letter I received from Mr. John Connelly, one of the city committee, who

frequently left his brethren in the city hall, and spent many hours in visiting and prescribing for the sick. "The publications (says he) of some physicians, that there were but few persons infected with the yellow fever, and that many were ill with colds and common remitting and fall fevers, proved fatal to almost every family which was credulous enough to believe them. That opinion slew its hundreds, if not its thousands, many of whom did not send for a physician until they were in the last stage of the disorder, and beyond the power of medicine."

3. The interference of the friends of the stimulating system, in dissuading patients from submitting to sufficient evacuations.

4. The deceptions which were practised by some patients upon their physicians, in their reports of the quantity of blood they had lost, or of the quality and number of their evacuations by stool.

5. The impracticability of procuring bleeders as soon as bleeding was prescribed. Life in this disease, as in the apoplexy, frequently turned upon that operation being performed within an _hour_. It was often delayed, from the want of a bleeder, one or two days.

6. The inability of physicians, from the number of their patients, and from frequent indisposition, to visit the sick, at such times as was necessary to watch the changes in their disease.

7. The great accumulation and concentration of the miasmata in sick rooms, from the continuance of the disease in the city, whereby the system was exposed to a constant stimulus, and the effect of the evacuations was thus defeated.

8. The want of skill or fidelity in nurses to administer the medicines properly; to persuade patients to drink frequently; also to supply them with food or cordial drinks when required in the night.

9. The great degrees of debility induced in the systems of many of the people who were affected by the disease, from fatigue in attending their relations or friends.

10. The universal depression of mind, amounting in some instances to despair, which affected many people. What medicine could act upon a patient who awoke in the night, and saw through the broken and faint light of a candle, no human creature, but a black nurse, perhaps asleep in a distant corner of the room; and who heard no noise, but that of a hearse conveying, perhaps, a neighbour or a friend to the grave? The state of mind under which many were affected by the disease, is so well described by the Rev. Dr. Smith, in the case of his wife, in a letter I received from him in my sick room, two days after her death, that I hope I shall be excused for inserting an extract from it. It forms a part of the history of the disease. The letter was written in answer to a short note of condolence which I sent to the doctor immediately after hearing of Mrs. Smith's death. After some pathetic expressions of grief, he adds, "The scene of her funeral, and some preceding circumstances, can never depart from my mind. On our return from a visit to our daughter, whom we had been striving to console on the death of Mrs. Keppele, who was long familiar and dear to both, my dear wife, passing the burying-ground gate, led me into the ground, viewed the graves of her two children, called the old grave-digger, marked a spot for herself as close as possible to them and the grave of Dr. Phineas Bond, whose memory she adored. Then, by the side of the spot she had chosen, we found room and chose _mine_, pledging ourselves to each other, and directing the grave-digger that this should be the order of our interment. We returned to our house. Night approached. I hoped my dear wife had gone to rest, as she had chosen, since her return from nursing her daughter, to sleep in a chamber by herself, through fear of infecting her grandchild and me. But it seems she closed not her eyes; sitting with them fixed through her chamber window on Mrs. Keppele's house, till about midnight she saw her hearse, and followed it with her eyes as far as it could be seen. Two days afterwards Mrs. Rodgers, her next only surviving intimate friend, was carried past her window, and by no persuasion could I draw her from thence, nor stop her sympathetic foreboding tears, so long as her eyes could follow the funeral, which was through two squares, from Fourth to Second-street, where the hearse disappeared." The doctor proceeds in describing the distress of his wife. But pointed as his expressions are, they do not convey the gloomy state of her mind with so much force as she has done it herself in two letters to her niece, Mrs. Cadwallader, who was then in the country. The one was dated the 9th, the other the 11th of October. I shall insert a few extracts from each of them.

October 9th. "It is not possible for me to pass the streets without walking in a line with the dead, passing infected houses, and looking into open graves. This has been the case for many weeks." "I don't know what to write; my head is gone, and my heart is torn to pieces." "I intreat you to have no fears on my account. I am in the hands of a just and merciful God, and his will be done."

October 11th. "Don't wonder that I am so low to-day. My heart is sunk down within me."

The next day this excellent woman sickened, and died on the 19th of the same month.

If in a person possessed naturally of uncommon equanimity and fortitude, the distresses of our city produced such dejection of spirits, what must have been their effect upon hundreds, who were not endowed with those rare and extraordinary qualities of mind! Death in this, as well as in many other cases in which medicine had done its duty, appeared to be the inevitable consequence of the total abstraction of the energy of the mind in restoring the natural motions of life.

Under all the circumstances which have been mentioned, which opposed the system of depletion in the cure of this fever, it was still far more successful than any other mode of cure that had been pursued before in the United States, or in the West-Indies.

Three out of four died of the disease in Jamaica, under the care of Dr. Hume.

Dr. Blane considers it as one of the "most mortal" of diseases, and Dr. Jackson places a more successful mode of treating it among the subjects which will admit of "innovation" in medicine.

After the 15th of September, my success was much limited, compared with what it had been before that time. But at no period of the disease did I lose more than one in twenty of those whom I saw on the first day, and attended regularly through every stage of the fever, provided they had not been previously worn down by attending the sick.

The following statement, which will admit of being corrected, if it be inaccurate, will, I hope, establish the truth of the above assertions.

About one half of the families whom I have attended for many years, left the city. Of those who remained, many were affected by the disease. Out of the whole of them, after I had adopted my second mode of practice, I lost but five heads of families, and about a dozen servants and children. In no instance did I lose both heads of the same family. My success in these cases was owing to two causes: 1st, To the credit my former patients gave to my public declaration, that we had only _one_ fever in the city: hence they applied on the _first_ day, and sometimes on the _first_ hour of their indisposition; and 2dly, To the numerous pledges many of them had seen of the safety and efficacy of copious blood-letting, by my advice, in other diseases: hence my prescription of that necessary remedy was always obeyed in its utmost extent. Of the few adults whom I lost, among my former patients, two of them were old people, two took laudanum, without my knowledge, and one refused to take medicine of any kind; all the rest had been worn down by previous fatigue.

I have before said that a great number of the blacks were my patients. Of these not one died under my care. This uniform success, among those people, was not owing altogether to the mildness of the disease, for I shall say presently, that a great proportion of a given number died, under other modes of practice.

In speaking of the comparative effects of purging and bleeding, it may not be amiss to repeat, that not one pregnant woman, to whom I prescribed them, died, or suffered abortion. Where the tonic remedies were used, abortion or death, and, in many instances, both, were nearly universal.

Many whole families, consisting of five, six, and, in three instances, of nine members, were recovered by plentiful purging and bleeding. I could swell this work by publishing a list of those families; but I take more pleasure in adding, that I was not singular in my success in the use of the above remedies. They were prescribed with great advantage by many of the physicians of the city, who had for a while given tonic medicines without effect. I shall not mention the names of any of the physicians who _totally_ renounced those medicines, lest I should give offence by not mentioning them all. Many large families were cured by some of them, after they adopted and prescribed copious purging and blood-letting. One of them cured ten in the family of Mr. Robert Haydock, by means of those remedies. In one of that family, the disease came on with a vomiting of black bile.

But the use of the new remedies was not directed finally by the physicians alone. The clergy, the apothecaries, many private citizens, several intelligent women, and two black men, prescribed them with great success. Nay more, many persons prescribed them to themselves, and, as I shall say hereafter, with a success that was unequalled by any of the regular or irregular practitioners in the city.

It was owing to the almost universal use of purging and bleeding, that the mortality of the disease diminished, in proportion as the number of persons who were affected by it increased, about the middle of October. It was scarcely double of what it was in the middle of September, and yet six times the number of persons were probably at that time confined by it.

The success of copious purging and bleeding was not confined to the city of Philadelphia. Several persons, who were infected in town, and sickened in the country, were cured by them.

Could a comparison be made of the number of patients who died of the yellow fever in 1793, after having been plentifully bled and purged, with those who died of the same disease in the years 1699, 1741, 1747, and 1762, I am persuaded that the proportion would be very small in the year 1793, compared with the former years[95]. Including all who died under every mode of treatment, I suspect the mortality to be less, in proportion to the population of the city, and the number of persons who were affected, than it was in any of the other years that have been mentioned.

[95] It appears from one of Mr. Norris's letters, dated the 9th of November, O. S. that there died 220 persons, in the year 1699, with the yellow fever. Between 80 and 90 of them, he says, belonged to the society of friends. The city, at this time, probably, did not contain more than 2 or 3000 people, many of whom, it is probable, fled from the disease.

Not less than 6000 of the inhabitants of Philadelphia probably owe their lives to purging and bleeding, during the autumn.

I proceed with reluctance to inquire into the comparative success of the French practice. It would not be difficult to decide upon it from many facts that came under my notice in the city; but I shall rest its merit wholly upon the returns of the number of deaths at Bush-hill. This hospital, after the 22d of September, was put under the care of a French physician, who was assisted by one of the physicians of the city. The hospital was in a pleasant and airy situation; it was provided with all the necessaries and comforts for sick people that humanity could invent, or liberality supply. The attendants were devoted to their duty; and cleanliness and order pervaded every room in the house. The reputation of this hospital, and of the French physician, drew patients to it in the early stage of the disease. Of this I have been assured in a letter from Dr. Annan, who was appointed to examine and give orders of admission into the hospital, to such of the poor of the district of Southwark, as could not be taken care of in their own houses. Mr. Olden has likewise informed me, that most of the patients who were sent to the hospital by the city committee (of which he was a member) were in the first stage of the fever. With all these advantages, the deaths between the 22d of September and the 6th of November, amounted to 448 out of 807 patients who were admitted into the hospital within that time. Three fourths of all the blacks (nearly 20) who were patients in this hospital died. A list of the medicines prescribed there may be seen in the minutes of the proceedings of the city committee. Calomel and jalap are not among them. _Moderate_ bleeding and purging with glauber's salts, I have been informed, were used in some cases by the physicians of this hospital. The proportion of deaths to the recoveries, as it appears in the minutes of the committee from whence the above report is taken, is truly melancholy! I hasten from it therefore to a part of this work, to which I have looked with pleasure, ever since I sat down to compose it.

I have said that the clergy, the apothecaries, and many other persons who were uninstructed in the principles of medicine, prescribed purging and bleeding with great success in this disease. Necessity gave rise to this undisciplined sect of practitioners, for they came forward to supply the places of the regular bred physicians who were sick or dead. I shall mention the names of a few of those persons who distinguished themselves as volunteers in this new work of humanity. The late Rev. Mr. Fleming, one of the ministers of the catholic church, carried the purging powders in his pocket, and gave them to his poor parishioners with great success. He even became the advocate of the new remedies. In a conversation I had with him, on the 22d of September, he informed me, that he had advised four of our physicians, whom he met a day or two before, "to renounce the pride of science, and to adopt the new mode of practice, for that he had witnessed its good effects in many cases." Mr. John Keihmle, a German apothecary, has assured me, that out of 314 patients whom he visited, and 187 for whom he prescribed from the reports of their friends, he lost but 47 (which is nearly but one in eleven), and that he treated them all agreeably to the method which I had recommended. The Rev. Mr. Schmidt, one of the ministers of the Lutheran church, was cured by him. I have before mentioned an instance of the judgment of Mr. Connelly, and of his zeal in visiting and prescribing for the sick. His remedies were bleeding and purging. He, moreover, bore a constant and useful testimony against bark, wine, laudanum, and the warm bath[96]. Mrs. Paxton, in Carter's-alley, and Mrs. Evans, the wife of Mr. John Evans, in Second-street, were indefatigable; the one in distributing mercurial purges composed by herself, and the other in urging the necessity of _copious_ bleeding and purging among her friends and neighbours, as the only safe remedies for the fever. These worthy women were the means of saving many lives[97]. Absalom Jones and Richard Allen, two black men, spent all the intervals of time, in which they were not employed in burying the dead, in visiting the poor who were sick, and in bleeding and purging them, agreeably to the directions which had been printed in all the newspapers. Their success was unparalleled by what is called regular practice. This encomium upon the practice of the blacks will not surprise the reader, when I add that they had no fear of putrefaction in the fluids, nor of the calumnies of a body of fellow-citizens in the republic of medicine to deter them from plentiful purging and bleeding. They had, besides, no more patients than they were able to visit two or three times a day. But great as their success was, it was exceeded by those persons who, in despair of procuring medical aid of any kind, purged and bled themselves. This palm of superior success will not be withheld from those people when I explain the causes of it. It was owing to their _early_ use of the proper remedies, and to their being guided in the repetition of them, by the continuance of a tense pulse, or of pain and fever. A day, an afternoon, and even an hour, were not lost by these people in waiting for the visit of a physician, who was often detained from them by sickness, or by new and unexpected engagements, by which means the precious moment for using the remedies with effect passed irrevocably away. I have stated these facts from faithful inquiries, and numerous observations. I could mention the names and families of many persons who thus cured themselves. One person only shall be mentioned, who has shown by her conduct what reason is capable of doing when it is forced to act for itself. Mrs. Long, a widow, after having been twice unsuccessful in her attempts to procure a physician, undertook at last to cure herself. She took several of the mercurial purges, agreeably to the printed directions, and had herself bled _seven_ times in the course of five or six days. The indication for repeating the bleeding was the continuance of the pain in her head. Her recovery was rapid and complete. The history of it was communicated to me by herself, with great gratitude, in my own house, during my second confinement with the fever. To these accounts of persons who cured themselves in the city, I could add many others, of citizens who sickened in the country, and who cured themselves by plentiful bleeding and purging, without the attendance of a physician.

[96] In the letter before quoted, from Mr. Connelly, he expresses his opinion of those four medicines in the following words: "Laudanum, bark, and wine have put a period to the existence of some, where the fever has been apparently broken, and the patients in a fair way of recovery; a single dose of laudanum has hurried them suddenly into eternity. I have visited a few patients where the hot bath was used, and am convinced that it only tended to weaken and relax the system, without producing any good effect."

[97] The yellow fever prevailed at the Caraccos, in South-America, in October, 1793, with great mortality, more especially among the Spanish troops. Nearly all died who were attended by physicians. Recourse was finally had to the old women, who were successful in almost every case to which they were called. Their remedies were a liquor called _narencado_ (a species of lemonade) and a tea made of a root called _fistula_. With these drinks they drenched their patients for the first two or three days. They induced plentiful sweats, and, probably, after blunting, discharged the bile from the bowels. I received this information from an American gentleman, who had been cured, by one of those Amazons in medicine, in the above way.

From a short review of these facts, reason and humanity awake from their long repose in medicine, and unite in proclaiming, that it is time to take the cure of pestilential epidemics out of the hands of physicians, and to place it in the hands of the people. Let not the reader startle at this proposition. I shall give the following reasons for it.

1. In consequence of these diseases affecting a great number of people at one time, it has always been, and always will be impossible, for them _all_ to have the benefit of medical aid, more especially as the proportion of physicians to the number of sick, is generally diminished upon these occasions, by desertion, sickness, and death.

2. The safety of committing to the people the cure of pestilential fevers, particularly the yellow fever and the plague, is established by the simplicity and uniformity of their causes, and of their remedies. However diversified they may be in their symptoms, the system, in both diseases, is generally under a state of undue excitement or great depression, and in most cases requires the abstraction of stimulus in a greater or less degree, or in a sudden or gradual manner. There can never be any danger of the people injuring themselves by mistaking any other disease for an _epidemic_ yellow fever or plague, for no other febrile disease can prevail with them. It was probably to prevent this mistake, that the Benevolent Father of mankind, who has permitted no evil to exist which does not carry its antidote along with it, originally imposed that law upon all great and mortal epidemics.

