AN
ACCOUNT
OF THE
Bilious remitting and intermitting
YELLOW FEVER,
AS IT APPEARED IN
PHILADELPHIA,
IN THE YEAR 1794.



MEDICAL
Inquiries and Observations:
CONTAINING
AN ACCOUNT
OF THE
Bilious remitting and intermitting
YELLOW  FEVER,
AS IT APPEARED IN PHILADELPHIA IN THE YEAR 1794.
TOGETHER WITH
AN INQUIRY
INTO THE
PROXIMATE CAUSE OF FEVER;
AND
A Defence of Blood-letting
AS A
REMEDY     
FOR
CERTAIN  DISEASES.
By Benjamin Rush, M.D.
PROFESSOR OF THE INSTITUTES, AND OF CLINICAL MEDICINE,
IN THE UNIVERSITY OF PENNSYLVANIA.
VOLUME  IV.
PHILADELPHIA;
PRINTED BY THOMAS DOBSON, AT THE STONE-HOUSE,
N° 41, SOUTH SECOND-STREET.
1796. 



THE PREFACE.
It is common in the Preface to
Medical books to extol facts, at the expence of
theory. Were I disposed to consider the com-
parative merit of each of them, I should derive
most of the evils of medicine from supposed
facts, and ascribe all the remedies which have
been uniformly and extensively useful, to such
theories as are true. Facts are combined and
rendered useful, only by means of theories; and
the more disposed men are to reason, the more
minute and extensive they become in their ob-
servations. Under the influence of these opi-
nions, I have ventured to deliver, in the follow-
ing pages, some new principles in medicine. I
wish it had been convenient to have kept
them a few years longer from the public eye,
in order to have improved them by flow and
frequent revisions; but the importunities of
b my

vi THE PREFACE.
my pupils, added to a sense of the precarious
tenure by which I hold a laborious life, have
induced me to publish them in their present
concise and immature state. If they lead the
reader to exercise his reason in examining
them carefully, he will readily supply my de-
ficiency of time and study in preparing them
for the press. He will reject what is erro-
neous in them, and apply what is not so, to
all the diseases of the human body.
The Account of the Yellow Fever, as it
appeared in Philadelphia in 1794, will,  I
hope, be useful, by bringing more facts to
light upon the subject of its origin, and by
exhibiting that variety in the symptoms and
method of cure, which is produced by the dif-
ference of season in all epidemics.
In stating the conduct, and opposing the
opinions of my medical brethren, I have not
been actuated by the least unkindness to any
one of them. I lament being called to this
painful duty, but it must be performed by
somebody, and in this way only can we dis-
charge 

THE PREFACE. vii
charge our obligations to those men who, at
the expense of character and fortune, have
put us in the peaceable possession of all our
knowledge in medicine ; for, however strange
it may appear, I believe we have not admitted
a useful medical principle, or remedy of any
kind, but what has  cost the authors of them
more or less conflicts with cotemporary phy-
sicians.
If the principles contained in this volume
mould be received with candour, they shall be
followed (life and health  permitting) by an
application  of them to the cure of the gout,
And of the diseases of the mind.
BENJAMIN RUSH.
2d July, 1796. 

The reader is desired to correct the following mistakes: -
In Page 3, line 14 from the top, for them,  read the earth. In
line the last of the same page, for be, read become.
p. 71, line 12, insert the word hot, before climates.
the last line of p. 96, insert without malignant symptoms, after
the word intermittent, and erase the same in the first line
of p. 97.
p. 103, line the 8th  from  the bottom, insert though it was
performed sparingly towards its close, after the word fever.
p. 110, line the 3d from the top, instead of appear to have
thrown, insert probably threw.  In line 4th, instead of and,
read for. And in lines 8 and 9, instead of and I think,
read or perhaps.
p. 232, line 14th from the top, instead of connected with,
read confined to. 

CONTENTS. 
Page
ACCOUNT of the weather and diseases which
preceded the yellow fever in 1794, - I
Names given to it by some of the physicians of the city, 13
Conduct of the Committee of Health, and their report
from an examination of some of the physicians, 15
Reasons why the prevalence of the yellow fever in a city
should always be made public, - 23
Its predisposing and exciting causes, - 25
Its symptoms, - 27
Its forms or type,- 44
Its predominance over all other diseases, - 50
Its contagious quality, and its peculiar effects upon the
body, where it did not excite fever, - 53
Methods of obviating the contagion of the yellow fever, 56
Methods of preventing its spreading in a city, - 58
Difference in its degrees and extent of contagion, at
different times, and in different countries, - 61
Of the origin of the fever of 1794, - 63
An exception to the influence of rain in checking it, 67
Observations 


vii 
CONTENTS.
Observations on the state of the atmosphere which dis-
poses to malignant or inflammatory fevers, 75
The influence of marsh exhalations on the bodies of
certain domestic animals, - 79
Comparative view of the relative contagious nature,
distance of infection, and mortality of contagious
fevers, - 80
Method of treating the yellow fever of 1794, - 83
Appearances of the blood, - 86
Comparative view of the success of the Philadelphia
and Baltimore methods of treating it, with that
which has been common in the West Indies, 114
AN Inquiry into the PROXIMATE CAUSE OF FEVER, 121
Of the symptoms of fever, - 141
Of the states of fever, - 149
Of the nosological arrangement of diseases, 150
A table of fevers, according to their different degrees
of inflammatory action, - 153
Of states of fever which are general, - 155
- which are general and local, 167
Of misplaced states of fevers, - 174
A DEFENCE OF BLOOD-LETTING, - 183
Its natural indications, - 186
Its advantages, - 188
The objections to it stated and answered, - 195
Comparative view of the effects of blood-letting, and
other depleting remedies, - 214
Of 

CONTENTS. IX 
Of the indications of blood-letting from the state of
the pulse, - 223
- from the character of the reigning epidemic, 228
- from the constitution of the patient, - 229
- from the place from which persons have lately
arrived, or in which they have been born, ibidem
- from the appearances of the blood, - 230
Of the quantity of blood which may be drawn in in-
flammatory fever, - 234
Of the quantity which should be drawn at one time, 239
Of arteriotomy, - 241
The place from which  blood should be drawn, 242
Of cupping, - 243
Of the time for bleeding in fevers, - ibid.
The effects of blood-letting about the cessation of men-
struation, - 246
Of its effects in facilitating parturition, - ibid.
- in hydrophobia, - 247
-  in dislocations, - ibid.
- in certain diseases of old people, 248
Opposition to blood-letting in the United States, ibid.
Its origin derived in part from a political cause, 251
General reflections and conclusion, - 254



AN
ACCOUNT, &c.
I CONCLUDED the History of the symp-
toms of the Bilious Remitting Yellow Fever as
it appeared in Philadelphia in the year 1793, by
taking notice that the diseases which succeeded that
fatal epidemic, were all of a highly inflammatory
nature.
I have formerly described the weather and dis-
eases of the months of March and April in the
spring of 1794.
The weather during the first three weeks of the
month of May was dry and temperate, with now
and then a cold day and night. The strawberries
were ripe on the 15th, and cherries on the 22d
day of the month in several of the city gardens.
VOL. IV. A A shower 

2 AN ACCOUNT OF THE
A shower of hail fell on the afternoon of the 22d,
which broke the glass windows of many houses. A
single stone of this hail was found to weigh two
drachms. Several people collected a quantity of it,
and preserved it till the next day in their cellars,
when they used it for the purpose of cooling their
wine. The weather after this hail storm was rainy
during the remaining part of the month. The
diseases were still inflammatory. Many persons were
afflicted with a sore mouth in this month.
The weather in June was pleasant and tempe-
rate. Several intermittents, and two very acute
pleurisies occurred in my practice during this month.
The intermittents were uncommonly obstinate, and
would not yield to the largest doses of the bark.
In a son of Mr. Samuel Coates of seven years
old, the bark produced a sudden translation of this
state of fever to the head, where it produced all the
symptoms of the first stage of internal dropsy of
the brain. This once formidable disorder yielded
in this case to three bleedings, and other depleting
medicines. The blood drawn in every instance
was sizy.
From the inflammatory complexion of the dis-
eases of the spring, and of the beginning of June,
I expected 

BILIOUS YELLOW FEVER, IN  1794. 3
I expected the fevers of the summer and autumn
would be of a violent and malignant nature. I was
the more disposed to entertain this opinion from
observing the stagnating filth of the gutters of our
city ; for the citizens of Philadelphia having an in-
terest in rejecting the proofs of the generation of
the epidemic of 1793 in their city, had neglected to
introduce the regulations which were necessary to
prevent the production of a similar fever from do-
mestic putrefaction. They had, it is true, taken
pains to remove the earth and offal matters which
accumulated in the streets ; but these, from their
being always dry, were inoffensive as remote causes
of disease. Perhaps the removal of them did harm,
by preventing the absorption of the miasmata which
were constantly exhaled from the gutters.
On the 6th of June Dr. Physick called upon
me, and informed me that he had a woman in the
yellow fever under his care. The information did
not surprise me, but it awakened suddenly in my
mind the most distressing emotions. I advised him
to inform the mayor of the city of the case, but
by no means to make it more public, for I hoped
that it might be a sporadic instance of the disorder,
and that it might not be general in the city.
A 2 On 

4 AN ACCOUNT OF THE
On the 12th of the month my fears of the re-
turn of the yellow fever were revived by visiting
Mr. Isaac Morris, whom I found very ill with a
violent puking, great pain in his head, a red eye,
and a flow tense pulse. I ordered him to be bled,
and purged him plentifully with jalap and calomel.
His blood had that appearance which has been
compared by authors to the washings of raw flesh
in water. Upon his recovery he told me that he
"suspected he had had the yellow fever, for that
his feelings were exactly such as they had been in
the fall of  1793, at which time he had an attack
of that disorder."
On the 14th of June I was sent for in the ab-
sense of Dr. Mease, to visit his sister in a fever. Her 
mother who had become intimately acquainted with
the yellow fever by nursing her son and mother in
it, the year before, at once decided upon the name
of her daughter's disorder. Her symptoms were
violent, but they appeared in an intermitting form.
Each paroxysm of her fever was like a hurricane to
her whole system. It excited apprehensions of im-
mediate dissolution in the minds of all her friends.
The loss of sixty ounces of blood by five bleedings,
copious doses of calomel and jalap, and a large blis-
ter to her neck, soon vanquished this malignant in-
termittent

BILIOUS YELLOW FEVER, IN 1794. 5
termittent, without the aid of a single dose of
bark.
During the remaining part of the month I was
called to several cases of fever which had symptoms
of malignity of a suspicious nature. The son of
Mr. Andrew Brown had an hæmorrhage from his
nose in a fever, and a case of menorrhagia occurred
in a woman who was affected with but a slight de-
gree of fever.
In the course of this, month I met with several
cases of swelled testicles, which had succeeded fevers 
so slight as to have required no medical aid. Dr.
Desportes records similar instances of a swelling in
the testicles which appeared during the prevalence 
of the yellow fever in St. Domingo in the year
1741.*
In the month of July I visited James Lefferty and
William Adams, both of whom had, with the usual
symtoms of yellow fever, a yellow colour on their
skin. I likewise attended three women, in whom I
discovered the disease under forms in which I had
often seen it in the year 1793. In two of them it
appeared with symptoms of a violent colic, which
*Historie des Maladies de Saint Domingue, p. 112.
A 3 yielded 

6 AN ACCOUNT OF THE
yielded only to frequent bleedings. In the third, 
it appeared with symptoms of pleurisy, which was
attended with a constant hæmorrhage from the ute-
rus, although blood was drawn almost daily from
her arm for six or seven days. About the middle
of this month many people complained of a sickness
at stomach, which in some cases produced a puking,
without any symptoms of fever.
During the month of August, I was called to
Peter Denham, Mrs. Bruce, a son of Jacob Grib-
ble's, Mr. Cole, John Madge, Mrs. Gardiner, Miss
Purdon, Mrs. Gavin, and Benjamin Cochran, each
of whom had all the usual symptoms of the yellow
fever. I found Mr. Cochran sitting on the side of
his bed, with a pot in his hand, into which he was
discharging black bile from his stomach, on the 6th
day of the disorder. He died on the next day.
Mrs. Gavin died on the 6th day of her disorder,
from a want of sufficient bleeding, to which she ob-
jected from the influence of her friends. Besides
the above persons, I visited Mr. George Eyre at
Kensington, Mr. Thomas Fitzsimons, and Thomas
M'Kean, jun. son of the chief justice of Pennsyl-
vania, all of whom had the disorder, but in a mo-
derate degree. From none of them had I as yet
observed the fever to be propagated by contagion,
and therefore I took no steps to alarm my fellow-
citizens 
 

BILIOUS YELLOW FEVER, IN 1794. 73
citizens with the unwelcome news of its being in
town. But my mind was not easy in this situation,
for I daily heard of persons who died of the disor-
der, who might probably have been saved had they
applied early for relief, or had a suspicion become
general among all our physicians of the existence of
the yellow fever in the city. The colera infantum
was common during this, and part of the preceding
month. It was more obstinate and more fatal than
in common years.
On the 12th of this month a letter from Baltimore
announced the existence of the yellow fever in that
city. One of the patients whom I visited in this
month, in the fever, Mr. Cole, brought the conta-
gion of it in his body from that place.
On the 25th of the month two members of a
committee lately appointed by the government of
the state, for taking care of the health of the city,
called upon me to know whether the yellow fever
was in town. I told them it was, and mentioned
some of the cases that had come under my notice;
but informed them at the same time, that I had
seen no case in which it had been contagious, and
that in every case where I had been called early,
and where my prescriptions had been followed, the
disease had yielded to medicine.
A 4 On 


8 AN ACCOUNT OF THE
On the 29th of the month, I received an invita-
tion to attend a meeting of the Committee of
Health, at their office in Walnut Street. They
interrogated me respecting the intelligence I had
given to two of their members on the 25th. I re-
peated it to them, and mentioned the names of all
the persons I had attended in the yellow fever since
the 9th of June.
As I considered the filth of the gutters, and the
stagnating water in the neighbourhood of the city
to be the remote causes of this fever, I advised  the
Committee to have them both removed, and thereby
to prevent the spreading of the disorder.
On the first week in September the disease ap-
peared to be contagious in several families, and the
number of my patients was thereby daily multi-
plied. I now considered it as criminal to conceal
any longer the prevalence of the disease in our city,
or to elude the inquiries that were directed to me
by my fellow-citizens, respecting it. In vain did I
wait for the alarm to come from another quarter.
I recollected the slanders to which I had exposed
myself the year before, by giving the first notice of
the prevalence of the fever in our city. But I did
not hesitate in this situation, to offer up my reputa-
tion a second time as a sacrifice for the lives of my
fellow 

BILIOUS YELLOW FEVER, IN 1794. 9
fellow-citizens. In order to render the information
as public as possible, I addressed a letter to the
mayor of the city on the 2d of September, in which
I stated the existence, and contagious nature of
the disease. The contents of this letter, and my
information to the Committee of Health respecting
the yellow fever, drew upon me the following at-
tack in Mr. Fenno's newspaper.
For the Gazette of the United States.
" MR. FENNO,
" I BEG leave, through the channel of
your paper, to enquire of the physician who re-
ported to the inspectors of health last Friday, that
" the yellow fever had again made its appearance
in this city, but that it was not at present conta-
gious," what could have induced him to make such
a report ? No benefit can arise to the public from
a knowledge of such a fact, admitting it to be as
stated; but a great deal of damage : because such
reports cannot fail of alarming and filling with
dread, the minds of those who are not possessed of
the Doctor's fine discernment and capacity of split-
ting diseases into grades, sub-grades, and semi-
grades; therefore such a report will not only ren-
der multitudes uneasy, and interrupt the usual course
of

1O AN ACCOUNT OF THE
of business, but injure the interest and reputation of
the city in several other respects.
" If the disease really existed, it would be com-
mendable to sound the alarm - it  would  be crimi-
nal to be silent;  but if it is not in the city, or if
being  in the city, it is not contagious, it is the
height of cruelty to create useless terror and alarm
in the minds of the citizens.
"But Mr. Fenno, is it not very extraordinary,
if the disease is in the city, and the physician allu-
ded to  has had twenty-fix cases of it since June,
that it has appeared to none of the other physi-
cians, not even to those who attend the Dispensary,
which I am assured from the best authority is the
case?
" A physician who has great weight with the cre-
dulous and ignorant, has already attempted to ruin
the reputation of this flourishing and delightful
city, by publishing an opinion that the late pesti-
lential fever was generated in it; and that its situa-
tion and climate is favourable to the generation of
the most malignant maladies. If such an opinion
was not believed by every man who knows the cha-
racter of that physician to be a mere invention to
support a mistaken theory, or that it proceeded
from 

BILIOUS YELLOW FEVER, IN 1794. II
from a rage for being esteemed the most learned
man in the universe; the author would in a few
years have the divine satisfaction of seeing this po-
pulous and prosperous city deserted by all its opu-
lent inhabitants, and become a solitary waste where
he might sit alone, smiling ghastly o'er its ruins,
and enjoying the fruits of his singular opinion.'
" If the opinion of that physician was founded
in fact, Mr. Fenno, such would be the blessed con-
sequence ; for who that has any regard for health
or life would venture to remain in a city notorious
for generating plagues which put life in perpetual
jeopardy ?
" This, however, fortunately is not credited, and
the city, in spite of the reveries of philosophers,
physicians, and conjurers, will flourish for ages yet
to come ; and when all the sources of stagnant wa-
ter in its suburbs come to be removed or corrected,
it will be one of the most healthy situations in Ame-
rica. Open on every side to the access of the
winds - with a  dry  soil - streets favourably arran-
ged - the inhabitants industrious, cleanly, and well
informed - it cannot in the nature of things be un-
healthy. Compare its bills of mortality with those
of Paris, London, Edinburgh, Vienna, or Stock-
holm, 


12 AN ACCOUNT OF THE
holm, and you will at once be convinced how much
more healthful it is than either of those.
" Be under no concern my fellow-citizens, the
yellow fever is not in our city, nor is it possible for 
it to be generated in it, in its present situation.
WALTER QUŒRIST."
On the 13th of September I wrote a second let
ter to the Committee of Health, in which I de-
clared the disease to be contagious, and urged them
to make the information I gave them public. My
reasons for this advice were stated in the follow-
ing words: "It will excite the citizens to apply
early for medical aid, and it will produce in the
minds of such of the physicians as are unprejudiced,
an early suspicion of the presence of the disease, in
those cases where it comes on with its less obvious
symptoms."
None of these communications produced the ef-
fect that was intended by them. Dr. Physick and
Dr. Dewees supported me in my declaration, but
their testimony did not protect me from the grossest
calumnies of my fellow-citizens. One of my friends
informed me that he had heard a propossal in a
public 

BILIOUS YELLOW FEVER, IN 1794. 13
public company to " drum me out of the city." A
charge of insanity which had been made against
me the year before, was now revived, and propa-
gated with so much confidence, that one of my
patients who had believed it, expressed her surprise
at perceiving no deviation from my ordinary man-
ner, in a sick-room. Several of the physicians of
the city united in the flanders which were thrown
out against me ; and notwithstanding they daily at-
tended, or lost patients in the yellow fever, they
denied that any cases of it had occurred in their
practice. To these cases they gave other names.
I shall briefly enumerate these names, together
with the opinions of some of the physicians respect-
ing the fever. This detail will be useful; for by
exposing the danger and fatal consequences of error
and deception, we shall prevent their being repeat-
ed, and thereby prepare the way for the more
ready and universal admission of truth, upon the
subject of the fever. Thus ignorance and vice will
appear, even in the science of medicine, not to have
existed in vain.
It was called,
1. A common intermittent. 2. A bilious fever.
3. An inflammatory remitting fever. 4. A putrid
fever. 5. A nervous fever. 6. A dropsy of the
brain. 

14 AN ACCOUNT OF THE
brain. 7. A lethargy. 8. Pleurisy. 9. Gout.
10. Rheumatism. 11. Colic. 12. Dysentery.
And 13. Sore throat. *
It was said further, not to be the yellow fever
because it was not contagious, and because some
who had died of it, had not a sighing in the be-
ginning, and a black vomiting in the close of the
disease. Even where the black vomiting and yel-
low skin occurred, they were said not to constitute
a yellow fever, for that those symptoms occurred in
other fevers.
A further detail of the names of this fever, and
of the opinions of the physicians will appear pre-
sently in their report to the Committee of Health
on the 30th of September.
Truth, it has often been said, is an unit, but
this is not the case with error. While the phy-
sicians who asserted that the yellow fever was in
town, agreed in fixing the same name to every case
of it, the physicians who propagated the contrary
opinion, gave different names to the same fever.
* A sore throat sometimes occurs as a symptom of the yel-
low fever. It is taken notice of by Dr.Blane in his History
of the Fever in the West Indies.
In

BILIOUS YELLOW FEVER, IN 1794. 15
In one instance a citizen of Philadelphia was said
by one of his physicians to have died of a lethargy,
and by another, of a nervous fever. To keep up
the latter idea, his death was announced in the
public papers, to have occurred after an illness of
two weeks.
I hope to shew hereafter, that it is not more im-
proper to say that men are of different species, be-
cause they are tall and short, or because some are
long, and others short lived, than that fevers are
of different species, because they vary in their symp-
toms and duration.
The conduct of the Committee of Health was
not less improper that that of the physicians. They
not only refused to make the existence of the fever
in the city public, but refused to open Bush-hill
hospital for the reception of the poor, although that
convenient and spacious building had been hired
by the city for that purpose, and sent several poor
persons to the hospital at State Island. This situa-
tion was preferred to Bush-hill, to prevent the citi-
zens being alarmed, and probably to favour the
opinion that the disease was imported. About the
same time they sent invitations to all the physicians
in the city (Dr. Physick, Dr. Dewees, and one more
excepted) to attend a meeting of the Board, at
the 

l6 AN ACCOUNT OF THE
the City Hall, in order to ascertain the state of
the city. The following publication was the result
of that meeting.
HEALTH-OFFICE,
Port of Philadelphia, 1st October, 1794.
" The Board of Health, feeling, in common with
the rest of their fellow-citizens, a concern for the
interest and safety of the city, were induced to make
a general invitation to the Faculty, to meet them
at the City Hall, on Tuesday the 30th September,
in order that from their communications a just state
of the health of the city might be obtained. Ac-
cordingly, the following physicians were pleased to
attend, viz.
Dr. Samuel Duffield, 
Dr. Parke, 
Dr. Dunlap, 
Dr. Wistar, 
Dr. Porter, 
Dr. Annan,
Dr. Kuhn,
Dr. Hodge,
Dr. Currie,
Dr. Benj. Duffield.
and
Dr. Woodhouse.
"From the whole of these gentlemen, to the
question of a contagious disease (that is, a disease
which had been communicated from one person to
another) existing at this time, there were answers
in the negative.
4 " It 

BILIOUS YELLOW FEVER, IN 1794. 17
" It was then proposed that cases of autumnal
fevers, which were considered dangerous to the pa-
tients, should be mentioned. To this
" Dr. Currie answered, that an aged female in a
remittent fever, and a boy in the yellow fever,
were the only cases apparently dangerous under his
care.
" Dr. Benjamin Duffield has two cases of au-
tumnal remittent fevers, dangerous, without any
contagion annexed to it.
" Dr. Parke has one case, considered dangerous.
" Dr. Wistar. One case that may be dangerous.
" Dr. Hodge. Five cases that probably will be-
come putrid and dangerous.
" Dr. Barton, thought not present, communicated
through a member of the Board, that he has n
case of a contagious nature.
" Drs. Rush and Say, not being present, were so
obliging as to make their communications in writing,
which are hereto subjoined. - From
VOL. IV. B Dr. 

18 AN ACCOUNT OF THE
" Dr. Rush. 'Out of about thirty patients whom
I visit daily, who are confined by bilious remitting
and intermitting fevers, twelve of them have fevers
of the highest or most inflammatory degree, com-
monly called yellow fevers. All of them are tend-
ing to a favourable issue, and from the mode in
which they have been treated, I hope no contagion
will be generated by them.'
" From Dr. Say. 'Within the compass of my
practice there are a number of people labouring
under remitting and intermitting fevers: I have
had, I have no doubt, several cases within the ten
days past, of the malignant fever, though at pre-
sent I do not know that I have a decided case of
that kind.'
" The Board of Health, in addition to the fore-
going remark, that they are not acquainted with
any cases of a dangerous nature, other than has
been already stated - and upon the whole, cannot
but felicitate their fellow-citizens, at a time when
alarms and injurious reports have been industriously
circulated to the prejudice of the health of the city,
that amongst the practice of such a number of phy-
sicians, there is not one case of a contagious nature
apparent, and so very few who are dangerously ill.
The 

BILIOUS YELLOW FEVER, IN 1794. 19
" The board further have the pleasure to inform
the citizens that although the house at Bush-Hill
was prepared for the reception of such sick persons
as were proper objects for that place on the 26th
of last month, there is not now, nor has there been
a single patient there.
" By order, and on behalf of the Board of Health.
JACOB MORGAN, Chairman."
" The citizens are requested to meet this evening
at 6 o'clock, at the City Hall, to take into considera-
tion the alarming accounts of the progress of a conta-
gious disorder at Baltimore, and to devise proper mea-
sures to protect the citizens from the effects thereof."
The reader will please to take notice, that the
question by the Committee, was whether " a con-
tagious disease existed at this time in the city."
Why was not an inquiry made whether the yellow
fever existed at that time in the city ? or, Why was
that fever designated by its being contagious, a
character which by no means belongs to it univer-
sally, and that does not constitute its principal dan-
ger ; for it is well known that in the West Indies,
it affects so seldom by contagion, as to furnish a
controversy among West Indian physicians, con-
B 2 cerning 

20 AN ACCOUNT OF THE
cerning its contagious nature? Even in the city of
Philadelphia, it was not uniformly contagious in
1793, many having escaped it who were constant-
ly exposed to its contagion. But further. Why,
was there no retrospect in the inquiry into the state
of the city, during the weeks or months that had
preceded the 30th of September? Two of the
physicians who asserted that they then had no cases
of yellow fever under their care, had acknowledg-
ed that they had had several cases of it a few weeks
before. It is impossible to review this report,
without blushing for the shameful submission made
by the science of medicine, to the commercial spirit
of the city.
But let not the reader complain of the physicians
and citizens of Philadelphia alone. A similar con-
duct has existed in all cities, upon the appearance
of great and mortal epidemics.
It prevailed lately in Algiers, where the Dey
refused to let some American prisoners leave a town
infected by the plague, denying the existence of
the disorder in that place.* Successive attempts by
numerous publications, were made to conceal the
prevalence of the yellow fever in the cities of New
* See Col. Humphries's letter to the citizens of the United
States, dated Lisbon, July 11, 1794.
York, 
 

BILIOUS YELLOW FEVER, IN 1794. 21
York, Baltimore and Charleston, for two years
past. Such was this selfish disposition in the Com-
mittee of Health in New York in the year 1795,
that they wrote to the Committee of Health in Phi-
ladelphia, to deliver up the names of several per-
sons who had in private letters to their friends,
which had been published, asserted that the yellow
fever prevailed in that city. But the contracted
spirit of this Committee did not end here. After
they were compelled to acknowledge the prevalence
of the fever among them, they endeavoured to
compose the fears of their fellow citizens, by in-
forming them, that a " large proportion of 
deaths hitherto reported, had fallen among emi-
grants lately from Europe, strangers, and other
transient persons," † thereby intimating, that the
obligations to sympathy should be confined wholly
to permanent and wealthy citizens.
Nor is it any thing new for mortal diseases to re-
ceive mild and harmless names from physicians.
The plague was called a spotted fever or several
months, by some of the physicians of London in the
year 1665.
† Report of the Committee of Health of New York, dated
Friday evening, September 18, 1795.
B 3  Added

22 AN ACCOUNT OF THE 
Added to that servility to wealth, which disposes
physicians to deny the existence of pestilential fevers
in cities, there were two other reasons which led some
of the physicians of Philadelphia, to deny the pre-
valence of the yellow fever in our city ; these reasons
were; first, The change which they had made in their
practice, for they had adopted the depleting system
in a certain degree; but they declared that they used
it not in the yellow fever, but in an inflammatory
bilious remittent; and secondly, Their inability  to
derive the disease from importation. To have ac-
knowledged the existence of the disease in our city,
therefore, would have been a direliction of two of
the principal errors held by them in the year 
1793. 
Thus while nurses, bleeders, clergymen and oc-
casional visitors of the sick, and in some instances,
the sick themselves, united in deciding upon the cha-
racter and name of our fever, a majority of the
physicians united in persuading the citizens that it
existed only in the imaginations of two or three
men.
From a review of the conduct of cities upon the
subject of diseases, an important inference may be
made ; and that is, to consider their public reports in
favour 

BILIOUS YELLOW FEVER, IN 1794. 23
favour of the health of their inhabitants, as the
precursors of great and mortal epidemics.
It has been asked, why I am more anxious to have
the existence of the yellow fever believed, than any
of the other physicians of the city ; and why I did
not cure it, without calling it by its unpopular
name? To this I answer, that I consider the making
the disease public, as soon as it appears in a city,
and the calling it by its common and vulgar name,
to be a duty, indirectly included in that divine pre-
cept which forbids the taking away a human life.
Dr. Sydenham acknowledges that he generally lost
the first four or five patients he met with in a new
disease, and all candid physicians must confess the
want of the same success in the beginning, that
they have in the close of a new epidemic. Now this
want of success may at all times be prevented from
becoming general, by notice being given of the
existence of a new disease as soon as it makes its
appearance. The propagation of the disease when
contagious, may moreover be checked, or its malig-
nity mitigated, by means of diet, or medicine,
when its prevalence is generally known, and thereby
many thousand lives may be saved. There was
once a law in Pennsylvania, which punished the
concealment of a malignant and contagious disease
in the city of Philadelphia, Such a law would be a
E4 blessing

24 AN ACCOUNT OF THE
blessing every country. Whole communities
might be saved by it.
Notwithstanding the pains which were taken to
discredit the report of the existence of the yellow
fever in the city, it was finally believed by many
citizens, and a number of families in consequence
of it, left the city. And in spite of the harmless
names of intermitting and remitting fever, and the
like, which were given to the disorder, the bodies
of persons who had died with it, were conveyed
to the grave in several instances upon a hearse,
the way in which those who died of the yellow fever
were buried the year before.
From the influence of occasional showers of rain,
in the months of September and October, the disease
was frequently checked, so as to disappear alto-
gether for two or three days in my circle of practice.
It was observed that while showers of rain checked
it, moist or damp weather without rain, favoured
its propagation. It was further kept from becoming
general by the mode of treating it; for nearly all
the physicians purged, and bled more or less, in
every case of fever they were called to, by which
means the production of a large mass of contagion,
was prevented. This peculiarity in the practice of
the opposing physicians, did not escape the notice
of

BILIOUS YELLOW FEVER, IN 1794. 25
of several of the reflecting citizens of Philadelphia,
who remarked very properly, that two or three
bleedings, and purges of calomel and jalap were not
the usual remedies for intermitting and remitting se-
vers of common years.
The cold weather in October checked the fever,
but it did not banish it from the city. It appeared
in November, and in all the succeeding winter and
spring months. The weather during these months
being uncommonly moderate, will account for its
not being destroyed at the time in which the disease
actually disappeared in former years.
The causes which predisposed to this fever were
the same as in the year 1793. Persons of full ha-
bits, strangers, and negroes were most subject to it.
It may seem strange to those persons who have read
that the negroes are seldom affected with this fever
in the West Indies, that they were so much affected
by it in Philadelphia. There were two reasons for
it. Their manner of living was as plentiful as that
of white people in the West Indies, and they gene-
rally resided in alleys and on the skirts of the city,
where they were more exposed to noxious exhala-
tion, than in its more open and central parts.
The summer fruits, from being eaten before they
were ripe, or in too large a quantity, became fre-
quently 

26 AN ACCOUNT OF THE 
quently exciting causes of this fever. It was awa-
kened in one of my patients by a supper of peaches
and milk. Cucumbers in several instances gave vi-
gor to the miasmata which had been previously re-
ceived into the system. Terror excited it in two of
my patients. In one of them, a young woman,
this terror was produced by hearing, while she sat
at dinner, that a hearse had passed by her door with
a person on it who had died of the yellow fever.
Vexation excited it in a foreign master of a vessel
in consequence of a young woman suddenly break-
ing an engagement to marry him. The disease ter-
minated fatally in this instance.
It was sometimes unfortunate for patients when
the disease was excited by an article of diet, or by
any other cause which acted suddenly upon the sys-
tem ; for it led both them, and in some instances
their physicians, to confound those exciting causes
with its remote cause, and to view the disease with-
out the least relation to the prevailing epidemic. It
was from this mistake that many persons were said
to die of intemperance, of eating ice creams, and
of trifling colds, who certainly died of the yellow
fever. The rum, the ice creams, and the changes
in the air, in all these cases acted like sparks
of fire which set in motion the quiescent particles
of tinder or gunpowder.
I shall 
       

BILIOUS YELLOW FEVER, IN 1794. 27
I shall now proceed to describe the symptoms
which this fever assumed during the periods which
have been mentioned. This detail will be interest-
ing to physicians who wish to see how little nature
regards the nosological arrangement of authors in
the formation of the symptoms of diseases, and how
much the seasons influence epidemics. A physician
who had practiced medicine near sixty years in the
city of Philadelphia, declared that he had never seen
the dysentery assume the same symptoms in any two
successive years. The same may be said probably
of nearly all epidemic diseases.
In the arrangement of the symptoms of this fever,
I shall follow the order I adopted in my Account
of the Yellow Fever of 1793, and describe them
as they appeared in the sanguiferous system - the
liver, lungs, and brain - the alimentary canal - the
secretions and excretions - the nervous system - the
senses and appetites upon the skin, and in the blood.
Two premonitory symptoms struck me this year
which I did not observe in 1793. One of them
was a frequent discharge of pale urine for a day
or two before the commencement of the fever; the
other was sleep unusually sound, the night before the
attack of the fever. The former symptom was a pre-
cursor of the plague of Bassora in the year 1773.
I. I 

