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diff --git a/58862-0.txt b/58862-0.txt new file mode 100644 index 0000000..cca99e2 --- /dev/null +++ b/58862-0.txt @@ -0,0 +1,8453 @@ +*** START OF THE PROJECT GUTENBERG EBOOK 58862 *** + + + +Note: Project Gutenberg also has an HTML version of this + file which includes the original illustrations. + See 58862-h.htm or 58862-h.zip: + (http://www.gutenberg.org/files/58862/58862-h/58862-h.htm) + or + (http://www.gutenberg.org/files/58862/58862-h.zip) + + + Images of the original pages are available through + Internet Archive. See + https://archive.org/details/b21935142_0004 + + + 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 III: see http://www.gutenberg.org/ebooks/58861 + + +Transcriber's note: + + The ligature oe has been marked as [oe]. + + Text in italics has been enclosed by underscores (_text_). + + + + + + 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. IV. + + 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 IV. + + _page_ + + _An account of the bilious yellow fever, as it appeared in + Philadelphia in 1797_ 1 + + _An account of the bilious yellow fever, as it appeared in + Philadelphia in 1798_ 63 + + _An account of the bilious yellow fever, as it appeared in + Philadelphia in 1799_ 89 + + _An account of sporadic cases of yellow fever, as they appeared + in Philadelphia in 1800_ 101 + + _An account of sporadic cases of yellow fever, as they appeared + in Philadelphia in 1801_ 109 + + _An account of the measles, as they appeared in Philadelphia in + 1801_ 115 + + _An account of the yellow fever, as it appeared in 1802_ 121 + + _An account of the yellow fever, as it appeared in 1803_ 131 + + _An account of sporadic cases of yellow fever, as they appeared + in 1804_ 145 + + _An account of the yellow fever, as it appeared in 1805_ 151 + + _An inquiry into the various sources of the usual forms of the + summer and autumnal disease in the United States, and the means + of preventing them_ 161 + + _Facts, intended to prove the yellow fever not to be contagious_ 221 + + _Defence of blood-letting, as a remedy in certain diseases_ 273 + + _An inquiry into the comparative states of medicine in + Philadelphia, between the years 1760 and 1766, and 1805_ 363 + + * * * * * + + + + + AN ACCOUNT + + OF THE + + BILIOUS REMITTING AND INTERMITTING + + _YELLOW FEVER_, + + AS IT + + APPEARED IN PHILADELPHIA, + + IN 1797. + + +The winter of 1797 was in general healthy. During the spring, which was +cold and wet, no diseases of any consequence occurred. The spring +vegetables were late in coming to maturity, and there were every where in +the neighbourhood of Philadelphia scanty crops of hay. In June and July +there fell but little rain. Dysenteries, choleras, scarlatina, and mumps, +appeared in the suburbs in the latter month. On the 8th of July I visited +Mr. Frisk, and on the 25th of the same month I visited Mr. Charles Burrel +in the yellow fever, in consultation with Dr. Physick. They both +recovered by the use of plentiful depleting remedies. + +The weather from the 2d to the 9th of August was rainy. On the 1st of +this month I was called to visit Mr. Nathaniel Lewis, in a malignant +bilious fever. On the 3d I visited Mr. Elisha Hall, with the same +disease. He had been ill several days before I saw him. Both these +gentlemen died on the 6th of the month. They were both very yellow after +death. Mr. Hall had a black vomiting on the day he died. + +The news of the death of these two citizens, with unequivocal symptoms of +yellow fever, excited a general alarm in the city. Attempts were made to +trace it to importation, but a little investigation soon proved that it +was derived from the foul air of a ship which had just arrived from +Marseilles, and which discharged her cargo at Pinestreet wharf, near the +stores occupied by Mr. Lewis and Mr. Hall. Many other persons about the +same time were affected with the fever from the same cause, in Water and +Penn-streets. About the middle of the month, a ship from Hamburgh +communicated the disease, by means of her foul air, to the village of +Kensington. It prevailed, moreover, in many instances in the suburbs, and +in Kensington, from putrid exhalations from gutters and marshy grounds, +at a distance from the Delaware, and from the foul ships which have been +mentioned. Proofs of the truth of each of these assertions were +afterwards laid before the public. + +The disease was confined chiefly to the district of Southwark and the +village of Kensington, for several weeks. In September and October, many +cases occurred in the city, but most of them were easily traced to the +above sources. + +The following account of the weather, during the months of August, +September, and October was obtained from Mr. Thomas Pryor. It is +different from the weather in 1793. It is of consequence to attend to +this fact, inasmuch as it shows that an inflammatory constitution of the +atmosphere can exist under different circumstances of the weather. It +likewise accounts for the variety in the symptoms of the fever in +different years and countries. Such is the influence of season and +climate upon the symptoms of this fever, that it led Dr. M'Kitterick to +suppose that the yellow fever of Charleston, so accurately described by +Dr. Lining, in the second volume of the Physical and Literary Essays of +Edinburgh, was a different disease from the yellow fever of the +West-Indies[1]. + + [1] De Febre Indiæ-Occidentalis Maligna Flava, p. 12. + + + METEOROLOGICAL OBSERVATIONS, + + _MADE IN PHILADELPHIA_. + + AUGUST, 1797. + + +--+-----+------+----------------------------------------------+ + |D.|Ther.|Barom.| Winds and Weather. | + +--+--+--+------+----------------------------------------------+ + | 1|73|75|30 0|S. E. E. Rain in the forenoon and afternoon. | + | 2|72|76|30 0|N. E. by E. Cloudy, with rain in the afternoon| + | | | | | and night. Wind E. by N. | + | 3|72|78|30 6|E. 1/2 N. Rain in the morning, and all day and| + | | | | | night. | + | 4|72|78|30 4|E. Rained hard all day and at night. | + | 5|74|79|29 84|Wind light, S. W. Cloudy. Rain this morning. | + | | | | | The air extremely damp; wind shifted | + | | | | | to N. W. This evening heavy showers, | + | | | | | with thunder. | + | 6|73|76|30 86|W. N. W. Cloudy. | + | 7|70|76|30 4|N. W. Close day. Rain in the evening and | + | | | | | all night. Wind to E. | + | 8|72|76|29 95|E. Rain this morning. | + | 9|72|76|29 86|S. W. Cloudy morning. | + |10|69|73|30 16|N. W. Clear. | + |11|70|74|30 25|N. W. Clear. Rain all night. | + |12|71|74|30 5|S. W. Cloudy. Rain in the morning. Cloudy | + | | | | | all day. Rain at night. | + |13|73|75|29 87|S. W. Cloudy. Rain all day. | + |14|70|74|29 9|N. W. Clear fine morning. | + |15|56|60|30 15|N. W. Clear fine morning. | + |16|60|64|30 24|N. W. Clear fine morning. | + |17|60|65|30 24|N. W. Air damp. | + |18|68|75|30 4|S. W. Cloudy. Rain, with thunder at night: | + | | | | | a fine shower. | + |19|72|78|29 7|N. W. Clear. Cloudy in the evening, with | + | | | | | thunder. | + |20|70|77|29 8|W. N. W. Fine clear morning. | + |21|74|76|29 9|N. W. Clear to E. | + |22|68|76| |E. Small shower this morning. Hard shower | + | | | | | at 11, A. M. Wind N. E. | + |23|71|76|29 92|E. Cloudy. At noon calm. | + |24|71|75|29 95|Calm morning and clear. | + |25|70|75|30 5|N. E. Clear. Rain in the afternoon, with | + | | | | | thunder. | + |26|70|75|30 5|S. E. Rain in the morning. Rained hard in the | + | | | | | night, with thunder, N. W. | + |27|68|76|29 9|N. W. Fine clear morning. | + |28|64|75|29 96|N. W. Clear. | + |29|59|70|30 0|E. Clear. | + |30|70|76|30 1|E. by S. Rain in the morning. | + |31|68|74|30 14|S. E. Cloudy. Damp air and sultry. | + +--+--+--+------+----------------------------------------------+ + + + SEPTEMBER, 1797. + + +--+-----+------+----------------------------------------------+ + |D.|Ther.|Barom.| Winds and Weather. | + +--+-----+------+----------------------------------------------+ + | 1|73|80|30 6|S. W. Cloudy. Damp air. Rain in the morning | + | 2|79|80|29 9|N. W. Clear. Cloudy in the evening, with | + | | | | | lightning to the southward. | + | 3|68|74|30 0|N. by W. Cloudy. Clear in the afternoon and | + | | | | | night. | + | 4|66|74|30 7|W. N. W. Clear fine morning. | + | 5|58|73|30 1|N. W. Clear. Cloudy in the evening. | + | 6|58|72|30 13|Fresh at E. Clear. Rain in the evening. | + | 7|56|76|30 28|E. Clear. Cloudy in the evening. | + | 8|54|65|30 1|N. E. Clear and cool morning. Flying clouds at| + | | | | | noon. | + | 9|56|65|30 1|E. N. E. Clear. | + |10|58|63|30 26|N. E. Clear fine morning. Wind fresh at N. E. | + | | | | | all day. | + |11|53|64|30 13|N. to E. with flying clouds. | + |12|51|62|30 6|W. N. W. Clear cool morning. | + |13|56|67|30 3|S. W. Cloudy. Clear in the afternoon. | + |14|64|70|29 98|S. W. Clear. | + |15|66|73|29 85|S. W. Rain in the morning. Cloudy in the | + | | | | | afternoon. | + |16|62|70|29 95|N. W. Clear. | + |17|56|67|30 0|N. W. Clear. | + |18|58|63|29 88|E. Cloudy. Rained all day, and thunder. | + | | | |29 62| Rained very heavy at night. | + |19|55|63|29 75|W. N. W. Clear fine morning. | + |20|47|63|30 8|W. N. W. Clear fine morning. New moon | + | | | | | at 9 50 morning. | + |21|46|60|30 0|N. E. Clear fine morning; to S. E. in the | + | | | | | evening. Cloudy at night. | + |22|56|65|30 4|N. W. Rain in the morning. Rain at night. | + |23|56|66|30 0|N. N. E. Cloudy. | + |24|52|66|29 9|E. by S. Clear fine morning. Cloudy at night | + | | | |29 78| | + |25|56|68|29 37|W. N. W. Clear fine morning; clear all day. | + |26|58|68|29 95|E. In the morning flying clouds. | + |27|48|63|30 2|N. W. Clear fine morning; clear all day. | + |28|48|63|30 2|W. N. W. Clear fine morning; clear all day. | + |29|54|63|30 15|E. Clear fine morning. | + |30|60|65|30 26|E. Fresh. Cloudy morning. Rain in the night | + +--+--+--+------+----------------------------------------------+ + + + OCTOBER, 1797. + + +--+-----+------+----------------------------------------------+ + |D.|Ther.|Barom.| Winds and Weather. | + +--+-----+------+----------------------------------------------+ + | 1|55|65|30 16|N. E. Rain this morning, and great, part of | + | | | | | the day. | + | 2|55|66|30 0|N. W. Clear. | + | 3|60|70|29 9|S. E. Clear. Air damp. | + | 4|60|70|29 5|W. N. W. Rain this morning. | + | 5|46|60|30 0|W. N. W. to S. by W. in the evening. Clear | + | | | | | all day. White frost this morning. | + | 6|55|65|30 0|S. W. Clear fine morning. White frost. | + | 7|56|76|30 0|S. W. Cloudy. Rain in the night. | + | 8|56|70|30 29|S. Cloudy this morning; air damp. Wind | + | | | | | shifted to W. N. W. Blows fresh. | + | 9|50|60|29 85|W. N. W. Clear morning. Fresh at N. W. | + | | | | | in the evening. | + |10|40|58|30 1|W. N. W. Clear. Frost this morning. | + |11|38|56|30 2|W. N. W. Cloudy. | + |12|34|52|30 38|W. N. W. Clear. Ice this morning. | + |13|35|55|30 5|N. Clear fine morning. Ice this morning. | + |14|40|60|30 28|N. E. Cloudy. | + |15|50|65|30 16|W. N. W. Clear. | + |16|36|56|30 2|W. N. W. Clear fine morning. | + |17|37|56|30 18|W. N. W. Clear fine morning. | + |18|47|60|29 86|W. N. W. Clear fine weather. | + |19|48|60|30 6|N. W. Clear fine day. | + |20|42|55|30 8|N. E. Cloudy. Rain in the afternoon and | + | | | | | night. Blows fresh at N. E. | + |21|42|50|29 92|N. E. Blows fresh (with a little rain). | + | | | | | Thunder in the night, with rain. | + |22|44|56|29 57|N. W. Rain in the morning. | + |23|44|56|29 95|S. W. Clear fine morning. | + |24|42|54|30 5|N. E. Cloudy. A great deal of rain in the | + | | | | | night. | + |25|40|52|30 15|N. E. Clear fine morning. | + |26|36|48|30 29|W. N. W. Clear. | + |27|34|46|30 23|Fresh at S. W. Clear. | + |28|40|52|29 95|W. N. W. Cloudy. | + |29|34|46|29 82|W. Cloudy. | + |30|32|42|29 93|N. W. Clear. Hard frost this morning. | + |31|38|48|30 18|W. S. W. Cloudy part of this day; clear the | + | | | | | remainder. | + +--+--+--+------+----------------------------------------------+ + +In addition to the register of the weather it may not be improper to add, +that moschetoes were more numerous during the prevalence of the fever +than in 1793. An unusual number of ants and cockroaches were likewise +observed; and it was said that the martins and swallows disappeared, for +a while, from the city and its neighbourhood. + +A disease prevailed among the cats some weeks before the yellow fever +appeared in the city. It excited a belief in an unwholesome state of the +atmosphere, and apprehensions of a sickly fall. It generally proved fatal +to them. + +After the first week in September there were no diseases to be seen but +yellow fever. In that part of the town which is between Walnut and +Vine-streets it was uncommonly healthy. A similar retreat of inferior +diseases has been observed to take place during the prevalence of the +plague in London, Holland, and Germany, according to the histories of +that disease by Sydenham, Diemerbroeck, Sennertus, and Hildanus. It +appears, from the register of the weather, that it rained during the +greatest part of the day on the 1st of October. The effects of this rain +upon the disease shall be mentioned hereafter. On the 10th the weather +became cool, and on the nights of the 12th and 13th of the month there +was a frost accompanied with ice, which appeared to give a sudden and +complete check to the disease. + +The reader will probably expect an account of the effects of this +distressing epidemic upon the public mind. The terror of the citizens for +a while was very great. Rumours of an opposite and contradictory nature +of the increase and mortality of the fever were in constant circulation. +A stoppage was put to business, and it was computed that about two thirds +of the inhabitants left the city. + +The legislature of the state early passed a law, granting 10,000 dollars +for the relief of the sufferers by the fever. The citizens in and out of +town, as also many of the citizens of our sister states, contributed more +than that sum for the same charitable purpose. This money was issued by a +committee appointed by the governor of the state. An hospital for the +reception of the poor was established on the east side of the river +Schuylkill, and amply provided with every thing necessary for the +accommodation of the sick. Tents were likewise pitched on the east side +of Schuylkill, to which all those people were invited who were exposed to +the danger of taking the disease, and who had not means to provide a +more comfortable retreat for themselves in the country. + +I am sorry to add that the moral effects of the fever upon the minds of +our citizens were confined chiefly to these acts of benevolence. Many of +the publications in the newspapers upon its existence, mode of cure, and +origin partook of a virulent spirit, which ill accorded with the +distresses of the city. It was a cause of lamentation likewise to many +serious people, that the citizens in general were less disposed, than in +1793, to acknowledge the agency of a divine hand in their afflictions. In +some a levity of mind appeared upon this solemn occasion. A worthy +bookseller gave me a melancholy proof of this assertion, by informing me, +that he had never been asked for playing cards so often, in the same +time, as he had been during the prevalence of the fever. + +Philadelphia was not the only place in the United States which suffered +by the yellow fever. It prevailed, at the same time, at Providence, in +Rhode-Island, at Norfolk, in Virginia, at Baltimore, and in many of the +country towns of New-England, New-Jersey, and Pennsylvania. + +The influenza followed the yellow fever, as it did in the year 1793. It +made its appearance in the latter end of October, and affected chiefly +those citizens who had been out of town. + +The predisposing causes of the yellow fever, in the year 1797, were the +same as in the year 1793. Strangers were as usual most subject to it. The +heat of the body in such persons, in the West-Indies, has been found to +be between three and four degrees above that of the temperature of the +natives. This fact is taken notice of by Dr. M'Kitterick, and to this he +ascribes, in part, the predisposition of new comers to the yellow fever. + +In addition to the common exciting causes of this disease formerly +enumerated, I have only to add, that it was induced in one of my patients +by smoking a segar. He had not been accustomed to the use of tobacco. + +I saw no new premonitory symptoms of this fever except a tooth-ach. It +occurred in Dr. Physick, Dr. Caldwell, and in my pupil, Mr. Bellenger. In +Miss Elliot there was such a soreness in her teeth, that she could hardly +close her mouth on the day in which she was attacked by the fever. +Neither of these persons had taken mercury to obviate the disease. + +I shall now deliver a short account of the symptoms of the yellow fever, +as they appeared in several of the different systems of the body. + +I. There was but little difference in the state of the pulse in this +epidemic from what has been recorded in the fevers of 1793 and 1794. I +perceived a pulse, in several cases, which felt like a soft quill which +had been _shattered_ by being trodden upon. It occurred in Dr. Jones and +Dr. Dobell, and in several other persons who had been worn down by great +fatigue, and it was, in every instance, followed by a fatal issue of the +fever. In Dr. Jones this state of the pulse was accompanied with such a +difficulty of breathing, that every breath he drew, on the day of his +attack, he informed me, was the effort of a sigh. He died on the 17th of +September, and on the sixth day of his fever. + +The action of the arteries was, as usual, very irregular in many cases. +In some there was a distressing throbbing of the vessels in the brain, +and in one of my patients a similar sensation in the bowels, but without +pain. Many people had issues of blood from their blisters in this fever. + +I saw nothing new in the effects of the fever upon the liver, lungs, +brain, nor upon the stomach and bowels. + +II. The excretions were distinguished by no unusual marks. I met with no +recoveries where there were not black stools. They excoriated the rectum +in Dr. Way. It was a happy circumstance where morbid bilious matter came +away in the beginning of the disease. But it frequently resisted the most +powerful cathartics until the 5th or 7th day of the fever, at which time +it appeared rather to yield to the disorganization of the liver than to +medicine. Where sufficient blood-letting had been previously used, the +patient frequently recovered, even after the black discharges from the +bowels took place in a late stage of the disease. + +Dr. Coxe informed me, that he attended a child of seventeen months old +which had _white_ stools for several days. Towards the close of its +disease it had black stools, and soon afterwards died. + +Several of my patients discharged worms during the fever. In one instance +they were discharged from the mouth. + +A preternatural frequency in making pale water attended the first attack +of the disease in Mr. Joseph Fisher. + +A discharge of an unusual quantity of urine preceded, a few hours, the +death of the daughter of Mrs. Read. + +In two of my patients there was a total suppression of urine. In one of +them it continued five days without exciting any pain. + +There was no disposition to sweat after the first and second days of the +fever. Even in those states of the fever, in which the intermissions were +most complete, there was seldom any moisture, or even softness on the +skin. This was so characteristic of malignity in the bilious fever, that +where I found the opposite state of the skin, towards the close of a +paroxysm, I did not hesitate to encourage my patient, by assuring him +that his fever was of a mild nature, and would most probably be safe in +its issue. + +III. I saw no unusual marks of the disease in the nervous system. The +mind was seldom affected by delirium after the loss of blood. There was +a disposition to shed tears in two of my patients. One of them wept +during the whole time of a paroxysm of the fever. In one case I observed +an uncommon dulness of apprehension, with no other mark of a diseased +state of the mind. It was in a man whose faculties, in ordinary health, +acted with celerity and vigour. + +Dr. Caldwell informed me of a singular change which took place in the +operations of his mind during his recovery from the fever. His +imagination carried him back to an early period of his life, and engaged +him, for a day or two, in playing with a bow and arrow, and in amusements +of which he had been fond when a boy. A similar change occurred in the +mind of my former pupil, Dr. Fisher, during his convalescence from the +yellow fever in 1793. He amused himself for two days in looking over the +pictures of a family Bible which lay in his room, and declared that he +found the same kind of pleasure in this employment that he did when a +child. However uninteresting these facts may now appear, the time will +come when they may probably furnish useful hints for completing the +physiology and pathology of the mind. + +Where blood-letting had not been used, patients frequently died of +convulsions. + +IV. The senses of seeing and feeling were impaired in several cases. Mrs. +Bradford's vision was so weak that she hardly knew her friends at her +bed-side. I had great pleasure in observing this alarming symptom +suddenly yield to the loss of four ounces of blood. + +Several persons who died of this fever did not, from the beginning to the +end of the disease, feel any pain. I shall hereafter endeavour to explain +the cause of this insensible state of the nerves. + +The appetite for food was unimpaired for three days in Mr. Andrew Brown, +at a time when his pulse indicated a high grade of the fever. I heard of +several persons who ate with avidity just before they died. + +V. Glandular swellings were very uncommon in this fever. I should have +ascribed their absence to the copious use of depleting remedies in my +practice, had I not been informed that morbid affections of the lymphatic +glands were unknown in the city hospital, where blood-letting was seldom +used, and where the patients, in many instances, died before they had +time to take medicine of any kind. + +VI. The skin was cool, dry, smooth, and even shining in some cases. +Yellowness was not universal. Those small red spots, which have been +compared to moscheto bites, occurred in several of my patients. Dr. John +Duffield, who acted as house surgeon and apothecary at the city hospital, +informed me that he saw vibices on the skin in many cases, and that they +were all more or less sore to the touch. + +VII. The blood was dissolved in a few cases. That appearance of the +blood, which has been compared to the washings of flesh, was very common. +It was more or less sizy towards the close of the disease in most cases. +I have suspected, from this circumstance, that this mark of ordinary +morbid action or inflammation was in part the effect of the mercury +acting upon the blood-vessels. It is well known that sizy blood generally +accompanies a salivation. If this conjecture be well founded, it will not +militate against the use of mercury in malignant fevers, for it shows +that this valuable medicine possesses a power of changing an +extraordinary and dangerous degree of morbid action in the blood-vessels +to that which is more common and safe. I have seldom seen a yellow fever +terminate fatally after the appearance of sizy blood. + +Dr. Stewart informed me, that in those cases in which the serum of the +blood had a yellow colour, it imparted a saline taste only to his tongue. +He was the more struck with this fact, as he perceived a strong bitter +state upon his skin, in a severe attack of the yellow fever in 1793. + +I proceed next to take notice of the type of the fever. + +In many cases, it appeared in the form of a remitting and intermitting +fever. The quotidian and tertian forms were most common. In Mr. Robert +Wharton, it appeared in the form of a quartan. But it frequently assumed +the character which is given of the same fever in Charleston, by Dr. +Lining. It came on without chills, and continued without any remission +for three days, after which the patient believed himself to be well, and +sometimes rose from his bed, and applied to business. On the fourth or +fifth day, the fever returned, and unless copious evacuations had been +used in the early stage of the disease, it generally proved fatal. +Sometimes the powers of the system were depressed below the return of +active fever, and the patient sunk away by an easy death, without pain, +heat, or a quick pulse. I have been much puzzled to distinguish a crisis +of the fever on the third or fourth day, from the insidious appearance +which has been described. It deceived me in 1793. It may be known by a +preternatural coolness in the skin, and languor in the pulse, by an +inability to sit up long without fatigue or faintness, by a dull eye, and +by great depression of mind, or such a flow of spirits as sometimes to +produce a declaration from the patient that "he feels too well." Where +these symptoms appear, the patient should be informed of his danger, and +urged to the continuance of such remedies as are proper for him. + +The following states or forms were observable in the fever: + +1. In a few cases, the miasmata produced death in four and twenty hours, +with convulsions, coma, or apoplexy. + +2. There were _open_ cases, in which the pulse was full and tense as in a +pleurisy or rheumatism, from the beginning to the end of the fever. They +were generally attended with a good deal of pain. + +3. There were _depressed_ or _locked_ cases, in which there were a sense +of great debility, but little or no pain, a depressed and slow pulse, a +cool skin, cold hands and feet, and obstructed excretions. + +4. There were _divided_ or _mixed_ cases, in which the pulse was active +until the 4th day, after which it became depressed. All the other +symptoms of the locked state of the fever accompanied this depressed +state of the pulse. + +5. There were cases in which the pulse imparted a perception like that of +a soft and _shattered_ quill. I have before mentioned that this state of +the pulse occurred in Dr. Jones and Dr. Dobell. I felt it but once, and +on the day of his attack, in the latter gentleman, and expressed my +opinion of his extreme danger to one of my pupils upon my return from +visiting him. I did not meet with a case which terminated favourably, +where I perceived this _shattered_ pulse. A disposition to sweat occurred +in this state of the fever. + +6. There were what Dr. Caldwell happily called _walking_ cases. The +patients here were flushed or pale, had a full or tense pulse, but +complained of no pain, had a good appetite, and walked about their rooms +or houses, as if they were but little indisposed, until a day or two, +and, in some instances, until a few hours before they died. We speak of +a _dumb_ gout and _dumb_ rheumatism; with equal propriety, the epithet +might be applied to this form of yellow fever in its early stage. The +impression of the remote cause of the fever, in these cases, was beyond +sensation, for, upon removing a part of it by bleeding or purging, the +patients complained of pain, and the excitement of the muscles passed so +completely into the blood-vessels and alimentary canal, as to convert the +fever into a common and more natural form. These cases were always +dangerous, and, when neglected, generally terminated in death. Mr. +Brown's fever came on in this insidious shape. It was cured by the loss +of upwards of 100 ounces of blood, and a plentiful salivation. + +7. There was the _intermitting_ form in this fever. This, like the last, +often deceived the patient, by leading him to suppose his disease was of +a common or trifling nature. It prevented Mr. Richard Smith from applying +for medical aid in an attack of the fever for several days, by which +means it made such an impression upon his viscera, that depleting +remedies were in vain used to cure him. He died in the prime of life, +beloved and lamented by a numerous circle of relations and friends. + +8. There was a form of this fever in which it resembled the mild +remittent of common seasons. It was distinguished from it chiefly by the +black colour of the intestinal evacuations. + +9. There were cases of this fever so light, that patients were said to be +neither _sick_ nor _well_; or, in other words, they were sick and well +half a dozen times in a day. Such persons walked about, and transacted +their ordinary business, but complained of dulness, and, occasionally, of +shooting pains in their heads. Sometimes the stomach was affected with +sickness, and the bowels with diarrh[oe]a or costiveness. All of them +complained of night sweats. The pulse was quicker than natural, but +seldom had that convulsive action which constitutes fever. Purges always +brought away black stools from such patients, and this circumstance +served to establish its relationship to the prevailing epidemic. Now and +then, by neglect or improper treatment, it assumed a higher and more +dangerous grade of the fever, and became fatal, but it more commonly +yielded to nature, or to a single dose of purging physic. + +10. There were a few cases in which the skin was affected with universal +yellowness, but without more pain or indisposition than usually occurs in +the jaundice. They were very frequent in the year 1793, and generally +prevail in the autumn, in all places subject to bilious fever. + +11. There were _chronic_ cases of this fever. It is from the want of +observation that physicians limit the duration of the yellow fever to +certain days. I have seen many instances in which it has been protracted +into what is called by authors a slow nervous fever. The wife of captain +Peter Bell died with a black vomiting after an illness of nearly one +month. Dr. Pinckard, formerly one of the physicians of the British army +in the West-Indies, in a late visit to this city informed me, that he had +often seen the yellow fever put on a chronic form in the West-India +islands. + +In delivering this detail of the various forms of the yellow fever, I am +aware that I oppose the opinions of many of my medical brethren, who +ascribe to it a certain uniform character, which is removed beyond the +influence of climate, habit, predisposition, and the different strength +and combinations of remote and exciting causes. This uniformity in the +symptoms of this fever is said to exist in the West-Indies, and every +deviation from it in the United States is called by another name. The +following communication, which I received from Dr. Pinckard, will show +that this disease is as different in its forms in the West-Indies as it +is in this country. + +"The yellow fever, as it appeared among the troops in Guiana and the +West-India islands, in the years 1796 and 1797, exhibited such perpetual +instability, and varied so incessantly in its character, that I could not +discover any one symptom to be decidedly diagnostic; and hence I have +been led into an opinion that the yellow fever, so called, is not a +distinct or specific disease, but merely an aggravated degree of the +common remittent or bilious fever of hot climates, rendered irregular in +form, and augmented in malignity, from appearing in subjects unaccustomed +to the climate. + _Philadelphia, January 12th, 1798._" + +Many other authorities equally respectable with Dr. Pinckard's, among +whom are Pringle, Huck, and Hunter, might be adduced in support of the +unity of bilious fever. But to multiply them further would be an act of +homage to the weakness of human reason, and an acknowledgment of the +infant state of our knowledge in medicine. As well might we suppose +nature to be an artist, and that diseases were shaped by her like a piece +of statuary, or a suit of clothes, by means of a chissel, or pair of +scissars, as admit every different form and grade of morbid action in the +system to be a distinct disease. + +Notwithstanding the fever put on the eleven forms which have been +described, the moderate cases were few, compared with those of a +malignant and dangerous nature. It was upon this account that the +mortality was greater in the same number of patients, who were treated +with the same remedies, than it was in the years 1793 and 1794. The +disease, moreover, partook of a more malignant character than the two +epidemics that have been mentioned. The yellow fever in Norfolk, Drs. +Taylor and Hansford informed me, in a letter I received from them, was +much more malignant and fatal, under equal circumstances, than it was in +1795. + +There were evident marks of the disease attacking more persons three days +before, and three days after the _full_ and _change_ of the moon, and of +more deaths occurring at those periods than at any other time. The same +thing has been remarked in the plague by Diemerbroeck, in the fevers of +Bengal by Dr. Balfour, and in those of Demarara by Dr. Pinckard. + +During the prevalence of the fever I attended the following persons who +had been affected by the epidemic of 1793, viz. Dr. Physick, Thomas +Leaming, Thomas Canby, Samuel Bradford, and George Loxley, also Mrs. +Eggar, who had a violent attack of it in the year 1794. Samuel Bradford +was likewise affected by it in 1794. + +During my intercourse with the sick, I felt the miasmata of the fever +operate upon my system in the most sensible manner. It produced languor, +a pain in my head, and sickness at my stomach. A sighing attended me +occasionally, for upwards of two weeks. This symptom left me suddenly, +and was succeeded by a hoarseness, and, at times, with such a feebleness +in my voice as to make speaking painful to me. Having observed this +affection of the trachea to be a precursor of the fever in several cases, +it kept me under daily apprehensions of being confined by it. It +gradually went off after the first of October. I ascribed my recovery +from it, and a sudden diminution of the effects of the miasmata upon my +system, to a change produced in the atmosphere by the rain which fell on +that day. + +The peculiar matter emitted by the breath or perspiration of persons +affected by this fever, induced a sneezing in Dr. Dobell, every time he +went into a sick room. Ambrose Parey says the same thing occurred to +him, upon entering the room of patients confined by the plague. + +The gutters emitted, in many places, a sulphureous smell during the +prevalence of the fever. Upon rubbing my hands together I could at any +time excite a similar smell in them. I have taken notice of this effect +of the matters which produced the disease upon the body, in the year +1794. + +In order to prevent an attack of the fever, I carefully avoided all its +exciting causes. I reduced my diet, and lived sparingly upon tea, coffee, +milk, and the common fruits and garden vegetables of the season, with a +small quantity of salted meat, and smoked herring. My drinks were milk +and water, weak claret and water, and weak porter and water. I sheltered +myself as much as possible from the rays of the sun, and from the action +of the evening air, and accommodated my dress to the changes in the +temperature of the atmosphere. By similar means, I have reason to +believe, many hundred people escaped the disease, who were constantly +exposed to it. + +The number of deaths by the fever, in the months of August, September, +and October, amounted to between ten and eleven hundred. In the list of +the dead were nine practitioners of physic, several of whom were +gentlemen of the most respectable characters. This number will be thought +considerable when it is added, that not more than three or four and +twenty physicians attended patients in the disease. Of the survivors of +that number, eight were affected with the fever. This extraordinary +mortality and sickness among the physicians must be ascribed to their +uncommon fatigue in attending upon the sick, and to their inability to +command their time and labours, so as to avoid the exciting causes of the +fever. + +Among the medical gentlemen whose deaths have been mentioned, was my +excellent friend, Dr. Nicholas Way. I shall carry to my grave an +affectionate remembrance of him. We passed our youth together in the +study of medicine, and lived to the time of his death in the habits of +the tenderest friendship. In the year 1794, he removed from Wilmington, +in the Delaware state, to Philadelphia, where his talents and manners +soon introduced him into extensive business. His independent fortune +furnished his friends with arguments to advise him to retire from the +city, upon the first appearance of the fever. But his humanity prevailed +over the dictates of interest and the love of life. He was active and +intelligent in suggesting and executing plans to arrest the progress of +the disease, and to lessen the distresses of the poor. On the 27th of +August, he was seized, after a ride from the country in the evening air, +with a chilly fit and fever. I saw him the next day, and advised the +usual depleting remedies. He submitted to my prescriptions with +reluctance, and in a sparing manner, from an opinion that his fever was +nothing but a common remittent. To enforce obedience to my advice, I +called upon Dr. Griffitts to visit him with me. Our combined exertions to +overcome his prejudices against our remedies were ineffectual. At two +o'clock in the afternoon, on the sixth day of his disease, with an aching +heart I saw the sweat of death upon his forehead, and felt his cold arm +without a pulse. He spoke to me with difficulty: upon my rising from his +bed-side to leave him, his eyes filled with tears, and his countenance +spoke a language which I am unable to describe. I promised to return in a +short time, with a view of attending the last scene of his life. +Immediately after I left his room, he wept aloud. I returned hastily to +him, and found him in convulsions. He died a few hours afterwards. Had I +met with no other affliction in the autumn of 1797 than that which I +experienced from this affecting scene, it would have been a severe one; +but it was a part only of what I suffered from the death of other +friends, and from the malice of enemies. + +I beg the reader's pardon for this digression. It shall be the last time +and place in which any notice shall be taken of my sorrows and +persecutions in the course of these volumes. + +Soon after the citizens returned from the country, the governor of the +state, Mr. Mifflin, addressed a letter to the college of physicians of +Philadelphia, requesting to know the origin, progress, and nature of the +fever which had recently afflicted the city, and the means of preventing +its return. He addressed a similar letter to me, to be communicated to +such gentlemen of the faculty of medicine, as were not members of the +college of physicians. + +The college, in a memorial to the legislature of the state, asserted that +the fever had been imported in two ships, the one from Havannah, the +other from Port au Prince, and recommended, as the most effectual means +of preventing its recurrence, a more rigid quarantine law. + +The gentlemen of the faculty of medicine, thirteen in number, in two +letters to the governor of the state, the one in their private capacity, +and the other after they had associated themselves into an "Academy of +Medicine," asserted that the fever had originated from the putrid +exhalations from the gutters and streets of the city, and from ponds and +marshy grounds in its neighbourhood; also from the foul air of two ships, +the one from Marseilles and the other from Hamburgh. They enumerated all +the common sources of malignant fevers, and recommended the removal of +them from the city, as the most effectual method of preventing the return +of the fever. These sources of fever, and the various means of destroying +them, shall be mentioned in another place. + +I proceed now to say a few words upon the treatment which was used in +this fever. It was, in general, the same as that which was pursued in the +fevers of 1793 and 1794. + +I began the cure, in most cases, by _bleeding_, when I was called on the +first day of the disease, and was happy in observing its usual salutary +effects in its early stage. On the second day, it frequently failed of +doing service, and on the subsequent days of the fever, I believe, it +often did harm; more especially if no other depleting remedy had preceded +it. The violent action of the blood-vessels in this disease, when left to +itself for two or three days, fills and suffocates the viscera with such +an immense mass of blood, as to leave a quantity in the vessels so small, +as barely to keep up the actions of life. By abstracting but a few ounces +of this circulating blood, we precipitate death. In those cases where a +doubt is entertained of such an engorgement of stagnating blood having +taken place, it will always be safest to take but three or four ounces at +a time, and to repeat it four or five times a day. By this mode of +bleeding, we give the viscera an opportunity of emptying their +superfluous blood into the vessels, and thereby prevent their collapsing, +from the sudden abstraction of the stimulus which remained in them. I +confine this observation upon bleeding, after the first stage of the +disease, only to the epidemic of 1797. It was frequently effectual when +used for the first time after the first and second days, in the fevers of +1793 and 1794, and it is often useful in the advanced stage of the common +bilious fever. The different and contradictory accounts of the effects of +bleeding in the yellow fever, in the West-Indies, probably originate in +its being used in different stages of the disease. Dr. Jackson, of the +British army, in his late visit to Philadelphia, informed me, that he had +cured nineteen out of twenty of all the soldiers whom he attended, by +copious bleeding, provided it was performed within six hours after the +attack of the fever. Beyond that period, it mitigated its force, but +seldom cured. The quantity of blood drawn by the doctor, in this early +stage of the disease, was always from twenty to thirty ounces. I have +said the yellow fever of 1797 was more malignant than the fevers of 1793 +and 1794. Its resemblance to the yellow fever in the West-Indies, in not +yielding to bleeding after the first day, is a proof of this assertion. + +I was struck, during my attendance upon this fever, in observing the +analogy between its _mixed_ form and the malignant state of the +small-pox. The fever, in both, continues for three or four days without +any remission. They both have a second stage, in which death usually +takes place, if the diseases be left to themselves. By means of copious +bleeding in their first, they are generally deprived of their malignity +and mortality in their second stage. This remark, so trite in the +small-pox, has been less attended to in the yellow fever. The bleeding in +the first stage of this disease does not, it is true, destroy it +altogether, any more than it destroys an eruption in the second stage of +the small-pox, but it weakens it in such a manner that the patient passes +through its second stage without pain or danger, and with no other aid +from medicine than what is commonly derived from good nursing, proper +aliment, and a little gently opening physic. + +It is common with those practitioners who object to bleeding in the +yellow fever, to admit it occasionally in _robust_ habits. This rule +leads to great error in practice. From the weak action of predisposing, +or exciting causes, the disease often exists in a feeble state in such +habits, while from the protracted or violent operation of the same +causes, it appears in great force in persons of delicate constitutions. A +physician, therefore, in prescribing for a patient in this fever, should +forget the natural strength of his muscles, and accommodate the loss of +blood wholly to the morbid strength of his disease. + +The quantity of blood drawn in this fever was always proportioned to its +violence. I cured many by a single bleeding. A few required the loss of +upwards of a hundred ounces of blood to cure them. The persons from whom +that large quantity of blood was taken, were, Messieurs Andrew Brown, +Horace Hall, George Cummins, J. Ramsay, and George Eyre. But I was not +singular in the liberal and frequent use of the lancet. The following +physicians drew the quantities of blood annexed to their respective names +from the following persons, viz. + + Dr. Dewees 176 ounces from Dr. Physick, + Dr. Griffitts 110 Mr. S. Thomson, + Dr. Stewart 106 Mrs. M'Phail, + Dr. Cooper 150 Mr. David Evans, + Dr. Gillespie 103 himself. + +All the above named persons had a rapid and easy recovery, and now enjoy +good health. I lost but one patient who had been the subject of early and +copious bleeding. His death was evidently induced by a supper of +beef-stakes and porter, after he had exhibited the most promising signs +of convalescence. + + + OF PURGING. + +From the great difficulty that was found in discharging bile from the +bowels, by the common modes of administering purges, Dr. Griffitts +suggested to me the propriety of giving large doses of calomel, without +jalap or any other purging medicine, in order to loosen the bile from its +close connection with the gall-bladder and duodenum, during the first day +of the disease. This method of discharging acrid bile was found useful. +I observed the same relief from large evacuations of f[oe]tid bile, in +the epidemic of 1797, that I have remarked in the fever of 1793. Mr. +Bryce has taken notice of the same salutary effects from similar +evacuations, in the yellow fever on board the Busbridge Indiaman, in the +year 1792. His words are: "It was observable, that the more dark-coloured +and f[oe]tid such discharges were, the more early and certainly did the +symptoms disappear. Their good effects were so instantaneous, that I have +often seen a man carried up on deck, perfectly delirious with subsultus +tendinum, and in a state of the greatest apparent debility, who, after +one or two copious evacuations of this kind, has returned of himself, and +astonished at his newly acquired strength[2]." Very different are the +effects of tonic remedies, when given to remove this apparent debility. +The clown who supposes the crooked appearance of a stick, when thrust +into a pail of water, to be real, does not err more against the laws of +light, than that physician errs against a law of the animal economy, who +mistakes the debility which arises from oppression for an exhausted state +of the system, and attempts to remove it by stimulating medicines. + + [2] Annals of Medicine, p. 123. + +After unlocking the bowels, by means of calomel and jalap, in the +beginning of the fever, I found no difficulty afterwards in keeping them +gently open by more lenient purges. In addition to those which I have +mentioned in the account of the fever of 1793, I yielded to the advice of +Dr. Griffitts, by adopting the soluble tartar, and gave small doses of it +daily in many cases. It seldom offended the stomach, and generally +operated, without griping, in the most plentiful manner. + +However powerful bleeding and purging were in the cure of this fever, +they often required the aid of a _salivation_ to assist them in subduing +it. + +Besides the usual methods of introducing mercury into the system, Dr. +Stewart accelerated its action, by obliging his patients to wear socks +filled with mercurial ointment; and Dr. Gillespie aimed at the same +thing, by injecting the ointment, in a suitable vehicle, into the bowels, +in the form of glysters. + +The following fact, communicated to me by Dr. Stewart, will show the +safety of large doses of calomel in this fever. Mrs. M'Phail took 60 +grains of calomel, by mistake, at a dose, after having taken three or +four doses, of 20 grains each, on the same day. She took, in all, 356 +grains in six days, and yet, says the doctor, "such was the state of her +stomach and intestines, that that large quantity was retained without +producing the least griping, or more stools than she had when she took +three grains every two hours." + +I observed the mercury to affect the mouth and throat in the following +ways. 1. It sometimes produced a swelling only in the throat, resembling +a common inflammatory angina. 2. It sometimes produced ulcers upon the +lips, cheeks, and tongue, without any discharge from the salivary glands. +3. It sometimes produced swellings and ulcers in the gums, and loosened +the teeth without inducing a salivation. 4. There were instances in which +the mercury induced a rigidity in the masseter muscles of the jaw, by +which means the mouth was kept constantly open, or so much closed, as to +render it difficult for the patient to take food, and impossible for him +to masticate it. 5. It sometimes affected the salivary glands only, +producing from them a copious secretion and excretion of saliva. But, 6. +It more frequently acted upon all the above parts, and it was then it +produced most speedily its salutary effects. 7. The discharge of the +saliva frequently took place only during the remission or intermission of +the fever, and ceased with each return of its paroxysms. 8. The +salivation did not take place, in some cases, until the solution of the +fever. This was more especially the case in those forms of the fever in +which there were no remissions or intermissions. 9. It ceased in most +cases with the fever, but it sometimes continued for six weeks or two +months after the complete recovery of the patient. 10. The mercury rarely +dislodged the teeth. Not a single instance occurred of a patient losing a +tooth in the city hospital, where the physicians, Dr. J. Duffield +informed me, relied chiefly upon a salivation for a cure of the fever. +11. Sometimes the mercury produced a discharge of blood with the saliva. +Dr. Coulter, of Baltimore, gave me an account, in a letter dated the 17th +of September, 1797, of a boy in whom a hæmorrhage from the salivary +glands, excited by calomel, was succeeded by a plentiful flow of saliva, +which saved his patient. I saw no inconvenience from the mixture of blood +with saliva in any of my patients. It occurred in Dr. Caldwell, Mr. +Bradford, Mr. Brown, and several others. + +It has been said that mercury does no service unless it purges or +salivates. I am disposed to believe that it may act as a counter stimulus +to that of the miasmata of the yellow fever, and thus be useful without +producing any evacuation from the bowels or mouth. It more certainly +acts in this way, provided blood-letting has preceded its exhibition. I +have supposed the stimulus from the remote cause of the yellow fever to +be equal in force to five, and that of mercury to three. To enable the +mercury to produce its action upon the system, it is necessary to reduce +the febrile action, by bleeding, to two and a half, or below it, so that +the stimulus of the mercury shall transcend it. The safety of mercury, +when introduced into the system, has three advantages as a stimulus over +that of the matter which produces the fever. 1. It excites an action in +the system preternatural only in _force_. It does not derange the +_natural_ order of actions. 2. It determines the actions chiefly to +external parts of the body. And, 3. It fixes them, when it affects the +mouth and throat, upon parts which are capable of bearing great +inflammation and effusion without any danger to life. The stimulus which +produces the yellow fever acts in ways the reverse of those which have +been mentioned. It produces violent _irregular_ or _wrong_ actions. It +determines them to internal parts of the body, and it fixes them upon +viscera which bear, with difficulty and danger, the usual effects of +disease. A late French writer, Dr. Fabre, ascribed to diseases a +centrifugal, and a centripetal direction. From what has been said it +would seem, the former belongs to mercury, and the latter to the yellow +fever. + +Considering the great prejudices against blood-letting, I have wished to +combat this fever with mercury alone. But, for reasons formerly given, I +have been afraid to trust to it without the assistance of the lancet. The +character of the fever, moreover, like that which the poet has ascribed +to Achilles, is of "so swift, irritable, inexorable, and cruel" a nature, +that it would be unsafe to rely exclusively upon a medicine which is not +only of less efficacy than bleeding, but often slow and uncertain in its +operation, _more especially_ upon the throat and mouth. + +Let not the reader be offended at my attempts to reason. I am aware of +the evils which the weak and perverted exercise of this power of the mind +has introduced into medicine. But let us act with the same consistency +upon this subject that we do in other things. + +We do not consign a child to its cradle for life, because it falls in its +first unsuccessful efforts to use its legs. In like manner we must not +abandon reason, because, in our first efforts to use it, we have been +deceived. A single just principle in our science will lead to more +truth, in one year, than whole volumes of uncombined facts will do in a +century. + +I lost but two patients in this epidemic in whom the mercury excited a +salivation. One of them died from the want of nursing; the other by the +late application of the remedy. + + + OF EMETICS. + +It was said a practitioner, who was opposed to bleeding and mercury, +cured this fever by means of strong emetics. I gave one to a man who +refused to be bled. It operated freely, and brought on a plentiful sweat. +The next day he arose from his bed, and went to his work. On the fourth +day he sent for me again. My son visited him, and found him without a +pulse. He died the next day. + +I heard of two other persons who took emetics in the beginning of the +fever, without the advice of a physician, both of whom died. + +Dr. Pinckard informed me, that their effects were generally hurtful in +the violent grades of the yellow fever in the West-Indies. The same +information has since been given to me by Dr. Jackson. In the second and +third grades of the bilious fever they appear not only to be safe, but +useful. + + + OF DIET AND DRINKS. + +The advantages of a weak vegetable diet were very great in this fever. I +found but little difficulty, in most cases, in having my prohibition of +animal food complied with before the crisis of the fever, but there was +often such a sudden excitement of the appetite for it, immediately +afterwards, that it was difficult to restrain it. I have mentioned the +case of a young man, who was upon the recovery, who died in consequence +of supping upon beef-stakes. Many other instances of the mortality of +this fever from a similar cause, I believe, occurred in our epidemic, +which were concealed from our physicians. I am not singular in ascribing +the death of convalescents to the too early use of animal food. Dr. +Poissonnier has the following important remark upon this subject. "The +physicians of Brest have observed, that the relapses in the malignant +fever, which prevailed in their naval hospitals, were as much the effect +of a fault in the diet of the sick as of the contagious air to which they +were exposed, and that as many patients perished from this cause as from +the original fever. For this reason light soups, with leguminous +vegetables in them, panada, rice seasoned with cinnamon, fresh eggs, &c. +are all that they should be permitted to eat. The use of flesh should be +forbidden for many days after the entire cure of the disorder[3]." + + [3] Maladies de Gens de Mer, vol. i. p. 345. + +Dr. Huxham has furnished another evidence of the danger from the +premature use of animal food, in his history of a malignant fever which +prevailed at Plymouth, in the year 1740. "If any one (says the doctor) +made use of a flesh or fish diet, before he had been very well purged, +and his recovery confirmed, he infallibly indulged himself herein at the +utmost danger of his life[4]." + + [4] Epidemics, vol. ii. p. 67. + +In addition to the mild articles of diet, mentioned by Dr. Poissonnier, I +found bread and milk, with a little water, sugar, and the pulp of a +roasted apple mixed with it, very acceptable to my patients during their +convalescence. Oysters were equally innocent and agreeable. Ripe grapes +were devoured by them with avidity, in every stage of the fever. The +season had been favourable to the perfection of this pleasant fruit, and +all the gardens in the city and neighbourhood in which it was cultivated +were gratuitously opened by the citizens for the benefit of the sick. + +The drinks were, cold water, toast and water, balm tea, water in which +jellies of different kinds had been dissolved, lemonade, apple water, +barley and rice water, and, in cases where the stomach was affected with +sickness or puking, weak porter and water, and cold camomile tea. In the +convalescent stage of the fever, and in such of its remissions or +intermissions as were accompanied with great languor in the pulse, +wine-whey, porter and water, and brandy and water, were taken with +advantage. + +Cold water applied to the body, cool and fresh air, and cleanliness, +produced their usual good effects in this fever. In the external use of +cold water, care was taken to confine it to such cases as were +accompanied with preternatural heat, and to forbid it in the cold fit of +the fever, and in those cases which were attended with cold hands and +feet, and where the disease showed a disposition to terminate, in its +first stage, by a profuse perspiration. It has lately given me great +pleasure to find the same practice, in the external use of cold water in +fevers, recommended by Dr. Currie of Liverpool, in his medical reports of +the effects of water, cold and warm, as a remedy in febrile diseases. Of +the benefit of fresh air in this fever, Dr. Dawson of Tortola has lately +furnished me with a striking instance. He informed me, that by removing +patients from the low grounds on that island, where the fever is +generated, to a neighbouring mountain, they generally recovered in a few +days. + +Finding a disagreeable smell to arise from vinegar sprinkled upon the +floor, after it had emitted all its acid vapour, I directed the floors of +sick rooms to be sprinkled only with water. I found the vapour which +arose from it to be grateful to my patients. A citizen of Philadelphia, +whose whole family recovered from the fever, thought he perceived evident +advantages from tubs of fresh water being kept constantly in the sick +rooms. + + + OF TONIC REMEDIES. + +There were now and then remissions and intermissions of the fever, +accompanied with such signs of danger from debility, as to render the +exhibition of a few drops of laudanum, a little wine-whey, a glass of +brandy and water, and, in some instances, a cup of weak chicken-broth, +highly necessary and useful. In addition to these cordial drinks, I +directed the feet to be placed in a tub of warm water, which was +introduced under the bed-clothes, so that the patient was not weakened by +being raised from a horizontal posture. All these remedies were laid +aside upon the return of a paroxysm of fever. + +I did not prescribe bark in a single case of this disease. An infusion of +the quassia root was substituted in its room, in several instances, with +advantage. + +_Blisters_ were applied as usual, but, from the insensibility of the +skin, they were less effectual than applications of mustard to the arms +and legs. It is a circumstance worthy of notice, that while the stomach, +bowels, and even the large blood-vessels are sometimes in a highly +excited state, and overcharged, as it were, with life, the whole surface +of the body is in a state of the greatest torpor. To attempt to excite it +by internal remedies is like adding fuel to a chimney already on fire. +The excitement of the blood-vessels, and the circulation of the blood, +can only be equalized by the application of stimulants to the skin. +These, to be effectual, should be of the most powerful kind. Caustics +might probably be used in such cases with advantage. I am led to this +opinion by a fact communicated to me by Dr. Stewart. A lighted candle, +which had been left on the bed of a woman whom he was attending in the +apparent last stage of the yellow fever, fell upon her breast. She was +too insensible to feel, or too weak to remove it. Before her nurse came +into her room, it had made a deep and extensive impression upon her +flesh. From that time she revived, and in the course of a few days +recovered. As a tonic remedy in this fever, Dr. Jackson has spoken to me +in high terms of the good effects of riding in a carriage. Patients, he +informed me, who were moved with difficulty, after riding a few miles +were able to sit up, and, when they returned from their excursions, were +frequently able to walk to their beds. + +Much has been said, of late years, in favour of the application of warm +olive oil to the body in the plague, and a wish has been expressed, by +some people, that its efficacy might be tried in the yellow fever. Upon +examining the account of this remedy, as published by Mr. Baldwin, three +things suggest themselves to our notice. 