3. The history of the yellow fever in the West-Indies proves the advantage of trusting patients to their own judgment. Dr. Lind has remarked, that a greater proportion of sailors who had no physicians recovered from that fever, than of those who had the best medical assistance. The fresh air of the deck of a ship, a purge of salt water, and the free use of cold water, probably triumphed here over the cordial juleps of physicians.

4. By committing the cure of this and other pestilential epidemics to the people, all those circumstances which prevented the universal success of purging and bleeding, in this disease, will have no operation. The fever will be mild in most cases, for all will prepare themselves to receive it, by a vegetable diet, and by moderate evacuations. The remedies will be used the _moment_ the disease is felt, or even seen, and its violence and danger will thereby be obviated. There will then be no disputes among physicians, about the nature of the disease, to distract the public mind, for they will seldom be consulted in it. None will suffer from chronic debility induced by previous fatigue in attending the sick, nor from the want of nurses, for few will be so ill as to require them, and there will be no "foreboding" fears of death, or despair of recovery, to invite an attack of the disease, or to ensure its mortality.

The small-pox was once as fatal as the yellow fever and the plague. It has since yielded as universally to a vegetable diet and evacuations, in the hands of apothecaries, the clergy, and even of the good women, as it did in the hands of doctors of physic.

They have narrow conceptions, not only of the Divine goodness, but of the gradual progress of human knowledge, who suppose that all pestilential diseases shall not, like the small-pox, sooner or later cease to be the scourge and terror of mankind.

For a long while, air, water, and even the light of the sun, were dealt out by physicians to their patients with a sparing hand. They possessed, for several centuries, the same monopoly of many artificial remedies. But a new order of things is rising in medicine. Air, water, and light are taken without the advice of a physician, and bark and laudanum are now prescribed every where by nurses and mistresses of families, with safety and advantage. Human reason cannot be stationary upon these subjects. The time must and will come, when, in addition to the above remedies, the general use of calomel, jalap, and the lancet, shall be considered among the most essential articles of the knowledge and rights of man.

It is no more necessary that a patient should be ignorant of the medicine he takes, to be cured by it, than that the business of government should be conducted with secrecy, in order to insure obedience to just laws. Much less is it necessary that the means of life should be prescribed in a dead language, or dictated with the solemn pomp of a necromancer. The effects of imposture, in every thing, are like the artificial health produced by the use of ardent spirits. Its vigour is temporary, and is always followed by misery and death.

The belief that the yellow fever and the plague are necessarily mortal, is as much the effect of a superstitious torpor in the understanding, as the ancient belief that the epilepsy was a supernatural disease, and that it was an offence against Heaven to attempt to cure it. It is partly from the influence of this torpor in the minds of some people, that the numerous cures of the yellow fever, performed by a few simple remedies, were said to be of _other_ diseases. It is necessary, for the conviction of such persons, that patients should always _die_ of that, and other dangerous diseases, to prove that they have been affected by them.

The repairs which our world is destined to undergo will be incomplete, until pestilential fevers cease to be numbered among the widest outlets of human life.

There are many things which are now familiar to women and children, which were known a century ago only to a few men who lived in closets, and were distinguished by the name of philosophers.

We teach a hundred things in our schools less useful, and many things more difficult, than the knowledge that would be necessary to cure a yellow fever or the plague.

In my attempts to teach the citizens of Philadelphia, by my different publications, the method of curing themselves of yellow fever, I observed no difficulty in their apprehending every thing that was addressed to them, except what related to the different states of the pulse. All the knowledge that is necessary to discover when blood-letting is proper, might be taught to a boy or girl of twelve years old in a few hours. I taught it in less time to several persons, during the prevalence of the epidemic.

I would as soon believe that ratafia was intended by the Author of Nature to be the only drink of man, instead of water, as believe that the knowledge of what relates to the health and lives of a _whole_ city, or nation, should be confined to one, and that a small or a privileged order of men. But what have physicians, what have universities or medical societies done, after the labours and studies of many centuries, towards lessening the mortality of pestilential fevers? They have either copied or contradicted each other, in all their publications. Plagues and malignant fevers are still leagued with war and famine, in their ravages upon human life.

To prevent the formation and mortality of this fever, it will be necessary, when it makes its appearance in a city or country, to publish an account of those symptoms which I have called the _precursors_ of the disease, and to exhort the people, as soon as they feel those symptoms, to have immediate recourse to the remedies of purging or bleeding. The danger of delay in using one, or both these remedies, should be inculcated in the strongest terms, for the disease, like Time, has a lock on its forehead, but is bald behind. The bite of a rattle-snake is seldom fatal, because the medicines which cure it are applied or taken as soon as the poison comes in contact with the blood. There is less danger to be apprehended from the yellow fever than from the poison of the snake, provided the remedies for it are administered within a few hours after it is excited into action.

Let persons who are subject to chronic pains, or diseases of any kind, be advised not to be deceived by them. Every pain, at such a time, is the beginning of the disease; for it always acts first on debilitated parts of the body. From an ignorance of this law of epidemics many persons, by delaying their applications for help, perished with our fever.

Let nature be trusted into no case whatever, to cure this disease; and let no attack of it, however light, be treated with neglect. Death as certainly performs his work, when he steals on the system in the form of a mild intermittent, as he does, when he comes on with the symptoms of apoplexy, or a black vomiting.

Cleanliness, in houses and dress, cannot be too often inculcated during the prevalence of a yellow fever.

Let it not be supposed, that I mean that the history which I have given of the method of cure of this epidemic, should be applied, in all its parts, to the yellow fevers which may appear hereafter in the United States, or which exist at all times in the West-India islands. Season and climate vary this, as well as all other diseases. Bark and wine, so fatal in this, may be proper in a future yellow fever. But in the climate of the United States, I believe it will seldom appear with such symptoms of prostration and weakness, as not to require, in its first stage, evacuations of some kind.

The only inquiry, when the disease makes its appearance, should be, from what part of the body these evacuations should be procured; the order which should be pursued in obtaining them; and the quantity of each of the matters to be discharged, which should be withdrawn at a time.

Thus far did I venture, from my theory of the disease, and from the authorities of Dr. Hillary and Dr. Mosely, to decide in favour of evacuations in the yellow fever; but Dr. Wade, and Mr. Chisholm again support me by their practice in the fevers of the East and West-Indies. They both gave strong mercurial purges, and bled in some cases. Dr. Wade confirmed, by his practice, the advantage of _gradually_ abstracting stimulus from the system. He never drew blood, even in the most inflammatory cases, until he had first discharged the contents of the bowels. The doctor has further established the efficacy of a vegetable diet and of water as a drink, as the best means of preventing the disease in a hot climate.

The manner in which the miasmata that produce the plague act upon the system is so much like that which has been described in the yellow fever, and the accounts of the efficacy of low diet, in preparing the body for its reception, and of copious bleeding, cold air, and cold water, in curing it, are so similar, that all the directions which relate to preventing, mitigating, or curing the yellow fever may be applied to it. The fluids in the plague show a greater tendency to the skin, than they do in the yellow fever. Perhaps, upon this account, the early use of powerful sudorifics may be more proper in the former than in the latter disease. From the influence of early purging and bleeding in promoting sweats in the yellow fever, there can be little doubt but the efforts of nature to unload the system in the plague, through the channel of the pores, might be accelerated by the early use of the same remedies. One thing, with respect to the plague, is certain, that its cure depends upon the abstraction of stimulus, either by means of plentiful sweats, or of purulent matter from external sores. Perhaps the efficacy of these remedies depends wholly upon their elevating the system from its prostrated state in a _gradual_ manner. If this be the case, those natural discharges might be easily and effectually imitated by small and repeated bleedings.

To correspond in quantity with the discharge from the skin, blood-letting in the plague, when indicated, should be copious. A profuse sweat, continued for twenty-four hours, cannot fail of wasting many pounds of the fluids of the body. This was the duration of the critical sweats in the famous plague which was known by the name of the English sweating sickness, and which made its appearance in the army of Henry VII. in Milford-Haven in Wales, and spread from thence through every part of the kingdom.

The principles which lead to the prevention and cure of the yellow fever and the plague, apply with equal force to the mitigation of the measles, and to the prevention or mitigation of the scarlatina anginosa, the dysentery, and the inflammatory jail fever. I have remarked elsewhere[98], that a previous vegetable diet lessened the violence and danger of the measles. Dr. Sims taught me, many years ago, to prevent or mitigate the scarlatina anginosa, by means of gentle purges, after children are infected by it[99]. Purges of salts have in many instances preserved whole families and neighbourhoods from the dysentery, where they have been exposed to its remote cause. During the late American war, an emetic seldom failed of preventing an attack of the hospital fever, when given in its forming state[100]. I have had no experience of the effects of previous evacuations in abating the violence, or preventing the mortality of the malignant sore throat, but I can have no doubt of their efficacy, from the sameness of the state of the system in that disease, as in other malignant fevers. The debility induced in it is from depression, and the supposed symptoms of putrefaction are nothing but the disguised effects of a sudden and violent pressure of an inflammatory stimulus upon the arterial system.

[98] Vol. ii.

[99] Medical Memoirs, vol. i.

[100] Vol. i.

With these observations I close the history of the rise, progress, symptoms, and treatment of the bilious remitting yellow fever, which appeared in Philadelphia in the year 1793. My principal aim has been to revive and apply to it the principles and practice of Dr. Sydenham, and, however coldly those principles and that practice may be received by some physicians of the present day, I am convinced that experience, in all ages and in all countries, will vouch for their truth and utility.

A NARRATIVE

OF THE

_STATE OF THE BODY AND MIND_

OF THE AUTHOR,

DURING THE PREVALENCE OF THE FEVER.

Narratives of escapes from great dangers of shipwreck, war, captivity, and famine have always formed an interesting part of the history of the body and mind of man. But there are deliverances from equal dangers which have hitherto passed unnoticed; I mean from pestilential fevers. I shall briefly describe the state of my body and mind during my intercourse with the sick in the epidemic of 1793. The account will throw additional light upon the disease, and probably illustrate some of the laws of the animal economy. It will, moreover, serve to furnish a lesson to all who may be placed in similar circumstances to commit their lives, without fear, to the protection of that Being, who is able to save to the uttermost, not only from future, but from present evil.

Some time before the fever made its appearance, my wife and children went into the state of New-Jersey, where they had long been in the habit of spending the summer months. My family, about the 25th of August, consisted of my mother, a sister, who was on a visit to me, a black servant man, and a mulatto boy. I had five pupils, viz. Warner Washington and Edward Fisher, of Virginia, John Alston, of South-Carolina, and John Redman Coxe (grandson to Dr. Redman) and John Stall, both of this city. They all crowded around me upon the sudden increase of business, and with one heart devoted themselves to my service, and to the cause of humanity.

The credit which the new mode of treating the disease acquired, in all parts of the city, produced an immense influx of patients to me from all quarters. My pupils were constantly employed; at first in putting up purging powders, but, after a while, only in bleeding and visiting the sick.

Between the 8th and the 15th of September I visited and prescribed for between a hundred and a hundred and twenty patients a day. Several of my pupils visited a fourth or fifth part of that number. For a while we refused no calls. In the short intervals of business, which I spent at my meals, my house was filled with patients, chiefly the poor, waiting for advice. For many weeks I seldom ate without prescribing for numbers as I sat at my table. To assist me at these hours, as well as in the night, Mr. Stall, Mr. Fisher, and Mr. Coxe accepted of rooms in my house, and became members of my family. Their labours now had no remission.

Immediately after I adopted the antiphlogistic mode of treating the disease, I altered my manner of living. I left off drinking wine and malt liquors. The good effects of the disuse of these liquors helped to confirm me in the theory I had adopted of the disease. A troublesome head-ach, which I had occasionally felt, and which excited a constant apprehension that I was taking the fever, now suddenly left me. I likewise, at this time, left off eating solid animal food, and lived wholly, but sparingly, upon weak broth, potatoes, raisins, coffee, and bread and butter.

From my constant exposure to the sources of the disease, my body became highly impregnated with miasmata. My eyes were yellow, and sometimes a yellowness was perceptible in my face. My pulse was preternaturally quick, and I had profuse sweats every night. These sweats were so offensive, as to oblige me to draw the bed-clothes close to my neck, to defend myself from their smell. They lost their f[oe]tor entirely, upon my leaving off the use of broth, and living entirely upon milk and vegetables. But my nights were rendered disagreeable, not only by these sweats, but by the want of my usual sleep, produced in part by the frequent knocking at my door, and in part by anxiety of mind, and the stimulus of the miasmata upon my system. I went to bed in conformity to habit only, for it ceased to afford me rest or refreshment. When it was evening I wished for morning; and when it was morning, the prospect of the labours of the day, at which I often shuddered, caused me to wish for the return of evening. The degrees of my anxiety may be easily conceived when I add, that I had at one time upwards of thirty heads of families under my care; among these were Mr. Josiah Coates, the father of eight, and Mr. Benjamin Scull and Mr. John Morell, both fathers of ten children. They were all in imminent danger; but it pleased God to make me the instrument of saving each of their lives. I rose at six o'clock, and generally found a number of persons waiting for advice in my shop or parlour. Hitherto the success of my practice gave a tone to my mind, which imparted preternatural vigour to my body. It was meat and drink to me to fulfil the duties I owed to my fellow-citizens, in this time of great and universal distress. From a hope that I might escape the disease, by avoiding every thing that could excite it into action, I carefully avoided the heat of the sun, and the coldness of the evening air. I likewise avoided yielding to every thing that should raise or depress my passions. But, at such a time, the events which influence the state of the body and mind are no more under our command than the winds or weather. On the evening of the 14th of September, after eight o'clock, I visited the son of Mrs. Berriman, near the Swedes's church, who had sent for me early in the morning. I found him very ill. He had been bled in the forenoon, by my advice, but his pulse indicated a second bleeding. It would have been difficult to procure a bleeder at that late hour. I therefore bled him myself. Heated by this act, and debilitated by the labours of the day, I rode home in the evening air. During the ensuing night I was much indisposed. I rose, notwithstanding, at my usual hour. At eight o'clock I lost ten ounces of blood, and immediately afterwards got into my chair, and visited between forty and fifty patients before dinner. At the house of one of them I was forced to lie down a few minutes. In the course of this morning's labours my mind was suddenly thrown off its pivots, by the last look, and the pathetic cries, of a friend for help, who was dying under the care of a French physician. I came home about two o'clock, and was seized, immediately afterwards, with a chilly fit and a high fever. I took a dose of the mercurial medicine, and went to bed. In the evening I took a second purging powder, and lost ten ounces more of blood. The next morning I bathed my face, hands, and feet in cold water for some time. I drank plentifully, during the day and night, of weak hyson tea, and of water, in which currant jelly had been dissolved. At eight o'clock I was so well as to admit persons who came for advice into my room, and to receive reports from my pupils of the state of as many of my patients as they were able to visit; for, unfortunately, they were not able to visit them all (with their own) in due time; by which means several died. The next day I came down stairs, and prescribed in my parlour for not less than a hundred people. On the 19th of the same month, I resumed my labours, but in great weakness. It was with difficulty that I ascended a pair of stairs, by the help of a banister. A slow fever, attended with irregular chills, and a troublesome cough, hung constantly upon me. The fever discovered itself in the heat of my hands, which my patients often told me were warmer than their own. The breath and exhalations from the sick now began to affect me, in small and infected rooms, in the most sensible manner. On the morning of the 4th of October I suddenly sunk down, in a sick room, upon a bed, with a giddiness in my head. It continued for a few minutes, and was succeeded by a fever, which confined me to my house the remaining part of the day.

