SECTION I.

VARIOUS and numerous are the opinions on the origin and nature of the yellow fever. The first is, that it was imported from the empire of Siam, [Page 4]into the West-India islands by a French squadron, returning from thence, in the year 1689; and which was obliged, by stress of weather, to put into Fort Royal, in Martinico ^*. It is true, in­deed, that, as soon as these ships arrived, their crews, as well as the crews of many others, were much infected with a very malignant fever. Great number perished, together with many inhabitants of the island. From Fort Royal the malady was imported, by some commissioned ships, into St. Christopher's and into Hispaniola, where it made great havock. In Port-de-Paix, and several other places, its effects were so dread­ful, during many years after, that, in the year 1692, a royal edict, from the king of France, ordered a quarantine for all ships coming from Martinico. Two years after, and even so late as 1708, penal laws, inflicting the punish­ment of death, were passed in commercial towns against any seaman or passenger who should come on shore without a legal examination or permit. The malignancy of the disorder was such, says Mr. Morean de St. Mery, "as to cause corrup­ted blood to run out from all the organs, and even from the pores of the skin, which was after­wards covered with bloody spots." Since that fa­tal epocha, several accounts have been publish­ed of a particular kind of malignant fever raging, [Page 5]at certain periods and seasons of the year, in all the tropical countries; which, in all its symptoms was nearly like the yellow fever. One of the oldest and most satisfactory accounts which we have of the malady of Siam, or of the yellow fever, is that of Mr. Pouppe Desportes ^*, a French physician, sent to Hispaniola, by the king of France, in the year 1732, to superintend the regulations and esta­blishments of the hospitals in the colony. It is true that some symptoms of the fe [...]er described by that candid writer, seem never to have occur­red in the American yellow fever; but they can­not constitute a material difference. They only lead to prove, that the same disordered may take va­rious shapes, and characters, according to circum­stances of soil and climate. Pouppe Desportes cal­led the fever an pestilential one, and had no doubt of its contagious nature. He enumerated more dreadful diagnostics than any we know of. Be­sides the black vomit, and the j [...]ice, he ob­served that suppurations and mortifications on the joints were often its forerunners. The successive stages of the disease, as described by him, corre­spond with what we have experienced here; and, from a comparative statement of the temperature and variation of the atmosphere, during many years, he drew the decided opinion, that the ma­lady of Siam was always an immediate effect of [Page 6]noxious exhalations, produced by the united agen­cy of storms, rains, and great heats.

Another respectable witness of the same dis­ease, is Mr. Dazille, physician appointed by the king in Hispaniola, about twenty years ago ^*. He reports that he was called in, at Cape Francois, with three other physicians, to consult on the case of a Mr. Lambert, who had lately arrived from Europe, and thus expresses himself. "On the se­venth day of his sickness, Mr. Lambert was stand­ing up in the middle of his room, not complain­ing of any kind of pain. He appeared much dis­pleased at our meeting for consultation, and af­firmed that the was not sick. His pulse was inter­mitting, and a little febrile; his conversation was somewhat incoherent; and his eyes were tinged with a light yellow hue. I firmly declared to the physicians, that, in the evening, he would die. We met again at twelve o'clock; when we found him as yellow as a marigold and in a state of coma. His [...]glutition was already difficult, and he died at [...] half after seven in the evening!

"I was sometime after, requested, by the vis­count de [...]hoiseul, to visit Mr. de Sainthenay, knight of St. Louis, &c. I found him sitting at his desk counting money. Since the fourth day of his sickness, he had been yellow and over his [Page 7]body. His countenance was anxious and much altered; his pulse very bad; and his skin had al­ready that cold moisture which so peculiarly de­signates the last stage of this kind of malignant fever. I immediately sent word to the viscount, that Mr. de S. would die on the same day, which was, unfortunately, the case."

Experience had taught Mr. Dazille the insidi­ous and deceiving appearances peculiarly remark­able in the malady of Siam, or yellow fever; and he cautions his medical readers not hastily to prognosticate the fate of their patients. He and several other French writers have positively as­serted that this fever was introduced into the West-Indies from Asia, about a century before. Although it has all the features of a contagion, to prove that opinion, yet it is very strange that it never has been imported into Europe, notwith­standing the uninterupted intercourse of all the European powers with their islands. Time and experience have proved to them, that the malig­nancy and frequency of fevers in the tropical countries could not reach Europe. However, it cannot be inconsistent to suppose, that, if the malady of Siam had been imported from so dis­tant a region as the East-Indies into tropical Ame­rica, it might, of course, have been received in the south of Europe; since there is no great dif­ference between the climates of New-York or Newhaven, and those of Cadiz or Marseilles. [Page 8]Indeed, if there is a difference, it surely will he favourable to the hypothesis, that such a fever could have been imported often into the southern latitudes of Europe. This was never the case, I believe, however, but once; when, in the year 1757, an English man of war from Quebec arri­ved in Plymouth with the yellow fever, which was very soon subdued by the climate, and did not leave the least marks of contagion.

But it may be said, that, by its nature, this fe­ver is confined to tropical countries, and seldom or never can spread in the northern latitudes, un­less it should there meet with an uncommon de­gree of heat, as is often the case in North Ame­rica. Such objections may be refuted, by consider­ing, that the yellow fever does not precisely break out during the heat of our tropical days, but on the return of the variable days of autumn. Shall we not then say, that the yellow fever may arise from some source colder and nearer than Siam or other tropical countries?

I find that Hypocrates has known, and men­tioned the chief symptoms of this kind of malig­nant fever; and has noticed the spontaneous vo­mitings of the bile, the jaundice, and the black vomit, &c ^*. The warm climate in which he lived, could, indeed, give him frequent opportunities of [Page 9]observing all the effects of any infecting effluvia on the human body. His rules and precepts still hold good in the symptoms of our yellow fever. Why then should we search for its origin in distant countries, whilst we are surrounded with the same causes and circumstances that generated the yellow fever in the island of Cos, in the West-India islands, and in Siam, as well as in Ame­rica?

It is an unquestionable truth, that a contagious disorder may be imported; and that this frequently happens, can be proved by many historical and re­cent facts. Against these we do not pretend to op­pose any dogmatical assertion. But, if the malignant scourge has always been introduced by extraneous causes, and could never exist in our climate but by importation, why does it reach our shores, so late as the month of August? Why is the plague of the American tropical islands increased by the mild and moderate temperature of our autumn? If it be answered, that the contagion must acquire its growth during the hot summer of the islands, before it can be transported, they thus asse [...] positive contradiction. On one side, they cr [...] the fever in the hotest country of the earth; on the other, they support its progress in cooler p [...] and seasons. Should it be acknowledged that the yellow fever often breaks out, in the islands, du­ring their winter, or early in their spring, it ne­vertheless [Page 10]would not explain, why we do not re­ceive it, on the return of our hot days.

An imported contagion might, indeed, be more heightened in certain places than in others; but as the contagion of the plague, the venereal lues, the itch, the scurvy, the small pox, &c. are active in any part of the world, why does not this complaint spread to our inland places, country seats, and towns; among our robust farmers and the numerous inhabitants of our back countries? Are these places so perfectly airy and refreshed, that this kind of contagion cannot reach them? Should it be answered, that in maritime towns only the atmosphere can receive and transmit the seed of contagion, it is obviously admitting that there is an unquestionable ground to assert, that the fever is generated among us.

Why is it that people, attached to a certain mode of life, and careful in the use of certain pre­ventives, may expose themselves to the floating contagion, without fear as well as without effect? Are they more favoured by nature, disposition, and constitution? If it is said, that a perfect state of health does not admit this kind of contagion, is not, what we suppose, admitted, that an imper­fect state of health will easily be acted upon by an impure atmosphere, or by exhalations from cor­rupted animal, or vegetable substances?

[Page 11]Infine, there are authentic proofs that the yel­low fever has sometimes, appeared in isolated cases, in Philadelphia, and other towns. It did not spread, however, except in the years 1762, 1793, and 1797. Doctor Hilary has also observed, and positively ascertained, that once in Barbadoes the yellow fever was not communicated even to the attendants of the sick. As this strange circumstance cannot be explained, except by the state of the air, is it not enough from his assertion, and from the repeated instances in which it did not spread, to derive the grounds of our opinion, that this fever is sometimes generated by principles contained in our own atmosphere? After all these arguments, gentlemen, against the importation of the yellow fever, from Siam or from the West-India islands, it would be unfair not to take notice of the arguments by which it has been deduced from a different ori­gin. These grounds or proofs are but few and equi­vocal, and most of them will contribute to support our opinion. It is said, firstly, that, in all places and towns in America, which have been infected with the yellow fever, it has been easy to trace its origin to certain ships from the West-Indies, &c. Now, I shall not recapitulate to you those tedious enquiries into facts that every party have ingeniously and with equal success controverted; for, should they prove the possibility of the impor­tation of the contagion, it will not affect our doc­trine. Such facts, indeed, ought rather to impress [Page 12]upon our minds, the important truths of the dan­gerous effects of any kind of effluvia from cor­rupted vegetable or animal substances, which are so often unavoidably engendered in the cargoes of ships coming from tropical countries in the hot seasons of the year. Of this, there are as many instances as there are eminent medical writers, on the subject of contagion.

Secondly, The importation of the yellow fe­ver cannot be doubted, when it is so often known to have raged on board of vessels both at sea and in port. Indeed, the French have derived their name of this fever, from its peculiar frequency among seaman; and several of their writers have called it la matelote. Be this as it may, two rea­sons are obvious, even in our opinion, to render the yellow fever more frequent among seamen. One is, that they are constantly predisposed to bilious complaints, as we shall hereafter explain; and the other, that they are continually exposed to putrid exhalations.

Thirdly, If these towns and places had not re­ceived, the contagion from tropical countries, we should find in our historical records more frequent instances of a malady that is supposed to be of a domestic origin. Formerly our summers were still hotter, and more insupportable than they are at present; and our towns, or rather villages, were destitute of any improvement, were often filthy and necessarily neglected; yet they were remarkably [Page 13]healthy. Against objections so obstinately urged, I could oppose undeniable proofs of great changes in many towns and places, of variations in the air, winds, and atmosphere, from whole­some to pestilential, and vice versa; but we have no certain data from such fluctuating pre­mises to direct our enquiries. It is, therefore, un­necessary to insist on them here, while we can, in a few words, satisfy our reason and judgement from well-known facts, more applicable to the point in controversy. Is it not true, that putrid effluvia, infections vapours, and poisonous mias­mata, must be more abundant and permanent, more often generated, and more fully diffemina­ted, in populous and large towns than in villages or thinly inhabited places?

I do not find, gentlemen, among the English medical writers, any other peculiar opinion, on the origin of the yellow fever, except that of Dr. Warren, who implicitly believed, that it had been first brought from Palestine to Mar­seilles, and from thence to Martinico and to Bar­badoes, about thirty or forty years ago. All the works I have read, agree generally in the support of the doctrine of local exhalations. It is now time, however, for me to dwell a little on the opinions which, though much divided, have nevertheless prevailed in Philadelphia, both among physicians and others. The college of phy­sicians of this city, had officially expressed, in the [Page 14]year 1793, an opinion, that the fever had been im­ported from the West-India islands, and that it was very contagious. They have, by no means, depar­ted this year, from that declaration. As we have not any publication, collectively, from that body, that could exhibit more, and stronger arguments than merely their opinion of its importation, I suppose, that it is unnecessary for me to say any thing either for or against the opinion. An almost equal number of physicians, among whom are many eminent characters, have uniformly supported the contrary doctrine, that the fever was of a domes­tic origin; and that it resulted from corrupted substances in the cargoes confined in ships' holes, as well as from those impure exhalations to which we are exposed. Among these last, however, a distinction should be carefully made of those who acknowledge its highly contagious nature, and the few who yet think that it is not of such a malignant character. I hasten to observe, that this assertion has been repeatedly published by a few European and West-India practitioners, who have had but few opportunities of seeing many instances of the malady of Siam, at least in Hispani­ola, where it has very seldom appeared for these last twenty years, and where they have a better opportunity of treating the amphimerina biliosa of Savage, or what they call la fievre lipyrienne, or the Tritacophya Americana ^*. These are [Page 15]simply reduced to an inflammatory typhus, and to the putrid malignant fever. This capital mistake has been, consequently, connected with asser­tions destitute of necessary demonstration; it has exposed to doubt, and almost denied, some fundamental principles of phisiology and practice, respecting infectious disorders and epidemics of camps, jails, ships, and of all crowded places ^*. In a word, this mistake has erected a doctrine void of the deference due to the authority of writers in the healing art of the former and present age.

I shall analyse, with more pleasure, the contra­ry opinion, for which documents, enquiries, and liberal and candid discussions, have been procu­red and unremittingly pursued by several physi­cians. Among these Dr. B. Rush deserves particu­lar notice; because he has supported it, since the year 1793, both in his lectures of the institutes of medicine, in the university of Pennsylvania, and in several treatises he has since published on the yel­low fever. He has never ceased to warm his fel­low citizens of the presence or proximity of the cause of this contagion, in their sea-ports, wharves, streets, and stagnant waters. He has ex­plained the phenomena of exhalation from a com­bination of vegetable and and animal putrefac­tion; and, being aware, by long experience, and [Page 16]an elightened judgement, that the inhabitants of this place were particularly subject to billious fe­vers during the autumn, from sudden changes, and the extremes of the climate, and from the grossness and indigestive quality of their aliments, he early understood that infectious miasmata could aggra­vate the bilious remittent, and convert it into a ma­lignant and contagious fever. On this judicious ground he founded his theory and practice, and we shall see hereafter of what importance it has been to the discovery of truth, and the improve­ment of medical practice.

Having hitherto stated, gentlemen, the histori­cal opinions of the most enlightened physicians of Europe and of America, I must observe, that it was my purpose to point out such of their opi­nions as were more congenial to the true basis of the theory to which I have confined myself; and to illustrate a position which has already occupi­ed so greatly the public attention. I shall add a few more arguments to support the local origin of the yellow fever and its highly contagious na­ture.

