HISTORY 135F

Infectious and Epidemic Disease in History

Department of History
University of California, Irvine
 Instructor:    Dr. Barbara J. Becker

Week 7.  Cure?

An Account of the Bilious Remitting Yellow Fever,
as it Appeared in Philadelphia, in the Year 1793 (1815)
by Dr. Benjamin Rush (1746-1813)

[NOTE:  Benjamin Rush first published his account of Philadelphia's 1793 yellow fever epidemic in 1794.]

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

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

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

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

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

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

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

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

Upon coming out of Mrs. Le Maigre's room I remarked to Dr. Foulke and Dr. Hodge, that I had seen an unusual number of bilious fevers, accompanied with symptoms of uncommon malignity, and that I suspected ail was not right in our city.  Dr. Hodge immediately replied, that a fever of a most malignant kind had carried off four or five persons within sight of Mr. Le Maigre's door, and that one of them had died in twelve hours after the attack of the disease.  This information satisfied me that my apprehensions were well founded.

Philadelphia, 1793

The Origin of the Fever
The origin of this fever was discovered to me at the same time, from the account which Dr Foulke gave me of a quantity of damaged coffee which had been thrown upon Mr. Ball's wharf (site 3 on map of Philadelphia above), and in the adjoining dock, on the 24th of July, nearly in a line with Mr. Le Maigre's house, and which had putrefied there to the great annoyance of the whole neigbourhood [sic].

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

This discovery of the malignity, extent, and origin of a fever which I knew to be attended with great danger and mortality, gave me great pain.  I did not hesitate to name it the bilious remitting yellow fever.

[Here's how the above text appeared in Rush's first edition (1794)]:

...Her sister Mrs. Leaming had visited her during her illness, and probably caught the fever from her, for she perfectly recollected perceiving a peculiar smell unlike any thing she had been accustomed to in a sickroom, as soon as she entered the chamber where her sister lay.  Young Mr. McNair and Mrs. Palmer's two sons had spent the whole day in a compting house, near where the coffee was exposed, and each of them had complained of having been made sick by its offensive smell, and Mr. Aston had frequently been in Water-street near the source of the exhalation.

The discovery of the malignity, extent, and origin of a fever which I knew to be highly contagious, as well as mortal, gave me great pain....

I had once seen it epidemic in Philadelphia, in the year 1762....

Upon my leaving Mrs. Le Maigre's, I expressed my distress at what I had discovered, to several of my fellow citizens.  The report of a malignant and mortal fever being in town spread in every direction, but it did not gain universal credit.  Some of those physicians who had not seen patients in it denied that any such fever existed, and asserted (though its mortality was not denied) that it was nothing but the common annual remittent of the city.  Many of the citizens joined the physicians in endeavouring to discredit the account I had given of this fever, and for a while it was treated with ridicule or contempt....

Factors that Destroy the Equilibrium of a Body's System and Predispose an Individual to the Fever

1.  Great labour, or exercise of body, or mind:

  • a long walk
  • gunning
  • a hard trotting horse
  • riding on horseback, and in the sun
  • a fall
  • a stroke upon the head
  • exertions on the night of the 7th of September, in extinguishing the fire which consumed Mr. Dobson's printing office
  • working the fire engines, for the purpose of laying the dust in the streets
2.  Heat, from every cause:
  • the heat of the sun, especially among labouring people
  • the heat of common fires; hence the greater mortality of the disease among bakers, blacksmiths, and hatters
3.  Intemperance in eating or drinking:
  • a plentiful meal, and a few extra glasses of wine
  • even the smallest deviation from the customary stimulus of diet, in respect to quality or quantity
  • a supper of twelve oysters
  • half an ounce of meat
  • even a supper of sallad, dressed after the French fashion
4.  Fear.
  • sudden paroxysm of fear
  • some timid people escaped the disease (perhaps moderate degree counteracts the excessive stimulus of the miasmata)
  • fear did no harm after the disease was formed (led me not to conceal from my patients the true name of this fever)
  • fear cooperated with some of my remedies in reducing the morbid excitement of the arterial system
5.  Grief.
  • attendants upon the sick were not susceptible while there was hope of patient's recovery
  • extinction of hope, by death, frequently produced it within a day or two afterwards in near relations of the deceased
  • those attending patients who recovered were seized with the disease a day or two after they were relieved from toils and anxiety of nursing
6.  Cold.
  • diminution of the necessary and natural heat of the body
  • night air
  • wet feet
  • every change in the weather  (persons habitually exposed to cool air, were less liable to the disease than others)
  • exposure to cool air after violent exercise
7.  Sleep.
  • sleep disposed miasmata to act with such force upon the system as to destroy its equilibrium
  • want of bed-clothes suited to the midnight or morning coolness of the air
8.  Immoderate evacuations.
  • excessive use of purging remedies which should only be used in moderate quantities....
Who was Affected by the Fever
All ages were affected by this fever, but persons between fourteen and forty years of age were most subject to it.  Many old people had it, but it was not so fatal to them as to robust persons in middle life.  It affected children of all ages....