28 AN ACCOUNT OF THE
I. I observed but few symptoms in the sanguife-
rous system different from what I have mentioned
in the fever of the preceding year. The slow and
intermitting pulse occurred in many, and a pulse
nearly imperceptible, in three instances. It was sel-
dom very frequent. In John Madge, an English
farmer who had just arrived in our city, it beat only
64 strokes in a minute for several days, while
he was so ill as to require three bleedings a-day,
and at no time of his fever did his pulse exceed
96 strokes in a minute. In Miss Sally Eyre the
pulse at one time was at 176, and at another time
it was at 140; but this frequency of pulse was
very rare. In a majority of the cases which came
under my notice, where the danger was great, it
seldom exceeded 80 strokes in a minute, I have
been thus particular in describing the frequency of
the pulse, because custom has created an expectation
of that part of the history of fevers; but my at-
tention was directed chiefly to the different degrees
of force in the pulse as manisefted by its tension,
fulness, intermissions, and inequality of action. The
hobbling pulse was common. In John Geraud, I
perceived a quick stroke to succeed every two
strokes of an ordinary healthy pulse. The inter-
mitting and depressed pulse occurred in many cases.
I called it the year before a sulky pulse. One of my
pupils, Mr. Alexander, called it more properly a
locked 
       

BILIOUS YELLOW FEVER, IN 1794. 29
locked pulse. I think I observed this state of the
pulse to occur chiefly in persons in whom the fever
came on without a chilly fit.
Hæmorrhages occurred in all the grades of this
fever, but less frequently in my practice this year
than in the year before. It occurred after a ninth
bleeding in Miss Sally Eyre from the nose and bowels.
It occurred from the nose after a sixth bleeding in
Mrs. Gardiner, who was at that time in the sixth
month of her pregnancy. This symptom, which
was accompanied by a tense and quick pulse, in-
duced me to repeat the bleeding a seventh time.
The blood was very sizy. I mention this fact to
establish the opinion that hæmorrhages depend upon
too much action in the blood-vessels, and that they
are not occasioned by a dissolved state of the blood.
There was a disposition at this time to hæmor-
rhage in persons who were in apparent good health.
A private in a company of volunteers commanded
by Major M'Pherson, informed me that three of
his messmates were affected by a bleeding at the
nose for several days after they left the city on their
way to quell the insurrection in the western coun-
ties of Pennsylvania.
II. The liver did not exhibit the usual marks
of inflammation. Perhaps my mode of treating the
fever 

30 AN ACCOUNT OF THE
fever prevented those symptoms of hepatic affec-
tion which belong to the yellow fever in tropical
climates. The lungs were frequently affected; and
hence the disease was in many instances called a
pleurisy or a catarrh. This inflammation of the
lungs occurred in a more especial manner in the
winter season. It was distinguished from the pleu-
risies of common years by a red eye; by a vomit-
ing of green or yellow bile ; by black stools; and
by requiring very copious blood-letting to cure it.
The head was affected in this fever, not only
with coma and delirium, but with mania. This
symptom was so common as to give rise to an opi-
nion that madness was epidemic in our city. I saw
no case of it which was not connected with other
symptoms of the bilious remitting fever. The Rev.
Mr. Keating, one of the ministers of the Roman
church, informed me that he had been called to
visit seven deranged persons in his congregation in
the course of one week, in the month of March.
Two of them had made attempts upon their lives.
This mania was probably, in each of the above
cases, a symptom only of general fever. The dila-
tation of the pupil was universal in this fever.
Sore eyes were common during the prevalence
of this fever. In Mrs. Learning this affection of
the eyes was attended with a fever of a tertian type.
III. The

BILIOUS YELLOW FEVER, IN 1794. 31
III. The alimentary canal suffered as usual in
this fever. A vomiting was common upon the
first attack of the disorder. I observed this symp-
tom to be less common after the cold and rainy
weather which took place about the firs of Oc-
tober.
I have in another place mentioned the influence
of the weather upon the symptoms of this disease.
In addition to the facts which have been formerly
recorded, I shall add one more from Dr. Desportes.
He tells us, that in dry weather the disease affects
the head, and that the bowels in this case are
more obstinately costive than in moist weather.
This influence of the atmosphere on the yellow
fever will not surprise those physicians who recollect
the remarkable passage in Hippocrates in which
he says, that in the violent heats of summer, fevers
appeared, but without any sweat; but if a shower,
though ever so slight, appeared, a sweat broke
out in the beginning. * I observed further, that
a vomiting rarely attended those cases in which
there was an absence of a chilly fit in the begin-
ning of the fever. The same observation is made
by Dr. Desportes. †
* Epidemics, Book XI. Sect. 1.
† Les Maladies de St. Domingue, Vol. I. p. 193.
The 

32 AN ACCOUNT OF THE
The matter discharged by vomiting was green
or yellow bile in most cases. Mrs. Jones, the
wife of Captain Lloyd Jones, and one other per-
son, discharged black bile within one hour after
they were attacked by the fever. I have taken
notice in the second edition of my Account of the
Yellow Fever, that a discharge of bile in the be-
ginning of this fever was always a favourable
symptom. Dr. Davidson of St. Vincents, in a let-
ter to me, dated the 22d July 1794, makes the
same remark. It shews that the biliary ducts are 
open, and that the bile is not in that viscid and
impacted state which is described in the dissections
of Dr. Mitchel. A distressing pain in the sto-
mach, called by Dr. Cullen gastrodynia, attended
in two instances. A burning pain in the stomach,
and a soreness to the touch of its whole external
region, occurred in three or four eases. Two of
them were in March 1795. In Mrs. Vogles, who
had the fever in September 1794, the sensibility
of the pit of the stomach was so exquisite, that
she could not bear the weight of a sheet upon it.
Pains in the bowels were very common. They
formed the true bilious colic, so often mentioned
by West India writers. In John Madge these pains
produced a hardness and contraction of the whole
external region of the bowels. They were perio-
1 dical 

BILIOUS YELLOW FEVER, IN 1794. 33
dical in Miss Nancy Eyre, and in Mrs Gardiner,
and in both cases were attended with diarrhœa.
COSTIVENESS without pain was common, and
in some cases so extremely obstinate as to resist for
several days the successive and alternated use of
all the usual purges of the shops.
Flatulency was less common in this fever than in
the year 1793.
The disease appeared with symptoms of dysentery
in several cases.
IV. The following is an account of the state of
the SECRETIONS and EXCRETIONS in this fever.
A puking of bile was more common this year,
than in year 1793. It was generally, of a green
or yellow colour. I have remarked before, that two
of my patients discharged black bile within an hour
after they were affected by the fever, and many
discharged that kind of matter which has been
compared to coffee grounds, towards the close of
the disease.
The fæces were black, in most cases where the
symptoms of the highest grade of the fever attend-
VOL. IV. c ed. 

34 AN ACCOUNT OF THE
ed. In one very malignant case, the most drastic
purges brought away by fifty evacuations, nothing
but natural stools. The purges were continued,
and finally black fæces were discharged which pro-
duced immediate relief. In one person, the fæces
were of a light colour. In this patient the yellow-
ness in the face was of an orange colour, and con-
tinued so for several weeks after his recovery.
The urine was in most cases high coloured. It
was scanty in quantity in Peter Brown, and totally
suppressed in John Madge for two days. I ascribed
this defect of natural action in the kidneys, to an
engorgement in their blood vessels, similar to that
which takes place in the lungs and brain in this
fever. I had for some time entertained this idea
of a morbid affection of the kidneys, but I have
lately been confirmed in it by the account which
Dr. Chisholm gives of the state of one of the
kidneys in a man whom he lost with the Beul-
lam fever at Grenada. " The right kidney (says
the Doctor) was mortified, although during his ill-
ness no symptom of inflammation of that organ was
perceived." * It would seem as if the want of
action in the kidneys, and a defect in their functions
* Essay on the Malignant Pestilential Fever introduced into
the West Indies from Beullam, p. 137.
were 

BILIOUS YELLOW FEVER, IN 1794. 35
were not necessarily attended with pain. I recollect
to have met with several cases in 1793, in which
there was a total absence of pain in a suppression
of urine, of several days' continuance. The same
observation is made by Dr. Chisholm, in his ac-
count of the Beullam fever of Grenada.* From
this fact it seems probable, that pain is not the
effect of any determinate state of animal fibres,
but requires the concurrence of morbid, or pre-
ternatural excitement to produce it. I met with but
one case of strangury in this fever. It terminated
favourably in a few days. I have never seen death
in a single instance in a fever from any cause,
where a strangury attended, and I do not re-
collect ever to have seen a fatal issue to a fever
where this symptom was accidentally produced by
a blister. From this fact there would seem to be
a connection between a morbid excitement in the
neck of the bladder, and the safety of more vital
parts of the body. The idea of this connection
was first suggested to me "four-and-twenty years
ago, by the late Dr. James Leiper of Maryland,
who informed me that he had sometimes cured the
most dangerous cases of pleurisy after the usual re-
medies had failed, by exciting a strangury by
means of the tincture of Spanish flies, mixed with
camphorated spirit of wine.
* P. 224.
C 2 The 

36 AN ACCOUNT OF THE
The tongue was always moist in the beginning of
the fever, but it was generally of a darker colour than
last year. When the disease was lest to itself, or
treated with bark and wine, the tongue became of
a fiery red colour or dry and furrowed, as in the
typhus fever.
SWEATS were more common in the remissions of
this fever, than they were in the year 1793, but
they seldom terminated the disease. During the
course of the sweats, I observed a deadly coldness
over the whole body to continue in several in-
stances, but without any danger or inconvenience
to the patient. In two of the worst cases I at-
tended, there were remissions, but no sweats un-
til the day on which the fever terminated. In
several of my patients the fever wore away with-
out the least moisture on the skin. The milk in one
case was of a greenish colour, such as sometimes appears
in the serum of the blood. In another female pa-
tient who gave suck, there was no diminution in
the quantity of her milk during the whole time of
her fever, nor did her infant suffer the least injury
from sucking her breasts.
I observed tears to flow from the eye of a young
woman in this fever, at a time when her mind seemed
free from distress of every kind.
V. I pro- 

BILIOUS YELLOW FEVER, IN 1794. 37
V. I proceed next to mention the symptoms of
this fever in the nervous system.
Delirium was less common than last year. I
was much struck in observing John Madge, who
had retained his reason while he was so ill as to
require three bleedings a day, to become delirious
as soon as he began to recover, at which time his
pulse rose from between 60, and 70 to 96 strokes
in a minute. I saw one case of extreme danger
in which an hysterical laughing and weeping al-
ternately attended.
I have before mentioned the frequency of mania
as a symptom of this disease. An obstinate wakeful-
ness attended the convalescence from this fever in
Peter Brown, John Madge, and Mr.Cole.
Fainting was more common in this fever than
in the fever of 1793. It ushered in the disease
in one of my patients, and it occurred in several
instances after bleeding, where the quantity of
blood drawn was very moderate.
Several people complained of giddiness in the
first attact of the fever, before they were confined
to their beds. Sighing was less common, but a
hiccup was more so, than in the year before.
C 3 John 

38 AN ACCOUNT OF THE
John Madge had an immobility in his limbs
bordering upon palsy. A weakness in the wrists
in one case succeeded a violent attack of the
fever.
Peter Brown complained of a most acute pain
in the muscles of one of his legs. It afterwards
became so much inflamed as to require external
applications to prevent the inflammation terminating
in an abscess. Mrs. Mitchell complained of severe
cramps in her legs.
The sensations of pain in this fever were often
expressed in extravagant language. The pain in the
head in a particular manner was compared to repeat-
ed strokes of a hammer upon the brain, and in two
cases in which this pain was accompanied by great
heat, it was compared to the boiling of a pot.
The more the pains were confined to the bones
and back, the less danger was to be apprehended
from the disease. I saw no case of death from the
yellow fever in 1793, where the patient complain-
ed much of pain in the back. It is easy to conceive
how this external determination of morbid action,
should preserve more vital parts. The bilious fever
of 1780 was a harmless disease, only because it
spent its whole force chiefly upon the limbs. This
was 

BILIOUS YELLOW FEVER, IN 1794. 39
was so generally the case, that it acquired from the
pains in the bones which accompanied it, the name
of the "break bone fever." Hippocrates has re-
marked that pains which descend, in a fever, are
more favourable than those which ascend. This
is probably true, but, I did not observe any such
peculiarity in the translation of pain in this fever. 
The following fact from  Dr. Grainger will add
weight to the above observations. He observed
the pains in a malignant fever which were diffused
through the whole head, though excruciating, were
much less dangerous, than when they were con-
fined to the temples, or forehead. †
I saw two cases in which a locked jaw attended.
In one of them it occurred only during one parox-
ysm of the fever. In both it yielded in half an
hour to blood-letting. I met with one case in which
there was universal tetanus. I should have suspect-
ed this to have been the primary disease, had not
two persons been infected by the patient thus dis-
ordered, with the yellow fever.
The countenance sometimes put on a ghastly ap-
pearance in the height of a paroxysm of the fever.
* Epidemics, book II. section 2.
† Historia febris anomalæ Batavæ Annorum 1746, 1747,
1748, cap. I.
c 4 The 

40 AN ACCOUNT OF THE
The face of a lady admired when in health for un-
common beauty, was so much distorted by the
commotions of her whole system in a fit of the fever,
as to be viewed with horror by all her friends.
VI. The senses and appetites were affected in this
fever in the following manner.
A total blindness occurred in two persons during
the exacerbation of the fever, and ceased during its
remissions. - A great intolerance of light occurred
in several cases. It was most observable in John
Madge during his convalescence.
A soreness in the sense of touch, was so exquisite
in Mrs Kapper about the crisis of her fever, that
the pressure of a piece of fine muslin upon her skin
gave her pain.
Peter Brown with great heat in his skin, and
a quick pulse, had no thirst, but a most intense
degree of thirst was very common in this fever. It
produced the same extravagance of expression that
I formerly said was produced by pain. One of my
patients Mr. Cole said he "could drink up the
ocean." I did not observe thirst to be connected
with any peculiar state of the pulse.
George 

BILIOUS YELLOW FEVER, IN 1794. 41
George Eyre and Henry Clymer, had an unusual
degree of appetite just before the usual time of the
return of a paroxysm of fever.
A young man complained to me of being afflicted
with nocturnal emissions of seed during his conva-
lescence. This symptom is not a new one in malig-
nant fevers. Hippocrates takes notice of it.* I
met with one instance of it among the sporadic cases
of yellow fever which occurred in 1793. It some-
times occurs according to Lomius in the commotions
of the whole system which take place in epilepsy.
VII. The disease made an impression upon the
lymphatic system. Four of my patients had glan-
dular swellings : two of them were in the groin ; a
third was in the parotid ; and the fourth was in the
maxillary glands. Two of these swellings sup-
purated.
VIII. The yellowness of the skin which sometimes
attends this fever, was more universal, but more
faint than in the year 1793. It was in many cases
composed of such a mixture of colours as to resemble
polished mahogany. But in a few cases, the yellow-
ness was of a deep orange colour. The former went
off with the fever, but the latter often continued for
several weeks after the patients recovered. In some
* Epidemics, book IV.
instances 

42 AN ACCOUNT OF THE
instances a red colour predominated to such a de-
gree in the face as to produce an appearance of in-
flammation.
In Mrs. Vogles a yellowness appeared in her eyes
during the paroxysm of her fever, and went off in
its remissions.
In James Lefferty the yellowness affected every
part of his body, except his hands, which were as
pale as in a common fever.
Peter Brown tinged his sheets of a yellow colour
by night sweats, many weeks after his recovery.
There was an exudation from the soles of the
feet of Richard Wells's maid, which tinged a towel
of a yellow colour.
In my Account of the Yellow Fever of 1793, I
ascribed the yellow colour of the skin wholly to a
mixture of bile with the blood. I am satisfied that
this is the cause of it in those cases where the colour
is deep, and endures for several weeks beyond the
crisis of the fever; but where it is transitory, and
above all, where it is local, or appears only for a
few hours during the paroxysm of the fever, it ap-
pears probable that it is connected with the mode
of

BILIOUS YELLOW FEVER, IN 1794. 43
of aggregation of the blood, and that it is produced
wholly by some peculiar action in the blood-vessels.
A similar colour takes place from the bite of certain
animals, and from contusions of the skin; in nei-
ther of which cases has a suspicion been entertained
of an absorption or mixture of bile with the blood.
A troublesome itching, with an eruption of red
blotches on the skin, attended on the first day of the
attack of the fever in Mrs. Gardiner.
A roughness of the skin, and a disposition in it
to peel off, appeared about the crisis of the fever in
Miss Sally Eyre.
That species of eruption which I have elsewhere
compared to moscheto bites, appeared in Mrs. Sellers.
John Ray, a day labourer to whom I was called
in the last stage of the fever, had petechiæ on his
breast the day before he died.
That burning heat on the skin, from which this
fever in some countries has derived the name of
Causus, was more common this year than last.
It was sometimes local, and sometimes general. I
perceived it in an exquisite degree in the cheeks
only of Miss Sally Eyre, and over the whole body
of 

44 AN ACCOUNT OF THE
of John Ray. It had no connection with the ra-
pidity, or force of the circulation of the blood in
the latter instance, for it was most intense at a time
when he had no pulse.
It is remarkable that the heat of the skin has no
connection with the state of the pulse. This fact
did not escape Dr. Chisholm. He says he found
the skin to be warm while the pulse was at 52, and
that it was sometimes disagreeably cold when the
pulse was as quick as in ordinary fever. *
IX. I have in another place rejected putrefaction
from the blood as the cause or effect of this fever.
I shall mention the changes which were induced in
its appearances when I come to treat of the method
of cure.
Having described the symptoms of this fever as
they appeared in different parts of the body, I shall
now add a few observations upon its type, or ge-
neral character.
I shall begin this part of the history of the fever
by remarking, that we had but one reigning disease
in town during the autumn and winter ; that this
was a bilious remitting, or intermitting, and
* P. 117.
sometimes 

BILIOUS YELLOW FEVER, IN 1794. 45
sometimes a yellow fever; and that all the fevers
from other remote causes than exhalation or conta-
gion, partook more or less of the symptoms of the
prevailing epidemic. As well might we distinguish
the rain which falls in gentle showers in Great Bri-
tain, from that which is poured in torrents from the
clouds in the West Indies, by different names and
qualities, as impose specific names and characters
upon the different states of bilious fever.
The forms in which this fever appeared were as
follow.
1. A tertian fever. Several persons died of the
third fit of tertians who were so well as to go
abroad on the intermediate day of the fever. It is
no new thing for malignant fevers to put on the
form of a tertian. Hippocrates long ago remarked,
that intermittents sometimes degenerate into malig-
nant acute diseases; and hence he advises physicians
to be upon their guard on the 5th, 7th, 9th, and
even on the 14th day of such fevers.*
2. It appeared most frequently in the form of a re-
mittent. The exacerbations occurred most commonly
in the evening. In some there were exacerbations
* De Morb. Popular. L. VII.
in 

46 AN ACCOUNT OF THE
in the morning as well as in the evening. But I
met with several patients who appeared to be better
and worse half a dozen times in a day. In each of
these cases, there were evident remissions and exa-
cerbations of the fever.
It affirmed in several instances the symptoms of a
colic, and colera morbus. In one case the fever,
after the colic was cured, ended in a regular inter-
mittent. In another, the colic was accompanied by
a hæmorrhage from the nose. I distinguished this
bilious colic from that which is excited by lighter
causes, by its always coming on with more or less of
a chilliness.* The symptoms of colic and colera
morbus occurred most frequently in June and July.
4. It appeared in the form of a dysentery in a
boy of William Corfield, and in a man whom my
pupil Mr. Alexander visited in the neighbourhood
of Harrowgate.
5. It appeared in one case in the form of an apo-
plexy.
6. It disguised itself in the form of madness.
* See Sydenham, Vol. I. p. 212.
I 7. During 

BILIOUS YELLOW FEVER, IN 1794. 47
7. During the month of November, and in all
the winter months, it was accompanied with pains
in the sides and breast, constituting what nosologists
call the "pleuritis biliosa."
8. The puerperile fever was accompanied during
the summer and autumn, with more violent symptoms
than usual. Dr. Physick informed me, that two
women to whom he was called soon after their deli-
very, died of uterine hæmorrhages ; and that he had
with difficulty recovered two other lying-in women,
who were afflicted with that symptom of a malig-
nant diathesis in the blood-vessels.
9. Even dropsies partook more or less of the in-
flammatory and bilious character of this fever.
10. It blended itself with  the scarlatina. The
blood in this disorder, and in the puerperile fever,
had exactly the same appearance that it had in the
yellow fever. A yellowness in the eyes accompa-
nied the latter disease in one case that came under
my notice.
A slight shivering ushered in the fever in several
instances. But the worst cases I saw, came on
without a chilly fit, or the least sense of coldness
in any part of the body.
Such 
 

48 AN  ACCOUNT OF THE
Such was the predominance of the intermitting,
remitting, and bilious fever, that the measles, the
small-pox, and even the gout itself, partook more or
less of its character. There were several instances in
which the measles, and one, in which the gout ap-
peared with quotidian exacerbations ; and two in
which madness appeared regularly in the form of a
tertian.
I mentioned formerly that this fever sometimes
went off with a sweat, when it appeared in a tertian
form. This was always the case with the second
grade of the fever, but never with the first degree
of it before the 3d or 4th paroxysm of the fever;
nor did a sweat occur on the 5th or 7th day, except
after the use of depleting remedies. This peculia-
rity in the fever of this year was so fixed, that it
gave occasion for my comparing it in my intercourse
with my patients, to a lion on the first seven days,
and to a lamb during the remaining part of its du-
ration.
The fever differed from the fever of the prece-
ding year in an important particular. I saw or
heard of no case which terminated in death on the
first or third day. In every case, the fever came on
fraught with paroxysms. The moderate degrees of
it were of so chronic a nature as to continue for
2 several 

BILIOUS YELLOW FEVER, IN 1794. 49
several weeks when left to themselves. I wish this
peculiarity in the epidemic which I am now de-
scribing, to be remembered; for it will serve here-
after to explain the reason why a treatment appa-
rently different, should be alike successful in differ-
ent seasons and in different countries.
The crisis of the fever occurred on uneven days
more frequently than in the fever of the year 1793.
I remarked formerly * that remissions were more
common in the yellow fever than in the common
bilious fever. The same observation applies to
critical days. They were observable in almost every
case in which the disease was not strangled in its
birth. Dr. Chisholm describes the same peculiarity
in the Boullam fever. "I have not met with any
disease (says the Doctor) in which the periods were
more accurately ascertained." †
The unity of the states of fever of the autumn
appeared, not only in the sameness of some of their
most characteristic symptoms, but in their mutually
propagating each other. The most malignant states
of yellow fever were propagated from a moderate
remittent, in a servant girl in Mr. Mitchell's family,
* Account of the Yellow Fever of 1793. † P. 141.
vol. iv. D and 


50 AN ACCOUNT OF THE
and a moderate remittent was created in two per-
sons by a man who died of the yellow fever.
In addition to the instances formerly enumera-
ted *, of the predominance of powerful epidemics
over other diseases, I shall add two more, which I
have lately met with in the course of my reading.
Dr. Chisholm, in describing the pestilential fever
introduced into the West Indies from Boullam, has
the following remarks. "Most other diseases de-
generated into, or partook very much of this. Dy-
senteries suddenly stopped, and were immediately
succeeded by the symptoms of the pestilential fever.
Catarrhal complaints, simple at first, soon changed
their nature : convalescents from other diseases were
very subject to this, but it generally proved mild.
Those labouring at the same time under chronic
complaints, particularly rheumatism and hepatitis,
were very subject to it. The puerperile fever be-
came malignant, and of course fatal; and even preg-
nant negro women, who otherwise might have had
it in the usual mild degree peculiar to that descrip-
tion of people, were reduced to a very dangerous
situation by it. In short, every disease in which the
patient was liable to infection, sooner or later af-
*Account of the Yellow Fever, in 1793.
sumed 
        

BILIOUS YELLOW FEVER, IN 1794. 51
sumed the appearance, and acquired the danger of
the pestilential fever." *
It is worthy of notice, that the fever described
by Dr. Chisolm did not infect beyond the distance
of ten feet. Let us not be surprised therefore,
that the yellow fever which infects across streets,
should impart its symptoms to all other diseases.
Dr. Desortes ascribes the same universal empire
to the yellow fever which prevailed in St. Domingo
in the fummer of 1733. " The fever of Siam (says
the Doctor) conveyed an infinite number of men to
the grave in a short time ; but I saw but one wo-
man who was attacked by it."
" The Violence of this disease was such, that it
subjected all other diseases, and reigned alone. This
is the character of all contagious and pestilential
diseases. Sydenham, and before him Diemerbrock, 
have remarked this of the plague." †
In Baltimore the small-pox in the natural way
was attended with unusual malignity and morta-
* P. 129, 130.
† P. 40, 41. See also p. 111-230, 231. Vol. I.
D 2 lity, 

52 AN ACCOUNT OF THE
lity, occasioned by its being combined with the reign-
ing yellow fever.
It has been urged as an objection to the influence
of powerful epidemics chasing away, or blending
with fevers of inferior force, that the measles some-
times supplant the small-pox, and mild intermittents
take the place of fevers of great malignity. This
fact did not escape the microscopic eye of Dr.
Sydenham, nor is it difficult to explain the cause of
it. It is well known that epidemics, like simple
fevers, are most violent at their first appearance,
and that they gradually lose their force as they dis-
appear; now it is in their evanescent and feeble state,
that they are jostled out of their order of danger or
force, and yield to the youthful strength of epide-
mics, more feeble under equal circumstances of age
than themselves. It would seem from this fact, that
an inflammatory constitution of the air, and power-
ful epidemics both in their aggregate and individual
forms, possessed a common character. They all in-
vade with the fury of a savage, and retire with the
gentleness of a civilized foe.
It is agreeable to discover from these facts and
observations, that epidemic diseases, however irre-
gular they appear at first sight, are all subject to cer-
tain laws, and partake of the order and harmony of
the universe.
I have 

BILIOUS YELLOW FEVER, IN I794. 53
I have remarked that this fever was contagious
in a very few instances compared with the preceding
year, but its operation upon the body, where, from
the absence of an exciting cause, it did not produce
fever, was the same as I have elsewhere described.
The sensations which I experienced in entering a
room where a person was confined with this fever,
were so exactly the same with those I felt the year
before, that I think I could have distinguished the
presence of the disease without the assistance of my
eyes, or without asking a single question. After
sitting a few minutes near a person ill with this fever
I became languid, and fainty. Weakness and chilli-
ness, followed every visit I paid to a gentleman at
Mr. Oellers's hotel, which continued for half an
hour. A burning in my stomach, great heaviness,
and a slight inflammation in my eyes with a constant
discharge of a watery humour from them for two
days, succeeded the first visit I paid to Mrs. Sellers.
These symptoms came on in less than ten minutes
after I left her room. They were probably excited
thus early, and in the degree which I have mention-
ed, by my having received her breath in my face by
inspecting her tonsils, which were ulcerated on the first
attack of the fever. Three days after my eyes re-
covered from their watery and inflamed state, I was
exposed to the action of the contagion in a con-
centrated state by bleeding Mrs. Lloyd Jones.
D 3 One 

54 AN ACCOUNT OF THE
One of my eyes again became sore, and discharged
water for two or three days afterwards. I have
related these facts chiefly with a view of offering a
conjecture as to the cause of the universal preva-
lence of opthalmias, or what are called sore eyes,
during the prevalence of great and powerful epi-
demics.* They were common in all the sickly parts
of the United States, in the year 1793, and ap-
peared in many places, as well as in Philadelphia
in the Autumn of 1794. They are probably oc-
casioned by a feeble and partial action of exhalation
or contagion upon the system. 
I recollect having more than once perceived a
smell which had been familiar to me during the time
I was exposed to the contagion of the yellow fever
in 1793. It resembled the smell of the liver of
fulphur. I suspected for a while that it arose from
the exhalations of the gutters of the city. But an
accident taught me that it was produced by the
perspiration of my body. Upon rubbing my hands,
this odor was encreased so as to become not only
more perceptible to myself, but in the most sensible
degree to my pupil Mr. Otto. From this fact I
was satisfied that I was strongly impregnated with
the contagion, and I was led by it to live chiefly
*Hippocrates's Epidemics.
upon 

BILIOUS YELLOW FEVER, IN I794. 55
upon vegetables, to drink no wine, and to avoid
with double care, all the usual exciting causes of
fever.
There was another mark by which I distinguished
the presence of the contagion of this fever in my
system, and that was, wine imparted a burning sen-
sation to my tongue and throat, such as is felt
after it has been taken in excess, or in the beginning
so a fever. Several persons who were exposed to
the contagion of this fever informed me that wine
even in the smallest quantity, affected them exactly
in the same manner.
I saw one instance in which the disease was ex-
cited in twelve hours after the contagion was taken
into the body. A lady lately from Rhode Island
who laid so near a sick gentleman in public house
as to be disturbed by his groans, humanely went
into his room in the morning to offer him all the
relief that lay in her power. She found him in the
act of puking black matter, and was much shocked
at the yellow colour of his face. She did not suspect
his disorder to be the yellow fever, for his phy-
sicians had denied or concealed it in the family.
The speedy death of this gentleman induced her to
change her lodgings. In the evening of the same day
she went to the theatre, where she was seized with a
D 4 chilly 

56 AN ACCOUNT OF THE
chilly fit. The next day I was sent for to visit her.
I found her ill with all the symptoms of the yellow
fever. She was cured, but the danger and distress
from which she escaped, furnished an affecting in-
stance of the cruelty of concealing or denying the
existence of contagious and malignant diseases.
The contagious quality of this fever I have re-
marked, was not confined to its most malignant de-
grees. Malignity in a fever is not essential to the
generation of contagion. Under certain circum-
stances of the atmosphere, the mildest intermittents 
are sometimes propagated by contagion.
I attended four persons in this fever who had had
it, the year before.
I have mentioned elsewhere that the common
modes of preventing the action of contagion on
the system had not only sailed, but had probably
favoured the spreading of the fever in 1793. I was
made happy by observing that Dr. Chisholm had
borne a testimony against them, in his account of the
jail fever of Grenada. It is by destroying a con-
fidence in supposed preventives of the disease, that
we shall lead people to the more rational ones of tem-
perance and gentle doses of physic. To a vegetable
diet may be added such a mixture of pepper as shall
keep 

BILIOUS YELLOW FEVER, IN 1794. 57
keep up a constant and vigorous tone in the stomach
and bowels, without imparting the least new action
to the blood vessels. Mr. Bruce says in his travels,
that in one of the sickly countries which he visited,
the inhabitants obviated malignant fevers, by this
practice. The quantity of pepper mixed with their
rice was so great (he says), as to inflame the throats
of persons who were not accustomed to it. To this
preventive, they add, abstinence from ardent spirits,
from weak broths, and decayed fruit. They
moreover eat their principal meat after sun-set,
when the coolness of the night air imparts a tone
to the stomach and thereby facilitates digestion.
It may appear paradoxical at first sight, how
generous living should protect from common bilious,
and low jail fevers, while it encreases the predispo-
sition to the yellow, and other pestilential fevers.
The reason is plain. The action in the blood vessels
in the common bilious and jail fevers is so feeble,
that a full diet creates an action in the vessels supe-
rior to it, while the action excited by the contagion
of pestilential fevers is so violent, as not only to
refuse to yield to the stimulus of diet, but to be
greatly increased by it.
Mr. Bruce relates further that those persons, who
lived in smoky houses, escaped bilious fevers. The
effect 


58 AN ACCOUNT OF THE
effect of smoke in checking contagion was evident,
in the hospitals constructed without chimneys by Dr.
Tilton, during the late war. The fire was kindled
in the middle of the earthen floor of the hospital in
a hole made in the earth, and the smoke after per-
vading the room, escaped through a hole in the
roof of the building in a perpendicular direction to
the fire place. Dr. Clark has added another fact
in favor of the prophylactic virtues of smoke. In
one instance which came under his notice, it pre-
served the cooks who worked in a galley from being
affected by a contagious fever.*
I have hitherto mentioned the means of prevent-
ing the attack of this fever upon individuals. I
shall now add a few directions for preventing its ad-
mission and propagation in cities.
1st. Let a law be passed to compel physicians
under a severe penalty, to report to a Committee ap-
pointed for that purpose, the existence of a malignant
contagious fever, as soon as they discover it in any
part of  the city. Let this Committee call a council
of physicians to examine the case so reported ; and
if a majority of them concur in opinion of its con-
tagious and dangerous nature, let the following steps
be taken.
*Vol. I. p. 166.
2dly. 


BILIOUS YELLOW FEVER, IN I794. 59
2dly, If the fever appear to have been imported
from a foreign country, let the infected vessel be
removed from the wharf, and carefully washed and
fumigated in the channel of the river, and let her
cargo, if any part of it has been landed, be conveyed
from the city.
3dly. If the fever appear to be of domestic
origin, let the putrid matter which produced it be
removed, or covered, so as effectually to destroy all
possibility of future exhalation from it. While these
precautions are going forward,
4thly. Let all the families which are within
fifty yards of the infected person or persons be
ordered instantly to remove into houses or tents, to
be provided for them at the public expense. Let
chains then be placed across the streets which lead
to the sick, and let guards be appointed to prevent
all access to the infected parts of the city, except
by physicians, and nurses, and such other persons as
are necessary to be employed in a manner to be
mentioned presently.
The plan of removing the well instead of the sick,
to prevent the progress of pestilential fevers is not
a new one. It has been practised with sucess in
Russia, and it has the following circumstances to re-
commend 

60 AN ACCOUNT OF THE
commend it. 1. It will prevent the contagion being
spread by the sick in passing through the streets out
of the city. 2. It will not be repugnant to hu-
manity ; for if the sick be not suddenly destroyed by
being informed of the cruel fate which awaits them,
they often perish from the motion which is necessary
to remove them, or from the anguish of being torn
from their families, or friends. 3. The discovery,
and declaration of the existence of malignant and
contagious fevers will be early, and unequivocal,
when an expulsion from the city will not be dreaded
from it, and when the danger of the disease will
thereby be lessened, by the ceasing of noises of all
kinds in the neighbourhood, and the improbability
of the sick creating a reflected atmosphere of conta-
gion from the persons who may be infected by
them.
5. After the creation of the temporary desert in
the neighbourhood of the sick (which may be done
without their knowledge) let the process of nature
for destroying contagion and morbid exhalations be
imitated. Let artificial showers of rain be poured
down by means of fire engines upon the infected
houses and upon the adjacent parts of the streets,
two or three times a day. This may be done by
means of the city engines used for extinguishing
fire.
The 

BILIOUS YELLOW FEVER, IN 1794. 61
The wealthy inhabitants of Smyrna preserve
themselves in health by thus wetting their houses,
while the plague is destroying thousands of their less
opulent, or provident neighbours.
Let it not be inferred from the enumeration of
the means of preventing the contagion of this fever,
that I admit a contagious nature to be one of its
characteristic marks. Far from it. It is an acci-
dental circumstance produced chiefly by the con-
currence of the weather. The following statement
of facts relative to its contagious character in dif-
ferent seasons, and countries, is the result of much
inquiry upon this subject.
1st. It is in no instance contagious in some cases.
2dly. It is sometimes propagated by strangers,
to strangers only, in the West Indies.
3dly. It sometimes affects the natives, as well as
strangers, in the West India Islands. 
4thly. It affects strangers, natives, and negroes.
in some instances. This was the case in Philadel-
phia in 1793, and in Norfolk in 1795.
5thly. It affects adults only, and none under
puberty, as in Jamaica according to Dr. Hume.
6thly.

