An account of the bilious remitting yellow fever, as it appeared in the city of Philadelphia, in the year 1793. By Benjamin Rush, M.D. Professor of the institutes, and of clinical medicine, in the University of Pennsylvania.

AN ACCOUNT, &c.

BEFORE I proceed to describe the fever which is to be the subject of this Essay, it will be proper to give a short account of the diseases which preceded it.

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

The MUMPS which made their appearance in December 1792, continued to prevail during the month of January 1793. Besides this disorder, there were many cases of catarrh in the city,

brought on chiefly by the inhabitants exposing themselves for several hours on the damp ground in viewing the aerial voyage of Mr Blanchard on the 9th day of the month.

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

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

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

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

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

The weather was uniformly warm in July. The scarlatina continued during the beginning of this month, with symptoms of great violence. A son of James Sharswood, aged seven years, had with the common symptoms of this disorder, great pains and swellings in his limbs, accompanied with a tense pulse. I attempted in vain to relieve him by vomits and purges. On the 10th day of the month, I ordered six ounces of blood to be drawn from his arm, which I observed afterwards to be very sizy. The next day he was nearly well. Be|tween the 22d and the 24th days of the month, there died three persons whose respective ages were 80, 92, and 96½. The weather at this time

was extremely warm. I have elsewhere taken no|tice of the fatal influence of extreme heat, as well as cold, upon human life in old people. A few bilious remitting fevers appeared towards the close of this month. One of them under my care, ended in a tedious typhus mitior, from which the patient was recovered with great difficulty. It was the son of Dr Hutchins of the island of Bar|badoes.

The weather for the first two or three weeks in August was temperate, and pleasant. The colera morbus, and remitting fevers were now common. The latter were attended with some inflammatory action in the pulse, and a determination to the breast. Several dysenteries appeared at this time, both in the city and in its neighbourhood. During the latter part of July, and the beginning of this month, a number of the distressed inhabitants of St Domingo, who had escaped the desolation of fire and sword, arrived in the city. Soon after their arrival, the influenza made its appearance, and spread rapidly among our citizens. The scar|latina still kept up a feeble existence among chil|dren. The above diseases were universal, but they were not attended with much mortality. They prevailed in different parts of the city, and each seemed to appear occasionally to be the ruling

epidemic. The weather continued to be warm and dry. There was a heavy rain on the 25th of the month, which was remembered by the citi|zens of Philadelphia as the last that fell, for many weeks afterwards.

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

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

I beg pardon for the length of this introduction. Some parts of it, I hope, will not appear useless in the sequel of this work.

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

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

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

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

an haemorrhage from the nose came on, and on the morning of the 12th he died.

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

On the 14th day of this month I was sent for to visit Mrs Leaming, the wife of Mr Thomas Lea|ming. I suspected at first that she had the influ|enza, but in a day or two, her fever put on bili|ous symptoms. She was affected with an uncom|mon disposition to faint. Her pulse was languid, but tense. I took a few ounces of blood from her,

and purged her with salts, and calomel. I after|wards gave her a small dose of laudanum which disagreed with her. In my note book, I find I have recorded, that "she was the worse for it." I was led to make this remark by its being so very uncommon, for a person who had been properly bled and purged, to take laudanum in a com|mon bilious fever, without being benefited by it. She recovered however slowly, and was yellow for many days afterwards.

On the morning of the 18th of this month, I was requested to visit Peter Aston, in Vine-street▪ in consultation with Dr Say. I found him on the 3d day of a most acute bilious fever. His eyes were inflamed, and his face flushed with a deep red colour. His pulse seemed to forbid evacua|tions. We prescribed the strongest cordials; but to no purpose. We found him at 6 o'clock in the evening, sitting upon the side of his bed, per|fectly sensible, but without a pulse, with cold clam|my hands, and his face of a yellowish colour. He died a few hours after we left him.

None of the cases which I have mentioned, excited the least apprehension of the existence of a yellow fever in our city; for I had frequently seen sporadic cases in which the common bilious fever

of Philadelphia, had put on symptoms of great ma|lignity, and terminated fatally in a few days, and now and then with a yellow colour on the skin, before, or immediately after death.

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

Upon coming out of Mrs Le Maigre's room, I remarked to Dr Foulke and Dr Hodge, that I had seen an unusual number of bilious fevers, ac|companied with symptoms of uncommon malig|nity, and that I suspected all was not right in our city. Dr Hodge immediately replied, that a fever of a most malignant kind had carried off four or five persons within sight of Mr Le Maigre's door, and that one of them had died in twelve hours af|ter the attack of the disorder. This information satisfied me that my apprehensions were well found|ed. The origin of this fever was discovered to

me at the same time, from the account which Dr Foulke gave me of a quantity of damaged coffee which had been thrown upon Mr Ball's wharf, and in the adjoining dock, on the 24th of July, nearly in a line with Mr Le Maigre's house, and which had putrefied there to the great annoyance of the whole neighbourhood.

After this consultation I was soon able to trace all the cases of fever which I have mentioned to this source. Dr Hodge lived a few doors above Mr Le Maigre's, where his child had been expo|sed to the exhalation from the coffee for several days. Mrs Bradford had spent an afternoon in a house directly opposite to the wharf and dock on which the putrid coffee had emitted its noxious effluvia, a few days before her sickness, and had been much incommoded by it. Her sister Mrs Leaming had visited her during her illness, and probably caught the fever from her, for she per|fectly recollected perceiving a peculiar smell unlike to any thing she had been accustomed to in a sick room, as soon as she entered the chamber where her sister lay. Young Mr M'Nair and Mrs Pal|mer's two sons had spent whole days in a compting house, near where the coffee was exposed, and each of them had complained of having been made

sick by its offensive smell, and Mr Aston had fre|quently been in Water-street near the source of the exhalation.

This discovery of the malignity—extent—and origin of a fever which I knew to be highly con|tagious, as well as mortal, gave me great pain. I did not hesitate to name it, the Bilious remitting Yellow Fever. I had once seen it epidemic in Philadelphia, in the year 1762. Its symptoms were among the first impressions which diseases made upon my mind. I had recorded some of these symptoms. I had likewise recorded its mor|tality. I shall here introduce a short account of it from a note book which I kept during my ap|prenticeship.

In the year 1762, in the months of August, September, October, November and Decem|ber, the bilious yellow fever prevailed in Phi|ladelphia, after a very hot summer, and spread like a plague, carrying off daily for some time, upwards of twenty persons.

The patients were generally seized with ri|gors, which were succeeded with a violent fever, and pains in the head and back. The pulse was full, and sometimes irregular. The eyes

were inflamed, and had a yellowish cast, and a vomiting almost always attended.

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

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

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

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

Upon my leaving Mrs Le Maigre's, I expressed my distress at what I had discovered, to several of my fellow citizens. The report of a malignant and contagious fever being in town, spread in eve|ry direction, but it did not gain universal credit. Some of those physicians who had not seen pati|ents in it, denied that any such fever existed, and asserted (though its mortality was not denied) that it was nothing but the common annual re|mittent

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of it, and into the nature of the disease. In con|sequence of this order, I received the following letter from Dr Hutchinson.

DEAR SIR,

A CONSIDERABLE alarm has taken place, in consequence of the appearance of an infectious disorder in this city; from which the governor has been induced to direct me to make enquiries rela|tive to the existence and nature of such disorder. In executing this duty, I must rely on the assistance of such of my medical brethren as may have been call|ed to attend any of the persons supposed to have been infected: as I understand you have had seve|ral of them under your care, I Would be much obliged to you to communicate to me (as speedily as can be done with convenience to yourself) such facts as you have been able to ascertain relative to the existence of such disorder; in what part of the city it prevails; when it was introduced; and what was the probable cause of it.

I am, Sir, With the greatest respect, Your obedient servant, J. HUTCHINSON.

AUGUST 24th, 1793.

Dr Benjamin Rush.

To this letter I wrote the following answer a few hours after it came to hand.

DEAR SIR,

A MALIGNANT fever has lately ap|peared in our city, originating I believe from some damaged coffee, which putrified on a wharf near Arch-street. This fever was confined for a while to Water-street, between Race and Arch-streets; but I have lately met with it in Second-street, and in Kensington; but whether propagated by conta|gion, or by the original exhalation, I cannot tell. The disease puts on all the intermediate forms of a mild remittent, and a typhus gravior. I have not seen a fever of so much malignity, so general, since the year 1762.

From, dear sir, Yours sincerely, BENJ. RUSH.

August 24th, 1793.

A FEW days afterwards, the following publica|cation, by Dr Hutchinson, appeared in the Ame|rican Daily Advertiser of August 28th.

THE governor having directed an inquiry to ascertain the facts, respecting the existence of a contagious fever in the city, and the probable means of removing it, Dr Hutchinson, the physician of the port, has made the fol|lowing statement upon the subject, in a letter to Natha|niel Falconer, Esq. health-officer of the port of Phila|delphia.

DEAR SIR,

IMMEDIATELY on the receipt of your letter, with the enclosure from the governor, sta|ting that a considerable alarm had taken place, in consequence of the appearance of an infectious dis|order in this city, I endeavoured to take measures to ascertain the facts, relative to the existence of such disease: for this purpose, I wrote to such of my medical brethren, who had been called on to attend persons supposed to have been infected; and from their answers, as well as from my own obser|vations, I am convinced that a malignant fever has lately made its appearance in Water-street and in Kensington; principally in Water-street between Arch and Race-streets. This part of the city I examined personally on Thursday and Friday last, and found that east of Front-street, and between Arch and Race-streets, sixty-seven persons were diseased, many with the malignant fever. Thir|teen of them are since dead, and numbers remain ill. For a while this fever was confined to the

abovementioned part of the city, but the disorder is spreading, and now appears in other places, so that several are affected in other parts of Water-street, some in Second-street, some in Vine-street, some in Carter's-alley, some in other streets; but in most cases the contagion can be traced to Wa|ter-street. Dr Say, who has attended more in this disease than any other physician, informs me, that he first observed it in Kensington, on the fifth or sixth of this month; that he did not perceive it in Water-street, until about the twelfth or fifteenth, but that on its appearance in the latter place, the whole neighbourhood was soon affected—He fur|ther informs me, that he has at this time upwards of 40 patients, which he supposes to be infected; and that he has lost about 20 patients in this disease, since its first appearance. As far as I have been able to ascertain, the number of persons who have died altogether of this fever, amounts to 40 or thereabouts* 4.1.

The general opinion both of the medical gentle|men, and of the inhabitants of Water-street is, that the contagion originated from some damaged cof|fee, or other putrified vegetable and animal matters;

and, on enquiry, it appears, that on a few wharfs above Arch-street, there was not only a quantity of damaged coffee, which was extremely offensive, ex|posed for some time, but also some putrid hides, and other putrid animal and vegetable substances. Should, however, Dr Say's opinion be well found|ed, that he observed the disease in Kensington pre|viously to its appearance in Water-street, this can|not be the original cause of the contagion.

It does not appear to be an imported disease; for I have heard of no foreigners or sailors that have hitherto been infected; nor has it been found in any lodging houses; but it is, on the contrary, principally confined to the inhabitants of Water-street, and such as have done business, or had con|siderable intercourse, with that part of the city. The Dispensary physicians tell me, that out of the large number of sick, now under the care of that charitable institution, they have had but one per|son afflicted with this fever. In the Pennsylvania Hospital, the disorder does not exist.

The disease appears differently in different per|sons; it puts on all the intermediate forms between a mild remittent and the worst species of Typhus Gravior.

I enclose you a copy of the proceedings of the college of physicians, which contains their recom|mendation of the means for preventing the future progress of the disease.

I am, with the greatest respect, Your most obedient servant, J. HUTCHINSON.

PHILADELPHIA, August 27th, 1793,

The disease continued to spread, and with a de|gree of mortality that had long been unknown by common fevers.

On the 25th of the month, the college of physi|cians was summoned by their president to meet, in order to consult about the best methods of treating this fever, and of checking its progress in the city. After some consideration upon the nature of the dis|ease, a committee was appointed to draw up some directions for those purposes; and the next day the following were presented to the college, and adopt|ed unanimously by them. They were afterwards published in most of the news papers.

PHILADELPHIA, August 26th, 1793,

THE college of physicians having taken into con|sideration the malignant and contagious fever that

now prevails in this city, have agreed to recom|mend to their fellow citizens the following means of preventing its progress.

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

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

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

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

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

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

7th. To keep the streets and wharfs of the city as clean as possible.—As the contagion of the dis|ease may be taken into the body and pass out of it, without producing the fever, unless it be render|ed active by some occasional cause, the following means should be attended to, to prevent the conta|gion being excited into action in the body.

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

9th. To avoid standing or sitting in the sun; al|so in a current of air, or in the evening air.

10th. To accommodate the dress to the wea|ther; and to exceed rather in warm than in cool cloathing.

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

The college conceive fires to be very ineffectual, if not dangerous means of checking the progress of this fever. They have reason to place more de|pendence upon the burning of gun-powder. The be|nefits of vinegar and camphor, are confined chiefly to infected rooms, and they cannot be used too fre|quently upon handkerchiefs, or in smelling-bottles,

by persons whose duty calls them to visit or attend the sick.

Signed by order of the college,

• WILLIAM SHIPPEN, JUN. Vice President.
• SAMUEL P. GRIFFITTS, Secretary.

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

Mr DUNLAP,

A DOUBT has been expressed by Dr Hutchinson, in his letter to the health-officer, whe|ther the malignant fever, which now prevails in our city, originated in an exhalation from some putrid coffee on a wharf, between Arch and Race-streets, because it made its first appearance at Kensington.

Upon enquiry, it appears that the first persons who died with this fever, about the 5th of the month, in that village, had been previously exposed to the atmosphere of the wharf, and that three of the crew of the Danish ship, who are now ill with it at Kensington, received the seeds of the disease on board their ship, while she lay at or near Race-street wharf. If these facts could not be ascer|tained, it does not follow, that the disease was not generated by the putrid coffee; for, morbid ex|halations, it is well known, produce fevers at the distance of two and three miles, where they are not opposed by houses, woods, or a hilly country. This is obvious to all the farmers who live in the neighbourhood of mill-ponds.

It is no new thing for the effluvia of putrid vegetables to produce malignant fevers. Cab|bage, onions, black pepper, and even the mild po|tatoe, when in a state of putrefaction, have all been the remote causes of malignant fevers. The noxious quality of the effluvia from mill-ponds, is derived wholly from a mixture of the putrified leaves and bark of trees, with water.

It is much less common for the effluvia of pu|trid animal matters to produce fevers. How sel|dom do we hear of them in the neghbourhood of

slaughter-houses, or of the work-shops of skinners or curriers?

These observations are intended to serve two purposes: 1st, To support the opinion of Dr Hutchinson, that the malignant fever, which has excited so general, and so just an alarm in our city, is not an imported disease; and, 2dly, To direct the attention of our citizens to the spot from whence this severe malady has been derived. It will be impossible to check it during the continuance of warm and dry weather, while any of the impure matter which produced it, remains upon the pesti|lential wharf.

R.

This publication had no other effect, than to produce fresh clamours against the author; for the citizens as well as most of the physicians of Phila|delphia had adopted a traditional opinion, that the yellow fever could exist among us, only by impor|tation from the West Indies.

In consequence, however, of a letter from Dr Foulke to the Mayor of the city, in which he had de|cided, in a positive manner in favour of the genera|tion of the fever from the putrid coffee; the mayor gave orders for the removal of the coffee, and the

cleaning of the wharf and dock. It was said that measures were taken for this purpose; but Dr Foulke, who visited the place where the coffee lay, has repeatedly assured me, that they were so far from being effectual, that an offensive smell was exhaled from it many days afterwards.

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

The seeds of the fever, whether received into the body, from the putrid effluvia of the coffee, or by contagion, generally excited the disease in a few days. I met with several cases in which it acted, so as to produce a fever on the same day, in which it was received into the system, and I heard of two cases in which it excited sickness, fainting, and fever, within one hour after the persons were exposed to it. I met with no instance in which there was a longer interval than sixteen days, be|tween the contagion being received into the body, and the production of the disease.

This poison acted differently in different consti|tutions, according to previous habits, to the de|grees

of predisposing debililty, or to the quantity and concentration of the contagion which was ap|plied to the body.

