SECTION I.

VARIOUS and numerous are the opinions on the origin and nature of the yellow fever. The firſt is, that it was imported from the empire of Siam, into the Weſt-India iſlands by a French ſquadron, returning from thence, in the year 1689; and which was obliged, by ſtreſs of weather, to put into Fort Royal, in MartinicoVide Deſcription de la partie Franc, de St. Domingue par Moreau de St. Mery, p. 700.. It is true, indeed, that, as ſoon as theſe ſhips arrived, their crews, as well as the crews of many others, were much infected with a very malignant fever. Great number periſhed, together with many inhabitants of the iſland. From Fort Royal the malady was imported, by ſome commiſſioned ſhips, into St. Chriſtopher's and into Hiſpaniola, where it made great havock. In Port-de-Paix, and ſeveral other places, its effects were ſo dreadful, during many years after, that, in the year 1692, a royal edict, from the king of France, ordered a quarantine for all ſhips coming from Martinico. Two years after, and even ſo late as 1708, penal laws, inflicting the puniſhment of death, were paſſed in commercial towns againſt any ſeaman or paſſenger who ſhould come on ſhore without a legal examination or permit. The malignancy of the diſorder was ſuch, ſays Mr. Morean de St. Mery, "as to cauſe corrupted blood to run out from all the organs, and even from the pores of the ſkin, which was afterwards covered with bloody ſpots." Since that fatal epocha, ſeveral accounts have been publiſhed of a particular kind of malignant fever raging, at certain periods and ſeaſons of the year, in all the tropical countries; which, in all its ſymptoms was nearly like the yellow fever. One of the oldeſt and moſt ſatisfactory accounts which we have of the malady of Siam, or of the yellow fever, is that of Mr. Pouppe DeſportesVide Maladies de St. Domingue., a French phyſician, ſent to Hiſpaniola, by the king of France, in the year 1732, to ſuperintend the regulations and eſtabliſhments of the hoſpitals in the colony. It is true that ſome ſymptoms of the fe • er deſcribed by that candid writer, ſeem never to have occurred in the American yellow fever; but they cannot conſtitute a material difference. They only lead to prove, that the ſame diſordered may take various ſhapes, and characters, according to circumſtances of ſoil and climate. Pouppe Deſportes called the fever an peſtilential one, and had no doubt of its contagious nature. He enumerated more dreadful diagnoſtics than any we know of. Beſides the black vomit, and the j 〈…〉 ice, he obſerved that ſuppurations and mortifications on the joints were often its forerunners. The ſucceſſive ſtages of the diſeaſe, as deſcribed by him, correſpond with what we have experienced here; and, from a comparative ſtatement of the temperature and variation of the atmoſphere, during many years, he drew the decided opinion, that the malady of Siam was always an immediate effect of noxious exhalations, produced by the united agency of ſtorms, rains, and great heats.

Another reſpectable witneſs of the ſame diſeaſe, is Mr. Dazille, phyſician appointed by the king in Hiſpaniola, about twenty years agoVide Obſervations ſur les Maladies des Negres.. He reports that he was called in, at Cape Francois, with three other phyſicians, to conſult on the caſe of a Mr. Lambert, who had lately arrived from Europe, and thus expreſſes himſelf. "On the ſeventh day of his ſickneſs, Mr. Lambert was ſtanding up in the middle of his room, not complaining of any kind of pain. He appeared much diſpleaſed at our meeting for conſultation, and affirmed that the was not ſick. His pulſe was intermitting, and a little febrile; his converſation was ſomewhat incoherent; and his eyes were tinged with a light yellow hue. I firmly declared to the phyſicians, that, in the evening, he would die. We met again at twelve o'clock; when we found him as yellow as a marigold and in a ſtate of coma. His •• glutition was already difficult, and he died at • half after ſeven in the evening!

"I was ſometime after, requeſted, by the viſcount de •• hoiſeul, to viſit Mr. de Sainthenay, knight of St. Louis, &c. I found him ſitting at his deſk counting money. Since the fourth day of his ſickneſs, he had been yellow and over his body. His countenance was anxious and much altered; his pulſe very bad; and his ſkin had already that cold moiſture which ſo peculiarly deſignates the laſt ſtage of this kind of malignant fever. I immediately ſent word to the viſcount, that Mr. de S. would die on the ſame day, which was, unfortunately, the caſe."

Experience had taught Mr. Dazille the inſidious and deceiving appearances peculiarly remarkable in the malady of Siam, or yellow fever; and he cautions his medical readers not haſtily to prognoſticate the fate of their patients. He and ſeveral other French writers have poſitively aſſerted that this fever was introduced into the Weſt-Indies from Aſia, about a century before. Although it has all the features of a contagion, to prove that opinion, yet it is very ſtrange that it never has been imported into Europe, notwithſtanding the uninterupted intercourſe of all the European powers with their iſlands. Time and experience have proved to them, that the malignancy and frequency of fevers in the tropical countries could not reach Europe. However, it cannot be inconſiſtent to ſuppoſe, that, if the malady of Siam had been imported from ſo diſtant a region as the Eaſt-Indies into tropical America, it might, of courſe, have been received in the ſouth of Europe; ſince there is no great difference between the climates of New-York or Newhaven, and thoſe of Cadiz or Marſeilles. Indeed, if there is a difference, it ſurely will he favourable to the hypotheſis, that ſuch a fever could have been imported often into the ſouthern latitudes of Europe. This was never the caſe, I believe, however, but once; when, in the year 1757, an Engliſh man of war from Quebec arrived in Plymouth with the yellow fever, which was very ſoon ſubdued by the climate, and did not leave the leaſt marks of contagion.

But it may be ſaid, that, by its nature, this fever is confined to tropical countries, and ſeldom or never can ſpread in the northern latitudes, unleſs it ſhould there meet with an uncommon degree of heat, as is often the caſe in North America. Such objections may be refuted, by conſidering, that the yellow fever does not preciſely break out during the heat of our tropical days, but on the return of the variable days of autumn. Shall we not then ſay, that the yellow fever may ariſe from ſome ſource colder and nearer than Siam or other tropical countries?

I find that Hypocrates has known, and mentioned the chief ſymptoms of this kind of malignant fever; and has noticed the ſpontaneous vomitings of the bile, the jaundice, and the black vomit, &cVid. Aphor. Hypocrat. Aphor. 22, 23, and 62, ſec. iv.. The warm climate in which he lived, could, indeed, give him frequent opportunities of obſerving all the effects of any infecting effluvia on the human body. His rules and precepts ſtill hold good in the ſymptoms of our yellow fever. Why then ſhould we ſearch for its origin in diſtant countries, whilſt we are ſurrounded with the ſame cauſes and circumſtances that generated the yellow fever in the iſland of Cos, in the Weſt-India iſlands, and in Siam, as well as in America?

It is an unqueſtionable truth, that a contagious diſorder may be imported; and that this frequently happens, can be proved by many hiſtorical and recent facts. Againſt theſe we do not pretend to oppoſe any dogmatical aſſertion. But, if the malignant ſcourge has always been introduced by extraneous cauſes, and could never exiſt in our climate but by importation, why does it reach our ſhores, ſo late as the month of Auguſt? Why is the plague of the American tropical iſlands increaſed by the mild and moderate temperature of our autumn? If it be anſwered, that the contagion muſt acquire its growth during the hot ſummer of the iſlands, before it can be tranſported, they thus aſſe ••• poſitive contradiction. On one ſide, they cr ••• the fever in the hoteſt country of the earth; on the other, they ſupport its progreſs in cooler p ••• and ſeaſons. Should it be acknowledged that the yellow fever often breaks out, in the iſlands, during their winter, or early in their ſpring, it nevertheleſs would not explain, why we do not receive it, on the return of our hot days.

An imported contagion might, indeed, be more heightened in certain places than in others; but as the contagion of the plague, the venereal lues, the itch, the ſcurvy, the ſmall pox, &c. are active in any part of the world, why does not this complaint ſpread to our inland places, country ſeats, and towns; among our robuſt farmers and the numerous inhabitants of our back countries? Are theſe places ſo perfectly airy and refreſhed, that this kind of contagion cannot reach them? Should it be anſwered, that in maritime towns only the atmoſphere can receive and tranſmit the ſeed of contagion, it is obviouſly admitting that there is an unqueſtionable ground to aſſert, that the fever is generated among us.

Why is it that people, attached to a certain mode of life, and careful in the uſe of certain preventives, may expoſe themſelves to the floating contagion, without fear as well as without effect? Are they more favoured by nature, diſpoſition, and conſtitution? If it is ſaid, that a perfect ſtate of health does not admit this kind of contagion, is not, what we ſuppoſe, admitted, that an imperfect ſtate of health will eaſily be acted upon by an impure atmoſphere, or by exhalations from corrupted animal, or vegetable ſubſtances?

Infine, there are authentic proofs that the yellow fever has ſometimes, appeared in iſolated caſes, in Philadelphia, and other towns. It did not ſpread, however, except in the years 1762, 1793, and 1797. Doctor Hilary has alſo obſerved, and poſitively aſcertained, that once in Barbadoes the yellow fever was not communicated even to the attendants of the ſick. As this ſtrange circumſtance cannot be explained, except by the ſtate of the air, is it not enough from his aſſertion, and from the repeated inſtances in which it did not ſpread, to derive the grounds of our opinion, that this fever is ſometimes generated by principles contained in our own atmoſphere? After all theſe arguments, gentlemen, againſt the importation of the yellow fever, from Siam or from the Weſt-India iſlands, it would be unfair not to take notice of the arguments by which it has been deduced from a different origin. Theſe grounds or proofs are but few and equivocal, and moſt of them will contribute to ſupport our opinion. It is ſaid, firſtly, that, in all places and towns in America, which have been infected with the yellow fever, it has been eaſy to trace its origin to certain ſhips from the Weſt-Indies, &c. Now, I ſhall not recapitulate to you thoſe tedious enquiries into facts that every party have ingeniouſly and with equal ſucceſs controverted; for, ſhould they prove the poſſibility of the importation of the contagion, it will not affect our doctrine. Such facts, indeed, ought rather to impreſs upon our minds, the important truths of the dangerous effects of any kind of effluvia from corrupted vegetable or animal ſubſtances, which are ſo often unavoidably engendered in the cargoes of ſhips coming from tropical countries in the hot ſeaſons of the year. Of this, there are as many inſtances as there are eminent medical writers, on the ſubject of contagion.

Secondly, The importation of the yellow fever cannot be doubted, when it is ſo often known to have raged on board of veſſels both at ſea and in port. Indeed, the French have derived their name of this fever, from its peculiar frequency among ſeaman; and ſeveral of their writers have called it la matelote. Be this as it may, two reaſons are obvious, even in our opinion, to render the yellow fever more frequent among ſeamen. One is, that they are conſtantly prediſpoſed to bilious complaints, as we ſhall hereafter explain; and the other, that they are continually expoſed to putrid exhalations.

Thirdly, If theſe towns and places had not received, the contagion from tropical countries, we ſhould find in our hiſtorical records more frequent inſtances of a malady that is ſuppoſed to be of a domeſtic origin. Formerly our ſummers were ſtill hotter, and more inſupportable than they are at preſent; and our towns, or rather villages, were deſtitute of any improvement, were often filthy and neceſſarily neglected; yet they were remarkably healthy. Againſt objections ſo obſtinately urged, I could oppoſe undeniable proofs of great changes in many towns and places, of variations in the air, winds, and atmoſphere, from wholeſome to peſtilential, and vice verſa; but we have no certain data from ſuch fluctuating premiſes to direct our enquiries. It is, therefore, unneceſſary to inſiſt on them here, while we can, in a few words, ſatisfy our reaſon and judgement from well-known facts, more applicable to the point in controverſy. Is it not true, that putrid effluvia, infections vapours, and poiſonous miaſmata, muſt be more abundant and permanent, more often generated, and more fully diffeminated, in populous and large towns than in villages or thinly inhabited places?

I do not find, gentlemen, among the Engliſh medical writers, any other peculiar opinion, on the origin of the yellow fever, except that of Dr. Warren, who implicitly believed, that it had been firſt brought from Paleſtine to Marſeilles, and from thence to Martinico and to Barbadoes, about thirty or forty years ago. All the works I have read, agree generally in the ſupport of the doctrine of local exhalations. It is now time, however, for me to dwell a little on the opinions which, though much divided, have nevertheleſs prevailed in Philadelphia, both among phyſicians and others. The college of phyſicians of this city, had officially expreſſed, in the year 1793, an opinion, that the fever had been imported from the Weſt-India iſlands, and that it was very contagious. They have, by no means, departed this year, from that declaration. As we have not any publication, collectively, from that body, that could exhibit more, and ſtronger arguments than merely their opinion of its importation, I ſuppoſe, that it is unneceſſary for me to ſay any thing either for or againſt the opinion. An almoſt equal number of phyſicians, among whom are many eminent characters, have uniformly ſupported the contrary doctrine, that the fever was of a domeſtic origin; and that it reſulted from corrupted ſubſtances in the cargoes confined in ſhips' holes, as well as from thoſe impure exhalations to which we are expoſed. Among theſe laſt, however, a diſtinction ſhould be carefully made of thoſe who acknowledge its highly contagious nature, and the few who yet think that it is not of ſuch a malignant character. I haſten to obſerve, that this aſſertion has been repeatedly publiſhed by a few European and Weſt-India practitioners, who have had but few opportunities of ſeeing many inſtances of the malady of Siam, at leaſt in Hiſpaniola, where it has very ſeldom appeared for theſe laſt twenty years, and where they have a better opportunity of treating the amphimerina bilioſa of Savage, or what they call la fievre lipyrienne, or the Tritacophya Americana Savage's Noſologia, cla •• , ii. febr.. Theſe are ſimply reduced to an inflammatory typhus, and to the putrid malignant fever. This capital miſtake has been, conſequently, connected with aſſertions deſtitute of neceſſary demonſtration; it has expoſed to doubt, and almoſt denied, ſome fundamental principles of phiſiology and practice, reſpecting infectious diſorders and epidemics of camps, jails, ſhips, and of all crowded placesIt has narrowly reduced medical aſſiſtance to the inſufficient method of diluting, cooling draughts, and feeble cathartics.. In a word, this miſtake has erected a doctrine void of the deference due to the authority of writers in the healing art of the former and preſent age.

I ſhall analyſe, with more pleaſure, the contrary opinion, for which documents, enquiries, and liberal and candid diſcuſſions, have been procured and unremittingly purſued by ſeveral phyſicians. Among theſe Dr. B. Ruſh deſerves particular notice; becauſe he has ſupported it, ſince the year 1793, both in his lectures of the inſtitutes of medicine, in the univerſity of Pennſylvania, and in ſeveral treatiſes he has ſince publiſhed on the yellow fever. He has never ceaſed to warm his fellow citizens of the preſence or proximity of the cauſe of this contagion, in their ſea-ports, wharves, ſtreets, and ſtagnant waters. He has explained the phenomena of exhalation from a combination of vegetable and and animal putrefaction; and, being aware, by long experience, and an elightened judgement, that the inhabitants of this place were particularly ſubject to billious fevers during the autumn, from ſudden changes, and the extremes of the climate, and from the groſſneſs and indigeſtive quality of their aliments, he early underſtood that infectious miaſmata could aggravate the bilious remittent, and convert it into a malignant and contagious fever. On this judicious ground he founded his theory and practice, and we ſhall ſee hereafter of what importance it has been to the diſcovery of truth, and the improvement of medical practice.

Having hitherto ſtated, gentlemen, the hiſtorical opinions of the moſt enlightened phyſicians of Europe and of America, I muſt obſerve, that it was my purpoſe to point out ſuch of their opinions as were more congenial to the true baſis of the theory to which I have confined myſelf; and to illuſtrate a poſition which has already occupied ſo greatly the public attention. I ſhall add a few more arguments to ſupport the local origin of the yellow fever and its highly contagious nature.

A ſtriking circumſtance was formerly exhibited by Pouppe Deſpartes, a French phyſician, ſent by the king into Hiſpaniola. During many years he accurately obſerved the ſtate of the atmoſphere in the ſpring and ſummer. He noticed, that frequent and heavy rains, interrupted by ſerene weather, and intervals of heat, in thoſe tropical countries, was productive of more dangerous exhalations from the earth. He was thus enabled to foretell the appearance of the peſtilential malady of Siam, as he called it. He obſerved, alſo, that, after heavy rains, the noxious effects of exhalations were checked by winds, or other circumſtances. A few caſes from this very juſt authority, will ſerve to warn the inhabitants of our towns of the terrible effects of the exhalations to which they will be expoſed, by the concurrence of rains, after long draughts, with the intenſe heat of the ſummers, if they retain among themſelves all the materials of vegetable and animal corruption. Theſe materials ſeem to increaſe with our population; and, in Philadelphia, I believe, there are more of them than in any other town in the union. They may conſiſt of the logs which form our wharves, and which project to a conſiderable diſtance in the water; of the boards with which almoſt all incloſures of lots and houſes are ſurrounded; of the roofs of all our houſes; of numerous privy-houſes which are ſeldom emptied; and of many ponds and ſtagnant waters, both in the city and ſuburbs. If it ſhould appear ſtrange to point out, among the ſources of exhalation, the very wood which we neceſſarily make uſe of for our dwellings and ports, I intreat my reader, before he rejects my aſſertion, carefully to enquire into the natured laws and effects of exhalations from wood, timbers, new ſhips, cellars, foreſts, &c. of which he will find ample documents in the writings of doctor Lind and others. Let him call to mind the number of wooden works in all our cities and ports, where the tide ſucceſſively uncovers and expoſes the wharves to the ſchorching rays of the ſun, and then let him draw his concluſions.

In proof of the fermentation of animal ſubſtances, particularly during the heat of ſummer, which I have already ſuggeſted, I ſhall propoſe an experiment. Let a candle be lowered into a ditch, by means of a line, and it will be found, that the mephitic aſcending gas, will put out the light in proportion as it approaches the ſurface of the earth, and this effect will be much more certain in the latter end, than in the beginning of the hot ſeaſon. When this gas aſcends and is received into the atmoſphere, it doubtleſs breeds contagion and death; and I am fully ſatisfied, that many people have, as well as myſelf, perceived and ſmelt its effluvia, chiefly during the calm and clear nights of the month of September. Several intereſting publications have appeared in the papers of Philadelphia on this ſubjectIt has been ſtrongly contended in ſame of them, that the waters of the wells of Philadelphia are rendered noxious by • utial grounds and others cauſes. I confeſs I have not yet heard ſufficient objections to deſtroy this opinion. By the effect of ſome local impregnations, ſeveral of our wells are particularly remarked for their bad waters. A reſpectable chymiſt of this city, analyſed the water of his own well, and found that it contained a quantity of magneſia, muriatic ſalt, and uncombined alkali. This certainly does not prove much in favour of our waters; and I am fully aware, that this ſubject requires a more particular inveſtiation. I hope, therefore, 〈◊〉 all attract the attention and fix the obſervation of ſome of our learned and philanthropic citizens.. From this ſhort ſketch we may conclude, that the opinion of the yellow fever being generated among us, is founded upon good ground; and that it would be in vain to attack this opinion by the objections which have been mentioned and refuted above. For further ſatisfaction, we ſhall add, that the circumſtance of its having appeared but once in Philadelphia, before the year 1793, does not imply that it cannot be of a domeſtic origin; ſince it is obvious, that it might have actually ſubſiſted in ſome or few caſes, among thoſe bilious fevers that are endemic among us in the autumn, without having been much taken notice of.

Would it be juſt to ſay, that this epidemic has never made its appearance in Philadelphia, except in 1762, 1793, and 1797, while there are creditable witneſſes who have poſitively ſeen and obſerved it, every year ſince the attention of phyſicians and others has been kept up by the recollection of the calamity? This fever, though ſo highly contagious as to be compared even to the plague, may, like the plague, be widely propagated or entirely imp • ded by cauſes that favour of oppoſe its progreſs; for unaccountable changes and variations of heat and weather, have ſometimes put an end to the latter in the heat of the ſummer, and they have alſo increaſed it in the middle of the winter. The caſe No. 1, was that of a father ſurrounded with a numerous family of whom not one was infected but himſelf. The ſame fact has occurred to my obſervation, in almoſt every family, in which the diſorder proved mortal. In ſuch caſes, the patients ſecrete very little of the putrid miaſmata; they are much leſs infectious, becauſe the poiſon is kept in their body to deſtroy the functions of life; and one of the moſt deceiving ſymptoms is, that they ſeldom emit any diſa •••• able ſmell. It is quite the reverſe, however, when they recover; and phyſicians and nurſes are well acquainted with the inſupportable foetor, peculiar to that fever, which exudes from their bodies, and continues, for a long time after, in their bed and clothes. Conſequently one or many mortal caſes of the yellow fever may have happened, without having been followed by contagion.

