refused to admit the presence of the yellow fever in the city, was
because they could not fix upon a vestige of its being imported. On the
25th of August, the brig Commerce arrived in the river, from St. Mark,
commanded by Captain Shirtliff. After lying five days at the fort, she
came up to the city. A boy, who had been shut out from his lodgings,
went, in a state of intoxication, and slept on her deck, exposed to the
night air, in consequence of which the fever was excited in him. This
event gave occasion, for a few days, to a report that the disease was
imported, and several of the physicians, who had neglected to attend to
all the circumstances that have been stated, admitted the yellow fever to
be in town. An investigation of this supposed origin of the disease soon
discovered that it had no foundation. At the time of the arrival of this
ship, I had attended nearly thirty persons with the fever, and upwards of
a hundred had had it, under the care of other physicians.
The generation of the yellow fever in our city was rendered more certain
by the prevalence of bilious diseases in every part of the United States,
and, in several of them, in the grade of yellow fever. It was common in
Charleston, in South-Carolina, where it carried off many people, and
where no suspicion was entertained of its being of West-India origin. It
prevailed with great mortality at that part of the city of Baltimore,
which is known by the name of Fell's Point, where, Dr. Drysdale assures
me, it was evidently generated. A few sporadic cases of it occurred in
New-York, which were produced by the morbid exhalation from the docks of
that city. Sporadic cases of it occurred likewise in most of the states,
in which the proofs of its being generated were obvious to common
observation; and where the symptoms of depressed pulse, yellowness of the
skin, and black discharges from the bowels and stomach (symptoms which
mark the highest grade of bilious remitting fever) did not occur, the
fevers in all their form of tertian, quotidian, colic, and dysentery,
were uncommonly obstinate or fatal in every state in the union. In
New-Haven only, where the yellow fever was epidemic, it was said to have
been imported from Martinique, but this opinion was proved to be
erroneous by unanswerable documents, published afterwards in the Medical
Repository, by Dr. Elisha Smith, of New-York.
The year 1795 furnished several melancholy proofs of the American origin
of the yellow fever. All the physicians and citizens of New-York and
Norfolk agree in its having been generated in their respective cities
that year. It prevailed with great mortality at the same time in the
neighbourhood of the lakes, and on the waters of the Genesee river, in
the state of New-York. From its situation it obtained the name of the
lake and Genesee fever. It was so general, in some parts of that new
country, as to affect horses.
Thus have I endeavoured to fix the predisposing and remote causes of the
yellow fever in our country. The remote cause is sometimes so powerful as
to become an exciting cause of the disease, but in general both the
predisposing and remote causes are harmless in the system, until they are
roused into action by some exciting cause.
I shall conclude this account of the symptoms and origin of the yellow
fever by relating two facts, which serious and contemplating minds will
apply to a more interesting subject.
1. Notwithstanding the numerous proofs of the prevalence of the yellow
fever in Philadelphia in the year 1794, which have been mentioned, there
are many thousands of our citizens, and a majority of our physicians, who
do not believe that a case of it existed at that time in the city; nor is
a single record of it to be met with in any of the newspapers, or other
public documents of that year. Let us learn from this fact, that the
denial of events, or a general silence upon the subject of them, is no
refutation of their truth, where they oppose the pride or interests of
the learned, or the great.
2. Notwithstanding the general denial of the existence of the yellow
fever in Philadelphia, and the silence observed by our newspapers
relative to it in 1794, there was scarcely a citizen or physician who,
three years afterwards, did not admit of its having prevailed in that
year. We learn from this fact another important truth, that departed
vice and error have no friends nor advocates.
OF THE METHOD OF CURE.
The remedies employed for the cure of this fever were the same that I
employed the year before. I shall only relate such effects of them as
tend more fully to establish the practice adopted in the year 1793, and
such as escaped my notice in my former remarks upon those remedies. My
method of cure consisted,
I. In the abstraction of the stimulus of blood and heat from the whole
body, and of bile and other acrid humours from the bowels, by means of
the following remedies:
1. Bleeding.
2. Purging.
3. Cool air and cold drinks.
4. Cold water applied to the external parts of the body, and to the
bowels by means of glysters.
