the immense portion of stimulus under which the +arterial system laboured, and thus gradually relieved it from its low and +weakening degrees of depression. Bleeding was fatal in these cases, +probably because it removed this depression in too sudden a manner. + +The principle of the gradual abstraction, as well as of the gradual +application of stimuli to the body, opens a wide field for the +improvement of medicine. Perhaps all the discoveries of future ages will +consist more in a new application of established principles, and in new +modes of exhibiting old medicines, than in the discovery of new theories, +or of new articles of the materia medica. + +The reasons which induced me to prescribe purging and bleeding, in so +liberal a manner, naturally led me to recommend _cool_ and _fresh air_ to +my patients. The good effects of it were obvious in almost every case in +which it was applied. It was equally proper whether the arterial system +was depressed, or whether it discovered, in the pulse, a high degree of +morbid excitement. Dr. Griffitts furnished a remarkable instance of the +influence of cool air upon the fever. Upon my visiting him, on the +morning of the 8th of October, I found his pulse so full and tense as to +indicate bleeding, but after sitting a few minutes by his bed-side, I +perceived that the windows of his room had been shut in the night by his +nurse, on account of the coldness of the night air. I desired that they +might be opened. In ten minutes afterwards the doctor's pulse became so +much slower and weaker that I advised the postponement of the bleeding, +and recommended a purge instead of it. The bleeding notwithstanding +became necessary, and was used with great advantage in the afternoon of +the same day. + +The cool air was improper only in those cases where a chilliness attended +the disease. + +For the same reason that I advised cool air, I directed my patients to +use cold _drinks_. They consisted of lemonade, tamarind, jelly and raw +apple water, toast and water, and of weak balm, and camomile tea. The +subacid drinks were preferred in most cases, as being not only most +agreeable to the taste, but because they tended to compose the stomach. +All these drinks were taken in the early stage of the disease. Towards +the close of it, I permitted the use of porter and water, weak punch, and +when the stomach would bear it, weak wine-whey. + +I forbade all cordial and stimulating food in the active state of the +arterial system. The less my patients ate, of even the mildest vegetable +food, the sooner they recovered. Weak coffee, which (as I have formerly +remarked) was almost universally agreeable, and weak tea were always +inoffensive. As the action of the pulse diminished, I indulged my +patients with weak chocolate; also with milk, to which roasted apples, or +minced peaches, and (where they were not to be had), bread or Indian mush +were added. + +Towards the crisis, I advised the drinking of weak chicken, veal, or +mutton broth, and after the crisis had taken place, I permitted mild +animal food to be eaten in a small quantity, and to be increased +according to the waste of the excitability of the system. This strict +abstinence which I imposed upon my patients did not escape obloquy; but +the benefits they derived from it, and the ill effects which arose in +many cases from a contrary regimen, satisfied me that it was proper in +every case in which it was prescribed. + +_Cold water_ was a most agreeable and powerful remedy in this disease. I +directed it to be applied by means of napkins to the head, and to be +injected into the bowels by way of glyster. It gave the same ease to +both, when in pain, which opium gives to pain from other causes. I +likewise advised the washing of the face and hands, and sometimes the +feet, with cold water, and always with advantage. It was by suffering the +body to lie for some time in a bed of cold water, that the inhabitants of +the island of Massuah cured the most violent bilious fevers[84]. When +applied in this way, it _gradually_ abstracts the heat from the body, and +thereby lessens the action of the system. It differs as much in its +effects upon the body from the cold bath, as rest in a cold room, differs +from exercise in the cold and open air. + + [84] Bruce's Travels. + +I was first led to the practice of the partial application of cold water +to the body, in fevers of too much force in the arterial system, by +observing its good effects in active hæmorrhages, and by recollecting the +effects of a partial application of warm water to the feet, in fevers of +an opposite character. Cold water when applied to the feet as certainly +reduces the pulse in force and frequency, as warm water, applied in the +same way, produces contrary effects upon it. In an experiment which was +made at my request, by one of my pupils, by placing his feet in cold pump +water for a few minutes, the pulse was reduced 24 strokes in a minute, +and became so small as hardly to be perceptible. + +But this effect of cold water, in reducing the frequency of the pulse, is +not uniform. In weak and irritable habits, it increases its frequency. +This has been fully proved by a number of experiments, made by my former +pupil, Dr. Stock, of Bristol, in England, and published in his "Medical +Collections of the Effects of Cold, as a Remedy in certain Diseases[85]." + + [85] Page 185. + +In the use of the remedies which were necessary to overcome the +inflammatory action of the system, I was obliged to reduce it below its +natural point of excitement. In the present imperfect state of our +knowledge in medicine, perhaps no disease of too much action can be cured +without it. + +Besides the remedies which have been mentioned, I was led to employ +another of great efficacy. I had observed a favourable issue of the +fever, in every case in which a spontaneous discharge took place from the +salivary glands. I had observed further, that all such of my patients +(one excepted) as were salivated by the mercurial purges recovered in a +few days. This early suggested an idea to me that the calomel might be +applied to other purposes than the discharging of bile from the bowels. I +ascribed its salutary effects, when it salivated in the first stage of +the disease, to the excitement of inflammation and effusion in the +throat, diverting them from more vital parts of the body. In the second +stage of the disease, I was led to prescribe it as a stimulant, and, with +a view of obtaining this operation from it, I aimed at exciting a +salivation, as speedily as possible, in all cases. Two precedents +encouraged me to make trial of this remedy. + +In the month of October, 1789, I attended a gentleman in a bilious fever, +which ended in many of the symptoms of a typhus mitior. In the lowest +state of his fever, he complained of a pain in his right side, for which +I ordered half an ounce of mercurial ointment to be rubbed on the part +affected. The next day, he complained of a sore mouth, and, in the course +of four and twenty hours, he was in a moderate salivation. From this time +his pulse became full and slow, and his skin moist; his sleep and +appetite suddenly returned, and in a day or two he was out of danger. The +second precedent for a salivation in a fever, which occurred to me, was +in Dr. Haller's short account of the works of Dr. Cramer[86]. The +practice was moreover justified, in point of safety, as well as the +probability of success, by the accounts which Dr. Clark has lately given +of the effects of a salivation in the dysentery[87]. I began by +prescribing the calomel in small doses, at short intervals, and +afterwards I directed large quantities of the ointment to be rubbed upon +the limbs. The effects of it, in every case in which it affected the +mouth, were salutary. Dr. Woodhouse improved upon my method of exciting +the salivation, by rubbing the gums with calomel, in the manner directed +by Mr. Clare. It was more speedy in its operation in this way than in any +other, and equally effectual. Several persons appeared to be benefited by +the mercury introduced into the system in the form of an ointment, where +it did _not_ produce a salivation. Among these, were the Rev. Dr. +Blackwell, and Mr. John Davis. + + [86] Bibliotheca Medicinæ Practicæ, vol. iii. p. 491. + + [87] Diseases of Long Voyages to Hot Climates, vol. ii. p. 334. + +Soon after the above account was written of the good effects of a +mercurial salivation in this fever, I had great satisfaction in +discovering that it had been prescribed with equal, and even greater +success, by Dr. Wade in Bengal, in the year 1791, and by Dr. Chisholm in +the island of Granada, in the cure of bilious yellow fevers[88]. Dr. Wade +did not lose one, and Dr. Chisholm lost only one out of forty-eight +patients in whom the mercury affected the salivary glands. The latter +gave 150 grains of calomel, and applied the strongest mercurial ointment +below the groin of each side, in some cases. He adds further, that not a +single instance of a relapse occurred, where the disease was cured by +salivation. + + [88] Medical Commentaries, vol. xviii. p. 209, 288. + +After the reduction of the system, _blisters_ were applied with great +advantage to every part of the body. They did most service when they were +applied to the crown of the head. I did not see a single case, in which a +mortification followed the sore, which was created by a blister. + +Brandy and water, or porter and water, when agreeable to the stomach, +with now and then a cup of chicken broth, were the drinks I prescribed to +assist in restoring the tone of the system. + +In some cases I directed the limbs to be wrapped in flannels dipped in +warm spirits, and cataplasms of bruised garlic to be applied to the feet. +But my principal dependence, next to the use of mercurial medicines, for +exciting a healthy action in the arterial system, was upon mild and +gently stimulating food. This consisted of rich broths, the flesh of +poultry, oysters, thick gruel, mush and milk, and chocolate. I directed +my patients to eat or drink a portion of some of the above articles of +diet every hour or two during the day, and in cases of great debility, +from an exhausted state of the system, I advised their being waked for +the same purpose two or three times in the night. The appetite frequently +craved more savoury articles of food, such as beef-stakes and sausages; +but they were permitted with great caution, and never till the system had +been prepared for them by a less stimulating diet. + +There were several _symptoms_ which were very distressing in this +disease, and which required a specific treatment. + +For the vomiting, with a burning sensation in the stomach, which came on +about the fifth day, I found no remedy equal to a table spoonful of sweet +milk, taken every hour, or to small draughts of milk and water. I was +led to prescribe this simple medicine from having heard, from a +West-India practitioner, and afterwards read, in Dr. Hume's account of +the yellow fever, encomiums upon the milk of the cocoa-nut for this +troublesome symptom. Where sweet milk failed of giving relief, I +prescribed small doses of sweet oil, and in some cases a mixture of equal +parts of milk, sweet oil, and molasses. They were all intended to dilute +or blunt the acrimony of the humours, which were either effused or +generated in the stomach. Where they all failed of checking the vomiting, +I prescribed weak camomile tea, or porter, or cyder and water, with +advantage. In some of my patients the stomach rejected all the mixtures +and liquors which have been mentioned. In such cases I directed the +stomach to be left to itself for a few hours, after which it sometimes +received and retained the drinks that it had before rejected, provided +they were administered in a small quantity at a time. + +The vomiting was sometimes stopped by a blister applied to the external +region of the stomach. + +A mixture of liquid laudanum and sweet oil, applied to the same place, +gave relief where the stomach was affected by pain only, without a +vomiting. + +I have formerly mentioned that a distressing _pain_ often seized the +lower part of the _bowels_. I was early taught that laudanum was not a +proper remedy for it. It yielded in almost every case to two or three +emollient glysters, or to the loss of a few ounces of blood. + +The convalescence from this fever was in general rapid, but in some cases +it was very slow. I was more than usually struck by the great resemblance +which the system in the convalescence from this fever bore to the state +of the body and mind in old age. It appeared, 1. In the great weakness of +the body, more especially of the limbs. 2. In uncommon depression of +mind, and in a great aptitude to shed tears. 3. In the absence or short +continuance of sleep. 4. In the frequent occurrence of appetite, and, in +some cases, in its inordinate degrees. And 5. In the loss of the hair of +the head, or in its being suddenly changed in some cases to a grey +colour. + +Pure air, gentle exercise, and agreeable society removed the debility +both of body and mind of this premature and temporary old age. I met with +a few cases, in which the yellow colour continued for several weeks +after the patient's recovery from all the other symptoms of the fever. It +was removed most speedily and effectually by two or three moderate doses +of calomel and rhubarb. + +A feeble and irregular intermittent was very troublesome in some people, +after an acute attack of the fever. It yielded gradually to camomile or +snake-root tea, and country air. + +In a publication, dated the 16th of September, I recommended a diet of +milk and vegetables, and cooling purges to be taken once or twice a week, +to the citizens of Philadelphia. This advice was the result of the theory +of the disease I had adopted, and of the successful practice which had +arisen from it. In my intercourse with my fellow-citizens, I advised this +regimen to be regulated by the degrees of fatigue and foul air to which +they were exposed. I likewise advised moderate blood-letting to all such +persons as were of a plethoric habit. To men whose minds were influenced +by the publications in favour of bark and wine, and who were unable at +that time to grasp the extent and force of the remote cause of this +terrible fever, the idea of dieting, purging, or bleeding the inhabitants +of a whole village or city appeared to be extravagant and absurd: but I +had not only the analogy of the regimen made use of to prepare the body +for the small-pox, but many precedents in favour of the advice. Dr. +Haller has given extracts from the histories of two plagues, in which the +action of the miasmata was prevented or mitigated by bleeding[89]. Dr. +Hodges confirms the utility of the same practice. The benefits of low +diet, as a preventive of the plague, were established by many authors, +long before they received the testimony of the benevolent Mr. Howard in +their favour. Socrates in Athens, and Justinian in Constantinople, were +preserved, by means of their abstemious modes of living, from the plagues +which occasionally ravaged those cities. By means of the low diet, gentle +physic, and occasional bleedings, which I thus publicly recommended, the +disease was prevented in many instances, or rendered mild where it was +taken. But my efforts to prevent the disease in my fellow-citizens did +not end here. I advised them, not only in the public papers, but in my +intercourse with them, to avoid heat, cold, labour, and every thing else +that could excite the miasmata (which I knew to be present in all their +bodies) into action. I forgot, upon this occasion, the usual laws which +regulate the intercourse of man with man in the streets, and upon the +public roads, in my excursions into the neighbourhood of the city. I +cautioned many persons, whom I saw walking or riding in an unsafe manner, +of the danger to which they exposed themselves; and thereby, I hope, +prevented an attack of the disease in many people. + + [89] Bibliotheca Medicinæ Practicæ, vol. ii. p. 93. and 387. + +It was from a conviction of the utility of low diet, gentle evacuations, +and of carefully shunning all the exciting causes which I have mentioned, +that I concealed, in no instance, from my patients the name of their +disease. This plainness, which was blamed by weak people, produced strict +obedience to my directions, and thereby restrained the progress of the +fever in many families, or rendered it, when taken, as mild as +inoculation does the small-pox. The opposite conduct of several +physicians, by preventing the above precautions, increased the mortality +of the disease, and, in some instances, contributed to the extinction of +whole families. + +I proceed now to make a few remarks upon the remedies recommended by +Doctors Kuhn and Stevens, and by the French physicians. The former were +bark, wine, laudanum, spices, the elixir of vitriol, and the cold bath. + +In every case in which I prescribed bark, it was offensive to the +stomach. In several tertians which attended the convalescence from a +common attack of the fever, I found it always unsuccessful, and once +hurtful. Mr. Willing took it for several weeks without effect. About half +a pint of a weak decoction of the bark produced, in Mr. Samuel Meredith, +a paroxysm of the fever, so violent as to require the loss of ten ounces +of blood to moderate it. Dr. Annan informed me that he was forced to +bleed one of his patients twice, after having given him a small quantity +of bark, to hasten his convalescence. + +It was not in this epidemic only that the bark was hurtful. Baron +Humboldt informed me, that Dr. Comoto had assured him, it hastened death +in every case in which it was given in the yellow fever of Vera Cruz. If, +in any instance, it was inoffensive, or did service, in our fever, I +suspect it must have acted upon the bowels as a purge. Dr. Sydenham says +the bark cured intermittents by this evacuation[90]; and Mr. Bruce says +it operated in the same way, when it cured the bilious fevers at Massuah. + + [90] Vol. i. p. 440. + +_Wine_ was nearly as disagreeable as the bark to the stomach, and equally +hurtful. I tried it in every form, and of every quality, but without +success. It was either rejected by the stomach, or produced in it a +burning sensation. I should suspect that I had been mistaken in my +complaints against wine, had I not since met with an account in Skenkius +of its having destroyed all who took it in the famous Hungarian fever, +which prevailed, with great mortality, over nearly every country in +Europe, about the middle of the 16th century[91]. Dr. Wade declares wine +to be "ill adapted to the fevers of Bengal, where the treatment has been +proper in other respects." + + [91] Omnes qui vini potione non abstinuerunt, interiere, adeo ut summa + spes salvationis in vini abstinentia collocata videreter. Lib. vi. + p. 847. + +_Laudanum_ has been called by Dr. Mosely "a fatal medicine" in the yellow +fever. In one of my patients, who took only fifteen drops of it, without +my advice, to ease a pain in his bowels, it produced a delirium, and +death in a few hours. I was much gratified in discovering that my +practice, with respect to the use of opium in this fever, accorded with +Dr. Wade's in the fever of Bengal. He tells us, "that it was mischievous +in almost every instance, even in combination with antimonials." + +The _spices_ were hurtful in the first stage of the fever, and, when +sufficient evacuations had been used, they were seldom necessary in its +second. + +The _elixir of vitriol_ was, in general, offensive to the stomach. + +The _cold bath_ was useful in those cases where its sedative prevailed +over its stimulating effects. But this could not often happen, from the +suddenness and force, with which the water was thrown upon the body. In +two cases in which I prescribed it, it produced a gentle sweat, but it +did not save life. In a third it removed a delirium, and reduced the +pulse for a few minutes, in frequency and force, but this patient died. +The recommendation of it indiscriminately, in all cases, was extremely +improper. In that chilliness and tendency to fainting upon the least +motion, which attended the disease in some patients, it was an unsafe +remedy. I heard of a woman who was seized with delirium immediately after +using it, from which she never recovered; and of a man who died a few +minutes after he came out of a bathing tub. Had this remedy been the +exclusive antidote to the yellow fever, the mortality of the disease +would have been but little checked by it. Thousands must have perished +from the want of means to procure tubs, and of a suitable number of +attendants to apply the water, and to lift the patient in and out of bed. +The reason of our citizens ran before the learning of the friends of this +remedy, and long before it was abandoned by the physicians, it was +rejected as useless, or not attempted, because impracticable, by the good +sense of the city. It is to be lamented that the remedy of cold water has +suffered in its character by the manner in which it was advised. In +fevers of too much action, it reduces the morbid excitement of the +blood-vessels, provided it be _applied without force_, and for a +considerable time, to the body. It is in the jail fever, and in the +second stage of the yellow fever only, in which its stimulant and tonic +powers are proper. Dr. Jackson establishes this mode of using it, by +informing us, that when it did service, it "gave vigour and tone" to the +system[92]. + + [92] Fevers of Jamaica. + +A mode of practice which I formerly mentioned in this fever, consisted of +a union of the evacuating and tonic remedies. The physicians who adopted +this mode gave calomel by itself, in small doses, on the first or second +day of the fever, bled once or twice, in a sparing manner, and gave the +bark, wine, and laudanum, in large quantities, upon the first appearance +of a remission. After they began the use of these remedies purging was +omitted, or, if the bowels were moved, it was only by means of gentle +glysters. This practice, I shall say hereafter, was not much more +successful than that which was recommended by Dr. Kuhn and Dr. Stevens. +It resembled throwing water and oil at the same time upon a fire, in +order to extinguish it. + +The _French_ remedies were nitre and cremor tartar, in small doses, +centaury tea, camphor, and several other warm medicines; subacid drinks, +taken in large quantities, the warm bath, and moderate bleeding. + +After what has been said it must be obvious to the reader, that the nitre +and cremor tartar, in small doses, could do no good, and that camphor and +all cordial medicines must have done harm. The diluting subacid drinks, +which the French physicians gave in large quantities, were useful in +diluting and blunting the acrimony of the bile, and to this remedy, +assisted by occasional bleeding, I ascribe most of the cures which were +performed by those physicians. + +Those few persons in whom the _warm bath_ produced copious and universal +sweats recovered, but, in nearly all the cases which came under my +notice, it did harm. + +I come now to inquire into the comparative success of all the different +modes of practice which have been mentioned. + +I have already said that ten out of thirteen patients whom I treated with +bark, wine, and laudanum, and that three out of four, in whom I added the +cold bath to those remedies, died. Dr. Pennington informed me, that he +had lost all the patients (six in number) to whom he had given the above +medicines. Dr. Johnson assured me, with great concern, about two weeks +before he died, that he had not recovered a single patient by them. Whole +families were swept off where these medicines were