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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.

_page_

_An account of the bilious yellow fever, as it appeared in

Philadelphia in 1797_ 1

_An account of the bilious yellow fever, as it appeared in

Philadelphia in 1798_ 63

_An account of the bilious yellow fever, as it appeared in

Philadelphia in 1799_ 89

_An account of sporadic cases of yellow fever, as they appeared

in Philadelphia in 1800_ 101

_An account of sporadic cases of yellow fever, as they appeared

in Philadelphia in 1801_ 109

_An account of the measles, as they appeared in Philadelphia in

1801_ 115

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

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

_An account of sporadic cases of yellow fever, as they appeared

in 1804_ 145

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

_An inquiry into the various sources of the usual forms of the

summer and autumnal disease in the United States, and the means

of preventing them_ 161

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

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

_An inquiry into the comparative states of medicine in

Philadelphia, between the years 1760 and 1766, and 1805_ 363

* * * * *

AN ACCOUNT

OF THE

BILIOUS REMITTING AND INTERMITTING

_YELLOW FEVER_,

AS IT

APPEARED IN PHILADELPHIA,

IN 1797.

The winter of 1797 was in general healthy. During the spring, which was

cold and wet, no diseases of any consequence occurred. The spring

vegetables were late in coming to maturity, and there were every where in

the neighbourhood of Philadelphia scanty crops of hay. In June and July

there fell but little rain. Dysenteries, choleras, scarlatina, and mumps,

appeared in the suburbs in the latter month. On the 8th of July I visited

Mr. Frisk, and on the 25th of the same month I visited Mr. Charles Burrel

in the yellow fever, in consultation with Dr. Physick. They both

recovered by the use of plentiful depleting remedies.

The weather from the 2d to the 9th of August was rainy. On the 1st of

this month I was called to visit Mr. Nathaniel Lewis, in a malignant

bilious fever. On the 3d I visited Mr. Elisha Hall, with the same

disease. He had been ill several days before I saw him. Both these

gentlemen died on the 6th of the month. They were both very yellow after

death. Mr. Hall had a black vomiting on the day he died.

The news of the death of these two citizens, with unequivocal symptoms of

yellow fever, excited a general alarm in the city. Attempts were made to

trace it to importation, but a little investigation soon proved that it

was derived from the foul air of a ship which had just arrived from

Marseilles, and which discharged her cargo at Pinestreet wharf, near the

stores occupied by Mr. Lewis and Mr. Hall. Many other persons about the

same time were affected with the fever from the same cause, in Water and

Penn-streets. About the middle of the month, a ship from Hamburgh

communicated the disease, by means of her foul air, to the village of

Kensington. It prevailed, moreover, in many instances in the suburbs, and

in Kensington, from putrid exhalations from gutters and marshy grounds,

at a distance from the Delaware, and from the foul ships which have been

mentioned. Proofs of the truth of each of these assertions were

afterwards laid before the public.

The disease was confined chiefly to the district of Southwark and the

village of Kensington, for several weeks. In September and October, many

cases occurred in the city, but most of them were easily traced to the

above sources.

The following account of the weather, during the months of August,

September, and October was obtained from Mr. Thomas Pryor. It is

different from the weather in 1793. It is of consequence to attend to

this fact, inasmuch as it shows that an inflammatory constitution of the

atmosphere can exist under different circumstances of the weather. It

likewise accounts for the variety in the symptoms of the fever in

different years and countries. Such is the influence of season and

climate upon the symptoms of this fever, that it led Dr. M'Kitterick to

suppose that the yellow fever of Charleston, so accurately described by

Dr. Lining, in the second volume of the Physical and Literary Essays of

Edinburgh, was a different disease from the yellow fever of the

West-Indies[1].

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

METEOROLOGICAL OBSERVATIONS,

_MADE IN PHILADELPHIA_.

AUGUST, 1797.

