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 by 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. Many similar cases might be mentioned. Even children took two or three doses of it with perfect safety. This will not surprise those physicians who have been in the practice of giving from ten to twenty grains of mercury, with an equal quantity of jalap as a worm purge, and from fifty to a hundredgrains of calomel, in the course of four or five days, in the internal dropsy of the brain. But 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. One of them had twice miscarried in the course of the two or three last years of her life. She bore a healthy child three months after her recovery from the yellow fever.
No one has ever objected to theindiscriminatemode of preparing the body for the small-pox by purging medicines. Theuniforminflammatory diathesis of that disease justifies the practice, in a certain degree, in all habits. The yellow fever admits of a sameness of cure much more than the small-pox, for it ismoreuniformly and more highly inflammatory. An observation of Dr. Sydenham upon epidemics applies, in its utmost extent, to our late fever. “Now it must be observed (says this most acute physician) that some epidemic diseases, in some years, are uniformly and constantly the same[73].” However diversified our fever wasin some of its symptoms, it was in all cases accompanied by more or less inflammatory diathesis, and by a morbid state of the alimentary canal.
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 surprised by the disease 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. I am led to make this assertion, not only from the authority of Dr. Sydenham, who often mentions the good effectsof bleeding in moderating or checking a diarrhœa, but by having heard no complaints of patients being purged to death by this medicine, after blood-letting was universally adopted by all the physicians in the city.
It was remarked that the demand for this purging powder continued to increase under all opposition, and that the sale of it by the apothecaries was greatest towards the close of the disease. I shall hereafter say that this was not the case with the West-India remedies.
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 thefirsttime 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. Dr. Lawrence informed me that he had cured many patients by it of the yellow fever which prevailed in New-York, in the year 1791, and the New-York papers have told us that several practitionershad been in the habit of giving it in the autumnal fevers, with great success, in the western parts of that state. They had probably learned the use of it from Dr. Young, who formerly practised in that part of the United States, and who lost no opportunity of making its praises public wherever he went.
I have only to add to my account of that purging medicine, that, under an expectation that the yellow fever would mingle some of its bilious symptoms with the common inflammatory fevers of the winter and first spring months, I gave that purge in the form of pills, in every case of inflammatory fever to which I was called. The fatal issue of several fevers in the city, during the winter, in which this precaution had been neglected, convinced me that my practice was proper and useful.
It is to be lamented that all new remedies are forced to pass through a fiery ordeal. Opium and bark were long the objects of terror and invective in the schools of medicine. They were administered only by physicians for many years, and that too with all the solemnity of a religious ceremony. This error, with respect to those medicines, has at last passed away. It will, I hope, soon be succeeded by a time when the prejudices againsttenandten, ortenandfifteen, will sleep with the vulgar fears which were formerly entertained of the bark producing diseases and death, years after it had been taken, by “lying in the bones.”
The theory of this fever which led me to administer purges, determined me to use blood-letting, as soon as it should be indicated. I am disposed to believe that I was tardy in the use of this remedy, and I shall long regret the loss of three patients, who might probably have been saved by it. I cannot blame myself for not having used it earlier, for the immense number of patients which poured in upon me, in the first week of September, prevented my attending so much to each of them, as was necessary to determine upon the propriety of this evacuation. I was in the situation of a surgeon in a battle, who runs to every call, and only stays long enough with each soldier to stopthe bleeding of his wound, while the increase of the wounded, and the unexpected length of the battle, leave his original patients to suffer from the want of more suitable dressings. The reasons which determined me to bleed were,
1. The state of the pulse, which became more tense, in proportion as the weather became cool.
2. The appearance of a moist andwhitetongue, on the first day of the disease, a certain sign of an inflammatory fever.
3. The frequency of hæmorrhages from every part of the body, and the perfect relief given in some cases by them.
4. The symptoms of congestion in the brain, resembling those which occur in the first stage of hydrocephalus internus, a disease in which I had lately used bleeding with success.
5. The character of the diseases which had preceded the yellow fever. They were all more or less inflammatory. Even the scarlatina anginosa had partaken so much of that diathesis, as to require bleeding to subdue it.
6. The warm and dry weather which had likewise preceded the fever. Dr. Sydenham attributes a highly inflammatory state of the small-pox to a previously hot and dry summer; and I have since observed, that Dr. Hillary takes notice of inflammatory fevers having frequently succeeded hot and dry weather in Barbadoes[74]. He informs us further, that the yellow fever is always most acute and inflammatory after a very hot season[75].
7. The authority of Dr. Mosely had great weight with me in advising the loss of blood, more especially as his ideas of the highly inflammatory nature of the fever accorded so perfectly with my own.
8. I was induced to prescribe blood-letting by recollecting its good effects in Mrs. Palmer's son, whom I bled on the 20th of August, and who appeared to have been recovered by it.
Having begun to bleed, I was encouraged to continue it by the appearance of the blood, and by the obvious and very great relief my patients derived from it.
The following is a short account of the appearances of the blood drawn from a vein in this disease.
1. It was, in the greatest number of cases, without any separation into crassamentum and serum, and of a scarlet colour.
2. There was in many cases a separation of the blood into crassamentum andyellowserum.
3. There were a few cases in which this separation took place, and the serum was of anaturalcolour.
4. There were many cases in which the blood was as sizy as in pneumony and rheumatism.
5. The blood was in some instances covered above with blue pellicle of sizy lymph, while the part which lay in the bottom of the bowl was dissolved. The lymph was in two cases mixed with green streaks.
6. It was in a few instances of a dark colour, and as fluid as molasses. I saw this kind of blood in a man who walked about his house during the whole of his sickness, and who finally recovered.Both this, and the fifth kind of blood which has been mentioned, occurred chiefly where bleeding had been omitted altogether, or used too sparingly in the beginning of the disease.
7. In some patients the blood, in the course of the disease, exhibited nearlyallthe appearances which have been mentioned. They were varied by the time in which the blood was drawn, and by the nature and force of the remedies which had been used in the disease.
The effects of blood-letting upon the system were as follow:
1. It raised the pulse when depressed, and quickened it, when it was preternaturally slow, or subject to intermissions.
2. It reduced its force and frequency.
3. It checked in many cases the vomiting which occurred in the beginning of the disease, and thereby enabled the stomach to retain the purging medicine. It likewise assisted the purge in preventing the dangerous or fatal vomiting which came on about the fifth day.