In some constitutions the contagion was at once a remote, a predisposing, and an exciting cause of the disease; hence some persons were affected by it, who had not departed in any instance from their or|dinary habits of living, as to diet, dress, and exer|cise. But it was more frequently brought on by some predisposing, or exciting cause. I shall briefly enumerate each of them.

Whatever be the specific quality of the matter which produced the fever, it is certain, that it acted as a stimulus upon the whole system. In a moderate degree, it produced only a quickness and fulness of the pulse, but when it was more active, it induced that species of debility which has been happily called indirect. It is the reverse of direct debility, which is produced by the ab|straction of natural, and usual stimuli from the body. When the contagion acted with so much force, as to induce indirect debility, a fever some|times followed without the aid of an exciting cause, but this was seldom the case. In ninety-nine cases out of an hundred, which came under my notice, I could distinctly trace the formation

of the disease to some of the following causes, act|ing separately, or in greater or less combination, and inducing indirect or direct debility upon the system. The causes which induced indirect debi|lity were,

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

2. HEAT, from every cause, but more especially the heat of the sun, was a very common exciting cause of the disorder. It aided the stimulus of the contagion in bringing on indirect debility. The re|gister of the weather during the latter end of Au|gust—the whole of September, and the first two weeks in October, will shew how much the heat of the sun must have contributed to excite the dis|ease, more especially among labouring people. The heat of common fires, likewise became a fre|quent cause of the activity of the contagion, where it had been received into the body; hence the greater mortality of the disease among bakers, blacksmiths, and hatters, than among any other class of people.

3. INTEMPERANCE in eating or drinking. A plentiful meal, and a few extra-glasses of wine, sel|dom failed of exciting the fever. But where the body was strongly impregnated with the contagion, even the smallest deviation from the customary stimulus of diet, in respect to quality or quantity, roused the contagion into action. A supper of twelve oysters in one, and only three, in another of my patients, produced the disease. A half an ounce of meat rendered the contagion active in a lady, who had lived by my advice for two

weeks upon milk and vegetables. A supper of sallad dressed after the French fashion, excited it in one of Dr Mease's patients. It is because men are more predisposed by their constitution, and employments, to indirect debility than wo|men, and that young and middle aged persons are more predisposed to this species of debility than old people; that more men than women, and more young than old people, were affected by the disorder.

There were several exciting causes of the disease, which acted by inducing direct debility upon the system. It may appear difficult at first sight to ex|plain, how causes so opposite in their nature, as in|direct and direct debility should produce exactly the same effect. The difficulty vanishes when we reflect, that the abstraction of one stimulus, by accumulating the excitability of the system, en|creases the force of those which remain. The contagion when received into the body, was fre|quently innocent, until it was aided by the addi|tion of a new, or by the abstraction of a customary stimulus. The causes which acted in the latter way were,

1. FEAR. This passion debilitates, only be|cause it abstracts its antagonist passion of courage.

In many people the disease was excited by a sud|den paroxism of fear; but I saw some remarkable instances where timid people escaped the disease, although they were constantly exposed to it. Per|haps a moderate degree of fear served to balance the tendency of the system to indirect debility from the excessive stimulus of the contagion, and there|by to preserve it in a state of healthy equilibrium. I am certain that fear did no harm, after the dis|ease was formed, in those cases where a morbid excess of action, or prostration of the moving powers from excess of stimulus, had taken place. It was an early discovery of this fact which led me not to conceal from my patients the true name of this fever, when I was called to them on the day of their being attacked by it. The fear, co-ope|rated with some of my remedies (to be mention|ed hereafter) in reducing the morbid excitement of the arterial system.

2. GRIEF. It was remarkable that the great|est concentration of the contagion did not pro|duce the disease in many cases in the atten|dants upon the sick, while there was a hope of their recovery. The grief which followed the extinction of hope, by death, frequently produ|ced the disease within a day or two afterwards, and that, not in one person only, but often in most

of the near relations of the diseased. But the dis|ease was also produced by a change in the state of the mind directly opposite to that which has been mentioned. Many persons that attended patients who recovered, were seized with the disorder a day or two after they were relieved from the toils and anxiety of nursing. The collapse of the mind from the abstraction of the stimulus of hope and desire, by their ample gratification, probably pro|duced that debility, and loss of the equilibrium in the system which favoured the activity of the contagion.

The effects of both the states of mind which have been described, have been happily illustrated by two facts which are recorded by Dr Jackson.* 6.1 He tells us that the garrisons of Savannah and York Town, were both healthy during the siege of those towns, but that the former became sick|ly as soon as the French and American armies re|treated from before it, and the latter, immediately after its capitulation.

3. COLD. It will not be necessary to pause here, to prove that cold is a negative quality, and produced only by the absence of heat. Its action

in exciting the disease, depended upon the dimi|nution of the necessary and natural heat of the bo|dy, and thereby so far destroying the equilibrium of the system, as to enable the contagion to pro|duce excessive or convulsive motions in the blood vessels. The night air, even in the warm month of September, was often so cool as to excite the disease where the dress and bed clothes were not accommodated to it. It was excited in one case by a person's only wetting his feet in the month of October, and neglecting afterwards to change his shoes and stockings. Every change in the weather, that was short of producing frost, evi|dently encreased the number of sick people. This was obvious after the 18th and 19th of September, when the mercury fell to 44°, and 45°. The hopes of the city received a severe disappoint|ment upon this occasion, for I well recollect there was a general expectation that this change in the weather would have checked the disorder. The same increase of the number of sick, was observ|ed to follow the cool weather which succeeded the 6th and 7th of October, on which days the mercury fell to 43° and 46°.

It was observed that those persons who were habitually exposed to the cool air, were less liable to the disease than others. I ascribe it to the ha|bitual

impression of the cool night air upon the bodies of the city watchmen, that only four or five of them out of 25 were affected by the dis|order.

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

4. SLEEP. A great proportion of all who were affected by this fever, were attacked in the night. Sleep induced direct debility, and thereby dispo|sed the contagion which floated in the blood, to act with such force upon the system as to destroy its equilibrium, and thus to excite a fever. The influence of sleep as a predisposing, and exciting cause was often assisted by the want of bed cloaths, suited to the midnight or morning coolness of the air.

5. IMMODERATE EVACUATIONS. The efficacy of moderate purging and bleeding in preventing the disease, led some people to use those remedies in an excess, which both predisposed to the dis|ease, and excited it. The morbid effects of these evacuations, were much aided by fear, for it was this passion which perverted the judgment in such

a manner, as to lead to the excessive use of reme|dies, which to be effectual, should only be used in moderate quantities.

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

The precursors, or premonitory signs of this fever were, costiveness, a dull pain in the right side, defect of appetite, flatulency, perverted taste, heat in the stomach, giddiness, or pain in the head, a dull—watery—brilliant, yellow or red eye, dim and imperfect vision, a hoarseness, or slight sore throat, low spirits, or unusual vivacity, a moisture on the hands, a disposition to sweat at nights, or after moderate exercise, or a sudden suppression of night sweats. The dull eye, and the lowness of spirits appeared to be the effects of such an excess in the stimulus of the contagion as to induce indirect debility, while the brilliant eye, and the unusual vivacity, seemed to have been produced by a less quantity of the contagion act|ing as a cordial upon the system. More or less of these symptoms, frequently continued for two or

three days before the patients were confined to their beds, and in some people they continued du|ring the whole time of its prevalence in the city, without producing the disease. I wish these symp|toms to be remembered by the reader. They will form the corner stone of a system which I hope will either eradicate the disorder altogether, or render it as safe as an intermitting fever, or as the small pox when it is received by inoculation.

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

Upon entering a sick room where a patient was confined by this fever, the first thing that struck the eye of a physician, was the countenance. It was as much unlike that which is exhibited in the common bilions fever, as the face of a wild, is unlike the face of a mild domestic animal. The eyes were sad, watery, and so inflamed in

some cases as to resemble two balls of fire. Some|times they had a most brilliant or ferocious ap|pearance▪ The face was suffused with blood, or of a dusky colour, and the whole countenance was downcast and clouded. After the 10th of Sep|tember, when a determination of blood to the brain became universal, there was a preternatural dilatation of the pupil. Sighing attended in al|most every case. The skin was dry, and frequent|ly of its natural temperature. These were the principal symptoms which discovered themselves to the eye, and hand of a physician. The an|swers to the first questions proposed upon visiting a patient, were calculated to produce a belief in the mind of a physician, that the disease under which the patient laboured, was not the prevail|ing malignant epidemic. I did not for many weeks meet with a dozen patients, who acknowledged that they had any other indisposition than a com|mon cold, or a slight remitting, or intermitting fever. I was particularly struck with this self de|ception in many persons, who had nursed relations that had died with the yellow fever, or who had been exposed to its contagion in families, or neigh|bourhoods, where it had prevailed for days and even weeks with great mortality. I shall hereaf|ter trace a part of this disposition in the sick to deceive themselves, to the influence of certain

publications which appeared soon after the disease became epidemic in the city.

In the further history of this fever, I shall de|scribe its symptoms as they appeared.

• I. In the sanguiferous system.
• II. In the liver, lungs, and brain.
• III. In the alimentary canal; in which I include the stomach as well as the bowels.
• IV. In the secretions and excretions.
• V. In the nervous system.
• VI. In the senses and appetites.
• VII. In the lymphatic and glandular system.
• VIII. Upon the skin.
• IX. In the blood.

After having finished this detail, I shall men|tion some general characters of the disease, and

afterwards subdivide it into classes, according to its degrees and duration.

I. The BLOOD VESSELS (and not the stomach and bowels according to Dr Warren) are the "seat and throne" of this as well as of all other fevers. I have publicly taught for seve|ral years, that a fever is occasioned by a convul|sion in the arterial system. When the epidemic, which we are now considering, came on with a full, tense, and quick pulse, this convulsion was very perceptible; but it frequently came on with a weak pulse; often without any preternatu|ral frequency or quickness, and sometimes so low as not to be perceived without pressing the artery at the wrists. In many cases the pulse intermitted after the 4th, in some after the 5th, and in others after the 14th stroke. These intermissions occur|red in several persons who were infected, but who were not confined by the fever. They likewise continued in several of my patients for many days after their recovery. This was the case in particu|lar in Mrs Clymer, Mrs Palmer's son William, and in a son of Mr William Compton. In some there was a preternatural slowness of the pulse. It beat 44 strokes in a minute in Mr B. W. Morris—48 in Mr Thomas Wharton, Jun. and 64 in Mr William

Sansom, at a time when they were in the most im|minent danger. Dr Physic informed me, that in one of his patients the pulse was reduced in fre|quency to 30 strokes in a minute. All these different states of the pulse have been taken notice of by authors who have described pestilential fe|vers.* 6.2 They have been improperly ascribed to the absence of fever: I would rather suppose that they are occasioned by the stimulus of the conta|gion, acting upon the arteries with too much force to admit of their being excited into quick and con|vulsive motions. The remedy which removed it (to be mentioned hereafter) will render this expla|nation of its cause still more probable. Milton describes a darkness, from an excess of light. In like manner, we observe in this small intermitting and slow pulse, a deficiency of strength from an excess of force applied to it. In every case of it which came under my notice, it was likewise tense or chorded. This species of pulse occurred chief|ly in the month of August, and in the first ten days in September. I had met with it former|ly in a sporadic case of yellow fever. It was new to all my pupils. One of them, Mr Wash|ington,

gave it the name of the "undiscribable pulse." It aided in determining the specific na|ture of this fever before the common bilious re|mittent disappeared in the city. For a while, I ascribed this peculiarity in the pulse, more especi|ally its slowness, to an affection of the brain only, and suspected that it was produced, by what I have taken the liberty elsewhere to call the phrenicula, or inflammatory state of the internal dropsy of the brain, and which I have remarked to be an occa|sional symptom and consequence of remitting fe|ver.* 6.3 I was the more disposed to adopt this opi|nion, from perceiving this slow and intermitting pulse more frequently in children than in adults. Impressed with this idea, I requested Mr Coxe, one of my pupils, to assist me in examining the state of the eye. For two days we discovered no change in it, but on the third day after we began to in|spect the eyes, we both perceived a preternatural dilatation of the pupils in different patients; and we seldom afterwards saw an eye in which it was absent. In Dr Say it was attended by a squinting, a symptom which marks a high degree of a mor|bid affection of the brain. Had this slowness or intermission in the pulse occurred only after signs of inflammation or congestion had appeared in the

brain, I should have supposed that it had been de|rived wholly from that cause; but I well recollect having felt it several days before I could discover the least change in the pupil of the eye. I am for|ced therefore to call in the operation of another cause, to assist in accounting for this state of the pulse, and this I take to be a spasmodic affection, accompanied with preternatural dilatation or con|traction of the heart. Lieutaud mentions this spe|cies of pulse in several places, as occurring with an undue enlargement of this muscle* 6.4. Dr Ferriar describes a case, in which a low, irregular, inter|mitting and hardly perceptible pulse, attended a morbid dilatation of the heart.† 6.5 In a letter I lately received from Mr Hugh Ferguson, a stu|dent of medicine in the college of Edinburgh, written from Dublin, during the time of a visit to his father, and dated September 30th, 1793, I find a fact which throws additional light upon this sub|ject. "A case (says my young correspondent) where a remarkable intermission of pulse was ob|served, occurred in this city last year. A gentle|man of the medical profession, middle aged, of a de|licate habit of body, and who had formerly suffer|ed

phthisical attacks, was attacked with the acute rheumatism. Some days after he was taken ill, he complained of uncommon fulness, and a very peculiar kind of sensation about the praecordia, which it was judged proper to relieve by copious blood-letting. This being done, the uneasiness went off. It returned however three or four times, and was as often relieved by bleeding. During each of his fits (if I may call them so), the pa|tient experienced an almost total remission of his pains in his limbs; but they returned with equal or greater violence after blood-letting. During the fit there was an intermission of the pulse (the first time) of no less than thirteen strokes. It was when beating full, strong, and slow. The third intermission was of nine strokes. The gentleman soon recovered, and has enjoyed good health for ten months past. The opinion of some of his phy|sicians was, that the heart was affected as a mus|cle, by the rheumatism, and alternated with the limbs."

I am the more inclined to believe the peculia|rity in the pulse which has been mentioned in the yellow fever, arose in part from a spasmodic affec|tion of the heart, from the frequency of an uncom|mon palpitation of this muscle, which I discovered in this disorder, more especially in old people.

The disposition likewise to syncope and sighing, which so often occurred, can be explained upon no other principle than inflammation, spasm, dilata|tion, or congestion in the heart. After the 10th of September this undescribable or sulky pulse (for by the latter epithet I sometimes called it) became less observable: and in proportion as the weather became cool, it totally disappeared. It was gradually succeeded by a pulse, full, tense, quick, and as fre|quent as in pleurisy or rheumatism. It differed how|ever from a pleuritic or rheumatic pulse, in impar|ting a very different sensation to the fingers. No two strokes seemed to be exactly alike. Its ac|tion was of a hobbling nature. It was at this time so familiar to me, that I think I could have distin|guished the disease by it, without seeing the pati|ent. It was remarkable, that this pulse attended the yellow fever even when it appeared in the mild form of an intermittent, and in those cases where the patients were able to walk about, or go a|broad. It was nearly as tense in the remissions and intermissions of the fever, as it was in the ex|acerbations. It was an alarming symptom, and when the only remedy which was effectual to re|move it, was neglected, such a change in the sys|tem was induced, as frequently brought on death in a few days.

This change in the pulse, from extreme low|ness, to fulness and activity, appeared to be owing to the diminution of the heat of the weather, which by its stimulus, added to that of the con|tagion, had induced those symptoms of indirect debility in the pulse, which have been mentioned.

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

HEMORRHAGIES belong to the symptoms of this fever as they appeared in the sanguiferous sys|tem. They occurred in the beginning of the dis|order chiefly from the nose and uterus. Some|times but a few drops of blood distilled from the nose. The menses were unusual in their quantity, when they appeared at their stated periods, but they often came on a week or two before the usual time of their appearance. I saw one case of an hemorrhage from the lungs on the first day of the fever, which was mistaken for a common hemop|tysis. As the disease advanced, the discharges of blood became more universal. They occurred from the gums, ears, stomach, bowels, and urinary pas|sages. Drops of blood issued from the inner Can|thus

of the left eye of Mr Josiah Coates. Dr Wood|house attended a lady who bled from the holes in her ears, which had been made by ear rings. Many bled from the orifices which had been made by bleeding, several days after they appeared to have been healed, and some from wounds which had been made in veins in unsuccessful attempts to draw blood. These last hemorrhages were very troublesome, and in some cases precipitated death.