II. In creating a diversion of congestion, inflammation, and serous
effusion, from the brain and viscera to the mouth, by means of a
salivation, and to the external parts of the body, by means of blisters.
III. In restoring the strength of the system, by tonic remedies.
I proceed to make a few remarks upon the remedies set down under each of
the above heads.
I. I have taken notice that this fever differed from the fever of 1793,
in coming forward in July and August with a number of paroxysms, which
refused to yield to purging alone. I therefore began the cure of every
case I was called to by _bleeding_.
I shall mention the effects of this remedy, and the circumstances,
manner, and degrees in which I used it occasionally, in this fever, in my
Defence of Blood-letting. Under the present head I shall only furnish the
reader with a table of the quantity of blood drawn from a number of my
patients in the course of the disease. From several of them the quantity
set down was taken in three, four, and five days. I shall afterwards
describe the appearances of the blood.
+-----------+------------------+-----------+------------+
| Month. | Patients. | Quantity. | Number of |
| | | ounces. | times bled.|
+-----------+------------------+-----------+------------+
| August. | Peter Denham | 50 | 5 |
| | Mrs. Bruce | 70 | 7 |
| | Andrew Gribble, | | |
| | aged 15 years. | 50 | 5 |
| | John Madge | 150 | 12 |
| | Peter Brown | 80 | 8 |
| September.| Mrs. Gardiner | 80 | 7 |
| | Miss Sally Eyre | 80 | 9 |
| | Mrs. Gass | 50 | 3 |
| | Richard Wells's | | |
| | maid | 100 | 10 |
| | Mr. Norval | 100 | 9 |
| | Mr. Harrison | 90 | 9 |
| | Henry Clymer | 80 | 8 |
| October. | Mrs. Mitchell | 120 | 13 |
| | Mrs. Lenox | 80 | 7 |
| | Mrs. Kapper | 140 | 11 |
| | Rev. Dr. Magaw's | | |
| | maid | 100 | 10 |
| | Miss Hood | 100 | 10 |
| | Mrs. Vogles | 70 | 5 |
| 1795 | Guy Stone | 100 | 9 |
| January. | Benj. Hancock | 100 | 10 |
| | Mr. Benton | 130 | 13 |
| | Mrs. Fries | 150 | 15 |
| | Mrs. Garrigues | 80 | 7 |
+-----------+------------------+-----------+------------+
Three of the women, whose names I have mentioned, were in the advanced
stage of pregnancy, viz. Mrs. Gardiner, Mrs. Gass, and Mrs. Garrigues.
They have all since borne healthy children. I have omitted the names of
above one hundred persons who had the fever, from whom I drew thirty or
forty ounces of blood, by two or three bleedings. I did not cure a single
person without at least one bleeding.
It is only by contemplating the extent in which it is necessary to use
this remedy, in order to overcome a yellow fever, that we can acquire
just ideas of its force. Hitherto this force has been estimated by no
other measure than the grave, and this, we know, puts the strength of all
diseases upon a level.
The blood drawn in this fever exhibited the following appearances;
1. It was dissolved in a few instances.
2. The crassamentum of the blood was so partially dissolved in the serum,
as to produce an appearance in the serum resembling the washings of flesh
in water.
3. The serum was so lightly tinged of a _red_ colour as to be perfectly
transparent.
4. The serum was, in many cases, of a deep yellow colour.
5. There was, in every case in which the blood was not dissolved, or in
which the second appearance that has been mentioned did not take place, a
beautiful scarlet-coloured sediment in the bottom of the bowl, forming
lines, or a large circle. It seemed to be a tendency of the blood to
dissolution. This state of the blood occurred in almost all the diseases
of the last two years, and in some in which there was not the least
suspicion of the miasmata of the yellow fever.
6. The crassamentum generally floated in the serum, but it sometimes sunk
to the bottom of the bowl. In the latter case the serum had a muddy
appearance.
7. I saw but one case in which there was not a separation of the
crassamentum and serum of the blood. Its colour in this case was of a
deep scarlet. In the year 1793 this appearance was very common.
8. I saw one case in which the blood drawn, amounting to 14 ounces,
separated partially, and was of a deep _black_ colour. This blood was
taken from Mr. Norval, a citizen of North-Carolina.