4. It lessened the difficulty of opening the bowels. Upon this account, in one of my addresses to the citizens of Philadelphia, I advised bleeding to be usedbefore, as well as after taking the mercurial purge. Dr. Woodhouse informed me that he had several times seen patients call for the close-stool while the blood was flowing from the vein.
5. It removed delirium, coma, and obstinate wakefulness. It also prevented or checked hæmorrhages; hence perhaps another reason why not a single instance of abortion occurred in such of my female patients as were pregnant.
6. It disposed, in some cases, to a gentle perspiration.
7. It lessened the sensible debility of the system; hence patients frequently rose from their beds, and walked across their rooms, in a few hours after the operation had been performed.
8. The redness of the eyes frequently disappeared in a few hours after bleeding. Mr. Coxe observed a dilated pupil to contract to its natural size within a few minutes after he had bound up the arm of his patient. I remarked, in the former part of this work, that blindness in many instancesattended or followed this fever. But two such cases occurred among my patients. In one of them it was of short continuance, and in the other it was probably occasioned by the want of sufficient bleeding. In every case of blindness that came to my knowledge bleeding had been omitted, or used only in a very moderate degree.
9. It easedpain. Thousands can testify this effect of blood-letting. Many of my patients whom I bled with my own hand acknowledged to me, while the blood was flowing, that they were better; and some of them declared, that all their pains had left them before I had completely bound up their arms.
10. But blood-letting had, in many cases, an effect the opposite ofeasingpain. It frequently increased it in every part of the body, more especially in the head. It appeared to be the effect of the system rising suddenly from a state of great depression, and of an increased action of the blood-vessels which took place in consequence of it. I had frequently seen complaints of the breast, and of the head, made worse by a single bleeding, and from the same cause. It was in some cases an unfortunate event in the yellow fever, for it prevented the blood-letting being repeated, by excitingor strengthening the prejudices of patients and physicians against it. In some instances the patients grew worse after a second, and, in one, after a third bleeding. This was the case in Miss Redman. Her pains increased after three bleedings, but yielded to the fourth. Her father, Dr. Redman, concurred in this seemingly absurd practice. It was at this time my old preceptor in medicine reminded me of Dr. Sydenham's remark, that moderate bleeding did harm in the plague where copious bleeding was indicated, and that in the cure of that disease, we should leave nature wholly to herself, or take the cure altogether out of her hands. The truth of this remark was very obvious. By taking away as much blood as restored the blood-vessels to a morbid degree of action, without reducing this action afterwards, pain, congestion, and inflammation were frequently increased, all of which were prevented, or occurred in a less degree, when the system rose gradually from the state of depression which had been induced by the great force of the disease. Under the influence of the facts and reasonings which have been mentioned I bore the same testimony in acute cases, against what was calledmoderatebleeding that I did against bark, wine, and laudanum in this fever.
11. Blood-letting, when usedearlyon the first day, frequently strangled the disease in its birth, and generally rendered it more light, and the convalescence more speedy and perfect. I am not sure that it ever shortened the duration of the fever where it was not used within a few hours of the time of its attack. Under every mode of treatment it seemed disposed, after it was completely formed, to run its course. I was so satisfied of this peculiarity in the fever, that I ventured in some cases to predict the day on which it would terminate, notwithstanding I took the cure entirely out of the hands of nature. I did not lose a patient on the third, whom I bled on the first or second day of the disease.
12. In those cases which ended fatally, blood-letting restored, or preserved the use of reason, rendered death easy, and retarded the putrefaction of the body after death.
I shall now mention some of the circumstances which directed and regulated the use of this remedy.
1. Where bleeding had been omitted for three days, in acute cases, it was seldom useful. Where purging had been used, it was sometimes successful.I recovered two patients who had taken the mercurial purges, whom I bled for the first time on the seventh day. One of them was the daughter of Mr. James Cresson, the other was a journeyman ship-carpenter at Kensington. In those cases where bleeding had been used on the first day, it was both safe and useful to repeat it every day afterwards, during the continuance of the fever.
2. I preferred bleeding in the exacerbation of the fever. The remedy here was applied when the disease was in its greatest force. A single paroxysm was like a sudden squall to the system, and, unless abated by bleeding or purging, often produced universal disorganization. I preferred the former to the latter remedy in cases of great danger, because it was more speedy, and more certain in its operation.
3. I bled in several instances in the remission of the fever, where the pulse was tense and corded. It lessened the violence of the succeeding paroxysm.
4. I bled in all those cases in which the pulse was preternaturally slow, provided it was tense. Mr. Benj. W. Morris, Mr. Thomas Wharton, jun. and Mr. Wm. Sansom, all owe their lives probably to their having been bled in the abovestate of the pulse. I was led to use bleeding in this state of the pulse, not only by the theory of the disease which I had adopted, but by the success which had often attended this remedy, in a slow and depressed state of the pulse in apoplexy and pneumony. I had moreover the authority of Dr. Mosely in its favour, in the yellow fever, and of Dr. Sydenham, in his account of a new fever, which appeared in the year 1685. The words of the latter physician are so apposite to the cases which have been mentioned, that I hope I shall be excused for inserting them in this place. “All the symptoms of weakness (says our author) proceed from nature's being in a manner oppressed and overcome by the first attack of the disease, so as not to be able to raise regular symptoms adequate to the violence of the fever. I remember to have met with a remarkable instance of this, several years ago, in a young man I then attended; for though he seemed in a manner expiring, yet the outward parts felt so cool, that I could not persuade the attendants he had a fever, which could not disengage, and show itself clearly, because the vessels were so full as to obstruct the motion of the blood. However, I said, that they would soon find the fever rise high enough upon bleeding him. Accordingly, after taking away a large quantity of blood, as violent a fever appeared as ever I met with, anddid not go off till bleeding had been used three or four times[76].”
5. I bled in those cases in which the fever appeared in a tertian form, provided the pulse was full and tense. I well recollect the surprise with which Mr. Van Berkel heard this prescription from me, at a time when he was able to walk and ride out on the intermediate days of a tertian fever. The event which followed this prescription showed that it was not disproportioned to the violence of his disease, for it soon put on such acute and inflammatory symptoms as to require six subsequent bleedings to subdue it.
6. I bled in those cases where patients were able to walk about, provided the pulse was the same as has been mentioned under the fourth head. I was determined as to the propriety of bleeding in these two supposed mild forms of the fever, by having observed each of them, when left to themselves, frequently to terminate in death.