+--+-----+------+----------------------------------------------+

+--+--+--+------+----------------------------------------------+

| 1|73|75|30 0|S. E. E. Rain in the forenoon and afternoon. |

| 2|72|76|30 0|N. E. by E. Cloudy, with rain in the afternoon|

| 3|72|78|30 6|E. 1/2 N. Rain in the morning, and all day and|

| 4|72|78|30 4|E. Rained hard all day and at night. |

| 5|74|79|29 84|Wind light, S. W. Cloudy. Rain this morning. |

| 6|73|76|30 86|W. N. W. Cloudy. |

| 7|70|76|30 4|N. W. Close day. Rain in the evening and |

| 8|72|76|29 95|E. Rain this morning. |

| 9|72|76|29 86|S. W. Cloudy morning. |

|10|69|73|30 16|N. W. Clear. |

|11|70|74|30 25|N. W. Clear. Rain all night. |

|12|71|74|30 5|S. W. Cloudy. Rain in the morning. Cloudy |

|13|73|75|29 87|S. W. Cloudy. Rain all day. |

|14|70|74|29 9|N. W. Clear fine morning. |

|15|56|60|30 15|N. W. Clear fine morning. |

|16|60|64|30 24|N. W. Clear fine morning. |

|17|60|65|30 24|N. W. Air damp. |

|18|68|75|30 4|S. W. Cloudy. Rain, with thunder at night: |

|19|72|78|29 7|N. W. Clear. Cloudy in the evening, with |

|20|70|77|29 8|W. N. W. Fine clear morning. |

|21|74|76|29 9|N. W. Clear to E. |

|22|68|76| |E. Small shower this morning. Hard shower |

|23|71|76|29 92|E. Cloudy. At noon calm. |

|24|71|75|29 95|Calm morning and clear. |

|25|70|75|30 5|N. E. Clear. Rain in the afternoon, with |

|26|70|75|30 5|S. E. Rain in the morning. Rained hard in the |

|27|68|76|29 9|N. W. Fine clear morning. |

|28|64|75|29 96|N. W. Clear. |

|29|59|70|30 0|E. Clear. |

|30|70|76|30 1|E. by S. Rain in the morning. |

|31|68|74|30 14|S. E. Cloudy. Damp air and sultry. |

+--+--+--+------+----------------------------------------------+

SEPTEMBER, 1797.

+--+-----+------+----------------------------------------------+

+--+-----+------+----------------------------------------------+

| 1|73|80|30 6|S. W. Cloudy. Damp air. Rain in the morning |

| 2|79|80|29 9|N. W. Clear. Cloudy in the evening, with |

| 3|68|74|30 0|N. by W. Cloudy. Clear in the afternoon and |

| 4|66|74|30 7|W. N. W. Clear fine morning. |

| 5|58|73|30 1|N. W. Clear. Cloudy in the evening. |

| 6|58|72|30 13|Fresh at E. Clear. Rain in the evening. |

| 7|56|76|30 28|E. Clear. Cloudy in the evening. |

| 8|54|65|30 1|N. E. Clear and cool morning. Flying clouds at|

| 9|56|65|30 1|E. N. E. Clear. |

|10|58|63|30 26|N. E. Clear fine morning. Wind fresh at N. E. |

|11|53|64|30 13|N. to E. with flying clouds. |

|12|51|62|30 6|W. N. W. Clear cool morning. |

|13|56|67|30 3|S. W. Cloudy. Clear in the afternoon. |

|14|64|70|29 98|S. W. Clear. |

|15|66|73|29 85|S. W. Rain in the morning. Cloudy in the |

|16|62|70|29 95|N. W. Clear. |

|17|56|67|30 0|N. W. Clear. |

|18|58|63|29 88|E. Cloudy. Rained all day, and thunder. |

| | | |29 62| Rained very heavy at night. |

|19|55|63|29 75|W. N. W. Clear fine morning. |

|20|47|63|30 8|W. N. W. Clear fine morning. New moon |

|21|46|60|30 0|N. E. Clear fine morning; to S. E. in the |

|22|56|65|30 4|N. W. Rain in the morning. Rain at night. |

|23|56|66|30 0|N. N. E. Cloudy. |

|24|52|66|29 9|E. by S. Clear fine morning. Cloudy at night |

| | | |29 78| |

|25|56|68|29 37|W. N. W. Clear fine morning; clear all day. |

|26|58|68|29 95|E. In the morning flying clouds. |

|27|48|63|30 2|N. W. Clear fine morning; clear all day. |

|28|48|63|30 2|W. N. W. Clear fine morning; clear all day. |

|29|54|63|30 15|E. Clear fine morning. |

|30|60|65|30 26|E. Fresh. Cloudy morning. Rain in the night |

+--+--+--+------+----------------------------------------------+

OCTOBER, 1797.

