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Draft of a letter from Dr. John Warren:

Boston Dec 22, 1798

I have just received your favor of 19 inst. and am certainly sorry you should have formed an opinion that I have been inattentive to the contents of your first letter on the subject of the epidemic. I very highly approve of the plan communicated and should immediately have answered it had I not concluded it most expedient to wait for further facts than could possibly have been connected at that time. The principle of those were such as were connected with the origin of the disease and the fatality that attended it. Many circumstances respecting the collection of putrid substances in stores and cellars were suspected to have existed under a concealment which there was reason to believe might be removed after the fever had subsided, and accurate returns, it was hoped, would be made of the number of those who had been sick and of those who had died with the disease. In neither of these particulars have I yet been able to procure such satisfactory information as I could have wished, but shall readily offer such an account of the disorder as my present materials have enabled me to prepare.

The first unequivocal appearance of the malignant fever in Boston was on the 20th of July 1798 (though one family had been attacked with a fever attended with unusual symptoms as early as the middle of June; but as no other instances occurred for so long a time of an alarming nature, some doubts may perhaps be justly entertained of the identify of the affection.) Three or four cases only I believe happened between this and the end of the latter end of the month. The two first of these were young men empoyed in stores directly opposite to each other on Green's wharf near the town dock - and few days after three or four persons were seized with the same complaints while pursuing their several occupations in Market square on the east and south sides of Fanueil Hall or the Market house.

In the beginning of the month of August six or seven persons were taken sick in the same neighborhood chiefly young men between 16 & 24 years of age while employed in the stores and counting houses there situated. The stores in merchant row extending from the Market to State street were more particularly visited with the fever; and in the course of the same month a family at the bottom of State street & several persons at Heiser's dock were taken sick. At this place a kind of bason formed between a point of the town projecting from fort hill and the long wharf which is constantly receiving the offals of fish & other animal substances which from its situation could not be washed off by the waters contained in it. This spot is remarkable for having been the residence of most of the persons first attacked with the bilious remittent fever of 1798.

In the latter end of this month the number of sick continued to increase, but the attacks were principally confined to the above mentioned quarter till at length the disease appeared on the south side of fort hil, at some distance to the southward of Oliver's dock, reaching as it were over the summit of the hill without lighting upon the inhabitants on the north of the eminence. The fatality of the disease was probably greater here than in any other part of the town of equal population and it was nearly the last place in which it appeared.

Very few families who remained in their own houses upon the hill escaped the attack of the disease and the progress of it in all the places above mentioned seemed to have been arrested only by the evacuation of the buildings in that part. In the latter end of August and thro the month of Sept. many persons were seized in Gore (?) street, which runs northerly from market or Dock square along the heads of the wharves and on the eastern side of town.

Thro the whole period of the sickness scarcely was a person was seized with the disorder who had not resided or been in daily employment in the vicinity of these places. The subjects of the disease were generally natives of the town. Chiefly in the prime of life & in the vigor of health. I recollect no instance of any of the French inhabitants being assailed by it, & have heard only one or two instances of the Blacks being affected with it.

That the fever was in degree contagious I cannot entertain a doubt; but that it was not as in a very high degree I am as fully persuaded from the small number of cases in which there was reason to believe it would not have been taken in any other way. In most instances where contagion might have been suspected, the subjects were so situated, that they might have received it from the same source as those with whom they had communicated. I cannot learn that any evidence has been furnished of infection by the sick, who had been removed to the country, though there were many instances of such removals under the most malignant forms which it assumed.

The fever was generally ushered in by a chill, but I think by no means equal to that which commonly preceded fevers of the ardent kind; nor in proportion to the violence of its subsequent periods. In a short time the rigors were succeeded by excessive heat, the pulse which had been small and contracted became hard and full, the respiration laborious from violent oppression at the ------lus cordis; the tongue assumed a whitish cast; the eyes became highly inflamed; while the pains in the head, back and legs became intolerably severe. To these symptoms succeeded nausea and vomiting of a highly bilious matter, seldom attended with Diarrhea, but often with a burning at the stomach, tenderness of the abdomen, paucity of urine and in one instance a Dysuria [painful discharge of urine] with a great proportion of blood at each evacuation of that fluid.

These appearances usually continued about 48 hours, after which they suddenly gave place to a very different train of symptoms. The pulse sunk astonishingly and became intermittent; the heat and pains entirely subsided and the patient supposed himself to be out of danger. From a perfect possession of all his intellectual faculties with a serenity of mind, which in no other disease is I believe so generally observed to accompany its last stages, on about the 5th day from the accession of the fever, he fell into a state of insensibility and thence sunk gently into the arms of death. In others this change was less rapid - the pulse became gradually smaller, the distressing symptoms slowly abated, a coldness of the extremities took place and continued for several days before death, accompanied with alarming sweats often without any perceptible pulse in the wrists for several hours before the fatal termination.