7. I paid no regard to the dissolved state of the blood, when it appeared on the first or second day of the disease, but repeated the bleedings afterwardsin every case, where the pulse continued to indicate it. It was common to see sizy blood succeed that which was dissolved. This occurred in Mr. Josiah Coates, and Mr. Samuel Powel. Had I believed that this dissolved state of the blood arose from its putrefaction, I should have laid aside my lancet as soon as I saw it; but I had long ago parted with all ideas of putrefaction in bilious fevers. The refutation of this doctrine was the object of one of my papers in the Medical Society of Edinburgh, in the year 1767. The dissolved appearance of the blood, I suppose to be the effect of a certain action of the blood-vessels upon it. It occurs in fevers which depend upon the sensible qualities of the air, and in which no putrid or foreign matter has been introduced into the system.
8. The presence of petechiæ did not deter me from repeating blood-letting, where the pulse retained its fulness or tension. I prescribed it with success in the cases of Dr. Mease, and of Mrs. Gebler, in Dock-street, in each of whom petechiæ had appeared. Bleeding was equally effectual in the case of the Rev. Mr. Keating, at a time when his arms were spotted with that species of eruptions which I have compared to moscheto-bites. I hadprecedents in Dr. De Haen[77]and Dr. Sydenham[78], in favour of this practice. So far from viewing these eruptions as signs of putrefaction, I considered them as marks of the highest possible inflammatory diathesis. They disappeared in each of the above cases after bleeding.
9. In determining the quantity of blood to be drawn, I was governed by the state of the pulse, and by the temperature of the weather. In the beginning of September, I found one or two moderate bleedings sufficient to subdue the fever; but in proportion as the system rose by the diminution of the stimulus of heat, and the fever put on morevisiblesigns of inflammatory diathesis, more frequent bleedings became necessary. I bled many patients twice, and a few three times a day. I preferred frequent and small, to large bleedings, in the beginning of September; but towards the height and close of the epidemic, I saw no inconvenience from the loss of a pint, and even twenty ounces of blood at a time. I drew from many persons seventy and eighty ounces in five days; and from a few, a much larger quantity. Mr. Gribble, cedar-cooper, in Front-street, lost byten bleedings a hundred ounces of blood; Mr. George, a carter in Ninth-street, lost about the same quantity by five bleedings; and Mr. Peter Mierken, one hundred and fourteen ounces in five days. In the last of the above persons the quantity taken was determined by weight. Mr. Toy, blacksmith near Dock-street, was eight times bled in the course of seven days. The quantity taken from him was about a hundred ounces. The blood in all these cases was dense, and in the last, very sizy. They were all attended in the month of October, and chiefly by my pupil, Mr. Fisher; and they were all, years afterwards, living and healthy instances of the efficacy of copious blood-letting, and of the intrepidity and judgment of their young physician. Children, and even old people, bore the loss of much more blood in this fever than in common inflammatory fevers. I took above thirty ounces, in five bleedings, from a daughter of Mr. Robert Bridges, who was then in the 9th year of her age. Even great debility, whether natural or brought on by previous diseases, did not, in those few cases in which it yielded to the fever, deprive it of the uniformity of its inflammatory character. The following letter from Dr. Griffitts, written soon after his recovery from a third attack of the fever, and just before he went into the country for the re-establishment of his health, willfurnish a striking illustration of the truth of the above observation.
“I cannot leave town without a parting adieu to my kind friend, and sincere prayers for his preservation.
“I am sorry to find that the use of the lancet is still so much dreaded by too many of our physicians; and, while lamenting the death of a valuable friend this morning, I was told that he was bled butonceduring his disease. Now if my poor frame, reduced by previous sickness, great anxiety, and fatigue, and a very low diet, could bearsevenbleedings in five days, besides purging, and no diet but toast and water, what shall we say of physicians who bleed but once?
“October 19th, 1793.”
I have compared a paroxysm of this fever to a sudden squall; but the disease in its whole course was like a tedious equinoctial gale acting upon a ship at sea; its destructive force was only to be opposed by handing every sail, and leaving the system to float, as it were, under bare poles. Such was the fragility (if I may be allowed the expression) of the blood-vessels, that it was necessary tounload them of their contents, in order to prevent the system sinking from hæmorrhages, or from effusions in the viscera, particularly the brain.
9. Such was the indomitable nature of the pulse, in some patients, that it did not lose its force after numerous and copious bleedings. In all such cases I considered the diminution of its frequency, and the absence of a vomiting, as signals to lay aside the lancet. The continuance of this preternatural force in the pulse appeared to be owing to the miasmata, which were universally diffused in the air, acting upon the arterial system in the same manner that it did in persons who were in apparent good health.
Thus have I mentioned the principal circumstances which were connected with blood-letting in the cure of the yellow fever. I shall now consider the objections that were made to it at the time, and since the prevalence of the fever.
It was said that the bleeding was unnecessarily copious; and that many had been destroyed by it. To this I answer, that I did not lose a single patient whom I bled seven times or more in this fever. As a further proof that I did not draw an ounce of blood too much it will only be necessaryto add, that hæmorrhages frequently occurred after a third, a fourth, and in one instance (in the only son of Mr. William Hall) after a sixth bleeding had been used; and further, that not a single death occurred from natural hæmorrhages in the first stage of the disease. A woman, who had been bled by my advice, awoke the night following in a bath of her blood, which had flowed from the orifice in her arm. The next day she was free from pain and fever. There were many recoveries in the city from similar accidents. There were likewise some recoveries from copious natural hæmorrhages in the more advanced stages of the disease, particularly when they occurred from the stomach and bowels. I left a servant maid of Mrs. Morris's, in Walnut-street, who had discharged at least four pounds of blood from her stomach, without a pulse, and with scarcely a symptom that encouraged a hope of her life; but the next day I had the pleasure of finding her out of danger.
It was remarked that fainting was much less common after bleeding in this fever than in common inflammatory fevers. This circumstance was observed by Dr. Griffitts, as well as myself. It has since been confirmed to me by three of the principal bleeders in the city, who performed theoperation upwards of four thousand times. It occurred chiefly in those cases where it was used for the first time on the third or fourth day of the disease. A swelling of the legs, moreover, so common after plentiful bleeding in pneumony and rheumatism, rarely succeeded the use of this remedy in the yellow fever.