62 AN ACCOUNT OF THE
6thly. It affects adults and children of all ages.
This was evident in Philadelphia in 1793.
7thly. It affects other animals as well as the
human species. It affected fowls and ducks in New
York in the year 1795, and it affected cattle in
Virginia, as I shall say presently, in the year 1794.
8thly. It affects the inhabitants of cities, and
not of the country, as in Charleston in the years
1732, 1739, 1745, and 1748, and in Philadelphia
in the year 1793.
9thly. It affects the inhabitants of both cities,
and country, as in the state of New York in the
year 1791.*
From these facts it would appear, that to suppose
this fever should infect uniformly in all cases in order
to acquire a contagious character, is as absurd as to
suppose that cold and heat do not produce inflam-
matory fevers, because thousands of people are con-
stantly exposed to them, without being indisposed.
An aptitude or predisposition from season, climate,
or constitution, must concur to render the contagion
of this, as well as other malignant fevers sufficiently
* Dr. Addoms's Thesis.
active 

BILIOUS YELLOW FEVER, IN 1794. 63
active to produce a disease. As well might a tra-
veller attempt to describe the climate of a new
country, from the history of a single season, as a
physician fix the character of an epidemic from its
appearance in one season, or in one country. To
know a disease perfectly, it should be seen, or
studied in successive seasons, and in different coun-
tries.
It remains now that I mention the origin of this
fever. This was very evident. It was produced
by the exhalations from the gutters, and the stag-
nating ponds of water in the neighbourhood of the
city. Where there was most exhalation, there were
most persons affected by the fever. Hence the poor
people, who generally live in the neighbourhood of
the ponds in the suburbs, were the greatest sufferers
by it. Four persons had the fever in Spruce, be-
tween Fourth and Fifth Streets, in which part of
the city, the smell from the gutters was extremely
offensive every evening. In Water Street between
Market and Walnut Streets, many persons had the
fever: now the filth of that confined part of the
city is well known to every citizen. - I have before
remarked that one reason why most of our physicians
refused to admit the presence of the yellow fever
in the city, was  because they could not fix upon a
vestige of its being imported. On the 25th of
August

64 AN ACCOUNT OF THE
August the Brig Commerce arrived in the river
from St. Mark, commanded by Captain Shirtliff.
After lying five days at the Fort she came up to the
city. A boy who had been shut out from his lodgings,
went in a state of intoxication, and slept on her deck,
exposed to the night air, in consequence of which
the fever was excited in him. This event gave oc-
casion for a few days to a report that the disease was
imported, and several of the physicians who had
neglected to attend to all the circumstances that
have been stated, admitted the yellow fever to be
in town. An investigation of this supposed origin
of the disease soon discovered that it had no foun-
dation. At the time of the arrival of this ship I
had attended nearly thirty persons with the fever,
and upwards of an hundred had had it, under the
care of other physicians.
Since the publication of my proofs of the gene-
ration of the yellow fever, in our city in the year
1793, I have had many reasons to be confirmed in
the opinion I then defended. My arguments have
carried conviction to the minds of every unpre-
judiced citizen of the United States. Dr. Priestley,
whose knowledge and judgment upon subjects con-
nected with volatile fluids, whether pure or impure,
must be admitted by all who know him, has admit-
ted my facts and reasonings, notwithstanding he sat
down 

BILIOUS YELLOW FEVER, IN I794. 65
down to read them under the influence of prejudices
on the other side of the question. Dr. Black the
father of modern chemistry, has likewise admitted
my opinion of the origin of the yellow fever of
1793, in a conversation with my former pupil Dr.
Coxe in Edinburgh. The two following facts will
help still further to establish the origin of the bilious
fever in its different grades, from vegetable putre-
faction, and will shew that in medicine, as well as
in government, great events, often spring from little
causes. In a letter I received near two years ago
from Dr. George Davidson of the island of St.Vin-
cents dated July 22nd 1794, is the following com-
munication.
" The yellow fever is evidently produced by a
peculiar state of the air, and by marsh exhalations.
The situation of those habitations where it first ap-
pears, near to stagnant water, or swamps, point out
this to be its origin. The governor's guard on this
Island was stationed in an old bathing house. The
stream of water which had run through it, had been
diverted from it, but a quantity of mud and filth
had been allowed to accumulate in a watering stone
trough near the door; in consequence of which
several of the guards were seized before morning
with the usual symptoms of the yellow fever. Above
ten died before the cause was discovered, and im-
VOL IV. e mediately 


66 AN ACCOUNT OF THE
mediately upon removing it, the guard became
healthy."
The children of a family in this city, were ob-
served for several succesive years to be affected by
a bilious remitting fever. The physician of the
family the late Dr. Phineas Bond, observing no
other persons to be affected in the same way in the
neighbourhood, suspected that the fever arose from
some local cause. He examined the yard belonging
to the house, where he found an offensive duck
pond. This pond was filled up, and the family
remained afterwards free from an annual bilious
fever.
Sporadic cases of fever, I believe, are often created
by the noxious air of water courses, cellars, and
sinks of houses that are equally unsuspected with
the filth of the duck pond. A citizen of Philadel-
phia who had a sink in his kitchen, lost a number of
dogs and cats by convulsions. At length one of his
servants was affected with the same disorder. This
led him to investigate the cause of it. He soon
traced it to his sink. By altering its construction,
so as to prevent the escape of noxious air from it,
he destroyed its unwholesome quality, so that dogs
and cats lived in good health afterwards in his
kitchen.
In 

BILIOUS YELLOW FEVER, IN 1794. 67
In my former publication upon the yellow fever,
I mentioned the effects of heavy rains in checking
it. But several observations made in the West In-
dies prove that this effect of rain is not uniform.
The following fact extracted from a second letter from
Dr. Davidson, dated the 12th of November 1794,
will explain the cause of the occasional deviations
from the general remark upon this subject.
"Being ordered (says the Doctor) up to Bar-
badoes last November upon service, I found that the
troops there had suffered considerably by that for-
midable scourge the yellow fever. The season had
been remarkably dry. It was observed that a rainy
season contributed to make the troops healthier,
excepting at Constitution hill, where the sixth regi-
ment was stationed, and where a heavy shower of
rain never failed to bring back the fever after it
had ceased for some time. I found the barrack
where this regiment was, surrounded by a pond of
brackish water, which being but imperfectly drained
by the continuance of the drought, the surface was
covered with a green scum which prevented the ex-
halation of marshy exhalation. After a heavy
shower of rain this scum was broken, and the mias-
mata were evolved, and acted with double force
in proportion to the time of their retention."
E 2 The 

68 AN ACCOUNT OF THE
The generation of the yellow fever in our city
was rendered more certain by the prevalence of
bilious diseases in every part of the United States,
and in several of them, in the grade of yellow fever.
It was common in Charleston in South Carolina,
where it carried off many people, and where no sus-
picion was entertained of its being of West India
origin. It prevailed with great mortality at that
part of the city of Baltimore which is known by the
name of Fell's Point, where Dr. Drysdale assures 
me it was evidently generated. A few sporadic
cases of it occurred in New York, which were pro-
duced by the morbid exhalation from the docks of
that city. Sporadic cases of it occurred likewise in
most of the states, in which the proofs of its being
generated were obvious to common observation;
and where the symptoms of depressed pulse, yellow-
ness of the skin, and black discharges from the bowels
and stomach (symptoms which mark the highest
grade of bilious remitting fever) did not occur, the
fevers in all their forms of tertian, quotidian, colic,
and dysentery, were uncommonly obstinate, or fatal
in every state in the Union. In New Haven only
where the yellow fever was epidemic, it was said to
have been imported from Martinique. It is possible
this was the case, but I suspect that this fever has
often been ascribed to importation, from the circum-
stance 

BILI0US YELLOW FEVER, IN  1794. 69
stance of its appearing first on board of ships, and
among sailors who have just arrived from West India 
voyages, into whom the seeds of the hveit are often
conveyed by the proximity of the ships to filthy
wharves and docks, and in whom they are after-
wards excited into action by hard labour or intem-
perance. But where this is not the case, I believe
the disease is sometimes excited by the effluvia of
such parts of the cargoes of ships as are capable of
putrefaction, and which act with morbid force as
soon as they are brought into contact with the air.
A solitary instance of a fever which terminated fa-
tally, occurred in this city a few years ago, from
the smell of wine, which had become putrid in the
hold of a ship, but which was inoffensive until it was
removed.
For a while I believed that I was the first person
who had asserted that a yellow fever had been ge-
nerated in Philadelphia ; but my friend Mr. Samuel
Coates, lately put into my hands a clinical lecture
delivered in the Pennsylvania Hospital by the late
Dr. Thomas Bond, on the 3d of December 1766, 
and which was preserved by order of the managers
in the third volume of their Minutes, in which the
Doctor says that he had seen the yellow fever five
times in Philadelphia. The second time he saw
it, it was indigenous, from evident causes, and
E 3 was 

70 AN ACCOUNT OF THE
was confined to one square of the city. The loca-
lity of this fever designates its putrid origin, and
bilious character. Bilious fevers of all degrees are
often limited in their progress by winds, trees, hills,
houses, and other circumstances. Dr. Bond men-
tions in the same lecture that an intermittent pre-
vailed in the year 1765 from the southern parts of
Philadelphia to Georgia, affecting two-thirds of all
the inhabitants in that extensive tract of country;
and yet at this time the city of Philadelphia, except
its southern suburbs, was healthy. The break-bone,
or bilious fever of 1780, was confined chiefly to
the eastern and southern streets of Philadelphia.
The year 1795 furnished several melancholy;
proofs of the American origin of the yellow fever.
All the Physicians and citizens of New-York and
Norfolk agree in its having been generated in their
respective cities last year. It prevailed with great
mortality at the same time in the neighbourhood
of the Lakes, and on the waters of the Genesee
river in the state of New-York. From its situation,
it obtained the name of the Lake and Genesee fever.
It was so malignant in some parts of that new coun-
try as to affect horses.
I have been frequently rebuked by my friends for
my attempts to prove that the yellow fever is one
of

BILIOUS YELLOW FEVER, IN 1794. 71
of the indigenous diseases of our country, inasmuch
as the opinion exposed me to much unnecessary per-
section, and thereby created an opposition to the
remedies I had used and recommended for the cure
of that disorder. I have constantly answered these
remonstrances by declaring the establishment of my
opinion to be deeply interesting to mankind, and
particularly to the inhabitants of the United States,
where an idea that the yellow fever could exist
among us only by importation has, until lately, very
generally prevailed.
Climates and seasons are not necessarily sickly;
The sun would seldom smite by day, nor the moon by
night, were pains taken to prevent the accumula-
tion and putrefaction of those matters which occa-
sion malignant bilious fevers. Those parts of the
West India islands which are removed from the
neighbourhood of marsh exhalations, are uncom-
monly healthy. Of this Dr. Lind has given us
many striking instances. Dr. Chisholm has lately
added his testimony to the truth of the same obser-
vation.* It is further confirmed by the following
extract of a letter from Dr. Davidson, dated No-
vember 12th, 1794. " I have mentioned an in-
stance (says the Doctor) of the remarkable good
* Introduction, p. 30.
E. 4 state 


72 AN ACCOUNT OF THE
state of health which the 66th regiment enjoyed at
St. Vincents for several years, upon a high hill
above the town, removed from all exhalations, and
in a situation kept at all times cool by the blowing
of a constant trade wind. They did not lose du-
ring eighteen months above two or three men (the
regiment was completed to the peace establishment),
and during eight years, they lost only two officers,
one of whom, the quarter master, resided constantly
in town, and died from over fatigue ; the other ar-
rived very ill from Antigua, and died within a few
days afterwards." But this is not all. There are
many proofs that uncommon degrees of longevity
as well as health, are to be met with in all the West
India Islands.
These facts are important, inasmuch as they
manifest the goodness of Heaven in having surren-
dered every part of the globe to man in a state ca-
pable of being inhabited and enjoyed. They shew
moreover the connection between health and longe-
vity, and the reason and labour of man.
Under the impression of this sentiment, it would
be criminal in me to cease to propagate the opinion
of the domestic origin of the yellow fever. It leads
to the annihilation of more human misery than is
produced by war or famine. From the success
which 

BILIOUS YELLOW FEVER, IN I794. 73
which has attended perseverance in inculcating opi-
nions equally odious and unpopular, I am satisfied
that truth, upon this subject, must prevail, and that
I shall sooner or later be believed and forgiven.
To every natural evil Heaven has discovered or
prepared an antidote. The yellow fever furnishes
no exception to this remark. The means of pre-
venting it are as much under the power of human
reason and industry, as the means of preventing the
evils of lightning and common fire. I am so satis-
fied of the truth of this opinion, that I look for a
time, when our courts of law shall punish cities and
villages for permitting a single case of bilious or yel-
low fever to exist within their jurisdiction.
I shall conclude this account of the origin of the
yellow fever by relating a fact which serious and
contemplating minds will apply to a more interesting
subject.
Notwithstanding the numerous proofs of the pre-
valence of the yellow fever in Philadelphia in the
year 1794 which have been mentioned, there are
many thousands of our citizens, and a majority of
our physicians, who do not believe that a case of it
existed at that time in the city ; nor is a single re-
cord of it to be met with in any of the newspapers,
or 

74 AN ACCOUNT OF THE
or other public documents of that year. Let us
learn from this fact, that the denial of events, or a
general silence upon the subject of them, is no refu-
tation of their truth, where they oppose the pride
or interests of the learned or the great.
What the exact state of the atmosphere is, which
disposes to malignant fevers, is difficult to determine.
Two things are obvious with respect to it. 1. It
pervades at the same time a great extent of coun-
try. This was evident in the years 1793 and 1794
in the United States. During the same year the
yellow fever was epidemic in most of the West In-
dia islands. Many of the epidemics mentioned by
Dr. Sims * affected in the same years the most re-
mote parts of the continent of Europe. Even the
ocean partakes of a morbid constitution in its atmo-
sphere, and diseases at sea, sympathise in violence
with those of the land, at an immense distance from
each other. This appears in a letter from a surgeon
on board a British ship of war to Mr Gooch, pub-
lished in the third volume of his medical and surgical
observations. 2. This predisposing state of the at-
mosphere to induce malignant diseases continues for
several years, under all the circumstances of wet
and dry, and of hot and cold weather.
* Medical Memoirs, Vol. I.
The 

BILIOUS YELLOW FEVER, IN I794. 75
The weather in 1794 differed materially from
the weather in 1793, in the United States, in each
of the above particulars ; and yet the atmosphere
continued to maintain that quality which predisposes
to a malignant state of bilious fever.
This morbid peculiarity in the air is taken notice
of by Dr. Sydenham, and acknowledged by him as
an obscure circumstance in the history of epidemics.
It resembles a solitary fever and a general epide-
mic, in beginning with violence, and gradually wast-
ing its inflammatory force by time. To what change
in the state of the air, or to what impregnation of
it, shall we attribute its disposition to impart a
greater degree of malignity or inflammatory diathesis
to diseases at one time than at another ? Hippocrates,
who felt the influence of this diathesis in his prac-
tice, ascribes it to "a divine something" in the at-
mofphere. Dr. Sydenham attributes it to certain
mineral vapours exhaled from the bowels of the
earth. I have suspected it to be the effect of a pre-
ternatural quantity of oxygen in the atmosphere. I
know that the experiments of Mr. Sheele and Mr.
Cavendish prove that the proportions of azote and
oxygen are the same in different situations and dif-
ferent kinds of weather; but as their experiments
were not made at a time  when diseases of a high
degree of inflammatory action were epidemic, I do
not 
 

76 AN ACCOUNT OF THE
not think they militate against my hypothesis. I
lament that the want of eudiometrical instruments
prevented my deciding this question by actual expe-
riments, during the prevalence of our late inflamma-
tory epidemics; but the following facts will, I
hope, render the hypothesis probable. 1. The dis-
ease was most violent in those persons in whom there
is supposed to be the greatest quantity of oxygen,
viz. the young and the robust, and more especially
those who live freely. 2. It affected those persons
most violently who had lately arrived from places
or situations in which oxygen abounded. Country
people suffered more, under equal circumstances,
from the fever, than the citizens of Philadelphia;
but it was most violent in persons who, after spend-
ing four or five weeks at the sea-shore, returned to
the city in the months of September and October.
This was the case with Peter Brown and Henry
Clymer, who sickened soon after they inhaled the
atmosphere of our city, and were both affected by
the fever in a very high degree. I should have
suspected that the uncommon malignity of the dis-
ease in those two gentlemen arose from the indo-
lence and plentiful diet which constitute part of the
pleasure of an excursion to the sea-shore, had I not
met with several cases of equal violence in persons
who had just arrived from sea voyages, under cir-
tumstances by no means apt to produce inflammable
diathesis 

BILIOUS-YELLOW FEVER, IN 1794. 77
diathesis in the blood-vessels. 3. The colour of the
blood in most cases of yellow fever, as I shall say
hereafter, was such as is imparted by oxygen. It is
possible the air may communicate as much oxygen
to the blood, as is sufficient to produce a predispo-
sition to inflammatory diseases, and yet refuse to dis-
cover itself in an undue quantity to an eudiometri-
cal experiment; for Dr. Beddoes, to whose autho-
rity upon this subject I yield my judgment, says,
and I believe very justly, in a letter I received from
him, dated May 3d, 1795, that "he has no doubt, 
but a small excess of oxygen is equal to the produc-
tion of highly inflammatory action."
If it should be found hereafter, that no excess
in the quantity of oxygen in the atmosphere takes
place during the prevalence of malignant fevers, I
shall still suspect it to be their predisposing cause,
and that it may possibly be derived from the ali-
ments and fruits of the season ; for all writers take
notice of a connection between great and mortal
epidemics, and a deviation in quality or quantity
from common years in the vegetable products of the
earth.
The exhalations or gases, which by acting upon
an inflammatory predisposition produce a yellow
fever, have been called by different names, accord-
ing 

78 AN ACCOUNT OF THE
ing as they act in a simple or compound state. They
all act as stimulants upon the whole system, and in
a more especial manner upon the liver. This is evi-
dent, not only in the affections of that viscus in
bilious fevers, but in the morbid appearances of the
liver in cattle that feed in marshy pasture in the fall
of the year. These appearances were so universally
admitted to be the effect of an unwholesome atmo-
sphere among the ancients, that they inspected the
livers of animals, in order to determine on the
healthy or unhealthy situation of the spots on which
they wished to live.
Dr. Cleghorn describes a morbid state of the
liver in cattle in an unhealthy part of the island of
Minorca. Dr. Grainger takes notice of the same ap-
pearances in the livers of several domestic animals in
Holland, in the year 1743.* But our own country
has furnished facts to illustrate the truth of this ob-
servation. Mr. James Wardrobe, near Richmond
in Virginia, informed me, that in the month of Au-
gust 1794, at a time when bilious fevers were pre-
valent in the neighbourhood, his cattle were seized
with a disease which is known by the name of the
yellow water, and which appears to be a true yel-
low fever. They were attacked with a staggering.
* Cap. III.
Their 

BILIOUS YELLOW FEVER, IN 1794. 79
Their eyes were muddy or serocious: a costivness
attended in all cases. It killed in two days. Fifty-
two of his cattle perished by it. Upon opening se-
veral of their dead bodies, he found the liver swell-
ed and ulcerated. The blood was dissolved in the
veins. In the bladder of one of them he found
thirteen pints of blood and water. Curiosity led
him to inoculate two of his calves from the blood
of a diseased animal. They both sickened in eight
days, and after being lightly indisposed, they both
recovered.
I have avoided deciding upon the specific nature
of the exhalations which induce diseases : This sub-
ject has been pursued with great ardor by Professor
Mitchell of New-York. His accurate knowledge of
the laws of the animal economy, added to the re-
cords of the late unsuccessful application of the prin-
ciples of electricity and fixed air to medicine, will, I
hope, defend him from an undue application of his
ingenious discoveries to the theory and practice of
physic.
It is no objection to the influence of these exhala-
tions in disordering the liver, that the cattle killed
and sold in the Philadelphia market in the autumns of
1793 and 1794 exhibited, in only one instance that
has come to my knowledge, the least mark of dis-
ease;


80 AN ACCOUNT OF THE
ease; for those cattle fed in pastures previously to
their being killed, in which no exhalation took
place. This was evident from the uncommon healthi-
ness of the people in that part of the neighbour-
hood of the city, from  whence the cattle  were
brought a day or two before they were killed.
Thus I have endeavoured to fix the predisposing
and remote causes of the yellow fever in our coun-
try. The remote cause is sometimes so powerful,
as to become an exciting cause of the disease; but
in general, both the predisposing and remote causes
are harmless in the system, until they are roused into
action by some exciting cause.
Before I proceed to mention the remedies which
were used in the cure of the fever which has been
described, I shall subjoin scales of the relative conta-
gious nature, of the distance of infection, and of the
mortality of the most common contagious fevers,
beginning with those which predominate under each
heads
I
A scale of the extent or universality of contagious
fevers.
1. Small-pox.
2 Measles.
4 3.In- 

BILIOUS YELLOW FEVER, IN 1794. 81
3. Influenza.
4. Plague.
5. Bilious fever in the Form, of yellow fever
in certain seasons and places.
6. Cynanche scarlatina.
7. Cynanche maligna
8. The dysentery.
9. The common bilious remitting fever.
10. The common intermitting fever.
The influence of climate, weather and habit of
body, sometimes vary this scale,. but the relative
order in which the above fevers affect a greater or
less number of people, I believe in common years,
and in most countries, accords with the observations
of most physicians.
II.
Scale of the relative distance at which contagious
fevers propagate themselves.
1. Smallpox.
2. Measles.
3. Influenza.
4.Yellow fever.
5. Plague.
6. Jail fever.
7. Cynanche maligna.
vol. IV. F. 8. Cynan- 

82 AN ACCOUNT OF THE
8. Cynanche scarlatina.
9. Dysentery.
10. The common intermitting fever.
III.
Scale of the relative mortality of contagious
diseases.
1. The plague.
2. The yellow fever.
3. The jail fever;
4. The cynanche maligna.
5. The dysentery.
6. The natural small-pox.
7. The cynanche scarlatina.
8. The influenza and measles.
9. The common bilious fever.
10. The common intermitting fever.
The above scale represents the relative order of
contagious fevers when left to themselves. Diffe-
rence of climate, season, habit of body, and above
all, difference of treatment greatly vary their re-
lative mortality. For example, in Jamaica a fourth
and in St. Domingo one half sometimes die of the
yellow fever who take bark and wine, whereas in
Philadelphia the mortality, as will be shewn here-
after does not exceed more than one in fifty, where
depleting remedies are used in their proper extent.
Method 

BILIOUS YELLOW FEVER, IN 1794. 83
Of the Method of Cure.
THE remedies employed for the cure
of this fever, were the same that I employed the
year before. I shall only relate such effects of them
as tend  more fully to establish the practice adopted
in the year 1793, and such as escaped my notice in
my former observations upon those remedies. My
method of cure consisted
I. In the abstraction of the stimulus of blood, and
heat from the whole body, and of bile, and other
acrid humors from the bowels, by means of the fol-
lowing-remedies :
1. Bleeding.
2. Purging.
3. Cool air, and cold drinks.
4. Cold water applied to the external parts
of the body, and to the bowels by means of
glysters.
F 2 II. In 

84 AN ACCOUNT OF THE
II. In creating a diversion of congestion, inflam
mation, and serous effusion, from the brain and vis-
cera to the mouth, by means of a salivation, and
to the external parts of the body, by means of
blisters.
III. In restoring the strength of the system, by
tonic remedies.
I proceed to make a few remarks upon the reme-
dies set down under each of the above heads.
I. OF BLEEDING
I HAVE taken notice that this fever dif-
fered from the fever of 1793, in coming forward
in July and August with a number of paroxysms,
which refused to yield to purging alone. I there-
fore began the cure of every case I was called to by
bleeding.
I shall mention the effects of this remedy and the
circumstances, manner and degrees in which I used
it occasionally, in this fever, in my defence of blood-
letting. Under the present head I shall only fur-
nish the reader with a table of the quantity of blood
drawn 
  

BILIOUS YELLOW FEVER, IN 1794. 85
drawn from a number of my patients in the course
of the disease. From several of them the quantity
set down, was taken in three, four, and five days.
I shall afterwards describe the appearances of the
blood.
Month. Patients. Quantity ounces. Number of times bled.
August Peter Denham 50 5
Mrs. Bruce. 70 7
Andrew Gribble 
aged 15 years. 50 5
John Madge. 150 12
Peter Brown. 80 8
September. Mrs. Gardiner. 80 7
Miss Sally Eyre 80 9
Mrs. Gass 50 3
Richard Wells's 
maid. 100 10
Mr. Norval. 100	9
Mr. Harrison. 90 9
Henry Clymer 80 8
October. Mrs. Mitchell. 120 13
Mrs. Lenox. 80	7
Ms. Kapper 140 11
Rev. Dr. Magaw's		
maid 100 10
Miss Hood 100 10
Mrs. Vogles. 70 5
1795 Guy stone 100 9
January Benj. Hancock. 100 10
Mr. Benton. 130 13
Mrs. Fries 150 15
Mrs. Garrigues, 80 7
F 3 Three

86
AN ACCOUNT OF THE
Three of the women whose names I have men-
tioned, were in the advanced stage of pregnancy,
viz. Mrs. Gardiner, Mrs. Gass, and Mrs. Garrigues.
They have all since borne healthy children. I have
omitted the names of above one hundred persons
who had the fever, from whom I drew thirty or
forty ounces of blood by two or three bleedings.
I did not cure a single person without at least one
bleeding.
It is only by contemplating the extent in which
it is necessary to use this remedy, in order to over-
come a yellow fever, that we can acquire just ideas
of its force. Hitherto this force has been estimated
by no other measure than the grave, and this we
know puts the strength of all diseases upon a level.
The blood drawn in this fever exhibited the fol-
lowing appearances.
1. It was dissolved in a few instances.
2. The crassamentum of the blood was so partially
dissolved in the serum as to produce an appearance
in the serum resembling the washings of flesh in
water.
3. The serum was so lightly tinged of a red
colour as to be perfectly transparent.
4. The 

BILIOUS YELLOW FEVER, IN 1794. 87
4. The serum was in many cases of a deep yellow
colour.
5. There was in every case in which the blood
was not dissolved, or in which the second appearance
that has been mentioned did not take place, a beau-
tiful scarlet coloured sediment in the bottom of the
bowl, forming lines, or a large circle. It seemed to
be a tendency of the blood to dissolution. This state
of the blood occurred in almost all the diseases of the
last two years, and in some in which there was not
the least suspicion of the miasmata or contagion of
the yellow fever.
6. The crassamentum generally floated in the
serum, but it sometimes sunk to the bottom of the
bowl. In the latter case, the serum had a muddy
appearance.
7. I saw but one case in which there was not a
separation of the crassamentum and serum of the
blood. Its colour in this case was of a deep scarlet.
In the year 1793 this appearance was very common.
8. I saw one case in which the blood drawn,
amounting to 14 ounces, separated partially, and was
of a deep black colour. This blood was taken from
Mr. Norval a citizen of North Carolina, who had 
F4 been

88 AN ACCOUNT OF THE 
been infected with the fever by sleeping in the same
room with Mr. Harrison, a citizen of Virginia.
9. There was in several instances a transparent
jelly-like pellicle which covered the crassamentum
of the blood; and which was easily separated from
it, without altering its texture. It appeared to have-
no connection with the blood.
10. The blood towards the crisis of the fever in-
many people exhibited the usual forms of inflam-
matory crust. It was cupped in many instances.
11. After the loss of 70 or 80 ounces of blood,
there was an evident disproportion of the quantity
of crassamentum to the serum. It was sometimes less 
by one half, than in the first bleedings.
Under this head, it will be proper to mention
that the blood when it happened to flow along the
external part of the arm in falling into the bowl,
was so warm as to excite an unpleasant sensation of
heat in several patients.
To the appearances exhibited by the blood to the
eye, I shall add a fact communicated to me by a
German bleeder who followed his business in the
City during the prevalence of the fever in 1793.
He 

BILIOUS YELLOW FEVER, IN I794. 89
He informed me that he could distinguish a yellow.
fever from all other states of fever, by a peculiar
smell which the blood emitted while it was flowing
from a vein. From the certainty of his decision in
one case which came under my notice, before a sus-
picion had taken place of the fever being in the,
city, I am disposed to believe that there is a founda-
tion for his remark.
2. OF PURGING.
I HAVE but little to add under this head
to the observations that I have made upon this re-
medy in the year 1793. I purged with jalap, calo-
mel, and gamboge until I obtained large and dark-co-
loured stools ; after which I kept the bowels gently
open every day with castor oil, cremor tartar, or
Glauber salts. I gave calomel in much larger quan-
tities that I did the year before. John Madge took
nearly 150 grains of it in six days. I should have
thought this a large quantity, had I not since read
that Dr. Chisholm gave 400 grains of it to one
patient in the course of his fever, and 50 grains to 
another at a single dose, three times a day. I found
strong mercurial purges to be extremely useful in
the 

90 AN ACCOUNT OF THE
the winter months, when the fever put on symp-
toms of pleurisy. I am not singular in ascribing
much to the efficacy of purges in the bilious pleu-
risy. Dr. Desportes tells us, that he found the
pleurisy of St. Domingo, which was of the bilious
kind, to end happily in proportion as the bowels
were kept constantly open. * Nor am I singular in
keeping my eye upon the original type of a disease,
which only changes its symptoms with the weather
or the season, and in treating it with the same re-
medies. Dr. Sydenham bled as freely in the diar-
rhœa of 1668, as he had done in the inflammatory
fever of the preceding year. † How long the pleu-
risies of winter, in the city of Philadelphia, may con-
tinue to retain the bilious symptoms of autumn,
which they have assumed for three years past, I
know not; but the late Dr. Faysseaux of South
Carolina informed me, that for many years he had
not seen a pleurisy in Charleston with the common
inflammatory symptoms which characterized that dis-
order, when he was a student of medicine. They
all now put on bilious symptoms, and require strong
purges to cure them. The pleurisies which the late
Dr. Chalmers supposes he cured by purging, were
probably nothing but bilious fevers, in which the
cool weather had excited some pleuritic symptoms.
* P. 140. † Wallis's edition, p. 211. Vol. I.
3. I

BILIOUS YELLOW FEVER, IN 1794. 91
3. I have nothing to add to the observations I
have elsewhere published upon the efficacy of cool
air and cold drinks in this fever. They were both
equally pleasant and useful, and contributed, with
cleanliness, very much to the success of my practice.
4. Cold water applied to the external parts of the
body, and injected into the bowels by way of gly-
ster, did great service in many cases. John Madge
found great relief from cloths dipped in cold wa-
ter and applied to the lower part of his belly. They
eased a pain in his bowels, and procured a dis-
charge of urine. A throbbing and most distressing
pain in the head, was relieved by the same remedy
in Mrs. Vogles and Mrs. Lenox. The cloths were
applied for three successive days and nights to Mrs.
Lenox's head, during an inflammation of her brain,
which succeeded her fever, and were changed
during the greater part of the time, every ten or
fifteen minutes. In 1795 I increased the coldness
of pump water when used in this way, by dissolving
ice in it, and in some cases I applied powdered ice
in a bladder to the head, with great advantage.
The following facts will shew the good effects of
cold water in this, as well as other fevers of too
much action. In the afternoon of one of those days
in which my system was impregnated with the conta-
gion

92 AN ACCOUNT OF THE
gion of the yellow fever, I felt so much indisposed
that I deliberated whether I should go to bed, or 
visit a patient about a mile in the country. The
afternoon was cool and, rainy. I recollected at this 
time a case related by Dr. Daignan, a French phy-
sician, of a man who was cured of the plague by
being forced to lie all night in an open field in a
shower of rain. I got into my chair, and exposed 
myself to the rain. It was extremely grateful to
my feelings. In two hours I returned, when to
my great satisfaction I found all my feverish symp-
toms had left me, nor had I the least return of 
them afterwards. Dr. Caldwell, who acted as a
surgeon of a regimen in the expedition against the
insurgents in the western counties of Pennsylvania,
furnished me, in a letter dated frqm Bedford, Octo-
ber 20th, 1794, with an account of his having been
cured of a fever by a more copious use of the same
remedy. "I was (says the Doctor) to use a vulgar,
expression, wet to the skin, and had no opportunity
of shifting my clothes for several hours." In conse-
quence of this thorough bathing, and my subsequent
exposure to a cool air, I was relieved from every
symptom of indisposition in a few hours, and have en-
joyed more than my usual stock of health ever since."
The efficacy of cold water in preventing and 
curing inflammation, may be conceived from its ef-
fects 

BILIOUS YELLOW FEVER, IN 1794. 93
fects when used with mud or clay, for obviating the
pain and inflammation which arise from the sting of
venomous insects. The same remedy applied for
half an hour has lately, it is said, been equally ef-
fectual in preventing the deleterious effects of the
bite of rattle-snake.
II. The good effects I had observed from a SA-
LIVATION in the yellow fever of 1793, induced me
to excite it as early as possible in all those cases
which did not yield immediately to bleeding - and
purging. I was delighted with its effects in every
case in which I used it. These effects were as fol-
low :
1. It immediately attracted and concentrated in
the mouth, all the scattered pains of every part of
the body.
2. It checked a nausea and vomiting.
3. It gradually, when it was copious, reduced the
pulse, and thereby prevented the necessity of further
bleeding or purging.
I wish it were possible to render the use of this
remedy universal in the treatment of malignant fe-
vers. Dr. Chisholm, in his Account of the Boul-
lam

