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Title: Medical Inquiries and Observations, Vol. III (of 4) - The Second Edition, Revised and Enlarged by the Author
Author: Rush, Benjamin
Language: English
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                           MEDICAL INQUIRIES

                                  AND

                             OBSERVATIONS.

                        BY BENJAMIN RUSH, M. D.

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

                            IN FOUR VOLUMES.

                                VOL. III.

                          THE SECOND EDITION,

                  REVISED AND ENLARGED BY THE AUTHOR.

                             PHILADELPHIA,

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

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

                                 1805.

                   *       *       *       *       *


                         CONTENTS OF VOLUME III.

                                                                   _page_

  _Outlines of a theory of fever_                                      1

  _An account of the bilious yellow fever, as it appeared in
  Philadelphia in 1793_                                               67

  _An account of the bilious yellow fever, as it appeared in
  Philadelphia in 1794_                                              355

  _An account of sporadic cases of bilious yellow fever, as they
  appeared in Philadelphia in 1795 and 1796_                         435

                   *       *       *       *       *



                                OUTLINES

                                  OF A

                           _THEORY OF FEVER_.


As many of the diseases which are the subjects of these volumes belong to
the class of fevers, the following remarks upon their theory are intended
to render the principles and language I have adopted, in the history of
their causes, symptoms, and cure, intelligible to the reader.

I am aware that this theory will suffer by being published in a detached
state from the general view of the proximate cause of disease which I
have taught in my lectures upon pathology, as well as from its being
deprived of that support which it would receive from being accompanied
with an account of the remedies for fever, and the times and manner of
exhibiting them, all of which would have served to illustrate and
establish the facts and reasonings which are to follow upon this
difficult and interesting inquiry.

I shall not attempt to give a definition of fever. It appears in so many
different forms, that a just view of it can only be given in a minute
detail of all its symptoms and states.

In order to render the theory, which I am about to deliver, more simple
and intelligible, it will be necessary to premise a few general
propositions.

I. Fevers of all kinds are preceded by general debility. This debility is
natural or accidental. The former is the effect of the sanguineous
temperament, and exists at all times in many constitutions. The latter is
induced,

1. By such preternatural or unusual stimuli, as, after first elevating
the excitement of the system above its healthy grade, and thereby wasting
a part of its strength, or what Dr. Brown calls excitability, and Darwin
sensorial power, afterwards reduces it down to that state which I shall
call debility of action. Or,

2. It is induced by such an abstraction of natural stimuli as to reduce
the system _below_ its healthy grade of excitement, and thereby to induce
what Dr. Brown calls _direct_ debility, but what I shall call debility
from abstraction. This general debility is the same, whether brought on
by the former or the latter causes. When induced by the latter, the
system becomes more excitable than when induced by the former causes, and
hence an attack of fever is more frequently invited by it, than by that
state of debility which succeeds the application of an undue portion of
stimulating powers. To this there is an exception, and that is, when the
remote causes of fever act with so much force and rapidity as _suddenly_
to depress the system, without an intermediate elevation of it, and
before sufficient time is given to expend any part of its strength or
excitability, or to produce the debility of action. The system in this
state, is exactly similar to that which arises from a sudden reduction of
its healthy excitement, by the abstraction of stimuli. This debility from
abstraction, moreover, is upon a footing with the debility from action,
when it is of a _chronic_ nature. They both alike expend so much of the
quality or substance of excitability, as to leave the system in a state
in which irritants are seldom able to excite the commotions of fever, and
when they do, it is of a feeble nature, and hence we observe persons who
have been long exposed to debilitating causes of both kinds, often escape
fevers, while those who are _recently_ debilitated, are affected by them,
under the same circumstances of exposure to those causes.

That fevers are preceded by general debility I infer from their causes,
all of which act by reducing the excitement of the system, by the
abstraction of stimuli, or by their excessive or unusual application. The
causes which operate in the former way are,

1. Cold. This is universally acknowledged to be a predisposing cause of
fever. That it debilitates, I infer, 1. From the languor which is
observed in the inhabitants of cold countries, and from the weakness
which is felt in labour or exercise in cold weather. 2. From the effects
of experiments, which prove, that cold air and cold water lessen the
force and frequency of the pulse.

2. The debilitating passions of fear, grief, and despair.

3. All excessive evacuations, whether by the bowels, blood-vessels,
pores, or urinary passages.

4. Famine, or the abstraction of the usual quantity of nourishing food.

The causes which predispose to fever by the excessive or unusual
application of stimuli are,

1. Heat. Hence the greater frequency of fevers in warm climates, and in
warm weather.

2. Intemperance in eating and drinking.

3. Unusual labour or exercise.

4. Violent emotions, and stimulating passions of the mind.

5. Certain causes which act by over-stretching a part, or the whole of
the body, such as lifting heavy weights, external violence acting
mechanically in wounding, bruising, or compressing particular parts,
extraneous substances acting by their bulk or gravity, burning, and the
like[1]. The influence of debility in predisposing to fevers is further
evident from their attacking so often in the night, a time when the
system is more weak than at any other, in the four and twenty hours.

  [1] Cullen's First Lines.

II. Debility being thus formed in the system, by the causes which have
been enumerated, a _sudden_ accumulation of excitability takes place,
whereby a predisposition is created to fever. The French writers have
lately called this predisposition "vibratility," by which they mean a
liableness in it to be thrown into vibrations or motions, from
pre-existing debility. It is not always necessary that a fever should
follow this state of predisposition. Many people pass days and weeks
under it, without being attacked by a fever, by carefully or accidentally
avoiding the application of additional stimuli or irritants to their
bodies: but the space between this state of predisposition, when it is
recent, and a fever, is a very small one; for, independently of
additional stimuli, the common impressions which support life sometimes
become irritants, and readily add another link to the chain of causes
which induce fever, and that is,

III. Depression of the whole system, or what Dr. Brown calls indirect
debility. It manifests itself in weakness of the limbs, inability to
stand or walk without pain, or a sense of fatigue, a dry, cool, or cold
skin, chilliness, a shrinking of the hands and face, and a weak or quick
pulse. These symptoms characterize what I have called in my lectures the
forming state of fever. It is not necessary that a paroxysm of fever
should follow this depressed state of the system, any more than the
debility that has been described. Many people, by rest, or by means of
gentle remedies, prevent its formation; but where these are neglected,
and the action of stimuli, whether morbid or natural, are continued,

IV. Re-action is induced, and in this re-action, according to its greater
or less force and extent, consist the different degrees of fever. It is
of an irregular or a _convulsive_ nature. In common cases, it is seated
primarily in the blood-vessels, and particularly in the arteries. These
pervade every part of the body. They terminate upon its whole surface, in
which I include the lungs and alimentary canal, as well as the skin. They
are the outposts of the system, in consequence of which they are most
exposed to cold, heat, intemperance, and all the other external and
internal, remote and exciting causes of fever, and are first roused into
resistance by them.

Let it not be thought, from these allusions, that I admit Dr. Cullen's
supposed vires naturæ medicatrices to have the least agency in this
re-action of the blood-vessels. I believe it to be altogether the effect
of their elastic and muscular texture, and that it is as simply
mechanical as motion from impressions upon other kinds of matter.

That the blood-vessels possess muscular fibres, and that their
irritability or disposition to motion depends upon them, has been
demonstrated by Dr. Vasschuer and Mr. John Hunter, by many experiments.
It has since been proved by Spallanzani, in an attempt to refute it. Even
Dr. Haller, who denies the muscularity and irritability of the
blood-vessels, implies an assent to them in the following words: "There
are nerves which descend for a long way together through the surface of
the artery, and at last vanish in the cellular substance of the vessel,
of which we have a specimen in the external and internal carotids, and in
the arch of the aorta; and from these do not the arteries seem to derive
a muscular and convulsive force very different from that of their simple
elasticity? Does not it show itself plainly in _fevers_, faintings,
palsies, consumptions, and passions of the mind[2]?"

  [2] First Lines, sect. 32 of the chapter on arteries.

The re-action or morbid excitement of the arteries discovers itself in
preternatural force, or frequency in their pulsations. In _ordinary_
fever, it is _equally_ diffused throughout the whole sanguiferous
system, for the heart and arteries are so intimately connected, that,
like the bells of the Jewish high-priest, when one of them is touched,
they all vibrate in unison with each other. To this remark there are some
exceptions.

1. The arteries are sometimes affected with great morbid excitement,
while the natural functions of the heart are unimpaired. This occurs in
those states of fever in which patients are able to sit up, and even to
walk about, as in pulmonary consumption, and in hectic fever from all its
causes.

2. The heart and pulmonary artery are sometimes affected with great
morbid excitement, while the pulsations of the arteries on the wrists are
perfectly natural.

3. The morbid excitement of the arteries is sometimes greater on one side
of the body than on the other. This is obvious in the difference in the
number and force of the pulsations in the different arms, and in the
different and opposite appearances of the blood drawn from their veins,
under equal circumstances.

4. The arteries in the head, lungs, and abdominal viscera are sometimes
excited in a high degree, while the arteries in the extremities exhibit
marks of a feeble morbid action. Fevers attended with these and other
deviations from their common phenomena, have been called by Dr. Alibert,
_altaxiques_. They occur most frequently in malignant fevers.

While morbid excitement thus pervades generally or partially the
sanguiferous system, depression and debility are increased in the
alimentary canal, and in the nervous and muscular systems. In the
stomach, bowels, and muscles, this debility is occasioned by their
excitement being abstracted, and translated to the blood-vessels.

I shall now endeavour to illustrate the propositions which have been
delivered, by taking notice of the manner in which fevers are produced by
some of its most obvious and common causes.

Has the body been debilitated by exposure to the cold air? its
excitability is thereby increased, and heat acts upon it with an
accumulated force: hence the frequency of catarrhs, pleurisies, and other
inflammatory fevers in the spring, after a cold winter; and of bilious
remittents in the autumn, when warm days succeed to cold and damp
nights. These diseases are seldom felt for the first time in the open
air, but generally after the body has been exposed to cold, and
afterwards to the heat of a warm room or a warm bed. Mild intermittents
have frequently been observed to acquire an inflammatory type in the
Pennsylvania hospital, in the months of November and December, from the
heat of the stove rooms acting upon bodies previously debilitated and
rendered excitable by cold and disease.

Has there been an abstraction of heat by a sudden shifting of the wind
from the south-west to the north-west or north-east points of the
compass, or by a cold night succeeding to a warm day? a fever is thereby
frequently excited. These sources of fever occur every autumn in
Philadelphia. The miasmata which exist in the body at that time in a
harmless state, are excited into action, in a manner to be mentioned
presently, by the debility from cold, aided in the latter case by the
inaction of sleep, suddenly induced upon the system.

Again: has the body been _suddenly_ debilitated by labour or exercise?
its excitement is thereby diminished, but its excitability is increased
in such a manner that a full meal, or an intemperate glass of wine, if
taken _immediately_ after the fatigue is induced upon the body, excites a
fever: hence the frequency of fevers in persons upon their return from
hunting, surveying, long rides, or from a camp life.

But how shall we account for the production of fever from the measles and
small-pox, which attack so uniformly, and without predisposing debility
from any of its causes which have been enumerated? I answer, that the
contagions of those diseases seldom act so as to produce fever, until the
system is first depressed. This is obvious from their being preceded by
languor, and all the other symptoms formerly mentioned, which constitute
the forming state of fever. The miasmata which induce the plague and
yellow fever, when they are not preceded by the usual debilitating and
predisposing causes, generally induce the same depression of the system,
previously to their exciting fever. Even wounds, and other local
irritants seldom induce fever before they have first produced the
symptoms of depression formerly mentioned. I shall presently mention the
exceptions to this mode of producing fever from contagious miasmata and
local injuries, and show that they do not militate against the truth of
the general proposition that has been delivered.

It may serve still further to throw light upon this part of our subject
to take notice of the difference between the action of stimuli upon the
body predisposed by debility and excitability to fever, and their action
upon it when there is no such predisposition to fever.

In health there is a constant and just proportion between the degrees of
excitement and excitability, and the force of stimuli. But this is not
the case in a predisposition to a fever. The ratio between the action of
stimuli and excitement, and excitability is destroyed; and hence the
former act upon the latter with a force which produces irregular action,
or a convulsion in the arterial system. When the body is debilitated, and
its excitability increased, either by fear, darkness, or silence, a
sudden noise occasions a short convulsion. We awake, in like manner, in a
light convulsion, from the sudden opening of a door, or from the
sprinkling of a few drops of water in the face, after the excitability of
the system has been accumulated by a night's sleep. In a word, it seems
to be a law of the system, that stimulus, in an over-proportion to
excitability, either produces convulsion, or goes so far beyond it, as to
destroy motion altogether in death.

