Chapter IX: Part 9

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

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

"_Philadelphia, September 15, 1793._

"MY DEAR FATHER,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

AN ACCOUNT

OF THE

BILIOUS REMITTING AND INTERMITTING

_YELLOW FEVER_,

AS IT

APPEARED IN PHILADELPHIA,

IN THE YEAR 1794.

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

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

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

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

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

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

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

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

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

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

In the course of this month, I met with several cases of swelled testicles, which had succeeded fevers so slight as to have required no medical aid. Dr. Desportes records similar instances of a swelling in the testicles, which appeared during the prevalence of the yellow fever in St. Domingo, in the year 1741[103].

[103] Histoire des Maladies de Saint Domingue, p. 112.

In the month of July, I visited James Lefferty and William Adams, both of whom had, with the usual symptoms of yellow fever, a yellow colour on their skin. I likewise attended three women, in whom I discovered the disease under forms in which I had often seen it in the year 1793. In two of them it appeared with symptoms of a violent colic, which yielded only to frequent bleedings. In the third, it appeared with symptoms of pleurisy, which was attended with a constant hæmorrhage from the uterus, although blood was drawn almost daily from her arm, for six or seven days. About the middle of this month many people complained of nausea, which in some cases produced a puking, without any symptoms of fever.

During the month of August, I was called to Peter Denham, Mrs. Bruce, a son of Jacob Gribble, Mr. Cole, John Madge, Mrs. Gardiner, Miss Purdon, Mrs. Gavin, and Benjamin Cochran, each of whom had all the usual symptoms of the yellow fever. I found Mr. Cochran sitting on the side of his bed, with a pot in his hand, into which he was discharging black matter from his stomach, on the 6th day of the disease. He died on the next day. Mrs. Gavin died on the 6th day of her disease, from a want of sufficient bleeding, to which she objected from the influence of her friends. Besides the above persons, I visited Mr. George Eyre at Kensington, Mr. Thomas Fitzsimons, and Thomas M'Kean, jun. son of the chief justice of Pennsylvania, all of whom had the disease, but in a moderate degree. During this time I took no steps to alarm my fellow-citizens with the unwelcome news of its being in town. But my mind was not easy in this situation, for I daily heard of persons who died of the disease, who might probably have been saved had they applied early for relief, or had a suspicion become general among all our physicians of the existence of the yellow fever in the city. The cholera infantum was common during this, and part of the preceding month. It was more obstinate and more fatal than in common years.

On the 12th of this month, a letter from Baltimore announced the existence of the yellow fever in that city. One of the patients whom I visited in this month, in the fever, Mr. Cole, brought the seeds of it in his body from that place.

On the 25th of the month, two members of a committee, lately appointed by the government of the state, for taking care of the health of the city, called upon me to know whether the yellow fever was in town. I told them it was, and mentioned some of the cases that had come under my notice; but informed them, at the same time, that I had seen no case in which it had been contagious, and that, in every case where I had been called early, and where my prescriptions had been followed, the disease had yielded to medicine.

On the 29th of the month I received an invitation to attend a meeting of the committee of health, at their office at Walnut-street. They interrogated me respecting the intelligence I had given to two of their members on the 25th. I repeated it to them, and mentioned the names of all the persons I had attended in the yellow fever since the 9th of June.

Neither this, nor several subsequent communications to the committee of health produced the effect that was intended by them. Dr. Physick and Dr. Dewees supported me in my declaration, but their testimony did not protect me from the clamours of my fellow-citizens, nor from the calumnies of some of my brethren, who, while they daily attended or lost patients in the yellow fever, called it by the less unpopular names of

1. A common intermittent. 2. A bilious fever. 3. An inflammatory remitting fever. 4. A putrid fever. 5. A nervous fever. 6. A dropsy of the brain. 7. A lethargy. 8. Pleurisy. 9. Gout. 10. Rheumatism. 11. Colic. 12. Dysentery. And 13. Sore throat.

It was said further, by several of the physicians of the city, not to be the yellow fever, because some who had died of it had not a sighing in the beginning, and a black vomiting in the close of the disease. Even where the black vomiting and yellow skin occurred, they were said not to constitute a yellow fever, for that those symptoms occurred in other fevers.

Let not the reader complain of the citizens and physicians of Philadelphia alone. A similar conduct has existed in all cities upon the appearance of great and mortal epidemics.