II. I come now to mention the symptoms of this fever as they appeared in the LIVER, the LUNGS, and the BRAIN. From the histories which I had read of this disorder, I was early led to ex|amine the state of the LIVER, but I was surprised to find so few marks of hepatic affection. I met with but two cases in which the patient could lie only on the right side. Many complained of a dull pain in the region of the liver, but very few complained of that soreness to the touch, about the pit of the stomach which is taken notice of by authors, and which was universal in the yellow fever in 1762. In proportion as the cool weather advanced, a preternatural determination of the blood took place chiefly to the lungs and brain. Many were affected with pneumonic symptoms,

and some appeared to die of sudden effusions of blood or serum in the lungs. It was an unex|pected effusion of this kind which put an end to the life of Mrs Keppele after she had exhibited hopeful signs of a recovery.

I saw one person who recovered from an affection of the lungs, by means of a copious expectoration of yellow phlegm and mucus. But the BRAIN was principally affected with morbid congestion in this disorder. It was indicated by the suffusion of blood in the face, by the redness of the eyes, by a dila|tation of the pupils, by the pain in the head, by the hemorrhagies from the nose and ears, by the sickness, or vomiting, and by an almost universal costive state of the bowels. I wish to impress the reader with these facts, for they formed one of the strongest indications for the use of the remedies which I adopted for the cure of this disorder. It is difficult to determine the exact state of these viscera in every case of bilious and yellow fever. Inflammation certainly takes place in some cases, and internal hemorrhagies in others; but I believe the most frequent affection of these viscera consists in a certain morbid accumulation of blood in them, which has been happily called by Dr Clark an engorgement or choaking of the blood vessels. I

believe further with Dr Clark* 6.6 and Dr Balfour† 6.7, that death in most cases in bilious fevers is the effect of these morbid congestions, and wholly un|connected with direct debility or a supposed putre|faction in the fluids. It is true the dissections of Dr Physic and Dr Cathrall discovered no morbid appearances in either of the viscera which have been mentioned, but it should be remembered, that these dissections were made early in the disorder. Dr Annan attended the dissection of a brain of a patient who died at Bush-hill some days afterwards, and observed the blood vessels to be unusually turgid. In those cases where con|gestion only takes place, it is as easy to conceive that all morbid appearances in the brain may cease after death, as that the suffusion of blood in the face should disappear after the retreat of the blood from the extremities of the vessels in the last mo|ments of life. It is no new thing for morbid affections of the brain to leave either slender or no marks of disease after death. Dr Quin has given a dissection of the brain of a child that died with all the symptoms of hydrocephalus inter|nus, and yet nothing was discovered in the brain but a slight turgescence of its blood vessels. Dr

Girdlestone says, no injury appeared in the brains of those persons who died of the symptomatic apo|plexy, which occurred in a spasmodic disease which he describes in the East Indies; and Mr Clark in|forms us, that the brain was in a natural state in every case of death from puerperile fever, not|withstanding it seemed to be affected in many cases soon after the attack of that disorder* 6.8.

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

III. The STOMACH and BOWELS Were affected in many ways in this fever. The disease seldom appeared without nausea or vomiting. In some cases, they both occurred for several days, or a week before they were accompanied by any fever. This was more frequently the case, where the dis|ease was taken by exhalation from the putrid coffee, than by contagion. Sometimes a pain, known by the name of gastrodynia, ushered in the disease. The stomach was so extremely irritable as to reject drinks of every kind. Sometimes green or yellow bile was rejected on the first day of the disorder, by vomiting; but I much oftener saw it continue for two days without discharging any thing from the stomach, but the drinks which were taken by the patient. If the fever in any case came on without vomiting, or if it had been checked by remedies that were ineffectual, to remove it altogether, it generally appeared, or returned, on the 4th or 5th day of the disorder. I dreaded this symptom on those days, for although it was not always the forerun|ner of death, yet it generally rendered the reco|very more difficult and tedious. In some cases the vomiting was more or less constant from the be|ginning to the end of the disorder, whether it ter|minated in life or death.

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

Flatulency was an almost universal symptom in every stage of this disorder. It was very distres|sing in many cases. It occurred chiefly in the sto|mach.

The BOWELS were generally costive, and in some patients, as obstinately so, as in the dry gripes. In some cases there was all the pain and distress of a bilious colic, and in others, the tenes|mus, and mucous and bloody discharges of a true dysentery. A diarrhoea introduced the disease in in a few persons, but it was chiefly in those who had been previously indisposed with weak bowels.

A painful tension of the abdomen took place in many, accompanied in some instances by a dull, and in others, by an acute pain in the lower part of the belly.

The vomiting and costiveness in the first stage of this fever, I believe were occasioned chiefly by the morbid state of the brain. But the vomiting and burning in the stomach, and the pain in the bowels which occurred on the 4th and 5th days, appeared to be the effects of inflammation induced in part by the effusion of acrid bile into the alimentary canal, and in part by a change in the action of the coats of the stomach and bowels, induced by effu|sions of serum or red blood, similar to those which take place on the skin in malignant fevers, and which are known by the name of petechiae. I am the more disposed to ascribe a large portion of the inflammation, erosions, and mortifications, which have been observed after death in the stomach and bowels in this fever, to the latter cause, from the discovery which has been made of petechiae and carbuncles in the bowels in the plague, exactly simi|lar to those which are found on the external parts of the body in that disorder* 6.9.

IV. I come now to describe the state of the SECRETIONS and EXCRETIONS, as they appeared in different stages of this fever.

There appeared to be a preternatural secretion and excretion of bile. It was discharged from the stomach and bowels in large quantities, and of very different qualities and colours.

1. On the first and second days of the disorder, many patients puked from half a pint to nearly a quart of green or yellow bile. Four cases came under my notice in which black bile was dis|charged on the first day. Three of these patients recovered. I ascribed their recovery, to the bile not having as yet acquired acrimony enough to in|flame, or-corrode the stomach.

2. There was frequently on the 4th or 5th day, a discharge of matter from the stomach, resembling coffee impregnated with its grounds. This was always an alarming symptom. I believed it at first to be a modification of vitiated bile, but I was led afterwards by its resemblance to the urine (to be described hereafter) to suspect that it was pro|duced by a morbid secretion in the liver, and ef|fused from it into the stomach. Many recovered who discharged this coffee-coloured matter.

3. Towards the close of the disease, there was a discharge of matter of a deep or pale black colour, from the stomach. Flakey substances frequent|ly floated in the bason or chamber-pot upon the surface of this matter. It appeared to be bile in a highly acrid state. That the bile may become ex|tremely acrid in this stage of the disorder is evident from several observations and experiments. Dr Physic's hand was inflamed in consequence of its being wetted by bile in this state, in dissecting a dead body. Dr Arthaud examined the body of a soldier who died of the yellow fever at the French Cape on the 16th of May 1789, whose bile im|parted a green colour* 6.10, to the tincture of radishes. I am not certain that the black matter, which was discharged in the last stage of this disorder, was al|ways vitiated or acrid bile. It was probably in some cases, the matter which was formed in con|sequence of the mortification of the stomach. The matter which was discharged from carbuncles on the skin, as I shall say hereafter, was always of a dark colour. Several dissections of persons who have died of the yellow fever, have shewn abscesses in the stomach, not unlike external carbuncles. May not the black matter in some cases be derived from these internal carbuncle-like abscesses?

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

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

The colour, quality, and quantity of the faeces depended very much upon the treatment of the disease. Where active purges had been given, the stools were copious, foetid, and of a black or dark colour. Where they were spontaneous, or excited by weak purges, they had a more natural ap|pearance. In both cases, they were sometimes of a green, and sometimes of an olive colour. Their smell was more or less foetid, according to the time in which they had been detained in the bowels. I visited a lady who had passed several days with|out a stool, and who had been treated with tonic remedies. I gave her a purge, which in a few hours procured a discharge of faeces so ex|tremely foetid, that they produced fainting in an old woman who attended her. The acrimony of the faeces was such as to excoriate the rectum, and sometimes to produce an extensive inflammation all around its external termination. The quantity of the stools produced by a single purge was in many cases very great. They could be accounted for only by calling in the constant, and rapid formation of them, by preternatural effusions of bile into the bowels.

I attended one person, and heard of two others, in whom the stools were as white as in the jaun|dice. I suspected in these cases, the bile was so

impacted in the gall bladder, or in its ducts, as not to be discharged in a sufficient quantity to co|lour the foeces. Large round worms were fre|quently discharged with the stools.

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

A total deficiency of the urine took place in many people for a day or two, without pain. Dr Sydenham takes notice of the same symptom in the highly inflammatory small pox.* 6.11 It general|ly accompanied, or portended great danger. I suspected that it was connected in this disease, as in the hydrocephalus internus, with a morbid state of the brain. I heard of one case in which there

was a suppression of urine, which could not be re|lieved without the use of the catheter.

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

Dr Arthaud informs us in the history of the dissection before quoted, that the urine after death imparted a green colour to the tincture of radishes.

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

There was in some cases a preternatural secre|tion and excretion of mucus from the glands of the throat. It was discharged by an almost con|stant hawking and spitting. All who had this symptom recovered.

The TONGUE was in every case moist, and of a white colour on the first and second days of the fever. As the disease advanced, it as|sumed a red colour, and a smooth shining ap|pearance. It was not quite dry in this state Towards the close of the fever, a dry black streak appeared in its middle, which gradu|ally extended to every part of it. Few reco|vered after this appearance on the tongue took place.

V. In the NERVOUS SYSTEM the symptoms of the fever were different according as it affected the brain—the muscles—the nerves—or the mind. The sudden and violent action of the contagion, induced apoplexy in several people. In some, it brought on syncope, and in others, convulsions in every part of the body. The apoplectic cases generally proved fatal, for they fell chiefly upon hard drinkers. Persons affected by syncope, or convulsions, sometimes fell down in the streets. Two cases of this kind happened near my house.

One of them came under my notice. He was supposed by the bye-standers to be drunken, but his countenance, and convulsive motions, soon convinced me that this was not the case.

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

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

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

There was in some instances a deficiency of sen|sibility, but in others a degree of it, extending to

every part of the body, which rendered the appli|cation of common rum to the skin, and even the least motion of the limbs painful.

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

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

The mind suffered with the morbid states of the brain and nerves. A delirium was a common symptom. It alternated in some cases with the exacerbations and remissions of the fever. In

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

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

I observed in several persons the operations of the understanding to be unimpaired, throughout

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

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

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

The pain which attended the disorder was dif|ferent according as the system was affected by direct or indirect debility. In those cases in which the system sunk under the violent impression of the contagion, there was little or no pain. In

proportion as the system was relieved from this oppression it recovered its sensibility. The pain in the head, was acute and distressing. It affected the eye balls in a peculiar manner. A pain ex|tended in some cases from the back of the head, down the neck. The ears were affected in several persons with a painful sensation, which they com|pared to a string drawing their two ears together through the brain. The sides, and the regions of the stomach, liver and bowels, were all, in differ|ent people, the scats of either dull or acute pains. The stomach towards the close of the disorder was affected with a burning or spasmodic pain of the most distressing nature. It produced in some cases great anguish of body and mind. In others it pro|duced cries and shrieks which were often heard on the opposite side of the streets to where the patients lay. The back suffered very much in this disorder. The stoutest men complained, and even groaned un|der it. An acute pain extended in some cases from the back, to one or both thighs. The arms and legs sympathized with every other part of the body. One of my patients, upon whose limbs the disease fell, with its principal force, said that his legs felt as if they had been scraped with a sharp instru|ment. The sympathy of friends with the distresses of the sick, extended to a small part of their misery, when it did not include their sufferings from pain.

One of the dearest friends I ever lost by death, declared in the height of her illness, that "no one knew the pains of a yellow fever, but those who felt them."

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

The thirst was moderate or absent in some cases, but it occurred in the greatest number of persons whom I saw in this fever. Sometimes it was very intense. One of my patients who suf|fered by an excessive draught of cold water, de|clared just before he died, that "he could drink up the Delaware." It was always an alarming symptom, when this thirst came on in this extra|vagant

degree in the last stage of the disorder. In the beginning of the fever, it generally abated upon the appearance of a moist skin. Water, was preferred to all other drinks.

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

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

The convalescence from this disorder was mark|ed in some instances, by a sudden revival of the

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

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

In one of the cases of inguinal buboes, the whole force of the disease seemed to be collected into the

lymphatic system. The patient walked about, and had no fever nor pain in any part of his body, except in his groin. In another case which came under my care, a swelling and pain extended from the groin along the spermatic cord into one of the testicles. These glandular swellings were not pe|culiar to our late epidemic. They occurred in the yellow fever of Jamaica as described by Dr Williams, and always with a happy issue of the disorder* 6.12. A similar concentration of the con|tagion of the plague in the lymphatic glands, is taken notice of by Dr Patrick Russel.

VIII. The SKIN exhibited many marks of this fever. It was preternaturally warm in some cases, but it was often preternaturally cool. In some there was a distressing coldness in the limbs for two or three days. The yellow colour from which this fever has derived its name, was not universal. It seldom appeared where purges had been given in sufficient doses. The yellowness rarely appear|ed before the third, and generally about the fifth or seventh day of the fever. Its early appearance always denoted great danger. It sometimes appear|ed first on the neck and breast, instead of the eyes. In one of my patients it discovered itself first be|hind

one of his ears, and on the crown of his head, which had been bald for several years. The re|missions and exacerbations of the fever seemed to have an influence upon this colour, for it appeared and disappeared altogether, or with fainter or deep|er shades of yellow, two or three times in the course of the disorder. The eyes seldom escaped a yellow tinge; and yet I saw a number of cases in which the disease appeared with uncommon ma|lignity and danger, without the presence of this symptom. Two very different causes have been supposed to produce this yellow colour of the skin. By some it has been attributed to the dissolution of the blood; but I shall say hereafter, that the blood was seldom dissolved in this fever. The yel|low colour, moreover, occurred in those cases where the blood exhibited an inflammatory crust, and it continued in many persons for five or six weeks after their recovery. From these facts it is evi|dent, that the yellowness was in all cases the effect of an absorption and mixture of bile with the blood.

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

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

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

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

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

4. Many persons had eruptions which resem|bled moschetto bites. They were red and circum|scribed. They appeared chiefly on the arms, but they sometimes extended to the breast. Like the yellow colour of the skin, they appeared and dis|appeared two or three times in the course of the disorder.

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

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

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

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

Notwithstanding this disposition to cutaneous eruptions in this disorder, it was remarkable that blisters were much less disposed to mortify than in the common nervous fever. I met with only one case in which a deep-seated ulcer followed the ap|plication

of blisters to the legs. Such was the in|sensibility of the skin in some people, that blisters made no impression upon it.