2. Many of the indispositions, and much of the subsequent weakness of persons who had been cured by copious blood-letting, have been ascribed to it. This is so far from being true that the reverse of it has occurred in many cases. Mr. Mierken worked in his sugar-house, in good health, nine days after his last bleeding; and Mr. Gribble and Mr. George seemed, by their appearance, to have derived fresh vigour from their evacuations. I could mention the names of many people who assured me their constitutions had been improved by the use of those remedies; and I know several persons in whom they have carried off habitual complaints. Mr. Richard Wells attributed his relief from a chronic rheumatism to the copious bleeding and purging which were used to cure him of the yellow fever; and Mr. William Young, the bookseller, was relieved of a chronic pain in his side, by means of the same remedies.
3. It was said, that blood-letting was prescribed indiscriminately in all cases, without any regard to age, constitution, or the force of the disease. This is not true, as far as it relates to my practice. In my prescriptions for patients whom I was unable to visit, I advised them, when they were incapable of judging of the state of the pulse, to be guided in the use of bleeding, by the degrees of pain they felt, particularly in the head; and I seldom advised it for thefirsttime, after the second or third day of the disease.
In pneumonies which affect whole neighbourhoods in the spring of the year, bleeding is the universal remedy. Why should it not be equally so, in a fever which is of a more uniform inflammatory nature, and which tends more rapidly to effusions, in parts of the body much more vital than the lungs?
I have before remarked, that the debility which occurs in the beginning of the yellow fever, arises from a depressed state of the system. The debility in the plague is of the same nature. It has long been known that debility from the sudden abstraction of stimuli is to be removed by thegradualapplication of stimuli, but it has been less observed, that the excess of stimulus in the system is bestremoved in agradualmanner, and that too in proportion to the degrees of depression, which exist in the system.
This principle in the animal economy has been acknowledged by the practice of occasionally stopping the discharge of water from a canula in tapping, and of blood from a vein, in order to prevent fainting.
Child-birth induces fainting, and sometimes death, only by thesuddenabstraction of the stimulus of distention and pain.
In all those cases where purging or bleeding have produced death in the yellow fever or plague, when they have been used on the first or second day of those diseases, I suspect that it was occasioned by the quantity of the stimulus abstracted being disproportioned to the degrees of depression in the system. The following facts will I hope throw light upon this subject.
1. Dr. Hodges informs us, that “although blood could not be drawn in the plague, even in the smallest quantity without danger, yet ahundredtimes the quantity of fluids was discharged in pus from buboes without inconvenience[79].”
2. Pareus, after condemning bleeding in the plague, immediately adds an account of a patient, who was saved by a hæmorrhage from the nose, which continuedtwodays[80].
3. I have before remarked that bleeding proved fatal in three cases in the yellow fever, in the month of August; but at that time I saw one, and heard of another case, in which death seemed to have been prevented by a bleeding at the nose. Perhaps the uniform good effects which were observed to follow a spontaneous hæmorrhage from an orifice in the arm, arose wholly from thegradualmanner in which the stimulus of the blood was in this way abstracted from the body. Dr. Williams relates a case of the recovery of a gentleman from the yellow fever, by means of small hæmorrhages, which continued three days, from wounds in his shoulders made by being cupped. He likewise mentions several other recoveries by hæmorrhages from the nose, after “a vomitingof black humours and a hiccup had taken place[81].”
4. There is a disease in North-Carolina, known among the common people by the name of the “pleurisy in the head.” It occurs in the winter, after a sickly autumn, and seems to be an evanescent symptom of a bilious remitting fever. The cure of it has been attempted by bleeding, in the common way, but generally without success. It has, however, yielded to this remedy in another form, that is, to the discharge of a few ounces of blood obtained by thrusting a piece of quill up the nose.
5. Riverius describes a pestilential fever which prevailed at Montpellier, in the year 1623, which carried off one half of all who were affected by it[82]. After many unsuccessful attempts to cure it, this judicious physician prescribed the loss oftwoorthreeounces of blood. The pulse rose with this small evacuation. Three or four hours afterwards he drew six ounces of blood from his patients, and with the same good effect. The next day he gave a purge, which, he says, rescued hispatients from the grave. All whom he treated in this manner recovered. The whole history of this epidemic is highly interesting, from its agreeing with our late epidemic in so many of its symptoms, more especially as they appeared in the different states of the pulse.
An old and intelligent citizen of Philadelphia, who remembers the yellow fever of 1741, says that when it first made its appearance bleeding was attended with fatal consequences. It was laid aside afterwards, and the disease prevailed with great mortality until it was checked by the cold weather. Had blood been drawn in the manner mentioned by Riverius, or had it been drawn in the usual way, after the abstraction of the stimulus of heat by the cool weather, the disease might probably have been subdued, and the remedy of blood-letting thereby have recovered its character.
Dr. Hodges has another remark, in his account of the plague in London in the year 1665, which is still more to our purpose than the one which I have quoted from it upon this subject. He says that “bleeding, as a preventive of the plague, was only safe and useful when the blood was drawn byasmallorifice, and asmallquantity taken atdifferenttimes[83].”
I have remarked, in the history of this fever, that it was often cured on the first or second day by a copious sweat. The Rev. Mr. Ustick was one among many whom I could mention, who were saved from a violent attack of the fever by this evacuation. It would be absurd to suppose that the miasmata which produced the disease were discharged in this manner from the body. The sweat seemed to cure the fever only by lessening the quantity of the fluids, and thusgraduallyremoving the depression of the system. The profuse sweats which sometimes cure the plague, as well as the disease which is brought on by the bite of poisonous snakes, seem to act in the same way.
The system, in certain states of malignant fever, resembles a man struggling beneath a load of two hundred weight, who is able to lift but one hundred and seventy-five. In order to assist him it will be to no purpose to attempt to infuse additional vigour into his muscles by the use of a whip or of strong drink. Every exertion will serve onlyto waste his strength. In this situation (supposing it impossible to divide the weight which confines him to the ground) let the pockets of this man be emptied of their contents, and let him be stripped of so much of his clothing as to reduce his weight five and twenty or thirty pounds. In this situation he will rise from the ground; but if the weights be abstracted suddenly, while he is in an act of exertion, he will rise with a spring that will endanger a second fall, and probably produce a temporary convulsion in his system. By abstracting the weights from his body more gradually, he will rise by degrees from the ground, and the system will accommodate itself in such a manner to the diminution of its pressure, as to resume its erect form, without the least deviation from the natural order of its appearance and motions.
