It was said a practitioner, who was opposed to bleeding and mercury, cured this fever by means of strong emetics. I gave one to a man who refused to be bled. It operated freely, and brought on a plentiful sweat. The next day he arose from his bed, and went to his work. On the fourth day he sent for me again. My son visited him, and found him without a pulse. He died the next day.
I heard of two other persons who took emetics in the beginning of the fever, without the advice of a physician, both of whom died.
Dr. Pinckard informed me, that their effects were generally hurtful in the violent grades of the yellow fever in the West-Indies. The same information has since been given to me by Dr. Jackson. In the second and third grades of the bilious fever they appear not only to be safe, but useful.
The advantages of a weak vegetable diet were very great in this fever. I found but little difficulty, in most cases, in having my prohibition of animal food complied with before the crisis of the fever, but there was often such a sudden excitement of the appetite for it, immediately afterwards, that it was difficult to restrain it. I have mentioned the case of a young man, who was upon the recovery, who died in consequence of supping upon beef-stakes. Many other instances of the mortality of this fever from a similar cause, I believe, occurred in our epidemic, which were concealed from our physicians. I am not singular in ascribing the death of convalescents to the too early use of animal food. Dr. Poissonnier has the following important remark upon this subject. “The physicians of Brest have observed, that the relapses in the malignant fever, which prevailed in their naval hospitals, were as much the effect of a fault in the diet of the sick as of the contagious air to which they were exposed, and that as many patients perished from this cause as from the original fever. For this reason light soups, with leguminous vegetables in them, panada, rice seasoned with cinnamon, fresh eggs, &c. are all that they should be permitted to eat. The use of flesh should be forbidden for many days after the entire cure of the disorder[3].”
Dr. Huxham has furnished another evidence of the danger from the premature use of animal food, in his history of a malignant fever which prevailed at Plymouth, in the year 1740. “If any one (says the doctor) made use of a flesh or fish diet, before he had been very well purged, and his recovery confirmed, he infallibly indulged himself herein at the utmost danger of his life[4].”
In addition to the mild articles of diet, mentioned by Dr. Poissonnier, I found bread and milk, with a little water, sugar, and the pulp of a roasted apple mixed with it, very acceptable to my patients during their convalescence. Oysters were equally innocent and agreeable. Ripe grapes were devoured by them with avidity, in every stage of the fever. The season had been favourable to the perfection of this pleasant fruit, and all the gardens in the city and neighbourhood in which it was cultivated were gratuitously opened by the citizens for the benefit of the sick.
The drinks were, cold water, toast and water, balm tea, water in which jellies of different kinds had been dissolved, lemonade, apple water, barley and rice water, and, in cases where the stomach was affected with sickness or puking, weak porter and water, and cold camomile tea. In the convalescent stage of the fever, and in such of its remissions or intermissions as were accompanied with great languor in the pulse, wine-whey, porter and water, and brandy and water, were taken with advantage.
Cold water applied to the body, cool and fresh air, and cleanliness, produced their usual good effects in this fever. In the external use of cold water, care was taken to confine it to such cases as were accompanied with preternatural heat, and to forbid it in the cold fit of the fever, and in those cases which were attended with cold hands and feet, and where the disease showed a disposition to terminate, in its first stage, by a profuse perspiration. It has lately given me great pleasure to find the same practice, in the external use of cold water in fevers, recommended by Dr. Currie of Liverpool, in his medical reports of the effects of water, cold and warm, as a remedy in febrile diseases. Of the benefit of fresh air in this fever, Dr. Dawson of Tortola has lately furnished me with a striking instance. He informed me, that by removing patients from the low grounds on that island, where the fever is generated, to a neighbouring mountain, they generally recovered in a few days.
Finding a disagreeable smell to arise from vinegar sprinkled upon the floor, after it had emitted all its acid vapour, I directed the floors of sick rooms to be sprinkled only with water. I found the vapour which arose from it to be grateful to my patients. A citizen of Philadelphia, whose whole family recovered from the fever, thought he perceived evident advantages from tubs of fresh water being kept constantly in the sick rooms.
There were now and then remissions and intermissions of the fever, accompanied with such signs of danger from debility, as to render the exhibition of a few drops of laudanum, a little wine-whey, a glass of brandy and water, and, in some instances, a cup of weak chicken-broth, highly necessary and useful. In addition to these cordial drinks, I directed the feet to be placed in a tub of warm water, which was introduced under the bed-clothes, so that the patient was not weakened by being raised from a horizontal posture. All these remedies were laid aside upon the return of a paroxysm of fever.