IX. How far the blood may be considered as the vehicle of the contagion, it is not my business at present to inquire; nor shall I in this place men|tion the different appearances it exhibited when drawn from a vein. It has been supposed to un|dergo a change from a healthy to a putrid state; and many of the symptoms of the fever which have been described, particularly the hemorrhagies and eruptions on the skin, have been ascribed to this supposed putrefaction of the blood. It would be easy to multiply arguments to prove, that no such thing as putrefaction can take place in the blood; and that the symptoms which have been supposed to prove its existence, are all effects of a sudden, violent, and rapid inflammatory ac|tion, or pressure upon the blood-vessels; and hence the external and internal hemorrhagies. The pe|techiae on the surface of the skin depend upon the same cause. They are nothing but effusions of se|rum or red blood, from a rupture or preternatural dilatation of the capillary vessels* 6.13. The smell

emitted from persons affected by this disease was far from being of a putrid nature; and if this had been the case, it would not have proved the exi|stence of putrefaction in the blood; for a putrid smell is often discharged from the lungs, and from the pores in sweat, which is wholly unconnected with a putrid, or perhaps any other morbid state of the blood. There are plants which discharge an odor, which conveys to the nose a sensation like that of putrefaction; and yet these plants exist at the same time, in a state of the most healthy vege|tation: nor does the early putrid smell of a body which perishes with this fever, prove a putrid change to have taken place in the blood before death. All animals which die suddenly, and with|out loss of blood, are disposed to a speedy putre|faction. This has long been remarked in animals that have been killed after a chace, or by light|ning. The poisonous air called samiel, which is described by Chardin, produces, when it destroys life, instant putrefaction. The bodies of men who die of violent passions, or after strong convulsions, or even after great muscular exertion, putrefy in a few hours after death. The healthy state of

the body depends upon a certain state of arrange|ment in the fluids. A derangement of these fluids is the natural consequence of the violent and ra|pid motions, or of the undue pressure upon the so|lids, which have been mentioned. It occurs in every case of death from indirect debility, whe|ther it be induced by the excessive stimulus of con|tagion, by the volatile vitriolic acid which is sup|posed to constitute the destructive samiel wind, or by violent commotions excited in the body by ex|ternal or internal causes. The practice among fishermen in some countries, of breaking the heads of their fish as soon as they are taken out of the wa|ter, in order to retard their putrefaction, proves the truth of the explanation I have given of its cause, soon after death. The sudden extinction of life in the fish, prevents those convulsive or violent mo|tions which induce sudden disorganization in their bodies. It was remarkable that putrefaction took place most speedily after death from the yellow fever, where the commotions of the system were not relieved by evacuations. In those cases where purges and bleeding had been used, putrefaction did not take place sooner after death than is com|mon in any other febrile disease, under equal cir|cumstances of heat and air.

There is a fact mentioned by Dr Ferriar, from Dr Hamilton, late professor of anatomy at Glas|gow,

which may seem at first sight to militate against the facts I have mentioned. He says that he had observed bodies which were brought into the dissecting room, that had petechiae on them, were longer in putrefying than any others. The fevers of which the poor (the common subjects of dissection) die, are generally of the low ner|vous kind. Great direct debility is the charac|teristic of these fevers. The petechiae which oc|cur in them, appear in the last stage of this direct debility. They are the effect, not of too much impetus in the blood, as in the yellow fever, but of a defect or total absence of it in the last hours of life. The slow progress of the body to pu|trefaction after death, in the instances mentioned by Dr Hamilton, seems to depend upon the same cause as that to which I have ascribed it in those cases of death from the yellow fever, in which e|vacuations had been used, viz. direct debility. In the former cases this slowness of putrefaction is induced by nature—in the latter by art. The effects of debility from both causes are, notwith|standing, the same.

Thus have I described the symptoms of this fe|ver. From the history I have given, it appears that it counterfeited nearly all the acute and chronic diseases, to which the human body is sub|ject. An epitome, both of its symptoms and its the|ory,

is happily delivered by Dr Sydenham in the following words. After describing the epidemic cough, pleurisy, and peripneumony of 1675, he adds, "But in other epidemics, the symptoms are so slight from the disturbance raised in the blood by the morbific particles contained in the mass, that nature being in a manner oppressed, is rendered unable to produce regular symptoms that are suitable to the disease; and almost all the phaenomena that happen are irregular, by reason of the entire subversion of the animal oeconomy; in which case the fever is often depressed, which of its own nature, would be very high. Some|times also fewer signs of a fever appear than the nature of the disease requires, from a translation of the malignant cause, either to the nervous sy|stem, to some other parts of the body, or to some of the juices not contained in the blood; whilst the morbific matter is yet turgid"* 6.14.

The disease ended in death in various ways. In some it was sudden; in others it came on by gra|dual approaches. In some the last hours of life were marked with great pain, and strong convul|sions; but in many more, death seemed to insinu|ate itself into the system, with all the gentleness of

natural sleep. Mr Powell expired with a smile on his countenance. Dr Griffitts informed me that Dr Johnson exhibited the same symptom in the last hours of his life. This placid appearance of the countenance, in the act of dying, was not new to me. It frequently occurs in diseases which affect the brain and nerves. I lost a patient three years ago in the gout, who not only smiled, but laughed, a few minutes before he expired.

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

In every case of this disorder which came under my notice, there were evident remissions, or inter|missions of the fever, or of such symptoms as were substituted for fever. I have long considered with Mr Senac, a tertian as the only original type of all fevers. The bilious yellow fever indicated its descent from this parent disorder. I met with many cases of regular tertians in which the pa|tients were so well on the intermediate days as to go abroad. It appeared in this form in Mr Van Berkel the minister of the United Netherlands. Nor was this mild form of the fever devoid of danger. Many died who neglected it as a trifling disorder, or who took the common remedies for

intermittents to cure it. It generally ended in a remittent before it destroyed the patient. The tertian type discovered itself in some people after the more violent symptoms of the fever had been subdued, and continued in them for several weeks. It changed from a tertian to a quartan type in Mr Thomas Willing, nearly a month after his reco|very from the more acute and inflammatory symp|toms of the disorder.

It is nothing new for a malignant fever to ap|pear in the form of a tertian. It is frequently the garb of the plague. Riverius describes a tertian fever which proved fatal on the third day, which was evidently derived from the same exhalation which produced a continual malignant fever.* 6.15

The remissions were more evident in this, than in the common bilious fever. They generally oc|curred in the forenoon. It was my misfortune to be deprived by the great number of my patients, of that command of time which was necessary to watch the exacerbations of this fever under all their various changes, as to time, force, and duration. From all the observations that were suggested by

visits, at hours that were seldom left to my choice, I was led to conclude, that the fever exhibited in different people all that variety of forms which has been described by Dr Cleghorn in his account of the tertian fever of Minorca. A violent ex|acerbation on even days was evidently attended with more danger than on odd days. The same thing was observed by Dr Mitchell in the Yellow Fever of Virginia in the year 1741.

If (says he) the exacerbations were on equal days, they generally died in the third paroxysm, or the 6th day, but if on unequal days, they recovered on the 7th.

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

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

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

I think I observed the fever to terminate on the third day more frequently in August, and during the first ten days in September, than it did after the weather became cool. In this, it resembled the common bilious remittents of our city, also the simple tertians described by Dr Cleghorn* 6.16. The danger seemed to be in proportion to the tendency of the disease to a speedy crisis, hence more died in August in proportion to the number who were affected than in September or October, when the disease was left to itself. But, however strange after this remark it may appear, the dis|ease yielded to the remedies which finally subdued it, more speedily and certainly upon its first ap|pearance in the city, than it did two or three weeks afterwards.

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

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

The first includes those in whom the stimulus of the contagion, produced the symptoms of indi|rect debility, such as coma, languor, sighing, a dis|position to syncope, and a weak, or slow pulse.

The second includes those in whom the conta|gion acted with less force, producing great pain in the head, and other parts of the body; deli|rium, vomiting, heat, thirst, and a quick, tense, or full pulse, with obvious remissions or intermissions of the fever.

The third class includes all those persons in whom the stimulus of the contagion acted so fee|bly as not to confine them to their beds or houses.

This class of persons affected by the yellow fever, was very numerous. Many of them recovered without medical aid, or by the use of domestic prescriptions; many of them recovered in conse|quence of a spontaneous diarrhoea, or plentiful sweats; many were saved by moderate bleeding, and purging; while some died, who conceived their complaints to be occasioned by a common cold, and neglected to take proper care of them|selves, or to use the necessary means for their re|covery. It is not peculiar to the contagion of the yellow fever to produce this feeble operation up|on the system. It has been observed in the south|ern states of America, that in those seasons in which the common bilious fever is epidemic "no body is quite well," and that what are called in those states "inward fevers" are universal. The small-pox even in the natural way, does not always confine the patient; and thousands pass through the plague without being confined to their beds or houses. Dr Hodges prescribed for this class of patients in his parlour in London in the year 1665, and Dr Patrick Russel did the same from a chamber window fifteen feet above the level of the street at Aleppo. Notwithstanding the mild form the plague put on in these cases, it often proved fatal according to Dr Russel. I have in|troduced these facts chiefly with a view of prepa|ring

the reader to reject the opinion that we had two species of fever in the city at the same time; and to shew that the yellow fever appears in a more simple form than with "strongly marked" characters; or in other words, with a yellow skin, and a black vomitting.

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

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

The only case like influenza which I saw after the 5th of September, was in a girl of 14 years of age, on the 13th of the month. It came on with a sneezing and cough. I was called to her on the third day of her disorder. The instant I felt

her pulse, I pronounced her disease to be the yel|low fever. Her father was offended with this opinion, although he lived in a highly infected neighbourhood, and objected to the remedies I prescribed for her. In a few days she died. In the course of ten days, her father and sister were infected, and both died I was informed, with the usual symptoms of the yellow fever.

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

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

Dr Sydenham makes the same remark upon the plague in London in 1665. Dr Hodges in his account of the same plague, says that "at the rise of the plague all other distempers, went into it, but at its declension, that it degenerated into others, as inflammations, headach, quinsies, dy|senteries, small-pox, measles, fevers, and hectics, wherein the plague yet predominated* 6.17."

During the prevalence of the plague in Grand Cairo, no sporadic disease of any kind makes its appearance. The same observation is made by Sauvage in his account of the plague at Alais in the province of Languedoc† 6.18.

The small-pox though a disease of less force than the plague, has often chased it from Constantino|ple, probably from its infecting at a greater distance than the plague. But this exclusive prevalence of a single epidemic is not confined to the plague and small-pox. Dr Sydenham's writings are full of proofs of the dominion of febrile diseases over each other: Hence after treating upon a sympto|matic

pleurisy, which sometimes accompanied a slow fever in the year 1675, and which had pro|bably been injudiciously treated by some of those physicians who prescribe for the name of a disease, he delivers the following aphorism, "whoever in the cure of fevers, hath not always in view, the constitution of the year, inasmuch as it tends to produce some particular epidemic disease, and likewise to reduce all the cotemporary diseases to its own form and likeness, proceeds in an uncer|tain and fallacious way* 6.19." It appears further from the writings of this excellent physician, that where the monarchy of a single disease was not immediately acknowledged, by a sudden retreat of all cotemporary diseases, they were forced to do homage to it, by wearing its livery. It would be easy to multiply proofs of this assertion, from the numerous histories of epidemics which are to be found in his works. I shall mention only one or two of them. A continual fever accompanied by a dry skin, had prevailed for some time in the city of London. During the continuance of this fever, the regular small-pox made its appearance. It is peculiar to the small-pox when of a distinct nature, to be attended by irregular sweats before the eruption of the pocks. The continual fever

now put on a new symptom. It was attended by sweats in its first stage, exactly like those which at|tended the eruptive fever of the small-pox* 6.20. This despotism of a powerful epidemic, extended it|self to the most trifling indispositions. It even blended itself, Dr Sydenham tells us, with the commotions excited in the system by the suppres|sion of the lochia, as well as with the common puerperile fever† 6.21. Dr Morton, has left testimo|nies behind him in different parts of his works, which establish, in the most ample manner, the truth of Dr Sydenham's observations. Dr Hux|ham describes the small-pox as blending some of its symptoms with those of a slow fever at Ply|mouth in the year 1729‡ 6.22. Dr Cleghorn menti|ons a constitution of the air at Minorca, so highly inflammatory, "that not only tertian fevers, but even a common hurt or bruise required more plentiful evacuations than ordinary."§ 6.23 Riverius informs us in his history of a pestilential fever that prevailed in France, that "it united itself with phrenitis, angina, pleurisy, peripneumony, hepa|titis, dysentery, and many other diseases‖ 6.24."

The bilious remitting fever which prevailed in Philadelphia in 1780, chased away every other febrile disease; and the scarlatina anginosa which prevailed in our city in 1783 and 1784, furnished a striking proof of the influence of epidemics over each other. In the account which I published of this disease, in the year 1789, there are the follow|ing remarks. "The intermitting fever which made its appearance in August, was not lost du|ring the month of September. It continued to prevail, but with several peculiar symptoms. In many persons it was accompanied by an eruption on the skin, and a swelling of the hands and feet. In some it was attended with sore throat, and pains behind the ears. Indeed such was the pre|valence of the contagion which produced the scar|latina anginosa, that many hundred people com|plained of sore throats, without any other symp|tom of indisposition. The slightest exciting cause, and particularly cold, seldom failed of producing the disorder* 6.25."

I shall mention only one more authority in fa|vour of the influence of a single epidemic upon diseases. It is taken from Mr Clark's essay on the epidemic disease of lying-in women, of the

years 1787 and 1788. "There does not appear to be any thing in a parturient state, which can prevent women from being affected by the gene|ral causes of disease at that time; and should they become ill, their complaints will probably partake of the nature of the reigning epidemic* 6.26." I have said that the fever sometimes put on the symp|toms of dysentery, pleurisy, rheumatism, colic, palsy, and even of the locked jaw. That these were not original diseases, but symptomatic af|fections only of the reigning epidemic, will appear from other histories of bilious fevers. Dr Bal|four tells us in his account of the intestinal remit|ting fever of Bengal† 6.27, that it often appeared with symptoms of dysentery, rheumatism, and pleurisy. Dr Cleghorn and Dr Lind mention many cases of the bilious fever appearing in the form of a dysentery. Dr Clark ascribes the dysentery, the diarrhoea, the colic, and even the palsy, to the same contagion which produced the bilious fever in the East Indies‡ 6.28; and Dr Hunter, in his trea|tise upon the diseases of Jamaica, mentions the locked jaw as one of its occasional symptoms.

Even the different grades of this fever, from the mildest intermittent to the most acute continual fe|ver, have been distinctly traced by Lancissi to the same marsh exhalation* 6.29.

However irrefragably these numerous facts and authorities establish the assertion of the preva|lence of but one powerful epidemic at a time, the proposition will receive fresh support, from attend|ing to the effects of two impressions of unequal force made upon the system at the same time: only one of them is felt: hence the gout is said to cure all other diseases. By its superior pain it destroys sensations of a less painful nature. The small-pox and measles have sometimes existed to|gether in the body; but this has, I believe, sel|dom occurred, where one of them has not been the predominating disease† 6.30. In this respect, this combination of epidemics only conforms to the general law which has been mentioned.

I beg pardon for the length of this digression. I did not introduce it to expose the mistakes of those physicians who found as many diseases in our city,

as the yellow fever had symptoms, but to vindi|cate myself from the charge of innovation, in ha|ving uniformly and unequivocally asserted, after the first week in September, that the yellow fever was the only febrile disease which prevailed in the city. I shall hereafter mention some facts upon the subject of the extent of the contagion, which will add such weight to the assertion, as to render the disbelief of it, as much a mark of a deficiency of reason, as it is of reading and observation.

Science has much to deplore from the multipli|cation of diseases. It is as repugnant to truth in medicine, as polytheism is to truth in religion. The physician who considers every different affec|tion of the different systems in the body, or every affection of different parts of the same system, as distinct diseases, when they arise from one cause, resembles the Indian or African savage, who con|siders water, dew, ice, frost, and snow, as distinct essences: while the physician who considers the morbid affections of every part of the body, how|ever diversified they may be in their form or de|grees) as derived from one cause, resembles the philosopher, who considers dew, ice, frost, and snow, as different modifications of water, and as derived simply from the absence of heat.

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

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

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

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

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

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

It is nothing new, for epidemics to affect per|sons of one nation, and to pass by persons of other nations in the same city or country. At Nimu|guen in the year 1736, Deigner informs us that the French people, (two old men excepted), and the Jews, escaped a dysentery which was univer|sal among persons of all other nations. Ramazini tells us that the Jews at Modena, escaped a tertian fever which affected nearly all the other inhabi|tants of the town. Shenkius says that the Dutch

and Italians escaped a plague which prevailed for two years in one of the towns of Switzerland, and Dr Bell, in an inaugural dissertaion published at Edinburgh in 1779, remarks that the jail fever which attacked the soldiers of the Duke of Buc|cleugh's regiment, spared the French prisoners who were guarded by them. It is difficult to account for these facts. However numerous their causes may be, a difference in diet which is as much a distinguishing mark of nations as dress, or man|ners, will probably be found to be one of them.

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

For the American Daily Advertiser.

