V >*.«, -. > *-#vxj « /T" >.e aq^.q '.:.£ i >Qrc e o ee e/ouoiwoo ec^ fix.*- \j Lust/ $ "7 Surgeon Generals Office 4oo^ cfe 3a x^xt'jX^su fr No...!a./..."-fi(U-» tA/eefttn. cc oee cg ae-ocma agaQQaooo^oe^ aS / 2- J- -3 A ..ST R E A T I S E \ V Ox ' ON THE Synochus Icleroides, o R YELLOW FE V E R; AS IT LATELY APPEARED IN THE CITT of P HILA DE LP HI A. EXHIBITING A CONCISE VIEW OF ITS RISE, PROGRESS AND SYMPTOMS, TOGETHER WITH THE METHOD OF TREATMENT FOUND MOST SUCCESSFUL} ALSO REMARKS ON THE NATURE OF ITS CONTAGION, AND DIREC- TIONS FOR PREVENTING THE INTRODUCTION OF THK SAME MALADY, JN.FUTURE. By WILLIAM CU RRIE, FELLOW OF THE COLLEGE OF PHYSICIANS, AND MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY. PHILADELPHIA; Printed by THOMAS DOBSON, No. 41, south SECOND-STREET. M,DCC,XCIV. T 6 HIS EXCELLENCY THOMAS MIFFLIN, Governor of Pennfylvania. S IR, INI O T the fplendor of your fla^ tion, but the qualities of your heart, fo confpicuoufly difplayed during the prevalence of the late deftructive malady in this city, in- duce me to infcribe the following treatife ( iv ) treatice to your excellency. You are therefore requefted to accept it; not as a compliment, but as a tribute to which you are juftly en- titled, from Your moft fincere, And very humble fervant, The AUTHOR. Philadelphia, January 20th 1794. PREFACE. J\ S every invention, difcovery, or improve- ment, is more or lefs ufeful and intereffing, in proportion as it contributes to the prefervation of health, life, profperity, and fatisfadion; and as the author of the following pages is perfuaded, that very material improvements were made in the treatment of the fynochus ideroides or yel- low fever, which lately prevailed in this city, and proved fo deftrudive and diftreffing to its in- habitants, he thinks it his duty to lay the fame before the public, together with his obferva- tions and fentiments on other circumftances, relative to that difeafe; that if it mould ever appear here again (as there is too much rea- fon ( ™ ) foil to apprehend, unlefs much caution is ob- ferved to prevent it, from our conftant inter- courfe with the Weft Indies, where ftrangers are feldom long exempt from it) phyficians may not again be at a lofs for a diredory, deri- ved from adual experience and obfervation. He however does not pretend to have been the improver of the treatment, or the difcover- cr of the means moil efFedual in the cure, which is recommended in the following pa- ges. On the contrary, he believes they were adopted from the joint deliberations of the col- lege of phyficians, in conlequence of fome of its members having obferved their good effeds when the difeafe firft appeared, and was mifta- ken for a higher grade of the bilious remittent fever of the autumnal feafon. Inftead of at- tending to fyftematic arrangement in the fol- lowing little produdion, he has contented him- iclf with enumerating fymptoms and circum- ftances as they occurred to him, while enga- ged in pradice; and offering his fentiments in the order in which they happened to arife. Br ( viii ) By this method he hopes to efcape the imputa- tion of pedantry : and though thofe who pre- fer the fhidied and formal arrangement of the fchools, to the fimplicity and order of nature, may condemn his manner, he hopes the mat- ter it contains, and the importance of the fub- jed, will fecure him the approbation of all thofe who prefer utility to formality and fa- fhion. To men of tafte indeed, fome apology is due for the imperfedions of its ftyle and compontion ; but if want of leifure and fre- quent interruption are ever admitted as an a- pology for a trefpafs of this nature, he is cer- tainly entitled to fome indulgence on the pre- fent occafionj efpecially as he can allure them, that truth has been his aim, his end the public good. January 24th, 1794. :1th' A S K E T G H OF THE RISE and PROGRESS O F T H E DISEASE. TH E difeafe which we are about to de~ fcribe, made its firft appearance in Wf- ter flreet between Mulberry and Saflafras ftreets, the beginning of Auguft 17 93, and ap- pears to have been imported by a vefTel which arrived in this port, and lay at a wharf ia that neighbourhood the latter end of July.* B Fromr^ * See Mr M. Carey's account of the rife and progress of the difeafe, lately publifhed. ( * ) From this fource it fpread gradually by contagion over the greater! part of the city; and was more or lefs rapid in its progrefs, ac- cording as people had more or lefs intercourfe with the fick, and according as the weather was more or lefs cold : for though it was pro- pagated by contagion, the fenfible qualities of the atmofphere had a furprifing efFed in ren- dering the contagion more or lefs adive, as well as in-its influence on the fymptoms of thofe labouring under the difeafe. The greatefl number confined with the difeafe, was about the middle of Odober; but as the weather became cold and frofly, its de- clenfion was fo rapid that it appeared as if ex- tinguifhed by a miracle: for by the tenth of November, there was fcarcely a perfon to be found with it. The whole number that died of this difeafe in the city, appears from the regifters of deaths kept by the different religious focieties, to have been ( 3 ) been about 3500. In the regifters of tfie? deaths which have been kept by thofe focie- ties, there is no difcrimination made between thofe who died of the yellow fever and of o- ther difeafes ; and the whole number of deaths appears to have been 4048, from the ift of Augufl to the 10th of November; of which above 500 are fuppofed to have died of other difeafes. At one period there appears to have been more than eight thoufand perfons confi- ned by it at the fame time ; though at that time near twenty thoufand of the inhabitants had retired from the city. That the long continuance of heat and drought which preceded this difeafe had no fhare in its generation, is certain, from its be- ing confined for fome time to that part of the city where it commenced : for almoft every cafe which occurred for the firfl week or two, could be traced to that fource, and was pro- pagated to others in fucceflion. B 2 This ( 4 ) This fever correfponded in moft of its lea- ding and charaderiftic fymptoms, with the fynochus icteroides occidentalis, or yellow fe- ver of the Weft Indies. A fever of the fame kind has prevailed here three times before, viz. in the years 1740, 1747 and 1762. In the year 1740, it was introduced by means of a trunk of wearing apparel, which had belonged to a gentleman who died of it in Barbadoes. The family to whom the trunk Was fent firft took the difeafe ; and from them it fpread into the town, and deftroyed above two hundred people; as we are informed by the celebrated Lind, in his treatife on fevers and infedion. The only account I have been able to obtain refpeding its appearance in 1747, is what is contained in Mr Lardner's letter, of which the following is a copy. .^PHILA ( s ) Philadelphia, Sept. $d, 1747.- (0. S.J " SINCE my laft, a contagious fever has raged amongft us, which admits of no relief, cure, or abatement; never intermitting to the lall moment of life. It has carried off*three of my moft intimate acquaintance ; among which are my dear friends Andrew Hamilton and Mr Currie. Philadelphia has been a melan- choly place, and many whofe bufinefs and fa* mily would permit them, have fled the city. But the air is now become much cooler, and thofe under the diforder revive. The fymp- toms (a pain in the head and back, vomiting, Sec.) are lefs violent, and the fever gradually abates. Meffrs. Allen and Turner's family are yet under the difeafe ; the one having loft a near relation, and Mr Allen himfelf not out of danger. " September 24th. The yellow fever is ftill amongft us : yefterday was buried young Sa- muel Powell who died of it." It ( « ) It is aftonifhing that the phyficians of that time left nothing on record refpeding fo de- ftrudive a malady. Perhaps if the notes of Doctors Zachary,Graham, Kearfley,and Cad- wallader were infpeded, fome important fads might yet be difcovered. Dr Griffiths' mo- ther who had the difeafe at that time is ftill a- five. The third time of its appearance it was in^ troduced (according to the notes of Dr Red- man of this city) about the latter end of Au- gufl, by a mariner from the Havanna : it came to its height about the 25th of September, and from that time gradually declined, and was en- tirely extinguifhed by the middle of Odober. Neither the flate of the weather, nor the num- ber of deaths which occurred at that time, are Jcnown, no regifter having been preferved, The fever at that time was circumfcribetj to Pine or Union ftreet Northerly, and three or four fauares from thence Southerly, and extended ( 7 ) extended from Water ftreet, to Third or Fourth ftreet Wefterly. Its firft and greater! ravages were about the New Market, which lay near the fource where the difeafe origi- nated. It fpread at that time, as the one we are about to defcribe did, from family to fa- mily, as they happened to have intercourfe one with another. A fever of the fame kind, alfo prevailed at Charlefton, South Carolina, in the years 1732, 1739, 1745 and 1748; an account of which has been given by Dr. Lining, and publifhed in the fecond Vol. Phyfical and Li- terary EfTays of Edinburgh. The difeafe each time that it prevailed in Carolina, was traced to fome perfon lately arrived from fome of the Weft India Iflands, We arc alfo informed by Dr Lind, in his treatife on hot climates, that a fimilar difeafe occurred in Cadiz, in Spain, the latter end of the fummer of 1764, of which an hundred perfons ( 9 ) perfons fometimes died in a day; that its ra- vages were at that time entirely confined to that city, and that thofe who retired to the country efcaped it. Though the difeafe we are about to defcribe was highly contagious, the influence of the contagion was circumfcribed to a narrow fphere, for none but thofe who approached near to the fick, or to fuch articles as had been in contad with them, or within the fphere of their effluvia fo as to be impregna- ted thereby were affeded, All that fhut themfelves up in their houfes, retired into the country, or avoided entering into infcded houfes, and all intercourfe with the fick, or infeded