NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service bo ACCOUNT ,a,,- OF THE Contagious Epidemic Yellow Fever> WHICH PREVAILED IN PHILADELPHIA IN THE SUMMER and AUTUMN of 1797; . COMPRISING The quejlitns of its caufes and dome/lie origin, charattert^ medical treatment, and preventives* By FELIX PASCALIS OUVIERE, M. D. CORRESPONDING MEMBER OF THE MEDICAL SOCIETY OP CONNECTICUT, AND RESIDENT MEMBER OF THE PHILADEDPHIA ACADEMY OF MEDICINE. " Figttlus quidem figulo in> controverted ; for, mould they prove the pofii I ility of the impor- tation of the contagion, it will not affect cur doc- trine. Such facts, indeed, ought rather to imprefi. 12 ACCOUNT OF THE upon our minds, the important truths of the dan- gerous effects of any kind of effluvia from cor- rupted vegetable or animal fubftances, which are fo often unavoidably engendered in the cargoes of mips coming from tropical countries in the hot feafons of the year. Of this, there are as many inftances as there are eminent medical writers, on the fubject of contagion. Secondly, The importation of the yellow fe- ver cannot be doubted, when it is fo often known to have raged on board of veiTels both at fea and in port. Indeed, the French have derived their name of this fever, from its peculiar frequency among feaman; and feveral of their writers have called it la matelote. Be this as it may, two rea- fons are obvious, even in our opinion, to render the yellow fever more frequent among feamen. One is, that they are conftantly predifpofed to bilious complaints, as we fhall hereafter explain; and the other, that they are continually expofed to putrid exhalations. Thirdly, If thefe towns and places had not re- ceived, the contagion from tropical countries, we mould find in our hiftorical records more frequent inftances of a malady that is fuppofed to be of a domeftic origin. Formerly our fummers were ftill hotter, and more infupportable than they are at prefent; and our towns, or rather villages, were deftituteofanyimprovement,were often filthy and peceflarily neglected ; yet they were remarkably EPIDEMIC YELLOW FEVER. *3 healthy. Againft objections fo obftinately urged, I could oppofe undeniable proofs of great changes in many towns and places, of variations in the air, winds, and atmofphere, from whole- fome to peftilential, and vice verja ; but we have no certain data from fuch fluctuating pre- mifes to direct our enquiries. It is, therefore, un- neceffary to infift on them here, while we can, in a few words, fatisfy our reafon and judgement from well-known facts, more applicable to the point in controverfy. Is it not true, that putrid effluvia, infectious vapours, and poifouous miaf- mata, muft be more abundant and permanent, more often generated, and more fully difTemina- ted,in populous and large towns than in villages or thinly inhabited places ? I do not find, gentlemen, among the Englifh medical writers, any other peculiar opinion, on the origin of the yellow fever, except that of Dr. Warren, who implicitly believed, that it had been firft brought from Paleftine to Mar- feilles, and from thence to Martinico and to Bar- badoes, about thirty or forty years ago. All the works I have read, agree generally in the fupport of the doctrine of local exhalations. It is now time, however, for me to dwell a little on the opinions which, though much divided, have neverthelefs prevailed in Philadelphia, both among phyficians and others. The college of phy- ficians of this city, had officially expreffed, in the i4 ACCOUNT OF THE year 1793, an °pinion> that the feverhad becn im" ported from the Weft-India ifiands, and that it was very contagious. They have, by no means, depar- ted this year, from that.declaration. As we have not any publication, collectively, from that body, that could exhibit more, and ftronger arguments than merely their opinion of its importation, I fuppofe, that it is unneceffary for me to fay any thing either for or againft the opinion. An almoft equal number of phyficians, among whom are many. eminent characters, have uniformly fupported the contrary doctrine, that the fever was of a domes- tic origin ; and that it refulted from corrupted fabftances in the cargoes confined in fliips' holes, as well as from thofe impure exhalations to which we are expofed. Among thefe laft, however, a diftinction fhould be carefully made of thofe • who acknowledge its highly contagious nature, and the few who yet think that it is not of fnch a malignant character. I haften to obferve, that this affertion has been repeatedly publifhed Ly a few European and Weft-India practitioners, who have had but few opportunities of feeing many inftances of the malady of Siam, at leaft in Hifpani- ola, where it has very feldom appeared for thefe laft twenty years,- and where they have a better opportunity of treating the amphimerina biliofa of Savage, or what they call \zfievre lipyrienne or the Tritaeophya Americana*. Thefe are * Savage's Nofologia, claff. ii. febr. EPIDEMIC YELLOW FEVER. »* fimply reduced to an inflammatory typhus, and to the putrid malignant fever. This capital miftake has been, confequently, connected with afler- tions deftitute of necefTary demonftration ; it has expofed to doubt, and almoft denied, fome fundamental principles of phihology and practice, reflecting infectious uiforders and epidemics of camps, jails, fliips, and of all crowded places*. In a word, this miftake has erected a doctrine void of the deference due to the authority of writers in the healing art of the former and prefent age, I fhall analyfe, with more pleafure, the contra- ry opinion, for which documents, enquiries, and liberal and candid difcuffions, have been procu- red and unremittingly purfued by feveral phyfi- cians. xAmongthefe Dr.B. Rufhdeferves particu- lar notice ; becaufe he has fupported it, fince the year 1793, Dotn m bis lectures of the inftitutes of medicine, in the univerflty of Pennfylvania,andin feveral treatifes he has fince publifhed on the yel- low fever. He has never ceafed to warn his fel- low citizens of the prefence or proximity of the caufe of this contagion, in their fea-ports, wharves, ftreets, and ftagnant waters. He has ex- plained the phenomena of exhalation from a com- bination of vegetable and and animal putrefac- tion ; and, being aware, by long experience, and * It hns narrowly reduced medical afliftance to the infufiici- ent method of" diluting, cooling draught, and feeble cathartics, 16 ACCOUNT OF THE an enlightened judgement, that the inhabitants of this place were particularly fubject to billious fe- vers during the autumn, from fudden changes, and the extremes of the climate, and from the groffnefs and indigeftive quality of their aliments, he early underftoodthat infectious miafmata could aggra- vate tjie bilious remittent, and convert it into a ma- lignant and contagious fever. On this judicious ground he founded his theory and practice, and we fhall fee hereafter of what importance it has been to the difcovery of truth, and the improve- ment of medical practice. Having hitherto ftated, gentlemen, the hiftori- cal opinions of the raoft enlightened phyficians of Europe and of America, I muft obferve, that it was my purpofe to point out fuch of their opi- nions as were more congenial to the true bafis of the theory to which I have confined myfelf; and to illuftrate a pofition which has already occupi- ed fo greatly the public attention. I fhall add a few more arguments to fupport the local origin of the yellow fever and its highly contagious na- ture. A ftriking circumftance was formerly exhibi- ted by Pouppe Defpartes, a French phyfician, fent by the king into Hifpaniola. During many years he accurately obferved the ftate of the at- mofphere in the fpring and fummer. He noticed, that frequent and heavy rains, interrupted by fe- EPIDEMIC YELLOW FEVER. 17 rene weather, and intervals of heat, in thofe tro- pical countries, was productive of more dange- rous exhalations from the earth. He was thus ena- bled to foretell the appearance of the peftiler.tial malady of Siam, as he called it. He obferved, alfo, that, after heavy rains, the noxio's effects of ex- halations were checked by winds, or other circum- ftances. A few cafes from this veryjuft authority, will ferve to warn the inhabitants of our towns of the terrible effects of the exhalations to which they will be expofet', by the concurrence of rains, after long draughts, with the intenfe heat of the fum- mers, if they retain among themfclvesall the ma- terials of vegetable and animal corruption. Thefe materials feem to increafe with our population; and, in Philadelphia, I believe, there are more of them than in any other town in the union. TheyN may confift of the logs which form our wharvesj and which project to a confidrrable diftance in the water j of the boards with which almoft all in- clofuresof lots and houfes are furrounded; of the roofs of all our houfes; of numerous privy-houfes which are feldom emptied; and of many ponds and ftagnant waters, both in the city and fuburbs. If it fhould appear ftrange to point out, amongthe fources of exhalation, the very wood which we ne- ceffarily make ufe of for our dwellings and ports, I intreat my reader, before he rejects my afTertion, carefully to enquire into the natural laws and effects of exhalations from wood, timbers, new D 1$ ACCOUNT OF THE {hips, cellars, forefts, Sec. of which he will find ample documents in the writings of doctor Lind and others. Let him call to mind the number of wooden works in all our cities and ports, where the tide fucceflively uncovers and expofes the wharves to the fchorching rays of the fun, and then let him draw his conclufions. In proof of the fermentation of animal fubflan- ces, particularly during the heat offummer, which I have already fuggefted, I fhall propofe an expe- riment. Let a candle be lowered into a ditch, by means of a line, and it will be found, that the me- phitic afcending gas, will put out the light in pro- portion as it approaches the furfaceof the earth, and this effect will be much more certain in the latter end, than in the beginning of the hot feafon. When this gas afcends and is received into the atmofphere, it doubtlefs breeds contagion and death ; and I am fully fatisfied, that many people have, as well as myfelf, perceived and frnelt its effluvia, chiefly du- ring the calm and clear nights of the month of Sep- tember. Several interefting publications have appeared in the papers of Philadelphia on this fub- ject*. From this fliort fketch we may conclude, * It has been ftrongly contended in fome of them, that the wa- ters of the wells of Philadelphia are rendered noxious by burial grounds and other caufes. I confefs I have not yet heard fufficient; Ctbje&ions to deftroy this opinion. By the effect of fome local im- pregnations, feveral of our wells are particularly remarked for their bad waters. A resectable chyrr.iit of this city, analyftd the EPIDEMIC YELLOW FfcVER. 19 that the opinion of the yellow fever being generated among us, is founded upon pood ground ; and that it would be in vain to attack this opinion by the objections which have been mentioned and refu- ted above. For further fatisfaction, we fhall add, that the circumftance of its having appeared but once in Philadelphia, before the year I793» does not imply that it cannot be of a domeftic origin ; fince it is obvious, that it might have ac- tually fubfifted in fome or few cafes, among thofe bilious fevers that are endemic am->ng us in the autumn, without having beenmuch taken notice of. Would it be juft to fay, that this epidemic has never made its appearance in Philadelphia, ex- cept in 1762, 1793, and i79/i while there are creditable witneffes who have pofitively feen and obferved it, every year fince the atten- tion of phyficians and others has been kept up by the recollection of the calamity ? This fever, though fo highly contagious as to be compared even to the plague, may, like the plague, be wide- ly propagated or entirely impeded by caufes that favour or oppofe its progrefs ; for unaccoun- table changes and variations of heat and wea- water of his own well, and found that it contained a quantity of magnefia, muriatic fait, and uncombined alkali. This certain- ly does not prove much in favour of our waters; and I am ful- Jy aware, that this fubject requires a more particular inveftiation. I hope, thercfsce, it will attract the attention and fix the obftfr- vation of fome of our learned and philanthropic citizens. *o ACCOUNT OF THE ther, have fome Limes put an end to the latter in the heat of the fummer, and they have alfo in- creafed it in the middle of the winter. The cafe No. i,\v.'s that of a father furrounded with a numerous family of whom not one was infected but himielf. The fame facl hzs occurred to my obfervation, in almoft every family, in which the disorder proved mortil. In fuch cafes, the parents fecrete very little of the putrid miaf- mata ; they are much lefs infectious, becaufe the poifon is kept in their body to deftroy the func- tions of life ; and one of the moft deceiving fymp- toms is, that they feldom emit any difagrceable fmell. It is quite the reverfe, however, when they recover; and phyficians and nurfes are well acquainted with the infupportable fcetor, peculiar to that fever, which exudes from their bodies, and continues, for a long time after, in their bed and clothes. Confeqnently one or many mortal cafes of the yellow fever may have happened, without having been followedJby contagion. But it is farther objected, that the traces of the importation have been vifibly marked in Phila- delphia ; where the fever, having been commu- nicated by fomebody from Southwark, has in- fected the moft diftant part, which is Kenfington, and the houfes on the Frank ford road ; meanwhile there were but few fcattered cafes in the centre and northern partsof the city. This laft mentioned theatre of the difeafe, would, however, have been preferved iron, contagion if the epidemic was of EPIDEMIC YELLOW FEVER. Si a domeftic origin ; for the place is cuite open, and prefents a view of many country feats, and being not on tliefame ftraight line cf the town, it cannot receive its exhalations. However linking and conclufive this whole objection fee ins to be, yet what will be thought at laft, by an unprejudi- ced reader, when he re^ollcchs that Kenfingtcn, and all the adjacent grounds, are wholly a kind of naval yard, full of timber, and more than any other part of our iuburbs, furrounded with niarfhy grounds, and ftagnant waters. The adjacent banks of the river are, befides, filled up with all the rubbifh of new and old timber. So much for the origin.of the yellow fever in Kenfington, &c. In fupport of the opinion, that the yellow fexer is of domeftic origin, why fliould we not derive, gentlemen, fome authority from the medical doctrine already known and promul- gated in all the fchools of the world ; of the pof- Able infection of diforders generated in places where people are crowded, or where unwholefome exhalations are produced ? The hiftory of jail diftempers^of fevers on board of fleets, and of va- rious diforders in camps, teaches us that it is not requifite to fearch for the origin of our calamity in diftant countries. We muftnot be unaccuftomed to the idea, that our atmofphere may bepoifoned as eafily as a plant growing in our fields. From all the corners of our extenfive continent, winds may blow over us, as dreadful as the Siroco of Ara- __ ACCOUNT OF THE bia and as the Harv:r.ttan of oriental Africa. Bar- ren and uninhabited lands, thick and extenfivefo- fefts, have been known to fpread, even to the dis- tance of many miles into the fea, miafmata of con- tagion and death. To incredulous and fyfter ntic theorifts, I fhall exhibit the faithful evidences which we may derive from theinftinct of ominous birds. If my mind was not diftracted by error and prejudice, I faw, repeatedly, during the two in- ftances of our calamity, vultures flying over our afflicted town. Thefe kinds of volatile and carnivorous animals, never wander but in the « currents of miafmata and putrefaction. This is the means by which, in a few hours, they reach their diftant and putrid prey. This is alfo a proof that our atmofphere was infected with the corruption which created our epidemic. For an imported diforder cannot infect the atmofphere, any more than our fources of exhalation. It remains now with me, gentlemen, to make a few more obfervationson the contagious power of theyellow fever. Ihave already noticed, that very few opponents have appeared againft that opini- on ; and it is certain, it will meet with none in the fchools of America. The doctrine of the noxious qualities or fubftances of which the air and winds may be the vehicles, has been handed down to us by Hypocrates ; and wonderful im- provements in chymiftry have ftill better explain- ed this truth, and all its phenomena 5 for the EPIDEMIC YELLOW FEVER. ?j idea of contagion implies nothing elfe but the tranfmiflion of certain principles of diforder, whether conveyed through the medium of the air or by an immediate contact. When this effect takes place, bodies are laid to be infected ; and fureiy as many diforders as by their particular effluvia always excite the fame morbid ftate, fo many muft be contagious. Happily, in the long catalogue of dikaies to which we are fubject, thefe are, comparatively, few. Although conta- gion may arife from noxious effluvia, floating in the air, yet it feems that the fame principles ac- quire more malignancy when they are propa- gated by the channel of difeafed human bodies. In them, the contagious miafmata regenerate and multiply ; and, if they were not checked by fa- vourable changes in the atmofphere, who could forefee an end to a malignant contagion * 1 Such * Dr. Poiflonier, and Dr. Lind have tranfmitted us the follow- ing memorable account of the contagious fever which ravaged the fleet of Mr. Dubois de Laraotte, in the year 1757, in the town of Bred. This fleet was, at firft, joined at Breft by two mips of the line, the Glorieux and the Due de Bourgogne, both of which had received on board fome men from the hofpital at Rochefort. Dur- ing their ftay at Breft, the contagion wasfo rapid, that they were obliged to fend four hundred of their fick on (hore. On the 3d of May, the fleet failed from Brcft to Louiibourg, but both during their pafi'age to, and ftay in that port, the fever became general, and was attended with a confidc-rable mortali- ty. On the 20th of Oaoiw, the fleet failed from Louifbourg, ta- 24 ACCOUNT OF THE are, alas ! thofe contagious poifons, the elements of which are heavy and fixed; they are indepen- king on board their fick, but leaving about four hundred in a dy- :;-)_; date. At fea, t!:e contagion acquired new vigour. In a very fhort time, the whole fquadron was difabled ; anil, on their ar- lival at Breft, on the 22J of November, the few remaining fea- men were fcatcely fuiiicienc to navigate their (hips, laving no lefs than four thoufand men ill. All their furgeor.sand almoners were either fick or dead ; and, when they arrived, fea men were immediately fent on board to bring them to anchor, and furgeons t"> afiiit the fick. Unfortunately, four thoufand more arrived, at the farm time, from Quebec, in the Bi-zirn- ami Celebr?, two men cf war, i:ito which tie ficknefs was communicated by the above fcjujdrrn. During the general confufion, they had been promif- ctr ufly crowded into the town of Breft, wherever they could get ;sdmi_ion. Fikeen hofpitals were, at iaft fitted up. Phyficians and fur/r..-is came from all parts vt France, an! voluntaiily gave their fenices, befides thofe who were commiii'oned by the court. T!.v-icfphais were fo crowded, that at laft the mortality fpread among the attendants Five phyficians, one hundred and fifty furgeons, and two hundred almoners and nurfes, fell viclims, together with a great number of flavts, who were engaged to al it the fick, upon a nr>mife to receive their liberty. From the- attendants, the fever paffed to the lower clafs of people in Breft, among whom it quickly o.iftufed itfelf. The havoc then became general; and the houfes were filled w ith the dying and the dead. A proclamation from authority, had promifed the fick", that they would be yro\i.icd with the attendance of a phyfician, or any ether r.ectlLry mesns of afiirtance, if they would give proper notic?. But, it was foon found, that, in many houfes, not one was left who could give the notice, and that, in others, dead belies fcodremam-d without burial. In fine, the month of April brought ?. gradual ard abfolute ceffation of this contagious epiJenvc, whkh, in lefs than five months, fweFt off ten thoufand people in the hofpit,], alone, befides the inhabitants who di.vi in the to*n cf Brett, _p..l -,\ho could rr: be numbered !!! EPIDEMIC YELLOW FEVER. a5 •dent of our controul, and from generation to ge- neration they perpetuate among men, and af- flict or blemifh the nobleft family of the living creation. But the yellow fever, gentlemen, has manife£ ted fuch particular characters of a highly contagi- ous malignancy, that it fuggefled to many, no doubt, the idea of importation, which could not indeed, be denied, were there not fo many and fuch powerful reafons to invalidate it. It was not like an epidemic which ftrikes only at certain in- dividuals, of the fame difpofition, or defects of conftitution ; and thus difclofes, at laft, what kind of victim it endangers. It does not, like the ague, threaten thofe of lax nerves and fibres; like the catarrhs or influenza, falling upon the humourous ; like the autumnal fevers, afflicliBg the bilious ; and like inflammatory diforders, fei- zing upon the plethoric ; no, the yellow fever has fpared neither fex nor age. The infant in the cra- dle, as well as the mofc aged, were alike expofed to its attacks. It feemed, indeed, very general among poor, intemperate people, and in filthy houfes ; but we have feen alfo its power on thofe, who, among all the comforts and coveniencies of life, were unfortunately reached by it. Its irre- gular march and progrefs, its appearance in op- pofite extremities of the city, without any vifible way of propagation, could not be explained, had E .5 ACCOUNT OF THE it been an epidemic retaking from general extcr* nal cr.ufes, ana not pofTefi-ng any conta&ion. Mcrtovei, thefe principles and facts o-rinot, in theleaft, be irvalidated by oc.jecting, that a con- tagious diforuer could not remain confined in maritime towns; and thrt, like the plague, it v/ouid have found its way to populated coun- try places ; for c en the plague abated entirely in Aleppo in the height of the fummcr, when the extreme heat, dilating too much tire peftilential miafm ita, probably rendered them harir.lefs. It disappeared in Vienna, in 1713, as foon as tem- pcftuous winds blew away its aerial venom. By other unaccountable caufes, it equally broke cut during the winter and fummer, and alfo equal- ly dif-ppeared, during each contrary fcafon, in Okfacow, in the years 1727 and 1738. If the plague could be checked by contrary changes of feafon, and even by the heat of the fummer, who will be aftonifhed at finding that fome reafons alfo excludes generally the yellow fever from the coun- try ? Thefe reafons are not incomprehenflble; for the pure, open, and elaftic air of the country, muft difpel.the infectious miafmata. And there, with all the balfamic- and wholefome fragrance cf a ufeful vegetation, with all the benefit of exercife and falutary labour, preventives enough may be found againft contagion.. EPIDEMIC YELLOW FEVER. t-t .. Let us now enumerate the fundamental obfer- vations which refult from this'firft fection. I/?, The yellow fever is generated by pu- trid effluvia from vegetable and animal fermenta- tion. ily, The opinion that it was imported, on_ hundred years ago, from the kingdom of Siam, into the Weft-India iflands, and from thefe iflands to North America, cannot be a elm it ted ci-:- clufively, to its being generated fpontancouily in every warm country, from the abot ementioned caufes. %ly, We may more affirmatively pronounce, that the yellow fever may be an indigenous dif- eafe among us, fince it was obferved by ancient phyficians in fimilar climates, andpiob?bly under (imilar caufes ; fince we are expofed to fuch ex- halations as feem adequate to its generation ; and finally, fince, in the paft progrefs of the difeafe, there muft have been fome place and time in which it was generated and not imported. . 4fy, The yellow fever is of a highly malignant nature and contagious power. 2S . * ACCOUNT OF THE SECTION II. Phyfiologicat and Pathological Defcription of the Tellow Fever. From all the documents whichhave been trans- mitted to us, both by Englifli and French writers, there is no room to doubt, that the diforder which they have called the malady of Siam, the mate- fate, or the yellow fever, is exactly the fame which has, in feveral inftances, "raged among us. It feems, however, that our epidemic, differs, though not materially, in fome of its fymptoms, from that of the tropical countries. Dr. Johnfon, has, indeed, acknovyledged three kinds of yellow fever. With refpect to them, I fhall, juft fmrply remark, that, if there are three diftinct and appa- rent degrees, they muft be owing to the following obvious circumftances. Firft, that of its effects or attacks on a patient who quickly becomes its vic- tim ; fecond, of one who, without great difficul- ty, or danger, palfes through itsftages ; and laftly, of thofe, who, with proper afllftance, get over the refolution and crifis. Thefe three characters, are, undoubtedly, the natural refult of the differ- ent degrees of contagion, or of the conftitution, habit, and previous complaints of the patient. There is confequently but one fort of yellow fe- ver. This malady fhould, befides, be confidered only during two of its periods, that oflts/ymptomr and that of the crifis, In praftice, this divifion is EPIDEMIC YELLOW FEVER. 