IT has been remarked, that the black people have in no one instance been infected with the malignant fever which now prevails in our city. The late Dr Lining, of South Carolina, long ago made the same remark. There is

something very singular (says the Doctor) in the constitution of the Negroes which renders them not liable to this fever; for though many of them were as much exposed as the nurses to the infec|tion, yet I never knew of one instance of this fever among them, though they are equally sub|ject with the white people to the bilious fever* 7.1.

The only design of this remark is, to suggest to our citizens the safety and propriety of employing black people to nurse and attend persons infected by this fever; also, to hint to the black people, that a noble opportunity is now put into their hands, of manifesting their gratitude to the inha|bitants of that city, which first planned their eman|cipation from slavery, and who have since afforded them so much protection and support, as to place them, in point of civil and religious privileges, upon a footing with themselves.

A day or two after this publication, the follow|ing letter from the Mayor of the city, to Mr Clay|poole the printer of the Mail, appeared in his paper.

SIR,

IT is with peculiar satisfaction that I communicate to the public, through your paper, that the AFRICAN SOCIETY, touched with the distresses which arise from the present dangerous disorder, have voluntarily undertaken to furnish nurses to attend the afflicted: and that by applying to ABSALOM JONES and WILLIAM GRAY, both members of that society, they may be supplied.

MATTH. CLARKSON, Mayor.

September 6th, 1793.

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

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

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

1st. To the great indirect debility induced upon their systems by fatigue in attending their masters and mistresses, or their children. Indirect debility, according to its degrees and duration seems to have had the same effect upon the mortality of this fever, that it has upon the mortality of an inflam|mation of the lungs. When it is moderate and of short duration, it predisposes only to a common pneumony, but when it is violent and protracted, in its degrees and duration, it predisposes to a pul|monary consumption.

2dly. To their receiving large quantities of contagion into their bodies, and in a most concen|trated state by being obliged to perform the most menial offices for the sick, and by washing, as well as removing infected linen, and the like.

3dly. To their being left more alone in con|fined or distant rooms, and thereby suffering from depression of spirits, or the want of a punctual supply of food and medicines.

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

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

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

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

Many people who were infected in the city, were attacked by the disease in the country, but they propagated it in very few instances, even to persons who slept in the same room with them.

Dr Lind informs us that many persons escaped the yellow fever which prevailed in Pensacola in the year 1765, by retiring to the ships which lay in the harbour, and that when the disease had been taken, the pure air of the water changed it

into an intermitting fever* 8.1. The same changes have frequently been produced in malignant fevers, by sending patients infected with them from the foul air of a city, into the pure air of the country.

Persons confined in the House of Employment, in the Hospital, and in the Jail, were preserved from the fever. The airy and remote situation of those buildings, was probably the chief means of their preservation. Perhaps they derived addi|tional security from their simple diet, their exemp|tion from hard labour, and from being constantly sheltered from heat and cold.

Several families who shut up their front and back doors and windows, and avoided going out of their houses except to procure provisions, esca|ped the disorder.

I have taken some pains to ascertain whether any class of tradesmen escaped the fever, or whe|ther there was any species of labour which pro|tected from it. The result of my inquiries is as follows: Three butchers only out of nearly one hundred who remained in the city, died with the disorder. Many of them attended the markets

every day. Two painters, who worked at their business during the whole time of the prevalence of the fever, and in exposed situations, escaped it. Out of forty scavengers who were employed in collecting and carrying away the dirt of the streets, only one caught the fever and died. Very few grave-diggers, compared with the number who were employed in that business, were infected; and it is well known, that scarcely an instance was heard of persons taking the disease, who were constantly employed in digging cellars. The fact is not new that grave-diggers escape the conta|gion of malignant fevers. It is taken notice of by Dr Clark. There seems to be something in the fresh earth which attracts or destroys by mixture, contagion of every kind. Clothes infected by the small-pox are more certainly purified by being bu|ried under ground, than in any other way. Even poisons are rendered inert, by the action of the earth upon them. Dogs have long ago established this fact, by scratching a hole in the ground, and burying their limbs or noses in it, when bitten by poisonous snakes. The practice I have been told, has been imitated with success by the settlers upon new lands in several parts of the United States.

It was said by some physicians in the public pa|pers, that the neighbourhood of the grave-yards

was more infected than other parts of the city. The reverse of this assertion was true in several cases, owing probably to the line of communica|tion of the contagion being broken by the absence of houses, and to its being diluted and weakened by its mixture with the air of the grave-yards; for this air was pure, compared with that which stagnated in the streets.

It was said further, that the disease was propa|gated by the inhabitants assembling on Sundays for public worship; and as a proof of this asser|tion, it was reported, that the deaths were more numerous on Sundays than on other days; occa|sioned by the contagion received on one Sunday, producing death on the succeding first day of the week. The register of the deaths shows that this was not the case. I am disposed to believe that few|er people sickened on Sundays, than on any other day of the week; owing to the general rest from labour, which I have before said was one of the exciting causes of the disease. From some facts to be mentioned presently, it will appear probable, that places of public worship, in consequence of their size, as well as of their being shut up during the greatest part of the week, were the freest from contagion of any houses in the city. It is agree|able to discover in this, as well as in all other cases

of public and private duty, that the means of health, and moral happiness are in no one instance opposed to each other.

There were for several weeks two sources of infection, viz. exhalation, and contagion. The ex|halation infected at the distance of three and four hundred yards; while the contagion infected only across the streets. The more narrow the street, the more certainly the contagion infected. Few escaped it in alleys. After the 15th of Septem|ber, the atmosphere of every street in the city was loaded with contagion; and there were few citi|zens in apparent good health, who did not ex|hibit one or more of the following marks of its presence in their bodies.

1. A yellowness in the eyes, and a sallow co|lour upon the skin.

2. A preternatural quickness in the pulse. I found but two exceptions to this remark, out of a great number of persons whose pulses I examined. In one of them it discovered several preternatural intermissions in the course of a minute. This quickness of pulse occurred in the negroes, as well as in the white people. I met with it in a woman who had had the yellow fever in 1762.

In two women, and in one man above 70, the pulse beat upwards of 90 strokes in a minute. This preternatural state of the pulse, during the prevalence of a pestilential fever in persons in health, is taken notice of by Reverius* 8.2.

3. Frequent and copious discharges by the skin of yellow sweats. In persons who were much ex|posed to the contagion, these sweats sometimes had an offensive smell, resembling that of the wash|ings of a gun.

4. A scanty discharge of high coloured or tur|bid urine.

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

6. Costiveness.

7. Wakefulness.

8. Head-ach.

9. A preternatural dilatation of the pupils.—This was universal. I was much struck in obser|ving

the pupil in one of the eyes of a young man who called upon me for advice, to be of an oblong figure. Whether it was natural, or the effect of the contagion acting on his brain, I could not determine.

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

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

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

Citizens thus impregnated with the contagion, communicated it in several instances to their coun|try friends. The disease produced in this way was very light, amounting in all the cases that came under my notice, to little more than a sickness at stomach or vomiting.

The smell of the contagion, as emitted from a patient in a clean room, was like that of the small-pox, but in most cases of a less disagreeable na|ture. Putrid smells in sick rooms were the ef|fects of a mixture of the contagion with some fil|thy matters. In small rooms, crouded in some in|stances with four or five sick people, there was an effluvia that produced giddiness, sickness at sto|mach, a weakness of the limbs, faintness, and in some cases a diarrhoea. I met with a fetid breath in one patient, which was not the effect of that medicine which sometimes produces it.

The contagion adhered to all kinds of cloath|ing, and seemed to be propagated by them. It

was in no instance communicated by means of pa|per; a circumstance which contributed both to lessen and encrease the distress produced by the dis|ease, by enabling the citizens to keep up an inter|course, by letters with their country friends.

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

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

A meteor was seen at two o'clock in the morn|ing on or about the twelfth of September. It fell between Third-street and the Hospital, nearly in a line with Pine-street. Moschetoes (the usual attendants of a sickly autumn) were uncommonly

numerous. Here and there a dead cat added to the impurity of the air of the streets; for many of those animals perished with hunger in the city, in consequence of so many houses being deserted by the inhabitants who had fled into the country.

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

However inoffensive uniform heat, when agita|ted by gentle breezes may be, there is, I believe, no record of a dry, warm and stagnating air, having

existed for any length of time without pro|ducing diseases. Hippocrates in describing a pes|tilential fever, says the year in which it prevailed, was without a breeze of wind* 8.3. The same state of the atmosphere for six weeks, is mentioned in many of the histories of the plague which prevail|ed in London in 1665. Even the sea air itself becomes unwholesome by stagnating; hence Dr Clark informs us, that sailors become sickly after long calms in East India voyages† 8.4. Sir John Pringle delivers the following aphorism from a number of similar observations upon this subject. "When the heats come on soon, and continue throughout autumn, not moderated by winds, or rains, the season proves sickly, distempers appear early, and are dangerous‡ 8.5."

Who can review this account of the universal diffusion of the contagion of this disease, its uni|versal effects upon persons apparently in good health, and its accumulation and concentration, in consequence of the calmness of the air, and be+lieve, that it was possible for a febrile disease to

exist at that time in our city that was not derived from this contagion?

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

Mr Coxe, and several others, whose cases came under my notice.

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

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

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

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

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

Some were stiff within one hour after death. Others were not so, for six hours afterwards. This sudden stiffness after death, Dr Valli informs us, occurred in persons who died of the plague in Smyrna in the year 1784* 8.6.

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

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

Some putrefied in a short time after their disso|lution, but others had no smell for twelve, eigh|teen and twenty hours afterwards. This absence of smell occurred in those cases in which evacua|tions had been used without success in the treat|ment of the disease.

Many discharged large quantities of black mat|ter from the bowels, and others blood from the nose, mouth and bowels after death. The fre|quency of these discharges, gave rise to the prac|tice of pitching the joints of the coffins which were used to bury the dead.

The morbid appearances of the internal parts of the body as they appear by dissection after death, from the yellow fever, are different in dif|ferent countries, and in the same countries in dif|ferent years. I consider them all as effects only of a stimulus acting upon the whole system, and determined more or less by accidental circumstan|ces, to particular viscera. Perhaps the stimulus of the contagion determines the fluids more vio|lently in most cases to the liver, stomach, and bow|els, and thereby disposes them more than other

parts to inflammation and mortification, and to similar effusions and eruptions with those which take place on the skin. There can be no doubt of the contagion acting specifically upon the liver, and thereby altering the qualities of the bile. I transcribe with great pleasure the following ac|count of the state of the bile in a female slave of forty years of age from Dr Mitchell's history of the yellow fever, as it prevailed in Virginia in the years 1737 and 1741, inasmuch as it was part of that clue which led me to adopt one of the remedies on which much of the success of my practice depended.

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

its ropy consistence, seemed more peculiar to a bi|lious humour."

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

The liver in the abovementioned slave, was tur|gid and plump on its outside, but on its concave surface, two thirds of it were of a deep black co|lour, and round the gall-bladder, it seemed to be mortified and corrupted.

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

The omentum was so much wasted, that no|thing but its blood-vessels could be perceived.

The stomach was inflamed both on its outside and inside. It contained a quantity of bile of the same consistence, but of a blacker colour than that which was found in the gall bladder. Its villous coat like that of the duodenum, was covered with fuzzy and slimy matter. It moreover appeared to

be distended or swelled. This peculiarity in the inner coat of the stomach was universal in all the bodies that were opened, of persons who died of this disease.

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

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

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

Dr Mackittrick, in his inaugural dissertation published at Edinburgh in the year 1766 "De fe|bre Indiae occidentalis, Maligna Flava," or upon the yellow fever of the West Indies, says, that in some of the patients who died of it, he found the

liver sphacelated, the gall bladder full of black bile, and the veins turgid with black fluid blood. In others he found the liver no ways enlarged, and its "texture only vitiated." The stomach, the duodenum, and ilium, were remarkably infla|med in all cases. The pericardium contained a viscid yellow serum, and in a larger quantity than common. The urinary bladder was a little infla|med. The lungs were sound.

Dr Hume in describing the yellow fever of Ja|maica, informs us, that in several dead bodies which he opened, he found the liver enlarged and turgid with bile, and of a pale yellow colour. In some he found the stomach and duodenum infla|med. In one case he discovered black spots in the stomach, of the size of a crown piece. To this account he adds, "that he had seen some sub|jects opened, on whose stomachs no marks of in|flammation could be discovered; and yet these had excessive vomiting."

Dr Lind has furnished us with an account of the state of the body after death in his short histo|ry of the yellow fever, which prevailed at Cadiz in the year 1764. "The stomach, (he says) me|sentery, and intestines were covered with gangre|nous spots: there were ulcers on the orifice of the

stomach, and the liver and lungs were of a putrid colour and texture* 8.7."

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

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

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

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

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

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

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

In two other persons who died at a more ad|vanced period of the disease, the stomach appeared spotted in many places with extravasations, and the inflammation disappeared. It contained, as did also the intestines, a black liquor, which had been

vomited and purged before death. This black li|quor appears clearly to be an altered secretion from the liver; for a fluid in all respects of the same qualities was found in the gall-bladder. This liquor was so acrid, that it induced conside|rable inflammation and swelling on the operator's hands, which remained some days. The villous membrane of the intestines in these last two bodies was found inflamed in several places.

The liver was of its natural appearance, ex|cepting in one of the last persons, on the sur|face of which a very few distended veins were seen: all the other abdominal viscera were of a healthy appearance.

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

"The stomach of those who died early in the dis|ease was always contracted; but in those who died at a more advanced period of it, where extravasa|tions appeared, it was distended with air."

• P. S. PHISICK,
• J. CATHRALL.

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

Thus far have I delivered the history of the yel|low fever as it affected the human body with sick|ness and death. I shall now mention a few of those circumstances of public and private distress which attended it. I have before remarked, that the first reports of the existence of this fever were treated with neglect or contempt. A strange apa|thy pervaded all classes of people. While I bore my share of reproach for "terrifying our citizens with imaginary danger," I answered it by lament|ing "that they were not terrified enough." The publication from the college of physicians soon dissipated this indifference and incredulity. Fear or terror now sat upon every countenance. The disease appeared in many parts of the town, re|mote from the spot where it originated; although in every instance it was easily traced to it. This set the city in motion. The streets and roads leading from the city were crouded with families flying in every direction for safety to the country. Business began to languish. Water-street be|tween Market and Race-streets became a desart.

The poor were the first victims of the fever. From the sudden interruption of business, they suf|fered for a while from poverty, as well as disease. A large and airy house at Bush-hill about a mile from the city, was opened for their reception. This house, after it became the charge of a com|mittee appointed by the citizens on the 14th of September, was regulated and governed with the order and cleanliness of an old and established hos|pital. An American and French physician had the exclusive medical care of it after the 22d of September.

The contagion after the second week in Sep|tember, spared no rank of citizens. Whole fa|milies were confined by it. There was a deficiency of nurses for the sick, and many of those who were employed were unqualified for their business. There was likewise a great deficiency of physi|cians from the desertion of some, and the sickness and death of others. At one time, there were only three physicians who were able to do busi|ness out of their houses, and at this time, there were probably not less than 6,000 persons ill with the fever.

During the first three or four weeks of the prevalence of the disorder, I seldom went into a

house the first time, without meeting the parents or children of the sick in tears. Many wept aloud in my entry, or parlour, who came to ask for ad|vice for their relations. Grief, after awhile de|scended below weeping, and I was much struck in observing that many persons submitted to the loss of relations and friends, without shedding a tear, or manifesting any other of the common signs of grief.

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

The streets every where discovered marks of the distress that pervaded the city. More than one half the houses were shut up, although not more than one third of the inhabitants had fled into the country. In walking for many hundred yards, few persons were met, except such as were in quest of

a physician, a nurse, a bleeder, or the men who buried the dead. The hearse alone kept up the remembrance of the noise of carriages or carts in the streets. Funeral processions were laid aside. A black man, leading, or driving a horse, with a corpse on a pair of chair wheels, with now and then half a dozen relations or friends following at a distance from it, met the eye in most of the streets of the city at every hour of the day, while the noise of the same wheels passing slowly over the pavements, kept alive anguish and fear in the sick and well, every hour of the night* 9.1.