1. That the oil is effectual +only in the _forming_ state of the disease; 2. That the friction which is +used with it contributes to excite the torpid vessels of the skin; and 3. +That it acts chiefly by depleting from the pores of the body. From the +unity of the remedy of depletion, it is probable purging or bleeding +might be substituted to the expensive parade of the sweat induced by the +warm oil, and the smoke of odoriferous vegetables. But I must not conceal +here, that there are facts which favour an idea, that oil produces a +sedative action upon the blood-vessels, through the medium of the skin. +Bontius says it is used in this manner in the East-Indies, for the cure +of malignant fevers, after the previous use of bleeding and purging. It +seems to have been a remedy well known among the Jews; hence we find the +apostle James advises its being applied to the body, in addition to the +prayers of the elders of the church[5]. It is thus in other cases, the +blessings of Heaven are conveyed to men through the use of natural means. + + [5] Chapter v. verse 14. + +During the existence of the premonitory symptoms, and before patients +were confined to their rooms, a gentle purge, or the loss of a few ounces +of blood, in many hundred instances, prevented the formation of the +fever. I did not meet with a single exception to this remark. + +Fevers are the affliction chiefly of poor people. To prevent or to cure +them, remedies must be cheap, and capable of being applied with but +little attendance. From the affinity established by the Creator between +evil and its antidotes, in other parts of his works, I am disposed to +believe no remedy will ever be effectual in any general disease, that is +not cheap, and that cannot easily be made universal. + +It is to be lamented that the greatest part of all the deaths which +occur, are from diseases that are under the power of medicine. To prevent +their fatal issue, it would seem to be agreeable to the order of Heaven +in other things, that they should be attacked in their forming state. +Weeds, vermin, public oppression, and private vice, are easily eradicated +and destroyed, if opposed by their proper remedies, as soon as they show +themselves. The principal obstacle to the successful use of the antidotes +of malignant fevers, in their early stage, arises from physicians +refusing to declare when they appear in a city, and from their practice +of calling their mild forms by other names than that of a mortal +epidemic. + +I shall now say a few words upon the success of the depleting practice in +this epidemic. + +From the more malignant state of the fever, and from the fears and +prejudices that were excited against bleeding and mercury by means of the +newspapers, the success of those remedies was much less than in the years +1793 and 1794. Hundreds refused to submit to them at the _time_, and in +the _manner_, that were necessary to render them effectual. From the +publications of a number of physicians, who used the lancet and mercury +in their greatest extent, it appears that they lost but one in ten of all +they attended. It was said of several practitioners who were opposed to +copious bleeding, that they lost a much smaller proportion of their +patients with the prevailing fever. Upon inquiry, it appeared they had +lost many more. To conceal their want of success, they said their +patients had died of other diseases. This mode of deceiving the public +began in 1793. The men who used it did not recollect, that it is less in +favour of a physician's skill to lose patients in pleurisies, colics, +hæmorrhages, contusions, and common remittents, than in a malignant +yellow fever. + +Dr. Sayre attended fifteen patients in the disease, all of whom recovered +by the plentiful use of the depleting remedies. His place of residence +being remote from those parts of the city in which the fever prevailed +most, prevented his being called to a greater number of cases. + +A French physician, who bled and purged _moderately_, candidly +acknowledged that he saved but three out of four of his patients. + +In the city hospital, where bleeding was sparingly used, and where the +physicians depended chiefly upon a salivation, more than one half died of +all the patients who were admitted. It is an act of justice to the +physicians of the hospital to add, that many, perhaps most of their +patients, were admitted _after_ the first day of the disease. + +I cannot conclude this comparative view of the success of the different +modes of treating the yellow fever, without taking notice, that the +stimulating mode, as recommended by Dr. Kuhn and Dr. Stevens, in the year +1793, was deserted by every physician in the city. Dr. Stevens +acknowledged the disease to require a different treatment from that +which it required in the West-Indies; Dr. Kuhn adopted the lancet and +mercury in his practice; and several other physicians, who had written +against those remedies, or who had doubted of their safety and efficacy, +in 1793, used them with confidence, and in the most liberal manner, in +1797. + +In the histories I have given of the yellow fevers of 1793 and 1794, I +have scattered here and there a few observations upon their degrees of +danger, and the signs of their favourable or unfavourable issue. I shall +close the present history, by collecting those observations into one +view, and adding to them such other signs as have occurred to me in +observing this epidemic. + +Signs of moderate danger, and a favourable issue of the yellow fever. + +1. A chilly fit accompanying the attack of the fever. The longer this +chill continues, the more favourable the disease. + +2. The recurrence of chills every day, or twice a day, or every other +day, with the return of the exacerbations of the fever. A coldness of the +whole body, at the above periods, without chills, a coldness with a +profuse sweat, cold feet and hands, with febrile heat in other parts of +the body, and a profuse sweat without chills or coldness, are all less +favourable symptoms than a regular chilly fit, but they indicate less +danger than their total absence during the course of the fever. + +3. A puking of _green_ or _yellow_ bile on the first day of the disease +is favourable. A discharge of black bile, if it occur on the _first_ day +of the fever, is not unfavourable. + +4. A discharge of green and yellow stools. It is more favourable if the +stools are of a dark or black colour, and of a f[oe]tid and acrid nature, +on the first or second day of the fever. + +5. A softness and moisture on the skin in the beginning of the fever. + +6. A sense of pain in the head, or a sudden translation of pain from +internal to external parts of the body, particularly to the back. An +increase of pain after bleeding. + +7. A sore mouth. + +8. A moist white, or a yellow tongue. + +9. An early disposition to spit freely, whether excited by nature or the +use of mercury. + +10. Blood becoming sizy, after having exhibited the usual marks of great +morbid action in the blood-vessels. + +11. Great and exquisite sensibility in the sense of feeling coming on +near the close of the fever. + +12. Acute pains in the back and limbs. + +13. The appearance of an inflammatory spot on a finger or toe, Dr. H. +M'Clen says, is favourable. It appears, the doctor says, as if the cause +of the fever had escaped by explosion. + +Signs of great danger, and of an unfavourable issue of the yellow fever +are, + +1. An attack of the fever, suddenly succeeding great terror, anger, or +the intemperate use of venery, or strong drink. + +2. The first paroxysm coming on without any premonitory symptoms, or a +chilly fit. + +3. A coldness over the whole body without chills for two or three days. + +4. A sleepiness on the first and second days of the fever. + +5. Uncommon paleness of the face not induced by blood-letting. + +6. Constant or violent vomiting, without any discharge of bile. + +7. Obstinate costiveness, or a discharge of natural, or white stools; +also quick, watery stools after taking drink. + +8. A diarrh[oe]a towards the close of the fever. I lost two patients, in +1797, with this symptom, who had exhibited, a few days before, signs of a +recovery. Dr. Pinckard informed me, that it was generally attended with a +fatal issue in the yellow fever of the West-Indies. Diemerbroeck +declares, that "scarcely one in a hundred recovered, with this symptom, +from the plague[6]." + + [6] Lib. i. cap. 15. + +9. A suppression of urine. It is most alarming when it is without pain. + +10. A discharge of dark-coloured and bloody urine. + +11. A cold, cool, dry, smooth, or shining skin. + +12. The appearance of a yellow colour in the face on the first or second +day of the fever. + +13. The absence of pain, or a sudden cessation of it, with the common +symptoms of great danger. + +14. A disposition to faint upon a little motion, and fainting after +losing but a few ounces of blood. + +15. A watery, glassy, or brilliant eye. A red eye on the fourth or fifth +day of the disease. It is more alarming if it become so after having been +previously yellow. + +16. Imperfect vision, and blindness in the close of the disease. + +17. Deafness. + +18. A preternatural appetite, more especially in the last stage of the +fever. + +19. A slow, intermitting, and shattered pulse. + +20. Great restlessness, delirium, and long continued coma. + +21. A discharge of coffee-coloured or black matter from the stomach, +after the fourth day of the fever. + +22. A smooth red tongue, covered with a lead-coloured crust, while its +edges are of a bright red. + +23. A dull vacant face, expressive of distress. + +24. Great insensibility to common occurrences, and an indifference about +the issue of the disease. + +25. Uncommon serenity of mind, accompanied with an unusually placid +countenance. + +I shall conclude this head by the following remarks: + +1. The violence, danger, and probable issue of this fever, seem to be in +proportion to the duration and force of the predisposing and exciting +causes. However steady the former are in bringing on debility, and the +latter in acting as irritants upon accumulated excitability, yet a +knowledge of their duration and force is always useful, not only in +forming an opinion of the probable issue of the fever, but in regulating +the force of remedies. + +2. The signs of danger vary in different years, from the influence of the +weather upon the disease. + +3. Notwithstanding the signs of the favourable and unfavourable issue of +the fever are in general uniform, when the cure of the disease is +committed to nature, or to tonic medicines, yet they are far from being +so when the treatment of the fever is taken out of the hands of nature, +and attempted by the use of depleting remedies. We often see patients +recover with nearly all the unfavourable symptoms that have been +mentioned, and we sometimes see them die, with all those that are +favourable. The words of Morellus, therefore, which he has applied to the +plague, are equally true when applied to the yellow fever. "In the +plague, our senses deceive us. Reason deceives us. The aphorisms of +Hippocrates deceive us[7]." An important lesson may be learned from these +facts, and that is, never to give a patient over. On the contrary, it is +our duty in this, as well as in all other acute diseases, to dispute +every inch of ground with death. By means of this practice, which is +warranted by science, as well as dictated by humanity, the grave has +often been deprived for a while of its prey, and a prelude thereby +exhibited of that approaching and delightful time foretold by ancient +prophets, when the power of medicine over diseases shall be such, as to +render old age the only outlet of human life. + + [7] De Feb. Pestilent. cap. v. "Acutorum morborum incertæ admodum, ac + fallaces sunt prædictiones." + HIPPOCRATES. + + + + + AN ACCOUNT + + OF THE + + _BILIOUS YELLOW FEVER_, + + AS IT + + APPEARED IN PHILADELPHIA, + + IN THE YEAR 1798. + + +The yellow fever of the year 1797 was succeeded by scarlatina, catarrhs, +and bilious pleurisies, in the months of November and December of the +same year. The weather favoured the generation of the latter diseases. It +became suddenly cold about the middle of November. On the 5th of +December, the navigation of the Delaware was obstructed. There was a thaw +on the 13th and 14th of this month, but not sufficient to open the river. + +In the month of January, 1798, the fevers discovered an uncommon +determination to the brain. Four cases of the hydrocephalic state of +fever occurred under my care during this month, all of which yielded to +depleting remedies. The subjects of this state of fever were Mr. Robert +Lewis, and the daughters of Messrs. John Brooks, Andrew Ellicott, and +David Maffat. + +The weather was variable during the months of February and March. The +navigation of the Delaware was not completely opened until the latter end +of February. The diseases of these two months were catarrhs and bilious +pleurisies. The former were confined chiefly to children, and were cured +by gentle pukes, purges of calomel, and blood-letting. The last remedy +was employed twice in a child of Isaac Pisso, of six weeks old, and once +in a child of Thomas Billington, of three weeks old, with success. + +On the 7th of April, I visited Mr. Pollock, lately from the state of +Georgia, in consultation with Dr. Physick, in a yellow fever. He died the +evening after I saw him, on the third day of his disease. + +There was a snow storm on the 16th of April, and the weather was +afterwards very cold. Such leaves and blossoms as had appeared, were +injured by it. + +On the 1st of May, the mercury in Fahrenheit's thermometer rose to 84°. +The weather, during the latter part of this month, and in June, was very +dry. On the 6th of June, Dr. Cooper lost a patient in the yellow fever, +near the corner of Twelfth and Walnut-streets. Mark Miller died with the +same state of fever on the 2d of July. About a dozen cases of a similar +nature occurred, under the care of different practitioners, between the +2d and 20th of this month, and all of them in parts of the city remote +from Water-street. + +On the 19th of July, the weather was so cool as to render winter clothes +comfortable. A severe hail storm had occurred, a few days before, in the +neighbourhood of Wilmington, in the Delaware state. + +On the 21st of the month, the ship Deborah arrived from one of the +West-India islands, and discharged her cargo in the city. She was moored +afterwards at Kensington, where the foul air which was emitted from her +hold produced several cases of yellow fever, near the shores of that +village. + +In August the disease appeared in nearly every part of the city, and +particularly in places where there was the greatest exhalation from foul +gutters and common sewers. + +In describing the disease, as it appeared this year, I shall take notice +of its symptoms as they appeared in the blood-vessels, alimentary canal, +the tongue, the nervous system, in the eyes, the lymphatic system, and +the blood. + +The subjects which furnished the materials for this history were not only +private patients, but the poor in the city hospital, who were committed +to the care of Dr. Physick and myself, by the board of health. + +I. The pulse was, in many cases, less active in the beginning of this +fever than in former years. It was seldom preternaturally slow. It +resembled the pulse which occurs in the first stage of the common jail +fever. Hæmorrhages were common about the fourth and fifth days, and +generally from the gums, throat, or stomach. + +II. The whole alimentary canal was much affected in most cases. +Costiveness and a vomiting were general. The alvine discharges were +occasionally green, dark-coloured, black, and natural. The black vomiting +was more common this year than in former years, in all the forms of the +fever. It was sometimes suspended for several days before death, and +hopes were entertained of a recovery of patients in whom it had +appeared. In a boy, at the city hospital, it ceased ten days before he +died. It was sometimes succeeded by delirium or coma, but it more +commonly left the patient free of pain, and in the possession of all the +faculties of his mind. + +III. The tongue was by no means an index of the state of the fever, as in +the years 1793 and 1797. I saw several deaths, attended with a black +vomiting, in which the tongue retained a natural appearance. This +phenomenon at first deceived me. I ascribed it to such a concentration of +the disease in the stomach and other vital parts, as to prevent its +diffusing itself through the external parts of the system. We observe the +effects of the same cause in a natural state of the skin, and in a +natural appearance of the urine, in the most malignant forms of this +fever. + +IV. In the nervous system, the disease appeared with several new +symptoms. A relation of Peter Field attempted to bite his attendants in +the delirium of his fever, just before he died. + +I attended a young woman at Mrs. Easby's, who started every time I +touched her pulse. Loud talking, or a question suddenly proposed to her, +produced the same convulsive motion. She retained her reason during the +whole of her illness, and was cured by bleeding and a salivation. + +Hiccup was a common symptom. I saw but two patients recover who had it. +In one of them, Dr. Hedges, it came on after the sixth day of the fever, +and continued, without any other symptom of disease, for four or five +days. + +I lost a patient who complained of no pain but in the calves of his legs. +Dr. Physick lost a girl, in the city hospital, who complained only of +pains in her toes. Her stomach discovered, after death, strong marks of +inflammation. + +Many people passed through every stage of the disease, without uttering a +complaint of pain of any kind. + +An uncommon stiffness in the limbs preceded death a few hours, in several +cases. This stiffness ceased, in one of Dr. Physick's patients, +immediately after death, but returned as soon as he became cold. + +An obstinate wakefulness continued through the whole of the disease in +Dr. Leib. It was common during the convalescence, in many cases. + +The whole body was affected, in many cases, with a morbid sensibility, or +what has been called supersensation, so that patients complained of pain +upon being touched, when they were moved in their beds. This extreme +sensibility was general in parts to which blisters had been applied. It +continued through every stage of the disease. Dr. Physick informed me, +that he observed it in a man two hours before he died. In this man there +was an absence of pulse, and a coldness of his extremities. Upon touching +his wrist, he cried out, as if he felt great pain. + +V. A redness in the eyes was a general symptom. I saw few recoveries +where this redness was not removed. + +A discharge of matter from one ear relieved Mr. J. C. Warren from a +distressing pulsation of the arteries in his head. + +VI. Glandular swellings occurred in several instances. Two cases of them +came under my notice. They both terminated favourably. + +VII. The blood had its usual appearances in this disease. In the yellow +fever which prevailed at the same time in Boston, Dr. Rand says the +blood was sizy in but one out of a hundred cases. + +The forms of the fever were nearly similar to those which have been +described in the year 1797. I saw several cases in which the disease +appeared in the form of a tertian fever. In one of them it terminated in +death. + +The system, in many cases, was prostrated below the point of inflammatory +re-action. These were called, by some practitioners, typhous fevers. It +was the most dangerous and fatal form of the disease. Its frequent +occurrence gave occasion to a remark, that our epidemic resembled the +yellow fever of the West-Indies, much more than the fevers of 1793 and +1797. + +I attended two patients in whom the disease was protracted nearly to the +30th day. They both recovered. + +Dr. Francis Sayre informed me, that he saw a child, in which the morbid +affection of the wind-pipe, called cynanche trachealis, appeared with all +the usual symptoms of yellow fever. + +I attended one case in which the force of the disease was weakened, in +its first stage, by a profuse hæmorrhage from the bowels. This hæmorrhage +was followed by a bloody diarrh[oe]a, which continued for four or five +weeks. + +Persons of all ages and colours were affected by this fever. I saw a case +of it in a child of six months old. In the blacks, it was attended with +less violence and mortality than in white people. It affected many +persons who had previously had it. + +The disease was excited by the same causes which excited it in former +years. I observed a number of people to be affected by the fever, who +lived in solitude in their houses, without doing any business. The +system, in these persons, was predisposed to the disease, by the debility +induced by ceasing to labour at their former occupations. It was excited +in a young man by a fractured leg. He died five days afterwards, with a +black vomiting. I observed, in several instances, an interval of four and +five days between the debility induced upon the system by a predisposing, +and the action of an exciting cause. Dr. Clark says, he has seen an +interval of several weeks between the operation of those causes, in the +yellow fever of Dominique. These facts are worthy of notice, as they +lead to a protracted use of the means of obviating an attack of the +disease. + +During my attendance upon the sick, I twice perceived in my system the +premonitory signs of the epidemic. Its complete formation was prevented +each time by rest, a moderate dose of physic, and a plentiful sweat. + +I shall now take notice of the different manner in which patients died of +this fever. The detail may be useful, by unfolding new principles in the +animal economy, as well as new facts in the history of the disease. + +1. The disease terminated in death, in some instances, by means of +convulsions. + +2. By delirium, which prompted to exertions and actions similar to those +which take place in madness. + +3. By profuse hæmorrhages from the gums. This occurred in two patients of +Dr. Stewart. + +4. By an incessant vomiting and hiccup. + +5. By extreme pain in the calves of the legs and toes, which, by +destroying the excitement of the system, destroyed life. + +6. By a total absence of pain. In this way it put an end to the life of +Mr. Henry Hill. + +7. By a disposition to easy, and apparently natural sleep. I have reason +to believe that Mr. Hill encouraged this disposition to sleep, a few +hours before he died, under the influence of a belief that he would be +refreshed by it. Diemerbroeck says the plague often killed in the same +way. + +8. The mind was in many cases torpid, where no delirium attended, and +death was submitted to with a degree of insensibility, which was often +mistaken for fortitude and resignation. + +I shall now mention the morbid appearances exhibited by the bodies of +persons who died of this fever, as communicated to me by my friend, Dr. +Physick; being the result of numerous dissections made by him at the city +hospital. + +In all of them the stomach was inflamed. The matter which constitutes +what is called the _black vomit_, was found in the stomachs of several +patients who had not discharged it at any time by vomiting. In some +stomachs, he found lines which seemed to separate the living from their +dead parts. Those parts, though dead, were not always in a mortified +state. They were distinguished from the living parts by a peculiar +paleness, and by discovering a weak texture upon being pressed between +the fingers. He observed the greatest marks of inflammation in the +stomachs of several persons in whom there had been no vomiting, during +the whole course of the disease. The brain, in a few instances, +discovered marks of inflammation. Water was now and then found in its +ventricles, but always of its natural colour, even in those persons whose +skins were yellow. The liver suffered but little in this disease. It may +serve to increase our knowledge of the influence of local circumstances +upon epidemics to remark, that this viscus, which was rarely diseased in +the fever of Philadelphia in 1798, discovered marks of great inflammation +in the bodies which were examined by Dr. Rand and Dr. Warren, in the town +of Boston, where the yellow fever prevailed at the same time it did in +Philadelphia. + +The weather was hot and dry in August and September, during the +prevalence of this fever. Its influence upon animal and vegetable life +are worthy of notice. Moschetoes abounded, as usual in sickly seasons; +grasshoppers covered the ground in many places; cabbages and other garden +vegetables, and even fields of clover, were devoured by them. Peaches +ripened this year three weeks sooner than in ordinary summers, and apples +rotted much sooner than usual after being gathered in the autumn. Many +fruit-trees blossomed in October, and a second crop of small apples and +cherries were seen in November, on the west side of Schuylkill, near the +city. Meteors were observed in several places. On the 29th of September +there was a white frost. Its effects upon the fever were obvious and +general. It declined, in every part of the city, to such a degree as to +induce many people to return from the country. In the beginning of +October the weather again became warm, and the disease revived. It was +observable, that all great changes in the weather from heat to cold that +were short of frost, or of cold to heat, increased the mortality of the +fever. It spread most rapidly in moist weather. + +The origin of this fever was from the exhalations of gutters, docks, +cellars, common sewers, ponds of stagnating water, and from the foul air +of the ship formerly mentioned. + +The fever prevailed at the same time in the town of Chester, in +Pennsylvania; in Wilmington, in the state of Delaware; in New-York; in +New-London, in Connecticut; in Windsor, in Vermont; and in Boston; in all +which places its origin was traced to domestic sources. + +I shall now deliver a short account of the remedies employed in the cure +of this disease. + +I have said that the pulse was less active in this fever than in the +fevers of former years. It was seldom, however, so feeble as to forbid +bleeding. In Dr. Mease it called for the loss of 162 ounces of blood, and +in Mr. J. C. Warren for the loss of 200, by successive bleedings, before +it was subdued. But such cases were not common. In most of them, the +pulse flagged after two or three bleedings. But there were cases in which +the lancet was forbidden altogether. In these, the system appeared to be +prostrated, by the force of the miasmata, below the point of re-action. +This state of the disease manifested itself in a weak, quick, and +frequent pulse, languid eye, sighing, great inquietude, or great +insensibility. However unsafe bleeding was on the first day of this +fever, when it appeared with those symptoms, nature often performed that +operation upon herself from the gums, on the fourth or fifth day. I saw +several pounds of blood discharged on those days, and in that way, with +the happiest effects. It appeared to take place after the revival of the +blood-vessels from their prostrated state. + +From a conviction that the system was depressed only in these cases, and +finding that it did not rise upon blood-letting, I resolved to try the +effects of emetics, in exciting and equalizing the action of the +blood-vessels. The experience I had had of the inefficacy of this remedy +in 1793, and of its ill effects in one instance in 1797, led me to +exhibit it with a trembling hand. I gave it for the first time to a son +of Richard Renshaw. I had bled him but once, and had in vain tried to +bring on a salivation. On the fifth day of his disease, his pulse became +languid and slow, his skin cool, a hæmorrhage had taken place from his +gums, and he discovered a restlessness and anxiety which I had often seen +a few hours before death. He took four grains of tartar emetic, with +twenty grains of calomel, at two doses. They operated powerfully, upwards +and downwards, and brought away a large quantity of bile. The effects of +this medicine were such as I wished. The next day he was out of danger. I +prescribed the same medicine in many other cases with the same success. +To several of my patients I gave two emetics in the course of the +disease. Some of them discharged bile resembling in viscidity the white +of an egg. But I saw one case in which great relief was obtained from the +operation of an emetic, where no bile was discharged. + +In the exhibition of this remedy, I was regulated by the pulse. If I +found it languid on the first day of the fever, I gave it before any +other medicine. When it was full and tense, I deferred it until I had +reduced the pulse to the emetic point by bleeding and purges. I observed, +with great pleasure, that mercury affected the mouth more speedily and +certainly where an emetic had been administered, than in other cases, +probably from awakening, by its stimulus, the sensibility of the stomach; +for such was its torpor, that in one case ten grains of tartar emetic, +and in another thirty grains, did not operate upon it, so as to excite +even the slightest degree of nausea. + +In many cases, an emetic, given in the forming state of the disease, +seemed to effect an immediate cure. + +Purges produced the same salutary effects that they did in former years. +I always combined calomel with them in the first stage of the disease. + +A salivation was found to be the most certain remedy of any that was used +in this fever. I did not lose a single patient, in whom the mercury acted +upon the salivary glands. It was difficult to excite it in many cases, +from the mercury being rejected by the stomach, from its passing off by +the bowels, or from its stimulus being exceeded by the morbid action in +the blood-vessels. + +Bleeding rendered the action of the mercury upon the mouth more speedy +and more certain, but I saw several cases in which a salivation was +excited in the most malignant forms of the fever, where no blood had been +drawn. It will not be difficult to explain the reason of this fact if we +recur to what was said formerly of the prostration of the system in this +fever. In its worst forms, there is often a total absence, or a feeble +degree of action in the blood-vessels, from an excess of the stimulus of +the remote cause of the fever. Here the mercury meets with no resistance +in its tendency to the mouth. Bleeding in this case would probably do +harm, by taking off a part of the pressure upon the system, and thereby +produce a re-action in the vessels, that might predominate over the +action of the mercury. The disease here does that for us by its force, +which, in other cases, we effect by depleting remedies. + +Where the mercury showed a disposition to pass too rapidly through the +bowels, I observed no inconvenience from combining it with opium, in my +attempts to excite a salivation. The calomel was constantly aided by +mercurial ointment, applied by friction to different parts of the body. + +Now and then a salivation continued for weeks and months after the crisis +of this fever, to the great distress of the patient, and injury of the +credit of mercury as a remedy in this disease. Dr. Physick has +discovered, that in these cases the salivation is kept up by carious +teeth or bone, and that it is to be cured only by removing them. + +From the impracticability of exciting a salivation in all cases, I +attempted the cure of this fever, after bleeding, by means of copious +sweats. They succeeded in several instances where no other remedy +promised or afforded any relief. They were excited by wrapping the +patient in a blanket, with half a dozen hot bricks wetted with vinegar, +and applied to different parts of the body. The sweating was continued +for six hours, and repeated daily for four or five days. + +In those cases where the fever put on the form of an intermittent, I gave +bark after bleeding and purging with advantage. I gave it likewise in all +those cases where the fever put on the type of the slow chronic fever. +Laudanum was acceptable and useful in many cases of pain, wakefulness, +vomiting, and diarrh[oe]a, after the use of depleting remedies. + +I applied _blisters_ in the usual way in this fever, but I think with +less effect than in the yellow fevers of former years. + +To relieve a vomiting, which was very distressing in many cases about the +fourth and fifth days, I gave a julep, composed of the salt of tartar and +laudanum. I also gave Dr. Hosack's anti-emetic medicine, composed of +equal parts of lime-water and milk. I do not know that it saved any +lives, but I am sure it gave ease by removing a painful symptom, and +thus, where it did not cure, lessened the sufferings of the sick. + +The diet and drinks were the same in this fever as they were in the +fevers formerly described. + +Cool air, cold water, and cleanliness produced their usual salutary +effects in this fever. + +I shall now deliver a short account of the symptoms which indicated a +favourable and an unfavourable issue of the disease. + +It has been said[8], that the signs of danger vary in this fever, from +the influence of the weather. The autumn of 1798 confirmed, in many +instances, the truth of this remark. + + [8] History of the Fever in 1797. + +I saw no instance of death where a bleeding occurred from the gums on the +fourth or fifth day, provided depleting remedies had been used from the +beginning of the disease. Few recovered who had this symptom in 1793. + +I saw three recoveries after convulsions in the year 1798. All died who +were convulsed in 1793 and 1797. + +A dry, hoarse, and sore throat was followed by death in every case in +which it occurred in my practice. In the fever of 1793 a sore throat was +a favourable sign. It was one of the circumstances which determined me +to use a salivation in that fever. + +The absence of pain was always a bad sign. Small, but frequent stools, +and the continuance of a redness in the eyes after the ample use of +depleting remedies, were likewise bad signs. + +An appetite for food on the fourth or fifth day of the fever, without a +remission or cessation of the fever, was always unfavourable. + +A want of delicacy, in exposing parts of the body which are usually +covered, was a bad symptom. I saw but one recovery where it took place. +Boccacio says the same symptom occurred in the plague in Italy. "It +suspended (he tells us) all modesty, so that young women, of great rank +and delicacy, submitted to be attended, dressed, and even cleansed by +male nurses." + +I have remarked, in another place, that but two of my patients recovered +who had the hiccup. + +A dry tongue was a bad sign. I saw but one recovery where it occurred, +and none where the tongue was black. A moist and natural tongue, where +symptoms of violence or malignity appeared in other parts of the body, +was always followed by a fatal issue of the disease. + +A desire to ride out, or to go home, in persons who were absent from +their families, was, in every instance where it took place, a fatal +symptom. These desires arose from an insensibility to pain, or a false +idea of the state of the disease. It existed to such a degree in some of +the patients in the city hospital, that they often left their beds, and +dressed themselves, in order to go home. All these patients died, and +some of them in the act of putting on their clothes. + +From the history that has been given of the symptoms, treatment, and +prognosis of this fever, we see how imperfect all treatises upon +epidemics must be, which are not connected with climate and season. As +well might a traveller describe a foreign climate, by the state of the +weather, or by the productions of the earth, during a single autumn, as a +physician adopt a uniform opinion of the history, treatment, and +prognosis of a fever, from its phenomena in any one country, or during a +single season. + +There were three modes of practice used in this epidemic. The first +consisted in the exhibition of purges of castor oil, salts, and manna, +and cooling glysters, and in the use of the warm bath. These remedies +were prescribed chiefly by the French physicians. The second consisted in +the use of mercury alone, in such doses, and in such a manner, as to +excite a salivation. This mode was used chiefly by an itinerant and +popular quack. The third mode consisted in using all the remedies which I +have mentioned in the account of the treatment of this fever, and +accommodating them to the state of the disease. This mode of practice was +followed by most of the American physicians. + +The first mode of practice was the least successful. It succeeded only in +such cases as would probably have cured themselves. + +The second mode succeeded in mild cases, and now and then in that +malignant state of the fever, in which the action of the blood-vessels +was so much prostrated by the force of the miasmata, as to permit the +mercury to pass over them, and thus to act upon the salivary glands in +the course of four or five days. + +The last mode was by far the most successful. It is worthy of notice, +that the business and reputation of the physicians, during this epidemic, +were in the inverse ratio of their success. The number of deaths by it +amounted to between three and four thousand, among whom were three +physicians, and two students of medicine. Its mortality was nearly as +great as it was in 1793, and yet the number of people who were affected +by it was four times as great in 1793 as it was in 1798, for, in the +latter year, the city was deserted by nearly all its inhabitants. The +cause of this disproportion of deaths to the number who were sick, was +owing to the liberal and general use of the lancet in 1793, and to the +publications in 1797 having excited general fears and prejudices against +it in 1798. Such was the influence of these publications, that many +persons who had recovered from this fever in the two former years, by the +use of depleting remedies, deserted the physicians who had prescribed +them, and put themselves under the care of physicians of opposite modes +of practice. Most of them died. Two of them had been my patients, one of +whom had recovered of a third attack of the fever under my care. + + + + + AN ACCOUNT + + OF THE + + _BILIOUS YELLOW FEVER_, + + AS IT + + APPEARED IN PHILADELPHIA, + + IN THE YEAR 1799. + + +The diseases which succeeded the fever of 1798, in November and December, +were highly inflammatory. A catarrh was nearly universal. Several cases +of sore throat, and one of erysipelas, came under my care in the month of +November. The weather in December was extremely cold. It was equally so +in the beginning of January, 1799, accompanied with several falls of +snow. + +About the middle of the month, the weather moderated so much, so as to +open the navigation of the Delaware. I met with two cases of malignant +colic in the latter part of this month, and one of yellow fever. The last +was Swen Warner. Dr. Physick, who attended him with me, informed me that +he had, nearly at the same time, attended two other persons with the same +disease. + +The weather was very cold, and bilious pleurisies were common, during the +latter part of the month of February. + +March was equally cold. The newspapers contained accounts of the winter +having been uncommonly severe in Canada, and in several European +countries. + +The first two weeks in April were still cold. The Delaware, which had +been frozen a second time during the winter, was crossed near its origin, +on the ice, on the 15th day of this month. The diseases, though fewer +than in the winter, were bilious and inflammatory. During this month, I +was called to a case of yellow fever, which yielded to copious bleeding, +and other depleting medicines. + +May was colder than is usual in that month, but very healthy. + +In the first week of June, several cases of highly bilious fever came +under my care. In one of them, all the usual symptoms of the highest +grade of that fever occurred. On the 13th of the month, Dr. Physick +informed me, that he had lost a patient with that disease. On the 23d of +the same month, Joseph Ashmead, a young merchant, died of it. Several +other cases of the disease occurred between the 20th and 29th days of the +month, in different parts of the city. About this time, I was informed +that the inhabitants of Keys's-alley had predicted a return of the yellow +fever, from the trees before their doors emitting a smell, exactly the +same which they perceived just before the breaking out of that disease in +1793. + +In July, the city was alarmed, by Dr. Griffitts, with an account of +several cases of the fever in Penn-street, near the water. The strictness +with which the quarantine law had been executed, for a while rendered +this account incredible with many people, and exposed the doctor to a +good deal of obloquy. At length a vessel was discovered, that had arrived +from one of the West-India islands on the 14th of May, and one day before +the quarantine law was put into operation, from which the disease was +said to be derived. Upon investigating the state of this vessel, it +appeared that she had arrived with a healthy crew, and that no person had +been sick on board of her during her voyage. + +In the latter part of July and in the beginning of August, the disease +gradually disappeared from every part of the city. This circumstance +deserves attention, as it shows the disease did not spread by contagion. + +About this time we were informed by the newspapers, that dogs, geese, and +other poultry, also that wild pigeons were sickly in many parts of the +country, and that fish on the Susquehannah, and oysters in the Delaware +bay, were so unpleasant, that the inhabitants declined eating them. At +the same time, flies were found dead in great numbers, in the unhealthy +parts of the city. The weather was dry in August and September. There was +no second crop of grass. The gardens yielded a scanty supply of +vegetables, and of an inferior size and quality. Cherries were smaller +than usual, and pear and apple-trees dropped their fruits prematurely, in +large quantities. The peaches, which arrived at maturity, were small and +ill-tasted. The grain was in general abundant, and of a good quality. A +fly, of an unusual kind, covered the potatoe fields, and devoured, in +some instances, the leaves of the potatoe. This fly has lately been used +with success in our country, instead of the fly imported from Spain. It +is equal to it in every respect. Like the Spanish fly, it sometimes +induces strangury. + +About the middle of August the disease revived, and appeared in different +parts of the city. A publication from the academy of medicine, in which +they declared the seeds of the disease to spread from the atmosphere +only, produced a sudden flight of the inhabitants. In no year, since the +prevalence of the fever, was the desertion of the city so general. + +I shall now add a short account of the symptoms and treatment of this +epidemic. + +The arterial system was in most cases active. I met with a tense pulse in +a patient after the appearance of the black vomiting. Delirium was less +frequent in adults than in former years. In children there was a great +determination of the disease to the brain. + +I observed no new symptoms in the stomach and bowels. One of the worst +cases of the fever which I saw was accompanied with colic. A girl of +Thomas Shortall, who recovered, discharged 9 worms during her fever. It +appeared in Mr. Thomas Roan, one of my pupils, in the form of a +dysentery. + +A stiffness, such as follows death, occurred in several patients in the +city hospital before death. + +Miss Shortall had an eruption of pimples on her breast, such as I have +described in the short account I gave of the yellow fever of 1762 in this +city, in my account of the disease in 1793. + +The blood exhibited its usual appearances in the yellow fever. It was +seldom sizy till towards the close of the disease. + +The tongue was generally whitish. Sometimes it was of a red colour, and +had a polished appearance. I saw no case of a black tongue, and but few +that were yellow before the seventh day of the disease. + +The type of this disease was nearly the same as described in 1797. It now +and then appeared in the form of a quartan, in which state it generally +proved fatal. It appeared with rheumatic pains in one of my patients. It +blended itself with gout and small-pox. Its union with the latter disease +was evident in two patients in the city hospital, in each of whom the +stools were such as were discharged in the most malignant state of the +fever. + +The remedies for this fever were bleeding, vomits, purges, sweats, and a +salivation and blisters. + +There were few cases that did not indicate bleeding. It was performed, +when proper, in the usual way, and with its usual good effects. It was +indicated as much when the disease appeared in the bowels as in the +blood-vessels. Mr. Roan, in whom it was accompanied with symptoms of +dysentery, lost nearly 200 ounces of blood by twenty-two bleedings. + +I found the same benefit from emetics, in this fever, that I did in the +fever of 1798. They were never administered except on the first day, +before violent action had taken place in the system, or after it was +moderated by one or two bleedings. + +Purges of calomel and jalap, also castor oil, salts, and injections were +prescribed with their usual advantages. + +In those cases where the system was prostrated below the point of +re-action, I began the cure by sweating. Blankets, with hot bricks wetted +with vinegar, and the hot bath, as mentioned formerly, when practicable, +were used for this purpose. The latter produced, in a boy of 14 years of +age, who came into the city hospital without a pulse, and with a cold +skin, in a few hours, a general warmth and an active pulse. The +determination of the disease to the pores was evinced in one of my +patients, by her sweating under the use of the above-mentioned remedies, +for the first time in her life. A moisture upon her skin had never before +been induced, she informed me, even by the warmest day in summer. + +The advantages of a salivation were as great as in former years. From the +efficacy of bleeding, purges, emetics, and sweating, I had the pleasure +of seeing many recoveries before the mercury had time to affect the +mouth. In no one case did I rest the cure exclusively upon any one of +these remedies. The more numerous the outlets were to convey off +superfluous fluids and excitement from the body, the more safe and +certain were the recoveries. A vein, the gall-bladder, the bowels, the +pores, and the salivary glands were all opened, in succession, in part, +or together, according to circumstances, so as to give the disease every +possible chance of passing out of the body without injuring or destroying +any of its vital parts. + +Blisters were applied with advantage. The vomiting and sickness which +attend this fever were relieved, in many instances, by a blister to the +stomach. + +In those cases in which the fever was protracted to the chronic state, +bark, wine, laudanum, and æther produced the most salutary effects. I +think I saw life recalled, in several cases in which it appeared to be +departing, by frequent and liberal doses of the last of those medicines. +The bark was given, with safety and advantage, after the seventh day, +when the fever assumed the form of an intermittent. + +The following symptoms were generally favourable, viz. a bleeding from +the mouth and gums, and a disposition to weep, when spoken to in any +stage of the fever. + +A hoarseness and sore throat indicated a fatal issue of the disease, as +it did in 1798. Dr. Physick remarked, that all those persons who sighed +after waking suddenly, before they were able to speak, died. + +The recurrence of a redness of the eyes, after it had disappeared, or of +but one eye, was generally followed by death. I saw but one recovery with +a red face. + +I saw several persons, a few hours before death, in whom the countenance, +tongue, voice, and pulse were perfectly natural. They complained of no +pain, and discovered no distress nor solicitude of mind. Their danger was +only to be known by the circumstances which had preceded this apparently +healthy and tranquil state of the system. They had all passed through +extreme suffering, and some of them had puked black matter. + +The success of the mode of practice I have described was the same as in +former years, in private families; but in the city hospital, which was +again placed under the care of Dr. Physick and myself, there was a very +different issue to it, from causes that are too obvious to be mentioned. + +There were two opinions given to the public upon the subject of the +origin of this fever; the one by the academy of medicine, the other by +the college of physicians. The former declared it to be generated in the +city, from putrid domestic exhalations, because they saw it only in their +vicinity, and discovered no channel by which it could have been derived +from a foreign country; the latter asserted it to be "imported, because +it had been imported in former years." + + + + + AN + + ACCOUNT OF SPORADIC CASES + + OF + + _YELLOW FEVER_, + + AS THEY + + APPEARED IN PHILADELPHIA, + + IN 1800. + + +The weather in the month of January was less cold than is common in that +month. Catarrhs, the cynanche trachealis, and bilious pleurisies were +prevalent in every part of it. A few cases of yellow fever occurred +likewise during this month. + +Several cases of erysipelas appeared in February. + +The month of March was unusually healthy. + +The weather was warm in April, and the city as healthy as in March. + +It was equally so in May and June. The spring fruits appeared early in +the latter month, in large quantities, and were of an excellent quality. +Locusts were universal in June. They had not appeared since the year +1783. A record from the journal of the Swedish missionaries was published +at this time, which described their appearance in 1715, in which year it +was said to be very healthy. + +On the 14th of June there was a severe thunder gust, with more lightning +than had been known for seven years before. + +There fell, during all the months that have been mentioned, frequent and +plentiful showers of rain, which rendered the crops of grass luxuriant in +the neighbourhood of Philadelphia. + +The winds at this time were chiefly from the south-east. + +A few intermittents appeared in June, which yielded readily to the bark. + +On the 16th day of June, Dr. Physick informed me he had a black boy under +his care with the yellow fever. + +In July, the hooping cough, cholera infantum, and some cases of dysentery +and bilious fever appeared in the city. + +On the 30th of July, Dr. Pascalis informed me that he had lost a patient +on the fifth day of a yellow fever. + +In August, the dysentery was the principal form of disease that prevailed +in the city. + +On the 22d of this month, a woman died of the yellow fever in +Gaskill-street, under the care of Dr. Church. + +On the 28th and 30th, there fell an unusual quantity of rain. The winds +were south-west and north-west during the greatest part of the summer +months. The latter were sometimes accompanied with rain. + +On the 11th of September, a clerk of Mr. Levi