A striking circumstance was formerly exhibi­ted by Pouppe Despartes, a French physician, sent by the king into Hispaniola. During many years he accurately observed the state of the at­mosphere in the spring and summer. He noticed, that frequent and heavy rains, interrupted by se­rene [Page 17]weather, and intervals of heat, in those tro­pical countries, was productive of more dange­rous exhalations from the earth. He was thus ena­bled to foretell the appearance of the pestilential malady of Siam, as he called it. He observed, also, that, after heavy rains, the noxious effects of ex­halations were checked by winds, or other circum­stances. A few cases from this very just authority, will serve to warn the inhabitants of our towns of the terrible effects of the exhalations to which they will be exposed, by the concurrence of rains, after long draughts, with the intense heat of the sum­mers, if they retain among themselves all the ma­terials of vegetable and animal corruption. These materials seem to increase with our population; and, in Philadelphia, I believe, there are more of them than in any other town in the union. They may consist of the logs which form our wharves, and which project to a considerable distance in the water; of the boards with which almost all in­closures of lots and houses are surrounded; of the roofs of all our houses; of numerous privy-houses which are seldom emptied; and of many ponds and stagnant waters, both in the city and suburbs. If it should appear strange to point out, among the sources of exhalation, the very wood which we ne­cessarily make use of for our dwellings and ports, I intreat my reader, before he rejects my assertion, carefully to enquire into the natured laws and effects of exhalations from wood, timbers, new [Page 18]ships, cellars, forests, &c. of which he will find ample documents in the writings of doctor Lind and others. Let him call to mind the number of wooden works in all our cities and ports, where the tide successively uncovers and exposes the wharves to the schorching rays of the sun, and then let him draw his conclusions.

In proof of the fermentation of animal substan­ces, particularly during the heat of summer, which I have already suggested, I shall propose an expe­riment. Let a candle be lowered into a ditch, by means of a line, and it will be found, that the me­phitic ascending gas, will put out the light in pro­portion as it approaches the surface of the earth, and this effect will be much more certain in the latter end, than in the beginning of the hot season. When this gas ascends and is received into the atmosphere, it doubtless breeds contagion and death; and I am fully satisfied, that many people have, as well as myself, perceived and smelt its effluvia, chiefly du­ring the calm and clear nights of the month of Sep­tember. Several interesting publications have appeared in the papers of Philadelphia on this sub­ject ^*. From this short sketch we may conclude, [Page 19]that the opinion of the yellow fever being generated among us, is founded upon good ground; and that it would be in vain to attack this opinion by the objections which have been mentioned and refu­ted above. For further satisfaction, we shall add, that the circumstance of its having appeared but once in Philadelphia, before the year 1793, does not imply that it cannot be of a domestic origin; since it is obvious, that it might have ac­tually subsisted in some or few cases, among those bilious fevers that are endemic among us in the autumn, without having been much taken notice of.

Would it be just to say, that this epidemic has never made its appearance in Philadelphia, ex­cept in 1762, 1793, and 1797, while there are creditable witnesses who have positively seen and observed it, every year since the atten­tion of physicians and others has been kept up by the recollection of the calamity? This fever, though so highly contagious as to be compared even to the plague, may, like the plague, be wide­ly propagated or entirely imp [...]ded by causes that favour of oppose its progress; for unaccoun­table changes and variations of heat and wea­ther, [Page 20]have sometimes put an end to the latter in the heat of the summer, and they have also in­creased it in the middle of the winter. The case No. 1, was that of a father surrounded with a numerous family of whom not one was infected but himself. The same fact has occurred to my observation, in almost every family, in which the disorder proved mortal. In such cases, the patients secrete very little of the putrid mias­mata; they are much less infectious, because the poison is kept in their body to destroy the func­tions of life; and one of the most deceiving symp­toms is, that they seldom emit any disa [...]able smell. It is quite the reverse, however, when they recover; and physicians and nurses are well acquainted with the insupportable foetor, peculiar to that fever, which exudes from their bodies, and continues, for a long time after, in their bed and clothes. Consequently one or many mortal cases of the yellow fever may have happened, without having been followed by contagion.

But it is further objected, that the traces of the importation have been visibly marked in Phila­delphia; where the fever, having been commu­nicated by somebody from Southwark, has in­fected the most distant part, which is Kensington, and the houses on the Frankford road; meanwhile there were but few scattered cases in the centre and northern parts of the city. This last mentioned theatre of the disease, would, however, have been preserved from contagion if the epidemic was of [Page 21]a domestic origin; for the place is quite open, and presents a view of many country seats, and being not on the same straight line of the town, it cannot receive its exhalations. However striking and conclusive this whole objection seems to be, yet what will be thought at last, by an unprejudi­ced reader, when he recollects that Kensington, and all the adjacent grounds, are wholly a kind of naval yard, full of timber, and more than any other part of our suburbs, surrounded with marshy grounds, and stagnant waters. The adjacent banks of the river are, besides, filled up with all the rubbish of new and old timber. So much for the origin of the yellow fever in Kensington, &c.

In support of the opinion, that the yellow fever is of domestic origin, why should we not derive, gentlemen, some authority from the medical doctrine already known and promul­gated in all the schools of the world; of the pos­sible infection of disorders generated in places where people are crowded, or where unwholesome exhalations are produced? The history of jail distempers, of fevers on board of fleets, and of va­rious disorders in camps, teaches us that it is not requisite to search for the origin of our calamity in distant countries. We must not be unaccustomed to the id [...], that our atmosphere may be poisoned as easily as a plant growing in our fields. From all the corners of our extensive continent, winds, may blow [...] as dreadful as the [...] of Ara­bia [Page 22]and as the Harmattan of oriental Africa. Bar­ren and uninhabited lands, thick and extensive fo­rests, have been known to spread, even to the dis­tance of many miles into the sea, miasmata of con­tagion and death. To incredulous and systematic theorists, I shall exhibit the faithful evidences which we may derive from the instinct of ominous birds. If my mind was not distracted by error and prejudice, I saw, repeatedly, during the two in­stances of our calamity, vultures flying over our afflicted town. These kinds of volatile and carnivorous animals, never wander but in the currents of miasmata and putrefaction. This is the means by which, in a few hours, they reach their distant and putrid prey. This is also a proof that our atmosphere was infected with the corruption which created our epidemic. For an imported disorder cannot infect the atmosphere, any more than our sources of exhalation.

It remains now with me, gentlemen, to make a few more observations on the contagious power of the yellow fever. I have already notice, that very few opponents have appeared against that opini­on; and it is certain, it will meet with none in the schools of America. The doctrine of the noxious qualities or substances of which the air and winds may be the vehicles, has been handed down to us by Hypocrates; and wonderful im­provements in chymistry have still letter explain­ed this truth, and all its phenomena; for the [Page 23]idea of contagion implies nothing else but the transmission of certain principles of disorder, whether conveyed through the medium of the air or by an immediate contact. When this effect takes place, bodies are said to be infected; and surely as many disorders as by their particular effluvia always excite the same morbid state, so many must be contagious. Happily, in the long catalogue of diseases to which we are subject, these are, comparatively, few. Although conta­gion may arise from noxious effluvia, floating in the air, yet it seems that the same principles ac­quire more malignancy when they are propa­gated by the channel of diseased human bodies. In them, the contagious miasmata regenerated and multiply; and, if they were not checked by fa­vourable changes in the atmosphere, who could foresee an end to a malignant contagion ^*! Such [Page 24]are, alas! those contagious poisons, the elements of which are heavy and fixed; they are indepen­dent [Page 25]of our controul, and from generation to ge­neration they perpetuate among men, and af­flict or blemish the noblest family of the living creation.

But the yellow fever, gentlemen, has manifes­ted such particular characters of a highly contagi­ous malignancy, that it suggested to many, no doubt, the idea of importation, which could not indeed, be denied, were there not so many and such powerful reasons to invalidate it. It was not like an epidemic which strikes only at certain in­dividuals, of the same disposition, or defects of constitution; and thus discloses, at last, what kind of victim it endangers. It does not, like the ague, threaten those of lax nerves and fibres; like the catarrhs or influenza, falling upon the humourous; like the autumnal fevers, afflicting the bilious; and like inflammatory disorders, sei­zing upon the plethoric; no, the yellow fever has spared neither sex nor age. The infant in the cra­dle, as well as the most aged, were alike exposed to its attacks. It seemed, indeed, very general among poor, intemperate people, and in filthy houses; but we have seen also its power on those, who, among all the comforts and coveniencies of life, were unfortunately reached by it. Its irre­gular march and progress, its appearance in op­posite extremities of the city, without any visible way of propagation, could not be explain [...] [Page 26]it been an epidemic resulting from general exter­nal causes, and not possessing any contagion.

Moreover, these principles and facts cannot, in the least, be invalidated by objecting, that a con­tagious disorder could not remain confined in maritime towns; and that, like the plague, it would have found its way to populated coun­try places; for even the plague abated entirely in Aleppo in the height of the summer, when the extreme heat, dilating too much the pestilential miasmata, probably rendered them harmless. It disappeared in Vienna, in 1713, as soon as tem­pestuous winds blew away its aerial venom. By other unaccountable causes, it equally broke out during the winter and summer, and also equal­ly disappeared, during each contrary season, in Oksacow, in the years 1737 and 1738. If the plague could be checked by contrary changes of season, and even by the heat of the summer, who will be astonished at finding that some reasons also excludes generally the yellow fever from the coun­try? These reasons are not incomprehensible [...] for the pure, open, and elastic air of the country, must dispel the infectious miasmata. And there, with all the balsamic and wholesome fragrance of a useful vegetation, with all the benefit of exercise and salutary labour, preventives enough may be found against contagion.

[Page 27]Let us now enumerate the fundamental obser­vations which result from this first section.

1 st, The yellow fever is generated by pu­trid effluvia from vegetable and animal fermenta­tion.

2 ly, The opinion that it was imported, one hundred years ago, from the kingdom of Siam, into the West-India islands, and from these islands to North America, cannot be admitted ex­clusively, to its being generated spontaneously in every warm country, from the abovementioned causes.

3 ly, We may more affirmatively pronounce, that the yellow fever may be an indigenous dis­ease among us, since it was observed by ancient physicians in similar climates, and probably under similar causes; since we are exposed to such ex­halations as seem adequate to its generation; and finally, since, in the past progress of the disease, there must have been some place and time in which it was generated and not imported.

4 ly, The yellow fever is of a highly malignant nature and contagious power.

SECTION II. Physiological and Pathological Description of the Yellow Fever.

FROM all the documents which have been trans­mitted to us, both by English and French writers, there is no room to doubt, that the disorder which they have called the malady of Siam, the mate­lote, or the yellow fever, is exactly the same which has, in several instances, raged among us. It seems, however, that our epidemic, differs, though not materially, in some of its symptoms, from that of the tropical countries. Dr. Johnson, has, indeed, acknowledged three kinds of yellow fever. With respect to them, I shall, just simply remark, that, if there are three distinct and appa­rent degrees, they must be owing to the following obvious circumstances. First, that of its effects or attacks on a patient who quickly becomes its vic­tim; second, of one who, without great difficul­ty, or danger, passes through its stages; and lastly, if those, who, with proper assistance, get over the resolution and crisis. These three characters, are, undoubtedly, the natural result of the differ­ent degrees of contagion, or of the constitution, habit, and previous complaints of the patient. There is consequently out one sort of yellow fe­ver. This malady should, besides, be considered only during two of its periods, that of its symptoms and that of the crisis. In practice, this division [...] [Page 29]a very just one. It traces, exactly, the limits of medical treatment, and is a sure mean of sug­gesting true prognostics ^*. When death is unavoid­ably [Page 30]the final result of this disorder, it is equally horrid and insidious. Penetration and attention are, therefore, the first and most essential requi­sites to keep us from indulging those erroneous and false hopes, which, both the patient and his friends, are too apt to entertain. A turgency of the blood vessels, or what we call a plethoric state, may, during one or two days, precede the attack, but is seldom taken notice of by the patient; and no other previous indisposition can be remarked. Whatever then may be the state of the body, the fever suddenly and tumultuously breaks out. Spon­taneous vomitings of yellow, green, and gluti­nous bile; a depressing head ache; a numbness of the limbs, and joints; a burning heat in the face; and redness in the eyes; imme­diately take place. Such rapid and violent changes in the whole frame, are, I believe, un­common in any kind of fever, and belong only to the plague. During the two first days, this state admits of but little change. Short intermis­sions, are, however, sometimes obtained by means of the remedies which are administered. The patient may possess all the other febrile symp­toms; but I have seen none of them more fre­quent than delirium and coma. We next dis­cover an ominous and absolute prostration of strength, an abatement in the pulse, an entire ce [...]ation of feeling, and an insidious security in the patient, who fancies himself fast approaching [Page 31]to a recovery, and who only complains of a want of strength. He soon after, however, expe­riences frequent and short chills; and his evacua­tions are colliquative, foetid, with yellow or white matter. He then sighs deeply; is restless; and he cannot even bear the weight of a covering upon his body. He next appears totally insensible either to heat or cold; his skin is dry; there is no kind of exhalation of disagreeable smell about him, and even very little is perceived from his breath. He has no thirst, but he can drink any thing. Nauseous medicines, or agreeable food, are alike received into his stomach without sick­ening it. His tongue as yet portends nothing alarming; it is covered, however, with a kind of thick white crust, from the root to the edges, which remain perfectly red. In this state his urine seems stopped, although he drinks much; and, if he voids any, it is generally purulent. This period of the disease, in which the delusion of the patient exists, notwithstanding the cessation of his regular functions, is highly expressive of the disorder being unconquerable; and I ven­ture to assert, that when it is observed in the second or third day, it ought to determine the physician to give over, without hesitation, the least hope of a recovery. The patient will be in the agonies of death as soon as the third day arrives, and never later than the fifth.

[Page 32]Another more insidious stage than the former, may take place in the beginning of the dis [...]e, and last two or three days. It is not so [...] in its progress, but is equally fatal in its issue. In this case, an ardent fever, which, however [...]y be occasionally abated by judicious re [...] is the only characteristic. Under such circum [...]tan­ces, how anxiously ought the physician of [...]r to bring on a change or a crisis! On this [...]. I cannot too strongly insist: for here the [...] of that sickness lies, in which it is so difficult to re­cover any dangerous symptoms. Several of them are, however, to be remarked.

First, Although the patient may be acted upon by medicines, he is certainly deprived of salutary evacuations; and chiery of those which we shall hereafter describe as the only proof of a successful treatment. To be deprived of them, before the third day, is a sure prognostic of death.

Secondly, The patient complains but little; and a kind of stupidity, resulting from the slow­ness of his ideas, forms a striking contrast with the watchfulness and the confusion of his countenance. This symptom is more alarming, and is direc­tly opposite to the inquisitive anxiety and irresis­table uneasiness of patients in common cases. Those, therefore, who are best acquainted with the natural disposition of the person who is sick, will be best able to judge of this decisive symptom.

[Page 33] Thirdly, In all his actions the patient shews an uncommon degree of strength; while repeated exacerbations of fever, frequent bloodlettings, and want of nourishment, should render him very weak. This very strength, however, is unnatural and contrary to the appearance observed in fa­vourable cases. It is the effect of an universal spas­modic constriction of the nerves, and indicates the dreadful action of the morbid cause upon the vis­cera, and its manifested by a kind of trill in the nerves, or by an involuntary fluttering in the muscles, which we may evidently perceive, if we keep, attentively, during a few minutes, the hand or the arm of the patient in our hand. This last sign claimed my particular notice, and it has al­ways proved singularly useful to me.

