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Bilious Remitting Yellow Fever
Appeared in Philadelphia
in the Year 1793
(words in brown were deleted in later editions)
by Benjamin Rush
 Before I proceed to describe the fever which is the subject of the following history, it will be proper to give a short account of the diseases which preceded it.
The state of the weather during the first seven months of the year, and during the time in which the fever prevailed in the city, as recorded by Mr. Rittenhouse, will be inserted immediately after the history of the disease.
The MUMPS which made their appearance in December 1792, continued to prevail during the month of January 1793. Besides this disorder, there were many cases of catarrh in the city,  brought on chiefly by the inhabitants exposing themselves for several hours on the damp ground in viewing the aerial voyage of Mr. Blanchard on the 9th of the month.
The weather which had been moderate in December and January became cold in February. The mumps continued to prevail during this month with symptoms so inflammatory, as to require in some cases two bleedings. Many people complained this month of pains and swellings in the jaw. A few had the scarlatina anginosa.
The mumps, pains in the jaw, and scarlatina continued throughout the month of March. I was called to two cases of pleurisy in this month, which terminated in a temporary mania. One of them was in a woman of ninety years of age, who recovered. The blood drawn in the other case, (a gentleman from Maryland) was dissolved. The continuance of a tense pulse, induced me notwithstanding to repeat the bleeding. The blood was now fizy. A third bleeding was prescribed, and my patient recovered. Several cases of obstinate erysipelas succeeded inoculation in children during this, and the next month, one of which proved fatal.
 Blossoms were universal on the fruit-trees, in the gardens of Philadelphia, on the first day of April. The scarlatina anginosa continued to be the reigning epidemic in this month.
There were several warm days in May, but the city was in general healthy. The birds appeared two weeks sooner this spring than usual.
The register of the weather shows, that there were many warm days in June. The scarlatina continued to maintain its empire during this month.
The weather was uniformly warm in July. The scarlatina continued during the beginning of this month, with symptoms of great violence. A son of Mr. James Sharswood, aged seven years, had with the common symptoms of this disorder, great pains and swellings in his limbs, accompanied with a tense pulse. I attempted in vain to relieve him with vomits and purges. On the 10th day of the month, I ordered six ounces of blood to be drawn from his arm, which I observed afterwards to be very sizy. The next day he was nearly well. Between the 22d and the 24th days of the month there died three persons whose respective ages were 80, 92, 96. The weather at this time  was extremely warm. I have elsewhere taken notice of the fatal influence of extreme heat, as well as cold, upon human life in old people. A few bilious remitting fevers appeared towards the close of this month. One of them under my care, ended in a tedious typhus mitior, from which the patient was recovered with great difficulty. It was the son of Dr. Hutchins of the island of Barbadoes.
The weather for the first two or three weeks in August was temperate, and pleasant. The cholera morbus, and remitting fevers were now common. The latter were attended with some inflammatory action in the pulse, and a determination to the breast. Several dysentaries appeared at this time, both in the city and in its neighbourhood. During the latter part of July, and the beginning of this month, a number of distressed inhabitants of St. Domingo, who had escaped the desolation of fire and sword, arrived in the city. Soon after their arrival, the influenza made its appearance, and spread rapidly among our citizens. The scarlatina still kept up a feeble existence among children. The above diseases were universal, but they were not attended with much mortality. They prevailed in different parts of the city, and each seemed to appear occassionally to be the ruling  epidemic. The weather continued to be warm and dry. There was a heavy rain on the 25th of the month, which was remembered by the citizens of Philadelphia as the last that fell, for many weeks afterwards.
There was something in the heat and drought of the summer months, which was uncommon in their influence upon the human body. Labourers every where gave out (to use the country phrase) in harvest, and frequently too when the mercury in Fahrenheit's thermometer was under 84 degrees. It was ascribed by the country people to the calmness of the weather, which left the sweat produced by heat and labour, to dry slowly on the body.
The crops of grain and grass were impaired by the drought. The summer fruits were as plentiful as usual, particularly the melons, which were of an excellent quality. The influence of the weather upon the autumnal fruits, and upon vegetation in general, shall be mentioned hereafter.
I beg pardon for the length of this introduction. Some parts of it, I hope, will not appear useless in the sequel of this work.