fubftances, or with thofe who vifited the fick (for the idle curioiity of fervants, particularly of the hired girls, was the means of propagating the difeafe more than any other circumftance), though con- stantly abroad in the open ftreets, efcaped the 4ifeafe. ( 9 ) difeafe without exception. The prifoners in the jail and Work houfe—the penfioners in the poor houfe, and the patients and attend- ants at the hofpital, from whence all inter- courfe with the infeded was excluded, alfo entirely efcaped the difeafe. There was fomething however, In the ftate of the atmpfphere in the city, or in the con- ftitutions of the inhabitants, peculiarly fa- vourable to the operation of the contagion, very different from that of the country ; for when any perfon with the difeafe was remo- ved a few miles into the country, and even died of it, there is fcarce an inftance of its ha- ving been communicated to any perfon in the fame houfe, whereas when any one in a family took it and remained in the city, o- thers, and fometimes the whole of the family, foon after took the difeafe*. Thofe * This was alfo the cafe the laft time it occurred at Charlefton, as recorded by Dr. Lining—and alfo at Cadia in J 764, mentioned by Lind, ( 1° ) Thofe expofed to the contagion generally began to be affeded between the third and eighth day; we recoiled feveral that were certainly attacked on the fifth day, one on the third, and two not till the tenth day after ex- pofure. Thefe were afcertained by fuch cir- cumftances, as could not have deceived us. Thofe who had retired into the country, and again returned to the city during the preva- lence of the difeafe, were affeded more rea- dily and earlier than others, after fuch ex- pofure. The ftate of the mind feems to have had great influence, in* haftening or retarding the effeds of the contagibn ; thofe under the in- fluence'of fear, which was the cafe with the majority, were fooner affeded after expofure to the "contagion, than thofe who were lefs concerned. Every other debilitating power had a fimilar affed, fuch as an abftemious regimen, too much fatigue, frequent purging, blood-letting, and expofure to the night air, without ( « ) without exercife fufBcient to keep up a vi- gorous circulation. But a lax ftate of the bowels, and a moderate tone of the folids, appear to have contributed to render the dif- eafe more mild when it did attack thofe who were not greatly under the influence of terror. Neither age nor fex were exempt, not even infants at the breaft—but thofe that were fat, corpulent and indolent, were moft fufceptible ©f the contagion, and fuffered accordingly. While this formidable difeafe was making fuch ravages in the city, the country for fome miles around was never more healthy, efpe- cially in dry and elevated fituations. In the low and marfhy grounds, indeed, this was not the cafe; for at Harrifburgh on the Suf- quehanna, at Dover on the Delaware, and a few other places, bordering on rivers or large Creeks, whofe channels were almoil exhaufl- ed of their waters, by the long continuance of heat and drought, bilious fever, choleras, dyfenteries and cholics, were never known to be fo prevalent and mortal. The ( 12 ) . The French Weft Indians, particularly thofe from St. Domingo, who had taken fhel- ter here, from the ftorms of a fanguinary war, almoft to a man efcaped the difeafe, though they made no ufe of any precaution for the purpofe; while thofe from France were as liable to it as the Philadelphians. The reafon that the Weft Indians were not liable to it, is perhaps owing to the refemblanee, of the feafon to that of the climate from whence they came ; and to the effeds produced by the . frequent excretions of bile to which they are particularly fubjed, rendering the duodenum and biliary duds infenfible to the poifon. For it Is a lingular though a notorious fad, that the difeafe fcldom or ever affeds any but flran- gejrs or new comers from a colder or more tem- perate climate, in the Weft Indies; as we are informed by almoft all the writers on the fub- jed. But we were ftrangers or new comers to it to all intents and purpofes, with this diffe- ence, that it was brought to us inftead of our and ( »3 ) being taken to it; and for that reafon were fubjed to Its influence. There are however fome inftances mentioned by Hillary of its be- ing communicated by contagion at Barbadoes, and of a few Creoles being affeded by it. But this he fays was very rare, and after the dif- eafe had become very malignant. * The negroes that were natives of Ameri- ca * The lateft writer on thisfubjeft, Dr Jackfon, informs us that no negro immediately from the coaft of Africa has been known to be attacked by this difeafe ; neither have Creoles that have refided conftantly in the Iflands. Yet Creoles Or Africans who have been abfent a confiderable time, and refi- ded in colder climates, whether in Europe or the higher la- titudes of America, are not by any means exempted from it when they return to the Iflands. Europeans, particularly males, fuffer from it foon after their arrival in the Iflands ; but in general, after refiding there a year or two, they are very rarely attacked by it. Nor has it fcarcely ever been known to attack the fame perfon twice, except accidentally, after his return from a different and colder climate. The remicting fever, on the contrary, attacks perfons of all de- fcriptions, whether natives or foreigners. Nor are thofe who have once had it exempt from its future attack: a fact which prove* ( 14 ) ca were alfo liable to it, though not in the £ime proportion as the whites. This was not the cafe, according to the obfervations of Dr Lining, when it prevailed in Charlefton ; for at that time there was not an inftance of any negro being affeded by it, though as much expofed to the contagion as the whites. This with fome exceptions, is alfo the cafe with re- fped to the negroes in the Weft Indies; tho' Dr. Blane fays he faw a black woman die with all the fymptoms of it at Barbadoes, ha- ving caught it from nurfing fome feamen that were ill of it. The fame author is of opinion, that the difeafe cannot be generated in any place, proves that there actually exifts fome eflential difference be- tween the two difeafes ; or at leaft it fhews, that the revolu- tion of afeafon or two deftroys in the conftitutions of foreign- ers, a certain aptitude or difpofition for the one difeafe, which it ftill retains for the other. Perhaps this may be principally .owing to the effects produced on the biliary ducts and duo- denum, by.the frequent and copious fecretion of bile, to which the .inhabitants of Tropical climates are particularly fubjeft ; whereby they arc rendered infenfible to the contagi- on of this difeafe. ( "5 ) place, unlefs the. heat has been for fome time above 75 degrees. It is aflerted by Dr Li- ning, that thofe who have once had the dif- eafe, cannot take it a fecond time : but we have feen feveral inftances of its occurring a fecond time here, where the circumfiances were fo unequivocal, that it could not be fairly afcri- bed to a relapfe. As foon as the contagion had reached the central part of the city, the difeafe fpread with aftonifhing rapidity. In the courfe of Augufl, there were more than 300 funerals ; towards the clofe of the month, twenty were buried of a day. During the greater! part of this month, the mercury in the thermometer ran- ged from 80 to 900, in the afternoons; the iky generally clear, and the winds Wefterly. From the 25th to the end of the month the weather was cloudy, and a fmall quantity of rain fell. In September, the difeafe increafed ama- zingly. ( '6 ) zingly. In the courfe of the month, about 1400 citizens were added to the lift of mor- tality ; towards its clofe, from 50 to 90 were buried of a day, though the mercury now feldom rofe above 8o°. The weather was moftly fair; a few days were cloudy, but there was no rain. The wind ftill wefterly. Throughout the month the heat was general- ly moderate, and the weather uniform,, ex- cept from the 19th to the 23d, when it was unufually calm, " deprived of the refrefhing breeze," during which the mortality was great- er than at any other period in that month. From this time to the middle of Odober, the difeafe proceeded with an increafe of mor- tality, owing to the enlargement of the circle of contagion. From the ift to ^ the 17th, more than 1400 fell vidims to the malady—■ but from the 17th, to the ift of November, the bills of mortality leffened rapidly, though not regularly. The whole number of the deaths in this month, amounted to near 2000, 4 though ( '7 ) though one third of the inhabitants had for fome time before deferted the city, and retired into different parts of the country, as choice or chance direded. The thermometer was very variable all this month, generally below 8o°, but above 50° until the 27th* from which time to the end of the month, it was always below 50°, and one day below 400. The weather for the moft part fair, though fome rain fell on the 12th and 31 ft, and it was cloudy from the 25th to the end of the month. The wind ge- nerally from the N. and N. W. till the latter end of the month, but from that time N. N. E. Towards the laft of the month, the con- tagion declined apace, the funerals being re- duced to between 12 and 20 a day. From this time the weather became more wet, cold and frofty, and the difeafe declined fo rapid- ly, that on the 9th of November, the fune- rals in all the grave yards only amounted to fix. From this time every thing feemed to C fink ( i8 ) fink into that kind of placid calm, which gene- rally fucceeds a dying florm. The citizens who had retreated from the danger, now ventured back, and the ftreets and various departments of bufinefs, immediately refumed their former life and energy—commerce again fpread her white wings, and penfive mourning melan- choly, has fince given place to the cheerful face of joy. DEFI- DEFINITION. The Synochus Icteroides or Yellow Fever, derives its name from the inflammatory fymptoms, with which it begins, becoming putrid in its progrefs ; and from the yellownefs in the eyes and fkin, with which it is gene- rally accompanied. DESCRIPTION O F SYMPTOMS. I HE difeafe (whofe fymptoms are now to be delineated), was