used. But further, +most of those persons who received the seeds of the fever in the city, +and sickened in the country, or in the neighbouring towns, and who were +treated with tonic remedies, died. There was not a single cure performed +by them in New-York, where they were used in several sporadic cases with +every possible advantage. But why do I multiply proofs of their deadly +effects? The clamours of hundreds whose relations had perished by them, +and the fears of others, compelled those physicians who had been most +attached to them to lay them aside, or to prepare the way for them (as it +was called) by purging and bleeding. The bathing tub soon shared a worse +fate than bark, wine, and laudanum, and, long before the disease +disappeared, it was discarded by all the physicians in the city. + +In answer to these facts we are told, that Mr. Hamilton and his family +were cured by Dr. Stevens's remedies, and that Dr. Kuhn had administered +them with success in several instances. + +Upon these cures I shall insert the following judicious remarks from Dr. +Sydenham. "Success (says the doctor) is not a sufficient proof of the +excellency of a method of cure in acute diseases, since some are +recovered by the imprudent procedure of old women; but it is further +required, that the distemper should be _easily cured_, and yield +conformably to its _own_ nature[93]." And again, speaking of the cure of +the new fever of 1685, this incomparable physician observes, "If it be +objected that this fever frequently yields to a quite contrary method to +that which I have laid down, I answer, that the cure of a disease by a +method which is attended with success only _now_ and _then_, in a _few_ +instances, differs extremely from that practical method, the efficacy +whereof appears both from its recovering _greater numbers_, and all the +practical phenomena happening in the cure[94]." + + [93] Vol. ii. p. 254. + + [94] Vol, ii. p. 354. + +Far be it from me to deny that the depression of the system may not be +overcome by such stimuli as are more powerful than those which occasion +it. This has sometimes been demonstrated by the efficacy of bark, wine, +and laudanum, in the confluent and petechial small-pox; but even this +state of that disease yields more easily to blood-letting, or to +plentiful evacuations from the stomach and bowels, on the first or second +day of the eruptive fever. This I have often proved, by giving a large +dose of tartar emetic and calomel, as soon as I was satisfied from +circumstances, that my patient was infected with the small-pox. But the +depression produced by the yellow fever appears to be much greater than +that which occurs in the small-pox, and hence it more uniformly resisted +the most powerful tonic remedies. + +In one of my publications during the prevalence of the fever I asserted, +that the remedies of which I have given a history cured a greater +proportion than ninety-nine out of a hundred, of all who applied to me on +the first day of the disease, before the 15th day of September. I regret +that it is not in my power to furnish a list of them, for a majority of +them were poor people, whose names are still unknown to me. I was not +singular in this successful practice in the first appearance of the +disease. Dr. Pennington assured me on his death bed, that he had not lost +one, out of forty-eight patients whom he had treated agreeably to the +principles and practice I had recommended. Dr. Griffitts triumphed over +the disease in every part of the city, by the use of what were called the +new remedies. My former pupils spread, by their success, the reputation +of purging and bleeding, wherever they were called. Unhappily the +pleasure we derived from this success in the treatment of the disease, +was of short duration. Many circumstances contributed to lessen it, and +to revive the mortality of the fever. I shall briefly enumerate them. + +1. The distraction produced in the public mind, by the recommendation of +remedies, the opposites in every respect of purging and bleeding. + +2. The opinion which had been published by several physicians, and +inculcated by others, that we had other fevers in the city besides the +yellow fever. This produced a delay in many people in sending for a +physician, or in taking medicines, for two or three days, from a belief +that they had nothing but a cold, or a common fever. Some people were so +much deceived by this opinion, that they refused to send for physicians, +lest they should be infected by them with the yellow fever. In most of +the cases in which these delays took place, the disease proved mortal. + +To obviate a suspicion that I have laid more stress upon the fatal +influence of this error than is just, I shall here insert an extract of a +letter I received from Mr. John Connelly, one of the city committee, who +frequently left his brethren in the city hall, and spent many hours in +visiting and prescribing for the sick. "The publications (says he) of +some physicians, that there were but few persons infected with the yellow +fever, and that many were ill with colds and common remitting and fall +fevers, proved fatal to almost every family which was credulous enough to +believe them. That opinion slew its hundreds, if not its thousands, many +of whom did not send for a physician until they were in the last stage of +the disorder, and beyond the power of medicine." + +3. The interference of the friends of the stimulating system, in +dissuading patients from submitting to sufficient evacuations. + +4. The deceptions which were practised by some patients upon their +physicians, in their reports of the quantity of blood they had lost, or +of the quality and number of their evacuations by stool. + +5. The impracticability of procuring bleeders as soon as bleeding was +prescribed. Life in this disease, as in the apoplexy, frequently turned +upon that operation being performed within an _hour_. It was often +delayed, from the want of a bleeder, one or two days. + +6. The inability of physicians, from the number of their patients, and +from frequent indisposition, to visit the sick, at such times as was +necessary to watch the changes in their disease. + +7. The great accumulation and concentration of the miasmata in sick +rooms, from the continuance of the disease in the city, whereby the +system was exposed to a constant stimulus, and the effect of the +evacuations was thus defeated. + +8. The want of skill or fidelity in nurses to administer the medicines +properly; to persuade patients to drink frequently; also to supply them +with food or cordial drinks when required in the night. + +9. The great degrees of debility induced in the systems of many of the +people who were affected by the disease, from fatigue in attending their +relations or friends. + +10. The universal depression of mind, amounting in some instances to +despair, which affected many people. What medicine could act upon a +patient who awoke in the night, and saw through the broken and faint +light of a candle, no human creature, but a black nurse, perhaps asleep +in a distant corner of the room; and who heard no noise, but that of a +hearse conveying, perhaps, a neighbour or a friend to the grave? The +state of mind under which many were affected by the disease, is so well +described by the Rev. Dr. Smith, in the case of his wife, in a letter I +received from him in my sick room, two days after her death, that I hope +I shall be excused for inserting an extract from it. It forms a part of +the history of the disease. The letter was written in answer to a short +note of condolence which I sent to the doctor immediately after hearing +of Mrs. Smith's death. After some pathetic expressions of grief, he adds, +"The scene of her funeral, and some preceding circumstances, can never +depart from my mind. On our return from a visit to our daughter, whom we +had been striving to console on the death of Mrs. Keppele, who was long +familiar and dear to both, my dear wife, passing the burying-ground gate, +led me into the ground, viewed the graves of her two children, called the +old grave-digger, marked a spot for herself as close as possible to them +and the grave of Dr. Phineas Bond, whose memory she adored. Then, by the +side of the spot she had chosen, we found room and chose _mine_, pledging +ourselves to each other, and directing the grave-digger that this should +be the order of our interment. We returned to our house. Night +approached. I hoped my dear wife had gone to rest, as she had chosen, +since her return from nursing her daughter, to sleep in a chamber by +herself, through fear of infecting her grandchild and me. But it seems +she closed not her eyes; sitting with them fixed through her chamber +window on Mrs. Keppele's house, till about midnight she saw her hearse, +and followed it with her eyes as far as it could be seen. Two days +afterwards Mrs. Rodgers, her next only surviving intimate friend, was +carried past her window, and by no persuasion could I draw her from +thence, nor stop her sympathetic foreboding tears, so long as her eyes +could follow the funeral, which was through two squares, from Fourth to +Second-street, where the hearse disappeared." The doctor proceeds in +describing the distress of his wife. But pointed as his expressions are, +they do not convey the gloomy state of her mind with so much force as she +has done it herself in two letters to her niece, Mrs. Cadwallader, who +was then in the country. The one was dated the 9th, the other the 11th of +October. I shall insert a few extracts from each of them. + +October 9th. "It is not possible for me to pass the streets without +walking in a line with the dead, passing infected houses, and looking +into open graves. This has been the case for many weeks." "I don't know +what to write; my head is gone, and my heart is torn to pieces." "I +intreat you to have no fears on my account. I am in the hands of a just +and merciful God, and his will be done." + +October 11th. "Don't wonder that I am so low to-day. My heart is sunk +down within me." + +The next day this excellent woman sickened, and died on the 19th of the +same month. + +If in a person possessed naturally of uncommon equanimity and fortitude, +the distresses of our city produced such dejection of spirits, what must +have been their effect upon hundreds, who were not endowed with those +rare and extraordinary qualities of mind! Death in this, as well as in +many other cases in which medicine had done its duty, appeared to be the +inevitable consequence of the total abstraction of the energy of the mind +in restoring the natural motions of life. + +Under all the circumstances which have been mentioned, which opposed the +system of depletion in the cure of this fever, it was still far more +successful than any other mode of cure that had been pursued before in +the United States, or in the West-Indies. + +Three out of four died of the disease in Jamaica, under the care of Dr. +Hume. + +Dr. Blane considers it as one of the "most mortal" of diseases, and Dr. +Jackson places a more successful mode of treating it among the subjects +which will admit of "innovation" in medicine. + +After the 15th of September, my success was much limited, compared with +what it had been before that time. But at no period of the disease did I +lose more than one in twenty of those whom I saw on the first day, and +attended regularly through every stage of the fever, provided they had +not been previously worn down by attending the sick. + +The following statement, which will admit of being corrected, if it be +inaccurate, will, I hope, establish the truth of the above assertions. + +About one half of the families whom I have attended for many years, left +the city. Of those who remained, many were affected by the disease. Out +of the whole of them, after I had adopted my second mode of practice, I +lost but five heads of families, and about a dozen servants and children. +In no instance did I lose both heads of the same family. My success in +these cases was owing to two causes: 1st, To the credit my former +patients gave to my public declaration, that we had only _one_ fever in +the city: hence they applied on the _first_ day, and sometimes on the +_first_ hour of their indisposition; and 2dly, To the numerous pledges +many of them had seen of the safety and efficacy of copious +blood-letting, by my advice, in other diseases: hence my prescription of +that necessary remedy was always obeyed in its utmost extent. Of the few +adults whom I lost, among my former patients, two of them were old +people, two took laudanum, without my knowledge, and one refused to take +medicine of any kind; all the rest had been worn down by previous +fatigue. + +I have before said that a great number of the blacks were my patients. Of +these not one died under my care. This uniform success, among those +people, was not owing altogether to the mildness of the disease, for I +shall say presently, that a great proportion of a given number died, +under other modes of practice. + +In speaking of the comparative effects of purging and bleeding, it may +not be amiss to repeat, that not one pregnant woman, to whom I prescribed +them, died, or suffered abortion. Where the tonic remedies were used, +abortion or death, and, in many instances, both, were nearly universal. + +Many whole families, consisting of five, six, and, in three instances, of +nine members, were recovered by plentiful purging and bleeding. I could +swell this work by publishing a list of those families; but I take more +pleasure in adding, that I was not singular in my success in the use of +the above remedies. They were prescribed with great advantage by many of +the physicians of the city, who had for a while given tonic medicines +without effect. I shall not mention the names of any of the physicians +who _totally_ renounced those medicines, lest I should give offence by +not mentioning them all. Many large families were cured by some of them, +after they adopted and prescribed copious purging and blood-letting. One +of them cured ten in the family of Mr. Robert Haydock, by means of those +remedies. In one of that family, the disease came on with a vomiting of +black bile. + +But the use of the new remedies was not directed finally by the +physicians alone. The clergy, the apothecaries, many private citizens, +several intelligent women, and two black men, prescribed them with great +success. Nay more, many persons prescribed them to themselves, and, as I +shall say hereafter, with a success that was unequalled by any of the +regular or irregular practitioners in the city. + +It was owing to the almost universal use of purging and bleeding, that +the mortality of the disease diminished, in proportion as the number of +persons who were affected by it increased, about the middle of October. +It was scarcely double of what it was in the middle of September, and yet +six times the number of persons were probably at that time confined by +it. + +The success of copious purging and bleeding was not confined to the city +of Philadelphia. Several persons, who were infected in town, and sickened +in the country, were cured by them. + +Could a comparison be made of the number of patients who died of the +yellow fever in 1793, after having been plentifully bled and purged, with +those who died of the same disease in the years 1699, 1741, 1747, and +1762, I am persuaded that the proportion would be very small in the year +1793, compared with the former years[95]. Including all who died under +every mode of treatment, I suspect the mortality to be less, in +proportion to the population of the city, and the number of persons who +were affected, than it was in any of the other years that have been +mentioned. + + [95] It appears from one of Mr. Norris's letters, dated the 9th of + November, O. S. that there died 220 persons, in the year 1699, + with the yellow fever. Between 80 and 90 of them, he says, + belonged to the society of friends. The city, at this time, + probably, did not contain more than 2 or 3000 people, many of + whom, it is probable, fled from the disease. + +Not less than 6000 of the inhabitants of Philadelphia probably owe their +lives to purging and bleeding, during the autumn. + +I proceed with reluctance to inquire into the comparative success of the +French practice. It would not be difficult to decide upon it from many +facts that came under my notice in the city; but I shall rest its merit +wholly upon the returns of the number of deaths at Bush-hill. This +hospital, after the 22d of September, was put under the care of a French +physician, who was assisted by one of the physicians of the city. The +hospital was in a pleasant and airy situation; it was provided with all +the necessaries and comforts for sick people that humanity could invent, +or liberality supply. The attendants were devoted to their duty; and +cleanliness and order pervaded every room in the house. The reputation of +this hospital, and of the French physician, drew patients to it in the +early stage of the disease. Of this I have been assured in a letter from +Dr. Annan, who was appointed to examine and give orders of admission +into the hospital, to such of the poor of the district of Southwark, as +could not be taken care of in their own houses. Mr. Olden has likewise +informed me, that most of the patients who were sent to the hospital by +the city committee (of which he was a member) were in the first stage of +the fever. With all these advantages, the deaths between the 22d of +September and the 6th of November, amounted to 448 out of 807 patients +who were admitted into the hospital within that time. Three fourths of +all the blacks (nearly 20) who were patients in this hospital died. A +list of the medicines prescribed there may be seen in the minutes of the +proceedings of the city committee. Calomel and jalap are not among them. +_Moderate_ bleeding and purging with glauber's salts, I have been +informed, were used in some cases by the physicians of this hospital. The +proportion of deaths to the recoveries, as it appears in the minutes of +the committee from whence the above report is taken, is truly melancholy! +I hasten from it therefore to a part of this work, to which I have looked +with pleasure, ever since I sat down to compose it. + +I have said that the clergy, the apothecaries, and many other persons who +were uninstructed in the principles of medicine, prescribed purging and +bleeding with great success in this disease. Necessity gave rise to this +undisciplined sect of practitioners, for they came forward to supply the +places of the regular bred physicians who were sick or dead. I shall +mention the names of a few of those persons who distinguished themselves +as volunteers in this new work of humanity. The late Rev. Mr. Fleming, +one of the ministers of the catholic church, carried the purging powders +in his pocket, and gave them to his poor parishioners with great success. +He even became the advocate of the new remedies. In a conversation I had +with him, on the 22d of September, he informed me, that he had advised +four of our physicians, whom he met a day or two before, "to renounce the +pride of science, and to adopt the new mode of practice, for that he had +witnessed its good effects in many cases." Mr. John Keihmle, a German +apothecary, has assured me, that out of 314 patients whom he visited, and +187 for whom he prescribed from the reports of their friends, he lost but +47 (which is nearly but one in eleven), and that he treated them all +agreeably to the method which I had recommended. The Rev. Mr. Schmidt, +one of the ministers of the Lutheran church, was cured by him. I have +before mentioned an instance of the judgment of Mr. Connelly, and of his +zeal in visiting and prescribing for the sick. His remedies were bleeding +and purging. He, moreover, bore a constant and useful testimony against +bark, wine, laudanum, and the warm bath[96]. Mrs. Paxton, in +Carter's-alley, and Mrs. Evans, the wife of Mr. John Evans, in +Second-street, were indefatigable; the one in distributing mercurial +purges composed by herself, and the other in urging the necessity of +_copious_ bleeding and purging among her friends and neighbours, as the +only safe remedies for the fever. These worthy women were the means of +saving many lives[97]. Absalom Jones and Richard Allen, two black men, +spent all the intervals of time, in which they were not employed in +burying the dead, in visiting the poor who were sick, and in bleeding and +purging them, agreeably to the directions which had been printed in all +the newspapers. Their success was unparalleled by what is called regular +practice. This encomium upon the practice of the blacks will not surprise +the reader, when I add that they had no fear of putrefaction in the +fluids, nor of the calumnies of a body of fellow-citizens in the republic +of medicine to deter them from plentiful purging and bleeding. They had, +besides, no more patients than they were able to visit two or three times +a day. But great as their success was, it was exceeded by those persons +who, in despair of procuring medical aid of any kind, purged and bled +themselves. This palm of superior success will not be withheld from those +people when I explain the causes of it. It was owing to their _early_ use +of the proper remedies, and to their being guided in the repetition of +them, by the continuance of a tense pulse, or of pain and fever. A day, +an afternoon, and even an hour, were not lost by these people in waiting +for the visit of a physician, who was often detained from them by +sickness, or by new and unexpected engagements, by which means the +precious moment for using the remedies with effect passed irrevocably +away. I have stated these facts from faithful inquiries, and numerous +observations. I could mention the names and families of many persons who +thus cured themselves. One person only shall be mentioned, who has shown +by her conduct what reason is capable of doing when it is forced to act +for itself. Mrs. Long, a widow, after having been twice unsuccessful in +her attempts to procure a physician, undertook at last to cure herself. +She took several of the mercurial purges, agreeably to the printed +directions, and had herself bled _seven_ times in the course of five or +six days. The indication for repeating the bleeding was the continuance +of the pain in her head. Her recovery was rapid and complete. The history +of it was communicated to me by herself, with great gratitude, in my own +house, during my second confinement with the fever. To these accounts of +persons who cured themselves in the city, I could add many others, of +citizens who sickened in the country, and who cured themselves by +plentiful bleeding and purging, without the attendance of a physician. + + [96] In the letter before quoted, from Mr. Connelly, he expresses his + opinion of those four medicines in the following words: "Laudanum, + bark, and wine have put a period to the existence of some, where + the fever has been apparently broken, and the patients in a fair + way of recovery; a single dose of laudanum has hurried them + suddenly into eternity. I have visited a few patients where the + hot bath was used, and am convinced that it only tended to weaken + and relax the system, without producing any good effect." + + [97] The yellow fever prevailed at the Caraccos, in South-America, in + October, 1793, with great mortality, more especially among the + Spanish troops. Nearly all died who were attended by physicians. + Recourse was finally had to the old women, who were successful in + almost every case to which they were called. Their remedies were a + liquor called _narencado_ (a species of lemonade) and a tea made + of a root called _fistula_. With these drinks