Men were more subject to the disease than women.  Pregnancy seemed to expose women to it.

The refugees from the French West-Indies universally escaped it.  This was not the case with the natives of France, who had been settled in the city....

It is difficult to account for these facts.  However numerous their causes may be, a difference in diet, which is as much a distinguishing mark of nations as dress or manners, will probably be found to be one of them.

From the accounts of the yellow fever which had been published by many writers, I was led to believe that the negroes in our city would escape it....

It was not long after ... Africans undertook the execution of their humane offer of services to the sick before I was convinced I had been mistaken.  They took the disease in common with the white people, and many of them died with it.  I think I observed the greatest number of them to sicken after the mornings and evenings became cool.  A large number of them were my patients.  The disease was lighter in them than in white people.  I met with no case of hemorrhage in a black patient.

The tobacconists and persons who used tobacco did not escape the disease....

There did not appear to any advantage from smelling vinegar, tar, camphor, or volatile salts, in preventing the disease.  Bark and wine were equally ineffectual for that purpose.  I was called to many hundred people who were infected after using one or more of them.  Nor did the white washing walls secure families from the disease.  I am disposed to believe garlic was the only substance that was in any degree useful in preventing it.  I met with several persons who chewed it constantly, and who were much exposed to the miasmata without being infected.  All other substances seemed to do harm by, begetting a false confidence in the mind, to the exclusion of more rational preservatives.  I have suspected further, that such of them as were of a volatile nature helped to spread the disease by affording a vehicle for miasmata through the air.

There was great mortality in all those families who lived in wooden houses.  Whether this arose from the small size of these houses, or from the want of cleanliness of the people who occupied them, or from the miasmata becoming more accumulated, by adhering to the wood, I am unable to determine.  Perhaps it was the effect of the co-operation of all three of those causes....

The State of the Atmosphere
The state of the atmosphere, during the whole month of September, and the first two weeks in October, favoured the accumulation of the miasmata in the city.

The register of the weather shows how little the air was agitated by winds during the above time.  In vain were changes in the moon expected to alter the state of the air.  The light of the morning mocked the hopes that were raised by a cloudy sky, in the evening.  The sun ceased to be viewed with pleasure.  Hundreds sickened every day beneath the influence of his rays:   and even where they did not excite the disease, they produced a languor in the body unknown to the oldest inhabitant of the city, at the same season of the year.

A meteor was seen at two o'clock in the morning, on or about the twelfth of September.  It fell between Third-street and the hospital (just south of Rush's house, site 1, on map of Philadelphia above), nearly in a line with Pine-street.  Mosquetoes (the usual attendants of a sickly autumn) were uncommonly numerous.  Here and there a dead cat added to the impurity of the air of the streets.  It was supposed those animals perished with hunger in the city, in consequence of so many houses being deserted by the inhabitants who had fled into the country, but the observations of subsequent years made it more probable they were destroyed by the same morbid state of the atmosphere which produced the reigning epidemic.