But it is further objected, that the traces of the importation have been viſibly marked in Philadelphia; where the fever, having been communicated by ſomebody from Southwark, has infected the moſt diſtant part, which is Kenſington, and the houſes on the Frankford road; meanwhile there were but few ſcattered caſes in the centre and northern parts of the city. This laſt mentioned theatre of the diſeaſe, would, however, have been preſerved from contagion if the epidemic was of a domeſtic origin; for the place is quite open, and preſents a view of many country ſeats, and being not on the ſame ſtraight line of the town, it cannot receive its exhalations. However ſtriking and concluſive this whole objection ſeems to be, yet what will be thought at laſt, by an unprejudiced reader, when he recollects that Kenſington, and all the adjacent grounds, are wholly a kind of naval yard, full of timber, and more than any other part of our ſuburbs, ſurrounded with marſhy grounds, and ſtagnant waters. The adjacent banks of the river are, beſides, filled up with all the rubbiſh of new and old timber. So much for the origin of the yellow fever in Kenſington, &c.

In ſupport of the opinion, that the yellow fever is of domeſtic origin, why ſhould we not derive, gentlemen, ſome authority from the medical doctrine already known and promulgated in all the ſchools of the world; of the poſſible infection of diſorders generated in places where people are crowded, or where unwholeſome exhalations are produced? The hiſtory of jail diſtempers, of fevers on board of fleets, and of various diſorders in camps, teaches us that it is not requiſite to ſearch for the origin of our calamity in diſtant countries. We muſt not be unaccuſtomed to the id •• , that our atmoſphere may be poiſoned as eaſily as a plant growing in our fields. From all the corners of our extenſive continent, winds, may blow 〈◊〉 as dreadful as the 〈◊〉 of Arabia and as the Harmattan of oriental Africa. Barren and uninhabited lands, thick and extenſive foreſts, have been known to ſpread, even to the diſtance of many miles into the ſea, miaſmata of contagion and death. To incredulous and ſyſtematic theoriſts, I ſhall exhibit the faithful evidences which we may derive from the inſtinct of ominous birds. If my mind was not diſtracted by error and prejudice, I ſaw, repeatedly, during the two inſtances of our calamity, vultures flying over our afflicted town. Theſe kinds of volatile and carnivorous animals, never wander but in the currents of miaſmata and putrefaction. This is the means by which, in a few hours, they reach their diſtant and putrid prey. This is alſo a proof that our atmoſphere was infected with the corruption which created our epidemic. For an imported diſorder cannot infect the atmoſphere, any more than our ſources of exhalation.

It remains now with me, gentlemen, to make a few more obſervations on the contagious power of the yellow fever. I have already notice, that very few opponents have appeared againſt that opinion; and it is certain, it will meet with none in the ſchools of America. The doctrine of the noxious qualities or ſubſtances of which the air and winds may be the vehicles, has been handed down to us by Hypocrates; and wonderful improvements in chymiſtry have ſtill letter explained this truth, and all its phenomena; for the idea of contagion implies nothing elſe but the tranſmiſſion of certain principles of diſorder, whether conveyed through the medium of the air or by an immediate contact. When this effect takes place, bodies are ſaid to be infected; and ſurely as many diſorders as by their particular effluvia always excite the ſame morbid ſtate, ſo many muſt be contagious. Happily, in the long catalogue of diſeaſes to which we are ſubject, theſe are, comparatively, few. Although contagion may ariſe from noxious effluvia, floating in the air, yet it ſeems that the ſame principles acquire more malignancy when they are propagated by the channel of diſeaſed human bodies. In them, the contagious miaſmata regenerated and multiply; and, if they were not checked by favourable changes in the atmoſphere, who could foreſee an end to a malignant contagion

Dr. Poiſſonier, and Dr. Lind have tranſmitted us the following memorable account of the contagious fever which ravaged the fleet of Mr. Dubois de Lamotte, in the year 1757, in the town of Breſt.

This fleet was, at firſt, joined at Breſt by two ſhips of the line, the Gl • ri •• and the D • e de B •• rgogne, both of which had received on board ſome men from the hoſpital at Rochefort. During their ſtay at Breſt, the contagion was ſo rapid, that they were obliged to ſend four hundred of their ſick on ſhore.

On the 3d of May, the fleet ſailed from Breſt to Louiſbourg, but both during their paſſage to, and ſtay in that port, the fever became general, and was attended with a conſiderable mortality. On the 20th of October, the fleet ſailed from Louiſbourg, taking on board their ſick, but leaving about four hundred in a dying ſtare. At ſea, the contagion acquired new vigour In a very ſhort, time, the whole ſquadron was diſabled; and, on their arrival at Breſt, on the 22d of November, the few remaining ſeamen were ſcarcely ſufficient to navigate their ſhips, having no leſs than four thouſand men ill. All their ſurgeons and almoners were either ſick or dead; and, when they arrived, ſeamen were immediately ſent on board to bring them to anchor, and ſurgeons to aſſiſt the ſick. Unfortunately four thouſand more arrived, at the ſame time, from Quebec, in the Bizarre and Celebre, two men of war, into which the ſickneſs was communicated by the above ſquadrom. During the general confuſion, they had been promiſcuouſly crowded into the town of Breſt, wherever they could get admiſſion. Fifteen hoſpitals were at laſt ſitted up. Phyſicians and ſurgeons came from all parts of France, and voluntarily gave their ſervices, beſides thoſe who were commiſſioned by the court. The hoſpitals were ſo crowded, that at laſt the mortality ſpread among the attendants. Five phyſicians, one hundred and fifty ſurgeons, and two hundred almoners and nurſes, fell victims, together with a great number of ſlaves, who were engaged to aſſiſt the ſick, upon a promiſe to receive their liberty. From the attendants, the fever paſſed to the lower claſs of people in Breſt, among whom it quickly diffuſed itſelf. The havoc then became general; and the houſes were filled with the dying and the dead. A proclamation from authority, had promiſed the ſick, that they would be provided with the attendance of a phyſician, or any other neceſſary means of aſſiſtance, if they would give proper notice. But, it was ſoon found, that, in many houſes not one was left who could give the nonce, and that, in others dead bodies had remained without burial. In ſine, the month of April brought a gradual and abſolute ceſſation of this contagious epidemic, which, in leſs than five months, ſwept off ten thouſand people in the hoſpitals alone, beſides the inhabitants who • ied in the town of Breſt, and who could not be numbered!!!

! Such are, alas! thoſe contagious poiſons, the elements of which are heavy and fixed; they are independent of our controul, and from generation to generation they perpetuate among men, and afflict or blemiſh the nobleſt family of the living creation.

But the yellow fever, gentlemen, has manifeſted ſuch particular characters of a highly contagious malignancy, that it ſuggeſted to many, no doubt, the idea of importation, which could not indeed, be denied, were there not ſo many and ſuch powerful reaſons to invalidate it. It was not like an epidemic which ſtrikes only at certain individuals, of the ſame diſpoſition, or defects of conſtitution; and thus diſcloſes, at laſt, what kind of victim it endangers. It does not, like the ague, threaten thoſe of lax nerves and fibres; like the catarrhs or influenza, falling upon the humourous; like the autumnal fevers, afflicting the bilious; and like inflammatory diſorders, ſeizing upon the plethoric; no, the yellow fever has ſpared neither ſex nor age. The infant in the cradle, as well as the moſt aged, were alike expoſed to its attacks. It ſeemed, indeed, very general among poor, intemperate people, and in filthy houſes; but we have ſeen alſo its power on thoſe, who, among all the comforts and coveniencies of life, were unfortunately reached by it. Its irregular march and progreſs, its appearance in oppoſite extremities of the city, without any viſible way of propagation, could not be explain 〈…〉 it been an epidemic reſulting from general external cauſes, and not poſſeſſing any contagion.

Moreover, theſe principles and facts cannot, in the leaſt, be invalidated by objecting, that a contagious diſorder could not remain confined in maritime towns; and that, like the plague, it would have found its way to populated country places; for even the plague abated entirely in Aleppo in the height of the ſummer, when the extreme heat, dilating too much the peſtilential miaſmata, probably rendered them harmleſs. It diſappeared in Vienna, in 1713, as ſoon as tempeſtuous winds blew away its aerial venom. By other unaccountable cauſes, it equally broke out during the winter and ſummer, and alſo equally diſappeared, during each contrary ſeaſon, in Okſacow, in the years 1737 and 1738. If the plague could be checked by contrary changes of ſeaſon, and even by the heat of the ſummer, who will be aſtoniſhed at finding that ſome reaſons alſo excludes generally the yellow fever from the country? Theſe reaſons are not incomprehenſible • for the pure, open, and elaſtic air of the country, muſt diſpel the infectious miaſmata. And there, with all the balſamic and wholeſome fragrance of a uſeful vegetation, with all the benefit of exerciſe and ſalutary labour, preventives enough may be found againſt contagion.

Let us now enumerate the fundamental obſervations which reſult from this firſt ſection.

1ſt, The yellow fever is generated by putrid effluvia from vegetable and animal fermentation.

2ly, The opinion that it was imported, one hundred years ago, from the kingdom of Siam, into the Weſt-India iſlands, and from theſe iſlands to North America, cannot be admitted excluſively, to its being generated ſpontaneouſly in every warm country, from the abovementioned cauſes.

3ly, We may more affirmatively pronounce, that the yellow fever may be an indigenous diſeaſe among us, ſince it was obſerved by ancient phyſicians in ſimilar climates, and probably under ſimilar cauſes; ſince we are expoſed to ſuch exhalations as ſeem adequate to its generation; and finally, ſince, in the paſt progreſs of the diſeaſe, there muſt have been ſome place and time in which it was generated and not imported.

4ly, The yellow fever is of a highly malignant nature and contagious power.

SECTION II. Phyſiological and Pathological Deſcription of the Yellow Fever.

FROM all the documents which have been tranſmitted to us, both by Engliſh and French writers, there is no room to doubt, that the diſorder which they have called the malady of Siam, the matelote, or the yellow fever, is exactly the ſame which has, in ſeveral inſtances, raged among us. It ſeems, however, that our epidemic, differs, though not materially, in ſome of its ſymptoms, from that of the tropical countries. Dr. Johnſon, has, indeed, acknowledged three kinds of yellow fever. With reſpect to them, I ſhall, juſt ſimply remark, that, if there are three diſtinct and apparent degrees, they muſt be owing to the following obvious circumſtances. Firſt, that of its effects or attacks on a patient who quickly becomes its victim; ſecond, of one who, without great difficulty, or danger, paſſes through its ſtages; and laſtly, if thoſe, who, with proper aſſiſtance, get over the reſolution and criſis. Theſe three characters, are, undoubtedly, the natural reſult of the different degrees of contagion, or of the conſtitution, habit, and previous complaints of the patient. There is conſequently out one ſort of yellow fever. This malady ſhould, beſides, be conſidered only during two of its periods, that of its ſymptoms and that of the criſis. In practice, this diviſion 〈◊〉 a very juſt one. It traces, exactly, the limits of medical treatment, and is a ſure mean of ſuggeſting true prognoſticsI beg thoſe of my medical readers who are profeſſedly attached to the ſyſtem of Dr. Brown, and which appears to have been i 〈7 letters〉 ed into the univerſity of Pennſylvania, to direct the uſ • l •• of prejudice againſt a theory, and to examine with candour a work, written in the good old ſcientifical language of Hypocrates, Boerhaave, and Cullen; for I have not any prejudice myſelf againſt them. Till this day, theories have often changed, while practice remains the ſame: and it was the doctrine of a celebrated author (Dr. Cullen) that medical hypotheſis is but a chain to link facts together, (Analytical Review, Arg. 1789, Art. viii.l I have often been indured to contemplate this doctrine, either from the conſideration that men of great genius and information have adapted it, or from a determined reſolution not to condemn, what, perhaps. I did not properly underſtand. With great reluctance, however, I would have exchanged thoſe ſimple elements that ſo eaſily explain the laws of nature, the phenomena of life and vegetation, for a metaphiſical theory, which, from the poſitive qualities of bodies and ſubſtances, carries us into a ſeries of complex and occult modes of action. If a perſon can underſtand all the phenomena of health and life, by the obſcure ideas of excitement being always evolved in a ratio to the quantity of the excitability, and exciting powers, which muſt always bear a due proportion to each other, &c. let him enjoy his conviction. But, why cannot the ſame conviction reſult from the ſimple laws of human life, as anatomy and phiſiology exhibit them to our obſervation? As for the ſucceſs, which might in practice be derived from that theory, it is a delicate matter, and I will not avail myſelf of thoſe ſarcaſtic comments upon it which I have frequently read. This much I can ſay, that I believe the doctrine may be of ſome advantage with men of genius, but I am ſatisfied that it leads to capital miſtakes, thoſe who direct themſelves by it, whilſt they do not 〈…〉 ſufficiently the 〈…〉 of nature.. When death is unavoidably the final reſult of this diſorder, it is equally horrid and inſidious. Penetration and attention are, therefore, the firſt and moſt eſſential requiſites to keep us from indulging thoſe erroneous and falſe hopes, which, both the patient and his friends, are too apt to entertain. A turgency of the blood veſſels, or what we call a plethoric ſtate, may, during one or two days, precede the attack, but is ſeldom taken notice of by the patient; and no other previous indiſpoſition can be remarked. Whatever then may be the ſtate of the body, the fever ſuddenly and tumultuouſly breaks out. Spontaneous vomitings of yellow, green, and glutinous bile; a depreſſing head ache; a numbneſs of the limbs, and joints; a burning heat in the face; and redneſs in the eyes; immediately take place. Such rapid and violent changes in the whole frame, are, I believe, uncommon in any kind of fever, and belong only to the plague. During the two firſt days, this ſtate admits of but little change. Short intermiſſions, are, however, ſometimes obtained by means of the remedies which are adminiſtered. The patient may poſſeſs all the other febrile ſymptoms; but I have ſeen none of them more frequent than delirium and coma. We next diſcover an ominous and abſolute proſtration of ſtrength, an abatement in the pulſe, an entire ce • ation of feeling, and an inſidious ſecurity in the patient, who fancies himſelf faſt approaching to a recovery, and who only complains of a want of ſtrength. He ſoon after, however, experiences frequent and ſhort chills; and his evacuations are colliquative, foetid, with yellow or white matter. He then ſighs deeply; is reſtleſs; and he cannot even bear the weight of a covering upon his body. He next appears totally inſenſible either to heat or cold; his ſkin is dry; there is no kind of exhalation of diſagreeable ſmell about him, and even very little is perceived from his breath. He has no thirſt, but he can drink any thing. Nauſeous medicines, or agreeable food, are alike received into his ſtomach without ſickening it. His tongue as yet portends nothing alarming; it is covered, however, with a kind of thick white cruſt, from the root to the edges, which remain perfectly red. In this ſtate his urine ſeems ſtopped, although he drinks much; and, if he voids any, it is generally purulent. This period of the diſeaſe, in which the deluſion of the patient exiſts, notwithſtanding the ceſſation of his regular functions, is highly expreſſive of the diſorder being unconquerable; and I venture to aſſert, that when it is obſerved in the ſecond or third day, it ought to determine the phyſician to give over, without heſitation, the leaſt hope of a recovery. The patient will be in the agonies of death as ſoon as the third day arrives, and never later than the fifth.

Another more inſidious ſtage than the former, may take place in the beginning of the diſ ••• e, and laſt two or three days. It is not ſo 〈◊〉 in its progreſs, but is equally fatal in its iſſue. In this caſe, an ardent fever, which, however • y be occaſionally abated by judicious re •••• is the only characteriſtic. Under ſuch circum • tances, how anxiouſly ought the phyſician of •••• r to bring on a change or a criſis! On this 〈◊〉 . I cannot too ſtrongly inſiſt: for here the 〈◊〉 of that ſickneſs lies, in which it is ſo difficult to recover any dangerous ſymptoms. Several of them are, however, to be remarked.

Firſt, Although the patient may be acted upon by medicines, he is certainly deprived of ſalutary evacuations; and chiery of thoſe which we ſhall hereafter deſcribe as the only proof of a ſucceſsful treatment. To be deprived of them, before the third day, is a ſure prognoſtic of death.

Secondly, The patient complains but little; and a kind of ſtupidity, reſulting from the ſlowneſs of his ideas, forms a ſtriking contraſt with the watchfulneſs and the confuſion of his countenance. This ſymptom is more alarming, and is directly oppoſite to the inquiſitive anxiety and irreſiſtable uneaſineſs of patients in common caſes. Thoſe, therefore, who are beſt acquainted with the natural diſpoſition of the perſon who is ſick, will be beſt able to judge of this deciſive ſymptom.

Thirdly, In all his actions the patient ſhews an uncommon degree of ſtrength; while repeated exacerbations of fever, frequent bloodlettings, and want of nouriſhment, ſhould render him very weak. This very ſtrength, however, is unnatural and contrary to the appearance obſerved in favourable caſes. It is the effect of an univerſal ſpaſmodic conſtriction of the nerves, and indicates the dreadful action of the morbid cauſe upon the viſcera, and its manifeſted by a kind of trill in the nerves, or by an involuntary fluttering in the muſcles, which we may evidently perceive, if we keep, attentively, during a few minutes, the hand or the arm of the patient in our hand. This laſt ſign claimed my particular notice, and it has always proved ſingularly uſeful to me.

Fourthly, and laſtly, we may always diſcover, that each of the exacerbations of the fever are preceded by horripilatio, or violent chill. After theſe four ſymptoms have taken place, we ſhould never put any dependence either on the pulſe or the tongue; for, whether the pulſe be febrile or not, intermitting or regular, it prognoſticates nothing deciſive for the patient, unleſs we can diſtinguiſh it hard, and tenſe, and poſſeſſing a ſpaſmodic and fatal conſtriction. The tongue alſo preſages nothing concluſive; it will be found white or ſoul all over its upper ſurface, and its edges red. If the patient remains for ſome time without drink, a triangular red ſpot will appear from the edge to the centre of the tongue. But after a diluting draught this diſappears; and theſe ſtates take place, both in caſes of death and recovery. One appearance of the tongue, however, is ominous in the firſt days of the diſeaſe; which is, when it turns black or brown, before the laſt exacerbation of the fever, which generally ſubſides on the fourth day. Iliccough or an abſolute ſuppreſſion of urine, are likewiſe very dangerous ſymptoms, if they take place before the time of the reſolution of the fever; but if the firſt happens after it, it happily conſtitutes the final and ſalutary criſis.

Another ſymptom uſual in malignant fevers, but particularly in this, is a kind of ſmall red petechiae, very ſimilar to free bites. They appear on the hands, the neck, the breaſt, and alſo on the face. Many ſuppoſe that they are from the bites of muſquitoes, or of other inſects. A phyſician may know better, but cannot derive from them any thing further than a proof of the malignancy of the fever. (Vide caſe No. 4.)

I dwell more particularly upon theſe apparently trifling circumſtances, becauſe they are of the utmoſt importance towards aſſiſting us in our enquiries. Phyſicians are, alas! pecularly liable to error in a diſorder ſo difficult to judge, and ſo violent in its attacks. From an affectionate regard to their patients, or from a reaſonable pride in their own medical ſkill, they are ſometimes over confident of their ſucceſs; and too frequently, in the event, the friends of the patient, are unhappily plunged into diſpair, at the diſappointment of their expectations. Would it not be more prudent, then, in caſes of iminent danger, to caution them againſt it; and thus, when the utmoſt of our ſkill is baffled, to deſerve their confidence and gratitude by our candour?