+--+-----+------+----------------------------------------------+

+--+-----+------+----------------------------------------------+

| 1|55|65|30 16|N. E. Rain this morning, and great, part of |

| 2|55|66|30 0|N. W. Clear. |

| 3|60|70|29 9|S. E. Clear. Air damp. |

| 4|60|70|29 5|W. N. W. Rain this morning. |

| 5|46|60|30 0|W. N. W. to S. by W. in the evening. Clear |

| 6|55|65|30 0|S. W. Clear fine morning. White frost. |

| 7|56|76|30 0|S. W. Cloudy. Rain in the night. |

| 8|56|70|30 29|S. Cloudy this morning; air damp. Wind |

| 9|50|60|29 85|W. N. W. Clear morning. Fresh at N. W. |

|10|40|58|30 1|W. N. W. Clear. Frost this morning. |

|11|38|56|30 2|W. N. W. Cloudy. |

|12|34|52|30 38|W. N. W. Clear. Ice this morning. |

|13|35|55|30 5|N. Clear fine morning. Ice this morning. |

|14|40|60|30 28|N. E. Cloudy. |

|15|50|65|30 16|W. N. W. Clear. |

|16|36|56|30 2|W. N. W. Clear fine morning. |

|17|37|56|30 18|W. N. W. Clear fine morning. |

|18|47|60|29 86|W. N. W. Clear fine weather. |

|19|48|60|30 6|N. W. Clear fine day. |

|20|42|55|30 8|N. E. Cloudy. Rain in the afternoon and |

|21|42|50|29 92|N. E. Blows fresh (with a little rain). |

|22|44|56|29 57|N. W. Rain in the morning. |

|23|44|56|29 95|S. W. Clear fine morning. |

|24|42|54|30 5|N. E. Cloudy. A great deal of rain in the |

|25|40|52|30 15|N. E. Clear fine morning. |

|26|36|48|30 29|W. N. W. Clear. |

|27|34|46|30 23|Fresh at S. W. Clear. |

|28|40|52|29 95|W. N. W. Cloudy. |

|29|34|46|29 82|W. Cloudy. |

|30|32|42|29 93|N. W. Clear. Hard frost this morning. |

|31|38|48|30 18|W. S. W. Cloudy part of this day; clear the |

+--+--+--+------+----------------------------------------------+

In addition to the register of the weather it may not be improper to add,

that moschetoes were more numerous during the prevalence of the fever

than in 1793. An unusual number of ants and cockroaches were likewise

observed; and it was said that the martins and swallows disappeared, for

a while, from the city and its neighbourhood.

A disease prevailed among the cats some weeks before the yellow fever

appeared in the city. It excited a belief in an unwholesome state of the

atmosphere, and apprehensions of a sickly fall. It generally proved fatal

to them.

After the first week in September there were no diseases to be seen but

yellow fever. In that part of the town which is between Walnut and

Vine-streets it was uncommonly healthy. A similar retreat of inferior

diseases has been observed to take place during the prevalence of the

plague in London, Holland, and Germany, according to the histories of

that disease by Sydenham, Diemerbroeck, Sennertus, and Hildanus. It

appears, from the register of the weather, that it rained during the

greatest part of the day on the 1st of October. The effects of this rain

upon the disease shall be mentioned hereafter. On the 10th the weather

became cool, and on the nights of the 12th and 13th of the month there

was a frost accompanied with ice, which appeared to give a sudden and

complete check to the disease.

The reader will probably expect an account of the effects of this

distressing epidemic upon the public mind. The terror of the citizens for

a while was very great. Rumours of an opposite and contradictory nature

of the increase and mortality of the fever were in constant circulation.

A stoppage was put to business, and it was computed that about two thirds

of the inhabitants left the city.

The legislature of the state early passed a law, granting 10,000 dollars

for the relief of the sufferers by the fever. The citizens in and out of

town, as also many of the citizens of our sister states, contributed more

than that sum for the same charitable purpose. This money was issued by a

committee appointed by the governor of the state. An hospital for the

reception of the poor was established on the east side of the river

Schuylkill, and amply provided with every thing necessary for the

accommodation of the sick. Tents were likewise pitched on the east side

of Schuylkill, to which all those people were invited who were exposed to

the danger of taking the disease, and who had not means to provide a

more comfortable retreat for themselves in the country.

I am sorry to add that the moral effects of the fever upon the minds of

our citizens were confined chiefly to these acts of benevolence. Many of

the publications in the newspapers upon its existence, mode of cure, and

origin partook of a virulent spirit, which ill accorded with the

distresses of the city. It was a cause of lamentation likewise to many

serious people, that the citizens in general were less disposed, than in

1793, to acknowledge the agency of a divine hand in their afflictions. In

some a levity of mind appeared upon this solemn occasion. A worthy

bookseller gave me a melancholy proof of this assertion, by informing me,

that he had never been asked for playing cards so often, in the same

time, as he had been during the prevalence of the fever.

Philadelphia was not the only place in the United States which suffered

by the yellow fever. It prevailed, at the same time, at Providence, in

Rhode-Island, at Norfolk, in Virginia, at Baltimore, and in many of the

country towns of New-England, New-Jersey, and Pennsylvania.

The influenza followed the yellow fever, as it did in the year 1793. It

made its appearance in the latter end of October, and affected chiefly

those citizens who had been out of town.

The predisposing causes of the yellow fever, in the year 1797, were the

same as in the year 1793. Strangers were as usual most subject to it. The

heat of the body in such persons, in the West-Indies, has been found to

be between three and four degrees above that of the temperature of the

natives. This fact is taken notice of by Dr. M'Kitterick, and to this he

ascribes, in part, the predisposition of new comers to the yellow fever.

In addition to the common exciting causes of this disease formerly

enumerated, I have only to add, that it was induced in one of my patients

by smoking a segar. He had not been accustomed to the use of tobacco.

I saw no new premonitory symptoms of this fever except a tooth-ach. It

occurred in Dr. Physick, Dr. Caldwell, and in my pupil, Mr. Bellenger. In

Miss Elliot there was such a soreness in her teeth, that she could hardly

close her mouth on the day in which she was attacked by the fever.

Neither of these persons had taken mercury to obviate the disease.

I shall now deliver a short account of the symptoms of the yellow fever,

as they appeared in several of the different systems of the body.

I. There was but little difference in the state of the pulse in this

epidemic from what has been recorded in the fevers of 1793 and 1794. I

perceived a pulse, in several cases, which felt like a soft quill which

had been _shattered_ by being trodden upon. It occurred in Dr. Jones and

Dr. Dobell, and in several other persons who had been worn down by great

fatigue, and it was, in every instance, followed by a fatal issue of the

fever. In Dr. Jones this state of the pulse was accompanied with such a

difficulty of breathing, that every breath he drew, on the day of his

attack, he informed me, was the effort of a sigh. He died on the 17th of

September, and on the sixth day of his fever.