I did not prescribe bark in a single case of this disease. An infusion of the quassia root was substituted in its room, in several instances, with advantage.
Blisters were applied as usual, but, from the insensibility of the skin, they were less effectual than applications of mustard to the arms and legs. It is a circumstance worthy of notice, that while the stomach, bowels, and even the large blood-vessels are sometimes in a highly excited state, and overcharged, as it were, with life, the whole surface of the body is in a state of the greatest torpor. To attempt to excite it by internal remedies is like adding fuel to a chimney already on fire. The excitement of the blood-vessels, and the circulation of the blood, can only be equalized by the application of stimulants to the skin. These, to be effectual, should be of the most powerful kind. Caustics might probably be used in such cases with advantage. I am led to this opinion by a fact communicated to me by Dr. Stewart. A lighted candle, which had been left on the bed of a woman whom he was attending in the apparent last stage of the yellow fever, fell upon her breast. She was too insensible to feel, or too weak to remove it. Before her nurse came into her room, it had made a deep and extensive impression upon her flesh. From that time she revived, and in the course of a few days recovered. As a tonic remedy in this fever, Dr. Jackson has spoken to me in high terms of the good effects of riding in a carriage. Patients, he informed me, who were moved with difficulty, after riding a few miles were able to sit up, and, when they returned from their excursions, were frequently able to walk to their beds.
Much has been said, of late years, in favour of the application of warm olive oil to the body in the plague, and a wish has been expressed, by some people, that its efficacy might be tried in the yellow fever. Upon examining the account of this remedy, as published by Mr. Baldwin, three things suggest themselves to our notice. 1. That the oil is effectual only in the forming state of the disease; 2. That the friction which is used with it contributes to excite the torpid vessels of the skin; and 3. That it acts chiefly by depleting from the pores of the body. From the unity of the remedy of depletion, it is probable purging or bleeding might be substituted to the expensive parade of the sweat induced by the warm oil, and the smoke of odoriferous vegetables. But I must not conceal here, that there are facts which favour an idea, that oil produces a sedative action upon the blood-vessels, through the medium of the skin. Bontius says it is used in this manner in the East-Indies, for the cure of malignant fevers, after the previous use of bleeding and purging. It seems to have been a remedy well known among the Jews; hence we find the apostle James advises its being applied to the body, in addition to the prayers of the elders of the church[5]. It is thus in other cases, the blessings of Heaven are conveyed to men through the use of natural means.
During the existence of the premonitory symptoms, and before patients were confined to their rooms, a gentle purge, or the loss of a few ounces of blood, in many hundred instances, prevented the formation of the fever. I did not meet with a single exception to this remark.
Fevers are the affliction chiefly of poor people. To prevent or to cure them, remedies must be cheap, and capable of being applied with but little attendance. From the affinity established by the Creator between evil and its antidotes, in other parts of his works, I am disposed to believe no remedy will ever be effectual in any general disease, that is not cheap, and that cannot easily be made universal.
It is to be lamented that the greatest part of all the deaths which occur, are from diseases that are under the power of medicine. To prevent their fatal issue, it would seem to be agreeable to the order of Heaven in other things, that they should be attacked in their forming state. Weeds, vermin, public oppression, and private vice, are easily eradicated and destroyed, if opposed by their proper remedies, as soon as they show themselves. The principal obstacle to the successful use of the antidotes of malignant fevers, in their early stage, arises from physicians refusing to declare when they appear in a city, and from their practice of calling their mild forms by other names than that of a mortal epidemic.
I shall now say a few words upon the success of the depleting practice in this epidemic.
From the more malignant state of the fever, and from the fears and prejudices that were excited against bleeding and mercury by means of the newspapers, the success of those remedies was much less than in the years 1793 and 1794. Hundreds refused to submit to them at the time, and in the manner, that were necessary to render them effectual. From the publications of a number of physicians, who used the lancet and mercury in their greatest extent, it appears that they lost but one in ten of all they attended. It was said of several practitioners who were opposed to copious bleeding, that they lost a much smaller proportion of their patients with the prevailing fever. Upon inquiry, it appeared they had lost many more. To conceal their want of success, they said their patients had died of other diseases. This mode of deceiving the public began in 1793. The men who used it did not recollect, that it is less in favour of a physician's skill to lose patients in pleurisies, colics, hæmorrhages, contusions, and common remittents, than in a malignant yellow fever.
Dr. Sayre attended fifteen patients in the disease, all of whom recovered by the plentiful use of the depleting remedies. His place of residence being remote from those parts of the city in which the fever prevailed most, prevented his being called to a greater number of cases.
A French physician, who bled and purged moderately, candidly acknowledged that he saved but three out of four of his patients.
