Volume III: see https://www.gutenberg.org/ebooks/58861

Transcriber's note:

The ligature oe has been marked as [oe].

Text in italics has been enclosed by underscores (_text_).

MEDICAL INQUIRIES

AND

OBSERVATIONS.

BY BENJAMIN RUSH, M. D.

PROFESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINE, AND OF CLINICAL PRACTICE, IN THE UNIVERSITY OF PENNSYLVANIA.

IN FOUR VOLUMES.

VOL. IV.

THE SECOND EDITION,

REVISED AND ENLARGED BY THE AUTHOR.

PHILADELPHIA,

PUBLISHED BY J. CONRAD & CO. CHESNUT-STREET, PHILADELPHIA; M. & J. CONRAD & CO. MARKET-STREET, BALTIMORE; RAPIN, CONRAD, & CO. WASHINGTON; SOMERVELL & CONRAD, PETERSBURG; AND BONSAL, CONRAD, & CO. NORFOLK.

PRINTED BY T. & G. PALMER, 116, HIGH-STREET.

1805.

* * * * *

CONTENTS OF VOLUME IV.

_page_

_An account of the bilious yellow fever, as it appeared in Philadelphia in 1797_ 1

_An account of the bilious yellow fever, as it appeared in Philadelphia in 1798_ 63

_An account of the bilious yellow fever, as it appeared in Philadelphia in 1799_ 89

_An account of sporadic cases of yellow fever, as they appeared in Philadelphia in 1800_ 101

_An account of sporadic cases of yellow fever, as they appeared in Philadelphia in 1801_ 109

_An account of the measles, as they appeared in Philadelphia in 1801_ 115

_An account of the yellow fever, as it appeared in 1802_ 121

_An account of the yellow fever, as it appeared in 1803_ 131

_An account of sporadic cases of yellow fever, as they appeared in 1804_ 145

_An account of the yellow fever, as it appeared in 1805_ 151

_An inquiry into the various sources of the usual forms of the summer and autumnal disease in the United States, and the means of preventing them_ 161

_Facts, intended to prove the yellow fever not to be contagious_ 221

_Defence of blood-letting, as a remedy in certain diseases_ 273

_An inquiry into the comparative states of medicine in Philadelphia, between the years 1760 and 1766, and 1805_ 363

* * * * *

AN ACCOUNT

OF THE

BILIOUS REMITTING AND INTERMITTING

_YELLOW FEVER_,

AS IT

APPEARED IN PHILADELPHIA,

IN 1797.

The winter of 1797 was in general healthy. During the spring, which was cold and wet, no diseases of any consequence occurred. The spring vegetables were late in coming to maturity, and there were every where in the neighbourhood of Philadelphia scanty crops of hay. In June and July there fell but little rain. Dysenteries, choleras, scarlatina, and mumps, appeared in the suburbs in the latter month. On the 8th of July I visited Mr. Frisk, and on the 25th of the same month I visited Mr. Charles Burrel in the yellow fever, in consultation with Dr. Physick. They both recovered by the use of plentiful depleting remedies.

The weather from the 2d to the 9th of August was rainy. On the 1st of this month I was called to visit Mr. Nathaniel Lewis, in a malignant bilious fever. On the 3d I visited Mr. Elisha Hall, with the same disease. He had been ill several days before I saw him. Both these gentlemen died on the 6th of the month. They were both very yellow after death. Mr. Hall had a black vomiting on the day he died.

The news of the death of these two citizens, with unequivocal symptoms of yellow fever, excited a general alarm in the city. Attempts were made to trace it to importation, but a little investigation soon proved that it was derived from the foul air of a ship which had just arrived from Marseilles, and which discharged her cargo at Pinestreet wharf, near the stores occupied by Mr. Lewis and Mr. Hall. Many other persons about the same time were affected with the fever from the same cause, in Water and Penn-streets. About the middle of the month, a ship from Hamburgh communicated the disease, by means of her foul air, to the village of Kensington. It prevailed, moreover, in many instances in the suburbs, and in Kensington, from putrid exhalations from gutters and marshy grounds, at a distance from the Delaware, and from the foul ships which have been mentioned. Proofs of the truth of each of these assertions were afterwards laid before the public.

The disease was confined chiefly to the district of Southwark and the village of Kensington, for several weeks. In September and October, many cases occurred in the city, but most of them were easily traced to the above sources.

The following account of the weather, during the months of August, September, and October was obtained from Mr. Thomas Pryor. It is different from the weather in 1793. It is of consequence to attend to this fact, inasmuch as it shows that an inflammatory constitution of the atmosphere can exist under different circumstances of the weather. It likewise accounts for the variety in the symptoms of the fever in different years and countries. Such is the influence of season and climate upon the symptoms of this fever, that it led Dr. M'Kitterick to suppose that the yellow fever of Charleston, so accurately described by Dr. Lining, in the second volume of the Physical and Literary Essays of Edinburgh, was a different disease from the yellow fever of the West-Indies[1].

[1] De Febre Indiæ-Occidentalis Maligna Flava, p. 12.

METEOROLOGICAL OBSERVATIONS,

_MADE IN PHILADELPHIA_.

AUGUST, 1797.

+--+-----+------+----------------------------------------------+ |D.|Ther.|Barom.| Winds and Weather. | +--+--+--+------+----------------------------------------------+ | 1|73|75|30 0|S. E. E. Rain in the forenoon and afternoon. | | 2|72|76|30 0|N. E. by E. Cloudy, with rain in the afternoon| | | | | | and night. Wind E. by N. | | 3|72|78|30 6|E. 1/2 N. Rain in the morning, and all day and| | | | | | night. | | 4|72|78|30 4|E. Rained hard all day and at night. | | 5|74|79|29 84|Wind light, S. W. Cloudy. Rain this morning. | | | | | | The air extremely damp; wind shifted | | | | | | to N. W. This evening heavy showers, | | | | | | with thunder. | | 6|73|76|30 86|W. N. W. Cloudy. | | 7|70|76|30 4|N. W. Close day. Rain in the evening and | | | | | | all night. Wind to E. | | 8|72|76|29 95|E. Rain this morning. | | 9|72|76|29 86|S. W. Cloudy morning. | |10|69|73|30 16|N. W. Clear. | |11|70|74|30 25|N. W. Clear. Rain all night. | |12|71|74|30 5|S. W. Cloudy. Rain in the morning. Cloudy | | | | | | all day. Rain at night. | |13|73|75|29 87|S. W. Cloudy. Rain all day. | |14|70|74|29 9|N. W. Clear fine morning. | |15|56|60|30 15|N. W. Clear fine morning. | |16|60|64|30 24|N. W. Clear fine morning. | |17|60|65|30 24|N. W. Air damp. | |18|68|75|30 4|S. W. Cloudy. Rain, with thunder at night: | | | | | | a fine shower. | |19|72|78|29 7|N. W. Clear. Cloudy in the evening, with | | | | | | thunder. | |20|70|77|29 8|W. N. W. Fine clear morning. | |21|74|76|29 9|N. W. Clear to E. | |22|68|76| |E. Small shower this morning. Hard shower | | | | | | at 11, A. M. Wind N. E. | |23|71|76|29 92|E. Cloudy. At noon calm. | |24|71|75|29 95|Calm morning and clear. | |25|70|75|30 5|N. E. Clear. Rain in the afternoon, with | | | | | | thunder. | |26|70|75|30 5|S. E. Rain in the morning. Rained hard in the | | | | | | night, with thunder, N. W. | |27|68|76|29 9|N. W. Fine clear morning. | |28|64|75|29 96|N. W. Clear. | |29|59|70|30 0|E. Clear. | |30|70|76|30 1|E. by S. Rain in the morning. | |31|68|74|30 14|S. E. Cloudy. Damp air and sultry. | +--+--+--+------+----------------------------------------------+

SEPTEMBER, 1797.

+--+-----+------+----------------------------------------------+ |D.|Ther.|Barom.| Winds and Weather. | +--+-----+------+----------------------------------------------+ | 1|73|80|30 6|S. W. Cloudy. Damp air. Rain in the morning | | 2|79|80|29 9|N. W. Clear. Cloudy in the evening, with | | | | | | lightning to the southward. | | 3|68|74|30 0|N. by W. Cloudy. Clear in the afternoon and | | | | | | night. | | 4|66|74|30 7|W. N. W. Clear fine morning. | | 5|58|73|30 1|N. W. Clear. Cloudy in the evening. | | 6|58|72|30 13|Fresh at E. Clear. Rain in the evening. | | 7|56|76|30 28|E. Clear. Cloudy in the evening. | | 8|54|65|30 1|N. E. Clear and cool morning. Flying clouds at| | | | | | noon. | | 9|56|65|30 1|E. N. E. Clear. | |10|58|63|30 26|N. E. Clear fine morning. Wind fresh at N. E. | | | | | | all day. | |11|53|64|30 13|N. to E. with flying clouds. | |12|51|62|30 6|W. N. W. Clear cool morning. | |13|56|67|30 3|S. W. Cloudy. Clear in the afternoon. | |14|64|70|29 98|S. W. Clear. | |15|66|73|29 85|S. W. Rain in the morning. Cloudy in the | | | | | | afternoon. | |16|62|70|29 95|N. W. Clear. | |17|56|67|30 0|N. W. Clear. | |18|58|63|29 88|E. Cloudy. Rained all day, and thunder. | | | | |29 62| Rained very heavy at night. | |19|55|63|29 75|W. N. W. Clear fine morning. | |20|47|63|30 8|W. N. W. Clear fine morning. New moon | | | | | | at 9 50 morning. | |21|46|60|30 0|N. E. Clear fine morning; to S. E. in the | | | | | | evening. Cloudy at night. | |22|56|65|30 4|N. W. Rain in the morning. Rain at night. | |23|56|66|30 0|N. N. E. Cloudy. | |24|52|66|29 9|E. by S. Clear fine morning. Cloudy at night | | | | |29 78| | |25|56|68|29 37|W. N. W. Clear fine morning; clear all day. | |26|58|68|29 95|E. In the morning flying clouds. | |27|48|63|30 2|N. W. Clear fine morning; clear all day. | |28|48|63|30 2|W. N. W. Clear fine morning; clear all day. | |29|54|63|30 15|E. Clear fine morning. | |30|60|65|30 26|E. Fresh. Cloudy morning. Rain in the night | +--+--+--+------+----------------------------------------------+

OCTOBER, 1797.

+--+-----+------+----------------------------------------------+ |D.|Ther.|Barom.| Winds and Weather. | +--+-----+------+----------------------------------------------+ | 1|55|65|30 16|N. E. Rain this morning, and great, part of | | | | | | the day. | | 2|55|66|30 0|N. W. Clear. | | 3|60|70|29 9|S. E. Clear. Air damp. | | 4|60|70|29 5|W. N. W. Rain this morning. | | 5|46|60|30 0|W. N. W. to S. by W. in the evening. Clear | | | | | | all day. White frost this morning. | | 6|55|65|30 0|S. W. Clear fine morning. White frost. | | 7|56|76|30 0|S. W. Cloudy. Rain in the night. | | 8|56|70|30 29|S. Cloudy this morning; air damp. Wind | | | | | | shifted to W. N. W. Blows fresh. | | 9|50|60|29 85|W. N. W. Clear morning. Fresh at N. W. | | | | | | in the evening. | |10|40|58|30 1|W. N. W. Clear. Frost this morning. | |11|38|56|30 2|W. N. W. Cloudy. | |12|34|52|30 38|W. N. W. Clear. Ice this morning. | |13|35|55|30 5|N. Clear fine morning. Ice this morning. | |14|40|60|30 28|N. E. Cloudy. | |15|50|65|30 16|W. N. W. Clear. | |16|36|56|30 2|W. N. W. Clear fine morning. | |17|37|56|30 18|W. N. W. Clear fine morning. | |18|47|60|29 86|W. N. W. Clear fine weather. | |19|48|60|30 6|N. W. Clear fine day. | |20|42|55|30 8|N. E. Cloudy. Rain in the afternoon and | | | | | | night. Blows fresh at N. E. | |21|42|50|29 92|N. E. Blows fresh (with a little rain). | | | | | | Thunder in the night, with rain. | |22|44|56|29 57|N. W. Rain in the morning. | |23|44|56|29 95|S. W. Clear fine morning. | |24|42|54|30 5|N. E. Cloudy. A great deal of rain in the | | | | | | night. | |25|40|52|30 15|N. E. Clear fine morning. | |26|36|48|30 29|W. N. W. Clear. | |27|34|46|30 23|Fresh at S. W. Clear. | |28|40|52|29 95|W. N. W. Cloudy. | |29|34|46|29 82|W. Cloudy. | |30|32|42|29 93|N. W. Clear. Hard frost this morning. | |31|38|48|30 18|W. S. W. Cloudy part of this day; clear the | | | | | | remainder. | +--+--+--+------+----------------------------------------------+

In addition to the register of the weather it may not be improper to add, that moschetoes were more numerous during the prevalence of the fever than in 1793. An unusual number of ants and cockroaches were likewise observed; and it was said that the martins and swallows disappeared, for a while, from the city and its neighbourhood.

A disease prevailed among the cats some weeks before the yellow fever appeared in the city. It excited a belief in an unwholesome state of the atmosphere, and apprehensions of a sickly fall. It generally proved fatal to them.

After the first week in September there were no diseases to be seen but yellow fever. In that part of the town which is between Walnut and Vine-streets it was uncommonly healthy. A similar retreat of inferior diseases has been observed to take place during the prevalence of the plague in London, Holland, and Germany, according to the histories of that disease by Sydenham, Diemerbroeck, Sennertus, and Hildanus. It appears, from the register of the weather, that it rained during the greatest part of the day on the 1st of October. The effects of this rain upon the disease shall be mentioned hereafter. On the 10th the weather became cool, and on the nights of the 12th and 13th of the month there was a frost accompanied with ice, which appeared to give a sudden and complete check to the disease.

The reader will probably expect an account of the effects of this distressing epidemic upon the public mind. The terror of the citizens for a while was very great. Rumours of an opposite and contradictory nature of the increase and mortality of the fever were in constant circulation. A stoppage was put to business, and it was computed that about two thirds of the inhabitants left the city.

The legislature of the state early passed a law, granting 10,000 dollars for the relief of the sufferers by the fever. The citizens in and out of town, as also many of the citizens of our sister states, contributed more than that sum for the same charitable purpose. This money was issued by a committee appointed by the governor of the state. An hospital for the reception of the poor was established on the east side of the river Schuylkill, and amply provided with every thing necessary for the accommodation of the sick. Tents were likewise pitched on the east side of Schuylkill, to which all those people were invited who were exposed to the danger of taking the disease, and who had not means to provide a more comfortable retreat for themselves in the country.

I am sorry to add that the moral effects of the fever upon the minds of our citizens were confined chiefly to these acts of benevolence. Many of the publications in the newspapers upon its existence, mode of cure, and origin partook of a virulent spirit, which ill accorded with the distresses of the city. It was a cause of lamentation likewise to many serious people, that the citizens in general were less disposed, than in 1793, to acknowledge the agency of a divine hand in their afflictions. In some a levity of mind appeared upon this solemn occasion. A worthy bookseller gave me a melancholy proof of this assertion, by informing me, that he had never been asked for playing cards so often, in the same time, as he had been during the prevalence of the fever.

Philadelphia was not the only place in the United States which suffered by the yellow fever. It prevailed, at the same time, at Providence, in Rhode-Island, at Norfolk, in Virginia, at Baltimore, and in many of the country towns of New-England, New-Jersey, and Pennsylvania.

The influenza followed the yellow fever, as it did in the year 1793. It made its appearance in the latter end of October, and affected chiefly those citizens who had been out of town.