The action of the arteries was, as usual, very irregular in many cases.

In some there was a distressing throbbing of the vessels in the brain,

and in one of my patients a similar sensation in the bowels, but without

pain. Many people had issues of blood from their blisters in this fever.

I saw nothing new in the effects of the fever upon the liver, lungs,

brain, nor upon the stomach and bowels.

II. The excretions were distinguished by no unusual marks. I met with no

recoveries where there were not black stools. They excoriated the rectum

in Dr. Way. It was a happy circumstance where morbid bilious matter came

away in the beginning of the disease. But it frequently resisted the most

powerful cathartics until the 5th or 7th day of the fever, at which time

it appeared rather to yield to the disorganization of the liver than to

medicine. Where sufficient blood-letting had been previously used, the

patient frequently recovered, even after the black discharges from the

bowels took place in a late stage of the disease.

Dr. Coxe informed me, that he attended a child of seventeen months old

which had _white_ stools for several days. Towards the close of its

disease it had black stools, and soon afterwards died.

Several of my patients discharged worms during the fever. In one instance

they were discharged from the mouth.

A preternatural frequency in making pale water attended the first attack

of the disease in Mr. Joseph Fisher.

A discharge of an unusual quantity of urine preceded, a few hours, the

death of the daughter of Mrs. Read.

In two of my patients there was a total suppression of urine. In one of

them it continued five days without exciting any pain.

There was no disposition to sweat after the first and second days of the

fever. Even in those states of the fever, in which the intermissions were

most complete, there was seldom any moisture, or even softness on the

skin. This was so characteristic of malignity in the bilious fever, that

where I found the opposite state of the skin, towards the close of a

paroxysm, I did not hesitate to encourage my patient, by assuring him

that his fever was of a mild nature, and would most probably be safe in

its issue.

III. I saw no unusual marks of the disease in the nervous system. The

mind was seldom affected by delirium after the loss of blood. There was

a disposition to shed tears in two of my patients. One of them wept

during the whole time of a paroxysm of the fever. In one case I observed

an uncommon dulness of apprehension, with no other mark of a diseased

state of the mind. It was in a man whose faculties, in ordinary health,

acted with celerity and vigour.

Dr. Caldwell informed me of a singular change which took place in the

operations of his mind during his recovery from the fever. His

imagination carried him back to an early period of his life, and engaged

him, for a day or two, in playing with a bow and arrow, and in amusements

of which he had been fond when a boy. A similar change occurred in the

mind of my former pupil, Dr. Fisher, during his convalescence from the

yellow fever in 1793. He amused himself for two days in looking over the

pictures of a family Bible which lay in his room, and declared that he

found the same kind of pleasure in this employment that he did when a

child. However uninteresting these facts may now appear, the time will

come when they may probably furnish useful hints for completing the

physiology and pathology of the mind.

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

convulsions.

IV. The senses of seeing and feeling were impaired in several cases. Mrs.

Bradford's vision was so weak that she hardly knew her friends at her

bed-side. I had great pleasure in observing this alarming symptom

suddenly yield to the loss of four ounces of blood.

Several persons who died of this fever did not, from the beginning to the

end of the disease, feel any pain. I shall hereafter endeavour to explain

the cause of this insensible state of the nerves.

The appetite for food was unimpaired for three days in Mr. Andrew Brown,

at a time when his pulse indicated a high grade of the fever. I heard of

several persons who ate with avidity just before they died.

V. Glandular swellings were very uncommon in this fever. I should have

ascribed their absence to the copious use of depleting remedies in my

practice, had I not been informed that morbid affections of the lymphatic

glands were unknown in the city hospital, where blood-letting was seldom

used, and where the patients, in many instances, died before they had

time to take medicine of any kind.

VI. The skin was cool, dry, smooth, and even shining in some cases.

Yellowness was not universal. Those small red spots, which have been

compared to moscheto bites, occurred in several of my patients. Dr. John

Duffield, who acted as house surgeon and apothecary at the city hospital,

informed me that he saw vibices on the skin in many cases, and that they

were all more or less sore to the touch.

VII. The blood was dissolved in a few cases. That appearance of the

blood, which has been compared to the washings of flesh, was very common.

It was more or less sizy towards the close of the disease in most cases.

I have suspected, from this circumstance, that this mark of ordinary

morbid action or inflammation was in part the effect of the mercury

acting upon the blood-vessels. It is well known that sizy blood generally

accompanies a salivation. If this conjecture be well founded, it will not

militate against the use of mercury in malignant fevers, for it shows

that this valuable medicine possesses a power of changing an

extraordinary and dangerous degree of morbid action in the blood-vessels

to that which is more common and safe. I have seldom seen a yellow fever

terminate fatally after the appearance of sizy blood.

Dr. Stewart informed me, that in those cases in which the serum of the

blood had a yellow colour, it imparted a saline taste only to his tongue.

