Oct. 21, 1793

An Account of the origin, symptoms, and treatment of the epidemic fever, which now prevails in the city of Philadelphia, in a letter from Dr. Benjamin Rush, to Dr. John Rodgers, physician, in New York. 

My dear friend, 

In compliance with your request, I set down at a late hour, and after a busy day, to give you an account of the origin, symptoms, and treatment of the fever, which has prevailed with so much mortality in our city, for the last six weeks. 

I shall begin by observing, that I have satisfactory documents to prove, that the disease was generated in our city. To suppose, because the yellow fever is an endemic of the West-Indies, and because it seldom occurs in North America, that it can exist among us, only by importation, is as absurd as to suppose that the hurricanes are so common in the West Indies, and which occur here only once in 20 or 30 years, are all imported from that country.

The disease attacks in a variety of ways, according to the habit and predisposition of the patient, or the nature and force of the existing cause. It sometimes comes on in the form of quotidian or tertian- Many are indisposed for two or three days with headache, and pains in the back, side, or bones, without much perceptible fever. But in a majority, it attacks with chills, head-ache, sickness or vomiting, and severe pains in the limbs or back. The pulse, in this state of the disease, since the 10th day of September, has generally been full and tense- the tongue whitish and moist- the eyes red- the pupils dilated- the urine high colored- the thirst great, and the skin hot and dry. These symptoms remit every day, or every other day, and from the tertian type, which in its original and natural form, a recovery or death, generally happens in acute cases, on the 3rd, 5th, or 7th days. It attacks all ages. Even young children are not exempted from it, but it is most acute, and most mortal in young persons, between 14 and 25. 

Before the 10th of September, I found strong purges of calomel and jalap, alone, given on given on the first day of the disease, sufficient to conquer it in most cases. They brought away large quantities of green, dark colored, or black bile of a most feotid and acrid nature. The pulse, which in the warm weather, was weak and low, rose with every evacuation. The skin likewise which remained dry under the most powerful sudorifics, became moist under the use of those active remedies. 

Since the 10th of September, I have found bleeding, in addition to the mercurial purges, to be necessary in nineteen cases out of twenty. The pulse- the appearance of the blood, the spontaneous hemorrhages,  and the weather (exclusive of the stimulus of the contagion) all indicated the use of the lancet. At first I found the loss of 10 or 12 ounces of blood sufficient to subdue the pulse, but I have been obliged, gradually, as the season advanced, to increase the quantity to sixty, seventy, and even eighty ounces, and in most cases the happiest effects. I have observed the most speedy convalescence, where the bleeding has been the most profuse, and as a proof that it has not been carried to excess, I have observed in no one instance, the least inconvenience to succeed it. 

I have bled in three cases where I have seen incipient petechiae, and in each case, with success. I was warranted in this bold practice, not only by the tension of the pulse, but by a precedent for it, which I recollected in the works of Dr. De Hach, of Vienna. 

I bleed not only in the exacerbations of the fever, but likewise in its remissions and intermittent, where I find a low, slow, but corded pulse. I have recovered two patients with this pulse, in whom it beat less than 50 strokes in a minute. 

On every day of the disease, after giving the mercurial medicine, I prescribe a purge. Castor oil- salts- cremor tartar- sulphur, and glisters, answer in most cases, but in some, I have been obliged to have recourse to calomel and gamboge in moderate doses. I was led to purge every day, not only by recollecting the advantages of that practice in the yellow fever of 1762, in carrying off the re-accumulated bile, but by observing the disease in all cases to attack a weak or previously disordered part of the body. The purging aerates and artificial weak part, which by inviting a determination of the fluids to the bowels, prevents those effusions to the brain, stomach, bowels, liver, and lungs, which bring on death. 

