22. The cephalic, in which are included the phrenitic, lethargic, apoplectic, paralytic, hydrocephalic, and maniacal states of fever. That madness is originally a state of fever, I infer, 1. From its causes, many of which are the same as those which induce all the other states of fever. 2. From its symptoms, particularly a full, tense, quick, and sometimes a slow pulse. 3. From the inflammatory appearances of the blood which has been drawn to relieve it. And, 4. From the phenomena exhibited by dissection in the brains of maniacs, being the same as are exhibited by other inflamed viscera after death. These are, effusions of water or blood, abscesses, and schirrus. The hardness in the brains of maniacs, taken notice of by several authors, is nothing but a schirrus (sui generis), induced by the neglect of sufficient evacuations in this state of fever. The reader will perceive by these observations, that I reject madness from its supposed primary seat in the mind or nerves. It is as much an original disease of the blood-vessels, as any other state of fever. It is to phrenitis, what pulmonary consumption is to pneumony. The derangement in the operations of the mind is the effect only of a chronic inflammation of the brain, existing without an abstraction of muscular excitement.

23. The nephritic state of fever is often induced by calculi, but it frequently occurs in the gout, small-pox, and malignant states of fever. There is such an engorgement, or choaking of the vessels of the kidneys, that the secretion of the urine is sometimes totally obstructed, so that the bladder yields no water to the catheter. It is generally accompanied with a full or tense pulse, great pain, sickness, or vomiting, high coloured urine, and a pain along the thigh and leg, with occasionally a retraction of one of the testicles. It exists sometimes without any pain. Of this I met with several instances in the yellow fever of 1793. I include diabetes in this state of fever.

24. The hydropic state of fever, in which are included collections of water, in the lungs, cavity of the thorax, cavity of the abdomen, ovaria, scrotum, testicles, and lower extremities, and usually preceded, and generally accompanied with morbid action in the blood-vessels. That dropsy is a state of fever, I have endeavoured to prove in another place[10]. Nineteen dropsies out of twenty appear to be original arterial diseases, and the water, which has been supposed to be their cause, is as much the effect of preternatural and morbid action in the blood-vessels, as pus, gangrene, and schirrus are of previous inflammation. This has been demonstrated, by the late Dr. Cooper, in a man who died of an ascites in the Pennsylvania hospital. Pus and blood, as well as water, were found in the cavity of the abdomen. It is no objection to this theory of dropsy, that we sometimes find water in the cavities of the body after death, without any marks of inflammation in the contiguous blood-vessels. We often find pus, both in the living and dead body, under the same circumstances, where we are sure it was not preceded by any of the obvious marks of inflammation.

25. The hæmorrhagic state of fever, in which are included discharges of blood from the nose, lungs, stomach, liver, bowels, kidneys and bladder, hæmorrhoidal vessels, uterus, and skin. Hæmorrhages have been divided into active and passive. It would be more proper to divide them, like other states of general fever, into hæmorrhages of strong and feeble morbid action. There is seldom an issue of blood from a vessel in which there does not exist preternatural or accumulated excitement. We observe this hæmorrhagic state of fever most frequently in malignant fevers, in pulmonary consumption, in pregnancy, and in that period of life in which the menses cease to be regular.

26. The amenorrhagic state of fever occurs more frequently than is suspected by physicians. A full and quick pulse, head-ach, thirst, and preternatural heat often accompany a chronic obstruction of the menses. The inefficacy, and even hurtful effects, of what are called emenagogue medicines, in this state of the system, without previous depletion, show the propriety of introducing it among the different states of fever.

I have designedly omitted to take notice of other states of general fever accompanied with local disease, because they are most frequently combined with some one or more of those which have been mentioned. They may all be seen in Dr. Cullen's Synopsis, with their supposed respective generic characters, under the class of pyrexiæ, and the order of fevers. We come now in the

III. And last place, to mention the misplaced states of fever. The term is not a new one in medicine. The gout is said to be misplaced, when it passes from the feet to the viscera. The periodical pains in the head, eyes, ears, jaws, hips, and back, which occur in the sickly autumnal months, and which impart no fulness, force, nor frequency to the pulse, are all misplaced fevers. There are, besides these, many other local morbid affections, which are less suspected of belonging to febrile diseases. The nature of these states of fever may easily be understood, by recollecting one of the laws of sensation, that is, that certain impressions, which excite neither sensation nor motion in the part of the body to which they are applied, excite both in another part. Thus worms, which are not felt in the stomach or bowels, often produce a troublesome sensation in the throat, and a stone, which is attended with no pain in the bladder, produces a troublesome itching in the glans penis. In like manner, the irritants which produce fever in ordinary cases pass through the blood-vessels, and convey their usual morbid effects into a remote part of the body which has been prepared to receive them by previous debility. That this is the case, I infer further, from fevers being called back from their misplaced or suffocated situations, by creating an artificial debility in the arteries by the abstraction of blood. This is often done in muscular convulsions, and in several diseases of the brain.