He was the more struck with this fact, as he perceived a strong bitter

state upon his skin, in a severe attack of the yellow fever in 1793.

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

In many cases, it appeared in the form of a remitting and intermitting

fever. The quotidian and tertian forms were most common. In Mr. Robert

Wharton, it appeared in the form of a quartan. But it frequently assumed

the character which is given of the same fever in Charleston, by Dr.

Lining. It came on without chills, and continued without any remission

for three days, after which the patient believed himself to be well, and

sometimes rose from his bed, and applied to business. On the fourth or

fifth day, the fever returned, and unless copious evacuations had been

used in the early stage of the disease, it generally proved fatal.

Sometimes the powers of the system were depressed below the return of

active fever, and the patient sunk away by an easy death, without pain,

heat, or a quick pulse. I have been much puzzled to distinguish a crisis

of the fever on the third or fourth day, from the insidious appearance

which has been described. It deceived me in 1793. It may be known by a

preternatural coolness in the skin, and languor in the pulse, by an

inability to sit up long without fatigue or faintness, by a dull eye, and

by great depression of mind, or such a flow of spirits as sometimes to

produce a declaration from the patient that "he feels too well." Where

these symptoms appear, the patient should be informed of his danger, and

urged to the continuance of such remedies as are proper for him.

The following states or forms were observable in the fever:

1. In a few cases, the miasmata produced death in four and twenty hours,

with convulsions, coma, or apoplexy.

2. There were _open_ cases, in which the pulse was full and tense as in a

pleurisy or rheumatism, from the beginning to the end of the fever. They

were generally attended with a good deal of pain.

3. There were _depressed_ or _locked_ cases, in which there were a sense

of great debility, but little or no pain, a depressed and slow pulse, a

cool skin, cold hands and feet, and obstructed excretions.

4. There were _divided_ or _mixed_ cases, in which the pulse was active

until the 4th day, after which it became depressed. All the other

symptoms of the locked state of the fever accompanied this depressed

state of the pulse.

5. There were cases in which the pulse imparted a perception like that of

a soft and _shattered_ quill. I have before mentioned that this state of

the pulse occurred in Dr. Jones and Dr. Dobell. I felt it but once, and

on the day of his attack, in the latter gentleman, and expressed my

opinion of his extreme danger to one of my pupils upon my return from

visiting him. I did not meet with a case which terminated favourably,

where I perceived this _shattered_ pulse. A disposition to sweat occurred

in this state of the fever.

6. There were what Dr. Caldwell happily called _walking_ cases. The

patients here were flushed or pale, had a full or tense pulse, but

complained of no pain, had a good appetite, and walked about their rooms

or houses, as if they were but little indisposed, until a day or two,

and, in some instances, until a few hours before they died. We speak of

a _dumb_ gout and _dumb_ rheumatism; with equal propriety, the epithet

might be applied to this form of yellow fever in its early stage. The

impression of the remote cause of the fever, in these cases, was beyond

sensation, for, upon removing a part of it by bleeding or purging, the

patients complained of pain, and the excitement of the muscles passed so

completely into the blood-vessels and alimentary canal, as to convert the

fever into a common and more natural form. These cases were always

dangerous, and, when neglected, generally terminated in death. Mr.

Brown's fever came on in this insidious shape. It was cured by the loss

of upwards of 100 ounces of blood, and a plentiful salivation.

7. There was the _intermitting_ form in this fever. This, like the last,

often deceived the patient, by leading him to suppose his disease was of

a common or trifling nature. It prevented Mr. Richard Smith from applying

for medical aid in an attack of the fever for several days, by which

means it made such an impression upon his viscera, that depleting

remedies were in vain used to cure him. He died in the prime of life,

beloved and lamented by a numerous circle of relations and friends.

8. There was a form of this fever in which it resembled the mild

remittent of common seasons. It was distinguished from it chiefly by the

black colour of the intestinal evacuations.

9. There were cases of this fever so light, that patients were said to be

neither _sick_ nor _well_; or, in other words, they were sick and well

half a dozen times in a day. Such persons walked about, and transacted

their ordinary business, but complained of dulness, and, occasionally, of

shooting pains in their heads. Sometimes the stomach was affected with

sickness, and the bowels with diarrh[oe]a or costiveness. All of them

complained of night sweats. The pulse was quicker than natural, but

seldom had that convulsive action which constitutes fever. Purges always

brought away black stools from such patients, and this circumstance

served to establish its relationship to the prevailing epidemic. Now and

then, by neglect or improper treatment, it assumed a higher and more

dangerous grade of the fever, and became fatal, but it more commonly

yielded to nature, or to a single dose of purging physic.

10. There were a few cases in which the skin was affected with universal

yellowness, but without more pain or indisposition than usually occurs in

the jaundice. They were very frequent in the year 1793, and generally

prevail in the autumn, in all places subject to bilious fever.