they drenched their + patients for the first two or three days. They induced plentiful + sweats, and, probably, after blunting, discharged the bile from + the bowels. I received this information from an American + gentleman, who had been cured, by one of those Amazons in + medicine, in the above way. + +From a short review of these facts, reason and humanity awake from their +long repose in medicine, and unite in proclaiming, that it is time to +take the cure of pestilential epidemics out of the hands of physicians, +and to place it in the hands of the people. Let not the reader startle at +this proposition. I shall give the following reasons for it. + +1. In consequence of these diseases affecting a great number of people at +one time, it has always been, and always will be impossible, for them +_all_ to have the benefit of medical aid, more especially as the +proportion of physicians to the number of sick, is generally diminished +upon these occasions, by desertion, sickness, and death. + +2. The safety of committing to the people the cure of pestilential +fevers, particularly the yellow fever and the plague, is established by +the simplicity and uniformity of their causes, and of their remedies. +However diversified they may be in their symptoms, the system, in both +diseases, is generally under a state of undue excitement or great +depression, and in most cases requires the abstraction of stimulus in a +greater or less degree, or in a sudden or gradual manner. There can never +be any danger of the people injuring themselves by mistaking any other +disease for an _epidemic_ yellow fever or plague, for no other febrile +disease can prevail with them. It was probably to prevent this mistake, +that the Benevolent Father of mankind, who has permitted no evil to exist +which does not carry its antidote along with it, originally imposed that +law upon all great and mortal epidemics. + +3. The history of the yellow fever in the West-Indies proves the +advantage of trusting patients to their own judgment. Dr. Lind has +remarked, that a greater proportion of sailors who had no physicians +recovered from that fever, than of those who had the best medical +assistance. The fresh air of the deck of a ship, a purge of salt water, +and the free use of cold water, probably triumphed here over the cordial +juleps of physicians. + +4. By committing the cure of this and other pestilential epidemics to the +people, all those circumstances which prevented the universal success of +purging and bleeding, in this disease, will have no operation. The fever +will be mild in most cases, for all will prepare themselves to receive +it, by a vegetable diet, and by moderate evacuations. The remedies will +be used the _moment_ the disease is felt, or even seen, and its violence +and danger will thereby be obviated. There will then be no disputes among +physicians, about the nature of the disease, to distract the public +mind, for they will seldom be consulted in it. None will suffer from +chronic debility induced by previous fatigue in attending the sick, nor +from the want of nurses, for few will be so ill as to require them, and +there will be no "foreboding" fears of death, or despair of recovery, to +invite an attack of the disease, or to ensure its mortality. + +The small-pox was once as fatal as the yellow fever and the plague. It +has since yielded as universally to a vegetable diet and evacuations, in +the hands of apothecaries, the clergy, and even of the good women, as it +did in the hands of doctors of physic. + +They have narrow conceptions, not only of the Divine goodness, but of the +gradual progress of human knowledge, who suppose that all pestilential +diseases shall not, like the small-pox, sooner or later cease to be the +scourge and terror of mankind. + +For a long while, air, water, and even the light of the sun, were dealt +out by physicians to their patients with a sparing hand. They possessed, +for several centuries, the same monopoly of many artificial remedies. But +a new order of things is rising in medicine. Air, water, and light are +taken without the advice of a physician, and bark and laudanum are now +prescribed every where by nurses and mistresses of families, with safety +and advantage. Human reason cannot be stationary upon these subjects. The +time must and will come, when, in addition to the above remedies, the +general use of calomel, jalap, and the lancet, shall be considered among +the most essential articles of the knowledge and rights of man. + +It is no more necessary that a patient should be ignorant of the medicine +he takes, to be cured by it, than that the business of government should +be conducted with secrecy, in order to insure obedience to just laws. +Much less is it necessary that the means of life should be prescribed in +a dead language, or dictated with the solemn pomp of a necromancer. The +effects of imposture, in every thing, are like the artificial health +produced by the use of ardent spirits. Its vigour is temporary, and is +always followed by misery and death. + +The belief that the yellow fever and the plague are necessarily mortal, +is as much the effect of a superstitious torpor in the understanding, as +the ancient belief that the epilepsy was a supernatural disease, and that +it was an offence against Heaven to attempt to cure it. It is partly from +the influence of this torpor in the minds of some people, that the +numerous cures of the yellow fever, performed by a few simple remedies, +were said to be of _other_ diseases. It is necessary, for the conviction +of such persons, that patients should always _die_ of that, and other +dangerous diseases, to prove that they have been affected by them. + +The repairs which our world is destined to undergo will be incomplete, +until pestilential fevers cease to be numbered among the widest outlets +of human life. + +There are many things which are now familiar to women and children, which +were known a century ago only to a few men who lived in closets, and were +distinguished by the name of philosophers. + +We teach a hundred things in our schools less useful, and many things +more difficult, than the knowledge that would be necessary to cure a +yellow fever or the plague. + +In my attempts to teach the citizens of Philadelphia, by my different +publications, the method of curing themselves of yellow fever, I observed +no difficulty in their apprehending every thing that was addressed to +them, except what related to the different states of the pulse. All the +knowledge that is necessary to discover when blood-letting is proper, +might be taught to a boy or girl of twelve years old in a few hours. I +taught it in less time to several persons, during the prevalence of the +epidemic. + +I would as soon believe that ratafia was intended by the Author of Nature +to be the only drink of man, instead of water, as believe that the +knowledge of what relates to the health and lives of a _whole_ city, or +nation, should be confined to one, and that a small or a privileged order +of men. But what have physicians, what have universities or medical +societies done, after the labours and studies of many centuries, towards +lessening the mortality of pestilential fevers? They have either copied +or contradicted each other, in all their publications. Plagues and +malignant fevers are still leagued with war and famine, in their ravages +upon human life. + +To prevent the formation and mortality of this fever, it will be +necessary, when it makes its appearance in a city or country, to publish +an account of those symptoms which I have called the _precursors_ of the +disease, and to exhort the people, as soon as they feel those symptoms, +to have immediate recourse to the remedies of purging or bleeding. The +danger of delay in using one, or both these remedies, should be +inculcated in the strongest terms, for the disease, like Time, has a lock +on its forehead, but is bald behind. The bite of a rattle-snake is seldom +fatal, because the medicines which cure it are applied or taken as soon +as the poison comes in contact with the blood. There is less danger to be +apprehended from the yellow fever than from the poison of the snake, +provided the remedies for it are administered within a few hours after it +is excited into action. + +Let persons who are subject to chronic pains, or diseases of any kind, be +advised not to be deceived by them. Every pain, at such a time, is the +beginning of the disease; for it always acts first on debilitated parts +of the body. From an ignorance of this law of epidemics many persons, by +delaying their applications for help, perished with our fever. + +Let nature be trusted into no case whatever, to cure this disease; and +let no attack of it, however light, be treated with neglect. Death as +certainly performs his work, when he steals on the system in the form of +a mild intermittent, as he does, when he comes on with the symptoms of +apoplexy, or a black vomiting. + +Cleanliness, in houses and dress, cannot be too often inculcated during +the prevalence of a yellow fever. + +Let it not be supposed, that I mean that the history which I have given +of the method of cure of this epidemic, should be applied, in all its +parts, to the yellow fevers which may appear hereafter in the United +States, or which exist at all times in the West-India islands. Season and +climate vary this, as well as all other diseases. Bark and wine, so fatal +in this, may be proper in a future yellow fever. But in the climate of +the United States, I believe it will seldom appear with such symptoms of +prostration and weakness, as not to require, in its first stage, +evacuations of some kind. + +The only inquiry, when the disease makes its appearance, should be, from +what part of the body these evacuations should be procured; the order +which should be pursued in obtaining them; and the quantity of each of +the matters to be discharged, which should be withdrawn at a time. + +Thus far did I venture, from my theory of the disease, and from the +authorities of Dr. Hillary and Dr. Mosely, to decide in favour of +evacuations in the yellow fever; but Dr. Wade, and Mr. Chisholm again +support me by their practice in the fevers of the East and West-Indies. +They both gave strong mercurial purges, and bled in some cases. Dr. Wade +confirmed, by his practice, the advantage of _gradually_ abstracting +stimulus from the system. He never drew blood, even in the most +inflammatory cases, until he had first discharged the contents of the +bowels. The doctor has further established the efficacy of a vegetable +diet and of water as a drink, as the best means of preventing the disease +in a hot climate. + +The manner in which the miasmata that produce the plague act upon the +system is so much like that which has been described in the yellow fever, +and the accounts of the efficacy of low diet, in preparing the body for +its reception, and of copious bleeding, cold air, and cold water, in +curing it, are so similar, that all the directions which relate to +preventing, mitigating, or curing the yellow fever may be applied to it. +The fluids in the plague show a greater tendency to the skin, than they +do in the yellow fever. Perhaps, upon this account, the early use of +powerful sudorifics may be more proper in the former than in the latter +disease. From the influence of early purging and bleeding in promoting +sweats in the yellow fever, there can be little doubt but the efforts of +nature to unload the system in the plague, through the channel of the +pores, might be accelerated by the early use of the same remedies. One +thing, with respect to the plague, is certain, that its cure depends upon +the abstraction of stimulus, either by means of plentiful sweats, or of +purulent matter from external sores. Perhaps the efficacy of these +remedies depends wholly upon their elevating the system from its +prostrated state in a _gradual_ manner. If this be the case, those +natural discharges might be easily and effectually imitated by small and +repeated bleedings. + +To correspond in quantity with the discharge from the skin, blood-letting +in the plague, when indicated, should be copious. A profuse sweat, +continued for twenty-four hours, cannot fail of wasting many pounds of +the fluids of the body. This was the duration of the critical sweats in +the famous plague which was known by the name of the English sweating +sickness, and which made its appearance in the army of Henry VII. in +Milford-Haven in Wales, and spread from thence through every part of the +kingdom. + +The principles which lead to the prevention and cure of the yellow fever +and the plague, apply with equal force to the mitigation of the measles, +and to the prevention or mitigation of the scarlatina anginosa, the +dysentery, and the inflammatory jail fever. I have remarked +elsewhere[98], that a previous vegetable diet lessened the violence and +danger of the measles. Dr. Sims taught me, many years ago, to prevent or +mitigate the scarlatina anginosa, by means of gentle purges, after +children are infected by it[99]. Purges of salts have in many instances +preserved whole families and neighbourhoods from the dysentery, where +they have been exposed to its remote cause. During the late American war, +an emetic seldom failed of preventing an attack of the hospital fever, +when given in its forming state[100]. I have had no experience of the +effects of previous evacuations in abating the violence, or preventing +the mortality of the malignant sore throat, but I can have no doubt of +their efficacy, from the sameness of the state of the system in that +disease, as in other malignant fevers. The debility induced in it is from +depression, and the supposed symptoms of putrefaction are nothing but the +disguised effects of a sudden and violent pressure of an inflammatory +stimulus upon the arterial system. + + [98] Vol. ii. + + [99] Medical Memoirs, vol. i. + + [100] Vol. i. + +With these observations I close the history of the rise, progress, +symptoms, and treatment of the bilious remitting yellow fever, which +appeared in Philadelphia in the year 1793. My principal aim has been to +revive and apply to it the principles and practice of Dr. Sydenham, and, +however coldly those principles and that practice may be received by some +physicians of the present day, I am convinced that experience, in all +ages and in all countries, will vouch for their truth and utility. + + + A NARRATIVE + + OF THE + + _STATE OF THE BODY AND MIND_ + + OF THE AUTHOR, + + DURING THE PREVALENCE OF THE FEVER. + +Narratives of escapes from great dangers of shipwreck, war, captivity, +and famine have always formed an interesting part of the history of the +body and mind of man. But there are deliverances from equal dangers which +have hitherto passed unnoticed; I mean from pestilential fevers. I shall +briefly describe the state of my body and mind during my intercourse with +the sick in the epidemic of 1793. The account will throw additional light +upon the disease, and probably illustrate some of the laws of the animal +economy. It will, moreover, serve to furnish a lesson to all who may be +placed in similar circumstances to commit their lives, without fear, to +the protection of that Being, who is able to save to the uttermost, not +only from future, but from present evil. + +Some time before the fever made its appearance, my wife and children went +into the state of New-Jersey, where they had long been in the habit of +spending the summer months. My family, about the 25th of August, +consisted of my mother, a sister, who was on a visit to me, a black +servant man, and a mulatto boy. I had five pupils, viz. Warner Washington +and Edward Fisher, of Virginia, John Alston, of South-Carolina, and John +Redman Coxe (grandson to Dr. Redman) and John Stall, both of this city. +They all crowded around me upon the sudden increase of business, and with +one heart devoted themselves to my service, and to the cause of humanity. + +The credit which the new mode of treating the disease acquired, in all +parts of the city, produced an immense influx of patients to me from all +quarters. My pupils were constantly employed; at first in putting up +purging powders, but, after a while, only in bleeding and visiting the +sick. + +Between the 8th and the 15th of September I visited and prescribed for +between a hundred and a hundred and twenty patients a day. Several of my +pupils visited a fourth or fifth part of that number. For a while we +refused no calls. In the short intervals of business, which I spent at +my meals, my house was filled with patients, chiefly the poor, waiting +for advice. For many weeks I seldom ate without prescribing for numbers +as I sat at my table. To assist me at these hours, as well as in the +night, Mr. Stall, Mr. Fisher, and Mr. Coxe accepted of rooms in my house, +and became members of my family. Their labours now had no remission. + +Immediately after I adopted the antiphlogistic mode of treating the +disease, I altered my manner of living. I left off drinking wine and malt +liquors. The good effects of the disuse of these liquors helped to +confirm me in the theory I had adopted of the disease. A troublesome +head-ach, which I had occasionally felt, and which excited a constant +apprehension that I was taking the fever, now suddenly left me. I +likewise, at this time, left off eating solid animal food, and lived +wholly, but sparingly, upon weak broth, potatoes, raisins, coffee, and +bread and butter. + +From my constant exposure to the sources of the disease, my body became +highly impregnated with miasmata. My eyes were yellow, and sometimes a +yellowness was perceptible in my face. My pulse was preternaturally +quick, and I had profuse sweats every night. These sweats were so +offensive, as to oblige me to draw the bed-clothes close to my neck, to +defend myself from their smell. They lost their f[oe]tor entirely, upon +my leaving off the use of broth, and living entirely upon milk and +vegetables. But my nights were rendered disagreeable, not only by these +sweats, but by the want of my usual sleep, produced in part by the +frequent knocking at my door, and in part by anxiety of mind, and the +stimulus of the miasmata upon my system. I went to bed in conformity to +habit only, for it ceased to afford me rest or refreshment. When it was +evening I wished for morning; and when it was morning, the prospect of +the labours of the day, at which I often shuddered, caused me to wish for +the return of evening. The degrees of my anxiety may be easily conceived +when I add, that I had at one time upwards of thirty heads of families +under my care; among these were Mr. Josiah Coates, the father of eight, +and Mr. Benjamin Scull and Mr. John Morell, both fathers of ten children. +They were all in imminent danger; but it pleased God to make me the +instrument of saving each of their lives. I rose at six o'clock, and +generally found a number of persons waiting for advice in my shop or +parlour. Hitherto the success of my practice gave a tone to my mind, +which imparted preternatural vigour to my body. It was meat and drink to +me to fulfil the duties I owed to my fellow-citizens, in this time of +great and universal distress. From a hope that I might escape the +disease, by avoiding every thing that could excite it into action, I +carefully avoided the heat of the sun, and the coldness of the evening +air. I likewise avoided yielding to every thing that should raise or +depress my passions. But, at such a time, the events which influence the +state of the body and mind are no more under our command than the winds +or weather. On the evening of the 14th of September, after eight o'clock, +I visited the son of Mrs. Berriman, near the Swedes's church, who had +sent for me early in the morning. I found him very ill. He had been bled +in the forenoon, by my advice, but his pulse indicated a second bleeding. +It would have been difficult to procure a bleeder at that late hour. I +therefore bled him myself. Heated by this act, and debilitated by the +labours of the day, I rode home in the evening air. During the ensuing +night I was much indisposed. I rose, notwithstanding, at my usual hour. +At eight o'clock I lost ten ounces of blood, and immediately afterwards +got into my chair, and visited between forty and fifty patients before +dinner. At the house of one of them I was forced to lie down a few +minutes. In the course of this morning's labours my mind was suddenly +thrown off its pivots, by the last look, and the pathetic cries, of a +friend for help, who was dying under the care of a French physician. I +came home about two o'clock, and was seized, immediately afterwards, with +a chilly fit and a high fever. I took a dose of the mercurial medicine, +and went to bed. In the evening I took a second purging powder, and lost +ten ounces more of blood. The next morning I bathed my face, hands, and +feet in cold water for some time. I drank plentifully, during the day and +night, of weak hyson tea, and of water, in which currant jelly had been +dissolved. At eight o'clock I was so well as to admit persons who came +for advice into my room, and to receive reports from my pupils of the +state of as many of my patients as they were able to visit; for, +unfortunately, they were not able to visit them all (with their own) in +due time; by which means several died. The next day I came down stairs, +and prescribed in my parlour for not less than a hundred people. On the +19th of the same month, I resumed my labours, but in great weakness. It +was with difficulty that I ascended a pair of stairs, by the help of a +banister. A slow fever, attended with irregular chills, and a troublesome +cough, hung constantly upon me. The fever discovered itself in the heat +of my hands, which my patients often told me were warmer than their own. +The breath and exhalations from the sick now began to affect me, in +small and infected rooms, in the most sensible manner. On the morning of +the 4th of October I suddenly sunk down, in a sick room, upon a bed, with +a giddiness in my head. It continued for a few minutes, and was succeeded +by a fever, which confined me to my house the remaining part of the day. + +Every moment in the intervals of my visits to the sick was employed in +prescribing, in my own house, for the poor, or in sending answers to +messages from my patients; time was now too precious to be spent in +counting the number of persons who called upon me for advice. From +circumstances I believe it was frequently 150, and seldom less than 50 in +a day, for five or six weeks. The evening did not bring with it the least +relaxation from my labours. I received letters every day from the +country, and from distant parts of the union, containing inquiries into +the mode of treating the disease, and after the health and lives of +persons who had remained in the city. The business of every evening was +to answer these letters, also to write to my family. These employments, +by affording a fresh current to my thoughts, kept me from dwelling on the +gloomy scenes of the day. After these duties were performed, I copied +into my note book all the observations I had collected during the day, +and which I had marked with a pencil in my pocket-book in sick rooms, or +in my carriage. To these constant labours of body and mind were added +distresses from a variety of causes. Having found myself unable to comply +with the numerous applications that were made to me, I was obliged to +refuse many every day. My sister counted forty-seven in one forenoon +before eleven o'clock. Many of them left my door with tears, but they did +not feel more distress than I did from refusing to follow them. Sympathy, +when it vents itself in acts of humanity, affords pleasure, and +contributes