Nor is it any thing new for mortal diseases to receive mild and harmless names from physicians. The plague was called a spotted fever, for several months, by some of the physicians of London, in the year 1665.

Notwithstanding the pains which were taken to discredit the report of the existence of the yellow fever in the city, it was finally believed by many citizens, and a number of families in consequence of it left the city. And in spite of the harmless names of intermitting and remitting fever, and the like, which were given to the disease, the bodies of persons who had died with it were conveyed to the grave, in several instances, upon a hearse, the way in which those who died of the yellow fever were buried the year before.

From the influence of occasional showers of rain, in the months of September and October, the disease was frequently checked, so as to disappear altogether for two or three days in my circle of practice. It was observed, that while showers of rain lessened, moist or damp weather, without rain, increased it.

The cold weather in October checked the fever, but it did not banish it from the city. It appeared in November, and in all the succeeding winter and spring months. The weather, during these months, being uncommonly moderate, will account for its not being destroyed at the time in which the disease usually disappeared in former years.

The causes which predisposed to this fever were the same as in the year 1793. Persons of full habits, strangers, and negroes, were most subject to it. It may seem strange to those persons who have read that the negroes are seldom affected with this fever in the West-Indies, that they were so much affected by it in Philadelphia. There were two reasons for it. Their manner of living was as plentiful as that of white people in the West-Indies, and they generally resided in alleys and on the skirts of the city, where they were more exposed to noxious exhalation, than in its more open and central parts.

The summer fruits, from being eaten before they were ripe, or in too large a quantity, became frequently exciting causes of this fever. It was awakened in one of my patients by a supper of peaches and milk. Cucumbers, in several instances, gave vigour to the miasmata which had been previously received into the system. Terror excited it in two of my patients. In one of them, a young woman, this terror was produced by hearing, while she sat at dinner, that a hearse had passed by her door with a person on it who had died of the yellow fever. Vexation excited it in a foreign master of a vessel, in consequence of a young woman suddenly breaking an engagement to marry him. The disease terminated fatally in this instance.

It was sometimes unfortunate for patients when the disease was excited by an article of diet, or by any other cause which acted suddenly upon the system; for it led both them, and in some instances their physicians, to confound those exciting causes with its remote cause, and to view the disease without the least relation to the prevailing epidemic. It was from this mistake that many persons were said to die of intemperance, of eating ice creams, and of trifling colds, who certainly died of the yellow fever. The rum, the ice creams, and the changes in the air, in all these cases, acted like sparks of fire which set in motion the quiescent particles of tinder or gunpowder.

I shall now proceed to describe the symptoms which this fever assumed during the periods which have been mentioned. This detail will be interesting to physicians who wish to see how little nature regards the nosological arrangement of authors, in the formation of the symptoms of diseases, and how much the seasons influence epidemics. A physician, who had practised medicine near sixty years in the city of Philadelphia, declared that he had never seen the dysentery assume the same symptoms in any two _successive_ years. The same may be said probably of nearly all epidemic diseases.

In the arrangement of the symptoms of this fever, I shall follow the order I adopted in my Account of the Yellow Fever of 1793, and describe them as they appeared in the sanguiferous system, the liver, lungs, and brain, the alimentary canal, the secretions and excretions, the nervous system, the senses and appetites, upon the skin, and in the blood.

Two premonitory symptoms struck me this year, which I did not observe in 1793. One of them was a frequent discharge of pale urine for a day or two before the commencement of the fever; the other was sleep unusually sound, the night before the attack of the fever. The former symptom was a precursor of the plague of Bassora, in the year 1773.

I. I observed but few symptoms in the sanguiferous system different from what I have mentioned in the fever of the preceding year. The slow and intermitting pulse occurred in many, and a pulse nearly imperceptible, in three instances. It was seldom very frequent. In John Madge, an English farmer, who had just arrived in our city, it beat only 64 strokes in a minute, for several days, while he was so ill as to require three bleedings a day, and at no time of his fever did his pulse exceed 96 strokes in a minute. In Miss Sally Eyre, the pulse at one time was at 176, and at another time it was at 140; but this frequency of pulse was very rare. In a majority of the cases which came under my notice, where the danger was great, it seldom exceeded 80 strokes in a minute. I have been thus particular in describing the frequency of the pulse, because custom has created an expectation of that part of the history of fevers; but my attention was directed chiefly to the different degrees of _force_ in the pulse, as manifested by its tension, fulness, intermissions, and inequality of action. The _hobbling_ pulse was common. In John Geraud, I perceived a quick stroke to succeed every two strokes of an ordinary healthy pulse. The intermitting, chorded, and depressed pulse occurred in many cases. I called it the year before a _sulky_ pulse. One of my pupils, Mr. Alexander, called it more properly a _locked_ pulse. I think I observed this state of the pulse to occur chiefly in persons in whom the fever came on without a chilly fit.

