letter I received from Mr. Hugh Ferguson, then a student of medicine in

the college of Edinburgh, written from Dublin, during the time of a visit to his father, and dated September 30th, 1793, I find a fact which throws additional light upon this subject. "A case (says my young correspondent) where a remarkable intermission of pulse was observed, occurred in this city last year. A gentleman of the medical profession, middle aged, of a delicate habit of body, and who had formerly suffered phthisical attacks, was attacked with the acute rheumatism. Some days after he was taken ill, he complained of uncommon fulness, and a very peculiar kind of sensation about the præcordia, which it was judged proper to relieve by copious blood-letting. This being done, the uneasiness went off. It returned, however, three or four times, and was as often relieved by bleeding. During each of his fits (if I may call them so), the patient experienced an almost total remission of his pains in his limbs; but they returned with equal or greater violence after blood-letting. During the fit there was an intermission of the pulse (the first time) of no less than thirteen strokes. It was when beating full, strong, and slow. The third intermission was of nine strokes. The gentleman soon recovered, and has enjoyed good health for ten months past. The opinion of some of his physicians was, that the heart was affected, as a muscle, by the rheumatism, and alternated with the limbs."

[16] Outlines of a Theory of Fever.

[17] Vergasca, Sorbait, and Boate in Haller's Bibliotheca Medicinæ, vol. iii. also by Dr. Stubbs in the Philosophical Transactions, and Riverius in his treatise de febre pestilenti.

[18] Historia Anatomica Medica, vol ii. obs. 405, 418, 423, 510.

[19] Medical Histories and Reflections, p. 150.

I am the more inclined to believe the peculiarity in the pulse which has been mentioned in the yellow fever, arose in part from a spasmodic affection of the heart, from the frequency of an uncommon palpitation of this muscle, which I discovered in this disease, more especially in old people. The disposition, likewise, to syncope and sighing, which so often occurred, can be explained upon no other principle than inflammation, spasm, dilatation, or congestion in the heart. After the 10th of September this undescribable or _sulky_ pulse (for by the latter epithet I sometimes called it) became less observable, and, in proportion as the weather became cool, it totally disappeared. It was gradually succeeded by a pulse full, tense, quick, and as frequent as in pleurisy or rheumatism. It differed, however, from a pleuritic or rheumatic pulse, in imparting a very different sensation to the fingers. No two strokes seemed to be exactly alike. Its action was of a hobbling nature. It was at this time so familiar to me that I think I could have distinguished the disease by it without seeing the patient. It was remarkable that this pulse attended the yellow fever even when it appeared in the mild form of an intermittent, and in those cases where the patients were able to walk about or go abroad. It was nearly as _tense_ in the remissions and intermissions of the fever as it was in the exacerbations. It was an alarming symptom, and when the only remedy which was effectual to remove it was neglected, such a change in the system was induced as frequently brought on death in a few days.

This change of the pulse, from extreme lowness to fulness and activity, appeared to be owing to the diminution of the heat of the weather, which, by its stimulus, added to that of the remote cause, had induced those symptoms of depression of the pulse which have been mentioned.

The pulse most frequently lessened in its fulness, and became gradually weak, frequent, and imperceptible before death, but I met with several cases in which it was full, active, and even tense in the last hours of life.

_Hæmorrhages_ belong to the symptoms of this fever as they appeared in the sanguiferous system. They occurred in the beginning of the disease, chiefly from the nose and uterus. Sometimes but a few drops of blood distilled from the nose. The menses were unusual in their quantity when they appeared at their stated periods, but they often came on a week or two before the usual time of their appearance. I saw one case of a hæmorrhage from the lungs on the first day of the fever, which was supposed to be a common hæmoptysis. As the disease advanced the discharges of blood became more universal. They occurred from the gums, ears, stomach, bowels, and urinary passages. Drops of blood issued from the inner canthus of the left eye of Mr. Josiah Coates. Dr. Woodhouse attended a lady who bled from the holes in her ears which had been made by ear-rings. Many bled from the orifices which had been made by bleeding, several days after they appeared to have been healed, and some from wounds which had been made in veins in unsuccessful attempts to draw blood. These last hæmorrhages were very troublesome, and in some cases precipitated death.

II. I come now to mention the symptoms of this fever as they appeared in the _liver_, the _lungs_, and the _brain_. From the histories which I had read of this disease, I was early led to examine the state of the _liver_, but I was surprised to find so few marks of hepatic affection. I met with but two cases in which the patient could lie only on the right side. Many complained of a dull pain in the region of the liver, but very few complained, in the beginning of the disease, of that soreness to the touch, about the pit of the stomach, which is taken notice of by authors, and which was universal in the yellow fever in 1762. In proportion as the cool weather advanced, a preternatural determination of the blood took place chiefly to the lungs and brain. Many were affected with pneumonic symptoms, and some appeared to die of sudden effusions of blood or serum in the lungs. It was an unexpected effusion of this kind which put an end to the life of Mrs. Keppele after she had exhibited hopeful signs of a recovery.

I saw one person who recovered from an affection of the lungs, by means of a copious expectoration of yellow phlegm and mucus. But the _brain_ was principally affected with morbid congestion in this disease. It was indicated by the suffusion of blood in the face, by the redness of the eyes, by a dilatation of the pupils, by the pain in the head, by the hæmorrhages from the nose and ears, by the sickness or vomiting, and by an almost universal costive state of the bowels. I wish to impress the reader with these facts, for they formed one of the strongest indications for the use of the remedies which I adopted for the cure of this disease. It is difficult to determine the exact state of these viscera in every case of bilious and yellow fever. Inflammation certainly takes place in some cases, and internal hæmorrhages in others; but I believe the most frequent affection of these viscera consists in a certain morbid accumulation of blood in them, which has been happily called, by Dr. Clark, an _engorgement_ or choaking of the blood-vessels. I believe further, with Dr. Clark[20] and Dr. Balfour[21], that death in most cases in bilious fevers is the effect of these morbid congestions, and wholly unconnected with an exhausted state of the system, or a supposed putrefaction in the fluids. It is true, the dissections of Dr. Physick and Dr. Cathrall (to be mentioned hereafter) discovered no morbid appearances in any of the viscera which have been mentioned, but it should be remembered, that these dissections were made early in the disease. Dr. Annan attended the dissection of a brain of a patient who died at Bush-hill some days afterwards, and observed the blood-vessels to be unusually turgid. In those cases where congestion only takes place, it is as easy to conceive that all morbid appearances in the brain may cease after death, as that the suffusion of blood in the face should disappear after the retreat of the blood from the extremities of the vessels, in the last moments of life. It is no new thing for morbid excitement of the brain to leave either slender, or no marks of disease after death. This, I have said, is often the case where it exceeds that degree of action which produces an effusion of red blood into serous vessels, or what is called inflammation[22]. Dr. Quin has given a dissection of the brain of a child that died with all the symptoms of hydrocephalus internus, and yet nothing was discovered in the brain but a slight turgescence of its blood-vessels. Dr. Girdlestone says, no injury appeared in the brains of those persons who died of the symptomatic apoplexy, which occurred in a spasmodic disease which he describes in the East-Indies; and Mr. Clark informs us, that the brain was in a natural state in every case of death from puerperile fever, notwithstanding it seemed to be affected in many cases soon after the attack of that disease[23].

[20] Vol. i. p. 168.

[21] Treatise on the Intestinal Remitting Fever, p. 125.

[22] Outlines of a theory of fever.

[23] Essay on the Epidemic Disease of Lying-in Women, of the years 1787 and 1788, p. 34.

I wish it to be remembered here, that the yellow fever, like all other diseases, is influenced by climate and season. The determination of the fluids is seldom the same in different years, and I am sure it varied with the weather in the disease which I am now describing. Dr. Jackson speaks of the head being most affected in the West-India fevers in _dry_ situations. Dr. Hillary says, that there was an unusual determination of the blood towards the brain, after a _hot_ and _dry_ season, in the fevers of Barbadoes in the year 1753; and Dr. Ferriar, in his account of an epidemic jail fever in Manchester, in 1789, 1790, informs us, that as soon as frost set in, a delirium became a more frequent symptom of that disease, than it had been in more temperate weather.

III. The _stomach_ and _bowels_ were affected in many ways in this fever. The disease seldom appeared without nausea or vomiting. In some cases, they both occurred for several days or a week before they were accompanied by any fever. Sometimes a pain, known by the name of gastrodynia, ushered in the disease. The stomach was so extremely irritable as to reject drinks of every kind. Sometimes green or yellow bile was rejected on the first day of the disease by vomiting; but I much oftener saw it continue for two days without discharging any thing from the stomach, but the drinks which were taken by the patient. If the fever in any case came on without vomiting, or if it had been checked by remedies that were ineffectual to remove it altogether, it generally appeared, or returned, on the 4th or 5th day of the disease. I dreaded this symptom on those days, for although it was not always the forerunner of death, yet it generally rendered the recovery more difficult and tedious. In some cases the vomiting was more or less constant from the beginning to the end of the disease, whether it terminated in life or death.

The vomiting which came on about the 4th or 5th day, was accompanied with a burning pain in the region of the stomach. It produced great anxiety, and tossing of the body from one part of the bed to another. In some cases, this painful burning occurred before any vomiting had taken place. Drinks were now rejected from the stomach so suddenly, as often to be discharged over the hand that lifted them to the head of the patient. The contents of the stomach (to be mentioned hereafter) were sometimes thrown up with a convulsive motion, that propelled them in a stream to a great distance, and in some cases all over the clothes of the by-standers.

Flatulency was an almost universal symptom, in every stage of this disease. It was very distressing in many cases. It occurred chiefly in the stomach.

The _bowels_ were generally costive, and in some patients as obstinately so as in the dry gripes. In some cases there was all the pain and distress of a bilious colic, and in others, the tenesmus, and mucous and bloody discharges of a true dysentery. A diarrh[oe]a introduced the disease in a few persons, but it was chiefly in those who had been previously indisposed with weak bowels. A painful tension of the abdomen took place in many, accompanied in some instances by a dull, and in others by an acute pain in the lower part of the belly.

IV. I come now to describe the state of the _secretions_ and _excretions_ as they appeared in different stages of this fever.

In some cases there was a constipation of the liver, if I may be allowed that expression, or a total obstruction of secretion and excretion of bile, but more frequently a preternatural secretion and excretion of it took place. It was discharged, in most cases, from the stomach and bowels in large quantities, and of very different qualities and colours.

1. On the first and second days of the disease many patients puked from half a pint to nearly a quart of green or yellow bile. Four cases came under my notice in which black bile was discharged on the _first_ day. Three of these patients recovered.

2. There was frequently, on the 4th or 5th day, a discharge of matter from the stomach, resembling coffee impregnated with its grounds. This was always an alarming symptom. I believed it at first to be a modification of vitiated bile, but subsequent dissections by Dr. Physick have taught me that it was the result of the first stage of those morbid actions in the stomach, which afterwards produce the black vomit. Many recovered who discharged this coffee-coloured matter.

3. Towards the close of this disease, there was a discharge of matter of a deep or pale black colour, from the stomach. Flakey substances frequently floated in the bason or chamber-pot upon the surface of this matter. It was what is called the _black vomit_. It was formerly supposed to be vitiated bile, but it has been proved by Dr. Stewart, and afterwards by Dr. Physick, to be the effect of disease in the stomach.

4. There was frequently discharged from the stomach in the close of the disease, a large quantity of grumous blood, which exhibited a dark colour on its outside, resembling that of some of the matters which have been described, and which I believe was frequently mistaken for what is commonly known by the name of the _black vomit_. Several of my patients did me the honour to say, I had cured them after that symptom of approaching dissolution had made its appearance; but I am inclined to believe, dark-coloured blood only, or the coffee-coloured matter, was mistaken for the matters which constitute the fatal black vomiting. I except here the black discharge before-mentioned, which took place in three cases on the first day of the disease. This I have no doubt was bile, but it had not acquired its greatest acrimony, and it was discharged before mortification, or even inflammation could have taken place in the stomach. Several persons died without a black vomiting of any kind.

Along with all the discharges from the stomach which have been described, there was occasionally a large worm, and frequently large quantities of mucus and tough phlegm.

The colour, quality, and quantity of the _fæces_ depended very much upon the treatment of the disease. Where active purges had been given, the stools were copious, f[oe]tid, and of a black or dark colour. Where they were spontaneous, or excited by weak purges, they had a more natural appearance. In both cases they were sometimes of a green, and sometimes of an olive colour. Their smell was more or less f[oe]tid, according to the time in which they had been detained in the bowels. I visited a lady who had passed several days without a stool, and who had been treated with tonic remedies. I gave her a purge, which in a few hours procured a discharge of fæces so extremely f[oe]tid, that they produced fainting in an old woman who attended her. The acrimony of the fæces was such as to excoriate the rectum, and sometimes to produce an extensive inflammation all around its external termination. The quantity of the stools produced by a single purge was in many cases very great. They could be accounted for only by calling in the constant and rapid formation of them, by preternatural effusions of bile into the bowels.

I attended one person, and heard of two others, in whom the stools were as white as in the jaundice. I suspected, in these cases, the liver to be so constipated or paralyzed by the disease, as to be unable to secrete or excrete bile to colour the fæces. Large round worms were frequently discharged with the stools.

The _urine_ was in some cases plentiful, and of a high colour. It was at times clear, and at other times turbid. About the 4th or 5th day, it sometimes assumed a dark colour, and resembled strong coffee. This colour continued, in one instance, for several days after the patient recovered. In some, the discharge was accompanied by a burning pain, resembling that which takes place in a gonorrh[oe]a. I met with one case in which this burning came on only in the evening, with the exacerbation of the fever, and went off with its remission in the morning.

A total deficiency of the urine took place in many people for a day or two, without pain. Dr. Sydenham takes notice of the same symptom in the highly inflammatory small-pox[24]. It generally accompanied or portended great danger. I heard of one case in which there was a _suppression_ of urine, which could not be relieved without the use a the catheter.

[24] Wallis's edition, vol. i. p. 197.

A young man was attended by Mr. Fisher, one of my pupils, who discharged several quarts of limpid urine just before he died.

Dr. Arthaud informs us, in the history of a dissection of a person who died of the yellow fever, that the urine after death imparted a green colour to the tincture of radishes[25].

[25] Rosier's Journal for January, 1790, vol. xxxvi. p. 380.

Many people were relieved by copious _sweats_ on the first day of the disease. They were in some instances spontaneous, and in others they were excited by diluting drinks, or by strong purges. These sweats were often of a yellow colour, and sometimes had an offensive smell. They were in some cases cold, and attended at the same time with a full pulse. In general, the skin was dry in the beginning, as well as in the subsequent stages of the disease. I saw but few instances of its terminating like common fevers, by sweat after the third day. I wish this fact to be remembered by the reader, for it laid part of the foundation of my method of treating this fever.

There was in some cases a preternatural secretion and excretion of _mucus_ from the glands of the throat. It was discharged by an almost constant hawking and spitting. All who had this symptom recovered.

The _tongue_ was in every case moist, and of a white colour, on the first and second days of the fever. As the disease advanced, it assumed a red colour, and a smooth shining appearance. It was not quite dry in this state. Towards the close of the fever, a dry black streak appeared in its middle, which gradually extended to every part of it. Few recovered after this appearance on the tongue took place.

V. In the _nervous system_ the symptoms of the fever were different, according as it affected the brain, the muscles, the nerves, or the mind. The sudden and violent action of the miasmata induced apoplexy in several people. In some, it brought on syncope, and in others, convulsions in every part of the body. The apoplectic cases generally proved fatal, for they fell chiefly upon hard drinkers. Persons affected by syncope, or convulsions, sometimes fell down in the streets. Two cases of this kind happened near my house. One of them came under my notice. He was supposed by the by-standers to be drunk, but his countenance and convulsive motions soon convinced me that this was not the case.

A coma was observed in some people, or an obstinate wakefulness in every stage of the disease. The latter symptom most frequently attended the convalescence. Many were affected with immobility, or numbness in their limbs.

These symptoms were constant, or temporary, according to the nature of the remedies which were made use of to remove them. They extended to all the limbs, in some cases, and only to a part of them in others. In some, a violent cramp, both in the arms and legs, attended the first attack of the fever. I met with one case in which there was a difficulty of swallowing, from a spasmodic affection of the throat, such as occurs in the locked jaw.

A hiccup attended the last stage of this disease, but I think less frequently than the last stage of the common bilious fever. I saw but five cases of recovery where this symptom took place.

There was, in some instances, a deficiency of sensibility, but, in others, a degree of it extending to every part of the body, which rendered the application of common rum to the skin, and even the least motion of the limbs painful.

I was surprised to observe the last stage of this fever to exhibit so few of the symptoms of the common typhus or chronic fever. Tremors of the limbs and twitchings of the tendons were uncommon. They occurred only in those cases in which there was a predisposition to nervous diseases, and chiefly in the convalescent state of the disease.

While the muscles and nerves in many cases exhibited so many marks of preternatural weakness, in some they appeared to be affected with preternatural excitement. Hence patients in the close of the disease often rose from their beds, walked across their rooms, or came down stairs, with as much ease as if they had been in perfect health. I lost a patient in whom this state of morbid strength occurred to such a degree, that he stood up before his glass and shaved himself, on the day on which he died.

The mind suffered with the morbid states of the brain and nerves. A delirium was a common symptom. It alternated in some cases with the exacerbations and remissions of the fever. In some, it continued without a remission, until a few hours before death. Many, however, passed through the whole course of the disease without the least derangement in their ideas, even where there were evident signs of a morbid congestion in the brain. Some were seized with maniacal symptoms. In these there was an _apparent_ absence of fever. Such was the degree of this mania in one man, that he stripped off his shirt, left his bed, and ran through the streets, with no other covering than a napkin on his head, at 8 o'clock at night, to the great terror of all who met him. The symptoms of mania occurred most frequently towards the close of the disease, and sometimes continued for many days and weeks, after all other febrile symptoms had disappeared.

The temper was much affected in this fever. There were few in whom it did not produce great depression of spirits. This was the case in many, in whom pious habits had subdued the fear of death. In some the temper became very irritable. Two cases of this kind came under my notice, in persons who, in good health, were distinguished for uncommon sweetness of disposition and manners.

I observed in several persons the operations of the understanding to be unimpaired, throughout the whole course of the fever, who retained no remembrance of any thing that passed in their sickness. My pupil, Mr. Fisher, furnished a remarkable example of this correctness of understanding, with a suspension of memory. He neither said nor did any thing, during his illness, that indicated the least derangement of mind, and yet he recollected nothing that passed in his room, except my visits to him. His memory awakened upon my taking him by the hand, on the morning of the 6th day of his disease, and congratulating him upon his escape from the grave.

In some, there was a weakness, or total defect of memory, for several weeks after their recovery. Dr. Woodhouse informed me that he had met with a woman, who, after she had recovered, could not recollect her own name.

Perhaps it would be proper to rank that self-deception with respect to the nature and danger of the disease, which was so universal, among the instances of derangement of mind.

The pain which attended the disease was different, according to the different states of the system. In those cases in which it sunk under the violence of the disease, there was little or no pain. In proportion as the system was relieved from this oppression, it recovered its sensibility. The pain in the head was acute and distressing. It affected the eye-balls in a peculiar manner. A pain extended, in some cases, from the back of the head down the neck. The ears were affected, in several persons, with a painful sensation, which they compared to a string drawing their two ears together through the brain. The sides, and the regions of the stomach, liver, and bowels, were all, in different people, the seats of either dull or acute pains. The stomach, towards the close of the disease, was affected with a burning or spasmodic pain of the most distressing nature. It produced, in some cases, great anguish of body and mind. In others it produced cries and shrieks, which were often heard on the opposite side of the streets to where the patients lay. The back suffered very much in this disease. The stoutest men complained, and even groaned under it. An acute pain extended, in some cases, from the back to one or both thighs. The arms and legs sympathized with every other part of the body. One of my patients, upon whose limbs the disease fell with its principal force, said that his legs felt as if they had been scraped with a sharp instrument. The sympathy of friends with the distresses of the sick extended to a small part of their misery, when it did not include their sufferings from pain. One of the dearest friends I ever lost by death declared, in the height of her illness, that "no one knew the pains of a yellow fever, but those who felt them."

VI. The _senses_ and _appetites_ exhibited several marks of the universal ravages of this fever upon the body. A deafness attended in many cases, but it was not often, as in the nervous fever, a favourable symptom. A dimness of sight was very common in the beginning of the disease. Many were affected with temporary blindness. In some there was a loss of sight in consequence of gutta serena, or a total destruction of the substance of the eye. There was in many persons a soreness to the touch which extended all over the body. I have often observed this symptom to be the forerunner of a favourable issue of a nervous fever, but it was less frequently the case in this disease.

The _thirst_ was moderate or absent in some cases, but it occurred in the greatest number of persons whom I saw in this fever. Sometimes it was very intense. One of my patients, who suffered by an excessive draught of cold water, declared, just before he died, that "he could drink up the Delaware." It was always an alarming symptom when this thirst came on in this extravagant degree in the last stage of the disease. In the beginning of the fever it generally abated upon the appearance of a moist skin. Water was preferred to all other drinks.

The _appetite_ for food was impaired in this, as in all other fevers, but it returned much sooner than is common after the patient began to recover. Coffee was relished in the remissions of the fever, in every stage of the disease. So keen was the appetite for solid, and more especially for animal food, after the solution of the fever, that many suffered from eating aliment that was improper from its quality or quantity. There was a general disrelish for wine, but malt liquors were frequently grateful to the taste.

Many people retained a relish for tobacco much longer after they were attacked by this fever, and acquired a relish for it much sooner after they began to recover, than are common in any other febrile disease. I met with one case in which a man, who was so ill as to require two bleedings, continued to chew tobacco through every stage of his fever.

The convalescence from this disease was marked, in some instances, by a sudden revival of the venereal appetite. Several weddings took place in the city between persons who had recovered from the fever. Twelve took place among the convalescents in the hospital at Bush-hill. I wish I could add that the passion of the sexes for each other, among those subjects of public charity, was always gratified only in a lawful way. Delicacy forbids a detail of the scenes of debauchery which were practised near the hospital, in some of the tents which had been appropriated for the reception of convalescents. It was not peculiar to this fever to produce this morbid excitability of the venereal appetite. It was produced in a much higher degree by the plague which raged in Messina in the year 1743.

VII. The _lymphatic_ and _glandular system_ did not escape without some signs of this disease. I met with three cases of swellings in the inguinal, two in the parotid, and one in the cervical glands: all these patients recovered without a suppuration of their swellings. They were extremely painful in one case in which no redness or inflammation appeared. In the others there was considerable inflammation and but little pain.

In one of the cases of inguinal buboes, the whole force of the disease seemed to be collected into the lymphatic system. The patient walked about, and had no fever nor pain in any part of his body, except in his groin. In another case which came under my care, a swelling and pain extended from the groin along the spermatic cord into one of the testicles. These glandular swellings were not peculiar to this epidemic. They occurred in the yellow fever of Jamaica, as described by Dr. Williams, and always with a happy issue of the disease[26]. A similar concentration of the contagion of the plague in the lymphatic glands is taken notice of by Dr. Patrick Russel.

[26] Essay on the Bilious or Yellow Fever, p. 35.

VIII. The _skin_ exhibited many marks of this fever. It was preternaturally warm in some cases, but it was often preternaturally cool. In some there was a distressing coldness in the limbs for two or three days. The yellow colour from which this fever has derived its name, was not universal. It seldom appeared where purges had been given in sufficient doses. The yellowness rarely appeared before the third, and generally about the fifth or seventh day of the fever. Its early appearance always denoted great danger. It sometimes appeared first on the neck and breast, instead of the eyes. In one of my patients it discovered itself first behind one of his ears, and on the crown of his head, which had been bald for several years. The remissions and exacerbations of the fever seemed to have an influence upon this colour, for it appeared and disappeared altogether, or with fainter or deeper shades of yellow, two or three times in the course of the disease. The eyes seldom escaped a yellow tinge; and yet I saw a number of cases in which the disease appeared with uncommon malignity and danger, without the presence of this symptom.

There was a clay-coloured appearance in the face, in some cases, which was very different from the yellow colour which has been described. It occurred in the last stage of the fever, and in no instance did I see a recovery after it.

There were eruptions of various kinds on the skin, each of which I shall briefly describe.

1. I met with two cases of an eruption on the skin, resembling that which occurs in the scarlet fever. Dr. Hume says, pimples often appear on the pit of the stomach, in the yellow fever of Jamaica. I examined the external region of the stomach in many of my patients, without discovering them.

2. I met with one case in which there was an eruption of watery blisters, which, after bursting, ended in deep, black sores.

3. There was an eruption about the mouth in many people, which ended in scabs, similar to those which take place in the common bilious fever. They always afforded a prospect of a favourable issue of the disease.