The predisposing causes of the yellow fever, in the year 1797, were the same as in the year 1793. Strangers were as usual most subject to it. The heat of the body in such persons, in the West-Indies, has been found to be between three and four degrees above that of the temperature of the natives. This fact is taken notice of by Dr. M'Kitterick, and to this he ascribes, in part, the predisposition of new comers to the yellow fever.

In addition to the common exciting causes of this disease formerly enumerated, I have only to add, that it was induced in one of my patients by smoking a segar. He had not been accustomed to the use of tobacco.

I saw no new premonitory symptoms of this fever except a tooth-ach. It occurred in Dr. Physick, Dr. Caldwell, and in my pupil, Mr. Bellenger. In Miss Elliot there was such a soreness in her teeth, that she could hardly close her mouth on the day in which she was attacked by the fever. Neither of these persons had taken mercury to obviate the disease.

I shall now deliver a short account of the symptoms of the yellow fever, as they appeared in several of the different systems of the body.

I. There was but little difference in the state of the pulse in this epidemic from what has been recorded in the fevers of 1793 and 1794. I perceived a pulse, in several cases, which felt like a soft quill which had been _shattered_ by being trodden upon. It occurred in Dr. Jones and Dr. Dobell, and in several other persons who had been worn down by great fatigue, and it was, in every instance, followed by a fatal issue of the fever. In Dr. Jones this state of the pulse was accompanied with such a difficulty of breathing, that every breath he drew, on the day of his attack, he informed me, was the effort of a sigh. He died on the 17th of September, and on the sixth day of his fever.

The action of the arteries was, as usual, very irregular in many cases. In some there was a distressing throbbing of the vessels in the brain, and in one of my patients a similar sensation in the bowels, but without pain. Many people had issues of blood from their blisters in this fever.

I saw nothing new in the effects of the fever upon the liver, lungs, brain, nor upon the stomach and bowels.

II. The excretions were distinguished by no unusual marks. I met with no recoveries where there were not black stools. They excoriated the rectum in Dr. Way. It was a happy circumstance where morbid bilious matter came away in the beginning of the disease. But it frequently resisted the most powerful cathartics until the 5th or 7th day of the fever, at which time it appeared rather to yield to the disorganization of the liver than to medicine. Where sufficient blood-letting had been previously used, the patient frequently recovered, even after the black discharges from the bowels took place in a late stage of the disease.

Dr. Coxe informed me, that he attended a child of seventeen months old which had _white_ stools for several days. Towards the close of its disease it had black stools, and soon afterwards died.

Several of my patients discharged worms during the fever. In one instance they were discharged from the mouth.

A preternatural frequency in making pale water attended the first attack of the disease in Mr. Joseph Fisher.

A discharge of an unusual quantity of urine preceded, a few hours, the death of the daughter of Mrs. Read.

In two of my patients there was a total suppression of urine. In one of them it continued five days without exciting any pain.

There was no disposition to sweat after the first and second days of the fever. Even in those states of the fever, in which the intermissions were most complete, there was seldom any moisture, or even softness on the skin. This was so characteristic of malignity in the bilious fever, that where I found the opposite state of the skin, towards the close of a paroxysm, I did not hesitate to encourage my patient, by assuring him that his fever was of a mild nature, and would most probably be safe in its issue.

III. I saw no unusual marks of the disease in the nervous system. The mind was seldom affected by delirium after the loss of blood. There was a disposition to shed tears in two of my patients. One of them wept during the whole time of a paroxysm of the fever. In one case I observed an uncommon dulness of apprehension, with no other mark of a diseased state of the mind. It was in a man whose faculties, in ordinary health, acted with celerity and vigour.

Dr. Caldwell informed me of a singular change which took place in the operations of his mind during his recovery from the fever. His imagination carried him back to an early period of his life, and engaged him, for a day or two, in playing with a bow and arrow, and in amusements of which he had been fond when a boy. A similar change occurred in the mind of my former pupil, Dr. Fisher, during his convalescence from the yellow fever in 1793. He amused himself for two days in looking over the pictures of a family Bible which lay in his room, and declared that he found the same kind of pleasure in this employment that he did when a child. However uninteresting these facts may now appear, the time will come when they may probably furnish useful hints for completing the physiology and pathology of the mind.

Where blood-letting had not been used, patients frequently died of convulsions.

IV. The senses of seeing and feeling were impaired in several cases. Mrs. Bradford's vision was so weak that she hardly knew her friends at her bed-side. I had great pleasure in observing this alarming symptom suddenly yield to the loss of four ounces of blood.

Several persons who died of this fever did not, from the beginning to the end of the disease, feel any pain. I shall hereafter endeavour to explain the cause of this insensible state of the nerves.

The appetite for food was unimpaired for three days in Mr. Andrew Brown, at a time when his pulse indicated a high grade of the fever. I heard of several persons who ate with avidity just before they died.

V. Glandular swellings were very uncommon in this fever. I should have ascribed their absence to the copious use of depleting remedies in my practice, had I not been informed that morbid affections of the lymphatic glands were unknown in the city hospital, where blood-letting was seldom used, and where the patients, in many instances, died before they had time to take medicine of any kind.

VI. The skin was cool, dry, smooth, and even shining in some cases. Yellowness was not universal. Those small red spots, which have been compared to moscheto bites, occurred in several of my patients. Dr. John Duffield, who acted as house surgeon and apothecary at the city hospital, informed me that he saw vibices on the skin in many cases, and that they were all more or less sore to the touch.

VII. The blood was dissolved in a few cases. That appearance of the blood, which has been compared to the washings of flesh, was very common. It was more or less sizy towards the close of the disease in most cases. I have suspected, from this circumstance, that this mark of ordinary morbid action or inflammation was in part the effect of the mercury acting upon the blood-vessels. It is well known that sizy blood generally accompanies a salivation. If this conjecture be well founded, it will not militate against the use of mercury in malignant fevers, for it shows that this valuable medicine possesses a power of changing an extraordinary and dangerous degree of morbid action in the blood-vessels to that which is more common and safe. I have seldom seen a yellow fever terminate fatally after the appearance of sizy blood.

Dr. Stewart informed me, that in those cases in which the serum of the blood had a yellow colour, it imparted a saline taste only to his tongue. He was the more struck with this fact, as he perceived a strong bitter state upon his skin, in a severe attack of the yellow fever in 1793.

I proceed next to take notice of the type of the fever.

In many cases, it appeared in the form of a remitting and intermitting fever. The quotidian and tertian forms were most common. In Mr. Robert Wharton, it appeared in the form of a quartan. But it frequently assumed the character which is given of the same fever in Charleston, by Dr. Lining. It came on without chills, and continued without any remission for three days, after which the patient believed himself to be well, and sometimes rose from his bed, and applied to business. On the fourth or fifth day, the fever returned, and unless copious evacuations had been used in the early stage of the disease, it generally proved fatal. Sometimes the powers of the system were depressed below the return of active fever, and the patient sunk away by an easy death, without pain, heat, or a quick pulse. I have been much puzzled to distinguish a crisis of the fever on the third or fourth day, from the insidious appearance which has been described. It deceived me in 1793. It may be known by a preternatural coolness in the skin, and languor in the pulse, by an inability to sit up long without fatigue or faintness, by a dull eye, and by great depression of mind, or such a flow of spirits as sometimes to produce a declaration from the patient that "he feels too well." Where these symptoms appear, the patient should be informed of his danger, and urged to the continuance of such remedies as are proper for him.

The following states or forms were observable in the fever:

1. In a few cases, the miasmata produced death in four and twenty hours, with convulsions, coma, or apoplexy.

2. There were _open_ cases, in which the pulse was full and tense as in a pleurisy or rheumatism, from the beginning to the end of the fever. They were generally attended with a good deal of pain.

3. There were _depressed_ or _locked_ cases, in which there were a sense of great debility, but little or no pain, a depressed and slow pulse, a cool skin, cold hands and feet, and obstructed excretions.

4. There were _divided_ or _mixed_ cases, in which the pulse was active until the 4th day, after which it became depressed. All the other symptoms of the locked state of the fever accompanied this depressed state of the pulse.

5. There were cases in which the pulse imparted a perception like that of a soft and _shattered_ quill. I have before mentioned that this state of the pulse occurred in Dr. Jones and Dr. Dobell. I felt it but once, and on the day of his attack, in the latter gentleman, and expressed my opinion of his extreme danger to one of my pupils upon my return from visiting him. I did not meet with a case which terminated favourably, where I perceived this _shattered_ pulse. A disposition to sweat occurred in this state of the fever.

6. There were what Dr. Caldwell happily called _walking_ cases. The patients here were flushed or pale, had a full or tense pulse, but complained of no pain, had a good appetite, and walked about their rooms or houses, as if they were but little indisposed, until a day or two, and, in some instances, until a few hours before they died. We speak of a _dumb_ gout and _dumb_ rheumatism; with equal propriety, the epithet might be applied to this form of yellow fever in its early stage. The impression of the remote cause of the fever, in these cases, was beyond sensation, for, upon removing a part of it by bleeding or purging, the patients complained of pain, and the excitement of the muscles passed so completely into the blood-vessels and alimentary canal, as to convert the fever into a common and more natural form. These cases were always dangerous, and, when neglected, generally terminated in death. Mr. Brown's fever came on in this insidious shape. It was cured by the loss of upwards of 100 ounces of blood, and a plentiful salivation.

7. There was the _intermitting_ form in this fever. This, like the last, often deceived the patient, by leading him to suppose his disease was of a common or trifling nature. It prevented Mr. Richard Smith from applying for medical aid in an attack of the fever for several days, by which means it made such an impression upon his viscera, that depleting remedies were in vain used to cure him. He died in the prime of life, beloved and lamented by a numerous circle of relations and friends.

8. There was a form of this fever in which it resembled the mild remittent of common seasons. It was distinguished from it chiefly by the black colour of the intestinal evacuations.

9. There were cases of this fever so light, that patients were said to be neither _sick_ nor _well_; or, in other words, they were sick and well half a dozen times in a day. Such persons walked about, and transacted their ordinary business, but complained of dulness, and, occasionally, of shooting pains in their heads. Sometimes the stomach was affected with sickness, and the bowels with diarrh[oe]a or costiveness. All of them complained of night sweats. The pulse was quicker than natural, but seldom had that convulsive action which constitutes fever. Purges always brought away black stools from such patients, and this circumstance served to establish its relationship to the prevailing epidemic. Now and then, by neglect or improper treatment, it assumed a higher and more dangerous grade of the fever, and became fatal, but it more commonly yielded to nature, or to a single dose of purging physic.

10. There were a few cases in which the skin was affected with universal yellowness, but without more pain or indisposition than usually occurs in the jaundice. They were very frequent in the year 1793, and generally prevail in the autumn, in all places subject to bilious fever.

11. There were _chronic_ cases of this fever. It is from the want of observation that physicians limit the duration of the yellow fever to certain days. I have seen many instances in which it has been protracted into what is called by authors a slow nervous fever. The wife of captain Peter Bell died with a black vomiting after an illness of nearly one month. Dr. Pinckard, formerly one of the physicians of the British army in the West-Indies, in a late visit to this city informed me, that he had often seen the yellow fever put on a chronic form in the West-India islands.

In delivering this detail of the various forms of the yellow fever, I am aware that I oppose the opinions of many of my medical brethren, who ascribe to it a certain uniform character, which is removed beyond the influence of climate, habit, predisposition, and the different strength and combinations of remote and exciting causes. This uniformity in the symptoms of this fever is said to exist in the West-Indies, and every deviation from it in the United States is called by another name. The following communication, which I received from Dr. Pinckard, will show that this disease is as different in its forms in the West-Indies as it is in this country.

"The yellow fever, as it appeared among the troops in Guiana and the West-India islands, in the years 1796 and 1797, exhibited such perpetual instability, and varied so incessantly in its character, that I could not discover any one symptom to be decidedly diagnostic; and hence I have been led into an opinion that the yellow fever, so called, is not a distinct or specific disease, but merely an aggravated degree of the common remittent or bilious fever of hot climates, rendered irregular in form, and augmented in malignity, from appearing in subjects unaccustomed to the climate. _Philadelphia, January 12th, 1798._"

Many other authorities equally respectable with Dr. Pinckard's, among whom are Pringle, Huck, and Hunter, might be adduced in support of the unity of bilious fever. But to multiply them further would be an act of homage to the weakness of human reason, and an acknowledgment of the infant state of our knowledge in medicine. As well might we suppose nature to be an artist, and that diseases were shaped by her like a piece of statuary, or a suit of clothes, by means of a chissel, or pair of scissars, as admit every different form and grade of morbid action in the system to be a distinct disease.

Notwithstanding the fever put on the eleven forms which have been described, the moderate cases were few, compared with those of a malignant and dangerous nature. It was upon this account that the mortality was greater in the same number of patients, who were treated with the same remedies, than it was in the years 1793 and 1794. The disease, moreover, partook of a more malignant character than the two epidemics that have been mentioned. The yellow fever in Norfolk, Drs. Taylor and Hansford informed me, in a letter I received from them, was much more malignant and fatal, under equal circumstances, than it was in 1795.

There were evident marks of the disease attacking more persons three days before, and three days after the _full_ and _change_ of the moon, and of more deaths occurring at those periods than at any other time. The same thing has been remarked in the plague by Diemerbroeck, in the fevers of Bengal by Dr. Balfour, and in those of Demarara by Dr. Pinckard.

During the prevalence of the fever I attended the following persons who had been affected by the epidemic of 1793, viz. Dr. Physick, Thomas Leaming, Thomas Canby, Samuel Bradford, and George Loxley, also Mrs. Eggar, who had a violent attack of it in the year 1794. Samuel Bradford was likewise affected by it in 1794.

During my intercourse with the sick, I felt the miasmata of the fever operate upon my system in the most sensible manner. It produced languor, a pain in my head, and sickness at my stomach. A sighing attended me occasionally, for upwards of two weeks. This symptom left me suddenly, and was succeeded by a hoarseness, and, at times, with such a feebleness in my voice as to make speaking painful to me. Having observed this affection of the trachea to be a precursor of the fever in several cases, it kept me under daily apprehensions of being confined by it. It gradually went off after the first of October. I ascribed my recovery from it, and a sudden diminution of the effects of the miasmata upon my system, to a change produced in the atmosphere by the rain which fell on that day.

The peculiar matter emitted by the breath or perspiration of persons affected by this fever, induced a sneezing in Dr. Dobell, every time he went into a sick room. Ambrose Parey says the same thing occurred to him, upon entering the room of patients confined by the plague.

The gutters emitted, in many places, a sulphureous smell during the prevalence of the fever. Upon rubbing my hands together I could at any time excite a similar smell in them. I have taken notice of this effect of the matters which produced the disease upon the body, in the year 1794.

In order to prevent an attack of the fever, I carefully avoided all its exciting causes. I reduced my diet, and lived sparingly upon tea, coffee, milk, and the common fruits and garden vegetables of the season, with a small quantity of salted meat, and smoked herring. My drinks were milk and water, weak claret and water, and weak porter and water. I sheltered myself as much as possible from the rays of the sun, and from the action of the evening air, and accommodated my dress to the changes in the temperature of the atmosphere. By similar means, I have reason to believe, many hundred people escaped the disease, who were constantly exposed to it.

The number of deaths by the fever, in the months of August, September, and October, amounted to between ten and eleven hundred. In the list of the dead were nine practitioners of physic, several of whom were gentlemen of the most respectable characters. This number will be thought considerable when it is added, that not more than three or four and twenty physicians attended patients in the disease. Of the survivors of that number, eight were affected with the fever. This extraordinary mortality and sickness among the physicians must be ascribed to their uncommon fatigue in attending upon the sick, and to their inability to command their time and labours, so as to avoid the exciting causes of the fever.

