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 diarrh[oe]a, 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 diarrh[oe]a, 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.
[8] History of the Fever in 1797.
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.