4. Many persons had eruptions which resembled moscheto bites. They were red and circumscribed. They appeared chiefly on the arms, but they sometimes extended to the breast. Like the yellow colour of the skin, they appeared and disappeared two or three times in the course of the disease.

5. Petechiæ were common in the latter stage of the fever. They sometimes came on in large, and at other times in small red blotches; but they soon acquired a dark colour. In most cases they were the harbingers of death.

6. Several cases of carbuncles, such as occur in the plague, came under my notice. They were large and hard swellings on the limbs, with a black apex, which, upon being opened, discharged a thin, dark-coloured, bloody matter. From one of these malignant sores a hæmorrhage took place, which precipitated the death of the amiable widow of Dr. John Morris.

7. A large and painful anthrax on the back succeeded a favourable issue of the fever in the Rev. Dr. Blackwell.

8. I met with a woman who showed me the marks of a number of small boils on her face and neck, which accompanied her fever.

Notwithstanding this disposition to cutaneous eruptions in this disease, it was remarkable that blisters were much less disposed to mortify than in the common nervous fever. I met with only one case in which a deep-seated ulcer followed the application of blisters to the legs. Such was the insensibility of the skin in some people, that blisters made no impression upon it.

IX. The _blood_ in this fever has been supposed to undergo a change from a healthy to a putrid state, and many of its symptoms which have been described, particularly the hæmorrhages and eruptions on the skin, have been ascribed to this supposed putrefaction of the blood. It would be easy to multiply arguments, in addition to those mentioned in another place[27], to prove that no such thing as putrefaction can take place in the blood, and that the symptoms which have been supposed to prove its existence are all effects of a sudden, violent, and rapid inflammatory action or pressure upon the blood-vessels, and hence the external and internal hæmorrhages. The petechiæ on the surface of the skin depend upon the same cause. They are nothing but effusions of serum or red blood, from a rupture or preternatural dilatation of the capillary vessels[28]. The smell emitted from persons affected by this disease was far from being of a putrid nature; and if this had been the case, it would not have proved the existence of putrefaction in the blood, for a putrid smell is often discharged from the lungs, and from the pores in sweat, which is wholly unconnected with a putrid, or perhaps any other morbid state of the blood. There are plants which discharge an odour which conveys to the nose a sensation like that of putrefaction; and yet these plants exist, at the same time, in a state of the most healthy vegetation: nor does the early putrid smell of a body which perishes with this fever prove a putrid change to have taken place in the blood before death. All animals which die suddenly, and without loss of blood, are disposed to a speedy putrefaction. This has long been remarked in animals that have been killed after a chase, or by lightning. The poisonous air called _samiel_, which is described by Chardin, produces, when it destroys life, instant putrefaction. The bodies of men who die of violent passions, or after strong convulsions, or even after great muscular exertion, putrify in a few hours after death. The healthy state of the body depends upon a certain state of arrangement in the fluids. A derangement of these fluids is the natural consequence of the violent and rapid motions, or of the undue pressure upon the solids, which have been mentioned. It occurs in cases of death which are induced by the excessive force of stimulus, whether it be from miasmata, or the volatile vitriolic acid which is supposed to constitute the destructive samiel wind, or from violent commotions excited in the body by external or internal causes. The practice among fishermen, in some countries, of breaking the heads of their fish as soon as they are taken out of the water, in order to retard their putrefaction, proves the truth of the explanation I have given of its cause, soon after death. The sudden extinction of life in the fish prevents those convulsive or violent motions, which induce sudden _disorganization_ in their bodies. It was observed that putrefaction took place most speedily after death from the yellow fever, where the commotions of the system were not relieved by evacuations. In those cases where purges and bleeding had been used, putrefaction did not take place sooner after death than is common in any other febrile disease, under equal circumstances of heat and air.

[27] Outlines of a Theory of Fever.

[28] See Wallis's edition of Sydenham, vol. i. p. 165. vol. ii. p. 52, 94, 98, 350; De Haen's Ratio Medendi, vol. ii. p. 162. vol. iv. p. 172; Gaubii Pathologia, sect. 498; and Dr. Seybert's inaugural dissertation, entitled "An Attempt to Disprove the Doctrine of Putrefaction of the Blood in Living Animals," published in Philadelphia in 1793.

Thus have I described the symptoms of this fever. From the history I have given, it appears that it counterfeited nearly all the acute and chronic forms of disease to which the human body is subject. An epitome, both of its symptoms and its theory, is happily delivered by Dr. Sydenham, in the following words. After describing the epidemic cough, pleurisy, and peripneumony of 1675, he adds, "But in other epidemics, the symptoms are so slight from the disturbance raised in the blood by the morbific particles contained in the mass, that nature being in a manner _oppressed_, is rendered unable to produce _regular_ symptoms that are suitable to the disease; and almost all the phenomena that happen are _irregular_, by reason of the entire _subversion_ of the animal economy; in which case the fever is often _depressed_, which, of its own nature, would be very high. Sometimes also fewer signs of a fever appear than the nature of the disease requires, from a translation of the malignant cause, either to the nervous system, or to some other parts of the body, or to some of the juices not contained in the blood; whilst the morbific matter is yet turgid[29]."

[29] Wallis's edition, vol. i. p. 344.

The disease ended in death in various ways. In some it was sudden; in others it came on by gradual approaches. In some the last hours of life were marked with great pain, and strong convulsions; but in many more, death seemed to insinuate itself into the system, with all the gentleness of natural sleep. Mr. Powell expired with a smile on his countenance. Dr. Griffitts informed me that Dr. Johnson exhibited the same symptom in the last hours of his life. This placid appearance of the countenance, in the act of dying, was not new to me. It frequently occurs in diseases which affect the brain and nerves. I lost a patient, in the year 1791, with the gout, who not only smiled, but laughed, a few minutes before he expired.

I proceed now to mention some peculiarities of the fever, which could not be brought in under any of the foregoing heads.

In every case of this disease which came under my notice, there were evident remissions, or intermissions of the fever, or of such symptoms as were substituted for fever. I have long considered, with Mr. Senac, a _tertian_ as the only original type of all fevers. The bilious yellow fever indicated its descent from this parent disease. I met with many cases of regular tertians, in which the patients were so well on the intermediate days as to go abroad. It appeared in this form in Mr. Van Berkel, the minister of the United Netherlands. Nor was this mild form of the fever devoid of danger. Many died who neglected it, or who took the common remedies for intermittents to cure it. It generally ended in a remittent before it destroyed the patient. The tertian type discovered itself in some people after the more violent symptoms of the fever had been subdued, and continued in them for several weeks. It changed from a tertian to a quartan type in Mr. Thomas Willing, nearly a month after his recovery from the more acute and inflammatory symptoms of the disease.

It is nothing new for a malignant fever to appear in the form of a tertian. It is frequently the garb of the plague. Riverius describes a tertian fever which proved fatal on the third day, which was evidently derived from the same exhalation which produced a continual malignant fever[30].

[30] De Febre Pestilenti, vol. xi. p. 93.

The remissions were more evident in this, than in the common bilious fever. They generally occurred in the forenoon. It was my misfortune to be deprived, by the great number of my patients, of that command of time which was necessary to watch the exacerbations of this fever under all their various changes, as to time, force, and duration. From all the observations that were suggested by visits, at hours that were seldom left to my choice, I was led to conclude, that the fever exhibited in different people all that variety of forms which has been described by Dr. Cleghorn, in his account of the tertian fever of Minorca. A violent exacerbation on even days was evidently attended with more danger than on odd days. The same thing was observed by Dr. Mitchell in the yellow fever of Virginia, in the year 1741. "If (says he) the exacerbations were on equal days, they generally died in the third paroxysm, or the sixth day; but if on unequal days, they recovered on the seventh."

The deaths which occurred on the 3d, 5th, and 7th days, appeared frequently to be the effects of the commotions or depression, produced in the system on the 2d, 4th, and 6th days.

The remission on the third day was frequently such as to beget a belief that the disease had run its course, and that all danger was over. A violent attack of the fever on the 4th day removed this deception, and, if a relaxation had taken place in the use of proper remedies on the 3d day, death frequently occurred on the 5th or the 7th.

The termination of this fever in life and death was much more frequent on the 3d, 5th, 7th, 9th, and 11th days, than is common in the mild remitting fever. Where death occurred on the even days, it seemed to be the effect of a violent paroxysm of the fever, or of great vigour of constitution, or of the force of medicines which protracted some of the motions of life beyond the close of the odd days which have been mentioned.

I think I observed the fever to terminate on the third day more frequently in August, and during the first ten days in September, than it did after the weather became cool. In this it resembled the common bilious remittents of our city, also the simple tertians described by Dr. Cleghorn[31]. The danger seemed to be in proportion to the tendency of the disease to a speedy crisis, hence more died in August in proportion to the number who were affected than in September or October, when the disease was left to itself. But, however strange after this remark it may appear, the disease yielded to the remedies which finally subdued it more speedily and certainly upon its first appearance in the city, than it did two or three weeks afterwards.

[31] Diseases of Minorca, p. 185.

The disease continued for fifteen, twenty, and even thirty days in some people. Its duration was much influenced by the weather, and by the use or neglect of certain remedies (to be mentioned hereafter) in the first stage of the disease.

It has been common with authors to divide the symptoms of this fever into three different stages. The order I have pursued in the history of those symptoms will render this division unnecessary. It will I hope be more useful to divide the patients affected with the disease into three classes.

The _first_ includes those in whom the stimulus of the miasmata produced coma, languor, sighing, a disposition to syncope, and a weak or slow pulse.

The _second_ includes those in whom the miasmata acted with less force, producing great pain in the head, and other parts of the body; delirium, vomiting, heat, thirst, and a quick, tense, or full pulse, with obvious remissions or intermissions of the fever.

The _third_ class includes all those persons in whom the miasmata acted so feebly as not to confine them to their beds or houses. This class of persons affected by the yellow fever was very numerous. Many of them recovered without medical aid, or by the use of domestic prescriptions; many of them recovered in consequence of a spontaneous diarrh[oe]a, or plentiful sweats; many were saved by moderate bleeding and purging; while some died, who conceived their complaints to be occasioned by a common cold, and neglected to take proper care of themselves, or to use the necessary means for their recovery. It is not peculiar to the yellow fever to produce this feeble operation upon the system, It has been observed in the southern states of America, that in those seasons in which the common bilious fever is epidemic "no body is quite well," and that what are called in those states "inward fevers" are universal. The small-pox, even in the natural way, does not always confine the patient; and thousands pass through the plague without being confined to their beds or houses. Dr. Hodges prescribed for this class of patients in his parlour in London, in the year 1665, and Dr. Patrick Russel did the same from a chamber window fifteen feet above the level of the street at Aleppo. Notwithstanding the mild form the plague put on in these cases, it often proved fatal according to Dr. Russel. I have introduced these facts chiefly with a view of preparing the reader to reject the opinion that we had two species of fever in the city at the same time; and to show that the yellow fever appears in a more simple form than with "strongly marked" characters; or, in other words, with a yellow skin and a black vomiting.

It was remarkable that this fever always found out the weak part of every constitution it attacked. The head, the lungs, the stomach, the bowels, and the limbs, suffered more or less, according as they were more or less debilitated by previous inflammatory or nervous diseases, or by a mixture of both, as in the gout.

I have before remarked, that the influenza, the scarlatina, and a mild bilious remittent, prevailed in the city, before the yellow fever made its appearance. In the course of a few weeks they all disappeared, or appeared with symptoms of the yellow fever; so that, after the first week of September, it was the solitary epidemic of the city.

The only case like influenza which I saw after the 5th of September, was in a girl of 14 years of age, on the 13th of the month. It came on with a sneezing and cough. I was called to her on the third day of her disease. The instant I felt her pulse, I pronounced her disease to be the yellow fever. Her father was offended with this opinion, although he lived in a highly infected neighbourhood, and objected to the remedies I prescribed for her. In a few days she died. In the course of ten days, her father and sister were infected, and both died, I was informed, with the usual symptoms of the yellow fever.

It has been an axiom in medicine, time immemorial, that no two fevers of unequal force can exist long together in the same place. As this axiom seems to have been forgotten by many of the physicians of Philadelphia, and as the ignorance or neglect of it led to that contrariety of opinion and practice, which unhappily took place in the treatment of the disease, I hope I shall be excused by those physicians to whom this fact is as familiar as the most simple law of nature, if I fill a few pages with proofs of it, from practical writers.

Thucydides long ago remarked, that the plague chased all other diseases from Athens, or obliged them to change their nature, by assuming some of its symptoms.

Dr. Sydenham makes the same remark upon the plague in London, in 1665. Dr. Hodges, in his account of the same plague, says, that "at the rise of the plague all other distempers went into it, but that, at its declension, it degenerated into others, as inflammations, head-ach, quinsies, dysenteries, small-pox, measles, fevers, and hectics, wherein the plague yet predominated[32]."

[32] Dr. Hodge's Account of the Plague in London, p. 26.

During the prevalence of the plague in Grand Cairo, no sporadic disease of any kind makes its appearance. The same observation is made by Sauvage, in his account of the plague at Alais, in the province of Languedoc[33].

[33] Sed hoc observatu dignum fuit, omnes alios morbos acutos, durante peste siluisse, et omnes morbos acutos e pestis genere suisse. Nosologia Methodica, vol. i. p. 416.

The small-pox, though a disease of less force than the plague, has often chased it from Constantinople, probably from its being in a declining state. But this exclusive prevalence of a single epidemic is not confined to the plague and small-pox. Dr. Sydenham's writings are full of proofs of the dominion of febrile diseases over each other. Hence, after treating upon a symptomatic pleurisy which sometimes accompanied a slow fever, in the year 1675, and which had probably been injudiciously treated by some of those physicians who prescribe for the name of a disease, he delivers the following aphorism: "Whoever, in the cure of fevers, hath not always in view the constitution of the year, inasmuch as it tends to produce some particular epidemic disease, and likewise to reduce all the cotemporary diseases to its own form and likeness, proceeds in an uncertain and fallacious way[34]." It appears further, from the writings of this excellent physician, that where the monarchy of a single disease was not immediately acknowledged, by a sudden retreat of all cotemporary diseases, they were forced to do homage to it, by wearing its livery. It would be easy to multiply proofs of this assertion, from the numerous histories of epidemics which are to be found in his works. I shall mention only one or two of them. A continual fever, accompanied by a dry skin, had prevailed for some time in the city of London. During the continuance of this fever, the regular small-pox made its appearance. It is peculiar to the small-pox, when of a distinct nature, to be attended by irregular sweats before the eruption of the pock. The continual fever now put on a new symptom. It was attended by sweats in its first stage, exactly like those which attended the eruptive fever of the small-pox[35]. This despotism of a powerful epidemic extended itself to the most trifling indispositions. It even blended itself, Dr. Sydenham tells us, with the commotions excited in the system by the suppression of the lochia, as well as with the common puerperile fever[36]. Dr. Morton has left testimonies behind him, in different parts of his works, which establish, in the most ample manner, the truth of Dr. Sydenham's observations. Dr. Huxham describes the small-pox as blending some of its symptoms with those of a slow fever, at Plymouth, in the year 1729[37]. Dr. Cleghorn mentions a constitution of the air at Minorca, so highly inflammatory, "that not only tertian fevers, but even a common hurt or bruise required more plentiful evacuations than ordinary[38]." Riverius informs us, in his history of a pestilential fever that prevailed in France, that "it united itself with phrenitis, angina, pleurisy, peripneumony, hepatitis, dysentery, and many other diseases[39]."

[34] Vol. i. p. 340.

[35] Vol. i. p. 352.

[36] Vol. ii. p. 164. See also p. 1, 109, 122, 204, 212, 233, 274, 355, 358-9, and 436.

[37] De Aere et Morb. Epidem. p. 33, 34.

[38] Page 285.

[39] De Febre Pestilenti, vol. ii. p. 95.

The bilious remitting fever which prevailed in Philadelphia, in 1780, chased away every other febrile disease; and the scarlatina anginosa which prevailed in our city, in 1783 and 1784, furnished a striking proof of the influence of epidemics over each other. In the account which I published of this disease, in the year 1789, there are the following remarks. "The intermitting fever which made its appearance in August was not lost during the month of September. It continued to prevail, but with several peculiar symptoms. In many persons it was accompanied by an eruption on the skin, and a swelling of the hands and feet. In some it was attended with sore throat, and pains behind the ears. Indeed such was the prevalence of the contagion which produced the scarlatina anginosa, that many hundred people complained of sore throats, without any other symptom of indisposition. The slightest exciting cause, and particularly cold, seldom failed of producing the disease[40]."

[40] Vol. i.

I shall mention only one more authority in favour of the influence of a single epidemic upon diseases. It is taken from Mr. Clark's essay on the epidemic disease of lying-in women, of the years 1787 and 1788. "There does not appear to be any thing in a parturient state which can prevent women from being affected by the general causes of disease at that time; and should they become ill, their complaints will probably partake of the nature of the reigning epidemic[41]." I have said that the fever sometimes put on the symptoms of dysentery, pleurisy, rheumatism, colic, palsy, and even of the locked jaw. That these were not original diseases, but symptomatic affections only of the reigning epidemic, will appear from other histories of bilious fevers. Dr. Balfour tells us, in his account of the intestinal remitting fever of Bengal[42], that it often appeared with symptoms of dysentery, rheumatism, and pleurisy. Dr. Cleghorn and Dr. Lind mention many cases of the bilious fever appearing in the form of a dysentery. Dr. Clark ascribes the dysentery, the diarrh[oe]a, the colic, and even the palsy, to the same cause which produced the bilious fever in the East-Indies[43]; and Dr. Hunter, in his treatise upon the diseases of Jamaica, mentions the locked jaw as one of its occasional symptoms. Even the different grades of this fever, from the mildest intermittent to the most acute continual fever, have been distinctly traced by Lancissi to the same marsh exhalation[44].

[41] Page 28.

[42] Page 132.

[43] Observations on the Diseases in Long Voyages to the East-Indies, vol. i. p. 13, 14, 48, 151. vol. ii. p. 99, 318, and 320.

[44] Lib. ii. cap. v.

However irrefragably these numerous facts and authorities establish the assertion of the prevalence of but one powerful epidemic at a time, the proposition will receive fresh support, from attending to the effects of two impressions of unequal force made upon the system at the same time: only one of them is felt; hence the gout is said to cure all other diseases. By its superior pain it destroys sensations of a less painful nature. The small-pox and measles have sometimes existed together in the body; but this has, I believe, seldom occurred, where one of them has not been the predominating disease[45]. In this respect, this combination of epidemics only conforms to the general law which has been mentioned.

[45] Hunter on the Venereal Disease, introduction, p. 3.

I beg pardon for the length of this digression. I did not introduce it to expose the mistakes of those physicians, who found as many diseases in our city as the yellow fever had symptoms, but to vindicate myself from the charge of innovation, in having uniformly and unequivocally asserted, after the first week in September, that the yellow fever was the only febrile disease which prevailed in the city.

Science has much to deplore from the multiplication of diseases. It is as repugnant to truth in medicine, as polytheism is to truth in religion. The physician who considers every different affection of the different systems in the body, or every affection of different parts of the same system, as distinct diseases, when they arise from one cause, resembles the Indian or African savage, who considers water, dew, ice, frost, and snow, as distinct essences; while the physician who considers the morbid affections of every part of the body (however diversified they may be in their form or degrees) as derived from one cause, resembles the philosopher who considers dew, ice, frost, and snow, as different modifications of water, and as derived simply from the absence of heat.

Humanity has likewise much to deplore from this paganism in medicine. The sword will probably be sheathed for ever, as an instrument of death, before physicians will cease to add to the mortality of mankind, by prescribing for the names of diseases.

The facts I have delivered upon this subject will admit of a very important application to the cure, not only of the yellow fever, but of all other acute and dangerous epidemics. I shall hereafter assign a final cause for the law of epidemics which has been mentioned, which will discover a union of the goodness of the Supreme Being with one of the greatest calamities of human life.

All ages were affected by this fever, but persons between fourteen and forty years of age were most subject to it. Many old people had it, but it was not so fatal to them as to robust persons in middle life. It affected children of all ages. I met with a violent case of the disease, in a child of four months, and a moderate case of it, in a child of but ten weeks old. The latter had a deep yellow skin. Both these children recovered.

The proportion of children who suffered by this fever may be conceived from a single fact. Seventy-five persons were buried in the grave-yard of the Swedish church in the months of August, September, and October, twenty-four of whom were children. They were buried chiefly in September and October; months in which children generally enjoy good health in our city.

Men were more subject to the disease than women. Pregnancy seemed to expose women to it.

The refugees from the French West-Indies universally escaped it. This was not the case with the natives of France, who had been settled in the city.

It is nothing new for epidemics to affect persons of one nation, and to pass by persons of other nations, in the same city or country. At Nimeguen, in the year 1736, Deigner informs us, that the French people (two old men excepted), and the Jews, escaped a dysentery which was universal among persons of all other nations. Ramazini tells us, that the Jews at Modena escaped a tertian fever which affected nearly all the other inhabitants of the town. Shenkius says, that the Dutch and Italians escaped a plague, which prevailed for two years in one of the towns of Switzerland; and Dr. Bell, in an inaugural dissertation, published at Edinburgh, in 1779, remarks, that the jail fever, which attacked the soldiers of the duke of Buccleugh's regiment, spared the French prisoners who were guarded by them. It is difficult to account for these facts. However numerous their causes may be, a difference in diet, which is as much a distinguishing mark of nations as dress or manners, will probably be found to be one of them.

From the accounts of the yellow fever which had been published by many writers, I was led to believe that the negroes in our city would escape it. In consequence of this belief, I published the following extract in the American Daily Advertiser, from Dr. Lining's history of the yellow fever, as it had four times appeared in Charleston, in South-Carolina.

"There is something very singular (says the doctor) in the constitution of the negroes, which renders them not liable to this fever; for though many of them were as much exposed as the nurses to the infection, yet I never knew of one instance of this fever among them, though they are equally subject with the white people to the bilious fever[46]."

[46] Essays and Observations, Physical and Literary, vol. xi. page 409.

A day or two after this publication the following letter from the mayor of the city, to Mr. Claypoole, the printer of the Mail, appeared in his paper.

"SIR,

"It is with peculiar satisfaction that I communicate to the public, through your paper, that the AFRICAN SOCIETY, touched with the distresses which arise from the present dangerous disorder, have voluntarily undertaken to furnish nurses to attend the afflicted; and that, by applying to ABSALOM JONES and WILLIAM GRAY, both members of that society, they may be supplied. MATTH. CLARKSON, _September 6th, 1793._ _Mayor_."

It was not long after these worthy Africans undertook the execution of their humane offer of services to the sick before I was convinced I had been mistaken. They took the disease in common with the white people, and many of them died with it. I think I observed the greatest number of them to sicken after the mornings and evenings became cool. A large number of them were my patients. The disease was lighter in them than in white people. I met with no case of hæmorrhage in a black patient.

The tobacconists and persons who used tobacco did not escape the disease. I observed snuff-takers to be more devoted to their boxes than usual, during the prevalence of the fever.

I have remarked, formerly, that servant maids suffered much by the disease. They were the only patients I lost in several large families. I ascribe their deaths to the following causes:

_1st._ To the great and unusual debility induced upon their systems by labour in attending their masters and mistresses, or their children. Debility, according to its degrees and duration, seems to have had the same effect upon the mortality of this fever that it has upon the mortality of an inflammation of the lungs. When it is moderate and of short duration it predisposes only to a common pneumony, but when it is violent and protracted, in its degrees and duration, it predisposes to a pulmonary consumption.

_2dly._ To their receiving large quantities of impure air into their bodies, and in a most concentrated state, by being obliged to perform the most menial offices for the sick, and by washing, as well as removing foul linen, and the like.

_3dly._ To their being left more alone in confined or distant rooms, and thereby suffering from depression of spirits, or the want of a punctual supply of food and medicines.

There did not appear to be any advantage from smelling vinegar, tar, camphor, or volatile salts, in preventing the disease. Bark and wine were equally ineffectual for that purpose. I was called to many hundred people who were infected after using one or more of them. Nor did the white washing of walls secure families from the disease. I am disposed to believe garlic was the only substance that was in any degree useful in preventing it. I met with several persons who chewed it constantly, and who were much exposed to the miasmata, without being infected. All other substances seemed to do harm by begetting a false confidence in the mind, to the exclusion of more rational preservatives. I have suspected further, that such of them as were of a volatile nature helped to spread the disease by affording a vehicle for miasmata through the air.

There was great mortality in all those families who lived in wooden houses. Whether this arose from the small size of these houses, or from the want of cleanliness of the people who occupied them, or from the miasmata becoming more accumulated, by adhering to the wood, I am unable to determine. Perhaps it was the effect of the co-operation of all three of those causes.