In the city hospital, where bleeding was sparingly used, and where the physicians depended chiefly upon a salivation, more than one half died of all the patients who were admitted. It is an act of justice to the physicians of the hospital to add, that many, perhaps most of their patients, were admitted after the first day of the disease.
I cannot conclude this comparative view of the success of the different modes of treating the yellow fever, without taking notice, that the stimulating mode, as recommended by Dr. Kuhn and Dr. Stevens, in the year 1793, was deserted by every physician in the city. Dr. Stevens acknowledged the disease to require a different treatment from that which it required in the West-Indies; Dr. Kuhn adopted the lancet and mercury in his practice; and several other physicians, who had written against those remedies, or who had doubted of their safety and efficacy, in 1793, used them with confidence, and in the most liberal manner, in 1797.
In the histories I have given of the yellow fevers of 1793 and 1794, I have scattered here and there a few observations upon their degrees of danger, and the signs of their favourable or unfavourable issue. I shall close the present history, by collecting those observations into one view, and adding to them such other signs as have occurred to me in observing this epidemic.
Signs of moderate danger, and a favourable issue of the yellow fever.
1. A chilly fit accompanying the attack of the fever. The longer this chill continues, the more favourable the disease.
2. The recurrence of chills every day, or twice a day, or every other day, with the return of the exacerbations of the fever. A coldness of the whole body, at the above periods, without chills, a coldness with a profuse sweat, cold feet and hands, with febrile heat in other parts of the body, and a profuse sweat without chills or coldness, are all less favourable symptoms than a regular chilly fit, but they indicate less danger than their total absence during the course of the fever.
3. A puking of green or yellow bile on the first day of the disease is favourable. A discharge of black bile, if it occur on the first day of the fever, is not unfavourable.
4. A discharge of green and yellow stools. It is more favourable if the stools are of a dark or black colour, and of a fœtid and acrid nature, on the first or second day of the fever.
5. A softness and moisture on the skin in the beginning of the fever.
6. A sense of pain in the head, or a sudden translation of pain from internal to external parts of the body, particularly to the back. An increase of pain after bleeding.
7. A sore mouth.
8. A moist white, or a yellow tongue.
9. An early disposition to spit freely, whether excited by nature or the use of mercury.
10. Blood becoming sizy, after having exhibited the usual marks of great morbid action in the blood-vessels.
11. Great and exquisite sensibility in the sense of feeling coming on near the close of the fever.
12. Acute pains in the back and limbs.
13. The appearance of an inflammatory spot on a finger or toe, Dr. H. M'Clen says, is favourable. It appears, the doctor says, as if the cause of the fever had escaped by explosion.
Signs of great danger, and of an unfavourable issue of the yellow fever are,
1. An attack of the fever, suddenly succeeding great terror, anger, or the intemperate use of venery, or strong drink.
2. The first paroxysm coming on without any premonitory symptoms, or a chilly fit.
3. A coldness over the whole body without chills for two or three days.
4. A sleepiness on the first and second days of the fever.
5. Uncommon paleness of the face not induced by blood-letting.
6. Constant or violent vomiting, without any discharge of bile.
7. Obstinate costiveness, or a discharge of natural, or white stools; also quick, watery stools after taking drink.
8. A diarrhœa towards the close of the fever. I lost two patients, in 1797, with this symptom, who had exhibited, a few days before, signs of a recovery. Dr. Pinckard informed me, that it was generally attended with a fatal issue in the yellow fever of the West-Indies. Diemerbroeck declares, that “scarcely one in a hundred recovered, with this symptom, from the plague[6].”
9. A suppression of urine. It is most alarming when it is without pain.
10. A discharge of dark-coloured and bloody urine.
11. A cold, cool, dry, smooth, or shining skin.
12. The appearance of a yellow colour in the face on the first or second day of the fever.
13. The absence of pain, or a sudden cessation of it, with the common symptoms of great danger.
14. A disposition to faint upon a little motion, and fainting after losing but a few ounces of blood.
15. A watery, glassy, or brilliant eye. A red eye on the fourth or fifth day of the disease. It is more alarming if it become so after having been previously yellow.