23 a very juft one. It traces, exactly, the limits of medical treatment, and is a fare mean of fug- gefting trueprognoftics*. When death is unavoid- * I beg thofe of my medical readers who are profeffedly at- tached to the fyftem of Dr. Bro^n, and which appears to have been introduced into the univerfity of Pennfylvar.ia, to diveft themfelves of prejudice againft a theory, and to examine with can- dour a work, written in the good old fcientifical language of Hv- pnerates, Boerhaave, and Cullen; for 1 have not any prejudice^ myfelf againft them. " Till this day, theories have often changed, " while praclice remains the fame ; and it was the docdrineof a " celebrated author (Dr. Cullen) that medical hypothefis is but a •* chain to link farts together;" [Analytical Review, Aug. 1789, Jtrt. viii.) I have often been induced to contemplate this doc- trine, either from the confideration that men of great genius and, information have adopted it, or from a determined refolution not to condemn, what, perhaps, I did not properly underftand. With great reluctance, however, I would have exchanged thofe Ample elements that fo eafily explain the laws of nature, the phe- nomena of life and vegetation, for a metaphifical theory, which. from the pofitive qualities of bodies and fubftances, carries us in- to a feries of complex and occult modes of action. If a perfon can underftand all the phenomena of health and life, by the obfeure ideas of excitement being always evolved in a ratio to the quan- tity of the excitability, and exciting powers, which muft al- ways bear a due proportion to each other, &c. let him enjoy hi? conviction. But, why cannot the fame conviction refult from the fimple laws of human life, as anatomy and phifiology exhibit them to our obfervation ? As for the fticcefs, which might in practice be derived from that theory, it is a delicate matter, and I will not avail myfelf of thofe farcaftic comments upon it which I have frequently read. This much I can fay, that I be- lieve the doctrine may be of fome advantage with men of genius, but I am fatistled that it leads to capital miftakes, thofe who di- rect themfelves by it, whilft they do not underftand fulficiently tht fundamental laws of nature* jo ACCOUNT OP THE ably the final refult of this diforder, it is equally horrid and infidious. Penetration and attention are, therefore, the firft and moft erfential requi- res to keep us from indulging thofe erroneous and falfe hopes, which, both the patient and his friends, are too apt to entertain. A turgency of the blood veflels, or what we call a plethoric ftate, may, during one or two days, precede the attack, but is feldom taken notice of by the patient; and no other previous indifpofition can be remarked. Whatever then may be the ftate of the body, the. fever fuddenly and tumultuoufly breaks out. Spon- taneous vomitings of yellow, green, and gluti- nous bile ; a depreffing head ache ; a numbnefs of the limbs, and joints; a burning heat in the face; and rednefs in the eyes; inline-? diaiely take place. Such rapid and violent changes in the whole frame, are, I believe, un* common in any kind of fever, and belong only to the plague. During the two firft days, this ftate admits of but little change. Short intermif- fions, are, however, fometimes obtained by means of the remedies which are adminiftered. The patient may pofTefs all the other febrile fymp- toms; but I have feen none of them more fre- quent than delirium and coma. We next dis- cover an ominous and abfolute proftration of ftrcngth, an abatement in the pulfe, an entire ceHation of feelinp-, and an infidious fecurity in the patient, who fancies himfelf faft approaching EPIDEMIC YELLOW FEVER. 3» to a recovery, and who only complains of a want of ftrength. He foon after, however, expe- riences frequent and fhort chills; and his evacua- tions are colliquative, foetid, with yellow or white matter. He then fighs deeply ; is reftlcfs ; and he cannot even bear the weight of a covering upon his body. He next appears totally infenfible either to heat or cold; his fkin is dry; there is no kind of exhalation or difagreeable fmejl about him, and even very little is perceived from his breath. He has no thirft, but he can urink any thing. Naufeous medicines, or agreeable food, are alike received into his ftomach without fick- enino- it. His tongue as yet portends nothing alarming; it is covered, however, with a kind of thick white cruft, from the root to the edges, which remain perfectly red. In this ftate his urine feems flopped, although he drinks much; and, if he voids any, it is generally purulent. This period of the difeafe, in which the delufion of the patient exifts, notwithftanding the ceffation of his regular functions, is highly expreffive of the diforder being unconquerable; and I ven- ture to affert, that when it is obferved in the fecond or third day, it ought to determine the phyfician to give over, without hefitation, the ieaft hope of a recovery.The patient will be in the agonies of death as foon as the third d?y in-rivcs, hiiu nsver later than the fifth. j_ ACCOUNT OF THE Another more infidious ftage than the former1, may take place in the beginning of the difeafe, and laft two or three days. It is not fo rapid in its progrefs, but is equally fatal in its iffue. In this cafe, an ardent fever, which, however may be occafionally abated by judicious remedies, is the only characteriftic. Under fuch circumftan- ces, how anxioufly ought the phyfician endeavour to bring on a change or a crifis ! On this point, I cannot too ftrongly infift : for here the deception of that ficknefs lies, in which it isfo difficult to dis- cover any dangerous fymptoms. Several of them are, however, to be remarked. Firfl, Although the patient may be acted upon by medicines, he is certainly deprived of falutary evacuations ; and chiefly of thofe which we fhall hereafter defcribe as the only proof of a fuccefsful treatment. To be deprived of them, before the third day, is a fure prognoftic of death. Secondly, The patient complains but little ; and a kind of ftupidity, refulting from the flow- nefsof his ideas, forms a ftrikingcontraft with the watchfulnefs and the confufion of his countenance. This fymptom is more alarming, and is direc- tly oppofite to the inquifitive anxiety and irrefif- table uneafmefs of» patients in common cafes. Thofe, therefore,who are heft acquainted with the natural difpofition of the perfon who is fick, will bebeft able to judge of this decifive fymptom. EPIDEMIC YELLOW FEVER. 33 Thirdly, In all his actions the patient fiiews an uncommon degree of ftrength; while repeated exacerbations of fever, frequent bloodlettings,and want of nourifhment, mould render him very weak. This very ftrength, however, is unnatural and contrary to the appearance obferved in fa- vourable cafes. It is the effect of an univerfal fpaf- modic conftriction of the nerves, and indicates the dreadful action of the morbid caufe upon the vif- cera, and is manifefted by a kind of trill in the nerves, or by an involuntary fluttering in the mufcles, which wp may evidently perceive, if we keep, attentively, during a few minutes, the hand or the arm of the patient in our hand. This laft fign claimed my particular notice, and it has al- ways proved Angularly ufeful to me. Fourthly, and laftly, we may always difcover, that each of the exacerbations of the fever are preceded by horripilatio, or violent chill. After thefe four fymptoms have taken place, we mould never put any dependence either on the pulfe or the tongue ; for, whether the pulfe be febrile or not, intermitting or regular, it progno£ ticates nothipg decifive for the patient, unlefs we can diftinguifli it hard, and tenfe, and pofTeffing a fpafmodic and fatal conftriction. The tongue alfo prefages nothing conclufive ; it Vill be found white or foul all over its upper furface, and its edges red. If the patient remains for fome time F ACCOUNT OF THE without d-h'.k, a triangular red fpot will appear fromtl'.eedgeto the centre of the tongue. But after a dilntingdrauohtthis dii^ppcars ; and thele Mates t.:ke place, both in cafes of death and recovery. One appearance of the tongue, however, is omi- ■nnis in the firft days of the difeafe; which is, v her it turns black or brewn, befo: ethe laft exa- (.- -.at!, n of the fever, which generally fubfides on the fourth clay. Hiccough or an abfolute fupr: ciT.on of urine, are like wife very dangerous fvmptoms, if they take place before the time of the refolution of the fever; t>ut if the firft hap- pens after it, it happily conftitutes the final and faiutary crifis. Another fymptom ufual in malignant fevers, but particularly in this, is a kind of fmall red petechii, very fimilar to flee bites. They appear on the hands, the neck, the breaft, and alfo on the face. Many fuppofe that they are from the bites of mufquitoes, or of other infects. A phyfician may know better, but cannot derive from them anything further than a proof of the malignancy of the fever. (Vide cale No. 4.) I dwell more particularly upon thefe apparent- ly triding circumftances, Lecaufe they are of the Utmoft. importance towards aiilfting us in our en- quiries. Phyficians rre, alas! pecularly liable to error in ?. difordcr fo difficult to judge, and fo violent in its attacks. From an affectionate regard EPIDEMIC YELLOW FEVER. 35 Jo their patients, or from a reafonable pride in their own medical fkiil, they are fometimes over confident of their fuccefs ; and too frequently, in, the event, the friends of the patient, are unhappily plunged into difpair, at the difappointrnent of their expectations. Would it not be more pru- dent, then, in cafes of iminer.t ch^ie", to cau- tion them againft it; and thus, when the utmoffc of our Ikill is baffled, to deferve the.r confidence and gratitude by our candour ? I now arrive at that fatal peri d, vv ?n, V V the deadly eTet of the decompofition r: j mor- tification of the animal fluids, all the f-:r.rgles of nature are entirely overcome. On tk^ fhurr! cury, this period is announced by the palenefi of tl ;_-fMn and the extreme debility of'the pulfe; nrkf:, indeed, as it frequently happens, a ftill more \ i< - lent degree of contagion has, through uncommon circumftanGes, produced thefe fymptoms fooner. The feelings of the unhappy patient have now loft fo much of their power thatlie is totally incapable of giving any account of his confufed fenfations. His fkin becomes gradually tinged with a yellowi/h colour, while his lower extremities become of a deep red and are a little fwelled. The eyes loofe that remarkable animation which they before pof- felted, and appear defponding; while the coun- tenance becomes confufed and grim. Naufea, at tljis period, is a common fymptom. If drink be thrown up, it is not altered from the 3 The opinion, that the yellow fever is a true bi- lious one, and differs only in degree, wThich is the higheft and the moft malignant, has been al- ready known and fatisfactorily proved by Dr. B. Ruflr*. With this principle as a guide, many er- rors, fyftems and conjectures might have been long fince difpelled, or at leaft better explained. Thehiftory of its fymptoms, exhibits, in the plain- eft manner, the corruption and malignancy of the bile. As foon as the patient is fcized, he fpon- taneoufly vomits bile; and if he recover, it is by the means of fuccefsful and copious evacuations of hepatic and cyftic bile. If he die, it is evident- ly in confequence of the mixture of the bile with the blood, and the mortification of all its vifcer_> and refervoirs. All the anxieties, naufea, pains, obftructions, and exacerbations of fever, in every cafe, feem evidently caufed by the fermentation, the ftagnation, and the acrimony of the bile. In {hort, if morbid bodies be examined by defection, new ravages of the bile are alfo difcovered. From * Account of the bilious retnittir.o velloiv fever, -tc in tha year 1793, by B. Rufli, M. D. 44 ACCOUNT OF THE thefe facts, what other inferences can be drawn, but that of fixing the pathology of the yellow fe- ver in thofclaws and accidents that are connected with the bile. In order then to eftablifh fome rea- sonable ground, let us firft enquire to what uni- form caufe we may attribute all the above men- tioned fymptoms. Hippocrates has obferved*, that autumnal fe- vers were attended with jaundice, in confequence of people living upon rich beef, and Boer- haave! admits acrid bile and poifon among the caufes of the worft kind of jaundice. The liver, from its nature and functions, receives a great quantity of blood from the venaporta, to prepare the bile; we may therefore conclude, that difeafes of that vifcera, might difturb or alter the bile, and vice verja. But, if a poifonous exhalation has, by its affinity with the bile, diffufed itfelf in the alimentary canal, it is very probable that the infection will early reach, by many known paffages, its very fource; and the liver, the gall bladder, the duodenum, the ftomach,&c. will then be difeafed by a poifoned fluid, which ftimu- lates, inflames, and corrodes them. Hence the jpontaneou? vomitings of the bile, Befides, before this infected bile could be fufficiently diluted, neutralized, and evacuated, it is obvious to think, that the whole liver, being affected either direct- * Aphor. 62, SeCl. IV, + Idlerus multiplex. § 916, EPIDEMIC YELLOW FEVER. 4< ly or indirectly, will no longer be fo eafi'iy infil- trated nor receive that mafs of blood it ought to admit ; and this, by revulfion, will pals down the iliac and mefentcric veins tothejf laft anaflomoies with the fmalleft arteries ; and hence the violent and inflammatory fev?r with all its attending fymp- toms. Nature has but two or three davs to ilip- port the violence of fuch a ftruggle. The poifon ceafes not to act iron the very texture and mem- branes where it is inclofed; it may perhaps be poured again* from the liver into the duo- denum and the ftomach, withftronger acrimony ; and there is always enough of it to contaminate the blood in the venaporta and that of the vena cava, from which it mixes at laft with the general mafs, and produces the black vomit and theiderus. I need not to relate all the other ac- * I have it in my power clearly to prove, that the black vo- mit is the hepatic bile itfelf, which is completely corrupted in the liver, and confequently mixed with the blood, by an authentic fad, taken from an account of the difledions of Dr. Phyfick and Dr. Cathrall, publiihed in Dr. Rufli's account of the yellow fever of 1793, page 12 r. 11 In two other perfons, the ftomach contained, as did alfo the « inteftines, a biack liquor, which had been vomited and purged " before death. This black liquor appears clearly to be an alter- «* ed fecretion from the liver; for a fluid, in all refpeCls of the " fame qualities, was.found in the gall-bladder. This liquor was " fo acrid, that it produced confiderable inflammation and fwel- " ling on the operator's hand, which remained fome days. The " vifcous membrane of the intefriiiw:-, in thefe laft two buiics, '■' va> found inflamed in fr.venl rh,:\ " 4* ACCOUNT OF THE cidents of gangrene, hemorrhage, eruptions ofany kind, and of death ; becaufe, to my medical rea- ders, this theory, founded upon facts, will be diffident to account for every thing. Another frriking proof in favour of this theory, may alfo be drawn from the inarch of the difeafe in a re- covering patient. His cure will either be rapid or tedious according to the efficacy of his evacua- tions, which, at firft, being cluefly compofed of the cyftic bile, appear very green, but afterwards turn to a yellow colour, owing to the hepatic. It muft, however, ft ill be remembered, that no fymptom, diagnoftic, crifis, or accident, can bet- ter defignate any future fuccefs, than a continu- ed and uninterrupted evacution of the bile. Af- ter all thefe phyfiological and pathological argu- ments, we muft undoubtedly conclude, jfi, That the yellow fever is the firft and high- eft degree of malignant bilious fever, the proxi- mate caufe of which is a contagious gas received into the alimentary channel, and into all the vif- cera of the bile; and that this original circum- ftance diftinguifhes it from the plague, which is produced by a poifon immediately received into the blood. zdly, The contagious miafmata which confti- tutes the yellow fever, is, at firft, received into the bile. It there alters it and flops its circulation, excretion, and fecretion ; and it afterward:., by EPIDEMIC YELLOW FEVER. 47 its acrimony, inflames and produces a mortifica- tion of the abdominalia, and a decompofition or putrefaction of the blood*. idly, It appears, alfo, that there is but one fort * My difiertation in anfwcr to the honorary prize-queflion pro- pofed by the Medical Society of Connecticut, in the year 179^ on the chymical properties of the yellow fever of New- York, &c contains a theory apparently contrary to the above phyfiological and pathological arguments. It is confequently requifite for me either to make fome apology or to give a proper explanation.Were no improvement to be expected from repeated inftances of the fame fails, any fcientifical attempt would no longer be praife- vvorthy, nor repeated investigation meritorious. My theoretical conjecture, however, that the calorie of a hot fummer, might produce, by the abforption of aqueous particles, the fermentation Or putrefaction of the blood, and thus create a malignant fever, is the nataral refult of adopted clement* and principles., By the help of thefe, we never fall into contradictory opinions, although we are liable to miftaken applications. Befules, I had long fince fufpeCted that contagious effluvia might contaminate and rorrupt the animal fluids, as well as that they might be altered by the lofs of fome of their component parts; and this was my be- lief in the above mentioned differtation. << It may be faid, thu: contagions miafmata, whether imported or locally produced, when admitted into the blood, will caufe its putrefaction. We know that there are fome proofs of fuch dreadful effects, and we are acquainted with the deleterious qualities cf mephitic air. There are, no doubt, other caufes, which alio defiroy the equili- brium of our component parts. There are, in fact, chymical phe- nomena) which may arife in auy town or neighbourhood where there are pefiilential effluvia.*' Vide Drfertatian on the prize-quefim propffd by the Medical Scciety of Conneftkut on the diymical proper- ties of the efflu-via of the contagim of tbryrlUxv fiver in -V-ic-i'-ivf, Aft. XI. P. 9. 48 ACCOUNT OF THE of yellow fever ;' that its different degrees of malignancy originate from obvious circumftances ; and that the diforder will prove fatal or not, ac- cording to the mode of treatment, or to the na- ture of the conftitution and previous ftate of the body of the patient. afhly, There are but two periods of the di£ order, that of the fymptoms, and that of the crifes. The firft generally laft three days, feldom five, and inftances have even occurred of but one day. The crifes always prove mortal if they appear before the third day. The fymptoms are, fpontaneous vomitings of the bile, or naufea ; violent fever ; ficknefs of the ftomach ; florid ftate of the face ; reftleffnefs ; pains in the limbs and in the back; and a prof- tration of ftrength. The crifes are, hemorrhages ; fwelling and fup- puration of the parotids; petechia?; jaundice; fluxes from the bowels; and black vomit. $thly, In cafes of recovery, the fever is remit- tent during feven days, like the caujos or febris ardens ; all the crifes may fafely take place on or after the fifth day, except the black vomit ; but early and profufe evacuations of hepatic and cyftic bile are the only critical figns and proofs of next recovery. EPIDEMIC YELLOW FEVER. 49 SECTION III. Method of Treatment of the Yellow Fever* Within thefe laft five years, the period in which the yellow fever has made its general appearance in America, feveral methods of treatment hav. been publifhed here; and the fame fubject has alfo been ably difcuffed by ma- ny eminent Weft-India writers. I will not, gen- tlemen, attempt to comment or decide upon the refpective merits of either ; but, I muft confefs, that I have never yet been able fufficiently to difcover by what indications the ufe of their re- medies was to be directed. Thus it frequently happens that they fometimes fucceed and fome- times not; and the mercury, bleedings, bark, cold or warm baths, acids, blifters, Sec. often fail- ed even in the hand's of thofe who contended the moft warmly for their application. If they afterwards attempted to explain under what circumftances their propofed method has fail- ed, they have generally offered vague pretences and uncertain rules. Let us then, with can- dour, declare this unexceptionable rule in me- dicine, that no method of cure fhould ever be depended on, unlefs it be founded on fuch H $a ACCOUNT OF THE rational grounds that the remedies employed will anfwer, under every circumftance, the indications of the difeafe. Experience has, at hft, proved that bleeding and mercury are iufficiently powerful to conquer the moft ma- lignant degrees of the yellow fever; yet, in the ufe of thefe remedies, the greateft care and cir- Cumfpection are requifite in order to infure ttheir fuccefs. Before I enter upon the explana- tion of my method of treatment of the yellow fever, and of the proper mode of adminik tering thefe fundamental remedies, fuffer me, gentlemen, to obferve, that, in America at leaft, Dr. B. rlufh has the honour to ftand foremoft in fupport of their efficacy. While no other method feemed equally fuccefsful, that of ve- nefection and calomel was fupported, during the two inftances of our calamity, notwithftanding the moft bitter invectives and farcaftic publica- tions were continually levelled againft it. Some unfortunate and unfuccefsful cafes were held out as proofs of its danger ; and the charge of pro- fufe and indifcriminate bleeding wras exbited as a murderous practice. Thefe objections, how- ever, when weighed with impartiality, will be found to refutt from the unavoidable incon- veniencies of a temporary and violent epide- mic. One may arife from the method of indica- tions, which cannot, in cafes fo uncommon, be equally well-underftood by every phyfician ; and EPIDEMIC YELLOW FEVER. Si the other, fromtheimpoflibilityof conducting the fick with regularity anddifpatcb, among fo great a number of patients, who are often deprived even of the neceffary accommodations, or who fre- quently miftake their own cafes ; and who, in the height of their defpondency, communicate their terrors to the attendants. Too profufe and indifcriminate bloodletting, may have occurred in feveral inftances ; but I am happy in affert- ing that, as far as I am acquainted with them, they could not be fairly derived either from the private or public opinions of Dr.r_ufh. It is, therefore, peculiarly pleafing to me, that I am thus able, in fome meafure, to vindicate the character of an eminent and humane phyfician ; and more cfpe- cially Co, becaufe in fome points of theory I may be found to diffent from him. It is only from the pathology of the yellow fever, that any fafe or efficacious rules for its cure can be derived. For every judicious ob- ferver, will candidly acknowledge, that, if the numerous remedies which have hitherto been re- commended for the yellow fever, have produced a cure, they have like wife too frequently failed. If then it be a fact, that the contagion peculiarly connects itfelf with the bile, and corrupts it, we may clearly and fafely eftablifh, as afirfi in- dication, that the bile ought to be fpeedily eva- cuated, purified, and renewed. If it be true, that 52 ACCOUNT OF THE the morbid ftate of the bile caufes its ftagnation, produces obftructions in the liver, and prevents the entrance of a confiderable quantity of blood into that large vifcera, we may point out as ano- ther fundamental indication, the neceffity of fpee- dily oppofing the immenfe revulfion of the blood in the arterial fyftem, which increafes the general fpafms, together with all the fymptoms of inflammation, and which continually endangers the life of the patient*. Infine, if it be a fact that the bile, when infected, will contaminate the blood, and vice verf'a; and when the whole frame, labours under iminent danger of putrefac- tion, thatthfiKmimal fluids muft undergo a depura- tory crifis within a certain fpaceof time, and that by the means of natural or artificial exertions, it will be neceffary to be well-acquainted with all the accidents attending malignant and putrid fevers, to •accomplifh all the jecondary indications, and to obtain, as regularly as poffible, a perfect refolu- tion of the malady, without unneceffary or dan- gerous means. To give, however, gentlemen, a * I find with pleafure that the theory of this pathology has been already adopted by refpeCtable writers, and has been afcri- bed to the bilious fevers of warm countries, among which our yellow fever is of the firft and moft malignant degree. " Whenever there is a deficiency in the powers of the circu- " lating fyftem, the larger veffels are diftended, particularly the " vena portarum ; this caufes the bilious evacuations in warm «< climates." Critical Review for May, j 7 95, on Ruftft bilicut jtl-, Ij-jj fever. EPIDEMIC YELLOW FEVER. 53 more explanatory view of primary zxxdfecondary indications, for the mode of treatment of the yel- low fever, fuffer me to exemplify them by the fol- lowing hiftorical cafe, wherein I fhall notice the minuteft circumftances, both with regard to the difeafe and to the medical prefcriptions which were adminiftered. T . .. B... about twenty-two years of age, was of a found conftitution, and of a regular life. He had lately loft his father and a brother in the prevailing fever. After their death, he, with the reft of the family, went into the country ; but he had already been infected with the contagion, This was foon manifested by all the alarmino fymptoms, but chiefly by the fpontaneous puking of the bile. He was immediately carried back to town, where proper affiftance might be obtained ; and, before a phyfician could be fent for, an expe- rienced nurfe had ordered him to be copioufly bled, and had given him a dofe of falts. Thefe orders were good but infufficient, and nothing further was done until the evening of the fecond day. At this time I was called in, when I found him extremely ill, and very nearly approaching to that proftration of organic action which does not even give time for an exacerbation of fever. Having juft loft his parent and a brother with this fame difeafe, he could not but confider liimfelf alfo as a devoted victim. His fpirits were, there- j4 ACCOUNT OF THE fore, uncommonly low, and he appeared invo- luntarily to flied tears. This circumftance, agree- ably to the rule of Hippocrates, I confiderccl as an ominous and fatal prognoftic. A confufed and grim countenance, cold extremities., and a hard and low pulfe, marked the rapid progrefs of the difeafe, during only thirty hours of ficknefs. All the good effects that might have refulted from the firft copious bleeding, had been loft ; fince no proper help had been adminiftered for the eva- cuation of the bile. My firft confederation was, therefore, to endeavour to raife the exacerbation of the fever to its natural courfe; for wuthout it the difeafe can never go regularly through its different periods, and the patient will irrevoca- bly die, if he is fo much exhaufted that it cannot be produced. To obtain, therefore, this defira- blc change, I depended much upon the action of the mind on the nerves, and eadeavoured much to raife the hope and confidence of the defpairing patient. While I kept his pulfe and hand within mine, they acquired a fenfible energy. His extre- mities became warm ; and, wifhing to remove every obftacle to the operations of the treatment, I immediately ordered a carminative and nitrous injection. Thus I confidered that the previous congestions of the feces might be difcharged, and that the fubfequent and neceffary evacuations could no longer be retarded. At night, the patient was, agreeably to my willies and expeaa- EPIDEMIC YELLOW FEVER. 