I have said, formerly, that intemperance in drinking predisposed to the disease; but there were several instances of persons having escaped it who were constantly under the influence of strong drink. The stimulus of ardent spirits probably predominated over the stimulus of the miasmata, and thus excited an artificial fever which defended the system from that which was epidemic.

I heard of some sea-faring people who lived on board their vessels who escaped the disease. The smell of the tar was supposed to have preserved them; but, from its being ineffectual in other cases, I am disposed to ascribe their escape to the infected air of the city being destroyed by a mixture with the water of the Delaware.

Many people who were infected in the city were attacked by the disease in the country, but they did not propagate it, even to persons who slept in the same room with them.

Dr. Lind informs us that many persons escaped the yellow fever which prevailed in Pensacola in the year 1765, by retiring to the ships which lay in the harbour, and that when the disease had been taken, the pure air of the water changed it into an intermitting fever[47]. The same changes have frequently been produced in malignant fevers, by sending patients infected with them from the foul air of a city, into the pure air of the country.

[47] Diseases of Warm Climates, p. 169.

Persons confined in the house of employment, in the hospital, and in the jail, escaped the fever. The airy and remote situation of those buildings was probably the chief means of their preservation. Perhaps they derived additional security from their simple diet, their exemption from hard labour, and from being constantly sheltered from heat and cold.

Several families, who shut up their front and back doors and windows, and avoided going out of their houses except to procure provisions, escaped the disease.

I have taken some pains to ascertain, whether any class of tradesmen escaped the fever, or whether there was any species of labour which protected from it. The result of my inquiries is as follows: Three butchers only, out of nearly one hundred who remained in the city, died with the disease. Many of them attended the markets every day. Two painters, who worked at their business during the whole time of the prevalence of the fever, and in exposed situations, escaped it. Out of forty scavengers who were employed in collecting and carrying away the dirt of the streets, only one was affected by the fever and died. Very few grave-diggers, compared with the number who were employed in that business, were infected; and it is well known, that scarcely an instance was heard of persons taking the disease, who were constantly employed in digging cellars. The fact is not new that grave-diggers escape malignant fevers. It is taken notice of by Dr. Clark.

It was said by some physicians in the public papers, that the neighbourhood of the grave-yards was more infected than other parts of the city. The reverse of this assertion was true in several cases, owing probably to the miasmata being diluted and weakened by its mixture with the air of the grave-yards: for this air was pure, compared with that which stagnated in the streets.

It was said further, that the disease was propagated by the inhabitants assembling on Sundays for public worship; and, as a proof of this assertion, it was reported, that the deaths were more numerous on Sundays than on other days; occasioned by the infection received on one Sunday producing death on the succeeding first day of the week. The register of the deaths shows that this was not the case. I am disposed to believe that fewer people sickened on Sundays, than on any other day of the week; owing to the general rest from labour, which I have before said was one of the exciting causes of the disease. From some facts to be mentioned presently, it will appear probable, that places of public worship, in consequence of their size, as well as of their being shut up during the greatest part of the week, were the freest from miasmata of any houses in the city. It is agreeable to discover in this, as well as in all other cases of public and private duty, that the means of health and moral happiness are in no one instance opposed to each other.

The disease, which was at first confined to Water-street, soon spread through the whole city. After the 15th of September, the atmosphere of every street in the city was charged with miasmata; and there were few citizens in apparent good health, who did not exhibit one or more of the following marks of their presence in their bodies.

1. A yellowness in the eyes, and a sallow colour upon their skin.

2. A preternatural quickness in the pulse. I found but two exceptions to this remark, out of a great number of persons whose pulses I examined. In one of them it discovered several preternatural intermissions in the course of a minute. This quickness of pulse occurred in the negroes, as well as in the white people. I met with it in a woman who had had the yellow fever in 1762. In two women, and in one man above 70, the pulse beat upwards of 90 strokes in a minute. This preternatural state of the pulse during the prevalence of a pestilential fever, in persons in health, is taken notice of by Riverius[48].

[48] "Pulsus sanorum pulsibus similes admodum, periculosi."--_De Febre Pestilenti, p. 114._

3. Frequent and copious discharges by the skin of yellow sweats. In some persons these sweats sometimes had an offensive smell, resembling that of the washings of a gun.

4. A scanty discharge of high coloured or turbid urine.

5. A deficiency of appetite, or a greater degree of it than was natural.

6. Costiveness.

7. Wakefulness.

8. Head-ach.

9. A preternatural dilatation of the pupils. This was universal. I was much struck in observing the pupil in one of the eyes of a young man who called upon me for advice, to be of an oblong figure. Whether it was natural, or the effect of the miasmata acting on his brain, I could not determine.

It will be thought less strange that the miasmata should produce these changes in the systems of persons who resided constantly in the city, when I add, that many country people who spent but a few hours in the streets in the day, in attending the markets, were infected by the disease, and sickened and died after they returned home; and that others, whom business compelled to spend a day or two in the city during the prevalence of the fever, but who escaped an attack of it, declared that they were indisposed, during the whole time, with languor or head-ach.

I was led to observe and record the above effects of the miasmata upon persons in apparent good health, by a fact I met with in Dr. Mitchell's history of the yellow fever in Virginia, in the year 1741. In that fever, blood drawn from a vein was always dissolved. The same state of the blood was observed in many persons who had been exposed to the miasmata, who discovered no other symptom of the disease.

A woman whom I had formerly cured of a mania, who lived in an infected neighbourhood, had a fresh attack of that disease, accompanied by an unusual menstrual flux. I ascribed both these complaints to the action of the miasmata upon her system.

The smell emitted from a patient, in a clean room, was like that of the small-pox, but in most cases of a less disagreeable nature. Putrid smells in sick rooms were the effects of the excretions, or of some other filthy matters. In small rooms, crowded in some instances with four or five sick people, there was an effluvia that produced giddiness, sickness at stomach, a weakness of the limbs, faintness, and in some cases a diarrh[oe]a. I met with a f[oe]tid breath in one patient, which was not the effect of that medicine which sometimes produces it.

The state of the atmosphere, during the whole month of September, and the first two weeks in October, favoured the accumulation of the miasmata in the city.

The register of the weather shows how little the air was agitated by winds during the above time. In vain were changes in the moon expected to alter the state of the air. The light of the morning mocked the hopes that were raised by a cloudy sky in the evening. The sun ceased to be viewed with pleasure. Hundreds sickened every day beneath the influence of his rays: and even where they did not excite the disease, they produced a languor in the body unknown to the oldest inhabitant of the city, at the same season of the year.

A meteor was seen at two o'clock in the morning, on or about the twelfth of September. It fell between Third-street and the hospital, nearly in a line with Pine-street. Moschetoes (the usual attendants of a sickly autumn) were uncommonly numerous. Here and there a dead cat added to the impurity of the air of the streets. It was supposed those animals perished with hunger in the city, in consequence of so many houses being deserted by the inhabitants who had fled into the country, but the observations of subsequent years made it more probable they were destroyed by the same morbid state of the atmosphere which produced the reigning epidemic.

It appears further, from the register of the weather, that there was no rain between the 25th of August and the 15th of October, except a few drops, hardly enough to lay the dust of the streets, on the 9th of September, and the 12th of October. In consequence of this drought, the springs and wells failed in many parts of the country. The dust in some places extended two feet below the surface of the ground. The pastures were deficient, or burnt up. There was a scarcity of autumnal fruits in the neighbourhood of the city. But while vegetation drooped or died from the want of moisture in some places, it revived with preternatural vigour from unusual heat in others. Cherry-trees blossomed, and apple, pear, and plum-trees bore young fruit in several gardens in Trenton, thirty miles from Philadelphia, in the month of October.

However inoffensive uniform heat, when agitated by gentle breezes, may be, there is, I believe, no record of a dry, warm, and stagnating air, having existed for any length of time without producing diseases. Hippocrates, in describing a pestilential fever, says the year in which it prevailed was without a breeze of wind[49]. The same state of the atmosphere, for six weeks, is mentioned in many of the histories of the plague which prevailed in London, in 1665[50]. Even the sea air itself becomes unwholesome by stagnating; hence Dr. Clark informs us, that sailors become sickly after long calms in East-India voyages[51]. Sir John Pringle delivers the following aphorism from a number of similar observations upon this subject: "When the heats come on soon, and continue throughout autumn, not moderated by winds or rains, the season proves sickly, distempers appear early, and are dangerous[52]."

[49] "Sine aura, usque annus fuit."--_Epid. 3._

[50] Letter from Sir John Bernard to Dr. Floyer, p. 233.

[51] Vol. i. p. 5.

[52] Diseases of the Army, p. 5. of the 7th London edition.

Who can review this account of the universal diffusion of the miasmata which produced this disease, its universal effects upon persons apparently in good health, and its accumulation and concentration, in consequence of the calmness of the air, and believe that it was possible for a febrile disease to exist at that time in our city that was not derived from that source?

The West-India writers upon the yellow fever have said that it is seldom taken twice, except by persons who have spent some years in Europe or America in the interval between its first and second attack. I directed my inquiries to this question, and I now proceed to mention the result of them. I met with five persons, during the prevalence of the disease, who had had it formerly, two of them in the year 1741, and three in 1762, who escaped it in 1793, although they were all more or less exposed to the infection. One of them felt a constant pain in her head while the disease was in her family. Four of them were aged, and of course less liable to be acted upon by the miasmata than persons in early or middle life. Mr. Thomas Shields furnished an unequivocal proof that the disease could be taken after an interval of many years. He had it in the year 1762, and narrowly escaped from a violent attack of it this year. Cases of reinfection were very common during the prevalence of this fever. They occurred most frequently where the first attack had been light. But they succeeded attacks that were severe in Dr. Griffitts, Dr. Mease, my pupil Mr. Coxe, and several others, whose cases came under my notice.

I have before remarked that the miasmata sometimes excited a fever as soon as they were taken into the body, but that they often lay there from one to sixteen days before they produced the disease. How long they existed in the body after a recovery from the fever I could not tell, for persons who recovered were, in most cases, exposed to their action from external sources. The preternatural dilatation of the pupils was a certain mark of the continuance of some portion of them in the system. In one person who was attacked with the fever on the night of the 9th of October, the pupils did not contract to their natural dimensions until the 7th of November.

Having described the effects of the miasmata upon the body, I proceed now to mention the changes induced upon it by death.

Let us first take a view of it as it appeared soon after death. Some new light may perhaps be thrown upon the proximate cause of the disease by this mode of examining the body.

My information upon this subject was derived from the attendants upon the sick, and from the two African citizens who were employed in burying the dead, viz. Richard Allen and Absalom Jones. The coincidence of the information received from different persons satisfied me that all that I shall here relate is both accurate and just.

A deep yellow colour appeared in many cases within a few minutes after death. In some the skin became purple, and in others black. I heard of one case in which the body was yellow above, and black below its middle. In some the skin was as pale as it is in persons who die of common fevers. A placid countenance was observed in many, resembling that which occurs in an easy and healthful sleep.

Some were stiff within one hour after death. Others were not so for six hours afterwards. This sudden stiffness after death, Dr. Valli informs us, occurred in persons who died of the plague in Smyrna, in the year 1784[53].

[53] Experiments on Animal Electricity, p. 90.

Some grew cold soon after death, while others retained a considerable degree of heat for six hours, more especially on their backs.

A stream of tears appeared on the cheeks of a young woman, which seemed to have flowed after her death.

Some putrified in a short time after their dissolution, but others had no smell for twelve, eighteen, and twenty hours afterwards. This absence of smell occurred in those cases in which evacuations had been used without success in the treatment of the disease.

Many discharged large quantities of black matter from the bowels, and others blood from the nose, mouth, and bowels after death. The frequency of these discharges gave rise to the practice of pitching the joints of the coffins which were used to bury the dead.

The morbid appearances of the internal parts of the body, as they appear by dissection after death from the yellow fever, are different in different countries, and in the same countries in different years. I consider them all as effects only of a stimulus acting upon the whole system, and determined more or less by accidental circumstances to particular viscera. Perhaps the stimulus of the miasmata determines the fluids more violently in most cases to the liver, stomach, and bowels, and thereby disposes them more than other parts to inflammation and mortification, and to similar effusions and eruptions with those which take place on the skin. There can be no doubt of the miasmata acting upon the liver, and thereby altering the qualities of the bile. I transcribe, with great pleasure, the following account of the state of the bile in a female slave of forty years of age, from Dr. Mitchell's History of the Yellow Fever, as it prevailed in Virginia, in the years 1737 and 1741, inasmuch as it was part of that clue which led me to adopt one of the remedies on which much of the success of my practice depended.

"The gall bladder (says the doctor) appeared outwardly of a deep yellow, but within was full of a black ropy coagulated atrabilis, which sort of substance obstructed the pori biliarii, and ductus choledochus. This atrabilis was hardly fluid, but upon opening the gall bladder, it retained its form and shape, without being evacuated, being of the consistence of a thin extract, and, within, glutinous and ropy, like soap when boiling. This black matter seemed so much unlike bile, that I doubted if there were any bile in the gall bladder. It more resembled bruised or mortified blood, evacuated from the mortified parts of the liver, surrounding it, although it would stain a knife or probe thrust into it of a yellow colour, which, with its ropy consistence, seemed more peculiar to a bilious humour."

The same appearance of the bile was discovered in several other subjects dissected by Dr. Mitchell.

The liver, in the above-mentioned slave, was turgid and plump on its outside, but on its concave surface, two thirds of it were of a deep black colour, and round the gall bladder it seemed to be mortified and corrupted.

The duodenum was lined on its inside, near the gall bladder, with a viscid ropy bile, like that which has been described. Its villous coat was lined with a thick fur or slime, which, when scraped or pealed off, the other vascular and muscular coats of the gut appeared red and inflamed.

The omentum was so much wasted, that nothing but its blood-vessels could be perceived.

The stomach was inflamed, both on its outside and inside. It contained a quantity of bile of the same consistence, but of a blacker colour than that which was found in the gall bladder. Its villous coat, like that of the duodenum, was covered with fuzzy and slimy matter. It moreover appeared to be distended or swelled. This peculiarity in the inner coat of the stomach was universal in all the bodies that were opened, of persons who died of this disease.

The lungs, instead of being collapsed, were inflated as in inspiration. They were all over full of black or livid spots. On these spots were to be seen small vesicles or blisters, like those of an erysipelas or gangrene, containing a yellow humour.

The blood-vessels in general seemed empty of blood, even the vena cava and its branches; but the vena portarum was full and distended as usual. The blood seemed _collected_ in the _viscera_; for upon cutting the lungs or sound liver or spleen, they bled freely.

The brain was not opened in this body, but it was not affected in three others whose brains were examined.

Dr. Mackittrick, in his inaugural dissertation, published at Edinburgh in the year 1766, "De Febre Indiæ Occidentalis, Maligna Flava," or upon the yellow fever of the West-Indies, says, that in some of the patients who died of it, he found the liver sphacelated, the gall bladder full of black bile, and the veins turgid with black fluid blood. In others he found the liver no ways enlarged, and its "texture only vitiated." The stomach, the duodenum, and ilium, were remarkably inflamed in all cases. The pericardium contained a viscid yellow serum, and in a larger quantity than common. The urinary bladder was a little inflamed. The lungs were sound.

Dr. Hume, in describing the yellow fever of Jamaica, informs us, that in several dead bodies which he opened, he found the liver enlarged and turgid with bile, and of a pale yellow colour. In some he found the stomach and duodenum inflamed. In one case he discovered black spots in the stomach, of the size of a crown piece. To this account he adds, "that he had seen some subjects opened, on whose stomachs _no marks of inflammation_ could be discovered; and yet these had excessive vomiting."

Dr. Lind has furnished us with an account of the state of the body after death, in his short history of the yellow fever, which prevailed at Cadiz, in the year 1764. "The stomach (he says), mesentery, and intestines, were covered with gangrenous spots; there were ulcers on the orifice of the stomach, and the liver and lungs were of a putrid colour and texture[54]."

[54] Diseases of Warm Climates, p. 125.

To these accounts of the morbid appearances of the body after death from the yellow fever I shall only add the account of several dissections, which was given to the public in Mr. Brown's Gazette, during the prevalence of this epidemic, by Dr. Physick and Dr. Cathrall.

"Being well assured of the great importance of dissections of morbid bodies in the investigation of the nature of diseases, we have thought it of consequence that some of those dead of the present prevailing malignant fever should be examined; and, without enlarging on our observations, it appears at present sufficient to state the following facts.

"1st. That the brain in all its parts has been found in a natural condition.

"2d. That the viscera of the thorax are perfectly sound. The blood, however, in the heart and veins is fluid, similar, in its consistence, to the blood of persons who have been hanged, or destroyed by electricity.

"3d. That the stomach, and beginning of the duodenum, are the parts that appear most diseased. In two persons who died of the disease on the 5th day, the villous membrane of the stomach, especially about its smaller end, was found highly inflamed; and this inflammation extended through the pylorus into the duodenum, some way. The inflammation here was exactly similar to that induced in the stomach by acrid poisons, as by arsenic, which we have once had an opportunity of seeing in a person destroyed by it.

"The bile in the gall-bladder was quite of its natural colour, though very viscid.

"In another person, who died on the 8th day of the disease, several spots of extravasation were discovered between the membranes, particularly about the smaller end of the stomach, the inflammation of which had considerably abated. Pus was seen in the beginning of the duodenum, and the villous membrane at this part was thickened.

"In two other persons, who died at a more advanced period of the disease, the stomach appeared spotted in many places with extravasations, and the inflammation disappeared. It contained, as did also the intestines, a black liquor, which had been vomited and purged before death. This black liquor appears clearly to be an altered secretion from the liver; for a fluid in all respects of the same qualities was found in the gall bladder. This liquor was so acrid, that it induced considerable inflammation and swelling on the operator's hands, which remained some days. The villous membrane of the intestines, in these last two bodies, was found inflamed in several places.

"The liver was of its natural appearance, excepting in one of the last persons, on the surface of which a very few distended veins were seen: all the other abdominal viscera were of a healthy appearance.

"The external surface of the stomach, as well as of the intestines, was quite free from inflammation; the veins being distended with blood, which appeared through the transparent peritonium, gave them a dark colour.

"The stomach of those who died early in the disease was always contracted; but in those who died at a more advanced period of it, where extravasations appeared, it was distended with air. "P. S. PHYSICK, "J. CATHRALL."

I have before remarked, that these dissections were made early in the disease, and that Dr. Annan attended a dissection of a body at Bush-hill, some time afterwards, in which an unusual turgescence appeared in the vessels of the brain.

Thus far have I delivered the history of the yellow fever, as it affected the human body with sickness and death. I shall now mention a few of those circumstances of public and private distress which attended it. I have before remarked, that the first reports of the existence of this fever were treated with neglect or contempt. A strange apathy pervaded all classes of people. While I bore my share of reproach for "terrifying our citizens with imaginary danger," I answered it by lamenting "that they were not terrified enough." The publication from the college of physicians soon dissipated this indifference and incredulity. Fear or terror now sat upon every countenance. The disease appeared in many parts of the town, remote from the spot where it originated; although, for a while, in every instance, it was easily traced to it. This set the city in motion. The streets and roads leading from the city were crowded with families flying in every direction for safety to the country. Business began to languish. Water-street, between Market and Race-streets, became a desert. The poor were the first victims of the fever. From the sudden interruption of business they suffered for a while from poverty as well as from disease. A large and airy house at Bush-hill, about a mile from the city, was opened for their reception. This house, after it became the charge of a committee appointed by the citizens on the 14th of September, was regulated and governed with the order and cleanliness of an old and established hospital. An American and French physician had the exclusive medical care of it after the 22d of September.

The disease, after the second week in September, spared no rank of citizens. Whole families were confined by it. There was a deficiency of nurses for the sick, and many of those who were employed were unqualified for their business. There was likewise a great deficiency of physicians, from the desertion of some, and the sickness and death of others. At one time there were but three physicians who were able to do business out of their houses, and at this time there were probably not less than 6000 persons ill with the fever.

During the first three or four weeks of the prevalence of the disease I seldom went into a house the first time, without meeting the parents or children of the sick in tears. Many wept aloud in my entry, or parlour, who came to ask for advice for their relations. Grief after a while descended below weeping, and I was much struck in observing that many persons submitted to the loss of relations and friends without shedding a tear, or manifesting any other of the common signs of grief.

A cheerful countenance was scarcely to be seen in the city for six weeks. I recollect once, in entering the house of a poor man, to have met a child of two years old that smiled in my face. I was strangely affected with this sight (so discordant to my feelings and the state of the city) before I recollected the age and ignorance of the child. I was confined the next day by an attack of the fever, and was sorry to hear, upon my recovery, that the father and mother of this little creature died a few days after my last visit to them.

The streets every where discovered marks of the distress that pervaded the city. More than one half the houses were shut up, although not more than one third of the inhabitants had fled into the country. In walking for many hundred yards, few persons were met, except such as were in quest of a physician, a nurse, a bleeder, or the men who buried the dead. The hearse alone kept up the remembrance of the noise of carriages or carts in the streets. Funeral processions were laid aside. A black man, leading or driving a horse, with a corpse on a pair of chair wheels, with now and then half a dozen relations or friends following at a distance from it, met the eye in most of the streets of the city, at every hour of the day, while the noise of the same wheels passing slowly over the pavements, kept alive anguish and fear in the sick and well, every hour of the night[55].

[55] In the Life of Thomas Story, a celebrated preacher among the friends, there is an account of the distress of the city, in its infant state, from the prevalence of the yellow fever, in the autumn of 1699, nearly like that which has been described. I shall insert the account in his own words. "Great was the fear that fell on all flesh. I saw no lofty or airy countenance, nor heard any vain jesting to move men to laughter. Every face gathered paleness, and many hearts were humbled, and countenances fallen and sunk, as such that waited every moment to be summoned to the bar, and numbered to the grave." The same author adds, that six, seven, and sometimes eight, died of this fever in a day, for several weeks. His fellow-traveller, and companion in the ministry, Roger Gill, discovered upon this occasion an extraordinary degree of christian philanthropy. He publicly offered himself, in one of the meetings of the society, as a sacrifice for the people, and prayed that "God would please to accept of his life for them, that a stop might be put to the contagion." He died of the fever a few days afterwards.

But a more serious source of the distress of the city arose from the dissentions of the physicians, about the nature and treatment of the fever. It was considered by some as a modification of the influenza, and by others as the jail fever. Its various grades and symptoms were considered as so many different diseases, all originating from different causes. There was the same contrariety in the practice of the physicians that there was in their principles. The newspapers conveyed accounts of both to the public, every day. The minds of the citizens were distracted by them, and hundreds suffered and died from the delays which were produced by an erroneous opinion of a plurality of diseases in the city, or by indecision in the choice, or a want of confidence in the remedies of their physician.

The science of medicine is related to every thing, and the philosopher as well as the christian will be gratified by knowing the effects of a great and mortal epidemic upon the morals of a people. It was some alleviation of the distress produced by it, to observe its influence upon the obligations of morality and religion. It was remarked during this time, by many people, that the name of the Supreme Being was seldom profaned, either in the streets, or in the intercourse of the citizens with each other. But two robberies, and those of a trifling nature, occurred in nearly two months, although many hundred houses were exposed to plunder, every hour of the day and night. Many of the religious societies met two or three times a week, and some of them every evening, to implore the interposition of Heaven to save the city from desolation. Humanity and charity kept pace with devotion. The public have already seen accounts of their benevolent exercises in other publications. It was my lot to witness the uncommon activity of those virtues upon a smaller scale. I saw little to blame, but much to admire and praise in persons of different professions, both sexes, and of all colours. It would be foreign to the design of this work to draw from the obscurity which they sought, the many acts of humanity and charity, of fortitude, patience, and perseverance, which came under my notice. They will be made public and applauded elsewhere.

But the virtues which were excited by our calamity were not confined to the city of Philadelphia. The United States wept for the distresses of their capital. In several of the states, and in many cities and villages, days of humiliation and prayer were set apart to supplicate the Father of Mercies in behalf of our afflicted city. Nor was this all. From nearly every state in the union the most liberal contributions of money, provisions, and fuel were poured in for the relief and support of such as had been reduced to want by the suspension of business, as well as by sickness and the death of friends.