V. There is but one exciting cause of fever, and that is stimulus. Heat,
alternating with cold[3], marsh and human miasmata, contagions and
poisons of all kinds, intemperance, passions of the mind, bruises, burns,
and the like, all act by a stimulating power only, in producing fever.
This proposition is of great application, inasmuch as it cuts the sinews
of the division of diseases from their remote causes. Thus it establishes
the sameness of a pleurisy, whether it be excited by heat succeeding
cold, or by the contagions of the small-pox and measles, or by the
miasmata of the yellow fever.

  [3] Perhaps there is no greater enemy to the life of man than cold.
      Dr. Sydenham ascribes nearly all fevers to it, particularly to
      leaving off winter clothes too soon, and to exposing the body to
      cold after it has been heated. These sources of fever, he adds,
      destroy more than the plague, sword, or famine.--_Wallis's edition,
      vol. I. p. 357._

To this proposition there is a seeming objection. Cold, sleep, immoderate
evacuations, and the debilitating passions of grief and fear (all of
which abstract excitement) appear to induce fever without the
interposition of a stimulus. In all these cases, the _sudden_ abstraction
of excitement destroys the equilibrium of the system, by which means the
blood is diverted from its natural channels, and by acting with
preternatural force in its new directions, becomes an irritant to the
blood-vessels, and thus a stimulating and exciting cause of fever. When
it is induced by cold alone, it is probable so much of the perspirable
matter may be retained as to co-operate, by its irritating qualities, in
exciting the fever.

VI. There is but one fever. However different the predisposing, remote,
or exciting causes of fever may be, whether debility from abstraction or
action, whether heat or cold succeeding to each other, whether marsh or
human miasmata, whether intemperance, a fright, or a fall, still I
repeat, there can be but one fever. I found this proposition upon all the
supposed variety of fevers having but one proximate cause. Thus fire is a
unit, whether it be produced by friction, percussion, electricity,
fermentation, or by a piece of wood or coal in a state of inflammation.

VII. All ordinary fever being seated in the blood-vessels, it follows, of
course, that all those local affections we call pleurisy, angina,
phrenitis, internal dropsy of the brain, pulmonary consumption, and
inflammation of the liver, stomach, bowels, and limbs, are symptoms only
of an original and primary disease in the sanguiferous system. The truth
of this proposition is obvious from the above local affections
succeeding primary fever, and from their alternating so frequently with
each other. I except from this remark those cases of primary affections
of the viscera which are produced by local injuries, and which, after a
while, bring the whole sanguiferous system into sympathy. These cases are
uncommon, amounting, probably, to not more than one in a hundred of all
the cases of local affection which occur in general fever.

In my 4th proposition I have called the action of the arteries
_irregular_ in fever, to distinguish it from that excess of action which
takes place after violent exercise, and from that quickness which
accompanies fear or any other directly debilitating cause. The action of
the arteries here is _regular_, and, when felt in the pulse, affords a
very different sensation from that _jerking_ which we feel in the pulse
of a patient labouring under a fever.

This irregular action is, in other words, a _convulsion_ in the
sanguiferous, but more obviously, in the arterial system.

That this is the case I infer from the strict analogy between symptoms of
fever, and convulsions in the nervous system. I shall briefly mention the
particulars in which this analogy takes place.

1. Are convulsions in the nervous system preceded by debility? So is the
convulsion of the blood-vessels in fever.

2. Does debility induced on the whole, or on a part only, of the nervous
system, predispose to general convulsions, as in tetanus? So we observe
debility, whether it be induced on the whole or on a part of the arterial
system, predisposes to general fever. This is obvious in the fever which
ensues alike from cold applied to every part of the body, or from a
stream of cold air falling upon the neck, or from the wetting of the
feet.

3. Do tremors precede convulsions in the nervous system? So they do the
convulsion of the blood-vessels in fever.

4. Is a coldness in the extremities a precursor of convulsions in the
nervous system? So it is of fever.

5. Do convulsions in the nervous system impart a jerking sensation to the
fingers? So does the convulsion of fever in the arteries, when felt at
the wrists.

6. Are convulsions in the nervous system attended with alternate action
and remission? So is the convulsion of fever.

7. Do convulsions in the nervous system return at regular and irregular
periods? So does fever.

8. Do convulsions in the nervous system, under certain circumstances,
affect the functions of the brain? So do certain states of fever.

9. Are there certain convulsions in the nervous system which affect the
limbs, without affecting the functions of the brain, such as tetanus, and
chorea sancti viti? So there are certain fevers, particularly the common
hectic, which seldom produces delirium, or even head-ach, and frequently
does not confine a patient to his bed.

10. Are there local convulsions in the nervous system, as in the hands,
feet, neck, and eye-lids? So there are local fevers. Intermittents often
appear in the autumn with periodical heat and pains in the eyes, ears,
jaws, and back.

11. Are there certain grades in the convulsions of the nervous system, as
appears in the hydrophobia, tetanus, epilepsy, hysteria, and
hypochondriasis? So there are grades in fevers, as in the plague, yellow
fever, small-pox, rheumatism, and common remitting and intermitting
fevers.

12. Are nervous convulsions most apt to occur in infancy? So are fevers.

13. Are persons once affected with nervous convulsions frequently subject
to them through life? So are persons once affected with fever. The
intermitting fever often returns with successive springs or autumns, and,
in spite of the bark, sometimes continues for many years in all climates
and seasons.

14. Is the strength of the nervous system increased by convulsions? This
is so evident that it often requires four or five persons to confine a
delicate woman to her bed in a convulsive fit. In like manner the
strength of the arterial system is increased in a fever. This strength is
great in proportion to the weakness of every other part of the body.

15. Do we observe certain nervous convulsions to affect some parts of the
nervous system more than others, or, in other words, do we observe
preternatural strength or excitement to exist in one part of the nervous
system, while other parts of the same system exhibit marks of
preternatural weakness or defect of excitement? We observe the same thing
in the blood-vessels in a fever. The pulse at the wrist is often _tense_,
while the force of the heart is very much diminished. A delirium often
occurs in a fever from excess of excitement in the blood-vessels of the
brain, while the pulse at the wrist exhibits every mark of preternatural
weakness.

16. Is there a rigidity of the muscles in certain nervous diseases, as in
catalepsy? Something like this solstice in convulsion occurs in that
state of fever in which the pulse beats but sixty, or fewer strokes in a
minute.

17. Do convulsions go off _gradually_ from the nervous system, as in
tetanus, and chorea sancti viti? So they do from the arterial
blood-vessels in certain states of fever.

18. Do convulsions go off _suddenly_ in any cases from the nervous
system? The convulsion in the blood-vessels goes off in the same manner
by a sweat, or by a hæmorrhage, frequently in the course of a night, and
sometimes in a single hour.

19. Does palsy in some instances succeed to convulsions in the nervous
system? Something like a palsy occurs in fevers of great inflammatory
action in the arteries. They are often inactive in the wrists, and in
other parts of the body, from the immense pressure of the remote cause of
the fever upon them.

From the facts and analogies which have been mentioned, I have been led
to conclude that the common forms of fever are occasioned simply by
irregular action, or convulsion in the blood-vessels.

The history of the phenomena of fever, as delivered in the foregoing
pages, resolves itself into a chain, consisting of the five following
links.

1. Debility from action, or the abstraction of stimuli. When this
debility is induced by action, it is sometimes preceded by elevated
excitement in the blood-vessels, from the first impressions of stimuli
upon them.

2. An increase of their excitability.

3. Stimulating powers applied to them.

4. Depression. And,

5. Irregular action or convulsion.

The whole of the links of this chain are perceptible only when the fever
comes on in a _gradual_ manner. But I wish the reader to remember, that
the same remote cause is often debilitating, stimulating, and depressing,
and that, in certain fevers, the remote cause sometimes excites
convulsions in the blood-vessels without being preceded by preternatural
debility and excitability, and with but little or no depression of the
system. This has often been observed in persons who have been suddenly
exposed to those marsh and human miasmata which produce malignant fevers.
It sometimes takes place likewise in fevers induced by local injuries.
The blood-vessels in these cases are, as it were, taken by storm, instead
of regular approaches.

I might digress here, and show that all diseases, whether they be seated
in the arteries, muscles, nerves, brain, or alimentary canal, are all
preceded by debility; and that their essence consists in irregular
action, or in the absence of the natural order of motion, produced or
invited by predisposing debility. I might further show, that all the
moral, as well as physical evil of the world consists in predisposing
weakness, and in subsequent derangement of action or motion; but these
collateral subjects are foreign to our present inquiry.

Let us now proceed to examine how far the theory which has been delivered
accords with the phenomena of fever.

I shall divide these phenomena into two kinds.

I. Such as are transient, and more or less common to all fevers. These I
shall call _symptoms_ of fever.

II. Such as, being more permanent and fixed, have given rise to certain
specific names. These I shall call _states_ of fever.

I shall endeavour to explain and describe each of them in the order in
which they have been mentioned.

I. Lassitude is the effect of the depression of the whole system, which
precedes fever.

The same cause, when it acts upon the extremities of the blood-vessels,
produces coldness and chills. This is obvious to any person, under the
first impression of the miasmata which bring on fevers, also under the
influence of fatigue, and debilitating passions of the mind. The absence
of chills indicates the sensibility of the external parts of the body to
be suspended or destroyed, as well as their irritability; hence when
death occurs in the fit of an intermittent, there is no chill. A chilly
fit, for the same reason, seldom occurs in the most malignant cases of
fever. It is sometimes excited by blood-letting, only because it weakens
those fevers to such a degree, as to carry the blood-vessels back to the
grade of depression. Coldness and chills are likewise removed by
blood-letting, only because it enables the arteries to re-act in such a
manner as to overcome the depression that induced it. It has been
remarked, that the chilly fit, in common fevers, seldom appears in its
full force until the patient approaches a fire, or lies down on a warm
bed; for in these situations sensibility is restored by the stimulus of
the heat acting upon the extremities of the blood-vessels. The first
impressions of the rays of the sun, in like manner, often produce
coldness and chills in the torpid bodies of old and weakly people.

Tremors are the natural consequence of the abstraction of that support
which the muscles receive from the fulness and tension of the
blood-vessels. It is from this retreat of the blood towards the viscera,
that the capillary arteries lose their fulness and tension; hence they
contract like other soft tubes that are emptied of their contents. This
contraction has been called a spasm, and has improperly been supposed to
be the proximate cause of fever. From the explanation that has been given
of its cause, it appears, like the coldness and chills, to be nothing but
an accidental concomitant, or effect of a paroxysm of fever.

The local pains in the head, breast, and bones in fever, appear to be the
effects of the irregular determination of the blood to those parts, and
to morbid action being thereby induced in them.

The want of appetite and costiveness are the consequences of a defect of
secretion of the gastric juice, and the abstraction of excitement or
natural action from the stomach and bowels.

The inability to rise out of bed, and to walk, is the effect of the
abstraction of excitement from the muscles of the lower limbs.

The dry skin or partial sweats appear to depend upon diminished or
partial action in the vessels which terminate on the surface of the
body.

The high-coloured and pale urine are occasioned by an excess or a
deficiency of excitement in the secretory vessels of the kidneys.

The suppression of the urine seems to arise from what Dr. Clark calls an
engorgement, or choaking of the vessels of the kidneys. It occurs most
frequently in malignant fevers.

Thirst is probably the effect of a preternatural excitement of the
vessels of the fauces. It is by no means a uniform symptom of fever. We
sometimes observe it, in the highest degree, in the last stage of
diseases, induced by the retreat of the last remains of excitement from
every part of the body, to the throat.

The white tongue is produced by a change in the secretion which takes
place in that organ. Its yellow colour is the effect of bile; its dryness
is occasioned by an obstruction of secretion, or by the want of action in
the absorbents; and its dark and black colour, by a tendency to
mortification.

It will be difficult to account for the variety in the degrees and
locality of _heat_ in the body in a fever, until we know more of the
cause of animal heat. From whatever cause it be derived, its excess and
deficiency, as well as all its intermediate degrees, are intimately
connected with more or less excitement in the arterial system. It is not
necessary that this excitement should exist only in the large
blood-vessels. It will be sufficient for the purpose of creating great
heat, if it occur only in the cutaneous vessels; hence we find a hot skin
in some cases of malignant fever in which there is an absence of pulse.