55 fions, feized with a violent exacerbation of fever, attended with delirium. This ftate gave the po- fitive indication of a copious bleeding; for by it I fulfilled the fecond fundamental indication abovementioned, viz. that of emptying the blood- veffels, when the blood can be no longer admit- ted into the liver, and when the large veffels are in a ftate of infection. Agreeably to tins indica- tion, the patient loft fifteen ounces of blood on the night of the fecond day. Without iofing time, the bile was to be evacuated ; for a favour- able relaxation, and an abfolute ceffation of fpafms, irritation, and inflammation, always fuc- ceed a copious bleeding, and at this time the me- dicines have confequently more power. I direc- ted the patient, therefore, to take immediately, . and every two hours after, a dofe of calomel gvi. jalap, gx. and fcamm. of Alep. gii. This prefcription was to be alternately followed with proper diluting and cooling drinks. On the third day, the medicine operated fatisfactorily ; for a prodigious quantity of green or cyftic bile was evacuated. The pulfe, however, exhibited a ftate of conftriction, and the Stomach was fick. Let us now venture a few conjectures on thefe unfavourable fymptoms. Among the remedies which we employ, there are many, whole power and efficacy we can underftand and analyfc ; but there are others alfo which may anfwer all our 56 ACCOUNT OF THE willies, without our being able to account for their fuccefsful operation. Thus, if in the remo- teft foldings and cavities of our vifcera, there cxift a corrupted fluid which we wifli to evacu- ate, it is Obvious that venefection, affecting the whole fyftem and diftcnding the nerves and the veflels,will operate on each difeafed part; yet how does it happen that a mercurial powder fo effectu- ally obtains the fecretion of the hepatic and cyftic bile ? This circumftance, as well as that of the fame effect being produced by the regulus of antimo- ny, when taken into the ftomach, cannot as yet be explained. In the cafe now under contempla- tion, twelve grains of calomel, mixed with other draftics, was fufflcient to evacuate a great quan- tity of cyftic bile. It was not, therefore, impro- bable, that by a continued action of the mercury another quantity of bile might be forced out and fecreted from the liver to the duodenum and the ftomach. It was the acridity of this bile which caufed the conftriction of the pulfe, and which fickened the ftomach. Under thefe circumftances I confidered it fafcr to effect its evacuation by a vomit than otherwife ; and I confequently order- ed an emetic. It produced the happieft effects I for, at the clofe of the third day, the patient had fcarcely any inflammatory fymptoms, and en- joyed a vifible remifiion of fever. His fkin ap- peared moift ; and his countenance was more cool and placid. All his fenfations were agree- EPIDEMIC YELLOW FEVER. 57 ably affected by the comforts of a good bed, and a room warmed and purified by a chimney fire. It fliould appear, gentlemen, that our patient is now brought, from the moft perilous ftate to the point of recovery. The moles movenda of the arterial fyftem, and of the large infardted veffels, have been relieved, and the contaminated bile evacuated. Thus, therefore, two important in- dications have been timely fulfilled ; and the actual ftate of the patient appears to be that of the vis viU, which always marks the beginning of the convalefcence. But you will remember that the laft indication has not yet been obtained, and that, within a certain fpace of time, it muft be effected either by natural or artificial exertions. This indication has already been defcribed as re- lating to the depuratory crifis of the whole flu- ids, when they have been more or lefs contami- nated ; and it comprifes all the fecondary ones for the treatment of malignant and bilious remit- tents. It is beyond the power of medicine to abridge the courfes and periods of thefe fevers. But, notwithftanding their different ftages cannot be fo accurately traced as would enable us to form a nomenclature, yet* fome general rules have been deduced ; and, upon the authority of thefe, it muft be allowed, that the bilious remit- tent, like the caufos or febrir ardens, muft laft four or feven days, and may even be protracted I & ACCOUNT OF THE try nine or fourteen. Exceptions to iliis march ■are very fc'arce ; and the cafe No. 6, which was perfectly refolved in three days, I never could account for in any other way than the following. By the primary effects of the contagion on the bile, the patient did not receive its fecondary tranfmiflion into the blood, and had not confe- quently the elaboration of nature to fuffer, but was cured as foon as the evacuations of the he- patic and cyftic bile were obtained. But, gentlemen, the illnefs of my young pa- tient did not end at the point I have laft mention-1 ed ; for I foon difcovered another paroxiftn of* fever. For the relief of this I prefcribed gentle remedies, fuch as carminitive injections and di- luting draughts; and a previous warm bath had been applied to the inferior extremities and ab- domen. You will thus perceive, that I confider mild operations only as defirable, during the ex- acerbations of the fever, except that bleeding is requifite when its inflammatory characters are too high. In the prefent cafe, I could fee no urg- ing necefTity for venefection ; for the bile had al- ready been evacuated, and the remiffion of the fymptoms and fever had been regular and uni- form. Befides endeavouring to prefcrve the life of his patient, a phyfieian fhould be careful in the ufe of thofe means which, by their frequency, may create other difeafes, or render the convale- EPIDEMIC YELLOW FEVER. 59 ^cence very long and perilous. Oa the night of the fourth day, the fever of the patient was fo violent, that, in his delirium, he got up and went naked into feveral corners of the houfe. How wonderful, gentlemen, are the exertions of Na- ture when flie is properly affifted 1 As foon as this exacerbation was over, the patient had feve- veral copious difcharges of bile; red petecha; were obferved on his breaft and arms ; and his falivary glands being a little affected, he had a falutary and frequent fpitting. The crifis pecu- liar to the malady was now beginning to appear. The rednefs of the fkin began gradually to change to a whitifh hue, which I judged would, at a pro- per time, turn yellow. What were then my ob- fervations; what was I to do; and what had I to expect ? The revulfion of the blood from the veins into the arterial fyftem was certainiy finifh- ed; and the corrupted bile, by which the liver wasinfarcted,was fecreting and diffufing partly in the bowels, and partly in the blood. Mercurial draf- tics were ftill neceffary ; and, by their means, I again procured copious evacuations of yellow bile which was probably from the liver. On the fifth day, the yellownefs was vifible ; a quantity of this ftagnant bile having mixed with the blood. It was then neceffary to accelerate and Stimulate the circulation by fudorifics and tonics ; and the ftomach, being languid and exhaufted, fpme reftorative and nourifhing fubftances w?r cury, applied externally, cannot be ufeful but in the laft indication. idly, The firft indication will be alfo fucceff- inliy aflifted by the ufe and action of an anti- monial emetic; but, before this and the calomel could be efficaciously adminiftered,the fyftem muft be brought to a confiderable relaxation and tem- porary ceffation of the inflammatory fymptoms, ^thly, Profufe and repeated bleedings are the only fure means of abating the inflammation, and of fulfilling all the views of the fecond indica- tion, which occur at the exacerbation of the fe- ver. There may, however, be fome advantage jn fparing the blood; but, during the three firft days, not to take enough of it would be fatal. $thly, The laft indication requires all the me- dical rules for the treatment of malignant fevers within a certain fpace of time ; but the two firft muft be completely obferved within three days ; for, in the latter period, the contagious miafma- ta may already have contaminated all the animal fluids and mortified feveral vifcera. 6thly and lafily, With the above indications, rules, and remedies, in conjunction with the fol- lowing practical cautions, the treatment of the EPIDEMIC YELLOW FEVER. 63 yellow fever cannot fail of fuccefs, if the patient? be free from previous complaints of difeafed vif- cera or vitiated conftitution. SECTION IK Practical Cautions for the Treatment of the TcUovt Fever. OMNE NIMIUM NATURiE INIMICUM. Hip. Aphor. 51. Seel. 2. This was one of the cautions laid down by the immortal father of the medical art, who was poffeffed of all the treafures both of judgment and experience. " All that is to much is contra- " ry to Nature;" and even our important difco- veries of afpecific and of remedies for the yellow fever, will become dangerous if we administer them without proportion or reftraint. I fhall, therefore, gentlemen, proceed to confider a few- important cautions in venefection and the ufe of mercury for the cure of the yellow fever, and then enumerate fuch other objects as relate merely to the patient. It is a well authenticated fact, that frequent fuccefs has attended profufe blood letting in the yellow fever. If the injudicious and illiberal at- 64 ACCOUNT Or THE tacks that have been levelled againft it during our late calamity, have deftroyed the confidence of fome of the patients and their attendants, it has been owingtotheforceof ridicule which is too apt to feduce unreflecting minds. But time and expe- rience lead to truth and will furmount every ob- ftacle. When the celebrated Moliere had, by fe- veral dramatic pieces, painted the medical pro- feflion in the moft ludicrous colours, the public laughed at the ignorance of pretended phyficians. But the refult was, that a more juft difcrimina- tion was afterwards made between them and practitioners of genuine refpect ability. However, the public will doubtlefs readily acknowledgethat facts and principles will always ftand forth againft every farcaftic affailant. To thofe who think that indifcriminate bloodletting was recommen- ded as a fpecific in the yellow fever, we would remark, that the principles held out by phyfici- ans, ought always to be examined with imparti- ality and attention. We fay, it is true, that, for the cure of the yellow fever, we muft bleed early and as copioufly as fifteen or twenty ounces at a time ; that, in each exacerbation of fever, during the three firft days, bleeding ought to be free in proportion to the apparent inflammatory fymptoms or elevation of the pulfe ; that the Stagnation of the bile in the liver and other vif- cera infarcted, fufpending the circulation of the blood in the large veffels, ought partly to be EPIDEMIC YELLOW FEVER. 6; confidered as an immediate caufe of mortifica- tion, and partly requiring a great depletion of blood ; that the power and efficacy of mercu- rial draftic doles, being always in a ratio to the relaxation of the fyftem, it will be previoufly ne- ceffary to relax by bleeding, and this perhaps as often as they are adminiftered ; that the mcafure of bloodletting has no bounds but that of a vifible and favourable change, and no terms to its reiteration, but the marked period where the effects of the malady are irrevocably fixed for death or recovery. After admitting thefe ge- neral rules, two cautions arife from pathological principles, viz. the time of bleeding and the quan- tity of blood to be taken. If venefection pro- duces fuch powerful changes in the equilibrium of the animal fluids, and if it relaxes the folids, we ought not to have recourfe to it, without a Strict attention to the ftage of the malady, to the exacerbation of the fever, and to the formation of certain crifes. \fi, During the three"firft days of the fever, this remedy will doubtlefs anfwer all the aforefaid indications and purpofes ; but, when the effects of the contagion are diffufed in the vifcera and blood, as is generally the cafe after the third day, bloodletting may anfwer very well for certain fecondary fymptoms, but would then be ufelefs for primary indications ; and even if the patient was likely to recover, fuch means as have an enweakening tendency, would only retard K 66 ACCOUNT OF THE the favourable event. Hence arifes the practical caution of fparing blood, if poffible, after the third day. idly, As the exacerbation of the fever ex- hibits all the extent and degrees of the inflam- matory fymptoms, it affords the beft opportunity of judging of the neceffary quantity of blood to be taken< At this period, alfo, the blood-veflels are infarcted or are in a ftate of congeflion ; while, at any other, nature feems to reft, and it is perhaps better to let her help the patient with- out disturbing the crifes and operations of the fe- ver. Hence arifes the practical method of bleed- ing at the very moment of exacerbation ; but fel- dom before and never immediately after. For, in the firft cafe,we may retard it, when it is effentially neceffary, and in the fecond, we inter vert its ef- fects and render them incomplete. 3/y, We have already noticed, that the admiffion of the bile into the blood, the hemorrhage, eruptions on the fkin, Sec. were crifes of the difeafe, and that when one or many of them take place, the fate of the patient is decided. If he has not, how- ever, been bled, before thefe fymptoms take place, it is feldom in his favour; and if a cafe fhould happen, in which nature, without the afliftance of bloodletting, fhould effect the refolu- tion of the difeafe, it muft be owing to the un- corrupted ftate of the whole mafs of forces and fluids. If then, thefe happy effects can be as- cribed to fuch a ftate, we muft be careful not to EPIDEMIC YELLOW FEVER. 67 commit the iffue of a recovery, or create irrepa- rable accidents, by a diminution of thefe forces and fluids. Hence arifes another practical caution of fparing the blood after the appearance of one or more of the crifes. It would be very difficult and almoft impoffible to trace all thofe circum- ftances, which are to be difcovered and deter- mined by accurate attention and judgment. One inftance, however, in the cafe of T. B. above related, may fervc to illuftrate the caution upon bloodletting. His fituation feemed to require a third bleeding, and but little danger could have refulted from it. It will be remembered, that he had been copioufly bled at firft, while in the country, and that, deprived of any further ad- vice, he remained without medical affiftance till the latter end of the fecond day. At this time, he was in the moft alarming fituation, and I wai- ted anxioufiy for the fecond exacerbation, which took place in the night, and indicated a fecond copious bleeding. Its effects were fo favourable, and it produced fo happy a change, that, at the time of the approach of the third exacerbation, I was convinced it would be regular, and not at- tended with too much inflammatory diathefis ; for the patient had Still continued to evacuate bile. I then left it entirely to the forces of nature. It was indeed violent; but its effects prefen- ted regular crifes as far as medical rules defignate. Infine, I concluded, that if this laft 68 ACCOUNT OF THE exacerbation could, without bleeding, be atten- ded with many favourable fymptoms, I might continue the treatment without ufing it any fur- ther. I afterwards received the greateft benefit from this referve ; for it rendered the convale- fcence of the patient very fhort. This generally is the cafe with thofe who lofe but little blood*. (Vide cafe 7.) The exhibition of the calomel, in the yellow fever, will prefent to us more important and un- objectionable grounds of caution, when we re- trace the different modes of the operation of this precious medicine, in order to confine its ufe to what abfolutely requires it. We have feen that, as a draftic purge, it was particularly adapted to the excretion of the hepatic and cyftic bile. To this ftriking circumftance, we cannot help afcribing the repeated fuccefs of thofe phyficians who firft recommended the ufe of this medicine. We are * Mr. Lieutaud, phyfician of the late king of France, has proved that profufe bleeding caufes fuch a relaxation of all the blood veffels, as greatly to enlarge their capacities, which, by admitting more Wood than is neceffary, creates all the maladies incident to a plethoric ftate. It will, confequently, be of the ut- moft fervice to our patient to fpare as much blood as poffible. The mercurial draftics fhould be given immediately after bloodletting, ^s they will then produce a more efficacious effect; and, as the exacerbations after the third day till the end of the fever, arc al- ways decreasing, it muft be concluded, tha,t, admitting the reme- dy indifpenfable during the three firft days, neccflity will hardly be found for more than three or four venefections. EPIDEMIC YELLOW FEVER. 6g alfo acquainted with its effects as a fialogogue or falivating remedy ; fince many phyficians have thought that this kind of operation could be pro- duced by it only, and could be depended upon. Infine, the ufe of mercury, in the form of oint- ment, has been applied in many cafes of the yellow fever, and I fhall therefore, examine whe- ther it will thus anfwer fome ufeful purpofes or not. From thefe preliminaries, gentlemen, I fhall derive only one propofition, for practical caution reflecting the ufe of mercury, including all my own rules. The calomel, or ?nercurius dulcis, fhould never be adminifiered as a falivating remedy in the yellozu fever. It is fufficient to diredits aCtion towards the bowels by the help of other powerful drafiics. It will affifi the crifis of the fuppuration of the paro- tids if it can take place. The external application of mercury will not effect an evacuation of the bile, and could not anfwer but for the depuration of the fyfiem if the patient had not exacerbations of fe- ver ; but in this hypothefis the remedy mufi prove ufelefs and dangerous. Several important queftions arife from the preceding propofition. What are the objections againft the falivating method \ Is the crifis of the fwelling and fuppuration of the parotids differ- ent from common falivation ? Can it take place 7o ACCOUNT OF THE in the yellow fever without the action of mercu- ry ? If it is a fuccefsful crifis, why do we avoid exciting it ? And finally, if a mercurial prepa- ration, taken internally, is allowed to be a good fpecific, why does another fimple mercurial pre- paration, applied externally, prove ufelefs or dan- gerous ? Let us now refume each of thefe quef- tions, and candidly inveftigate them, unattended with a lengthy and fcientifical collection of au- thorities, with which I fuppofe my medical rea- der well acquainted. In every kind of complaint there is not one of thofe revolutions or admira- ble crifes in the frame, which are excited by the combined act ion of remedies, with a view of ob- taining a ceffation of the diforder, that is not an exact imitation of what the natural and fpontane- ous laws would accomplish, if they were not ob- ftructed. The beft, therefore, we can do is what nature frequently operates without our aSfiftance, and often before it can even be obtained. Thus, among all the fingular circumftances to be re- marked at the end or refolution of malignant fe- vers, the fwelling and fuppuration of the glands and parotids has been noticed as one of the moft favourable crifes, and I have already obferved that Fouppe Defportes, in his defcription of the malady of Siam, had particularly noticed its final and fuccefsful operation. To his authority I could fubjoin that of many phyfiologicai writers. Ex- perience alio has exhibited to me feveral inftan- EPIDEMIC YELLOW FEVER. 71 ces of the moft perfect and fuccefsful fuppura- tion of the parotids, in the yellow fever, with- out much mercury or none at all. (Vide cafes No. 8 and 10.) I do not doubt, gentlemen, but to this crifis, which is not uncommon, we are in- debted for the confiftent and bold attempt of the phyficians who firft difcovered the fuccefs of ca- lomel in the yellow fever. They did not perhaps notice, that it cured by its draftic power, and that a fuccecding fuppuration of the parotids was rather a fpontaneous crifis, than the effect of the remedy. Bat if this be fo, there are others alfo which Spontaneously prognofticate a perfect cure in all malignant fevers, as well as in our epide- mic. Thefe are yellownefs, profufe evacuations from the bowels,hemorrhages,tranfudation of cor- rupted blood from the lips*, Sec. All thefe crifes, * This is one of the moft fingular crifes I ever faw ; and, as it occurs but feldom to pra&itioncrs, I think it deferves defec- tion. The fubject was a poor man, of about thirty years of age. He was in the third day of his feyer, entirely in the hands cf na- ture, and deflitute of any propei affiftance. Although he vvas very ill, the ufual medical affiftance operated fo favourably, that I defired he might not be fent to the hofpital. On the fifth day, fome blood ran from different parts of his lips; where it foon har- dened and thickened fo much, that he could hardly receive any thing into his mouth. The leaft motion or violence would caufe a new hemorrhage. On the feventh day, the yellownefs appeared much left than is common; but the fize and weight of thofe black fcabs were fo great, that they reached the noftrils, and ren- dered the refpiration very difficult. The patient was in the great- eft torture, and mads a hideous appearance. I ordered the lips 72 ACCOUNT OF THE which are equally good when they take place at a proper time, appear various in different kinds of malignant fever. Thus, the yeliownefs is particularly characteristic of our fever, and the lymphatic fwellings, in the fame manner, defig- nate the plague, Sec. But, if in both difeafes, the fuppuration of the parotids could be excited, by art or nature, the one would not be attended with a jaundice, nor the other with a fwelling ; for there is',never more than one crifis peculi- arly fpontaneous. The moft convincing proof, however, that the fuppuration of the parotids ought to be confidered as a fpontaneous crifis in this fever, may be derived from the obferva- tion which every practitioner muft have made on theprogrefs, ftages, and fpace of time, through which a falivation is commonly artificially ob- tained. Few inftances are found, even among de- licate patients, in which it breaks out in lefs than eight days, and it generally takes two or three weeks. As much time is afterwards necef- fary to obtain, by it, a ceffation of the exiftinu fymptom or difeafe. Now, it muft be remem- bered, that five or fix days only embrace all the periods and iSfue of the yellow fever. Confe- quently, if a fuppuration of the parotids takes to be wafhed with fome warm mucilage. A few pieces of fcab were foon detached, but new beds formed again though much thinner. They gradually diminifhed during the convalefcence, which was otherwife rapid and regular. EPIDEMIC YELLOW FEVER. 73 place, it will rather be fpontaneous, than be the refult of a few dofes of calomel; for the courfts of the difeafe is too rapid to depend upon its falivating effects. But if the crifes of afwelling and fuppuration of the parotids is to be consider- ed as a fpontaneous refult, peculiar to one indivi- dual, and not to another ; if it be a mere chance to receive it, as well as to be favoured with another as hemorrhage, flux of the bowels, dec. will it be prudent to administer the calomel as a falivary medicine only ? Will net the fafety of fo rapid and violent a diforder be committed to an un- certain effect ? And will not the treatment be ren- dered an obftacle to fuch means as nature em- ploys to get rid of the imminent morbid caufe ? To enforce this argument, wc muft examine what indications, facts, and theories, have united in fupport of calomel. This medicine has un- doubtedly a peculiar efficacy in evacuating the bile, and in cleaning the infarcted liver; and I truft that no fyftematie practitioner will deny the truth of this fact. Why then do they prefer an uncertain operation to that which is as eafily and as well produced in all fubjects ? Why would they endanger the iflue of the malady, by fixing the whole effects of the mercury upon the prima viae, in order to confine its action on the faliva- >ry glands only, and thus render it ufelefs in the evacuation of thefpecific contagion, at a time when 7, # ACCOUNT OF THE the moft urging neceSfity calls for it ? Why would they give time to the poifoned bile to injure its refervoirs, and then, by pouring into the blood, infect the whole fyftem r Why woulpl they believe that the evacuation of that/pecific contagion can be better effected by means of the falivary glands than by the natural excretory organs, as long as its fources in the vifcera are not emptied ? Such, however, weuld be the effects cf adopting exclu- fiveiy the idea of falivation by calomel for the cure of the yellow fever. In dwelling a little longer, upon a fubject of fo much importance, I do not, gentlemen, fear to be tedious ; and I truftl P:all be excufed when I attribute many unfuccefsful inftances of our treatment of the yellow fever, by calomel and bleeding, to the neglect of the confiderations I fhall now fubmit to your attention. I have alrea- dy obferved, that when the hepatic and cyftic bile are evacuated, the fyftem remained more or lefs infected; becaufe the large blood veffels, which pour into the liver, and receive its blood again, muft have waflied off enough of the con- tagious bile. I alfo ftated, that to repair fuch ef- fects, a general depuratory crifis was afterwards to take place, within a certain fpace of time, and by natural or artificial means. As this phyfiolo- gical rule cannot be denied, it muft be acknow- ledged, by every practitioner, that it would be EPIDEMIC YELLOW FEVER. 