The number of deaths between the 1st of August and the 9th of November amounted to four thousand and forty-four. I shall here insert a register of the number which occurred on each day, beginning on the 1st of August, and ending on the 9th of November. By comparing it with the register of the weather it will show the influence of the latter on the disease. Several of the deaths in August were from other acute diseases, and a few in the succeeding months were from such as were of a chronic nature.

died. | August 1 9 | 2 8 | 3 9 | 4 10 | 5 10 | 6 3 | 7 12 | 8 5 | 9 11 | 10 6 | 11 7 | 12 5 | 13 11 | 14 4 | 15 9 | 16 7 | 17 6 | 18 5 | 19 9 | 20 7 | 21 8 | 22 13 | 23 10 | 24 17 | 25 12 | 26 17 | 27 12 | 28 22 | 29 24 | 30 20 | 31 17 | September 1 17 | 2 18 | 3 11 | 4 23 | 5 20 | 6 24 | 7 18 | 8 42 | 9 32 | 10 29 | 11 23 | 12 33 | 13 37 | 14 48 | 15 56 | 16 67 | 17 81 | 18 68 | 19 61 | 20 67 | 21 57 | 22 76 | 23 68 | 24 96 | 25 87 | 26 52 | 27 60 | 28 51 | 29 57 | 30 63 | October 1 74 | 2 66 | 3 78 | 4 58 | 5 71 | 6 76 | 7 82 | 8 90 | 9 102 | 10 93 | 11 119 | 12 111 | 13 104 | 14 81 | 15 80 | 16 70 | 17 80 | 18 59 | 19 65 | 20 55 | 21 59 | 22 82 | 23 54 | 24 38 | 25 35 | 26 23 | 27 13 | 28 24 | 29 17 | 30 16 | 31 21 | November 1 13 | 2 21 | 3 15 | 4 15 | 5 14 | 6 11 | 7 15 | 8 8 | 9 6 | ---- | Total[56] 3881 |

[56] In the above accounts there is a deficiency of returns from several grave-yards of 163.

From this table it appears that the principal mortality was in the second week of October. A general expectation had obtained, that cold weather was as fatal to this fever as heavy rains. The usual time for its arrival had come, but the weather was still not only moderate, but warm. In this awful situation, the stoutest hearts began to fail. Hope sickened, and despair succeeded distress in almost every countenance. On the _fifteenth_ of October, it pleased God to alter the state of the air. The clouds at last dropped health in showers of rain, which continued during the whole day, and which were succeeded for several nights afterwards by cold and frost. The effects of this change in the weather appeared first in the sudden diminution of the sick, for the deaths continued for a week afterwards to be numerous, but they were of persons who had been confined before, or on the day in which the change had taken place in the weather.

The appearance of this rain was like a dove with an olive branch in its mouth to the whole city. Public notice was given of its beneficial effects, in a letter subscribed by the mayor of Philadelphia, who acted as president of the committee, to the mayor of New-York. I shall insert the whole of this letter. It contains, besides the above information, a record of the liberality of that city to the distressed inhabitants of Philadelphia.

"SIR,

"I am favoured with your letter of the 12th instant, which I have communicated to the committee for the relief of the poor and afflicted of this city.

"It is with peculiar satisfaction that I execute their request, by making, in their name, on behalf of our suffering fellow-citizens, the most grateful acknowledgements for the seasonable benevolence of the common council of the city of New-York. Their sympathy is balm to our wounds.

"We acknowledge the Divine interposition, whereby the hearts of so many around us have been touched with our distress, and have united in our relief.

"May the Almighty Disposer of all events be graciously pleased to protect your citizens from the dreadful calamity with which we are now visited; whilst we humbly kiss the rod, and improve by the dispensation.

"The part, sir, which you personally take in our afflictions, and which you have so pathetically expressed in your letter, excites in the breasts of the committee the warmest sensations of fraternal affection.

"The refreshing rain which fell the day before yesterday, though light, and the cool weather which hath succeeded, appear to have given a check to the prevalence of the disorder: of this we have satisfactory proofs, as well in the decrease of the funerals, as in the applications for removal to the hospital.

"I have, at your request, this day drawn upon you, at sight, in favour of the president and directors of the Bank of North America, for the sum of five thousand dollars, the benevolent donations of the common council of the city of New-York.

"With sentiments of the greatest esteem and regard,

"I am, sir, "Your most obedient humble servant,

"MATTH. CLARKSON.

_"Philadelphia, Oct. 17, 1793._ _"Richard Varick, mayor of the city of New-York."_

It is no new thing for bilious fevers, of every description, to be checked or subdued by _wet_ and _cold_ weather.

The yellow fever which raged in Philadelphia in 1699, and which is taken notice of by Thomas Story in his journal, ceased about the latter end of October, or the beginning of November. Of this there are satisfactory proofs, in the register of the interments in the friends' burying-ground, and in a letter, dated November 9th, old style, 1699, from Isaac Norris to one of his correspondents, which his grandson, Mr. Joseph P. Norris, politely put into my hands, with several others, which mention the disease, and all written in that memorable year in Philadelphia. The letter says, "It has pleased God to put a stop to our sore visitation, and town and country are now generally healthy." The same disease was checked by wet and cold weather in the year 1741. Of this there is a proof in a letter from Dr. Franklin to one of his brothers, who stopped at Burlington, on his way from Boston to Philadelphia, on account of the fever, until he was assured by the doctor, that a thunder gust, which had cooled the air, had rendered it safe for him to come into the city[57]. Mr. Lynford Lardner, in a letter to one of his English friends, dated September 24, 1747, old style, after mentioning the prevalence of the fever in the city, says, "the weather is now much cooler, and those under the disorder revive. The symptoms are less violent, and the fever gradually abates."

[57] From a short note in the register of the interments in the friends' burying-ground, it appears that the fever this year made its first appearance in the month of June. The following is a copy of that note: "12th of the 6th month (O. S.), 1741, a malignant yellow fever now spreads much." Besides that note, there is the following: "25th of the 7th month (O. S.), 1741, many who died of the above distemper were persons lively, and strong, and in the prime of their time."

I have in vain attempted to procure an account of the time of the commencement of cold weather in the autumn of 1762. In the short history of the fever of that year, which I have inserted from my note book, I have said that it continued to prevail in the months of November and December. The register of the interments in the friends' burying-ground in those months confirms that account. They were nearly as numerous in November and December as in September and October, viz. in September 22, in October 27, in November 19, and in December 26.

The bilious remitting fever of 1780 yielded to cool weather, accompanied by rain and an easterly wind[58].

[58] Vol. i.

Sir John Pringle will furnish ample satisfaction to such of my readers as wish for more proofs of the efficacy of heavy rains, and cold weather, in checking the progress and violence of autumnal remitting fevers[59].

[59] P. 5, 56, 180, and 323.

From the 15th of October the disease not only declined, but assumed more obvious inflammatory symptoms. It was, as in the beginning, more necessarily fatal where left to itself, but it yielded more certainly to art than it did a few weeks before. The duration of it was now more tedious than in the warmer weather.

There were a few cases of yellow fever in November and December, after the citizens who had retired to the country returned to the city.

I heard of but three persons who returned to the city being infected with the disease; so completely was its cause destroyed in the course of a few weeks.

In consequence of a proclamation by the governor, and a recommendation by the clergy of Philadelphia, the 12th of December was observed as a day of thanksgiving throughout the state, for the extinction of the disease in the city.

It was easy to distinguish, in walking the streets, the persons who had returned from the country to the city, from those who had remained in it during the prevalence of the fever. The former appeared ruddy and healthy, while the latter appeared of a pale or sallow colour.

It afforded a subject of equal surprise and joy to behold the suddenness with which the city recovered its former habits of business. In the course of six weeks after the disease had ceased, nothing but fresh graves, and the black dresses of many of the citizens, afforded a public trace of the distress which had so lately prevailed in the city.

The month of November, and all the winter months which followed the autumnal epidemic, were in general healthy. A catarrh affected a number of people in November. I suspected it to be the influenza which had revived from a dormant state, and which had not spent itself, when it yielded to the predominance of the yellow fever. This opinion derives some support from a curious fact related by the late Mr. Hunter of the revival of the small-pox in a patient, in whom it had been suspended for some time by the measles[60]. The few fevers which prevailed in the winter were highly inflammatory. The small-pox in the natural way was in several instances confluent; and in one or two fatal. I was prepared to expect this inflammatory diathesis in the fevers of the winter; for I had been taught by Dr. Sydenham, that the diseases which follow a great and mortal epidemic partake more or less of its general character. But the diseases of the winter had a peculiarity still more extraordinary; and that was, many of them had several of the symptoms of the yellow fever, particularly a puking of bile, dark-coloured stools, and a yellow eye. Mr. Samuel D. Alexander, a student of medicine from South-Carolina, who was seized with a pneumony about Christmas, had, with a yellow eye, a dilated pupil and a hard pulse, which beat only fifty strokes in a minute. His blood was such as I had frequently observed in the yellow fever. Dr. Griffitts informed me that he attended a patient on the 9th of January, in a pneumony, who had a universal yellowness on his skin. I met with a case of pneumony on the 20th of the same month, in which I observed the same degrees of redness in the eyes that were common in the yellow fever. My pupil, Mr. Coxe, lost blood in an inflammatory fever, on the 18th of February, which was dissolved. Mr. Innes, the brewer, had a deep yellow colour in his eyes, on the fourth day of a pneumony, on the 27th of the same month; and Mr. Magnus Miller had the same symptom of a similar disease on the 16th of March. None of these bilious and anomalous symptoms of the inflammatory fevers of the winter and spring surprised me. I had been early taught, by Dr. Sydenham, that the epidemics of autumn often insinuate some of their symptoms into the winter diseases which follow them. Dr. Cleghorn informs us, that "the pleurisies which succeeded the autumnal tertians in Minorca, were accompanied by a vomiting and purging of green or yellow bilious matters[61]."

[60] Introduction to a Treatise on the Venereal Disease, p. 3. of the American edition.

[61] Page 273.

It belongs to powerful epidemics to be followed by similar diseases after they disappear, as well as to run into others at their first appearance. In the former case it is occasioned by a peculiar state of the body, created by the epidemic constitution of the air, not having been changed by the weather which succeeded it.

The weather in March resembled that of May; while the weather in April resembled that of March in common years. A rash prevailed in many families, in April, accompanied in a few cases by a sore throat. It was attended with an itching, a redness of the eyes, and a slight fever in a few instances. The small-pox by inoculation in this month was more mortal than in former years. However unimportant these facts may appear at this time, future observations may perhaps connect them with a similar constitution of the air which produced the previous autumnal epidemic.

The appearance of bilious symptoms in the diseases of the winter, excited apprehensions in several instances of the revival of the yellow fever. The alarms, though false, served to produce vigilance and industry in the corporation, in airing and purifying such houses and articles of furniture as belonged to the poor; and which had been neglected in the autumn, after the ceasing of the disease.

The modes of purifying houses, beds, and clothes were various. Fumigations of nitre and aromatic substances were used by some people. Burying infected articles of furniture under ground, and baking them in ovens, were used by others. Some destroyed all their beds and clothing that had been infected, or threw them into the Delaware. Many white-washed their walls, and painted the wood-work of their house. I did not conceive the seeds of the disease required all, or any of those means to destroy it. I believed _cold_ and _water_ to be sufficient for that purpose. I therefore advised keeping the windows of infected rooms open night and day, for a few days; to have the floors and walls of houses well washed; and to expose beds and such articles of household furniture as might be injured by washing, upon the bare earth for a week or two, taking care to turn them every day. I used no other methods of destroying the accumulated miasmata in my house and furniture, and experience showed that they were sufficient.

It is possible a portion of the excretions of the sick may be retained in clothes or beds, so as to afford an exhalation that may in the course of a succeeding summer and autumn, or from accidental warmth at any time, create a solitary case of fever, but it cannot render it epidemic. A trunk full of clothes, the property of Mr. James Bingham, who died of the yellow fever in one of the West-India islands about 50 years ago, was opened, some months after they were received by his friends, by a young man who lived in his brother's family. This young man took the disease, and died; but without infecting any of the family; nor did the disease spread afterwards in the city. The father of Mr. Joseph Paschall was infected with the yellow fever of 1741, by the smell of a foul bed in passing through Norris's Alley, in the latter end of December, after the disease had left the city. He died on the 25th of the month, but without reviving the fever in the city, or even infecting his family.

The matter which produced the fever in both these cases, had nothing specific in it. It acted in the same manner that the exhalation from any other putrid matters would have done in a highly concentrated state.

In a letter from Dr. Senter of Newport, dated January 7th, 1794, I find the following fact, which I shall communicate in his own words. It is introduced to support the principle, that the yellow fever does not spread by contagion. "This place (says the doctor) has traded formerly very much to the West-India islands, and more or less of our people have died there every season, when the disease prevails in those parts. Clothes of these unfortunate people have been repeatedly brought home to their friends, without any accident happening to them."

I feel with my reader the fatigue of this long detail of facts, and equal impatience with him to proceed to the history of the treatment of the fever; but I must beg leave to detain him a little longer from that part of the work, while I resume the subject of the origin of the fever. It is an interesting question, as it involves in it the means of preventing the return of the disease, and thereby of saving the lives of thousands of our citizens.

Soon after the fever left the city, the governor of the state addressed a letter to the college of physicians, requesting to know their opinion of its origin; if imported, from what _place_, at what _time_, and in what _manner_. The design of this inquiry was to procure such information as was proper to lay before the legislature, in order to improve the laws for preventing the importation or generation of infectious diseases, or to enact new ones, if necessary for that purpose. To the governor's letter the college of physicians sent the following answer:

"SIR,

"It has not been from a want of respect to yourself, nor from inattention to the subject, that your letter of the 30th ult. was not sooner answered; but the importance of the questions proposed has made it necessary for us to devote a considerable portion of time and attention to the subject, in order to arrive at a safe and just conclusion.

"No instance has ever occurred of the disease called the _yellow fever_ having been generated in this city, or in any other parts of the United States, as far as we know; but there have been frequent instances of its having been imported, not only into this, but into other parts of North-America, and prevailing there for a certain period of time; and from the rise, progress, and nature of the malignant fever, which began to prevail here about the beginning of last August, and extended itself gradually over a great part of the city, we are of opinion that this disease was imported into Philadelphia, by some of the vessels which arrived in the port after the middle of July. This opinion we are further confirmed in by various accounts we have received from unquestionable authorities.

"Signed, by order of the college of physicians,

"JOHN REDMAN, _President_.

"_November 26th, 1793._ "_To the governor of Pennsylvania._"

Dr. Redman, the president of the college, Dr. Foulke, and Dr. Leib, dissented from the report contained in this letter. I have been necessarily led to continue it in the present edition of this work, not only because all the other members of that body still retain their belief of the importation of the fever, but as a reason for republishing the facts and arguments in support of its domestic origin.

I have asserted, in the introduction to the history of this fever, that I believed it to have been generated in our city; I shall now deliver my reasons for that belief.

1. The yellow fever in the West-Indies, and in all other countries where it is endemic, is the offspring of vegetable putrefaction. Heat, exercise, and intemperance in drinking (says Dr. Lind) _dispose_ to this fever in hot climates, but they do not produce it without the concurrence of a remote cause. This remote cause exists at all times, in some spots of the islands, but in other parts even of the same islands, where there are no marsh exhalations, the disease is unknown. I shall not waste a moment in inquiring into the truth of Dr. Warren's account of the origin of this fever. It is fully refuted by Dr. Hillary, and it is treated as chimerical by Dr. Lind. They have very limited ideas of the history of this fever who suppose it to be peculiar to the East or West-Indies. It was admitted to have been generated in Cadiz after a hot and dry summer in 1764, and in Pensacola in 1765[62]. The tertian fever of Minorca, when it attacked Englishmen, put on the usual symptoms of the yellow fever[63]. In short, this disease appears, according to Dr. Lind, in all the southern parts of Europe, after hot and dry weather[64].

[62] Lind on the Diseases of Hot Climates, p. 36 and 124.

[63] Cleghorn, p. 176.

[64] Diseases of Hot Climates, p. 123.

2. The same causes (under like circumstances) must always produce the same effects. There is nothing in the air of the West-Indies, above other hot countries, which disposes it to produce a yellow fever. Similar degrees of heat, acting upon dead and moist vegetable matters, are capable of producing it, together with all its various modifications, in every part of the world. In support of this opinion, I shall transcribe part of a letter from Dr. Miller, formerly of the Delaware state, and now of New-York.

"_Dover, Nov. 5, 1793._

"DEAR SIR,

"Since the middle of last July we have had a bilious colic epidemic in this neighbourhood, which exhibits phænomena very singular in this climate; and, so far as I am informed, unprecedented in the medical records, or popular traditions of this country. To avoid unnecessary details it will suffice at present to observe, that the disease, on this occasion, has assumed, not only all the essential characters, but likewise all the violence, obstinacy, and malignity described by the East and West-Indian practitioners. If any difference can be observed it seems here to manifest higher degrees of stubbornness and malignity than we usually meet in the histories of tropical writers. In the course of the disease, not only extreme constipation, frequent vomiting, and the most excruciating pains of the bowels and limbs, harass the unhappy patient; but to these succeed paralysis, convulsions, &c. and almost always uncommon muscular debility, oppression of the præcordia, &c. are the consequence of a severe attack. Bile discharged in enormous quantities constantly assumes the most corrupted and acrimonious appearances, commonly æruginous in a very high degree, and sometimes quite atrabilious.

"The inference I mean to draw from the phænomena of this disease, as it appears in this neighbourhood, and which I presume will also apply to your epidemic, is _this_, that from the uncommon protraction and intenseness of our summer and autumnal heats, but principally from the unusual drought, we have had, since the middle of July, a near approach to a _tropical_ season, and that of consequence we ought not to be surprised if tropical diseases, even of the most malignant nature, are _engendered_ amongst us."

To the above information it may be added, that the dysentery which prevailed during the autumn of 1793, in several of the villages of Pennsylvania, was attended with a malignity and mortality unknown before in any part of the state. I need not pause to remark that this dysentery arose from putrid exhalation, and that it is, like the bilious colic, only a modification of bilious fever.

But further, a malignant fever, resembling that which was epidemic in our city, prevailed during the autumn in many parts of the United States, viz. at Lynn in Massachusetts, at Weatherfield and Coventry in Connecticut, at New-Galloway in the state of New-York, on Walkill and on Pensocken creeks in New-Jersey, at Harrisburgh and Hummelstown in Pennsylvania, in Caroline county in Maryland, on the south branch of the Potowmac in Hardie county, also in Lynchburgh and in Alexandria in Virginia, and in several counties in North-Carolina. In none of these places was there a suspicion of the disease being imported from abroad, or conveyed by an intercourse with the city of Philadelphia.

It is no objection to the inference which follows from these facts, that the common remitting fever was not known during the above period in the neighbourhood of this city, and in many other parts of the state, where it had usually appeared in the autumnal months. There is a certain combination of moisture with heat, which is essential to the production of the remote cause of a bilious fever. Where the heat is so intense, or of such long duration, as wholly to dissipate moisture, or when the rains are so great as totally to overflow the marshy ground, or to wash away putrid masses of matter, no fever can be produced.

Dr. Dazilles, in his treatise upon the diseases of the negroes in the West-Indies, informs us, that the _rainy_ season is the most healthy at Cayenne, owing to the neighbouring morasses being _deeply_ overflowed; whereas, at St. Domingo, a _dry_ season is most productive of diseases, owing to its favouring those degrees of moisture which produce morbid exhalations. These facts will explain the reason why, in certain seasons, places which are naturally healthy in our country become sickly, while those places which are naturally sickly escape the prevailing epidemic. Previously to the dissipation of the moisture from the putrid masses of vegetable matters in our streets, and in the neighbourhood of the city, there were (as several practitioners can testify) many cases of mild remittents, but they all disappeared about the first week in September.

It is worthy of notice, that the yellow fever prevailed in Virginia in the year 1741, and in Charleston, in South-Carolina, in the year 1699, in both which years it prevailed in Philadelphia. Its prevalence in Charleston is taken notice of in a letter, dated November 18th, O. S. 1699, from Isaac Norris to one of his correspondents. The letter says, that "150 persons had died in Charleston in a few days," that "the survivors fled into the country," and that "the town was thinned to a very few people." Is it not probable, from the prevalence of this fever twice in two places in the same years, that it was produced (as in 1793) by a general constitution of air, co-operating with miasmata, which favoured its generation in different parts of the continent? But again, such was the state of the air in the summer of 1793, that it predisposed other animals to diseases, besides the human species. In some parts of New-Jersey, a disease prevailed with great mortality among the horses, and in Virginia among the cows, during the autumn. The urine in both was yellow.--Large abscesses appeared in different parts of the body in the latter animals, which, when opened, discharged a yellow serous fluid. From the colour of these discharges, and of the urine, the disease got the name of the _yellow water_.

3. I have before remarked, that a quantity of damaged coffee was exposed at a time (July the 24th) and in a situation (on a wharf and in a dock) which favoured its putrefaction and exhalation. Its smell was highly putrid and offensive, insomuch that the inhabitants of the houses in Water and Front-streets, who were near it, were obliged, in the hottest weather, to exclude it by shutting their doors and windows. Even persons, who only walked along those streets, complained of an intolerable f[oe]tor, which, upon inquiring, was constantly traced to the putrid coffee. It should not surprise us, that this seed, so inoffensive in its natural state, should produce, after its putrefaction, a violent fever. The records of medicine (to be mentioned hereafter) furnish instances of similar fevers being produced, by the putrefaction of many other vegetable substances.

4. The rapid progress of the fever from Water-street, and the courses through which it travelled into other parts of the city, afford a strong evidence that it was at first propagated by exhalation from the putrid coffee. It was observed that it passed first through those alleys and streets which were in the course of the winds that blew across the dock and wharf, where the coffee had been thrown in a state of putrefaction.

5. Many persons who had worked, or even visited, in the neighbourhood of the exhalation from the coffee, early in the month of August, were indisposed afterwards with sickness, puking, and yellow sweats, long before the air of Water-street was so much impregnated with the exhalation, as to produce such effects; and several patients, whom I attended in the yellow fever, declared to me, or to their friends, that their indispositions began exactly at the time they inhaled the offensive effluvia of the coffee.

6. The first cases of the yellow fever have been clearly traced to the sailors of the vessel who were first exposed to the effluvia of the coffee. Their sickness commenced with the day on which the coffee began to emit its putrid smell. The disease spread with the increase of the poisonous exhalation. A journeyman of Mr. Peter Brown's, who worked near the corner of Race and Water-streets, caught the disease on the 27th of July. Elizabeth Hill, the wife of a fisherman, was infected by only sailing near the pestilential wharf, about the 1st of August, and died at Kensington on the 14th of the same month. Many other names might be mentioned of persons who sickened during the last week in July or the first week in August, who ascribed their illnesses to the smell of the coffee.

7. It has been remarked that this fever did not spread in the country, when carried there by persons who were infected, and who afterwards died with it. During four times in which it prevailed in Charleston, in no one instance, according to Dr. Lining, was it propagated in any other part of the state.

8. In the histories of the disease which have been preserved in this country, it has _six_ times appeared about the first or middle of August, and declined or ceased about the middle of October: viz. in 1732, 1739, 1745, and 1748 in Charleston, in 1791 in New-York, and in 1793 in Philadelphia. This frequent occurrence of the yellow fever at the usual period of our common bilious remittents, cannot be ascribed to accidental coincidence, but must be resolved, in most cases, into the combination of more active miasmata with the predisposition of a tropical season. In speaking of a tropical season, I include that kind of weather in which rains and heats are alternated with each other, as well as that which is uniformly warm.

9. Several circumstances attended this epidemic, which do not occur in the West-India yellow fever. It affected children as well as adults, in common with our annual bilious fevers. In the West-Indies, Dr. Hume tells us, it never attacked any person under puberty. It had, moreover, many peculiar symptoms (as I have already shown) which are not to be met with in any of the histories of the West India yellow fever.

10. Why should it surprise us to see a yellow fever generated amongst us? It is only a higher grade of a fever which prevails every year in our city, from vegetable putrefaction. It conforms, in the difference of its degrees of violence and danger, to season as well as climate, and in this respect it is upon a footing with the small-pox, the measles, the sore-throat, and several other diseases. There are few years pass, in which a plethoric habit, and more active but limited miasmata, do not produce sporadic cases of true yellow fever in Philadelphia. It is very common in South and North-Carolina and in Virginia, and there are facts which prove, that not only strangers, but native individuals, and, in one instance, a whole family, have been carried off by it in the state of Maryland. It proved fatal to one hundred persons in the city of New-York in the year of 1791, where it was evidently generated by putrid exhalation. The yellow colour of the skin has unfortunately too often been considered as the characteristic mark of this fever, otherwise many other instances of its prevalence might be discovered, I have no doubt, in every part of the United States. I wish, with Dr. Mosely, the term _yellow_ could be abolished from the titles of this fever, for this colour is not only frequently absent, but sometimes occurs in the mildest bilious remittents. Dr. Haller, in his pathology, describes an epidemic of this kind in Switzerland, in which this colour generally attended, and I have once seen it almost universal in a common bilious fever, which prevailed in the American army, in the year 1776.