94 AN ACCOUNT OF THE
lam fever, has done much to establish its safety and
efficacy. It is a rare occurrence for a patient that
has been sufficiently bled and purged, to die after a
salivation takes place. The artificial disease excited
by the mercury, suspends or destroys disease in every
part of the body. The occasional inconveniences
which attend it, are not to be named with its cer-
tain and universal advantages. During the whole
of the late season in which the yellow fever pre-
vailed, I saw but two instances in which it probably
loosened or destroyed the teeth. I am not satisfied
that the mercury was the cause of the injury or loss
of those teeth ; for who has not seen malignant fe-
vers terminate in ulcers, which have ended in the
erosions of bony parts of the body ?
It has been justly remarked, that there can be
but one action at a time in the blood-vessels. This
was frequently illustrated by the manner in which
mercury acted upon the system in this fever. It sel-
dom salivated until the fever intermitted or declined.
I saw several cases in which the salivation came on
during the intermission, and went off during its ex-
acerbation ; and many, in which there was no sa-
livation until the morbid action had ceased altoge-
ther in the blood-vessels, by the solution of the fe-
ver. It is because the action of the vessels in epi-
lepsy and pulmonary consumption surpasses the sti-
mulus 

BILIOUS YELLOW FEVER, IN 1794. 95
mulus of the mercury, that it is so difficult to excite
a salivation in both those disorders.
Let not the advocates for the healing powers, of
nature complain of a salivation as an unnatural re-
medy in fevers. Dr. Sydenham speaks in high 
terms of it in the fever of 1670, 1671, and 1672,
and says that it cured it when it was so malig-
nant, as to be accompanied by purple spots on the
body.
Blisters, when applied at a proper time, did great
service in this fever. This time was, when the fe-
ver was so much weakened by evacuations, that the
artificial pain excited by the stimulus of the blisters
destroyed, and, like a conductor, conveyed off, all
the natural pain of the body. It is from ignorance,
or inattention to the proper stage of fevers in which
blisters have been applied, that there have been so
many disputes among physicians respecting their effi-
cacy. When applied in a state of great arterial
action, they do harm: When applied after that ac-
tion has nearly ceased, they do little or no service.
I have called the period in which blisters are useful,
the blistering point. In bilious fevers this point is
generally circumscribed within eight-and-forty hours.
* Vol. II. p. 212.
The

96 AN ACCOUNT OF THE
The effects of blisters were as follow:
1. They concentrated, like a salivation, all the
scattered pains of the body, and thereby
2. Reduced the pulse in force and frequency.
3. They instantly checked - a sickness at the sto-
mach and vomiting.
4. They often induced a gentle moisture upon the
skin.
I found it of little consequence to what part of
the body the blisters were applied ; for I observed
a pain in the head, and even delirium, to be as
speedily and certainly cured by blisters upon the
wrists, as they-were by a large blister to the neck.
III. After the reduction of the morbid action of
the blood-vessels, by means of the  remedies which
have been  mentioned, I seldom made use of any
other tonic than a nourishing and gently stimulating
diet. This consisted of summer fruits, bread and
milk, chicken broth, the white meats, eggs, oysters,
and malt liquors, more especially porter. I made
many attempts to cure this fever when it appeared
in the form of a simple intermittent, by means of
4 BARK, 

BILIOUS YELLOW FEVER, IN I794. 97
Bark, without malignant symptoms, but always,
except in two instances, without success; and in them
it did not take effect until after bleeding. In seve-
ral cases it evidently did harm. I should have sus-
pected my judgment in these observations respecting
this medicine, had I not been assured by Dr. Grif-
fitts, Dr. Physick, and Dr. Woodhouse, that it was
equally ineffectual in their practice, in nearly all
the cases in which they gave it, and even where
blood-letting had been premised. Dr. Woodhouse
saw a case in which near a pound of bark had
been taken without effect;  and another, in which
a fatal dropsy succeeded its use. Dr. Griffitts ex-
cepted from his testimony against the bark, the cases
of seven persons from the country, who brought
the seeds of the intermitting fever with them to
the city. In them, the bark succeeded without
previous bleeding. The facility with which these
seven cases of intermitting fever were cured by the
bark, clearly proves that fevers of the same season
differ very much, according to the nature of the
exhalations which excite them. The intermittents in
these strangers were excited by miasma of less
force than that which was generated in our city,
in which, from the greater heat of the atmosphere,
and the more heterogeneous nature of the putrid
matters which stagnate in our ponds and gutters,
the exhalation probably possesses a more active and
VOL. IV. G stimulating 

98 AN ACCOUNT OF THE
stimulating quality. Thus the mild remittents in
June and in the beginning of July, which were
produced by the usual filth of the streets of Phila-
delphia, in the year 1793, differed very much from
the malignant remitting yellow fever which was pro-
duced by the stench of the putrid coffee a few weeks
afterwards.
Sir John Pringle long ago taught the inefficacy
of bark in certain bilious fevers. But Dr Chisholm
has done great service to medicine by recording its
ill effects in the Boullam fever. "Head ach, (says
the Doctor) a heavy dull eye, with a considerable
protrusion from its orbits, low spirits, thirst, and a
total want of appetite, were the  general consequen-
ces of the treatment with bark without the previous
antiphlogistic."
I have mentioned a case of internal dropsy of the
brain having been produced by the improper use of
the bark in a son of Mr. Coates. I have no doubt
but this disorder, as also palsy, and consumption,
obstructions of the liver and bowels, and dropsies
of the belly and limbs, are often induced by the use
of the bark during an inflammatory state of the
blood-vessels. It is to be lamented that the associ-
ation of certain diseases and remedies in the minds
of physicians, becomes so fixed, as to refuse to yield
to

BILIOUS YELLOW FEVER, IN 1794. 99
to the influence of reason. Thus pain and opium,
dropsy and foxglove, low spirits and assafœtida,
and above all, an intermitting fever and bark, are
all connected together in common practice as mecha-
nically, as the candle and the snuffers are in the
mind of an old and steady house servant. To abo-
lish mischief of these mechanical associations in
medicine, it will be necessary for physicians to pre-
scribe only for the different states of the system.
Finding the bark to be so universally ineffectual
or hurtful, I substituted Columbo root, the Carri-
bean bark and several other bitters in its place, but
without success. They did less harm than the
Jesuit's bark, but they did not check the return of 
a single paroxysm of fever.
I know that bark was given in this fever in some
instances in which the patients recovered; but they
were subject during the winter, and in the following
spring, to frequent relapses, and in some instances to
affections of the brain and lungs. In the highest
grade of the fever it certainly accelerated a supposed
putrefaction of the blood, and precipitated death.
The practice of physicians who create this gangre-
nous state of fever by means of the bark, resembles
the conduct of a horse, who attempt by pawing to
G2 remove 

100 AN ACCOUNT OF THE
remove his shadow in a stream of water, and thereby
renders it so turbid that he is unable to drink it.
Should the immediate success of tonic, and de-
pleting remedies in destroying the fever be equal,
the effects of the former upon the constitution can-
not fail of being less safe than the latter remedies.
They cure by overstraining the powers of life. There
is the same difference therefore between the two
modes of practice, that there is between gently lift-
ing the latch of a door, and breaking it open in
order to go into a house.
WINE was hurtful in every case of yellow fever
in which it was given while there were any remains
of inflammatory action in the system. I recollect
that a few spoonsful of it, which Mr. Harrison of
Virginia took in the depressed state of his pulse,
excited a sensation in his stomach which he com-
pared to a fire. Even wine-whey, in the excitable
state of the system induced by this fevers, was some-
times hurtful. In a patient of Dr. Physick who
was on the recovery, it produced a relapse that had
nearly proved fatal in the year 1795. Dr. Desper-
rieres ascribes the death of a patient to a small
quantity of wine given to him by a black nurse.*
* Vol. II. p. 108.
These

BILIOUS YELLOW FEVER, IN 1794. 101
These facts are important, inasmuch as wine is a
medicine which patients are most apt to use in all
cases, without the advice of a physician.
I observed OPIUM to be less hurtful in this fever
than it was in the fever of 1793. I administered a
few drops of laudanum, in one case in the form of a
glyster in a violent pain of the bowels, with evident
advantage, before the inflammatory action of the
blood vessels was subdued. In this way I have often
obtained the composing effects of laudanum where
it has been rejected by the stomach. But I gave it
sparingly, and in small doses only, in the early stage
of the fever. John Madge, whose pains in his
bowels were often as exquisite as they are in the
most acute colic, did not take a single drop of it.
I used no anodyne in his case but bleeding, and ap-
plications of cold water to the inside and outside of
his bowels. After the fever had passed the seventh
day, and had been so far subdued by copious eva-
cuations as to put on the form of a common inflam-
matory intermittent, I gave laudanum during the
intermissions of the fever with great advantage. In
some cases, it suddenly checked the paroxysms of
the fever, while in many more it only moderated
them, but in such a manner, that they wore them-
selves away in eight or ten days. One of my female
patients who had taken bitters of every kind, with-
G3 out 


102 AN ACCOUNT OF THE
out effect to cure a tertian which succeeded a yel-
low fever, took a large dose of laudanum in the in-
terval of her paroxysms to cure a tooth ach. To
her great surprise it removed  her tertian. The
effects of laudanum in this fever were very different
from those of bark. Where it did no service, it did
not, like the bark do any harm.
Perhaps this difference in the operation of those
two medicines depended upon the bark acting  with
an astringent, as well as stimulating power chiefly
upon the blood vessels, while the action of the
opium was more simply stimulating, and diffused at
the same time over all the systems of the body.
I shall say in another place that I sometimes direct-
ed a few drops of laudanum to be given in that state
of extreme debility which succeeds a paroxysm of
fever, with evident advantage.
NITRE, so useful in common inflammatory fevers,
was in most cases so offensive to the stomach in this
fever, that I was seldom able to give it. Where
the stomach retained it, I did not perceive it to do
any service.
ANTIMONIALS were as ineffectual as nitre in
abating the action of the sanguiferous system, and in
producing 
       

BILIOUS YELLOW FEVER, IN 1794. 103
producing a sweat. I should as soon expect to com-
pose a storm by music, as to cure a yellow fever
by such feeble remedies.
Thus have I finished the history of the symptoms,
origin, and cure of the yellow fever as it appeared in
Philadelphia in 1794 and in the winter of 1795.
The efficacy of the remedies which have been men-
tioned, was established by almost universal success.
Out of upwards of 200 patients to whom I was call-
ed in the first stage of the fever between the 12th
of June 1794 and the first of April 1795, I lost but
four persons in whom the unequivocal symptoms had
occurred, which characterise the first grade of the
disease.
It will be useful, I hope, to relate the cases of the
patients whom I lost, and to mention the causes of
their deaths. The first of them was Mrs. Gavin.
She objected to a fifth bleeding in the beginning of
a paroxysm of her fever, and died from the want
of it. Her death was ascribed to the frequency of
her bleedings by the enemies of the depleting system.
It was said that she had been bled ten times, owing
to ten marks of a lancet having been discovered on
her arms after death, five of which were occasioned
by unsuccessful attempts to bleed her. She died
with the usual symptoms of congestion in her brain.
G4 Mr. 


104 AN ACCOUNT OF THE
Mr. Marr, to whom I was called on the first day
of his disorder, died in a paroxysm of his fever which
came on in the middle of the 7th night, after six
bleedings. I had left him the night before nearly
free of fever, and in good spirits. He might pro-
bably have been saved, (humanly speaking) by one
more bleeding in the exacerbation of what appeared
to be the critical paroxysm of his fever.
Mr. Montford of the State of Georgia died under
the joint care of Dr. Physick and myself. He had
been cured by plentiful bleeding, and purging,
but had relapsed. He appeared to expire in a sainty
fit in the first stage of a paroxysm of the fever.
Death from this cause (which occurs most frequently
where bloodletting is not used) is common in the
yellow fever of the West Indies. Dr. Bisset in de-
scribing the different ways in which the disease ter-
minates fatally says. " In a few cases, the patient
is carried off by an unexpected syncope." 
A servant of Mr. Henry Mitchell, to whom I
was called in the early stage of his disorder, died
in consequence of a sudden effusion in his lungs
which had been weakened by a previous pulmonary
complaint.
* Medical Essays and Observations, p. 28.
I wish 

BILIOUS YELLOW FEVER, IN 1794. I05
I wish the friends of bark and wine in the yel-
low fever, or of moderate bleeding with antimonial
medicines, would publish an account of the number
of their deaths by the fever, within the period I
have mentioned, and with the same fidelity I have
done. The contrast would for ever decide the con-
troversy in favour of copious depletion. The mor-
tality under the tonic mode of practice may easily
be conceived from the acknowledgement of one of
the gentlemen who used it, but who premised it,
in many cases, by two and three bleedings. He
informed Dr. Woodhouse that out of twenty-seven
patients whom he had attended in the yellow fever,
he had saved but nine. Other practitioners were,
I believe, equally unsuccessful in proportion to the
number of patients whom they attended, The
reader will not admit of many deaths having occur-
red from the diseases (formerly enumerated) to
which they were ascribed, when he recollects that
even a single death from most of them, in common
seasons, is a rare occurrence in the practice of re-
gular bred physicians.
In answer to the account I have given of the mor-
tality of the fever in 1794, it will be said, that 30
persons died less in that year, than in the healthy
year of 1792. To account for this, it will be ne-
cessary to recollect that the inhabitants of Philadel
phia 

106 AN ACCOUNT OF THE
phia were reduced in number upwards of 4000,
in the year 1793 and of course that the proportion
of deaths was greater in 1794 than it was in 1792
although the number was less. It is remarkable
that the burials in the strangers' grave yard amount-
ed in the year 1792 to but 201, whereas in 1794
they were 676. From this it appears, that the deaths
must have been very numerous among new comers
(as they are sometimes called) in the year 1794
compared with common years. Now this will easily
be accounted for when we recollect, that these
people who were chiefly labourers, were exposed to
the constantly exciting causes of the disease, and
that in all countries they are the principal sufferers
by it.
But in order to do justice to this comparative
view of the mortality induced by the yellow fever
in the year 1794, it will be necessary to examine the
bill of mortality of the succeeding year. By this it
appears that 2274 persons died in 1795, making
1139 more than died in 1794. The greatness
of this mortality, I well recollect, surprized many of
the citizens of Philadelphia who had just passed an
autumn which was not unusually sickly, and who
had forgotten the uncommon mortality of the months
of January, February and March, which succeeded
the autumn of 1794.
It 

BILIOUS YELLOW FEVER, IN 1794. 107
It will probably be asked, how it came to pass,
that I attended so many more patients in this fever
than any of my brethren. To this I answer, that
since the year 1793 a great proportion of my patients
have constituted of strangers, and of the poor; and
as they are more exposed to the disease than other
people, it follows, that of the persons affected by
the fever, a greater proportion must have fallen to
my share as patients, than to other physicians. My
ability to attend a greater number of patients than
most of my brethren, was facilitated by my having
at the time of the fever, several ingenious and active
pupils,  who assisted me in visiting and prescribing
for the sick. These pupils were, Ashton Alexander
(now physician at Baltimore), John Otto, Nathaniel
Potter (now physicians in Philadelphia), and Gilbert
Watson.
The antiphlogistic remedies were not successful in
Philadelphia, in the yellow fever, in my hands
alone. They were equally, and perhaps more so,
in the hands of my friends Dr. Griffitts, Dr. Phy-
sick, Dr. Dewees, and Dr. Woodhouse.
They were moreover successful at the same time
in New Haven, Baltimore, and in Charleston in
South Carolina. Eighteen out of twenty died of
all  who took bark and wine in New Haven, but
only 

108 AN ACCOUNT OF THE
only one in ten, of those who used the depleting
medicines. In a letter from Dr. Brown, a phy-
sician of eminence in Baltimore, dated November
27th, 1794, he says, "of the many cases which fell 
to my care, two only proved mortal where I was
called on the fist day of the disease, and had an un-
controuled opportunity to follow my judgment.
Where salivation took place, I had no case of mor-
tality; and in two of those cases a black vomiting
occurred." Dr. Ramsay of Charleston, in a letter
to one of his friends in this city, dated October
14th, 1794, subscribes to the efficacy of the same
practice in a fever which prevailed at that time in
Charleston, and  which, he says, resembled the yel-
low fever of Philadelphia in the year 1793.
But the success of the depleting system was not
confined to the United States. In a letter before
quoted, which I received from Dr. Davidson of St.
Vincents, dated July 22d, 1794, there is the fol-
lowing testimony in favour of evacuations from the
blood-vessels, bowels, and salivary glands.
" Where the fever comes on with great deter-
mination to the head, and an affection of the sto-
mach, in consequence of that determination, vio-
lent head ach, redness of the eyes, turgescence of
the face, impatience of light, &c. attended with
a full 

BILIOUS YELLOW FEVER, IN 1794. 1O9
a full and hard pulse, blood-letting should be em-
ployed freely and repeatedly, cold applications should
be applied to the head, and purging medicines
should be employed. As a purge, calomel has been
used with the greatest advantage, sometimes by it-
self, but most frequently combined with some active
purgative medicine, such as jalap. From some
peculiarity in the disease, an uncommon quantity
of the calomel is necessary to affect the bowels and
salivary glands. As I found a small quantity of
it did not produce the effect I wished for promptly,
I have gradually increased the quantity, until I 
now venture to give ten grains of it, combined
with five of jalap, every two hours until stools are
procured. The calomel is then given by itself.
" The patients have generally an aversion to
wine. The bark is seldom found of much advan-
tage in this state of the fever, and frequently
brought on a return of the vomiting. I preferred
to it, in a remission of the symptoms, a vinous
infusion of the quassia, which fat better upon the
stomach."
In the island of Jamaica, the depleting system
has been divided. It appears from several publica-
tions in the Kingston papers, that Dr. Grant had
adopted blood-letting, while most of the physicians
of 

110
AN ACCOUNT OF THE 
of the island rest the cure of the yellow fever
upon strong mercurial purges. The ill effects of
moderate bleeding appear to have thrown the lan-
cet into disrepute ; and the balance of success, from
those publications, is evidently in favour of simple
purging. I have no doubt of the truth of the
above statement of the controversy between the
exclusive advocates for bleeding and purging; and
I think the superior efficacy of the latter remedy
may be explained in the following manner.
In warm climates the yellow fever is generally,
as it was in Philadelphia in the month of August
and in the beginning of September 1793, a dis-
ease of but two or three paroxysms. It is some-
times, I believe, only a simple ephemera. In these
cases, purging alone is sufficient to reduce the sys-
tem, without the aid of bleeding. It was found
to be so, until the beginning of September in 1793,
in most cases in Philadelphia. The extreme de-
pression of the system in the yellow fever in warm
weather and in hot climates, renders the restora-
tion of it to a healthy state of action more gradual,
and of course more safe, by means of purging, than
bleeding. The latter remedy does harm, only by
restoring the blood-vessels too suddenly to preterna-
tural action, without reducing them afterwards.
Had bleeding been practised agreeably to the me-
thod 

BILIOUS YELLOW FEVER, IN 1794. 111 
thod described by Riverius, (mentioned in a former
publication*), or had the fever in Jamaica run on
to more than four or five paroxysms, I am sure the
loss of blood would have been not only safe, but
generally beneficial. I have, in another place, † 
given my reasons why moderate bleeding in this, as
well as many other diseases, does harm. In those
cases where it has occurred in large quantities from
natural hæmorrhages, it has always done service in
the West Indies. The inefficacy, and in some cases,
the evils, of moderate blood-letting are not confined
to the yellow fever. It is equally ineffectual, and
in some instances equally hurtful, in apoplexy, in-
ternal dropsy of the brain, pleurisy, and pulmonary
consumption. Where all the different states of the
pulse which indicate the loss of blood are perfectly
understood, and blood-letting conformed in time and
in quantity to them, it never can do harm in any
disease. It is only when it is prescribed empirically,
without the direction of just principles, that it has
ever proved hurtful.  Thus the fertilizing vapors
of heaven, when  they fall only in dew, or in profuse
showers of rain, are either insufficient to promote
vegetation, or altogether destructive to it.
There may be habits in which great and long
protracted debility, whether direct or indirect, may
* Account of the Yellow Fever in 1793. † Ibidem.
have 

112 AN ACCOUNT OF THE 
have so far exhausted the active powers of the sys-
tem, as to render bleeding altogether improper in
this disease, in a West India climate. Such habits
are sometimes produced in soldiers and sailors by
the hardships of a military and naval life. Bleed-
ing in such cases Dr. Davidson assures me in a let-
ter dated from Martinique, February 29th, 1796,
did no good. The cure was effected under these
circumstances by purges, and large doses of calomel.
But where this chronic debility does not occur,
bleeding, when properly used, can never be inju-
rious, even in a tropical climate, in the yellow fever.
Of this there are many proofs in the writings of
the most respectable English and French physicians.
In spite of the fears and clamors which have been
lately excited against it in Jamaica, my late friend
and cotemporary at the college of Edinburgh, Dr.
Broadbelt, in a letter from  Spanish Town, dated
January 6th, 1795, and my former pupil Dr. Wes-
ton, in a letter from St. Ann's Bay, dated June
17th, 1795, both assure me that they have used it
in this fever with great success. Dr. Weston says
that he bled "copiously three times in 24 hours, and
thereby saved his patient."
Dr. Chisholm has lately endeavoured to rest the
cure of malignant fevers wholly upon the evacua-
tion obtained from the salivary glands, by means of
1 mercurv. 

BILIOUS YELLOW FEVER, IN I794. 113
mercury. I have no doubt of the efficacy of the
Doctor's practice, but from his own account it was
much less successful than the practice in the United
States has been, from the combined operation of
bleeding, purging, and a salivation. From the de-
scription which the Doctor has given of the state
of the pulse, of the frequent hæmorrhages which
occurred in the Boullam fever, and of the state of
the brain after death, I am satisfied that bleeding
and purging would have rendered his practice much
more successful. Notwithstanding the Boullam fever
was highly inflammatory, it was materially different
from the yellow fever of the West Indies and of
the American States. This appears 1. From its
origin, it having been produced by human mias-
mata in an African vessel which arrived at Gre-
nada, and not by marsh exhalation. 2. From its
being contagious in the West Indies, which Dr.
Chisholm says is never the case with the yellow
fever*. 3. From its infecting at the distance of but
6, 8, or 10 feet; whereas the yellow fever infects
at the distance of 20 and 30 feet. 4. From the
yellow fever, and a fever composed of the com-
bined contagions of the Boullam and yellow fevers,
prevailing at the same time in Grenada.
* P. 147. 
H I say 

114 AN ACCOUNT OF THE 
I say nothing of the difference of the symptoms
in the two fevers, for this depends upon circum-
stances purely accidental. In both, the contagion
acts like other violent and general stimuli, which all
produce nearly the same effects upon the system.
From Dr.Chisholm being unacquainted at the
time he composed his book, with the history of the
yellow fever of Philadelphia in the year 1793, he
has asserted that it was the same disease that pre-
vailed at Grenada, and that is had been conveyed
from that island to Philadelphia. The assertion fur-
nished a short lived triumph to some of the physi-
cians of Philadelphia ; but the facts which I have
mentioned from the Doctor's book, soon shewed it
to be without the least foundation.
The superior advantages of the North American 
mode of treating the yellow fever by means of all
the common antiphlogistic remedies, will appear
from comparing its success, with that of the West
India physicians, under all the modes of practice
which have been adopted in the islands. Dr. Des-
portes lost one half of all the patients he attended
in the yellow fever in one season in St. Domingo. *
His remedies were moderate bleeding, and purging,
and the copious use of diluting drinks. Dr Bisset
* Vol. I. p. 55.
1 says, 
      

BILIOUS YELLOW FEVER, IN I794. 115
says, "the yellow fever is often under particular
circumstances very fatal, carrying off four or five in
seven whom it attacks, and sometimes, but seldom,
it is so favourable, as to carry off only one patient
in five or fix."* The Doctor does not describe the
practice under which this mortality takes place.
Dr. Home, I have elsewhere remarked,† lost "one
out of four of his patients in Jamaica. His remedies
were moderate bleeding, and purging, and after-
wards bark, wine, and external applications of blan-
kets, dipped in hot vinegar.
Dr. Blane pronounces the yellow fever to be "one
of the most fatal diseases to which the human body
is subject, and in which human art is the most unavail-
ing. "His remedies were bleeding, bark, blisters,
acid drinks, saline draughts, and camomile tea.
Dr. Chisholm acknowledges that he lost one in
twelve of all the patients he attended in the jail
fever. His principal remedy was a salivation. I
shall hereafter shew the inferiority of this single
mode of depleting, to a combination of it with bleed-
ing and purging. In Philadelphia, and Baltimore
where bleeding, purging, and salivation were used
* Medical Essays and Observations, p. 29,
† Account of the yellow fever in 1793.
H 2 in 

116 AN ACCOUNT OF THE
in due time, and after the manner that has been
described, not more than one in fifty died of the yel-
low fever. It is probable that greater certainty and
success in the treatment of this disease, will not easily
be attained, for idiosyncracy, and habits of intem-
perance which resist or divert the operation of the
most proper remedies, a dread of the lancet, or the
delay of an hour in the use of it, the partial appli-
cation of that or any other remedy, the unexpected
recurrence of a paroxysm of fever in the middle of
the night, or the clandestine exhibition of wine or
laudanum by friends, or neighbours, often defeat the
best concerted plans of cure by a physician. Heaven
in this, as in other instances, kindly limits human
power, and benevolence, that in all situations man
may remember his dependence upon the power and
goodness of his Creator.*
* An innate dread of the lancet, deprived the world pre-
maturely, of the talents and virtues of William Bradford
Esq. Attorney General of the United States, on the 23d of
August 1795. He reused to submit to bleeding in a malig-
nant bilious fever for five days, during which time such ef-
fusions took place, as rendered that, and other remedies in-
effectual in his case. I shall long, very long, mourn the
death of this excellent man. He was to me a friend and a
brother. The delay of bleeding for one night only, during
a severe paroxysm of the same state of fever, deprived me of
a beloved pupil Mr. Gilbert Watson on the 25th of Septem-
ber of the same year. He caught it by the most extraordinary
exertions 
       

BILIOUS YELLOW FEVER, IN 1794. 117
This victory incomplete as it is, over a disease,
once the terror and scourge of mankind, has not
been a cheap one. It has been purchased at the
expense of much labour and obloquy. The num-
ber of the persons who have died under my care,
has been much exaggerated, and the most affecting
stories have been circulated of their dying under the
immediate use of my remedies. A single death
where bleeding had been used without success, has
injured my reputation more than twenty deaths
created by the neglect of it, or by the improper
use of tonic remedies, have injured other phy-
sicians. Nay, further, the paleness which is induced
by bleeding, has in a single instance, been urged
with more success to discredit my practice, than a
dozen deaths would have been, had I confined myself
to the usual remedies for fever. The reader will
conceive of the horror with which my practice of
bleeding in this fever is viewed, when I add, that
a lady who visited one of my female patients whom
I had bled several times, implored her upon her knees
not to permit me to bleed her any more. Her
prayer had no effect. I bled her frequently after-
wards, but that she might not be disturbed by a
repetition of the entreaties of her friend, I concealed
exertions of skill and humanity in attending and nursing a
sick family, on the Delaware, about 20 miles from Phila-
delphia.
H 3 the 

118 AN ACCOUNT &c.
the blood, at her request, each time after drawing it
in a closet, nor was it known that I did so, until
some time after her recovery.
I commit the calumnies which have followed my
opinions and practice in this fever, to the dust. If
the foil, I have endeavoured to cultivate, should
afford a plentiful harvest to my pupils, I shall not
repine, although I have reaped nothing from it, but
briars and thorns. And if my labours upon this
subject should be blessed to the conviction and benefit
of the citizens of Philadelphia, I shall rejoice in my
persecutions. 
To that BEING who often makes use of weak and
unworthy instruments to accomplish the purposes
of his benevolence, in order thereby to fix the gra-
titude of his creatures upon his own almighty power
and goodness, I desire thus publicly to record my
acknowledgments for having made me in the smallest
degree useful to my fellow men in any part of the
world, by the revival and application of remedies
which have subdued, in a great measure object, the force of
a once formidable and mortal disorder. To his great
and holy name be ascribed honor, and power, and
glory, by all his intelligent creatures, for ever, and
ever. 

AN
INQUIRY
INTO THE
PROXIMATE CAUSE
OF
FEVER.

 

AN
INQUIRY, &c.
HAVING yielded to the solicitations of
my pupils to publish a defence of blood-letting in
certain diseases, I found that I could not do justice
to the subject, as it relates to the cure of fevers,
without first delivering a few observations upon that
state of the blood-vessels, which constitutes the
proximate cause of fever. I shall therefore proceed
briefly to deliver the substance of what I have taught
for several years upon this subject in the University
of Pennsylvania, and what has, for many years, re-
gulated my practice in the treatment of fevers.
Previously to my entering upon this subject, I
shall give a short account of the changes which I
have made in my opinions upon it. My first prin-
ciples in medicine were derived from Dr. Boer-
haave, and from his aphorisms as explained by
Vanswieten, I adopted my first ideas of fever.
The 

122 ON THE PROXIMATE
The reader may easily conceive of the pains I took
to become master of this subject, when I add, that
before I was twenty years of age, I abridged all
those volumes of Vanswieten's Commentaries on
Dr. Boerhaave's aphorisms which treat of fever.
I need hardly add, that Dr. Boerhaave placed its
proximate cause wholly in a lentor of the blood,
and in morbific matter.
When I went to Edinburgh in the year 1766, I
relinquished this theory of fever, and embraced a
more rational one, first proposed by Dr. Hoffman,
and afterwards revived with many advantages by
Dr. Cullen, I mean the theory of a spasm upon the
extremities of the capillary vessels in every part of
the surface of the body. Soon after my settlement
in Philadelphia in the year 1769 I found that this
theory did not accord with many of the phenomena
of fever. I was therefore forced to desert it ; and
for many years I floundered upon an ocean of
doubt and uncertainty with respect to the proximate
cause of fever. Many painful hours have I spent
in contemplating this subject. At length light broke
in upon my mind. The phenomena of fever suddenly
appeared to me in a new order. I instantly combined
them into a new theory. Whether this theory be
just, or not, time must discover. Since I have
adopted it, my practice in fevers has been more sim-
ple, 

CAUSE OF FEVER. 123 
pie, and far more successful than formerly. It has
moreover thrown a light upon the proximate cause
of several other diseases, and led to a practice equally
simple and successful in them. I feel no shame in
thus publicly acknowledging that I have more than
once changed my opinions in medicine. To be un-
changeable, belongs only to that being who sees
things in their order and relation to each other by
a single act of intuition. A change in opinions is
the necessary effect of succession in the acquisition of
knowledge, and I believe a new truth is seldom ac-
quired by men of common education, but at the ex-
pence of an old error.
I shall not attempt to give a definition of fever.
It appears in so many different forms, that a just
view of it can only be given in a minute detail of all
its symptoms and states.
In order to render the theory of fever, which I
am about to deliver, more simple and intelligible,
it will be necessary to premise a few general pro-
positions.
I. Fevers of all kinds are preceded by general
debility. This debility is of two kinds, viz. direct
and indirect. The former depends upon an ab-
straction of usual and natural stimuli; the latter
upon 


124 ON THE PROXIMATE
upon an increase of natural, or upon the action of
preternatural stimuli upon the body. However op-
posite these causes of debility may be, they unite
in their effects, and that in such a manner, that direct
and indirect debility are frequently to be distinguish-
ed, only by a knowledge of the causes which in-
duce them.
That fevers are preceded by general debility, I
infer from their causes. These act directly or in-
directly on the system. I shall first mention those
causes of fever which act by inducing direct, and
afterwards those which act by inducing indirect de-
bility.
The former are,
1. Cold. This is universally acknowledged to be
a predisposing cause of fever. That it debilitates, I
infer, 1. From the languor which is observed in the
inhabitants of cold countries; and from the weakness
which is felt in labour or exercise in cold weather.
2. From the effects of experiments, which prove,
that cold air and cold water lessen the force and
frequency of the pulse.
The other causes of direct debility which predis-
pose to fever are,
2. The 


CAUSE OF FEVER. 125
2. The debilitating passions of fear, grief, and
despair.
3. All excessive evacuations, whether by the
bowels, blood-vessels, pores, or urinary passages.
4. Famine, or the abstraction of the usual quan-
tity of nourishing food.
The causes which predispose to fever by inducing
indirect debility are,
1. Heat. Hence the greater frequency of fevers
in warm climates and in warm weather.
2. Intemperance in eating and drinking.
3. Fatigue.
4. Certain causes which act by over-stretching a
part or the whole of the body, such as lifting heavy
weights, external violence acting mechanically in
wounding, bruising, or compressing particular parts,
extraneous substances acting by their bulk or gra-
vity, burning, and the like. * Some of these causes
act locally, but they affect the system secondarily by
* Cullen's First Lines.
inducing 


126 ON THE PROXIMATE
inducing in it indirect debility. I infer further, that
fevers depend upon predisposing debility from the
time in which they most commonly attack, viz. in
the night, when the system is in a state of debility ;
and from the symptoms which accompany the at-
tack of a fever, such as weakness in the limbs, in-
ability to stand or walk, coldness or chills, sleepiness,
a shrinking of the hands and face, and a weak or
quick pulse.
In answer to this general proposition it may be
said, that contagions, whether of the small-pox or
measles, act without the predisposition of debility ;
and that this predisposition is not necessary to pro-
duce a fever from the contagions of the plague or
yellow fever. To this I reply, that none of those
contagions act so as to produce fever, until they
have first induced indirect debility ; and that their
action is more speedy, certain, and violent in pro-
portion to the degrees of direct or indirect debility
which have preceded them. This is so well known,
that the safety or fatal issue of fevers from conta-
gion is generally expected, from their having been
preceded by more or less of the enumerated causes
of direct or indirect debility.
II. Debility is always succeeded by increased ex-
citability, or a greater aptitude to be acted upon
by 

CAUSE OF FEVER. 127
by stimuli. This increase of excitability is said by
Dr. Brown to be confined only to a state of direct
debility, but it takes place in all cases of indirect
debility; where it is suddenly induced upon the sys-
tem. Indirect and direct debility are upon a foot-
ing, where they are of a chronic nature. They
both equally expend the excitability of the system,
and leave it in a state in which stimuli generally
act with too little force upon it to excite in it the
commotions of fever.
III. The diminution or abstraction of one stimulus
is always followed by the increased action of others.
Let us apply these principles, before we lose sight
of them, to the production of fever.
Has the body been debilitated by long exposure
to the cold air? - its excitability is thereby in-
creased, and heat acts upon it with an accumulated
force; hence the frequency of catarrhs, pleurisies,
and other inflammatory fevers in the spring, after
a cold winter; and of bilious remittents in the au-
tumn, when warm days succeed to cold and damp
nights. These diseases are seldom felt for the first
time in the open air, but generally after the body
has been exposed to cold, and afterwards to the heat
of a warm  room or a warm bed. Mild intermit-
tents 