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

The science of medicine is related to every thing, and the philosopher as well as the Chris|tian will be gratified by knowing the effects of a great and mortal epidemic upon the morals of a people. It was some alleviation of the distress

produced by it, to observe its influence upon the obligations of morality and religion. It was re|marked during this time, by many people that the name of the Supreme Being was seldom profaned either in the streets, or in the intercourse of the citizens with each other. Two robberies only, and those of a trifling nature, occured in nearly two months, although many hundred houses were ex|posed to plunder, every hour of the day and night. Many of the religious societies met two or three times a week, and some of them every evening, to implore the interposition of heaven to save the city from desolation. Humanity and charity kept pace with devotion. The public have already seen accounts of their benevolent exercises in other publications. It was my lot to witness the uncom|mon activity of those virtues upon a smaller scale. I saw little to blame, but much to admire and praise in persons of different professions, both sexes, and of all colours. It would be foreign to the design of this work, to draw from the obscurity which they sought, the many acts of humanity and charity, of fortitude, patience, and perseve|rance which came under my notice. They will be made public, and applauded elsewhere.

But the virtues which were excited by our ca|lamity, were not confined to the city of Philadel|phia.

The United States wept for the distresses of their capital. In several of the states, and in many cities, and villages, days of humiliation and prayer were set apart to supplicate the Father of mercies in behalf of our afflicted city. Nor was this all. From nearly every state in the Union, the most liberal contributions of money, provisions, and fuel, were poured in for the relief and support of such as had been reduced to want, by the sus|pension of business, as well as by sickness, and the death of friends.

The number of deaths between the first of Au|gust and the ninth of November, amounted to four thousand and forty four. I shall here insert a register of the number which occurred on each day, beginning on the first of August and ending on the ninth of November. By comparing it with the register of the weather, it will shew the influence of the latter on the disease. Several of the deaths in August were from other acute dis|orders, and a few in the succeeding months were from such as were of a chronic nature.

		died.			died.
August	1	9	Brought forward		325
	2	8	September	1	17
	3	9		2	18
	4	10		3	11
	5	10		4	23
	6	3		5	20
	7	12		6	24
	8	5		7	18
	9	11		8	42
	10	6		9	32
	11	7		10	29
	12	5		11	23
	13	11		12	33
	14	4		13	37
	15	9		14	48
	16	7		15	56
	17	6		16	67
	18	5		17	81
	19	9		18	68
	20	7		19	61
	21	8		20	67
	22	13		21	57
	23	10		22	76
	24	17		23	68
	25	12		24	96
	26	17		25	87
	27	12		26	52
	28	22		27	60
	29	24		28	51
	30	20		29	57
	31	17		30	63
		325			1768

		died.			died.
Brought forward		1768	Brought forward		3318
October	1	74	October	21	59
	2	66		22	82
	3	78		23	54
	4	58		24	38
	5	71		25	35
	6	76		26	23
	7	82		27	13
	8	90		28	24
	9	102		29	17
	10	93		30	16
	11	119		31	21
	12	111	November	1	13
	13	104		2	21
	14	81		3	15
	15	80		4	15
	16	70		5	14
	17	80		6	11
	18	59		7	15
	19	65		8	8
	20	55		9	6
		3318		Total,	388••* 9.2

From this table it appears that the principal mortality was in the second week of October. A general expectation had obtained, that cold wea|ther was as fatal to the contagion of this fever as

heavy rains. The usual time for its arrival had come, but the weather was still not only moderate, but warm. In this awful situation, the stoutest hearts began to fail. Hope sickened, and despair succeeded distress in almost every countenance. On the fifteenth of October it pleased God to alter the state of the air. The clouds at last drop|ped health in showers of rain, which continued during the whole day, and which were succeeded for several nights afterwards by cold and frost. The effects of this change in the weather, appear|ed first in the sudden diminution of the sick, for the deaths continued for a week afterwards to be numerous, but they were of persons who had been confined before, or on the day in which the change had taken place in the weather.

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

SIR,

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

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

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

May the almighty disposer of all events be gra|ciously pleased to protect your citizens from the dreadful calamity with which we are now visited; whilst we humbly kiss the rod, and improve by the dispensation.

The part, sir, which you personally take in our afflictions, and which you have so pathetically ex|pressed in your letter, excites in the breasts of the

Committee the warmest sensations of fraternal af|fection.

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

I have at your request, this day drawn upon you, at sight, in favour of the President and Di|rectors of the Bank of North America, for the sum of five thousand dollars, the benevolent dona|tions of the Common-Council of the city of New-York.

With sentiments of the greatest esteem and regard,

I am, Sir, Your most obedient humble servant, MATTH. CLARKSON

.

Philadelphia, Oct. 17, 1793.

Richard Varick, Mayor of the city of New-York.

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

The yellow fever which raged in Philadelphia in 1699, and which is taken notice of by Thomas Story in his Journal, ceased about the latter end of October, or the beginning of November. Of this there are satisfactory proofs in the register of the interments in the Friends burying-ground, and in a letter dated November 9th, Old Style, 1699, from Isaac Norris to one of his correspon|dents, which his grand-son Mr Joseph P. Norris, politely put into my hands, with several others, which mention the disease, and all written in that memorable year in Philadelphia. The letter says, "It has pleased God to put a stop to our sore vi|sitation, and town and country are now generally healthy." The same disease was checked by wet and cold weather in the year 1741. Of this there is a proof in a letter from Dr Franklin to one of his brothers, who stopped at Burlington, on his way from Boston to Philadelphia on account of the fever, until he was assured by the Doctor, that a thunder gust which had cooled the air, had ren|dered it safe for him to come into the city* 10.1. Mr

Lynford Lardner in a letter to one of his English friends, dated September 24, 1747, Old Style, after mentioning the prevalence of the fever in the city, says "the weather is now much cooler, and those under the disorder revive. The symp|toms are less violent, and the fever gradually abates."

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

The bilious remitting fever of 1780, yielded to cool weather, accompanied by rain, and an eas|terly wind* 10.2.

Sir John Pringle will furnish ample satisfaction, to such of my readers as wish for more proofs of the efficacy of heavy rains, and cold weather, in checking the progress and violence of autumnal remitting fevers† 10.3.

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

There were a few cases of yellow fever in No|vember, and December, after the citizens who had retired to the country, returned to the city.

I heard of only three persons who returned to the city being infected with the disorder; so com|pletely

was the contagion destroyed in the course of a few weeks.

In consequence of a proclamation by the Go|vernor, and a recommendation by the Clergy of Philadelphia, the 12th of December was observed as a day of thanksgiving throughout the state, for the extinction of the disorder in the city.

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

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

The month of November, and all the winter months which followed the autumnal epidemic, were in general healthy. A catarrh affected a

number of people in November. I suspected it to be the influenza which had revived from a dor|mant state; and which had not spent itself when it yielded to the predominance of the yellow fe|ver. This opinion derives some support from a curious fact related by the late Mr Hunter of the revival of the small-pox in a patient, in whom it had been suspended for some time by the mea|sles* 10.4. The few fevers which prevailed in the winter were highly inflammatory. The small-pox in the natural way was in several instances confluent; and in one or two fatal. I was prepared to expect this inflammatory diathe|sis in the fevers of the winter; for I had been taught by Dr Sydenham, that the diseases which follow a great and mortal epidemic, partake more or less of its general character. But the diseases of the winter had a peculiarity still more extraor|dinary; and that was, many of them had several of the symptoms of the yellow fever, particularly a puking of bile, dark-coloured stools, and a yel|low eye. Mr Samuel D. Alexander, a student of medicine from South Carolina, who was seized with a pneumony about Christmas, had with a yellow eye, a dilated pupil, and a hard pulse

which beat only 50 strokes in a minute. His blood was such as I had frequently observed in the yellow fever. Dr Griffitts informed me, that he attended a patient on the 9th of January in a pneumony, who had an universal yellowness on his skin. I met with a case of pneumony on the 20th of the same month, in which I observed the same degrees of redness in the eyes that were common in the yellow fever. My pupil Mr Coxe, lost blood in an inflammatory fever, on the 18th of February, which was dissolved. Mr James In|nis, the brewer, had a deep yellow colour in his eyes, on the fourth day of a pneumony, on the 27th of the same month; and Mr Magnus Miller had the same symptom of a similar disorder, on the 16th of March. None of these bilious and ano|malous symptoms of the inflammatory fevers of the winter and spring surprised me. I had been ear|ly taught by Dr Sydenham, that the epidemics of autumn often insinuate some of their symptoms in|to the winter diseases which follow them. Dr Cleghorn informs us, that "the pleurisies which succeeded the autumnal tertians in Minorca, were accompanied by a vomiting and purging of green or yellow bilious matters* 10.5.

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

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

The appearance of bilious symptoms in the dis|eases of the winter, excited apprehensions in seve|ral instances of the revival of the yellow fever. The alarms though false, served to produce vigi|lance and industry in the corporation, in airing and purifying such houses and articles of furniture

as belonged to the poor; and which had been ne|glected in the autumn, after the ceasing of the dis|ease.

The modes of purifying houses, beds, and clothes were various. Fumigations of nitre and aromatic substances were used by some people. Burying infected articles of furniture under ground, and baking them in ovens, were used by others. Some destroyed all their beds and cloth|ing that had been infected, or threw them into the Delaware. Many white-washed their walls, and painted the wood-work of their house. Is did not conceive the contagion required all, or any of those means to destroy it. I believed cold and water to be sufficient for that purpose. I therefore advised keeping the windows of infected rooms open night and day, for a few days; to have the floors and walls of houses well washed; and to expose beds and such articles of household furniture as might be injured by washing, upon the bare earth for a week or two, taking care to turn them every day. I used no other methods of destroying the accumulated contagion in my house and furniture, and experience showed that they were sufficient. Those branches of my fa|mily who had been absent during the prevalence of the fever (amounting to eleven in number) re|turned

to the city on the 22d of November, and occupied the house and beds which had been highly infected, without suffering a moment's in|disposition from it. The weather of the winter favoured the complete destruction of the conta|gion. It was alternately moderate and cold; by which means the contagion, if accidentally revi|ved by the former, was more effectually destroyed by the latter state of the air.

It is possible a portion of the contagion may ex|ist in clothes or bedding, under such circumstan|ces of warmth, as to be excited into action in the course of the approaching summer and autumn; but it cannot spread without a corresponding con|stitution of the atmosphere. A trunk full of in|fected clothes, the property of Mr James Bing|ham, who died of the yellow fever in one of the West India islands about 40 years ago, was open|ed some months after they were received by his friends, by a young man who lived in his bro|ther's family. This young man took the disease, and died; but without infecting any of the fami|ly: nor did the disease spread afterwards in the city.

The father of Mr Joseph Paschall was infected with the yellow fever of 1741, by the smell of a

bed in passing through Norris's Alley, in the lat|ter end of December, after the disease had left the city. He died on the 25th of the month, but without reviving the fever in the city, or even in|fecting his family.

In a letter from Dr Senter of Newport, dated January 7th, 1794, I find the following fact, which I shall communicate in his own words. It is in|troduced to support the principle, that the yellow fever cannnot spread in any country without the concurrence of a predisposing constitution of air. "This place (says the Doctor) has traded formerly very much to the West India islands, and more or less of our people have died there every season, when the disease prevails in those parts. Clothes of these unfortunate people have been re|peatedly brought home to their friends, without any accident happening to them."

It is not peculiar to the contagion of the yellow fever to require the concurrence of a morbid consti|tution of the air to excite it into action. The con|tagion of the plague perished twice in the city of Larnica, without spreading, from the absence of that necessary state of the air, in the year 1759* 10.6.

Several persons it is said died of the yellow fe|ver in the summer and autumn of 1763, the year after it had been epidemic in our city. I witnessed the symptoms which immediately preceded the death of one of them. Whether the disease in this case was produced by a revival of the conta|gion, or by miasmata generated in the city, I am unable to determine.

Dr Mitchell informs us, that the disease appear|ed in Virginia in the spring of 1742, after the au|tumn of 1741. In this case the contagion was probably kept alive during the winter by the want of cleanliness in the negro-quarters; and perhaps by moderate weather.

These are the only facts which support the fears of the return of the disease to our city, in the course of the present year. To aid our hopes, that this will not be the case, I have great pleasure in ad|ding, that it has never occurred in successive years either in this city or in Charleston; in one of which there are records of its having been five, and in the other four times epidemic.

I feel with my reader the fatigue of this long detail of facts, and equal impatience with him, to proceed to the history of the treatment of the fe|ver;

but I must beg leave to detain him a little longer from that part of the work, while I resume the subject of the origin of the fever. It is an in|teresting question, as it involves in it the means of preventing a return of the disorder.

Soon after the fever left the city, the governor of the state addressed a letter to the College of Physicians, requesting to know their opinion of its origin; if imported; from what place; at what time; and in what manner. The design of this in|quiry was to procure such information as was pro|per to lay before the legislature, in order to im|prove the laws for preventing the importation or generation of infectious diseases, or to enact new ones, if necessary for that purpose. To the go|vernor's letter, the College of Physicians sent the following answer:

SIR,

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

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

Signed by order of the College of Physicians, JOHN REDMAN, PRESIDENT.

November 26th, 1793.

To the Governor of Pennsylvania.

Three members of the College dissented from the report contained in this letter. They were Dr Redman the President of the College, Dr Foulke, and Dr Leib.

I am sorry to meet my brethren upon every ques|tion of our late epidemic in a field of controversy. In the present they will have a great advantage over me, for the prejudices of the citizens of Philadel|phia are in their favour. Loathsome and dangerous diseases have been considered by all nations as of foreign extraction. The venereal disease and the leprosy have no native country, if we believe all the authors who have written upon their origin. Pros|per Alpinus, derives the almost yearly plagues of Cairo from Syria, and Dr Warren flattered the people of Barbadoes, by an attempt to persuade them, that the yellow fever of the West Indies, was originally imported from Siam. This princi|ple of referring the origin of the evils of life, from ourselves to others, is universal. It disco|vered itself in paradise, and it is every where, an essential feature in the character of man.

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

1. The yellow fever in the West Indies and in all other countries where it is endemic, is the off|spring of vegetable putrefaction. Heat, exercise, and intemperance in drinking, (says Dr Lind) dis|pose

to this fever in hot climates, but they do not produce it, without the concurrence of a remote cause. This remote cause exists at all times, in some spots of the Islands, but in other parts of even the same islands, where there are no marsh exhalations, the disease is unknown. I shall not waste a moment in enquiring into the truth of Dr Warren's account of the origin of this fever. It is fully refuted by Dr Hillary, and it is treated as chimerical by Dr Lind. They have very limited ideas of the history of this fever who suppose it to be peculiar to the East or West Indies. It was generated in Cadiz after a hot and dry summer in 1764, and in Pensacola in 1765* 11.1. The tertian fever of Minorca, when it attacked Englishmen put on the usual symptoms of the yellow fever† 11.2. In short, this disease, ap|pears according to Dr Lind, in all the southern parts of Europe, after hot, and dry weather‡ 11.3.

2. The same causes (under like circumstances) must always produce the same effects. There is nothing in the air of the West Indies above other hot countries, which disposes it to produce a yel|low fever. Similar degrees of heat, acting upon

dead and moist vegetable matters, are capable of producing it, together with all its various modifi|cations, in every part of the world. In support of this opinion, I shall transcribe part of a letter from Dr Miller, of the Delaware state.

Dover, Nov. 5, 1793.

DEAR SIR,

SINCE the middle of last July, we have had a Bilious Colic epidemic in this neigh|bourhood which exhibits phaenomena very singu|lar in this climate; and so far as I am informed, unprecedented in the medical records, or popular traditions of this country. To avoid unnecessary details, it will suffice at present to observe, that the disease on this occasion, has assumed not only all the essential characters, but likewise all the vio|lence, obstinacy and malignity described by the East and West Indian practitioners. If any differ|ence can be observed, it seems here to manifest higher degrees of stubbornness and malignity, than we usually meet in the histories of tropical wri|ters. In the course of the disease, not only ex|treme constipation, frequent vomiting, and the most excruciating pains of the bowels and limbs, harrass the unhappy patient; but to these succeed paralysis, convulsions, &c. and almost always un|common

muscular debility,—oppression of the praecordia, &c. are the consequence of a severe attack. Bile discharged in enormous quantities, constantly assumes the most corrupted and acri|monious appearances, commonly aeruginous in a very high degree, and sometimes quite atrabilious.