Under this class of fevers are included

27. The chronic hepatic state of fever. The causes, symptoms, and remedies of the liver disease of the East-Indies, as mentioned by Dr. Girdlestone, all prove that it is nothing but a bilious fever translated from the blood-vessels, and absorbed, or suffocated, as it were, in the liver. This view of the chronic hepatitis is important, inasmuch as it leads to the liberal use of all the remedies which cure bilious fever. Gall stones and contusions now and then produce a hepatitis, but under no other circumstances do I believe it ever exists, but as a symptom of general or latent fever.

28. The hæmorrhoids are frequently a local disease, but they are sometimes accompanied with pain, giddiness, chills, and an active pulse. When these symptoms occur, it should be considered as a hæmorrhoidal state of fever.

29. The opthalmia, when it occurs, as it frequently does in sickly seasons, with a quick and tense pulse, and pains diffused over the whole head, may properly be called an opthalmic state of fever.

30. The tooth-ach, and

31. Ear-ach, when they arise from colds, and are attended with great heat, a quick and tense pulse, and pains in the head, are odontalgic and otalgic states of fever.

32. The apthæ, from the pain and fever which attend them, are justly entitled to the name of the apthous state of fever.

33. The symptoms of scrophula, as described by Dr. Hardy, in his treatise on the glandular disease of Barbadoes, clearly prove it to be a misplaced state of fever.

34. The scurvy has lately been proved by Dr. Claiborne, in his inaugural dissertation, published in the year 1797, to arise from so many of the causes, and to possess so many of the symptoms, of the low chronic and petechial states of fever, that I see no impropriety in considering it as a state of fever.

35. The convulsive or spasmodic state of fever. Convulsions, it is well known, often usher in fevers, more especially in children. But the connection between spasmodic affections and fever, in adults, has been less attended to by physicians. The same causes which produced general fever and hepatitis in the East-Indies, in some soldiers, produced locked jaw in others. Several of the symptoms of this disease, as described by Dr. Girdlestone, such as coldness on the surface of the body, cold sweats on the hands and feet, intense thirst, a white tongue, incessant vomitings, and carbuncles, all belong to the malignant state of fever[11]. By means of blood-letting, and the other remedies for the violent state of bilious fever, I have seen the convulsions in this disease translated from the muscles to the blood-vessels, where they immediately produced all the common symptoms of fever.

36. The hysterical and hypochondriacal states of fever. The former is known by a rising in the throat, which is for the most part erroneously ascribed to worms, by pale urine, and by a disposition to shed tears, or to laugh upon trifling occasions. The latter discovers itself by false opinions of the nature and danger of the disease under which the patient labours. Both these states of the nervous system occur frequently in the gout and in the malignant state of fever. It is common to say, in such cases, that patients have a complication of diseases; but this is not true, for the hysterical and hypochondriacal symptoms are nothing but the effects of one remote cause, concentrating its force chiefly upon the nerves and muscles.

37. The cutaneous state of fever. Dr. Sydenham calls a dysentery a “febris introversa.” Eruptions of the skin are often nothing but the reverse of this introverted fever. They are a fever translated to the skin; hence we find them most common in those countries and seasons in which fevers are epidemic. The prickly heat, the rash, and the essere of authors, are all states of misplaced fever. “Agues, fevers, and even pleurisies (says Mr. Townsend, in his Journey through Spain[12]), are said often to terminate in scabies, and this frequently gives place to them, returning, however, when the fever ceases. In adults it takes possession of the hands and arms, with the legs and thighs, covering them with a filthy crust.” Small boils are common among the children in Philadelphia, at the time the cholera infantum makes its appearance. These children always escape the summer epidemic. The elephantiasis described by Dr. Hillary, in his account of the diseases of Barbadoes, is evidently a translation of an intermittent to one of the limbs. It is remarkable, that the leprosy and malignant fevers of all kinds have appeared and declined together in the same ages and countries. But further, petechiæ sometimes appear on the skin without fever. Cases of this kind, with and without hæmorrhages, are taken notice of by Riverius[13], Dr. Duncan, and many other practical writers. They are cotemporary or subsequent to fevers of a malignant complexion. They occur likewise in the scurvy. From some of the predisposing, remote, and exciting causes of this disease, and from its symptoms and remedies, I have suspected it, like the petechiæ mentioned by Riverius, to be originally a fever generated by human miasmata, in a misplaced state. The hæmorrhages which sometimes accompany the scurvy, certainly arise from a morbid state of the blood-vessels. The heat and quick pulse of fever are probably absent, only because the preternatural excitement of the whole sanguiferous system is confined to those extreme or cutaneous vessels which pour forth blood. In like manner the fever of the small-pox deserts the blood-vessels, as soon as a new action begins on the skin. Or perhaps the excitability of the larger blood-vessels may be so far exhausted by the long or forcible impression of the remote and predisposing causes of the scurvy, as to be incapable of undergoing the convulsive action of general fever.

With this I close my inquiry into the cause of fever. It is imperfect from its brevity, as well as from other causes. I commit it to my pupils to be corrected and improved.

AN ACCOUNT
OF THE
Bilious Remitting Yellow Fever,
AS IT
APPEARED IN PHILADELPHIA,
IN THE YEAR 1793.