Fourthly, and lastly, we may always discover, that each of the exacerbations of the fever are preceded by horripilatio, or violent chill. After these four symptoms have taken place, we should never put any dependence either on the pulse or the tongue; for, whether the pulse be febrile or not, intermitting or regular, it prognos­ticates nothing decisive for the patient, unless we can distinguish it hard, and tense, and possessing a spasmodic and fatal constriction. The tongue also presages nothing conclusive; it will be found white or soul all over its upper surface, and its edges red. If the patient remains for some time [Page 34]without drink, a triangular red spot will appear from the edge to the centre of the tongue. But after a diluting draught this disappears; and these states take place, both in cases of death and recovery. One appearance of the tongue, however, is omi­nous in the first days of the disease; which is, when it turns black or brown, before the last exa­cerbation of the fever, which generally subsides on the fourth day. Iliccough or an absolute suppression of urine, are likewise very dangerous symptoms, if they take place before the time of the resolution of the fever; but if the first hap­pens after it, it happily constitutes the final and salutary crisis.

Another symptom usual in malignant fevers, but particularly in this, is a kind of small red petechiae, very similar to free bites. They appear on the hands, the neck, the breast, and also on the face. Many suppose that they are from the bites of musquitoes, or of other insects. A physician may know better, but cannot derive from them any thing further than a proof of the malignancy of the fever. (Vide case No. 4.)

I dwell more particularly upon these apparent­ly trifling circumstances, because they are of the utmost importance towards assisting us in our en­quiries. Physicians are, alas! pecularly liable to error in a disorder so difficult to judge, and so violent in its attacks. From an affectionate regard [Page 35]to their patients, or from a reasonable pride in their own medical skill, they are sometimes over confident of their success; and too frequently, in the event, the friends of the patient, are unhappily plunged into dispair, at the disappointment of their expectations. Would it not be more pru­dent, then, in cases of iminent danger, to cau­tion them against it; and thus, when the utmost of our skill is baffled, to deserve their confidence and gratitude by our candour?

I now arrive at that fatal period, when, by the deadly effect of the decomposition and mor­tification of the animal fluids, all the struggles of nature are entirely overcome. On the fourth day, this period is announced by the paleness of the s [...] and the extreme debility of the pulse; unless, indeed, as it frequently happens, a still more vio­lent degree of contagion has, through uncommon circumstances, produce these symptoms sooner. The feelings of the unhappy patient have now lost so much of their power that he is totally incapable of giving any account of his confused sensations. His skin becomes gradually tinged with a yellowish colour, while his lower extremities become of a deep red and are a little swelled. The eyes loose that remarkable animation which they before pos­sessed, and appear desponding; while the coun­tenance becomes confused and grim. Nausea [...] at this period, is a common symptom. If drink be thrown up, it is not altered from the [Page 36]state in which it was taken, unless indeed, by ha­ving acquired a ropiness, and being mixed with small flakes of dark coloured matter. A black or brown fluid, much like coffee grounds, is next vo­mitted. If this does not take place, it is only owing to a want of strength; and the stomach is, then, much more oppressed; and the patient may be expected to die early in the fifth day, or sooner. Stools are also frequent and easy, but very offensive. They are yellow, grey, and of a sooty colour, and contain a few flakes of white or red. Delirium in this stage is very common. Frequent instances are also seen of patients preser­ving their reason till the last moment, (Vide case No. 4,) when a cloud suffuses their eyes, and makes them averse to the light. During all this time, the pulse is in a deceiving state. It keeps, for the most part, quite calm, and is a little febrile, or perhaps not so at all. It occasionally, however, appears intermitting, unequal, and different on one side of the body from what it is on the other. This is generally its last expression of energy, and may be owing to a spasmodic constriction. In such cases, it sometimes rises to an unexpected vigour, and is the forerunner of a temporary re­lief. The patient talks much of his expected reco­very, and will sometimes even try, with success, to give deceiving proofs of it. He wishes to take exercise and to pursue his business. He will get up; want to dress himself; and will walk very [Page 37]freely. I have seen a few who, on these occasions, were able to set in company. Every one was as­tonished, and would remark no other alterations than that of a deep orange colour all over his bo­dy, an incoherence in his conversation, and a very confused look. How short, alas! and deceiving is this last spark of life? A cool moisture and a total prostration of strength succeeds, and suddenly conquers this elasticity of the fibres. On a sudden, the pulse disappears; the extreme­ties cool; the convulsions of the stomach are re­newed, with accute pains, caused by a slight pres­sure in the abdomen; and a deplorable, though short agony, terminates the disorder, after having diffused a putrifying poison in the blood, and des­troyed the noblest viscera by mortification. (Vide case No. 5.)

Such are the periods and symptoms of the yel­low fever, which has been distinguished, by se­veral writers, as a particular species of the most malignant kind. When there exists an error in the treatment, or any dangerous circumstances in the constitution of the patient, he must certainly fall a victim. The disease remains the same, however, in its nature and operation; and we will find, among those who happily recover, no other chan­ges than those which constitute an issue prompted by accidental or unavoidable causes, and which take certain modifications from the constitution, the sex, the age, or previous indisposition of the [Page 38]patient. Let us now direct our enquiry further, by a review of the different stages of the malady, when it can be conquered by nature or by art.

It was the doctrine of Hippocrates, that, on the breaking out of any acute malady, there were symptoms pointedly prognosticating its fatal issue, or the probability of its cure. Thus he remarked, that, if the patient, on being taken, was discove­red involuntarily to shed tears, or if he was sei­zed with convulsive fits, he would either die, or labour under a very long and dangerous attack. Medical practice, in our day, is, however, great­ly improved, and is attended with far different and happier results. We have seen and known many who have recovered from pestilential and malignant disorders, who, at first, had exhi­bited the most portentous symptoms. (Vide cases No. 6 and 7.) Whatever these symptoms may be, in the first day of the disease, any unfavoura­ble judgement must be suspended. In fact, if obvi­ous indications have been faithfully followed, on the second day, we may discover beneficial and critical perspirations, remissions of the fever, and salutary evacuations. The latter must be repea­ted, copious, and of a dark green colour. Instead of that prostration of organic strength, which we have noticed above, the patient complains only of a natural weakness; and when he takes refresh­ment, by a few hours of sleep, he keeps a peace­able situation in his bed. Upon comparative obser­vation, [Page 39]it must be acknowledged, that, instead of weakening the organic sensations, the yellow fe­fever irritates and heightens their powers; for, if but a sight dose of physic be given to the patient it will be very powerfully felt. His taste is like­wise equally affected by nauseous medicines, by refreshing liquors, and by the most wholesome nourishments. The coma and delirium may take place, without being ominous; the pulse may be rapid and revulsive without a convulsive constric­tion. The least noise provokes in him a sorrowful anxiety; but this symptom is for better than a deceiving security and a portentous cessation of his complaints. The fever keeps the patient, ge­nerally, in this situation for three days. On the fourth, the change operates; and is, indeed, con­nected with some apparently dangerous circum­stances, which are very critical; but, which, in the end, become salutary. The chief of these are, the affection of the stomach, and its repeated nau­sea, joined to frequent vomitings, attended with a pain which a gentle pressure accutely exasperates. Proper medical assistance gradually relieves this and other acciedents; but, until the sixth day, no safe proofs of a good issue are to be perceived. Should, however, a few paroxisns of fever be re­peated, so much the better, provided they are unattended with a chill. These will serve to de­termine a happy resolution; for the yellow fever, when treated with succes [...], runs [...] the c [...]es [Page 40]or febris ardent, and is remitting during seven days. The yellowness of the skin usually ap­pears after the exacerbation of the fifth day. It is not interspersed with any shade or red spots, and there are scarcely any which are apparent on the extremities. This jaundice begins to disap­pear on the seventh day. In the beginning, the tongue does not much differ from what I have above described in the worst cases. In these cases however, it every day acquires a more uniform paleness, or small red spots; and upon the whole seems of a more spongy and porous substance.

It is a general observation in medicine, that in proportion as the resolution of an acute disease is perfect, the weaker the patient afterwards feels himself. This state of the body is also, one of the best means by which we can judge of the safety of organic life. Agreeably to these principles, the pa­tient who recovers from the yellow fever under­goes great exertions and a very difficult struggle. In this exhausted state, he is doomed to a tedious convalescence, and may esteem himself happy if he recover from it in a space of time equal to that of the disease.

Several other circumstances more particularly designating the character of the yellow fever, when carried to a successful issue, remain to be mentioned.

[Page 41]The West-India writers have observed in this disorder, some singular symptoms, many of which were seldom seen in the American epidemic. They may, however, from obvious circumstan­ces, become symptoms of death, or crises of a cure. These are,

1 st, Hemorrhage from the nose.

2 dly, Swelling and suppuration of the parotids.

3 dly, Anthrax, or any other eruption on the skin.

4 dly, Aperture of the orifice after bleeding, at­tended with a mortification of its edges.

5 thly, Acute pains on the limbs, and suppu­rations on the joints.

6 thly, Spots of dry mortification.

I frequently saw the first of these in Philadel­phia, and it proved fatal or not, according to the pathological rules of Boerrhaave: ‘"Si Tertio vel quarto die parca, Lethalis; optima fiet die decretorio." § [...]41.’

The second has occurred, though seldom, in my practice. When it did appear, it was perfect, and generally succeeded on the fifth day, and al­ways immediately resolved the malady.

[Page 42]The fourth presented itself as an hemorrhage. This I attributed to obvious circumstances. The mortification of the orifice of the veins, however, I have seen in almost all the dying subjects; of the third and the last I have met with but one instance.

The fifth frequently took place as a pain, but never as a suppuration.

Upon the whole, the only critical diagnostics which have been peculiar to the yellow fever of Philadelphia, were, the hemorrhage and the swel­ling of the parotids ^*; but these very diagnostics, together with the jaundice, were either favourab­ble symptoms of forerunners of certain death, ac­cording to the time in which they appeared. In fact, we learn, by the pathology of the human body, that, in all acute disorders, Nature re­quires a certain space of time either to cure, to resolve, or to disperse the morbid cause under which the body is labouring; and the most per­fect proof that the attempts of art or of nature have failed is when we too early discover incom­plete effects or a false crisis. Of these however, an explanation will be given in the section on the treat­ment of the yellow fever; notwithstanding I shall explain the real pathology of one of the most hor­rid disorders that ever afflicted the human race. [Page 43]I here repeat with confidence that nothing but facts will be the basis of a theory that has no connection with any new system, and which will be an answer to these questions why the yellow fever is attended with spontaneous vomitings of the bile, with a jaundice, with black vomit, &c.?

The opinion that the yellow fever is a true bi­lious one, and differs only in degree, which is the highest and the most malignant, has been al­ready known and satisfactorily proved by Dr. B. Rush ^*. With this principle as a guide, many er­rors, systems and conjectures might have been long since dispelled, or at least better explained. The history of its symptoms, exhibits, in the plain­est manner, the corruption and malignancy of the bile. As soon as the patient is seized, he spon­taneously vomits bile; and if he recover, it is by the means of successful and copious evacuations of hepatic and cystic bile. If he die, it is evident­ly in consequence of the mixture of the bile with the blood, and the mortification of all its viscera and reservoirs. All the anxieties, nausea, pains, obstructions, and exacerbations of fever, in every case, seem evidently caused by the fermentation, the stagnation, and the acrimony of the bile. In short, if morbid bodies be examined by defection, new ravages of the bile are also discovered. From [Page 44]these facts, what other inferences can be drawn, but that of fixing the pathology of the yellow fe­ver in those laws and accidents that are connected with the bile. In order then to establish some rea­sonable ground, let us first enquire to what uni­form cause we may attribute all the above men­tioned symptoms.

Hippocrates has observed ^*, that autumnal fe­vers were attended with jaundice, in consequence of people living upon rich beef, and Boer­haave admits acrid bile and poison among the causes of the worst kind of jaundice. The liver, from its nature and functions, receives a great quantity of blood from the venaporta, to prepare the bile; we may therefore conclude, that diseases of that viscera, might disturb or alter the bile, and vice versa. But, if a poisonous exhalation has, by its affinity with the bile, diffused itself in the alimentary canal, it is very probable that the infection will early reach, by many known passages, its very source; and the liver, the gall bladder, the duodenum, the stomach, &c. will then be diseased by a poisoned [...] which stimu­lates, inflames, and corrodes th [...]e the spontaneous vomitings of the bile. Besides, before this infected bile could be sufficiently diluted, neutralized, and evacuated, it is obvious to think, that the whole liver, ^† being affected either direct­ly [Page 45]or indirectly, will no longer be so easily infil­trated nor receive that mass of blood it ought to admit; and this, by revulsion, will pass down the iliac and mesenteric veins to the [...] last anastomoses with the smallest arteries; and hence the violent and inflammatory fever with all its attending symp­toms. Nature has but two or three days to sup­port the violence of such a struggle. The poison ceases not to act upon the very texture and mem­branes where it is inclosed; it may perhaps be poured again ^* from the liver into the duo­denum and the stomach, with stronger acrimony; and there is always enough of it to contaminate the blood in the venaporta and that of the vena cava, from which it mixes at last with the general mass, and produces the black vomit and the icterus. I need not to relate all the other ac­cidents [Page 46]of gangrene, hemorrhage, eruptions of any kind, and of death; because, to my medical rea­ders, this theory, founded upon facts, will be sufficient to account for every thing. Another striking proof in favour of this theory, may also be drawn from the march of the disease in a re­covering patient. His cure will either be rapid or tedious according to the efficacy of his evacua­tions, which, at first, being chiefly composed of the cystic bile, appear very green, but afterwards turn to a yellow colour, owing to the hepatic. It must, however, still be remembered, that no symptom, diagnostic, crisis, or accident, can bet­ter designate any future success, than a continu­ed and uninterrupted evacution of the bile. Af­ter all these physiological and pathological argu­ments, we must undoubtedly conclude,

1 st, That the yellow fever is the first and high­est degree of malignant bilious fever, the proxi­mate cause of which is a contagious gas received into the alimentary channel, and into all the vis­cera of the bile; and that this original circum­stance distinguishes it from the plague, which is produced by a poison immediately received into the blood.

2 dly, The contagious miasmata which consti­tutes the yellow fever, is, at first, received into the bile. I [...] there alters i [...]nd stops its circulation, excretion, and secretion; and it afterwards, by [Page 47]its acrimony, inflames and produces a mortifica­tion of the abdominalia, and a decomposition or putrefaction of the blood ^*.

3 dly, It appears, also, that there is but one sort [Page 48]of yellow fever; that its different degrees of malignancy originate from obvious circumstances; and that the disorder will prove fatal or not, ac­cording to the mode of treatment, or to the na­ture of the constitution and previous state of the body of the patient.

