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.

Of the Method of Cure.

IN the introduction to the history of the fever, I mentioned the remedies which I used with success, in several cases which occurred in the beginning of August. I had seen, and re|corded in my note book, the efficacy of gentle purges in the yellow fever of 1762; but finding them unsuccessful after the 20th of August, and observing the disease to assume uncommon symp|toms of great indirect debility, I laid them aside, and had recourse to a gentle vomit of ipecacuanha on the first day of the fever, and to the usual re|medies for exciting the action of the sanguiferous system. I gave bark in all its usual forms of in|fusion, powder, and tincture. I joined wine, brandy, and aromatics with it. I applied blisters to the limbs, neck, and head. Finding them all ineffectual, I attempted to rouse the system by wrapping the whole body, agreeably to Dr

Hume's practice, in blankets dipped in warm vi|negar. To these remedies I added one more: I rubbed the right side with mercurial ointment, with a view of exciting the action of the vessels in the whole system, through the medium of the li|ver, which I then supposed to be principally, tho' symptomatically, affected by the disease. None of these remedies appeared to be of any service; for although three out of thirteen recovered of those to whom they were applied, yet I have reason to believe that they would have recovered much sooner had the cure been trusted to nature. Per|plexed and distressed by my want of success in the treatment of this fever, I waited upon Dr Stephens, an eminent and respectable physician from St Croix, who happened then to be in our city, and asked for such advice and information upon the subject of the disease, as his extensive practice in the West Indies would naturally sug|gest. He politely informed me that he had long ago laid aside evacuations of all kinds in the yel|low fever; that they had been found to be hurt|ful, and that the disease yielded more readily to bark, wine, and above all, to the use of the cold bath. He advised the bark to be given in large quantities by way of glyster, as well as in the usual way; and he informed me of the manner in which the cold bath should be used, so as to de|rive

the greatest benefit from it. This mode of treating the yellow fever appeared to be reason|able. I had used bark in the manner he recom|mended it in several cases of sporadic yellow fever with success in former years. I had moreover the authority of several other physicians of repu|tation in its favour. Dr Cleghorn tells us, that "he sometimes gave the bark when the bowels were full of vicious humours. These humours (he says) are produced by the fault of the circu|lation. The bark by bracing the solids, enables them to throw off the excrementitious fluids, by the proper emunctories* 1.1."

I began the use of each of Dr Stevens's reme|dies the next day after my interview with him, with great confidence of their success. I prescri|bed bark in large quantities; in one case I ordered it to be injected into the bowels every four hours. I directed buckets full of cold water to be thrown frequently upon my patients. The bark was offensive to the stomach, or rejected by it in every case in which I prescribed it. The cold bath was grateful, and produced relief in several cases by inducing a moisture on the skin. For a while I had hopes of benefit to my

patients from the use of these remedies, but in a few days, I was distressed to find they were not more effectual than those I had previously used. Three out of four of my patients died to whom the cold bath was administered in addition to the tonic remedies before mentioned.

Baffled in every attempt to stop the ravages of this fever, I anticipated all the numerous and complicated distresses in our city, which pestilential diseases have so often produced in other coun|tries. The fever had a malignity, and an obstinacy which I had never before observed in any disease, and it spread with a rapidity and mortality, far beyond what it did in the year 1762. Heaven alone bore witness to the anguish of my soul in this awful situation. But I did not abandon a hope that the disease might yet be cured. I had long believed that good was commensurate with evil, and that there does not exist a disease for which the goodness of Providence has not provi|ded a remedy. Under the impression of this be|lief, I applied myself with fresh ardour to the in|vestigation of the disease before me. I ransacked my library, and pored over every book that treated of the yellow fever. The result of my researches for a while was fruitless. The accounts of the symptoms and cure of the disease by the

authors I consulted, were contradictory, and none of them appeared altogether applicable to the pre|vailing epidemic. Before I desisted from the in|quiry to which I had devoted myself, I recollected that I had among some old papers, a manuscript account of the yellow fever as it prevailed in Vir|ginia in the year 1741, which had been put into my hands by Dr Franklin, a short time before his death. I had read it formerly, and made extracts from it into my lectures upon that disorder. I now read it a second time. I paused upon every sentence; even words in some places arrested and fixed my attention. In reading the history of the method of cure, I was much struck with the fol|lowing passages.

"It must be remarked, that this evacuation (meaning by purges) is more necessary in this, than in most other fevers. The abdominal viscera are the parts principally affected in this disease, but by this timely evacuation, their feculent cor|ruptible contents are discharged, before they cor|rupt and produce any ill effects, and their various emunctories, and secerning vessels are set open, so as to allow a free discharge of their contents, and consequently a security to the parts them|selves, during the course of the disease. By this evacuation the very minera of the disease, pro|ceeding

from the putrid miasma fermenting with the salivary, bilious, and other inquiline humours of the body, is sometimes eradicated by timely emptying the abdominal viscera on which it first fixes, after which a gentle sweat does as it were nip it in its bud. Where the primae viae, but especially the stomach, is loaded with an offensive matter, or contracted, and convulsed with the ir|ritation of its stimulus, there is no procuring a laudable sweat, till that is removed; after which a necessary quantity of sweat breaks out of its own accord, these parts promoting it when by an ab|sterging medicine, they are eased of the burden or stimulus which oppresses them."

"All these acute putrid fevers, ever require some evacuation to bring them to a perfect crisis, and solution, and that even by stools, which must be promoted by art, where nature does not do the business herself. On this account an ill-timed scrupulousness about the weakness of the body, is of bad consequence in these urging circumstances; for it is that which seems chiefly to make evacua|tions necessary, which nature ever attempts, after the humours are fit to be expelled, but is not able to accomplish for the most part in this disease; and I can affirm, that I have given a purge in this case, when the pulse has been so low, that it could hardly

be felt, and the debility extreme, yet both one, and the other have been restored by it."

"This evacuation, must be procured by leni|tive chologoque purges."