generally preceded by a flight indifpofition, fuch as mufcular de- bility, and fenfe of laffitude, on exercife or motion, drowfinefs, flight pain and giddinefs in the head, pain in the back and loins, defec- C 2 tive ( 20 ) tive appetite, dyfpcptic fympl'oms, fuch as flatulent erudations, lofs of appetite, &c. After this prelude, which feldom continued fiiore than 6 or 8 hours, and fometimes with- out any fuch prelude at all, a chilly fit, al- ternated with glowing flufhes of heat, came on, generally in the after part of the night, or fore part of the day ; which, after a dura- tion, for the moft part fhort, though fome- times of 12 or 14 hours continuance, gave place to thofe fymptoms which defignate a confirmed fever of the inflammatory type, which increafed in violence as the day ad- vanced ; and continued with little or no vari- ation, till towards morning, when fome alle- viation with refped to violence wTas generally obfervable, but in fcarcely any inftance was there fo much abatement as could be proper- ly called a remiflion. The pulfe, after the feverifh flate became eftablifhed, was generally quick and tenfe, and during the exacerbation, it was alfo full and [ 2l ) and ftrong. In the carotid and temporal arte- ries in particular, it was ftrong and throbbing ; refpiration hurried; the fkin very hot and dry ; and the face highly flufhed ; the eyes re- markably red, hot, and painful, as if irritated by fmall grit or fand ; accompanied with a tor- turing pain in the head, back, loins, and large joints, fhooting from temple to temple, and extending from the loins to the hips and down the thighs ; the thirft considerable, but not in- fatiable ; the tongue white, moifl, and clam- my ; the bowels either coftive, or difcharging thin, watery, and fometimes bloody, ftools ; the urine high-coloured, cloudy, and fmall in quantity ; the ftomach diflcnded, painful, ten- der, and irritable, efpecially after taking any kind of drink or aliment; frequently affeded with lick qualms, and more or lefs propenfity ? to puke, but feldom bringing up any thing ; a fenfe of ftridure and oppreflion at the pre- cordia, as if tight bound with a belt; great reft- leflnefs, with moaning and fighing; and fre- quently fluffing of pofture in fearch of eafe ; fome ( " ) fome confufion of the intellects, attended with conftant pervigilium ; but feldom fo much de- rangement of the reafoning faculty as to a- mount to violent delirium ; frequent hemor- rhages from one or both noftrils, during the afternoon exacerbations in young pcrfons of both fexes ; and in thofe of one of the fexes at two different periods of life. In fome the head was mofl affeded ; in others the flomach. In perfons under puberty, fymptoms of hy- drocephalus internus frequently occured in the courfe of this ftage. In men verging on old age, the difeafe ufually began \\ itli fymptoms refembling apoplexy, unlcfs prevented by a difcharge of blood from the hemorrhoidal vcf- fels. When ftools were procured by art, the firfl were generally foft and white, but feldom bi- lious. The contents thrown out from the flomach were generally the drinks or aliment laft received. Sometimes mixed with matter of a fea-green colour and bitter tafte, but of- ten ( *3 ) ten without either. The fuffufion and infla- med appearance of the eyes, conftantly increa- fed in proportion to the violence of fever and date of the difeafe. The preceding fymptoms which may be confidered as limiting the firft ftage of the dif- eafe, continued with more or lefs violence from one to three days, and fometimes longer; and then abated fuddenly, fucceeded foon after by the appearance of a yellow tinge in the eyes, face, and neck, or by a copious evacuation of bilious matter by flool ; and die patient fpee- dily recovered, except that his flomach remain- ed weak, and his appetite defedive for fome time : or no bilious ftools taking place at the time, or foon after the ideroitous appearance became obfervable, the difeafe proceeded to the fecond ftage, in which there was a diminution of force in fome of the fymptoms; an increafe in others ; and an acceffion of new ones. The inflammatory fymptoms which before, in many refpeds refembled thofe of the idiopathic gaf- tritis* ( H ) tritis, now became mixed more or lefs with fymptoms of nervous affedion. The pulfe though ftill quick, was no longer full or tenfe ; the refpiration alfo continued quick and hur- ried ; and the fkin, though lefs hot, was more dry and parched, except during the ad of vo- miting, and then the moiflure was only par- tial, chiefly abo^ the neck and forehead. The ■tongue now appeared more dry and foul, par- ticularly in the middle; the thirft became in- variable; the ftomachfo irritable, and the reach- ing and propensity to puke fo conftant, that no- thing could be retained on it, but was caft up the inftantit was fwallowed,accompanied with vio- lent ftraining and noife ; but the matter thrown up appeared very little if any changed in ap- pearance, except being mixed with mucus and more ropy than when drank : the flomach was alfo conftantly affeded with a conftant burn- ing heat, which occafioned the moft excruci- ating agony and diftrefs. The anxiety at the precordia alfo hourly increafed, and foon be- came infupportable torture : the fighing, reft- leflnefs. ( 25 ) leffnefs, and tofting to and fro became perpe- tual ; the eyes and countenance were expref- five of the deepeft anguifh and defpair; and a delirium refembling mania was by no means uncommon. As thefe fymptoms became more diftrefling, the yellownefs which before was faint and partial, afliimed a deep orange or faffron colour, and extended itfelf over the whole furface of the body; fo that the patient refembled one with an obftinate and invete- rate jaundice. When thefe fymptoms had continued with increasing violence to the end of the fecond, or beginning of the third, day, fometimes earlier, and fometimes later, they all fuddenly vanifhed, and left the patient for a time perfedly eafy and tranquil. But this fa- lacious truce, fo flattering to the inexperien- ced, as well as to the patient, was foon fucceed- ed by a different, and though lefs acutely pain- ful, more hopelefs and defperate train of fymp- toms, which marked the third and laft ftage of this domeftic tragedy. The whole furface of the body now became of a cadaverous cold- ( 26 ) nefs, with the pulfe flow and foft, in fome not exceeding 40 ftrokes in a minute, but as regu- lar as in health. The refpiration was flow and deep ; and the yellownefs of the eyes and fkin appeared of a deep tawny or dull copper- colour ; the tongue much cleaner and moiftcr than in either of the former ftages ; the vomit- ing was alfo lefs frequent, but in a much lar- ger quantity when it did occur ; and the pati- ent always had fome refpite after emptying his flomach, till a lerge quantity of fluid was again accumulated ; when it was again fpout- ed up in an enormous quantity, and general- ry of a dark colour and turbid confidence, re- fembling coffee-grounds; and when ftools oc- curred at this time, they generally had the fame appearance ; but fometimes refembled tar or molaffes. The patient was generally at this time affeded with a kind ef cheerful delirium, imagining himfelf well: he could feldom be retained in bed, but walked about till exhaust- ed with fatigue. The delirium was generally fucceeded, the day following, cr the day after, by ( 27 ) by coma, from which the patient was occasi- onally roufed by vomiting and uneafy dreams ; and when roufed, ftarted up, and attempted to get out of bed ; and when prevented, immedi- ately funk down again into a ftate of number- ing infeneibility; and if afked, when rou- fed from his coma, how he did, his conftant reply was " very well i" As the debility in- creafed, the face and breaft became fpotted, as if fprinided with ink ; and a deep dufky yel- low and purple colour, refembling blood fet- tled in a bruifed part, pervaded the whole fur- face of the body. The- refpiration now be- came deep and flow, frequently interrupted by a fobbing kind of fighing and conftant hiccup. Thefe were fucceeded by dimnefs of vifion— difficulty of fwallowing —lofs of fpeech—rat- tling in the throat—fliort and convulfive breathing—funk and irregular pulfe—cold fweats—and finally death. But in more protraded and lefs violent cafes, inftead of the black vomiting and co- ma, ( 28 ) ma, the patient frequently became affeded with fymptoms refembling thofe which are commonly met with in a protraded and inve- terate fcurvy: In thefe the countenance ap- peared bloated and livid, as well as yellow, and blood perpetually oozed from different parts of the body ; particularly from the nofe, gums, and hemorrhoidal veffels. Some had aptha? or fuperficial ulcerations, in the roof of the mouth, and hi the throat, and parts which had been bliflered; and fome had a frequent vomiting, or rather gulping up of dark grumous blood from the fauces and flo- mach, or a difcharge of it by ftool. Several in this fituation, lived many days without any other morbid appearance, except a conftant and diftresTing watchfulnefs; fitting up or walking about conftantly, but without any appetite or extraordinary third, or apparent delirium ; till, exhausted by a hidden hemorr- hagic difcharge, or by a more gradual drain of blood, they funk infenfibly into the arms of death, without a struggle or a groan. When ( 29 ) When the difeafe terminated favourably, it was generally before the fifth day, frequently on the fecond or third; and when it termi- nated fatally, it was generally on the fourth, fifth, or fixth day; fometimes earlier and fometimes later; but when the patient furvi- ved the feventh day, without the acceffion of the black vomiting, coma, or fcorbutic fymp- toms, or great and increasing debility, the difeafe generally terminated favourably. This was the moft ufual appearance and pro- grefs of this formidable and too often fatal dif- eafe, through its feveral ftagec. But there were very furprifing variations in the appearance it affumed, both in refped to the duration of the feveral stages, and the state of the fymp- toms, according to the particular constitutions and temperaments of different patients, the ftate of the weather, the