9. There was, in several instances, a transparent jelly-like pellicle
which covered the crassamentum of the blood, and which was easily
separated from it without altering its texture. It appeared to have no
connection with the blood.
10. The blood, towards the crisis of the fever in many people, exhibited
the usual forms of inflammatory crust. It was cupped in many instances.
11. After the loss of 70 or 80 ounces of blood there was an evident
disproportion of the quantity of crassamentum to the serum. It was
sometimes less, by one half, than in the first bleedings.
Under this head it will be proper to mention that the blood, when it
happened to flow along the external part of the arm in falling into the
bowl, was so warm as to excite an unpleasant sensation of heat in several
patients.
To the appearances exhibited by the blood to the eye, I shall add a fact
communicated to me by a German bleeder, who followed his business in the
city during the prevalence of the fever in 1793. He informed me that he
could distinguish a yellow fever from all other states of fever, by a
peculiar smell which the blood emitted while it was flowing from a vein.
From the certainty of his decision in one case which came under my
notice, before a suspicion had taken place of the fever being in the
city, I am disposed to believe that there is a foundation for his remark.
II. I have but little to add to the remarks I made upon the use of
_purging_ in the year 1793. I gave jalap, calomel, and gamboge until I
obtained large and dark-coloured stools; after which I kept the bowels
gently open every day with castor oil, cremor tartar, or glauber's salts.
I gave calomel in much larger quantities than I did the year before. John
Madge took nearly 150 grains of it in six days. I should have thought
this a large quantity, had I not since read that Dr. Chisholm gave 400
grains of it to one patient in the course of his fever, and 50 grains to
another at a single dose, three times a day. I found strong mercurial
purges to be extremely useful in the winter months, when the fever put on
symptoms of pleurisy. I am not singular in ascribing much to the efficacy
of purges in the bilious pleurisy. Dr. Desportes tells us that he found
the pleurisy of St. Domingo, which was of the bilious kind, to end
happily in proportion as the bowels were kept constantly open[121]. Nor
am I singular in keeping my eye upon the original type of a disease,
which only changes its symptoms with the weather or the season, and in
treating it with the same remedies. Dr. Sydenham bled as freely in the
diarrh[oe]a of 1668 as he had done in the inflammatory fever of the
preceding year[122]. How long the pleurisies of winter, in the city of
Philadelphia, may continue to retain the bilious symptoms of autumn,
which they have assumed for three years past, I know not; but the late
Dr. Faysseaux, of South-Carolina, informed me, that for many years he had
not seen a pleurisy in Charleston with the common inflammatory symptoms
which characterised that disease when he was a student of medicine. They
all now put on bilious symptoms, and require strong purges to cure them.
The pleurisies which the late Dr. Chalmers supposes he cured by purging
were probably nothing but bilious fevers, in which the cool weather had
excited some pleuritic symptoms.
[121] Page 140.
[122] Wallis's edition, p. 211. vol. i.
I have nothing to add to the remarks I have elsewhere published upon the
efficacy of _cool air_ and _cold drinks_ in this fever. They were both
equally pleasant and useful, and contributed, with cleanliness, very much
to the success of my practice.
4. _Cold water_, applied to the external parts of the body, and injected
into the bowels by way of glyster, did great service in many cases. John
Madge found great relief from cloths dipped in cold water, and applied to
the lower part of his belly. They eased a pain in his bowels, and
procured a discharge of urine. A throbbing and most distressing pain in
the head was relieved by the same remedy, in Mrs. Vogles and Mrs. Lenox.
The cloths were applied for three successive days and nights to Mrs.
Lenox's head, during an inflammation of her brain, which succeeded her
fever, and were changed, during the greater part of the time, every ten
or fifteen minutes. In 1795, I increased the coldness of pump water, when
used in this way, by dissolving ice in it, and in some cases I applied
powdered ice in a bladder to the head, with great advantage.
The following facts will show the good effects of cold water in this, as
well as other fevers of too much action.
In the afternoon of one of those days in which my system was impregnated
with the miasmata of the yellow fever, I felt so much indisposed that I
deliberated whether I should go to bed or visit a patient about a mile in
the country. The afternoon was cool and rainy. I recollected, at this
time, a case related by Dr. Daignan, a French physician, of a man who was
cured of the plague, by being forced to lie all night in an open field,
in a shower of rain. I got into my chair, and exposed myself to the rain.