It appears further, from the register of the weather, that there was no rain between the 25th of August and the 15th of October, except a few drops, hardly enough to lay the dust of the streets, on the 9th of September, and the 12th of October.  In consequence of this drought, the springs and wells failed in many parts of the country.  The dust in some places extended two feet below the surface of the ground.  The pastures were deficient, or burnt up.  There was a scarcity of autumnal fruits in the neighbourhood of the city.  But while vegetation drooped or died from the want of moisture in some places, it revived with preternatural vigour from unusual heat in others.  Cherry-trees blossomed, and apple, pear, and plum-trees bore young fruit in several gardens in Trenton, thirty miles from Philadelphia, in the month of October.

However inoffensive uniform heat, when agitated by gentle breezes, may be, there is, I believe, no record of a dry, warm, and stagnating air having existed for any length of time without producing diseases.  Hippocrates, in describing a pestilential fever, says the year in which it prevailed was without a breeze of wind.  The same state of the atmosphere, for six weeks, is mentioned in many of the histories of the plague which prevailed in London, in 1665.  Even the sea air itself becomes unwholesome by stagnating....

Who can review this account of the universal diffusion of the miasmata which produced this disease, its universal effects upon persons apparently in good health, and its accumulation and concentration, in consequence of the calmness of the air, and believe that it was possible for a febrile disease to exist at that time in our city that was not derived from that source?

Circumstances of Public and Private Distress
...[T]he first reports of the existence of this fever were treated with neglect or contempt.  A strange apathy pervaded all classes of people.  While I bore my share of reproach for "terrifying our citizens with imaginary danger," I answered it by lamenting "that they were not terrified enough."  The publication from the college of physicians soon dissipated this indifference and incredulity.  Fear or terror now sat upon every countenance.  The disease appeared in many parts of the town, remote from the spot where it originated; although, for a while, in every instance, it was easily traced to it.  This set the city in motion.  The streets and roads leading from the city were crowded with families flying in every direction for safety to the country.  Business began to languish.  Water-street, between Market and Race-streets (section of Water-street near site 3 on map of Philadelphia above), became a desert.  The poor were the first victims of the fever.  From the sudden inturruption [sic] of business they suffered for a while from poverty as well as from disease.  A large and airy house at Bush-hill (site 4 on map of Philadelphia above), about a mile from the city was opened for their reception.  This house, after it became the charge of a committee appointed by the citizens on the 14th of September, was regulated and governed with the order and cleanliness of an old and established hospital.  An American and French physician had the exclusive medical care of it after the 22d of September.

The disease, after the second week in September, spared no rank of citizens.  Whole families were confined by it.  There was a deficiency of nurses for the sick, and many of those who were employed were unqualified for their business.  There was likewise a great deficiency of physicians, from the dissertion of some, and the sickness and death of others.  At one time there were but three physicians who were able to do business out of their houses, and at this time there were probably not less than 6000 persons ill with the fever.

During the first three or four weeks of the prevalence of the disease I seldom went into a house the first time without meeting the parents or children of the sick in tears.  Many wept aloud in my entry, or parlour, who came to ask for advice for their relations.  Grief after a while descended below weeping, and I was much struck in observing that many persons submitted to the loss of relations and friends without shedding a tear, or manifesting any other of the common signs of grief.

A cheerful countenance was scarcely to be seen in the city for six weeks.  I recollect once, in entering the house of a poor man, to have met a child of two years old that smiled in my face.  I was strangely affected with this sight (so discordant to my findings and the state of the city) before I recollected the age and ignorance of the child.  I was confined the next day by an attack of the fever, and was sorry to hear, upon my recovery, that the father and mother of this little creature died a few days after my last visit to them.

The streets every where discovered marks of the distress that pervaded the city.  More than one half the houses were shut up, although not more than one third of the inhabitants had fled into the country.  In walking for many hundred yards, few persons were met, except such as were in quest of a physician, a nurse, a bleeder, or the men who buried the dead.  The hearse alone kept up the remembrance of the noise of carriages or carts in the streets.  Funeral processions were laid aside.  A black man, leading or driving a horse, with a corpse on a pair of chair wheels, with now and then half a dozen relations or friends following at a distance from it, met the eye in most of the streets of the city, at every hour of the day, while the noise of the same wheels passing slowly over the pavements, kept alive anguish and fear in the sick and well, every hour of the night.