75 impofiible, as well as improper, to excite, in every patient, the fame final and depuratory crifis. They will remember, that, in a woman, it may, perhaps, take place by a difcharge from the ute- rus, and in men, by perfpiration, hemorrhages*, evacuations from the bowels, Sec. The difcove- ry of what will be the tendency of the patient, and by wdiat crifis he will be finally affifted, re- mains confeqnently with us. When this is made, we fhall be obliged again to acknowledge, that the calomel, when adminiftered to falivate, will, in many cafes, counteract the march of the dif- eafe ; and that it will obftruct every crifis, but that of the mouth. A purge counteracts the fa- * I remember feeing, during the late calamity, a publication in one of the newfpapers of Philadelphia, in which the writer pre- tended to prove the necefiity of bleeding in the yellow fever, by the frequent hemorrhages of the patient. I differ greatly from this opinion, and believe it might occafion conilderable miftakes in practice. In the higheft turgency of the blood-veffels, the fmall or capillary ones, have, according to their fize, as much to refift as the largeft, which are feldom known to burft, even when the pulfe is in the higheft ftate of elevation, except in cafes of appo- plexy, when the blood cannot return into the heart. Hemorrhages are always the effect of a lefion or of the morbid ftate of the tex- ture of the veffels. In acute difeafes, they originate from the vaf- cular fyftem; and they never happen during the exacerbations, but on the contrary during the remiffions, and when the pulfe has returned to its greateft calm. At this period, the relaxed vafcu- lar fyftem, pours off a fluid ejefted from the circulation, and not refumed in the veins. It is from this caufe that hemorrhages in fevers are confidered as ominous prognoftics, according to the time of their appearance. *,6 ACCOUNT OF THE livation, while the latter has the fame effect upon all that can be obtained by hemorrhages, perf- pirations, Sec. It follows, therefore, that, if the patient has neither time or a natural tendency to undergo the operation of falivating, this means. would be contrary to the cure of the yellow fever. The practice of exciting a falivation, for the cure of feveral difeafes,will better explain its equi- vocal effects in the yellow fever. By it, the morbid caufe istranfported from any part of the body or from the blood, into the falivary glands, from whence it is infenfibly waflied out, attended with a moft offenfive fmell; and the mercury fecretes, by thefe glands, a great quantity of faliva. Should others give a different explanation of this phenome- non, yet we muft all agree as to the fact, and this is fufficient. It cannot be denied but that the affection of the mouth varies afterwards very much among different individuals, and although this circum- ftance cannot be accounted for, the refults may be fatisfactory and have the defired effect. There are patients on whom the greateft quantity of mercury has never been able to affect their mouths. Some receive an eafy affection in the fublinguals and maxillary, but their fpitting is unattended with a fwelling of the parotids, and consequently has no critical good effect. The ftate of the teeth, their being covered with ear- thy fcales, or much decayed, and previous mala- EPIDEMIC YELLOW FEVER. 77 dies of the gums, may, in many cafes, render the action of the mercury fo painful and even dan- gerous, by hemorrhages, that the courfe of the medicine muft be interrupted, without fulfilling the adopted intention. Infine, the practice of ad- ministering mercury, without falivation, by the means of certain precautions, recommended by many phyficians as equally fuccefsful and Safer in the refults, are confederations fufliciently pow- erful to make us difapproveof the falivating me- thod in a diforder fo rapid, and the malignancy of which, might be conquered by lefs equivocal means. Returning my former propofition, I recom- mend, as an important caution, that calomel fhould never be administered by itfelf nor in the method or proportions intended for falivation ; that, on the contrary, it muft be but about the third part of a draftic mixture, by the means of which it will immediately be diffufed into the bowels ; and that, if, in fpite of jalap, fcammo- nea, or gamboge, it is retained too long without operation, an oily cathartic, or fome neutral falts, fhould be given to prevent the mercury from ai- cending, and to enforce the bilious evacuations, the importance of which has been Sufficiently proved.This method leaves always time enough for the crifis of the mouth if it is neccfTarily in- tended by nature. It helps it fufliciently, and it 78 ACCOUNTOFTHE even accelerates its appearance, and gives it all the characters that can render it perfect and fa- lutary. Such cafes have occurred to me in the proportion of one out of ten*. Few obfervations remain againft the external application of mercurial ointment. Admitting that it tends to the purification of the blood, what will be thought if the original caufe and the foam of contagion are not destroyed ? The refervoirs of the bile are not emptied by mercu- rial frictions. This remedy, therefore, cannot an- fwer any good purpofe, except after the firft pe- riod of the difeafe, when previous evacuations have been accomplished. This hypothesis, how- * In pracVifing the method of adminiftering calomel, in the proportion of a third againft two-thirds of other draftics, as ja- lap, fcammonea, &c. the following has been the refult of my practice in the worft cafes. Out of feven patients to whom the calomel was carefully ad- miniftered as a draftic, I loft only one. I had one fpontaneous fuppuration of the parotids out of ten. One accidental affection of the mouth, with gentle fpitting, unavoidably caufed by the calomel, and without confequence, out of four. One critical refolution by hemorrhage, out of three. One by eruptions out of twenty. And, finally, one by tranfudation of the blood from the lips out of fifty. EPIDEMIC YELLOW FEVER. 79 ever, would Still be liable to confiderable objec- tions, fuch as the exacerbations of the fever, and the turgency of the blood-veflels, which never fail to manifest themfelves as foon as the mer- cury is admitted into the circulation. The firft would be considerably counteracted by mercu- rial frictions, while they are neceffary to termi- nate the malady within a certain fpace of time ; and the other would become precifely one of its moft dangerous fymptoms, and would be renew- ed and fettled before we could have time to op- pofe it, or to obtain any dccifivc and good refult. I faw, in the laft prevalence of the fever, a ro- buft young man, in the fourth day of his fick- nefs, who had been regularly rubbed with mer- curial ointment. The excretory evacuations had been neglected ; he had not the leaft affection of the mouth ; and he died on the fifth day. Some practical cautions reflecting emetics alfo demand our attention. I have already Stated their ufcfulnefs in emptying the Stomach and duode- num, when, in the courfe of the firft period, thefe vifcera are fickened, notwithftanding every other application has been fuccefsful. If the mercury, in fhort, promotes the fecretion of the bile from the liver, this favourable operation is immediate- ly followed by a ficknefs of the ftomach, and then the emetic is neceffary. (Vide cafe No. 7.) In many inftances, the patients difcover a great go ACCOUNT OF THE averfion to this remedy, and if they are of a delicate nervous conftitution they frequently re- fufe to take it. In fuch cafes I employ an equiva- j lent remedy, Strongly recommended by the inge- nious Mr. Dubois de Rochefort, in his Materia j Medica. He calls it un emetique cathartique en lavage. One grain of tartar emetic, or one grain and an half at moft, is to be diffolved, with half , an ounce, or three drams, of fait of Glaubert, in about two pounds of water. The patient is to drink it by tumblers full every hour. This medi- cine is notnaufeous ; it feldom excites vomitting ; and it is always fure to empty the ftomach and bowels downwards. It is a general obfervation in practice, that the patient Should, in all acute di£ , orders, be prepared, by various depleting reme- dies, for all the fubfequent operations. But we muft cautioufly avoid giving of pukes in the be- ginning of the yellow fever, and particularly fo if a profufe bleeding has not immediately preceded it. Indeed, the turgency of the arterial fyftem is then fo great, that the convulfions of the ftomach may have dreadful confequences. I have fre- quently feen them followed with fuch fatal acci- dents, that I think it my duty to mention the ne- ceflity of a cautious referve*. * It is a general cuftom among practitioners, to prefciibe biif- ters in defperate cafes, and 1 have often been ftrongly importun- ed to r.dminifter them, by the nurfes and friends of the patients, whch: lop:s cf their efficacy arc Sincere, but who are unacquain- EPIDEMIC YELLOW FEVER. 81 Admitting the above practical cautions to be adopted by thofe phyficians, who, with great pro* propriety, have chofen calomel and bleeding for the cure of the yellow fever, ftill, gentlemen, if the patient labours under the complaints of difeafed vifcera and vitiated conftitution, or if he has not made timely application for medical affiftance, they are not fufticient. Under this two- fold consideration, every impartial judge will make due allowances for the medical art in un- fortunate cafes of death. It is too true, that, during the prevalence of a dreadful and conta- gious epidemic, confufion and deSpair, feclufion from intercourfe, and erroneous opinions on the firft fymptoms of complaint, expofe the patient to diffident delays and improper meafures ; but experience and the warnings of phyficians, ought to teach our fellow citizens the importance of an early application to medical aid, in the cure of one of the moft malignant diforders that ever was known among nations. In cafes where the difeafe would have gone through its periods in the ted with their real confequenccs. I fhall not here enquire into the nature and extent of their utility, nor the method of their application. After referring to all that has been difcovered and adopted in the treatment of the yellow fever, it muft be allowed that they are abfolutely ufelefs, and cannot anfwer the leaft pur- pofe in any period of the diforder. As, therefore, there are fuch numerous diftrefling circumftances attending an unfortunate iffu^ of the treatment of the yellow fever, humanity require* us to exclude this excrutiating application. M %t ACCOUNT OF THE ftiort fpace of three days, one day loft proved fatal. Thofe alfo, in whom the malady was of longer continuance, and who remained unaflifted during the firft days, found, alas! a fimilar fate. Let no one, therefore, for his own fake, be carelefs about any flight inftance of complaint which he may experience during the prevalence of an epidemic ; for, although various degreed of bilious or other complaints may appear, and though their mildnefs may have nothing common with the rapid and malignant effects of the former, yet, at the firft call, the phyfican himfelf feels obliged to employ all the energy of his practice, notwithftanding he fees but partial and fufpicious fymptoms. His feverity of judg- ment and prefcription, will not be attended with dangerous confequences; but will happily pre- pare the proper treatment for any unexpected ma- lignant cafe. In order to illuftrate the importance of an ear- ly application to phyficians, during the feafon which unfortunately creates all degrees of bilious, remittent, and malignant fevers in thefe climates, I fhall familiarly relate an instructive inftance of errors of judgment, in a cafe of apparently com- mon and trifling indifpofition, and of the inutility of medical aid when applied for too late. To- wards the clofe of our late calamity, I was fent for by the wife of an unfortunate hufband., EPIDEMIC YELLOW FEVER. 83 From motives of the moft unequivocal tendernefs and affection, fhe unhappily deprived him of fuch timely aid as would undoubtedly have faved his life. u During four nights She had not left his bed- fide. Perfuaded that fhe knew, by experience, his indifpofition, fhe continued all this time to give him fuch remedies as fhe thought proper. She re- fufed at firft to admit me into his room ; for the frequent vifits of phyficians to infected houfes alarmed her very much. She faid that fhe had been fo fecluded from any kind of intercourfe with others, that, thank God, the yellow fever had fpared every one of her family. She obfer- ved, that fhe had called me for fome advice re- fpecting the indifpofition of her dear hufband; but (he was happy to think, that there would not be much occafion for medical aid; for, fince fhe had fent her meffage, he appeared to be on the point of recovery. He was up, walking about the room ; and he intended, next day, to ride out to the country." This laft circumftance, ftruck me with the apprehenfion that this was the laft day of the life of the patient; and, that I might be better able to judge, I requefted her to give me an account of his indifpofition from the begin- ning. " He was taken, fhe replied, with a flight fever and puking, owing to a little intemperance on the preceding day ; and his head ache and pain in the limbs, fhe knew very well, proceeded from a violent cold, which fhe always cured with fweat-* .84 ACCOUNT OF THE ing teas. She had afterwards given him a few pills, which operated faithfully, and the pains and fever happily fubfided. The patient had, laft night, puked fomething of a black colour; but fhe did not wonder at it, as fhe had previously complied with his wifh of giving him fome coffee andtoa£ ted bread. He now felt very eafy, though a lit- tle weak, which was of courfe ; and fhe could not expect him to be better. In fhort, fhe had at- tended and nurfed fo many fick, among friends and relations, that fhe was fufliciently acquainted with the neceffary management and cautions ! 1" I cannot tell, after fuch a recital, which ftruck me moft, the innocent confidence of the wife, her un- fufpedting ignorance, the irrevocable fate of her hufband, or the painful talk which devolved upon me, of destroying fo many erroneous opinions, and plunging, by one word, the whole family in the moft unexpected diftrefs. Myfilence was in- terrupted by the patient, who called us up, ex- preffing fome uneafinefs and wifhing to lie down again. His pulfe was fmall, tenfe, and intermit- tent ; and a black inftead of a yellow hue was fuffufed all over his body. The confufion of his look, was highly expreSfive of inftant danger; and being fuddenly taken with the moft extreme weaknefs, he could hardly anfwer to but few of my questions. His wife was now feized withafto- nifhment; and, taking advantage of the circum- ftances of the moment, I retired with her from EPIDEMIC YELLOW FEVER. 8$ the prefence of an object who v/as every moment becoming a more deplorable proof of her blind- ed confidence—a victim of a culpable fecurity— an object whom fhe faw no more 1 But if this lingular cafe, the error of which cannot be afcri- bed to neglect, may appear rare ; yet how many others have I feen, and how many deaths may be attributed to parfimony, indifference, and the want of timely medical affiftance! The laft fubject of practical caution, gentle- men, that has occurred to mc in the treatment of the yellow fever, is ftill more ferious than the preceding ones, and of more certain fatal confe- quences. In other acute diforders, a phyfician may perhaps find out fome means of relief, and calculate by them a fuccefsful mode of treatment, notwithftanding the patient may labour under pre- vious complaints of difeafed vifcera or injured conftitution ; but in our epidemic there is no fuch profpect, or at leaft it is very faint. During the two periods of its prevalence, I never met with an inftance of recovery from it, when the whole frame had been materially injured by certain caufes. A pulmonic affection, however, when not too far advanced, would not, I believe, readily prefent an obstacle to the cure, as I have once feen exemplified; becaufe the proximate caufe of our fever lies entirely in the bile and alimenta- ry channelr But I fhall always defpair, at the firft |6 ACCOUNTOFTHE view, of thofe who have confiderable obstructions or congestions in the liver, or who have unfortu- nately kept in their constitution any fcorbutic teint or remains of fyphillitic contagion. On the -dreadful effects of this laft, in the malignant yel- low fever, I fhall prefentyou a few important re- flexions ; and that they may be carefully contemp- lated by my young readers, is the philanthropic wi'r; dictated by too many fatal inftances. It has been evidently remarked, that the epidemic acted moft feverely upon young and robuft men, and that its victims were chiefly of that defcription. This is a pofitive fact, the elucidation of which will not appear Strange, when it is remembered that it is not eafy to get rid of the poifon receiv- ed in the embraces of prostitution; that many methods for its cure are truly deceiving ; that fome noble vifcera may, by it, remain elTentially difeafed ; and that the blood, which contains its particles, will be fooner and unavoidably conta- minated by another contagion. The moft fa- vourable fymptoms do not always juftify the con- fidence eifher of the patient or phyfician ; for we are unacquainted with all the changes and ihapes of a malady which has been juftly termed a Proteus- or a Cameleon*. We are daily taught by experience, that, by the ceffation of one of its fymptoms,we are not to judge of a perfect cure. It * Vide Aftruc on venereal difeafes* EPIDEMIC YELLOW FEVER. ** deceives us and the patient alfo; for it often lurks within the body, without diffufing into the blood, or producing any mark of infection. Since there are external fwellings and various forts of tumours which we attribute to the venereal lues, why Should we doubt but that they may exift in- ternally, or within fome noble glands ? How of- ten, indeed, the proftrate gland remains ulcera- ted, fwelled, and tumefied with exuberances, af- ter the improper cure of a gonorrhoea, by Strong aftringents, I leave thofe to determine, who are acquainted with the precious enquiries of two famous furgeons on that fubject, Petit of France, and Hunter of England. In thefe cafes it is very eafy to appreciate, without further explana- tion, what will be the effects on the fecretions ^ of the urine, on the functions of the kidneys, and on the bowels. To fuch internal and chro- nical caufes, we muft afcribe the numerous ob- ftinate and long complaints, which baffle medical Skill until their primitive caufe is cured. Mania, hypocondria, epilepfy, and the long lift of ner- vous complaints, may originate from the fimple irregularity of fecretion of urine into the kidneys ; for apart of that fluid remaining in tiie blood, muft afterwards affect the whole, or at leaft a part of the frame. But fuch circumftances have a deci- ded effect in acute, malignant, and contagious fe- vers. The violence of the firft fymptoms is an additional evil to the enweakened vifcera ; for 93 ACCOUNTOFTHE by it they are immediately brought to the brink of destruction. The Struggles, the exertions, and the efforts of nature, are then foon exhaufted ; and if there is a fcale of the natural degrees of health, of thofe which may be depended on above it, and of thofe under which the phenomena of life ceafes, what proportion remains for medical expectation and fkill, when fuch complicated caufes abforb the whole balance of what is term- ed excitability by one, and what is thought to be the whole extent of. natural laws by another ? Were it not a point of delicacy, gentlemen, for a practitioner to produce reflections on com- plaints, that, according to the opinion of many, would blemiSh the memory of the dead, I would fupport this difcuffion with the evidences of ma- ny cafes. May thofe who are apprifed that youth and robuft conftitution have been fo cruelly ex- pofed to the deadly blows of the malignant fcourge, beware of the enticements of prostitu- tion, and oppofe them by the dictates of reafon, religion, decency, and felf-prefervation. CONCLUSIVE REFLEXIONS. ifi, When the congestion of the blood in the large veffels is diminifhed, and when the critical evacuations of the hepatic and cyftic EPIDEMIC; YELLOW FEVER. 89 bile are obtained, bleeding is no longer requisite during the fubfequent days of the fever; and this is a caution for the fuccefs of the final crifes and of the convalefcence. Under a general rule, which phyficians only can determine, it may be obferved, that venefection is to be copioufly ap- plied, during the three firft days, at each exacer- bation, and fifteen or twenty ounces at a time for adults. idly, Salivation attended with a fuppuration of the parotids is not to be propofed exclusively of other crifes. If it takes place fpontaneoufly, it becomes falutary. The effect of mercurial draf- tics in the bowels is to be unremittingly purfued ; but the external application of mercury is ufe- lefs and dangerous. 3dly,The antimonial emetics and the cathartico- emetic anfwer the moft direct intentions, pro- vided the turgency of the blood veffels has aba- ted. qthly, Previous complaints in the liver, in the bladder, in the urinary paffage, &c. ; and fcorbu- tic and venereal affections, are unexceptionable obftacles to the cure of the yellow fever. N ACCOUNT OF THE SECTION V* General Means to prevent the Generation and In- troduction of the Tellow Fever. Two contrary opinions have appeared on fhe origin of the yellow fever, and have been officially tranfmitted to the executive, by medi- cal bodies of Philadelphia. An attentive public, who know that truth cannot be contradictory, muft \ doubtlefs feel deeply concerned ; and will regret that, after repeated calamities, no unanimous im- provement fhould be made among the learned on fo interefting a fubject* Under thefe circumftances it becomes neceffary, that, while meafures are adopting to prevent its importation,the probability of its domeftic generation fhould not be forgot- ten 4 The public precautions fhould not be foun- ded folely on the particular opinions of either party ; and experience may hereafter afford us fufficient and fuch unexceptionable proof, as , will leave room but for one opinion upon the fubject. I do not, therefore, gentlemen, difap- prove o£ any meafures that may be adopted to prevent the importation of the yellow fever ; on the contrary you will difcover that the above theory has a fenfible advantage over the latter, EPIDEMIC YELLOW FEVER. 91 «• for it alfo admits of all the neceffary precautions againft the effects of noxious exhalations from the holds of Ships or veffels arriving from tropi- cal countries in the hot feafon of the year. If we do not implicitly believe that this contagious epi- demic is imported from one country to another, like the plague or the leprofy, ftill we admit that it may poflibly originate on board of Ships during a long paffage, which contain animal or vegeta- ble fubftances in a ftate of fermentation ; that, raging contagioufly among crews from tropical iflands, when the remains of them come to mix with our citizens, it may fpread its infection among them, and chiefly during the hot feafon of the year ; and that, infine, when a contagious diftemper is known to rage in any part of the world, our intercourfe with it fhould be cautious and fubject to lawful controul. Thus far, there- fore, we coincide in the meafures of the implicit believers of local importation. We defire, how- ever, above every thing they have as yet fuggef- ted, to fix the obfervation of our fellow citizens on the domeftic fources of contagion to which they are expofed. Thefe are felf-evident, and demand our moft pointed attention. Why then are we taught to look upon them with indifference, and to confine our refearches exclufively to the Ships and men that arrive in our harbours, from diftant countries, which at leaft have been confidera- bly purified by the tempeftuous winds of the feas ? 92 ACCOUNT OF THE In order to proceed regularly from the propo- rtions I have above ftated, I deduce the follow- ing means to prevent the introduction and gene- ration of the yellow fever. " I have already proved, lfi. that it was generated by putrid effluvia from vegetable and animal fermentation ; and idlv, that the opinion of its importation could not be admitted exclufively to its fpontaneous ge- neration, in every warm country, from the above- mentioned caufes." It of courfe follows, that to oppofe the polfibility of its importation, and of its breaking from corrupted cargoes, it would be expedient to remove fuch Ships from our Shores as are loaded with colonial produce, at leaft du- ring the months of June, July, Auguft, Septem- ber, and October. The rule for admitting thefe articles fhould be defined according to their good or corrupted ftate, a few days after the ftiips have been unloaded. No intercourfe with their crews Should be permitted during five days af- ter. But if a veffel is fuppofed to contain corrup- ted miafmata, and authenticated cafes of any kind of bilious fever fhould be found on board, the fick ought to be removed to a diftant hof- pital, and the fhip and company perform a qua- rantine of ten days. As the outlines of the report of the committee of the legislature of this ftate, during the prefent leflion, are chiefly founded on the belief of the EPIDEMIC YELLOW FEVER. 93 foreign origin of the yellow fever, there is no doubt but fuch efficacious meafures will be adop- ted as will prevent the -dangerous effects of cor- rupted cargoes and waters in the holds of fhip-> ping. I fhall, therefore, confine my obfervations to an examination of the means which experience will hereafter dictate to be exclusively adopted againft more threatening caufes of contagion.. Philadelphia, fituated on the weft bank of the Delaware, and on the narrowest fpace between the Schuylkill and that river, may be wholly de- signated in the form of a parallelogram, the fquares of which are interfered by wide crofs- ftreets, which raife very little, in certain points, from the fouth to the north, but which are open to all the winds, and to all the emanations of the Surrounding fields, ponds, marfhes, andfwamps. The conveniencies of footways, their cleannefs, and the uniform practice of the inhabitants in fre- quently wafliing the outfide of their houfes, give to the city a lingular appearance of regularity and neatnefs highly admired by foreigners. It contains, however,fome capital defects; and too many unfavourable circumftances concur to in- jure its falubrity. Water-ftreet, thirty feet wide, extending from the northern liberties to Pine- ftreet, parallel with the courfe of the Delaware, is in a confined low fituation. Through the whole of its extent, it has but few vacancies, is com- 54 ACCOUNT OF THE pactly built, very difagreeable, and is totally de- prived of back yards on the fide of Front-ftreet. The fame is to be obferved with refpect to Penn- gfeet. It likewife runs along the river from Pine to Cedar-ftreet; and, in the late cafes of epide- mic, both have been particularly marked as the firft feat of the difeafe. The main height of the ground on which the city Stands, is nearly forty feet above the Delaware. Many ftreets are, how- ever, lower ; and, confequently, the adjacent ground, intended for the continuation of the origi- nal plan, is in many places marfhy. Some parts of it contain large and deep ponds ; and thefe Stag- nant waters are to be feen, more or lefs, in almoft all the points of the circumference of the city, The general convenience of Shipping, to which Philadelphia is indebted for her rapid increafeof wealth and population, has rendered her wharves neceffary. They are compofed of made ground, formed by the means of log cafements filled with earth and Stones ; and they extend along the front of the city.and fuburbs to the distance of about two miles. As I fhall, in the courfe of my obferva- tions, avert more particularly to this circum- ftance, I fhall now obferve that they are elevated above the higheft tides, fo that, at low water, their vertical fides are expofed, for near five feet, to the rays of the fun. In the Northern Liberties and the district of Southwark, there are many EPIDEMIC YELLOW FEVER. 