16. Imperfect vision, and blindness in the close of the disease.
17. Deafness.
18. A preternatural appetite, more especially in the last stage of the fever.
19. A slow, intermitting, and shattered pulse.
20. Great restlessness, delirium, and long continued coma.
21. A discharge of coffee-coloured or black matter from the stomach, after the fourth day of the fever.
22. A smooth red tongue, covered with a lead-coloured crust, while its edges are of a bright red.
23. A dull vacant face, expressive of distress.
24. Great insensibility to common occurrences, and an indifference about the issue of the disease.
25. Uncommon serenity of mind, accompanied with an unusually placid countenance.
I shall conclude this head by the following remarks:
1. The violence, danger, and probable issue of this fever, seem to be in proportion to the duration and force of the predisposing and exciting causes. However steady the former are in bringing on debility, and the latter in acting as irritants upon accumulated excitability, yet a knowledge of their duration and force is always useful, not only in forming an opinion of the probable issue of the fever, but in regulating the force of remedies.
2. The signs of danger vary in different years, from the influence of the weather upon the disease.
3. Notwithstanding the signs of the favourable and unfavourable issue of the fever are in general uniform, when the cure of the disease is committed to nature, or to tonic medicines, yet they are far from being so when the treatment of the fever is taken out of the hands of nature, and attempted by the use of depleting remedies. We often see patients recover with nearly all the unfavourable symptoms that have been mentioned, and we sometimes see them die, with all those that are favourable. The words of Morellus, therefore, which he has applied to the plague, are equally true when applied to the yellow fever. “In the plague, our senses deceive us. Reason deceives us. The aphorisms of Hippocrates deceive us[7].” An important lesson may be learned from these facts, and that is, never to give a patient over. On the contrary, it is our duty in this, as well as in all other acute diseases, to dispute every inch of ground with death. By means of this practice, which is warranted by science, as well as dictated by humanity, the grave has often been deprived for a while of its prey, and a prelude thereby exhibited of that approaching and delightful time foretold by ancient prophets, when the power of medicine over diseases shall be such, as to render old age the only outlet of human life.
Footnotes:
[1] De Febre Indiæ-Occidentalis Maligna Flava, p. 12.
[2] Annals of Medicine, p. 123.
[3] Maladies de Gens de Mer, vol. i. p. 345.
[4] Epidemics, vol. ii. p. 67.
[5] Chapter v. verse 14.
[6] Lib. i. cap. 15.
[7] De Feb. Pestilent. cap. v. “Acutorum morborum incertæ admodum, ac fallaces sunt prædictiones.”
HIPPOCRATES.
The yellow fever of the year 1797 was succeeded by scarlatina, catarrhs, and bilious pleurisies, in the months of November and December of the same year. The weather favoured the generation of the latter diseases. It became suddenly cold about the middle of November. On the 5th of December, the navigation of the Delaware was obstructed. There was a thaw on the 13th and 14th of this month, but not sufficient to open the river.
In the month of January, 1798, the fevers discovered an uncommon determination to the brain. Four cases of the hydrocephalic state of fever occurred under my care during this month, all of which yielded to depleting remedies. The subjects of this state of fever were Mr. Robert Lewis, and the daughters of Messrs. John Brooks, Andrew Ellicott, and David Maffat.
The weather was variable during the months of February and March. The navigation of the Delaware was not completely opened until the latter end of February. The diseases of these two months were catarrhs and bilious pleurisies. The former were confined chiefly to children, and were cured by gentle pukes, purges of calomel, and blood-letting. The last remedy was employed twice in a child of Isaac Pisso, of six weeks old, and once in a child of Thomas Billington, of three weeks old, with success.
On the 7th of April, I visited Mr. Pollock, lately from the state of Georgia, in consultation with Dr. Physick, in a yellow fever. He died the evening after I saw him, on the third day of his disease.
There was a snow storm on the 16th of April, and the weather was afterwards very cold. Such leaves and blossoms as had appeared, were injured by it.
On the 1st of May, the mercury in Fahrenheit's thermometer rose to 84°. The weather, during the latter part of this month, and in June, was very dry. On the 6th of June, Dr. Cooper lost a patient in the yellow fever, near the corner of Twelfth and Walnut-streets. Mark Miller died with the same state of fever on the 2d of July. About a dozen cases of a similar nature occurred, under the care of different practitioners, between the 2d and 20th of this month, and all of them in parts of the city remote from Water-street.
On the 19th of July, the weather was so cool as to render winter clothes comfortable. A severe hail storm had occurred, a few days before, in the neighbourhood of Wilmington, in the Delaware state.
On the 21st of the month, the ship Deborah arrived from one of the West-India islands, and discharged her cargo in the city. She was moored afterwards at Kensington, where the foul air which was emitted from her hold produced several cases of yellow fever, near the shores of that village.
In August the disease appeared in nearly every part of the city, and particularly in places where there was the greatest exhalation from foul gutters and common sewers.
In describing the disease, as it appeared this year, I shall take notice of its symptoms as they appeared in the blood-vessels, alimentary canal, the tongue, the nervous system, in the eyes, the lymphatic system, and the blood.