Every moment in the intervals of my visits to the sick was employed in prescribing, in my own house, for the poor, or in sending answers to messages from my patients; time was now too precious to be spent in counting the number of persons who called upon me for advice. From circumstances I believe it was frequently 150, and seldom less than 50 in a day, for five or six weeks. The evening did not bring with it the least relaxation from my labours. I received letters every day from the country, and from distant parts of the union, containing inquiries into the mode of treating the disease, and after the health and lives of persons who had remained in the city. The business of every evening was to answer these letters, also to write to my family. These employments, by affording a fresh current to my thoughts, kept me from dwelling on the gloomy scenes of the day. After these duties were performed, I copied into my note book all the observations I had collected during the day, and which I had marked with a pencil in my pocket-book in sick rooms, or in my carriage. To these constant labours of body and mind were added distresses from a variety of causes. Having found myself unable to comply with the numerous applications that were made to me, I was obliged to refuse many every day. My sister counted forty-seven in one forenoon before eleven o'clock. Many of them left my door with tears, but they did not feel more distress than I did from refusing to follow them. Sympathy, when it vents itself in acts of humanity, affords pleasure, and contributes to health; but the reflux of pity, like anger, gives pain, and disorders the body. In riding through the streets, I was often forced to resist the entreaties of parents imploring a visit to their children, or of children to their parents. I recollect, and even _yet_ with pain, that I tore myself at one time from five persons in Moravian-alley, who attempted to stop me, by suddenly whipping my horse, and driving my chair as speedily as possible beyond the reach of their cries.

The solicitude of the friends of the sick for help may further be conceived of, when I add, that the most extravagant compensations were sometimes offered for medical services, and, in one instance, for only a single visit. I had no merit in refusing these offers, and I have introduced an account of them only to inform such physicians as may hereafter be thrown into a similar situation, that I was favoured with an exemption from the fear of death, in proportion as I subdued every selfish feeling, and laboured exclusively for the benefit of others. In every instance in which I was forced to refuse these pathetic and earnest applications, my distress was heightened by the fear that the persons, whom I was unable to visit, would fall into improper hands, and perish by the use of bark, wine, and laudanum.

But I had other afflictions besides the distress which arose from the abortive sympathy which I have described. On the 11th of September, my ingenious pupil, Mr. Washington, fell a victim to his humanity. He had taken lodgings in the country, where he sickened with the disease. Having been almost uniformly successful in curing others, he made light of his fever, and concealed the knowledge of his danger from me, until the day before he died. On the 18th of September Mr. Stall sickened in my house. A delirium attended his fever from the first hour it affected him. He refused, and even resisted force when used to compel him to take medicine. He died on the 23d of September[101]. Scarcely had I recovered from the shock of the death of this amiable youth, when I was called to weep for a third pupil, Mr. Alston, who died in my neighbourhood the next day. He had worn himself down, before his sickness, by uncommon exertions in visiting, bleeding, and even sitting up with sick people. At this time Mr. Fisher was ill in my house. On the 26th of the month, at 12 o'clock, Mr. Coxe, my only assistant, was seized with the fever, and went to his grandfather's. I followed him with a look, which I feared would be the last in my house. At two o'clock my sister, who had complained for several days, yielded to the disease, and retired to her bed. My mother followed her, much indisposed, early in the evening. My black servant man had been confined with the fever for several days, and had on that day, for the first time, quitted his bed. My little mulatto boy, of eleven years old, was the only person in my family who was able to afford me the least assistance. At eight o'clock in the evening I finished the business of the day. A solemn stillness at that time pervaded the streets. In vain did I strive to forget my melancholy situation by answering letters, and by putting up medicines, to be distributed next day among my patients. My faithful black man crept to my door, and at my request sat down by the fire, but he added, by his silence and dullness, to the gloom which suddenly overpowered every faculty of my mind.

[101] This accomplished youth had made great attainments in his profession. He possessed, with an uncommon genius for science, talents for music, painting, and poetry. The following copy of an unfinished letter to his father (who had left the city) was found among his papers after his death. It shows that the qualities of his heart were equal to those of his head.

"_Philadelphia, September 15, 1793._

"MY DEAR FATHER,

"I take every moment I have to spare to write to you, which is not many; but you must excuse me, as I am doing good to my fellow-creatures. At this time, every moment I spend in idleness might probably cost a life. The sickness increases every day, but most of those who die, die for want of good attendance. We cure all we are called to on the first day, who are well attended, but so many doctors are sick, the poor creatures are glad to get a doctor's servant."

On the first day of October, at two o'clock in the afternoon, my sister died. I got into my carriage within an hour after she expired, and spent the afternoon in visiting patients. According as a sense of duty, or as grief has predominated in my mind, I have approved, and disapproved of this act, ever since. She had borne a share in my labours. She had been my nurse in sickness, and my casuist in my choice of duties. My whole heart reposed itself in her friendship. Upon being invited to a friend's house in the country, when the disease made its appearance in the city, she declined accepting the invitation, and gave as a reason for so doing, that I might probably require her services in case of my taking the disease, and that, if she were sure of dying, she would remain with me, provided that, by her death, she could save my life. From this time I declined in health and strength. All motion became painful to me. My appetite began to fail. My night sweats continued. My short and imperfect sleep was disturbed by distressing or frightful dreams. The scenes of them were derived altogether from sick rooms and grave-yards. I concealed my sorrows as much as possible from my patients; but when alone, the retrospect of what was past, and the prospect of what was before me, the termination of which was invisible, often filled my soul with the most poignant anguish. I wept frequently when retired from the public eye, but I did not weep over the lost members of my family alone. I beheld or heard every day of the deaths of citizens, useful in public, or amiable in private life. It was my misfortune to lose as patients the Rev. Mr. Fleming and Mr. Graesel, both exhausted by their labours of piety and love among the poor, before they sickened with the disease. I saw the last struggles of departing life in Mr. Powel, and deplored, in his death, an upright and faithful servant of the public, as well as a sincere and affectionate friend. Often did I mourn over persons who had, by the most unparalleled exertions, saved their friends and families from the grave, at the expence of their own lives. Many of these martyrs to humanity were in humble stations. Among the members of my profession, with whom I had been most intimately connected, I had daily cause of grief and distress. I saw the great and expanded mind of Dr. Pennington, shattered by delirium, just before he died. He was to me dear and beloved, like a younger brother. He was, moreover, a Joab in the contest with the disease. Philadelphia must long deplore the premature death of this excellent physician. Had he lived a few years longer, he would have filled an immense space in the republic of medicine[102]. It was my affliction to see my friend Dr. John Morris breathe his last, and to hear the first effusions of the most pathetic grief from his mother, as she bursted from the room in which he died. But I had distress from the sickness, as well as the deaths of my brethren in physic. My worthy friends, Dr. Griffitts, Dr. Say, and Dr. Mease, were suspended by a thread over the grave, nearly at the same time. Heaven, in mercy to me, as well as in kindness to the public and their friends, preserved their lives. Had they died, the measure of my sorrows would have been complete.

[102] Before he finished his studies in medicine, he published a volume of ingenious and patriotic "Chemical and Economical Essays, designed to illustrate the connection between the theory and practice of chemistry, and the application of that science to some of the arts and manufactures of the United States of America."

I have said before, that I early left off drinking wine; but I used it in another way. I carried a little of it in a vial in my pocket, and when I felt myself fainty, after coming out of a sick room, or after a long ride, I kept about a table spoonful of it in my mouth for half a minute, or longer, without swallowing it. So weak and excitable was my system, that this small quantity of wine refreshed and invigorated me as much as half a pint would have done at any other time. The only difference was, that the vigour I derived from the wine in the former, was of shorter duration than when taken in the latter way.

For the first two weeks after I visited patients in the yellow fever, I carried a rag wetted with vinegar, and smelled it occasionally in sick rooms: but after I saw and felt the signs of the universal presence of miasmata in my system, I laid aside this and all other precautions. I rested myself on the bed-side of my patients, and I drank milk or ate fruit in their sick rooms. Besides being saturated with miasmata, I had another security against being infected in sick rooms, and that was, I went into scarcely a house which was more infected than my own. Many of the poor people, who called upon me for advice, were bled by my pupils in my shop, and in the yard, which was between it and the street. From the want of a sufficient number of bowls to receive their blood, it was sometimes suffered to flow and putrify upon the ground. From this source, streams of miasmata were constantly poured into my house, and conveyed into my body by the air, during every hour of the day and night.

The deaths of my pupils and sister have often been urged as objections to my mode of treating the fever. Had the same degrees of labour and fatigue, which preceded the attack of the yellow fever in each of them, preceded an attack of a common pleurisy, I think it probable that some, or perhaps all of them, would have died with it. But when the influence of the concentrated miasmata which filled my house was added to that of constant fatigue upon their bodies, what remedies could be expected to save their lives? Under the above circumstances, I consider the recovery of the other branches of my family from the fever (and none of them escaped it) with emotions, such as I should feel had we all been revived from apparent death by the exertions of a humane society.

For upwards of six weeks I did not taste animal food, nor fermented liquors of any kind. The quantity of aliment which I took, inclusive of drinks, during this time, was frequently not more than one or two pounds in a day. Yet upon this diet I possessed, for a while, uncommon activity of body. This influence of abstinence upon bodily exertion has been happily illustrated by Dr. Jackson, in his directions for preserving the health of soldiers in hot climates. He tells us, that he walked a hundred miles in three days, in Jamaica, during which time he breakfasted on tea, supped on bread and salad, and drank nothing but lemonade or water. He adds further, that he walked from Edinburgh to London in eleven days and a half, and that he travelled with the most ease when he only breakfasted and supped, and drank nothing but water. The fatigue of riding on horseback is prevented or lessened by abstinence from solid food. Even the horse suffers least from a quick and long journey when he is fed sparingly with hay. These facts add weight to the arguments formerly adduced, in favour of a vegetable diet, in preventing or mitigating the action of the miasmata of malignant fevers upon the system. In both cases the abstraction of stimulus removes the body further from the reach of undue excitement and morbid depression.

Food supports life as much by its stimulus, as by affording nourishment to the body. Where an artificial stimulus acts upon the system the natural stimulus of food ceases to be necessary. Under the influence of this principle, I increased or diminished my food with the signs I discovered of the increase or diminution of the seeds of the disease in my body. Until the 15th of September I drank weak coffee, but after that time I drank nothing but milk, or milk and water, in the intervals of my meals. I was so satisfied of the efficacy of this mode of living, that I believed life might have been preserved, and a fever prevented, for many days, with a much greater accumulation of miasmata in my system, by means of a total abstinence from food. Poison is a relative term, and an excess in quantity, or a derangement in place, is necessary to its producing deleterious effects. The miasmata of the yellow fever produced sickness and death only from the excess of their quantity, or from their force being increased by the addition of those other stimuli which I have elsewhere called exciting causes.

In addition to low diet, as a preventive of the disease, I obviated costiveness by taking occasionally a calomel pill, or by chewing rhubarb.

I had read and taught, in my lectures, that fasting increases acuteness in the sense of touch. My low living had that effect, in a certain degree, upon my fingers. I had a quickness in my perception, of the state of the pulse in the yellow fever, that I had never experienced before in any other disease. My abstemious diet, assisted perhaps by the state of my feelings, had likewise an influence upon my mind. Its operations were performed with an ease and a celerity, which rendered my numerous and complicated duties much less burdensome than they would probably have been under other circumstances of diet, or a less agitated state of my passions.

My perception of the lapse of time was new to me. It was uncommonly slow. The ordinary business and pursuits of men appeared to me in a light that was equally new. The hearse and the grave mingled themselves with every view I took of human affairs. Under these impressions I recollect being as much struck with observing a number of men, employed in digging the cellar of a large house, as I should have been, at any other time, in seeing preparations for building a palace upon a cake of ice. I recollect, further, being struck with surprise, about the 1st of October, in seeing a man busily employed in laying in wood for the approaching winter. I should as soon have thought of making provision for a dinner on the first day of the year 1800.

In the account of my distresses, I have passed over the slanders which were propagated against me by some of my brethren. I have mentioned them only for the sake of declaring, in this public manner, that I most heartily forgive them; and that if I discovered, at any time, an undue sense of the unkindness and cruelty of those slanders, it was not because I felt myself injured by them, but because I was sure they would irreparably injure my fellow-citizens, by lessening their confidence in the only remedies that I believed to be effectual in the reigning epidemic. One thing in my conduct towards these gentlemen may require justification; and that is, my refusing to consult with them. A Mahometan and a Jew might as well attempt to worship the Supreme Being in the same temple, and through the medium of the same ceremonies, as two physicians of opposite principles and practice attempt to confer about the life of the same patient. What is done in consequence of such negotiations (for they are not consultations) is the ineffectual result of neutralized opinions; and wherever they take place, should be considered as the effect of a criminal compact between physicians, to assess the property of their patients, by a shameful prostitution of the dictates of their consciences. Besides, I early discovered that it was impossible for me, by any reasonings, to change the practice of some of my brethren. Humanity was, therefore, on the side of leaving them to themselves; for the extremity of _wrong_ in medicine, as in morals and government, is often a less mischief than that mixture of _right_ and _wrong_ which serves, by palliating, to perpetuate evil.

After the loss of my health I received letters from my friends in the country, pressing me, in the strongest terms, to leave the city. Such a step had become impracticable. My aged mother was too infirm to be removed, and I could not leave her. I was, moreover, part of a little circle of physicians, who had associated themselves in support of the new remedies. This circle would have been broken by my quitting the city. The weather varied the disease, and, in the weakest state of my body, I expected to be able, from the reports of my pupils, to assist my associates in detecting its changes, and in accommodating our remedies to them. Under these circumstances it pleased God to enable me to reply to one of the letters that urged my retreat from the city, that "I had resolved to stick to my principles, my practice, and my patients, to the last extremity."

On the 9th of October, I visited a considerable number of patients, and, as the day was warm, I lessened the quantity of my clothing. Towards evening I was seized with a pain in the back, which obliged me to go to bed at eight o'clock. About twelve I awoke with a chilly fit. A violent fever, with acute pains in different parts of my body, followed it. At one o'clock I called for Mr. Fisher, who slept in the next room. He came instantly, with my affectionate black man, to my relief. I saw my danger painted in Mr. Fisher's countenance. He bled me plentifully, and gave me a dose of the mercurial medicine. This was immediately rejected. He gave me a second dose, which likewise acted as an emetic, and discharged a large quantity of bile from my stomach. The remaining part of the night was passed under an apprehension that my labours were near an end. I could hardly expect to survive so violent an attack of the fever, broken down, as I was, by labour, sickness, and grief. My wife and seven children, whom the great and distressing events that were passing in our city had jostled out of my mind for six or seven weeks, now resumed their former place in my affections. My wife had stipulated, in consenting to remain in the country, to come to my assistance in case of my sickness; but I took measures which, without alarming her, proved effectual in preventing it. My house was enveloped in foul air, and the probability of my death made her life doubly necessary to my family. In the morning the medicine operated kindly, and my fever abated. In the afternoon it returned, attended with a great inclination to sleep. Mr. Fisher bled me again, which removed the sleepiness. The next day the fever left me, but in so weak a state, that I awoke two successive nights with a faintness which threatened the extinction of my life. It was removed each time by taking a little aliment. My convalescence was extremely slow. I returned, in a very gradual manner, to my former habits of diet. The smell of animal food, the first time I saw it at my table, forced me to leave the room. During the month of November, and all the winter months, I was harassed with a cough, and a fever somewhat of the hectic kind. The early warmth of the spring removed those complaints, and restored me, through Divine goodness, to my usual state of health.

I should be deficient in gratitude, were I to conclude this narrative without acknowledging my obligations to my surviving pupils, Mr. Fisher and Mr. Coxe, for the great support and sympathy I derived from them in my labours and distresses.

