while there were any remains of inflammatory action in the system. I
recollect that a few spoonsful of it, which Mr. Harrison of Virginia
took in the depressed state of his pulse, excited a sensation in his
stomach which he compared to a fire. Even wine-whey, in the excitable
state of the system induced by this fever, was sometimes hurtful. In a
patient of Dr. Physick, who was on the recovery, it produced a relapse
that had nearly proved fatal, in the year 1795. Dr. Desperrieres ascribes
the death of a patient to a small quantity of wine given to him by a
black nurse[124]. These facts are important, inasmuch as wine is a
medicine which patients are most apt to use in all cases, without the
advice of a physician.
[124] Vol. ii. p. 108.
I observed _opium_ to be less hurtful in this fever than it was in the
fever of 1793. I administered a few drops of laudanum, in one case, in
the form of a glyster, in a violent pain of the bowels, with evident
advantage, before the inflammatory action of the blood-vessels was
subdued. In this way I have often obtained the composing effects of
laudanum where it has been rejected by the stomach. But I gave it
sparingly, and in small doses only, in the early stage of the fever. John
Madge, whose pains in his bowels were often as exquisite as they are in
the most acute colic, did not take a single drop of it. I used no anodyne
in his case but bleeding, and applications of cold water to the inside
and outside of his bowels. After the fever had passed the seventh day,
and had been so far subdued by copious evacuations as to put on the form
of a common inflammatory intermittent, I gave laudanum during the
intermissions of the fever with great advantage. In some cases it
suddenly checked the paroxysms of the fever, while in many more it only
moderated them, but in such a manner that they wore themselves away in
eight or ten days. One of my female patients, who had taken bitters of
every kind without effect to cure a tertian, which succeeded a yellow
fever, took a large dose of laudanum, in the interval of her paroxysms,
to cure a tooth-ach. To her great surprise it removed her tertian. The
effects of laudanum in this fever were very different from those of bark.
Where it did no service it did not, like the bark, do any harm.
Perhaps this difference in the operation of those two medicines depended
upon the bark acting with an astringent, as well as stimulating power,
chiefly upon the blood-vessels, while the action of the opium was more
simply stimulating, and diffused at the same time over all the systems of
the body.
I shall say in another place that I sometimes directed a few drops of
laudanum to be given in that state of extreme debility which succeeds a
paroxysm of fever, with evident advantage.
_Nitre_, so useful in common inflammatory fevers, was in most cases so
offensive to the stomach in this fever, that I was seldom able to give
it. Where the stomach retained it I did not perceive it to do any
service.
_Antimonials_ were as ineffectual as nitre in abating the action of the
sanguiferous system, and in producing a sweat. I should as soon expect to
compose a storm by music, as to cure a yellow fever by such feeble
remedies.
Thus have I finished the history of the symptoms, origin, and cure of the
yellow fever as it appeared in Philadelphia in 1794, and in the winter of
1795. The efficacy of the remedies which have been mentioned was
established by almost universal success. Out of upwards of 200 patients
to whom I was called on the first stage of the fever, between the 12th of
June, 1794, and the 1st of April, 1795, I lost but four persons, in whom
the unequivocal symptoms had occurred, which characterize the first grade
of the disease.
It will be useful, I hope, to relate the cases of the patients whom I
lost, and to mention the causes of their deaths. The first of them was
Mrs. Gavin. She objected to a fifth bleeding in the beginning of a
paroxysm of her fever, and died from the want of it. Her death was
ascribed to the frequency of her bleedings by the enemies of the
depleting system. It was said that she had been bled ten times, owing to
ten marks of a lancet having been discovered on her arms after death,
five of which were occasioned by unsuccessful attempts to bleed her. She
died with the usual symptoms of congestion in her brain.
Mr. Marr, to whom I was called on the first day of his disease, died in a
paroxysm of his fever which came on in the middle of the seventh night,
after six bleedings. I had left him, the night before, nearly free of
fever, and in good spirits. He might probably have been saved (humanly
speaking) by one more bleeding in the exacerbation of what appeared to be
the critical paroxysm of his fever.
Mr. Montford, of the state of Georgia, died under the joint care of Dr.