But a more serious source of the distress of the city arose from the dissentions of the physicians, about the nature and treatment of the fever.  It was considered by some as a modification of the influenza, and by others as the jail fever [typhus].  Its various grades and symptoms were considered as so many different diseases, all originating from different causes.  There was the same contrariety in the practice of the physicians that there was in their principles.  The newspapers conveyed accounts of both to the public, every day.  The minds of the citizens were distracted by them, and hundreds suffered and died from the delays which were produced by an erroneous opinion of a plurality of diseases in the city, or by indecision in the choice, or a want of confidence in the remedies of their physician.

The science of medicine is related to every thing, and the philosopher as well as the Christian will be gratified by knowing the effects of a great and mortal epidemic upon the morals of a people.  It was some alleviation of the distress produced by it, to observe its influence upon the obligations of morality and religion.  It was remarked during this time, by many people, that the name of the Supreme Being was seldom profaned, either in the streets, or in the intercourse of the citizens with each other.  But two robberies, and those of a trifling nature, occurred in nearly two months, although many hundred houses were exposed to plunder, every hour of the day and night.  Many of the religious societies met two or three times a week, and some of them every evening, to implore the interposition of Heaven to save the city from desolation.  Humanity and charity kept pace with devotion.  The public have already seen accounts of their benevolent exercises in other publications.  It was my lot to witness the uncommon activity of those virtues upon a smaller scale.  I saw little to blame, but much to admire and praise in persons of different professions, both sexes, and of all colours....

The Domestic Source of the Fever
I have asserted, in the introduction to the history of this fever, that I believed it to have been generated in our city; I shall now deliver my reasons for that belief.
1.  The yellow fever in the West-Indies, and in all other countries where it is endemic, is the offspring of vegetable putrefaction....  [I]n ... parts ... of the same islands, where there are no marsh exhalations, the disease is unknown.

2.  The same causes (under like circumstances) must always produce the same effects.

3.  I have before remarked, that a quantity of damaged coffee was exposed at a time (July, the 24th) and in a situation (on a wharf and in a dock) which favoured its putrefaction and exhalation.  Its smell was highly putrid and offensive, insomuch that the inhabitants of the houses in Water and Front-streets, who were near it, were obliged, in the hottest weather, to exclude it by shutting their doors and windows.  Even persons, who only walked along those streets, complained of an intolerable fetor [foul smell], which upon inquiring, was constantly traced to the putrid coffee.  It should not surprise us, that this seed, so inoffensive in its natural state, should produce, after its putrefaction, a violent fever.  The records of medicine ... furnish instances of similar fevers being produced by the putrefaction of many other vegetable substances.

4.  The rapid progress of the fever from Water-street and the courses through which it travelled into other parts of the city, afford a strong evidence that it was at first propagated by exhalation from the putrid coffee.  It was observed that it passed first through those alleys and streets which were in the course of the winds that blew across the dock and wharf, where the coffee had been thrown in a state of putrefaction.

5.  Many persons who had worked, or even visited, in the neighbourhood of the exhalation from the coffee, early in the month of August, were indisposed afterwards with sickness, puking, and yellow sweats, long before the air of Water-street was so much impregnated with the exhalation, as to produce such effects; and several patients, whom I attended in the yellow fever, declared to me, or to their friends, that their indispositions began exactly at the time they inhaled the offensive effluvia of the coffee.

6.  The first cases of the yellow fever have been clearly traced to the sailors of the vessel who were first exposed to the effluvia of the coffee.  Their sickness commenced with the day on which the coffee began to emit its putrid smell.  The disease spread with the increase of the poisonous exhaltion.  A journeyman of Mr. Peter Brown, who worked near the corner of Race and Water-streets (see "early cases of yellow fever" on map of Philadelphia), caught the disease on the 27th of July.  Elizabeth Hill, the wife of a fisherman, was infected by only sailing near the pestilential wharf, about the 1st of August, and died at Kensington on the 14th of the same month.  Many other names might be mentioned of persons who sickened during the last week in July or the first week in August, who ascribed their illness to the smell of the coffee.