11. There were _chronic_ cases of this fever. It is from the want of

observation that physicians limit the duration of the yellow fever to

certain days. I have seen many instances in which it has been protracted

into what is called by authors a slow nervous fever. The wife of captain

Peter Bell died with a black vomiting after an illness of nearly one

month. Dr. Pinckard, formerly one of the physicians of the British army

in the West-Indies, in a late visit to this city informed me, that he had

often seen the yellow fever put on a chronic form in the West-India

islands.

In delivering this detail of the various forms of the yellow fever, I am

aware that I oppose the opinions of many of my medical brethren, who

ascribe to it a certain uniform character, which is removed beyond the

influence of climate, habit, predisposition, and the different strength

and combinations of remote and exciting causes. This uniformity in the

symptoms of this fever is said to exist in the West-Indies, and every

deviation from it in the United States is called by another name. The

following communication, which I received from Dr. Pinckard, will show

that this disease is as different in its forms in the West-Indies as it

is in this country.

"The yellow fever, as it appeared among the troops in Guiana and the

West-India islands, in the years 1796 and 1797, exhibited such perpetual

instability, and varied so incessantly in its character, that I could not

discover any one symptom to be decidedly diagnostic; and hence I have

been led into an opinion that the yellow fever, so called, is not a

distinct or specific disease, but merely an aggravated degree of the

common remittent or bilious fever of hot climates, rendered irregular in

form, and augmented in malignity, from appearing in subjects unaccustomed

to the climate.

_Philadelphia, January 12th, 1798._"

Many other authorities equally respectable with Dr. Pinckard's, among

whom are Pringle, Huck, and Hunter, might be adduced in support of the

unity of bilious fever. But to multiply them further would be an act of

homage to the weakness of human reason, and an acknowledgment of the

infant state of our knowledge in medicine. As well might we suppose

nature to be an artist, and that diseases were shaped by her like a piece

of statuary, or a suit of clothes, by means of a chissel, or pair of

scissars, as admit every different form and grade of morbid action in the

system to be a distinct disease.

Notwithstanding the fever put on the eleven forms which have been

described, the moderate cases were few, compared with those of a

malignant and dangerous nature. It was upon this account that the

mortality was greater in the same number of patients, who were treated

with the same remedies, than it was in the years 1793 and 1794. The

disease, moreover, partook of a more malignant character than the two

epidemics that have been mentioned. The yellow fever in Norfolk, Drs.

Taylor and Hansford informed me, in a letter I received from them, was

much more malignant and fatal, under equal circumstances, than it was in

1795.

There were evident marks of the disease attacking more persons three days

before, and three days after the _full_ and _change_ of the moon, and of

more deaths occurring at those periods than at any other time. The same

thing has been remarked in the plague by Diemerbroeck, in the fevers of

Bengal by Dr. Balfour, and in those of Demarara by Dr. Pinckard.

During the prevalence of the fever I attended the following persons who

had been affected by the epidemic of 1793, viz. Dr. Physick, Thomas

Leaming, Thomas Canby, Samuel Bradford, and George Loxley, also Mrs.

Eggar, who had a violent attack of it in the year 1794. Samuel Bradford

was likewise affected by it in 1794.

During my intercourse with the sick, I felt the miasmata of the fever

operate upon my system in the most sensible manner. It produced languor,

a pain in my head, and sickness at my stomach. A sighing attended me

occasionally, for upwards of two weeks. This symptom left me suddenly,

and was succeeded by a hoarseness, and, at times, with such a feebleness

in my voice as to make speaking painful to me. Having observed this

affection of the trachea to be a precursor of the fever in several cases,

it kept me under daily apprehensions of being confined by it. It

gradually went off after the first of October. I ascribed my recovery

from it, and a sudden diminution of the effects of the miasmata upon my

system, to a change produced in the atmosphere by the rain which fell on

that day.

The peculiar matter emitted by the breath or perspiration of persons

affected by this fever, induced a sneezing in Dr. Dobell, every time he

went into a sick room. Ambrose Parey says the same thing occurred to

him, upon entering the room of patients confined by the plague.

The gutters emitted, in many places, a sulphureous smell during the

prevalence of the fever. Upon rubbing my hands together I could at any

time excite a similar smell in them. I have taken notice of this effect

of the matters which produced the disease upon the body, in the year

1794.

In order to prevent an attack of the fever, I carefully avoided all its

exciting causes. I reduced my diet, and lived sparingly upon tea, coffee,

milk, and the common fruits and garden vegetables of the season, with a

small quantity of salted meat, and smoked herring. My drinks were milk

and water, weak claret and water, and weak porter and water. I sheltered

myself as much as possible from the rays of the sun, and from the action

of the evening air, and accommodated my dress to the changes in the

temperature of the atmosphere. By similar means, I have reason to

believe, many hundred people escaped the disease, who were constantly

exposed to it.

The number of deaths by the fever, in the months of August, September,

and October, amounted to between ten and eleven hundred. In the list of

the dead were nine practitioners of physic, several of whom were

gentlemen of the most respectable characters. This number will be thought

considerable when it is added, that not more than three or four and

twenty physicians attended patients in the disease. Of the survivors of

that number, eight were affected with the fever. This extraordinary

mortality and sickness among the physicians must be ascribed to their

uncommon fatigue in attending upon the sick, and to their inability to

command their time and labours, so as to avoid the exciting causes of the

fever.