I now arrive at that fatal period, when, by the deadly effect of the decompoſition and mortification of the animal fluids, all the ſtruggles of nature are entirely overcome. On the fourth day, this period is announced by the paleneſs of the ſ ••• and the extreme debility of the pulſe; unleſs, indeed, as it frequently happens, a ſtill more violent degree of contagion has, through uncommon circumſtances, produce theſe ſymptoms ſooner. The feelings of the unhappy patient have now loſt ſo much of their power that he is totally incapable of giving any account of his confuſed ſenſations. His ſkin becomes gradually tinged with a yellowiſh colour, while his lower extremities become of a deep red and are a little ſwelled. The eyes looſe that remarkable animation which they before poſſeſſed, and appear deſponding; while the countenance becomes confuſed and grim. Nauſea • at this period, is a common ſymptom. If drink be thrown up, it is not altered from the ſtate in which it was taken, unleſs indeed, by having acquired a ropineſs, and being mixed with ſmall flakes of dark coloured matter. A black or brown fluid, much like coffee grounds, is next vomitted. If this does not take place, it is only owing to a want of ſtrength; and the ſtomach is, then, much more oppreſſed; and the patient may be expected to die early in the fifth day, or ſooner. Stools are alſo frequent and eaſy, but very offenſive. They are yellow, grey, and of a ſooty colour, and contain a few flakes of white or red. Delirium in this ſtage is very common. Frequent inſtances are alſo ſeen of patients preſerving their reaſon till the laſt moment, (Vide caſe No. 4,) when a cloud ſuffuſes their eyes, and makes them averſe to the light. During all this time, the pulſe is in a deceiving ſtate. It keeps, for the moſt part, quite calm, and is a little febrile, or perhaps not ſo at all. It occaſionally, however, appears intermitting, unequal, and different on one ſide of the body from what it is on the other. This is generally its laſt expreſſion of energy, and may be owing to a ſpaſmodic conſtriction. In ſuch caſes, it ſometimes riſes to an unexpected vigour, and is the forerunner of a temporary relief. The patient talks much of his expected recovery, and will ſometimes even try, with ſucceſs, to give deceiving proofs of it. He wiſhes to take exerciſe and to purſue his buſineſs. He will get up; want to dreſs himſelf; and will walk very freely. I have ſeen a few who, on theſe occaſions, were able to ſet in company. Every one was aſtoniſhed, and would remark no other alterations than that of a deep orange colour all over his body, an incoherence in his converſation, and a very confuſed look. How ſhort, alas! and deceiving is this laſt ſpark of life? A cool moiſture and a total proſtration of ſtrength ſucceeds, and ſuddenly conquers this elaſticity of the fibres. On a ſudden, the pulſe diſappears; the extremeties cool; the convulſions of the ſtomach are renewed, with accute pains, cauſed by a ſlight preſſure in the abdomen; and a deplorable, though ſhort agony, terminates the diſorder, after having diffuſed a putrifying poiſon in the blood, and deſtroyed the nobleſt viſcera by mortification. (Vide caſe No. 5.)

Such are the periods and ſymptoms of the yellow fever, which has been diſtinguiſhed, by ſeveral writers, as a particular ſpecies of the moſt malignant kind. When there exiſts an error in the treatment, or any dangerous circumſtances in the conſtitution of the patient, he muſt certainly fall a victim. The diſeaſe remains the ſame, however, in its nature and operation; and we will find, among thoſe who happily recover, no other changes than thoſe which conſtitute an iſſue prompted by accidental or unavoidable cauſes, and which take certain modifications from the conſtitution, the ſex, the age, or previous indiſpoſition of the patient. Let us now direct our enquiry further, by a review of the different ſtages of the malady, when it can be conquered by nature or by art.

It was the doctrine of Hippocrates, that, on the breaking out of any acute malady, there were ſymptoms pointedly prognoſticating its fatal iſſue, or the probability of its cure. Thus he remarked, that, if the patient, on being taken, was diſcovered involuntarily to ſhed tears, or if he was ſeized with convulſive fits, he would either die, or labour under a very long and dangerous attack. Medical practice, in our day, is, however, greatly improved, and is attended with far different and happier reſults. We have ſeen and known many who have recovered from peſtilential and malignant diſorders, who, at firſt, had exhibited the moſt portentous ſymptoms. (Vide caſes No. 6 and 7.) Whatever theſe ſymptoms may be, in the firſt day of the diſeaſe, any unfavourable judgement muſt be ſuſpended. In fact, if obvious indications have been faithfully followed, on the ſecond day, we may diſcover beneficial and critical perſpirations, remiſſions of the fever, and ſalutary evacuations. The latter muſt be repeated, copious, and of a dark green colour. Inſtead of that proſtration of organic ſtrength, which we have noticed above, the patient complains only of a natural weakneſs; and when he takes refreſhment, by a few hours of ſleep, he keeps a peaceable ſituation in his bed. Upon comparative obſervation, it muſt be acknowledged, that, inſtead of weakening the organic ſenſations, the yellow fefever irritates and heightens their powers; for, if but a ſight doſe of phyſic be given to the patient it will be very powerfully felt. His taſte is likewiſe equally affected by nauſeous medicines, by refreſhing liquors, and by the moſt wholeſome nouriſhments. The coma and delirium may take place, without being ominous; the pulſe may be rapid and revulſive without a convulſive conſtriction. The leaſt noiſe provokes in him a ſorrowful anxiety; but this ſymptom is for better than a deceiving ſecurity and a portentous ceſſation of his complaints. The fever keeps the patient, generally, in this ſituation for three days. On the fourth, the change operates; and is, indeed, connected with ſome apparently dangerous circumſtances, which are very critical; but, which, in the end, become ſalutary. The chief of theſe are, the affection of the ſtomach, and its repeated nauſea, joined to frequent vomitings, attended with a pain which a gentle preſſure accutely exaſperates. Proper medical aſſiſtance gradually relieves this and other acciedents; but, until the ſixth day, no ſafe proofs of a good iſſue are to be perceived. Should, however, a few paroxiſns of fever be repeated, ſo much the better, provided they are unattended with a chill. Theſe will ſerve to determine a happy reſolution; for the yellow fever, when treated with ſucceſ • , runs 〈◊〉 the c ••• es or febris ardent, and is remitting during ſeven days. The yellowneſs of the ſkin uſually appears after the exacerbation of the fifth day. It is not interſperſed with any ſhade or red ſpots, and there are ſcarcely any which are apparent on the extremities. This jaundice begins to diſappear on the ſeventh day. In the beginning, the tongue does not much differ from what I have above deſcribed in the worſt caſes. In theſe caſes however, it every day acquires a more uniform paleneſs, or ſmall red ſpots; and upon the whole ſeems of a more ſpongy and porous ſubſtance.

It is a general obſervation in medicine, that in proportion as the reſolution of an acute diſeaſe is perfect, the weaker the patient afterwards feels himſelf. This ſtate of the body is alſo, one of the beſt means by which we can judge of the ſafety of organic life. Agreeably to theſe principles, the patient who recovers from the yellow fever undergoes great exertions and a very difficult ſtruggle. In this exhauſted ſtate, he is doomed to a tedious convaleſcence, and may eſteem himſelf happy if he recover from it in a ſpace of time equal to that of the diſeaſe.

Several other circumſtances more particularly deſignating the character of the yellow fever, when carried to a ſucceſsful iſſue, remain to be mentioned.

The Weſt-India writers have obſerved in this diſorder, ſome ſingular ſymptoms, many of which were ſeldom ſeen in the American epidemic. They may, however, from obvious circumſtances, become ſymptoms of death, or criſes of a cure. Theſe are,

1ſt, Hemorrhage from the noſe.

2dly, Swelling and ſuppuration of the parotids.

3dly, Anthrax, or any other eruption on the ſkin.

4dly, Aperture of the orifice after bleeding, attended with a mortification of its edges.

5thly, Acute pains on the limbs, and ſuppurations on the joints.

6thly, Spots of dry mortification.

I frequently ſaw the firſt of theſe in Philadelphia, and it proved fatal or not, according to the pathological rules of Boerrhaave: "Si Tertio vel quarto die parca, Lethalis; optima fiet die decretorio." § • 41.

The ſecond has occurred, though ſeldom, in my practice. When it did appear, it was perfect, and generally ſucceeded on the fifth day, and always immediately reſolved the malady.

The fourth preſented itſelf as an hemorrhage. This I attributed to obvious circumſtances. The mortification of the orifice of the veins, however, I have ſeen in almoſt all the dying ſubjects; of the third and the laſt I have met with but one inſtance.

The fifth frequently took place as a pain, but never as a ſuppuration.

Upon the whole, the only critical diagnoſtics which have been peculiar to the yellow fever of Philadelphia, were, the hemorrhage and the ſwelling of the parotidsThe firſt were commonly from the noſe among men, and from the uterus among women of a competent age.; but theſe very diagnoſtics, together with the jaundice, were either favourabble ſymptoms of forerunners of certain death, according to the time in which they appeared. In fact, we learn, by the pathology of the human body, that, in all acute diſorders, Nature requires a certain ſpace of time either to cure, to reſolve, or to diſperſe the morbid cauſe under which the body is labouring; and the moſt perfect proof that the attempts of art or of nature have failed is when we too early diſcover incomplete effects or a falſe criſis. Of theſe however, an explanation will be given in the ſection on the treatment of the yellow fever; notwithſtanding I ſhall explain the real pathology of one of the moſt horrid diſorders that ever afflicted the human race. I here repeat with confidence that nothing but facts will be the baſis of a theory that has no connection with any new ſyſtem, and which will be an anſwer to theſe queſtions why the yellow fever is attended with ſpontaneous vomitings of the bile, with a jaundice, with black vomit, &c.?

The opinion that the yellow fever is a true bilious one, and differs only in degree, which is the higheſt and the moſt malignant, has been already known and ſatisfactorily proved by Dr. B. RuſhAccount of the bilious remitting yellow fever, &c. in the year 1793, by B. Ruſh. M. D.. With this principle as a guide, many errors, ſyſtems and conjectures might have been long ſince diſpelled, or at leaſt better explained. The hiſtory of its ſymptoms, exhibits, in the plaineſt manner, the corruption and malignancy of the bile. As ſoon as the patient is ſeized, he ſpontaneouſly vomits bile; and if he recover, it is by the means of ſucceſsful and copious evacuations of hepatic and cyſtic bile. If he die, it is evidently in conſequence of the mixture of the bile with the blood, and the mortification of all its viſcera and reſervoirs. All the anxieties, nauſea, pains, obſtructions, and exacerbations of fever, in every caſe, ſeem evidently cauſed by the fermentation, the ſtagnation, and the acrimony of the bile. In ſhort, if morbid bodies be examined by defection, new ravages of the bile are alſo diſcovered. From theſe facts, what other inferences can be drawn, but that of fixing the pathology of the yellow fever in thoſe laws and accidents that are connected with the bile. In order then to eſtabliſh ſome reaſonable ground, let us firſt enquire to what uniform cauſe we may attribute all the above mentioned ſymptoms.

Hippocrates has obſervedAphor. 62. Sect. IV., that autumnal fevers were attended with jaundice, in conſequence of people living upon rich beef, and Boerhaave admits acrid bile and poiſon among the cauſes of the worſt kind of jaundice. The liver, from its nature and functions, receives a great quantity of blood from the venaporta, to prepare the bile; we may therefore conclude, that diſeaſes of that viſcera, might diſturb or alter the bile, and vice verſa. But, if a poiſonous exhalation has, by its affinity with the bile, diffuſed itſelf in the alimentary canal, it is very probable that the infection will early reach, by many known paſſages, its very ſource; and the liver, the gall bladder, the duodenum, the ſtomach, &c. will then be diſeaſed by a poiſoned 〈◊〉 which ſtimulates, inflames, and corrodes th 〈…〉 e the ſpontaneous vomitings of the bile. Beſides, before this infected bile could be ſufficiently diluted, neutralized, and evacuated, it is obvious to think, that the whole liver,Icterus multiplex. § 916. being affected either directly or indirectly, will no longer be ſo eaſily infiltrated nor receive that maſs of blood it ought to admit; and this, by revulſion, will paſs down the iliac and meſenteric veins to the •• laſt anaſtomoſes with the ſmalleſt arteries; and hence the violent and inflammatory fever with all its attending ſymptoms. Nature has but two or three days to ſupport the violence of ſuch a ſtruggle. The poiſon ceaſes not to act upon the very texture and membranes where it is incloſed; it may perhaps be poured again

I have it in my power clearly to prove, that the black vomit is the hepatic bile itſelf, which is completely corrupted in the liver, and conſequently mixed with the blood, by an authentic fact, taken from an account of the diſſections of Dr. Phyſick and Dr. Cathrall, publiſhed in Dr. Ruſh's account of the yellow fever of 1793, page 121.

In two other perſons, the ſtomach contained, as did alſo the inteſtines, a black liquor, which had been vomited and purged before death. This black liquor appears clearly to be an altered ſecretion from the liver; for a fluid, in 〈…〉 eſpects of the ſame qualities, was found in the gall-bladder. This liquor was ſo acrid, that it produced conſiderable inflammation and ſwelling o • the operator's hand, which remained ſomedays. The viſcous membrane of the inteſtines, in theſe laſt 〈◊〉 bodies, was found inflamed in ſeveral places.

from the liver into the duodenum and the ſtomach, with ſtronger acrimony; and there is always enough of it to contaminate the blood in the venaporta and that of the vena cava, from which it mixes at laſt with the general maſs, and produces the black vomit and the icterus. I need not to relate all the other accidents of gangrene, hemorrhage, eruptions of any kind, and of death; becauſe, to my medical readers, this theory, founded upon facts, will be ſufficient to account for every thing. Another ſtriking proof in favour of this theory, may alſo be drawn from the march of the diſeaſe in a recovering patient. His cure will either be rapid or tedious according to the efficacy of his evacuations, which, at firſt, being chiefly compoſed of the cyſtic bile, appear very green, but afterwards turn to a yellow colour, owing to the hepatic. It muſt, however, ſtill be remembered, that no ſymptom, diagnoſtic, criſis, or accident, can better deſignate any future ſucceſs, than a continued and uninterrupted evacution of the bile. After all theſe phyſiological and pathological arguments, we muſt undoubtedly conclude,

1ſt, That the yellow fever is the firſt and higheſt degree of malignant bilious fever, the proximate cauſe of which is a contagious gas received into the alimentary channel, and into all the viſcera of the bile; and that this original circumſtance diſtinguiſhes it from the plague, which is produced by a poiſon immediately received into the blood.

2dly, The contagious miaſmata which conſtitutes the yellow fever, is, at firſt, received into the bile. I • there alters i •• nd ſtops its circulation, excretion, and ſecretion; and it afterwards, by its acrimony, inflames and produces a mortification of the abdominalia, and a decompoſition or putrefaction of the bloodMy diſſertation in anſwer to the honorary prize-queſtion propoſed by the Medical Society of Connecticut, in the year 1795, on the chymical properties of the yellow fever of New-York, &c. contains a theory apparently contrary to the above phyſiological and pathological arguments. It is conſequently requiſite for me either to make ſome apology or to give a proper explanation. Were no improvement to be expected from repeated inſtances of the ſame facts, any ſcientifical attempt would no longer the praiſeworthy, nor repeated inveſtigation meritorious. My theoretical conjecture, however, that the calorie of a hot ſummer, might produce, by the abſorption of aqueous particles, the fermentation or putrefaction of the blood, and thus create a malignant fever, is the natural reſult of adopted elements and principles. By the help of theſe, we never fall into contradictory opinions, although we are liable to miſtaken applications. Beſides, I had long ſince ſuſpected that contagious effluvia might contaminate and corrupt the animal fluids, as well as that they might be altered by the loſs of ſome of their component parts; and this was my belief in the above mentioned diſſertation. "It may be ſaid, that contagious miaſmata, whether imported or locally produced, when admitted into the blood, will cauſe its putrefaction. We know that there are ſome proofs of ſuch dreadful effects, and we are acquainted with the deleterious qualities of mephitic air. There are, no doubt, other cauſes, which alſo deſtroy the equilibrium of our component parts. There are, in fact, chymical phenomena, which may ariſe in any town or neighbourhood where there are peſtilential effluvia." Vide Diſſertation on the prize-queſtion propoſed by the Medical Society of Connecticut on the chymical properties of the effluvia of the contagion of 〈…〉 in New-York, A •• . XI. p. •• ..

3dly, It appears, alſo, that there is but one ſort of yellow fever; that its different degrees of malignancy originate from obvious circumſtances; and that the diſorder will prove fatal or not, according to the mode of treatment, or to the nature of the conſtitution and previous ſtate of the body of the patient.

4thly, There are but two periods of the diſorder, that of the ſymptoms, and that of the criſes. The firſt generally laſt three days, ſeldom five, and inſtances have even occurred of but one day. The criſes always prove mortal if they appear before the third day.

The ſymptoms are, ſpontaneous vomitings of the bile, or nauſea; violent fever; ſickneſs of the ſtomach; florid ſtate of the face; reſtleſſneſs; pains in the limbs and in the back; and a proſtration of ſtrength.

The criſes are, hemorrhages; ſwelling and ſuppuration of the parotids; petechiae; jaundice; fluxes from the bowels; and black vomit.

5thly, In caſes of recovery, the fever is remittent during ſeven days, like the cauſos or febris ardens; all the criſes may ſafely take place on or after the fifth day, except the black vomit; but early and profuſe evacuations of hepatic and cyſtic bile are the only critical ſigns and proofs of next recovery.

SECTION III. Method of Treatment of the Yellow Fever.

WITHIN theſe laſt five years, the period in which the yellow fever has made its general appearance in America, ſeveral methods of treatment have been publiſhed here; and the ſame ſubject has alſo been ably diſcuſſed by many eminent Weſt-India writers. I will not, gentlemen, attempt to comment or decide upon the reſpective merits of either; but, I muſt confeſs, that I have never yet been able ſufficiently to diſcover by what indications the uſe of their remedies was to be directed. Thus it frequently happens that they ſometimes ſucceed and ſometimes not; and the mercury, bleedings, bark, cold or warm baths, acids, bliſters, &c. often failed even in the hands of thoſe who contended the moſt warmly for their application. If they afterwards attempted to explain under what circumſtances their propoſed method has failed, they have generally offered vague pretences and uncertain rules. Let us then, with candour, declare this unexceptionable rule in medicine, that no method of cure ſhould ever be depended on, unleſs it be founded on ſuch rational grounds that the remedies employed will anſwer, under every circumſtance, the indications of the diſeaſe. Experience has, at laſt, proved that bleeding and mercury are ſufficiently powerful to conquer the moſt malignant degrees of the yellow fever; yet, in the uſe of theſe remedies, the greateſt care and circumſpection are requiſite in order to inſure their ſucceſs. Before I enter upon the explanation of my method of treatment of the yellow fever, and of the proper mode of adminiſtering theſe fundamental remedies, ſuffer me, gentlemen, to obſerve, that, in America at leaſt, Dr. B. Ruſh has the honour to ſtand foremoſt in ſupport of their efficacy. While no other method ſeemed equally ſucceſsful, that of veneſection and calomel was ſupported, during the two inſtances of our calamity, notwithſtanding the moſt bitter invectives and ſarcaſtic publications were continually levelled againſt it. Some unfortunate and unſucceſsful caſes were held out as proofs of its danger; and the charge of profuſe and indiſcriminate bleeding was exbited as a murderous practice. Theſe objections, however, when weighed with impartiality, will be found to reſult from the unavoidable inconveniencies of a temporary and violent epidemic. One may ariſe from the method of indications, which cannot, in caſes ſo uncommon, be equally well-underſtood by every phyſician; and the other, from the impoſſibility of conducting the ſick with regularity and diſpatch, among ſo great a number of patients, who are often deprived even of the neceſſary accommodations, or who frequently miſtake their own caſes; and who, in the height of their deſpondency, communicate their terrors to the attendants. Too profuſe and indiſcriminate bloodletting, may have occurred in ſeveral inſtances; but I am happy in aſſerting that, as far as I am acquainted with them, they could not be fairly derived either from the private or public opinions of Dr. Ruſh. It is, therefore, peculiarly pleaſing to me, that I am thus able, in ſome meaſure, to vindicate the character of an eminent and humane phyſician; and more eſpecially ſo, becauſe in ſome points of theory I may be found to diſſent from him.