The subjects which furnished the materials for this history were not only private patients, but the poor in the city hospital, who were committed to the care of Dr. Physick and myself, by the board of health.
I. The pulse was, in many cases, less active in the beginning of this fever than in former years. It was seldom preternaturally slow. It resembled the pulse which occurs in the first stage of the common jail fever. Hæmorrhages were common about the fourth and fifth days, and generally from the gums, throat, or stomach.
II. The whole alimentary canal was much affected in most cases. Costiveness and a vomiting were general. The alvine discharges were occasionally green, dark-coloured, black, and natural. The black vomiting was more common this year than in former years, in all the forms of the fever. It was sometimes suspended for several days before death, and hopes were entertained of a recovery of patients in whom it had appeared. In a boy, at the city hospital, it ceased ten days before he died. It was sometimes succeeded by delirium or coma, but it more commonly left the patient free of pain, and in the possession of all the faculties of his mind.
III. The tongue was by no means an index of the state of the fever, as in the years 1793 and 1797. I saw several deaths, attended with a black vomiting, in which the tongue retained a natural appearance. This phenomenon at first deceived me. I ascribed it to such a concentration of the disease in the stomach and other vital parts, as to prevent its diffusing itself through the external parts of the system. We observe the effects of the same cause in a natural state of the skin, and in a natural appearance of the urine, in the most malignant forms of this fever.
IV. In the nervous system, the disease appeared with several new symptoms. A relation of Peter Field attempted to bite his attendants in the delirium of his fever, just before he died.
I attended a young woman at Mrs. Easby's, who started every time I touched her pulse. Loud talking, or a question suddenly proposed to her, produced the same convulsive motion. She retained her reason during the whole of her illness, and was cured by bleeding and a salivation.
Hiccup was a common symptom. I saw but two patients recover who had it. In one of them, Dr. Hedges, it came on after the sixth day of the fever, and continued, without any other symptom of disease, for four or five days.
I lost a patient who complained of no pain but in the calves of his legs. Dr. Physick lost a girl, in the city hospital, who complained only of pains in her toes. Her stomach discovered, after death, strong marks of inflammation.
Many people passed through every stage of the disease, without uttering a complaint of pain of any kind.
An uncommon stiffness in the limbs preceded death a few hours, in several cases. This stiffness ceased, in one of Dr. Physick's patients, immediately after death, but returned as soon as he became cold.
An obstinate wakefulness continued through the whole of the disease in Dr. Leib. It was common during the convalescence, in many cases.
The whole body was affected, in many cases, with a morbid sensibility, or what has been called supersensation, so that patients complained of pain upon being touched, when they were moved in their beds. This extreme sensibility was general in parts to which blisters had been applied. It continued through every stage of the disease. Dr. Physick informed me, that he observed it in a man two hours before he died. In this man there was an absence of pulse, and a coldness of his extremities. Upon touching his wrist, he cried out, as if he felt great pain.
V. A redness in the eyes was a general symptom. I saw few recoveries where this redness was not removed.
A discharge of matter from one ear relieved Mr. J. C. Warren from a distressing pulsation of the arteries in his head.
VI. Glandular swellings occurred in several instances. Two cases of them came under my notice. They both terminated favourably.
VII. The blood had its usual appearances in this disease. In the yellow fever which prevailed at the same time in Boston, Dr. Rand says the blood was sizy in but one out of a hundred cases.
The forms of the fever were nearly similar to those which have been described in the year 1797. I saw several cases in which the disease appeared in the form of a tertian fever. In one of them it terminated in death.
The system, in many cases, was prostrated below the point of inflammatory re-action. These were called, by some practitioners, typhous fevers. It was the most dangerous and fatal form of the disease. Its frequent occurrence gave occasion to a remark, that our epidemic resembled the yellow fever of the West-Indies, much more than the fevers of 1793 and 1797.
I attended two patients in whom the disease was protracted nearly to the 30th day. They both recovered.
Dr. Francis Sayre informed me, that he saw a child, in which the morbid affection of the wind-pipe, called cynanche trachealis, appeared with all the usual symptoms of yellow fever.
I attended one case in which the force of the disease was weakened, in its first stage, by a profuse hæmorrhage from the bowels. This hæmorrhage was followed by a bloody diarrhœa, which continued for four or five weeks.
Persons of all ages and colours were affected by this fever. I saw a case of it in a child of six months old. In the blacks, it was attended with less violence and mortality than in white people. It affected many persons who had previously had it.