7.  It has been remarked that this fever did not spread in the country, when carried there by persons who were infected, and who afterwards died with it.  During four times in which it prevailed in Charleston, in no one instance, according to Dr. Lining, was it propagated in any other part of the state.

8.  In the histories of the disease which have been preserved in this country, it has six times appeared about the first or middle of August, and declined or ceased about the middle of October:  viz.  in 1732, 1739, 1745, and 1748 in Charleston, in 1791 in New-York, and in 1793 in Philadelphia.  This frequent occurrence of the yellow fever at the usual period of our common bilious remittens, cannot be ascribed to accidental coincidence, but must be resolved, in most cases, into the combination of more active miasmata with the predisposition of a tropical season.  In speaking of a tropical season, I include that kind of weather in which rains and heats are alternated with each other, as well as that which is uniformly warm.

9.  Several circumstances attended this epidemic, which do not occur in the West-India yellow fever.  It affected children as well as adults, in common with our annual bilious fevers.  In the West-Indies, Dr. Hume tells us, it never attacked any person under puberty.  It had, moreover, many peculiar symptoms (as I have already shown) which are not to be met with in any of the histories of the West-India yellow fever.

10.  Why should it surprise us to see a yellow fever generated amongst us?  It is only a higher grade of a fever which prevails every year in our city, from vegetable putrefaction.  It conforms, in the difference of its degrees of violence and danger to season as well as climate, and in this respect it is upon a footing with the small-pox, the measles, the sore-throat, and several other diseases....  It is very common in South and North-Carolina and in Virginia, and there are facts which prove, that not only strangers, but native individuals, and in one instance, a whole family, have been carried off by it in the state of Maryland.  It proved fatal to one hundred persons in the city of New-York in the year of 1791, where it was evidently generated by putrid exhalation.

The yellow colour of the skin has unfortunately too often been considered as the characteristic mark of this fever, otherwise many other instances of its prevalence might be discovered, I have no doubt, in every part of the United States.  I wish, with Dr. Mosely, the term yellow could be abolished from the titles of this fever, for this colour is not only frequently absent, but sometimes occurs in the mildest bilious remittents.  Dr. Haller, in his pathology, describes an epidemic of this kind in Switzerland, in which this colour generally attended, and I have once seen it almost universal in a common bilious fever, which prevailed in the American army, in the year 1776....

[It is my] opinion, that the plagues which occasionally desolated most of the countries of Europe, in former centuries, and which were always said to be of foreign extraction, were of domestic origin.  Between the years 1006 and 1680, the plague was epidemic fifty-two times all over Europe.  It prevailed fourteen times in the 14th century.  The state of Europe in this long period is well known.  Idleness, a deficiency of vegetable aliment, a camp life, from the frequency of wars, famine, an uncultivated and marshy soil, small cabins, and the want of cleanliness in dress, diet, and furniture, all concurred to generate pestilential diseases.  The plagues which prevailed in London, every year from 1593 to 1611, and from 1636 to 1649, I believe were generated in that city.  The diminution of plagues in Europe, more especially in London, appears to have been produced by the great change in the diet and manners of the people; also by the more commodious and airy forms of the houses of the poor, among whom the plague ahvays makes its first appearance.  It is true, these plagues, were said by authors to have been imported, either directly or indirectly, from the Levant; but the proofs of such importation were as vague and deficient as they were of the West-India origin of our epidemic.  The pestilential fevers which have been mentioned, have been described by authors by the generic name of the plague, but they appear to have originated from putrid vegetable exhalations, and to have resembled, in most of their symptoms, the West-India and North-American yellow fever.
Of the Method of Cure
...I had seen, and recorded in my note book, the efficacy of gentle purges in the yellow fever of 1762; but finding them unsuccessful after the 20th of August, and observing the disease to assume uncommon symptoms of great prostration of strength, I laid them aside, and had recourse to a gentle vomit of ipecacuanha [syrup of ipecac], on the first day of the fever, and to the usual remedies for exciting the action of the sanguiferous system.
  • I gave [Peruvian] bark in all its usual forms of infusion, powder, and tincture.
  • I joined wine, brandy, and aromatics with it.
  • I applied blisters to the limbs, neck, and head.
  • Finding them all ineffectual, I attempted to rouse the system by wrapping the whole body, agreeably to Dr. Hume's practice in blankets dipped in warm vinegar.
  • To these remedies I added one more:  I rubbed the right side with mercurial ointment, with a view of exciting the action of the vessels in the whole system through the medium of the liver, which I then supposed to be principally, though symptomatically, affected by the disease.
None of these remedies appeared to be of any service; for although three out of thirteen recovered, of those to whom they were applied, yet I have reason to believe that they would have recovered much sooner had the cure been trusted to nature.