Hæmorrhages occurred in all the grades of this fever, but less frequently in my practice this year than in the year before. It occurred, after a ninth bleeding, in Miss Sally Eyre, from the nose and bowels. It occurred from the nose, after a sixth bleeding, in Mrs. Gardiner, who was at that time in the sixth month of her pregnancy. This symptom, which was accompanied by a tense and quick pulse, induced me to repeat the bleeding a seventh time. The blood was very sizy. I mention this fact to establish the opinion that hæmorrhages depend upon too much action in the blood-vessels, and that they are not occasioned by a dissolved state of the blood.

There was a disposition at this time to hæmorrhage in persons who were in apparent good health. A private, in a company of volunteers commanded by Major M'Pherson, informed me that three of his messmates were affected by a bleeding at the nose, for several days after they left the city, on their way to quell the insurrection in the western counties of Pennsylvania.

II. The liver did not exhibit the usual marks of inflammation. Perhaps my mode of treating the fever prevented those symptoms of hepatic affection which belong to the yellow fever in tropical climates. The lungs were frequently affected; and hence the disease was in many instances called a pleurisy or a catarrh. This inflammation of the lungs occurred in a more especial manner in the winter season. It was distinguished from the pleurisies of common years by a red eye, by a vomiting of green or yellow bile, by black stools, and by requiring very copious blood-letting to cure it.

The head was affected, in this fever, not only with coma and delirium, but with mania. This symptom was so common as to give rise to an opinion that madness was epidemic in our city. I saw no case of it which was not connected with other symptoms of the bilious remitting fever. The Rev. Mr. Keating, one of the ministers of the Roman church, informed me that he had been called to visit seven deranged persons in his congregation, in the course of one week, in the month of March. Two of them had made attempts upon their lives. This mania was probably, in each of the above cases, a symptom only of general fever. The dilatation of the pupil was universal in this fever.

Sore eyes were common during the prevalence of this fever. In Mrs. Leaming, this affection of the eyes was attended with a fever of a tertian type.

III. The alimentary canal suffered as usual in this fever. A vomiting was common upon the first attack of the disease. I observed this symptom to be less common after the cold and rainy weather which took place about the first of October.

I have in another place mentioned the influence of the weather upon the symptoms of this disease. In addition to the facts which have been formerly recorded, I shall add one more from Dr. Desportes. He tells us, that in dry weather the disease affects the head, and that the bowels in this case are more obstinately costive than in moist weather. This influence of the atmosphere on the yellow fever will not surprise those physicians who recollect the remarkable passage in Hippocrates, in which he says, that in the violent heats of summer, fevers appeared, but without any sweat; but if a shower, though ever so slight, appeared, a sweat broke out in the beginning[104]. I observed further, that a vomiting rarely attended those cases in which there was an absence of a chilly fit in the beginning of the fever. The same observation is made by Dr. Desportes[105].

[104] Epidemics, book XI. sect. I.

[105] Les Maladies de St. Domingue, vol. I. p. 193.

The matter discharged by vomiting was green or yellow bile in most cases. Mrs. Jones, the wife of Captain Lloyd Jones, and one other person, discharged black bile within one hour after they were attacked by the fever. I have taken notice, in the History of the Yellow Fever of 1793, that a discharge of bile in the beginning of this fever was always a favourable symptom. Dr. Davidson of St. Vincents, in a letter to me, dated the 22d July, 1794, makes the same remark. It shows that the biliary ducts are open, and that the bile is not in that viscid and impacted state which is described in the dissections of Dr. Mitchel[106]. A distressing pain in the stomach, called by Dr. Cullen gastrodynia, attended in two instances. A burning pain in the stomach, and a soreness to the touch of its whole external region, occurred in three or four cases. Two of them were in March, 1795. In Mrs. Vogles, who had the fever in September, 1794, the sensibility of the pit of the stomach was so exquisite, that she could not bear the weight of a sheet upon it.

[106] Account of the Yellow Fever of 1793.