Among the medical gentlemen whose deaths have been mentioned, was my excellent friend, Dr. Nicholas Way. I shall carry to my grave an affectionate remembrance of him. We passed our youth together in the study of medicine, and lived to the time of his death in the habits of the tenderest friendship. In the year 1794, he removed from Wilmington, in the Delaware state, to Philadelphia, where his talents and manners soon introduced him into extensive business. His independent fortune furnished his friends with arguments to advise him to retire from the city, upon the first appearance of the fever. But his humanity prevailed over the dictates of interest and the love of life. He was active and intelligent in suggesting and executing plans to arrest the progress of the disease, and to lessen the distresses of the poor. On the 27th of August, he was seized, after a ride from the country in the evening air, with a chilly fit and fever. I saw him the next day, and advised the usual depleting remedies. He submitted to my prescriptions with reluctance, and in a sparing manner, from an opinion that his fever was nothing but a common remittent. To enforce obedience to my advice, I called upon Dr. Griffitts to visit him with me. Our combined exertions to overcome his prejudices against our remedies were ineffectual. At two o'clock in the afternoon, on the sixth day of his disease, with an aching heart I saw the sweat of death upon his forehead, and felt his cold arm without a pulse. He spoke to me with difficulty: upon my rising from his bed-side to leave him, his eyes filled with tears, and his countenance spoke a language which I am unable to describe. I promised to return in a short time, with a view of attending the last scene of his life. Immediately after I left his room, he wept aloud. I returned hastily to him, and found him in convulsions. He died a few hours afterwards. Had I met with no other affliction in the autumn of 1797 than that which I experienced from this affecting scene, it would have been a severe one; but it was a part only of what I suffered from the death of other friends, and from the malice of enemies.

I beg the reader's pardon for this digression. It shall be the last time and place in which any notice shall be taken of my sorrows and persecutions in the course of these volumes.

Soon after the citizens returned from the country, the governor of the state, Mr. Mifflin, addressed a letter to the college of physicians of Philadelphia, requesting to know the origin, progress, and nature of the fever which had recently afflicted the city, and the means of preventing its return. He addressed a similar letter to me, to be communicated to such gentlemen of the faculty of medicine, as were not members of the college of physicians.

The college, in a memorial to the legislature of the state, asserted that the fever had been imported in two ships, the one from Havannah, the other from Port au Prince, and recommended, as the most effectual means of preventing its recurrence, a more rigid quarantine law.

The gentlemen of the faculty of medicine, thirteen in number, in two letters to the governor of the state, the one in their private capacity, and the other after they had associated themselves into an "Academy of Medicine," asserted that the fever had originated from the putrid exhalations from the gutters and streets of the city, and from ponds and marshy grounds in its neighbourhood; also from the foul air of two ships, the one from Marseilles and the other from Hamburgh. They enumerated all the common sources of malignant fevers, and recommended the removal of them from the city, as the most effectual method of preventing the return of the fever. These sources of fever, and the various means of destroying them, shall be mentioned in another place.

I proceed now to say a few words upon the treatment which was used in this fever. It was, in general, the same as that which was pursued in the fevers of 1793 and 1794.

I began the cure, in most cases, by _bleeding_, when I was called on the first day of the disease, and was happy in observing its usual salutary effects in its early stage. On the second day, it frequently failed of doing service, and on the subsequent days of the fever, I believe, it often did harm; more especially if no other depleting remedy had preceded it. The violent action of the blood-vessels in this disease, when left to itself for two or three days, fills and suffocates the viscera with such an immense mass of blood, as to leave a quantity in the vessels so small, as barely to keep up the actions of life. By abstracting but a few ounces of this circulating blood, we precipitate death. In those cases where a doubt is entertained of such an engorgement of stagnating blood having taken place, it will always be safest to take but three or four ounces at a time, and to repeat it four or five times a day. By this mode of bleeding, we give the viscera an opportunity of emptying their superfluous blood into the vessels, and thereby prevent their collapsing, from the sudden abstraction of the stimulus which remained in them. I confine this observation upon bleeding, after the first stage of the disease, only to the epidemic of 1797. It was frequently effectual when used for the first time after the first and second days, in the fevers of 1793 and 1794, and it is often useful in the advanced stage of the common bilious fever. The different and contradictory accounts of the effects of bleeding in the yellow fever, in the West-Indies, probably originate in its being used in different stages of the disease. Dr. Jackson, of the British army, in his late visit to Philadelphia, informed me, that he had cured nineteen out of twenty of all the soldiers whom he attended, by copious bleeding, provided it was performed within six hours after the attack of the fever. Beyond that period, it mitigated its force, but seldom cured. The quantity of blood drawn by the doctor, in this early stage of the disease, was always from twenty to thirty ounces. I have said the yellow fever of 1797 was more malignant than the fevers of 1793 and 1794. Its resemblance to the yellow fever in the West-Indies, in not yielding to bleeding after the first day, is a proof of this assertion.

I was struck, during my attendance upon this fever, in observing the analogy between its _mixed_ form and the malignant state of the small-pox. The fever, in both, continues for three or four days without any remission. They both have a second stage, in which death usually takes place, if the diseases be left to themselves. By means of copious bleeding in their first, they are generally deprived of their malignity and mortality in their second stage. This remark, so trite in the small-pox, has been less attended to in the yellow fever. The bleeding in the first stage of this disease does not, it is true, destroy it altogether, any more than it destroys an eruption in the second stage of the small-pox, but it weakens it in such a manner that the patient passes through its second stage without pain or danger, and with no other aid from medicine than what is commonly derived from good nursing, proper aliment, and a little gently opening physic.

It is common with those practitioners who object to bleeding in the yellow fever, to admit it occasionally in _robust_ habits. This rule leads to great error in practice. From the weak action of predisposing, or exciting causes, the disease often exists in a feeble state in such habits, while from the protracted or violent operation of the same causes, it appears in great force in persons of delicate constitutions. A physician, therefore, in prescribing for a patient in this fever, should forget the natural strength of his muscles, and accommodate the loss of blood wholly to the morbid strength of his disease.

The quantity of blood drawn in this fever was always proportioned to its violence. I cured many by a single bleeding. A few required the loss of upwards of a hundred ounces of blood to cure them. The persons from whom that large quantity of blood was taken, were, Messieurs Andrew Brown, Horace Hall, George Cummins, J. Ramsay, and George Eyre. But I was not singular in the liberal and frequent use of the lancet. The following physicians drew the quantities of blood annexed to their respective names from the following persons, viz.

Dr. Dewees 176 ounces from Dr. Physick, Dr. Griffitts 110 Mr. S. Thomson, Dr. Stewart 106 Mrs. M'Phail, Dr. Cooper 150 Mr. David Evans, Dr. Gillespie 103 himself.

All the above named persons had a rapid and easy recovery, and now enjoy good health. I lost but one patient who had been the subject of early and copious bleeding. His death was evidently induced by a supper of beef-stakes and porter, after he had exhibited the most promising signs of convalescence.

OF PURGING.

From the great difficulty that was found in discharging bile from the bowels, by the common modes of administering purges, Dr. Griffitts suggested to me the propriety of giving large doses of calomel, without jalap or any other purging medicine, in order to loosen the bile from its close connection with the gall-bladder and duodenum, during the first day of the disease. This method of discharging acrid bile was found useful. I observed the same relief from large evacuations of f[oe]tid bile, in the epidemic of 1797, that I have remarked in the fever of 1793. Mr. Bryce has taken notice of the same salutary effects from similar evacuations, in the yellow fever on board the Busbridge Indiaman, in the year 1792. His words are: "It was observable, that the more dark-coloured and f[oe]tid such discharges were, the more early and certainly did the symptoms disappear. Their good effects were so instantaneous, that I have often seen a man carried up on deck, perfectly delirious with subsultus tendinum, and in a state of the greatest apparent debility, who, after one or two copious evacuations of this kind, has returned of himself, and astonished at his newly acquired strength[2]." Very different are the effects of tonic remedies, when given to remove this apparent debility. The clown who supposes the crooked appearance of a stick, when thrust into a pail of water, to be real, does not err more against the laws of light, than that physician errs against a law of the animal economy, who mistakes the debility which arises from oppression for an exhausted state of the system, and attempts to remove it by stimulating medicines.

[2] Annals of Medicine, p. 123.

After unlocking the bowels, by means of calomel and jalap, in the beginning of the fever, I found no difficulty afterwards in keeping them gently open by more lenient purges. In addition to those which I have mentioned in the account of the fever of 1793, I yielded to the advice of Dr. Griffitts, by adopting the soluble tartar, and gave small doses of it daily in many cases. It seldom offended the stomach, and generally operated, without griping, in the most plentiful manner.

However powerful bleeding and purging were in the cure of this fever, they often required the aid of a _salivation_ to assist them in subduing it.

Besides the usual methods of introducing mercury into the system, Dr. Stewart accelerated its action, by obliging his patients to wear socks filled with mercurial ointment; and Dr. Gillespie aimed at the same thing, by injecting the ointment, in a suitable vehicle, into the bowels, in the form of glysters.

The following fact, communicated to me by Dr. Stewart, will show the safety of large doses of calomel in this fever. Mrs. M'Phail took 60 grains of calomel, by mistake, at a dose, after having taken three or four doses, of 20 grains each, on the same day. She took, in all, 356 grains in six days, and yet, says the doctor, "such was the state of her stomach and intestines, that that large quantity was retained without producing the least griping, or more stools than she had when she took three grains every two hours."

I observed the mercury to affect the mouth and throat in the following ways. 1. It sometimes produced a swelling only in the throat, resembling a common inflammatory angina. 2. It sometimes produced ulcers upon the lips, cheeks, and tongue, without any discharge from the salivary glands. 3. It sometimes produced swellings and ulcers in the gums, and loosened the teeth without inducing a salivation. 4. There were instances in which the mercury induced a rigidity in the masseter muscles of the jaw, by which means the mouth was kept constantly open, or so much closed, as to render it difficult for the patient to take food, and impossible for him to masticate it. 5. It sometimes affected the salivary glands only, producing from them a copious secretion and excretion of saliva. But, 6. It more frequently acted upon all the above parts, and it was then it produced most speedily its salutary effects. 7. The discharge of the saliva frequently took place only during the remission or intermission of the fever, and ceased with each return of its paroxysms. 8. The salivation did not take place, in some cases, until the solution of the fever. This was more especially the case in those forms of the fever in which there were no remissions or intermissions. 9. It ceased in most cases with the fever, but it sometimes continued for six weeks or two months after the complete recovery of the patient. 10. The mercury rarely dislodged the teeth. Not a single instance occurred of a patient losing a tooth in the city hospital, where the physicians, Dr. J. Duffield informed me, relied chiefly upon a salivation for a cure of the fever. 11. Sometimes the mercury produced a discharge of blood with the saliva. Dr. Coulter, of Baltimore, gave me an account, in a letter dated the 17th of September, 1797, of a boy in whom a hæmorrhage from the salivary glands, excited by calomel, was succeeded by a plentiful flow of saliva, which saved his patient. I saw no inconvenience from the mixture of blood with saliva in any of my patients. It occurred in Dr. Caldwell, Mr. Bradford, Mr. Brown, and several others.

It has been said that mercury does no service unless it purges or salivates. I am disposed to believe that it may act as a counter stimulus to that of the miasmata of the yellow fever, and thus be useful without producing any evacuation from the bowels or mouth. It more certainly acts in this way, provided blood-letting has preceded its exhibition. I have supposed the stimulus from the remote cause of the yellow fever to be equal in force to five, and that of mercury to three. To enable the mercury to produce its action upon the system, it is necessary to reduce the febrile action, by bleeding, to two and a half, or below it, so that the stimulus of the mercury shall transcend it. The safety of mercury, when introduced into the system, has three advantages as a stimulus over that of the matter which produces the fever. 1. It excites an action in the system preternatural only in _force_. It does not derange the _natural_ order of actions. 2. It determines the actions chiefly to external parts of the body. And, 3. It fixes them, when it affects the mouth and throat, upon parts which are capable of bearing great inflammation and effusion without any danger to life. The stimulus which produces the yellow fever acts in ways the reverse of those which have been mentioned. It produces violent _irregular_ or _wrong_ actions. It determines them to internal parts of the body, and it fixes them upon viscera which bear, with difficulty and danger, the usual effects of disease. A late French writer, Dr. Fabre, ascribed to diseases a centrifugal, and a centripetal direction. From what has been said it would seem, the former belongs to mercury, and the latter to the yellow fever.

Considering the great prejudices against blood-letting, I have wished to combat this fever with mercury alone. But, for reasons formerly given, I have been afraid to trust to it without the assistance of the lancet. The character of the fever, moreover, like that which the poet has ascribed to Achilles, is of "so swift, irritable, inexorable, and cruel" a nature, that it would be unsafe to rely exclusively upon a medicine which is not only of less efficacy than bleeding, but often slow and uncertain in its operation, _more especially_ upon the throat and mouth.

Let not the reader be offended at my attempts to reason. I am aware of the evils which the weak and perverted exercise of this power of the mind has introduced into medicine. But let us act with the same consistency upon this subject that we do in other things.

We do not consign a child to its cradle for life, because it falls in its first unsuccessful efforts to use its legs. In like manner we must not abandon reason, because, in our first efforts to use it, we have been deceived. A single just principle in our science will lead to more truth, in one year, than whole volumes of uncombined facts will do in a century.

I lost but two patients in this epidemic in whom the mercury excited a salivation. One of them died from the want of nursing; the other by the late application of the remedy.

OF EMETICS.

It was said a practitioner, who was opposed to bleeding and mercury, cured this fever by means of strong emetics. I gave one to a man who refused to be bled. It operated freely, and brought on a plentiful sweat. The next day he arose from his bed, and went to his work. On the fourth day he sent for me again. My son visited him, and found him without a pulse. He died the next day.

I heard of two other persons who took emetics in the beginning of the fever, without the advice of a physician, both of whom died.

Dr. Pinckard informed me, that their effects were generally hurtful in the violent grades of the yellow fever in the West-Indies. The same information has since been given to me by Dr. Jackson. In the second and third grades of the bilious fever they appear not only to be safe, but useful.

OF DIET AND DRINKS.

The advantages of a weak vegetable diet were very great in this fever. I found but little difficulty, in most cases, in having my prohibition of animal food complied with before the crisis of the fever, but there was often such a sudden excitement of the appetite for it, immediately afterwards, that it was difficult to restrain it. I have mentioned the case of a young man, who was upon the recovery, who died in consequence of supping upon beef-stakes. Many other instances of the mortality of this fever from a similar cause, I believe, occurred in our epidemic, which were concealed from our physicians. I am not singular in ascribing the death of convalescents to the too early use of animal food. Dr. Poissonnier has the following important remark upon this subject. "The physicians of Brest have observed, that the relapses in the malignant fever, which prevailed in their naval hospitals, were as much the effect of a fault in the diet of the sick as of the contagious air to which they were exposed, and that as many patients perished from this cause as from the original fever. For this reason light soups, with leguminous vegetables in them, panada, rice seasoned with cinnamon, fresh eggs, &c. are all that they should be permitted to eat. The use of flesh should be forbidden for many days after the entire cure of the disorder[3]."

[3] Maladies de Gens de Mer, vol. i. p. 345.

Dr. Huxham has furnished another evidence of the danger from the premature use of animal food, in his history of a malignant fever which prevailed at Plymouth, in the year 1740. "If any one (says the doctor) made use of a flesh or fish diet, before he had been very well purged, and his recovery confirmed, he infallibly indulged himself herein at the utmost danger of his life[4]."

[4] Epidemics, vol. ii. p. 67.

In addition to the mild articles of diet, mentioned by Dr. Poissonnier, I found bread and milk, with a little water, sugar, and the pulp of a roasted apple mixed with it, very acceptable to my patients during their convalescence. Oysters were equally innocent and agreeable. Ripe grapes were devoured by them with avidity, in every stage of the fever. The season had been favourable to the perfection of this pleasant fruit, and all the gardens in the city and neighbourhood in which it was cultivated were gratuitously opened by the citizens for the benefit of the sick.