Perplexed and distressed by my want of success in the treatment of this fever, I [consulted] Dr. Stevens, an eminent and worthy physician from St. Croix, who happened then to be in our city, and asked for such advice and information upon the subject of the disease....  He advised the bark to be given in large quantities by way of clyster [enema], as well as in the usual way; and he informed me of the manner in which the cold bath should be used, so as to derive the greatest benefit from it.

This mode of treating the yellow fever, appeared to be reasonable....

I began the use of each of Dr. Stevens's remedies the next day ... with great confidence of their success....  For a while I had hopes of benefit to my patients from the use of these remedies, but, in a few days, I was distressed to find they were not more effectual than those I had previously used.  Three out of four of my patients died, to whom the cold bath was administered, in addition to the tonic remedies....

Baffled in every attempt to stop the ravages of this fever ... I did not abandon a hope that the disease might yet be cured.

I had long believed that good was commensurate with evil, and that there does not exist a disease for which the goodness of Providence has not provided a remedy.  Under the impression of this belief I applied myself with fresh ardour to the investigation of the disease before me.

I ransacked my library, and pored over every book that treated of the yellow fever.  The result of my researches for a while was fruitless.  The accounts of the symptoms and cure of the disease by the authors I consulted were contradictory, and none of them appeared altogether applicable to the prevailing epidemic.

...I recollected that I had, among some old papers, a manuscript account of the yellow fever as it prevailed in Virginia in the year 1741, which had been put into my hands by Dr. [Benjamin] Franklin, a short time before his death.  I had read it formerly, and made extracts from it into my lectures upon that disease.  I now read it a second time.  I paused upon every sentence; even words in some places arrested and fixed my attention.  In reading the history of the method of cure I was much struck with the following passages.

" It must be remarked, that this evacuation (meaning by purges) is more necessary in this than in most other fevers....  The abdominal [organs] are the parts principally affected in this disease, but by this timely evacuation their ... corruptible contents are discharged, before they corrupt and produce any ill effects....  All these acute putrid fevers ever require some evacuation to bring them to a perfect crisis and solution, and that even by stools, which must be promoted by art, where nature does not do the business herself....

"This evacuation must be procured by lenitive chologoque [soothing cathartic medicine that increases the flow of the bile] purges."

Here I paused.  A new train of ideas suddenly broke in upon my mind....  I adopted his theory and practice, and resolved to follow them.  It remained now only to fix upon a suitable purge to answer the purpose of discharging the contents of the bowels....

I suspected that my want of success in discharging this bile, in several of the cases in which I attempted the cure by purging, was owing to the feebleness of my purges.

 
Jalap
 
I had been in the habit of occasionally purging with calomel in bilious and inflammatory fevers, and had recommended the practice the year before in my lectures, not only from my own experience, but upon the authority of Dr. Clark....

It was ... universally known, and sometimes prescribed, by the simple name of ten and ten.  This mode of giving calomel occurred to me in preference to any other.  The jalap [dried root of a Mexican vine (Ipomoea purga) of the morning glory family, used as a purgative] appeared to be a necessary addition to it, in order to quicken its passage through the bowels; for calomel is slow in its operation, more especially when it is given in large doses.  I resolved, after mature deliberation, to prescribe this purge.