Among the medical gentlemen whose deaths have been mentioned, was my

excellent friend, Dr. Nicholas Way. I shall carry to my grave an

affectionate remembrance of him. We passed our youth together in the

study of medicine, and lived to the time of his death in the habits of

the tenderest friendship. In the year 1794, he removed from Wilmington,

in the Delaware state, to Philadelphia, where his talents and manners

soon introduced him into extensive business. His independent fortune

furnished his friends with arguments to advise him to retire from the

city, upon the first appearance of the fever. But his humanity prevailed

over the dictates of interest and the love of life. He was active and

intelligent in suggesting and executing plans to arrest the progress of

the disease, and to lessen the distresses of the poor. On the 27th of

August, he was seized, after a ride from the country in the evening air,

with a chilly fit and fever. I saw him the next day, and advised the

usual depleting remedies. He submitted to my prescriptions with

reluctance, and in a sparing manner, from an opinion that his fever was

nothing but a common remittent. To enforce obedience to my advice, I

called upon Dr. Griffitts to visit him with me. Our combined exertions to

overcome his prejudices against our remedies were ineffectual. At two

o'clock in the afternoon, on the sixth day of his disease, with an aching

heart I saw the sweat of death upon his forehead, and felt his cold arm

without a pulse. He spoke to me with difficulty: upon my rising from his

bed-side to leave him, his eyes filled with tears, and his countenance

spoke a language which I am unable to describe. I promised to return in a

short time, with a view of attending the last scene of his life.

Immediately after I left his room, he wept aloud. I returned hastily to

him, and found him in convulsions. He died a few hours afterwards. Had I

met with no other affliction in the autumn of 1797 than that which I

experienced from this affecting scene, it would have been a severe one;

but it was a part only of what I suffered from the death of other

friends, and from the malice of enemies.

I beg the reader's pardon for this digression. It shall be the last time

and place in which any notice shall be taken of my sorrows and

persecutions in the course of these volumes.

Soon after the citizens returned from the country, the governor of the

state, Mr. Mifflin, addressed a letter to the college of physicians of

Philadelphia, requesting to know the origin, progress, and nature of the

fever which had recently afflicted the city, and the means of preventing

its return. He addressed a similar letter to me, to be communicated to

such gentlemen of the faculty of medicine, as were not members of the

college of physicians.

The college, in a memorial to the legislature of the state, asserted that

the fever had been imported in two ships, the one from Havannah, the

other from Port au Prince, and recommended, as the most effectual means

of preventing its recurrence, a more rigid quarantine law.

The gentlemen of the faculty of medicine, thirteen in number, in two

letters to the governor of the state, the one in their private capacity,

and the other after they had associated themselves into an "Academy of

Medicine," asserted that the fever had originated from the putrid

exhalations from the gutters and streets of the city, and from ponds and

marshy grounds in its neighbourhood; also from the foul air of two ships,

the one from Marseilles and the other from Hamburgh. They enumerated all

the common sources of malignant fevers, and recommended the removal of

them from the city, as the most effectual method of preventing the return

of the fever. These sources of fever, and the various means of destroying

them, shall be mentioned in another place.

I proceed now to say a few words upon the treatment which was used in

this fever. It was, in general, the same as that which was pursued in the

fevers of 1793 and 1794.

I began the cure, in most cases, by _bleeding_, when I was called on the

first day of the disease, and was happy in observing its usual salutary

effects in its early stage. On the second day, it frequently failed of

doing service, and on the subsequent days of the fever, I believe, it

often did harm; more especially if no other depleting remedy had preceded

it. The violent action of the blood-vessels in this disease, when left to

itself for two or three days, fills and suffocates the viscera with such

an immense mass of blood, as to leave a quantity in the vessels so small,

as barely to keep up the actions of life. By abstracting but a few ounces

of this circulating blood, we precipitate death. In those cases where a

doubt is entertained of such an engorgement of stagnating blood having

taken place, it will always be safest to take but three or four ounces at

a time, and to repeat it four or five times a day. By this mode of

bleeding, we give the viscera an opportunity of emptying their

superfluous blood into the vessels, and thereby prevent their collapsing,

from the sudden abstraction of the stimulus which remained in them. I

confine this observation upon bleeding, after the first stage of the

disease, only to the epidemic of 1797. It was frequently effectual when

used for the first time after the first and second days, in the fevers of

1793 and 1794, and it is often useful in the advanced stage of the common

bilious fever. The different and contradictory accounts of the effects of

bleeding in the yellow fever, in the West-Indies, probably originate in

its being used in different stages of the disease. Dr. Jackson, of the

British army, in his late visit to Philadelphia, informed me, that he had

cured nineteen out of twenty of all the soldiers whom he attended, by

copious bleeding, provided it was performed within six hours after the

attack of the fever. Beyond that period, it mitigated its force, but

seldom cured. The quantity of blood drawn by the doctor, in this early

stage of the disease, was always from twenty to thirty ounces. I have

said the yellow fever of 1797 was more malignant than the fevers of 1793

and 1794. Its resemblance to the yellow fever in the West-Indies, in not

yielding to bleeding after the first day, is a proof of this assertion.