The drinks were, cold water, toast and water, balm tea, water in which jellies of different kinds had been dissolved, lemonade, apple water, barley and rice water, and, in cases where the stomach was affected with sickness or puking, weak porter and water, and cold camomile tea. In the convalescent stage of the fever, and in such of its remissions or intermissions as were accompanied with great languor in the pulse, wine-whey, porter and water, and brandy and water, were taken with advantage.

Cold water applied to the body, cool and fresh air, and cleanliness, produced their usual good effects in this fever. In the external use of cold water, care was taken to confine it to such cases as were accompanied with preternatural heat, and to forbid it in the cold fit of the fever, and in those cases which were attended with cold hands and feet, and where the disease showed a disposition to terminate, in its first stage, by a profuse perspiration. It has lately given me great pleasure to find the same practice, in the external use of cold water in fevers, recommended by Dr. Currie of Liverpool, in his medical reports of the effects of water, cold and warm, as a remedy in febrile diseases. Of the benefit of fresh air in this fever, Dr. Dawson of Tortola has lately furnished me with a striking instance. He informed me, that by removing patients from the low grounds on that island, where the fever is generated, to a neighbouring mountain, they generally recovered in a few days.

Finding a disagreeable smell to arise from vinegar sprinkled upon the floor, after it had emitted all its acid vapour, I directed the floors of sick rooms to be sprinkled only with water. I found the vapour which arose from it to be grateful to my patients. A citizen of Philadelphia, whose whole family recovered from the fever, thought he perceived evident advantages from tubs of fresh water being kept constantly in the sick rooms.

OF TONIC REMEDIES.

There were now and then remissions and intermissions of the fever, accompanied with such signs of danger from debility, as to render the exhibition of a few drops of laudanum, a little wine-whey, a glass of brandy and water, and, in some instances, a cup of weak chicken-broth, highly necessary and useful. In addition to these cordial drinks, I directed the feet to be placed in a tub of warm water, which was introduced under the bed-clothes, so that the patient was not weakened by being raised from a horizontal posture. All these remedies were laid aside upon the return of a paroxysm of fever.

I did not prescribe bark in a single case of this disease. An infusion of the quassia root was substituted in its room, in several instances, with advantage.

_Blisters_ were applied as usual, but, from the insensibility of the skin, they were less effectual than applications of mustard to the arms and legs. It is a circumstance worthy of notice, that while the stomach, bowels, and even the large blood-vessels are sometimes in a highly excited state, and overcharged, as it were, with life, the whole surface of the body is in a state of the greatest torpor. To attempt to excite it by internal remedies is like adding fuel to a chimney already on fire. The excitement of the blood-vessels, and the circulation of the blood, can only be equalized by the application of stimulants to the skin. These, to be effectual, should be of the most powerful kind. Caustics might probably be used in such cases with advantage. I am led to this opinion by a fact communicated to me by Dr. Stewart. A lighted candle, which had been left on the bed of a woman whom he was attending in the apparent last stage of the yellow fever, fell upon her breast. She was too insensible to feel, or too weak to remove it. Before her nurse came into her room, it had made a deep and extensive impression upon her flesh. From that time she revived, and in the course of a few days recovered. As a tonic remedy in this fever, Dr. Jackson has spoken to me in high terms of the good effects of riding in a carriage. Patients, he informed me, who were moved with difficulty, after riding a few miles were able to sit up, and, when they returned from their excursions, were frequently able to walk to their beds.

Much has been said, of late years, in favour of the application of warm olive oil to the body in the plague, and a wish has been expressed, by some people, that its efficacy might be tried in the yellow fever. Upon examining the account of this remedy, as published by Mr. Baldwin, three things suggest themselves to our notice. 1. That the oil is effectual only in the _forming_ state of the disease; 2. That the friction which is used with it contributes to excite the torpid vessels of the skin; and 3. That it acts chiefly by depleting from the pores of the body. From the unity of the remedy of depletion, it is probable purging or bleeding might be substituted to the expensive parade of the sweat induced by the warm oil, and the smoke of odoriferous vegetables. But I must not conceal here, that there are facts which favour an idea, that oil produces a sedative action upon the blood-vessels, through the medium of the skin. Bontius says it is used in this manner in the East-Indies, for the cure of malignant fevers, after the previous use of bleeding and purging. It seems to have been a remedy well known among the Jews; hence we find the apostle James advises its being applied to the body, in addition to the prayers of the elders of the church[5]. It is thus in other cases, the blessings of Heaven are conveyed to men through the use of natural means.

[5] Chapter v. verse 14.

During the existence of the premonitory symptoms, and before patients were confined to their rooms, a gentle purge, or the loss of a few ounces of blood, in many hundred instances, prevented the formation of the fever. I did not meet with a single exception to this remark.

Fevers are the affliction chiefly of poor people. To prevent or to cure them, remedies must be cheap, and capable of being applied with but little attendance. From the affinity established by the Creator between evil and its antidotes, in other parts of his works, I am disposed to believe no remedy will ever be effectual in any general disease, that is not cheap, and that cannot easily be made universal.

It is to be lamented that the greatest part of all the deaths which occur, are from diseases that are under the power of medicine. To prevent their fatal issue, it would seem to be agreeable to the order of Heaven in other things, that they should be attacked in their forming state. Weeds, vermin, public oppression, and private vice, are easily eradicated and destroyed, if opposed by their proper remedies, as soon as they show themselves. The principal obstacle to the successful use of the antidotes of malignant fevers, in their early stage, arises from physicians refusing to declare when they appear in a city, and from their practice of calling their mild forms by other names than that of a mortal epidemic.

I shall now say a few words upon the success of the depleting practice in this epidemic.

From the more malignant state of the fever, and from the fears and prejudices that were excited against bleeding and mercury by means of the newspapers, the success of those remedies was much less than in the years 1793 and 1794. Hundreds refused to submit to them at the _time_, and in the _manner_, that were necessary to render them effectual. From the publications of a number of physicians, who used the lancet and mercury in their greatest extent, it appears that they lost but one in ten of all they attended. It was said of several practitioners who were opposed to copious bleeding, that they lost a much smaller proportion of their patients with the prevailing fever. Upon inquiry, it appeared they had lost many more. To conceal their want of success, they said their patients had died of other diseases. This mode of deceiving the public began in 1793. The men who used it did not recollect, that it is less in favour of a physician's skill to lose patients in pleurisies, colics, hæmorrhages, contusions, and common remittents, than in a malignant yellow fever.

Dr. Sayre attended fifteen patients in the disease, all of whom recovered by the plentiful use of the depleting remedies. His place of residence being remote from those parts of the city in which the fever prevailed most, prevented his being called to a greater number of cases.

A French physician, who bled and purged _moderately_, candidly acknowledged that he saved but three out of four of his patients.

In the city hospital, where bleeding was sparingly used, and where the physicians depended chiefly upon a salivation, more than one half died of all the patients who were admitted. It is an act of justice to the physicians of the hospital to add, that many, perhaps most of their patients, were admitted _after_ the first day of the disease.

I cannot conclude this comparative view of the success of the different modes of treating the yellow fever, without taking notice, that the stimulating mode, as recommended by Dr. Kuhn and Dr. Stevens, in the year 1793, was deserted by every physician in the city. Dr. Stevens acknowledged the disease to require a different treatment from that which it required in the West-Indies; Dr. Kuhn adopted the lancet and mercury in his practice; and several other physicians, who had written against those remedies, or who had doubted of their safety and efficacy, in 1793, used them with confidence, and in the most liberal manner, in 1797.

In the histories I have given of the yellow fevers of 1793 and 1794, I have scattered here and there a few observations upon their degrees of danger, and the signs of their favourable or unfavourable issue. I shall close the present history, by collecting those observations into one view, and adding to them such other signs as have occurred to me in observing this epidemic.

Signs of moderate danger, and a favourable issue of the yellow fever.

1. A chilly fit accompanying the attack of the fever. The longer this chill continues, the more favourable the disease.

2. The recurrence of chills every day, or twice a day, or every other day, with the return of the exacerbations of the fever. A coldness of the whole body, at the above periods, without chills, a coldness with a profuse sweat, cold feet and hands, with febrile heat in other parts of the body, and a profuse sweat without chills or coldness, are all less favourable symptoms than a regular chilly fit, but they indicate less danger than their total absence during the course of the fever.

3. A puking of _green_ or _yellow_ bile on the first day of the disease is favourable. A discharge of black bile, if it occur on the _first_ day of the fever, is not unfavourable.

4. A discharge of green and yellow stools. It is more favourable if the stools are of a dark or black colour, and of a f[oe]tid and acrid nature, on the first or second day of the fever.

5. A softness and moisture on the skin in the beginning of the fever.

6. A sense of pain in the head, or a sudden translation of pain from internal to external parts of the body, particularly to the back. An increase of pain after bleeding.

7. A sore mouth.

8. A moist white, or a yellow tongue.

9. An early disposition to spit freely, whether excited by nature or the use of mercury.

10. Blood becoming sizy, after having exhibited the usual marks of great morbid action in the blood-vessels.

11. Great and exquisite sensibility in the sense of feeling coming on near the close of the fever.

12. Acute pains in the back and limbs.

13. The appearance of an inflammatory spot on a finger or toe, Dr. H. M'Clen says, is favourable. It appears, the doctor says, as if the cause of the fever had escaped by explosion.

Signs of great danger, and of an unfavourable issue of the yellow fever are,

1. An attack of the fever, suddenly succeeding great terror, anger, or the intemperate use of venery, or strong drink.

2. The first paroxysm coming on without any premonitory symptoms, or a chilly fit.

3. A coldness over the whole body without chills for two or three days.

4. A sleepiness on the first and second days of the fever.

5. Uncommon paleness of the face not induced by blood-letting.

6. Constant or violent vomiting, without any discharge of bile.

7. Obstinate costiveness, or a discharge of natural, or white stools; also quick, watery stools after taking drink.

8. A diarrh[oe]a towards the close of the fever. I lost two patients, in 1797, with this symptom, who had exhibited, a few days before, signs of a recovery. Dr. Pinckard informed me, that it was generally attended with a fatal issue in the yellow fever of the West-Indies. Diemerbroeck declares, that "scarcely one in a hundred recovered, with this symptom, from the plague[6]."

[6] Lib. i. cap. 15.

9. A suppression of urine. It is most alarming when it is without pain.

10. A discharge of dark-coloured and bloody urine.

11. A cold, cool, dry, smooth, or shining skin.

12. The appearance of a yellow colour in the face on the first or second day of the fever.

13. The absence of pain, or a sudden cessation of it, with the common symptoms of great danger.

14. A disposition to faint upon a little motion, and fainting after losing but a few ounces of blood.

15. A watery, glassy, or brilliant eye. A red eye on the fourth or fifth day of the disease. It is more alarming if it become so after having been previously yellow.

16. Imperfect vision, and blindness in the close of the disease.

17. Deafness.

18. A preternatural appetite, more especially in the last stage of the fever.

19. A slow, intermitting, and shattered pulse.

20. Great restlessness, delirium, and long continued coma.

21. A discharge of coffee-coloured or black matter from the stomach, after the fourth day of the fever.

22. A smooth red tongue, covered with a lead-coloured crust, while its edges are of a bright red.

23. A dull vacant face, expressive of distress.

24. Great insensibility to common occurrences, and an indifference about the issue of the disease.

25. Uncommon serenity of mind, accompanied with an unusually placid countenance.

I shall conclude this head by the following remarks:

1. The violence, danger, and probable issue of this fever, seem to be in proportion to the duration and force of the predisposing and exciting causes. However steady the former are in bringing on debility, and the latter in acting as irritants upon accumulated excitability, yet a knowledge of their duration and force is always useful, not only in forming an opinion of the probable issue of the fever, but in regulating the force of remedies.

2. The signs of danger vary in different years, from the influence of the weather upon the disease.

3. Notwithstanding the signs of the favourable and unfavourable issue of the fever are in general uniform, when the cure of the disease is committed to nature, or to tonic medicines, yet they are far from being so when the treatment of the fever is taken out of the hands of nature, and attempted by the use of depleting remedies. We often see patients recover with nearly all the unfavourable symptoms that have been mentioned, and we sometimes see them die, with all those that are favourable. The words of Morellus, therefore, which he has applied to the plague, are equally true when applied to the yellow fever. "In the plague, our senses deceive us. Reason deceives us. The aphorisms of Hippocrates deceive us[7]." An important lesson may be learned from these facts, and that is, never to give a patient over. On the contrary, it is our duty in this, as well as in all other acute diseases, to dispute every inch of ground with death. By means of this practice, which is warranted by science, as well as dictated by humanity, the grave has often been deprived for a while of its prey, and a prelude thereby exhibited of that approaching and delightful time foretold by ancient prophets, when the power of medicine over diseases shall be such, as to render old age the only outlet of human life.

[7] De Feb. Pestilent. cap. v. "Acutorum morborum incertæ admodum, ac fallaces sunt prædictiones." HIPPOCRATES.

AN ACCOUNT

OF THE

_BILIOUS YELLOW FEVER_,

AS IT

APPEARED IN PHILADELPHIA,

IN THE YEAR 1798.

The yellow fever of the year 1797 was succeeded by scarlatina, catarrhs, and bilious pleurisies, in the months of November and December of the same year. The weather favoured the generation of the latter diseases. It became suddenly cold about the middle of November. On the 5th of December, the navigation of the Delaware was obstructed. There was a thaw on the 13th and 14th of this month, but not sufficient to open the river.

In the month of January, 1798, the fevers discovered an uncommon determination to the brain. Four cases of the hydrocephalic state of fever occurred under my care during this month, all of which yielded to depleting remedies. The subjects of this state of fever were Mr. Robert Lewis, and the daughters of Messrs. John Brooks, Andrew Ellicott, and David Maffat.

The weather was variable during the months of February and March. The navigation of the Delaware was not completely opened until the latter end of February. The diseases of these two months were catarrhs and bilious pleurisies. The former were confined chiefly to children, and were cured by gentle pukes, purges of calomel, and blood-letting. The last remedy was employed twice in a child of Isaac Pisso, of six weeks old, and once in a child of Thomas Billington, of three weeks old, with success.

On the 7th of April, I visited Mr. Pollock, lately from the state of Georgia, in consultation with Dr. Physick, in a yellow fever. He died the evening after I saw him, on the third day of his disease.

There was a snow storm on the 16th of April, and the weather was afterwards very cold. Such leaves and blossoms as had appeared, were injured by it.

On the 1st of May, the mercury in Fahrenheit's thermometer rose to 84°. The weather, during the latter part of this month, and in June, was very dry. On the 6th of June, Dr. Cooper lost a patient in the yellow fever, near the corner of Twelfth and Walnut-streets. Mark Miller died with the same state of fever on the 2d of July. About a dozen cases of a similar nature occurred, under the care of different practitioners, between the 2d and 20th of this month, and all of them in parts of the city remote from Water-street.

On the 19th of July, the weather was so cool as to render winter clothes comfortable. A severe hail storm had occurred, a few days before, in the neighbourhood of Wilmington, in the Delaware state.

On the 21st of the month, the ship Deborah arrived from one of the West-India islands, and discharged her cargo in the city. She was moored afterwards at Kensington, where the foul air which was emitted from her hold produced several cases of yellow fever, near the shores of that village.

In August the disease appeared in nearly every part of the city, and particularly in places where there was the greatest exhalation from foul gutters and common sewers.

In describing the disease, as it appeared this year, I shall take notice of its symptoms as they appeared in the blood-vessels, alimentary canal, the tongue, the nervous system, in the eyes, the lymphatic system, and the blood.

The subjects which furnished the materials for this history were not only private patients, but the poor in the city hospital, who were committed to the care of Dr. Physick and myself, by the board of health.