I cannot help taking notice, in this place, of an omission in the answer to the governor's letter, by the college of physicians. The governor requested to know whether it was imported; if it were, from _what place_, at _what time_, and in _what manner_. In the answer of the college of physicians to the governor's letter no notice was taken of any of those questions. In vain did Dr. Foulke call upon the college to be more definite in their answer to them. They had faithfully sought for the information required, but to no purpose. The character of their departed brother, Dr. Hutchinson, for capacity and vigilance in his office, as inspector of sickly vessels, was urged without effect as an argument against the probability of the disease being imported. Public report had derived it from several different islands; had chased it from ship to ship, and from shore to shore; and finally conveyed it at different times into the city, alternately by dead and living bodies; and from these tales, all of which, when investigated, were proved to be without foundation, the college of physicians composed their letter. It would seem, from this conduct of the college, as if medical superstition had changed its names, and that, in accounting for the origin of pestilential fevers, celestial, planetary, and demoniacal influence had only yielded to the term _importation_.

Let not the reader reject the opinion I have delivered because it is opposed by so great a majority of the physicians of Philadelphia. A single physician supported an opinion of the existence of the plague at Messina, in the year 1743, in opposition to all the physicians (33 in number) of that city. They denied the disease in question to exist, because it was not accompanied by glandular swellings. Time showed that they were all mistaken, and the plague, which might probably have been checked, at its first appearance, by their united efforts, was, by means of their ignorance, introduced with great mortality into every part of the city. This disposition of physicians to limit the symptoms of several other diseases, cannot be sufficiently lamented. The frequent absence of a yellow colour, in this epidemic, led to mistakes which cost the city of Philadelphia several hundred lives.

The letter of the college of physicians has served to confirm me in an opinion, that the plagues which occasionally desolated most of the countries of Europe, in former centuries, and which were always said to be of foreign extraction, were of domestic origin. Between the years 1006 and 1680, the plague was epidemic fifty-two times all over Europe. It prevailed fourteen times in the 14th century. The state of Europe, in this long period, is well known. Idleness, a deficiency of vegetable aliment, a camp life, from the frequency of wars, famine, an uncultivated and marshy soil, small cabins, and the want of cleanliness in dress, diet, and furniture, all concurred to generate pestilential diseases. The plagues which prevailed in London, every year from 1593 to 1611, and from 1636 to 1649, I believe were generated in that city. The diminution of plagues in Europe, more especially in London, appears to have been produced by the great change in the diet and manners of the people; also by the more commodious and airy forms of the houses of the poor, among whom the plague _always_ makes its first appearance. It is true, these plagues were said by authors to have been imported, either directly or indirectly, from the Levant; but the proofs of such importation were as vague and deficient as they were of the West-India origin of our epidemic. The pestilential fevers which have been mentioned, have been described by authors by the generic name of the plague, but they appear to have originated from putrid vegetable exhalations, and to have resembled, in most of their symptoms, the West-India and _North-American_ yellow fever.

I shall resume this interesting subject in another place, in which I shall mention a number of additional facts, not only in support of the domestic origin of the bilious yellow fever, but of its not spreading by contagion, and of course of its being impossible to import it. I shall at the same time enumerate all its different sources, and point out the means of destroying or removing them, and thus of exterminating the disease from our country.

With these observations I conclude the history of the epidemic fever of the year 1793. A few of its symptoms, which have been omitted in this history, will be included in the method of cure, for they were discovered or produced by the remedies which were given for that purpose.

[Hand] The following page begins an account of the states of the thermometer and weather, from the 1st of January to the 1st of August, and of the states of the barometer, thermometer, winds, and weather, from the 1st of August to the 9th of November, 1793. The times of observation, for the first three months are at 7 in the morning, and 2 in the afternoon; for the next five months they are at 6 in the morning, and 3 in the afternoon. From the 1st of October to the 9th of November, they are as in the first three months.

_January, 1793._ _February, 1793._ +----+---------+----------------------+---------+---------------------+ | | Therm. | Weather. | Therm. | Weather. | | D. | 7h | 2h | | 7h | 2h | | +----+----+----+----------------------+----+----+---------------------+ | 1 | 27 | 30 | Cloudy. | 9 | 26 | Fair, hazy. | | 2 | 30 | 41 | Fair, cloudy. | 25 | 34 | Rain, ditto. | | 3 | 30 | 33 | Cloudy, rain. | 33 | 37 | Cloudy, fair. | | 4 | 38 | 41 | Rain, cloudy. | 25 | 46 | Cloudy, fair. | | 5 | 35 | 42 | Fair, cloudy. | 36 | 44 | Cloudy, ditto. | | 6 | 33 | 47 | Cloudy, fair. | 35 | 46 | Cloudy, rain. | | 7 | 38 | 51 | Fair, fair. | 36 | 40 | Cloudy, fair. | | 8 | 32 | 49 | Fair, ditto. | 28 | 44 | Cloudy, ditto. | | 9 | 33 | 48 | Hazy, fair. | 42 | 50 | Rain, fair. | | 10 | 38 | 51 | Fair, ditto. | 38 | 40 | Cloudy, fair. | | 11 | 35 | 48 | Fair, clouds. | 19 | 27 | Fair, cloudy. | | 12 | 31 | 42 | Fair, ditto. | 20 | 28 | Snow, cloudy. | | 13 | 28 | 42 | Fair, ditto. | 22 | 31 | Cloudy, snow. | | 14 | 25 | 27 | Hail, snow, sleet. | 27 | 39 | Cloudy, fair. | | 15 | 32 | 37 | Clouds, mist. | 18 | 40 | Fair, ditto. | | 16 | 37 | 39 | Rain, ditto. | 29 | 42 | Cloudy, ditto. | | 17 | 37 | 45 | Rain, snow, fair. | 44 | 48 | Rain, ditto. | | 18 | 32 | 52 | Fair, ditto. | 39 | 49 | Cloudy, fair. | | 19 | 37 | 48 | Fair, ditto. | 31 | 41 | Cloudy, rain. | | 20 | 33 | 47 | Hazy, cloudy. | 52 | 53 | Rain, fair. | | 21 | 36 | 47 | Cloudy, fair. | 37 | 49 | Fair, ditto. | | 22 | 27 | 32 | Fair, ditto. | 29 | 34 | Fair, ditto. | | 23 | 22 | 37 | Fair, ditto. | 22 | 34 | Snow, cloudy. | | 24 | 30 | 39 | Cloudy, ditto. | 54 | 59 | Rain, cloudy. | | 25 | 30 | 41 | Fair, hazy. | 34 | 35 | Cloudy, ditto. | | 26 | 31 | -- | Fair. | 35 | 43 | Rain, mist. | | 27 | 23 | 38 | Fair, cloudy, snow. | 43 | 43 | Rain, cloudy. | | 28 | 35 | 45 | Cloudy, fair. | 14 | 26 | Fair, ditto. | | 29 | 29 | 37 | Fair, ditto. | | | | | 30 | 22 | 23 | Snow, hail. | | | | | 31 | 25 | 32 | Cloudy, fair. | | | | +----+----+----+----------------------+----+----+---------------------+ _March, 1793._ _April, 1793._ +----+---------+----------------------+---------+---------------------+ | | Therm. | Weather. | Therm. | Weather. | | D. | 7h | 2h | | 7h | 2h | | +----+----+----+----------------------+----+----+---------------------+ | 1 | 20 | 38 | Fair, ditto. | 45 | 70 | Cloudy, fair. | | 2 | 31 | 51 | Hazy, cloudy. | 47 | 71 | Fair, ditto. | | 3 | 48 | 63 | Rain, fair. | 56 | 80 | Fair, ditto. | | 4 | 43 | 61 | Hazy, ditto. | 51 | 72 | Cloudy, fair. | | 5 | 51 | 52 | Rain, fair. | 53 | 61 | Cloudy, rain. | | 6 | 32 | 50 | Fair, ditto. | 60 | 76 | Misty, fair. | | 7 | 36 | 62 | Fair, ditto, clouds. | 51 | 65 | Fair, ditto. | | 8 | 54 | 60 | Cloudy, rain. | 46 | 74 | Fair, ditto. | | 9 | 26 | 41 | Fair, ditto. | 55 | 71 | Fair, cloudy. | | 10 | 29 | 51 | Fair, ditto. | 50 | 56 | Fair, ditto. | | 11 | 43 | 55 | Rain, ditto. | 37 | 63 | Fair, ditto. | | 12 | 40 | 43 | Cloudy, ditto. | 54 | 62 | Cloudy, rain, fair. | | 13 | 38 | 39 | Cloudy, fair. | 49 | 62 | Fair, ditto. | | 14 | 26 | 44 | Fair, ditto. | 50 | 70 | Fair, ditto. | | 15 | 32 | 59 | Fair, ditto. | 45 | 55 | Rain, cloudy. | | 16 | 52 | 62 | Cloudy, fair. | 46 | 62 | Cloudy, fair. | | 17 | 51 | 72 | Cloudy, fair. | 48 | 67 | Fair, clouds, fair. | | 18 | 58 | 69 | Hazy, cloudy. | 52 | 66 | Cloudy, fair. | | 19 | 53 | 59 | Fair, ditto. | 52 | 75 | Fair, ditto. | | 20 | 42 | 61 | Fair, ditto. | 52 | 49 | Rain, cloudy. | | 21 | 41 | 43 | Rain, cloudy. | 44 | 47 | Cloudy, ditto. | | 22 | 31 | 47 | Fair, ditto. | 43 | 46 | Rain, cloudy. | | 23 | 35 | 57 | Fair, ditto. | 42 | 63 | Fair, ditto. | | 24 | 37 | 50 | Fair, ditto. | 44 | 68 | Fair, ditto. | | 25 | 35 | 59 | Fair, ditto. | 45 | 65 | Cloudy, ditto. | | 26 | 47 | 54 | Cloudy, rain. | 53 | 57 | Cloudy, rain. | | 27 | 43 | 51 | Fair, cloudy. | 47 | 46 | Rain, ditto. | | 28 | 33 | 45 | Fair, clouds, fair. | 44 | 54 | Rain, cloudy. | | 29 | 34 | 57 | Fair, ditto. | 40 | 59 | Fair, ditto. | | 30 | 41 | 58 | Cloudy, fair. | 40 | 65 | Fair, ditto. | | 31 | 42 | 61 | Cloudy, fair. | | | | +----+----+----+----------------------+----+----+---------------------| _May, 1793._ _June, 1793._ +----+---------+----------------------+---------+---------------------+ | | Therm. | Weather. | Therm. | Weather. | | D. | 7h | 2h | | 7h | 2h | | +----+----+----+----------------------+----+----+---------------------+ | 1 | 45 | 69 | Foggy, cloudy. | 53 | 61 | Rain, showery. | | 2 | 52 | 73 | Fog, clouds, fair. | 54 | 64 | Clouds, showers. | | 3 | 60 | 63 | Rain, ditto. | 55 | 62 | Cloudy, rain, fair. | | 4 | 60 | 80 | Fair, ditto. | 54 | 60 | Rain, do. cloudy. | | 5 | 55 | 56 | Cloudy, ditto. | 58 | 72 | Cloudy, fair, rain. | | 6 | 47 | 58 | Cloudy, fair. | -- | 71 | Cloudy, rain. | | 7 | 50 | 68 | Cloudy, fair. | 68 | 78 | Fair, ditto. | | 8 | 59 | 78 | Cloudy, fair. | 65 | -- | Fair, ditto. | | 9 | 61 | 79 | Foggy, fair. | 70 | 88 | Fog, fair. | | 10 | 65 | 71 | Rain, hazy. | 74 | 90 | Fair, ditto. | | 11 | 55 | 75 | Cloudy, fair. | 76 | 90 | Fair, ditto. | | 12 | 61 | 76 | Cloudy, rain. | 75 | 88 | Fair, showers. | | 13 | 57 | 78 | Fair, ditto. | 74 | 81 | Cloudy, rain. | | 14 | 59 | 83 | Fair, cloudy. | 63 | 77 | Fair, ditto. | | 15 | 60 | 71 | Fair, ditto. | 63 | 82 | Fair, hazy. | | 16 | 50 | 69 | Fair, ditto. | 67 | 85 | Fair, ditto. | | 17 | 48 | 74 | Fair, ditto. | 74 | 89 | Fair, showers. | | 18 | 61 | 81 | Cloudy, fair. | 73 | 88 | Fair, ditto. | | 19 | 65 | 85 | Fair, rain. | 77 | 91 | Fair, ditto. | | 20 | 65 | 87 | Fair, ditto. | 79 | 88 | Fair, rain, fair. | | 21 | 68 | 86 | Fair, ditto, clouds. | 75 | 85 | Cloudy, rain. | | 22 | 72 | 80 | Clouds, gusts. | 58 | 78 | Cloudy, fair. | | 23 | 94 | 79 | Cloudy, fair. | 58 | 78 | Fair, ditto. | | 24 | 58 | 75 | Fair, ditto. | 60 | 79 | Fair, ditto. | | 25 | 52 | 70 | Fair, cloudy. | 67 | 74 | Cloudy, rain. | | 26 | 61 | 66 | Rain, ditto. | 66 | 69 | Cloudy, rain. | | 27 | 68 | 84 | Cloudy, fair. | 68 | 80 | Cloudy, fair. | | 28 | 70 | 68 | Fair, clouds, rain. | 71 | 85 | Cloudy, fair. | | 29 | 57 | 62 | Cloudy, rain, clouds.| 77 | 88 | Cloudy, ditto. | | 30 | 54 | 57 | Cloudy, rain. | 74 | 90 | Fair, ditto. | | 31 | 54 | 60 | Clouds, ditto. | | | | +----+----+----+----------------------+----+----+---------------------+

JULY, 1793. +-----+------------+-----------+-------------+--------------------+ | | Barom. | Ther. | Winds. | Weather. | | | 6 3 | 6 3 | 6 3 | | |Days.|A. M. P. M.|A. M. P. M.|A. M. P. M.| | | | | | | | | 1 |30 0 29 9| 77 88 | W W |fair. | | 2 |29 8 29 7| 77 81 | W |fair, showers. | | 3 |29 9 30 0| 74 80 | E E |cloudy. | | 4 |30 1 30 0| 70 83 | E SW |cloudy, fair, rain. | | 5 |30 0 29 9| 76 90 | NW SW |fair, ditto. | | 6 |29 9 29 9| 78 91 | SW SW |cloudy, thunder. | | 7 |29 9 30 0| 73 88 | NE NW |fair, clouds. | | 8 |30 1 30 1| 72 85 | E E |cloudy, fair. | | 9 |30 0 29 8| 73 81 | S SW |cloudy, ditto. | | 10 |30 0 30 0| 70 84 | W NW |fair, ditto. | | 11 |30 0 30 0| 74 88 | NW NW |fair, clouds. | | 12 |30 1 30 2| 70 84 | N N |fair, ditto. | | 13 |30 1 30 0| 68 83 | NW NW |fair, ditto. | | 14 |30 0 30 0| 65 80 | N Calm |fair, hazy. | | 15 |30 0 29 9| 66 75 | SW SW |cloudy, ditto. | | 16 |29 8 29 7| 70 83 | W W |rain, fair. | | 17 |29 8 29 9| 68 81 | NW NW |fair, ditto. | | 18 |30 0 30 0| 66 86 | W SW |fair, ditto. | | 19 |29 9 29 9| 75 85 | SW W |fair, cloudy, rain. | | 20 |30 0 30 0| 72 87 | W NW |fair, ditto, shower.| | 21 |30 1 30 1| 70 86 | NW NW |fair, ditto. | | 22 |30 0 30 0| 72 87 | SW SW |fair, ditto. | | 23 |30 0 30 0| 73 91 | SW SW |fair, cloudy. | | 24 |29 9 29 9| 75 89 | Calm W |cloudy, fair. | | 25 |30 1 30 1| 71 83 | NW NNW |fair, ditto. | | 26 |30 2 30 2| 63 82 | N NE |fair, ditto. | | 27 |30 2 30 1| 64 81 | S calm S |fair, cloudy. | | 28 |30 1 30 0| 72 85 | Calm NNE |cloudy, fair. | | 29 |30 1 30 1| 74 85 | SSE NE |cloudy, ditto, rain.| | 30 |30 1 30 0| 73 86 | S SW |cloudy, fair. | | 31 |29 9 29 8| 76 80 | SSW SW |cloudy, rain, fair. | +-----+------------+-----------+-------------+--------------------+

AUGUST, 1793. +-----+------------+-----------+-------------+--------------------+ | | Barom. | Ther. | Winds. | Weather. | | | 6 3 | 6 3 | 6 3 | 6 3 | |Days.|A. M. P. M.|A. M. P. M.|A. M. P. M.|A. M. P. M. | | 1 |29 95 30 0| 65 77 | WNW NW |cloudy, fair, | | 2 |30 1 30 1| 63 81 | NW SW |fair, fair, | | 3 |30 6 29 95| 62 82 | N NNE |fair, fair, | | 4 |29 97 30 0| 65 87 | S SW |fair, fair, | | 5 |30 5 30 1| 73 90 | SSW SW |fair, fair, | | 6 |30 2 30 0| 77 87 | SW W |cloudy, fair, | | 7 |30 12 30 1| 68 83 | NW W |fair, fair, | | 8 |30 1 29 95| 69 86 | SSE SSE |fair, rain, | | 9 |29 8 29 75| 75 85 | SSW SW |cloudy, fair, | | 10 |29 9 29 9| 67 82 | W SW |fair, fair, | | 11 |30 0 30 0| 70 84 | SW WSW |cloudy, cloudy, | | 12 |30 0 30 0| 70 87 | W W |fair, fair, | | 13 |30 5 30 0| 71 89 | SW W |fair, fair, | | 14 |30 0 29 95| 75 82 | SW SW |fair, rain, | | 15 |30 0 30 1| 72 75 | NNE NE |fair, cloudy, | | 16 |30 1 30 1| 70 83 | NNE NE |fair, fair, | | 17 |30 1 30 0| 71 86 | SW SW |fair, fair, | | 18 |30 1 30 1| 73 89 | calm SW |fair, fair, | | 19 |30 1 30 0| 72 82 | N N |fair, cloudy, | | 20 |30 1 30 12| 69 82 | NNE NNE |fair, fair, | | 21 |30 15 30 25| 62 83 | N NNE |fair, fair, | | 22 |30 3 30 35| 63 86 | NE SE |fair, fair, | | 23 |30 25 30 15| 63 85 | calm S |fair, fair, | | 24 |30 1 30 1| 73 81 | calm calm |cloudy, rain, | | 25 |30 1 30 1| 71 66 | NE NE |rain, gr. rain, | | 26 |30 15 30 2| 59 69 | NE NE |cloudy, cloudy, | | 27 |30 2 30 2| 65 73 | NE NE |cloudy, cloudy, | | 28 |30 2 30 15| 67 80 | S calm |cloudy, clearin. | | 29 |30 16 30 15| 72 86 | calm SW |cloudy, fair, | | 30 |30 1 30 1| 74 87 | calm SW |fair, fair, | | 31 |30 0 30 0| 74 84 | SW NW |rain, fair. | +-----+------------+-----------+-------------+--------------------+

SEPTEMBER, 1793. +-----+------------+-----------+-------------+--------------------+ | | Barom. | Ther. | Winds. | Weather. | | | 6 3 | 6 3 | 6 3 | 6 3 | |Days.|A. M. P. M.|A. M. P. M.|A. M. P. M.|A. M. P. M. | | 1 |30 0 29 30| 71 86 | calm SW |fog, fair, | | 2 |29 75 29 8| 73 86 | SW SW |fair, fair, | | 3 |30 0 | 60 | NW N |fair, fair, | | 4 |30 15 30 15| 55 75 | W W |fair, fair, | | 5 |30 15 30 1| 62 80 | SE S |fair, cloudy, | | 6 |29 97 29 95| 70 89 | WSW W |fair, cloudy, | | 7 |30 0 30 0| 65 77 | WNW NW |fair, fair, | | 8 |30 1 30 1| 64 70 | calm calm |cloudy, cloudy, | | 9 |30 0 30 0| 66 80 | SE NW |rain, fair, | | 10 |30 0 30 0| 64 72 | N NNE |fair, cloudy, | | 11 |30 1 30 0| 62 72 | NNE N |cloudy, fair, | | 12 |29 96 29 9| 58 76 | NW NNW |fair, fair, | | 13 |29 95 30 0| 57 72 | NW N |fair, fair, | | 14 |30 0 30 5| 58 79 | NW NW |fair, fair, | | 15 |30 0 29 97| 65 80 | N S |fair, fair, | | 16 |29 9 29 | 70 84 | S SW |cloudy, fair, | | 17 |29 8 29 85| 66 67 | N N |cloudy, cloudy, | | 18 |30 3 | 44 | N |fair, | | 19 |30 4 30 35| 45 70 | calm SW |fair, fair, | | 20 |30 3 30 15| 54 69 | calm SE |hazy, hazy, | | 21 |30 0 29 0| 59 78 | calm |cloudy, fair, | | 22 |30 0 30 0| 63 83 | calm |cloudy, fair, | | 23 |30 1 30 1| 62 80 | calm SE |cloudy, cloudy, | | 24 |30 2 30 2| 65 70 | NE ENE |cloudy, fair, | | 25 |30 15 30 0| 61 68 | NE NE |cloudy, cloudy, | | 26 |29 8 29 7| 58 79 | N N |cloudy, fair, | | 27 |29 7 | 64 | NW NW |cloudy, fair, | | 28 |30 5 30 15| 54 73 | NW NW |fair, fair, | | 29 |30 3 30 3| 56 74 | NE ENE |cloudy, fair, | | 30 |30 35 30 3| 57 75 | calm SW |foggy, fair. | +-----+------------+-----------+-------------+--------------------+

OCTOBER, 1793. +-----+------------+-----------+-------------+--------------------+ | | | | | | | | Barom. | Ther. | Winds. | Weather. | | | | | | | | | 7 2 | 7 2 | 7 2 | 7 2 | |Days.|A. M. P. M.|A. M. P. M.|A. M. P. M.|A. M. P. M. | | 1 |30 15 30 5| 64 80 | SW SW |cloudy, fair, | | 2 |29 9 30 5| 70 72 | W NNW |cloudy, fair, | | 3 |30 2 30 15| 50 72 | W SW |fair, fair, | | 4 |29 75 29 7| 59 72 | SW W |cloudy, cloudy, | | 5 |30 0 30 1| 58 66 | N N |fair, fair, | | 6 |30 3 30 3| 43 66 | NE W |fair, fair, | | 7 |30 45 | 46 | calm |fair, | | 8 |30 6 30 6| 53 68 | N N |fair, fair, | | 9 |30 5 30 4| 53 70 | NW NW |fair, fair, | | 10 |30 2 30 2| 49 74 | E NW |fair, fair, | | 11 |30 0 29 85| 51 74 | W W |fair, fair, | | 12 |29 6 29 55| 58 64 | SW NW |rain, rain, | | 13 |29 85 29 9| 49 69 | NW NW |fair, fair, | | 14 |30 5 30 0| 52 76 | SW SW |calm, fair, | | 15 |29 75 29 8| 56 54 | SW N |fair, rain, | | 16 |30 0 30 0| 37 53 | NNW N |fair, fair, | | 17 |30 1 30 1| 37 60 | NE NE |fair, fair, | | 18 |30 1 30 1| 41 62 | NW NW |fair, fair, | | 19 |30 0 29 9| 51 66 | N N |cloudy, fair, | | 20 |30 0 30 0| 44 54 | NW N |fair, fair, | | 21 |30 0 30 2| 49 59 | N NW |fair, fair, | | 22 |29 6 29 5| 51 65 | NW NW |fair, fair, | | 23 |29 8 29 8| 47 60 | W W |fair, fair, | | 24 |30 3 30 4| 36 59 | W NW |fair, fair, | | 25 |30 4 30 3| 46 71 | S S |cloudy, do. h-w. | | 26 |30 2 30 2| 60 72 | calm SW |cloudy, cloudy, | | 27 |30 3 30 3| 44 44 | NNE NNE |cloudy, cloudy, | | 28 |30 2 30 1| 34 37 | N N |cloudy, cloudy, | | 29 |29 85 29 85| 28 44 | NNW NW |fair, fair, | | 30 |30 1 30 1| 28 49 | calm SW |hazy, hazy, | | 31 |30 15 30 2| 42 45 | calm NNE |cloudy, rain. | +-----+------------+-----------+-------------+--------------------+

NOVEMBER, 1793. +-----+------------+-----------+-------------+--------------------+ | | Barom. | Ther. | Winds. | Weather. | | | 7 2 | 7 2 | 7 2 | 7 2 | |Days.|A. M. P. M.|A. M. P. M.|A. M. P. M.| A. M. P. M. | | 1 |30 1 30 1| 40 41 | NNE NE |rain, cloudy, | | 2 |30 3 30 25| 32 49 | NNE NE |fair, fair, | | 3 |30 1 30 0| 43 56 | calm SW |cloudy, cloudy, | | 4 |29 8 29 9| 55 67 | SW SW |cloudy, fair, | | 5 |30 15 30 1| 50 64 | NE NE |rain, rain, | | 6 |29 8 29 65| 63 67 | S S |cloudy, cloudy, | | 7 |29 8 29 8| 44 64 | calm SW |fair, fair, | | 8 |29 8 29 85| 43 56 | SSW SW |fair, fair, | | 9 |29 9 29 95| 42 64 | SW SW |fair, fair, | +-----+------------+-----------+-------------+--------------------+

OF THE METHOD OF CURE.