I have in nearly every case for the last three weeks, rejected bark, wine, and laudanum in the first stage of the disorder, even though the most perfect intermission of the fever took place. Nor do I conceive those medicines to be necessary in the convalescent state of the disease. Mild and nourishing diet, restores the strength much sooner than the most powerful tonics. I have reason to believe laudanum to be poison when given with an active or corded pulse in this fever. 

The next articles to purging and bleeding in my materia medica, are cool air and cool drinks. I often direct the head to be bathed, and the hands and face to be washed with cold water. Toast and water, balm tea, lemonade, tamarind water, barly water, and apple water, are the common drinks of my patients. The less they eat in the first stage of the disorder, the better. As soon as the pulse is reduced, I indulge them in whine whey, bread, or roasted apples, or mush in milk, chicken, beef, mutton, or veal broth, coffee and tea with buttered toast, and weak chocolate- I forbid the use of animal food, until they are able to walk about. Cleanliness is advised in every stage of the disorder, with gentle exercise, and country air to complete the cure. 

In those few cases where the disease comes on in typhoid or typhus symptoms, I recommend the common remedies for those states of fever. 

If sufficient bleeding and purging have been omitted in the beginning of the disorder, and hemorrhages, with petechiae, a low pulse and black vomiting, have come on, little can be done. The ceremonies of bark, glysters, and the cold bath, may be performed in such cases, but I have heard of no instance in which they have done any service. 

I think I have seen blisters afford relief in local determinations to the head, breast and stomach, after sufficient evacuations have been used. 

Where a troublesome vomiting does not yield to blood-letting, I know of no remedies equal to a table spoon full of sweet milk given every half hour, or to weak chamomile tea.

Where a dull pain the bowels attends with a full, or corded pulse, I have prescribed glysters of cold water with evident advantage. Where flatulency attends, I prescribe chamomile tea, or weak brandy and water, provided the pulse be sufficiently reduced. 

By means of the remedies before mentioned, I think I was the unworthy instrument in the hands of a kind Providence, of recovering more than ninety-nine out of an hundred of my patients, before my late indisposition. A number died during the few days of my confinement, from the want of well-timed bleeding and purging. Since my recovery, the disease has become more violent and obstinate, and some have died under my care, from my inability from weakness, and occasional returns of my fever, to be early and punctual in my attendance, upon them; for a recovery often depends upon the application of the remedies, not only on a certain day, but frequently at a certain hour. The concentration of the contagion in every part of the city, moreover has increased the difficulty of curing the disease, for it constantly counteracts the use of the remedies which are intended to abstract stimulus, hence we observe (other circumstances being equal) there is most mortality where there is most contagion. The delays in procuring bleeders, and the ignorance and neglect of nurses added to some other circumstances too gloomy to be mentioned, have contributed very much of late, to increase the mortality of the disorder. But with punctual and skillful medical assistance, good nursing, and airy rooms. I am still of the opinion, that this disease as much under the power of medicine as the measles, or influenza. 

The newspapers have informed you, how much the opinions and practice, I have delivered in this letter have been opposed by many of the physicians, of our city. They first called the prevailing epidemic, the jail fever. They might as well have called it the small pox. They have declared, that we have two distinct fevers in town- the one a putrid yellow fever, the other a common remittent. It would not have been more absurd, to have asserted that we have two suns and two moons shining upon our globe. What makes this mistake the more inexcusable is, the common remitting fever, which has been confounded with the present highly contagious epidemic, has not been observed as usual, in the suburbs, or in the neighborhood of the city. 

But the mistakes of some of my brethren have not ended here. Where the disease has made its chief impression on the head, it has been called the internal dropsy of the brain. Where it has attacked the throat, as it has been done in some mild cases, it has been called an angina maligna. Where it has attacked the sides, it has been called a pleurisy. And in one person in whom it first effected the bowels, it was treated as a bilious colic. The disorder in this case terminated in a black vomiting, & death on the third day. 