It is only from the pathology of the yellow fever, that any ſafe or efficacious rules for its cure can be derived. For every judicious obſerver, will candidly acknowledge, that, if the numerous remedies which have hitherto been recommended for the yellow fever, have produced a cure, they have likewiſe too frequently failed. If then it be a fact, that the contagion peculiarly connects itſelf with the bile, and corrupts it, we may clearly and ſafely eſtabliſh, as a firſt indication, that the bile ought to be ſpeedily evacuated, purified, and renewed. If it be true, that the morbid ſtate of the bile cauſes its ſtagnation, produces obſtructions in the liver, and prevents the entrance of a conſiderable quantity of blood into that large viſcera, we may point out as another fundamental indication, the neceſſity of ſpeedily oppoſing the immenſe revulſion of the blood in the arterial ſyſtem, which increaſes the general ſpaſms, together with all the ſymptoms of inflammation, and which continually endangers the life of the patient

I find with pleaſure that the theory of this pathology has been already adopted by reſpectable writers, and has been aſcribed to the bilious fevers of warm countries, among which our yellow fever is of the firſt and moſt malignant degree.

Whenever there is a deficiency in the powers of the circulating ſyſtem, the larger veſſels are diſtended, particularly the vena portarum; this cauſes the bilious evacuations in warm climates. Critical Review for May, 1795, on Ruſh's bilious yellow fever.

. Infine, if it be a fact that the bile, when infected, will contaminate the blood, and vice verſa; and when the whole frame, labours under iminent danger of putrefaction, that the animal fluids muſt undergo a depuratory criſis within a certain ſpace of time, and that by the means of natural or artificial exertions, it will be neceſſary to be well-acquainted with all the accidents attending malignant and putrid fevers, to accompliſh all the ſecondary indications, and to obtain, as regularly as poſſible, a perfect reſolution of the malady, without unneceſſary or dangerous means. To give, however, gentlemen, a more explanatory view of primary and ſecondary indications, for the mode of treatment of the yellow fever, ſuffer me to exemplify them by the following hiſtorical caſe, wherein I ſhall notice the minuteſt circumſtances, both with regard to the diſeaſe and to the medical preſcriptions which were adminiſtered.

T ... B ... about twenty-two years of age, was of a ſound conſtitution, and of a regular life. He had lately loſt his father and a brother in the prevailing fever. After their death, he, with the reſt of the family, went into the country; but he had already been infected with the contagion. This was ſoon manifeſted by all the alarming ſymptoms, but chiefly by the ſpontaneous puking of the bile. He was immediately carried back to town, where proper aſſiſtance might be obtained; and, before a phyſician could be ſent for, an experienced nurſe had ordered him to be copiouſly bled, and had given him a doſe of ſalts. Theſe orders were good but inſufficient, and nothing further was done until the evening of the ſecond day. At this time I was called in, when I found him extremely ill, and very nearly approaching to that proſtration of organic action which does not even give time for an exacerbation of fever. Having juſt loſt his parent and a brother with this ſame diſeaſe, he could not but conſider himſelf alſo as a devoted victim. His ſpirits were, therefore uncommonly low, and he appeared involuntarily to shed tears. This circumſtance, agreeably to the rule of Hippocrates, I conſidered as an ominous and fatal prognoſtic. A confuſed and gr •• n c •• ntenants, cold extremities, and a hard and low pulſe, marked the rapid progreſs of the diſeaſe, during only thirty hours of ſickneſs. All the good effects that might have reſulted from the firſt copious bleeding had been loſt; ſince no proper help had been 〈…〉 ed for the evacuation of the bile. My firſt conſideration was, therefore, to endeavour to ra • ſe 〈…〉 cervation of the fever to its natural co 〈…〉 the diſeaſe can never go reg 〈…〉 y the •• gh ••• different periods, and the patient will irrevo •• bly die, if he is ſo much exhauſted that it cannot be produced. To obtain, therefore, this deſirable change, I depended much upon the action of the mind on the nerves, and eadeavoured much to raiſe the hope and confidence of the deſpairing patient. Whi •• I kept his pulſe and hand within n •• e, they acquired a ſenſible energy. His extremities became warm; and, wiſhing to remove every obſtacle to the operations of the treatment, I immediately ordered a carminative and nitrous 〈◊〉 Thus I conſidered that the previous congeſtion • of the foeces might be diſcharged, and that the ſubſequent and neceſſary evacuations could no lo ••• r be retarded. At night, the patient was, agreeably to my wiſhes and expectatations, ſeized with a violent exacerbation of fever, attended with delirium. This ſtate gave the poſitive, indication of a copious bleeding; for by it I fulfilled the ſecond fundamental indication abovementioned, viz. that of emptying the blood-veſſels, when the blood can be no longer admitted into the liver, and when the large veſſels are in a ſtate of infection. Agreeably to this indication, the patient loſt fifteen ounces of blood on the night of the ſecond day. Without loſing-time, the bile was to be evacuated; for a favourable relaxation, and an abſolute ceſſation of ſpaſms, irritation, and inflammation, always ſucceed a copious bleeding, and at this time the medicines have conſequently more power. I directed the patient, therefore, to take immediately, and every two hours after, a doſe of calomel gvi. jalap, gx. and ſcamm. of Alep. gii.. This preſcription was to be alternately followed with proper diluting and cooling drinks. On the third day, the medicine operated ſatisfactorily; for a prodigious quantity of green or cyſtic bile was evacuated. The pulſe, however, exhibited a ſtate of conſtriction, and the ſtomach was ſick.

Let us now venture a few conjectures on theſe unfavourable ſymptoms. Among the remedies which we employ, there are many, whoſe power and efficacy we can underſtand and analyſe; but there are others alſo which may anſwer all our wiſhes, without our being able to account for their ſucceſsful operation. Thus, if in the remoteſt foldings and cavities of our viſcera, there exiſt a corrupted fluid which we wiſh to evacuate, it is obvious that venefection, affecting the whole ſyſtem and diſtending the nerves and the veſſels, will operate on each diſeaſed part; yet how does it happen that a mercurial powder ſo effectually obtains the ſecretion of the hepatic and cyſtic bile? This circumſtance, as well as that of the ſame effect being produced by the regulus of antimony, when taken into the ſtomach, cannot as yet be explained. In the caſe now under contemplation, twelve grains of calomel, mixed with other draſtics, was ſufficient to evacuate a great quantity of cyſtic bile. It was not, therefore, improbable, that by a continued action of the mercury another quantity of bile might be forced out and ſecreted from the liver to the duodenum and the ſtomach. It was the acridity of this bile which cauſed the conſtriction of the pulſe, and which ſickened the ſtomach. Under theſe circumſtances I conſidered it ſafer to effect its evacuation by a vomit than otherwiſe; and I conſequently ordered an emetic. It produced the happieſt effects; for, at the cloſe of the third day, the patient had ſcarcely any inflammatory ſymptoms, and enjoyed a viſible remiſſion of fever. His ſkin appeared moiſt; and his countenance was more cool and placid. All his ſenſations were agreeably affected by the comforts of a good bed, and a room warmed and purified by a chimney fire.

It ſhould appear, gentlemen, that our patient is now brought, from the moſt perilous ſtate to the point of recovery. The moles movenda of the arterial ſyſtem, and of the large infarcted veſſels; have been relieved, and the contaminated bile evacuated. Thus, therefore, two important indications have been timely fulfilled; and the actual ſtate of the patient appears to be that of the vis vitae, which always marks the beginning of the convaleſcence. But you will remember that the laſt indication has not yet been obtained, and that, within a certain ſpace of time, it muſt be effected either by natural or artificial exertions. This indication has already been deſcribed as relating to the depuratory criſis of the whole fluids, when they have been more or leſs contaminated; and it compriſes all the ſecondary ones for the treatment of malignant and bilious remittents. It is beyond the power of medicine to abridge the courſes and periods of theſe fevers. But, notwithſtanding their different ſtages cannot be ſo accurately traced as would enable us to form a nomenclature, yet ſome general rules have been deduced; and, upon the authority of theſe, it muſt be allowed, that the bilious remittent, like the cauſos or febris ardens, muſt laſt four or ſeven days, and may even be protracted to nine or fourteen. Exceptions to this march are very ſcarce; and the caſe No. 6, which was perfectly reſolved in three days, I never could account for in any other way than the following. By the primary effects of the contagion on the bile, the patient did not receive its ſecondary tranſmiſſion into the blood, and had not conſequently the elaboration of nature to ſuffer, but was cured as ſoon as the evacuations of the hepatic and cyſtic bile were obtained.

But, gentlemen, the illneſs of my young patient did not end at the point I have laſt mentioned; for I ſoon diſcovered another paroxiſm of fever. For the relief of this I preſcribed gentle remedies, ſuch as carminative injections and diluting draughts; and previous warm bath had been applied to the inferior extremities and abdomen. You will thus perceive, that I conſider mild operations only as deſirable, during the exacerbations of the fever, except that bleeding is requiſite when its inflammatory characters are too high. In the preſent caſe, I could ſee no urging neceſſity for veneſection; for the bile had already been evacuated, and the remiſſion of the ſymptoms and fever had been regular and uniform. Beſides endeavouring to preſerve the life of his patient, a phyſician ſhould be careful in the uſe of thoſe means which, by their frequency, may create other diſeaſes, or render the convaleſcence very long and perilous. On the night of the fourth day, the fever of the patient was ſo violent, that, in his delirium, he got up and went naked into ſeveral corners of the houſe. How wonderful, gentlemen, are the exertions of Nature when ſhe is properly aſſiſted! As ſoon as this exacerbation was over, the patient had ſeveveral copious diſcharges of bile; red petechiae were obſerved on his breaſt and arms; and his ſalivary glands being a little affected, he had a ſalutary and frequent ſpitting. The criſis peculiar to the malady was now beginning to appear. The redneſs of the ſkin began gradually to change to a whitiſh hue, which I judged would, at a proper time, turn yellow. What were then my obſervations; what was I to do; and what had I to expect? The revulſion of the blood from the veins into the arterial ſyſtem was certainly finiſhed; and the corrupted bile, by which the liver was infarcted, was ſecreting and diffuſing partly in the bowels, and partly in the blood. Mercurial draſtics were ſtill neceſſary; and, by their means, I again procured copious evacuations of yellow bile which was probably from the liver. On the fifth day, the yellowneſs was viſible; a quantity of this ſtagnant bile having mixed with the blood. It was then neceſſary to accelerate and ſtimulate the circulation by ſudorifics and tonics; and the ſtomach, being languid and exhauſted, ſome reſtorative and nouriſhing ſubſtances were to be adminiſtered. Thus, from the fifth to the ſixth day, the patient was aſſiſted, and enjoyed ſome natural ſleep. His fever had been very moderate and attended with but little delirium. On the ſixth, obſerving no further exiſting cauſe of irritation, I ordered a mild nitrous cathartic to keep up the motion of the bowels, and to prepare, by natural evacuations, if poſſible, the approaching final reſolution of the malady. This took place, during the night of the ſeventh day, by an equal and profuſe perſpiration, by copious urines, containing a thick yellow ſediment, and by repeated diſcharges from the bowels.. I then deſired that the patient ſhould be put in clean linen and in another bed. I muſt not, however, omit obſerving, that the ſheets and clothes with which he had been covered during the laſt days of his illneſs, were ſpotted with a kind of yellow purulent matter, and had a very offenſive ſmell. This circumſtance is always a ſtriking proof of the final depuratory criſis terminating a malignant fever, and more peculiarly exhaling the contagious miaſmata of the yellow fever.

From this moment, the patient could not, with any probability, experience any further exacerbations of fever; and he wanted no further aſſiſtance than ſuch as is neceſſary to convaleſcents. He was in this ſtate during five or ſix days, and a gradual nouriſhment, with two grains of opium, given at night, were for ſome time adminiſtered. This remedy is very reſtorative after acute and dangerous diſeaſes. It calms the general irritation of the viſcera; it fixes the oſcillation of the nerves; it procures repoſe and comfort; it gives ſome tonic power to the alimentary channel; and, infine, it helps the diſperſion of the yellow ſerum remaining in the cellular membranes.

A ſcrutiniſing peruſal of the preceding caſe, will, perhaps, gentlemen, afford a better idea of my method of treatment of the yellow fever, than any treatiſe I could give. I ſhall, therefore, conclude this ſection with the following propoſitions.

1ſt. The pathology of the yellow fever ſuggeſts three indications to be obſerved in the method of treatment. The firſt is the ſpeedy evacuation and renovation of the corrupted and acrib bile; the ſecond, to counteract the progreſs of inflammation and to diſcuſs the congeſtion of the large blood veſſels, which cannot diſcharge into the liver; and the laſt, to aſſiſt the depuratory criſis of the whole ſyſtem, which is to be effected within a certain ſpace of time, and by natural or artificial means.

2dly, The calomel is a ſpecific of unexceptionable ſucceſs, to evacuate the hepatic and cyſtic bile; provided its action be directed towards the bowels, by being united with other draſtics. As a ſialagogue it may be favourable: and the mercury, applied externally, cannot be uſeful but in the laſt indication.

3dly, The firſt indication will be alſo ſucceſſfully aſſiſted by the uſe and action of an antimonial emetic; but, before this and the calomel could be efficaciouſly adminiſtered, the ſyſtom muſt be brought to a conſiderable relaxation and temporary ceſſation of the inflammatory ſymptoms.

4thly, Profuſe and repeated bleedings are the only ſure means of abating the inflammation, and of fulfilling all the views of the ſecond indication, which occur at the exacerbation of the fever. There may, however, be ſome advantage in ſparing the blood; but, during the three firſt days, not to take enough of it would be fatal.

5thly, The laſt indication requires all the medical rules for the treatment of malignant fevers within a certain ſpace of time; but the two firſt muſt be completely obſerved within three days; for, in the latter period, the contagious miaſmata may already have contaminated all the animal fluids and mortified ſeveral viſcera.

6thly and laſtly, With the above indications, rules, and remedies, in conjunction with the following practical cautions, the treatment of the yellow fever cannot fail of ſucceſs, if the patient be free from previous complai • ts of diſeaſed viſcera or vitiated conſtitution.

SECTION IV. Practical Cautions for the Treatment of the Yellow Fever. OMNE NIMIUM NATURAE INIMICUM. Hip. Aphor. 51. Sect. 2.

THIS was one of the cautions laid down by the immortal father of the medical art, who was poſſeſſed of all the treaſures both of judgment and experience. All that is too much is contrary to Nature; and even our important diſcoveries of a ſpecific and of remedies for the yellow fever, will become dangerous if we adminiſter them without proportion or reſtraint. I ſhall, therefore, gentlemen, proceed to conſider a few important cautions in veneſection and the uſe of mercury for the cure of the yellow fever, and then enumerate ſuch other objects as relate merely to the patient.

It is a well authenticated fact, that frequent ſucceſs has attended profuſe blood letting in the yellow fever. If the injudicious and illiberal attacks that have been levelled againſt it during our late calamity, have deſtroyed the confidence of ſome of the patients and their attendants, it has been owing to the force of ridicule which is too apt to ſeduce unreflecting minds. But time and experience lead to truth and will ſurmount every obſtacle. When the celebrated Moliere had, by ſeveral dramatic pieces, painted the medical profeſſion in the moſt ludicrous colours, the public laughed at the ignorance of pretended phyſicians. But the reſult was, that a more juſt diſcrimination was afterwards made between them and practitioners of genuine reſpectability. However, the public will doubtleſs readily acknowledge that facts and principles will always ſtand forth againſt every ſarcaſtic aſſailant. To thoſe who think that indiſcriminate bloodletting was recommended as a ſpecific in the yellow fever, we would remark, that the principles held out by phyſicians, ought always to be examined with impartiality and attention. We ſay, it is true, that, for the cure of the yellow fever, we muſt bleed early and as copiouſly as fifteen or twenty ounces at a time; that, in each exacerbation of fever, during the three firſt days, bleeding ought to be free in proportion to the apparent inflammatory ſymptoms or elevation of the pulſe; that the ſtagnation of the bile in the liver and other viſcera infarcted, ſuſpending the circulation of the blood in the large veſſels, ought partly to be conſidered as an immediate cauſe of mortification, and partly requiring a great depletion of blood; that the power and efficacy of mercurial draſtic doſes, being always in a ratio to the relaxation of the ſyſtem, it will be previouſly neceſſary to relax by bleeding, and this perhaps as often as they are adminiſtered; that the meaſure of bloodletting has no bounds but that of a viſible and favourable change, and no terms to its reiteration, but the marked period where the effects of the malady are irrevocably fixe • for death or recovery. After admitting theſe general rules, two cautions ariſe from pathological principles, viz. the time of bleeding and the quantity of blood to be taken. If veneſection produces ſuch powerful changes in the equilibrium of the animal fluids, and if it relaxes the ſolids, we ought not to have recourſe to it, without a ſtrict attention to the ſtage of the malady, to the exacerbation of the fever, and to the formation of certain criſes. 1ſt, During the three firſt days of the fever, this remedy will doubtleſs anſwer all the aforeſaid indications and purpoſes; but, when the effects of the contagion are diffuſed in the viſcera and blood, as is generally the caſe after the third day, bloodletting may anſwer very well for certain ſecondary ſymptoms, but would then be uſeleſs for primary indications; and even if the patient was likely to recover, ſuch means as have an enweakening tendency, would only retard the favourable event. Hence ariſes the practical caution of ſparing blood, if poſſible, after the third day. 2dly, As the exacerbation of the fever exhibits all the extent and degrees of the inflammatory ſymptoms, it affords the beſt opportunity of judging of the neceſſary quantity of blood to be taken. At this period, alſo, the blood-veſſels are infarcted or are in a ſtate of congeſtion; while, at any other, nature ſeems to reſt, and it is perhaps better to let her help the patient without diſturbing the criſes and operations of the fever. Hence ariſes the practical method of bleeding at the very moment of exacerbation; but ſeldom before and never immediately after. For, in the firſt caſe, we may retard it, when it is eſſentially neceſſary, and in the ſecond, we intervert its effects and render them incomplete. 3ly, We have already noticed, that the admiſſion of the bile into the blood, the hemorrhage, eruptions on the ſkin, &c. were criſes of the diſeaſe, and that when one or many of them take place, the fate of the patient is decided. If he has not, however, been bled, before theſe ſymptoms take place, it is ſeldom in his favour; and if a caſe ſhould happen, in which nature, without the aſſiſtance of bloodletting, ſhould effect the reſolution of the diſeaſe, it muſt be owing to the uncorrupted ſtate of the whole maſs of forces and fluids. If then, theſe happy effects can be aſcribed to ſuch a ſtate, we muſt be careful not to commit the iſſue of a recovery, or create irreparable accidents, by a diminution of theſe forces and fluids. Hence ariſes another practical caution of ſparing the blood after the appearance of one or more of the criſes. It would be very difficult and almoſt impoſſible to trace all thoſe circumſtances, which are to be diſcovered and determined by accurate attention and judgment. One inſtance, however, in the caſe of T. B. above related, may ſerve to illuſtrate the caution upon bloodletting. His ſituation ſeemed to require a third bleeding, and but little danger could have reſulted from it. It will be remembered, that he had been copiouſly bled at firſt, while in the country, and that, deprived of any further advice, he remained without medical aſſiſtance till the latter end of the ſecond day. At this time, he was in the moſt alarming ſituation, and I waited anxiouſly for the ſecond exacerbation, which took place in the night, and indicated a ſecond copious bleeding. Its effects were ſo favourable, and it produced ſo happy a change, that, at the time of the approach of the third exacerbation, I was convinced it would be regular, and not attended with too much inflammatory diatheſis; for the patient had ſtill continued to evacuate bile. I then left it entirely to the forces of nature. It was indeed violent; but its effects preſented regular criſes as far as medical rules deſignate. Infine, I concluded, that if this laſt exacerbation could, without bleeding, be attended with many favourable ſymptoms, I might continue the treatment without uſing it any further. I afterwards received the greateſt benefit from this reſerve; for it rendered the convaleſcence of the patient very ſhort. This generally is the caſe with thoſe who loſe but little bloodMr. Lieutand, phyſician of the late king of France, has proved that profuſe bleeding cauſes ſuch a relaxation of all the blood veſſels, as greatly to enlarge their capacities, which, by admitting more blood than is neceſſary, creates all the maladies incident to a plethoric ſtate. It will, conſequently, be of the utmoſt ſervice to our patient to ſpare as much blood as poſſible. The mercurial draſtics ſhould be given immediately after bloodletting, as they will then produce a more efficacious effect; and, as the exacerbations after the third day till the end of the fever, are always decreaſing, it muſt be concluded, that, admitting the remedy indiſpenſable during the three firſt days, neceſſity will hardly be found for more than three or four veneſections.. (Vide caſe 7.)