It has been said that the stimulating remedies of bark, wine, and the cold bath, were proper in our late epidemic in August, and in the beginning of September, but that they were improper afterwards. If my theory be just, they were more improper in August and the beginning of September, than they were after the disease put on the outward and common signs of inflammatory diathesis. The reason why a few strong purges cured the disease at its first appearance, was, becausethey abstracted in agradualmanner some of the immense portion of stimulus under which the arterial system laboured, and thus gradually relieved it from its low and weakening degrees of depression. Bleeding was fatal in these cases, probably because it removed this depression in too sudden a manner.
The principle of the gradual abstraction, as well as of the gradual application of stimuli to the body, opens a wide field for the improvement of medicine. Perhaps all the discoveries of future ages will consist more in a new application of established principles, and in new modes of exhibiting old medicines, than in the discovery of new theories, or of new articles of the materia medica.
The reasons which induced me to prescribe purging and bleeding, in so liberal a manner, naturally led me to recommendcoolandfresh airto my patients. The good effects of it were obvious in almost every case in which it was applied. It was equally proper whether the arterial system was depressed, or whether it discovered, in the pulse, a high degree of morbid excitement. Dr. Griffitts furnished a remarkable instance of the influence of cool air upon the fever. Upon my visiting him, on the morning of the 8th of October, I found his pulse so full and tense as to indicatebleeding, but after sitting a few minutes by his bed-side, I perceived that the windows of his room had been shut in the night by his nurse, on account of the coldness of the night air. I desired that they might be opened. In ten minutes afterwards the doctor's pulse became so much slower and weaker that I advised the postponement of the bleeding, and recommended a purge instead of it. The bleeding notwithstanding became necessary, and was used with great advantage in the afternoon of the same day.
The cool air was improper only in those cases where a chilliness attended the disease.
For the same reason that I advised cool air, I directed my patients to use colddrinks. They consisted of lemonade, tamarind, jelly and raw apple water, toast and water, and of weak balm, and camomile tea. The subacid drinks were preferred in most cases, as being not only most agreeable to the taste, but because they tended to compose the stomach. All these drinks were taken in the early stage of the disease. Towards the close of it, I permitted the use of porter and water, weak punch, and when the stomach would bear it, weak wine-whey.
I forbade all cordial and stimulating food in the active state of the arterial system. The less my patients ate, of even the mildest vegetable food, the sooner they recovered. Weak coffee, which (as I have formerly remarked) was almost universally agreeable, and weak tea were always inoffensive. As the action of the pulse diminished, I indulged my patients with weak chocolate; also with milk, to which roasted apples, or minced peaches, and (where they were not to be had), bread or Indian mush were added.
Towards the crisis, I advised the drinking of weak chicken, veal, or mutton broth, and after the crisis had taken place, I permitted mild animal food to be eaten in a small quantity, and to be increased according to the waste of the excitability of the system. This strict abstinence which I imposed upon my patients did not escape obloquy; but the benefits they derived from it, and the ill effects which arose in many cases from a contrary regimen, satisfied me that it was proper in every case in which it was prescribed.
Cold waterwas a most agreeable and powerful remedy in this disease. I directed it to be applied by means of napkins to the head, and to be injected into the bowels by way of glyster. It gave thesame ease to both, when in pain, which opium gives to pain from other causes. I likewise advised the washing of the face and hands, and sometimes the feet, with cold water, and always with advantage. It was by suffering the body to lie for some time in a bed of cold water, that the inhabitants of the island of Massuah cured the most violent bilious fevers[84]. When applied in this way, itgraduallyabstracts the heat from the body, and thereby lessens the action of the system. It differs as much in its effects upon the body from the cold bath, as rest in a cold room, differs from exercise in the cold and open air.
I was first led to the practice of the partial application of cold water to the body, in fevers of too much force in the arterial system, by observing its good effects in active hæmorrhages, and by recollecting the effects of a partial application of warm water to the feet, in fevers of an opposite character. Cold water when applied to the feet as certainly reduces the pulse in force and frequency, as warm water, applied in the same way, produces contrary effects upon it. In an experiment which was made at my request, by one of my pupils, by placing his feet in cold pump water fora few minutes, the pulse was reduced 24 strokes in a minute, and became so small as hardly to be perceptible.
But this effect of cold water, in reducing the frequency of the pulse, is not uniform. In weak and irritable habits, it increases its frequency. This has been fully proved by a number of experiments, made by my former pupil, Dr. Stock, of Bristol, in England, and published in his “Medical Collections of the Effects of Cold, as a Remedy in certain Diseases[85].”
In the use of the remedies which were necessary to overcome the inflammatory action of the system, I was obliged to reduce it below its natural point of excitement. In the present imperfect state of our knowledge in medicine, perhaps no disease of too much action can be cured without it.
Besides the remedies which have been mentioned, I was led to employ another of great efficacy. I had observed a favourable issue of the fever, in every case in which a spontaneous discharge took place from the salivary glands. I had observed further, that all such of my patients (oneexcepted) as were salivated by the mercurial purges recovered in a few days. This early suggested an idea to me that the calomel might be applied to other purposes than the discharging of bile from the bowels. I ascribed its salutary effects, when it salivated in the first stage of the disease, to the excitement of inflammation and effusion in the throat, diverting them from more vital parts of the body. In the second stage of the disease, I was led to prescribe it as a stimulant, and, with a view of obtaining this operation from it, I aimed at exciting a salivation, as speedily as possible, in all cases. Two precedents encouraged me to make trial of this remedy.
In the month of October, 1789, I attended a gentleman in a bilious fever, which ended in many of the symptoms of a typhus mitior. In the lowest state of his fever, he complained of a pain in his right side, for which I ordered half an ounce of mercurial ointment to be rubbed on the part affected. The next day, he complained of a sore mouth, and, in the course of four and twenty hours, he was in a moderate salivation. From this time his pulse became full and slow, and his skin moist; his sleep and appetite suddenly returned, and in a day or two he was out of danger. The second precedent for a salivation in a fever, which occurredto me, was in Dr. Haller's short account of the works of Dr. Cramer[86]. The practice was moreover justified, in point of safety, as well as the probability of success, by the accounts which Dr. Clark has lately given of the effects of a salivation in the dysentery[87]. I began by prescribing the calomel in small doses, at short intervals, and afterwards I directed large quantities of the ointment to be rubbed upon the limbs. The effects of it, in every case in which it affected the mouth, were salutary. Dr. Woodhouse improved upon my method of exciting the salivation, by rubbing the gums with calomel, in the manner directed by Mr. Clare. It was more speedy in its operation in this way than in any other, and equally effectual. Several persons appeared to be benefited by the mercury introduced into the system in the form of an ointment, where it didnotproduce a salivation. Among these, were the Rev. Dr. Blackwell, and Mr. John Davis.