to health; but the reflux of pity, like anger, gives pain, +and disorders the body. In riding through the streets, I was often forced +to resist the entreaties of parents imploring a visit to their children, +or of children to their parents. I recollect, and even _yet_ with pain, +that I tore myself at one time from five persons in Moravian-alley, who +attempted to stop me, by suddenly whipping my horse, and driving my chair +as speedily as possible beyond the reach of their cries. + +The solicitude of the friends of the sick for help may further be +conceived of, when I add, that the most extravagant compensations were +sometimes offered for medical services, and, in one instance, for only a +single visit. I had no merit in refusing these offers, and I have +introduced an account of them only to inform such physicians as may +hereafter be thrown into a similar situation, that I was favoured with an +exemption from the fear of death, in proportion as I subdued every +selfish feeling, and laboured exclusively for the benefit of others. In +every instance in which I was forced to refuse these pathetic and earnest +applications, my distress was heightened by the fear that the persons, +whom I was unable to visit, would fall into improper hands, and perish by +the use of bark, wine, and laudanum. + +But I had other afflictions besides the distress which arose from the +abortive sympathy which I have described. On the 11th of September, my +ingenious pupil, Mr. Washington, fell a victim to his humanity. He had +taken lodgings in the country, where he sickened with the disease. Having +been almost uniformly successful in curing others, he made light of his +fever, and concealed the knowledge of his danger from me, until the day +before he died. On the 18th of September Mr. Stall sickened in my house. +A delirium attended his fever from the first hour it affected him. He +refused, and even resisted force when used to compel him to take +medicine. He died on the 23d of September[101]. Scarcely had I recovered +from the shock of the death of this amiable youth, when I was called to +weep for a third pupil, Mr. Alston, who died in my neighbourhood the next +day. He had worn himself down, before his sickness, by uncommon exertions +in visiting, bleeding, and even sitting up with sick people. At this time +Mr. Fisher was ill in my house. On the 26th of the month, at 12 o'clock, +Mr. Coxe, my only assistant, was seized with the fever, and went to his +grandfather's. I followed him with a look, which I feared would be the +last in my house. At two o'clock my sister, who had complained for +several days, yielded to the disease, and retired to her bed. My mother +followed her, much indisposed, early in the evening. My black servant man +had been confined with the fever for several days, and had on that day, +for the first time, quitted his bed. My little mulatto boy, of eleven +years old, was the only person in my family who was able to afford me the +least assistance. At eight o'clock in the evening I finished the business +of the day. A solemn stillness at that time pervaded the streets. In vain +did I strive to forget my melancholy situation by answering letters, and +by putting up medicines, to be distributed next day among my patients. My +faithful black man crept to my door, and at my request sat down by the +fire, but he added, by his silence and dullness, to the gloom which +suddenly overpowered every faculty of my mind. + + [101] This accomplished youth had made great attainments in his + profession. He possessed, with an uncommon genius for science, + talents for music, painting, and poetry. The following copy of an + unfinished letter to his father (who had left the city) was found + among his papers after his death. It shows that the qualities of + his heart were equal to those of his head. + + "_Philadelphia, September 15, 1793._ + + "MY DEAR FATHER, + + "I take every moment I have to spare to write to you, which is + not many; but you must excuse me, as I am doing good to my + fellow-creatures. At this time, every moment I spend in idleness + might probably cost a life. The sickness increases every day, but + most of those who die, die for want of good attendance. We cure + all we are called to on the first day, who are well attended, but + so many doctors are sick, the poor creatures are glad to get a + doctor's servant." + +On the first day of October, at two o'clock in the afternoon, my sister +died. I got into my carriage within an hour after she expired, and spent +the afternoon in visiting patients. According as a sense of duty, or as +grief has predominated in my mind, I have approved, and disapproved of +this act, ever since. She had borne a share in my labours. She had been +my nurse in sickness, and my casuist in my choice of duties. My whole +heart reposed itself in her friendship. Upon being invited to a friend's +house in the country, when the disease made its appearance in the city, +she declined accepting the invitation, and gave as a reason for so doing, +that I might probably require her services in case of my taking the +disease, and that, if she were sure of dying, she would remain with me, +provided that, by her death, she could save my life. From this time I +declined in health and strength. All motion became painful to me. My +appetite began to fail. My night sweats continued. My short and imperfect +sleep was disturbed by distressing or frightful dreams. The scenes of +them were derived altogether from sick rooms and grave-yards. I concealed +my sorrows as much as possible from my patients; but when alone, the +retrospect of what was past, and the prospect of what was before me, the +termination of which was invisible, often filled my soul with the most +poignant anguish. I wept frequently when retired from the public eye, but +I did not weep over the lost members of my family alone. I beheld or +heard every day of the deaths of citizens, useful in public, or amiable +in private life. It was my misfortune to lose as patients the Rev. Mr. +Fleming and Mr. Graesel, both exhausted by their labours of piety and +love among the poor, before they sickened with the disease. I saw the +last struggles of departing life in Mr. Powel, and deplored, in his +death, an upright and faithful servant of the public, as well as a +sincere and affectionate friend. Often did I mourn over persons who had, +by the most unparalleled exertions, saved their friends and families from +the grave, at the expence of their own lives. Many of these martyrs to +humanity were in humble stations. Among the members of my profession, +with whom I had been most intimately connected, I had daily cause of +grief and distress. I saw the great and expanded mind of Dr. Pennington, +shattered by delirium, just before he died. He was to me dear and +beloved, like a younger brother. He was, moreover, a Joab in the contest +with the disease. Philadelphia must long deplore the premature death of +this excellent physician. Had he lived a few years longer, he would have +filled an immense space in the republic of medicine[102]. It was my +affliction to see my friend Dr. John Morris breathe his last, and to hear +the first effusions of the most pathetic grief from his mother, as she +bursted from the room in which he died. But I had distress from the +sickness, as well as the deaths of my brethren in physic. My worthy +friends, Dr. Griffitts, Dr. Say, and Dr. Mease, were suspended by a +thread over the grave, nearly at the same time. Heaven, in mercy to me, +as well as in kindness to the public and their friends, preserved their +lives. Had they died, the measure of my sorrows would have been complete. + + [102] Before he finished his studies in medicine, he published a volume + of ingenious and patriotic "Chemical and Economical Essays, + designed to illustrate the connection between the theory and + practice of chemistry, and the application of that science to + some of the arts and manufactures of the United States of + America." + +I have said before, that I early left off drinking wine; but I used it in +another way. I carried a little of it in a vial in my pocket, and when I +felt myself fainty, after coming out of a sick room, or after a long +ride, I kept about a table spoonful of it in my mouth for half a minute, +or longer, without swallowing it. So weak and excitable was my system, +that this small quantity of wine refreshed and invigorated me as much as +half a pint would have done at any other time. The only difference was, +that the vigour I derived from the wine in the former, was of shorter +duration than when taken in the latter way. + +For the first two weeks after I visited patients in the yellow fever, I +carried a rag wetted with vinegar, and smelled it occasionally in sick +rooms: but after I saw and felt the signs of the universal presence of +miasmata in my system, I laid aside this and all other precautions. I +rested myself on the bed-side of my patients, and I drank milk or ate +fruit in their sick rooms. Besides being saturated with miasmata, I had +another security against being infected in sick rooms, and that was, I +went into scarcely a house which was more infected than my own. Many of +the poor people, who called upon me for advice, were bled by my pupils in +my shop, and in the yard, which was between it and the street. From the +want of a sufficient number of bowls to receive their blood, it was +sometimes suffered to flow and putrify upon the ground. From this source, +streams of miasmata were constantly poured into my house, and conveyed +into my body by the air, during every hour of the day and night. + +The deaths of my pupils and sister have often been urged as objections to +my mode of treating the fever. Had the same degrees of labour and +fatigue, which preceded the attack of the yellow fever in each of them, +preceded an attack of a common pleurisy, I think it probable that some, +or perhaps all of them, would have died with it. But when the influence +of the concentrated miasmata which filled my house was added to that of +constant fatigue upon their bodies, what remedies could be expected to +save their lives? Under the above circumstances, I consider the recovery +of the other branches of my family from the fever (and none of them +escaped it) with emotions, such as I should feel had we all been revived +from apparent death by the exertions of a humane society. + +For upwards of six weeks I did not taste animal food, nor fermented +liquors of any kind. The quantity of aliment which I took, inclusive of +drinks, during this time, was frequently not more than one or two pounds +in a day. Yet upon this diet I possessed, for a while, uncommon activity +of body. This influence of abstinence upon bodily exertion has been +happily illustrated by Dr. Jackson, in his directions for preserving the +health of soldiers in hot climates. He tells us, that he walked a hundred +miles in three days, in Jamaica, during which time he breakfasted on tea, +supped on bread and salad, and drank nothing but lemonade or water. He +adds further, that he walked from Edinburgh to London in eleven days and +a half, and that he travelled with the most ease when he only breakfasted +and supped, and drank nothing but water. The fatigue of riding on +horseback is prevented or lessened by abstinence from solid food. Even +the horse suffers least from a quick and long journey when he is fed +sparingly with hay. These facts add weight to the arguments formerly +adduced, in favour of a vegetable diet, in preventing or mitigating the +action of the miasmata of malignant fevers upon the system. In both cases +the abstraction of stimulus removes the body further from the reach of +undue excitement and morbid depression. + +Food supports life as much by its stimulus, as by affording nourishment +to the body. Where an artificial stimulus acts upon the system the +natural stimulus of food ceases to be necessary. Under the influence of +this principle, I increased or diminished my food with the signs I +discovered of the increase or diminution of the seeds of the disease in +my body. Until the 15th of September I drank weak coffee, but after that +time I drank nothing but milk, or milk and water, in the intervals of my +meals. I was so satisfied of the efficacy of this mode of living, that I +believed life might have been preserved, and a fever prevented, for many +days, with a much greater accumulation of miasmata in my system, by means +of a total abstinence from food. Poison is a relative term, and an excess +in quantity, or a derangement in place, is necessary to its producing +deleterious effects. The miasmata of the yellow fever produced sickness +and death only from the excess of their quantity, or from their force +being increased by the addition of those other stimuli which I have +elsewhere called exciting causes. + +In addition to low diet, as a preventive of the disease, I obviated +costiveness by taking occasionally a calomel pill, or by chewing rhubarb. + +I had read and taught, in my lectures, that fasting increases acuteness +in the sense of touch. My low living had that effect, in a certain +degree, upon my fingers. I had a quickness in my perception, of the state +of the pulse in the yellow fever, that I had never experienced before in +any other disease. My abstemious diet, assisted perhaps by the state of +my feelings, had likewise an influence upon my mind. Its operations were +performed with an ease and a celerity, which rendered my numerous and +complicated duties much less burdensome than they would probably have +been under other circumstances of diet, or a less agitated state of my +passions. + +My perception of the lapse of time was new to me. It was uncommonly slow. +The ordinary business and pursuits of men appeared to me in a light that +was equally new. The hearse and the grave mingled themselves with every +view I took of human affairs. Under these impressions I recollect being +as much struck with observing a number of men, employed in digging the +cellar of a large house, as I should have been, at any other time, in +seeing preparations for building a palace upon a cake of ice. I +recollect, further, being struck with surprise, about the 1st of October, +in seeing a man busily employed in laying in wood for the approaching +winter. I should as soon have thought of making provision for a dinner on +the first day of the year 1800. + +In the account of my distresses, I have passed over the slanders which +were propagated against me by some of my brethren. I have mentioned them +only for the sake of declaring, in this public manner, that I most +heartily forgive them; and that if I discovered, at any time, an undue +sense of the unkindness and cruelty of those slanders, it was not because +I felt myself injured by them, but because I was sure they would +irreparably injure my fellow-citizens, by lessening their confidence in +the only remedies that I believed to be effectual in the reigning +epidemic. One thing in my conduct towards these gentlemen may require +justification; and that is, my refusing to consult with them. A Mahometan +and a Jew might as well attempt to worship the Supreme Being in the same +temple, and through the medium of the same ceremonies, as two physicians +of opposite principles and practice attempt to confer about the life of +the same patient. What is done in consequence of such negotiations (for +they are not consultations) is the ineffectual result of neutralized +opinions; and wherever they take place, should be considered as the +effect of a criminal compact between physicians, to assess the property +of their patients, by a shameful prostitution of the dictates of their +consciences. Besides, I early discovered that it was impossible for me, +by any reasonings, to change the practice of some of my brethren. +Humanity was, therefore, on the side of leaving them to themselves; for +the extremity of _wrong_ in medicine, as in morals and government, is +often a less mischief than that mixture of _right_ and _wrong_ which +serves, by palliating, to perpetuate evil. + +After the loss of my health I received letters from my friends in the +country, pressing me, in the strongest terms, to leave the city. Such a +step had become impracticable. My aged mother was too infirm to be +removed, and I could not leave her. I was, moreover, part of a little +circle of physicians, who had associated themselves in support of the +new remedies. This circle would have been broken by my quitting the city. +The weather varied the disease, and, in the weakest state of my body, I +expected to be able, from the reports of my pupils, to assist my +associates in detecting its changes, and in accommodating our remedies to +them. Under these circumstances it pleased God to enable me to reply to +one of the letters that urged my retreat from the city, that "I had +resolved to stick to my principles, my practice, and my patients, to the +last extremity." + +On the 9th of October, I visited a considerable number of patients, and, +as the day was warm, I lessened the quantity of my clothing. Towards +evening I was seized with a pain in the back, which obliged me to go to +bed at eight o'clock. About twelve I awoke with a chilly fit. A violent +fever, with acute pains in different parts of my body, followed it. At +one o'clock I called for Mr. Fisher, who slept in the next room. He came +instantly, with my affectionate black man, to my relief. I saw my danger +painted in Mr. Fisher's countenance. He bled me plentifully, and gave me +a dose of the mercurial medicine. This was immediately rejected. He gave +me a second dose, which likewise acted as an emetic, and discharged a +large quantity of bile from my stomach. The remaining part of the night +was passed under an apprehension that my labours were near an end. I +could hardly expect to survive so violent an attack of the fever, broken +down, as I was, by labour, sickness, and grief. My wife and seven +children, whom the great and distressing events that were passing in our +city had jostled out of my mind for six or seven weeks, now resumed their +former place in my affections. My wife had stipulated, in consenting to +remain in the country, to come to my assistance in case of my sickness; +but I took measures which, without alarming her, proved effectual in +preventing it. My house was enveloped in foul air, and the probability of +my death made her life doubly necessary to my family. In the morning the +medicine operated kindly, and my fever abated. In the afternoon it +returned, attended with a great inclination to sleep. Mr. Fisher bled me +again, which removed the sleepiness. The next day the fever left me, but +in so weak a state, that I awoke two successive nights with a faintness +which threatened the extinction of my life. It was removed each time by +taking a little aliment. My convalescence was extremely slow. I returned, +in a very gradual manner, to my former habits of diet. The smell of +animal food, the first time I saw it at my table, forced me to leave the +room. During the month of November, and all the winter months, I was +harassed with a cough, and a fever somewhat of the hectic kind. The early +warmth of the spring removed those complaints, and restored me, through +Divine goodness, to my usual state of health. + +I should be deficient in gratitude, were I to conclude this narrative +without acknowledging my obligations to my surviving pupils, Mr. Fisher +and Mr. Coxe, for the great support and sympathy I derived from them in +my labours and distresses. + +I take great pleasure likewise in acknowledging my obligations to my +former pupil, Dr. Woodhouse, who assisted me in the care of my patients, +after I became so weak as not to be able to attend them with the +punctuality their cases required. The disinterested exploits of these +young gentlemen in the cause of humanity, and their success in the +treatment of the disease, have endeared their names to hundreds, and, at +the same time, afforded a prelude of their future eminence and usefulness +in their profession. + +But wherewith shall I come before the great FATHER and REDEEMER of men, +and what shall I render unto him for the issue of my life from the grave? + + ----Here all language fails:---- + Come then, expressive silence, muse his praise. + + + + + AN ACCOUNT + + OF THE + + BILIOUS REMITTING AND INTERMITTING + + _YELLOW FEVER_, + + AS IT + + APPEARED IN PHILADELPHIA, + + IN THE YEAR 1794. + + +I concluded the history of the symptoms of the bilious remitting yellow +fever, as it appeared in Philadelphia in the year 1793, by taking notice, +that the diseases which succeeded that fatal epidemic were all of a +highly inflammatory nature. + +In that history I described the weather and diseases of the months of +March and April, in the spring of 1794. + +The weather, during the first three weeks of the month of May, was dry +and temperate, with now and then a cold day and night. The strawberries +were ripe on the 15th, and cherries on the 22d day of the month, in +several of the city gardens. A shower of hail fell on the afternoon of +the 22d, which broke the glass windows of many houses. A single stone of +this hail was found to weigh two drachms. Several people collected a +quantity of it, and preserved it till the next day in their cellars, when +they used it for the purpose of cooling their wine. The weather, after +this hail storm, was rainy during the remaining part of the month. The +diseases were still inflammatory. Many persons were afflicted with a sore +mouth in this month. + +The weather in June was pleasant and temperate. Several intermittents, +and two very acute pleurisies, occurred in my practice during this month. +The intermittents were uncommonly obstinate, and would not yield to the +largest doses of the bark. + +In a son of Mr. Samuel Coates, of seven years old, the bark produced a +sudden translation of this state of fever to the head, where it produced +all the symptoms of the first stage of internal dropsy of the brain. This +once formidable disease yielded, in this case, to three bleedings, and +other depleting medicines. The blood drawn in every instance was sizy. + +From the inflammatory complexion of the diseases of the spring, and of +the beginning of June, I expected the fevers of the summer and autumn +would be of a violent and malignant nature. I was the more disposed to +entertain this opinion from observing the stagnating filth of the gutters +of our city; for the citizens of Philadelphia, having an interest in +rejecting the proofs of the generation of the epidemic of 1793 in their +city, had neglected to introduce the regulations which were necessary to +prevent the production of a similar fever from domestic putrefaction. +They had, it is true, taken pains to remove the earth and offal matters +which accumulated in the streets; but these, from their being always dry, +were inoffensive as remote causes of disease. Perhaps the removal of the +earth did harm, by preventing the absorption of the miasmata which were +constantly exhaled from the gutters. + +On the 6th of June, Dr. Physick called upon me, and informed me that he +had a woman in the yellow fever under his care. The information did not +surprise me, but it awakened suddenly in my mind the most distressing +emotions. I advised him to inform the mayor of the city of the case, but +by no means to make it more public, for I hoped that it might be a +sporadic instance of the disease, and that it might not become general in +the city. + +On the 12th of the month, my fears of the return of the yellow fever were +revived by visiting Mr. Isaac Morris, whom I found very ill with a +violent puking, great pain in his head, a red eye, and a slow tense +pulse. I ordered him to be bled, and purged him plentifully with jalap +and calomel. His