Before I proceed to deliver the history of this fever, it will be proper to give a short account of the diseases which preceded it.

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

The mumps, which made their appearance in December, 1792, continued to prevail during the month of January, 1793. Besides this disease there were many cases of catarrh in the city, brought on chiefly by the inhabitants exposing themselves for several hours on the damp ground, in viewing the aërial voyage of Mr. Blanchard, on the 9th day of the month.

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

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

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

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

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

The weather was uniformly warm in July. The scarlatina continued during the beginning of this month, with symptoms of great violence. A son of James Sharswood, aged seven years, had, with the common symptoms of this disease, great pains and swellings in his limbs, accompanied with a tense pulse. I attempted in vain to relieve him by vomits and purges. On the 10th day of the month, I ordered six ounces of blood to be drawn from his arm, which I observed afterwards to be very sizy. The next day he was nearly well. Between the 22d and the 24th days of the month, there died three persons, whose respective ages were 80, 92, and 96½. The weather at this time was extremely warm. I have elsewhere taken notice of the fatal influence of extreme heat, as well as cold, upon human life in old people. A few bilious remitting fevers appeared towards the close of this month. One of them under my care ended in a typhus or chronic fever, from which the patient was recovered with great difficulty. It was the son of Dr. Hutchins, of the island of Barbadoes.

The weather, for the first two or three weeks in August, was temperate and pleasant. The cholera morbus and remitting fevers were now common. The latter, were attended with some inflammatory action in the pulse, and a determination to the breast. Several dysenteries appeared at this time, both in the city and in its neighbourhood. During the latter part of July, and the beginning of this month, a number of the distressed inhabitants of St. Domingo, who had escaped the desolation of fire and sword, arrived in the city. Soon after their arrival, the influenza made its appearance, and spread rapidly among our citizens. The scarlatina still kept up a feeble existence among children. The above diseases were universal, but they were not attended with much mortality. They prevailed in different parts of the city, and each seemed to appear occasionally to be the ruling epidemic. The weather continued to be warm and dry. There was a heavy rain on the 25th of the month, which was remembered by the citizens of Philadelphia, as the last that fell for many weeks afterwards.

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

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

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

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

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

On the same day, I was called to the son of Mrs. M'Nair, who had been seized violently with all the usual symptoms of a bilious fever. I purged him plentifully with salts and cremor tartar, and took ten or twelve ounces of blood from his arm. His symptoms appeared to yield to these remedies; but on the 10th of the month a hæmorrhage from the nose came on, and on the morning of the 12th he died.

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

On the 14th day of this month I was sent for to visit Mrs. Leaming, the wife of Mr. Thomas Leaming. I suspected at first that she had the influenza, but in a day or two her fever put on bilious symptoms. She was affected with an uncommon disposition to faint. Her pulse was languid, but tense. I took a few ounces of blood from her, and purged her with salts and calomel. I afterwards gave her a small dose of laudanum which disagreed with her. In my note book I find I have recorded that “she was worse for it.” I was led to make this remark by its being so very uncommon for a person, who had been properly bled and purged, to take laudanum in a common bilious fever without being benefited by it. She recovered, however, slowly, and was yellow for many days afterwards.

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

None of the cases which I have mentioned excited the least apprehension of the existence of a malignant or yellow fever in our city; for I had frequently seen sporadic cases in which the common bilious fever of Philadelphia had put on symptoms of great malignity, and terminated fatally in a few days, and now and then with a yellow colour on the skin, before or immediately after death.

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

Upon coming out of Mrs. Le Maigre's room I remarked to Dr. Foulke and Dr. Hodge, that I had seen an unusual number of bilious fevers, accompanied with symptoms of uncommon malignity, and that I suspected all was not right in our city. Dr. Hodge immediately replied, that a fever of a most malignant kind had carried off four or five persons within sight of Mr. Le Maigre's door, and that one of them had died in twelve hours after the attack of the disease. This information satisfied me that my apprehensions were well founded. The origin of this fever was discovered to me at the same time, from the account which Dr. Foulke gave me of a quantity of damaged coffee which had been thrown upon Mr. Ball's wharf, and in the adjoining dock, on the 24th of July, nearly in a line with Mr. Le Maigre's house, and which had putrefied there to the great annoyance of the whole neighbourhood.

After this consultation I was soon able to trace all the cases of fever which I have mentioned to this source. Dr. Hodge lived a few doors above Mr. Le Maigre's, where his child had been exposed to the exhalation from the coffee for several days. Mrs. Bradford had spent an afternoon in a house directly opposite to the wharf and dock on which the putrid coffee had emitted its noxious effluvia, a few days before her sickness, and had been much incommoded by it. Her sister, Mrs. Leaming, had visited her during her illness at her house, which was about two hundred yards from the infected wharf. Young Mr. M'Nair and Mrs. Palmer's two sons had spent whole days in a compting house near where the coffee was exposed, and each of them had complained of having been made sick by its offensive smell, and Mr. Aston had frequently been in Water-street near the source of the exhalation.