I take great pleasure likewise in acknowledging my obligations to my former pupil, Dr. Woodhouse, who assisted me in the care of my patients, after I became so weak as not to be able to attend them with the punctuality their cases required. The disinterested exploits of these young gentlemen in the cause of humanity, and their success in the treatment of the disease, have endeared their names to hundreds, and, at the same time, afforded a prelude of their future eminence and usefulness in their profession.

But wherewith shall I come before the great FATHER and REDEEMER of men, and what shall I render unto him for the issue of my life from the grave?

----Here all language fails:---- Come then, expressive silence, muse his praise.

AN ACCOUNT

OF THE

BILIOUS REMITTING AND INTERMITTING

_YELLOW FEVER_,

AS IT

APPEARED IN PHILADELPHIA,

IN THE YEAR 1794.

I concluded the history of the symptoms of the bilious remitting yellow fever, as it appeared in Philadelphia in the year 1793, by taking notice, that the diseases which succeeded that fatal epidemic were all of a highly inflammatory nature.

In that history I described the weather and diseases of the months of March and April, in the spring of 1794.

The weather, during the first three weeks of the month of May, was dry and temperate, with now and then a cold day and night. The strawberries were ripe on the 15th, and cherries on the 22d day of the month, in several of the city gardens. A shower of hail fell on the afternoon of the 22d, which broke the glass windows of many houses. A single stone of this hail was found to weigh two drachms. Several people collected a quantity of it, and preserved it till the next day in their cellars, when they used it for the purpose of cooling their wine. The weather, after this hail storm, was rainy during the remaining part of the month. The diseases were still inflammatory. Many persons were afflicted with a sore mouth in this month.

The weather in June was pleasant and temperate. Several intermittents, and two very acute pleurisies, occurred in my practice during this month. The intermittents were uncommonly obstinate, and would not yield to the largest doses of the bark.

In a son of Mr. Samuel Coates, of seven years old, the bark produced a sudden translation of this state of fever to the head, where it produced all the symptoms of the first stage of internal dropsy of the brain. This once formidable disease yielded, in this case, to three bleedings, and other depleting medicines. The blood drawn in every instance was sizy.

From the inflammatory complexion of the diseases of the spring, and of the beginning of June, I expected the fevers of the summer and autumn would be of a violent and malignant nature. I was the more disposed to entertain this opinion from observing the stagnating filth of the gutters of our city; for the citizens of Philadelphia, having an interest in rejecting the proofs of the generation of the epidemic of 1793 in their city, had neglected to introduce the regulations which were necessary to prevent the production of a similar fever from domestic putrefaction. They had, it is true, taken pains to remove the earth and offal matters which accumulated in the streets; but these, from their being always dry, were inoffensive as remote causes of disease. Perhaps the removal of the earth did harm, by preventing the absorption of the miasmata which were constantly exhaled from the gutters.

On the 6th of June, Dr. Physick called upon me, and informed me that he had a woman in the yellow fever under his care. The information did not surprise me, but it awakened suddenly in my mind the most distressing emotions. I advised him to inform the mayor of the city of the case, but by no means to make it more public, for I hoped that it might be a sporadic instance of the disease, and that it might not become general in the city.

On the 12th of the month, my fears of the return of the yellow fever were revived by visiting Mr. Isaac Morris, whom I found very ill with a violent puking, great pain in his head, a red eye, and a slow tense pulse. I ordered him to be bled, and purged him plentifully with jalap and calomel. His blood had that appearance which has been compared by authors to the washings of raw flesh in water. Upon his recovery, he told me that he "suspected he had had the yellow fever, for that his feelings were exactly such as they had been in the fall of 1793, at which time he had an attack of that disease."

On the 14th of June, I was sent for, in the absence of Dr. Mease, to visit his sister in a fever. Her mother, who had become intimately acquainted with the yellow fever, by nursing her son and mother in it, the year before, at once decided upon the name of her daughter's disease. Her symptoms were violent, but they appeared in an intermitting form. Each paroxysm of her fever was like a hurricane to her whole system. It excited apprehensions of immediate dissolution in the minds of all her friends. The loss of sixty ounces of blood, by five bleedings, copious doses of calomel and jalap, and a large blister to her neck, soon vanquished this malignant intermittent, without the aid of a single dose of bark.

During the remaining part of the month, I was called to several cases of fever, which had symptoms of malignity of an alarming nature. The son of Mr. Andrew Brown had a hæmorrhage from his nose in a fever, and a case of menorrhagia occurred in a woman, who was affected with but a slight degree of fever.

In the course of this month, I met with several cases of swelled testicles, which had succeeded fevers so slight as to have required no medical aid. Dr. Desportes records similar instances of a swelling in the testicles, which appeared during the prevalence of the yellow fever in St. Domingo, in the year 1741[103].

[103] Histoire des Maladies de Saint Domingue, p. 112.

In the month of July, I visited James Lefferty and William Adams, both of whom had, with the usual symptoms of yellow fever, a yellow colour on their skin. I likewise attended three women, in whom I discovered the disease under forms in which I had often seen it in the year 1793. In two of them it appeared with symptoms of a violent colic, which yielded only to frequent bleedings. In the third, it appeared with symptoms of pleurisy, which was attended with a constant hæmorrhage from the uterus, although blood was drawn almost daily from her arm, for six or seven days. About the middle of this month many people complained of nausea, which in some cases produced a puking, without any symptoms of fever.

During the month of August, I was called to Peter Denham, Mrs. Bruce, a son of Jacob Gribble, Mr. Cole, John Madge, Mrs. Gardiner, Miss Purdon, Mrs. Gavin, and Benjamin Cochran, each of whom had all the usual symptoms of the yellow fever. I found Mr. Cochran sitting on the side of his bed, with a pot in his hand, into which he was discharging black matter from his stomach, on the 6th day of the disease. He died on the next day. Mrs. Gavin died on the 6th day of her disease, from a want of sufficient bleeding, to which she objected from the influence of her friends. Besides the above persons, I visited Mr. George Eyre at Kensington, Mr. Thomas Fitzsimons, and Thomas M'Kean, jun. son of the chief justice of Pennsylvania, all of whom had the disease, but in a moderate degree. During this time I took no steps to alarm my fellow-citizens with the unwelcome news of its being in town. But my mind was not easy in this situation, for I daily heard of persons who died of the disease, who might probably have been saved had they applied early for relief, or had a suspicion become general among all our physicians of the existence of the yellow fever in the city. The cholera infantum was common during this, and part of the preceding month. It was more obstinate and more fatal than in common years.

On the 12th of this month, a letter from Baltimore announced the existence of the yellow fever in that city. One of the patients whom I visited in this month, in the fever, Mr. Cole, brought the seeds of it in his body from that place.

On the 25th of the month, two members of a committee, lately appointed by the government of the state, for taking care of the health of the city, called upon me to know whether the yellow fever was in town. I told them it was, and mentioned some of the cases that had come under my notice; but informed them, at the same time, that I had seen no case in which it had been contagious, and that, in every case where I had been called early, and where my prescriptions had been followed, the disease had yielded to medicine.

On the 29th of the month I received an invitation to attend a meeting of the committee of health, at their office at Walnut-street. They interrogated me respecting the intelligence I had given to two of their members on the 25th. I repeated it to them, and mentioned the names of all the persons I had attended in the yellow fever since the 9th of June.

Neither this, nor several subsequent communications to the committee of health produced the effect that was intended by them. Dr. Physick and Dr. Dewees supported me in my declaration, but their testimony did not protect me from the clamours of my fellow-citizens, nor from the calumnies of some of my brethren, who, while they daily attended or lost patients in the yellow fever, called it by the less unpopular names of

1. A common intermittent. 2. A bilious fever. 3. An inflammatory remitting fever. 4. A putrid fever. 5. A nervous fever. 6. A dropsy of the brain. 7. A lethargy. 8. Pleurisy. 9. Gout. 10. Rheumatism. 11. Colic. 12. Dysentery. And 13. Sore throat.

It was said further, by several of the physicians of the city, not to be the yellow fever, because some who had died of it had not a sighing in the beginning, and a black vomiting in the close of the disease. Even where the black vomiting and yellow skin occurred, they were said not to constitute a yellow fever, for that those symptoms occurred in other fevers.

Let not the reader complain of the citizens and physicians of Philadelphia alone. A similar conduct has existed in all cities upon the appearance of great and mortal epidemics.

Nor is it any thing new for mortal diseases to receive mild and harmless names from physicians. The plague was called a spotted fever, for several months, by some of the physicians of London, in the year 1665.

Notwithstanding the pains which were taken to discredit the report of the existence of the yellow fever in the city, it was finally believed by many citizens, and a number of families in consequence of it left the city. And in spite of the harmless names of intermitting and remitting fever, and the like, which were given to the disease, the bodies of persons who had died with it were conveyed to the grave, in several instances, upon a hearse, the way in which those who died of the yellow fever were buried the year before.

From the influence of occasional showers of rain, in the months of September and October, the disease was frequently checked, so as to disappear altogether for two or three days in my circle of practice. It was observed, that while showers of rain lessened, moist or damp weather, without rain, increased it.

The cold weather in October checked the fever, but it did not banish it from the city. It appeared in November, and in all the succeeding winter and spring months. The weather, during these months, being uncommonly moderate, will account for its not being destroyed at the time in which the disease usually disappeared in former years.

The causes which predisposed to this fever were the same as in the year 1793. Persons of full habits, strangers, and negroes, were most subject to it. It may seem strange to those persons who have read that the negroes are seldom affected with this fever in the West-Indies, that they were so much affected by it in Philadelphia. There were two reasons for it. Their manner of living was as plentiful as that of white people in the West-Indies, and they generally resided in alleys and on the skirts of the city, where they were more exposed to noxious exhalation, than in its more open and central parts.

The summer fruits, from being eaten before they were ripe, or in too large a quantity, became frequently exciting causes of this fever. It was awakened in one of my patients by a supper of peaches and milk. Cucumbers, in several instances, gave vigour to the miasmata which had been previously received into the system. Terror excited it in two of my patients. In one of them, a young woman, this terror was produced by hearing, while she sat at dinner, that a hearse had passed by her door with a person on it who had died of the yellow fever. Vexation excited it in a foreign master of a vessel, in consequence of a young woman suddenly breaking an engagement to marry him. The disease terminated fatally in this instance.

It was sometimes unfortunate for patients when the disease was excited by an article of diet, or by any other cause which acted suddenly upon the system; for it led both them, and in some instances their physicians, to confound those exciting causes with its remote cause, and to view the disease without the least relation to the prevailing epidemic. It was from this mistake that many persons were said to die of intemperance, of eating ice creams, and of trifling colds, who certainly died of the yellow fever. The rum, the ice creams, and the changes in the air, in all these cases, acted like sparks of fire which set in motion the quiescent particles of tinder or gunpowder.

I shall now proceed to describe the symptoms which this fever assumed during the periods which have been mentioned. This detail will be interesting to physicians who wish to see how little nature regards the nosological arrangement of authors, in the formation of the symptoms of diseases, and how much the seasons influence epidemics. A physician, who had practised medicine near sixty years in the city of Philadelphia, declared that he had never seen the dysentery assume the same symptoms in any two _successive_ years. The same may be said probably of nearly all epidemic diseases.

In the arrangement of the symptoms of this fever, I shall follow the order I adopted in my Account of the Yellow Fever of 1793, and describe them as they appeared in the sanguiferous system, the liver, lungs, and brain, the alimentary canal, the secretions and excretions, the nervous system, the senses and appetites, upon the skin, and in the blood.

Two premonitory symptoms struck me this year, which I did not observe in 1793. One of them was a frequent discharge of pale urine for a day or two before the commencement of the fever; the other was sleep unusually sound, the night before the attack of the fever. The former symptom was a precursor of the plague of Bassora, in the year 1773.

I. I observed but few symptoms in the sanguiferous system different from what I have mentioned in the fever of the preceding year. The slow and intermitting pulse occurred in many, and a pulse nearly imperceptible, in three instances. It was seldom very frequent. In John Madge, an English farmer, who had just arrived in our city, it beat only 64 strokes in a minute, for several days, while he was so ill as to require three bleedings a day, and at no time of his fever did his pulse exceed 96 strokes in a minute. In Miss Sally Eyre, the pulse at one time was at 176, and at another time it was at 140; but this frequency of pulse was very rare. In a majority of the cases which came under my notice, where the danger was great, it seldom exceeded 80 strokes in a minute. I have been thus particular in describing the frequency of the pulse, because custom has created an expectation of that part of the history of fevers; but my attention was directed chiefly to the different degrees of _force_ in the pulse, as manifested by its tension, fulness, intermissions, and inequality of action. The _hobbling_ pulse was common. In John Geraud, I perceived a quick stroke to succeed every two strokes of an ordinary healthy pulse. The intermitting, chorded, and depressed pulse occurred in many cases. I called it the year before a _sulky_ pulse. One of my pupils, Mr. Alexander, called it more properly a _locked_ pulse. I think I observed this state of the pulse to occur chiefly in persons in whom the fever came on without a chilly fit.

Hæmorrhages occurred in all the grades of this fever, but less frequently in my practice this year than in the year before. It occurred, after a ninth bleeding, in Miss Sally Eyre, from the nose and bowels. It occurred from the nose, after a sixth bleeding, in Mrs. Gardiner, who was at that time in the sixth month of her pregnancy. This symptom, which was accompanied by a tense and quick pulse, induced me to repeat the bleeding a seventh time. The blood was very sizy. I mention this fact to establish the opinion that hæmorrhages depend upon too much action in the blood-vessels, and that they are not occasioned by a dissolved state of the blood.

There was a disposition at this time to hæmorrhage in persons who were in apparent good health. A private, in a company of volunteers commanded by Major M'Pherson, informed me that three of his messmates were affected by a bleeding at the nose, for several days after they left the city, on their way to quell the insurrection in the western counties of Pennsylvania.

II. The liver did not exhibit the usual marks of inflammation. Perhaps my mode of treating the fever prevented those symptoms of hepatic affection which belong to the yellow fever in tropical climates. The lungs were frequently affected; and hence the disease was in many instances called a pleurisy or a catarrh. This inflammation of the lungs occurred in a more especial manner in the winter season. It was distinguished from the pleurisies of common years by a red eye, by a vomiting of green or yellow bile, by black stools, and by requiring very copious blood-letting to cure it.

The head was affected, in this fever, not only with coma and delirium, but with mania. This symptom was so common as to give rise to an opinion that madness was epidemic in our city. I saw no case of it which was not connected with other symptoms of the bilious remitting fever. The Rev. Mr. Keating, one of the ministers of the Roman church, informed me that he had been called to visit seven deranged persons in his congregation, in the course of one week, in the month of March. Two of them had made attempts upon their lives. This mania was probably, in each of the above cases, a symptom only of general fever. The dilatation of the pupil was universal in this fever.

Sore eyes were common during the prevalence of this fever. In Mrs. Leaming, this affection of the eyes was attended with a fever of a tertian type.

III. The alimentary canal suffered as usual in this fever. A vomiting was common upon the first attack of the disease. I observed this symptom to be less common after the cold and rainy weather which took place about the first of October.

I have in another place mentioned the influence of the weather upon the symptoms of this disease. In addition to the facts which have been formerly recorded, I shall add one more from Dr. Desportes. He tells us, that in dry weather the disease affects the head, and that the bowels in this case are more obstinately costive than in moist weather. This influence of the atmosphere on the yellow fever will not surprise those physicians who recollect the remarkable passage in Hippocrates, in which he says, that in the violent heats of summer, fevers appeared, but without any sweat; but if a shower, though ever so slight, appeared, a sweat broke out in the beginning[104]. I observed further, that a vomiting rarely attended those cases in which there was an absence of a chilly fit in the beginning of the fever. The same observation is made by Dr. Desportes[105].