The exhibition of the calomel, in the yellow fever, will preſent to us more important and unobjectionable grounds of caution, when we retrace the different modes of the operation of this precious medicine, in order to confine its uſe to what abſolutely requires it. We have ſeen that, as a draſtic purge, it was particularly adapted to the excretion of the hepatic and cyſtic bile. To this ſtriking circumſtance, we cannot help aſcribing the repeated ſucceſs of thoſe phyſicians who firſt recommended the uſe of this medicine. We are alſo acquainted with its effects as a ſialogogue or ſalivating remedy; ſince many phyſicians have thought that this kind of operation could be produced by it only, and could be depended upon. Infine, the uſe of mercury, in the form of ointment, has been applied in many caſes of the yellow fever, and I ſhall therefore, examine whether it will thus anſwer ſome uſeful purpoſes or not. From theſe preliminaries, gentlemen, I ſhall derive only one propoſition, for practical caution reſpecting the uſe of mercury, including all my own rules.

The calomel, or mercurius dulcis, ſhould never be adminiſtered as a ſalivating remedy in the yellow fever. It is ſufficient to direct its action towards the bowels by the help of other powerful draſtics. It will aſſiſt the criſis of the ſuppuration of the parotids if it can take place. The external application of mercury will not effect an evacuation of the bile, and could not anſwer but for the depuration of the ſyſtem if the patient had not exacerbations of fever; but in this hypotheſis the remedy muſt prove uſeleſs and dangerous.

Several important queſtions ariſe from the preceding propoſition. What are the objections againſt the ſalivating method? Is the criſis of the ſwelling and ſuppuration of the parotids different from common ſalivation? Can it take place in the yellow fever without the action of mercury? If it is a ſucceſsful criſis, why do we avoid exciting it? And finally, if a mercurial preparation, taken internally, is allowed to be a good ſpecific, why does another ſimple mercurial preparation, applied externally, prove uſeleſs or dangerous? Let us now reſume each of theſe queſtions, and candidly inveſtigate them, unattended with a lengthy and ſcientifical collection of authorities, with which I ſuppoſe my medical reader well acquainted. In every kind of complaint there is not one of thoſe revolutions or admirable criſes in the frame, which are excited by the combined action of remedies, with a view of obtaining a ceſſation of the diſorder, that is not an exact imitation of what the natural and ſpontaneous laws would accompliſh, if they were not obſtructed. The beſt, therefore, we can do is what nature frequently operates without our aſſiſtance, and often before it can even be obtained. Thus, among all the ſingular circumſtances to be remarked at the end or reſolution of malignant fevers, the ſwelling and ſuppuration of the glands and parotids has been noticed as one of the moſt favourable criſes, and I have already obſerved that Pouppe Deſportes, in his deſcription of the malady of Siam, had particularly noticed its final and ſucceſsful operation. To his authority I could ſubjoin that of many phyſiological writers. Experience alſo has exhibited to me ſeveral inſtances of the moſt perfect and ſucceſsful ſuppuration of the parotids, in the yellow fever, without much mercury or none at all. (Vide caſes No. 8 and 10.) I do not doubt, gentlemen, but to this criſis, which is not uncommon, we are indebted for the conſiſtent and bold attempt of the phyſicians who firſt diſcovered the ſucceſs of calomel in the yellow fever. They did not perhaps notice, that it cured by its draſtic power, and that a ſucceeding ſuppuration of the parotids was rather a ſpontaneous criſis, than the effect of the remedy. But if this be ſo, there are others alſo which ſpontaneouſly prognoſticate a perfect cure in all malignant fevers, as well as in our epidemic. Theſe are yellowneſs, profuſe evacuations from the bowels, hemorrhages, tranſudation of corrupted blood from the lipsThis is one of the moſt ſingular criſes I ever ſaw; and, as it occurs but ſeldom to practitioners, I think it deſerves deſcription. The ſubject was a poor man, of about thirty years of age. He was in the third day of his fever, entirely in the hands of nature, and deſtitute of any proper aſſiſtance. Although he was very ill, the uſual medical aſſiſtance operated ſo favourably, that I deſired he might not be ſent to the hoſpital. On the fifth day, ſome blood ran from different parts of his lips; where it ſoon hardened and thickened ſo much, that he could hardly received any thing into his mouth. The leaſt motion or violence would cauſe a new hemorrhage. On the ſeventh day, the yellowneſs appeared much leſs than is common; but the ſize and weight of thoſe black ſcabs were ſo great, that they reached the noſtrils, and rendered the reſpiration very difficult. The patient was in the greateſt torture, and made a hideous appearance. I ordered the lips to be waſhed with ſome warm mucilage. A few pieces of ſcab were ſoon detached, but new beds formed again though much thinner. They gradually diminiſhed during the convaleſcence, which was otherwiſe rapid and regular., &c. All theſe criſes, which are equally good when they take place at a proper time, appear various in different kinds of malignant fever. Thus, the yellowneſs is particularly characteriſtic of our fever, and the lymphatic ſwellings, in the ſame manner, deſignate the plague, &c. But, if in both diſeaſes, the ſuppuration of the parotids could be excited, by art or nature, the one would not be attended with a jaundice, nor the other with a ſwelling; for there is never more than one criſis peculiarly ſpontaneous. The moſt convincing proof, however, that the ſuppuration of the parotids ought to be conſidered as a ſpontaneous criſis in this fever, may be derived from the obſervation which every practitioner muſt have made on the progreſs, ſtages, and ſpace of time, through which a ſalivation is commonly artificially obtained. Few inſtances are found, even among delicate patients, in which it breaks out in leſs than eight days, and it generally takes two or three weeks. As much time is afterwards neceſſary to obtain, by it, a ceſſation of the exiſting ſymptom or diſeaſe. Now, it muſt be remembered, that five or ſix days only embrace all the periods and iſſue of the yellow fever. Conſequently, if a ſuppuration of the parotids takes place, it will rather be ſpontaneous, than be the reſult of a few doſes of calomel; for the courſe of the diſeaſe is too rapid to depend upon its ſalivating effects. But if the criſes of a ſwelling and ſuppuration of the parotids is to be conſidered as a ſpontaneous reſult, peculiar to one individual, and not to another; if it be a mere chance to receive it, as well as to be favoured with another as hemorrhage, flux of the bowels, &c. will it be prudent to adminiſter the calomel as a ſalivary medicine only? Will not the ſafety of ſo rapid and violent a diſorder be committed to an uncertain effect? And will not the treatment be rendered an obſtacle to ſuch means as nature employs to get rid of the imminent morbid cauſe?

To enforce this argument, we muſt examine what indications, facts, and theories, have united in ſupport of calomel. This medicine has undoubtedly a peculiar efficacy in evacuating the bile, and in cleaning the infarcted liver; and I truſt that no ſyſtematic practitioner will deny the truth of this fact. Why then do they prefer an uncertain operation to that which is as eaſily and as well produced in all ſubjects? Why would they endanger the iſſue of the malady, by fixing the whole effects of the mercury upon the primae viae, in order to confine its action on the ſalivary glands only, and thus render it uſeleſs in the evacuation of the ſpecific contagion, at a time when the moſt urging neceſſity calls for it? Why would they give time to the poiſoned bile to injure its reſervoirs, and then, by pouring into the blood, infect the whole ſyſtem? Why would they believe that the evacuation of that ſpecific contagion can be better effected by means of the ſalivary glands than by the natural excretory organs, as long as its ſources in the viſcera are not emptied? Such, however, would be the effects of adopting excluſively the idea of ſalivation by calomel for the cure of the yellow fever.

In dwelling a little longer, upon a ſubject of ſo much importance, I do not, gentlemen, fear to be tedious; and I truſt I ſhall be excuſed when I attribute many unſucceſsful inſtances of our treatment of the yellow fever, by calomel and bleeding, to the neglect of the conſiderations I ſhall now ſubmit to your attention. I have already obſerved, that when the hepatic and cyſtic bile are evacuated, the ſyſtem remained more or leſs infected; becauſe the large blood veſſels, which pour into the liver, and receive its blood again, muſt have waſhed off enough of the contagious bile. I alſo ſtated, that to repair ſuch effects, a general depuratory criſis was afterwards to take place, within a certain ſpace of time, and by natural or artificial means. As this phyſiological rule cannot be denied, it muſt be acknowledged, by every practitioner, that it would be impoſſible, as well as improper, to excite, in every patient, the ſame final and depuratory criſis. They will remember, that, in a woman, it may, perhaps, take place by a diſcharge from the uterus, and in men, by perſpiration, hemorrhagesI remember ſeeing, during the late calamity, a publication in one of the newſpapers of Philadelphia, in which the writer pretended to prove the neceſſity of bleeding in the yellow fever, by the frequent hemorrhages of the patient. I differ greatly from this opinion, and believe it might occaſion conſiderable miſtakes in practice. In the higheſt turgency of the blood-veſſels, the ſmall or capillary ones, have, according to their ſize, as much to reſiſt as the largeſt, which are ſeldom known to burſt, even when the pulſe is in the higheſt ſtate of elevation, except in caſes of appoplexy, when the blood cannot return into the heart. Hemorrhages are always the effect of a leſion or of the morbid ſtate of the texture of the veſſels. In 〈◊〉 diſeaſes, they originate from the vaſcular ſyſtem; and they never happen during the exacerbations, but on the contrary during the remiſſions, and when the pulſe has returned to its greateſt calm. At this period, the relaxed vaſcular ſyſtem, pours off a fluid ejected from the circulation, and not reſumed in the veins. It is from this cauſe that hemorrhages in fevers are conſidered as ominous prognoſtics, according to the time of their appearance., evacuations from the bowels, &c. The diſcovery of what will be the tendency of the patient, and by what criſis he will be finally aſſiſted, remains conſequently with us. When this is made, we ſhall be obliged again to acknowledge, that the calomel, when adminiſtered to ſalivate, will, in many caſes, counteract the march of the diſeaſe; and that it will obſtruct every criſis, but that of the mouth. A purge counteracts the ſalivation, while the latter has the ſame effect upon all that can be obtained by hemorrhages, perſpirations, &c. It follows, therefore, that, if the patient has neither time or a natural tendency to undergo the operation of ſalivating, this means would be contrary to the cure of the yellow fever.

The practice of exciting a ſalivation, for the cure of ſeveral diſeaſes, will better explain its equivocal effects in the yellow fever. By it, the morbid cauſe is tranſported from any part of the body or from the blood, into the ſalivary glands, from whence it is inſenſibly waſhed out, attended with a moſt offenſive ſmell; and the mercury ſecretes, by theſe glands, a great quantity of ſaliva. Should others give a different explanation of this phenomenon, yet we muſt all agree as to the fact, and this is ſufficient. It cannot be denied but that the affection of the mouth varies afterwards very much among different individuals, and although this circumſtance cannot be accounted for, the reſults may be ſatisfactory and have the deſired effect. There are patients on whom the greateſt quantity of mercury has never been able to affect their mouths. Some receive an eaſy affection in the ſublinguals and maxillary, but their ſpitting is unattended with a ſwelling of the parotids, and conſequently has no critical good effect. The ſtate of the teeth, their being covered with earthy ſcales, or much decayed, and previous maladies of the gums, may, in many caſes, render the action of the mercury ſo painful and even dangerous, by hemorrhages, that the courſe of the medicine muſt be interrupted, without fulfilling the adopted intention. Infine, the practice of adminiſtering mercury, without ſalivation, by the means of certain precautions, recommended by many phyſicians as equally ſucceſsful and ſafer in the reſults, are conſiderations ſufficiently powerful to make us diſapprove of the ſalivating method in a diſorder ſo rapid, and the malignancy of which, might be conquered by leſs equivocal means.

Reſuming my former propoſition, I recommend, as an important caution, that calomel ſhould never be adminiſtered by itſelf nor in the method or proportions intended for ſalivation; that, on the contrary, it muſt be but about the third part of a draſtic mixture, by the means of which it will immediately be diffuſed into the bowels; and that, if, in ſpite of jalap, ſcammonea, or gamboge, it is retained too long without operation, an oily cathartic, or ſome neutral ſalts, ſhould be given to prevent the mercury from aſcending, and to enforce the bilious evacuations, the importance of which has been ſufficiently proved. This method leaves always time enough for the criſis of the mouth if it is neceſſarily intended by nature. It helps it ſufficiently, and it even accelerates its appearance, and gives it all the characters that can render it perfect and ſalutary. Such caſes have occurred to me in the proportion of one out of ten

In practiſing the method of adminiſtering calomel, in the proportion of a third againſt two-thirds of other draſtics, as jalap, ſcammonea, &c. the following has been the reſult of my practice in the worſt caſes.

Out of ſeven patients to whom the calomel was carefully adminiſtered as a draſtic, I loſt only one.

I had one ſpontaneous ſuppuration of the parotids out of ten.

One accidental affection of the mouth, with gentle ſpitting, unavoidably cauſed by the calomel, and without conſequence, out of four.

One critical reſolution by hemorrhage, out of three.

One by eruptions out of twenty.

And, finally, one by tranſudation of the blood from the lips out of fifty.

.

Few obſervations remain againſt the external application of mercurial ointment. Admitting that it tends to the purification of the blood, what will be thought if the original cauſe and the foam of contagion are not deſtroyed? The reſervoirs of the bile are not emptied by mercurial frictions. This remedy, therefore, cannot anſwer any good purpoſe, except after the firſt period of the diſeaſe, when previous evacuations have been accompliſhed. This hypotheſis, however, would ſtill be liable to conſiderable objections, ſuch as the exacerbations of the fever, and the turgency of the blood-veſſels, which never fail to manifeſt themſelves as ſoon as the mercury is admitted into the circulation. The firſt would be conſiderably counteracted by mercurial frictions, while they are neceſſary to terminate the malady within a certain ſpace of time; and the other would become preciſely one of its moſt dangerous ſymptoms, and would be renewed and ſettled before we could have time to oppoſe it, or to obtain any deciſive and good reſult. I ſaw, in the laſt prevalence of the fever, a robuſt young man, in the fourth day of his ſickneſs, who had been regularly rubbed with mercurial ointment. The excretory evacuations had been neglected; he had not the leaſt affection of the mouth; and he died on the fifth day.

Some practical cautions reſpecting emetics alſo demand our attention. I have already ſtated their uſefulneſs in emptying the ſtomach and duodenum, when, in the courſe of the firſt period, theſe viſcera are ſickened, notwithſtanding every other application has been ſucceſsful. If the mercury, in ſhort, promotes the ſecretion of the bile from the liver, this favourable operation is immediately followed by a ſickneſs of the ſtomach, and then the emetic is neceſſary. (Vide caſe No. 7.) In many inſtances, the patients diſcover a great averſion to this remedy, and if they are of a delicate nervous conſtitution they frequently refuſe to take it. In ſuch caſes I employ an equivalent remedy, ſtrongly recommended by the ingenious Mr. Dubois de Rochefort, in his Materia Medica. He calls it un emetique cathartique en lavage. One grain of tartar emetic, or one grain and an half at moſt, is to be diſſolved, with half an ounce, or three drams, of ſalt of Glaubert, in about two pounds of water. The patient is to drink it by tumblers full every hour. This medicine is not nauſeous; it ſeldom excites vomitting; and it is always ſure to empty the ſtomach and bowels downwards. It is a general obſervation in practice, that the patient ſhould, in all acute diſorders, be prepared, by various depleting remedies, for all the ſubſequent operations. But we muſt cautiouſly avoid giving of pukes in the beginning of the yellow fever, and particularly ſo if a profuſe bleeding has not immediately preceded it. Indeed, the turgency of the arterial ſyſtem is then ſo great, that the convulſions of the ſtomach may have dreadful conſequences. I have frequently ſeen them followed with ſuch fatal accidents, that I think it my duty to mention the neceſſity of a cautious reſerveIt is a general cuſtom among practitioners, to preſcribe bliſters in deſperate caſes, and I have often been ſtrongly importuned to adminiſter them, by the nurſes and friends of the patients, whoſe hopes of their efficacy are ſincere, but who are unacquainted with their real conſequences. I ſhall not here enquire into the nature and extent of their utility, nor the method of their application. After referring to all that has been diſcovered and adopted in the treatment of the yellow fever, it muſt be allowed that they are abſolutely uſeleſs, and cannot anſwer the leaſt purpoſe in any period of the diſorder. As, therefore, there are ſuch numerous diſtreſſing circumſtances attending an unfortunate iſſue of the treatment of the yellow fever, humanity requires us to exclude this excrutiating application..

Admitting the above practical cautions to be adopted by thoſe phyſicians, who, with great propropriety, have choſen calomel and bleeding for the cure of the yellow fever, ſtill, gentlemen, if the patient labours under the complaints of diſeaſed viſcera and vitiated conſtitution, or if he has not made timely application for medical aſſiſtance, they are not ſufficient. Under this twofold conſideration, every impartial judge will make due allowances for the medical art in unfortunate caſes of death. It is too true, that, during the prevalence of a dreadful and contagious epidemic, confuſion and deſpair, ſecluſion from intercourſe, and erroneous opinions on the firſt ſymptoms of complaint, expoſe the patient to diſſident delays and improper meaſures; but experience and the warnings of phyſicians, ought to teach our fellow citizens the importance of an early application to medical aid, in the cure of one of the moſt malignant diſorders that ever was known among nations. In caſes where the diſeaſe would have gone through its periods in the ſhort ſpace of three days, one day loſt proved fatal. Thoſe alſo, in whom the malady was of longer continuance, and who remained unaſſiſted during the firſt days, found, alas! a ſimilar fate. Let no one, therefore, for his own ſake, be careleſs about any ſlight inſtance of complaint which he may experience during the prevalence of an epidemic; for, although various degrees of bilious or other complaints may appear, and though their mildneſs may have nothing common with the rapid and malignant effects of the former, yet, at the firſt call, the phyſican himſelf feels obliged to employ all the energy of his practice, notwithſtanding he ſees but partial and ſuſpicious ſymptoms. His ſeverity of judgment and preſcription, will not be attended with dangerous conſequences; but will happily prepare the proper treatment for any unexpected malignant caſe.

In order to illuſtrate the importance of an early application to phyſicians, during the ſeaſon which unfortunately creates all degrees of bilious, remittent, and malignant fevers in theſe climates, I ſhall familiarly relate an inſtructive inſtance of errors of judgment, in a caſe of apparently common and trifling indiſpoſition, and of the inutility of medical aid when applied for too late. Towards the cloſe of our late calamity, I was ſent for by the wife of an unfortunate huſband. From motives of the moſt unequivocal tenderneſs and affection, ſhe unhappily deprived him of ſuch timely aid as would undoubtedly have ſaved his life. "During four nights ſhe had not left his bedſide. Perſuaded that ſhe knew, by experience, his indiſpoſition, ſhe continued all this time to give him ſuch remedies as ſhe thought proper. She refuſed at firſt to admit me into his room; for the frequent viſits of phyſicians to infected houſes alarmed her very much. She ſaid that ſhe had been ſo ſecluded from any kind of intercourſe with others, that, thank God, the yellow fever had ſpared every one of her family. She obſerved, that ſhe had called me for ſome advice reſpecting the indiſpoſition of her dear huſband; but ſhe was happy to think, that there would not be much occaſion for medical aid; for, ſince ſhe had ſent her meſſage, he appeared to be on the point of recovery. He was up, walking about the room; and he intended, next day, to ride out to the country." This laſt circumſtance, ſtruck me with the apprehenſion that this was the laſt day of the life of the patient; and, that I might be better able to judge, I requeſted her to give me an account of his indiſpoſition from the beginning. "He was taken, ſhe replied, with a ſlight fever and puking, owing to a little intemperance on the preceding day; and his head ache and pain in the limbs, ſhe knew very well, proceeded from a violent cold, which ſhe always cured with ſweating tear. She had afterwards given him a few pills, which operated faithfully, and the pains and fever happily ſubſided. The patient had, laſt night, puked ſomething of a black colour; but ſhe did not wonder at it, as ſhe had previouſly complied with his wiſh of giving him ſome coffee and toaſted bread. He now felt very eaſy, though a little weak, which was of courſe; and ſhe could not expect him to be better. In ſhort, ſhe had attended and nurſed ſo many ſick, among friends and relations, that ſhe was ſufficiently acquainted with the neceſſary management and cautions!!" I cannot tell, after ſuch a recital, which ſtruck me moſt, the innocent confidence of the wife, her unſuſpecting ignorance, the irrevocable fate of her huſband, or the painful taſk which devolved upon me, of deſtroying ſo many erroneous opinions, and plunging, by one word, the whole family in the moſt unexpected diſtreſs. My ſilence was interrupted by the patient, who called us up, expreſſing ſome uneaſineſs and wiſhing to lie down again. His pulſe was ſmall, tenſe, and intermittent; and a black inſtead of a yellow hue was ſuffuſed all over his body. The confuſion of his look, was highly expreſſive of inſtant danger; and being ſuddenly taken with the moſt extreme weakneſs, he could hardly anſwer to but few of my queſtions. His wife was now ſeized with aſtoniſhment; and, taking advantage of the circumſtances of the moment, I retired with her from the preſence of an object who was every moment becoming a more deplorable proof of her blinded confidence—a victim of a culpable ſecurity— an object whom ſhe ſaw no more! But if this ſingular caſe, the error of which cannot be aſcribed to neglect, may appear rare; yet how many others have I ſeen, and how many deaths may be attributed to parſimony, indifference, and the want of timely medical aſſiſtance!

