AN ACCOUNT OF THE Bilious Remitting Fever, AS IT APPEARED IN PHILADELPHIA, IN THE SUMMER AND AUTUMN OF THE YEAR 1780.
BEFORE I proceed to describe this fever, it will be necessary to give a short account of the wea|ther, and of the diseases which preceded it.
THE spring of 1780 was dry and cool. A catarrh appeared among children between one year and seven years of age. It was accompanied by a defluxion from the eyes and nose, and by a cough and dyspnoea, resem|bling, in some instances, the cynanche trachealis, and in others, a peripneumony. In some cases it was com|plicated with the symptoms of a bilious remitting, and intermitting fever. The exacerbations of this fever were always attended by dyspnoea and cough. A few patients expectorated blood. Some had swellings be|hind the ears, and others were affected with small ul|cers in the throat. I met with only one case of this fever in which the pulse indicated bleeding. The rest yielded in a few days to emetics, blisters, and the bark, assisted by the usual more simple remedies in such disorders.
Page 90 AN intermittent prevailed among adults in the month of May.
JULY and August were uncommonly warm. The mercury stood on the 6th of August at 94 1/2°, on the 15th of the same month at 95°, and for several days afterwards at 90°. Many labouring people perished during this month by the heat, and by drinking, not only cold water, but cold liquors of several kinds, while they were under the violent impressions of the heat.
THE vomiting and purging prevailed universally, during these two warm months, among the children, and with uncommon degrees of mortality. Children from one year to eight and nine years old were like|wise very generally affected by blotches and little boils, especially in their faces. An eruption on the skin, called by the common people the prickly heat, was very common at this time among persons of all ages. The winds during these months blew chiefly from the south, and south-west. Of course they passed over the land which lies between the city, and the conflux of the rivers Delaware and Schuylkill, the peculiar situation of which, at that time, has been al|ready described.
THE dock, and the streets of Philadelphia, supplied the winds at this season, likewise, with a portion of their unwholesome exhalations*.
THE remitting fever made its first appearance in July and August, but its symptoms were so mild, and Page 91 its extent so confined, that it excited no apprehensions of its subsequent more general prevalence throughout the city.
ON the 19th of August the air became suddenly very cool. Many hundred people in the city com|plained, the next day, of different degrees of in|disposition, from a sense of lassitude, to a fever of the remitting type. This was the signal of the epi|demic. The weather continued cool during the re|maining part of the month, and during the whole month of September. From the exposure of the dis|trict of Southwark (which is often distinguished by the name of the Hill) to the south-west winds, the fever made its first appearance in that appendage of the city. Scarcely a family, and in many families, scarcely a member of them, escaped it. From the Hill it gra|dually travelled along the Second-street from the De|laware, improperly called Front-street. For a while it was confined to this street only, after it entered the city, and hence it was called by some people the Front-street fever. It gradually spread through other parts of the city, but with very different degrees of vio|lence. It prevailed but little in the Northern Liberties. It was scarcely known beyond Fourth-street from the Delaware. Intemperance in eating or drinking, ri|ding in the sun or rain, watching, fatigue, or even a fright, but more frequently cold, all served to excite the seeds of this fever into action, wherever they existed.
ALL ages, and both sexes were affected by this fever. Seven of the practitioners of physic were confined by it nearly at the same time. The city, du|ring the prevalence of the fever, was filled with an unusual number of strangers, many of whom, particu|larly Page 92 of the Friends (whose yearly meeting was held in the month of September) were affected by it.
THIS fever generally came on with rigor, but sel|dom with a regular chilly fit, and often without any sensation of cold. In some persons it was introduced by a slight sore throat, and in others, by a hoarseness which was mistaken for a common cold. A giddiness in the head was the forerunner of the disease in some people. This giddiness attacked so suddenly, as to produce, in several instances, a faintiness, and even symptoms of apoplexy. It was remarkable that all those persons who were affected in this violent manner, recovered in two or three days.
I MET with one instance of this fever attacking with coma, and another with convulsions, and with many instances in which it was introduced by a delirium.
THE pains which accompanied this fever were ex|quisitely severe in the head, back, and limbs. The pains in the head were sometimes in the back parts of it, and at other times they occupied only the eyeballs. In some people, the pains were so acute in their backs and hips, that they could not lie in bed. In others, the pains affected the neck and arms, so as to pro|duce in one instance a difficulty of moving the fingers of the right hand. They all complained more or less of a soreness in the seats of these pains, particularly when they occupied the head and eyeballs. A few complained of their flesh being sore to the touch, in every part of the body. From these circumstances, the disease was sometimes believed to be a rheumatism. But its more general name among all classes of people was, the Break-bone fever.
Page 93 I MET with one case of pain in the back, and ano|ther of an acute ear-ach, both of which returned pe|riodically every night, and without any fever.