Hollingsworth, and, on the +12th, a clerk of Mr. John Connelly, died with the yellow fever. + +A plentiful shower of rain fell on the night of the 21st of this month. + +About this time there appeared one and twenty cases of yellow fever in +Spruce-street, between Front and Second-streets. They were all in the +neighbourhood of putrid exhalations. Fourteen of them ended fatally. + +No one of the above cases of malignant fever could be traced to a ship, +or to a direct or indirect intercourse with persons affected by that +disease. + +While Philadelphia was thus visited by a few sporadic cases only of +yellow fever, it was epidemic in several of the cities of the United +States, particularly in New-York, Providence, in Rhode Island, Norfolk, +and Baltimore. In the last named place, it was publicly declared by the +committee of health to be of domestic origin. + +The dysentery was epidemic, at the same time, in several of the towns of +Massachusetts and New-Hampshire. It was attended with uncommon mortality +at Hanover, in the latter state. + +This difference in the states of health and sickness in the different +parts of the United States must be sought for chiefly in the different +states of the weather in those places. The exemption of Philadelphia from +the yellow fever, as an epidemic, may perhaps be ascribed to the strength +and vigour of the vegetable products of the year, which retarded their +putrefaction; to frequent showers of rain, which washed away the filth +of the streets and gutters; and to the perfection of the summer and +autumnal fruits. + +The months of November and December this year were uncommonly healthy. +During the former, several light shocks of earthquakes were felt in +Lancaster and Harrisburg, in Pennsylvania, and in Wilmington, in the +state of Delaware. + + + + + AN + + ACCOUNT OF SPORADIC CASES + + OF + + _YELLOW FEVER_, + + AS THEY + + APPEARED IN PHILADELPHIA, + + IN 1801. + + +The month of January was intensely cold. In February it became more +moderate. The diseases, during these two months, were catarrhs and a few +pleurisies. + +In March and April there fell an unusual quantity of rain. The hay +harvest began in the neighbourhood of Philadelphia on the 28th of May. A +few mild cases of scarlatina anginosa occurred during these months. + +In June the weather was dry and healthy. + +On the 8th of July, a case of yellow fever occurred in the practice of +Dr. Stewart. About the 15th of the month, a patient died with it in the +Pennsylvania hospital. Dr. Physick informed me that he had, at the same +time, two patients under his care with that disease. Several cases of the +measles appeared in the south end of the city during this month. In every +part of it, the weather was warm and dry, in consequence of which there +were no second crops of grass, and a smaller quantity than usual of +summer fruits and vegetables. The winds were less steady than they had +been for seven years. They blew, every two or three days, from nearly +every point of the compass. + +On the 4th of August there fell a considerable quantity of rain, which +was succeeded by cool and pleasant weather. The cholera morbus was a +frequent disease among both adults and children in the city, and the +dysentery in several of the adjoining counties of the state. + +A number of emigrant families arrived this month from Ireland and Wales, +who brought with them the ship fever. They were carefully attended, at +the lazaretto and the city hospital, in airy rooms, by which means they +did not propagate the disease. Contrary to its usual character, it +partook of the remissions of the bilious fever, probably from the +influence of the season upon it. + +In September there were a few extremely warm days. In the beginning and +middle of the month a number of mild remittents occurred, and about the +22d there were five or six cases of yellow fever in Eighth-street, +between Chesnut and Walnut-streets, in two houses ill ventilated, and +exposed to a good deal of exhalation. I attended most of these cases in +consultation with Dr. Gallaher. One of the persons who was affected with +this fever puked black matter while I sat by his bed-side, a few hours +before he died. + +During the summer and autumn of this year, a number of cases of yellow +fever appeared at New-Bedford, Portland, and Norwich, in the New-England +states; in New-York; in some parts of New-Jersey; and in Northampton and +Bucks counties, in Pennsylvania. It prevailed so generally in New-York, +as to produce a considerable desertion of the city. In none of the above +places could the least proof be adduced of the disease being imported. In +Philadelphia its existence was doubted or denied by most of the citizens, +because it appeared in situations remote from the water, and of course +could not be derived from any foreign source. + +It will be difficult to tell why the fever appeared only in sporadic +cases in Philadelphia. Perhaps its prevalence as an epidemic was +prevented by the plentiful rains in the spring months, by the absence of +moisture from the filth of the streets and gutters, in consequence of the +dry weather in June and July, by the vigour and perfection of the +products of the earth, and by the variable state of the winds in the +month of July. If none of these causes defended the city from more +numerous cases of the yellow fever, it must be resolved into the want of +a concurring inflammatory constitution of the atmosphere with the common +impure sources of that disease. + +On the 12th of November, about twelve o'clock in the night, an earthquake +was felt in Philadelphia, attended with a noise as if something heavy had +fallen upon a floor. Several cases of scarlet fever appeared in December, +but the prevailing disease, during the two last autumnal and the first +winter months, was the measles. I have taken notice that it appeared in +the south end of the city in July. During the months of August and +September it was stationary, but in October, November, and December it +spread through every part of the city. The following circumstances +occurred in this epidemic, as far as it came under my notice. + + + + + AN ACCOUNT + + OF + + THE MEASLES, + + AS THEY + + APPEARED IN PHILADELPHIA, + + IN THE YEAR 1801. + + +I. The disease wore the livery of the autumnal fever in the following +particulars. + +It was strongly marked by remissions and intermissions. The exacerbations +came on chiefly at night. + +There were in many cases a constant nausea, and discharge of bile by +puking. + +I saw one case in which the disease appeared with a violent cholera +morbus, and several in which it was accompanied with diarrh[oe]a and +dysentery. + +II. Many severe cases of phrenzy, and two of cynanche trachealis appeared +with the measles. + +III. A distressing sore mouth followed them, in a child of two years old, +that came under my care. + +IV. A fatal hydrocephalus internus followed them in a boy of eight years +old, whom I saw two days before he died. + +V. I met with a few cases in which the fever and eruption came on in the +same day, but I saw one case in which the eruption did not take place +until the tenth, and another, in which it did not appear until the +fourteenth day after the fever. + +VI. Two children had pustules on their skins, resembling the small-pox, +before the eruption of the measles. + +VII. Many children had coughs and watery eyes, but without the measles. +The same children had them two or three weeks afterwards. + +VIII. Many people who had had the measles, had coughs during the +prevalence of the measles, resembling the cough which occurs in that +disease. + +The remedies made use of in my practice were, + +1. Bleeding, from four to sixty ounces, according to the age of the +patient, and the state of the pulse. This remedy relieved the cough, +eased the pains in the head, and in one case produced, when used a third +time, an immediate eruption of the measles. + +2. Lenient purges. + +3. Demulcent drinks. + +4. Opiates at night. + +5. Blisters. And, + +6. Astringent medicines, where a diarrh[oe]a took place. + +I saw evident advantages from advising a vegetable diet to many children, +as soon as any one of the families to which they belonged were attacked +by the measles. + +I lost but one patient in this disease, and that was a child in +convulsions. I ascribed my success to bleeding more generally and more +copiously than I had been accustomed to do, in the measles of former +years. + + + + + AN ACCOUNT + + OF THE + + _BILIOUS YELLOW FEVER_, + + AS IT + + APPEARED IN PHILADELPHIA, + + IN THE YEAR 1802. + + +The weather during the month of January was unusually moderate and +pleasant. In the latter end of it, many shrubs put forth leaves and +blossomed. I saw a leaf of the honeysuckle, which was more than an inch +in length, and above half an inch in breadth. There was but one fall of +snow, and that a light one, during the whole month. + +The winds blew chiefly from the south-west in February. There was a light +fall of snow on the 6th. A shad was caught in the Delaware, near the +city, on the 17th. On the 18th and 19th of the month, the weather became +suddenly very cold. On the 22d there was a snow storm, and on the 28th, +rain and a general thaw. + +In March, the weather was wet, cold, and stormy, with the exception of a +few pleasant days. + +The scarlatina anginosa and the cynanche trachealis were the principal +diseases that prevailed during the three months that have been mentioned. + +In April, there were several frosts, which destroyed the blossoms of the +peach-trees. + +In May, the weather was so cool as to make fires agreeable to the last +day of the month. The wind blew chiefly, during the whole of it, from the +north-east. + +The scarlatina continued to be the reigning disease. I saw one fatal case +of it, in which a redness only, without any ulcers or sloughs, appeared +in the throat; and I attended another, in which a total immobility in the +limbs was substituted by nature for the pain and swellings in those parts +which generally attend the disease. There were three distinct grades of +this epidemic. It was attended with such inflammatory or malignant +symptoms, in some instances, as to require two or three bleedings; in +others it appeared with a typhoid pulse, which yielded to emetics: +turbith mineral was preferred for this purpose; while a redness, without +a fever, which yielded to a single purge, was the only symptom of it in +many people. + +The weather was cool, rainy, and hot, in succession, in the month of +June. The scarlatina continued to be the prevailing disease. + +During the first and second weeks in July, there fell a good deal of +rain. On the 4th of the month I was called to visit Mrs. Harris, in +Front-street, between Arch and Market-streets, with a bilious fever. The +scarlatina had imparted to it a general redness on her skin, which +induced her to believe it was that disease, and to neglect sending for +medical relief for several days. She died on the 13th of the month, with +a red eye, a black tongue, hiccup, and a yellow skin. Three other cases +of malignant bilious fever occurred this month. Two of them were attended +by Dr. Dewees and Dr. Otto. + +On the 15th of the month, the city was alarmed by an account of this +fever having appeared near the corners of Front and Vine-streets, a part +of the city which had for many weeks before been complained of by many +people for emitting a f[oe]tid smell, derived from a great quantity of +filthy matters stagnating in that neighbourhood, and from the foul air +discharged from a vessel called the Esperanza, which lay at Vine-street +wharf. + +On the 2d of August, it appeared in other parts of the city, particularly +in Front and Water-streets, near the draw-bridge, where it evidently +originated from putrid sources. Reports were circulated that it was +derived from contagion, conveyed to Vine-street wharf in the timbers of a +vessel called the St. Domingo Packet, but faithful and accurate inquiries +proved that this vessel had been detained one and twenty days, and well +cleaned at the lazaretto, and that no one, of fourteen men who had worked +on board of her afterwards, had been affected with sickness of any kind. + +On the 5th of August, the board of health publicly declared the fever to +be contagious, and advised an immediate desertion of the city. The advice +was followed with uncommon degrees of terror and precipitation. + +The disease continued, in different parts of the city, during the whole +of August and September. On the 5th of October, the citizens were +publicly invited from the country by the board of health. + +During this season, the yellow fever was epidemic in Baltimore and +Wilmington. In the former place it was admitted by their board of health, +and in the latter it was proved by Dr. Vaughan, to be of domestic origin. +It prevailed, at the same time, in Sussex county and near Woodbury, in +New-Jersey. Sporadic cases of it likewise occurred in New-York and +Boston, and in Portsmouth, in New-Hampshire. The chronic fever was +epidemic in several of the towns of North-Carolina; cases of fever, which +terminated in a swelling and mortification of the legs, and in death on +the third day, appeared on the waters of the Juniata, in Pennsylvania; +and bilious fevers, of a highly inflammatory grade, were likewise common +near Germantown and Frankford, in the neighbourhood of Philadelphia. + +But few of the cases of yellow fever which have been mentioned came under +my care, but I saw a considerable number of fevers of a less violent +grade. They were the inflammatory, bilious, mild remitting, chronic, and +intermitting fevers, and the febricula. They appeared, in some instances, +distinct from each other, but they generally blended their symptoms in +their different stages. The yellow fever often came on in the mild form +of an intermittent, and even a febricula, and as often, after a single +paroxysm, ended in a mild remittent or chronic fever. When it appeared in +the latter form, it was frequently attended with a slow or low pulse, and +a vomiting and hiccup, such as attend in the yellow fever. This diversity +of symptoms, with which the summer and autumnal fever came on, made it +impossible to decide upon its type on the day of its attack. Having been +deceived in one instance, I made it a practice afterwards to watch every +case I was called to with double vigilance, lest it should contract a +malignant form in my hands, without my being prepared to meet it. Of the +five original and obvious cases of yellow fever to which I was called, I +saved none, for I saw but one of them before the last stage of the +disease. In many others, I have reason to believe I prevented that +malignant form of fever, by the early and liberal use of depleting +medicines. The practice of those physicians who attended most of the +persons who had the yellow fever, was much less successful than in our +former epidemics. I suspected at the time, and I was convinced +afterwards, that it was occasioned by relying exclusively upon bleeding, +purges, and mercury. The skin, in several of the cases which I saw, was +covered with moisture. This clearly pointed out nature's attempt to +relieve herself by sweating. Upon my mentioning this fact to the late Dr. +Pfeiffer, jun. he instantly adopted my opinion, and informed me, as a +reason for doing so, that he had heard of several whole families in the +Northern Liberties, where the disease prevailed most, who, by attacking +it in its forming state by profuse sweats, had cured themselves, without +the advice of a physician. + + + + + AN ACCOUNT + + OF THE + + _BILIOUS YELLOW FEVER_, + + AS IT + + APPEARED IN PHILADELPHIA, + + IN 1803. + + +The weather in January was uniformly cold. On the 21st of the month, the +Delaware was completely frozen. + +On the 4th of February there was a general thaw, attended with a storm of +hail, thunder, and lightning, which lasted about three quarters of an +hour. The diseases of both these winter months were catarrhs and bilious +pleurisies. The latter appeared in a tertian type. The pain in the side +was most sensible every other day. + +The weather was cold and dry in March, in consequence of which, +vegetation was unusually backward in April. The hooping cough, catarrhs, +and scarlatina were the diseases of this month. + +The beginning of May was very cool. There was ice on the 7th of the +month. The winds, during the greatest parts of this and the previous +month, were from the north-east. + +In June, the weather was cool. Intermittents were common in this month, +as well as in May. Such was the predominance of this type of fever over +all other diseases, that it appeared in the form of profuse sweats, every +other night, in a lady under the care of Dr. Dewees and myself, in the +puerperile fever. On the intermediate nights she had a fever, without the +least moisture on her skin. There were a few choleras this month. During +the latter end of the month, I lost a patient with many of the symptoms +of yellow fever. + +The weather in July was alternately hot, moderate, and cool, with but +little rain. The first two weeks of this month were healthy. A few +tertian fevers occurred, which readily yielded to bark, without previous +bleeding. Between the 25th and 31st of the month, three deaths took place +from the yellow fever. + +In the month of August, the weather was the same as in July, except that +there fell more rain in it. Mild remittents and cholera infantum were +now common. There were likewise several cases of yellow fever during +this month. One of them was in Fromberger's-court. It was induced by the +f[oe]tor of putrid fish in a cellar. A malignant dysentery was epidemic +during this month in the upper part of Germantown, and in its +neighbourhood. Several persons, Dr. Bensell informed me, died of it in +thirty hours sickness. It prevailed, at the same time, in many parts of +the New-England states. + +In September, cases of yellow fever appeared in different parts of the +city, but chiefly in Water, near Walnut-street. On the 12th of the month, +the board of health published a declaration of its existence in the city, +but said it was not contagious. This opinion gave great offence, for it +was generally said to have been imported by means of a packet-boat from +New-York, where the fever then prevailed, because a man had sickened and +died in the neighbourhood of the wharf where this packet was moored. It +was to no purpose to oppose to this belief, proofs that no sick person, +and no goods supposed to be infected, had arrived in this boat, and that +no one of three men, who had received the seeds of the disease in +New-York, had communicated it to any one of the families in Philadelphia, +in which they had sickened and died. + +The disease assumed a new character this year, and was cured by a +different force of medicine from that which was employed in some of the +years in which it had prevailed in Philadelphia. + +I shall briefly describe it in each of the systems, and then take notice +of some peculiarities which attended it. Afterwards I shall mention the +remedies which were effectual in curing it. + +1. The pulse was moderately _tense_ in most cases. It intermitted in one +case, and in several others the tension was of a transient nature. + +Hæmorrhages occurred in many cases. They were chiefly from the nose, but +in some instances they occurred from the stomach, bowels, and +hæmorrhoidal vessels. + +2. Great flatulency attended in the stomach, but sickness and vomiting +were much less frequent than in former years. I saw but one case in which +diarrh[oe]a attended this fever. + +3. I did not meet with a single instance of a glandular swelling in any +part of the body. + +4. There was a general disposition to sweat in this fever from its +beginning. Two of my patients died, in whom no moisture could be excited +on the skin. But I recovered one with a dry skin, by means of a purge, +two bleedings, and blisters. + +An efflorescence on the skin occurred in several instances. I saw black +matter discharged from a blister in one case, and blood in another. + +5. The stools were green and black. Bile was generally discharged in +puking. + +6. The blood exhibited the following appearances: siziness, lotura +carnium, sunken crassamentum, red sediment, and what is called dense or +unseparated blood. I saw no instance of its being dissolved. + +7. The tongue was whitish and dark-coloured. This diseased appearance +continued, in some instances, several days after a recovery took place. I +saw no smooth, red, nor black tongue, and but one dry and one _natural_ +tongue. The latter was followed by death. + +I did not see a single case in which the disease came on without an +exciting cause; such as light clothing and bed-clothes, sitting at doors +after night, a long walk, gunning, and violent and unusual exercises of +any kind. It was excited in a number of people by their exertions to +extinguish a fire which took place in Water-street, between Market and +Chesnut-streets, on the morning of the 25th of August. I saw a fatal +instance of it succeed a severe tooth-ach. Whether this pain was the +exciting cause, or the first morbid symptom of the fever, I know not; but +I was led by it to bleed a young lady twice who complained of that pain, +and who had at the same time a tense pulse. Her blood had the usual +appearances which occur in the yellow fever. + +The disease had different appearances in different parts of the city. It +was most malignant in Water-street; but in many instances it became less +so, as it travelled westward, so that about Ninth-street it appeared in +the form of a common intermittent. + +In every part of the city it often came on, as in the year 1802, in all +the milder forms of autumnal fever formerly enumerated, and went off with +the usual symptoms of yellow fever. Again, it came on with all the force +and malignity of a yellow fever, and terminated, in a day or two, in a +common remittent or intermittent. These modes of attack were so common, +that it was impossible to tell what the character, or probable issue of a +fever would be, for two or three days. + +The following remedies were found, very generally, to be effectual in +this fever. + +1. Moderate bleeding. I bled but three patients three, and only one, four +times. In general, the loss of from ten to twenty ounces of blood, +reduced the pulse from a synocha to a synoichoid or typhoid state, and +thereby prepared the system for other remedies. + +2. Purges were always useful. I gave calomel and jalap, castor oil, +salts, and senna, according to the grade of the disease, and often +according to the humour or taste of the patient. I aided these purges by +glysters. In one case, where a griping and black stools attended, I +directed injections of lime water and milk to be used, with the happiest +effects. + +3. I gave emetics in many cases with advantage, but never while the pulse +was full or tense. + +4. Having observed, as in the year 1802, a spontaneous moisture on the +skin on the first day of the disease, in several cases, I was led to +assist this disposition in nature to be relieved by the pores, by means +of sweating remedies, but in no instance did I follow it, without +previous evacuations from the blood-vessels or bowels; for, however +useful the intimations of nature may be in acute diseases, her efforts +should never be trusted to alone, inasmuch as they are in most cases too +feeble to do service, or so violent as to do mischief. I saw one death, +and I heard of another, from an exclusive reliance upon spontaneous +sweats in the beginning of this fever. The remedies I employed to promote +this evacuation by the pores were, an infusion of the eupatorium +perfoliatum in boiling water, aided by copious warm drinks, and hot +bricks and blankets, applied to the external surface of the body. The +eupatorium sometimes sickened the stomach, and puked. The sweats were +intermitted, and renewed two or three times in the course of four and +twenty hours. + +5. I derived great advantage from the application of blisters to the +wrists, _before_ the system descended to what I have elsewhere called, +the blistering point. This was on the second and third days. My design, +in applying them thus early, was to attract morbid excitement to the +extremities, and thereby to create a substitute for a salivation. They +had this effect. The pain, increase of fever, and occasional strangury, +which were produced by them, served like anchors to prevent the system +being drifted and lost, by the concentration of morbid excitement in the +stomach and brain, on the fourth, fifth, sixth, and seventh days of the +disease. It gave me great pleasure to find, upon revising Dr. Home's +account of the yellow fever, that this mode of applying blisters, in the +early stage of the disease, was not a new one. He often applied them in +the first stage of the fever, more especially when the yellow colour of +the skin made its appearance on the first or second day. By the advice of +Dr. Cheney, of Jamaica, he was led to prefer them to the thighs, instead +of the trunk of the body, or the legs and arms. He forbids their ever +being applied below the calf of the legs. This caution is probably more +necessary in the West-Indies than in the United States. The pain and +inflammation excited by the blisters were mitigated by soft poultices of +bread and milk. The strangury soon yielded to demulcent drinks, +particularly to flaxseed tea. + +I was happy in not being compelled, by the violence or obstinacy of this +fever, to resort to a salivation in order to cure it, in a single +instance; the discharges from the stomach and bowels, and from the veins, +pores, and skin, having proved sufficient to convey the disease out of +the system. + +Two persons recovered this year who had the black vomiting. One of them +was by means of large quantities of brandy and volatile alkali, +administered by Dr. John Dorsey, in the city hospital; the other was by +means of lime and water and milk, given by an intelligent nurse to one of +my patients, during the interval of my visits to her. + +From the history which has been given of the symptoms of this fever; from +the less force of medicine that was necessary to subdue it; from the +safety and advantage of blisters in its _early_ stage; and from the small +proportion which the deaths bore to the number of those who were +affected, being seldom more than five in a hundred (including all the +grades and forms of the disease), in the practice of most of the +physicians, it is evident this fever was of a less malignant nature than +it had been in most of the years in which it had been epidemic. There was +one more circumstance which proved its diminution of violence, and that +was, a more feeble operation of its remote cause. In the year 1802, +nearly all the persons who were affected with the fever in the +neighbourhood of Vine and Water-streets, and in Water, between Walnut and +Spruce-streets, died. This year, but two died of a great number who were +sick in the former, and not one out of twelve who were sick in the latter +place. The filth, in both parts of the city, was the same in both years. +This difference in the violence and mortality of the fever was probably +occasioned by a less concentrated state of the miasmata which produced +it, or by the co-operation of a less inflammatory constitution of the +atmosphere. + +The yellow fever was epidemic, during the summer and autumn of this year, +in New-York, and in Alexandria, in Virginia. In the latter place, Dr. +Dick has informed the public, it was derived from domestic +putrefaction. + + + + + AN + + ACCOUNT OF SPORADIC CASES + + OF + + _YELLOW FEVER_, + + AS THEY + + APPEARED IN PHILADELPHIA, + + IN 1804. + + +The month of January was marked by deep snows, rain, clear and cold +weather, and by the general healthiness of the city. + +In February there fell a deep snow, which was followed by several very +cold days. There was likewise a fall of snow in March, which was +succeeded by an uncommon degree of cold. Catarrhs and bilious pleurisies +were very common during both these months. + +In the beginning of April, the weather was cold and rainy. There were but +few signs of vegetation before the 15th of the month. Bilious pleurisies +were still the principal diseases which prevailed in the city. + +The month of May was wet, cool, and healthy. + +In June, the winds were easterly, and the weather rainy. The crops of +grass were luxuriant. It was remarked, that the milk of cows that fed +upon this grass yielded less butter than usual, and that horses that fed +upon it, sweated profusely with but little exercise. On the third of the +month, I was called upon by Dr. Physick to visit his father, who was ill +with a bilious fever. He died on the seventh, with a red eye, hiccup, and +black vomiting. + +Four persons had the yellow fever in the month of July. One of them was +in Fourth-street, between Pine and Lombard-streets, another was in +Fifth-street, between Race and Vine-streets, both of whom recovered. The +remaining two were in the Pennsylvania hospital, both of whom died. +Remitting and intermitting fevers were likewise common in this month. + +In August, those fevers assumed a chronic form. During this month, there +died an unusual number of children with the cholera morbus. + +The city was uncommonly healthy in September. A storm of wind and rain, +from the south-east, proved destructive to the crops of cotton this +month, on the sea coast of South-Carolina. + +In October, intermittents were very common between Eighth-street and +Schuylkill. One case of yellow fever came under my care, in conjunction +with Dr. Gallaher, on the western banks of that river. + +While Philadelphia and all the cities of the United States (Charleston +excepted) were thus exempted from the yellow fever as an epidemic, the +western parts of all the middle, and several of the southern states, were +visited with the bilious fever, in all its different forms. In Delaware +county, in the state of New-York, at Mill river, in Connecticut, and in +several of the middle counties of Pennsylvania, it prevailed in the form +of a yellow fever. In other parts of the United States, it appeared +chiefly as a highly inflammatory remittent. It was so general, that not +only whole families, but whole neighbourhoods were confined by it. Many +suffered from the want of medical advice and nursing, and some from the +want of even a single attendant. In consequence of the general prevalence +of this fever in some parts of Pennsylvania, the usual labours of the +season were suspended. Apples fell and perished upon the ground; no +winter grain was sowed; and even cows passed whole days and nights +without being milked. + +The mortality of this fever was considerable, where those distressing +circumstances took place. In more favourable circumstances, it yielded to +early depletion, and afterwards to the bark. Relapses were frequent, from +premature exposure to the air. Those only escaped them who had been +salivated, by accident or design, for the cure of the fever. + +This disease was observed very generally to prevail most in high +situations, which had been for years distinguished for their healthiness, +while the low grounds, and the banks of creeks and rivers, were but +little affected by it. The unusual quantity of rain, which had fallen +during the summer months, had produced moisture in the former places, +which favoured putrefaction and exhalation, while both were prevented, in +the latter places, by the grounds being completely covered with water. + + + + + AN ACCOUNT + + OF THE + + _BILIOUS YELLOW FEVER_, + + AS IT + + APPEARED IN PHILADELPHIA, + + IN THE YEAR 1805. + + +For a history of the uncommonly cold and tempestuous winter of 1804 and +1805, the reader is referred to the Account of the Climate of +Pennsylvania, in the first volume of these Inquiries and Observations. + +During the months of January, February, and March, there were a number of +bilious catarrhs and pleurisies. + +On the 7th of April, I visited a patient in the yellow fever with Dr. +Stewart. He was cured, chiefly by copious bleeding. + +The weather was rainy in May. After the middle of June, and during the +whole month of July, there fell no rain. The mercury in Fahrenheit +fluctuated, for ten days, between 90° and 94°, during this month. The +diseases which occurred in it were cholera infantum, dysenteries, a few +common bilious, and eight cases of yellow fever. Three of the last were +in Twelfth, between Locust and Walnut-streets, and were first visited, on +the 14th and 15th of the month, by Dr. Hartshorn, as out-patients of the +Pennsylvania hospital. Two of them were attended, about a week +afterwards, by Dr. Church, in Southwark, and the remaining three by Dr. +Rouisseau and Dr. Stewart, in the south end of the city. + +On the third of August, there fell a heavy shower of rain, but the +weather, during the remaining part of the month, was warm and dry. The +pastures were burnt up, and there was a great deficiency of summer +vegetables in the neighbourhood of Philadelphia. The water in the +Schuylkill was lower by three inches than it had been in the memory of a +man of 70 years of age, who had lived constantly within sight of it. + +In September, a number of cases of yellow fever appeared in Southwark[9], +near Catharine-street. They were readily traced to a large bed of +oysters, which had putrified on Catharine-street wharf, and which had +emitted a most offensive exhalation throughout the whole neighbourhood, +for several weeks before the fever made its appearance. This exhalation +proved fatal to a number of cats and dogs, and it now became obvious that +the two cases of yellow fever, that were attended by Dr. Church, in the +month of July, were derived from it. An attempt was made to impose a +belief that they were taken by contagion from a ship at the lazaretto, +which had lately arrived from the West-Indies, but a careful +investigation of this tale proved, that neither of the two subjects of +the fever had been on board that, nor any other ship, then under +quarantine. + + [9] This extensive district is continued, from the city of + Philadelphia, along the Delaware, but is not subject to its + government. + +The fever prevailed during the whole of this month in Southwark. A few +cases of it appeared in the city, most of which were in persons who had +resided in, or visited that district. It was brought on by weak exciting +causes in Southwark, but the cases which originated in the city, required +strong exciting causes to produce them. + +A heavy rain, accompanied with a good deal of wind, on the 28th of +September, and a frost on the night of the 7th of October, gave a +considerable check to the fever. + +But few cases of it came under my care. Having perceived the same +disposition in nature to relieve herself by the pores, that I observed in +the years 1802 and 1803, my remedies were the same as in the latter year, +and attended with the same success. Dr. Caldwell and Dr. Stewart, whose +practice was extensive in Southwark, informed me, those remedies had been +generally successful in their hands. + +The only new medicine that the experience of this year suggested in this +disease, was for one of its most distressing and dangerous symptoms, that +is, the vomiting which occurs in its second stage. Dr. Physick +discovered, that ten drops of the spirit of turpentine, given every two +hours, in a little molasses, or syrup, or sweet oil, effectually checked +it in several instances, in patients who afterwards recovered. It was +administered with equal success in a case which came under my care, after +an absence of pulse, and a coldness of the extremities had taken place. +Dr. Church informed me that he gave great relief to the sick in the city +hospital, by this medicine, by prescribing it in glysters, as well as by +the mouth, in distressing affections of the stomach and bowels. + +Dr. Stewart observed that all those persons who had been affected by the +yellow fever in former years, had mild remittents in the same situations +that others had the prevailing epidemic in a malignant form. + +In one of four bodies the doctor examined, he found six, and in another +three intussusceptions of the intestines, without any signs of +inflammation. He discovered the common marks of disease from this fever +in other parts of those bodies. + +The deaths from this fever amounted to between three and four hundred. +They would probably have been more numerous, had not those families who +were in competent circumstances fled into the country, and had not the +poor been removed, by the board of health, from the infected atmosphere +of Southwark, to tents provided for them in the neighbourhood of the +city; and they would probably have been fewer, considering the tractable +nature of the disease, when met by suitable remedies in its early stage, +had not the sick concealed their indisposition, in many instances, for +two or three days, lest they should be dragged to the city hospital, or +have centinels placed at their doors, to prevent any communication with +their friends and neighbours. While these attempts were made to check +the progress of the fever, it did not escape the notice of many of the +citizens of Philadelphia, that not a single instance occurred of its +being communicated by contagion, in any of the families in the city, in +which persons had sickened or died with it, and that while the sick were +deprived of the kind offices of their friends and neighbours, lest they +should be infected, physicians, and the members of the board of health, +passed by the guards every day, in their visits to the same sick people, +and afterwards mixed with their fellow-citizens, in every part of the +city, without changing their clothes. + +The yellow fever appeared early in the season in New-Haven, in +Connecticut, and in Providence, on Rhode-Island, in both of which places +it was derived from putrid exhalation, and was speedily and effectually +checked by removing the healthy persons who lived in its neighbourhood to +a distance from it. Several sporadic cases of it occurred during the +autumn in Gloucester county, in New-Jersey, and in Mifflin and Chester +counties, in Pennsylvania. It was epidemic in New-York at the same time +it prevailed in Southwark and Philadelphia. The following extract of a +letter from the health officer of New-York, to one of his friends, +contains a satisfactory proof that it was not, in that city, an imported +disease. + + _Quarantine-ground, Sept. 7._ + +I most sincerely and tenderly deplore the unfortunate situation of our +city. What do people say now of the origin of the disease? You may state, +for the information of those who wished to be informed, that not a single +vessel, on board of which a person has been sick with fever of any kind, +or on board of which any person has died with any disease, while in the +West-Indies, or on the voyage home, has ever gone up to the city during +this whole season. This we know, and this we vouch for; and farther +state, that all the cases of fever that have come down as from the city, +have been _all_ people of, and belonging to the city, and unconnected +with the shipping, excepting one, a sailor, who had no connection with +any foul vessel. There is not a shadow of proof or suspicion that can +attach to the health-office, or to infected vessels, this season. + + I am, &c. + JOHN R. B. RODGERS. + +Having concluded the history of the bilious yellow fever, as it has +appeared in eleven successive years, since 1793, as an epidemic, or in +sporadic cases, I shall proceed next to enumerate all the sources of +that fever, as well as all the other usual forms of the summer and +autumnal disease of the United States, and afterwards mention the means +of preventing them. + + + + + AN INQUIRY + + INTO + + THE VARIOUS SOURCES + + OF THE USUAL FORMS OF + + _SUMMER & AUTUMNAL DISEASE_ + + IN THE UNITED STATES, + + AND THE MEANS OF PREVENTING THEM. + + +The business of the following inquiry is, + +I. To enumerate the various sources of the usual forms of the summer and +autumnal disease in the United States. And, + +II. To mention the means of preventing them. + +To render the application of those means as extensive as possible, it +will be proper to mention, under the first head, all those sources of +summer and autumnal disease, which have been known to produce it in other +countries, as well as in the United States. They are, + +1. Exhalations from marshes. These are supposed to be partly of a +vegetable, and partly of an animal nature. They are derived from the +shores of creeks and mill ponds, as well as from low and wet grounds; +also from the following vegetable substances in a state of putrefaction. + +2. Cabbage. A malignant fever was produced at Oxford, by a putrid heap of +this vegetable some years ago, which proved fatal to many of the +inhabitants, and to several of the students of the university at that +place. + +3. Potatoes. Nearly a whole ship's crew perished at Tortola, by removing +from her hold, a quantity of putrid potatoes. + +4. Pepper. + +5. Indian meal. + +6. Onions. + +7. Mint. + +8. Anise and caraway seeds, confined in the hold of a ship. + +9. Coffee. "About the time," says Dr. Trotter, "when notice was taken of +the putrifying coffee on the wharf at Philadelphia, in the year 1793, a +captain of a man of war, just returned from the Jamaica station, informed +me, that several vessels laden with the same produce came to Kingston, +from St. Domingo. During the distracted state of that colony, this +article, with other productions, had been allowed to spoil and ferment. +The evolution of a great quantity of fixed air, or carbonic acid gas, was +the consequence; and in these vessels, when opening the hatchways, such +was its concentrated state, that the whole of the crew, in some of them, +were found dead on the deck. A pilot boarded one of them in this +condition, and had nearly perished himself[10]." + + [10] Medicina Nautica, p. 324. + +10. Chocolate shells. + +11. Cotton which had been wetted on board of a vessel that arrived in +New-York, a few years ago, from Savannah, in Georgia. + +12. Hemp, flax, and straw. + +13. The canvas of an old tent. + +14. Old books, and old paper money, that had been wetted, and confined in +close rooms and closets. + +15. The timber of an old house. A fever produced by this cause is +mentioned by Dr. Haller, in his Bibliotheca Medicinæ. + +16. Green wood confined in a close cellar during the summer months. A +fever from this cause was once produced in this city, in a family that +was attended by the late Dr. Cadwallader. + +17. The green timber of a new ship. Captain Thomas Bell informed me, that +in a voyage to the East-Indies, in the year 1784, he lost six of his men +with the scurvy, which he supposed to be derived wholly from the foul air +emitted by the green timber of his ship. The hammocks which were near the +sides of the ship rotted during the voyage, while those which were +suspended in the middle of the ship, retained their sound and natural +state. This scurvy has been lately proved by Dr. Claiborne, in an +ingenious inaugural dissertation, published in Philadelphia, in the year +1798, to be a misplaced state of malignant fever. Dr. Lind mentions +likewise the timber of new ships as one of the sources of febrile +diseases. The timber of soldiers' huts, and of the cabins of men who +follow the business of making charcoal in the woods, often produce +fevers, as soon as the bark begins to rot and fall from them, which is +generally on the second year after they are erected. Fevers have been +excited even by the exhalation from trees, that have been killed by being +girdled in an old field. + +18. The stagnating air of the hold of a ship. + +19. Bilge water. + +20. Water that had long been confined in hogsheads at sea. + +21. Stagnating rain water. + +22. The stagnating air of close cellars. + +23. The matters which usually stagnate in the gutters, common sewers, +docks, and alleys of cities, and in the sinks of kitchens. A citizen of +Philadelphia, who had a sink in his kitchen, lost a number of cats and +dogs by convulsions. At length one of his servants was affected with the +same disease. This led him to investigate the cause of it. He soon traced +it to his sink. By altering its construction, so as to prevent the escape +of noxious air from it, he destroyed its unwholesome quality, so that all +his domestics lived in good health in his kitchen-afterwards. + +24. Air emitted by agitating foul and stagnating water. Dr. Franklin was +once infected with an intermitting fever from this cause. + +25. A duck pond. The children of a family in this city were observed, for +several successive years, to be affected with a bilious remitting fever. +The physician of the family, Dr. Phineas Bond, observing no other persons +to be affected with the same fever in the neighbourhood, suspected that +it arose from some local cause. He examined the yard belonging to the +house, where he found an offensive duck pond. The pond was filled with +earth, and the family were afterwards free from an annual bilious fever. + +26. A hog-stye has been known to produce violent bilious fevers +throughout a whole neighbourhood in Philadelphia. + +27. Weeds cut down, and exposed to heat and moisture near a house. + +Fevers are less frequently produced by putrid animal, than by putrid +vegetable matters. There are, however, instances of their having been +generated by the following animal substances in a state of putrefaction. + +1. Human bodies that have been left unburied upon a field of battle. + +2. Salted beef and pork. + +3. Locusts. + +4. Raw hides confined in stores, and in the holds of ships. + +5. A whale thrown upon the sea shore in Holland. + +6. A large bed of oysters. The malignant fevers which prevailed in +Alexandria, in Virginia, in 1803, and in Southwark, adjoining +Philadelphia, in the year 1805, were derived from this cause[11]. + + [11] It has been a common practice with many families, in New-York and + Philadelphia, for several years past, to lay in a winter store of + oysters in their cellars in the fall of the year. May not a part + of these oysters, left in these cellars from forgetfulness, or + from being unfit for use, become, by putrifying there, the cause + of malignant fevers in the succeeding summer and autumn? + +7. The entrails of fish. And, + +8. Privies. The diarrh[oe]a and dysentery are produced, oftener than any +other form of summer and autumnal disease, by the f[oe]tor of privies. +During the revolutionary war, an American regiment, consisting of 600 +men, were affected with a dysentery, from being encamped near a large +mass of human fæces. The disease was suddenly checked by removing their +encampment to a distance from it. Five persons in one family were +affected with the yellow fever in Philadelphia, in 1805, who lived in a +house in which a privy in the cellar emitted a most offensive smell. No +one of them had been exposed to the foul air of Southwark, in which the +fever chiefly prevailed in the autumn of that year. Three of them +sickened at the same time, which obviated the suspicion of the disease +being produced by contagion. + +There are several other sources of malignant fevers besides those which +have been mentioned. They are, exhalations from volcanoes, wells, and +springs of water; also flesh[12], fish, and vegetables, eaten in a +putrid state; but these seldom act in any country, and two of them only, +and that rarely, in the United States. + + [12] The following fact, communicated to me by Mr. Samuel Lyman, a + member of congress from the state of Massachusetts, shows the + importance of attending to the condition of butchers' meat in our + attempts to prevent malignant fevers. + + A farmer in New-Hampshire, who had overheated a fat ox by + excessive labour in the time of harvest, perceiving him to be + indisposed, instantly killed him, and sent his flesh to a + neighbouring market. Of twenty four persons who ate of this flesh, + fifteen died in a few days. The fatal disease produced by this + aliment fell, with its chief force, upon the stomach and bowels. + +The usual forms of the disease produced by miasmata from the sources of +them which have been enumerated are, + +1. Malignant or bilious yellow fever. + +2. Inflammatory bilious fever. + +3. Mild remittent. + +4. Mild intermittent. + +5. Chronic, or what is called nervous fever. + +6. Febricula. + +7. Dysentery. + +8. Colic. + +9. Cholera morbus. + +10. Diarrh[oe]a. + +In deriving all the above forms of disease from miasmata, I do not mean +to insinuate, that sporadic cases of each of them are not produced by +other causes. + +In designating them by a single name, I commit no breach upon the ancient +nomenclature of medicine. The gout affects not only the blood-vessels and +bowels, but every other part of the body, and yet no writer has, upon +that account, distinguished it by a plural epithet. + +The four last of the forms of disease, that have been mentioned, have +been very properly called intestinal states of fever. They nearly accord, +in their greater or less degrees of violence and danger, with the first +four states of fever which occupy the blood-vessels, and in the order in +which both of them have been named. I shall illustrate this remark by +barely mentioning the resemblance of the yellow fever to the dysentery, +in being attended with costiveness in its first stage, from a suspended +or defective secretion or excretion of bile, and in terminating very +generally in death, when not met by the early use of depleting remedies. + +The variety in the forms and grades of the summer and autumnal disease, +in different seasons, and their occasional changes into each other in the +same seasons, are to be sought for in the variety of the sensible and +insensible qualities of the atmosphere, of the course of the winds, and +of the aliments of different years. + +II. The means of preventing the different forms of disease that have been +mentioned, come next under our consideration. + +Happily for mankind, Heaven has kindly sent certain premonitory signs of +the most fatal of them. These signs appear, + +I. Externally, in certain changes in previous diseases, in the +atmosphere, and in the animal and vegetable creation. + +II. In the human body. + +1. The first external premonitory sign that I shall mention is, an +unusual degree of violence in the diseases of the previous year or +season. Many proofs of the truth of this remark are to be met with in the +works of Dr. Sydenham. It has been confirmed in Philadelphia, in nearly +all her malignant fevers since the year 1793. It would seem as if great +and mortal epidemics, like the planets, had satellites revolving round +them, for they are not only preceded, but accompanied and followed, by +diseases which appear to reflect back upon them some of their malignity. +But there is an exception to this remark, for we now and then observe +uncommon and general healthiness, before the appearance of a malignant +epidemic. This was the case in Philadelphia, previously to the fevers of +1798 and 1799. I have ascribed this to the stimulus of the pestilential +miasmata barely overcoming the action of weak diseases, without being +powerful enough to excite a malignant fever. + +2. Substances, painted with white lead, and exposed to the air, suddenly +assuming a dark colour; and winds from unusual quarters, and unusual and +long protracted calms, indicate the approach of a pestilential disease. +The south winds have blown upon the city of Philadelphia, ever since +1793, more constantly than in former years. A smokiness or mist in the +air, the late Dr. Matthew Wilson has remarked, generally precedes a +sickly autumn in the state of Delaware. + +3. Malignant and mortal epidemics are often preceded by uncommon sickness +and mortality among certain birds and beasts. They have both appeared, +chiefly among wild pigeons and cats in the United States. The mortality +among cats, previous to the appearance of epidemics, has been taken +notice of in other countries. Dr. Willan says it occurred in the city of +London, between the 20th of March and the 20th of April, in the year +1797, before a sickly season, and Dr. Buneiva says it preceded a mortal +epidemic in Paris. The cats, the doctor remarks, lose, on the second day +of their disease, the power of emitting electrical sparks from their +backs, and, when thrown from a height, do not, as in health, fall upon +their feet[13]. + + [13] Medical Journal, vol. iv. + +4. The common house fly has nearly disappeared from our cities, +moschetoes have been multiplied, and several new insects have appeared, +just before the prevalence of our late malignant epidemics. + +5. Certain trees have emitted an unusual smell; the leaves of others have +fallen prematurely; summer fruits have been less in size, and of an +inferior quality; and apples and pears have been knotty, in the summers +previous to several of our malignant autumnal fevers. Dr. Ambrose Parey +says, an unusually rapid growth of mushrooms once preceded the plague in +Paris. + +II. The premonitory signs of an approaching malignant epidemic in the +human body are, + +1. A sudden drying up, or breaking out of an old sore; fresh eruptions in +different parts of the body; a cessation of a chronic disease, or a +conversion of a periodical into a continual disease. Of this there were +many instances in Philadelphia, in the year 1793. + +2. A peculiar sallowness of the complexion. This was observed to be +general in Philadelphia, previous to the yellow fever of 1793. Dr. Dick +informed me, that he had observed the same appearance in the faces of the +people of Alexandria, accompanied in some cases with a yellowness of the +eyes, during the summer of 1793, and previous to the appearance of a +violent bilious fever on the banks of the Potomac. + +3. I have observed one or more of the following symptoms, namely, +head-ach; a decay, or increase of appetite; costiveness; a diminished or +increased secretion of urine; a hot and offensive breath[14]; constant +sweats, and sometimes of a f[oe]tid nature, or a dry skin; wakefulness, +or a disposition to early or protracted sleep; a preternaturally frequent +pulse; unusual vivacity, or depression of spirits; fatigue and sweats +from light exertions; hands, when rubbed, emitting a smell like hepar +sulphuris; and, lastly, a sense of burning in the mouth; to be present in +different persons, during the prevalence of our malignant epidemics. + + [14] I have once known this breath, in a gentleman who had carried the + seeds of the yellow fever in his body from Philadelphia into its + neighbourhood, create sickness at the stomach in his wife; and I + have heard of an instance in which a person, who left Philadelphia + when highly impregnated with the miasmata of the same fever, + creating sickness at the stomach in four or five persons who sat + at the same table with him in the country. None of the above + persons were afterwards affected by the fever. In an anonymous + history of the plague in London, in the year 1664, in the + possession of the author, it is said, the breath was a well-known + signal of infection to persons who were not infected, and that + whenever it was perceived, individuals and companies fled from it. + The sickness in the above-mentioned persons was similar to that + which is sometimes excited by the smell of a sore leg, or a + gun-shot wound, upon the removal of its first dressing. It does + not produce fever, because there is no predisposition to it. + +The means of preventing the different forms of our summer and autumnal +disease come next under our consideration. I shall first mention such as +have been most effectual in guarding against its malignant form, and +afterwards take notice of such as are proper in its milder grades. These +means naturally divide themselves again, + +I. Into such as are proper to protect individuals. + +II. Such as are proper to defend whole communities from the disease. And, + +III. Such as are proper to exterminate it, by removing its causes. + +I. Of the means of protecting individuals. + +Where flight is practicable, it should be resorted to in every case, to +avoid an attack of a malignant fever. The heights of Germantown and Darby +have, for many years, afforded a secure retreat to a large