Eruptions seem to depend upon effusions of serum, lymph, or red blood
upon the skin, with or without inflammation, in the cutaneous vessels.

I decline taking notice in this place of the symptoms which are produced
by the debility from action and abstraction, and by the depression of the
system. They appear not only in the temperature of the body, but in all
the different symptoms of fever. It is of importance to know when they
originate from the former, and when from the latter causes, as they
sometimes require very different and opposite remedies to remove them.

It remains only to explain the cause why excess in the force or frequency
of the action of the blood-vessels should succeed debility in a part, or
in the whole of the body, and be connected for days and weeks with
depression and preternatural debility in the nerves, brain, muscles, and
alimentary canal. I shall attempt the explanation of this phenomenon by
directing the attention of the reader to the operations of nature in
other parts of her works.

1. A calm may be considered as a state of debility in the atmosphere. It
predisposes to a current of air. But is this current proportioned to the
loss of the equilibrium of the air? By no means. It is excessive in its
force, and tends thereby to destroy the works both of nature and art.

2. The passions are given to man on purpose to aid the slow and uncertain
operations of reason. But is their action always proportioned to the
causes which excite them? An acute pneumony, brought on by the trifling
injury done to the system by the fatigue and heat of an evening spent in
a dancing assembly, is but a faint representation of the immense
disproportion between a trifling affront, and that excess of passion
which seeks for gratification in poison, assassination, or a duel. The
same disproportion appears between cause and effect in public bodies. A
hasty word, of no mischievous influence, has often produced convulsions,
and even revolutions, in states and empires.

If we return to the human body we shall find in it many other instances
of the disproportion between stimulus and action, besides that which
takes place in the excitement of fever.

3. A single castor oil nut, although rejected by the stomach upon its
first effort in vomiting, has, in one instance that came within my
knowledge, produced a vomiting that continued nearly four and twenty
hours. Here the duration of action was far beyond all kind of proportion
to the cause which excited it.

4. A grain of sand, after being washed from the eye, is often followed by
such an inflammation or excess in the action of the vessels of the eye,
as to require bleeding, purging, and blistering to remove it.

Could we comprehend every part of the sublime and ineffable system of the
divine government, I am sure we should discover nothing in it but what
tended ultimately to order. But the natural, moral, and political world
exhibit every where marks of disorder, and the instruments of this
disorder, are the operations of nature. Her influence is most obvious in
the production of diseases, and in her hurtful or ineffectual efforts to
remove them[4]. In again glancing at this subject I wish it to be
remembered that those operations were not originally the means of
injuring or seducing man, and that I believe a time will come when the
exact relation, between cause and effect, or, in other words, the
dominion of order shall be restored over every action of his body and
mind, and health and happiness again be the result of every movement of
nature.

  [4] See the Comparative View of the Diseases of the Indians and of
      Civilized Nations. Vol. I.

From the view I have given of the state of the blood-vessels in fever,
the reader will perceive the difference between my opinions and Dr.
Brown's upon this subject. The doctor supposes a fever to consist in
debility. I do not admit debility to be a disease, but place it wholly in
morbid excitement, invited and fixed by previous debility. He makes a
fever to consist in a change only of a _natural_ action of the
blood-vessels. I maintain that it consists in a _preternatural_ and
convulsive action of the blood-vessels. Lastly, Dr. Brown supposes
excitement and excitability to be _equally_ diffused over the whole body,
but in unhealthy proportions to each other. My theory places fever in
excitement and excitability _unequally_ diffused, manifesting themselves,
at the _same time_, in morbid actions, depression, and debility from
abstraction, in different parts of the body. No new excitement from
without is infused into the system by the irritants which excite a fever.
They only destroy its equal and natural distribution; for while the
arteries are in a plus, the muscles, stomach, and bowels are in a minus
state of excitement, and the business of medicine is to equalize it in
the cure of fever, that is, to abstract its excess from the
blood-vessels, and to restore it to the other parts of the body.

II. I come now to apply the theory which I have delivered to the
explanation and description of the different phenomena or states of
fever.

I have said in my sixth proposition that there is but one fever. Of
course I do not admit of its artificial division into genera and species.
A disease which so frequently changes its form and place, should never
have been designated, like plants and animals, by unchangeable
characters. The oak tree and the lion possess exactly the same properties
which they did nearly 6000 years ago. But who can say the same thing of
any one disease? The pulmonary consumption is sometimes transformed into
head-ach, rheumatism, diarrh[oe]a, and mania, in the course of two or
three months, or the same number of weeks. The bilious fever often
appears in the same person in the form of colic, dysentery, inflammation
of the liver, lungs, and brain, in the course of five or six days. The
hypochondriasis and the hysteria seldom fail to exchange their symptoms
twice in the four and twenty hours. Again: the oak tree has not united
with any of the trees of the forest, nor has the lion imparted his
specific qualities to any other animal. But who can apply similar remarks
to any one disease? Phrenitis, gastritis, enteritis, nephritis, and
rheumatism all appear at the same time in the gout and yellow fever. Many
observations of the same kind might be made, to show the disposition of
nearly all other diseases to anastomose with each other. To describe them
therefore by any fixed or specific characters is as impracticable as to
measure the dimensions of a cloud on a windy day, or to fix the component
parts of water by weighing it in a hydrostatic balance. Much mischief
has been done by nosological arrangements of diseases. They erect
imaginary boundaries between things which are of a homogeneous nature.
They degrade the human understanding, by substituting simple perceptions
to its more dignified operations in judgment and reasoning. They gratify
indolence in a physician, by fixing his attention upon the name of a
disease, and thereby leading him to neglect the varying state of the
system. They moreover lay a foundation for disputes among physicians, by
diverting their attention from the simple, predisposing, and proximate,
to the numerous, remote, and exciting causes of diseases, or to their
more numerous and complicated effects. The whole materia medica is
infected with the baneful consequences of the nomenclature of diseases,
for every article in it is pointed only against their names, and hence
the origin of the numerous contradictions among authors who describe the
virtues and doses of the same medicines. By the rejection of the
artificial arrangement of diseases, a revolution must follow in medicine.
Observation and judgment will take the place of reading and memory, and
prescriptions will be conformed to existing circumstances. The road to
knowledge in medicine by this means will likewise be shortened; so that a
young man will be able to qualify himself to practise physic at as much
less expence of time and labour than formerly, as a child would learn to
read and write by the help of the Roman alphabet, instead of Chinese
characters.

In thus rejecting the nosologies of the schools, I do not wish to see
them banished from the libraries of physicians. When consulted as
histories of the effects of diseases only, they may still be useful. I
use the term diseases, in conformity to custom, for, properly speaking,
disease is much a unit as fever. It consists simply of morbid action or
excitement in some part of the body. Its different seats and degrees
should no more be multiplied into different diseases, than the numerous
and different effects of heat and light upon our globe should be
multiplied into a plurality of suns.

The advocates for Dr. Cullen's system of medicine will not, I hope, be
offended by these observations. His immense stock of reputation will
enable him to sustain the loss of his nosology without being impoverished
by it. In my attempts to introduce a new arrangement of fevers, I shall
only give a new direction to his efforts to improve the healing art.

Were it compatible with the subject of the present inquiry, it would be
easy to show, that the same difficulties and evils are to be expected
from Dr. Darwin's division of diseases, as they affect the organs of
sensation and motion, and as they are said to be exclusively related by
association and volition, that have been deprecated from their divisions
and subdivisions by the nosologists. Diseases, like vices, with a few
exceptions, are necessarily undisciplined and irregular. Even the genius
of Dr. Darwin has not been able to compel them to move within lines.

I return from this digression to remark that morbid action in the
blood-vessels, whether it consist in preternatural force and frequency,
or preternatural force without frequency, or frequency without force,
constitutes fever. Excess in the force and frequency in the pulsations of
the arteries have been considered as the characteristic marks of what is
called inflammatory fever. There are, however, symptoms which indicate a
much greater excess of irritating impressions upon the blood-vessels.
These are preternatural slowness, intermissions, and depression in the
pulse, such as occur in certain malignant fevers.

But there is a grade of fever, which transcends in force that which
produces inflammation. It occurs frequently in hydrophobia, dysentery,
colic, and, baron Humboldt lately informed me, upon the authority of Dr.
Comoto, of Vera Cruz, in the yellow fever of that city, when it proves
fatal in a few hours after it attacks. In vain have physicians sought to
discover, by dissections, the cause of fever in those cases, when
followed by death, in the parts of the body in which it was supposed,
from pain and other symptoms, to be principally seated. Those parts have
frequently exhibited no marks of inflammation, nor of the least deviation
from a healthy state. I have ascribed this apparent absence of disease to
the serous vessels being too highly excited, and thereby too much
contracted, to admit the entrance of red blood into them. I wish these
remarks to be remembered by the student of medicine. They have delivered
me from the influence of several errors in pathology; and they are
capable, if properly extended and applied, of leading to many important
deductions in the practice of physic.

I shall now briefly mention the usual effects of fever, or morbid
excitement in the blood-vessels, when not removed by medicine. They are,

1. Inflammation. It is produced by an effusion of red particles of blood
into serous vessels, constituting what Dr. Boerhaave calls error loci. It
is the second grade of fever, and, in fevers of great violence, does not
take place until morbid excitement has continued for some time, or has
been reduced by bleeding.

2. Secretion, or an effusion from rupture, of the serum of the blood,
constituting dropsies.

3. Secretion of lymph or fibrin, forming a membrane which adheres to
certain surfaces in the body.

4. Secretion of pus, also of sloughs.

5. An effusion by rupture, or a congestion of all the component parts of
the blood.

6. Gangrene from the death of the blood-vessels.

7. Rupture of blood-vessels, producing hæmorrhage.

8. Redness, phlegmon, pustules, and petechiæ on the skin, and tubercles
in the lungs, and on the liver and bowels.

9. Schirrus.

10. Calcareous and other earthy matters. Both these take place only in
the feeble and often imperceptible grades of morbid action in the
blood-vessels.

11. Death. This arises from the following causes.

1. Sudden destruction of the excitability of the blood-vessels.

2. A disorganization of parts immediately necessary to life.

3. A change in the fluids, so as to render them destructive to what are
called the vital organs.

4. Debility, from the exhausted or suspended state of the excitability of
the blood-vessels.

All these effects of fever are different according to its grade. Dr.
Blane says fevers are rarely inflammatory in the West-Indies; that is,
they pass rapidly from simple morbid excitement to congestion,
hæmorrhage, gangrene, and death. This remark is confirmed by Dr.
Dalzelle, who says the pneumony in the negroes, in the French West-India
islands, rarely appears in any other form than that of the notha, from
the arteries in the lungs being too much stimulated to produce common
inflammation; but such is the force of morbid excitement in hot climates,
that it sometimes passes suddenly over all its intermediate effects, and
discovers itself only in death. This appears to have taken place in the
cases at Vera Cruz, mentioned by baron Humboldt.

All the different states of fever may be divided,

I. Into such as affect the whole arterial system; but with no, or very
little local disease.

II. Into such as affect the whole arterial system, and are accompanied at
the same time with evident local disease.

III. Into such as appear to pass by the arterial system, and to fix
themselves upon other parts of the body. I shall call these states of
fever _misplaced_.

I. To the first class of the states of fever belong,

1. The malignant. It constitutes the highest grade of morbid diathesis.
It is known by attacking frequently without a chilly fit, by coma, a
depressed, slow, or intermitting pulse, and sometimes by the absence of
pain, and with a natural temperature or coldness of the skin. It occurs
in the plague, in the yellow fever, in the gout, in the small-pox and
measles, in the hydrophobia, and after taking opium and other stimulating
substances. Dr. Quier has described a pleurisy in Jamaica, in which some
of those malignant symptoms took place. They are the effect of such a
degree of impression as to prostrate the arterial system, and to produce
a defect of action from an excess of force. Such is this excess of force,
in some instances, in this state of fever, that it induces general
convulsions, tetanus, and palsy, and sometimes extinguishes life in a few
hours, by means of apoplexy or syncope. From its being accompanied with
these symptoms, it has received the name of _adynamique_ by Dr. Alibert.
The less violent degrees of stimulus in this state of fever produce palsy
in the blood-vessels. It probably begins in the veins, and extends
gradually to the arteries. It seems further to begin in the extremities
of the arteries, and to extend by degrees to their origin in the heart.
This is evident in the total absence of pulse which sometimes takes place
in malignant fevers, four and twenty, and even eight and forty hours
before death. But there are cases in which this palsy affects both the
veins and arteries at the same time. It is probably from this
simultaneous affection of the blood-vessels, that the arteries are found
to be nearly full of blood after death from malignant fevers. The
depressed, and intermitting pulse which occurs in the beginning of these
fevers perhaps depends upon a tendency to palsy in the arteries,
independently of an affection of the heart or brain.