4 thly, There are but two periods of the dis­order, that of the symptoms, and that of the crises. The first generally last three days, seldom five, and instances have even occurred of but one day. The crises always prove mortal if they appear before the third day.

The symptoms are, spontaneous vomitings of the bile, or nausea; violent fever; sickness of the stomach; florid state of the face; restlessness; pains in the limbs and in the back; and a pros­tration of strength.

The crises are, hemorrhages; swelling and sup­puration of the parotids; petechiae; jaundice; fluxes from the bowels; and black vomit.

5 thly, In cases of recovery, the fever is remit­tent during seven days, like the causos or febris ardens; all the crises may safely take place on or after the fifth day, except the black vomit; but early and profuse evacuations of hepatic and cystic bile are the only critical signs and proofs of next recovery.

SECTION III. Method of Treatment of the Yellow Fever.

WITHIN these last five years, the period in which the yellow fever has made its general appearance in America, several methods of treatment have been published here; and the same subject has also been ably discussed by ma­ny eminent West-India writers. I will not, gen­tlemen, attempt to comment or decide upon the respective merits of either; but, I must confess, that I have never yet been able sufficiently to discover by what indications the use of their re­medies was to be directed. Thus it frequently happens that they sometimes succeed and some­times not; and the mercury, bleedings, bark, cold or warm baths, acids, blisters, &c. often fail­ed even in the hands of those who contended the most warmly for their application. If they afterwards attempted to explain under what circumstances their proposed method has fail­ed, they have generally offered vague pretences and uncertain rules. Let us then, with can­dour, declare this unexceptionable rule in me­dicine, that no method of cure should ever be depended on, unless it be founded on such [Page 50]rational grounds that the remedies employed will answer, under every circumstance, the indications of the disease. Experience has, at last, proved that bleeding and mercury are sufficiently powerful to conquer the most ma­lignant degrees of the yellow fever; yet, in the use of these remedies, the greatest care and cir­cumspection are requisite in order to insure their success. Before I enter upon the explana­tion of my method of treatment of the yellow fever, and of the proper mode of adminis­tering these fundamental remedies, suffer me, gentlemen, to observe, that, in America at least, Dr. B. Rush has the honour to stand foremost in support of their efficacy. While no other method seemed equally successful, that of ve­nesection and calomel was supported, during the two instances of our calamity, notwithstanding the most bitter invectives and sarcastic publica­tions were continually levelled against it. Some unfortunate and unsuccessful cases were held out as proofs of its danger; and the charge of pro­fuse and indiscriminate bleeding was exbited as a murderous practice. These objections, how­ever, when weighed with impartiality, will be found to result from the unavoidable incon­veniencies of a temporary and violent epide­mic. One may arise from the method of indica­tions, which cannot, in cases so uncommon, be equally well-understood by every physician; and [Page 51]the other, from the impossibility of conducting the sick with regularity and dispatch, among so great a number of patients, who are often deprived even of the necessary accommodations, or who fre­quently mistake their own cases; and who, in the height of their despondency, communicate their terrors to the attendants. Too profuse and indiscriminate bloodletting, may have occurred in several instances; but I am happy in assert­ing that, as far as I am acquainted with them, they could not be fairly derived either from the private or public opinions of Dr. Rush. It is, therefore, peculiarly pleasing to me, that I am thus able, in some measure, to vindicate the character of an eminent and humane physician; and more espe­cially so, because in some points of theory I may be found to dissent from him.

It is only from the pathology of the yellow fever, that any safe or efficacious rules for its cure can be derived. For every judicious ob­server, will candidly acknowledge, that, if the numerous remedies which have hitherto been re­commended for the yellow fever, have produced a cure, they have likewise too frequently failed. If then it be a fact, that the contagion peculiarly connects itself with the bile, and corrupts it, we may clearly and safely establish, as a first in­dication, that the bile ought to be speedily eva­cuated, purified, and renewed. If it be true, that [Page 52]the morbid state of the bile causes its stagnation, produces obstructions in the liver, and prevents the entrance of a considerable quantity of blood into that large viscera, we may point out as ano­ther fundamental indication, the necessity of spee­dily opposing the immense revulsion of the blood in the arterial system, which increases the general spasms, together with all the symptoms of inflammation, and which continually endangers the life of the patient ^*. Infine, if it be a fact that the bile, when infected, will contaminate the blood, and vice versa; and when the whole frame, labours under iminent danger of putrefac­tion, that the animal fluids must undergo a depura­tory crisis within a certain space of time, and that by the means of natural or artificial exertions, it will be necessary to be well-acquainted with all the accidents attending malignant and putrid fevers, to accomplish all the secondary indications, and to obtain, as regularly as possible, a perfect resolu­tion of the malady, without unnecessary or dan­gerous means. To give, however, gentlemen, a [Page 53]more explanatory view of primary and secondary indications, for the mode of treatment of the yel­low fever, suffer me to exemplify them by the fol­lowing historical case, wherein I shall notice the minutest circumstances, both with regard to the disease and to the medical prescriptions which were administered.

T ... B ... about twenty-two years of age, was of a sound constitution, and of a regular life. He had lately lost his father and a brother in the prevailing fever. After their death, he, with the rest of the family, went into the country; but he had already been infected with the contagion. This was soon manifested by all the alarming symptoms, but chiefly by the spontaneous puking of the bile. He was immediately carried back to town, where proper assistance might be obtained; and, before a physician could be sent for, an expe­rienced nurse had ordered him to be copiously bled, and had given him a dose of salts. These orders were good but insufficient, and nothing further was done until the evening of the second day. At this time I was called in, when I found him extremely ill, and very nearly approaching to that prostration of organic action which does not even give time for an exacerbation of fever. Having just lost his parent and a brother with this same disease, he could not but consider himself also as a devoted victim. His spirits were, there­fore [Page 54]uncommonly low, and he appeared invo­luntarily to shed tears. This circumstance, agree­ably to the rule of Hippocrates, I considered as an ominous and fatal prognostic. A confused and gr [...]n c [...]ntenants, cold extremities, and a hard and low pulse, marked the rapid progress of the disease, during only thirty hours of sickness. All the good effects that might have resulted from the first copious bleeding had been lost; since no proper help had been [...]ed for the eva­cuation of the bile. My first consideration was, therefore, to endeavour to ra [...]se [...]cervation of the fever to its natural co [...] the disease can never go reg [...]y the [...]gh [...] different periods, and the patient will irrevo [...] ­bly die, if he is so much exhausted that it cannot be produced. To obtain, therefore, this desira­ble change, I depended much upon the action of the mind on the nerves, and eadeavoured much to raise the hope and confidence of the despairing patient. Whi [...] I kept his pulse and hand within n [...]e, they acquired a sensible energy. His extre­mities became warm; and, wishing to remove every obstacle to the operations of the treatment, I immediately ordered a carminative and nitrous [...] Thus I considered that the previous congestion [...] of the foeces might be discharged, and that the subsequent and necessary evacuations could no lo [...]r be retarded. At night, the patient was, agreeably to my wishes and expecta­tations, [Page 55]seized with a violent exacerbation of fever, attended with delirium. This state gave the po­sitive, indication of a copious bleeding; for by it I fulfilled the second fundamental indication abovementioned, viz. that of emptying the blood-vessels, when the blood can be no longer admit­ted into the liver, and when the large vessels are in a state of infection. Agreeably to this indica­tion, the patient lost fifteen ounces of blood on the night of the second day. Without losing-time, the bile was to be evacuated; for a favour­able relaxation, and an absolute cessation of spasms, irritation, and inflammation, always suc­ceed a copious bleeding, and at this time the me­dicines have consequently more power. I direc­ted the patient, therefore, to take immediately, and every two hours after, a dose of calomel gvi. jalap, gx. and scamm. of Alep. gii.. This prescription was to be alternately followed with proper diluting and cooling drinks. On the third day, the medicine operated satisfactorily; for a prodigious quantity of green or cystic bile was evacuated. The pulse, however, exhibited a state of constriction, and the stomach was sick.

Let us now venture a few conjectures on these unfavourable symptoms. Among the remedies which we employ, there are many, whose power and efficacy we can understand and analyse; but there are others also which may answer all our [Page 56]wishes, without our being able to account for their successful operation. Thus, if in the remo­test foldings and cavities of our viscera, there exist a corrupted fluid which we wish to evacu­ate, it is obvious that venefection, affecting the whole system and distending the nerves and the vessels, will operate on each diseased part; yet how does it happen that a mercurial powder so effectu­ally obtains the secretion of the hepatic and cystic bile? This circumstance, as well as that of the same effect being produced by the regulus of antimo­ny, when taken into the stomach, cannot as yet be explained. In the case now under contempla­tion, twelve grains of calomel, mixed with other drastics, was sufficient to evacuate a great quan­tity of cystic bile. It was not, therefore, impro­bable, that by a continued action of the mercury another quantity of bile might be forced out and secreted from the liver to the duodenum and the stomach. It was the acridity of this bile which caused the constriction of the pulse, and which sickened the stomach. Under these circumstances I considered it safer to effect its evacuation by a vomit than otherwise; and I consequently order­ed an emetic. It produced the happiest effects; for, at the close of the third day, the patient had scarcely any inflammatory symptoms, and en­joyed a visible remission of fever. His skin ap­peared moist; and his countenance was more cool and placid. All his sensations were agree­ably [Page 57]affected by the comforts of a good bed, and a room warmed and purified by a chimney fire.

It should appear, gentlemen, that our patient is now brought, from the most perilous state to the point of recovery. The moles movenda of the arterial system, and of the large infarcted vessels; have been relieved, and the contaminated bile evacuated. Thus, therefore, two important in­dications have been timely fulfilled; and the actual state of the patient appears to be that of the vis vitae, which always marks the beginning of the convalescence. But you will remember that the last indication has not yet been obtained, and that, within a certain space of time, it must be effected either by natural or artificial exertions. This indication has already been described as re­lating to the depuratory crisis of the whole flu­ids, when they have been more or less contami­nated; and it comprises all the secondary ones for the treatment of malignant and bilious remit­tents. It is beyond the power of medicine to abridge the courses and periods of these fevers. But, notwithstanding their different stages cannot be so accurately traced as would enable us to form a nomenclature, yet some general rules have been deduced; and, upon the authority of these, it must be allowed, that the bilious remit­tent, like the causos or febris ardens, must last four or seven days, and may even be protracted [Page 58]to nine or fourteen. Exceptions to this march are very scarce; and the case No. 6, which was perfectly resolved in three days, I never could account for in any other way than the following. By the primary effects of the contagion on the bile, the patient did not receive its secondary transmission into the blood, and had not conse­quently the elaboration of nature to suffer, but was cured as soon as the evacuations of the he­patic and cystic bile were obtained.

But, gentlemen, the illness of my young pa­tient did not end at the point I have last mention­ed; for I soon discovered another paroxism of fever. For the relief of this I prescribed gentle remedies, such as carminative injections and di­luting draughts; and previous warm bath had been applied to the inferior extremities and ab­domen. You will thus perceive, that I consider mild operations only as desirable, during the ex­acerbations of the fever, except that bleeding is requisite when its inflammatory characters are too high. In the present case, I could see no urg­ing necessity for venesection; for the bile had al­ready been evacuated, and the remission of the symptoms and fever had been regular and uni­form. Besides endeavouring to preserve the life of his patient, a physician should be careful in the use of those means which, by their frequency, may create other diseases, or render the convale­scence [Page 59]very long and perilous. On the night of the fourth day, the fever of the patient was so violent, that, in his delirium, he got up and went naked into several corners of the house. How wonderful, gentlemen, are the exertions of Na­ture when she is properly assisted! As soon as this exacerbation was over, the patient had seve­veral copious discharges of bile; red petechiae were observed on his breast and arms; and his salivary glands being a little affected, he had a salutary and frequent spitting. The crisis pecu­liar to the malady was now beginning to appear. The redness of the skin began gradually to change to a whitish hue, which I judged would, at a pro­per time, turn yellow. What were then my ob­servations; what was I to do; and what had I to expect? The revulsion of the blood from the veins into the arterial system was certainly finish­ed; and the corrupted bile, by which the liver was infarcted, was secreting and diffusing partly in the bowels, and partly in the blood. Mercurial dras­tics were still necessary; and, by their means, I again procured copious evacuations of yellow bile which was probably from the liver. On the fifth day, the yellowness was visible; a quantity of this stagnant bile having mixed with the blood. It was then necessary to accelerate and stimulate the circulation by sudorifics and tonics; and the stomach, being languid and exhausted, some restorative and nourishing substances were [Page 60]to be administered. Thus, from the fifth to the sixth day, the patient was assisted, and enjoyed some natural sleep. His fever had been very moderate and attended with but little delirium. On the sixth, observing no further existing cause of irritation, I ordered a mild nitrous cathartic to keep up the motion of the bowels, and to prepare, by natural evacuations, if possible, the approaching final resolution of the malady. This took place, during the night of the seventh day, by an equal and profuse perspiration, by copious urines, containing a thick yellow sediment, and by repeated discharges from the bowels.. I then desired that the patient should be put in clean linen and in another bed. I must not, however, omit observing, that the sheets and clothes with which he had been covered during the last days of his illness, were spotted with a kind of yellow purulent matter, and had a very offensive smell. This circumstance is always a striking proof of the final depuratory crisis terminating a malig­nant fever, and more peculiarly exhaling the contagious miasmata of the yellow fever.

From this moment, the patient could not, with any probability, experience any further exacer­bations of fever; and he wanted no further as­sistance than such as is necessary to convale­scents. He was in this state during five or six days, and a gradual nourishment, with two grains of [Page 61]opium, given at night, were for some time adminis­tered. This remedy is very restorative after acute and dangerous diseases. It calms the general ir­ritation of the viscera; it fixes the oscillation of the nerves; it procures repose and comfort; it gives some tonic power to the alimentary chan­nel; and, infine, it helps the dispersion of the yellow serum remaining in the cellular mem­branes.

A scrutinising perusal of the preceding case, will, perhaps, gentlemen, afford a better idea of my method of treatment of the yellow fever, than any treatise I could give. I shall, therefore, con­clude this section with the following propositions.

1 st. The pathology of the yellow fever sug­gests three indications to be observed in the me­thod of treatment. The first is the speedy eva­cuation and renovation of the corrupted and acrib bile; the second, to counteract the pro­gress of inflammation and to discuss the conges­tion of the large blood vessels, which cannot dis­charge into the liver; and the last, to assist the depuratory crisis of the whole system, which is to be effected within a certain space of time, and by natural or artificial means.

2 dly, The calomel is a specific of unexception­able success, to evacuate the hepatic and cystic bile; provided its action be directed towards the [Page 62]bowels, by being united with other drastics. As a sialagogue it may be favourable: and the mer­cury, applied externally, cannot be useful but in the last indication.