number of the +citizens of Philadelphia, from their late annual epidemics. It were to be +wished our governments possessed a power of compelling our citizens to +desert the whole, or parts, of infected cities and villages. In this way +the yellow fever was suddenly annihilated in Providence, on +Rhode-Island, and in New-Haven, in Connecticut, in the year 1805. But the +same power should rigorously prevent the removal of the sick, except it +be that class of them which have neither homes nor friends. The less the +distance they are carried beyond the infected atmosphere, the better. The +injury sustained by conveying them in a jolting carriage, for two or +three miles, has often been proclaimed in the reports of our city +hospitals, of patients being admitted without a pulse, and dying a few +hours afterwards. + +In leaving a place infected by miasmata, care should be taken not to +expose the body to great cold, heat, or fatigue, for eighteen or twenty +days, lest they should excite the dormant seeds of the disease into +action. + +But where flight is not enforced by law, or where it is not practicable, +or preferred, safety should be sought for in such means as reduce the +preternatural tone and fulness induced in the blood-vessels by the +stimulus of the miasmata, and the suppression of customary secretions. +These are, + +1. A diet, accommodated to the greater or less exposure of the body to +the action of miasmata, and to the greater or less degrees of labour, or +exercise, which are taken. In cases of great exposure to an infected +atmosphere, with but little exercise, the diet should be simple in its +quality, and small in its quantity. Fresh meats and wine should be +avoided. A little salted meat, and Cayenne pepper with vegetables, +prevent an undue languor of the stomach, from the want of its usual +cordial aliments. The less mortality of the yellow fever in the French +and Spanish West-India islands than in the British, has been justly +attributed to the more temperate habits of the natives of France and +Spain. The Bramins, who live wholly upon vegetables, escape the malignant +fevers of India, while whole regiments of Europeans, who eat animal food, +die in their neighbourhood. The people of Minorca, Dr. Cleghorn says, who +reside near gardens, and live chiefly upon fruit during the summer, +escape the violent autumnal fever of that island. The field negroes of +South-Carolina owe their exemption from bilious fevers to their living +chiefly upon vegetables. There is a fact which shows, that not only +temperance, but abstinence bordering upon famine, has afforded a +protection from malignant fevers. In a letter which I received a few +months ago, from the Rev. Thomas Hall, chaplain to the British factory at +Leghorn, containing an account of the yellow fever which prevailed in +that city, in the summer and autumn of 1804, there is the following +communication. "Of the _rich_, who live in large airy houses, there died +but four persons with the fever. Of the _commodious_, who live +comfortably, but not affluently, there died ten. Of the _poor_, who +inhabited small and crowded rooms, in the dirty and confined parts of the +city, there died nearly seven hundred. But of the _beggars_, who had +scarcely any thing to eat, and who slept half naked every night upon hard +pavements, not one died." From the reduced and exhausted state of the +system in these people, they were incapable, if I may be allowed the +expression, of the combustion of fever. Persons reduced by chronic +diseases, in like manner, often escape such as are acute. Six French +ships of the line landed 300 sick, at St. Domingo, while the yellow fever +prevailed there in the year 1745, and yet no one of them was infected by +it[15]. + + [15] Desportes, vol. i. p. 140. + +Where the body is exposed to miasmata, and a great deal of exercise taken +at the same time, broths, a little wine, or malt liquors, may be used +with the fruits and garden vegetables of the season, with safety and +advantage. The change from a full to a low diet should be made gradually. +When made suddenly, it predisposes to an attack of the disease. + +2. Laxative medicines. Hundreds, perhaps thousands, of the citizens of +Philadelphia were indebted for their preservation from the yellow fever +to the occasional use of a calomel pill, a few grains of rhubarb, or a +table-spoonful of sweet, or castor oil, during the prevalence of our late +pestilential fevers. Even the air of Batavia has been deprived of its +poisonous quality, by means of this class of medicines. A citizen of +Philadelphia asked a captain of a New-England ship, whom he met at that +island, how he preserved the whole crew of his ship in health, while half +the sailors of all the other ships in the harbour were sick or dead. He +informed him, that it was by giving each of them a gentle purge of +sulphur every day. + +3. A plentiful perspiration, or moderate sweats, kept up by means of warm +clothing and bed-clothes. The excretion which takes place by the skin, is +a discharge of the first necessity. I have never known an instance of a +person's being attacked by the yellow fever in whom this discharge was +constant, and equally diffused all over the body. Its effects are equally +salutary in preventing the plague. So well known is this fact, that Mr. +Volney informs us, in his Travels into Egypt, that the common salutation +at Cairo, during the prevalence of the plague, is, "Do you sweat freely?" +For the purpose of promoting this excretion, flannel shirts or +waistcoats worn next to the skin have been found more useful than linen. +As the perspiration and sweats, which are thus discharged in a +pestilential season, are often unusual in their quantity, and of a morbid +quality, clean body-linen or flannel should be put on every day, and +where this is not practicable, that which has been worn should be +exchanged every morning and evening for that which has been exposed +during the previous day and night, in a dry air. + +4. Blood-letting. In addition to the authorities of Dr. Haller and Dr. +Hodges, mentioned in another place[16], in favour of this remedy, I shall +subjoin a few others. Dr. Mitchell, in his Account of the Yellow Fever +which prevailed in Virginia, in the year 1741, informs us, that it was +often prevented in persons who were under the influence of its remote +cause, by the loss of a few ounces of blood. It was formerly a practice +among the physicians in St. Domingo, to bleed whole regiments of troops +as soon as they arrived from France, by which means they were preserved +from the malignant fever of the island. + + [16] Account of the Yellow Fever in 1793, vol. iii. + +During the short visit paid to this city, in the year 1798, by Dr. +Borland, a respectable physician of the British army, he put into my +hands the following communication. "In the beginning of August, 1797, 109 +Dutch artillery arrived at Port au Prince, in the Bangalore transport. +The florid appearance of the men, their cumbersome clothing, and the +season of the year, seemed all unfavourable omens of the melancholy fate +we presumed awaited them. It was, however, thought a favourable +opportunity, by Dr. Jackson and myself, to try what could be done in +warding off the fever. It was accordingly suggested to Monsieur +Conturier, the chief surgeon of the foreign troops, and the surgeon of +the regiment, that the whole detachment should be blooded freely, and +that, the morning after, a dose of physic should be administered to every +man. This was implicitly complied with, a day or two after, and at this +moment in which I write, although a period of four months has elapsed, +but two of that detachment have died, one of whom was in a dangerous +state when he landed. A success unparalleled during the war in St +Domingo! It is true, several have been attacked with the disease, but in +those the symptoms were less violent, and readily subsided by the use of +the lancet. + +"The _crew_ of the Bangalore, on her arrival at Port au Prince, consisted +of twenty-eight men. With them no preventive plan was followed. In a very +few weeks eight died, and at present, of the original number, but +fourteen remain." + +All these depleting remedies, whether used separately or together, induce +such an artificial debility in the system, as disposes it to vibrate more +readily under the impression of the miasmata. Thus the willow rises, +after bowing before a blast of wind, while the unyielding oak falls to +the ground by its side. It is from the similarity of the natural weakness +in the systems of women, in the West-Indies, with that which has been +induced by the artificial means that have been mentioned, that they so +generally escape the malignant endemic of the islands. + +A second class of preventives of malignant fever are such as obviate the +internal action of miasmata, by exciting a general or partial +determination to the external surface of the body. These are, + +1. The warm bath. I have known this grateful remedy used with success in +our city. It serves the treble purposes of keeping the skin clean, and +the pores open, and of defending what are called the vital organs from +disease, by inviting its remote cause to the external surface of the +body. + +2. The cold bath, or cold water applied to the external surface of the +body. Ulloa, in his travels through Cuba, tells us the Spaniards make it +a practice, when partially wetted by the rain, to plunge themselves, with +their wet clothes on, into the first stream of water they meet with +afterwards, by which means they avoid taking the fever of the island. +Where this cannot be conveniently done, the peasants strip off their +clothes, and put them under a shelter, and receive showers of rain upon +their naked bodies, and thus preserve themselves from the fever. Dr. +Baynard has left it upon record, in his treatise upon the cold bath, that +those persons who lived in water-mills, also watermen, bargemen, and +fishermen, who were employed upon the river, and in dabbling in cold +water, were rarely affected by the plague in London, in 1665, and that +but two persons died with it on London bridge. The water carriers at +Cairo, Mr. Volney says, uniformly escape the plague; and Dr. Chisholm +informs us, that those negroes in Demarara who go naked, and are thereby +disposed not to avoid showers of rain, are never affected with the fever +of that country. + +3. Washing the body, every morning and evening, with salt water. A whole +ship's crew from Philadelphia was preserved by this means from the yellow +fever, some years ago, in one of the West-India islands, while a large +proportion of the crews of several ships, that lay in the same harbour, +perished by that disease. + +4. Anointing the body with oil. The natives of Africa, and some American +Indians, use this preventive with success during their sickly seasons. It +has lately been used, it is said, with effect in preventing the plague. +Its efficacy for that purpose was first suggested by no oilman having +died of that disease during four years, in which time 100,000 people +perished with it in Egypt. Oliver, in his Travels into that country, says +the men who make and sell butter, are equally fortunate in escaping it. + +5. Issues, setons, and blisters belong to this class of preventives of +malignant and bilious fevers. Issues, according to Parisinus, +Florentinus, Forestus, and several other authors quoted by Diemerbroeck, +have prevented the plague in many hundred instances. Paræus says, all who +had ulcers from the venereal disease, or any other cause, escaped it. Dr. +Hodges owed his preservation from the plague in London, in 1665, to an +issue in his leg. He says he always felt a slight pain in it when he went +into a sick room. Dr. Gallaher ascribed his escape from the yellow fever +of 1799 to a perpetual blister, which he applied to his arm for that +purpose. Dr. Barton favoured me with the sight of a letter from Dr. James +Stevens, dated January 12, 1801, in which he says he believed Dr. Beach +(formerly of Connecticut) had been preserved from the bilious fever by a +seton in his side. He adds further, that Dr. Beach had been called to +attend the labourers at the Onandoga salt springs, in the state of +New-York, ninety-eight of whom out of a hundred had the bilious fever. Of +the two who escaped it, one had a sore leg, the other what is called a +scald-head. The discharge from the sores in each of them, as well as from +the doctor's issue, was more copious during the prevalence of the fever, +than it had been at any other time. + +A third class of preventives of malignant fever, are such as excite a +general action, more powerful than that which the miasmata are disposed +to create in the system, or an action of a contrary nature. These are, + +1. Onions and garlic. All those citizens who used these vegetables in +their diet, escaped the yellow fever in 1793. The greater exemption of +the natives of France from this disease, wherever they are exposed to it, +than of the inhabitants of other European countries, has been ascribed in +part to the liberal use of those condiments in their food. The Jews, it +has been said, have often owed to them their preservation from the +plagues which formerly prevailed in Europe. It is probable leeks and +onions, which to this day form a material part of the diet of the +inhabitants of Egypt, were cultivated and eaten originally as the means +of obviating the plagues of that country. I have been at a loss to know +why the Author of Nature, who has endowed these vegetables with so many +excellent qualities for diet and medicine, should have accompanied them +with such a disagreeable smell. Perhaps the reason was, kindly to force +them into universal use; for it is remarkable their smell in the breath +is imperceptible to those who use them. + +2. Calomel, taken in such small doses as gently to affect the gums. It +preserved most of the crew of a Russian ship at Plymouth, in the year +1777, from a fever generated by filth in her hold. In a letter which I +received from Captain Thomas Truxton, in the year 1797, he informed me, +that an old and respectable merchant at Batavia had assured him, he had +been preserved in good health by calomel, taken in the way that has been +mentioned, during the sickly seasons, for upwards of thirty years. The +mortality of the fevers of that island may easily be conceived of, when I +add, on the authority of a physician quoted in Sir George Staunton's +Account of his Embassy to China, that one half of all new comers die +there on the first year of their arrival. + +Our principal dependence should be placed upon those two preventives +under this head. There are several others which have been in common use, +some of which I believe are hurtful, and the rest are of feeble, or +doubtful efficacy. They are, + +3. Wine and ardent spirits. They both prevent a malignant fever, only +when they excite an action in the system above that which is ordinarily +excited by the miasmata of the fever; but this cannot be done without +producing intoxication, which, to be effectual, must be perpetual; for +the weakness and excitability, which take place in the intervals of +drunkenness, predispose to the disease. Agreeably to this remark, I +observed three persons, who were constantly drunk, survive two of our +most fatal epidemics, while all those persons who were alternately drunk +and sober, rarely escaped an attack of the fever. In most of them, it +terminated in death. + +4. Tobacco. Many hundreds of the citizens of Philadelphia can witness, +that no benefit was derived from this weed, in any of the ways in which +it is commonly used, in the late epidemics of our city. Mr. Howard says +it has no effect in preserving from the plague. + +5. Camphor suspended in a bag round the neck, and rags wetted in vinegar, +and applied to the nose. These means were in general use in the fever of +1793, in Philadelphia, but they afforded no protection from it. It is +possible they had a contrary effect, by entangling, in their volatile +particles, more of the miasmata of the fever, and thus increasing a +predisposition to it. + +A fourth class of the preventives of malignant fevers are certain +substances which are said to destroy miasmata by entering into mixture +with them. Two persons, who were very much exposed to the causes of the +fever in 1798, took each of them a table spoonful of sweet oil every +morning. They both escaped the fever. Did the oil, in these cases, act by +destroying miasmata in the stomach chemically? or did it defend the +stomach mechanically from their action? or did it prevent the disease, +only by gently opening the bowels? It is certain the fat of pork meat +protects the men who work in the lead-mines of Great-Britain from the +deleterious effects which the fumes of that metal are apt to bring upon +the stomach and bowels, and that a poisoned arrow, discharged into the +side of a hog, will not injure him, if it be arrested by the fat which +lines that part of his body. + +The vapour which issues from fresh earth has been supposed to destroy the +miasmata which produce malignant fevers, by entering into mixture with +them. Most of the men who were employed in digging graves and cellars, +and in removing the dirt from the streets of Philadelphia, in 1793, +escaped the fever of that year. In the new settlements of our country, it +is said, the poison of the rattlesnake is deprived of its deadly effects +upon the body, by thrusting the wounded limb into a hole, recently made +in the earth. The fable of Anteus, who rose with renewed strength from +the ground after repeated falls, was probably intended to signify, among +other things, the salutary virtues which are contained in the effluvia +which issue from fresh clods of earth. + +3. There are many facts which show the efficacy of the volatile alkali in +destroying, by mixture, the poison of snakes. One of them was lately +communicated to the public by Dr. Ramsay, of South-Carolina. What would +be the effect of the daily use of a few tea spoonfuls of this medicine in +a liquid form, and of frequently washing the body with it, during the +prevalence of pestilential epidemics? + +The miasmata which produce malignant fevers often exist in an inoffensive +state in the body, for weeks, and perhaps months, without doing any harm. +With but a few exceptions, they seldom induce a disease without the +reinforcement of an exciting cause. In vain, therefore, shall we use all +the preventives that have been recommended, without, + +V. Avoiding of all its exciting causes. These are, + +1. Heat and cold. While the former has excited the yellow fever in +thousands, the latter has excited it in tens of thousands. It is not in +middle latitudes only that cold awakens this disease in the body. Dr. +Mosely says it is a more frequent exciting cause of that, and of other +diseases, in the island of Jamaica, than in any of the most temperate +climates of the globe. It is this which renders cases of yellow fever, +when epidemic in our cities, more numerous in the cool months of +September and October, than in July and August. For the purpose of +avoiding this pernicious and universal influence of cold, the clothing +and bed-covers should be rather warmer in those months, in middle and +northern latitudes, than is agreeable, and fires should be made every +morning and evening in common sitting rooms, and during the whole day, +when the weather is damp or cool. They serve, not only to prevent the +reduction of the excitement of the blood-vessels, by the gradual and +imperceptible abstraction of the heat of the body, but to convey up a +chimney all the unwholesome air that accumulates in those rooms during a +sickly season. By these precautions, I have known whole families +preserved in health, while all their neighbours who neglected them, have +been confined by a prevailing autumnal fever. + +3. The early morning and evening air, even in warm weather. + +4. Fatigue from amusements, such as fishing, gunning, and dancing, and +from _unusual_ labour or exercise. The effects of fatigue from this +cause have been already noticed[17], in the maids of large families +being the only persons who die of the fever, in consequence of their +having performed great and _unusual_ services to those branches of the +family who survive them, while nurses, who only exercise their ordinary +habits in attending sick people, are seldom carried off by it. + + [17] Account of the Yellow Fever in 1793, vol. iii. + +5. Intemperance in eating and drinking. + +6. Partaking of _new_ aliments and drinks. The stomach, during the +prevalence of malignant fevers, is always in an irritable state, and +constantly disposed to be affected by impressions that are not habitual +to it. + +7. Violent emotions or passions of the mind. + +8. The entire cessation of moderate labour. This, by permitting the mind +to ramble upon subjects of terror and distress, and by exposing the body +to idleness and company, favours an attack of fever. A predisposition to +it, is likewise created by alternating labour and idleness with each +other. + +9. The continuance of hard labour. The miasmata which produce malignant +fevers sometimes possess so much force, that the least addition to it, +even from customary acts of labour, is sufficient to excite the disease. +In this case, safety should be sought in retirement, more especially by +those persons whose occupations expose them to the heat of fires, and the +rays of the sun, such as hatters, smiths, bricklayers, and house and ship +carpenters. The wealthy inhabitants of Constantinople and Smyrna +erroneously suppose they escape the contagion of the plague, by shutting +themselves up in their houses during its prevalence. They owe their +preservation chiefly to their being removed, by an exemption from care +and business, from all its exciting causes. Most of the nobility and +gentry of Moscow, by these means escaped a plague which carried off +27,000 persons in that city, in the year 1771, and many whole families in +Philadelphia were indebted for their safety to the same precautions in +the year 1793. Confinement is more certain in its beneficial effects, +when persons occupy the upper stories only of their houses. The +inhabitants of St. Lucia, Dr. Chisholm says, by this means often escape +the yellow fever of that island. Such is the difference between the +healthiness of the upper and lower stories of a house, that, travellers +tell us, birds live in the former, and die in the latter, during the +prevalence of a plague in the eastern countries. + +All the exciting causes that have been enumerated should be avoided with +double care three days before, and three days after, as well as on the +days of the full and change of the moon. The reason for this caution was +given in the account of the yellow fever in Philadelphia in the year +1797. + +To persons who have retired from infected cities, or countries, it will +be necessary to suggest a caution, not to visit them while the malignant +fever from which they fled prevails in them. Dr. Dow informed me, in his +visit to Philadelphia in the year 1800, that the natives and old citizens +of New-Orleans who retired into the country, and returned during the +prevalence of the yellow fever in that city, the year before, were often +affected by it, while all such persons as did not change their residence, +escaped it. The danger from visiting an infected city is greater to +persons who breathe an atmosphere of a uniform temperature, than one that +is subject to alternate changes in its degrees of heat and cold. The +inhabitants of Mexico, Baron Humboldt informed me, who descend from their +elevated situation, where the thermometer seldom varies more than ten +degrees in the year, and visit Vera Cruz during the prevalence of the +yellow fever in that city, are much oftener affected by it than the new +comers from the variable climates of European countries. But the habits +of insensibility to the impressions of the miasmata of this disease in +one country, do not always protect the system from their action in +another. The same illustrious traveller informed me, that the inhabitants +of the Havannah who visit Vera Cruz, and the inhabitants of Vera Cruz who +visit the Havannah, are affected in common with strangers with the fever +of those places. + +I shall take leave of this part of our subject, by adding, that I am so +much impressed with a belief in the general, and almost necessary +connection of an exciting cause with a yellow fever, that were I to enter +a city, and meet its inhabitants under the first impressions of terror +and distress from its appearance, my advice to them should be, "BEWARE, +not of contagion, for the yellow fever of our country is not contagious, +nor of putrid exhalations, when the duties of humanity or consanguinity +require your attendance, but BEWARE OF EXCITING CAUSES!" + +In the mild grades of the summer and autumnal fevers of the United +States, the means of prevention should be different from those which have +been recommended to prevent the yellow fever. They consist of such things +as gently invigorate the system, and thus create an action superior to +that which the miasmata have excited in it. The means commonly employed +for this purpose are, + +1. Cordial diet and drinks; consisting of salted meat, and fish, with a +moderate quantity of wine and malt liquors. Dr. Blane says, the British +soldiers who lived upon salt meat, during the American war, were much +less afflicted with the intermitting fever than the neighbouring country +people; and, it is well known, the American army was much less afflicted +with summer and autumnal fevers, after they exchanged their fresh meat +for rations of salted beef and pork. Ardent spirits should be used +cautiously, for, when taken long enough to do good, they create a +dangerous attachment to them. A strong infusion of any bitter herb in +water, taken upon an empty stomach, is a cheap substitute for all the +above liquors where they cannot be afforded. The Peruvian bark has in +many instances been used with success as a preventive of the mild grades +of the summer and autumnal fevers of our country. + +2. An equable and constant perspiration. This should be kept up by all +the means formerly mentioned for that purpose. + +3. Avoiding certain exciting causes, particularly great heat and cold, +fatigue, long intervals between meals, intemperance, and the morning and +evening air, more especially during the lunar periods formerly mentioned. +Dr. Lind says, the farmers of Holdernesse, in England, who go out early +to their work, are seldom long lived, probably from their constitutions +being destroyed by frequent attacks of intermitting fevers, to which that +practice exposes them. Where peculiar circumstances of business render it +necessary for persons to inhale the morning air, care should be taken +never to do it without first eating a cordial breakfast. + +The _intestinal_ state of our summer and autumnal disease requires +several specific means to prevent it, different from those which have +been advised to defend the blood-vessels from fever. Unripe and decayed +fruit should be avoided, and that which is ripe and sound should not be +eaten in an excessive quantity. Spices, and particularly Cayenne pepper, +and the red pepper of our country, should be taken daily with food. Mr. +Dewar, a British surgeon, tells us, the French soldiers, while in Egypt, +carried pepper in boxes with them, wherever they went, to eat with the +fruits of the country, and thereby often escaped its diseases. The whole +diet, during the prevalence of intestinal diseases, when they are not +highly inflammatory, should be of a cordial nature. A dysentery +prevailed, a few years ago, upon the Potomac, in a part of the country +which was inhabited by a number of protestant and catholic families. The +disease was observed to exist only in the former. The latter, who ate of +salted fish every Friday, and occasionally on other days of the week, +very generally escaped it. In the year 1759, a dysentery broke out in the +village of Princeton, in New-Jersey, and affected many of the students of +the college. It was remarked, that it passed by all those boys who came +from the cities of New-York and Philadelphia. This was ascribed to their +having lived more upon tea and coffee than the farmers' sons in the +college; for those cordial articles of diet were but rarely used, six and +forty years ago, in the farm houses of the middle states of America. I +mentioned formerly that the cordial diet of the inhabitants of our cities +was probably the reason why the dysentery so seldom prevailed as an +epidemic in them. + +Another means of preventing the dysentery is, by avoiding costiveness, +and by occasionally taking purging physic, even when the bowels are in +their natural state. A militia captain, in the Pennsylvania service, +preserved his whole company from a dysentery which prevailed in a part of +the American army at Amboy, in the year 1776, by giving each of them a +purge of sea-water. He preserved his family, and many of his neighbours, +some years afterwards, from the same disease, by dividing among them a +few pounds of purging salts. It was prevented, a few years ago, in the +academy of Bordentown, in New-Jersey, by giving all the boys molasses, in +large quantities, in their diet and drinks. The molasses probably acted +only by keeping the bowels in a laxative state. + +As the dysentery is often excited by the dampness of the night air, great +care should be taken to avoid it, and, when necessarily exposed to it, to +defend the bowels by more warmth than other parts of the body. The +Egyptians, Mr. Dewar says, tie a belt about their bowels for that +purpose, and with the happiest effects. + +II. I come now, according to the order I proposed, to mention the means +of preserving whole cities or communities from the influence of those +morbid exhalations which produce the different forms of summer and +autumnal disease, and, in particular, that which is of a malignant +nature. + +As the flight of a whole city is rarely practicable, it will be necessary +to point out the means of destroying the morbid miasmata. + +1. Where the putrid matters which emit them are of a small extent, they +should be covered with water or earth. Purchas tells us, 500 persons less +died of the plague the day after the Nile overflowed the grounds which +had emitted the putrid exhalations that produced it, than had died the +day before. During the prevalence of a malignant fever, it will be unsafe +to remove putrid matters. A plague was generated by an attempt to remove +the filth which had accumulated on the banks of the waters which surround +the city of Mantua, during the summer and autumnal months[18]. Even a +shower of rain, by disturbing the green pellicle which is sometimes +formed over putrid matters, I shall mention in another place, has let +loose exhalations that have produced a pestilential disease. + + [18] Burserus. + +2. Impregnating the air with certain effluvia, which act either by +destroying miasmata by means of mixture, or by exciting a new action in +the system, has, in some instances, checked the progress of a malignant +fever. The air extricated from fermenting wines, during a plentiful +vintage, Vansweiten tells us, has once checked the ravages of a plague in +Germany. Ambrose Parey informs us, the plague was checked in a city in +Italy by killing all the cats and dogs in the place, and leaving them to +putrify in the streets. Mr. Bruce relates, that all those persons who +lived in smoky houses, in one of the countries which he visited, escaped +bilious fevers, and Dr. Clark mentions an instance, in which several +cooks, who were constantly exposed to smoke, escaped a fever which +affected the whole crew of a galley. The yellow fever has never appeared +within the limits of the effluvia of the sal ammoniac manufactory, nor of +the tan-pits in the suburbs of Philadelphia, nor has the city of London +been visited with a plague since its inhabitants have used sea-coal for +fuel. But other causes have contributed more certainly to the exemption +of that city from the plague for upwards of a century, one of which shall +be mentioned under our next head. + +3. Desquenette tells us, the infection of the plague never crosses the +Nile, and that it is arrested by means of ditches, dug and filled with +water for that purpose. Dr. Whitman has remarked, that the plague never +passes from Abydos, on the Turkish, to Mito, on the European side of the +water of the Dardanelles, which forms the entrance to Constantinople. +The yellow fever has never been known to pass from Philadelphia to the +Jersey shore, and the miasmata generated on the east side of the +Schuylkill rarely infect the inhabitants of the opposite side of the +river. Many persons found safety from the plague of London, in 1665, by +flying to ships which lay in the middle of the Thames, and, it is well +known, no instance of yellow fever occurred in those Philadelphia +families that confined themselves to ships in the middle of the Delaware, +in the year 1793. But three or four, of four hundred men, on board a ship +of war called the Jason, commanded by captain Coteneuil, perished with an +epidemic yellow fever, in the year 1746, at St. Domingo, in consequence, +Dr. Desportes says, of her hold being constantly half filled with +water[19]. I have multiplied facts upon this subject, because they lead +to important conclusions. They show the immense consequence of frequently +washing the streets and houses of cities, both to prevent and check +pestilential fevers. What would be the effect of placing tubs of fresh +water in the rooms of patients infected with malignant fevers, and in an +atmosphere charged with putrid exhalations? Their efficacy in absorbing +the matter which constitutes the odour of fresh paint, favours a hope +that they would be useful for that purpose. I have mentioned an instance, +in the Account of the Yellow Fever in Philadelphia, in the year 1797, in +which they were supposed to have been employed with evident advantage. + + [19] Vol. I. p. 161. + +4. Intercepting the passage of miasmata to the inhabitants of cities. +Varro, in his Treatise upon Agriculture, relates, that his namesake +Varro, a Roman general, was in great danger of suffering, with a large +fleet and army, from a malignant fever at Conyra. Having discovered the +course of the miasmata which produced it to be from the south, he +fastened up all the southern windows and doors of the houses in which his +troops were quartered, and opened new ones to the north, by which means +he preserved them from the fever which prevailed in all the other houses +of the town and neighbourhood. Mr. Howard advises keeping the doors and +windows, of houses which are exposed to the plague, constantly shut, +except during the time of sunshine. + +Several other means have been recommended to preserve cities from +malignant fevers during their prevalence, which are of doubtful +efficacy, or evidently hurtful. They are, + +5. Strewing lime over putrid matters. Dr. Dalzelle says, he once checked +a bilious fever, by spreading twelve barrels of lime on a piece of marshy +ground, from whence the exhalations that produced it were derived[20]. A +mixture of quick lime and ashes in water, when thrown into a privy, +discharges from it a large quantity of offensive air, and leaves it +afterwards without a smell. As this foul air is discharged into the +atmosphere, it has been doubted whether the lime and ashes should be used +for that purpose, after a malignant fever has made its appearance. + + [20] Sur les Maladies des Climats Chauds. + +6. Mr. Quiton Morveau has lately proposed the muriatic gas as a means of +destroying miasmata. However effectual it may be in destroying the +volatile and foul excretions which are discharged from the human body in +confined situations, as in filthy jails, hospitals, and ships, it is not +calculated to oppose the seeds of a disease which exist in the +atmosphere, and which are diffused over a large extent of city or +country. Mr. Morveau ascribes great virtues to it, in checking the +malignant fever in Cadiz, in 1801, but from the time at which it was +used, being late in the autumn, there is more reason to believe it had +run its ordinary course, or that it was destroyed by cold weather. + +7. The explosion of gunpowder has been recommended for checking +pestilential diseases. Mr. Quiton Morveau says, it destroys the offensive +odour of putrid exhalations, but does not act upon the fevers produced by +them. + +8. Washing the floors of houses with a solution of alkaline salts in +water, has been recommended by Dr. Mitchell, as an antidote to malignant +fevers. As yet, I believe, there are no facts which establish the +efficacy of the practice, when they are produced by exhalations from +decayed vegetable and animal substances in a putrid state. + +9. Large fires have sometimes been made in cities, in order to destroy +the miasmata of pestilential diseases. They were obviously hurtful in the +plague of London, in the year 1665. Dr. Hodges, who relates this fact, +says, "Heaven wept for the mistake of kindling them, and mercifully put +them out, with showers of rain." + +I cannot conclude this head, without lamenting the want of laws in all +our states, to compel physicians to make public the first cases of +malignant fever that come under their notice. The cry of fire is not more +useful to save a city from destruction, than the early knowledge of such +cases would be to save it from the ravages of pestilential and mortal +epidemics. Hundreds of instances have occurred, in all ages and +countries, in which they might have been stifled in their birth, by the +means that have been mentioned, had this practice been adopted. But when, +and where, will science, humanity, and government first combine to +accomplish this salutary purpose? Most of our histories of mortal +epidemics abound with facts which show a contrary disposition and conduct +in physicians, rulers, and the people. I shall mention one of these facts +only, to show how far we must travel over mountains of prejudice and +error, before we shall witness that desirable event. It is extracted from +the second volume of the Life of the late Empress of Russia. "The Russian +army (says the biographer), after defeating the Turks, on entering their +territories were met by the plague, and brought it to their country, +where the folly of several of their generals contributed to its +propagation, as if they thought by a military word of command to alter +the nature of things. Lieutenantgeneral Stoffeln, at Yassy, where the +pestilence raged in the winter of 1770, issued peremptory orders that its +name should not be pronounced; he even obliged the physicians and +surgeons to draw up a declaration in writing, that it was only _a spotted +fever_. One honest surgeon of the name of Kluge refused to sign it. In +this manner the season of prevention was neglected. Several thousand +Russian soldiers were by this means carried off. The men fell dead upon +the road in heaps. The number of burghers that died was never known, as +they had run into the country, and into the forests. At length the havoc +of death reached the general's own people: he remained true to his +persuasion, left the town, and went into the more perilous camp. But his +intrepidity availed him nothing; he died of the plague in July, +1771[21]." + + [21] The above disease appears to have been the camp fever, the origin + and character of which will be noticed in the next article. + +III. Let us now consider, in the last place, the means of exterminating +malignant and other forms of summer and autumnal disease, by removing +their causes. These means are, + +1. The removal or destruction of all those putrid matters formerly +enumerated, which are capable of producing fevers. Many of the +institutions of the Jewish nation, for this purpose, are worthy of our +imitation. The following verses contain a fund of useful knowledge upon +this subject.--"Thou shalt have a place without the camp, whether thou +shalt go forth abroad; and shalt have a paddle upon thy weapon, and it +shall be when thou wilt ease thyself abroad, thou shalt dig therewith, +and shalt turn back, and cover that which cometh from thee; for the Lord +thy God walketh in the midst of thy camp to deliver thee, therefore shall +he _see no unclean thing in thee_, and turn away from thee." Deuteronomy, +chapter xxiii. verses 12, 13, and 14. "But the flesh of the bullock, and +his skin, and his dung, shalt thou _burn with fire without the camp_." +Exodus, chapter xxxix. verse 14. The advantages of thus burying and +removing all putrid matters, and of burning such as were disposed to a +speedy putrefaction, in a crowded camp, and in a warm climate, are very +obvious. Their benefits have often been realized in other countries. The +United Provinces of Holland hold their exemption from the plague, only by +the tenure of their cleanliness. In the character given by Luther of Pope +Julius, he says, "he kept the streets of Rome so clean and sweet, that +there were no plagues nor sicknesses during his time." The city of Oxford +was prepared to afford an asylum to the royal family of Great-Britain +from the plague, when it ravaged London, and other parts of England, in +the year 1665, only in consequence of its having been cleaned, some years +before, by the Bishop of Winchester. In a manuscript account of the life +of Doctor, afterwards Governor Colden, of New-York, there is the +following fact. It was first communicated to the public in the daily +gazette of the capital of that state, on the 30th of October, 1799. "A +malignant fever having raged with exceeding violence for two summers +successively in the city of New-York, about forty years ago, he +communicated his thoughts to the public, on the most probable cure of the +calamity. He published a little treatise on the occasion, in which he +collected the sentiments of the best authority, on the bad effects of +_stagnating waters_, _moist air_, _damp cellars_, _filthy shores_, and +_dirty streets_. He showed how much these nuisances prevailed in many +parts of the city, and pointed out the remedies. The corporation of the +city voted him their thanks, adopted his reasoning, and established a +plan for draining and cleaning the city, which was attended with the most +happy effects." The advantages of burning offal matters, capable by +putrefaction of producing fevers, has been demonstrated by those +housekeepers, who, instead of collecting the entrails of fish and +poultry, and the parings and skins of vegetables, in barrels, instantly +throw them into their kitchen fires. The families of such persons are +generally healthy. + +2. In the construction of cities, narrow streets and alleys should be +carefully avoided. Deep lots should be reserved for yards and gardens for +all the houses, and subterraneous passages should be dug to convey, when +practicable, to running water, the contents of privies, and the foul +water of kitchens. In cities that are wholly supplied with fresh water by +pipes from neighbouring springs or rivers, all the evils from privies +might be prevented by digging them so deep as to connect them with water. +Great advantages, it has been suggested, would arise in the construction +of cities, from leaving open squares, equal in number and size to those +which are covered with houses. The light and dark squares of a +chequer-board might serve as models for the execution of such a plan. The +city of London, which had been afflicted nearly every year for above half +a century by the plague, has never been visited by it since the year +1666. In that memorable year, while the inhabitants were venting their +execrations upon a harmless bale of silks imported from Holland, as the +vehicle of the seeds of their late mortal epidemic, Heaven kindly pointed +out, and removed its cause, by permitting a fire to destroy whole +streets and lanes of small wooden buildings, which had been the +reservoirs of filth for centuries, and thereby the sources of all the +plagues of that city[22]. Those streets and lanes were to London, what +Water-street and Farmer's-row are to Philadelphia, Fell's-point to +Baltimore, the slips and docks to New-York, and Water-street to the town +of Norfolk. + + [22] A proposal was made to replace the houses that had been burnt, by + similar buildings, and upon the same space of ground. Sir + Christopher Wren opposed it, and with the following argument: "By + so doing, you will show you have not _deserved_ the late fire!" + +3. Where the different forms of summer and autumnal disease arise from +marsh exhalations, they should be destroyed by drains, by wells +communicating with their subterraneous springs, or by cultivating upon +them certain grasses, which form a kind of mat over the soil, and, when +none of these modes of destroying them is practicable, by overflowing +them with water. + +I have met with many excellent quotations from a work upon this part of +our subject, by Tozzetti, an Italian physician, from which, I have no +doubt, much useful information might be obtained. The Rev. Thomas Hall, +to whom I made an unsuccessful application for this work, speaks of it, +in his answer to my letter, in the following terms. "It is in such high +estimation, that the late emperor Leopold, when grand duke of Tuscany, +caused it to be re-printed at his own expence, and presented it to his +friends. The consequence of this was, it influenced the owners of low +marshy grounds, in the neighbourhood of the river Arno, to drain and +cultivate them, and thereby rendered the abode of noxious air, and +malignant fevers, a terrestrial paradise." + +4. The summer and autumnal diseases of our country have often followed +the erection of mill-dams. They may easily be obviated by surrounding +those receptacles of water with trees, which prevent the sun's acting +upon their shores, so as to exhale miasmata from them. Trees planted upon +the sides of creeks and rivers, near a house, serve the same salutary +purpose. + +5. It has often been observed, that families enjoy good health, for many +years, in the swamps of Delaware and North-Carolina, while they are in +their natural state, but that sickness always follows the action of the +rays of the sun upon the moist surface of the earth, after they are +cleared. For this reason, the cultivation of a country should always +follow the cutting down of its timber, in order to prevent the new +ground becoming, by its exhalations, a source of disease. + +6. In commercial cities, no vessel that arrives with a cargo of +putrescent articles should ever be suffered to approach a wharf, before +the air that has been confined in her hold has been discharged. The same +thing should be done after the arrival of a vessel from a distant or hot +country, though her cargo be not capable of putrefaction, for air +acquires a morbid quality by stagnating contiguous to wood, under +circumstances formerly mentioned. + +All these modes of removing the causes of malignant and yellow fevers, +and of promoting strict and universal cleanliness, are of more +consequence in the middle and northern states of America, than in +countries uniformly warm, inasmuch as the disease may be taken as often +as our inhabitants are exposed to its sources. In the West-Indies, a +second attack of the yellow fever is prevented by the insensibility +induced upon the system, by its being constantly exposed to the +impressions of heat and exhalation. After a seasoning, as it is called, +or a residence of two or three years in those islands, the miasmata +affect the old settlers, as they do the natives, only with mild +remittents. Nearly the same thing takes place at Madras, in the +East-Indies, where, Dr. Clark says, the exhalations which bring on +bilious fevers, colic, cholera, and spasmodic affections in new comers, +produce a puking in the morning, only in old residents. But very +different is the condition of the inhabitants of the middle and northern +states of America, in whom the winters prevent the acquisition of habits +of insensibility to the heat and exhalations of the previous summers, and +thus place them every year in the condition of new comers in the West and +East-Indies, or of persons who have spent two or three years in a cold +climate. This circumstance increases the danger of depopulation from our +malignant epidemics, and should produce corresponding exertions to +prevent them. + +In enumerating the various means of preventing and exterminating the +malignant forms of fever, it may appear strange that I have said nothing +of the efficacy of quarantines for that purpose. Did I believe these +pages would be read only by the citizens of Pennsylvania, I would do +homage to their prejudices, by passing over this subject by a respectful +and melancholy silence; but as it is probable they will fall into the +hands of physicians and citizens of other states, I feel myself under an +obligation to declare, that I believe quarantines are of no efficacy in +preventing the yellow fever, in any other way than by excluding the +unwholesome air that is generated in the holds of ships, which may be +done as easily in a single day, as in weeks or months. They originated in +error, and have been kept up by a supine and traditional faith in the +opinions and conduct of our ancestors in medicine. Millions of dollars +have been wasted by them. From their influence, the commerce, +agriculture, and manufactures of our country have suffered for many +years. But this is not all. Thousands of lives have been sacrificed, by +that faith in their efficacy, which has led to the neglect of domestic +cleanliness. Distressing as these evils are, still greater have +originated from them; for a belief in the contagious nature of the yellow +fever, which is so solemnly enforced by the execution of quarantine laws, +has demoralized our citizens. It has, in many instances, extinguished +friendship, annihilated religion, and violated the sacraments of nature, +by resisting even the loud and vehement cries of filial and parental +blood. + +While I thus deny the yellow fever to be the offspring of a specific +contagion, and of course incapable of being imported so as to become an +epidemic in any country, I shall admit presently, that the excretions of +a patient in this disease may, by confinement, become so acrid as to +produce, under circumstances to be mentioned hereafter, a similar disease +in a person, but from this person it cannot be communicated, if he +possess only the common advantages of pure air and cleanliness. To +enforce a quarantine law, therefore, under such a contingent +circumstance, and at the expence of such a profusion of blessings as have +been mentioned, is to imitate the conduct of the man, who, in attempting +to kill a fly upon his child's forehead, knocked out its brains. + +From the detail that has been given of the sources of malignant fevers, +and of the means of preventing them, it is evident that they do not exist +by an unchangeable law of nature, and that Heaven has surrendered every +part of the globe to man, in a state capable of being inhabited, and +enjoyed. The facts that have been mentioned show further, the connection +of health and longevity, with the reason and labour of man. + +To every natural evil the Author of Nature has kindly prepared an +antidote. Pestilential fevers furnish no exception to this remark. The +means of preventing them are as much under the power of human reason and +industry, as the means of preventing the evils of lightning and common +fire. I am so satisfied of the truth of this opinion, that I look for a +time when our courts of law shall punish cities and villages, for +permitting any of the sources of bilious and malignant fevers to exist +within their jurisdiction. + +I have repeatedly asserted the yellow fever of the United States not to +be contagious. I shall now mention the proofs of that assertion, and +endeavour to explain instances of its supposed contagion upon other +principles. + + + + + FACTS, + + INTENDED TO PROVE + + _THE YELLOW FEVER_ + + NOT TO BE CONTAGIOUS. + + +When fevers are communicated from one person to another, it is always in +one of the following ways. 1. By secreted matters. 