This _prostrate_ state of fever more frequently when left to itself
terminates in petechiæ, buboes, carbuncles, abscesses, and
mortifications, according as serum, lymph, or red blood is effused in the
viscera or external parts of the body. These morbid appearances have been
ascribed to putrefaction, and the fever has received, from its supposed
presence, the name of putrid. The existence of putrefaction in the blood
in a fever is rendered improbable,

1. By Dr. Seybert's experiments[5], which prove that it does not take
place in the blood in a living state. It occurs in the excretions of
bile, fæces, and urine, but in this case it does not act as a ferment,
but a stimulus only upon the living body.

  [5] Inaugural dissertation, entitled, "An Attempt to disprove the
      Putrefaction of the Blood in Living Animals."

2. By similar appearances, with those which have been ascribed to
putrefaction, having been produced by lightning, by violent emotions of
the mind, by extreme pain, and by every thing else which induces sudden
and universal disorganization in the fluids and solids of the body. The
following facts clearly prove that the symptoms which have been supposed
to designate a putrid fever, are wholly the effect of mechanical action
in the blood-vessels, and are unconnected with the introduction of a
putrid ferment in the blood.

Hippocrates relates the case of a certain Antiphillus, in whom a putrid
bilious fever (as he calls it) was brought on by the application of a
caustic to a wound[6].

  [6] Epidemics, book iv.

An acute pain in the eye, Dr. Physick informed me, produced the symptoms
of what is called a putrid fever, which terminated in death in five days,
in St. George's hospital, in the year 1789.

Dr. Baynard relates, upon the authority of a colonel Bampfield, that a
stag, which he had chased for some time, stopped at a brook of water in
order to drink. Soon afterwards it fell and expired. The colonel cut its
throat, and was surprised to perceive the blood which issued from it had
a putrid and offensive smell[7].

Dr. Desportes takes notice that a fish, which he calls a sucker, affected
the system nearly in the same manner as the miasmata of the yellow fever.
A distressing vomiting, a coldness of the extremities, and an absence of
pulse, were some of the symptoms produced by it, and an inflammation and
mortification of the stomach and bowels, were discovered after death to
be the effects of its violent operation.

Even opium, in large doses, sometimes produces by its powerful stimulus
the same symptoms which are produced by the stimulus of marsh miasmata.
These symptoms are a slow pulse, coma, a vomiting, cold sweats, a sallow
colour of the face, and a suppression of the discharges by the urinary
passages and bowels.

Error is often perpetuated by words. A belief in the putrefaction of the
blood has done great mischief in medicine. The evil is kept up, under the
influence of new theories, by the epithet putrid, which is still applied
to fever in all our medical books. For which reason I shall reject it
altogether hereafter, and substitute in its room.

  [7] Treatise on the Cold Bath.

2. The _gangrenous_ state of fever; for what appear to some physicians to
be signs of putrefaction, are nothing but the issue of a violent
inflammation left in the hands of nature, or accelerated by stimulating
medicines. Thus the sun, when viewed at mid-day, appears to the naked
eye, from the excess of its splendour, to be a mass of darkness, instead
of an orb of light.

The same explanation of what are called putrid symptoms in fever, is very
happily delivered by Mr. Hunter in the following words: "It is to be
observed (says this acute physiologist) that when the attack upon these
organs, which are principally connected with life, proves fatal, that the
effects of the inflammation upon the constitution run through all the
stages with more rapidity than when it happens in other parts; so that at
its very beginning, it has the same effect upon the constitution which is
only produced by the second stage of inflammation in other parts[8]."

  [8] Treatise on Inflammation. chap. I. 8.

3. The _synocha_, or the common inflammatory state of fever, attacks
suddenly with chills, and is succeeded by a quick, frequent, and tense
pulse, great heat, thirst, and pains in the bones, joints, breast, or
sides. These symptoms sometimes occur in the plague, the jail and yellow
fever, and the small-pox; but they are the more common characteristics of
pleurisy, gout, and rheumatism. They now and then occur in the influenza,
the measles, and the puerperile fever.

4. The _synochus_ state of fever is known by a full, quick, and round
pulse without tension. The autumnal bilious fever and colic, also the
gout, often appear in this form.

5. There is a state of fever in which the pulse is small, but tense and
quick. The patient, in this state of fever, is seldom confined to his
bed. We observe it sometimes in the chronic rheumatism, and in pulmonary
consumption. The inflammatory state of this grade of fever is proved from
the inefficacy of the volatile tincture of guaiacum and other stimulants
to remove it, and from its yielding so suddenly to blood-letting. I have
called it the _synochula_ state of fever.

6. There is a state of fever inclining more to the synocha, than what is
called the typhus, or low chronic state of fever. I have called it the
_synochoid_ state of fever.

7. The _typhus_ state of fever is generally preceded by all those
circumstances which debilitate the system, both by the action and
abstraction of stimuli. It is known by a weak and frequent pulse, a
disposition to sleep, a torpor of the alimentary canal, tremors of the
hands, a dry tongue, and, in some instances, by a diarrh[oe]a. These
symptoms occur most frequently in what is called the jail, the ship, and
the hospital fever. I heard of it in a few cases in the yellow fever of
1793, and all writers take notice of cases of the plague, which run on
into a slow fever that continues 30 or 40 days. I have seen it succeed
the common bilious fever, pleurisy, and influenza. It has been confounded
with the malignant state of fever, or what is called the typhus gravior;
but it differs widely from it in being accompanied by a feeble excitement
in the blood-vessels, from a feeble stimulus, and by the usual signs of
debility from abstraction in every other part of the body.

From the accession of new stimuli, or an increase in the force of former
ones, this typhus state of fever sometimes assumes, on the 11th, 14th,
and even 20th days, the symptoms of the synocha state of fever. It will
be useful to remember this remark, not only because it establishes the
unity of fever, but because it will justify the use of a remedy, seldom
prescribed after the disease has acquired that name which associates it
with stimulating medicines.

The common name of this state of fever, is the _nervous_ fever. This name
is improper; for it invades the nervous system by pain, delirium, and
convulsions much less than several other states of fever. To prevent the
absurd and often fatal association of ideas upon the treatment of this
state of fever, I have called it, from its duration, the _low chronic_
state of fever. I have adopted the term _low_, from Dr. Butter's account
of the remitting fever of children, in order to distinguish it from
states of fever to be mentioned hereafter, in which the patient is not
confined to his bed. This new name of the typhus or nervous fever
establishes its analogy with several other diseases. We have the acute
and the chronic rheumatism; the acute and chronic pneumony, commonly
called the pleurisy and pulmonary consumption; the acute and chronic
inflammation of the brain, known unfortunately by the unrelated names of
phrenitis, madness, and internal dropsy of the brain. Why should we
hesitate, in like manner, in admitting acute and chronic fever, in all
those cases where no local inflammation attends?

8. The _typhoid_ state of fever is composed of the synocha and low
chronic states of fever. It is the _slow_ nervous fever of Dr. Butter.
The excitement of the blood-vessels is somewhat greater than in the _low_
chronic state of fever. Perhaps the muscular fibres of the blood-vessels,
in this state of fever, are affected by different degrees of stimulus and
excitement. Supposing a pulse to consist of eight cords, I think I have
frequently felt more or less of them tense or relaxed, according as the
fever partook more or less of the synocha, or low chronic states of
fever. This state of fever occurs most frequently in what are called the
hectic and puerperal fevers, and in the scarlatina.

9. The _hectic_ state of fever differs from all the other states of
fever, by the want of regularity in its paroxysms, in which chills,
fevers, and sweats are included; and by the brain, nerves, muscles, and
alimentary canal being but little impaired in their functions by it. It
appears to be an exclusive disease of the blood-vessels. It occurs in the
pulmonary consumption, in some cases of lues, of scrophula, and of the
gout, and after most of the states of fever which have been described.
The force of the pulse is various, being occasionally synochoid, typhoid,
and typhus.

10. Intermissions, or the _intermitting_ and remitting states of fever,
are common to all the states of fever which have been mentioned. But they
occur most distinctly and universally in those which partake of the
bilious diathesis. They have been ascribed to the reproduction of bile,
to the recurrence of debility, and to the influence of the heavenly
bodies upon the system. None of these hypotheses has explained the
recurrence of fever, where the bile has not been in fault, where debility
is uniform, and where the paroxysms of fever do not accord with the
revolutions of any part of the solar system. I have endeavoured to
account for the recurrence of the paroxysm of fever, in common with all
other periodical diseases, by means of a natural or adventitious
association of motions. Dr. Percival has glanced at this law of animal
matter; and Dr. Darwin has explained by it, in the most ingenious manner,
many natural and morbid actions in the human body.

11. There is a state of fever in which the morbid action of the
blood-vessels is so feeble as scarcely to be perceptible. Like the
hectic state of fever, it seldom affects the brain, nerves, muscles, or
alimentary canal. It is known in the southern states of America by the
name of _inward_ fevers. The English physicians formerly described it by
the name of febricula.

These eleven states of fever may be considered as _primary_ in their
nature. All the states which remain to be enumerated belong to some one
of them, or they are compounds of two, three, or more of them. Even these
primary states of fever seldom appear in the simple form in which they
have been described. They often blend their symptoms; and sometimes all
the states appear at different times in the course of a fever. This
departure from a uniformity in the character of fevers must be sought for
in the changes of the weather, in the casual application of fresh
irritants, or in the operation of the remedies which have been employed
to cure them.

To the first class of the states of fever belong the sweating, the
fainting, the burning, and the cold and chilly states of fever.

12. The _sweating_ state of fever occurs in the plague, in the yellow
fever, in the small-pox, the pleurisy, the rheumatism, and in the hectic
and intermitting states of fever. Profuse sweats appeared every other day
in the autumnal fever of 1795 in Philadelphia, without any other symptom
of an intermittent. The English sweating sickness was nothing but a
symptom of the plague. The sweats in all these cases are the effects of
morbid and excessive action, concentrated in the capillary vessels.

13. The _fainting_ state of fever accompanies the plague, the yellow
fever, the small-pox, and some states of pleurisy. It is the effect of
great depression; hence it occurs most frequently in the beginning of
those states of fever.

14. The _burning_ state of fever has given rise to what has been called a
species of fever. It is the causus of authors. Dr. Mosely, who rejects
the epithet of yellow, when applied to the bilious fever, because it is
only one of its accidental symptoms, very improperly distinguishes the
same fever by another symptom, viz. the burning heat of the skin, and
which is not more universal than the yellowness which attends it.

15. The _cold_ and _chilly_ state of fever differs from a common chilly
fit, by continuing four or five days, and to such a degree, that the
patient frequently cannot bear his arms out of the bed. The coldness is
most obstinate in the hands and feet. A _coolness_ only of the skin
attends in some cases, which is frequently mistaken for an absence of
fever.

Having mentioned those states of fever which affect the arterial system
without any, or with but little local disease, I proceed next to
enumerate those states of fever which belong to the

II. Class of the order that was mentioned, in which there are local
affections combined with general fever. They are,

16. The _intestinal_ state of fever. I have been anticipated in giving
this epithet to fever, by Dr. Balfour[9]. It includes the cholera morbus,
diarrh[oe]a, dysentery, and colic. The remitting bilious fever appears,
in all the above forms, in the summer months. They all belong to the
febris introversa of Dr. Sydenham. The jail fever appears likewise
frequently in the form of diarrh[oe]a and dysentery. The dysentery is the
offspring of marsh and human miasmata, but it is often induced in a weak
state of the bowels, by other exciting causes. The colic occasionally
occurs with states of fever to be mentioned hereafter.

  [9] Account of the Intestinal Remitting Fever of Bengal.

17. The _pulmonary_ state of fever includes the true and bastard pneumony
in their acute forms; also catarrh from cold and influenza, and the
chronic form of pneumony in what is called pulmonary consumption.