Physick and myself. He had been cured by plentiful bleeding and purging,
but had relapsed. He appeared to expire in a fainty fit in the first
stage of a paroxysm of the fever. Death from this cause (which occurs
most frequently where blood-letting is not used) is common in the yellow
fever of the West-Indies. Dr. Bisset, in describing the different ways in
which the disease terminates fatally, says, "In a few cases the patient
is carried off by an _unexpected syncope_[125]."
[125] Medical Essays and Observations, p. 28.
A servant of Mr. Henry Mitchel, to whom I was called in the early stage
of his disease, died in consequence of a sudden effusion in his lungs,
which had been weakened by a previous pulmonary complaint.
I wish the friends of bark and wine in the yellow fever, or of _moderate_
bleeding with antimonial medicines, would publish an account of the
number of their deaths by the fever, within the period I have mentioned,
and with the same fidelity I have done. The contrast would for ever
decide the controversy in favour of copious depletion. The mortality
under the tonic mode of practice may easily be conceived from the
acknowledgment of one of the gentlemen who used it, but who premised it,
in many cases, by two and three bleedings. He informed Dr. Woodhouse,
that out of twenty-seven patients, whom he had attended in the yellow
fever, he had saved but nine. Other practitioners were, I believe,
equally unsuccessful, in proportion to the number of patients whom they
attended. The reader will not admit of many deaths having occurred from
the diseases (formerly enumerated) to which they were ascribed, when he
recollects that even a single death from most of them, in common seasons,
is a rare occurrence in the practice of regular bred physicians.
In answer to the account I have given of the mortality of the fever in
1794, it will be said, that 30 persons died less in that year, than in
the healthy year of 1792. To account for this, it will be necessary to
recollect that the inhabitants of Philadelphia were reduced in number
upwards of 4000, in the year 1793, and of course that the proportion of
deaths was greater in 1794 than it was in 1792, although the number was
less. It is remarkable that the burials in the strangers' grave-yard
amounted in the year 1792 to but 201, whereas in 1794 they were 676. From
this it appears, that the deaths must have been very numerous among new
comers (as they are sometimes called) in the year 1794, compared with
common years. Now this will easily be accounted for, when we recollect
that these people, who were chiefly labourers, were exposed to the
constantly exciting causes of the disease, and that, in all countries,
they are the principal sufferers by it.
But in order to do justice to this comparative view of the mortality
induced by the yellow fever in the year 1794, it will be necessary to
examine the bill of mortality of the succeeding year. By this it appears
that 2274 persons died in 1795, making 1139 more than died in 1794. The
greatness of this mortality, I well recollect, surprized many of the
citizens of Philadelphia, who had just passed an autumn which was not
unusually sickly, and who had forgotten the uncommon mortality of the
months of January, February, and March, which succeeded the autumn of
1794.
It will probably be asked, how it came to pass that I attended so many
more patients in this fever than any of my brethren. To this I answer,
that, since the year 1793, a great proportion of my patients have
consisted of strangers, and of the poor; and as they are more exposed to
the disease than other people, it follows, that of the persons affected
by the fever, a greater proportion must have fallen to my share as
patients, than to other physicians. My ability to attend a greater number
of patients than most of my brethren, was facilitated by my having, at
the time of the fever, several ingenious and active pupils, who assisted
me in visiting and prescribing for the sick. These pupils were, Ashton
Alexander and Nathaniel Potter (now physicians at Baltimore), John Otto
(now physician in Philadelphia), and Gilbert Watson (since dead of the
yellow fever).
The antiphlogistic remedies were not successful in Philadelphia, in the
yellow fever, in my hands alone. They were equally, and perhaps more so,
in the hands of my friends Dr. Griffitts, Dr. Physick, Dr. Dewees, and
Dr. Woodhouse.
They were moreover successful at the same time in New Haven, Baltimore,
and in Charleston, in South-Carolina. Eighteen out of twenty died of all
who took bark and wine in New-Haven, but only one in ten of those who
used the depleting medicines. In a letter from Dr. Brown, a physician of
eminence in Baltimore, dated November 27th, 1794, he says, "of the many
cases which fell to my care, two only proved mortal where I was called on
the first day of the disease, and had an uncontrouled opportunity to
follow my judgment. Where salivation took place, I had no case of
mortality; and in two of those cases, a black vomiting occurred." Dr.