Soon after the above account was written of the good effects of a mercurial salivation in this fever, I had great satisfaction in discovering that it hadbeen prescribed with equal, and even greater success, by Dr. Wade in Bengal, in the year 1791, and by Dr. Chisholm in the island of Granada, in the cure of bilious yellow fevers[88]. Dr. Wade did not lose one, and Dr. Chisholm lost only one out of forty-eight patients in whom the mercury affected the salivary glands. The latter gave 150 grains of calomel, and applied the strongest mercurial ointment below the groin of each side, in some cases. He adds further, that not a single instance of a relapse occurred, where the disease was cured by salivation.
After the reduction of the system,blisterswere applied with great advantage to every part of the body. They did most service when they were applied to the crown of the head. I did not see a single case, in which a mortification followed the sore, which was created by a blister.
Brandy and water, or porter and water, when agreeable to the stomach, with now and then a cup of chicken broth, were the drinks I prescribed to assist in restoring the tone of the system.
In some cases I directed the limbs to be wrapped in flannels dipped in warm spirits, and cataplasms of bruised garlic to be applied to the feet. But my principal dependence, next to the use of mercurial medicines, for exciting a healthy action in the arterial system, was upon mild and gently stimulating food. This consisted of rich broths, the flesh of poultry, oysters, thick gruel, mush and milk, and chocolate. I directed my patients to eat or drink a portion of some of the above articles of diet every hour or two during the day, and in cases of great debility, from an exhausted state of the system, I advised their being waked for the same purpose two or three times in the night. The appetite frequently craved more savoury articles of food, such as beef-stakes and sausages; but they were permitted with great caution, and never till the system had been prepared for them by a less stimulating diet.
There were severalsymptomswhich were very distressing in this disease, and which required a specific treatment.
For the vomiting, with a burning sensation in the stomach, which came on about the fifth day, I found no remedy equal to a table spoonful of sweet milk, taken every hour, or to small draughtsof milk and water. I was led to prescribe this simple medicine from having heard, from a West-India practitioner, and afterwards read, in Dr. Hume's account of the yellow fever, encomiums upon the milk of the cocoa-nut for this troublesome symptom. Where sweet milk failed of giving relief, I prescribed small doses of sweet oil, and in some cases a mixture of equal parts of milk, sweet oil, and molasses. They were all intended to dilute or blunt the acrimony of the humours, which were either effused or generated in the stomach. Where they all failed of checking the vomiting, I prescribed weak camomile tea, or porter, or cyder and water, with advantage. In some of my patients the stomach rejected all the mixtures and liquors which have been mentioned. In such cases I directed the stomach to be left to itself for a few hours, after which it sometimes received and retained the drinks that it had before rejected, provided they were administered in a small quantity at a time.
The vomiting was sometimes stopped by a blister applied to the external region of the stomach.
A mixture of liquid laudanum and sweet oil, applied to the same place, gave relief where thestomach was affected by pain only, without a vomiting.
I have formerly mentioned that a distressingpainoften seized the lower part of thebowels. I was early taught that laudanum was not a proper remedy for it. It yielded in almost every case to two or three emollient glysters, or to the loss of a few ounces of blood.
The convalescence from this fever was in general rapid, but in some cases it was very slow. I was more than usually struck by the great resemblance which the system in the convalescence from this fever bore to the state of the body and mind in old age. It appeared, 1. In the great weakness of the body, more especially of the limbs. 2. In uncommon depression of mind, and in a great aptitude to shed tears. 3. In the absence or short continuance of sleep. 4. In the frequent occurrence of appetite, and, in some cases, in its inordinate degrees. And 5. In the loss of the hair of the head, or in its being suddenly changed in some cases to a grey colour.
Pure air, gentle exercise, and agreeable society removed the debility both of body and mind of this premature and temporary old age. I met with afew cases, in which the yellow colour continued for several weeks after the patient's recovery from all the other symptoms of the fever. It was removed most speedily and effectually by two or three moderate doses of calomel and rhubarb.
A feeble and irregular intermittent was very troublesome in some people, after an acute attack of the fever. It yielded gradually to camomile or snake-root tea, and country air.
In a publication, dated the 16th of September, I recommended a diet of milk and vegetables, and cooling purges to be taken once or twice a week, to the citizens of Philadelphia. This advice was the result of the theory of the disease I had adopted, and of the successful practice which had arisen from it. In my intercourse with my fellow-citizens, I advised this regimen to be regulated by the degrees of fatigue and foul air to which they were exposed. I likewise advised moderate blood-letting to all such persons as were of a plethoric habit. To men whose minds were influenced by the publications in favour of bark and wine, and who were unable at that time to grasp the extent and force of the remote cause of this terrible fever, the idea of dieting, purging, or bleeding the inhabitants of a whole village or city appeared to beextravagant and absurd: but I had not only the analogy of the regimen made use of to prepare the body for the small-pox, but many precedents in favour of the advice. Dr. Haller has given extracts from the histories of two plagues, in which the action of the miasmata was prevented or mitigated by bleeding[89]. Dr. Hodges confirms the utility of the same practice. The benefits of low diet, as a preventive of the plague, were established by many authors, long before they received the testimony of the benevolent Mr. Howard in their favour. Socrates in Athens, and Justinian in Constantinople, were preserved, by means of their abstemious modes of living, from the plagues which occasionally ravaged those cities. By means of the low diet, gentle physic, and occasional bleedings, which I thus publicly recommended, the disease was prevented in many instances, or rendered mild where it was taken. But my efforts to prevent the disease in my fellow-citizens did not end here. I advised them, not only in the public papers, but in my intercourse with them, to avoid heat, cold, labour, and every thing else that could excite the miasmata (which I knew to be present in all their bodies) into action. I forgot, upon this occasion, the usual laws which regulate the intercourse of man withman in the streets, and upon the public roads, in my excursions into the neighbourhood of the city. I cautioned many persons, whom I saw walking or riding in an unsafe manner, of the danger to which they exposed themselves; and thereby, I hope, prevented an attack of the disease in many people.
It was from a conviction of the utility of low diet, gentle evacuations, and of carefully shunning all the exciting causes which I have mentioned, that I concealed, in no instance, from my patients the name of their disease. This plainness, which was blamed by weak people, produced strict obedience to my directions, and thereby restrained the progress of the fever in many families, or rendered it, when taken, as mild as inoculation does the small-pox. The opposite conduct of several physicians, by preventing the above precautions, increased the mortality of the disease, and, in some instances, contributed to the extinction of whole families.