[104] Epidemics, book XI. sect. I.

[105] Les Maladies de St. Domingue, vol. I. p. 193.

The matter discharged by vomiting was green or yellow bile in most cases. Mrs. Jones, the wife of Captain Lloyd Jones, and one other person, discharged black bile within one hour after they were attacked by the fever. I have taken notice, in the History of the Yellow Fever of 1793, that a discharge of bile in the beginning of this fever was always a favourable symptom. Dr. Davidson of St. Vincents, in a letter to me, dated the 22d July, 1794, makes the same remark. It shows that the biliary ducts are open, and that the bile is not in that viscid and impacted state which is described in the dissections of Dr. Mitchel[106]. A distressing pain in the stomach, called by Dr. Cullen gastrodynia, attended in two instances. A burning pain in the stomach, and a soreness to the touch of its whole external region, occurred in three or four cases. Two of them were in March, 1795. In Mrs. Vogles, who had the fever in September, 1794, the sensibility of the pit of the stomach was so exquisite, that she could not bear the weight of a sheet upon it.

[106] Account of the Yellow Fever of 1793.

Pains in the bowels were very common. They formed the true bilious colic, so often mentioned by West-India writers. In John Madge these pains produced a hardness and contraction of the whole external region of the bowels. They were periodical in Miss Nancy Eyre, and in Mrs. Gardiner, and in both cases were attended with diarrh[oe]a.

Costiveness without pain was common, and, in some cases, so extremely obstinate as to resist, for several days, the successive and alternated use of all the usual purges of the shops.

Flatulency was less common in this fever than in the year 1793.

The disease appeared with symptoms of dysentery in several cases.

IV. The following is an account of the state of the _secretions_ and _excretions_ in this fever.

A puking of bile was more common this year than in the year 1793. It was generally of a green or yellow colour. I have remarked before, that two of my patients discharged black bile within an hour after they were affected by the fever, and many discharged that kind of matter which has been compared to coffee grounds, towards the close of the disease.

The fæces were black in most cases where the symptoms of the highest grade of the fever attended. In one very malignant case the most drastic purges brought away, by fifty evacuations, nothing but natural stools. The purges were continued, and finally black fæces were discharged, which produced immediate relief[107]. In one person the fæces were of a light colour. In this patient the yellowness in the face was of an orange colour, and continued so for several weeks after his recovery.

[107] In the account of the effects of morbid action and inflammation, in the Outlines of the Theory of Fever, the author neglected to mention the change of certain fluids from their natural to a dark colour. It appears in the secretions of the stomach and bowels, in the bile, in the urine, in carbuncles, and occasionally in the matter which is produced by blisters. All these changes occur in the yellow fever, and, in common with the other effects of fever that have been enumerated, are the result of peculiar actions in the vessels, derived from _one_ cause, viz. morbid excitement.

The urine was, in most cases, high coloured. It was scanty in quantity in Peter Brown, and totally suppressed in John Madge for two days. I ascribed this defect of natural action in the kidneys to an _engorgement_ in their blood-vessels, similar to that which takes place in the lungs and brain in this fever. I had for some time entertained this idea of a morbid affection of the kidneys, but I have lately been confirmed in it by the account which Dr. Chisholm gives of the state of one of the kidneys, in a man whom he lost with the Beullam fever, at Grenada. "The right kidney (says the doctor) was mortified, although, during his illness, no symptom of inflammation of that organ was perceived[108]." It would seem as if the want of action in the kidneys, and a defect in their functions were not necessarily attended with pain. I recollect to have met with several cases in 1793, in which there was a total absence of pain in a suppression of urine of several days continuance. The same observation is made by Dr. Chisholm, in his account of the Beullam fever of Grenada[109]. From this fact it seems probable, that pain is not the effect of any determinate state of animal fibres, but requires the concurrence of morbid or preternatural excitement to produce it. I met with but one case of strangury in this fever. It terminated favourably in a few days. I have never seen death, in a single instance, in a fever from any cause, where a strangury attended, and I have seldom seen a fatal issue to a fever, where this symptom was accidentally produced by a blister. From this fact there would seem to be a connection between a morbid excitement in the neck of the bladder, and the safety of more vital parts of the body. The idea of this connection was first suggested to me, above thirty years ago, by the late Dr. James Leiper, of Maryland, who informed me that he had sometimes cured the most dangerous cases of pleurisy, after the usual remedies had failed, by exciting a strangury, by means of the tincture of Spanish flies mixed with camphorated spirit of wine.

[108] Essay on the Malignant Pestilential Fever introduced into the West-Indies from Beullam, p. 137.

[109] Page 224.

The tongue was always moist in the beginning of the fever, but it was generally of a darker colour than last year. When the disease was left to itself, or treated with bark and wine, the tongue became of a fiery red colour, or dry and furrowed, as in the typhus fever.

_Sweats_ were more common in the remissions of this fever, than they were in the year 1793, but they seldom terminated the disease. During the course of the sweats, I observed a deadly coldness over the whole body to continue in several instances, but without any danger or inconvenience to the patient. In two of the worst cases I attended, there were remissions, but no sweats until the day on which the fever terminated. In several of my patients, the fever wore away without the least moisture on the skin. The _milk_, in one case, was of a greenish colour, such as sometimes appears in the serum of the blood. In another female patient who gave suck, there was no diminution in the quantity of her milk during the whole time of her fever, nor did her infant suffer the least injury from sucking her breasts.

I observed tears to flow from the eye of a young woman in this fever, at a time when her mind seemed free from distress of every kind.

V. I proceed next to mention the symptoms of this fever in the nervous system.

Delirium was less common than last year. I was much struck in observing John Madge, who had retained his reason while he was so ill as to require three bleedings a day, to become delirious as soon as he began to recover, at which time his pulse rose from between 60 and 70, to 96 strokes in a minute. I saw one case of extreme danger, in which a hysterical laughing and weeping alternately attended.

I have before mentioned the frequency of mania as a symptom of this disease. An obstinate wakefulness attended the convalescence from this fever in Peter Brown, John Madge, and Mr. Cole.

Fainting was more common in this fever than in the fever of 1793. It ushered in the disease in one of my patients, and it occurred in several instances after bleeding, where the quantity of blood drawn was very moderate.

Several people complained of giddiness in the first attack of the fever, before they were confined to their beds. Sighing was less common, but a hiccup was more so, than in the year before.

John Madge had an immobility in his limbs bordering upon palsy. A weakness in the wrists in one case succeeded a violent attack of the fever.

Peter Brown complained of a most acute pain in the muscles of one of his legs. It afterwards became so much inflamed as to require external applications to prevent the inflammation terminating in an abscess. Mrs. Mitchell complained of severe cramps in her legs.

The sensations of pain in this fever were often expressed in extravagant language. The pain in the head, in a particular manner, was compared to repeated strokes of a hammer upon the brain, and in two cases, in which this pain was accompanied by great heat, it was compared to the boiling of a pot.

The more the pains were confined to the bones and back, the less danger was to be apprehended from the disease. I saw no case of death from the yellow fever in 1793, where the patient complained much of pain in the back. It is easy to conceive how this external determination of morbid action should preserve more vital parts. The bilious fever of 1780 was a harmless disease, only because it spent its whole force chiefly upon the limbs. This was so generally the case, that it acquired, from the pains in the bones which accompanied it, the name of the "break bone fever." Hippocrates has remarked that pains which descend, in a fever, are more favourable than those which ascend[110]. This is probably true, but I did not observe any such peculiarity in the translation of pain in this fever. The following fact from Dr. Grainger will add weight to the above observations. He observed the pains in a malignant fever which were diffused through the whole head, though excruciating, were much less dangerous than when they were confined to the temples or forehead[111].

[110] Epidemics, book ii. sect. 2.

[111] Historia Febris Anomalæ Batavæ Annorum 1746, 1747, 1748, cap. i.

I saw two cases in which a locked jaw attended. In one of them it occurred only during one paroxysm of the fever. In both it yielded in half an hour to blood-letting. I met with one case in which there was universal tetanus. I should have suspected this to have been the primary disease, had not two persons been infected in the same house with the yellow fever.

The countenance sometimes put on a ghastly appearance in the height of a paroxysm of the fever. The face of a lady, admired when in health for uncommon beauty, was so much distorted by the commotions of her whole system, in a fit of the fever, as to be viewed with horror by all her friends.

VI. The senses and appetites were affected in this fever in the following manner.

A total blindness occurred in two persons during the exacerbation of the fever, and ceased during its remissions. A great intolerance of light occurred in several cases. It was most observable in John Madge during his convalescence.

A soreness in the sense of touch was so exquisite in Mrs. Kapper, about the crisis of her fever, that the pressure of a piece of fine muslin upon her skin gave her pain.

Peter Brown, with great heat in his skin, and a quick pulse, had no thirst, but a most intense degree of thirst was very common in this fever. It produced the same extravagance of expression that I formerly said was produced by pain. One of my patients, Mr. Cole, said he "could drink up the ocean." I did not observe thirst to be connected with any peculiar state of the pulse.

George Eyre and Henry Clymer had an unusual degree of appetite, just before the usual time of the return of a paroxysm of fever.

A young man complained to me of being afflicted with nocturnal emissions of seed during his convalescence. This symptom is not a new one in malignant fevers. Hippocrates takes notice of it[112]. I met with one instance of it among the sporadic cases of yellow fever which occurred in 1795. It sometimes occurs, according to Lomius, in the commotions of the whole system which take place in epilepsy.

[112] Epidemics, book IV.

VII. The disease made an impression upon the lymphatic system. Four of my patients had glandular swellings: two of them were in the groin; a third was in the parotid; and the fourth was in the maxillary glands. Two of these swellings suppurated.

VIII. The yellowness of the skin, which sometimes attends this fever, was more universal, but more faint than in the year 1793. It was, in many cases, composed of such a mixture of colours, as to resemble polished mahogany. But, in a few cases, the yellowness was of a deep orange colour. The former went off with the fever, but the latter often continued for several weeks after the patients recovered. In some instances a red colour predominated to such a degree in the face, as to produce an appearance of inflammation.

In Mrs. Vogles a yellowness appeared in her eyes during the paroxysm of her fever, and went off in its remissions.

In James Lefferty the yellowness affected every part of his body, except his hands, which were as pale as in a common fever.

Peter Brown tinged his sheets of a yellow colour, by night sweats, many weeks after his recovery.

There was an exudation from the soles of the feet of Richard Wells's maid, which tinged a towel of a yellow colour.

In my Account of the Yellow Fever of 1793, I ascribed the yellow colour of the skin wholly to a mixture of bile with the blood. I believe that this is the cause of it, in those cases where the colour is deep, and endures for several weeks beyond the crisis of the fever; but where it is transitory, and, above all, where it is local, or appears only for a few hours, during the paroxysm of the fever, it appears probable that it is connected with the mode of aggregation of the blood, and that it is produced wholly by some peculiar action in the blood-vessels. A similar colour takes place from the bite of certain animals, and from contusions of the skin, in neither of which cases has a suspicion been entertained of an absorption or mixture of bile with the blood.

A troublesome itching, with an eruption of red blotches on the skin, attended on the first day of the attack of the fever, in Mrs. Gardiner.

A roughness of the skin, and a disposition in it to peel off, appeared about the crisis of the fever, in Miss Sally Eyre.

That species of eruption, which I have elsewhere compared to moscheto bites, appeared in Mrs. Sellers.

John Ray, a day labourer, to whom I was called in the last stage of the fever, had petechiæ on his breast the day before he died.

That burning heat on the skin, called by the ancients "calor mordens," and from which this fever, in some countries, has derived the name of _causus_, was more common this year than last. It was sometimes local, and sometimes general. I perceived it in an exquisite degree in the cheeks only of Miss Sally Eyre, and over the whole body of John Ray. It had no connection with the rapidity or force of the circulation of the blood in the latter instance, for it was most intense at a time when he had no pulse.

It is remarkable that the heat of the skin has no connection with the state of the pulse. This fact did not escape Dr. Chisholm. He says he found the skin to be warm while the pulse was at 52, and that it was sometimes disagreeably cold when the pulse was as quick as in ordinary fever[113].

[113] Page 117.

IX. I have in another place rejected putrefaction from the blood as the cause or effect of this fever. I shall mention the changes which were induced in its appearances when I come to treat of the method of cure.

Having described the symptoms of this fever as they appeared in different parts of the body, I shall now add a few observations upon its type or general character.

I shall begin this part of the history of the fever by remarking, that we had but one reigning disease in town during the autumn and winter; that this was a bilious remitting, or intermitting, and sometimes a yellow fever; and that all the fevers from other remote causes than putrid exhalation, partook more or less of the symptoms of the prevailing epidemic. As well might we distinguish the rain which falls in gentle showers in Great-Britain, from that which is poured in torrents from the clouds in the West-Indies, by different names and qualities, as impose specific names and characters upon the different states of bilious fever.

The forms in which this fever appeared were as follow.

1. A tertian fever. Several persons died of the third fit of tertians, who were so well as to go abroad on the intermediate day of the fever. It is no new thing for malignant fevers to put on the form of a tertian. Hippocrates long ago remarked, that intermittents sometimes degenerate into malignant acute diseases; and hence he advises physicians to be on their guard upon the 5th, 7th, 9th, and even on the 14th day of such fevers[114].

[114] De Morb. Popular. lib. VII.

2. It appeared most frequently in the form of a remittent. The exacerbations occurred most commonly in the evening. In some there were exacerbations in the morning as well as in the evening. But I met with several patients who appeared to be better and worse half a dozen times in a day. In each of these cases, there were evident remissions and exacerbations of the fever.

It assumed, in several instances, the symptoms of a colic and cholera morbus. In one case the fever, after the colic was cured, ended in a regular intermittent. In another, the colic was accompanied by a hæmorrhage from the nose. I distinguished this bilious colic from that which is excited by lighter causes, by its always coming on with more or less of a chilliness[115]. The symptoms of colic and cholera morbus occurred most frequently in June and July.

[115] See Sydenham, vol. I. p. 212.

4. It appeared in the form of a dysentery in a boy of William Corfield, and in a man whom my pupil, Mr. Alexander, visited in the neighbourhood of Harrowgate.

5. It appeared, in one case, in the form of an apoplexy.

6. It disguised itself in the form of madness.

7. During the month of November, and in all the winter months, it was accompanied with pains in the sides and breast, constituting what nosologists call the "pleuritis biliosa."

8. The puerperile fever was accompanied, during the summer and autumn, with more violent symptoms than usual. Dr. Physick informed me, that two women, to whom he was called soon after their delivery, died of uterine hæmorrhages; and that he had with difficulty recovered two other lying-in women, who were afflicted with that symptom of a malignant diathesis in the blood-vessels.

9. Even dropsies partook more or less of the inflammatory and bilious character of this fever.

10. It blended itself with the scarlatina. The blood, in this disease, and in the puerperile fever, had exactly the same appearance that it had in the yellow fever. A yellowness in the eyes accompanied the latter disease in one case that came under my notice.

A slight shivering ushered in the fever in several instances. But the worst cases I saw came on without a chilly fit, or the least sense of coldness in any part of the body.

Such was the predominance of the intermitting, remitting, and bilious fever, that the measles, the small-pox, and even the gout itself, partook more or less of its character. There were several instances in which the measles, and one in which the gout appeared with quotidian exacerbations; and two in which madness appeared regularly in the form of a tertian.