Here I paused. A new train of ideas suddenly broke in upon my mind. I believed the weak and low pulse which I had observed in this fever, to be the effect of debility of the indirect kind, but the unsuccessful issue of purging, and even of a spontaneous diarrhoea, in a patient of Dr Hutchin|son's had led me not only to doubt of, but to dread its effects. My fears from this evacuation were confirmed, by the communications I had re|ceived from Dr Stevens. I had been accustomed to raising a weak and low pulse in pneumony and apoplexy, by means of blood-letting, but I had attended less to the effects of purging in produ|cing this change in the pulse. Dr Mitchell in a moment dissipated my ignorance and fears upon this subject. I adopted his theory, and practice, and resolved to follow them. It remained now only to fix upon a suitable purge to answer the purpose of discharging the contents of the bowels. I have before described the state of the bile in the gall-bladder, and duodenum in an extract from the history of a dissection made by Dr

Mitchell. I suspected that my want of success in discharging this bile, in several of the cases in which I attempted the cure by purging, was owing to the feebleness of my purges. I had been in the habit of occasionally purging with calomel in bilious and inflammatory fevers, and had re|commended the practice the year before in my lectures, not only from my own experience, but upon the authority of Dr Clark. I had more|over, other precedents for its use in the practice of Sir John Pringle, Dr Cleghorn, and Dr Balfour, in diseases of the same class with the yellow fever. But these were not all my vouchers for the safety, and efficacy of calomel. In my attendance upon the military hospitals during the late war, I had seen it given combined with jalap in the bilious fever by Dr Thomas Young, a senior surgeon in the hospitals. His usual dose, was ten grains of each of them. This was given once or twice a day, until it procured large evacuations from the bowels. For a while I remonstrated with the Doctor against this purge, as being dispropor|tioned to the violence and danger of the fever; but I was soon satisfied that it was as safe as cre|mor tartar, or glauber's salts. It was adopted by several of the surgeons of the hospital, and was universally known, and sometimes prescribed, by the simple name of ten and ten. This mode of

giving calomel occurred to me in preference to any other. The jalap appeared to be a necessary addition to it, in order to quicken its passage through the bowels; for calomel is slow in its operation, more especially when it is given in large doses. I resolved after mature deliberation, to prescribe this purge. Finding ten grains of jalap insufficient to carry the calomel through the bow|els, in the rapid manner I wished, I added fifteen grains of the former, to ten of the latter; but even this dose was slow, and uncertain in its ope|ration. I then issued three doses, each consisting of fifteen grains of jalap, and ten of calomel; one to be given every six hours until they procured four or five large evacuations. The effects of this powder, not only answered, but far exceeded my expectations. It perfectly cured four out of the first five patients to whom I gave it, notwith|standing some of them were advanced several days in the disorder. Mr Richard Spain, a block-ma|ker, in Third-street, took eighty grains of calomel, and rather more of rhubarb and jalap mixed with it, on the two last days of August, and on the first day of September. He had passed twelve hours, before I began to give him this medicine, without a pulse, and with a cold sweat on all his limbs. His relations had given him over, and one of his neighbours complained to me, of my neglecting

to advise them to make immediate preparations for his funeral. But in this situation, I did not despair of his recovery. Dr Mitchell's account of the effects of purging in raising the pulse, ex|citing a hope that he might be saved provided his bowels could be opened. I now committed the exhibition of the purging medicine to Mr Stall, one of my pupils, who mixed it, and gave it with his own hand three or four times a day. At length, it operated and produced two copious, foetid stools. His pulse rose immediately afterwards, and a universal moisture on his skin, succeeded the cold sweat on his limbs. In a few days he was out of danger, and he now lives in good health as the first fruits of the efficacy of mercu|rial purges in the yellow fever.

After such a pledge of the safety and success of my new medicine, I gave it afterwards with con|fidence. I communicated the prescription to such of the practitioners as I met in the streets. Some of them I found had been in the use of calomel for several days, but as they had given it in small and single doses only, and had followed it by large doses of bark, wine, and laudanum, they had done little or no good with it. I imparted the prescription to the College of Physicians, on the third of September, and endeavoured to remove

the fears of my fellow citizens, by assuring them that the disease was no longer incurable. Mr Lewis, the lawyer, Dr M'llvaine, Mrs Bethel, her two sons, and a servant maid, and Mr Peter Baynton's whole family, (nine in number) were some of the first trophies of this new remedy. The credit it acquired, brought me an immense accession of business. It still continued to be al|most uniformly effectual in all those which I was able to attend, either in person, or by my pupils. Dr Griffitts, Dr Say, Dr Pennington, and my former pupils who had settled in the city, viz. Dr Leib, Dr Porter, Dr Annan, Dr Woodhouse, and Dr Mease, were among the first physicians who adopted it. I can never forget the transport with which Dr Pennington ran across the street, to inform me, a few days after he began to give strong purges, that the disease, yielded to them in every case. But I did not rely upon purging alone, to cure the disease. The theory of its proximate cause, which I had adopted, led me to use other remedies, to abstract excess of stimulus from the system. These were blood-letting, cool air, cold drinks, low diet, and applications of cold water to the body. I had bled Mrs Bradford, Mrs Leaming, and one of Mrs Palmer's sons with success, early in the month of August. But I had witnessed the bad effects of bleeding in the first

week in September, in two of my patients who had been bled without my knowledge, and who appeared to have died in consequence of it. I had moreover, heard of a man who had been bled on the first day of the disorder, who died in twelve hours afterwards. These cases produced caution, but they did not deter me from bleeding as soon as I found the disease to change its type, and in|stead of tending to a crisis on the third, to protract itself to a later day. I began by drawing a small quantity at a time. The appearance of the blood, and its effects upon the system, satisfied me of its safety and efficacy. Never before did I experi|ence such sublime joy as I now felt in contemplat|ing the success of my remedies. It repaid me for all the toils and studies of my life. The con|quest of this formidable disease, was not the effect of accident, nor of the application of a single re|medy; but, it was the triumph of a principle in medicine. The reader will not wonder at this joyful state of my mind, when I add a short extract from my note book, dated the 10th of September. "Thank God! Out of one hundred patients, whom I have visited, or prescribed for, this day, I have lost none."