128 ON THE PROXIMATE
tents have frequently been observed to acquire an
inflammatory type in the Pennsylvania hospital, in
the months of November and December, from the
heat of the stove rooms acting upon bodies previ-
ously debilitated by cold and disease.
Has there been an abstraction of heat by a hid-
den shifting of the wind from the south-west to the
north-west or north-east points of the compass, or
by a cold night succeeding to a warm day ? - fever
is thereby frequently excited. These sources of fever
occur every autumn in Philadelphia. The mias-
mata or contagion which exist in the body at that
time in a harmless state, are excited into action by
the debility from cold, aided in the latter case by
the inaction of sleep suddenly induced upon the system.
Again: Has the body been suddenly debilitated
by fatigue ? - its excitement is thereby diminished,
but its excitability is increased in such a manner that
the stimulus of a full meal, or an intemperate glass
of wine, if taken immediately after the fatigue is
induced upon the body, excites a fever ; hence the
frequency of fevers in persons upon their return
from hunting, surveying, long rides, or from a camp
life. A fever from the last cause, was very com-
mon during the late war in America. A hot sup-
per, and afterwards the heat of a warm bed, some-
times 
               

CAUSE OF FEVER. 129
times induced not only fever, but a convulsion in
the nervous system in many persons the night after
they returned from the coarse diet of the camp,
and from sleeping upon an earthen or wooden floor.
Many other instances might be mentioned of fever
being brought on by ordinary stimuli, acting upon
increase or accumulated excitability.
This connection of excitability with debility, has
lately been pointed out by the French physicians by
the terms "laxitè vibratile," by which they mean
a liableness in the system to be thrown into vibra-
tions or motions by the predisposition of debility.
That this vibratility, or disposition to preterna-
tural motion in animal matter, is the predisposing
cause of fevers, is evident from their occurring in
those stages of life in which it is most common, as
in infancy, childhood, youth, and middle life. Fe-
vers are less common in old age, for the vibra-
tility of the sanguiferous system, in which I shall
presently say the proximate cause of ordinary fever
is seated, generally declines in old people. It even
lessens in the skin, as appears by contracting it for
half a minute between the fingers.
IV. The stimuli which are the remote or exciting
causes of fever, act in a manner wholly different
I from 

130 ON THE PROXIMATE
from what they do, upon a body in which there is
no predisposition to fever. In health there is a con-
stant and just proportion between the degrees of
excitement and excitability, and the force of stimuli.
But this is not the case in a predisposition to a fe-
ver. The ratio between the action of stimuli and
excitement, and excitability is destroyed ; and hence
the former act upon the latter with a force which
produces irregular action, or a convulsion in the ar-
terial system. When the body is debilitated, and
its excitability increased, either by fear, darkness,
or silence, a sudden noise occasions a short convul-
sion. We awake in like manner in a light convul-
sion, from the sudden opening of a door, or from
the sprinkling of a few drops of water in the face,
after the excitability of the system has been accu-
mulated by a night's sleep. In a word, it seems to
be a law of the system that stimulus, in an over-pro-
portion to excitability, either produces convulsion,
or goes so far beyond it, as to destroy motion alto-
gether in death.
V. The stimuli which induce the irregular action
or convulsion of fever, act, for the most part, pri-
marily upon the sanguiferous, and particularly upon
the arterial system. The arteries pervade every
part of the body. They terminate on every part
of its surface, in which I include the lungs and ali-
mentary 
               

CAUSE OF FEVER. 131
mentary canal, as well as the skin. It is from this
circumstance that they are so easily affected by cold,
heat, and all the other remote and exciting causes
of fever. I need not pause to prove that the blood-
vessels possess muscular fibres, and that their irrita-
bility, or disposition to motion, depends upon them.
This has been demonstrated by Dr. Vasschuer and
Mr. John Hunter by many experiments. Dr. Boer-
haave admits it in the history he has given in his In-
stitutes, of an ox that was killed immediately after
it had been violently heated by running away. The
coats of its arteries were suffused with blood, in
consequence of inflammation. Even Dr. Haller,
who denies the muscularity and irritability of the
blood-vessels, implies an assent to them in the fol-
lowing words: " There are nerves which descend
for a long way together through the surface of the
artery, and at last vanish in the cellular substance of
the vessel, of which we have a specimen in the ex-
ternal and internal carotids, and in the arch of the
aorta; and from these do not the arteries seem to
derive a muscular and convulsive force very different
from that of their simple elasticity ? Does not this
shew itself plainly in fevers, faintings, palsies, con-
sumption, and passions of the mind ?" *
* First Lines, § 32. of the chapter on the Arteries.
I 2 The 

132 ON THE PROXIMATE
The morbid action of the blood-vessels discovers
itself in preternatural force or frequency in the pul-
sations of the arteries. In this state of the arteries,
the stomach, bowels, and muscles exhibit marks of
preternatural weakness, for natural excitement is
abstracted from them, and concentrated  in the san-
guiferous system.
VI. There is but one remote cause of fever, and
that is stimulus. Heat, alternating with cold, *
marsh and human miasmata, contagions and poisons
of all kinds, intemperance, passions of the mind,
bruises, burns, and the like, all act by a stimulating
power only, in producing fever. This proposition
is of great application, inasmuch as it cuts the sinews
of the division of diseases from their remote causes.
Thus it establishes the sameness of a pleurisy, whe-
ther it be excited by heat succeeding cold, or by the
contagion of the small-pox, measles, or yellow fever.
VII. There is but one fever. However different
the predisposing, remote, or exciting causes of fever
* Dr. Sydenham ascribes nearly all fevers to this cause,
particularly to leaving off winter clothes too soon, and to ex-
posing the body to cold after it has been heated. These two
sources of fever, he adds, destroy more than the plague, sword,
or famine.
Wallis's Edition, Vol. I. p. 357.
may 

CAUSE OF FEVER. 133
may be, whether direct or indirect debility,  whe-
ther heat or cold succeeding to each other, whether
marsh or human miasmata, whether intemperance,
a fright, or a fall, still I repeat, there can be but
one fever. I found this proposition upon all the
supposed variety of fevers having but one proxi-
mate cause. Thus fire is an unit, whether it be
produced by friction, percussion, electricity, fermen-
tation, or by a piece of wood or coal in a state of
inflammation.
VIII. All ordinary fever being seated in the
blood-vessels, it follows of course, that all those
local affections we call pleurisy, angina, phrenitis,
internal dropsy of the brain, pulmonary consump-
tion, and inflammation of the liver, stomach, bowels,
and limbs, are symptoms only of an original and
primary disease in the sanguiferous system. The
truth of this proposition is obvious, from the above
local affections succeeding primary fever, and from
their alternating so frequently with each other. I
except from this remark those cases of primary af-
fections of the viscera which are produced by local
injuries, and which, after a while, bring the whole
sanguiferous system into sympathy. These cases are
uncommon, amounting probably to not, more than
one in a hundred of all the cases of local affection
which occur in general fever.
13 Having 


134 ON THE PROXIMATE
Having premised these general propositions, I
go on to remark, that a fever (when not misplaced)
consists in a morbid excitement and irregular action
in the blood-vessels, more especially in the arteries.
This morbid excitement, or irregular action, mani-
fests itself to the fingers, when pressed upon the
radial artery, by preternatural fulness, force, and
frequency, or by preternatural slowness, intermis-
sions and depression in what are called inflammatory
fevers, and by preternatural frequency without ful-
ness or force, in what are called typhus fevers.
I have called the action of the arteries irregular
in fever, to distinguish it from that excess of action
which takes place after violent exercise, and from
that quickness which accompanies fear or any other
directly debilitating cause. The action of the arteries
here is regular, and  when felt in the pulse, affords a
very different perception to the mind from that
which we feel in the pulse of a patient labouring
under a fever.
This irregular action is in other words, a CON-
VULSION in the sanguiferous, but more obviously, in
the arterial system.
That this is the case I infer from the strict analogy
between symptoms of fever, and convulsions in the
nervous 

CAUSE OF FEVER. 135
nervous system. I shall briefly mention the particu-
lars in which this analogy takes place.
1. Are convulsions in the nervous system pre-
ceded by debility? So is the convulsion of the blood-
vessels in fever.
2. Does debility induced on the whole, or on a
part only, of the nervous system, predispose to
general convulsions, as in tetanus? So we observe
debility, whether it be induced on the whole or on
a part of the arterial system, predisposes to general
fever. This is obvious in the fever which ensues
alike from cold applied to every part of the body,
or from a stream of cold air falling upon the neck,
or from the wetting of the feet.
3. Do tremors precede convulsions in the nervous
system ? So they do the convulsion of the blood-
vessels in fever.
4. Is a coldness in the extremities a precursor
of convulsions in the nervous system? So it is of
fever.
5. Do convulsions in the nervous system impart
a jerking sensation to the fingers? So does the con-
I 4 vulsion 

136 ON THE PROXIMATE
vulsion of fever in the arteries, when felt at the
wrists.
6. Are convulsions in the nervous system attended
with alternate action and remission? So is the con-
vulsion of fever.
7. Do convulsions in the nervous system return
at regular and irregular periods? So does fever.
8. Do convulsions in the nervous system, under
certain circumstances, affect the functions of the
brain? So do certain states of fever.
9. Are there certain convulsions in the nervous
system which affect the limbs, without affecting the
functions of the brain, such as tetanus, and chorea
sancti Viti? So there are certain fevers, particularly
the common hectic, which seldom produces delirium
or even headach, and frequently does not confine
a patient to his bed.
10. Are there local convulsions in the nervous
system, as in the hands, feet, neck, and eye-lids ?
So there are local fevers. Intermittents often appear
in the autumn with periodical heat and pains in the
eyes, ears, jaws, and back.
11. Are

CAUSE OF FEVER. 137
11. Are there certain grades in the convulsions of
the nervous system, as appears in the hydrophobia,
tetanus, epilepsy, hysteria and, hypochondriasis? So
there are grades in fevers, as in the plague, yellow
fever, small-pox, rheumatism, and common remitting
and intermitting fevers.
12: Are nervous convulsions most apt to occur in
infancy? So are fevers.
13. Are persons once affected with nervous con-
vulsions, frequently subject to them through life?
So are persons once affected with fever. The inter-
mitting fever often returns with successive springs or
autumns, and in spite of the bark, sometimes con-
tinues for many years in all climates and seasons.
14. Is the strength of the nervous system increased
by convulsions? This is so evident, that it often re-
quires four or five persons to confine a delicate
woman to her bed in a convulsive fit. In like man-
ner the strength of the arterial system is increased in
a fever. This strength is great in proportion to the
weakness of every other part of the body.
15. Do we observe certain nervous convulsions
to affect some parts of the nervous system more
than others, or in other words, do we observe pre-
ternatural 

138 ON THE PROXIMATE
ternatural strength or excitement, to exist in one
part of the nervous system, while other parts of
the same system exhibit marks of preternatural
weakness, or defect of excitement? We observe
the same thing in the blood-vessels in a fever. The
pulse at the wrist is often tense, while the force
of the heart is very much diminished. A delirium
often occurs in a fever from excess of excitement in
the blood-vessels of the brain, while the pulse at the
wrist exhibits every mark of preternatural weak-
ness.
16. Is there a rigidity of the muscles in certain
nervous diseases, as in catalepsy? Something like
this solstice in convulsion occurs in that state of fever
in which the pulse beats but 60, or fewer strokes in
a minute.
17. Do convulsions go off gradually from the
nervous system, as in tetanus, and chorea sancti Viti ?
So they do from the arterial blood-vessels in certain
states of fever.
18. Do convulsions go off suddenly in any cases
from the nervous system? The convulsion in the
blood-vessels, goes off in the same manner by a
sweat, or by an hæmorrhage, frequently in the
course of a night, and sometimes in a single hour.
19. Does 

CAUSE OF FEVER. 139
19. Does palsy in some instances succeed to con-
vulsions in the nervous system? Something like a
palsy occurs in the blood-vessels in fevers of great
inflammatory action. I shall hereafter ascribe the
dissolved appearance of the blood in malignant fevers
to this tendency of the blood-vessels to a paralytic
state. It begins in the veins in which muscular action
is more feeble than in the arteries. This has been
proved by Dr. Mitchell in his account of the yellow
fever in Virginia in the year 1741. He found the
blood to be dissolved when drawn from the veins,
which when drawn from the arteries of the same
persons, exhibited no marks of dissolution. This fact
is of great importance in medicine, as I hope to
shew when I come to treat of blood-letting.
From the facts and analogies which have been
mentioned, I have been led to believe that irregular
action or a convulsion in the blood-vessels, is the
proximate cause of fever.
There is a wonderful frugality in the operations
of nature. Two instruments are never employed
by her to accomplish that which can be effected by
one. As the predisposing and remote causes of all
general diseases are simple, so is the proximate. My
theory of fever then resolves itself into a chain, con-
sisting of four links. I. Predisposing debility, or
weakened 

140 ON THE PROXIMATE
weakened excitement of the blood-vessels. 2. An
increase of their excitability. 3. Stimulating powers
applied to them. And, 4. Irregular action or con-
vulsion.
I might digress here, and shew that all diseases,
whether they be seated in the arteries, muscles,
nerves, brain, or alimentary canal, are all preceded
by debility; and that their essence consists in irre-
gular action, or in the absence of the natural order
of motion, produced or invited by predisposing de-
bility. Hence they have very properly been called
DISORDERS. I might further shew, that all the
moral as well as physical evil of the world consists
in predisposing weakness, and in subsequent de-
rangement of action or motion ; but these collateral
subjects are foreign to our present inquiry.
Let us now proceed to examine how far the
theory, which has been delivered, accords with the
phenomena of fever.
I shall divide these phenomena into two kinds.
I. Such as are transient, and more or less com-
mon to all fevers. These I shall call symptoms of
fever.
II. Such 

CAUSE OF FEVER. 141
II. Such as, being more permanent and fixed,
have given rise to certain specific names. These I
shall call states of fever.
I shall endeavour to explain and describe each of
them in the order in which they have been men-
tioned.
I. Lassitude is the natural effect of the predis-
posing debility which precedes fever.
Coldness and chills are the effects of the abstrac-
tion of excitement, or natural motion from the sur-
face of the body. The absence of chills indicates
the sensibility of the external parts of the body to
be suspended or destroyed, as well as their irrita-
bility ; hence where death occurs in the fit of an
intermittent, there is no chill. A chilly fit, for the
same reason, seldom occurs in the most malignant
cases of fever. It has been remarked, that the
chilly fit, in common fevers, seldom appears in its
full force until the patient approaches a fire, or lies
down in a warm bed; for in these situations the sen-
sibility of the system is restored by the stimulus of
the heat acting upon the extremities of the blood-
vessels. It is produced in a mechanical manner, and
is by no means the effect of an effort of the healing
powers of nature to save the system from destruction.
Tremors 

142 ON THE PROXIMATE
Tremors are the natural consequence of the ab-
straction of that support which the muscles receive
from the fulness and tension of the blood-vessels.
It is from this retreat of the blood towards the vis-
cera, that the capillary arteries lose their fulness and
tension; hence they contract like other soft tubes
that are emptied of their contents. This contraction
has been called a spasm, and has improperly been
supposed to be the proximate cause of fever. From
the explanation that has been given of its cause, it
appears like the coldness and chills, to be nothing
but an accidental concomitant or effect of a pa-
roxysm of fever.
The local pains in the head, breast, and bones in
fever, appear to be the effects of the irregular de-
termination of the blood to those parts, and to mor-
bid action being thereby induced in them.
The vomiting and diarrhœa are produced by mor-
bid excitement in the vessels of the stomach and
bowels.
The want of appetite and costiveness are the con-
sequences of a defect of excitement or natural ac-
tion in the same parts of the body.
The 

CAUSE OF FEVER. 143
The dry skin or partial sweats appear to depend
upon diminished or partial action in the vessels
which terminate on the surface of the body.
The high coloured and pale urine, are occasioned
by an excess or a deficiency of excitement in the
secretory vessels of the kidneys.
The suppression of the urine seems to arise from
what Dr. Clark calls an engorgement, or choaking
of the vessels of the kidneys. It occurs most fre-
quently in malignant fevers.
Thirst is probably the effect of a preternatural
excitement of the vessels of the fauces. It is by
no means an uniform symptom of fever. We some-
times observe it in the highest degree, in the last
stage of diseases, induced by the retreat of the last
remains of excitement from every part of the body,
to the throat.
The white tongue is produced by a change in
the secretion which takes place in that organ. Its
yellow colour is the effect of bile; its dryness, is
occasioned by an obstruction of secretion ; and its
dark and black colour, by a tendency to mortifica-
tion.
It 

144 ON THE PROXIMATE
It will be difficult to account for the variety in
the degrees and locality of heat in the body in a
fever, until we know more of the cause of animal
heat. From whatever cause it be derived, its excess
and deficiency, as well as all its intermediate de-
grees, are intimately connected with more or less
excitement in the arterial system. It is not necessary
that this excitement should exist only in the large
blood-vessels. It will be sufficient for the purpose
of creating great heat, if it occur only in the cuta-
neous vessels;  hence we find a hot skin in some
cases of malignant fever in which there is an ab-
sence of pulse. A defect of excitement produced
by great excess of stimulus, as in the fist stage of
violent malignant fevers, is often accompanied by a
deficiency of heat, and in some instances by a cold-
ness on the surface of the body. In these cases
there is a defect of excitement in the vessels of the
skin as well as in the larger blood-vessels. Local
heat, whether in the head, breast, hands, or feet,
I suppose to be the effect of local excitement.
Eruptions seem to depend upon effusions of se-
rum, lymph, or red blood upon the skin, with or
without inflammation, in the cutaneous vessels. 
I decline taking notice in this place of the same-
ness of the symptoms which are produced by in-
4 direct 
                

CAUSE OF FEVER. 145
direct and direct debility in the system. They ap-
pear not only in the temperature of the body, but
in all the different symptoms of fever. It is of im-
portance to know when they originate from the
former, and when from the latter states of debility,
as they require very different and opposite remedies
to remove them.
It remains only to explain the cause, why excess
in the force or frequency of the action of the
blood-vessels should succeed debility in a part, or
in the whole of the body, and be connected for days
and weeks with preternatural debility in the mus-
cles, nerves, brain, and alimentary canal. I shall
attempt the explanation of this phenomenon by
directing the attention of the reader to the opera-
tions of nature in other parts of her works.
1. A calm may be considered as a state of de-
bility in the atmosphere. It predisposes to a cur-
rent of air. But is this current proportioned to
the loss of the equilibrium of the air? By no means:
It is excessive in its force, and tends thereby to de-
stroy the works both of nature and art.
2. The passions are given to man on purpose to
aid the flow and uncertain operations of reason.
But is their action always proportioned to the causes
which excite them? An acute pneumony brought
k on 

146 ON THE PROXIMATE
on by the trifling injury done to the system by the
fatigue and heat of an evening spent in a dancing
assembly, is but a faint representation of the im-
mense disproportion between a trifling affront, and
that excess of passion which seeks for gratification in
poison, assassination, or a duel. The same dispropor-
tion appears between cause and effect in public bo-
dies. A hasty word of no mischievous influence,
has often produced convulsions, and even revolu-
tions, in states and empires.
If we return to the human body, we shall find in
it many other instances of the disproportion between
stimulus and action, besides that which takes place
in the exciting and proximate cause of fever.
3. A single castor oil nut, although rejected by
the stomach upon its first effort in vomiting, has, in
one instance that came within my knowledge, pro-
duced a vomiting that continued nearly twenty-four
hours. Here the duration of action was far beyond
all kind of proportion to the cause which excited it.
4. A grain of sand, after being washed from
the eye, is often followed by such an inflammation,
or excess in the action of the vessels of the eye, as
to require bleeding, purging, and blistering to re-
move it.
Could 

CAUSE OF FEVER. 147
Could we comprehend every part of the sublime
and ineffable system of the natural, moral, and po-
litical government of the world, I am sure we should
discover nothing in it, but what tended ultimately
to order and happiness. But there is evil in the
world, and the operations of nature, which were
originally the ministers of goodness only to man,
are in many instances the vehicles of this evil. In
religion and morals, as well as in medicine, nature
leads to error and destruction. When we worship
the fun, a cat, a crocodile, or the devil, we follow
nature. When we lie, steal, and commit murder
and adultery, we follow nature. In like manner,
when we indulge every appetite and passion of our
patients in sickness, and create hæmorrhages, ob-
structions, dropsies, palsies, apoplexies, and death,
by neglecting bleeding and purging in fevers, we
follow nature. But while I maintain this unusual
language in medicine, let it be remembered, that
the operations of nature were not originally the
means of seducing or injuring man ; and Revelation
assures us, that a time will come, when the dominion
of order shall be restored over every action of his
body and mind, and health and happiness again be
the result of every movement of nature.
From the view I have given of the state of the
blood-vessels in fever, the reader will perceive the
K 2 difference  

148 ON THE PROXIMATE
difference between my opinions and Dr. Brown's
upon this subject. The Doctor supposes a fever to
consist in debility, I do not admit debility to be a
disease, but place it wholly in morbid excitement,
invited and fixed by previous debility. He makes
a fever to consist in a change only of a natural
action of the blood-vessels. I maintain that it con-
sists in a preternatural and convulsive action of the
blood-vessels. Lastly, Dr. Brown supposes excite
ment and excitability to be equal in fever. My
theory supposes a fever to be the reverse of this.
It consists in unequal or divided excitement and ex-
citability. Health consists in the equality and uni-
formity of them both; and the business of medi-
cine, as I shall say hereafter, is to equalize them in
the cure of fever ; that is, to abstract their excess
from the blood-vessels, and to restore them to the
other parts of the body.
It belongs to this part of our view of fever to
repeat from Dr. Boerhaave, that its termination is
always in health, in another disease, or in death.
A slight fever only can terminate in health. All
fevers of violent action, when left to themselves, or
when partially cured, terminate in other diseases,
or in death. The last is the effect of the single or
combined operation of the following causes: 1. Ef-
fusions in parts essential to life. 2. Such a change
being 

CAUSE OF FEVER. 149
being induced in the excretions, by the violent 
action of the vessels upon the blood, as to render 
them destructive to the organs of the body. 3. The 
inability of the system, from universal direct debi-
lity, to receive impressions, or to support the mo-
tions of life. Or lastly, death from fever is the 
effect of the combined operation of all the three 
causes that have been mentioned. I cannot dismiss 
the blood-vessels, as the seat of a general and fre-
quent disease, without lamenting that their physio-
logy and pathology have been so little studied by 
physicians. They are the first born parts of the hu-
man body; they support, in a great measure, the 
sensibility and irritability of the nervous system; 
they are the centinels of the whole system in sleep; 
and, they are the last retreat of departing life. 
II. I come now to apply the theory which I have 
delivered, to the explanation and description of the 
different phenomena or states of fever.
I have said that there is but one fever. Of course
I do not admit of its artificial division into genera 
and species. A disease which so frequently changes 
its form and place, should never have been desig-
nated, like plants and animals, by unchangeable cha-
racters. The oak tree and lion posess exactly the 
same properties which they did near 6000 years ago. 
K 3 But 

150 ON THE PROXIMATE
But who can say the same thing of any one disease?
The pulmonary consumption is sometimes transform-
ed into head ach, rheumatism, diarrhœa, and mania,
in the course of two or three months, or the same
number of weeks. The bilious fever often appears
in the same person in the form of colic, dysentery,
inflammation of the liver, lungs, and brain, in the
course of five or six days. The hypochondriasis and
the hysteria seldom fail to exchange their symptoms
twice in the four-and-twenty hours. Again: The
oak tree has not united with any of the trees of the
forest, nor has the lion imparted his specific qua-
lities to any other animal. But who can apply simi-
lar remarks to any one disease? Phrenitis, gastritis,
enteritis, nephritis, and rheumatism, all appear at
the same time in the gout and yellow fever. Many
observations of the same kind might be made upon
all other diseases. To describe them therefore by
any fixed or specific characters, is as impracticable as
to measure the dimensions of a cloud on a windy
day, or to fix the component parts of water by
weighing it in a hydrostatic balance. Much mischief
has been done by nosological arrangements of diseases.
They erect imaginary boundaries between things
which are of a homogeneous nature. They de-
grade the human understanding, by substituting
simple perceptions, to its more dignified operations
of 

CAUSE OF FEVER. 151
of judgment and reasoning. They gratify indolence
in a physician, by fixing his attention upon the
name of a disease, and thereby leading him to ne-
glect the varying state of the system. They more-
over lay a foundation for disputes among physicians,
by diverting their attention from the simple predis-
posing and proximate, to the numerous, remote,
and exciting causes of diseases, or to their more nu-
merous and complicated effects. The whole materia
medica is infected  with the baneful consequences of
the nomenclature of diseases; for every article in
it is pointed only against their names, and hence
the origin of the numerous contradictions among
authors who describe the virtues and doses of the
same medicines. By the rejection of the artificial
arrangement of diseases, a revolution must follow
in medicine. Observation and judgment will take
the place of reading and memory, and prescriptions
will be conformed to existing circumstances. The road
to knowledge in medicine by this means will likewise
be shortened; so that a young man will be able to
qualify himself to practice physic at as much less ex-
pense of time and labour than formerly, as a child
would learn to read and write by the help of the
Roman alphabet, instead of Chinese characters.
In thus rejecting the nosologies of the schools,
I do not wish to see them banished from the libra-
K 4 ries 

152 ON THE PROXIMATE
ries of physicians. When consulted as histories of
the effects of diseases only, they may still be useful.
I use the term diseases, in conformity to custom, for
properly speaking, disease is as much a unit as fever.
It consists simply of morbid action or excitement in
some part of the body. Its different seats and de-
grees, should no more be multiplied into different
diseases, than the numerous and different effects of
heat, and light upon our globe should be multiplied
into a plurality of suns.
The advocates for Dr. Cullen's system of medi-
dicine, will not, I hope, be offended by these obser-
vations. His immense flock of reputation, will
enable him to sustain the loss of his nosology, without
being impoverished by it. In my attempts to in-
troduce a new arrangement of diseases, I shall only
give a new direction to his efforts to improve the
healing art.
I have considered morbid action in the blood-
vessels, whether it consist in preternatural force and
frequency, or preternatural force without frequency,
or frequency without force, to constitute the proxi-
mate cause of fever. Excess in the force and fre-
quency of the blood-vessels, has been considered as
the characteristic mark of what is called inflam-
matory fever. But there are marks which indicate
a much greater excess of stimulus upon the blood-
vessels. 

CAUSE OF FEVER. 153
vessels. These are preternatural slowness, inter-
missions and depression in the pulse, such as occur
in certain malignant fevers. In applying my theory
of fever to the explanation of all its different states,
I am led by this view of its inflammatory state, to
consider them in the order of their inflammatory
character, or according to the force of stimulus
which acts upon the blood-vessels. The following
appears to be the usual order of inflammatory
diathesis, presented to us by nature, in the different
fevers which are described by authors ;
1. The plague.
2. The yellow fever.
3. The natural small-pox.
4. The malignant sore throat.
5. The fever from the alternate action of cold
and heat on the body, appearing with the symp-
toms of pleurisy, rhumatism, tonic gout, internal
dropsy of the brain, and pulmonary consumption.
6. The measles.
7. Catarrh from cold, and influenza from con-
tagion.
8. The common remitting fever, appearing oc-
casionally with the symptoms of colic, dysentery,
inflammation of the liver, and internal dropsy of
the brain.
9. The scarlatina, puerperile and hectic fevers.
10. The 


154 0N THE PROXIMATE
10. The jail fever.
11. The common mild intermittent.
This scale of the degrees of morbid action in
fevers is taken from their usual symptoms. They
vary with climate, season, and habit. There are in-
termittents, jail, and puerperile fevers, so inflam-
matory as to require frequent bleedings to cure
them ; and there are cases of plague, yellow fever,
and pleurisy, which yield to a single dose of purging
physic. It is upon the account of this want of
uniformity in the character of fevers, and the in-
fluence of climate, season, and habit upon them, that
I shall follow Dr. Clark, by substituting in the place
of their usual names, certain definite states which
may be applied, with varying circumstances, to them
all.
1. I shall divide them into such as affect the whole
arterial system, with no, or but little local affection.
2. Into such as affect the whole arterial system,
and are accompanied at the same time with evident
local affections. And,
3. Into such as appear to pass by the arterial
system, and to fix themselves upon other parts of
the 

CAUSE OF FEVER. 155
the body. These states of fever I shall call
misplaced.
1. I shall begin under the first head, with the
MALIGNANT state of fever. It constitutes the
highest grade of inflammatory diathesis. It is known
by attacking frequently without a chilly fit, by
coma, a depressed, flow, or intermitting pulse, and
sometimes by a natural temperature or coldness of
the skin. It occurs in the plague, in the yellow
fever, in the gout, and in the small-pox. Dr. Quier
has described a pleurisy in Jamaica, in which some of
those malignant symptoms took place. They are
the effect of such a degree of stimulus as to prostrate
the arterial system, and to produce a defect of action
from an excess of force. Such is this excess of force
in some instances in this state of fever, that it induces
general convulsions, tetanus, and palsy, and some-
times extinguishes life in a few hours by means of
apoplexy or syncope. The less violent degrees of
stimulus in this state of fever produce palsy in the
blood-vessels. It probably begins in the veins, and
extends gradually to the arteries. It seems further
to begin in the extremities of the arteries, and to
extend by degrees to their origin in the heart. This
is evident in the total absence of pulse which some-
times takes place in malignant fevers four-and-
twenty, and even eight and forty hours before
death.