I mentioned formerly that this fever sometimes went off with a sweat, when it appeared in a tertian form. This was always the case with the second grade of the fever, but never with the first degree of it, before the third or fourth paroxysm; nor did a sweat occur on the fifth or seventh day, except after the use of depleting remedies. This peculiarity in the fever of this year was so fixed, that it gave occasion for my comparing it, in my intercourse with my patients, to a lion on the first seven days, and to a lamb during the remaining part of its duration.

The fever differed from the fever of the preceding year in an important particular. I saw or heard of no case which terminated in death on the first or third day. In every case, the fever came on fraught with paroxysms. The moderate degrees of it were of so chronic a nature as to continue for several weeks, when left to themselves. I wish this peculiarity in the epidemic which I am now describing to be remembered; for it will serve hereafter to explain the reason why a treatment apparently different should be alike successful, in different seasons and in different countries.

The crisis of the fever occurred on uneven days more frequently than in the fever of the year 1793.

I remarked formerly[116] that remissions were more common in the yellow fever than in the common bilious fever. The same observation applies to critical days. They were observable in almost every case in which the disease was not strangled in its birth. Dr. Chisholm describes the same peculiarity in the Beullam fever. "I have not met with any disease (says the doctor) in which the periods were more accurately ascertained[117]."

[116] Account of the Yellow Fever of 1793.

[117] Page 141.

In addition to the instances formerly enumerated[118], of the predominance of powerful epidemics over other diseases, I shall add two more, which I have lately met with in the course of my reading.

[118] Account of the Yellow Fever in 1793.

Dr. Chisholm, in describing the pestilential fever introduced into the West-Indies from Beullam, has the following remarks. "Most other diseases degenerated into, or partook very much of this. Dysenteries suddenly stopped, and were immediately succeeded by the symptoms of the pestilential fever. Catarrhal complaints, simple at first, soon changed their nature; convalescents from other diseases were very subject to this, but it generally proved mild. Those labouring at the same time under chronic complaints, particularly rheumatism and hepatitis, were very subject to it. The puerperile fever became malignant, and of course fatal; and even pregnant negro women, who otherwise might have had it in the usual mild degree peculiar to that description of people, were reduced to a very dangerous situation by it. In short, every disease in which the patient was liable to infection, sooner or later assumed the appearance, and acquired the danger of the pestilential fever[119]."

[119] Page 129, 130.

Dr. Desportes ascribes the same universal empire to the yellow fever which prevailed in St. Domingo, in the summer of 1733. "The fever of Siam (says the doctor) conveyed an infinite number of men to the grave, in a short time; but I saw but one woman who was attacked by it." "The violence of this disease was such, that it subjected all other diseases, and reigned alone. This is the character of all contagious and pestilential diseases. Sydenham, and before him Diemerbroek, have remarked this of the plague[120]."

[120] Page 40, 41. See also p. 111, 230, 231. vol. I.

In Baltimore, the small-pox in the natural way was attended with unusual malignity and mortality, occasioned by its being combined with the reigning yellow fever.

It has been urged as an objection to the influence of powerful epidemics chasing away, or blending with fevers of inferior force, that the measles sometimes supplant the small-pox, and mild intermittents take the place of fevers of great malignity. This fact did not escape the microscopic eye of Dr. Sydenham, nor is it difficult to explain the cause of it. It is well known that epidemics, like simple fevers, are most violent at their first appearance, and that they gradually lose their force as they disappear; now it is in their evanescent and feeble state, that they are jostled out of their order of danger or force, and yield to the youthful strength of epidemics, more feeble under equal circumstances of age than themselves. It would seem, from this fact, that an inflammatory constitution of the air, and powerful epidemics, both in their aggregate and individual forms, possessed a common character. They all invade with the fury of a savage, and retire with the gentleness of a civilized foe.

It is agreeable to discover from these facts and observations, that epidemic diseases, however irregular they appear at first sight, are all subject to certain laws, and partake of the order and harmony of the universe.

The action of the miasmata upon the body, when, from the absence of an exciting cause, they did not produce fever, was the same as I have elsewhere described. The sensations which I experienced, in entering a small room where a person was confined with this fever, were so exactly the same with those I felt the year before, that I think I could have distinguished the presence of the disease without the assistance of my eyes, or without asking a single question. After sitting a few minutes in a sick room, I became languid and fainty. Weakness and chilliness followed every visit I paid to a gentleman at Mr. Oellers's hotel, which continued for half an hour. A burning in my stomach, great heaviness, and a slight inflammation in my eyes, with a constant discharge of a watery humour from them for two days, succeeded the first visit I paid to Mrs. Sellers. These symptoms came on in less than ten minutes after I left her room. They were probably excited thus early, and in the degree which I have mentioned, by my having received her breath in my face by inspecting her tonsils, which were ulcerated on the first attack of the fever. I formerly supposed these changes in my body were proofs of the contagious nature of the yellow fever, but I shall hereafter explain them upon other principles.

I recollect having more than once perceived a smell which had been familiar to me during the prevalence of the yellow fever in 1793. It resembled the smell of liver of sulphur. I suspected for a while that it arose from the exhalations of the gutters of the city. But an accident taught me that it was produced by the perspiration of my body. Upon rubbing my hands, this odour was increased so as to become not only more perceptible to myself, but in the most sensible degree to my pupil, Mr. Otto. From this fact, I was convinced that I was strongly impregnated with miasmata, and I was led by it to live chiefly upon vegetables, to drink no wine, and to avoid, with double care, all the usual exciting causes of fever.

There was another mark by which I distinguished the presence of the seeds of this fever in my system, and that was, wine imparted a burning sensation to my tongue and throat, such as is felt after it has been taken in excess, or in the beginning of a fever. Several persons, who were exposed to the miasmata, informed me that wine, even in the smallest quantity, affected them exactly in the same manner.

I attended four persons in this fever who had had it the year before.

It remains now that I mention the origin of this fever. This was very evident. It was produced by the exhalations from the gutters, and the stagnating ponds of water in the neighbourhood of the city. Where there was most exhalation, there were most persons affected by the fever. Hence the poor people, who generally live in the neighbourhood of the ponds in the suburbs, were the greatest sufferers by it. Four persons had the fever in Spruce, between Fourth and Fifth-streets, in which part of the city the smell from the gutters was extremely offensive every evening. In Water-street, between Market and Walnut-streets, many persons had the fever: now the filth of that confined part of the city is well known to every citizen.

I have before remarked, that one reason why most of our physicians refused to admit the presence of the yellow fever in the city, was because they could not fix upon a vestige of its being imported. On the 25th of August, the brig Commerce arrived in the river, from St. Mark, commanded by Captain Shirtliff. After lying five days at the fort, she came up to the city. A boy, who had been shut out from his lodgings, went, in a state of intoxication, and slept on her deck, exposed to the night air, in consequence of which the fever was excited in him. This event gave occasion, for a few days, to a report that the disease was imported, and several of the physicians, who had neglected to attend to all the circumstances that have been stated, admitted the yellow fever to be in town. An investigation of this supposed origin of the disease soon discovered that it had no foundation. At the time of the arrival of this ship, I had attended nearly thirty persons with the fever, and upwards of a hundred had had it, under the care of other physicians.

The generation of the yellow fever in our city was rendered more certain by the prevalence of bilious diseases in every part of the United States, and, in several of them, in the grade of yellow fever. It was common in Charleston, in South-Carolina, where it carried off many people, and where no suspicion was entertained of its being of West-India origin. It prevailed with great mortality at that part of the city of Baltimore, which is known by the name of Fell's Point, where, Dr. Drysdale assures me, it was evidently generated. A few sporadic cases of it occurred in New-York, which were produced by the morbid exhalation from the docks of that city. Sporadic cases of it occurred likewise in most of the states, in which the proofs of its being generated were obvious to common observation; and where the symptoms of depressed pulse, yellowness of the skin, and black discharges from the bowels and stomach (symptoms which mark the highest grade of bilious remitting fever) did not occur, the fevers in all their form of tertian, quotidian, colic, and dysentery, were uncommonly obstinate or fatal in every state in the union. In New-Haven only, where the yellow fever was epidemic, it was said to have been imported from Martinique, but this opinion was proved to be erroneous by unanswerable documents, published afterwards in the Medical Repository, by Dr. Elisha Smith, of New-York.

The year 1795 furnished several melancholy proofs of the American origin of the yellow fever. All the physicians and citizens of New-York and Norfolk agree in its having been generated in their respective cities that year. It prevailed with great mortality at the same time in the neighbourhood of the lakes, and on the waters of the Genesee river, in the state of New-York. From its situation it obtained the name of the lake and Genesee fever. It was so general, in some parts of that new country, as to affect horses.

Thus have I endeavoured to fix the predisposing and remote causes of the yellow fever in our country. The remote cause is sometimes so powerful as to become an exciting cause of the disease, but in general both the predisposing and remote causes are harmless in the system, until they are roused into action by some exciting cause.

I shall conclude this account of the symptoms and origin of the yellow fever by relating two facts, which serious and contemplating minds will apply to a more interesting subject.

1. Notwithstanding the numerous proofs of the prevalence of the yellow fever in Philadelphia in the year 1794, which have been mentioned, there are many thousands of our citizens, and a majority of our physicians, who do not believe that a case of it existed at that time in the city; nor is a single record of it to be met with in any of the newspapers, or other public documents of that year. Let us learn from this fact, that the denial of events, or a general silence upon the subject of them, is no refutation of their truth, where they oppose the pride or interests of the learned, or the great.

2. Notwithstanding the general denial of the existence of the yellow fever in Philadelphia, and the silence observed by our newspapers relative to it in 1794, there was scarcely a citizen or physician who, three years afterwards, did not admit of its having prevailed in that year. We learn from this fact another important truth, that departed vice and error have no friends nor advocates.

OF THE METHOD OF CURE.

The remedies employed for the cure of this fever were the same that I employed the year before. I shall only relate such effects of them as tend more fully to establish the practice adopted in the year 1793, and such as escaped my notice in my former remarks upon those remedies. My method of cure consisted,

I. In the abstraction of the stimulus of blood and heat from the whole body, and of bile and other acrid humours from the bowels, by means of the following remedies:

1. Bleeding.

2. Purging.

3. Cool air and cold drinks.

4. Cold water applied to the external parts of the body, and to the bowels by means of glysters.

II. In creating a diversion of congestion, inflammation, and serous effusion, from the brain and viscera to the mouth, by means of a salivation, and to the external parts of the body, by means of blisters.

III. In restoring the strength of the system, by tonic remedies.

I proceed to make a few remarks upon the remedies set down under each of the above heads.

I. I have taken notice that this fever differed from the fever of 1793, in coming forward in July and August with a number of paroxysms, which refused to yield to purging alone. I therefore began the cure of every case I was called to by _bleeding_.

I shall mention the effects of this remedy, and the circumstances, manner, and degrees in which I used it occasionally, in this fever, in my Defence of Blood-letting. Under the present head I shall only furnish the reader with a table of the quantity of blood drawn from a number of my patients in the course of the disease. From several of them the quantity set down was taken in three, four, and five days. I shall afterwards describe the appearances of the blood.

+-----------+------------------+-----------+------------+ | Month. | Patients. | Quantity. | Number of | | | | ounces. | times bled.| +-----------+------------------+-----------+------------+ | August. | Peter Denham | 50 | 5 | | | Mrs. Bruce | 70 | 7 | | | Andrew Gribble, | | | | | aged 15 years. | 50 | 5 | | | John Madge | 150 | 12 | | | Peter Brown | 80 | 8 | | September.| Mrs. Gardiner | 80 | 7 | | | Miss Sally Eyre | 80 | 9 | | | Mrs. Gass | 50 | 3 | | | Richard Wells's | | | | | maid | 100 | 10 | | | Mr. Norval | 100 | 9 | | | Mr. Harrison | 90 | 9 | | | Henry Clymer | 80 | 8 | | October. | Mrs. Mitchell | 120 | 13 | | | Mrs. Lenox | 80 | 7 | | | Mrs. Kapper | 140 | 11 | | | Rev. Dr. Magaw's | | | | | maid | 100 | 10 | | | Miss Hood | 100 | 10 | | | Mrs. Vogles | 70 | 5 | | 1795 | Guy Stone | 100 | 9 | | January. | Benj. Hancock | 100 | 10 | | | Mr. Benton | 130 | 13 | | | Mrs. Fries | 150 | 15 | | | Mrs. Garrigues | 80 | 7 | +-----------+------------------+-----------+------------+

Three of the women, whose names I have mentioned, were in the advanced stage of pregnancy, viz. Mrs. Gardiner, Mrs. Gass, and Mrs. Garrigues. They have all since borne healthy children. I have omitted the names of above one hundred persons who had the fever, from whom I drew thirty or forty ounces of blood, by two or three bleedings. I did not cure a single person without at least one bleeding.

It is only by contemplating the extent in which it is necessary to use this remedy, in order to overcome a yellow fever, that we can acquire just ideas of its force. Hitherto this force has been estimated by no other measure than the grave, and this, we know, puts the strength of all diseases upon a level.

The blood drawn in this fever exhibited the following appearances;

1. It was dissolved in a few instances.

2. The crassamentum of the blood was so partially dissolved in the serum, as to produce an appearance in the serum resembling the washings of flesh in water.

3. The serum was so lightly tinged of a _red_ colour as to be perfectly transparent.

4. The serum was, in many cases, of a deep yellow colour.

5. There was, in every case in which the blood was not dissolved, or in which the second appearance that has been mentioned did not take place, a beautiful scarlet-coloured sediment in the bottom of the bowl, forming lines, or a large circle. It seemed to be a tendency of the blood to dissolution. This state of the blood occurred in almost all the diseases of the last two years, and in some in which there was not the least suspicion of the miasmata of the yellow fever.

6. The crassamentum generally floated in the serum, but it sometimes sunk to the bottom of the bowl. In the latter case the serum had a muddy appearance.

7. I saw but one case in which there was not a separation of the crassamentum and serum of the blood. Its colour in this case was of a deep scarlet. In the year 1793 this appearance was very common.

8. I saw one case in which the blood drawn, amounting to 14 ounces, separated partially, and was of a deep _black_ colour. This blood was taken from Mr. Norval, a citizen of North-Carolina.

9. There was, in several instances, a transparent jelly-like pellicle which covered the crassamentum of the blood, and which was easily separated from it without altering its texture. It appeared to have no connection with the blood.

10. The blood, towards the crisis of the fever in many people, exhibited the usual forms of inflammatory crust. It was cupped in many instances.

11. After the loss of 70 or 80 ounces of blood there was an evident disproportion of the quantity of crassamentum to the serum. It was sometimes less, by one half, than in the first bleedings.

Under this head it will be proper to mention that the blood, when it happened to flow along the external part of the arm in falling into the bowl, was so warm as to excite an unpleasant sensation of heat in several patients.

To the appearances exhibited by the blood to the eye, I shall add a fact communicated to me by a German bleeder, who followed his business in the city during the prevalence of the fever in 1793. He informed me that he could distinguish a yellow fever from all other states of fever, by a peculiar smell which the blood emitted while it was flowing from a vein. From the certainty of his decision in one case which came under my notice, before a suspicion had taken place of the fever being in the city, I am disposed to believe that there is a foundation for his remark.