3 dly, The first indication will be also success­fully assisted by the use and action of an anti­monial emetic; but, before this and the calomel could be efficaciously administered, the systom must be brought to a considerable relaxation and tem­porary cessation of the inflammatory symptoms.

4 thly, Profuse and repeated bleedings are the only sure means of abating the inflammation, and of fulfilling all the views of the second indica­tion, which occur at the exacerbation of the fe­ver. There may, however, be some advantage in sparing the blood; but, during the three first days, not to take enough of it would be fatal.

5 thly, The last indication requires all the me­dical rules for the treatment of malignant fevers within a certain space of time; but the two first must be completely observed within three days; for, in the latter period, the contagious miasma­ta may already have contaminated all the animal fluids and mortified several viscera.

6 thly and lastly, With the above indications, rules, and remedies, in conjunction with the fol­lowing practical cautions, the treatment of the [Page 63]yellow fever cannot fail of success, if the patient be free from previous complai [...]ts of diseased vis­cera or vitiated constitution.

SECTION IV. Practical Cautions for the Treatment of the Yellow Fever.

THIS was one of the cautions laid down by the immortal father of the medical art, who was possessed of all the treasures both of judgment and experience. ‘All that is too much is contra­ry to Nature;’ and even our important disco­veries of a specific and of remedies for the yellow fever, will become dangerous if we administer them without proportion or restraint. I shall, therefore, gentlemen, proceed to consider a few important cautions in venesection and the use of mercury for the cure of the yellow fever, and then enumerate such other objects as relate merely to the patient.

It is a well authenticated fact, that frequent success has attended profuse blood letting in the yellow fever. If the injudicious and illiberal at­tacks [Page 64]that have been levelled against it during our late calamity, have destroyed the confidence of some of the patients and their attendants, it has been owing to the force of ridicule which is too apt to seduce unreflecting minds. But time and expe­rience lead to truth and will surmount every ob­stacle. When the celebrated Moliere had, by se­veral dramatic pieces, painted the medical pro­fession in the most ludicrous colours, the public laughed at the ignorance of pretended physicians. But the result was, that a more just discrimina­tion was afterwards made between them and practitioners of genuine respectability. However, the public will doubtless readily acknowledge that facts and principles will always stand forth against every sarcastic assailant. To those who think that indiscriminate bloodletting was recommen­ded as a specific in the yellow fever, we would remark, that the principles held out by physici­ans, ought always to be examined with imparti­ality and attention. We say, it is true, that, for the cure of the yellow fever, we must bleed early and as copiously as fifteen or twenty ounces at a time; that, in each exacerbation of fever, during the three first days, bleeding ought to be free in proportion to the apparent inflammatory symptoms or elevation of the pulse; that the stagnation of the bile in the liver and other vis­cera infarcted, suspending the circulation of the blood in the large vessels, ought partly to be [Page 65]considered as an immediate cause of mortifica­tion, and partly requiring a great depletion of blood; that the power and efficacy of mercu­rial drastic doses, being always in a ratio to the relaxation of the system, it will be previously ne­cessary to relax by bleeding, and this perhaps as often as they are administered; that the measure of bloodletting has no bounds but that of a visible and favourable change, and no terms to its reiteration, but the marked period where the effects of the malady are irrevocably fixe [...] for death or recovery. After admitting these ge­neral rules, two cautions arise from pathological principles, viz. the time of bleeding and the quan­tity of blood to be taken. If venesection pro­duces such powerful changes in the equilibrium of the animal fluids, and if it relaxes the solids, we ought not to have recourse to it, without a strict attention to the stage of the malady, to the exacerbation of the fever, and to the formation of certain crises. 1 st, During the three first days of the fever, this remedy will doubtless answer all the aforesaid indications and purposes; but, when the effects of the contagion are diffused in the viscera and blood, as is generally the case after the third day, bloodletting may answer very well for certain secondary symptoms, but would then be useless for primary indications; and even if the patient was likely to recover, such means as have an enweakening tendency, would only retard [Page 66]the favourable event. Hence arises the practical caution of sparing blood, if possible, after the third day. 2 dly, As the exacerbation of the fever ex­hibits all the extent and degrees of the inflam­matory symptoms, it affords the best opportunity of judging of the necessary quantity of blood to be taken. At this period, also, the blood-vessels are infarcted or are in a state of congestion; while, at any other, nature seems to rest, and it is perhaps better to let her help the patient with­out disturbing the crises and operations of the fe­ver. Hence arises the practical method of bleed­ing at the very moment of exacerbation; but sel­dom before and never immediately after. For, in the first case, we may retard it, when it is essentially necessary, and in the second, we intervert its ef­fects and render them incomplete. 3 ly, We have already noticed, that the admission of the bile into the blood, the hemorrhage, eruptions on the skin, &c. were crises of the disease, and that when one or many of them take place, the fate of the patient is decided. If he has not, how­ever, been bled, before these symptoms take place, it is seldom in his favour; and if a case should happen, in which nature, without the assistance of bloodletting, should effect the resolu­tion of the disease, it must be owing to the un­corrupted state of the whole mass of forces and fluids. If then, these happy effects can be as­cribed to such a state, we must be careful not to [Page 67]commit the issue of a recovery, or create irrepa­rable accidents, by a diminution of these forces and fluids. Hence arises another practical caution of sparing the blood after the appearance of one or more of the crises. It would be very difficult and almost impossible to trace all those circum­stances, which are to be discovered and deter­mined by accurate attention and judgment. One instance, however, in the case of T. B. above related, may serve to illustrate the caution upon bloodletting. His situation seemed to require a third bleeding, and but little danger could have resulted from it. It will be remembered, that he had been copiously bled at first, while in the country, and that, deprived of any further ad­vice, he remained without medical assistance till the latter end of the second day. At this time, he was in the most alarming situation, and I wai­ted anxiously for the second exacerbation, which took place in the night, and indicated a second copious bleeding. Its effects were so favourable, and it produced so happy a change, that, at the time of the approach of the third exacerbation, I was convinced it would be regular, and not at­tended with too much inflammatory diathesis; for the patient had still continued to evacuate bile. I then left it entirely to the forces of nature. It was indeed violent; but its effects presen­ted regular crises as far as medical rules designate. Infine, I concluded, that if this last [Page 68]exacerbation could, without bleeding, be atten­ded with many favourable symptoms, I might continue the treatment without using it any fur­ther. I afterwards received the greatest benefit from this reserve; for it rendered the convale­scence of the patient very short. This generally is the case with those who lose but little blood ^*. (Vide case 7.)

The exhibition of the calomel, in the yellow fever, will present to us more important and un­objectionable grounds of caution, when we re­trace the different modes of the operation of this precious medicine, in order to confine its use to what absolutely requires it. We have seen that, as a drastic purge, it was particularly adapted to the excretion of the hepatic and cystic bile. To this striking circumstance, we cannot help ascribing the repeated success of those physicians who first recommended the use of this medicine. We are [Page 69]also acquainted with its effects as a sialogogue or salivating remedy; since many physicians have thought that this kind of operation could be pro­duced by it only, and could be depended upon. Infine, the use of mercury, in the form of oint­ment, has been applied in many cases of the yellow fever, and I shall therefore, examine whe­ther it will thus answer some useful purposes or not. From these preliminaries, gentlemen, I shall derive only one proposition, for practical caution respecting the use of mercury, including all my own rules.

The calomel, or mercurius dulcis, should never be administered as a salivating remedy in the yellow fever. It is sufficient to direct its action towards the bowels by the help of other powerful drastics. It will assist the crisis of the suppuration of the paro­tids if it can take place. The external application of mercury will not effect an evacuation of the bile, and could not answer but for the depuration of the system if the patient had not exacerbations of fe­ver; but in this hypothesis the remedy must prove useless and dangerous.

Several important questions arise from the preceding proposition. What are the objections against the salivating method? Is the crisis of the swelling and suppuration of the parotids differ­ent from common salivation? Can it take place [Page 70]in the yellow fever without the action of mercu­ry? If it is a successful crisis, why do we avoid exciting it? And finally, if a mercurial prepa­ration, taken internally, is allowed to be a good specific, why does another simple mercurial pre­paration, applied externally, prove useless or dan­gerous? Let us now resume each of these ques­tions, and candidly investigate them, unattended with a lengthy and scientifical collection of au­thorities, with which I suppose my medical rea­der well acquainted. In every kind of complaint there is not one of those revolutions or admira­ble crises in the frame, which are excited by the combined action of remedies, with a view of ob­taining a cessation of the disorder, that is not an exact imitation of what the natural and spontane­ous laws would accomplish, if they were not ob­structed. The best, therefore, we can do is what nature frequently operates without our assistance, and often before it can even be obtained. Thus, among all the singular circumstances to be re­marked at the end or resolution of malignant fe­vers, the swelling and suppuration of the glands and parotids has been noticed as one of the most favourable crises, and I have already observed that Pouppe Desportes, in his description of the malady of Siam, had particularly noticed its final and successful operation. To his authority I could subjoin that of many physiological writers. Ex­perience also has exhibited to me several instan­ces [Page 71]of the most perfect and successful suppura­tion of the parotids, in the yellow fever, with­out much mercury or none at all. (Vide cases No. 8 and 10.) I do not doubt, gentlemen, but to this crisis, which is not uncommon, we are in­debted for the consistent and bold attempt of the physicians who first discovered the success of ca­lomel in the yellow fever. They did not perhaps notice, that it cured by its drastic power, and that a succeeding suppuration of the parotids was rather a spontaneous crisis, than the effect of the remedy. But if this be so, there are others also which spontaneously prognosticate a perfect cure in all malignant fevers, as well as in our epide­mic. These are yellowness, profuse evacuations from the bowels, hemorrhages, transudation of cor­rupted blood from the lips ^*, &c. All these crises, [Page 72]which are equally good when they take place at a proper time, appear various in different kinds of malignant fever. Thus, the yellowness is particularly characteristic of our fever, and the lymphatic swellings, in the same manner, desig­nate the plague, &c. But, if in both diseases, the suppuration of the parotids could be excited, by art or nature, the one would not be attended with a jaundice, nor the other with a swelling; for there is never more than one crisis peculi­arly spontaneous. The most convincing proof, however, that the suppuration of the parotids ought to be considered as a spontaneous crisis in this fever, may be derived from the observa­tion which every practitioner must have made on the progress, stages, and space of time, through which a salivation is commonly artificially ob­tained. Few instances are found, even among de­licate patients, in which it breaks out in less than eight days, and it generally takes two or three weeks. As much time is afterwards neces­sary to obtain, by it, a cessation of the existing symptom or disease. Now, it must be remem­bered, that five or six days only embrace all the periods and issue of the yellow fever. Conse­quently, if a suppuration of the parotids takes [Page 73]place, it will rather be spontaneous, than be the result of a few doses of calomel; for the course of the disease is too rapid to depend upon its salivating effects. But if the crises of a swelling and suppuration of the parotids is to be consider­ed as a spontaneous result, peculiar to one indivi­dual, and not to another; if it be a mere chance to receive it, as well as to be favoured with another as hemorrhage, flux of the bowels, &c. will it be prudent to administer the calomel as a salivary medicine only? Will not the safety of so rapid and violent a disorder be committed to an un­certain effect? And will not the treatment be ren­dered an obstacle to such means as nature em­ploys to get rid of the imminent morbid cause?

To enforce this argument, we must examine what indications, facts, and theories, have united in support of calomel. This medicine has un­doubtedly a peculiar efficacy in evacuating the bile, and in cleaning the infarcted liver; and I trust that no systematic practitioner will deny the truth of this fact. Why then do they prefer an uncertain operation to that which is as easily and as well produced in all subjects? Why would they endanger the issue of the malady, by fixing the whole effects of the mercury upon the primae viae, in order to confine its action on the saliva­ry glands only, and thus render it useless in the evacuation of the specific contagion, at a time when [Page 74]the most urging necessity calls for it? Why would they give time to the poisoned bile to injure its reservoirs, and then, by pouring into the blood, infect the whole system? Why would they believe that the evacuation of that specific contagion can be better effected by means of the salivary glands than by the natural excretory organs, as long as its sources in the viscera are not emptied? Such, however, would be the effects of adopting exclu­sively the idea of salivation by calomel for the cure of the yellow fever.

In dwelling a little longer, upon a subject of so much importance, I do not, gentlemen, fear to be tedious; and I trust I shall be excused when I attribute many unsuccessful instances of our treatment of the yellow fever, by calomel and bleeding, to the neglect of the considerations I shall now submit to your attention. I have alrea­dy observed, that when the hepatic and cystic bile are evacuated, the system remained more or less infected; because the large blood vessels, which pour into the liver, and receive its blood again, must have washed off enough of the con­tagious bile. I also stated, that to repair such ef­fects, a general depuratory crisis was afterwards to take place, within a certain space of time, and by natural or artificial means. As this physiolo­gical rule cannot be denied, it must be acknow­ledged, by every practitioner, that it would be [Page 75]impossible, as well as improper, to excite, in every patient, the same final and depuratory crisis. They will remember, that, in a woman, it may, perhaps, take place by a discharge from the ute­rus, and in men, by perspiration, hemorrhages ^*, evacuations from the bowels, &c. The discove­ry of what will be the tendency of the patient, and by what crisis he will be finally assisted, re­mains consequently with us. When this is made, we shall be obliged again to acknowledge, that the calomel, when administered to salivate, will, in many cases, counteract the march of the dis­ease; and that it will obstruct every crisis, but that of the mouth. A purge counteracts the sa­livation, [Page 76]while the latter has the same effect upon all that can be obtained by hemorrhages, pers­pirations, &c. It follows, therefore, that, if the patient has neither time or a natural tendency to undergo the operation of salivating, this means would be contrary to the cure of the yellow fever.

The practice of exciting a salivation, for the cure of several diseases, will better explain its equi­vocal effects in the yellow fever. By it, the morbid cause is transported from any part of the body or from the blood, into the salivary glands, from whence it is insensibly washed out, attended with a most offensive smell; and the mercury secretes, by these glands, a great quantity of saliva. Should others give a different explanation of this phenome­non, yet we must all agree as to the fact, and this is sufficient. It cannot be denied but that the affection of the mouth varies afterwards very much among different individuals, and although this circum­stance cannot be accounted for, the results may be satisfactory and have the desired effect. There are patients on whom the greatest quantity of mercury has never been able to affect their mouths. Some receive an easy affection in the sublinguals and maxillary, but their spitting is unattended with a swelling of the parotids, and consequently has no critical good effect. The state of the teeth, their being covered with ear­thy scales, or much decayed, and previous mala­dies [Page 77]of the gums, may, in many cases, render the action of the mercury so painful and even dan­gerous, by hemorrhages, that the course of the medicine must be interrupted, without fulfilling the adopted intention. Infine, the practice of ad­ministering mercury, without salivation, by the means of certain precautions, recommended by many physicians as equally successful and safer in the results, are considerations sufficiently pow­erful to make us disapprove of the salivating me­thod in a disorder so rapid, and the malignancy of which, might be conquered by less equivocal means.