In the introduction to the history of the fever, I mentioned the remedies which I used with success, in several cases which occurred in the beginning of August. I had seen, and recorded in my note book, the efficacy of gentle purges in the yellow fever of 1762; but finding them unsuccessful after the 20th of August, and observing the disease to assume uncommon symptoms of great prostration of strength, I laid them aside, and had recourse to a gentle vomit of ipecacuanha, on the first day of the fever, and to the usual remedies for exciting the action of the sanguiferous system. I gave bark in all its usual forms of infusion, powder, and tincture. I joined wine, brandy, and aromatics with it. I applied blisters to the limbs, neck, and head. Finding them all ineffectual, I attempted to rouse the system by wrapping the whole body, agreeably to Dr. Hume's practice, in blankets dipped in warm vinegar. To these remedies I added one more: I rubbed the right side with mercurial ointment, with a view of exciting the action of the vessels in the whole system, through the medium of the liver, which I then supposed to be principally, though symptomatically, affected by the disease. None of these remedies appeared to be of any service; for although three out of thirteen recovered, of those to whom they were applied, yet I have reason to believe that they would have recovered much sooner had the cure been trusted to nature. Perplexed and distressed by my want of success in the treatment of this fever, I waited upon Dr. Stephens, an eminent and worthy physician from St. Croix, who happened then to be in our city, and asked for such advice and information upon the subject of the disease, as his extensive practice in the West-Indies would naturally suggest. He politely informed me, that he had long ago laid aside evacuations of all kinds in the yellow fever; that they had been found to be hurtful, and that the disease yielded more readily to bark, wine, and, above all, to the use of the cold bath. He advised the bark to be given in large quantities by way of glyster, as well as in the usual way; and he informed me of the manner in which the cold bath should be used, so as to derive the greatest benefit from it. This mode of treating the yellow fever appeared to be reasonable. I had used bark, in the manner he recommended it, in several cases of sporadic yellow fever, with success, in former years. I had, moreover, the authority of several other physicians of reputation in its favour. Dr. Cleghorn tells us, that "he sometimes gave the bark when the bowels were full of vicious humours. These humours (he says) are produced by the fault of the circulation. The bark, by bracing the solids, enables them to throw off the excrementitious fluids, by the proper emunctories[65]."

[65] Page 223.

I began the use of each of Dr. Stevens's remedies the next day after my interview with him, with great confidence of their success. I prescribed bark in large quantities: in one case I ordered it to be injected into the bowels every four hours. I directed buckets full of cold water to be thrown frequently upon my patients. The bark was offensive to the stomach, or rejected by it, in every case in which I prescribed it. The cold bath was grateful, and produced relief in several cases, by inducing a moisture on the skin. For a while I had hopes of benefit to my patients from the use of these remedies, but, in a few days, I was distressed to find they were not more effectual than those I had previously used. Three out of four of my patients died, to whom the cold bath was administered, in addition to the tonic remedies before-mentioned.

Baffled in every attempt to stop the ravages of this fever, I anticipated all the numerous and complicated distresses in our city, which pestilential diseases have so often produced in other countries. The fever had a malignity and an obstinacy which I had never before observed in any disease, and it spread with a rapidity and mortality far beyond what it did in the year 1762. Heaven alone bore witness to the anguish of my soul in this awful situation. But I did not abandon a hope that the disease might yet be cured. I had long believed that good was commensurate with evil, and that there does not exist a disease for which the goodness of Providence has not provided a remedy. Under the impression of this belief I applied myself with fresh ardour to the investigation of the disease before me. I ransacked my library, and pored over every book that treated of the yellow fever. The result of my researches for a while was fruitless. The accounts of the symptoms and cure of the disease by the authors I consulted were contradictory, and none of them appeared altogether applicable to the prevailing epidemic. Before I desisted from the inquiry to which I had devoted myself, I recollected that I had, among some old papers, a manuscript account of the yellow fever as it prevailed in Virginia in the year 1741, which had been put into my hands by Dr. Franklin, a short time before his death. I had read it formerly, and made extracts from it into my lectures upon that disease. I now read it a second time. I paused upon every sentence; even words in some places arrested and fixed my attention. In reading the history of the method of cure I was much struck with the following passages.

"It must be remarked, that this evacuation (meaning by purges) is more necessary in this than in most other fevers. The abdominal viscera are the parts principally affected in this disease, but by this timely evacuation their feculent corruptible contents are discharged, before they corrupt and produce any ill effects, and their various emunctories and secerning vessels are set open, so as to allow a free discharge of their contents, and consequently a security to the parts themselves, during the course of the disease. By this evacuation the very minera of the disease, proceeding from the putrid miasmata fermenting with the salivary, bilious, and other inquiline humours of the body, is sometimes eradicated by timely emptying the abdominal viscera, on which it first fixes, after which a gentle sweat does as it were nip it in its bud. Where the primæ viæ, but especially the stomach, is loaded with an offensive matter, or contracted and convulsed with the irritation of its stimulus, there is no procuring a laudable sweat till that is removed; after which a necessary quantity of sweat breaks _out of its own accord_, these parts promoting it when by an absterging medicine they are eased of the burden or stimulus which oppresses them."

"All these acute putrid fevers ever require some evacuation to bring them to a perfect crisis and solution, and that even by stools, which must be promoted by art, where nature does not do the business herself. On this account an _ill-timed scrupulousness about the weakness of the body_ is of bad consequence in these urging circumstances; for it is that which seems chiefly to make evacuations necessary, which nature ever attempts, after the humours are fit to be expelled, but is not able to accomplish for the most part in this disease; and I can affirm that I have given a purge in this case, when _the pulse has been so low, that it could hardly be felt_, and the _debility extreme_, yet _both one and the other_ have been _restored by it_."

"This evacuation must be procured by _lenitive chologoque_ purges."

Here I paused. A new train of ideas suddenly broke in upon my mind. I believed the weak and low pulse which I had observed in this fever, to be the effect of debility from a depressed state of the system, but the unsuccessful issue of purging, and even of a spontaneous diarrh[oe]a, in a patient of Dr. Hutchinson, had led me not only to doubt of, but to dread its effects. My fears from this evacuation were confirmed, by the communications I had received from Dr. Stevens. I had been accustomed to raising a weak and low pulse in pneumony and apoplexy, by means of blood-letting, but I had attended less to the effects of purging in producing this change in the pulse. Dr. Mitchell in a moment dissipated my ignorance and fears upon this subject. I adopted his theory and practice, and resolved to follow them. It remained now only to fix upon a suitable purge to answer the purpose of discharging the contents of the bowels. I have before described the state of the bile in the gall-bladder and duodenum, in an extract from the history of a dissection made by Dr. Mitchell. I suspected that my want of success in discharging this bile, in several of the cases in which I attempted the cure by purging, was owing the feebleness of my purges. I had been in the habit of occasionally purging with calomel in bilious and inflammatory fevers, and had recommended the practice the year before in my lectures, not only from my own experience, but upon the authority of Dr. Clark. I had, moreover, other precedents for its use in the practice of sir John Pringle, Dr. Cleghorn, and Dr. Balfour, in diseases of the same class with the yellow fever. But these were not all my vouchers for the safety and efficacy of calomel. In my attendance upon the military hospitals during the late war, I had seen it given combined with jalap in the bilious fever by Dr. Thomas Young, a senior surgeon in the hospitals. His usual dose was ten grains of each of them. This was given once or twice a day until it procured large evacuations from the bowels. For a while I remonstrated with the doctor against this purge, as being disproportioned to the violence and danger of the fever; but I was soon satisfied that it was as safe as cremor tartar or glauber's salts. It was adopted by several of the surgeons of the hospital, and was universally known, and sometimes prescribed, by the simple name of _ten_ and _ten_. This mode of giving calomel occurred to me in preference to any other. The jalap appeared to be a necessary addition to it, in order to quicken its passage through the bowels; for calomel is slow in its operation, more especially when it is given in large doses. I resolved, after mature deliberation, to prescribe this purge. Finding ten grains of jalap insufficient to carry the calomel through the bowels in the rapid manner I wished, I added fifteen grains of the former to ten of the latter; but even this dose was slow and uncertain in its operation. I then issued three doses, each consisting of fifteen grains of jalap and ten of calomel; one to be given every six hours until they procured four or five large evacuations. The effects of this powder not only answered, but far exceeded my expectations. It perfectly cured four out of the first five patients to whom I gave it, notwithstanding some of them were advanced several days in the disease. Mr. Richard Spain, a block-maker, in Third-street, took eighty grains of calomel, and rather more of rhubarb and jalap mixed with it, on the two last days of August, and on the first day of September. He had passed twelve hours, before I began to give him this medicine, without a pulse, and with a cold sweat on all his limbs. His relations had given him over, and one of his neighbours complained to me of my neglecting to advise them to make immediate preparations for his funeral. But in this situation I did not despair of his recovery, Dr. Mitchell's account of the effects of purging in raising the pulse, exciting a hope that he might be saved, provided his bowels could be opened. I now committed the exhibition of the purging medicine to Mr. Stall, one of my pupils, who mixed it, and gave it with his own hand, three or four times a day. At length it operated, and produced two copious, f[oe]tid stools. His pulse rose immediately afterwards, and a universal moisture on his skin succeeded the cold sweat on his limbs. In a few days he was out of danger, and soon afterwards appeared in the streets in good health, as the first fruits of the efficacy of mercurial purges in the yellow fever.

After such a pledge of the safety and success of my new medicine, I gave it afterwards with confidence. I communicated the prescription to such of the practitioners as I met in the streets. Some of them I found had been in the use of calomel for several days, but as they had given it in small and single doses only, and had followed it by large doses of bark, wine, and laudanum, they had done little or no good with it. I imparted the prescription to the college of physicians, on the third of September, and endeavoured to remove the fears of my fellow-citizens, by assuring them that the disease was no longer incurable. Mr. Lewis, the lawyer, Dr. M'Ilvaine, Mrs. Bethel, her two sons, and a servant maid, and Mr. Peter Baynton's whole family (nine in number), were some of the first trophies of this new remedy. The credit it acquired, brought me an immense accession of business. It still continued to be almost uniformly effectual in all those which I was able to attend, either in person, or by my pupils. Dr. Griffitts, Dr. Say, Dr. Pennington, and my former pupils who had settled in the city, viz. Dr. Leib, Dr. Porter, Dr. Annan, Dr. Woodhouse, and Dr. Mease, were among the first physicians who adopted it. I can never forget the transport with which Dr. Pennington ran across Third-street to inform me, a few days after he began to give strong purges, that the disease yielded to them in every case. But I did not rely upon purging alone to cure the disease. The theory of it which I had adopted led me to use other remedies to abstract excess of stimulus from the system. These were _blood-letting_, _cool air_, _cold drinks_, _low diet_, and _applications of cold water_ to the body. I had bled Mrs. Bradford, Mrs. Leaming, and one of Mrs. Palmer's sons with success, early in the month of August. But I had witnessed the bad effects of bleeding in the first week in September, in two of my patients who had been bled without my knowledge, and who appeared to have died in consequence of it. I had, moreover, heard of a man who had been bled on the first day of the disease, who died in twelve hours afterwards. These cases produced caution, but they did not deter me from bleeding as soon as I found the disease to change its type, and instead of tending to a crisis on the third, to protract itself to a later day. I began by drawing a small quantity at a time. The appearance of the blood, and its effects upon the system, satisfied me of its safety and efficacy. Never before did I experience such sublime joy as I now felt in contemplating the success of my remedies. It repaid me for all the toils and studies of my life. The conquest of this formidable disease was not the effect of accident, nor of the application of a single remedy; but it was the triumph of a principle in medicine. The reader will not wonder at this joyful state of my mind when I add a short extract from my note book, dated the 10th of September. "Thank God! out of one hundred patients, whom I have visited or prescribed for this day, I have lost none."

Being unable to comply with the numerous demands which were made upon me for the purging powders, notwithstanding I had requested my sister, and two other persons to assist my pupils in putting them up; and, finding myself unable to attend all the persons who sent for me, I furnished the apothecaries with the recipe for the mercurial purges, together with printed directions for giving them, and for the treatment of the disease.

Hitherto there had been great harmony among the physicians of the city, although there was a diversity of sentiment as to the nature and cure of the prevailing fever. But this diversity of sentiment and practice was daily lessening, and would probably have ceased altogether in a few days, had it not been prevented by two publications, the one by Dr. Kuhn, and the other by Dr. Stevens, in which they recommended bark, wine, and other cordials, and the cold bath, as the proper remedies for the disease. The latter dissuaded from the use of evacuations of all kinds. This method of cure was supported by a letter from Alexander Hamilton, Esq. then secretary of the treasury of the United States, to the college of physicians, in which he ascribed his recovery from the fever to the use of those remedies, administered by the hand of Dr. Stevens. The respectable characters of those two physicians procured an immediate adoption of the mode of practice recommended by them, by most of the physicians of the city, and a general confidence in it by all classes of citizens. Had I consulted my interest, or regarded the certain consequences of opposing the use of remedies rendered suddenly popular by the names that were connected with them, I should silently have pursued my own plans of cure, with my old patients who still confided in them; but I felt, at this season of universal distress, my professional obligations to _all_ the citizens of Philadelphia to be superior to private and personal considerations, and therefore determined at every hazard to do every thing in my power to save their lives. Under the influence of this disposition, I addressed a letter to the college of physicians, in which I stated my objections to Dr. Kuhn and Dr. Stevens's remedies, and defended those I had recommended. I likewise defended them in the public papers against the attacks that were made upon them by several of the physicians of the city, and occasionally addressed such advice to the citizens as experience had suggested to be useful to _prevent_ the disease, particularly low diet, gentle doses of laxative physic, avoiding its exciting causes, and prompt applications for medical aid. In none of the recommendations of my remedies did I claim the credit of their discovery. On the contrary, I constantly endeavoured to enforce their adoption, by mentioning precedents in favour of their efficacy, from the highest authorities in medicine. This controversy with my brethren, with whom I had long lived in friendly intercourse, carried on amidst the most distressing labours, was extremely painful to me, and was submitted to only to prevent the greater evil of the depopulation of our city by the use of remedies which had been prescribed by myself, as well as others, not only without effect, but with evident injury to the sick. The repeated and numerous instances of their inefficacy, in some of the most opulent families in the city, and the almost uniform success of the depleting remedies, happily restored the public mind, after a while, from its distracted state, and procured submission to the latter from nearly all the persons who were affected by the fever.

Besides the two modes of practice which have been described, there were two others: the one consisted of _moderate_ purging with calomel only, and moderate bleeding, on the first or second day of the fever, and afterwards by the copious use of bark, wine, laudanum, and aromatic tonics. This practice was supported by an opinion, that the fever was inflammatory in its first, and putrid in its second stage. The other mode referred to was peculiar to the French physicians, several of whom had arrived in the city from the West-Indies, just before the disease made its appearance. Their remedies were various. Some of them prescribed nitre, cremor tartar, camphor, centaury tea, the warm bath, glysters, and moderate bleeding, while a few used lenient purges, and large quantities of tamarind water, and other diluting drinks. The dissentions of the American physicians threw a great number of patients into the hands of these French physicians. They were moreover supposed to be better acquainted with the disease than the physicians of the city, most of whom, it was well known, had never seen it before.

I shall hereafter inquire into the relative success of each of the four modes of practice which have been mentioned.

Having delivered a general account of the remedies which I used in this disease, I shall now proceed to make a few remarks upon each of them. I shall afterwards mention the effects of the remedies used by other physicians.

OF PURGING.

I have already mentioned my reasons for promoting this evacuation, and the medicine I preferred for that purpose. It had many advantages over any other purge. It was detergent to the bile and mucus which lined the bowels. It probably acted in a peculiar manner upon the biliary ducts, and it was rapid in its operation. One dose was sometimes sufficient to open the bowels; but from two to six doses were often necessary for that purpose; more especially as part of them was frequently rejected by the stomach. I did not observe any inconvenience from the vomiting which was excited by the jalap. It was always without that straining which was produced by emetics; and it served to discharge bile when it was lodged in the stomach. Nor did I rest the discharge of the contents of the bowels on the issue of one cleansing on the first day. There is, in all bilious fevers, a reproduction of morbid bile as fast as it is discharged. I therefore gave a purge every day while the fever continued. I used castor oil, salts, cremor tartar, and rhubarb (after the mercurial purges had performed their office), according to the inclinations of my patients, in all those cases where the bowels were easily moved; but where this was not the case, I gave a single dose of calomel and jalap every day. Strong as this purge may be supposed to be, it was often ineffectual; more especially after the 20th of September, when the bowels became more obstinately constipated. To supply the place of the jalap, I now added gamboge to the calomel. Two grains and a half of each, made into a pill, were given to an adult every six hours, until they procured four or five stools. I had other designs in giving a purge every day, besides discharging the re-accumulated bile. I had observed the fever to fall with its principal force upon such parts of the body as had been previously weakened by any former disease. By creating an artificial weak part in the bowels, I diverted the force of the fever to them, and thereby saved the liver and brain from fatal or dangerous congestions. The practice was further justified by the beneficial effects of a plentiful spontaneous diarrh[oe]a in the beginning of the disease[66]; by hæmorrhages from the bowels, when they occurred from no other parts of the body, and by the difficulty or impracticability of reducing the system by means of plentiful sweats. The purges seldom answered the intentions for which they were given, unless they produced four or five stools a day. As the fever showed no regard to day or night in the hours of its exacerbations, it became necessary to observe the same disregard to time in the exhibition of purges: I therefore prescribed them in the evening, at all times when the patient had passed a day without two or three plentiful stools. When purges were rejected, or slow in their operation, I always directed opening glysters to be given every two hours. The effects of purging were as follow:

1. It raised the pulse when low, and reduced it when it was preternaturally tense or full.

2. It revived and strengthened the patient. This was evident in many cases, in the facility with which patients who had staggered to a close-stool, walked back again to their beds after a copious evacuation. Dr. Sydenham takes notice of a similar increase of strength after a plentiful sweat in the plague. They both acted by abstracting excess of stimulus, and thereby removing the depression of the system.

3. It abated the paroxysm of the fever. Hence arose the advantage of giving a purge in some cases in the evening, when an attack of the fever was expected in the course of the night.

4. It frequently produced sweats when given on the first or second day of the fever, after the most powerful sudorifics had been taken to no purpose.

5. It sometimes checked that vomiting which occurs in the beginning of the disease, and it always assisted in preventing the more alarming occurrence of that symptom about the 4th or 5th day.

6. It removed obstructions in the lymphatic system. I ascribe it wholly to the action of mercury, that in no instance did any of the glandular swellings, which I formerly mentioned, terminate in a suppuration.

7. By discharging the bile through the bowels as soon and as fast as it was secreted, it prevented, in most cases, a yellowness of the skin.

[66] In some short manuscript notes upon Dr. Mitchell's account of the yellow fever in Virginia, in the year 1741, made by the late Dr. Kearsley, sen. of this city, he remarks, that in the yellow fever which prevailed in the same year in Philadelphia, "some recovered by an _early_ discharge of _black_ matter by stool." This gentleman, Dr. Redman informed me, introduced purging with glauber's salts in the yellow fever in our city. He was preceptor to Dr. Redman in medicine.

However salutary the mercurial purge was, objections were made to it by many of our physicians; and prejudices, equally weak and ill-founded, were excited against it. I shall enumerate, and answer those objections.

1. It was said to be of too drastic a nature. It was compared to arsenic; and it was called a dose for a horse. This objection was without foundation. Hundreds who took it declared they had never taken so mild a purge. I met with but one case in which it produced bloody stools; but I saw the same effect from a dose of salts. It sometimes, it is true, operated from twenty to thirty times in the course of twenty-four hours; but I heard of an equal number of stools in two cases from salts and cremor tartar. It is not an easy thing to affect life, or even subsequent health, by copious or frequent purging. Dr. Kirkland mentions a remarkable case of a gentleman who was cured of a rheumatism by a purge, which gave him between 40 and 50 stools. This patient had been previously affected by his disease 16 or 18 weeks[67]. Dr. Mosely not only proves the safety, but establishes the efficacy of numerous and copious stools in the yellow fever. Dr. Say probably owes his life to three and twenty stools procured by a dose of calomel and gamboge, taken by my advice. Dr. Redman was purged until he fainted, by a dose of the same medicine. This venerable gentleman, in whom 70 years had not abated the ardour of humanity, nor produced obstinacy of opinion, came forward from his retirement, and boldly adopted the remedies of purging and bleeding, with success in several families, before he was attacked by the disease. His recovery was as rapid, as the medicine he had used was active in its operation. Besides taking the above purge, he lost twenty ounces of blood by two bleedings[68].

[67] Treatise on the Inflammatory Rheumatism, vol. i. p. 407.

[68] Dr. Redman was not the only instance furnished by the disease, in which _reason_ got the better of the habits of old age, and of the formalities of medicine. About the time the fever declined, I received a letter from Dr. Shippen, sen. (then above 82 years of age), dated Oxford Furnace, New-Jersey, October 13th, 1793, in which, after approving in polite terms of my mode of practice, he adds, "Desperate diseases require desperate remedies. I would only propose some small addition to your present method. Suppose you should substitute, in the room of the jalap, _six_ grains of gamboge, to be mixed with ten or fifteen grains of calomel; and after a dose or two, as occasion may require, you should bleed your patients _almost_ to death, at least to _fainting_; and then direct a plentiful supply of mallows tea, with fresh lemon juice, and sugar and barley water, together with the most simple, _mild_, and nutricious food." The doctor concludes his letter by recommending to my perusal Dr. Dover's account of nearly a whole ship's crew having been cured of a yellow fever, on the coast of South-America, by being bled until they fainted.

But who can suppose that a dozen or twenty stools in a day could endanger life, that has seen a diarrh[oe]a continue for several months, attended with fifteen or twenty stools every day, without making even a material breach in the constitution? Hence Dr. Hillary has justly remarked, that "it rarely or never happens that the purging in this disease, though violent, takes the patient off, but the fever and inflammation of the bowels[69]." Dr. Clark in like manner remarks, that evacuations do not destroy life in the dysentery, but the fever, with the emaciation and mortification which attend and follow the disease[70].

[69] Diseases of Barbadoes, p. 212.

[70] Diseases in Voyages to Hot Climates, vol. ii. p. 322.

2. A second objection to this mercurial purge was, that it excited a salivation, and sometimes loosened the teeth. I met with but two cases in which there was a loss of teeth from the use of this medicine, and in both the teeth were previously loose or decayed. The salivation was a trifling evil, compared with the benefit which was derived from it. I lost only one patient in whom it occurred. I was taught, by this accidental effect of mercury, to administer it with other views than merely to cleanse the bowels, and with a success which added much to my confidence in the power of medicine over this disease. I shall mention those views under another head.

3. It was said that the mercurial purge excoriated the rectum, and produced the symptoms of pain and inflammation in that part, which were formerly mentioned.

To refute this charge, it will be sufficient to remark that the bile produces the same excoriation and pain in the rectum in the bilious and yellow fever, where no mercury has been given to discharge it. In the bilious remitting fever which prevailed in Philadelphia in 1780, we find the bile which was discharged by "gentle doses of salts, and cream of tartar, or the butternut pill, was so acrid as to excoriate the rectum, and so offensive as to occasion, in some cases, sickness and faintness both in the patients, and in their attendants[71]."

[71] Vol. i.

Dr. Hume says further upon this subject, that the rectum was so much excoriated by the natural discharge of bile in the yellow fever, as to render it impossible to introduce a glyster pipe into it.

4. It was objected to this purge, that it inflamed and lacerated the stomach and bowels. In support of this calumny, the inflamed and mortified appearances, which those viscera exhibited upon dissection in a patient who died at the hospital at Bush-hill, were spoken of with horror in some parts of the city. To refute this objection it will only be necessary to review the account formerly given of the state of the stomach and bowels after death from the yellow fever, in cases in which no mercury had been given. I have before taken notice that sir John Pringle and Dr. Cleghorn had prescribed mercurial purges with success in the dysentery, a disease in which the bowels are affected with more irritation and inflammation than in the yellow fever. Dr. Clark informs us that he had adopted this practice. I shall insert the eulogium of this excellent physician upon the use of mercury in the dysentery in his own words. "For several years past, when the dysentery has resisted the common mode of practice, I have administered mercury with the greatest success; and am thoroughly persuaded that it is possessed of powers to _remove inflammation_ and _ulceration_ of the intestines, which are the chief causes of death in this distemper[72]."

[72] Vol. ii. p. 342.