manner of treat- ment, &c. A fketch of thef^ we (hall now proceed to enurnc- ( 3° ) enumerate. In fome cafes iigris of debility In all the fundions, and a putrefcent tendency in the whole system, were apparent at a very early period of the difeafe. In thefe cafes the anxiety at the precordia was conftant, the sighing frequent—the yellownefs of the eyes and fkin became confpicuous very early—the exacerbations and remiffions of fever fcarcely perceptible—the pulfe quick and weak, fkin dry and parched, reftleffnefs and pervigilium great, vomiting conftant, and on the fecond or third day of a black colour—the ftools alfo black and gelatinous—the flomach constantly affeded with a violent cardialgia, or a burn- ing heat, which the miferable fufferer faid felt as if fcalded or. burnt by a coal of fire ; no pofture gave e^fe, and whatever was fwallow- ed, except very fmall draughts of toaft and water, weak -barley water, or fimple fpring water, increafed the agony to the moft exqui- fite torture. It was in this form of the dif- eafe, that the method publifhed by Dr Kuhn, particularly applied. And it was the form ni ( 3i ) in which the difeafe moft frequently appear- ed all the month of Augufl. In other cafes the generality of the fymp- toms refembled thofe of the autumnal remit- tent, combined with jaundice—and in fome no yellownefs or black vomiting occurred at all; but in thefe the eyes were almoft always highly inflamed for a day or two, but when a diarrhoea, accompanied with a difcharge of bile fpontaneoufly occurred, or was procured by purgatives or glifters, the yellownefs or ideroitous appearance was frequently pre- vented. It was often difficult to diflinguifh this dif- eafe at the beginning from the influenza, which was prevalent in the city, and fpread over all the Southern states and over the Weftern ter- ritory, before the yellow fever had made much progrefs in the city. The influence of terror alfo occafioned great variation in its fymp- toms. That the ufual difeafe of the feafon, the ( 32 ) the remitting fever, was often blended with this difeafe, is by no means improbable. For though two epidemics arising from a change or alteration in the fenfible qualities of the air, or from any invifible miafma diffufed abroad to a confiderabie extent in the atmofpherc, cannot exift together, yet there s nothing more certain than that a contagious difeafe, and a difeafe depending on climate, feafon, and foil, may exift at the fame time and in the fame place. Of this we have feveral exam- ples in the works of Lind, Ruffel, &c. A preternatural difcharge of bile, was by no means a common circumstance in, any form or at any period of the difeafe, as has been already obferved. Diffedions made not only at Cadiz and the Weft Indies, but alfo in this city, demonstrate that this is owing to an inflammatory affedion of the flomach, du- odenum and dudus choledochus: And it is more than probable, that the black matter brought up by vomiting, was the fphacelatcd furface of thofe parts mixed with coagulated bloody ( 33 ) blood, bile, and the contents laft taken into the flomach. The white colour of the ftools fo common in the beginning of the difeafe, alfo indicated an obftrudion to the excretion of bile. When the fever was protradedj ac- cumulations of bile frequently took plaee, as was evident from the tenfion of the right hypochondrium, and the foetid and copious difcharges coloured with that fluid, which fre- quently appeared after an adive purge. Dr. Jackfon relates that while he resided in Jamaica, between the years 1774 and 1782, he opened feveral perfons who died of this difeafe, and obferved that the flomach and in- testines had a dirty yellow appearance, and were highly putrefied, and much distended with wind—the liver and fpleen generally enlarged in fize, and the colour of the liver often of a deeper yellow than any other part of the abdominal vifcera—the gall bladder for the moft part moderately full, and of a thick confidence and black colour—the bilia- D ry ( 34 ) ry duds enlarged and filled with a fimilar flu- id, while the veffels of the liver bore the marks of uncommon diftention. A dark coloured turbid fluid was always obfervable in the ca- vity of the flomach, fimilar to that ufually thrown up in the laft ftage of the illnefs ; and the villous coat of that organ was alio abraded in various places, and at the fame time, fpots were obferved on different parts of its furface, which appeared to be incipient mortifications. The superior portions of the intestinal canal, had alfo frequently a fimilar appearance. From thefe and other diffedions, much light has been thrown upon the feat, and nature of this difeafe.* * See Jackfou on the fevers cf Jamaica, p. 265. PROG- ( 35 ) PROGNOSIS. IN THE FIRST STAGE. The favourable Signs were, Hemorrhages from the nofe, with relief of the head during the exacerbations. A gradual redudion of the pulfe, heat, and oppreffion at the precordia. A diarrhoea or laxative ftools, mixed with bile coming on before the third day. When in the decline of this ftage, there was a conftant retching to vomit, without bringing up any thing or vomiting the drinks only, accompanied with a burning heat and tendernefs at the flomach, with pain or op- preffion ; it was almoft a certain indication that the yellownefs, or bilious effufion, would D 2 foon ( 36 ) foon make its appearance. When the allevi- ation of the fymptoms, efpecially of the op- preffion and weight at the precordia or epi- gastric region took place, and were accompa- nied with, or fucceeded by, a bilious diarrhoea, it always afforded a favourable prognostic. Unfavourable Signs. STRONG, hard, and quick pulfe, with ferocious delirium, and pervigilium ; or quick, fmall and irregular pulfe, with low delirium, great mufcular debility, exquifite pain at the flomach, oppreffion and fenfe of ftridure at the precordia, great thirft, conftant naufca and retching, and reftlenefs; obftinate coftive- nefs, and the ftools when procured of a foft consistence, in lumps, and of a whitifh colour. A want of action in the bowels, and great in- fen Ability to purges and glyIters, alfo gave room for much apprehension, I N I 37 ) IN THE SECOND STAGE. The favourable Signs were, A N abatement of the vomiting, anxiety and oppreffion at the precordia—relief from the burning pain at the ftomach—-natural heat in the forehead and limbs, open bowels and natural coloured ftools—turbid urine, &c. Unfavourable Signs* AN increafe of mufcular debility, oppref- fion, anxiety, inceffant vomiting, a rapid in- creafe of the ideroitous afped, reftleffnefs and frequent fighing, coftivenefs or bloody ftools, accompanied with a painful tenefmus ; hollow eyes, fhrunk countenance, and fhrill feeble voice; an obstinate and painful pervigilium ; the ( 38 ) the patient continuing wide awake, In a flate of the moft uneafy agitation, with his fenfes and reafon but little impaired. But the fymp- toms expreffive of the greateft danger were, an invincible irritability of the ftomach, which prevented it from retaining any kind of drink, aliment, or medicines, and a gradual receffion of heat from the furface of the body. IN THE THIRD STAGE. Favourable Signs. A GRADUAL return of heat to the fur- face of the body, ceffation of delirium, and change of colour in the matter vomited up. Unfa- ( 59 ) Unfavourable Signs. ALMOST all the fymptoms in this ftage indicated a fatal event, particularly the fudden ceffation of pain and fever ; coldnefs of the face and limbs, and the black vomitings, or black ftools; conftant fingultus, coma, and hemorrhagy ; a fenfe of great weight and stric- ture about the epigaftric region ; deep and fre- quent fighing ; and great failure of strength de- noted danger in every ftage. When in this ftage deep coma took place, it generally deno- ted a fpeedy diffolution. OF 0 F THE METHOD O F CURE. Je ROM the preceding account of the various forms in which the fynochus icleroides appear- ed, the reader will at once perceive, that no one mode of treatment could be with propri- ety pursued ; but that it was requisite to vary it, as the fymptoms indicated an inflammatory or putrid type, as well as to adjust it to the fe- veral ftages of the difeafe. But in all cafes which began with inflammatory fymptoms, whether they ended in thofe which indicated putridity or not, the following treatment was found moft certain and fuccefsful. Blood-let- ting ( 4^ ) ting generally afforded relief in all cafes, when the adivity of the arterial fyftem was evident; and the head and epigastrium were at the fame time much affeded: and this operation was found ferviceable when repeated every fix or eight hours, for the first twenty-four or thir- ty-fix hours after the eftablifhment of the pa- roxysm ; and in every fubfequent exacerbation fo long as thofe fymptoms continued in any considerable degree*. To thofe who con- demn bleeding under fuch circumstances, we may fay with Sydenham, when fpeaking of the plague, " they either did not bleed early enough, or too fparingly." To thofe accuf- tomed to fee frequent cafes of idiopathic gaf- tritis, where the danger is feldom indicated fully by the pulfe, the propriety of this prac- tice will be at once obvious. In conjundion with * The fir ft blood drawn in the fever feldom fheved any white glutinous covering or fize, but after the fecond bleeding, this appearance was feldom abfent; though it was never thick or very tough. The craffamentum was bulky, flat, and fmooth, and never rofe into that cup-like or fand-box form which is common in cafes of pneumonic inflammation. ( 42 } x with blood-letting, mercurial purges were found more certain in their effeds and more ferviceable than any other kind; efpecially when exhibited in dofes of from fix to twelve grains, and repeated every fix or eight hours till a copious difcharge by ftool took place; and more efpecially when their opera- tion was promoted by mild laxative enemas, administered three or four hours after each dofe of the mercurial purge. Thofe who have not had an opportunity of obferving the good effeds of this pradice, will perhaps think it a very hazardous one. But when they consider the difficulty of retaining the faline and lefs adive purges on the ftomach, and the very