It was extremely grateful to my feelings. In two hours I returned, when,
to my great satisfaction, I found all my feverish symptoms had left me,
nor had I the least return of them afterwards.
Dr. Caldwell, who acted as a surgeon of a regiment, in the expedition
against the insurgents in the western counties of Pennsylvania, furnished
me, in a letter dated from Bedford, October 20th, 1794, with an account
of his having been cured of a fever, by a more copious use of the same
remedy. "I was (says the doctor), to use a vulgar expression, _wet to the
skin_, and had no opportunity of shifting my clothes for several hours.
In consequence of this thorough bathing, and my subsequent exposure to a
cool air, I was relieved from every symptom of indisposition in a few
hours, and have enjoyed more than my usual stock of health ever since."
The efficacy of cold water, in preventing and curing inflammation, may be
conceived from its effects when used with mud or clay, for obviating the
pain and inflammation which arise from the sting of venomous insects. The
same remedy, applied for half an hour, has lately, it is said, been
equally effectual in preventing the deleterious effects of the bite of a
rattle-snake.
II. The good effects I had observed from a _salivation_ in the yellow
fever of 1793, induced me to excite it as early as possible, in all those
cases which did not yield immediately to bleeding and purging. I was
delighted with its effects in every case in which it took place. These
effects were as follow:
1. It immediately attracted and concentrated in the mouth all the
scattered pains of every part of the body.
2. It checked a nausea and vomiting.
3. It gradually, when it was copious, reduced the pulse, and thereby
prevented the necessity of further bleeding or purging.
I wish it were possible to render the use of this remedy universal in the
treatment of malignant fevers. Dr. Chisholm, in his account of the
Beullam fever, has done much to establish its safety and efficacy. It is
a rare occurrence for a patient that has been sufficiently bled and
purged, to die after a salivation takes place. The artificial disease
excited by the mercury suspends or destroys disease in every part of the
body. The occasional inconveniences which attend it are not to be named
with its certain and universal advantages. During the whole of the season
in which the yellow fever prevailed, I saw but two instances in which it
probably loosened or destroyed the teeth. I am not certain that the
mercury was the cause of the injury or loss of those teeth; for who has
not seen malignant fevers terminate in ulcers, which have ended in the
erosions of bony parts of the body?
It has been justly remarked, that there can be but one action at a time
in the blood-vessels. This was frequently illustrated by the manner in
which mercury acted upon the system in this fever. It seldom salivated
until the fever intermitted or declined. I saw several cases in which
the salivation came on during the intermission, and went off during its
exacerbation; and many, in which there was no salivation until the morbid
action had ceased altogether in the blood-vessels, by the solution of the
fever. It is because the action of the vessels, in epilepsy and pulmonary
consumption, surpasses the stimulus of the mercury, that it is so
difficult to excite a salivation in both those diseases.
Let not the advocates for the healing powers of nature complain of a
salivation as an unnatural remedy in fevers. Dr. Sydenham speaks in high
terms of it, in the fever of 1670, 1671, and 1672, in which cases it
occurred spontaneously, and says that it cured it when it was so
malignant as to be accompanied by purple spots on the body[123].
[123] Vol. ii. p. 212.
Blisters, when applied at a _proper_ time, did great service in this
fever. This time was, when the fever was so much weakened by evacuations,
that the artificial pain excited by the stimulus of the blisters
destroyed, and, like a conductor, conveyed off all the natural pain of
the body. It is from ignorance, or inattention to the proper stage of
fevers in which blisters have been applied, that there have been so many
disputes among physicians respecting their efficacy. When applied in a
state of great arterial action, they do harm; when applied after that
action has nearly ceased, they do little or no service. I have called the
period in which blisters are useful the _blistering point_. In bilious
fevers this point is generally circumscribed within eight and forty
hours.
The effects of blisters were as follow:
1. They concentrated, like a salivation, all the scattered pains of the
body, and thereby,
2. Reduced the pulse in force and frequency.
3. They instantly checked a sickness at the stomach and vomiting.
4. They often induced a gentle moisture upon the skin.
I found it of little consequence to what part of the body the blisters
were applied; for I observed a pain in the head, and even delirium, to be
as speedily and certainly cured by blisters upon the wrists, as they were
by a large blister to the neck.