2. By excreted +matters. The small-pox and measles are communicated in the former way; +the jail, or, as it is sometimes called, the ship, or camp, and hospital +fever, is communicated only by means of the excretions of the body. The +perspiration, by acquiring a morbid and irritating quality more readily +than any other excretion, in consequence of its stagnation and +confinement to the body in a tedious jail fever, is the principal means +of its propagation. The perspiration[23] is, moreover, predisposed to +acquire this morbid and acrid quality by the filthiness, scanty, or bad +aliment, and depression of mind, which generally precede that fever. It +is confined to sailors, passengers, soldiers, prisoners, and patients, in +foul and crowded ships, tents, jails, and hospitals, and to poor people +who live in small, damp, and confined houses. It prevails chiefly in cool +and cold weather, but is never epidemic; for the excreted matters which +produce the fever do not float in the external atmosphere, nor are they +communicated, so as to produce disease, more than a few feet from the +persons who exhale them. They are sometimes communicated by means of the +clothes which have been worn by the sick, and there have been instances +in which the fever has been produced by persons who had not been confined +by it, but who had previously been exposed to all the causes which +generate it. It has been but little known in the United States since the +revolutionary war, at which time it prevailed with great mortality in the +hospitals and camps of the American army. It has now and then appeared in +ships that were crowded with passengers from different parts of Europe. +It is a common disease in the manufacturing towns of Great-Britain, where +it has been the subject of several valuable publications, particularly by +Dr. Smith and Dr. John Hunter. Dr. Haygarth has likewise written upon it, +but he has unfortunately confounded it with the West-India and American +yellow fever, which differs from it in prevailing chiefly in warm +climates and seasons; in being the offspring of dead and putrid vegetable +and animal matters; in affecting chiefly young and robust habits; in +being generally accompanied with a diseased state of the stomach, and an +obstruction or preternatural secretion and excretion of bile; in +terminating, most commonly, within seven days; in becoming epidemic +_only_ by means of an impure atmosphere; and in not furnishing ordinarily +those excretions which, when received into other bodies, reproduce the +same disease. + + [23] The deleterious nature of this fluid, and its disposition to + create disease, under the above circumstances, has been happily + illustrated by Dr. Mitchill, in an ingenious letter to Dr. Duncan, + of Edinburgh, published in the fourth volume of the Annals of + Medicine. + +I have been compelled to employ this tedious description of two forms of +fever, widely different from each other in their causes, symptoms, and +duration, from the want of two words which shall designate them. Dr. +Miller has boldly and ingeniously proposed to remedy this deficiency in +our language, by calling the former _idio-miasmatic_, and the latter +_koino-miasmatic_ fevers, thereby denoting their _private_ or _personal_, +and their _public_ or _common_ origin[24]. My best wishes attend the +adoption of those terms! + + [24] Medical Repository, hexade ii. vol. i. + +I return to remark, that the yellow fever is not contagious in its simple +state, and that it spreads exclusively by means of exhalations from +putrid matters, which are diffused in the air. This is evident from the +following considerations: + +1. It does not spread by contagion in the West-Indies. This has been +proved in the most satisfactory manner by Drs. Hillary, Huck, Hunter, +Hector M'Lean, Clark, Jackson, Borland, Pinckard, and Scott. Dr. Chisholm +stands alone, among modern physicians, in maintaining a contrary opinion. +It would be easy to prove, from many passages in the late edition of the +doctor's learned and instructive volumes, that he has been mistaken; and +that the disease was an endemic of every island in which he supposed it +to be derived from contagion. A just idea of the great incorrectness of +all his statements, in favour of his opinion, may be formed from the +letter of J. F. Eckard, Esq. Danish consul, in Philadelphia, to Dr. James +Mease, published in a late number of the New-York Medical Repository[25]. + + [25] For February, March, and April, 1804. + +2. The yellow fever does not spread in the country, when carried thither +from the cities of the United States. + +3. It does not spread in yellow fever hospitals, when they are situated +beyond the influence of the impure air in which it is generated. + +4. It does not spread in cities (as will appear hereafter) from any +specific matter emitted from the bodies of sick people. + +5. It generally requires the co-operation of an _exciting_ cause, with +miasmata, to produce it. This is never the case with diseases which are +universally acknowledged to be contagious. + +6. It is not propagated by the artificial means which propagate +contagious diseases. Dr. Ffirth inoculated himself above twenty times, in +different parts of his body, with the black matter discharged from the +stomachs of patients in the yellow fever, and several times with the +serum of the blood, and the saliva of patients ill with that disease, +without being infected by them; nor was he indisposed after swallowing +half an ounce of the black matter recently ejected from the stomach, nor +by exposing himself to the vapour which was produced by throwing a +quantity of that matter upon iron heated over a fire[26]. + + [26] Inaugural Dissertation on Malignant Fever, &c. published in June, + 1804. + +To the first four of these assertions there are some seeming exceptions +in favour of the propagation of this fever by contagion. I shall briefly +mention them, and endeavour to explain them upon other principles. + +The circumstances which seem to favour the communication of the yellow +fever from one person to another, by means of what has been supposed to +be contagion, are as follow: + +1. A patient being attended in a small, filthy, and _close_ room. The +excretions of the body, when thus accumulated, undergo an additional +putrefactive process, and acquire the same properties as those putrid +animal matters which are known to produce malignant fevers. I have heard +of two or three instances in which a fever was produced by these means in +the country, remote from the place where it originated, as well as from +every external source of putrid exhalation. The plague is sometimes +propagated in this way in the low and filthy huts which compose the +alleys and narrow streets of Cairo, Smyrna, and Constantinople. + +2. A person sleeping in the sheets, or upon a bed impregnated with the +sweats or other excretions, or being exposed to the smell of the foul +linen, or other clothing of persons who had the yellow fever. The disease +here, as in the former case, is communicated in the same way as from any +other putrid animal matters. It was once received in Philadelphia from +the effluvia of a chest of unwashed clothes, which had belonged to one of +our citizens who had died with it in Barbadoes; but it extended no +further in a large family than to the person who opened the chest. I have +heard of but two instances more of its having been propagated by these +means in the United States, in which case the disease perished with the +unfortunate subjects of it. + +To the above insolated cases of the yellow fever being produced by the +clothing of persons who had died of it, I shall oppose a fact +communicated to me by Dr. Mease. While the doctor resided at the +lazaretto, as inspector of sickly vessels, between May, 1794, and the +same month in 1798, the clothing contained in the chests and trunks of +all the seamen and others, belonging to Philadelphia, who had died of the +yellow fever in the West-Indies, or on their passage home, and the linen +of all the persons who had been sent from the city to the lazaretto with +that disease, amounting in all to more than one hundred, were opened, +exposed to the air, and washed, by the family of the steward of the +hospital, and yet no one of them contracted the least indisposition from +them. + +I am disposed to believe the linen, or any other clothing of a person in +good health that had been strongly impregnated with sweats, and +afterwards suffered to putrify in a confined place, would be more apt to +produce a yellow fever in a summer or autumnal month, than the linen of a +person who had died of that disease, with the usual absence of a moisture +on the skin. The changes which the healthy excretions by the pores +undergo by putrefaction, may easily be conceived, by recollecting the +offensive smell which a pocket-handkerchief acquires that has been used +for two or three days to wipe away the sweat of the face and hands in +warm weather[27]. + + [27] See Van Swieten on Epidemic Diseases, Aphorism 1408. + +3. The protraction of a yellow fever to such a period as to dispose it to +assume the symptoms, and to generate the peculiar and highly volatilised +exhalation from the pores of the skin which takes place in the jail +fever. I am happy in finding I am not the author of this opinion. Sir +John Pringle, Dr. Monro, and Dr. Hillary, speak of a contagious fever +produced by the combined action of marsh and human miasmata. The first of +those physicians supposes the Hungarian bilious fever, which prevailed +over the continent of Europe in the seventeenth century, was sometimes +propagated in this way, as well as by marsh and other putrid exhalations. +Dr. Richard Pearson, in his observations upon the bilious fevers which +prevailed in the neighbourhood of Birmingham, in England, in the years +1797, 1798, and 1799, has the following remark: "In its first stage, this +fever did not appear to be contagious, but it evidently was so after the +eleventh and fourteenth day, when the _typhoid_ state was induced[28]." +As this protracted state of bilious fever rarely occurs in our country, +it has seldom been communicated in this way. + + [28] Page 13. + +It is not peculiar, I believe, to a bilious and yellow fever, when much +protracted beyond its ordinary duration, to put on the symptoms of the +jail fever. The same appearances occur in the pleurisy, and in other, of +what Dr. Sydenham calls _intercurrent_ fevers, all of which I have no +doubt, under certain circumstances of filth, confinement, and long +duration, would produce a fever in persons who were exposed to it. This +fever, if the weather were cold, would probably put on inflammatory +symptoms, and be added, in our nosologies, to the class of contagious +diseases. + +From the necessary influence of time, in thus rendering fevers of all +kinds now and then contagious by excretion, it follows, that the yellow +fever, when of its usual short duration, is incapable of generating that +excretion, and that, instead of being considered as the only form of +bilious fever that possesses a power of propagating itself, it should be +considered as the only one that is devoid of it. + +4. Miasmata, whether from marshes, or other external sources, acting upon +a system previously impregnated with the excreted matters which produce +the jail or ship fever. Mr. Lempriere informs us, that he saw what were +supposed to be cases of yellow fever communicated by some sailors who +brought the seeds of the ship fever with them to the island of Jamaica. +The fevers which affected most of the crews of the Hussar frigate, +mentioned by Dr. Trotter[29], and of the Busbridge Indiaman, described +by Mr. Bryce[30], appear to have been the effect of the combined +operation of foul air in those ships, and human excretions, upon their +systems. The disease was barely tinged with bilious symptoms, and hence +the facility with which it was cured, for the jail fever more readily +yields to medicine than the yellow fever. The former was probably excited +by some latent exhalation from dead matters in the holds of the ships, +and hence we find it ceased on shore, where it was deprived of its +exciting cause. It is true, great pains were taken to clean the hold and +decks of the Busbridge, but there are foul matters which adhere to the +timbers of ships, and which, according to Dr. Lind, are sometimes +generated by those timbers when new, that are not to be destroyed by any +of the common means employed for that purpose. Of this Dr. Kollock has +furnished us with a most satisfactory proof, in his history of the yellow +fever, which prevailed on board of the frigate General Greene, on her +voyage to the Havanna, in the year 1799. "The air in the hold of the +vessel (says the doctor) was so contaminated, as to extinguish lights +immediately, and candles in the cockpit were almost as useless from the +same cause. The fish were thrown overboard, and the decks washed and +scoured, the ventilator and wind sails put in motion, and every measure +of purification adopted that their situation allowed; notwithstanding +these precautions disease invaded us. The men were unceasing in their +exertions to purify the ship; washing, scouring with vinegar, burning +powder and vinegar, old junk, and sulphur, added to constant ventilation, +proved unequal even to the amelioration of their calamities, while they +were in the latitude of _great heat_. After the removal of the sick, the +ship was disburthened of her stores, ballast, &c. cleansed and +white-washed throughout; still new cases occurred for nearly two months. +Some days, two, three, or four were sent off to the hospital, which would +seem to indicate the retention of some portion of this noxious principle, +which was lodged beyond the reach of the cleansing process." That this +noxious principle or matter existed in the ship, and not in the bodies of +the crew, is evident from its not having been communicated, in a single +instance by a hundred of them who were sent to an hospital on +Rhode-Island, notwithstanding an intercourse sufficient to propagate it +was necessarily kept up with the inhabitants. Even their nurses did not +take it[31]. + + [29] Medicina Nautica, p. 360. + + [30] Annals of Medicine, vol. i. p. 116. + + [31] Medical Repository, vol. iv. No. 1. + +5. A fifth instance in which contagion has been supposed to take place in +the yellow fever is, where the exhalation from the excretions of a +patient in that disease acts as an _exciting_ cause, in persons +previously impregnated with the marsh, or other external miasmata, which +produce it. The activity of this exhalation, even when it is attended +with no smell, is so great, as to induce sickness, head-ach, vertigo, and +fainting. It is not peculiar to the exhalations from such patients to +produce morbid effects upon persons who visit them. The odour emitted by +persons in the confluent small-pox has been known to produce the same +symptoms, together with a subsequent fever and apthous sore throat. This +has been remarked long ago by Dr. Lind, and latterly by Dr. Willan, in +his Reports of the Diseases of London[32]. That the yellow fever is often +excited in this way, without the intervention of a supposed specific +contagion, I infer from its sometimes spreading through whole families, +who have breathed the same impure atmosphere with the person first +infected by the fever. This is more especially the case where the +impression made by the exhalation from the sick person is assisted by +fear, fatigue, or anxiety of mind in other branches of the family. In +favour of this mode of exciting the yellow fever, Dr. Otto communicated +to me the following fact. In the autumn of the year 1798, it prevailed +upon the _shores_ of the Delaware, in Gloucester county, in New-Jersey. A +mild remittent prevailed at the same time on the _high_ grounds, a few +miles from the river. During this time, the doctor observed, if a person +who had inhaled the seeds of the yellow fever in Philadelphia afterwards +came into a family _near_ the river, the same disease appeared in several +instances in one or more branches of that family; but where persons +brought the fever from the city, and went into a family on the _high_ +grounds, where the mild remittents prevailed, there was not a single +instance of a yellow fever being excited by them in any of its members. +This fact is important, and of extensive application. It places the +stimulus from the breath, or other exhalations of persons affected by the +yellow fever, upon a footing with intemperance, fatigue, heat, and all +the common exciting causes of the disease; none of which, it is well +known, can produce it, except in persons who have previously inhaled the +putrid miasmata, which in all countries are its only remote cause. The +city of Philadelphia has furnished, in all our yellow fever years, many +additional proofs of the correctness of Dr. Otto's remark. In the months +of July and August, when miasmata are generally local, and float chiefly +near to their hot beds, the docks and holds of ships, persons who are +affected by these miasmata, and sicken in other parts of the city, never +communicate the disease; but after the less prepared and heterogeneous +filth of our whole city has been acted on by an autumnal, as well as +summer sun, so as to emit pestilential exhalations into all our streets +and alleys, the fever is now and then excited in the manner that has been +mentioned, by a single person in a whole family. The common intermittents +of the southern states are often excited in the same way, without being +suspected of spreading by contagion. Even the jail or hospital fever is +vindicated by Dr. Hunter from the highly contagious nature which has been +ascribed to it, upon the same principle. His words, which are directly to +my purpose, are as follow: "In considering the extent and power of the +contagion [meaning of the jail or hospital fever], I am not inclined to +impute to this cause the fevers of all those who are taken ill in one +family after the first, as they are all along exposed to the same +vitiated air which occasions the first fever. In like manner, when a poor +woman visits some of her sick neighbours, and is taken ill herself, and +afterwards some of her children, I would not impute the disease to +infection alone; she and her family having previously lived in the same +kind of vitiated air which originally produced the fever. If the cases in +which the infection meets with the poison already _half formed_ be +excepted, the disease in itself will be found to be much less infectious +than has been commonly supposed[33]." By the modes of communicating the +yellow fever which have been admitted, the dysentery, and all the milder +forms of autumnal fevers, have been occasionally propagated, and perhaps +oftener than the first-named disease, from their being more apt to run on +to the typhus or chronic state. Of this I could adduce many proofs, not +only from books, but from my own observations; but none of these diseases +spread by contagion, or become epidemic from that cause in any country. A +contrary opinion, I know, is held by Dr. Cleghorn, and Dr. Clarke; but +they have deceived themselves, as they formerly deceived me, by not +attending to the difference between secreted contagions and morbid +excretions from the body, produced by the causes which have been +enumerated, and which are rare and accidental concomitants of bilious or +summer diseases. + + [32] Page 13 and 113. + + [33] Medical Transactions, vol. iii. p. 351. + +6. The last instance of supposed contagion of the yellow fever is said to +arise from the effluvia of a putrid body that has died of that disease. +The effluvia in this case act either as the putrified excretions +mentioned under the first head, or as an exciting cause upon miasmata, +previously received into the system. A dead body, in a state of +putrefaction from any other disease, would produce, under the same +circumstances of season and predisposition, the same kind and degrees of +fever. + +The similarity of the fever induced by the means that have been +enumerated, with the fever from which it was derived, has been supposed +to favour the opinion of its being communicated by a specific contagion. +But let it be recollected that the yellow fever is, at the time of its +being supposed to be thus received, the reigning epidemic, and that +irritants of all kinds necessarily produce that disease. The morbid +sweats which now and then produce an intermitting fever, and the alvine +excretions which occasionally produce a dysentery, act only by exciting +morbid actions in the system, which conform in their symptoms to an +immutable and universal law of epidemics. It is only when those two +diseases generally prevail, that they seem to produce each other. + +Thus have I explained all the supposed cases of contagion of the yellow +fever. To infer from the solitary instances of it thus excited, is to +reason as incorrectly as to say the small-pox is not contagious, because +we now and then meet with persons who cannot be infected by it. + +From the explanation that has been given of the instances of supposed +contagion of the yellow fever, we are compelled to resort to certain +noxious qualities in the atmosphere, as the exclusive causes of the +prevalence, not only of that fever, but (with a few exceptions) of all +other epidemic diseases. It is true, we are as yet ignorant of the +precise nature of those qualities in the air which produce epidemics; but +their effects are as certainly felt by the human body as the effects of +heat, and yet who knows the nature of that great and universal principle +of activity in our globe? + +That the yellow fever is propagated by means of an impure atmosphere, at +all times, and in all places, I infer from the following facts: + +1. It appears only in those climates and seasons of the year in which +heat, acting upon moist animal and vegetable matters, fills the air with +their putrid exhalations. A vertical sun, pouring its beams for ages +upon a dry soil; and swamps, defended from the influence of the sun by +extensive forests, have not, in a single instance, produced this disease. + +2. It is unknown in places where a connection is not perceptible between +it, and marshes, mill-ponds, docks, gutters, sinks, unventilated ships, +and other sources of noxious air. The truth of this remark is established +by the testimonies of Dr. Lind and Dr. Chisholm, and by many facts in +Lempriere's excellent History of the Diseases of Jamaica. Dr. Davidson +furnished me with a striking confirmation of their remarks, in the +following extract from a letter, dated November 12th, 1794. "I have +mentioned (says the doctor) an instance of the remarkable good health +which the 66th regiment enjoyed at St. Vincents for several years, upon a +high hill above the town, removed from all exhalations, and in a +situation kept at all times cool by the blowing of a constant trade wind. +They did not lose, during eighteen months, above two or three men (the +regiment was completed to the peace establishment), and during eight +years they lost but two officers, one of whom, the quarter-master, +resided constantly in town, and died from over fatigue; the other arrived +very ill from Antigua, and died within a few days afterwards." + +In the United States, no advocate for the specific nature or importation +of the yellow fever, has ever been able to discover a single case of it +beyond the influence of an atmosphere rendered impure by putrid +exhalations. + +It is no objection to the truth of this remark, that malignant bilious +fevers sometimes appear upon the summits of hills, while their +declivities, and the vallies below, are exempted from them. The miasmata, +in all these cases, are arrested by those heights, and are always to be +traced to putrefaction and exhalation in their neighbourhood. Nor is it +any objection to the indissoluble connection between putrid exhalations +and the yellow fever, which has been mentioned, that the disease +sometimes appears in places remote from the source of miasmata in _time_ +and _place_. The bilious pleurisies, which occur in the winter and +spring, after a sickly autumn, prove that they are retained in the body +for many months, and although they are sometimes limited in their extent +to a single house, and often to a village, a city, and the banks of a +creek or river, yet they are now and then carried to a much greater +distance. Mr. Lempriere, in his valuable Observations upon the Diseases +of the British Army in Jamaica, informs us, that Kingston is sometimes +rendered sickly by exhalations from a lagoon, which lies _nine_ miles to +the eastward of that town[34]. The greater or less distance, to which +miasmata are carried from the place where they are generated, appears to +depend upon their quantity, upon the force and duration of currents of +wind which act upon them, and upon their being more or less opposed by +rivers, woods, water, houses, wells, or mountains. + + [34] Vol. i. p. 84. + +3. It is destroyed, like its fraternal diseases, the common bilious and +intermitting fevers, by means of _long-continued_ and _heavy_ rains[35]. +When rains are heavy, but of short duration, they suspend it only in warm +weather; but when they are succeeded by cold weather, they destroy all +the forms of bilious fever. The malignant tertians, described by Dr. +Cleghorn, always ceased about the autumnal equinox; for at that time, +says the doctor, "Rain falls in such torrents as to tear up trees by the +roots, carry away cattle, break down fences, and do considerable mischief +to the gardens and vineyards; but, after a long and scorching summer, +they are very acceptable and beneficial, for they mitigate the excessive +heat of the air, and give a check to epidemical diseases[36]." There are +facts, however, which would seem to contradict the assertion that +miasmata are suspended or destroyed by heavy rains. Dr. Lind, in his +Treatise upon the Diseases of Hot Climates, mentions instances in which +they suddenly created fevers. It is probable, in these cases the rains +may have had that effect, by disturbing the pellicle which time often +throws over the surface of stagnating pools of water, and putrid matters +on dry land. I was led to entertain this opinion by a fact mentioned in a +letter I received from Dr. Davidson, dated November 4th, 1794. "Being +ordered (says the doctor) up to Barbadoes, last November, upon service, I +found that the troops had suffered considerably by that formidable +scourge, the yellow fever. The season had been remarkably dry. It was +observed, a rainy season contributed to make the season healthier, +excepting at Constitution-Hill, where the sixth regiment was stationed, +and where a heavy shower of rain seldom failed to bring back the fever, +after it had ceased for some time. I found the barrack, where this +regiment was, surrounded by a pond of brackish water, which, being but +imperfectly drained by the continuance of the drought, the surface was +covered with a green scum, which prevented the exhalation of marshy +putrefaction. After a heavy shower of rain, this scum was broken, and the +miasmata evolved, and acted with double force, according to the time of +their secretion." + + [35] Clarke on the Diseases of Long Voyages to Hot Climates, p. 116. + + [36] Diseases of Minorca, p. 8. + +4. It is completely destroyed by frost. As neither rains nor frosts act +in sick rooms, nor affect the bodies of sick people, they must annihilate +the disease by acting exclusively upon the atmosphere. Very different in +their nature are the small-pox and measles, which are propagated by +specific contagion. They do not wait for the suns of July or August, nor +do they require an impure atmosphere, or an exciting cause, to give them +activity. They spread in the winter and spring, as well as in the summer +and autumnal months: wet and dry weather do not arrest their progress, +and frost (so fatal to the yellow fever), by rendering it necessary to +exclude cold air from sick rooms, increases the force of their contagion, +and thereby propagates them more certainly through a country. + +5. It is likewise destroyed, by intense heat, and high winds. The latter, +we are sure, like heavy rains and frost, do not produce that salutary +effect by acting upon the bodies, or in the rooms of sick people. + +It is worthy of notice, that while the activity of miasmata is destroyed +by cold, when it descends to frost; by heat, when it is so intense as to +dry up all the sources of putrid exhalation; by heavy rains, when they +are succeeded by cool weather; and by high winds, when they are not +succeeded by warm weather; they are rendered more active by cool, warm, +and damp weather, and by light winds. The influence of damp weather, in +retaining and propagating miasmata, will be readily admitted, by +recollecting how much more easily hounds track their prey, and how much +more extensively odours of all kinds pervade the atmosphere, when it is +charged with moisture, than in dry weather. + +It has been asked, if putrid matters produce malignant bilious fevers in +our cities, why do they not produce them in Lisbon, and in several other +of the filthiest cities in the south of Europe? To this I answer, that +filth and dirt are two distinct things. The streets of a city may be very +_dirty_, that is, covered with mud composed of inoffensive clay, sand, or +lime, and, at the same time, be perfectly free from those _filthy_ +vegetable and animal matters which, by putrefaction, contaminate the air. +But, admitting the streets of those cities to abound with the filthy +matters that produce pestilential diseases in other countries, it is +possible the exhalations from them may be so _constant_, and so +_powerful_, in their impressions upon the bodies of the inhabitants, as +to produce, from habit, no morbid effects, or but feeble diseases, as was +remarked formerly, is the case in the natives and old settlers in the +East and West-Indies. But if this explanation be not satisfactory, it may +be resolved into a partial absence of an inflammatory constitution of the +air, which, I shall say presently, must concur in producing pestilential +diseases. Such deviations from uniformity in the works of Nature are +universal. In the present instances, they no more invalidate the general +proposition of malignant fevers being every where of domestic origin, +than the exemption of Ireland from venomous reptiles, proves they are not +generated in other countries, or that the pleurisy and rheumatism are not +the effects of the alternate action of cold and heat upon the body, +because hundreds, who have been exposed to them under equal +circumstances, have not been affected by those diseases. There may be +other parts of the world in which putrid matters do not produce bilious +malignant diseases from the causes that have been mentioned, or from some +unknown cause, but I am safe in repeating, there never was a bilious +epidemic yellow fever that could not be traced to putrid exhalation. + +It has been asked, if the yellow fever be not imported, why does it make +its first appearance among sailors, and near the docks and wharves of our +cities? I answer, this is far from being true. The disease has as often +appeared first at a distance from the shores of our cities as near them, +but, from its connection with a ship not being discovered, it has been +called by another name. But where the first cases of it occur in sailors, +I believe the seeds of it are always previously received by them from our +filthy docks and wharves, or from the foul air which is discharged with +the cargoes of the ships in which they have arrived, which seeds are +readily excited in them by hard labour, or intemperance, so as to produce +the disease. That this is the case, is further evident from its appearing +in them, only in those months in which the bilious fever prevails in our +cities. + +It has been asked further, why were not these bilious malignant fevers +more common before the years 1791, 1792, and 1793? To this I answer, by +repeating what was mentioned in another place[37], that our climate has +been gradually undergoing a change. The summers are more alternated by +hot and cool, and wet and dry weather, than in former years. The winters +are likewise less uniformly cold. Grass is two or three weeks later in +the spring in affording pasture to cattle than it was within the memory +of many thousand people. Above all, the summer has encroached upon the +autumn, and hence the frequent accounts we read in our newspapers of +trees blossoming, of full grown strawberries and raspberries being +gathered, and of cherries and apples, of a considerable size, being seen, +in the months of October and November, in all the middle states. By means +of this protraction of the heat of summer, more time is given for the +generation of putrid exhalations, and possibly for their greater +concentration and activity in producing malignant bilious diseases. + + [37] Account of the Climate of Pennsylvania, vol i. + +It has been asked again, why do not the putrid matters which produce the +yellow fever in some years produce it _every_ year? This question might +be answered by asking two others. 1st. Why, if the yellow fever be +derived from the We st-Indies, was it not imported every year before 1791, +and before the existence, or during the feeble and partial operation of +quarantine laws? It is no answer to this question to say, that a war is +necessary to generate the disease in the islands, for it exists in some +of them at all times, and the seasons of its prevalence in our cities +have, in many instances, had no connection with war, nor with the +presence of European armies in those and in other sickly parts of the +globe. During the seven years revolutionary war it was unknown as an +epidemic in the United States, and yet sailors arrived in all our cities +daily from sickly islands, in small and crowded vessels, and sometimes +covered with the rags they had worn in the yellow fever, in British +hospitals and jails. I ask, 2dly, why does the dysentery (which is +certainly a domestic disease) rise up in our country, and spread sickness +and death through whole families and villages, and disappear from the +same places for fifteen or twenty years afterwards? + +The want of uniformity in the exhalations of our country in producing +those diseases depends upon their being combined with more or less heat +or moisture; upon the surface of the earth being completely dry, or +completely covered with water[38]; upon different currents of winds, or +the total absence of wind; upon the disproportion of the temperature of +the air in the day and night; upon the quantity of dew; upon the early or +late appearance of warm or cold weather; and upon the predisposition of +the body to disease, derived from the quality of the aliments of the +season. A similar want of uniformity in the annual operations of our +climate appears in the size and quality of grain, fruits, and vegetables +of all kinds. + + [38] In the Account of the Yellow Fever of 1793, the different and + opposite effects of a dry and rainy season in producing bilious + fevers are mentioned from Dr. Dazilles. In the autumn of 1804, I + have elsewhere remarked, after a summer in which there had fallen + an unusual quantity of rain, the bilious fevers appeared chiefly + on the high grounds in Pennsylvania, which were in a state of + moisture, while scarcely a case of them appeared in the + neighbourhood of marshes, or low grounds, owing to their being so + completely covered with water, as to be incapable of generating, + by putrefaction, the miasmata which produce those forms of + disease. + +But the greater violence and mortality of our bilious fevers, than in +former years, must be sought for chiefly in an inflammatory or malignant +constitution of the atmosphere, the effects of which have been no less +obvious upon the small-pox, measles, and the intercurrent fevers of Dr. +Sydenham, than they are upon the summer and autumnal disease that has +been mentioned. + +This malignant state of the air has been noticed, under different names, +by all the writers upon epidemics, from Hippocrates down to the present +day. It was ascribed, by the venerable father of physic, to a "divine +something" in the atmosphere. Dr. Sydenham, whose works abound with +references to it, supposes it to be derived from a mineral exhalation +from the bowels of the earth. From numerous other testimonies of a belief +in the influence of the insensible qualities of the air, altering the +character of epidemics, I shall select the following: + +"It is certain (says Dr. Mosely) that diseases undergo changes and +revolutions. Some continue for a succession of years, and vanish when +they have exhausted the temporary, but secret cause which produced them. +Others have appeared and disappeared suddenly; and others have their +periodical returns." + +The doctor ascribes a malignant fever among the dogs in Jamaica +(improperly called, from one of its symptoms, hydrophobia), to a change +in the atmosphere, in the year 1783. It was said to have been imported, +but experience, he says, proved the fact to be otherwise[39]. + + [39] Treatise upon Tropical Diseases, p. 43, 44. + +"This latent malignity in the atmosphere (says Baron Vansweiten) is known +only by its effects, and cannot easily be reduced to any known species +of acrimony." In another place he says, "It seems certain that this +unknown matter disposes all the humours to a sudden and bad +putrefaction[40]." + + [40] Commentaries on Boerhaave's Aphorisms, vol. v. p. 226, 230. + +Dr. John Stedman has related many facts, in his Essay upon Insalutary +Constitutions of the Air, which prove, that diseases are influenced by a +quality in it, which, he says, "is productive of corruption," but which +has hitherto eluded the researches of physicians[41]. + + [41] Page 135. + +Mr. Lempriere, after mentioning the unusual mortality occasioned by the +yellow fever, within the last five or six years, in the island of +Jamaica, ascribes it wholly "to that particular constitution of +atmosphere upon which the existence of epidemics, at one period rather +than another, depend[42]." + + [42] Vol. ii. p. 31. + +Not only diseases bear testimony to a change in the atmosphere, but the +whole vegetable and animal creation concur in it, proofs of which were +mentioned in another place. Three things are remarkable with respect to +this inflammatory constitution of the air. + +1. It is sometimes of a local nature, and influences the diseases of a +city, or country, while adjoining cities and countries are exempted from +it. + +2. It much oftener pervades a great extent of country. This was evident +in the years 1793 and 1794, in the United States. During the same years, +the yellow fever prevailed in most of the West-India islands. Many of the +epidemics mentioned by Dr. Sims, in the first volume of the Medical +Memoirs, affected, in the same years, the most remote parts of the +continent of Europe. Even the ocean partakes of a morbid constitution of +its atmosphere, and diseases at sea sympathise in violence with those of +the land, at an immense distance from each other. This appears in a +letter from a surgeon, on board a British ship of war, to Mr. Gooch, +published in the third volume of his Medical and Surgical Observations. + +3. The predisposing state of the atmosphere to induce malignant diseases +continues for several years, under all the circumstances of wet and dry, +and of hot and cold weather. This will appear, from attending to the +accounts which have been given of the weather, in all the years in which +the yellow fever has prevailed in Philadelphia since 1792[43]. The remark +is confirmed by all the records of malignant epidemics. + + [43] Vol. iii. and iv. + +It is to no purpose to say, the presence of the peculiar matter which +constitutes an inflammatory or malignant state of the air has not been +detected by any chemical agents. The same thing has been justly said of +the exhalations which produce the bilious intermitting, remitting, and +yellow fever. No experiment that has yet been made, has discovered their +presence in the air. The eudiometer has been used in vain for this +purpose. In one experiment made by Dr. Gattani, the air from a marsh at +the mouth of the river Vateline was found to be apparently purer by two +degrees than the air on a neighbouring mountain, which was 2880 feet +higher than the sea. The inhabitants of the mountain were notwithstanding +healthy, while those who lived in the neighbourhood of the marsh were +annually afflicted with bilious and intermitting fevers[44]. The +contagions of the small-pox and measles consist of matter, and yet who +has ever discovered this matter in the air? We infer the existence of +those remote causes of diseases in the atmosphere only from their +effects. Of the existence of putrid exhalations in it, there are other +evidences besides bilious and yellow fevers. They are sometimes the +objects of the sense of smelling. We see them in the pale or sallow +complexions of the inhabitants of the countries which generate them, and +we observe them occasionally in the diseases of several domestic animals. +The most frequent of these diseases are inflammation, tubercles, and +ulcers in the liver. Dr. Cleghorn describes a diseased state of that +viscus in cattle, in an unhealthy part of the island of Minorca. Dr. +Grainger takes notice of several morbid appearances in the livers of +domestic animals in Holland, in the year 1743. But the United States have +furnished facts to illustrate the truth of this remark. Mr. James +Wardrobe, near Richmond, in Virginia, informed me, that in August, 1794, +at a time when bilious fevers were prevalent in his neighbourhood, his +cattle were seized with a disease, which, I said formerly, is known by +the name of the yellow water, and which appears to be a true yellow +fever. They were attacked with a staggering. Their eyes were muddy, or +ferocious. A costiveness attended in all cases. It killed in two days. +Fifty-two of his cattle perished by it. Upon opening the bodies of +several of them, he found the liver swelled and ulcerated. The blood was +dissolved in the veins. In the bladder of one of them, he found thirteen +pints of blood and water. Similar appearances were observed in the livers +of sheep in the neighbourhood of Cadiz, in the year 1799, during the +prevalence of the yellow fever in that city. They were considered as such +unequivocal marks of an unwholesome atmosphere among the ancients, that +they examined the livers of domestic animals, in order to determine on +the healthy or unhealthy situation of the spot on which they wished to +live. + + [44] Alibert's Dissertation sur les Fievres Pernicieuses et Attaxiques + Intermittentes, p. 185. + +The advocates for the yellow fever being a specific disease, and +propagated only by contagion, will gain nothing by denying an +inflammatory constitution of the atmosphere (the cause of which is +unknown to us) to be necessary to raise common remittents to that grade +in which they become malignant yellow fevers; for they are obliged to +have recourse to an unknown quality in the air, every time they are +called upon to account for the disease prevailing chiefly in our cities, +and not spreading when it is carried from them into the country. The same +reference to an occult quality in the air is had by all the writers upon +the plague, in accounting for its immediate and total extinction, when it +is carried into a foreign port. + +In speaking of the influence of an inflammatory constitution of the +atmosphere in raising common bilious, to malignant yellow fevers, I wish +not to have it supposed, that its concurrence is necessary to produce +sporadic cases of that, or any other malignant disease. Strong exciting +causes, combined with highly volatilized and active miasmata, I believe, +will produce a yellow fever at any time. I have seen one or more such +cases almost every year since I settled in Philadelphia, and particularly +when my business was confined chiefly to that class of people who live +near the wharves, and in the suburbs, and who are still the first, and +frequently the only victims of the yellow fever. + +It has been said, exultingly, that the opinion of the importation of the +yellow fever is of great antiquity in our country, and that it has lately +been admitted by the most respectable physicians in Britain and France, +and sanctioned by the laws of several of the governments in Europe. Had +antiquity, numbers, rank, and power been just arguments in favour of +existing opinions, a thousand truths would have perished in their birth, +which have diffused light and happiness over every part of our globe. In +favour of the ancient and general belief of the importation of the yellow +fever, there are several obvious reasons. The idea is produced by a +single act of the mind. It requires neither comparison nor reasoning to +adopt it, and therefore accords with the natural indolence of man. It, +moreover, flatters his avarice and pride, by throwing the origin of a +mortal disease from his property and country. The principle of thus +referring the origin of the evils of life from ourselves to others is +universal. It began in paradise, and has ever since been an essential +feature in the character of our species. It has constantly led +individuals and nations to consider loathsome and dangerous diseases as +of foreign extraction. The venereal disease and the leprosy have no +native country, if we believe all the authors who have written upon them. +Prosper Alpinus derives the plagues of Cairo from Syria, and the +physicians of Alexandria import them from Smyrna or Constantinople. The +yellow fever is said to have been first brought from Siam (where there +are proofs it never existed) to the West-Indies, whence it is believed to +be imported into the cities of the United States. From them, Frenchmen +and Spaniards say it has been re-shipped, directly or indirectly, to St. +Domingo, Havanna, Malaga, Cadiz, and other parts of the world. Weak and +absurd credulity! the causes of the ferocious and mortal disease which we +thus thrust from our respective ports, like the sin of Cain, "lie +exclusively at our own doors." + +Lastly, it has been asserted, if we admit the yellow fever to be an +indigenous disease of our cities, we shall destroy their commerce, and +the value of property in them, by disseminating a belief, that the cause +of our disease is fixed in our climate, and that it is out of the power +of human means to remove it. The reverse of this supposition is true. If +it be an imported disease, our case is without a remedy; for if, with all +the advantages of quarantine laws enforced by severe penalties, and +executed in the most despotic manner, the disease has existed annually, +in most of our cities, as an epidemic, or in sporadic cases, ever since +the year 1791, it will be in vain to expect, from similar measures, a +future exemption from it. Nothing but a belief in its domestic origin, +and the adoption of means founded upon that belief, can restore the +character of our climate, and save our commercial cities from +destruction. Those means are cheap, practicable, and certain. They have +succeeded, as I shall say presently, in other countries. + +From the account that has been given of the different ways in which this +disease is communicated from one person to another, and from the facts +which establish its propagation exclusively through the medium of the +atmosphere, when it becomes epidemic, we may explain several things which +belong to its history, that are inexplicable upon the principle of its +specific contagion. + +1. We learn the reason why, in some instances, the fever does not spread +from a person who sickens or dies at sea, who had carried the seeds of it +in his body from a sickly shore. It is because no febrile miasmata exist +in the bodies of the rest of the crew to be excited into action by any +peculiar smell from the disease, or by fear or fatigue, and because no +morbid excretions are generated by the person who dies. The fever which +prevailed on board the Nottingham East-Indiaman, in the year 1766, +affected those forty men only, who had slept on shore on the island of +Joanna twenty days before. Had the whole crew been on shore, the disease +would probably have affected them all, and been ascribed to contagion +generated by the first persons who were confined by it[45]. A Danish +ship, in the year 1768, sent twelve of her crew on shore for water. They +were all seized after their return to the ship with malignant fever, and +died without infecting any person on board, and from the same causes +which preserved the crew of the Nottingham Indiaman[46]. + + [45] Observations on the Bilious Fevers usual in voyages to the + East-Indies, by James Badinach, M. D. Medical Observations and + Inquiries, vol. iv. + + [46] Clarke on the Diseases of Long Voyages to Hot Climates, p. 123, + 125. + +2. We learn the reason why the disease sometimes spreads through a whole +ship's crew, apparently from one or more affected persons. It is either +because they have been confined to small and close berths by bad weather, +or because the fever has been protracted to a typhus or chronic state, or +because the bodies of the whole crew are impregnated with morbid +miasmata, and thus predisposed to have the disease excited in the manner +that has been mentioned. In the last way it was excited in most of the +crew of the United States frigate, in the Delaware, opposite to the city +of Philadelphia, in the year 1797. It appears to have spread, from a +similar cause, from a few sailors, on board the Grenville Indiaman, after +touching at Batavia. The whole crew had been predisposed to the disease +by inhaling the noxious air of that island. + +The same reasons account for the fever expiring in a healthy village or +country; also for its spreading when carried to those towns which are +seated upon creeks or rivers, and in the neighbourhood of marsh +exhalations. It has uniformly perished in the high and healthy village of +Germantown, when carried from Philadelphia, and has three times appeared +to be contagious near the muddy shores of the creeks which flow through +Wilmington and Chester. + +3. From the facts that have been mentioned, we are taught to disbelieve +the possibility of the disease being imported in the masts and sails of a +ship, by a contagious matter secreted by a sailor who may have sickened +or died on board her, on a passage from a West-India island. The death in +most of the cases supposed to be imported, in this way, occurs within a +few days after the ship leaves her West-India port, or within a few days +after her arrival. In the former case, the disease is derived from +West-India miasmata; in the latter, it is derived, as was before +remarked, either from the foul air of the hold of the ship, or of the +dock or wharf to which the ship is moored. + +Many other facts might be adduced to show the yellow fever not to be an +imported disease. It has often prevailed among the Indians remote from +the sea coast, and many hundred cases of it have occurred, since the year +1793, on the inland waters of the United States, from the Hudson and +Susquehannah, to the rivers of the Mississippi. In South-America, Baron +Humboldt assured me, it is every where believed to be an endemic of that +country. + +These simple and connected facts, in which all the physicians in the +United States who derive the yellow fever from domestic causes have +agreed, will receive fresh support by comparing them with the different +and contrary opinions of the physicians who maintain its importation. +Some of them have asserted it to be a specific disease, and derived it +from the East and West-Indies; others derive it from Beulam, on the coast +of Africa; a third sect have called it a ship fever; a fourth have +ascribed it to a mixture of imported contagion with the foul air of our +cities; while a fifth, who believed it to be imported in 1793, have +supposed it to be the offspring of a contagion left by the disease of +that year, revived by the heat of our summers, and disseminated, ever +since, through the different cities of our country. The number of these +opinions, clearly proves, that no one of them is tenable. + +A belief in the non-contagion of the yellow fever, or of its being +incommunicable except in one of the five ways that have been mentioned, +is calculated to produce the following good effects: + +1. It will deliver the states which have sea-ports from four-fifths of +the expences of their present quarantine laws and lazarettoes. A very +small apparatus, in laws and officers, would be sufficient to prevent the +landing of persons affected by the ship fever in our cities, and the more +dangerous practice, of ships pouring streams of pestilential air, from +their holds, upon the citizens who live near our docks and wharves. + +2. It will deliver our merchants from the losses incurred by the delays +of their ships, by long and unnecessary quarantines. It will, moreover, +tend to procure the immediate admission of our ships into foreign ports, +by removing that belief in the contagious nature of the yellow fever, +which originated in our country, and which has been spread, by the public +acts of our legislatures and boards of health, throughout the globe. + +3. It will deliver our citizens from the danger to which they are +exposed, by spending the time of the quarantine, on board of vessels in +the neighbourhood of the marshes, which form the shores of the rivers or +coasts of quarantine roads. This danger is much increased by idleness, +and by the vexation which is excited, by sailors and passengers being +detained, unnecessarily, fifteen or twenty days from their business and +friends. + +4. It will lead us to a speedy removal of all the excretions, and a +constant ventilation of the rooms of patients in the yellow fever, and +thereby to prevent the accumulation, and further putrefaction of those +exhalations which may reproduce it. + +5. It is calculated to prevent the desertion of patients in the yellow +fever, by their friends and families, and to produce caution in them to +prevent the excitement of the disease in their own bodies, by means of +low diet and gentle physic, proportioned to the impurity of the air, and +to the anxiety and fatigue to which they are exposed in attending the +sick. + +6. It will put an end to the cruel practice of quieting the groundless +fears of a whole neighbourhood, by removing the poor who are affected by +the fever, from their houses, and conveying them, half dead with disease +and terror, to a solitary or crowded hospital, or of nailing a yellow +flag upon the doors of others, or of fixing a guard before them, both of +which have been practised in Philadelphia, not only without any good +effect, but to the great injury of the sick. + +7. By deriving the fever from our own climate and atmosphere, we shall be +able to foresee its approach in the increased violence of common +diseases, in the morbid state of vegetation, in the course of the winds, +in the diseases of certain brute animals, and in the increase of common, +or the appearance of uncommon insects. + +8. A belief in the non-contagion of the yellow fever, and its general +prevalence from putrid animal and vegetable matters _only_, is calculated +to lead us to drain or cover marshy grounds, and to remove from our +cities all the sources of impure air, whether they exist in the holds of +ships, in docks, gutters, and common sewers, or in privies, gardens, +yards, and cellars, more especially during the existence of the signs of +a malignant constitution of the air. A fever, the same in its causes, and +similar to it in many of its symptoms, that is, the plague, has been +extirpated, by extraordinary degrees of cleanliness, from the cities of +Holland, Great-Britain, and several other parts of Europe. + +The reader will perceive, from these facts and reasonings, that I have +relinquished the opinion published in my account of the yellow fever in +the years 1793, 1794, and 1797, respecting its contagious nature. I was +misled by Dr. Lining, and several West-India writers, in ascribing a much +greater extent to the excreted matters in producing the disease, than I +have since discovered to be correct, and by Bianchi, Lind, Clark, and +Cleghorn, in admitting even the common bilious fever to be contagious. +The reader will perceive, likewise, that I have changed my opinion +respecting one of the modes in which the plague is propagated. I once +believed, upon the authorities of travellers, physicians, and schools of +medicine, that it was a highly contagious disease. I am now satisfied +this is not the case; but, from the greater number of people who are +depressed and debilitated by poverty and famine, and who live in small +and filthy huts[47] in the cities of the east, than in the cities of the +United States, I still believe it to be more frequently communicated from +an intercourse with sick people by the morbid excretions of the body, +than the yellow fever is in our country. For the change of my opinion +upon this subject, I am indebted to Dr. Caldwell's and Mr. Webster's +publications upon pestilential diseases, and to the travels of Mariti and +Sonnini into Syria and Egypt. I reject, of course, with the contagious +quality of the plague, the idea of its ever being imported into any +country so as to become epidemic, by means of a knife-case, a piece of +cotton, or a bale of silks, with the same decision that I do all the +improbable and contradictory reports of an epidemic yellow fever being +imported in a sailor's jacket, or in the timbers and sails of a ship that +had been washed by the salt water, and fanned by the pure air of the +ocean, for several weeks, on her passage from the West-Indies to the +United States. + + [47] M. Savary, in his Travels, says, two hundred persons live in Cairo + within a compass that accommodates but thirty persons in Paris. + +It gives me pleasure to find this unpopular opinion of the non-contagion +of the plague is not a new one. It was held by the Faculty of Medicine in +Paris, in the beginning of the eighteenth century, and it has since been +defended by Dr. Stoll, of Vienna, Dr. Samoilowitz, of Russia, and several +other eminent physicians. Dr. Herberden has lately called in question the +truth of all the stories that are upon record of the plague having been +imported into England in the last century, and the researches of Sir +Robert Wilson of the British army, and of Assellini, and several other +French physicians, have produced the most satisfactory proofs of its not +being a contagious disease in its native country. A discovery more +pregnant with blessings to mankind has seldom been made. Pyramids of +error, the works of successive ages and nations, must fall before it, and +rivers of tears must be dried up by it. It is impossible fully to +appreciate the immense benefits which await this mighty achievement of +our science upon the affairs of the globe. Large cities shall no longer +be the hot-beds of disease and death. Marshy grounds, teeming with +pestilential exhalations, shall become the healthy abodes of men. A +powerful source of repulsion between nations shall be removed, and +commerce shall shake off the fetters which have been imposed upon it by +expensive and vexatious quarantines. A red or a yellow eye shall no +longer be the signal to desert a friend or a brother to perish alone in a +garret or a barn, nor to expel the stranger from our houses, to seek an +asylum in a public hospital, to avoid dying in the street. The number of +diseases shall be lessened, and the most mortal of them shall be struck +out of the list of human evils. To accelerate these events, it is +incumbent upon the physicians of the United States to second the +discoveries of their European brethren. It becomes them constantly to +recollect, that we are the centinels of the health and lives of our +fellow-citizens, and that there is a grade of benevolence in our +profession much higher than that which arises from the cure of diseases. +It consists in exterminating their causes. + + + + + A DEFENCE + + OF + + _BLOOD-LETTING_, + + AS A + + REMEDY FOR CERTAIN DISEASES. + + +Blood-letting, as a remedy for fevers, and certain other diseases, having +lately been the subject of much