o-reat difficulty of procuring copious evacua- tions by ftool, without which the topical affec- tion which obftruds the paffage of the bile eould not be removed, nor the propenfity to puke relieved ; they will change their fen- timents ; for, notwithstanding the inflamed and irritable state of thofe parts, calomel in large dofes, paffed the pybones, and occafion- ed ( 43 ) ed lefs Irritation till it had reached the intef- tines, and was lefs liable to be caft up than a- ny other purgative. But, however preconceived theories might influence others, we who were not prejudiced in favour of any particular hypothefis, and who had daily opportunities of feeing its ef- feds, not only in our own pradice, but in that of others, are convinced that it was more certain in its operation, and in general as fafe as any other. In a few perfons of delicate or infirm con- stitutions, indeed it proved injurious; and particularly when administered after the in- flammatory fymptoms had fubfided. When it proved injurious before the inflammatory fymptoms were removed, it appeared to have induced an inflammation in the intestines, and a very painful and troublefome tenefmus. And when it proved injurious in a later ftage, it was in confequence of the debility occafion- ed ( 44 ) ed by its operation or the ptyalifm, which too frequently fucceeded the too frequent and in- judicious exhibition of it. Unlefs fpeedy and decided meafures are taken in this ftage of the difeafe, all our future endeavours to remove it, will generally be ineffectual. And furely, in a difeafe which had foiled every method formerly employed, fome innovation was juf- tifiable. Thefe cafes, however, were very rare in comparifon with thofe wherein it ope- rated gently, and to good effed. As we ne- ver administered it when putrid fymptoms were prevalent or the debility very great, or in any ftage of the difeafe, but the first; we cannot fpeak with any certainty of its effeds, under any other circumstance or period. We feldom had occafion, even in the firft ftage of the difeafe, when inflammatory fymp- toms were prevalent, to exhibit mercurial purges after copious evacuations w^ere procu- red, but found thofe of a milder kind, fuch as fal. cath. crem. tart, or caftor oil, generally fufficient ( 43 ) fufficient to keep the bowels in a laxative state, when the ftomach would bear them, and when it would not, glifters made of an infufion of fena3 leaves, manna and common fait, with the addition of a little oil, generally anfwered the purpofe. We found the moft difficult part in the treatment, consisted in putting the ftomach in a condition to retain any thing; the faline draught in the ad of effervefcence, fo ufeful for that purpofe in other fevers, fel- dom produced any permanent effed in this; magnefia taken in a draught of fweetened wa- ter, feeeied to have a better effed when im- mediately followed by a draught of acid be- verage ; but there was nothing fo certain as a copious diarrhoea when it could be procu- red.* When on the first or fecond day of the * If in any cafe, the patient recovered by the means re- commended by the Weft India writers, and adopted by fe- veral, particularly by the French phyficians who praftifed here during the prevalence of the difeafe, this fortunate e- ven appears to have been more owing to a favourable ftate of the conftitution, or to a lower degree of the difeafe, than to the efficacy of their feeble and imperfe& method of treatment. ( 4« ) the difeafe the face was greatly flufhed, the veffels of the tunica adnata very red and tur- gid, and the patient was affeded with feroci- ous delirium, refembling that which occurs in phrenitis, he generally died in a fhort time, unlefs immediately and copioufly blooded, purged and reftrided to a cooling and abste- mious regimen. The antiphlogistic regimen was always found to agree better than that of the vinous or cordial kind ; not only while the pulfe con- tinued full and adive, but when it was low and quick, previous to the acceffion of typhous fymptoms. The patient was accordingly di- reded to drink toaft and water, lemonade, ta- marind-water, barley-water, and any other diluting, mild, fedative drink, that was grate- ful to the palate, and rested easiest on the fto- mach. Frefh air was constantly admitted into the fick room, and cold vinegar and water fre- quently ( 47 ) quently fprinkled upon the floor. This was found much more refrefhing than flafhing gun-powder, or burning nitre and charcoal in the chamber ; as thefe latter, though they fur- nilh a quantity of pure air, always increafed its heat; and thereby counterbalanced the good effeds that might otherwife have been derived from them. The bed and body-linen were alfo direded to be changed every day, or eve- ry fecond day at farthest. W7hen a repetition of blood-letting during the firft and fecond day of the complaint, did not remove the pain in the head and back, and the diftrefs at the ftomach, and when every thino- was vomited up as foon as taken ; re- courfe was immediately had to purging cly- fters, and to the application of epifpaftics to the ftomach and legs, or to the back and in- fide of the thighs : the latter method is prefer- ed by Dr Hume of Jamaica, to any otherj from a fuppofttion, that an inflammation rai- fed on an inferior part, always relieves that fubfift. > ( 48 ) fubfifting in a fuperior one. At prcfent it is fuppofed to be owing to a change of adion, from one part of the fyftem to another. Opium was alfo frequently employed in a foiid form as direded by Hillary of Barbadoes, with a view of relieving the vomiting ; but in general was found to aggravate it. The fa- line draught given in the ad of effervefcence, or magnesia as already mentioned, had a bet- ter effed, but was by no means certain: nor in fad was any thing elfe found to have any permanent effed on this fymptom, except gly- fters, brifk purges, and blifters. But thefe. when judicioufly and early applied feldom failed of affording relief. Baths of various kinds were occafionally employed, but feldom with fuch manifeft ef- fed as to induce us to fay much in their fa- vour, except wafhing the limbs with fimple water of tepid warmth, to keep the fkin foft, and take off ftridure and refiftance from the furface. ( 49 ) furface. When the topical affedion of the ftomach was relieved, a folution of Rochelle falts, in thin veal or fowl broth, with the ad- dition of a little common marine fait, was in general more certain and lefs irritating than any other laxative. (A drachm of this fait requires about two ounces of boiling water to diffolve it perfedly.) The inflamed ftate of the ftomach deterred us from employing eme- tics, or any antimonial preparations : but from the trials of others, we are convinced that they feldom were of fervice, but often the reverfe. When purges produced copious, fcetid and bi- lious ftools early in the difeafe, it generally terminated favourably and fpeedily. In the fecond ftage of this fever, (which however, feldom took place when the reme- dies beforementioned were early and judici- oufly employed and duly perfifted in), we found a very different treatment proper, from that which was neceffary in the firft ftage; fox the inflammatory ftate now, for the moft E part ( SP ) part, rapidly verged towards gangrene; and the mufcular weaknefs was fuch as to render bleeding inadmiffible; and the irritable ftate of the ftomach precluded all expedation from purgatives, as they were rejeded as well as every thing elfe the inftant they reached the ftomach. Our only refource, therefore, was in warm antifeptic fomentations, applied by means of flannel cloths to the ftomach, thighs, legs and hands, finapifms to the feet, aroma- tic and effential oils, or fpices slewed in bran- dy to the ftomach ; or the application of blif- ters, and the frequent exhibition of laxative glifters ; and after a free evacution, the injec- tion of bark decodion, and a few drops of laudanum, with fome farinaceous or mucila- ginous liquor, into the intestines—(here per- haps, wafhing the patient's whole body with cold water, and afterwards wrapping it in a blanket wrung out of a hot decodion, and the fubfequent application of blisters, would have been beneficial; but we were afraid to try them). Vinous and cordial drinks as well ) X s< ) well as all kinds of aliment, invariably aggra- vated this fymptom, and encreafed or produ- ced the cardialgia ; but fmall draughts of cold Water generally gave inftant eafe. When by thefe means the topical inflammation of the epigastric region was removed, all the fymp- toms gradually fubfided, and the patient reco- vered. But when thefe means failed, and the black vomiting came on, accompanied with coldnefs, and a cadaverous appearance of the extremities, and a dark yellow and purple afped of the countenance, our pradice was to employ a ftrong decodion of peruvian bark— an infufion of camomile flowers, and toaft and water lightly acidulated with the elixir of vitriol, and in fome cafes a mixture of brandy and water—and to dired glifters com- pofed of a ftrong decodion of bark, with the addition of fifteen or twenty drops of lauda- num, to be administered every two or three hours; applying at the fame time, finapifms and jugs of hot water, to different parts of the patient's body. We alfo direded all the E- % drinks' ( 5* ) drinks to be given in a tepid ftate. Hot fpi- ced wine, wine and water, and various other liquors were often tried, but in general with fuch bad fuccefs, that we cannot recommend them in fuch circumftances. Hot brandy toddy, however, with the addition of a large quantity of powdered nutmeg, in conjundion with external heat and acrid stimulating ap- plications, often had evident good effeds. When indeed the difeafe began with great prostration of strength, and other fymptoms which denote a typhous diathefis, we found wine not only fafe, but more ufeful than any other article. In thefe cafes alfo, the early ufe of the bark in various forms, together with the liberal ufe of laudanum and volatile falts were of fervice ; but that which was moft particular- ly fo, was the fhower-bath of falt-water, ap- plied- quite cold three times aday, the patient fitting in an arm chair, in a large tub for the purpofe, his head being previoufly fhaved or covered with a thin bathing cap of oiled cloth. But ( S3 ) But after the acceffion of this ftage, in which the black vomiting and coldnefs of the limbs were the moft predominant fymptoms, all at- tempts to relieve were generally ineffedual.