Being unable to comply with the numerous demands which were made upon me for the purg|ing

powders, notwithstanding I had requested my sister, and two other persons to assist my pupils in putting them up; and finding myself unable to attend all the persons who sent for me, I furnished the apothecaries with the recipe for the mercurial purges, together with a copy of the following di|rections, for giving them, and for the treatment of the disorder.

"As soon as you are affected, (whether by night or day) with a pain in the head, or back, sick|ness at stomach, chills or fever; more especially, if those symptoms be accompanied by a redness, or faint yellowness in the eyes, take one of the pow|ders in a little sugar and water, every six hours, until they produce four or five large evacuations from the bowels—drink plentifully of water gruel, or barley water, or chicken water, or any other mild drink that is agreeable, to assist the opera|tion of the physic. It will be proper to lie in bed while the medicine is operating; by which means a plentiful sweat will be more easily brought on. After the bowels are thoroughly cleansed, if the pulse be full or tense, eight or ten ounces of blood should be taken from the arm, and more, if the tension or fulness of the pulse should continue. Balm tea, toast and water, lemonade, tamarind water, weak camomile tea, or barley water should

be drank during this state of the disorder—and the bowels should be kept constantly open, either by another powder, or by small doses of cremor tartar, or cooling salts, or by common opening glysters; but if the pulse should become weak and low after the bowels are cleansed, infusions of camomile and snake-root in water, elixir of vi|triol, and laudanum; also wine and water, or wine, punch, and porter should be given, and the bark either in infusion in water or in substance, may be administered in the intermission of the fe|ver. Blisters may likewise be applied to the sides, neck, or head in this state of the disorder, and the lower limbs may be wrapped up in flannels wetted in hot vinegar or water. The food should consist of gruel, sago, panada, tapioca, tea, coffee, weak chocolate, wine whey, chicken broth, and the white meats, according to the weak or active state of the system. The fruits of the season may be eaten with advantage at all times. Fresh air should be admitted into the room in all cases, and cool air when the pulse is full and tense. The floor should be sprinkled now and then with vine|gar, and the discharges from the body be re|moved as speedily as possible."

"The best preventives of the disorder, are a temperate diet, consisting chiefly of vegetables,

great moderation in the exercises of body and mind, warm cloathing, cleanliness, and a gently open state of the bowels."

Hitherto there had been great harmony among the physicians of the city, although there was a diversity of sentiment as to the nature and cure of the prevailing fever. But this diversity of sen|timent and practice, was daily lessening, and would probably have ceased altogether in a few days, had not the following publication subscribed A. K. and said to be written by Dr Adam Kuhn, made its appearance on the 11th of September, in the General Advertiser, from which it was copied into all the papers of the city.

PHILADELPHIA, Sept. 7th, 1793.

SIR,

I RECEIVED your letter to day, and shall with pleasure give you every information in my power respecting the malignant fever, which proves so fatal among us. As I consider debility and putrefaction the alarming circumstances to be attended to, and to be obviated from the earliest commencement of the disease, my method of treat|ment is instituted accordingly, and has been gene|rally successful. I do not administer any emetic,

do I give a laxative, unless indicated by costive|ness, when I recommend cream of tartar or castor oil, but prefer a clyster to either. In case of nau|sea I order a few bowls of camomile tea to be taken▪ if the nausea continues, it is to be relieved with the saline draught in a state of effervescence, elixir of vitriol, and if necessary, laudanum. The sickness of the stomach may also be alleviated by applying mint, cloves, or any other spice with wine or spirits to the pit of the stomach. The stomach being composed, 20 drops of elixir of vitriol are to be taken every two hours in a tea cup full of 〈◊〉〈◊〉 cold camomile tea, and if bark can be retained, two drachms of the best pale bark in substance are to be given every two hours, alter|nately with the elixir of vitriol. When an ounce of bark has been administered in this manner, the dose is to be diminished to one drachm every two hours, as the continuance of the large doses might disorder the stomach or bowels. Should the bark prove purgative it will be necessary to give 10 or 15 drops of laudanum after every stool. But if the bark cannot be retained on the stomach, 20 drops of elixir of vitriol are to be taken every hour, and recourse must be had to bark clysters.

Two ounces of bark are to be put into three half pints of boiling water, and boiled down to a

pint; the decoction to be strained, and to 4 ounces of the decoction we add from two to four drachms of finely powdered bark and fifty drops of lauda|num. This mixture is to be injected every four hours or oftner if the symptoms are violent. One or two glasses of Madeira wine may be added to each injection where the debility is great. Wine is to be given from the beginning; at first the weaker wines such as claret and rhenish; if these cannot be had, Lisbon or Madeira diluted with rich lemonade. The quantity is to be de|termined by the effects it produces and by the state of debility which prevails, guarding against its oc|casioning or encreasing the heat, restlessness and delirium. I prefer pale bark from a conviction that most of the red bark offered for sale, is adul|terated. But I place the greated dependance for the cure of the disease, on throwing cool water twice a day over the naked body. The patient is to be placed in a large empty tub, and two buckets full of water, of the temperature of about 75 or 80 degrees of Fahrenheit's thermometer, according to the state of the atmosphere, are to be thrown over him.

He is then to be wiped dry and put to bed; it is commonly followed by an easy perspiration and is always attended with great refreshment to the

patient. This remedy however must be applied from the earliest attack of the disease and conti|nued regularly through the whole course of it. Of regimen it is needless to say much to you: ripe fruits, sago with wine, and rich wine-whey are the most proper. A spacious chamber with a free circulation of air, and repeatedly changing the bed and body linen are highly necessary. If the bark clysters should bring on costiveness the laudanum may occasionally be omitted; if this is not attended with the desired consequences, we have recourse to a common injection. Sprinkling the chamber with vinegar, washing the face, neck, hands and feet with it, and then wiping them dry, will have their use. The fumes of vinegar and of nitre will contribute much to sweeten the air in the chamber.

I am, &c. A. K.