The laſt ſubject of practical caution, gentlemen, that has occurred to me in the treatment of the yellow fever, is ſtill more ſerious than the preceding ones, and of more certain fatal conſequences. In other acute diſorders, a phyſician may perhaps find out ſome means of relief, and calculate by them a ſucceſsful mode of treatment, notwithſtanding the patient may labour under previous complaints of diſeaſed viſcera or injured conſtitution; but in our epidemic there is no ſuch proſpect, or at leaſt it is very faint. During the two periods of its prevalence, I never met with an inſtance of recovery from it, when the whole frame had been materially injured by certain cauſes. A pulmonic affection, however, when not too far advanced, would not, I believe, readily preſent an obſtacle to the cure, as I have once ſeen exemplified; becauſe the proximate cauſe of our fever lies entirely in the bile and alimentary channel. But I ſhall always deſpair, at the firſt view, of thoſe who have conſiderable obſtructions or congeſtions in the liver, or who have unfortunately kept in their conſtitution any ſcorbutic t • int or remains of ſyphillitic contagion. On the dreadful effects of this laſt, in the malignant yellow fever, I ſhall preſent you a few important reflexions; and that they may be carefully contemplated by my young readers, is the philanthropic wiſh dictated by too many fatal inſtances. It has been evidently remarked, that the epidemic acted moſt ſeverely upon young and robuſt men, and that its victims were chiefly of that deſcription. This is a poſitive fact, the elucidation of which will not appear ſtrange, when it is remembered that it is not eaſy to get rid of the poiſon received in the embraces of proſtitution; that many methods for its cure are truly deceiving; that ſome noble viſcera may, by it, remain eſſentially diſeaſed; and that the blood, which contains its particles, will be ſooner and unavoidably contaminated by another contagion. The moſt favourable ſymptoms do not always juſtify the confidence either of the patient or phyſician; for we are unacquainted with all the changes and ſhapes of a malady which has been juſtly termed a Proteus or a CameleonVide Aſtruc on venereal diſeaſes.. We are daily taught by experience, that, by the ceſſation of one of its ſymptoms, we are not to judge of a perfect cure. It deceives us and the patient alſo; for it often lurks within the body, without diffuſing into the blood, or producing any mark of infection. Since there are external ſwellings and various ſorts of tumours which we attribute to the venereal lues, why ſhould we doubt but that they may exiſt internally, or within ſome noble glands? How often, indeed, the proſtrate gland remains ulcerated, ſwelled, and tumefied with exuberances, after the improper cure of a gonorrhoea, by ſtrong aſtringents, I leave thoſe to determine, who are acquainted with the precious enquiries of two famous ſurgeons on that ſubject, Petit of France, and Hunter of England. In theſe caſes it is very eaſy to appreciate, without further explanation, what will be the effects on the ſecretions of the urine, on the functions of the kidneys, and on the bowels. To ſuch internal and chronical cauſes, we muſt aſcribe the numerous obſtinate and long complaints, which baffle medical ſkill until their primitive cauſe is cured. Mania, hypocondria, epilepſy, and the long liſt of nervous complaints, may originate from the ſimple irregularity of ſecretion of urine into the kidneys; for a part of that fluid remaining in the blood, muſt afterwards affect the whole, or at leaſt a part of the frame. But ſuch circumſtances have a decided effect in acute, malignant, and contagious fevers. The violence of the firſt ſymptoms is an additional evil to the enweakened viſcera; for by it they are immediately brought to the brink of deſtruction. The ſtruggles, the exertions, and the efforts of nature, are then ſoon exhauſted; and if there is a ſcale of the natural degrees of health, of thoſe which may be depended on above it, and of thoſe under which the phenomena of life ceaſes, what proportion remains for medical expectation and ſkill, when ſuch complicated cauſes abſorb the whole balance of what is termed excitability by one, and what is thought to be the whole extent of natural laws by another? Were it not a point of delicacy, gentlemen, for a practitioner to produce reflections on complaints, that, according to the opinion of many, would blemiſh the memory of the dead, I would ſupport this diſcuſſion with the evidences of many caſes. May thoſe who are appriſed that youth and robuſt conſtitution have been ſo cruelly expoſed, to the deadly blows of the malignant ſcourge, bew • re of the enticements of proſtitution, and oppoſe them by the dictates of reaſon, religion, decency, and ſelf-preſervation.

SECTION V. General Means to prevent the Generation and Introduction of the Yellow Fever.

Two contrary opinions have appeared on the origin of the yellow fever, and have been officially tranſmitted to the executive, by medical bodies of Philadelphia. An attentive public, who know that truth cannot be contradictory, muſt doubtleſs feel deeply concerned; and will regret that, after repeated calamities, no unanimous improvement ſhould be made among the learned on ſo intereſting a ſubject. Under theſe circumſtances it becomes neceſſary, that, while meaſures are adopting to prevent its importation, the probability of its domeſtic generation ſhould not be forgotten. The public precautions ſhould not be founded ſolely on the particular opinions of either p • rty; and experience may hereafter afford us ſufficient and ſuch unexceptionable proof, as will leave room but for one opinion upon the ſubject. I do not, therefore, gentlemen, diſapprove of any meaſures that may be adopted to prevent the imp • rtation of the yellow fever; on the contrary you will diſcover that the above theory has a ſenſible advantage over the latter, for it alſo admits of all the neceſſary precautions againſt the effects of noxious exhalations from the holds of ſhips or veſſels arriving from tropical countries in the hot ſeaſon of the year. If we do not implicitly believe that this contagious epidemic is imported from one country to another, like the plague or the leproſy, ſtill we admit that it may poſſibly originate on board of ſhips during a long paſſage, which contain animal or vegetable ſubſtances in a ſtate of fermentation; that, raging contagiouſly among crews from tropical iſlands, when the remains of them come to mix with our citizens, it may ſpread its infection among them, and chiefly during the hot ſeaſon of the year; and that, infine, when a contagious diſtemper is known to rage in any part of the world, our intercourſe with it ſhould be cautions and ſubject to lawful controul. Thus far, therefore, we coincide in the meaſures of the implicit believers of local importation. We deſire, however, above every thing they have as yet ſuggeſted, to fix the obſervation of our fellow citizens on the domeſtic ſources of contagion to which they are expoſed. Theſe are ſelf-evident, and demand our moſt pointed attention. Why then are we taught to look upon them with indifference, and to confine our reſearches excluſively to the ſhip • and men that arrive in our harbours, from diſtant countries, which at leaſt h 〈…〉 conſiderably purified by the 〈…〉 of the ſeas?

In order to proceed regularly from the propoſitions I have above ſtated, I deduce the following means to prevent the introduction and generation of the yellow fever. "I have already proved, 1ſt. that it was generated by putrid effluvia from vegetable and animal fermentation; and 2dly, that the opinion of its importation could not be admitted excluſively to its ſpontaneous generation, in every warm country, from the above-mentioned cauſes." It of courſe follows, that to oppoſe the poſſibility of its importation, and of its breaking from corrupted cargoes, it would be expedient to remove ſuch ſhips from our ſhores as are loaded with colonial produce, at leaſt during the months of June, July, Auguſt, September, and October. The rule for admitting theſe articles ſhould be defined according to their good or corrupted ſtate, a few days after the ſhips have been unloaded. No intercourſe with their crews ſhould be permitted during five days after. But if a veſſel is ſuppoſed to contain corrupted miaſmata, and authenticated caſes of any kind of bilious fever ſhould be found on board, the ſick ought to be removed to a diſtant hoſpital, and the ſhip and company perform a quarantine of ten days.

As the outlines of the rep ••• of the committee of the legiſlature of this ſtate, during the preſent ſeſſion, are chiefly founded 〈◊〉 the belief of the foreign origin of the yellow fever, there is no doubt but ſuch efficacious meaſures will be adopted as will prevent the dangerous effects of corrupted cargoes and waters in the holds of ſhipping. I ſhall, therefore, confine my obſervations to an examination of the means which experience will hereafter dictate to be excluſively adopted againſt more threatening cauſes of contagion.

Philadelphia, ſituated on the weſt bank of the Delaware, and on the narroweſt ſpace between the Schuylkill and that river, may be wholly deſignated in the form of a parallelogram, the ſquares of which are interſected by wide croſs-ſtreets, which raiſe very little, in certain points, from the ſouth to the north, but which are open to all the winds, and to all the emanations of •• e ſurrounding fields, ponds, marſhes, and ſwamps. The conveniencies of foot ways, their cleanneſs, and the uniform practice of the inhabitants in frequently waſhing the outſide of their houſes, give to the city a ſingular appearance of regularity and neatneſs highly admired by foreigners. It contains, however, ſome capital defects; and too many unfavourable circumſtances concur to injure its ſalubrity. Water-ſtreet, thirty feet wide, extending from the northern liberties to Pine-ſtreet, parallel with the courſe of the Delaware, is in a confined low ſituation. Though the whole of its extent, it has but few vacancies, is compactly built, very diſagreeable, and is totally deprived of back yards on the ſide of Frount-ſtreet. The ſame is to be obſerved with reſpect to Penn-ſtreet. It likewiſe runs along the river from Pine to Cedar-ſtreet; and, in the late caſes of epidemic, both have been particularly marked as the firſt ſeat of the diſeaſe. The main height of the ground on which the city ſtands, is nearly forty feet above the Delaware. Many ſtreets are, however, lower; and, conſequently, the adjacent ground, intended for the continuation of the original plan, is in many places marſhy. Some parts of it contain large and de 〈…〉 and the • e ſtagnant waters are to be ſee 〈…〉 in almoſt all the points of the circumference of the city.

The general convenience of ſhipping to which Philadelphia is indebted for her rapid increaſ • of wealth and population, has rendered her whatever neceſſary. They are compoſed of made groun • formed by the means of log caſements filled with earth and ſtones; and they extend along the front of the city and ſuburbs to the diſtance of about two miles. As I ſhall, in the courſe of my obſervations, avert more particularly to this circumſtance, I ſhall now obſerve that they are elevated above the higheſt tides, ſo that at low water, their vertical ſides are expoſed, for near five feet, to the rays of the ſun. In the Northern Liberties and the diſtrict of Southwark, there are many vacancies on the banks of the river. Owing to the periodical floods, theſe form large miry grounds, which are never dry, but covered either with thick beds of filth from the adjoining ſtreets or habitations, or with rubbiſh, old timber, &c. Theſe ſources of exhalation are not of the moſt indifferent conſequence.

Our city is ſupplied with no running waters or fountains, and but few ciſterns are to be found in private houſes. Wells only are dug, in diſtributive number, in different parts of the city and ſuburbs. A pump is placed in each well, and water is thus eaſily obtained for all the wants of life. A gutter, formed by the elevation of the foot way, and by the gradual deſcent of the ſtreet to each ſide, ſeems ſufficient to receive and carry down the dropping waters. 〈◊〉 declivity of the ſtreets, in ſome places, however, is worn down; and the waters ſtagnate, more or leſs, in all the gutters. During the heat of ſummer, they receive the filth from the houſes, and become very noxious for want of being drained, and more eſpecially ſo, ſince they are daily reserved by the pumps. The inhabitants ſeem generally indifferent about theſe waters, becauſe they do not ſee but ſmall ponds of black and green water; but, as they are repeated, I am perſuated that they add much 〈◊〉 the quantity of putrid and 〈◊〉 wholeſome exhal •••• .

There are twenty-eight houſes for public worſhip in Philadelphia, and I believe as many grave-yards within the city and ſuburbs. It ſeems yet to be queſtioned whether they are really of a noxious nature or not. It is ſaid that, as the graves are uſually dug to the depth of ſix feet, the health of the citizens cannot be injured by them. Even admitting this obſervation to be true, yet, if dangerous vapours cannot immediately riſe from the grave-yards, by the effect of the heat, they may otherwiſe be diſengaged, by the hydraulick laws of ſubterraneous waters. For, ſuppoſing a grave-yard in a very elevated part of the city, as that of the Friends, at the corner of Arch and Fourth-ſtreets, which is beſides near five feet above the ſtreet, within a ſtony encloſure, it will be granted that the dead are on a level with many different parts of the city, and in ſome caſes even above it. Now, ſince it is acknowledged that the greateſt elevation of the city from the river is forty feet, and that many of the grave-yards are on the higheſt grounds, it will evidently appear, that the inhabitants living in a lower part of the city, will receive exhalations from the earth, of moiſture and waters that have been infiltrated through an elliptic plan and through a vaſt number of dead bodies. This obſervation will be found to agree with the hydraulick laws; for, according to them, in ſaturated grounds, evaporation collects the waters by infiltration from higher ſurrounding points in the ſame manner, that, to obtain water from the the higheſt parts, we dig for its evacuation at the lower ones. This explanation, gentlemen, will ſhew how the evaporations in moſt of the low parts of our city, are rendered noxious by the putrefaction of thouſands of dead bodies, and may be carried from one point to another, by means of the grave-yards being intermixed with our dwellings, beſides their immediate effect in altering the waters collected in our wells.

Laſtly, we have a more dangerous ſource of putrid animal exhalations, which is more ſenſibly diſcovered in thickly inhabited places after the heat, and at the cloſe of ſummer.

Each dwelling has a privy-houſe, ſituated at the fartheſt end of the yard; and the houſes on the eaſt ſide of Front-ſtreet have them in their cellars. The ditches upon which they ſtand, are dug to a conſiderable depth and built round with ſtones or bricks. Many of them are twenty fee • deep, but this circumſtance removes ſtill further the idea of cleaning them. After many years the fermentation cauſes offenſive vapours during the ſummer; and it is very ſeldom the caſe that the ditches are cleaned more than once in ten years, when it is often conſidered caſier to fill them with ſtones, and to dig others. The fact is, gentlemen, that towards the end of the ſummer, that is to ſay, after the action of the heat has ſufficiently excited fermentation, mephitic gas aſcends from the ditch. Our inhabitants are ſo well appriſed of this, that they always provide their little-houſes with a vent hole. This is a proof that the depth of the ditch is not a preſervative againſt its noxious vapours; for the rarefaction and the heat of our atmoſphere could raiſe them from a much more diſtant centre. The abſorption of the within contained fluids is ſo ſlow, in moiſt and impregnated grounds, that they wholly remain and ſerve to accumulate the maſs of fermentating animal ſubſtances. If a lighted candle be lowered into one of theſe ditches, by means of a line, it will often be put out; and when the temperature of autumn does not oppoſe the dilation of the aſcending gas, it is plentifully diffuſed round the houſes, yards, and alleys, where it is often ſenſibly ſmelt, chiefly when the air is calm and ſultry.

After the enumeration of ſo many cauſes and dangerous ſources of putrid exhalation, will not our minds, gentlemen, be impreſſed when the reflection of Dr. Lind, that, "next to infection, the moſt frequent cauſe of fevers is perhaps the offenſive and polluted air in unhealthy places;" and that our calamity, periodically breaking out, at a certain ſeaſon of the year, was not merely imported?

There are, in Philadelphia, many other ſources of putrid effluvia

There are ſeveral ſinks in Philadelphia, to receive the waters from the gutters, at thoſe points where a declivity can no longer be given to their beds. Two very remarkable ones at the corners of High and Fourth-ſtreets, were, during laſt ſummer and fall, productive of the moſt offenſive exhalations and became a mere nuiſance. It is very probable, that, by ſome defect or other, the waters in them were obſtructed; and I take the liberty to direct my requeſt to the proper authorities, to have theſe ſinks examined and repaired. As many cats were ſtarved, in conſequence of the deſertion of the city, there was, I am perſuaded, a quantity of carrion in them. Called out frequently during the night, I could ſtrongly perceive the ſmell as far as Arch-ſtreet on one ſide, and Cheſnut on the other. I employed ſome hours in following the current of exhalation, and was at laſt ſatisfied as to its true origin.

There were alſo ſeveral ſinks in Pear-ſtreet, in Cheſnut-ſtreet, at the corner of Dock and Walnut-ſtreets, and in other parts, the canals of which have been, I believe, deſtroyed, but the holes left open, and the people of the neighbouring houſes ſtill continue to throw their filth in them. I have been informed, by a very reſpectable citizen, that he obſerved, during the two inſtances of our calamity, that theſe vent-holes of putrefaction had been productive of a great number of death in their neighbourhoods.

, which perhaps are unavoidable, and are common to all other thickly inhabited places in the world, but which ought to attract the attention of our public authorities; ſince they are much more dangerous in a place expoſed to the heat of the tropical countries. For theſe, as well as for the preceding obſervations, I hardly think it neceſſary, gentlemen, to dwell much upon the direct meaſures that ſhould be adopted by the citizens at large, againſt the different cauſes of our epidemic. If they were not kept in a ſtate of incertitude, with reſpect to its real origin, their wiſdom and prudence would enable them to make the proper regulations. But alas! thoſe who are induced, after ſufficient contemplation, to predict that the fever will frequently rage again in Philadelphia, know how many opponents there are to this melancholy truth, and have very little hopes of obtaining a majority in favour of their advices. Yet, if I cannot flatter myſelf with gaining many proſelytes to my opinion, I conſider it as a duty and a pleaſure to throw my mite of information and firm belief, into the fluctuating ſcale of public opinion. Under the influence of this ſentiment, I aſſert, that the only ſure and efficacious means of preſerving Philadelphia from contagious malignant fevers, will be thoſe that are directly calculated to remove or deſtroy, if poſſible, the ſources of putrid exhalation from animal and vegetable ſubſtances that are contained within our precincts. Theſe means, gentlemen, are of ſuch a magnitude, th •• neither time or great expence would be able to effect them, if religious prejudices, views of mercantile intereſt, and opinions of party ſpirit, are ſuffered to thwart their execution. Before I attempt to enumerate them permit me to make a few reflexions more on the chymical principles and reſults of putrid exhalations.

Firſt, In whatever light we conſider the component parts of vapours and gaſſes, either according to the former or new nomenclature of chymiſtry, this much will be acknowledged, that life is oppoſed to the putrid fermentation of animal or vegetable ſubſtances; and that, as ſoon as they are deprived of it, they neceſſarily fall into a complete ſtate of putrefaction, which is more or leſs accelerated, according to the quantity of heat or caloric, of air and of water, in which they are immerſed.

2dly, As ſoon as the putrid fermentation takes place, a new combination ariſes of ſeveral ſubſtances, which have a peculiar tendency to unite to the air by the help of the heat, or to the water by their affinity to them; ſo that both fluids, being conſiderably altered in their nature, will preſent a quite contrary effect to that they would have exhibited at firſt, viz. the very air which was good for life and health, will produce a quite contrary effect, &c.

3dly, Among the different qualities of the ſubſtances diſengaged from animal fermentation, there are two very remarkable and which conſtitute all the degrees of noxious exh •• ations. The firſt is their extreme tendency unite with air and water, (Vide Diction. de Chimie, par Macquer, art. GAS); and the other is a certain degree of their development, which is impoſſible to account for, in which whether in a fluid or ſolid ſtate, their immediate contact with any living body, ſuddenly deſtroys or ſuſpends the phenomenon of life. A traveller found the body of a drowned man that had been waſhed on the ſhore by the flood. As he perceived no foetor, in examining the corpſe, he inadvertantly plunged his finger into a ſoft and putrified limb. From the finger the mortification was ſo rapid to the vitals, that he had no time to be aſſiſted, and he died. Anatomical diſſection has alſo proved the truth of this terrible and dangerous ſtate of putrefaction. Its various degrees muſt undoubtedly breed different kinds of diſeaſe and contagion.