blood had that appearance which has been compared by +authors to the washings of raw flesh in water. Upon his recovery, he told +me that he "suspected he had had the yellow fever, for that his feelings +were exactly such as they had been in the fall of 1793, at which time he +had an attack of that disease." + +On the 14th of June, I was sent for, in the absence of Dr. Mease, to +visit his sister in a fever. Her mother, who had become intimately +acquainted with the yellow fever, by nursing her son and mother in it, +the year before, at once decided upon the name of her daughter's disease. +Her symptoms were violent, but they appeared in an intermitting form. +Each paroxysm of her fever was like a hurricane to her whole system. It +excited apprehensions of immediate dissolution in the minds of all her +friends. The loss of sixty ounces of blood, by five bleedings, copious +doses of calomel and jalap, and a large blister to her neck, soon +vanquished this malignant intermittent, without the aid of a single dose +of bark. + +During the remaining part of the month, I was called to several cases of +fever, which had symptoms of malignity of an alarming nature. The son of +Mr. Andrew Brown had a hæmorrhage from his nose in a fever, and a case of +menorrhagia occurred in a woman, who was affected with but a slight +degree of fever. + +In the course of this month, I met with several cases of swelled +testicles, which had succeeded fevers so slight as to have required no +medical aid. Dr. Desportes records similar instances of a swelling in the +testicles, which appeared during the prevalence of the yellow fever in +St. Domingo, in the year 1741[103]. + + [103] Histoire des Maladies de Saint Domingue, p. 112. + +In the month of July, I visited James Lefferty and William Adams, both of +whom had, with the usual symptoms of yellow fever, a yellow colour on +their skin. I likewise attended three women, in whom I discovered the +disease under forms in which I had often seen it in the year 1793. In two +of them it appeared with symptoms of a violent colic, which yielded only +to frequent bleedings. In the third, it appeared with symptoms of +pleurisy, which was attended with a constant hæmorrhage from the uterus, +although blood was drawn almost daily from her arm, for six or seven +days. About the middle of this month many people complained of nausea, +which in some cases produced a puking, without any symptoms of fever. + +During the month of August, I was called to Peter Denham, Mrs. Bruce, a +son of Jacob Gribble, Mr. Cole, John Madge, Mrs. Gardiner, Miss Purdon, +Mrs. Gavin, and Benjamin Cochran, each of whom had all the usual symptoms +of the yellow fever. I found Mr. Cochran sitting on the side of his bed, +with a pot in his hand, into which he was discharging black matter from +his stomach, on the 6th day of the disease. He died on the next day. Mrs. +Gavin died on the 6th day of her disease, from a want of sufficient +bleeding, to which she objected from the influence of her friends. +Besides the above persons, I visited Mr. George Eyre at Kensington, Mr. +Thomas Fitzsimons, and Thomas M'Kean, jun. son of the chief justice of +Pennsylvania, all of whom had the disease, but in a moderate degree. +During this time I took no steps to alarm my fellow-citizens with the +unwelcome news of its being in town. But my mind was not easy in this +situation, for I daily heard of persons who died of the disease, who +might probably have been saved had they applied early for relief, or had +a suspicion become general among all our physicians of the existence of +the yellow fever in the city. The cholera infantum was common during +this, and part of the preceding month. It was more obstinate and more +fatal than in common years. + +On the 12th of this month, a letter from Baltimore announced the +existence of the yellow fever in that city. One of the patients whom I +visited in this month, in the fever, Mr. Cole, brought the seeds of it in +his body from that place. + +On the 25th of the month, two members of a committee, lately appointed by +the government of the state, for taking care of the health of the city, +called upon me to know whether the yellow fever was in town. I told them +it was, and mentioned some of the cases that had come under my notice; +but informed them, at the same time, that I had seen no case in which it +had been contagious, and that, in every case where I had been called +early, and where my prescriptions had been followed, the disease had +yielded to medicine. + +On the 29th of the month I received an invitation to attend a meeting of +the committee of health, at their office at Walnut-street. They +interrogated me respecting the intelligence I had given to two of their +members on the 25th. I repeated it to them, and mentioned the names of +all the persons I had attended in the yellow fever since the 9th of June. + +Neither this, nor several subsequent communications to the committee of +health produced the effect that was intended by them. Dr. Physick and Dr. +Dewees supported me in my declaration, but their testimony did not +protect me from the clamours of my fellow-citizens, nor from the +calumnies of some of my brethren, who, while they daily attended or lost +patients in the yellow fever, called it by the less unpopular names of + +1. A common intermittent. 2. A bilious fever. 3. An inflammatory +remitting fever. 4. A putrid fever. 5. A nervous fever. 6. A dropsy of +the brain. 7. A lethargy. 8. Pleurisy. 9. Gout. 10. Rheumatism. 11. +Colic. 12. Dysentery. And 13. Sore throat. + +It was said further, by several of the physicians of the city, not to be +the yellow fever, because some who had died of it had not a sighing in +the beginning, and a black vomiting in the close of the disease. Even +where the black vomiting and yellow skin occurred, they were said not to +constitute a yellow fever, for that those symptoms occurred in other +fevers. + +Let not the reader complain of the citizens and physicians of +Philadelphia alone. A similar conduct has existed in all cities upon the +appearance of great and mortal epidemics. + +Nor is it any thing new for mortal diseases to receive mild and harmless +names from physicians. The plague was called a spotted fever, for several +months, by some of the physicians of London, in the year 1665. + +Notwithstanding the pains which were taken to discredit the report of the +existence of the yellow fever in the city, it was finally believed by +many citizens, and a number of families in consequence of it left the +city. And in spite of the harmless names of intermitting and remitting +fever, and the like, which were given to the disease, the bodies of +persons who had died with it were conveyed to the grave, in several +instances, upon a hearse, the way in which those who died of the yellow +fever were buried the year before. + +From the influence of occasional showers of rain, in the months of +September and October, the disease was frequently checked, so as to +disappear altogether for two or three days in my circle of practice. It +was observed, that while showers of rain lessened, moist or damp weather, +without rain, increased it. + +The cold weather in October checked the fever, but it did not banish it +from the city. It appeared in November, and in all the succeeding winter +and spring months. The weather, during these months, being uncommonly +moderate, will account for its not being destroyed at the time in which +the disease usually disappeared in former years. + +The causes which predisposed to this fever were the same as in the year +1793. Persons of full habits, strangers, and negroes, were most subject +to it. It may seem strange to those persons who have read that the +negroes are seldom affected with this fever in the West-Indies, that they +were so much affected by it in Philadelphia. There were two reasons for +it. Their manner of living was as plentiful as that of white people in +the West-Indies, and they generally resided in alleys and on the skirts +of the city, where they were more exposed to noxious exhalation, than in +its more open and central parts. + +The summer fruits, from being eaten before they were ripe, or in too +large a quantity, became frequently exciting causes of this fever. It was +awakened in one of my patients by a supper of peaches and milk. +Cucumbers, in several instances, gave vigour to the miasmata which had +been previously received into the system. Terror excited it in two of my +patients. In one of them, a young woman, this terror was produced by +hearing, while she sat at dinner, that a hearse had passed by her door +with a person on it who had died of the yellow fever. Vexation excited it +in a foreign master of a vessel, in consequence of a young woman suddenly +breaking an engagement to marry him. The disease terminated fatally in +this instance. + +It was sometimes unfortunate for patients when the disease was excited by +an article of diet, or by any other cause which acted suddenly upon the +system; for it led both them, and in some instances their physicians, to +confound those exciting causes with its remote cause, and to view the +disease without the least relation to the prevailing epidemic. It was +from this mistake that many persons were said to die of intemperance, of +eating ice creams, and of trifling colds, who certainly died of the +yellow fever. The rum, the ice creams, and the changes in the air, in all +these cases, acted like sparks of fire which set in motion the quiescent +particles of tinder or gunpowder. + +I shall now proceed to describe the symptoms which this fever assumed +during the periods which have been mentioned. This detail will be +interesting to physicians who wish to see how little nature regards the +nosological arrangement of authors, in the formation of the symptoms of +diseases, and how much the seasons influence epidemics. A physician, who +had practised medicine near sixty years in the city of Philadelphia, +declared that he had never seen the dysentery assume the same symptoms in +any two _successive_ years. The same may be said probably of nearly all +epidemic diseases. + +In the arrangement of the symptoms of this fever, I shall follow the +order I adopted in my Account of the Yellow Fever of 1793, and describe +them as they appeared in the sanguiferous system, the liver, lungs, and +brain, the alimentary canal, the secretions and excretions, the nervous +system, the senses and appetites, upon the skin, and in the blood. + +Two premonitory symptoms struck me this year, which I did not observe in +1793. One of them was a frequent discharge of pale urine for a day or two +before the commencement of the fever; the other was sleep unusually +sound, the night before the attack of the fever. The former symptom was a +precursor of the plague of Bassora, in the year 1773. + +I. I observed but few symptoms in the sanguiferous system different from +what I have mentioned in the fever of the preceding year. The slow and +intermitting pulse occurred in many, and a pulse nearly imperceptible, in +three instances. It was seldom very frequent. In John Madge, an English +farmer, who had just arrived in our city, it beat only 64 strokes in a +minute, for several days, while he was so ill as to require three +bleedings a day, and at no time of his fever did his pulse exceed 96 +strokes in a minute. In Miss Sally Eyre, the pulse at one time was at +176, and at another time it was at 140; but this frequency of pulse was +very rare. In a majority of the cases which came under my notice, where +the danger was great, it seldom exceeded 80 strokes in a minute. I have +been thus particular in describing the frequency of the pulse, because +custom has created an expectation of that part of the history of fevers; +but my attention was directed chiefly to the different degrees of _force_ +in the pulse, as manifested by its tension, fulness, intermissions, and +inequality of action. The _hobbling_ pulse was common. In John Geraud, I +perceived a quick stroke to succeed every two strokes of an ordinary +healthy pulse. The intermitting, chorded, and depressed pulse occurred in +many cases. I called it the year before a _sulky_ pulse. One of my +pupils, Mr. Alexander, called it more properly a _locked_ pulse. I think +I observed this state of the pulse to occur chiefly in persons in whom +the fever came on without a chilly fit. + +Hæmorrhages occurred in all the grades of this fever, but less frequently +in my practice this year than in the year before. It occurred, after a +ninth bleeding, in Miss Sally Eyre, from the nose and bowels. It occurred +from the nose, after a sixth bleeding, in Mrs. Gardiner, who was at that +time in the sixth month of her pregnancy. This symptom, which was +accompanied by a tense and quick pulse, induced me to repeat the bleeding +a seventh time. The blood was very sizy. I mention this fact to establish +the opinion that hæmorrhages depend upon too much action in the +blood-vessels, and that they are not occasioned by a dissolved state of +the blood. + +There was a disposition at this time to hæmorrhage in persons who were in +apparent good health. A private, in a company of volunteers commanded by +Major M'Pherson, informed me that three of his messmates were affected by +a bleeding at the nose, for several days after they left the city, on +their way to quell the insurrection in the western counties of +Pennsylvania. + +II. The liver did not exhibit the usual marks of inflammation. Perhaps my +mode of treating the fever prevented those symptoms of hepatic affection +which belong to the yellow fever in tropical climates. The lungs were +frequently affected; and hence the disease was in many instances called a +pleurisy or a catarrh. This inflammation of the lungs occurred in a more +especial manner in the winter season. It was distinguished from the +pleurisies of common years by a red eye, by a vomiting of green or yellow +bile, by black stools, and by requiring very copious blood-letting to +cure it. + +The head was affected, in this fever, not only with coma and delirium, +but with mania. This symptom was so common as to give rise to an opinion +that madness was epidemic in our city. I saw no case of it which was not +connected with other symptoms of the bilious remitting fever. The Rev. +Mr. Keating, one of the ministers of the Roman church, informed me that +he had been called to visit seven deranged persons in his congregation, +in the course of one week, in the month of March. Two of them had made +attempts upon their lives. This mania was probably, in each of the above +cases, a symptom only of general fever. The dilatation of the pupil was +universal in this fever. + +Sore eyes were common during the prevalence of this fever. In Mrs. +Leaming, this affection of the eyes was attended with a fever of a +tertian type. + +III. The alimentary canal suffered as usual in this fever. A vomiting was +common upon the first attack of the disease. I observed this symptom to +be less common after the cold and rainy weather which took place about +the first of October. + +I have in another place mentioned the influence of the weather upon the +symptoms of this disease. In addition to the facts which have been +formerly recorded, I shall add one more from Dr. Desportes. He tells us, +that in dry weather the disease affects the head, and that the bowels in +this case are more obstinately costive than in moist weather. This +influence of the atmosphere on the yellow fever will not surprise those +physicians who recollect the remarkable passage in Hippocrates, in which +he says, that in the violent heats of summer, fevers appeared, but +without any sweat; but if a shower, though ever so slight, appeared, a +sweat broke out in the beginning[104]. I observed further, that a +vomiting rarely attended those cases in which there was an absence of a +chilly fit in the beginning of the fever. The same observation is made by +Dr. Desportes[105]. + + [104] Epidemics, book XI. sect. I. + + [105] Les Maladies de St. Domingue, vol. I. p. 193. + +The matter discharged by vomiting was green or yellow bile in most cases. +Mrs. Jones, the wife of Captain Lloyd Jones, and one other person, +discharged black bile within one hour after they were attacked by the +fever. I have taken notice, in the History of the Yellow Fever of 1793, +that a discharge of bile in the beginning of this fever was always a +favourable symptom. Dr. Davidson of St. Vincents, in a letter to me, +dated the 22d July, 1794, makes the same remark. It shows that the +biliary ducts are open, and that the bile is not in that viscid and +impacted state which is described in the dissections of Dr. Mitchel[106]. +A distressing pain in the stomach, called by Dr. Cullen gastrodynia, +attended in two instances. A burning pain in the stomach, and a soreness +to the touch of its whole external region, occurred in three or four +cases. Two of them were in March, 1795. In Mrs. Vogles, who had the fever +in September, 1794, the sensibility of the pit of the stomach was so +exquisite, that she could not bear the weight of a sheet upon it. + + [106] Account of the Yellow Fever of 1793. + +Pains in the bowels were very common. They formed the true bilious colic, +so often mentioned by West-India writers. In John Madge these pains +produced a hardness and contraction of the whole external region of the +bowels. They were periodical in Miss Nancy Eyre, and in Mrs. Gardiner, +and in both cases were attended with diarrh[oe]a. + +Costiveness without pain was common, and, in some cases, so extremely +obstinate as to resist, for several days, the successive and alternated +use of all the usual purges of the shops. + +Flatulency was less common in this fever than in the year 1793. + +The disease appeared with symptoms of dysentery in several cases. + +IV. The following is an account of the state of the _secretions_ and +_excretions_ in this fever. + +A puking of bile was more common this year than in the year 1793. It was +generally of a green or yellow colour. I have remarked before, that two +of my patients discharged black bile within an hour after they were +affected by the fever, and many discharged that kind of matter which has +been compared to coffee grounds, towards the close of the disease. + +The fæces were black in most cases where the symptoms of the highest +grade of the fever attended. In one very malignant case the most drastic +purges brought away, by fifty evacuations, nothing but natural stools. +The purges were continued, and finally black fæces were discharged, which +produced immediate relief[107]. In one person the fæces were of a light +colour. In this patient the yellowness in the face was of an orange +colour, and continued so for several weeks after his recovery. + + [107] In the account of the effects of morbid action and inflammation, + in the Outlines of the Theory of Fever, the author neglected to + mention the change of certain fluids from their natural to a dark + colour. It appears in the secretions of the stomach and bowels, + in the bile, in the urine, in carbuncles, and occasionally in the + matter which is produced by blisters. All these changes occur in + the yellow fever, and, in common with the other effects of fever + that have been enumerated, are the result of peculiar actions in + the vessels, derived from _one_ cause, viz. morbid excitement. + +The urine was, in most cases, high coloured. It was scanty in quantity in +Peter Brown, and totally suppressed in John Madge for two days. I +ascribed this defect of natural action in the kidneys to an _engorgement_ +in their blood-vessels, similar to that which takes place in the lungs +and brain in this fever. I had for some time entertained this idea of a +morbid affection of the kidneys, but I have lately been confirmed in it +by the account which Dr. Chisholm gives of the state of one of the +kidneys, in a man whom he lost with the Beullam fever, at Grenada. "The +right kidney (says the doctor) was mortified, although, during his +illness, no symptom of inflammation of that organ was perceived[108]." It +would seem as if the want of action in the kidneys, and a defect in +their functions were not necessarily attended with pain. I recollect to +have met with several cases in 1793, in which there was a total absence +of pain in a suppression of urine of several days continuance. The same +observation is made by Dr. Chisholm, in his account of the Beullam fever +of Grenada[109]. From this fact it seems probable, that pain is not the +effect of any determinate state of animal fibres, but requires the +concurrence of morbid or preternatural excitement to produce it. I met +with but one case of strangury in this fever. It terminated favourably in +a few days. I have never seen death, in a single instance, in a fever +from any cause, where a strangury attended, and I have seldom seen a +fatal issue to a fever, where this symptom was accidentally produced by a +blister. From this fact there would seem to be a connection between a +morbid excitement in the neck of the bladder, and the safety of more +vital parts of the body. The idea of this connection was first suggested +to me, above thirty years ago, by the late Dr. James Leiper, of Maryland, +who informed me that he had sometimes cured the most dangerous cases of +pleurisy, after the usual remedies had failed, by exciting a strangury, +by means of the tincture of Spanish flies mixed with camphorated spirit +of wine. + + [108] Essay on the Malignant Pestilential Fever introduced into the + West-Indies from Beullam, p. 137. + + [109] Page 224. + +The tongue was always moist in the beginning of the fever, but it was +generally of a darker colour than last year. When the disease was left to +itself, or treated with bark and wine, the tongue became of a fiery red +colour, or dry and furrowed, as in the typhus fever. + +_Sweats_ were more common in the remissions of this fever, than they were +in the year 1793, but they seldom terminated the disease. During the +course of the sweats, I observed a deadly coldness over the whole body to +continue in several instances, but without any danger or inconvenience to +the patient. In two of the worst cases I attended, there were remissions, +but no sweats until the day on which the fever terminated. In several of +my patients, the fever wore away without the least moisture on the skin. +The _milk_, in one case, was of a greenish colour, such as sometimes +appears in the serum of the blood. In another female patient who gave +suck, there was no diminution in the quantity of her milk during the +whole time of her fever, nor did her infant suffer the least injury from +sucking her breasts. + +I observed tears to flow from the eye of a young woman in this fever, at +a time when her mind seemed free from distress of every kind. + +V. I proceed next to mention the symptoms of this fever in the nervous +system. + +Delirium was less common than last year. I was much struck in observing +John Madge, who had retained his reason while he was so ill as to require +three bleedings a day, to become delirious as soon as he began to +recover, at which time his pulse rose from between 60 and 70, to 96 +strokes in a minute. I saw one case of extreme danger, in which a +hysterical laughing and weeping alternately attended. + +I have before mentioned the frequency of mania as a symptom of this +disease. An obstinate wakefulness attended the convalescence from this +fever in Peter Brown, John Madge, and Mr. Cole. + +Fainting was more common in this fever than in the fever of 1793. It +ushered in the disease in one of my patients, and it occurred in several +instances after bleeding, where the quantity of blood drawn was very +moderate. + +Several people complained of giddiness in the first attack of the fever, +before they were