95 vacancies on the banks of the river. Owing to the periodical floods, thefe form large tniry grounds, which are never dry, but covered either with thick beds of filth from the adjoining ftreets or habitations, or with rubbiSh, old timber, Sec? Thefe fources of exhalation are not of the moft indifferent confequence. Our city is fupplied with no running waters or fountains, and but few cifterns are to be found in private houfes. Wells only are dug, in distri- butive number, in different parts of the city and fuburbs. A pump is placed in each well, and wa- ter is thus eafily 'obtained for all the wants of life. A gutter, formed by the elevation of the foot way, and by the gradual defcent of the Street to each fide, feems fufficient to receive and carry down the dropping waters. The declivity of the ftreet, in fome places, however, is worn down ; and the waters Stagnate, more or lefs, in all the gutters. During the heat of fummer, they re- ceive the filth from the houfes, and become very noxious for want of being drained, and more ef- pecially fo, fince they are da,ily renewed by the pumps. The inhabitants feem generally indiffer- ent about thefe waters, becaufe they do not fee but fmall ponds of black and green water ; but, as they are repeated, I am perfuaded that they add much to thequantity of putrid and unwhole- fome exhalations. 96 ACCOUNT OF THE There are twenty-eight houfes for public woi- fhip in Philadelphia, and I believe as many grave- yards within the city and fuburbs. It feems yet to be questioned whether they are really of a noxious nature or not. It is faid that, as the graves are ufually dug to the depth of fix feet, the health of the citizens cannot be injured by them. Even admitting this observation to be true, yet, if dangerous vapours cannot immediately rife from the grave-yards, by the effect of the heat, they may otherwife be difengaged, by the hydraulick laws of fubterraneous waters. For, fuppofing a grave-yard in a very elevated part of the city, as that of the Friends, at the corner of Arch and Fourth-Streets, which is befides near five feet above the Street, within a Stony enclo- sure, it will be granted that the dead are on a level with many different parts of the city, and in fome cafes even above it. Now, Since it is ac- knowledged that the greateft elevation of the ci- ty from the river is forty feet, and that many of the-grave-yards are on the higheft grounds, it will evidently appear, that the inhabitants liv- ing in a lower part of the city, will receive ex- halations from the earth, of moifturc and waters that have been infiltrated through an elliptic plan and through a vaft number of dead bodies. This obfervation will be found to agree with the hy- draulick laws ; for, according to them, in fat ura- te d grounds, evaporation collects the waters by EPIDEMIC YELLOW FEVER. 9? infiltration from higher furrounding points, in the fame manner, that, to obtain water from the the higheft parts, we dig for its evacuation at the lower ones. This explanation, gentlemen, will fliew how the evaporations in moft of the low parts of our city, are rendered noxious by the putrefaction of thou fan ds of dead bodies, and may be carried from one point to another, by means of the grave-yards being intermixed with our dwellings, befides their immediate ef- fect in altering the waters collected in our wells. Laftly, we have a more dangerous fource of putrid animal exhalations, which is more feK- fibly difcovered in thickly inhabited places af- ter the heat, and at the clofe of fummer. Each dwelling has a privy-houfe, fituated at the fartheft end of the yard ; and the houfes on the eaft fide of Front-ftreet have them in their cellars. The ditches upon which they Stand, are dug to a confiderable depth and built round with Stones or bricks. Many of them are twenty feet deep, but this circumftance removes ftill further the idea of cleaningthem., After many years the fermentation caufes of- fensive vapours during the fummer ; and it is very feldom the cafe that the ditches are clean- ed more than once in ten years, when it is of- O 98 ACCOUNT OF THE ten confidered eafier to fill them with Stones, and to dig others. The fact is, gentlemen, that towards the end of the fummer, that is to fay, after the action of the heat has fufliciently ex- cited fermentation, mephitic gas afcends from the ditch. Our inhabitants are fo well apprifed of this, that they always provide their little- houfes with a vent hole. This is a proof that the depth of the ditch is not a prefervr.tive a- gainft its noxious vapours ; for the rarefaction and the heat of our atmofphere could raife them from a much more diftant centre. The abforption of the within contained fluids is fo flow, in moift and impregnated grounds, that they wholly remain and fervc to accumulate the mafs of fermentating animal fubftances. If a lighted candle be lowered into one of thefe ditches, by means of a line, it will often be put out ; and when the temperature of autumn does not oppofe the dilation of the afcending gas, it is plentifully d iff ufe d round the houfes, yards, and alleys, where it is often fenfibly imelt, chiefly when the air is calm and fultry. After the enumeration of fo many caufes and dangerous fources of putrid exhalation, will not our minds, gentlemen, be impreSTed with the reflection of Dr. Lind, that, " next to infection, the moft frequent caufe of fevers EPIDEMIC YELLOW FEVER. 99 is perhaps the offensive and polluted air in un- healthy places;" and that our calamity, perio- dically breaking out, at a certain feafon of the year, was not merely imported ? There are, in Philadelphia, many other fources of putrid effluvia*", whjch perhaps are * Tlierc are feveral finks in Philadelphia, to receive the waters from the gutters, at thefe points where a declivity can no longer be given to their beds. Two very remarkable ones at the corners of High and Fourth-ftrects, were, during laft fummer and fall, productive of the moft cfrenfive exhalations and became a mere nuifance. It is vtry probable, that, by fome defect or other, the waters in them were ob- ftructed; and I take the liberty to direct my requeft to the proper authorities, to have thefe finks examined and repaired. As many cats were ftarved, in confequence of the defer- tion cf the city, there was, I am perfuaded, a quantity of car- rion in them. Called out frequently during the night, I could ftrongly perceive the fmell as far as Arch-ftreet on one fide, and Chefnut on the other. I employed fome hours in follow- ing the current of exhalation, and wa9 at laft fatisfied as to its true origin. There were alfo feveral finks in Pear-ftreet, in Chefnut. ftreet, at the corner of Dock and Walnut-ftreets, and in other parts, the canals of which have been, I believe, deftroyed, but the holes left open, aud the people of the neighbouring houfes ftill continue to throw their filtri in them. I have been informed, by a very refpectable citizen, that he obferved, du, ring the two inftances of our calamity, that thefe vent-holes of putrefadion had been productive of a great number o; deaths in their neighbourhoods. loo ACCOUNT OF THE unavoidable, and are common to all other thickly inhabited places in the world, but which ought to attract the attention of our public authorities; fince they are much more dangerous in a place expofed to the heat of the tropical countries. For thefe, as well as for the preceding observations, I hardly think it ne- ceffary,* gentlemen, to dwell much upon the direct meafures that fhould be adopted by the citizens at large, againft the different caufes of our epidemic. If they were not kept in a ftate of incertitude, with refpect to its real origin, their wifdom and prudence would enable them to make the proper regulations. But alas ! thofe who are induced, after fufficient con- templation, to predict that the fever will fre- quently rage again in Philadelphia, know how many opponents there are to this melancholy truth, and have very little hopes of obtaining a majority in favour of their advices. Yet, if I cannot flatter myfelf with gaining many pro- felytes to my opinion, I confider it as a duty and a pleafure to throw my mite of informa- tion and firm belief, into the fluctuating fcale of public opinion. Under the influence of this fentiment, I affert, that the only fure and effi- cacious means of preferving Philadelphia from contagious malignant fevers, will be thofe that are directly calculated to remove or dtftroy, EPIDEMIC YELLOW FEVER. IOI if poflible, the fources of putrid exhalation from animal and vegetable fubftances that are contained within our precincts. Thefe means, gentlemen, are of inch a magnitude, that, neither time or great expence would be able to effect them, if religious prejudices, views of mercantile interest, and opinions of party Spirit, are Suffered to thwart their execution. Before I attempt to enumerate them permit me to make a few reflexions more on the chymical principles and refults of putrid ex- halations. Firfi, In whatever light we confider the com- ponent parts of vapours and gaffes, either ac- cording to the former or new nomenclature of chymiftry, this much will be acknowledged, that life is oppofcd to the putrid fermentation of animal or vegetable fubftances ; and that, as foon as they are deprived of it, they necei- farily fall into a complete ftate of putrefaction, which is more or lefs accelerated, according to the quantity of heat or caloric, of air and of water, in which they are immerfed. idly, As foon as the putrid fermentation takes place, a new combination arifes of feve- ral fubftances, which have a peculiar tendency to unite to the air by the help of the heat, or icz ACCOUNT OF THE to the water by their affinity to them ; fo that both fluids, being confiderably altered in their nature, will prefent a quite contrary effect to that they would have exhibited at firft, viz. the very air which was good for life and health,will produce a quite contrary effect, &c. ^dly, Among the different qualities of the fubftances difengaged from animal fermenta- tion, there are two very remarkable and which conftitute all the degrees of noxious exhala- tions. The firft is their extreme tendency to unite with air and water, {Vide Diction, de Ch'unic, par Macquer, art. gas) ; and the other is a certain degree of their developement, which is impoffible to account for, in which whether in a fluid or folid ftate, their imme- diate contact with any living body, fuddenly deftroys or fufpends the phenomenon of life. A traveller found the body of a drowned man tliat had been wafhed on the Shore by the flood. As he perceived no fcstor, in examining the corpfe, he inadvertantly plunged his finger into a ft .ft and putrificd limb. From the finger the mortification was fo rapid to the vitals, that lie had no time to be afiifted, and he died. Anatomical difTection has alfo proved the truth of this terrible and dangerous ftate of pu- trefaction. Its various degrees muft undoubt- EPIDEMIC YELLOW FEVER. 103 edly breed different kinds of difeafe and con- tagion. Afthly, Thefe exhalations are, moreover, fub- ject to other laws and phenomena of nature, which fometimes occafion them to be harmlefs when they are moft dreaded, or very noxious and fatal while they are not perceived or even thought of. Heat, without aqueous particles, raifes them, and winds carry them through immenfe regions. They feem vifibly to be a kind of meteor ; their operation on the body is terrible, and they in fome meafure deftroy the vitals without any contagious or poifonous ef- fect. Such are thofe remarkable winds and va- pours, fo well known in the deferts of Africa, and which originate in the mountains of Abyi- finia*. Heat, alfo, may dilate them to fuch a degree that they become harmlefs. This is the cafe when it puts an end to the plague in the hotteft countries of the earth. Aqueous vapours, without much heat, can difen- gage but little of thefe exhalation?, and it is then very common to perceive much fee- tor, without receiving any injury from it. Thus people attending the fick, diflecting of dead bodies, butchers, tanners, and all thofe who are frequently among exhalations from animal * Vide Brace's Travels through Ab\£i.ia, tci ACCOUNT OF THE fermentation, are not known to be injured at _I1. Thofe exhalations which are fufpended above a corpfe, within a metallic or wooden coffin, do not want much heat or moifture, to become fatal as foon as broken open. A.mephi- tic gas then appears Similar to that which we difcover in our chymical experiments. Its ef- fects are fudden againft every living body ; but it can be almoft deftroyed or rendered harm- lefs, by aqueous vapours, and may be totally abfbrbcd by vegetables. This air or exhala- * tion occafioned the death of many citizens of Paris, who, in the month of Auguft, 1792, wcre-inftantly killed by its contact, -while they were breaking the tombs, to take away the leaden coffins, for materials of military ammu- nition. $thly, Fevers produced by exhalations are remarkably various, according to their places, time, and feafon. What a ftriking difference was there between the elephantiafis of Athens, the plagr.e of Marfeilles, the fore-throat of Italy, and the fweating ficknefs of England \ We could hardly find, in the prefent day, any pathological fimilarity among the dreadful epi- demics of Norway and Holland ; the anomolous malignant obferved by Hoffman in Germany, during the years 1727, 1728, and 1729; the in- EPIDEMIC YELLOW FEVER. iof termittent ague of marfhy places; the camp diffenteries ; the hofpital contagious petechia; ; the convulsive malignant related by Dr. Chif holm, which he thought had been imported from Guinea into the Weft-Indies ; the vomito pietro of the Spaniards in Vera Cruz ; and the yellow fever of the tropical countries, Sec. 6thly and lafily, The concurrence of rains, ftorms, and heat, are neceffary to develope noxious exhalations from vegetable and animal fermentation. The conjectures refulting from attentive obfervations are, that intenfe heat, without wind, after heavy rains and foutherly ftorms, is moft productive of noxious exhala- tions in places containing materials for vegeta- ble and animal fermentation. Thefe elementary laws, refpecting the na- ture and effects of exhalations, I have, gentle- men, endeavoured to prefent, unaccompanied with any fcientifical method, in order that every defcription of my readers might be- come better acquainted with them, and finally apply the following means as the only preven- tives againft the generation of the yellow fe- ver * :— * The committee of the houfe of reprefentatives of this ftate, on the health laws, have, in their report, exprefletl themfelves in the following terms. P Io6 ACCOUNT OF THfc GENERAL MEANS. \fi, The removal of all grave-yards to ma- ny miles diftant from the city and fuburbs. " Although your committee are decidedly of opinion, af- ter the moft attentive invefiigation, that the difeafe which ra- vaged this city and its fuburbs, in the year 1793, and the late autumn, was of foreign origin, they nevetthclefs believe that there exifted at thofe periods a certain condition of the at- mofphere which favoured its propagation, and without which it could not have been tranfmitted to any alarming extent. It being a defideratum, that fuch a ftate of air fhould be coun- teracted, which affords nourifhment to contagion, they cannot too ftrongly inculcate the neceflity of a fupply of pure water to the city, and of the ftriCkft attention to fuch regulations as will keep it and its environs free from putrefactive fub- ftances." I am happy to think that the above certain condition of the atmofphere, to which the alarming extent of our difeafe has been afcribed, and which has not been explained by the re- porters, may be fully underftood, by the means of elementary chymical obfervation ; and thofe who are decidedly of opi- nion, that the yellow fever is of foreign origin, fhould not for- get that, in this age, there is no certain noxious condition of the atmofphere, but has been fubmitted to fhe moft attentive chymkal invefiigation and analyfis. This much, however, may be afierted, that the defideratum to counteract an unhealthy ftate of the air, by rendering it free from putrefaction, per- fectly coincides with our theory, obfervations, and general propofed means of preventing the generation of the yellow fever. EPIDEMIC YELLOW FEVE%T. ,0<> idly, The fpeedy accomplishment of the ad- vice of Dr. Franklin, to obtain freSh and run- ning waters in the main partsof the city ; and a police law enacted, ordering all the gutters to be wafiied once a week, during four months of the hot feafon. %dly, Stone wharves ; and their owners obliged to cover them once a year with a coat of tar. The vacancies on the banks of the river, within the city and fuburbs, to be overfpread with a bead of gravel. ^thly, A police law for the clearing of privy ditches, once every winter, and obliging th* owners to throw in fo many buShels of lime, according to their diameter, in the beginning of the fummer. $thly, Gutters, Sinks, cellars, market-Stalls, tanner's and butcher's yards, to be ordered under the infpection of commiSfioners and phy- ficians, during the Cix months of fummer and autumn. dthly, Veffels from the Weft-India iflands, and other tropical countries, fubject to an infpection of their cargoes and holds ; unloaded at a distance from the city ; kept with their crews, under a quarantine of five days, lo6 „- ACCOUNT OF THE during the four months of June, July, Auguft, and September, and a longer time according to the wholefomcnefs of the Ships and health of the men. SECTION VI. Particular Preventives againfi the Tellovf Fever. This fection, gentlemen, I would confider as the leaft ufeful of my effay, if any of my readers expected to find in it fecret receipts or infallible remedies, and if they believed that I thought my advices, joined to thofe of the moft eminent phyficians, fufficient to render them invulnerable to one of the moft rapid and fero- cious diforders. Where is the art that can in- dubitably face danger, can always elude its Strokes, or refift its efforts, whether in battles or in any kind of human infirmities? Alas! when the beft preventives have been made ufe of, and the mode of living rendered fcrupuloufly cautious, ftill there are many chances of infec- tion againft one of prefervation ; becaufe the attendants of the fick, as well as thofe citizens who are detained in town by the neceffary pur- EPIDEMIC YELLOW FEVER. fuits of bufinefs, are expofed to the fatigue, the anxiety of mind, and all the other inconveni- encies attending a general calamity, and, un- der fuch circumftances, it is not always in hu- man power, totally to avoid the means of in- fection. Thus we have feen many of our phyficians, who, during the late calamity, were among the foremoft in attending on the Sick, become the victims of its ravages ! Their names and memories deferve the tribute of ho- nour and of gratitude*. To us, gentlemen, they have given a noble example. Let us then fhed a tear upon their tombs ; and, like them, pledge ourfelves as the friends of humanity. Phyficians and others who firft fufpected the domeftic origin of our fever, advifed their fel- low citizens to remove to the country. How- ever efficacious this meafure was to thofe who * The following are the names of the phyficians, who, in difcharging their profefiional duties, fell victims to the yellow ferer. Doaors WAY, THOMPSON, JONES, PLEASANTS, DOBELL, ANAN, HUNT, and CLARKE, lately from Ireland. no ACCOUNT OF THE could afford the expencrs attending it, what diftrefs did it not produce among the labour- ing clafs of our citizens, to the public func- tionaries, and to thofe whom public or private concerns retained at the theatre of the cala- mity ! By defertion, indeed, the laft preva- lence was rendered more afflictive than that of 1793, although it wras not fo extenfive in its ravages ; and it will always be my wifli, that, during fuch a period, we may experience lefs of thst ruinous and unexpected difperflon of our citizens. When this is the cafe, there is no kind of diftrefs to which our patiepts are not expofed. Inftances, likewife, were known of malignant cafes and of deaths among the fugitives. A mortal infection was thus propa- gated in feveral furrounding country places, for how could they eScape the neceffary com- munications and intercourfe ? In European places expofed to peftilential difeafes, it is a fupreme law, that, during their prevalence, the inhabitants are not fuffered to quit their places of abode. Far be it from me to wifh for fuch an inhofpitable meafure. It is only mentioned to fuggeft, that it is a question whether more good than evil would not arife to the community at large, if, free from terror, affifted by proper and efficacious meafures, en- couraged by numerous inftances of preferva- EPIDEMIC YELLOW FEVER. m tion in town and recovery among the patients, they could be perfuaded to fee the Short period of an epidemic fpent, unaccompanied with the tenfold calamities and misfortunes of defer- tiom However rapid the effects of an existing con- tagion may be upon healthy people,we can derive from our Stated principles, three powerful mo- tives of confidence and fecurity. The firft re- fults from the nature and operation of the con- tagion on the bile only ; the fecond, from the poSfible removal of the fick from numerous families, or an abfolute ceffation of intercourfe with them ; and the laft from efficaciously ex- perienced cautions even in cafes of the nearcft danger. t. The yellow fever, we have already faid, is merely a bilious one of the moft malignant degree. Its operations and fymptoms arc wholly upon and from the bile. Our inhabitants are particularly fubjedt to bilious complaints in a certain feafon of the year, and when the laft are endemics, the former will turn out to be air epidemic of the fevereft kind. We have feen alfo that bilious and yellow fevers commonly fell upon thofe in whom the its ACCOUNT OF THE bile was of a thick or vitiated nature, and who, by habitual neglect, intemperance, or other unhealthy mode of living, expofed that fecre- tion to a ftate of Stagnancy and corruption. Such fimplc and reafonable given obfervations mould heip us to fix upon a fuccefsful method of diet, of remedies, and of cautions, during the perilous prevalence of the yellow fever. At fuch a period, a vegetable diet will be a fure preventive againft animal corruption ; and ani- mal food of the lighteft kind, being always fufficient for neceffary nutriment, if preferred to heavy and grofs meats, will not excite fo great a fermentation of the animal fluids. Sim- ple tonic drinks, mcafured according to the wanted digestive power, will preferve us from thofe inflammatory and heated motions of cir- culation w-hich always attend the face and feelings of drinkers of Strong wines and fpi- ritous liquors, which is an obstacle to the for- mation and fecretion of liquid and pure bile. But it may be faid, that luch a plan of diet would not be fufficient, during the exhaufting heat of the weather and the neceffary fatigues of life, and particularly fo at a time when the body feems to want more Stimulating means to raife the lownefs of our ftrength and fpirits. This, gentlemen, is true, and this feeling is powerful ; but we ought not to fuffer our ha- EPIDEMIC YELLOW FEVER. u3 bits or misinformation, to make us miftake the proper means. I have been frequently more a- nimated and refrefhed by a warm bath, during the heat of fummer, by an airing in the coun- try, or by a cooling medicine, than I could poffibly be by the moSl fucculent cordial. In fact, we may compare our body, charged with fo ma- ny fpringy actions, to a bow, the elaftic power of which would be loft if it was ftiffened by the effect of a drying fire, but which would be bet- ter preferved if kept in a foft and moift tempe- rature. Befides, when we feel very weak, it is often becaufe the vis vita;, elevated to an un- common degree above the point of health, ap- proaches to its end, the fame as when it is too low ; and then relaxing means are proper, fa- lutary, and fuccefsful. It is obferved that we ne- ver more frequently experience the effects of weaknefs, brought on by the heat of our fluids, than in the fummer. At this feafon, we are pe- culiarly expofed to obstructions in the alimen- tentary channel, crudities of the ftomach, and ceffations of daily evacuations. This laft effect is unavoidable, even among the moft regular constitutions; but evacuating medicines oppofe to it an infallible power. A puke or a draftic never fails in removing thofe crudities or obstructions ; and, if they are mercurial or antimonial; they will more properly difcufs O ii4 ACCOUNT OF THE the refervoirs of the bile, and renew that ani- mal fluid, the fermentation of which becomes fb dangerous. I had frequent opportunities, during the two prevalences of the yellow fe- ver, to give this advice to people, who ap- peared to enjoy a regular degree of health. A flight indifpofition, which could hardly call for their attention, at another time, was then a fufficient motive for applying to cautious meafures* I never hefitatcd, when the fubject could bear it, to prefcribe a puke at firft, and a mercurial draftic after. In this manner, and with much furprife, I timely delivered many of them of a prodigious quantity of unnatural, black corrupted bile, from which a dangerous fit of ficknefs would undoubtedly have origina- ted. (Vide cafe No. II.) Yet they afterwards lived healthy, notwithftanding the heat of the feafon and the prevalence of the contagion. It is, in fine, a neceffary caution, repeatedly to have recourfe to fuch medical affiftance ; for it is acknowledged, both by phyficians and others, that repeated cafes of infection may occur. Frequent walks and airings, chiefly during the cool moifture of the morning-and evening, taken to fome diftant places from our fultry dwellings, will be another falutary practice. EPIDEMIC YELLOW FEVER. »'5 It interrupts the action of the exifting exhala- tions, and refreshes us by the help of a purer and more elaftic atmofphere. It alfo aflifts the functions that are the moft endangered, and frequently breaks the courfe of annual and ac- cidental difeafes. In moft of the