N. B. The practice of applying the cold bath in fevers is not new. In a malignant fever which prevailed at Breslau in Silesia and proved ex|tremely fatal, yielded to none of the usual reme|dies, Dr De Haehn a physician of the place had recourse to this remedy and found it effectual. It has also been used with advantage in England in

putrid fevers. In many of the West India islands it is generally employed in their malignant fevers. Dr Stevens, a gentleman of high character in his profession, who is now in this city, assures me that in the island of St. Croix where he practised me|dicine many years, it has been found more effec|tual than any method heretofore practised.

I am moreover indebted to Dr Stevens for the following observations: that laxatives are ne|ver employed but when clysters are not attended with the desired effect of moving the bowels; that in violent attacks of the disease the bark clysters are repeated every two hours, and the water is applied to the body every 6 or 8 hours and even more frequently; that when there is a disposition to diarrhoea, the elixir of vitriol has a tendency to encrease it, and is therefore laid aside, and that the disease which he has seen in this country is of the same nature with the malignant fever of the West Indies.

To obviate the effects of this letter upon the minds of the citizens, I published the next day an account of the ill success which had attended the use of the remedies recommended by Dr Kuhn, in my practice, and of the happy effects of mercurial purges and bleeding. This publication was con|cluded with the following remarks.

The yellow fever now prevailing in our city, differs very materially from that which prevails in the West Indies, and in several particulars from that of the year 1762. This will easily be be|lieved, by all those who attend to the influence of climate and seasons, upon diseases. Prescribing for the name of a disease, without a due regard to the above circumstances, has slain more than the sword.

My only design in withdrawing myself for a moment from the solemn duties to my fellow citi|zens, in which I am now engaged, is to bear a testimony against a method of treating the present disorder, which if persisted in, would probably have aided it in desolating three fourths of our city.

I have had so many unequivocal proofs of the success of the short and simple mode which I have adopted, of treating this disorder, that I am now satisfied, that under more favourable circum|stances of attendance upon the sick, the disease would yield to the power of medicine with as much certainty as a common intermitting fever.

BENJ. RUSH.

September 11, 1793.

The above address to the citizens, produced the following letter from Dr Kuhn to the Mayor of the city.

SIR,

IF you are of opinion that the en|closed statement can have the least tendency to abate the apprehensions of the citizens, I beg of you to make any use of it you may think proper.

I am, with respect, Your most humble servant, A. KUHN.

September 13, 1793.

Matthew Clarkson, Esq. Mayor of the city of Philadelphia.

"FROM the 23d of August, the day on which I saw the first patient in the yellow fever, to the the third of September, when I was my|self confined with a remittent fever, I visited sixty persons ill of various complaints. The greater part were indisposed with remittent and inter|mittent fevers, which always prevail among us at this season of the year, which all yielded readily to our mode of treating those diseases, except in one gentleman, who had been many years an invalid. Seven only of this num|ber

had the yellow fever; three of them were patients of other gentlemen of the Faculty. Of these seven, I was called to four, in the early stage of the disease. Three of them are now well; the other was in the fourth day of the disease, when I became unwell myself. He had then no unfavourable symptoms; but died on the eighth day from the time he was seized."

A day or two afterwards, the following letter appeared in all the newspapers from Mr Hamilton, the Secretary of the Treasury of United States, to the College of Physicians.

GENTLEMEN,

MOTIVES of humanity and friendship to the citizens of Philadelphia, induce me to address to you this letter, in the hope that it may be in some degree instrumental in diminish|ing the present prevailing calamity. It is natural to be afflicted not only at the mortality which is said to obtain, but at the consequences of that undue panic which is fast depopulating the city, and suspending business both public and private.

I have myself been attacked with the reigning putrid fever, and with violence—but I trust that I am now completely out of danger. This I

am to attribute, under God, to the skill and care of my friend Doctor Stevens, a gentleman lately from the island of St. Croix, one to whose talents I can attest, from an intimate acquaintance began in early youth, whose medical opportunities have been of the best, and who has had the advantage of much experience both in Europe (having been in Edinburgh some years since, when the same fever raged there) and in the West Indies, where it is frequent. His mode of treating the disorder varies essentially from that which has been gene|rally practised—And I am persuaded, where pur|sued, reduces it to one of little more than ordinary hazard.

I know him so well, that I entertain no doubt, that he will freely impart his ideas to you, collec|tively or individually; and being in my own person a witness to the efficacy of his plan, I venture to believe, that if adopted, and if the courage of the citizens can be roused, many lives will be saved, and much ill prevented. I may add, that as far as can be yet pronounced, its efficacy has been alike proved on Mrs Hamilton, who is now in the disorder, contracted from me, with every favour|able appearance.

In giving you this information, Gentlemen, I have done what I thought discharging a duty. I only add, that if any conference with Dr Stevens, is desired, that he is going to-morrow to New-York, from which journey he has been detained several days on my account.

I am, Gentlemen, with respect, your obedient servant,A. HAMILTON.

September, 11.

He lodges at Mrs Williams's, corner of Spruce and Third streets.

College of Physicians.

This letter was followed by a letter from Dr Stephens to Dr Redman, the president of the College of Physicians, which was published in the Federal Gazette of the 16th of September.

SIR,

IN compliance with the request of the learned body over whom you preside, I now chearfully transmit them a few brief and detached observations on the nature and treatment of the

present malignant and fatal disorder which pre|vails in this city. Their humane anxiety to as|certain the real character of the complaint, and to establish some fixed and steady mode of cure for it, are fresh proofs of their benevolence, and clearly evinces that disinterested liberality for which they are so eminently distinguished. I only regret that their application to me has ap|proached so near the moment of my departure, that I have not sufficient leisure to elucidate the subject so amply and so satisfactorily as the impor|tance of it deserves. Imperfect, however, as the enclosed sketch may be, I can with truth assure them, that it is the result of extensive experience and accurate observation; and that it is dictated solely by a philanthropic desire of checking the ravages of disease, and of restoring tranquillity to the dejected minds of the public.