Pains in the bowels were very common. They formed the true bilious colic, so often mentioned by West-India writers. In John Madge these pains produced a hardness and contraction of the whole external region of the bowels. They were periodical in Miss Nancy Eyre, and in Mrs. Gardiner, and in both cases were attended with diarrh[oe]a.

Costiveness without pain was common, and, in some cases, so extremely obstinate as to resist, for several days, the successive and alternated use of all the usual purges of the shops.

Flatulency was less common in this fever than in the year 1793.

The disease appeared with symptoms of dysentery in several cases.

IV. The following is an account of the state of the _secretions_ and _excretions_ in this fever.

A puking of bile was more common this year than in the year 1793. It was generally of a green or yellow colour. I have remarked before, that two of my patients discharged black bile within an hour after they were affected by the fever, and many discharged that kind of matter which has been compared to coffee grounds, towards the close of the disease.

The fæces were black in most cases where the symptoms of the highest grade of the fever attended. In one very malignant case the most drastic purges brought away, by fifty evacuations, nothing but natural stools. The purges were continued, and finally black fæces were discharged, which produced immediate relief[107]. In one person the fæces were of a light colour. In this patient the yellowness in the face was of an orange colour, and continued so for several weeks after his recovery.

[107] In the account of the effects of morbid action and inflammation,
in the Outlines of the Theory of Fever, the author neglected to
mention the change of certain fluids from their natural to a dark
colour. It appears in the secretions of the stomach and bowels,
in the bile, in the urine, in carbuncles, and occasionally in the
matter which is produced by blisters. All these changes occur in
the yellow fever, and, in common with the other effects of fever
that have been enumerated, are the result of peculiar actions in
the vessels, derived from _one_ cause, viz. morbid excitement.

The urine was, in most cases, high coloured. It was scanty in quantity in Peter Brown, and totally suppressed in John Madge for two days. I ascribed this defect of natural action in the kidneys to an _engorgement_ in their blood-vessels, similar to that which takes place in the lungs and brain in this fever. I had for some time entertained this idea of a morbid affection of the kidneys, but I have lately been confirmed in it by the account which Dr. Chisholm gives of the state of one of the kidneys, in a man whom he lost with the Beullam fever, at Grenada. "The right kidney (says the doctor) was mortified, although, during his illness, no symptom of inflammation of that organ was perceived[108]." It would seem as if the want of action in the kidneys, and a defect in their functions were not necessarily attended with pain. I recollect to have met with several cases in 1793, in which there was a total absence of pain in a suppression of urine of several days continuance. The same observation is made by Dr. Chisholm, in his account of the Beullam fever of Grenada[109]. From this fact it seems probable, that pain is not the effect of any determinate state of animal fibres, but requires the concurrence of morbid or preternatural excitement to produce it. I met with but one case of strangury in this fever. It terminated favourably in a few days. I have never seen death, in a single instance, in a fever from any cause, where a strangury attended, and I have seldom seen a fatal issue to a fever, where this symptom was accidentally produced by a blister. From this fact there would seem to be a connection between a morbid excitement in the neck of the bladder, and the safety of more vital parts of the body. The idea of this connection was first suggested to me, above thirty years ago, by the late Dr. James Leiper, of Maryland, who informed me that he had sometimes cured the most dangerous cases of pleurisy, after the usual remedies had failed, by exciting a strangury, by means of the tincture of Spanish flies mixed with camphorated spirit of wine.

[108] Essay on the Malignant Pestilential Fever introduced into the
West-Indies from Beullam, p. 137.

[109] Page 224.

The tongue was always moist in the beginning of the fever, but it was generally of a darker colour than last year. When the disease was left to itself, or treated with bark and wine, the tongue became of a fiery red colour, or dry and furrowed, as in the typhus fever.

_Sweats_ were more common in the remissions of this fever, than they were in the year 1793, but they seldom terminated the disease. During the course of the sweats, I observed a deadly coldness over the whole body to continue in several instances, but without any danger or inconvenience to the patient. In two of the worst cases I attended, there were remissions, but no sweats until the day on which the fever terminated. In several of my patients, the fever wore away without the least moisture on the skin. The _milk_, in one case, was of a greenish colour, such as sometimes appears in the serum of the blood. In another female patient who gave suck, there was no diminution in the quantity of her milk during the whole time of her fever, nor did her infant suffer the least injury from sucking her breasts.