discussion, and many objections having +been made to it, which appear to be founded in error and fear, I have +considered that a defence of it, by removing those objections, might +render it more generally useful, in every part of the United States. + +I shall begin this subject by remarking, that blood-letting is indicated, +in fevers of great morbid excitement, + +1. By the sudden suppression or diminution of the natural discharges by +the pores, bowels, and kidneys, whereby a plethora is induced in the +system. + +2. By the habits of the persons who are most subject to such fevers. + +3. By the theory of fever. I have attempted to prove that the higher +grades of fever depend upon morbid and excessive action in the +blood-vessels. It is connected, of course, with preternatural sensibility +in their muscular fibres. The blood is the most powerful irritant which +acts upon them. By abstracting a part of it, we lessen the principal +cause of the fever. The effect of blood-letting is as immediate and +natural in removing fever, as the abstraction of a particle of sand is, +to cure an inflammation of the eye, when it arises from that cause. + +4. By the symptoms of the first stage of violent fevers, such as a +sleepiness and an oppressed pulse, or by delirium, with a throbbing +pulse, and great pains in every part of the body. + +5. By the rupture of the blood-vessels, which takes place from the +quantity or impetus of the blood in fevers of great morbid action. Let no +one call bleeding a cruel or unnatural remedy. It is one of the specifics +of nature; but in the use of it she seldom affords much relief. She +frequently pours the stimulating and oppressing mass of blood into the +lungs and brain; and when she finds an outlet for it through the nose, it +is discharged either in such a deficient or excessive quantity, as to be +useless or hurtful. By artificial blood-letting, we can choose the _time_ +and _place_ of drawing blood, and we may regulate its quantity by the +degrees of action in the blood-vessels. The disposition of nature to cure +violent morbid action by depletion, is further manifested by her +substituting, in the room of blood-letting, large, but less safe and less +beneficial, evacuations from the stomach and bowels. + +6. By the relief which is obtained in fevers of violent action by +remedies of less efficacy (to be mentioned hereafter), which act +indirectly in reducing the force of the sanguiferous system. + +7. By the immense advantages which have attended the use of blood-letting +in violent fevers, when used at a proper time, and in a quantity suited +to the force of the disease. I shall briefly enumerate these advantages. + +1. It frequently strangles a fever, when used in its forming state, and +thereby saves much pain, time, and expence to a patient. + +2. It imparts strength to the body, by removing the depression which is +induced by the remote cause of the fever. It moreover obviates a +disposition to faint, which arises from this state of the system. + +3. It reduces the uncommon frequency of the pulse. The loss of ten ounces +of blood reduced Miss Sally Eyre's pulse from 176 strokes to 140, in a +few minutes, in the fever of the year 1794. Dr. Gordon mentions many +similar instances of its reducing the frequency of the pulse, in the +puerperile fever. + +4. It renders the pulse more frequent when it is preternaturally slow. + +5. It checks the nausea and vomiting, which attend the malignant state of +fever. Of this I saw many instances in the year 1794. Dr. Poissonnier +Desperrieres confirms this remark, in his Account of the Fevers of St. +Domingo; and adds further, that it prevents, when sufficiently copious, +the troublesome vomiting which often occurs on the fifth day of the +yellow fever[48]. It has the same effect in preventing the diarrh[oe]a in +the measles. + + [48] Traite des Fievres de l'Isle de St. Domingue, vol. ii. p. 76. + +6. It renders the bowels, when costive, more easily moved by purging +physic. + +7. It renders the action of mercury more speedy and more certain, in +exciting a salivation. + +8. It disposes the body to sweat spontaneously, or renders diluting and +diaphoretic medicines more effectual for that purpose. + +9. It _suddenly_ removes a dryness, and _gradually_ a blackness, from the +tongue. Of the former effect of bleeding, I saw two instances, and of the +latter, one, during the autumn of 1794. + +10. It removes or lessens pain in every part of the body, and more +especially in the head. + +11. It removes or lessens the burning heat of the skin, and the burning +heat in the stomach, so common and so distressing in the yellow fever. + +12. It removes a constant chilliness, which sometimes continues for +several days, and which will neither yield to cordial drinks, nor warm +bed-clothes. + +13. It checks such sweats as are profuse without affording relief, and +renders such as are partial and moderate, universal and salutary. + +14. It sometimes checks a diarrh[oe]a and tenesmus, after astringent +medicines have been given to no purpose. This has often been observed in +the measles. + +15. It suddenly cures the intolerance of light which accompanies many of +the inflammatory states of fever. + +16. It removes coma. Mr. Henry Clymer was suddenly relieved of this +alarming symptom, in the fever of 1794, by the loss of twelve ounces of +blood. + +17. It induces sleep. This effect of bleeding is so uniform, that it +obtained, in the year 1794, the name of an anodyne in several families. +Sleep sometimes stole upon the patient while the blood was flowing. + +18. It prevents effusions of serum and blood. Hæmorrhages seldom occur, +where bleeding has been sufficiently copious. + +19. It belongs to this remedy to prevent the chronic diseases of cough, +consumption, jaundice, abscess in the liver, and all the different states +of dropsy which so often follow autumnal fevers. + +My amiable friend, Mrs. Lenox, furnished an exception to this remark, in +the year 1794. After having been cured of the yellow fever by seven +bleedings, she was affected, in consequence of taking a ride, with a +slight return of fever, accompanied by an acute pain in the head, and +some of the symptoms of a dropsy of the brain. As her pulse was tense and +quick, I advised repeated bleedings to remove it. This prescription, for +reasons which it is unnecessary to relate, was not followed at the time, +or in the manner, in which it was recommended. The pain, in the mean +time, became more alarming. In this situation, two physicians were +proposed by her friends to consult with me. I objected to them both, +because I knew their principles and modes of practice to be contrary to +mine, and that they were proposed only with a view of wresting the lancet +from my hand. From this desire of avoiding a controversy with my +brethren, where conviction was impossible on either side, as well as to +obviate all cause of complaint by my patient's friends, I offered to take +my leave of her, and to resign her wholly to the care of the two +gentlemen who were proposed to attend her with me. To this she objected +in a decided manner. But that I might not be suspected of an undue +reliance upon my own judgment, I proposed to call upon Dr. Griffitts or +Dr. Physick to assist me in my attendance upon her. Both these physicians +had renounced the prejudices of the schools in which they had been +educated, and had conformed their principles and practice to the present +improving state of medical science. My patient preferred Dr. Griffitts, +who, in his first visit to her, as soon as he felt her pulse, proposed +more bleeding. The operation was performed by the doctor himself, and +repeated daily for five days afterwards. From an apprehension that the +disease was so fixed as to require some aid to blood-letting, we gave her +calomel in such large doses as to excite a salivation. By the use of +these remedies she recovered slowly, but so perfectly as to enjoy her +usual health. + +20. Bleeding prevents the termination of malignant, in the gangrenous +state of fever. This effect of blood-letting will enable us to understand +some things in the writings of Dr. Morton and Dr. Sydenham, which at +first sight appear to be unintelligible. Dr. Morton describes what he +calls a putrid fever, which was epidemic and fatal, in the year 1678. Dr. +Sydenham, who practised in London at the same time, takes no notice of +this fever. The reason of his silence is obvious. By copious bleeding, he +prevented the fever of that year from running on to the gangrenous state, +while Dr. Morton, by neglecting to bleed, created the supposed putrid +fevers which he has described. + +It has been common to charge the friends of blood-letting with _temerity_ +in their practice. From this view which has been given of it, it appears, +that it would be more proper to ascribe _timidity_ to them, for they +bleed to prevent the offensive and distressing consequences of neglecting +it, which have been mentioned. + +21. It cures, without permitting a fever to put on those alarming +symptoms, which excite constant apprehensions of danger and death, in the +minds of patients and their friends. It is because these alarming +symptoms are prevented, by bleeding, that patients are sometimes +unwilling to believe they have been cured by it, of a malignant fever. +Thus, the Syrian leper of old, viewed the water of Jordan as too simple +and too common to cure a formidable disease, without recollecting that +the remedies for the greatest evils of life are all simple, and within +the power of the greatest part of mankind. + +22. It prepares the way for the successful use of the bark and other +tonic remedies, by destroying, or so far weakening, a morbid action in +the blood-vessels, that a medicine of a moderate stimulus afterwards +exceeds it in force, and thereby restores equable and healthy action to +the system. + +23. Bleeding prevents relapses. It, moreover, prevents that +predisposition to the intermitting and pleuritic states of fever, which +so frequently attack persons in the spring, who have had the bilious +remitting fever in the preceding autumn. + +But great and numerous as the advantages of blood-letting are in fevers, +there have been many objections to it. I shall briefly enumerate, and +endeavour to refute the errors upon this subject. + +Blood-letting has been forbidden by physicians, by the following +circumstances, and states of the system. + +1. By warm weather. Galen bled in a plague, and Aræteus in a bilious +fever, in a warm climate. Dr. Sydenham and Dr. Hillary inform us, that +the most inflammatory fevers occur in, and succeed hot weather. Dr. +Cleghorn prescribed it copiously in the warm months, in Minorca. Dr. +Mosely cured the yellow fever by this remedy, in Jamaica. Dr. Broadbelt, +and Dr. Weston, in the same island, have lately adopted his successful +practice. Dr. Desportes speaks in the highest terms of it in all the +inflammatory diseases of St. Domingo. He complains of the neglect of it +in the rheumatism, in consequence of which, he says, the disease produces +abscesses in the lungs[49]. I have never, in any year of my practice, +been restrained by the heat of summer in the use of the lancet, where the +pulse has indicated it to be necessary, and have always found the same +advantages from it, as when I have prescribed it in the winter or spring +months. + + [49] Page 35. + +In thus deciding in favour of bleeding in warm weather, I do not mean to +defend its use to the same extent, as to diseases, or to quantity, in the +native and long settled inhabitants of hot climates, as in persons who +have recently migrated to them, or who live in climates alternately hot +and cold. + +2. Being born, and having lived in a warm climate. This is so far from +being an objection to blood-letting in an inflammatory disease, that it +renders it more necessary. I think I have lost several West-India +patients from the influence of this error. + +3. Great apparent weakness. This, in acute and violent fevers, is always +from a depressed state of the system. It resembles, in so many +particulars, that weakness which is the effect of the abstraction of +stimulus, that it is no wonder they have been confounded by physicians. +This sameness of symptoms from opposite states of the system is taken +notice of by Hippocrates. He describes convulsions, and particularly a +hiccup, as occurring equally from repletion and inanition, which answer +to the terms of depression, and debility from action and abstraction. The +natural remedy for the former is depletion, and no mode of depleting is +so effectual or safe as blood-letting. But the great objection to this +remedy is, when a fever of great morbid excitement affects persons of +delicate constitutions, and such as have long been subject to debility of +the chronic kind. In this state of the system there is the same morbid +and preternatural action in the blood-vessels, that there is in persons +of robust habits, and the same remedy is necessary to subdue it in both +cases. It is sometimes indicated in a larger quantity in weakly than in +robust people, by the plethora which is more easily induced in their +relaxed and yielding blood-vessels, and by the greater facility with +which ruptures and effusions take place in their viscera. Thus it is more +necessary to throw overboard a large part of the cargo of an old and +leaky vessel in a storm, than of a new and strong one. I know that +vomits, purges, sweats, and other evacuating remedies, are preferred to +bleeding in weakly constitutions, but I hope to show hereafter, that +bleeding is not only more effectual, but more safe in such habits, than +any other depleting remedy. + +4. Infancy and childhood. This is so far from being an objection to +bleeding, that the excitable state of the blood-vessels in those periods +of life, renders it peculiarly necessary in their inflammatory diseases. +Dr. Sydenham bled children in the hooping cough, and in dentition. I have +followed his practice, and bled as freely in the violent states of fever +in infancy as in middle life. I bled my eldest daughter when she was but +six weeks old, for convulsions brought on by an excessive dose of +laudanum given to her by her nurse; and I bled one of my sons twice, +before he was two months old, for an acute fever which fell upon his +lungs and bowels. In both cases, life appeared to be saved by this +remedy. + +5. Old age. The increase of appetite in old people, their inability to +use sufficient exercise, whereby their blood-vessels become relaxed, +plethoric, and excitable, and above all, the translation of the strength +of the muscles to the arteries, and of plethora to the veins, all +indicate bleeding to be more necessary (in equal circumstances) in old, +than in middle aged people. My practice in the diseases of old people has +long been regulated by the above facts. I bled Mrs. Fullarton twice in a +pleurisy in January, 1804, in the 84th year of her age, and thereby cured +her disease. I am not the author of this practice. Botallus left a +testimony in favour of it nearly 200 years ago[50], and it has since been +confirmed by the experience of Hoffman, and many other physicians. An +ignorance of, or inattention to this change in the state of the +blood-vessels, in persons in the decline of life, and the neglect of the +only remedy indicated by it, is probably the reason why diseases often +prove fatal to them, which in early or middle life cured themselves, or +yielded to a single dose of physic, or a few ounces of bark. + + [50] Magis esse adjuvandos senes, missione sanguinis dum morbus + postulat, aut corpus eorum habitus malus est, quam ubi hæc (quod + absonum videbitur) juvenibus contingunt. + De Cur. per Sang. missionem, cap. 11. § 11. + +6. The time of menstruation. The uterus, during this period, is in an +inflamed state, and the whole system is plethoric and excitable, and of +course disposed to a violent degree of fever, from all the causes which +excite it. Bleeding, therefore, is more indicated, in fever of great +morbid action, at this time, than at any other. Formerly the natural +discharge from the uterus was trusted to, to remove a fever contracted +during the time of menstruation; but what relief can the discharge of +four or five ounces of blood from the uterus afford, in a fever which +requires the loss of 50, or perhaps of 100 ounces to cure it? + +7. Pregnancy. The inflammation and distention induced upon the uterus +directly, and indirectly upon the whole system by pregnancy, render +bleeding, in the acute states of fever, more necessary than at other +times. I have elsewhere mentioned the advantages of bleeding pregnant +women, in the yellow fever. I did not learn the advantages of the +practice in that disease. I bled Mrs. Philler 11 times in seven days, in +a pleurisy during her pregnancy, in the month of March, 1783. Mrs. Fiss +was bled 13 times in the spring of 1783; and Mrs. Kirby 16 times in the +same condition, by my orders, in the winter of 1786, in a similar +disease. All these women recovered, and the children they carried during +their illness, are at this time alive, and in good health. + +8. Fainting after bleeding. This symptom is accidental in many people. No +inference can be drawn from it against blood-letting. It often occurs +after the first and second bleedings in a fever, but in no subsequent +bleeding, though it be repeated a dozen times. Of this I saw several +instances, in the yellow fever of 1794. The pulse, during the fainting, +is often tense and full. + +9. Coldness of the extremities, and of the whole body. This cold state of +fever when it occurs early, yields more readily to bleeding, than to the +most cordial medicines. + +10. Sweats are supposed to forbid blood-letting. I have seen two +instances of death, from leaving a paroxysm of malignant fever to +terminate itself by sweating. Dr. Sydenham has taught a contrary practice +in the following case. "While this constitution (says the doctor) +prevailed, I was called to Dr. Morice, who then practised in London. He +had this fever, attended with profuse sweats, and numerous petechiæ. By +the consent of some other physicians, our joint friends, he was blooded, +and rose from his bed, his body being first wiped dry. He found +immediate relief from the use of a cooling diet and medicines, the +dangerous symptoms soon going off; and by continuing this method he +recovered in a few days[51]." In the same fever, the doctor adds further, +"For though one might expect great advantages in pursuing an indication +taken from what generally proves serviceable (viz. sweating), yet I have +found, by constant experience, that the patient not only finds no relief, +but, contrariwise, is more heated thereby; so that frequently a delirium, +petechiæ, and other very dangerous symptoms immediately succeed such +_sweats_[52]." + + [51] Wallis's edition, vol. i. p. 210. + + [52] Vol. i. p. 208. + +Morgagni describes a malignant fever which prevailed in Italy, in which +the patients died in profuse sweats, while their physicians were looking +for a crisis from them. Bleeding would probably have checked these +sweats, and cured the fever. + +11. Dissolved blood, and an absence of an inflammatory crust on its +crassamentum. I shall hereafter place dissolved blood at the highest +point of a scale, which is intended to mark the different degrees of +morbid action in the system. I have mentioned, in the Outlines of a +Theory of Fever, that it is the effect of a tendency to a palsy, induced +by the violent force of impression upon the blood-vessels. This +appearance of the blood in certain states of fever, instead of forbidding +bleeding, is the most vehement call of the system for it. Nor is the +absence of a crust on the crassamentum of the blood, a proof of the +absence of great morbid diathesis, or a signal to lay aside the lancet. +On the contrary, I shall show hereafter, that there are several +appearances of the blood which indicate more morbid action in the +blood-vessels than a sizy or inflammatory crust. + +12. An undue proportion of serum to crassamentum in the blood. This +predominance of water in the blood has often checked sufficient +blood-letting. But it should be constantly disregarded while it is +attended with those states of pulse (to be mentioned hereafter) which +require bleeding. + +14. The presence of petechiæ on the skin. These, I have elsewhere said, +are the effects of the gangrenous state of fever. Dr. Sydenham and Dr. de +Haen have taught the safety and advantage of bleeding, when these spots +are accompanied by an active pulse. A boy of Mr. John Carrol owes his +recovery from the small-pox to the loss of fifty ounces of blood, by five +bleedings, at a time when nearly every pock on his arms and legs had a +purple appearance. Louis XIV was bled five times in the small-pox, when +he was but thirteen years of age, and thereby probably saved from the +grave, to the great honour and emolument of the single physician who +urged it against the advice of all the other physicians of the court. Dr. +Cleghorn mentions a single case of the success of bleeding in the +petechial small-pox. His want of equal success afterwards, in similar +cases, was probably occasioned by his bleeding too sparingly, that is, +but three or four times. + +Abscesses and sore breasts, which accompany or succeed fever, are no +objections to blood-letting, provided the pulse indicate the continuance +of inflammatory diathesis. They depend frequently upon the same state of +the system as livid effusions on the skin. + +14. The long duration of fever. Inflammatory diathesis is often +protracted for many weeks, in the chronic state of fever. It, moreover, +frequently revives after having disappeared, from an accidental irritant +affecting some part of the body, particularly the lungs and brain. I bled +a young man of James Cameron, in the autumn of 1794, four times between +the 20th and 30th days of a chronic fever, in consequence of a pain in +the side, accompanied by a tense pulse, which suddenly came on after the +20th day of his disease. His blood was sizy. His pain and tense pulse +were subdued by the bleeding, and he recovered. I bled the late Dr. Prowl +twelve times, in a fever which continued thirty days, in the autumn of +the year 1800. I wish these cases to be attended to by young +practitioners. The pulmonary consumption is often the effect of a chronic +fever, terminating with fresh inflammatory symptoms, by effusions in the +lungs. It may easily be prevented by forgetting the number of the days of +our patient's fever, and treating the pulmonary affection as if it were a +recent complaint. + +15. Tremors and slight convulsions in the limbs. Bark, wine, laudanum, +and musk are generally prescribed to remove these symptoms; but, to be +effectual, they should, in most cases, be preceded by the loss of a few +ounces of blood. + +16. Bleeding is forbidden after the fifth or seventh day in a pleurisy. +This prohibition was introduced into medicine at a time when a fear was +entertained of arresting the progress of nature in preparing and +expelling morbific matter from the system. From repeated experience I can +assert, that bleeding is safe in every stage of pleurisy in which there +is pain, and a tense and oppressed pulse; and that it has, when used for +the first time after the fifth and seventh days, saved many lives. +Bleeding has likewise been limited to a certain number of ounces in +several states of fever. Were the force of the remote cause of a fever, +its degrees of violence, and the habits of the subject of it, always the +same, this rule would be a proper one; but, this not being the case, we +must be governed wholly by the condition of the system, manifested +chiefly by the state of the pulse. To admit of copious bleeding in one +state of fever, and not in another, under equal circumstances of morbid +excitement, is to prescribe for its name, and to forget the changes which +climate, season, and previous habits create in all its different states. + +17. The loss of a sufficient quantity of blood is often prevented by +patients being apparently _worse_, after the first or second bleeding. +This change for the worse, shows itself in some one or more of the +following symptoms, viz. increase of heat, chills, delirium, hæmorrhages, +convulsions, nausea, vomiting, faintness, coma, great weakness, pain, a +tense, after a soft pulse, and a reduction of it in force and frequency. +They are all occasioned by the system rising suddenly from a state of +extreme depression, in consequence of the abstraction of the pressure of +the blood to a state of vigour and activity, so great, in some instances, +as to reproduce a depression below what existed in the system before a +vein was opened; or it is occasioned by a translation of morbid action +from one part of the body to another. + +The chills which follow bleeding are the effects of a change in the +fever, from an uncommon to a common state of malignity. They occur +chiefly in those violent cases of fever which come on without a chilly +fit. + +The hæmorrhages produced by bleeding are chiefly from the nose, +hæmorrhoidal vessels, or uterus, and of course are, for the most part, +safe. + +Uncommon weakness, succeeding blood-letting, is the effect of sudden +depression induced upon the whole system, by the cause before-mentioned, +or of a sudden translation of the excitement of the muscles into the +blood-vessels, or some other part of the body. These symptoms, together +with all the others which have been mentioned, are so far from +forbidding, that they all most forcibly indicate a repetition of +blood-letting. + +I shall briefly illustrate, by the recital of three cases, the good +effects of bleeding, in removing pain, and the preternatural slowness and +weakness of the pulse, when produced by the use of that remedy. + +In the month of June of 1795, I visited Dr. Say in a malignant fever, +attended with pleuritic symptoms, in consultation with Dr. Physick. An +acute pain in his head followed six successive bleedings. After a seventh +bleeding, he had no pain. His fever soon afterwards left him. In thus +persevering in the use of a remedy, which, for several days, appeared to +do harm, we were guided wholly by the state of his pulse, which uniformly +indicated, by its force, the necessity of more bleeding. + +In the autumn of 1794, I was sent for to visit Samuel Bradford, a young +man of about 20 years of age, son of Mr. Thomas Bradford, who was ill +with the reigning malignant epidemic. His pulse was at 80. I drew about +12 ounces of blood from him. Immediately after his arm was tied up, his +pulse fell to 60 strokes in a minute. I bled him a second time, but more +plentifully than before, and thereby, in a few minutes, brought his pulse +back again to 80 strokes in a minute. A third bleeding the next day, +aided by the usual purging physic, cured him in a few days. + +In the month of March, 1795, Dr. Physick requested me to visit, with him, +Mrs. Fries, the wife of Mr. John Fries, in a malignant fever. He had bled +her four times. After the fourth bleeding, her pulse suddenly fell, so as +scarcely to be perceptible. I found her hands and feet cold, and her +countenance ghastly, as if she were in the last moments of life. In this +alarming situation, I suggested nothing to Dr. Physick but to follow his +judgment, for I knew that he was master of that law of the animal economy +which resolved all her symptoms into an oppressed state of the system. +The doctor decided in a moment in favour of more bleeding. During the +flowing of the blood, the pulse rose. At the end of three, ten, and +seventeen hours it fell, and rose again by three successive bleedings, in +all of which she lost about thirty ounces of _sizy_ blood. So great was +the vigour acquired by the pulse, a few days after the paroxysms of +depression, which have been described, were relieved, that it required +seven more bleedings to subdue it. I wish the history of these two cases +to be carefully attended to by the reader. I have been thus minute in the +detail of them, chiefly because I have heard of practitioners who have +lost patients by attempting to raise a pulse that had been depressed by +bleeding, in a malignant fever, by means of cordial medicines, instead of +the repeated use of the lancet. The practice is strictly rational; for, +in proportion as the blood-vessels are weakened by pressure, the quantity +of blood to be moved should be proportioned to the diminution of their +strength. + +This depressed state of the pulse, whether induced by a paroxysm of +fever, or by blood-letting, is sometimes attended with a strong pulsation +of the arteries in the bowels and head. + +I have mentioned, among the _apparent_ bad effects of bleeding, that it +sometimes changes a soft into a tense pulse. Of this I saw a remarkable +instance in Captain John Barry, in the autumn of 1795. After the loss of +130 ounces of blood in a malignant yellow fever, his pulse became so soft +as to indicate no more bleeding. In this situation he remained for three +days, but without mending as rapidly as I expected from the state of his +pulse. On the fourth day he had a hæmorrhage from his bowels, from which +he lost above a pint of blood. His pulse now suddenly became tense, and +continued so for two or three days. I ascribed this change in his pulse +to the vessels of the bowels, which had been oppressed by congestion, +being so much relieved by the hæmorrhage, as to resume an inflammatory +action. I have observed a similar change to take place in the pulse, +after a third bleeding, in a case of hæmorrhoidal fever, which came under +my notice in the month of January, 1803. It is thus we see the +blood-vessels, in a common phlegmon, travel back again, from a tendency +to mortification, to the red colour and pain of common inflammation. + +From a review of the commotions excited in the system by bleeding, a +reason may be given why the physicians, who do not bleed in the depressed +state of the pulse, have so few patients in what they call malignant +fevers, compared with those who use a contrary practice. The disease, in +such cases, being locked up, is not permitted to unfold its true +character; and hence patients are said to die of apoplexy, lethargy, +cholera, dysentery, or nervous fever, who, under a different treatment, +would have exhibited all the marks of an ordinary malignant fever. + +In obviating the objections to blood-letting from its apparent evils, I +have said nothing of the apparent bad effects of other remedies. A nausea +is often rendered worse by an emetic, and pains in the bowels are +increased by a purge. But these remedies notwithstanding maintain, and +justly too, a high character among physicians. + +19. Bleeding has been accused of bringing on a nervous, or the chronic +state of fever. The use of this remedy, in a degree so moderate as to +obviate the putrid or gangrenous state of fever only, may induce the +chronic state of fever; for it is the effect, in this case, of the +remains of inflammatory diathesis in the blood-vessels; but when blood is +drawn proportioned to the morbid action in the system, it is impossible +for a chronic fever to be produced by it. Even the excessive use of +blood-letting, however injurious it may be in other respects, cannot +produce a chronic fever, for it destroys morbid action altogether in the +blood-vessels. + +20. Bleeding has been charged with being a weakening remedy. I grant that +it is so, and in this, its merit chiefly consists. The excessive morbid +action of the blood-vessels must be subdued in part, in a fever, before +stimulating remedies can be given with safety or advantage. Now this is +usually attempted by depleting medicines, to be mentioned hereafter, or +it is left to time and nature, all of which are frequently either +deficient, or excessive in their operations; whereas bleeding, by +suddenly reducing the morbid action of the blood-vessels to a wished-for +point of debility, saves a great and unnecessary waste of excitability, +and thus prepares the body for the exhibition of such cordial remedies as +are proper to remove the debility which predisposed to the fever. + +21. It has been said that bleeding renders the habitual use of it +necessary to health and life. This objection to blood-letting is founded +upon an ignorance of the difference between the healthy, and morbid +action of the blood-vessels. Where blood is drawn in health, such a +relaxation is induced in the blood-vessels, as to favour the formation of +plethora, which may require habitual bleeding to remove it; but where +blood is drawn only in the inflammatory state of fever, the blood-vessels +are reduced from a morbid degree of strength to that which is natural, in +which state no predisposition to plethora is created, and no foundation +laid for periodical blood-letting. But there are cases which require even +this evil, to prevent a greater. Thus we cure a strangulated hernia, when +no fever attends, by the most profuse bleeding. The plethora and +predisposition to disease which follow it are trifling, compared with +preventing certain and sudden death. + +22. Bleeding has been accused of bringing on an intermitting fever. This +is so far from being an objection to it, that it should be considered as +a new argument in its favour; for when it produces that state of fever, +it converts a latent, and perhaps a dangerous disease, into one that is +obvious to the senses, and under the dominion of medicine. Nor is it an +objection to blood-letting, that, when used in an inflammatory +intermittent, it sometimes changes it into a continual fever. An instance +of the good effects of this change occurred in the Pennsylvania hospital, +in an obstinate tertian, in the year 1804. The continual fever, which +followed the loss of blood, was cured in a few days, and by the most +simple remedies. + +23. It has been said that bleeding, more especially where it is copious, +predisposes to effusions of serum in the lungs, chest, bowels, limbs, and +brain. In replying to this objection to bleeding, in my public lectures, +I have addressed my pupils in the following language: "Ask the poor +patients who come panting to the door of our hospital, with swelled legs +and hard bellies, every fall, whether they have been too copiously bled, +and they will all tell you, that no lancet has come near their arms. Ask +the parents who still mourn the loss of children who have died, in our +city, of the internal dropsy of the brain, whether they were destroyed +by excessive blood-letting? If the remembrance of the acute sufferings +which accompanied their sickness and death will permit these parents to +speak, they will tell you, that every medicine, except bleeding, had been +tried to no purpose in their children's diseases. Go to those families in +which I have practised for many years, and inquire, whether there is a +living or a dead instance of dropsy having followed, in any one of them, +the use of my lancet? Let the undertakers and grave-diggers bear witness +against me, if I have ever, in the course of my practice, conveyed the +body of a single dropsical patient into their hands, by excessive +blood-letting? No. Dropsies, like abscesses and gangrenous eruptions upon +the skin, arise, in most cases, from the _want_ of sufficient bleeding in +inflammatory diseases. Debility, whether induced by action or +abstraction, seldom disposes to effusion. Who ever heard of dropsy +succeeding famine? And how rarely do we see it accompany the extreme +debility of old age?" + +"If ever bleeding kills," says Botallus, either directly or indirectly, +through the instrumentality of other diseases, "it is not from its +excess, but because it is not drawn in a sufficient quantity, or at a +proper time[53]." And, again, says this excellent writer, "One hundred +thousand men perish from the want of blood-letting, or from its being +used out of time, to one who perishes from too much bleeding, prescribed +by a physician[54]." + + [53] Cap. viii. § 4. + + [54] Cap. xxxvi. § 4. + +It is remarkable, that the dread of producing a dropsy by bleeding, is +confined chiefly to its use in malignant fevers; for the men who urge +this objection to it, do not hesitate to draw four or five quarts of +blood in the cure of the pleurisy. The habitual association of the lancet +with this disease, has often caused me to rejoice when I have heard a +patient complain of a pain in his side, in a malignant fever. It insured +to me his consent to the frequent use of the lancet, and it protected me, +when it was used unsuccessfully, from the clamours of the public, for few +people censure copious bleeding in a pleurisy. + +24. Against blood-letting it has been urged, that the Indians of our +country cure their inflammatory fevers without it. To relieve myself from +the distressing obloquy to which my use of this remedy formerly exposed +me, I have carefully sought for, and examined their remedies for those +fevers, with a sincere desire to adopt them; but my inquiries have +convinced me, that they are not only disproportioned to the habits and +diseases of civilized life, but that they are far less successful than +blood-letting, in curing the inflammatory fevers which occur among the +Indians themselves. + +25. Evacuating remedies of another kind have been said to be more safe +than bleeding, and equally effectual, in reducing the inflammatory state +of fever. I shall enumerate each of these evacuating remedies, and then +draw a comparative view of their effects with blood-letting. They are, + +I. Vomits. + +II. Purges. + +III. Sweats. + +IV. Salivation. And, + +V. Blisters. + +I. Vomits have often been effectual in curing fevers of a mild character. +They discharge offensive and irritating matters from the stomach; they +lessen the fulness of the blood-vessels, by determining the serum of the +blood through the pores; and they equalize the excitement of the system, +by inviting its excessive degrees from the blood-vessels to the stomach +and muscles. But they are, + +1. Uncertain in their operation, from the torpor induced by the fever +upon the stomach. + +2. They are unsafe in many conditions of the system, as in pregnancy, and +a disposition to apoplexy and ruptures. Life has sometimes been destroyed +by their inducing cramp, hæmorrhage, and inflammation in the stomach. + +3. They are not subject to the controul of a physician, often operating +more, or less than was intended by him, or indicated by the disease. + +4. They are often ineffectual in mild, and always so in fevers of great +morbid action. + +II. Purges are useful in discharging acrid fæces and bile from the bowels +in fevers. They act, moreover, by creating an artificial weak part, and +thus invite morbid excitement from the blood-vessels to the bowels. They +likewise lessen the quantity of blood, by preventing fresh accessions of +chyle being added to it; but like vomits they are, + +1. Uncertain in their operation; and from the same cause. Many ounces of +salts and castor oil, and whole drachms of calomel and jalap, have often +been given, without effect, to remove the costiveness which is connected +with the malignant state of fever. + +2. They are not subject to the direction of a physician, with respect to +the time of their operation, or the quantity or quality of matter they +are intended to discharge from the bowels. + +3. They are unsafe in the advanced stage of fevers. Dr. Physick informed +me, that three patients died in the water-closet, under the operation of +purges, in St. George's hospital, during his attendance upon it. I have +seen death, in several instances, succeed a plentiful spontaneous stool +in debilitated habits. + +III. Sweating was introduced into practice at a time when morbific matter +was supposed to be the proximate cause of fever. It acts, not by +expelling any thing exclusively morbid from the blood, but by +abstracting a portion of its fluid parts, and thus reducing the action of +the blood-vessels. This mode of curing fever is still fashionable in +genteel life. It excites no fear, and offends no sense. The sweating +remedies have been numerous, and fashion has reigned as much among them, +as in other things. Alexipharmic waters, and powders, and all the train +of sudorific medicines, have lately yielded to the different preparations +of antimony, particularly to James's powder. I object to them all, + +1. Because they are uncertain; large and repeated doses of them being +often given to no purpose. + +2. Because they are slow, and disagreeable, where they succeed in curing +fever. + +3. Because, like vomits and purges, they are not under the direction of a +physician, with respect to the quantity of fluid discharged by them. + +4. Because they are sometimes, even when most profuse, ineffectual in the +cure of fever. + +5. The preparations of antimony, lately employed for the purpose of +exciting sweats, are by no means safe. They sometimes convulse the +system by a violent puking. Even the boasted James's powder has done +great mischief. Dr. Goldsmith and Mr. Howard, it is said, were destroyed +by it. + +None of these objections to sweating remedies are intended to dissuade +from their use, when nature shows a disposition to throw off a fever by +the pores of the skin; but, even then, they often require the aid of +bleeding to render them effectual for that purpose. + +IV. Mercury, the Sampson of the materia medica, after having subdued the +venereal disease, the tetanus, and many other formidable diseases, has +lately added to its triumphs and reputation, by overcoming the +inflammatory and malignant state of fever. I shall confine myself, in +this place, to its depleting operation, when it acts by exciting a +salivation. From half a pound to two pounds of fluid are discharged by it +in a day. The depletion in this way is gradual, whereby fainting is +prevented. By exciting and inflaming the glands of the mouth and throat, +excitement and inflammation are abstracted from more vital parts. In +morbid congestion and excitement in the brain, a salivation is of eminent +service, from the proximity of the discharge to the part affected. But I +object to it, as an exclusive evacuant in the cure of fever, + +1. Because it is sometimes impossible, by the largest doses of mercury, +to excite it, when the exigences of the system render it most necessary. + +2. Because it is not so quick in its operation, as to be proportioned to +the rapid progress of the malignant state of fever. + +3. Because it is at all times a disagreeable, and frequently a painful +remedy, more especially where the teeth are decayed. + +4. Because it cannot be proportioned in its duration, or in the quantity +of fluid discharged by it, to the violence or changes in the fever. + +Dr. Chisholm relied, for the cure of the Beullam fever at Grenada, +chiefly upon this evacuation. I have mentioned the ratio of success which +attended it. + +V. Blisters are useful in depleting from those parts which are the seats +of topical inflammation. The relief obtained by them in this way more +than balances their stimulus upon the whole system need hardly say, that +their effects in reducing the morbid and excessive action of the +blood-vessels are very feeble. To depend upon them in cases of great +inflammatory action, is as unwise as it would be to attempt to bale the +water from a leaky and sinking ship by the hollow of the hand, instead of +discharging it by two or three pumps. + +VI. Abstemious diet has sometimes been prescribed as a remedy for fever. +It acts directly by the abstraction of the stimulus of food from the +stomach, and indirectly by lessening the quantity of blood. It can bear +no proportion, in its effects, to the rapidity and violence of an +inflammatory fever. In chronic fever, such as occurs in the pulmonary +consumption, it has often been tried to no purpose. Long before it +reduces the pulse, it often induces such a relaxation of the tone of the +stomach and bowels as to accelerate death. To depend upon it therefore in +the cure of inflammatory fever, whether acute or chronic, is like +trusting to the rays of the sun to exhale the water of an overflowing +tide, instead of draining it off immediately, by digging a hole in the +ground. But there are cases in which the blood-vessels become so +insolated, that they refuse to yield their morbid excitement to depletion +from any outlet, except from themselves. I attended a sailor, in the +Pennsylvania hospital, in 1799, who was affected with deafness, attended +with a full and tense pulse. I prescribed for it, purging, blisters, and +low diet, but without any effect. Perceiving no change in his pulse, nor +in his disease, from those remedies, I ordered him to lose ten ounces of +blood. The relief obtained by this evacuation induced me to repeat it. By +means of six bleedings he was perfectly cured, without the aid of any +other remedy. + +Bleeding has great advantages over every mode of depleting that has been +mentioned. + +1. It abstracts one of the exciting causes, viz. the stimulus of the +blood, from the seat of fever. I have formerly illustrated this advantage +of blood-letting, by comparing it to the abstraction of a grain of sand +from the eye to cure an opthalmia. The other depleting remedies are as +indirect and circuitous in their operation in curing fever, as vomits and +purges would be to remove an inflammation in the eye, while the grain of +sand continued to irritate it. + +2. Blood-letting is quick in its operation, and may be accommodated to +the rapidity of fever, when it manifests itself in apoplexy, palsy, and +syncope. + +3. It is under the command of a physician. He may bleed _when_ and +_where_ he pleases, and may suit the _quantity_ of blood he draws, +exactly to the condition of his patient's system. + +4. It may be performed with the least attendance of nurses or friends. +This is of great importance to the poor at all times, and to the rich +during the prevalence of mortal epidemics. + +5. It disturbs the system much less than any of the other modes of +depleting, and therefore is best accommodated to that state of the +system, in which patients are in danger of fainting or dying upon being +moved. + +6. It is a more delicate depleting remedy than most of those which have +been mentioned, particularly vomits, purges, and a salivation. + +7. There is no immediate danger to life from its use. Patients have +sometimes died under the operation of vomits and purges, but I never saw +nor heard an instance of a patient's dying in a fainty fit, brought on by +bleeding. + +8. It is less weakening, when used to the extent that is necessary to +cure, than the same degrees of vomiting, purging, and sweating. + +9. Convalescence is more rapid and more perfect after bleeding, than +after the successful use of any of the other evacuating remedies. + +By making use of blood-letting in fevers, we are not precluded from the +benefits of the other evacuating remedies. Some of them are rendered more +certain and more effectual by it, and there are cases of fever, in which +the combined or successive application of them all is barely sufficient +to save life. + +To rely upon any one evacuating remedy, to the exclusion of the others, +is like trusting to a pair of oars in a sea voyage, instead of spreading +every sail of a ship. + +I suspect the disputes about the eligibility of the different remedies +which have been mentioned, have arisen from an ignorance that they all +belong to one class, and that they differ only in their force and manner +of operation. Thus the physicians of the last century ascribed different +virtues to salts of different names, which the chemists of the present +day have taught us are exactly the same, and differ only in the manner of +their being prepared. + +Having replied to the principal objections to blood-letting, and stated +its comparative advantages over other modes of depletion, I proceed next +to mention the circumstances which should regulate the use of it. These +are, + +I. The state of the pulse. + +The following states of the pulse indicate the necessity of bleeding. + +1. A full, frequent, and tense pulse, such as occurs in the pulmonary, +rheumatic, gouty, phrenitic, and maniacal states of fever. + +2. A full, frequent, and jerking pulse, without tension, such as +frequently occurs in the vertiginous, paralytic, apoplectic, and hydropic +states of fever. + +3. A small, frequent, but tense pulse, such as occurs in the chronic, +pulmonary, and rheumatic states of fever. + +4. A tense and _quick_ pulse, without much preternatural frequency. This +state of the pulse is common in the yellow fever. + +5. A slow but tense pulse, such as occurs in the apoplectic, +hydrocephalic, and malignant states of fever, in which its strokes are +from 60 to 90, in a minute. + +6. An uncommonly frequent pulse, without much tension, beating from 120 +to 170 or 180 strokes in a minute. This state of the pulse occurs +likewise in the malignant states of fever. + +7. A soft pulse, without much frequency or fulness. I have met with this +state of the pulse in affections of the brain, and in that state of +pulmonary fever which is known by the name of pneumonia notha. It +sometimes, I have remarked, becomes tense after bleeding. + +8. An intermitting pulse. + +9. A depressed pulse. + +10. An imperceptible pulse. The slow, intermitting, depressed, and +imperceptible states of the pulse are supposed exclusively to indicate +congestion in the brain. But they are all, I believe, occasioned likewise +by great excess of stimulus acting upon the heart and arteries. A pulse +more tense in one arm than in the other, I have generally found to attend +a morbid state of the brain. Much yet remains to be known of the signs of +a disease in the brain, by the states of the pulse; hence Mr. Hunter has +justly remarked, that "In inflammation of the brain, the pulse varies +more than in inflammations of any other part; and perhaps we are led to +judge of inflammation there, more from _other_ symptoms than the +pulse[55]." + + [55] Treatise on Inflammation, chap. iii. 9. + +The slow, uncommonly frequent, intermitting, and imperceptible states of +the pulse, which require bleeding, may be distinguished from the same +states of the pulse, which arise from an exhausted state of the system, +and that forbid bleeding, by the following marks: + +1. They occur in the beginning of a fever. + +2. They occur in the paroxysms of fevers which have remissions and +exacerbations. + +3. They sometimes occur after blood-letting, from causes formerly +mentioned. + +4. They sometimes occur, and continue during the whole course of an +inflammation of the stomach and bowels. And, + +5. They occur in relapses, after the crisis of a fever. + +The other states of the pulse indicate bleeding in every stage of fever, +and in every condition of the system. I have taken notice, in another +place, of the circumstances which render it proper in the advanced stage +of chronic fever. + +If all the states of pulse which have been enumerated indicate bleeding, +it must be an affecting consideration to reflect, how many lives have +been lost, by physicians limiting the use of the lancet only to the tense +or full pulse! + +I wish it comported with the proposed limits of this essay to illustrate +and establish, by the recital of cases, the truth of these remarks upon +the indications of bleeding from the pulse. It communicates much more +knowledge of the state of the system than any other sign of disease. Its +frequency (unconnected with its other states), being under the influence +of diet, motion, and the passions of the mind, is of the least +consequence. In counting the number of its strokes, we are apt to be +diverted from attending to its irregularity and force; and in these, it +should always be remembered, fever chiefly consists. The knowledge +acquired by attending to these states of the pulse is so definite and +useful, and the circumstances which seduce from a due attention to them +are so erroneous in their indications, that I have sometimes wished the +Chinese custom of prescribing, from feeling the pulse only, without +seeing or conversing with the patient, were imposed upon all physicians. + +To render the knowledge of the indications of blood-letting, from the +state of the pulse, as definite and correct as possible, I shall add, for +the benefit of young practitioners, the following directions for feeling +it. + +1. Let the arm be placed in a situation in which all the muscles which +move it shall be completely relaxed; and let it, at the same time, be +free from the pressure of the body upon it. + +2. Feel the pulse, in all obscure or difficult cases, in both arms. + +3. Apply all the fingers of one hand, when practicable, to the pulse. For +this purpose, it will be most convenient to feel the pulse of the right +hand with your left, and of the left hand with your right. + +4. Do not decide upon blood-letting, in difficult cases, until you have +felt the pulse for some time. The Chinese physicians never prescribe +until they have counted 49 strokes. + +5. Feel the pulse at the intervals of four or five minutes, when you +suspect that its force has been varied by any circumstance not connected +with the disease, such as emotions of the mind, exercise, eating, +drinking, and the like. + +6. Feel the pulsations of the arteries in the temples and in the neck, +when the pulse is depressed or imperceptible in the wrists. + +7. Request silence in a sick room, and close your eyes, in feeling a +pulse in difficult cases. By so doing, you will concentrate the +sensations of your ears and eyes, in your fingers. + +In judging of the states of the pulse which have been enumerated, it will +be necessary always to remember the natural difference, in its frequency +and force, in old people and children; also in the morning and evening, +and in the sleeping and waking states of the system. + +Much yet remains to be known upon this subject. I have mentioned the +different states of the pulse, which call for bleeding, but it is more +difficult to know when to prescribe it, when the pulse imparts no sign of +disease. In general it may be remarked, where the disease is _recent_, +the part affected important to life, and incapable of sustaining violent +morbid action long, without danger of disorganization, where pain is +great, and respiration difficult, the pulse may be disregarded in the use +of the lancet. + +But to return. + +II. Regard should be had to the character of the reigning epidemic, in +deciding upon blood-letting. If the prevailing fever be of a highly +inflammatory nature, bleeding may be used with more safety, in cases +where the indications of it from the pulse are somewhat doubtful. The +character of a previous epidemic should likewise direct the use of the +lancet. The pestilential fever which followed the plague in London, in +1665, Dr. Sydenham says, yielded only to blood-letting. It is equally +necessary in all the febrile diseases which succeed malignant fevers. + +III. Regard should be had to the weather and season of the year. Dr. +Hillary and Dr. Huxham both say it is much more necessary in dry, than in +wet weather, and, all physicians know, it is more copiously indicated in +the spring and autumn, than in summer and winter. + +IV. The constitution of a patient, and more especially his habits with +respect to blood-letting, should be taken into consideration, in +prescribing it. If he be plethoric, and accustomed to bleeding in former +indispositions, it will be more necessary, than in opposite states and +habits of the system. Nature will expect it. + +V. The corpulency of a patient should regulate the use of the lancet. A +butcher of great observation informed me, that a fat ox did not yield +more than from one half, to one third of the quantity of blood of a lean +one, of the same size of bone, and it is well known, that the loss of a +small quantity of blood, after cutting off the head of a fowl, is always +a sign of its being fit for the table. The pressure of fat upon the +blood-vessels produces the same effects in the human species that it does +in those animals; of course, less blood should be drawn from fat, than +from lean people, under equal circumstances of disease. + +VI. As persons have more or less blood in their vessels, according to +their size, less blood should be drawn, under equal circumstances, from +small than large people. + +VII. Regard should be had to the age of adults in prescribing bleeding. +In persons between fifty and sixty years of age, for reasons formerly +mentioned, more blood may be drawn than in middle life, in similar +diseases. In persons beyond 70, it will be necessary to regulate the +quantity to be drawn by other signs than the pulse, or the appearances of +the blood, the former being generally full, and sometimes tense, and the +latter often putting on the sign of the second grade of morbid action +formerly described. + +VIII. Regard should be had to the country or place from which persons +affected with fevers have arrived, in prescribing the loss of blood. +Fevers, in America, are more inflammatory than fevers, in persons of +equal rank, in Great-Britain. A French physician once said, it was safer +to draw a hogs-head of wine from a Frenchman's veins, than a quarter of a +hundred pounds of beef from an Englishman's, meaning to convey an idea of +the difference in the grades of morbid or inflammatory action in the +diseases of the inhabitants of France and England, and of the difference +in the quantity of blood proper to be drawn in each of them. A similar +difference exists between the grades of fever in Great-Britain and +America. From a want of attention to this circumstance, I saw a common +pleurisy end in an abscess of the lungs, in a sea captain, in the city of +London, in the year 1769, who was attended by a physician of the first +reputation in England. He was bled but once. His pulse and American +constitution called for the loss of 50 or 60 ounces of blood. + +IX. Regard should be had to the structure and situation of the parts +diseased with febrile action. The brain, from its importance to all the +functions of life, the rectum, the bladder, and the trachea, when +inflamed, and the intestines, when strangulated, from their being removed +so much out of the influence of the great circulation, all require more +copious bleeding than the same degrees of disease in the lungs, and some +other parts of the body. + +X. After blood-letting has been performed, the appearances of the blood +should be attended to, in order to judge of the propriety of repeating +it. I shall briefly describe these appearances, and arrange them in the +order in which they indicate the different degrees of inflammatory +diathesis, beginning with the highest. + +1. Dissolved blood. It occurs in the malignant states of fever. I have +seen it several times in the pleurisy, and have once heard of it in a +case of gout. I have ascribed this decomposition of the blood to such a +violent degree of action in the blood-vessels, as to dispose them to a +paralytic state. It is generally considered as a signal to lay aside the +lancet. If it occur in the _first stage_ of a fever, it indicates a very +opposite practice. By repeated bleedings, the vessels recover their +natural action, and the blood becomes _reduced_ to its original texture. +Of this I have had frequent experience, since the year 1793. It required +three successive bleedings to restore the blood from a dissolved, to a +coagulable state, in Mr. Benton. It afterwards became very sizy. If this +dissolved blood appear towards the close of a malignant fever, no other +benefit than the protraction of life for a day or two, or an easy death, +can be expected from repeating the bleeding, even though it be indicated +by a tense pulse; for the viscera are generally so much choaked by the +continuance of violent action in the blood-vessels, that they are seldom +able to discharge the blood which distends them, into the cavity in the +vessels, which is created by the abstraction of blood from a vein. There +is some variety in the appearance of this state of the blood, which +indicates more or less violent pressure upon the blood-vessels. It +threatens most danger to life when it resembles molasses in its +consistence. The danger is less when the part which is dissolved occupies +the bottom of the bowl, and when its surface is covered with a sizy +pellicle or coat. + +Does not the restoration of the blood from its disorganized state, by +means of bleeding, suggest an idea of a similar change being practicable +in the solids, when they are disorganized by disease? And are we not led +hereby to an animating view of the extent and power of medicine? + +2. Blood of a scarlet colour, without any separation into crassamentum or +serum, indicates a second degree of morbid action. It occurs likewise in +the malignant state of fever. It is called improperly dense blood. It +occurs in old people. + +3. Blood in which part of the crassamentum is dissolved in the serum, +forming a resemblance to what is called the lotura carnium, or the +washings of flesh in water. + +4. Crassamentum sinking to the bottom of a bowl in yellow serum. + +5. Crassamentum floating in serum, which is at first turbid, but which +afterwards becomes yellow and transparent, by depositing certain red and +fiery particles of the blood in the bottom of the bowl. + +6. Sizy blood, or blood covered with a buffy coat. The more the +crassamentum appears in the form of a cup, the more inflammatory action +is said to be indicated by it. This appearance of the blood occurs in all +the common states of inflammatory fever. It occurs too in the mild state +of malignant fevers, and in the close of such of them as have been +violent. It is not always confined to the common inflammatory state of +the pulse, for I have observed it occasionally in most of the different +states of the pulse which have been described. The appearance of this +buffy coat on the blood in the yellow fever is always favourable. It +shows the disease to be tending from an uncommon to a _common_ degree of +inflammatory diathesis. It has been remarked, that blood which resembles +claret in its colour, while flowing, generally puts on, when it cools, a +sizy appearance. + +It would seem, from these facts, that the power of coagulation in the +blood was lessened in an exact ratio to the increase of action upon the +blood-vessels, and that it was increased in proportion to the diminution +of that action, to that degree of it which constitutes what I have called +_common_ inflammatory action. + +Here, as upon a former occasion, we may say with concern, if bleeding be +indicated by all the appearances of the blood which have been enumerated, +how many lives have been lost by physicians limiting the use of the +lancet to those cases only, where the blood discovered an inflammatory +crust! + +These remarks upon the relative signs of inflammatory action in the +blood-vessels, should be admitted with a recollection that they are all +liable to be varied by a moderate, or violent exacerbation of fever, by +the size of the stream of blood, and by the heat, coldness, and form of +the cup into which the blood flows. Even blood drawn, under exactly equal +circumstances, from both arms, exhibited, in a case of pleurisy +communicated to me by Dr. Mitchell, of Kentucky, very different +appearances. That which was taken from one arm was sizy, while that which +was taken from the other was of a scarlet colour. That which is drawn +from a vein in the arm, puts on, likewise, appearances very different +from that which is discharged from the bowels, in a dysentery. These +facts were alluded to in the Outlines of the Theory of Fever[56], in +order to prove that unequal excitement takes place, not only in the +different systems of the body, but in the same system, particularly in +the blood-vessels. They likewise show us the necessity of attending to +the state of the _pulse_ in both arms, as well as in other parts of the +body, in prescribing blood-letting. When time, and more attention to that +index of the state of the system in fevers, shall have brought to light +all the knowledge that the pulse is capable of imparting, the appearances +of the blood, in fevers, will be regarded as little as the appearances of +the urine. + + [56] Vol. iii. + +XI. Blood-letting should always be copious where there is danger from +sudden and great congestion or inflammation, in vital parts. This danger +is indicated most commonly by pain; but there may be congestion in the +lungs, liver, bowels, and even in the head, without pain. In these cases, +the state of the pulse should always govern the use of the lancet. + +XII. What quantity of blood may be taken, with safety, from a patient in +an inflammatory fever? To answer this question it will be necessary to +remark, 1. That, in a person of an ordinary size, there are supposed to +be contained between 25 and 28 pounds of blood; and 2. That much more +blood may be taken when the blood-vessels are in a state of morbid +excitement and excitability, than at any other time. One of the uses of +the blood is to stimulate the blood-vessels, and thereby to assist in +originating and preserving animal life. In a healthy state of the +vessels, the whole mass of the blood is necessary for this purpose; but +in their state of morbid excitability, a much less quantity of blood than +what is natural (perhaps in some cases four or five pounds) are +sufficient to keep up an equal and vigorous circulation. Thus very small +portions of light and sound are sufficient to excite vision and hearing +in an inflamed, and highly excitable state of the eyes and ears. Thus +too, a single glass of wine will often produce delirium in a fever in a +man, who, when in health, is in the habit of drinking a bottle every day, +without having his pulse quickened by it. + +An ignorance of the quantity of blood which has been drawn by design, or +lost by accident, has contributed very much to encourage prejudices +against blood-letting. Mr. Cline drew 320 ounces of blood in 20 days +from a patient in St. Thomas's hospital, who laboured under a contusion +of the head. But this quantity is small compared with the quantity lost +by a number of persons, whose cases are recorded by Dr. Haller[57]. I +shall mention a few of them. One person lost 9 pounds of blood, a second +12, a third 18, and a fourth 22, from the nose, at one time. A fifth lost +12 pounds by vomiting in one night, and a sixth 22 from the lungs. A +gentleman at Angola lost between 3 and 4 pounds daily from his nose. To +cure it, he was bled 97 times in one year. A young woman was bled 1020 +times in 19 years, to cure her of plethora which disposed her to +hysteria. Another young woman lost 125 ounces of blood, by a natural +hæmorrhage, every month. To cure it, she was bled every day, and every +other day, for 14 months. In none of these instances, was death the +consequence of these great evacuations of blood. On the contrary, all the +persons alluded to, recovered. Many similar instances of the safety, and +even benefit of profuse discharges of blood, by nature and art, might be +mentioned from other authors. I shall insert only one more, which shall +be taken from Dr. Sydenham's account of the cure of the plague. "Among +the other calamities of the civil war which afflicted this nation, the +plague also raged in several places, and was brought by accident from +another place to Dunstar Castle, in Somersetshire, where some of the +soldiers dying suddenly, with an eruption of spots, it likewise seized +several others. It happened at that time that a surgeon, who had +travelled much in foreign parts, was in the service there, and applied to +the governor for leave to assist his fellow-soldiers who were afflicted +with this dreadful disease, in the best manner he was able; which being +granted, he took so large a quantity of blood from every one at the +beginning of the disease, and before any swelling was perceived, that +they were ready to faint, and drop down, for he bled them all standing, +and in the open air, and had no vessel to measure the blood, which +falling on the ground, the quantity each person lost could not, of +course, be known. The operation being over, he ordered them to lie in +their tents; and though he gave no kind of remedy after bleeding, yet of +the numbers that were thus treated, not a single person died. I had this +relation from Colonel Francis Windham, a gentleman of great honour and +veracity, and at this time governor of the castle[58]." + + [57] Elementa Physiologiæ, vol. iv. p. 45. + + [58] Vol. i. p. 131. + +Again. An ignorance of the rapid manner in which blood is regenerated, +when lost or drawn, has helped to keep up prejudices against +blood-letting. A person (Dr. Haller says) lost five pounds of blood daily +from the hæmorrhoidal vessels for 62 days, and another 75 pounds of blood +in 10 days. The loss each day was supplied by fresh quantities of +aliment. + +These facts, I hope, will be sufficient to establish the safety and +advantages of plentiful blood-letting, in cases of violent fever; also to +show the fallacy and danger of that practice which attempts the cure of +such cases of fever, by what is called _moderate_ bleeding. There are, it +has been said, no half truths in government. It is equally true, that +there are no half truths in medicine. This half-way practice of moderate +bleeding, has kept up the mortality of pestilential fevers, in all ages, +and in all countries. I have combated this practice elsewhere[59], and +have asserted, upon the authority of Dr. Sydenham, that it is much better +not to bleed at all, than to draw blood disproportioned in quantity to +the violence of the fever. If the state of the pulse be our guide, the +continuance of its inflammatory action, after the loss of even 100 ounces +of blood, indicates the necessity of more bleeding, as much as it did the +first time a vein was opened. In the use of this remedy it may be truly +said, as in many of the enterprizes of life, that nothing is done, while +any thing remains to be done. Bleeding should be repeated while the +symptoms which first indicated it continue, should it be until +four-fifths of the blood contained in the body are drawn away. In this +manner we act in the use of other remedies. Who ever leaves off giving +purges in a colic, attended with costiveness, before the bowels are +opened? or who lays aside mercury as a useless medicine, because a few +doses of it do not cure the venereal disease? + + [59] Account of the Yellow Fever in 1793. + +I shall only add under this head, that I have always observed the cure of +a malignant fever to be most complete, and the convalescence to be most +rapid, when the bleeding has been continued until a _paleness_ is induced +in the face, and until the patient is able to sit up without being +fainty. After these circumstances occur, a moderate degree of force in +the pulse will gradually wear itself away, without doing any harm. + +XIII. In drawing blood, the quantity should be large or small at a time, +according to the state of the system. In cases where the pulse acts with +force and freedom, from 10 to 20 ounces of blood may be taken at once; +but in cases where the pulse is much depressed, it will be better to take +away but a few ounces at a time, and to repeat it three or four times a +day. By this means the blood-vessels more _gradually_ recover their +vigour, and the apparent bad effects of bleeding are thereby prevented. +Perhaps the same advantages might be derived, in many other cases, from +the gradual abstraction of stimuli, that are derived from the gradual +increase of their force and number, in their application to the body. For +a number of facts in support of this practice, the reader is referred to +the history of the yellow fever, in the year 1793. In an inflammatory +fever, the character of which is not accurately known, it is safest to +begin with moderate bleeding, and to increase it in quantity, according +as the violence and duration of the disease shall make it necessary. In +fevers, and other diseases, which run their courses in a few days or +hours, and which threaten immediate dissolution, there can be no limits +fixed to the quantity of blood which may be drawn at once, or in a short +time. Botallus drew three, four, and five pints in a day, in such cases. +Dr. Jackson drew fifty-six ounces of blood, at one time, from a Mr. +Thompson, of the British hospitals, in a fever of great violence and +danger. This patient was instantly relieved from what he styled "chains +and horrors." In three or four hours he was out of danger, and in four +days, the doctor adds, returned to his duty[60]. Dr. Physick drew ninety +ounces, by weight, from Dr. Dewees, in a sudden attack of the apoplectic +state of fever, at one bleeding, and thereby restored him so speedily to +health, that he was able to attend to his business in three days +afterwards. In chronic states of fever, of an inflammatory type, small +and frequent bleedings, are to be preferred to large ones. We use +mercury, antimony, and diet drinks as alteratives in many diseases with +advantage. We do not expect to remove debility by two or three immersions +in a cold bath. We persist with patience in prescribing all the above +remedies for months and years, before we expect to reap the full benefits +of them. Why should not blood-letting be used in the same way, and have +the same chance of doing good? I have long ago adopted this _alterative_ +mode of using it, and I can now look around me, and with pleasure behold +a number of persons of both sexes who owe their lives to it. In many +cases I have prescribed it once in two or three months, for several +years, and in some I have advised it every two weeks, for several months. + + [60] Remarks on the Constitution of the Medical Department of the + British Army. + +There is a state of fever in which an excess in the action of the +blood-vessels is barely perceptible, but which often threatens immediate +danger to life, by a determination of blood to a vital part. In this case +I have frequently seen the scale turn in favour of life, by the loss of +but four or five ounces of blood. The pressure of this, and even of a +much less quantity of blood in the close of a fever, I believe, as +effectually destroys life as the excess of several pounds does in its +beginning. + +In cases where bleeding does not cure, it may be used with advantage as a +_palliative_ remedy. Many diseases induce death in a full and highly +excited state of the system. Here opium does harm, while bleeding affords +certain relief. It belongs to this remedy, in such cases, to ease pain, +to prevent convulsions, to compose the mind, to protract the use of +reason, to induce sleep, and thus to smooth the passage out of life. + +XIV. Bleeding from an artery, commonly called arteriotomy, would probably +have many advantages over venesection, could it be performed at all times +with ease and safety. Blood discharged by hæmorrhages affords more +relief, in fevers, than an equal quantity drawn from a vein, chiefly +because it is poured forth, in the former case, from a ruptured artery. I +mentioned formerly, that Dr. Mitchell had found blood drawn from an +artery to be what is called dense, at a time when that which was drawn +from a vein, in the same persons, was dissolved. This fact may possibly +admit of some application. In the close of malignant fevers, where +bleeding has been omitted in the beginning of the disease, blood drawn +from a vein is generally so dissolved, as to be beyond the reach of +repeated bleedings to restore it to its natural texture. In this case, +arteriotomy might probably be performed with advantage. The arteries, +which retain their capacity of life longer than the veins, by being +relieved from the immediate pressure of blood upon them, might be enabled +so to act upon the torpid veins, as to restore their natural action, and +thereby to arrest departing life. Arteriotomy might further be used with +advantage in children, in whom it is difficult, and sometimes +impracticable to open a vein. + +XV. Much has been said about the proper place from whence blood should be +drawn. Bleeding in the foot was much used formerly, in order to excite a +revulsion from the head and breast; but our present ideas of the +circulation of the blood have taught us, that it may be drawn from the +arm with equal advantage in nearly all cases. To bleeding in the foot +there are the following objections: 1. The difficulty of placing a +patient in a situation favourable to it. 2. The greater danger of +wounding a tendon in the foot than in the arm, And, 3. The impossibility +of examining the blood after it is drawn; for, in this mode of bleeding, +the blood generally flows into a basin or pail of water. + +Under this head I shall decide upon the method of drawing blood by means +of cups and leeches, in the inflammatory state of fever. Where an +inflammatory fever arises from local affection, or from contusion in the +head or breast, or from a morbid excitement in those, above other parts +of the arterial system, they may be useful; but where local affection is +a symptom of general and equable fever only, it can seldom be necessary, +except where bleeding from the arm has been omitted, or used too +sparingly, in the beginning of a fever; by which means such fixed +congestion often takes place, as will not yield to general bleeding. + +XVI. Much has been said likewise about the proper time for bleeding in +fevers. It may be used at all times, when indicated by the pulse and +other circumstances, in continual fevers; but it should be used chiefly +in the paroxysms of such as intermit. I have conceived this practice to +be of so much consequence, that, when I expect a return of the fever in +the night, I request one of my pupils to sit up with my patients all +night, in order to meet the paroxysm, if necessary, with the lancet. But +I derive another advantage from fixing a centinel over a patient in a +malignant fever. When a paroxysm goes off in the night, it often leaves +the system in a state of such extreme debility, as to endanger life. In +this case, from five to ten drops of laudanum, exhibited by a person who +is a judge of the pulse, obviate this alarming debility, and often induce +easy and refreshing sleep. By treating the human body like a corded +instrument, in thus occasionally relaxing or bracing the system, +according to the excess or deficiency of stimulus, in those hours in +which death most frequently occurs, I think I have been the means of +saving several valuable lives. + +XVII. The different positions of the body influence the greater or less +degrees of relief which are obtained by blood-letting. Where there is a +great disposition to syncope, and where it is attended with alarming and +distressing circumstances, blood should be drawn in a recumbent posture, +but where there is no apprehension or dread of fainting, it may be taken +in a sitting posture. The relief will be more certain if the patient be +able to stand while he is bled. A small quantity of blood, drawn in this +posture, brings on fainting, and the good effects which are often derived +from it. It should therefore be preferred, where patients object to +copious or frequent bleedings. The history of the success of this +practice in the British army, recently mentioned from Dr. Sydenham, +furnishes a strong argument in its favour. + +I regret that the limits I have fixed to this Defence of Blood-letting +will not admit of my applying the principles which have been delivered, +to all the inflammatory states of fever. In a future essay, I hope to +establish its efficacy in the maniacal state of fever. I have said that +madness is the effect of a chronic inflammation in the brain. Its remedy, +of course, should be frequent and copious blood-letting. Physical and +moral evil are subject to similar laws. The mad-shirt, and all the common +means of coercion, are as improper substitutes for bleeding, in madness, +as the whipping-post and pillory are for solitary confinement and +labour, in the cure of vice. The pulse should govern the use of the +lancet in this, as well as in all the _ordinary_ states of fever. It is +the dial-plate of the system. But in the _misplaced_ states of fever, the +pulse, like folly in old age, often points at a different mark from +nature. In all such cases, we must conform our practice to that which has +been successful in the reigning epidemic. A single bleeding, when +indicated by this circumstance, often converts a fever from a suffocated, +or latent, to a sensible state, and thus renders it a more simple and +manageable disease. + +It is worthy of consideration here, how far local diseases, which have +been produced by fevers, might be cured by re-exciting the fever. Sir +William Jones says, the physicians in Persia always begin the cure of the +leprosy by blood-letting[61]. Possibly this remedy diffuses the disease +through the blood-vessels, and thereby exposes it to be more easily acted +upon by other remedies. + + [61] Asiatic Essays. + +Having mentioned the states of fever in which blood-letting is indicated, +and the manner in which it should be performed, I shall conclude this +inquiry by pointing out the states of fever in which it is forbidden, or +in which it should be cautiously or sparingly performed. This subject is +of consequence, and should be carefully attended to by all who wish well +to the usefulness and credit of the lancet. + +1. It is forbidden in that state of fever, as well as in other diseases, +in which there is reason to believe the brain or viscera are engorged +with blood, and the whole system prostrated below the point of re-action. +I have suggested this caution in another place[62]. The pulse in these +cases is feeble, and sometimes scarcely perceptible, occasioned by the +quantity of blood in the blood-vessels being reduced, in consequence of +the stagnation of large portions of it in the viscera. By bleeding in +these cases, we deprive the blood-vessels of the feeble remains of the +stimulus which keep up their action, and thus precipitate death. The +remedies here should be frictions, and stimulating applications to the +extremities, and gentle stimuli taken by the mouth, or injected into the +bowels. As soon as the system is a little excited by these remedies, +blood may be drawn, but in small quantities at a time, and perhaps only +by means of cups or leaches applied to the seats of the congestions of +the blood. After the vessels are excited by the equable diffusion of the +blood through all their parts, it may with safety be drawn from the arm, +provided it be indicated by the pulse. + + [62] Vol. iii. + +2. It is seldom proper beyond the third day, in a malignant fever, if it +has not been used on the days previous to it, and for the same reason +that has been given under the former head. Even the tension of the pulse +is not always a sufficient warrant to bleed, for in three days, in a +fever which runs its course in five days, the disorganization of the +viscera is so complete, that a recovery is scarcely to be expected from +the lancet. The remedies which give the only chance of relief in this +case, are purges, blisters, and a salivation. + +3. Where fevers are attended with paroxysms, bleeding should be omitted, +or used with great caution, in the close of those paroxysms. The debility +which accompanies the intermission of the fever is often so much +increased by the recent loss of blood, as sometimes to endanger life. + +4. Bleeding is forbidden, or should be used cautiously in that malignant +state of fever, in which a weak morbid action, or what Dr. Darwin calls a +tendency to inirritability, takes place in the blood-vessels. It is +known by a weak and frequent pulse, such as occurs in the typhus fever, +and in the plague in warm climates. I have often met with it in the +malignant sore throat, and occasionally in the pleurisy and yellow fever. +The remedies here should be gentle vomits or purges, and afterwards +cordials. Should the pulse be too much excited by them, bleeding may be +used to reduce it. + +5. It should be used sparingly in the diseases of habitual drunkards. The +morbid action in such persons, though often violent, is generally +transient. It may be compared to a soap-bubble. The arteries, by being +often overstretched by the stimulus of strong drink, do not always +contract with the diminution of blood, and such patients often sink, from +this cause, from the excessive use of the lancet. + +6. It has been forbidden after the suppurative process has begun in local +inflammation. It constantly retards the suppuration, when begun, in the +angina tonsillaris, and thus protracts that disease. To this rule there +are frequent exceptions. + +7. It should be omitted in pneumony, after copious expectoration has +taken place. This discharge is local depletion, and, though slow in its +effects compared with bleeding, it serves the same purpose in relieving +the lungs. The lancet can only be required where great pain in coughing, +and a tense pulse, attend this stage of the disease. + +8. It may be omitted (except when the blood-vessels are insulated) in +those diseases in which there is time to wait, without danger to life, or +future health, for the circuitous operation of purging medicines, or +abstemious diet. + +9. It should be avoided, when it can be done without great danger to +life, where there is a great and constitutional dread of the operation. +In such cases, it has sometimes done harm to the patient, and injured the +credit of the lancet. + +10. There are cases in which sizy blood should not warrant a repetition +of blood-letting. Mr. White informs us, in the History of the Bilious +Fever which has lately prevailed at Bath, that bleeding, in many cases in +which this appearance of the blood took place, was useless or hurtful. In +some of the fevers of our own country, we sometimes see sizy blood +followed by symptoms which forbid the repeated use of the lancet, but +which yield to other depleting remedies, or to such as are of a cordial +nature. I have seen the same kind of blood, a few hours before death, in +a pulmonary consumption, and three days after a discharge of a gallon and +a half of blood from the stomach by vomiting. + +11. Even a tense pulse does not always call for the repeated use of the +lancet. I have mentioned one case, viz. on the third or fourth days of a +malignant fever, in which it is improper. There are instances of +incurable consumptions from tubercles and ulcers in the lungs, in which +the pulse cannot be made to feel the least diminution of tension by +either copious or frequent bleedings. There are likewise cases of hepatic +fever, in which the pulse cannot be subdued by this remedy. This tense +state of the pulse is the effect of a suppurative process in the liver. +If a sufficient quantity of blood has been drawn in the first stage of +this disease, there is little danger from leaving the pulse to reduce or +wear itself down by a sudden or gradual discharge of the hepatic +congestion. The recovery in this case is slow, but it is for the most +part certain. I have once known a dropsy and death induced by the +contrary practice. + +12. and lastly. There is sometimes a tension in the pulse in hæmorrhages, +that will not yield to the lancet. The man whose blood was sizy, three +days after losing a gallon and a half of it from his stomach, had a tense +pulse the day before he died; and I once perceived its last strokes to be +tense, in a patient whom I lost in a yellow fever by a hæmorrhage from +the nose. The only circumstance that can justify bleeding in these cases +is extreme pain, in which case, the loss of a few ounces of blood is a +more safe and effectual remedy than opium. + +I shall now add a few remarks upon the efficacy of blood-letting, in +diseases which are not supposed to belong to the class of fevers, and +which have not been included in the preceding volumes. + +I. The philosophers, in describing the humble origin of man, say that he +is formed "inter stercus et urinam." The divines say that he is +"conceived in sin, and shapen in iniquity." I believe it to be equally +true, and alike humiliating, that he is conceived and brought forth in +disease. + +This disease appears in pregnancy and parturition. I shall first +endeavour to prove this to be the case, and afterwards mention the +benefits of blood-letting in relieving it, in both cases. + +In pregnancy, the uterus is always affected with that grade of morbid +action which I formerly called inflammation. This is evident from its +exhibiting all its usual phænomena in other parts of the body. These are, + +1. Swelling, or enlargement. + +2. Hæmorrhage. The lochia are nothing but a slow and spontaneous bleeding +performed by nature, and intended to cure the inflammation of the uterus +after parturition. + +3. Abscesses, schirri, and cancers. It is true, those disorders sometimes +occur in women that have never borne children. In these cases, they are +the effects of the inflammation excited by the menstrual disease. + +4. A full, quick, and tense or frequent pulse; pain; want of +appetite[63]; sickness at stomach; puking; syncope; and sometimes +convulsions in every part of the body. + + [63] Dr. Hunter used to teach, in his lectures, that the final cause of + the want of appetite, during the first months of pregnancy, was to + obviate plethora, which disposed to abortion. This plethora should + have been called an inflammatory disease, in which abstinence is + useful. + +5. Sizy blood. This occurs almost uniformly in pregnancy. + +6. A membrane. Dr. Scarpa has proved the membrana decidua, which is +formed during pregnancy, to be in every respect the same in its +properties with the membrane which is formed upon other inflamed +surfaces, particularly the trachea, the pleura, and the inside of the +bowels. Thus we see all the common and most characteristic symptoms and +effects of inflammation, in other parts of the body, are exhibited by the +uterus in pregnancy. + +These remarks being premised, I proceed to remark, that blood-letting is +indicated, in certain states of pregnancy, by all the arguments that have +been used in favour of it in any other inflammatory disease. The degree +of inflammation in the womb, manifested by the pulse, pain, and other +signs of disease, should determine the quantity of blood to be drawn. Low +diet, gentle purges, and constant exercise, are excellent substitutes for +it, but where they are not submitted to, blood-letting should be employed +as a substitute for them. In that disposition to abortion, which occurs +about the third month of pregnancy, small and frequent bleedings should +be preferred to all other modes of depletion. I can assert, from +experience, that they prevent abortion, nearly with as much certainty as +they prevent a hæmorrhage from the lungs: for what is an abortion but a +hæmoptysis (if I may be allowed the expression) from the uterus? During +the last month of pregnancy, the loss of from twelve to twenty ounces of +blood has the most beneficial effects, in lessening the pains and danger +of child-birth, and in preventing its subsequent diseases. + +The doctrine I have aimed to establish leads, not only to the use of +blood-letting in the disease of pregnancy, when required, but to a more +copious use of it, when combined with other diseases, than in those +diseases in a simple state. This remark applies, in a particular manner, +to those spasms and convulsions which sometimes occur in the latter +months of pregnancy. Without bleeding, they are always fatal. By copious +bleeding, amounting in some instances to 80 and 100 ounces, they are +generally cured. + +Let it not be supposed that blood-letting is alike proper and useful in +every state of pregnancy. There are what are called slow or chronic +inflammations, in which the diseased action of the blood-vessels not only +forbids it, but calls for cordial and stimulating remedies. The same +feeble state of inflammation sometimes takes place in the pregnant +uterus. In these cases cordials and stimulants should be preferred to the +lancet. + +_Parturition_ is a higher grade of disease than that which takes place in +pregnancy. It consists of convulsive or clonic spasms in the uterus, +supervening its inflammation, and is accompanied with chills, heat, +thirst, a quick, full, tense, or a frequent and depressed pulse, and +great pain. By some divines these symptoms, and particularly pain, have +been considered as a standing and unchangeable punishment of the original +disobedience of woman, and, by some physicians, as indispensably +necessary to enable the uterus to relieve itself of its burden. By +contemplating the numerous instances in which it has pleased God to bless +the labours and ingenuity of man, in lessening or destroying the effects +of the curse inflicting upon the earth, and by attending to the histories +of the total exemption from pain in child-bearing that are recorded of +the women in the Brasils, Calabria, and some parts of Africa, and of the +small degrees of it which are felt by the Turkish women, who reduce their +systems by frequent purges of sweet oil during pregnancy, I was induced +to believe pain does not accompany child-bearing by an immutable decree +of Heaven. By recollecting further how effectually blood-letting relieves +many other spasmodic and painful diseases, and how suddenly it relaxes +rigidity in the muscles, I was led, in the year 1795, to suppose it might +be equally effectual in lessening the violence of the disease and pains +of parturition. I was encouraged still more to expect this advantage from +it, by having repeatedly observed the advantages of copious bleeding for +inflammatory fevers, just before delivery, in mitigating its pains, and +shortening its duration. Upon my mentioning these reflections and facts +to Dr. Dewees, I was much gratified in being informed, that he had been +in the practice, for several years before his removal from Abingdon to +Philadelphia, of drawing _large_ quantities of blood during parturition, +and with all the happy effects I had expected from it. The practice has +been strongly inculcated by the doctor in his lectures upon midwifery, +and has been ably defended and supported by a number of recent facts, in +an ingenious inaugural dissertation, published by Dr. Peter Miller, in +the year 1804. It has been generally adopted by the practitioners of +midwifery, of both sexes, in Philadelphia. + +I do not mean to insinuate that bleeding is a new remedy in parturition. +It has long ago been advised and used in France, and even by the midwives +of Genoa, in Italy, but never, in any country, in the large quantities +that have been recommended by Dr. Dewees, that is, from 20 to 80 ounces, +or until signs of fainting are induced, nor under the influence of the +theory of parturition, being a violent disease. + +But the advantages of this remedy are not confined to lessening the pains +of delivery. It prevents after pains; favours the easy and healthy +secretion of milk; prevents sore breasts, swelled legs, puerperile fever, +and all the distressing train of anomalous complaints that often follow +child-bearing. Dr. Hunter informed his pupils, in his lectures upon +midwifery, in the year 1769, that he had often observed the most rapid +recoveries to succeed the most severe labours. The severity of the pains +in these cases created a disease, which prevented internal congestions in +the womb. Bleeding, by depleting the uterus, obviates at once both +disease and congestion. Its efficacy is much aided by means of glysters, +which, by emptying the lower bowels, lessen the pressure upon the uterus. + +Let it not be inferred, from what has been said in favour of +blood-letting in parturition, that it is proper in all cases. Where there +has been great previous inanition, and where there are marks of languor, +and feeble morbid action in the system, the remedies should be of an +opposite nature. Opium and other cordials are indicated in these cases. +Their salutary effects in exciting the action of the uterus, and +expediting delivery, are too well known to be mentioned. + +I have expressed a hope in another place[64], that a medicine would be +discovered that should suspend sensibility altogether, and leave +irritability, or the powers of motion, unimpaired, and thereby destroy +labour pains altogether. I was encouraged to cherish this hope, by having +known delivery to take place, in one instance, during a paroxysm of +epilepsy, and having heard of another, during a fit of drunkenness, in a +woman attended by Dr. Church, in both of which there was neither +consciousness, nor recollection of pain. + + [64] Medical Repository, vol. vi. + +2. During the period in which the menses are said to dodge, and for a +year or two after they cease to flow, there is a morbid fulness and +excitement in the blood-vessels, which are often followed by head-ach, +cough, dropsy, hæmorrhages, glandular obstructions, and cancers. They may +all be prevented by frequent and moderate bleedings. + +3. It has been proved, by many facts, that opium, when taken in an +excessive dose, acts by inducing a similar state of the system with that +which is induced by the miasmata which bring on malignant and +inflammatory fevers. The remedy for the disease produced by it (where a +vomiting cannot be excited to discharge the opium) has been found to be +copious blood-letting. Of its efficacy, the reader will find an account +in four cases, published in the fifth volume of the New-York Medical +Repository. + +4. It is probable, from the uniformly stimulating manner in which poisons +of all kinds act upon the human body, that bleeding would be useful in +obviating their baneful effects. Dr. John Dorsey has lately proved its +efficacy, in the case of a child that was affected with convulsions, in +consequence of eating the leaves of the datura stramonium. + +5. It has been the misfortune of diabetes to be considered by physicians +as exclusively a local disease of weak morbid action, or as the effect of +simple debility in the kidneys; and hence stimulating and tonic medicines +have been exclusively prescribed for it. This opinion is not a correct +one. It often affects the whole arterial system, more especially in its +first stage, with great morbid action. In two cases of it, where this +state of the blood-vessels took place, I have used blood-letting with +success, joined with the common remedies for inflammatory diseases. + +6. In dislocated bones which resist both skill and force, it has been +suggested, that bleeding, till fainting is induced, would probably induce +such a relaxation in the muscles as to favour their reduction. This +principle was happily applied, in the winter of 1795, by Dr. Physick, in +the Pennsylvania hospital, in a case of dislocated humerus of two months +continuance. The doctor bled his patient till he fainted, and then +reduced his shoulder in less than a minute, and with very little exertion +of force. The practice has since become general in Philadelphia, in +luxations of large bones, where they resist the common degrees of +strength employed to reduce them. + +In contemplating the prejudices against blood-letting, which formerly +prevailed so generally in our country, I have been led to ascribe them to +a cause wholly political. We are descended chiefly from Great-Britain, +and have been for many years under the influence of English habits upon +all subjects. Some of these habits, as far as they relate to government, +have been partly changed; but in dress, arts, manufactures, manners, and +science, we are still governed by our early associations. Britain and +France have been, for many centuries, hereditary enemies. The hostility +of the former to the latter nation, extends to every thing that belongs +to their character. It discovers itself, in an eminent degree, in diet +and medicine. Do the French love soups? the English prefer solid flesh. +Do the French love their meats well cooked? the English prefer their +meats but half roasted. Do the French sip coffee after dinner? the +English spend their afternoons in drinking Port and Madeira wines. Do the +French physicians prescribe purges and glysters to cleanse the bowels? +the English physicians prescribe vomits for the same purpose. Above all, +do the French physicians advise bleeding in fevers? the English +physicians forbid it, in most fevers, and substitute sweating in the room +of it. Here then we discover the source of the former prejudices and +errors of our country-men, upon the subject of blood-letting. They are of +British origin. They have been inculcated in British universities, and in +British books; and they accord as ill with our climate and state of +society, as the Dutch foot stoves did with the temperate climate of the +Cape of Good Hope[65]. + + [65] I have frequently been surprised, in visiting English patients, to + hear them say, when I have prescribed bleeding, that their + physicians in England had charged them never to be bled. This + advice excluded all regard to the changes which climate, diet, new + employments, and age might induce upon the system. I am disposed + to believe that many lives are lost, and numerous chronic diseases + created in Great-Britain, by the neglect of bleeding in fevers. My + former pupil, Dr. Fisher, in a letter from the university of + Edinburgh, dated in the winter of 1795, assured me, that he had + cured several of his fellow-students of fevers (contrary to + general prejudice) by early bleeding, in as easy and summary a way + as he had been accustomed to see them cured in Philadelphia, by + the use of the same remedy. Dr. Gordon, of Scotland, and several + other physicians in Great-Britain, have lately revived the lancet, + and applied it with great judgment and success to the cure of + fevers. + +It is probable the bad consequences which have followed the +indiscriminate use of the lancet France, and some other countries, may +have contributed in some degree to create the prejudices against it, +which are entertained by the physicians in Great-Britain. Bleeding, like +opium, has lost its character, in many cases, by being prescribed for the +_name_ of a disease. It is still used, Mr. Townsend tells us, in this +empirical way in Spain, where a physician, when sent for to a patient, +orders him to be bled before he visits him. The late just theory of the +manner in which opium acts upon the body, has restrained its mischief, +and added greatly to its usefulness. In like manner, may we not hope, +that just theories of diseases, and proper ideas of the manner in which +bleeding acts in curing them, will prevent a relapse into the evils which +formerly accompanied this remedy, and render it a great and universal +blessing to mankind? + + + + + AN INQUIRY + + INTO THE + + _Comparative State of Medicine_, + + IN PHILADELPHIA, + + BETWEEN THE YEARS 1760 AND 1766, + + AND THE YEAR 1805. + + +In estimating the progress and utility of medicine, important advantages +may be derived from taking a view of its ancient, and comparing it with +its present state. To do this upon an extensive scale, would be +difficult, and foreign to the design of this inquiry. I shall therefore +limit it, to the history of the diseases and medical opinions which +prevailed, and of the remedies which were in use, in the city of +Philadelphia, between the years 1760 and 1766, and of the diseases, +medical opinions, and remedies of the year 1805. The result of a +comparative view of each of them, will determine whether medicine has +declined or improved, in that interval of time, in this part of the +world. + +To derive all the benefits that are possible from such an inquiry, it +will be proper to detail the causes, which, by acting upon the human +body, influence the subjects that have been mentioned, in those two +remote periods of time. + +Those causes divide themselves into climate, diet, dress, and certain +peculiar customs; on each of which I shall make a few remarks. + +After what has been said, in the history of the Climate of Pennsylvania, +in the first volume of these Inquiries, it will only be necessary in this +place briefly to mention, that the winters in Philadelphia, between the +years 1760 and 1766, were almost uniformly cold. The ground was generally +covered with snow, and the Delaware frozen, from the first or second week +in December, to the last week in February, or the first week in March. +Thaws were rare during the winter months, and seldom of longer duration +than three or four days. The springs began in May. The summers were +generally warm, and the air seldom refreshed by cool north-west winds. +Rains were frequent and heavy, and for the most part accompanied with +thunder and lightning. The autumns began in October, and were gradually +succeeded by cool and cold weather. + +The diet of the inhabitants of Philadelphia, during those years, +consisted chiefly of animal food. It was eaten, in some families, three +times, and in all, twice a day. A hot supper was a general meal. To two +and three meals of animal food in a day, many persons added what was then +called "a relish," about an hour before dinner. It consisted of a slice +of ham, a piece of salted fish, and now and then a beef-steak, +accompanied with large draughts of punch or toddy. Tea was taken in the +interval between dinner and supper. + +In many companies, a glass of wine and bitters was taken a few minutes +before dinner, in order to increase the appetite. + +The drinks, with dinner and supper, were punch and table beer. + +Besides feeding thus plentifully in their families, many of the most +respectable citizens belonged to clubs, which met in the city in winter, +and in its vicinity, under sheds, or the shade of trees, in summer, once +and twice a week, and, in one instance, every night. They were drawn +together by suppers in winter, and dinners in summer. Their food was +simple, and taken chiefly in a solid form. The liquors used with it were +punch, London porter, and sound old Madeira wine. + +Independently of these clubs, there were occasional meetings of citizens, +particularly of young men, at taverns, for convivial purposes. A house in +Water-street, known by the name of the Tun tavern, was devoted chiefly to +this kind of accidental meetings. They were often followed by midnight +sallies into the streets, and such acts of violence and indecency, as +frequently consigned the perpetrators of them afterwards into the hands +of the civil officers and physicians of the city. + +Many citizens, particularly tradesmen, met every evening for the purpose +of drinking beer, at houses kept for that purpose. Instances of +drunkenness were rare at such places. The company generally parted at ten +o'clock, and retired in an orderly manner to their habitations. Morning +drams, consisting of cordials of different kinds, were common, both in +taverns and private houses, but they were confined chiefly to the lower +class of people. + +From this general use of distilled and fermented liquors, drunkenness was +a common vice in all the different ranks of society. + +The dresses of the men, in the years alluded to, were composed of cloth +in winter, and of thin woollen or silk stuffs in summer. Wigs composed +the covering of the head, after middle life, and cocked hats were +universally worn, except by the men who belonged to the society of +friends. + +The dresses of the women, in the years before mentioned, consisted +chiefly of silks and calicoes. Stays were universal, and hoops were +generally worn by the ladies in genteel life. Long cloth or camblet +cloaks were common, in cold weather, among all classes of women. + +The principal custom under this head, which influenced health and life, +was that which obliged women, after lying-in, "to sit up for company;" +that is, to dress themselves, every afternoon on the second week after +their confinement, and to sit for four or five hours, exposed to the +impure air of a crowded room, and sometimes to long and loud +conversations. + +Porches were nearly universal appendages to houses, and it was common for +all the branches of a family to expose themselves upon them, to the +evening air. Stoves were not in use, at that time, in any places of +public worship. + +Funerals were attended by a large concourse of citizens, who were thereby +often exposed to great heat and cold, and sometimes to standing, while +the funeral obsequies were performed, in a wet or damp church-yard. + +The human mind, in this period of the history of our city, was in a +colonized state, and the passions acted but feebly and partially upon +literary and political subjects. + +We come now to mention the diseases which prevailed in our city between +the years 1760 and 1766. + +The cholera morbus was a frequent disease in the summer months. + +Sporadic cases of dysentery were at that time common. I have never seen +that disease epidemic in Philadelphia. + +The intermitting fever prevailed in the month of August, and in the +autumn, chiefly in the suburbs and neighbourhood of the city. In the year +1765, it was epidemic in Southwark, and was so general, at the same time, +as to affect two thirds of the inhabitants of the southern states. This +fact is mentioned by Dr. Bond, in a lecture preserved in the minutes of +the managers of the Pennsylvania hospital. + +The slow chronic fever, called at that time the nervous fever, was very +common, in the autumnal months, in the thickly settled parts of the city. + +The bilious fever prevailed, at the same time, in Southwark. The late Dr. +Clarkson, who began to practise medicine in that part of the city, in the +year 1761, upon hearing some of his medical brethren speak of the +appearance of bilious remittents in its middle and northern parts, about +the year 1778, said they had long been familiar to him, and that he had +met with them every year since his settlement in Philadelphia[66]. + + [66] From the early knowledge this excellent physician and worthy man + had thus acquired of the bilious remitting fever, he was very + successful in the treatment of it. It was by instruction conveyed + by him to me with peculiar delicacy, that I was first taught the + advantages of copious evacuations from the bowels in that disease. + I had been called, when a young practitioner, to visit a gentleman + with him in a bilious pleurisy. A third or fourth bleeding, which + I advised, cured him. The doctor was much pleased with its effect, + and said to me afterwards, "Doctor, you and I have each a great + fault in our practice; I do not bleed enough, you do not purge + enough." + +The yellow fever prevailed in the neighbourhood of Spruce-street wharf, +and near a filthy stream of water which flowed through what is now called +Dock-street, in the year 1762. Some cases of it appeared likewise in +Southwark. It was scarcely known in the north and west parts of the city. +No desertion of the citizens took place at this time, nor did the fear of +contagion drive the friends of the sick from their bed-sides, nor prevent +the usual marks of respect being paid to them after death, by following +their bodies to the grave. A few sporadic cases of the same grade of +fever appeared in the year 1763. + +Pneumonies, rheumatisms, inflammatory sore throats, and catarrhs were +frequent during the winter and spring months. The last disease was +induced, not only by sudden changes in the weather, but often by exposure +to the evening air, on porches in summer, and by the damp and cold air of +places of public worship in winter. + +The influenza was epidemic in the city in the spring of the year 1761. + +The malignant sore throat proved fatal to a number of children in the +winter of 1763. + +The scarlet fever prevailed generally in the year 1764. It resembled the +same disease, as described by Dr. Sydenham, in not being accompanied by a +sore throat. + +Death from convulsions in pregnant women, also front parturition, and the +puerperile fever, were common between the years 1760 and 1766. Death was +likewise common between the 50th and 60th years of life from gout, +apoplexy, palsy, obstructed livers, and dropsies. A club, consisting of +about a dozen of the first gentlemen in the city, all paid, for their +intemperance, the forfeit of their lives between those ages, and most of +them with some one, or more of the diseases that have been mentioned. I +sat up with one of that club on the night of his death. Several of the +members of it called at his house, the evening before he died, to inquire +how he was. One of them, upon being informed of his extreme danger, spoke +in high and pathetic terms of his convivial talents and virtues, and +said, "he