I. The pulse was, in many cases, less active in the beginning of this fever than in former years. It was seldom preternaturally slow. It resembled the pulse which occurs in the first stage of the common jail fever. Hæmorrhages were common about the fourth and fifth days, and generally from the gums, throat, or stomach.

II. The whole alimentary canal was much affected in most cases. Costiveness and a vomiting were general. The alvine discharges were occasionally green, dark-coloured, black, and natural. The black vomiting was more common this year than in former years, in all the forms of the fever. It was sometimes suspended for several days before death, and hopes were entertained of a recovery of patients in whom it had appeared. In a boy, at the city hospital, it ceased ten days before he died. It was sometimes succeeded by delirium or coma, but it more commonly left the patient free of pain, and in the possession of all the faculties of his mind.

III. The tongue was by no means an index of the state of the fever, as in the years 1793 and 1797. I saw several deaths, attended with a black vomiting, in which the tongue retained a natural appearance. This phenomenon at first deceived me. I ascribed it to such a concentration of the disease in the stomach and other vital parts, as to prevent its diffusing itself through the external parts of the system. We observe the effects of the same cause in a natural state of the skin, and in a natural appearance of the urine, in the most malignant forms of this fever.

IV. In the nervous system, the disease appeared with several new symptoms. A relation of Peter Field attempted to bite his attendants in the delirium of his fever, just before he died.

I attended a young woman at Mrs. Easby's, who started every time I touched her pulse. Loud talking, or a question suddenly proposed to her, produced the same convulsive motion. She retained her reason during the whole of her illness, and was cured by bleeding and a salivation.

Hiccup was a common symptom. I saw but two patients recover who had it. In one of them, Dr. Hedges, it came on after the sixth day of the fever, and continued, without any other symptom of disease, for four or five days.

I lost a patient who complained of no pain but in the calves of his legs. Dr. Physick lost a girl, in the city hospital, who complained only of pains in her toes. Her stomach discovered, after death, strong marks of inflammation.

Many people passed through every stage of the disease, without uttering a complaint of pain of any kind.

An uncommon stiffness in the limbs preceded death a few hours, in several cases. This stiffness ceased, in one of Dr. Physick's patients, immediately after death, but returned as soon as he became cold.

An obstinate wakefulness continued through the whole of the disease in Dr. Leib. It was common during the convalescence, in many cases.

The whole body was affected, in many cases, with a morbid sensibility, or what has been called supersensation, so that patients complained of pain upon being touched, when they were moved in their beds. This extreme sensibility was general in parts to which blisters had been applied. It continued through every stage of the disease. Dr. Physick informed me, that he observed it in a man two hours before he died. In this man there was an absence of pulse, and a coldness of his extremities. Upon touching his wrist, he cried out, as if he felt great pain.

V. A redness in the eyes was a general symptom. I saw few recoveries where this redness was not removed.

A discharge of matter from one ear relieved Mr. J. C. Warren from a distressing pulsation of the arteries in his head.

VI. Glandular swellings occurred in several instances. Two cases of them came under my notice. They both terminated favourably.

VII. The blood had its usual appearances in this disease. In the yellow fever which prevailed at the same time in Boston, Dr. Rand says the blood was sizy in but one out of a hundred cases.

The forms of the fever were nearly similar to those which have been described in the year 1797. I saw several cases in which the disease appeared in the form of a tertian fever. In one of them it terminated in death.

The system, in many cases, was prostrated below the point of inflammatory re-action. These were called, by some practitioners, typhous fevers. It was the most dangerous and fatal form of the disease. Its frequent occurrence gave occasion to a remark, that our epidemic resembled the yellow fever of the West-Indies, much more than the fevers of 1793 and 1797.

I attended two patients in whom the disease was protracted nearly to the 30th day. They both recovered.

Dr. Francis Sayre informed me, that he saw a child, in which the morbid affection of the wind-pipe, called cynanche trachealis, appeared with all the usual symptoms of yellow fever.

I attended one case in which the force of the disease was weakened, in its first stage, by a profuse hæmorrhage from the bowels. This hæmorrhage was followed by a bloody diarrh[oe]a, which continued for four or five weeks.

Persons of all ages and colours were affected by this fever. I saw a case of it in a child of six months old. In the blacks, it was attended with less violence and mortality than in white people. It affected many persons who had previously had it.

The disease was excited by the same causes which excited it in former years. I observed a number of people to be affected by the fever, who lived in solitude in their houses, without doing any business. The system, in these persons, was predisposed to the disease, by the debility induced by ceasing to labour at their former occupations. It was excited in a young man by a fractured leg. He died five days afterwards, with a black vomiting. I observed, in several instances, an interval of four and five days between the debility induced upon the system by a predisposing, and the action of an exciting cause. Dr. Clark says, he has seen an interval of several weeks between the operation of those causes, in the yellow fever of Dominique. These facts are worthy of notice, as they lead to a protracted use of the means of obviating an attack of the disease.

During my attendance upon the sick, I twice perceived in my system the premonitory signs of the epidemic. Its complete formation was prevented each time by rest, a moderate dose of physic, and a plentiful sweat.

I shall now take notice of the different manner in which patients died of this fever. The detail may be useful, by unfolding new principles in the animal economy, as well as new facts in the history of the disease.

1. The disease terminated in death, in some instances, by means of convulsions.

2. By delirium, which prompted to exertions and actions similar to those which take place in madness.

3. By profuse hæmorrhages from the gums. This occurred in two patients of Dr. Stewart.

4. By an incessant vomiting and hiccup.

5. By extreme pain in the calves of the legs and toes, which, by destroying the excitement of the system, destroyed life.

6. By a total absence of pain. In this way it put an end to the life of Mr. Henry Hill.

7. By a disposition to easy, and apparently natural sleep. I have reason to believe that Mr. Hill encouraged this disposition to sleep, a few hours before he died, under the influence of a belief that he would be refreshed by it. Diemerbroeck says the plague often killed in the same way.

8. The mind was in many cases torpid, where no delirium attended, and death was submitted to with a degree of insensibility, which was often mistaken for fortitude and resignation.

I shall now mention the morbid appearances exhibited by the bodies of persons who died of this fever, as communicated to me by my friend, Dr. Physick; being the result of numerous dissections made by him at the city hospital.

In all of them the stomach was inflamed. The matter which constitutes what is called the _black vomit_, was found in the stomachs of several patients who had not discharged it at any time by vomiting. In some stomachs, he found lines which seemed to separate the living from their dead parts. Those parts, though dead, were not always in a mortified state. They were distinguished from the living parts by a peculiar paleness, and by discovering a weak texture upon being pressed between the fingers. He observed the greatest marks of inflammation in the stomachs of several persons in whom there had been no vomiting, during the whole course of the disease. The brain, in a few instances, discovered marks of inflammation. Water was now and then found in its ventricles, but always of its natural colour, even in those persons whose skins were yellow. The liver suffered but little in this disease. It may serve to increase our knowledge of the influence of local circumstances upon epidemics to remark, that this viscus, which was rarely diseased in the fever of Philadelphia in 1798, discovered marks of great inflammation in the bodies which were examined by Dr. Rand and Dr. Warren, in the town of Boston, where the yellow fever prevailed at the same time it did in Philadelphia.

The weather was hot and dry in August and September, during the prevalence of this fever. Its influence upon animal and vegetable life are worthy of notice. Moschetoes abounded, as usual in sickly seasons; grasshoppers covered the ground in many places; cabbages and other garden vegetables, and even fields of clover, were devoured by them. Peaches ripened this year three weeks sooner than in ordinary summers, and apples rotted much sooner than usual after being gathered in the autumn. Many fruit-trees blossomed in October, and a second crop of small apples and cherries were seen in November, on the west side of Schuylkill, near the city. Meteors were observed in several places. On the 29th of September there was a white frost. Its effects upon the fever were obvious and general. It declined, in every part of the city, to such a degree as to induce many people to return from the country. In the beginning of October the weather again became warm, and the disease revived. It was observable, that all great changes in the weather from heat to cold that were short of frost, or of cold to heat, increased the mortality of the fever. It spread most rapidly in moist weather.

The origin of this fever was from the exhalations of gutters, docks, cellars, common sewers, ponds of stagnating water, and from the foul air of the ship formerly mentioned.

The fever prevailed at the same time in the town of Chester, in Pennsylvania; in Wilmington, in the state of Delaware; in New-York; in New-London, in Connecticut; in Windsor, in Vermont; and in Boston; in all which places its origin was traced to domestic sources.

I shall now deliver a short account of the remedies employed in the cure of this disease.

I have said that the pulse was less active in this fever than in the fevers of former years. It was seldom, however, so feeble as to forbid bleeding. In Dr. Mease it called for the loss of 162 ounces of blood, and in Mr. J. C. Warren for the loss of 200, by successive bleedings, before it was subdued. But such cases were not common. In most of them, the pulse flagged after two or three bleedings. But there were cases in which the lancet was forbidden altogether. In these, the system appeared to be prostrated, by the force of the miasmata, below the point of re-action. This state of the disease manifested itself in a weak, quick, and frequent pulse, languid eye, sighing, great inquietude, or great insensibility. However unsafe bleeding was on the first day of this fever, when it appeared with those symptoms, nature often performed that operation upon herself from the gums, on the fourth or fifth day. I saw several pounds of blood discharged on those days, and in that way, with the happiest effects. It appeared to take place after the revival of the blood-vessels from their prostrated state.

From a conviction that the system was depressed only in these cases, and finding that it did not rise upon blood-letting, I resolved to try the effects of emetics, in exciting and equalizing the action of the blood-vessels. The experience I had had of the inefficacy of this remedy in 1793, and of its ill effects in one instance in 1797, led me to exhibit it with a trembling hand. I gave it for the first time to a son of Richard Renshaw. I had bled him but once, and had in vain tried to bring on a salivation. On the fifth day of his disease, his pulse became languid and slow, his skin cool, a hæmorrhage had taken place from his gums, and he discovered a restlessness and anxiety which I had often seen a few hours before death. He took four grains of tartar emetic, with twenty grains of calomel, at two doses. They operated powerfully, upwards and downwards, and brought away a large quantity of bile. The effects of this medicine were such as I wished. The next day he was out of danger. I prescribed the same medicine in many other cases with the same success. To several of my patients I gave two emetics in the course of the disease. Some of them discharged bile resembling in viscidity the white of an egg. But I saw one case in which great relief was obtained from the operation of an emetic, where no bile was discharged.

In the exhibition of this remedy, I was regulated by the pulse. If I found it languid on the first day of the fever, I gave it before any other medicine. When it was full and tense, I deferred it until I had reduced the pulse to the emetic point by bleeding and purges. I observed, with great pleasure, that mercury affected the mouth more speedily and certainly where an emetic had been administered, than in other cases, probably from awakening, by its stimulus, the sensibility of the stomach; for such was its torpor, that in one case ten grains of tartar emetic, and in another thirty grains, did not operate upon it, so as to excite even the slightest degree of nausea.

In many cases, an emetic, given in the forming state of the disease, seemed to effect an immediate cure.

Purges produced the same salutary effects that they did in former years. I always combined calomel with them in the first stage of the disease.

A salivation was found to be the most certain remedy of any that was used in this fever. I did not lose a single patient, in whom the mercury acted upon the salivary glands. It was difficult to excite it in many cases, from the mercury being rejected by the stomach, from its passing off by the bowels, or from its stimulus being exceeded by the morbid action in the blood-vessels.

Bleeding rendered the action of the mercury upon the mouth more speedy and more certain, but I saw several cases in which a salivation was excited in the most malignant forms of the fever, where no blood had been drawn. It will not be difficult to explain the reason of this fact if we recur to what was said formerly of the prostration of the system in this fever. In its worst forms, there is often a total absence, or a feeble degree of action in the blood-vessels, from an excess of the stimulus of the remote cause of the fever. Here the mercury meets with no resistance in its tendency to the mouth. Bleeding in this case would probably do harm, by taking off a part of the pressure upon the system, and thereby produce a re-action in the vessels, that might predominate over the action of the mercury. The disease here does that for us by its force, which, in other cases, we effect by depleting remedies.

Where the mercury showed a disposition to pass too rapidly through the bowels, I observed no inconvenience from combining it with opium, in my attempts to excite a salivation. The calomel was constantly aided by mercurial ointment, applied by friction to different parts of the body.

Now and then a salivation continued for weeks and months after the crisis of this fever, to the great distress of the patient, and injury of the credit of mercury as a remedy in this disease. Dr. Physick has discovered, that in these cases the salivation is kept up by carious teeth or bone, and that it is to be cured only by removing them.

From the impracticability of exciting a salivation in all cases, I attempted the cure of this fever, after bleeding, by means of copious sweats. They succeeded in several instances where no other remedy promised or afforded any relief. They were excited by wrapping the patient in a blanket, with half a dozen hot bricks wetted with vinegar, and applied to different parts of the body. The sweating was continued for six hours, and repeated daily for four or five days.

In those cases where the fever put on the form of an intermittent, I gave bark after bleeding and purging with advantage. I gave it likewise in all those cases where the fever put on the type of the slow chronic fever. Laudanum was acceptable and useful in many cases of pain, wakefulness, vomiting, and diarrh[oe]a, after the use of depleting remedies.

I applied _blisters_ in the usual way in this fever, but I think with less effect than in the yellow fevers of former years.

To relieve a vomiting, which was very distressing in many cases about the fourth and fifth days, I gave a julep, composed of the salt of tartar and laudanum. I also gave Dr. Hosack's anti-emetic medicine, composed of equal parts of lime-water and milk. I do not know that it saved any lives, but I am sure it gave ease by removing a painful symptom, and thus, where it did not cure, lessened the sufferings of the sick.

The diet and drinks were the same in this fever as they were in the fevers formerly described.

Cool air, cold water, and cleanliness produced their usual salutary effects in this fever.

I shall now deliver a short account of the symptoms which indicated a favourable and an unfavourable issue of the disease.

It has been said[8], that the signs of danger vary in this fever, from the influence of the weather. The autumn of 1798 confirmed, in many instances, the truth of this remark.

[8] History of the Fever in 1797.

I saw no instance of death where a bleeding occurred from the gums on the fourth or fifth day, provided depleting remedies had been used from the beginning of the disease. Few recovered who had this symptom in 1793.

I saw three recoveries after convulsions in the year 1798. All died who were convulsed in 1793 and 1797.

A dry, hoarse, and sore throat was followed by death in every case in which it occurred in my practice. In the fever of 1793 a sore throat was a favourable sign. It was one of the circumstances which determined me to use a salivation in that fever.

The absence of pain was always a bad sign. Small, but frequent stools, and the continuance of a redness in the eyes after the ample use of depleting remedies, were likewise bad signs.

An appetite for food on the fourth or fifth day of the fever, without a remission or cessation of the fever, was always unfavourable.

A want of delicacy, in exposing parts of the body which are usually covered, was a bad symptom. I saw but one recovery where it took place. Boccacio says the same symptom occurred in the plague in Italy. "It suspended (he tells us) all modesty, so that young women, of great rank and delicacy, submitted to be attended, dressed, and even cleansed by male nurses."

I have remarked, in another place, that but two of my patients recovered who had the hiccup.

A dry tongue was a bad sign. I saw but one recovery where it occurred, and none where the tongue was black. A moist and natural tongue, where symptoms of violence or malignity appeared in other parts of the body, was always followed by a fatal issue of the disease.

A desire to ride out, or to go home, in persons who were absent from their families, was, in every instance where it took place, a fatal symptom. These desires arose from an insensibility to pain, or a false idea of the state of the disease. It existed to such a degree in some of the patients in the city hospital, that they often left their beds, and dressed themselves, in order to go home. All these patients died, and some of them in the act of putting on their clothes.