18. The _eruptive_ state of fever includes the small-pox, measles,
erysipelas, miliary fever, chicken-pox, and pemphigus.

19. The _anginose_ state of fever includes all those affections of the
throat which are known by the names of cynanche inflammatoria,
tonsillaris, parotidea, maligna, scarlatina, and trachealis. The cynanche
trachealis is a febrile disease. The membrane which produces suffocation
and death in the wind-pipe is the effect of inflammation. It is said to
be formed, like other membranes which succeed inflammation, from the
coagulable lymph of the blood.

20. The _rheumatic_ state of fever is confined chiefly to the labouring
part of mankind. The topical affection is seated most commonly in the
joints and muscles, which, from being exercised more than other parts of
the body, become more debilitated, and are, in consequence thereof,
excited into morbid and inflammatory action.

21. The _arthritic_ or _gouty_ state of fever differs from the rheumatic,
in affecting, with the joints and muscles, all the nervous and lymphatic
systems, the viscera, and the skin. Its predisposing, exciting, and
proximate causes are the same as the rheumatic and other states of fever.
It bears the same ratio to rheumatism, which the yellow fever bears to
the common bilious fever. It is a fever of more force than rheumatism.

22. The _cephalic_, in which are included the phrenitic, lethargic,
apoplectic, paralytic, hydrocephalic, and maniacal states of fever. That
madness is originally a state of fever, I infer, 1. From its causes, many
of which are the same as those which induce all the other states of
fever. 2. From its symptoms, particularly a full, tense, quick, and
sometimes a slow pulse. 3. From the inflammatory appearances of the blood
which has been drawn to relieve it. And, 4. From the phenomena exhibited
by dissection in the brains of maniacs, being the same as are exhibited
by other inflamed viscera after death. These are, effusions of water or
blood, abscesses, and schirrus. The hardness in the brains of maniacs,
taken notice of by several authors, is nothing but a schirrus (sui
generis), induced by the neglect of sufficient evacuations in this state
of fever. The reader will perceive by these observations, that I reject
madness from its supposed primary seat in the mind or nerves. It is as
much an original disease of the blood-vessels, as any other state of
fever. It is to phrenitis, what pulmonary consumption is to pneumony. The
derangement in the operations of the mind is the effect only of a chronic
inflammation of the brain, existing without an abstraction of muscular
excitement.

23. The _nephritic_ state of fever is often induced by calculi, but it
frequently occurs in the gout, small-pox, and malignant states of fever.
There is such an engorgement, or choaking of the vessels of the kidneys,
that the secretion of the urine is sometimes totally obstructed, so that
the bladder yields no water to the catheter. It is generally accompanied
with a full or tense pulse, great pain, sickness, or vomiting, high
coloured urine, and a pain along the thigh and leg, with occasionally a
retraction of one of the testicles. It exists sometimes without any pain.
Of this I met with several instances in the yellow fever of 1793. I
include diabetes in this state of fever.

24. The _hydropic_ state of fever, in which are included collections of
water, in the lungs, cavity of the thorax, cavity of the abdomen, ovaria,
scrotum, testicles, and lower extremities, and usually preceded, and
generally accompanied with morbid action in the blood-vessels. That
dropsy is a state of fever, I have endeavoured to prove in another
place[10]. Nineteen dropsies out of twenty appear to be original arterial
diseases, and the water, which has been supposed to be their cause, is as
much the effect of preternatural and morbid action in the blood-vessels,
as pus, gangrene, and schirrus are of previous inflammation. This has
been demonstrated, by the late Dr. Cooper, in a man who died of an
ascites in the Pennsylvania hospital. Pus and blood, as well as water,
were found in the cavity of the abdomen. It is no objection to this
theory of dropsy, that we sometimes find water in the cavities of the
body after death, without any marks of inflammation in the contiguous
blood-vessels. We often find pus, both in the living and dead body, under
the same circumstances, where we are sure it was not preceded by any of
the obvious marks of inflammation.

  [10] On Dropsies, vol. II.

25. The _hæmorrhagic_ state of fever, in which are included discharges of
blood from the nose, lungs, stomach, liver, bowels, kidneys and bladder,
hæmorrhoidal vessels, uterus, and skin. Hæmorrhages have been divided
into active and passive. It would be more proper to divide them, like
other states of general fever, into hæmorrhages of strong and feeble
morbid action. There is seldom an issue of blood from a vessel in which
there does not exist preternatural or accumulated excitement. We observe
this hæmorrhagic state of fever most frequently in malignant fevers, in
pulmonary consumption, in pregnancy, and in that period of life in which
the menses cease to be regular.

26. The _amenorrhagic_ state of fever occurs more frequently than is
suspected by physicians. A full and quick pulse, head-ach, thirst, and
preternatural heat often accompany a chronic obstruction of the menses.
The inefficacy, and even hurtful effects, of what are called emenagogue
medicines, in this state of the system, without previous depletion, show
the propriety of introducing it among the different states of fever.

I have designedly omitted to take notice of other states of general fever
accompanied with local disease, because they are most frequently
combined with some one or more of those which have been mentioned. They
may all be seen in Dr. Cullen's Synopsis, with their supposed respective
generic characters, under the class of pyrexiæ, and the order of fevers.
We come now in the

III. And last place, to mention the _misplaced_ states of fever. The term
is not a new one in medicine. The gout is said to be misplaced, when it
passes from the feet to the viscera. The periodical pains in the head,
eyes, ears, jaws, hips, and back, which occur in the sickly autumnal
months, and which impart no fulness, force, nor frequency to the pulse,
are all misplaced fevers. There are, besides these, many other local
morbid affections, which are less suspected of belonging to febrile
diseases. The nature of these states of fever may easily be understood,
by recollecting one of the laws of sensation, that is, that certain
impressions, which excite neither sensation nor motion in the part of the
body to which they are applied, excite both in another part. Thus worms,
which are not felt in the stomach or bowels, often produce a troublesome
sensation in the throat, and a stone, which is attended with no pain in
the bladder, produces a troublesome itching in the glans penis. In like
manner, the irritants which produce fever in ordinary cases pass through
the blood-vessels, and convey their usual morbid effects into a remote
part of the body which has been prepared to receive them by previous
debility. That this is the case, I infer further, from fevers being
called back from their misplaced or suffocated situations, by creating an
artificial debility in the arteries by the abstraction of blood. This is
often done in muscular convulsions, and in several diseases of the brain.

Under this class of fevers are included

27. The _chronic hepatic_ state of fever. The causes, symptoms, and
remedies of the liver disease of the East-Indies, as mentioned by Dr.
Girdlestone, all prove that it is nothing but a bilious fever translated
from the blood-vessels, and absorbed, or suffocated, as it were, in the
liver. This view of the chronic hepatitis is important, inasmuch as it
leads to the liberal use of all the remedies which cure bilious fever.
Gall stones and contusions now and then produce a hepatitis, but under no
other circumstances do I believe it ever exists, but as a symptom of
general or latent fever.

28. The hæmorrhoids are frequently a local disease, but they are
sometimes accompanied with pain, giddiness, chills, and an active pulse.
When these symptoms occur, it should be considered as a _hæmorrhoidal_
state of fever.

29. The opthalmia, when it occurs, as it frequently does in sickly
seasons, with a quick and tense pulse, and pains diffused over the whole
head, may properly be called an _opthalmic_ state of fever.

30. The tooth-ach, and

31. Ear-ach, when they arise from colds, and are attended with great
heat, a quick and tense pulse, and pains in the head, are _odontalgic_
and _otalgic_ states of fever.

32. The apthæ, from the pain and fever which attend them, are justly
entitled to the name of the _apthous_ state of fever.

33. The symptoms of scrophula, as described by Dr. Hardy, in his treatise
on the glandular disease of Barbadoes, clearly prove it to be a
_misplaced_ state of fever.

34. The scurvy has lately been proved by Dr. Claiborne, in his inaugural
dissertation, published in the year 1797, to arise from so many of the
causes, and to possess so many of the symptoms, of the low chronic and
petechial states of fever, that I see no impropriety in considering it as
a state of fever.

35. The _convulsive_ or _spasmodic_ state of fever. Convulsions, it is
well known, often usher in fevers, more especially in children. But the
connection between spasmodic affections and fever, in adults, has been
less attended to by physicians. The same causes which produced general
fever and hepatitis in the East-Indies, in some soldiers, produced locked
jaw in others. Several of the symptoms of this disease, as described by
Dr. Girdlestone, such as coldness on the surface of the body, cold sweats
on the hands and feet, intense thirst, a white tongue, incessant
vomitings, and carbuncles, all belong to the malignant state of
fever[11]. By means of blood-letting, and the other remedies for the
violent state of bilious fever, I have seen the convulsions in this
disease translated from the muscles to the blood-vessels, where they
immediately produced _all_ the common symptoms of fever.

  [11] Essay on the Spasmodic Affections in India, p. 53, 54, 55.

36. The _hysterical_ and _hypochondriacal_ states of fever. The former is
known by a rising in the throat, which is for the most part erroneously
ascribed to worms, by pale urine, and by a disposition to shed tears, or
to laugh upon trifling occasions. The latter discovers itself by false
opinions of the nature and danger of the disease under which the patient
labours. Both these states of the nervous system occur frequently in the
gout and in the malignant state of fever. It is common to say, in such
cases, that patients have a complication of diseases; but this is not
true, for the hysterical and hypochondriacal symptoms are nothing but the
effects of one remote cause, concentrating its force chiefly upon the
nerves and muscles.

37. The _cutaneous_ state of fever. Dr. Sydenham calls a dysentery a
"febris introversa." Eruptions of the skin are often nothing but the
reverse of this introverted fever. They are a fever translated to the
skin; hence we find them most common in those countries and seasons in
which fevers are epidemic. The prickly heat, the rash, and the essere of
authors, are all states of misplaced fever. "Agues, fevers, and even
_pleurisies_ (says Mr. Townsend, in his Journey through Spain[12]), are
said often to terminate in scabies, and this frequently gives place to
them, returning, however, when the fever ceases. In adults it takes
possession of the hands and arms, with the legs and thighs, covering them
with a filthy crust." Small boils are common among the children in
Philadelphia, at the time the cholera infantum makes its appearance.
These children always escape the summer epidemic. The elephantiasis
described by Dr. Hillary, in his account of the diseases of Barbadoes, is
evidently a translation of an intermittent to one of the limbs. It is
remarkable, that the leprosy and malignant fevers of all kinds have
appeared and declined together in the same ages and countries. But
further, petechiæ sometimes appear on the skin without fever. Cases of
this kind, with and without hæmorrhages, are taken notice of by
Riverius[13], Dr. Duncan, and many other practical writers. They are
cotemporary or subsequent to fevers of a malignant complexion. They occur
likewise in the scurvy. From some of the predisposing, remote, and
exciting causes of this disease, and from its symptoms and remedies, I
have suspected it, like the petechiæ mentioned by Riverius, to be
originally a fever generated by human miasmata, in a misplaced state. The
hæmorrhages which sometimes accompany the scurvy, certainly arise from a
morbid state of the blood-vessels. The heat and quick pulse of fever are
probably absent, only because the preternatural excitement of the whole
sanguiferous system is confined to those extreme or cutaneous vessels
which pour forth blood. In like manner the fever of the small-pox deserts
the blood-vessels, as soon as a new action begins on the skin. Or perhaps
the excitability of the larger blood-vessels may be so far exhausted by
the long or forcible impression of the remote and predisposing causes of
the scurvy, as to be incapable of undergoing the convulsive action of
general fever.

  [12] Vol. II. Dublin edition, p. 262.

  [13] Praxis Medica, lib. xviii. cap. i.

With this I close my inquiry into the cause of fever. It is imperfect
from its brevity, as well as from other causes. I commit it to my pupils
to be corrected and improved.

              "We think our fathers fools, so wise we grow.
               Our wiser sons, _I hope_, will think us so."



                               AN ACCOUNT

                                 OF THE

                    _Bilious Remitting Yellow Fever_,

                                  AS IT

                        APPEARED IN PHILADELPHIA,

                            IN THE YEAR 1793.


Before I proceed to deliver the history of this fever, it will be proper
to give a short account of the diseases which preceded it.

The state of the weather during the first seven months of the year, and
during the time in which the fever prevailed in the city, as recorded by
Mr. Rittenhouse, will be inserted immediately after the history of the
disease.