Resuming my former proposition, I recom­mend, as an important caution, that calomel should never be administered by itself nor in the method or proportions intended for salivation; that, on the contrary, it must be but about the third part of a drastic mixture, by the means of which it will immediately be diffused into the bowels; and that, if, in spite of jalap, scammo­nea, or gamboge, it is retained too long without operation, an oily cathartic, or some neutral salts, should be given to prevent the mercury from as­cending, and to enforce the bilious evacuations, the importance of which has been sufficiently proved. This method leaves always time enough for the crisis of the mouth if it is necessarily in­tended by nature. It helps it sufficiently, and it [Page 78]even accelerates its appearance, and gives it all the characters that can render it perfect and sa­lutary. Such cases have occurred to me in the proportion of one out of ten ^*.

Few observations remain against the external application of mercurial ointment. Admitting that it tends to the purification of the blood, what will be thought if the original cause and the foam of contagion are not destroyed? The reservoirs of the bile are not emptied by mercu­rial frictions. This remedy, therefore, cannot an­swer any good purpose, except after the first pe­riod of the disease, when previous evacuations have been accomplished. This hypothesis, how­ever, [Page 79]would still be liable to considerable objec­tions, such as the exacerbations of the fever, and the turgency of the blood-vessels, which never fail to manifest themselves as soon as the mer­cury is admitted into the circulation. The first would be considerably counteracted by mercu­rial frictions, while they are necessary to termi­nate the malady within a certain space of time; and the other would become precisely one of its most dangerous symptoms, and would be renew­ed and settled before we could have time to op­pose it, or to obtain any decisive and good result. I saw, in the last prevalence of the fever, a ro­bust young man, in the fourth day of his sick­ness, who had been regularly rubbed with mer­curial ointment. The excretory evacuations had been neglected; he had not the least affection of the mouth; and he died on the fifth day.

Some practical cautions respecting emetics also demand our attention. I have already stated their usefulness in emptying the stomach and duode­num, when, in the course of the first period, these viscera are sickened, notwithstanding every other application has been successful. If the mercury, in short, promotes the secretion of the bile from the liver, this favourable operation is immediate­ly followed by a sickness of the stomach, and then the emetic is necessary. (Vide case No. 7.) In many instances, the patients discover a great [Page 80]aversion to this remedy, and if they are of a delicate nervous constitution they frequently re­fuse to take it. In such cases I employ an equiva­lent remedy, strongly recommended by the inge­nious Mr. Dubois de Rochefort, in his Materia Medica. He calls it un emetique cathartique en lavage. One grain of tartar emetic, or one grain and an half at most, is to be dissolved, with half an ounce, or three drams, of salt of Glaubert, in about two pounds of water. The patient is to drink it by tumblers full every hour. This medi­cine is not nauseous; it seldom excites vomitting; and it is always sure to empty the stomach and bowels downwards. It is a general observation in practice, that the patient should, in all acute dis­orders, be prepared, by various depleting reme­dies, for all the subsequent operations. But we must cautiously avoid giving of pukes in the be­ginning of the yellow fever, and particularly so if a profuse bleeding has not immediately preceded it. Indeed, the turgency of the arterial system is then so great, that the convulsions of the stomach may have dreadful consequences. I have fre­quently seen them followed with such fatal acci­dents, that I think it my duty to mention the ne­cessity of a cautious reserve ^*.

[Page 81]Admitting the above practical cautions to be adopted by those physicians, who, with great pro­propriety, have chosen calomel and bleeding for the cure of the yellow fever, still, gentlemen, if the patient labours under the complaints of diseased viscera and vitiated constitution, or if he has not made timely application for medical assistance, they are not sufficient. Under this two­fold consideration, every impartial judge will make due allowances for the medical art in un­fortunate cases of death. It is too true, that, during the prevalence of a dreadful and conta­gious epidemic, confusion and despair, seclusion from intercourse, and erroneous opinions on the first symptoms of complaint, expose the patient to dissident delays and improper measures; but experience and the warnings of physicians, ought to teach our fellow citizens the importance of an early application to medical aid, in the cure of one of the most malignant disorders that ever was known among nations. In cases where the disease would have gone through its periods in the [Page 82]short space of three days, one day lost proved fatal. Those also, in whom the malady was of longer continuance, and who remained unassisted during the first days, found, alas! a similar fate. Let no one, therefore, for his own sake, be careless about any slight instance of complaint which he may experience during the prevalence of an epidemic; for, although various degrees of bilious or other complaints may appear, and though their mildness may have nothing common with the rapid and malignant effects of the former, yet, at the first call, the physican himself feels obliged to employ all the energy of his practice, notwithstanding he sees but partial and suspicious symptoms. His severity of judg­ment and prescription, will not be attended with dangerous consequences; but will happily pre­pare the proper treatment for any unexpected ma­lignant case.

In order to illustrate the importance of an ear­ly application to physicians, during the season which unfortunately creates all degrees of bilious, remittent, and malignant fevers in these climates, I shall familiarly relate an instructive instance of errors of judgment, in a case of apparently com­mon and trifling indisposition, and of the inutility of medical aid when applied for too late. To­wards the close of our late calamity, I was sent for by the wife of an unfortunate husband. [Page 83]From motives of the most unequivocal tenderness and affection, she unhappily deprived him of such timely aid as would undoubtedly have saved his life. "During four nights she had not left his bed­side. Persuaded that she knew, by experience, his indisposition, she continued all this time to give him such remedies as she thought proper. She re­fused at first to admit me into his room; for the frequent visits of physicians to infected houses alarmed her very much. She said that she had been so secluded from any kind of intercourse with others, that, thank God, the yellow fever had spared every one of her family. She obser­ved, that she had called me for some advice re­specting the indisposition of her dear husband; but she was happy to think, that there would not be much occasion for medical aid; for, since she had sent her message, he appeared to be on the point of recovery. He was up, walking about the room; and he intended, next day, to ride out to the country." This last circumstance, struck me with the apprehension that this was the last day of the life of the patient; and, that I might be better able to judge, I requested her to give me an account of his indisposition from the begin­ning. "He was taken, she replied, with a slight fever and puking, owing to a little intemperance on the preceding day; and his head ache and pain in the limbs, she knew very well, proceeded from a violent cold, which she always cured with sweat­ing [Page 84]tear. She had afterwards given him a few pills, which operated faithfully, and the pains and fever happily subsided. The patient had, last night, puked something of a black colour; but she did not wonder at it, as she had previously complied with his wish of giving him some coffee and toas­ted bread. He now felt very easy, though a lit­tle weak, which was of course; and she could not expect him to be better. In short, she had at­tended and nursed so many sick, among friends and relations, that she was sufficiently acquainted with the necessary management and cautions!!" I cannot tell, after such a recital, which struck me most, the innocent confidence of the wife, her un­suspecting ignorance, the irrevocable fate of her husband, or the painful task which devolved upon me, of destroying so many erroneous opinions, and plunging, by one word, the whole family in the most unexpected distress. My silence was in­terrupted by the patient, who called us up, ex­pressing some uneasiness and wishing to lie down again. His pulse was small, tense, and intermit­tent; and a black instead of a yellow hue was suffused all over his body. The confusion of his look, was highly expressive of instant danger; and being suddenly taken with the most extreme weakness, he could hardly answer to but few of my questions. His wife was now seized with asto­nishment; and, taking advantage of the circum­stances of the moment, I retired with her from [Page 85]the presence of an object who was every moment becoming a more deplorable proof of her blind­ed confidence—a victim of a culpable security— an object whom she saw no more! But if this singular case, the error of which cannot be ascri­bed to neglect, may appear rare; yet how many others have I seen, and how many deaths may be attributed to parsimony, indifference, and the want of timely medical assistance!

The last subject of practical caution, gentle­men, that has occurred to me in the treatment of the yellow fever, is still more serious than the preceding ones, and of more certain fatal conse­quences. In other acute disorders, a physician may perhaps find out some means of relief, and calculate by them a successful mode of treatment, notwithstanding the patient may labour under pre­vious complaints of diseased viscera or injured constitution; but in our epidemic there is no such prospect, or at least it is very faint. During the two periods of its prevalence, I never met with an instance of recovery from it, when the whole frame had been materially injured by certain causes. A pulmonic affection, however, when not too far advanced, would not, I believe, readily present an obstacle to the cure, as I have once seen exemplified; because the proximate cause of our fever lies entirely in the bile and alimenta­ry channel. But I shall always despair, at the first [Page 86]view, of those who have considerable obstructions or congestions in the liver, or who have unfortu­nately kept in their constitution any scorbutic t [...]int or remains of syphillitic contagion. On the dreadful effects of this last, in the malignant yel­low fever, I shall present you a few important re­flexions; and that they may be carefully contemp­lated by my young readers, is the philanthropic wish dictated by too many fatal instances. It has been evidently remarked, that the epidemic acted most severely upon young and robust men, and that its victims were chiefly of that description. This is a positive fact, the elucidation of which will not appear strange, when it is remembered that it is not easy to get rid of the poison receiv­ed in the embraces of prostitution; that many methods for its cure are truly deceiving; that some noble viscera may, by it, remain essentially diseased; and that the blood, which contains its particles, will be sooner and unavoidably conta­minated by another contagion. The most fa­vourable symptoms do not always justify the con­fidence either of the patient or physician; for we are unacquainted with all the changes and shapes of a malady which has been justly termed a Proteus or a Cameleon ^*. We are daily taught by experience, that, by the cessation of one of its symptoms, we are not to judge of a perfect cure. It [Page 87]deceives us and the patient also; for it often lurks within the body, without diffusing into the blood, or producing any mark of infection. Since there are external swellings and various sorts of tumours which we attribute to the venereal lues, why should we doubt but that they may exist in­ternally, or within some noble glands? How of­ten, indeed, the prostrate gland remains ulcera­ted, swelled, and tumefied with exuberances, af­ter the improper cure of a gonorrhoea, by strong astringents, I leave those to determine, who are acquainted with the precious enquiries of two famous surgeons on that subject, Petit of France, and Hunter of England. In these cases it is very easy to appreciate, without further explana­tion, what will be the effects on the secretions of the urine, on the functions of the kidneys, and on the bowels. To such internal and chro­nical causes, we must ascribe the numerous ob­stinate and long complaints, which baffle medical skill until their primitive cause is cured. Mania, hypocondria, epilepsy, and the long list of ner­vous complaints, may originate from the simple irregularity of secretion of urine into the kidneys; for a part of that fluid remaining in the blood, must afterwards affect the whole, or at least a part of the frame. But such circumstances have a deci­ded effect in acute, malignant, and contagious fe­vers. The violence of the first symptoms is an additional evil to the enweakened viscera; for [Page 88]by it they are immediately brought to the brink of destruction. The struggles, the exertions, and the efforts of nature, are then soon exhausted; and if there is a scale of the natural degrees of health, of those which may be depended on above it, and of those under which the phenomena of life ceases, what proportion remains for medical expectation and skill, when such complicated causes absorb the whole balance of what is term­ed excitability by one, and what is thought to be the whole extent of natural laws by another? Were it not a point of delicacy, gentlemen, for a practitioner to produce reflections on com­plaints, that, according to the opinion of many, would blemish the memory of the dead, I would support this discussion with the evidences of ma­ny cases. May those who are apprised that youth and robust constitution have been so cruelly ex­posed, to the deadly blows of the malignant scourge, bew [...]re of the enticements of prostitu­tion, and oppose them by the dictates of reason, religion, decency, and self-preservation.

SECTION V. General Means to prevent the Generation and In­troduction of the Yellow Fever.

Two contrary opinions have appeared on the origin of the yellow fever, and have been officially transmitted to the executive, by medi­cal bodies of Philadelphia. An attentive public, who know that truth cannot be contradictory, must doubtless feel deeply concerned; and will regret that, after repeated calamities, no unanimous im­provement should be made among the learned on so interesting a subject. Under these circumstances it becomes necessary, that, while measures are adopting to prevent its importation, the probability of its domestic generation should not be forgot­ten. The public precautions should not be foun­ded solely on the particular opinions of either p [...]rty; and experience may hereafter afford us sufficient and such unexceptionable proof, as will leave room but for one opinion upon the subject. I do not, therefore, gentlemen, disap­prove of any measures that may be adopted to prevent the imp [...]rtation of the yellow fever; on the contrary you will discover that the above theory has a sensible advantage over the latter, [Page 91]for it also admits of all the necessary precautions against the effects of noxious exhalations from the holds of ships or vessels arriving from tropi­cal countries in the hot season of the year. If we do not implicitly believe that this contagious epi­demic is imported from one country to another, like the plague or the leprosy, still we admit that it may possibly originate on board of ships during a long passage, which contain animal or vegeta­ble substances in a state of fermentation; that, raging contagiously among crews from tropical islands, when the remains of them come to mix with our citizens, it may spread its infection among them, and chiefly during the hot season of the year; and that, infine, when a contagious distemper is known to rage in any part of the world, our intercourse with it should be cautions and subject to lawful controul. Thus far, there­fore, we coincide in the measures of the implicit believers of local importation. We desire, how­ever, above every thing they have as yet sugges­ted, to fix the observation of our fellow citizens on the domestic sources of contagion to which they are exposed. These are self-evident, and demand our most pointed attention. Why then are we taught to look upon them with indifference, and to confine our researches exclusively to the ship [...] and men that arrive in our harbours, from distant countries, which at least h [...] considera­bly purified by the [...] of the seas?

[Page 92]In order to proceed regularly from the propo­sitions I have above stated, I deduce the follow­ing means to prevent the introduction and gene­ration of the yellow fever. "I have already proved, 1 st. that it was generated by putrid effluvia from vegetable and animal fermentation; and 2 dly, that the opinion of its importation could not be admitted exclusively to its spontaneous ge­neration, in every warm country, from the above-mentioned causes." It of course follows, that to oppose the possibility of its importation, and of its breaking from corrupted cargoes, it would be expedient to remove such ships from our shores as are loaded with colonial produce, at least du­ring the months of June, July, August, Septem­ber, and October. The rule for admitting these articles should be defined according to their good or corrupted state, a few days after the ships have been unloaded. No intercourse with their crews should be permitted during five days af­ter. But if a vessel is supposed to contain corrup­ted miasmata, and authenticated cases of any kind of bilious fever should be found on board, the sick ought to be removed to a distant hos­pital, and the ship and company perform a qua­rantine of ten days.