From the history that has been given of the symptoms, treatment, and prognosis of this fever, we see how imperfect all treatises upon epidemics must be, which are not connected with climate and season. As well might a traveller describe a foreign climate, by the state of the weather, or by the productions of the earth, during a single autumn, as a physician adopt a uniform opinion of the history, treatment, and prognosis of a fever, from its phenomena in any one country, or during a single season.

There were three modes of practice used in this epidemic. The first consisted in the exhibition of purges of castor oil, salts, and manna, and cooling glysters, and in the use of the warm bath. These remedies were prescribed chiefly by the French physicians. The second consisted in the use of mercury alone, in such doses, and in such a manner, as to excite a salivation. This mode was used chiefly by an itinerant and popular quack. The third mode consisted in using all the remedies which I have mentioned in the account of the treatment of this fever, and accommodating them to the state of the disease. This mode of practice was followed by most of the American physicians.

The first mode of practice was the least successful. It succeeded only in such cases as would probably have cured themselves.

The second mode succeeded in mild cases, and now and then in that malignant state of the fever, in which the action of the blood-vessels was so much prostrated by the force of the miasmata, as to permit the mercury to pass over them, and thus to act upon the salivary glands in the course of four or five days.

The last mode was by far the most successful. It is worthy of notice, that the business and reputation of the physicians, during this epidemic, were in the inverse ratio of their success. The number of deaths by it amounted to between three and four thousand, among whom were three physicians, and two students of medicine. Its mortality was nearly as great as it was in 1793, and yet the number of people who were affected by it was four times as great in 1793 as it was in 1798, for, in the latter year, the city was deserted by nearly all its inhabitants. The cause of this disproportion of deaths to the number who were sick, was owing to the liberal and general use of the lancet in 1793, and to the publications in 1797 having excited general fears and prejudices against it in 1798. Such was the influence of these publications, that many persons who had recovered from this fever in the two former years, by the use of depleting remedies, deserted the physicians who had prescribed them, and put themselves under the care of physicians of opposite modes of practice. Most of them died. Two of them had been my patients, one of whom had recovered of a third attack of the fever under my care.

AN ACCOUNT

OF THE

_BILIOUS YELLOW FEVER_,

AS IT

APPEARED IN PHILADELPHIA,

IN THE YEAR 1799.

The diseases which succeeded the fever of 1798, in November and December, were highly inflammatory. A catarrh was nearly universal. Several cases of sore throat, and one of erysipelas, came under my care in the month of November. The weather in December was extremely cold. It was equally so in the beginning of January, 1799, accompanied with several falls of snow.

About the middle of the month, the weather moderated so much, so as to open the navigation of the Delaware. I met with two cases of malignant colic in the latter part of this month, and one of yellow fever. The last was Swen Warner. Dr. Physick, who attended him with me, informed me that he had, nearly at the same time, attended two other persons with the same disease.

The weather was very cold, and bilious pleurisies were common, during the latter part of the month of February.

March was equally cold. The newspapers contained accounts of the winter having been uncommonly severe in Canada, and in several European countries.

The first two weeks in April were still cold. The Delaware, which had been frozen a second time during the winter, was crossed near its origin, on the ice, on the 15th day of this month. The diseases, though fewer than in the winter, were bilious and inflammatory. During this month, I was called to a case of yellow fever, which yielded to copious bleeding, and other depleting medicines.

May was colder than is usual in that month, but very healthy.

In the first week of June, several cases of highly bilious fever came under my care. In one of them, all the usual symptoms of the highest grade of that fever occurred. On the 13th of the month, Dr. Physick informed me, that he had lost a patient with that disease. On the 23d of the same month, Joseph Ashmead, a young merchant, died of it. Several other cases of the disease occurred between the 20th and 29th days of the month, in different parts of the city. About this time, I was informed that the inhabitants of Keys's-alley had predicted a return of the yellow fever, from the trees before their doors emitting a smell, exactly the same which they perceived just before the breaking out of that disease in 1793.

In July, the city was alarmed, by Dr. Griffitts, with an account of several cases of the fever in Penn-street, near the water. The strictness with which the quarantine law had been executed, for a while rendered this account incredible with many people, and exposed the doctor to a good deal of obloquy. At length a vessel was discovered, that had arrived from one of the West-India islands on the 14th of May, and one day before the quarantine law was put into operation, from which the disease was said to be derived. Upon investigating the state of this vessel, it appeared that she had arrived with a healthy crew, and that no person had been sick on board of her during her voyage.

In the latter part of July and in the beginning of August, the disease gradually disappeared from every part of the city. This circumstance deserves attention, as it shows the disease did not spread by contagion.

About this time we were informed by the newspapers, that dogs, geese, and other poultry, also that wild pigeons were sickly in many parts of the country, and that fish on the Susquehannah, and oysters in the Delaware bay, were so unpleasant, that the inhabitants declined eating them. At the same time, flies were found dead in great numbers, in the unhealthy parts of the city. The weather was dry in August and September. There was no second crop of grass. The gardens yielded a scanty supply of vegetables, and of an inferior size and quality. Cherries were smaller than usual, and pear and apple-trees dropped their fruits prematurely, in large quantities. The peaches, which arrived at maturity, were small and ill-tasted. The grain was in general abundant, and of a good quality. A fly, of an unusual kind, covered the potatoe fields, and devoured, in some instances, the leaves of the potatoe. This fly has lately been used with success in our country, instead of the fly imported from Spain. It is equal to it in every respect. Like the Spanish fly, it sometimes induces strangury.

About the middle of August the disease revived, and appeared in different parts of the city. A publication from the academy of medicine, in which they declared the seeds of the disease to spread from the atmosphere only, produced a sudden flight of the inhabitants. In no year, since the prevalence of the fever, was the desertion of the city so general.

I shall now add a short account of the symptoms and treatment of this epidemic.

The arterial system was in most cases active. I met with a tense pulse in a patient after the appearance of the black vomiting. Delirium was less frequent in adults than in former years. In children there was a great determination of the disease to the brain.

I observed no new symptoms in the stomach and bowels. One of the worst cases of the fever which I saw was accompanied with colic. A girl of Thomas Shortall, who recovered, discharged 9 worms during her fever. It appeared in Mr. Thomas Roan, one of my pupils, in the form of a dysentery.

A stiffness, such as follows death, occurred in several patients in the city hospital before death.

Miss Shortall had an eruption of pimples on her breast, such as I have described in the short account I gave of the yellow fever of 1762 in this city, in my account of the disease in 1793.

The blood exhibited its usual appearances in the yellow fever. It was seldom sizy till towards the close of the disease.

The tongue was generally whitish. Sometimes it was of a red colour, and had a polished appearance. I saw no case of a black tongue, and but few that were yellow before the seventh day of the disease.

The type of this disease was nearly the same as described in 1797. It now and then appeared in the form of a quartan, in which state it generally proved fatal. It appeared with rheumatic pains in one of my patients. It blended itself with gout and small-pox. Its union with the latter disease was evident in two patients in the city hospital, in each of whom the stools were such as were discharged in the most malignant state of the fever.

The remedies for this fever were bleeding, vomits, purges, sweats, and a salivation and blisters.

There were few cases that did not indicate bleeding. It was performed, when proper, in the usual way, and with its usual good effects. It was indicated as much when the disease appeared in the bowels as in the blood-vessels. Mr. Roan, in whom it was accompanied with symptoms of dysentery, lost nearly 200 ounces of blood by twenty-two bleedings.

I found the same benefit from emetics, in this fever, that I did in the fever of 1798. They were never administered except on the first day, before violent action had taken place in the system, or after it was moderated by one or two bleedings.

Purges of calomel and jalap, also castor oil, salts, and injections were prescribed with their usual advantages.

In those cases where the system was prostrated below the point of re-action, I began the cure by sweating. Blankets, with hot bricks wetted with vinegar, and the hot bath, as mentioned formerly, when practicable, were used for this purpose. The latter produced, in a boy of 14 years of age, who came into the city hospital without a pulse, and with a cold skin, in a few hours, a general warmth and an active pulse. The determination of the disease to the pores was evinced in one of my patients, by her sweating under the use of the above-mentioned remedies, for the first time in her life. A moisture upon her skin had never before been induced, she informed me, even by the warmest day in summer.

The advantages of a salivation were as great as in former years. From the efficacy of bleeding, purges, emetics, and sweating, I had the pleasure of seeing many recoveries before the mercury had time to affect the mouth. In no one case did I rest the cure exclusively upon any one of these remedies. The more numerous the outlets were to convey off superfluous fluids and excitement from the body, the more safe and certain were the recoveries. A vein, the gall-bladder, the bowels, the pores, and the salivary glands were all opened, in succession, in part, or together, according to circumstances, so as to give the disease every possible chance of passing out of the body without injuring or destroying any of its vital parts.

Blisters were applied with advantage. The vomiting and sickness which attend this fever were relieved, in many instances, by a blister to the stomach.

In those cases in which the fever was protracted to the chronic state, bark, wine, laudanum, and æther produced the most salutary effects. I think I saw life recalled, in several cases in which it appeared to be departing, by frequent and liberal doses of the last of those medicines. The bark was given, with safety and advantage, after the seventh day, when the fever assumed the form of an intermittent.

The following symptoms were generally favourable, viz. a bleeding from the mouth and gums, and a disposition to weep, when spoken to in any stage of the fever.

A hoarseness and sore throat indicated a fatal issue of the disease, as it did in 1798. Dr. Physick remarked, that all those persons who sighed after waking suddenly, before they were able to speak, died.

The recurrence of a redness of the eyes, after it had disappeared, or of but one eye, was generally followed by death. I saw but one recovery with a red face.

I saw several persons, a few hours before death, in whom the countenance, tongue, voice, and pulse were perfectly natural. They complained of no pain, and discovered no distress nor solicitude of mind. Their danger was only to be known by the circumstances which had preceded this apparently healthy and tranquil state of the system. They had all passed through extreme suffering, and some of them had puked black matter.

The success of the mode of practice I have described was the same as in former years, in private families; but in the city hospital, which was again placed under the care of Dr. Physick and myself, there was a very different issue to it, from causes that are too obvious to be mentioned.

There were two opinions given to the public upon the subject of the origin of this fever; the one by the academy of medicine, the other by the college of physicians. The former declared it to be generated in the city, from putrid domestic exhalations, because they saw it only in their vicinity, and discovered no channel by which it could have been derived from a foreign country; the latter asserted it to be "imported, because it had been imported in former years."

AN

ACCOUNT OF SPORADIC CASES

OF

_YELLOW FEVER_,

AS THEY

APPEARED IN PHILADELPHIA,

IN 1800.

The weather in the month of January was less cold than is common in that month. Catarrhs, the cynanche trachealis, and bilious pleurisies were prevalent in every part of it. A few cases of yellow fever occurred likewise during this month.

Several cases of erysipelas appeared in February.

The month of March was unusually healthy.

The weather was warm in April, and the city as healthy as in March.

It was equally so in May and June. The spring fruits appeared early in the latter month, in large quantities, and were of an excellent quality. Locusts were universal in June. They had not appeared since the year 1783. A record from the journal of the Swedish missionaries was published at this time, which described their appearance in 1715, in which year it was said to be very healthy.

On the 14th of June there was a severe thunder gust, with more lightning than had been known for seven years before.

There fell, during all the months that have been mentioned, frequent and plentiful showers of rain, which rendered the crops of grass luxuriant in the neighbourhood of Philadelphia.

The winds at this time were chiefly from the south-east.

A few intermittents appeared in June, which yielded readily to the bark.

On the 16th day of June, Dr. Physick informed me he had a black boy under his care with the yellow fever.

In July, the hooping cough, cholera infantum, and some cases of dysentery and bilious fever appeared in the city.

On the 30th of July, Dr. Pascalis informed me that he had lost a patient on the fifth day of a yellow fever.

In August, the dysentery was the principal form of disease that prevailed in the city.

On the 22d of this month, a woman died of the yellow fever in Gaskill-street, under the care of Dr. Church.

On the 28th and 30th, there fell an unusual quantity of rain. The winds were south-west and north-west during the greatest part of the summer months. The latter were sometimes accompanied with rain.

On the 11th of September, a clerk of Mr. Levi Hollingsworth, and, on the 12th, a clerk of Mr. John Connelly, died with the yellow fever.

A plentiful shower of rain fell on the night of the 21st of this month.

About this time there appeared one and twenty cases of yellow fever in Spruce-street, between Front and Second-streets. They were all in the neighbourhood of putrid exhalations. Fourteen of them ended fatally.

No one of the above cases of malignant fever could be traced to a ship, or to a direct or indirect intercourse with persons affected by that disease.

While Philadelphia was thus visited by a few sporadic cases only of yellow fever, it was epidemic in several of the cities of the United States, particularly in New-York, Providence, in Rhode Island, Norfolk, and Baltimore. In the last named place, it was publicly declared by the committee of health to be of domestic origin.

The dysentery was epidemic, at the same time, in several of the towns of Massachusetts and New-Hampshire. It was attended with uncommon mortality at Hanover, in the latter state.

This difference in the states of health and sickness in the different parts of the United States must be sought for chiefly in the different states of the weather in those places. The exemption of Philadelphia from the yellow fever, as an epidemic, may perhaps be ascribed to the strength and vigour of the vegetable products of the year, which retarded their putrefaction; to frequent showers of rain, which washed away the filth of the streets and gutters; and to the perfection of the summer and autumnal fruits.

The months of November and December this year were uncommonly healthy. During the former, several light shocks of earthquakes were felt in Lancaster and Harrisburg, in Pennsylvania, and in Wilmington, in the state of Delaware.

AN

ACCOUNT OF SPORADIC CASES

OF

_YELLOW FEVER_,

AS THEY

APPEARED IN PHILADELPHIA,

IN 1801.

The month of January was intensely cold. In February it became more moderate. The diseases, during these two months, were catarrhs and a few pleurisies.

In March and April there fell an unusual quantity of rain. The hay harvest began in the neighbourhood of Philadelphia on the 28th of May. A few mild cases of scarlatina anginosa occurred during these months.

In June the weather was dry and healthy.

On the 8th of July, a case of yellow fever occurred in the practice of Dr. Stewart. About the 15th of the month, a patient died with it in the Pennsylvania hospital. Dr. Physick informed me that he had, at the same time, two patients under his care with that disease. Several cases of the measles appeared in the south end of the city during this month. In every part of it, the weather was warm and dry, in consequence of which there were no second crops of grass, and a smaller quantity than usual of summer fruits and vegetables. The winds were less steady than they had been for seven years. They blew, every two or three days, from nearly every point of the compass.

On the 4th of August there fell a considerable quantity of rain, which was succeeded by cool and pleasant weather. The cholera morbus was a frequent disease among both adults and children in the city, and the dysentery in several of the adjoining counties of the state.

A number of emigrant families arrived this month from Ireland and Wales, who brought with them the ship fever. They were carefully attended, at the lazaretto and the city hospital, in airy rooms, by which means they did not propagate the disease. Contrary to its usual character, it partook of the remissions of the bilious fever, probably from the influence of the season upon it.

In September there were a few extremely warm days. In the beginning and middle of the month a number of mild remittents occurred, and about the 22d there were five or six cases of yellow fever in Eighth-street, between Chesnut and Walnut-streets, in two houses ill ventilated, and exposed to a good deal of exhalation. I attended most of these cases in consultation with Dr. Gallaher. One of the persons who was affected with this fever puked black matter while I sat by his bed-side, a few hours before he died.

During the summer and autumn of this year, a number of cases of yellow fever appeared at New-Bedford, Portland, and Norwich, in the New-England states; in New-York; in some parts of New-Jersey; and in Northampton and Bucks counties, in Pennsylvania. It prevailed so generally in New-York, as to produce a considerable desertion of the city. In none of the above places could the least proof be adduced of the disease being imported. In Philadelphia its existence was doubted or denied by most of the citizens, because it appeared in situations remote from the water, and of course could not be derived from any foreign source.