cities of Eu- rope, where the ftreets arc irregular, a long experience has Shewn, that the moft effential caufes of their falubrity are, pure waters and public walks ; and every means, both natural and artificial, has been employed to render the Jatter delightful. Fafhion, in this point, has been invariably adhered.to; and though pub- lic walks may be the theatre of a Shewy Style of drefs and manners, or of idle talks and in- terviews, yet they notwithftanding remain a cheap means of exercife, whereby health is preferved and difeafes difpelled. Sedentary life, long fittings in religious meetings, feclu- fion of one fociety from another, protracted clubs for various kinds of entertainment, for politics, for interest, and numerous and ftrict- ly fafhionable tea-parties, are manners and cuftoms particularly obferved among the citi- zens of our metropolis. Can I then, gentlemen, be blamed, when I affirm, that, medically fpeaking, they have a contrary tendency to that of exercife, taken in a pure air, and a far n6 ACCOUNT OF THE different effect to thofe of lively manners and more recreative life ? II. Another motive of fecurity for the citi- zens at large, during the prevalence of a con- tagious epidemic, would be, I have already faid, the removal of the fick, or an abfolute ceffation ef intercourfe with them. This mea- fure, during the late calamity, was ordered by a proclamation from our governor. He was blamed by many who thought only of the in- conveniences arifing, in its execution, to the fick, who were reluctant to leave their homes and their chofen attendants ; and the frequent inftances of miftaken cafes was another caufe of their difapprobation of the meafure. This opposition prevailed to fuch a degree, that ma- ny obstinately remained fecluded in their own houfes, died there, and their bodies were af- terwards fecretly carried to the diftant grave- yard of the Wigwam hofpital. Thefe inconve- niencies cannot be denied, but the efficacious and vigilant meafures of authority might at laft conquer them. The idea that they are a violation of the rights of humanity and of per- fonal liberty, may be oppofed by good argu- ments. Public fafety, and a care for the health and lives of the community at large, have of- |cn commanded ftill more fevere meafures. At EPIDEMIC YELLOW FEVER. n- this prefent time, if a perfon who Is perform- ing a quarantine on board of a Ship or in the lazaretto at Marfeilles, is detected in violating the limits of his confinement, the ceiitinel has orders to kill him inftantly, and yet this mea- fure has been dictated by the voice of humanity. Another argument will enforce the neceflity of restraining perfon all iberty in cafes of contagion. It is the cuftomary right by which the neighbour- ing States exclude us from theufual intercourfe with them. The time may come, which heaven forbid, when the contagious power of this epi- demic, may fuggeft to neighbouring districts the neceflity of a temporary feclufion, and par- ticularly fo, if fevere regulations are not adop- ted among ourfelves. Will it then appear in- humane, if we ourfelves are obliged to forbid any communication with the fick, their houfes, and the ftreets in which they are Situated ? The diftreffes of this fevere meafure would, no doubt, be foftened, if feveral hofpitals were fit- ted up, and a choice left to the patients of their own attendants. They could be thus fup- plied with more private accommodations at their own expence, while the poor and forlorn would be taken into thofe public houfes which have been already fufliciently well regulated and fupplied with every neceffary by the vigi- ki. ACCOUNT OF THE lant care, and generous donations of our citi- zens, during our paft calamities. Infine, if thefe general meafures are never adopted, we Should at leaft be cautious to fufpend any intercourfe with the infected houfes and ftreets, although it will be moftly too late when the contagion has been fuffered to fpread. Patriotifm and candour, both of phyficians and citizens, would foon afcertain the prefcnce of the fcourge. The miftakes of an ifolated judgment may be obvi- ated by previous appointment of many phyfi- cians toyifit and confult upon each new cafe and patient. During the laft prevalence, the public were cautioned that many deaths were afcribed to the yellow fever, fome weeks be- fore they would believe it; but they foon ac- knowledged that they received proper and timely information, owing to the attention of well known phyficians. This is an unquestion- able refqlt from what we have Stated of the nature and operation of putrid exhalations, that s*s foon as their firft effects are difcover- ed, in the early ftage of the feafon, we might think it in our j>ower to be prepared againft fubfcqiiently created cafes, and againft the contagion from bodies. Thefe are known to emit, in cafes of death, almoft none, and to be- come dangerous only in the laft periods of the ficknefs when they recover. EPIDEMIC YELLOW FEVER. 119 III. There are other meafures which expe- rience has proved extremely fuccefsful for preferving even thofe who are obliged to re- main in infected places. It has been officially reported to the governor, that, in thehofpitals, during the late prevalence, the contagion had not fpread among the attendants. This would be incredible were we not apprifed of the re- serves and cautions that are naturally made ufe of, invented, and dictated by neceflity when it becomes the fuprcme law. The origin of the famous vinegar of four thieves, fo much recom* mended as a preventive againft the plague, is a proof of that beneficial induftry, and I ne- ver found better or more medical means em- ployed with fuccefs, than among thofe who do not hefitate to exchange many chances of dan* ger againft a valuable compenfation. Yet all their induftry is afiifted with nothing elfe than What is in the power of every one* llefuming, my enquiries, and the effects of their general method, I found three refults from takingvari- ous medicines and from diet. One is, that they reduced the fyftem, and abated, confequently, any difpofition to inflammatory or phlogiftic diathefis ; the fecond, that they kept them- felves in a continual ftate of evacuation, and thus were never fufliciently acted upon by the contagious miafmata; and the laft, that they re- !2o ACCOUNT OF THE newed the bile and rendered it more pure, more fluid, and of a quite contrary ftate to that which constitutes a bilious malignancy. Thefe three rules or indications are equal to any that the medical art can fuggeft and pre- fcribe ; and, as far as they could be well under- ftood by individuals, and anfwered to by eafy means, they would, I believe, moftly render the contagion harmlefs to healthy people, and juftify a very frequent ufe of warm baths, pre- vious bleedings, and the occafional administra- tion of pukes and mercurial draftics, fuch as we employ in the treatment of our patients. Some of my readers would, perhaps, here wifh to be informed, as well as in every other medical work, what peculiar dofes, powders, or pills,and the quantity adminiftered, fhould be particularly employed as preventives againft the yellow fever. I do not wifh to make a fecret of the moft minute circumftances for the proper ufe of bleedings, pukes, and mercurial draftics, but I have already faid enough upon that fubject. A ftill more ufeful piece of advice Shall here be riven, viz. that it is not byfaturation or quan- tity only that medicines are rendered efficaci- ous, nor without thofe proportions and modifi- cation, which the various conftitutions of dif- fer Jnt patients require, and of which phyfici- EPIDEMIC YELLOW FEVER. 121 ans can be the only proper judges. I confe- quently prefer that preventive medicines Should always be prepared according to what is requisite for each conftitution and by the previous indifpofition of body. The moft imposing name, affixed to a pill or powder, will not make it better, if given and employed without any neceffary restriction whatever, but would, on the contrary, cover great blunders and miftakes. Such is the cafe of thofe patent medicines, which, in the immenfe catalogue of their virtual properties, include all the feries of human infirmities, but which are at laft given up as dangerous or equivocal remedies. To their patrons, however, I am willing to grant, that, if it was poffible to afcertain above what point they are variously noxious, before any obtained fuccefs, and under which propor- tion they would fail or become ufelefs, they would not be thought a great nuifance among the credulous, whatever power they may be pofleffed of. The attendants of the fick Should always be attentive to keep a fire in the patient's room, although the warm weather might render it uncomfortable. This I confider as a pow- erful mean for purifying and renewing the Uiclofed air, which is inftantly abforbed with R i_-_ ACCOUNT OF THt any morbid exhalation. The phenomenon of fire, cannot take place but by an immenfe con-> fumption of air, and it thus becomes a draw- ing ventilator. This meafure not only destroys any floating contrgion for the benefit of the attendants, but I have obferved it to be very iifeful to the patient, whofe body fhould not be immerfed in its own infectious emanations* and who cannot yet bear to be expofed to the variable external temperature. Infine, by the means of fire, a falutary and fragrant fteam can be immediately procured, in the critical mo- ment of foetid and dangerous evacuations. Various means have been alfo recommended as preventives by expanding round ourfelves volatile and chymical fubftances to neutralife, as it were, the putrid miafmata. Although this method is very uncertain, yet much benefit may be obtained when the current of an arti- ficial vapour breaks or alters a contagious one. Thefe means, however, too often act unfa- vourably towards the conftitution, and have a tendency to enweaken the nerves, while it is highly requisite that the body be kept in the very point of health. Every one knows, in this refpect, the effects of camphor and of muik. The aromatics have a contrary and better ef- fect, becaufe they are equally tonics and ami-. EPIDEMIC YELLOW FEVER. »»3 £ optics. We fhould, therefore, conftantly make ufe of their effential oils, of their artificial perfumes, and of the fragrancy of their plants. I have feen alfo the ftrongeft vinegar general- ly ufed againft peftilential emanations, and its ebullition with fugar upon red hot iron, pro- duces an agreeable and falutary vapour. Much has been faid upon the fubject of de- stroying or wafliing with caution the clothes and beds of the fick. None, I believe, are more infectious than thofe of a recovered patient. I have collected, on that fcore, the moft fatis- factory proofs, that a patient may be even re- infected in his own bed and clothes ; and this is undoubtedly the origin of thofe Strange cafes, the ftages of which run through a longer courfe, and repeated recoveries and relaxes, which is quite contrary to the known periods of a malig- nant fever. It is perhaps ufelefs and even incon- venient frequently to trouble a patient by giving him the comfort of frefh, clean, warm clothes, but it is abfolutely neceffary to do fo as foon as a profufe perfpiration has marked the end or a favourable crifis of the malady. If the care of the infected linen is left entirely to the nurfes and fervants, they muft be directed to fold them immediately, and to throw them into cold water, where J24 ACCOUNT OF THE they fhould be kept for twenty-four hours, co- vered wTith aShes to be filtrated into lie, with which they muft be wafhed. The fame care fhould be extended to the beds. At leaft they fhould not be ufed again but after repeated night and morning airings. Infine, the attendants fhould be careful to promote in themfelves a a conftant Spitting, and to avoid, as much as poflible, fw alio wing the faliva. But let it be re- membered, that, with thefe general cautions, and many more too tedious to be related, at the clofie of the feventh day, thf convalefcent patient can no longer tranfmit any contagion. His recovering ftate, is a proof of the purity of his blood. How diftreSfing, therefore, would it be, under a falfe idea of danger, ftill to con- tinue our intercourfe with him with referve and caution, when it is no longer neceffary. He has been already too long'obliged to con- fider himfelf as an object of terror and dere- liction. To what a perilous defpondency has he not been delivered by fugitive friends and re- lations ! To what afflictive folitude has he not been condemned, while excruciated by a devouring poifon! The arm of Providence could alone help him from under the two fold preffure of his body and of his mind ! The for- mer may counteract the laws of life as foon and as irrevocably as the latter ! And ye attendants EPIDEMIC YELLOW FEVER. i*$ of the fick, if a liberal and philanthropic mind ennobles your cares and fervices to your fellow beings ; if you are not ft rangers to a moral Sympathy—to the Supreme maxim of doing to others as you would be done by; and if it is your pride not to value your dangerous taSk by pecuniary compenfations, you deferve protection from heaven and refpect from your fellow citizens. But fuch a meritorious claim is loft by mere mercenary fervices, which be- come baneful to unfortunate patients whom your expreffed terrors and affected impa- tience, loudly befpeak as objects of horror in the creation. Deipair, abfolute defpon- dency, and depreSfion of fpirits, will foon fubdue the fmall Share of organic ftrength left to them in this ferocious diforder. Their fate is in your hands, more than in medical fkill, if charitable cares, hopeful words, and apparent confidence, are not continually and ingeniously offered, as the moft fucefsful comfort that will help, both the power of nature, and the wif- dom of phyficians. ABSTRACTS. Firfi, Particular preventives againft the yellow fever are deduced from its nature and i_5 ACCOUNT OF THE characters cf highly malignant bilious. Its in- fection will have but little power, or none at all, againft thofe whofe bile is kept in a pure ftate, by vegetable diet, or light nourishment, and often renewed by depleting remedies, fueh as have been recommended for the treatment of the diforder. Secondly, Refreshing exercife in the morning or evening, recreative life, and free from in- tenfe labour ; antiphlogiftic remedies, and other means as they occur to proper experience and judgment, are always fufficient to difpel that inflammatory difpofitiop which aggravates a ma- lignant fever, and to avoid an immediate effect from their miafmata. Thirdly, Intercourfe with infected people is to be carefully avoided: their houfes fhould. be under a fingular guard and exclusion. At- tendants of the fick are to be excepted, if they are particularly addicted to proper care and cleannefs in their perfons. Fourthly, Attendants of the fick fhould fubject themfelves to more frequent ufe of the above remedies and diet under medical prefcription. By keeping chimney fires in the room of the pa- tient they will not be endangered. They are EPIDEMIC 'iELLOW FEVER. __} recommended to have and take effences or" perfumes of an aromatic nature ; and to make frequent fumigations with aromatic herbs and alfo with vinegar or fugar burnt on red hot; iron. . ■. t, Fifthly, Infected beds and clothes are objects of great caution,when not immediately deftroy- ed. They may be fafely kept in cold water, co- vered with, afltcs, to be filtrated into lie and waflied with. SECTION VIL Hifiories of Cafes.----No. I. 7" '•<•; J. W. upwards of forty-five,v/as corpulent*', •fanguineo-phlegmatic, robuft, and apt to in- dulge in the ufe of fpiritous liquors. For fome years, hehad been fubject, duringthe winter, to pains in the breaft, and to congestion of bile in the ftomach. He was foon relieved by dilu- ting and depleting remedies ; but, after feveral relapfes, I had fufficient reafon to think his complaint a chronical one, originating from fome ferious caufe. He oppofed any further in- vestigation, always depending upon a real cure. He was taken, on the 22c! of July, of the 123 ACCOUNT OF THE laft feafon, with all the alarming fymptoms of4 the yellow fever, and was treated accordingly, As his pulfe was hectic, in the beginning, I was not furprifed to find him worfe on the fecond and third days. The evacuations were always colliquative and foetid, his urine fuppreffed, and copious bleeding, could never abate the gene- ral fymptoms. I affirmed, to his friends, that he would die in two days. I neverthclefs endea- voured to enquire from his neareft relation in- to fuch circumftances as would lead to a diC- covery of the real chronical caufe, which was fb highly aggravating this acute malady ; and it was at laft difcovered, that, for nine years paft, he had been fubject to what was termed, the gravel. Sufficient inductions could im- mediately explain my fufpicions, although it was too late to remedy a difeafed vifcera. It was interesting to afcertain the cafe, and I ob- tained leave from the patient to introduce a catheter and a bougie into his bladder. With the firft I found infurmountable obstacles ; but, with the latter, I penetrated all the meatus urinar'ms, where I felt three Strictures. The fartheft was formed by the fwelling of the proftrate, and the bougie retained the fliape of a fcrew. A laft attempt with a catheter dif- covered a large and foft tumour arifing from the neck of the bladder, and from it I drew EPIDEMIC YELLOW FEVER. 129 Jiure blood and clots of brown matter. The next day, the fifth, the patient was as yellow as a marigold ; he feemed choaked with an infil- led fluid in his Stomach, and he expired in the evening. OBSERVATIONS. It would be fuperfluous to explain the pri mordial caufe of thefe Strictures, of the fwel- ling of the proftrate, and the tumour projecting within the bladder. It would rather appear ftrange that the patient had fo long complain? ed of the gravel, without ever being obliged to apply to more direct and efficacious meafures, if we were unacquainted with the indiftinct and confufed feelings of thofe who have long laboured under a chronical complaint. This patient was more affected by the effect than by the caufe. When the fecretions from the blad- der and kidneys were totally difordered, the blood retained much of the urine, and caufed the fecretion in the liver to be more copious and corrupted. Thus frequent bilious congef- tions took place in the ftomach, Sec. With this previous complaint, the leaft degree of malig- nancy, added to the bile, could not but agra- vate the rapid and fatal periods of the yellow S \ i2o ACCOUNT OF THE fever ; for no regular fecretion could be fettled ao-ain in the liver, orbe drawn from the bladder. Both vifcera were vitiated and difeafed. To this and to any fimilar cafe, the Only prognof- tic will be an immediate death. case-No, ii. C. D. was a man of fifty years of age, of a very thin habit, with large and numerous blood veffels ; of a merry difpofition ; and who had unrefervedly ufed high food and Strong li- quors. He was ftill very cautious, in the month of October, 1793, anc* continued to live in a country place in the neighbourhood. The com- pany of a friend induced him to come in town, and he was immediately taken. His previous complaints were faid to be a constant rheumatic affection, in the thighs and hips. He had alfo frequently experienced paroxifms of gravel, and no more could be faid on that relpect. His fever was very high ; his face red, lurid, and all his frame agitated. A copious bleeding, nitrous drinks, and mercurial draftics, were adminiftered in the fecond day. They afforded but a very fhort remiflion. The evacuations **- EPIDEMIC YELLOW FEVER. »3* contained very little bile ; the urine was very clear ; and he felt an uncommon proftration of* ftrength. I had, from the patient himfelf, that he did not feel whether he had a ftomach and a belly. I conceived him to be under a ve- ry fatal prognofis. Two other bleedings were ordered in a Short interval, with more power- ful evacuations, and an emetic. They had not the leaft favourable effects. He continued reft- lefs, afleep, and had a violent chill. His defpon- dency grew more alarming. He loft all feeling. The jaundice came on rapidly, on the third day, tinged with a blackifh hue ; and he died on the ourth. OBSERVATIONS. If the firft mercurial draftics, adminif- tered a little after venefection and when the exacerbation abates, are unattended with a pro- fufe difcharge of green bile, we will proba- bly fail in all the fubfequent applications ; be- caufe there is not any other combination of re- medies to overcome the increafing rcfiftance of the morbid caufe. Proftration of ftrength is, alfo, a premature fymptom of death, when it appears without previous critical operations. Inline, the fecond exacerbation of this patient j,, ACCOUNT OF THE came on with a chill, and nothing could be more ominous. Early on the fecond day, fuch were the certain figns of his death, yet I had drawn a much more pofitive prognostic of a fa- tal iffue when I was firft informed of his pre- vious pains called rhucmatic, and of his affec- tion of the gravel. Whatever kind of obstruc- tion may happen, in the urinary paffages, they are moftly attended with numb pains in the hips and thighs. Thefe moftly prove the existence pf a difeafed vicera in the lumbary region, which aggravates a malignant fever to death. CASE—No. III. A young gentleman, J. T. of a tender con- ftitution, fanguineo-phlegmatic; of irritable nerves, fober life, thin habit, and fubject to frequent weaknefs of the ftomach, was feized with a fhivering, internal burning heat, retching, fpontaneous puking of bile, and the moft tumultuous fever. Headach, pains in the limbs, with exceSfive anxiety of mind and body, had increafed to an infupportable degree, when I firft faw him ; and nothing better could be done than to open a vein and let out twelve EPIDEMIC YELLOW FEVER. -33 ounces of blood. The ufual mercurial draftics were given after the exacerbation, in very fmalldofes, and their operation was very incon- siderable and contained very little bile. The urine appeared turbid and fcetid. The fecond day offered a very gloomy profpcct for the fu- ture iffuc. The countenance and look of the patient were confufed, although he was beauti- fully red coloured, and I difcovered retch- ings and fome convulfions in the mufcles of the arm and a general fpafmodic ftate, with a flight pain in the pit of the ftomach. His tongue was covered with a thick yellowifn craft, and his pulfe very hard. I thus judged that the fmal- left benefit had not been obtained, and that the cafe was more perilous. With the inten- tion of oppofingthe fpafms and irritation, of re- laxing them to the greateftpoflible degree, and of procuring afterwards critical evacuations, he was ordered to be put into a femi- warm bath, and bled after it. With thefe pre- vious means, it was probable that the opera- tion of an antimonial emetic would be regular. It certainly anfwered to profufe evacuation of hepatic bile, but it drew the patient into the moft alarming faintnefs and convulfion. We were then in the third day 1 I gave up all my hopes. Other remedies, as blisters, and draftics, were fubfequently adminiftered to gratify the foli- ij4 ACCOUNT OF THE tucle of friends ; but the amiable youth rapid- ly Shewed more dangerous fymptoms. A deep orange colour fuffufed all over his body on the fourth day ; fome black, ycllowifh, and fcetid ftools took place, and his delirium in- creafed to disparity. In the evening, he got up, could walk, and in many other exertions, fur- prifed the vigilance of his attendants, until he was feized with agonizing pains ; he expired early on the fifth clay. OBSERVATIONS. This is another of thofe melancholy in- ftances in which a fuperior power overcomes, all at once, the Strength of the body, the Skill of the medical art, and the aid of natural exer- tions. In it I never experienced the leaft bene- fit from any kind of application, nor could I diftinguifh any thing but the rapid destruction of the whole frame. I could not regret that he had not loft more blood, fince two copious bleeding had afforded no means of relief. I could not accufe the violent operation of a puke, which in its proportions and circumftances is not known to be of fuch a dangerous effect. But as I had been informed that the patient had been previ- ously much fubject to ficknefs of the ftomach, EPIDEMIC YELLOW FEVER. 13; for which he repeatedly applied to medical aid, I more diligently enquired and remained, at laft, fatisfied, that he was in the cafe of a dif- eafed vifcera, and this explained why, early in rhe firft day, his urine wras fo highly foetid. CASE—No. IV, The moft irifidious cafe was that of B. a robuft young man, of twenty-three, brought up to hard labour, of a bilious temperament, of a middling fize and regular habit, Strong nerves and hard fibres. The moft particular care was paid to him, and he went through all the ftages of the malady without any very alar- ming fymptom; for he died on the eigthth day, after a Short agony, without any previous prof- tration of ftrength or a moment of delirium. Of the ufual crifes of the yellow fever, the jaundice only had been marked fince the fifth day. It is true the urine was very rare, but bleedings, mercurial draftics, and other reme- dies, had all produced vifible effects, and fatis- factory relief. Every night the patient appear- ed to be refrefhed with a few hours of Sleep. If he had fome anxiety, it was rather from t3S ACCOUNT OF THE his mind than from his body. Sitting upori his bed, converfing, and directing himfelf the preparations of medicine, was his Situation more or ljfs, until the laft moment of his life, and I confefs that, during four days, he deceived my expectation. My reader will now recollect fome obfervations made in p. 32, respecting dangerous fymptoms, which it is fo difficult to diftinguifh. I have there Stated that want of fufficient evacuations of bile, lofs of painful anxieties of the body, an uncommon degree of ftrength and chills preceding the fever, and mufcular convulfions, were the on- ly''remaining but fatal fymptoms in infldiou3 cafes. Thefe were all the ftriking figns distinct- ly marked in this patient; and, in fpite of the apparent mildnefs of all other fymptoms, they always conftituted an alarming prognofls,which the iffue justified by a fudden death. It was very interesting to afcertain what previous diforder in the conftitution, or in any vifcera, had aggravated the cafe of this robuft young man ; but, if there was any, I could not difco- ver it, and remained fatisfied writh that general opinion, that detraction of life is more fre- quently caufed by unobferved violation of natu- ral laws, than by effects that Strike our fenies and our feelings. EPIDEMIC YELLOW FEVER. 