III. After the reduction of the morbid action of the blood-vessels, by
means of the remedies which have been mentioned, I seldom made use of any
other tonic than a nourishing and gently stimulating diet. This consisted
of summer fruits, bread and milk, chicken broth, the white meats, eggs,
oysters, and malt liquors, more especially porter. I made many attempts
to cure this fever when it appeared in the form of a simple intermittent,
without malignant symptoms, by means of _bark_, but always, except in two
instances, without success; and in them it did not take effect until
after bleeding. In several cases it evidently did harm. I should have
suspected my judgment in these observations respecting this medicine, had
I not been assured by Dr. Griffitts, Dr. Physick, and Dr. Woodhouse, that
it was equally ineffectual in their practice, in nearly all the cases in
which they gave it, and even where blood-letting had been premised. Dr.
Woodhouse saw a case in which near a pound of bark had been taken without
effect; and another in which a fatal dropsy succeeded its use. Dr.
Griffitts excepted, from his testimony against the bark, the cases of
seven persons from the country, who brought the seeds of the intermitting
fever with them to the city. In them the bark succeeded without previous
bleeding. The facility with which these seven cases of intermitting
fever were cured by the bark, clearly proves that fevers of the same
season differ very much, according to the nature of the exhalation which
excites them. The intermittents in these strangers were excited by
miasmata of less force than that which was generated in our city, in
which, from the greater heat of the atmosphere, and the more
heterogeneous nature of the putrid matters which stagnate in our ponds
and gutters, the exhalation probably possesses a more active and
stimulating quality. Thus the mild remittents in June, and in the
beginning of July, which were produced by the usual filth of the streets
of Philadelphia, in the year 1793, differed very much from the malignant
remitting yellow fever which was produced by the stench of the putrid
coffee a few weeks afterwards.
Sir John Pringle long ago taught the inefficacy of bark in certain
bilious fevers. But Dr. Chisholm has done great service to medicine by
recording its ill effects in the Beullam fever. "Head-ach (says the
doctor), a heavy dull eye, with a considerable protrusion from its
orbits, low spirits, thirst, and a total want of appetite, were the
general consequences of the treatment with bark without the previous
antiphlogistic."
I have mentioned a case of internal dropsy of the brain having been
produced by the improper use of the bark, in a son of Mr. Coates. I have
no doubt but this disease, as also palsy and consumption, obstructions of
the liver and bowels, and dropsies of the belly and limbs, are often
induced by the use of the bark, during an inflammatory state of the
blood-vessels. It is to be lamented that the association of certain
diseases and remedies, in the minds of physicians, becomes so fixed, as
to refuse to yield to the influence of reason. Thus pain and opium,
dropsy and foxglove, low spirits and assaf[oe]tida, and, above all, an
intermitting fever and bark, are all connected together, in common
practice, as mechanically as the candle and the snuffers are in the mind
of an old and steady house servant. To abolish the mischief of these
mechanical associations in medicine, it will be necessary for physicians
to prescribe only for the different states of the system.
Finding the bark to be so universally ineffectual or hurtful, I
substituted Columbo root, the Carribean bark, and several other bitters,
in its place, but without success. They did less harm than the jesuit's
bark, but they did not check the return of a single paroxysm of fever.
I know that bark was given in this fever in some instances in which the
patients recovered; but they were subject, during the winter, and in the
following spring, to frequent relapses, and, in some instances, to
affections of the brain and lungs. In the highest grade of the fever it
certainly accelerated a supposed putrefaction of the blood, and
precipitated death. The practice of physicians who create this gangrenous
state of fever by means of the bark, resembles the conduct of a horse,
who attempts by pawing to remove his shadow in a stream of water, and
thereby renders it so turbid that he is unable to drink it.
Should the immediate success of tonic and depleting remedies in
destroying the fever be equal, the effects of the former upon the
constitution cannot fail of being less safe than the latter remedies.
They cure by overstraining the powers of life. There is the same
difference, therefore, between the two modes of practice, that there is
between gently lifting the latch of a door, and breaking it open in order
to go into a house.