156 ON THE PROXIMATE
death. But there are cases in which this palsy
affects both the veins and arteries at the same time.
It is probably from this simultaneous affection of the
blood-vessels, that the arteries are found to be nearly
full of blood after death from malignant fevers.
The depressed, and intermitting pulse which occurs
in the beginning of these fevers perhaps depends
upon a tendency to palsy in the arteries indepen-
dently of an affection of the heart or brain.
This depressed state of fever more frequently when
left to itself terminates in petechiæ, buboes, car-
buncles, abscesses and mortifications, according as
serum, lymph, or red blood is effused in the viscera
or external parts of the body. These morbid ap-
pearances have been ascribed to putrefaction, and
the fever has received, from its supposed presence,
the name of putrid. The existence of putrefaction
in the blood in a fever is rendered improbable,
1. By Dr. Seybert's experiments * which prove
that it does not take place in the blood in a living
state. It occurs in the excretions of bile, fæces,
and urine, but in this case it does not act as a fer-
ment, but a stimulus only upon the living body.
* Inaugural dissertation entitled, " An Attempt to disprove
the putrefaction of the blood in living animals."
2. By 


CAUSE OF FEVER. 157
2. By similar appearances, with those which have
been ascribed to putrefaction, having been produced
by lightning, by violent emotions of the mind, by
extreme pain, and by every thing else which induces
sudden and universal disorganization in the fluids and
solids of the body. To the facts mentioned in a
former work,* with a view of refuting the opinion
of putrefaction taking place in the blood, I shall add
some others, which clearly prove that the symptoms
which have been supposed to designate a putrid
fever, are wholly the effect of mechanical action in
the blood-vessels, and are unconnected with the in-
troduction of a putrid ferment into the blood.
Hippocrates relates the case of a certain Antiphil-
lus, in whom a putrid bilious fever (as he calls it)
was brought on by the application of a caustic to a
wound.†
An acute pain in the eye, Dr. Physick inform-
ed me, produced what are called the symptoms of
a putrid fever, which terminated in death in five
days, in St. George's hospital in the year 1789.
Dr. Desportes takes notice that a fish which he
calls a sucker, affected the system nearly in the same
* Account of the yellow fever, in 1793.
† Epidemics, book iv.
manner 

158 ON THE PROXIMATE
manner as the contagion of the yellow fever. A
distressing vomiting, a coldness of the extremities,
and an absence of pulse, were some of the symptoms
produced by it, and an inflammation and mortifi-
cation of the stomach and bowels, were discovered
after death to be the effects of its violent operation.
Even opium in large doses, sometimes produces
by its powerful stimulus the same symptoms which
are produced by the stimulus of what are called
putrid contagions. These symptoms are, a slow
pulse, coma, a vomiting, cold sweats, a sallow colour
of the face, and a suppression of the discharges by
the urinary passages and bowels.
Error is often perpetuated by words. A belief
in the putrefaction of the blood has done great mis-
chief in medicine. The evil is kept up, under the in-
fluence of new theories, by the epithet putrid, which
is still applied to fever in all our medical books.
For which reason I shall reject it altogether hereafter,
and substitute in its room
2. The GANGRENOUS state of fever, for what
appear to some physicians to be signs of putrefaction,
are nothing but the issue of a violent inflammation
left in the hands of nature, or accelerated by stimu-
lating medicines. Thus the fun, when viewed at
mid-day 
               

CAUSE OF FEVER. 159
mid-day, appears to the naked eye, from the excess
of its splendor, to be a mass of darkness, instead of
an orb of light.
The same explanation of what are called putrid
symptoms in fever, is very happily delivered by Mr.
Hunter in the following words: "It is to be ob-
served (says this acute physiologist) that when the
attack upon these organs, which are principally
connected with life, proves fatal, that the effects of
the inflammation upon the constitution, run through
all the stages with more rapidity than when it hap-
pens in other parts ; so that at its very beginning,
it has the same effect upon the constitution, which
is only produced by the second stage of inflamma-
tion in other parts." *
3. The SYNOCHA, or the common inflammatory
state of fever, attacks suddenly with chills, and is
succeeded by a quick, frequent, and tense pulse,
great heat, thirst, and pains in the bones, joints,
breast, or sides. These symptoms sometimes occur
in the plague, the jail and yellow fever, and the
small-pox ; but they are the more common charac-
teristics of pleurisy, gout, and rheumatism. They
now and then occur in the influenza, the measles
and the puerperile fever.
* Treatise on Inflammation, chap. I. 8.
4. The

160 ON THE PROXIMATE
4. The BILIOUS state of fever is produced by
marsh miasmata or contagion, acting specifically-
upon the biliary ducts, or it may be induced by the
usual remote causes of the gout. It is known by
a full, quick, and tense pulse, or by a quick, full,
and round pulse, without tension, and by a dis-
charge of green, dark coloured, or black bile from
the stomach and bowels.
Besides these occasional forms of bilious fever, it
sometimes puts on the symptoms of a hectic. I
have seen many instances of it in the autumn. The
patient feels no pain in his head, has a tolerable
appetite, and is able to sit up, and even to do bu-
siness. My late invaluable friend Dr. Clarkson,
died of this state of bilious fever.
5. The TYPHUS state of fever is generally pre-
ceded by all those circumstances which induce direct
debility. It is known by a weak and frequent
pulse, a disposition to sleep, a torpor of the alimen-
tary canal, tremors of the hands, a dry tongue, and,
in some instances, by a diarrhœa. These symp-
toms occur most frequently in the mild grades of
the jail fever, and in the close of all the inflamma-
tory states of fevers in which depleting remedies
have not been used in their first stage. I heard
of it in a few cases in the yellow fever of 1793,
4 and 


CAUSE OF FEVER. l6l
and all writers take notice of cases of the plague,
which run on into a slow fever that continues 30
and 40 days. I have seen it succeed the common
bilious fever, pleurisy, and influenza. It has been
confounded with the malignant state of fever, under
the name of typhus gravior; but it differs widely
from it in being accompanied by a feeble excitement
in the blood-vessels, from a feeble stimulus, and by
the usual signs of direct debility in every other part
of the body.
From the accession of new stimuli, or an increase
in the force of former ones, this typhus state of
fever sometimes assumes, on the 11th, 14th, and
even 20th days, the symptoms of the synocha state
of fever. It will be useful to remember this ob-
servation, not only because it establishes the unity
of fever, but because it will justify the use of a
remedy, seldom prescribed after the disease has
acquired that name which associates it with stimu-
lating medicines.
The common name of this state of fever is, the
nervous fever. This name is improper; for it in-
vades the nervous system by pain, delirium, and
convulsions much less than several other states of
fever. To prevent the absurd, and often fatal asso-
ciation of ideas upon the treatment of this state of
L fever,

l62 ON THE PROXIMATE
fever, I shall hereafter call it, from its duration, the
low chronic state of fever. I have adopted the term
low, from Dr. Butter's account of the remitting
fever of children, in order to distinguish it from
states of fever to be mentioned hereafter, in which
the patient is not confined to his bed. This new
name of the typhus or nervous fever, establishes its
analogy with several other diseases. We have the
acute and the chronic rheumatism; the acute and
chronic pneumony, commonly called the pleurisy
and pulmonary consumption ; the acute and chronic
inflammation of the brain, known unfortunately by
the unrelated names of phrenitis, madness, and in-
ternal dropsy of the brain. Why should we hesi-
tate, in like manner, in admitting acute and chro-
nic fever in all those cases where no local inflamma-
tion attends.
6. The typhoid state of fever is composed of the
synocha and low chronic states of fever. It is the
slow nervous fever of Dr. Butter. The excitement
of the blood-vessels is somewhat greater than in the
low chronic state of fever. Perhaps the muscular
fibres of the blood-vessels, in this state of fever, are
affected by different degrees of stimulus and excite-
ment. Supposing a pulse to consist of eight cords,
I think I have frequently felt more or less of them
tense or relaxed, according as the fever partook
more 
                

CAUSE OF FEVER. 163
more or less of the synocha, or low chronic states
of fever. This state of fever occurs most frequently
in what are called the hectic and puerperal fevers,
and in the scarlatina.
Both the low chronic, and the typhoid states of
fever (the fever generated in jails, ships, and hospi-
tals excepted) are most frequently artificial diseases.
They are created by the negligence of patients, in
not sending for early medical aid, or by the ignorance
of physicians in not using sufficient evacuations.
7. There is a state of fever inclining more to the
synocha than what is called the typhus, or low
chronic state of fever. I have called it the syno-
choid state of fever.
8. There is a state of fever in which the pulse is
small, but tense and quick. The patient, in this
state of fever, is seldom confined to his bed. We
observe it sometimes in the chronic rheumatism, and
in pulmonary consumption. The inflammatory state
of this grade of fever is proved from the inefficacy
of the volatile tincture of guaiacum and other stimu-
lants to remove it, and from its yielding so suddenly
to blood-letting. I have called it the synochula state
of fever.
L2 9. The 

164 ON THE PROXIMATE
9. The HECTIC state of fever differs from all the
other states of fever, by the want of regularity in
its paroxysms, in which chills, fever, and sweats are
included ; and by the brain, nerves, muscles, and
alimentary canal, being but little impaired in their
functions by it. It appears to be an exclusive dif-
ease of the blood-vessels. It occurs in the pulmo-
nary consumption, in some cases of lues, of scro-
phula, and of the gout, and after most of the states
of fever which have been described. The force of
the pulse is various, being occasionally synochoid,
typhoid, and typhus.
10. There is a state of fever in which the mor-
bid action of the blood-vessels is so feeble, as scarcely
to be perceptible. Like the hectic state of fever, it
seldom affects the brain, nerves, muscles, or alimen-
tary canal. It is known in the southern states of
America, by the name of INWARD fevers. The
English physicians formerly described it by the name
of febricula.
11. Intermissions, or the INTTERMITTING and re-
mitting states of fever, are common to all th states
of fever which have been mentioned. But they oc-
cur most distinctly and universally in those which
partake of the bilious diathesis. They have been
ascribed to the reproduction of the stimulus of bile,
to 

CAUSE OF FEVER. 165
to the recurrence of debility, and to the influence
of the heavenly bodies upon the system. None of
these hypotheses has explained the recurrence of
fever, where the bile has not been in fault, where
debility is uniform, and where the paroxysms of
fever do not accord with the revolutions, of any
part of the solar system. I have endeavoured to
account for the recurrence of the paroxysm of fe-
ver, in common with all other periodical diseases,
by means of a natural or adventitious association
of motions. Dr. Percival has glanced at this law
of animal matter; and Dr. Darwin has explained
by it, in the most ingenious manner, many natural
and morbid actions in the human body.
12. The SWEATING state of fever occurs in the
plague, in the yellow fever, in the small-pox, the
pleurisy, the rheumatism, and in the hectic and in-
termitting states of fever. Profuse sweats appeared
every other day in the autumnal fever of 1795 in
Philadelphia, without any other symptom of an in-
intermittent. The English sweating sickness was
nothing but a symptom of the plague. The sweats
in all these cases are the effects of morbid and ex-
cessive action, concentrated in the capillary vessels.
13. The FAINTING state of fever accompanies
the plague, the yellow fever, the small-pox, and
L 3 some

166 ON THE PROXIMATE
some states of pleurisy. It is the effect of great
indirect debility; hence it occurs most frequently
in the beginning of those states of fever.
14. The BURNING state of fever has given rise to
what has been called a species of fever. It is the
causus of authors. Dr. Mosely, who rejects the
epithet of yellow, when applied to the bilious
fever, because it is only one of its accidental
symptoms, very improperly distinguishes the same
fever by another symptom, viz. the burning heat
of the skin, and which is not more universal than
the yellowness which attends it.
15. The COLD and CHILLY state of fever differs
from a common chilly fit, by continuing four or
five days, and to such a degree, that the patient
frequently cannot bear his arms out of the bed.
The coldness is most obstinate in the hands and feet.
A COOLNESS only of the skin attends in some cases,
which is frequently mistaken for an absence of fe-
ver.
Having mentioned those states of fever which
affect the arterial system, without any, or with
but little  topical affection, I proceed next to enu-
merate those states of fever in which there are
local affections combined more or less with general 
fever. 

CAUSE OF FEVER. 167
fever. They depend, i. Upon local debility in
the part affected. 2. Upon increased excitability in
the part, in consequence of this debility. And, 3. 
Upon the morbid excitement induced in the part, 
by the stimulus of distention from the blood, and
by the effusion of serum, lymph, or red globules in
the weakened, and afterwards inflamed part. The
reader will perceive here that I adopt the error loci
of Dr. Boerhaave, as a link in the chain of causes
which produce local inflammation. The states of
fever which belong to this second head are as follow.
16. The INTESTINAL state of fever. I have
been anticipated in giving this epithet to fever, by
Dr. Balfour. * It includes the colera morbus, diar-
rhœa, dysentery, and colic. The remitting bilious
fever appears, in all the above forms, in the summer
months. They all belong to the febris introversa
of Dr. Sydenham. The jail fever appears likewise
frequently in the form of diarrhœa and dysentery.
The dysentery is the offspring of miasmata and con-
tagion, but it is often induced in a weak state of
the bowels, by other exciting causes. The colic
occasionally occurs with states of fever to be men-
tioned hereafter.
* Account of the Intestinal Remitting Fever of Bengal.
L4 17. The 

l68 ON THE PROXIMATE
17. The PULMONARY state of fever includes the
true and bastard pneumony in their acute forms;
also catarrh from cold and contagion, and the chro-
nic form of pneumony in what is called pulmonary
consumption.
18. The ANGINOSE state of fever includes all
those affections of the throat which are known by the 
names, of cynanche, inflammation, tonsillaris, paro-
tidea, maligna, scarlatina, and trachealis. The cy-
nanche trachealis is a febrile disease. The mem-
brane which produces suffocation and death in the
wind-pipe, is the effect of inflammation. It is pro-
bably formed, like other membranes which suc-
ceed inflammation from the coagulable lymph of
the blood.
19. The RHEUMATIC state of fever is confined
chiefly to the labouring part of mankind. The
topical affection is seated most commonly in the
joints and muscles, which from being exercised
more than other parts of the body, become more
debilitated, and are, in consequence thereof, ex-
cited into morbid or inflammatory action.
20. The ARTHRITIC or GOUTY state of fever,
differs from the rheumatic, in affecting, with the
joints and muscles, all the nervous and lymphatic
systems, 

CAUSE OF FEVER. 169
systems, the viscera, and the skin; also in having
a specific remote cause, viz. intemperance. Its
predisposing, exciting, and proximate causes are the
same as the rheumatic and other states of fever.
It bears the same ratio to rheumatism, which the
yellow fever bears to the common bilious fever.
It is a fever of more force than rheumatism.
21. The MANIACAL state of fever. I prove
mania to be a fever, 1. From its causes, which
are the same as those which induce all the other
states of fever. 2. From its symptoms, particu-
larly a full, tense, quick, and sometimes a slow
pulse. 3. From the inflammatory appearances of
the blood which has been drawn to relieve it.
And, 4. From the phenomena exhibited by direc-
tion in the brains of maniacs, being the same as are
exhibited by other inflamed viscera after death.
These are, effusions of water or blood, abscesses,
and schirrus. The hardness in the brains of ma-
niacs, taken notice of by several authors, is no-
thing but a schirrus (sui generis) induced by the
neglect of sufficient evacuations in this state of fever.
The reader will perceive by these observations,
that I reject madness from its supposed primary
seat in the mind or nerves. It is as much an ori-
ginal disease of the blood-vessels, as any other state
of fever. It is to phrenitis, what pulmonary con-
sumption 

170 ON THE PROXIMATE
sumption is to pneumony. The derangement in
the operations of the mind is the effect only of
a chronic inflammation of the brain, existing with-
out an abstraction of muscular excitement.
22. The APOPLECTIC, 23. the PHRENITIC,
24. the PARALYTIC, 25. the LETHARGIC, and 26.
the VERTIGNOUS states of fever, often accom-
pany the malignant state of fever. They are com-
monly the effects of strong stimuli acting suddenly
upon the brain in the beginning of fever; but they
sometimes occur in the close of the common states
of fever, more especially where blood-letting has
not been used in a sufficient quantity.
27. The HYDROCEPHALIC state of fever occurs
chiefly in children. The water which is found in
the brain, is the effect of inflammation. To the
proofs from dissections which I published formerly,*
of the inflammatory nature of this state of fever, I
shall add one more, communicated to me by my for-
mer pupil Dr. Coxe, in a letter from London, dated
July 17th, 1795. "It so happened (says my inge-
nious correspondent) that at the time of my receiv-
ing your letter, Dr. Clark was at the hospital. I
read to him that part of it which relates to your
success in the treatment of hydrocephalus internus.
* Medical Inquiries and Observations, Vol. II.
He 

CAUSE OF FEVER. 171
He was much pleased with it, and mentioned to me
a fact, which strongly corroborates your idea of its
being a primary inflammation of the brain. This
fact was, that upon opening, not long since, the head
of a child who had died of this disease, he found
between three and four ounces of water in the ven-
tricles of the brain ; also an inflammatory crust on
the optic nerves, as thick as he had ever observed it
on the intestines in a state of inflammation. The
child lost its sight before it died. The crust account-
ed, in a satisfactory manner, for its blindness. Per-
haps something similar may be always noticed in the
dissections of such as die of this disease, in whom
the eyes are much affected."
30. The NEPHRITIC state of fever is often in-
duced by calculi, but it frequently occurs in the
gout, small-pox, and malignant states of fever. There
is such an engorgement, or choaking of the vessels
of the kidneys, that the secretion of the urine is
sometimes totally obstructed, so that the bladder
yields no water to the catheter. It is generally ac-
companied with a full or tense pulse, great pain,
sickness, or vomiting, high coloured urine, and a
pain along the thigh and leg, with occasionally a
retraction of one of the testicles. It exists some-
times without any pain. Of this I met with several
instances in the yellow fever of 1793.
31. The 

172 ON THE PROXIMATE 
31. The DROPSY, whether local or general is a
state of fever. There are several states of fever
which are more frequently accompanied by serous
effusions than others. These are the scarlet, the
puerperal, and the rheumatic states of fever. They
all dispose to effusions in the limbs. Intermittents
tend to produce those conjestions in the abdominal
viscera which terminate in effusions in the belly. A
neglected catarrh, and a half cured pneumony, tend
to produce effusions in the thorax, while a chronic
phrenitis relieves itself by an effusion of water in the
brain. Nineteen dropsies, out of twenty appear to
be original arterial diseases and the water, which
has been supposed to be the cause of the dropsy, is as
much the effect of preternatural and morbid action
in the blood-vessels, as pus, gangrene, and schirrus
are of previous inflammation. The common febrile
symptoms which accompany dropsy, render this
highly probable; but it has lately been demon-
strated by dissection, by Mr. Samuel Cooper, the
apothecary of the Pennsylvania hospital, in a man
who died of an ascites. Pus and blood, as well as
water, were found in the cavity of the abdomen.*
* The origin of dropsy, in the neglect of blood-letting in
fevers, has been ascertained by many observations; hence
that disease occurs most frequently where bleeding is seldom
used. Dr. Wilkes mentions a fact which is directly to our
purpose. "After the last epidemical fever (says the Doctor),
It 

CAUSE OF FEVER. 173
It is no objection to this theory of dropsy, that
we sometimes find water in the cavities of the body
after death, without any marks of inflammation on
the contiguous blood-vessels. We often find pus
both in the living and dead body under the same
circumstances, where we are sure it was preceded
by inflammation.
33. The ERUPTIVE state of fever includes the
small-pox, measles, and all the other exanthemata of
Dr. Cullen.
33. The HÆMORRHAGIC state of fever is always
the effect of preternatural excitement in the blood-
vessels. Hæmorrhages have been divided into active
and passive. It would be more proper to divide
them, like other states of general fever, into hæmor-
rhages of strong and feeble morbid action. There
is seldom an issue of blood from a vessel in which
there does not exist preternatural or accumulated
excitement. We observe this hæmorrhagic state of
fever most frequently in malignant fevers, in pul-
monary consumption, in pregnancy, and in that
period of life in which the menses cease to be regular.
which began at Kidderminster in 1728, and soon after spread,
not only over Great Britain, but all Europe, more people
died dropsical in three years, than did perhaps in 20, or 30
years before."
Historical Essay on the dropsy, p. 326.
33. The 

174 ON THE PROXIMATE
34. The AMENORRHAGIC state of fever occurs 
more frequently than is suspected by physicians.
A full and quick pulse, thirst, and preternatural
heat, often accompany a chronic obstruction of the
menses. The inefficacy and even hurtful effects,
of what are called emenagogue medicines, in this
state of the system, without previous depletion, shew
the propriety of introducing it among the different
states of fever.
35. The  hæmorrhoids  are frequently a local
disease, but they are sometimes accompanied with
pain, giddiness, chills and an active pulse. When
this is the case, I have given them the name of the
HÆMORRHOIDAL state of fever.
36. The opthalmia when it occurs with the symp-
toms of general fever, may properly be considered
as an OPTHALMIC state of fever.
We come now in the third and last place to mention
the misplaced states of fever. The term is not a
new one in medicine. We read of misplaced gout.
Morbid excitement, in several  other states of
fever, is equally liable to be translated from the
blood-vessels to other parts of the system. The
periodical pains in the head, eyes, ears, jaws, hips
and back, which occur in the sickly autumnal
months, 

CAUSE OF FEVER. 175
months, and which impart no fulness, force, or fre-
quency to the pulse, are all misplaced fevers. But
there are other morbid affections which are less
suspected of belonging to febrile disorders. These
are,
37. The HEPATIC state of fever. The causes,
symptoms, and remedies of the liver disorder of the
East Indies, as mentioned by Dr. Gravenstine, all
prove that it is nothing but a bilious fever translated
from the blood-vessels, and absorbed, or suffocated
as it were in the liver. This view of the chronic
hepatitis is important, inasmuch as it leads to the
liberal use of all the remedies which cure bilious
fever. Gall stones and contusions, now and then
produce a hepatitis, but under no other circum-
stances do I believe it ever exists, but as a symptom
of general, or latent fever.
38. The CONVULSIVE or spasmodic state of fever.
Convulsions it is well known often usher in fevers,
more especially in children. But the connection
between spasmodic affections, and fever in adults
has been less attended to by physicians. The same
causes which produced general fever and hepatitis
in the East Indies, in some soldiers, produced locked
jaw in others. Several of the symptoms of this disor-
der as described by Dr. Girdlestone, such as coldness
on 

176 ON TH PROXIMATE
on the surface of the body, cold sweats on the hands
and feet, intense thirst, a white tongue, incessant
vomitings, and carbuncles, all belong to the malig-
nant state of fever.* By means of blood-letting,
and the other remedies for the violent state of bilious
fever, I have seen the convulsions in this disorder,
translated from the muscles to the blood-vessels,
where they immediately produced all the common
symptoms of fever.
39. The HYSTERICAL and HYPOCHONDRIACAL
states of fever. The former is known by a rising
in the throat, which is for the most part erroneously
ascribed to worms, by pale urine, and by a disposi-
tion to shed tears, or to laugh upon trifling oc-
casions. The latter discovers itself by false opinions
of the nature and danger of the disease under which
the patient labours. Both these states of the ner-
vous system occur frequently in the gout and in the
malignant state of fever. It is common to say,
in such cases, that patients have a complication of
diseases; but this is not true, for the hysterical and
hypochondrical symptoms are nothing but the effects
of one remote cause, concentrating its force chiefly
upon the nerves, and muscles. It was in this state
of fever that patients sat up, walked about their
* Essay on the Spasmodic Affections in India, p. 53. 54. 55.
I rooms,  
              

CAUSE OF FEVER. 177
rooms, and even went out into the streets a few
hours before they died, in the epidemic of 1793 in
Philadelphia.
40. The CUTANEOUS state of fever. Dr. Sy-
denham calls a dysentery a "a febris introversa."
Eruptions of the skin are often nothing but the
reverse of this introverted fever. They are a fever
translated to the skin ; hence we find them most com-
mon in those countries and seasons in which fevers
are epidemic. The prickly heat, the rash, and the
effere of authors, are all states of misplaced fever.
" Agues, fevers, and even pleurisies (says Mr.
Townsend in his journey through Spain *) are said
often to terminate in scabies, and this frequently
gives place to them, returning however when the
fever ceases. In adults it takes possession of the
hands and arms, with the legs and thighs, covering
them with a filthy crust." Small boils are common
among the children in Philadelphia, at the time
the colera infantum makes its appearance. These
children always escape the summer epipdemic. The
elephantiasis described by Dr. Hillary in his account
of the diseases of Barbadoes, is evidently a transla-
tion of an intermittent to one of the limbs. It is
remarkable that he leprosy and malignant fevers of 
* Vol. H. Dublin edition, p. 262.
M all 

178 ON THE PROXIMATE
all kinds have appeared and declined together in
the same ages and countries. But further, petechiæ
sometimes appear on the skin without fever. Cases
of this kind with, and without hæmorrhages, are
taken notice of by Riverius,* Dr. Duncan, and
many other practical writers. They are cotempo-
rary, or subsequent to fevers of a malignant com-
plexion. They occur likewise in the scurvy. From
some of the predisposing, remote and exciting causes
of this disease, and from its symptoms and remedies,
I have suspected it, like the petechiæ mentioned by
Riverius, to be originally a fever generated by
human miasmata, in a misplaced state. The hæmor-
rhages which sometimes accompany the scurvy, cer-
tainly arise from a morbid state of the blood-vessels.
The heat, and quick pulse of fever, are probably
absent, only because the preternatural excitement
of the whole sanguiferous system is confined to those
extreme or cutaneous vessels which pour forth
blood. In like manner the fever of the small-pox
deserts the blood-vessels, as soon as a new action
begins on the skin. Or perhaps the excitability of
the larger blood-vessels may be so far exhausted by
the long, or forcible impression of the remote and
predisposing causes of the scurvy, as to be incapable
of undergoing the convulsive action of general fever.
* Praxs Medica, lib. xviii. cap. i.
With

CAUSE OF FEVER. 179
With this, I close my inquiry into the proximate
cause of fever. It is imperfect from its brevity, as
well as from other causes. I commit it to my pupils
to be corrected and improved.
"We think our fathers fools, so wise we grow.
"Our wiser sons I hope will think us so."




A
DEFENCE
OF
BLOOD-LETTING
AS A
REMEDY
FOR
CERTAIN DISEASES



A
DEFENCE, &c.
BEFORE I proceed to the  Defence of
Blood-letting as a remedy for certain diseases, par-
ticularly for fevers, it will be necessary to introduce
a syllabus of all the usual remedies for fever, in its
ordinary state. They consist,
I. Of such things as lessen, by the abstraction of
stimulus, the morbid and excessive action of the
blood-vessels.
II. Of such, as by exciting action in the stomach,
bowels, brain, nerves, muscles, and skin, equalize
the excitement of the whole system, and thereby in-
directly destroy a weak but morbid action in the
blood-vessels, by imparting to them a more vigo-
rous and healthy action.
I. The remedies which belong to the FIRST ge-
neral head are, 
M4 I. Eva-

184 A DEFENCE OF BLOOD-LETTING. 
I. Evacuants. These are,
1. Blood-letting.
2. Vomits.
3. Purges.
4. Sweating medicines.
5. A salivation.
6. Blisters.
II. Remedies which abstract the stimulus
- of heat by 1. cold air,
2. cold water, and,
3. ice.
- of food by 4. abstinence.
- of sound and light by 5. silence and darkness.
- of invigorating passions by 6. moderate fear.
- of motion by 7. rest.
- of acrimony by 8. diluting drinks, and,
9. cleanliness.
III. Remedies which divert local congestion, in-
flammation, and serous effusion from vital parts, to
such as are less essential to life. These are all such
as are mentioned under the head of evacuants, par-
ticularly a salivation and blisters.
IV. Medicines said to possess sedative powers,
such as
1. Nitre, and other neutral salts.
2. Certain 

A DEFENCE OF BLOOD-LETTING. 185
2. Certain preparations of antimony.
3. Sugar of lead.
4. Fox-glove.
5. Applications of sweet oil to the external
surface of the body.
II. The remedies which belong to the SECOND
general head, are stimulants. These divide them-
felves naturally into such as are internal, and such
as are external.
I. The internal stimulants may further be divided
into medicines and aliments. The medicines are
1. All fermented and distilled liquors.
2. Volatile alkali.
3. Empyreumatic and aromatic oils.
4. Opium.
5. Æther.
6. Bark, and bitters of all kinds.
7. Mercury.
8. Pure air.
9. The invigoration of the passions and understanding.
The aliments include such vegetable and animal
matters, as are commonly used in diet, together
with fago, saloop, tapioca, and the like.
II. The 

186 A DEFENCE OF BLOOD-LETTING.
II. The external stimulants are
I. Several of the internal stimulants so pre-
pared, as to be applied to different parts of the
body, as the nose, the temples, the external re-
gions of the stomach and bowels, the limbs, and
the lower intestines, by way of glyster.
2. The cold and warm baths.
3. Blisters.
4. Cataplasms of onions, garlic, and mustard,
to the feet.
5. Caustics.
6. Boiling water.
I return now, agreeably to the title of this essay,
to consider BLOOD-LETTING as a remedy for fevers,
and certain other diseases. In treating of the
comparative advantages of blood-letting, I shall
be under the necessity of making a few remarks
upon each of the remedies set down in the syllabus,
under the head of evacuants.
I shall begin this subject by remarking, that
blood-letting is indicated in the inflammatory state
of fever,
1. By the hidden suppression or diminution of
the natural discharges by the pores, bowels, and kid-
neys, whereby a plethora is induced in the system.
2. By 

A DEFENCE OF BLOOD-LETTING. 187
2. By the robust habits of the persons who are
most subject to the inflammatory state of fever.
3. By the proximate cause of fever. I have at-
tempted to prove that the inflammatory state of
fever depends upon morbid and excessive action in
the blood-vessels. It is connected, of course, with
preternatural sensibility in their muscular fibres.
The blood is one of the most powerful stimuli which
act upon them. By abstracting a part of it, we
lessen the principal cause of the fever. The effect
of blood-letting is as immediate and natural in re-
moving fever, as the abstraction of a particle of sand
is to cure an inflammation of the eye, when it arises
from that cause.
4. By the symptoms of the first stage of this state
of fever, such as a sleepiness and an oppressed pulse,
or by delirium, with a throbbing pulse and great
pains, in every part of the body.
5. By the rupture of the blood-vessels, which
takes place from the quantity or impetus of the
blood in inflammatory fever. Let no one call bleed-
ing a cruel or unnatural remedy. It is one of the
specifics of nature; but in the use of it she seldom
affords much relief. She frequently pours the stimu-
lating and oppressing mass of blood into the lungs
and 


188 A DEFENCE OF BLOOD-LETTING.
and brain; and when she finds an outlet for it
through the nose, it is discharged either in such a
deficient or excessive quantity, as to be useless or
hurtful. By artificial blood-letting, we can choose
the time and place of drawing blood, and we may
regulate its quantity by the degrees of action in the
blood-vessels. The disposition of nature to cure
the inflammatory state of fever by depletion, is fur-
ther manifested by her substituting, in the room of
blood-letting, large, but less safe and less beneficial,
evacuations from the stomach and bowels.
6. By the relief which is obtained in fevers of
violent action by remedies of less efficacy (to be
mentioned hereafter) which act indirectly in re-
ducing the force of the sanguiferous system.
7. By the immense advantages which have at-
tended the use of blood-letting in the inflammatory
state of fever, when used at a proper time, and in a
quantity suited to the force of the disease. I shall
briefly enumerate these advantages.
1. It frequently strangles a fever when used in
its forming state, and thereby saves much pain, time,
and expense to a patient.
2. It imparts strength to the body, by removing
the pressure of indirect debility. It moreover ob-
viates 

A DEFENCE OF BLOOD-LETTING. 189
viates a disposition to faint, which arises from this
state of the system.
3. It reduces the uncommon frequency of the
pulse. The loss of ten ounces of blood reduced
Miss Sally Eyre's pulse from 176 strokes to 140
in a few minutes, in the fever of the year 1794.
4. It renders the pulse more frequent when it
is preternaturally slow.
5. It checks the nausea and vomiting which at-
tend the malignant state of fever. Of this I saw
many instances in the year 1794. Dr. Poissonnier
Desperrieres confirms this Jiemark in his Account of
the Fevers of St. Domingo ; and adds further, that
it prevents, when sufficiently copious, the trouble-
some vomiting which often, occurs on the fifth day
of the yellow fever. *
6. It renders the bowels, when costive, more
easily moved by purging physic.
7. It renders the action of mercury more speedy
and more certain in exciting a salivation.
* Traitè des fievres de L'isle de St. Domingue. Vol. II. 
p. 76.
8. It

190 A DEFENCE OF BLOOD-LETTlNG.
8. It disposes the body to sweat spontaneously,
or renders diluting and diaphoretic medicines more
effectual for that purpose.
9. It suddenly removes a dryness, and gradually
a blackness, from the tongue. Of the former ef-
fect of bleeding, I saw two instances, and of the lat-
ter, one, during the autumn of 1794.
10. It removes or lessens pain in every part of
the body, and more especially in the head.
11. It removes or lessens the burning heat of the
skin, and the burning heat in the stomach, so com-
mon and so distressing in the yellow fever.
12. It removes a constant chilliness which some-
times continues for several  days, and which will
neither yield to cordial drinks, nor warm bed-cloaths.
13. It checks such sweats as are profuse with-
out affording relief, and renders such as are partial
and moderate, universal and salutary.
14. It sometimes checks a diarrhoea and tenesmus,
after astringent medicines have been given to no
purpose. This has often been observed in the
measles.
15. It 

A DEFENCE OF BLOOD-LETTING. 191
15. It suddenly cures the intolerance of light
which accompanies many of the inflammatory states
of fever.
16. It removes coma. Mr. Henry Clymer was
suddenly relieved of this alarming symptom in the
fever of 1794, by the loss of twelve ounces of
blood.
17. It induces sleep. This effect of bleeding is
so uniform, that it obtained, in the year 1794, the
name of an anodyne in several families. Sleep
sometimes stole upon the patient while the blood
was slowing.
18. It prevents effusions of serum  and blood.
Hæmorrhages seldom occur where bleeding has been
sufficiently copious.
19. It belongs to this remedy to prevent the
chronic diseases of cough, consumption, jaundice,
abscess in the liver, and all the different states of
dropsy which so often follow autumnal fevers.
My amiable friend Mrs Lenox, furnished an ex-
ception to this remark in the year 1794. After
having been cured of the yellow fever by seven
bleedings, she was affected, in consequence of taking
a ride, 

192 A DEFENCE OF BLOOD-LETTING.
a ride, with slight return of fever, accompanied
by an acute pain in the head, which I was afraid
would end in a dropsy of the brain. As her pulse
was tense and quick, I advised repeated bleedings to
remove it. This prescription, for reasons which it
is unnecessary to relate, was not followed at this
time, or in the manner, in which it was recom-
mended. The pain, in the mean time, became
more alarming. In this situation, two physicians
were proposed by her friends to consult with me.
I objected to them both, because I knew their prin-
ciples and modes of practice to be contrary to mine,
and that they were proposed only with a view of
wresting the lancet from my hand. From this desire
of avoiding a controversy with my brethren, where
conviction was impossible on either side, as well as
to obviate all cause of complaint by my patient's
friends, I offered to take my leave of her, and to
resign her wholly to the care of the two gentlemen
who were proposed to attend her with me. To this
she objected in a decided manner. But that I might
not be suspected of an undue reliance upon my own
judgment, I proposed to call upon Dr. Griffitts or
Dr. Physick to assist me in my attendance upon her.
Both these physicians had renounced the prejudices
of the schools in which they had been educated,
and had conformed their principles and practice to
the present improving state of medical science. My
I patient 

A DEFENCE OF BLOOD-LETTING. 193
patient preferred Dr. Griffitts, who in his first visit to
her, as soon as he felt her pulse, proposed more bleed-
ing. The operation was performed by the Doctor
himself, and repeated daily for five days afterwards.
From an apprehension that the disorder was so fixed
as to require some aid to blood-letting, we gave her
calomel in such large doses as to excite a salivation.
By the use of these remedies she recovered slowly,
but so perfectly as to enjoy her usual health.
20. Bleeding prevents the termination of the in-
flammatory, in the gangrenous and chronic states of
fever. This effect of blood-letting will enable us to
understand some things in the writings of Dr. Mor-
ton, and Dr. Sydenham which at first sight appear to
be unintelligible. Dr. Morton describes what he
calls a putrid fever, which was epidemic, and fatal
in the year 1678. Dr. Sydenham, who practised
in London at the same time, takes no notice of this
fever. The reason of his silence is obvious. By
copious bleeding he prevented the fever of that year
from running on to the gangrenous state, while Dr.
Morton by neglecting to bleed, created the supposed
putrid fevers which he has described.
It has been common to charge the friends of
blood-letting with temerity in their practice. From
this view which has been given of it, it appears that
N it 

194 A DEFENCE OF BLOOD-LETTING.
it would be more proper to ascribe timidity to them,
for they bleed to prevent the offensive and distress-
ing consequences of neglecting it, which have been
mentioned.
21. It cures without permitting a fever to put
on those alarming symptoms, which excite constant
apprehensions of danger and death in the minds of
patients and their friends. It is because these
alarming symptoms are prevented, by bleeding,
that patients are sometimes unwilling to believe
they have been cured by it, of a malignant fever.
Thus the Syrian Leper of old, viewed the water of
Jordan as too simple, and too common to cure a for-
midable disease, without recollecting that the reme-
dies for the greatest evils of life are all simple, and
within the power of the greatest part of mankind. 
22. It prepares the way for the successful use of
the bark and other tonic remedies, by destroying,
or so far weakning, a morbid action in the blood-
vessels, that a medicine of a moderate stimulus after-
wards exceeds it in force, and thereby restores
equable and healthy action to the system.
23. Bleeding prevents relapses. It moreover
prevents that predisposition to the intermitting, and
pleuritic states of fever which so frequently attack
persons 
 


A DEFENCE OF BLOOD-LETTING. 195
persons in the spring, who have had the bilious re-
mitting fever in the preceding autumn.
But great and numerous as the advantages of
blood-letting are in fevers, there have been many
objections to it. I shall briefly enumerate, and en-
deavour to refute the errors upon this subject.
Blood-letting has been forbidden by physicians,
by the following circumstances, and states of the
system.
1. By warm weather. Galen bled in a plague,
and Aræteus in a bilious fever, in a warm cli-
mate. Dr. Sydenham and Dr. Hillary, inform us
that the most inflammatory fevers occur in, and suc-
ceed hot weather. Dr. Cleghorn prescribed it
copiously in the warm months, in Minorca. Dr.
Mosely cured the yellow fever by this remedy in
Jamaica. Dr. Broadbelt and Dr. Weston in the
same Island have lately adopted his successful prac-
tice. Dr. Desportes speaks in the highest terms
of it in all the inflammatory diseases of St. Domingo.
He complains of the neglect of it in the rheumatism,
in consequence of which he says, the disease pro-
duces abscesses in the lungs.* I have never in any
* P. 35-
N 2 year 

196 A DEFENCE OF BLOOD-LETTING.
year of my practice, been restrained by the heat of
summer in the use of the lancet, where the pulse has
indicated it to be necessary, and have always found
the same advantages from it, as when I have pre-
scribed it in the winter or spring months.
The relaxation and debility of the body in warm
weather, and in hot climates, has not been understood
until lately, to be of the indirect kind. Of course,
instead of forbidding, it requires depletion to remove
it. It is lessened at all times by abstemious living,
and by gentle doses of physic, but when the stimulus
of a fever is added to that of the heat of the fun,
blood-letting is often more necessary to remove it,
than it is in cool weather, or in temperate climates.
2. Being born, and having lived in a warm cli-
mate. This is so far from being an objection to
blood-letting in an inflammatory disease, that it ren-
ders it more necessary. I think I have lost several
West India patients from the influence of this
error.
3. Great apparent weakness. This, in acute and
violent fevers is always of the indirect kind. It is
induced by pressure upon the sources of strength in
the muscles. It resembles in so many particulars
that weakness, which is the effect of the abstraction
of 

