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. ounces. | Number of 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 | 8 | |
| 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 diarrhœa 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.
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].
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 assafœtida, 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.
Wine was hurtful in every case of yellow fever in which it was given, 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.
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].”
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, [**amp]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 [**LQU]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, [**LQU]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.
Dr. Home, I have elsewhere remarked[128], lost [**LQU]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.
Dr. Blane pronounces the yellow fever to be [**LQU]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.
Footnotes:
[103] Histoire des Maladies de Saint Domingue, p. 112.
[104] Epidemics, book XI. sect. I.
[105] Les Maladies de St. Domingue, vol. I. p. 193.
[106] Account of the Yellow Fever of 1793.
[107] In the account of the effects of morbid action and inflammation, in the Outlines of the Theory of Fever, the author neglected to mention the change of certain fluids from their natural to a dark colour. It appears in the secretions of the stomach and bowels, in the bile, in the urine, in carbuncles, and occasionally in the matter which is produced by blisters. All these changes occur in the yellow fever, and, in common with the other effects of fever that have been enumerated, are the result of peculiar actions in the vessels, derived from one cause, viz. morbid excitement.
[108] Essay on the Malignant Pestilential Fever introduced into the West-Indies from Beullam, p. 137.
[110] Epidemics, book ii. sect. 2.
[111] Historia Febris Anomalæ Batavæ Annorum 1746, 1747, 1748, cap. i.
[112] Epidemics, book IV.
[114] De Morb. Popular. lib. VII.
[115] See Sydenham, vol. I. p. 212.
[116] Account of the Yellow Fever of 1793.
[118] Account of the Yellow Fever in 1793.
[120] Page [40], [41]. See also p. [111], [230], [231]. vol. [I].
[122] Wallis's edition, p. 211. vol. i.
[125] Medical Essays and Observations, p. 28.
[127] Medical Essays and Observations, p. 29.
[128] Account of the Yellow Fever of 1793.
AN
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.
The rain which fell about the middle of July checked this fever. August, September, and October were unusually healthy. A few cases of malignant sore throat appeared in November. They were, in all the patients that came under my notice, attended with bilious discharges from the stomach and bowels. So little rain fell during the autumnal months, that the wheat perished in many places. The weather in December was extremely cold. The lamps of the city were, in several instances, extinguished by it, on the night of the 23d of the month, at which time the mercury stood at 2° below 0 in the thermometer.
The yellow fever prevailed this year in Charleston, in South-Carolina, where it was produced by putrid exhalations from the cellars of houses which had been lately burnt. It was said by the physicians of that place not to be contagious. The same fever prevailed, at the same time, at Wilmington, in North-Carolina, and at Newburyport, in the state of Massachusetts. In the latter place, it was produced by the exhalation of putrid fish, which had been carelessly thrown upon a wharf.
END OF VOL. III.
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