137 CASE—No. V. Mr. F\ d' E. a foreign gentleman, was taken In the latter end of Auguft. He was upwards of thirty-fix, of a pale complexion, tall and Slim in his body, bilious-choleric in his temperament, of great fenfibility, and of afedentary life. Recent misfortunes had much undermined a consti- tution naturally Strong. He had lately been fubject to frequent indifpofitions of the ftomach, and chiefly fo fifteen days before his laft ficknefs, during which time he had entirely loft his ap- petite. Probably he received the infection in the company of a friend who fell a victim, a few days before, and it quickly disturbed.the opertion of every function. His firft and fponta- neous pukings of the bile were very considera- ble, as well as his inflammatory diathefis. He loft near forty ounces of blood, in lefs than twenty-four hours. On the fecond day, all eva- cuations had been colliquative, foetid, and without cyftic bile. In the exacerbation of the following night, he complained of an internal burning heat, and his eyes appeared red and T i<8 ACCOUNT OF THE inflamed. In vain did I again employ the beft: of an antiphlogiftic method ; and neither anti- mony or mercury could Stimulate the refer- voirs of the bile. On the third day no dejec- tion of the mind was remarked; but, on the contrary, an incoherent converfation, a Stu- pid and grim look, and a conftant watch* fulnefs prevailed, fo that he could not bear the Slightest covering in the way of bed-clothes, and was often indulged in the trial of feveral beds, to find a diverfion to the anxieties of his body. At fuch a fight we gave way to defpairy and medical prefcriptions were but formalities of circumftairce ! The urine was to- tally fuppreffed on the fourth day, a Stricture on the breaft fuceeeded,with great difficulty of the deglutition, and with an eafneft defire of drinking, he hardly could fwallow a few drops of any liquid. The jaundice was diftufing ra- pidly, leaving pale red fpots on the joints. His Spontaneous ftools were highly foetid, black like foot, and full of white and red flakes, very Si- milar to parcels of teguments of the bowels. Never, never, were greater ravages and putrefcence feen in the human frame, except in the plague 1 Yet the pulfe was regular. On the forenoon of the fifth day, our unfortunate pa- tient got up and completely dreffed himfelf. With an uncommon vigour he came down from EPIDEMIC YELLOW FEVER. 13q a bed room, into the yard, to fit and converfe with aftonifhed friends. No longer than half an hour was the delufion of health and life given to him. Alas! an horrid look, a deep yellow colour, and a blackifh hue diifufed over his face formed a countenance which could no longer deceive a medical obfcrver. The motions of his body were now anfwered by pains in the abdominalia; his pulfe became convulfive ; a tumultuous delirium marked his agony ; and he died late in the night, when a great quantity of putrid blood burft and was difchargcd from the bowels, OBSERVATIONS. That the extremely malignant cafe of this patient had been aggravated by a previ- ous ftate of ficknefs, is unquestionably true. From the beft teftinjonies, proofs were derived of fome obstructions in the liver, or of fuch atrabilious affections as are frequent among peo- ple of his turn and defcription. When all the animal fluids are vitiated, and of courfe their vital power enweakened, how great muft be the power of a contagious virus on more corrup- tible juices ? This inftance, with fuch a princi- ple, would then totally contradict the obferva- -4o ACCOUNT OF THE tion of Dr. Hoffman, upon thofe who labour un- der hypochondriacal complaints,whom he thinks are very rarely feized with epidemic or contagi- ous difeafes, or even with the plague itfelf. (Hoff- man's Practice of Medicine, chap. vi. art. hyp.) If fuch an effect was ever obferved to be true, it was furely owing to the ufe of thofe medicines to which fuch patients have constantly re- courfe to relieve themfelves. As they promote at leaft feveral evacuations, they are, more or lefs, preventives againft the abforption of dangerous miafmata. Never were the charac- ters and fymptoms of the yellow fever more ftrikingly marked, except in the black vomit, which did not take place. But the black matter was plentifully difcharged from the bowels. It excoriated them and no doubt it infufed itfelf Into the abdominalia. The.renewal of vigour, which fo peculiarly and infidioufly fucceeds in the very laft Stage of the yellow fever, was extraordinary in this fubject and equal to the violence of all other fymptoms. At fuch a de- gree of the yellow fever, its medical investiga- tion would not leave room to the leaft fuccefs- ful application. Its turbulent and rapid courfe could not be fufpended by human aid ; but let us truft to a more confoling opinion, which numerous facts will bring now to the moft in- controvertible light. Epidemic yellow fever. hi CASE—No. VI. A young man, of about twenty-five, of a florid countenance, plethoric habit, of a labo- rious and irregular life, was feized with a vio- lent fit of epilepfy in the Street. He was taken up and carried to his bed in that ftate of ftupor which accompanies fuch paroxifms. His pulfe was depreffed and intermittent; but, as foon as he was copioufly bled, he vomited a great quantity of yellow bile, and an exacer- bation of high fever immediately came on, which caufed another bleeding to be prefcri- bed, with an antimonial emetic, a few hours after. It did not produce the leaft motion, although he had been bled twice,which I afcri- bed to the higheft degree of fpafmodic and in- flammatory diathefis. In fact, his tongue and face were yet of a red fiery colour, and his fenfibility was not yet restored. I feared that an immediate bleeding could not bring any further relaxation, nor procure evacuations of the bile, and that I fhould foon loofe my patient. In this perilous fituation, I could truft only to na- ture. The orifice of the bleeding was examined I- AC COUNT OF THE and covered with a greafed lint, and the ban- dage was relaxed with the view of procuring, du- ring the night, a fpontaneous dif charge of blood, left the next exacerbation fliould be kept up too high, and leave again a tonic re-action. No instructions were left to the attendants, for fear of dangerous mifapprehenfions. Nitrous and copious injections were ordered for every two hours, and a dofe of mercurial draftic pills was given before the fever, and the fame after it. All that had been forefeen and wiflied for happenr ed. The fever foon became fo turbulent on the delirious patient, that the blood burfted out from the orifice which had been prepared, and continued to run to more than fourteen ounces, and until the patient was deluged with it. The fever than abated with a relaxation ; as the ab- idomen had been refreflied by many injections, the crifis happened to be more complete. The former emetic, and the mercurial pills, opera- ted all at once, and theycaufed, in every way, prodigious.difcharges of dark green bile,which, by its acrimony, excoriated the fphincters of the fundament. Early the next day, I faw the patient in this favourable ftate. He felt extreme- ly weak, buthis pulfe, and his fkin were good. I continued and kept up the flux and evacua- tions from the bowels, until they appeared of a natural colour; and, on the forenoon of the I EPIDEMIC YELLOW FEVER. i43 third day, the fortunate patient perfectly re- covered and could refume his daily labour. OBSERVATIONS. It has been frequently feen, during the two laft prevalences of the yellow fever in Phila- delphia, that the breaking of the malady was marked by an epileptical fit, as it often happens in the flu all pox and feveral other cafes ; for, in whatever pathology epilepfy is understood, it is admitted thatitmay originate from ftrongfpafms in the ftomach and inteftines. That the effect or action of a highly malignant contagion can at firft be entirely directed on the nervous fyf- tem, is likewife beyond any doubt. With thefe previous hints, and with the certainty that the patient had never been fubject to that complaint, nor particularly to any other, the circumftance alone of the prevailing epidemic, juftified an immediate treatment for the yellow fever. The continuation of the inflammatory fymptoms af- ter two fucceflive bleedings, and the ineffica- cy of an antimonial emetic, evinced what has been already Stated of the impoffibility of de- livering the body of the contaminated bile, or of the fpecific contagion, left an artificial or na- tural relaxation is timely brought on. The &ct 144 ACCOUNT OF THE alfo proved, that I ought not to have hefitated for a tliird bleeding, in the firft day, although two preceding ones proved inefficacious ; but I yet question whether the effect of the latter had been Co well applied as the fponta- neous bleeding, the meafure of v/hich I left to the force of the next exacerbation. Beit as it may, the profufe difcharge of dark green bile, was as fudden as the refiftance had appear- ed obftinate. Another interefting ground of obfervation occurs in the above cafe. What is the reafon of its being evolved in fo Short a time as three days ? The moft fortunate ftages of the yellow fever do generally run during feven days, and was not the former inftance an ephemeric cafe to be judged in afar differ- ent manner, and abfolutely diftinct from the yellow fever ? All thefe objections will be fully explained,. to the reader, if he recollects the pathological rule abovementioned, concerning the periods and duration of malignant fevers. They have been obferved to be included in four or feven days, and fometimes in nine, and even in four- teen. Admitting, confequently, that the illnefs of this patient had begun feveral hours before his epileptical fit, we will find this refolution correfponding exactly to the fourth day. But EPIDEMIC YELLOW FEVER. »« another reafon ftrikes us When we confider that the iffue of the malady muft, neceflarily, depend very much upon the effect or quantity of the fpecific contagion that has been diffufed from the bile into the blood. When the former is timely evacuated and renewed, the latter remains to be purified* This operation we have faid, nature may perform,within a certain fpace of time, and with the help of artificial or Spontaneous means ; fuppoiing thus that the contaminated bile has not had fufficient time to communicate its virus to the blood, and that it has been fpeedily all evacuated, nothing will remain to be done; and with this obtained ef- fect, the diforder will be put to an end ; but if, on the contrary, the blood has been infected9 then the fever and all its fymptoms attending the malignancy of its caufe, will laft, more or lefs, a 'certain time, until a perfect depura- tion has taken place. Infine, the Short duration of this violent cafe will ftill be more juftly afcribed to the prefervation of the blood in its natural ftate, if we recollect the numerous and familiar cafes of thofe who have certain- ly received the infection, judged its firft effects, and fpeedily counteracted them, yet without any further confequences of illnefs. V 146" ACCOUNT OF THE CASE—No. VII. II. L. an aged woman, of a lively difpofition, active body, and induftrious life, had remarka- bly Spent thirty years of her life in the moft perfect health. In attending the fick, who had recovered, fhe took the infection. Although flie had all the ufual fymptoms and puked much, flie thought but little of her cafe. She had herfelf bled copioufly, applied a blifter to her breaft, and hardly permitted herfelf to be under me- dical direction. I faw her late in the evening of the fecond day, full of courage and fpirits ; but, as during the remiflion of the fever, her pulfe was hard and tenfe, and as fhe was in an unnatural agitation, her cafe was, at leaft, ve- ry ferious. The epifpaftic platter was imme- diately taken of. Diluting drinks, and carmina- tive and nitrous injections were ordered, with mercurial draftics in pills at different times. All thefe remedies anfwered very well, and produced copious evacuations of green bile. On the fourth day, the pulfe was yet a little convulsive, and the exacerbation brought on a delirium. Thinking it not very neceffary to EPIDEMIC YELLOW FEVER. 147 relax the fyftem, by means of bleeding, for fear of counteracting too much the organic ftrength of an aged body, I gave a cathartico- emetic, with previous dilutings. One grain of antimoniated tartar, diffolved with an ounce of fait of glaubert, in a quart of water, a half a pint of which was to be taken every two hours,'caufed little retchings, but produced a prodigious evacuation of yellow, green, brown, and clammy matters. Therefultion of the difor- der was prefumed, and fome opium was ad- ministered. Yet, on the fixth day, we were threatened with a melancholic difappointment. An eruption of fmall red petechia? appeared on the breaft, thighs, and arms; the root of the tongue was bordering on the black colour ; the pulfe was bad; the ftomach threw up eve- ry thing, without much anxiety to the patient, who feemed reduced to an alarming proftration of ftrength, and fome black blood had been difcharged by the Stools. Two circumftances only fupported my hope ; the jaundice was yet almoft imperceptible, and flatulencies in the large inteftines, with a tendency to local in- flammation and tenefmus, promifed a favoura- ble and determined crifis. Fomentations were ordered on the abdomen and mercurial draftics were given again, with alternative dofes of caftor oil. At laft a purulent and bloody 143 ACCOUNTOFTHE flux fettled itfelf and lafted till the ninth day, for the prefervation of the life and perfect reco- very of the patient. OBSERVATIONS. In two inftances, during this treatment, it feemed uncertain whether it was justifiable to have omitted more frequent bleedings. Yet this referve, I would never neglect in aged people, who are fooner brought to a dangerous weaknefs, than to a falutary relaxation, whofc fluids befides are never of the fame inflamma- tory degree as obferved among young fubjects. The good conftitution of the patient, I own, helped her in thefe uninterrupted evacuations during nine days ; but from this cafe what remarkable inductions of their importance may we nofc deduce notwithftanding the fymp- toms are dangerons, and although the patient fliould be in momentary but deceiving appear- ances of recovery! CASE—No. VIII. A. M. upwards of forty-five, full of juices, of a plethoric temperament and ftrong confti- EPIDEMIC YELLOW FEVER. 149 tution, which had been a little impaired by a deep wound received in the breaft, took the yellow fever, as many people did, by keeping a good tonic and uncautious life in a diftant country place, and then coming occasionally into town, and expofing themfelves to our fultry and impure atmofphere. Two copious bleedings, a warm bathing, nitrous injections, diluting drinks, cathartico-emetics, and mer- curial draftics, procured fufficient evacuations of bile, and nothing altered tfie regularity of the exacerbations. On the fourth day, a confi- derable eruption of fmall red petechias broke out, almoft all over the body, and the patient informed me of a violent pain felt in the paro- tid glands. A cool fweat diffufed all over his head, and he was in a great febrile anxiety. Forefeeing a falutary crifis from the mouth, I rendered the draftics more mercurial and fafe- ly waited for the refult. The fwelling of the parotids rapidly came on. It broke out on thefe- venthdaywithan infupportable ftench and the moft profufe falivation. The patient could not fpeak, and large ulcers on the gums and fauces, rendered his deglutition very difficult. It was a pleafing profpect that this crifis would throw off the contagious matter from the inmoft receffes and happily terminate the yellow fever without any further neceffary application ; but i5o ACCOUNT OF THE the inflammation of the mouth grew fo alarming that it threatened with danger of another kind, whilft the patient could not fwallow any nou- rishment, and as the internal erofions gave way to frequent fmall haemorrhages. Such an irritat- ing caufe excited a fymptomatic fever, attended with extreme anxiety of the mind and body. The infection from the falivary glands was fo great that it was infupportably fmelt, even at a great distance from the patient, and in Spite of an ardent chimney fire. It was indeed recei- ved by many perfons; and upwards of two gallons of faliva was one day evacuated. Care was taken to relieve the gums, by cleaning the teeth and fcraping out feveral thick fcales. Gen- tle antifceptic and aftringent emulfions were ufed in the way of frequent gargarifm. To the abfolute ceffation of nourishment 1 fubfti- tuted injections, with the liquor of boiled beef and mutton. It was, in fine, but at the tenth day after the falivation, and the Sixteenth of confinement, that the patient began to recover from his mifery and from the yellow fever. OBSERVATIONS. The quantity of calomel, mixed with other draftics, and adminiftered to this patient be- EPIDEMIC YELLOW FEVER. ict fore the crifis of the mouth was promoted, could not be more than ten grains in my own preparations. Yet, agreeably to the intention of evacuating the bile, it had been all preci- pitated downwards, by the power of other draftics, and after very particular obfervation; fo that nothing or very little of that Specific medicine could remain in the prima vi&, to pro- mote fuch a falivation in a man of Strong con- ftitution. It is true, that as foon as its approach was perceived and determined, more mercury wasufecl; but always with the caution to direct its effects towards the bowels. It thus remain- ed to be concluded, that the crifis was altoge- ther fpontaneous', and Rich as may fncceed in every malignant fever, and once out of ten cafes in the yellow fever. A remarkable circumftance alfo fixes our attention in this fubject. Whatever means of refolution we have feen terminating the yellow fever, I do not remember of a Single inftance without jaundice, except when the fwelling and fuppuration of the parotids have been fpontaneous. If the morbid bile, thrown into the blood, conftitutes the regular duration of the malignant diforder, within a certain fpace of time, with the visible effect of jaundice, it is a fact, that, before this morbid fluid could rjz ACCOUNT OF THE be confined in the laft receffes of the circula- tion over the fkin, it may be determined by ad- mirable laws, but almoft unknown to us, to fix itfelf within the falivary glands, from where it will poured off, like a torrent, in a more diluted ftate. This happy effect will, then, fup- prefs the jaundice and evince the neceflity of a crifis, to help the patient in getting rid of fb great a quantity of noxious and morbid fluids. The above cafe, with one of the following, will alfo fuggeft further cautions to the atten- dants ; for the infectious matter poured off by falivation appeared to be more intenfe, and of a more penetrating malignancy than is com- monly produced in other fecretions. The operator who had cleaned the teeth of this patient, was immediately taken with an hor- rid pain in the arm, and an eruption on it of a gangrenous nature, of which I fhall fpeak hereafter. As long as the ptyalfm is kept up, the enftiing difcharges, which in thefe Cafes are purulent, and form a fediment, fhould be received in veffels prepared for the purpofe, and half filled up with lime or any other ab- forbant earth. The linen likewife, fo often wanted to cover or wipe the mouth, fhould be frequently changed and Wafhcd with the fame care as above defcribed, Sec. EPIDEMIC YELLOW FEVER. 153 CASE—No. IX. A girl of twenty, fanguineo-choleric, health- ful, and previously indifpofed, by impreflions from cold and moifture, was taken with the moft violent fymptoms of the prevailing epi- demic. The ufual applications of copious bleedings, of mercurial draftics, bathings, &c. anfwered in the moft fatisfactory manner, and nothing very remarkable occurred until the fourth day. The evacuations had been fo pro- fufe and acrid that inflamed excoriations had enfued and formed a large ulcer on the levator ani. She was now In a great defpondency, and fometimes delirious ; her tongue was covered with a thick yellow cruft. Happening to take her hand and feel her pulfe, fhe fuddenly fcreamed in a moft violent manner, and She complained that I had broken her arm ; being not a little furprifed and thinking fuch an affertion a deli- rious one, I freely retook her hand, but fcream- ing again, fhe looked at me with horror, Sec. When appeafed by proper words, flie convei;- fed very fenfibly, and abfolutely convinced me X ,5+ ACCOUNT OF THE that the leaft preffure upon her limbs was an- fwered by the moft excruciating pains in her bones. It was enquired what were thofe pains when She moved herfelf, or herlimbs. She an- fwered that flie felt pains every where, that flie preferred to be motionlefs, and that they were more violent in the extremities, Unobferved trials were made to afcertain the truth of the whole ; and nothing could be be more certain nor more ftrange. This ftage of the malady was the moft critical, 2nd al- though She began to be yellow on the breaft, und the face, fome other crifis was to be expec- ted, and to its approach I attributed this in- comprehensible diagnostic. It was rather plea- fing to reflect that, if the wrant of organic fen- flbility would have been alarming, this extra- ordinary addition to it could on the contrary be taken as a favourable Sign. Having obferved a tendency to fome evacuations, of the uterus, emollient fomentations were ordered on the in- guinal regions, and the calomel mixed with em- menagogues was continued. Thefe ftrange pains continued four and twenty hours, but decreafed gradually as a critical and abundant discharge of corrupted and very offenfive blood took place. The convalefcence was immediate and |he recovery perfect. EPIDEMIC YELLOW FEVER. '*_ OBSERVATIO NS. If ^the lues venera, the fcurvy, the arthritis or any other malady vitiating or obstructing the lymph, are marked by pains in the bones and in their articulations, it will not appear irnpoSfible, that the virus of this malignant fe- ver, yet more fubtile and infectious to animal fluids,will produce the relatedeffects,when it has been poured into the circulation. If a flight touch could exafperate fuch pains, it was the effect of a nervous mobility, which is feen of- ten productive of more aftonifhing effects. The whole of thefe fymptoms were yet of a favourable augur, however bad and alarming this ftage of the malady appeared to be, Since nothing could better prove the genuine and una- duitered ftate of vital laws, than acute fenfa- tions in the inmoft receffes of the body* CASE—No. X. M. S. a gentleman upwards of forty, cor- pulent, robuft, and healthful, lately from the European continent, prone to a fedentary life, but regularly addicted to a wholefome and light diet, was taken during the fever of 1793. Unacquainted with all the fatal circumftances of the prevailing epidemic, he applied to fome ,56 ACCOUNT OF THE fimple evacuating remedies, until his ftate grew very alarming, towards the end of the fecond day- At this moment, a friend who Slept in the fame room with him, and who had been ne- glected during four days of ficknefs, was dy- ing. All thefe circumftances threw him into dreadful convulsive motions. A vein being opened, the convulsions increafed, and never ceafed but by the means of an antimonial eme- tic, the operation of which produced much good and gave fome regularity to the courfe of the malady. At the firft appearance of an exacerbation of fever, having propofed blood letting, the patient, who never was bled be- fore this attack of ficknefs, and to whom the laft bleeding had not appeared beneficial, utter- ly refufed to comply with this prefcription, and fimple depleting remedies only were ufed. On the fourth day he was in a great duil- nefs, dejection, and defpondency of mind ; livid and yellowiSh large petechia; appeared and covered his body r but a more alarming fymptom was that of a violent fingultus or hiccough immediately acceding. The reader muft be informed, that the liberty of directing this treatment was every day checked by the patient. Although little hope was entertained, the opportunity of his delirium was feized to EPIDEMIC YELLOW FEVER. 157 administer antifceptic and draftic injections, withblifters. The jaundice, the petechia;, and the hiccough, feemed to be aggravated, and at laft, to our great aftonilhment, on the fif- teenth day of his ficknefs, fymptoms were feen. of a recovery which proved effectual and per- fect. OBSERVATIONS. It muft be confeffed, that medical theory had but little participation to this unexpected cure. Moreover, this was one of thofe memo- rable inftances, and not uncommon indeed, in which particular laws and fymptoms being un- obferved, We are efpecially deceived in our prognoftics and miftaken in our fears. It is to be lamented that, in fuch cafes, the medical art is not in poffeffion of more decifive rules than thofe which are commonly obferved; for there is no fatal prognoftic, but we may find, although very feldom, its exception for a con- trary iffue, and no favourable admitted fymp- toms but were alfo fucceeded by unexpected death. No doubt, this limitation of human knowledge devoted, more than once, victims to a fatal or premature dereliction, and raifed op- probious reproaches againft the medical fcience; i$8 ACCOUNT OF THE yet reafon and experience will unite to juftify human errors and ignorance, as long as we will be furrounded by myfterious laws in nature. But what we can fay is that, if every age has added new treafures to our felicitous investiga- tions, why fliould we defpair to difclofe at laft all the means that may concur to the fafety of our life and prefervation of our health? With this juft confidence, practitioners in phy- fic will never think that talk fuperfluous devol- ved to them of attaining, by one way or ano- ther, to that philofophical Stone of their profef- fion, THE ART OF CERTAIN PROGNOSTICS. ItS elements, it is true, are perhaps as extenfive as all the caufes concurring for the phenomenon of life, and as much as the innumerable com- binations that may counteract it; but let us indulge the confoling hope, that that analyfis, which has fubmitted to our fpeculations, as many extenfive laws of nature, from the rol- ling planets and lightenings above, down to the ambient fluids which are unperceived by our fenfes ; the fame analogies, I fay, might fome- times, and with a far more glorious fuccefs, em- brace all the laws of nature, round the bed of a patient. This is a theatre, where we only can inveftigate effects almoft unknown, and feldom adverted to in fchools and books ; nay, effects EPIDEMIC YELLOW FEVER. 