A DEFENCE OF BLOOD-LETTING. 197
of stimulus, that it is no wonder they have been
confounded by physicians. This sameness of symp-
toms from opposite states of the system is taken
notice of by Hippocrates. He describes convulsions,
and particularly a hiccup as occurring equally from
repletion and inanition which answer to the modern
terms of indirect, and direct debility. The natural
remedy for the former is depletion, and no mode
of depleting is so effectual or safe as blood-letting.
But, the great objection to this remedy is when the
inflammatory state of fever, affects persons of delicate
constitutions, and such as have long been subject to
direct debility of the chronic kind. In this state of
the system, there is the same morbid and preter-
natural action in the blood-vessels, that there is in
persons of robust habits, and the same remedy is
necessary to subdue it in both cases. It is sometimes
indicated in a larger quantity in weakly, than in
robust people, by the  plethora which is more easily
induced in their relaxed, and yielding blood-vessels,
and by the greater facility with which ruptures and
effusions take place in their viscera. Thus it is more
necessary to throw overboard, a large part of the
cargo of an old and leaky vessel in a storm, than of
a new and strong one. I know that vomits, purges,
sweats, and other evacuating remedies, are preferred
to bleeding in weakly constitutions, but I hope to
shew hereafter, that bleeding is not only more ef-
N 3 fectual,

198 A DEFENCE OF BLOOD-LETTING.
fectual, but more safe in such habits, than any other
depleting remedy.
4. Infancy and childhood. This is so far from
being an objection to bleeding, that the excitable
state of the blood-vessels in those periods of life,
renders it peculiarly necessary in their inflammatory
diseases. Dr. Sydenham bled children in the hoop-
ing cough, and in dentition. I have followed his
practice, and bled as freely in the inflammatory state
of fever in infancy as in middle life. I bled my
eldest daughter when she was but six weeks old,
for convulsions brought on by an excessive dose of
laudanum given to her by her nurse ; and I bled my
youngest son twice before he was two months old,
for an inflammatory fever which fell upon his lungs
and bowels. In both cases, life appeared to be saved
by this remedy.
5. Old age. The increase of appetite in old
people, their inability to use sufficient exercise,
whereby their blood-vessels become relaxed, ple-
thoric and excitable, and above all, the translation
of the strength of the muscles to the arteries, and of
plethora to the veins, all indicate bleeding to be
more necessary (in equal circumstances) in old than
in middle aged people. I am not the author of this
opinion. Botallus left a testimony in favor of it
nearly 

A DEFENCE OF BLOOD-LETTING. 199
nearly 200 years ago,* and it has since been con-
firmed by the experience of Hoffman, and many other
physicians. An ignorance of, or inattention to this
change in the state of the blood-vessels, in persons
in the decline of life, and the neglect of the only
remedy indicated by it, is probably the reason why
diseases often prove fatal to them, which in early,
or middle life cured themselves, or yielded to a single
dose of physic, or a few ounces of bark.
6. The time of menstruation. The system during
this period is plethoric and excitable, and of course
disposed to a violent degree of inflammatory fever,
from all the causes which excite it. Bleeding therefore
is more indicated in an inflammatory state of fever,
at this time, than at any other. Formerly the na-
tural discharge from the uterus was trusted to, to
remove a fever contracted during the time of men-
struation. But what relief can the discharge of
four or five ounces of blood from the uterus afford,
in a fever which requires the loss of 50, or perhaps
of an 100 ounces to cure it ?
7. PREGNANCY. The distention induced upon
the uterus directly, and indirectly upon the whole
* Magis esse adjuvandos senes, missione sanguinis dum
morbus postulat, aut corpus eorum habitus malus est, quam
ubi hæc (quod absonum videbitur) juvenibus contingunt,
De Cur. per Sang, missionem, cap. 11. § 11.
N 4 system

200 A DEFENCE OF BLOOD-LETTING.
system by the fœtus, renders bleeding in the inflam-
matory state of fever, more necessary than at other
times. I have elsewhere mentioned the advantages
of bleeding pregnant women, in the yellow fever.
I did not learn the advantages of the practice in that
disease. I bled Mrs. Philler 11 times in seven days,
in a pleurisy during her pregnancy, in the month of
March 1783. Mrs. Fiss, was bled 13 times in
the spring of 1783; and Mrs. Kirby 16 times in the
same condition by my orders in the winter of 1786,
in a similar disease. All these women recovered,
and the children they carried during their illness,
are at this time alive, and in good health.
8. Fainting after bleeding. This symptom is
accidental in many people. No inference can be
drawn from it against blood-letting. It often occurs
after the first and second bleedings in a fever, but
in no subsequent bleeding, though it be repeated
a dozen times. Of this I saw several instances in
the yellow fever of 1794. The pulse during the
fainting, is often tense and full.
9. Coldness of the extremities, and of the whole
body. This cold state of fever when it occurs early,
yields more readily to bleeding, than to the most
cordial medicines.
10. Sweats 

A DEFENCE OF BLOOD-LETTING. 201
10. Sweats are supposed to forbid blood-letting.
I have seen two instances of death, from leaving a
paroxysm of malignant fever to terminate itself by
sweating. Dr. Sydenham has taught a contrary
practice in the following case. "While this con-
stitution (says the Doctor) prevailed, I was called
to Dr. Morice, who then practised in London. He
had this fever, attended with profuse sweats and nu-
merous petechiæ. By the consent of some other
physicians, our joint friends, he was blooded, and
rose from his bed, his body being first wiped dry.
He found immediate relief from the use of a cooling
diet and medicines, the dangerous symptoms soon
going off; and by continuing this method he reco-
vered in a few days."* In the same fever, the
Doctor adds further, "For though one might ex-
pect great advantages in pursuing an indication
taken from what generally proves serviceable (viz.
sweating), yet I have found by constant experience,
that the patient not only finds no relief, but con-
trarywise, is more heated thereby; so that fre-
quently a delirium, petechiæ, and other very dan-
gerous symptoms immediately succeed such sweats." †
Morgagni describes a malignant fever which pre-
vailed in Italy, in which the patients died in pro-
fuse sweats, while their physicians were looking for
* Wallis's edition, Vol. I. p. 210. † Vol. I. p. 208.
a crisis 

202 A DEFENCE OF BLOOD-LETTING.
a crisis from them. Bleeding would probably have
checked these sweats and cured the fever.
II. Dissolved blood, and an absence of an inflam-
matory crust on its crassamentum. I shall hereafter
place dissolved blood at the highest point of a scale,
which is intended to mark the different degrees of
inflammatory diathesis in the system. I have men-
tioned in the inquiry into the proximate cause of
fever, that it is the effect of a tendency to a palsy,
induced by the violent force of impression upon the
blood-vessels. This appearance of the blood in cer-
tain states of fever, instead of forbidding bleeding,
is the most vehement call of the system for it. Nor
is the absence of a crust on the crassamentum of the
blood, a proof of the absence of inflammatory dia-
thesis, or a signal to lay aside the lancet. On the
contrary, I shall shew hereafter, that there are seve-
ral appearances of the blood which indicate more
morbid action in the blood-vessels than a sizy or in-
flammatory crust.
12. An undue proportion of serum to crassamen-
tum in the blood. This predominance of water in
the blood has often checked sufficient blood-letting.
But it should be constantly disregarded while it is
attended with those states of pulse (to be mentioned
hereafter) which require bleeding.
13. The 

A DEFENCE OF BLOOD-LETTING. 203
13. The presence of petechiæ on the skin. These,
I have elsewhere said, are the effects of the gangre-
nous state of fever. Dr. Sydenham and Dr. de
Haen have taught the safety and advantage of
bleeding, when these spots are accompanied by
an active pulse. A boy of Mr. John Carrol owes
his recovery from the small-pox to the loss of
fifty ounces of blood, by five bleedings, at a time
when nearly every pock on his arms and legs had
a purple appearance. Lewis XIV. was bled five
times in the small-pox, when he was only thirteen
years of age, and thereby probably saved from the
grave, to the great honour and emolument of the
single physician who urged it against the advice of
all the other physicians of the court. Dr. Cleghorn
mentions a single case of the success of bleeding in
the petechial small-pox. His want of equal success
afterwards, in similar cases, was probably occasioned
by his bleeding too sparingly, that is, but three or
four times.
Abscesses and sore breasts, which accompany or
succeed fever, are no objections to blood-letting,
provided the pulse indicates the continuance of inflam-
matory diathesis. They depend frequently upon the
same state of the system, as livid effusions on the skin.
14. The long duration of fever. Inflammatory 
diathesis is often protracted for many weeks, in the
chronic 


204 A DEFENCE OF BLOOD-LETTTNG.
chronic state of fever. It moreover frequently re-
vives after having disappeared, from an accidental
stimulus affecting some part of the body, particularly
the lungs and brain. I bled a young man of James
Cameron, in the autumn of 1794, four times be-
tween the 20th and 30th days of a chronic fever,
in consequence of a pain in the side, accompanied
by a tense pulse, which suddenly came on after the
20th day of his disease. His blood was sizy. His
pain and tense pulse were subdued by the bleeding,
and he recovered. I wish this case to be attended
to by young practitioners. The pulmonary con-
sumption is often the effect of a chronic fever, ter-
minating with fresh inflammatory symptoms, by effu-
sions in the lungs. It may easily be prevented, by
forgetting the number of the days of our patient's
fever, and treating the pulmonary affection as if it
were a recent complaint.
15. Tremors and slight convulsions in the limbs.
Bark, wine, laudanum, and musk are generally pre-
scribed to remove these symptoms; but to be effec-
tual, they should, in most cases, be preceded by the
loss of a few ounces of blood.
16. Bleeding is forbidden after the 5th or 7th
day in a pleurisy. This prohibition was introduced
into medicine at a time when a fear was enter-
tained 
        

A DEFENCE OF BLOOD-LETTING. 205
tained of arresting the progress of nature in pre-
paring and expelling morbific matter from the sys-
tem. From repeated experience I can assert, that
bleeding is safe in every stage of pleurisy in which
there is pain and a tense and oppressed pulse; and
that it has, when used for the first time after the
5th and 7th days, saved many lives.
17. The loss of a sufficient quantity of blood is
often prevented by patients being apparently worse,
after the first or second bleeding. This change for
the worse shews itself in some one or more of the
following symptoms, viz. increase of heat, chills,
delirium, hæmorrhages, convulsions, nausea, vomit-
ing, faintness, coma, great weakness, pain, a tense
after a soft pulse, and a reduction of it in force
and frequency. They are all occasioned by the sys-
tem rising suddenly from a state of extreme de-
pression, in consequence of the abstraction of the
pressure of the blood to a state of vigour and ac-
tivity, so great in some instances, as to re-produce
a depression below what existed in the system be-
fore a vein was opened; or it is occasioned by a 
translation of morbid action from one part of the 
body to another.
The chills which follow bleeding are the effects
of a change in the fever, from an uncommon to a
common 
 

206 A DEFENCE OF BLOOD-LETTING.
common state of malignity. They occur chiefly in
those violent cases of fever which come on without
a chilly fit.
The hæmorrhages produced by bleeding, are
chiefly from the nose, hæmorrhoidal vessels, or ute-
rus, and of course are, for the most part, safe.
Uncommon weakness succeeding blood-letting, is
the effect of sudden indirect debility induced upon
the whole system, by the cause before mentioned,
or of a sudden translation of the excitement of the
muscles into the blood-vessels, or some other part of
the body. These symptoms, together with all the
others which have been mentioned, are so far from
forbidding, that they all most forcibly indicate a re-
petition of blood-letting.
I shall briefly illustrate, by the recital of three
cases, the good effects of bleeding, in removing pain,
and the preternatural flowness, and weakness of the
pulse, when produced by the use of that remedy.
In the month of June of 1795, I visited Dr. Say in
a malignant fever, attended with pleuritic symptoms,
in consultation with Dr. Physick. An acute pain in
his head followed six successive bleedings. After a
seventh bleeding he had no pain. His fever soon
afterwards

A DEFENCE OF BLOOD-LETTING. 207
afterwards left him. In thus persevering in the
use of a remedy which, for several days, appeared to
do harm, we were guided wholly by the state of his
pulse, which uniformly indicated, by its force, the
necessity of more bleeding.
In the autumn of 1794,1 was sent for to visit Sa-
muel Bradford, a young man of about 20 years of
age, son of Mr. Thomas Bradford, who was ill with
the reigning malignant epidemic. His pulse was at
80. I drew about 12 ounces of blood from him. Im-
mediately after his arm was tied up, his pulse fell to
60 strokes in a minute. I bled him a second time, but
more plentifully than before, and thereby, in a few
minutes, brought his pulse back again to 80 strokes
in a minute. A third bleeding the next day, aided
by the usual purging physic, cured him in a few days.
In the month of March 1795, Dr. Physick re-
quested me to visit, with him, Mrs. Fries, the wife of
Mr. John Fries, in a malignant fever. He had bled
her four times. After the fourth bleeding, her pulse
suddenly fell, so as scarce to be perceptible. I found
her hands and feet cold, and her countenance
ghastly, as a person's in the last moments of life. In
this alarming situation, I suggested nothing to Dr.
Physick but to follow his judgment, for I knew that
he was master of that law of the animal economy
which 

208 A DEFENCE OF BLOOD-LETTING.
which resolved all her symptoms into an oppressed
state of the system. The Doctor decided in a mo-
ment in favour of more bleeding. During the flow-
ing of the blood, the pulse rose. At the end of
three, ten, and seventeen hours it fell, and rose
again by three successive bleedings, in all of which she
lost about thirty ounces of sizy blood. So great was
the vigour acquired by the pulse, a few days after
the paroxysms of depression, which have been de-
scribed, were relieved, that it required seven more
bleedings to subdue it. I wish the history of these
two cases to be carefully attended to by the reader.
I have been thus minute in the detail of them, chiefly
because I heard of several practitioners who, I am
persuaded, have lost patients by attempting to raise
a pulse that had been depressed by bleeding, in a
malignant fever, by means of cordial medicines, in-
stead of the repeated use of the lancet. The prac-
tice is strictly rational; for in proportion as the
blood-vessels are weakened by pressure, the quantity
of blood to be moved should be proportioned to the
diminution of their strength.
It is remarkable that this depressed state of the
pulse, whether induced by a paroxysm of fever, or
by blood-letting, is sometimes attended with a strong
pulsation of the arteries in the bowels and head.
4 I have 
 

A DEFENCE OF BLOOD-LETTING. 209
I have mentioned among the apparent bad effects
of bleeding, that it sometimes changes a soft into a
tense pulse. Of this I saw a remarkable instance
in Captain John Barry in the autumn of 1795.
After the loss of 130 ounces of blood in a malig-
nant yellow fever, his pulse became so soft as to in-
dicate no more bleeding. In this situation he re-
mained for three days, but without mending as
rapidly as I expected from the state of his pulse.
On the 4th day he had an hæmorrhage from his
bowels, from which he lost above a pint of blood.
His pulse now suddenly became tense, and continued
so for two or three days. I ascribed this change in
his pulse to the vessels of the bowels, which had
been oppressed by congestion, being so much re-
lieved by the hæmorrhage, as to resume an in-
flammatory action. It is thus we see the blood-ves-
sels, in a common phlegmon, travel back again from
a tendency to mortification, to the red colour and
pain of common inflammation.
From a review of the commotions excited in the
system by bleeding, a reason may be given why the
physicians who do not bleed in the depressed state
of the pulse, have so few patients in what they call
malignant fevers, compared with those who use a
contrary practice. The disease, in such cases, being
locked up, is not permitted to unfold its true cha-
o racter;

210 A DEFENCE OF BLOOD-LETTING.
racter ; and hence patients are said to die of apo-
plexy, lethargy, colera, dysentery, or nervous fe-
ver, who, under a different treatment, would have
exhibited all the marks of an ordinary malignant
fever.
In obviating the objections to blood-letting from
its apparent evils, I have said nothing of the appa-
rent bad effects of other remedies. A nausea is
often rendered worse by an emetic, and pains in the
bowels are increased by a purge. But these reme-
dies notwithstanding maintain, and justly too, a high
character among physicians.
18. Bleeding has been accused of bringing on a
nervous, or the chronic state of fever. The use of
this remedy, in a degree so moderate as to obviate
the putrid or gangrenous state of fever only, may
induce the chronic state of fever; for it is the
effect, in this case, of the remains of inflammatory
diathesis in the blood-vessels; but when blood is
drawn proportioned to the morbid action in the sys-
tem, it is impossible for a chronic fever to be pro-
duced by it. Even the excessive use of blood-let-
ting, however injurious it may be in other respects,
cannot produce a chronic fever, for it destroys mor-
bid action altogether in the blood-vessels.
19. Bleed- 

A DEFENCE OF BLOOD-LETTING. 211
19. Bleeding has been charged with being a
weakening remedy. I grant that it is so, and in
this its merit chiefly consists. The morbid action of
the blood-vessels must be subdued in part, in an in-
flammatory fever, before tonic remedies can be
given with safety or advantage. Now this is usually
attempted by depleting medicines, to be mentioned
hereafter, or it is left to time and nature, all of
which are frequently either deficient or excessive in
their operations ; whereas bleeding, by suddenly re-
ducing the morbid action of the blood-vessels to a
wished-for-point  of debility, saves a great and un-
necessary waste of excitability, and thus prepares
the body for the exhibition of such cordial remedies
as are proper to remove the debility which predis-
posed to the fever.
20. It has been said that bleeding renders the
habitual use of it necessary to health and life. This
objection to blood-letting is founded upon an igno-
rance of the difference between the healthy and mor-
bid action of the blood-vessels. Where blood is
drawn in health, such a relaxation is induced in the
blood-vessels, as to favour the formation of ple-
thora, which may require habitual bleeding to re-
move it; but where blood is drawn only in the in-
flammatory state of fever, the blood-vessels are re-
duced from a morbid degree of strength to that
O 2 which 

212 A DEFENCE OF BLOOD-LETTING.
which is natural; in which state no predisposition
to plethora is created, and no foundation laid for pe-
riodical blood-letting.
21. It has keen said that bleeding, more espe-
cially where it is copious, predisposes to effusions of
serum in the lungs, chest, bowels, limbs, and brain. In
replying to this objection to bleeding, in my public
lectures, I have addressed by pupils in the following
language : "Ask the poor patients who come pant-
ing to the door of our hospital, with swelled legs and
hard bellies, every fall, whether they have been too
copiously bled, and they will all tell you, that no
lancet has come near their arms. Ask the parents
who still mourn the loss of children who have died
in our city of the internal dropsy of the brain, whe-
ther they were destroyed by excessive blood-letting ?
If the remembrance of the acute sufferings which
accompanied their sickness and death will permit
these parents to speak, they will tell you, that every
medicine, except bleeding, had been tried to no
purpose in their children's disorders. Go to those
families in which I have practised for many years,
and inquire, whether there is a living or a dead
instance of dropsy having followed, in any one of
them, the use of my lancet ? Let the undertakers
and grave-diggers bear witness against me, if I have
ever, in the course of my practice, conveyed the
body, 
         

A DEFENCE OF BLOOD-LETTING. 213
body of a single dropsical patient into their hands,
by excessive blood-letting ?" No. Dropsies, like
abscesses and gangrenous eruptions upon the skin,
arise, in most cases, from the want of sufficient
bleeding in inflammatory diseases. Debility, when
of a direct kind, whether induced by art or nature,
seldom disposes to effusion. Who ever heard of
dropsy succeeding famine ? And how rarely do we
see it accompany the extreme direct debility of old
age?
"If ever bleeding kills," says Botallus, either
directly or indirectly, through the instrumentality of
other diseases, "it is not from its excess, but be-
cause it is not drawn in a sufficient quantity, or at
a proper time."* And again, says this excellent
writer, "One hundred thousand men perish from
the want of blood-letting, or from its being used
out of time, to one who perishes from too much
bleeding, prescribed by a physician." †
It is remarkable, that the dread of producing a
dropfy by bleeding, is confined chiefly to its use in
malignant fevers ; for the men who urge this objec-
tion to it, do not hesitate to draw four or five quarts
of blood in the cure of pleurisy, and of a strangu-
* Cap. viii. § 4. † Cap. xxxvi. § 4.
0 3 lated 

214 A DEFENCE OF BLOOD-LETTING.
lated hernia. The habitual association of the lancet
with the former of those disorders, has often caused
me to rejoice when I have heard a patient complain
of a pain in his side in a malignant fever. It insured
to me his consent to the frequent use of the lancet,
and it protected me, when it was used unsuccess-
fully, from the clamours of the public, for few peo-
ple censure copious bleeding in a pleurisy.
22. Evacuating remedies of another kind have
been said to be more safe, and equally effectual, in
reducing the inflammatory state of fever. I shall
recapitulate each of those evacuating remedies, and
then draw a comparative view of their effects with
blood-letting. They are,
I. Vomits.
II. Purges.
III. Sweats.
IV. Salivation. And,
V. Blisters.
I. Vomits have often been effectual in curing
fevers of a mild character. They discharge offen-
sive 
 

A DEFENCE OF BLOOD-LETTING. 215
five and stimulating matters from the stomach; they
lessen the fulness of the blood-vessels, by deter-
mining the serum of the blood through the pores ;
and they equalize the excitement of the system, by
inviting its excessive degrees from the blood-vessels
to the stomach and muscles. But they are,
1. Uncertain in their operation, from the torpor
induced by the fever upon the stomach.
2. They are unsafe in many conditions of the
system, as in pregnancy and a disposition to apoplexy
and ruptures. Life has sometimes been destroyed
by their inducing cramp, hemorrhage, and inflam-
mation in the stomach.
3. They are not subject to the controul of a phy-
sician, often operating more or less than was intended
by him, or indicated by the disease.
4. They are often ineffectual in mild, and always
so in fevers of great inflammatory action.
II. Purges are useful in discharging acrid fæces
and bile from the bowels in fevers. They act more-
over by creating an artificial weak part, and thus
invite morbid excitement from the blood-vessels to
the bowels. They likewise lessen the quantity of
O 4 blood, 

216 A DEFENCE OF BLOOD-LETTING.
blood by preventing fresh accessions of chyle, being
added to it; but like vomits they are,
1. Uncertain in their operation; and from the
fame cause. Many ounces of salts and castor oil, and
whole drachms of calomel and jalap, have often been
given, without effect, to remove the coftiveness which
is connected with the malignant state of fever.
2. They are not subject to the direction of a
physician, with respect to the time of their opera-
tion, or the quantity or quality of matter they are
intended to discharge from the bowels.
3. They are unsafe in the advanced stage of
fevers. Dr. Physick informed me that three patients
died in the water closet under the operation of purges
in St. George's hospital during his attendance upon
it. I have seen death in several instances succeed a
plentiful spontaneous stool in debilitated habits.
III. Sweating was introduced into practice at a
time when morbific matter was supposed to be the
proximate cause of fever. It acts, not by expelling
any thing exclusively morbid from the blood, but
by abstracting a portion of its fluid parts, and thus
reducing the action of the blood-vessels. This mode
of curing fever is still fashionable in genteel life. It
excites 

A DEFENCE OF BLOOD-LETTING. 217
excites no fear, and offends no sense. The sweating
remedies have been numerous, and fashion has
reigned as much among them, as in other things.
Alexipharmic waters, and powders, and all the
train of sudorific medicines, have lately yielded to
the different preparations of antimony, particularly
to James's powder. I object to them all,
1. Because they are uncertain; large and re-
peated doses of them being often given to no purpose.
2. Because they are slow, and disagreeable,
where they succeed in curing fever.
3. Because, like vomits and purges, they are not
under the direction of a physician, with respect to
the quantity of fluid discharged by them.
4. Because they are sometimes, even when most
profuse, ineffectual in the cure of fever.
5. The preparations of antimony lately employed
for the purpose of exciting sweats, are by no means
safe. They sometimes convulse the system by a
violent puking. Even the boasted James's powder
has done great mischief. Dr. Goldsmith and Mr.
Howard, it is said were destroyed by it.
IV. Mer- 


218 A DEFENCE OF BLOOD-LETTING.
IV. Mercury, the Sampson of the Materia Medica,
after having subdued the venereal disease, the
tetanus, and many other formidable disorders, has
lately added to its triumphs and reputation, by over-
coming the inflammatory and malignant state of
fever. I shall confine myself in this place to its de-
pleting operation when it acts by exciting a saliva-
tion. From half a pound to two pounds of fluid,
are discharged by it in a day. The depletion in
this way is gradual, whereby fainting is prevented.
By exciting and inflaming the glands of the mouth
and throat, excitement and inflammation are ab-
stracted from more vital parts. In morbid con-
gestion and excitement in the brain, a salivation is
of eminent service, from the proximity of the dis-
charge to the part affected. But I object to it as
an exclusive evacuant in the cure of fever.
1. Because it is sometimes impossible by the
largest doses of mercury, to excite it, when the
exigencies of the system render it most necessary.
2. Because it is not so quick in its operation, as
to be proportioned to the rapid progress of the
malignant state of fever.
3. Because it is at all times a disagreeable, and
frequently a painful remedy, more especially where
the teeth are decayed.
4. Because 
 

A DEFENCE OF BLOOD-LETTING. 219
4. Because it cannot be proportioned in its dura-
tion, or in the quantity of fluid discharged by it, to
the violence, or changes in the fever.
Dr. Chisholm relied, for the cure of the Boullam
fever at Grenada, chiefly upon this evacuation. I
have mentioned the ratio of success which attended
it.
V. BLISTERS are useful in depleting from those
parts which are the seats of topical inflammation.
The relief obtained by them in this way, more than
balances their stimulus upon the whole system. I
need hardly say, that their effects in reducing the
morbid and excessive action of the blood-vessels are
very feeble. To depend upon them in cases of
great inflammatory action, is as unwise, as it would
be to attempt to bale the water from a leaky and
sinking ship by the hollow of the hand, instead of
discharging it by two or three pumps.
Abstemious diet has sometimes been prescribed
as a remedy for fever. It acts directly by the ab-
traction of the stimulus of food from the stomach,
and indirectly by lessening the quantity of blood. It
can bear no proportion in its effects, to the rapidity,
and violence of an inflammatory fever. In chronic
fever such as occurs in the pulmonary consumption,
it 

220 A DEFENCE OF BLOOD-LETTING.
it has often been tried to no purpose. Long before
it reduces the pulse, it often induces such a relaxation
of the tone of the stomach and bowels as to accelerate
death. To depend upon it therefore in the cure
of inflammatory fever whether acute or chronic, is
like trusting to the rays of the sun to exhale the
water of an overflowing tide, instead of draining it
off immediately by digging a hole in the ground.
Bleeding has great advantages over every mode
of depleting that has been mentioned.
1. It abstracts one of the exciting causes, viz. the
stimulus of the blood from the seat of fever. I have
formerly illustrated this advantage of blood-letting
by comparing it to the abstraction of a grain of sand
from the eye to cure an opthalmia. The other
depleting remedies are as indirect and circuitous in
their operation in curing fever, as vomits and
purges would be to remove an inflammation in the
eye, while the grain of sand continued to irritate it.
2. Blood-letting is quick in its operation, and may
be accommodated to the rapidity of fever, when it
manifests itself in apoplexy, palsy, and syncope.
3. It is under the command of a physician. He
may bleed when and where he pleases, and may
suit 
        

A DEFENCE OF BLOOD-LETTING. 221
suit the quantity of blood he draws, exactly to the
condition of his patient's system.
4. It may be performed with the least attendance
of nurses or friends. This is of great importance
to the poor at all times, and to the rich during the
prevalence of contagious and mortal epidemics.
5. It disturbs the system much less than any of
the other modes of depleting, and therefore is best
accommodated to that state of the system, in which
patients are in danger of fainting or dying upon
being moved.
6. It is a more delicate depleting remedy than
most of those which have been mentioned, particu-
larly vomits, purges, and a salivation.
7. There is no immediate danger to life from its
use. Patients have sometimes died under the opera-
tion of vomits and purges, but I never saw nor
heard an instance of a patient's dying in a fainty fit,
brought on by bleeding.
8. It is less weakening, when used to the extent
that is necessary to cure, than the same degrees of
vomiting, purging, and sweating.
9. Con- 

222 A DEFENCE OF BLOOD-LETTING.
9. Convalescence is more rapid and more perfect
after bleeding, than after the successful use of any of
the other evacuating remedies.
By making use of blood-letting in fevers, we are
not precluded from the benefits of the other evacua-
ting remedies. Some of them are rendered more
certain and more effectual by it, and there are cases
of fever, in which the combined or successive applica-
of them all, is barely sufficient to save life.
To rely upon any one evacuating remedy, to the
exclusion of the others, is like trusting to a pair of
oars in a sea voyage, instead of spreading every sail
of a ship.
I suspect the disputes about the eligibility of the
different remedies which have been mentioned, have
arisen from an ignorance that they all belong to one
class, and that they differ only in their force and
manner of operation. Thus the physicians of the
last century ascribed different virtues to salts of dif-
ferent names, which the chemists of the present day
have taught us are exactly the same, and differ only
in the manner of their being prepared.
Having replied to the principal objections to blood-
letting, and stated its comparative advantages over
other

A DEFENCE OF BLOOD-LETTING. 223
other modes of depletion, I proceed next to mention
the circumstances which should regulate the use of it.
These are,
I. The state of the PULSE.
The following states of the pulse indicate the ne-
cessity of bleeding.
1. A full, frequent, and tense pulse, such as oc-
curs in the pulmonary, rheumatic, gouty, phrenitic,
and maniacal states of fever.
2. A full, frequent, and jerking pulse, without
tension, such as frequently occurs in the vertiginous,
paralytic, apoplectic, and hydropic states of fever.
3. A small, frequent, but tense pulse, such as oc-
curs in the chronic, pulmonary, and rheumatic states
of fever.
4. A tense and quick pulse, without much preter-
natural frequency. This state of the pulse is com-
mon in the yellow fever.
5. A slow but tense pulse, such as occurs in the
apoplectic, hydrocephalic, and malignant states of
fever, in which its strokes are from 60, to 9, in a
minute.
6. An

224 A DEFENCE OF BLOOD-LETTING.
6. An uncommonly frequent pulse, without much
tension, beating from 120 to 170 or 180 strokes in
a minute. This state of the pulse occurs likewise in
the malignant states of fever.
7. A soft pulse, without much frequency or ful-
ness. I have met with this state of the pulse in af-
fections of the brain, and in that state of pulmo-
nary fever which is known by the name of pneu-
monia notha. It sometimes, I have remarked, be-
comes tense after bleeding.
8. An intermitting pulse.
9. A depressed pulse.
10. An imperceptible pulse. The slow, inter-
mitting, depressed, and imperceptible states of the
pulse, are supposed exclusively to indicate congestion
in the brain. But they are all, I believe, occa-
sioned likewise by great excess of stimulus acting
upon the heart and arteries. A pulse more tense in
one arm than in the other, I have generally found
to attend a morbid state of the brain. Much yet
remains to be known of the signs of a disease in the
brain, by the states of the pulse ; hence Mr. Hun-
ter has justly remarked, that "In inflammation of
the brain, the pulse varies more than in inflamma-
2 tions 

A DEFENCE OF BLOOD-LETTING. 225
tions of any other part; and perhaps we are led to
judge of inflammation there, more from other symp-
toms than the pulse." *
The slow, uncommonly frequent, intermitting,
and imperceptible states of the pulse which require
bleeding, may be distinguished from the same states
of the pulse, which arise from direct debility or an
exhausted state of the system, and that forbid bleed-
ing by the following marks.
1. They occur in the beginning of a fever.
2. They occur in the paroxysms of fevers which
have remissions and exacerbations.
3. They sometimes occur after blood-letting,
from causes formerly mentioned.
4. They sometimes occur, and continue during
the whole course of an inflammation of the stomach
and bowels. And,
5. They occur in relapses, after the crisis of a
fever.
The other states of the pulse indicate bleeding in
every stage of fever, and in every condition of the
* Chap. iii. 9.
P system. 