As the outlines of the rep [...] of the committee of the legislature of this state, during the present session, are chiefly founded [...] the belief of the [Page 93]foreign origin of the yellow fever, there is no doubt but such efficacious measures will be adop­ted as will prevent the dangerous effects of cor­rupted cargoes and waters in the holds of ship­ping. I shall, therefore, confine my observations to an examination of the means which experience will hereafter dictate to be exclusively adopted against more threatening causes of contagion.

Philadelphia, situated on the west bank of the Delaware, and on the narrowest space between the Schuylkill and that river, may be wholly de­signated in the form of a parallelogram, the squares of which are intersected by wide cross-streets, which raise very little, in certain points, from the south to the north, but which are open to all the winds, and to all the emanations of [...]e surrounding fields, ponds, marshes, and swamps. The conveniencies of foot ways, their cleanness, and the uniform practice of the inhabitants in fre­quently washing the outside of their houses, give to the city a singular appearance of regularity and neatness highly admired by foreigners. It contains, however, some capital defects; and too many unfavourable circumstances concur to in­jure its salubrity. Water-street, thirty feet wide, extending from the northern liberties to Pine-street, parallel with the course of the Delaware, is in a confined low situation. Though the whole of its extent, it has but few vacancies, is com­pactly [Page 94]built, very disagreeable, and is totally de­prived of back yards on the side of Frount-street. The same is to be observed with respect to Penn-street. It likewise runs along the river from Pine to Cedar-street; and, in the late cases of epide­mic, both have been particularly marked as the first seat of the disease. The main height of the ground on which the city stands, is nearly forty feet above the Delaware. Many streets are, how­ever, lower; and, consequently, the adjacent ground, intended for the continuation of the origi­nal plan, is in many places marshy. Some parts of it contain large and de [...] and the [...]e stag­nant waters are to be see [...] in almost all the points of the circumference of the city.

The general convenience of shipping to which Philadelphia is indebted for her rapid increas [...] of wealth and population, has rendered her whatever necessary. They are composed of made groun [...] formed by the means of log casements filled with earth and stones; and they extend along the front of the city and suburbs to the distance of about two miles. As I shall, in the course of my observa­tions, avert more particularly to this circum­stance, I shall now observe that they are elevated above the highest tides, so that at low water, their vertical sides are exposed, for near five feet, to the rays of the sun. In the Northern Liberties and the district of Southwark, there are many [Page 95]vacancies on the banks of the river. Owing to the periodical floods, these form large miry grounds, which are never dry, but covered either with thick beds of filth from the adjoining streets or habitations, or with rubbish, old timber, &c. These sources of exhalation are not of the most indifferent consequence.

Our city is supplied with no running waters or fountains, and but few cisterns are to be found in private houses. Wells only are dug, in distri­butive number, in different parts of the city and suburbs. A pump is placed in each well, and wa­ter is thus easily obtained for all the wants of life. A gutter, formed by the elevation of the foot way, and by the gradual descent of the street to each side, seems sufficient to receive and carry down the dropping waters. [...] declivity of the streets, in some places, however, is worn down; and the waters stagnate, more or less, in all the gutters. During the heat of summer, they re­ceive the filth from the houses, and become very noxious for want of being drained, and more es­pecially so, since they are daily reserved by the pumps. The inhabitants seem generally indiffer­ent about these waters, because they do not see but small ponds of black and green water; but, as they are repeated, I am persuated that they add much [...] the quantity of putrid and [...] whole­some exhal [...].

[Page 96]There are twenty-eight houses for public wor­ship in Philadelphia, and I believe as many grave-yards within the city and suburbs. It seems yet to be questioned whether they are really of a noxious nature or not. It is said that, as the graves are usually dug to the depth of six feet, the health of the citizens cannot be injured by them. Even admitting this observation to be true, yet, if dangerous vapours cannot immediately rise from the grave-yards, by the effect of the heat, they may otherwise be disengaged, by the hydraulick laws of subterraneous waters. For, supposing a grave-yard in a very elevated part of the city, as that of the Friends, at the corner of Arch and Fourth-streets, which is besides near five feet above the street, within a stony enclo­sure, it will be granted that the dead are on a level with many different parts of the city, and in some cases even above it. Now, since it is ac­knowledged that the greatest elevation of the ci­ty from the river is forty feet, and that many of the grave-yards are on the highest grounds, it will evidently appear, that the inhabitants liv­ing in a lower part of the city, will receive ex­halations from the earth, of moisture and waters that have been infiltrated through an elliptic plan and through a vast number of dead bodies. This observation will be found to agree with the hy­draulick laws; for, according to them, in satura­ted grounds, evaporation collects the waters by [Page 97]infiltration from higher surrounding points in the same manner, that, to obtain water from the the highest parts, we dig for its evacuation at the lower ones. This explanation, gentlemen, will shew how the evaporations in most of the low parts of our city, are rendered noxious by the putrefaction of thousands of dead bodies, and may be carried from one point to another, by means of the grave-yards being intermixed with our dwellings, besides their immediate ef­fect in altering the waters collected in our wells.

Lastly, we have a more dangerous source of putrid animal exhalations, which is more sen­sibly discovered in thickly inhabited places af­ter the heat, and at the close of summer.

Each dwelling has a privy-house, situated at the farthest end of the yard; and the houses on the east side of Front-street have them in their cellars. The ditches upon which they stand, are dug to a considerable depth and built round with stones or bricks. Many of them are twenty fee [...] deep, but this circumstance removes still further the idea of cleaning them. After many years the fermentation causes of­fensive vapours during the summer; and it is very seldom the case that the ditches are clean­ed more than once in ten years, when it is of­ten [Page 98]considered casier to fill them with stones, and to dig others. The fact is, gentlemen, that towards the end of the summer, that is to say, after the action of the heat has sufficiently ex­cited fermentation, mephitic gas ascends from the ditch. Our inhabitants are so well apprised of this, that they always provide their little-houses with a vent hole. This is a proof that the depth of the ditch is not a preservative a­gainst its noxious vapours; for the rarefaction and the heat of our atmosphere could raise them from a much more distant centre. The absorption of the within contained fluids is so slow, in moist and impregnated grounds, that they wholly remain and serve to accumulate the mass of fermentating animal substances. If a lighted candle be lowered into one of these ditches, by means of a line, it will often be put out; and when the temperature of autumn does not oppose the dilation of the ascending gas, it is plentifully diffused round the houses, yards, and alleys, where it is often sensibly smelt, chiefly when the air is calm and sultry.

After the enumeration of so many causes and dangerous sources of putrid exhalation, will not our minds, gentlemen, be impressed when the reflection of Dr. Lind, that, "next to infection, the most frequent cause of fevers [Page 99]is perhaps the offensive and polluted air in un­healthy places;" and that our calamity, perio­dically breaking out, at a certain season of the year, was not merely imported?

There are, in Philadelphia, many other sources of putrid effluvia ^*, which perhaps are [Page 100]unavoidable, and are common to all other thickly inhabited places in the world, but which ought to attract the attention of our public authorities; since they are much more dangerous in a place exposed to the heat of the tropical countries. For these, as well as for the preceding observations, I hardly think it ne­cessary, gentlemen, to dwell much upon the direct measures that should be adopted by the citizens at large, against the different causes of our epidemic. If they were not kept in a state of incertitude, with respect to its real origin, their wisdom and prudence would enable them to make the proper regulations. But alas! those who are induced, after sufficient con­templation, to predict that the fever will fre­quently rage again in Philadelphia, know how many opponents there are to this melancholy truth, and have very little hopes of obtaining a majority in favour of their advices. Yet, if I cannot flatter myself with gaining many pro­selytes to my opinion, I consider it as a duty and a pleasure to throw my mite of informa­tion and firm belief, into the fluctuating scale of public opinion. Under the influence of this sentiment, I assert, that the only sure and effi­cacious means of preserving Philadelphia from contagious malignant fevers, will be those that are directly calculated to remove or destroy, [Page 101]if possible, the sources of putrid exhalation from animal and vegetable substances that are contained within our precincts. These means, gentlemen, are of such a magnitude, th [...] neither time or great expence would be able to effect them, if religious prejudices, views of mercantile interest, and opinions of party spirit, are suffered to thwart their execution. Before I attempt to enumerate them permit me to make a few reflexions more on the chymical principles and results of putrid ex­halations.

First, In whatever light we consider the com­ponent parts of vapours and gasses, either ac­cording to the former or new nomenclature of chymistry, this much will be acknowledged, that life is opposed to the putrid fermentation of animal or vegetable substances; and that, as soon as they are deprived of it, they neces­sarily fall into a complete state of putrefaction, which is more or less accelerated, according to the quantity of heat or caloric, of air and of water, in which they are immersed.

2 dly, As soon as the putrid fermentation takes place, a new combination arises of seve­ral substances, which have a peculiar tendency to unite to the air by the help of the heat, or [Page 102]to the water by their affinity to them; so that both fluids, being considerably altered in their nature, will present a quite contrary effect to that they would have exhibited at first, viz. the very air which was good for life and health, will produce a quite contrary effect, &c.

3 dly, Among the different qualities of the substances disengaged from animal fermenta­tion, there are two very remarkable and which constitute all the degrees of noxious exh [...]a­tions. The first is their extreme tendency unite with air and water, ( Vide Diction. de Chimie, par Macquer, art. GAS); and the other is a certain degree of their development, which is impossible to account for, in which whether in a fluid or solid state, their imme­diate contact with any living body, suddenly destroys or suspends the phenomenon of life. A traveller found the body of a drowned man that had been washed on the shore by the flood. As he perceived no foetor, in examining the corpse, he inadvertantly plunged his finger into a soft and putrified limb. From the finger the mortification was so rapid to the vitals, that he had no time to be assisted, and he died. Anatomical dissection has also proved the truth of this terrible and dangerous state of pu­trefaction. Its various degrees must undoubt­edly [Page 103]breed different kinds of disease and con­tagion.

4 thly, These exhalations are, moreover, sub­ject to other laws and phenomena of nature, which sometimes occasion them to be harmless when they are most dreaded, or very noxious and fatal while they are not perceived or even thought of. Heat, without aqueous particles, raises them, and winds carry them through immense regions. They seem visibly to be a kind of meteor; their operation on the body is terrible, and they in some measure destroy the vitals without any contagious or poisonous ef­fect. Such are those remarkable winds and va­pours, so well known in the deserts of Africa, and which originate in the mountains of Abys­sinia ^*. Heat, also, may dilate them to such a degree that they become harmless. This is the case when it puts an end to the plague in the hottest countries of the earth. Aqueous vapours, without much heat, can disen­gage but little of these exhalations, and it is then very common to perceive much foe­tor, without receiving any injury from it. Thus people attending the sick, dissecting of dead bodies, butchers, tanners, and all those who are frequently among exhalations from animal [Page 104]fermentation, are not known to be injured at all. Those exhalations which are suspended above a corpse, within a metallic or wooden coffin, do not want much heat or moisture, to become fatal as soon as broken open. A mephi­tic gas then appears similar to that which we discover in our chymical experiments. Its ef­fects are sudden against every living body; but it can be almost destroyed or rendered harm­less, by aqueous vapours, and may be totally absorbed by vegetables. This air or exhala­tion occasioned the death of many citizens of Paris, who, in the month of August, 1792, were instantly killed by its contact, while they were breaking the tombs, to take away the leaden coffins, for materials of military ammu­nition.

5 thly, Fevers, produced by exhalations are remarkably various, according to their places, time, and season. What a striking difference was there between the elephantiasis of Athens, the plague of Marseilles, the sore-throat of Italy, and the sweating sickness of England? We could hardly find, in the present day, any pathological similarity among the dreadful epi­demics of Norway and Holland; the anomolous malignant observed by Hoffman in Germany, during the years 1727, 1728, and 1729; the in­termittent [Page 105]ague of marshy places; the camp dissenteries; the hospital contagious petechiae; the convulsive malignant related by Dr. Chis­holm, which he thought had been imported from Guinea into the West-Indies; the vomito pietro of the Spaniards in Vera Cruz; and the yellow fever of the tropical countries, &c.

6 thly and lastly, The concurrence of rains, storms, and heat, are necessary to develope noxious exhalations from vegetable and animal fermentation. The conjectures resulting from attentive observations are, that intense heat, without wind, after heavy rains and southerly storms, is most productive of noxious exhala­tions in places containing materials for vegeta­ble and animal fermentation.

These elementary laws, respecting the na­ture and effects of exhalations, I have, gentle­men, endeavoured to present, unaccompanied with any scientifical method, in order that every description of my readers might be­come better acquainted with them, and finally apply the following means as the only preven­tives against the generation of the yellow fe­ver ^*:—

SECTION VI. Particular Preventives against the Yellow Fever.

THIS section, gentlemen, I would consider as the least useful of my essay, if any of my readers expected to find in it secret receipts or infallible remedies, and if they believed that I thought my advices, joined to those of the most eminent physicians, sufficient to render them invulnerable to one of the most rapid and fero­cious disorders. Where is the art that can in­dubitably face danger, can always elude its strokes, or resist its efforts, whether in battles or in any kind of human infirmities? Alas! when the best preventives have been made use of, and the mode of living rendered scrupulously cautious, still there are many chances of infec­tion against one of preservation; because the attendants of the sick, as well as those citizens who are detained in town by the necessary pur­suits [Page 109]of business, are exposed to the fatigue, the anxiety of mind, and all the other inconveni­encies attending a general calamity, and, un­der such circumstances, it is not always in hu­man power, totally to avoid the means of in­fection. Thus we have been seen many of our physicians, who, during the late calamity, were among the foremost in attending on the sick, become the victims of its ravages! Their names and memories deserve the tribute of ho­nour and of gratitude ^*. To us, gentlemen, they have given a noble example. Let us then shed a tear upon their tombs; and, like them, pledge ourselves as the friends of humanity.

Physicians and others who first suspected the domestic origin of our fever, advised their fel­low citizens to remove to the country. How­ever efficacious this measure was to those who [Page 110]could afford the expences attending it, what distress did it not produce among the labour­ing class of our citizens, to the public func­tionaries, and to those whom public or private concerns retained at the theatre of the cala­mity! By desertion, indeed, the last preva­lence was rendered more afflictive than that of 1793, although it was not so extensive in its ravages; and it will always be my wish, that, during such a period, we may experience less of that ruinous and unexpected dispersion of our citizens. When this is the case, there is no kind of distress to which our patients are not exposed. Instances, likewise, were known of malignant cases and of deaths among the fugitives. A mortal infection was thus propa­gated in several surrounding country places, for how could they escape the necessary com­munications and intercourse? In European places exposed to pestilential diseases, it is a supreme law, that, during their prevalence, the inhabitants are not suffered to quit their places of abode. Far be it from me to wish for such an inhospitable measure. It is only mentioned to suggest, that it is a question whether more good than evil would not arise to the community at large, if, free from terror, assisted by proper and efficacious measures, en­couraged by numerous instances of preserva­tion [Page 111]in town and recovery among the patients, they could be persuaded to see the short period of an epidemic spent, unaccompanied with the tenfold calamities and misfortunes of deser­tion.