5. It was urged against this powerful and efficacious medicine, that it was prescribed indiscriminately in all cases, and that it did harm in all weak habits. To this I answer, that there was no person so weak by constitution or a previous disease, as to be injured by a single dose of this medicine. Mrs. Meredith, the wife of the treasurer of the United States, a lady of uncommon delicacy of constitution, took two doses of the powder in the course of twelve hours, not only without any inconvenience, but with an evident increase of strength soon afterwards. Many similar cases might be mentioned. Even children took two or three doses of it with perfect safety. This will not surprise those physicians who have been in the practice of giving from ten to twenty grains of mercury, with an equal quantity of jalap as a worm purge, and from fifty to a hundred grains of calomel, in the course of four or five days, in the internal dropsy of the brain. But I am happy in being able to add further, that many women took it in every stage of pregnancy without suffering the least inconvenience from it. Out of a great number of pregnant women whom I attended in this fever I did not lose one to whom I gave this medicine, nor did any of them suffer an abortion. One of them had twice miscarried in the course of the two or three last years of her life. She bore a healthy child three months after her recovery from the yellow fever.

No one has ever objected to the _indiscriminate_ mode of preparing the body for the small-pox by purging medicines. The _uniform_ inflammatory diathesis of that disease justifies the practice, in a certain degree, in all habits. The yellow fever admits of a sameness of cure much more than the small-pox, for it is _more_ uniformly and more highly inflammatory. An observation of Dr. Sydenham upon epidemics applies, in its utmost extent, to our late fever. "Now it must be observed (says this most acute physician) that some epidemic diseases, in some years, are uniformly and constantly the same[73]." However diversified our fever was in some of its symptoms, it was in all cases accompanied by more or less inflammatory diathesis, and by a morbid state of the alimentary canal.

[73] Vol. i. p. 9.

Much has been said of the bad effects of this purge from its having been put up carelessly by the apothecaries, or from its having been taken contrary to the printed directions, by many people. If it did harm in any one case (which I do not believe) from the former of the above causes the fault is not mine. Twenty men employed constantly in putting up this medicine would not have been sufficient to have complied with all the demands which were made of me for it. Hundreds who were in health called or sent for it as well as the sick, in order to have it in readiness in case they should be surprised by the disease in the night, or at a distance from a physician.

In all the cases in which this purge was supposed to have been hurtful, when given on the first or second day of the disease, I believe it was because it was not followed by repeated doses of the same, or of some other purge, or because it was not aided by blood-letting. I am led to make this assertion, not only from the authority of Dr. Sydenham, who often mentions the good effects of bleeding in moderating or checking a diarrh[oe]a, but by having heard no complaints of patients being purged to death by this medicine, after blood-letting was universally adopted by all the physicians in the city.

It was remarked that the demand for this purging powder continued to increase under all opposition, and that the sale of it by the apothecaries was greatest towards the close of the disease. I shall hereafter say that this was not the case with the West-India remedies.

It is possible that this purge sometimes proved hurtful when it was given on the fifth day of the disease, but it was seldom given for the _first_ time after the third day, and when it was, the patient was generally in such a situation that nothing did him either good or harm.

I derived great pleasure from hearing, after the fever had left the city, that calomel had been given with success as a purge in bilious fevers in other parts of the union besides Philadelphia. Dr. Lawrence informed me that he had cured many patients by it of the yellow fever which prevailed in New-York, in the year 1791, and the New-York papers have told us that several practitioners had been in the habit of giving it in the autumnal fevers, with great success, in the western parts of that state. They had probably learned the use of it from Dr. Young, who formerly practised in that part of the United States, and who lost no opportunity of making its praises public wherever he went.

I have only to add to my account of that purging medicine, that, under an expectation that the yellow fever would mingle some of its bilious symptoms with the common inflammatory fevers of the winter and first spring months, I gave that purge in the form of pills, in every case of inflammatory fever to which I was called. The fatal issue of several fevers in the city, during the winter, in which this precaution had been neglected, convinced me that my practice was proper and useful.

It is to be lamented that all new remedies are forced to pass through a fiery ordeal. Opium and bark were long the objects of terror and invective in the schools of medicine. They were administered only by physicians for many years, and that too with all the solemnity of a religious ceremony. This error, with respect to those medicines, has at last passed away. It will, I hope, soon be succeeded by a time when the prejudices against _ten_ and _ten_, or _ten_ and _fifteen_, will sleep with the vulgar fears which were formerly entertained of the bark producing diseases and death, years after it had been taken, by "lying in the bones."

OF BLOOD-LETTING.

The theory of this fever which led me to administer purges, determined me to use blood-letting, as soon as it should be indicated. I am disposed to believe that I was tardy in the use of this remedy, and I shall long regret the loss of three patients, who might probably have been saved by it. I cannot blame myself for not having used it earlier, for the immense number of patients which poured in upon me, in the first week of September, prevented my attending so much to each of them, as was necessary to determine upon the propriety of this evacuation. I was in the situation of a surgeon in a battle, who runs to every call, and only stays long enough with each soldier to stop the bleeding of his wound, while the increase of the wounded, and the unexpected length of the battle, leave his original patients to suffer from the want of more suitable dressings. The reasons which determined me to bleed were,

1. The state of the pulse, which became more tense, in proportion as the weather became cool.

2. The appearance of a moist and _white_ tongue, on the first day of the disease, a certain sign of an inflammatory fever.

3. The frequency of hæmorrhages from every part of the body, and the perfect relief given in some cases by them.

4. The symptoms of congestion in the brain, resembling those which occur in the first stage of hydrocephalus internus, a disease in which I had lately used bleeding with success.

5. The character of the diseases which had preceded the yellow fever. They were all more or less inflammatory. Even the scarlatina anginosa had partaken so much of that diathesis, as to require bleeding to subdue it.

6. The warm and dry weather which had likewise preceded the fever. Dr. Sydenham attributes a highly inflammatory state of the small-pox to a previously hot and dry summer; and I have since observed, that Dr. Hillary takes notice of inflammatory fevers having frequently succeeded hot and dry weather in Barbadoes[74]. He informs us further, that the yellow fever is always most acute and inflammatory after a very hot season[75].

[74] Diseases of Barbadoes, p. 16, 43, 46, 48, 52, 122.

[75] Page 147.

7. The authority of Dr. Mosely had great weight with me in advising the loss of blood, more especially as his ideas of the highly inflammatory nature of the fever accorded so perfectly with my own.

8. I was induced to prescribe blood-letting by recollecting its good effects in Mrs. Palmer's son, whom I bled on the 20th of August, and who appeared to have been recovered by it.

Having begun to bleed, I was encouraged to continue it by the appearance of the blood, and by the obvious and very great relief my patients derived from it.

The following is a short account of the appearances of the blood drawn from a vein in this disease.

1. It was, in the greatest number of cases, without any separation into crassamentum and serum, and of a scarlet colour.

2. There was in many cases a separation of the blood into crassamentum and _yellow_ serum.

3. There were a few cases in which this separation took place, and the serum was of a _natural_ colour.

4. There were many cases in which the blood was as sizy as in pneumony and rheumatism.

5. The blood was in some instances covered above with blue pellicle of sizy lymph, while the part which lay in the bottom of the bowl was dissolved. The lymph was in two cases mixed with green streaks.

6. It was in a few instances of a dark colour, and as fluid as molasses. I saw this kind of blood in a man who walked about his house during the whole of his sickness, and who finally recovered. Both this, and the fifth kind of blood which has been mentioned, occurred chiefly where bleeding had been omitted altogether, or used too sparingly in the beginning of the disease.

7. In some patients the blood, in the course of the disease, exhibited nearly _all_ the appearances which have been mentioned. They were varied by the time in which the blood was drawn, and by the nature and force of the remedies which had been used in the disease.

The effects of blood-letting upon the system were as follow:

1. It raised the pulse when depressed, and quickened it, when it was preternaturally slow, or subject to intermissions.

2. It reduced its force and frequency.

3. It checked in many cases the vomiting which occurred in the beginning of the disease, and thereby enabled the stomach to retain the purging medicine. It likewise assisted the purge in preventing the dangerous or fatal vomiting which came on about the fifth day.

4. It lessened the difficulty of opening the bowels. Upon this account, in one of my addresses to the citizens of Philadelphia, I advised bleeding to be used _before_, as well as after taking the mercurial purge. Dr. Woodhouse informed me that he had several times seen patients call for the close-stool while the blood was flowing from the vein.

5. It removed delirium, coma, and obstinate wakefulness. It also prevented or checked hæmorrhages; hence perhaps another reason why not a single instance of abortion occurred in such of my female patients as were pregnant.

6. It disposed, in some cases, to a gentle perspiration.

7. It lessened the sensible debility of the system; hence patients frequently rose from their beds, and walked across their rooms, in a few hours after the operation had been performed.

8. The redness of the eyes frequently disappeared in a few hours after bleeding. Mr. Coxe observed a dilated pupil to contract to its natural size within a few minutes after he had bound up the arm of his patient. I remarked, in the former part of this work, that blindness in many instances attended or followed this fever. But two such cases occurred among my patients. In one of them it was of short continuance, and in the other it was probably occasioned by the want of sufficient bleeding. In every case of blindness that came to my knowledge bleeding had been omitted, or used only in a very moderate degree.

9. It eased _pain_. Thousands can testify this effect of blood-letting. Many of my patients whom I bled with my own hand acknowledged to me, while the blood was flowing, that they were better; and some of them declared, that all their pains had left them before I had completely bound up their arms.

10. But blood-letting had, in many cases, an effect the opposite of _easing_ pain. It frequently increased it in every part of the body, more especially in the head. It appeared to be the effect of the system rising suddenly from a state of great depression, and of an increased action of the blood-vessels which took place in consequence of it. I had frequently seen complaints of the breast, and of the head, made worse by a single bleeding, and from the same cause. It was in some cases an unfortunate event in the yellow fever, for it prevented the blood-letting being repeated, by exciting or strengthening the prejudices of patients and physicians against it. In some instances the patients grew worse after a second, and, in one, after a third bleeding. This was the case in Miss Redman. Her pains increased after three bleedings, but yielded to the fourth. Her father, Dr. Redman, concurred in this seemingly absurd practice. It was at this time my old preceptor in medicine reminded me of Dr. Sydenham's remark, that moderate bleeding did harm in the plague where copious bleeding was indicated, and that in the cure of that disease, we should leave nature wholly to herself, or take the cure altogether out of her hands. The truth of this remark was very obvious. By taking away as much blood as restored the blood-vessels to a morbid degree of action, without reducing this action afterwards, pain, congestion, and inflammation were frequently increased, all of which were prevented, or occurred in a less degree, when the system rose gradually from the state of depression which had been induced by the great force of the disease. Under the influence of the facts and reasonings which have been mentioned I bore the same testimony in acute cases, against what was called _moderate_ bleeding that I did against bark, wine, and laudanum in this fever.

11. Blood-letting, when used _early_ on the first day, frequently strangled the disease in its birth, and generally rendered it more light, and the convalescence more speedy and perfect. I am not sure that it ever shortened the duration of the fever where it was not used within a few hours of the time of its attack. Under every mode of treatment it seemed disposed, after it was completely formed, to run its course. I was so satisfied of this peculiarity in the fever, that I ventured in some cases to predict the day on which it would terminate, notwithstanding I took the cure entirely out of the hands of nature. I did not lose a patient on the third, whom I bled on the first or second day of the disease.

12. In those cases which ended fatally, blood-letting restored, or preserved the use of reason, rendered death easy, and retarded the putrefaction of the body after death.

I shall now mention some of the circumstances which directed and regulated the use of this remedy.

1. Where bleeding had been omitted for three days, in acute cases, it was seldom useful. Where purging had been used, it was sometimes successful. I recovered two patients who had taken the mercurial purges, whom I bled for the first time on the seventh day. One of them was the daughter of Mr. James Cresson, the other was a journeyman ship-carpenter at Kensington. In those cases where bleeding had been used on the first day, it was both safe and useful to repeat it every day afterwards, during the continuance of the fever.

2. I preferred bleeding in the exacerbation of the fever. The remedy here was applied when the disease was in its greatest force. A single paroxysm was like a sudden squall to the system, and, unless abated by bleeding or purging, often produced universal disorganization. I preferred the former to the latter remedy in cases of great danger, because it was more speedy, and more certain in its operation.

3. I bled in several instances in the remission of the fever, where the pulse was tense and corded. It lessened the violence of the succeeding paroxysm.

4. I bled in all those cases in which the pulse was preternaturally slow, provided it was tense. Mr. Benj. W. Morris, Mr. Thomas Wharton, jun. and Mr. Wm. Sansom, all owe their lives probably to their having been bled in the above state of the pulse. I was led to use bleeding in this state of the pulse, not only by the theory of the disease which I had adopted, but by the success which had often attended this remedy, in a slow and depressed state of the pulse in apoplexy and pneumony. I had moreover the authority of Dr. Mosely in its favour, in the yellow fever, and of Dr. Sydenham, in his account of a new fever, which appeared in the year 1685. The words of the latter physician are so apposite to the cases which have been mentioned, that I hope I shall be excused for inserting them in this place. "All the symptoms of weakness (says our author) proceed from nature's being in a manner oppressed and overcome by the first attack of the disease, so as not to be able to raise regular symptoms adequate to the violence of the fever. I remember to have met with a remarkable instance of this, several years ago, in a young man I then attended; for though he seemed in a manner expiring, yet the outward parts felt so cool, that I could not persuade the attendants he had a fever, which could not disengage, and show itself clearly, because the vessels were so full as to obstruct the motion of the blood. However, I said, that they would soon find the fever rise high enough upon bleeding him. Accordingly, after taking away a large quantity of blood, as violent a fever appeared as ever I met with, and did not go off till bleeding had been used three or four times[76]."

[76] Vol. ii. p. 351.

5. I bled in those cases in which the fever appeared in a tertian form, provided the pulse was full and tense. I well recollect the surprise with which Mr. Van Berkel heard this prescription from me, at a time when he was able to walk and ride out on the intermediate days of a tertian fever. The event which followed this prescription showed that it was not disproportioned to the violence of his disease, for it soon put on such acute and inflammatory symptoms as to require six subsequent bleedings to subdue it.

6. I bled in those cases where patients were able to walk about, provided the pulse was the same as has been mentioned under the fourth head. I was determined as to the propriety of bleeding in these two supposed mild forms of the fever, by having observed each of them, when left to themselves, frequently to terminate in death.

7. I paid no regard to the dissolved state of the blood, when it appeared on the first or second day of the disease, but repeated the bleedings afterwards in every case, where the pulse continued to indicate it. It was common to see sizy blood succeed that which was dissolved. This occurred in Mr. Josiah Coates, and Mr. Samuel Powel. Had I believed that this dissolved state of the blood arose from its putrefaction, I should have laid aside my lancet as soon as I saw it; but I had long ago parted with all ideas of putrefaction in bilious fevers. The refutation of this doctrine was the object of one of my papers in the Medical Society of Edinburgh, in the year 1767. The dissolved appearance of the blood, I suppose to be the effect of a certain action of the blood-vessels upon it. It occurs in fevers which depend upon the sensible qualities of the air, and in which no putrid or foreign matter has been introduced into the system.

8. The presence of petechiæ did not deter me from repeating blood-letting, where the pulse retained its fulness or tension. I prescribed it with success in the cases of Dr. Mease, and of Mrs. Gebler, in Dock-street, in each of whom petechiæ had appeared. Bleeding was equally effectual in the case of the Rev. Mr. Keating, at a time when his arms were spotted with that species of eruptions which I have compared to moscheto-bites. I had precedents in Dr. De Haen[77] and Dr. Sydenham[78], in favour of this practice. So far from viewing these eruptions as signs of putrefaction, I considered them as marks of the highest possible inflammatory diathesis. They disappeared in each of the above cases after bleeding.

[77] Ratio Medendi, vol. ii. p. 162. vol. iv. p. 172.

[78] Vol. i. p. 210, and 264.

9. In determining the quantity of blood to be drawn, I was governed by the state of the pulse, and by the temperature of the weather. In the beginning of September, I found one or two moderate bleedings sufficient to subdue the fever; but in proportion as the system rose by the diminution of the stimulus of heat, and the fever put on more _visible_ signs of inflammatory diathesis, more frequent bleedings became necessary. I bled many patients twice, and a few three times a day. I preferred frequent and small, to large bleedings, in the beginning of September; but towards the height and close of the epidemic, I saw no inconvenience from the loss of a pint, and even twenty ounces of blood at a time. I drew from many persons seventy and eighty ounces in five days; and from a few, a much larger quantity. Mr. Gribble, cedar-cooper, in Front-street, lost by ten bleedings a hundred ounces of blood; Mr. George, a carter in Ninth-street, lost about the same quantity by five bleedings; and Mr. Peter Mierken, one hundred and fourteen ounces in five days. In the last of the above persons the quantity taken was determined by weight. Mr. Toy, blacksmith near Dock-street, was eight times bled in the course of seven days. The quantity taken from him was about a hundred ounces. The blood in all these cases was dense, and in the last, very sizy. They were all attended in the month of October, and chiefly by my pupil, Mr. Fisher; and they were all, years afterwards, living and healthy instances of the efficacy of copious blood-letting, and of the intrepidity and judgment of their young physician. Children, and even old people, bore the loss of much more blood in this fever than in common inflammatory fevers. I took above thirty ounces, in five bleedings, from a daughter of Mr. Robert Bridges, who was then in the 9th year of her age. Even great debility, whether natural or brought on by previous diseases, did not, in those few cases in which it yielded to the fever, deprive it of the uniformity of its inflammatory character. The following letter from Dr. Griffitts, written soon after his recovery from a third attack of the fever, and just before he went into the country for the re-establishment of his health, will furnish a striking illustration of the truth of the above observation.

"I cannot leave town without a parting adieu to my kind friend, and sincere prayers for his preservation.

"I am sorry to find that the use of the lancet is still so much dreaded by too many of our physicians; and, while lamenting the death of a valuable friend this morning, I was told that he was bled but _once_ during his disease. Now if my poor frame, reduced by previous sickness, great anxiety, and fatigue, and a very low diet, could bear_ seven_ bleedings in five days, besides purging, and no diet but toast and water, what shall we say of physicians who bleed but once?

"_October 19th, 1793._"

I have compared a paroxysm of this fever to a sudden squall; but the disease in its whole course was like a tedious equinoctial gale acting upon a ship at sea; its destructive force was only to be opposed by handing every sail, and leaving the system to float, as it were, under bare poles. Such was the fragility (if I may be allowed the expression) of the blood-vessels, that it was necessary to unload them of their contents, in order to prevent the system sinking from hæmorrhages, or from effusions in the viscera, particularly the brain.

9. Such was the indomitable nature of the pulse, in some patients, that it did not lose its force after numerous and copious bleedings. In all such cases I considered the diminution of its frequency, and the absence of a vomiting, as signals to lay aside the lancet. The continuance of this preternatural force in the pulse appeared to be owing to the miasmata, which were universally diffused in the air, acting upon the arterial system in the same manner that it did in persons who were in apparent good health.

Thus have I mentioned the principal circumstances which were connected with blood-letting in the cure of the yellow fever. I shall now consider the objections that were made to it at the time, and since the prevalence of the fever.

It was said that the bleeding was unnecessarily copious; and that many had been destroyed by it. To this I answer, that I did not lose a single patient whom I bled seven times or more in this fever. As a further proof that I did not draw an ounce of blood too much it will only be necessary to add, that hæmorrhages frequently occurred after a third, a fourth, and in one instance (in the only son of Mr. William Hall) after a sixth bleeding had been used; and further, that not a single death occurred from natural hæmorrhages in the first stage of the disease. A woman, who had been bled by my advice, awoke the night following in a bath of her blood, which had flowed from the orifice in her arm. The next day she was free from pain and fever. There were many recoveries in the city from similar accidents. There were likewise some recoveries from copious natural hæmorrhages in the more advanced stages of the disease, particularly when they occurred from the stomach and bowels. I left a servant maid of Mrs. Morris's, in Walnut-street, who had discharged at least four pounds of blood from her stomach, without a pulse, and with scarcely a symptom that encouraged a hope of her life; but the next day I had the pleasure of finding her out of danger.

It was remarked that fainting was much less common after bleeding in this fever than in common inflammatory fevers. This circumstance was observed by Dr. Griffitts, as well as myself. It has since been confirmed to me by three of the principal bleeders in the city, who performed the operation upwards of four thousand times. It occurred chiefly in those cases where it was used for the first time on the third or fourth day of the disease. A swelling of the legs, moreover, so common after plentiful bleeding in pneumony and rheumatism, rarely succeeded the use of this remedy in the yellow fever.

2. Many of the indispositions, and much of the subsequent weakness of persons who had been cured by copious blood-letting, have been ascribed to it. This is so far from being true that the reverse of it has occurred in many cases. Mr. Mierken worked in his sugar-house, in good health, nine days after his last bleeding; and Mr. Gribble and Mr. George seemed, by their appearance, to have derived fresh vigour from their evacuations. I could mention the names of many people who assured me their constitutions had been improved by the use of those remedies; and I know several persons in whom they have carried off habitual complaints. Mr. Richard Wells attributed his relief from a chronic rheumatism to the copious bleeding and purging which were used to cure him of the yellow fever; and Mr. William Young, the bookseller, was relieved of a chronic pain in his side, by means of the same remedies.

3. It was said, that blood-letting was prescribed indiscriminately in all cases, without any regard to age, constitution, or the force of the disease. This is not true, as far as it relates to my practice. In my prescriptions for patients whom I was unable to visit, I advised them, when they were incapable of judging of the state of the pulse, to be guided in the use of bleeding, by the degrees of pain they felt, particularly in the head; and I seldom advised it for the _first_ time, after the second or third day of the disease.

In pneumonies which affect whole neighbourhoods in the spring of the year, bleeding is the universal remedy. Why should it not be equally so, in a fever which is of a more uniform inflammatory nature, and which tends more rapidly to effusions, in parts of the body much more vital than the lungs?

I have before remarked, that the debility which occurs in the beginning of the yellow fever, arises from a depressed state of the system. The debility in the plague is of the same nature. It has long been known that debility from the sudden abstraction of stimuli is to be removed by the _gradual_ application of stimuli, but it has been less observed, that the excess of stimulus in the system is best removed in a _gradual_ manner, and that too in proportion to the degrees of depression, which exist in the system.

This principle in the animal economy has been acknowledged by the practice of occasionally stopping the discharge of water from a canula in tapping, and of blood from a vein, in order to prevent fainting.

Child-birth induces fainting, and sometimes death, only by the _sudden_ abstraction of the stimulus of distention and pain.

In all those cases where purging or bleeding have produced death in the yellow fever or plague, when they have been used on the first or second day of those diseases, I suspect that it was occasioned by the quantity of the stimulus abstracted being disproportioned to the degrees of depression in the system. The following facts will I hope throw light upon this subject.

1. Dr. Hodges informs us, that "although blood could not be drawn in the plague, even in the smallest quantity without danger, yet a _hundred_ times the quantity of fluids was discharged in pus from buboes without inconvenience[79]."

[79] Page 114.

2. Pareus, after condemning bleeding in the plague, immediately adds an account of a patient, who was saved by a hæmorrhage from the nose, which continued _two_ days[80].

[80] Skenkius, lib. vi. p. 881.

3. I have before remarked that bleeding proved fatal in three cases in the yellow fever, in the month of August; but at that time I saw one, and heard of another case, in which death seemed to have been prevented by a bleeding at the nose. Perhaps the uniform good effects which were observed to follow a spontaneous hæmorrhage from an orifice in the arm, arose wholly from the _gradual_ manner in which the stimulus of the blood was in this way abstracted from the body. Dr. Williams relates a case of the recovery of a gentleman from the yellow fever, by means of small hæmorrhages, which continued three days, from wounds in his shoulders made by being cupped. He likewise mentions several other recoveries by hæmorrhages from the nose, after "a vomiting of black humours and a hiccup had taken place[81]."

[81] Essay on the Bilious or Yellow Fever of Jamaica, p. 40.

4. There is a disease in North-Carolina, known among the common people by the name of the "pleurisy in the head." It occurs in the winter, after a sickly autumn, and seems to be an evanescent symptom of a bilious remitting fever. The cure of it has been attempted by bleeding, in the common way, but generally without success. It has, however, yielded to this remedy in another form, that is, to the discharge of a few ounces of blood obtained by thrusting a piece of quill up the nose.

5. Riverius describes a pestilential fever which prevailed at Montpellier, in the year 1623, which carried off one half of all who were affected by it[82]. After many unsuccessful attempts to cure it, this judicious physician prescribed the loss of _two_ or _three_ ounces of blood. The pulse rose with this small evacuation. Three or four hours afterwards he drew six ounces of blood from his patients, and with the same good effect. The next day he gave a purge, which, he says, rescued his patients from the grave. All whom he treated in this manner recovered. The whole history of this epidemic is highly interesting, from its agreeing with our late epidemic in so many of its symptoms, more especially as they appeared in the different states of the pulse.