Ramsay, of Charleston, in a letter to one of his friends in this city,
dated October 14th, 1794, subscribes to the efficacy of the same
practice in a fever which prevailed at that time in Charleston, and
which, he says, resembled the yellow fever of Philadelphia in the year
1793.
But the success of the depleting system was not confined to the United
States. In a letter before quoted, which I received from Dr. Davidson, of
St. Vincents, dated July 22d, 1794, there is the following testimony in
favour of evacuations from the blood-vessels, bowels, and salivary
glands:
"Where the fever comes on with great determination to the head, and an
affection of the stomach, in consequence of that determination, violent
head-ach, redness of the eyes, turgescence of the face, impatience of
light, &c. attended with a full and hard pulse, _blood-letting_ should be
employed _freely_ and _repeatedly_, cold applications should be applied
to the head, and purging medicines should be employed. As a purge,
_calomel_ has been used with the greatest advantage, sometimes by itself,
but most frequently combined with some active purgative medicine, such as
jalap. From some peculiarity in the disease, an uncommon quantity of the
calomel is necessary to affect the bowels and salivary glands. As I found
a small quantity of it did not produce the effect I wished for promptly,
I have gradually increased the quantity, until I now venture to give
_ten_ grains of it, combined with five of jalap, every _two_ hours until
stools are procured. The calomel is then given by itself.
"The patients have generally an aversion to wine. The bark is seldom
found of much advantage in this state of the fever, and frequently
brought on a return of the vomiting. I preferred to it, in a remission of
the symptoms, a vinous infusion of the quassia, which sat better upon the
stomach."
In the island of Jamaica, the depleting system has been divided. It
appears, from several publications in the Kingston papers, that Dr. Grant
had adopted blood-letting, while most of the physicians of the island
rest the cure of the yellow fever upon strong mercurial purges. The ill
effects of _moderate_ bleeding probably threw the lancet into disrepute,
for the balance of success, from those publications, is evidently in
favour of simple purging. I have no doubt of the truth of the above
statement of the controversy between the exclusive advocates for bleeding
and purging; or perhaps the superior efficacy of the latter remedy may be
explained in the following manner.
In warm climates, the yellow fever is generally, as it was in
Philadelphia in the month of August and in the beginning of September,
1793, a disease of but two or three paroxysms. It is sometimes, I
believe, only a simple ephemera. In these cases, purging alone is
sufficient to reduce the system, without the aid of bleeding. It was
found to be so until the beginning of September, in 1793, in most cases
in Philadelphia. The great prostration of the system in the yellow fever,
in warm weather and in hot climates, renders the restoration of it to a
healthy state of action more gradual, and of course more safe, by means
of purging than bleeding. The latter remedy does harm, from the system
being below the point of re-action, after the pressure of the blood is
taken from it, or by restoring the blood-vessels too suddenly to
preternatural action, without reducing them afterwards. Had bleeding been
practised agreeably to the method described by Riverius (mentioned in the
history of the fever of 1793), or had the fever in Jamaica run on to more
than four or five paroxysms, it is probable the loss of blood would have
been not only safe, but generally beneficial. I have, in the same
history, given my reasons why _moderate_ bleeding in this, as well as
many other diseases, does harm. In those cases where it has occurred in
large quantities from natural hæmorrhages, it has always done service in
the West-Indies. The inefficacy, and, in some cases, the evils, of
_moderate_ blood-letting are not confined to the yellow fever. It is
equally ineffectual, and, in some instances, equally hurtful, in
apoplexy, internal dropsy of the brain, pleurisy, and pulmonary
consumption. Where all the different states of the pulse which indicate
the loss of blood are perfectly understood, and blood-letting conformed
in _time_ and in _quantity_ to them, it never can do harm, in any
disease. It is only when it is prescribed empirically, without the
direction of just principles, that it has ever proved hurtful. Thus the
fertilizing vapours of heaven, when they fall only in dew, or in profuse
showers of rain, are either insufficient to promote vegetation, or
altogether destructive to it.