This discovery of the malignity, extent, and origin of a fever which I knew to be attended with great danger and mortality, gave me great pain. I did not hesitate to name it the bilious remitting yellow fever. I had once seen it epidemic in Philadelphia, in the year 1762. Its symptoms were among the first impressions which diseases made upon my mind. I had recorded some of these symptoms, as well as its mortality. I shall here introduce a short account of it, from a note book which I kept during my apprenticeship.

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

“The patients were generally seized with rigours, which were succeeded with a violent fever, and pains in the head and back. The pulse was full, and sometimes irregular. The eyes were inflamed, and had a yellowish cast, and a vomiting almost always attended.

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

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

“An excessive heat and burning about the region of the liver, with cold extremities, portended death to be at hand.”

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

Upon my leaving Mrs Le Maigre's, I expressed my distress at what I had discovered, to several of my fellow-citizens. The report of a malignant and mortal fever being in town spread in every direction, but it did not gain universal credit. Some of those physicians who had not seen patients in it denied that any such fever existed, and asserted (though its mortality was not denied) that it was nothing but the common annual remittent of the city. Many of the citizens joined the physicians in endeavoring to discredit the account I had given of this fever, and for a while it was treated with ridicule or contempt. Indignation in some instances was excited against me, and one of my friends, whom I advised in this early stage of the disease to leave the city, has since told me that for that advice “he had hated me.”

My lot in having thus disturbed the repose of the public mind, upon the subject of general health, was not a singular one. There are many instances upon record, of physicians who have rendered themselves unpopular, and even odious to their fellow-citizens, by giving the first notice of the existence of malignant and mortal diseases. A physician, who asserted that the plague was in Messina, in the year 1743, excited so much rage in the minds of his fellow-citizens against him, as to render it necessary for him to save his life by retreating to one of the churches of that city.

In spite, however, of all opposition, the report of the existence of a malignant fever in the city gained so much ground, that the governor of the state directed Dr. Hutchinson, the inspector of sickly vessels, to inquire into the truth of it, and into the nature of the disease.

In consequence of this order, the doctor wrote letters to several of the physicians in the city, requesting information relative to the fever. To his letter to me, dated the 24th of August, I replied on the same day, and mentioned not only the existence of a malignant fever, but the streets it occupied, and my belief of its being derived from a quantity of coffee which had putrified on a wharf near Arch-street. This, and other information collected by the doctor, was communicated to the health officer, in a letter dated the 27th of August, in which he mentioned the parts of the city where the disease prevailed, and the number of persons who had died of it, supposed by him to be about 40, but which subsequent inquiries proved to be more than 150. He mentioned further, in addition to the damaged coffee, some putrid hides, and other putrid animal and vegetable substances, as the supposed cause of the fever, and concluded by saying, as he had not heard of any foreigners or sailors being infected, nor of its being found in any lodging-houses, that “it was not an imported disease.”

In the mean while the disease continued to spread, and with a degree of mortality that had never been known from common fevers.

On the 25th of the month, the college of physicians was summoned by their president to meet, in order to consult about the best methods of checking the progress of the fever in the city. After some consideration upon the nature of the disease, a committee was appointed to draw up some directions for those purposes; and the next day the following were presented to the college, and adopted unanimously by them. They were afterwards published in most of the newspapers.

Philadelphia, August 26th, 1793.

The college of physicians having taking into consideration the malignant and contagious fever that now prevails in this city, have agreed to recommend to their fellow-citizens the following means of preventing its progress.

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

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

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

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

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

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

7th. To keep the streets and wharves of the city as clean as possible. As the contagion of the disease may be taken into the body, and pass out of it without producing the fever, unless it be rendered active by some occasional cause, the following means should be attended to, to prevent the contagion being excited into action in the body.

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

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

10th. To accommodate the dress to the weather, and to exceed rather in warm, than in cool clothing.

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

The college conceive fires to be very ineffectual, if not dangerous means of checking the progress of this fever. They have reason to place more dependence upon the burning of gunpowder. The benefits of vinegar and camphor are confined chiefly to infected rooms, and they cannot be used too frequently upon handkerchiefs, or in smelling-bottles, by persons whose duty calls to visit or attend the sick.

Signed by order of the college,      
WILLIAM SHIPPEN, jun.
Vice president.         
SAMUEL P. GRIFFITTS,
Secretary.            

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

This address had no other effect than to produce fresh clamours against the author; for the citizens, as well as most of the physicians of Philadelphia, had adopted a traditional opinion that the yellow fever could exist among us only by importation from the West-Indies.

In consequence, however, of a letter from Dr. Foulke to the mayor of the city, in which he had decided, in a positive manner, in favour of the generation of the fever from the putrid coffee, the mayor gave orders for the removal of the coffee, and the cleaning of the wharf and dock. It was said that measures were taken for this purpose; but Dr. Foulke, who visited the place where the coffee lay, repeatedly assured me, that they were so far from being effectual, that an offensive smell was exhaled from it many days afterwards.