[82] De Febre Pestilenti, vol. ii. p. 145, 146, and 147.

An old and intelligent citizen of Philadelphia, who remembers the yellow fever of 1741, says that when it first made its appearance bleeding was attended with fatal consequences. It was laid aside afterwards, and the disease prevailed with great mortality until it was checked by the cold weather. Had blood been drawn in the manner mentioned by Riverius, or had it been drawn in the usual way, after the abstraction of the stimulus of heat by the cool weather, the disease might probably have been subdued, and the remedy of blood-letting thereby have recovered its character.

Dr. Hodges has another remark, in his account of the plague in London in the year 1665, which is still more to our purpose than the one which I have quoted from it upon this subject. He says that "bleeding, as a preventive of the plague, was only safe and useful when the blood was drawn by a _small_ orifice, and a _small_ quantity taken at _different_ times[83]."

[83] Page 209.

I have remarked, in the history of this fever, that it was often cured on the first or second day by a copious sweat. The Rev. Mr. Ustick was one among many whom I could mention, who were saved from a violent attack of the fever by this evacuation. It would be absurd to suppose that the miasmata which produced the disease were discharged in this manner from the body. The sweat seemed to cure the fever only by lessening the quantity of the fluids, and thus _gradually_ removing the depression of the system. The profuse sweats which sometimes cure the plague, as well as the disease which is brought on by the bite of poisonous snakes, seem to act in the same way.

The system, in certain states of malignant fever, resembles a man struggling beneath a load of two hundred weight, who is able to lift but one hundred and seventy-five. In order to assist him it will be to no purpose to attempt to infuse additional vigour into his muscles by the use of a whip or of strong drink. Every exertion will serve only to waste his strength. In this situation (supposing it impossible to divide the weight which confines him to the ground) let the pockets of this man be emptied of their contents, and let him be stripped of so much of his clothing as to reduce his weight five and twenty or thirty pounds. In this situation he will rise from the ground; but if the weights be abstracted suddenly, while he is in an act of exertion, he will rise with a spring that will endanger a second fall, and probably produce a temporary convulsion in his system. By abstracting the weights from his body more gradually, he will rise by degrees from the ground, and the system will accommodate itself in such a manner to the diminution of its pressure, as to resume its erect form, without the least deviation from the natural order of its appearance and motions.

It has been said that the stimulating remedies of bark, wine, and the cold bath, were proper in our late epidemic in August, and in the beginning of September, but that they were improper afterwards. If my theory be just, they were more improper in August and the beginning of September, than they were after the disease put on the outward and common signs of inflammatory diathesis. The reason why a few strong purges cured the disease at its first appearance, was, because they abstracted in a _gradual_ manner some of the immense portion of stimulus under which the arterial system laboured, and thus gradually relieved it from its low and weakening degrees of depression. Bleeding was fatal in these cases, probably because it removed this depression in too sudden a manner.

The principle of the gradual abstraction, as well as of the gradual application of stimuli to the body, opens a wide field for the improvement of medicine. Perhaps all the discoveries of future ages will consist more in a new application of established principles, and in new modes of exhibiting old medicines, than in the discovery of new theories, or of new articles of the materia medica.

The reasons which induced me to prescribe purging and bleeding, in so liberal a manner, naturally led me to recommend _cool_ and _fresh air_ to my patients. The good effects of it were obvious in almost every case in which it was applied. It was equally proper whether the arterial system was depressed, or whether it discovered, in the pulse, a high degree of morbid excitement. Dr. Griffitts furnished a remarkable instance of the influence of cool air upon the fever. Upon my visiting him, on the morning of the 8th of October, I found his pulse so full and tense as to indicate bleeding, but after sitting a few minutes by his bed-side, I perceived that the windows of his room had been shut in the night by his nurse, on account of the coldness of the night air. I desired that they might be opened. In ten minutes afterwards the doctor's pulse became so much slower and weaker that I advised the postponement of the bleeding, and recommended a purge instead of it. The bleeding notwithstanding became necessary, and was used with great advantage in the afternoon of the same day.

The cool air was improper only in those cases where a chilliness attended the disease.

For the same reason that I advised cool air, I directed my patients to use cold _drinks_. They consisted of lemonade, tamarind, jelly and raw apple water, toast and water, and of weak balm, and camomile tea. The subacid drinks were preferred in most cases, as being not only most agreeable to the taste, but because they tended to compose the stomach. All these drinks were taken in the early stage of the disease. Towards the close of it, I permitted the use of porter and water, weak punch, and when the stomach would bear it, weak wine-whey.

I forbade all cordial and stimulating food in the active state of the arterial system. The less my patients ate, of even the mildest vegetable food, the sooner they recovered. Weak coffee, which (as I have formerly remarked) was almost universally agreeable, and weak tea were always inoffensive. As the action of the pulse diminished, I indulged my patients with weak chocolate; also with milk, to which roasted apples, or minced peaches, and (where they were not to be had), bread or Indian mush were added.

Towards the crisis, I advised the drinking of weak chicken, veal, or mutton broth, and after the crisis had taken place, I permitted mild animal food to be eaten in a small quantity, and to be increased according to the waste of the excitability of the system. This strict abstinence which I imposed upon my patients did not escape obloquy; but the benefits they derived from it, and the ill effects which arose in many cases from a contrary regimen, satisfied me that it was proper in every case in which it was prescribed.

_Cold water_ was a most agreeable and powerful remedy in this disease. I directed it to be applied by means of napkins to the head, and to be injected into the bowels by way of glyster. It gave the same ease to both, when in pain, which opium gives to pain from other causes. I likewise advised the washing of the face and hands, and sometimes the feet, with cold water, and always with advantage. It was by suffering the body to lie for some time in a bed of cold water, that the inhabitants of the island of Massuah cured the most violent bilious fevers[84]. When applied in this way, it _gradually_ abstracts the heat from the body, and thereby lessens the action of the system. It differs as much in its effects upon the body from the cold bath, as rest in a cold room, differs from exercise in the cold and open air.

[84] Bruce's Travels.

I was first led to the practice of the partial application of cold water to the body, in fevers of too much force in the arterial system, by observing its good effects in active hæmorrhages, and by recollecting the effects of a partial application of warm water to the feet, in fevers of an opposite character. Cold water when applied to the feet as certainly reduces the pulse in force and frequency, as warm water, applied in the same way, produces contrary effects upon it. In an experiment which was made at my request, by one of my pupils, by placing his feet in cold pump water for a few minutes, the pulse was reduced 24 strokes in a minute, and became so small as hardly to be perceptible.

But this effect of cold water, in reducing the frequency of the pulse, is not uniform. In weak and irritable habits, it increases its frequency. This has been fully proved by a number of experiments, made by my former pupil, Dr. Stock, of Bristol, in England, and published in his "Medical Collections of the Effects of Cold, as a Remedy in certain Diseases[85]."

[85] Page 185.

In the use of the remedies which were necessary to overcome the inflammatory action of the system, I was obliged to reduce it below its natural point of excitement. In the present imperfect state of our knowledge in medicine, perhaps no disease of too much action can be cured without it.

Besides the remedies which have been mentioned, I was led to employ another of great efficacy. I had observed a favourable issue of the fever, in every case in which a spontaneous discharge took place from the salivary glands. I had observed further, that all such of my patients (one excepted) as were salivated by the mercurial purges recovered in a few days. This early suggested an idea to me that the calomel might be applied to other purposes than the discharging of bile from the bowels. I ascribed its salutary effects, when it salivated in the first stage of the disease, to the excitement of inflammation and effusion in the throat, diverting them from more vital parts of the body. In the second stage of the disease, I was led to prescribe it as a stimulant, and, with a view of obtaining this operation from it, I aimed at exciting a salivation, as speedily as possible, in all cases. Two precedents encouraged me to make trial of this remedy.

In the month of October, 1789, I attended a gentleman in a bilious fever, which ended in many of the symptoms of a typhus mitior. In the lowest state of his fever, he complained of a pain in his right side, for which I ordered half an ounce of mercurial ointment to be rubbed on the part affected. The next day, he complained of a sore mouth, and, in the course of four and twenty hours, he was in a moderate salivation. From this time his pulse became full and slow, and his skin moist; his sleep and appetite suddenly returned, and in a day or two he was out of danger. The second precedent for a salivation in a fever, which occurred to me, was in Dr. Haller's short account of the works of Dr. Cramer[86]. The practice was moreover justified, in point of safety, as well as the probability of success, by the accounts which Dr. Clark has lately given of the effects of a salivation in the dysentery[87]. I began by prescribing the calomel in small doses, at short intervals, and afterwards I directed large quantities of the ointment to be rubbed upon the limbs. The effects of it, in every case in which it affected the mouth, were salutary. Dr. Woodhouse improved upon my method of exciting the salivation, by rubbing the gums with calomel, in the manner directed by Mr. Clare. It was more speedy in its operation in this way than in any other, and equally effectual. Several persons appeared to be benefited by the mercury introduced into the system in the form of an ointment, where it did _not_ produce a salivation. Among these, were the Rev. Dr. Blackwell, and Mr. John Davis.

[86] Bibliotheca Medicinæ Practicæ, vol. iii. p. 491.

[87] Diseases of Long Voyages to Hot Climates, vol. ii. p. 334.

Soon after the above account was written of the good effects of a mercurial salivation in this fever, I had great satisfaction in discovering that it had been prescribed with equal, and even greater success, by Dr. Wade in Bengal, in the year 1791, and by Dr. Chisholm in the island of Granada, in the cure of bilious yellow fevers[88]. Dr. Wade did not lose one, and Dr. Chisholm lost only one out of forty-eight patients in whom the mercury affected the salivary glands. The latter gave 150 grains of calomel, and applied the strongest mercurial ointment below the groin of each side, in some cases. He adds further, that not a single instance of a relapse occurred, where the disease was cured by salivation.

[88] Medical Commentaries, vol. xviii. p. 209, 288.

After the reduction of the system, _blisters_ were applied with great advantage to every part of the body. They did most service when they were applied to the crown of the head. I did not see a single case, in which a mortification followed the sore, which was created by a blister.

Brandy and water, or porter and water, when agreeable to the stomach, with now and then a cup of chicken broth, were the drinks I prescribed to assist in restoring the tone of the system.

In some cases I directed the limbs to be wrapped in flannels dipped in warm spirits, and cataplasms of bruised garlic to be applied to the feet. But my principal dependence, next to the use of mercurial medicines, for exciting a healthy action in the arterial system, was upon mild and gently stimulating food. This consisted of rich broths, the flesh of poultry, oysters, thick gruel, mush and milk, and chocolate. I directed my patients to eat or drink a portion of some of the above articles of diet every hour or two during the day, and in cases of great debility, from an exhausted state of the system, I advised their being waked for the same purpose two or three times in the night. The appetite frequently craved more savoury articles of food, such as beef-stakes and sausages; but they were permitted with great caution, and never till the system had been prepared for them by a less stimulating diet.

There were several _symptoms_ which were very distressing in this disease, and which required a specific treatment.

For the vomiting, with a burning sensation in the stomach, which came on about the fifth day, I found no remedy equal to a table spoonful of sweet milk, taken every hour, or to small draughts of milk and water. I was led to prescribe this simple medicine from having heard, from a West-India practitioner, and afterwards read, in Dr. Hume's account of the yellow fever, encomiums upon the milk of the cocoa-nut for this troublesome symptom. Where sweet milk failed of giving relief, I prescribed small doses of sweet oil, and in some cases a mixture of equal parts of milk, sweet oil, and molasses. They were all intended to dilute or blunt the acrimony of the humours, which were either effused or generated in the stomach. Where they all failed of checking the vomiting, I prescribed weak camomile tea, or porter, or cyder and water, with advantage. In some of my patients the stomach rejected all the mixtures and liquors which have been mentioned. In such cases I directed the stomach to be left to itself for a few hours, after which it sometimes received and retained the drinks that it had before rejected, provided they were administered in a small quantity at a time.

The vomiting was sometimes stopped by a blister applied to the external region of the stomach.

A mixture of liquid laudanum and sweet oil, applied to the same place, gave relief where the stomach was affected by pain only, without a vomiting.

I have formerly mentioned that a distressing _pain_ often seized the lower part of the _bowels_. I was early taught that laudanum was not a proper remedy for it. It yielded in almost every case to two or three emollient glysters, or to the loss of a few ounces of blood.

The convalescence from this fever was in general rapid, but in some cases it was very slow. I was more than usually struck by the great resemblance which the system in the convalescence from this fever bore to the state of the body and mind in old age. It appeared, 1. In the great weakness of the body, more especially of the limbs. 2. In uncommon depression of mind, and in a great aptitude to shed tears. 3. In the absence or short continuance of sleep. 4. In the frequent occurrence of appetite, and, in some cases, in its inordinate degrees. And 5. In the loss of the hair of the head, or in its being suddenly changed in some cases to a grey colour.

Pure air, gentle exercise, and agreeable society removed the debility both of body and mind of this premature and temporary old age. I met with a few cases, in which the yellow colour continued for several weeks after the patient's recovery from all the other symptoms of the fever. It was removed most speedily and effectually by two or three moderate doses of calomel and rhubarb.

A feeble and irregular intermittent was very troublesome in some people, after an acute attack of the fever. It yielded gradually to camomile or snake-root tea, and country air.

In a publication, dated the 16th of September, I recommended a diet of milk and vegetables, and cooling purges to be taken once or twice a week, to the citizens of Philadelphia. This advice was the result of the theory of the disease I had adopted, and of the successful practice which had arisen from it. In my intercourse with my fellow-citizens, I advised this regimen to be regulated by the degrees of fatigue and foul air to which they were exposed. I likewise advised moderate blood-letting to all such persons as were of a plethoric habit. To men whose minds were influenced by the publications in favour of bark and wine, and who were unable at that time to grasp the extent and force of the remote cause of this terrible fever, the idea of dieting, purging, or bleeding the inhabitants of a whole village or city appeared to be extravagant and absurd: but I had not only the analogy of the regimen made use of to prepare the body for the small-pox, but many precedents in favour of the advice. Dr. Haller has given extracts from the histories of two plagues, in which the action of the miasmata was prevented or mitigated by bleeding[89]. Dr. Hodges confirms the utility of the same practice. The benefits of low diet, as a preventive of the plague, were established by many authors, long before they received the testimony of the benevolent Mr. Howard in their favour. Socrates in Athens, and Justinian in Constantinople, were preserved, by means of their abstemious modes of living, from the plagues which occasionally ravaged those cities. By means of the low diet, gentle physic, and occasional bleedings, which I thus publicly recommended, the disease was prevented in many instances, or rendered mild where it was taken. But my efforts to prevent the disease in my fellow-citizens did not end here. I advised them, not only in the public papers, but in my intercourse with them, to avoid heat, cold, labour, and every thing else that could excite the miasmata (which I knew to be present in all their bodies) into action. I forgot, upon this occasion, the usual laws which regulate the intercourse of man with man in the streets, and upon the public roads, in my excursions into the neighbourhood of the city. I cautioned many persons, whom I saw walking or riding in an unsafe manner, of the danger to which they exposed themselves; and thereby, I hope, prevented an attack of the disease in many people.

[89] Bibliotheca Medicinæ Practicæ, vol. ii. p. 93. and 387.

It was from a conviction of the utility of low diet, gentle evacuations, and of carefully shunning all the exciting causes which I have mentioned, that I concealed, in no instance, from my patients the name of their disease. This plainness, which was blamed by weak people, produced strict obedience to my directions, and thereby restrained the progress of the fever in many families, or rendered it, when taken, as mild as inoculation does the small-pox. The opposite conduct of several physicians, by preventing the above precautions, increased the mortality of the disease, and, in some instances, contributed to the extinction of whole families.

I proceed now to make a few remarks upon the remedies recommended by Doctors Kuhn and Stevens, and by the French physicians. The former were bark, wine, laudanum, spices, the elixir of vitriol, and the cold bath.

In every case in which I prescribed bark, it was offensive to the stomach. In several tertians which attended the convalescence from a common attack of the fever, I found it always unsuccessful, and once hurtful. Mr. Willing took it for several weeks without effect. About half a pint of a weak decoction of the bark produced, in Mr. Samuel Meredith, a paroxysm of the fever, so violent as to require the loss of ten ounces of blood to moderate it. Dr. Annan informed me that he was forced to bleed one of his patients twice, after having given him a small quantity of bark, to hasten his convalescence.

It was not in this epidemic only that the bark was hurtful. Baron Humboldt informed me, that Dr. Comoto had assured him, it hastened death in every case in which it was given in the yellow fever of Vera Cruz. If, in any instance, it was inoffensive, or did service, in our fever, I suspect it must have acted upon the bowels as a purge. Dr. Sydenham says the bark cured intermittents by this evacuation[90]; and Mr. Bruce says it operated in the same way, when it cured the bilious fevers at Massuah.

[90] Vol. i. p. 440.

_Wine_ was nearly as disagreeable as the bark to the stomach, and equally hurtful. I tried it in every form, and of every quality, but without success. It was either rejected by the stomach, or produced in it a burning sensation. I should suspect that I had been mistaken in my complaints against wine, had I not since met with an account in Skenkius of its having destroyed all who took it in the famous Hungarian fever, which prevailed, with great mortality, over nearly every country in Europe, about the middle of the 16th century[91]. Dr. Wade declares wine to be "ill adapted to the fevers of Bengal, where the treatment has been proper in other respects."

[91] Omnes qui vini potione non abstinuerunt, interiere, adeo ut summa spes salvationis in vini abstinentia collocata videreter. Lib. vi. p. 847.

_Laudanum_ has been called by Dr. Mosely "a fatal medicine" in the yellow fever. In one of my patients, who took only fifteen drops of it, without my advice, to ease a pain in his bowels, it produced a delirium, and death in a few hours. I was much gratified in discovering that my practice, with respect to the use of opium in this fever, accorded with Dr. Wade's in the fever of Bengal. He tells us, "that it was mischievous in almost every instance, even in combination with antimonials."

The _spices_ were hurtful in the first stage of the fever, and, when sufficient evacuations had been used, they were seldom necessary in its second.

The _elixir of vitriol_ was, in general, offensive to the stomach.

The _cold bath_ was useful in those cases where its sedative prevailed over its stimulating effects. But this could not often happen, from the suddenness and force, with which the water was thrown upon the body. In two cases in which I prescribed it, it produced a gentle sweat, but it did not save life. In a third it removed a delirium, and reduced the pulse for a few minutes, in frequency and force, but this patient died. The recommendation of it indiscriminately, in all cases, was extremely improper. In that chilliness and tendency to fainting upon the least motion, which attended the disease in some patients, it was an unsafe remedy. I heard of a woman who was seized with delirium immediately after using it, from which she never recovered; and of a man who died a few minutes after he came out of a bathing tub. Had this remedy been the exclusive antidote to the yellow fever, the mortality of the disease would have been but little checked by it. Thousands must have perished from the want of means to procure tubs, and of a suitable number of attendants to apply the water, and to lift the patient in and out of bed. The reason of our citizens ran before the learning of the friends of this remedy, and long before it was abandoned by the physicians, it was rejected as useless, or not attempted, because impracticable, by the good sense of the city. It is to be lamented that the remedy of cold water has suffered in its character by the manner in which it was advised. In fevers of too much action, it reduces the morbid excitement of the blood-vessels, provided it be _applied without force_, and for a considerable time, to the body. It is in the jail fever, and in the second stage of the yellow fever only, in which its stimulant and tonic powers are proper. Dr. Jackson establishes this mode of using it, by informing us, that when it did service, it "gave vigour and tone" to the system[92].

[92] Fevers of Jamaica.

A mode of practice which I formerly mentioned in this fever, consisted of a union of the evacuating and tonic remedies. The physicians who adopted this mode gave calomel by itself, in small doses, on the first or second day of the fever, bled once or twice, in a sparing manner, and gave the bark, wine, and laudanum, in large quantities, upon the first appearance of a remission. After they began the use of these remedies purging was omitted, or, if the bowels were moved, it was only by means of gentle glysters. This practice, I shall say hereafter, was not much more successful than that which was recommended by Dr. Kuhn and Dr. Stevens. It resembled throwing water and oil at the same time upon a fire, in order to extinguish it.

The _French_ remedies were nitre and cremor tartar, in small doses, centaury tea, camphor, and several other warm medicines; subacid drinks, taken in large quantities, the warm bath, and moderate bleeding.

After what has been said it must be obvious to the reader, that the nitre and cremor tartar, in small doses, could do no good, and that camphor and all cordial medicines must have done harm. The diluting subacid drinks, which the French physicians gave in large quantities, were useful in diluting and blunting the acrimony of the bile, and to this remedy, assisted by occasional bleeding, I ascribe most of the cures which were performed by those physicians.

Those few persons in whom the _warm bath_ produced copious and universal sweats recovered, but, in nearly all the cases which came under my notice, it did harm.

I come now to inquire into the comparative success of all the different modes of practice which have been mentioned.

I have already said that ten out of thirteen patients whom I treated with bark, wine, and laudanum, and that three out of four, in whom I added the cold bath to those remedies, died. Dr. Pennington informed me, that he had lost all the patients (six in number) to whom he had given the above medicines. Dr. Johnson assured me, with great concern, about two weeks before he died, that he had not recovered a single patient by them. Whole families were swept off where these medicines were used. But further, most of those persons who received the seeds of the fever in the city, and sickened in the country, or in the neighbouring towns, and who were treated with tonic remedies, died. There was not a single cure performed by them in New-York, where they were used in several sporadic cases with every possible advantage. But why do I multiply proofs of their deadly effects? The clamours of hundreds whose relations had perished by them, and the fears of others, compelled those physicians who had been most attached to them to lay them aside, or to prepare the way for them (as it was called) by purging and bleeding. The bathing tub soon shared a worse fate than bark, wine, and laudanum, and, long before the disease disappeared, it was discarded by all the physicians in the city.

In answer to these facts we are told, that Mr. Hamilton and his family were cured by Dr. Stevens's remedies, and that Dr. Kuhn had administered them with success in several instances.

Upon these cures I shall insert the following judicious remarks from Dr. Sydenham. "Success (says the doctor) is not a sufficient proof of the excellency of a method of cure in acute diseases, since some are recovered by the imprudent procedure of old women; but it is further required, that the distemper should be _easily cured_, and yield conformably to its _own_ nature[93]." And again, speaking of the cure of the new fever of 1685, this incomparable physician observes, "If it be objected that this fever frequently yields to a quite contrary method to that which I have laid down, I answer, that the cure of a disease by a method which is attended with success only _now_ and _then_, in a _few_ instances, differs extremely from that practical method, the efficacy whereof appears both from its recovering _greater numbers_, and all the practical phenomena happening in the cure[94]."

[93] Vol. ii. p. 254.

[94] Vol, ii. p. 354.

Far be it from me to deny that the depression of the system may not be overcome by such stimuli as are more powerful than those which occasion it. This has sometimes been demonstrated by the efficacy of bark, wine, and laudanum, in the confluent and petechial small-pox; but even this state of that disease yields more easily to blood-letting, or to plentiful evacuations from the stomach and bowels, on the first or second day of the eruptive fever. This I have often proved, by giving a large dose of tartar emetic and calomel, as soon as I was satisfied from circumstances, that my patient was infected with the small-pox. But the depression produced by the yellow fever appears to be much greater than that which occurs in the small-pox, and hence it more uniformly resisted the most powerful tonic remedies.

In one of my publications during the prevalence of the fever I asserted, that the remedies of which I have given a history cured a greater proportion than ninety-nine out of a hundred, of all who applied to me on the first day of the disease, before the 15th day of September. I regret that it is not in my power to furnish a list of them, for a majority of them were poor people, whose names are still unknown to me. I was not singular in this successful practice in the first appearance of the disease. Dr. Pennington assured me on his death bed, that he had not lost one, out of forty-eight patients whom he had treated agreeably to the principles and practice I had recommended. Dr. Griffitts triumphed over the disease in every part of the city, by the use of what were called the new remedies. My former pupils spread, by their success, the reputation of purging and bleeding, wherever they were called. Unhappily the pleasure we derived from this success in the treatment of the disease, was of short duration. Many circumstances contributed to lessen it, and to revive the mortality of the fever. I shall briefly enumerate them.

1. The distraction produced in the public mind, by the recommendation of remedies, the opposites in every respect of purging and bleeding.

2. The opinion which had been published by several physicians, and inculcated by others, that we had other fevers in the city besides the yellow fever. This produced a delay in many people in sending for a physician, or in taking medicines, for two or three days, from a belief that they had nothing but a cold, or a common fever. Some people were so much deceived by this opinion, that they refused to send for physicians, lest they should be infected by them with the yellow fever. In most of the cases in which these delays took place, the disease proved mortal.

To obviate a suspicion that I have laid more stress upon the fatal influence of this error than is just, I shall here insert an extract of a