ways. 1. It sometimes produced a swelling only in the throat, resembling
a common inflammatory angina. 2. It sometimes produced ulcers upon the
lips, cheeks, and tongue, without any discharge from the salivary glands.
3. It sometimes produced swellings and ulcers in the gums, and loosened
the teeth without inducing a salivation. 4. There were instances in which
the mercury induced a rigidity in the masseter muscles of the jaw, by
which means the mouth was kept constantly open, or so much closed, as to
render it difficult for the patient to take food, and impossible for him
to masticate it. 5. It sometimes affected the salivary glands only,
producing from them a copious secretion and excretion of saliva. But, 6.
It more frequently acted upon all the above parts, and it was then it
produced most speedily its salutary effects. 7. The discharge of the
saliva frequently took place only during the remission or intermission of
the fever, and ceased with each return of its paroxysms. 8. The
salivation did not take place, in some cases, until the solution of the
fever. This was more especially the case in those forms of the fever in
which there were no remissions or intermissions. 9. It ceased in most
cases with the fever, but it sometimes continued for six weeks or two
months after the complete recovery of the patient. 10. The mercury rarely
dislodged the teeth. Not a single instance occurred of a patient losing a
tooth in the city hospital, where the physicians, Dr. J. Duffield
informed me, relied chiefly upon a salivation for a cure of the fever.
11. Sometimes the mercury produced a discharge of blood with the saliva.
Dr. Coulter, of Baltimore, gave me an account, in a letter dated the 17th
of September, 1797, of a boy in whom a hæmorrhage from the salivary
glands, excited by calomel, was succeeded by a plentiful flow of saliva,
which saved his patient. I saw no inconvenience from the mixture of blood
with saliva in any of my patients. It occurred in Dr. Caldwell, Mr.
Bradford, Mr. Brown, and several others.
It has been said that mercury does no service unless it purges or
salivates. I am disposed to believe that it may act as a counter stimulus
to that of the miasmata of the yellow fever, and thus be useful without
producing any evacuation from the bowels or mouth. It more certainly
acts in this way, provided blood-letting has preceded its exhibition. I
have supposed the stimulus from the remote cause of the yellow fever to
be equal in force to five, and that of mercury to three. To enable the
mercury to produce its action upon the system, it is necessary to reduce
the febrile action, by bleeding, to two and a half, or below it, so that
the stimulus of the mercury shall transcend it. The safety of mercury,
when introduced into the system, has three advantages as a stimulus over
that of the matter which produces the fever. 1. It excites an action in
the system preternatural only in _force_. It does not derange the
_natural_ order of actions. 2. It determines the actions chiefly to
external parts of the body. And, 3. It fixes them, when it affects the
mouth and throat, upon parts which are capable of bearing great
inflammation and effusion without any danger to life. The stimulus which
produces the yellow fever acts in ways the reverse of those which have
been mentioned. It produces violent _irregular_ or _wrong_ actions. It
determines them to internal parts of the body, and it fixes them upon
viscera which bear, with difficulty and danger, the usual effects of
disease. A late French writer, Dr. Fabre, ascribed to diseases a
centrifugal, and a centripetal direction. From what has been said it
would seem, the former belongs to mercury, and the latter to the yellow
fever.
Considering the great prejudices against blood-letting, I have wished to
combat this fever with mercury alone. But, for reasons formerly given, I
have been afraid to trust to it without the assistance of the lancet. The
character of the fever, moreover, like that which the poet has ascribed
to Achilles, is of "so swift, irritable, inexorable, and cruel" a nature,
that it would be unsafe to rely exclusively upon a medicine which is not
only of less efficacy than bleeding, but often slow and uncertain in its
operation, _more especially_ upon the throat and mouth.
Let not the reader be offended at my attempts to reason. I am aware of
the evils which the weak and perverted exercise of this power of the mind
has introduced into medicine. But let us act with the same consistency
upon this subject that we do in other things.
We do not consign a child to its cradle for life, because it falls in its
first unsuccessful efforts to use its legs. In like manner we must not
abandon reason, because, in our first efforts to use it, we have been
deceived. A single just principle in our science will lead to more
truth, in one year, than whole volumes of uncombined facts will do in a
century.
I lost but two patients in this epidemic in whom the mercury excited a
salivation. One of them died from the want of nursing; the other by the
late application of the remedy.
OF EMETICS.
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.
OF DIET AND DRINKS.
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]."
[3] Maladies de Gens de Mer, vol. i. p. 345.
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]."
[4] Epidemics, vol. ii. p. 67.
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.
OF TONIC REMEDIES.
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.
[5] Chapter v. verse 14.
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 f[oe]tid 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 diarrh[oe]a 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]."
[6] Lib. i. cap. 15.
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.
[7] De Feb. Pestilent. cap. v. "Acutorum morborum incertæ admodum, ac
fallaces sunt prædictiones."
HIPPOCRATES.
AN ACCOUNT
OF THE
_BILIOUS YELLOW FEVER_,
AS IT
APPEARED IN PHILADELPHIA,
IN THE YEAR 1798.