The disease was excited by the same causes which excited it in former years. I observed a number of people to be affected by the fever, who lived in solitude in their houses, without doing any business. The system, in these persons, was predisposed to the disease, by the debility induced by ceasing to labour at their former occupations. It was excited in a young man by a fractured leg. He died five days afterwards, with a black vomiting. I observed, in several instances, an interval of four and five days between the debility induced upon the system by a predisposing, and the action of an exciting cause. Dr. Clark says, he has seen an interval of several weeks between the operation of those causes, in the yellow fever of Dominique. These facts are worthy of notice, as they lead to a protracted use of the means of obviating an attack of the disease.
During my attendance upon the sick, I twice perceived in my system the premonitory signs of the epidemic. Its complete formation was prevented each time by rest, a moderate dose of physic, and a plentiful sweat.
I shall now take notice of the different manner in which patients died of this fever. The detail may be useful, by unfolding new principles in the animal economy, as well as new facts in the history of the disease.
1. The disease terminated in death, in some instances, by means of convulsions.
2. By delirium, which prompted to exertions and actions similar to those which take place in madness.
3. By profuse hæmorrhages from the gums. This occurred in two patients of Dr. Stewart.
4. By an incessant vomiting and hiccup.
5. By extreme pain in the calves of the legs and toes, which, by destroying the excitement of the system, destroyed life.
6. By a total absence of pain. In this way it put an end to the life of Mr. Henry Hill.
7. By a disposition to easy, and apparently natural sleep. I have reason to believe that Mr. Hill encouraged this disposition to sleep, a few hours before he died, under the influence of a belief that he would be refreshed by it. Diemerbroeck says the plague often killed in the same way.
8. The mind was in many cases torpid, where no delirium attended, and death was submitted to with a degree of insensibility, which was often mistaken for fortitude and resignation.
I shall now mention the morbid appearances exhibited by the bodies of persons who died of this fever, as communicated to me by my friend, Dr. Physick; being the result of numerous dissections made by him at the city hospital.
In all of them the stomach was inflamed. The matter which constitutes what is called the black vomit, was found in the stomachs of several patients who had not discharged it at any time by vomiting. In some stomachs, he found lines which seemed to separate the living from their dead parts. Those parts, though dead, were not always in a mortified state. They were distinguished from the living parts by a peculiar paleness, and by discovering a weak texture upon being pressed between the fingers. He observed the greatest marks of inflammation in the stomachs of several persons in whom there had been no vomiting, during the whole course of the disease. The brain, in a few instances, discovered marks of inflammation. Water was now and then found in its ventricles, but always of its natural colour, even in those persons whose skins were yellow. The liver suffered but little in this disease. It may serve to increase our knowledge of the influence of local circumstances upon epidemics to remark, that this viscus, which was rarely diseased in the fever of Philadelphia in 1798, discovered marks of great inflammation in the bodies which were examined by Dr. Rand and Dr. Warren, in the town of Boston, where the yellow fever prevailed at the same time it did in Philadelphia.
The weather was hot and dry in August and September, during the prevalence of this fever. Its influence upon animal and vegetable life are worthy of notice. Moschetoes abounded, as usual in sickly seasons; grasshoppers covered the ground in many places; cabbages and other garden vegetables, and even fields of clover, were devoured by them. Peaches ripened this year three weeks sooner than in ordinary summers, and apples rotted much sooner than usual after being gathered in the autumn. Many fruit-trees blossomed in October, and a second crop of small apples and cherries were seen in November, on the west side of Schuylkill, near the city. Meteors were observed in several places. On the 29th of September there was a white frost. Its effects upon the fever were obvious and general. It declined, in every part of the city, to such a degree as to induce many people to return from the country. In the beginning of October the weather again became warm, and the disease revived. It was observable, that all great changes in the weather from heat to cold that were short of frost, or of cold to heat, increased the mortality of the fever. It spread most rapidly in moist weather.
The origin of this fever was from the exhalations of gutters, docks, cellars, common sewers, ponds of stagnating water, and from the foul air of the ship formerly mentioned.
The fever prevailed at the same time in the town of Chester, in Pennsylvania; in Wilmington, in the state of Delaware; in New-York; in New-London, in Connecticut; in Windsor, in Vermont; and in Boston; in all which places its origin was traced to domestic sources.
I shall now deliver a short account of the remedies employed in the cure of this disease.