Finding ten grains of jalap insufficient to carry the calomel through the bowels in the rapid manner I wished, I added fifteen grains of the former to ten of the latter; but even this dose was slow and uncertain in its operation.

I then issued three doses, each consisting of fifteen grains of jalap and ten of calomel; one to be given every six hours until they procured four or five large evacuations.  The effects of this powder not only answered, but far exceeded my expectations.  It perfectly cured four out of the first five patients to whom I gave it, notwithstanding some of them were advanced several days in the disease....

After such a pledge of the safety and success of my new medicine, I gave it with confidence.  I communicated the prescription to such of the practitioners as I met in the streets.  Some of them I found had been in the use of calomel for several days, but as they had given it in small and single doses only, and had followed it by large doses of bark, wine, and laudanum, they had done little or no good with it.

I imparted the prescription to the college of physicians, on the third of September, and endeavoured to remove the fears of my fellow-citizens, by assuring them that the disease was no longer incurable....

The credit it acquired, brought me an immense accession of business.  It still continued to be almost uniformly effectual in all those which I was able to attend, either in person, or by my pupils....

But I did not rely upon purging alone to cure the disease.  The theory of it which I had adopted led me to use other remedies to abstract excess of stimulus from the system.  These were blood-letting, cool air, cold drinks, low diet, and applications of cold water to the body....

Never before did I experience such sublime joy as I now felt in contemplating the success of my remedies.  It repaid me for all the toils and studies of my life.  The conquest of this formidable disease was not the effect of accident, nor of the application of a single remedy; but it was the triumph of a principle in medicine.  The reader will not wonder at this joyful state of my mind when I add a short extract from my note book, dated the 10th of September.  "Thank God! out of one hundred patients, whom I have visited or prescribed for this day, I have lost none."

Being unable to comply with the numerous demands which were made upon me for the purging powders ... and, finding myself unable to attend all the persons who sent for me, I furnished the apothecaries with the recipe for the mercurial purges, together with printed directions for giving them, and for the treatment of the disease.

Response of the Medical Community to Mercurial Purges
Hitherto there had been great harmony among the physicians of the city, although there was a diversity of sentiment as to the nature and cure of the prevailing fever.  But this diversity of sentiment and practice was daily lessening, and would probably have ceased altogether in a few days, had it not been prevented by two publications, the one by Dr. Kuhn, and the other by Dr. Stevens, in which they recommended bark, wine, and other cordials, and the cold bath, as the proper remedies for the disease.  The latter dissuaded from the use of evacuations of all kinds....

I felt, at this season of universal distress, my professional obligations to all the citizens of Philadelphia to be superior to private and personal considerations, and therefore determined at every hazard to do every thing in my power to save their lives.  Under the influence of this disposition, I addressed a letter to the college of physicians, in which I stated my objections to Dr. Kuhn and Dr. Stevens's remedies, and defended those I had recommended.

I likewise defended them in the public papers against the attacks that were made upon them by several of the physicians of the city, and occasionally addressed such advice to the citizens as experience had suggested to be useful to prevent the disease, particularly low diet, gentle doses of laxative physic, avoiding its exciting causes, and prompt applications for medical aid....

This controversy with my brethren, with whom I had long lived in friendly intercourse, carried on amidst the most distressing labours, was extremely painful to me, and was submitted to only to prevent the greater evil of the depopulation of our city by the use of remedies which had been prescribed by myself, as well as others, not only without effect, but with evident injury to the sick....

Objections to the Mercurial Purge, and Answers to Them
However salutary the mercurial purge was, objections were made to it by many of our physicians; and prejudices, equally weak and ill-founded, were excited against it.  I shall enumerate, and answer those objections.
1.  It was said to be of too drastic a nature.  It was compared to arsenic; and it was called a dose for a horse.
This objection was without foundation.  Hundreds who took it declared they had never taken so mild a purge....  It sometimes, it is true, operated from twenty to thirty times in the course of twenty-four hours; but I heard of an equal number of stools in two cases from salts and cremor tartar.  It is not an easy thing to affect life, or even subsequent health, by copious or frequent purging....