It will be difficult to tell why the fever appeared only in sporadic cases in Philadelphia. Perhaps its prevalence as an epidemic was prevented by the plentiful rains in the spring months, by the absence of moisture from the filth of the streets and gutters, in consequence of the dry weather in June and July, by the vigour and perfection of the products of the earth, and by the variable state of the winds in the month of July. If none of these causes defended the city from more numerous cases of the yellow fever, it must be resolved into the want of a concurring inflammatory constitution of the atmosphere with the common impure sources of that disease.

On the 12th of November, about twelve o'clock in the night, an earthquake was felt in Philadelphia, attended with a noise as if something heavy had fallen upon a floor. Several cases of scarlet fever appeared in December, but the prevailing disease, during the two last autumnal and the first winter months, was the measles. I have taken notice that it appeared in the south end of the city in July. During the months of August and September it was stationary, but in October, November, and December it spread through every part of the city. The following circumstances occurred in this epidemic, as far as it came under my notice.

AN ACCOUNT

OF

THE MEASLES,

AS THEY

APPEARED IN PHILADELPHIA,

IN THE YEAR 1801.

I. The disease wore the livery of the autumnal fever in the following particulars.

It was strongly marked by remissions and intermissions. The exacerbations came on chiefly at night.

There were in many cases a constant nausea, and discharge of bile by puking.

I saw one case in which the disease appeared with a violent cholera morbus, and several in which it was accompanied with diarrh[oe]a and dysentery.

II. Many severe cases of phrenzy, and two of cynanche trachealis appeared with the measles.

III. A distressing sore mouth followed them, in a child of two years old, that came under my care.

IV. A fatal hydrocephalus internus followed them in a boy of eight years old, whom I saw two days before he died.

V. I met with a few cases in which the fever and eruption came on in the same day, but I saw one case in which the eruption did not take place until the tenth, and another, in which it did not appear until the fourteenth day after the fever.

VI. Two children had pustules on their skins, resembling the small-pox, before the eruption of the measles.

VII. Many children had coughs and watery eyes, but without the measles. The same children had them two or three weeks afterwards.

VIII. Many people who had had the measles, had coughs during the prevalence of the measles, resembling the cough which occurs in that disease.

The remedies made use of in my practice were,

1. Bleeding, from four to sixty ounces, according to the age of the patient, and the state of the pulse. This remedy relieved the cough, eased the pains in the head, and in one case produced, when used a third time, an immediate eruption of the measles.

2. Lenient purges.

3. Demulcent drinks.

4. Opiates at night.

5. Blisters. And,

6. Astringent medicines, where a diarrh[oe]a took place.

I saw evident advantages from advising a vegetable diet to many children, as soon as any one of the families to which they belonged were attacked by the measles.

I lost but one patient in this disease, and that was a child in convulsions. I ascribed my success to bleeding more generally and more copiously than I had been accustomed to do, in the measles of former years.

AN ACCOUNT

OF THE

_BILIOUS YELLOW FEVER_,

AS IT

APPEARED IN PHILADELPHIA,

IN THE YEAR 1802.

The weather during the month of January was unusually moderate and pleasant. In the latter end of it, many shrubs put forth leaves and blossomed. I saw a leaf of the honeysuckle, which was more than an inch in length, and above half an inch in breadth. There was but one fall of snow, and that a light one, during the whole month.

The winds blew chiefly from the south-west in February. There was a light fall of snow on the 6th. A shad was caught in the Delaware, near the city, on the 17th. On the 18th and 19th of the month, the weather became suddenly very cold. On the 22d there was a snow storm, and on the 28th, rain and a general thaw.

In March, the weather was wet, cold, and stormy, with the exception of a few pleasant days.

The scarlatina anginosa and the cynanche trachealis were the principal diseases that prevailed during the three months that have been mentioned.

In April, there were several frosts, which destroyed the blossoms of the peach-trees.

In May, the weather was so cool as to make fires agreeable to the last day of the month. The wind blew chiefly, during the whole of it, from the north-east.

The scarlatina continued to be the reigning disease. I saw one fatal case of it, in which a redness only, without any ulcers or sloughs, appeared in the throat; and I attended another, in which a total immobility in the limbs was substituted by nature for the pain and swellings in those parts which generally attend the disease. There were three distinct grades of this epidemic. It was attended with such inflammatory or malignant symptoms, in some instances, as to require two or three bleedings; in others it appeared with a typhoid pulse, which yielded to emetics: turbith mineral was preferred for this purpose; while a redness, without a fever, which yielded to a single purge, was the only symptom of it in many people.

The weather was cool, rainy, and hot, in succession, in the month of June. The scarlatina continued to be the prevailing disease.

During the first and second weeks in July, there fell a good deal of rain. On the 4th of the month I was called to visit Mrs. Harris, in Front-street, between Arch and Market-streets, with a bilious fever. The scarlatina had imparted to it a general redness on her skin, which induced her to believe it was that disease, and to neglect sending for medical relief for several days. She died on the 13th of the month, with a red eye, a black tongue, hiccup, and a yellow skin. Three other cases of malignant bilious fever occurred this month. Two of them were attended by Dr. Dewees and Dr. Otto.

On the 15th of the month, the city was alarmed by an account of this fever having appeared near the corners of Front and Vine-streets, a part of the city which had for many weeks before been complained of by many people for emitting a f[oe]tid smell, derived from a great quantity of filthy matters stagnating in that neighbourhood, and from the foul air discharged from a vessel called the Esperanza, which lay at Vine-street wharf.

On the 2d of August, it appeared in other parts of the city, particularly in Front and Water-streets, near the draw-bridge, where it evidently originated from putrid sources. Reports were circulated that it was derived from contagion, conveyed to Vine-street wharf in the timbers of a vessel called the St. Domingo Packet, but faithful and accurate inquiries proved that this vessel had been detained one and twenty days, and well cleaned at the lazaretto, and that no one, of fourteen men who had worked on board of her afterwards, had been affected with sickness of any kind.

On the 5th of August, the board of health publicly declared the fever to be contagious, and advised an immediate desertion of the city. The advice was followed with uncommon degrees of terror and precipitation.

The disease continued, in different parts of the city, during the whole of August and September. On the 5th of October, the citizens were publicly invited from the country by the board of health.

During this season, the yellow fever was epidemic in Baltimore and Wilmington. In the former place it was admitted by their board of health, and in the latter it was proved by Dr. Vaughan, to be of domestic origin. It prevailed, at the same time, in Sussex county and near Woodbury, in New-Jersey. Sporadic cases of it likewise occurred in New-York and Boston, and in Portsmouth, in New-Hampshire. The chronic fever was epidemic in several of the towns of North-Carolina; cases of fever, which terminated in a swelling and mortification of the legs, and in death on the third day, appeared on the waters of the Juniata, in Pennsylvania; and bilious fevers, of a highly inflammatory grade, were likewise common near Germantown and Frankford, in the neighbourhood of Philadelphia.

But few of the cases of yellow fever which have been mentioned came under my care, but I saw a considerable number of fevers of a less violent grade. They were the inflammatory, bilious, mild remitting, chronic, and intermitting fevers, and the febricula. They appeared, in some instances, distinct from each other, but they generally blended their symptoms in their different stages. The yellow fever often came on in the mild form of an intermittent, and even a febricula, and as often, after a single paroxysm, ended in a mild remittent or chronic fever. When it appeared in the latter form, it was frequently attended with a slow or low pulse, and a vomiting and hiccup, such as attend in the yellow fever. This diversity of symptoms, with which the summer and autumnal fever came on, made it impossible to decide upon its type on the day of its attack. Having been deceived in one instance, I made it a practice afterwards to watch every case I was called to with double vigilance, lest it should contract a malignant form in my hands, without my being prepared to meet it. Of the five original and obvious cases of yellow fever to which I was called, I saved none, for I saw but one of them before the last stage of the disease. In many others, I have reason to believe I prevented that malignant form of fever, by the early and liberal use of depleting medicines. The practice of those physicians who attended most of the persons who had the yellow fever, was much less successful than in our former epidemics. I suspected at the time, and I was convinced afterwards, that it was occasioned by relying exclusively upon bleeding, purges, and mercury. The skin, in several of the cases which I saw, was covered with moisture. This clearly pointed out nature's attempt to relieve herself by sweating. Upon my mentioning this fact to the late Dr. Pfeiffer, jun. he instantly adopted my opinion, and informed me, as a reason for doing so, that he had heard of several whole families in the Northern Liberties, where the disease prevailed most, who, by attacking it in its forming state by profuse sweats, had cured themselves, without the advice of a physician.

AN ACCOUNT

OF THE

_BILIOUS YELLOW FEVER_,

AS IT

APPEARED IN PHILADELPHIA,

IN 1803.

The weather in January was uniformly cold. On the 21st of the month, the Delaware was completely frozen.

On the 4th of February there was a general thaw, attended with a storm of hail, thunder, and lightning, which lasted about three quarters of an hour. The diseases of both these winter months were catarrhs and bilious pleurisies. The latter appeared in a tertian type. The pain in the side was most sensible every other day.

The weather was cold and dry in March, in consequence of which, vegetation was unusually backward in April. The hooping cough, catarrhs, and scarlatina were the diseases of this month.

The beginning of May was very cool. There was ice on the 7th of the month. The winds, during the greatest parts of this and the previous month, were from the north-east.

In June, the weather was cool. Intermittents were common in this month, as well as in May. Such was the predominance of this type of fever over all other diseases, that it appeared in the form of profuse sweats, every other night, in a lady under the care of Dr. Dewees and myself, in the puerperile fever. On the intermediate nights she had a fever, without the least moisture on her skin. There were a few choleras this month. During the latter end of the month, I lost a patient with many of the symptoms of yellow fever.

The weather in July was alternately hot, moderate, and cool, with but little rain. The first two weeks of this month were healthy. A few tertian fevers occurred, which readily yielded to bark, without previous bleeding. Between the 25th and 31st of the month, three deaths took place from the yellow fever.

In the month of August, the weather was the same as in July, except that there fell more rain in it. Mild remittents and cholera infantum were now common. There were likewise several cases of yellow fever during this month. One of them was in Fromberger's-court. It was induced by the f[oe]tor of putrid fish in a cellar. A malignant dysentery was epidemic during this month in the upper part of Germantown, and in its neighbourhood. Several persons, Dr. Bensell informed me, died of it in thirty hours sickness. It prevailed, at the same time, in many parts of the New-England states.

In September, cases of yellow fever appeared in different parts of the city, but chiefly in Water, near Walnut-street. On the 12th of the month, the board of health published a declaration of its existence in the city, but said it was not contagious. This opinion gave great offence, for it was generally said to have been imported by means of a packet-boat from New-York, where the fever then prevailed, because a man had sickened and died in the neighbourhood of the wharf where this packet was moored. It was to no purpose to oppose to this belief, proofs that no sick person, and no goods supposed to be infected, had arrived in this boat, and that no one of three men, who had received the seeds of the disease in New-York, had communicated it to any one of the families in Philadelphia, in which they had sickened and died.

The disease assumed a new character this year, and was cured by a different force of medicine from that which was employed in some of the years in which it had prevailed in Philadelphia.

I shall briefly describe it in each of the systems, and then take notice of some peculiarities which attended it. Afterwards I shall mention the remedies which were effectual in curing it.

1. The pulse was moderately _tense_ in most cases. It intermitted in one case, and in several others the tension was of a transient nature.

Hæmorrhages occurred in many cases. They were chiefly from the nose, but in some instances they occurred from the stomach, bowels, and hæmorrhoidal vessels.

2. Great flatulency attended in the stomach, but sickness and vomiting were much less frequent than in former years. I saw but one case in which diarrh[oe]a attended this fever.

3. I did not meet with a single instance of a glandular swelling in any part of the body.

4. There was a general disposition to sweat in this fever from its beginning. Two of my patients died, in whom no moisture could be excited on the skin. But I recovered one with a dry skin, by means of a purge, two bleedings, and blisters.

An efflorescence on the skin occurred in several instances. I saw black matter discharged from a blister in one case, and blood in another.

5. The stools were green and black. Bile was generally discharged in puking.

6. The blood exhibited the following appearances: siziness, lotura carnium, sunken crassamentum, red sediment, and what is called dense or unseparated blood. I saw no instance of its being dissolved.

7. The tongue was whitish and dark-coloured. This diseased appearance continued, in some instances, several days after a recovery took place. I saw no smooth, red, nor black tongue, and but one dry and one _natural_ tongue. The latter was followed by death.

I did not see a single case in which the disease came on without an exciting cause; such as light clothing and bed-clothes, sitting at doors after night, a long walk, gunning, and violent and unusual exercises of any kind. It was excited in a number of people by their exertions to extinguish a fire which took place in Water-street, between Market and Chesnut-streets, on the morning of the 25th of August. I saw a fatal instance of it succeed a severe tooth-ach. Whether this pain was the exciting cause, or the first morbid symptom of the fever, I know not; but I was led by it to bleed a young lady twice who complained of that pain, and who had at the same time a tense pulse. Her blood had the usual appearances which occur in the yellow fever.

The disease had different appearances in different parts of the city. It was most malignant in Water-street; but in many instances it became less so, as it travelled westward, so that about Ninth-street it appeared in the form of a common intermittent.

In every part of the city it often came on, as in the year 1802, in all the milder forms of autumnal fever formerly enumerated, and went off with the usual symptoms of yellow fever. Again, it came on with all the force and malignity of a yellow fever, and terminated, in a day or two, in a common remittent or intermittent. These modes of attack were so common, that it was impossible to tell what the character, or probable issue of a fever would be, for two or three days.

The following remedies were found, very generally, to be effectual in this fever.

1. Moderate bleeding. I bled but three patients three, and only one, four times. In general, the loss of from ten to twenty ounces of blood, reduced the pulse from a synocha to a synoichoid or typhoid state, and thereby prepared the system for other remedies.

2. Purges were always useful. I gave calomel and jalap, castor oil, salts, and senna, according to the grade of the disease, and often according to the humour or taste of the patient. I aided these purges by glysters. In one case, where a griping and black stools attended, I directed injections of lime water and milk to be used, with the happiest effects.

3. I gave emetics in many cases with advantage, but never while the pulse was full or tense.

4. Having observed, as in the year 1802, a spontaneous moisture on the skin on the first day of the disease, in several cases, I was led to assist this disposition in nature to be relieved by the pores, by means of sweating remedies, but in no instance did I follow it, without previous evacuations from the blood-vessels or bowels; for, however useful the intimations of nature may be in acute diseases, her efforts should never be trusted to alone, inasmuch as they are in most cases too feeble to do service, or so violent as to do mischief. I saw one death, and I heard of another, from an exclusive reliance upon spontaneous sweats in the beginning of this fever. The remedies I employed to promote this evacuation by the pores were, an infusion of the eupatorium perfoliatum in boiling water, aided by copious warm drinks, and hot bricks and blankets, applied to the external surface of the body. The eupatorium sometimes sickened the stomach, and puked. The sweats were intermitted, and renewed two or three times in the course of four and twenty hours.

5. I derived great advantage from the application of blisters to the wrists, _before_ the system descended to what I have elsewhere called, the blistering point. This was on the second and third days. My design, in applying them thus early, was to attract morbid excitement to the extremities, and thereby to create a substitute for a salivation. They had this effect. The pain, increase of fever, and occasional strangury, which were produced by them, served like anchors to prevent the system being drifted and lost, by the concentration of morbid excitement in the stomach and brain, on the fourth, fifth, sixth, and seventh days of the disease. It gave me great pleasure to find, upon revising Dr. Home's account of the yellow fever, that this mode of applying blisters, in the early stage of the disease, was not a new one. He often applied them in the first stage of the fever, more especially when the yellow colour of the skin made its appearance on the first or second day. By the advice of Dr. Cheney, of Jamaica, he was led to prefer them to the thighs, instead of the trunk of the body, or the legs and arms. He forbids their ever being applied below the calf of the legs. This caution is probably more necessary in the West-Indies than in the United States. The pain and inflammation excited by the blisters were mitigated by soft poultices of bread and milk. The strangury soon yielded to demulcent drinks, particularly to flaxseed tea.

