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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. IV.
THE SECOND EDITION,
REVISED AND ENLARGED BY THE AUTHOR.
PHILADELPHIA,
PUBLISHED BY J. CONRAD & CO. CHESNUT-STREET, PHILADELPHIA; M. & J. CONRAD & CO. MARKET-STREET, BALTIMORE; RAPIN, CONRAD, & CO. WASHINGTON; SOMERVELL & CONRAD, PETERSBURG; AND BONSAL, CONRAD, & CO. NORFOLK.
PRINTED BY T. & G. PALMER, 116, HIGH-STREET.
1805.

CONTENTS OF VOLUME IV.

AN ACCOUNT
OF THE
BILIOUS REMITTING AND INTERMITTING
YELLOW FEVER.
AS IT
APPEARED IN PHILADELPHIA,
IN 1797.

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

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

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

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

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

METEOROLOGICAL OBSERVATIONS,
MADE IN PHILADELPHIA.
AUGUST, 1797.

SEPTEMBER, 1797.

OCTOBER, 1797.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The following states or forms were observable in the fever:

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

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

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

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

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

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

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

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

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

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

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

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

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

Philadelphia, January 12th, 1798.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

OF PURGING.

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

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

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

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

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

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

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

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

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

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

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

OF EMETICS.

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

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

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

OF DIET AND DRINKS.

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

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

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

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

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

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

OF TONIC REMEDIES.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

7. A sore mouth.

8. A moist white, or a yellow tongue.

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

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

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

12. Acute pains in the back and limbs.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

17. Deafness.

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

19. A slow, intermitting, and shattered pulse.

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

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

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

23. A dull vacant face, expressive of distress.

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

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

I shall conclude this head by the following remarks:

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

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

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

Footnotes:

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

[2] Annals of Medicine, p. 123.

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

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

[5] Chapter v. verse 14.

[6] Lib. i. cap. 15.

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

HIPPOCRATES.

AN ACCOUNT
OF THE
BILIOUS YELLOW FEVER.
AS IT
APPEARED IN PHILADELPHIA,
IN 1798.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

4. By an incessant vomiting and hiccup.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Footnote:

[8] History of the Fever in 1797.