4thly, Theſe exhalations are, moreover, ſubject to other laws and phenomena of nature, which ſometimes occaſion them to be harmleſs when they are moſt dreaded, or very noxious and fatal while they are not perceived or even thought of. Heat, without aqueous particles, raiſes them, and winds carry them through immenſe regions. They ſeem viſibly to be a kind of meteor; their operation on the body is terrible, and they in ſome meaſure deſtroy the vitals without any contagious or poiſonous effect. Such are thoſe remarkable winds and vapours, ſo well known in the deſerts of Africa, and which originate in the mountains of AbyſſiniaVide Bruse's Travels through Abyſſinia,. Heat, alſo, may dilate them to ſuch a degree that they become harmleſs. This is the caſe when it puts an end to the plague in the hotteſt countries of the earth. Aqueous vapours, without much heat, can diſengage but little of theſe exhalations, and it is then very common to perceive much foetor, without receiving any injury from it. Thus people attending the ſick, diſſecting of dead bodies, butchers, tanners, and all thoſe who are frequently among exhalations from animal fermentation, are not known to be injured at all. Thoſe exhalations which are ſuſpended above a corpſe, within a metallic or wooden coffin, do not want much heat or moiſture, to become fatal as ſoon as broken open. A mephitic gas then appears ſimilar to that which we diſcover in our chymical experiments. Its effects are ſudden againſt every living body; but it can be almoſt deſtroyed or rendered harmleſs, by aqueous vapours, and may be totally abſorbed by vegetables. This air or exhalation occaſioned the death of many citizens of Paris, who, in the month of Auguſt, 1792, were inſtantly killed by its contact, while they were breaking the tombs, to take away the leaden coffins, for materials of military ammunition.

5thly, Fevers, produced by exhalations are remarkably various, according to their places, time, and ſeaſon. What a ſtriking difference was there between the elephantiaſis of Athens, the plague of Marſeilles, the ſore-throat of Italy, and the ſweating ſickneſs of England? We could hardly find, in the preſent day, any pathological ſimilarity among the dreadful epidemics of Norway and Holland; the anomolous malignant obſerved by Hoffman in Germany, during the years 1727, 1728, and 1729; the intermittent ague of marſhy places; the camp diſſenteries; the hoſpital contagious petechiae; the convulſive malignant related by Dr. Chiſholm, which he thought had been imported from Guinea into the Weſt-Indies; the vomito pietro of the Spaniards in Vera Cruz; and the yellow fever of the tropical countries, &c.

6thly and laſtly, The concurrence of rains, ſtorms, and heat, are neceſſary to develope noxious exhalations from vegetable and animal fermentation. The conjectures reſulting from attentive obſervations are, that intenſe heat, without wind, after heavy rains and ſoutherly ſtorms, is moſt productive of noxious exhalations in places containing materials for vegetable and animal fermentation.

Theſe elementary laws, reſpecting the nature and effects of exhalations, I have, gentlemen, endeavoured to preſent, unaccompanied with any ſcientifical method, in order that every deſcription of my readers might become better acquainted with them, and finally apply the following means as the only preventives againſt the generation of the yellow fever

The committee of the houſe of repreſentatives of this ſtate, on the health laws, have, in their report, expreſſed themſelves in the following terms.

"Although your committee are decidedly of opinion, after the moſt attentive inveſtigation, that the diſeaſe which ravaged this city and its ſuburbs, in the year 1793 and the late autumn, was of foreign origin, they nevertheleſs believe that there exiſted at thoſe periods a certain condition of the atmoſphere which ſavoured its propagation, and without which it could not have been tranſmitted to any a •••• ing extent. It being a deſideratum, that ſuch a ſtate of air ſhould be counteracted, which affords nouriſhment to contagion, they cannot too ſtrongly inculcate the neceſſity of a ſupply of pure water to the city, and of the ſtricteſt attention to ſuch regulations as will keep it and its environs free from putrefactive ſubſtances."

I am happy to think that the above certain condition of the atmoſphere, to which the alarming extent of our diſeaſe has been aſcribed, and which has not been explained by the rep ••••• , may be fully underſtood, by the means of elementary chymical obſervation; and thoſe who are decidedly of opinion, that they yellow fever is of foreign origin, ſhould not forget that, in this age, there is no certain noxious condition of the atmoſphere, but has been ſubmitted to the moſt attentive chymical inveſtigation and analyſis. This much, however, may be aſſerted, that the deſideratum to counteract an unhealthy ſtate of the air, by rendering it free from putrefaction, perfectly coincides with our theory, obſervations, and general propoſed means of preventing the generation of the yellow fever.

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GENERAL MEANS.

1ſt, The removal of all grave-yards to many miles diſtant from the city and ſuburbs.

2dly, The ſpeedy accompliſhment of the advice of Dr. Franklin, to obtain freſh and running waters in the main parts of the city; and a police law enacted, ordering all the gutters to be waſhed once a week, during four months of the hot ſeaſon.

3dly, Stone wharves; and their owners obliged to cover them once a year with a coat of tar. The vacancies on the banks of the river, within the city and ſuburbs, to be overſpread with a bead of gravel.

4thly, A police law for the clearing of privy ditches, once every winter, and obliging the owners to throw in ſo many buſhels of lime, according to their diameter, in the beginning of the ſummer.

5thly, Gutters, ſinks, cellars, market-ſtalls, tanner's and butcher's yards, to be ordered under the inſpection of commiſſioners and phyſicians, during the ſix months of ſummer and autumn.

6thly, Veſſels from the Weſt-India iſlands, and other tropical countries, ſubject to an inſpection of their cargoes and holds, unloaded at a diſtance from the city; kept with their crews, under a quarantine of five days, during the four months of June, July, Auguſt, and September, and a longer time according to the wholeſomeneſs of the ſhips and health of the men.

SECTION VI. Particular Preventives againſt the Yellow Fever.

THIS ſection, gentlemen, I would conſider as the leaſt uſeful of my eſſay, if any of my readers expected to find in it ſecret receipts or infallible remedies, and if they believed that I thought my advices, joined to thoſe of the moſt eminent phyſicians, ſufficient to render them invulnerable to one of the moſt rapid and ferocious diſorders. Where is the art that can indubitably face danger, can always elude its ſtrokes, or reſiſt its efforts, whether in battles or in any kind of human infirmities? Alas! when the beſt preventives have been made uſe of, and the mode of living rendered ſcrupulouſly cautious, ſtill there are many chances of infection againſt one of preſervation; becauſe the attendants of the ſick, as well as thoſe citizens who are detained in town by the neceſſary purſuits of buſineſs, are expoſed to the fatigue, the anxiety of mind, and all the other inconveniencies attending a general calamity, and, under ſuch circumſtances, it is not always in human power, totally to avoid the means of infection. Thus we have been ſeen many of our phyſicians, who, during the late calamity, were among the foremoſt in attending on the ſick, become the victims of its ravages! Their names and memories deſerve the tribute of honour and of gratitude

The following are the names of the phyſicians, who, in diſcharging their profeſſional duties, fell victims to the yellow fever.

Doctors WAY, THOMPSON, JONES, PLEASANTS, DOBELL, ANAN, HUNT, and CLARKE, lately from Ireland.

. To us, gentlemen, they have given a noble example. Let us then ſhed a tear upon their tombs; and, like them, pledge ourſelves as the friends of humanity.

Phyſicians and others who firſt ſuſpected the domeſtic origin of our fever, adviſed their fellow citizens to remove to the country. However efficacious this meaſure was to thoſe who could afford the expences attending it, what diſtreſs did it not produce among the labouring claſs of our citizens, to the public functionaries, and to thoſe whom public or private concerns retained at the theatre of the calamity! By deſertion, indeed, the laſt prevalence was rendered more afflictive than that of 1793, although it was not ſo extenſive in its ravages; and it will always be my wiſh, that, during ſuch a period, we may experience leſs of that ruinous and unexpected diſperſion of our citizens. When this is the caſe, there is no kind of diſtreſs to which our patients are not expoſed. Inſtances, likewiſe, were known of malignant caſes and of deaths among the fugitives. A mortal infection was thus propagated in ſeveral ſurrounding country places, for how could they eſcape the neceſſary communications and intercourſe? In European places expoſed to peſtilential diſeaſes, it is a ſupreme law, that, during their prevalence, the inhabitants are not ſuffered to quit their places of abode. Far be it from me to wiſh for ſuch an inhoſpitable meaſure. It is only mentioned to ſuggeſt, that it is a queſtion whether more good than evil would not ariſe to the community at large, if, free from terror, aſſiſted by proper and efficacious meaſures, encouraged by numerous inſtances of preſervation in town and recovery among the patients, they could be perſuaded to ſee the ſhort period of an epidemic ſpent, unaccompanied with the tenfold calamities and misfortunes of deſertion.

However rapid the effects of an exiſting contagion may be upon healthy people, we can derive from our ſtated principles, three powerful motives of confidence and ſecurity. The firſt reſults from the nature and operation of the contagion on the bile only; the ſecond, from the poſſible removal of the ſick from numerous families, or an abſolute ceſſation of intercourſe with them; and the laſt from efficaciouſly experienced cautions even in caſes of the neareſt danger.

I. The yellow fever, we have already ſaid, is merely a bilious one of the moſt malignant degree. Its operations and ſymptoms are wholly upon and from the bile. Our inhabitants are particularly ſubject to bilious complaints in a certain ſeaſon of the year, and when the laſt are endemics, the former will turn out to be an epidemic of the ſevereſt kind.

We have ſeen alſo that bilious and yellow fevers commonly fell upon thoſe in whom the bile was of a thick or vitiated nature, and who, by habitual neglect, intemperance, or other unhealthy mode of living, expoſed that ſecretion to a ſtate of ſtagnancy and corruption. Such ſimple and reaſonable given obſervations ſhould help us to fix upon a ſucceſsful method of diet, of remedies, and of cautions, during the perilous prevalence of the yellow fever. At ſuch a period, a vegetable diet will be a ſure preventive againſt animal corruption; and animal food of the lighteſt kind, being always ſufficient for neceſſary nutriment, if preferred to heavy and groſs meats, will not excite ſo great a fermentation of the animal fluids. Simple tonic drinks, meaſured according to the wanted digeſtive power, will preſerve us from thoſe inflammatory and heated motions of circulation which always attend the face and feelings of drinkers of ſtrong wines and ſpiritous liquors, which is an obſtacle to the formation and ſecretion of liquid and pure bile. But it may be ſaid, that ſuch a plan of diet would not be ſufficient, during the exhauſting heat of the weather and the neceſſary fatigues of life, and particularly ſo at a time when the body ſeems to want more ſtimulating means to raiſe the lowneſs of our ſtrength and ſpirits. This, gentlemen, is true, and this feeling is powerful; but we ought not to ſuffer our habits or miſinformation, to make us miſtake the proper means. I have been frequently more animated and refreſhed by a warm bath, during the heat of ſummer, by an airing in the country, or by a cooling medicine, than I could poſſibly be by the moſt ſucculent cordial. In fact, we may compare our body, charged with ſo many ſpringy actions, to a bow, the elaſtic power of which would be loſt if it was ſtiffened by the effect of a drying fire, but which would be better preſerved if kept in a ſoft and moiſt temperature. Beſides, when we feel very weak, it is often becauſe the vis vitae, elevated to an uncommon degree above the point of health, approaches to its end, the ſame as when it is too low; and then relaxing means are proper, ſalutary, and ſucceſsful. It is obſerved that we never more frequently experience the effects of weakneſs, brought on by the heat of our fluids, than in the ſummer. At this ſeaſon, we are peculiarly expoſed to obſtructions in the alimententary channel, crudities of the ſtomach, and ceſſations of daily evacuations. This laſt effect is unavoidable, even among the moſt regular conſtitutions; but evacuating medicines oppoſe to it an infallible power. A puke or a draſtic never fails in removing thoſe crudities or obſtructions; and, if they are mercurial or antimonial, they will more properly diſcuſs the reſervoirs of the bile, and renew that animal fluid, the fermentation of which becomes ſo dangerous. I had frequent opportunities, during the two prevalences of the yellow fever, to give this advice to people, who appeared to enjoy a regular degree of health. A ſlight indiſpoſition, which could hardly call for their attention, at another time, was then a ſufficient motive for applying to cautious meaſures. I never heſitated, when the ſubject could bear it, to preſcribe a puke at firſt, and a mercurial draſtic after. In this manner, and with much ſurpriſe, I timely delivered many of them of a prodigious quantity of unnatural, black corrupted bile, from which a dangerous fit of ſickneſs would undoubtedly have originated. (Vide caſe No. II.) Yet they afterwards lived healthy, notwithſtanding the heat of the ſeaſon and the prevalence of the contagion. It is, in fine, a neceſſary caution, repeatedly to have recourſe to ſuch medical aſſiſtance; for it is acknowledged, both by phyſicians and others, that repeated caſes of infection may occur.

Frequent walks and airings, chiefly during the cool moiſture of the morning and evening, taken to ſome diſtant places from our ſultry dwellings, will be another ſalutary practice. It interrupts the action of the exiſting exhalations, and refreſhes us by the help of a purer and more elaſtic atmoſphere. It alſo aſſiſts the functions that are the moſt endangered, and frequently breaks the courſe of annual and accidental diſeaſes. In moſt of the cities of Europe, where the ſtreets are irregular, a long experience has ſhewn, that the moſt eſſential cauſes of their ſalubrity are, pure waters and public walks •• and every means, both natural and artificial, has been employed to render the latter delightful. Faſhion, in this point, has been invariably adhered to; and though public walks may be the theatre of a ſhewy ſtyle of dreſs and manners, or of idle talks and interviews, yet they notwithſtanding remain a cheap means of exerciſe, whereby health is preſerved and diſeaſes diſpelled. Sedentary life, long ſittings in religious meetings, ſecluſion of one ſociety from another, protracted clubs for various kinds of entertainment, for politics, for intereſt, and numerous and ſtrictly faſhionable tea-parties, are manners and cuſtoms particularly obſerved among the citizens of our metropolis. Can I then, gentlemen, be blamed, when I affirm, that, medically ſpeaking, they have a contrary tendency to that of exerciſe, taken in a pure air, and a far different effect to thoſe of lively manners and more recreative life?

II. Another motive of ſecurity for the citizens at large, during the prevalence of a contagious epidemic, would be, I have already ſaid, the removal of the ſick, or an abſolute ceſſation of intercourſe with them. This meaſure, during the late calamity, was ordered by a proclamation from our governor. He was blamed by many who thought only of the inconveniences ariſing, in its execution, to the ſick, who were reluctant to leave their homes and their choſen attendants; and the frequent inſtances of miſtaken caſes was another cauſe of their diſapprobation of the meaſure. This oppoſition prevailed to ſuch a degree, that many obſtinately remained ſecluded in their own houſes, died there, and their bodies were afterwards ſecretly carried to the diſtant graveyard of the Wigwam hoſpital. Theſe inconveniencies cannot be denied, but the efficacious and vigilant meaſures of authority might at laſt conquer them. The idea that they are a violation of the rights of humanity and of perſonal liberty, may be oppoſed by good argument • Public ſafety, and a care for the health and lives of the community at large, have often commanded ſtill more ſevere meaſures. At this preſent time, if a perſon who is performing a quarantine on board of a ſhip or in the lazaretto at Marſcilles, is detected in violating the limits of his confinement, the centinel has orders to kill him inſtantly, and yet this meaſure has been dictated by the voice of humanity.

Another argument will enforce the neceſſity of reſtraining perſonal liberty in caſes of contagion. It is the cuſtomary right by which the neighbouring ſtates exclude us from the uſual intercourſe with them. The time may come, which heaven forbid, when the contagious power of this epidemic, may ſuggeſt to neighbouring diſtricts the neceſſity of a temporary ſecluſion, and particularly ſo, if ſevere regulations are not adopted among ourſelves. Will it then appear inhumane, if we ourſelves are obliged to forbid any communication with the ſick, their houſes, and the ſtreets in which they are ſituated? The diſtreſſes of this ſevere meaſure would, no doubt, be ſoftened, if ſeveral hoſpitals were fitted up, and a choice left to the patients of their own attendants. They could be thus ſupplied with more private accommodations at their own expence, while the poor and forlorn would be taken into thoſe public houſes which have been already ſufficiently well regulated and ſupplied with every neceſſary by the vigilant care, and generous donations of our citizens, during our paſt calamities. Infine, if theſe general meaſures are never adopted, we ſhould at leaſt be cautious to ſuſpend any intercourſe with the infected houſes and ſtreets, although it will be moſtly too late when the contagion has been ſuffered to ſpread. Patriotiſm and candour, both of phyſicians and citizens, would ſoon aſcertain the preſence of the ſcourge. The miſtakes of an iſolated judgment may be obviated by previous appointment of many phyſicians to viſit and conſult upon each new caſe and patient. During the laſt prevalence, the public were cautioned that many deaths were aſcribed to the yellow fever, ſome weeks before they would believe it; but they ſoon acknowledged that they received proper and timely information, owing to the attention of well known phyſicians. This is an unqueſtionable reſult from what we have ſtated of the nature and operation of putrid exhalations, that as ſoon as their firſt effects are diſcovered, in the early ſtage of the ſeaſon, we might think it in our power to be prepared againſt ſubſequently created caſes, and againſt the contagion from bodies. Theſe are known to emit, in caſes of death, almoſt none, and to become dangerous only in the laſt periods of the ſickneſs when they recover.

III. There are other meaſures which experience has proved extremely ſucceſsful for preſerving even thoſe who are obliged to remain in infected places. It has been officially reported to the governor, that, in the hoſpitals, during the late prevalence, the contagion had not ſpread among the attendants. This would be incredible were we not appriſed of the reſerves and cautions that are naturally made uſe of, invented, and dictated by neceſſity when it becomes the ſupreme law. The origin of the famous vinegar of four thieves, ſo much recommended as a preventive againſt the plague, is a proof of that beneficial induſtry, and I never found better or more medical means employed with ſucceſs, than among thoſe who do not heſitate to exchange many chances of danger againſt a valuable compenſation. Yet all their induſtry is aſſiſted with nothing elſe than what is in the power of every one. Reſuming, my enquiries, and the effects of their general method, I found three reſults from taking various medicines and from diet. One is, that they reduced the ſyſtem, and abated, conſequently, any diſpoſition to inflammatory or phlogiſtic diatheſis; the ſecond, that they kept themſelves in a continual ſtate of evacuation, and thus were never ſufficiently acted upon by the contagious miaſmata; and the laſt, that they renewed the bile and rendered it more pure, more fluid, and of a quite contrary ſtate to that which conſtitutes a bilious malignancy. Theſe three rules or indications are equal to any that the medical art can ſuggeſt and preſcribe; and, as far as they could be well underſtood by individuals, and anſwered to by eaſy means, they would, I believe, moſtly render the contagion harmleſs to healthy people, and juſtify a very frequent uſe of warm baths, previous bleedings, and the occaſional adminiſtration of pukes and mercurial draſtics, ſuch as we employ in the treatment of our patients.

Some of my readers would, perhaps, here wiſh to be informed, as well as in every other medical work, what peculiar doſes, powders, or pills, and the quantity adminiſtered, ſhould be particularly employed as preventives againſt the yellow fever. I do not wiſh to make a ſecret of the moſt minute circumſtances for the proper uſe of bleedings, pukes, and mercurial draſtics, but I have already ſaid enough upon that ſubject. A ſtill more uſeful piece of advice ſhall here be given, viz. that it is not by ſaturation or quantity only that medicines are rendered efficacious, nor without thoſe proportions and modification, which the various conſtitutions of different patients require, and of which phyſicians can be the only proper judges. I conſequently prefer that preventive medicines ſhould always be prepared according to what is requiſite for each conſtitution and by the previous indiſpoſition of body. The moſt impoſing name, affixed to a pill or powder, will • make it better, if given and employed without any neceſſary reſtriction whatever, but would, on the contrary, cover great blunders and miſtakes. Such is the caſe of thoſe patent medicines, which, in the immenſe catalogue of their virtual properties, include all the ſeries of human infirmities, but which are at laſt given up as dangerous or equivocal remedies. To their patrons, however, I am willing to grant, that, if it was poſſible to aſcertain above what point they are variouſly noxious, before any obtained ſucceſs, and under which proportion they would fail or become uſeleſs, they would not be thought a great nuiſance among the credulous, whatever power they may be poſſeſſed of.