This disorder arises from contagion. Its ap|proaches are slow and insiduous at the commence|ment. It is ushered in with a slight degree of lan|guor and lassitude, loss of appetite, restlessness and disturbed dreams, depression of spirits, and a want of inclination to perform the ordinary occupations of life. The patient does not consider himself suf|ficiently sick to complain or call in the assistance of a physician. His feelings are rather unplea|sant

than alarming. This train of symptoms con|tinue for two or three days, and if not removed by timely aid, is succeeded by a sharp pain in the head, anxiety, and suppression about the praecor|dia, a feeble pulse, great prostration of strength, and a variety of other morbid phenomena, which are too well known to the faculty to need descrip|tion. In the first stage of the disorder, a little at|tention, and the well directed efforts of a skilful practitioner, may generally prove successful in mi|tigating the violence of future symptoms, and pre|venting either much danger or long confinement.

At the first appearance of languor, lassitude, &c. especially if the patient has been near the source of contagion, he should carefully avoid all fatigue of body and application of mind. Every thing that can tend to debilitate should be care|fully guarded against. He should remain at per|fect rest. His diet should be fuller and more cor|dial than usual, and a few extraordinary glasses of old Madeira may be allowed. He should take the cold bath every morning; and if his sleep is disturbed, a gentle opiate combined with a few grains of the volatile salts and some grateful aro|matic may be administered at night. A few doses of good genuine bark may be taken in powder during the day; and if the stomach should be af|fected

with nausea, a strong decoction of the same may be substituted. Great care should be taken to keep the mind of the patient calm and serene,—neither to terrify it with needless apprehension, nor alarm it by the melancholy relation of the spreading mortality which surrounds him. It is at this stage of the complaint, that the physician may lay the foundation of future success. But unfortunately, it is also the period of the disease which is commonly too much neglected by the pa|tient. Gentlemen of the faculty are rarely called in until the symptoms are more alarming and dan|gerous. But it is a matter of material conse|quence to the patient to know that by a little at|tention at the commencement, and by carefully watching the approaches of the disease even tho' it should be contracted, it may be rendered mild, and may terminate favourably. It is also of equal consequence for practitioners to attend to these particulars in laying down the prophylaxis to their patients.

When the disorder has gained ground and be|come violent and when the danger is imminent, the most unremitted exertions should be made by the physician to mitigate the symptoms. The nausea and vomiting may be relieved by an infusion of ca|momile flowers, given frequently until the stomach

is sufficiently emptied of all crude matter. Small doses of a cordial mixture composed of the oil of peppermint and compound spirits of lavender, may then be taken until the fever abates. If, notwith|standing, the irritability of the stomach should still continue, recourse must be instantly had to the cold bath, which must be used every two hours or oftener if the urgency of the symptoms should require it. After each immersion a glass of old Madeira, or a little brandy burnt with cinnamon, may be administered. Flannel cloths wrung out of spirits of wine, impregnated with spices, may be applied to the pit of the stomach, and changed frequently.

An injection containing an ounce of powder|ed bark, mixed with thin salap or ••ago, to which a tea-spoon full of laudanum has been added, should be administered. These injections may be continued every two or three hours, omitting the laudanum after the first. As soon as the stomach can bear the medicines and nourishment, the bark may be administered in small doses; as much Ma|deira wine may be given as the patient can bear without affecting his head, or heating him too much. All emetics and violent cathartics should be avoided. If the bowels should not be suffici|ciently open, a laxative clyster may be necessary,

or a few grains of powdered rhubarb added to each dose of bark until the desired effect is pro|duced. If diarrhoea should prevail, it must be checked by starch injections blended with lauda|num by the tinctura E. kino japonica, or a decoc|tion of carcarilla. All drastic cathartics do in|jury when the disease is in its advanced stage. If stupor, coma, or delirium should come on, a large blister should be applied between the shoulders, and small ones to the thighs; stimulant cataplasms should also be applied to to the soles of the feet: when hemorrhagies appear, the elixir of vitriol may be administered in conjunction with the bark, but great care should be taken to prevent it from affecting the bowels.

If the pulse should be much sunk, the pro|stration of strength great, and subsultus tendinum take place, small doses of the liquor mineralis Hoffmanni, or even vitriolic aether diluted with water may be given. Musk and camphor in this stage of the disease have likewise proved effectual. Upon the whole, sir, I may sum up this hasty out|line, by inculcating the use of the tonic plan in its fullest extent, and by warning against the ill con|sequences of debilitating applications, or profuse evacuations in every period of the disease: the cold bath, bark and wine, a spacious well ventila|ted

room, frequent change of bed and body linen, and attention to rest and quiet, if properly perse|vered in, will in most cases prove successful, and strip this formidable disease of its malignity, its terror, and its danger.

The description I have given of this disorder, and the utility of the plan of cure I have laid down, are confirmed by experience and coincides with our reason and the soundest theory; the cause producing the effect is a strong debilitating power; the symptoms occasioned by its applica|tion, indicate extreme debility in the animal func|tions, and great derangement of the nervous sys|tem: ought not therefore the remedies adapted to this complaint to be cordial, stimulating, and tonic? Should not violent evacuations, which evi|dently weaken and relax, be avoided? These are hints which it would be presumptuous and assu|ming in me to extend or dwell upon: to gentle|men of such eminence as your colleagues, it is suf|ficient to point out what reason and experience conjointly suggest to me. Their superior judg|ment will, I am convinced, supply every deficien|cy, and enable them to pursue that plan which is best adapted to public utility, and the effectual re|moval of the present dreadful malady. If the few observations I have suggested be serviceable to

the inhabitants of this city, my intentions will be fully answered, and my feelings completely grati|fied.

I have the honour to be, Sir, Your most obedient servant, EDWARD STEVENS.

Sept. 16th, 1793.

John Redman, M. D. president of the College of Physicians.

An essay upon the theory of this disease at this juncture, would have been as ill-timed as a dis|course upon tactics would be to an army in the height of a battle; but Dr Stevens's publication made it necessary for me to appeal to the reason of my brethren upon the theory of the disease. I did it in a few words in the following address to the College of Physicians.