II. I have but little to add to the remarks I made upon the use of _purging_ in the year 1793. I gave jalap, calomel, and gamboge until I obtained large and dark-coloured stools; after which I kept the bowels gently open every day with castor oil, cremor tartar, or glauber's salts. I gave calomel in much larger quantities than I did the year before. John Madge took nearly 150 grains of it in six days. I should have thought this a large quantity, had I not since read that Dr. Chisholm gave 400 grains of it to one patient in the course of his fever, and 50 grains to another at a single dose, three times a day. I found strong mercurial purges to be extremely useful in the winter months, when the fever put on symptoms of pleurisy. I am not singular in ascribing much to the efficacy of purges in the bilious pleurisy. Dr. Desportes tells us that he found the pleurisy of St. Domingo, which was of the bilious kind, to end happily in proportion as the bowels were kept constantly open[121]. Nor am I singular in keeping my eye upon the original type of a disease, which only changes its symptoms with the weather or the season, and in treating it with the same remedies. Dr. Sydenham bled as freely in the diarrh[oe]a of 1668 as he had done in the inflammatory fever of the preceding year[122]. How long the pleurisies of winter, in the city of Philadelphia, may continue to retain the bilious symptoms of autumn, which they have assumed for three years past, I know not; but the late Dr. Faysseaux, of South-Carolina, informed me, that for many years he had not seen a pleurisy in Charleston with the common inflammatory symptoms which characterised that disease when he was a student of medicine. They all now put on bilious symptoms, and require strong purges to cure them. The pleurisies which the late Dr. Chalmers supposes he cured by purging were probably nothing but bilious fevers, in which the cool weather had excited some pleuritic symptoms.

[121] Page 140.

[122] Wallis's edition, p. 211. vol. i.

I have nothing to add to the remarks I have elsewhere published upon the efficacy of _cool air_ and _cold drinks_ in this fever. They were both equally pleasant and useful, and contributed, with cleanliness, very much to the success of my practice.

4. _Cold water_, applied to the external parts of the body, and injected into the bowels by way of glyster, did great service in many cases. John Madge found great relief from cloths dipped in cold water, and applied to the lower part of his belly. They eased a pain in his bowels, and procured a discharge of urine. A throbbing and most distressing pain in the head was relieved by the same remedy, in Mrs. Vogles and Mrs. Lenox. The cloths were applied for three successive days and nights to Mrs. Lenox's head, during an inflammation of her brain, which succeeded her fever, and were changed, during the greater part of the time, every ten or fifteen minutes. In 1795, I increased the coldness of pump water, when used in this way, by dissolving ice in it, and in some cases I applied powdered ice in a bladder to the head, with great advantage.

The following facts will show the good effects of cold water in this, as well as other fevers of too much action.

In the afternoon of one of those days in which my system was impregnated with the miasmata of the yellow fever, I felt so much indisposed that I deliberated whether I should go to bed or visit a patient about a mile in the country. The afternoon was cool and rainy. I recollected, at this time, a case related by Dr. Daignan, a French physician, of a man who was cured of the plague, by being forced to lie all night in an open field, in a shower of rain. I got into my chair, and exposed myself to the rain. It was extremely grateful to my feelings. In two hours I returned, when, to my great satisfaction, I found all my feverish symptoms had left me, nor had I the least return of them afterwards.

Dr. Caldwell, who acted as a surgeon of a regiment, in the expedition against the insurgents in the western counties of Pennsylvania, furnished me, in a letter dated from Bedford, October 20th, 1794, with an account of his having been cured of a fever, by a more copious use of the same remedy. "I was (says the doctor), to use a vulgar expression, _wet to the skin_, and had no opportunity of shifting my clothes for several hours. In consequence of this thorough bathing, and my subsequent exposure to a cool air, I was relieved from every symptom of indisposition in a few hours, and have enjoyed more than my usual stock of health ever since."

The efficacy of cold water, in preventing and curing inflammation, may be conceived from its effects when used with mud or clay, for obviating the pain and inflammation which arise from the sting of venomous insects. The same remedy, applied for half an hour, has lately, it is said, been equally effectual in preventing the deleterious effects of the bite of a rattle-snake.

II. The good effects I had observed from a _salivation_ in the yellow fever of 1793, induced me to excite it as early as possible, in all those cases which did not yield immediately to bleeding and purging. I was delighted with its effects in every case in which it took place. These effects were as follow:

1. It immediately attracted and concentrated in the mouth all the scattered pains of every part of the body.

2. It checked a nausea and vomiting.

3. It gradually, when it was copious, reduced the pulse, and thereby prevented the necessity of further bleeding or purging.

I wish it were possible to render the use of this remedy universal in the treatment of malignant fevers. Dr. Chisholm, in his account of the Beullam fever, has done much to establish its safety and efficacy. It is a rare occurrence for a patient that has been sufficiently bled and purged, to die after a salivation takes place. The artificial disease excited by the mercury suspends or destroys disease in every part of the body. The occasional inconveniences which attend it are not to be named with its certain and universal advantages. During the whole of the season in which the yellow fever prevailed, I saw but two instances in which it probably loosened or destroyed the teeth. I am not certain that the mercury was the cause of the injury or loss of those teeth; for who has not seen malignant fevers terminate in ulcers, which have ended in the erosions of bony parts of the body?

It has been justly remarked, that there can be but one action at a time in the blood-vessels. This was frequently illustrated by the manner in which mercury acted upon the system in this fever. It seldom salivated until the fever intermitted or declined. I saw several cases in which the salivation came on during the intermission, and went off during its exacerbation; and many, in which there was no salivation until the morbid action had ceased altogether in the blood-vessels, by the solution of the fever. It is because the action of the vessels, in epilepsy and pulmonary consumption, surpasses the stimulus of the mercury, that it is so difficult to excite a salivation in both those diseases.

Let not the advocates for the healing powers of nature complain of a salivation as an unnatural remedy in fevers. Dr. Sydenham speaks in high terms of it, in the fever of 1670, 1671, and 1672, in which cases it occurred spontaneously, and says that it cured it when it was so malignant as to be accompanied by purple spots on the body[123].

[123] Vol. ii. p. 212.

Blisters, when applied at a _proper_ time, did great service in this fever. This time was, when the fever was so much weakened by evacuations, that the artificial pain excited by the stimulus of the blisters destroyed, and, like a conductor, conveyed off all the natural pain of the body. It is from ignorance, or inattention to the proper stage of fevers in which blisters have been applied, that there have been so many disputes among physicians respecting their efficacy. When applied in a state of great arterial action, they do harm; when applied after that action has nearly ceased, they do little or no service. I have called the period in which blisters are useful the _blistering point_. In bilious fevers this point is generally circumscribed within eight and forty hours.

The effects of blisters were as follow:

1. They concentrated, like a salivation, all the scattered pains of the body, and thereby,

2. Reduced the pulse in force and frequency.

3. They instantly checked a sickness at the stomach and vomiting.

4. They often induced a gentle moisture upon the skin.

I found it of little consequence to what part of the body the blisters were applied; for I observed a pain in the head, and even delirium, to be as speedily and certainly cured by blisters upon the wrists, as they were by a large blister to the neck.

III. After the reduction of the morbid action of the blood-vessels, by means of the remedies which have been mentioned, I seldom made use of any other tonic than a nourishing and gently stimulating diet. This consisted of summer fruits, bread and milk, chicken broth, the white meats, eggs, oysters, and malt liquors, more especially porter. I made many attempts to cure this fever when it appeared in the form of a simple intermittent, without malignant symptoms, by means of _bark_, but always, except in two instances, without success; and in them it did not take effect until after bleeding. In several cases it evidently did harm. I should have suspected my judgment in these observations respecting this medicine, had I not been assured by Dr. Griffitts, Dr. Physick, and Dr. Woodhouse, that it was equally ineffectual in their practice, in nearly all the cases in which they gave it, and even where blood-letting had been premised. Dr. Woodhouse saw a case in which near a pound of bark had been taken without effect; and another in which a fatal dropsy succeeded its use. Dr. Griffitts excepted, from his testimony against the bark, the cases of seven persons from the country, who brought the seeds of the intermitting fever with them to the city. In them the bark succeeded without previous bleeding. The facility with which these seven cases of intermitting fever were cured by the bark, clearly proves that fevers of the same season differ very much, according to the nature of the exhalation which excites them. The intermittents in these strangers were excited by miasmata of less force than that which was generated in our city, in which, from the greater heat of the atmosphere, and the more heterogeneous nature of the putrid matters which stagnate in our ponds and gutters, the exhalation probably possesses a more active and stimulating quality. Thus the mild remittents in June, and in the beginning of July, which were produced by the usual filth of the streets of Philadelphia, in the year 1793, differed very much from the malignant remitting yellow fever which was produced by the stench of the putrid coffee a few weeks afterwards.

Sir John Pringle long ago taught the inefficacy of bark in certain bilious fevers. But Dr. Chisholm has done great service to medicine by recording its ill effects in the Beullam fever. "Head-ach (says the doctor), a heavy dull eye, with a considerable protrusion from its orbits, low spirits, thirst, and a total want of appetite, were the general consequences of the treatment with bark without the previous antiphlogistic."

I have mentioned a case of internal dropsy of the brain having been produced by the improper use of the bark, in a son of Mr. Coates. I have no doubt but this disease, as also palsy and consumption, obstructions of the liver and bowels, and dropsies of the belly and limbs, are often induced by the use of the bark, during an inflammatory state of the blood-vessels. It is to be lamented that the association of certain diseases and remedies, in the minds of physicians, becomes so fixed, as to refuse to yield to the influence of reason. Thus pain and opium, dropsy and foxglove, low spirits and assaf[oe]tida, and, above all, an intermitting fever and bark, are all connected together, in common practice, as mechanically as the candle and the snuffers are in the mind of an old and steady house servant. To abolish the mischief of these mechanical associations in medicine, it will be necessary for physicians to prescribe only for the different states of the system.

Finding the bark to be so universally ineffectual or hurtful, I substituted Columbo root, the Carribean bark, and several other bitters, in its place, but without success. They did less harm than the jesuit's bark, but they did not check the return of a single paroxysm of fever.

I know that bark was given in this fever in some instances in which the patients recovered; but they were subject, during the winter, and in the following spring, to frequent relapses, and, in some instances, to affections of the brain and lungs. In the highest grade of the fever it certainly accelerated a supposed putrefaction of the blood, and precipitated death. The practice of physicians who create this gangrenous state of fever by means of the bark, resembles the conduct of a horse, who attempts by pawing to remove his shadow in a stream of water, and thereby renders it so turbid that he is unable to drink it.

Should the immediate success of tonic and depleting remedies in destroying the fever be equal, the effects of the former upon the constitution cannot fail of being less safe than the latter remedies. They cure by overstraining the powers of life. There is the same difference, therefore, between the two modes of practice, that there is between gently lifting the latch of a door, and breaking it open in order to go into a house.

_Wine_ was hurtful in every case of yellow fever in which it was given, while there were any remains of inflammatory action in the system. I recollect that a few spoonsful of it, which Mr. Harrison of Virginia took in the depressed state of his pulse, excited a sensation in his stomach which he compared to a fire. Even wine-whey, in the excitable state of the system induced by this fever, was sometimes hurtful. In a patient of Dr. Physick, who was on the recovery, it produced a relapse that had nearly proved fatal, in the year 1795. Dr. Desperrieres ascribes the death of a patient to a small quantity of wine given to him by a black nurse[124]. These facts are important, inasmuch as wine is a medicine which patients are most apt to use in all cases, without the advice of a physician.

[124] Vol. ii. p. 108.

I observed _opium_ to be less hurtful in this fever than it was in the fever of 1793. I administered a few drops of laudanum, in one case, in the form of a glyster, in a violent pain of the bowels, with evident advantage, before the inflammatory action of the blood-vessels was subdued. In this way I have often obtained the composing effects of laudanum where it has been rejected by the stomach. But I gave it sparingly, and in small doses only, in the early stage of the fever. John Madge, whose pains in his bowels were often as exquisite as they are in the most acute colic, did not take a single drop of it. I used no anodyne in his case but bleeding, and applications of cold water to the inside and outside of his bowels. After the fever had passed the seventh day, and had been so far subdued by copious evacuations as to put on the form of a common inflammatory intermittent, I gave laudanum during the intermissions of the fever with great advantage. In some cases it suddenly checked the paroxysms of the fever, while in many more it only moderated them, but in such a manner that they wore themselves away in eight or ten days. One of my female patients, who had taken bitters of every kind without effect to cure a tertian, which succeeded a yellow fever, took a large dose of laudanum, in the interval of her paroxysms, to cure a tooth-ach. To her great surprise it removed her tertian. The effects of laudanum in this fever were very different from those of bark. Where it did no service it did not, like the bark, do any harm.

Perhaps this difference in the operation of those two medicines depended upon the bark acting with an astringent, as well as stimulating power, chiefly upon the blood-vessels, while the action of the opium was more simply stimulating, and diffused at the same time over all the systems of the body.

I shall say in another place that I sometimes directed a few drops of laudanum to be given in that state of extreme debility which succeeds a paroxysm of fever, with evident advantage.

_Nitre_, so useful in common inflammatory fevers, was in most cases so offensive to the stomach in this fever, that I was seldom able to give it. Where the stomach retained it I did not perceive it to do any service.

_Antimonials_ were as ineffectual as nitre in abating the action of the sanguiferous system, and in producing a sweat. I should as soon expect to compose a storm by music, as to cure a yellow fever by such feeble remedies.

Thus have I finished the history of the symptoms, origin, and cure of the yellow fever as it appeared in Philadelphia in 1794, and in the winter of 1795. The efficacy of the remedies which have been mentioned was established by almost universal success. Out of upwards of 200 patients to whom I was called on the first stage of the fever, between the 12th of June, 1794, and the 1st of April, 1795, I lost but four persons, in whom the unequivocal symptoms had occurred, which characterize the first grade of the disease.

It will be useful, I hope, to relate the cases of the patients whom I lost, and to mention the causes of their deaths. The first of them was Mrs. Gavin. She objected to a fifth bleeding in the beginning of a paroxysm of her fever, and died from the want of it. Her death was ascribed to the frequency of her bleedings by the enemies of the depleting system. It was said that she had been bled ten times, owing to ten marks of a lancet having been discovered on her arms after death, five of which were occasioned by unsuccessful attempts to bleed her. She died with the usual symptoms of congestion in her brain.

Mr. Marr, to whom I was called on the first day of his disease, died in a paroxysm of his fever which came on in the middle of the seventh night, after six bleedings. I had left him, the night before, nearly free of fever, and in good spirits. He might probably have been saved (humanly speaking) by one more bleeding in the exacerbation of what appeared to be the critical paroxysm of his fever.

Mr. Montford, of the state of Georgia, died under the joint care of Dr. Physick and myself. He had been cured by plentiful bleeding and purging, but had relapsed. He appeared to expire in a fainty fit in the first stage of a paroxysm of the fever. Death from this cause (which occurs most frequently where blood-letting is not used) is common in the yellow fever of the West-Indies. Dr. Bisset, in describing the different ways in which the disease terminates fatally, says, "In a few cases the patient is carried off by an _unexpected syncope_[125]."

[125] Medical Essays and Observations, p. 28.

A servant of Mr. Henry Mitchel, to whom I was called in the early stage of his disease, died in consequence of a sudden effusion in his lungs, which had been weakened by a previous pulmonary complaint.

I wish the friends of bark and wine in the yellow fever, or of _moderate_ bleeding with antimonial medicines, would publish an account of the number of their deaths by the fever, within the period I have mentioned, and with the same fidelity I have done. The contrast would for ever decide the controversy in favour of copious depletion. The mortality under the tonic mode of practice may easily be conceived from the acknowledgment of one of the gentlemen who used it, but who premised it, in many cases, by two and three bleedings. He informed Dr. Woodhouse, that out of twenty-seven patients, whom he had attended in the yellow fever, he had saved but nine. Other practitioners were, I believe, equally unsuccessful, in proportion to the number of patients whom they attended. The reader will not admit of many deaths having occurred from the diseases (formerly enumerated) to which they were ascribed, when he recollects that even a single death from most of them, in common seasons, is a rare occurrence in the practice of regular bred physicians.