confined to their beds. Sighing was less common, but a +hiccup was more so, than in the year before. + +John Madge had an immobility in his limbs bordering upon palsy. A +weakness in the wrists in one case succeeded a violent attack of the +fever. + +Peter Brown complained of a most acute pain in the muscles of one of his +legs. It afterwards became so much inflamed as to require external +applications to prevent the inflammation terminating in an abscess. Mrs. +Mitchell complained of severe cramps in her legs. + +The sensations of pain in this fever were often expressed in extravagant +language. The pain in the head, in a particular manner, was compared to +repeated strokes of a hammer upon the brain, and in two cases, in which +this pain was accompanied by great heat, it was compared to the boiling +of a pot. + +The more the pains were confined to the bones and back, the less danger +was to be apprehended from the disease. I saw no case of death from the +yellow fever in 1793, where the patient complained much of pain in the +back. It is easy to conceive how this external determination of morbid +action should preserve more vital parts. The bilious fever of 1780 was a +harmless disease, only because it spent its whole force chiefly upon the +limbs. This was so generally the case, that it acquired, from the pains +in the bones which accompanied it, the name of the "break bone fever." +Hippocrates has remarked that pains which descend, in a fever, are more +favourable than those which ascend[110]. This is probably true, but I did +not observe any such peculiarity in the translation of pain in this +fever. The following fact from Dr. Grainger will add weight to the above +observations. He observed the pains in a malignant fever which were +diffused through the whole head, though excruciating, were much less +dangerous than when they were confined to the temples or forehead[111]. + + [110] Epidemics, book ii. sect. 2. + + [111] Historia Febris Anomalæ Batavæ Annorum 1746, 1747, 1748, cap. i. + +I saw two cases in which a locked jaw attended. In one of them it +occurred only during one paroxysm of the fever. In both it yielded in +half an hour to blood-letting. I met with one case in which there was +universal tetanus. I should have suspected this to have been the primary +disease, had not two persons been infected in the same house with the +yellow fever. + +The countenance sometimes put on a ghastly appearance in the height of a +paroxysm of the fever. The face of a lady, admired when in health for +uncommon beauty, was so much distorted by the commotions of her whole +system, in a fit of the fever, as to be viewed with horror by all her +friends. + +VI. The senses and appetites were affected in this fever in the following +manner. + +A total blindness occurred in two persons during the exacerbation of the +fever, and ceased during its remissions. A great intolerance of light +occurred in several cases. It was most observable in John Madge during +his convalescence. + +A soreness in the sense of touch was so exquisite in Mrs. Kapper, about +the crisis of her fever, that the pressure of a piece of fine muslin upon +her skin gave her pain. + +Peter Brown, with great heat in his skin, and a quick pulse, had no +thirst, but a most intense degree of thirst was very common in this +fever. It produced the same extravagance of expression that I formerly +said was produced by pain. One of my patients, Mr. Cole, said he "could +drink up the ocean." I did not observe thirst to be connected with any +peculiar state of the pulse. + +George Eyre and Henry Clymer had an unusual degree of appetite, just +before the usual time of the return of a paroxysm of fever. + +A young man complained to me of being afflicted with nocturnal emissions +of seed during his convalescence. This symptom is not a new one in +malignant fevers. Hippocrates takes notice of it[112]. I met with one +instance of it among the sporadic cases of yellow fever which occurred in +1795. It sometimes occurs, according to Lomius, in the commotions of the +whole system which take place in epilepsy. + + [112] Epidemics, book IV. + +VII. The disease made an impression upon the lymphatic system. Four of my +patients had glandular swellings: two of them were in the groin; a third +was in the parotid; and the fourth was in the maxillary glands. Two of +these swellings suppurated. + +VIII. The yellowness of the skin, which sometimes attends this fever, was +more universal, but more faint than in the year 1793. It was, in many +cases, composed of such a mixture of colours, as to resemble polished +mahogany. But, in a few cases, the yellowness was of a deep orange +colour. The former went off with the fever, but the latter often +continued for several weeks after the patients recovered. In some +instances a red colour predominated to such a degree in the face, as to +produce an appearance of inflammation. + +In Mrs. Vogles a yellowness appeared in her eyes during the paroxysm of +her fever, and went off in its remissions. + +In James Lefferty the yellowness affected every part of his body, except +his hands, which were as pale as in a common fever. + +Peter Brown tinged his sheets of a yellow colour, by night sweats, many +weeks after his recovery. + +There was an exudation from the soles of the feet of Richard Wells's +maid, which tinged a towel of a yellow colour. + +In my Account of the Yellow Fever of 1793, I ascribed the yellow colour +of the skin wholly to a mixture of bile with the blood. I believe that +this is the cause of it, in those cases where the colour is deep, and +endures for several weeks beyond the crisis of the fever; but where it is +transitory, and, above all, where it is local, or appears only for a few +hours, during the paroxysm of the fever, it appears probable that it is +connected with the mode of aggregation of the blood, and that it is +produced wholly by some peculiar action in the blood-vessels. A similar +colour takes place from the bite of certain animals, and from contusions +of the skin, in neither of which cases has a suspicion been entertained +of an absorption or mixture of bile with the blood. + +A troublesome itching, with an eruption of red blotches on the skin, +attended on the first day of the attack of the fever, in Mrs. Gardiner. + +A roughness of the skin, and a disposition in it to peel off, appeared +about the crisis of the fever, in Miss Sally Eyre. + +That species of eruption, which I have elsewhere compared to moscheto +bites, appeared in Mrs. Sellers. + +John Ray, a day labourer, to whom I was called in the last stage of the +fever, had petechiæ on his breast the day before he died. + +That burning heat on the skin, called by the ancients "calor mordens," +and from which this fever, in some countries, has derived the name of +_causus_, was more common this year than last. It was sometimes local, +and sometimes general. I perceived it in an exquisite degree in the +cheeks only of Miss Sally Eyre, and over the whole body of John Ray. It +had no connection with the rapidity or force of the circulation of the +blood in the latter instance, for it was most intense at a time when he +had no pulse. + +It is remarkable that the heat of the skin has no connection with the +state of the pulse. This fact did not escape Dr. Chisholm. He says he +found the skin to be warm while the pulse was at 52, and that it was +sometimes disagreeably cold when the pulse was as quick as in ordinary +fever[113]. + + [113] Page 117. + +IX. I have in another place rejected putrefaction from the blood as the +cause or effect of this fever. I shall mention the changes which were +induced in its appearances when I come to treat of the method of cure. + +Having described the symptoms of this fever as they appeared in different +parts of the body, I shall now add a few observations upon its type or +general character. + +I shall begin this part of the history of the fever by remarking, that we +had but one reigning disease in town during the autumn and winter; that +this was a bilious remitting, or intermitting, and sometimes a yellow +fever; and that all the fevers from other remote causes than putrid +exhalation, partook more or less of the symptoms of the prevailing +epidemic. As well might we distinguish the rain which falls in gentle +showers in Great-Britain, from that which is poured in torrents from the +clouds in the West-Indies, by different names and qualities, as impose +specific names and characters upon the different states of bilious fever. + +The forms in which this fever appeared were as follow. + +1. A tertian fever. Several persons died of the third fit of tertians, +who were so well as to go abroad on the intermediate day of the fever. It +is no new thing for malignant fevers to put on the form of a tertian. +Hippocrates long ago remarked, that intermittents sometimes degenerate +into malignant acute diseases; and hence he advises physicians to be on +their guard upon the 5th, 7th, 9th, and even on the 14th day of such +fevers[114]. + + [114] De Morb. Popular. lib. VII. + +2. It appeared most frequently in the form of a remittent. The +exacerbations occurred most commonly in the evening. In some there were +exacerbations in the morning as well as in the evening. But I met with +several patients who appeared to be better and worse half a dozen times +in a day. In each of these cases, there were evident remissions and +exacerbations of the fever. + +It assumed, in several instances, the symptoms of a colic and cholera +morbus. In one case the fever, after the colic was cured, ended in a +regular intermittent. In another, the colic was accompanied by a +hæmorrhage from the nose. I distinguished this bilious colic from that +which is excited by lighter causes, by its always coming on with more or +less of a chilliness[115]. The symptoms of colic and cholera morbus +occurred most frequently in June and July. + + [115] See Sydenham, vol. I. p. 212. + +4. It appeared in the form of a dysentery in a boy of William Corfield, +and in a man whom my pupil, Mr. Alexander, visited in the neighbourhood +of Harrowgate. + +5. It appeared, in one case, in the form of an apoplexy. + +6. It disguised itself in the form of madness. + +7. During the month of November, and in all the winter months, it was +accompanied with pains in the sides and breast, constituting what +nosologists call the "pleuritis biliosa." + +8. The puerperile fever was accompanied, during the summer and autumn, +with more violent symptoms than usual. Dr. Physick informed me, that two +women, to whom he was called soon after their delivery, died of uterine +hæmorrhages; and that he had with difficulty recovered two other lying-in +women, who were afflicted with that symptom of a malignant diathesis in +the blood-vessels. + +9. Even dropsies partook more or less of the inflammatory and bilious +character of this fever. + +10. It blended itself with the scarlatina. The blood, in this disease, +and in the puerperile fever, had exactly the same appearance that it had +in the yellow fever. A yellowness in the eyes accompanied the latter +disease in one case that came under my notice. + +A slight shivering ushered in the fever in several instances. But the +worst cases I saw came on without a chilly fit, or the least sense of +coldness in any part of the body. + +Such was the predominance of the intermitting, remitting, and bilious +fever, that the measles, the small-pox, and even the gout itself, partook +more or less of its character. There were several instances in which the +measles, and one in which the gout appeared with quotidian exacerbations; +and two in which madness appeared regularly in the form of a tertian. + +I mentioned formerly that this fever sometimes went off with a sweat, +when it appeared in a tertian form. This was always the case with the +second grade of the fever, but never with the first degree of it, before +the third or fourth paroxysm; nor did a sweat occur on the fifth or +seventh day, except after the use of depleting remedies. This peculiarity +in the fever of this year was so fixed, that it gave occasion for my +comparing it, in my intercourse with my patients, to a lion on the first +seven days, and to a lamb during the remaining part of its duration. + +The fever differed from the fever of the preceding year in an important +particular. I saw or heard of no case which terminated in death on the +first or third day. In every case, the fever came on fraught with +paroxysms. The moderate degrees of it were of so chronic a nature as to +continue for several weeks, when left to themselves. I wish this +peculiarity in the epidemic which I am now describing to be remembered; +for it will serve hereafter to explain the reason why a treatment +apparently different should be alike successful, in different seasons and +in different countries. + +The crisis of the fever occurred on uneven days more frequently than in +the fever of the year 1793. + +I remarked formerly[116] that remissions were more common in the yellow +fever than in the common bilious fever. The same observation applies to +critical days. They were observable in almost every case in which the +disease was not strangled in its birth. Dr. Chisholm describes the same +peculiarity in the Beullam fever. "I have not met with any disease (says +the doctor) in which the periods were more accurately ascertained[117]." + + [116] Account of the Yellow Fever of 1793. + + [117] Page 141. + +In addition to the instances formerly enumerated[118], of the +predominance of powerful epidemics over other diseases, I shall add two +more, which I have lately met with in the course of my reading. + + [118] Account of the Yellow Fever in 1793. + +Dr. Chisholm, in describing the pestilential fever introduced into the +West-Indies from Beullam, has the following remarks. "Most other diseases +degenerated into, or partook very much of this. Dysenteries suddenly +stopped, and were immediately succeeded by the symptoms of the +pestilential fever. Catarrhal complaints, simple at first, soon changed +their nature; convalescents from other diseases were very subject to +this, but it generally proved mild. Those labouring at the same time +under chronic complaints, particularly rheumatism and hepatitis, were +very subject to it. The puerperile fever became malignant, and of course +fatal; and even pregnant negro women, who otherwise might have had it in +the usual mild degree peculiar to that description of people, were +reduced to a very dangerous situation by it. In short, every disease in +which the patient was liable to infection, sooner or later assumed the +appearance, and acquired the danger of the pestilential fever[119]." + + [119] Page 129, 130. + +Dr. Desportes ascribes the same universal empire to the yellow fever +which prevailed in St. Domingo, in the summer of 1733. "The fever of Siam +(says the doctor) conveyed an infinite number of men to the grave, in a +short time; but I saw but one woman who was attacked by it." "The +violence of this disease was such, that it subjected all other diseases, +and reigned alone. This is the character of all contagious and +pestilential diseases. Sydenham, and before him Diemerbroek, have +remarked this of the plague[120]." + + [120] Page 40, 41. See also p. 111, 230, 231. vol. I. + +In Baltimore, the small-pox in the natural way was attended with unusual +malignity and mortality, occasioned by its being combined with the +reigning yellow fever. + +It has been urged as an objection to the influence of powerful epidemics +chasing away, or blending with fevers of inferior force, that the measles +sometimes supplant the small-pox, and mild intermittents take the place +of fevers of great malignity. This fact did not escape the microscopic +eye of Dr. Sydenham, nor is it difficult to explain the cause of it. It +is well known that epidemics, like simple fevers, are most violent at +their first appearance, and that they gradually lose their force as they +disappear; now it is in their evanescent and feeble state, that they are +jostled out of their order of danger or force, and yield to the youthful +strength of epidemics, more feeble under equal circumstances of age than +themselves. It would seem, from this fact, that an inflammatory +constitution of the air, and powerful epidemics, both in their aggregate +and individual forms, possessed a common character. They all invade with +the fury of a savage, and retire with the gentleness of a civilized foe. + +It is agreeable to discover from these facts and observations, that +epidemic diseases, however irregular they appear at first sight, are all +subject to certain laws, and partake of the order and harmony of the +universe. + +The action of the miasmata upon the body, when, from the absence of an +exciting cause, they did not produce fever, was the same as I have +elsewhere described. The sensations which I experienced, in entering a +small room where a person was confined with this fever, were so exactly +the same with those I felt the year before, that I think I could have +distinguished the presence of the disease without the assistance of my +eyes, or without asking a single question. After sitting a few minutes in +a sick room, I became languid and fainty. Weakness and chilliness +followed every visit I paid to a gentleman at Mr. Oellers's hotel, which +continued for half an hour. A burning in my stomach, great heaviness, and +a slight inflammation in my eyes, with a constant discharge of a watery +humour from them for two days, succeeded the first visit I paid to Mrs. +Sellers. These symptoms came on in less than ten minutes after I left her +room. They were probably excited thus early, and in the degree which I +have mentioned, by my having received her breath in my face by inspecting +her tonsils, which were ulcerated on the first attack of the fever. I +formerly supposed these changes in my body were proofs of the contagious +nature of the yellow fever, but I shall hereafter explain them upon other +principles. + +I recollect having more than once perceived a smell which had been +familiar to me during the prevalence of the yellow fever in 1793. It +resembled the smell of liver of sulphur. I suspected for a while that it +arose from the exhalations of the gutters of the city. But an accident +taught me that it was produced by the perspiration of my body. Upon +rubbing my hands, this odour was increased so as to become not only more +perceptible to myself, but in the most sensible degree to my pupil, Mr. +Otto. From this fact, I was convinced that I was strongly impregnated +with miasmata, and I was led by it to live chiefly upon vegetables, to +drink no wine, and to avoid, with double care, all the usual exciting +causes of fever. + +There was another mark by which I distinguished the presence of the seeds +of this fever in my system, and that was, wine imparted a burning +sensation to my tongue and throat, such as is felt after it has been +taken in excess, or in the beginning of a fever. Several persons, who +were exposed to the miasmata, informed me that wine, even in the smallest +quantity, affected them exactly in the same manner. + +I attended four persons in this fever who had had it the year before. + +It remains now that I mention the origin of this fever. This was very +evident. It was produced by the exhalations from the gutters, and the +stagnating ponds of water in the neighbourhood of the city. Where there +was most exhalation, there were most persons affected by the fever. Hence +the poor people, who generally live in the neighbourhood of the ponds in +the suburbs, were the greatest sufferers by it. Four persons had the +fever in Spruce, between Fourth and Fifth-streets, in which part of the +city the smell from the gutters was extremely offensive every evening. In +Water-street, between Market and Walnut-streets, many persons had the +fever: now the filth of that confined part of the city is well known to +every citizen. + +I have before remarked, that one reason why most of our physicians +refused to admit the presence of the yellow fever in the city, was +because they could not fix upon a vestige of its being imported. On the +25th of August, the brig Commerce arrived in the river, from St. Mark, +commanded by Captain Shirtliff. After lying five days at the fort, she +came up to the city. A boy, who had been shut out from his lodgings, +went, in a state of intoxication, and slept on her deck, exposed to the +night air, in consequence of which the fever was excited in him. This +event gave occasion, for a few days, to a report that the disease was +imported, and several of the physicians, who had neglected to attend to +all the circumstances that have been stated, admitted the yellow fever to +be in town. An investigation of this supposed origin of the disease soon +discovered that it had no foundation. At the time of the arrival of this +ship, I had attended nearly thirty persons with the fever, and upwards of +a hundred had had it, under the care of other physicians. + +The generation of the yellow fever in our city was rendered more certain +by the prevalence of bilious diseases in every part of the United States, +and, in several of them, in the grade of yellow fever. It was common in +Charleston, in South-Carolina, where it carried off many people, and +where no suspicion was entertained of its being of West-India origin. It +prevailed with great mortality at that part of the city of Baltimore, +which is known by the name of Fell's Point, where, Dr. Drysdale assures +me, it was evidently generated. A few sporadic cases of it occurred in +New-York, which were produced by the morbid exhalation from the docks of +that city. Sporadic cases of it occurred likewise in most of the states, +in which the proofs of its being generated were obvious to common +observation; and where the symptoms of depressed pulse, yellowness of the +skin, and black discharges from the bowels and stomach (symptoms which +mark the highest grade of bilious remitting fever) did not occur, the +fevers in all their form of tertian, quotidian, colic, and dysentery, +were uncommonly obstinate or fatal in every state in the union. In +New-Haven only, where the yellow fever was epidemic, it was said to have +been imported from Martinique, but this opinion was proved to be +erroneous by unanswerable documents, published afterwards in the Medical +Repository, by Dr. Elisha Smith, of New-York. + +The year 1795 furnished several melancholy proofs of the American origin +of the yellow fever. All the physicians and citizens of New-York and +Norfolk agree in its having been generated in their respective cities +that year. It prevailed with great mortality at the same time in the +neighbourhood of the lakes, and on the waters of the Genesee river, in +the state of New-York. From its situation it obtained the name of the +lake and Genesee fever. It was so general, in some parts of that new +country, as to affect horses. + +Thus have I endeavoured to fix the predisposing and remote causes of the +yellow fever in our country. The remote cause is sometimes so powerful as +to become an exciting cause of the disease, but in general both the +predisposing and remote causes are harmless in the system, until they are +roused into action by some exciting cause. + +I shall conclude this account of the symptoms and origin of the yellow +fever by relating two facts, which serious and contemplating minds will +apply to a more interesting subject. + +1. Notwithstanding the numerous proofs of the prevalence of the yellow +fever in Philadelphia in the year 1794, which have been mentioned, there +are many thousands of our citizens, and a majority of our physicians, who +do not believe that a case of it existed at that time in the city; nor is +a single record of it to be met with in any of the newspapers, or other +public documents of that year. Let us learn from this fact, that the +denial of events, or a general silence upon the subject of them, is no +refutation of their truth, where they oppose the pride or interests of +the learned, or the great. + +2. Notwithstanding the general denial of the existence of the yellow +fever in Philadelphia, and the silence observed by our newspapers +relative to it in 1794, there was scarcely a citizen or physician who, +three years afterwards, did not admit of its having prevailed in that +year. We learn from this fact another important truth, that departed +vice and error have no friends nor advocates. + + + + + OF THE METHOD OF CURE. + + +The remedies employed for the cure of this fever were the same that I +employed the year before. I shall only relate such effects of them as +tend more fully to establish the practice adopted in the year 1793, and +such as escaped my notice in my former remarks upon those remedies. My +method of cure consisted, + +I. In the abstraction of the stimulus of blood and heat from the whole +body, and of bile and other acrid humours from the bowels, by means of +the following remedies: + +1. Bleeding. + +2. Purging. + +3. Cool air and cold drinks. + +4. Cold water applied to the external parts of the body, and to the +bowels by means of glysters. + +II. In creating a diversion of congestion, inflammation, and serous +effusion, from the brain and viscera to the mouth, by means of a +salivation, and to the external parts of the body, by means of blisters. + +III. In restoring the strength of the system, by tonic remedies. + +I proceed to make a few remarks upon the remedies set down under each of +the above heads. + +I. I have taken notice that this fever differed from the fever of 1793, +in coming forward in July and August with a number of paroxysms, which +refused to yield to purging alone. I therefore began the cure of every +case I was called to by _bleeding_. + +I shall mention the effects of this remedy, and the circumstances, +manner, and degrees in which I used it occasionally, in this fever, in my +Defence of Blood-letting. Under the present head I shall only furnish the +reader with a table of the quantity of blood drawn from a number of my +patients in the course of the disease. From several of them the quantity +set down was taken in three, four, and five days. I shall afterwards +describe the appearances of the blood. + + +-----------+------------------+-----------+------------+ + | Month. | Patients. | Quantity. | Number of | + | | | ounces. | times bled.