* When * The principal aim to be kept in view in this ftate of the difeafe, is to recal and fupport the determination of the fluids to the furface. Death may be prevented, even after black- vomiting has appeared with all its terrors, if a remedy can be found powerful enough to excite the action of the extreme veffels, and to recal the determination from the internal parts, to the furface of the body. For this purpofe, we are told by Dr Jackfon, that he has employed alternately warm and cold bathing with fuccefs: he has even wrapped the bo- dy in a blanket, foaked in water, in which a large portion of fait was diffolved; or which had been fteeped in hot brandy Or rum; enjoining at the fame time the liberal ufe of wine or any other grateful cordial, to be taken as warm as poffi- ble in fmall and repeated draughts. He alfo mentions ha- ving heard of feveral well-attefted inftances of perfons being relieved of the black vomiting and their lives faved, by plen- tiful draughts of rum and water. In other cafes he thinks wafhing the whole body firft with cold water, and then wrap- ping it in the blankets fteeped in hot brandy or rum, and gi- ving warm cordial drinks anfwered ftiU better. (See his Treatife, p. 226.) We found brandy and water and beef- tea refted better on many ftomachs, and ftrengthened them more than any thing elfe, after the removal of fever and pain, and all the other fymptoms except debility and dyfpepua. ( 34 ) When the difeafe did not appear to be confined more particularly to any one part of the1 fyftem than another, but was univerfally diffufed ; and when nervous fymptoms with great prostration of strength, were confpicu- oufly predominant, which was frequently the cafe during the greateft part of the month of August, the treatment recommended by Dr Edward Stephens, a phyfician of great repute at St Croix, was employed with more fuccefs than any other; of which the following is an abftrad. " The naufea and vomiting may be relieved by an infufion of camomile flowers, given frequently until the ftomach is suffici- ently emptied of all crude matters. Small do- fes of a cordial mixture compofed of the oil of peppermint and compound fpirits of laven- der, may then be taken until the ficknefs a- bates. If notwithftanding, the irritability of the ftomach fhould continue, recourfe must be instantly had to the cold bath, which must be ufed every two hours or oftener if the urgen- cy of the fymptoms fhould require it: after each ( 55 ) each immerfion a glafs of old Madeira or a lit- tle brandy burnt with cinnamon may be ad- ministered. Flannel cloths wrung out of fpkit of wine, impregnated with fpices, may be applied to the pit of the ftomach and changed frequently. An injedion containing an ounce of powdered bark, mixed with thin falep or fago, to which a tea-fpoon-full of laudanum has been added, fhould be administered. Thefe injedions may be continued every two or three hours, omitting the laudanum after the first—as foon as the ftomach can bear medicines and nou- rifhment, the bark may be administered in fmall dofes—and as much madeira wine may be given as the patient can bear, without af- fecting his head or heating him too much. All emetics and violent cathartics fhould be avoid- ed. If the bowels fhould not be diffidently open, a laxative clyster may be neceffary, or a few grains of powdered rhubarb added to each dofe of .bark, until the defired effed is produced. ( 56 ) produced. If diarrhoea fhould prevail, it muft be checked by ftarch injedions, blended with laudanum, by the tin dure E. kino, japonica, or a decodion of cafcarilla ; for a diarrhea, efpecially when profufe, is always injurious when the difeafe is in an advanced ftage, or when the debility is great. If ftupor, coma, or delirium fhould come on, a large blister fhould be applied between the fhoulders, fmall ones to the thighs, and stimulating cataplafms to the foles of the feet. When hemorrhages appear, the elixir of vi- triol may be joined with the bark, but great care fhould be taken to prevent it from affed- ing the bowels, If the pulfe fhould be much funk, the pro- ftration of strength great, and fubfultus tendi- num take place, fmall dofes of the liquor mi- neralis Hoffmanni, or even vitriolic aether, di- luted with water may be given. Mufk and camphor in this fituation, have alfo proved effedual. C 57 ) effedual. Upon the whole this outline may be summed up under the recited circumftan- ces, by faying that the cold bath, bark and wine, a fpacious well ventilated room, fre- quent change of bed and body linen, and at- tention to reft, and quiet if properly perfeve- red, is all that can be done with any profped of fuccefs." We were led with other phyficians of this city, to make trial of mercurial purges in the early ftage of this difeafe, from having obfer- ved their good effeds in bilious remittents^ when fymptoms of accumulated bile were prefent; and are furprized that the Weft In- dia praditioners never made trial of it in a dif- eafe, which the generality of them acknowledge is the moft defperate and mortal to which mankind are liable, and which has heretofore baffled all their fkill; efpecially as fome of them imagine it to be only a higher grade of the bilious remittent, of tropical climates ; and as mercurial cathartics are recommended oc- cafionally ( 5§ ) caiionally for the removal of bilious accumu- lations, by feveral modern authors, particu- larly by Balfour, Blane and Clark. Dr. Wil- liams indeed, (who publifhed a treatife on the yellow fever at Jamaica in 1750), though he makes no mention of mercury, fays he found jallap or fcammony in dofes of 20 or 30- grains, given after an antiemetic draught, and repeated as often as it was thrown up till it operated freely by ftool, more effedual, not only in relieving the incessant propensity to puke at the beginning of the difeafe, but in mitigating every painful and febrile fymptom, and adds that though he can adduce no mo- dern authorityrin support of his pradice, he can recommend it fiom his own experience. We can fay the fame of mercurial purges, with this addition, that when they operated copioufly, which was generally the cafe when a laxative glyfter was injeded, a few hours after them, the vomiting or the propeniity thereto became more moderate, and in many cafes was entirely removed. With ( 59 ) . With refped to blood-letting,"there is much contrariety ol fentiment among the Weft In- dia phyficians ; the generality of them re- straining the operation to the firft and fecond days, from the commencement of the difeafe, and to a very fparing quantity: whereas Dr. Mofely advifes it without limitation, even ad deliquium, and a repetition fo long as the pulfe continues preternaturally quick, and the fkin exhibits much feverilh heat. And Williams advifes opening the temporal artery, when the pain in the head is great, and the fever high. But though Mofely is of the fame opinion with Williams, with refped to purg- ing for relieving the irritability of the ftomach, fo Ion": as the feverilh heat is evident, with- out regarding the ftate of the pulfe, he makes no mention .of mercurial purges, but places his chief dependence on a folutioii of vitrio- lated tartar and emollient glyfters ; and as foon as that is accomplished, has immediate re- courfe to the bark in various forms, as may be mod grateful to the ftomach. Blane ( 60 ) Blane and Jackfon have given a more ac- curate defcription of the difeafe, but Mofely certainly underftood its nature and treatment better than either, though he may perhaps fometimes have carried his plan too far for the constitutions of the generality of citizens. For hardy athletic mariners we believe it was the beft mode of treatment that was known at the time he pra&difed in Jamaica. OBSERVA- OBSERVATIONS ON THE 0 RIG IN and NATURE O F T H E CONTAGION. iHE R E is no difeafe on which the influ- ence of climate and feafon is fo confpicuous as on the yellow fever. In the iflands and countries within the tro- pics, where the difeafe is generated, the phyfi- cians who pradice in thofe parts have no idea of its being contagious ; but becaufe it rarely attacks the natives of that climate, and is con- fined to foreigners from a colder climate, they afcribe C 62 ) aferibe it to the eflecls of fatigue and heat, ex- pofure to night air, or to fome irregularity, &c. Numerous obfervations however prove, that it Is highly contagious when conveyed, to other countries,efpeciallyin populous cities with clofe built ftreets, when the heat of the weather is e- qual to, or exceeds that of, tropical climates. For examples of this, the reader is referred to Lind en Hot Climates-; to- Lining's account of its feveral occurrences at Charlefton, publifhed in the 2d volume of the Physical and Litera- ry Effays of Edinburgh; and to the history cf its rife and progrefs as it lately appeared in Philadelphia, publifhed by Mr Carey. For- mer obfervations alfo mew, that the contagion has always been fo effectually' destroyed by- cold and frosty weather, that it has never been known to revive the following fpring or sum- mer. As the contagious miafmata, or deleterious corpufcles of this contagion, or whatever elfe it may be fuppofed to consist of, is neither vi- fibls nor can be rendered cognizable to the 4 fenfes ( 63 ) fenfes by any means hitherto invented, we can only determine its existence and judge of its nature from its effeds. And as the fource from whence it is derived, and the means by which it is generated, have never been investi- gated or even fufpeded as we know of, we can only form a judgment of that circum- stance from analogy, which at best is but a problematical guide. The yellow fever, though it agrees with the typhus, jail or hofpital fever, and thepef- tilence in being capable of affeding found perfons under certain circumftances, who hap- pen to approach within a certain diftance of its fource, or of fubfiances which have already been within that diftance, and imbibed the contagious effluvia, differs materially from the former, in not being capable of producing any morbid effed in cold and frofty weather, un- lefs the heat of the chamber where it may chance to lurk, be raifed and continued for fome hours above fifty or sixty degrees, or ac- cording ( 6+ ) cording to the learned and obferving Blane, 75 degrees—and from the latter in not lofing its power, and declining as the heats of dim- mer, in countries where they are very hot come to the c height, as well as by the cold of winter—and from both in the manner of its attack, and the appearance of the fymptoms in the progrefs of the difeafe. And though it refembles the influenza in the fuddennefs of attack, it differs from it materially in the faci- lity of communication, the rapidity of its pro- grefs, and the extenfivenefs of its fway—the one being confined to cities, and taking fome months to finifh its progrefs—the other fpread- ing over whole continents, in the courfe of as many weeks. Nor does it agree in its effeds with the mi- afmata, which arife from putrefying fubflan- ces, or from a marfhy foil in any one circum* fiance, except being extinguifhed by cold and frofty, and perhaps rainy weather.