I have said that the pulse was less active in this fever than in the fevers of former years. It was seldom, however, so feeble as to forbid bleeding. In Dr. Mease it called for the loss of 162 ounces of blood, and in Mr. J. C. Warren for the loss of 200, by successive bleedings, before it was subdued. But such cases were not common. In most of them, the pulse flagged after two or three bleedings. But there were cases in which the lancet was forbidden altogether. In these, the system appeared to be prostrated, by the force of the miasmata, below the point of re-action. This state of the disease manifested itself in a weak, quick, and frequent pulse, languid eye, sighing, great inquietude, or great insensibility. However unsafe bleeding was on the first day of this fever, when it appeared with those symptoms, nature often performed that operation upon herself from the gums, on the fourth or fifth day. I saw several pounds of blood discharged on those days, and in that way, with the happiest effects. It appeared to take place after the revival of the blood-vessels from their prostrated state.
From a conviction that the system was depressed only in these cases, and finding that it did not rise upon blood-letting, I resolved to try the effects of emetics, in exciting and equalizing the action of the blood-vessels. The experience I had had of the inefficacy of this remedy in 1793, and of its ill effects in one instance in 1797, led me to exhibit it with a trembling hand. I gave it for the first time to a son of Richard Renshaw. I had bled him but once, and had in vain tried to bring on a salivation. On the fifth day of his disease, his pulse became languid and slow, his skin cool, a hæmorrhage had taken place from his gums, and he discovered a restlessness and anxiety which I had often seen a few hours before death. He took four grains of tartar emetic, with twenty grains of calomel, at two doses. They operated powerfully, upwards and downwards, and brought away a large quantity of bile. The effects of this medicine were such as I wished. The next day he was out of danger. I prescribed the same medicine in many other cases with the same success. To several of my patients I gave two emetics in the course of the disease. Some of them discharged bile resembling in viscidity the white of an egg. But I saw one case in which great relief was obtained from the operation of an emetic, where no bile was discharged.
In the exhibition of this remedy, I was regulated by the pulse. If I found it languid on the first day of the fever, I gave it before any other medicine. When it was full and tense, I deferred it until I had reduced the pulse to the emetic point by bleeding and purges. I observed, with great pleasure, that mercury affected the mouth more speedily and certainly where an emetic had been administered, than in other cases, probably from awakening, by its stimulus, the sensibility of the stomach; for such was its torpor, that in one case ten grains of tartar emetic, and in another thirty grains, did not operate upon it, so as to excite even the slightest degree of nausea.
In many cases, an emetic, given in the forming state of the disease, seemed to effect an immediate cure.
Purges produced the same salutary effects that they did in former years. I always combined calomel with them in the first stage of the disease.
A salivation was found to be the most certain remedy of any that was used in this fever. I did not lose a single patient, in whom the mercury acted upon the salivary glands. It was difficult to excite it in many cases, from the mercury being rejected by the stomach, from its passing off by the bowels, or from its stimulus being exceeded by the morbid action in the blood-vessels.
Bleeding rendered the action of the mercury upon the mouth more speedy and more certain, but I saw several cases in which a salivation was excited in the most malignant forms of the fever, where no blood had been drawn. It will not be difficult to explain the reason of this fact if we recur to what was said formerly of the prostration of the system in this fever. In its worst forms, there is often a total absence, or a feeble degree of action in the blood-vessels, from an excess of the stimulus of the remote cause of the fever. Here the mercury meets with no resistance in its tendency to the mouth. Bleeding in this case would probably do harm, by taking off a part of the pressure upon the system, and thereby produce a re-action in the vessels, that might predominate over the action of the mercury. The disease here does that for us by its force, which, in other cases, we effect by depleting remedies.
Where the mercury showed a disposition to pass too rapidly through the bowels, I observed no inconvenience from combining it with opium, in my attempts to excite a salivation. The calomel was constantly aided by mercurial ointment, applied by friction to different parts of the body.
Now and then a salivation continued for weeks and months after the crisis of this fever, to the great distress of the patient, and injury of the credit of mercury as a remedy in this disease. Dr. Physick has discovered, that in these cases the salivation is kept up by carious teeth or bone, and that it is to be cured only by removing them.
From the impracticability of exciting a salivation in all cases, I attempted the cure of this fever, after bleeding, by means of copious sweats. They succeeded in several instances where no other remedy promised or afforded any relief. They were excited by wrapping the patient in a blanket, with half a dozen hot bricks wetted with vinegar, and applied to different parts of the body. The sweating was continued for six hours, and repeated daily for four or five days.
In those cases where the fever put on the form of an intermittent, I gave bark after bleeding and purging with advantage. I gave it likewise in all those cases where the fever put on the type of the slow chronic fever. Laudanum was acceptable and useful in many cases of pain, wakefulness, vomiting, and diarrhœa, after the use of depleting remedies.
I applied blisters in the usual way in this fever, but I think with less effect than in the yellow fevers of former years.