I was happy in not being compelled, by the violence or obstinacy of this fever, to resort to a salivation in order to cure it, in a single instance; the discharges from the stomach and bowels, and from the veins, pores, and skin, having proved sufficient to convey the disease out of the system.

Two persons recovered this year who had the black vomiting. One of them was by means of large quantities of brandy and volatile alkali, administered by Dr. John Dorsey, in the city hospital; the other was by means of lime and water and milk, given by an intelligent nurse to one of my patients, during the interval of my visits to her.

From the history which has been given of the symptoms of this fever; from the less force of medicine that was necessary to subdue it; from the safety and advantage of blisters in its _early_ stage; and from the small proportion which the deaths bore to the number of those who were affected, being seldom more than five in a hundred (including all the grades and forms of the disease), in the practice of most of the physicians, it is evident this fever was of a less malignant nature than it had been in most of the years in which it had been epidemic. There was one more circumstance which proved its diminution of violence, and that was, a more feeble operation of its remote cause. In the year 1802, nearly all the persons who were affected with the fever in the neighbourhood of Vine and Water-streets, and in Water, between Walnut and Spruce-streets, died. This year, but two died of a great number who were sick in the former, and not one out of twelve who were sick in the latter place. The filth, in both parts of the city, was the same in both years. This difference in the violence and mortality of the fever was probably occasioned by a less concentrated state of the miasmata which produced it, or by the co-operation of a less inflammatory constitution of the atmosphere.

The yellow fever was epidemic, during the summer and autumn of this year, in New-York, and in Alexandria, in Virginia. In the latter place, Dr. Dick has informed the public, it was derived from domestic putrefaction.

AN

ACCOUNT OF SPORADIC CASES

OF

_YELLOW FEVER_,

AS THEY

APPEARED IN PHILADELPHIA,

IN 1804.

The month of January was marked by deep snows, rain, clear and cold weather, and by the general healthiness of the city.

In February there fell a deep snow, which was followed by several very cold days. There was likewise a fall of snow in March, which was succeeded by an uncommon degree of cold. Catarrhs and bilious pleurisies were very common during both these months.

In the beginning of April, the weather was cold and rainy. There were but few signs of vegetation before the 15th of the month. Bilious pleurisies were still the principal diseases which prevailed in the city.

The month of May was wet, cool, and healthy.

In June, the winds were easterly, and the weather rainy. The crops of grass were luxuriant. It was remarked, that the milk of cows that fed upon this grass yielded less butter than usual, and that horses that fed upon it, sweated profusely with but little exercise. On the third of the month, I was called upon by Dr. Physick to visit his father, who was ill with a bilious fever. He died on the seventh, with a red eye, hiccup, and black vomiting.

Four persons had the yellow fever in the month of July. One of them was in Fourth-street, between Pine and Lombard-streets, another was in Fifth-street, between Race and Vine-streets, both of whom recovered. The remaining two were in the Pennsylvania hospital, both of whom died. Remitting and intermitting fevers were likewise common in this month.

In August, those fevers assumed a chronic form. During this month, there died an unusual number of children with the cholera morbus.

The city was uncommonly healthy in September. A storm of wind and rain, from the south-east, proved destructive to the crops of cotton this month, on the sea coast of South-Carolina.

In October, intermittents were very common between Eighth-street and Schuylkill. One case of yellow fever came under my care, in conjunction with Dr. Gallaher, on the western banks of that river.

While Philadelphia and all the cities of the United States (Charleston excepted) were thus exempted from the yellow fever as an epidemic, the western parts of all the middle, and several of the southern states, were visited with the bilious fever, in all its different forms. In Delaware county, in the state of New-York, at Mill river, in Connecticut, and in several of the middle counties of Pennsylvania, it prevailed in the form of a yellow fever. In other parts of the United States, it appeared chiefly as a highly inflammatory remittent. It was so general, that not only whole families, but whole neighbourhoods were confined by it. Many suffered from the want of medical advice and nursing, and some from the want of even a single attendant. In consequence of the general prevalence of this fever in some parts of Pennsylvania, the usual labours of the season were suspended. Apples fell and perished upon the ground; no winter grain was sowed; and even cows passed whole days and nights without being milked.

The mortality of this fever was considerable, where those distressing circumstances took place. In more favourable circumstances, it yielded to early depletion, and afterwards to the bark. Relapses were frequent, from premature exposure to the air. Those only escaped them who had been salivated, by accident or design, for the cure of the fever.

This disease was observed very generally to prevail most in high situations, which had been for years distinguished for their healthiness, while the low grounds, and the banks of creeks and rivers, were but little affected by it. The unusual quantity of rain, which had fallen during the summer months, had produced moisture in the former places, which favoured putrefaction and exhalation, while both were prevented, in the latter places, by the grounds being completely covered with water.

AN ACCOUNT

OF THE

_BILIOUS YELLOW FEVER_,

AS IT

APPEARED IN PHILADELPHIA,

IN THE YEAR 1805.

For a history of the uncommonly cold and tempestuous winter of 1804 and 1805, the reader is referred to the Account of the Climate of Pennsylvania, in the first volume of these Inquiries and Observations.

During the months of January, February, and March, there were a number of bilious catarrhs and pleurisies.

On the 7th of April, I visited a patient in the yellow fever with Dr. Stewart. He was cured, chiefly by copious bleeding.

The weather was rainy in May. After the middle of June, and during the whole month of July, there fell no rain. The mercury in Fahrenheit fluctuated, for ten days, between 90° and 94°, during this month. The diseases which occurred in it were cholera infantum, dysenteries, a few common bilious, and eight cases of yellow fever. Three of the last were in Twelfth, between Locust and Walnut-streets, and were first visited, on the 14th and 15th of the month, by Dr. Hartshorn, as out-patients of the Pennsylvania hospital. Two of them were attended, about a week afterwards, by Dr. Church, in Southwark, and the remaining three by Dr. Rouisseau and Dr. Stewart, in the south end of the city.

On the third of August, there fell a heavy shower of rain, but the weather, during the remaining part of the month, was warm and dry. The pastures were burnt up, and there was a great deficiency of summer vegetables in the neighbourhood of Philadelphia. The water in the Schuylkill was lower by three inches than it had been in the memory of a man of 70 years of age, who had lived constantly within sight of it.

In September, a number of cases of yellow fever appeared in Southwark[9], near Catharine-street. They were readily traced to a large bed of oysters, which had putrified on Catharine-street wharf, and which had emitted a most offensive exhalation throughout the whole neighbourhood, for several weeks before the fever made its appearance. This exhalation proved fatal to a number of cats and dogs, and it now became obvious that the two cases of yellow fever, that were attended by Dr. Church, in the month of July, were derived from it. An attempt was made to impose a belief that they were taken by contagion from a ship at the lazaretto, which had lately arrived from the West-Indies, but a careful investigation of this tale proved, that neither of the two subjects of the fever had been on board that, nor any other ship, then under quarantine.

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

The fever prevailed during the whole of this month in Southwark. A few cases of it appeared in the city, most of which were in persons who had resided in, or visited that district. It was brought on by weak exciting causes in Southwark, but the cases which originated in the city, required strong exciting causes to produce them.

A heavy rain, accompanied with a good deal of wind, on the 28th of September, and a frost on the night of the 7th of October, gave a considerable check to the fever.

But few cases of it came under my care. Having perceived the same disposition in nature to relieve herself by the pores, that I observed in the years 1802 and 1803, my remedies were the same as in the latter year, and attended with the same success. Dr. Caldwell and Dr. Stewart, whose practice was extensive in Southwark, informed me, those remedies had been generally successful in their hands.

The only new medicine that the experience of this year suggested in this disease, was for one of its most distressing and dangerous symptoms, that is, the vomiting which occurs in its second stage. Dr. Physick discovered, that ten drops of the spirit of turpentine, given every two hours, in a little molasses, or syrup, or sweet oil, effectually checked it in several instances, in patients who afterwards recovered. It was administered with equal success in a case which came under my care, after an absence of pulse, and a coldness of the extremities had taken place. Dr. Church informed me that he gave great relief to the sick in the city hospital, by this medicine, by prescribing it in glysters, as well as by the mouth, in distressing affections of the stomach and bowels.

Dr. Stewart observed that all those persons who had been affected by the yellow fever in former years, had mild remittents in the same situations that others had the prevailing epidemic in a malignant form.

In one of four bodies the doctor examined, he found six, and in another three intussusceptions of the intestines, without any signs of inflammation. He discovered the common marks of disease from this fever in other parts of those bodies.

The deaths from this fever amounted to between three and four hundred. They would probably have been more numerous, had not those families who were in competent circumstances fled into the country, and had not the poor been removed, by the board of health, from the infected atmosphere of Southwark, to tents provided for them in the neighbourhood of the city; and they would probably have been fewer, considering the tractable nature of the disease, when met by suitable remedies in its early stage, had not the sick concealed their indisposition, in many instances, for two or three days, lest they should be dragged to the city hospital, or have centinels placed at their doors, to prevent any communication with their friends and neighbours. While these attempts were made to check the progress of the fever, it did not escape the notice of many of the citizens of Philadelphia, that not a single instance occurred of its being communicated by contagion, in any of the families in the city, in which persons had sickened or died with it, and that while the sick were deprived of the kind offices of their friends and neighbours, lest they should be infected, physicians, and the members of the board of health, passed by the guards every day, in their visits to the same sick people, and afterwards mixed with their fellow-citizens, in every part of the city, without changing their clothes.

The yellow fever appeared early in the season in New-Haven, in Connecticut, and in Providence, on Rhode-Island, in both of which places it was derived from putrid exhalation, and was speedily and effectually checked by removing the healthy persons who lived in its neighbourhood to a distance from it. Several sporadic cases of it occurred during the autumn in Gloucester county, in New-Jersey, and in Mifflin and Chester counties, in Pennsylvania. It was epidemic in New-York at the same time it prevailed in Southwark and Philadelphia. The following extract of a letter from the health officer of New-York, to one of his friends, contains a satisfactory proof that it was not, in that city, an imported disease.

_Quarantine-ground, Sept. 7._

I most sincerely and tenderly deplore the unfortunate situation of our city. What do people say now of the origin of the disease? You may state, for the information of those who wished to be informed, that not a single vessel, on board of which a person has been sick with fever of any kind, or on board of which any person has died with any disease, while in the West-Indies, or on the voyage home, has ever gone up to the city during this whole season. This we know, and this we vouch for; and farther state, that all the cases of fever that have come down as from the city, have been _all_ people of, and belonging to the city, and unconnected with the shipping, excepting one, a sailor, who had no connection with any foul vessel. There is not a shadow of proof or suspicion that can attach to the health-office, or to infected vessels, this season.

I am, &c. JOHN R. B. RODGERS.

Having concluded the history of the bilious yellow fever, as it has appeared in eleven successive years, since 1793, as an epidemic, or in sporadic cases, I shall proceed next to enumerate all the sources of that fever, as well as all the other usual forms of the summer and autumnal disease of the United States, and afterwards mention the means of preventing them.

AN INQUIRY

INTO

THE VARIOUS SOURCES

OF THE USUAL FORMS OF

_SUMMER & AUTUMNAL DISEASE_

IN THE UNITED STATES,

AND THE MEANS OF PREVENTING THEM.

The business of the following inquiry is,

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

II. To mention the means of preventing them.

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

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

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

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

4. Pepper.

5. Indian meal.

6. Onions.

7. Mint.

8. Anise and caraway seeds, confined in the hold of a ship.

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

[10] Medicina Nautica, p. 324.

10. Chocolate shells.

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

12. Hemp, flax, and straw.

13. The canvas of an old tent.

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

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

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

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

18. The stagnating air of the hold of a ship.

19. Bilge water.

20. Water that had long been confined in hogsheads at sea.

21. Stagnating rain water.

22. The stagnating air of close cellars.

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

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

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

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

27. Weeds cut down, and exposed to heat and moisture near a house.

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

1. Human bodies that have been left unburied upon a field of battle.

2. Salted beef and pork.

3. Locusts.

4. Raw hides confined in stores, and in the holds of ships.

5. A whale thrown upon the sea shore in Holland.

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

[11] It has been a common practice with many families, in New-York and Philadelphia, for several years past, to lay in a winter store of oysters in their cellars in the fall of the year. May not a part of these oysters, left in these cellars from forgetfulness, or from being unfit for use, become, by putrifying there, the cause of malignant fevers in the succeeding summer and autumn?

7. The entrails of fish. And,

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

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

[12] The following fact, communicated to me by Mr. Samuel Lyman, a member of congress from the state of Massachusetts, shows the importance of attending to the condition of butchers' meat in our attempts to prevent malignant fevers.

A farmer in New-Hampshire, who had overheated a fat ox by excessive labour in the time of harvest, perceiving him to be indisposed, instantly killed him, and sent his flesh to a neighbouring market. Of twenty four persons who ate of this flesh, fifteen died in a few days. The fatal disease produced by this aliment fell, with its chief force, upon the stomach and bowels.

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

1. Malignant or bilious yellow fever.

2. Inflammatory bilious fever.

3. Mild remittent.

4. Mild intermittent.

5. Chronic, or what is called nervous fever.

6. Febricula.

7. Dysentery.

8. Colic.

9. Cholera morbus.

10. Diarrh[oe]a.

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

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

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

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

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

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

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

II. In the human body.

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

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

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

[13] Medical Journal, vol. iv.

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

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

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

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

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

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

[14] I have once known this breath, in a gentleman who had carried the seeds of the yellow fever in his body from Philadelphia into its neighbourhood, create sickness at the stomach in his wife; and I have heard of an instance in which a person, who left Philadelphia when highly impregnated with the miasmata of the same fever, creating sickness at the stomach in four or five persons who sat at the same table with him in the country. None of the above persons were afterwards affected by the fever. In an anonymous history of the plague in London, in the year 1664, in the possession of the author, it is said, the breath was a well-known signal of infection to persons who were not infected, and that whenever it was perceived, individuals and companies fled from it. The sickness in the above-mentioned persons was similar to that which is sometimes excited by the smell of a sore leg, or a gun-shot wound, upon the removal of its first dressing. It does not produce fever, because there is no predisposition to it.

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

I. Into such as are proper to protect individuals.

II. Such as are proper to defend whole communities from the disease. And,

III. Such as are proper to exterminate it, by removing its causes.

I. Of the means of protecting individuals.

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

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

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

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

[15] Desportes, vol. i. p. 140.

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

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

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

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

[16] Account of the Yellow Fever in 1793, vol. iii.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

V. Avoiding of all its exciting causes. These are,

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

3. The early morning and evening air, even in warm weather.

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

[17] Account of the Yellow Fever in 1793, vol. iii.

5. Intemperance in eating and drinking.

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

7. Violent emotions or passions of the mind.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[18] Burserus.

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

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

[19] Vol. I. p. 161.

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

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

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

[20] Sur les Maladies des Climats Chauds.

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

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

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

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

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

[21] The above disease appears to have been the camp fever, the origin and character of which will be noticed in the next article.

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

1. The removal or destruction of all those putrid matters formerly enumerated, which are capable of producing fevers. Many of the institutions of the Jewish nation, for this purpose, are worthy of our imitation. The following verses contain a fund of useful knowledge upon this subject.--"Thou shalt have a place without the camp, whether thou shalt go forth abroad; and shalt have a paddle upon thy weapon, and it shall be when thou wilt ease thyself abroad, thou shalt dig therewith, and shalt turn back, and cover that which cometh from thee; for the Lord thy God walketh in the midst of thy camp to deliver thee, therefore shall he _see no unclean thing in thee_, and turn away from thee." Deuteronomy,