226 A DEFENCE OF BLOOD-LETTING
system. I have taken notice, in another place, of
the circumstances which render it proper in the ad-
vanced stage of chronic fever.
If all the states of pulse which have been enume-
rated, indicate bleeding, it must be an affecting
consideration to reflect, how many lives have been
lost by physicians limiting the use of the lancet only
to the tense or full pulse!
I wish it comported with the proposed limits of
this essay to illustrate and establish, by the recital of
cases, the truth of these remarks upon the indica-
tions of bleeding from the pulse. It is the truest
index of the state of the system, and when it is per-
fectly understood, it never deceives. Its frequency,
(unconnected with its other states), being under the
influence of diet, motion, and the passions of the
mind, is of the least consequence. In counting the
number of its strokes,  we are apt to be diverted
from attending to its irregularity and force ; and in
these, it should always be remembered, fever chiefly
consists. The knowledge acquired by attending to
these states of the pulse is so definite and useful,
and the circumstances which seduce from a due at-
tention to them are so erroneous in their indications,
that I have sometimes wished the Chinese custom of
prescribing, from feeling the pulse only, without
seeing 

A DEFENCE OF BLOOD-LETTING. 227
seeing or conversing with the patient, were imposed
upon all physicians.
To render the knowledge of the indications of
blood-letting from the state of the pulse as definite
and correct as possible, I shall add, for the benefit
of young practitioners, the following directions for
feeling it.
1. Let the arm be placed in a situation in which
all the muscles which move it shall be completely
relaxed ; and let it, at the same time, be free from
the pressure of the body upon it.
2. Feel the pulse in all obscure or difficult cases,
in both arms.
3. Apply all the fingers of one hand, when prac-
ticable, to the pulse. For this purpose it will be
most convenient to feel the pulse of the right hand
with your left, and of the left hand with your right.
4. Do not decide upon blood-letting in difficult
cases, until you have felt the pulse for some time.
The Chinese physicians never prescribe until they
have counted 49 strokes.
5. Feel the pulse at the intervals of four or five
minutes, when you suspect that its force has been
P 2 varied 

228 A DEFENCE OF BLOOD-LETTING.
varied by any circumstance not connected with the
disease, such as emotions of the mind, exercise, eat-
ing, drinking, and the like.
6. Feel the pulsations of the arteries in the tem-
ples and in the neck, when the pulse is depressed or
imperceptible in the wrists.
7. Request silence in a sick room, and close
your eyes in feeling a pulse in difficult cases. By
so doing, yon will concentrate the sensations of your
ears and eyes, in your fingers.
In judging of the states of the pulse which have
been enumerated, it will be necessary always to re-
member the natural difference in its frequency and
force in old people and children; also in the morn-
ing and evening, and in the sleeping and waking
states of the system.
But to return.
II. Regard should be had to the character of the
reigning epidemic, in deciding upon blood-letting.
If the prevailing fever be of a highly inflammatory
nature, bleeding may be used with more safety in
cases where the indications of it from the pulse are
somewhat doubtful. The character of a previous
epidemic should likewise direct the use of the lancet.
The 

A DEFENCE OF BLOOD-LETTING. 229
The pestilential fever which followed the plague in
London in 1665, Dr. Sydenham says, yielded only
to blood-letting. It is equally necessary in all the
febrile diseases which succeed malignant fevers.
III. The constitution of a patient, and more espe-
cially his habits with respect to blood-letting, should
be taken into consideration, in prescribing it. If he
be plethoric, and accustomed to bleeding in former
indispositions, it will be more necessary than in op-
posite states and habits of the system.
IV. Regard should be had to the country or place
from which persons affected with fevers have lately
arrived, in prescribing the loss of blood. Fevers
in America are more inflammatory than fevers in
persons of equal rank in Great Britain. From a
want of attention to this circumstance, I saw a com-
mon pleurisy end in an abscess in the lungs, in a
sea-captain in the city of London, in the year 1769,
who was attended by a physician of the first repu-
tation in England. He was bled but once. His
cure was afterwards trusted to sudorific draughts.
His pulse and his American constitution indicated
the loss of 50 or 60 ounces of blood.
V. After blood-letting has been performed, the
appearances of the blood should be attended to, 
P3 in 


230 A DEFENCE OF BLOOD-LETTING.
in order to judge of the propriety of repeating it.
I shall briefly describe these appearances, and ar-
range them in the order in which they indicate
the different degrees of inflammatory diathesis, be-
ginning with the highest.
1. Dissolved blood. It occurs in the malignant
states of fever. I have seen it several times in
the pleurisy, and have once heard of it in a case of
gout. I have ascribed this decomposition of the
blood to such a violent degree of stimulus upon
the blood-vessels, as to dispose them to a paralytic
state. It is generally considered as a signal to lay
aside the lancet. If it occur in the first stage of
a fever, it indicates a very opposite practice. By
repeated bleedings, the vessels recover their natu-
ral action, and the blood becomes reduced to its
original texture. Of this I have had frequent ex-
perience since the year 1793. It required three
successive bleedings to restore the blood from  a
dissolved to a coagulable state in Mr. Benton. It
afterwards became very sizy. If this dissolved blood
appear towards the close of a malignant fever, no
other benefit than the protraction of life for a day
or two, or an easy death, can be expected from
repeating the bleeding, even though it be indicated
by a tense pulse; for the viscera are generally so
much choaked by the continuance of violent action
in 

A DEFENSE OF BLOOD-LETTING. 231
In the-blood-vessels, that they are seldom able to
discharge the blood which distends them, into the
cavity in the vessels which is created by the ab-
straction of blood from a vein. There is some
variety in the appearance of this state of the blood,
which indicates more or less violent pressure upon
the blood-vessels. It threatens most danger to life
when it resembles molasses in its consistence. The
danger is less when the part which is dissolved
occupies the bottom of the bowl, and when its
surface is covered with a sizy pellicle or coat.
Does not the restoration of the blood from its dis-
organized state, by means of bleeding, suggest an
idea of a similar change being practicable in the so-
lids, when they are disorganized by disease? And
are we not led hereby to an animating view of the
extent and power of medicine ?
2. Blood of a scarlet colour, without any separa-
tion into crassamentum or serum, indicates a second
degree of inflammatory action. It occurs likewise
in the malignant state of fever.
3. Blood in which part of the crassamentum is
dissolved in the serum, forming a resemblance to
what is called the lotura carnium, or the washings
of flesh in water,
P 4 4. Cras- 


232 A DEFENCE OF BLOOD-LETTING.
4. Crassamentum sinking to the bottom of a bowl
In yellow serum.
5. Crassamentum floating in serum which is at
first turbid, but which afterwards becomes yellow
and transparent by depositing certain red and fiery
particles of the blood in the bottom of the bowl.
6. Sizy blood, or blood covered with a buffy
coat. The more the crassamentum appears in the
form of a cup, the more inflammatory action is said
to be indicated by it. This appearance of the blood
occurs in all the common states of inflammatory
fever. It occurs too in the mild state of malignant
fevers, and in the close of such of them as have
been violent. It is not always connected with the
common inflammatory state of the pulse, for I have
observed it occasionally in most of the different states
of the pulse which have been described. The ap-
pearance of this buffy coat on the blood in the yel-
low fever, is always favourable. It shews the dis-
ease to be tending from an uncommon, to a common
degree of inflammatory diathesis.
It would seem, from these facts, as if the power
of coagulation in the blood was lessened in an exact
ratio to the increase of stimulus upon the blood-
vessela and that it was increased in proportion to
the 

A DEFENCE OF BLOOED-LETTING. 233
the diminution of that stimulus, to that degree of
action which constitutes what I have called common
inflammatory action.
Here as upon a former occasion we may say with
concern, if bleeding be indicated by all the appear-
ances of the blood which have been enumerated,
how many lives have been lost by physicians limiting
the use of the lancet to those cases only, where the
blood discovered an inflammatory crust !
These remarks upon the relative signs of inflam-
matory action in the blood-vessels, should be admit-
ted with a recollection that they are all liable to be
varied by a moderate, or violent exacerbation of
fever, by the size of the stream of blood, and by the
heat, coldness, and form of the cup into which the
blood flows. This occasional uncertainty in the in-
dications of the state of fever by the blood, should
lead us back to the PULSE. When time, and more
attention to this index of the state of the system in
fevers, shall have brought to light all the knowledge
that the pulse is capable of imparting, the ap-
pearances of the blood in fevers, will be regarded
as little as the appearances of the urine.
VI. Blood-letting should always be copious where
there is danger from congestion or inflammation,
in 

234 A DEFENCE OF BLOOD-LETTING.
in vital parts. This danger is indicated most com-
monly by pain; but there may be congestion in the
liver, bowels, and even in the head, without pain.
In these cases, the state of the pulse should always
govern the use of the lancet.
VII. What quantity of blood may be taken, with
safety, from a patient in an inflammatory fever? To
answer this question it will be necessary to remark,
1. That in a person of an ordinary size, there are
supposed to be contained between 25 and 28 pounds
of blood, and 2. That much more blood may be
taken when the blood-vessels are in a state of morbid
excitement and excitability, than at any other time.
One of the uses of the blood is to stimulate the
blood-vessels, and thereby to assist in originating,
and preserving animal life. In a healthy state of
the vessels, the whole mass of the blood is necessary
for this purpose ; but in their state of morbid ex-
citability, a much less quantity of blood than what
is natural, (perhaps in some cases four or five
pounds) are sufficient to keep up an equal and
vigorous circulation. Thus very small portions of
light, and sound, are sufficient to excite vision and
hearing in an inflamed, and highly excitable state
of the eyes and ears. Thus too, a single glass of
wine will often produce delirium in a fever in a
man. who, when in health, is in the habit of drinking
a bottle 

A DEFENCE OF BLOOD-LETTING. 235
a bottle every day without having his pulse quick-
ened by it.
An ignorance of the quantity of blood which has
been drawn by design, or lost by accident, has con-
tributed very much to encourage prejudices against
blood-letting. Mr. Cline drew 320 ounces of blood
in 20 days from a patient in St. Thomas's hospital,
who laboured under a contusion of the head. But
this quantity is small compared with the quantity
lost by a number of persons whose cases are recorded
by Dr. Haller.* I shall mention a few of them.
One person lost 9 pounds of blood, a second 12,'
a third 18, and  a fourth 22, from the nose at
one time. A fifth lost 12 pounds by vomiting
in one night, and a sixth 22 from the lungs. A
gentleman at Angola lost between 3 and 4 pounds
daily from his nose. To cure it he was bled 97
times in one year. A young woman was bled 1020
times in 19 years, to cure her of plethora which
disposed her to hysteria. Another young woman lost
125 ounces of blood by a natural hæmorrhage every
month. To cure it, she was bled every day, and
every other day for 14 months. In none of these
instances, was death the consequence of these great
evacuations of blood. On the contrary, all the per-
* Elementa Physiologiæ, vol. iv. p. 45.
sons 

236 A DEFENCE OF BLOOD-LETTING.
sons alluded to, recovered. Many similar instances
of the safety, and even benefit of profuse discharges
of blood by nature and art, might be mentioned
from other authors. I shall insert only one more,
which shall be taken from Dr. Sydenham's account
of the cure of the plague. "Among the other
calamities of the civil war which afflicted this nation,
the plague also raged in several places, and was
brought by accident from another place to Dunstar
Castle in Somersetshire, where some of the soldiers
dying suddenly, with an eruption of spots, it like-
wise seized several others. It happened at that time
that a surgeon who had travelled much in foreign
parts, was in the service there, and applied to the
governor for leave to assist his fellow soldiers who
were afflicted with this dreadful disease in the best
manner he was able ; which being granted, he took
so large a quantity of blood from every one at the
beginning of the disease, and before any swelling
was perceived, that they were ready to faint, and
drop down, for he bled them all standing, and in
the open air and had no vessel to measure the blood,
which falling on the ground, the quantity each per-
son lost, could not of course be known. The opera-
ion being over, he ordered them to lie in their
tents; and though he gave no kind of remedy after
bleeding, yet of the numbers that were thus treated,
not a single person died. I had this relation from
colonel 
        

A DEFENCE OF BLOOD-LETTING. 237
colonel Francis Windham a gentleman of great
honor, and veracity, and at this time governor of
the Castle." *
Again. An ignorance of the rapid manner in
which blood is regenerated when lost or drawn, has
helped to keep up prejudices against blood-letting.
A person (Dr. Haller says) lost five pounds of blood
daily from the hæmorrhoidal vessels for 62 days,
and another 75 pounds of blood in 10 days. The
loss each day was supplied by fresh quantities of
aliment.
These facts I hope, will be sufficient to establish
the safety and advantages of plentiful blood-letting
in cases of violent fever ; also to shew the fallacy
and danger of that practice which attempts the cure
of such cases of fever, by what is called moderate
bleeding. There are, it has been said, no half
truths in government. It is equally true, that there
are no half truths in medicine. This half-way prac-
tice of moderate bleeding, has kept up the mortality
of pestilential fevers in all ages, and in all coun-
tries.
I have combated this practice elsewhere,† and
have asserted, upon the authority of Dr. Syden-
* Vol. I. p. 131. † Account of the Yellow Fever, in 1793.
ham, 


238 A DEFENCE OF BLOOD-LETTING.
ham, that it is much better not to bleed at all, than
to draw blood disproportioned in quantity to the
violence of the fever. If the state of the pulse be
our guide, the continuance of its inflammatory action,
after the loss of even an 100 ounces of blood, in-
dicates the necessity of more bleeding, as much as
it did the first time a vein was opened. In the
use of this remedy it may be truly said, as in many
of the enterprizes of life, that nothing is done, while
any thing remains to be done. Bleeding should be
repeated while the symptoms which at first indicated
it continue, should it be until four-fifths of the blood
contained in the body are drawn away. In this
manner we act in the use of other remedies. Who
ever leaves off giving purges in a colic, attended
with costiveness, before the bowels are opened ? or
who lays aside mercury as a useless medicine, because
a few doses of it do not cure the venereal disease ?
I shall only add under this head, that I have
always observed the cure of a malignant fever to be
most complete, and the convalescence to be most
rapid, when the bleeding has been continued until
a paleness is induced in the face, and until the patient
is able to sit up without being fainty. After these
circumstances occur, a moderate degree of force in
the pulse will gradually wear itself away without
doing any harm.
VIII. In 

A DEFENCE OF BLOOD-LETTING. 239
VIII. In drawing blood, the quantity should be
large or small at a time, according to the state of
the system. In cases where the pulse acts with force
and freedom, from 10 to 20 ounces of blood may
be taken at once; but in cases of great indirect de-
bility, where the pulse is depressed, it will be bet
ter to take away but a few ounces at a time, and to
repeat it three or four times a-day. By this means
the blood-vessels more gradually recover their vigour,
and the apparent bad effects of bleeding are thereby
prevented. Perhaps the same advantages might be
derived in many other cases from the gradual ab-
straction of stimuli, that are derived from the gra-
dual increase of their force and number, in their ap-
plication to the body. In an inflammatory fever, the
character of which is not accurately known, it is
safest to begin with moderate bleeding, and to in-
crease it in quantity, according as the violence and
duration of the disease shall make it necessary. In
fevers and other diseases which run their courses in a
few days or hours, and which threaten immediate
dissolution, there can be no limits fixed to the quan-
tity of blood which may be drawn at once, or in a
short time. Botallus drew 3, 4, and 5 pints in a
day in such cases. Dr. Physick drew 90 ounces by
weight from Dr. Dewees, in a sudden attack of the
apoplectic state of fever, at one bleeding, and there
by

240 A DEFENCE OF BLOOD-LETTING.
by restored him so speedily to health, that he was
able to attend to his business in three days afterwards.
In chronic states of fever, of an inflammatory type,
small and frequent bleedings are to be preferred to
large ones. We use mercury, antimony, and diet
drinks as alteratives in many diseases with advan-
tage. We do not expect to cure certain diseases of
debility by two or three immersions in a cold bath.
We persist with patience in prescribing all the above
remedies for months and years, before we expect to
reap the full benefits of them. Why should not
blood-letting be used in the same way, and have the
same chance of doing good. I have long ago adopted
this alterative mode of using it, and I can now look
around me, and with pleasure behold a number of
persons of both sexes who owe their lives to it. In
many cases I have prescribed it once in two or three
months for several years; and in some I have ad-
vised it every two weeks, for several months.
There is a state of fever in which an excess in the
action of the blood-vessels is barely perceptible, but
which often threatens immediate danger to life, by
a determination of blood to a vital part. In this
case, I have frequently seen the scale turn in favour
of life, by the loss of but four or five ounces of
blood. The pressure of this, and even of a much
4 less 

A DEFENCE OF BLOOD-LETTING. 241
less quantity of blood in the close of a fever, I be-
lieve as effectually destroys life, as the excess of
several pounds does in its beginning.
In cases where bleeding does not cure, it may be
used with advantage as a palliative remedy. Many
diseases induce death in a full and highly excited
state of the system. Here opium does harm, while
bleeding affords certain relief. It belongs to this
remedy, in such cases, to ease pain, to prevent con-
vulsions, to compose the mind, to protract the use of
reason, to induce sleep, and thus to smooth the pas-
sage out of life.
IX. Bleeding from an artery, commonly called
arteriotomy, would probably have many advantages
over venesection, could it be performed at all times
with ease and safety. Blood discharged by hæmor-
rhages affords more relief in fevers than an equal
quantity drawn from a vein, chiefly because it is
poured forth in the former case from a ruptured
artery. I mentioned formerly, that Dr. Mitchell had
found blood drawn from an artery to be what is
called dense, at a time when that which was drawn
from a vein in the same persons, was dissolved.
This fact may possibly admit of some application. In
the close of malignant  fevers, where bleeding has
been omitted in the beginning of the disorder, blood
Q drawn 

242 A DEFENCE OF BLOOD-LETTING.
drawn from a vein is generally so dissolved, as to be
beyond the reach of repeated bleedings to restore it
to its natural texture. In this case, arteriotomy
might probably be performed with advantage. The
arteries, which retain their capacity of life longer
than the veins, by being relieved from the imme-
diate pressure of blood upon them, might be en-
abled so to act upon the torpid veins, as to restore
their natural action, and thereby to arrest departing
life. Arteriotomy might further be used with ad-
vantage in children, in whom it is difficult, and
sometimes impracticable to open a vein.
X. Much has been said about the proper place
from whence blood should be drawn. Bleeding in
the foot was much used formerly, in order to ex-
cite a revulsion from the head and breast; but our
present ideas of the circulation of the blood have
taught us, that it may be drawn from the arm with
equal advantage in nearly all cases. To bleeding in
the foot there are the following objections.: 1. The
difficulty of placing a patient in a situation favour-
able to it. 2. The greater danger of wounding a
tendon in the foot than in the arm. And, 3. The
impossibility of examining the blood after it is
drawn;  for in this mode of bleeding, the blood
generally flows into a bason or pail of water.
Under 

A DEFENCE OF BLOOD-LETTING. 243
Under this head I shall decide upon the method
of drawing blood by means of cups, in the inflam-
matory state of fever. Where an inflammatory fever
arises from local affection, or from contusion in the
head or breast, or from a morbid excitement in
those, above other parts of the arterial system, they
may be useful; but where local affection is a symp-
tom of general and equable fever only, it can sel-
dom be necessary, except where bleeding from the
arm has been omitted, or used too sparingly in the
beginning of a fever; by which means such fixed
congestion often takes place, as will not yield to ge-
neral bleeding.
XI. Much has been said likewise about the pro-
per time for bleeding in fevers. It may be used
at all times, when indicated by the pulse and other
circumstances, in continual fevers; but it should
be used chiefly in the paroxysms of such as inter-
mit. I have conceived, this practice to be of so much
consequence, that when I expect a return of the
fever in the night, I request one of my pupils to
sit up with my patients all night, in order to meet
the paroxysm, if necessary, with the lancet. But
I derive another advantage from fixing a centinel
over a patient in a malignant fever. When a
paroxysm goes off in the night, it often leaves the
system in a state of such extreme debility as to
Q2 endanger 


244 A DEFENCE OF BLOOD-LETTING.
endanger life. In this case,from 5 to 10 drops
of laudanum, exhibited by a person who is a judge
of the pulse, obviate this alarming debility, and
often induce easy and refreshing sleep. By treat-
ing the human body like a corded instrument, in
thus occasionally relaxing or bracing the system,
according to the excess or deficiency of stimulus
in those hours in which death most frequently oc-
curs, I think I have been the means of saving
several valuable lives.
I regret that the limits I have fixed to this
defence of blood-letting will not admit of my ap-
plying the principles which I have delivered, to
all the inflammatory states of fever. I have shewn,
in a former publication, the advantages of bleed-
ing in the hydropic state of fever. In a future
essay, I hope to establish its efficacy in the gouty
and maniacal states of fever. I have said that
madness is the effect of a chronic inflammation in
the brain. Its remedy, of course, should be fre-
quent and copious blood-letting. Physical and mo-
ral evil are subject to similar laws. The mad-
sturt, and all the common means of coercion are
as improper substitutes for bleeding in madness,
as the whipping-post and pillory are for soli-
tary confinement and labour, in the cure of vice.
The pulse should govern the use of the lancet in
this, 
        

A DEFENCE OF BLOOD-LETTING. 245
this, as well as in all the ordinary states of fever.
It is the dial-plate of the system. But in the mis-
placed states of fever, the pulse, like folly in old
age, often points at a different mark from nature.
In all such cases, we must conform our practice
to that which has been successful in the reigning
epidemic. A single bleeding, when indicated by
this circumstance, often converts a fever from a
suffocated or latent, to a sensible state, and thus
renders it a more simple and manageable disease.
It is worthy of consideration here, how far lo-
cal diseases, which have been produced by fevers,.
might be cured by re-exciting the fever. Sir
William Jones says the physicians in Persia always
begin the cure of the leprosy by blood-letting. *.
Possibly this remedy diffuses the disease through
the blood-vessels, and thereby exposes it to be
more easily acted upon by other remedies.
I intended to have enlarged upon the good ef-
fects of bleeding in several diseases which are not
accompanied with fever, but having trespassed too
long upon the reader's patience, by the minute-
ness of my details upon this subject, I shall take
notice at present of its efficacy in but the five
following morbid states of the system.
*Asiatic Essays.
Q3. I. During 


246. A DEFENCE OF BLOOD-LETTING.
1.During the period in which the menses cease
to slow, there is always a morbid fulness and excite-
ment in the blood-vessels; hence the head achs,
coughs, dropsies, hemorrhages, glandular obstruc-
tions, and cancers, which occur in that stage of life.
They may all be prevented by frequent and mode-
rate blood-letting.
2. Pain is probably not connected necssarily with
child-bearing. Many of the other evils inflicted
upon the human race, in consequence of the disobe-
dience of our first parents, have been lessened or
eradicated by the ingenuity of man. The pain of
child-bearing travellers tell us, is much lessened
among the Turkish women, by their taking sweet
oil (which acts as a purge) during their pregnancy.
Direct debility, whether induced by saffing or long
and flow diseases, tends alike to mitigate the pains of
labour. These facts have led me to inquire, whe-
ther blood-letting does not produce the same effect.
I have often observed labours to be short and com-
paratively easy, which have succeeded a fever that
has been cured by bleeding. Upon my mentioning
this fact to Dr. Dewees, he informed me that he
had often bled when parturition was flow, and that
he Had always found that he thereby both shortened
and lessened the pains of labour.
3. I hate 

A DEFENCE OF BLOOD-LETTING. 247
3. I have said that there is but one remote cause
of fever. Of course there can be no essential dif-
ference between the stimulus of the saliva of a rabid
animal, and the stimulus of contagion or miasmata,
in inducing morbid actions in the system. The heat,
thirst, quick and tense pulse, and local effusions which
occur in the hydrophobia, indicate it to be a spas-
modic state of fever. As there is but one remote,*
and one proximate cause of fever, so there is but one
method of curing it, and that is by reducing morbid
action when it is excessive by depletion, and after-
wards removing debility by tonic remedies. I can
fee no reason why the hydrophobia should not yield
to these obvious, and universal principles in medi-
cine. From its great forces it is probable it will 
require the most copious bleeding, and afterwards
the most powerful tonics to cure it of any disorder
in the world.
4. In dislocations of bones which resist both skill
and force, it has been suggested that bleeding, un-
*The exciting cause of fever, which may be considered as
forming an exception to this simple view of its remote cause,
is nothing but a reinforcement of the remote cause, when it
is too feeble to excite fever. It generally acts as a stimulus,
and when it acls by abstracting a natural stimulus from the
body, it throws such a balance of force into the scale of the
remote cause, as to enable it to induce fever. 

248 A DEFENCE OF BLOOD-LETTING.
til fainting is induced, would produce such a re-
laxation in the muscles as to favour their reduction.
This principle was happily applied in the winter of
1795, by Dr. Physick in the Pennsylvania hospital,
in a case of a dislocated humerus of two months
continuance. The Doctor bled this patient until
he fainted, and then reduced his shoulder in less
than a minute, with a very small exertion of force.
5. I have elsewhere spoken in favour of blood-let-
ting in some of the diseases of old age.* The palsy,
apoplexy, cough, and colic, so common among old
people, might, I believe be prevented in many in-
stances by the occasional, but moderate use of this
remedy.
Thus have I finished my defence of blood-letting
as a remedy for certain diseases. Let not the reader
suppose that I am unduly attached to it. I have
little reason to be so, for the dread of my using it
in every disease, and the false reports of my using
it in equal degrees in diseases of opposite characters,
have deprived me probably of many thousand pounds
in the course of my life. But my predilection for
the lancet above all other depleting remedies, has
affected my happiness, much more than my interest,
* Medical Inquiries, and Observations, Vol. II.
It 

A DEFENCE OF BLOOD-LETTING. 249
It has made the duties of my profession (which would
otherwise be pleasant) extremely painful to me.
Often have I been forced to submit my judgment to
the fears and prejudices of my patients, and thereby
to consume days and weeks in curing a disease
which might have been cured in some instances by
the loss of a few ounces of blood, in a day or an
hour. Often, when the appearance of danger has
made the prescription of blood-letting necessary to
save life, have I read disaffection to it in dejected
looks, or tears, and sometimes heard it in the
screams of a whole family. And often have I been
reproached for killing people by bleeding, who
have died, only because they submitted to the re-
medy when it was too late, or because it was too
sparingly administered to do them service. Nor have
the testimonies of whole families and neighbourhoods
who have been cured of malignant fevers by bleed-
ing, balanced the discredit of the loss of the few
patients in whom it was thus improperly used; for
the recoveries in those cases have been considered
as remarkable, only because the patients survived
the frequent use of the lancet.
It was in consequence of the violence that blood-
letting offered to the feelings of his patients, and to
the practice of cotemporary physicians, that Dr.
Sydenham 
 

250 A DEFENCE OF BLOOD-LETTING.
Sydenham was forced to adopt sweating as a sub-
stitute for bleeding in the plague, and to use it very
sparingly in the rheumatism. I have reason to la-
ment his having accommodated this favourite re-
medy to ignorance or fear in a single disease. Had
he persisted in the use of it, he would indeed have
blessed mankind, and rescued me."
We are sometimes told by the terrorists in medi-
cine, that the Indians cure their inflammatory fevers
without bleeding. To relieve myself from the dis-
tress and obloquy to which my use of this remedy
exposed me, I have carefully sought for, and ex-
amined their remedies for inflammatory fever with
a sincere desire to adopt them; but my inquiries
have satisfied me, that they are not only wholly
disproportioned to the habits of civilized life, but
that they are far less successful than blood-letting
even among themselves. With the same wish to
avoid a painful conflict with the fears and prejudices
of my patients, I have prescribed all the remedies
which are set down under the first head of the syl-
labus, as substitutes for bleeding, but I am sorry
to add, without effect. However useful they may
be as auxiliaries to blood-letting, they are all feeble
without it, when used to cure a fever of violent in-
flmmatory action.
In 

A DEFENCE OF BLOOD-LETTING. 251
In contemplating the prejudices against blood-let-
ting which prevail so generally in our country, I
have been led to ascribe them to a cause wholly
political. We are descended chiefly from Great
Britain, and have been for many years under the
influence of English habits upon all subjects. Some
of these habits, as far as they relate to government,
have been partly changed; but in dress, arts, manu-
factures, manners, and science, we are still governed
by our early associations. Britain and France have
been for many centuries hereditary enemies. The
hostility of the former to the latter nation, extends
to every thing that belongs to their character. It
discovers itself, in an eminent degree, in diet and
medicine. Do the French love soups ? the English
prefer solid flesh. Do the French love their meats
well cooked ? the English prefer their meats but
half roasted. Do the French sip coffee after dinner?
the English spend their afternoons in drinking Port
and Madeira wines. Do the French physicians pre-
scribe purges and glysters to cleanse the bowels ?
the English physicians prescribe vomits for the same
purpose. Above all, do the French physicians ad-
vise bleeding in fevers ? the English physicians forbid
it, in most fevers, and substitute sweating in the
room of it. Here then we discover the source of
the prejudices and errors of our countrymen, upon
the subject of blood-letting. They are of British
origin. 

252 A DEFENCE OF BLOOD-LETTING.
origin. They have been inculcated upon us in
British universities, and in British books ; and they
accord, as illy with our climate, and state of society,
as the Dutch foot stoves did, with the temperate cli-
mate of the Cape of Good Hope.*
It is probable the bad consequences which have
followed the indiscrimate, use of the lancet in
France, and some other countries, may have con-
tributed in some degree to create the prejudices
against it, which are entertained by the physicians in
Great Britain. Bleeding like opium has lost its cha-
* I have frequently been surprized in visiting English
patients, to hear them say, when I have prescribed bleeding,
that their physicians in England, had charged them never to
be bled. This advice excluded all regard to the changes
which climate, diet, new employments, and age might in-
duce upon the system. I am disposed to believe that many
lives are lost, and numerous chronic diseases created in Great
Britain by the neglect of bleeding in fevers. My former pupil
Dr. Fisher in a letter from the University of Edinburgh,
dated in the Winter of 1795, assures me that he had cured
several of his fellow students of fevers (contrary to general
prejudice) by early bleeding, in as easy and summary a way
as he had been accustomed to see them cured in Philadelphia,
by the use of the same remedy. Dr. Gordon of Scotland,
and several other physicians in Great Britain have lately re-
vived the lancet, and applied it with great judgment, and
success to the cure of fevers.
racter 

A DEFENCE OF BLOOD-LETTING. 253
racter in many cases by being prescribed for the name
of a disease. It is still used, Mr. Townsend tells us,
in this empirical way in Spain, where a physician,
when sent for to a patient, orders him to be bled
before he visits him. The late just theory of the
manner in which opium acts upon the body, has re-
strained its mischief, and added greatly to its useful-
ness. In like manner, may we not hope that just
theories of diseases, and proper ideas of the manner
in which bleeding acts in curing them, will prevent
a relapse into the evils which formerly accompanied
this remedy, and render it a great and universal
blessing to mankind ?
I have great pleasure in acknowledging, that the
establishment and defence of blood-letting has not
been committed to me alone, in the city of Philadel-
phia. A number of our physicians, highly respect-
able for talents and knowledge, have adopted this
invaluable remedy, and have used it with a success
which has rendered their practice reputable to them-
selves, and beneficial to the public. The superior
success of the friends of blood-letting in recovering 
patients, is acknowledged by all ranks of citizens;
but they have been taught by some of the physicians 
of the city to believe, that this success does not ex-
tend to malignant and dangerous diseases. For ex-
ample. These gentlemen say the yellow fevers 
which 

254 A DEFENCE OF BLOOD-LETTING.
which we cure by copious blood-letting are common
remittents or intermittents; and that the manias,
the internal dropsies of the brain, and the pulmo-
nary consumptions which we prevent, or cure, by
the same remedy, are either transient derangements
of mind from trifling fevers, or common head achs,
or colds. But error and calumny in this, as in many
other cases, refute themselves. It is well known
that all those diseases have prevailed for several years
in our city, and that most of our physicians have had
their usual proportion of patients in them. It is
scarcely possible that we should maintain our propor-
tion of business, and not meet with the same num-
ber of cases of those diseases as our brethren. We
do meet with them, and we prevent their mortality,
in a great degree, by copious or frequent blood-
letting.
From the influence which this detraction from the
merit of bleeding has upon its success, we are forced
to lament, that the greatest possible benefits will
never be derived from it, until the same uniformity
of opinion and practice obtain with respect to its use,
which prevails with respect to the use of pure air and
cool drinks in fevers.
How long error, ignorance, prejudice, and in-
terest, upon the subject of blood-letting, shall con-
4 tinue 
 

A DEFENCE OF BLOOD-LETTING. 255
tinue to render fevers one of the principal outlets of
human life, I know not; but their influence cannot
last always. Perhaps the blessings of speedy health,
long life, and more universal population, which are
insured in a great degree by the use of this re-
medy, may be reserved by heaven for a more vir-
tuous and enlightened race of men, than those who
compose the present inhabitants of our globe.
I shall conclude this work by a reflection which
has been suggested by some of the preceding pages.
The present is an eventful æra in human affairs.
Our world appears to be upon the eve of a great
and universal revolution. This revolution, I be-
lieve, will ultimately be in favour of human happi-
ness. I do not found my belief of a change for the
better, in the condition of mankind, upon the pre-
sent state of things; for every view we can take of
them, whether it be directed to morals, religion, or
government, exhibits the reverse of such a change.
I believe in the rapid approach of a new order of
things, from the coincidence of present events with
the predictions contained in the Old and New Testa-
ments. These predictions are now accomplishing by
natural means. Events, essential to each other, have
lately taken place, as if by concert, in different na-
tions ; and truths, essential to those events, have
been 

256 A DEFENCE OF BLOOD-LETTING.
been discovered or revived in different parts of the
world. Thus, in a former age, the discovery of the
art of printing was connected with the revival of
letters, and a change in the moral and religious state
of Europe. Thus, too, the application of the load-
stone to the purpose of navigation, immediately pre-
ceded the discovery and settlement of America.
One of the predictions alluded to in the Old Testa-
ment is, that agriculture, civilization, peace, and just
government shall be introduced into the eastern coun-
tries, and of course, that an immense increase of the
human species shall be effected by their influence, in
that part of the globe. To this delightful change
in the state of the eastern part of the world, there
exists but one natural obstacle; and that is, the
plague and other malignant fevers still continue to
depopulate whole cities and nations, thereby often
producing every species of public and private misery.
The extent of this misery may easily be conceived of,
by the recital of a single and recent event. In the
year 1773 one of those malignant fevers destroyed
275,000 people in Bassorah, amounting to seven-
eighths of the inhabitants of that city. To obviate
the objection to the fulfilment of ancient prophecy,
from the prevalence of malignant and destructive
fevers in the east, it will only be necessary to attend
to what has seen said by Dr. Hartley, upon the
propagation of Christianity throughout the world by
1 natural 
 

A DEFENCE OF BLOOD-LETTING. 257
natural means. " Mankind (says this enlightened
philosopher and Christian) seem to have it in their
power to obtain such qualifications in a natural way,
as, by being conferred upon the Apostles in a super-
natural one, were the principal means of their suc-
cess in the first propagation of the Gospel.
"Thus, as the Apostles had the power of heal-
ing miraculously, future missionaries may, in a short
time, accomplish themselves with the knowledge of
all the chief practical rules of medicine. This art is
wonderfully simplified of late years, and is improving
every day in simplicity and efficacy. And it may
be hoped, that a few theoretical positions, well as-
certained, with a moderate experience, may enable
the young practitioner to proceed to a considerable
variety of cases with safety and success." *
What Dr. Hartley preconceived with respect to
diseases in general, has, we hope, been realized with
respect to malignant fevers. If we may judge from
the success which has lately attended the treatment
of one of them in the cities of Baltimore and Phila-
delphia, we may safely assert, that no one of them
is incurable. It will not be necessary to send men,
educated in colleges, into the Asiatic countries to
* Observations on Man, Proposition clxxxiii. p. 378.
cure 

258 A DEFENCE OF BLOOD-LETTING.
cure their pestilential diseases. Men, and even wo-
men, may be employed for that purpose, who have
not perverted their reason by a servile attachment to
any system of medicine. It will be sufficient for our
missionaries to know, that a powerful epidemic chases
away, or mixes with all other diseases, to be ac-
quainted with the different states of the pulse, to be
able to open a vein, to administer a few strong doses
of purging physic, and to gratify the calls of nature
in their patients for cold water and cool air.
I enjoy, in the prospect of these events, a conso-
lation which surpasses, beyond calculation, all the
distress and pain I have felt from my unsuccessful at-
tempts to introduce the remedies for malignant
fevers into general use among the citizens of Phila-
delphia ; for the men who are to live an hundred
years hence, and in foreign countries, should be con-
sidered as equally fellow citizens with those who are
our coevals, and who live and die in the same coun-
try with us.
THE END.