To relieve a vomiting, which was very distressing in many cases about the fourth and fifth days, I gave a julep, composed of the salt of tartar and laudanum. I also gave Dr. Hosack's anti-emetic medicine, composed of equal parts of lime-water and milk. I do not know that it saved any lives, but I am sure it gave ease by removing a painful symptom, and thus, where it did not cure, lessened the sufferings of the sick.
The diet and drinks were the same in this fever as they were in the fevers formerly described.
Cool air, cold water, and cleanliness produced their usual salutary effects in this fever.
I shall now deliver a short account of the symptoms which indicated a favourable and an unfavourable issue of the disease.
It has been said[8], that the signs of danger vary in this fever, from the influence of the weather. The autumn of 1798 confirmed, in many instances, the truth of this remark.
I saw no instance of death where a bleeding occurred from the gums on the fourth or fifth day, provided depleting remedies had been used from the beginning of the disease. Few recovered who had this symptom in 1793.
I saw three recoveries after convulsions in the year 1798. All died who were convulsed in 1793 and 1797.
A dry, hoarse, and sore throat was followed by death in every case in which it occurred in my practice. In the fever of 1793 a sore throat was a favourable sign. It was one of the circumstances which determined me to use a salivation in that fever.
The absence of pain was always a bad sign. Small, but frequent stools, and the continuance of a redness in the eyes after the ample use of depleting remedies, were likewise bad signs.
An appetite for food on the fourth or fifth day of the fever, without a remission or cessation of the fever, was always unfavourable.
A want of delicacy, in exposing parts of the body which are usually covered, was a bad symptom. I saw but one recovery where it took place. Boccacio says the same symptom occurred in the plague in Italy. “It suspended (he tells us) all modesty, so that young women, of great rank and delicacy, submitted to be attended, dressed, and even cleansed by male nurses.”
I have remarked, in another place, that but two of my patients recovered who had the hiccup.
A dry tongue was a bad sign. I saw but one recovery where it occurred, and none where the tongue was black. A moist and natural tongue, where symptoms of violence or malignity appeared in other parts of the body, was always followed by a fatal issue of the disease.
A desire to ride out, or to go home, in persons who were absent from their families, was, in every instance where it took place, a fatal symptom. These desires arose from an insensibility to pain, or a false idea of the state of the disease. It existed to such a degree in some of the patients in the city hospital, that they often left their beds, and dressed themselves, in order to go home. All these patients died, and some of them in the act of putting on their clothes.
From the history that has been given of the symptoms, treatment, and prognosis of this fever, we see how imperfect all treatises upon epidemics must be, which are not connected with climate and season. As well might a traveller describe a foreign climate, by the state of the weather, or by the productions of the earth, during a single autumn, as a physician adopt a uniform opinion of the history, treatment, and prognosis of a fever, from its phenomena in any one country, or during a single season.
There were three modes of practice used in this epidemic. The first consisted in the exhibition of purges of castor oil, salts, and manna, and cooling glysters, and in the use of the warm bath. These remedies were prescribed chiefly by the French physicians. The second consisted in the use of mercury alone, in such doses, and in such a manner, as to excite a salivation. This mode was used chiefly by an itinerant and popular quack. The third mode consisted in using all the remedies which I have mentioned in the account of the treatment of this fever, and accommodating them to the state of the disease. This mode of practice was followed by most of the American physicians.
The first mode of practice was the least successful. It succeeded only in such cases as would probably have cured themselves.
The second mode succeeded in mild cases, and now and then in that malignant state of the fever, in which the action of the blood-vessels was so much prostrated by the force of the miasmata, as to permit the mercury to pass over them, and thus to act upon the salivary glands in the course of four or five days.
The last mode was by far the most successful. It is worthy of notice, that the business and reputation of the physicians, during this epidemic, were in the inverse ratio of their success. The number of deaths by it amounted to between three and four thousand, among whom were three physicians, and two students of medicine. Its mortality was nearly as great as it was in 1793, and yet the number of people who were affected by it was four times as great in 1793 as it was in 1798, for, in the latter year, the city was deserted by nearly all its inhabitants. The cause of this disproportion of deaths to the number who were sick, was owing to the liberal and general use of the lancet in 1793, and to the publications in 1797 having excited general fears and prejudices against it in 1798. Such was the influence of these publications, that many persons who had recovered from this fever in the two former years, by the use of depleting remedies, deserted the physicians who had prescribed them, and put themselves under the care of physicians of opposite modes of practice. Most of them died. Two of them had been my patients, one of whom had recovered of a third attack of the fever under my care.