GENTLEMEN,

IT is with extreme regret that I have read Dr Steven's letter to the president of our College in one of the news-papers. It will,

I fear, co-operate with Dr. Kuhn's plan of treat|ing the disorder, and Mr Hamilton's well-meant letter, in adding to the mortality of the disorder. If I should survive my present labours, I hope to prove that Dr Stevens's theory of the disease in the West Indies, is as erroneous, as the practice he has recommended has been fatal, in Philadel|phia. It is a most inflammatory disorder in its first stage. The contagion, it is true, in its first action upon the system, frequently produces debi|lity; but the debility here is of the indirect kind, and arises wholly from an excess of the stimulus of contagion upon the system. This indirect debility, as in many other diseases, yields only to the ab|straction of other stimuli, and to none so speedily as to large evacuations from the bowels and the blood-vessels.

I have so high an opinion of Dr Stevens's candor and liberality as a gentleman and a physi|cian, that I shall make no apology for thus pub|licly dissenting from his opinions and practice.

Could patients be visited by physicians as of|ten, and attended by nurses as carefully, as in other acute diseases, I am satisfied that the mode of treating it which I have adopted and recom|mended,

would soon reduce it in point of danger and mortality, to a level with a common cold.

From, Gentlemen, Your sincere friend and brother, B. RUSH.

Sept. 17th, 1793.

During this controversy with the opinions and practice of Dr Kuhn and Dr Stevens, I published in the Federal Gazette, the following letter to the College of Physicians; also some additions to the directions I had published with the mercurial purges.

GENTLEMEN,

As the weekly meetings of our College have become no longer practicable, I have taken the liberty of communicating to you, the result of further observations upon the pre|vailing epidemic.

I have found bleeding to be useful, not only in cases where the pulse was full and quick, but where it was slow and tense. I have bled in one case, where the pulse beat only 48 strokes in a minute, and recovered my patient by it. The pulse became more full and more frequent after

it. This state of the pulse seems to arise from an inflamed state of the brain, which shows itself in a preternatural dilatation of the pupils of the eyes. It is always unsafe to trust to the most perfect re|missions of fever and pain in this state of the pulse. It indicates the necessity of more bleeding and purging. I have found it to occur most fre|quently in children.

I have bled twice in many, and in one acute case, four times, with the happiest effects. I con|sider intrepidity in the use of the lancet at present to be as necessary, as it is in the use of mercury and jalap, in this insidious and ferocious disease.

I lament the contrariety of opinion among the members of our College, upon the remedies proper in this disease. This contrariety seems to arise from the yellow fever being confounded with the jail or hospital fever. The fevers of Breslau, Vienna, and Edinburgh, mentioned in some late publications, in which the cold bath was used with so much success, were of the latter kind. The two diseases are totally different from each other in their cause, seasons of prevailing, symptoms, danger, and method of cure.

From, Gentlemen, Your friend and brother, BENJ. RUSH.

Sept. 12th, 1793.

FEDERAL GAZETTE.

Dr Rush regrets, that he is unable to com|ply with all the calls of his fellow citizens, who are indisposed with the prevailing fever. He begs leave to recommend to such of them as cannot have the benefit of medical aid, to take the mer|curial purges, which may now be had with suit|able directions at most of the apothecaries, and to lose ten or twelve ounces of blood as soon as is convenient after taking the purges, if the head|ach and fever continue. Where the purges can|not be obtained, or do not operate speedily, bleeding may now be used before they are taken. The almost universal success with which it hath pleased God to bless the remedies of strong mer|curial purges and bleeding in this disorder, ena|bles Dr Rush to assure his fellow citizens, that there is no more danger to be apprehended from it, when those remedies are used in its early stage, than there is from the measles or the influenza.

Dr Rush assures his fellow citizens further, that the risk from visiting and attending the sick, in common cases, at present, is not greater than from walking the streets. He hopes this informa|tion will be attended to, as many of the sick suffer greatly from the want of the assistance of bleeders, and of the attendance of nurses and friends.

While the disease was so generally mortal, or the successful mode of treating it only partially adopted, Dr Rush advised his friends to leave the city: at present he conceives this advice to be unnecessary; not only because the disease is now under the power of medicine, but because the citizens who now wish to fly into the country, cannot avoid carrying the infection with them. They had better remain near to medical aid, and avoid exciting the infection into action, which is now in their bodies, by a strict attention to former directions.

Dr R. does not believe it will be prudent for those persons who are in the country to return to town, until after frost or heavy rains have taken place; both of which alike weaken or destroy the contagion of the yellow fever.

September 12th, 1793.

Having mentioned the conditional use of bark, wine, and laudanum, in my first publication, and finding them not only useless, but hurtful, I pub|lished the following address to the citizens of Phi|ladelphia, on the 16th of September. In this address I repeated my advice to live upon a milk and vegetable diet.

Dr Rush recommends to all such of his fel|low citizens as are exposed to the contagion of the prevailing fever, to live upon a milk and ve|getable diet, and take cooling purges once or twice a week. The effects of this regimen in ren|dering the disease mild (where it is taken) are nearly the same as in preparing the body for the small-pox.

Dr R. advises those persons who cannot ob|tain the attendance of a physician, by no means to take vomits, bark, wine, or laudanum, during the first three or four days of the disorder. As the disease is highly inflammatory at present in its first stages, the only proper remedies for it are, strong purges, copious bleeding, if the pulse be full or tense, or if it be slower than natural, and at the same time subject to pauses in its pulsa|tion.

During this inflammatory state of the disease, the drinks should be simple and cold. No animal food should be tasted; cool air should be admit|ted into the room, and napkins dipped in pump water, should be applied frequently to the fore|head.

Dr. R. recommends further, that the beds and clothes of persons who have had the disease, should, upon no account, be exposed to the heat of the sun, but be washed in warm, or soaked in cold water.

"It would be an act of great humanity to the city, to provide all the physicians and bleeders, with horses and chairs, as it will be impossible for them long to escape the disease, while they are so much pre-disposed to it by constant fatigue."

September 16th, 1793.

I shall mention hereafter the substitutes I used for the tonic remedies which I had thus publicly decried.

On the 20th of September the following pub|lication appeared in the Federal Gazette, sub|scribed by Dr Currie.