I proceed now to make a few remarks upon the remedies recommended by Doctors Kuhn and Stevens, and by the French physicians. The former were bark, wine, laudanum, spices, the elixir of vitriol, and the cold bath.
In every case in which I prescribed bark, it was offensive to the stomach. In several tertians which attended the convalescence from a common attack of the fever, I found it always unsuccessful, and once hurtful. Mr. Willing took it for several weeks without effect. About half a pint of a weak decoction of the bark produced, in Mr. Samuel Meredith, a paroxysm of the fever, so violent as to require the loss of ten ounces of blood to moderate it. Dr. Annan informed me that he was forced to bleed one of his patients twice, after having given him a small quantity of bark, to hasten his convalescence.
It was not in this epidemic only that the bark was hurtful. Baron Humboldt informed me, that Dr. Comoto had assured him, it hastened death in every case in which it was given in the yellow fever of Vera Cruz. If, in any instance, it was inoffensive, or did service, in our fever, I suspect it must have acted upon the bowels as a purge. Dr. Sydenham says the bark cured intermittents by this evacuation[90]; and Mr. Bruce says it operated in the same way, when it cured the bilious fevers at Massuah.
Winewas nearly as disagreeable as the bark to the stomach, and equally hurtful. I tried it in every form, and of every quality, but without success. It was either rejected by the stomach, or produced in it a burning sensation. I should suspect that I had been mistaken in my complaints against wine, had I not since met with an account in Skenkius of its having destroyed all who took it in the famous Hungarian fever, which prevailed, with great mortality, over nearly every country in Europe, about the middle of the 16th century[91]. Dr. Wade declares wine to be “ill adapted to the fevers of Bengal, where the treatment has been proper in other respects.”
Laudanumhas been called by Dr. Mosely “a fatal medicine” in the yellow fever. In one of my patients, who took only fifteen drops of it, without my advice, to ease a pain in his bowels, it produced a delirium, and death in a few hours. I was much gratified in discovering that my practice, with respect to the use of opium in this fever, accorded with Dr. Wade's in the fever of Bengal. He tells us, “that it was mischievous inalmost every instance, even in combination with antimonials.”
Thespiceswere hurtful in the first stage of the fever, and, when sufficient evacuations had been used, they were seldom necessary in its second.
Theelixir of vitriolwas, in general, offensive to the stomach.
Thecold bathwas useful in those cases where its sedative prevailed over its stimulating effects. But this could not often happen, from the suddenness and force, with which the water was thrown upon the body. In two cases in which I prescribed it, it produced a gentle sweat, but it did not save life. In a third it removed a delirium, and reduced the pulse for a few minutes, in frequency and force, but this patient died. The recommendation of it indiscriminately, in all cases, was extremely improper. In that chilliness and tendency to fainting upon the least motion, which attended the disease in some patients, it was an unsafe remedy. I heard of a woman who was seized with delirium immediately after using it, from which she never recovered; and of a man who died a few minutes after he came out of a bathing tub. Had this remedy been the exclusive antidote to the yellowfever, the mortality of the disease would have been but little checked by it. Thousands must have perished from the want of means to procure tubs, and of a suitable number of attendants to apply the water, and to lift the patient in and out of bed. The reason of our citizens ran before the learning of the friends of this remedy, and long before it was abandoned by the physicians, it was rejected as useless, or not attempted, because impracticable, by the good sense of the city. It is to be lamented that the remedy of cold water has suffered in its character by the manner in which it was advised. In fevers of too much action, it reduces the morbid excitement of the blood-vessels, provided it beapplied without force, and for a considerable time, to the body. It is in the jail fever, and in the second stage of the yellow fever only, in which its stimulant and tonic powers are proper. Dr. Jackson establishes this mode of using it, by informing us, that when it did service, it “gave vigour and tone” to the system[92].
A mode of practice which I formerly mentioned in this fever, consisted of a union of the evacuating and tonic remedies. The physicians who adopted this mode gave calomel by itself, in small doses, onthe first or second day of the fever, bled once or twice, in a sparing manner, and gave the bark, wine, and laudanum, in large quantities, upon the first appearance of a remission. After they began the use of these remedies purging was omitted, or, if the bowels were moved, it was only by means of gentle glysters. This practice, I shall say hereafter, was not much more successful than that which was recommended by Dr. Kuhn and Dr. Stevens. It resembled throwing water and oil at the same time upon a fire, in order to extinguish it.
TheFrenchremedies were nitre and cremor tartar, in small doses, centaury tea, camphor, and several other warm medicines; subacid drinks, taken in large quantities, the warm bath, and moderate bleeding.
After what has been said it must be obvious to the reader, that the nitre and cremor tartar, in small doses, could do no good, and that camphor and all cordial medicines must have done harm. The diluting subacid drinks, which the French physicians gave in large quantities, were useful in diluting and blunting the acrimony of the bile, and to this remedy, assisted by occasional bleeding, I ascribemost of the cures which were performed by those physicians.
Those few persons in whom thewarm bathproduced copious and universal sweats recovered, but, in nearly all the cases which came under my notice, it did harm.
I come now to inquire into the comparative success of all the different modes of practice which have been mentioned.
I have already said that ten out of thirteen patients whom I treated with bark, wine, and laudanum, and that three out of four, in whom I added the cold bath to those remedies, died. Dr. Pennington informed me, that he had lost all the patients (six in number) to whom he had given the above medicines. Dr. Johnson assured me, with great concern, about two weeks before he died, that he had not recovered a single patient by them. Whole families were swept off where these medicines were used. But further, most of those persons who received the seeds of the fever in the city, and sickened in the country, or in the neighbouring towns, and who were treated with tonic remedies, died. There was not a single cure performedby them in New-York, where they were used in several sporadic cases with every possible advantage. But why do I multiply proofs of their deadly effects? The clamours of hundreds whose relations had perished by them, and the fears of others, compelled those physicians who had been most attached to them to lay them aside, or to prepare the way for them (as it was called) by purging and bleeding. The bathing tub soon shared a worse fate than bark, wine, and laudanum, and, long before the disease disappeared, it was discarded by all the physicians in the city.
In answer to these facts we are told, that Mr. Hamilton and his family were cured by Dr. Stevens's remedies, and that Dr. Kuhn had administered them with success in several instances.