There may be habits in which great and long protracted debility may have
so far exhausted the active powers of the system, as to render bleeding
altogether improper in this disease, in a West-India climate. Such habits
are sometimes produced in soldiers and sailors, by the hardships of a
military and naval life. Bleeding in such cases, Dr. Davidson assures me,
in a letter dated from Martinique, February 29th, 1796, did no good. The
cure was effected, under these circumstances, by purges, and large doses
of calomel. But where this chronic debility does not occur, bleeding,
when properly used, can never be injurious, even in a tropical climate,
in the yellow fever. Of this there are many proofs in the writings of the
most respectable English and French physicians. In spite of the fears and
clamours which have been lately excited against it in Jamaica, my late
friend and contemporary at the college of Edinburgh, Dr. Broadbelt, in a
letter from Spanish Town, dated January 6th, 1795, and my former pupil,
Dr. Weston, in a letter from St. Ann's Bay, dated June 17th, 1795, both
assure me, that they have used it in this fever with great success. Dr.
Weston says that he bled "_copiously_ three times in twenty-four hours,
and thereby saved his patient."
The superior advantages of the North-American mode of treating the yellow
fever, by means of _all_ the common antiphlogistic remedies, will appear
from comparing its success with that of the West-India physicians, under
all the modes of practice which have been adopted in the islands. Dr.
Desportes lost one half of all the patients he attended in the yellow
fever in one season in St. Domingo[126]. His remedies were _moderate_
bleeding and purging, and the copious use of diluting drinks. Dr. Bisset
says, "the yellow fever is often under particular circumstances very
fatal, carrying off four or five in seven whom it attacks, and sometimes,
but seldom, it is so favourable as to carry off only one patient in five
or six[127]." The doctor does not describe the practice under which this
mortality takes place.
[126] Vol. i. p. 55.
[127] Medical Essays and Observations, p. 29.
Dr. Home, I have elsewhere remarked[128], lost "one out of four of his
patients in Jamaica." His remedies were _moderate_ bleeding and purging,
and afterwards bark, wine, and external applications of blankets dipped
in hot vinegar.
[128] Account of the Yellow Fever of 1793.
Dr. Blane pronounces the yellow fever to be "one of the most fatal
diseases to which the human body is subject, and in which human art is
the most unavailing." His remedies were bleeding, bark, blisters, acid
drinks, saline draughts, and camomile tea.
Dr. Chisholm acknowledges that he lost one in twelve of all the patients
he attended in the fever of Grenada. His principal remedy was a
salivation. I shall hereafter show the inferiority of this single mode of
depleting, to a combination of it with bleeding and purging. In
Philadelphia and Baltimore, where bleeding, purging, and salivation were
used in due time, and after the manner that has been described, not more
than one in fifty died of the yellow fever. It is probable that greater
certainty and success in the treatment of this disease will not easily be
attained, for idiosyncracy, and habits of intemperance which resist or
divert the operation of the most proper remedies, a dread of the lancet,
or the delay of an hour in the use of it, the partial application of that
or any other remedy, the unexpected recurrence of a paroxysm of fever in
the middle of the night, or the clandestine exhibition of wine or
laudanum by friends or neighbours, often defeat the best concerted plans
of cure by a physician. Heaven in this, as in other instances, kindly
limits human power and benevolence, that in all situations man may
remember his dependence upon the power and goodness of his Creator.
AN
ACCOUNT
OF
SPORADIC CASES
OF
_BILIOUS YELLOW FEVER_,
IN PHILADELPHIA,
IN THE YEARS 1795 AND 1796.
In my account of the yellow fever, as it appeared in Philadelphia in the
year 1794, I took notice of several cases of it which occurred in the
spring of the year 1795. Before I proceed to deliver the history of this
disease as it appeared in 1797, I shall mention the diseases and state of
the weather which occurred during the remaining part of the year 1795,
and the whole of the year 1796. This detail of facts, apparently
uninteresting to the reader in the present state of our knowledge of
epidemics, may possibly lead to principles at a future day.
The month in of April, 1795, was wet and cold. All the diseases of this
month partook of the inflammatory character of the preceding winter and
autumn, except the measles, which were unusually mild.
The weather in May was alternately wet, cool, and warm. A few cases of
malignant fever occurred this month, but with moderate symptoms. In June
the weather was cool and pleasant. The measles put on more inflammatory
symptoms than in the preceding months. I had two cases of mania under my
care this month, and one of rheumatism, which were attended with
intermissions and exacerbations every other day.