Mr BROWN,

IT affords me particular satisfac|tion, that I now have it in my power to inform my fellow citizens, that the progress of the infec|tious fever has greatly abated, and that with a

little longer perseverance in avoiding intercourse with the infected, as far as humanity will permit, paying at the same time, proper attention to fu|migating and ventilating the houses, clothing, and utensils from whence the sick have been removed, or where they have been confined, the infection which has proved so mortal, will most certainly, be entirely eradicated in a few days. The best method for effecting this, is contained in a late publication by the learned Dr Russel.

I have made the strictest enquiry respecting the number at present confined by the genuine yellow fever, and am convinced that it does not exceed 40 or 50 in the whole city.

There is, however, another formidable dis|ease prevalent, by which, I have reason to believe, there are above a thousand ill at this time.

The disease I mean, is the common remittent or fall fever. This fever, however, is not in|fectious.

When the remitting fever attacks persons not fully recovered from the effects of the influenza, (which is also still prevalent here) it occasions a violent determination of the blood to the head,

accompanied with acute pain, a redness of the eyes, with a faint tinge of yellow—the pulse is quick and the skin hot. This is the disease which is so much under the power of blood-letting and purging; and is as different from the infectious, or genuine yellow fever, as the sun is from the moon, or light from darkness.

In the fall fever, which succeeds the influenza, the eye is sprightly, though red, the face turgid and flushed:—Whereas, in the genuine yellow fever, the eye is dull and inanimate, and suffused with a dusky brown, the face pale, shrunk, and cadaverous, almost from the first attack. It is in the remitting fever, with the violent affection of the head, that the mode of treatment advised by Dr Rush, can only be proper; and not in the in|fectious or yellow fever. On the contrary, in the yellow fever, it cannot fail of being certain death. In the yellow fever, the means recom|mended by Dr Kuhn and Dr Stevens, are the most effectual, and the only ones that can be relied on, with such a variation as circumstances, and the period of the disease may indicate.

It is in the fall fever, circumstanced as already described, that there is safety in visiting and at|tending the sick, because this fever is not conta|gious.

Can there be the same safety in visiting patients confined with the genuine yellow fever, which made its appearance in Water-street, the third of August last? Let those judge who have had opportunities of seeing its ravages! Is that fever, in which the bond of union is immediately dissolved between the solids and fluids, and where the purple current issues from every pore, the same as that, for which Dr Rush directs bleeding and purging? and can there be safety in visiting persons so affected? Have we all got the conta|gion of the yellow fever in our bodies, only wait|ing for some exciting cause to put it into action? By no means. The disease, which Dr Rush calls the yellow fever, and of which Dr P. says he has cured such numbers by the new method, is only the fall fever, operating on persons who have been previously affected by the influenza.

It is time the veil should be withdrawn from your eyes, my fellow citizens!

WM. CURRIE.

Sept. 17th, 1793.

To this, I published the following answer the next day.

Dr Rush is extremely sorry to differ from his friend Dr Currie, in his opinion respecting the prevailing epidemic, published in the Federal Ga|zette of last evening. Dr R. asserts, from the au|thority of Dr Sydenham, as well as from the observations of three and thirty years upon epide|mic diseases, that no two epidemics of unequal force can exist long together in the same place; and he is sure, from what he has seen of the pre|sent disease, that all the fevers now in the city, are from one cause, and that they all require dif|ferent portions of the same remedies. Dr R. has no other motives for wishing to be believed by his fellow citizens in these assertions, than to beget a confidence in them, in remedies, which he con|ceives to be as rational, as he knows them to be successful in the prevailing disorder. If Dr Cur|rie will consult Blane, Hume, Lining, and Hillary, upon the subject of the yellow fever, he will find that they all describe it as making its first attack with the symptoms of a bilious remittent. Dr R. perfectly recollects its appearing not only in this form, but in that of an intermittent, in the year 1762.

Among many arguments which might be ad|duced to prove that all our present fevers arise from one source, and require the same treatment,

(varied according to their degrees of violence) Dr R. will mention only one, and that is, he has cured many persons by plentiful purging and bleeding, of the present epidemic, who have lived in families, in which persons had died with a black vomiting, and a yellow skin.

No one can suppose that Dr. R's late indis|position (after having been constantly exposed for three weeks, to the contagion of the yellow fever in all its degrees of malignity) was not occasioned by an attack of that disorder, and yet he owes his perfect recovery through divine goodness, sim|ply to two copious bleedings, and two doses of the mercurial medicine, and that too, in the short term of only two days.

September 18th, 1793.

Besides the publications I have mentioned, Dr Wistar addressed a history of an attack he had of the fever, to the physicians of Philadelphia, in the General Advertiser of the 26th of Septem|ber. He began it by observing, that "he be|lieved many persons had been supposed to have been cured of the disease, who had never had it," and he concluded without deciding upon any of the remedies which were the subjects of con|troversy. He added a strong testimony from his

own experience of the efficacy of cool air in abating the excessive action of the arterial system.

I pass over many anonymous essays upon the fever, which appeared in the newspapers; also several, from medical gentlemen who beheld the disease at a distance. They all tended more or less to distract the public mind, and to lessen the confidence of the citizens in the simple, and pow|erful remedies which I had recommended.

In support of the efficacy of these remedies, Dr Porter, Dr Annan, and Dr Mease, gave very de|cided testimonies in the public papers. I shall insert as an epitome of them all, the following let|ter from Dr Porter.

DEAR SIR,

AS I know it will afford you much pleasure, I send you the following statement of cases. Within three days past I have been called to thirty seven persons labouring under the prevailing epidemic. I have treated them all in the new method, with the greatest success; nearly half of them are so far recovered as to require no farther assistance from me. I cannot avoid men|tioning one case of a man in whom the advantages

of bleeding were remarkable.—The pain in his head was so violent as to lead me to order bleed|ing previous to purging—from some inaccuracy in the operation, he lost a greater quantity than I directed, his attendants suppose sixteen ounces; the consequence however was, that at my next visit I found that my patient had walked out per|fectly recovered. This case was clearly marked with all the symptoms attendant on the disease in its first stages, particularly pain in the head and redness in the eyes.