A NAUSEA universally, and in some instances, a vomiting, accompanied by a disagreeable taste in the mouth, attended this fever. The bowels were, in most cases, regular, except where the disease fell with its whole force upon them, producing a symptomatic dysentery*.
THE tongue was generally moist, and tinctured of a yellow color.
THE urine was high coloured, and in its usual quantity in fevers.
THE skin was generally moist, especially where the disease terminated on the third or fourth day.
THE pulse was quick and full, but never hard in a single patient that came under my care, till the 28th of September.
IT was remarkable, that little, and in some instances, no thirst attended this fever.
A SCREATUS, or constant hawking and spitting, attended in many cases through the whole disease, and was a favourable symptom.
THERE were generally remissions in this fever every morning, and sometimes in the evening. The Page 94 exacerbations were more severe every other day, and two exacerbations were often observed in one day.
A RASH often appeared on the third and fourth days, which proved favourable. This rash was ac|companied in some cases by a burning in the palms of the hands and soles of the feet. Many people at this time, who were not confined to their beds, and some, who had no fever, had an efflorescence on their skins.
IN several persons the force of the disease seemed to fall upon the face, producing swellings under the jaw and in the ears, which in some instances terminat|ed in abscesses.
WHEN the fever did not terminate on the third or fourth day, it frequently ran on to the eleventh, four|teenth, and even twentieth days, assuming in its pro|gress, according to its duration, the usual symptoms of the typhus gravior, or mitior, of Doctor Cullen. In some cases, the discharge of a few spoonfuls of blood from the nose accompanied a solution of the fever on the third or fourth day; while in others, a profuse haemorrhage from the nose, mouth, and bowels, on the tenth and eleventh days, preceded a fatal issue of the disease.
SEVERAL cases came under my care, in which the fever was succeeded by a jaundice.
THE disease terminated in some cases without sweat|ing, or a sediment in the urine; nor did I find such patients more disposed to relapse than others, pro|vided they took a sufficient quantity of the bark.
Page 95 ABOUT the beginning of October the weather be|came cool, accompanied by rain and an easterly wind. This cool and wet weather continued for four days. The mercury in the thermometer fell to 60°, and fires became agreeable. From this time the fever evidently declined, or was accompanied with inflammatory symp|toms. On the 16th of October, I met with a case of inflammatory angina; and on the next day I vi|sited a patient who had a complication of the bilious fever with a pleurisy, and whose blood discovered strong marks of the presence of the inflammatory di|athesis. His stools were of a green and black color. On the third day of his disorder the rash appeared on his skin, and on the fourth, in consequence of a second bleeding, his fever terminated with the com|mon symptoms of a crisis.
DURING the latter end of October, and the first weeks in November, the mercury in the thermome|ter fluctuated between 50° and 60°. Pleurisies and inflammatory diseases of all kinds now made their ap|pearance. They were more numerous and more acute, than in this stage of the autumn, in former years. I met with one case of pleurisy in November, which did not yield to less than four plentiful bleedings.
I SHALL now add a short account of the METHOD I pursued in the treatment of this fever.
I GENERALLY began by giving a gentle vomit of tartar emetic. This medicine, if given while the fe|ver was in its forming state, frequently produced an immediate cure; and if given after its formation, on the first day, seldom sailed of producing a crisis on the third or fourth day. The vomit always discharg|ed Page 96 more or less bile. If a nausea, or an ineffectual attempt to vomit continued after the exhibition of the tartar emetic, I gave a second dose of it, with the happiest effects.
IF the vomit failed of opening the bowels, I gave gentle doses of salts and cream of tartar*, or of the butter-nut pill†, so as to procure two or three plentiful stools. The matter discharged from the bowels was of a highly bilious nature. It was sometimes so acrid as to excoriate the rectum, and so offensive, as to occasion, in some cases, sickness and faintiness both in the patients and in their attendants. In every in|stance the patients found relief by these evacuations, especially from the pains in the head and limbs.
IN those cases, where the prejudices of the pati|ents against an emetic, or where an advanced state of pregnancy, or an habitual predisposition to hoematemesis occurred, I discharged the bile entirely by means of the lenient purges that have been mentioned. In this practice I had the example of Doctor Cleghorn, who prescribed purges with great success in a fever of the same species in Minorca, with that which has been de|scribed‡. Doctor Lining prescribed purges with equal success in an autumnal pleurisy in South-Caro|lina, which I take to be a species of a bilious remit|tent, accompanied by an inflammatory affection of the breast.
Page 97 AFTER evacuating the contents of the stomach and bowels, I gave small doses of tartar emetic mixed with Glauber's salt. This medicine excited a general perspira|tion. It likewise kept the bowels gently open, by which means the bile was discharged as fast as it was accumulated.