* For the miafmata * Sse remarks on this fubjecl, publifhed in the Federal Gazette ( 65 ) iniafmata of marines, are diffufed through, the atmofphere to a considerable didance from their fource, and affed numbers at the fame time, and the difeafes produced fereby, are not contagious ; whereas the miafmata which occasion the yellow fever, are confined to a very narrow fphere, and only affed 4hofe that happen to come within that fphere, or in contad with, or near to fuch perfons, or fuch fubdances as have been within that fphere, fo as to receive the contagious effluvia; and the difeafe produced by thefe miafmata is conta- gious, and propagated in fucceffion from one to another, in propprtioh as there is more or lefs intercourfe between the found and the fick, provided a date of the atmofphere, with refped to heat and fome other circumdances, exid at the fame time favourable for propaga- ting the contagion, What thefe circumdan- ces are, will be mentioned in the fequel. But if this difeafe. is neither a modification of the F pestilence Gazette, dated November 18th, and Dunlap's American Ac!* vtrtifer, December 20th, 1793. ( 66 ) pedilence—the typhus—the influenza—or a higher grade of the bilious remittent fever.— What is it ? From what fource does it origi- nate, or by what means is it generated ? That it originates within the tropics, and feldom if ever in any other climate is generally admit- ted—but from what fource or how generated, is the question. It is well known to every one converfant with medical fubjeds, that other contagious miafmata are frequently generated in clofe crowded or unventilated places, particularly in jails, hofpitals and fhips of war, unlefs the body and bed clothes are frequently changed and kept clean, and the air frequently renew- ed, in confequence of the effluvia constantly iffuing from the lungs and pores of the fkin, at the fame time that a portion of the pure and vivifying principle of the air, is gradually exhausted by the fame circum- stance. It is alfo a fad well eftablifhed, that perfons thus circumstanced, frequently com- municate ( 67 ) municate a difeafe to thofe who chance to come into the fame place, or in contad with flich fubftances as have been within a certain diftance of them, fo as to imbibe a quantity of the effluvia iffuing from them, efpecially when rendered volatile by heat, without being in any apparent degree affeded in their health themfelves.* May not the contagion of the yellow fever therefore be generated in the dirty, confined, and suffocating cabins of the unfortunate flaves, (who are deprived of the means as well as the relifh for cleanlinefs and agreeable appearance, which aduates the minds of independent free- men), exalted into a pestilential quality by long continued heat; and may not the consti- tutions of the inhabitants from the fame caufe, in conjundion with the purity of the air from conftant ventilation, be rendered incapable of F 2 being * For examples of this the reader is requefted to confult the works of Pringle, Lind and Blane, Writers defervedly of the higheft authority in medicine. ( 68 ) being affeded by it; while drangcrs, whofe conditutions are differently difpofed, feldom efcape ? The putrefadion of dead animal matter can, have no fhare in generating the difeafe, as it gives out nothing but a little hydrogen or in- flammable air different from vegetable fub- dances in that procefs. To fuppofe with Drs Warren and Defportes that the contagion by which the difeafe is pro- duced and propagated, was fird introduced into the Iflands by a crew of fick perfons that arrived there about the year 1730, from Si- am in the Ead Indies ; and that it has been fcdered there ever fince, as the fmall pox has been in ether countries, would have fome ap- pearance of plausibility, if like that difeafe it made no didindion between natives and fo- reigners ; and a greater or lefs number of the inhabitants were always affeded by it: but as that is not the cafe, fuch an opinion mud be ground- ( 69 ) groundlefs. - For instead of affeding the na- tives, it is almod entirely confined to mari- ners from long voyages, and foul and crowded fhips ; and to foldiers confined in hofpitals, or crowded together in huts or barracks. And when it happens to be conveyed to other coun- tries, its influence is entirely exerted upon the inhabitants of cities ; and is obferved to be mod contagious in thofe parts where the air is moft confined and impure—when the days are very hot and the nights cool. Hence it appears, that in order to give effed to the contagion of this fever, it is neceffary that there fhould be a certain constitution of the air, in conjundion with great heat. Let us therefore enquire into the circum- ftances which give this morbific constitution to the atmofphere, that if the contagion fhould ever be introduced here again, we may not only efcape its effeds by retreating into the country, but if possible, difarm it of its power, and prevent it from fpreading, and affeding thofe who remain in the city. That ( 7° ) That all contagious difeafes receive their full force from a particular constitution or con- dition of the atmofphere, appears certain, from a multiplicity of concurring obfervations made by different authors at different periods and in different countries. In what this particular constitution of the atmofphere confifts, which in one year and in the fame fituation favours the fpreading of contagion, and in another year in the fame feafon and in the fame place, checks or extinguifhes it, has been varioufly explained by different writers : but as no ex- planation hitherto attempted is perfedly fatis- fadory, we beg leave to offer one which we think lefs exceptionable,* During a long continuance of dry and hot weather, the atmofphere becomes more or lefs charged with exhalations from various four- ces, in proportion to the moidure of the foil, &c, which are more or lefs injurious to health, in * See on this fubjefl particularly the works of Sydenham, Ruffel, and Lind, ( 7» ) in proportion to the quantity of animal and vegetable substances in a ftate of putrefadion, which cover or are mixed with the foil, the refpiration of animals, the combuftion of fuel, &c. while it is at the fame time robbed by thefe peoceffes of a confiderable portion of its vivifying principle, at prefent known by the name of oxygen gas, or pure air.. It is cer- tain that the air is faturated by fome other sub- stance, or deprived of a portion of its vivify- ing principle by fome means or other ; other- wife we know from the moft unqueftionable obfervations, that it would always neutralize, corred, diffipate, or precipitate the matter of contagion, however minute and fubtle the cor- pufcles may be of which it confifts. For it is well known that no contagious difeafe can fpread, or become epidemic, on mountains, or on open and extensive plains, where the foil is dry, cleared, and cultivated ; whereas it is with difficulty it can be prevented in populous ci- ties, with clofe built ftreets and narrow alleys, or in low champaign countries, where venti- lation is obftruded by furrounding woods. I 72 ) In populous cities in fultry weather the ex- halations, from the vaults, privies, finks, few- ers, gutters, fhambles, flaughter-houfes, tan- yards, from refpiration, and the combuftion of fuel, and a variety of other proceffes of na- ture and art, are inconceivably great. Nor can fuch exhalations fail of filling the air with a noxious mafs of invifible corpufcles ; at the fame time that the procefs by which they are generated fpoliates the fame atmofphere of a principle, on the prefence of which, both life and flame depend for their continuance. ,-------——---■---------" It is not air That from a thoufand lungs reeks back to thine. Sated with exhalations rank and fell, The fpoil of dunghills, and the putrid thaw Of nature ; when from fhape and texture, fhc Relapfes into fighting elements : It is not air, but floats a naufeous mafs Of all obfcene, corrupt, offenfive things ; Which ftill ranker grows with fickly reft, And poifons the balfamic blood." Armstrong on Health. MEANS MEANS FOR PREVENTING THE INTRODUCTION OF CONTAGION INTO SEA-PORT TOWNS. X H E moft effedual means of preventing the introdudion of contagious difeafes into a- ny fea-port town, is to ered at a convenient diftance therefrom, four feparate hofpitals, with large airy apartments. One of thefe hof- pitals to be appropriated for perfons with du- bious fymptoms. A fecond for perfons ma- nifestly infeded. A third for convalefcents from the difeafe. A fourth for purifying the body, the wearing apparel, and bed clothes : this ( 74 ) this lad fhould be provided with bathing tubs, and materials for fumigating. A bath- ing chamber and frefh clean apparel fhould al- fo be provided near to each hofpital, for each patient, before his admiffion into either ; ex- cept his weaknefs or fever fhould make the bath hazardous-. Each apartment fhould be feparated by means of a partition, to prevent any effed from each other; and fhould