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

The seeds of the fever, when received into the body, were generally excited into action in a few days. I met with several cases in which they acted so as to produce a fever on the same day in which they were received into the system, and I heard of two cases in which they excited sickness, fainting, and fever within one hour after the persons were exposed to them. I met with no instance in which there was a longer interval than sixteen days between their being received into the body and the production of the disease.

This poison acted differently in different constitutions, according to previous habits, to the degrees of predisposing debility, or to the quantity and concentration of the miasmata which had been received into the body.

In some constitutions, the miasmata were at once a remote, a predisposing, and an exciting cause of the disease; hence some persons were affected by them, who had not departed in any instance from their ordinary habits of living, as to diet, dress, and exercise. But it was more frequently brought on by those causes acting in succession to each other.

I shall here refer the reader to the principles laid down in the outlines of the theory of fever, for an account of the manner in which the system was predisposed to this disease, by the debility induced by the reduction of its excitement, by action and abstraction, and by subsequent depression. Where a predisposition was thus produced, the fever was excited by the following causes, acting directly or indirectly upon the system. Where this predisposition did not exist, the exciting causes produced both the predisposition and the disease. They were,

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

2. Heat, from every cause, but more especially the heat of the sun, was a very common exciting cause of the disease. The register of the weather during the latter end of August, the whole of September, and the first two weeks in October will show how much the heat of the sun must have contributed to excite the disease, more especially among labouring people. The heat of common fires likewise became a frequent cause of the activity of the miasmata where they had been received into the body; hence the greater mortality of the disease among bakers, blacksmiths, and hatters than among any other class of people.

3. Intemperance in eating or drinking. A plentiful meal, and a few extra glasses of wine seldom failed of exciting the fever. But where the body was strongly impregnated with the seeds of the disease, even the smallest deviation from the customary stimulus of diet, in respect to quality or quantity, roused them into action. A supper of twelve oysters in one, and of but three in another, of my patients produced the disease. Half an ounce of meat excited it in a lady who had lived, by my advice, for two weeks upon milk and vegetables, and even a supper of sallad, dressed after the French fashion, excited it in one of Dr. Mease's patients.

4. Fear. In many people the disease was excited by a sudden paroxysm of fear; but I saw some remarkable instances where timid people escaped the disease, although they were constantly exposed to it. Perhaps a moderate degree of fear served to counteract the excessive stimulus of the miasmata, and thereby to preserve the body in a state of healthy equilibrium. I am certain that fear did no harm after the disease was formed, in those cases where great morbid excess of action had taken place. It was an early discovery of this fact which led me not to conceal from my patients the true name of this fever, when I was called to them on the day of their being attacked by it. The fear co-operated with some of my remedies (to be mentioned hereafter) in reducing the morbid excitement of the arterial system.

5. Grief. It was remarkable that the disease was not excited in many cases in the attendants upon the sick, while there was a hope of their recovery. The grief which followed the extinction of hope, by death, frequently produced it within a day or two afterwards, and that not in one person only, but often in most of the near relations of the deceased. But the disease was also produced by a change in the state of the mind directly opposite to that which has been mentioned. Many persons that attended patients who recovered, were seized with the disease a day or two after they were relieved from the toils and anxiety of nursing. The collapse of the mind from the abstraction of the stimulus of hope and desire, by their ample gratification, probably produced that debility, and loss of the equilibrium in the system, which favoured the activity of the miasmata in the manner formerly mentioned[14].

The effects of both the states of mind which have been described, have been happily illustrated by two facts which are recorded by Dr. Jackson[15]. He tells us, that the garrisons of Savannah and York-Town were both healthy during the siege of those towns, but that the former became sickly as soon as the French and American armies retreated, from before it, and the latter, immediately after its capitulation.

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

It was observed that those persons who were habitually exposed to the cool air, were less liable to the disease than others. I ascribe it to the habitual impression of the cool night air upon the bodies of the city watchmen, that but four or five of them, out of twenty-five, were affected by the disease.

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

7. Sleep. A great proportion of all who were affected by this fever, were attacked in the night. Sleep induced what I have called debility from abstraction, and thereby disposed the miasmata which floated in the blood, to act with such force upon the system as to destroy its equilibrium, and thus to excite a fever. The influence of sleep as a predisposing, and exciting cause was often assisted by the want of bed-clothes, suited to the midnight or morning coolness of the air.

8. Immoderate evacuations. The efficacy of moderate purging and bleeding in preventing the disease, led some people to use those remedies in an excess, which both predisposed to the disease, and excited it. The morbid effects of these evacuations, were much aided by fear, for it was this passion which perverted the judgment in such a manner, as to lead to the excessive use of remedies, which, to be effectual, should only be used in moderate quantities.