However rapid the effects of an existing con­tagion may be upon healthy people, we can derive from our stated principles, three powerful mo­tives of confidence and security. The first re­sults from the nature and operation of the con­tagion on the bile only; the second, from the possible removal of the sick from numerous families, or an absolute cessation of intercourse with them; and the last from efficaciously ex­perienced cautions even in cases of the nearest danger.

I. The yellow fever, we have already said, is merely a bilious one of the most malignant degree. Its operations and symptoms are wholly upon and from the bile. Our inhabitants are particularly subject to bilious complaints in a certain season of the year, and when the last are endemics, the former will turn out to be an epidemic of the severest kind.

We have seen also that bilious and yellow fevers commonly fell upon those in whom the [Page 112]bile was of a thick or vitiated nature, and who, by habitual neglect, intemperance, or other unhealthy mode of living, exposed that secre­tion to a state of stagnancy and corruption. Such simple and reasonable given observations should help us to fix upon a successful method of diet, of remedies, and of cautions, during the perilous prevalence of the yellow fever. At such a period, a vegetable diet will be a sure preventive against animal corruption; and ani­mal food of the lightest kind, being always sufficient for necessary nutriment, if preferred to heavy and gross meats, will not excite so great a fermentation of the animal fluids. Sim­ple tonic drinks, measured according to the wanted digestive power, will preserve us from those inflammatory and heated motions of cir­culation which always attend the face and feelings of drinkers of strong wines and spi­ritous liquors, which is an obstacle to the for­mation and secretion of liquid and pure bile. But it may be said, that such a plan of diet would not be sufficient, during the exhausting heat of the weather and the necessary fatigues of life, and particularly so at a time when the body seems to want more stimulating means to raise the lowness of our strength and spirits. This, gentlemen, is true, and this feeling is powerful; but we ought not to suffer our ha­bits [Page 113]or misinformation, to make us mistake the proper means. I have been frequently more a­nimated and refreshed by a warm bath, during the heat of summer, by an airing in the coun­try, or by a cooling medicine, than I could possibly be by the most succulent cordial. In fact, we may compare our body, charged with so ma­ny springy actions, to a bow, the elastic power of which would be lost if it was stiffened by the effect of a drying fire, but which would be bet­ter preserved if kept in a soft and moist tempe­rature. Besides, when we feel very weak, it is often because the vis vitae, elevated to an un­common degree above the point of health, ap­proaches to its end, the same as when it is too low; and then relaxing means are proper, sa­lutary, and successful. It is observed that we ne­ver more frequently experience the effects of weakness, brought on by the heat of our fluids, than in the summer. At this season, we are pe­culiarly exposed to obstructions in the alimen­tentary channel, crudities of the stomach, and cessations of daily evacuations. This last effect is unavoidable, even among the most regular constitutions; but evacuating medicines oppose to it an infallible power. A puke or a drastic never fails in removing those crudities or obstructions; and, if they are mercurial or antimonial, they will more properly discuss [Page 114]the reservoirs of the bile, and renew that ani­mal fluid, the fermentation of which becomes so dangerous. I had frequent opportunities, during the two prevalences of the yellow fe­ver, to give this advice to people, who ap­peared to enjoy a regular degree of health. A slight indisposition, which could hardly call for their attention, at another time, was then a sufficient motive for applying to cautious measures. I never hesitated, when the subject could bear it, to prescribe a puke at first, and a mercurial drastic after. In this manner, and with much surprise, I timely delivered many of them of a prodigious quantity of unnatural, black corrupted bile, from which a dangerous fit of sickness would undoubtedly have origina­ted. (Vide case No. II.) Yet they afterwards lived healthy, notwithstanding the heat of the season and the prevalence of the contagion. It is, in fine, a necessary caution, repeatedly to have recourse to such medical assistance; for it is acknowledged, both by physicians and others, that repeated cases of infection may occur.

Frequent walks and airings, chiefly during the cool moisture of the morning and evening, taken to some distant places from our sultry dwellings, will be another salutary practice. [Page 115]It interrupts the action of the existing exhala­tions, and refreshes us by the help of a purer and more elastic atmosphere. It also assists the functions that are the most endangered, and frequently breaks the course of annual and ac­cidental diseases. In most of the cities of Eu­rope, where the streets are irregular, a long experience has shewn, that the most essential causes of their salubrity are, pure waters and public walks [...]and every means, both natural and artificial, has been employed to render the latter delightful. Fashion, in this point, has been invariably adhered to; and though pub­lic walks may be the theatre of a shewy style of dress and manners, or of idle talks and in­terviews, yet they notwithstanding remain a cheap means of exercise, whereby health is preserved and diseases dispelled. Sedentary life, long sittings in religious meetings, seclu­sion of one society from another, protracted clubs for various kinds of entertainment, for politics, for interest, and numerous and strict­ly fashionable tea-parties, are manners and customs particularly observed among the citi­zens of our metropolis. Can I then, gentlemen, be blamed, when I affirm, that, medically speaking, they have a contrary tendency to that of exercise, taken in a pure air, and a far [Page 116]different effect to those of lively manners and more recreative life?

II. Another motive of security for the citi­zens at large, during the prevalence of a con­tagious epidemic, would be, I have already said, the removal of the sick, or an absolute cessation of intercourse with them. This mea­sure, during the late calamity, was ordered by a proclamation from our governor. He was blamed by many who thought only of the in­conveniences arising, in its execution, to the sick, who were reluctant to leave their homes and their chosen attendants; and the frequent instances of mistaken cases was another cause of their disapprobation of the measure. This opposition prevailed to such a degree, that ma­ny obstinately remained secluded in their own houses, died there, and their bodies were af­terwards secretly carried to the distant grave­yard of the Wigwam hospital. These inconve­niencies cannot be denied, but the efficacious and vigilant measures of authority might at last conquer them. The idea that they are a violation of the rights of humanity and of per­sonal liberty, may be opposed by good argu­ment [...] Public safety, and a care for the health and lives of the community at large, have of­ten commanded still more severe measures. At [Page 117]this present time, if a person who is perform­ing a quarantine on board of a ship or in the lazaretto at Marscilles, is detected in violating the limits of his confinement, the centinel has orders to kill him instantly, and yet this mea­sure has been dictated by the voice of humanity.

Another argument will enforce the necessity of restraining personal liberty in cases of contagion. It is the customary right by which the neighbour­ing states exclude us from the usual intercourse with them. The time may come, which heaven forbid, when the contagious power of this epi­demic, may suggest to neighbouring districts the necessity of a temporary seclusion, and par­ticularly so, if severe regulations are not adop­ted among ourselves. Will it then appear in­humane, if we ourselves are obliged to forbid any communication with the sick, their houses, and the streets in which they are situated? The distresses of this severe measure would, no doubt, be softened, if several hospitals were fit­ted up, and a choice left to the patients of their own attendants. They could be thus sup­plied with more private accommodations at their own expence, while the poor and forlorn would be taken into those public houses which have been already sufficiently well regulated and supplied with every necessary by the vigi­lant [Page 118]care, and generous donations of our citi­zens, during our past calamities. Infine, if these general measures are never adopted, we should at least be cautious to suspend any intercourse with the infected houses and streets, although it will be mostly too late when the contagion has been suffered to spread. Patriotism and candour, both of physicians and citizens, would soon ascertain the presence of the scourge. The mistakes of an isolated judgment may be obvi­ated by previous appointment of many physi­cians to visit and consult upon each new case and patient. During the last prevalence, the public were cautioned that many deaths were ascribed to the yellow fever, some weeks be­fore they would believe it; but they soon ac­knowledged that they received proper and timely information, owing to the attention of well known physicians. This is an unquestion­able result from what we have stated of the nature and operation of putrid exhalations, that as soon as their first effects are discover­ed, in the early stage of the season, we might think it in our power to be prepared against subsequently created cases, and against the contagion from bodies. These are known to emit, in cases of death, almost none, and to be­come dangerous only in the last periods of the sickness when they recover.

[Page 119]III. There are other measures which expe­rience has proved extremely successful for preserving even those who are obliged to re­main in infected places. It has been officially reported to the governor, that, in the hospitals, during the late prevalence, the contagion had not spread among the attendants. This would be incredible were we not apprised of the re­serves and cautions that are naturally made use of, invented, and dictated by necessity when it becomes the supreme law. The origin of the famous vinegar of four thieves, so much recom­mended as a preventive against the plague, is a proof of that beneficial industry, and I ne­ver found better or more medical means em­ployed with success, than among those who do not hesitate to exchange many chances of dan­ger against a valuable compensation. Yet all their industry is assisted with nothing else than what is in the power of every one. Resuming, my enquiries, and the effects of their general method, I found three results from taking vari­ous medicines and from diet. One is, that they reduced the system, and abated, consequently, any disposition to inflammatory or phlogistic diathesis; the second, that they kept them­selves in a continual state of evacuation, and thus were never sufficiently acted upon by the contagious miasmata; and the last, that they re­newed [Page 120]the bile and rendered it more pure, more fluid, and of a quite contrary state to that which constitutes a bilious malignancy. These three rules or indications are equal to any that the medical art can suggest and pre­scribe; and, as far as they could be well under­stood by individuals, and answered to by easy means, they would, I believe, mostly render the contagion harmless to healthy people, and justify a very frequent use of warm baths, pre­vious bleedings, and the occasional administra­tion of pukes and mercurial drastics, such as we employ in the treatment of our patients.

Some of my readers would, perhaps, here wish to be informed, as well as in every other medical work, what peculiar doses, powders, or pills, and the quantity administered, should be particularly employed as preventives against the yellow fever. I do not wish to make a secret of the most minute circumstances for the proper use of bleedings, pukes, and mercurial drastics, but I have already said enough upon that subject. A still more useful piece of advice shall here be given, viz. that it is not by saturation or quan­tity only that medicines are rendered efficaci­ous, nor without those proportions and modifi­cation, which the various constitutions of dif­ferent patients require, and of which physici­ans [Page 121]can be the only proper judges. I conse­quently prefer that preventive medicines should always be prepared according to what is requisite for each constitution and by the previous indisposition of body. The most imposing name, affixed to a pill or powder, will [...] make it better, if given and employed without any necessary restriction whatever, but would, on the contrary, cover great blunders and mistakes. Such is the case of those patent medicines, which, in the immense catalogue of their virtual properties, include all the series of human infirmities, but which are at last given up as dangerous or equivocal remedies. To their patrons, however, I am willing to grant, that, if it was possible to ascertain above what point they are variously noxious, before any obtained success, and under which propor­tion they would fail or become useless, they would not be thought a great nuisance among the credulous, whatever power they may be possessed of.

The attendants of the sick should always be attentive to keep a fire in the patient's room, although the warm weather might render it uncomfortable. This I consider as a pow­erful mean for purifying and renewing the inclosed air, which is instantly absorbed with [Page 122]any morbid exhalation. The phenomenon of fire, cannot take place but by an immense con­sumption of air, and it thus becomes a draw­ing ventilator. This measure not only destroys any floating contagion for the benefit of the attendants, but I have observed it to be very useful to the patient, whose body should not be immersed in its own infectious emanations, and who cannot yet bear to be exposed to the variable external temperature. Infine, by the means of fire, a salutary and fragrant steam can be immediately procured, in the critical mo­ment of foetid and dangerous evacuations.

Various means have been also recommended as preventives by expanding round ourselves volatile and chymical substances to neutralise, as it were, the putrid miasmata. Although this method is very uncertain, yet much benefit may be obtained when the current of an arti­ficial vapour breaks or alters a contagious one. These means, however, too often act unfa­vourably towards the constitution, and have a tendency to enweaken the nerves, while it is highly requisite that the body be kept in the very point of health. Every one knows, in this respect, the effects of camphor and of musk. The aromatics have a contrary and better ef­fect, because they are equally tonics and anti­sceptics. [Page 123]We should, therefore, constantly make use of their essential oils, of their artificial perfumes, and of the fragrancy of their plants. I have seen also the strongest vinegar general­ly used against pestilential emanations, and its ebullition with sugar upon red hot iron, pro­duces an agreeable and salutary vapour.

Much has been said upon the subject of de­stroying or washing with caution the clothes and beds of the sick. None, I believe, are more infectious than those of a recovered patient. I have collected, on that score, the most satis­factory proofs, that a patient may be even re­infected in his own bed and clothes; and this is undoubtedly the origin of those strange cases, the stages of which run through a longer course, and repeated recoveries and relaxes, which is quite contrary to the known periods of a malig­nant fever. it is perhaps useless and even incon­venient frequently to trouble a patient by giving him the comfort of fresh, clean, warm clothes, but it is absolutely necessary to do so as soon as a profuse perspiration has marked the end or a favourable crisis of the malady. If the care of the infected linen is left entirely to the nurses and servants, they must be directed to fold them immediately, and to throw them into cold water, where [Page 124]they should be kept for twenty-four hours, co­vered with ashes to be filtrated into lie, with which they must be washed. The same care should be extended to the beds. At least they should not be used again but after repeated night and morning airings. Infine, the attendants should be careful to promote in themselves a a constant spitting, and to avoid, as much as possible, swallowing the saliva. But let it be re­membered, that, with these general cautions, and many more too tedious to be related, at the close of the seventh day, the convalescent patient can no longer transmit any contagion. His recovering state, is a proof of the purity of his blood. How distressing, therefore, would it be, under a false idea of danger, still to con­tinue our intercourse with him with reserve and caution, when it is no longer necessary. He has been already too long obliged to con­sider himself as an object of terror and dere­liction. To what a perilous despondency has he not been delivered by fugitive friends and re­lations! To what afflictive solitude has he not been condemned, while excruciated by a devouring poison! The arm of Providence could alone help him from under the two fold pressure of his body and of his mind! The for­mer may counteract the laws of life as soon and as irrevocably as the latter! And ye attendants [Page 125]of the sick, if a liberal and philanthropic mind ennobles your cares and services to your fellow beings; if you are not strangers to a moral sympathy—to the supreme maxim of doing to others as you would be done by; and if it is your pride not to value your dangerous task by pecuniary compensations, you deserve protection from heaven and respect from your fellow citizens. But such a meritorious claim is lost by mere mercenary services, which be­come baneful to unfortunate patients whom your expressed terrors and affected impa­tience, loudly bespeak as objects of horror in the creation. Despair, absolute despon­dency, and depression of spirits, will soon subdue the small share of organic strength left to them in this ferocious disorder. Their fate is in your hands, more than in medical skill, if charitable cares, hopeful words, and apparent confidence, are not continually and ingeniously offered, as the most sucessful comfort that will help, both the power of nature, and the wis­dom of physicians.

SECTION VII.