have windows that will both Aide up and down, for the admiffidn of frefh, and expulfion of foul, air. (For the manner of condruding thefe, fee Mackiterick*s Medical cautions.) Thefe hofpitals fhould be at fome diftance from each other, on as elevated and dry a si- tuation as can be conveniently found. When a fufpeded fhip arrives, the whole crew fhould be compelled by law to perform qua- rantine for 14 days at leaf!; the found to re- main on board; the fick or indifpofed in a marine hofpital or infirmary. By this it would be afcertained with certainty, whether there was contagion on board or not. MEANS MEANS FOR PREVENTING THE SPREADING OF CONTAGIOUS DISEASES, WHEN THEY HAPPEN TO BE IN- TRODUCED INTO A CITY. HEN a contagious difeafe breales out in a city, the moft certain means of prevent- ing it from becoming epidemic, or from fpreading, is to prohibit all intercourfe be- tween the found and the infeded; and to commit the difeafed to the care of perfons commiffioned for that purpofe. As foon therefore, as the difeafe appears in any fami- ly, both the found and the fick fhould be im- mediately feparated and removed to other a- partments, at fome diftance from the town, W ( 76 ) and a confiderable diftance from each other, and the houfe where the difeafe appeared fhould immediately be purified by the means hereafter direded.. ■ , Infirmaries for this purpofe fhould be built at the public cxpence, on dry and elevated fi- tuations, particularly on the high and gravelly banks of rivers or conftant streams of water, open on all fides to the free accefs of the air, provided with every neceflary, and fupported at the public expence. But perfons in afflu- ent circumftances though compelled to leave the city, fhould be allowed to retire to private infirmaries at their own expence,' provided they conformed to the rules of the public infirmaries, in every other refped. Every family in the neighbourhood where the infedion prevailed, fhould alfo be obliged under a heavy penalty, to remove to another part till all danger from contagion be over; and no perfon be permitted to return to an infeded ( 77 ) infeded houfe, or to ufe any article where the contagion existed, till purified by the means hereafter direded. Nor fhould any perfon who has recovered from the difeafe be permitted to return to the city, or to his own houfe, till he has after fuch recovery, repeat- edly undergone the ablution of both the warm and cold bath, changed every article of his cloathing, and performed a quarantine of at lead 14 days, fo as to render his return per- fedly fafe to the community. If proper attention had been paid to thefe diredions, which have been colleded from the moft refpedable fources ; and the fubftance of which was earnestly advifed by the college of phyficians, the calamity by which all defcrip- tions in this city fo lately differed, would have been prevented. And that a drid and punc- tual obfervance thereof in future, will prevent the like calamity, we are as certain as we are of any axiom in natural philofophy. In ( 78 ) In a letter from Dr Waterhoufe, the prefent refpedable profeffor of the theory and pradice of medicine in the university of Cambridge, Maffachufetts, dated September 28th, 1778, we find the following information refpeding the means which have been found effedual for preventing the fmall pox hom fpreading among the inhabitants of Newport, the capi- tal of Rhode-Ifland, when it happened to be introduced there, by means of any veffel; and will apply equally well in preventing any o- ther contagious difeafe from becoming epide- mic. " When a veffel arrives in the harbour with the fmall pox on board, every perfon with the difeafe is immediately taken by officers ap- pointed for the purpofe, to Coader's harbour, a little iiland about three miles from Newport, where there is an hofpital and every neceflary provided for their reception and accomoda- tion. And the veffei having a jack hoided in her fhrouds, is obliged to perform quarantine. " None ( 79 ) " None of the bedding or wearing apparel made ufe of by the patients during their day at the hofpital, are permitted to be brought away; nor are the patients who recover from the difeafe, allowed to leave the hofpital, till they have undergone feveral ablutions in warm water, and till at leaf! one week has elapfed af- ter their recovery, let the difeafe be ever fo light. " When any perfon in the town is fufped- ed of having taken the infedion, the family is obliged, under a heavy penalty, to give im- mediate notice to one or more infpedors. If thefe, in conjundion with a phyfician, pro- nounce the difeafe to be the fmall pox, the fa- mily has little more to do with the patient; but he is from that time to the termination of the difeafe, wholly under the diredion of thefe officers, who remove him to Coaster's harbour. Formerly they carried the fick perfon on a fleigh in a box in form of a large ched, with a fmall bed in it; the cover of which was per- forated with holes fufficient to fupply the pa- tient ( 8o- ) tient with air. But the inhabitants percei- ving that this formidable apparatus had all ill effed on timorous minds, difcontinued the box, and fubdituted a fedan chair. It has hap- pened more than once, that the difeafe wasfo far advanced before it was known to be the fmall pox, that the patient could not be remo- ved without the greated hazard. In that cafe the street was boarded up ; an advertifement publifhed in the news-papers, and guards pla- ced to prevent any perfon from approaching within a certain diftance of the houfe." MEANS FOR DESTROYING CONTAGION. Jljl EAT, fumigation and lime-wafhing ap- pear to be the most effedual means of destroy- ing the contagion adhering to the walls, floors, and ( 8i ) and furniture of houfes, and to bedding, wear- ing apparel, and to other materials which have been expofed to it. For this purpofe the bedding and wearing apparel being hung on lines acrofs the room, iron pots placed on bricks in the centre, and at each corner of the chamber or apartment fhould be nearly filled with alternate layers of powdered fulphur or nitre, and charcoal; and a piece of oakum dipt in tar, to ferve as a match, being placed in each pot, the fire-place being previoufly clofed, and the windows lhut doWn, is to be fet on fire, and then the door to be fliut; obferving to let in frefh air occa- fionally, and to relight them when extinguifh- ed ; but cautioufly avoiding going in till the door and windows have been for fome time opened to prevent fuffocation. When this process has been continued for three or four days, the door, windows, and chimney are to be opened, and left open day and G night ( 82 ) night for at leaf! a fortnight. By this time every particle of contagion will be perfedly extinguifhed, efpecially if the air of the room had been greatly heated immediately before the admiffion of frefh air: for by great heat it is attenuated and diffipated, and by cooler and pure air entirely changed in its nature and qualities, if there is any faith to be put in the experiments of the committee of phyficians ap- pointed by the emprefs of Ruffia, to fuper- intend the hofpitals, when a peflilential fever- prevailed at Mofcow in the year 1771, related by Mertens in his medical history of that dif- eafe : or if the obfervations of the experienced Lind, and the intelligent Ruffcl, are to be cre- dited. For greater fecurity, the walls of the houfe where infeded perfons have lain, fhould al- ways be whitc-wafhed with lime, and a quan- tity of the fame article fhould be thrown into the privies, as it is a certain corredor of conta- gion and putrefadion, as well as deftrudive to every fpecies of animalcule. A P P E N D I X. Copy of the report of the College of Phyficians^ in anfwer to the Governors enquiries, refpec^ ting the origin of the late epidemic; and their directions for extinguifnng latent in* feflion. Sir, IT has not been from a want of re- fped to yourfelf, nor from inattention to the fubjed, that your letter of the 30th ult. was not fooner anfwered; but the importance of the questions propofed, has made it neceflary for us to devote a confiderable portion of time and attention to the fubjed, in order to ar- rive at a fafe and juft conclusion. No instance has ever occurred of the dif- eafe, called the Yellow Fever, having been ge- nerated in this city, or in any other part of the United States, as far as we know; but there have been frequent inftances of its ha- ving been imported, not only into this, but 84 APPENDIX. into other parts of North America, and pre- vailing there for a certain period of time ; and from the rife, progrefs, and nature of the ma- lignant fever, which began to prevail here a- bout the beginning of laft August, and ex- tended itfelf gradually over a great part of the city ; we are of opinion that this difeafe was imported into Philadelphia, by fome of the veffels which arrived in the port after the middle of July. This opinion we are fur- ther confirmed in, by the various account* we have received from unqueftionable autho- rities. TO PURIFY THE CITY FROM - LATENT INFECTION,^ r W E beg leave to recommend, that every houfe, particularly thofe in which there have been any fick, fhould be thoroughly cleanfed7 and kept open for fome weeks, fo as to ad- mit frefh air through every aperture. The walls fhould be white-wafhed, and gun-pqw- der burned in all the apartments. The beds and APPENDIX. 85 and woollen apparel of the infeded, fhould either be destroyed or fmoaked with gun-pow- der in a clofe room, and afterwards expofed to the open air and rain. Unflaked lime fhould be thrown down the neceffaries; the dreets fhould alfo be kept clean, efpecially in the confined parts of the city. In anfwer to your lad question, permit us to obferve, that we trust the early attention of the legiflature will be direded to the port, with refped to the officers and other necefla- ry arrangements, and on fuch an occasion the College will ever cheerfully co-operate with them, in their endeavours to prevent the in- trodudion of contagious maladies in future. By order of the College of Phyficians. JOHN REDMAN, Prefident* November 26th, 1793. MecL.Wisfc. WZ MO Ctfbt TO ^•1 i *r ^. h> *Vfl t4 -Jri i*?**^' X ^ ~A -V^ik-^fi