Upon these cures I shall insert the following judicious remarks from Dr. Sydenham. “Success (says the doctor) is not a sufficient proof of the excellency of a method of cure in acute diseases, since some are recovered by the imprudent procedure of old women; but it is further required, that the distemper should beeasily cured, and yield conformably to itsownnature[93].” And again, speakingof the cure of the new fever of 1685, this incomparable physician observes, “If it be objected that this fever frequently yields to a quite contrary method to that which I have laid down, I answer, that the cure of a disease by a method which is attended with success onlynowandthen, in afewinstances, differs extremely from that practical method, the efficacy whereof appears both from its recoveringgreater numbers, and all the practical phenomena happening in the cure[94].”
Far be it from me to deny that the depression of the system may not be overcome by such stimuli as are more powerful than those which occasion it. This has sometimes been demonstrated by the efficacy of bark, wine, and laudanum, in the confluent and petechial small-pox; but even this state of that disease yields more easily to blood-letting, or to plentiful evacuations from the stomach and bowels, on the first or second day of the eruptive fever. This I have often proved, by giving a large dose of tartar emetic and calomel, as soon as I was satisfied from circumstances, that my patient was infected with the small-pox. But the depression produced by the yellow fever appears to be much greater than that which occurs in the small-pox,and hence it more uniformly resisted the most powerful tonic remedies.
In one of my publications during the prevalence of the fever I asserted, that the remedies of which I have given a history cured a greater proportion than ninety-nine out of a hundred, of all who applied to me on the first day of the disease, before the 15th day of September. I regret that it is not in my power to furnish a list of them, for a majority of them were poor people, whose names are still unknown to me. I was not singular in this successful practice in the first appearance of the disease. Dr. Pennington assured me on his death bed, that he had not lost one, out of forty-eight patients whom he had treated agreeably to the principles and practice I had recommended. Dr. Griffitts triumphed over the disease in every part of the city, by the use of what were called the new remedies. My former pupils spread, by their success, the reputation of purging and bleeding, wherever they were called. Unhappily the pleasure we derived from this success in the treatment of the disease, was of short duration. Many circumstances contributed to lessen it, and to revive the mortality of the fever. I shall briefly enumerate them.
1. The distraction produced in the public mind, by the recommendation of remedies, the opposites in every respect of purging and bleeding.
2. The opinion which had been published by several physicians, and inculcated by others, that we had other fevers in the city besides the yellow fever. This produced a delay in many people in sending for a physician, or in taking medicines, for two or three days, from a belief that they had nothing but a cold, or a common fever. Some people were so much deceived by this opinion, that they refused to send for physicians, lest they should be infected by them with the yellow fever. In most of the cases in which these delays took place, the disease proved mortal.
To obviate a suspicion that I have laid more stress upon the fatal influence of this error than is just, I shall here insert an extract of a letter I received from Mr. John Connelly, one of the city committee, who frequently left his brethren in the city hall, and spent many hours in visiting and prescribing for the sick. “The publications (says he) of some physicians, that there were but few persons infected with the yellow fever, and that many were ill with colds and common remittingand fall fevers, proved fatal to almost every family which was credulous enough to believe them. That opinion slew its hundreds, if not its thousands, many of whom did not send for a physician until they were in the last stage of the disorder, and beyond the power of medicine.”
3. The interference of the friends of the stimulating system, in dissuading patients from submitting to sufficient evacuations.
4. The deceptions which were practised by some patients upon their physicians, in their reports of the quantity of blood they had lost, or of the quality and number of their evacuations by stool.
5. The impracticability of procuring bleeders as soon as bleeding was prescribed. Life in this disease, as in the apoplexy, frequently turned upon that operation being performed within anhour. It was often delayed, from the want of a bleeder, one or two days.
6. The inability of physicians, from the number of their patients, and from frequent indisposition, to visit the sick, at such times as was necessary to watch the changes in their disease.
7. The great accumulation and concentration of the miasmata in sick rooms, from the continuance of the disease in the city, whereby the system was exposed to a constant stimulus, and the effect of the evacuations was thus defeated.
8. The want of skill or fidelity in nurses to administer the medicines properly; to persuade patients to drink frequently; also to supply them with food or cordial drinks when required in the night.
9. The great degrees of debility induced in the systems of many of the people who were affected by the disease, from fatigue in attending their relations or friends.
10. The universal depression of mind, amounting in some instances to despair, which affected many people. What medicine could act upon a patient who awoke in the night, and saw through the broken and faint light of a candle, no human creature, but a black nurse, perhaps asleep in a distant corner of the room; and who heard no noise, but that of a hearse conveying, perhaps, a neighbour or a friend to the grave? The state of mind under which many were affected by the disease, is so well described by the Rev. Dr. Smith, in thecase of his wife, in a letter I received from him in my sick room, two days after her death, that I hope I shall be excused for inserting an extract from it. It forms a part of the history of the disease. The letter was written in answer to a short note of condolence which I sent to the doctor immediately after hearing of Mrs. Smith's death. After some pathetic expressions of grief, he adds, “The scene of her funeral, and some preceding circumstances, can never depart from my mind. On our return from a visit to our daughter, whom we had been striving to console on the death of Mrs. Keppele, who was long familiar and dear to both, my dear wife, passing the burying-ground gate, led me into the ground, viewed the graves of her two children, called the old grave-digger, marked a spot for herself as close as possible to them and the grave of Dr. Phineas Bond, whose memory she adored. Then, by the side of the spot she had chosen, we found room and chosemine, pledging ourselves to each other, and directing the grave-digger that this should be the order of our interment. We returned to our house. Night approached. I hoped my dear wife had gone to rest, as she had chosen, since her return from nursing her daughter, to sleep in a chamber by herself, through fear of infecting her grandchild and me. But it seems she closed not her eyes; sitting with them fixed throughher chamber window on Mrs. Keppele's house, till about midnight she saw her hearse, and followed it with her eyes as far as it could be seen. Two days afterwards Mrs. Rodgers, her next only surviving intimate friend, was carried past her window, and by no persuasion could I draw her from thence, nor stop her sympathetic foreboding tears, so long as her eyes could follow the funeral, which was through two squares, from Fourth to Second-street, where the hearse disappeared.” The doctor proceeds in describing the distress of his wife. But pointed as his expressions are, they do not convey the gloomy state of her mind with so much force as she has done it herself in two letters to her niece, Mrs. Cadwallader, who was then in the country. The one was dated the 9th, the other the 11th of October. I shall insert a few extracts from each of them.