 I now enter upon a detail of some solitary cases of the epidemic, which soon afterwards spread distress through our city, and terror throughout the United States.
On the 5th of the August, I was requested by Dr. Hodge to visit his child. I found it ill with a fever of the bilious kind, which terminated (with a yellow skin) in death on the 7th of the same month.
On the 6th of August, I was called to Mrs. Bradford, the wife of Mr. Thomas Bradford. She had all the symptoms of a bilious remittent, but they were so acute, as to require two bleedings, and several successive doses of physic. The last purge she took was a dose of calomel, which operated plentifully. For several days after her recovery, her eyes and face were of a yellow colour.
On the same day, I was called to the son of Mrs. McNair, who had been seized violently with all the usual symptoms of a bilious fever. I purged him plentifully with salts adn 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  an haemorrhage of 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 Chestnut-street. He had been indisposed for several days with a sick stomach and vomiting after eating. He now complained of fever and headach. 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 to visit his brother William, who was seized with all the symptoms of the same disorder. On the 5th day his headach became extremely acute, and his pulse fell to sixty strokes in a minute. I suspected congestion to have taken place in his brain, and ordered him to lose eight ounces of blood. His pulse became more frequent, and less tense after bleeding, and he recovered in a day or two afterwards.
On the 14th day of this month I was sent for to visit Mrs. Leaming, the wife of Mr. Thomas Leaming. I suspected at the 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 the 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, 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 in the 3d 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 was 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 yellow fever in our city; for I had frequently seen sporadic cases in which the common bilious fever  of Philadelphia, had put on symptoms of great malignity, and terminated fatally in a few days, and now and then with a yellow colour on the skin, before or immediately after death.
On the 19th of this month, I was requested to visit the wife of Mr. Peter Le Maigre, in Water-street, between Arch and Race streets, in consultation with Dr. Foulke and Dr. Hodge. I found her in the last stage of a highly bilious fever. She vomited constantly, and complained of great heat and burning in her stomach. The most powerful cordials, and tonics were prescribed, but to no purpose. She died on the evening of the next day.
Upon coming out of Mrs. Le Maigre's room, I remarked to Dr. Foulke and Dr. Hodge, that I had seen an unusual number of bilious fevers, accompanied with symptoms of uncommon malignity, and that I suspected all was not right in our city. Dr. Hodge immediately replied, that a fever of a most malignant kind had carried off four or five persons within sight of Mr. Le Maigre's door, and that one of them had died in twelve hours after the attack of the disorder. This information satisfied me that my apprehensions were well founded. The origin of the fever was discovered to  me at the same time, from the account which Dr. Foulke gave me of a quantity of damaged coffee which had been thrown upon Mr. Ball's wharf, and in the adjoining dock, on the 24th of July, nearly in a line with Mr. Le Maigre's house, and which had putrefied there to the great annoyance of the whole neighbourhood.
After this consultation I was soon able to trace all the cases of fever which I have mentioned to this source. Dr. Hodge lived a few doors about Mr. Le Maigr'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, 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 did not hesitate to name it, the Bilious remitting Yellow Fever. I had once seen it epidemic in Philadelphia, in the year 1762. Its symptoms were among the first impressions which diseases made upon my mind. I had recorded some of these symptoms. I had likewise recorded its mortality. I shall here introduce a short account of it from a note book which I kept during my apprenticeship.
"In the year 1762, in the months of August, September, October, November and December, the bilious yellow fever prevailed in Philadelphia, after a very hot summer, and spread like a plague, carrying off daily for some time, upwards of twenty persons.
"The patients were generally seized with rigors, which were succeeded with a violent fever, and pains in the head and back. The pulse was full, and sometimes irregular. They eyes were  inflamed, and had a yellowish cast, and a vomiting almost always attended.
"The 3d, 5th, and 7th days were mostly critical, and the disease generally terminated on one of them, in life or death.
"An eruption on the 3d or 7th day over the body, proved salutary.
"An excessive heat, and burning about the region of the liver, with cold extremities, portended death to be at hand."
I have taken notice in my note book, of the principal remedy which was prescribed inthis fever by my preceptor in medicine, Dr. Redman; but this shall be mentioned hereafter.
Upon my leaving Mrs. Le Maigre's, I expressed my distress at what I had discovered, to several of my fellow-citizens. The report of a malignant and contagious 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. Indignation in some instances was excited against me, and one of my friends whom I advised in this early stage of the disorder, to leave the city, has since told me that for that advice, "he had hated me."