had spent 200 evenings a year with him, for the last twenty +years of his life." These evenings were all spent at public houses. + +The colica pictonum, or dry gripes, was formerly a common disease in this +city. It was sometimes followed by a palsy of the upper and lower +extremities. Colics from crapulas were likewise very frequent, and now +and then terminated in death. + +Many children died of the cholera infantum, cynanche trachealis, and +hydrocephalus internus. The last disease was generally ascribed to worms. + +Fifteen or twenty deaths occurred, every summer, from drinking cold pump +water, when the body was in a highly excitable state, from great beat and +labour. + +The small-pox, within the period alluded to, was sometimes epidemic, and +carried off many citizens. In the year 1759, Dr. Barnet was invited from +Elizabeth-town, in New-Jersey, to Philadelphia, to inoculate for the +small-pox. The practice, though much opposed, soon became general. About +that time, Dr. Redman published a short defence of it, and recommended +the practice to his fellow-citizens in the most affectionate language. +The success of inoculation was far from being universal. Subsequent +improvements in the mode of preparing the body, and treating the eruptive +fever, have led us to ascribe this want of success to the deep wound made +in the arm, to the excessive quantity of mercury given to prepare the +body, and to the use of a warm regimen in the eruptive fever. + +The peculiar customs and the diseases which have been enumerated, by +inducing general weakness, rendered the pulmonary consumption a frequent +disease among both sexes. + +Pains and diseases from decayed teeth were very common, between the years +1760 and 1766. At that time, the profession of a dentist was unknown in +the city. + +The practice of physic and surgery were united, during those years, in +the same persons, and physicians were seldom employed as man-midwives, +except in preternatural and tedious labours. + +The practice of surgery was regulated by Mr. Sharp's treatise upon that +branch of medicine. + +Let us now take a view of the medical opinions which prevailed at the +above period, and of the remedies which were employed to cure the +diseases that have been mentioned. + +The system of Dr. Boerhaave then governed the practice of every physician +in Philadelphia. Of course diseases were ascribed to morbid acrimonies, +and other matters in the blood, and the practice of those years was +influenced by a belief in them. Medicines were prescribed to thin, and to +incrassate the blood, and diet drinks were administered in large +quantities, in order to alter its qualities. Great reliance was placed +upon the powers of nature, and critical days were expected with +solicitude, in order to observe the discharge of the morbid cause of +fevers from the system. This matter was looked for chiefly in the urine, +and glasses to retain it were a necessary part of the furniture of every +sick room. To ensure the discharge of the supposed morbid matter of +fevers through the pores, patients were confined to their beds, and +fresh, with cool air, often excluded by close doors and curtains. The +medicines to promote sweats were generally of a feeble nature. The +spiritus mindereri, and the spirit of sweet nitre were in daily use for +that purpose. In dangerous cases, saffron and Virginia snake-root were +added to them. + +Blood-letting was used plentifully in pleurisies and rheumatisms, but +sparingly in all other diseases. Blood was often drawn from the feet, in +order to excite a revulsion of disease from the superior parts of the +body. It was considered as unsafe, at that time, to bleed during the +monthly disease of the female sex. + +Purges or vomits began the cure of all febrile diseases, but as the +principal dependence was placed upon sweating medicines, those powerful +remedies were seldom repeated in the subsequent stages of fevers. To this +remark there was a general exception in the yellow fever of 1762. Small +doses of glauber's salts were given every day after bleeding, so as to +promote a gentle, but constant discharge from the bowels. + +The bark was administered freely in intermittents. The prejudices against +it at that time were so general among the common people, that it was +often necessary to disguise it. An opinion prevailed among them, that it +lay in their bones, and that it disposed them to take cold. It was seldom +given in the low and gangrenous states of fever, when they were not +attended with remissions. + +The use of opium was confined chiefly to ease pain, to compose a cough, +and to restrain preternatural discharges from the body. Such were the +prejudices against it, that it was often necessary to conceal it in other +medicines. It was rarely taken without the advice of a physician. + +Mercury was in general use in the years that have been mentioned. I have +said it was given to prepare the body for the small-pox. It was +administered by my first preceptor in medicine, Dr. Redman, in the same +disease, when it appeared in the natural way, with malignant or +inflammatory symptoms, in order to keep the salivary glands open and +flowing, during the turn of the pock. He gave it likewise liberally in +the dry gripes. In one case of that disease, I well remember the pleasure +he expressed, in consequence of its having affected his patient's mouth. + +But to Dr. Thomas Bond the city of Philadelphia is indebted for the +introduction of mercury into general use, in the practice of medicine. He +called it emphatically "a revolutionary remedy," and prescribed it in all +diseases which resisted the common modes of practice. He gave it +liberally in the cynanche trachealis. He sometimes cured madness, by +giving it in such quantities as to excite a salivation. He attempted to +cure pulmonary consumption by it, but without success; for, at that time, +the influence of the relative actions of different diseases and remedies, +upon the human body, was not known, or, if known, no advantage was +derived from it in the practice of medicine. + +The dry gripes were cured, at that time, by a new and peculiar mode of +practice, by Dr. Thomas Cadwallader. He kept the patient easy by gentle +anodynes, and gave lenient purges, only in the beginning of the disease; +nor did he ever assist the latter by injections till the fourth and fifth +days, at which time the bowels discharged their contents in an easy +manner. It was said this mode of cure prevented the paralytic symptoms, +which sometimes follow that disease. It was afterwards adopted and highly +commended by the late Dr. Warren, of London. + +Blisters were in general use, but seldom applied before the latter stage +of fevers. They were prescribed, for the first time, in hæmorrhages, and +with great success, by Dr. George Glentworth. + +Wine was given sparingly, even in the lowest stage of what were then +called putrid and nervous fevers. + +The warm and cold baths were but little used in private practice. The +former was now and then employed in acute diseases. They were both used +in the most liberal manner, together with the vapour and warm air baths, +in the Pennsylvania hospital, by Dr. Thomas Bond. An attempt was made to +erect warm and cold baths, in the neighbourhood of the city, and to +connect them with a house of entertainment, by Dr. Lauchlin M'Clen, in +the year 1761. The project was considered as unfriendly to morals, and +petitions, from several religious societies, were addressed to the +governor of the province, to prevent its execution. The enterprize was +abandoned, and the doctor soon afterwards left the city. + +Riding on horseback, the fresh air of the sea-shore, and long journies, +were often prescribed to invalids, by all the physicians of that day. + +I come now to mention the causes which influence the diseases, also the +medical opinions and remedies of the present time. In this part of our +discourse, I shall follow the order of the first part of our inquiry. + +I have already taken notice of the changes which the climate of +Philadelphia has undergone since the year 1766. + +A change has of late years taken place in the dress of the inhabitants of +Philadelphia. Wigs have generally been laid aside, and the hair worn cut +and dressed in different ways. Round hats, with high crowns, have become +fashionable. Umbrellas, which were formerly a part of female dress only, +are now used in warm and wet weather, by men of all ranks in society; and +flannel is worn next to the skin in winter, and muslin in summer, by many +persons of both sexes. Tight dresses are uncommon, and stays are unknown +among our women. It is to be lamented that the benefits to health which +might have been derived from the disuse of that part of female dress, +have been prevented by the fashion of wearing such light coverings over +the breasts and limbs. The evils from this cause, shall be mentioned +hereafter. + +A revolution has taken place in the diet of our citizens. Relishes and +suppers are generally abolished; bitters, to provoke a preternatural +appetite, also meridian bowls of punch, are now scarcely known. Animal +food is eaten only at dinner, and excess in the use of it is prevented, +by a profusion of excellent summer and winter vegetables. + +Malt liquors, or hydrant water, with a moderate quantity of wine, are +usually taken with those simple and wholesome meals. + +Clubs, for the exclusive purpose of feeding, are dissolved, and succeeded +by family parties, collected for the more rational entertainments of +conversation, dancing, music, and chess. Taverns and beer-houses are much +less frequented than formerly, and drunkenness is rarely seen in genteel +life. The tea table, in an evening, has now become the place of resort of +both sexes, and the midnight serenade has taken place of the midnight +revels of the young gentlemen of former years. + +In doing justice to the temperance of the modern citizens of +Philadelphia, I am sorry to admit, there is still a good deal of secret +drinking among them. Physicians, who detect it by the diseases it +produces, often lament the inefficacy of their remedies to remove them. +In addition to intemperance from spiritous liquors, a new species of +intoxication from opium has found its way into our city. I have known +death, in one instance, induced by it. + +The following circumstances have had a favourable influence upon the +health of the present inhabitants of Philadelphia. + +The improvements in the construction of modern houses, so as to render +them cooler in summer, and warmer in winter. + +The less frequent practice of sitting on porches, exposed to the dew, in +summer evenings. + +The universal use of stoves in places of public worship. + +The abolition of the custom of obliging lying-in women to sit up for +company. + +The partial use of Schuylkill or hydrant water, for culinary and other +purposes. + +The enjoyment of pure air, in country seats, in the neighbourhood of the +city. They not only preserve from sickness during the summer and autumn, +but they render families less liable to diseases during the other seasons +of the year. + +And, lastly, the frequent use of private, and public warm and cold baths. +For the establishment of the latter, the citizens of Philadelphia are +indebted to Mr. Joseph Simons. + +The following circumstances have an unfavourable influence upon the +health of our citizens. + +Ice creams taken in excess, or upon an empty stomach. + +The continuance of the practice of attending funerals, under all the +circumstances that were mentioned in describing the customs which +prevailed in Philadelphia, between the years 1760 and 1766. + +The combined influence of great heat and intemperance in drinking, acting +upon passions unusually excited by public objects, on the 4th of July, +every year. + +The general and inordinate use of segars. + +The want of sufficient force in the water which falls into the common +sewers to convey their contents into the Delaware, renders each of their +apertures a source of sickly exhalations to the neighbouring streets and +squares. + +The compact manner in which the gutters are now formed, by preventing the +descent of water into the earth, has contributed very much to retain the +filth of the city, in those seasons in which they are not washed by rain, +nor by the waste water of the pumps and hydrants. + +The timbers of many of the wharves of the city have gone to decay. The +docks have not been cleaned since the year 1774, and many of them expose +large surfaces to the action of the sun at low water. The buildings have +increased in Water-street, and with them there has been a great increase +of that kind of filth which is generated in all houses; the stores in +this street often contain matters which putrify; from all which there is, +in warm weather, a constant emission of such a f[oe]tid odour, as to +render a walk through that street, by a person who does not reside there, +extremely disagreeable, and sometimes to produce sickness and vomiting. + +In many parts of the vicinity of the city are to be seen pools of +stagnating water, from which there are exhaled large quantities of +unhealthy vapours, during the summer and autumnal months. + +The privies have become so numerous, and are often so full, as to become +offensive in most of the compact parts of the city, more especially in +damp weather. + +The pump water is impregnated with many saline and aërial matters of an +offensive nature. + +While these causes exert an unfriendly influence upon the bodies of the +citizens of Philadelphia, the extreme elevation or depression of their +passions, by the different issues of their political contests (now far +surpassing, in their magnitude, the contests of former years), together +with their many new and fortuitous modes of suddenly acquiring and +losing property, predispose them to many diseases of the mind. + +The present diseases of Philadelphia come next under our consideration. + +Fevers have assumed several new forms since the year 1766. The mild +bilious fever has gradually spread over every part of the city. It +followed the filth which was left by the British army in the year 1778. +In the year 1780, it prevailed, as an epidemic, in Southwark, and in +Water and Front-streets, below Market-street[67]. In the years 1791 and +1792, it assumed an inflammatory appearance, and was accompanied, in many +cases, with hepatic affections. The connection of our subject requires +that I should barely repeat, that it appeared in 1793 as an epidemic, in +the form of what is called yellow fever, in which form it has appeared, +in sporadic cases, or as an epidemic, every year since. During the reign +of this high grade of bilious fever, mild intermittents and remittents, +and the chronic or nervous forms of the summer and autumnal fever, have +nearly disappeared. + + [67] It appears, from the account given by Mr. White of the bilious + fever of Bath, that it prevailed several years in its suburbs, + before it became general in that city. It is remarkable, that + Southwark was nearly the exclusive seat, not only of the bilious + or break-bone fever of 1780, but of the intermitting fever in + 1765, taken notice of by Dr. Bond, and of the yellow fever of + 1805. + +Inflammations and obstructions of the liver have been more frequent than +in former years, and even the pneumonies, catarrhs, intercurrent, and +other fevers of the winter and spring months, have all partaken more or +less of the inflammatory and malignant nature of the yellow fever. + +The pulmonary consumption continues to be a common disease among both +sexes. + +The cynanche trachealis, the scarlatina anginosa, the hydrocephalus +internus, and cholera infantum, are likewise common diseases in +Philadelphia. + +Madness, and several other diseases of the mind, have increased since the +year 1766, from causes which have been mentioned. + +Several of the different forms of gout are still common among both sexes. + +Apoplexy and palsy have considerably diminished in our city. It is true, +the bills of mortality still record a number of deaths from the former, +every year; but this statement is incorrect, if it mean a disease of the +brain only, for sudden deaths from all their causes are returned +exclusively under the name of apoplexy. The less frequent occurrence of +this disease, also of palsy, is probably occasioned by the less +consumption of animal food, and of distilled and fermented liquors, by +that class of citizens who are most subject to them, than in former +years. Perhaps the round hat, and the general use of umbrellas, may have +contributed to lessen those diseases of the brain. + +The dropsy is now a rare disease, and seldom seen even in our hospital. + +The colica pictonum, or dry gripes, is scarcely known in Philadelphia. I +have ascribed this to the use of flannel next to the skin as a part of +dress, and to the general disuse of punch as a common drink. + +The natural small-pox is nearly extirpated, and the puerperile fever is +rarely met with in Philadelphia. The scrophula is much less frequent than +in former years. It is confined chiefly to persons in humble life. + +I proceed, in the order that was proposed, to take notice of the present +medical opinions which prevail among the physicians of Philadelphia. The +system of Dr. Boerhaave long ago ceased to regulate the practice of +physic. It was succeeded by the system of Dr. Cullen. In the year 1790, +Dr. Brown's system of medicine was introduced and taught by Dr. Gibbon. +It captivated a few young men for a while, but it soon fell into +disrepute. Perhaps the high-toned diseases of our city exposed the +fallacy and danger of the remedies inculcated by it, and afforded it a +shorter life than it has had in many other countries. In the year 1790, +the author of this inquiry promulgated some new principles in medicine, +suggested by the peculiar phænomena of the diseases of the United States. +These principles have been so much enlarged and improved by the +successive observations and reasonings of many gentlemen in all the +states, as to form an American system of medicine. This system rejects +the nosological arrangement of diseases, and places all their numerous +forms in morbid excitement, induced by irritants acting upon previous +debility. It rejects, likewise, all prescriptions for the names of +diseases, and, by directing their applications wholly to the forming and +fluctuating states of diseases, and the system, derives from a few active +medicines all the advantages which have been in vain expected from the +numerous articles which compose European treatises upon the materia +medica. This system has been adopted by a part of the physicians of +Philadelphia, but a respectable number of them are still attached to the +system of Dr. Cullen. + +A great change has taken place in the remedies which are now in common +use in Philadelphia. I shall briefly mention such of them as are new, and +then take notice of the new and different modes of exhibiting such as +were in use between the years 1760 and 1766. + +Vaccination has been generally adopted in our city, in preference to +inoculation with variolous matter. + +Digitalis, lead, zinc, and arsenic are now common remedies in the hands +of most of our practitioners. + +Cold air, cold water, and ice are among the new remedies of modern +practice in Philadelphia. + +Blood-letting is now used in nearly all diseases of violent excitement, +not only in the blood-vessels, but in other parts of the body. Its use is +not, as in former times, limited to ounces in specific diseases, but +regulated by their force, and the importance of the parts affected to +health and life; nor is it forbidden, as formerly, in infancy, in extreme +old age, in the summer months, nor in the period of menstruation, where +symptoms of a violent, or of a suffocated disease, manifested by an +active or a feeble pulse, indicate it to be necessary. + +Leeches are now in general use in diseases which are removed, by their +seat or local nature, beyond the influence of the lancet. For the +introduction of this excellent remedy into our city we are indebted to +Mr. John Cunitz. + +Opium and bark, which were formerly given in disguise, or with a +trembling hand, are now, not only prescribed by physicians, but often +purchased, and taken without their advice, by many of the citizens of +Philadelphia. They even occupy a shelf in the closets of many families. + +The use of mercury has been revived, and a salivation has been extended; +with great improvements and success, to nearly all violent and obstinate +diseases. Nor has the influence of reason over ignorance and prejudice, +with respect to that noble medicine, stopped here. Cold water, once +supposed to be incompatible with its use, is now applied to the body, in +malignant fevers, in order to insure and accelerate its operation upon +the salivary glands. + +Wine is given in large quantities, when indicated, without the least fear +of producing intoxication. + +The warm and cold baths, which were formerly confined chiefly to patients +in the Pennsylvania hospital, are now common prescriptions in private +practice. + +Exercise, country air, and the sea shore, are now universally recommended +in chronic diseases, and in the debility which precedes and follows them. + +Great pains are now taken to regulate the quantity and quality of +aliments and drinks, by the peculiar state of the system. + +Let us now inquire into the influence of the new opinions in medicine, +and the new remedies which have been mentioned, upon human life. + +The small-pox, once the most fatal and universal of all diseases, has +nearly ceased to occupy a place in our bills of mortality, by the +introduction of vaccination in our city. For the prompt adoption of this +great discovery, the citizens of Philadelphia owe a large debt of +gratitude to Dr. Coxe, and Mr. John Vaughan. + +Fevers, from all their causes, and in all their forms, with the exception +of the bilious yellow fever, now yield to medicine. Even that most +malignant form of febrile diseases is treated with more success in +Philadelphia than in other countries. It would probably seldom prove +mortal, did a belief in its being derived from an impure atmosphere, and +of its exclusive influence upon the body, while it prevailed as an +epidemic, obtain universally among the physicians and citizens of +Philadelphia. + +The pulmonary consumption has been prevented, in many hundred instances, +by meeting its premonitory signs, in weakness and feeble morbid +excitement in the whole system, by country air, gentle exercise, and +gently stimulating remedies. Even when formed, and tending rapidly to its +last stage, it has been cured by small and frequent bleedings, digitalis, +and a mercurial salivation. + +The hydrocephalus internus, the cynanche trachealis, and cholera +infantum, once so fatal to the children of our city, now yield to +medicine in their early stages. The two former are cured by copious +bleeding, aided by remedies formerly employed in them without success. +The last is cured by moderate bleeding, calomel, laudanum, and country +air. + +The gout has been torn from its ancient sanctuary in error and prejudice, +and its acute paroxysms now yield with as much certainty to the lancet, +as the most simple inflammatory diseases. + +The dropsy is cured by renouncing the unfortunate association of specific +remedies with its name, and accommodating them to the degrees of +excitement in the blood-vessels. + +The tetanus from wounds is now prevented, in most cases, by inflaming the +injured parts, and thereby compelling them to defend the whole system, by +a local disease. Where this preventing remedy has been neglected, and +where tetanus arises from other causes than wounds, it has often been +cured by adding to the diffusible stimulus of opium, the durable stimuli +of bark and wine. + +Death from drinking cold water, in the heated state of the body, is now +obviated by previously wetting the hands or feet with the water; and +when this precaution is neglected, the disease induced by it is generally +cured by large doses of liquid laudanum. + +Madness, which formerly doomed its miserable subjects to cells or chains +for life, has yielded to bleeding, low diet, mercury, the warm and cold +baths, fresh air, gentle exercise, and mild treatment, since its seat has +been discovered to be in the blood-vessels of the brain. + +The last achievement of our science in Philadelphia, that I shall +mention, consists in the discovery and observation of the premonitory +signs of violent and mortal diseases, and in subduing them by simple +remedies, in their forming state. By this means, death has been despoiled +of his prey, in many hundred instances. + +In this successful conflict of medicine with disease and death, midwifery +and surgery have borne a distinguished part. They derive their claims to +the gratitude of the citizens of Philadelphia from the practice of each +of them being more confined, than formerly, to a few members of our +profession. It is in consequence of the former being exercised only by +physicians of regular and extensive educations, that death from +pregnancy and parturition is a rare occurrence in Philadelphia. + +I should greatly exceed the limits prescribed to this inquiry, should I +mention how much pain and misery have been relieved, and how often death +has been baffled in his attempts upon human life, by several late +improvements in old, and the discovery of new remedies in surgery. I +shall briefly name a few of them. + +In cases of blindness, from a partial opacity of the cornea, or from a +closure of the natural pupil, a new pupil has been made; and where the +cornea has been partially opaque, the opening through the iris has been +formed, opposite to any part of it, which retained its transparency. + +The cure of fractures has been accelerated by blood-letting, and, where +the union of a broken bone has not taken place from a defect of bony +matter, it has been produced by passing a seton between the fractured +ends of the bone, and effecting a union thereby between them. Luxations, +which have long resisted both force and art, have been reduced in a few +minutes, and without pain, by bleeding at deliquium animi. + +Old sores have been speedily healed, by destroying their surfaces, and +thereby placing them in the condition of recent accidents. + +The fruitless application of the trepan, in concussions of the brain, has +been prevented by copious bleeding, and a salivation. + +A suppression of urine has been cured, by the addition of a piece of a +bougie to a flexible catheter. + +Strictures in the urethra have been removed by means of a caustic, also, +in a more expeditious way, by dividing them with a lancet. + +Hydrocele has been cured by a small puncture, and afterwards exciting +inflammation and adhesion by an injection of wine into the tunica +vaginalis testis. + +The popliteal aneurism and varicose veins have both been removed by +operations that were unknown a few years ago. + +For the introduction of several of those new surgical remedies, and for +the discovery and improvement of others, the citizens of Philadelphia are +indebted to Dr. Physick. They are likewise indebted to him and Dr. +Griffitts for many of the new and successful modes of practice, in the +diseases that have been mentioned. Even the few remedies that have been +suggested by the author of these inquiries, owe their adoption and +usefulness chiefly to the influence of those two respectable and popular +physicians. + +Before I dismiss this part of our subject, I have only to add, that since +the cure and extraction of the teeth have become a distinct branch of the +profession of medicine, several diseases which have arisen from them, +when decayed, have been detected and cured[68]. + + [68] The late Mr. Andrew Spence was the first regular bred dentist that + settled in Philadelphia. There are now several well educated + gentlemen in the city of that profession. + +We have thus taken a comparative view of the medical theories and +remedies of former and modern times, and of their different influence +upon human life. To exhibit the advantages of the latter over the former, +I shall mention the difference in the number of deaths in three +successive years, at a time when the population of the city and suburbs +was supposed to amount to 30,000 souls, and in three years, after the +population exceeded double that number. + +Between the 25th of December, 1771, and the 25th of December, 1772, there +died 1291 persons. + +Between the same days of the same months, in 1772 and 1773, there died +1344 persons. + +Within the same period of time, between 1773 and 1774, the deaths +amounted to 1021, making in all 3,656. I regret that I have not been able +to procure the returns of deaths in years prior to those which have been +mentioned. During the three years that have been selected, no unusually +mortal diseases prevailed in the city. The measles were epidemic in 1771, +but were not more fatal than in common years. + +Between the 25th of December, 1799, and the 25th of December, 1800, there +died 1525 persons. + +Between the same days of the same months, in the years 1801 and 1802, +there died 1362 persons. + +Within the same period of time, between 1802 and 1803, the deaths +amounted to 1796, making in all 4,883. + +Upon these returns it will be proper to remark, that several hundreds of +the deaths, in 1802 and 1803, were from the yellow fever, and that many +of them were of strangers. Of 68 persons, who were interred in the +Swedes' church-yard alone, one half were of that description of people. +Deducting 500 from both those causes of extra-mortality in the three +years, between 1799 and 1803, the increase of deaths above what they were +in the years 1771 and 1774 is but 727. Had diseases continued to be as +mortal as they were thirty years ago, considering the present state of +our population, the number of deaths would have been more than 7,312. + +To render the circumstances of the statement of deaths that has been +given perfectly equal, it will be necessary to add, that the measles +prevailed in the city, in the year 1802, as generally as they did in +1771. + +From the history that has been given, of the effects of the late +improvements and discoveries in medicine upon human life, in +Philadelphia, we are led to appreciate its importance and usefulness. It +has been said, by its enemies, to move; but its motions have been +asserted to be only in a circle. The facts that have been stated clearly +prove, that it has moved, and rapidly too, within the last thirty years, +in a straight line. + +To encourage and regulate application and enterprize in medicine +hereafter, let us inquire to what causes we are indebted for the late +discoveries and improvements in our science, and for their happy effects +in reducing the number of deaths so far below their former proportion to +the inhabitants of Philadelphia. + +The first cause I shall mention is the great physical changes which have +taken place in the manners of our citizens in favour of health and life. + +A second cause, is the assistance which has been afforded to the practice +of physic, by the numerous and important discoveries that have lately +been made in anatomy, natural history, and chemistry, all of which have +been conveyed, from time to time, to the physicians of the city, by means +of the Philadelphia and hospital libraries, and by the lectures upon +those branches of science which are annually delivered in the university +of Pennsylvania. + +3. The application of reasoning to our science has contributed greatly to +extend its success in the cure of diseases. Simply to observe and to +remember, are the humblest operations of the human mind. Brutes do both. +But to _theorize_, that is, to _think_, or, in other language, to compare +facts, to reject counterfeits, to dissolve the seeming affinity of such +as are not true, to combine those that are related, though found in +remote situations from each other, and, finally, to deduce practical and +useful inferences from them, are the high prerogatives and interest of +man, in all his intellectual pursuits, and in none more, than in the +profession of medicine. + +4. The accommodation of remedies to the changes which are induced in +diseases by the late revolutions in our climate, seasons, and manners, +has had a sensible influence in improving the practice of medicine in our +city. The same diseases, like the descendants of the same families, lose +their resemblance to each other by the lapse of time; and the almanacks +of 1803 might as well be consulted to inform us of the monthly phases of +the moon of the present year, as the experience of former years, or the +books of foreign countries, be relied upon to regulate the practice of +physic at the present time, in any of the cities of the United States. + +5. From the diffusion of medical knowledge among all classes of our +citizens, by means of medical publications, and controversies, many +people have been taught so much of the principles and practice of physic, +as to be able to prescribe for themselves in the forming state of acute +diseases, and thereby to prevent their fatal termination. It is to this +self-acquired knowledge among the citizens of Philadelphia, that +physicians are in part indebted for not being called out of their beds so +frequently as in former years. There are few people who do not venture to +administer laudanum in bowel complaints, and there are some persons in +the city, who have cured the cynanche trachealis when it has occurred in +the night, by vomits and bleeding, without the advice of a physician. The +disuse of suppers is another cause why physicians enjoy more rest at +night than formerly, for many of their midnight calls, were to relieve +diseases brought on by that superfluous meal. + +6. The dispensary instituted in our city, in the year 1786, for the +medical relief of the poor, has assisted very much in promoting the +empire of medicine over disease and death. Some lives have likewise been +saved by the exertions of the humane society, by means of their printed +directions to prevent sudden death; also, by the medical services which +have lately been extended to out-patients, by order of the managers of +the Pennsylvania hospital. + +7thly and lastly. A change, favourable to successful practice in +Philadelphia, has taken place in the conduct of physicians to their +patients. A sick room has ceased to be the theatre of imposture in dress +and manners, and prescriptions are no longer delivered with the pomp and +authority of edicts. On the contrary, sick people are now instructed in +the nature of their diseases, and informed of the names and design of +their medicines, by which means faith and reason are made to co-operate +in adding efficacy to them. Nor are patients left, as formerly, by their +physicians, under the usual appearances of dissolution, without the aid +of medicine. By thus disputing every inch of ground with death, many +persons have been rescued from the grave, and lived, years afterwards, +monuments of the power of the healing art. + +From a review of what has been effected within the last nine and thirty +years, in lessening the mortality of many diseases, we are led to look +forward with confidence and pleasure to the future achievements of our +science. + +Could we lift the curtain of time which separates the year 1843 from our +view, we should see cancers, pulmonary consumptions, apoplexies, palsies, +epilepsy, and hydrophobia struck out of the list of mortal diseases, and +many others which still retain an occasional power over life, rendered +perfectly harmless, _provided_ the same number of discoveries and +improvements shall be made in medicine in the intermediate years, that +have been made since the year 1766. + +But in vain will the avenues of death from those diseases be closed, +while the more deadly yellow fever is permitted to supply their place, +and to spread terror, distress, and poverty through the city, by +destroying the lives of her citizens by hundreds or thousands every year. +Dear cradle of liberty of conscience in the western world! nurse of +industry and arts! and patron of pious and benevolent institutions! may +this cease to be thy melancholy destiny! May Heaven dispel the errors and +prejudices of thy citizens upon the cause and means of preventing their +pestilential calamities! and may thy prosperity and happiness be revived, +extended, and perpetuated for ages yet to come! + + * * * * * + + + + + INDEX. + + + A + + Anthelmintics, i. 228 + Arsenic, a remedy for cancerous sores, i. 240 + Army of the United States, diseases of, i. 269 + ----, causes of, i. 272 + ----, remedies for, i. ibid. + Agriculture, the practice of, recommended to country physicians, i. 388 + Age, old, observations on the state of the body and mind in, i. 427 + ----, its diseases, i. 446 + ----, ----, their remedies, i. 449 + Air, cool, its good effects in the yellow fever of 1793, iii. 279 + Association of ideas, its effects upon morals, ii. 45 + + B. + + Barometer, its mean elevation in Philadelphia, i. 96 + Blisters, their efficacy in obstinate intermittents, i. 179 + ----, ----, in the bilious fever of 1780, i. 128 + ----, ----, in the yellow fever of 1803, when applied in its early + stage, iv. 141 + Bed, lying in, useful in the bilious fever of 1780, i. 128 + Bleeding, its efficacy in the cure of obstinate intermittents, i. 179 + ----, ----, in the yellow fever of 1793, iii. 253 + ----, reasons for the practice, iii. 254 + ----, circumstances which regulated it, iii. 261 + ----, objections to it answered, iii. 269 + ----, gradual manner of abstracting blood recommended, iii. 273 + Blood-letting, defence of it as a remedy for certain diseases, iv. 275 + ----, indicated in fevers, iv. ibid. + ----, its good effects in fevers, iv. 277 + ----, objections to it answered, iv. 284 + ----, its comparative advantages, iv. 313 + ----, circumstances which should regulate its use, iv. 316 + ----, appearances of the blood, iv. 326 + ----, when forbidden, or to be used cautiously, iv. 344 + ----, its advantages in pregnancy, iv. 349 + ----, in parturition, iv. 353 + ----, during the cessation of the menses, iv. 356 + ----, in curing the disease induced by a large dose of opium, iv. 357 + ----, in curing the disease induced by poison, iv. ibid. + ----, in diabetes, iv. ibid. + ----, in dislocated bones, iv. 358 + Blood, quantity drawn from several persons in 1797, iv. 37 + ----, appearances of it in 1793, iii. 256 + ----, ----, in 1794, iii. 404 + + C. + + Civilization, diseases derived from it, i. 32 + ----, ----, not necessarily connected with it, i. 60 + Climate of Pennsylvania, account of, i. 71 + ----, its changes, i. 76 + ----, its temperature, i. 78 + ----, its effects upon health and life, i. 108 + Calomel, useful joined with emetics in scarlatina anginosa, i. 144 + ----, its effects as a purge, when combined with jalap, in the yellow + fever, iii. 241 + ----, objections to it answered, iii. 243 + Contagious, the yellow fever not so, iv. 223 + Cholera infantum described, i. 157 + ----, a form of bilious fever, i. 158 + ----, its remedies, i. 160 + ----, means of preventing it, i. 164 + Cynanche trachealis, its different names, i. 169 + ----, appearances in the trachea after death, i. 170 + ----, its different grades, i. 171 + ----, its remedies in its forming state, i. ibid. + ----, its remedies after it is formed, i. 172 + ----, favourable and unfavourable signs of its issue, i. 174 + Consumption, pulmonary, thoughts on, i. 199 + ----, pulmonary, Indians, and persons who lead laborious lives, not + subject to it, i. 200 + ----, radical remedies for it in exercise, labour, and the hardships of + a camp and naval life, i. 204 + ----, its causes, ii. 62 + ----, not contagious, ii. 79 + ----, tracheal, described, ii. 84 + ----, its remedies, ii. 87 + ----, premonitory signs, ii. ibid. + ----, of the remedies for its inflammatory state, ii. 89 + ----, of blood-letting, ii. ibid. + ----, of a vegetable diet, ii. 104 + ----, of the remedies for its hectic state, ii. 107 + ----, for its typhus state, ii. 108 + ----, of its radical remedies, ii. 128 + ----, of exercise, ii. ibid. + ----, of travelling, ii. 137 + ----, signs of its long or short duration, and of its issue in life and + death, ii. 144 + ----, its different ways of terminating in death, ii. 147 + College of physicians, their letter to the citizens of Philadelphia, + declaring the existence of the yellow fever in the city, &c. in 1793, + iii. 82 + ----, their letter to the governor of the state, on the origin of the + yellow fever in 1793, iii. 197 + ----, their opinion of the origin of the fever in 1799, iv. 100 + + D. + + Diseases of the Indians, i. 16 + ----, from civilization, i. 30 + ----, produced by ardent spirits, i. 343 + ----, of the military hospitals, during the revolutionary war between + Great-Britain and the United States, i. 269 + ----, of old age, i. 446 + Drunkenness, a fit of it described, i. 338 + ----, remedies for it, i. 374 + Disease, summer and autumnal, its sources, iv. 163 + ----, means of preventing it in its malignant forms, iv. 173 + ----, in its mild forms, iv. 198 + ----, in its intestinal forms, iv. 200 + ----, of preserving cities and communities from them, iv. 202 + ----, of exterminating them, iv. 210 + ----, from drinking cold water, i. 186 + ----, ----, how prevented, i. ibid. + ----, ----, its cure, i. 185 + Dropsies, their causes, ii. 151 + ----, divided into inflammatory, and of weak morbid action in the + blood-vessels, ii. 157 + ----, remedies for the inflammatory state of, ii. 160 + ----, ----, with weak morbid action in the blood-vessels, ii. 176 + Dropsy of the brain, internal, ii. 192 + ----, its history, ii. 195 + ----, its causes, ii. 203 + ----, its cure, ii. 210 + Distress, familiarity with it, its moral effects, ii. 46 + Death, its proximate cause, ii. 447 + + E. + + Emetics, useful in the bilious fever of 1780, i. 186 + ----, in the scarlatina anginosa of 1783 and 1784, i. 144 + ----, in the yellow fever of 1798, iv. 79 + ----, in the yellow fever of 1799, iv. 97 + ----, hurtful in the yellow fever of 1797, iv. 44 + Exhalations, putrid, their sources and effects in producing the + summer and autumnal disease, iv. 163 + + F. + + Faculty, moral, inquiry into the influence of physical causes on, ii. 3 + Fruits, summer, useful in destroying worms, i. 229 + Fever, bilious, history of it in 1780, i. 117 + ----, outlines of a theory of, iii. 3 + ----, its unity asserted, iii. 17 + ----, unity of its exciting causes, iii. 16 + ----, objections to a nosological arrangement of its different + forms, iii. 33 + ----, effects of, iii. 39 + ----, different states of, enumerated, iii. 41 + ----, objections to putrefaction in, iii. 43 + ----, bilious yellow, history of, in 1793, iii. 69 + ----, ----, its exciting causes, iii. 88 + ----, ----, its premonitory signs, iii. 93 + ----, ----, its first symptoms, iii. 95 + ----, ----, symptoms of it in the blood-vessels, iii. 97 + ----, ----, ----, in the liver, lungs, and brain, iii. 104 + ----, ----, ----, in the stomach and bowels, iii. 108 + ----, ----, ----, in the secretions and excretions, iii. 110 + Fever, bilious yellow, symptoms of it, in the nervous system, iii. 116 + ----, ----, ----, in the senses and appetites, iii. 122 + ----, ----, ----, in the lymphatic and glandular system, iii. 124 + ----, ----, ----, on the skin, iii. 125 + ----, ----, ----, in the blood, iii. 128 + ----, ----, nature of the black vomit, iii. 111 + ----, ----, types of the, iii. 135 + ----, ----, the empire of, over all other diseases, iii. 139 + ----, ----, who most subject to it, iii. 148 + ----, ----, negroes affected by it in common with white people, + iii. 151 + ----, ----, state of the atmosphere during the prevalence of, iii. 158 + ----, ----, signs of the presence of miasmata in the body, + universal, iii. 157 + ----, ----, cases of re-infection, iii. 164 + ----, ----, external appearances of the body after death in, iii. 165 + ----, ----, appearances of the body by dissection, iii. 167 + ----, ----, account of the distress of the city, iii. 175 + ----, ----, its moral effects upon the inhabitants, iii. 179 + ----, ----, number of deaths from it, iii. 181 + ----, ----, is checked and destroyed by rain, iii. 184 + ----, ----, inquiry into its origin by the governor of the + state, iii. 196 + ----, ----, said to be imported by the college of physicians, iii. 197 + ----, ----, objections to their opinion, and proofs of its domestic + origin, iii. 198 + ----, the sameness of its origin with the plague, iii. 211 + ----, state of the weather in 1793, iii. 215 + ----, method of cure, iii. 223 + ----, dissentions of the physicians, iii. 235 + ----, of purging, iii. 239 + ----, its salutary effects, iii. 241 + ----, objections to it answered, iii. 243 + ----, blood-letting, its utility, iii. 253 + ----, salivation, its utility, iii. 284 + ----, convalescence, iii. 289 + ----, remarks on the use of stimulating remedies in this fever, + iii. 292 + ----, comparative view of the success of all the modes of practice + employed in the fever, iii. 298 + Fever, yellow, of 1794, history of, iii. 357 + ----, its exciting causes, iii. 367 + ----, symptoms in the different systems of the body, iii. 369 + ----, in the blood-vessels, iii. ibid. + ----, in the viscera, iii. 371 + ----, in the alimentary canal, iii. 373 + ----, in the secretions and excretions, iii. 375 + ----, in the nervous system, iii. 379 + ----, in the senses and appetites, iii. 383 + ----, in the lymphatic system, iii. ibid. + ----, in the blood, iii. 387 + ----, different forms of the fever, iii. 388 + ----, its origin, iii. 397 + ----, method of cure, iii. 401 + ----, bleeding, iii. 402 + Fever, yellow, of 1794, good effects of cool air and cold water in, + iii. 409 + ----, of a salivation, iii. 411 + ----, of blisters, iii. 413 + ----, of tonic remedies, iii. 415 + ----, of the inefficacy of bark, iii. ibid. + ----, of the effects of wine, iii. 418 + ----, ----, of opium, iii. 419 + ----, ----, of nitre, iii. 421 + ----, ----, of antimonials, iii. ibid. + Fever, yellow, sporadic cases of, in the years 1795 and 1796, iii. 437 + Fever, yellow, of 1797, iv. 3 + ----, symptoms of, iv. 13 + ----, type of, iv. 20 + ----, different forms of, iv. 21 + ----, influence of the moon upon it, iv. 27 + ----, number of deaths, particularly of physicians, iv. 30 + ----, origin of it, iv. 33 + ----, its remedies, iv. ibid. + ----, of bleeding, iv. ibid. + ----, of purging medicines, iv. 37 + ----, of a salivation, iv. 39 + ----, different ways in which mercury acted upon the mouth and throat, + iv. 40 + ----, of emetics, iv. 44 + ----, of diet and drinks, iv. 45 + ----, of tonic remedies, iv. 49 + ----, of blisters, iv. ibid. + ----, of sweet oil, iv. 51 + Fever, yellow, of 1797, relative success of different modes of + practice, iv. 53 + ----, signs of a favourable and unfavourable issue of the fever, + iv. 55 + Fever, yellow, of 1798, account of, iv. 67 + ----, symptoms of, iv. 68 + ----, in the blood-vessels, iv. ibid. + ----, alimentary canal, iv. ibid. + ----, on the tongue, iv. 69 + ----, in the nervous system, iv. ibid. + ----, in the eyes, lymphatics, and blood, iv. 71 + ----, different modes in which it terminated in death, iv. 74 + ----, state of the weather in 1798, iv. 77 + ----, origin of the fever, iv. 78 + ----, remedies for it, iv. ibid. + ----, bleeding, iv. ibid. + ----, emetics, iv. 79 + ----, purges, iv. 81 + ----, of a salivation, iv. ibid. + ----, of sweats, iv. 82 + ----, of bark, iv. 83 + ----, of blisters, iv. ibid. + ----, symptoms which indicated a favourable and unfavourable issue of + the disease, iv. 84 + ----, different modes of practice in this fever, and their different + success, iv. 85 + Fever, bilious, of 1799, iv. 91 + ----, sickliness among certain animals, iv. 94 + ----, its symptoms, iv. 95 + ----, its remedies, iv. 97 + Fever, yellow, of 1799, signs of a favourable and unfavourable issue of + it, iv. 99 + ----, its origin, iv. 100 + Fever, yellow, sporadic cases of, in 1800, iv. 103 + ----, ----, in 1801, iv. 111 + Fever, yellow, of 1802, account of, iv. 123 + ----, its origin, iv. 123 + ----, its types, iv. 127 + Fever, yellow, as it appeared in 1803, iv. 133 + ----, symptoms of, iv. 136 + ----, remedies for, iv. 139 + Fever, yellow, sporadic cases in 1804, iv. 147 + Fever, yellow, as it appeared in 1805, iv. 153 + ----, its origin, iv. 155 + ----, its remedies, iv. 156 + ----, not contagious, iv. 223 + + G. + + Gout, peculiarities belonging to it, ii. 227 + ----, its remote causes, ii. 230 + ----, women most subject to it, ii. 232 + ----, its exciting causes, ii. ibid. + ----, its symptoms, ii. 234 + ----, method of cure, ii. 251 + ----, remedies in its forming state, ii. 253 + ----, in a paroxysm, when attended with great morbid or inflammatory + action in the blood-vessels, ii. 252 + ----, when attended with weak morbid action in the blood-vessels, + ii. 269 + ----, remedies for its symptoms, ii. 275 + ----, means for preventing the return of inflammatory, ii. 285 + ----, with weak morbid action, ii. 293 + + H. + + Hospitals, their origin, i. 55 + ----, military, their evils, i. 276 + ----, constructed with ground floors, to be preferred in fevers, i. 275 + Heat, greatest in Philadelphia, i. 87 + Habit, its effects upon morals, ii. 43 + Hæmoptysis, observations on, i. 191 + Hydrophobia, observations on, ii. 301 + ----, its causes, ii. 302 + ----, its symptoms in rabid animals, ii. 306 + ----, ----, in the human species, ii. 308 + ----, supposed to be a malignant fever, ii. ibid. + ----, remedies to prevent it, ii. 315 + ----, ----, to cure it in its malignant or inflammatory state, ii. 317 + ----, ----, to cure it when attended with weak morbid action in the + blood-vessels, ii. 323 + ----, death from it, supposed to be from suffocation, ii. 326 + ----, laryngotomy suggested to prevent it, ii. 332 + + I. + + Indians, oration on their diseases and remedies, i. 3 + ----, peculiar customs of their women, i. 9 + ----, ----, of their men, i. 11 + ----, ----, of both sexes, i. 12 + Indians, their diseases, i. 16 + ----, their remedies, i. 20 + ----, comparative view of their diseases and remedies with those of + civilized nations, i. 39 + Iron, its preparations useful in destroying worms, i. 232 + Imitation, its effects upon morals, ii. 42 + Influenza, account of it, as it appeared in Philadelphia in 1789, 1790, + and 1791, ii. 353 + ----, history of its symptoms, ii. 354 + ----, mode of treatment, ii. 360 + Jaw-fall, or trismus, in infants, i. 254 + + L. + + Laudanum, its efficacy in the disease brought on by drinking cold water + in hot weather, i. 185 + Legs, sore, observations on, i. 411 + ----, classes of people most subject to them, i. 412 + ----, their remedies, i. 416 + Longevity, circumstances which favour it, i. 428 + Life, animal, inquiry into its causes, ii. 371 + ----, a forced state, or the effects of impressions, ii. 377 + ----, enumeration of those impressions, ii. 378 + ----, how supported in sleep, ii. 397 + ----, in the f[oe]tus in utero, ii. 404 + ----, in infancy, ii. 405 + ----, in youth, ii. 409 + ----, in middle life, ii. 410 + ----, in old age, ii. ibid. + ----, in persons blind, or deaf and dumb from their birth, ii. 414 + ----, in idiots, ii. 416 + ----, after long abstinence, ii. 417 + ----, in asphyxia, ii. 419 + ----, in the Indians of North-America, ii. 427 + ----, in the Africans, ii. 428 + ----, in the Turkish empire, ii. 429 + ----, in China and the East-Indies, ii. 431 + ----, in the poor inhabitants of Europe, ii. 432 + ----, stimuli which act alike in promoting it upon all nations, ii. 434 + ----, how supported in sundry animals, ii. 441 + ----, its extinction in death, how effected, ii. 447 + + M. + + Midwifery, the practice of it more successful by men than by women, + i. 53 + Manufactures, sedentary, unfriendly to the health of men, i. 65 + Measles, history of, in 1789, ii. 338 + ----, their symptoms, ii. 339 + ----, a spurious, or external form of them described, ii. 342 + ----, remedies used in them, ii. 346 + ----, history of them, as they appeared in 1801, iv. 117 + Medicine, an inquiry into its comparative state, in Philadelphia, + between 1760 and 1766, and 1805, iv. 365 + Diet of the inhabitants between 1760 and 1766, iv. 366 + Dresses, iv. 368 + Customs which had an influence on health, iv. 369 + Diseases, iv. 370 + + N. + + Nature, meaning of the term, i. 35 + ----, the extent of her powers in curing diseases, i. 20 + Nosology, objections to it, iii. 33 + Negroes subject to the yellow fever in common with the white people, + iii. 366 + + O. + + Opium, useful in the bilious fever of 1780, i. 130 + ----, the disease induced by it cured by blood-letting, iv. 357 + Onion juice, useful in destroying worms, i. 231 + + P. + + Philadelphia, its situation, i. 74 + ----, population, i. 76 + ----, diseases between 1760 and 1766, and 1805, iv. 365 + Purges, useful in the bilious fever of 1780, i. 127 + ----, ----, in the yellow fever of 1793, iii. 231 + ----, objections to them answered, iii. 243 + Pulse, state of, in old people, i. 439 + ----, in the yellow fever of 1793, in persons not confined with it, + iii. 157 + ----, in fevers, when it indicates blood-letting, iv. 316 + Putrefaction, does not take place in the blood, iii. 43 + Pregnancy, a morbid state of the system, iv. 349 + ----, effects of blood-letting in relieving its diseases, iv. ibid. + Parturition, a disease, iv. 353 + ----, effects of blood-letting in lessening its pains, iv. ibid. + + Q. + + Quarantine laws, their inefficacy to prevent a yellow fever, iv. 218 + ----, their evils, iv. ibid. + + R. + + Rain, usual quantity in Pennsylvania, i. 72 + Revolution, American, its influence upon the human body and mind, + i. 279 + + S. + + Snow, common depth in Pennsylvania, i. 91 + Sweating described among the Indians of North-America, i. 22 + Scarlatina anginosa of 1783 and 1784 described, i. 138 + ----, additional observations on, i. 147 + ----, prevented by gentle purges, i. 151 + ----, cured by emetics in its forming state, i. 150 + Salt, common, useful in the hæmoptysis, i. 192 + ----, in destroying worms, i. 230 + Sugar, useful in destroying worms, i. ibid. + Spirits, ardent, their effects upon the human body and mind, i. 337 + ----, diseases produced by them, i. 343 + ----, their effects on property, i. 347 + ----, substitutes for them, i. 353 + ----, persons predisposed to their use, i. 360 + ----, their influence upon the population of the United States, i. 364 + Sweats, useful in the yellow fever of 1803, iv. 140 + Salivation, its usefulness in the yellow fever of 1793, iii. 284 + ----, ----, of 1794, iii. 411 + ----, ----, of 1797, iv. 49 + ----, ----, of 1798, iv. 81 + Small-pox, new mode of inoculating for, i. 311 + + T. + + Tetanus, its causes, i. 248 + ----, its remedies when from wounds, i. 256 + ----, ----, when from other causes, i. 259 + + W. + + Winters, cold, in Pennsylvania, i. 76, 77, 79 + Winds, common, in Pennsylvania, i. 90 + Water, cold, disease from drinking it when the body is preternaturally + heated, i. 184 + Worms, natural to young children, and to young animals, i. 218 + ----, intended, probably, to prevent disease, i. 219 + ----, destroyed by medicines that act mechanically and chemically upon + them, i. 128 + Wounds, gun-shot, in joints, followed by death, i. 274 + + + FINIS. + + * * * * * + + LATELY PUBLISHED, + +And for sale by CONRAD & CO. at their stores in Philadelphia, Baltimore, +Washington, Petersburg, and Norfolk, + +_The Philadelphia Medical and Physical Journal_, collected and arranged +by _Benjamin Smith Barton_, professor of materia medica, natural history, +and botany, in the University of Pennsylvania. Volume I. Price, in +boards, 2 dollars. + +_A System of Surgery_. By _Benjamin Bell_, member of the Royal Colleges +of Surgeons of Edinburgh and Ireland, &c. &c. 4 vols. 8vo. Price 14 +dollars. + +_A Treatise on the Fevers of Jamaica_, with some Observations on the +Intermitting Fever of America; and an Appendix, containing some Hints on +the Means of Preserving the Health of Soldiers in Hot Climates. By +_Robert Jackson_, M. D. + + * * * * * + + IN THE PRESS, + + _The Philadelphia Medical and Physical Journal._ Part I. Vol. II. + + + + + * * * * * + + + + +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 58862 *** |