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

The precursors, or premonitory signs of this fever were, costiveness, a dull pain in the right side, defect of appetite, flatulency, perverted taste, heat in the stomach, giddiness, or pain in the head, a dull, watery, brilliant, yellow, or red eye, dim and imperfect vision, a hoarseness, or slight sore throat, low spirits, or unusual vivacity, a moisture on the hands, a disposition to sweat at nights, or after moderate exercise, or a sudden suppression of night sweats. The dull eye, and the lowness of spirits, appeared to be the effects of such an excess in the stimulus of the miasmata as to induce depression, while the brilliant eye, and the unusual vivacity, seemed to have been produced by a less quantity of the miasmata acting as a cordial upon the system. More or less of these symptoms frequently continued for two or three days before the patients were confined to their beds, and in some people they continued during the whole time of its prevalence in the city, without producing the disease. I wish these symptoms to be remembered by the reader. They will form the corner stone of a system which I hope will either eradicate the disease altogether, or render it as safe as an intermitting fever, or as the small-pox when it is received by inoculation.

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

Upon entering a sick room where a patient was confined by this fever, the first thing that struck the eye of a physician was the countenance. It was as much unlike that which is exhibited in the common bilious fever, as the face of a wild, is unlike the face of a mild domestic animal. The eyes were sad, watery, and so inflamed, in some cases, as to resemble two balls of fire. Sometimes they had a most brilliant or ferocious appearance. The face was suffused with blood, or of a dusky colour, and the whole countenance was downcast and clouded. After the 10th of September, when a determination of blood to the brain became universal, there was a preternatural dilatation of the pupil. Sighing attended in almost every case. The skin was dry, and frequently of its natural temperature. These were the principal symptoms which discovered themselves to the eye and hand of a physician. The answers to the first questions proposed upon visiting a patient, were calculated to produce a belief in the mind of a physician, that the disease under which the patient laboured was not the prevailing malignant epidemic. I did not for many weeks meet with a dozen patients, who acknowledged that they had any other indisposition than a common cold, or a slight remitting or intermitting fever. I was particularly struck with this self-deception in many persons, who had nursed relations that had died with the yellow fever, and who had been exposed to it in neighbourhoods where it had prevailed for days and even weeks with great mortality. I shall hereafter trace a part of this disposition in the sick to deceive themselves to the influence of certain publications, which appeared soon after the disease became epidemic in the city.

In the further history of this fever, I shall describe its symptoms as they appeared,

I. In the sanguiferous system.

II. In the liver, lungs, and brain.

III. In the alimentary canal; in which I include the stomach as well as the bowels.

IV. In the secretions and excretions.

V. In the nervous system.

VI. In the senses and appetites.

VII. In the lymphatic and glandular system.

VIII. Upon the skin.

IX. In the blood.

After having finished this detail, I shall mention some general characters of the disease, and afterwards subdivide it into classes, according to its degrees and duration.

I. The blood-vessels were affected more or less in every case of this fever. I have elsewhere said, that a fever is occasioned by a convulsion in the arterial system[16]. When the epidemic, which we are now considering, came on with a full, tense, and quick pulse, this convulsion was very perceptible; but it frequently came on with a weak pulse, often without any preternatural frequency or quickness, and sometimes so low as not to be perceived without pressing the artery at the wrists. In many cases the pulse intermitted after the fourth, in some after the fifth, and in others after the fourteenth stroke. These intermissions occurred in several persons who were infected, but who were not confined by the fever. They likewise continued in several of my patients for many days after their recovery. This was the case in particular in Mrs. Clymer, Mrs. Palmer's son William, and in a son of Mr. William Compton. In some, there was a preternatural slowness of the pulse. It beat 44 strokes in a minute in Mr. B. W. Morris, 48 in Mr. Thomas Wharton, jun. and 64 in Mr. William Sansom, at a time when they were in the most imminent danger. Dr. Physick informed me, that in one of his patients the pulse was reduced in frequency to 30 strokes in a minute. All these different states of the pulse have been taken notice of by authors who have described pestilential fevers[17]. They have been improperly ascribed to the absence of fever: I would rather suppose that they are occasioned by the stimulus of the remote cause acting upon the arteries with too much force to admit of their being excited into quick and convulsive motions. The remedy which removed it (to be mentioned hereafter) will render this explanation of its cause still more probable. Milton describes a darkness from an excess of light. In like manner we observe, in this small, intermitting, and slow pulse, a deficiency of strength from an excess of force applied to it. In nearly every case of it which came under my notice, it was likewise tense or chorded. This species of pulse occurred chiefly in the month of August, and in the first ten days in September. I had met with it formerly in a sporadic case of yellow fever. It was new to all my pupils. One of them, Mr. Washington, gave it the name of the “undescribable pulse.” It aided in determining the character of this fever before the common bilious remittent disappeared in the city. For a while, I ascribed this peculiarity in the pulse, more especially its slowness, to an affection of the brain only, and suspected that it was produced by what I have taken the liberty elsewhere to call the phrenicula, or inflammatory state of the internal dropsy of the brain, and which I have remarked to be an occasional symptom and consequence of remitting fever. I was the more disposed to adopt this opinion, from perceiving this slow, chorded, and intermitting pulse more frequently in children than in adults. Impressed with this idea, I requested Mr. Coxe, one of my pupils, to assist me in examining the state of the eyes. For two days we discovered no change in them, but on the third day after we began to inspect them, we both perceived a preternatural dilatation of the pupils, in different patients; and we seldom afterwards saw an eye in which it was absent. In Dr. Say it was attended by a squinting, a symptom which marks a high degree of a morbid affection of the brain. Had this slowness or intermission in the pulse occurred only after signs of inflammation or congestion had appeared in the brain, I should have supposed that it had been derived wholly from that cause; but I well recollect having felt it several days before I could discover the least change in the pupil of the eye. I am forced therefore to call in the operation of another cause, to assist in accounting for this state of the pulse, and this I take to be a spasmodic affection, accompanied with preternatural dilatation or contraction of the heart. Lieutaud mentions this species of pulse in several places, as occurring with an undue enlargement of that muscle[18]. Dr. Ferriar describes a case, in which a low, irregular, intermitting, and hardly perceptible pulse attended a morbid dilatation of the heart[19]. In a letter I received from Mr. Hugh Ferguson, then a student of medicine in the college of Edinburgh, written from Dublin, during the time of a visit to his father, and dated September 30th, 1793, I find a fact which throws additional light upon this subject. “A case (says my young correspondent) where a remarkable intermission of pulse was observed, occurred in this city last year. A gentleman of the medical profession, middle aged, of a delicate habit of body, and who had formerly suffered phthisical attacks, was attacked with the acute rheumatism. Some days after he was taken ill, he complained of uncommon fulness, and a very peculiar kind of sensation about the præcordia, which it was judged proper to relieve by copious blood-letting. This being done, the uneasiness went off. It returned, however, three or four times, and was as often relieved by bleeding. During each of his fits (if I may call them so), the patient experienced an almost total remission of his pains in his limbs; but they returned with equal or greater violence after blood-letting. During the fit there was an intermission of the pulse (the first time) of no less than thirteen strokes. It was when beating full, strong, and slow. The third intermission was of nine strokes. The gentleman soon recovered, and has enjoyed good health for ten months past. The opinion of some of his physicians was, that the heart was affected, as a muscle, by the rheumatism, and alternated with the limbs.”