I CONSTANTLY recommended to my patients, in this stage of the disorder, to lie in bed. This favoured the eruption of the rash, and the solution of the disease by perspiration. Persons who struggled against the fever by sitting up, or who attempted to shake it off by labor or exercise, either sunk under it, or had a slow recovery.
A CLERGYMAN of a respectable character from the country, who was attacked by the disease in the city, returned home, from a desire of being attended by his own family, and died in a few days afterwards. This is only one, of many cases, in which I have ob|served travelling, even in the easiest carriages, to prove fatal in fevers after they were formed, or after the first symptoms had shewn themselves. The quickest and most effectual way of conquering a fever, in most cases, is, by an early submission to it.
THE drinks I recommended to my patients were sage and baum teas, apple* and tamarind water, weak punch, lemonade, and wine whey.
I FOUND obvious advantages in many cases, from the use of pediluvia, every night.
IN every case, I found my patients refreshed and relieved, by frequent changes of their linen.
Page 98 ON the third or fourth day, in the forenoon; the pains in the head and back generally abated, with a sweat which was diffused over the whole body. The pulse at this time remained quick and weak. This was, however, no objection to the use of the bark, a few doses of which immediately abated its quickness, and prevented a return of the fever.
IF the fever continued beyond the third or fourth day without an intermission, I always had recourse to blisters. Those which were applied to the neck, and behind the ears, produced the most immediate good effects. They seldom failed of producing an inter|mission in the fever, the day after they were applied. Where delirium or coma attended, I applied the blis|ter to the neck on the first day of the disorder. A worthy family in this city will always ascribe the life of a promising boy of ten years old, to the early ap|plication of a blister to the neck, in this fever.
WHERE the fever did not yield to blisters, and assumed the symptoms of typhus gravior or mitior, I gave the medicines usually exhibited in both the species of that fever.
I TOOK notice in the history of this fever, that it was sometimes accompanied by the symptoms of a dysentery. Where this disorder appeared, I prescrib|ed lenient purges and opiates. Where these failed of success, I gave the bark in the intermissions of the pain in the bowels, and applied blisters to the wrists. The good effects of these remedies led me to conclude, that the dysentery was the febris introversa of Doctor Sydenham.
Page 99 I AM happy in having an opportunity, in this place, of bearing a testimony in favor of the usefulness of OPI|UM in this disorder, after the necessary evacuations had been made. I yielded, in prescribing it at first, to the earnest solicitations of my patients for something to give them relief from their insupportable pains, par|ticularly when they were seated in the eyeballs and head. Its salutary effects in procuring sweat, and a remission of the fever, led me to prescribe it afterwards in almost every case, and always with the happiest ef|fects. Those physicians enjoy but little pleasure in practising physic, who know not how much of the pain and anguish of fevers, of a certain kind, may be lessened, by the judicious use of opium.
IN treating of the remedies used in this disorder, I have taken no notice of blood-letting. Out of seve|ral hundred patients whom I visited in this fever, I did not meet with a single case, before the 27th of September, in which the state of the pulse indicated this evacuation. It is true, the pulse was full, but ne|ver hard. I acknowledge that I was called to several patients who had been bled without the advice of a physician, who recovered afterwards on the usual days of the solution of the fever. This can only be ascrib|ed to that disposition which Doctor Cleghorn attributes to fevers, to preserve their types under every variety of treatment, as well as constitution. But I am bound to declare further, that I heard of several cases, in which bleeding was followed by a fatal termination of the disease.
IN this fever relapses were very frequent, from ex|posure to the rain, sun, or night-air, and from an ex|cess in eating or drinking.
Page 100 THE CONVALESCENCE from this disease was mark|ed with a number of extraordinary symptoms, which rendered patients the subjects of medical attention for many days after the pulse became perfectly regular, and after the crisis of the disease.
A BITTER taste in the mouth, accompanied by a yellow color of the tongue, continued for near a week.
MOST of those who recovered, complained of nau|sea and a total want of appetite. A faintiness, espe|cially upon sitting up in bed, or in a chair, followed this fever. A weakness in the knees was universal. I met with two patients, who were most sensible of this weakness in the right knee. An inflammation in one eye, and in some instances in both eyes, occurred in several patients after their recovery.
BUT the most remarkable symptom of the conva|lescence from this fever, was an uncommon dejection of spirits. I attended two young ladies who shed tears while they vented their complaints of their sickness and weakness. One of them very aptly proposed to me, to change the name of the disorder, and to call it, in its present stage, instead of the Break-bone, the Break-heart fever.
TO remove these symptoms, I gave the tincture of bark and elixir of vitriol in frequent doses. I likewise recommended the plentiful use of ripe fruits; but I saw the best effects from temperate meals of oysters, and a liberal use of porter. To these 〈◊〉 added, gentle ex|ercise in the open air, which gradually completed the cure.