The weather on the 19th, 20th, 21st, and 22d days of July was very warm,
the mercury being at 90° in Fahrenheit's thermometer. The fevers of this
month were all accompanied with black discharges from the bowels. Mr.
Kittera, one of the representatives of Pennsylvania in the congress of
the United States, in consequence of great fatigue on a warm day, was
affected with the usual symptoms of the yellow fever. During his illness
he constantly complained of more pain in the left, than in the right side
of his head. His pulse was more tense in his left, than in his right arm.
During his convalescence, it was more quick in the left arm, than it was
in the right. He was cured by a salivation and the loss of above 100
ounces of blood. His head-ach was relieved by the application of a
bladder half filled with ice to his forehead.
Most of the cases of bilious fever, which came under my notice, were
attended with quotidian, tertian, or quartan intermissions. In a few of
my patients there was a universal rash.
Dr. Woodhouse informed me, that he had seen several instances in which
the yellow fever appeared in the same place in which some soldiers had
laboured under the dysentery. These facts show the unity of fever, and
the impracticability of a nosological arrangement of diseases.
The cholera infantum was severe and fatal, in many instances, during this
month. It yielded to blood-letting in a child of Mr. Conyngham, which was
but four months old. In a child of seven weeks old which came under my
care, I observed the coldness, chills, hot fits, and remissions of the
bilious fever to be as distinctly marked as ever I had seen them in adult
patients. In a child of Mr. Darrach, aged 5 months, the discharges from
the bowels were of a black colour. I mention these facts in support of an
opinion I formerly published, that the cholera infantum is a bilious
fever, and that it rises and falls in its violence with the bilious fever
of grown persons.
About the latter end of this month and the beginning of August, there
were heavy showers of rain, which carried away fences, bridges, barns,
mills, and dwelling-houses in many places. Several cases of bilious
yellow fever occurred in the month of August. In one of them it was
accompanied with that morbid affection in the wind-pipe which has been
called cynanche trachealis. It was remarkable that sweating became a more
frequent symptom of the fevers of this month than it had been in July.
Hippocrates ascribes this change in the character of bilious fevers to
rainy weather. Perhaps it was induced by the rain which fell in the
beginning of the month, in the fevers which have been named.
Among the persons affected with the yellow fever during this month, was
William Bradford, Esq. the attorney-general of the United States. From a
dread of the lancet he objected to being bled in the early stage of his
disease, in consequence of which he died on the 23d of August, in the
39th year of his age, amidst the tears of numerous friends, and the
lamentations of his whole country.
On the 30th and 31st of August, there was a fall of rain, which suddenly
checked the fever of the season, insomuch that the succeeding autumnal
months were uncommonly healthy. Several showers of rain had nearly the
same effect in New-York, where this fever carried off, in a few weeks,
above 700 persons. It prevailed, at the same time, and with great
mortality, in the city of Norfolk, in Virginia.
In both those cities, as well as in Philadelphia, the disease was
evidently derived from putrid exhalation.
In the same month, the dysentery prevailed in Newhaven, in Connecticut,
and in the same part of the town in which the yellow fever had prevailed
the year before. The latter disease was said to have been imported, but
the prevalence of the dysentery, under the above circumstances, proved
that both diseases were of domestic origin.
The fever, as it appeared in Philadelphia, yielded in most cases to
depleting remedies. After purging and blood-letting, I gave bark, where
the fever intermitted, with advantage. It was effectual only when given
in large doses. In one instance, it induced a spitting of blood, which
obliged me to lay it aside.
The winter of 1796 was uncommonly moderate. There fell a good deal of
rain, but little snow. The navigation of the Delaware was stopped but two
or three days during the whole season. Catarrhs were frequent, but very
few violent or acute diseases occurred in my practice. The month of March
and the first week in April were uncommonly dry. Several cases of
malignant bilious fever came under my care during these months. A little
girl, of five years old, whom I lost in this fever, became yellow in two
hours after her death.
The measles prevailed in April, and were of a most inflammatory nature.
The weather in May and June was uncommonly wet. The fruit was much
injured, and a great deal of hay destroyed by it. On the 14th of June,
General Stewart died, with all the usual symptoms of a fatal yellow
fever. Several other cases of it, in this and in the succeeding month,
proved mortal, but they excited no alarm in the city, as the physicians
who attended them called them by other names.