The tongue seldom became much coated to the last. Delirium was by no means generally attendant and a yellowness of the skin was far from being universal - sometimes however this appearance was observed within the three first days, often on the fourth and fifth and I was induced rather to consider it an accident than a constituent character of the disease.

For the discoveries which were made on the dissection of some of the persons who died with the disease, I beg leave to refer you to a publication in the Boston Centinel made during the prevalence of the disorder in this place and subscribed by Doctor Isaac Rand President of the Medical Society and myself.

We had heretofore treated our patients agreeably to the method practiced at Philadelphia in 1793, with bleeding in most instances and active purges of Jal. [jalap] & Cal.[calomel] or Rochelle salts. The diseased state of the liver, the known effects of mercury on hepatitis and a recollection of the suggestion contained in Dr. Rush's publication on the yellow fever, together with those of several other celebrated writers on the same subject induced us to enter immediately on the use of calomel in small doses as recommended in our paper above referred to.

In my own practice I now usually commenced the treatment by bleeding from ten to sixteen ounces, & followed it with a dose of between ten & fifteen grains of Cal. with between twenty and twenty-five grs, of Jal., or an ounce of Rochelle salts or more according to the constitution. Immediately after the operation of those medicines I began with the use of Cal. in small doses in pills of a gr. every hour and sometimes of 3 grs. every 2 hours - within the first 24 hours but scarely ever after. I found occasion frequently to repeat the bleeding two or three times, & it is worthy of remark that in scarcely a single instance was this operation performed without almost instantaneous relief, altho' in most cases, a few hours after there was a recurrence of the symptoms. The blood for the most part was uncommonly dark. In three cases there was no separation of serum from the coagulated mass at the end of 28 hours. In two of these (& they were the only cases in which I observed it) a firm buff was formed on its surface, and all three died of the disease.

The calomel was often continued through the whole course of the fever and a ptyalism was usually brought on within three or four days, tho' sometimes upwards of 200 grns. were given at a rate of a grain every hour without any specific effect on the salivary glands. In proportion as the soreness of the mouth advanced, the symptoms universally gave way, and in every patient, two only excepted, this effect of the medicine was a certain pledge of recovery. In this exception were comprehended two patients of the same family, a father & daughter, both of whom has survived the 12th day of the disorder, had compious hemorrhages from the mouth (a circumstance which also attended on many who recovered) & and died in a state of apparent putrefaction.

The purgative medicines were generally repeated every second day, or an enema of water gruel was administered occasionally if the bowels were constipated; but if otherwise and the Cal. passed off by those emunctories, opium was combined with it in sufficient quantities to restrain the discharge. The evacuation which took place from the intestines during the use of the mercury were almost universally of a remarkably black color generally approaching to a deep green, but by no mean extremely foetid. When spontaneous they were often observed to be of the color & consistence of water gruel.

In cases of very laborious respiration, which was frequently in an extreme degree distressing, especially after the first 36 or 48 hours had elapsed, blisters applied either to the chest or extremities had a favorable effect; on the latter they were most useful in the advanced stages of the disease, by exciting to action the debilitated vessels, and by restoring circulation & warmth to the parts. In the same intention wine, snake root and the bark were sometimes used with advantage.

The diet was generally of the lightest & most cooling nature. Barley water, apple water & spruce beer were generally both grateful and salutary. The warm bath was often exhibited with apparent success, especially in the beginning of the disease, & when a copious sweat had been induced by it. The cold bath was also resorted to by some respectable practitioners and perhaps under some circumstance with good effects, but I have no reason to think it was generally salutary.

Upon the whole I believe the most efficacious remedy and the only one to be relied on is mercury. It is certain that as far as my observation has extended under no other method of treatment did so many recover, and there were but few instances of fatal termination where it had been administered from the commencement of the fever.

Various have been the causes assigned to this disease. That its origin was domestic I have not a single doubt. No instance of the arrival of any vessel from the warmer latitudes with sickness on board has been discovered and it is believe that the local causes are sufficiently numerous to account for its existence. At most of the places where its ravages have been made, very large quantities of putrid substances has been sometime accumulating. The offals from the fish market as well damaged fresh and salted fish to an immense amount had been thrown into the dock. A very great number of raw hides had been imported & stored in places contiguous to those in which business was constantly going on. The influence of a continued heat thro the summer to a degree scarcely know before in this country had rendered these articles highly putrid and from the same cause several articles of provision such as barrelled beef & c. which had been prepared for exportation but by reasons of the restraints laid on our commerce retained in store, had become tainted. The effects of these were in some instances incontestably evinced. Three lads who had been employed in repacking beef were at about the same time seized with the disease in its most fatal form; and a person who had purchased some of the hides at a low price immediately after their removeal fell a sacrifice to his folly.

Two or three thousand of the inhabitants removed into the country and returned about the middle of October, when the decline of the disease justified the measure.