I am the more inclined to believe the peculiarity in the pulse which has been mentioned in the yellow fever, arose in part from a spasmodic affection of the heart, from the frequency of an uncommon palpitation of this muscle, which I discovered in this disease, more especially in old people. The disposition, likewise, to syncope and sighing, which so often occurred, can be explained upon no other principle than inflammation, spasm, dilatation, or congestion in the heart. After the 10th of September this undescribable or sulky pulse (for by the latter epithet I sometimes called it) became less observable, and, in proportion as the weather became cool, it totally disappeared. It was gradually succeeded by a pulse full, tense, quick, and as frequent as in pleurisy or rheumatism. It differed, however, from a pleuritic or rheumatic pulse, in imparting a very different sensation to the fingers. No two strokes seemed to be exactly alike. Its action was of a hobbling nature. It was at this time so familiar to me that I think I could have distinguished the disease by it without seeing the patient. It was remarkable that this pulse attended the yellow fever even when it appeared in the mild form of an intermittent, and in those cases where the patients were able to walk about or go abroad. It was nearly as tense in the remissions and intermissions of the fever as it was in the exacerbations. It was an alarming symptom, and when the only remedy which was effectual to remove it was neglected, such a change in the system was induced as frequently brought on death in a few days.

This change of the pulse, from extreme lowness to fulness and activity, appeared to be owing to the diminution of the heat of the weather, which, by its stimulus, added to that of the remote cause, had induced those symptoms of depression of the pulse which have been mentioned.

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

Hæmorrhages belong to the symptoms of this fever as they appeared in the sanguiferous system. They occurred in the beginning of the disease, chiefly from the nose and uterus. Sometimes but a few drops of blood distilled from the nose. The menses were unusual in their quantity when they appeared at their stated periods, but they often came on a week or two before the usual time of their appearance. I saw one case of a hæmorrhage from the lungs on the first day of the fever, which was supposed to be a common hæmoptysis. As the disease advanced the discharges of blood became more universal. They occurred from the gums, ears, stomach, bowels, and urinary passages. Drops of blood issued from the inner canthus of the left eye of Mr. Josiah Coates. Dr. Woodhouse attended a lady who bled from the holes in her ears which had been made by ear-rings. Many bled from the orifices which had been made by bleeding, several days after they appeared to have been healed, and some from wounds which had been made in veins in unsuccessful attempts to draw blood. These last hæmorrhages were very troublesome, and in some cases precipitated death.

II. I come now to mention the symptoms of this fever as they appeared in the liver, the lungs, and the brain. From the histories which I had read of this disease, I was early led to examine the state of the liver, but I was surprised to find so few marks of hepatic affection. I met with but two cases in which the patient could lie only on the right side. Many complained of a dull pain in the region of the liver, but very few complained, in the beginning of the disease, of that soreness to the touch, about the pit of the stomach, which is taken notice of by authors, and which was universal in the yellow fever in 1762. In proportion as the cool weather advanced, a preternatural determination of the blood took place chiefly to the lungs and brain. Many were affected with pneumonic symptoms, and some appeared to die of sudden effusions of blood or serum in the lungs. It was an unexpected effusion of this kind which put an end to the life of Mrs. Keppele after she had exhibited hopeful signs of a recovery.