159 unavoidably and often miftaken by the influ- ence of methods and fyftems. If I dare to declare it and to appeal to my judgment, I believe there is not a judicious and experien- ced phyfician but whofe opinion is fettled fafc and free, when conceived rather on the bed fide of his patient, than when aided by any other authority, By what expreffion or power, in the coun- tenance of a patient, without any reference to fymptoms and circumftances, are we deter- mined? Is there not fomething undefined in the motions, or in the mufcles, in the corref pondence of thefe with the mental faculties, that equally contradicts received opinions, fymptomatic refults, and fuggefts true prog- nostics ? If we can point out frequent inftances where our judgment has been ftrikingly de- cided by means, thoroughly unaccountable, would it be inipoffible to analyfe them, or to direct our attention to many others? Let us rather fear, that, in fact, we are not fufliciently acquainted with the laws or effects of life and health. Our phyfiological methods feem to have included a feries of moft ftriking circumftances; and a veil has been thrown upon any thing apparently unattainable by the multitude. W7e judge of debility and we have no certain fcale i6o ACCOUNT OF THE of the vital ftrength applicable to all ages and cafes. We remark feveral degrees of fever, and we remain abfolutely ignorant of its hy- draulick and ftatick caufes. We conceive that life cannot be without motion, and it would be iinpoffible for us to reconcile its acceleration withhealth, and its abatement with death. After long obfervations we have known, the degree of our animal heat, when in a ftateof health, and of its variations neceffarily refultingfrom ceffation of health, we could not exactly apply a Single one to any malady whatever. Infine, the ope- rations of the mind we fubordinate to the pre- cepts of our art, and from thofe of a patient we hardly could know how to derive fome help for our fuccefs. Many other points are bounds and limits of our knowledge, and will long render it imperfect. But if the few which I have mentioned give a true, though imper- fect idea of what it remains to us to be acquain- ted with, to be unexceptionable good judges inhuman difeafes, I have fufliciently juftified unavoidable errors of practitioners in their prognoftics, after having exemplified the fpon- taneous and natural cure of one of the moft fatal diforders. EPIDEMIC YELLOW FEVER. 161 CASE—No. XI. An unmarried woman, of thirty-fix, of fan-* guine complexion, regular habits, and nimble body, went through the firft ftages of the yel- low fever, without any alarming Symptoms. Our ufual applications were faithfully obferved except in one point. She was fo extremely pre- judiced againft the very name of mercury, that it would have been a very provoking meafure to infift on its exhibition, without dif- guifing it. I therefore diminished considerably the doles, and involved them with aromatic effences. It was not perceived in the leaft and nothing disturbed our harmony; becaufe the known efficacy and ftimulating power of that fpecific on the falival glands could never take place. On the fourth day, while flic was in every way worfe than ever, flie complained of a dull pain in the parotids, without any apparent fwelling; emollient fomentations were ordered round the neck and on the breaft. On the fixth day the fwelling and inflam- mation of the mouth were fettled ; on the fe- Y 162 ACCOUNT OFTHE vcnth, coming into the room of the patient, an infupportable ftench abfolutely fimilar to fer- mentation of fceces ftruck me, and it could not be difcovered to originate but in the faliva- tion, which continued near eight days, profufe, regular, and fuccefsful. No jaundice appear- ed on the body of the patient. The prefence of the infecting miafmata could never be en- tirely covered by fumigations and other in- gredients. Nobody came in the houfe of this female, until flie began to recover, but were immediately indiipofed or effectually took the yellow fever. OBSE R VAT IONS. As the fmalleft quantity of calomel has been known fufficient to promote a falivaiion among delicate and irritable constitutions, I would not deduce much from this inftance, if 1 had not been obliged to employ means which were to counteract abfolutely fuch effects. Moreover, it was never obferved that the pa- tient felt any previous and gradual affection in her mouth, as it is fo common and unavoid- able to be acted upon by that mineral fpe- citic. It was no longer adminifiiered than was neceffary for the evacuations of bile, EPIDEMIC YELLOW FEVER. i53 even fince the third day: yet the crifis ra- pidly attained to the higheft degree, with the perfect cure of the patient. It therefore refted with me to judge this fwelling and fup- puration of the parotids, to be merely a fpontaneous crifis, fuch as occurs in malig- nant fevers and in the yellow fever, but fuch as is ufelefs and dangerous to promote ar- tificially, among thole who might be of a different tendency and cured by a different crifis. CASE—No. XII. andlafi. I am of a bilious choleric temperament, and irritable nerves. The leaft indifpofition, and chiefly the prefence of infectious exhalations, is fo foon felt, that neither can obtain time enough to agravate itfelf. As often as I had percei- ved the dangerous effluvia, I alfo experienced a fubfequent indifpofition, of which, fpeedy and proper means always prevented me from knowing any further confequences. When I thought neceffary to fcrapethe teeth of the pa- tient of the above cafe, No. 10, which being covered with thick fcales, exafperated much 164 ACCOUNT OF THE more the inflammation of the gums, I re- ally put too much my fenfes, with my hand, in contact with a very fubtile and infectious emanation. The confequence was, that I foon felt a very numb pain at each fide of the con- dyles, on the lower extremity of my right os humeri. It is a very remarkable circumftance, that, from an eminence of thofe condyles, fe- veral mufcles of the hand and fingers take their origin. The pain grew fo infupportable, while it was independent of my motions, that fmall dofes of opium were requisite for ne- ceffary reft. Emollient and refolutive poultices really exafperated the pain, and my anxiety, was as often renewed, fince I could only form conjectures of its probable caufe. A few days brought on a more ferious diagnostic, a violent headach anddifordered functions,which Speedi- ly fuggeftedthe neceflity of an emetic. This was the firft means of relief that I found to my pain; and while I was fubmitting myfelf to the ope- rations of mercurial draftics, I difcovered that the infection of the yellow fever was the caufe of my ftrange indifpofition. On one part, copi- ous difcharges of dark green bile, were re- peatedly obtained, and on the other, my elbow fwelled and inflammed. Numerous phlictenesy fullof fania, formed on it and broke out; thick teguments turned black and detached in a fcab EPIDEMIC YELLOW FEVER. i5j of two inches in diameter, with the abfolute ceffation of any pain and a perfect restoration cf health. OBSERVATIONS. We have already feen, that Pouppe Defpor- tes notices the malady of Sia?n to be fometimes remarkably preceded by fuppurations of the joints, and dry fpots of mortification on the (kin. He accounted for thefe and other extraor- dinary fymptoms, by the effects of a poifon, which he called pefiilential, that fometimes fixed itfelf in parts distinct from the vifcera. This poifon is, moft commonly, inhaled through the mouth, in refpiration, whence it diffufes through the alimentary channel, difturbs, at firft, all its functions, and contaminates all its fluids. The abforhent lymphatic veffels take their rife from the fkin, which may determine fuch a fingular cafe, whenever they come in contact with the infection, fo immediately as I -did when my hand and fingers were intro- duced into the mouth of the patient. Whether the fubfequent violent illnefs was fymptomatic of the affection of the arm, or whether I had likewife received the infection in the bile, I am not able to de- termine ; though, tome, the latter feemsmoft 166 ACCOUNT OF THE probable, as the pain remained invariably on the fiuue point, and never extended further vp the os humeri; and yet, the morbid caufe in the vifcera was proved both by the illnefs p.nd the evacuations. The cutaneous teguments which really mortified and formed a pretty thick efchar, preceded by phlidenes, were my demonstrative proofs of the virulence of a poi- fon which had on the fkin as much power as a a burn, when Seconded by natural exertions, and emollient poultices, it exuded out- wardly. This inftance will, above all, juftify my above theories and obfervations on the greater danger of infection from recovering patients: the more contagious miafmata they throw off, the more certain is their recovery, CONCLUSION, Gentlemen, I WOULD, perhaps, deferve the re- proach of having affumed too great and bold a confidence, if I now fhould omit earneftly to folicityour indulgence and that of the public. EPIDEMIC YELLOW FEVER. 167 The fubject I have treated, requires undoubted- ly longer investigations and many more of thofe qualificationswhich are acceffary to a writer. It is true, the language to which I was obliged to entruft my obfervations, which never was that of my youth nor of habitude, could not be but a rugged and difficult road, where I ought to have feared to entangle my reader. To fuch a confideration, I had furely facrificed my emulation and my attempt, had I not been much more impreffed upon with the duty of joining what I could of my views to all thofe from which the whole nation expect to derive fome relief againft fo great a calamity. Truth could never be attained, if difcuffions from various fides and opinions were not alike insti- tuted by free and liberal communications. The public claims, as it were, that every one fhould be listened to who thinks that he can contribute to the common welfare. It is of no importance if the learned are divided among themfelves, it always is and always will be fo, until the truth comes out. There are be- sides principles or opinions which are not to be exclufivcly for the learned, whatever maybe their conteft andfyftems, On the con- trary if thefe opinions are good and fafe, they Spread and propagate among the people at large, becaufe there is much reafon and good i63 ACCOUNT OF THE fenfe, and no party fpirit among the people. This is the caufe why it has happened fo of- ten that the public have adopted found and definitive opinions, wdiile the learned had not yet fettled their own variances. J. James Rouffjau reports, that a peafant of Silefia had the honour of fettling a great and ferious fcientifical conteft among the learned in Ger- many, who could not agree, or explain, in the fame way, how a child could be born with a golden tooth 1! He firft thought it neceffary to eftablifh the fact, and this he took the trouble upon himfelf to go, which he proved to be a falfliood. Far be it from me, gentlemen, by relating this fact, to throw out any alluflon againft phy- ficians of this §city, with whom, I am not fb happy as to agree in opinion, on feveral of the above fubjects ; it will be fufficient, perhaps, to declare that I profefs the greateft refpect for many of them ; but there are many inftances to prove, that, in matters of fact and reafon, the tribunal of the public opinion will, at laft, be the b-jft judge. It was thus in Marfeillies in the year 1720. While the plague was rapidly Spreading and raging, phyficians and furgcons publicly declared, that the prevailing difeafe was not the plague, nor even contagious; and EPIDEMIC YELLOW FEVER* 1*9 the famous Dr. Aftruc had to contend againft all of them, until the fact and the public pro- claimed the plague. Unfortunately, Philadel- phia will be expofed to the dreadful experience of more facts, and then the public will decide againft all the all edged authorities and fyftems. Thus to the public, as a fellow citizen, I thought it my duty, to fulfil this tafk, and to you, gentlemen, as a phyfician, to prefent my in- vestigations and experience. Befides, if every man be indebted to the country aad commu- nity to which he choofes to belong, it is my peculiar fatisfaction in jbeing enabled to pay this tribute of gratitude to the citzens of Phi- ladelphia. On thefe motives, therefore, I ground my claim for the indulgence I folicit for this publication ; and, however imperfect it may appear, in the extent, difcernment, and foreign drefs of my obfervations, if, among the poilible farcafms of criticifm, no kind of merit w^ould be beftowed on my work, ftill it will remain as a proof of labour and philanthro*- phy; the one is the virtue of a citizen, and the other the character of a phyfician, Z V: . . ' Jf.'f "'. ■£■1. i:J. '5° ACCOUNT OF Tllfi ■ft POSTSCRIPTS IT has been without reference to anotomica. or phyfiological difcuffions that I have explain- ed the proximate caufe of feveral fymptoms and of the jaundice in the yellow fever, by the immediate paffage of the infected bile into the blood from the pori biliarii into the vena cava, or at laft by the fimple and immediate abforp- tion of the bile into the lymphatic veffels, which cxift in that vifcera as numerous as in many others, when it is flopped or obstructed in its excretory ducts. I was led to that indifference by contemplating that each theory refuming the fame refult of the admiflion of the bile in all our fluids, it was unneceffary to ftate by what procefs it had taken place.- Another ar- gument alfo ftruck me in this acute diforder, as well as in many others, in which the jaun- dice is frequently an attending fymptom or a crifis, although I have not mentioned it in any of the above reflections. Each of our fecre- tions have more than one object of neceffary EPIDEMIC YELLOW FEVER. 171 operation to fulfil for the animal economy. Thus it can be faid, that the fimple perfpiration of the fkin, while evacuating a Superfluous fluid, wafhes and opens the pores. The fecretion of urine not only filtrates and reduces the blood to its proper degree of fluidity, but it is a ve- hicle intended to carry off any heterogenous fubftance admitted into it. The bile, prepared in the liver, befides being a neceffary liquor in the digestion, will be the means of difcharg- ing from the blood thofe elementary fubftances which were created and added to it by the chyli- fication. But, if the bile originally received it^ component parts from the blood, we muft fup- pofe that as foon as its fecretion is interrupted, the blood will retain all thofe component parts ; they will then gradually increafe to fuch a quantity that they will be by another law emit- ted ii> the receffes of the circulation, and there form the jaundice. Therefore, in any theory v/e may admit three origins of icterus; one by the infufion of the bile already formed, and poured from its excretory ducts into the laft ramifications of the vena cava ; another by the abforbing lymphatic veffels; and a laft, by the biliary component parts retained and re-. maining in the blood whenever that fecretion cannot take place. Other circumftances en- force the poflibility of this laft means of jayjv i7_ ACCOUNT OF THE dice, when we confider how many caufes may retard the circulation of the blood in the vena portarum, in confequence of fome inflammation or morbid action within the ab- domen, where are Situated all the branches that form its trunk. It is alio admitted, that, in warm countries, the powers of circulation are much enweakened, by which means the large veffels may be distended, and the bile not fuf- ficiently renewed or diluted. Hence arife bili- ous diforders and bilious evacuations, Sea Such are the general grounds by which I ever thought that feveral fymptoms as well as the jaundice in the yellow fever, might equally be underftood in any of the above theories ; but, I have fince had the opportunity of consider- ing a very folid objection againft a prefumed caufe of the jaundice in the yellow fever, ad- mitting that, by observation and fatisfactory experiments, it has been proved, that, in cafe of Stoppage or obstruction, the bile is fooner, caller, and even immediately returned by the lymphatic veffels, inftead of the veins. This abforption, it is faid, cannot originate but with a Stoppage of the bile in its excretory ducts, or with an obstruction in the liver; yet neither are found by diffection or fymptoms, in cafes of the yellow fever. Its jaundice, therefore, cqnftitutes no fimilarity with any other kind EPIDEMIC YELLOW FEVER. 17j pf remittent fever or bilious diforder ; and it is yet a problematic fubject and a morbus fid generis. This objection, I muft own, came to me from a refpectable quarter, and is connected with fo many other authorities of facts and opinions, that it indifpenfably demanded a fe- rious consideration of the fubject, in order ci- ther to correct my pointed errors, or to ba- lance the argument by fatisfactory reafons. In the mean time, to my medical reader it will obvioufly appear, that, my only motive for this controverfy, is from a confiftency and adhe- rence to the chief opinions of the fubject upon which I have treated. Thus it will be Stated, Firft, as a general view, that the for- mation of jaundice in any cafe of the only cef- fation of proper fecretion of bile, acknow- ledges fo many probable caufes, different from any fort of obstruction in the**liver, that it could not be confined to the theory of the ab- forption of lymphatic veffels. We fee the poi- fibility of an inflammatory and morbid action in the abdomen from the ihteftines or the Sto- mach, and from the diaphragm, immediately distending or obstructing the blood in the nu- merous branches of the vena porta, and fufpending the circulation in that large veffel, more probably fo when we confide^ i-;4 ACCOUNT OF THE that this heavy column of blood muft be affifted in its courfe, by all the furrounding motions and vibrations. Now, it will always be fafe to conclude, that, if the blood does not fecretc in the liver, and particularly fo in acute fe- vers, the principal character of which is a diir turbed circulation, it will keep the bilious com- ponent matter, which it fliould lofe, in the liver, and from that muft arife an accidental icterus. But it is objected, that, even in this cafe, bile fhould be left in the blood, as it finds} its elements in the liver. I deny that however, and very confidently, until it fhall be proved that water could be obtained without oxygen or hydrogen; or that in any of our glands there is an inexhaustible quantity of the component parts of oils, acids, falts, water, Sec. Secondly, The poffible and immediate infu- fion of the bile from the pori biliarii into the minuteft ramifications of veins and arteries, is by no means improbable or impoffible, although it is granted that their lymphatic branches (as they appear to be) do not belong to the abfor- bent fyftem; for injections have been made, with fuccefs, from the hepatic duct into the ve-r na cava and vena porta. But nothing could bet- ter prove, this immediate infufion of bile into the blooc, than frequent cafes of fudden, EPIDEMIC YELLOW FEVER. *7J jaundice, by a wound on the head, by too_ great haemorrhages and profufe bleedings, by a fit of paffion or anger, and alfo by the effect of Strong and acrid medicines. It occurs ve- ry often alfo in practice, among ordinary and quite contrary cafes to any kind of hepatitis^ when we find, chiefly towards the end, the eyes of our patients very yellow. This is a cer- tain degree of jaundice ; yet it could not take place in confequence of obstructions, nor by the minute procefs of all the windings of the abforbent fyftem*. The bile has, therefore, been immediately fqueezed and poured int« blood veffels. Thirdly, Were the abforbent power of the lymphatic veins the only means and caufe 6f jaundice, it could not certainly proceed but by fuch Stoppages and obstructions as! after a while would force and open the valves Of the mouth of the faid lymphatic veins ; for, in any other State, the abforption of the bile could not be affected, as is proved by our iifual ftate of health. But we fee the contrary in the yellow fever; no previous fymptoms * Some anato'ro-ifb contend that nothing is more rapid in the circulation, than the abforption of the lacleal veficls and lymphatic veins. This I grant; but what will be faid if the fluid expofed to abforption becomes thick and tough ? t75 ACCOUNT OF THE induced ns to fvippofe the formation of an ob- struction. Spontaneous and profufe evacua- tions of bile, and a great quantity of it acrid, always diffufed all along the alimentary chan- nel, feems to prove, that the ufual excretory ducts arev opened, and that the only quality of the bile is altered. Let us, then, turn the ar- gument in another manner. There is no ob- struction of the liver nor Stoppage of the bile in the yellow fever, yet the jaundice regular- ly takes place; this muft, therefore, proceed from fome other potable means of jaundice. Fourthly, Is there no other State in the con- glomerate glands, but that of obstruction, that can disturb the fecret ions and then expofe their fluids to the effects of the abforbent fyftem I Are they not fubject alfo to a quite contrary State, to that of atrophy f Although we cannot precisely account for their median* icai functions, muft wre not fuppofe, that, what \\c call an obstruction, when we fee a hard exuberance, or feel a heavy fweljing in fome parts, that this State has been preceded by feve- ral degrees of ceneeftion znd infarctjanwhicli confiderably distended the vafcular, villous, or parenchimatous fubftaiices, and, of courfe, much better favoured the tranfudation of certain fluids, within the abforbent fyftem. It is not EPIDEMIC YELLOW FEVER. 177 indeed when we feel an obftruction in the li- ver, or a fkirrus, or any other unnatural al- teration, that we fhould fear that other ope- ration of the lymphatic veins ; becaufe in this State, various fluids have no longer any circu- lation nor connection among themfelves; but on the contrary, this abforption has more probably taken place when the obftruction was forming, and when the fluids were yet fufliciently liquid in their circulation. It is not, therefore, neceffary, to have any vifible obstruction in the liver or Stoppage in the ex- cretory ducts of the bile, to have a fubfequent jaundice ; this without the former happens in the yellow fever, and it is often Ceen without obstructions, nor fkirrus in feveral r utances. It may then have originated folely from the cnthickening of the bile in the pari billiard, Sec. Fifthly, Let us never confine ourfelves with- in narrower bounds, than thofe which belong to the admirable laws of nature. Such a large and important vifcera as the liver muft have more than one means to difcharge the bile which it cannot empty. That of abforption only would be eventually interrupted or inconsidera- ble. The blood may refume it, to a certain quantity and pour it into the kidneys,or into any other fecretion, as known facts have frequent- ly proved. I alfo, readily believe, that the A a 178 ACCOUNT OF THE lacteal veffels may take it from the intestines, when there is nothing in them but bile, and difcharge it into the thoracic duct, along with the lymphatic veins. I hope, therefore, that the above argument, the ground of which I had lefs the intention to remove than to explain, leaves principles enough with fufficient means to the above theory on the yellow fever, and to all the fubfequent opinions, A famous doctrine has been introduced into the medical world, and it is yet vigoroufly fup- ported and even improved by numerous par- tizans. We may call it the doctrine of direct and indirect debility, or the Stimulating fyfc tern, The fupporters of it fay, that it has fuc- ceeded to the imperfect doctrine of fpafms and conftrictions, the fame as this latter had exploded the old and more imperfect one of vifcidity and lentor. It feems that unfor- tunately that by thofe methods of definition, ftiodern and ancient difeoverics are equally marked either with exclufive advantages or with reproachfull defects. Thus the ungra- cious abufe of words finally will divide lear- ned men, as it evidently created many heretics, and fectaries during paft nges of cbriftendom. Yet whatever may be the inflexible dogma- tifm of thofe who miftake true learning, by praifing only one doctrine, who will dcs. EPIDEMIC YELL0V7 FEVER. i7.j ny but every judicious phyfician confiders it as his duty to examine all doctrines,%nd all methods, with an impartial and unbiafled mind to call to his aid all the good refults from ob- fervations and principles. It was with the motive of avoiding the abufe of words and definition that I introduced only the name of Dr. Brown in my note, p. 29, the author of the doctrine abovementioned ; although I ought not to have omitted to obferve that the actual profeffor of the institutes of medicine, was rot precifely fubordinate to the Brownonian fyf- tem ; fince, on the contrary, he has improved on it, by his excellent views on morbid exciic- ment on the preternatural and convulfive adieus of the blood veffels, on the inequality in fevers, of excitement and excitability, and on the necef- fity of abstracting what we lhoiild call in other words, fpafms, irritation, inflammation, Sec, and, in one word, fuggefting the relaxation without which no falutary crifis are ever ot> tained, It has been faid, in page 14, that as" we " have not any publication, collectively, from w that body (the college ofphylicians) that could " exhibit more, and Stronger arguments than c< merely their opinion of its importation, Ifup- pof» that }s unneceffary for me to fay any u thing eu'.1|?r for or againft the opinion." This might be dtr-nC(j a material inaccuracy m ACCOUNT OF THE if I fliould not add a neceffary explanation. That body, has, in feveral circumftances, publifhed the authentic facts, by which it has appeared that the diforder has been impor- ted from foreign countries. The reader will re- member, that I have not drawn the leaft con- troverfy from any of the facts concern- ing the importation of the fever nor of of the means which have been alledged to have fpread it. Their authenticity and moft ftri- king circumftances never could weaken the contrary belief, which implies the eventual generation of the fever on board of fhips from tropical countries, and as it is contagious, we do not deny that an infected feaman might, of courfe, communicate it to his attendants. If a whole crew alfo or a part of it, came from a known infected place to another of very hot temperature, they furely may be dan- gerous. Thefe chances are acknowledged or granted; but, to fuch chances we will not give up a matter of principles, of analogy, and an opinion, the arguments of which, in the conftitution of the air, are even employ- ed by the opponent believers. Therefore, if the facts proving the importation to others, prove to me nothing elfe than the generation of the yellow fever on board of fhips, it will not be improper to conclude, that with ^Y fuch arguments one fide has nothi^a Stronger than merely their opinion. F I v i S. Ji