My lot in having thus disturbed the repose of the public mind, upon the subject of general health, was not a singular one. There are many instances upon record, of physicians who have rendered themselves unpopular, and even odious to their fellow citizens, by giving the first notice of the existence of malignant and mortal disease. A physician who asserted that the plague was in Messina in the year 1743, excited so much rage in teh minds of his fellow citizens against him, as to render it necessary for him to save his life, by retreating to one of the churches of that city.
In spite, however, of all opposition, the report of the existence of a malignant and contagious fever in the city, gained so much ground, that the governor of the state directed Dr. Hutchinson, the inspector of sickly vessels, to inquire into the truth  of it, and into the nature of the disease. In consequence of this order, I received the following letter from Dr. Hutchinson.
(more to come)
Of the Method of Cure
 In the introduction to the history of the fever, I mentioned the remedies which I used with success, in several cases which occurred in the beginning of August. I had seen, and recorded in my note book, the efficacy of gentle purges in the yellow fever of 1762; but finding them unsatisfactory after the 20th of August, and observing the disease to assume uncommon symptoms of great indirect debility. I laid them aside, and had recourse to a gentle vomit of ipecacuanha on the first day of the fever, and to the usual remedies for exciting the action of the sanguiferous system. I gave bark in all its usual forms of infusion, powder, and tincture. I joined wine, brandy and aromatics with it. I applyed 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, tho' 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 waited upon Dr. Stevens, an eminent and respectable physician from St. Croix, who happened them to be in our city, and asked for such advice and information upon the subject of the disease, as his extensive practice in the West Indies would naturally suggest. He politely informed me that he had long ago laid aside evacuations of all kinds in the yellow fever; that they have been found to be hurtful, and that the disease yielded more readily to bark, wine, and above all, to the use of the cold bath. He advised the bark to be given in large quantities by way of glyster, 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 had used bark in the manner he recommended it in several cases of the sporadic yellow fever with success in former years. I had moreover the authority of several other physicians of reputation in its favour. Dr. Cleghorn tells us, that "he sometimes gave the bark when the bowels were full of vicious humours. These humours (he says) are produced by the fault of the circulation. The bark by bracing the solids, enables them to throw off the excrementitious fluids, by proper emunctories."
I began the use of each of Dr. Steven's remedies the next day after my interview with him, with great confidence of their success. I prescribed bark in large quantities; in one case I ordered it to be injected into the bowels every four hours. I directed buckets full of cold water to be thrown frequently upon my patients. The bark was offensive to the stomach, or rejected by it in every case in which I prescribed it. The cold bath was grateful, and produced relief in several cases by inducing a moisture on the skin. 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 before mentioned.
Baffled in every attempt to stop the ravages of this fever, I anticipated all the numerous and complicated distresses in our city, which pestilential diseases have so often produced in other countries. The fever had a malignity, and an obstinacy which I had never before observed in any disease, and it spread with a rapidity and mortality, far beyond what it did in the year 1762. Heaven alone bore witness to the anguish of my soul in this awful situation. But 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 account 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. Before I desisted from the inquiry to which I devoted myself, I recollected that I had among some old papers, a manuscript account of the yellow fever as it prevailed in Virginia in the years 1741, which had been put into my hands by Dr. Franklin, a short time before his death. I had read it formerly, and made extracts from it into my lectures upon that disorder. 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 viscera are the parts principally affected in this disease, but by timely evacuation, their seculent corruptible contents are discharged, before they corrupt and produce any ill effects, and their various emunctories, and secerning vessels are set open, so as to allow a free discharge of their contents, and consequently a security to the parts themselves, during the course of the disease. By this evacuation the very minera of the disease, proceeding from the putrid miasma fermenting with the salivary, bilious, and other inquiline humours of the body, is sometimes eradicated by timely emptying the abdominal viscera on which it first fixes, after which a gentle sweat does as it were nip it in its bud. Where the primae viae, but especially the stomach, is loaded with an offensive matter, or contracted, and convulsed with the irritation of its stimulus, there is no procuring a laudable sweat, till that is removed; after which a necessary quantity of sweat breaks out of its own accord, these parts promoting it when by an absterging medicine, they are eased of the burden or stimulus which oppresses them."