The attendants of the ſick ſhould always be attentive to keep a fire in the patient's room, although the warm weather might render it uncomfortable. This I conſider as a powerful mean for purifying and renewing the incloſed air, which is inſtantly abſorbed with any morbid exhalation. The phenomenon of fire, cannot take place but by an immenſe conſumption of air, and it thus becomes a drawing ventilator. This meaſure not only deſtroys any floating contagion for the benefit of the attendants, but I have obſerved it to be very uſeful to the patient, whoſe body ſhould not be immerſed in its own infectious emanations, and who cannot yet bear to be expoſed to the variable external temperature. Infine, by the means of fire, a ſalutary and fragrant ſteam can be immediately procured, in the critical moment of foetid and dangerous evacuations.

Various means have been alſo recommended as preventives by expanding round ourſelves volatile and chymical ſubſtances to neutraliſe, as it were, the putrid miaſmata. Although this method is very uncertain, yet much benefit may be obtained when the current of an artificial vapour breaks or alters a contagious one. Theſe means, however, too often act unfavourably towards the conſtitution, and have a tendency to enweaken the nerves, while it is highly requiſite that the body be kept in the very point of health. Every one knows, in this reſpect, the effects of camphor and of muſk. The aromatics have a contrary and better effect, becauſe they are equally tonics and antiſceptics. We ſhould, therefore, conſtantly make uſe of their eſſential oils, of their artificial perfumes, and of the fragrancy of their plants. I have ſeen alſo the ſtrongeſt vinegar generally uſed againſt peſtilential emanations, and its ebullition with ſugar upon red hot iron, produces an agreeable and ſalutary vapour.

Much has been ſaid upon the ſubject of deſtroying or waſhing with caution the clothes and beds of the ſick. None, I believe, are more infectious than thoſe of a recovered patient. I have collected, on that ſcore, the moſt ſatisfactory proofs, that a patient may be even reinfected in his own bed and clothes; and this is undoubtedly the origin of thoſe ſtrange caſes, the ſtages of which run through a longer courſe, and repeated recoveries and relaxes, which is quite contrary to the known periods of a malignant fever. it is perhaps uſeleſs and even inconvenient frequently to trouble a patient by giving him the comfort of freſh, clean, warm clothes, but it is abſolutely neceſſary to do ſo as ſoon as a profuſe perſpiration has marked the end or a favourable criſis of the malady. If the care of the infected linen is left entirely to the nurſes and ſervants, they muſt be directed to fold them immediately, and to throw them into cold water, where they ſhould be kept for twenty-four hours, covered with aſhes to be filtrated into lie, with which they muſt be waſhed. The ſame care ſhould be extended to the beds. At leaſt they ſhould not be uſed again but after repeated night and morning airings. Infine, the attendants ſhould be careful to promote in themſelves a a conſtant ſpitting, and to avoid, as much as poſſible, ſwallowing the ſaliva. But let it be remembered, that, with theſe general cautions, and many more too tedious to be related, at the cloſe of the ſeventh day, the convaleſcent patient can no longer tranſmit any contagion. His recovering ſtate, is a proof of the purity of his blood. How diſtreſſing, therefore, would it be, under a falſe idea of danger, ſtill to continue our intercourſe with him with reſerve and caution, when it is no longer neceſſary. He has been already too long obliged to conſider himſelf as an object of terror and dereliction. To what a perilous deſpondency has he not been delivered by fugitive friends and relations! To what afflictive ſolitude has he not been condemned, while excruciated by a devouring poiſon! The arm of Providence could alone help him from under the two fold preſſure of his body and of his mind! The former may counteract the laws of life as ſoon and as irrevocably as the latter! And ye attendants of the ſick, if a liberal and philanthropic mind ennobles your cares and ſervices to your fellow beings; if you are not ſtrangers to a moral ſympathy—to the ſupreme maxim of doing to others as you would be done by; and if it is your pride not to value your dangerous taſk by pecuniary compenſations, you deſerve protection from heaven and reſpect from your fellow citizens. But ſuch a meritorious claim is loſt by mere mercenary ſervices, which become baneful to unfortunate patients whom your expreſſed terrors and affected impatience, loudly beſpeak as objects of horror in the creation. Deſpair, abſolute deſpondency, and depreſſion of ſpirits, will ſoon ſubdue the ſmall ſhare of organic ſtrength left to them in this ferocious diſorder. Their fate is in your hands, more than in medical ſkill, if charitable cares, hopeful words, and apparent confidence, are not continually and ingeniouſly offered, as the moſt ſuceſsful comfort that will help, both the power of nature, and the wiſdom of phyſicians.

SECTION VII.

CONCLUSION. GENTLEMEN,

I WOULD, perhaps, deſerve the reproach of having aſſumed too great and bold a confidence, if I now ſhould omit earneſtly to ſolicit your indulgence and that of the public The ſubject I have treated, requires undoubtedly longer inveſtigations and many more of thoſe qualifications which are acceſſary to a writer. It is true, the language to which I was obliged to entruſt my obſervations, which never was that of my youth nor of habitude, could not be but a rugged and difficult road, where I ought to have feared to entangle my reader. To ſuch a conſideration, I had ſurely ſacrificed my emulation and my attempt, had I not been much more impreſſed upon with the duty of joining what I could of my views to all thoſe from which the whole nation expect to derive ſome relief againſt ſo great a calamity. Truth could never be attained, if diſcuſſions from various ſides and opinions were not alike inſtituted by free and liberal communications. The public claims, as it were, that every one ſhould be liſtened to who thinks that he can contribute to the common welfare. It is of no importance if the learned are divided among themſelves, it always is and always will be ſo, until the truth comes out. There are beſides principles or opinions which are not to be excluſively for the learned, whatever may be their conteſt and ſyſtems. On the contrary, if theſe opinions are good and ſafe, they ſpread and propagate among the people at large, becauſe there is much reaſon and good ſenſe, and no party ſpirit among the people. This is the cauſe why it has happened ſo often that the public have adopted ſound and definitive opinions, while the learned had not yet ſettled their own variances. J. James Rouſſeau reports, that a peaſant of Sileſia had the honour of ſettling a great and ſerious ſcientifical conteſt among the learned in Germany, who could not agree, or explain, in the ſame way, how a child could be born with a golden tooth!! He firſt thought it neceſſary to eſtabliſh the fact, and this he took the trouble upon himſelf to do, which he proved to be a falſhood.

Far be it from me, gentlemen, by relating this fact, to throw out any alluſion againſt phyſicians of this city, with whom, I am not ſo happy as to agree in opinion, on ſeveral of the above ſubjects; it will be ſufficient, perhaps, to declare that I profeſs the greateſt reſpect for many of them; but there are many inſtances to prove, that, in matters of fact and reaſon, the tribunal of the public opinion will, at laſt, be the beſt judge. It was thus in Marſeillies in the year 1720. While the plague was rapidly ſpreading and raging, phyſicians and ſurgeons publicly declared, that the prevailing diſeaſe was not the plague, nor even contagious; and the famous Dr. Aſtruc had to contend againſt all of them, until the fact and the public proclaimed the plague. Unfortunately, Philadelphia will be expoſed to the dreadful experience of more facts, and then the public will decide againſt all the alledged authorities and ſyſtems. Thus to the public, as a fellow citizen, I thought it my duty, to fulfil this taſk, and to you, gentlemen, as a phyſician, to preſent my inveſtigations and experience. Beſides, if every man be indebted to the country and community to which he chooſes to belong, it is my peculiar ſatisfaction in being enabled to pay this tribute of gratitude to the citzens of Philadelphia. On theſe motives, therefore, I ground my claim for the indulgence I ſolicit for this publication; and, however imperfect it may appear, in the extent, diſcernment, and foreign dreſs of my obſervations, if, among the poſſible ſarcaſms of criticiſm, no kind of merit would be beſtowed on my work, ſtill it will remain as a proof of labour and philanthrophy; the one is the virtue of a citizen, and the other the character of a phyſician.

POSTSCRIPT.

IT has been without reference to anotomical or phyſiological diſcuſſions that I have explained the proximate cauſe of ſeveral ſymptoms and of the jaundice in the yellow fever, by the immediate paſſage of the infected bile into the blood from the pori biliarii into the vena cava, or at laſt by the ſimple and immediate abſorption of the bile into the lymphatic veſſels, which exiſt in that viſcera as numerous as in many others, when it is ſtopped or obſtructed in its excretory ducts. I was led to that indifference by contemplating that each theory reſuming the ſame reſult of the admiſſion of the bile in all our fluids, it was unneceſſary to ſtate by what proceſs it had taken place. Another argument alſo ſtruck me in this acute diſorder, as well as in many others, in which the jaundice is frequently an attending ſymptoms or a criſis, although I have not mentioned it in any of the above reflections. Each of our ſecretions have more than one object of neceſſary operation to fulfil for the animal economy. Thus it can be ſaid, that the ſimple perſpiration of the ſkin, while evacuating a ſuperfluous fluid, waſhes and opens the pores. The ſecretion of urine not only filtrates and reduces the blood to its proper degree of fluidity, but it is a vehicle intended to carry off any heterogenous ſubſtance admitted into it. The bile, prepared in the liver, beſides being a neceſſary liquor in the digeſtion, will be the means of diſcharging from the blood thoſe elementary ſubſtances which were created and added to it by the chylification. But, if the bile originally received its component parts from the blood, we muſt ſuppoſe that as ſoon as its ſecretion is interrupted, the blood will retain all thoſe component parts; they will then gradually increaſe to ſuch a quantity that they will be by another law emitted in the receſſes of the circulation, and there form the jaundice. Therefore, in any theory we may admit three origins of icterus; one by the infuſion of the bile already formed, and poured from its excretory ducts into the laſt ramifications of the vena cava; another by the abſorbing lymphatic veſſels; and a laſt, by the biliary component parts retained and remaining in the blood whenever that ſecretion cannot take place. Other circumſtances enforce the poſſibility of this laſt means of jaundice, when we conſider how many cauſes may retard the circulation of the blood in the vena portarum, in conſequence of ſome inflammation or morbid action within the abdomen, where are ſituated all the branches that form its trunk. It is alſo admitted, that, in warm countries, the powers of circulation are much enweakened, by which means the large veſſels may be diſtended, and the bile not ſufficiently renewed or diluted. Hence ariſe bilious diſorders and bilious evacuations, &c. Such are the general grounds by which I ever thought that ſeveral ſymptoms as well as the jaundice in the yellow fever, might equally be underſtood in any of the above theories; but, I have ſince had the opportunity of conſidering a very ſolid objection againſt a preſumed cauſe of the jaundice in the yellow fever, admitting that, by obſervation and ſatisfactory experiments, it has been proved, that, in caſe of ſtoppage or obſtruction, the bile is ſooner, eaſier, and even immediately reſumed by the lymphatic veſſels, inſtead of the veins. This abſorption, it is ſaid, cannot originate but with a ſtoppage of the bile in its excretory ducts, or with an obſtruction in the liver; yet neither are found by diſſection or ſymptoms, in caſes of the yellow fever. Its jaundice, therefore, conſtitutes no ſimilarity with any other kind of remittent fever or bilious diſorder; and it is yet a problematic ſubject and a morbus ſui generis. This objection, I muſt own, came to me from a reſpectable quarter, and is connected with ſo many other authorities of facts and opinions, that it indiſpenſably demanded a ſerious conſideration of the ſubject, in order either to correct my pointed errors, or to balance the argument by ſatisfactory reaſons. In the mean time, to my medical reader it will obviouſly appear, that, my only motive for this controverſy, is from a conſiſtency and adherence to the chief opinions of the ſubject upon which I have treated. Thus it will be ſtated,

Firſt, as a general view, that the formation of jaundice in any caſe of the only ceſſation of proper ſecretion of bile, acknowledges ſo many probable cauſes, different from any ſort of obſtruction in the liver, that it could not be confined to the theory of the abſorption of lymphatic veſſels. We ſee the poſſibility of an inflammatory and morbid action in the abdomen from the inteſtines or the ſtomach, and from the diaphragm, immediately diſtending or obſtructing the blood in the numerous branches of the vena porta, and ſuſpending the circulation in that large veſſel, more probably ſo when we conſider that this heavy column of blood muſt be aſſiſted in its courſe, by all the ſurrounding motions and vibrations. Now, it will always be ſafe to conclude, that, if the blood does not ſecrete in the liver, and particularly ſo in acute fevers, the principal character of which is a diſturbed circulation, it will keep the bilious component matter, which it ſhould loſe, in the liver, and from that muſt ariſe an accidental icterus. But it is objected, that, even in this caſe, bile ſhould be left in the blood, as it finds its elements in the liver. I deny that however, and very confidently, until it ſhall be proved that water could be obtained without oxygen or hydrogen; or that in any of our glands there is an inexhauſtible quantity of the component parts of oils, acids, ſalts, water, &c.

Secondly, The poſſible and immediate infuſion of the bile from the pori biliarii into the minuteſt ramifications of veins and arteries, is by no means improbable or impoſſible, although it is granted that their lymphatic branches (as they appear to be) do not belong to the abſorbent ſyſtem; for injections have been made, with ſucceſs, from the hepatic dact into the vena cava and vena porta. But nothing could better prove, this immediate infuſion of bile into the blood, than frequent caſes of ſudden jaundice, by a wound on the head, by too great haemorrhages and profuſe bleedings, by a fit of paſſion or anger, and alſo by the effect of ſtrong and acrid medicines. It occurs very often alſo in practice, among ordinary and quite contrary caſes to any kind of hepatitis, when we find, chiefly towards the end, the eyes of our patients very yellow. This is a certain degree of jaundice; yet it could not take place in conſequence of obſtructions, nor by the minute proceſs of all the windings of the abſorbent ſyſtemSome anatomiſts contend that nothing is more rapid in the circulation, than the abſorption of the lacteal veſſels and lymphatic veins. This I grant; but what will be ſaid if the fluid expoſed to abſurption becomes thick and tough?. The bile has, therefore, been immediately ſqueezed and poured into blood veſſels.

Thirdly, Were the abſorbent power of the lymphatic veins the only means and cauſe of jaundice, it could not certainly proceed but by ſuch ſtoppages and obſtructions as after a while would force and open the valves of the mouth of the ſaid lymphatic veins; for, in any other ſtate, the abſorption of the bile could not be affected, as is proved by our uſual ſtate of health. But we ſee the contrary in the yellow fever; no previous ſymptoms induced us to ſuppoſe the formation of an obſtruction. Spontaneous and profuſe evacuations of bile, and a great quantity of it acrid, always diffuſed all along the alimentary channel, ſeems to prove, that the uſual excretory ducts are opened, and that the only quality of the bile is altered. Let us, then, turn the argument in another manner. There is no obſtruction of the liver nor ſtoppage of the bile in the yellow fever, yet the jaundice regularly takes place; this muſt, therefore, proceed from ſome other poſſible means of jaundice.

Fourthly, Is there no other ſtate in the conglomerate glands, but that of obſtruction, that can diſturb the ſecretions and then expoſe their fluids to the effects of the abſorbent ſyſtem? Are they not ſubject alſo to a quite contrary ſtate, to that of atrophy? Although we cannot preciſely account for their mechanical functions, muſt we not ſuppoſe, that, what we call an obſtruction, when we ſee a hard exuberance, or feel a heavy ſwelling in ſome parts, that this ſtate has been preceded by ſeveral degrees of congeſtion and infarction which conſiderably diſtended the vaſcular, villous, or parenchimatous ſubſtances, and, of courſe, much better favoured the tranſudaton of certain fluids within the abſorbent ſyſtem. It is not indeed when we feel an obſtruction in the liver, or a ſkirrus, or any other unnatural alteration, that we ſhould fear that other operation of the lymphatic veins; becauſe in this ſtate, various fluids have no longer any circulation nor connection among themſelves; but on the contrary, this abſorption has more probably taken place when the obſtruction was forming, and when the fluids were yet ſufficiently liquid in their circulation. It is not, therefore, neceſſary, to have any viſible obſtruction in the liver or ſtoppage in the excretory ducts of the bile, to have a ſubſequent jaundice; this without the former happens in the yellow fever, and it is often ſeen without obſtructions, nor ſkirrus in ſeveral inſtances. It may then have originated ſolely from the enthickening of the bile in the pori billiarii, &c.

Fifthly, Let us never confine ourſelves within narrower bounds, than thoſe which belong to the admirable laws of nature. Such a large and important viſcera as the liver muſt have more than one means to diſcharge the bile which it cannot empty. That of abſorption only would be eventually interrupted or inconſiderable. The blood may reſume it, to a certain quantity and pour it into the kidneys, or into any other ſecretion, as known facts have frequently proved. I alſo, readily believe, that the lacteal veſſels may take it from the inteſtines, when there is nothing in them but bile, and diſcharge it into the thoracic duct, along with the lymphatic veins. I hope, therefore, that the above argument, the ground of which I had leſs the intention to remove than to explain, leaves principles enough with ſufficient means to the above theory on the yellow fever, and to all the ſubſequent opinions.

A famous doctrine has been introduced into the medical world, and it is yet vigorouſly ſupported and even improve by numerous partizans. We may call it the doctrine of direct and indirect debility, or the ſtimulating ſyſtem. The ſupporters of it ſay, that it has ſucceeded to the imperfect doctrine of ſpaſms and conſtrictions, the ſame as this latter had exploded the old and more imperfect one of viſcidity and lentor. It ſeems that unfortunately that by thoſe methods of definition, modern and ancient diſcoveries are equally marked either with excluſive advantages or with reproachfull defects. Thus the ungracious abuſe of words finally will divide learned men, as it evidently created many heretics, and ſectaries during paſt ages of chriſtendom. Yet whatever may be the inflexible dogmatiſm of thoſe who miſtake true learning, by praiſing only one doctrine, who will deny but every judicious phyſician conſiders it as his duty to examine all doctrines, and all methods, with an impartial and unbiaſſed mind to call to his aid all the good reſults from obſervations and principles. It was with the motive of avoiding the abuſe of words and definition that I introduced only the name of Dr. Brown in my note, p. 29, the author of the doctrine abovementioned; although I ought not to have omitted to obſerve that the actual profeſſor of the inſtitutes of medicine, was not preciſely ſubordinate to the Brownonian ſyſtem; ſince, on the contrary, he has improved on it, by his excellent views on morbid excitement on the preternatural and convulſive actions of the blood veſſels, on the inequality in fevers, of excitement and excitability, and on the neceſſity of abſtracting what we ſhould call in other words, ſpaſms, irritation, inflammation, &c. and, in one word, ſuggeſting the relaxation without which no ſolutary criſis are ever obtained.

It has been ſaid, in page 14, that as we have not any publication, collectively, from that body (the college of phyſicians) that could exhibit more, and ſtronger arguments than merely their opinion of its importation, I ſuppoſe that is unneceſſary for me to ſay any thing either for or againſt the opinion. This might be deemed a material inaccuracy if I ſhould not add a neceſſary explanation. That body, has, in ſeveral circumſtances, publiſhed the authentic facts, by which it has appeared that the diſorder has been imported from foreign countries. The reader will remember, that I have not drawn the leaſt controverſy from any of the facts concerning the importation of the fever nor of of the means which have been alledged to have ſpread it. Their authenticity and moſt ſtriking circumſtances never could weaken the contrary belief, which implies the eventual generation of the fever on board of ſhips from tropical countries, and as it is contagious, we do not deny that an infected ſeaman might, of courſe, communicate it to his attendants. If a whole crew alſo or a part of it, came from a known infected place to another of very hot temperature, they ſurely may be dangerous. Theſe chances are acknowledged or granted; but, to ſuch chances we will not give up a matter of principles, of analogy, and an opinion, the arguments of which, in the conſtitution of the air, are even employed by the opponent believers. Therefore, if the facts proving the importation to others, prove to me nothing elſe than the generation of the yellow fever on board of ſhips, it will not be improper to conclude, that with only ſuch arguments one ſide has nothing ſtronger than merely their opinion.