Dr. Clark ... remarks, that evacuations do not destroy life in the dysentery, but the fever, with the emaciation and mortification which attend and follow the disease.

2.  A second objection to this mercurial purge was, that it excited a salivation, and sometimes loosened the teeth.
I met with but two cases in which there was a loss of teeth from the use of this medicine, and in both the teeth were previously loose or decayed.  The salivation was a trifling evil, compared with the benefit which was derived from it....
3.  It was said that the mercurial purge excoriated the rectum, and produced the symptoms of pain and inflammation in that part....
To refute this charge, it will be sufficient to remark, that the bile produces the same excoriation and pain in the rectum in the bilious and yellow fever, where no mercury has been given to discharge it....
4.  It was objected to this purge, that it inflamed and lacerated the stomach and bowels....
To refute this objection it will only be necessary to review the account formerly given of the state of the stomach and bowels after death from the yellow fever, in cases in which no mercury had been given....  Dr. Clark informs us ... "For several years past, when the dysentery has resisted the common mode of practice, I have administered mercury with the greatest success; and am thoroughly persuaded that it is possessed of powers to remove inflammation and ulceration of the intestines, which are the chief causes of death in this distemper."
5.  It was urged against this powerful and efficacious medicine, that it was prescribed indiscriminately in all cases, and that it did harm in all weak habits.
To this I answer, that there was no person so weak in constitution or a previous disease, as to be injured by a single dose of this medicine.  Mrs. Meredith, the wife of the treasurer of the United States, a lady of uncommon delicacy of constitution, took two doses of the powder in the course of twelve hours, not only without any inconvenience, but with an evident increase of strength soon afterwards....  Even children took two or three large doses of it with perfect  safety....  I am happy in being able to add further, that many women took it in every stage of pregnancy without suffering the least inconvenience from it.  Out of a great number of pregnant women whom I attended in this fever I did not lose one to whom I gave this medicine, nor did any of them suffer an abortion....

Much has been said of the bad effects of this purge from its having been put up carelessly by the apothecaries, or from its having been taken contrary to the printed directions by many people.  If it did harm in any one case (which I do not believe) from the former of the above causes the fault is not mine.  Twenty men employed constantly in putting up this medicine would not have been sufficient to have complied with all the demands which were made of me for it.  Hundreds who were in health called or sent for it as well as the sick, in order to have it in readiness, in case they should be surprized by the disease in the night, or at a distance in the night, or at a distance from a physician.

In all the cases in which this purge was supposed to have been hurtful, when given on the first or second day of the disease, I believe it was because it was not followed by repeated doses of the same, or of some other purge, or because it was not aided by blood-letting....

It is possible that this purge sometimes proved hurtful when it was given on the fifth day of the disease, but it was seldom given for the first time after the third day, and when it was, the patient was generally in such a situation that nothing did him either good or harm.

I derived great pleasure from hearing, after the fever had left the city, that calomel had been given with success as a purge in bilious fevers in other parts of the union besides Philadelphia....

 
Go to:
  • "Procuring the Small Pox," selected communications on the method of inoculation, from the Philosophical Transactions of the Royal Society of London (1714-1723);
  • An Inquiry into the Causes and Effects of the Variolae Vaccinae.... (1798) by Edward Jenner (1749-1843); and
  • A Short Account of the Malignant Fever Lately Prevalent in Philadelphia... (1794) by Mathew Carey (1760-1839);
  • a letter addressed to "My beloved Sister" (September 25, 1793) written by Margaret (Hill) Morris (1737-1816);
  • An Enquiry into, and Observations Upon the Causes and Effects of the Epidemic Disease Which raged in Philadelphia from the month of August till towards the middle of December 1793 (1794) by Dr. Jean Devèze (1753-1829); and
  • "Yellow Fever," in Vol. XV, The International Cyclopedia (1898).
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