In answer to the account I have given of the mortality of the fever in 1794, it will be said, that 30 persons died less in that year, than in the healthy year of 1792. To account for this, it will be necessary to recollect that the inhabitants of Philadelphia were reduced in number upwards of 4000, in the year 1793, and of course that the proportion of deaths was greater in 1794 than it was in 1792, although the number was less. It is remarkable that the burials in the strangers' grave-yard amounted in the year 1792 to but 201, whereas in 1794 they were 676. From this it appears, that the deaths must have been very numerous among new comers (as they are sometimes called) in the year 1794, compared with common years. Now this will easily be accounted for, when we recollect that these people, who were chiefly labourers, were exposed to the constantly exciting causes of the disease, and that, in all countries, they are the principal sufferers by it.

But in order to do justice to this comparative view of the mortality induced by the yellow fever in the year 1794, it will be necessary to examine the bill of mortality of the succeeding year. By this it appears that 2274 persons died in 1795, making 1139 more than died in 1794. The greatness of this mortality, I well recollect, surprized many of the citizens of Philadelphia, who had just passed an autumn which was not unusually sickly, and who had forgotten the uncommon mortality of the months of January, February, and March, which succeeded the autumn of 1794.

It will probably be asked, how it came to pass that I attended so many more patients in this fever than any of my brethren. To this I answer, that, since the year 1793, a great proportion of my patients have consisted of strangers, and of the poor; and as they are more exposed to the disease than other people, it follows, that of the persons affected by the fever, a greater proportion must have fallen to my share as patients, than to other physicians. My ability to attend a greater number of patients than most of my brethren, was facilitated by my having, at the time of the fever, several ingenious and active pupils, who assisted me in visiting and prescribing for the sick. These pupils were, Ashton Alexander and Nathaniel Potter (now physicians at Baltimore), John Otto (now physician in Philadelphia), and Gilbert Watson (since dead of the yellow fever).

The antiphlogistic remedies were not successful in Philadelphia, in the yellow fever, in my hands alone. They were equally, and perhaps more so, in the hands of my friends Dr. Griffitts, Dr. Physick, Dr. Dewees, and Dr. Woodhouse.

They were moreover successful at the same time in New Haven, Baltimore, and in Charleston, in South-Carolina. Eighteen out of twenty died of all who took bark and wine in New-Haven, but only one in ten of those who used the depleting medicines. In a letter from Dr. Brown, a physician of eminence in Baltimore, dated November 27th, 1794, he says, "of the many cases which fell to my care, two only proved mortal where I was called on the first day of the disease, and had an uncontrouled opportunity to follow my judgment. Where salivation took place, I had no case of mortality; and in two of those cases, a black vomiting occurred." Dr. Ramsay, of Charleston, in a letter to one of his friends in this city, dated October 14th, 1794, subscribes to the efficacy of the same practice in a fever which prevailed at that time in Charleston, and which, he says, resembled the yellow fever of Philadelphia in the year 1793.

But the success of the depleting system was not confined to the United States. In a letter before quoted, which I received from Dr. Davidson, of St. Vincents, dated July 22d, 1794, there is the following testimony in favour of evacuations from the blood-vessels, bowels, and salivary glands:

"Where the fever comes on with great determination to the head, and an affection of the stomach, in consequence of that determination, violent head-ach, redness of the eyes, turgescence of the face, impatience of light, &c. attended with a full and hard pulse, _blood-letting_ should be employed _freely_ and _repeatedly_, cold applications should be applied to the head, and purging medicines should be employed. As a purge, _calomel_ has been used with the greatest advantage, sometimes by itself, but most frequently combined with some active purgative medicine, such as jalap. From some peculiarity in the disease, an uncommon quantity of the calomel is necessary to affect the bowels and salivary glands. As I found a small quantity of it did not produce the effect I wished for promptly, I have gradually increased the quantity, until I now venture to give _ten_ grains of it, combined with five of jalap, every _two_ hours until stools are procured. The calomel is then given by itself.

"The patients have generally an aversion to wine. The bark is seldom found of much advantage in this state of the fever, and frequently brought on a return of the vomiting. I preferred to it, in a remission of the symptoms, a vinous infusion of the quassia, which sat better upon the stomach."

In the island of Jamaica, the depleting system has been divided. It appears, from several publications in the Kingston papers, that Dr. Grant had adopted blood-letting, while most of the physicians of the island rest the cure of the yellow fever upon strong mercurial purges. The ill effects of _moderate_ bleeding probably threw the lancet into disrepute, for the balance of success, from those publications, is evidently in favour of simple purging. I have no doubt of the truth of the above statement of the controversy between the exclusive advocates for bleeding and purging; or perhaps the superior efficacy of the latter remedy may be explained in the following manner.

In warm climates, the yellow fever is generally, as it was in Philadelphia in the month of August and in the beginning of September, 1793, a disease of but two or three paroxysms. It is sometimes, I believe, only a simple ephemera. In these cases, purging alone is sufficient to reduce the system, without the aid of bleeding. It was found to be so until the beginning of September, in 1793, in most cases in Philadelphia. The great prostration of the system in the yellow fever, in warm weather and in hot climates, renders the restoration of it to a healthy state of action more gradual, and of course more safe, by means of purging than bleeding. The latter remedy does harm, from the system being below the point of re-action, after the pressure of the blood is taken from it, or by restoring the blood-vessels too suddenly to preternatural action, without reducing them afterwards. Had bleeding been practised agreeably to the method described by Riverius (mentioned in the history of the fever of 1793), or had the fever in Jamaica run on to more than four or five paroxysms, it is probable the loss of blood would have been not only safe, but generally beneficial. I have, in the same history, given my reasons why _moderate_ bleeding in this, as well as many other diseases, does harm. In those cases where it has occurred in large quantities from natural hæmorrhages, it has always done service in the West-Indies. The inefficacy, and, in some cases, the evils, of _moderate_ blood-letting are not confined to the yellow fever. It is equally ineffectual, and, in some instances, equally hurtful, in apoplexy, internal dropsy of the brain, pleurisy, and pulmonary consumption. Where all the different states of the pulse which indicate the loss of blood are perfectly understood, and blood-letting conformed in _time_ and in _quantity_ to them, it never can do harm, in any disease. It is only when it is prescribed empirically, without the direction of just principles, that it has ever proved hurtful. Thus the fertilizing vapours of heaven, when they fall only in dew, or in profuse showers of rain, are either insufficient to promote vegetation, or altogether destructive to it.

There may be habits in which great and long protracted debility may have so far exhausted the active powers of the system, as to render bleeding altogether improper in this disease, in a West-India climate. Such habits are sometimes produced in soldiers and sailors, by the hardships of a military and naval life. Bleeding in such cases, Dr. Davidson assures me, in a letter dated from Martinique, February 29th, 1796, did no good. The cure was effected, under these circumstances, by purges, and large doses of calomel. But where this chronic debility does not occur, bleeding, when properly used, can never be injurious, even in a tropical climate, in the yellow fever. Of this there are many proofs in the writings of the most respectable English and French physicians. In spite of the fears and clamours which have been lately excited against it in Jamaica, my late friend and contemporary at the college of Edinburgh, Dr. Broadbelt, in a letter from Spanish Town, dated January 6th, 1795, and my former pupil, Dr. Weston, in a letter from St. Ann's Bay, dated June 17th, 1795, both assure me, that they have used it in this fever with great success. Dr. Weston says that he bled "_copiously_ three times in twenty-four hours, and thereby saved his patient."

The superior advantages of the North-American mode of treating the yellow fever, by means of _all_ the common antiphlogistic remedies, will appear from comparing its success with that of the West-India physicians, under all the modes of practice which have been adopted in the islands. Dr. Desportes lost one half of all the patients he attended in the yellow fever in one season in St. Domingo[126]. His remedies were _moderate_ bleeding and purging, and the copious use of diluting drinks. Dr. Bisset says, "the yellow fever is often under particular circumstances very fatal, carrying off four or five in seven whom it attacks, and sometimes, but seldom, it is so favourable as to carry off only one patient in five or six[127]." The doctor does not describe the practice under which this mortality takes place.

[126] Vol. i. p. 55.

[127] Medical Essays and Observations, p. 29.

Dr. Home, I have elsewhere remarked[128], lost "one out of four of his patients in Jamaica." His remedies were _moderate_ bleeding and purging, and afterwards bark, wine, and external applications of blankets dipped in hot vinegar.

[128] Account of the Yellow Fever of 1793.

Dr. Blane pronounces the yellow fever to be "one of the most fatal diseases to which the human body is subject, and in which human art is the most unavailing." His remedies were bleeding, bark, blisters, acid drinks, saline draughts, and camomile tea.

Dr. Chisholm acknowledges that he lost one in twelve of all the patients he attended in the fever of Grenada. His principal remedy was a salivation. I shall hereafter show the inferiority of this single mode of depleting, to a combination of it with bleeding and purging. In Philadelphia and Baltimore, where bleeding, purging, and salivation were used in due time, and after the manner that has been described, not more than one in fifty died of the yellow fever. It is probable that greater certainty and success in the treatment of this disease will not easily be attained, for idiosyncracy, and habits of intemperance which resist or divert the operation of the most proper remedies, a dread of the lancet, or the delay of an hour in the use of it, the partial application of that or any other remedy, the unexpected recurrence of a paroxysm of fever in the middle of the night, or the clandestine exhibition of wine or laudanum by friends or neighbours, often defeat the best concerted plans of cure by a physician. Heaven in this, as in other instances, kindly limits human power and benevolence, that in all situations man may remember his dependence upon the power and goodness of his Creator.

AN

ACCOUNT

OF

SPORADIC CASES

OF

_BILIOUS YELLOW FEVER_,

IN PHILADELPHIA,

IN THE YEARS 1795 AND 1796.

In my account of the yellow fever, as it appeared in Philadelphia in the year 1794, I took notice of several cases of it which occurred in the spring of the year 1795. Before I proceed to deliver the history of this disease as it appeared in 1797, I shall mention the diseases and state of the weather which occurred during the remaining part of the year 1795, and the whole of the year 1796. This detail of facts, apparently uninteresting to the reader in the present state of our knowledge of epidemics, may possibly lead to principles at a future day.

The month in of April, 1795, was wet and cold. All the diseases of this month partook of the inflammatory character of the preceding winter and autumn, except the measles, which were unusually mild.

The weather in May was alternately wet, cool, and warm. A few cases of malignant fever occurred this month, but with moderate symptoms. In June the weather was cool and pleasant. The measles put on more inflammatory symptoms than in the preceding months. I had two cases of mania under my care this month, and one of rheumatism, which were attended with intermissions and exacerbations every other day.

The weather on the 19th, 20th, 21st, and 22d days of July was very warm, the mercury being at 90° in Fahrenheit's thermometer. The fevers of this month were all accompanied with black discharges from the bowels. Mr. Kittera, one of the representatives of Pennsylvania in the congress of the United States, in consequence of great fatigue on a warm day, was affected with the usual symptoms of the yellow fever. During his illness he constantly complained of more pain in the left, than in the right side of his head. His pulse was more tense in his left, than in his right arm. During his convalescence, it was more quick in the left arm, than it was in the right. He was cured by a salivation and the loss of above 100 ounces of blood. His head-ach was relieved by the application of a bladder half filled with ice to his forehead.

Most of the cases of bilious fever, which came under my notice, were attended with quotidian, tertian, or quartan intermissions. In a few of my patients there was a universal rash.

Dr. Woodhouse informed me, that he had seen several instances in which the yellow fever appeared in the same place in which some soldiers had laboured under the dysentery. These facts show the unity of fever, and the impracticability of a nosological arrangement of diseases.

The cholera infantum was severe and fatal, in many instances, during this month. It yielded to blood-letting in a child of Mr. Conyngham, which was but four months old. In a child of seven weeks old which came under my care, I observed the coldness, chills, hot fits, and remissions of the bilious fever to be as distinctly marked as ever I had seen them in adult patients. In a child of Mr. Darrach, aged 5 months, the discharges from the bowels were of a black colour. I mention these facts in support of an opinion I formerly published, that the cholera infantum is a bilious fever, and that it rises and falls in its violence with the bilious fever of grown persons.

About the latter end of this month and the beginning of August, there were heavy showers of rain, which carried away fences, bridges, barns, mills, and dwelling-houses in many places. Several cases of bilious yellow fever occurred in the month of August. In one of them it was accompanied with that morbid affection in the wind-pipe which has been called cynanche trachealis. It was remarkable that sweating became a more frequent symptom of the fevers of this month than it had been in July. Hippocrates ascribes this change in the character of bilious fevers to rainy weather. Perhaps it was induced by the rain which fell in the beginning of the month, in the fevers which have been named.

Among the persons affected with the yellow fever during this month, was William Bradford, Esq. the attorney-general of the United States. From a dread of the lancet he objected to being bled in the early stage of his disease, in consequence of which he died on the 23d of August, in the 39th year of his age, amidst the tears of numerous friends, and the lamentations of his whole country.

On the 30th and 31st of August, there was a fall of rain, which suddenly checked the fever of the season, insomuch that the succeeding autumnal months were uncommonly healthy. Several showers of rain had nearly the same effect in New-York, where this fever carried off, in a few weeks, above 700 persons. It prevailed, at the same time, and with great mortality, in the city of Norfolk, in Virginia.

In both those cities, as well as in Philadelphia, the disease was evidently derived from putrid exhalation.

In the same month, the dysentery prevailed in Newhaven, in Connecticut, and in the same part of the town in which the yellow fever had prevailed the year before. The latter disease was said to have been imported, but the prevalence of the dysentery, under the above circumstances, proved that both diseases were of domestic origin.

The fever, as it appeared in Philadelphia, yielded in most cases to depleting remedies. After purging and blood-letting, I gave bark, where the fever intermitted, with advantage. It was effectual only when given in large doses. In one instance, it induced a spitting of blood, which obliged me to lay it aside.

The winter of 1796 was uncommonly moderate. There fell a good deal of rain, but little snow. The navigation of the Delaware was stopped but two or three days during the whole season. Catarrhs were frequent, but very few violent or acute diseases occurred in my practice. The month of March and the first week in April were uncommonly dry. Several cases of malignant bilious fever came under my care during these months. A little girl, of five years old, whom I lost in this fever, became yellow in two hours after her death.

The measles prevailed in April, and were of a most inflammatory nature. The weather in May and June was uncommonly wet. The fruit was much injured, and a great deal of hay destroyed by it. On the 14th of June, General Stewart died, with all the usual symptoms of a fatal yellow fever. Several other cases of it, in this and in the succeeding month, proved mortal, but they excited no alarm in the city, as the physicians who attended them called them by other names.

The rain which fell about the middle of July checked this fever. August, September, and October were unusually healthy. A few cases of malignant sore throat appeared in November. They were, in all the patients that came under my notice, attended with bilious discharges from the stomach and bowels. So little rain fell during the autumnal months, that the wheat perished in many places. The weather in December was extremely cold. The lamps of the city were, in several instances, extinguished by it, on the night of the 23d of the month, at which time the mercury stood at 2° below 0 in the thermometer.

The yellow fever prevailed this year in Charleston, in South-Carolina, where it was produced by putrid exhalations from the cellars of houses which had been lately burnt. It was said by the physicians of that place not to be contagious. The same fever prevailed, at the same time, at Wilmington, in North-Carolina, and at Newburyport, in the state of Massachusetts. In the latter place, it was produced by the exhalation of putrid fish, which had been carelessly thrown upon a wharf.

END OF VOLUME III.

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Transcriber's note:

The original spelling and minor inconsistencies in the spelling and formatting have been maintained.

Obvious misprints have been corrected.

Partly repeated chapter headings have been deleted.