| + +-----------+------------------+-----------+------------+ + | August. | Peter Denham | 50 | 5 | + | | Mrs. Bruce | 70 | 7 | + | | Andrew Gribble, | | | + | | aged 15 years. | 50 | 5 | + | | John Madge | 150 | 12 | + | | Peter Brown | 80 | 8 | + | September.| Mrs. Gardiner | 80 | 7 | + | | Miss Sally Eyre | 80 | 9 | + | | Mrs. Gass | 50 | 3 | + | | Richard Wells's | | | + | | maid | 100 | 10 | + | | Mr. Norval | 100 | 9 | + | | Mr. Harrison | 90 | 9 | + | | Henry Clymer | 80 | 8 | + | October. | Mrs. Mitchell | 120 | 13 | + | | Mrs. Lenox | 80 | 7 | + | | Mrs. Kapper | 140 | 11 | + | | Rev. Dr. Magaw's | | | + | | maid | 100 | 10 | + | | Miss Hood | 100 | 10 | + | | Mrs. Vogles | 70 | 5 | + | 1795 | Guy Stone | 100 | 9 | + | January. | Benj. Hancock | 100 | 10 | + | | Mr. Benton | 130 | 13 | + | | Mrs. Fries | 150 | 15 | + | | Mrs. Garrigues | 80 | 7 | + +-----------+------------------+-----------+------------+ + +Three of the women, whose names I have mentioned, were in the advanced +stage of pregnancy, viz. Mrs. Gardiner, Mrs. Gass, and Mrs. Garrigues. +They have all since borne healthy children. I have omitted the names of +above one hundred persons who had the fever, from whom I drew thirty or +forty ounces of blood, by two or three bleedings. I did not cure a single +person without at least one bleeding. + +It is only by contemplating the extent in which it is necessary to use +this remedy, in order to overcome a yellow fever, that we can acquire +just ideas of its force. Hitherto this force has been estimated by no +other measure than the grave, and this, we know, puts the strength of all +diseases upon a level. + +The blood drawn in this fever exhibited the following appearances; + +1. It was dissolved in a few instances. + +2. The crassamentum of the blood was so partially dissolved in the serum, +as to produce an appearance in the serum resembling the washings of flesh +in water. + +3. The serum was so lightly tinged of a _red_ colour as to be perfectly +transparent. + +4. The serum was, in many cases, of a deep yellow colour. + +5. There was, in every case in which the blood was not dissolved, or in +which the second appearance that has been mentioned did not take place, a +beautiful scarlet-coloured sediment in the bottom of the bowl, forming +lines, or a large circle. It seemed to be a tendency of the blood to +dissolution. This state of the blood occurred in almost all the diseases +of the last two years, and in some in which there was not the least +suspicion of the miasmata of the yellow fever. + +6. The crassamentum generally floated in the serum, but it sometimes sunk +to the bottom of the bowl. In the latter case the serum had a muddy +appearance. + +7. I saw but one case in which there was not a separation of the +crassamentum and serum of the blood. Its colour in this case was of a +deep scarlet. In the year 1793 this appearance was very common. + +8. I saw one case in which the blood drawn, amounting to 14 ounces, +separated partially, and was of a deep _black_ colour. This blood was +taken from Mr. Norval, a citizen of North-Carolina. + +9. There was, in several instances, a transparent jelly-like pellicle +which covered the crassamentum of the blood, and which was easily +separated from it without altering its texture. It appeared to have no +connection with the blood. + +10. The blood, towards the crisis of the fever in many people, exhibited +the usual forms of inflammatory crust. It was cupped in many instances. + +11. After the loss of 70 or 80 ounces of blood there was an evident +disproportion of the quantity of crassamentum to the serum. It was +sometimes less, by one half, than in the first bleedings. + +Under this head it will be proper to mention that the blood, when it +happened to flow along the external part of the arm in falling into the +bowl, was so warm as to excite an unpleasant sensation of heat in several +patients. + +To the appearances exhibited by the blood to the eye, I shall add a fact +communicated to me by a German bleeder, who followed his business in the +city during the prevalence of the fever in 1793. He informed me that he +could distinguish a yellow fever from all other states of fever, by a +peculiar smell which the blood emitted while it was flowing from a vein. +From the certainty of his decision in one case which came under my +notice, before a suspicion had taken place of the fever being in the +city, I am disposed to believe that there is a foundation for his remark. + +II. I have but little to add to the remarks I made upon the use of +_purging_ in the year 1793. I gave jalap, calomel, and gamboge until I +obtained large and dark-coloured stools; after which I kept the bowels +gently open every day with castor oil, cremor tartar, or glauber's salts. +I gave calomel in much larger quantities than I did the year before. John +Madge took nearly 150 grains of it in six days. I should have thought +this a large quantity, had I not since read that Dr. Chisholm gave 400 +grains of it to one patient in the course of his fever, and 50 grains to +another at a single dose, three times a day. I found strong mercurial +purges to be extremely useful in the winter months, when the fever put on +symptoms of pleurisy. I am not singular in ascribing much to the efficacy +of purges in the bilious pleurisy. Dr. Desportes tells us that he found +the pleurisy of St. Domingo, which was of the bilious kind, to end +happily in proportion as the bowels were kept constantly open[121]. Nor +am I singular in keeping my eye upon the original type of a disease, +which only changes its symptoms with the weather or the season, and in +treating it with the same remedies. Dr. Sydenham bled as freely in the +diarrh[oe]a of 1668 as he had done in the inflammatory fever of the +preceding year[122]. How long the pleurisies of winter, in the city of +Philadelphia, may continue to retain the bilious symptoms of autumn, +which they have assumed for three years past, I know not; but the late +Dr. Faysseaux, of South-Carolina, informed me, that for many years he had +not seen a pleurisy in Charleston with the common inflammatory symptoms +which characterised that disease when he was a student of medicine. They +all now put on bilious symptoms, and require strong purges to cure them. +The pleurisies which the late Dr. Chalmers supposes he cured by purging +were probably nothing but bilious fevers, in which the cool weather had +excited some pleuritic symptoms. + + [121] Page 140. + + [122] Wallis's edition, p. 211. vol. i. + +I have nothing to add to the remarks I have elsewhere published upon the +efficacy of _cool air_ and _cold drinks_ in this fever. They were both +equally pleasant and useful, and contributed, with cleanliness, very much +to the success of my practice. + +4. _Cold water_, applied to the external parts of the body, and injected +into the bowels by way of glyster, did great service in many cases. John +Madge found great relief from cloths dipped in cold water, and applied to +the lower part of his belly. They eased a pain in his bowels, and +procured a discharge of urine. A throbbing and most distressing pain in +the head was relieved by the same remedy, in Mrs. Vogles and Mrs. Lenox. +The cloths were applied for three successive days and nights to Mrs. +Lenox's head, during an inflammation of her brain, which succeeded her +fever, and were changed, during the greater part of the time, every ten +or fifteen minutes. In 1795, I increased the coldness of pump water, when +used in this way, by dissolving ice in it, and in some cases I applied +powdered ice in a bladder to the head, with great advantage. + +The following facts will show the good effects of cold water in this, as +well as other fevers of too much action. + +In the afternoon of one of those days in which my system was impregnated +with the miasmata of the yellow fever, I felt so much indisposed that I +deliberated whether I should go to bed or visit a patient about a mile in +the country. The afternoon was cool and rainy. I recollected, at this +time, a case related by Dr. Daignan, a French physician, of a man who was +cured of the plague, by being forced to lie all night in an open field, +in a shower of rain. I got into my chair, and exposed myself to the rain. +It was extremely grateful to my feelings. In two hours I returned, when, +to my great satisfaction, I found all my feverish symptoms had left me, +nor had I the least return of them afterwards. + +Dr. Caldwell, who acted as a surgeon of a regiment, in the expedition +against the insurgents in the western counties of Pennsylvania, furnished +me, in a letter dated from Bedford, October 20th, 1794, with an account +of his having been cured of a fever, by a more copious use of the same +remedy. "I was (says the doctor), to use a vulgar expression, _wet to the +skin_, and had no opportunity of shifting my clothes for several hours. +In consequence of this thorough bathing, and my subsequent exposure to a +cool air, I was relieved from every symptom of indisposition in a few +hours, and have enjoyed more than my usual stock of health ever since." + +The efficacy of cold water, in preventing and curing inflammation, may be +conceived from its effects when used with mud or clay, for obviating the +pain and inflammation which arise from the sting of venomous insects. The +same remedy, applied for half an hour, has lately, it is said, been +equally effectual in preventing the deleterious effects of the bite of a +rattle-snake. + +II. The good effects I had observed from a _salivation_ in the yellow +fever of 1793, induced me to excite it as early as possible, in all those +cases which did not yield immediately to bleeding and purging. I was +delighted with its effects in every case in which it took place. These +effects were as follow: + +1. It immediately attracted and concentrated in the mouth all the +scattered pains of every part of the body. + +2. It checked a nausea and vomiting. + +3. It gradually, when it was copious, reduced the pulse, and thereby +prevented the necessity of further bleeding or purging. + +I wish it were possible to render the use of this remedy universal in the +treatment of malignant fevers. Dr. Chisholm, in his account of the +Beullam fever, has done much to establish its safety and efficacy. It is +a rare occurrence for a patient that has been sufficiently bled and +purged, to die after a salivation takes place. The artificial disease +excited by the mercury suspends or destroys disease in every part of the +body. The occasional inconveniences which attend it are not to be named +with its certain and universal advantages. During the whole of the season +in which the yellow fever prevailed, I saw but two instances in which it +probably loosened or destroyed the teeth. I am not certain that the +mercury was the cause of the injury or loss of those teeth; for who has +not seen malignant fevers terminate in ulcers, which have ended in the +erosions of bony parts of the body? + +It has been justly remarked, that there can be but one action at a time +in the blood-vessels. This was frequently illustrated by the manner in +which mercury acted upon the system in this fever. It seldom salivated +until the fever intermitted or declined. I saw several cases in which +the salivation came on during the intermission, and went off during its +exacerbation; and many, in which there was no salivation until the morbid +action had ceased altogether in the blood-vessels, by the solution of the +fever. It is because the action of the vessels, in epilepsy and pulmonary +consumption, surpasses the stimulus of the mercury, that it is so +difficult to excite a salivation in both those diseases. + +Let not the advocates for the healing powers of nature complain of a +salivation as an unnatural remedy in fevers. Dr. Sydenham speaks in high +terms of it, in the fever of 1670, 1671, and 1672, in which cases it +occurred spontaneously, and says that it cured it when it was so +malignant as to be accompanied by purple spots on the body[123]. + + [123] Vol. ii. p. 212. + +Blisters, when applied at a _proper_ time, did great service in this +fever. This time was, when the fever was so much weakened by evacuations, +that the artificial pain excited by the stimulus of the blisters +destroyed, and, like a conductor, conveyed off all the natural pain of +the body. It is from ignorance, or inattention to the proper stage of +fevers in which blisters have been applied, that there have been so many +disputes among physicians respecting their efficacy. When applied in a +state of great arterial action, they do harm; when applied after that +action has nearly ceased, they do little or no service. I have called the +period in which blisters are useful the _blistering point_. In bilious +fevers this point is generally circumscribed within eight and forty +hours. + +The effects of blisters were as follow: + +1. They concentrated, like a salivation, all the scattered pains of the +body, and thereby, + +2. Reduced the pulse in force and frequency. + +3. They instantly checked a sickness at the stomach and vomiting. + +4. They often induced a gentle moisture upon the skin. + +I found it of little consequence to what part of the body the blisters +were applied; for I observed a pain in the head, and even delirium, to be +as speedily and certainly cured by blisters upon the wrists, as they were +by a large blister to the neck. + +III. After the reduction of the morbid action of the blood-vessels, by +means of the remedies which have been mentioned, I seldom made use of any +other tonic than a nourishing and gently stimulating diet. This consisted +of summer fruits, bread and milk, chicken broth, the white meats, eggs, +oysters, and malt liquors, more especially porter. I made many attempts +to cure this fever when it appeared in the form of a simple intermittent, +without malignant symptoms, by means of _bark_, but always, except in two +instances, without success; and in them it did not take effect until +after bleeding. In several cases it evidently did harm. I should have +suspected my judgment in these observations respecting this medicine, had +I not been assured by Dr. Griffitts, Dr. Physick, and Dr. Woodhouse, that +it was equally ineffectual in their practice, in nearly all the cases in +which they gave it, and even where blood-letting had been premised. Dr. +Woodhouse saw a case in which near a pound of bark had been taken without +effect; and another in which a fatal dropsy succeeded its use. Dr. +Griffitts excepted, from his testimony against the bark, the cases of +seven persons from the country, who brought the seeds of the intermitting +fever with them to the city. In them the bark succeeded without previous +bleeding. The facility with which these seven cases of intermitting +fever were cured by the bark, clearly proves that fevers of the same +season differ very much, according to the nature of the exhalation which +excites them. The intermittents in these strangers were excited by +miasmata of less force than that which was generated in our city, in +which, from the greater heat of the atmosphere, and the more +heterogeneous nature of the putrid matters which stagnate in our ponds +and gutters, the exhalation probably possesses a more active and +stimulating quality. Thus the mild remittents in June, and in the +beginning of July, which were produced by the usual filth of the streets +of Philadelphia, in the year 1793, differed very much from the malignant +remitting yellow fever which was produced by the stench of the putrid +coffee a few weeks afterwards. + +Sir John Pringle long ago taught the inefficacy of bark in certain +bilious fevers. But Dr. Chisholm has done great service to medicine by +recording its ill effects in the Beullam fever. "Head-ach (says the +doctor), a heavy dull eye, with a considerable protrusion from its +orbits, low spirits, thirst, and a total want of appetite, were the +general consequences of the treatment with bark without the previous +antiphlogistic." + +I have mentioned a case of internal dropsy of the brain having been +produced by the improper use of the bark, in a son of Mr. Coates. I have +no doubt but this disease, as also palsy and consumption, obstructions of +the liver and bowels, and dropsies of the belly and limbs, are often +induced by the use of the bark, during an inflammatory state of the +blood-vessels. It is to be lamented that the association of certain +diseases and remedies, in the minds of physicians, becomes so fixed, as +to refuse to yield to the influence of reason. Thus pain and opium, +dropsy and foxglove, low spirits and assaf[oe]tida, and, above all, an +intermitting fever and bark, are all connected together, in common +practice, as mechanically as the candle and the snuffers are in the mind +of an old and steady house servant. To abolish the mischief of these +mechanical associations in medicine, it will be necessary for physicians +to prescribe only for the different states of the system. + +Finding the bark to be so universally ineffectual or hurtful, I +substituted Columbo root, the Carribean bark, and several other bitters, +in its place, but without success. They did less harm than the jesuit's +bark, but they did not check the return of a single paroxysm of fever. + +I know that bark was given in this fever in some instances in which the +patients recovered; but they were subject, during the winter, and in the +following spring, to frequent relapses, and, in some instances, to +affections of the brain and lungs. In the highest grade of the fever it +certainly accelerated a supposed putrefaction of the blood, and +precipitated death. The practice of physicians who create this gangrenous +state of fever by means of the bark, resembles the conduct of a horse, +who attempts by pawing to remove his shadow in a stream of water, and +thereby renders it so turbid that he is unable to drink it. + +Should the immediate success of tonic and depleting remedies in +destroying the fever be equal, the effects of the former upon the +constitution cannot fail of being less safe than the latter remedies. +They cure by overstraining the powers of life. There is the same +difference, therefore, between the two modes of practice, that there is +between gently lifting the latch of a door, and breaking it open in order +to go into a house. + +_Wine_ was hurtful in every case of yellow fever in which it was given, +while there were any remains of inflammatory action in the system. I +recollect that a few spoonsful of it, which Mr. Harrison of Virginia +took in the depressed state of his pulse, excited a sensation in his +stomach which he compared to a fire. Even wine-whey, in the excitable +state of the system induced by this fever, was sometimes hurtful. In a +patient of Dr. Physick, who was on the recovery, it produced a relapse +that had nearly proved fatal, in the year 1795. Dr. Desperrieres ascribes +the death of a patient to a small quantity of wine given to him by a +black nurse[124]. These facts are important, inasmuch as wine is a +medicine which patients are most apt to use in all cases, without the +advice of a physician. + + [124] Vol. ii. p. 108. + +I observed _opium_ to be less hurtful in this fever than it was in the +fever of 1793. I administered a few drops of laudanum, in one case, in +the form of a glyster, in a violent pain of the bowels, with evident +advantage, before the inflammatory action of the blood-vessels was +subdued. In this way I have often obtained the composing effects of +laudanum where it has been rejected by the stomach. But I gave it +sparingly, and in small doses only, in the early stage of the fever. John +Madge, whose pains in his bowels were often as exquisite as they are in +the most acute colic, did not take a single drop of it. I used no anodyne +in his case but bleeding, and applications of cold water to the inside +and outside of his bowels. After the fever had passed the seventh day, +and had been so far subdued by copious evacuations as to put on the form +of a common inflammatory intermittent, I gave laudanum during the +intermissions of the fever with great advantage. In some cases it +suddenly checked the paroxysms of the fever, while in many more it only +moderated them, but in such a manner that they wore themselves away in +eight or ten days. One of my female patients, who had taken bitters of +every kind without effect to cure a tertian, which succeeded a yellow +fever, took a large dose of laudanum, in the interval of her paroxysms, +to cure a tooth-ach. To her great surprise it removed her tertian. The +effects of laudanum in this fever were very different from those of bark. +Where it did no service it did not, like the bark, do any harm. + +Perhaps this difference in the operation of those two medicines depended +upon the bark acting with an astringent, as well as stimulating power, +chiefly upon the blood-vessels, while the action of the opium was more +simply stimulating, and diffused at the same time over all the systems of +the body. + +I shall say in another place that I sometimes directed a few drops of +laudanum to be given in that state of extreme debility which succeeds a +paroxysm of fever, with evident advantage. + +_Nitre_, so useful in common