The _mumps_, which made their appearance in December, 1792, continued to
prevail during the month of January, 1793. Besides this disease there
were many cases of catarrh in the city, brought on chiefly by the
inhabitants exposing themselves for several hours on the damp ground, in
viewing the aërial voyage of Mr. Blanchard, on the 9th day of the month.

The weather, which had been moderate in December and January, became cold
in February. The mumps continued to prevail during this month with
symptoms so inflammatory as to require, in some cases, two bleedings.
Many people complained this month of pains and swellings in the jaws. A
few had the scarlatina anginosa.

The mumps, pains in the jaws, and scarlatina continued throughout the
month of March. I was called to two cases of pleurisy in this month,
which terminated in a temporary mania. One of them was in a woman of
ninety years of age, who recovered. The blood drawn in the other case (a
gentleman from Maryland) was dissolved. The continuance of a tense pulse
induced me, notwithstanding, to repeat the bleeding. The blood was now
sizy. A third bleeding was prescribed, and my patient recovered. Several
cases of obstinate erysipelas succeeded inoculation in children during
this and the next month, one of which proved fatal.

Blossoms were universal on the fruit-trees, in the gardens of
Philadelphia, on the first day of April. The scarlatina anginosa
continued to be the reigning epidemic in this month.

There were several warm days in May, but the city was in general healthy.
The birds appeared two weeks sooner this spring than usual.

The register of the weather shows, that there were many warm days in
June. The scarlatina continued to maintain its empire during this month.

The weather was uniformly warm in July. The scarlatina continued during
the beginning of this month, with symptoms of great violence. A son of
James Sharswood, aged seven years, had, with the common symptoms of this
disease, great pains and swellings in his limbs, accompanied with a tense
pulse. I attempted in vain to relieve him by vomits and purges. On the
10th day of the month, I ordered six ounces of blood to be drawn from his
arm, which I observed afterwards to be very sizy. The next day he was
nearly well. Between the 22d and the 24th days of the month, there died
three persons, whose respective ages were 80, 92, and 96-1/2. The weather
at this time was extremely warm. I have elsewhere taken notice of the
fatal influence of extreme heat, as well as cold, upon human life in old
people. A few bilious remitting fevers appeared towards the close of this
month. One of them under my care ended in a typhus or chronic fever, from
which the patient was recovered with great difficulty. It was the son of
Dr. Hutchins, of the island of Barbadoes.

The weather, for the first two or three weeks in August, was temperate
and pleasant. The cholera morbus and remitting fevers were now common.
The latter, were attended with some inflammatory action in the pulse, and
a determination to the breast. Several dysenteries appeared at this time,
both in the city and in its neighbourhood. During the latter part of
July, and the beginning of this month, a number of the distressed
inhabitants of St. Domingo, who had escaped the desolation of fire and
sword, arrived in the city. Soon after their arrival, the influenza made
its appearance, and spread rapidly among our citizens. The scarlatina
still kept up a feeble existence among children. The above diseases were
universal, but they were not attended with much mortality. They prevailed
in different parts of the city, and each seemed to appear occasionally to
be the ruling epidemic. The weather continued to be warm and dry. There
was a heavy rain on the 25th of the month, which was remembered by the
citizens of Philadelphia, as the last that fell for many weeks
afterwards.

There was something in the heat and drought of the summer months which
was uncommon, in their influence upon the human body. Labourers every
where gave out (to use the country phrase) in harvest, and frequently too
when the mercury in Fahrenheit's thermometer was under 84°. It was
ascribed by the country people to the calmness of the weather, which left
the sweat produced by heat and labour to dry slowly upon the body.

The crops of grain and grass were impaired by the drought. The summer
fruits were as plentiful as usual, particularly the melons, which were of
an excellent quality. The influence of the weather upon the autumnal
fruits, and upon vegetation in general, shall be mentioned hereafter.

I now enter upon a detail of some solitary cases of the epidemic, which
soon afterwards spread distress through our city, and terror throughout
the United States.

On the 5th of August, I was requested by Dr. Hodge to visit his child. I
found it ill with a fever of the bilious kind, which terminated (with a
yellow skin) in death on the 7th of the same month.

On the 6th of August, I was called to Mrs. Bradford, the wife of Mr.
Thomas Bradford. She had all the symptoms of a bilious remittent, but
they were so acute as to require two bleedings, and several successive
doses of physic. The last purge she took was a dose of calomel, which
operated plentifully. For several days after her recovery, her eyes and
face were of a yellow colour.

On the same day, I was called to the son of Mrs. M'Nair, who had been
seized violently with all the usual symptoms of a bilious fever. I purged
him plentifully with salts and cremor tartar, and took ten or twelve
ounces of blood from his arm. His symptoms appeared to yield to these
remedies; but on the 10th of the month a hæmorrhage from the nose came
on, and on the morning of the 12th he died.

On the 7th of this month I was called to visit Richard Palmer, a son of
Mrs. Palmer, in Chesnut-street. He had been indisposed for several days
with a sick stomach, and vomiting after eating. He now complained of a
fever and head-ach. I gave him the usual remedies for the bilious fever,
and he recovered in a few days. On the 15th day of the same month I was
sent for to visit his brother William, who was seized with all the
symptoms of the same disease. On the 5th day his head-ach became
extremely acute, and his pulse fell to sixty strokes in a minute. I
suspected congestion to have taken place in his brain, and ordered him to
lose eight ounces of blood. His pulse became more frequent, and less
tense after bleeding, and he recovered in a day or two afterwards.

On the 14th day of this month I was sent for to visit Mrs. Leaming, the
wife of Mr. Thomas Leaming. I suspected at first that she had the
influenza, but in a day or two her fever put on bilious symptoms. She was
affected with an uncommon disposition to faint. Her pulse was languid,
but _tense_. I took a few ounces of blood from her, and purged her with
salts and calomel. I afterwards gave her a small dose of laudanum which
disagreed with her. In my note book I find I have recorded that "she was
worse for it." I was led to make this remark by its being so very
uncommon for a person, who had been properly bled and purged, to take
laudanum in a common bilious fever without being benefited by it. She
recovered, however, slowly, and was yellow for many days afterwards.

On the morning of the 18th of this month I was requested to visit Peter
Aston, in Vine-street, in consultation with Dr. Say. I found him on the
third day of a most acute bilious fever. His eyes were inflamed, and his
face flushed with a deep red colour. His pulse seemed to forbid
evacuations. We prescribed the strongest cordials, but to no purpose. We
found him, at 6 o'clock in the evening, sitting upon the side of his bed,
perfectly sensible, but without a pulse, with cold clammy hands, and his
face of a yellowish colour. He died a few hours after we left him.

None of the cases which I have mentioned excited the least apprehension
of the existence of a malignant or yellow fever in our city; for I had
frequently seen sporadic cases in which the common bilious fever of
Philadelphia had put on symptoms of great malignity, and terminated
fatally in a few days, and now and then with a yellow colour on the skin,
before or immediately after death.

On the 19th of this month I was requested to visit the wife of Mr. Peter
Le Maigre, in Water-street, between Arch and Race-streets, in
consultation with Dr. Foulke and Dr. Hodge. I found her in the last stage
of a highly bilious fever. She vomited constantly, and complained of
great heat and burning in her stomach. The most powerful cordials and
tonics were prescribed, but to no purpose. She died on the evening of the
next day.

Upon coming out of Mrs. Le Maigre's room I remarked to Dr. Foulke and Dr.
Hodge, that I had seen an unusual number of bilious fevers, accompanied
with symptoms of uncommon malignity, and that I suspected all was not
right in our city. Dr. Hodge immediately replied, that a fever of a most
malignant kind had carried off four or five persons within sight of Mr.
Le Maigre's door, and that one of them had died in twelve hours after the
attack of the disease. This information satisfied me that my
apprehensions were well founded. The origin of this fever was discovered
to me at the same time, from the account which Dr. Foulke gave me of a
quantity of damaged coffee which had been thrown upon Mr. Ball's wharf,
and in the adjoining dock, on the 24th of July, nearly in a line with Mr.
Le Maigre's house, and which had putrefied there to the great annoyance
of the whole neighbourhood.

After this consultation I was soon able to trace all the cases of fever
which I have mentioned to this source. Dr. Hodge lived a few doors above
Mr. Le Maigre's, where his child had been exposed to the exhalation from
the coffee for several days. Mrs. Bradford had spent an afternoon in a
house directly opposite to the wharf and dock on which the putrid coffee
had emitted its noxious effluvia, a few days before her sickness, and had
been much incommoded by it. Her sister, Mrs. Leaming, had visited her
during her illness at her house, which was about two hundred yards from
the infected wharf. Young Mr. M'Nair and Mrs. Palmer's two sons had spent
whole days in a compting house near where the coffee was exposed, and
each of them had complained of having been made sick by its offensive
smell, and Mr. Aston had frequently been in Water-street near the source
of the exhalation.

This discovery of the malignity, extent, and origin of a fever which I
knew to be attended with great danger and mortality, gave me great pain.
I did not hesitate to name it the _bilious remitting yellow fever_. I had
once seen it epidemic in Philadelphia, in the year 1762. Its symptoms
were among the first impressions which diseases made upon my mind. I had
recorded some of these symptoms, as well as its mortality. I shall here
introduce a short account of it, from a note book which I kept during my
apprenticeship.

"In the year 1762, in the months of August, September, October, November,
and December, the bilious yellow fever prevailed in Philadelphia, after a
_very hot summer_, and spread like a plague, carrying off daily, for some
time, upwards of twenty persons.

"The patients were generally seized with rigours, which were succeeded
with a violent fever, and pains in the head and back. The pulse was full,
and sometimes irregular. The eyes were inflamed, and had a yellowish
cast, and a vomiting almost always attended.

"The 3d, 5th, and 7th days were mostly critical, and the disease
generally terminated on one of them, in life or death.

"An eruption on the 3d or 7th day over the body proved salutary.

"An excessive heat and burning about the region of the liver, with cold
extremities, portended death to be at hand."

I have taken notice, in my note book, of the principal remedy which was
prescribed in this fever by my preceptor in medicine, but this shall be
mentioned hereafter.

Upon my leaving Mrs Le Maigre's, I expressed my distress at what I had
discovered, to several of my fellow-citizens. The report of a malignant
and mortal fever being in town spread in every direction, but it did not
gain universal credit. Some of those physicians who had not seen patients
in it denied that any such fever existed, and asserted (though its
mortality was not denied) that it was nothing but the common annual
remittent of the city. Many of the citizens joined the physicians in
endeavoring to discredit the account I had given of this fever, and for a
while it was treated with ridicule or contempt. Indignation in some
instances was excited against me, and one of my friends, whom I advised
in this early stage of the disease to leave the city, has since told me
that for that advice "he had hated me."

My lot in having thus disturbed the repose of the public mind, upon the
subject of general health, was not a singular one. There are many
instances upon record, of physicians who have rendered themselves
unpopular, and even odious to their fellow-citizens, by giving the first
notice of the existence of malignant and mortal diseases. A physician,
who asserted that the plague was in Messina, in the year 1743, excited so
much rage in the minds of his fellow-citizens against him, as to render
it necessary for him to save his life by retreating to one of the
churches of that city.

In spite, however, of all opposition, the report of the existence of a
malignant fever in the city gained so much ground, that the governor of
the state directed Dr. Hutchinson, the inspector of sickly vessels, to
inquire into the truth of it, and into the nature of the disease.

In consequence of this order, the doctor wrote letters to several of the
physicians in the city, requesting information relative to the fever. To
his letter to me, dated the 24th of August, I replied on the same day,
and mentioned not only the existence of a malignant fever, but the
streets it occupied, and my belief of its being derived from a quantity
of coffee which had putrified on a wharf near Arch-street. This, and
other information collected by the doctor, was communicated to the health
officer, in a letter dated the 27th of August, in which he mentioned the
parts of the city where the disease prevailed, and the number of persons
who had died of it, supposed by him to be about 40, but which subsequent
inquiries proved to be more than 150. He mentioned further, in addition
to the damaged coffee, some putrid hides, and other putrid animal and
vegetable substances, as the supposed cause of the fever, and concluded
by saying, as he had not heard of any foreigners or sailors being
infected, nor of its being found in any lodging-houses, that "it was not
an imported disease."

In the mean while the disease continued to spread, and with a degree of
mortality that had never been known from common fevers.

On the 25th of the month, the college of physicians was summoned by their
president to meet, in order to consult about the best methods of checking
the progress of the fever in the city. After some consideration upon the
nature of the disease, a committee was appointed to draw up some
directions for those purposes; and the next day the following were
presented to the college, and adopted unanimously by them. They were
afterwards published in most of the newspapers.

