Volume 1 — 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 weather, and of the diseases which preceded its appearance.

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 dyspnœa, resembling, in some instances, the cynanche trachealis, and in others a peripneumony. In some cases it was complicated with the symptoms of a bilious remitting, and intermitting fever. The exacerbations of this fever were always attended with dyspnœa and cough. A few patients expectorated blood. Some had swellings behind their ears, and others were affected with small ulcers 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 diseases.

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 likewise 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 already described.

The dock, and the streets of Philadelphia, supplied the winds at this season, likewise, with a portion of their unwholesome exhalations.

The muschetoes were uncommonly numerous during the autumn. A certain sign (says Dr. Lind) of an unwholesome atmosphere.

The remitting fever made its first appearance in July and August, but its symptoms were so mild, and 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 complained, the next day, of different degrees of indisposition, from a sense of lassitude, to a fever of the remitting type. This was the signal of the epidemic. The weather continued cool during the remaining part of the month, and during the whole month of September. From the exposure of the district 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 gradually travelled along the second street from the Delaware, 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 violence. It prevailed but little in the Northern Liberties. It was scarcely known beyond Fourth-street from the Delaware. Intemperance in eating or drinking, riding 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, where-ever 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, during the prevalence of the fever, was filled with an unusual number of strangers, many of whom, particularly the Friends (whose yearly meeting was held in the month of September), were affected by it. No other febrile disease was observed during this time in the city.

This fever generally came on with rigour, but seldom 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 faintness, 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 exquisitely 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 produce 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.

I met with one case of pain in the back, and another of an acute ear-ach, both of which returned periodically 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 dysentery.

The tongue was generally moist, and tinctured of a yellow colour.

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 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 accompanied, 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 terminated in abscesses.

When the fever did not terminate on the third or fourth day, it frequently ran on to the eleventh, fourteenth, and even twentieth days, assuming in its progress, according to its duration, the usual symptoms of the typhus gravior, or mitior, of Doctor Cullen. In some cases, the discharge of a few spoons-full of blood from the nose accompanied a solution of the fever on the third or fourth day; while in others, a profuse hæmorrhage 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 sweating, or a sediment in the urine; nor did I observe such patients more disposed to relapse than others, provided they took a sufficient quantity of the bark.

About the beginning of October the weather became 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 by inflammatory symptoms. On the 16th of October, I met with a case of inflammatory angina; and on the next day I visited 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 diathesis. His stools were of a green and black colour. On the third day of his disease a rash appeared on his skin, and on the fourth, in consequence of a second bleeding, his fever terminated with the common symptoms of a crisis.

During the latter end of October, and the first weeks in November, the mercury in the thermometer fluctuated between 50° and 60°. Pleurisies and inflammatory diseases of all kinds now made their appearance. 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 fever was in its forming state, frequently produced an immediate cure; and if given after its formation, on the first day, seldom failed of producing a crisis on the third or fourth day. The vomit always discharged 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[37], or of the butter-nut pill[38], 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 faintness both in the patients and in their attendants. In every instance, the patients found relief by these evacuations, especially from the pains in the head and limbs.

In those cases, where the prejudices of the patients against an emetic, or where an advanced state of pregnancy, or a habitual predisposition to a vomiting of blood 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 kind in Minorca, with that which has been described[39]. Doctor Lining prescribed purges with equal success in an autumnal pleurisy in South Carolina, which I take to have been a form of a bilious remittent, accompanied by an inflammatory affection of the breast.

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 perspiration. 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 labour 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 observed travelling, even in the easiest carriages, to prove fatal in fevers after they were formed, or after the first symptoms had shown 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 balm teas, weak punch, lemonade, wine whey, tamarind and apple water.

The apple water should be made by pouring boiling water upon slices of raw apples. It is more lively than that which is made by pouring the water on roasted apples.

I found obvious advantages, in many cases, from the use of pediluvia, every night.

In every case, I found the patients refreshed and relieved by frequent changes of their linen.

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 intermission in the fever, the day after they were applied. Where delirium or coma attended, I applied the blister to the neck on the first day of the disease. A worthy family in this city will always ascribe the life of a promising boy, of ten years old, to the early application of a blister to the neck, in this fever.

Where the fever did not yield to blisters, and assumed malignant, or typhus symptoms, I gave the medicines usually exhibited in both those states of fever.

I took notice, in the history of this fever, that it was sometimes accompanied with symptoms of a dysentery. Where this disease appeared, I prescribed 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 Dr. Sydenham.

I am happy in having an opportunity, in this place, of bearing a testimony in favour of the usefulness of OPIUM in this disease, 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, particularly 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 effects. 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 disease, I have taken no notice of blood-letting. Out of several 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 never 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 only can be ascribed 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 exposure to the rain, sun, or night air, and from an excess in eating or drinking.

The convalescence from this disease was marked by 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 colour on the tongue, continued for near a week.

Most of those who recovered complained of nausea, and a total want of appetite. A faintness, especially 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 convalescence from this fever, was an uncommon dejection of the 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 disease, 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 was added, gentle exercise in the open air, which gradually completed the cure.

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