inflammatory fevers, was in most cases so +offensive to the stomach in this fever, that I was seldom able to give +it. Where the stomach retained it I did not perceive it to do any +service. + +_Antimonials_ were as ineffectual as nitre in abating the action of the +sanguiferous system, and in producing a sweat. I should as soon expect to +compose a storm by music, as to cure a yellow fever by such feeble +remedies. + +Thus have I finished the history of the symptoms, origin, and cure of the +yellow fever as it appeared in Philadelphia in 1794, and in the winter of +1795. The efficacy of the remedies which have been mentioned was +established by almost universal success. Out of upwards of 200 patients +to whom I was called on the first stage of the fever, between the 12th of +June, 1794, and the 1st of April, 1795, I lost but four persons, in whom +the unequivocal symptoms had occurred, which characterize the first grade +of the disease. + +It will be useful, I hope, to relate the cases of the patients whom I +lost, and to mention the causes of their deaths. The first of them was +Mrs. Gavin. She objected to a fifth bleeding in the beginning of a +paroxysm of her fever, and died from the want of it. Her death was +ascribed to the frequency of her bleedings by the enemies of the +depleting system. It was said that she had been bled ten times, owing to +ten marks of a lancet having been discovered on her arms after death, +five of which were occasioned by unsuccessful attempts to bleed her. She +died with the usual symptoms of congestion in her brain. + +Mr. Marr, to whom I was called on the first day of his disease, died in a +paroxysm of his fever which came on in the middle of the seventh night, +after six bleedings. I had left him, the night before, nearly free of +fever, and in good spirits. He might probably have been saved (humanly +speaking) by one more bleeding in the exacerbation of what appeared to be +the critical paroxysm of his fever. + +Mr. Montford, of the state of Georgia, died under the joint care of Dr. +Physick and myself. He had been cured by plentiful bleeding and purging, +but had relapsed. He appeared to expire in a fainty fit in the first +stage of a paroxysm of the fever. Death from this cause (which occurs +most frequently where blood-letting is not used) is common in the yellow +fever of the West-Indies. Dr. Bisset, in describing the different ways in +which the disease terminates fatally, says, "In a few cases the patient +is carried off by an _unexpected syncope_[125]." + + [125] Medical Essays and Observations, p. 28. + +A servant of Mr. Henry Mitchel, to whom I was called in the early stage +of his disease, died in consequence of a sudden effusion in his lungs, +which had been weakened by a previous pulmonary complaint. + +I wish the friends of bark and wine in the yellow fever, or of _moderate_ +bleeding with antimonial medicines, would publish an account of the +number of their deaths by the fever, within the period I have mentioned, +and with the same fidelity I have done. The contrast would for ever +decide the controversy in favour of copious depletion. The mortality +under the tonic mode of practice may easily be conceived from the +acknowledgment of one of the gentlemen who used it, but who premised it, +in many cases, by two and three bleedings. He informed Dr. Woodhouse, +that out of twenty-seven patients, whom he had attended in the yellow +fever, he had saved but nine. Other practitioners were, I believe, +equally unsuccessful, in proportion to the number of patients whom they +attended. The reader will not admit of many deaths having occurred from +the diseases (formerly enumerated) to which they were ascribed, when he +recollects that even a single death from most of them, in common seasons, +is a rare occurrence in the practice of regular bred physicians. + +In answer to the account I have given of the mortality of the fever in +1794, it will be said, that 30 persons died less in that year, than in +the healthy year of 1792. To account for this, it will be necessary to +recollect that the inhabitants of Philadelphia were reduced in number +upwards of 4000, in the year 1793, and of course that the proportion of +deaths was greater in 1794 than it was in 1792, although the number was +less. It is remarkable that the burials in the strangers' grave-yard +amounted in the year 1792 to but 201, whereas in 1794 they were 676. From +this it appears, that the deaths must have been very numerous among new +comers (as they are sometimes called) in the year 1794, compared with +common years. Now this will easily be accounted for, when we recollect +that these people, who were chiefly labourers, were exposed to the +constantly exciting causes of the disease, and that, in all countries, +they are the principal sufferers by it. + +But in order to do justice to this comparative view of the mortality +induced by the yellow fever in the year 1794, it will be necessary to +examine the bill of mortality of the succeeding year. By this it appears +that 2274 persons died in 1795, making 1139 more than died in 1794. The +greatness of this mortality, I well recollect, surprized many of the +citizens of Philadelphia, who had just passed an autumn which was not +unusually sickly, and who had forgotten the uncommon mortality of the +months of January, February, and March, which succeeded the autumn of +1794. + +It will probably be asked, how it came to pass that I attended so many +more patients in this fever than any of my brethren. To this I answer, +that, since the year 1793, a great proportion of my patients have +consisted of strangers, and of the poor; and as they are more exposed to +the disease than other people, it follows, that of the persons affected +by the fever, a greater proportion must have fallen to my share as +patients, than to other physicians. My ability to attend a greater number +of patients than most of my brethren, was facilitated by my having, at +the time of the fever, several ingenious and active pupils, who assisted +me in visiting and prescribing for the sick. These pupils were, Ashton +Alexander and Nathaniel Potter (now physicians at Baltimore), John Otto +(now physician in Philadelphia), and Gilbert Watson (since dead of the +yellow fever). + +The antiphlogistic remedies were not successful in Philadelphia, in the +yellow fever, in my hands alone. They were equally, and perhaps more so, +in the hands of my friends Dr. Griffitts, Dr. Physick, Dr. Dewees, and +Dr. Woodhouse. + +They were moreover successful at the same time in New Haven, Baltimore, +and in Charleston, in South-Carolina. Eighteen out of twenty died of all +who took bark and wine in New-Haven, but only one in ten of those who +used the depleting medicines. In a letter from Dr. Brown, a physician of +eminence in Baltimore, dated November 27th, 1794, he says, "of the many +cases which fell to my care, two only proved mortal where I was called on +the first day of the disease, and had an uncontrouled opportunity to +follow my judgment. Where salivation took place, I had no case of +mortality; and in two of those cases, a black vomiting occurred." Dr. +Ramsay, of Charleston, in a letter to one of his friends in this city, +dated October 14th, 1794, subscribes to the efficacy of the same +practice in a fever which prevailed at that time in Charleston, and +which, he says, resembled the yellow fever of Philadelphia in the year +1793. + +But the success of the depleting system was not confined to the United +States. In a letter before quoted, which I received from Dr. Davidson, of +St. Vincents, dated July 22d, 1794, there is the following testimony in +favour of evacuations from the blood-vessels, bowels, and salivary +glands: + +"Where the fever comes on with great determination to the head, and an +affection of the stomach, in consequence of that determination, violent +head-ach, redness of the eyes, turgescence of the face, impatience of +light, &c. attended with a full and hard pulse, _blood-letting_ should be +employed _freely_ and _repeatedly_, cold applications should be applied +to the head, and purging medicines should be employed. As a purge, +_calomel_ has been used with the greatest advantage, sometimes by itself, +but most frequently combined with some active purgative medicine, such as +jalap. From some peculiarity in the disease, an uncommon quantity of the +calomel is necessary to affect the bowels and salivary glands. As I found +a small quantity of it did not produce the effect I wished for promptly, +I have gradually increased the quantity, until I now venture to give +_ten_ grains of it, combined with five of jalap, every _two_ hours until +stools are procured. The calomel is then given by itself. + +"The patients have generally an aversion to wine. The bark is seldom +found of much advantage in this state of the fever, and frequently +brought on a return of the vomiting. I preferred to it, in a remission of +the symptoms, a vinous infusion of the quassia, which sat better upon the +stomach." + +In the island of Jamaica, the depleting system has been divided. It +appears, from several publications in the Kingston papers, that Dr. Grant +had adopted blood-letting, while most of the physicians of the island +rest the cure of the yellow fever upon strong mercurial purges. The ill +effects of _moderate_ bleeding probably threw the lancet into disrepute, +for the balance of success, from those publications, is evidently in +favour of simple purging. I have no doubt of the truth of the above +statement of the controversy between the exclusive advocates for bleeding +and purging; or perhaps the superior efficacy of the latter remedy may be +explained in the following manner. + +In warm climates, the yellow fever is generally, as it was in +Philadelphia in the month of August and in the beginning of September, +1793, a disease of but two or three paroxysms. It is sometimes, I +believe, only a simple ephemera. In these cases, purging alone is +sufficient to reduce the system, without the aid of bleeding. It was +found to be so until the beginning of September, in 1793, in most cases +in Philadelphia. The great prostration of the system in the yellow fever, +in warm weather and in hot climates, renders the restoration of it to a +healthy state of action more gradual, and of course more safe, by means +of purging than bleeding. The latter remedy does harm, from the system +being below the point of re-action, after the pressure of the blood is +taken from it, or by restoring the blood-vessels too suddenly to +preternatural action, without reducing them afterwards. Had bleeding been +practised agreeably to the method described by Riverius (mentioned in the +history of the fever of 1793), or had the fever in Jamaica run on to more +than four or five paroxysms, it is probable the loss of blood would have +been not only safe, but generally beneficial. I have, in the same +history, given my reasons why _moderate_ bleeding in this, as well as +many other diseases, does harm. In those cases where it has occurred in +large quantities from natural hæmorrhages, it has always done service in +the West-Indies. The inefficacy, and, in some cases, the evils, of +_moderate_ blood-letting are not confined to the yellow fever. It is +equally ineffectual, and, in some instances, equally hurtful, in +apoplexy, internal dropsy of the brain, pleurisy, and pulmonary +consumption. Where all the different states of the pulse which indicate +the loss of blood are perfectly understood, and blood-letting conformed +in _time_ and in _quantity_ to them, it never can do harm, in any +disease. It is only when it is prescribed empirically, without the +direction of just principles, that it has ever proved hurtful. Thus the +fertilizing vapours of heaven, when they fall only in dew, or in profuse +showers of rain, are either insufficient to promote vegetation, or +altogether destructive to it. + +There may be habits in which great and long protracted debility may have +so far exhausted the active powers of the system, as to render bleeding +altogether improper in this disease, in a West-India climate. Such habits +are sometimes produced in soldiers and sailors, by the hardships of a +military and naval life. Bleeding in such cases, Dr. Davidson assures me, +in a letter dated from Martinique, February 29th, 1796, did no good. The +cure was effected, under these circumstances, by purges, and large doses +of calomel. But where this chronic debility does not occur, bleeding, +when properly used, can never be injurious, even in a tropical climate, +in the yellow fever. Of this there are many proofs in the writings of the +most respectable English and French physicians. In spite of the fears and +clamours which have been lately excited against it in Jamaica, my late +friend and contemporary at the college of Edinburgh, Dr. Broadbelt, in a +letter from Spanish Town, dated January 6th, 1795, and my former pupil, +Dr. Weston, in a letter from St. Ann's Bay, dated June 17th, 1795, both +assure me, that they have used it in this fever with great success. Dr. +Weston says that he bled "_copiously_ three times in twenty-four hours, +and thereby saved his patient." + +The superior advantages of the North-American mode of treating the yellow +fever, by means of _all_ the common antiphlogistic remedies, will appear +from comparing its success with that of the West-India physicians, under +all the modes of practice which have been adopted in the islands. Dr. +Desportes lost one half of all the patients he attended in the yellow +fever in one season in St. Domingo[126]. His remedies were _moderate_ +bleeding and purging, and the copious use of diluting drinks. Dr. Bisset +says, "the yellow fever is often under particular circumstances very +fatal, carrying off four or five in seven whom it attacks, and sometimes, +but seldom, it is so favourable as to carry off only one patient in five +or six[127]." The doctor does not describe the practice under which this +mortality takes place. + + [126] Vol. i. p. 55. + + [127] Medical Essays and Observations, p. 29. + +Dr. Home, I have elsewhere remarked[128], lost "one out of four of his +patients in Jamaica." His remedies were _moderate_ bleeding and purging, +and afterwards bark, wine, and external applications of blankets dipped +in hot vinegar. + + [128] Account of the Yellow Fever of 1793. + +Dr. Blane pronounces the yellow fever to be "one of the most fatal +diseases to which the human body is subject, and in which human art is +the most unavailing." His remedies were bleeding, bark, blisters, acid +drinks, saline draughts, and camomile tea. + +Dr. Chisholm acknowledges that he lost one in twelve of all the patients +he attended in the fever of Grenada. His principal remedy was a +salivation. I shall hereafter show the inferiority of this single mode of +depleting, to a combination of it with bleeding and purging. In +Philadelphia and Baltimore, where bleeding, purging, and salivation were +used in due time, and after the manner that has been described, not more +than one in fifty died of the yellow fever. It is probable that greater +certainty and success in the treatment of this disease will not easily be +attained, for idiosyncracy, and habits of intemperance which resist or +divert the operation of the most proper remedies, a dread of the lancet, +or the delay of an hour in the use of it, the partial application of that +or any other remedy, the unexpected recurrence of a paroxysm of fever in +the middle of the night, or the clandestine exhibition of wine or +laudanum by friends or neighbours, often defeat the best concerted plans +of cure by a physician. Heaven in this, as in other instances, kindly +limits human power and benevolence, that in all situations man may +remember his dependence upon the power and goodness of his Creator. + + + + + AN + + ACCOUNT + + OF + + SPORADIC CASES + + OF + + _BILIOUS YELLOW FEVER_, + + IN PHILADELPHIA, + + IN THE YEARS 1795 AND 1796. + + +In my account of the yellow fever, as it appeared in Philadelphia in the +year 1794, I took notice of several cases of it which occurred in the +spring of the year 1795. Before I proceed to deliver the history of this +disease as it appeared in 1797, I shall mention the diseases and state of +the weather which occurred during the remaining part of the year 1795, +and the whole of the year 1796. This detail of facts, apparently +uninteresting to the reader in the present state of our knowledge of +epidemics, may possibly lead to principles at a future day. + +The month in of April, 1795, was wet and cold. All the diseases of this +month partook of the inflammatory character of the preceding winter and +autumn, except the measles, which were unusually mild. + +The weather in May was alternately wet, cool, and warm. A few cases of +malignant fever occurred this month, but with moderate symptoms. In June +the weather was cool and pleasant. The measles put on more inflammatory +symptoms than in the preceding months. I had two cases of mania under my +care this month, and one of rheumatism, which were attended with +intermissions and exacerbations every other day. + +The weather on the 19th, 20th, 21st, and 22d days of July was very warm, +the mercury being at 90° in Fahrenheit's thermometer. The fevers of this +month were all accompanied with black discharges from the bowels. Mr. +Kittera, one of the representatives of Pennsylvania in the congress of +the United States, in consequence of great fatigue on a warm day, was +affected with the usual symptoms of the yellow fever. During his illness +he constantly complained of more pain in the left, than in the right side +of his head. His pulse was more tense in his left, than in his right arm. +During his convalescence, it was more quick in the left arm, than it was +in the right. He was cured by a salivation and the loss of above 100 +ounces of blood. His head-ach was relieved by the application of a +bladder half filled with ice to his forehead. + +Most of the cases of bilious fever, which came under my notice, were +attended with quotidian, tertian, or quartan intermissions. In a few of +my patients there was a universal rash. + +Dr. Woodhouse informed me, that he had seen several instances in which +the yellow fever appeared in the same place in which some soldiers had +laboured under the dysentery. These facts show the unity of fever, and +the impracticability of a nosological arrangement of diseases. + +The cholera infantum was severe and fatal, in many instances, during this +month. It yielded to blood-letting in a child of Mr. Conyngham, which was +but four months old. In a child of seven weeks old which came under my +care, I observed the coldness, chills, hot fits, and remissions of the +bilious fever to be as distinctly marked as ever I had seen them in adult +patients. In a child of Mr. Darrach, aged 5 months, the discharges from +the bowels were of a black colour. I mention these facts in support of an +opinion I formerly published, that the cholera infantum is a bilious +fever, and that it rises and falls in its violence with the bilious fever +of grown persons. + +About the latter end of this month and the beginning of August, there +were heavy showers of rain, which carried away fences, bridges, barns, +mills, and dwelling-houses in many places. Several cases of bilious +yellow fever occurred in the month of August. In one of them it was +accompanied with that morbid affection in the wind-pipe which has been +called cynanche trachealis. It was remarkable that sweating became a more +frequent symptom of the fevers of this month than it had been in July. +Hippocrates ascribes this change in the character of bilious fevers to +rainy weather. Perhaps it was induced by the rain which fell in the +beginning of the month, in the fevers which have been named. + +Among the persons affected with the yellow fever during this month, was +William Bradford, Esq. the attorney-general of the United States. From a +dread of the lancet he objected to being bled in the early stage of his +disease, in consequence of which he died on the 23d of August, in the +39th year of his age, amidst the tears of numerous friends, and the +lamentations of his whole country. + +On the 30th and 31st of August, there was a fall of rain, which suddenly +checked the fever of the season, insomuch that the succeeding autumnal +months were uncommonly healthy. Several showers of rain had nearly the +same effect in New-York, where this fever carried off, in a few weeks, +above 700 persons. It prevailed, at the same time, and with great +mortality, in the city of Norfolk, in Virginia. + +In both those cities, as well as in Philadelphia, the disease was +evidently derived from putrid exhalation. + +In the same month, the dysentery prevailed in Newhaven, in Connecticut, +and in the same part of the town in which the yellow fever had prevailed +the year before. The latter disease was said to have been imported, but +the prevalence of the dysentery, under the above circumstances, proved +that both diseases were of domestic origin. + +The fever, as it appeared in Philadelphia, yielded in most cases to +depleting remedies. After purging and blood-letting, I gave bark, where +the fever intermitted, with advantage. It was effectual only when given +in large doses. In one instance, it induced a spitting of blood, which +obliged me to lay it aside. + +The winter of 1796 was uncommonly moderate. There fell a good deal of +rain, but little snow. The navigation of the Delaware was stopped but two +or three days during the whole season. Catarrhs were frequent, but very +few violent or acute diseases occurred in my practice. The month of March +and the first week in April were uncommonly dry. Several cases of +malignant bilious fever came under my care during these months. A little +girl, of five years old, whom I lost in this fever, became yellow in two +hours after her death. + +The measles prevailed in April, and were of a most inflammatory nature. +The weather in May and June was uncommonly wet. The fruit was much +injured, and a great deal of hay destroyed by it. On the 14th of June, +General Stewart died, with all the usual symptoms of a fatal yellow +fever. Several other cases of it, in this and in the succeeding month, +proved mortal, but they excited no alarm in the city, as the physicians +who attended them called them by other names. + +The rain which fell about the middle of July checked this fever. August, +September, and October were unusually healthy. A few cases of malignant +sore throat appeared in November. They were, in all the patients that +came under my notice, attended with bilious discharges from the stomach +and bowels. So little rain fell during the autumnal months, that the +wheat perished in many places. The weather in December was extremely +cold. The lamps of the city were, in several instances, extinguished by +it, on the night of the 23d of the month, at which time the mercury stood +at 2° below 0 in the thermometer. + +The yellow fever prevailed this year in Charleston, in South-Carolina, +where it was produced by putrid exhalations from the cellars of houses +which had been lately burnt. It was said by the physicians of that place +not to be contagious. The same fever prevailed, at the same time, at +Wilmington, in North-Carolina, and at Newburyport, in the state of +Massachusetts. In the latter place, it was produced by the exhalation of +putrid fish, which had been carelessly thrown upon a wharf. + + + END OF VOLUME III. + + + + + * * * * * + + + + +Transcriber's note: + +The original spelling and minor inconsistencies in the spelling and +formatting have been maintained. + +Obvious misprints have been corrected. + +Partly repeated chapter headings have been deleted. + + + +*** END OF THE PROJECT GUTENBERG EBOOK 58861 *** |