With great regard, I am your Obedient servant, JOHN PORTER.

September 17.

Dr Rush.

The safety of the new remedies (as they were sometimes called) was finally admitted by their greatest enemies, but their efficacy was supposed to be confined only to common remittents, to the influenza, or to pleurisies, and other inflammatory fevers; for those diseases were believed to be con|stantly present in the city; and the certificates which were published of large families having been cured of the yellow fever by the new reme|dies,

were discredited, or treated with contempt, because the patients had recovered without a yel|low colour in their faces.

To refute this error, as well as to shew that I was not singular in my opinions respecting blood-letting, purges, and opium, I published the fol|lowing extracts from Dr Mosely, in the Federal Gazette of the 11th of October.

MR BROWN,

A NUMBER of the physicians of this city, who suppose that we have two fevers now prevailing among us, have asserted that a yellow colour is essential to what is called the yel|low fever. The following extract from Dr Mosely will shew how much they have been mistaken. This judicious physician practised physic many years in Jamaica, and saw the fever which he describes, in all its different forms.

"I have used (says the Doctor) the word yel|low in compliance with custom; but I even distrust that name, as the inexperienced may be looking out for that appearance, and not find, until it is too late, the disease he has to contend with. And indeed, the yellowness of the skin, like the black

vomiting, is not an invariable symptom of this fever. Those who are fortunate enough to re|cover, seldom have it; and many die without its appearance. Besides, the yellowness alone, leads to nothing certain; it may arise from an inoffen|sive suffusion of bile." p. 411—second edition.

The present epidemic has likewise been called a putrid fever and the remedies for the cure of that species of fever have been very generally pre|scribed. The following extract from the same author will show the error and mischief of that opinion and practice:

"This disease is in the highest degree possi|ble, an inflammatory one, accompanied with such symptoms, in a greater extent as attend all inflam|matory fevers, and most strikingly the reverse of any disease that is putrid, or of one continued ex|acerbation. It attacks all such people and under such circumstances as are seldom the objects of putrid diseases." p. 412.

In another place he says, Bleeding must be performed, and repeated every six or eight hours, or whenever the exacerbations come on, while the heat, fullness of pulse, and pains con|tinue;

and if these symptoms be violent and ob|stinate, and do not abate during the first 36 or 48 hours of the fever, bleeding should be executed even to fainting. Taking away only six or eight ounces of blood because the patient may be faint, which is a symptom of the disease, is doing no|thing towards the cure. Where bleeding is im|proper, no blood should be taken away; where it is proper that quantity will not relieve, and it is losing that time, which can never be regained. p. 427—428.

On PURGES, the doctor makes the following remarks.

"When a sufficient quantity of blood has been taken away, (which is never done) let the patient's habit be what it may, while the heat, reiterated exacerbations, flushings in the face, thirst, pains in the head, and burning in the eyes remain, the next step is to evacuate the contents of the bow|els, and turn the humours downwards." p. 435.

Speaking of opium, the Doctor says, In a fever so highly inflammatory, where the contents of the whole alimentary canal are so hot and acrid, opium must be a fatal medicine. p. 459.

To these quotations I shall only add, that the disease, from the influence of the cool weather is probably more universally, and more highly in|flammatory, in our city, and requires more copious evacuations than in the Island of Jamaica. It certainly requires more speedy and more plentiful bleeding than a common pleurisy, inasmuch as the blood-vessels, rendered weak by the previous hot summer, are in more danger of being ruptured both externally and internally, from the violent stimulus of the contagion, than in an inflamma|tory fever, which succeeds cold weather.

BENJ. RUSH.

October 9, 1793.

In justice to Dr Currie, I take great pleasure in inserting the following short address to the citi|zens, in which the retracts the opinion he had given to the public in the Federal Gazette of the the 20th of September.

October 2d, 1793.

ALL the physicians engaged in practice at present in the city, agree with Dr Rush that blood-letting and copious purging are requisite in the cure of the prevailing epidemic, in every

case, where inflammatory symptoms are evident, and that the dispute hitherto has been about the name of the disease, rather than the proper mode of treatment.

W. CURRIE.

The conclusion of the above address was unfor|tunately erroneous. The dispute between the physicians turned upon more interesting points than the name of the disease, as must be very ob|vious from the perusal of the preceding pages.

I have suppressed a letter to Dr John Rodgers of New York, dated the third of October, con|taining a short history of the treatment of the dis|ease, only because it will be detailed more fully in this work. That publication was intended as an answer to many letters which I received from practitioners in the country, requesting an account of my mode of treating the disorder. I have like|wise suppressed a second letter to Dr Rodgers, containing some extracts from Dr Sydenham, which were intended to establish the exclusive in|fluence of powerful epidemics over inferior febrile diseases. This subject has been discussed in a more ample manner in the history of the fever.

From the different publications which I have inserted, it appears that there were two modes of practice pursued; the one dictated by an opinion that the disease was highly putrid, and the other, that it was of a highly inflammatory nature. But besides these there were two other modes of treat|ing the disease, the one by moderate purging with calomel only, and moderate bleeding, on the first or second day of the fever, and afterwards by the copious use of bark, wine, laudanum, and aro|matic tonics. This practice was supported by an opinion, that the fever was inflammatory in its first, and putrid in its second stage; the other mode referred to, was peculiar to the French physicians, several of whom had arrived in the city from the West Indies just before the disorder made its appearance. Their remedies were va|rious. Some of them prescribed nitre, cremor tartar, camphor, centaury tea, the warm bath, glysters, and moderate bleeding, while a few, used lenient purges, and large quantities of tama|rind water, and other diluting drinks. The dis|sentions of the American physicians threw a great number of patients into the hands of these French physicians. They were moreover supposed to be better acquainted with the disease than the physi|cians of the city, most of whom it was well known had never seen it before.

I shall hereafter inquire into the relative success of each of the four modes of practice which have been mentioned.

Having delivered a general account of the re|medies which I used in this disorder, I shall now proceed to make a few remarks upon each of them. I shall afterwards mention the effects of the remedies used by other physicians.

Notes

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