I was struck, during my attendance upon this fever, in observing the

analogy between its _mixed_ form and the malignant state of the

small-pox. The fever, in both, continues for three or four days without

any remission. They both have a second stage, in which death usually

takes place, if the diseases be left to themselves. By means of copious

bleeding in their first, they are generally deprived of their malignity

and mortality in their second stage. This remark, so trite in the

small-pox, has been less attended to in the yellow fever. The bleeding in

the first stage of this disease does not, it is true, destroy it

altogether, any more than it destroys an eruption in the second stage of

the small-pox, but it weakens it in such a manner that the patient passes

through its second stage without pain or danger, and with no other aid

from medicine than what is commonly derived from good nursing, proper

aliment, and a little gently opening physic.

It is common with those practitioners who object to bleeding in the

yellow fever, to admit it occasionally in _robust_ habits. This rule

leads to great error in practice. From the weak action of predisposing,

or exciting causes, the disease often exists in a feeble state in such

habits, while from the protracted or violent operation of the same

causes, it appears in great force in persons of delicate constitutions. A

physician, therefore, in prescribing for a patient in this fever, should

forget the natural strength of his muscles, and accommodate the loss of

blood wholly to the morbid strength of his disease.

The quantity of blood drawn in this fever was always proportioned to its

violence. I cured many by a single bleeding. A few required the loss of

upwards of a hundred ounces of blood to cure them. The persons from whom

that large quantity of blood was taken, were, Messieurs Andrew Brown,

Horace Hall, George Cummins, J. Ramsay, and George Eyre. But I was not

singular in the liberal and frequent use of the lancet. The following

physicians drew the quantities of blood annexed to their respective names

from the following persons, viz.

Dr. Dewees 176 ounces from Dr. Physick,

Dr. Griffitts 110 Mr. S. Thomson,

Dr. Stewart 106 Mrs. M'Phail,

Dr. Cooper 150 Mr. David Evans,

Dr. Gillespie 103 himself.

All the above named persons had a rapid and easy recovery, and now enjoy

good health. I lost but one patient who had been the subject of early and

copious bleeding. His death was evidently induced by a supper of

beef-stakes and porter, after he had exhibited the most promising signs

of convalescence.

OF PURGING.

From the great difficulty that was found in discharging bile from the

bowels, by the common modes of administering purges, Dr. Griffitts

suggested to me the propriety of giving large doses of calomel, without

jalap or any other purging medicine, in order to loosen the bile from its

close connection with the gall-bladder and duodenum, during the first day

of the disease. This method of discharging acrid bile was found useful.

I observed the same relief from large evacuations of f[oe]tid bile, in

the epidemic of 1797, that I have remarked in the fever of 1793. Mr.

Bryce has taken notice of the same salutary effects from similar

evacuations, in the yellow fever on board the Busbridge Indiaman, in the

year 1792. His words are: "It was observable, that the more dark-coloured

and f[oe]tid such discharges were, the more early and certainly did the

symptoms disappear. Their good effects were so instantaneous, that I have

often seen a man carried up on deck, perfectly delirious with subsultus

tendinum, and in a state of the greatest apparent debility, who, after

one or two copious evacuations of this kind, has returned of himself, and

astonished at his newly acquired strength[2]." Very different are the

effects of tonic remedies, when given to remove this apparent debility.

The clown who supposes the crooked appearance of a stick, when thrust

into a pail of water, to be real, does not err more against the laws of

light, than that physician errs against a law of the animal economy, who

mistakes the debility which arises from oppression for an exhausted state

of the system, and attempts to remove it by stimulating medicines.

[2] Annals of Medicine, p. 123.

After unlocking the bowels, by means of calomel and jalap, in the

beginning of the fever, I found no difficulty afterwards in keeping them

gently open by more lenient purges. In addition to those which I have

mentioned in the account of the fever of 1793, I yielded to the advice of

Dr. Griffitts, by adopting the soluble tartar, and gave small doses of it

daily in many cases. It seldom offended the stomach, and generally

operated, without griping, in the most plentiful manner.

However powerful bleeding and purging were in the cure of this fever,

they often required the aid of a _salivation_ to assist them in subduing

it.

Besides the usual methods of introducing mercury into the system, Dr.

Stewart accelerated its action, by obliging his patients to wear socks

filled with mercurial ointment; and Dr. Gillespie aimed at the same

thing, by injecting the ointment, in a suitable vehicle, into the bowels,

in the form of glysters.

The following fact, communicated to me by Dr. Stewart, will show the

safety of large doses of calomel in this fever. Mrs. M'Phail took 60

grains of calomel, by mistake, at a dose, after having taken three or

four doses, of 20 grains each, on the same day. She took, in all, 356

grains in six days, and yet, says the doctor, "such was the state of her

stomach and intestines, that that large quantity was retained without

producing the least griping, or more stools than she had when she took

three grains every two hours."

Medical Inquiries and Observations, Vol. 4 The Second Edition, Revised and Enlarged by the Author · 第 1 / 18 段