The success of the new remedies has at last created such a clamor in their favor, that most of our physicians have been forced to adopt them. The bleed however as yet sparingly, and purge after the first day only with lenient physic. Some of them blend wine, bark, and laudanum with them. They might as well throw water and oil at the same time upon fire in order to extinguish it. 

I must here pay a tribute of respect to the memory of my much loved friend Dr. Pennington, who adopted the new remedies as soon as they were mentioned to him. His expanded mind was not cast in a common mould. It vibrated a unison with truth, the moment it came in contact with it. My excellent and judicious friend Dr. Griffiths, was likewise an early and decided friend to plentiful purging and bleeding. Such of our former pupils as are settled in this city, recommend them, and I hear from all quarters, with success. 

 It was extremely unfortunate that the new remedies were ever connected with my name. I have no other merit, than that of having early adopted, and extended a mode of treating the disorder, which I had learned in the year 1762, from my first preceptor in medicine, Dr. Redman, and which is strongly recommended by Hillary, Mosely, Mitchell, Kirby, and many other writers upon this fever. In my first address to the public, I acknowledged that I received the first hints of the safety and efficacy of Jalap and mercury in this disorder, in the military hospitals, in the year 1777, and from a description of the disease nearly related to ours, in a East-India publication. 

In the use of all my remedies, I have in this disease repudiated names and, been governed only by the condition of the system. 

I am indebted to Dr. Syndenham, as well as to my own observations, for the decided manner in which I have rejected the idea of a common remittent in our city. I have been told, that by propagating this opinion, I terrify my patients. Perhaps I do, but I save them by their fears; for I excite in them at once a speedy application for help, and a faithful obedience to all of my prescriptions. Universal truth, is universal interest, and falsehood and misery always go hand in hand. The opinion which has been published by some of our physicians, that we have now a mild and malignant fever in our city, has led all those people, in whom the fever has come on in an insidious form, to neglect themselves for several days, under the idea, that they had nothing but a common fall fever, and from this deception, I believe that hundreds have perished by the disorder. 

I cannot conclude this letter, without lamenting further, that several publications, from men who had never seen the disorder, or who had seen only a few cases of it, have contributed very much to distract the public mind; to lessen a confidence in mercurial purges and bleeding- and to produce an indiscriminate use of general remedies, without any respect to the state of the system, and thereby to add to the mortality of the disease. 

Adieu, my dear friend- I shall only add, my prayers, that your city may be preserved from the calamities which now afflicts ours, and that you may never know, from experience, the labors, the anxiety, the deep domestic distress, and the calumnies, which for six weeks past, have been the portion of,

Your Sincere friend, and 

Former preceptor in Medicine, 

Benjamin Rush

Philadelphia, October 3, 1793

Notes*

Each purge consists of 10 grains of calomel, and 15 of jalap. One should be given every 6 hours, or until 4 or 5 large evacuations are procured from the bowels. 

Each dose consists of two or three grains of calomel, and 2 grains of gamboge, made into a pill with a little flour and common syrup. A dose should be given two or three times a day, so as to procure large evacuations from the bowels. 

The Bark has been recommended as a preventative of the fever. However proper it might have been during the warm weather, I am satisfied that it is not so now. So universally is the contagion diffused, through every part of the city, that out of a great number of persons in apparent and good health, whose pulses I have examined, I have met with only two, in whom they were not fuller and quicker than natural. In two old persons in good health, between 70 and 80, the pulse best between ninety and an hundred strokes in a minute. I have found this preternatural fullness and quickness in the pulses of black, as well as of white people; also in a woman who had yellow fever in 1761. This state of the pulse cannot be ascribed to fear, for that passion weakens it. The only preventatives that experience warrants, are, a temperate diet- the loss of a little blood- and keeping the bowels gently open. To these should be added, great caution in avoiding fatigue- the hot sun and the night air. 

One of these gentlemen urged in a consultation, as an object on to plentiful bleeding, that there were only ten pounds of blood in the human body.