Rush's Account of the 1798 Epidemic
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An Account
of the
Bilious Yellow Fever
As It
Appeared in Philadelphia
in the Year 1798
by Benjamin Rush
The yellow fever of the year 1797 was succeeded
by scarlatina, catarrhs, 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 degrees. 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 a Kensington, where
the foul air which was emitted from her hold produced several
cases of yellow fever, near the shores of the 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. Haemorrhages 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 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 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 continues 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 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 haemorrhage
from the bowels. This haemorrhage was followed by a bloody
diarrhoea, 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 peope 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 to
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 haemorrhages 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. These parts, though
dead, were not always in a mortified state. They were
distinguished from the living parts by a peculiar paleness, and
be discharging 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 of the 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 color,
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 season; 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 soon 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 less than that degree which produces frost, also
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 ounces, 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
bloodletting, 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 salivation. On the fifth day of his disease,
his pulse became languid and slow, and his skin cool, a
haemorrhage had taken place from this 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 for 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 diarrhoea, 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 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, 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.
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 occured 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 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 the epidemic 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 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.
The first mode of practice was the least
successful. If succeeded only in such cases as would probably
have cured themselves.
The second mode succeeded in mild cases, and
now and then in that malignant state of the fever, in which the
action of the blood-vessels was so much prostrated by the force
of the miasmata, as to permit the mercury to pass over them, and
thus to act upon the salivary glands in the course of four or
five days.
The last mode was by far the most successful.
It is worthy of notice, that the business and reputation of the
physicians, during this epidemic, were in the inverse ratio of
their success. The number of deaths by it amounted to between
three and four thousand, among whom were three physicians, and
two students of medicine. Its mortality was nearly as great as it
was in 1793, and yet the number of people who were affected by it
was four times as great in 1793 as it was in 1798, for, in the
latter year, the city was deserted by nearly all its inhabitants.
The cause of this disproportion of deaths to the number who were
sick, was owing to the liberal and general use of the lancet in
1793, and to the publications in 1797 having excited general
fears and prejudices against it in 1798. Such was the influence
of these publications, that many persons who had recovered from
this fever in the two former years, by the use of depleting
remedies, deserted the physicians who had prescribed them, and
put themselves under the care of physicians of opposite modes of
practice. Most of them died. Two of them had been my patients,
one of whom had recovered of a third attack of the fever under my
care.
transcribed by Bob Arnebeck
(For Arnebeck's take on the 1798
epidemic see Chapter 14
of his book "Destroying
Angel.")
Other Rush memoirs on this web site: Memoir of the 1799 epidemic and A
partial transcription of the memoir of the 1793 epidemic
And you might want to look at: An historian's view of
Anderson's Fever 1793
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