I saw one person who recovered from an affection of the lungs, by means of a copious expectoration of yellow phlegm and mucus. But the brain was principally affected with morbid congestion in this disease. It was indicated by the suffusion of blood in the face, by the redness of the eyes, by a dilatation of the pupils, by the pain in the head, by the hæmorrhages from the nose and ears, by the sickness or vomiting, and by an almost universal costive state of the bowels. I wish to impress the reader with these facts, for they formed one of the strongest indications for the use of the remedies which I adopted for the cure of this disease. It is difficult to determine the exact state of these viscera in every case of bilious and yellow fever. Inflammation certainly takes place in some cases, and internal hæmorrhages in others; but I believe the most frequent affection of these viscera consists in a certain morbid accumulation of blood in them, which has been happily called, by Dr. Clark, an engorgement or choaking of the blood-vessels. I believe further, with Dr. Clark[20] and Dr. Balfour[21], that death in most cases in bilious fevers is the effect of these morbid congestions, and wholly unconnected with an exhausted state of the system, or a supposed putrefaction in the fluids. It is true, the dissections of Dr. Physick and Dr. Cathrall (to be mentioned hereafter) discovered no morbid appearances in any of the viscera which have been mentioned, but it should be remembered, that these dissections were made early in the disease. Dr. Annan attended the dissection of a brain of a patient who died at Bush-hill some days afterwards, and observed the blood-vessels to be unusually turgid. In those cases where congestion only takes place, it is as easy to conceive that all morbid appearances in the brain may cease after death, as that the suffusion of blood in the face should disappear after the retreat of the blood from the extremities of the vessels, in the last moments of life. It is no new thing for morbid excitement of the brain to leave either slender, or no marks of disease after death. This, I have said, is often the case where it exceeds that degree of action which produces an effusion of red blood into serous vessels, or what is called inflammation[22]. Dr. Quin has given a dissection of the brain of a child that died with all the symptoms of hydrocephalus internus, and yet nothing was discovered in the brain but a slight turgescence of its blood-vessels. Dr. Girdlestone says, no injury appeared in the brains of those persons who died of the symptomatic apoplexy, which occurred in a spasmodic disease which he describes in the East-Indies; and Mr. Clark informs us, that the brain was in a natural state in every case of death from puerperile fever, notwithstanding it seemed to be affected in many cases soon after the attack of that disease[23].

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

III. The stomach and bowels were affected in many ways in this fever. The disease seldom appeared without nausea or vomiting. In some cases, they both occurred for several days or a week before they were accompanied by any fever. Sometimes a pain, known by the name of gastrodynia, ushered in the disease. The stomach was so extremely irritable as to reject drinks of every kind. Sometimes green or yellow bile was rejected on the first day of the disease by vomiting; but I much oftener saw it continue for two days without discharging any thing from the stomach, but the drinks which were taken by the patient. If the fever in any case came on without vomiting, or if it had been checked by remedies that were ineffectual to remove it altogether, it generally appeared, or returned, on the 4th or 5th day of the disease. I dreaded this symptom on those days, for although it was not always the forerunner of death, yet it generally rendered the recovery more difficult and tedious. In some cases the vomiting was more or less constant from the beginning to the end of the disease, whether it terminated in life or death.

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

Flatulency was an almost universal symptom, in every stage of this disease. It was very distressing in many cases. It occurred chiefly in the stomach.

The bowels were generally costive, and in some patients as obstinately so as in the dry gripes. In some cases there was all the pain and distress of a bilious colic, and in others, the tenesmus, and mucous and bloody discharges of a true dysentery. A diarrhœa introduced the disease in a few persons, but it was chiefly in those who had been previously indisposed with weak bowels. A painful tension of the abdomen took place in many, accompanied in some instances by a dull, and in others by an acute pain in the lower part of the belly.

IV. I come now to describe the state of the secretions and excretions as they appeared in different stages of this fever.

In some cases there was a constipation of the liver, if I may be allowed that expression, or a total obstruction of secretion and excretion of bile, but more frequently a preternatural secretion and excretion of it took place. It was discharged, in most cases, from the stomach and bowels in large quantities, and of very different qualities and colours.

1. On the first and second days of the disease many patients puked from half a pint to nearly a quart of green or yellow bile. Four cases came under my notice in which black bile was discharged on the first day. Three of these patients recovered.

2. There was frequently, on the 4th or 5th day, a discharge of matter from the stomach, resembling coffee impregnated with its grounds. This was always an alarming symptom. I believed it at first to be a modification of vitiated bile, but subsequent dissections by Dr. Physick have taught me that it was the result of the first stage of those morbid actions in the stomach, which afterwards produce the black vomit. Many recovered who discharged this coffee-coloured matter.

3. Towards the close of this disease, there was a discharge of matter of a deep or pale black colour, from the stomach. Flakey substances frequently floated in the bason or chamber-pot upon the surface of this matter. It was what is called the black vomit. It was formerly supposed to be vitiated bile, but it has been proved by Dr. Stewart, and afterwards by Dr. Physick, to be the effect of disease in the stomach.

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