I observed tears to flow from the eye of a young woman in this fever, at a time when her mind seemed free from distress of every kind.

V. I proceed next to mention the symptoms of this fever in the nervous system.

Delirium was less common than last year. I was much struck in observing John Madge, who had retained his reason while he was so ill as to require three bleedings a day, to become delirious as soon as he began to recover, at which time his pulse rose from between 60 and 70, to 96 strokes in a minute. I saw one case of extreme danger, in which a hysterical laughing and weeping alternately attended.

I have before mentioned the frequency of mania as a symptom of this disease. An obstinate wakefulness attended the convalescence from this fever in Peter Brown, John Madge, and Mr. Cole.

Fainting was more common in this fever than in the fever of 1793. It ushered in the disease in one of my patients, and it occurred in several instances after bleeding, where the quantity of blood drawn was very moderate.

Several people complained of giddiness in the first attack of the fever, before they were confined to their beds. Sighing was less common, but a hiccup was more so, than in the year before.

John Madge had an immobility in his limbs bordering upon palsy. A weakness in the wrists in one case succeeded a violent attack of the fever.

Peter Brown complained of a most acute pain in the muscles of one of his legs. It afterwards became so much inflamed as to require external applications to prevent the inflammation terminating in an abscess. Mrs. Mitchell complained of severe cramps in her legs.

The sensations of pain in this fever were often expressed in extravagant language. The pain in the head, in a particular manner, was compared to repeated strokes of a hammer upon the brain, and in two cases, in which this pain was accompanied by great heat, it was compared to the boiling of a pot.

The more the pains were confined to the bones and back, the less danger was to be apprehended from the disease. I saw no case of death from the yellow fever in 1793, where the patient complained much of pain in the back. It is easy to conceive how this external determination of morbid action should preserve more vital parts. The bilious fever of 1780 was a harmless disease, only because it spent its whole force chiefly upon the limbs. This was so generally the case, that it acquired, from the pains in the bones which accompanied it, the name of the "break bone fever." Hippocrates has remarked that pains which descend, in a fever, are more favourable than those which ascend[110]. This is probably true, but I did not observe any such peculiarity in the translation of pain in this fever. The following fact from Dr. Grainger will add weight to the above observations. He observed the pains in a malignant fever which were diffused through the whole head, though excruciating, were much less dangerous than when they were confined to the temples or forehead[111].

[110] Epidemics, book ii. sect. 2.

[111] Historia Febris Anomalæ Batavæ Annorum 1746, 1747, 1748, cap. i.

I saw two cases in which a locked jaw attended. In one of them it occurred only during one paroxysm of the fever. In both it yielded in half an hour to blood-letting. I met with one case in which there was universal tetanus. I should have suspected this to have been the primary disease, had not two persons been infected in the same house with the yellow fever.

The countenance sometimes put on a ghastly appearance in the height of a paroxysm of the fever. The face of a lady, admired when in health for uncommon beauty, was so much distorted by the commotions of her whole system, in a fit of the fever, as to be viewed with horror by all her friends.

VI. The senses and appetites were affected in this fever in the following manner.

A total blindness occurred in two persons during the exacerbation of the fever, and ceased during its remissions. A great intolerance of light occurred in several cases. It was most observable in John Madge during his convalescence.

A soreness in the sense of touch was so exquisite in Mrs. Kapper, about the crisis of her fever, that the pressure of a piece of fine muslin upon her skin gave her pain.

Peter Brown, with great heat in his skin, and a quick pulse, had no thirst, but a most intense degree of thirst was very common in this fever. It produced the same extravagance of expression that I formerly said was produced by pain. One of my patients, Mr. Cole, said he "could drink up the ocean." I did not observe thirst to be connected with any peculiar state of the pulse.

George Eyre and Henry Clymer had an unusual degree of appetite, just before the usual time of the return of a paroxysm of fever.

A young man complained to me of being afflicted with nocturnal emissions of seed during his convalescence. This symptom is not a new one in malignant fevers. Hippocrates takes notice of it[112]. I met with one instance of it among the sporadic cases of yellow fever which occurred in 1795. It sometimes occurs, according to Lomius, in the commotions of the whole system which take place in epilepsy.

[112] Epidemics, book IV.

VII. The disease made an impression upon the lymphatic system. Four of my patients had glandular swellings: two of them were in the groin; a third was in the parotid; and the fourth was in the maxillary glands. Two of these swellings suppurated.