                                       _Philadelphia, August 26th, 1793._

The college of physicians having taking into consideration the malignant
and contagious fever that now prevails in this city, have agreed to
recommend to their fellow-citizens the following means of preventing its
progress.

1st. That all unnecessary intercourse should be avoided with such persons
as are infected by it.

2d. To place a mark upon the door or window of such houses as have any
infected persons in it.

3d. To place the persons infected in the centre of large and airy rooms,
in beds without curtains, and to pay the strictest regard to cleanliness,
by frequently changing their body and bed linen, also by removing, as
speedily as possible, all offensive matters from their rooms.

4th. To provide a large and airy hospital, in the neighbourhood of the
city, for the reception of such poor persons as cannot be accommodated
with the above advantages in private houses.

5th. To put a stop to the tolling of the bells.

6th. To bury such persons as die of this fever in carriages, and in as
private a manner as possible.

7th. To keep the streets and wharves of the city as clean as possible. As
the contagion of the disease may be taken into the body, and pass out of
it without producing the fever, unless it be rendered active by some
occasional cause, the following means should be attended to, to prevent
the contagion being excited into action in the body.

8th. To avoid all fatigue of body and mind.

9th. To avoid _standing_ or _sitting_ in the sun; also in a current of
air, or in the evening air.

10th. To accommodate the dress to the weather, and to exceed rather in
warm, than in cool clothing.

11th. To avoid intemperance, but to use fermented liquors, such as wine,
beer, and cyder, in moderation.

The college conceive _fires_ to be very ineffectual, if not dangerous
means of checking the progress of this fever. They have reason to place
more dependence upon the burning of _gunpowder_. The benefits of
_vinegar_ and _camphor_ are confined chiefly to infected rooms, and they
cannot be used too frequently upon handkerchiefs, or in
smelling-bottles, by persons whose duty calls to visit or attend the
sick.

                     Signed by order of the college,

                                             WILLIAM SHIPPEN, jun.
                                               _Vice president_.

                                             SAMUEL P. GRIFFITTS,
                                                 _Secretary_.

From a conviction that the disease originated in the putrid exhalations
from the damaged coffee, I published in the American Daily Advertiser, of
August 29th, a short address to the citizens of Philadelphia, with a view
of directing the public attention to the spot where the coffee lay, and
thereby of checking the progress of the fever as far as it was continued
by the original cause.

This address had no other effect than to produce fresh clamours against
the author; for the citizens, as well as most of the physicians of
Philadelphia, had adopted a traditional opinion that the yellow fever
could exist among us only by importation from the West-Indies.

In consequence, however, of a letter from Dr. Foulke to the mayor of the
city, in which he had decided, in a positive manner, in favour of the
generation of the fever from the putrid coffee, the mayor gave orders for
the removal of the coffee, and the cleaning of the wharf and dock. It was
said that measures were taken for this purpose; but Dr. Foulke, who
visited the place where the coffee lay, repeatedly assured me, that they
were so far from being effectual, that an offensive smell was exhaled
from it many days afterwards.

I shall pass over, for the present, the facts and arguments on which I
ground my assertion of the generation of this fever in our city. They
will come in more properly in the close of the history of the disease.

The seeds of the fever, when received into the body, were generally
excited into action in a few days. I met with several cases in which they
acted so as to produce a fever on the same day in which they were
received into the system, and I heard of two cases in which they excited
sickness, fainting, and fever within one hour after the persons were
exposed to them. I met with no instance in which there was a longer
interval than sixteen days between their being received into the body and
the production of the disease.

This poison acted differently in different constitutions, according to
previous habits, to the degrees of predisposing debility, or to the
quantity and concentration of the miasmata which had been received into
the body.

In some constitutions, the miasmata were at once a remote, a
predisposing, and an exciting cause of the disease; hence some persons
were affected by them, who had not departed in any instance from their
ordinary habits of living, as to diet, dress, and exercise. But it was
more frequently brought on by those causes acting in succession to each
other.

I shall here refer the reader to the principles laid down in the outlines
of the theory of fever, for an account of the manner in which the system
was predisposed to this disease, by the debility induced by the reduction
of its excitement, by action and abstraction, and by subsequent
depression. Where a predisposition was thus produced, the fever was
excited by the following causes, acting directly or indirectly upon the
system. Where this predisposition did not exist, the exciting causes
produced both the predisposition and the disease. They were,

1. _Great labour_, or exercises of body or mind, in walking, riding,
watching, or the like. It was labour which excited the disease so
universally among the lower class of people. A long walk often induced
it. Few escaped it after a day, or even a few hours spent in gunning. A
hard trotting horse brought it on two of my patients. Perhaps riding on
horseback, and in the sun, was the exciting cause of the disease in most
of the citizens and strangers who were affected by it in their flight
from the city. A fall excited it in a girl, and a stroke upon the head
excited it in a young man who came under my care. Many people were seized
with the disease in consequence of their exertions on the night of the
7th of September, in extinguishing the fire which consumed Mr. Dobson's
printing-office, and even the less violent exercise of working the fire
engines, for the purpose of laying the dust in the streets, added
frequently to the number of the sick.

2. _Heat_, from every cause, but more especially the heat of the sun, was
a very common exciting cause of the disease. The register of the weather
during the latter end of August, the whole of September, and the first
two weeks in October will show how much the heat of the sun must have
contributed to excite the disease, more especially among labouring
people. The heat of common fires likewise became a frequent cause of the
activity of the miasmata where they had been received into the body;
hence the greater mortality of the disease among bakers, blacksmiths, and
hatters than among any other class of people.

3. _Intemperance_ in eating or drinking. A plentiful meal, and a few
extra glasses of wine seldom failed of exciting the fever. But where the
body was strongly impregnated with the seeds of the disease, even the
smallest deviation from the customary stimulus of diet, in respect to
quality or quantity, roused them into action. A supper of twelve oysters
in one, and of but three in another, of my patients produced the disease.
Half an ounce of meat excited it in a lady who had lived, by my advice,
for two weeks upon milk and vegetables, and even a supper of sallad,
dressed after the French fashion, excited it in one of Dr. Mease's
patients.

4. _Fear._ In many people the disease was excited by a sudden paroxysm of
fear; but I saw some remarkable instances where timid people escaped the
disease, although they were constantly exposed to it. Perhaps a moderate
degree of fear served to counteract the excessive stimulus of the
miasmata, and thereby to preserve the body in a state of healthy
equilibrium. I am certain that fear did no harm after the disease was
formed, in those cases where great morbid excess of action had taken
place. It was an early discovery of this fact which led me not to conceal
from my patients the true name of this fever, when I was called to them
on the _day_ of their being attacked by it. The fear co-operated with
some of my remedies (to be mentioned hereafter) in reducing the morbid
excitement of the arterial system.

5. _Grief._ It was remarkable that the disease was not excited in many
cases in the attendants upon the sick, while there was a hope of their
recovery. The grief which followed the extinction of hope, by death,
frequently produced it within a day or two afterwards, and that not in
one person only, but often in most of the near relations of the deceased.
But the disease was also produced by a change in the state of the mind
directly opposite to that which has been mentioned. Many persons that
attended patients who recovered, were seized with the disease a day or
two after they were relieved from the toils and anxiety of nursing. The
collapse of the mind from the abstraction of the stimulus of hope and
desire, by their ample gratification, probably produced that debility,
and loss of the equilibrium in the system, which favoured the activity
of the miasmata in the manner formerly mentioned[14].

  [14] Outlines of a Theory of Fever.

The effects of both the states of mind which have been described, have
been happily illustrated by two facts which are recorded by Dr.
Jackson[15]. He tells us, that the garrisons of Savannah and York-Town
were both healthy during the siege of those towns, but that the former
became sickly as soon as the French and American armies retreated, from
before it, and the latter, immediately after its capitulation.

  [15] Treatise on the Fevers of Jamaica, p. 298.

6. _Cold._ Its action, in exciting the disease, depended upon the
diminution of the necessary and natural heat of the body, and thereby so
far destroying the equilibrium of the system, as to enable the miasmata
to produce excessive or convulsive motions in the blood-vessels. The
night air, even in the warm month of September, was often so cool as to
excite the disease, where the dress and bed-clothes were not accommodated
to it. It was excited in one case by a person's only wetting his feet, in
the month of October, and neglecting afterwards to change his shoes and
stockings. Every change in the weather, that was short of producing
frost, evidently increased the number of sick people. This was obvious
after the 18th and 19th of September, when the mercury fell to 44° and
45°. The hopes of the city received a severe disappointment upon this
occasion, for I well recollect there was a general expectation that this
change in the weather would have checked the disease. The same increase
of the number of sick was observed to follow the cool weather which
succeeded the 6th and 7th of October, on which days the mercury fell to
43° and 46°.

It was observed that those persons who were _habitually_ exposed to the
cool air, were less liable to the disease than others. I ascribe it to
the _habitual_ impression of the cool night air upon the bodies of the
city watchmen, that but four or five of them, out of twenty-five, were
affected by the disease.

After the body had been heated by violent exercise, a breeze of cool air
sometimes excited the disease in those cases where there had been no
change in the temperature of the weather.

7. _Sleep._ A great proportion of all who were affected by this fever,
were attacked in the night. Sleep induced what I have called debility
from abstraction, and thereby disposed the miasmata which floated in the
blood, to act with such force upon the system as to destroy its
equilibrium, and thus to excite a fever. The influence of sleep as a
predisposing, and exciting cause was often assisted by the want of
bed-clothes, suited to the midnight or morning coolness of the air.

8. _Immoderate evacuations._ The efficacy of moderate purging and
bleeding in preventing the disease, led some people to use those remedies
in an excess, which both predisposed to the disease, and excited it. The
morbid effects of these evacuations, were much aided by fear, for it was
this passion which perverted the judgment in such a manner, as to lead to
the excessive use of remedies, which, to be effectual, should only be
used in moderate quantities.

The disease appeared with different symptoms, and in different degrees,
in different people. They both varied likewise with the weather. In
describing the disease, I shall take notice of the changes in the
symptoms, which were produced by changes in the temperature of the air.

The precursors, or premonitory signs of this fever were, costiveness, a
dull pain in the right side, defect of appetite, flatulency, perverted
taste, heat in the stomach, giddiness, or pain in the head, a dull,
watery, brilliant, yellow, or red eye, dim and imperfect vision, a
hoarseness, or slight sore throat, low spirits, or unusual vivacity, a
moisture on the hands, a disposition to sweat at nights, or after
moderate exercise, or a sudden suppression of night sweats. The dull eye,
and the lowness of spirits, appeared to be the effects of such an excess
in the stimulus of the miasmata as to induce depression, while the
brilliant eye, and the unusual vivacity, seemed to have been produced by
a less quantity of the miasmata acting as a cordial upon the system. More
or less of these symptoms frequently continued for two or three days
before the patients were confined to their beds, and in some people they
continued during the whole time of its prevalence in the city, without
producing the disease. I wish these symptoms to be remembered by the
reader. They will form the corner stone of a system which I hope will
either eradicate the disease altogether, or render it as safe as an
intermitting fever, or as the small-pox when it is received by
inoculation.

Frequent as these precursors of the fever were, they were not universal.
Many went to bed in good health, and awoke in the night with a chilly
fit. Many rose in the morning after regular and natural sleep, and were
seized at their work, or after a walk, with a sudden and unexpected
attack of the fever. In most of these cases the disease came on with a
chilly fit, which afforded by its violence or duration a tolerable
presage of the issue of the disease.

Upon entering a sick room where a patient was confined by this fever, the
first thing that struck the eye of a physician was the countenance. It
was as much unlike that which is exhibited in the common bilious fever,
as the face of a wild, is unlike the face of a mild domestic animal. The
eyes were sad, watery, and so inflamed, in some cases, as to resemble two
balls of fire. Sometimes they had a most brilliant or ferocious
appearance. The face was suffused with blood, or of a dusky colour, and
the whole countenance was downcast and clouded. After the 10th of
September, when a determination of blood to the brain became universal,
there was a preternatural dilatation of the pupil. Sighing attended in
almost every case. The skin was dry, and frequently of its natural
temperature. These were the principal symptoms which discovered
themselves to the eye and hand of a physician. The answers to the first
questions proposed upon visiting a patient, were calculated to produce a
belief in the mind of a physician, that the disease under which the
patient laboured was not the prevailing malignant epidemic. I did not for
many weeks meet with a dozen patients, who acknowledged that they had any
other indisposition than a common cold, or a slight remitting or
intermitting fever. I was particularly struck with this self-deception in
many persons, who had nursed relations that had died with the yellow
fever, and who had been exposed to it in neighbourhoods where it had
prevailed for days and even weeks with great mortality. I shall hereafter
trace a part of this disposition in the sick to deceive themselves to the
influence of certain publications, which appeared soon after the disease
became epidemic in the city.