"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, when nature does not do the business herself. On this account an ill-timed scrupulousness about the weakness of the body, is of bad consequences in these urging circumstances; for it is that which seems chiefly to make evacuations necessary, which nature ever attempts, after the humours are fit to be expelled, but is not able to accomplish for the most part in this disease; and I can affirm, that I have given a purge in this case, when the pulse has been so low, that it could hardly  be felt, and the debility extreme, yet both one, and the other have restored by it"
"This evacuation must be procured by lenitive chologoque purges."
Here I paused. A new train of ideas suddenly broke in upon my mind. I believed the weak and low pulse which I had observed in this fever, to be the effect of debility of the indirect kind, but the unsuccessful issue of purging, and even of a spontaneous diarrhoea, in a patients of Dr. Hutchinson's had led me not only to doubt of, but to dread its effects. My fears from this evacuation were confirmed, by the communications I had received from Dr. Stevens. I had been accustomed to raising a weak and low pulse in pneumony and apoplexy, by means of blood-letting, but I had attended less to the effects of purging in producing this change in pulse. Dr. Mitchell in a moment dissipated my ignorance and fears upon this subject. 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 have before described the state of the bile in the gall-bladder, and duodenum in an extract from the history of a dissection made by Dr.  Mitchell I suspected that my want of success in discharging this bile, in several of the cases in which I attempted to cure by purging, was owing to the feebleness of my purges. 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. Clarke. I had moreover, other precedents, for its use in the practice of Sir John Pringle, Dr. Cleghorn, and Dr. Balfour, in diseases of the same class with the yellow fever. But these were not all my vouchers for the safety, and efficacy of calomel. In my attendance upon the military hospitals during the late war, I had seen it given combined with jalap in the bilious fever, by Dr. Thomas Young, a senior surgeon in the hospitals. His usual dose, was ten grains of each of them. This was given once or twice a day, until it procured large evacuations from the bowels. For a while I remonstrated with the Doctor against this purge, as being disproportioned to the violence and danger of the fever; but I was soon satisfied that it was as safe as cremor tartar, or glauber's salts. It was adopted by several of the surgeons of the hospital, and 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 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 does was slow, and uncertain it 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 disorder. Mr. Richard Spain, a block-maker, in Third-street, took eighty grains of calomel, and rather more of rhubarb and jalap mixed with it, on the two last days of August, and on the first day of September. He had passed twelve hours, before I began to give him this medicine, without a pulse, and with a cold sweat on all his limbs. His relations had given him over, and one of his neighbours complained to me, of my neglecting  to advise them to make immediate preparations for his interment. But in this situation, I did not despair of his recovery. Dr. Mitchell's acccount of the effects of purging in raising the pulse, exciting a hope that he might be saved provided his bowels could be opened. I now committed the exhibition of the purging medicine to Mr. Stall, one of my pupils, who mixed it, and gave it with his own hand three or four times a day. At length it operated and produced two copious, foetid stools, His pulse rose immediately afterwards, and a universal moisture on his skin, succeeded the cold sweat on his limbs. In a few days he was out of danger, and he now lives in good health as the first fruits of the efficacy of mercurial purges in the yellow fever.
After such a pledge of the safety and success of my new medicine, I gave it afterwards with confidence. I communicated the prescriptions 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 endeavored to remove  the fears of my fellow citizens, by assuring them that the disease was no longer incurable. Mr. Lewis, the lawyer, Dr. McIlvaine, Mrs. Bethel, her two sons, and a servant maid, and Mr. Peter Bayton's whole family, (nine in number) were some of the first trophies of this new remedy. 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. Dr. Griffits, Dr. Say, Dr. Pennington, and my former pupils who had settled in the city, viz. Dr. Leib, Dr. Porter, Dr. Annan, Dr. Woodhouse, and Dr. Mease, were among the first physicians who adopted it. I can never forget the transport with which Dr. Pennington ran across the street to inform me, a few days after he began to give strong purges, that the disease, yielded to them in every case. But I did not rely upon purging alone, to cure the disease. The theory of its proximate cause, 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. I had bled Mrs. Bradford, Mrs. Leaming, and one of Mrs. Palmer's sons with success, early in the month of August. But I had witnessed the bad effects of bleeding in the first  week
(more to come)