The inference I mean to draw from the phae|nomena of this disease, as it appears in this neigh|bourhood, and which I presume will also apply to your epidemic, is THIS, that from the uncommon protraction and intenseness of our summer and autumnal heats, but principally from the unusual drought; we have had since the middle of July, a near approach to a TROPICAL season, and that of consequence we ought not to be surprized if tropical diseases, even of the most malignant na|ture, are ENGENDERED amongst us.

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

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

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

marshy ground, or to wash away putrid masses of matter, no fever can be produced.

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

It is worthy of notice, that the yellow fever pre|vailed in Virginia in the year 1741, and in Charles|ton in South Carolina in the year 1699, in both which years, it prevailed in Philadelphia. Its pre|valence in Charleston is taken notice of in a

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

3. I have before remarked that a quantity of damaged coffee, was exposed at a time (July the 24th) and in a situation (on a wharf, and in a dock) which favoured its putrefac|tion, and exhalation. Its smell was highly pu|trid

and offensive, insomuch that the inhabitants of the houses in Water and Front Streets, who were near it, were obliged in the hottest weather to exclude it, by shutting their doors and windows. Even persons, who only walked-along those streets, complained of an intolerable foetor, which upon enquiring, was constantly traced to the putrid cof|fee. It should not surprise us, that this seed, so inoffensive in its natural state, should produce, af|ter its putrefaction a violent fever. The records of medicine furnish instances of similar fevers be|ing produced, by the putrefaction of many other vegetable substances. Fourteen men out of six|teen, perished by a malignant fever, a few years ago, at the island of Tortola, from the effluvia ge|nerated by some putrefied potatoes, which were taken out of the hold of a Liverpool vessel. "The effluvia (says Dr Zimmerman) from a little heap of flax, has been known to occasion a malig|nant fever, which proved fatal to the family, in which it first began, and afterwards spread its Con|tagion through a whole country." Dr Rodgers in his treatise upon the diseases of Cork, mentions a malignant fever which swept away a great num|ber of the students of Wadham College in Ox|ford, "The singularity of the case (adds the Doc|tor) engaged all the gentlemen of the faculty, in a serious inquiry into the causes of so remarkable

an effect, and all agreed that the contagious infec|tion arose from the putrefaction of a vast quantity of cabbages thrown into a heap out of the several gardens near the College." Lancissi relates, that one end of the city of Rome was nearly desolated by the effluvia of some rotted hemp, which lay in the neighbourhood of the city. The same author remarks, that "fevers often prevail at Constanti|nople, which owe their origin to the hemp which is brought from Cairo, and which is put wet into the public granaries, and suffered to ferment du|ring the summer. It is afterwards sold, and the seeds of those diseases are afterwards spread among the people." Many other facts might be adduced of radishes, turnips, garlic, and sundry other vegetables, generating by putrefaction, fe|vers, similar to those which have been mentioned.

4. The rapid progress of the fever from Water-street, and the courses through which it travelled into other parts of the city, afford a strong evi|dence that it was at first propagated chiefly by ex|halation from the putrid coffee. It is remarkable that it passed first through those alleys, and streets which were in the course of the winds that blew across the dock and wharf where the coffee lay, and that persons were affected at a much greater distance from Water-street by that means, than

was afterwards known by means of the contagion which was generated by infected persons.

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

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

mentioned of persons who sickened during the last week in July or the first week in August, who ascribed their illnesses to the smell of the coffee. From three of those persons who came under my notice, the disease was evidently propagated by contagion: from one of them, to nearly a whole family, and from another to a girl of eight years old, who was led by curiosity to examine the yel|low colour which it was said had appeared in the face of the infected person, after death.

7. It has been remarked that this fever did not spread in the country, when carried there by per|sons who were infected, and who afterwards died with it. This I conceive was occasioned, in part by the contagion being deprived of the aid of mi|asmata from the putrid matter which first produced it in our city, and in part, by its being diluted, and thereby weakened by the pure air of the coun|try. During four times in which it prevailed in Charleston, in no one instance, according to Dr Lining, was it propagated in any other part of the state.

8. It is very remarkable that in the histories of the disorder which have been preserved in this country, it has six times appeared about the first

or middle of August, and declined, or ceased about the middle of October—viz. in 1732, 1739, 1745, and 1748 in Charleston; in 1791 in New-York, and in 1793 in Philadelphia. This fre|quent occurrence of the yellow fever at the usual period of our common bilious remittents, cannot be ascribed to accidental coincidence, but must be resolved in most cases into the combination of more active miasmata with the predisposition of a tropi|cal season. In speaking of a tropical season, I include that kind of weather in which rains and heats are alternated with each other, as well as that, which is uniformly warm.

9. Several circumstances attended the late epi|demic, which do not occur in the West-India yel|low fever. It affected children as well as adults in common with our annual bilious fevers. In the West Indies Dr Hume tells us it never attack|ed any person under puberty. It had, moreover, many peculiar symptoms (as I have already shewn) which are not to be met with in any of the histo|ries of the West-India yellow fever.

10. Why should it surprise us to see a yellow fever generated amongst us? It is only a higher grade of a fever which prevails every year in

our city, from vegetable putrefaction. It con|forms in the difference of its degrees of violence, and danger to season, as well as climate, and in this respect it is upon a footing with the small-pox, the measles, the fore-throat, and several other dis|eases. There are few years pass, in which a ple|thoric habit, and more active but limited mias|mata, do not produce Sporadic Cases of true yel|low fever in Philadelphia. It is very common in South and North Carolina and in Virginia, and there are facts which prove, that not only strangers, but native individuals, and in one instance, a whole family, have been carried off by it in the state of Maryland. It proved fatal to one hundred per|sons in the city of New-York in the year of 1791, where it was evidently generated by putrid exha|lation. The yellow colour of the skin, has unfor|tunately too often been considered as the charac|teristic mark of this fever, otherwise many other instances of its prevalence might be discovered, I have no doubt in every part of the United States. I wish with Dr Mosely, the term yellow, could be abolished from the titles of this fever, for this co|lour is not only frequently absent, but sometimes occurs in the mildest bilious remittents. Dr Hal|ler in his pathology, describes an epidemic of this kind in Swisserland, in which this colour generally attended, and I have once seen it almost universal

in a common bilious fever which prevailed in the American army in the year 1776.

If any thing could surprise me after reading the report of the College of Physicians that our late fever was imported, in spite of every possible evi|dence to the contrary, it would be the opinion which was delivered publicly by some leading members of the College, that no fever produced by vegetable putrefaction and exhalation, had ever been contagious. It is scarcely possible to open a practical book upon medicine, without meeting with facts which establish a contrary opinion. The fevers generated by putrid cabbage, men|tioned by Dr Rodgers, and by putrid flax men|tioned by Dr Zimmerman, were both contagious. Dr Lind ascribes the yellow fever every where to marsh or putrid vegetable exhalations; and this fever, we know, spreads by contagion. Dr Lind, Jun. establishes the contagious nature of the marsh fever which prevailed in Bengal in the year 1762. I shall transcribe his words upon this subject. "Although marsh miasmata (says he) first bring on the disease, yet contagion presently spreads it, and renders it more epidemic. Thus the Drake Indiaman continued free from the disorder for two weeks together, when she had no commu|nication with other ships; whereas as soon as the

disorder was brought on board, many were seized with it within a few days in such a manner as to leave no room to entertain the least doubt con|cerning its pestilential nature* 12.1."

Dr Clark mentions a contagious malignant fever from marsh miasmata, which prevailed at Prince's Island in the year 1771, and which after|wards infected the crew of the Grenville India|man† 12.2. The contagious pestilential fever in France, so accurately described by Riverius, was produced by an exhalation from putrid vegeta|bles, particularly hemp and flax‡ 12.3. Even inter|mittents, the most frequent and the most nume|rous offspring of marsh exhalation, are contagi|ous. Of this there are many proofs in practical authors. Bianchi describes an intermittent which was highly contagious at Wolfenbuttle in the year 1666§ 12.4. Dr Clark mentions a number of cases in which this mild species of fever was propagated by contagion. Dr Cleghorn has established the contagious nature of intermittents by many facts. After mentioning numerous instances of their ha|ving

spread in this way, he says, "These tertian•• have as good a right to be called contagious as the measles, small-pox, or any other disease* 12.5." The United States, in common with other coun|tries, have in many places exhibited proofs of the contagious nature of fevers, produced by putrid vegetable exhalations. The yellow fever which the citizens of New York wisely admit to have been generated in their city from vegetable putre|faction in the year 1791, spread by contagion† 12.6. The bilious fever which prevailed in Philadelphia in the year 1778, was evidently contagious; so were the bilious fevers which prevailed during the last autumn in Weathersfield, Harrisburgh, and on the south branch of the Potowmac. I hope I shall be excused by the physicians of other states (if this publication should fall into their hands) for having employed a single page in combating an error which is so obvious to common observa|tion. My only design in exposing it, is to prevent a repetition of its fatal influence in the only city in the world in which it has ever been believed or propagated.

I am far however from denying that this disease has not sometimes been imported into our coun|try. From the authority of Dr Lind, it appears that this has once been the case in Philadelphia. In this respect it is upon a footing with the plague, which is both an imported and a generated dis|ease, in the cities of the East. I am disposed how|ever to believe that the instances of the yellow fe|ver being imported are very few, compared with those of its being generated in our country. What makes this opinion probable is, that neither Great Britain nor Ireland have ever, to my knowledge, been infected by this fever, notwithstanding their long and frequent commercial intercourse with the West India islands. The summers in each of those countries, though seldom hot enough to generate a contagious yellow or bilious fever, are notwith|standing warm enough to favour the propagation of an imported contagion of that disorder. The jail fever which has more than once been introdu|ced into our city in crowded ships from Holland, I suspect has been sometimes mistaken for the yel|low fever of the West Indies. But I have ano|ther reason for discrediting some of the accounts of the importation of this fever, which have been handed down to us by former generations, and that is, the manner in which the College of Phy|sicians decided upon the question of the origin of

the disease now under consideration. The go|vernor of the state requested in his letter to them, to know whether it was imported; if it were, from what place, at what time, and in what man|ner. The report of the College of Physicians takes no notice of either of those questions. In vain did Dr Foulke call upon the college to be more definite in their answer to the governor's letter. They had faithfully sought for the infor|mation required, but to no purpose. The cha|racter of their departed brother Dr Hutchinson, for capacity and vigilance in his office, as inspec|tor of sickly vessels, was urged without effect as an argument against the probability of the disease being imported. Public report had derived it from several different islands; had chased it from ship to ship, and from shore to shore; and finally conveyed it at different times into the city, al|ternately by dead and living bodies; and from these tales, all of which when investigated, were proved to be without foundation, the College of Physicians composed their letter. It would seem from this conduct of the College as if medi|cal superstition had changed its names, and that in accounting for the origin of pestilential fevers, ce|lestial, planetary, and demoniacal influence, has only yielded to the term—importation.

Let not the reader reject the opinion I have de|livered, because it is opposed by so great a majo|rity of the physicians of Philadelphia. A single physician supported an opinion of the existence of the plague at Messina in the year 1743, in oppo|sition to all the physicians (33 in number) of that city. They denied the disease in question to exist, because it was not accompanied by glandular swel|lings. Time shewed that they were all mistaken, and the plague, which might probably have been checked at its first appearance by their united ef|forts, was by means of their ignorance, introdu|ced with great mortality into every part of the city. This disposition of physicians to limit the symptoms of several other diseases, cannot be suf|ficiently lamented. The frequent absence of a yellow colour in our late epidemic, led to mistakes which cost the city of Philadelphia several hun|dred lives.

The report of the College of Physicians has served to confirm me in an opinion, that the plagues which occasionally desolated most of the countries in Europe in former centuries, and which were always said to be of foreign extraction, were in most instances of domestic origin. Between the years 1006 and 1680, and plague was epidemic 52 times all over Europe. It prevailed 14 times in

14th century. The state of Europe in this long period, is well known. Idleness, a deficiency of vegetable aliment, a camp life from the frequency of wars, famine, an uncultivated and marshy soil, small cabins, and the want of cleanliness in dress, diet, and furniture, all concurred to generate pes|tilential diseases. The plagues which prevailed in London every year from 1593 to 1611, and from 1636 to 1649, I suspect were generated in that city. The diminution of plagues in Europe, more especially in London, appears to have been produced by the great change in the diet and man|ners of the people; also by the more commodious and airy forms of the houses of the poor, among whom the plague always makes its first appear|ance. It is true, these plagues were said by au|thors to have been imported either directly or in|directly from the Levant; but the proofs of such importation were in most cases as vague and defi|cient, as they were of the West India origin of our late epidemic. The pestilential fevers which have been mentioned, have been described by au|thors, by the generic name of the plague; but some of them appear to have originated from pu|trid vegetable exhalations, and to have resembled in most of their symptoms, the West India and North American yellow fever.

I am aware that the opinion and facts which I have stated upon the origin of the late epidemic, are not popular with our citizens, but I did not dare to conceal them; for I am persuaded a know|ledge and belief of them, involve in their conse|quences, the lives of millions that are yet unborn.

Commerce can no more be endangered than Re|ligion, by the publication of philosophical truth. On the contrary it must suffer most by the adop|tion of the traditional error which I have endea|voured to refute, for while the cause of a malig|nant fever is obvious to the senses, it will be easy to guard against it; but while it is believed that the disease may be imported, and no body know, from what place, at what time, and in what man|ner, we shall not only be careless in the midst of filth and danger, but our city will always hold its character for health by a timid and precarious te|nure. I am the more disposed to expect forgive|ness from my fellow citizens for this attempt to serve them, by the recollection of the sudden change in the health of our city which followed the arching the offensive dock between Front and Third streets in the year 1782. By advising that measure (in which I stood nearly alone) I incurred the censure of several valuable citizens. The bills of mortality however soon shewed that the mea|sure

was right, and I have since seen with great pleasure the extraordinary healthiness of our city, ascribed by indifferent people, to that, among other causes.

The climate of our country can no more suffer than the commerce of our city, by this investiga|tion; for it fixes the late fever, and all the other malignant fevers of the United States, upon putrid vegetable exhalation. Without the matrix of putrid vegetable matters, there can no more be a bilious or yellow fever generated amongst us, than there can be vegetation without earth—water or air. To ascribe our late disease therefore to the exclusive influence of the atmosphere, is a reflec|tion upon our climate which is equally unphiloso|phical and unjust.

Let it only be clearly proved, and boldly assert|ed, that a bilious yellow fever has been, and may be generated in our country, under the circum|stances before mentioned, and the return of it, as also of common bilious and intermitting fevers may every where be prevented by a due attention to the cleanliness of the wharfs and suburbs, as well as the streets of our cities, and towns; by draining and cultivating marshy grounds in their neighbourhood, and in the neighbourhood of

farm houses,—and where the last cannot be done, by sheltering them from the current of vegetable exhalations, by means of a body of trees that are of speedy growth. In this manner, malignant and deadly fevers have been banished from most of the cities in Europe.

I have hinted in the course of this history, at the resemblance which the yellow fever bears to the plague. Before I dismiss this part of my sub|ject, I shall briefly enumerate the circumstances, and symptoms, which belong to them in common; and afterwards mention those which are peculiar to each of them. The utility of this digression will, I hope appear hereafter, when I come to deli|ver the history of the cure of the yellow fever.—The principles which suggested and directed it, will apply alike to both diseases.

The circumstances and symptoms in which the plague, and the yellow fever (as it lately appeared in our city) resemble each other, are as follow:

In being accompanied and encreased by warm weather.

In affecting those people most generally who fol|low occupations which expose them to be much

heated. The bakers were great sufferers by the plagues at Aleppo, described by Dr P. Russel.

In affecting persons who are suddenly debili|tated by fear or grief.

In affecting all ages; also the poor more than the rich; men more than women; and persons of robust, more than those of weakly habits.

In attacking with, and without premonitory symptoms.

In being excited by intemperance, and labour.

In being accompanied by a full, tense, depressed, regular, or an intermitting pulse.

In being accompanied by hemorrhagies. These are less frequent in the plague than in the yellow fever.—Abortions are alike common in both diseases.

The following symptoms of our late yellow fever occur likewise in the plague.

Inflammation of the brain.

Inflammation, mortifications, and carbuncles in the alimentary canal and stomach.