In the further history of this fever, I shall describe its symptoms as
they appeared,

I. In the sanguiferous system.

II. In the liver, lungs, and brain.

III. In the alimentary canal; in which I include the stomach as well as
the bowels.

IV. In the secretions and excretions.

V. In the nervous system.

VI. In the senses and appetites.

VII. In the lymphatic and glandular system.

VIII. Upon the skin.

IX. In the blood.

After having finished this detail, I shall mention some general
characters of the disease, and afterwards subdivide it into classes,
according to its degrees and duration.

I. The _blood-vessels_ were affected more or less in every case of this
fever. I have elsewhere said, that a fever is occasioned by a convulsion
in the arterial system[16]. When the epidemic, which we are now
considering, came on with a full, tense, and quick pulse, this convulsion
was very perceptible; but it frequently came on with a weak pulse, often
without any preternatural frequency or quickness, and sometimes so low as
not to be perceived without pressing the artery at the wrists. In many
cases the pulse intermitted after the fourth, in some after the fifth,
and in others after the fourteenth stroke. These intermissions occurred
in several persons who were infected, but who were not confined by the
fever. They likewise continued in several of my patients for many days
after their recovery. This was the case in particular in Mrs. Clymer,
Mrs. Palmer's son William, and in a son of Mr. William Compton. In some,
there was a preternatural slowness of the pulse. It beat 44 strokes in a
minute in Mr. B. W. Morris, 48 in Mr. Thomas Wharton, jun. and 64 in Mr.
William Sansom, at a time when they were in the most imminent danger. Dr.
Physick informed me, that in one of his patients the pulse was reduced in
frequency to 30 strokes in a minute. All these different states of the
pulse have been taken notice of by authors who have described
pestilential fevers[17]. They have been improperly ascribed to the
absence of fever: I would rather suppose that they are occasioned by the
stimulus of the remote cause acting upon the arteries with too much force
to admit of their being excited into quick and convulsive motions. The
remedy which removed it (to be mentioned hereafter) will render this
explanation of its cause still more probable. Milton describes a
darkness from an excess of light. In like manner we observe, in this
small, intermitting, and slow pulse, a deficiency of strength from an
excess of force applied to it. In nearly every case of it which came
under my notice, it was likewise tense or chorded. This species of pulse
occurred chiefly in the month of August, and in the first ten days in
September. I had met with it formerly in a sporadic case of yellow fever.
It was new to all my pupils. One of them, Mr. Washington, gave it the
name of the "undescribable pulse." It aided in determining the character
of this fever before the common bilious remittent disappeared in the
city. For a while, I ascribed this peculiarity in the pulse, more
especially its _slowness_, to an affection of the brain only, and
suspected that it was produced by what I have taken the liberty elsewhere
to call the _phrenicula_, or inflammatory state of the internal dropsy of
the brain, and which I have remarked to be an occasional symptom and
consequence of remitting fever. I was the more disposed to adopt this
opinion, from perceiving this slow, chorded, and intermitting pulse more
frequently in children than in adults. Impressed with this idea, I
requested Mr. Coxe, one of my pupils, to assist me in examining the state
of the eyes. For two days we discovered no change in them, but on the
third day after we began to inspect them, we both perceived a
preternatural dilatation of the pupils, in different patients; and we
seldom afterwards saw an eye in which it was absent. In Dr. Say it was
attended by a squinting, a symptom which marks a high degree of a morbid
affection of the brain. Had this slowness or intermission in the pulse
occurred only after signs of inflammation or congestion had appeared in
the brain, I should have supposed that it had been derived wholly from
that cause; but I well recollect having felt it several days before I
could discover the least change in the pupil of the eye. I am forced
therefore to call in the operation of another cause, to assist in
accounting for this state of the pulse, and this I take to be a spasmodic
affection, accompanied with preternatural dilatation or contraction of
the heart. Lieutaud mentions this species of pulse in several places, as
occurring with an undue enlargement of that muscle[18]. Dr. Ferriar
describes a case, in which a low, irregular, intermitting, and hardly
perceptible pulse attended a morbid dilatation of the heart[19]. In a
letter I received from Mr. Hugh Ferguson, then a student of medicine in
the college of Edinburgh, written from Dublin, during the time of a visit
to his father, and dated September 30th, 1793, I find a fact which throws
additional light upon this subject. "A case (says my young correspondent)
where a remarkable intermission of pulse was observed, occurred in this
city last year. A gentleman of the medical profession, middle aged, of a
delicate habit of body, and who had formerly suffered phthisical attacks,
was attacked with the acute rheumatism. Some days after he was taken ill,
he complained of uncommon fulness, and a very peculiar kind of sensation
about the præcordia, which it was judged proper to relieve by copious
blood-letting. This being done, the uneasiness went off. It returned,
however, three or four times, and was as often relieved by bleeding.
During each of his fits (if I may call them so), the patient experienced
an almost total remission of his pains in his limbs; but they returned
with equal or greater violence after blood-letting. During the fit there
was an intermission of the pulse (the first time) of no less than
thirteen strokes. It was when beating full, strong, and slow. The third
intermission was of nine strokes. The gentleman soon recovered, and has
enjoyed good health for ten months past. The opinion of some of his
physicians was, that the heart was affected, as a muscle, by the
rheumatism, and alternated with the limbs."

  [16] Outlines of a Theory of Fever.

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

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

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

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

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

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

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

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

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

  [20] Vol. i. p. 168.

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

  [22] Outlines of a theory of fever.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  [27] Outlines of a Theory of Fever.

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

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

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

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

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

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

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

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

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

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

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

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

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

  [31] Diseases of Minorca, p. 185.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  [34] Vol. i. p. 340.

  [35] Vol. i. p. 352.

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

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

  [38] Page 285.

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

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

  [40] Vol. i.

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

  [41] Page 28.

  [42] Page 132.

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

  [44] Lib. ii. cap. v.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"SIR,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

6. Costiveness.

7. Wakefulness.

8. Head-ach.

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

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

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

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

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

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

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

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

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

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

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

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

  [51] Vol. i. p. 5.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"SIR,

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

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

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

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

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

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

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

"With sentiments of the greatest esteem and regard,

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

                                      "MATTH. CLARKSON.

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

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

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

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

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

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

  [58] Vol. i.

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

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

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

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

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

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

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

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

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

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

  [61] Page 273.

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

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

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

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

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

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

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

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

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

"SIR,

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

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

                          "Signed, by order of the college of physicians,

                                               "JOHN REDMAN, _President_.

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

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

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

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

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

  [63] Cleghorn, p. 176.

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

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

                                                  "_Dover, Nov. 5, 1793._

"DEAR SIR,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


                         OF THE METHOD OF CURE.

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

  [65] Page 223.

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

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

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

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

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

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

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

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

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

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

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

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


                               OF PURGING.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  [69] Diseases of Barbadoes, p. 212.

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

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

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

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

  [71] Vol. i.

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

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

  [72] Vol. ii. p. 342.

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

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

  [73] Vol. i. p. 9.

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

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

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

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

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

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

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


                            OF BLOOD-LETTING.

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

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

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

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

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

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

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

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

  [75] Page 147.

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

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

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

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

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

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

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

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

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

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

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

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

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

2. It reduced its force and frequency.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  [76] Vol. ii. p. 351.

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

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

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

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

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

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

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

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

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

"_October 19th, 1793._"

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

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

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

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

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

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

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

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

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

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

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

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

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

  [79] Page 114.

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

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

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

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

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

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

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

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

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

  [83] Page 209.

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

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

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

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

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

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

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

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

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

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

  [84] Bruce's Travels.

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

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

  [85] Page 185.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  [90] Vol. i. p. 440.

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

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

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

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

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

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

  [92] Fevers of Jamaica.

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

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

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

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

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

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

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

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

  [93] Vol. ii. p. 254.

  [94] Vol, ii. p. 354.

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

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

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

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

To obviate a suspicion that I have laid more stress upon the fatal
influence of this error than is just, I shall here insert an extract of a
letter I received from Mr. John Connelly, one of the city committee, who
frequently left his brethren in the city hall, and spent many hours in
visiting and prescribing for the sick. "The publications (says he) of
some physicians, that there were but few persons infected with the yellow
fever, and that many were ill with colds and common remitting and fall
fevers, proved fatal to almost every family which was credulous enough to
believe them. That opinion slew its hundreds, if not its thousands, many
of whom did not send for a physician until they were in the last stage of
the disorder, and beyond the power of medicine."

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  [98] Vol. ii.

  [99] Medical Memoirs, vol. i.

  [100] Vol. i.

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


                               A NARRATIVE

                                 OF THE

                      _STATE OF THE BODY AND MIND_

                             OF THE AUTHOR,

                   DURING THE PREVALENCE OF THE FEVER.

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

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

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

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

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

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

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

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

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

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

                                     "_Philadelphia, September 15, 1793._

        "MY DEAR FATHER,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



                               AN ACCOUNT

                                 OF THE

                   BILIOUS REMITTING AND INTERMITTING

                             _YELLOW FEVER_,

                                  AS IT

                        APPEARED IN PHILADELPHIA,

                            IN THE YEAR 1794.


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  [106] Account of the Yellow Fever of 1793.

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

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

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

The disease appeared with symptoms of dysentery in several cases.

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

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

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

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

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

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

  [109] Page 224.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  [112] Epidemics, book IV.

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

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

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

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

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

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

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

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

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

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

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

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

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

  [113] Page 117.

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

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

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

The forms in which this fever appeared were as follow.

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

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

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

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

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

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

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

6. It disguised itself in the form of madness.

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

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

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

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

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

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

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

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

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

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

  [116] Account of the Yellow Fever of 1793.

  [117] Page 141.

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

  [118] Account of the Yellow Fever in 1793.

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

  [119] Page 129, 130.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



                         OF THE METHOD OF CURE.


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

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

1. Bleeding.

2. Purging.

3. Cool air and cold drinks.

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

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

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

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

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

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

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

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

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

The blood drawn in this fever exhibited the following appearances;

1. It was dissolved in a few instances.

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

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

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

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

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

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

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

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

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

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

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

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

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

  [121] Page 140.

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

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

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

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

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

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

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

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

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

2. It checked a nausea and vomiting.

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

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

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

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

  [123] Vol. ii. p. 212.

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

The effects of blisters were as follow:

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

2. Reduced the pulse in force and frequency.

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

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

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

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

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

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

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

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

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

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

  [124] Vol. ii. p. 108.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  [126] Vol. i. p. 55.

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

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

  [128] Account of the Yellow Fever of 1793.

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

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



                                   AN

                                 ACCOUNT

                                   OF

                             SPORADIC CASES

                                   OF

                         _BILIOUS YELLOW FEVER_,

                            IN PHILADELPHIA,

                       IN THE YEARS 1795 AND 1796.


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


                           END OF VOLUME III.



                   *       *       *       *       *



Transcriber's note:

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

Obvious misprints have been corrected.

Partly repeated chapter headings have been deleted.





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large amount of text is helpful, please contact us. We encourage the use of
public domain materials for these purposes and may be able to help.

+ Keep it legal -  Whatever your use, remember that you are responsible for
ensuring that what you are doing is legal. Do not assume that just because
we believe a book is in the public domain for users in the United States,
that the work is also in the public domain for users in other countries.
Whether a book is still in copyright varies from country to country, and we
can't offer guidance on whether any specific use of any specific book is
allowed. Please do not assume that a book's appearance in Doctrine Publishing
ISYS search  means it can be used in any manner anywhere in the world.
Copyright infringement liability can be quite severe.

About ISYS® Search Software
Established in 1988, ISYS Search Software is a global supplier of enterprise
search solutions for business and government.  The company's award-winning
software suite offers a broad range of search, navigation and discovery
solutions for desktop search, intranet search, SharePoint search and embedded
search applications.  ISYS has been deployed by thousands of organizations
operating in a variety of industries, including government, legal, law
enforcement, financial services, healthcare and recruitment.



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