Costiveness or diarrhoea. Copious sweats in the beginning of the disease which afford relief.—A discharge of a blackish liquor from the stomach by vomiting, in the close of the disease.

A moist white tongue, in its beginning, and a dry black tongue in its last stage.

Absence of heat and thirst in some cases.

Convulsions, syncope, great depression of spirits, exquisite pain, so as to excite screamings in the sick. Delirium and a temporary loss of memory after recovery.

A red or a brilliant eye, and great venereal ex|citability in the convalescent state of the disease.

Buboes, and an exclusive affection of the lym|phatic glands.

Maculae, or red spots resembling flea bites, wa|tery vesicles, or blisters which end in mortifica|tions, petechiae, anthrax, and carbuncles.

Sizy, dense, or dissolved blood.

The plague appears in the forms of quotidian, tertian, and quartan fevers. It has different grades, also different durations, from one day to two, three and four weeks. It is most fatal at its first appearance. Convulsive twitchings of the tendons are less common in the plague, than in the nervous fever. It chases away, or unites with all other febrile diseases.

I have before remarked, that during the pre|valence of the plague, some foreigners escape the contagion.

The contagion of the plague infects the atmos|phere of a whole city, and is propagated without contact with the sick. Many people discover marks of the presence of this contagion in their bodies, who are in apparent good health; a dis|position to sweat is very common in such persons. The disease is sometimes propagated by contact by means of this sweat, when it affects the hands.

Persons infected with the contagion of the plague, communicate it before they are sensible of their being affected by it. The contagion is excited at different times, from the moment it is

received into the body, until the 16th day after|wards.

Persons who have had the plague, are capable of re-infection.

Brutes, as cats and dogs are affected in some instances, with symptoms of the plague, particu|larly buboes.

Persons confined in Seraglios in Eastern coun|tries, and in Monasteries in Catholic countries, also grave diggers, very often escape the plague.

The bodies of persons who die of the plague become stiff in some instances immediately after death. Tears likewise often appear on their cheeks.

Cold weather checks the plague, but not so uniformly as it does the yellow fever.

The diseases which succeed the plague, appear with more or less of its symptoms.

It will appear hereafter that the cure of the yellow fever, accorded in several particulars, with that of the plague.

The circumstances and symptoms in which the plague differs from the yellow fever are as follow:

A vomiting is less common in the plague, than in the yellow fever. Bile is less frequently dis|charged, and the stools are less foetid, and offensive.

There are small horny swellings upon the breast and limbs in the plague which did not occur in the yellow fever. They are called tokens.

The contagion of the plague does not infect as so great a distance, as the contagion of the yel|low fever.

It affects more universally, than the yellow fe|ver, and (with a few exceptions) it is more mor|tal when left to itself.

It sometimes prevails in cold weather. It pre|vails likewise in a greater variety of states of the atmosphere.

The body is of its usual, or of a greenish co|lour after death.

The plague is of animal origin. It is derived in some instances from dead animal matters. The

plagues which laid waste the Roman Empire in the reign of Justinian, are ascribed by Mr Gib|bon, to swarms of putrifying locusts. But the most frequent source of the plague is from human miasmata, rendered pestilential, by famine, grief, the want of cleanliness, and by a number of per|sons crouded together in small rooms, or houses.

The yellow fever has been confounded with the jail or hospital fever. I shall briefly enume|rate the circumstances and symptoms in which they agree and disagree.

The first are as follow:

The jail-fever affects persons who are debilita|ted by grief, fear, or intemperance.

The pulse is sometimes intermitting in this fe|ver. This is taken notice of by Dr Ferriar.

There are marks of congestion in the brain, without any signs of inflammation in it after death. There are likewise in this fever great depression of spirits, sighing, delirium, palsy, and a debilita|ted state of the memory after recovery. This occurs more frequently, and in a greater degree, after the jail, than after the yellow fever.

The eye is sometimes red, and sometimes dull in this fever. There is frequently an absence of thirst.

There is in the jail fever in its worst state, a suppression or great ••••at in the urine.

Buboes, petechiae, pain along the spermatic cord, a swelling of one testicle, ulcers in the throat, and abscesses in different parts of the body, have all occurred occasionally in this fever.

The circumstances and symptoms in which the jail fever differs from the yellow fever, are as fol|low:

It affects persons who have been previously weakened by other diseases, or who are of weakly habits.

The pulse is seldom full or tense, but generally weak and quick.

The tongue soon loses its whiteness and mois|ture, and assumes when dry, a dark colour.

The stomach is seldom disordered. The bowels are either in their natural state, or a diarrhoea at|tends.

The stools are seldom bilious, or preter|naturally foetid.

There are great twitchings in the tendons, and tremors in the tongue, and limbs.

Intermissions and remissions of the fever are sel|dom, or scarcely perceptible.

It prevails alike in the winter, spring, and au|tumn. It is moderated, or checked by warm weather, provided patients are placed in situations in which they can breathe a sufficient quantity of fresh air.

It is less contagious and mortal than the yellow fever.

It is derived from human miasmata produced under inferior degrees of all those circumstances, which favour the generation of the plague. It is, to the plague in its degree, what the common bilious, is, to the yellow fever.

There is a camp fever described by some au|thors, which is derived from a mixture of marsh and human miasmata. Its symptoms are com|pounded

of those which belong to the bilious, and jail fevers.

I shall not attempt to distinguish the yellow, from the common bilious fever. They are only different grades of the same disease. The follow|ing, appears to be the natural order of a scale of such fevers as are derived from marsh miasmata.

1. The yellow fever.

2. The common bilious remitting fever.

3. The intermitting fever.

4. The febricula of authors, or what are called "inward fevers" in the southern states. Differ|ent degrees of force in the remote cause, in con|junction with a difference in the sensible qualities of the air, frequently produce all those grades of bilious or marsh fever in different seasons, and sometimes, in the same season. The encrease, or abstraction of accidental stimuli, likewise often change these different states of bilious fever into each other. Thus, what are called inward fevers have often been excited by means of a ride, or a long walk, into an intermittent; an intermittent

has been changed by the premature use of the bark into a remitting fever, and a common remit|tent, has, by improper regimen or violent exer|cise, been excited into a yellow fever. The dan|ger in each case, is determined by the force of the miasmata, and the state of the air.

In contemplating the immense proportion of human misery, which is produced by pestilential diseases, we are naturally led to inquire whether their approaches are not indicated by some un|usual signs in the operations of nature. What is called instinct in many animals, has repeatedly taught them to foresee, and to avoid many natu|ral evils; and if reason has not taught man to do the same, it is probably because its exercises have not been directed to those subjects.

I have endeavoured to discover whether any thing uncommon occurred in the operations of na|ture in the atmosphere, or in the animal and ve|getable kingdoms in the course of the winter and summer, which preceded our late epidemic. The result of my inquiries is as follows.

The winter of 1793 was unusually moderate. It was supposed this had an influence upon the weather which favoured the generation and pro|pagation

of the disease. I should have been dis|posed to admit this opinion, had moderate winters in Pennsylvania been uniformly succeeded by sick|ly autumns. Livy records that a pestilential fever in Rome was preceded by an unusually cold win|ter* 12.7.

The wild pidgeons were common during the winter of 1793 in many parts of Pennsylvania. But they have occasionally appeared in great stocks in our state in former winters, without ha|ving been the harbingers of a sickly autumn.

Dr P. Russel says, that uncommon and violent diseases generally preceded the plague at Aleppo. Dr Sydenham informs us, that acute inflammatory fevers were the forerunners of the plague in Lon|don in 1665. I suspect that uncommon circum|stances attending certain diseases, either as to their violence or time of appearance, will be found to suggest a prelude to a sickly autumn in all coun|tries. The scarlatina anginosa I have remarked was attended with an uncommon degree of inflam|matory diathesis, in the month of July. Dr Por|ter informed me that he had been called to seve|ral cases of dysentery, attended with symptoms of

great malignity, in the neighbourhood of Frank|fort, in the months of July and August. Dr Sen|ter informed me in a letter dated the 26th of No|vember, 1793, that "during the last two summer months, fevers and fluxes were more obstinate than he had ever known them, at Newport in Rhode Island." My pupil Mr Nathaniel Potter, in a letter from Caroline county, in Maryland, dated November 1st, 1793, gave me the follow|ing information. "On my arrival at this place, on the first of August, I was informed by gentle|men of the faculty, that the dysentery had pre|vailed from the first of June to the fifteenth of July, with considerable mortality. From obser|vations and communications from different peo|ple in this county, I did not hesitate to predict a sickly autumn; for it is an invariable maxim here, both among physicians and farmers, that if the wheat be damaged by rust or blast, a contagi|ous dysentery is soon to follow; and the sooner in the summer the dysentery appears, the more violent and mortal will be the diseases of the autumn."

These communications, though short and few, will be useful if they serve to lead physicians to observe and record hereafter the diseases which precede universal and mortal epidemics.

There can be no doubt of a warm summer, whether it be wet or dry, having often preceded malignant autumnal fevers. Mr Norris in a let|ter to one of his friends, dated the 24th of Au|gust, O. S. says that "the summer of 1699 was the hottest he had ever felt, and that several had died in the harvest fields with the violence of the heat." It appears from another of Mr Norris's letters, dated the 12th of August, O. S. that the yellow fever made its first appearance in that month. The yellow fevers of 1762 and 1793, were both preceded by warm summers.

I have one more remark to mention upon this subject, which was communicated to me by a gen|tleman who had resided occasionally in southern and tropical countries. He informed me that he had observed in the month of July, several weeks before the yellow fever became general, a pecu|liar and universal allowness of complexion in the faces of the citizens of Philadelphia, such as he had observed to precede the prevalence of malig|nant bilious fevers in hot climates. Dr Dick in|formed me that he had observed the same appear|ance in the faces of people in Alexandria, accom|panied in some cases by a yellowness in the eyes, during the last summer, and some time before vio|lent

bilious fevers became epidemic upon the banks of the Potowmac.

With these observations I take leave of the his|tory of our late epidemic fever. A few of its symptoms which have been omitted in the history, will be included in the method of cure; for they were discovered or produced by the remedies which were used for that purpose.

Notes

• * 4.1

  The register of the deaths shows that it amounted at that time to upwards of 150.
• * 6.1

  Treatise on the Fevers of Jamaica, page 298.
• * 6.2

  Vergasca, Sorbait, and Boate in Haller's Biliotheca Me|dicinae, Vol. III. also by Dr Stubbs in the Philosophical Transactions, and Riverius in his treatise de febre pestilenti.
• * 6.3

  Medical Inquiries and Observations, Vol. II.
• * 6.4

  Historia Anatomica Medica, Vol. II. Obs. 405. 418. 423. 510.
• † 6.5

  Medical Histories and Reflections, p. 150.
• * 6.6

  Vol. i. p. 168.
• † 6.7

  Treatise on the Intestinal remitting Fever, p. 125.
• * 6.8

  Essay on the Epidemic Disease of Lying-in Women, of the years 1787 and 1783. p. 34.
• * 6.9

  Haller's Biliotheca Medicinae, vol. iv. p. 375.
• * 6.10

  Rosier's Journal for Jan. 1790. vol. xxxvi. p. 380.
• * 6.11

  Wallis's Edition, Vol. i. p. 197.
• * 6.12

  Essay on the Bilious or Yellow Fever, p. 35.
• * 6.13

  See Wallis's edition of Sydenham, Vol. I. p. 165. Vol. II. p. 52, 94, 98, 350. De Haen's Ratio Medendi, Vol. II. p. 162. Vol. IV. p. 172. Gaubii Pathologia § 498, and Dr Sybert's inaugural dissertation, entitled "An at|tempt to Disprove the doctrine of the Putrefaction of the Blood in Living Animals," published in Philadelphia in 1793.
• * 6.14

  Wallis's edition, Vol. I. P. 344.
• * 6.15

  De Febre Pestilenti, vol. xi. p 9••.
• * 6.16

  Diseases of Minorca, p. 185.
• * 6.17

  Dr Hodges Account of the Plague in London, p. 26.
• † 6.18

  Sed hoc observatu dignum fuit, omnes alios morbos acutos, durante peste ••iluisse, et omnes morbos acutos e pes|tis genere suisse. Nosologia Methodica, vol. i. p. 416.
• * 6.19

  Vol. i. p. 340.
• * 6.20

  Vol. i. p. 352.
• † 6.21

  Vol. ii. p. 164. see also p. 1. p. 109, 122, 204, 212, 233, 274, 355, 358-9, and 436.
• ‡ 6.22

  De Aere ••t morb. epidem. p. 33, 34.
• § 6.23

  Page 285.
• ‖ 6.24

  De Febre Pestilenti, vol. ii. p. 95.
• * 6.25

  Medical Inquiries and Observations, Lond. edit. Vol. I. p. 122.
• * 6.26

  Page ••••.
• † 6.27

  Page 1••••.
• ‡ 6.28

  Observations on the Diseases in long Voyages to the East Indies, Vol. I. p. 13, 14, 48, 151. Vol. II. p. 99, 318. and 320.
• * 6.29

  Lib. II. Cap. V.
• † 6.30

  Hunter on the Venereal Disease, introduction, p. 3.
• * 7.1

  Essays and Observations, Physical and Literary. Vol. xi. page 409.
• * 8.1

  Diseases of Warm Climates, p. 169.
• * 8.2

  "Pulsus sanorum pulsibus similes admodum, pericu|losi." De Febre Pestilenti, p. 114.
• * 8.3

  "Sine aura, usque annus fuit." Epid. 3.
• † 8.4

  Vol. i. p. 5.
• ‡ 8.5

  Diseases of the Army, P. 5. of the 7th London Edi|tion.
• * 8.6

  Experiments on Animal Electricity, p. 90.
• * 8.7

  Diseases of Warm Climates, p. 125.
• * 9.1

  In the life of Thomas Story a celebrated preacher among the Friends, there is an account of the distress of the city in its infant state from the prevalence of the yellow fever in the autumn of 1699, nearly like that which has been described I shall insert the account in his own words. "Great was the fear that fell on all flesh. I saw no lofty or airy countenance, nor heard any vain jesting to move men to laughter. Every face gathered pale|ness, and many hearts were humbled, and countenances fallen, and sunk, as such that waited every moment to be summoned to the bar, and numbered to the grave." The same author adds that six, seven, and sometimes eight died of this fever in a day for several weeks. His fellow tra|veller and companion in the ministry Roger Gill, disco|vered upon this occasion an extraordinary degree of Chris|tian philanthropy. He publicly offered himself in one of the meetings of the Society as a sacrifice for the people, and prayed that "God would please to accept of his life for them, that a stop might be put to the contagion." He died of the fever a few days afterwards.
• * 9.2

  In the above accounts there is a deficiency of returns from several grave-yard of 163.
• * 10.1

  From a 〈…〉〈…〉 in the register of the interments in the Friend's 〈◊〉〈◊〉 ground, 〈…〉〈…〉 year made its first appearance in the month of June. The following is a copy of that note. "12th of the 6th month (O. S.) 1741, a malignant yellow fever now spreads much." Besides that note, there is the following: "25th of the 7th month (O. S.) 1741, many who died of the above distemper, were persons lively, and strong, and in the prime of their time.
• * 10.2

  Medical Inquiries and Observations, London Edition, p. 106.
• † 10.3

  P. 5, 56, 180, and 323.
• * 10.4

  Introduction to a Treatise on the Venereal Disease, p. 3, of the American edition.
• * 10.5

  Page 273.
• * 10.6

  P. Russel, p. 4.
• * 11.1

  Lind on the Diseases of Hot Climates, p. 36 and 124.
• † 11.2

  Cleghorn, page 176.
• ‡ 11.3

  Diseases of Hot Climates, page 123.
• * 12.1

  Page 35, 36.
• † 12.2

  Observations on the Diseases of Long Voyages to hot countries, vol. i. p. 123, 124.
• ‡ 12.3

  De Febre Pestilenti, vol. ii. p. 97.
• § 12.4

  Histor. Hepat. p. 745.
• * 12.5

  Page 132.
• † 12.6

  Addoms's Inaugural Dissertation on the Malignant Fever which prevailed in New York, during the months of August, September, and October, in 1791, p. 7.
• * 12.7

  Riverius vol. ii. p. 98.